,ease tions.
Drug guide
ce ● Teach patient and caregivers that improvement in
once cognitive functioning may take months; degenerative
DAVIS’S
process is not reversed.
● Advise females of reproductive potential to notify
health care professional if pregnancy is planned or
1 mg, 28
0, 21 mg
suspected, or if breast feeding.
Evaluation/Desired Outcomes
AT A
GLANCE
release Name /bks_56299_davis_dg/56299_w 12/19/2019 12:10P
0. Oral ● Improvement in neurocognitive decline (memory,
rmint): attention, reasoning, language, ability to perform
ation simple tasks) in patients with Alzheimer’s disease.
BEERS REMS HIGH ALERT
Risk Evaluation and Mitigation
meperidine (me-per-i-deen) Systems (REMS) Icon
Demerol
n, rea- Name /bks_56299_davis_dg/56299_w 12/19/2019 12:10PM Plate # 0-Composite pg 1285 # 1
asks) Classification
Therapeutic: opioid analgesics The Beers Criteria for Potentially Inappro-
mia. Pharmacologic: opioid agonists priate Medication Use in Older Adults
Schedule II
ently Indications HIGH ALERT used safe
warfarin 1285
Moderate or severe pain (alone or with nonopioid
RED tab for High
HIGH ALERT used safely but may require more frequent PT/INR as-
sessmen
warfarin
sessments.
atients warfarin
agents). Anesthesia adjunct. Analgesic during labor.(war-fa-rin) (war-fa-rin) Adverse Reactions/Side Effects
s may be Alert medications
Preoperative sedation. Unlabeled Use: Coumadin,
Rigors.Jantoven Derm: dermal necrosis. GI: cramps, nausea. GU: Advers
capsules Action Coumadin,
Classification
Therapeutic: anticoagulants
Jantoven CALCIPHYLAXIS Interactions
. Hemat: BLEEDING. Misc: fever.
Derm:
amenda Pharmacologic: coumarins
se the
Icon forin the CNS.Classification
Binds to opiate receptors Alters the percep- Drug-Drug: Androgens, capecitabine, cefotetan,
chloramphenicol, clopidogrel, disulfiram, flucon- CALCIPHY
tion of and response to painful stimuli, while producing
Indications
mg pharmacogenomic Therapeutic:
generalized CNS depression. Therapeutic
Prophylaxis and treatment of: Venous thrombosis, Pul-
azole, fluoroquinolones, itraconazole, metroni-
Effects: anticoagulantsdazole (including vaginal use), thrombolytics, epti- Interac
y. content
Decrease in severity of pain.
monary embolism, Atrial fibrillation with embolization. fibatide, tirofiban, sulfonamides, quinidine,
food. Pharmacologic: coumarins
Management of myocardial infarction: Decreases risk quinine, NSAIDs, valproates, and aspirin mayqthe
of death, Decreases risk of subsequent MI, Decreases
response to warfarin andqthe risk of bleeding. Drug-D
ded. Do Pharmacokinetics risk of future thromboembolic events. Prevention of Chronic use of acetaminophen mayqthe risk of
Absorption: 50% from the GI tract; thrombus formation and embolization after prosthetic
well absorbed bleeding. Chronic alcohol ingestion maypaction of chloram
Life-threatening Indications
valve placement. warfarin; if chronic alcohol abuse results in significant
o not from IM sites. Oral doses are about
side effects in RED,
half
Actionas effective as liver damage, action of warfarin may beqdue toppro- azole, fl
ned, parenteral doses. Prophylaxis and
Interferes with hepatic treatment
synthesis of: Venousclotting
of vitamin K-dependent duction of factor. Acute alcohol ingestion may
thrombosis, Pul-
CAPITALIZEDWidely
Distribution: letters clotting factors (II, VII, IX, and X). Therapeutic Ef- qaction of warfarin. Barbiturates, carbamazepine,
distributed. fects:
Crosses the pla- dazole
ntire monary embolism, Atrial fibrillation
Prevention of thromboembolic events. rifampin, and hormonal
with contraceptives contain-
embolization.
ed; do centa; enters breast milk. Pharmacokinetics
ing estrogen maypthe anticoagulant response to
warfarin. Many other drugs may affect the activity of
fibatide
Protein Binding: Neonates: 52%; Management
Infants 3–Well
Absorption: of
mo:myocardial
18absorbed from the GI tract afterinfarction:
warfarin. Decreases risk quinine
Drug-drug,
85%; Adults:drug-food,
60– 80%. oral administration. Drug-Natural Products: St. John’s wortpeffect.
of death,
Distribution: Decreases
Crosses the placenta risk of
but does notsubsequent
en- qbleeding risk MI, Decreases
with anise, arnica, chamomile, response
and drug-natural
Metabolism and Excretion: Mostly ter breastmetabolized
milk. clove, dong quai, fenugreek, feverfew, garlic, gin-
hen to by the liver; some
product interactions converted to risk of
normeperidine,
Protein future which
Binding: thromboembolic
99%. events. Prevention
ger, ginkgo, Panax ginseng, licorice, of and others. Chronic
se. Take may accumulate and cause seizures. Metabolism
5% excreted andun-Excretion: Metabolized by the Drug-Food: Ingestion of large quantities of foods
ot just thrombus
liver. formation and embolization high in vitamin after prosthetic
K content (see list in Appendix K) bleeding
changed by the kidneys. Half-life: 42 hr. may antagonize the anticoagulant effect of warfarin.
veral Half-life: Neonates: 12– 39 hr;valve Infants placement.
