Health M atters

Warfarin (Coumadin®) You are taking Warfarin to prevent blood clots from forming. The more you know about Warfarin, the better you will be able to participate in managing your treatment. This booklet covers many safety issues that you must know about while taking this medication.

What is Warfarin? Warfarin is an anticoagulant. Anti means ‘against,’ and coagulant means ‘causing the blood to clot.’ Warfarin helps prevent blood clots from forming in your blood vessels. It can also help keep any clots you have from getting larger. Blood clots are dangerous because they can slow blood flow to your heart or brain. A blood clot may break off and travel to your lungs, brain, or heart.

How do I take my Warfarin? When taking Warfarin: • Take it at the same time each day and only once a day. • Use a daily pillbox to keep track of your doses. • If you forget to take the prescribed dose of Warfarin at the scheduled time, the dose should be taken as soon as possible on the same day. • You should not take the missed dose by doubling the daily dose to make up for missed doses. Do not take a double dose! • Always tell your health care provider about each missed dose.

How do I store my Warfarin? Store your pills at room temperature. Avoid extreme cold, heat, light, or dampness. Bathrooms are not a good place to keep Warfarin or any medication. Keep Warfarin and all medications away from children and pets.

How will my health care provider know if my Warfarin dose is right for me? Your health care provider will decide how much Warfarin you should take by testing your blood. The test shows how fast your blood clots. When you first start taking Warfarin, you will need a daily blood test. Then the test will be done weekly or monthly. This test is called the INR (International Normalized Ratio). It tells us that your Warfarin is working OK. If your INR is too high, your blood will take a long time to clot. If your INR is too low, your blood will clot more quickly. Your Warfarin dose will be changed based on your blood test result. This will help keep your INR at the right level. Your health care provider will decide what INR range is best for you.

What are the side effects and what do I need to do? q Bleeding Bleeding is the most common side effect of Warfarin.

Ø First Aid If you cut yourself, apply firm pressure to the area for 15 minutes. If the cut does not stop bleeding after 15 minutes, keep pressure on the area and go to the nearest emergency room. If the cut is large, apply firm pressure and immediately call 911 or go to the nearest emergency room. If you have a bad fall, hit your head, or are in an accident, call 911 or go to the nearest emergency room.

Ø Slight Bleeding You may have slight bleeding once in a while. Tell your health care provider if you have any of these signs:

Slight Bleeding • • •

Gums bleeding while brushing teeth Occasional nosebleeds Easy bruising • Menstrual bleeding that lasts longer than usual

Ø Major Bleeding Immediately call your health care provider or go to the nearest emergency room if you have any of these signs:

Major Bleeding • • • • • • • • • • • • •

Cut that will not stop bleeding within 15 minutes Unusual headache Feeling dizzy or faint Sudden change in speech or vision Numbness or tingling anywhere Sudden weakness in arms or legs Heavy bleeding from nose, gums or ears Coughing or vomiting blood (may look like coffee grounds) Severe pain (such as stomach ache, abdominal pain, headache) Heavy menstrual bleeding Bright red or black bowel movements or heavy hemorrhoid bleeding Red, rust, dark, coffee or cola-colored urine Pain, swelling, redness or warmth in the extremities or joints • Very tired or pale

q Blood clots Blood clots may develop if your INR is too low. Immediately call your health care provider or go to the nearest emergency room if you have any of these signs:

Blood Clots • • • • • • •

Unusual headache Feeling dizzy or faint Sudden change in speech or vision Numbness or tingling anywhere Sudden weakness in arms or legs Severe pain (such as stomach ache, abdominal pain, headache) Unusual pain, swelling, redness or warmth in the extremities or joints • Pale or cool leg, arm, finger or toe

q Skin necrosis Skin necrosis is when there is death of body tissue. It is a rare condition that can happen when taking Warfarin. It usually occurs on fat tissue such as the breast, buttocks or abdomen. It will start as a red, swollen, painful area on your skin. As it gets worse a black scab will develop. Call your health care provider immediately if you have these signs.

What else do I need to do? Many things in your everyday life can affect your Warfarin therapy. It is very important to follow all the instructions you are given by your health care team. Ø Diet: What you eat has a big effect on how Warfarin works. Vitamin K is a nutrient you need for many reasons. Vitamin K helps stop bleeding. Since you are taking Warfarin to stop blood clots from forming or getting larger, the amount of Vitamin K in your diet can affect how the Warfarin you take works. It is important that you eat some foods that contain Vitamin K for good nutrition. But, it is also important that you do not eat too much of these foods. • Your vitamin K intake should be about the same from week to week. • Foods with the most vitamin K are dark green and leafy vegetables (like broccoli and spinach). Based on the Vitamin K Point List below, try to eat about the same number of “Vitamin K points” each day (up to 16 per day). Your vitamin K points can vary up to 5 points a day. For example, if you normally eat 10 vitamin K points each day, then you can eat from 5 to 15 vitamin K points daily.

