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page 1 warfarin C O U M A D I N M A R E V A N IMPORTANT INFORMATION FOR PATIENTS (warfarin sodium) warfarin
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warfarin96 Merrindale Drive (Locked Bag 268)Croydon VIC 3136, Tel: (03) 9839 2800
Last revised: March 2010
C O U M A D I N M A R E V A N
IMPORTANT INFORMATION FOR PATIENTS (warfarin sodium)
warfarin
( )
AuthorsDr Leanne ChalmersLecturer in Therapeutics and Pharmacy Practice
Professor Gregory PetersonAssociate Dean Research, Professor of Pharmacy
Associate Professor Luke BereznickiDeputy Head, School of Medicine, Associate Head, PharmacyAssociate Professor in Pharmacy Practice
Pharmacy, School of Medicine and Unit for Medication OutcomesResearch and Education (UMORE)University of Tasmania
Contact details:Dr Leanne ChalmersPharmacy, School of Medicine, University of Tasmania, Private Bag 26, Hobart TAS 7001 Email: [email protected] note that we are unable to provide individual warfarin dosing advice. Your doctor (or the healthcare professional who manages your warfarin therapy) knows your medical history and is in the best position to offer you dosing advice. If you are unable to contact your usual healthcare professional, the emergency department of your local hospital may be able to assist you.
INDEX
TABLET PRESENTATION 2
ABOUT THIS BOOKLET 5
WARFARIN – AN OVERVIEW 6
WHAT IS WARFARIN? 8
A BIT MORE INFORMATION ABOUT ATRIAL FIBRILLATION 9
HOW DO YOU KNOW WARFARIN IS WORKING? INR TESTING 13
TAKING WARFARIN SAFELY 16
KEEPING YOUR INR STABLE 18
WARFARIN AND BLEEDING 31
WHERE CAN YOU FIND MORE INFORMATION? 35page 1
tABLEt PrEsENtAtIoN
There are two brands of warfarin available in Australia - Coumadin® and Marevan®.
Coumadin® and Marevan® are similar but NOT the same. There is no guarantee that you will obtain the same effect if you swap between brands. Unless directed by your doctor, you should always keep taking the brand you were first prescribed.
Both Coumadin® and Marevan® come in three different colours and each colour corresponds to a different strength. The strength is indicated by the number stamped on the tablet. Bottles of Coumadin® also have coloured lids and labels that match the tablet colour.
BE surE You ArE tAKING thE rIGht tABLEt BY ChECKING thE CoLour AND strENGth.
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You are taking: (cross out the brand that does not apply)*
Name:
Address:
Telephone:
Doctor: Telephone:
Brown 1 mg Blue 3 mg Pink 5 mg
Light Tan 1 mg Lavender 2 mg Green 5 mg
COUMADIN (warfarin sodium)
MAREVAN (warfarin sodium)
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PAtIENt INForMAtIoN
Reason for taking warfarin:
Warfarin brand:
Intended duration of warfarin therapy:
Date of commencement:
Target INR range:
Blood type:
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ABout thIs BooKLEt
Your doctor has prescribed you a medicine called warfarin. Warfarin is an “anticoagulant”, or anti-clotting medicine that is used to help prevent harmful blood clots from forming or to prevent worsening of existing clots. It has been used worldwide for over 60 years and is taken by many hundreds of thousands of people every day.
Warfarin therapy is highly effective but there is a lot you need to know to get the most benefit from it. This booklet is designed to help you to understand warfarin and to offer you some useful hints and tips on how you can work with your healthcare team to obtain the best possible results while taking warfarin.
At first, this information may seem a bit overwhelming, so keep this booklet in a safe place and feel free to read through it as often as you like. Remember that your doctors, nurses, pharmacists and other healthcare professionals are all there to help – don’t be afraid to ask any questions you may have.
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WArFArIN – AN oVErVIEW
• Warfarinisananti-clottingmedicine,or“anticoagulant”.Itisusedtopreventor treat unwanted blood clots within blood vessels.
