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Download DRUGS TO TRY AND AVOID IN WARFARIN PATIENTS
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COMMON WARFARIN DRUG INTERACTIONS The drugs in this list are more usually associated with loss of INR control in patients already established on warfarin. Patients already on any of these drugs may be started on warfarin and the dose adjusted as required. Drug interactions with warfarin tend to be variable and unpredictable and on the whole affect a fairly small proportion of patients. If any of the drugs below are to be started in these patients then the use of alternatives in the same therapeutic class may be considered. If this is not possible then the patients INR should be monitored as detailed below. Drugs marked * are liver enzyme inhibitors and increase the INR. They act very quickly (can be within 24 hours) and if the drug is withdrawn the effect disappears quickly depending on the drug half-life. The INR should if possible be monitored within 72 hours of starting the interacting drug. $ Drugs marked are liver enzyme inducers and decrease the INR. They act more slowly (up to a week) with peak effect at 2-3 weeks and can persist for up to 4 weeks after stopping depending on drug half-life. The INR will need checking after 1 week of concurrent therapy. Drugs in bold commonly cause variations in INR. N.B. If a patient on warfarin were started on ANY other new medication a repeat INR within 1 week would be a sensible precaution. Common drugs that increase the INR Gastrointestinal Cardiovascular CNS Anti-infectives (anti-infectives in general MAY cause raised INR’s) Endocrine NSAID’s N.B. ALL NSAID’s can increase the risk of bleeds and should be avoided where possible – IBUPROFEN (+/- PPI) is probably safest if an NSAID is required Miscellaneous Herbal preparations etc cimetidine*, omeprazole* amiodarone*, fibrates, fluvastatin*, propafenone*, propranolol, simvastatin* dextropropoxyphene* (in co-proxamol), fluvoxamine*, paracetamol (prolonged use at high dose), SSRI’s*, tramadol azole antifungals* (esp. miconazole including oral gel and vaginal), co-trimoxazole*, isoniazid*, macrolides* (can be serious but unpredictable), metronidazole*, quinolones* (can be serious but unpredictable), tetracyclines anabolic steroids (and danazol), high dose corticosteroids, glucagon (high dose 50mg+ over 2 days), flutamide, levothyroxine, propylthiouracil Do NOT use azapropazone and phenylbutazone alcohol (acute), allopurinol*, disulfiram, gemcitabine, fluorouracil, interferon, sulfinpyrazone, tamoxifen, zafirlukast* boldo, carnitine, cranberry juice*, devils claw, danshen, dong quai, fenugreek, fish oils, garlic, ginger, ginko biloba, glucosamine (+/- chondroitin), lycium*, mango, melilot, papain, PC-SPES, quilinggao, topical methylsalicylate, sweet woodruff, tonka Common drugs that decrease the INR Miscellaneous Herbal preparation etc Binding agents Warfarin antagonist $ $ $ Alcohol (chronic), azathioprine, barbiturates , bosentan , $ $ carbamazepine , griseofulvin , mercaptopurine, mesalmine, $ $ nevirapine , OCP/HRT, raloxifene, ribavarin, rifampicin (most potent inducer), trazadone $ avocado, co-enzyme Q10, green tea, natto, St Johns wort colestyramine, sucralfate vitamin K Antiplatelet drugs can increase the bleeding risk and should be used only if the benefit outweighs the bleeding risk Ginseng, phenytoin and quinidine can raise or lower INR N.B This list is not exhaustive Warfarin interactions H+T v7 Aug 2016 Review Aug 2018