NDC 70518-2380 Warfarin Sodium

Warfarin

NDC Product Code 70518-2380

NDC CODE: 70518-2380

Proprietary Name: Warfarin Sodium What is the Proprietary Name?
The proprietary name also known as the trade name is the name of the product chosen by the medication labeler for marketing purposes.

Non-Proprietary Name: Warfarin What is the Non-Proprietary Name?
The non-proprietary name is sometimes called the generic name. The generic name usually includes the active ingredient(s) of the product.

Drug Use Information

Drug Use Information
The drug use information is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate. This information is not individual medical advice and does not substitute for the advice of a health care professional. Always ask a health care professional for complete information about this product and your specific health needs.

  • This medication is used to treat blood clots (such as in deep vein thrombosis-DVT or pulmonary embolus-PE) and/or to prevent new clots from forming in your body. Preventing harmful blood clots helps to reduce the risk of a stroke or heart attack. Conditions that increase your risk of developing blood clots include a certain type of irregular heart rhythm (atrial fibrillation), heart valve replacement, recent heart attack, and certain surgeries (such as hip/knee replacement). Warfarin is commonly called a blood thinner, but the more correct term is anticoagulant. It helps to keep blood flowing smoothly in your body by decreasing the amount of certain substances (clotting proteins) in your blood.

Product Characteristics

Color(s):
BROWN (C48332 - LIGHT TAN)
Shape: OVAL (C48345)
Size(s):
11 MM
Imprint(s):
764;3;AN
Score: 2

NDC Code Structure

  • 70518 - Remedyrepack Inc.

NDC 70518-2380-0

Package Description: 100 POUCH in 1 BOX, UNIT-DOSE > 1 TABLET in 1 POUCH (70518-2380-1)

NDC Product Information

Warfarin Sodium with NDC 70518-2380 is a a human prescription drug product labeled by Remedyrepack Inc.. The generic name of Warfarin Sodium is warfarin. The product's dosage form is tablet and is administered via oral form.

Labeler Name: Remedyrepack Inc.

Dosage Form: Tablet - A solid dosage form containing medicinal substances with or without suitable diluents.

Product Type: Human Prescription Drug What kind of product is this?
Indicates the type of product, such as Human Prescription Drug or Human Over the Counter Drug. This data element matches the “Document Type” field of the Structured Product Listing.

Warfarin Sodium Active Ingredient(s)

What is the Active Ingredient(s) List?
This is the active ingredient list. Each ingredient name is the preferred term of the UNII code submitted.

  • WARFARIN SODIUM 3 mg/1

Inactive Ingredient(s)

About the Inactive Ingredient(s)
The inactive ingredients are all the component of a medicinal product OTHER than the active ingredient(s). The acronym "UNII" stands for “Unique Ingredient Identifier” and is used to identify each inactive ingredient present in a product.

  • HYDROXYPROPYL CELLULOSE (TYPE E) (UNII: 66O7AQV0RT)
  • LACTOSE MONOHYDRATE (UNII: EWQ57Q8I5X)
  • MAGNESIUM STEARATE (UNII: 70097M6I30)
  • STARCH, CORN (UNII: O8232NY3SJ)
  • FD&C YELLOW NO. 6 (UNII: H77VEI93A8)
  • FD&C BLUE NO. 2 (UNII: L06K8R7DQK)
  • FD&C RED NO. 40 (UNII: WZB9127XOA)

Administration Route(s)

What are the Administration Route(s)?
The translation of the route code submitted by the firm, indicating route of administration.

  • Oral - Administration to or by way of the mouth.
  • Oral - Administration to or by way of the mouth.

Pharmacological Class(es)

What is a Pharmacological Class?
These are the reported pharmacological class categories corresponding to the SubstanceNames listed above.

  • Vitamin K Antagonist - [EPC] (Established Pharmacologic Class)
  • Vitamin K Inhibitors - [MoA] (Mechanism of Action)

Product Labeler Information

What is the Labeler Name?
Name of Company corresponding to the labeler code segment of the Product NDC.

Labeler Name: Remedyrepack Inc.
Labeler Code: 70518
FDA Application Number: ANDA202202 What is the FDA Application Number?
This corresponds to the NDA, ANDA, or BLA number reported by the labeler for products which have the corresponding Marketing Category designated. If the designated Marketing Category is OTC Monograph Final or OTC Monograph Not Final, then the Application number will be the CFR citation corresponding to the appropriate Monograph (e.g. “part 341”). For unapproved drugs, this field will be null.

Marketing Category: ANDA - A product marketed under an approved Abbreviated New Drug Application. What is the Marketing Category?
Product types are broken down into several potential Marketing Categories, such as NDA/ANDA/BLA, OTC Monograph, or Unapproved Drug. One and only one Marketing Category may be chosen for a product, not all marketing categories are available to all product types. Currently, only final marketed product categories are included. The complete list of codes and translations can be found at www.fda.gov/edrls under Structured Product Labeling Resources.

Start Marketing Date: 10-23-2019 What is the Start Marketing Date?
This is the date that the labeler indicates was the start of its marketing of the drug product.

Listing Expiration Date: 12-31-2020 What is the Listing Expiration Date?
This is the date when the listing record will expire if not updated or certified by the product labeler.

Exclude Flag: N What is the NDC Exclude Flag?
This field indicates whether the product has been removed/excluded from the NDC Directory for failure to respond to FDA’s requests for correction to deficient or non-compliant submissions. Values = ‘Y’ or ‘N’.

* Please review the disclaimer below.

Warfarin Sodium Product Labeling Information

The product labeling information includes all published material associated to a drug. Product labeling documents include information like generic names, active ingredients, ingredient strength dosage, routes of administration, appearance, usage, warnings, inactive ingredients, etc.

Product Labeling Index

Warning: Bleeding Risk

  • Warfarin sodium  can cause major or fatal bleeding [
  • See Warnings and Precautions (5.1)].
  • Perform regular monitoring of INR in all treated patients [
  • See Dosage and Administration (2.1)].
  • Drugs, dietary changes, and other factors affect INR levels achieved with warfarin sodium  therapy [
  • See Drug Interactions (7)].
  • Instruct patients about prevention measures to minimize risk of bleeding and to report signs and symptoms of bleeding [
  • See Patient Counseling Information (17)].

1  Indications And Usage

  • Warfarin sodium tablets are indicated for: Prophylaxis and treatment of venous thrombosis and its extension, pulmonary embolism (PE).
  • Prophylaxis and treatment of thromboembolic complications associated with atrial fibrillation (AF) and/or cardiac valve replacement.
  • Reduction in the risk of death, recurrent myocardial infarction (MI), and thromboembolic events such as stroke or systemic embolization after myocardial infarction. Limitations of Use Warfarin sodium tablets have no direct effect on an established thrombus, nor does it reverse ischemic tissue damage. Once a thrombus has occurred, however, the goals of anticoagulant treatment are to prevent further extension of the formed clot and to prevent secondary thromboembolic complications that may result in serious and possibly fatal sequelae.

2.1 Individualized Dosing

The dosage and administration of warfarin sodium tablets must be individualized for each patient according to the patient’s International Normalized Ratio (INR) response to the drug. Adjust the dose based on the patient’s INR and the condition being treated. Consult the latest evidence-based clinical practice guidelines regarding the duration and intensity of anticoagulation for the indicated conditions.

