What are the discharge instructions for a patient on warfarin (Coumadin)?

From the Guidelines

Patients on warfarin should continue their medication as prescribed, with regular INR checks, and be aware of the signs of bleeding and the importance of consistent vitamin K intake and medical identification. When it comes to discharge instructions for a patient on warfarin, several key points must be considered to ensure the patient's safety and the effectiveness of their anticoagulation therapy.

Key Considerations for Discharge Instructions

• The patient should be instructed to take their warfarin exactly as prescribed, at the same time each day, and never to skip or double doses 1.
• Regular INR blood tests are crucial to monitor blood thinning levels, with the frequency determined by the healthcare provider 1.
• Patients should watch for signs of bleeding, such as unusual bruising, nosebleeds, blood in urine or stool, or severe headaches, which require immediate medical attention 1.
• Consistent vitamin K intake in the diet is important, as sudden changes can affect warfarin's effectiveness 1.
• It is essential for patients to inform all healthcare providers about their warfarin use before any procedures and to carry medical identification indicating they take blood thinners 1.
• Patients should avoid taking new medications, including over-the-counter drugs and supplements, without consulting their doctor, as many can interact with warfarin 1.
• Alcohol consumption should be limited, as it can increase the risk of bleeding 1.
• Patients should contact their healthcare provider immediately if they miss a dose, experience unusual bleeding, or develop an illness with vomiting or diarrhea 1.

Procedure-Specific Instructions

For patients undergoing endoscopic procedures, the management of warfarin depends on the risk level of the procedure and the patient's thrombotic risk.

• For low-risk procedures, warfarin can be continued, but the INR should be checked to ensure it is within the therapeutic range 1.
• For high-risk procedures in patients with low thrombotic risk, warfarin should be discontinued 5 days before the procedure, and the INR should be checked before the procedure to ensure it is <1.5 1.
• For high-risk procedures in patients with high thrombotic risk, warfarin should be temporarily discontinued and substituted with low molecular weight heparin (LMWH) 1.

By following these guidelines and instructions, patients on warfarin can minimize their risk of complications and ensure the effective management of their anticoagulation therapy.

From the FDA Drug Label

INFORMATION FOR PATIENTS The objective of anticoagulant therapy is to decrease the clotting ability of the blood so that thrombosis is prevented, while avoiding spontaneous bleeding. Patients should be advised: Strict adherence to prescribed dosage schedule is necessary. Do not take or discontinue any other medication, including salicylates (e.g., aspirin and topical analgesics), other over-the-counter medications, and botanical (herbal) products except on advice of the physician. Avoid alcohol consumption. Prothrombin time tests and regular visits to physician or clinic are needed to monitor therapy. Carry identification stating that warfarin sodium tablets are being taken. If the prescribed dose of warfarin sodium tablets is forgotten, notify the physician immediately Take the dose as soon as possible on the same day but do not take a double dose of warfarin sodium tablets the next day to make up for missed doses. The amount of vitamin K in food may affect therapy with warfarin sodium tablets. Eat a normal, balanced diet maintaining a consistent amount of vitamin K. Avoid drastic changes in dietary habits, such as eating large amounts of green leafy vegetables You should also avoid intake of cranberry juice or any other cranberry products. Notify your health care provider if any of these products are part of your normal diet. Contact physician to report any illness, such as diarrhea, infection or fever. Notify physician immediately if any unusual bleeding or symptoms occur Signs and symptoms of bleeding include: pain, swelling or discomfort, prolonged bleeding from cuts, increased menstrual flow or vaginal bleeding, nosebleeds, bleeding of gums from brushing, unusual bleeding or bruising, red or dark brown urine, red or tar black stools, headache, dizziness, or weakness

The discharge instructions for a patient on warfarin include:

• Strict adherence to the prescribed dosage schedule
• Avoiding other medications, including salicylates, over-the-counter medications, and botanical products, except on advice of the physician
• Avoiding alcohol consumption
• Regular prothrombin time tests and visits to the physician or clinic to monitor therapy
• Carrying identification stating that warfarin sodium tablets are being taken
• Notifying the physician immediately if a dose is forgotten, and taking the dose as soon as possible on the same day without taking a double dose the next day
• Maintaining a consistent diet with a normal amount of vitamin K, and avoiding drastic changes in dietary habits
• Avoiding cranberry juice and products
• Notifying the healthcare provider if any unusual bleeding or symptoms occur, and reporting any illness such as diarrhea, infection, or fever 2

From the Research

Discharge Instructions for Patients on Warfarin

When discharging a patient on warfarin, it is essential to provide clear instructions to ensure their safety and the effectiveness of their treatment. The following points should be considered:

• Monitoring of International Normalized Ratio (INR): The INR should be monitored frequently, especially after initiation of warfarin therapy 3, 4. The goal therapeutic INR range for patients treated with warfarin is most commonly 2 to 3 4.
• Dosing Adjustments: Adjusting a steady-state warfarin dose depends on the measured INR values and clinical factors 3. The dose does not need to be adjusted for a single INR that is slightly out of range, and most changes should alter the total weekly dose by 5% to 20% 3.
• Education on Treatment Goals and Adverse Effects: Patients starting anticoagulation therapy should receive education on treatment goals, adverse effects, and monitoring strategy 4.
• Self-Testing and Self-Management: Self-testing and self-management can be safe options for patients receiving warfarin who are motivated and show competence 4.
• Follow-Up Care: Patients should be instructed to follow up with their healthcare provider regularly to monitor their INR and adjust their warfarin dose as needed 3, 4.
• Bleeding Risk: Patients should be aware of the bleeding risk associated with warfarin therapy, even when their INR is in the target range 5. They should be instructed to report any signs of bleeding to their healthcare provider immediately.
• Interactions with Other Medications: Patients should be informed about potential interactions between warfarin and other medications, including over-the-counter medications and herbal supplements 4.
• Lifestyle Modifications: Patients should be advised to maintain a consistent diet and lifestyle, as changes in diet or lifestyle can affect their INR 3, 4.

Specific Instructions for Patients with Stable INRs

For patients with stable INRs, the frequency of INR testing can be extended from every 4 weeks to up to 12 weeks 6. However, patients should still be instructed to follow up with their healthcare provider regularly to monitor their INR and adjust their warfarin dose as needed.

Instructions for Patients with Elevated INR

Patients who have an elevated INR will need more frequent testing and may also require vitamin K1 3. For example, a nonbleeding patient with an INR of 9 can be given low-dose vitamin K1 (eg, 2.5 mg phytonadione, by mouth) 3. Patients who have an excessive INR with clinically important bleeding require clotting factors (eg, fresh-frozen plasma) as well as vitamin K1 3.