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Managing Your Warfarin (Coumadin®) A Patient’s Guide A Message To You
The goal of anticoagulation therapy with warfarin (Coumadin®) is to decrease the clotting ability of your blood so that blood clots are prevented. The most important aspect of warfarin therapy is to keep your levels within a therapeutic range. If your level goes too low, you are at risk for blood clots, if it goes too high, you are at risk for bleeding. Many factors can affect your level. In order to provide you with the safest and most effective therapy, your healthcare provider needs you to act as a partner in your care. Your role is to gain the necessary knowledge about your warfarin therapy and the factors that affect it, and then apply this knowledge to your daily activities. The purpose of this book is to empower you with that knowledge. If you have any questions or concerns about your warfarin therapy after reading this book, please speak with your healthcare provider. The Do’s and Don’ts of Warfarin (Coumadin®) Therapy Do’s:
• Do strictly adhere to the warfarin (Coumadin®) dosage prescribed by your healthcare
• Do get your INR level monitored on a regular basis.
• Do eat a normal, balanced diet maintaining a consistent amount of vitamin K. • Do tell your healthcare provider about any other medicines your are taking (prescription and
over-the-counter) as well as herbal/nutritional supplements. Also, talk to your healthcare provider before you change, start, or stop taking any other medicines.
• Do monitor yourself for any signs of bleeding.
• Do tell anyone giving you medical or dental care that you are taking warfarin. • Do wear a medic alert bracelet to identify yourself as being on warfarin.
• Do refill your prescriptions according to your healthcare provider’s orders.
• Do notify your healthcare provider immediately if you experience any signs of bleeding or
• Do take your warfarin at the same time each day, on an empty stomach.
• Do speak to your healthcare provider about any concerns you may have about taking Don’ts:
• Don’t take a double dose of warfarin (Coumadin®) the following day if you find you
missed a dose on the previous day. Notify your healthcare provider if you miss any doses.
• Don’t change your warfarin dosage without speaking to your healthcare provider.
• Don’t change, start, or stop any medications or nutritional supplements without speaking to
• Don’t make any drastic changes in your diet without speaking to your healthcare provider.
• Don’t participate in any activity or sport that may cause a traumatic injury.
• Don’t drink excessive alcohol. • Don’t take warfarin during pregnancy. What Is Warfarin (Coumadin®)?
Warfarin (Coumadin®) is an anticoagulant. Anti means against, and coagulant refers to blood clotting. Warfarin reduces the body’s ability to make blood clots.Your healthcare provider wants you to take warfarin because your body may makeclots that you don’t need. These clots can cause a serious medical problem. A clotcan move to another part of your body. For example, if a clot moves to your brain, itcan cause a stroke.The most common reasons for taking warfarin (Coumadin®) include:
• Deep Vein Thrombosis (DVT): this is a blood clot that occurs in a deep vein.
They most often occur in the legs, but can occur in other parts of your body as well.
• Pulmonary Embolus (PE): this is a blood clot in the lung. Most often, the
blood clot starts in the leg, breaks off, and travels to the lung.
• Atrial Fibrillation or atrial flutter: these are irregular heart rhythms that occur
in the upper chambers of the heart (the atria). The atria do not empty all of the blood, which can cause the leftover blood to form clots. If a clot goes into your circulation, it can cause a stroke.
• Mechanical heart valve replacement: blood clots can form on the mechanical
heart valve. If a clot forms on the valve, it can prevent the valve from functioning, or if the clot breaks off into your circulation, it can cause a stroke. People with mechanical heart valve replacements must be on warfarin therapy for life.
• Heart attack: sometimes warfarin is taken after a heart attack to lower the risk
of death, lower the risk of another heart attack, and lower the risk of stroke.
• Stroke: if a stroke is caused by a blood clot going to the brain, warfarin is used
• Transient Ischemic Attack (TIA) or “mini stroke”: Warfarin is given to
• After certain surgical procedures: some surgical procedures place a person at
high risk for developing a blood clot (for example, major orthopedic surgery). Warfarin is given temporarily after the surgery to prevent a clot from occurring. Warfarin (Coumadin®) is sometimes given for reasons other than those listed. If you have any questions or don’t understand something in this information, ask your healthcare provider for more information.
How Does Warfarin (Coumadin®) Work?
Warfarin (Coumadin®) partially blocks the re-use of vitamin K in your liver. Vitamin K is needed to make clotting factors that help the blood to clot and prevent bleeding. Vitamin K is found naturally in certain foods, such as green leafy vegetables. Warfarin (Coumadin®) reduces the body’s ability to make blood clots. It can help stop harmful clots from forming and keeps clots from getting larger. Warfarin does not break up existing blood clots. Warfarin (Coumadin®) begins to reduce blood clotting within 24 hours after taking the drug. The full effect may take 72 to 96 hours to occur. The anti-clotting effects of a single dose of warfarin last 2 to 5 days, but it is important for you to take your dose as prescribed by your healthcare provider.
