WARFARIN

					  WARFARIN
 MANAGEMENT
  GUIDELINES


                               WARFARIN
                                 WISE




                     FEBRUARY 2006

                  LIVERPOOL HOSPITAL




DEVELOPED AS PART OF THE “SAFER SYSTEMS SAVING LIVES “ PROJECT.
       WARFARIN MANAGEMENT IN ACUTE STROKE PATIENTS
                                        TABLE OF CONTENTS
ANTI-COAGULATION USING WARFARIN ........................................................ 1
   OUTCOME ................................................................................................................ 1
   GUIDELINES ............................................................................................................. 1
       1.   PRESCRIBING AND ADMINISTRATION ......................................................................... 1
       2.   MONITORING ........................................................................................................... 2
       3.   DRUG INTERACTIONS .............................................................................................. 2
       4.   INR GREATER THAN THERAPEUTIC RANGE ............................................................... 3
       5.   DISCHARGE INSTRUCTIONS ...................................................................................... 3
       6.   RENAL IMPAIRMENT ................................................................................................. 4
   COMPILED BY ........................................................................................................... 5
PATIENT EDUCATION & DISCHARGE MANAGEMENT ....................................... 6
WARFARIN THERAPY CHART ....................................................................... 7
DISCHARGE CHECKLIST .............................................................................. 8
   WARFARIN ALERT CARD SAMPLE ............................................................................... 8
WARFARIN: IMPORTANT INFORMATION FOR PATIENTS .................................... 9
   WARFARIN ALERT CARD ............................................................................................ 9
   INR BLOOD TESTS.................................................................................................... 9
   WARFARIN ............................................................................................................... 9
   WARFARIN DOSE ...................................................................................................... 9
   ADMINISTRATION TIME............................................................................................... 9
   LABORATORY TESTS ................................................................................................. 9
   OTHER MEDICATIONS .............................................................................................. 10
   DIETARY PRINCIPLES .............................................................................................. 10
   SURGICAL PROCEDURES ......................................................................................... 10
   TRAVEL .................................................................................................................. 10
   PREGNANCY ........................................................................................................... 10
   SIGNS OF BLEEDING ................................................................................................ 10




C:\Docstoc\Working\pdf\7e35bf09-6be3-43a5-9543-98d8e825663f.doc                                                  Table of Contents
ANTI-COAGULATION USING WARFARIN

OUTCOME
To promote therapeutic anti-coagulant levels the following guidelines should be implemented
to minimise the risk of bleeding and thromboembolism.

GUIDELINES
COUMADIN® is the preferred brand of Warfarin at Liverpool Health Service. Coumadin will
be supplied for all inpatients starting Warfarin. Patients already on the Marevan® brand
should use their own tablets, as Marevan and Coumadin are NOT EQUIVALENT.
Reference: Aust Prescriber Vol 21 No. 3 1998.

1.   PRESCRIBING AND ADMINISTRATION
    The prescribing doctor will write the indication for Warfarin, the duration of Warfarin therapy
     and the desired therapeutic INR range on the ‘Warfarin Therapy Chart’ (Page 7).
    For chronic AF and valve replacements, start Warfarin alone.
    For restarting Warfarin postoperatively, restart patient on ‘usual’ pre-operative
     maintenance dose - do not reload.
    For acute DVT or PE, start Warfarin on the same day as Heparin/Low Molecular Weight
     Heparin (LMWH) (see Table 4). It is generally recommended to overlap Heparin/LMWH
     with Warfarin for a minimum of five (5) days and until the INR is >2.0 for at least two (2)
     consecutive days.
    Assess each patient for risk factors for increased sensitivity to warfarin and therefore
     bleeding:
     Risk factors include:
     > 'frail' elderly;
     > low body weight;
     > abnormal liver function tests including albumin;
     > INR  1.4;
     > any other bleeding risk such as severe heart failure or low platelets; and
     > concomitant drugs which increase the effect of Warfarin (see Table 2).
    If no risk factors exist, start Warfarin at 5mg daily, monitor INR daily and adjust dose
     using the nomogram in Table 1.
    If risk factors exist, consider smaller loading doses (2 - 4mg) and seek senior/specialist
     advice. Monitor INR daily.
    High loading doses such as 10 mg should not be used as they may increase the risk of
     bleeding.
    Warfarin is to be administered at 1800 hours and must be prescribed before that time.
    Aged adjusted commencing dose:
     > 60 to 70 years - 4.5mg/day
     > 70 to 80 years - 4.0mg/day
     > 80 to 90 years - 3.5mg/day
     (Source: Sullivan Nicholaides Pathology)




