Warfarin counselling - Summary for OSCE PDF

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Warfarin Hello, my name is Rahman and I am a fourth year medical student at Keele university. Before we start can I confirm your name and DOB please. And what would you like to be called? Everything we discuss will remain confidential. Are you comfortable? I am here to discuss a couple of medications that you have asked some more information about, is that correct? Ok we are going to talk about warfarin first. I am going to tell you about how this work, why you need it and any side effects and complications. I-Tell me what you know about warfarin? C-is there anything that worries you about warfarin? E- what were you hoping we’d discuss today?

ACTION-“Warfarin is a type of medicine known as an anticoagulant. It helps to thin the blood, making it less likely that a dangerous blood clot could form.” “Warfarin can be used to treat people who have a previous blood clot in the leg or lungs. It can also be used to prevent future blood clots in people who are at high risk of having them in the future, such as people with an irregular heartbeat or an artificial heart valve.” “The action of warfarin can be rapidly reversed with an antidote in situations where we need to reduce the risk of bleeding.” Explain the role of INR in monitoring the effect of warfarin. “The INR is a measure of how long it takes blood to clot. In healthy people an INR of 1 is normal. Since you are at a higher risk for blood clots we want your blood to be thinner than normal and therefore take longer to clot. As a result, the target range for your INR would be between 2-3, meaning it takes two to three times as long for your blood to clot compared to someone not taking warfarin.” “In order to ensure that we keep your blood within the necessary range we will need to monitor your INR level every so often; this is done through a blood test. The blood tests will initially be frequent (every 3-4 days until two consecutive readings are within range), and then after this, you will be tested twice weekly for 1-2 weeks (again until two consecutive readings within range). Thereafter, testing can increase to longer periods (e.g. every 12 weeks). Your dose of warfarin will be adjusted based on the INR results with the aim of keeping it within the target range.”

TIMING- once daily tablet, usually in the evening and at the same time everyday HOW TO TAKE- it comes in tablet form. If you forget to take a dose, take it ASAP but don’t take 2 doses on the same day and inform doctor/INR clinic.

LENGTH OF TREATMENT- 3 months for provoked DVT, 6 months for unprovoked DVT/PE, lifelong for AF. EFFECTS TIME BEFORE – 2/3 DAYS TESTS- start 5 mg for 4 days then test INR on day 5 and 8, adjusting dose accordingly. Start with LMWH if immediate effect is required. INR is then checked regularly by the coagulation clinic.

IMPORTANT SIDE EFFECTS: bleeding, let the doctor know. Maybe nose bleeds, gum bleeds.

Less serious bleeds: heavier periods, occasional nosebleeds, bleeding from gums when brushing, bruising. “It is normal to bleed more easily when taking warfarin as the medication works by thinning the blood. Common types of bleeding include:  periods that are heavier and last longer than normal  bleeding for a little longer than usual if you cut yourself  occasional nosebleeds (that last for less than 10 minutes)  bleeding from your gums when you brush your teeth  bruises that come up more easily and take longer to fade than usual This type of bleeding is not dangerous and should stop by itself. If it happens, keep taking the warfarin, but tell your doctor if the bleeding bothers you or does not stop.”

Serious bleeds: “Occasionally, you can have serious bleeding from taking warfarin. This can be dangerous and needs urgent medical attention.” “Stop taking warfarin and call your doctor or anticoagulant clinic, or go to A&E if you experience:  red pee or black poo  large bruises or bruises that happen for no reason  nosebleeds that last longer than 10 minutes  blood in your vomit or you’re coughing up blood  severe headaches, fits (seizures), changes to your eyesight, numbness or tingling in your arms or legs, or feel very tired, weak or sick – these can be signs of bleeding in your brain  any bleeding from a cut or injury that will not stop or slow down”

diarrhoea, many drugs and food. Let you pharmacist know and doctor know when starting a new drug so they can make sure it is safe and alter anything that needs to be altered.

Common side effects Common side effects (other than bleeding) of warfarin include:  a mild rash  hair loss These side effects are typically mild and the patient should be advised to contact their doctor or pharmacist if they become bothersome.

Serious side effects Serious side effects of warfarin can include:  jaundice  skin necrosis As a result, patients should be advised to seek urgent medical review if they develop:  yellowing of the skin  painful swollen areas of skin

COMPLICATIONS& CONTRAINDICATIONS: pregnancy, haemorrhagic stroke, significant bleeding and patient at risk of falls. Have effective contraceptive when taking warfarin

SUPPLEMENTARY ADVICE: avoid liver, spinach, cranberry juice, alcohol binges, give anticoagulant book.

Lifestyle advice Diet Drastic changes in diet, especially an increase in consumption of foods high in vitamin K (such as broccoli, kale, or spinach) can potentially affect control of anticoagulation. If the patient ever wishes to significantly change their diet, they should inform the anticoagulant clinic so necessary dose adjustments and monitoring requirements can be fulfilled. Cranberry juice is also known to interact with warfarin and enhance its anticoagulant effect and therefore it should be avoided.

Alcohol Patients should limit their alcohol intake to a maximum of one or two drinks a day and never binge drink. If there are major changes in alcohol consumption (e.g. the patient stops drinking, or starts drinking more) the INR can be affected.

Other Patients should be advised to take extra care when carrying out routine tasks such as brushing teeth or shaving; a soft toothbrush or an electric razor can help. Patients should also be advised to inform their dentist that they take warfarin when booking an appointment as this may have implications for dental procedures.

Avoid contact sports Alert doctor/surgeon

Yellow booklets and alert card At the start of treatment, all patients should be provided with two yellow anticoagulant booklets, an INR monitoring booklet and a patient information booklet. Patients should also be provided with an anticoagulant alert card. Patients should be advised to always carry the anticoagulant alert card with them in case of an emergency and always take the yellow INR monitoring book with them to each appointment at the anticoagulant clinic and if possible to other appointments (e.g. GP, pharmacy reviews, dental appointments etc). The patient information book is a useful resource since it provides the patient with a point of reference and reinforces what has been covered in this guide....