  • 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. Venous Thromboembolism (including deep venous thrombosis [DVT] and PE) Adjust the warfarin dose to maintain a target INR of 2.5 (INR range, 2.0 to 3.0) for all treatment durations. The duration of treatment is based on the indication as follows:For patients with a DVT or PE secondary to a transient (reversible) risk factor, treatment with warfarin for 3 months is recommended.For patients with an unprovoked DVT or PE, treatment with warfarin is recommended for at least 3 months. After 3 months of therapy, evaluate the risk-benefit ratio of long-term treatment for the individual patient.For patients with two episodes of unprovoked DVT or PE, long-term treatment with warfarin is recommended. For a patient receiving long-term anticoagulant treatment, periodically reassess the risk-benefit ratio of continuing such treatment in the individual patient.Atrial Fibrillation In patients with non-valvular AF, anticoagulate with warfarin to target INR of 2.5 (range, 2.0 to 3.0).In patients with non-valvular AF that is persistent or paroxysmal and at high risk of stroke (i.e., having any of the following features: prior ischemic stroke, transient ischemic attack, or systemic embolism, or 2 of the following risk factors: age greater than 75 years, moderately or severely impaired left ventricular systolic function and/or heart failure, history of hypertension, or diabetes mellitus), long-term anticoagulation with warfarin is recommended.In patients with non-valvular AF that is persistent or paroxysmal and at an intermediate risk of ischemic stroke (i.e., having 1 of the following risk factors: age greater than 75 years, moderately or severely impaired left ventricular systolic function and/or heart failure, history of hypertension, or diabetes mellitus), long-term anticoagulation with warfarin is recommended.For patients with AF and mitral stenosis, long-term anticoagulation with warfarin is recommended.For patients with AF and prosthetic heart valves, long-term anticoagulation with warfarin is recommended; the target INR may be increased and aspirin added depending on valve type and position, and on patient factors.Mechanical and Bioprosthetic Heart Valves For patients with a bileaflet mechanical valve or a Medtronic Hall (Minneapolis, MN) tilting disk valve in the aortic position who are in sinus rhythm and without left atrial enlargement, therapy with warfarin to a target INR of 2.5 (range, 2.0 to 3.0) is recommended.For patients with tilting disk valves and bileaflet mechanical valves in the mitral position, therapy with warfarin to a target INR of 3.0 (range, 2.5 to 3.5) is recommended.For patients with caged ball or caged disk valves, therapy with warfarin to a target INR of 3.0 (range, 2.5 to 3.5) is recommended.For patients with a bioprosthetic valve in the mitral position, therapy with warfarin to a target INR of 2.5 (range, 2.0 to 3.0) for the first 3 months after valve insertion is recommended. If additional risk factors for thromboembolism are present (AF, previous thromboembolism, left ventricular dysfunction), a target INR of 2.5 (range, 2.0 to 3.0) is recommended.Post-Myocardial Infarction For high-risk patients with MI (e.g., those with a large anterior MI, those with significant heart failure, those with intracardiac thrombus visible on transthoracic echocardiography, those with AF, and those with a history of a thromboembolic event), therapy with combined moderate-intensity (INR, 2.0 to 3.0) warfarin plus low-dose aspirin (≤100 mg/day) for at least 3 months after the MI is recommended.Recurrent Systemic Embolism and Other Indications Oral anticoagulation therapy with warfarin has not been fully evaluated by clinical trials in patients with valvular disease associated with AF, patients with mitral stenosis, and patients with recurrent systemic embolism of unknown etiology. However, a moderate dose regimen (INR 2.0 to 3.0) may be used for these patients.

2.3 Initial And Maintenance Dosing

  • The appropriate initial dosing of warfarin sodium tablets varies widely for different patients. Not all factors responsible for warfarin dose variability are known, and the initial dose is influenced by:Clinical factors including age, race, body weight, sex, concomitant medications, and comorbiditiesGenetic factors (CYP2C9 and VKORC1 genotypes) [
  • See Clinical Pharmacology (12.5)]
  • Select the initial dose based on the expected maintenance dose, taking into account the above factors. Modify this dose based on consideration of patient-specific clinical factors. Consider lower initial and maintenance doses for elderly and/or debilitated patients and in Asian patients
  • [see Use in Specific Populations (8.5) and
  • Clinical Pharmacology (12.3)]. Routine use of loading doses is not recommended as this practice may increase hemorrhagic and other complications and does not offer more rapid protection against clot formation.
  • Individualize the duration of therapy for each patient. In general, anticoagulant therapy should be continued until the danger of thrombosis and embolism has passed [
  • See
  • Dosage and Administration (2.2)].
  • Dosing Recommendations without Consideration of Genotype If the patient’s CYP2C9 and VKORC1 genotypes are not known, the initial dose of warfarin sodium tablets is usually 2 mg to 5 mg once daily. Determine each patient’s dosing needs by close monitoring of the INR response and consideration of the indication being treated. Typical maintenance doses are 2 mg to 10 mg once daily.Dosing Recommendations with Consideration of Genotype Table 1 displays three ranges of expected maintenance warfarin sodium tablets doses observed in subgroups of patients having different combinations of CYP2C9 and VKORC1 gene variants [
  • See Clinical Pharmacology (12.5)]. If the patient’s CYP2C9 and/or VKORC1 genotype are known, consider these ranges in choosing the initial dose. Patients with CYP2C9 *1/*3, *2/*2, *2/*3, and *3/*3 may require more prolonged time (>2 to 4 weeks) to achieve maximum INR effect for a given dosage regimen than patients without these CYP variants.
  • Table 1: Three Ranges of Expected Maintenance Warfarin Sodium Tablets Daily Doses Based on CYP2C9 and VKORC1 Genotypes†  VKORC1   CYP2C9
  • †Ranges are derived from multiple published clinical studies. VKORC1 -1639G>A (rs9923231) variant is used in this table. Other co-inherited VKORC1 variants may also be important determinants of warfarin dose.
  • *1/*1 *1/*2  *1/*3  *2/*2  *2/*3  *3/*3  GG  5 mg to 7 mg  5 mg to 7 mg  3 mg to 4 mg  3 mg to 4 mg  3 mg to 4 mg  0.5 mg to 2 mg  AG  5 mg to 7 mg  3 mg to 4 mg  3 mg to 4 mg  3 mg to 4 mg  0.5 mg to 2 mg  0.5 mg to 2 mg  AA  3 mg to 4 mg  3 mg to 4 mg  0.5 mg to 2 mg  0.5 mg to 2 mg  0.5 mg to 2 mg  0.5 mg to 2 mg

2.4 Monitoring To Achieve Optimal Anticoagulation

Warfarin sodium tablets have a narrow therapeutic range (index), and its action may be affected by factors such as other drugs and dietary vitamin K. Therefore, anticoagulation must be carefully monitored during warfarin sodium tablets therapy. Determine the INR daily after the administration of the initial dose until INR results stabilize in the therapeutic range. After stabilization, maintain dosing within the therapeutic range by performing periodic INRs. The frequency of performing INR should be based on the clinical situation but generally acceptable intervals for INR determinations are 1 to 4 weeks. Perform additional INR tests when other warfarin products are interchanged with warfarin sodium tablets as well as whenever other medications are initiated, discontinued, or taken irregularly. Heparin, a common concomitant drug, increases the INR [


see Dosage and Administration (2.8) and


Drug Interactions (7)].


Determinations of whole blood clotting and bleeding times are not effective measures for monitoring of warfarin sodium tablets therapy.

2.5 Renal Impairment

No dosage adjustment is necessary for patients with renal failure. Monitor INR more frequently in patients with compromised renal function to maintain INR within the therapeutic range


[see


Warnings and Precautions (5.4) and


Use in Specific Populations (8.6)].

2.6 Missed Dose

The anticoagulant effect of warfarin sodium tablets persists beyond 24 hours. If a patient misses a dose of warfarin sodium tablets at the intended time of day, the patient should take the dose as soon as possible on the same day. The patient should not double the dose the next day to make up for a missed dose.

2.7 Treatment During Dentistry And Surgery

Some dental or surgical procedures may necessitate the interruption or change in the dose of warfarin sodium tablets therapy. Consider the benefits and risks when discontinuing warfarin sodium tablets even for a short period of time. Determine the INR immediately prior to any dental or surgical procedure. In patients undergoing minimally invasive procedures who must be anticoagulated prior to, during, or immediately following these procedures, adjusting the dosage of warfarin sodium tablets to maintain the INR at the low end of the therapeutic range may safely allow for continued anticoagulation.

2.8 Conversion From Other Anticoagulants

  • Heparin Since the full anticoagulant effect of warfarin sodium tablets is not achieved for several days, heparin is preferred for initial rapid anticoagulation. During initial therapy with warfarin sodium tablets, the interference with heparin anticoagulation is of minimal clinical significance. Conversion to warfarin sodium tablets may begin concomitantly with heparin therapy or may be delayed 3 to 6 days. To ensure therapeutic anticoagulation, continue full dose heparin therapy and overlap warfarin sodium tablets therapy with heparin for 4 to 5 days and until warfarin sodium tablets has produced the desired therapeutic response as determined by INR, at which point heparin may be discontinued.As heparin may affect the INR, patients receiving both heparin and warfarin sodium tablets should have INR monitoring at least:5 hours after the last intravenous bolus dose of heparin, or4 hours after cessation of a continuous intravenous infusion of heparin, or24 hours after the last subcutaneous heparin injection.Warfarin sodium tablets may increase the activated partial thromboplastin time (aPTT) test, even in the absence of heparin. A severe elevation (>50 seconds) in aPTT with an INR in the desired range has been identified as an indication of increased risk of postoperative hemorrhage.Other Anticoagulants Consult the labeling of other anticoagulants for instructions on conversion to warfarin sodium tablets.

3  Dosage Forms And Strengths

Warfarin Sodium Tablets USP, 1 mg are supplied as pink to light pink, oval shaped uncoated scored tablets with debossing ‘761’ and ‘1’ on either side of the breakline on one side and ‘AN’ on the other side.


