Possible Warfarin Interaction with Menthol Cough Drops

2005 ◽  
Vol 39 (2) ◽  
pp. 365-367 ◽  
Author(s):  
Paul J Kassebaum ◽  
Don L Shaw ◽  
Dave J Tomich
Keyword(s):  
Warfarin Therapy ◽  
Causality Assessment ◽  
White Male ◽  
Warfarin Dose ◽  
International Normalized Ratio ◽  
Warfarin Interaction ◽  
Case Summary ◽  
First Case ◽  
Patient Reported

OBJECTIVE: To report a case of possible interaction of menthol cough drops (Halls) with warfarin in a patient awaiting cardioversion. CASE SUMMARY: A 57-year-old white male awaiting cardioversion for atrial fibrillation was prescribed warfarin. His dosage was adjusted to 7 mg daily to provide stable international normalized ratio (INR) values of 2.28–2.68. Approximately one week later, his INR fell to 1.45. During a follow-up interview, the patient reported that he experienced a flu-like illness during the previous week and had been using menthol cough drops. No other potential causes for the decreased INR were found. Illness will most often elevate the INR; we therefore concluded that the cough drops were the likely cause of this reaction, and the warfarin dose was increased to 53 mg/wk. After discontinuing use of menthol cough drops, the warfarin dose was returned to the previous amount and the INR remained stabilized. DISCUSSION: An objective causality assessment suggests that the decreased INR was possibly related to the use of menthol cough drops during warfarin therapy. The active ingredient in these cough drops is menthol. Menthol has been shown to affect the pharmacokinetics of other drugs by inducing or inhibiting cytochrome P450 isoenzymes and slowing drug absorption. It is not clear whether these mechanisms played a role in this case. As of January 5, 2005 this is the first case report documenting an interaction between warfarin and cough drops containing menthol. CONCLUSIONS: This case documents a significant decrease in the INR following the use of menthol cough drops. Patients who are ill have several factors that can potentially affect their INR and should be monitored closely.

Levofloxacin and Warfarin Interaction

2002 ◽  
Vol 36 (10) ◽  
pp. 1554-1557 ◽  
Author(s):  
Cade B Jones ◽  
Susan E Fugate
Keyword(s):  
Binding Sites ◽  
Warfarin Therapy ◽  
Case Reports ◽  
Anticoagulation Therapy ◽  
Warfarin Dose ◽  
International Normalized Ratio ◽  
Minor Bleeding ◽  
Protein Binding Sites ◽  
Case Summary

OBJECTIVE: To report 4 cases of hypoprothrombotic response resulting from addition of levofloxacin therapy to chronic warfarin therapy and to review related literature to support or refute a warfarin—levofloxacin interaction. CASE SUMMARY: Four patients, 34–81 years old, were prescribed levofloxacin concomitantly with stable warfarin therapy. Three patients had a target international normalized ratio (INR) range of 2.0–3.0 and experienced an increase in INR to 3.5, 8.12, and 11.5 on days 11, 5, and 4 of a 10-day course of levofloxacin, respectively. The fourth patient experienced minor bleeding, with a slightly elevated INR on the second day of levofloxacin therapy that required up to a 19% warfarin dose reduction during levofloxacin treatment. DISCUSSION: An initial premarketing clinical trial concluded that levofloxacin had no effect on warfarin's pharmacokinetics and pharmacodynamic response. Two case reports have since documented an increase in INR in patients taking long-term warfarin on completion of levofloxacin therapy. Our case reports provide further evidence of a significant increase in INR observed during concomitant levofloxacin therapy. The proposed mechanism of this interaction is displacement of warfarin from protein binding sites, reduction in gut flora producing vitamin K, and decreased warfarin metabolism. CONCLUSIONS: Prolonged prothrombin response in patients undergoing chronic warfarin therapy has been well documented with many antibiotics, including fluoroquinolones. Recognition of newer antibiotics' effects on warfarin therapy is important to guide safe use and monitoring of anticoagulation therapy. Our case studies demonstrate significant elevations in INR values during and up to 1 day after levofloxacin therapy in patients undergoing stable warfarin therapy.

