your guide to coumadin(r)/warfarin therapy

Your Guide to Coumadin®/Warfarin Therapy

This booklet is based on a product developed by Carla Huber, A.R.N.P., M.S., Cedar Rapids CommunityAnticoagulation Clinic, Cedar Rapids, Iowa, under Agency for Healthcare Research and Quality (AHRQ) Grant No. 1 U18 HSO15830-01 to Kirkwood Community College.

This document is in the public domain and may be used andreprinted without special permission. Citation of the source isappreciated.

Notes:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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ContentsIntroduction .......................................................3

What Coumadin®/Warfarin is and What it Does for You ......................................................4

How to Take Coumadin®/Warfarin.....................5

Blood Tests.........................................................6

Possible Side Effects ...........................................7

Stay Safe While Taking Coumadin®/Warfarin......9

Use of Other Medications ................................11

Diet for Coumadin®/Warfarin Users .................14

Share Information With Your Other Doctors...16

Specific Conditions...........................................17

Atrial Fibrillation .......................................17

Deep Vein Thrombosis..............................17

Heart Attack .............................................18

Heart Valve Replacement ..........................18

Peripheral Vascular Disease........................18

Pregnancy and Breastfeeding.....................19

Pulmonary Embolism................................20

Stroke........................................................20

Valvular Heart Disease ..............................21

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IntroductionYour doctor, nurse, or other health professionalhas started you on the medicationCoumadin®/warfarin. Patients who are onCoumadin®/warfarin must be watched closely. Youwill need to have blood drawn often. You will alsoneed to be careful that you do not do somethingto hurt yourself and cause bleeding. Your doctorwill work with you to keep you healthy and safewhile you are taking Coumadin®/warfarin.

Starting on a new medicine, especially one youmay have to take for a long period of time, maymake you worry. To help you learn about yourmedication, your doctor has given you thisbooklet to take home and read. The informationin the booklet will help you understand why youare taking Coumadin®/warfarin and how to keepyourself healthy. Please take time to read all of theinformation in the booklet. If you have anyquestions call your doctor.

Reminders:

n Your doctor is here to help you.Call if you have questions.

n Your doctor’s phone number is:

_________________________

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You can stay healthy even when you have a healthproblem that needs special medication. You andyour doctor will work together as a team to makesure that taking a medication likeCoumadin®/warfarin does not stop you fromliving well and safely.

What Coumadin®/Warfarin isAnd What it Does for You

If your blood is too thickand forms clots, youcould be at risk for heartattack, stroke, and otherserious medicalproblems. Coumadin®/warfarin is a medicinethat will keep your bloodfrom clotting. The drugis an anticoagulant.“Anti” means againstand “coagulant” means

to thicken into a gel or solid. Sometimes this drugis called a blood thinner. Think of syrup beingpoured—it is sticky and thick and flows slowly.Coumadin®/warfarin helps your blood flow easierand not clot.

Coumadin®/warfarin will:

n Keep your blood from making clots.

n Help your blood flow easily.

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How to TakeCoumadin®/WarfarinAlways take your pills as directed. You must take thepills only on the days your doctor tells you to. Theamount of Coumadin®/warfarin each person needsis different. The dose is based on a blood test calledthe INR (International Normalized Ratio). Theamount of medication you take may change, basedon the blood test. It needs to be taken at the sametime, usually in the evening.

Coumadin®/warfarin can betaken with othermedications. Never skip adose and never take a doubledose. If you miss a dose,take it as soon as youremember. If you don’t

remember until the next day, please call your doctorfor instructions. If this happens on a weekend orholiday, skip the missed dose and start again thenext day. Mark the missing dose in a diary. A dailypillbox will help you keep track of your dose.

Checklist.

n Go for blood tests as directed.n Never skip a dose.n Never take a double dose.n Take Coumadin®/warfarin in the evening at

the same time as directed by your doctor.

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Blood Tests The doctor decides how muchCoumadin®/warfarin you need by testing yourblood. The test measures how fast your blood isclotting and lets the doctor know if your dosageshould change. If your blood test is too high, youmight be at risk for bleeding problems. If it is toolow, you might be at risk for forming clots. Yourdoctor has decided on a range on the blood testthat is right for you.

