Jantoven tablets

Description

Jantoven™ (crystalline warfarin sodium), is an anticoagulant which acts by inhibiting vitamin K-dependent coagulation factors. Chemically, it is 3-((alpha)-acetonylbenzyl)-4-hydroxycoumarin and is a racemic mixture of the R- and S-enantiomers. Crystalline warfarin sodium is an isopropanol clathrate. The crystallization of warfarin sodium virtually eliminates trace impurities present in amorphous warfarin. Its empirical formula is C 19 H 15 NaO 4 and its structural formula may be represented by the following:

images/18/42001451.jpg

Crystalline warfarin sodium occurs as a white, odorless, crystalline powder, is discolored by light and is very soluble in water; freely soluble in alcohol; very slightly soluble in chloroform and in ether.

Jantoven™ (Warfarin Sodium Tablets, USP) for oral use contain: 1 mg, 2 mg, 2 ½ mg, 3 mg, 4 mg, 5 mg, 6 mg, 7 ½ mg or 10 mg of crystalline warfarin sodium, USP. They also contain:

All Strengths:  Lactose monohydrate, magnesium stearate, povidone, and pregelatinized starch (corn).

1 mg:      FD&C Red #40 Aluminum Lake

2 mg:      FD&C Blue #2 Aluminum Lake and FD&C Red #40 Aluminum Lake

2 ½ mg:  D&C Yellow #10 Aluminum Lake and FD&C Blue #1 Aluminum Lake

3 mg:      Brown #75 Synthetic Brown Iron Oxide

4 mg:      FD&C Blue #1 Aluminum Lake

5 mg:      FD&C Yellow #6 Aluminum Lake

6 mg:      Yellow #10 Synthetic Yellow Iron Oxide, Black #85 Synthetic Black Iron Oxide
               and FD&C Blue #1 Aluminum Lake

7 ½ mg:  D&C Yellow #10 Aluminum Lake and FD&C Yellow #6 Aluminum Lake

10 mg:    Dye Free.

Clinical Pharmacology

Jantoven™ (Warfarin Sodium Tablets, USP) and other coumarin anticoagulants act by inhibiting the synthesis of vitamin K dependent clotting factors, which include Factors II, VII, IX and X, and the anticoagulant proteins C and S. Half-lives of these clotting factors are as follows: Factor II - 60 hours, VII - 4-6 hours, IX - 24 hours, and X - 48-72 hours. The half-lives of proteins C and S are approximately 8 hours and 30 hours, respectively. The resultant in vivo effect is a sequential depression of Factors VII, IX, X and II activities. Vitamin K is an essential cofactor for the post ribosomal synthesis of the vitamin K dependent clotting factors. The vitamin promotes the biosynthesis of (gamma)-carboxyglutamic acid residues in the proteins which are essential for biological activity. Warfarin is thought to interfere with clotting factor synthesis by inhibition of the regeneration of vitamin K 1 epoxide. The degree of depression is dependent upon the dosage administered. Therapeutic doses of warfarin decrease the total amount of the active form of each vitamin K dependent clotting factor made by the liver by approximately 30% to 50%.

An anticoagulation effect generally occurs within 24 hours after drug administration. However, peak anticoagulant effect may be delayed 72 to 96 hours. The duration of action of a single dose of racemic warfarin is 2 to 5 days. The effects of Jantoven™ may become more pronounced as effects of daily maintenance doses overlap. Anticoagulants have no direct effect on an established thrombus, nor do they reverse ischemic tissue damage. However, once a thrombus has occurred, the goal of anticoagulant treatment is to prevent further extension of the formed clot and prevent secondary thromboembolic complications which may result in serious and possibly fatal sequelae.

Pharmacokinetics:    Jantoven™ is a racemic mixture of the R- and S-enantiomers. The S-enantiomer exhibits 2-5 times more anticoagulant activity than the R-enantiomer in humans, but generally has a more rapid clearance.

Absorption:    Jantoven™ is essentially completely absorbed after oral administration with peak concentration generally attained within the first 4 hours.

Distribution:   There are no differences in the apparent volumes of distribution after intravenous and oral administration of single doses of warfarin solution. Warfarin distributes into a relatively small apparent volume of distribution of about 0.14 liter/kg. A distribution phase lasting 6 to 12 hours is distinguishable after rapid intravenous or oral administration of an aqueous solution. Using a one compartment model, and assuming complete bioavailability, estimates of the volumes of distribution of R- and S- warfarin are similar to each other and to that of the racemate. Concentrations in fetal plasma approach the maternal values, but warfarin has not been found in human milk (see WARNINGS - Lactation ). Approximately 99% of the drug is bound to plasma proteins.

Metabolism:   The elimination of warfarin is almost entirely by metabolism. Jantoven™ is stereoselectively metabolized by hepatic microsomal enzymes (cytochrome P-450) to inactive hydroxylated metabolites (predominant route) and by reductases to reduced metabolities (warfarin alcohols). The warfarin alcohols have minimal anticoagulant activity. The metabolites are principally excreted into the urine; and to a lesser extent into the bile. The metabolites of warfarin that have been identified include dehydrowarfarin, two diastereoisomer alcohols, 4'-, 6-, 7-, 8- and 10-hydroxywarfarin. The Cytochrome P-450 isozymes involved in the metabolism of warfarin include 2C9, 2C19, 2C8, 2C18,1A2, and 3A4. 2C9 is likely to be the principal form of human liver P-450 which modulates the in vivo anticoagulant activity of warfarin.

Excretion:   The terminal half-life of warfarin after a single dose is approximately one week; however, the effective half-life ranges from 20 to 60 hours, with a mean of about 40 hours. The clearance of R-warfarin is generally half that of S-warfarin, thus as the volumes of distribution are similar, the half-life of R-warfarin is longer than that of S-warfarin. The half-life of R-warfarin ranges from 37 to 89 hours, while that of S-warfarin ranges from 21 to 43 hours. Studies with radiolabeled drug have demonstrated that up to 92% of the orally administered dose is recovered in urine. Very little warfarin is excreted unchanged in urine. Urinary excretion is in the form of metabolites.

Elderly:   Patients 60 years or older appear to exhibit greater than expected PT/INR response to the anticoagulant effects of warfarin. The cause of the increased sensitivity to the anticoagulant effects of warfarin in this age group is unknown. This increased anticoagulant effect from warfarin may be due to a combination of pharmacokinetic and pharmacodynamic factors. Racemic warfarin clearance may be unchanged or reduced with increasing age. Limited information suggests there is no difference in the clearance of S-warfarin in the elderly versus young subjects. However, there may be a slight decrease in the clearance of R-warfarin in the elderly as compared to the young. Therefore, as patient age increases, a lower dose of warfarin is usually required to produce a therapeutic level of anticoagulation.

