Key:PJVWKTKQMONHTI-UHFFFAOYSA-N Y N Y Warfarin, sold under the brand name Coumadin among others, is a medication that is used as an (blood thinner). It is commonly used to treat such as and and to prevent in people who have,. Less commonly it is used following (STEMI) and. It is generally taken by mouth but may also be used. The common side effect is. Less common side effects may include areas of and.

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Use is not generally recommended during. It is recommended that the effects of warfarin typically be monitored by checking (INR) every one to four weeks. Many other medications and can interact with warfarin, either increasing or decreasing its effectiveness. The effects of warfarin may be reversed with (vitamin K1),,. Warfarin decreases by blocking an called that reactivates vitamin K 1. Without sufficient active vitamin K 1, II, VII, IX, and X have decreased clotting ability. The anticlotting and are also inhibited but to a lesser degree.

A few days are required for full effect to occur and these effects can last for up to five days. Warfarin first came into commercial use in 1948 as a. In 1954 it was approved for medical use in the United States. It is on the, the most effective and safe medicines needed in a. Warfarin is available as a. The wholesale cost in the is about US$1.12 to 7.20 for a typical month of treatment. In the United States it usually costs less than $25 a month.

Contents • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • Medical uses [ ] Warfarin is used to decrease the tendency for or as secondary prophylaxis (prevention of further episodes) in those individuals who have already formed a blood clot (). Warfarin treatment can help prevent formation of future blood clots and help reduce the risk of (migration of a thrombus to a spot where it blocks blood supply to a vital organ). Warfarin is best suited for anticoagulation (clot formation inhibition) in areas of slowly running blood (such as in veins and the pooled blood behind artificial and natural valves) and in blood pooled in dysfunctional cardiac atria.

Thus, common clinical indications for warfarin use are, the presence of,, and (where the embolized clots first form in veins). Warfarin is also used in. It has been used occasionally after heart attacks (), but is far less effective at preventing new thromboses in coronary arteries. Prevention of clotting in arteries is usually undertaken with, which act by a different mechanism from warfarin (which normally has no effect on platelet function).

Alternative anticoagulants [ ]. This section needs to be updated. Please update this article to reflect recent events or newly available information.

(October 2016) In some countries, other coumarins are used instead of warfarin, such as and. These have a shorter (acenocoumarol) or longer (phenprocoumon), and are not completely interchangeable with warfarin. Several types of anticoagulant drugs offering the efficacy of warfarin without a need for monitoring, such as,, and, have been approved in a number of countries for classical warfarin uses like the more common types of atrial fibrillation, and others in the same drug classes are under development.

There is a reversal agent available for dabigatran (idarucizumab) but not for apixaban, edoxaban and rivaroxaban. Dosing [ ] Dosing of warfarin is complicated because it is known to interact with many commonly used medications and. These interactions may enhance or reduce warfarin's anticoagulation effect. To optimize the therapeutic effect without risking dangerous side effects such as bleeding, close monitoring of the degree of anticoagulation is required by a blood test measuring an. During the initial stage of treatment, INR is checked daily; intervals between tests can be lengthened if the patient manages stable therapeutic INR levels on an unchanged warfarin dose.

Newer is available and has increased the ease of INR testing in the outpatient setting. Instead of a blood draw, the point of care test involves a simple finger prick. When initiating warfarin therapy ('warfarinization'), the doctor will decide how strong the anticoagulant therapy needs to be. The target INR level varies from case to case depending on the clinical indicators, but tends to be 2–3 in most conditions. In particular, target INR may be 2.5–3.5 (or even 3.0–4.5) in patients with one or more. In addition, for the first three days of 'warfarinization', the levels of protein C and protein S (anticoagulation factors) drop faster than procoagulation proteins such as factor II, VII, IX, and X.

Therefore, bridging anticoagulant therapies (usually heparin) are often used to reverse this temporary hypercoagulable state. Maintenance dose [ ]. Vitamin K1-warfarin interaction effect.

