Coumadin (Warfarin) Management Protocol (RN Only)

Coumadin (Warfarin) Management Protocol (RN Only)

1. This protocol is provided as a standardized guideline for Warfarin management by the RN because a patient with need for antithrombotic therapy is high risk for medical complications and requires close monitoring.

2. The two target ranges for anticoagulation intensity are:

a.Low2.0 -- 3.0

b.High2.5 -- 3.5

3. Decisions to adjust dosage are based upon INR trends versus a single value.

4. Basis for dosage adjustments:

1. Critical and very high states are evaluated to determine the possible cause and to correct any cause found. Occasionally these patients need hospitalization.
2. High & low states may require dosage adjustments. See algorithms.

5.Dosing principles:

a.Large INR fluctuations are avoided by:

1. Percentage (10-50%) changes in dose rather than holding or doubling dose.
2. Keeping day-to-day dosage changes to the smallest amount possible.
3. Daily dosing at the same time every day, preferably in the evening.
4. Wherever possible using small and methodical rather than large and aggressive dosing changes.

b.Weekly total dosage is used for evaluating and adjusting dosing schedules.

1. Tablet strengths are selected in order to keep the number of tablet sizes used to a minimum.

6. Follow-up intervals:

1. Follow-up intervals are guidelines and can be shorter or longer depending on risk factors, previous experiences, weekends, and convenience.
2. Maximum follow-up interval is 4 weeks except in unusual circumstances.
3. Follow up interval may be extended up to 3 months with provider approval if the INR is consistently stable with no change in Warfarin dose for greater than 6 months.

Initiation of Coumadin

1. See attached Warfarin Management Protocol number b. Initiation of Warfarin

Location of documents in the chart

1. Warfarin Management flow sheet and education records will be kept in the electronic health record

Date initiated: October 1, 2003

Date Revised: February 1, 2008, March 7, 2011, October 8, 2013

Date Reviewed: February 2, 2009, March 10, 2009, October 17, 2011

Next Review: October 2016, Medical Director

Emily Anderson, MDDate

Medical Director

Attachments:Warfarin-RN Teaching Guide

Warfarin Management

Warfarin Guidelines/Information Sheet

Warfarin “Do’s and Don’ts Quick guide

Warfarin Management Protocol

a.Maintenance Dosing and Monitoring of Warfarin

b.Initiation of Warfarin

c.High INR Algorithm

Warfarin-RN Teaching Guide

Upon initiation of Warfarin therapy, the provider will refer the patient to the Nurses who will provide patients with education regarding Warfarin use to include the following:

1. Introduction:

1. Provide patient with information explaining procedures involved in Warfarin management
2. Provide the patient with written information about Warfarin, lab testing, complications, risks, diet, and lifestyle

1. Education session(s) schedules to impart general information about Warfarin, lab testing, complications, risks, diet and lifestyle. (See Warfarin Guidelines/Information Sheet and Do’s & Don’ts Quick guide).

1. The attached education topic list:
2. Will be used by the RN to track teaching points
3. Will be used by the RN to note areas where further instruction is needed
4. Will be documented in the patient’s chart

1. Providers will be advised by the RN if any patient is unable or unwilling to follow the protocol as outlined. The provider will then need to make the risk/benefit recommendation about continuation of Warfarin therapy.

Warfarin Guidelines/ Information Sheet

A. General Facts

What is Warfarin?

Warfarin is an anticoagulant. Anti means against and coagulant refers to blood clotting. Warfarin helps prevent clots from forming in the blood. Warfarin is the generic name of the drug; Coumadin and Jantoven are brand names.

Reasons for Warfarin:

1. To reduce the formation of blood clots.

2.To reduce the risk of heart attack.

3. To reduce the risk of stroke.

4.To reduce your risk of death from certain conditions.

What it does:

1. Warfarin works by blocking the formation of vitamin K-dependent clotting factors in your liver.

2. It reduces clot formation in the blood stream, but it does not break up existing clots.

3. Warfarin does not take full effect until 3-5 days.

4. If your provider stops your Warfarin, the effects may last for about 2-5 days.

Length of Treatment:

1. Depends upon your diagnosis.

2. Patients will be advised of the expected end of treatment date.

B. Warfarin Brands

Generic vs. Brand Names

1. Either generic or brand name Warfarin can be used for anticoagulant effect.

a. The brand initially chosen must be continued during therapy.

b. If the brand is switched during therapy, dosage adjustments and INR testing will be more frequent and therapy may not be dependable.

