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Introductio
n:
• 1921: Dr. Frank
Schofield discovered that
cattle died of internal
bleeding after ingesting
mouldy sweet clover
(anticoagulant).
• 1940:The potent
anticoagulant was later
identified as warfarin by
Karl Paul Link
•1954: Approved to be
used in human.
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Prophylaxis and treatment of venous thrombosis
Pulmonary embolism
Thromboembolic disorder
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Warfarin contains racemic isomer of R and S.
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Initiation treatment should be individualized (eg: hepatic function,
nutritional status, concurrent therapy & risk of bleeding)
Adult:
Start therapy: 5-10mg daily for 2 days and monitor INR on to
determine the need for dose adjustment
Maintenance: 2-10mg daily and continue INR monitoring on daily
basis until INR stable and monitor on weekly/monthly basis (depend
on compliance)
Infant and Children:
Stat 0.2 mg/kg, 0.2mg/kg next day providing INR <1.3, then 0.05-
0.2mg/kg o.d =>Prophylaxis: INR 2-2.5 => Treatment: INR 2-3
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Cardiovascular: Edema, hemorrhagic shock
CNS: Fever, lethargy, malaise, headache, dizziness, stroke
Dermatological: Rash, dermatitis, urticaria, pruritis, alopecia,
skin gangrene (occur in the first few weeks)
GI: Anorexia, stomach cramps, abdominal pain, GI bleeding,
taste disturbance, mouth ulcer
Haematological: Haemorrhage, leucopenia, retroperitoneal
hematoma, agranulocytosis
Respiratory: Hemoptysis, pulmonary hemorrhage
Limbs: Purple toe syndrome (several weeks after treatment)
Hepatic: Jaundice, increase in transaminases
Genitourinary: Hematuria
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Pregnancy (Category X)
Alcoholism, dementia, psychoses
Bleeding tendency (eg: hemophilia/
Undergoing a surgical procedure
Recent intracranial haemorrhage
Tendency to fall
Condition predisposing to GI haemorrhage
Severe hepatic impairment
Uncontrolled hypertension?????
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Indication Targeted INR Targeted INR
Range
Thromboembolism in patient
with prosthetic heart valve 2.5-3.5 3.0
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Warfarin isomer S is metabolized by CYP2C9
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Decrease coagulation: Coenzyme Q10 & St
John’s Wort
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Warfarin is used as it is the only anti-
coagulant form that can be administered in
tablet form (others are admininstered via
IV/SC)
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Diet: Maintain normal diet after initiation of
warfarin therapy
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Check INR 3 days after taking oral antibiotics
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Take at the same time every day to avoid INR fluctuation
Note: Provide “anticoagulant book “ to allow patient to keep track with their dose.
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Warfarin available in Miri hospital
1mg (pink), 2mg(lavender), 5mg(peach)
List B drug
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Streif, W et al. 1999, ‘Analysis of Warfarin Therapy in Pediatric Patients: A
Prospective Cohort Study of 319 Patients ‘, blood, Vol. 94 No. 9 , pp.3007-
3014
Bluebook 2009
Hua, H.S, Lee, G.L, Peng, H.C 2005, Sarawak handbook of medical
emergencies, C.E publishing, Kuching
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