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Vega AJ, Smith C, Matejowsky HG, Thornhill KJ, Borne GE, Mosieri CN, Shekoohi S, Cornett EM, Kaye AD. Warfarin and Antibiotics: Drug Interactions and Clinical Considerations. Life (Basel) 2023; 13:1661. [PMID: 37629518 PMCID: PMC10455514 DOI: 10.3390/life13081661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/24/2023] [Accepted: 07/28/2023] [Indexed: 08/27/2023] Open
Abstract
Warfarin administration poses a notable challenge in clinical practice due to the increased susceptibility of patients to major bleeding, particularly when co-administered with other medications capable of modulating its metabolic pathways. Among these medications, antibiotics have been recognized as potential agents that can either induce or inhibit cytochrome P450-2C9, thereby impacting the effects of warfarin. A wealth of evidence from numerous studies consistently supports an elevated risk of serious bleeding in patients concurrently receiving antibiotics and warfarin therapy. This narrative review elucidates the intricate interactions between warfarin and various antibiotic classes. Notably, significant increases in the International Normalized Ratio (INR) were observed among warfarin-treated patients receiving penicillin derivatives, fluoroquinolones, TMP-SMX, and macrolides. Conversely, investigations have also demonstrated a reduction in INR levels in patients on warfarin when exposed to rifampin, a potent inducer of cytochrome P-450. Intriguingly, cephalosporin antibiotics and amoxicillin/clavulanate, despite not interfering with the cytochrome P450 system, exhibited a positive association with increased INR values. The findings of this narrative review underscore the importance of diligent monitoring in patients on warfarin requiring concomitant antibiotic therapy, as this surveillance strategy proves pivotal in mitigating the risk of major bleeding complications. Additionally, for patients necessitating cytochrome P450 inhibitors such as penicillin derivatives, fluoroquinolones, TMP-SMX, and macrolides, the consideration of dose reduction in warfarin therapy may confer substantial benefits in reducing the occurrence of major bleeding events. Similarly, patients who are co-administered rifampin alongside warfarin necessitate vigilant monitoring, with a potential need for escalating warfarin doses to counteract the risk of a hypercoagulable state.
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Affiliation(s)
- Alexis J. Vega
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA; (A.J.V.); (C.S.); (H.G.M.); (K.J.T.); (G.E.B.)
| | - Caitlin Smith
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA; (A.J.V.); (C.S.); (H.G.M.); (K.J.T.); (G.E.B.)
| | - Hannah Grace Matejowsky
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA; (A.J.V.); (C.S.); (H.G.M.); (K.J.T.); (G.E.B.)
| | - Katherine J. Thornhill
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA; (A.J.V.); (C.S.); (H.G.M.); (K.J.T.); (G.E.B.)
| | - Grant E. Borne
- School of Medicine, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA; (A.J.V.); (C.S.); (H.G.M.); (K.J.T.); (G.E.B.)
| | - Chizoba N. Mosieri
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA; (C.N.M.); (S.S.); (A.D.K.)
| | - Sahar Shekoohi
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA; (C.N.M.); (S.S.); (A.D.K.)
| | - Elyse M. Cornett
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA; (C.N.M.); (S.S.); (A.D.K.)
| | - Alan D. Kaye
- Department of Anesthesiology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA; (C.N.M.); (S.S.); (A.D.K.)
- Department of Pharmacology, Louisiana State University Health Sciences Center at Shreveport, 1501 Kings Highway, Shreveport, LA 71103, USA
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Sridharan K, Al Banna R, Husain A. Is there a circannual variation in the anticoagulation control of warfarin? Eur J Hosp Pharm 2023; 30:41-45. [PMID: 33903173 PMCID: PMC9811596 DOI: 10.1136/ejhpharm-2021-002793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 03/27/2021] [Accepted: 04/14/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND The literature regarding the seasonal variation in the therapeutic response to warfarin is somewhat contradictory, with several discrepancies. We assessed the influence of seasons on various pharmacodynamic indices of warfarin. METHODS A retrospective study was carried out in adults receiving warfarin for at least 6 months. Details of their demographic characteristics, duration and dose of warfarin therapy and values of prothrombin time international normalised ratio (PT-INR) were retrieved. Standard definitions were followed for defining various seasons, time in therapeutic range (TTR), log-INR variability and warfarin sensitivity index (WSI). National Institute for Health and Care Excellence (NICE) criteria were used for defining TTR into good (≥65%) and poor (<65%) anticoagulation control. RESULTS Two hundred and four patients were recruited. Only a subtle statistically significant difference was observed between the numbers of patients in the various PT-INR categories. However, no significant intra-individual differences were observed in mean TTR. Similarly, the proportion of patients with poor anticoagulation control, high INR variability and high WSI was not significantly different between summer, transition period 1, winter and transition period 2. CONCLUSION No clinically significant seasonal variations were observed in the therapeutic response to warfarin.