When warfarin levels are high, people have more risk of bleeding. Conversely, lower levels of warfarin lead to increased risk of blood clots. There is a narrow range where the benefits of warfarin are greater than the risks, its. Certain drugs, herbal medicines and foods can interact with warfarin, increasing or decreasing a previously stable warfarin level. Recommendations by many national bodies, including the, have been distilled to help manage dose adjustments. The of warfarin can fluctuate significantly depending on the amount of vitamin K 1 in the diet.

Keeping vitamin K 1 intake at a stable level can prevent these fluctuations. Leafy green vegetables tend to contain higher amounts of vitamin K 1.

Green parts of members of the family, such as,, and, are extremely rich sources of vitamin K; such as and, as well as the darker varieties of lettuces and other leafy greens, are also relatively high in vitamin K 1. Green vegetables such a peas and green beans do not have such high amounts of vitamin K 1 as leafy greens. Certain vegetable oils have high amounts of vitamin K 1.

Foods low in vitamin K 1 include roots, bulbs, tubers, and most fruits and fruit juices. Cereals, grains and other milled products are also low in vitamin K 1. Self-testing [ ]. Main article: Patients are making increasing use of self-testing and home monitoring of oral anticoagulation. International guidelines on home testing were published in 2005. The guidelines stated: 'The consensus agrees that patient self-testing and patient self-management are effective methods of monitoring oral anticoagulation therapy, providing outcomes at least as good as, and possibly better than, those achieved with an anticoagulation clinic.

All patients must be appropriately selected and trained. Currently available self-testing/self-management devices give INR results that are comparable with those obtained in laboratory testing.' A 2006 and of 14 randomized trials showed home testing led to a reduced incidence of complications ( and ) and improved the time in the. Contraindications [ ] All anticoagulants are generally contraindicated in situations where the reduction in clotting that they cause might lead to serious and potentially life-threatening bleeds.

This includes people with active bleeding conditions (such as gastrointestinal ulcers), or disease states with increased risk of bleeding e.g. Low platelets, severe liver disease, uncontrolled hypertension. For patients undergoing surgery, treatment with anticoagulants is generally suspended.

Similarly, spinal or lumbar puncture (e.g. Spinal injections, epidurals, etc.) carry increased risk so treatment is suspended prior to these procedures. Warfarin should not be given to people with until platelet count has improved or normalised. Warfarin is usually best avoided in people with protein C or protein S deficiency as these conditions increase the risk of skin necrosis, which is a rare but serious side effect associated with warfarin. Pregnancy [ ]. Further information: Warfarin is in pregnancy, as it passes through the barrier and may cause bleeding in the fetus; warfarin use during pregnancy is commonly associated with,,, and.

Coumarins (such as warfarin) are also, that is, they cause; the incidence of birth defects in infants exposed to warfarin appears to be around 5%, although higher figures (up to 30%) have been reported in some studies. Depending on when exposure occurs during pregnancy, two distinct combinations of congenital abnormalities can arise. First trimester of pregnancy [ ] Usually, warfarin is avoided in the first trimester, and a such as is substituted. With heparin, risk of maternal haemorrhage and other complications are still increased, but heparins do not cross the placental barrier, so do not cause birth defects. Various solutions exist for the time around delivery. When warfarin (or another 4-hydroxycoumarin derivative) is given during the first trimester—particularly between the sixth and ninth weeks of pregnancy—a constellation of birth defects known variously as (FWS), warfarin embryopathy, or coumarin embryopathy can occur. FWS is characterized mainly by abnormalities, which include nasal, a depressed or narrowed,, and in the,, and, which show a peculiar stippled appearance on., such as (unusually short fingers and toes) or underdeveloped extremities, can also occur.

Common nonskeletal features of FWS include and. Second trimester and later [ ] Warfarin administration in the second and third trimesters is much less commonly associated with birth defects, and when they do occur, are considerably different from fetal warfarin syndrome. The most common congenital abnormalities associated with warfarin use in late pregnancy are disorders, including and, and eye defects. Because of such later pregnancy birth defects, anticoagulation with warfarin poses a problem in pregnant women requiring warfarin for vital indications, such as stroke prevention in those with artificial heart valves. According to the American College of Chest Physicians (ACCP), warfarin may be used in lactating women who wish to breast-feed their infants. Available data does not suggest that warfarin crosses into the breast milk.