• How long you will need to take warfarin depends on the condition beingtreated and may vary from person to person.
• Yourdoctorwilladjustyourwarfarindosetofindtherightbalancebetweenbleeding and clotting. This is measured using a blood test called the “International Normalised Ratio”, or “INR”. The ideal INR range for most people is between 2 and 3.
• INRtestsmayberequiredasoftenaseverydayoreveryseconddaywhenyou first start warfarin, but generally only once or twice a month when your INR is stable.
• MakesureyouhaveyourINRtestsdoneeverytimetheyareorderedbyyourdoctor. Contact your doctor or laboratory after each INR test and keep a record of your INR results in the record section of this booklet. Bring this booklet to your next doctor visit.
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• Takeyourwarfarinatapproximatelythesametimeeachday,withorwithoutfood. Take the exact warfarin dose prescribed by your doctor. Some people might need to take different doses every second day or on different days of the week.
• Trytoavoidmissingdosesofwarfarin.Itisagoodideatokeeparecordofthe doses you take each day (this booklet can be used). If you do miss a dose, never take a double dose to catch up.
• Other medicines can affect how well warfarin works. Always talk to yourdoctor or pharmacist before starting or stopping any prescription or over-the-counter medicines, herbal medicines, vitamins or health supplements.
• Ensureallmembersofyourhealthcareteam(includingdoctors,specialists,dentists, nurses and pharmacists) know that you are taking warfarin.
• Maintain a healthy, well-balanced diet, with a consistent intake of green,leafy vegetables. Limit your alcohol intake.
• The major side effect of warfarin is bleeding. Watch yourself for signs ofbleeding and if you are concerned, contact your doctor as soon as possible. Think about ways you can reduce your risk of bleeding on a day-to-day basis.
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hoW DoEs WArFArIN WorK?
Warfarin is an anti-clotting medicine, or “anticoagulant” – a medicine that increases the time it takes for your blood to clot. Some people call it a “blood thinner” but your blood won’t actually look or feel any different while you are taking warfarin.
Warfarin helps to stop unwanted clots from forming inside blood vessels or to treat them if they occur. A clot will not usually form inside a blood vessel, but if it does it is called a “thrombosis”. A thrombosis can cause a stroke, a heart attack or a vein blockage in the legs or lungs. Warfarin helps to prevent or treat thrombosis by making it more difficult for the blood to form a clot.
The reasons why people may need to take warfarin include:
• Atrialfibrillation(“AF”),anirregularheartbeatthatcancausebloodclotsandstrokes;
• Blood clots in the legs (a “deep vein thrombosis” or “DVT”) or lungs (a“pulmonary embolism” or “PE”);
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• Certainbloodclottingproblems(forexample,antiphospholipidsyndrome,protein C deficiency and Factor V Leiden); and
• Mechanicalheartvalves.
Your doctor will be able to tell you why you are taking warfarin and how long you will need to take it. This varies according to the condition being treated and may vary from person to person.
A BIt MorE INForMAtIoN ABout AtrIAL FIBrILLAtIoN
If you are taking warfarin because you have atrial fibrillation (“AF”), you are not alone. It has been estimated that up to half a million Australians suffer from AF. You may not be aware of your AF on a daily basis – some people have no obvious signs or symptoms, but that does not mean that it is not there. Other people may notice heart palpitations, breathlessness, fainting or chest pain as a result of their AF.
Unfortunately, people with AF have a much higher risk of suffering a stroke than people whose hearts beat in a normal rhythm. In fact, people with AF are about five times more likely to suffer a stroke, and the strokes they suffer are often
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more severe. This is even true for people who have what is called “paroxysmal AF” – episodes of AF that come and go.
In AF, the top chambers of the heart (the “atria”) beat very fast and irregularly. This prevents the blood from travelling smoothly through the heart and may lead to the development of a blood clot in the heart. If part of this blood clot breaks off and travels through the bloodstream to the brain, then a stroke may occur.