Warfarin Sodium Tablets USP, 2 mg are supplied as lavender to light lavender, oval shaped uncoated scored tablets with debossing ‘762’ and ‘2’ on either side of the breakline on one side and ‘AN’ on the other side.


Warfarin Sodium Tablets USP, 2½mg are supplied as green to light green, oval shaped uncoated scored tablets with debossing ‘763’ and ‘2½’ on either side of the breakline on one side and ‘AN’ on the other side.


Warfarin Sodium Tablets USP, 3 mg are supplied as tan to light tan, oval shaped uncoated scored tablets with debossing ‘764’ and ‘3’ on either side of the breakline on one side and ‘AN’ on the other side.


Warfarin Sodium Tablets USP, 4 mg are supplied as blue to light blue, oval shaped uncoated scored tablets with debossing ‘765’ and ‘4’ on either side of the breakline on one side and ‘AN’ on the other side.


Warfarin Sodium Tablets USP, 5 mg are supplied as peach to light peach, oval shaped uncoated scored tablets with debossing ‘766’ and ‘5’ on either side of the breakline on one side and ‘AN’ on the other side.


Warfarin Sodium Tablets USP, 6 mg are supplied as teal to light teal, oval shaped uncoated scored tablets with debossing ‘767’ and ‘6’ on either side of the breakline on one side and  ‘AN’ on the other side.


Warfarin Sodium Tablets USP, 7½ mg are supplied as yellow to light yellow, oval shaped uncoated scored tablets with debossing ‘768’ and ‘7½’ on either side of the breakline on one side and  ‘AN’ on the other side.


Warfarin Sodium Tablets USP, 10 mg are supplied as white to off white, oval shaped uncoated scored tablets with debossing ‘769’ and ‘10’ on either side of the breakline on one side and  ‘AN’ on the other side.

4  Contraindications

  • Warfarin sodium is contraindicated in:PregnancyWarfarin sodium is contraindicated in women who are pregnant except in pregnant women with mechanical heart valves, who are at high risk of thromboembolism [
  • See Warnings and Precautions (5.7) and
  • Use in Specific Populations (8.1)
  • ]. Warfarin sodium can cause fetal harm when administered to a pregnant woman. Warfarin sodium exposure during pregnancy causes a recognized pattern of major congenital malformations (warfarin embryopathy and fetotoxicity), fatal fetal hemorrhage, and an increased risk of spontaneous abortion and fetal mortality. If warfarin sodium is used during pregnancy or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to a fetus [
  • See
  • Use in Specific Populations (8.1)].
  • Warfarin sodium is contraindicated in patients with:Hemorrhagic tendencies or blood dyscrasiasRecent or contemplated surgery of the central nervous system or eye, or traumatic surgery resulting in large open surfaces [
  • See Warnings and Precautions (5.8)]
  • Bleeding tendencies associated with:
  • − Active ulceration or overt bleeding of the gastrointestinal, genitourinary, or respiratory tract− Central nervous system hemorrhage− Cerebral aneurysms, dissecting aorta− Pericarditis and pericardial effusions− Bacterial endocarditisThreatened abortion, eclampsia, and preeclampsiaUnsupervised patients with conditions associated with potential high level of non-complianceSpinal puncture and other diagnostic or therapeutic procedures with potential for uncontrollable bleedingHypersensitivity to warfarin or to any other components of this product (e.g., anaphylaxis) [
  • See Adverse Reactions (6)]
  • Major regional or lumbar block anesthesiaMalignant hypertension

5.1 Hemorrhage

Warfarin sodium can cause major or fatal bleeding. Bleeding is more likely to occur within the first month. Risk factors for bleeding include high intensity of anticoagulation (INR >4.0), age greater than or equal to 65, history of highly variable INRs, history of gastrointestinal bleeding, hypertension, cerebrovascular disease, anemia, malignancy, trauma, renal impairment, certain genetic factors [


see Clinical Pharmacology (12.5)], certain concomitant drugs [


see Drug Interactions (7)], and long duration of warfarin therapy.


Perform regular monitoring of INR in all treated patients. Those at high risk of bleeding may benefit from more frequent INR monitoring, careful dose adjustment to desired INR, and a shortest duration of therapy appropriate for the clinical condition. However, maintenance of INR in the therapeutic range does not eliminate the risk of bleeding.Drugs, dietary changes, and other factors affect INR levels achieved with warfarin sodium therapy. Perform more frequent INR monitoring when starting or stopping other drugs, including botanicals, or when changing dosages of other drugs [


see Drug Interactions (7)].


Instruct patients about prevention measures to minimize risk of bleeding and to report signs and symptoms of bleeding [


see Patient Counseling Information (17)].

5.2 Tissue Necrosis

Warfarin sodium can cause necrosis and/or gangrene of skin and other tissues, which is an uncommon but serious risk (<0.1%). Necrosis may be associated with local thrombosis and usually appears within a few days of the start of warfarin sodium therapy. In severe cases of necrosis, treatment through debridement or amputation of the affected tissue, limb, breast, or penis has been reported.Careful clinical evaluation is required to determine whether necrosis is caused by an underlying disease. Although various treatments have been attempted, no treatment for necrosis has been considered uniformly effective. Discontinue warfarin sodium therapy if necrosis occurs. Consider alternative drugs if continued anticoagulation therapy is necessary.

5.3 Calciphylaxis

Warfarin sodium can cause fatal and serious calciphylaxis or calcium uremic arteriolopathy, which has been reported in patients with and without end-stage renal disease. When calciphylaxis is diagnosed in these patients, discontinue warfarin sodium and treat calciphylaxis as appropriate. Consider alternative anticoagulation therapy.

5.4 Acute Kidney Injury

In patients with altered glomerular integrity or with a history of kidney disease, acute kidney injury may occur with warfarin sodium, possibly in relation to episodes of excessive anticoagulation and hematuria


[see


Use in Specific Populations (8.6)]


. More frequent monitoring of anticoagulation is advised in patients with compromised renal function.

5.5 Systemic Atheroemboli And Cholesterol Microemboli

Anticoagulation therapy with warfarin sodium may enhance the release of atheromatous plaque emboli. Systemic atheroemboli and cholesterol microemboli can present with a variety of signs and symptoms depending on the site of embolization. The most commonly involved visceral organs are the kidneys followed by the pancreas, spleen, and liver. Some cases have progressed to necrosis or death. A distinct syndrome resulting from microemboli to the feet is known as “purple toes syndrome.” Discontinue warfarin sodium therapy if such phenomena are observed. Consider alternative drugs if continued anticoagulation therapy is necessary.

5.6 Limb Ischemia, Necrosis, And Gangrene In Patients With Hit And Hitts

Do not use warfarin sodium as initial therapy in patients with heparin-induced thrombocytopenia (HIT) and with heparin-induced thrombocytopenia with thrombosis syndrome (HITTS). Cases of limb ischemia, necrosis, and gangrene have occurred in patients with HIT and HITTS 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. Treatment with warfarin sodium may be considered after the platelet count has normalized.

5.7 Use In Pregnant Women With Mechanical Heart Valves

Warfarin sodium can cause fetal harm when administered to a pregnant woman. While warfarin sodium is contraindicated during pregnancy, the potential benefits of using warfarin sodium may outweigh the risks for pregnant women with mechanical heart valves at high risk of thromboembolism. In those individual situations, the decision to initiate or continue warfarin sodium should be reviewed with the patient, taking into consideration the specific risks and benefits pertaining to the individual patient’s medical situation, as well as the most current medical guidelines. Warfarin sodium exposure during pregnancy causes a recognized pattern of major congenital malformations (warfarin embryopathy and fetotoxicity), fatal fetal hemorrhage, and an increased risk of spontaneous abortion and fetal mortality. If this drug is used during pregnancy, or if the patient becomes pregnant while taking this drug, the patient should be apprised of the potential hazard to a fetus [


see Use in Specific Populations (8.1)].

5.8 Other Clinical Settings With Increased Risks

  • In the following clinical settings, the risks of warfarin sodium therapy may be increased:Moderate to severe hepatic impairmentInfectious diseases or disturbances of intestinal flora (e.g., sprue, antibiotic therapy)Use of an indwelling catheterSevere to moderate hypertensionDeficiency in protein C-mediated anticoagulant response: warfarin sodium reduces the synthesis of the naturally occurring anticoagulants, protein C and protein S. Hereditary or acquired deficiencies of protein C or its cofactor, protein S, have been associated with tissue necrosis following warfarin administration. Concomitant anticoagulation therapy with heparin for 5 to 7 days during initiation of therapy with warfarin sodium may minimize the incidence of tissue necrosis in these patients.Eye surgery: In cataract surgery, warfarin sodium use was associated with a significant increase in minor complications of sharp needle and local anesthesia block but not associated with potentially sight-threatening operative hemorrhagic complications. As warfarin sodium cessation or reduction may lead to serious thromboembolic complications, the decision to discontinue warfarin sodium before a relatively less invasive and complex eye surgery, such as lens surgery, should be based upon the risks of anticoagulant therapy weighed against the benefits.Polycythemia veraVasculitisDiabetes mellitus

5.9 Endogenous Factors Affecting Inr

The following factors may be responsible for


increased INR response: diarrhea, hepatic disorders, poor nutritional state, steatorrhea, or vitamin K deficiency.