scholarly journals Acute upper airway obstruction as a life-threatening complication of ventral bulla osteotomy: report of two consecutive cases

2021 ◽  
Vol 7 (1) ◽  
pp. 205511692110059
Author(s):  
Michal Vlasin ◽  
Richard Artingstall ◽  
Barbora Mala
Keyword(s):  
Airway Obstruction ◽  
Clinical Signs ◽  
Upper Airway ◽  
Upper Airway Obstruction ◽  
Single Session ◽  
Inflammatory Polyp ◽  
Case Summary ◽  
First Case ◽  
Life Threatening

Case summary This paper presents two cases of acute postoperative upper airway obstruction following ventral bulla osteotomy (VBO) in cats. The first cat underwent a unilateral left-sided VBO for a suspected inflammatory polyp. The second cat underwent a single-session bilateral VBO procedure for bilateral otitis media. In the first case, immediate re-intubation and a gradual lightening of the anaesthetic plane resolved the clinical signs; in the second case, the patient deteriorated and went into acute cardiorespiratory arrest and received cardiopulmonary resuscitation. Both patients recovered well and were discharged home 3 days after surgery. Both cases were reported to show no further clinical signs on postoperative follow-up 3 weeks and 4 months after surgery, respectively. Relevance and novel information Upper airway obstruction should be regarded as a potential complication of VBO in cats.

scholarly journals Impact of CYP2C9 and VKORC1 Polymorphisms on Warfarin Sensitivity and Responsiveness in Jordanian Cardiovascular Patients during the Initiation Therapy

Genes ◽  
2018 ◽  
Vol 9 (12) ◽  
pp. 578 ◽  
Author(s):  
Laith AL-Eitan ◽  
Ayah Almasri ◽  
Rame Khasawneh
Keyword(s):  
Warfarin Therapy ◽  
Catalytic Properties ◽  
Warfarin Dose ◽  
International Normalized Ratio ◽  
Nucleotide Polymorphisms ◽  
Single Nucleotide ◽  
Haplotype Blocks ◽  
Cardiovascular Patients ◽  
Cyp2c9 Gene ◽  
Vkorc1 Gene

Warfarin is an oral anticoagulant frequently used in the treatment of different cardiovascular diseases. Genetic polymorphisms in the CYP2C9 and VKORC1 genes have produced variants with altered catalytic properties. A total of 212 cardiovascular patients were genotyped for 17 Single Nucleotide Polymorphisms (SNPs) within the CYP2C9 and VKORC1 genes. This study confirmed a genetic association of the CYP2C9*3 and VKORC1 rs10871454, rs8050894, rs9934438, and rs17708472 SNPs with warfarin sensitivity. This study also found an association between CYP2C9 and VKORC1 genetic haplotype blocks and warfarin sensitivity. The initial warfarin dose was significantly related to the CYP2C9*3 polymorphism and the four VKORC1 SNPs (p < 0.001). There were significant associations between rs4086116 SNP and TAT haplotype within CYP2C9 gene and rs17708472 SNP and CCGG haplotype within VKORC1 gene and warfarin responsiveness. However, possessing a VKORC1 variant allele was found to affect the international normalized ratio (INR) outcomes during initiation of warfarin therapy. In contrast, there was a loose association between the CYP2C9 variant and INR measurements. These findings can enhance the current understanding of the great variability in response to warfarin treatment in Arabs.