Asians:   Asian patients may require lower initiation and maintenance doses of warfarin. One non-controlled study conducted in 151 Chinese outpatients reported a mean daily warfarin requirement of 3.3 ± 1.4 mg to achieve an INR of 2 to 2.5. These patients were stabilized on warfarin for various indications. Patient age was the most important determinant of warfarin requirement in Chinese patients with a progressively lower warfarin requirement with increasing age.

Renal Dysfunction:   Renal clearance is considered to be a minor determinant of anticoagulant response to warfarin. No dosage adjustment is necessary for patients with renal failure.

Hepatic Dysfunction:   Hepatic dysfunction can potentiate the response to warfarin through impaired synthesis of clotting factors and decreased metabolism of warfarin.

Clinical Trials

Atrial Fibrillation (AF):   In five prospective randomized controlled clinical trials involving 3711 patients with non-rheumatic AF, warfarin significantly reduced the risk of systemic thromboembolism including stroke (See Table 1 ). The risk reduction ranged from 60% to 86% in all except one trial (CAFA: 45%) which stopped early due to published positive results from two of these trials. The incidence of major bleeding in these trials ranged from 0.6 to 2.7% (See Table 1 ). Meta-analysis findings of these studies revealed that the effects of warfarin in reducing thromboembolic events including stroke were similar at either moderately high INR (2.0-4.5) or low INR (1.4-3.0). There was a significant reduction in minor bleeds at the low INR. Similar data from clinical studies in valvular atrial fibrillation patients are not available.

TABLE 1
CLINICAL STUDIES OF WARFARIN IN NON-RHEUMATIC AF PATIENTS *
N   Thromboembolism % Major Bleeding
Study
Warfarin-
Treated
Patients
Control
Patients
PT
Ratio
INR
% Risk
Reduction
p-
value
Warfarin-
Treated
Patients
Control
Patients
AFASAK 335 336 1.5-2.0 2.8-4.2 60 0.027 0.6 0.0
SPAF 210 211 1.3-1.8 2.0-4.5 67 0.01 1.9 1.9
BAATAF 212 208 1.2-1.5 1.5-2.7 86 <0.05 0.9 0.5
CAFA 187 191 1.3-1.6 2.0-3.0 45 0.25 2.7 0.5
SPINAF 260 265 1.2-1.5 1.4-2.8 79 0.001 2.3 1.5
*All study results of warfarin vs. control are based on intention-to-treat analysis and include ischemic stroke and systemic thromboembolism, excluding hemorrhage and transient ischemic attacks.

Myocardial Infarction:   WARIS (The Warfarin Re-Infarction Study) was a double-blind, randomized study of 1214 patients 2 to 4 weeks post-infarction treated with warfarin to a target INR of 2.8 to 4.8. [But note that a lower INR was achieved and increased bleeding was associated with INR's above 4.0; (see DOSAGE AND ADMINISTRATION )]. The primary endpoint was a combination of total mortality and recurrent infarction. A secondary endpoint of cerebrovascular events was assessed. Mean follow-up of the patients was 37 months. The results for each endpoint separately, including an analysis of vascular death, are provided in the following table:

TABLE 2
Event Warfarin
(N=607)
Placebo
(N=607)
RR (95%CI) % Risk
Reduction
( p
-value)
Total Patient Years of
  Follow-up
2018 1944    
Total Mortality
  Vascular Death
94 (4.7/100 py)
82 (4.1/100 py)
123 (6.3/100 py)
105 (5.4/100 py)
0.76 (0.60, 0.97)
0.78 (0.60, 1.02)
24 (p=0.030)
22 (p=0.068)
Recurrent MI
82 (4.1/100 py)
124 (6.4/100 py)
0.66 (0.51, 0.85)
34 (p=0.001)
Cerebrovascular Event
20 (1.0/100 py)
44 (2.3/100 py)
0.46 (0.28, 0.75)
54 (p=0.002)
RR = Relative risk; Risk reduction = (I-RR); CI = Confidence interval; MI = Myocardial infarction; py = patient years

Mechanical and Bioprosthetic Heart Valves:   In a prospective, randomized, open label, positive-controlled study (Mok et al, 1985) in 254 patients, the thromboembolic-free interval was found to be significantly greater in patients with mechanical prosthetic heart valves treated with warfarin alone compared with dipyridamole-aspirin (p<0.005) and pentoxifylline-aspirin (p<0.05) treated patients. Rates of thromboembolic events in these groups were 2.2, 8.6, and 7.9/100 patient years, respectively. Major bleeding rates were 2.5, 0.0, and 0.9/100 patient years, respectively.

In a prospective, open label, clinical trial (Saour et al, 1990) comparing moderate (INR 2.65) vs. high intensity (INR 9.0) warfarin therapies in 258 patients with mechanical prosthetic heart valves, thromboembolism occurred with similar frequency in the two groups (4.0 and 3.7 events/100 patient years, respectively). Major bleeding was more common in the high intensity group (2.1 events/100 patient years) vs. 0.95 events/100 patient years in the moderate intensity group.

In a randomized trial (Turpie et al, 1988) in 210 patients comparing two intensities of warfarin therapy (INR 2.0-2.25 vs. INR 2.5-4.0) for a three-month period following tissue heart valve replacement, thromboembolism occurred with similar frequency in the two groups (major embolic events 2.0% vs. 1.9%, respectively and minor embolic events 10.8% vs.10.2%, respectively). Major bleeding complications were more frequent with the higher intensity (major hemorrhages 4.6%) vs. none in the lower intensity.

Indications and Usage

Jantoven™ (Warfarin Sodium Tablets, USP) is indicated for the prophylaxis and/or treatment of venous thrombosis and its extension, and pulmonary embolism.

Jantoven™ is indicated for the prophylaxis and/or treatment of the thromboembolic complications associated with atrial fibrillation and/or cardiac valve replacement.

Jantoven™ is indicated to reduce the risk of death, recurrent myocardial infarction, and thromboembolic events such as stroke or systemic embolization after myocardial infarction.

Contraindications

Anticoagulation is contraindicated in any localized or general physical condition or personal circumstance in which the hazard of hemorrhage might be greater than the potential clinical benefits of anticoagulation, such as:

Pregnancy:    Jantoven™ (Warfarin Sodium Tablets, USP) is contraindicated in women who are or may become pregnant because the drug passes through the placental barrier and may cause fatal hemorrhage to the fetus in utero . Furthermore, there have been reports of birth malformations in children born to mothers who have been treated with warfarin during pregnancy.

Embryopathy characterized by nasal hypoplasia with or without stippled epiphyses (chondrodysplasia punctata) has been reported in pregnant women exposed to warfarin during the first trimester. Central nervous system abnormalities also have been reported, including dorsal midline dysplasia characterized by agenesis of the corpus callosum, Dandy-Walker malformation, and midline cerebellar atrophy. Ventral midline dysplasia, characterized by optic atrophy, and eye abnormalities have been observed. Mental retardation, blindness, and other central nervous system abnormalities have been reported in association with second and third trimester exposure. Although rare, teratogenic reports following in utero exposure to warfarin include urinary tract anomalies such as single kidney, asplenia, anencephaly, spina bifida, cranial nerve palsy, hydrocephalus, cardiac defects and congenital heart disease, polydactyly, deformities of toes, diaphragmatic hernia, and corneal leukoma, cleft palate, cleft lip, schizencephaly, and microcephaly.