Similarly, INR levels should be checked to avoid adverse effects. Adverse effects [ ] Bleeding [ ] The only common of warfarin is. The risk of severe bleeding is small but definite (a typically yearly rate of 1-3% has been reported) and any benefit needs to outweigh this risk when warfarin is considered. All types of bleeding occur more commonly, but the most severe ones are those involving the brain (intracerebral hemorrhage/hemorrhagic stroke) and the.

Risk of bleeding is increased if the INR is out of range (due to accidental or deliberate overdose or due to interactions). This risk increases greatly once the INR exceeds 4.5. A number of risk scores exist to predict bleeding in people using warfarin and similar anticoagulants. A commonly used score () includes known predictors of warfarin-related bleeding: uncontrolled high blood pressure (H), abnormal (A), previous stroke (S), known previous bleeding condition (B), previous labile INR when on anticoagulation (L), elderly as defined by age over 65 (E), and drugs associated with bleeding (e.g. Aspirin) or alcohol misuse (D). While their use is recommended in clinical practice guidelines, they are only moderately effective in predicting bleeding risk and do not perform well in predicting hemorrhagic stroke. Bleeding risk may be increased in people on.

Another score used to assess bleeding risk on anticoagulation, specifically Warfarin or Coumadin, is the ATRIA score, which uses a weighted additive scale of clinical findings to determine bleeding risk stratification. The risks of bleeding are increased further when warfarin is combined with such as,,.

Warfarin necrosis [ ]. Main article: A rare but serious complication resulting from treatment with warfarin is, which occurs more frequently shortly after commencing treatment in patients with a deficiency of. Protein C is an innate anticoagulant that, like the procoagulant factors that warfarin inhibits, requires vitamin K-dependent carboxylation for its activity. Biological Variation From Principles To Practice Pdf Test. Since warfarin initially decreases protein C levels faster than the coagulation factors, it can paradoxically increase the blood's tendency to coagulate when treatment is first begun (many patients when starting on warfarin are given in parallel to combat this), leading to massive thrombosis with skin and of limbs. Its natural counterpart,, occurs in children who are for certain protein C mutations. Osteoporosis [ ] After initial reports that warfarin could reduce, several studies have demonstrated a link between warfarin use and -related. A 1999 study in 572 women taking warfarin for, risk of and was increased; other fracture types did not occur more commonly.

A 2002 study looking at a randomly selected selection of 1523 patients with osteoporotic fracture found no increased exposure to anticoagulants compared to controls, and neither did stratification of the duration of anticoagulation reveal a trend towards fracture. A 2006 retrospective study of 14,564 Medicare recipients showed that warfarin use for more than one year was linked with a 60% increased risk of osteoporosis-related fracture in men; there was no association in women.

The mechanism was thought to be a combination of reduced intake of vitamin K, which is necessary for bone health, and inhibition by warfarin of vitamin K-mediated carboxylation of certain bone proteins, rendering them nonfunctional. Purple toe syndrome [ ] Another rare complication that may occur early during warfarin treatment (usually within 3 to 8 weeks of commencement) is. This condition is thought to result from small deposits of breaking loose and causing embolisms in blood vessels in the skin of the feet, which causes a blueish purple colour and may be painful. It is typically thought to affect the big toe, but it affects other parts of the feet as well, including the bottom of the foot (plantar surface). The occurrence of purple toe syndrome may require discontinuation of warfarin. Calcification [ ] Several studies have also implicated warfarin use in valvular and vascular calcification.

No specific treatment is available, but some modalities are under investigation. Overdose [ ] The major side effect of warfarin use is bleeding. Risk of bleeding is increased if the is out of range (due to accidental or deliberate overdose or due to interactions). Many drug interactions can increase the effect of warfarin, also causing an overdose. For people who need rapid reversal of warfarin such as due to serious bleeding or need emergency surgery, the effects of warfarin can be reversed with, (PCC), or (FFP) in addition to vitamin K. Blood products should not be routinely used to reverse warfarin overdose when vitamin K could work alone. PCC has been found to be better than FFP when rapid reversal is needed.

