Medications that contain pain relievers or antiinflammatories similar to aspirin such as ibuprofen (i.e., Motrin®, Advil®, Nuprin®), naproxen (Aleve®), or ketoprofen (Orudis®) should also be avoided unless approved by your doctor. Aspirin-free products, such as Tylenol® and Datril® which contain acetaminophen, are preferred for the treatment of pain or headaches. However, large doses of Tylenol® may increase the INR. Limit the amount you take to no more than 6 or 7 regular strength tablets a week. If you use higher doses of Tylenol®, try to take the same amount from week to week. Always inform the Anticoagulation Management Service when the amount you take changes.
Diet
Keep your diet consistent, especially the amount of green vegetables you eat. Foods high in vitamin K, such as those listed below may be eaten as long as the amounts remains the same from week to week. 1 portion = 2/3 cup avocados broccoli Brussels sprouts green cabbage chickpeas endive green tea (4-6 cups) kale lettuce • leaf • romaine liver mint leaf spinach greens • beet • collard • dandelion • mustard • turnip watercress
Common medications that affect warfarin (not a complete list)
Advil® Aleve® Alka-Seltzer® amiodarone Anacin® certain antibiotics certain antidepressants Ascriptin® Aspergum® Bayer Aspirin® Bufferin® Ecotrin ®
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Empirin® Excedrin P.M. ® Midol® Motrin® Nuprin® Pepto-Bismol® Orudis® Oruvail® Questran® Sine-Off Sinus® Tagamet®
Avoid “binge” eating or “crash” diets. Inform your doctor and AMS any major changes in your food intake, such as decreased appetite or weight reduction diets. If you become unable to eat or need tube feedings, notify AMS as your INR may need to be checked more frequently.
Alcohol Restrictions
Alcohol can cause changes in INR values. Therefore, alcohol should be avoided completely. If this is not possible, you need to be honest with the AMS staff about your usual intake of alcohol, and any deviation from the usual. Most important – avoid “binge” drinking.
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Possible Complications Herbal Medicines
You should be aware that many herbals or “natural” products may contain ingredients that affect your response to warfarin. Do not start or stop any herbal products without letting your AMS staff know. We may want to check your INR sooner than normal. Some herbals which may affect warfarin therapy include (not a complete list): • • • • feverfew garlic (large doses) ginseng ginkgo biloba • • • • St. John’s Wort coenzyme Q10 (ubiquinone) dong quai (angelica sinensis) vitamin E (large doses) Since anticoagulants decrease blood clotting, you may bleed more easily. Don’t be alarmed but call your doctor promptly if you develop any of the following: • Unusual bleeding from gums (use a soft toothbrush) • Excessive bleeding or oozing from cuts or wounds • Nosebleeds • • • • • Unexplained bruising or purplish areas on skin Excessive menstrual bleeding Red or dark brown urine; red or black stools Severe or prolonged stomach pain or backaches Severe or continuing headaches
Pregnancy
Warfarin can cause birth defects, especially during the first trimester of pregnancy, as well as bleeding complications. Because of this, it is generally not used during pregnancy. Women of childbearing age who are taking warfarin should ensure they use adequate birth control and let their physician and the AMS know if a pregnancy is planned. If anticoagulation therapy must continue through a pregnancy, a different type of anticoagulant such as heparin or enoxaparin may be used. During this time, your physician will be monitoring your anticoagulation therapy. Warfarin does not cross into breast milk so it is safe to use once your doctor restarts therapy.
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Medication Interactions
Many medications (both prescription and OTC) interact with warfarin. Always ask the doctor or pharmacist before taking any new medications, or before you stop taking any other medications. You should always read the labels of all medications before you take them. In general, avoid medications that contain aspirin, unless prescribed by your doctor. The risk of bleeding may increase when aspirin and warfarin are taken together. Do not take medications that have the following ingredients in them: • aspirin • acetylsalicylic acid
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• salicylate • ASA
Proper Use of this Medication
Take this medicine only as directed by your health care provider or pharmacist. Anticoagulation is an extremely delicate process. Relatively small changes in dose can make a big difference. Taking more than directed can increase your chance of serious bleeding. Taking less or stopping the medication could cause your blood to clot, resulting in a stroke, heart attack or other serious problems. • Know the strength of your warfarin dose. • Take your warfarin once each day at the same time. • If you miss a dose, take it as soon as possible if you remember the same day. However, if you do not remember until the next day, do not take the missed dose at all and restart at your usual prescribed dose. • Be sure to let your doctors, dentists and pharmacists know you are taking warfarin. • Store this medication out of the reach of children. In prescribing your anticoagulant drug dosage, your doctor or AMS staff’s goal is to produce an INR which prevents too much clot formation and at the same time does not allow excess bleeding. If you have any questions or if you want more information about this medicine, please ask your health care provider or pharmacist.