Spontaneous abortion and still birth are known to occur and a higher risk of fetal mortality is associated with the use of warfarin. Low birth weight and growth retardation have also been reported.

Women of childbearing potential who are candidates for anticoagulant therapy should be carefully evaluated and the indications critically reviewed with the patient. If the patient becomes pregnant while taking this drug, she should be apprised of the potential risks to the fetus, and the possibility of termination of the pregnancy should be discussed in light of those risks.

Hemorrhagic tendencies or blood dyscrasias.

Recent or contemplated surgery of:   (1) central nervous system; (2) eye; (3) traumatic surgery resulting in large open surfaces.

Bleeding tendencies associated with active ulceration or overt bleeding of:   (1) gastrointestinal, genitourinary or respiratory tracts; (2) cerebrovascular hemorrhage; (3) aneurysms-cerebral, dissecting aorta; (4) pericarditis and pericardial effusions; (5) bacterial endocarditis.

Threatened abortion, eclampsia and preeclampsia.

Inadequate laboratory facilities.

Unsupervised patients with senility, alcoholism, or psychosis or other lack of patient cooperation.

Spinal puncture and other diagnostic or therapeutic procedures with potential for uncontrollable bleeding.

Miscellaneous:   major regional, lumbar block anesthesia, malignant hypertension and known hypersensitivity to warfarin or to any other component of this product.

Warnings

The most serious risks associated with anticoagulant therapy with warfarin sodium are hemorrhage in any tissue or organ and, less frequently (<0.1%), necrosis and/or gangrene of skin and other tissues. The risk of hemorrhage is related to the level of intensity and the duration of anticoagulant therapy. Hemorrhage and necrosis have in some cases been reported to result in death or permanent disability. Necrosis appears to be associated with local thrombosis and usually appears within a few days of the start of anticoagulant therapy. In severe cases of necrosis, treatment through debridement or amputation of the affected tissue, limb, breast or penis has been reported. Careful diagnosis is required to determine whether necrosis is caused by an underlying disease. Warfarin therapy should be discontinued when warfarin is suspected to be the cause of developing necrosis and heparin therapy may be considered for anticoagulation. Although various treatments have been attempted, no treatment for necrosis has been considered uniformly effective. See below for information on predisposing conditions. These and other risks associated with anticoagulant therapy must be weighed against the risk of thrombosis or embolization in untreated cases.

It cannot be emphasized too strongly that treatment of each patient is a highly individualized matter. Jantoven™ (Warfarin Sodium Tablets, USP), a narrow therapeutic range (index) drug, may be affected by factors such as other drugs and dietary vitamin K. Dosage should be controlled by periodic determinations of prothrombin time (PT)/International Normalized Ratio (INR) or other suitable coagulation tests. Determinations of whole blood clotting and bleeding times are not effective measures for control of therapy. Heparin prolongs the one-stage PT. When heparin and Jantoven™ are administered concomitantly, refer below to CONVERSION FROM HEPARIN THERAPY for recommendations.

Caution should be observed when Jantoven™ is administered in any situation or in the presence of any predisposing condition where added risk of hemorrhage, necrosis and/or gangrene is present.

Anticoagulation therapy with Jantoven™ may enhance the release of atheromatous plaque emboli, thereby increasing the risk of complications from systemic cholesterol microembolization, including the "purple toes syndrome." Discontinuation of Jantoven™ therapy is recommended when such phenomena are observed.

Systemic atheroemboli and cholesterol microemboli can present with a variety of signs and symptoms including purple toes syndrome, livedo reticularis, rash, gangrene, abrupt and intense pain in the leg, foot, or toes, foot ulcers, myalgia, penile gangrene, abdominal pain, flank or back pain, hematuria, renal insufficiency, hypertension, cerebral ischemia, spinal cord infarction, pancreatitis, symptoms simulating polyarteritis, or any other sequelae of vascular compromise due to embolic occlusion. The most commonly involved visceral organs are the kidneys followed by the pancreas, spleen, and liver. Some cases have progressed to necrosis or death.

Purple toes syndrome is a complication of oral anticoagulation characterized by a dark, purplish or mottled color of the toes, usually occurring between 3-10 weeks, or later, after the initiation of therapy with warfarin or related compounds. Major features of this syndrome include purple color of plantar surfaces and sides of the toes that blanches on moderate pressure and fades with elevation of the legs; pain and tenderness of the toes; waxing and waning of the color over time. While the purple toes syndrome is reported to be reversible, some cases progress to gangrene or necrosis which may require debridement of the affected area, or may lead to amputation.

Heparin-induced thrombocytopenia:    Jantoven™ should be used with caution in patients with heparin-induced thrombocytopenia and deep venous thrombosis. Cases of venous limb ischemia, necrosis and gangrene have occurred in patients with heparin-induced thrombocytopenia and deep venous thrombosis when heparin treatment was discontinued and warfarin therapy was started or continued. In some patients sequelae have included amputation of the involved area and/or death (Warkentin et al, 1997).

A severe elevation (>50 seconds) in activated partial thromboplastin time (aPTT) with a PT/INR in the desired range has been identified as an indication of increased risk of postoperative hemorrhage.

The decision to administer anticoagulants in the following conditions must be based upon clinical judgment in which the risks of anticoagulant therapy are weighed against the benefits:

Lactation:   Based on very limited published data, warfarin has not been detected in the breast milk of mothers treated with warfarin. The same limited published data reports that breast-fed infants, whose mothers were treated with warfarin, had prolonged prothrombin times, although not as prolonged as those of the mothers. The decision to breast-feed should be undertaken only after careful consideration of the available alternatives. Women who are breastfeeding and anticoagulated with warfarin should be very carefully monitored so that recommended PT/INR values are not exceeded. It is prudent to perform coagulation tests and to evaluate Vitamin K status in infants at risk for bleeding tendencies before advising women taking warfarin to breast-feed. Effects in premature infants have not been evaluated.

Severe to moderate hepatic or renal insufficiency.

Infectious diseases or disturbances of intestinal flora: sprue, antibiotic therapy.

Trauma which may result in internal bleeding.

Surgery or trauma resulting in large exposed raw surfaces.

Indwelling catheters.

Severe to moderate hypertension.