Details on reversing warfarin are provided in from the. For people with an (INR) between 4.5 and 10.0, a small dose (about 1000 mcg = one milligram) of oral vitamin K is sufficient. When warfarin is being given and INR is in therapeutic range, simple discontinuation of the drug for five days is usually enough to reverse the effect and cause INR to drop below 1.5. Interactions [ ] Warfarin with many commonly used drugs, and the of warfarin varies greatly between patients. Some foods have also been reported to interact with warfarin. Apart from the metabolic interactions, highly protein bound drugs can displace warfarin from and cause an increase in the INR. This makes finding the correct dosage difficult, and accentuates the need of monitoring; when initiating a medication that is known to interact with warfarin (e.g.

), checks are increased or dosages adjusted until a new ideal dosage is found. When taken with NSAIDS (non-steroidal anti-inflammatory medications), warfarin increases the risk for gastrointestinal bleeding.

This increased risk is due to the anti-platelet effect of NSAIDS as well as the possible damage to the gastrointestinal mucosa. Many commonly used antibiotics, such as or the, will greatly increase the effect of warfarin by reducing the of warfarin in the body. Other can reduce the amount of the normal, which make significant quantities of vitamin K 1, thus potentiating the effect of warfarin. In addition, food that contains large quantities of vitamin K 1 will reduce the warfarin effect. Activity also appears to influence warfarin dosing requirements; (decreased thyroid function) makes people less responsive to warfarin treatment, while (overactive thyroid) boosts the anticoagulant effect.

Several mechanisms have been proposed for this effect, including changes in the rate of breakdown of clotting factors and changes in the metabolism of warfarin. Excessive use of alcohol is also known to affect the metabolism of warfarin and can elevate the INR and thus increase the risk of bleeding. (FDA) product insert on warfarin states that alcohol should be avoided. Warfarin also interacts with many herbs and spices, some used in food (such as and garlic) and others used purely for medicinal purposes (such as and ). All may increase bleeding and bruising in people taking warfarin; similar effects have been reported with () oil or fish oils., sometimes recommended to help with mild to moderate depression, reduces the effectiveness of a given dose of warfarin; it the enzymes that break down warfarin in the body, causing a reduced anticoagulant effect.

Between 2003 and 2004, the UK received several reports of increased INR and risk of haemorrhage in people taking warfarin and. Data establishing a causal relationship is still lacking, and a 2006 review found no cases of this interaction reported to the FDA; nevertheless, several authors have recommended that both doctors and patients be made aware of its possibility. The mechanism behind the interaction is still unclear. Chemistry [ ]. Acyclic tautomer (left) and cyclic hemiketal tautomer (right) X-ray crystallographic studies of warfarin show that it exists in form, as the cyclic, which is formed from the 4-hydroxycoumarin and the ketone in the 3-position substituent.

However, the existence of many 4-hydroxycoumadin anticoagulants (for example ) that possess no ketone group in the 3-substituent to form such a structure, suggests that the hemiketal must tautomerise to the 4-hydroxy form in order for warfarin to be active. Stereochemistry [ ] Warfarin contains a stereocenter and consists of two enantiomers. This is a, ie a 1: 1 mixture of ( R ) - and the ( S ) - form: Enantiomer of warfarin CAS-Nummer: 5543-58-8 CAS-Nummer: 5543-57-7 Pharmacology [ ]. 3 mg (blue), 5 mg (pink) and 1 mg (brown) warfarin tablets (UK colours) Pharmacokinetics [ ] Warfarin consists of a mixture of two active — R- and S- forms—each of which is cleared by different pathways. S-warfarin is 2-5 times more potent than the R-isomer in producing an anticoagulant response.

