warfarin flipchart

WarfarinNi sa Bula

Halo sa laketa

Talofa

Taloha ni

नमसतेSalaam

Kia ora

Welcome

Talofa lava

Kia Orana

Fakaalofa lahi atu

Malo e lelei© Warfarin Flipchart Group, 2005This is a clinical guideline only

Bonjour

Warfarin Flipchart Group:v Anne Blumgart, Principal DUE Pharmacist, CMDHBv Debi Smith, Anticoagulation Nurse Specialist, CMDHBv June Poole, Cardiac Nurse Specialist, CMDHBv Sheona Watson, Clinical Nurse Educator, CMDHBv Lauraine Cawker, Senior Cardiology Nurse, CMDHBv Elaine Chong, Dietician, CMDHB

Acknowledgements:v Reviewers: Sharon Jackson, Haematologist CMDHB & Clare

Hewison, Principal Surgical Pharmacist CMDHB v Pharmacy Department, Haematology Department & Cardiac Care

Unit at CMDHB for all their support with this projectv Roche Diagnostics New Zealandv Photography Department CMDHB

© Warfarin Flipchart Group, 2005This is a clinical guideline only

What is a clot and why did it happen?

• Blood clots are caused by a natural process in which blood cells and fibrin strands clump together to stop bleeding after a blood vessel has been injured

• They become dangerous when they block blood flow through an artery or vein

• If clots break off from the original site and travel through the bloodstream they can become stuck in another smaller blood vessel and block the blood supply there (embolus)

• Warfarin is used to thin the blood, thereby preventing blood clots from enlarging and new clots from forming (thrombi)

• Eventually blood clots dissolve over time by natural means


What is a clot and why did it happen?


Where did it happen?• Leg: A deep vein thrombosis (DVT) is a blood clot

that develops in a deep vein, usually in the leg. This can happen if the vein is damaged or if the flow of blood slows down or stops

• Lung: A blood clot usually forms in a peripheral vein and then travels back through the heart to a lung

• Heart: A small blood clot from the left atrium could travel to the coronary arteries and cause a heart attack

• Brain: A blood clot from the left atrium/ventricle could break off and block one of the arteries to the brain, causing a stroke


Where did it happen?


Clots can stick to man-made heart valves

• Blood could get trapped and clot on man-made heart valves

• Sometimes warfarin is used for six months after tissue valve insertion

• The clots could then break off and travel to other parts of the bodyØRecommend patient obtains a MedicAlert

bracelet, give form and explain procedure


Clots can stick to man-made heart valves


Atrial Fibrillation (AF)

• With AF the heart beats irregularly causing blood flow to be slowed and blood clots more likely to develop in the atria/heart

• Studies have shown that patients with AF who do not take warfarin are at increased risk of stroke


Atrial Fibrillation (AF)The heart beating normally

The heart beating irregularly - a clot can form


What makes clots more likely to happen?

• Venous blood clots usually form when blood flow becomes slowed because of damage to the inside of a blood vessel

The following make clots more likely to form:• Sitting or lying in one position for long periods of time

(immobility) (e.g. bed rest, air travel): Lack of exercise means that the blood does not flow easily through the veins

• Surgery: especially if lasts more than 30 minutes, or involves the leg joints or pelvis

• Major injuries, or paralysis• Cancer and its treatments• HRT, oral contraceptives, pregnancy• Being overweight: A substance called leptin is produced by fat

cells, which in turn affects blood cells, causing them to stick together

• Several inherited conditions


What makes clots more likely to happen?

• Surgery

• Immobility

• Being overweight

• Some inherited conditions


Warfarin stops clots from being made or getting bigger

• The brand of warfarin called Marevan® is preferred for use in New Zealand

• There is also another brand of warfarin called Coumadin®

• Marevan and Coumadin are not interchangeable• Always check that you are taking the right warfarin

tablet by checking the colour and strength• If your warfarin ever looks different to what you have

been having check with your pharmacist to ensure that you are receiving the correct brand and strength



Warfarin 1mg

Warfarin 3mg

Warfarin 5mg

Marevan

Marevan

Marevan



• The brand of warfarin called Marevan® is preferred for use in New Zealand

• There is also another brand of warfarin called Coumadin®

• Marevan and Coumadin are not interchangeable• Always check that you are taking the right warfarin

tablet by checking the colour and strength• If your warfarin ever looks different to what you have

been having check with your pharmacist to ensure that you are receiving the correct brand and strength


Coumadin

Warfarin 1mg

Coumadin

Warfarin 2mg

Coumadin

Warfarin 5mg



The right dose = the right INR

• INR 2.0-3.0: AF, cardioversion, mural thrombus, treatment of DVT or PE

• INR 2.5-3.5: Mechanical heart valves implanted after 1990

• INR 3.0-4.0: Mechanical heart valves implanted before 1990, recurrent DVT or PE whilst on warfarin

Reference1. Adult Anticoagulation Guidelines, Middlemore Hospital, CMDHB


ØTalk to your patient about his/her individual target INRTarget INR according to indication1:

ØConsult guidelines for target INR values for patients on dialysis as they may differ from above

The right dose = the right INR

1.5

2.0

2.5

3.0

3.5

4.0


Too high - may bleed

Too low - won’t work

Blood tests show how many tablets you need

• Before leaving the hospital or doctor’s surgery you will be given a laboratory form and told when to go for a blood test

• A house call can be arranged for you if you are unable to go to the laboratory

• Phone your doctor in the afternoon for the blood test results (INR)

• The doctor will tell you how many tablets to take depending on your blood test

• Write your blood test result (INR) in your warfarin book

Ø Ask the patient if they are able to work out how many tablets to take according to their current dose