Regulating yourblood withCoumadin®/ warfarinis like balancing ascale. If you take toomuch you will

increase bleeding; if you take too little, yourblood will clot. Getting your blood within thetarget range is getting it balanced.

When you first start taking Coumadin®/warfarinyou may have your blood checked often. Oncethe blood test is in the target range and thecorrect dose is reached, this test is done less often.Because your dose is based on the INR blood testit is very important that you get your blood testedon the date and at the time that you are told.

Illness can affect your INR blood test and yourCoumadin®/warfarin dose. If you become sickwith a fever, the flu, or an infection, call yourdoctor. Also call if you have diarrhea and vomitinglasting more than 1 day.

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Know your INR blood test range.

n My INR blood test range is:

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Possible Side EffectsSide effects with Coumadin®/warfarin mayhappen. Most side effects relate to how themedicine works. To lower the risk of bleeding,your blood Coumadin®/warfarin level will be keptwithin a range that is right for you. Even whenyour INR blood test is in range, you might see alittle bleeding like bruises on your body or slightgum bleeding when you brush your teeth. Some

people may experience hairloss or skin rashes, but this israre. If you noticesomething wrong that youfeel may be caused by yourmedication, call your doctor.

Slight bleeding—you may notice from time totime:

n Gum bleeding while brushing teeth.n Occasional nosebleed.n Easy bruising.n Bleeding after a minor cut that stops within

a few minutes.n Menstrual bleeding that is a little heavier

than normal.

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Major bleeding—call your doctor, or go tothe hospital emergency room right away ifyou have any of the following:

n Red, dark, coffee, or cola colored urine.

n Bowel movements that are red or look like tar.

n Bleeding from the gums or nose that does not stop quickly.

n Vomit that is coffee colored or bright red.

n Anything red in color that you cough up.

n Severe pain, such as a headache orstomachache.

n Sudden appearance of bruises for no reason.

n Menstrual bleeding that is much heavier than normal.

n A cut that will not stop bleeding within 10 minutes.

n A serious fall or hit on the head.

n Dizziness or weakness.

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Stay Safe While TakingCoumadin®/WarfarinYou will need to be careful using objects, such asknives and scissors, that could make you bleed.You will need to avoid some activities and sportsthat could cause injury. For example, it is not a

good idea to takeup risky sportswhile you are onCoumadin®/warfarin. Thisdoes not meanyou cannot dothe things thatyou enjoy. Butwhen doing

them, you need to think about how you canprotect yourself from injury. For example, if youlike to work in the yard, be sure to wear sturdyshoes and gloves. Activities that would be safe foryou include swimming and walking.

It is very important to know that you can bebleeding and not see any blood. For example, youcould fall and hit your head, and bleeding couldoccur under your skull. Or, you could fall andhurt your arm and notice a large purple bruise.This would be bleeding under the skin. Call yourdoctor or go to the hospital immediately ifyou have taken a bad fall, even if you are notbleeding.

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Talk to your doctor aboutwearing a medical alertbracelet or necklace. If youare badly injured andunable to speak, the

bracelet would tell health care workers that youare on Coumadin®/warfarin.

Stay active.

Exercise is important to your health.Think about the sports and activities youlike doing. Do they put you at risk forinjury? If so, try another activity and useprotective gear to keep you safe whileyou are doing it. For example, if you liketo ride your bike, be sure you wear ahelmet and gloves. If you would like tostart a new activity that will increase theamount of exercise you get every day,talk to your doctor.

To prevent injury; be careful:

Indoors

n Be very careful using knives and scissors.

n Use an electric razor.

n Use a soft toothbrush.

n Use waxed dental floss.

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n Do not use toothpicks.

n Wear shoes or non-skid slippers in the house.

n Take care trimming your toenails.

n Do not trim corns or calluses yourself.

Outdoors

n Always wear shoes.

n Be very careful with sharp tools; wear gloves when using them.

n Avoid activities and sports that can easily hurt you.

n Wear gardening gloves when doing yard work.

n Stay active.

