PATIENT EDUCATION GUIDE TO WARFARIN - Hamad

PATIENT EDUCATION GUIDETO WARFARIN

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PATIENT EDUCATION GUIDE TO WARFARIN

Table of Contents

Warfarin: General information l What is warfarin? 3l What is the difference between Coumadin®, Marevan®

and other warfarin brands? 3l How does warfarin work? 3l What is warfarin used for? 3l What does your doctor or pharmacist need to know about

your medical condition BEFORE prescribing warfarin for you? 4l How should I take warfarin? 4l What dosage of warfarin should I take? 4l How long will I need to take warfarin? 4l What should I do if I missed taking my prescribed warfarin dose? 5l How should I store warfarin? 5l Who should not take warfarin? 5l What does an allergic reaction to warfarin look like? 5l What are the possible side effect(s) of warfarin? 6l What are the signs of major bleeding? 6l How long does it take for warfarin to work? 6

INR monitoring l How can the effect(s) of warfarin be monitored? 7l Where and when should I check my INR? 7l How can I get the INR blood test appointments? 7l What may happen if I have a low INR or if I stop taking

my warfarin? 7

Warfarin-medication interactions l What medications can interact with warfarin? 9l What medications are NOT safe to be taken with warfarin? 9

Warfarin-herbal interactions 11

Warfarin and diet 12

Warfarin and alcohol 18

Warfarin and surgery/dental procedures 18

General lifestyle considerations 18

General recommendations 19

References 20

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WARFARIN

What is warfarin?

Warfarin (warf-ah-rin) sodium is the generic name of the medication. Coumadin® (Koo-muh-din) is the brand name.

Warfarin belongs to the anticoagulant or “blood thinner” group of medications. It prevents the formation of blood clots in blood vessels and keeps clots from getting larger; it does not dissolve existing blood clots.

What is the difference between Coumadin®, Marevan®, and other warfarin brands?

All of these brands contain warfarin. Inactive ingredients may vary between each brand. Switching between different brands may lead to a difference in International Normalized Ratio (INR) levels; INR is a test obtained from measurements of the time it takes blood to clot. It is recommended to be consistent with the same brand.

1 mg Coumadin®(pink, round)

2 mg Coumadin®(purple, round)

5 mg Coumadin®(peach, round)

3 mg Marevan® (blue, round)

Available brands and commonly prescribed strengths at Hamad Medical Corporation (HMC)

How does warfarin work?

The formation of a clot in the body is a complex process that involves multiple substances called clotting factors. Warfarin decreases the body’s ability to form blood clots by blocking the activation of vitamin K to its active form; vitamin K is essential to the formation of blood clots and is needed to prevent bleeding.

What is warfarin used for?

Warfarin is used to prevent the formation of blood clots in certain medical conditions: l Atrial fibrillation (a rapid disturbance of heartbeat). l Heart attack with clots in the left ventricle. l Heart valve disease or heart valve replacement. l Deep venous thrombosis (a blood clot in the arm or the leg). l Pulmonary embolism (a blood clot in the lungs).

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What does your doctor or pharmacist need to know about your medical condition BEFORE prescribing warfarin for you? l If you have an allergy to warfarin or any other ingredient of the medication. l If you are pregnant, may be pregnant, or are planning to become pregnant. l If you are breastfeeding. l If you drink alcohol. l If you fall often. l If you have past or present bleeding problems. l If you have past or present stomach or intestinal problems. l If you have liver or kidney problems (dysfunction). l If you have high blood pressure or diabetes.

How should I take warfarin?

Take your medication at the same time every day. Take your medication with or without food (if it causes a stomach upset, take it with food).

Take your medication exactly as prescribed.

What dosage of warfarin should I take?

The doctor or the pharmacist who is treating your condition will determine the correct and suitable dose of warfarin. Each patient has his/her own dosing regimen.

How long should I take warfarin?

It depends on the medical condition that you have. Some conditions need a life-long treatment with warfarin, while others only require short-term use of warfarin.

Your physician will determine how long you need to take this medication.

EACH STRENGTH OF WARFARIN HAS A DIFFERENT COLOR AND SHAPE. CONTACT YOUR DOCTOR OR PHARMACIST IF YOU NOTICE ANY CHANGE IN THE COLOR OR SHAPE OF YOUR MEDICATION.

