Warfarin: A Case Study

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warfarin

A 52 year old male warfarin (Coumadin) patient presents with an international normalized ratio (INR) of 3. The patient reports he is currently taking warfarin 5 mg once a day, lisinopril (Zestril) 5mg once a day and ibuprofen (Motrin) 400mg up to three times per day for chronic back pain. The patient also reports his diet is inconsistent, he consumes alcohol 3 - 4 days per week and he does not take his lisinopril on a consistent daily bases. What are the top five recommendations that should be made?

Recommendation One

The patient's INR is therapeutic; the most common target therapeutic INR range is 2 - 3. However it is on the high end of the therapeutic range. Therefore, it should be recommended that the patient's INR be routinely monitored.

Recommendation Two

The patient reports he is currently taking ibuprofen 400 mg, a nonsteroidal anti-inflammatory medication, up to three times per day. Ibuprofen may interact with warfain and lead to an increase in bleeding risk, as bleeding is one of the most common/dangerous side effects of warfarin. Therefore, it should be recommended that the patient uses another medication to manage his chronic back pain that will not lead to an increase in bleeding risk. Depending on the cause/severity of the patient's back pain acetaminophen (Tylenol) may be a viable option.

Recommendation Three

The patient reports his diet is inconsistent. Patient diet, especially the consumption of foods rich in vitamin K such as dark leafy vegetables, broccoli and cabbage may affect warfarin effectiveness. Therefore, it should be recommended that the patient maintain a consistent diet throughout his warfarin therapy to limit the potential for food-drug interactions.

Recommendation Four

The patient reports he consumes alcohol 3 - 4 days per week. Alcohol consumption may affect warfarin's effectiveness. Therefore, it should be recommended to the patient that he limit his alcohol consumption.

Recommendation Five

The patient reports he does not take his lisinopril every day. Lisinopril is an angiotensin-converting-enzyme (ACE) inhibitor used to lower elevated blood pressure. Lisinopril medication compliance is paramount to its effectiveness. Therefore, it should be recommended that the patient receive medication education regarding the importance of medication compliance. In addition, it should be recommended that the patient take his lisionpril daily as directed to maximize its effectiveness.

About the Author

Marc Macera, PharmD, RPh's picture

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Comments

Ph. Bhagavan P S RPh's picture

Excellant presentation Dr Macera. Not only case specific educative but also an alert to watch out for such inconsistencies elsewhere.

I am educated.

Thank you. I look for more such case studies.

Well. I came across 2 situations:

1. Patient: Female poorly built may be 50KG. little over 5', 89 Yrs vegetarian poor eater.

General health: Non diabetic, Non hypertension. But was on Bronchodilators (oral as well as inhalers) off and on. Quite active taking care of all her personal needs without dependence. Voracious reader of books.

She developped respiratory spasms due to smoke of crackers, walked into a hospital and got admitted.

Treatment started with Deriphylline, Solbutamol nebulizer and steroids and IV glucose saline.

3rd day she was tested for blood glucose that showed positive.

She was given oral antidiabetic tablet at night

She collapsed with severe hypoglycemia in the morning, glucose loading didn't help. and was carried out for last rites by evening.

Case-2: 26 year old lady in her 9th month of pregnancy found diabetic was admitted and given Insulin and steroid inj also.

Her sugar came down, delivered through C section and both mother and child are happy.

Your comment please

Bhagavan P.S. B Pharm

Rtd. Dy Dir.(Pharmacy),Govt of Karnataka, India

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