The good news is that by making it harder for your blood to clot within your heart, taking warfarin significantly reduces your risk of suffering a stroke because of your AF. Warfarin is highly effective in reducing strokes if you keep good control of your INR (described below). Therefore, it is very important that you take your warfarin exactly as prescribed by your doctor, even if you are feeling well. Following the advice in the “Taking Warfarin Safely” section of this booklet will also help you to obtain the best possible results while taking warfarin.
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hoW Do You KNoW WArFArIN Is WorKING?
The aim of taking warfarin is to slow down the clotting process, not to stop it completely as this would cause serious bleeding. Different people need different doses of warfarin to provide them with the right balance between bleeding and clotting.The only way that your doctor can tell whether warfarin is working safely and effectively is by doing regular blood tests. The results of these blood tests allow your doctor to prescribe the right dose of warfarin for you. As mentioned, the blood test for monitoring warfarin therapy is called the “International Normalised Ratio”, or “INR”.
WhAt Is thE INr?
The INR is a number that indicates how long your blood takes to clot. The INR of a person not taking warfarin is about 1. When you take warfarin your INR will be higher, which means that your blood takes longer to clot. For most people, the INR result that provides the best balance between the chances of bleeding and clotting is between 2 and 3 – this is called the “target INR range”. Your doctor will tell you what target INR range is right for you.
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If your doctor increases your warfarin dose, your INR will increase. If your warfarin dose decreases, your INR will decrease. These changes may not happen immediately. It may take 4 to 5 days before they are noticeable.
It is not always possible for every INR test result to be within your target INR range, but the more time you spend in this range, the lower your risk of bleeding and clotting. You can help to increase your time in target INR range by following the advice in the “Taking Warfarin Safely” section of this booklet.
International Normalised ratio
Co
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licat
ion
ris
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Clotting target range (2 - 3)
Bleeding
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How Often Will I Need to Have INR Tests?
How often you require your INR tests will vary from person to person, and depends on how long you have been taking warfarin. Most people require an INR test every day or every second day when they first start warfarin, but once your INR is stable within the target range, you may only require an INR test once or twice a month. You and your doctor will decide how often you need to have INR tests to ensure that your warfarin dose is safe and effective for you. Extra tests may be required in certain situations, for instance, if you start or stop another medicine that could change the effect of warfarin.
Options for INR Testing
There are a variety of options for INR testing:
1. Pathology Testing
Most people will have their INR tests at their doctor's surgery or at a pathology laboratory. A small blood sample is drawn from a vein and sent for testing. You then visit or call your doctor, pathology laboratory or another healthcare professional to obtain your results and instructions on the dose of warfarin you should take until your next INR test.
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2. Point-of-Care Testing
Point-of-care devices are now available for INR testing. These are portable devices very similar to the machines used to test blood sugar levels. These machines require a finger prick blood sample and allow the INR result to be obtained within a few minutes. Some doctors now have these monitors in their surgeries so testing can be done on the spot by the doctor or practice nurse.
3. INR Self-Monitoring
Point-of-care devices allow some people to do their own INR tests at a time that suits them - at home or even at work. This process is known as INR self-monitoring. If you are considering self-monitoring, it is important that you receive training in using a monitor and have a system of letting your doctor or healthcare professional know your INR results. It is also a good idea to compare the results fromyourpoint-of-caredevicewithapathologyINRtestatleasttwiceayearjustto be sure it is providing accurate readings.
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Just as everyone will need different doses of warfarin, everyone will find a way of INR monitoring that suits them. Discuss the options with your doctor or pharmacist - they can help you find the best INR testing option for you.