Vitamin K Point List Vitamin K Content High

Medium

Low

Food

Serving Size

Vitamin K Points

Collards (frozen), cooked

½ cup

11

Kale (frozen), cooked

½ cup

11

Spinach (frozen), chopped or leaf, cooked

½ cup

10

Turnip greens (frozen), cooked

½ cup

9

Mustard greens (frozen), cooked

½ cup

5

Brussels sprouts (frozen), cooked

½ cup

3

Parsley, raw

2 TBSP

3

Broccoli, cooked

½ cup

2

Cabbage, shredded, cooked

½ cup

2

Asparagus (frozen), cooked

½ cup

1

Beans, Green, snap (regular canned)

½ cup

1

Endive, chopped, raw

½ cup

1

Kelp (seaweed), raw

½ cup

1

Lettuce, Boston & Bibb, shredded or chopped, raw Lettuce, Green leaf, shredded, raw

1 cup

1

1 cup

1

Lettuce, Red leaf, shredded, raw

1 cup

1

Lettuce, Romaine/Cos, raw

1 cup

1

Okra (frozen), sliced, cooked

½ cup

1

2 medium (4 1/8") 1 cup

1

½ cup

0

Spring onion/scallion (including tops and bulb), raw Lettuce, Iceberg, shredded, raw Peas, Green, cooked

0

While taking Warfarin, keep your intake of foods with vitamin K steady. Each vitamin K point = about 50 micrograms of vitamin K Check these websites for the vitamin K content of foods: http://www.nal.usda.gov/fnic/foodcomp/search/ http://www.nal.usda.gov/fnic/foodcomp/Data/SR20/nutrlist/sr20a430.pdf If you have a question about a food that is not listed, speak with a Registered Dietitian (RD).

Grapefruit and grapefruit juice, mango, avocado and soy milk can affect how the Warfarin you take works. Make sure to let your health care provider know if you eat these foods. Cranberry juice and products might affect how the Warfarin you take works. There is a concern that drinking cranberry juice may increase the effect of Warfarin and increase the INR. This concern is based on reports of several patients who drank from 3 glasses to 2 quarts of cranberry juice daily for long periods of time. A formal study of 14 patients on Warfarin showed that drinking one glass of cranberry juice for 2 weeks had no effect on their INR. If you have questions about how this information relates to you, ask you health care provider. Make sure to let your health care provider know if you eat cranberries, cranberry juice or take cranberry supplements.

Ø Dietary supplements and oral supplements Many dietary and herbal supplements can increase or decrease the effect of the Warfarin you take. Dietary Supplements: • Dietary supplements include vitamins (like vitamin C or E), minerals (like calcium or iron) and botanicals (herbs and plant products, like gingko biloba or St. John’s wort). • Dietary supplements are not regulated by the government like medications. They can be sold without studying how well they work. Also, the actual content of the dietary supplements can vary. Not all dietary supplements are safe to use. • Like prescription medications, dietary supplements can have side effects or interact with other medications or dietary supplements. This can worsen health problems. • Always tell your health care provider if you are taking a dietary supplement. Make sure you tell them before stopping or starting any dietary supplements. Vitamin Supplements (like One-A-Day® and Centrum®): • While taking Warfarin, do not take any vitamin supplement that has more than 100% of the Recommended Daily Allowance (RDA) of any vitamin and especially of vitamins A, D, E, or K. • The vitamin K in supplements is absorbed more easily by your body than that from food. It may have more effect on the Warfarin that you take. • Always talk with your health care provider before starting or stopping any vitamin supplement. Botanicals – Herbal Supplements and Herbal Teas: • There are many herbal supplements and herbal teas that you should not use while taking Warfarin. This is because they can make your INR to go too high or too low. Examples of herbal products to avoid are listed in the chart on the next page.

•

•

Foods like garlic, ginger, clove, onions, parsley or horseradish are usually safe when you eat in the small amounts you use in cooking (for example, ½ teaspoon minced garlic in a recipe is fine). You should avoid these foods assupplements (see the list on the next page) If you have questions about a specific ingredient or recipe, speak with a Registered Dietitian (RD).

