warfarin sodium

(war' far in)

Coumadin, Warfilone (CAN)

Pregnancy Category X

Drug classes
Oral anticoagulant
Coumarin derivative

Therapeutic actions
Interferes with the hepatic synthesis of vitamin K-dependent clotting factors (factors II-
prothrombin, VII, IX, and X), resulting in their eventual depletion and prolongation of
clotting times.

Indications
• Venous thrombosis and its extension, treatment, and prophylaxis
• Treatment of thromboembolic complications of atrial fibrillation with
embolization, and cardiac valve replacement
• Pulmonary embolism, treatment, and prophylaxis
• Prophylaxis of systemic embolization after acute MI
• Unlabeld uses: prevention of recurrent TIAs, prevention of recurrent MI, adjunct
to therapy in small-cell carcinoma of the lung

Contraindications and cautions

• Contraindicated with allergy to warfarin; SBE; hemorrhagic disorders; TB;
hepatic diseases; GI ulcers; renal disease; indwelling catheters, spinal puncture;
aneurysm; diabetes; visceral carcinoma; uncontrolled hypertension; severe trauma
(including recent or contemplated CNS, eye surgery; recent placement of IUD);
threatened abortion, menometrorrhagia; pregnancy (fetal damage and death);
lactation (suggest using heparin if anticoagulation is required).
• Use cautiously with CHF, diarrhea, fever; thyrotoxicosis; senile, psychotic, or
depressed patients.

Available forms
Tablets—1, 2, 2.5, 3, 4, 5, 6, 7.5, 10 mg; powder for injection—2 mg

Dosages
Adjust dosage according to the one-stage PT to achieve and maintain 1.5–2.5 times the
control value or prothrombin activity 20%–30% of normal; PT ratio of 1.3–1.5 or INR of
2–3. IV use is reserved for situations in which oral warfarin is not feasible. Dosages are
the same for oral and IV forms.
ADULTS
Initially, 2–5 mg/day PO. Adjust dose according to PT response. For maintenance, 2–
10 mg/day PO based on PT ratio or INR.
GERIATRIC PATIENTS
Lower doses are usually needed; begin dosage lower than adult recommended and closely
monitor PT ratio or INR.

Pharmacokinetics
Route Peak Duration
Oral 1.5–3 days 2–5 days

Metabolism: Hepatic; T1/2: 1–2.5 days

Distribution: Crosses placenta; enters breast milk
Excretion: Feces and urine

IV facts
Preparation: Reconstitute vial with 2.7 mL of sterile water. Protect from light. Use
within 4 hr of reconstitution.
Infusion: Inject slowly over 1–2 min; switch to oral preparation as soon as possible.

Adverse effects
• Dermatologic: Alopecia, urticaria, dermatitis
• GI: Nausea, vomiting, anorexia, abdominal cramping, diarrhea, retroperitoneal
hematoma, hepatitis, jaundice, mouth ulcers
• GU: Priapism, nephropathy, red-orange urine
• Hematologic: Granulocytosis, leukopenia, eosinophilia; hemorrhage; GI or
urinary tract bleeding (hematuria, dark stools; paralytic ileus, intestinal
obstruction from hemorrhage into GI tract); petechiae and purpura, bleeding from
mucous membranes; hemorrhagic infarction, vasculitis, skin necrosis of female
breast; adrenal hemorrhage and resultant adrenal insufficiency; compressive
neuropathy secondary to hemorrhage near a nerve
• Other: Fever, "purple toes" syndrome