INratio2 CoaguChek Xs
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Your INr BLooD tEsts ArE IMPortANt
You can help with your warfarin therapy:
1. Know your target INR range;
2. Make sure you have your INR tests done every time they are ordered by your doctor;
3. Contact your doctor or laboratory as instructed after each INR test in case your warfarin dose needs to be changed; and
4. Record your INR results in the record section of this booklet.
tAKING WArFArIN sAFELY
Dosage
The dose (strength) of warfarin that your doctor has prescribed for you is in milligrams (mg). Make sure that you know what tablets you are meant to be taking to make up your dose. If you’re unsure, don’t be afraid to ask.
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Take your tablets at approximately the same time each day. Most people take their daily warfarin dose in the evening. This allows the dose to be changed if necessary on the day that an INR result is obtained, rather than waiting until the next day.
Some people might need to take different doses every second day or on different days of the week.
Warfarin can be taken with or without food.
Take the exact warfarin dose prescribed by your doctor. Don’t stop taking warfarin or change the dose unless your doctor tells you to.
IT IS IMPORTANT TO AVOID MISSING DOSES OF WARFARIN
Make warfarin part of your daily routine. Some people find that marking it off on a calendar or in their INR record booklet after they have taken their warfarin dose makes it easier to remember. Other people use pill boxes or blister packs. If you’re having problems remembering to take your warfarin, talk to your pharmacist about how they can help.
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Missing a dose
If you forget to take a dose of warfarin and then remember within 4 hours, you can still take your tablets.
If you forget for a longer time, do not take the tablets to catch up but take your next dose when it is due. Keep a record of any missed doses and tell your doctor or pathology laboratory.
NEVEr tAKE A DouBLE DosE
KEEPING Your INr stABLE
There are several things that you can do to help keep your INR stable within your target INR range. The most important things are:• Followtheinstructionsofyourhealthcareteamascloselyaspossible,and• Keep them informed of any changes in your health or lifestyle, including
changes in your medicines or diet.
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By working together, you can help your doctors, nurses, pharmacists and other healthcare professionals ensure you get full benefit from your warfarin therapy.
Many different things in your life may have an effect on warfarin and/or your INR. These include:
1. Other medicines you may be taking.
2. What you eat.
3. If you drink alcohol and, if so, the amount you drink.
4. Changes in your health.
Changes may also occur when you go home from hospital and when you go away on holidays. You may require additional blood tests at these times – let your doctor or healthcare professional know and they can help you decide.
other Medicines
Taking other medicines may interfere with the way warfarin works, either increasing its effect (and therefore increasing your chance of bleeding) or reducing its effect (and increasing your chance of clotting).
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ASSUME THAT ANY MEDICINE CAN AFFECT WARFARIN UNLESS ADVISED OTHERWISE - ALWAYS TALK TO YOUR DOCTOR OR PHARMACIST BEFORE STARTING OR STOPPING A MEDICINE
Keep a list of your medicines with you at all times.
Medicines that may interfere with warfarin include not only prescription medicines but also anything you might buy over-the-counter (in a pharmacy, supermarket or health food store) for a common cold, pain, constipation and so on.
Common medicines that may increase or decrease the effect of warfarin are listed in Table 1. This list does not include all the medicines that interfere with warfarin – it is safest to check with your doctor or pharmacist before starting or stopping any medicines, even those prescribed by another doctor or dentist, as you may require an additional INR test and your warfarin dose may need to beadjusted.
One group of medicines that often causes problems for people taking warfarin is antibiotics, which are medicines used to treat bacterial infections. As a
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general rule, it is a good idea to have an INR test 3 to 4 days after starting a course of antibiotics. Your doctor may then suggest that you take a lower dose of warfarin for a few days to ensure that your INR does not increase above your target INR range. Speak to your doctor for advice that is right for you.
What about Aspirin?
Some people take a small daily dose of aspirin as an anti-clotting medicine to prevent heart attacks or strokes. If you are already taking aspirin, check with your doctor to find out if you need to keep taking it while you are taking warfarin.
What about Pain-killers?