C. Side Effects / Possible Complications

Risks and Signs of Bleeding:

1. Excessive bleeding can increase your risk of anemia and heart attack or stroke.

2. Signs of bleeding are:

-Increased bleeding or bruising (after shaving, after brushing teeth, during menstruation)

-Headache, dizziness, or weakness

- Frequent or prolonged nosebleeds

-Vomiting or coughing up blood – call your doctor immediately

-Unusual bruising for unknown reasons/minimal trauma

Risks and Signs of Bleeding Continued:

-Bloody or dark brown urine

-Bloody or black looking stool

-Unusual pains or swelling

-Dark Purple or Black Toes – call your doctor immediately

Risks and Signs of Clotting:

1. Excessive clotting can increase your risk of heart attack, pulmonary embolus, or stroke.

2. Signs of excessive clotting are:

-Sudden onset of shortness of breath

-Sudden onset of sharp chest pain often associated with shortness of breath

-Leg or other extremity pain or swelling

-Leg or other extremity pain with discoloration

If Signs of Bleeding or Signs of Clotting Should Occur:

1. Call your provider and arrange for an appointment in the next 24 hours.

2. If your symptoms are interfering with your everyday tasks (particularly pain, shortness of breath, or bright red blood) go directly to the emergency room.

D. Taking Your Warfarin

Timing of Daily Dose:

1. Take your Warfarin the same time every day.

2. Best taken in the evening. (allows for ease of dosing changes)

3. Verify your correct dose of Warfarin on the bottle every time you take it.

4. If dose is missed, take the missed dose as soon as possible on the same day.

5. Do not take a double dose on the following day to make up for a missed dose.

6.If two daily doses in a row are missed, call your provider for advice.

Dosage Adjustments:

1.Will be based on your diagnosis, goal range, and INR results.

2.Directed by your provider.

3. Should not be adjusted without the knowledge of your provider.

4. Are used to control the “thinning” of the blood.

E. Lab Testing / Protime / INR

What is Protime/INR?

Protime is the shortened word for Prothrombin Time. This lab test measures how many seconds it takes the blood to clot. This result is used in a formula to come up with the “INR” or International Normalized Ratio. Using the INR allows for a standard result no matter what machine was used or what facility you go to. INR testing is very important. It helps your provider determine how fast your blood is clotting and whether your dose of Warfarin should change.

Scheduling INR Testing

1. Regularly scheduled INR testing is needed for your safety and continued good health.

2. Frequent testing is required on initiation of therapy and can usually be less frequent once the proper dose is reached.

3. The longest amount of time between INR testing should be 3-4 weeks.

4. Expect that you will receive information regarding dosage adjustment either immediately after your test or within 24 hours of having your INR performed.

5. Please call our clinic if you have not been contacted within 24 hours of your INR.

6. Several factors may affect your INR such as: sickness, stress, diet, surgery, medications, and increased physical activities and may require more frequent testing.

7. If you plan on traveling, you may need an INR test before you leave, or you may have to schedule one elsewhere.

F. Drug/Medication Interactions

Medications That Interact With Warfarin:

1. Because of many drug interactions with over-the-counter as well as prescription medications, please consult your health care provider before taking a new medication.

2. Always notify any health care provider, including your dentist, that you are taking Warfarin.

3. If starting a new medication that could interact with Warfarin, your provider may want to check your INR within 5 days of starting it.

4. Some of the medications that interact with Warfarin:

a. Tylenol (Acetaminophen)

b. Aspirin and aspirin containing ointments and skin creams

c. Ibuprofen (Motrin, Advil, Nuprin)

d. Naprosyn (Aleve, Orudis)

e. H2-receptor antagonists (Tagamet, Zantac, Pepcid)

f. Many antibiotics

5. Some of the vitamin/herbal preparations that interact with Warfarin:

a. Bromelains (plant enzymes) f. Clover

b. Cranberry and grapefruit products g. Coenzyme Q10

c. Garlic h. Green tea

d. Ginko i. Licorice

e. St. John’s Wort j. Black cohosh

6.Do not take Metamucil or other fiber supplements at the same time as your Warfarin. It may make it harder for your body to absorb it. Wait at least 2 hours before or after taking fiber.