3– 18 mo:
TIME/ACTION PROFILE 2.3 (effects on Route/Dosage warfarin
at a Headings
hr; Children highlighting
5– 8 yr: 3 hr; Adults: 2.5– 4 hr (qin tests)im- PO (Adults): 2– 5 mg/day for 2– 4 days; then adjust
daily dose by results of INR. Initiate therapy with lower liver dam
coagulation
e; con- considerations for function [7–
paired renal or hepatic Action 11 hr]).ONSET
ROUTE PEAK DURATION doses in geriatric or debilitated patients or in Asian pa-
and tients or those with CYP2C9*2 and/or CYP2C9*3 alleles ductionW
re start- patient populations
TIME/ACTION PROFILE (analgesia) Interferes
PO
with
36–72 hr
hepatic
5–7 days†
synthesis
2–5 days‡
orof vitamin
VKORC1 AA genotype.K-dependent
†At a constant dose PO (Children 1 mo): Initial loading dose— 0.2 qaction
s. Geri—concerns
ROUTE ONSET
for PEAKclotting factors (II, VII, IX, and X).
‡After discontinuation
DURATION Therapeutic
mg/kg (maximum dose: 10 mg) for 2– 4Ef-
days then ad-
e may older adults Contraindications/Precautions just daily dose by results of INR, use 0.1 mg/kg if liver rifampi
PO 15 min fects:
60 min 2–4Prevention
hr of thromboembolic
Contraindicated in: Uncontrolled bleeding; Open dysfunction is events.
present. Maintenance dose range—
bulation OB
IM and Lact— 10–15 min 30–50 min wounds;2–4 Activehr
ulcer disease; Recent brain, eye, or spi- 0.05– 0.34 mg/kg/day. ing estr
er activi-
information formin 40–60Pharmacokinetics Availability (generic available)
Subcut 10–15 nal cord2–4
min injuryhr
or surgery; Severe liver or kidney dis-
dication ease; Uncontrolled hypertension; OB: Crosses placenta Tablets: 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, warfarin
IV immediate 5–7 min and may2–3 causehr
pregnant and Absorption: fatal hemorrhage in the fetus. May also
cause congenital malformation. Well absorbed from 7.5 mg, 10 mg. Cost: Generic— 1 mg $10.83/100, 2
the 2.5GImgtract
mg $10.83/100, $10.83/100,after3 mg $10.83/100, warfarin
care breastfeeding
Contraindications/Precautions Use Cautiously in: Malignancy; Patients with his- 4 mg $10.83/100, 5 mg $8.52/100, 6 mg $10.64/100,
itamins, patients
Contraindicated in: Hypersensitivity;
oral tory administration.
of ulcer, liver disease, or acute kidney injury; His-
Hypersensi-
tory of poor compliance; Asian patients or those who
7.5 mg $10.83/100, 10 mg $10.83/100. Drug-N
ult with tivity to bisulfites
Pedi—concerns (some Distribution:
injectable products);
carry the Recent
CYP2C9*2 allele Crosses the placenta
and/or the CYP2C9*3
or with the VKORC1 AA genotype (qrisk of bleeding
allele, NURSING
Assessment
but does not en-
IMPLICATIONS qbleedi
terwithbreast milk. ● Assess for signs of bleeding and hemorrhage (bleed- clove, d
for children standard dosing; lower initial doses should be
considered); Geri: Due to greater than expected antico- ing gums; nosebleed; unusual bruising; tarry, black
Rep—considerations Protein
agulant response, Binding:
initiate and maintain 99%.
at lower doses; stools; hematuria; fall in hematocrit or BP; guaiac- ger, gin
Rep: Women of reproductive potential; Pedi: Has been positive stools, urine, or nasogastric aspirate).
for patients of Metabolism and Excretion: Metabolized by the
Canadian drug name. Genetic implication. Strikethrough Discontinued. Drug-F
reproductive age liver.
*CAPITALS indicates life-threatening; underlines indicate most frequent.
high in
Half-life: 42 hr. may anta
, led bleeding; Open
nt brain, eye, or spi- 0.05– 0.34 mg/kg/day.
ver orName
kidney dis- Availability (generic available)12/19/2019 12:10PM Plate # 0-Composite pg 1285 # 1
/bks_56299_davis_dg/56299_w
B: Crosses placenta Tablets: 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg,
the fetus. May also 7.5 mg, 10 mg. Cost: Generic— 1 mg $10.83/100, 2
mg $10.83/100, 2.5 mg $10.83/100, 3 mg $10.83/100,
Patients with his- 4 mg $10.83/100, 5 mg $8.52/100, 6 mg $10.64/100,
Name /bks_56299_davis_dg/56299_w 12/19/2019 12:10PM Plate # 0-Composite pg 1286 # 2
kidney injury; His-
atients or those who
7.5 mg $10.83/100, 10 mg $10.83/100.
Clearly defined nursing
NURSING IMPLICATIONS
he CYP2C9*3 allele,
qrisk of bleeding Assessment
responsibilities and priorities
doses should be ● Assess for signs of bleeding and hemorrhage (bleed-
warfarin 1285
han expected antico- ing gums; nosebleed; unusual bruising; tarry, black used safely but may require more frequent PT/INR as-
tain at lower doses; HIGH ALERT
stools; hematuria; fall in hematocrit or BP; guaiac- sessments.
warfarin
tial; Pedi: Has been 1286 positive stools, (war-fa-rin)
warfarin urine, or nasogastric aspirate).
