Coumadin Clinic -- Contract

What is Coumadin/Warfarin?

Coumadin/Warfarin is an anticoagulant (blood thinner). It reduces the formation of blood clots by blocking the formation of certain clotting factors.

Coumadin/Warfarin is used to prevent heart attacks, strokes, and blood clots in veins, arteries and lungs. It treats or prevents clots that may occur because of a type of abnormal heartbeat (atrial fibrillation) or heart valve replacement. Coumadin/Warfarin is also used to reduce risk of death or blood clotting events after a heart attack.

Coumadin/Warfarin begins to reduce blood clotting within 24 hours after taking the first dose. However, the full effect may take 3-5 days to occur. During this time you may need to be treated with injectable low molecular weight heparin until the full effect of Coumadin/Warfarin has occurred.

What are possible signs of too much Coumadin/Warfarin or a high INR?

Minor bleeding

• Gum bleeding while brushing teeth
• Occasional nose bleed
• Easy bruising
• Prolonged bleeding after minor cuts
• Prolonged menstrual bleeding

You may notice any of these symptoms from time to time. If you are unsure whether bleeding is significant, call the office. It may be necessary to have your INR checked to be sure.

Major bleeding

• Red or dark brown urine
• Red or black tarry stool
• Vomiting up blood or "coffee ground" material
• Coughing up blood
• Severe headache or stomachache
• Unexplained bruising
• Frequent nose bleeds, bleeding gums, or unusual bleeding
• Bleeding that doesn't stop after 10 to 15 minutes or is excessive
• If you have a serious fall or if you hit your head

If you experience any of these signs or symptoms, call the office or go to emergency room immediately.

What are the symptoms of too little Coumadin/Warfarin or a low INR?

Blood clotting

• Sudden weakness in any limb
• Numbness or tingling anywhere
• Visual changes or loss of sight in either eyes
• Sudden onset of slurred speech or inability to speak
• Dizziness or faintness
• New pain, swelling, redness, or heat in extremity
• New shortness of breath or chest pain

All of the above signs and symptoms can be serious. Remember call the office or go to the emergency room right away if any of them occur.

Things that may affect Coumadin/Warfarin levels.

• Medication changes or starting a new medication. Such as antibiotics, steroids, pain medicine, cough medicine. Or taking over the counter medicine like aspirin or aspirin containing products (if your physician has prescribed a daily aspirin, it is ok to take), Vitamin K, Vitamin C, Vitamin E, Herbal supplements, laxatives such as mineral oil or Ex Lax, antacids such as Maalox, Mylanta
• If you need a medication for mild pain relief, you can use Acetaminophen (Tylenol). Limit your use of acetaminophen to no more than 2 grams per day (6 of the 325 mg tablets or 4 of the 500mg tablets.)
• If you start a new medication, especially an antibiotic, pain medicine, steroids, and cough medicine, please contact our office with the name and dosage so we may dose your Coumadin/Warfarin appropriately
• Weight loss or gain/ exercise
• Acute illness - ex: congestive heart failure episode, nausea, vomiting, fever, ect.
• Smoking
• Traveling on long trips in car or plane
• Constipation or diarrhea
• CONSISTENCY IS IMPORTANT
• Contact our office with any these changes

How does diet affect Coumadin/Warfarin?

Foods high in Vitamin K decrease the effectiveness of Coumadin/Warfarin. Example: Cauliflower, scallions, peas, garbanzo beans, asparagus, green herbal teas, coffee, liverwurst, beef liver, soybean, canola oil, spinach, kale, turnip greens, mustard greens, broccoli, cabbage, lettuce, parsley and Brussels sprouts. You can eat foods with Vitamin K, just be CONSISTENT.

These foods high in Vitamin K should be limited to 1 serving a day.

• Kale, boiled, ½ cup
• Spinach, boiled, ½ cup
• Turnip greens, boiled, ½ cup
• Collard greens, boiled, ½ cup
• Swiss chard, boiled, ½ cup
• Parsley, raw, ¼ cup
• Mustard greens, boiled, ½ cup

Foods moderately high in Vitamin K should be limited to 3 servings a day

• Brussels sprouts, boiled, ½ cup
• Spinach, raw, 1 cup
• Turnip greens, raw, 1 cup
• Green leaf lettuce, 1 cup
• Broccoli, raw, 1 cup
• Endive, raw, 1 cup
• Romaine lettuce, raw 1 cup

Avoid sudden changes in your diet.

Avoid drinking alcohol, which can increase some side effects of Coumadin/Warfarin. For special occasions, limit to 1 alcohol drink. (1 drink= 1 beer= 1 glass of wine= 1 cocktail/shot).

How Coumadin/Warfarin levels are monitored

• How well anticoagulants work varies from person to person. Their effectiveness even varies from time to time in the same person
• Your Coumadin/Warfarin level will be monitored by a blood test. It measures how long it takes for your blood to clot. The blood test used is called an INR. The usual INR range for someone not taking Coumadin/Warfarin is 1.0. The usual range for people taking Coumadin/Warfarin is 2.0-3.0. (Your range is determined by your physician and may vary, occasionally 2.5-3.5)
• When your INR is too high you are at risk for bleeding, when your INR is too low you are at risk for blood clots. It is important to try to keep your INR in range. In therapeutic doses, Coumadin/Warfarin does not cause bleeding it only makes it harder to stop. Remember CONSISTENCY IS IMPORTANT to keep you INR in range
• When you first start Coumadin/Warfarin you will need frequent blood draws. As your INR stabilizes you will need less frequent INR draws, but never go longer than 30 days to have your INR level checked. Do not miss any scheduled blood draws
• When you have your INR drawn you will be contacted by the office within 24 hours. Based off your INR range you may need a dose adjustment. You will also be notified when to get your next INR drawn
• If you have an INR drawn and we do not contact you within 24 hours please contact our office at 586 776-8877

Other things to know

• Always take Coumadin/Warfarin the same time each day, preferably in the evening or at least 15 hours before having your blood drawn. You may take it with or without food
• Never skip a pill. If you miss a dose take it as soon as you remember that day, but if it is the next day do not double up on it, take your scheduled dose
• Notify our office if you miss 2 or more doses
• Notify all of your physicians, dentist and Pharmacist that you are taking Coumadin/Warfarin
• Carry an ID card or consider wearing a medical alert bracelet
• Because Coumadin/Warfarin dose can change from day to day, you may want to use a calendar to keep track of your dose. If you get confused on your dose just call our office
• Moderate exercise and activity are safe for most people taking Coumadin/Warfarin. Avoid any activity or sport that may result in a traumatic injury
• Must keep a current relationship with your physician (be seen at least once a year) to remain in the Coumadin clinic and to have your prescription for Coumadin filled
• Contact our office if you have been hospitalized
• Call the office any time you start a new medication or have a medication change

If surgery is needed

• Call our office if your Surgeon/ Dentist wants you to hold your Coumadin/Warfarin before surgery. Your physician will determine if it is ok to hold your Coumadin/Warfarin. Some people may need to take another anticoagulant while holding Coumadin/Warfarin

Please contact Cardiovascular Institute of MI.
Sandy Biesiada R.N., Bonnie Mellos R.N.
Or Kimm Jones M.A.
at 586 776-8877
with any questions or concerns

For free resources on how to take blood thinners safely call 1-800-358-9295 or go to AHRQPubs@ahrq.hhs.gov and ask for DVD Publication Number 09-0086-DVD and/or Booklet Publication Number 09-0086-C