Liverpool Stroke Unit Warfarin Management guidelines adapted from the Alfred Hospital Melbourne,   Page 1 of 10
Yarrawonga Health Service and Armidale Health Service, WA by the” Safer Systems Saving Lives”
project. Warfarin management in acute stroke patients. February 2006
                                                            (If Pre-Treatment INR, Hepatic Function and
TABLE 1                                                              Serum Albumin are Normal)
                                                                Day             INR              Dose
                                                                 1              <1.4             5 mg
Dosage Adjustment in a Patient Starting                                              <1.8                 5 mg
Warfarin                                                         2                 1.8 to 2.0             1 mg
                                                                                     >2.0                  Nil
Ensure the Patient is Entering Warfarin Dose                                         <2.0                 5 mg
and INR in the Warfarin Booklet and has                                            2.0 to2.5              4 mg
Acknowledged Education (See Page 6)                                                2.6 to2.9              3 mg
                                                                 3                 3.0 to3.2              2 mg
                                                                                   3.3 to3.5              1 mg
                                                                                     >3.5                  Nil
                                                                                     <1.4                 10 mg
                                                                                   1.4 to 1.5             7 mg
Based on Gedge et al a Comparison of a Low                                         1.6 to 1.7             6 mg
                                                                                   1.8 to 1.9             5 mg
Dose Warfarin Induction Regimen with the
                                                                 4                 2.0 to 2.3             4 mg
Modified Fennerty Regimen in Elderly Patients                                      2.4 to 3.0             3 mg
[Age Ageing 2000; 29:31-4]                                                         3.1 to 3.2             2 mg
                                                                                   3.3 to 3.5             1 mg
                                                                                     >3.5                  Nil
                                                           Dosage Adjustment After Day 4 Depends on
                                                                      Clinical Judgement

2.   MONITORING
    Daily INR monitoring and warfarin dose adjustment is necessary until the INR is therapeutic
     and stable.
    Blood should be collected for INR on the morning blood collection round. (Write Request
     Form previous day.)

3.   DRUG INTERACTIONS
    Certain drugs may increase or decrease the effect of Warfarin and the risk of bleeding/
     thrombosis (Table 2).
    When starting or stopping a drug, particularly antibiotics, the INR must be checked 1 to 2
     days after the change in therapy.

                                 SOME MAJOR DRUG INTERACTIONS WITH WARFARIN
TABLE 2                                  INCREASED                                          DECREASED
                                      Effect of Warfarin                                        Effect of Warfarin
                        Anti-Platelet Agents               Analgesics
                     Abciximab (ReoPro), Aspirin,      Paracetamol (Large                       Ascorbic Acid
                       Dipyridamole, NSAIDs,           Doses ie. 4 to 7g Per                   (Large Doses)
                        Clopidogrel, Tirofiban           Week), Tramadol                          Vitamin K
                          COX-2 Inhibitors               Anticonvulsants                     Anticonvulsants
                        Celecoxib, Rofecoxib                Phenytoin                         Carbamazepine,
Check with                                                                                        Phenytoin
Pharmacy or                   Antibiotics                    Selective Serotonin                 Antibiotics
Via Clinicians       Cephalosporins, Macrolides,             Reuptake Inhibitors            Rifampicin, Rifabutin
Health              Metronidazole, Sulphonamides,                Fluoxetine
Channel                Quinolones, Vancomycin
(Micromedex)                  Antifungals                          Tricyclic                        Sedatives
if More               Itraconazole, Fluconazole,               Antidepressants                     Barbiturates
Information                  Ketoconazole
Required                    Antiarrythmics                           Raloxifene,
                        Amiodarone, Mexiletine,                      Tamoxifen
                               Verapamil
                           Herbal Medicines                       Quinine and               Herbal Medicines
                    Dong Quai, Garlic, Papaya, St                  Quinidine               Ginseng, Slippery Elm
                   Johns Wort, Ginkgo, Ginger and                                            Bark, Green Tea,
                   Garlic (Large Amounts), Guarana                                           Co-Enzyme Q10


