Warfarin and opioid counseling Flashcards
What is normal INR?
0.8-1.2
What is the target INR for atrial fib?
2.0-3.0
What is the target INR for PE and DVT?
2.0-3.0
What is the target INR for aortic mechanical valve?
2.0-3.0
What is the target INR for mitral mechanical valve?
2.5-3.5
How would you start the consultation?
- Introduce yourself
- “We recommend that you start take this new medication called warfarin, because X)
- Have you heard of warfarin?
- I would like to explain how warfarin works and why we recommend this
How would you explain what warfarin is?
A medication that thins your blood, reducing the risk of blood clots forming in your heart, legs and lungs. This is why it is important to take regularly
How would you explain why someone needs to take warfarin?
You have been diagnosed with an irregular heart rhythm known as atrial fibrillation. This condition can increase your risk of developing blood clots in your heart, as well as increase the risk of having a stroke
Warfarin reduces the risk of you developing this problem
How would you explain how warfarin may impact someone’s life?
- Someone foods and natural health problems can affect warfarin levels, by either increasing or decreasing how well it works
- Vitamin K decreases the effect of warfarin. Foods rich in vitamin K such as broccoli, brussel sprouts and green leafy vegetables such as spinach, coriander and cabbage can be eaten in usual amounts, but you shouldn’t eat too much of these.
- Alcohol may increase the effect of warfarin. Alcohol can be consumed but at safe levels
- Patients should refrain from contact sports
- “If anyone is going to proscribe or advise medication, ask them if warfarin is okay”
How would you explain how the first dose of warfarin may affect someone?
- Everyone needs a different starting dose, and we need to monitor the thinness of your blood to see how well it is working. We would like to check this every four weeks to make sure warfarin is preventing the clots forming
- The dose of warfarin should be taken every day around the same time
- If you miss a dose, call your GP and take the missed dose as soon as you remember, but do not double up
- Warfarin tablets come in different colours which indicate the strength
On warfarin, watch out for…
- Bleeding and severe bruising
- Prolonged nose bleeds
- Coughing or vomiting up blood
- Passing foul smelling back tar like bowel motions
- Passing blood in the urine
If any of this happens, call GP or NHS
What decreases the INR?
- Chronic alcohol
- Vitamin K
- Azathioprine
- Rifampicin
- Oral contraceptive pill
- St John’s wort
- HRT
What increases the INR?
- Alcohol binge
- Cimetidine
- Omeprazole
- Amiodarone
- Levothyroxine
- Macrolide Abx
- Metronidazole
When giving opioids for pain, what would you ask first?
- Discuss the pain and the nature of and how this affects the patient’s life
- Ensure non opiate medication has been tried and optimised, following WHO ladder
- Ask about current medication and what the patient has tried so far. Ask about other options they might like to explore
How would you address patient concerns?
- Will I become addicted to morphine?
- Will morphine make me die sooner?
- If I take morphine now, does that mean it will not work later when I need it?
- This is extremely rare when morphine is taken in small doses to relieve pain
- There is no evidence to support this. However, the patient may have known someone who died after commencing treatment
- When pain worsens, this is often due to disease progression, not to morphine ceasing to work. In any case, morphine can be given in the quantities needed to control the pain
- Emphasise the need for regular administration and explain about breakthrough medication
- Discuss different routes of administration that may be relevant if problems are anticipated with oral medication
