Anticoagulation Clinic Protocol

Phone 954-262-4550, Fax 954-262-3865

This document serves to establish the Drug Therapy Management protocol

utilized by pharmacists at the NSU Clinic Pharmacy Anticoagulation Clinic for the
purposes of managing patients receiving warfarin therapy.

Pharmacists are authorized to order, interpret laboratory tests, and execute drug
therapy on behalf of a physician. The agreement between pharmacist and physician to
do so must be in writing, and describe the pharmacist’s methodology.

By signing this document, the named physician(s) agree with the named
pharmacist(s) to enter into a Collaborative Practice Agreement. This Agreement shall
allow the named pharmacists to manage patients’ anticoagulation therapy with warfarin
on behalf of the collaborating physician(s) as set forth in the attached protocol.

Goar Alvarez, PharmD, FASCP __________________________

Pharmacist Name Signature & Date

Aisy Aleu, Pharm.D., MBA __________________________

Pharmacist Name Signature & Date

David Pino, Pharm.D. __________________________

Pharmacist Name Signature & Date

Sonia Rivera, Pharm.D. __________________________

Pharmacist Name Signature & Date

Huy Pham, Pharm.D. __________________________

Pharmacist Name Signature & Date

Rucha Acharya, Pharm.D. __________________________

Pharmacist Name Signature & Date

_____________________________ _____________________________
Physician Name & License Signature & Date
 Anticoagulation Service Protocol
Purpose & Background
Through the use of an anticoagulation service provided by the Department of Pharmacy
Services, we provide continuity of care for patients. Numerous studies 1-3 have shown that
pharmacist-run anticoagulation clinics can improve compliance, reduce complications,
hospitalizations, and reduce overall costs.

Within the Nova Southeastern University Clinics, the medical staff commonly refers
individual patients to the Clinic Pharmacy for the management of International Normalized
Ratios (INR) and for the subsequent adjustment of warfarin dosing. Physicians from the
community may also refer patients to the NSU Pharmacy Anticoagulation Clinic by providing a
referral (see Attachment 1) and executing the Collaborative Practice Agreement. Patients will
not be seen at the NSU Pharmacy Anticoagulation Clinic without a physician referral.

Qualifications of Pharmacists
NSU Clinic pharmacists have all earned the degree Doctor of Pharmacy. Additionally,
each pharmacist is knowledgeable of clinic policies for the care and use of the CoaguChek  XS
Pro by Roche Diagnostics and current anticoagulation guidelines. Furthermore, each pharmacist
follows Occupational Safety and Health Administration’s (OSHA) guidelines for the disposal of
waste.

Prescriber Care Plan (Procedure)

Patients seen will be referred in writing to the anticoagulation service (see Attachment
1). The referring physician must execute the Collaborative Practice Agreement to have services
provided for their patients.

Once a patient is enrolled into the service, a record will be created. The record shall
include: Collaborative Practice Agreement, original referral, new patient information sheet,
HIPAA consent, finger-stick consent, pharmacist progress notes, copies of communications with
physicians, and any other relevant documentation.

The desired INR goal range assigned by the collaborating physician will be documented
in the Referral Form. The collaborating pharmacist will base the assessment and management of
warfarin therapy on the most recent Chest guidelines, available through the website
http://www.journal.chestnet.org, as well as publications provided by American Family Physician
(www.aafp.org). These guidelines will also guide changes to therapy for INR readings out of the
target range specified by the patient’s physician.

Note: The collaborating pharmacist will not initiate or discontinue warfarin

therapy. Pharmacists will modify warfarin dose to meet collaborating
physicians’ stated INR goals.

Upon the initial visit and at least annually thereafter, each patient will be verbally
educated regarding the rationale for therapy, importance of diet, need for compliance, signs &
symptoms of bleeding/clotting, which over the counter medications to avoid, and when to call
the pharmacist and/or physician. If available, the pharmacist will provide written materials to
reinforce the physician’s “Prescriber Care Plan”.
During each encounter, the pharmacist will:

 Review indication and duration of therapy.

