warfarin therapy
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| warfarin indication | prevention or treatment of thromboembolism
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| conditions for warfarin use | VTE, A fib, stroke, mechanical heart valves
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| usual starting dose of warfarin | 5mg po qd (2.5-10mg range)
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| start lower dose if | pt over 65y/o, abnormal liver fxn, malnourished, low vitamin K intake, recent surgery, medications inducing warfarin
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| subsequent warfarin dosing | based on INR
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| normal PT | 10-13seconds
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| INR reference | 1
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| goal INR normally | 2.0-3.0
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| goal INR mechanical valves | 2.5-3.5
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| goal INR prior to surgery | <1.5
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| INR monitoring: inpatient | every 1-3 days
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| INR monitoring: outpatient | within 3-5 days
every 4 weeks once stable
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| warfarin monitoring | BLEEDING
s/sx of thrombus
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| warfarin adverse effects | bleeding, alopecia, cold intolerance, skin necrosis, purple toe syndrome, rash, jaundice, vertebral and rib fractures
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| warfarin metabolism | CYP3A4 and CYP2C9
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| warfarin in hypothyroidism | increase dose
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| warfarin in hyperthyroidism | decrease dose
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| hypothyroid | more likely to clot
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| hyperthyroid | more likely to bleed
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| warfarin inducers | alcoholic grizly dic nabed (a) car (to) run phen phen
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| warfarin inhibitors | bac met ami (and) left the sorority assholes (to) make icy flowers sometimes
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| platelet fxn inhibitors | ASA NSAIDS, COX II inhibitors, acute alcohol
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| reduce GI flora synt of vitamin k | antibiotics
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| reduce GI absorption | cholestyramine, sucralfate
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| change protein binding | leflunamide, bactrim, alcohol
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| APAP | limit to <2g daily and short term
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| OTC warfarin interactions | boost, one a day (vit K) alka seltzer (ASA)
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| how much vitamin K to change INR 1 IU? | 714mcg weekly
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| herbals that inc. INR | garlic, ginger, chondroitin, glucosamine, horse chestnut, milk thistle, saw pamento, flax seed, fish oil
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| herbals that dec. INR | CoQ10, st. john's wort, green or herbal teas
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| herbals that are unpredictable on INR | ginseng
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| if adding warfarin to regimen | titrate to desired INR
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| adding if warfarin is already part of regimen | may see large fluctuations in INR so monitor it closely
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| long term/short term offender use | stabalize INR/monitor without dose change
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| when to check INR followin initiation or discontinuation of a drug | 3 days following
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| warfarin with inducer | increase warfarin dose
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| warfarin with inhibitor | decrease warfarin dose
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| dietary vitamin K sources | green vegetables, mayo, oils, soymilk,boost type deals
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| inpatient subtheraputic INR | give 1 additional "booster" dose *do not change weekly maintenance dose
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| outpatient subtheraputic INR | increase by fraction of weekly dose (10-20%)
check for transient factors
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| inpatient supratheraputic INR | hold one dose
adjust daily warfarin dose
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| outpatient supratheraputic INR | hold at least one dose
decrease weekly dose (10-20%)
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| CHEST recommendations INR 3.0-5.0 | if no bleeding, hold dose(s) decrease weekly dose by 0-10% -if transient factor no dose reduction
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| CHEST recommendations INR >5.0-9.0 | if no bleeding, hold dose(s) decrease weekly dose by 10-20% can consider po vit.K 1mg - 2.5mg if at high risk for bleeding
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| CHEST recommendations INR >9.0 | if no bleeding, hold dose(s) give po vit.K 2.5-5mg, reduce dose of warfarin once restarted
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| serious supratheraputic INR and bleed | hold warfarin, IV vit.K 10mg by slow infusion
supplement with frozen plasma, prothrombin complex, or recombinant factor VIIa
repeat vit.K in 12 hours if persisten elevated INR
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| vitamin K, Phytonadione (mephyton) | vit. k for clotting factors
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| vit.K oral route | onset 6-12 hours INR theraputic in 24-48 hours
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| vit.K IV route | onset 1-2 hours control of hemorrhage evident in 3-6 hours
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| vit.K IV or >5mg po | leads to overcorrection and warfarin resistance lasting up to a week
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| never administer warfarin IM | never administer warfarin IM
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