Interactions
Drug-drug
• Increased bleeding tendencies with salicylates, chloral hydrate, phenylbutazone,
clofibrate, disulfiram, chloramphenicol, metronidazole, cimetidine, ranitidine, co-
trimoxazole, sulfinpyrazone, quinidine, quinine, oxyphenbutazone, thyroid drugs,
glucagon, danazol, erythromycin, androgens, amiodarone, cefamandole,
cefoperazone, cefotetan, moxalactam, cefazolin, cefoxitin, ceftriaxone,
meclofenamate, mefenamic acid, famotidine, nizatidine, nalidixic acid
• Decreased anticoagulation effect may occur with barbiturates, griseofulvin,
rifampin, phenytoin, glutethimide, carbamazepine, vitamin K, vitamin E,
cholestyramine, aminoglutethimide, ethchlorvynol
• Altered effects with methimazole, propylthiouracil
• Increased activity and toxicity of phenytoin when taken with oral anticoagulants
Drug-lab test
• Red-orange discoloration of alkaline urine may interfere with some lab tests
Drug-alternative therapy
• Increased risk of bleeding if combined with angelica, cat's claw, chamomile,
chondroitin, feverfew, garlic, ginkgo, goldenseal, grape seed extract, green leaf
tea, horse chestnut seed, psyllium, and tumeric therapy

Nursing considerations
Assessment
• History: Allergy to warfarin; SBE; hemorrhagic disorders; TB; hepatic diseases;
GI ulcers; renal disease; indwelling catheters, spinal puncture; aneurysm;
diabetes; visceral carcinoma; uncontrolled hypertension; severe trauma;
threatened abortion, menometrorrhagia; pregnancy; lactation; CHF, diarrhea,
fever; thyrotoxicosis; senile, psychotic or depressed patients
• Physical: Skin lesions, color, temperature; orientation, reflexes, affect; P, BP,
peripheral perfusion, baseline ECG; R, adventitious sounds; liver evaluation,
bowel sounds, normal output; CBC, urinalysis, guaiac stools, PT, renal and
hepatic function tests

Interventions
• Do not use drug if patient is pregnant (heparin is anticoagulant of choice); advise
patient to use contraceptives.
• Monitor PT ratio or INR regularly to adjust dosage.
• Administer IV form to patients stabilized on Coumadin who are not able to take
oral drug. Dosages are the same. Return to oral form as soon as feasible.
• Do not change brand names once stabilized; bioavailability may be a problem.
• Evaluate patient regularly for signs of blood loss (petechiae, bleeding gums,
bruises, dark stools, dark urine). Maintain PT ratio of 1.3–1.5, 1.5–2 with
mechanical prosthetic valves or recurrent systemic embolism; INR ratio of 2–3,
3–4.5 with mechanical prosthetic valves or recurrent systemic emboli.
• Do not give patient any IM injections.
• Double check all drugs ordered for potential drug interaction; dosage of both
drugs may need to be adjusted.
• Use caution when discontinuing other drugs; warfarin dosage may need to be
adjusted; carefully monitor PT values.
• Keep vitamin K readily available in case of overdose.
• Arrange for frequent follow-up, including blood tests to evaluate drug effects.
• Evaluate for therapeutic effects: PT 1.5–2.5 times the control value; PT ratio, INR
within therapeutic range.

Teaching points
• Many factors may change your body's response to this drug—fever, change of
diet, change of environment, other medications. Your dosage may have to be
changed repeatedly. Write down changes that are prescribed.
• Do not start or stop taking any medication without consulting your health care
provider. Other drugs can affect your anticoagulant; starting or stopping another
drug can cause excessive bleeding or interfere with the desired drug effects.
 • Carry or wear a medical ID tag to alert emergency medical personnel that you are
taking this drug.
• Avoid situations in which you could be easily injured (contact sports, shaving
with a straight razor).
• Have periodic blood tests to check on the drug action. These tests are important.
• Use contraception; do not become pregnant while taking this drug.
• These side effects may occur: Stomach bloating, cramps (transient); loss of hair,
rash; orange-red discoloration to the urine (if upsetting, add vinegar to your urine
and the color should disappear).
• Report unusual bleeding (from brushing your teeth, excessive bleeding from
injuries, excessive bruising), black or bloody stools, cloudy or dark urine, sore
throat, fever, chills, severe headaches, dizziness, suspected pregnancy.

Adverse effects in Italic are most common; those in Bold are life-threatening.