 Review current medications (including OTC and herbal products), medication
adherence, side effects, and other clinically relevant information.
 Obtain a “finger stick” blood sample.
 If necessary, make warfarin dosage adjustments per “Prescriber Care Plan” (see Table
1).
 Complete a “Pharmacist Progress Note” (see Attachment 1).
 Transmit the “Pharmacist Progress Note” to the referring provider.
 Schedule the patient for a follow-up appointment.
o Determine follow-up appointments for patients that have been within range the
last 3 consecutive visits to be between 4 and 8 weeks 4 based on the
pharmacist’s professional judgement.
 Refer patients with an INR result value greater than 8 to the referring physician
immediately.
o If the referring physician is not immediately available, the pharmacist will
contact emergency services (911).
 Refer patients to the referring physician if they report major signs or symptoms of
thrombosis (i.e. pain/warmth in extremities, shortness of breath, etc.).

Dismissal from Service

The pharmacist will discharge patients from the Anticoagulation Clinic if they reach their
physician’s intended duration of therapy and/or the physician wishes to discontinue warfarin
therapy.
Because of the importance of regular monitoring with warfarin, the pharmacist may
dismiss patients from the Anticoagulation Clinic due to missed appointments. Missing three (3)
or more appointments may be considered grounds for dismissal from the clinic. If the patient is
dismissed because of missed appointments, the patient will receive a letter explaining that they
must contact the referring physician for new monitoring instructions. The physician will also
receive communication that we have dismissed the patient (see Attachment 4).
Billing
Patients will be charged $20.00 per visit (subject to change).
 Department of Pharmacy Services
Anticoagulation Clinic
Referral Form
Date: ___________________

Referring physician: _________________ Contact number: ______________

Fax number: _________________

Patient name: ______________________ Date of birth: _________________

Phone number: _______________

Indication for anticoagulation therapy:

 Prophylaxis of venous thrombosis  Atrial Fibrillation

 Treatment of venous thrombosis
 Treatment of Pulmonary Embolism
 Acute Myocardial Infarction (MI)
 Valvular heart disease
 Thrombophilia (Protein C and/or S deficiency)
 Mechanical Prosthetic valves
 Prevention of recurrent MI
 Other: _________________

Goal INR Range: Duration of therapy:

 2.0 – 3.0  3 months

 2.5 – 3.5  6 months
 Other: _____________  Lifetime
 Other: ____________
Warfarin initiation date: ___________ Last INR: ________ Date: ________

Current weekly warfarin regimen:

Sunday Monday Tuesday Wednesday Thursday Friday Saturday
___mg ___mg ___mg ___mg ___mg ___mg ___mg

Comments: ______________________________________________________________

Completed by: __________________ Referring physician: __________________

Please print Please sign

Please fax to (954) 262-3865 or send referral forms to the Anticoagulation

Clinic to set up an appointment for all patients. If you need further assistance with
initiation of warfarin therapy, contact our office to speak with an Anticoagulation Care
Staff Member.
 NSU Pharmacy Anticoagulation Clinic
3200 S University Drive
Ft. Lauderdale, FL 33328
Referrals: (954) 262-4550 Fax: (954) 262-3865
Pharmacist assessment at: Initial visit and annually thereafter

At this visit the following information was be addressed:

 Purpose of anticoagulation
 Role of warfarin
 How to take warfarin (time of day, dose, weekly schedule etc.)
 What to do for missed doses?
 What is the INR?
 Diet and its effect on INR
 Medication interactions
 Medication compliance / adherence
 Signs and symptoms of bleeding and clotting
 Role of the clinical pharmacist
 Importance of attending appointments / consequences of missed appointments

Along with this education, your finger will be pricked to obtain a small sample of blood.
This sample will help us determine your therapeutic response to your anticoagulation
therapy.

I understand the information provided today and have been provided written education
(in addition to verbal education) regarding my anticoagulation therapy.

_________________________________ _________________________
Patient: Print Name and Signature Date

_________________________________ _________________________
Pharmacist: Print Name and Signature Date

_________________________________ _________________________
Student Pharmacist: Print Name and Signature Date
 NSU Pharmacy Anticoagulation Clinic
Pharmacist Progress Note
Date: _________________________________
Patient name: _______________________________________ DOB: _____________________________________________
Patient’s pharmacy and phone #: __________________________________________________________________________
Referring physician: _________________________________ Drug/Food allergies: _________________________________
If patient is a female of child bearing age, Pregnant? Yes or No
Dosing regimen:
Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total

Other medications (Rx/OTC/herbal):

Anticoagulation indication: A.fib  DVT  PE  MVR  AVR  Hypercoag  Stroke  Other  _________
Goal INR: 2-3  2.5-3.5  Other  ________

Anticoagulation initiation date: _____/______ Duration: 3 months 6 months Lifetime Other _______
If this is not the initial visit, since the last anticoagulation clinic visit, has the patient experienced (check all that have occurred)?