The following factors may be responsible for


decreased INR response: increased vitamin K intake or hereditary warfarin resistance.

6  Adverse Reactions

  • The following serious adverse reactions to warfarin sodium are discussed in greater detail in other sections of the labeling:Hemorrhage
  • [see
  • Boxed Warning,
  • Warnings and Precautions (5.1),
  • And
  • Overdosage (10)]
  • Tissue Necrosis
  • [see
  • Warnings and Precautions (5.2)]
  • Calciphylaxis
  • [see
  • Warnings and Precautions (5.3)]
  • Acute Kidney Injury
  • [see
  • Warnings and Precautions (5.4)]
  • Systemic Atheroemboli and Cholesterol Microemboli
  • [see
  • Warnings and Precautions (5.5)]
  • Limb Ischemia, Necrosis, and Gangrene in Patients with HIT and HITTS
  • [see
  • Warnings and Precautions (5.6)]
  • Other Clinical Settings with Increased Risks
  • [see
  • Warnings and Precautions (5.8)]
  • Other adverse reactions to warfarin sodium include:Immune system disorders: hypersensitivity/allergic reactions (including urticaria and anaphylactic reactions)Vascular disorders: vasculitisHepatobiliary disorders: hepatitis, elevated liver enzymes. Cholestatic hepatitis has been associated with concomitant administration of warfarin sodium and ticlopidine.Gastrointestinal disorders: nausea, vomiting, diarrhea, taste perversion, abdominal pain, flatulence, bloatingSkin disorders: rash, dermatitis (including bullous eruptions), pruritus, alopeciaRespiratory disorders: tracheal or tracheobronchial calcificationGeneral disorders: chills

7.1  General Information

Drugs may interact with warfarin sodium through pharmacodynamic or pharmacokinetic mechanisms. Pharmacodynamic mechanisms for drug interactions with warfarin sodium are synergism (impaired hemostasis, reduced clotting factor synthesis), competitive antagonism (vitamin K), and alteration of the physiologic control loop for vitamin K metabolism (hereditary resistance). Pharmacokinetic mechanisms for drug interactions with warfarin sodium 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. More frequent INR monitoring should be performed when starting or stopping other drugs, including botanicals, or when changing dosages of other drugs, including drugs intended for short-term use (e.g., antibiotics, antifungals, corticosteroids)


[see


Boxed Warning]


.


Consult the labeling of all concurrently used drugs to obtain further information about interactions with warfarin sodium or adverse reactions pertaining to bleeding.

7.2 Cyp450 Interactions

  • CYP450 isozymes involved in the metabolism of warfarin include CYP2C9, 2C19, 2C8, 2C18, 1A2, and 3A4. The more potent warfarin
  • S-enantiomer is metabolized by CYP2C9 while the
  • R-enantiomer is metabolized by CYP1A2 and 3A4.
  • Inhibitors of CYP2C9, 1A2, and/or 3A4 have the potential to increase the effect (increase INR) of warfarin by increasing the exposure of warfarin.Inducers of CYP2C9, 1A2, and/or 3A4 have the potential to decrease the effect (decrease INR) of warfarin by decreasing the exposure of warfarin.Examples of inhibitors and inducers of CYP2C9, 1A2, and 3A4 are below in Table 2; however, this list should not be considered all-inclusive. Consult the labeling of all concurrently used drugs to obtain further information about CYP450 interaction potential. The CYP450 inhibition and induction potential should be considered when starting, stopping, or changing dose of concomitant medications. Closely monitor INR if a concomitant drug is a CYP2C9, 1A2, and/or 3A4 inhibitor or inducer. Table 2: Examples of CYP450 Interactions with Warfarin
  • Enzyme
  • Inhibitors
  • Inducers CYP2C9  amiodarone, capecitabine, cotrimoxazole, etravirine, fluconazole, fluvastatin, fluvoxamine, metronidazole, miconazole, oxandrolone, sulfinpyrazone, tigecycline, voriconazole, zafirlukast  aprepitant, bosentan, carbamazepine, phenobarbital, rifampin  CYP1A2  acyclovir, allopurinol, caffeine, cimetidine, ciprofloxacin, disulfiram, enoxacin, famotidine, fluvoxamine, methoxsalen, mexiletine, norfloxacin, oral contraceptives, phenylpropanolamine, propafenone, propranolol, terbinafine, thiabendazole, ticlopidine, verapamil, zileuton  montelukast, moricizine, omeprazole, phenobarbital, phenytoin, cigarette smoking  CYP3A4  alprazolam, amiodarone, amlodipine, amprenavir, aprepitant, atorvastatin, atazanavir, bicalutamide, cilostazol, cimetidine, ciprofloxacin, clarithromycin, conivaptan, cyclosporine, darunavir/ritonavir, diltiazem, erythromycin, fluconazole, fluoxetine, fluvoxamine, fosamprenavir, imatinib, indinavir, isoniazid, itraconazole, ketoconazole, lopinavir/ritonavir, nefazodone, nelfinavir, nilotinib, oral contraceptives, posaconazole, ranitidine, ranolazine, ritonavir, saquinavir, telithromycin, tipranavir, voriconazole, zileuton  armodafinil, amprenavir, aprepitant, bosentan, carbamazepine, efavirenz, etravirine, modafinil, nafcillin, phenytoin, pioglitazone, prednisone, rifampin, rufinamide

7.3 Drugs That Increase Bleeding Risk

Examples of drugs known to increase the risk of bleeding are presented in Table 3. Because bleeding risk is increased when these drugs are used concomitantly with warfarin, closely monitor patients receiving any such drug with warfarin. Table 3: Drugs that Can Increase the Risk of Bleeding  


Drug Class 


Specific Drugs Anticoagulants  argatroban, dabigatran, bivalirudin, desirudin, heparin, lepirudin  Antiplatelet Agents  aspirin, cilostazol, clopidogrel, dipyridamole, prasugrel, ticlopidine  Nonsteroidal Anti-Inflammatory Agents  celecoxib, diclofenac, diflunisal, fenoprofen, ibuprofen, indomethacin, ketoprofen, ketorolac, mefenamic acid, naproxen, oxaprozin, piroxicam, sulindac  Serotonin Reuptake Inhibitors  citalopram, desvenlafaxine, duloxetine, escitalopram, fluoxetine, fluvoxamine, milnacipran, paroxetine, sertraline, venlafaxine, vilazodone

7.4 Antibiotics And Antifungals

There have been reports of changes in INR in patients taking warfarin and antibiotics or antifungals, but clinical pharmacokinetic studies have not shown consistent effects of these agents on plasma concentrations of warfarin.Closely monitor INR when starting or stopping any antibiotic or antifungal in patients taking warfarin.

7.5 Botanical (Herbal) Products And Foods

More frequent INR monitoring should be performed when starting or stopping botanicals.Few adequate, well-controlled studies evaluating the potential for metabolic and/or pharmacologic interactions between botanicals and warfarin sodium exist. 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.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 warfarin sodium. Conversely, some botanicals may decrease the effects of warfarin sodium (e.g., co-enzyme Q


10, St. John’s wort, ginseng). Some botanicals and foods can interact with warfarin sodium through CYP450 interactions (e.g., echinacea, grapefruit juice, ginkgo, goldenseal, St. John’s wort).


The amount of vitamin K in food may affect therapy with warfarin sodium. Advise patients taking warfarin sodium to eat a normal, balanced diet maintaining a consistent amount of vitamin K. Patients taking warfarin sodium should avoid drastic changes in dietary habits, such as eating large amounts of green leafy vegetables.

8.1 Pregnancy

Risk SummaryWarfarin sodium is contraindicated in women who are pregnant except in pregnant women with mechanical heart valves, who are at high risk of thromboembolism, and for whom the benefits of warfarin sodium may outweigh the risks


[see


Warnings and Precautions (5.7)]


. Warfarin sodium can cause fetal harm. Exposure to warfarin during the first trimester of pregnancy caused a pattern of congenital malformations in about 5% of exposed offspring. Because these data were not collected in adequate and well-controlled studies, this incidence of major birth defects is not an adequate basis for comparison to the estimated incidences in the control group or the U.S. general population and may not reflect the incidences observed in practice. Consider the benefits and risks of warfarin sodium and possible risks to the fetus when prescribing warfarin sodium to a pregnant woman.