How is Warfarin (Coumadin®) Monitored
Warfarin (Coumadin®) is monitored by a blood test called an INR (International Normalized Ratio). When your INR falls within your range (for example, between 2.0 and 3.0), this means that your level is “therapeutic.” When your INR level goes below the range (for example, 1.5) this means your blood is “too thick,” and places you at risk for blood clots. In this situation, your healthcare provider will prescribe a higher dose of warfarin for you to take. If your INR goes above your range (for example, 4.5) this means your blood is “too thin,” and places you at risk for bleeding. In this situation, your healthcare provider will prescribe a lower dose of warfarin for you to take. Because warfarin (Coumadin®) affects each person differently, some people will be on small doses of warfarin and some will be on very large doses. Some people will achieve their appropriate INR quickly and others more slowly. The doseof warfarin you need is the one that keeps the INR in the therapeutic range for yourcondition. Many factors can affect your INR level including a change in diet, a change in medications, the onset of a new illness, or having to stop your warfarin for a procedure. When a person first starts taking warfarin (Coumadin®) the INR level tends to fluctuate up and down until the correct dose of warfarin is found that keeps your INR level stable. It is therefore very important to get your INR level checked frequently. In general, when you first start warfarin you will need to get your INR level checked 2 to 3 times a week for the first two weeks, then one to two times a week for two weeks, then every other week, then once a month. This may vary, depending on how your INR levels are. If the INR level becomes stable quickly,
you will go for INR blood tests less often, if the INR level does not become stable, you will need to go for INR blood tests more often. When your INR level is too high or too low, you often will not feel any symptoms. This is why it is so important to get your INR blood tests done regularly!
What Dose Do I Take?
Warfarin belongs to a category of drugs known as “narrow range of effectiveness” drugs. This means that there is a very narrow range where the drug is considered therapeutic. For most indications, the INR range is 2.0 to 3.0. For people with mechanical heart valve replacements and certain other conditions, the range is 2.5 to 3.5. These ranges are general recommendations. Your healthcare provider might prescribe a different range, depending on your particular condition. Warfarin (Coumadin®) and Drug Interactions
Warfarin (Coumadin®) interacts with hundreds of drugs including prescription and non-prescription (over-the-counter) drugs. Drug interactions can cause your INR to go too high (placing you at risk for bleeding) or cause your INR to go too low (placing you at risk for blood clots). Examples of some drugs that interact with warfarin are given below. The list is by no means all-inclusive. It is just to give you an idea of some of the more common drugs that interact with warfarin. It is very important for you to check with your healthcare provider before starting, changing, or stopping any drug, whether it be prescription or over-the-counter. If you need to be on a medicine that is known to interact with warfarin, it does not mean that you cannot take it. It does mean that you will need to get your INR monitored more closely when you start the new medicine. Prescription Drugs (by class): Common Over-the-Counter Drugs: Drug Interactions With Herbal Medicines
Herbal medicines can also cause dangerous drug interactions with Warfarin (Coumadin®). Keep in mind that just because an herbal product is advertised to be “all natural” does not necessarily mean it is safe. Below is a list of herbal products known to interact with warfarin. The list is not all-inclusive. If you want to take an herbal supplement, it is very important that you contact your healthcare provider before taking it.
Diet and Warfarin (Coumadin®) Therapy
Warfarin (Coumadin®) interacts with vitamin K in your diet. Vitamin K is necessary in the blood clotting process. Food sources with the highest amount of vitamin K include dark green leafy vegetables. This does not mean that you need to cut greenleafy vegetables out of your diet. These foods are heart healthy, they are high in lutein, which improves vision, and high in fiber, which is good for the gastrointestinal tract. The recommendation is to keep your diet consistent. This means that you should eat the same amount of vegetables from week to week. Do not eat a lot of dark green leafy vegetables one week, then none the following week. As long as you maintain a consistent amount of vitamin K in your diet, the warfarin will balance with it. If your vitamin K intake fluctuates, your INR level will fluctuate. Remember, just because a vegetable is green does not mean it is high in vitamin K. It is only the green leafy vegetables that are high in vitamin K. Examples of vegetables high in Examples of vegetables low in vitamin K: vitamin K:
Lettuce (except iceberg lettuce which is
Cauliflower (although it is white, it is
Other Dietary Considerations Dietary Supplements: Many dietary supplements contain vitamin K. Examples of these products include Ensure, Boost, and Carnation Instant Breakfast. The fact that these products contain vitamin K does not mean you should not use them. As with diet, keep your vitamin K intake consistent. If you have never used these products but would like to start, contact your healthcare provider. You will need to get your INR level monitored more closely when you start them. Vitamins: What vitamins are safe to take when you are taking warfarin (Coumadin®)? Below is a list of some of the most common vitamins and their effect on the INR level:
• B vitamins: no effect on the INR level
• Vitamin C: up to 500 mg per day will have no effect on the INR. Doses
greater than 500 mg may lower the INR level
• Vitamin E: up to 400 IU per day will have no effect on the INR. Doses above
• Multivitamins: most multivitamins contain small amounts of vitamin K. It is
okay to take them, but as goes with diet, be consistent in taking them every day to prevent your vitamin K intake from fluctuating. If you are not using multivitamins but would like to start, contact your healthcare provider. You will need to get your INR level monitored more closely when you start them.
