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warfarin

warfarin
Brand names: Coumadin
Form Strength
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 2B↑
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
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: Sep. 19, 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



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