Adverse outcomes in pregnancy occur regardless of the health of the mother or the use of medications. The estimated background risk of major birth defects and miscarriage for the indicated population is unknown. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2% to 4% and 15% to 20%, respectively.Clinical ConsiderationsFetal/Neonatal Adverse ReactionsIn humans, warfarin crosses the placenta, and concentrations in fetal plasma approach the maternal values. Exposure to warfarin during the first trimester of pregnancy caused a pattern of congenital malformations in about 5% of exposed offspring. Warfarin embryopathy is characterized by nasal hypoplasia with or without stippled epiphyses (chondrodysplasia punctata) and growth retardation (including low birth weight). Central nervous system and eye abnormalities have also been reported, including dorsal midline dysplasia characterized by agenesis of the corpus callosum, Dandy-Walker malformation, midline cerebellar atrophy, and ventral midline dysplasia characterized by optic atrophy. Mental retardation, blindness, schizencephaly, microcephaly, hydrocephalus, and other adverse pregnancy outcomes have been reported following warfarin exposure during the second and third trimesters of pregnancy


[see


Contraindications (4)].

8.2 Lactation

Risk SummaryWarfarin was not present in human milk from mothers treated with warfarin from a limited published study. Because of the potential for serious adverse reactions, including bleeding in a breastfed infant, consider the developmental and health benefits of breastfeeding along with the mother’s clinical need for warfarin sodium and any potential adverse effects on the breastfed infant from warfarin sodium or from the underlying maternal condition before prescribing warfarin sodium to a lactating woman.Clinical ConsiderationsMonitor breastfeeding infants for bruising or bleeding.DataHuman DataBased on published data in 15 nursing mothers, warfarin was not detected in human milk. Among the 15 full-term newborns, 6 nursing infants had documented prothrombin times within the expected range. Prothrombin times were not obtained for the other 9 nursing infants. Effects in premature infants have not been evaluated.

8.3 Females And Males Of Reproductive Potential

Pregnancy TestingWarfarin sodium can cause fetal harm


[see


Use in Specific Populations (8.1)].


Verify the pregnancy status of females of reproductive potential prior to initiating warfarin sodium therapy.ContraceptionFemalesAdvise females of reproductive potential to use effective contraception during treatment and for at least 1 month after the final dose of warfarin sodium.

8.4 Pediatric Use

Adequate and well-controlled studies with warfarin sodium have not been conducted in any pediatric population, and the optimum dosing, safety, and efficacy in pediatric patients is unknown. Pediatric use of warfarin sodium is based on adult data and recommendations, and available limited pediatric data from observational studies and patient registries. Pediatric patients administered warfarin sodium should avoid any activity or sport that may result in traumatic injury.The developing hemostatic system in infants and children results in a changing physiology of thrombosis and response to anticoagulants. Dosing of warfarin in the pediatric population varies by patient age, with infants generally having the highest, and adolescents having the lowest milligram per kilogram dose requirements to maintain target INRs. Because of changing warfarin requirements due to age, concomitant medications, diet, and existing medical condition, target INR ranges may be difficult to achieve and maintain in pediatric patients, and more frequent INR determinations are recommended. Bleeding rates varied by patient population and clinical care center in pediatric observational studies and patient registries.Infants and children receiving vitamin K-supplemented nutrition, including infant formulas, may be resistant to warfarin therapy, while human milk-fed infants may be sensitive to warfarin therapy.

8.5 Geriatric Use

Of the total number of patients receiving warfarin sodium in controlled clinical trials for which data were available for analysis, 1885 patients (24.4%) were 65 years and older, while 185 patients (2.4%) were 75 years and older. No overall differences in effectiveness or safety were observed between these patients and younger patients, but greater sensitivity of some older individuals cannot be ruled out.Patients 60 years or older appear to exhibit greater than expected INR response to the anticoagulant effects of warfarin [


see Clinical Pharmacology (12.3)]. Warfarin sodium is contraindicated in any unsupervised patient with senility. Conduct more frequent monitoring for bleeding with administration of warfarin sodium to elderly patients in any situation or with any physical condition where added risk of hemorrhage is present. Consider lower initiation and maintenance doses of warfarin sodium in elderly patients [


see Dosage and Administration (2.2, 2.3)].

8.6 Renal Impairment

Renal clearance is considered to be a minor determinant of anticoagulant response to warfarin. No dosage adjustment is necessary for patients with renal impairment. Instruct patients with renal impairment taking warfarin to monitor their INR more frequently


[see


Warnings and Precautions (5.4)]


.

8.7 Hepatic Impairment

Hepatic impairment can potentiate the response to warfarin through impaired synthesis of clotting factors and decreased metabolism of warfarin. Conduct more frequent monitoring for bleeding when using warfarin sodium in these patients.

10.1 Signs And Symptoms

Bleeding (e.g., appearance of blood in stools or urine, hematuria, excessive menstrual bleeding, melena, petechiae, excessive bruising or persistent oozing from superficial injuries, unexplained fall in hemoglobin) is a manifestation of excessive anticoagulation.

10.2 Treatment

The treatment of excessive anticoagulation is based on the level of the INR, the presence or absence of bleeding, and clinical circumstances. Reversal of warfarin sodium anticoagulation may be obtained by discontinuing warfarin sodium therapy and, if necessary, by administration of oral or parenteral vitamin K


1.


The use of vitamin K


1 reduces response to subsequent warfarin sodium therapy and patients may return to a pretreatment thrombotic status following the rapid reversal of a prolonged INR. Resumption of warfarin sodium administration reverses the effect of vitamin K, and a therapeutic INR can again be obtained by careful dosage adjustment. If rapid re-anticoagulation is indicated, heparin may be preferable for initial therapy.


Prothrombin complex concentrate (PCC), fresh frozen plasma, or activated Factor VII treatment may be considered if the requirement to reverse the effects of warfarin sodium is urgent. A risk of hepatitis and other viral diseases is associated with the use of blood products; PCC and activated Factor VII are also associated with an increased risk of thrombosis. Therefore, these preparations should be used only in exceptional or life-threatening bleeding episodes secondary to warfarin sodium overdosage.

11  Description

Crystalline warfarin sodium is an anticoagulant that acts by inhibiting vitamin K-dependent coagulation factors. The chemical name of warfarin sodium is 3-(α-acetonylbenzyl)-4-hydroxycoumarin sodium salt, which is a racemic mixture of the


R- and


S-enantiomers. Crystalline warfarin sodium is an isopropanol clathrate. Its empirical formula is C


19H


15NaO


4, and its structural formula is represented by the following:


Crystalline warfarin sodium occurs as a white, odorless, crystalline powder that is discolored by light. It is very soluble in water, freely soluble in alcohol, and very slightly soluble in chloroform and ether.Warfarin sodium tablets, USP (Crystalline) for oral use also contain:All strengths:               Hydroxypropyl Cellulose, Lactose Monohydrate, Magnesium Stearate and Pregelatinized Starch 1 mg:                           D&C Red No. 6 Barium Lake 2 mg:                           FD&C Blue No. 2 Aluminum Lake and FD&C Red No. 40 Aluminum Lake 2-1/2 mg:                     D&C Yellow No. 10 Aluminum Lake and FD&C Blue No. 1 Aluminum Lake 3 mg:                           FD&C Yellow No. 6 Aluminum Lake, FD&C Blue No. 2 Aluminum Lake, and FD&C Red No. 40 Aluminum Lake 4 mg:                           FD&C Blue No. 1 Aluminum Lake 5 mg:                           FD&C Yellow No. 6 Aluminum Lake 6 mg:                           FD&C Yellow No. 6 Aluminum Lake and FD&C Blue No. 1 Aluminum Lake 7-1/2 mg:                     D&C Yellow No. 10 Aluminum Lake and FD&C Yellow No. 6 Aluminum Lake 10 mg:                         Dye-free

12.1 Mechanism Of Action

Warfarin acts 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. Vitamin K is an essential cofactor for the post ribosomal synthesis of the vitamin K-dependent clotting factors. Vitamin K promotes the biosynthesis of γ-carboxyglutamic acid residues in the proteins that are essential for biological activity. Warfarin is thought to interfere with clotting factor synthesis by inhibition of the C1 subunit of vitamin K epoxide reductase (VKORC1) enzyme complex, thereby reducing the regeneration of vitamin K


1 epoxide [


see Clinical Pharmacology (12.5)].

12.2 Pharmacodynamics

An anticoagulation effect generally occurs within 24 hours after warfarin 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  warfarin sodium may become more pronounced as effects of daily maintenance doses overlap. This is consistent with the half-lives of the affected vitamin K-dependent clotting factors and anticoagulation proteins: Factor II - 60 hours, VII - 4 to 6 hours, IX - 24 hours, X - 48 to 72 hours, and proteins C and S are approximately 8 hours and 30 hours, respectively.