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PLEASE REPORT ANY SIGNS OF BLEEDING TO THE DOCTOR OR THE PHARMACIST WHO TREATS YOUR CONDITION.

What should I do if I missed taking my prescribed warfarin dose?

If you forget to take your prescribed warfarin dose and you remember during the same day, take it as soon as possible.If you forget to take your prescribed warfarin dose and you do not remember until the next day, do not take your missed dose; take only the next dose at the scheduled time (NEVER take two doses in the same day).

Keep track of all doses that you have missed and be sure to inform the doctor or the pharmacist who treats your condition. If you have missed a prescribed dosage and are concerned, or if you feel unwell, immediately call your doctor or pharmacist.

How should I store warfarin?

Warfarin should be stored in a closed container at roomtemperature, in a dry place, away from heat (do not leaveyour medication in the car); moisture, and direct sunlight(can affect the strength of your medication).

Keep all drugs out of the reach of children.

Who should not take warfarin?

Pregnant women, or women who are planning to become pregnant, should not take warfarin, unless prescribed by their physician.

What does an allergic reaction to warfarin look like?

Skin reactions (e.g. rash, itching, and hives) are the most common symptoms of an allergic reaction to warfarin.

Skin necrosis (death of tissue), shortness of breath, or purple toe syndrome are less common allergic reactions associated with taking warfarin (skin discoloration of hands and feet which may occur after 3 to 8 weeks).

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What are the possible side effect(s) of warfarin? Possible side effect(s) of warfarin include: l Minor bleeding from cuts or injuries. l Bleeding gum. l Menstrual bleeding (heavier than normal). l Nosebleeds. l Easy bruising. l Nausea and vomiting. l Red, pink, or brown urine. l Fever. l Hair loss (rare).

What are the signs/symptoms of major bleeding? The following may be signs of major bleeding: l Red or brown urine. l Red or black tar like stool. l Vomiting or coughing up blood. l Frequent nosebleeds, bleeding gums. l Unusual bleeding that doesn’t stop or is very heavy. l Unusual bruising. Severe headache or stomach ache. l Dizziness or weakness.

How long does it take for warfarin to work? Warfarin starts to prevent clots formation within 24 hours after the first dose. The full effect requires three to five days. Until the full effect is reached, your physician may prescribe an injectable blood thinner like heparin or enoxaparin (Clexane®).

IF YOU EXPERIENCE ANY SIGNS/SYMPTOMS OF MAJOR BLEEDING, STOP USING WARFARIN AND CALL THE EMERGENCY “999” IMMEDIATELY OR GO TO THE NEAREST EMERGENCY DEPARTMENT.

PLEASEREPORT ANY SIGNS OF BLEEDING TO THE DOCTOR OR THE PHARMACIST WHO TREATS YOUR CONDITION.

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INR MONITORING

How can the effect(s) of warfarin be monitored?

The effect(s) of warfarin is/are monitored by International Normalized Ratio (INR) blood test, where a very high INR may cause bleeding and a very low INR may cause clot formation. The INR therapeutic target is determined by your physician according to your medical condition.

Close INR monitoring will help your doctor or pharmacist to determine the appropriate dose of warfarin for you, to keep your INR within a therapeutic range.

Where and when should I check my INR? INR will be checked in Anticoagulation Management Service (AMS). Once you start your warfarin, INR will be checked two or three times per week. When INR level becomes stable (within therapeutic range), checking of the INR will be less frequent.

How can I get the INR blood test appointments?

Anticoagulation Management Service (AMS) will give you the next appointment date and time for INR checking.

What may happen if I have a low INR or if I stop taking my warfarin tablet?

A low INR, or stopping your warfarin without medical advice, may cause the development of blood clots that may block coronary arteries or may move to the legs, the lungs, or the brain, which may result in serious complications.

KEEPING APPOINTMENTS FOR INR CHECKING IS VERY IMPORTANT FOR MONITORING WARFARIN EFFECT.

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Signs of the development of blood clots include:

l Redness, pain, swelling or increased warmth in the arm, leg or foot.l New shortness of breath or chest pain.l Sudden slurred speech or difficulty in walking, arm weakness or numbness, drooping in the face or confusion.l Sudden visual changes or loss of sight in either eye.l Sudden dizziness or faintness.l Sudden sever headache. If you develop any of the mentioned signs, call for emergency assistance “999” immediately or go to the nearest emergency department.