Both the enantiomers of warfarin undergo CYP-mediated metabolism by many different CYPs to form 3',4',6,7,8 and 10-hydroxy warfarin metabolites, major being 7-OH warfarin formed from S-warfarin by CYP2C9 and 10-OH warfarin from R-warfarin by CYP3A4. Warfarin is slower acting than the common anticoagulant, though it has a number of advantages. Heparin must be given by injection, whereas warfarin is available orally. Warfarin has a long half-life and need only be given once a day.

Heparin can also cause a prothrombotic condition, (an antibody-mediated decrease in levels), which increases the risk for. It takes several days for warfarin to reach the therapeutic effect since the circulating coagulation factors are not affected by the drug (thrombin has a half-life time of days). Warfarin's long half-life means that it remains effective for several days after it was stopped. Furthermore, if given initially without additional anticoagulant cover, it can increase thrombosis risk (see below).

For these main reasons, hospitalised patients are usually given heparin with warfarin initially, the heparin covering the 3–5 day lag period and being withdrawn after a few days. Mechanism of action [ ] While warfarin is one of several drugs popularly referred to as a 'blood thinner;' this is a misnomer since it does not affect the of blood. Warfarin inhibits the -dependent synthesis of biologically active forms of the -dependent factors,, and, as well as the regulatory factors,, and. Other proteins not involved in blood clotting, such as, or, may also be affected. The precursors of these factors require of their residues to allow the coagulation factors to bind to surfaces inside blood vessels, on the vascular. The enzyme that carries out the carboxylation of glutamic acid is. The carboxylation reaction will proceed only if the carboxylase enzyme is able to convert a form of vitamin K (vitamin K hydroquinone) to vitamin K epoxide at the same time.

The vitamin K epoxide is in turn recycled back to vitamin K and vitamin K hydroquinone by another enzyme, the (VKOR). Warfarin inhibits epoxide reductase (specifically the VKORC1 subunit ), thereby diminishing available vitamin K and vitamin K hydroquinone in the tissues, which inhibits the carboxylation activity of the glutamyl carboxylase. When this occurs, the coagulation factors are no longer carboxylated at certain residues, and are incapable of binding to the surface of blood vessels, and are thus biologically inactive.

As the body's stores of previously produced active factors degrade (over several days) and are replaced by inactive factors, the anticoagulation effect becomes apparent. The coagulation factors are produced, but have decreased functionality due to undercarboxylation; they are collectively referred to as PIVKAs (proteins induced [by] vitamin K absence/antagonism), and individual coagulation factors as PIVKA- number (e.g.). The end result of warfarin use, therefore, is to diminish blood clotting in the patient. When warfarin is newly started, it may promote clot formation temporarily. This is because the level of and are also dependent on vitamin K activity.

Warfarin causes decline in protein C levels in first 36 hours. In addition, reduced levels of protein S lead to a reduction in activity of (for which it is the co-factor) and therefore reduced degradation of and. Although loading doses of warfarin over 5 mg also produce a precipitous decline in, resulting in an initial prolongation of the INR, full antithrombotic effect does not take place until significant reduction in factor II occurs days later. The haemostasis system becomes temporarily biased towards thrombus formation, leading to a prothrombotic state. Thus, when warfarin is loaded rapidly at greater than 5 mg per day, it is beneficial to co-administer, an anticoagulant that acts upon and helps reduce the risk of thrombosis, with warfarin therapy for four to five days, in order to have the benefit of anticoagulation from heparin until the full effect of warfarin has been achieved. Pharmacogenomics [ ] Warfarin activity is determined partially by genetic factors.

In two genes ( VKORC1 and CYP2C9) play a particularly large role in response to warfarin. Polymorphisms explain 30% of the dose variation between patients: particular mutations make VKORC1 less susceptible to suppression by warfarin.

There are two main haplotypes that explain 25% of variation: low-dose haplotype group (A) and a high-dose haplotype group (B). VKORC1 polymorphisms explain why African Americans are on average relatively resistant to warfarin (higher proportion of group B haplotypes), while Asian Americans are generally more sensitive (higher proportion of group A haplotypes). Group A VKORC1 polymorphisms lead to a more rapid achievement of a therapeutic INR, but also a shorter time to reach an INR over 4, which is associated with bleeding. Polymorphisms explain 10% of the dose variation between patients, mainly among patients as these variants are rare in African American and most Asian populations.

