Caution should be exercised when botanical medicines (botanicals) are taken concomitantly with warfarin sodium tablets. Few adequate, well-controlled studies exist evaluating the potential for metabolic and/or pharmacologic interactions between botanicals and warfarin sodium tablets. Due to a lack of manufacturing standardization with botanical medicinal preparations, the amount of active ingredients may vary. This could further confound the ability to assess potential interactions and effects on anticoagulation. It is good practice to monitor the patient’s response with additional PT/INR determinations when initiating or discontinuing botanicals.
Specific botanicals reported to affect warfarin sodium tablets therapy include the following:
- Bromelains, danshen, dong quai (Angelica sinensis), garlic, Ginkgo biloba, ginseng, and cranberry products are associated most often with an INCREASE in the effects of warfarin sodium tablets.
- Coenzyme Q10 (ubidecarenone) and St. John’s wort are associated most often with a DECREASE in the effects of warfarin sodium tablets.
Some botanicals may cause bleeding events when taken alone (e.g., garlic and Ginkgo biloba) and may have anticoagulant, antiplatelet and/or fibrinolytic properties. These effects would be expected to be additive to the anticoagulant effects of warfarin sodium tablets. Conversely, other botanicals may have coagulant properties when taken alone or may decrease the effects of warfarin sodium tablets.
Some botanicals that may affect coagulation are listed below for reference; however, this list should not be considered all-inclusive. Many botanicals have several common names and scientific names. The most widely recognized common botanical names are listed.
Botanicals that contain coumarins with potential anticoagulant effects:
|Angelica (Dong Quai)||(German and Roman)||Prickly Ash (Northern)|
|Asa Foetida||Horse Chestnut||Sweet Clover|
|Bogbean ‡||Horseradish||Sweet Woodruff|
|Boldo||Licorice †||Tonka Beans|
|Buchu||Meadowsweet ‡||Wild Carrot|
|Capsicum §||Nettle||Wild Lettuce|
Miscellaneous botanicals with anticoagulant properties:
Bladder Wrack (Fucus)
Botanicals that contain salicylate and/or have antiplatelet properties:
|Agrimony *||Dandelion †||Meadowsweet ‡|
|Aloe Gel||Feverfew||Onion ¶|
|Black Cohosh||German Sarsaparilla||Poplar|
|Bogbean ‡||Ginkgo Biloba||Tamarind|
|Cassia †|| |
Botanicals with fibrinolytic properties:
|Bromelains||Garlic ¶||Inositol Nicotinate|
|Capsicum §||Ginseng||Onion ¶|
Botanicals with coagulant properties:
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