Use of Other MedicationsWhen Coumadin®/warfarin is taken with othermedicines, it can change the way other medicineswork. Other medicines can also change the wayCoumadin®/warfarin works. It is very importantto talk with your doctor about all of the othermedicines that you are taking, including over-the-counter medicines, antibiotics, vitamins,or herbal products.

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Any product containing aspirin may lessen theblood’s ability to form clots and may harm youwhen you take Coumadin®/warfarin. If you takea daily aspirin, talk with your doctor aboutwhat dose it right for you.

Other medicines you get over-the-counter may haveaspirin in them. All medications must be approvedby your doctor, including medicines you have takenbefore you started Coumadin®/warfarin. Followingis a list of some common medications that shouldbe approved by your doctor.

Pain relievers, such as:n Excedrin®..n Acetaminophen (Tylenol®).n Naproxen (Aleve®).n Ibuprofen (Advil®, Motrin®, Nuprin®,

Midol®, Pamprin HB®).

Stomach remedies, such as: n Cimetidine (Tagamet HB®).n Bismuth Subsalicylate (Pepto Bismol®).n Laxatives and stool softeners.n Alka-Seltzer®.

Herbal products, such as:n garlic.n green tea.n ginkgo.

Vitamins

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Check the Coumadin®/warfarin you are taking.Does the medicine seemdifferent from whatyour doctor wrote onthe prescription or lookdifferent from what youexpected? Does yourrefill look different than

what you used before? Is the color the same aswhat you were previously given? If somethingseems different, ask the pharmacist to double-check it. Most errors are first found by patients.

Check your medicine.

Always tell your doctor about all themedicines you are taking. Tell yourdoctor when you start taking newmedicine and when you stop. Bring alist of current medications, over-the-counter drugs—such as aspirin—andany vitamins and herbal products youtake.

Medicines look different: Coumadin® pills (upper row) and generic warfarin (lower row)

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Diet for Coumadin®/WarfarinUsersThe foods you eat can affect how wellCoumadin®/warfarin works for you. The mostimportant thing to remember is to eat what younormally eat and not make any major changes inyour diet without calling your doctor. Do not goon a weight loss plan while takingCoumadin®/warfarin.

Vitamin K is important for blood to clot. SinceCoumadin®/warfarin works to keep blood fromclotting, high amounts of vitamin K might workagainst Coumadin®/warfarin. The highest amountof vitamin K is found in green and leafy vegetableslike broccoli, lettuce, cabbage, and spinach. It isimportant not to change your vitamin K intake.Keep your diet the same. If you normally eat asalad for lunch, keep eating a salad for lunch.

Call your doctor if you are unable to eat forseveral days, for whatever reason. Also call if youhave stomach problems, vomiting, or diarrheathat lasts more than 1 day. These problems couldaffect your Coumadin®/warfarin dosage.

Foods high in vitamin K:

Vegetables, such as:n Broccoli.

n Cabbage.

n Brussels sprouts.

n Green onions.

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Leafy greens, such as:n Lettuce.

n Spinach.

n Turnip, collard, and mustard greens.

n Parsley.

n Kale.

Meats, such as:n Beef liver.

n Pork liver.

Othern Mayonnaise.

n Margarine.

n Canola oil.

n Soybean oil.

n Vitamins.

Limit alcohol. Alcohol can affect yourCoumadin®/warfarin dosage but it does not meanyou must avoid all alcohol. Serious problems canoccur with alcohol and Coumadin®/warfarin whenyou drink more than 2 drinks a day or when youchange your usual pattern. Binge drinking is notgood for you. Be careful on special occasions orholidays and drink only what you usually wouldon any regular day of the week.

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Share Information With YourOther Doctors

Because you areon Coumadin®/warfarin you willbe seen regularlyby the doctorwho ordered yourmedication. Youmay also seeother doctorsregularly to keepyourself healthy.

When you seeother doctors it isvery importantthat you tell themyou are taking

Coumadin®/warfarin. It is a good idea to bringthis booklet with you to your appointments. Youshould also tell your dentist and the person whocleans your teeth. If another doctor orders a newmedication for you, please call the doctor whoordered your Coumadin®/warfarin so it can benoted in your file.

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Specific Conditions

Atrial fibrillation. Atrial fibrillation is a fairlycommon heart disorder. Sometimes your heartwill beat too fast or out of rhythm and may causeblood clots.