Unusual bruising or bleeding Acute illness within 10 days Thromboembolic s/sx

Blood in urine/change in urine color Falls or injury Hospitalization/ED visit
Blood in stool/change in stool color Nosebleeds Change in overall health
Excessive or change in alcohol intake Change in diet (Vit K rich foods) Change in medication

S:

O: Today’s INR ________________

Last Hgb/Hct (if available) _____________________ Date ___________
Annual Anticoagulation Education Date __________
Next Education Date

A:
1. Adherence to anticoagulation therapy
# of missed doses: within the last week: _____ within the last 2 weeks: _____ since last clinic visit: _____

2. Overall Assessment: Therapeutic  Subtherapeutic  Supratherapeutic 

P:
1. Coumadin/warfarin dose: STAY SAME  or CHANGE TO  :
Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total

2. Patient will RTC on ______/______/20______ at___________

3. Patient education provided:

Clinical Pharmacist: ___________________________ Student Pharmacist: ___________________________

Print name: ___________________________ Print name: ___________________________

Attachment 1. Pharmacist Progress Note

 Clinic Pharmacy
3200 S. University Dr.
Ft. Lauderdale, FL 33328
(954) 262-4550

Date
Patient Name
Address
City, State, Zip

Dear Patient,

The Nova Southeastern University Clinic Pharmacy has been unsuccessful in

attempting to reschedule your anticoagulation appointments. You have missed ###
appointments in the last insert timeframe. As has been explained to you during clinic
visit, your warfarin therapy requires constant monitoring.

Considering these facts, we must ask that you consider yourself removed from
our service. We will provide service for you for thirty days. You must contact your
physician to make alternative monitoring arrangements. Please note that failure to do
so may have severe consequences to your health.

If you have any questions, please contact your physician directly.

Sincerely,

______________________
First Last name, Pharm.D.
Clinical Pharmacist

CC: Referring Physician

Attachment 4. Dismissal Letter

 Prescriber Care Plan - Orders
Table 1. Warfarin Therapy Schematic5
Low Intensity (INR Range 2 – 3)

INR < 1.5 INR 1.5 – 1.9 INR 2 – 3 INR 3.1 – 3.9 INR 4.0 – 4.9 INR 5 - 8
1. Extra dose(s) 1. Increase dose 5- 1. No change in 1. Decrease weekly 1. Hold dose and/or 1. If no bleeding, hold
and/or increase 10% therapy dose by 5 – 10% decrease weekly next 1 - 2 doses
weekly dose by 2. RTC in 1 - 2 2. RTC in 4 - 8 2. RTC in 1 – 2 dose by 10% RTC in 4 – 8 days
10 – 20% weeks weeks4 weeks 2. RTC in 4 - 8 days 2. If bleeding, refer to
2. RTC in 4-8 days physician and/or
emergency services

High Intensity (INR Range 2.5 – 3.5)

INR < 1.5 INR 1.5 – 2.4 INR 2.5 – 3.5 INR 3.6 – 4 INR 4.5 – 6 INR 6 - 8
1. Extra dose(s) 1. Increase weekly 1. No change in 1. Hold dose and/or 1. Hold dose 1-2 1. If no bleeding, hold
and/or increase dose by 5 – 10% therapy decrease weekly days and next 1 - 2 doses
weekly dose by 2. RTC in 1 - 2 2. RTC in 4 - 8 dose by 5 – 10% decrease weekly RTC in 4 – 8 days
10 – 20% weeks weeks4 2. RTC in 1-2 weeks dose by 5 – 15% 2. If bleeding, refer to
2. RTC in 4-8 days 2. RTC in 2-4 weeks physician and/or
emergency services

Table 1. Low and High Intensity Dosage Adjustment Algorithm.

References
1. Wilt VM, Gums JG, Ahmed OI, Moore LM. Pharmacy operated anticoagulation service: Improved outcomes in patients on warfarin. Pharmacotherapy
1995;15:732-739.

