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warfarin

warfarin

Drug Name	Form	Strength	Non-Formulary	Restricted	TX Sub	Notes
Coumadin	TABLET, ORAL	1 mg; 2 mg; 2.5 mg; 5 mg

Display Coumarin Derivatives Class : 20120408

High Alert Drug : Policy

Medication comments:

High Alert Drug: warfarin
• Policy, protocol, and order sets for dosing and monitoring • Pharmacists follow patients daily for dosing, monitoring, prevention of adverse events • Pharmacists/nurses provide patient education. • Reversal agents and guidelines

Per policy, these hazardous drugs have special waste requirements.
Generic (Brand)	Waste Requirements
warfarin (Coumadin)	All tablets and packaging ⇒ BLACK BUCKET

USP <800> Hazardous Drug Assessment of Risk (AOR)
Per policy, these drugs are exempt from USP <800> handling requirements under normal circumstances. The following outlines must be followed.
generic (Brand) Route [Packaging: Manufacturer ⇒ Dispense]	Activities
warfarin (Coumadin, Jantoven) PO [UD ⇒ UD]	1 mg tablet 2 mg tablet (IMH) 2.5 mg tablet 5 mg tablet (IMH)	Stock @ IDBH? Y NIOSH Table 2^B↑
Pharmacy: Receiving / Storage / Preparation Exposure Risk: minimal	• Handling/preparation PPE Requirements: n/a
	• Receiving from Distributor: Standard
	• Pharmacy Storage Area: Carousel
	• Packaging/Reconstitution Location: n/a
	• Compounding (Non-Sterile/Sterile) Location: n/a
	• Omnicell Load: Yes
Transport	• Transport (dose is placed inside a plastic sealable bag): Standard
Nursing: Storage / Administration Exposure Risk: low	• Handling/administration PPE Requirements: via Mouth- Single pair of CX approved gloves via Tube- double CX gloves and gown Wash hands after handling
	• Storage of Finished dose in Nursing Area/Procedural Area: Omnicell
	• Signage on Patient Door Required: No
	• Manipulation of Dosage Form: Standard
	• Special Manipulation for Administration: n/a
Disposal / Spills	• Disposal of Drug Waste: Full- blue bin Trace/packaging- trash
	• Disposol of Used PPE: trash bin (inside plastic bag)
	• Spill management: n/a
Reason for exemption of USP<800> Containment Requirements: Purchased in final dosage form; packaged as unit dose. Does not require additional manipulation for dispensing.

Anticoagulant / Antiplatelet Stoppage For Procedures
generic (Brand)	Dept.	Procedure Type (hover over entry for examples)	Stop Medication Prior To Procedure Restart after:
warfarin (Coumadin)	Anesthesia	High-risk	5 days Restart after 6 hours
		Intermediate-risk	normal INR ( ≤ 1.2) Restart after 6 hours
		Low-risk	5 days Restart after 6 hours
		Patients with high risk of bleeding (eg, old age, history of bleeding tendency, concurrent uses of other anticoagulants/antiplatelets, liver cirrhosis or advanced liver disease, and advanced renal disease) undergoing low- or intermediate-risk procedures should be treated as intermediate or high risk, respectively.

	Radiology	Invasive Procedures	7 days
	Radiology	Paracentesis/Thoracentesis	5 days
	Surgery	High-risk	5 days, INR < 1.4 Restart after 12-24 hours
		Low-risk	5 days, INR < 1.4 Restart after 12-24 hours
		Bridging anticoagulation may be appropriate in patients who will have a very high thromboembolic risk with prolonged interruption of their anticoagulant, such as warfarin.

Enteral Drug Administration notes.
Generic (Brand)	Comments and Considerations	Recommendations for Administration with Enteral Nutrition
warfarin (Jantoven, Coumadin)	Variable Vit-K content, protein binding	Suggest holding tube feeding 1 hour before and 1 hour after administration. Avoid soy protein feeds.

2023 American Geriatrics Society Beers Criteria^® for potentially inappropriate medication use in older adults.
Medication:	warfarin (Coumadin, Jantoven)
Criteria 1: Potentially inappropriate medication use in older adults. (Table 2)
Drug(s)	for the treatment of nonvalvular atrial fibrillation or venous thromboembolism (VTE)
Rationale	Compared with DOACs, warfarin has higher risks of major bleeding (particularly intracranial bleeding) and similar or lower effectiveness for the treatment of nonvalvular atrial fibrillation and VTE. DOACs are thus the preferred choice for anticoagulation for most people with these conditions.
Recommendation	Avoid starting warfarin as initial therapy for the treatment of nonvalvular atrial fibrillation or VTE unless alternative options (i.e., DOACs) are contraindicated or there are substantial barriers to their use. For older adults who have been using warfarin long-term, it may be reasonable to continue this medication, particularly among those with well-controlled INRs (i.e., >70% time in the therapeutic range) and no adverse effects. See also criteria on rivaroxaban (Table 2) and dabigatran (Table 4) and footnote regarding choice among DOACs.
Quality of evidence: High, Strength of Recommendation: Strong

Criteria 4: Potentially clinically important drug-drug interactions that should be avoided in older adults. (Table 5)
Interacting drug(s) or class(es)	warfarin ⇄ amiodarone, ciprofloxacin, macrolides (excluding azithromycin), trimethoprim-sulfamethoxazole, SSRIs
Risk Rationale	Increased risk of bleeding.
Recommendation	Avoid when possible; if used together, monitor INR closely.
Quality of evidence: Moderate, Strength of Recommendation: Strong

Last updated: Dec. 6, 2025

Hazard.Drug Handling(USP 800) USP<800> Hazardous Drug / Assessment of Risk
Hazardous Waste BLACK BUCKET
Black Box Warnings Serious bleeding risk

UpToDate Lexidrug

Pharmacy Contact Info:

Main Inpatient Pharmacy: ext 4599, 3503
Fax: 704-878-7283

Director of Pharmacy - Randi Raynor, PharmD: ext 4501
Clinical Coordinator - Laura Rollings, PharmD: ext 4597
Pharmacy Informaticist - Stephen Pringle, PharmD: ext 7645
Pharmacy Technician Supervisor - Amy Wingler, CPhT: ext 7385
Pharmacy Automation Coordinator (Omnicell) - Melissa Fulford, CPhT: ext 3556

This site is intended for the staff of Iredell Health System. While others may view accessible pages, Iredell Health System makes no warranty, express or implied, as to the use of this information outside of Iredell Health System. The content of this policy and procedure document serves as guidance to the delivery of quality patient care. Care providers are expected to exercise critical thinking and situational awareness skills, and in specific situations to take such action as is necessary for the delivery of quality patient care.