12.3 Pharmacokinetics

Warfarin sodium is a racemic mixture of the


R- and


S-enantiomers of warfarin. The


S-enantiomer exhibits 2 to 5 times more anticoagulant activity than the


R-enantiomer in humans, but generally has a more rapid clearance.


Absorption Warfarin is essentially completely absorbed after oral administration, with peak concentration generally attained within the first 4 hours.Distribution Warfarin  shows a volume of distribution of about 0.14 L/kg. Approximately 99% of the drug is bound to plasma proteins. Metabolism The elimination of warfarin is almost entirely by metabolism. Warfarin is stereoselectively metabolized by hepatic cytochrome P-450 (CYP450) microsomal enzymes to inactive hydroxylated metabolites (predominant route) and by reductases to reduced metabolites (warfarin alcohols) with minimal anticoagulant activity. Identified metabolites of warfarin include dehydrowarfarin, two diastereoisomer alcohols, and 4′-, 6-, 7-, 8-, and 10- hydroxywarfarin. The CYP450 isozymes involved in the metabolism of warfarin include CYP2C9, 2C19, 2C8, 2C18, 1A2, and 3A4. CYP2C9, a polymorphic enzyme, is likely to be the principal form of human liver CYP450 that modulates the


in vivo anticoagulant activity of warfarin. Patients with one or more variant CYP2C9 alleles have decreased S-warfarin clearance [


see Clinical Pharmacology (12.5)].


Excretion The terminal half-life of warfarin after a single dose is approximately 1 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.Geriatric Patients Patients 60 years or older appear to exhibit greater than expected 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 but may be due to a combination of pharmacokinetic and pharmacodynamic factors. Limited information suggests there is no difference in the clearance of S-warfarin; 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 [


see Dosage and Administration (2.3, 2.4)].


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

12.5 Pharmacogenomics

CYP2C9 and VKORC1 Polymorphisms The


S-enantiomer of warfarin is mainly metabolized to 7-hydroxywarfarin by CYP2C9, a polymorphic enzyme. The variant alleles, CYP2C9*2 and CYP2C9*3, result in decreased


in vitro CYP2C9 enzymatic 7-hydroxylation of S-warfarin. The frequencies of these alleles in Caucasians are approximately 11% and 7% for CYP2C9*2 and CYP2C9*3, respectively.


Other CYP2C9 alleles associated with reduced enzymatic activity occur at lower frequencies, including *5, *6, and *11 alleles in populations of African ancestry and *5, *9, and *11 alleles in Caucasians.Warfarin reduces the regeneration of vitamin K from vitamin K epoxide in the vitamin K cycle through inhibition of VKOR, a multiprotein enzyme complex. Certain single nucleotide polymorphisms in the VKORC1 gene (e.g., –1639G>A) have been associated with variable warfarin dose requirements. VKORC1 and CYP2C9 gene variants generally explain the largest proportion of known variability in warfarin dose requirements.CYP2C9 and VKORC1 genotype information, when available, can assist in selection of the initial dose of warfarin [


see Dosage and Administration (2.3)].

13.1 Carcinogenesis, Mutagenesis, Impairment Of Fertility

Carcinogenicity, mutagenicity, or fertility studies have not been performed with warfarin.

14.1 Atrial Fibrillation

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 4). The risk reduction ranged from 60% to 86% in all except one trial (CAFA: 45%), which was 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 4). Table 4: Clinical Studies of Warfarin in Non-Rheumatic AF Patients*    N   


Thromboembolism   % Major Bleeding  *All study results of warfarin vs. control are based on intention-to-treat analysis and include ischemic stroke and systemic thromboembolism, excluding hemorrhagic stroke and transient ischemic attacks.  Study  


Warfarin-Treated Patients Control Patients PT Ratio INR % Risk Reduction 


p-value 


Warfarin-Treated Patients Control Patients AFASAK  335 336 1.5 to 2.0 2.8 to 4.2 60 0.027 0.6 0.0 SPAF  210 211 1.3 to 1.8 2.0 to 4.5 67 0.01 1.9 1.9 BAATAF  212 208 1.2 to 1.5 1.5 to 2.7 86 <0.05 0.9 0.5 CAFA  187 191 1.3 to 1.6 2.0 to 3.0 45 0.25 2.7 0.5 SPINAF  260 265 1.2 to 1.5 1.4 to 2.8 79 0.001 2.3 1.5Trials in patients with both AF and mitral stenosis suggest a benefit from anticoagulation with warfarin sodium [


see Dosage and Administration (2.2)].

14.2 Mechanical And Bioprosthetic Heart Valves

In a prospective, randomized, open-label, positive-controlled study in 254 patients with mechanical prosthetic heart valves, the thromboembolic-free interval was found to be significantly greater in patients treated with warfarin alone compared with dipyridamole/aspirin-treated patients (p<0.005) and pentoxifylline/aspirin-treated patients (p<0.05). The results of this study are presented in Table 5. Table 5: Prospective, Randomized, Open-Label, Positive-Controlled Clinical Study of Warfarin in Patients with Mechanical Prosthetic Heart Valves   


Patients Treated With    py=patient years   Event  Warfarin 


Dipyridamole/Aspirin 


Pentoxifylline/Aspirin Thromboembolism  2.2/100 py 8.6/100 py 7.9/100 py Major Bleeding  2.5/100 py 0.0/100 py 0.9/100 pyIn a prospective, open-label, clinical study comparing moderate (INR 2.65) versus 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 per 100 patient years, respectively). Major bleeding was more common in the high intensity group. The results of this study are presented in Table 6. Table 6: Prospective, Open-Label Clinical Study of Warfarin in Patients with Mechanical Prosthetic Heart Valves  


Event  


Moderate Warfarin Therapy


INR 2.65


 


High Intensity Warfarin Therapy


INR 9.0


   py=patient years  Thromboembolism  4.0/100 py 3.7/100 py Major Bleeding  0.95/100 py 2.1/100 pyIn a randomized trial in 210 patients comparing two intensities of warfarin therapy (INR 2.0 to 2.25 vs. INR 2.5 to 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 hemorrhages occurred in 4.6% of patients in the higher intensity INR group compared to zero in the lower intensity INR group.

14.3 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. The primary endpoint was a composite 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 Table 7. Table 7: WARIS – Endpoint Analysis of Separate Events        % Risk   


Warfarin   Placebo   


Reduction  


Event   (N=607)  


(N=607)  RR (95% CI)  


(


p-value)


   RR=Relative risk; Risk reduction=(1 - RR); CI=Confidence interval; MI=Myocardial infarction; py=patient years   Total Patient Years of      Follow-up  2018 1944   Total Mortality  94 (4.7/100 py) 123 (6.3/100 py) 0.76 (0.60, 0.97) 24 (p=0.030)      Vascular Death  82 (4.1/100 py) 105 (5.4/100 py) 0.78 (0.60, 1.02) 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)WARIS II (The Warfarin, Aspirin, Re-Infarction Study) was an open-label, randomized study of 3630 patients hospitalized for acute myocardial infarction treated with warfarin to a target INR2.8 to 4.2, aspirin 160 mg per day, or warfarin to a target INR 2.0 to 2.5 plus aspirin 75 mg per day prior to hospital discharge. The primary endpoint was a composite of death, nonfatal reinfarction, or thromboembolic stroke. The mean duration of observation was approximately 4 years. The results for WARIS II are provided in the Table 8. Table 8: WARIS II – Distribution of Events According to Treatment Group  


Event   Aspirin


(N=1206)


 


Warfarin


(N=1216)


 


Aspirin plus


Warfarin


(N=1208)


  Rate Ratio


(95% CI)


 


p-value


 


a Major bleeding episodes were defined as nonfatal cerebral hemorrhage or bleeding necessitating surgical intervention or blood transfusion.


 


b The rate ratio is for aspirin plus warfarin as compared with aspirin.


 


c The rate ratio is for warfarin as compared with aspirin.


 


d Minor bleeding episodes were defined as non-cerebral hemorrhage not necessitating surgical intervention or blood transfusion.


 


e Includes death, nonfatal reinfarction, and thromboembolic cerebral stroke.


  CI=confidence interval   ND=not determined   No. of Events   Major Bleeding


a 8 33 28 3.35


b (ND)


4.00


c (ND)


 ND


ND


 Minor Bleeding


d 39 103 133 3.21


b (ND)


2.55


c (ND)


 ND


ND


 Composite Endpoints


e 241 203 181 0.81 (0.69 to 0.95)


b0.71 (0.60 to 0.83)


c 0.03


0.001


      Reinfarction  117 90 69 0.56 (0.41 to 0.78)


b0.74 (0.55 to 0.98)


c <0.001


0.03


      Thromboembolic Stroke  32 17 17 0.52 (0.28 to 0.98)


b0.52 (0.28 to 0.97)


c 0.03


0.03


      Death  92 96 95  0.82There were approximately four times as many major bleeding episodes in the two groups receiving warfarin than in the group receiving aspirin alone. Major bleeding episodes were not more frequent among patients receiving aspirin plus warfarin than among those receiving warfarin alone, but the incidence of minor bleeding episodes was higher in the combined therapy group.

