This guideline reviews the indication for warfarin, duration or treatment for patients with a PE and/or lower limb DVT, the initiation of treatment, the management of peri-operative anticoagulation, the management of patients who are bleeding or with an elevated INR including those with a head injury and finally includes a section on patients on warfarin who also require an anti-platelet agent. Date: 14 June 2011 The BSH paid the expenses incurred during the writing of this guidance. None of the authors had conflicts of interest to declare. All authors have made a declaration of interests to the BSH and Task Force Chairs which may be viewed on request.The requested URL /scielo.php?pid=S1677-54492009000400010&script=sci_arttext&tlng=en was not found on this server.< Previous Article In This IssueNext Article In This Issue > Crowther MA, Julian J, McCarty D, et al. Treatment of warfarin-associated coagulopathy with oral vitamin K: a randomised controlled(All 2001 articles were reviewed for relevancy, and abstracts were last revised in
In patients who are receiving warfarin and have an international normalized ratio (INR) value between 4.5 and 10.0, does low-dose vitamin K lower the INR better than Randomized (allocation concealed*), blinded {patients, clinicians, and outcome assessors}†,* placebo-controlled trial with 3-month follow-up. 5 thromboembolism services at teaching hospitals in London and Hamilton, Ontario, 92 patients (mean age 65 y, 53% women) who were receiving warfarin and had an INR value between 4.5 and 10.0. Exclusion criteria were INR determined > 12 hours before screening, life expectancy < 10 days, need for immediate normalization of INR, severe liver disease, major bleeding in the previous month, allergy to vitamin K, bleeding diathesis or thrombolytic therapy within 48 hours of screening, inability to take oral medications, platelet count < 50 × 109/L, or geographic89 patients (97%) completed the trial and were analyzed. Patients were allocated to 1 mg of oral vitamin K (Abbott Laboratories, Montreal,
Quebec, Canada) (n = 46) or to placebo (n = 46). Proportion of patients with an INR value between 1.8 and 3.2 the day after the intervention. Patients were assessed for thrombotic and hemorrhagic events at 1 and 3 months after More patients who received vitamin K than patients who received placebo had INR values between 1.8 and 3.2 the day after the intervention (P = 0.001) (Table). No vitamin K-group patients and 4 placebo-group patients (9%) had an increase in INR values the day after treatment (P = 0.056). An INR value of < 1.8 occurred in 7 vitamin K-group patients (16%) and no placebo-group patients (P = 0.012). After the second day posttreatment, the INR values were similar inAt 3 months, fewer patients receiving vitamin K had bleeding episodes than did patients receiving placebo (4% vs 17%, P < 0.05). In patients who are receiving warfarin and have an international normalized ratio (INR) value between 4.5 and 10.0, low-dose vitamin K lowered the INR to between 1.8 and 3.2 the day after administration. Source of funding: No external funding. For correspondence: Dr. M.A. Crowther, Room L208, St. Joseph's Hospital, Hamilton, Ontario L8N 4A6, Canada. FAX 905-521-6034. ‡Abbreviations defined in Glossary; RBI, NNT, and CI calculated from data in article. In the United States, more than 1 million people per year receive anticoagulation therapy to treat or prevent various thromboembolic complications. Of those receiving such therapy, the INR values will be > 3.9 approximately 8% to 9% of the
The risk for substantial bleeding increases progressively with every 1-point increment of INR above 4.0 (2). For patients with serious bleeding, transfusion with fresh frozen plasma or prothrombin concentrate is the appropriate intervention. In asymptomatic patients, reduction of the INR can be achieved passively by withholding therapy or actively by administeringIs active treatment more safe and effective than passive withholding? recent review of the literature identified the need for large, well-designed, randomized controlled trials to answer this question (3). A previous prospective cohort study by Crowther and colleagues (4) suggested that 1 mg of oral vitamin K was safe and effective in reversing anticoagulation for most patients within 16 hours of treatment. The current study by Crowther and colleagues provides additional insight into optimal therapy. Oral vitamin K in asymptomatic patients without an overt bleeding risk produces a clinically important increase in
the proportion of target-range INR values. For unclear reasons, the intervention group had fewer bleeding episodes during the 3-month follow-up period. appears to be safe and effective, but it is also unclear whether additional benefit and equivalent safety exist using intravenous vitamin K administration. Brian P. Schmitt, MD, MPHNorthwestern University Medical SchoolChicago, Illinois, USA 1. The European Atrial Fibrillation Trial Study Group. Optimal oral anticoagulant therapy in patients with nonrheumatic atrial fibrillation and recent cerebral ischemia. N Engl J Med. 1995;333:5-10. 2. van der Meer FJ, Rosendaal FR, Vandenbroucke JP, Briet E. Bleeding complications in oral anticoagulant therapy. An analysis of risk factors. Arch Intern Med. 1993;153:1557-62. 3. Taylor CT, Chester EA, Byrd DC, Stephens MA. Vitamin K to reverse excessive anticoagulation: a review of the literature. 19:1415-25. [PubMed ID: 10600090] 4. Crowther MA, Donovan D, Harrison L, McGinnis J, Ginsberg J. Low-dose oral vitamin K reliably reverses over-anticoagulation due to warfarin.
