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AGENT NAME HERBAL SUPPLEMENTS Cinchona° Coenzyme Q-10 Danshen° Devil’s Claw° Dong Quai Echinacea° Feverfew Flaxseed° Garlic Ginger Ginkgo Ginseng Ipriflavone St John’s Wort Vitamin E IMPACT OF INTERACTION Decreases anticoagulant effect Increases risk of excessive bleeding Increases level of medication in the blood Increases effects with potential for bleeding Increases risk of excessive bleeding Increases level of medication in the blood Increases risk of excessive bleeding Reduces absorption Increases risk of excessive bleeding Increases risk of excessive bleeding Increases risk of excessive bleeding Increases risk of bleeding problems Increases level of medication in the blood Alters level of medication in the blood Helps prevent clotting MECHANISM OF ACTION LEVEL OF DOCUMENTATION LEVEL OF RISK Low ____ Blood thinning agent ____ ____ Affects metabolism Low ____ Unknown Low ____ Blood thinning agent ____ ____ Affects metabolism Low ____ Blood thinning agent ____ ____ Affects level of Warfarin in the bloodstream Blood thinning agent Low ____ ____ ____ Blood thinning agent ____ ____ Blood thinning agent ____ ____ ____ ____ ____ Affects metabolism ____ ____ Affects metabolism ____ ____ Prevents platelet sticking Low Troublesome AGENT NAME FOODS / BEVERAGES Alcohol Foods rich in Vitamin K1 Cranberry juice OTC MEDICATIONS Some NSAIDS2 Aspirin PRESCRIPTION MEDICATIONS Rx NSAIDS3 Sulfa Drugs4 1 IMPACT OF INTERACTION MECHANISM OF ACTION LEVEL OF DOCUMENTATION LEVEL OF RISK Decreases anticoagulant effect Decreases anticoagulant effect Increases risk of excessive bleeding Not clearly understood Low Agent in body’s natural clotting process Not clearly understood Low Dangerous (assumes chronic use) Dangerous Low Dangerous Increases risk of gastrointestinal bleeding Increases risk of excessive bleeding NSAIDS increase GI irritation and impair clot formation Blood thinning agent High Life Threatening High Life Threatening Increases risk of gastrointestinal bleeding Increases effects with potential for bleeding NSAIDS increase GI irritation and impair clot formation Unknown, but may be linked to decreased vitamin k production High Life Threatening High Life Threatening Includes foods such as green leafy vegetables, green tea, liver, and egg yolks. Includes Aleve, Ibuprofen, and Motrin. 3 Includes Anaprox, Anaprox DS, Ansaid, Arthrotec, Cataflam, Clinoril, Daypro, Diclofenac, Diflunisal, Dolobid, Etodolac, Feldene, Flurbiprofen, Indocin, Indocin SR, Indomethacin, Keteprofen, Ketorolac, Lodine, Lodine XL, Mefenamic acid, Meloxican, Mobic, Nabumetone, Naprelan, Naprosyn, Naproxen, Orudis, Oruvail, Oxaprozin, Piroxicam, Ponsel, Relafen, Sulindac, Tolectin, Tolectin DS, Tolmetin, Toradol, Voltaren, Voltaren XR. 4 Includes Bactrim DS, Bactrim SS, Cotrim DS, Cotrim SS, Erythromycin/sulfisoxazole, Gantanol, Gantrisin, Pediazole, Septra DS, Sulfatrim, Sulfamethizole, Sulfamethoxazole, sulfisoxazole, Thiosulfil Forte, trimethoprim/sulfamethoxazole. 2 AGENT NAME IMPACT OF INTERACTION MECHANISM OF ACTION LEVEL OF DOCUMENTATION LEVEL OF RISK Macrolides5 Increases effects with potential for bleeding High Life Threatening Quinolones6 Increases effects with potential for bleeding High Life Threatening Phenytoin7 Increases effects Inhibits metabolism. May be linked to decreased vitamin k production Unknown, but may be linked to decreased vitamin k production Unknown, but may relate to genetic metabolism disposition Interferes with liver enzymes that process warfarin Increases blood level of warfarin Increases body sensitivity to warfarin Increases blood level of warfarin Low Dangerous High Life Threatening Low (rare) High Life Threatening High Life Threatening High Dangerous Barbiturates8 Tamoxifen Danazol Amiodarone Anabolic Steroids9 5 Decreases effects with potential for dangerous blood clot formation Increases effects with potential for bleeding Increases effects with potential for bleeding Increases effects with potential for bleeding Increases effects with potential for bleeding Life Threatening Includes Azythromycin, Biaxin, Clarithromycin, Dynabac, Dirithromycin, E-Mycin, Erythromycin base, EES, Erythromycin ethyl succinate, Ery-Tab, Eryc, EryPed, Erythrocin, Erythromycin stearate, llosone, erythromycin estolate, Pediazole, erythromycin/sulfisoxazole, Tao, Troleandomycin, Zithromax. 6 Alatrofloxacin, Avelox, Cipro, Ciprofloxacin, Enoxacin, Floxin, Gatifloxacin, Levaquin, Levofloxacin, Lomefloxacin, Maxaquin, Moxifloxacin, Noroxin, Norfloxacin, Ofloxacin, Penetrex, Sparfloxacin, Tequin, Trovafloxacin, Trovan, Trovan IV, Zagam. 7 Includes Dilantin. 8 Includes aprobarbitol, amobarbital, butabarbital, talbutal, mephobarbital, pentobarbital, secobarbital, Phenobarbital 9 Includes oxymetholone, fluoxymesterone, methyltestosterone, stanozolol AGENT NAME IMPACT OF INTERACTION Antidepressants10 Increases effects with potential for bleeding Increases effects with potential for bleeding Antifungals11 Mevacor MECHANISM OF ACTION Inhibits liver enzymes that process warfarin when administered systemically LEVEL OF DOCUMENTATION LEVEL OF RISK Troublesome Dangerous High Dangerous Increases effects with Low potential for bleeding Quinidine Increases effects with High potential for bleeding Carbamazepine Decreases effects with Reduces circulating Low potential for dangerous levels of warfarin blood clot formation Cholesterol Decreases effects with Reduces absorption High 12 Drugs potential for dangerous blood clot formation Thyroid Increases effects with Increases prothrombin High Hormones13 potential for bleeding time Rifampin Speeds body’s Reduces circulating High elimination and levels of warfarin decreases effects °Indicates that, thus far, our research has identified only one source of information to verify this interaction. 10 Includes paroxetine, fluoxetine, sertraline Includes fluconazole and miconazole 12 Includes colestipol and cholestyramine 13 Includes dessicated thyroid, liothyronine, levothyroxine 11 Dangerous Dangerous Troublesome Troublesome Troublesome Troublesome Source List 1. Graedon J, Graedon T “Deadly Drug Interactions: The People’s Pharmacy Guide” St. Martin’s Griffin, 1995 2. MayoClinic.com Complementary and Alternative Medicine Center “Herb and Drug Interactions: ‘Natural’ Products Not Always Safe” December 31, 2003 3. MayoClinic.com Drug Search – Drug information provided by Micromedex Anticoagulants (systemic) May 18, 1999 4. Drug Digest Drug interactions search engine – Drug information provided by Express Scripts No date information provided 5. Stenton SB, Bungard TJ, Ackman ML “Interactions between Warfarin and Herbal Products, Minerals, and Vitamins: A Pharmacist’s Guide” Can J Hosp Pharm 2001; 54:186-92