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Affiliation(s)
- Kannan Sridharan
- Department of Pharmacology & Therapeutics, College of Medicine & Medical Sciences, Arabian Gulf University, Manama, Kingdom of Bahrain
| | - Rashed Al Banna
- Department of Cardiology, Salmaniya Medical Complex, Ministry of Health, Manama, Kingdom of Bahrain
| | - Aysha Husain
- Department of Cardiology, Salmaniya Medical Complex, Ministry of Health, Manama, Kingdom of Bahrain
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Irwin MN, Adie S, Sandison K, Alsomairy SA, Brancaccio A. Warfarin Dose Requirements in Adults Hospitalized With COVID-19 Infection: A Retrospective Case Series. J Pharm Pract 2021; 35:654-660. [PMID: 33719699 DOI: 10.1177/08971900211000705] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
PURPOSE To describe the impact of hospitalization with COVID-19 infection on warfarin dose requirements in adult inpatients. SUMMARY A retrospective chart review of 8 adults on warfarin admitted to Michigan Medicine with COVID-19 infection was conducted and reported as a case series. Outcomes of interest were difference in average daily dose of warfarin prior to admission (PTA) and while inpatient (IP), warfarin sensitivity, time in therapeutic range (TTR), confirmed or suspected thromboembolic event, any major or clinically significant bleeding episodes, and in-hospital mortality. IP average daily warfarin doses were lower when compared to PTA average daily doses [1.3 mg (1.3) vs. 6.2 mg (4.1)]. The mean percentage decrease in dose was 68.8% (23) and the mean absolute dose difference was 4.8 mg (4.3). Mean IP percentage tests in range was 30.8% (24.6) and mean IP warfarin sensitivity was 4.2 (3.8), both of which differed from PTA TTR and warfarin sensitivity for those with data available (n = 3, n = 6, respectively). One patient was treated for suspected acute pulmonary embolism while on warfarin and one patient experienced clinically relevant bleeding. In-hospital mortality was zero, mean length of stay (LOS) was 17 days (14.4), and mean intensive care unit (ICU) LOS for the 3 patients requiring ICU level care was 14.3 days (4.5). CONCLUSION Decreased warfarin dose requirements were evident in this group of adults hospitalized with COVID-19 infection. These findings suggest lower doses of warfarin may be needed to achieve therapeutic anticoagulation while inpatient.
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Affiliation(s)
- Madison N Irwin
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA.,University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Sarah Adie
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA.,University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Katherine Sandison
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA.,University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | | | - Adamo Brancaccio
- Department of Pharmacy, Michigan Medicine, Ann Arbor, MI, USA.,University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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Zou S, Wu L, Chen Z, Li X, Chen H, Tan X, Yu M. Effect of ABO Blood Groups on the Response to Warfarin. Am J Med Sci 2020; 360:50-54. [PMID: 32620221 DOI: 10.1016/j.amjms.2020.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 02/24/2020] [Accepted: 03/30/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Numerous studies have demonstrated that patients with non-O blood groups have a higher risk for venous thromboembolism than those with the O blood group. However, the effect of ABO blood groups on warfarin dose requirements in patients receiving anticoagulation in the Chinese Han population remains unknown. This study aimed to investigate the influence of ABO blood groups on warfarin dose requirements in a Chinese Han population. MATERIAL AND METHODS A retrospective study was conducted in the First Affiliated Hospital of Shantou University Medical College in South China. Three hundred and fifty-eight patients with a confirmed diagnosis of deep vein thrombosis or atrial fibrillation were included. The frequency of blood groups and warfarin dose requirements were determined. RESULTS Of 358 patients with deep vein thrombosis or atrial fibrillation, 111 patients had blood group A (31.01%), 104 patients had blood group B (29.05%), 20 patients had blood group AB (5.59%) and 123 patients had blood group O (34.36%). The patients in the O blood group had lower warfarin dose requirements than those in the A, B and AB blood groups. CONCLUSIONS Our study showed that patients with non-O blood groups require higher doses of warfarin.