Liverpool Stroke Unit Warfarin Management guidelines adapted from the Alfred Hospital Melbourne,           Page 2 of 10
Yarrawonga Health Service and Armidale Health Service, WA by the” Safer Systems Saving Lives”
project. Warfarin management in acute stroke patients. February 2006
4.   INR GREATER THAN THERAPEUTIC RANGE
    If INR is greater than the therapeutic range, see Table 3 for management.
    Contact prescribing doctor if INR > 6 and / or there is any bleeding during Warfarin therapy.

TABLE 3 :
                                                        BLEEDING


                                           NO                                                        YES




            INR < 5                   INR >5 TO <9                       INR >9                     INR >15
                                                                                                      OR
       Withhold Warfarin            Withhold Warfarin               Withhold Warfarin          Life Threatening
          Check INR                       Give                          and Give                  Bleeding or
          at 24 Hours                2mg Vitamin K                     5mgVitamin             Warfarin Overdose
        (No Vitamin K)                   (Oral)                           (IV)
      Resume Warfarin at
       Lower Dose when                                                                              Give
            INR is In                      OR                          Check INR              10mg Vitamin K (IV)
      Therapeutic Range             IF Rapid Reversal                  at 6 Hours              Supplement with
                                        Necessary                                                    FFP
                                           Give
            If Rapid                  4mg Vitamin K
      Reversal Necessary                                                If INR >4
                                          (Oral)                                                   Check INR
         (ie. Surgery)
                                                                         Give                      at 6 Hours
                                                                     5mg Vitamin K
                                       Check INR                          (IV)
             Give                      at 24 Hours
         2mg Vitamin K                                                                             If INR >4
            (Oral)
                                                                   Recheck at 6 Hours              Give
                                        If INR >4                                              10mg Vitamin K
                                                                   Then Daily for Three
                                                                         (3) Days                   (IV)
                                         Give
                                                                      (If INR Rises
                                     2mg Vitamin K
                                                                     LMO to Assess)
                                        (Oral)                                                  Recheck INR at
                                                                                              6 Hours Then Daily
                                                                                              for Three (3) Days
                                    Resume Warfarin                 Resume Warfarin                If INR >4
                                     at Lower Dose                   at Lower Dose             LMO to Assess -
                                        When In                         When In               Repeat Vitamin K
                                   Therapeutic Range               Therapeutic Range             as Necessary




     Oral Vitamin K tablets should not be used as only 10mg tablets are available. Use the IV
      injection (Konakion MM) solution orally.
     For oral administration give undiluted.
     For some conditions such as prosthetic heart valves, the degree of reversal must be decided
      on an individual basis.      All patients with bleeding should be evaluated to identify local
      anatomical reasons for bleeding. It may be advisable to consult HMO.
NOTE:
Clinical judgement to be used when assessing a patient’s severity to bleeding. Heparin to be
initiated when Vitamin K has been administered in excessive doses making the patient
unresponsive to Warfarin therapy. Heparin to be continued until Warfarin becomes therapeutic.

Notes on Vitamin K Administration:
  Use of Vitamin K may be followed by a period of Warfarin resistance. If after cessation of
   bleeding, anti-coagulation is once again necessary, eg. in patients with mechanical heart
   valves, Heparin may be required until INR levels are once again therapeutic.
    Do not mix ampoules of Vitamin K with other infusion solutions.

