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Patient’s instructions Warfarin/Coumadin™ What it is? Warfarin/Coumadin™ is a blood thinner. It helps prevent clots from forming in your blood vessels and heart. How to take your blood thinner? • Take it at the same time, every day! • Never stop a pill and Do Not take a double dose to make up for a missed dose. • Be sure to tell your doctor or pharmacist if you missed any doses so they can better understand how your medication is working. • Never change your dose with out talking to your doctor. • Let all your doctors, dentists and pharmacists know you are taking Warfarin. Blood Tests You might have to have your blood tested while you are taking Warfarin. The most common test is the Protime (PT) test which measures your International Normalized Ratio (INR). The INR/PT measures how fast your blood clots and if your medicine needs to be changed. Your doctor will let you know if you need this test. Coumadin™ and Vitamin K • When taking Warfarin, it is important to keep your Vitamin K intake as consistent as possible. Eat about the same amount of foods with Vitamin K each week. • Foods that you eat can effect how well your blood thinner works. Sudden increases in Vitamin K may decrease the effect of Warfarin. Also greatly lowering your intake of Vitamin K could increase the effect of Warfarin. • Your doctor will watch your INR closely. If you have changes in your INR month to month, aiming to keep your Vitamin K consistent may help stabilize your INR. • Not getting enough Vitamin K in your diet can increase your risk for osteoporosis, bone fractures, vascular disease and stroke. The following is a list of foods and their vitamin K content (notice serving sizes!). These foods are known as being high in vitamin K. However, some foods on the list are actually low (i.e. egg yolk, green tea vs. green tea leaves). Use this as a guide to aim for a consistent intake of foods high in Vitamin K! Item Avocado Asparagus Beef Liver Broccoli Broccoli Brussels sprouts Cabbage, red Cabbage, green Chinese cabbage Japanese cabbage (natto) Cabbage, boiled Cauliflower Cauliflower, green, raw Cauliflower, raw Chick Peas (garbanzo beans) Cucumber Egg Yolk Green Tea Leaves Green Tea Kiwi Green onions Onions (white) Onions Okra Peas, green (canned) Peas, green (raw) Seaweed, raw Soybeans Leafy Greens: Kale, raw Kale, frozen Spinach, raw Spinach, raw Spinach, canned Turnip greens, frozen Turnip greens, raw Turnip greens, raw Collards, raw Swiss chard, raw Mustard Greens Parsley, raw Green Leaf lettuce Lettuce, boston and bibb types Lettuce, romaine Lettuce, red leaf Lettuce, iceberg Serving Vitamin K (mcg) 1 whole 4 large spears 1 slice (130 kcals) 1 cup raw ½ cup cooked ½ cup cooked 1 cup raw 1 cup raw ½ cup cooked 1/2 cup cooked ½ cup cooked 1 cup cooked 1 cup uncooked 1 cup uncooked 1 cup ½ cup w/ skin 1 whole 100 grams 3.5 ounces 1 whole 1 Tbsp, raw 1 cup 1 cup raw 1 cup boiled ½ cup cooked 1 cup 1 cup ½ cup 1 cup 29 mcg 32 mcg 2.2 mcg 92.5 mcg 110 mcg 109 mcg 34 mcg 68 mcg 33 mcg 95 mcg 81.5 mcg 8.6 mcg 12.9 mcg 16.0 mcg 6.6 mcg 8.5 mcg 0.1 mcg 1428 mcg 0.03 mcg 30 mcg 12.4 mcg 207 mcg 0.6 mcg 1.1 mcg 32 mcg 64 mcg 36 mcg 26 mcg 33 mcg ½ cup cooked ½ cup cooked 1 cup uncooked ½ cup cooked ½ cup cooked ½ cup cooked ½ cup cooked 1 cup uncooked ½ cup cooked ½ cup cooked 1/2 cup cooked ¼ cup 1 cup, shredded 1 cup, shredded 1 cup, shredded 1 cup, shredded 1 cup, shredded 531 mcg 573 mcg 145 mcg 445 mcg 494 mcg 426 mcg 264 mcg 138 mcg 418 mcg 286 mcg 210 mcg 249 mcg (2 Tbsp=125 mcg) 63 mcg 56 mcg 48 mcg 39 mcg 17 mcg An easy way to aim for a consistent intake of Vitamin K is to use the two food lists below. Since these foods have moderately high or high amounts of Vitamin K, changes in your intake of these foods would have the greatest impact on your INR. • Foods high in Vitamin K – choose no more than ONE of these foods per day! Food Kale, fresh or frozen, boiled Spinach (fresh, frozen or canned), boiled Turnip greens, frozen Collards, fresh Turnip greens, fresh, boiled Swiss chard, fresh, boiled Parsley, raw Mustard greens, fresh, boiled • Foods moderately high in Vitamin K – choose no more than THREE of these foods per day! Food Spinach, fresh, raw, uncooked Turnip greens, raw, chopped, uncooked Broccoli, cooked Brussels sprouts, boiled Broccoli, raw, uncooked Japanese cabbage, boiled Green cabbage, boiled • Serving size ½ cup ½ cup ½ cup ½ cup ½ cup ½ cup ¼ cup ½ cup Serving size 1 cup 1 cup ½ cup ½ cup 1 cup ½ cup ½ cup Remember that how you prepare and cook can change the amount of Vitamin K in foods! Other Foods and Supplements and Coumadin • If you drink Cranberry juice, limit amount to 1 cup per day. • Alcohol – Drinking can effect reduce the effectiveness of Warfarin. Avoid drinking alcohol • Herbal/Vitamin Interaction - Avoid herbal supplements until you talk to your doctor! Herbal supplements can increase your risk of bleeding when taking Warfarin and may affect of your INR. The following herbal supplements should be avoided: Herbs and Supplements: Alfalfa Anglica (dong quai) Arnica Borage Celery Clove Cat’s Claw Coenzyme Q-10 Cranberry supplementation Fish oil Flaxseed oil Forskolin Garlic Gingko Biloba Ginseng Ginger extract Herbal teas: Chamomile Tonka beans Horse chestnut (buckeye, aesulus) Insositol hexaphosphate Kelpware Licorice Meadow Onion Extract Pau d’ arco Papain Parsley Passion flower Melitot (sweet clover) Quassia Quinine Red clover Reishi mushroom Rue Sweet woodruff St. John’s Wort Turmeric Willow bark Wheat grass Avoid separate Vitamin A, E, and C supplements. Vitamin supplements such as Vitamin E can increase your risk of bleeding. A multivitamin/mineral supplement is allowed, but it should NOT provide more than 100% of the Recommended Daily Intake (RDI) for vitamins A, E, C, and K. If you are taking a multivitamin/mineral supplement, be sure to do so consistently since some may contain vitamin K. It is important to check with your doctor before taking ANY vitamin supplements or herbal supplements! Supplements such as Ensure® and Boost® can contain significant amounts of Vitamin K. Consider these as a “high Vitamin K food” when you are aiming for a consistent intake of all foods containing Vitamin K. Always check with you doctor or pharmacist before taking any prescribed or overthe-counter medications to determine if an adjustment in your Warfarin is necessary (i.e. antibiotics and Prilosec). References: Cleveland Clinic: http://my.clevelandclinic.org/drugs/Coumadin/hic_Anticoagulant_Medication_Warfarin_Coumadin.aspx Agency for Healthcare Research & Quality. Blood Thinner Pills: Your Guide to Using Them Safely. www.ahrq.gov/ Accessed 1/9/2012 National Institutes of Health: http://ods.od.nih.gov/pubs/factsheets/coumadin1.pdf 4-12