IT IS VERY IMPORTANT TO BE COMMITTED TO YOUR APPOINTMENTS AND TO STAY IN CONTACT WITH THE DOCTOR OR THE PHARMACIST WHO IS TREATING YOUR CONDITION.

IT IS VERY IMPORTANT TO INFORM THE DOCTOR OR THE PHARMACIST WHO IS TREATING YOUR CONDITION ABOUT ANY CHANGES TO YOUR CONTACT INFORMATION.

IF YOU HAVE ANY QUESTIONS OR CONCERNS ABOUT YOUR WARFARIN, CALL THE DOCTOR OR THE PHARMACIST WHO IS TREATING YOUR CONDITION.

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WARFARIN-MEDICATION INTERACTIONS

What medications can interact with warfarin? Warfarin can interact with many prescription medications, over the counter medications (OTC), any multi-vitamins containing vitamin K, or herbal supplements. The interactions can affect the safety and efficacy of warfarin.

What medications are NOT safe to be taken with warfarin?

Unsafe OTC medications include, but are not limited to:

l Aspirin containing products, unless prescribed by your physician.l Bismuth subsalicylate containing products (Antacids and antidiarrheal agents).l Ibuprofen and naproxen containing products (analgesics).l Menthol containing drops (cough).l Omeprazole containing products (antacids).

ALWAYS INFORM THE DOCTOR OR THE PHARMACIST WHO IS TREATING YOUR CONDITION BEFORE STARTING OR STOPPING ANY MEDICATION.

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Medications that may have a strong interaction with warfarin:

Some medications may increase or decrease INR or change the effect of warfarin, including antibiotics, anti-inflammatory agents and pain killers, anti-platelet agnets and antacids. You should inform the doctor or the pharmacist who is treating your condition about starting or stopping these medications (Table 1):

Table 1: Examples of common drugs that interact with warfarin

Acarbose (Glucobay®) Gemfibrozil (Lopid®) Propafenone (Rythmol®)

Acetaminophen (Adol®)* Ibuprofen (Brufen®) Propylthiouracil (Propycil®)

Acetaminophen (Panadol®)* Indomethacin (Indocin®) Ranitidine (Zantac®)

Allopurinol (Zyloric®) Isoniazid (Nydrazid®) Rifampin (Rifadin®)

Amiodarone (Cordarone®) Itraconazole (Sporanox®) Rosuvastatin (Crestor®)

Amitriptyline (Elavil®) Ketoconazole (Nizoral®) Sertraline (Zoloft®)

Aspirin (Aspirin®) Levofloxacin (Levaquin®) Simvastatin (Zocor®)

Azithromycin (Zithromax®) Mefenamic Acid (Ponstel®) Spironolactone (Aldactone®)

Carbamazepine (Tegretol®) Meloxicam (Mobic®) Sucralfate (Carafate®)

Celecoxib (Celebrx®) Mesalamine (Asacol®) SulfaSALAzine (Sulfazine®)

Cholestryamine (Questran®) Mesalamine (Pentasa®) Sulfonamides (Bactrim®)

Ciprofloxacin (Ciprobay®) Metronidazole (Flagyl®) Sulfonamides (Septra®)

Clarithromycin (Klacid®) Moxifloxacin (Avelox®) Tamoxifen) Nolvadex® (

Clopidogrel (Plavix®) Naproxen (Naprosyn®) Thyroxin (Euthyrox®)

Cloxacillin (Coxapen®) Norfloxacin (Noroxin®) Ticagrelor (Brilinta®)

Erythromycin (Erythrocin®) Omeprazole (Losec®) Tramadol (Tramal®)

Fenofibrate (Lipanthyl®) Oral contraceptives Voriconazole (Vfend®)

Fluconazole (Diflucan®) Phenytoin (Epanutin®)

Fluoxetine (Prozac®) Prasugrel (Effient®)

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Table 2: Examples of herbal products that increase the risk of bleeding

Agrimony Celery seed Ginger Quassia

Alfalfa Chamomile Ginkgo Red clover

Aniseed Chinese wolfberry Horse chestnut Sweet woodruff

Arnica flower Clove Horseradish Tonka beans

Artemesia Dandelion Licorice Turmeric

Asafetida Danshen Kava kava Wild carrot

Buchu Dong quai Meadowsweet Wild lettuce

Bogbean Fenugreek Melilot Willow

Bromelain Feverfew Passionflower

Capsicum Fish oil Prickly ash

Cassia Garlic Poplar

WARFARIN-HERBAL INTERACTIONS

Herbal products may contain varying amounts of the active ingredient, unlisted ingredients, or potential contaminants which may result in instability, inconsistent effects or toxicity.Herbal products may interact with warfarin as some may contain high levels of vitamin K and this can increase or decrease warfarin absorption (Table 2 and 3).