Adverse Reactions/Side Effects
drug name. Genetic Coumadin,
● Assess for
implication. Jantoven
Strikethrough
evidence ofDiscontinued.
additional or increased ●Derm: dermal necrosis.
PO: Administer GI:at cramps,
medication same timenausea. GU:
each day.
indicates life-threatening; underlines indicateSymptoms
thrombosis. most frequent.
depend on area of involve- . Hemat:
Medication requires 3–BLEEDING Misc:
5 days to .reach effective
fever. lev-
Classification CALCIPHYLAXIS
ment.
Therapeutic: anticoagulants els; usually begun while patient is still on heparin.
● Lab Test Considerations:
coumarins Monitor PT, INR and ●Interactions
Do not interchange brands; potencies may not be
Pharmacologic:
other clotting factors frequently during therapy; Drug-Drug:
equivalent. Androgens, capecitabine, cefotetan, In-depth guidance
chloramphenicol, clopidogrel, disulfiram, flucon-
monitor more frequently in patients with renal im-
Indications
pairment. Therapeutic PT ranges 1.3– 1.5 times Patient/Family Teaching
azole, fluoroquinolones, itraconazole, metroni- for patient and
Prophylaxis ●dazole
Instruct patient to vaginal
take medication as directed. Take
greaterandthantreatment of: Venous
control; however, thethrombosis,
INR, a standard-Pul- (including use), thrombolytics, epti-
family education
monary embolism,
ized system thatAtrial fibrillation
provides a common withbasis
embolization.
for com- missed doses
fibatide, as soon
tirofiban, as rememberedquinidine,
sulfonamides, that day; do
Management of myocardial infarction: Decreases
municating and interpreting PT results, is usually re- risk not double
quinine, doses. valproates,
NSAIDs, Inform health and careaspirin
professional of
mayqthe
of death, Decreases riskINR
of (not
subsequent MI, Decreases missed doses at time of checkup or lab tests. Inform
ferenced. Normal on anticoagulants) is response to warfarin andqthe risk of bleeding.
risk of0.8–
future
1.2.thromboembolic
An INR of 2.5– 3.5events. Prevention for
is recommended of patients that anticoagulant effect may persist for 2– 5
Chronic use of acetaminophen mayqthe risk of
thrombus formation
patients and risk
at very high embolization after prosthetic
of embolization (for exam- days following discontinuation. Advise patient to
bleeding. Chronic alcohol
read Medication Guide beforeingestion maypaction
starting therapy andof
valve placement.
ple, patients with mitral valve replacement and ven- warfarin; if chronic alcohol
tricular hypertrophy). Lower levels are acceptable with each Rx refill in case of abuse
changes.results in significant
Action liver damage, action of warfarin may beqdue
● Review foods high in vitamin K (see Appendix K). toppro-
when risk is lower. Heparin may affect the PT/INR; duction
Interferes
drawwith
blood hepatic synthesis
for PT/INR of vitamin
in patients K-dependent
receiving both Patientofshould
clotting factor.
have Acutelimited
consistent alcohol ingestion
intake of thesemay
clotting factorsand (II,warfarin
VII, IX,atand X).5 Therapeutic Ef- qaction of vitamin
foods, as warfarin.K isBarbiturates,
the antidote forcarbamazepine,
warfarin, and
heparin least hr after the IV bolus rifampin,
fects:dose,
Prevention
4 hr after ofcessation
thromboembolic events.
of IV infusion, or 24 hr af- alternatingand hormonal
intake contraceptives
of these foods will cause PTcontain-
levels
ingtoestrogen maypthe
fluctuate. Advise patientanticoagulant response
to avoid cranberry juiceto
ter subcut heparin injection. Asian patients and
Pharmacokinetics warfarin. Many
or products other
during drugs may affect the activity of
therapy.
those who carry the CYP2C9*2 allele and/or the
Absorption: Well absorbed from the GI tract after
CYP2C9*3 allele, or those with VKORC1 AA genotype ●warfarin.
Caution patient to avoid IM injections and activities
oral administration.
may require more frequent monitoring and lower Drug-Natural
leading to injury.Products:
Instruct patientSt. to use a soft
John’s tooth-
wortpeffect.
Distribution:
doses. Crosses the placenta but does not en- brush, notrisk
qbleeding to floss,
with and
anise,to shave withchamomile,
arnica, an electric ra-
ter ●breast
Geri:milk.
Patients over 60 yr exhibit greater than ex- zor during warfarin therapy. Advise
clove, dong quai, fenugreek, feverfew, garlic, patient that veni-gin-
ProteinpectedBinding: 99%. Monitor for side effects at
PT/INR response. punctures
ger, ginkgo,and injection
Panax sites require
ginseng, application
licorice, of
and others.
pressure to prevent
Drug-Food: bleeding
Ingestion or hematoma
of large quantitiesforma-
of foods
Metabolism and Excretion:
lower therapeutic ranges. Metabolized by the
tion.
● Pedi: Achieving and maintaining therapeutic PT/INR
liver. high in vitamin K content (see list in Appendix K)
● Advise patient to report any symptoms of unusual
ranges may
Half-life: 42 hr. be more difficult in pediatric patients. may antagonize the anticoagulant effect of warfarin.