For most people taking warfarin, paracetamol is the safest choice if a pain-killer is required. However, if you start taking paracetamol regularly (for example, more than three or four times a week), let your doctor know as your warfarin dose may need to be decreased.
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table 1: Examples of possible interactions between medicines and warfarin.1-3
Medicines Interaction with warfarin Possible effect on INRAntibiotics (for example, ciprofloxacin, clarithromycin,
norfloxacin, roxithromycin, metronidazole, sulfamethoxazole + trimethoprim)
Increased risk of bleeding INR may increase
Anti-clotting medicines (for example, aspirin, clopidogrel, dipyridamole, prasugrel, ticagrelor)
Increased risk of bleeding No change
Antidepressant medicines (for example, citalopram, sertraline)
Increased risk of bleeding No change or INR may increase
Antifungal medicines (for example, fluconazole) Increased risk of bleeding INR may increaseCholesterol lowering medicines (for example, fenofibrate,
gemfibrozil, rosuvastatin, simvastatin)Increased risk of bleeding INR may increase
Medicines for abnormal heart rhythms (for example, amiodarone)
Increased risk of bleeding INR may increase
Medicines for epilepsy (for example, carbamazepine, phenytoin)
Increased risk of clotting INR may decrease
Pain-killers and anti-inflammatory medicines (for example, diclofenac, ibuprofen, naproxen, paracetamol)
Increased risk of bleeding No change or INR may increase
Thyroid medicines (for example, carbimazole, propylthiouracil, thyroxine)
Increased risk of bleeding or clotting
INR may increase or decrease
Ulcer or reflux medicines (e.g. antacids, omeprazole) Increased risk of bleeding or clotting
INR may increase or decrease
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Complementary and Alternative Medicines
A number of complementary and alternative medicines (“herbal medicines”), including vitamins and mineral supplements, can also affect how warfarin works. If you are taking multivitamins or other supplements, make sure they do not contain vitamin K, unless advised by your doctor.
Treat herbal medicines and supplements like any other medicines – discuss them with your doctor or pharmacist before you start or stop taking them. Also, let your doctor know if you change the amount or brand of herbal medicine or supplement that you are taking – different brands can sometimes contain different amounts of the active ingredients.
It is more difficult to predict the effect of complementary and alternative medicines on warfarin, but Table 2 lists a variety of these medicines that have an effect on warfarin and/or the INR.
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table 2: Examples of possible interactions between complementary and alternative medicines and warfarin.1,4,5
Medicines Interaction with warfarin Possible effect on INRCo-enzyme Q10 Increased risk of clotting INR may decreaseCranberry juice Increased risk of bleeding INR may increase
Danshen Increased risk of bleeding INR may increaseDong quai Increased risk of bleeding INR may increaseFenugreek Increased risk of bleeding INR may increaseFeverfew Increased risk of bleeding INR may increase
Fish oils (Omega-3) Increased risk of bleeding No change, or INR may increaseGarlic supplements Increased risk of bleeding No change, or INR may increase
Ginkgo biloba Increased risk of bleeding INR may increaseGinger supplements Increased risk of bleeding INR may increase
Ginseng Increased risk of clotting INR may decreaseGlucosamine and glucosamine/chondroitin Increased risk of bleeding INR may increase
Saw palmetto Increased risk of bleeding INR may increaseSt John’s wort Increased risk of clotting INR may decrease
Vitamin E (high doses) Increased risk of bleeding INR may increaseVitamin K Increased risk of clotting INR will decrease
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Warfarin and Food
In the past, there has been a lot of confusion about what people taking warfarin should and shouldn’t eat. There are two simple messages when it comes to warfarin and your diet: 1. Maintain a healthy, well-balanced diet. This includes plenty of wholegrain
breads and cereals, fruits and vegetables; moderate amounts of milk, cheese, yoghurt, lean meat, poultry, fish, legumes, nuts and eggs; and low quantities of sugar and fats, including butter, margarine and oil. This is important for everyone, whether or not they are taking warfarin.
