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Other Considerations

  • Avoid arterial punctures.

  • Hold warfarin for 2 doses prior to minor procedures, then restart usual dose of warfarin the following day.

  • Avoid aspirin, NSAIDs and other antiplatelet drugs unless required for specific disease management or clinical situation.

  • Consider alternative analgesics such as acetaminophen or choline magnesium trisalicylate (Trilisate®), as clinically appropriate, if analgesia is required.

  • No contact sports - but other normal activities are allowed.

  • Pregnancy

    • Warfarin should be used cautiously due to its potential teratogenic effects on the fetus.

    • Teenagers need to receive appropriate counseling.

    • Enoxaparin (Lovenox®) or other low molecular weight heparin is the treatment of choice for teens that require anticoagulation during pregnancy.

  • Surgery/invasive procedures:

    • Discontinue warfarin 5 days prior to surgery/invasive procedures unless the clinical situation requires an emergent intervention. For conditions necessitating more emergent intervention consult hematology.

    • Resume warfarin and heparin or LMW heparin 12 to 24 hours after surgery/invasive procedure. Continue the heparin or LMW heparin until the INR is therapeutic for 2 consecutive days.

    • Patients with mechanical/prosthetic mitral valves, atrial fibrillation or recent/recurrent thromboembolism require bridging with standard heparin or low molecular weight heparin. Consult hematology or cardiology (for specifically cardiac related problems).

  • Patients should consult physician for the following:

    • Significant changes in diet, formula intake for infants.

    • Introduction of new medication (e.g. antibiotics) and any over-the-counter (OTC) medication.

    • Changes in doses of on-going medications.

    • Infections.

    • Diarrhea and vomiting. 

References:

Ansell J, et al. Pharmacology and Management of the Vitamin K Antagonists: American College of Cheset Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 133 (6Suppl): 160S-198S, 2008 Jun.

Bolton-Maggs P , Brook L. The use of vitamin K for reversal of over-warfarinization in children. Br J Haematol 2002; 118:924.

David, M., et al. Warfarin Therapy in Children. Thrombosis Interest Group of Canada. May 2004. http://www.tigc.org/eguidelines/warfarinchildren04.htm. Accessed 10/21/08.

Horton, JD, et al. Warfarin Therapy: Evolving Strategies in Anticoagulation. American Family Physician; 1999 Feb; 59(3):635-646. http://www.aafp.org/afp/AFPprinter/990201ap/635.html

Lexi-Drugs Online/Pediatric Lexi-Drugs Online, Warfarin, http://online.lexi.com/crlsql/servlet/crlonline, Copyright © 1978-2008 Lexi-Comp, Inc, Hudson, OH 44236

Monagle P. Chalmers E. Chan A. DeVeber G. Kirkham F. Massicotte P. Michelson AD. Antithrombotic therapy in neonates and children: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). [Journal Article] Chest. 133(6 Suppl):887S-968S, 2008 Jun.

Monagle P. Chan A. Massicotte P. Chalmers E. Michelson AD. Antithrombotic therapy in children: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. [Review] [487 refs] [Guideline. Journal Article. Practice Guideline. Review] Chest. 126(3 Suppl):645S-687S, 2004 Sep.

Roach ES. Golomb MR. Adams R. Biller J. Daniels S. Deveber G. Ferriero D. Jones BV. Kirkham FJ. Scott RM. Smith ER. American Heart Association Stroke Council. Council on Cardiovascular Disease in the Young. Management of stroke in infants and children: a scientific statement from a Special Writing Group of the American Heart Association Stroke Council and the Council on Cardiovascular Disease in the Young. [Journal Article] Stroke. 39(9):2644-91, 2008 Sep.

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.