Alcohol: alcohol in moderation (up to 2 drinks per day) will have little effect on the INR level. Excess alcohol intake will elevate the INR level because both the alcohol and the warfarin (Coumadin®) are metabolized through the liver. If you have a problem with excessive alcohol intake and are taking warfarin, please speak with your healthcare provider. This lethal combination may place you at serious risk of a bleeding event. Side Effects of Warfarin (Coumadin®)
The most serious side effect of warfarin (Coumadin®) is bleeding. To lower the risk of bleeding, be sure to get your INR level monitored regularly. Monitor yourself for:
• Bleeding of gums when you brush your teeth
• Bowel movements that look red or black
• Excessive bleeding when you get your menstrual period or unexpected
If you develop minor bleeding (for example, a nosebleed or bleeding from the gums that stops within a few minutes) contact your healthcare provider. You will need to get your INR level checked. If you develop major bleeding (for example, vomiting blood or a nosebleed that won’t stop) go to the nearest emergency room. This could be a sign of a serious problem. If you are involved in any kind of traumatic accident (for example, a car accident or falling down and hitting your head on the pavement), go to the nearest emergency room. You will need to get checked for internal bleeding. Other side effects:
• Hair loss: hair loss is an infrequent side effect of warfarin therapy and is
• Rash: if you develop a rash after starting warfarin therapy notify your
• Pregnancy: if you become pregnant or are planning to become pregnant,
notify your healthcare provider. Warfarin (Coumadin®) is dangerous to the unborn baby and should not be taken during pregnancy.
• Avoid any activity or sport that may result in a traumatic injury.
• You may find that if you get a cut or scratch it may bleed longer than when
you were not taking warfarin. Just apply pressure to the area. It should stop within a few minutes.
• You may find that you bruise easier than when you were not on warfarin. Try
Commonly Asked Questions About Warfarin (Coumadin®) Therapy
• What is the best time to take warfarin (Coumadin®)? The most important thing to do is to take it at the same time each day. Ideally, you should take it in the evening, but choose a time of day that you will remember to take it. On the days, you are getting your INR level checked, do not take the warfarin before the blood test in case a change in your dosage needs to be made.
• Should I take warfarin with food or on an empty stomach? Warfarin (Coumadin®) should be taken on an empty stomach, either one half hour before or one hour after a meal. Food impairs the absorption of the drug. It is okay to take it after a light snack, but don’t take it after a full meal.
• How long will I need to be on warfarin (Coumadin®)? It is up to your healthcare provider to determine how long you will need to be on warfarin. Warfarin is used to treat many different conditions. For some, you will only need to be on it temporarily, for others you may need to be on it for life.
• What do I do if I travel? If necessary, your healthcare provider can make arrangements for you to have your INR level monitored while you are away. Remember to try to keep your diet consistent and to avoid excessive alcohol intake while you are away.
• What happens if I need surgery, dental work, or some type of invasive procedure? Any time you are to have any type of procedure done that could place you at risk of bleeding, notify your healthcare provider. Depending on the procedure, the warfarin may need to be temporarily stopped, or you may need an alternative method of anticoagulation. Always check with the healthcare provider who is managing your warfarin therapy before stopping it for any reason.
• How much warfarin (Coumadin®) is too much? There is no limit on the dosage of warfarin. You will need to take whatever dose keeps your INR level in the therapeutic range. For some people, it may be a very small dose, for others, it may be a large dose. If you hear from your friends or neighbors that they are taking a lower dose than you, don’t let it upset you. Warfarin dosage is individualized to each particular patient.
Adapted from: Your Guide to Coumadin®/Warfarin Therapy, AHRQ Pub. No. 08-0028-A Revised August 2008.
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