Sublingual administration of warfarin: a novel form of delivery

Current therapy for venous thromboembolism (VTE) includes the initiation of short acting parenteral agents, heparin, low-molecular-weight heparin, or fondaparinux, with subsequent conversion to oral warfarin therapy for the duration of anticoagulation. We present two patients who required long-term anticoagulation for VTE but because of gastrointestinal dysmotility issues were unable to use standard oral anticoagulation. Warfarin is water soluble and absorbed across the epithelium; therefore, we elected to administer warfarin sublingually in an effort to avoid the dysmotility issues while trying to achieve therapeutic anticoagulation. Using sublingual warfarin dosing we were able to achieve therapeutic anticoagulation without complications. Both patients required approximately 6 days to achieve a therapeutic International Normalized Ratio (INR). Neither patient reported adverse side effects related to the sublingual dosing. This unique form of warfarin delivery may be considered for patients with gastrointestinal dysmotility or other gastrointestinal issues which prevent oral use of medications.