Drugs to watch with WARFARIN

This guide is intended as a quick reference to highlight significant interactions between warfarin and commonly prescribed medicines. It is not intended to be exhaustive or give detailed information. Prescribers should refer to the SPCC or the BNF for further information. The guide also provides information on Herbal interactions with warfarin. NOTE: Use the medicines generic name when using the following lists.

Drugs which Increase Anticoagulant Effects of Warfarin

Interacting drug Alcohol Amiodarone Aspirin Additional Comment Fluctuations in prothrombin time in heavy drinkers or those with liver disease Slow onset may persist long after amiodarone is stopped. Monitor closely Avoid Aspirin as analgesic, use paracetamol as safer alternative. Low dose aspirin 75 100mg appears not to interact to any significant clinical extent. Significant avoid concomitant use Reduce warfarin dose by one third to a half initially and adjust accordingly. monitor closely Cefalexin, Cefradine, cefuroxime are safer alternatives Cefalexin, Cefradine, cefuroxime are safer alternatives Rare cases of increased INR and bleeding monitor if concurrent use Unpredictable but common interaction either monitor closely or use alternative H2 antagonist Reduce warfarin dose by one third to a half initially and adjust accordingly. monitor closely Rare but unpredictable monitor Serious interaction but unpredictable and uncommon use azithromycin as alternative Increase risk of bleeding due to antiplatelet effect (Manufacturer advises avoid concomitant use) Enhance or reduce effect of warfarin monitor closely Prolonged regular use Reduce warfarin dose and monitor INR closely Use half the dose of danazol initially. Effects on INR seem usually within 2 3 days monitor closely Rare but unpredictable monitor closely Unpredictable monitor Unpredictable monitor Increase risk of mild bleeding due to antiplatelet effect Serious but unpredictable. Elderly at greater risk. Monitor closely Monitor INR if adding or stopping esomeprazole Reduce warfarin dose by one third to a half initially and adjust accordingly. monitor closely Monitor closely and reduce warfarin dose if necessary Unpredictable monitor Monitor closely and reduce warfarin dose if necessary
May 2004

Azapropazone Bezafibrate Cefamandole Cefaclor Celecoxib Cimetidine Ciprofibrate Ciprofloxacin Clarithromycin Clopidogrel Colestyramine Co-Proxamol Co-Trimoxazole Danazol Dextropropoxyphene Diclofenac Diflunisal Dipyridamole Erythromycin Esomeprazole Fenofibrate Fluconazole Flurbiprofen Flutamide
NHSSB Prescribing Support Team

Interacting drug Gemfibrozil Itraconazole Ketoconazole Mefenamic acid Metronidazole Miconazole Ofloxacin Omeprazole

Paracetamol

Phenytoin Piroxicam Propafenone Rosuvastatin Simvastatin

Additional Comment Reduce warfarin dose by one third to a half initially and adjust accordingly. monitor closely Isolated reports but clinically significant monitor closely Monitor closely especially in the elderly A small reduction in warfarin may be needed Avoid where possible. Warfarin dose may need to be reduced by up to half and monitor closely Avoid - Potentially serious interaction. Use nystatin where possible Rare but unpredictable monitor Usually small but not clinically significant change in INR. However occasionally clinically significant interactions occur use lansoprazole as alternative Intermittent analgesic use unlikely to affect INR (less than 2.5g /week) Prolonged regular use of high doses have been found to increase the INR May reduce or enhance anticoagulant effects Monitor and reduce warfarin dose if necessary Monitor and reduce warfarin dose if necessary Generally small clinically irrelevant increase in anticoagulant effects. Monitor initially or after any dose increases in simvastatin Uncommon but unpredictable monitor or select ibuprofen or naproxen as alternative Monitor and reduce warfarin dose as necessary. (may require dose reduction of up to half ) Monitor and adjust warfarin dose if necessary No clinically relevant interaction

Sulindac Tamoxifen Thyroid Hormones Valproate

Drugs which Reduce Anticoagulant Effects of Warfarin

Interacting Drug Azathioprine Carbamazepine Colestyramine Oral contraceptives Phenobarbitone Phenytoin Rifabutin Comments Monitor as warfarin dose may need to be increased Dose of warfarin may need to be increased monitor closely. Alternatively no interaction with oxcarbazepine Enhance or reduce effect of warfarin monitor closely and adjust warfarin dose accordingly Generally avoid in thromboembolic disorders May require 30 60% increase in warfarin dose. Persists for up to 6 weeks on stopping phenobarbitone. Monitor May reduce or enhance anticoagulant effects monitor Monitor closely. Reduces anticoagulant effects within 5 7 days. Warfarin dose may need to be doubled or trebled and reduced on stopping Rifampicin/ Rifabutin Monitor closely. Reduces anticoagulant effects within 5 7 days. Warfarin dose may need to be doubled or trebled and reduced on stopping Rifampicin/ Rifabutin If patients are warfarin resistant it may be worth considering this interaction. Vitamin K may be present in enteral feeds, health foods, food supplements, green tea.
May 2004

Rifampicin

Vitamin K

NHSSB Prescribing Support Team

Drugs to watch with WARFARIN

Potential interactions between Warfarin and some commonly used Herbal Medicines
Note: There is relatively little information in the literature on drug interactions between warfarin and herbal medicines. However, there is increasing evidence to suggest that interactions do occur. In general, patients taking warfarin, which has a narrow therapeutic index, should avoid using herbal products unless advised to do so by their doctor and only with appropriate monitoring. Product Coenzyme Q10 Boldo / Fenugreek Dong Quai Potential interaction Reduces anticoagulant effect as structurally similar to vitamin K Modest increase in INR monitor and adjust if necessary. Increased risk of bleeding due to inhibition of COX and platelet aggregation Increased risk of bleeding due to inhibition of platelet aggregation Comment

Reports of marked increases in INR with concurrent use Do not take garlic supplements. Regular ingestion of foods containing small amounts of garlic should not pose a problem. Isolated reports only

Garlic

Gingko Biloba

Ginger Ginseng Glucosamine / Chondroitin St Johns Wort

Increased risk of bleeding due to inhibition of platelet aggregation and warfarin metabolism No reports of interactions in the literature Increased risk of bleeding due to inhibition of platelet aggregation Chondroitin has anticoagulant activity and should be avoided in patients taking warfarin Reduces anticoagulant effect of warfarin due to induction of hepatic enzymes and consequent increase in metabolism

MCA advice for management of patients already taking St Johns wort (SJW) check INR and stop SJW. Monitor INR closely as it may increase on stopping SJW. The dose of warfarin may need to be adjusted.

NHSSB Prescribing Support Team

May 2004