5.   DISCHARGE INSTRUCTIONS
    Discharging Medical Officer is responsible for Discharge Summary. Information to include:
     >      target INR;
     >      Warfarin dose;
     >      date of next test; and
     >      proposed duration of treatment.
     Include this information in the Discharge Summary.
Liverpool Stroke Unit Warfarin Management guidelines adapted from the Alfred Hospital Melbourne,               Page 3 of 10
Yarrawonga Health Service and Armidale Health Service, WA by the” Safer Systems Saving Lives”
project. Warfarin management in acute stroke patients. February 2006
    The ‘Warfarin Therapy Chart’ should be given to the patient and a copy to the patient’s GP,
     and the discharge checklist on the back of this chart should be completed and signed.
    The ‘Discharge Instructions’ should be completed by a medical officer and given to the
     patient.
    The ‘Patient Education and Discharge Management’ should be completed and
     counselling provided by the clinical pharmacist or appropriate Registered Nurse. A ‘Warfarin
     Alert Card’ and ‘Important Information for Patients’ should be given to the patient.

TABLE 4
SUGGESTED TREATMENT TIMETABLE
Timeline   Management Plan
                   Full Blood Count (FBC)
                   International Normalised Ratio (INR)
Pre
                   Activated Partial Thromboplastin Time (APTT)
Treatment
                   Biochemistry
                   Liver Function Test
Commencing         Oral Warfarin as Per Age Adjusted Nomogram
Day 1              S/C Enoxaparin (Clexane) 1mg/kg bd
                   Oral Warfarin as Per Age Adjusted Nomogram
Day 2
                   S/C Enoxaparin (Clexane) 1mg/kg bd
                   Full Blood Count (FBC)
                   International Normalised Ratio (INR)
Day 3
                   Oral Warfarin as Per Nomogram
                   S/C Enoxaparin (Clexane) 1mg/kg bd
                   Full Blood Count (FBC) - If Indicated
                   International Normalised Ratio (INR)
Day 4
                   Oral Warfarin as Per Nomogram
                   S/C Enoxaparin (Clexane) 1mg/kg bd
                   Full Blood Count (FBC) - If Indicated
                   International Normalised Ratio (INR) - If Indicated
Day 5
                   Oral Warfarin as Per Nomogram
                   S/C Enoxaparin (Clexane) 1mg/kg bd
                   Full Blood Count (FBC) - Note Platelets
                   International Normalised Ratio (INR) - If Indicated
Day 6              Cease S/C Enoxaparin (Clexane) 1mg/kg bd if INR is Therapeutic for the Previous 48
                   Hours (INR Range 2-3)
                   If INR Not Therapeutic Range Administer S/C Enoxaparin (Clexane) 1.5mg/kg
                   Full Blood Count (FBC) - If Indicated
                   International Normalised Ratio (INR)
Day 7
                   Cease S/C Enoxaparin (Clexane) 1mg/kg bd if INR is Therapeutic for the Previous 48
                   Hours (INR Range 2-3)
                   Continue Warfarinisation for at Least 3 Months
Post First         Check International Normalised Ratio (INR) Weekly as Appropriate
Week               GP / MO May Wish to Discuss Future Management and Duration of Treatment with a
                   Specialist Physician

6. RENAL IMPAIRMENT
The following dosage adjustments are recommended for the treatment dosage ranges. This
dosing applies to patients with a creatinine clearance of less than 30mL/min.
                                                                          Severe Renal Impairment
Drug                        Normal Dosing                                 Creatinine Clearance Less Than
                                                                          30mL/min
Enoxaparin                  1 mg/kg Twice Daily                           1 mg/kg Once Daily
Enoxaparin                  1.5 mg/kg Once Daily                          1 mg/kg Once Daily
Although no dosage adjustment is recommended in patients with moderate (creatinine
clearance 30-50mL/min) and mild (creatinine clearance 50-80mL/min) renal impairment,
careful clinical monitoring of potential bleeding complications is advised.