Known or suspected deficiency in protein C mediated anticoagulant response:   Hereditary or acquired deficiencies of protein C or its cofactor, protein S, have been associated with tissue necrosis following warfarin administration. Not all patients with these conditions develop necrosis, and tissue necrosis occurs in patients without these deficiencies. Inherited resistance to activated protein C has been described in many patients with venous thromboembolic disorders but has not yet been evaluated as a risk factor for tissue necrosis. The risk associated with these conditions, both for recurrent thrombosis and for adverse reactions, is difficult to evaluate since it does not appear to be the same for everyone. Decisions about testing and therapy must be made on an individual basis. It has been reported that concomitant anticoagulation therapy with heparin for 5 to 7 days during initiation of therapy with Jantoven™ may minimize the incidence of tissue necrosis. Warfarin therapy should be discontinued when warfarin is suspected to be the cause of developing necrosis and heparin therapy may be considered for anticoagulation.

Miscellaneous:   polycythemia vera, vasculitis, and severe diabetes.

Minor and severe allergic/hypersensitivity reactions and anaphylactic reactions have been reported.

In patients with acquired or inherited warfarin resistance, decreased therapeutic responses to Jantoven™ have been reported. Exaggerated therapeutic responses have been reported in other patients.

Patients with congestive heart failure may exhibit greater than expected PT/INR response to Jantoven™ , thereby requiring more frequent laboratory monitoring, and reduced doses of Jantoven™ .

Concomitant use of anticoagulants with streptokinase or urokinase is not recommended and may be hazardous. (Please note recommendations accompanying these preparations.)

Precautions

Periodic determination of PT/INR or other suitable coagulation test is essential.

Numerous factors, alone or in combination, including travel, changes in diet, environment, physical state and medication, including botanicals, may influence response of the patient to anticoagulants. It is generally good practice to monitor the patient's response with additional PT/INR determinations in the period immediately after discharge from the hospital, and whenever other medications, including botanicals, are initiated, discontinued or taken irregularly. The following factors are listed for reference; however, other factors may also affect the anticoagulant response.

Drugs may interact with Jantoven™ (Warfarin Sodium Tablets, USP) through pharmacodynamic or pharmacokinetic mechanisms. Pharmacodynamic mechanisms for drug interactions with Jantoven™ are synergism (impaired hemostasis, reduced clotting factor synthesis), competitive antagonism (vitamin K), and altered physiologic control loop for vitamin K metabolism (hereditary resistance). Pharmacokinetic mechanisms for drug interactions with Jantoven™ are mainly enzyme induction, enzyme inhibition, and reduced plasma protein binding. It is important to note that some drugs may interact by more than one mechanism.

The following factors, alone or in combination, may be responsible for INCREASED PT/INR response:

ENDOGENOUS FACTORS:

blood dyscrasias - see
diarrhea
hyperthyroidism
   CONTRAINDICATIONS
elevated temperature
poor nutritional state
cancer
hepatic disorders
steatorrhea
collagen vascular disease
   infectious hepatitis
vitamin K deficiency
congestive heart failure
   jaundice
 

EXOGENOUS FACTORS:

Potential drug interactions with Jantoven™ are listed below by drug class and by specific drugs.

Classes of Drugs
5-lipoxygenase Inhibitor
Antineoplastics **/*
  Fibric Acid Derivatives
Adrenergic Stimulants,
Antiparasitic/Antimicrobials
  HMG-CoA Reductase
    Central
Antiplatelet Drugs/Effects
    Inhibitors **/*
Alcohol Abuse Reduction
Antithyroid Drugs **/*
Leukotriene Receptor
  Preparations
Beta-Adrenergic Blockers
  Antagonist
Analgesics
Cholelitholytic Agents
Monoamine Oxidase
Anesthetics, Inhalation
Diabetes Agents, Oral
  Inhibitors
Antiandrogen
Diuretics **/*
Narcotics, prolonged
Antiarrhythmics **/*
Fungal Medications,
Nonsteroidal Anti-
Antibiotics **/*
  Intravaginal,
  Inflammatory Agents
  Aminoglycosides (oral)
Systemic **/*
Psychostimulants
  Cephalosporins,
Gastric Acidity and Peptic
Pyrazolones
    parenteral
  Ulcer Agents **/*
Salicylates
  Macrolides
Gastrointestinal
Selective Serotonin
  Miscellaneous
  Prokinetic Agents,
  Reuptake Inhibitors
  Penicillins, intravenous,
  Ulcerative Colitis Agents
Steroids, Adrenocortical **/*
    high dose
Gout Treatment Agents
Steroids, Anabolic (17-Alkyl
  Quinolones
Hemorrheologic Agents
  Testosterone Derivatives)
    (fluoroquinolones)
Hepatotoxic Drugs
Thrombolytics
  Sulfonamides, long acting
Hyperglycemic Agents
Thyroid Drugs
  Tetracyclines
Hypertensive Emergency
Tuberculosis Agents **/*
Anticoagulants
  Agents
Uricosuric Agents
Anticonvulsants **/*
Hypnotics **/*
Vaccines
Antidepressants **/*
Hypolipidemics **/*
Vitamins **/*
Antimalarial Agents
  Bile Acid-Binding Resins **/*

Specific Drugs Reported
acetaminophen
dicumarol
mefenamic acid
propylthiouracil **/*
alcohol **/*
difunisal
methimazole **/*
quinidine
allopurinol
disulfiram
methyldopa
quinine
aminosalicyclic acid
doxycycline
methylphenidate
ranitidine **/*
amiodarone HCl
erythromycin
methylsalicylate
rofecoxib
aspirin
ethacrynic acid
  ointment (topical)
sertraline
atorvastatin **/*
fenofibrate
metronidazole
simvastatin
azithromycin
fenoprofen
miconazole
stanozolol
capecitabine
fluconazole
  (intravaginal, systemic)
streptokinase
cefamandole
fluorouracil
moricizine
sulfamethizole
cefazolin
fluoxetine
  hydrochloride **/*
sulfamethoxazole
cefoperazone
flutamide
nalidixic acid
sulfinpyrazone
cefotetan
fluvastatin
naproxen
sulfisoxazole
cefoxitin
fluvoxamine
neomycin
sulindac
ceftriaxone
gemfibrozil
norfloxacin
tamoxifen
celecoxib
glucagon
ofloxacin
tetracycline
cerivastatin
halothane
olsalazine
thyroid
chenodiol
heparin
omeprazole
ticarcillin
chloramphenicol
ibuprofen
oxaprozin
ticlopidine
chloral hydrate **/*
ifosfamide
oxymetholone
tissue plasminogen
chlorpropamide
indomethacin
paroxetine
  activator (t-PA)
cholestyramine **/*
influenza virus
penicillin G,
tolbutamide
cimetidine
  vaccine
  intravenous
tramadol
ciprofloxacin
itraconazole
pentoxifylline
trimethoprim/
cisapride
Jantoven™
phenylbutazone
  sulfamethoxazole
clarithromycin
  overdose
phenytoin **/*
urokinase
clofibrate
ketoprofen
piperacillin
valproate
cyclophosphamide **/*
ketorolac
piroxicam
vitamin E
danazol
levamisole
pravastatin **/*
zafirlukast
dextran
levofloxacin
prednisone **/*
zileuton
dextrothyroxine
levothyroxine
propafenone
diazoxide
liothyronine
propoxyphene
diclofenac
lovastatin
propranolol
also: other medications affecting blood elements which may modify hemostasis
dietary deficiencies
prolonged hot weather
unreliable PT/INR determinations
**/*Increased and decreased PT/INR responses have been reported.