2. Maintain a consistent or “steady” diet - avoid crash dieting and binge eating. If your food intake and type of food eaten remains relatively constant, your INR is more likely to remain stable.
It is true that warfarin is affected by the amount of vitamin K in your diet. You do not need to avoid foods containing vitamin K, but should aim to keep their intake fairly constant.
Higher vitamin K levels in your body decrease the effect of warfarin so decrease your INR – your doctor may need to prescribe you a higher warfarin dose. Lower
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vitamin K levels increase the effect of warfarin and increase your INR, which increases your risk of bleeding unless your warfarin dose is decreased. Therefore, it is important to keep your intake of vitamin K as even as possible to keep your INR within your target range. Vitamin K is mainly found in green leafy vegetables such as spinach, silverbeet, Brussels sprouts, broccoli, parsley and certain lettuces. Generally, the greener the vegetable, the higher its vitamin K content.
this does not mean that you should cut out these foods from your diet. Instead you should eat a similar amount of these foods from day to day and from week to week. If you want to make any major changes to your eatingpattern,thisisfine–justdiscussitwithyourdoctorfirst.
Table 3 lists some common vegetables that contain high or moderate levels of vitamin K. Most other foods contain only low quantities of vitamin K. For more information about the amounts of vitamin K in other foods, ask your doctor for a copy of the booklet entitled "Eating well with warfarin". Or speak to your accredited, practising dietician.
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Cranberryjuiceandlargeamountsofsoymilkorcanolaoilcanalsointerferewith warfarin and affect your INR results. Consume these in moderation or talk to your doctor if you change your daily intake.
table 3: Common vegetables containing high or moderate levels of vitamin K.6
Asparagus KaleBroccoli Lettuce (gourmet) e.g. Butter lettuce (not Iceberg)
Brussels sprouts ParsleyCabbage SilverbeetEndive Spinach
Dietary Supplements: supplements such as Sustagen® and Resource® are recommended for some people who need extra calories and nutrients. Since these products are quite low in vitamin K they are unlikely to affect your INR.
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Warfarin and Alcohol
Consuming large amounts of alcohol, especially binge drinking, can affect your INR and may increase your risk of bleeding. It is best to drink only in moderation, and limit your daily intake to no more than 1 or 2 standard drinks a day, with at least 2 alcohol free days a week. Some people may have other medical reasons for avoiding alcohol completely. Discuss with your doctor the alcohol intake that is safe for you.
Warfarin and Your health
Many day-to-day illnesses (for example diarrhoea, vomiting, infection, fever, lossofappetiteandjaundice)mayaffectyourINR.Tellyourdoctorassoonaspossible if you develop any new illness.
ENsurE ALL MEMBErs oF Your hEALthCArE tEAM KNoW thAt You’rE tAKING WArFArIN
Before undergoing any treatment, surgery or dental work make sure that you inform the doctor, specialist or dentist performing the procedure that you are
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taking warfarin. Be sure to tell them well ahead of time as they may need to make special arrangements for you. Also tell the doctor or pathology laboratory who is supervising your warfarin therapy.
Ifyourequireanyemergencytreatmentfollowinganinjury(forexample, inahospital emergency department), be sure to mention that you are taking warfarin.
It is a good idea to wear an alert bracelet (such as a Medic Alert®) and/or to carry a warfarin identification card to notify other people that you are taking warfarin. Registering for personally controlled eHealth Record (PCEHR) is also a good idea. More information about eHealth Records is available at
http://www.ehealth.gov.au/internet/ehealth/publishing.nsf/content/home
PrEGNANCY Must BE AVoIDED
Warfarin can seriously harm an unborn baby. All women who may become pregnant should discuss with their doctor the possible risks and how to reduce those risks. If you wish to become pregnant, there are other anti-clotting
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medications available that are much safer during pregnancy than warfarin – talk to your doctor about your options.