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Affiliation(s)
- Shan Zou
- Department of Cardiology, the First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Lishan Wu
- Department of Cardiology, the First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Zeliang Chen
- Department of Cardiology, the First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Xiaohong Li
- Department of Cardiology, the First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Hongjuan Chen
- Department of Cardiology, the First Affiliated Hospital of Henan University of Science and Technology, Henan, China
| | - Xuerui Tan
- Department of Cardiology, the First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China
| | - Min Yu
- Department of Cardiology, the First Affiliated Hospital, Shantou University Medical College, Shantou, Guangdong, China.
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Sudas Na Ayutthaya N, Sakunrak I, Dhippayom T. Clinical Outcomes of Telemonitoring for Patients on Warfarin after Discharge from Hospital. Int J Telemed Appl 2018; 2018:7503421. [PMID: 30158972 PMCID: PMC6109538 DOI: 10.1155/2018/7503421] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 07/13/2018] [Accepted: 07/26/2018] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To evaluate the impact of telephone follow-up service on clinical outcomes in patients on warfarin when discharged from hospital. METHODS This randomized controlled trial was conducted at a general hospital in Thailand. Patients aged ≥20 years who were prescribed warfarin when discharged were eligible to participate in this study. They were randomly allocated, using a computer generated random number, to receive either telephone follow-up intervention or usual care. Participants in the intervention group received telephone follow-up by hospital pharmacists for three months. During each telephone call, pharmacists performed medicine use reviews and addressed any problems identified. KEY FINDINGS A total of 50 patients participated in this study. The proportion of international normalized ratio (INR) values in the target range for the telephone follow-up group (36/79, 45.6%) was higher than that in the usual care group (19/79, 24.1%), p=0.005. The mean time in the therapeutic range (TTR) in the telephone follow-up group was also higher than that in the usual care group (49.8±34.3 versus 28.0±27.5, p=0.017). All patients in the usual care group experienced one or more out-of-range INR values (25/25, 100%) compared to 21 out of 25 (84%) in the telephone follow-up group, p=0.037. There was no difference between the two groups in the incidence of complications or adverse events associated with warfarin. CONCLUSIONS The telephone follow-up service in recently discharged patients helps them achieve and maintain their INR target. This anticoagulant supportive service should be promoted to patients receiving warfarin therapy after discharge. This trial is registered with TCTR20180614006 (Thai Clinical Trials Registry).
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Affiliation(s)
- Natthaporn Sudas Na Ayutthaya
- Department of Pharmacy, Kamphaeng Phet Hospital, Mueang Kamphaeng Phet, Thailand
- Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Itsarawan Sakunrak
- Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
| | - Teerapon Dhippayom
- Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
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Abdel-Aziz MI, Ali MAS, Hassan AKM, Elfaham TH. Warfarin-drug interactions: An emphasis on influence of polypharmacy and high doses of amoxicillin/clavulanate. J Clin Pharmacol 2015; 56:39-46. [PMID: 26138877 DOI: 10.1002/jcph.583] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 06/29/2015] [Indexed: 11/06/2022]
Abstract
The objective of this study was to investigate the effect of polypharmacy and high doses of amoxicillin/clavulanate on warfarin response in hospitalized patients. This was a prospective cross-sectional observational study on 120 patients from July 2013 to January 2014. Potentially interacting drugs were classified according to their tendency of increasing international normalized ratio (INR) or bleeding risk. The 87.5% of patients prescribed high-dose amoxicillin/clavulanate (10-12 g daily) compared with 28.9% of patients prescribed a normal dose (up to 3.6 g daily) had INR values ≥ 4 during the hospital stay (P ≤ .001). Increased number of potentially interacting drugs that are known to increase INR was a significant predictor of having INR values ≥ 4 (OR, 2.5; 95%CI, 1.3-4.7), and increased number of potentially interacting drugs that are known to increase bleeding risk was a significant predictor of experiencing bleeding episodes (OR, 3.1; 95%CI, 1.3-7.3). High doses of amoxicillin/clavulanate were associated with a higher risk of over-anticoagulation when combined with warfarin than were normal doses. Increased risk of having INR ≥ 4 and bleeding events was associated with increased numbers of potentially interacting drugs prescribed, indicating that polypharmacy is a problem of concern. Frequent monitoring of warfarin therapy along with patients' medications is necessary to avoid complications.
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Affiliation(s)
- Mahmoud I Abdel-Aziz
- Department of Clinical Pharmacy, Faculty of Pharmacy, Assiut University, Assiut, Egypt
| | - Mostafa A Sayed Ali
- Department of Clinical Pharmacy, Faculty of Pharmacy, Assiut University, Assiut, Egypt
| | - Ayman K M Hassan
- Department of Cardiovascular Medicine, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Tahani H Elfaham
- Department of Pharmaceutics, Faculty of Pharmacy, Assiut University, Assiut, Egypt
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