Patient Factors That Influence Warfarin Dose Response

2010 ◽  
Vol 23 (3) ◽  
pp. 194-204 ◽  
Author(s):  
Pamela J. White
Keyword(s):  
Dose Response ◽  
Warfarin Therapy ◽  
Anticoagulation Therapy ◽  
Warfarin Dose ◽  
Therapeutic Index ◽  
International Normalized Ratio ◽  
Patient Factors ◽  
Disease States ◽  
Treatment And Prevention ◽  
Number Of Factors

Warfarin has long been the mainstay of oral anticoagulation therapy for the treatment and prevention of venous and arterial thrombosis. The narrow therapeutic index of warfarin, and the complex number of factors that influence international normalized ratio (INR) response, makes optimization of warfarin therapy challenging. Determination of the appropriate warfarin dose during initiation and maintenance therapy requires an understanding of patient factors that influence dose response: age, body weight, nutritional status, acute and chronic disease states, and changes in concomitant drug therapy and diet. This review will examine specific clinical factors that can affect the pharmacokinetics and pharmacodynamics of warfarin, as well as the role of pharmacogenetics in optimizing warfarin therapy.

Effect of Stress on International Normalized Ratio during Warfarin Therapy

2002 ◽  
Vol 36 (4) ◽  
pp. 617-620 ◽  
Author(s):  
Toni L Hawk ◽  
Dawn E Havrda
Keyword(s):  
Physical Activity ◽  
Drug Interactions ◽  
Patient Compliance ◽  
Warfarin Therapy ◽  
International Normalized Ratio ◽  
Anticoagulation Clinic ◽  
Stressful Events ◽  
Stressful Event ◽  
Dietary Changes ◽  
Case Summary

OBJECTIVE: To discuss the effect of stress on the international normalized ratio (INR) when patients are taking warfarin. CASE SUMMARY: Two patients at a pharmacist-managed anticoagulation clinic who were stable with anticoagulation developed elevated INR values after a stressful event occurred. All other factors known to elevate the INR were unchanged; furthermore, the INR values returned to the prior level of control after resolution of the stressful events. DISCUSSION: Management of anticoagulation with warfarin requires the knowledge of factors that may alter an INR. Many of these factors, such as dietary changes, illnesses, drug interactions, patient compliance, and physical activity, have been described. In spite of this understanding, many patients continue to experience variability in their INR values, suggesting there are other factors that can alter the INR that have not been fully described. The cases presented here demonstrate that stressful events, physical or psychological, can elevate the INR. The mechanism for this occurrence is unknown, but may be related to decreased metabolism of warfarin during stress. CONCLUSIONS: When an unexplained INR value exists, a stressor should be evaluated as a potential cause.

Capecitabine–Warfarin Interaction

2005 ◽  
Vol 39 (9) ◽  
pp. 1546-1551 ◽  
Author(s):  
Laurel M Janney ◽  
Nancee V Waterbury
Keyword(s):  
Warfarin Therapy ◽  
Case Reports ◽  
Package Insert ◽  
Warfarin Dose ◽  
Stage Iv ◽  
Warfarin Interaction ◽  
Weekly Dose ◽  
Close Monitoring ◽  
Metastatic Colon Cancer ◽  
Pharmacodynamic Interaction

OBJECTIVE: To report a case of concomitant warfarin therapy with consecutive cycles of capecitabine therapy, providing time of onset, magnitude, and assessment of the interaction. CASE SUMMARY: A 59-year-old man receiving chronic warfarin therapy for a mechanical mitral valve replacement was diagnosed with stage IV metastatic colon cancer. He was started on capecitabine/irinotecan after his cancer progressed with fluorouracil/leucovorin and the FOLFOX 6 regimen (oxaliplatin, leucovorin, and continuous fluorouracil infusion). He received 3 consecutive cycles of capecitabine/irinotecan with concomitant oral anticoagulation and, with each cycle, the warfarin dose was reduced. Over the course of these 3 cycles, the total weekly dose of warfarin was reduced by >85%. DISCUSSION: The capecitabine–warfarin interaction is clinically significant, requiring a black box warning in the package insert. The mechanism of action for the interaction is not clear, but may be related to down-regulation of CYP2C9 by capecitabine or its metabolites or a pharmacodynamic interaction with warfarin. A common response to this interaction, as discussed in previously published case reports, is the discontinuation of warfarin, capecitabine, or both. In this case, the Naranjo probability scale indicates a highly probable drug interaction between warfarin and capecitabine. CONCLUSIONS: As more patients require anticoagulation, and as chemotherapy agents such as capecitabine become available, the likelihood for these drug interactions increases. In our patient, close monitoring of therapy allowed successful use of warfarin and capecitabine.