Liverpool Stroke Unit Warfarin Management guidelines adapted from the Alfred Hospital Melbourne,   Page 4 of 10
Yarrawonga Health Service and Armidale Health Service, WA by the” Safer Systems Saving Lives”
project. Warfarin management in acute stroke patients. February 2006
COMPILED BY

    Safer Systems Saving Lives Collaboration. Liverpool Hospital. Warfarin in acute stroke
     patients program (WASPP) working party. April 2006
    Pharmacy Department in consultation with the Medical Services and the Pharmacy
     Advisory Committee.
    Armadale Health Service.

With reference and acknowledgements to:
    The Western Hospital Anti-coagulation and Thromboembolism Prophylaxis (Guidelines
     for), 1999.
    North Western Health, Prescriber Guidelines for Initiation of Full Anti-coagulation, 1999.
    The Alfred, Guidelines on the Use of Anticoagulants. 1998.
    Adapted from Wimmera Warfarin Therapy Chart in: Wimmera Clinical Risk Management
     - A Systematic Approach To Reducing Medical Errors. Wimmera Health Care Group,
     2001.




Liverpool Stroke Unit Warfarin Management guidelines adapted from the Alfred Hospital Melbourne,   Page 5 of 10
Yarrawonga Health Service and Armidale Health Service, WA by the” Safer Systems Saving Lives”
project. Warfarin management in acute stroke patients. February 2006
       LIVERPOOL HOSPITAL                                              PATIENT IDENTIFICATION

         HEALTH SERVICE                           UNIT RECORD NO: …………………………………………………….…………….

                                                  SURNAME: …………………………………………………………………………….
    PATIENT EDUCATION &
   DISCHARGE MANAGEMENT                           GIVEN NAMES:………………………………………………………….…………….

                                                  DATE of BIRTH: ………….../………....../…………...          Sex ……….……………..
       Date: ……………………………………..                                            (Or Affix Patient Label)

Education to begin at commencement of Warfarin Therapy including ongoing completion of the booklet               by the
patient. Only check patient’s knowledge twice if patient answered ‘no’ to any question in first session.
OBJECTIVES OF EDUCATION : Prior to Discharge the Patient Will be Able to:
1. Indicate that He/She has a Warfarin Education Booklet/ information sheet                             Yes      No
2. State that He/She has Read the Booklet/information sheet                                             Yes      No
3. Demonstrate that the Documentation of the Dose and INR in the Warfarin                               Yes      No
    Booklet/information sheet is up to Date
4. Explain the Action of Warfarin
 Anticoagulant drug, used to prevent or treat thrombosis by decreasing the clotting power of the       Yes      No
    blood.
5. Answer the Following Questions Regarding Warfarin
 Are you aware there are two brands of Warfarin? (Yes)                                                 Yes      No
 State the brand that you are on (Marevan / Coumadin).                                                 Yes      No
 Are the two brands the same? (No)                                                                     Yes      No
 Can you swap between brands? (No)                                                                     Yes      No
6. State: (a) Why He/She is Taking Warfarin
              (b) The Length of Time Required to Take Warfarin
 To prevent clot formation around the prosthetic or bioprosthetic valve.                               Yes      No
 To prevent the recurrence of deep vein thrombosis (DVT).                                              Yes      No
 To prevent clot formation in heart (Atrial Fibrillation).                                             Yes      No
 Length of time (see “planned duration” on Page 3).                                                    Yes      No
7. Identify the 3 manufactured doses of Warfarin brand he/she is taking:
 Coumadin 1 mg - Light Tan; 2 mg - Lavender; 5 mg - Green                                              Yes      No
8. State: (a) When to take Warfarin
 With the evening meal every day - use a calendar.                                                     Yes      No
              (b) Why it is Important to Take the Drug at the Same Time Every Day
 To maintain consistency for checking of INR.                                                          Yes      No
9. Outline the Steps to Take if They Forget to Take their Dose of Warfarin at 6.00pm
 If patient remembers within two to three hours they can take Warfarin.                                Yes      No
 If longer don’t take Warfarin, take next dose when it is due and tell your doctor or laboratory.      Yes      No
10. Outline When Blood Tests are Required at Home
 Every 2nd day until INR is stabilised, then as directed by the GP or Pathology Service.               Yes      No
11. Identify Significant Signs of Bleeding
 Obvious bleeding ie. cuts, nosebleed, bleeding gums.                                                  Yes      No
 Less obvious bleeding – urine, faeces, vomit and coughing.                                            Yes      No
12. State What He/She Will do in the Event of Signs of Bleeding
 Call the GP promptly.                                                                                 Yes      No
13. Identify other Medications that May Interfere with the Way that Warfarin Works
 Prescription medications and over the counter medications eg. aspirin, paracetamol or other pain      Yes      No
    medications, rubs, liniments, cold or cough preparations.
 Antacids, laxatives, multi-vitamins (may contain Vitamin K).                                          Yes      No
 Herbal medications.                                                                                   Yes      No
14. Identify Illnesses that Require Reporting to Their GP
 Diarrhoea, vomiting.                                                                                  Yes      No
 Infection or fever.                                                                                   Yes      No
 Pain, swelling or discomfort.                                                                         Yes      No
15. Understand Significant Dietary Facts
 Maintain a well balanced and consistent diet – Avoid crash dieting and binge eating.                  Yes      No
 Stabilise intake of Vitamin K. This includes green leafy vegetables.                                  Yes      No
 If taking vitamin or herbal supplements discuss with GP or pharmacist.                                Yes      No
 Take alcohol in moderation.                                                                           Yes      No
16. Understands the Discharge Instructions Sheet Completed by the Doctor                                Yes      No
17. Patient has had Warfarin Education with Pharmacist/RN                                               Yes      No
Pharmacist's Signature:                                                    Date:
Staff Members Signature:                                                   Designation:
SEND COMPLETED FORM TO PHARMACY                                                                        Issued: July 2004