2. Chiquette E, Amato MG, Bussey HI. Comparison of an anticoagulation clinic with usual medical care: anticoagulation control, patient outcomes, and
health care costs. Arch Intern Med 1998; 158: 1641-1647.

3. Witt DM, Sadler MA, Shanahan RL, Mazzoli G, Tillman DJ. Effect of a centralized clinical pharmacy anticoagulation service on the outcomes of
anticoagulation therapy. Chest 2005 May; 127 (5): 1515-22.

4. American College of Chest Physicians evidence-based clinical practice guidelines suggest up to 12 weeks.

5. Table 1 extracted from https://www.aafp.org/afp/2013/0415/p556.html retrieved on June 2, 2018

Table 2. Recommendation for Managing Elevated INRs or Bleeding

INR Patient’s Status Treatment plan

INR 4.5-8 No bleeding  The 2012 ACCP guidelines recommend against routine vitamin K
administration in this setting. Hold anticoagulation.
 Previously, the 2008 ACCP guidelines recommended if no risk factors
for bleeding exist, to omit the next 1 or 2 doses, monitor INR more
frequently, and resume with an appropriately adjusted dose when INR in
desired range. Oral vitamin K administration may be considered (1-2.5
mg).
 If other risk factors for bleeding exist. Others have recommended
consideration of vitamin K 1 mg orally or 0.5 mg IV.
INR >8 No bleeding  Contact referring collaborating physician and/or contacting Emergency
Services (911)
Any INR Major bleeding  Contact referring collaborating physician and/or contacting Emergency
Services (911)
Holbrook A, Schulman S, Witt D, et al. Evidence Based Management of Anticoagulant Therapy: Antithrombotic Therapy and Prevention of
Thrombosis, 9th ed. American College of Chest Physicians Evidence Based Clinical Practice Guidelines. CHEST. 2012;141:e152s-184s.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3278055/ Retrieved on Feb. 28, 2018

Table 3. Recommended INR Range and Duration of Therapy

Thromboembolic INR Duration Range Comments

Disorder Target/Range
Thromboembolism
Treatment (DVT,PE)
Provoked VTE event1 (2.5)2-3 3 months
Unprovoked: 1st VTE event
 Proximal or Distal1 (2.5)2-3 3 months After 3 months evaluate risk-
DVT benefit for extended therapy
 PE1 (2.5)2-3 >3 months After 3 months evaluate risk-
benefit for extended therapy
Unprovoked:2nd VTE event
 DVT or PE1 (2.5)2-3 >3 months
1
With malignancy (2.5)2-3 >3 months LMWH preferred over VKA
Valvular Heart Disease
Rheumatic mitral valve disease (2.5)2-3 Lifelong
with normal sinus rhythm (w/
left atrial diameter >55mm,
left atrial thrombus, afib or
previous systemic embolism)2
Valve Replacement-
Bioprosthetic
Mitral valve2 (2.5)2-3 3 months
Valve Replacement-
Mechanical
Aortic valve replacement2 (2.5)2-3 Lifelong
2
Mitral valve replacement 3(2.5-3.5) Lifelong
Dual aortic and mitral valve 3(2.5-3.5) Lifelong
replacement2
Thrombophilia with
Thromboembolic event
Antiphospholipid syndrome (2.5)2-3 Lifelong
with previous arterial or
venous thromboembolism3
Protein C or/and protein S (2.5)2-3 Lifelong The efficacy of Direct oral
deficiency3 anticoagulants (DOACs) may be
suitable in patients with biological
major thrombophilia.6 However,
due to the paucity of available
data, treatment with DOACs
should only be used if failure to
reach INR goal range with
warfarin.
Atrial Fibrillation
CHADS2 Score = 0 (Low risk No therapy
of stroke)4
7
CHADS2 Score = 1 2.5(2-3) Lifelong or aspirin 75mg-325mg daily
(Intermediate risk of stroke)4
CHADS2 Score ≥ 2 (High risk 2.5(2-3) Lifelong
of stroke)4
Mitral Stenosis4 2.5(2-3) Lifelong
Pre-Cardioversion (AF or AFL 2.5(2-3) 3 weeks
≥ 48 hours or unknown
duration)4
Post-Cardioversion4 2.5(2-3) 4 weeks
Ischemic Stroke
Cardioembolic stroke or TIA
 Cerebral venous sinus 2.5(2-3) 3-6 months
thrombosis5
 History of ischemic 2.5(2-3) Lifelong
stroke, TIA or AF5
Non-cardioembolic ischemic None Lifelong Use antiplatelet therapy
stroke
Secondary Prevention of
Cardioembolic Stroke
History of ischemic stroke or 2.5(2-3) Lifelong
TIA and AF5