Probable Warfarin–Simvastatin Interaction

2007 ◽  
Vol 41 (7-8) ◽  
pp. 1292-1295 ◽  
Author(s):  
Tone Westergren ◽  
Peder Johansson ◽  
Espen Molden
Keyword(s):  
Warfarin Therapy ◽  
Interaction Mechanism ◽  
International Normalized Ratio ◽  
Lipid Lowering ◽  
White Female ◽  
Lipid Lowering Therapy ◽  
Dose Requirement ◽  
Simvastatin Treatment ◽  
Lung Embolism

Objective: To report and discuss a case of fatal cerebral hemorrhage following a switch from atorvastatin to simvastatin in a patient taking warfarin. Case Summary: An 82-year-old white female was admitted to the hospital because of an international normalized ratio (INR) value greater than 8, which was detected at a routine follow-up visit to monitor warfarin therapy. Four weeks earlier her lipid-lowering therapy had been switched from atorvastatin 10 mg daily to simvastatin 10 mg daily. She had been treated with 2.5 mg of warfarin daily for almost 30 years due to episodes of deep venous thrombosis and lung embolism. Her INR had been stable within the treatment range (2.0–3.5) for more than 2 years before the INR increase. Upon hospitalization, she was given 5 mg of vitamin K orally, A few hours later she lost the feeling and movement of her right arm and a computed tomography scan showed major bleeding in the left cerebral hemisphere. She died the following day. Discussion: One study has shown a lack of interaction between warfarin and atorvastatin. In comparison, 3 studies have shown significant increases (10–30%) in warfarin effect and/or reductions in dose requirement after starling concomitant simvastatin treatment. The interaction mechanism between simvastatin and warfarin is not known but is possibly associated with reduced elimination of warfarin. Use of the Naranjo probability scale showed that the likelihood of warfarin-induced INR increase following the switch to simvastatin was probable. Conclusions: Atorvastatin and simvastatin appear to differ in their potential to interact with warfarin. Clinicians should be aware of the interaction risk when starting simvastatin treatment in patients on warfarin therapy.

scholarly journals A novel hypokalaemic polymyopathy and subsequent unrelated nutritional thiamine deficiency in a young Burmese cat

2021 ◽  
Vol 7 (2) ◽  
pp. 205511692110419
Author(s):  
Abigail Brough ◽  
Anne-Claire Duchaussoy
Keyword(s):  
Thiamine Deficiency ◽  
Subsequent Development ◽  
Serum Biochemistry ◽  
Genetic Mutation ◽  
Response To Treatment ◽  
Clinically Normal ◽  
Potassium Supplementation ◽  
Case Summary ◽  
First Case

Case summary An 8-month-old female spayed Burmese cat was referred for investigation of reduced appetite, reluctance to walk and jump and amaurosis. On serum biochemistry there was severe hypokalaemia and marked elevation of creatine kinase, suggestive of hypokalaemic polymyopathy. The neurological signs were consistent with thiamine deficiency. The cat was negative for the periodic hypokalaemic polymyopathy (PHP) of Burmese cats, and was ultimately diagnosed with a previously undescribed potassium wasting nephropathy requiring ongoing oral potassium supplementation. The response to treatment was excellent and the cat has remained clinically normal over a 12-month follow-up period. Relevance and novel information PHP in Burmese cats has been well described, but all cases to date have been shown to be secondary to a genetic mutation in WNK4, resulting in potassium wasting into the urine. This is the first case report of another potassium wasting nephropathy in a young Burmese cat, with subsequent development of nutritional thiamine deficiency.