The following factors, alone or in combination, may be responsible for DECREASED PT/INR response:

ENDOGENOUS FACTORS:

edema
hypothyroidism
hereditary coumarin resistance
nephrotic syndrome
hyperlipemia
 

EXOGENOUS FACTORS:

Potential drug interactions with Jantoven™ (Warfarin Sodium Tablets, USP) are listed below by drug class and by specific drugs.

Classes of Drugs
Adrenal Cortical Steroid
Antithyroid Drugs **/*
  Bile Acid-Binding Resins **/*
  Inhibitors
Barbiturates
  HMG-CoA Reductase
Antacids
Diuretics **/*
    Inhibitors **/*
Antianxiety Agents
Enteral Nutritional
Immunosuppressives
Antiarrhythmics **/*
  Supplements
Oral Contraceptives,
Antibiotics **/*
Fungal Medications,
  Estrogen Containing
Anticonvulsants **/*
  Systemic **/*
Selective Estrogen Receptor
Antidepressants **/*
Gastric Acidity and Peptic
  Modulators
Antihistamines
Ulcer Agents **/*
Steroids, Adrenocortical **/*
Antineoplastics **/*
Hypnotics **/*
Tuberculosis Agents **/*
Antipsychotic Medications
Hypolipidemics **/*
Vitamins **/*

Specific Drugs Reported
alcohol **/*
cyclophosphamide **/*
phenytoin **/*
aminoglutethimide
dicloxacillin
pravastatin **/*
amobarbital
ethchlorvynol
prednisone **/*
atorvastatin **/*
glutethimide
primidone
azathioprine
griseofulvin
propylthiouracil **/*
butabarbital
haloperidol
raloxifene
butalbital
Jantoven™ underdosage
ranitidine **/*
carbamazepine
meprobamate
rifampin
chloral hydrate **/*
6-mercaptopurine
secobarbital
chlordiazepoxide
methimazole **/*
spironolactone
chlorthalidone
moricizine hydrochloride **/*
sucralfate
cholestyramine **/*
nafcillin
trazodone
clozapine
paraldehyde
vitamin C (high dose)
corticotropin
pentobarbital
vitamin K
cortisone
phenobarbital
also:diet high in vitamin K
unreliable PT/INR determinations
**/*Increased and decreased PT/INR responses have been reported.

Because a patient may be exposed to a combination of the above factors, the net effect of Jantoven™ on PT/INR response may be unpredictable. More frequent PT/INR monitoring is therefore advisable. Medications of unknown interaction with coumarins are best regarded with caution. When these medications are started or stopped, more frequent PT/INR monitoring is advisable.

It has been reported that concomitant administration of warfarin and ticlopidine may be associated with cholestatic hepatitis. Botanical (Herbal) Medicines: Caution should be exercised when botanical medicines (botanicals) are taken concomitantly with Jantoven™ . Few adequate, well-controlled studies exist evaluating the potential for metabolic and/or pharmacologic interactions between botanicals and Jantoven™ . Due to a lack of manufacturing standardization with botanical medicinal preparations, the amount of active ingredients may vary. This could further confound the ability to assess potential interactions and effects on anticoagulation. It is good practice to monitor the patient's response with additional PT/INR determinations when initiating or discontinuing botanicals.

Specific botanicals reported to affect Jantoven™ therapy include the following:

  • Bromelains, danshen, dong quai ( Angelica sinensis ), garlic, Ginkgo biloba and ginseng are associated most often with an INCREASE in the effects of Jantoven™ .
  • Coenzyme Q 10 (ubidecarenone) and St. John's wort are associated most often with a DECREASE in the effects of Jantoven™ .

Some botanicals may cause bleeding events when taken alone (e.g., garlic and Ginkgo biloba) and may have anticoagulant, antiplatelet, and/or fibrinolytic properties. These effects would be expected to be additive to the anticoagulant effects of Jantoven™ . Conversely, other botanicals may have coagulant properties when taken alone or may decrease the effects of Jantoven™ .

Some botanicals that may affect coagulation are listed below for reference; however, this list should not be considered all-inclusive. Many botanicals have several common names and scientific names. The most widely recognized common botanical names are listed.

Botanicals that contain coumarins with potential anticoagulant effects:
Alfalfa
Capsicum 2
Horseradish
Red Clover
Angelica (Dong Quai)
Cassia 3
Licorice 3
Sweet Clover
Aniseed
Celery
Meadowsweet 1
Sweet Woodruff
Amica
Chamomile (German and
Nettle
Tonka Beans
Asa Foetida
Roman)
Parsley
Wild Carrot
Bogbean 1
Dandelion
Passion Flower
Wild Lettuce
Boldo
Fenugreek
Prickly Ash (Northern)
Buchu
Horse Chestnut
Quassia

Miscellaneous botanicals with anticoagulant properties:
Bladder Wrack (Fucus)
Pau d'arco

Botanicals that contain salicylate and/or have antiplatelet properties:
Agrimony 4
Dandelion
Meadowsweet 1
Aloe Gel
Feverfew
Onion 5
Aspen
Garlic 5
Policosanol
Black Cohosh
German Sarsaparilla
Poplar
Black Haw
Ginger
Senega
Bogbean 1
Ginkgo Biloba
Tamarind
Cassia 3
Ginseng (Panax) 5
Willow
Clove
Licorice 3
Wintergreen

Botanicals with fibrinolytic properties:
Bromelains
Garlic 5
Inositol Nicotinate
Capsicum 2
Ginseng (Panax) 5
Onion 5

Botanicals with coagulant properties:
Agrimony 4
Mistletoe 5
Goldenseal
Yarrow
1 Contains coumarins and salicylate.
2 Contains coumarins and has fibrinolytic properties.
3 Contains coumarins and has antiplatelet properties.
4 Contains salicylate and has coagulant properties.
5 Has antiplatelet and fibrinolytic properties.

Effect on Other Drugs:   Coumarins may also affect the action of other drugs. Hypoglycemic agents (chlorpropamide and tolbutamide) and anticonvulsants (phenytoin and phenobarbital) may accumulate in the body as a result of interference with either their metabolism or excretion.

Special Risk Patients:    Jantoven™ is a narrow therapeutic range (index) drug, and caution should be observed when warfarin sodium is administered to certain patients such as the elderly or debilitated or when administered in any situation or physical condition where added risk of hemorrhage is present.

Intramuscular (I.M.) injections of concomitant medications should be confined to the upper extremities which permits easy access for manual compression, inspections for bleeding and use of pressure bandages.