                                                                                                            Page 6 of 10
          LIVERPOOL HOSPITAL                                                          PATIENT IDENTIFICATION

            HEALTH SERVICE                                UNIT RECORD NO:         …………………………………………………….…………


   WARFARIN THERAPY CHART                                 SURNAME:        …………………………………………………………………………

                                                          GIVEN NAMES:        ………………………………………………………….…………
Name of GP: …………………………………………………….
Date: ………./………./……….                                      DATE of BIRTH:      ………….../…………...../…………...                   Sex ……….…………
Faxed: ………./………./……….. Faxed By: ……………….                                                (Or Affix Patient Label)

INDICATION:   Atrial Fibrillation Deep Vein Thrombosis  Pulmonary Embolism Prosthetic Valve
              Other: ……………………………………………………………………………………………………………………………
PRESCRIBER'S SIGNATURE:                           SURNAME (Print):


                              SUGGESTED THERAPEUTIC INR RANGES (TARGET INR)
Low Risk Mechanical Prosthetic Heart Valves                                                    2.0 to 3.0
High Risk Mechanical Prosthetic Heart Valves                                                   2.5 to 3.5
All other indications                                                                          2.0 to 3.0
This data should be                Date                                                 Planned           Usual Maintenance
                                                              Target INR
included in the Discharge      Commenced                                                Duration                Dose
Summary and the Warfarin
Booklet
INSTRUCTIONS FOR USE:
1. This WARFARIN THERAPY CHART must be used for EVERY patient on oral Anticoagulant Therapy.
2. The doctor should write in the Regular Medications section of the Medication Chart “SEE WARFARIN THERAPY
   CHART” or should apply the Warfarin sticker provided. If this is not done, then a nurse or pharmacist should do
   it.
3. YDHS ‘Guidelines for Anti-Coagulation Using Warfarin’ should be used when prescribing warfarin, which are
   available on all wards.
4. If patient's Marevan is unavailable, only Coumadin is kept at YDHS, so use Patient's own.
                      TREATMENT ORDERS / TELEPHONE ORDERS / RECORD OF TREATMENT
                                                    Time to                                      Administered
                         WARFARIN
   Date         INR                      Dosage       be          Nurse's Signature                                        Doctor's Signature




