Dosing

Initial<5mg:Elderly,CHF,malnutrition,liverdysfunction,high riskofbleeds Initial5mg:Otherwisehealthy Maintenance: 210mg/day Misseddose: Takeassoonaspossibleduringthe sameday.Donotdoubleuponthenextday.

Contraindications
Pregnancy Activebleeds Highnoncomplianceriskincludingalcoholismorpsychosis Regionalorlumbarblockanesthesia Blooddyscrasias Recentneuro,ocular,ortraumaticsurgeries

Indications
DVT/PE:Goal23 1stepisode(knownreversiblecause):3months 1stepisode(idiopathic):612months 2episodes:indefinite Afib:Goal23 Indefinite PostMI:Goal23 3monthspluslowdoseaspirin Valves:durationvariesbyvalvetype Bioprostheticvalve:Goal23 Mechanicalvalve:Goal2.53.5

SignsofOverdose
Melena Gumbleeds Petechiae Excessivebleeding Epistaxis Hematuria Excessivemenstruation

Skinnecrosisisarare,butseriousADR Herbalproducts Increaseeffect

Cranberryjuice,garlic,ginger,ginkgobiloba,ginseng

Decreaseeffect
Greentea,St.JohnsWort

Lastupdated5.15.10

Lastupdated5.15.10

PotentialDrugInteractions Increasedeffect/Toxicity
Flagyl Amiodarone SSRIs TCAs Bblockers Levothyroxine Phenytoin(initially) Fluconazole Bactrim Quinolones Allopurinol Omeprazole Statins(exceptPravachol) Alcohol(bingedrinking)

CounselingMUSTInclude: Reasonforanticoagulation Importanceofcarefuladherence Interactionswithfoodsanddrugs Bleedingriskandinjuryprevention Unsafealcoholconsumption ImportanceoffollowupINRmonitoring

Decreasedeffect
Barbiturates Rifampin Antacids Phenytoin(chronically) Nafcillin

Griseofulvin Hormonalcontraceptives Carbamazepine Bileacidsequestrants Alcohol(chronically)

VitaminK:VitaminKcandecreasetheeffectof CoumadinanddecreasetheINR.CONSISTENCYiskey! FoodshighinVitaminK

Broccoli Asparagus Collardgreens Cabbage Spinach Turnipgreens Lettuce Mayonnaise Brusselsprouts Nutritionalsupplementaldrinks:Boost,Ensure,Slimfast

Turningonthevideo: TurnonTV SelectPatientEducation ScrolldowntoselectHeartHealth ScrolldowntoselectStayingActive/HealthyWith BloodThinners

Lastupdated5.15.10

REFERENCES: Furie,B,Bouchard,BA,Furie,BC.Blood1999;93:1798 LexiCompOnlineResource.LexiDrugscopyright2009. AnsellJ;HirshJ;HylekE;JacobsonA;CrowtherM;PalaretiG.Pharmacology andmanagementofthevitaminKantagonists:AmericanCollegeofChest PhysiciansEvidenceBasedClinicalPracticeGuidelines(8thEdition).Chest. 2008Jun;133(6Suppl):160S198S. LimdiNA,VeenstraDL.WarfarinPharmacogenetics:RoleofCYP2C9and VKORC1EnzymesinWarfarinPharmacokineticsandPharmacodynamics. Pharmacotherapy.2008;28:10841097

Lastupdated5.15.10