These CYP2C9 polymorphisms do not influence time to effective INR as opposed to VKORC1, but does shorten the time to >4. Despite the promise of pharmacogenomic testing in warfarin dosing, its use in clinical practice is controversial. In August 2009 the concluded that 'the available evidence does not demonstrate that pharmacogenomic testing of CYP2C9 or VKORC1 to predict warfarin responsiveness improves health outcomes in beneficiaries.' A 2014 showed that using genotype-based dosing did not confer benefit in terms of time within therapeutic range, excessive anticoagulation (as defined by INR greater than 4), or a reduction in either or events.

History [ ] In the early 1920s, there was an outbreak of a previously unrecognized cattle disease in the northern United States and Canada. Cattle were after minor procedures and on some occasions, spontaneously. For example, 21 out of 22 cows died after dehorning and 12 out of 25 bulls died after castration. All of these animals had bled to death.

In 1921,, a Canadian, determined that the cattle were ingesting moldy made from, and that this was functioning as a potent anticoagulant. Only spoiled hay made from sweet clover (grown in northern states of the USA and in Canada since the turn of the century) produced the disease. Schofield separated good clover stalks and damaged clover stalks from the same hay mow, and fed each to a different rabbit.

The rabbit that had ingested the good stalks remained well, but the rabbit that had ingested the damaged stalks died from a haemorrhagic illness. A duplicate experiment with a different sample of clover hay produced the same result.

In 1929, North Dakota veterinarian Dr L.M. Roderick demonstrated that the condition was due to a lack of functioning. The identity of the anticoagulant substance in spoiled sweet clover remained a mystery until 1940. In 1933 and his lab of chemists working at the set out to isolate and characterize the haemorrhagic agent from the spoiled hay. Aki Ola Elective Mathematics Pdf. It took five years for Link's student Harold A. Campbell to recover 6 mg of crystalline anticoagulant.

Next, Link's student Mark A. Stahmann took over the project and initiated a large-scale extraction, isolating 1.8 g of recrystallized anticoagulant in about 4 months. This was enough material for Stahmann and Charles F. Huebner to check their results against Campbell's and to thoroughly characterize the compound.

Through degradation experiments they established that the anticoagulant was 3,3'-methylenebis-(4-hydroxycoumarin), which they later named. They confirmed their results by synthesizing dicoumarol and proving in 1940 that it was identical to the naturally occurring agent. Dicoumarol was a product of the plant molecule (not to be confused with Couma din, a later tradename for warfarin). Coumarin is now known to be present in many plants, and produces the notably sweet smell of freshly cut grass or hay and plants like; in fact, the plant's high content of coumarin is responsible for the original common name of 'sweet clover', which is named for its sweet smell, not its bitter taste. They are present notably in ( Galium odoratum, ), and at lower levels in,, and various other species. However, coumarins themselves do not influence clotting or warfarin-like action, but must first be metabolized by various fungi into compounds such as, then further (in the presence of naturally occurring ) into, in order to have any anticoagulant properties.

Fungal attack of the damaged and dying clover stalks explained the presence of the anticoagulant only in spoiled clover silages; dicoumarol is considered to be a fermentation product and. Over the next few years, numerous similar chemicals (specifically 4-hydroxycoumarins with a large substitutent at the 3 position) were found to have the same anticoagulant properties. The first drug in the class to be widely commercialized was itself, patented in 1941 and later used as a pharmaceutical. Karl Link continued working on developing more potent coumarin-based anticoagulants for use as, resulting in warfarin in 1948.

The name 'warfarin' stems from the acronym WARF, for + the ending -arin indicating its link with coumarin. Warfarin was first registered for use as a rodenticide in the US in 1948, and was immediately popular. Although warfarin was developed by Link, the Wisconsin Alumni Research Foundation financially supported the research and was assigned the patent. After an incident in 1951, where a inductee attempted suicide with multiple doses of warfarin in rodenticide but recovered fully after presenting to a hospital and being treated with vitamin K (by then known as a specific antidote), studies began in the use of warfarin as a therapeutic anticoagulant.