G. Nutrition and Diet

All About Vitamin K

Since Warfarin works by blocking the formation of vitamin K-dependent clotting factors in your liver, the intake of vitamin K in your diet can affect your therapy. Vitamin K is found in many foods and beverages. Most of the time these substances are not marked as containing vitamin K. It is important for you to keep your diet consistent so the amount of vitamin K you eat is consistent. You should however, avoid cranberry and grapefruit juice as they may alter liver process and affect therapy. If you travel, try to keep your eating habits and activity level as close to your usual routine as possible.

Some Foods High in Vitamin K:

-Leafy green vegetables

-Legumes such as beans and peas

-Vegetable oils and olestra

-Mayonnaise

-Herbal tea made with tonka beans, sweet clover, or sweet woodruff

-Green tea

-Boost and Ensure supplements, dieting drinks such as Slim Fast

Some Foods Low in Vitamin K:

-Roots, bulbs and tubers (carrots, onions, potatoes)

-Fleshy portion of fruits and fruit juices (remember to avoid cranberry and grapefruit juice)

-Cereal grains

-Most meats and fish

H. Lifestyle

Medical Care

Inform all providers of your use of Warfarin. This includes physicians, nurses, dentists, chiropractors, massage therapists and emergency room staff.

Activities

Avoid activities with high risk of injury. If you have questions, please ask your provider about that activity or sport. Exercise may decrease INR. Be consistent with exercise.

Fall and Injury Prevention

Do your best to reduce your risk of falling or suffering injury by removing throw rugs and any other obstacles on your floor or in your workplace. Be careful around stairs and if inclement/icy weather outside. If you take a serious fall or hit your head go to ER.

Surgery / Dentistry

Always consult your provider if surgery or dental procedures are planned. Adjustments in your INR and Warfarin therapy will need to be made under the supervision of your provider. Do not undertake surgery or dentistry without informing your provider and your dentist or surgeon.

Alcohol Use

Avoid alcohol. Alcohol can change the way your body responds to Warfarin. It may also change your absorption of nutrients and may increase your risk of bleeding from the stomach. It may put you at more risk for falls.

Tobacco Use

As well as being a health risk, fluctuations in tobacco use may affect your INR results.

Warfarin “Do’s and Don’ts Quick guide

Do’s

1. Do take your Warfarin as your provider advises
2. Do keep eating habits and activities similar each day
3. Do get your blood tested when you are supposed to
4. Do tell your healthcare provider about any other medications you are thinking about taking before you take them
5. Do go to your health care provider when you get sick, get hurt, or get a cut that will not stop bleeding
6. Do look for signs of bleeding. Tell your healthcare provider immediately. Your healthcare provider will decide if you need medical attention
7. Do tell anyone giving you medical or dental care that you are taking Warfarin
8. Do refill your prescriptions according to your healthcare provider’s orders
9. Do consider wearing a medical alert bracelet or carry a patient identification card indicating that you take Warfarin
10. Do tell your healthcare provider if you are planning to travel or will be unable to return for laboratory testing at the proper interval

Don’ts

1. Do not take an extra tablet to catch up
2. Do not take Warfarin if you are pregnant or may become pregnant
3. Do not take any medications before asking your healthcare provider
4. Do not switch brands of Warfarin unless specifically directed by our healthcare provider
5. Do not take Coumadin and generic Warfarin at the same time
6. Do not avoid foods that have vitamin K, simply keep your diet consistent
7. Avoid drastic changes in your dietary habits
8. Avoid alcohol consumption
9. Avoid activities or sport that may result in injury

Warfarin Management Protocol

A. Initiation of Warfarin

In stable patients initiating warfarin the 5 mg initiation protocol should be followed:

1. Obtain baseline INR and Initiate 5 mg daily for days 1-3
2. Schedule RN teaching Session
3. Obtain INR on day 4 and follow initiation protocol for days 4-7
4. Check INR on day 7 and make adjustments following maintenance protocol.

Note: When initiating Warfarin it takes 10-14 days to reach a steady state in the body, follow up should occur more frequently until INR is on a stable weekly dose.