References for this Table 3. Recommended INR Range and Duration of Therapy

1. Kearon C, Akl E, Comerota A, et al. Antithrombotic Therapy for VTE Disease : Antithrombotic Therapy and Prevention of Thrombosis,
9th ed. American College of Chest Physicians Evidence Based Clinical Practice Guidelines. CHEST. 2012;141: 419s-494s.
2. Whitlock R, Sun J, Fremes S, et al. Antithrombotic and Thrombolytic Therapy for Valvular Disease: Antithrombotic Therapy and
Prevention of Thrombosis, 9th ed. American College of Chest Physicians Evidence Based Clinical Practice Guidelines. CHEST.
2012;141:576s-600s.
3. Holbrook A, Schulman S, Witt D, et al. Evidence Based Management of Anticoagulant Therapy: Antithrombotic Therapy and Prevention
of Thrombosis, 9th ed. American College of Chest Physicians Evidence Based Clinical Practice Guidelines. CHEST. 2012;141:e152s-184s.
4. You J, Singer D, Howard P, et al. Antithrombotic Therapy for Atrial Fibrillation: Antithrombotic Therapy and Prevention of Thrombosis,
9th ed. American College of Chest Physicians Evidence Based Clinical Practice Guidelines. CHEST. 2012;141:e531s-575s.
5. Lansberg M, O’Donnell M, Khatri P, et al. Antithrombotic and Thrombolytic Therapy for Ischemic Stroke: Antithrombotic Therapy and
Prevention of Thrombosis, 9th ed. American College of Chest Physicians Evidence Based Clinical Practice Guidelines. CHEST.
2012;141:601s-636s.
6. Bertoletti L, Benhamou Y, Béjot Y, et al. Direct oral anticoagulant use in patients with thrombophilia, antiphospholipid syndrome or
venous thrombosis of unusual sites: A narrative review. Blood Rev. 2018.
7. UCSF Cardiology. Atrial Fibrillation Medical Management. https://cardiology.ucsf.edu/care/clinical/electro/fib-management.html.
Accessed February 28, 2018.
Table 4. INR Testing Frequency

INR Testing Frequency

After initiation of warfarin Check INR from weekly to up to 8 weeks

Consistently stable INRs Up to 8 weeks

***Stable- Patients taking the same dose for at least three

consecutive months are considered stable.

For patients taking VKA with previously stable INRs who Continue the current dose and recheck INR within 1-2 weeks.
present with a single out-of-range INR of ≤ 0.5 below or above
therapeutic.

Holbrook A, Schulman S, Witt D, et al. Evidence Based Management of Anticoagulant Therapy: Antithrombotic Therapy and Prevention of
Thrombosis, 9th ed. American College of Chest Physicians Evidence Based Clinical Practice Guidelines. CHEST. 2012;141:e152s-184s.

Table 5. CHA2DS2VASc Score

The CHADS2 score is a clinical prediction rule for estimating the risk of stroke in patients with non-rheumatic atrial fibrillation. It is
used to determine whether or not treatment is required with anticoagulation therapy or antiplatelet therapy

Provided by the chadsvasc.org.

Table 6. Medications, Dietary Supplements and Food that INCREASE the INR or Bleeding risk
Drug Class Known Interaction
Anti-Infective Ciprofloxacin Miconazole
Erythromycin Miconazole Vaginal Suppository
Clarithromycin Sulfamethoxazole (Bactrim/Septra)
Fluconazole Isoniazid
Metronidazole

Cardiovascular Amiodarone
Clofibrate
Diltiazem
Fenofibrate
Propafenone
Propranolol
Analgesics/Anti-inflammatories Acetaminophen Use the lowest possible dose and monitor
INR
NSAIDS
Salicylates
CNS Drugs Alcohol
Citalopram
Entacapone
Sertraline
Herbal Supplements Fish Oil Fenugreek
 Ginkgo biloba Feverfew
Quilinggao Saw palmetto
GI Drugs and Food Cimetidine
Mango
Omeprazole