Examples of Commonly Used Supplements and Herbal Teas to Avoid While Taking Warfarin Remember! Do not take any supplement or drink any herbal teas unless you discuss this with your health care provider first. Alfalfa Aloe gel Aniseed Black cohosh Bromelains Capsicum Chamomile (German, Roman) Clove Coenzyme Q-10 (ubidecarenone) Cranberry Dandelion Danshen

Dong quai (Angelica sinensis) Fenugreek Feverfew Fish Oil Garlic German Sarsaparilla Ginger Gingko biloba Ginseng (Panax) Goldenseal Horse chestnut Horseradish

Inositol nicotinate Licorice Mistletoe Nettle Onion Parsley Pau d’arco Red clover Senega St. John’s wort Wintergreen

Oral Supplements (like Ensure®, Glucerna® and Boost®): • Oral supplements usually do not have large amounts of vitamin K in an 8 ounce serving. • They also do contain a variety of vitamins and minerals. • Talk with your health care provider if you use oral supplements now or want to start.

Ø Other Medications and Warfarin: • •

•

Many medications, including prescription and over the counter nonprescription ones can increase or decrease the effect of the Warfarin you take. Make sure your health care provider knows all the medications you take, both prescription and non-prescription (like acetaminophen, aspirin, ibuprofen, non-steroidal anti-inflammatory drugs, cold and cough medicines, antacids, laxatives). Always talk with your health care provider before stopping or starting any medications.

Tell each of your health care providers about all of the prescription and non-prescription medications, dietary supplements and oral supplements that you take. Do not make any changes without telling your health care providers first! Ø Alcohol • •

Alcohol can interfere with Warfarin and other medications. Alcohol can lead to falls. Falling while on Warfarin can cause serious injuries. • If you drink alcohol, talk with your health care provider.

Ø Exercise • •

Speak with your health care provider before you start a new exercise program, or try to gain or lose weight. Avoid activities that could cause injury (such as football, wrestling, boxing).

Ø Daily Activities • Use an electric razor or hair-removal creams for shaving. • Use a soft-bristle tooth brush and waxed dental floss. Brush and floss your teeth gently. • Do not use toothpicks. • Wear shoes outside. Wear shoes or non-skid slippers inside. • Cut your toenails with care. Do not trim corns or calluses yourself. • Use knives or scissors with care. • Wear gardening gloves when you do yard work. • Wear gloves when using sharp tools and be very careful. • After getting your blood taken hold gauze firmly on the site for 5 minutes. Ø Check your house for safety hazards: Ÿ Remove all throw rugs and non-skid rugs, to prevent slipping. Ÿ Place all power cords away from walkways. Ÿ Make sure handrails are in place by stairs. Ÿ Install grab bars by the toilet and in the shower, if possible. Ÿ Put a non-skid tub mat in the shower. Ÿ Make sure there is good lighting in your home. Place a flashlight by your bed. Use nightlights.

Ø Travel Talk with your health care provider before traveling. You may need to have a blood test and your Warfarin dose adjusted before leaving. Always carry your medications with you when you travel. Do not put your medications in your luggage. Do not leave them in the car.

Ø Smoking Tell your health care provider if you smoke. Changes in the amount you smoke can affect your INR. Ø Surgery and Dental Work Tell all your doctors and dentists that you take Warfarin. You might need to have a blood test and stop your Warfarin before a dental or surgical procedure. Speak with your surgeon or dentist about your Warfarin before any kind of procedure. Your surgeon or dentist may need to talk with the health care provider who manages your Warfarin.

Ø Pregnancy and Lactation Women taking Warfarin should avoid pregnancy. They should use at least two forms of birth control while taking Warfarin. Warfarin can cause death or serious birth defects in the unborn baby. If you plan to become pregnant, be sure to speak with your health care provider to discuss the possible risks and how to reduce them. If you become or think you are pregnant while taking Warfarin, tell your health care provider immediately. Women who are or want to breastfeed their babies should speak with their health care providers. Warfarin can increase bleeding in the baby. Both the mother and baby need to be closely watched for bleeding if the mother breastfeeds.

What else do I need to know? Keep your healthcare provider’s telephone number with you. Wear or carry identification that says you are taking Warfarin. If you have vomiting, diarrhea, infection, or fever, call your healthcare provider. Being sick can change how Warfarin works. Do not switch brands of Warfarin without speaking with your health care provider.

Always talk to your healthcare provider before changing your medications, vitamins, herbal supplements, diet or exercise regimen.

This information is brief and general. It should not be the only source of your information on this health care topic. It is not to be used or relied on for diagnosis or treatment. It does not take the place of instructions from your doctor. Talk to your health care providers before making a health care decision. Copyright NewYork-Presbyterian Hospital. 2008. All rights reserved. RL 6.6 SAM 62.5 Date 9/08.