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Warfarin Sodium Heparin Names Coumadin, Jantoven Hep-Lock, Hepflush, Vasceze, Monoject, PosiFlush Indications Prophylaxis for clots associated with: A-fib, MI, prosthetic cardiac valves, PE, venous thromboembolism DIC, cardiac operation, venous thromboembolism, prophylaxis for clots associated with: A-fib, PE, arterial catheter-related thrombosis, venous catheter occlusion, acute coronary syndrome, acute STEMI, hemodialysis, inflammatory bowel disease, chronic interstitial cystitis, percutaneous coronary intervention, phlebitis, unstable angina, prosthetic valve endocarditis Dosing 2-10 mg, varying to maintain target INR 4,000-10,000 units every 4-8 hours to maintain target aPPT Contraindications Anesthesia, aneurisms, blood dyscrasias, eclampsia/preeclampsia, any condition which causes bleeding or has the potential for uncontrolled bleeding, traumatic surgery, bacterial endocarditis, pregnancy Active or uncontrolled bleeding (except DIC), thrombocytopenia, neonates/infants/pregnancy/nursing – do not give preps preserved with benzyl alcohol Precautions Prolonged therapy, anemia, age >65, history of highly variable INRs, HTN, renal impairmentDM, diarrhea, eye surgery, hepatic disorders, indwelling catheter use, disturbances of intestinal flora, poor nutritional state, steatorrhea, vasculitis, vitamin K deficiency, increased vitamin K intake Age >60, bacterial endocarditis, bleeding disorders, GI ulceration, history of heparin resistance, history of heparin-induced thrombocytopenia or thrombosis, hepatic disease, severe hypertension, menstruation, neonates and infants weighing <10 kg, major surgery, continuous tube drainage of stomach or small intestine Adverse effects Bleeding, alopecia, cholesterol embolus syndrome, tissue necrosis/gangrene, hypersensitivity Thrombocytopenia, increased ALT/AST levels, hemorrhage, heparin-induced thrombocytopenia with or without thrombosis, hypersensitivity, non-traumatic spinal subdural hematoma Pharmokinetics Half-life: 1 week Half-life: 1.5 hour Highly protein bound Extensive protein binding to LDL, globulins, and fibrinogen Mechanism of Action Inhibits the synthesis of vitamin K-dependent clotting factors (2, 7, 9, and 10) and the anticoagulant proteins C and S. Inhibits clotting at various points in the coagulation system. Administration Oral Injection (for IV only): Reconstitute with sterile water. Slow bolus over 12 minutes in peripheral vein. Use reconstituted solution within 4 hours, do not refrigerate Intermittent IV injection, IV infusion, or deep subQ. Avoid IM administration r/t hematoma formation. Do not use Heparin Lock Flush Solution for anticoagulation therapy. Consider benzyl alcohol load when using benzyl alcohol products. Invert IV solutions at least 6 times to prevent pooling. Monitoring PT/INR. In general, target INR is 2-3. Initially, INR daily until stabilized, then every 1-4 weeks. aPTT. The target aPTT is 1.5 to 2 times normal. Initially, check aPTT leels every 6 hours until stable, then every day at the same time. Periodic hematocrit, platelets, stool occult blood, Antidote and Toxicity Vitamin K1 (phytonadione) Protamine sulfate TOXICITY: INR <5.0 w/ no significant bleeding: lower dose or omit the next dose. TOXICITY: Treatment is symptomatic and supportive INR 5.0-9.0 w/ no significant bleeding: omit next 1-2 doses and/or oral vitamin K. Mild-Moderate: IV fluids and vasopressors as needed Severe: protamine sulfate, fluids, transfusions, vasopressors, INR >9.0 w/ no significant bleeding: hold doses and give oral vitamin K. SERIOUS BLEEDING: hold doses and give vitamin K by slow IV infusion along with fresh frozen plasma, prothrombin complex concentrates, or factor VII until bleeding is controlled. Clinical Teaching Report signs/symptoms hemorrhage, tissue necrosis, or hepatitis. Bleeding precautions. Avoid alcohol. Numerous drug-drug interactions. Avoid cranberry products. Consume a consistent amount of vitamin K. Vitamin K foods. Report signs/symptoms bleeding/ hemorrhage, rotate injection sites, avoid aspirin-containing products, call if dose is missed. When d/c-ing heparin and beginning Coumadin, sample INR at least 5 hours after last heparin bolus, 4 hours after discontinuing continuous IV heparin infusion, 24 hours after last subQ heparin injection. Monitor for signs and symptoms of necrosis or gangrene.