Warfarin Institute of America
DEDICATED TO YOUR HEALTH SINCE 2000
WARFARIN AND SHORT BOWEL SYNDROME
Matthew Thielbar, Pharm D Candidate
University of Colorado Health Sciences Center
School of Pharmacy
Patients who have short bowel syndrome have ≥ 50% of their small intestines removed.1 The small intestines are important for the absorption of macronutrients (proteins, carbohydrates, and fats), micronutrients (vitamins and minerals), and many medications.
The average length of the adult intestine is approximately 20 feet and therefore any shorter length will reduce the proportion of nutrients and medications that are absorbed.
Warfarin is absorbed in the GI tract, but it is not known exactly where in the GI tract.2 Warfarin studies were done in the 1950s and it is not economically feasible to perform additional absorption studies today.
Many patients that have short bowel syndrome have to be fed through enteral (feeding tube inserted into the stomach or intestine) or parenteral (feeding though an intravenously inserted line) nutrition. The main concern with both enteral and parenteral nutrition is the vitamin K that is included. Vitamin K as you may know counteracts the effects of warfarin.
There are a few ways to help make sure that you get maximal absorption when a patient is on enteral nutrition. In enteral nutrition food, liquids, and medications are all given through the same tube. The tube should be flushed out with approximately 30 mL of warm water before and after medication administration.3 Warfarin can be crushed into a fine powder immediately before giving. Warfarin is 99% protein bound (warfarin naturally binds to various proteins in your body) and protein that is in the feeding tube or that was just given can possibly “bind” the warfarin and cause it to be less active. Warfarin should be given 2 hours before or 4 hours after an enteral feeding.
There has been some question as to whether warfarin can be made into a liquid or any other dosage form other that a pill or injectable, which it is commercially available. After much searching warfarin may be able to be made into a liquid that is stable for 30 days. It will be difficult to find a pharmacy willing to compound this due to very limited information. The manufacture and other sources do not recommend that warfarin be compounded due to lack of stability information.
The best method for anticoagulation would be through injections such as Lovenox® (enoxaparin) or Fragmin® (dalteparin). These injections are given subcutaneously into the abdomen and provide immediate protection from blood clots. This may not be the most convenient method of anticoagulation but is the best in patients unable to absorb oral anticoagulants.
References:
1. Short bowel syndrome. http://www.emedicine.com/med/topic2746.htm
2. Micromedex Healthcare Series, (electronic system). Thompson Micromedex, Greenwood Village, CO, USA. Available at http://0-www.thompsonhc.com.library.uchsc.edu (cited 2/15/07)
3. A Resource Book for Delivering Enteral and Parenteral Nutrition for Adults. Available at: http://healthlinks.washington.edu/nutrition/section5.html. Cited 2/15/07
©2007 Matthew Thielbar Used by permission
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Last updated February 18, 2007