Assess PT/INR levels more frequently. bleeding or bruising (bleeding gums; nosebleed;
TIME/ACTION
● Monitor hepatic PROFILEfunction(effects on and peri-
and CBC before
Route/Dosage
black, tarry stools; hematuria; excessive menstrual
PO (Adults):
flow) and pain, 2– 5 mg/day
color, for 2– 4change
or temperature days; then
to anyadjust
coagulation tests) therapy.
odically throughout
areadose
daily of your body toofhealth
by results INR. care professional
Initiate therapy withimme-lower
● Monitor stool and urine for occult blood before and
ROUTEperiodicallyONSET PEAK
during therapy. DURATION diately.
doses Patientsorwith
in geriatric a deficiency
debilitated in protein
patients C and/pa-
or in Asian
PO ● Toxicity and hr
36–72 Overdose: 5–7Withholding
days† 2–51 or more
days‡
or Sor
tients mediated anticoagulant
those with CYP2C9*2response may be at alleles
and/or CYP2C9*3 W
doses of warfarin is usually sufficient if INR is exces- orgreater
VKORC1 risk
AAfor tissue necrosis.
genotype.
†At a constant dose or if minor bleeding occurs. If over-
sively elevated ●POInstruct patient
not
(Children to drink
1 mo): alcohol
Initial or take
loading other 0.2
dose—
‡Afterdose
discontinuation
occurs or anticoagulation needs to be immedi- Rx, OTC,
mg/kg or herbaldose:
(maximum products,
10 mg) especially
for 2– 4those
dayscon-
then ad-
ately reversed, the antidote is vitamin K
Contraindications/Precautions justtaining
daily aspirin
dose byorresults
NSAIDs,of or to start
INR, or stop
use 0.1 anyifnew
mg/kg liver
(phytonadione, Aquamephyton). medications is during
present.warfarin therapy without
Maintenance advice
dose range—
Contraindicated in: UncontrolledAdministration
bleeding; Open of dysfunction
of health care professional.
whole blood or plasma
disease;also may be required in se- 0.05– 0.34 mg/kg/day.
wounds; Active ulcer Recent brain,
vere bleeding because of the delayed onset of vita-
eye, or spi- ● Advise patient to notify health care professional if More patient
nal cord injury or surgery; Severe liver or kidney dis- Availability (generic
pregnancy is planned available)
or suspected or if breast feed-
min K.
ease; Uncontrolled hypertension; OB: Crosses placenta ing. 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg,
Tablets: safety information
andImplementation
may cause fatal hemorrhage in the fetus. May also ●7.5Instruct
mg, 10patient Generic—
to carry identification
1 mgdescribing
● High
cause congenital Do not confuse Coumadin (warfarin)
Alert:malformation. mgmedication
mg. Cost:
regimen
$10.83/100, at all
2.5 mg
$10.83/100, 2
times and to3 inform
$10.83/100, all
mg $10.83/100, than any other
with Avandia (rosiglitazone) or Cardura
Patients (doxazo-
Use Cautiously in: Malignancy; with his-
sin). Do not confuse Jantoven (warfarin) with Janu-
tory ofmet
ulcer, liver disease, or acute kidney injury; His-
health
4 mg
ulant
care personnel
$10.83/100,
therapy
5 mgcaring
before lab tests,
for patient
$8.52/100,
7.5 mg $10.83/100, 10 mg $10.83/100.
6 mgon$10.64/100,
treatment, or
anticoag-
surgery. drug guide
(sitagliptin/metformin) or Januvia (sitagliptin). ● Emphasize the importance of frequent lab tests to
tory●ofBecause
poor compliance; Asian patients
of the large number of medications or those who
capable
carry of
thesignificantly
CYP2C9*2 altering
allele and/or the CYP2C9*3
warfarin’s allele,
effects, careful
NURSING IMPLICATIONS
monitor coagulation factors.
or withmonitoring
the VKORC1 AA genotype qrisk
( of bleeding
is recommended when new agents are Assessment
Evaluation/Desired Outcomes
with standard
started ordosing; lowerare
other agents initial doses should
discontinued. be
Interactive ●● Prolonged
Assess forPT
signs of bleeding
(1.3– 2.0 times and hemorrhage
the control; (bleed-
may vary
considered);
potentialGeri:
shouldDuebetoevaluated
greater for
thanallexpected
new medica-antico- ing gums;
with nosebleed;
indication) unusual
or INR of 2– 4.5bruising; tarry,
without signs of black
agulant response,
tions (Rx, OTC, initiate and maintain
and herbal products).at lower doses; stools; hematuria; fall in hematocrit or BP; guaiac-
hemorrhage.
Rep: Women of reproductive potential; Pedi: Has been positive stools, urine, or nasogastric aspirate).
Canadian drug name. Genetic implication. Strikethrough Discontinued.
*CAPITALS indicates life-threatening; underlines indicate most frequent.
Find enhanced Canadian content
throughout—in the monographs,
appendices, and index.
, April Hazard Vallerand, PhD, RN, FAAN
Director, PhD Program
Distinguished Professor
College of Nursing Alumni Endowed Professor
Wayne State University
College of Nursing
Detroit, Michigan
Cynthia A. Sanoski, BS, PharmD, BCPS, FCCP
Department Chair and Associate Professor
Thomas Jefferson University
Jefferson School of Pharmacy
Philadelphia, Pennsylvania
Drug guide
ce ● Teach patient and caregivers that improvement in
once cognitive functioning may take months; degenerative
DAVIS’S
process is not reversed.