15  References

OSHA Hazardous Drugs. OSHA.http://www.osha.gov/SLTC/hazardousdrugs/index.html.

16  How Supplied/Storage And Handling

Tablets Warfarin Sodium Tablets USP, 1 mg are supplied as pink to light pink, oval shaped uncoated scored tablets with debossing ‘761’ and ‘1’ on either side of the breakline on one side and ‘AN’ on the other side.
They are available as follows:


Bottle of 100 Tablets:                        NDC 65162-761-10Bottle of 500 Tablets:                          NDC 65162-761-50Bottle of 1000 Tablets:                        NDC 65162-761-11Warfarin Sodium Tablets USP, 2 mg are supplied as lavender to light lavender, oval shaped uncoated scored tablets with debossing ‘762’ and ‘2’ on either side of the breakline on one side and ‘AN’ on the other side.
They are available as follows:


Bottle of 100 Tablets:                        NDC 65162-762-10Bottle of 500 Tablets:                        NDC 65162-762-50Bottle of 1000 Tablets:                       NDC 65162-762-11Warfarin Sodium Tablets USP, 2½mg are supplied as green to light green, oval shaped uncoated scored tablets with debossing ‘763’ and ‘2½’ on either side of the breakline on one side and ‘AN’ on the other side.
They are available as follows:


Bottle of 100   Tablets:                        NDC 65162-763-10Bottle of 500 Tablets:                          NDC 65162-763-50Bottle of 1000 Tablets:                         NDC 65162-763-11Warfarin Sodium Tablets USP, 3 mg are supplied as tan to light tan, oval shaped uncoated scored tablets with debossing ‘764’ and ‘3’ on either side of the breakline on one side and ‘AN’ on the other side.
They are available as follows:


Bottle of 100 Tablets:                          NDC 65162-764-10Bottle of 500 Tablets:                          NDC 65162-764-50Bottle of 1000 Tablets:                        NDC 65162-764-11Warfarin Sodium Tablets USP, 4 mg are supplied as blue to light blue, oval shaped uncoated scored tablets with debossing ‘765’ and ‘4’ on either side of the breakline on one side and ‘AN’ on the other side.
They are available as follows:


Bottle of 100 Tablets:                          NDC 65162-765-10Bottle of 500 Tablets:                          NDC 65162-765-50Bottle of 1000 Tablets:                         NDC 65162-765-11Warfarin Sodium Tablets USP, 5 mg are supplied as peach to light peach, oval shaped uncoated scored tablets with debossing ‘766’ and ‘5’ on either side of the breakline on one side and ‘AN’ on the other side.
They are available as follows:


Bottle of 100 Tablets:                         NDC 65162-766-10Bottle of 500 Tablets:                         NDC 65162-766-50Bottle of 1000 Tablets:                        NDC 65162-766-11Warfarin Sodium Tablets USP, 6 mg are supplied as teal to light teal, oval shaped uncoated scored tablets with debossing ‘767’ and ‘6’ on either side of the breakline on one side and  ‘AN’ on the other side.
They are available as follows:


Bottle of 100 Tablets:                          NDC 65162-767-10Bottle of 500 Tablets:                          NDC 65162-767-50Bottle of 1000 Tablets:                        NDC 65162-767-11Warfarin Sodium Tablets USP, 7½ mg are supplied as yellow to light yellow, oval shaped uncoated scored tablets with debossing ‘768’ and ‘7½’ on either side of the breakline on one side and  ‘AN’ on the other side.
They are available as follows:


Bottle of 100 Tablets:                        NDC 65162-768-10Bottle of 500 Tablets:                        NDC 65162-768-50Bottle of 1000 Tablets:                      NDC 65162-768-11Warfarin Sodium Tablets USP, 10 mg are supplied as white to off white, oval shaped uncoated scored tablets with debossing ‘769’ and ‘10’ on either side of the breakline on one side and  ‘AN’ on the other side.
They are available as follows:


Bottle of 100 Tablets:                        NDC 65162-769-10Bottle of 500 Tablets:                        NDC 65162-769-50Bottle of 1000 Tablets:                       NDC 65162-769-11 Protect from light and moisture. Store at 20° to 25°C (68° to 77°F); excursions permitted between 15° to 30°C (59° to 86°F) [see USP Controlled Room Temperature]. Dispense in a tight, light-resistant container as defined in the USP.Special HandlingProcedures for proper handling and disposal of potentially hazardous drugs should be considered. Guidelines on this subject have been published


[see References (


15)].


Pharmacy and clinical personnel who are pregnant should avoid exposure to crushed or broken tablets


[see Use in Specific Populations


(8.1)].

17  Patient Counseling Information

  • Advise the patient to read the FDA-approved patient labeling (Medication Guide). Instructions for PatientsAdvise patients to: Strictly adhere to the prescribed dosage schedule [
  • See Dosage and Administration (
  • 2.1)
  • ].
  • If the prescribed dose of warfarin sodium is missed, take the dose as soon as possible on the same day but do not take a double dose of warfarin sodium the next day to make up for missed doses [
  • See Dosage and Administration
  • (2.6)
  • ].
  • Obtain prothrombin time tests and make regular visits to their physician or clinic to monitor therapy [
  • See Dosage and Administration (
  • 2.1)
  • ].
  • Be aware that if therapy with warfarin sodium is discontinued, the anticoagulant effects of warfarin sodium may persist for about 2 to 5 days [
  • See Clinical Pharmacology (
  • 12.2)
  • ].
  • Avoid any activity or sport that may result in traumatic injury [
  • See Use in Specific Populations (
  • 8.4)
  • ]
  • . And to tell their physician if they fall often as this may increase their risk for complications.
  • Eat a normal, balanced diet to maintain a consistent intake of vitamin K. Avoid drastic changes in dietary habits, such as eating large amounts of leafy, green vegetables [
  • See Drug Interactions (
  • 7.5)
  • ].
  • Contact their physician to report any serious illness, such as severe diarrhea, infection, or fever
  • [see Warnings and Precautions (5) and
  • Adverse Reactions (6)].
  • Immediately contact their physician when experiencing pain and discoloration of the skin (a purple bruise like rash) mostly on areas of the body with a high fat content, such as breasts, thighs, buttocks, hips and abdomen [
  • See Warnings and Precautions (
  • 5.2)
  • ].
  • Immediately contact their physician when experiencing any unusual symptom or pain since warfarin sodium may cause small cholesterol or athero emboli. On feet it may appear as a sudden cool, painful, purple discoloration of toe(s) or forefoot [
  • See Warnings and Precautions (
  • 5.5)
  • ].
  • Immediately contact their physician when taking warfarin sodium after any heparin formulation therapy and experiencing bloody or black stools or appearence of bruises, or bleeding [
  • See Warnings and Precautions (
  • 5.6)
  • ].
  • To tell all of their healthcare professionals and dentists that they are taking warfarin sodium. This should be done before they have any surgery or dental procedure [
  • See Dosage and Administration (
  • 2.7)
  • ].
  • Carry identification stating that they are taking warfarin sodium.Bleeding RisksAdvise patients to:Notify their 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 [
  • See
  • Box Warning and
  • Warnings and Precautions (
  • 5.1)
  • ].
  • Concomitant Medications and Botanicals (Herbals)Advise patients to:Not take or discontinue any other drug, including salicylates (e.g., aspirin and topical analgesics), other over-the-counter drugs, and botanical (herbal) products except on advice of your physician [
  • See Drug Interactions (
  • 7)
  • ].
  • Pregnancy and NursingAdvise patients to:  Notify their physician if they are pregnant or planning to become pregnant or considering breast feeding [
  • See
  • Use in Specific Populations (8.1, 8.2,
  • 8.3)
  • ].
  • Avoid warfarin sodium during pregnancy except in pregnant women with mechanical heart valves, who are at risk of thromboembolism [
  • See
  • Contraindications (4)
  • ]. Use effective measures to avoid pregnancy while taking warfarin sodium. This is very important because their unborn baby could be seriously harmed if they take warfarin sodium while they are pregnant [
  • See
  • Use in Specific Populations (8.1,
  • 8.3)
  • ].
  • Manufactured by:Amneal Pharmaceuticals Pvt. Ltd.
  • Ahmedabad 382220, INDIA
  • Distributed by:
  • Amneal Pharmaceuticals LLC
  • Bridgewater, NJ 08807
  • Rev. 08-2017-03