Blood tests show how many tablets you need


Take your tablets at the same time every evening

Ø Discuss what time in the evening would best suit your patient to take their warfarin

• The patient should choose a convenient time and keep to that time as closely as possible

• Ask how they will remember to take their medication • Suggest they make a mark such as a cross on the

date in a warfarin book/on a calendar as a record of having taken the dose

• If a dose is forgotten it should be taken as soon as remembered

• If not remembered until the next day the patients should call their doctor to discuss what to do

• A double dose should never be taken to make up for a missed dose


Take your tablets at the same time every evening

Your doctor or nurse will tell you how many tablets to take and when to go for

your next blood test© Warfarin Flipchart Group, 2005This is a clinical guideline only

Call doctor or nurse if any of the following occurs

ØDiscuss the potential side-effects with the patient i.e. bleeding such as nose bleeds, blood in urine or stools (black bowel motions), changes to skin, gastrointestinal upsetsØDiscuss with patients that if they are ill it may

alter the effect of their warfarin treatment• Seek medical advice as soon as possible for

any unusual bruising or bleeding, severe unexplained pain, fever, vomiting, diarrhoea, infection


Call doctor or nurse if any of the following occurs:

• Any unusual bleeding or

bruising

• Severe unexplained pain

• Fever, vomiting,

diarrhoea, infection


Other medicines can affect warfarin: Ask you pharmacist or doctor about all your medicinesØStress the importance of not taking or using

any over-the-counter, herbal, or traditional medicines of any form, including topical preparations e.g. creams, without first discussing the potential for interaction with pharmacist or doctor

• Patient is only to take or use what is prescribed or recommended by doctor or pharmacist


Other medicines can affect warfarin:Ask your pharmacist or doctor

about all your medicines


Warfarin can harm an unborn baby

Ø Stress the importance of avoiding pregnancy when taking warfarin:• Warfarin crosses the placenta and can cause birth defects if taken in the

first three months of pregnancy2;3

• Warfarin can cause bleeding in the unborn baby and can also cause severe bleeding in the mother when the baby is born

• Medical advice must be obtained regarding effective contraception to prevent pregnancy when taking warfarin

• If the woman suspects she is pregnant while taking warfarin she must contact her doctor urgently

• If pregnancy is desired by a woman taking long-term warfarin, she must discuss the issue with her doctor before becoming pregnant – Review of anticoagulant management is essential, with counselling to

allow informed decision making regarding the risks associated with available anticoagulant options

References2. Therapeutics in Pregnancy and Lactation. Lee A, Inch S, Finnigan D. Therapeutics in Pregnancy and Lactation. Radcliffe Medical Press;

20003. Briggs GG, Freemand RK, Yaffe SJ. Drugs in Pregnancy and Lactation 6th ed. Philadelphia, Md: Lippincott Williams & Wilkins; 2002


Warfarin can harm an unborn baby

Don’t become pregnant

while taking

warfarin

Talk to your

doctor if you think

you might be pregnant


Warfarin can be used if you are breastfeeding

• Warfarin is considered compatible with breastfeeding, because of its poor excretion into milk and consequent lack of effects on the infants3

Reference3. Briggs GG, Freemand RK, Yaffe SJ. Drugs in Pregnancy and Lactation 6th ed. Philadelphia, Md: Lippincott

Williams & Wilkins; 2002


Warfarin can be used if you are breastfeeding


Mix your green vegetables with other coloured vegetables

• Eat a balanced diet that includes foods from all food groups

• Eat moderate amounts of different coloured vegetables (refer photos); do not eat excessive amounts of leafy greens

• Keep fat intake to a minimum• Avoid dramatic changes in the diet, unless

recommended by a health care providerØAdvise patients on dialysis to talk to a

dietician about diet (photos do not apply to these patients)


Mix your green vegetables with other coloured vegetables


Small amounts of alcohol only

• Alcohol can affect the blood thinning effect of warfarin

• Do not exceed two standard drinks per day

One standard drink is:• 300ml ordinary-strength beer• 60ml fortified wine (sherry, martini, port)• 30ml spirits (whisky, gin, vodka)• 100ml table wineØAdvise patients to avoid binge drinking


Small amounts of alcohol only


Avoid activities where you might get hurt easily and bleed too much

• Hazardous occupations or recreational activities may result in injury and bleedingØStress the need for care if the patient has a

job that may lead to injuryØStress the need to avoid sports or activities

where injury may resultØAdvise the patient to make their home

environment as safe as possible, (e.g. use a non-slip bath mat, exercise caution when using sharp knives)


Avoid activities where you might get hurt easily and bleed

too much


No new tattoos or piercing

ØAdvise patients to avoid having new tattoos or body piercing because of the increased risk of bleeding with warfarin


No new tattoos or piercing


No body massage

ØAdvise patients to avoid having massage, particularly deep tissue massage, because of the increased risk of bleeding with warfarin


No body massage


Tell your dentist that you are taking warfarin before your appointment

• Tell your dentist that you are taking warfarin before your appointment

• The possibility of bleeding from dental treatment will need to be taken into account by the dentist


Tell your dentist that you are taking warfarin before your appointment


Tell your doctor that you are taking warfarin before any surgery or

medical treatment

ØStress the need for the patient to discuss the fact that they are taking warfarin before undergoing any surgical or medical procedure to ensure that this is taken into account before, during and after treatment


Tell your doctor that you are taking warfarin before you have any surgery

or medical treatment


Follow these 3 steps:ØRevise the key steps involved in taking

warfarin:• Having a blood test on an appointed morning • Calling the doctor that same afternoon for

the INR result • Taking the prescribed dose of warfarin at the

same time each evening with a glass of water, then recording that the warfarin dose has been taken, e.g. by making a cross on a calendar


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Follow these 3 steps:


warfarin flipchart

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