● Advise females of reproductive potential to notify
health care professional if pregnancy is planned or
1 mg, 28
0, 21 mg
suspected, or if breast feeding.
Evaluation/Desired Outcomes
AT A
GLANCE
release Name /bks_56299_davis_dg/56299_w 12/19/2019 12:10P
0. Oral ● Improvement in neurocognitive decline (memory,
rmint): attention, reasoning, language, ability to perform
ation simple tasks) in patients with Alzheimer’s disease.
BEERS REMS HIGH ALERT
Risk Evaluation and Mitigation
meperidine (me-per-i-deen) Systems (REMS) Icon
Demerol
n, rea- Name /bks_56299_davis_dg/56299_w 12/19/2019 12:10PM Plate # 0-Composite pg 1285 # 1
asks) Classification
Therapeutic: opioid analgesics The Beers Criteria for Potentially Inappro-
mia. Pharmacologic: opioid agonists priate Medication Use in Older Adults
Schedule II
ently Indications HIGH ALERT used safe
warfarin 1285
Moderate or severe pain (alone or with nonopioid
RED tab for High
HIGH ALERT used safely but may require more frequent PT/INR as-
sessmen
warfarin
sessments.
atients warfarin
agents). Anesthesia adjunct. Analgesic during labor.(war-fa-rin) (war-fa-rin) Adverse Reactions/Side Effects
s may be Alert medications
Preoperative sedation. Unlabeled Use: Coumadin,
Rigors.Jantoven Derm: dermal necrosis. GI: cramps, nausea. GU: Advers
capsules Action Coumadin,
Classification
Therapeutic: anticoagulants
Jantoven CALCIPHYLAXIS Interactions
. Hemat: BLEEDING. Misc: fever.
Derm:
amenda Pharmacologic: coumarins
se the
Icon forin the CNS.Classification
Binds to opiate receptors Alters the percep- Drug-Drug: Androgens, capecitabine, cefotetan,
chloramphenicol, clopidogrel, disulfiram, flucon- CALCIPHY
tion of and response to painful stimuli, while producing
Indications
mg pharmacogenomic Therapeutic:
generalized CNS depression. Therapeutic
Prophylaxis and treatment of: Venous thrombosis, Pul-
azole, fluoroquinolones, itraconazole, metroni-
Effects: anticoagulantsdazole (including vaginal use), thrombolytics, epti- Interac
y. content
Decrease in severity of pain.
monary embolism, Atrial fibrillation with embolization. fibatide, tirofiban, sulfonamides, quinidine,
food. Pharmacologic: coumarins
Management of myocardial infarction: Decreases risk quinine, NSAIDs, valproates, and aspirin mayqthe
of death, Decreases risk of subsequent MI, Decreases
response to warfarin andqthe risk of bleeding. Drug-D
ded. Do Pharmacokinetics risk of future thromboembolic events. Prevention of Chronic use of acetaminophen mayqthe risk of
Absorption: 50% from the GI tract; thrombus formation and embolization after prosthetic
well absorbed bleeding. Chronic alcohol ingestion maypaction of chloram
Life-threatening Indications
valve placement. warfarin; if chronic alcohol abuse results in significant
o not from IM sites. Oral doses are about
side effects in RED,
half
Actionas effective as liver damage, action of warfarin may beqdue toppro- azole, fl
ned, parenteral doses. Prophylaxis and
Interferes with hepatic treatment
synthesis of: Venousclotting
of vitamin K-dependent duction of factor. Acute alcohol ingestion may
thrombosis, Pul-
CAPITALIZEDWidely
Distribution: letters clotting factors (II, VII, IX, and X). Therapeutic Ef- qaction of warfarin. Barbiturates, carbamazepine,
distributed. fects:
Crosses the pla- dazole
ntire monary embolism, Atrial fibrillation
Prevention of thromboembolic events. rifampin, and hormonal
with contraceptives contain-
embolization.
ed; do centa; enters breast milk. Pharmacokinetics
ing estrogen maypthe anticoagulant response to
warfarin. Many other drugs may affect the activity of
fibatide
Protein Binding: Neonates: 52%; Management
Infants 3–Well
Absorption: of
mo:myocardial
18absorbed from the GI tract afterinfarction:
warfarin. Decreases risk quinine
Drug-drug,
85%; Adults:drug-food,
60– 80%. oral administration. Drug-Natural Products: St. John’s wortpeffect.
of death,
Distribution: Decreases
Crosses the placenta risk of
but does notsubsequent
en- qbleeding risk MI, Decreases
with anise, arnica, chamomile, response
and drug-natural
Metabolism and Excretion: Mostly ter breastmetabolized
milk. clove, dong quai, fenugreek, feverfew, garlic, gin-
hen to by the liver; some
product interactions converted to risk of
normeperidine,
Protein future which
Binding: thromboembolic
99%. events. Prevention
ger, ginkgo, Panax ginseng, licorice, of and others. Chronic
se. Take may accumulate and cause seizures. Metabolism
5% excreted andun-Excretion: Metabolized by the Drug-Food: Ingestion of large quantities of foods
ot just thrombus
liver. formation and embolization high in vitamin after prosthetic
K content (see list in Appendix K) bleeding
changed by the kidneys. Half-life: 42 hr. may antagonize the anticoagulant effect of warfarin.
veral Half-life: Neonates: 12– 39 hr;valve Infants placement.