Caution should be observed when Jantoven™ (or warfarin) is administered concomitantly with nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, to be certain that no change in anticoagulation dosage is required. In addition to specific drug interactions that might affect PT/INR, NSAIDs, including aspirin, can inhibit platelet aggregation, and can cause gastrointestinal bleeding, peptic ulceration and/or perforation.

Acquired or inherited warfarin resistance should be suspected if large daily doses of Jantoven™ are required to maintain a patient's PT/INR within a normal therapeutic range.

Information for Patients:   The objective of anticoagulant therapy is to decrease the clotting ability of the blood so that thrombosis is prevented, while avoiding spontaneous bleeding. Effective therapeutic levels with minimal complications are in part dependent upon cooperative and well-instructed patients who communicate effectively with their physician. Patients should be advised: Strict adherence to prescribed dosage schedule is necessary. Do not take or discontinue any other medication, including salicylates (e.g., aspirin and topical analgesics), other over-the-counter medications, and botanical (herbal) products (e.g.,bromelains, coenzyme Q 10 , danshen, dong quai, garlic, Ginkgo biloba, ginseng and St. John's wort) except on advice of the physician. Avoid alcohol consumption. Do not take Jantoven™ during pregnancy and do not become pregnant while taking it (see CONTRAINDICATIONS ). Avoid any activity or sport that may result in traumatic injury. Prothrombin time tests and regular visits to physician or clinic are needed to monitor therapy. Carry identification stating that Jantoven™ is being taken. If the prescribed dose of Jantoven™ is forgotten, notify the physician immediately. Take the dose as soon as possible on the same day but do not take a double dose of Jantoven™ the next day to make up for missed doses. The amount of vitamin K in food may affect therapy with Jantoven™ . Eat a normal, balanced diet maintaining a consistent amount of vitamin K. Avoid drastic changes in dietary habits, such as eating large amounts of green leafy vegetables. Contact physician to report any illness, such as diarrhea, infection or fever. Notify physician immediately if any unusual bleeding or symptoms occur. Signs and symptoms of bleeding include: pain, swelling or discomfort, prolonged bleeding from cuts, increased menstrual flow or vaginal bleeding, nosebleeds, bleeding of gums from brushing, unusual bleeding or bruising, red or dark brown urine, red or tar black stools, headache, dizziness, or weakness. If therapy with Jantoven™ is discontinued, patients should be cautioned that the anticoagulant effects of Jantoven™ may persist for about 2 to 5 days. Patients should be informed that all warfarin sodium, USP products represent the same medication, and should not be taken concomitantly, as overdosage may result.

Carcinogenesis, Mutagenesis, Impairment of Fertility: Carcinogenicity and mutagenicity studies have not been performed with Jantoven™ . The reproductive effects of Jantoven™ have not been evaluated.

Use in Pregnancy:   Pregnancy Category X - See CONTRAINDICATIONS .

Pediatric Use:   Safety and effectiveness in pediatric patients below the age of 18 have not been established, in randomized, controlled clinical trials. However, the use of Jantoven™ in pediatric patients is well-documented for the prevention and treatment of thromboembolic events. Difficulty achieving and maintaining therapeutic PT/INR ranges in the pediatric patient has been reported. More frequent PT/INR determinations are recommended because of possible changing warfarin requirements.

Geriatric Use:   Patients 60 years or older appear to exhibit greater than expected PT/INR response to the anticoagulant effects of warfarin (see CLINICAL PHARMACOLOGY ). Jantoven™ is contraindicated in any unsupervised patient with senility. Caution should be observed with administration of warfarin sodium to elderly patients in any situation or physical condition where added risk of hemorrhage is present. Lower initiation and maintenance doses of Jantoven™ are recommended for elderly patients (see DOSAGE AND ADMINISTRATION ).

Adverse Reactions

Potential adverse reactions to Jantoven™ (Warfarin Sodium Tablets, USP) may include:

  • Fatal or nonfatal hemorrhage from any tissue or organ. This is a consequence of the anticoagulant effect. The signs, symptoms, and severity will vary according to the location and degree or extent of the bleeding. Hemorrhagic complications may present as paralysis; paresthesia; headache, chest, abdomen, joint, muscle or other pain; dizziness; shortness of breath, difficulty breathing or swallowing; unexplained swelling; weakness; hypotension; or unexplained shock. Therefore, the possibility of hemorrhage should be considered in evaluating the condition of any anticoagulated patient with complaints which do not indicate an obvious diagnosis. Bleeding during anticoagulant therapy does not always correlate with PT/INR. (See OVERDOSAGE - Treatment .)
  • Bleeding which occurs when the PT/INR is within the therapeutic range warrants diagnostic investigation since it may unmask a previously unsuspected lesion, e.g., tumor, ulcer, etc.
  • Necrosis of skin and other tissues. (See WARNINGS .)
  • Adverse reactions reported infrequently include: hypersensitivity/allergic reactions, systemic cholesterol microembolization, purple toes syndrome, hepatitis, cholestatic hepatic injury, jaundice, elevated liver enzymes, vasculitis, edema, fever, rash, dermatitis, including bullous eruptions, urticaria, abdominal pain including cramping, flatulence/bloating, fatigue, lethargy, malaise, asthenia, nausea, vomiting, diarrhea, pain, headache, dizziness, taste perversion, pruritis, alopecia, cold intolerance, and paresthesia including feeling cold and chills.

Rare events of tracheal or tracheobronchial calcification have been reported in association with long-term warfarin therapy. The clinical significance of this event is unknown. Priapism has been associated with anticoagulant administration, however, a causal relationship has not been established.

Overdosage

Signs and Symptoms:   Suspected or overt abnormal bleeding (e.g., appearance of blood in stools or urine, hematuria, excessive menstrual bleeding, melena, petechiae, excessive bruising or persistent oozing from superficial injuries) are early manifestations of anticoagulation beyond a safe and satisfactory level.

Treatment:   Excessive anticoagulation, with or without bleeding, may be controlled by discontinuing Jantoven™ (Warfarin Sodium Tablets, USP) therapy and if necessary, by administration of oral or parenteral vitamin K 1 . (Please see recommendations accompanying vitamin K 1 preparations prior to use.)

Such use of vitamin K 1 reduces response to subsequent Jantoven™ therapy. Patients may return to a pretreatment thrombotic status following the rapid reversal of a prolonged PT/INR. Resumption of Jantoven™ administration reverses the effect of vitamin K, and a therapeutic PT/INR can again be obtained by careful dosage adjustment. If rapid anticoagulation is indicated, heparin may be preferable for initial therapy.

If minor bleeding progresses to major bleeding, give 5 to 25 mg (rarely up to 50 mg) parenteral vitamin K 1 . In emergency situations of severe hemorrhage, clotting factors can be returned to normal by administering 200 to 500 mL of fresh whole blood or fresh frozen plasma, or by giving commercial Factor IX complex.

A risk of hepatitis and other viral diseases is associated with the use of these blood products; Factor IX complex is also associated with an increased risk of thrombosis. Therefore, these preparations should be used only in exceptional or life-threatening bleeding episodes secondary to Jantoven™ overdosage.