5. Crowther MA, Douketis JD, Schnurr T, et al, Oral vitamin K lowers the international normalized ratio more rapidly than subcutaneous vitamin K in the treatment of warfarin-associated coagulopathy. Ann Intern Med. 2002;137:251-4. This website can be viewed using the vertical display on your mobile device. What you eat and drink has the potential to affect how COUMADIN works in your body. Eat a normal, balanced diet. It’s important to be consistent in your diet, as changes can interact with your COUMADIN treatment and dose. Talk to your healthcare provider about any diet changes. Vitamin K is an essential part of the body's clotting process. Too much vitamin K in your diet can lower the effect of COUMADIN. Avoid eating large amounts of leafy green vegetables, as many of them contain large amounts of vitamin K. Additionally, certain vegetable oils contain vitamin K and should be limited. To help you track what you eat and the amount of vitamin K in your foods, we have some tools you can use.
It should be noted that the U.S. Food and Drug Administration recommends a daily intake of 80 micrograms of vitamin K, based on a 2000-calorie diet. Also, be sure to discuss with your healthcare provider any diet changes you are considering BEFORE you change your diet. What is the most important information I should know about COUMADIN® (warfarin sodium)? COUMADIN can cause bleeding which can be serious and sometimes lead to death. COUMADIN is a blood thinner medicine that lowers the chance of blood clots forming in your body. You may have a higher risk of bleeding if you take COUMADIN and: are 65 years of age or older have a history of stomach or intestinal bleeding have high blood pressure (hypertension) have a history of stroke, or “mini-stroke” (transient ischemic attack or TIA) have serious heart disease have a low blood count or cancer have had trauma, such as an accident or surgery take other medicines that increase your risk of bleeding, including:
a medicine that contains heparin other medicines to prevent or treat blood clots nonsteroidal anti-inflammatory drugs (NSAIDs) take warfarin sodium for a long time. Warfarin sodium is the active ingredient in COUMADIN Tell your healthcare provider if you take any of these medicines. Ask your healthcare provider if you are not sure if your medicine is one mentioned above. Many other medicines can interact with COUMADIN, and affect the dose you need or increase COUMADIN side effects. Do not change or stop any medicines, or start new ones, before talking to your healthcare provider. Do not take other medicines that contain warfarin sodium while taking COUMADIN. Get your regular blood test (INR test) to check for your response to COUMADIN, to see how fast your blood clots. Your healthcare provider will decide what INR numbers are best for you and adjust your dose of COUMADIN to keep your INR in your target range. Call your healthcare provider right away if you get any of the following signs or symptoms of bleeding problems:
pain, swelling, or discomfort headaches, dizziness, or weakness unusual bruising (bruises that develop without known cause or grow in size) bleeding from cuts that takes a long time to stop menstrual bleeding or vaginal bleeding that is heavier than normal pink or brown urine red or black stools vomiting blood or material that looks like coffee grounds Some foods and beverages can interact with COUMADIN and affect your treatment and dose. Eat a normal, balanced diet and talk to your healthcare provider before making any diet changes. Do not eat large amounts of leafy green vegetables, which contain vitamin K. Certain vegetable oils also contain large amounts of vitamin K. Too much vitamin K can lower the effect of COUMADIN. Do not take COUMADIN if: your chance of having bleeding problems is higher than the possible benefit of treatment; your healthcare provider will decide if COUMADIN is right for you. you are pregnant unless you have a mechanical heart valve.
COUMADIN may cause birth defects, miscarriage, or death of your unborn baby. you are allergic to warfarin or any of the other ingredients in COUMADIN. Before you take COUMADIN, tell your healthcare provider if you: have bleeding problems, fall often, have liver or kidney problems or are undergoing dialysis, have high blood pressure, have a heart problem called congestive heart failure, have diabetes, have any other medical conditions. are planning to have any surgery or dental procedure; your COUMADIN may need to be stopped for a short time, or your dose adjusted. are pregnant or plan to become pregnant or are considering breastfeeding while taking COUMADIN. Females who can become pregnant should use effective birth control during treatment, and for ≥ 1 months after the last dose of COUMADIN Tell your healthcare providers that you take COUMADIN, and about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements.
Some medicines may affect how COUMADIN works, or may increase your risk of bleeding. Keep a list of medicines to show your healthcare provider and pharmacist. COUMADIN may cause serious side effects including: Death of skin tissue (skin necrosis or gangrene). This can happen soon after starting COUMADIN, and happens because blood clots form and block blood flow to an area of your body. Call your healthcare provider right away if you have pain, color, or temperature changes to any area of your body. You may need medical care right away to prevent death or loss (amputation) of your affected body part.Call your healthcare provider right away if you have pain in your toes and they look purple or dark in color. These are not all the side effects of COUMADIN; tell your healthcare provider if you have any side effect that bothers you or does not go away.COUMADIN is a prescription medicine used to treat blood clots and to lower the chance of blood clots forming in your body.