Coumadin and Tube Feeding

After a more thorough reading and research to better understand this subject, I added excerpts and package them in such a way that readers would readily undestand and find answers to their curiosity. First of all I will start by describing the role of vit K in the coagulation process. Second, I will discuss why many of this tube feeding formulas can delay INR into a therapeutic level while on Warfarin. Lastly, I will correlate the role of coumadin and why we can’t give them together with formula feeding and what is the best practice.

Vitamin K is a fat-soluble coagulation vitamin that is stored in human body fats as well as in the liver.”In 1929, Danish scientist Henrik Dam investigated the role of cholesterol by feeding chickens a cholesterol-depleted diet.[4] After several weeks, the animals developed hemorrhages and started bleeding. These defects could not be restored by adding purified cholesterol to the diet. It appeared that—together with the cholesterol—a second compound had been extracted from the food, and this compound was called the coagulation vitamin. The new vitamin received the letter K because the initial discoveries were reported in a German journal, in which it was designated as Koagulationsvitamin. Edward Adelbert Doisy of Saint Louis University did much of the research that led to the discovery of the structure and chemical nature of vitamin K.[106] Dam and Doisy shared the 1943 Nobel Prize for medicine for their work on vitamin K (K1 and K2) published in 1939. Several laboratories synthesized the compound(s) in 1939. The precise function of vitamin K was not discovered until 1974, when three laboratories (Stenflo et al.,[110] Nelsestuen et al.,[111] and Magnusson et al.[112]) isolated the vitamin K-dependent coagulation factor prothrombin (Factor II) from cows that received a high dose of a vitamin K antagonist, warfarin. It was shown that, while warfarin-treated cows had a form of prothrombin that contained 10 glutamate amino acid residues near the amino terminus of this protein, the normal (untreated) cows contained 10 unusual residues that were chemically identified as gamma-carboxyglutamate, or Gla. The extra carboxyl group in Gla made clear that vitamin K plays a role in a carboxylation reaction during which Glu is converted into Gla. Vit K is an essential cofactor in carboxylation of vit k dependent coagulation proteins and this are… Factor 11(prothrombin), V11, 1X, X and vit k anticoagulant proteins C, S and Z.” This proteins needs vit K to be activated inorder to participate in clot formation.

Rich Sources of Vitamin K is found in a number of foods, including leafy greens, cauliflower,broccoli, asparagus, cabbage, spring onions, brussel sprouts, prunes, soybean oils and, liver. However, the chief source of vitamin K is synthesis by bacteria in the large intestine, and in most cases, absence of dietary vitamin K is not at all deleterious. Vitamin K is a fat-soluble vitamin and both dietary and microbial vitamin K are absorbed into intestinal lymph along with other lipids. The fetus obtains vitamin K from its mother by transplacental transfer.

Tube feeding formulas that includes..Glucerna, Jevity, Perative, Osmolite, Ensure to name a few have Soy lecithin and soy protein isolate ingredients. Soy Lecithin are extracted from soy bean oil and are generally used as a natural emulsifier or stabilizer. Soy being known as “meat without bone” is high in protein as well as a good source of …….V I T A M I N.. K.

Coumadin is a widely prescribed anticoagulant used to prevent thrombosis and as prophylaxis to prevent embolism. Commonly used for Atrial fibrillation, artificial heart valves, DVT and PE.

Coumadin works by directly inbiting vit K clotting factors, since protein C, an important thrombin formation regulator is dependent on vit K activity, it’s production is also reduced with Coumadin.

For patients who are acutely and chronically ill that are on Coumadin requiring tube feeding. It is imperative not to give Coumadin with tube feeding because the vit K content of this formulas antagonizes the anticoagulation effect of Warfarin. This direct weakening interaction delays the thinning of blood as a result INR’s therapeutic level is definitely hard to achieve.It is therefore recommended that tube feeding be held at least 1 hour early and 1 hour after the coumadin is administered. For intermittent tube feeding, it is recommended to give Coumadin, wait for an hour before administering the intermittent feed.This is to allow adequate absorption of Coumadin.

Also remember!!!!!!!!! what is the antidote for Coumadin poisoning? It’s Vitamin K!!!!!!!

My own patient encounter had led me to investigate and did my literature search. My patient had an MI with a large apical thrombus. Encephalopathy was a major setback leading to tube feeding and longer hospital stay. Inorder to keep this pt anticoagulated, Warfarin was started and bridged with Heparin IV. Pt received Coumadin dosed by pharmacy. 4th day of Coumadin intake INR remains at 1.3. Discussion with the pharmacist led to the recommendation to turn off tube feeding 1 hr before giving Coumadin then wait for another hour before restarting continuous tube feeding.5th day, INR jumped to 1.6 upon following said instruction. Once recovered from encephalopathy pt sent home with a therapeutic INR level.

Reference:
1. Vitamin K – Wikipedia, the free encyclopedia
en.wikipedia.org/wiki/Vitamin_K
2. Coumadin – Wikipedia, the free encyclopedia
en.wikipedia.org/wiki/Coumadin
3. Lecithin – Wikipedia, the free encyclopedia
en.wikipedia.org/wiki/Lecithin.