Purified Factor IX preparations should not be used because they cannot increase the levels of prothrombin. Factor VII and Factor X which are also depressed along with the levels of Factor IX as a result of Jantoven™ treatment. Packed red blood cells may also be given if significant blood loss has occurred. Infusions of blood or plasma should be monitored carefully to avoid precipitating pulmonary edema in elderly patients or patients with heart disease.

Dosage and Administration

The dosage and administration of Jantoven™ (Warfarin Sodium Tablets, USP) must be individualized for each patient according to the particular patient's PT/INR response to the drug. The dosage should be adjusted based upon the patient's PT/INR. (See LABORATORY CONTROL below for full discussion on INR.)

Venous Thromboembolism (including pulmonary embolism):   Available clinical evidence indicates that an INR of 2.0 to 3.0 is sufficient for prophylaxis and treatment of venous thromboembolism and minimizes the risk of hemorrhage associated with higher INRs. In patients with risk factors for recurrent venous thromboembolism including venous insufficiency, inherited thrombophilia, idiopathic venous thromboembolism, and a history of thrombotic events, consideration should be given to longer term therapy (Schulman et al, 1995 and Schulman et al, 1997).

Atrial Fibrillation:   Five recent clinical trials evaluated the effects of warfarin in patients with non-valvular atrial fibrillation (AF). Meta-analysis findings of these studies revealed that the effects of warfarin in reducing thromboembolic events including stroke were similar at either moderately high INR (2.0-4.5) or low INR (1.4-3.0). There was a significant reduction in minor bleeds at the low INR. Similar data from clinical studies in valvular atrial fibrillation patients are not available. The trials in non-valvular atrial fibrillation support the American College of Chest Physicians' (ACCP) recommendation that an INR of 2.0-3.0 be used for long term warfarin therapy in appropriate AF patients.

Post-Myocardial Infarction:   In post-myocardial infarction patients, Jantoven™ therapy should be initiated early (2-4 weeks post-infarction) and dosage should be adjusted to maintain an INR of 2.5-3.5 long-term. The recommendation is based on the results of the WARIS study in which treatment was initiated 2 to 4 weeks after the infarction. In patients thought to be at an increased risk of bleeding complications or on aspirin therapy, maintenance of Jantoven™ therapy at the lower end of this INR range is recommended.

Mechanical and Bioprosthetic Heart Valves:   In patients with mechanical heart valve(s), long term prophylaxis with warfarin to an INR of 2.5-3.5 is recommended. In patients with bioprosthetic heart valve(s), based on limited data, the American College of Chest Physicians recommends warfarin therapy to an INR of 2.0-3.0 for 12 weeks after valve insertion. In patients with additional risk factors such as atrial fibrillation or prior thromboembolism, consideration should be given for longer term therapy.

Recurrent Systemic Embolism:   In cases where the risk of thromboembolism is great, such as in patients with recurrent systemic embolism, a higher INR may be required.

An INR of greater than 4.0 appears to provide no additional therapeutic benefit in most patients and is associated with a higher risk of bleeding.

Initial Dosage:   The dosing of Jantoven™ must be individualized according to patient's sensitivity to the drug as indicated by the PT/INR. Use of a large loading dose may increase the incidence of hemorrhagic and other complications, does not offer more rapid protection against thrombi formation, and is not recommended. Lower initiation and maintenance doses are recommended for elderly and/or debilitated patients and patients with potential to exhibit greater than expected PT/INR response to Jantoven™ (see PRECAUTIONS ). Based on limited data, Asian patients may also require lower initiation and maintenance doses of Jantoven™ (see CLINICAL PHARMACOLOGY ). It is recommended that Jantoven™ therapy be initiated with a dose of 2 to 5 mg per day with dosage adjustments based on the results of PT/INR determinations.

Maintenance:   Most patients are satisfactorily maintained at a dose of 2 to 10 mg daily. Flexibility of dosage is provided by breaking scored tablets in half. The individual dose and interval should be gauged by the patient's prothrombin response.

Duration of Therapy:   The duration of therapy in each patient should be individualized. In general, anticoagulant therapy should be continued until the danger of thrombosis and embolism has passed.

Missed Dose:   The anticoagulant effect of Jantoven™ persists beyond 24 hours. If the patient forgets to take the prescribed dose of Jantoven™ at the scheduled time, the dose should be taken as soon as possible on the same day. The patient should not take the missed dose by doubling the daily dose to make up for the missed doses, but should refer back to his or her physician.

LABORATORY CONTROL:   The PT reflects the depression of vitamin K dependent Factors VII, X and II. There are several modifications of the one-stage PT and the physician should become familiar with the specific method used in his laboratory. The degree of anticoagulation indicated by any range of PTs may be altered by the type of thromboplastin used; the appropriate therapeutic range must be based on the experience of each laboratory. The PT should be determined daily after the administration of the initial dose until PT/INR results stabilize in the therapeutic range. Intervals between subsequent PT/INR determinations should be based upon the physician's judgment of the patient's reliability and response to Jantoven™ in order to maintain the individual within the therapeutic range. Acceptable intervals for PT/INR determinations are normally within the range of one to four weeks after a stable dosage has been determined. To ensure adequate control, it is recommended that additional PT tests are done when other warfarin products are interchanged with warfarin sodium tablets, USP, as well as whenever other medications are initiated, discontinued, or taken irregularly (see PRECAUTIONS ). Different thromboplastin reagents vary substantially in their sensitivity to sodium warfarin-induced effects on PT. To define the appropriate therapeutic regimen it is important to be familiar with the sensitivity of the thromboplastin reagent used in the laboratory and its relationship to the International Reference Preparation (IRP), a sensitive thromboplastin reagent prepared from human brain.

A system of standardizing the PT in oral anticoagulant control was introduced by the World Health Organization in 1983. It is based upon the determination of an International Normalized Ratio (INR) which provides a common basis for communication of PT results and interpretations of therapeutic ranges. The INR system of reporting is based on a logarithmic relationship between the PT ratios of the test and reference preparation. The INR is the PT ratio that would be obtained if the International Reference Preparation (IRP), which has an ISI of 1.0, were used to perform the test. Early clinical studies of oral anticoagulants, which formed the basis for recommended therapeutic ranges of 1.5 to 2.5 times control mean normal PT, used sensitive human brain thromboplastin. When using the less sensitive rabbit brain thromboplastins commonly employed in PT assays today, adjustments must be made to the targeted PT range that reflect this decrease in sensitivity.

The INR can be calculated as: INR = (observed PT ratio) ISI where the ISI (International Sensitivity Index) is the correction factor in the equation that relates the PT ratio of the local reagent to the reference preparation and is a measure of the sensitivity of a given thromboplastin to reduction of vitamin K-dependent coagulation factors; the lower the ISI, the more "sensitive" the reagent and the closer the derived INR will be to the observed PT ratio. 1

The proceedings and recommendations of the 1992 National Conference on Antithrombotic Therapy 2-4 review and evaluate issues related to oral anticoagulant therapy and the sensitivity of thromboplastin reagents and provide additional guidelines for defining the appropriate therapeutic regimen.