Medication Guide

  • Warfarin (WAR-far-in) Sodium Tablets, USP (Crystalline)What is the most important information I should know about warfarin sodium? Warfarin sodium can cause bleeding which can be serious and sometimes lead to death. This is because warfarin sodium is a blood thinner medicine that lowers the chance of blood clots forming in your body.You may have a higher risk of bleeding if you take warfarin sodium and: are 65 years of age or older have a history of stomach or intestinal bleeding have high blood pressure (hypertension) have a history of stroke, or “mini-stroke” (transient ischemic attack or TIA) have serious heart disease have a low blood count or cancer have had trauma, such as an accident or surgery have kidney problems take other medicines that increase your risk of bleeding, including: a medicine that contains heparinother medicines to prevent or treat blood clots nonsteroidal anti-inflammatory drugs (NSAIDs) take warfarin sodium for a long time. Warfarin sodium is the active ingredient in warfarin sodium tablets. Tell your healthcare provider if you take any of these medicines. Ask your healthcare provider if you are not sure if your medicine is one listed above. Many other medicines can interact with warfarin sodium and affect the dose you need or increase warfarin sodium side effects. Do not change or stop any of your medicines or start any new medicines before you talk to your healthcare provider.Do not take other medicines that contain warfarin sodium while taking warfarin sodium tablets. Get your regular blood test to check for your response to warfarin sodium. This blood test is called an INR test. The INR test checks to see how fast your blood clots. Your healthcare provider will decide what INR numbers are best for you. Your dose of warfarin sodium will be adjusted to keep your INR in a target range for you.
  • Call your healthcare provider right away if you get any of the following signs or symptoms of bleeding problems:pain, swelling, or discomfort headaches, dizziness, or weakness unusual bruising (bruises that develop without known cause or grow in size) nosebleeds bleeding gums bleeding from cuts takes a long time to stop menstrual bleeding or vaginal bleeding that is heavier than normal pink or brown urine red or black stools coughing up blood vomiting blood or material that looks like coffee grounds Some foods and beverages can interact with warfarin sodium and affect your treatment and dose. Eat a normal, balanced diet. Talk to your healthcare provider before you make any diet changes. Do not eat large amounts of leafy, green vegetables. Leafy, green vegetables contain vitamin K. Certain vegetable oils also contain large amounts of vitamin K. Too much vitamin K can lower the effect of warfarin sodium. Always tell all of your healthcare providers that you take warfarin sodium.Wear or carry information that you take warfarin sodium.See “What are the possible side effects of warfarin sodium?” for more information about side effects. What is warfarin sodium? Warfarin sodium is prescription medicine used to treat blood clots and to lower the chance of blood clots forming in your body. Blood clots can cause a stroke, heart attack, or other serious conditions if they form in the legs or lungs.Who should not take warfarin sodium?Do not take warfarin sodium if: your risk of having bleeding problems is higher than the possible benefit of treatment. Your healthcare provider will decide if warfarin sodium is right for you.
  • You are pregnant unless you have a mechanical heart valve. Warfarin sodium may cause birth defects, miscarriage, or death of your unborn baby.
  • You are allergic to warfarin or any of the other ingredients in warfarin sodium tablets. See the end of this leaflet for a complete list of ingredients in warfarin sodium tablets. Before taking warfarin sodium, tell your healthcare provider about all of your medical conditions, including if you:have bleeding problemsfall oftenhave liver problemshave kidney problems or are undergoing dialysishave high blood pressurehave a heart problem called congestive heart failurehave diabetesplan to have any surgery or a dental procedureare pregnant or plan to become pregnant. See “
  • Who should not take warfarin sodium?”
  • Your healthcare provider will do a pregnancy test before you start treatment with warfarin sodium. Females who can become pregnant should use effective birth control during treatment, and for at least 1 month after the last dose of warfarin sodium.are breastfeeding. You and your healthcare provider should decide if you will take warfarin sodium and breastfeed. Check your baby for bruising or bleeding if you take warfarin sodium and breastfeed.Tell all of your healthcare providers and dentists that you are taking warfarin sodium. They should talk to the healthcare provider who prescribed warfarin sodium for you before you have
  • Any surgery or dental procedure. Your warfarin sodium may need to be stopped for a short time or you may need your dose adjusted.
  • Tell your healthcare provider about all the medicines you take, including prescription and over-the-counter medicines, vitamins, and herbal supplements. Some of your other medicines may affect the way warfarin sodium works. Certain medicines may increase your risk of bleeding. See “
  • What is the most important information I should know about warfarin sodium?”
  • How should I take warfarin sodium? Take warfarin sodium exactly as prescribed. Your healthcare provider will adjust your dose from time to time depending on your response to warfarin sodium.
  • You must have regular blood tests and visits with your healthcare provider to monitor your condition. If you miss a dose of warfarin sodium, call your healthcare provider. Take the dose as soon as possible on the same day.
  • Do not take a double dose of warfarin sodium the next day to make up for a missed dose.
  • Call your healthcare provider right away if you:take too much warfarin sodiumare sick with diarrhea, an infection, or have a feverfall or injure yourself, especially if you hit your head. Your healthcare provider may need to check you.What should I avoid while taking warfarin sodium? Do not do any activity or sport that may cause a serious injury.
  • What are the possible side effects of warfarin sodium? Warfarin sodium may cause serious side effects, including: See “
  • What is the most important information I should know about warfarin sodium?”
  • Death of skin tissue (skin necrosis or gangrene). This can happen soon after starting warfarin sodium. It happens because blood clots form and block blood flow to an area of your body. Call your healthcare provider right away if you have pain, color, or temperature change to any area of your body. You may need medical care right away to prevent death or loss (amputation) of your affected body part.
  • Kidney problems. Kidney injury may happen in people who take warfarin sodium. Tell your healthcare provider right away if you develop blood in your urine. Your healthcare provider may do tests more often during treatment with warfarin sodium to check for bleeding if you already have kidney problems.
  • “Purple toes syndrome.” Call your healthcare provider right away if you have pain in your toes and they look purple in color or dark in color.
  • These are not all of the side effects of warfarin sodium. For more information, ask your healthcare provider or pharmacist.Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.How should I store warfarin sodium tablets? Store warfarin sodium tablets at 20° to 25°C (68° to 77°F); excursions permitted between 15° to 30°C (59° to 86°F).Keep warfarin sodium tablets in a tightly closed container. Keep warfarin sodium tablets out of the light and moisture.
  • Follow your healthcare provider or pharmacist instructions about the right way to throw away outdated or unused warfarin sodium.Females who are pregnant should not handle crushed or broken warfarin sodium tablets.Keep warfarin sodium tablets and all medicines out of the reach of children. General information about the safe and effective use of warfarin sodium. Medicines are sometimes prescribed for purposes other than those listed in a Medication Guide. Do not use warfarin sodium for a condition for which it was not prescribed. Do not give warfarin sodium to other people, even if they have the same symptoms that you have. It may harm them. You can ask your healthcare provider or pharmacist for information about warfarin sodium that is written for health professionals.If you would like more information, go to www.amneal.com or call 1-877-835-5472.What are the ingredients in warfarin sodium tablets? Active ingredient: Warfarin Sodium
  • Inactive ingredients: Hydroxypropyl Cellulose, Lactose Monohydrate, Magnesium Stearate and Pregelatinized Starch. The following tablets contain:
  • 1 mg:               D&C Red No. 6 Barium Lake
  • 2 mg:               FD&C Blue No. 2 Aluminum Lake and FD&C Red No. 40 Aluminum Lake
  • 2-1/2 mg:         D&C Yellow No. 10 Aluminum Lake and FD&C Blue No. 1 Aluminum Lake
  • 3 mg:               FD&C Yellow No. 6 Aluminum Lake, FD&C Blue No. 2 Aluminum Lake, and FD&C Red No. 40 Aluminum Lake
  • 4 mg:               FD&C Blue No. 1 Aluminum Lake
  • 5 mg:               FD&C Yellow No. 6 Aluminum Lake
  • 6 mg:               FD&C Yellow No. 6 Aluminum Lake and FD&C Blue No. 1 Aluminum Lake
  • 7-1/2 mg:         D&C Yellow No. 10 Aluminum Lake and FD&C Yellow No. 6 Aluminum Lake
  • This Medication Guide has been approved by the U.S. Food and Drug Administration. Manufactured by:
  • Amneal Pharmaceuticals Pvt. Ltd.
  • Ahmedabad 382220, INDIA
  • Distributed by:
  • Amneal Pharmaceuticals LLC
  • Bridgewater, NJ 08807
  • Rev. 08-2017-03

* Please review the disclaimer below.