                                                                                                                                                WARFARIN THERAPY CHART
                         (Coumadin)                                                       Date      Time        Initial
                                                     Given
                         WARFARIN             mg     1800
                         WARFARIN             mg     1800
                         WARFARIN             mg     1800
                         WARFARIN             mg     1800
                         WARFARIN             mg     1800
                         WARFARIN             mg     1800
                         WARFARIN             mg     1800
                         WARFARIN             mg     1800
                         WARFARIN             mg     1800
                         WARFARIN             mg     1800
                         WARFARIN             mg     1800
                                                                                                                                                MR/168




                         WARFARIN             mg     1800
                         WARFARIN             mg     1800
                         WARFARIN             mg     1800
                         WARFARIN             mg     1800

NEXT INR DUE AM ON: ……………………………………………………………………….. (Day and Date)
                                      COPY TO BE GIVEN TO PATIENT ON DISCHARGE




C:\Docstoc\Working\pdf\7e35bf09-6be3-43a5-9543-98d8e825663f.doc                                                                 Page 7 of 10
DISCHARGE CHECKLIST
The following checklist must be completed and signed prior to the patient being discharged
from Yarrawonga District Health Service. The relevant documentation is available in the
'Medication Procedures Manual' or in the 'Clinical Procedures Manual'.

                                                                                 Sign When
                                                                                 Completed
1.   The ‘Discharge Instructions’ should be completed and given to the
     patient.
2.   The ‘Patient Education and Discharge Management’ should be
     completed, with counselling provided or organised with the clinical
     pharmacist or Nurse.
3.   The ‘Warfarin: Important Information for Patients’ and a blue ‘Warfarin:
     Important Instructions for Patients’ book should be given to the patient.
4.   A ‘Warfarin Alert Card’ should be produced and given to the patient.

WARFARIN ALERT CARD SAMPLE
A personalised plastic ‘Warfarin Alert Card’ should be organised for the patient through the
ward pharmacist prior to discharge. If the patient is being discharged over the weekend, the
card can be sent to them. The following is a sample of what the card will look like:

      WARFARIN PATIENT                        IMPORTANT PATIENT
          DETAILS                                INFORMATION
Name: ……………………………………..
                                           Immediately consult doctor if
                                            increased     bruising,   blood
Indication: …………………………………                   stained vomit/urine, dark bowel
                                            actions,      nose        bleed,
Recommended INR: ……………………..                 headache/dizziness,
                                            joint/muscle /stomach / back
Expected Duration                           pain, leg weakness/numbness.
of Treatment: …………………………….
                                           Always attend for regular blood
Doctor: ……………………………………                      tests (INR).
                                           Ensure your doctor orders more
Please Show This Card When
                                            frequent   INRs     &     adjusts
Presenting    to     Hospital   &/or
Emergency     Department,     Doctor,       warfarin dose when new
Pharmacist or Dentist                       medications are started /
                                            stopped, regular medication
If this Card is Found Please Return         doses are changed or with
to Liverpool Hospital Health                reduced oral intake, illness and
Service Pharmacy Department (02)            vomiting.
98283000




                                                                                   Page 8 of 10
WARFARIN: IMPORTANT INFORMATION FOR PATIENTS
WARFARIN ALERT CARD
Please present this Card when attending for treatment or seeking advice from your doctor,
dentist, pharmacist, physiotherapist, occupational therapist or any other health practitioner.

INR BLOOD TESTS
After leaving hospital, your next INR test is due on: …………………………………… This test
can be performed by your local doctor, pathology laboratory. You must contact your Doctor
when you have your INR results to find out what your Warfarin dose should be.

WARFARIN
Warfarin belongs to a class of drugs known as anticoagulants, or ‘blood thinners’. It helps to
prevent the blood from clotting in your blood vessels (ie. arteries and veins).

There are TWO different brands of Warfarin, they are Marevan and Coumadin. (Yarrawonga
District Health Service only prescribes the Coumadin brand.)

Always use the same brand of Warfarin: do not swap Coumadin tablets for Marevan.

