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Background <p>Warfarin remains the most widely prescribed anticoagulant worldwide, particularly among elderly patients. Despite its therapeutic benefits, warfarin therapy is challenging to manage because of its narrow therapeutic index, substantial interindividual variability, and numerous drug-drug and drug-food interactions. This study evaluates the clinical presentations, associated factors, and outcomes of warfarin toxicity among elderly patients presenting to the emergency department (ED).</p> Methods <p>Elderly patients (≥ 65 years) presenting to the ED with a history of warfarin use and supratherapeutic INR values, as well as those with clinical manifestations consistent with warfarin toxicity despite therapeutic INR levels, were included. Demographics, comorbidities, presenting symptoms, warfarin indications and dosage, duration of therapy, initial INR results, and potential drug-drug or drug-food interactions were extracted from ED medical records. Outcomes, including in-hospital mortality, were also documented.</p> Results <p>A total of 53 patients were enrolled in the study. Among them, 28.3% had mechanical heart valves with INR values &gt; 3.5, and 15.1% presented despite having INR values within the therapeutic range. Pulmonary thromboembolism (PTE) was the most common indication for warfarin therapy (32.1%). The mean prescribed daily warfarin dose was 5.00 ± 1.47&#xa0;mg, and the mean duration of therapy was 2.47 ± 3.87 years. The mean initial INR level at presentation was 5.44 ± 1.86. Gastrointestinal bleeding (GIB) was the most frequent clinical presentation (34.0%). According to patient or caregiver reports, potential drug-drug or drug-food interactions likely contributed to warfarin toxicity in 71.7% of cases. Drug-drug interactions alone were deemed probable in 60.4%, with acetaminophen being the most frequently reported (49.1%). Potential drug-food interactions were suspected in 41.5%, most commonly involving garlic consumption (30.2%). No mortality was recorded during the ED stay, resulting in an overall mortality rate of 0%.</p> Conclusion <p>Warfarin toxicity should be promptly suspected in elderly ED patients presenting with bleeding, altered consciousness, or abdominal pain, even without supratherapeutic INR, especially in those with comorbidities. Our findings emphasize the need for targeted education of patients, caregivers, and healthcare providers on common drug-drug (e.g., acetaminophen, NSAIDs, antibiotics) and drug-food interactions to enhance awareness, improve safety, and reduce adverse outcomes.</p>

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Clinical Outcomes of Warfarin Toxicity in Elderly Emergency Department Patients: A Retrospective Study

  • 期刊论文

  • 发表日期：

    2026年4月1日

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  • Samad Shams Vahdati,
  • Pooneh Jabbaripour Sarmadian,
  • Alireza Ala,
  • Hamidreza Morteza Bagi,
  • Sogand Omidi,
  • Amirreza Jabbaripour Sarmadian

摘要

Background

Warfarin remains the most widely prescribed anticoagulant worldwide, particularly among elderly patients. Despite its therapeutic benefits, warfarin therapy is challenging to manage because of its narrow therapeutic index, substantial interindividual variability, and numerous drug-drug and drug-food interactions. This study evaluates the clinical presentations, associated factors, and outcomes of warfarin toxicity among elderly patients presenting to the emergency department (ED).

Methods

Elderly patients (≥ 65 years) presenting to the ED with a history of warfarin use and supratherapeutic INR values, as well as those with clinical manifestations consistent with warfarin toxicity despite therapeutic INR levels, were included. Demographics, comorbidities, presenting symptoms, warfarin indications and dosage, duration of therapy, initial INR results, and potential drug-drug or drug-food interactions were extracted from ED medical records. Outcomes, including in-hospital mortality, were also documented.

Results

A total of 53 patients were enrolled in the study. Among them, 28.3% had mechanical heart valves with INR values > 3.5, and 15.1% presented despite having INR values within the therapeutic range. Pulmonary thromboembolism (PTE) was the most common indication for warfarin therapy (32.1%). The mean prescribed daily warfarin dose was 5.00 ± 1.47 mg, and the mean duration of therapy was 2.47 ± 3.87 years. The mean initial INR level at presentation was 5.44 ± 1.86. Gastrointestinal bleeding (GIB) was the most frequent clinical presentation (34.0%). According to patient or caregiver reports, potential drug-drug or drug-food interactions likely contributed to warfarin toxicity in 71.7% of cases. Drug-drug interactions alone were deemed probable in 60.4%, with acetaminophen being the most frequently reported (49.1%). Potential drug-food interactions were suspected in 41.5%, most commonly involving garlic consumption (30.2%). No mortality was recorded during the ED stay, resulting in an overall mortality rate of 0%.

Conclusion

Warfarin toxicity should be promptly suspected in elderly ED patients presenting with bleeding, altered consciousness, or abdominal pain, even without supratherapeutic INR, especially in those with comorbidities. Our findings emphasize the need for targeted education of patients, caregivers, and healthcare providers on common drug-drug (e.g., acetaminophen, NSAIDs, antibiotics) and drug-food interactions to enhance awareness, improve safety, and reduce adverse outcomes.