The conversion of the INR to PT ratios for the less-intense (INR 2.0 to 3.0) and more intense (INR 2.5 to 3.5) therapeutic range recommended by the ACCP for thromboplastins over a range of ISI values is shown in TABLE 3. 5

TABLE 3
Relationship Between INR and PT Ratios For Thromboplastins With Different ISI Values (Sensitivities)
PT RATIOS
  ISI ISI ISI ISI ISI
  1.0 1.4 1.8 2.3 2.8
INR = 2.0-3.0
2.0-3.0 1.6-2.2 1.5-1.8 1.4-1.6 1.3-1.5
INR = 2.5-3.5
2.5-3.5 1.9-2.4 1.7-2.0 1.5-1.7 1.4-1.6

TREATMENT DURING DENTISTRY AND SURGERY:   The management of patients who undergo dental and surgical procedures requires close liaison between attending physicians, surgeons and dentists. PT/INR determination is recommended just prior to any dental or surgical procedure. In patients undergoing minimal invasive procedures who must be anticoagulated prior to, during, or immediately following these procedures, adjusting the dosage of Jantoven™ to maintain the PT/INR at the low end of the therapeutic range may safely allow for continued anticoagulation. The operative site should be sufficiently limited and accessible to permit the effective use of local procedures for hemostasis. Under these conditions, dental and minor surgical procedures may be performed without undue risk of hemorrhage. Some dental or surgical procedures may necessitate the interruption of Jantoven™ therapy. When discontinuing Jantoven™ even for a short period of time, the benefits and risks should be strongly considered.

CONVERSION FROM HEPARIN THERAPY:   Since the anticoagulant effect of Jantoven™ is delayed, heparin is preferred initially for rapid anticoagulation. Conversion to Jantoven™ may begin concomitantly with heparin therapy or may be delayed 3 to 6 days. To ensure continuous anticoagulation, it is advisable to continue full dose heparin therapy and that Jantoven™ therapy be overlapped with heparin for 4 to 5 days, until Jantoven™ has produced the desired therapeutic response as determined by PT/INR. When Jantoven™ has produced the desired PT/INR or prothrombin activity, heparin may be discontinued.

Jantoven™ may increase the aPTT test, even in the absence of heparin. During initial therapy with Jantoven™ , the interference with heparin anticoagulation is of minimal clinical significance.

As heparin may affect the PT/INR, patients receiving both heparin and Jantoven™ should have blood for PT/INR determination drawn at least:

  • 5 hours after the last IV bolus dose of heparin, or
  • 4 hours after cessation of a continuous IV infusion of heparin, or
  • 24 hours after the last subcutaneous heparin injection.

How Supplied

Jantoven™ (Warfarin Sodium Tablets, USP) for oral use, are supplied in the following forms:

1 mg - Compressed tablet, pink, round; one side scored and debossed WRF & 1, one side debossed 832, in bottles of
100 and 1000 and in unit dose cartons of 100 tablets (10 cards containing 10 tablets each).

2 mg - Compressed tablet, lavender, round; one side scored and debossed WRF & 2, one side debossed 832, in bottles of 100 and 1000 and in unit dose cartons of 100 tablets (10 cards containing 10 tablets each).

2 ½ mg - Compressed tablet, green, round; one side scored and debossed WRF & 2 ½ , one side debossed 832, in bottles of 100 and 1000 and in unit dose cartons of 100 tablets (10 cards containing 10 tablets each).

3 mg - Compressed tablet, tan, round; one side scored and debossed WRF & 3, one side debossed 832, in bottles of 100 and 1000 and in unit dose cartons of 100 tablets (10 cards containing 10 tablets each).

4 mg - Compressed tablet, blue, round; one side scored and debossed WRF & 4, one side debossed 832, in bottles of
100 and 1000 and in unit dose cartons of 100 tablets (10 cards containing 10 tablets each).

5 mg - Compressed tablet, peach, round; one side scored and debossed WRF & 5, one side debossed 832, in bottles of 100 and 1000 and in unit dose cartons of 100 tablets (10 cards containing 10 tablets each).

6 mg - Compressed tablet, teal, round; one side scored and debossed WRF & 6, one side debossed 832, in bottles of 100 and 1000 and in unit dose cartons of 100 tablets (10 cards containing 10 tablets each).

7 ½ mg - Compressed tablet, yellow, round; one side scored and debossed WRF & 7 ½ , one side debossed 832, in bottles of 100 and 500 and in unit dose cartons of 100 tablets (10 cards containing 10 tablets each).

10 mg - Compressed tablet, white, round; one side scored and debossed WRF & 10, one side debossed 832, in bottles of 100 and 500 and in unit dose cartons of 100 tablets (10 cards containing 10 tablets each).

Store at 20-25°C (68-77°F) and excursions permitted to 15-30°C (59-86°F) [see USP Controlled Room Temperature]. Keep tightly closed. Protect from light and moisture. Dispense in a tight, light-resistant container with a child-resistant closure.

Keep out of reach of children.

Rx only

References

  1. Poller, L.: Laboratory Control of Anticoagulant Therapy. Seminars in Thrombosis and Hemostasis, Vol. 12, No. 1, pp. 13-19, 1986.
  2. Hirsh, J.: Is the Dose of Warfarin Prescribed by American Physicians Unnecessarily High? Arch Int Med , Vol. 147, pp. 769-771, 1987.
  3. Cook, D.J., Guyatt, H.G., Laupacis, A., Sackett, D.L.: Rules of Evidence and Clinical Recommendations on the Use of Antithrombotic Agents. Chest ACCP Consensus Conference on Antithrombotic Therapy. Chest , Vol. 102(Suppl), pp. 305S-311S, 1992.
  4. Hirsh, J., Dalen, J., Deykin, D., Poller, L.: Oral Anticoagulants Mechanism of Action, Clinical Effectiveness, and Optimal Therapeutic Range. Chest ACCP Consensus Conference on Antithrombotic Therapy. Chest , Vol. 102(Suppl), pp. 312S-326S, 1992.
  5. Hirsh, J., M.D., F.C.C.P.: Hamilton Civic Hospitals Research Center, Hamilton, Ontario, Personal Communication.

Manufactured by

UPSHER-SMITH LABORATORIES, INC.

Minneapolis, MN 55447

JAPI.1203 - 00                                Revised 0703

PRODUCT PHOTO(S):

NOTE: These photos can be used only for identification by shape, color, and imprint. They do not depict actual or relative size.

The product samples shown here have been supplied by the manufacturer. While every effort has been made to assure accurate reproduction, please remember that any visual identification should be considered preliminary. In cases of poisoning or suspected overdosage, the drug's identity should be verified by chemical analysis.
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