If you become pregnant while taking warfarin, discuss this with your doctor as soon as possible.
Although warfarin must be avoided during pregnancy, it may be safe to take warfarin while breastfeeding. Consult your doctor for advice.
ChECK WIth thE DoCtor BEForE trAVELLING
Contact your doctor before you set off on any extended trips. While travelling, try to keep your diet and level of activity as close to normal as possible.
You may need an INR test while you are away. Ensure the information written in this booklet is up to date and take this booklet with you. If you consult a doctor while you are away, inform them you are taking warfarin. Make sure you take enough warfarin tablets with you to last the entire trip.
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WArFArIN AND BLEEDING
Themajorsideeffectofwarfarinisbleeding.
Your doctor will adjust your warfarin dose to maintain your INR within yourtarget range – this will significantly reduce your chance of experiencing excessive bleeding. You can help keep yourself well by watching out for signs of problem bleeding – if they are detected early, you can help to prevent small problems from becoming serious problems.
Even when your INR is in your target range, you may notice minor bleeding from time to time, such as:
• Occasionalnosebleeds.• Gumbleedingwhilebrushingteeth.• Easybruising.• Bleedingafteraminorcutthatstopswithinafewminutes.• Menstrualbleedingthatisalittleheavierthannormal.
Nose bleeds, gum bleeding and bleeding from minor cuts should all stop within a few minutes. If bleeding persists or you are at all concerned, contact your doctor as soon as possible.
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It is important for you to watch out for signs of serious bleeding, which should be reported urgently to your doctor. Signs of serious bleeding include:• Severebruisingthatgetsworse.• Anybleeding, includingnosebleedsorbleedinggums, that takesa long
time to stop.• Unexplainedbleedingorbruising (forexample,bruisesonyourbackand
chestwhenyouhaven’tinjuredyourself).• Menstrualbleedingthatismuchheavierthanusual,orunexplainedvaginal
bleeding.
Less obvious signs of serious bleeding that you should also be aware of include: • Darkredorbrownurine.• Red,darkbrownorblackbowelmotions.• Coughingupblood,oranythingred.• Bloodyordarkstained(e.g.coffeecolour)vomit.• Asevereheadacheordizziness.• Weaknessorlethargy.• Unusualpain,swellingordiscomfort.• Anydifficultyinbreathing.
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If any of these less obvious signs of bleeding occur you should contact your doctor immediately. If your doctor is unavailable, go to your nearest hospital emergency department.
If you are severely unwell, do not hesitate - call an ambulance immediately.
handy hints to reduce your Chances of Bleeding
Remember that because you are taking warfarin you have an increased chance of bleeding. There are several things that you can do to reduce your risk of experiencing bleeding problems:• Checkwithyourdoctorbeforebeginninganyactivity(e.g.sportingactivities)
with a high risk of injury. Avoid contact sports. Make sure that you useprotective gear, such as a helmet and gloves, if necessary.
• Thinkaboutyourday-to-dayactivities.Howcanyoureduceyourchancesofhurting yourself?
For example:- Use a non-slip bath mat in the bath or shower.- Use a soft bristle toothbrush.- Use an electric shaver when shaving.
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- Wear non-slip footwear or sturdy shoes to avoid trips and slips.- Wear gloves when gardening.- Have a clean bandage with you in case you scratch yourself and begin
to bleed.- Be careful around pets.- Takecarewithsharpobjectssuchaskitchenknives.
• Considertakingafirstaidcoursesothatyouknowhowtomanagecutsandotherinjuriesiftheyoccur.Askafamilymemberorfriendtojoinyou–thatway they’ll be able to look after you if you can’t!
• Reporttoyourdoctoranyfalls,blowstotheheadorbody,caraccidentsorothermajorinjuries.Youmaynotalwaysseevisiblesignsofbleedingfromaninternalinjury.
other side Effects
Occasionally people experience other side effects associated with taking warfarin. These side effects are rare but include unusual skin lesions, purple discolouration of the toes, hair loss or a rash.