It was found to be generally superior to dicoumarol, and in 1954 was approved for medical use in humans. An early recipient of warfarin was US president, who was prescribed the drug after having a heart attack in 1955.

The exact remained unknown until it was demonstrated, in 1978, that warfarin the enzyme and hence interferes with vitamin K metabolism. It has been posited that, and others conspired to use warfarin to poison Soviet leader. Warfarin is tasteless and colourless, and produces symptoms similar to those that Stalin exhibited. Pest control [ ] Rodents [ ]. Warning label on a tube of rat poison laid on a dike of the river in Steendorp, Belgium. The tube contains, a second-generation ('super-warfarin') anticoagulant. Coumarins (4-hydroxycoumarin derivatives) are used as for controlling and in residential, industrial, and agricultural areas.

Warfarin is both odorless and tasteless, and is effective when mixed with food, because the will return to the bait and continue to feed over a period of days until a lethal dose is accumulated (considered to be 1 mg/kg/day over about six days). It may also be mixed with and used as a tracking powder, which accumulates on the animal's skin and fur, and is subsequently consumed during grooming. The is 50–500 mg/kg. The value is 100 mg/m 3 (warfarin; various species). The use of warfarin itself as a rat poison is now declining, because many rat populations have developed resistance to it, and poisons of considerably greater potency are now available. Other 4-hydroxycoumarins used as rodenticides include and, which is sometimes referred to as 'super-warfarin', because it is more potent, longer-acting, and effective even in rat and mouse populations that are resistant to warfarin.

Unlike warfarin, which is readily excreted, newer anticoagulant poisons also in the liver and kidneys after ingestion. However, such rodenticides may also accumulate in and other animals that eat the poisoned rodents or baits. Vampire bats [ ] Warfarin is used to cull populations in areas where is a concern. Vampire bats are captured with and coated with a combination of and warfarin.

The bat returns to its roost and other members of the roost become poisoned as well by ingesting the warfarin after reciprocal grooming. Suspected vampire bat roosts may also be coated in the warfarin solution, though this kills other bat species and remains in the environment for years.

The efficacy of killing vampire bats to reduce rabies transmission is questionable, however; a study in Peru showed that culling programs did not lead to lower transmission rates of rabies to livestock and humans. Occupational safety [ ] People can be exposed to warfarin in the workplace by breathing it in, swallowing it, skin absorption, and eye contact. The (OSHA) has set the legal limit () for warfarin exposure in the workplace as 0.1 mg/m 3 over an 8-hour workday. The (NIOSH) has set a (REL) of 0.1 mg/m 3 over an 8-hour workday. At levels of 100 mg/m 3, warfarin is. It is classified as an in the United States as defined in Section 302 of the U.S.

11002), and is subject to strict reporting requirements by facilities which produce, store, or use it in significant quantities. Names [ ] Warfarin is a derivative of, an anticoagulant originally discovered in spoiled. Dicoumarol, in turn, is from, a sweet-smelling but coagulation-inactive chemical found in 'sweet' clover and (also known as cumaru from which coumarin's name derives). The name warfarin stems from its discovery at the, incorporating the acronym for the organization that funded the key research, WARF for the and the ending -arin, indicating its link with coumarin. The drug is marketed under many brand and generic names including Aldocumar, Anasmol, Anticoag, Befarin, Cavamed, Cicoxil, Circuvit, Cofarin, Coumadin, Coumadine, Cumar, Farin, Foley, Haemofarin, Jantoven, Kovar, Lawarin, Maforan, Marevan, Marfarin, Marivanil, Martefarin, Morfarin, Orfarin, Panwarfin, Scheme, Simarc, Varfarin, Varfarins, Varfine, Waran, Warcok, Warf, Warfareks, Warfarin, Warfarina, Warfarine, Warfarinum, Warfen, Warfin, Warik, Warin, Warlin, and Zyfarin.