Table 7. Medications, Dietary Supplements and Food that DECREASE the INR or Bleeding risk
Drug Class Known Interaction
Anti-Infective Griseofulvin
Nafcillin
Ribavirin
Rifampin
Cardiovascular Cholestyramine

Analgesics, Anti-inflammatory Mesalamine

CNS Drugs Barbiturates

Carbamazepine
GI Drugs and Food High content vitamin K food such as Avocado

Herbal Supplement Alfalfa

Green Tea
St. John’s Wort
Bold Terms- Generally avoid combination: Only use if benefit outweighs the risk.
Holbrook AM, Pereira JA, Labiris R, et al. Systematic overview of warfarin and its drug and food interactions. Arch Inter Med. 2005;165:1095-106.

Table 8. Warfarin Tablet Identification

Warfarin tablets have a color that indicated their strength. Or how many milligrams are in each tablet.

The color scheme is the same for all manufacturers of warfarin in the US (possible variation in shade). The shape of the tablet
indicates the company that makes it. Check your tablets each time you get them from the pharmacy to be sure you have the right
strength. Ask your pharmacist if the color or shape of your pill changes or if you have any questions.

Warfarin Tablet Identification. (n.d.). Retrieved January 22, 2018, from

https://health.ucsd.edu/specialties/anticoagulation/providers/warfarin/Pages/tablet-identification.aspx

Table 9. Direct oral anticoagulants (DOACs) used as an alternative treatment to warfarin in patients with Protein C & S deficiency
 Medication Name 13 Dose, Frequency & Route of Administration 13
Xarelto® (rivaroxaban) 15 mg PO BID for 21 days and then 20 PO daily.

Eliquis® (apixaban) 10 mg PO BID for 7 days and then 5 mg PO BID.

Pradaxa® (dabigatran) 150mg PO BID for 5-10 days

Savasya® (edoxaban) 60mg PO daily

References:
6. Wilt VM, Gums JG, Ahmed OI, Moore LM. Pharmacy operated anticoagulation service: Improved outcomes in patients on
warfarin. Pharmacotherapy 1995;15:732-739.

7. Chiquette E, Amato MG, Bussey HI. Comparison of an anticoagulation clinic with usual medical care: anticoagulation control,
patient outcomes, and health care costs. Arch Intern Med 1998; 158: 1641-1647.

8. Witt DM, Sadler MA, Shanahan RL, Mazzoli G, Tillman DJ. Effect of a centralized clinical pharmacy anticoagulation service
on the outcomes of anticoagulation therapy. Chest 2005 May; 127 (5): 1515-22.

9. U.S. Department of Labor: Occupation Safety & Health Administration http://www.osha.gov Accessed November 9, 2005.

10. Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service Model Version 2.0. American
Pharmacists Association and National Association of Chain Drug Stores Foundation. March 2008.

11. Ebell MH. A systematic approach to managing warfarin doses. Fam Pract Manag. 2005 May;12(5):77, 79-80, 83.
https://www.aafp.org/fpm/2005/0500/p77.html#fpm20050500p77-bt2 retreieved on Feb. 28, 2018

12. Ansell J, Hirsh J, Hylek E, Jacobson A, Crowther M, and Palareti G. The Pharmacology and Management of the Vitamin K
Antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8 th Edition). Chest. 2008;
126: 160S-198S.

13. Kearon C, Akl EA, Ornelas J, et al. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report.
Chest 2016; 149:315.

14. MacLean S, Mulla S, Akl EA, et al. Patient values and preferences in decision making for antithrombotic therapy: a systematic
review: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-
Based Clinical Practice Guidelines. Chest 2012; 141:e1S.

15. Wigle P, Hein B, Bloomfield HE, et al. Updated guidelines on outpatient anticoagulation. American Family Physician. 2013
Apr 15:87(8):556-66.

16. Warfarin Tablet Identification. (n.d.). Retrieved January 22, 2018, from
https://health.ucsd.edu/specialties/anticoagulation/providers/warfarin/Pages/tablet-identification.aspx

17. Holbrook AM, Pereira JA, Labiris R, et al. Systematic overview of warfarin and its drug and food interactions. Arch Inter Med.
2005;165:1095-106.

18. Lexicomp Online®,l Lexi-Drugs® , Hudson, Ohio: Lexi-Comp, Inc.; February 28, 2018.