Coumadin®/warfarin:

n Decreases the chance of blood clots.

n Helps the blood flow easier.

Deep vein thrombosis. Deep vein thrombosis(DVT) is a blood clot that has formed in a vein.The veins deep inside your leg, especially the calfand thigh, are the most common areas to find theclot. DVT can lead to damage of the blood vesselsin your leg. It can also cause a serious lungproblem. If the clot in the vein breaks away fromthe wall of the vein and travels to the lungs, it canblock blood flow to the lungs. This problem iscalled a pulmonary embolism.


n Decreases the chance of blood clots in the veins of your legs.

n Lowers your risk for DVT.

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Heart attack. A heart attack is caused by a lack ofblood supply to the heart. The lack of bloodhappens when one or more of the blood vesselspumping blood to the heart are blocked.



n Helps blood flow easier.

Heart valve replacement. There are many typesof artificial valves that are used to replace yourown heart valve. The material used to make thesevalves may cause blood to stick and form clots.Taking Coumadin®/warfarin lowers the chance ofblood clots around the valve.



Peripheral vascular disease. Peripheral vasculardisease is the buildup of plaque in the bloodvessels in your legs. Plaque is a fatty buildup thatmakes your blood vessels smaller. This buildup ofplaque reduces the flow of blood and increasesthe chance of blood clots.


n Helps blood flow easier through the smaller blood vessels.

n Decreases blood clots.

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Pregnancy and breastfeeding.

Warning!

Doctors warn against takingCoumadin®/warfarin if you are pregnantor planning to get pregnant. Coumadin®/warfarin may cause birth defects orbleeding that may harm or even lead tothe death of your unborn child.

If you are pregnant orplanning to get pregnant,tell your doctor. If you arepregnant and your doctorwants you to takeCoumadin®/warfarin, youmust be watched closelyby the doctor whoordered yourCoumadin®/warfarin andthe doctor who is caringfor you while you arepregnant and/orbreastfeeding.

If you are planning to breastfeed your baby or arealready breastfeeding, talk to your doctor. Yourdoctor may need to test you and your baby forthe effects of Coumadin®/warfarin.

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Pulmonary embolism. Pulmonary embolism is aserious health problem. In pulmonary embolism,a blood clot that formed in another part of yourbody, such as in your leg, breaks loose and movesthrough the blood to your lungs. The clot thengets stuck within a blood vessel that brings bloodto the lungs. The clot blocks the blood vessel soyour lungs do not get blood flow. If the lungscannot get enough blood, they will be damaged,and you will have difficulty breathing.



n Lowers your risk of pulmonary embolism.

Stroke. A stroke is sometimes called a brainattack. The cause of most strokes is a blood clotthat blocks a blood vessel in the brain. Thisblockage cuts off the blood flow to a part of thebrain. When the brain does not get enough bloodflow, the brain cells begin to die and braindamage can happen. Think about a hose attachedto a sprinkler for watering your lawn in the heatof summer. If there is a blockage in the hose, thewater will not come out of the sprinkler. After astroke, the type of problems the patient has

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depends on what part of the brain got blockedand did not get blood flow.


n Decreases the chance of blood clots in the blood vessels of your brain.

n Lowers your risk for a stroke.

Valvular heart disease. Valvular heart disease isany problem in one or more of the four valves inthe heart. Heart valves keep blood flowing in onedirection. They act as a door that swings openallowing blood to flow through the sections ofthe heart. The valve or door tightly shuts toprevent blood from backing up to where it camefrom. Valves can become thick, stiff, and narrow.This makes it hard for blood to get through thedoor. Valves can become floppy, just like a doorthat doesn’t shut tightly, and blood leaksbackward. When heart valves are not working likethey should, blood flow can become slowed andclots can form.


n Lowers the chance of blood clots.

n Helps blood flow easier.

U.S. Department ofHealth and Human Services

Public Health ServiceAgency for Healthcare Research and Quality540 Gaither RoadRockville, MD 20850

AHRQ Pub. No. 08-0028-AFebruary 2008

www.ahrq.gov

your guide to coumadin(r)/warfarin therapy

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