3– 18 mo:
TIME/ACTION PROFILE 2.3 (effects on Route/Dosage warfarin
at a Headings
hr; Children highlighting
5– 8 yr: 3 hr; Adults: 2.5– 4 hr (qin tests)im- PO (Adults): 2– 5 mg/day for 2– 4 days; then adjust
daily dose by results of INR. Initiate therapy with lower liver dam
coagulation
e; con- considerations for function [7–
paired renal or hepatic Action 11 hr]).ONSET
ROUTE PEAK DURATION doses in geriatric or debilitated patients or in Asian pa-
and tients or those with CYP2C9*2 and/or CYP2C9*3 alleles ductionW
re start- patient populations
TIME/ACTION PROFILE (analgesia) Interferes
PO
with
36–72 hr
hepatic
5–7 days†
synthesis
2–5 days‡
orof vitamin
VKORC1 AA genotype.K-dependent
†At a constant dose PO (Children 1 mo): Initial loading dose— 0.2 qaction
s. Geri—concerns
ROUTE ONSET
for PEAKclotting factors (II, VII, IX, and X).
‡After discontinuation
DURATION Therapeutic
mg/kg (maximum dose: 10 mg) for 2– 4Ef-
days then ad-
e may older adults Contraindications/Precautions just daily dose by results of INR, use 0.1 mg/kg if liver rifampi
PO 15 min fects:
60 min 2–4Prevention
hr of thromboembolic
Contraindicated in: Uncontrolled bleeding; Open dysfunction is events.
present. Maintenance dose range—
bulation OB
IM and Lact— 10–15 min 30–50 min wounds;2–4 Activehr
ulcer disease; Recent brain, eye, or spi- 0.05– 0.34 mg/kg/day. ing estr
er activi-
information formin 40–60Pharmacokinetics Availability (generic available)
Subcut 10–15 nal cord2–4
min injuryhr
or surgery; Severe liver or kidney dis-
dication ease; Uncontrolled hypertension; OB: Crosses placenta Tablets: 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg, warfarin
IV immediate 5–7 min and may2–3 causehr
pregnant and Absorption: fatal hemorrhage in the fetus. May also
cause congenital malformation. Well absorbed from 7.5 mg, 10 mg. Cost: Generic— 1 mg $10.83/100, 2
the 2.5GImgtract
mg $10.83/100, $10.83/100,after3 mg $10.83/100, warfarin
care breastfeeding
Contraindications/Precautions Use Cautiously in: Malignancy; Patients with his- 4 mg $10.83/100, 5 mg $8.52/100, 6 mg $10.64/100,
itamins, patients
Contraindicated in: Hypersensitivity;
oral tory administration.
of ulcer, liver disease, or acute kidney injury; His-
Hypersensi-
tory of poor compliance; Asian patients or those who
7.5 mg $10.83/100, 10 mg $10.83/100. Drug-N
ult with tivity to bisulfites
Pedi—concerns (some Distribution:
injectable products);
carry the Recent
CYP2C9*2 allele Crosses the placenta
and/or the CYP2C9*3
or with the VKORC1 AA genotype (qrisk of bleeding
allele, NURSING
Assessment
but does not en-
IMPLICATIONS qbleedi
terwithbreast milk. ● Assess for signs of bleeding and hemorrhage (bleed- clove, d
for children standard dosing; lower initial doses should be
considered); Geri: Due to greater than expected antico- ing gums; nosebleed; unusual bruising; tarry, black
Rep—considerations Protein
agulant response, Binding:
initiate and maintain 99%.
at lower doses; stools; hematuria; fall in hematocrit or BP; guaiac- ger, gin
Rep: Women of reproductive potential; Pedi: Has been positive stools, urine, or nasogastric aspirate).
for patients of Metabolism and Excretion: Metabolized by the
Canadian drug name. Genetic implication. Strikethrough Discontinued. Drug-F
reproductive age liver.
*CAPITALS indicates life-threatening; underlines indicate most frequent.
high in
Half-life: 42 hr. may anta
, led bleeding; Open
nt brain, eye, or spi- 0.05– 0.34 mg/kg/day.
ver orName
kidney dis- Availability (generic available)12/19/2019 12:10PM Plate # 0-Composite pg 1285 # 1
/bks_56299_davis_dg/56299_w
B: Crosses placenta Tablets: 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg,
the fetus. May also 7.5 mg, 10 mg. Cost: Generic— 1 mg $10.83/100, 2
mg $10.83/100, 2.5 mg $10.83/100, 3 mg $10.83/100,
Patients with his- 4 mg $10.83/100, 5 mg $8.52/100, 6 mg $10.64/100,
Name /bks_56299_davis_dg/56299_w 12/19/2019 12:10PM Plate # 0-Composite pg 1286 # 2
kidney injury; His-
atients or those who
7.5 mg $10.83/100, 10 mg $10.83/100.
Clearly defined nursing
NURSING IMPLICATIONS
he CYP2C9*3 allele,
qrisk of bleeding Assessment
responsibilities and priorities
doses should be ● Assess for signs of bleeding and hemorrhage (bleed-
warfarin 1285
han expected antico- ing gums; nosebleed; unusual bruising; tarry, black used safely but may require more frequent PT/INR as-
tain at lower doses; HIGH ALERT
stools; hematuria; fall in hematocrit or BP; guaiac- sessments.
warfarin
tial; Pedi: Has been 1286 positive stools, (war-fa-rin)
warfarin urine, or nasogastric aspirate).