If you notice any of these signs, or anything else that you feel may be caused by your warfarin, speak to your healthcare professional.
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WhErE CAN You FIND MorE INForMAtIoN?
As you continue to take warfarin, you will develop your own routines around taking your medicines and having your INR tests. Eventually, warfarin will become part of your normal life.
By being on the lookout for signs of bleeding and keeping in close contact with your healthcare team, you can be sure that you’ll be getting the most out of your warfarin therapy.
For further information on warfarin and INR testing, please contact your doctor, pharmacist or other healthcare professional. Other useful sources of information are:
• www.aspenpharma.com.au/warfarin
• www.anticoagulation.com.au
• Poisons Information line, for information on overdoses or poisoning: 13 11 26
• HealthDirect,forhealthadvicefromexperiencednurses:1800022222
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and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133(6 Suppl):160S-98S.
2. Jacobs LG. Warfarin pharmacology, clinical management, and evaluation of hemorrhagic risk for the elderly. Cardiol Clin 2008;26(2):157-67.
3. Baxter K (ed). Stockley's drug interactions. Pharmaceutical Press; 2010 [cited 2010 July 29]; Available from: http://www.medicinescomplete.com.
4. Jellin JM (ed). Natural medicines comprehensive database. Therapeutic Research Center; 2011 [cited 2011 June 2]; Available from: http://www.naturaldatabase.com.
5. Izzo AA, Ernst E. Interactions between herbal medicines and prescribeddrugs: an updated systematic review. Drugs 2009;69(13):1777-98.
6. USDA Agricultural Research Service. USDA National Nutrient Database for Standard Reference, Release 23. [cited 2011 June 2]; Available from: http://www.nal.usda.gov/fnic/foodcomp/search/
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Name: Telephone:
Doctor: Telephone:
Pathology lab: Telephone:
Warfarin brand: (Coumadin-Marevan)
Target INR: Other Medicines:
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Recommended Warfarin Dosage
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warfarinINR RECORD BOOK
C O U M A D I N M A R E V A N
(warfarin sodium) warfarin
NEW TABLET APPEARANCE - available soon (see details page (ii)
© Copyright 2012 Aspen Pharma Pty Ltd. No part of this publication may be reproduced by any process in any language without the written consent of Aspen Pharma Pty Limited.
This booklet is intended to provide information of a general nature only. It does not replace advice from your healthcare professional. Please consult your doctor or pharmacist if you have any questions in relation to warfarin. This is particularly important if you are taking any other medication in combination with warfarin. Also refer to any information your doctor or pharmacist may have provided you including any Consumer Medicine Information (CMI) sheets. Immediately telephone your doctor or the Poisons Information Centre (telephone 13 11 26) for advice, or go to the Accident and Emergency at your nearest hospital if you think that you or anyone else may have taken too much warfarin, even if there are no signs of discomfort or poisoning. This booklet has been developed and written by Dr. Leanne Chalmers, Professor Gregory Peterson and Associate Professor Luke Bereznicki, University of Tasmania with funding provided by Aspen Australia, suppliers of Coumadin and Marevan in Australia and New Zealand.
Aspen Australia comprises Aspen Asia Pacific Pty Ltd (ABN 75 146 444 484) and its subsidiaries, including Aspen Pharmacare Australia Pty Ltd (ABN 51 096 236 985), Aspen Pharma Pty Ltd (ABN 88 004 118 594), Aspen Nutritionals Australia Pty Limited (ACN160607509),Orphan Holdings Pty Ltd (ABN50 115 816 209), and Orphan Australia Pty Ltd (ABN 11 067 189 342). All sales and marketing requests to: Aspen Pharma Pty Ltd, 34-36 Chandos Street, St Leonards NSW 2065 Tel. +61 2 8436 8300 [email protected] www.aspenpharma.com.au Last revised: August 2015 ASP 821