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Changes in General Health
It is important to advise AMS staff about any significant changes to your health. Rapid changes in weight caused by illness with loss of appetite can significantly affect warfarin. In addition, any illness with prolonged nausea and vomiting, higher fever, or diarrhea can affect warfarin therapy and should be reported. We may want to check your INR level sooner than originally scheduled.
Safety Precautions
A normal lifestyle is possible while taking warfarin. However, because you bleed and bruise more easily, you should not do some things. You should avoid contact sports (football, hockey, soccer, wrestling, etc.), or activities where there is a high risk of injury. • Do not walk barefoot, especially outdoors • Use extreme care when handling sharp knives, garden tools, and broken glass.
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Medic Alert Tag
It is very important that you wear a medic alert tag and carry an ID card indicating you are on warfarin medication in cause you become injured or unconscious. This ID will alert those who are helping you that you are taking warfarin. You can pick up a brochure about medical alert identification at the Anticoagulation Management Service or at other pharmacies or doctor’s offices.
Warfarin (Coumadin®)
Anticoagulants, such as warfarin, decrease the clotting ability of the blood and help prevent harmful clots from forming in your blood vessels. Often referred to as “blood thinners”, they do not actually thin the blood. Anticoagulants also will not dissolve clots that have already formed. Warfarin is often used to prevent the formation of clots which have been associated with medical conditions such as deep vein thrombosis (blood clots in the leg), pulmonary embolism (clots in the lung) and an abnormal heart rhythm called “atrial fibrillation.” Warfarin is also used to prevent clots (i.e. stroke) in patients with heart valve replacements.
If you have any questions or problems regarding your anticoagulant therapy, you should call: Dr. Jill Leisure, Pharm. D. Dr. Angela Williams, Pharm. D. Dr. Lorrie Lala, Pharm.D (641) 422-6847 or 1-800-433-3883 ext 6847 For prescription renewals, call: Monica Murray, AMS technician 1-800-433-3883 ext 6847 If unable to reach the Anticoagulation Management Service or it is after office hours and there is a medical problem, please contact your physician or emergency room for treatment. Office hours are 8:00am to 4:30pm Monday through Friday. We are closed on holidays.
Blood Testing
The prothrombin time (PT) is a blood test used to evaluate how long it takes for the blood to clot and is reported as an “INR” value (International Normalized Ratio). AMS staff will adjust your warfarin dosage based on your INR results. Doses can range from 0.5mg to 20mg/day. Regular laboratory monitoring will prevent blood clots from forming and will decrease bleeding problems. Initially, the INR will usually be checked once or twice weekly. As the INR and dose of warfarin stabilize, the blood test will usually be done every four weeks for as long as you are on the medication.
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Mercy Medical Center – North Iowa
Anticoagulation Management Service (AMS)
Anticoagulation Therapy
Patient Information Pamphlet
Patient Name___________________ Target INR ___________________
Please contact the Anticoagulation Management Service (AMS) or primary health care provider should any of the following situations occur: 1. Unusual or unexplained bleeding as described in your clinic handbook. If the bleeding is continuous and will not stop, please go directly to the emergency room. 2. Illness causing vomiting, fever higher than 101.0 F or diarrhea lasting more than 48 hours (2 days). 3. You are ever prescribed an antibiotic for anything other than before a dental appointment. 4. Any time your prescription, OTC medications or herbal/alternative therapies are stopped or started. 5. You have been admitted to the hospital. Please have a nurse or a family member contact the clinic. 6. You are advised to stop Coumadin ® or warfarin for any reason. 7. You are told to change your dose of Coumadin® or warfarin by someone other than the AMS. 8. Anytime you think you may be having a problem related to your anticoagulation therapy. 9. If you need a refill phoned into the pharmacy for your Coumadin® or warfarin. 1-800-433-3883 ext 7522 10. Any time you need to change your appointment date. We appreciate notification if you need to change your INR draw date. This ensures that we are able to optimize your therapy and decrease delays in return calls.
Designed by Deanna Hansen, Pharm. D. Revised 9/04
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