WARFARIN DOSE
Warfarin is prescribed in milligrams. There are THREE different strengths of Coumadin:

   1mg Tablets: Light Tan Colour
   2mg Tablets: Lavender Colour
   5mg Tablets: Green Colour

Ensure you take the correct tablets by checking the colour and strength against the
dose prescribed by your doctor.

ADMINISTRATION TIME
Take the exact number of tablets prescribed under your doctor’s direction at the same time
each day. If you forget your regular daily dose, you may take that dose within 2-3 hours of
missing that dose. If 2-3 hours has already passed, please consult your doctor. Do not take
an extra dose on the next day.

LABORATORY TESTS
The safety and effectiveness of Warfarin must be monitored regularly by performing INR
blood tests. Your doctor will order these to ensure the correct amount of Warfarin is
prescribed.

The INR blood level should be measured every 1 to 2 days if:
   Starting warfarin for the first time.
   Starting warfarin again, after having stopped it for a surgical procedure or other reason.
   Starting on new medicines or herbal preparations that are prescribed by your doctor or
    bought over-the-counter (without a prescription).
   Stopping any prescribed or over-the-counter medicines or herbal preparations.
   You are eating less for any reason (eg. with illness, vomiting, fasting for religious
    reasons).

Consult your doctor & request an INR test if any of the above situations arise.




                                                                                    Page 9 of 10
After your INR test:
1.   Phone your doctor (or the laboratory where the test is performed) on the day
     your INR test is taken, and ask what, if any, dose adjustment is required.
2.   Write down the INR result and any dosage changes in your record book.
Once the INR result is stable, your INR may be monitored less frequently (usually
once every two to four weeks, depending upon your particular situation).

OTHER MEDICATIONS
Other medications may change the blood-thinning effect of warfarin. This includes
medicines that are prescribed by your doctor or bought over-the-counter without a
prescription (eg. Aspirin, cold and cough mixtures, laxatives, antacids, herbal, and
vitamin preparations).
If you take warfarin, please tell your doctor all the medicines and other
remedies you are taking. Please ensure you read the section on Laboratory
tests and the need for regular INR test if you start, stop, or change
medications.

DIETARY PRINCIPLES
    Avoid crash dieting and binge eating. Use alcohol in moderation - avoid binge
     drinking.
    If taking laxatives or antacids, use in moderation and discuss this with your
     doctor.
    Green leafy vegetables may be eaten in moderation (these contain Vitamin K,
     which opposes the action of Warfarin).

SURGICAL PROCEDURES
Your Warfarin may need to be stopped well before your surgery, dental work or
medical procedure (eg. Gastroscopy, colonoscopy, arthroscopy, emergency room
treatment after injury). At your first appointment please tell the doctor/dentist
performing your procedure that you are taking warfarin.

TRAVEL
Please ensure that your doctor provides you with a letter, and arranges for an INR
test and follow up with another doctor during your period of travel.

PREGNANCY
Warfarin should not be taken if you are pregnant, or are considering becoming
pregnant. If you become pregnant, you must report to your doctor immediately.
Please discuss an alternative type of anticoagulant therapy with your doctor.

SIGNS OF BLEEDING
Warfarin acts as a blood thinner and therefore it increases the risk of bruising and
bleeding.
Please attend your doctor or a hospital emergency department immediately if
you experience:
                               Red or dark urine or bowel actions.
                               Blood-stained vomit.
Less Obvious Signs:            Joint, muscle, stomach or back pain.
                               Leg weakness or numbness.
                               Headache, visual disturbance or dizziness.


                                                                                 Page 10 of 10
                             ANY OTHER UNUSUAL FEATURES.
                             Any bleeding that does not stop by itself (eg prolonged bleeding
                              from cuts).
Obvious Bleeding:            Nosebleeds.
                             Bleeding of gums from brushing.
                             Increased menstrual flow, vaginal bleeding.
Bruising:                    Increased or new appearance of black or blue bruise marks.

Acknowledgement to the Yarrawonga District Health Service Pharmacy Department,
the Alfred Hospital in Melbourne, and Armadale Hospital.




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