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?
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.
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.
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.
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.
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.