scholarly journals Smile — one of the important elements of face aesthetics

2019 ◽  
Vol 2 (2) ◽  
pp. 101-110
Author(s):  
Patrycja Przybylska ◽  
Tomasz Siniecki ◽  
Teresa Matthews‑Brzozowska
Keyword(s):  
Botulinum Toxin ◽  
Maximum Effect ◽  
Upper Lip ◽  
First Case ◽  
Patient Reported ◽  
Levator Labii Superioris ◽  
The Face ◽  
Gummy Smile

The harmony of the smile depends not only on the dentition, but also on the gum tissue, which excessively exposed can negatively affect aesthetics of the smile. Exposure of a small amount of gum during a smile is acceptable however a smile in which the exposure of the gum is more than 2 mm is considered an aesthetic defect called gummy smile. Among the causes of gingival smile listed are: shortened or hyperactive upper lip muscles (levator labii superioris, levator labii superioris alaeque nasi, zygomatic minor muscles), vertical maxillary excess, extrusion of alveolar ridges, altered passive eruption. In the case of hyperactive upper lip muscles, botulinum toxin can be used — this procedure was used in the described cases, and the effects were assessed using the FotoMedicus system and measurements of gingival exposure. In first case Bocouture botulinum toxin was administered on both sides, 4 units bilaterally in the levator labii superioris muscle and 2 units into levator anguli oris muscle. In total, 12 units were given. During the follow‑up the patient reported the start of the effect from the 5th day after the supply with the maximum effect after 12 days. A 6 mm correction of gummy smile was achieved. In the second case 4 units of botulinum toxin were applicated bilaterally into levator labii superioris alaeque nasi muscle. A 3 mm correction of gummy smile was achieved. The aesthetics of the face in a smile definitely improved in both men.

scholarly journals Clozapine-induced myocarditis: Two case reports and review of clinical presentation and recognition

2018 ◽  
Vol 8 (6) ◽  
pp. 303-308 ◽  
Author(s):  
Bryan K. Sackey ◽  
Troy A. Moore ◽  
Nicole L. Cupples ◽  
Cynthia A. Gutierrez
Keyword(s):  
Psychotic Disorders ◽  
Case Reports ◽  
White Male ◽  
Case Fatality ◽  
Signs And Symptoms ◽  
Primary Diagnosis ◽  
Reactive Protein ◽  
First Case ◽  
Patient Reported ◽  
Potential Risk Factors

Abstract Myocarditis is a potentially fatal cardiac disease marked by inflammation of the heart muscle. With a noted black-box warning, rates of clozapine-induced myocarditis are reportedly as high as 3%. Since the first case of clozapine-induced myocarditis was documented in 1994, more than 250 cases have been described in literature with an approximate 33% case-fatality rate. We report 2 cases of patients with primary psychotic disorders treated with clozapine, who developed signs and symptoms of myocarditis. The first was a 35-year-old white male patient with a primary diagnosis of schizoaffective disorder (bipolar type) who was initiated on clozapine after nonresponse to several therapies. On day 26, the patient was admitted to the emergency department for chest pain presenting with eosinophilia and notable elevations in several biomarkers, including troponin and C-reactive protein. The second patient was a 45-year-old black male who was initiated on clozapine for treatment-resistant schizophrenia. On day 13, the patient reported cardiac-related concerns (tachycardia) and flu-like symptoms resulting in hospitalization. Similarly, this patient demonstrated elevated biomarkers (troponin and creatine kinase). Both patients experienced resolution of symptoms after discontinuation of clozapine. Clozapine was not rechallenged for either patient. Review of literature further elucidates the relationship between clozapine and myocarditis, including potential risk factors, pathophysiology, and symptom presentation. Due to the potentially fatal nature of this condition, clinical vigilance and awareness is warranted upon initiation of clozapine through monitoring of symptoms along with cardiac and inflammatory biomarkers as indicated.

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