Aniseed

Garlic Ginger Licorice Tonka beans Kava kava

Chamomile Clove Fenugreek Horse chestnut

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WARFARIN AND DIET

l High level of vitamin K intake counteracts the warfarin effect and reduces the INR level to below the therapeutic range. This may lead to clot formation. l Low vitamin K intake may increase the INR level and increase the risk of bleeding.l Vitamin K naturally exists abundant in certain foods, such as green vegetables and some oils. l You should not avoid eating food rich in vitamin K if they are a part of your usual diet. Eating or drinking the same amount of vitamin K every day will help to have a better warfarin management.l Read nutritional labels and check the amount of vitamin K in the foods you consume. Enriched and fortified foods must be eaten with caution. Consult the doctor or the pharmacist who is treating your condition for a dietitian’s consultation.l Avoid grapefruit juice and cranberry juice, especially in large amounts, as they may raise INR significantly and may cause bleeding.

INFORM THE DOCTOR OR THE PHARMACIST WHO IS TREATING YOUR CONDITION IF YOU CHANGE YOUR DIET.

Table 3: Examples of herbal products that decrease the effect of warfarin

Coenzyme Q10 Ginseng St. John’s wort

Goldenseal Green tea Yarrow

Green tea Ginseng Echinacea -Goldenseal St. John’s Wort

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Examples of foods with high vitamin K content:

IT IS VERY IMPORTANT TO KEEP YOUR DIET AS CONSISTENT AS POSSIBLE.

Food ServingContent per measure (micrograms)

Food ServingContent per measure

Kale (cooked or drained)

130 gm (1 cup) 1146.6Mustard green (cooked or drained)

140 gm (1 cup) 829.8

Collards (cooked) 170 gm (1 cup) 1059.4Beet greens (cooked)

144 gm (1 cup) 697

Spinach (chopped or cooked)

190 gm (1 cup) 1027.3 Parsley, fresh10 gm (10 sprigs)

164

Turnip greens (cooked or drained)

164 gm (1 cup) 851

Kale (raw)

Mustard green (raw) Beet greens (raw) Parsley (raw)

Collards (raw) Spinach (raw) Turnip greens (raw)

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Endive (raw)

Examples of foods with moderate vitamin K content


Food ServingContent per measure(micrograms)

Brussels sprouts (cooked or drained)

155 gm (1 cup) 299.9 Coleslaw 99 gm (3/4 cup) 70.2

Broccoli (cooked or drained)

156 gm (1 cup) 220.1 Cabbage (raw) 70 gm (1 cup) 53.2

Onions, spring or scallions

100 gm (1 cup) 207 Mayonnaise13.8 gm (1 tablespoonful) 22.5

Lettuce, butterhead (raw)

163 gm (1 head) 166.7 Pine nuts 28.35 gm 15.3

Cabbage (cooked or drained)

150 gm (1 cup) 163.1 Margarine (regular)14.2 gm (1 tablespoonful) 13

Asparagus (cooked or drained)

180 gm (1 cup) 144 Canola oil14 gm (1 tablespoonful) 10

Endive (raw) 50 gm (1 cup) 115.5 Olive oil13.5 gm (1 tablespoonful) 8.1

Lettuce, green leaf (raw)

56 gm (1 cup) 70.7

Brussels sprouts

Cabbage (raw)

Broccoli (raw)

Asparagus (raw)

Onions, spring or scallions

Lettuce, butterhead (raw)

Lettuce, green leaf (raw)

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Coleslaw

Canola oil Olive oil

Mayonnaise Pine nuts Margarine

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Examples of foods with low vitamin K content:


Food ServingContent per measure(micrograms)

Okra (cooked or drained)

184 gm (1 cup) 88 Kiwifruit76 gm (1 medium)

