Warfarin (Coumadin©)
Name:	Indication:	Follow Up Notes:	

			

Warfarin (Coumadin®) is an anticoagulant medication, also called a blood thinner. Warfarin works to slow down blood clotting to an extent that prevents abnormal clots from developing or present clots from getting bigger. 

Warfarin therapy may be managed by your doctor, a pharmacist, nurse practitioner, or an anticoagulation clinic. In this document, we will refer to the person who is helping you manage your warfarin therapy as your “care provider”.

How often do I need to have my blood checked to prevent clots and bleeding?

•	A blood test called an INR is required to ensure your warfarin is working safely and effectively. An INR is required frequently at the start of warfarin therapy, then less frequently once your warfarin dose stabilizes. INRs are required at least once per month yet may be required more frequently if your INR is out of range. 
•	Your target INR is: 	to 	
•	Your warfarin dose may need to change from time to time depending on your INR result.
•	If your INR is above your target, your risk of bleeding will increase.
•	If your INR is below your target, you may have an increased chance of developing a clot.
•	 Diet, Illness, Medications, Errors such as missed doses or Events such as bleeding, bruising are important to report. Write down and report all changes in DIME (E) warfarin dose changes and the due date for the next INR.

How should warfarin be taken?

•	Warfarin should be taken around the same time every day exactly the way your care provider has told you to. It may be taken with food, or on an empty stomach, and may be taken with other medications; in other words, warfarin does NOT need to be taken separate from other medications.
•	The amount of warfarin that each person needs is different. Dose changes are often needed.
•	Warfarin comes in different colored pills; each color represents a different strength in milligrams (mg).
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•	Depending on your warfarin dose, you may need to break the tablets into halves or quarters. A pill cutter is recommended.
•	Check your tablet color before leaving the pharmacy. If your tablets look different than usual, talk to the pharmacist. The shape and color should not change unless your doctor tells you he/she is changing it.
What if I miss a dose?

•	If you miss a dose, take it soon as you remember later that day. Please tell your health care provider with your next INR test if any dose was missed between testing dates. If you have missed more than 2 doses, promptly tell your care provider as many missed doses may affect your INR.

What can change the effect of warfarin?

•	Diet – Warfarin works by disrupting the role of vitamin K (found mainly in green vegetables) which in return slows down blood clotting. However Vitamin K is an essential nutrient for your health. It is strongly encouraged that people eat green vegetables daily – do not restrict your intake of these healthy foods. Consistency in your diet is key. 
o	Alcohol -Having one or two alcoholic drinks a day is OK but do not binge drink. 
•	Illness - if you get sick with a cold, flu, vomiting, diarrhea or any other illness, your INR may be affected. Call your care provider if you have a new illness that lasts for more than 2-3 days as this could affect your warfarin effect. It is important to check your INR during this time as you may require a temporary dose adjustment until you recover. 
•	Medications - any change in medications, including dose changes, may affect your INR. This includes prescription medicines, over-the counter medicines, and herbal products. Be sure your doctor/pharmacist is aware you are taking warfarin. If you have any medication change, including dose changes or starting antibiotics you may need to check your INR within 3 days. Ask your care provider or pharmacist about this. Aspirin, drugs containing aspirin or medicines similar to aspirin may be harmful when taking warfarin as it can increase the risk of bleeding.
o	Below is a list of common medications that should be discussed with your doctor. Pain relievers, such as:
•	Excedrin®
•	Naproxen (Aleve®)
•	Ibuprofen (Advil®, Motrin®, Nuprin®, Midol®, Pamprin HB®)

•	Errors such as missed doses of warfarin - missing one or more doses may affect your INR. If you miss a dose, take the missed dose as soon as you remember. However, do NOT take a double dose the next day to make up for a missed dose. 

•	Events: Possible Side Effects- The major side effect of warfarin is bleeding. It is important to monitor your INR level so it is in the right range. If you become pregnant while taking warfarin, or if you plan to become pregnant while taking warfarin, contact your care provider.

If at any point you check your INR and it is greater or equal to 4.5, refer to eKite resources on the Kidclot.com website Module 6 on Warfarin Self-Management Series.  

Mild Bleeding
•	Nosebleeds - If your nose starts bleeding, pinch the nose and hold tightly for 10 minutes without stopping. If still bleeding, pinch and hold for another 10 minutes. If still bleeding with no improvement, seek medical attention immediately. 
•	Menstrual bleeding that is heavier than normal
•	Easy bruising
•	Bleeding after a cut that takes a little longer to stop.
•	Bleeding from the gums may be reduced by using a soft toothbrush.

Major Bleeding – Seek medical attention immediately. 
•	Red, pink or coffee colored urine
•	Red or black bowel movements
•	Coughing or vomiting up blood 
•	A serious fall or hit to the head
•	A severe headache with nausea or vomiting
•	Any bleeding that won’t stop with pressure application.
•	Unusual bruising for unknown reasons that grow darker or spread 

Safety 

Exercise is important to staying healthy. Continue your regular exercise but remember that, when you are taking warfarin, your risk of bleeding with injury is higher

•	Be sure to wear appropriate protective gear and receive appropriate training with sports (i.e. helmet with biking)
•	Avoid sports where injuries or falls are common (i.e. competitive contact sports) 
•	You may have your immunizations and flu shots while on warfarin. Apply pressure to the immunization site for 10 minutes after your immunization to prevent bleeding.
•	Be sure to contact your care provider if you have any scheduled surgical or dental procedures at least 7 days before the procedure.