Warfarin 5mg Initiation Protocol (Target 2.0-3.0)
Day / INR / Dosage
Day 1-3 / - / 5 mg
Day 4 / < 1.5 / 10 mg
1.5-1.9 / 5-7.5 mg
2.0-3.0 / 2.5-5.0mg
>3.0 / 0-2.5 mg
Day 5 / < 1.5 / 10 mg
1.5-1.9 / 5-7.5 mg
2.0-3.0 / 2.5-5.0mg
>3.0 / 0-2.5 mg
Day 6 / < 1.5 / 7.5-12.5 mg
1.5-1.9 / 5-10 mg
2.0-3.0 / 2.5- 5 mg
>3.0 / 0-2.5 mg
Day 7 / Make adjustments based on total weekly dose by following the maintenance protocol.

*Adapted Source: Crowther MA, et.al. Reply: Warfarin: less may be better. Annals of Internal Medicine 1997; 127 (4):33

*Example

1)Patient is seen in the clinic with a baseline INR of 1.0 and is initiated on 5 mg warfarin for days 1 -3.

2)Patient returns to clinic day 4 and now has an INR of 2.2, using the initiation protocol; the patient should be given a dose of warfarin between 2.5-5.0 mg daily.

3)Patient returns to clinic on day 7 and now has an INR of 2.6. The weekly dose should be estimated and the maintenance protocol should now be followed, with adjusts between 5-20%

B. Maintenance dosing and monitoring of Warfarin

INR Target 2.0-3.0
INR<1.5 / Increase weekly dose 10-20% / RTC 3-7 days
INR 1.5-1.9 / *If previously stable INR, with 1 out of range, consider continuing current dose.
*If not stable, increase weekly dose 10-15% / RTC 1-2 weeks
INR 2.0-3.0 / Continue same weekly dose / RTC 2-4 weeks
INR 3.1-3.5 / *If previously stable INR, with 1 out of range, consider continuing current dose.
*If not stable, decrease weekly dose 5-15% / RTC 1-2 weeks
INR 3.6-4.5 / Hold 1-2 doses, then decrease weekly dose 10-20% / RTC 3-7 days
INR >4.5-10 / *Alert Provider
*Hold 1-3 doses until INR is within therapeutic range, and decrease weekly dose 10-20%
*Follow High INR algorithm / RTC 3 days
INR > 10 / *Alert provider
*Follow High INR algorithm / RTC 1 day

* Table above adapted from UNC general internal medicine anticoagulation algorithm:

Follow up interval:

• If two INRs are in range then consider repeat INR in 2 weeks
• If next INR is in range then consider repeat INR in 3 weeks
• If next INR is in range then consider repeat INR in 4 weeks
• If next INR is in range then consider monthly INR
• If consistently stable INR with no change in dose for greater than 6 months consider extending follow up interval

INR Target 2.5-3.5
INR<2.0 / Increase weekly dose 10-20% / RTC 3-7 days
INR 2.0-2.4 / *If previously stable INR, with 1 out of range, consider continuing current dose.
*If not stable, increase weekly dose 10-15% / RTC 1-2 weeks
INR 2.5-3.5 / Continue same weekly dose / RTC 2-4 weeks
INR 3.6-4.0 / *If previously stable INR, with 1 out of range, consider continuing current dose.
*If not stable, decrease weekly dose 5-15% / RTC 1-2 weeks
INR 4.1-4.5 / Hold 1-2 doses, then decrease weekly dose 10-20% / RTC 3-7 days
INR >4.5-10 / *Alert Provider
*Hold 1-3 doses until INR is within therapeutic range, and decrease weekly dose 10-20%
*Follow High INR algorithm / RTC 3 days
INR > 10 / *Alert provider
*Follow High INR algorithm / RTC 1 day

* Table above adapted from UNC general internal medicine anticoagulation algorithm:

Follow up interval:

• If two INRs are in range then consider repeat INR in 2 weeks
• If next INR is in range then consider repeat INR in 3 weeks
• If next INR is in range then consider repeat INR in 4 weeks
• If next INR is in range then consider monthly INR
• If consistently stable INR with no change in dose for greater than 6 months consider extending follow up interval

C. High INR algorithm:

Source: PL Detail-Document, How to Manage High INRs in Warfarin Patients.Pharmacist’s Letter/Prescriber’s Letter. May 2012.

Lake SuperiorCommunityHealthCenterPage 1 of 12

Coumadin/Warfarin Management Protocol

Medical– Medication Management