30.6

Prunes (dried) 248 gm (1 cup) 64.7Cauliflower (cooked or drained)

180 gm (1 cup) 21.4

Celery (cooked or drained)

150 gm (1 cup) 56.7Beans, snap (cooked or boiled)

125 gm (1 cup) 20

Beans, snap (green)

135 gm (1 cup) 52.5 Carrots (raw) 110 gm (1 cup) 14.5

Rhubarb (cooked) 240 gm (1 cup) 50.6 Cashew nuts28.35 gm (18 nuts)

9.8

Cucumber (raw) 301 gm (1 large) 49.4 Chickpeas (boiled) 164 gm (1 cup) 6.6

Carrot juice (canned)

236 gm (1 cup) 36.6 Avocado (raw) 28.35 gm 6

Soybeans (boiled) 172 gm (1 cup) 33Lentils seeds (boiled)

198 gm (1 cup) 3.4

Sauerkraut (canned)

236 gm (1 cup) 30.7Lettuce, green leaf (raw)

Prunes (dried)

Cucumber

Celery

Carrots (raw or juice)

Snap beans

Soybeans

Okra

Rhubarb

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Kiwifruit Cauliflower

Avocado Lentils seeds

Cashew nuts Chickpeas

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WARFARIN AND ALCOHOL

WARFARIN AND SURGERY/DENTAL PROCEDURES

GENERAL LIFESTYLE CONSIDERATIONS

Drinking too much alcohol can raise INR significantly and may cause bleeding. Be transparent with the doctor or the pharmacist who is treating your condition about the quantity and frequency of your drinking.

If you drink, Limit alcoholic drinks to one ounce per week (1 Ounce = 30 mL).

If you have any surgery or dental procedures, you may need to stop taking warfarin temporarily, under the supervision of the doctor or the pharmacist who is treating your condition.

Lifestyle modifications may affect your INR, so it is important to tell the doctor or the pharmacist who is treating your condition if: l You change the amount of your exercise activity. l You plan to travel. l You become pregnant or you think you may be pregnant. l You consume more than one ounce alcoholic drinks per week.

REMEMBER TO GET A CLEARANCE FORM FROM YOUR CARDIOLOGIST BEFORE GOING TO HAVE ANY SURGERY OR DENTAL PROCEDURES WHILE YOU ARE TAKING WARFARIN

INFORM THE DOCTOR OR THE PHARMACIST WHO IS TREATING YOUR CONDITION IF YOU PLAN TO HAVE ANY SURGERY, MEDICAL, OR DENTAL PROCEDURES.

INFORM THE DOCTOR OR THE PHARMACIST WHO IS TREATING YOUR CONDITION IF YOU DEVELOP ANY NEW MEDICAL CONDITIONS.

INFORM THE DOCTOR OR THE PHARMACIST WHO IS TREATING YOUR CONDITION IF YOU DEVELOP VOMITING, DIARRHEA, AND FLU LIKE SYMPTOMS, FEVER OR INFECTION.

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GENERAL RECOMMENDATIONS

GENERAL RECOMMENDATIONS

l Use a soft toothbrush to prevent gum bleeding. l Be cautious when handling a razor or sharp objects, including nail cutters. l Keep your home safe to avoid falls. l Wear warfarin medical alert identification at all times (Bracelet or necklace). l Contact the doctor or the pharmacist who is treating your condition before starting any activity that may cause injury. l It is recommended using a pill box as a reminder to take your warfarin.

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REFERENCES

1. Lexicomp:

http://online.lexi.com/lco/action/doc/retrieve/docid/multinat_f/4668998

2. USDA National Nutrient Database for Standard Reference (2012)

https://www.ars.usda.gov/SP2UserFiles/Place/12354500/Data/SR25/nutrlist/sr25w430.pdf

3. National Library of Medicine (Drug Information portal)

http://druginfo.nlm.nih.gov/drugportal/drugportal.jsp?APPLICATION_NAME=drugportal

If you will not able to come/ missed your appointment, contact us on this number (07:00 to 15:00

every day except Friday and Saturday)

Anticoagulation Clinic, Heart Hospital, HMC

4439 5802 / 33405953

[email protected]

© 2015 Hamad Medical Corporation

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PATIENT EDUCATION GUIDE TO WARFARIN - Hamad