Adverse Reactions/Side Effects
drug name. Genetic Coumadin,
● Assess for
implication. Jantoven
Strikethrough
evidence ofDiscontinued.
additional or increased ●Derm: dermal necrosis.
PO: Administer GI:at cramps,
medication same timenausea. GU:
each day.
indicates life-threatening; underlines indicateSymptoms
thrombosis. most frequent.
depend on area of involve- . Hemat:
Medication requires 3–BLEEDING Misc:
5 days to .reach effective
fever. lev-
Classification CALCIPHYLAXIS
ment.
Therapeutic: anticoagulants els; usually begun while patient is still on heparin.
● Lab Test Considerations:
coumarins Monitor PT, INR and ●Interactions
Do not interchange brands; potencies may not be
Pharmacologic:
other clotting factors frequently during therapy; Drug-Drug:
equivalent. Androgens, capecitabine, cefotetan, In-depth guidance
chloramphenicol, clopidogrel, disulfiram, flucon-
monitor more frequently in patients with renal im-
Indications
pairment. Therapeutic PT ranges 1.3– 1.5 times Patient/Family Teaching
azole, fluoroquinolones, itraconazole, metroni- for patient and
Prophylaxis ●dazole
Instruct patient to vaginal
take medication as directed. Take
greaterandthantreatment of: Venous
control; however, thethrombosis,
INR, a standard-Pul- (including use), thrombolytics, epti-
family education
monary embolism,
ized system thatAtrial fibrillation
provides a common withbasis
embolization.
for com- missed doses
fibatide, as soon
tirofiban, as rememberedquinidine,
sulfonamides, that day; do
Management of myocardial infarction: Decreases
municating and interpreting PT results, is usually re- risk not double
quinine, doses. valproates,
NSAIDs, Inform health and careaspirin
professional of
mayqthe
of death, Decreases riskINR
of (not
subsequent MI, Decreases missed doses at time of checkup or lab tests. Inform
ferenced. Normal on anticoagulants) is response to warfarin andqthe risk of bleeding.
risk of0.8–
future
1.2.thromboembolic
An INR of 2.5– 3.5events. Prevention for
is recommended of patients that anticoagulant effect may persist for 2– 5
Chronic use of acetaminophen mayqthe risk of
thrombus formation
patients and risk
at very high embolization after prosthetic
of embolization (for exam- days following discontinuation. Advise patient to
bleeding. Chronic alcohol
read Medication Guide beforeingestion maypaction
starting therapy andof
valve placement.
ple, patients with mitral valve replacement and ven- warfarin; if chronic alcohol
tricular hypertrophy). Lower levels are acceptable with each Rx refill in case of abuse
changes.results in significant
Action liver damage, action of warfarin may beqdue
● Review foods high in vitamin K (see Appendix K). toppro-
when risk is lower. Heparin may affect the PT/INR; duction
Interferes
drawwith
blood hepatic synthesis
for PT/INR of vitamin
in patients K-dependent
receiving both Patientofshould
clotting factor.
have Acutelimited
consistent alcohol ingestion
intake of thesemay
clotting factorsand (II,warfarin
VII, IX,atand X).5 Therapeutic Ef- qaction of vitamin
foods, as warfarin.K isBarbiturates,
the antidote forcarbamazepine,
warfarin, and
heparin least hr after the IV bolus rifampin,
fects:dose,
Prevention
4 hr after ofcessation
thromboembolic events.
of IV infusion, or 24 hr af- alternatingand hormonal
intake contraceptives
of these foods will cause PTcontain-
levels
ingtoestrogen maypthe
fluctuate. Advise patientanticoagulant response
to avoid cranberry juiceto
ter subcut heparin injection. Asian patients and
Pharmacokinetics warfarin. Many
or products other
during drugs may affect the activity of
therapy.
those who carry the CYP2C9*2 allele and/or the
Absorption: Well absorbed from the GI tract after
CYP2C9*3 allele, or those with VKORC1 AA genotype ●warfarin.
Caution patient to avoid IM injections and activities
oral administration.
may require more frequent monitoring and lower Drug-Natural
leading to injury.Products:
Instruct patientSt. to use a soft
John’s tooth-
wortpeffect.
Distribution:
doses. Crosses the placenta but does not en- brush, notrisk
qbleeding to floss,
with and
anise,to shave withchamomile,
arnica, an electric ra-
ter ●breast
Geri:milk.
Patients over 60 yr exhibit greater than ex- zor during warfarin therapy. Advise
clove, dong quai, fenugreek, feverfew, garlic, patient that veni-gin-
ProteinpectedBinding: 99%. Monitor for side effects at
PT/INR response. punctures
ger, ginkgo,and injection
Panax sites require
ginseng, application
licorice, of
and others.
pressure to prevent
Drug-Food: bleeding
Ingestion or hematoma
of large quantitiesforma-
of foods
Metabolism and Excretion:
lower therapeutic ranges. Metabolized by the
tion.
● Pedi: Achieving and maintaining therapeutic PT/INR
liver. high in vitamin K content (see list in Appendix K)
● Advise patient to report any symptoms of unusual
ranges may
Half-life: 42 hr. be more difficult in pediatric patients. may antagonize the anticoagulant effect of warfarin.
Assess PT/INR levels more frequently. bleeding or bruising (bleeding gums; nosebleed;
TIME/ACTION
● Monitor hepatic PROFILEfunction(effects on and peri-
and CBC before
Route/Dosage
black, tarry stools; hematuria; excessive menstrual
PO (Adults):
flow) and pain, 2– 5 mg/day
color, for 2– 4change
or temperature days; then
to anyadjust
coagulation tests) therapy.
odically throughout
areadose
daily of your body toofhealth
by results INR. care professional
Initiate therapy withimme-lower
● Monitor stool and urine for occult blood before and
ROUTEperiodicallyONSET PEAK
during therapy. DURATION diately.
doses Patientsorwith
in geriatric a deficiency
debilitated in protein
patients C and/pa-
or in Asian
PO ● Toxicity and hr
36–72 Overdose: 5–7Withholding
days† 2–51 or more
days‡
or Sor
tients mediated anticoagulant
those with CYP2C9*2response may be at alleles
and/or CYP2C9*3 W
doses of warfarin is usually sufficient if INR is exces- orgreater
VKORC1 risk
AAfor tissue necrosis.
genotype.
†At a constant dose or if minor bleeding occurs. If over-
sively elevated ●POInstruct patient
not
(Children to drink
1 mo): alcohol
Initial or take
loading other 0.2
dose—
‡Afterdose
discontinuation
occurs or anticoagulation needs to be immedi- Rx, OTC,
mg/kg or herbaldose:
(maximum products,
10 mg) especially
for 2– 4those
dayscon-
then ad-
ately reversed, the antidote is vitamin K
Contraindications/Precautions justtaining
daily aspirin
dose byorresults
NSAIDs,of or to start
INR, or stop
use 0.1 anyifnew
mg/kg liver
(phytonadione, Aquamephyton). medications is during
present.warfarin therapy without
Maintenance advice
dose range—
Contraindicated in: UncontrolledAdministration
bleeding; Open of dysfunction
of health care professional.
whole blood or plasma
disease;also may be required in se- 0.05– 0.34 mg/kg/day.
wounds; Active ulcer Recent brain,
vere bleeding because of the delayed onset of vita-
eye, or spi- ● Advise patient to notify health care professional if More patient
nal cord injury or surgery; Severe liver or kidney dis- Availability (generic
pregnancy is planned available)
or suspected or if breast feed-
min K.
ease; Uncontrolled hypertension; OB: Crosses placenta ing. 1 mg, 2 mg, 2.5 mg, 3 mg, 4 mg, 5 mg, 6 mg,
Tablets: safety information
andImplementation
may cause fatal hemorrhage in the fetus. May also ●7.5Instruct
mg, 10patient Generic—
to carry identification
1 mgdescribing
● High
cause congenital Do not confuse Coumadin (warfarin)
Alert:malformation. mgmedication
mg. Cost:
regimen
$10.83/100, at all
2.5 mg
$10.83/100, 2
times and to3 inform
$10.83/100, all
mg $10.83/100, than any other
with Avandia (rosiglitazone) or Cardura
Patients (doxazo-
Use Cautiously in: Malignancy; with his-
sin). Do not confuse Jantoven (warfarin) with Janu-
tory ofmet
ulcer, liver disease, or acute kidney injury; His-
health
4 mg
ulant
care personnel
$10.83/100,
therapy
5 mgcaring
before lab tests,
for patient
$8.52/100,
7.5 mg $10.83/100, 10 mg $10.83/100.
6 mgon$10.64/100,
treatment, or
anticoag-
surgery. drug guide
(sitagliptin/metformin) or Januvia (sitagliptin). ● Emphasize the importance of frequent lab tests to
tory●ofBecause
poor compliance; Asian patients
of the large number of medications or those who
capable
carry of
thesignificantly
CYP2C9*2 altering
allele and/or the CYP2C9*3
warfarin’s allele,
effects, careful
NURSING IMPLICATIONS
monitor coagulation factors.
or withmonitoring
the VKORC1 AA genotype qrisk
( of bleeding
is recommended when new agents are Assessment
Evaluation/Desired Outcomes
with standard
started ordosing; lowerare
other agents initial doses should
discontinued. be
Interactive ●● Prolonged
Assess forPT
signs of bleeding
(1.3– 2.0 times and hemorrhage
the control; (bleed-
may vary
considered);
potentialGeri:
shouldDuebetoevaluated
greater for
thanallexpected
new medica-antico- ing gums;
with nosebleed;
indication) unusual
or INR of 2– 4.5bruising; tarry,
without signs of black
agulant response,
tions (Rx, OTC, initiate and maintain
and herbal products).at lower doses; stools; hematuria; fall in hematocrit or BP; guaiac-
hemorrhage.
Rep: Women of reproductive potential; Pedi: Has been positive stools, urine, or nasogastric aspirate).
Canadian drug name. Genetic implication. Strikethrough Discontinued.
*CAPITALS indicates life-threatening; underlines indicate most frequent.
Find enhanced Canadian content
throughout—in the monographs,
appendices, and index.
, April Hazard Vallerand, PhD, RN, FAAN
Director, PhD Program
Distinguished Professor
College of Nursing Alumni Endowed Professor
Wayne State University
College of Nursing
Detroit, Michigan
Cynthia A. Sanoski, BS, PharmD, BCPS, FCCP
Department Chair and Associate Professor
Thomas Jefferson University
Jefferson School of Pharmacy
Philadelphia, Pennsylvania
