International Journal of Cardiology 119 (2007) 107 – 108
www.elsevier.com/locate/ijcard
Letter to the Editor
Warfarin interaction with herbal drugs and food
Tsung O. Cheng
George Washington University, Washington, D.C., USA
Received 7 June 2006; accepted 7 June 2006
Available online 4 October 2006
Keywords: Warfarin; Danshen; Ginseng; Soy milk; Green tea
To the Editor,
The recent article by Feldstein et al. [1], using a strong
and quasi‐experimental design in ambulatory care, empha-
sized that warfarin medication interaction alerts only
modestly reduced the frequency of coprescribing the
interacting medications and advised that additional efforts
are required to further reduce rates of inappropriate
prescribing of warfarin with interacting drugs. Unfortu-
nately, the authors made no mention of warfarin interaction
with herbal drugs and food. Because one of every 5 (19%)
American patients take herbal medicines [2] and because
warfarin is one of the most commonly used cardiovascular
drugs, physicians should be aware of warfarin interaction
with herbal drugs and also food.
Several herbs may interact with warfarin, either increasing
or decreasing the anticoagulant effect [3–11]. For example,
danshen, a commonly used herbal drug for various symptoms
of coronary heart disease including angina, myocardial
infarction and heart failure [3,4,10,11], potentiates the anti-
coagulant effect of warfarin. On the other hand, ginseng,
another common and popular herb, decreases the anticoagulant
effect of warfarin [5,9]. To make the situation more confusing,
danshen may be not only taken by mouth but also inhaled; it
has been incorporated into some Chinese cigarettes [4,12].
Therefore, in taking history, the physician should not only ask
which herbs the patient is taking but also what brand of
cigarettes he or she is smoking [4,12]. The issue of herbal drug
interfering with warfarin action is further complicated by the
fact that over half of the herbal users do not disclose history of
herbal use to their physicians [2] and believe it would not be
important for their doctors to know about their herbal use [2].
E-mail address: tcheng@mfa.gwu.edu.
0167-5273/$ - see front matter © 2006 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijcard.2006.06.043
The most recent addition to the list of herb–warfarin
interaction is soy milk which may cause subtherapeutic INR
values [13]. Although soy milk is not a herb, it is widely
advocated as a nutritional supplement by practitioners of
both Western and traditional medicine. Soy milk has been
advocated as a health food not only for its antihypertensive
and antihyperlipidemic properties but also as a natural
alternative to hormone therapy [13]. The latter use has
attracted special attention in recent times in light of the
disquieting findings from the Women3s Health Initiative trial,
which demonstrated an increasing incidence of cardiovas-
cular events and breast cancer in postmenopausal women
taking hormone therapy [14].
Finally, green tea, which has been shown to be good for
cardiovascular health [15], may contain significant quan-
tities of vitamin K [16]. This exogenous administration of
vitamin K may antagonize the anticoagulant effect of
warfarin, leading to a decrease in the INR [16]. Therefore,
it is very important for every physician to be aware of the
possibility of warfarin interaction with herbal drugs or
food when excessive bleeding, unsuspected increase or
decrease of the prothrombin time or INR, or difficulty in
regulating the warfarin dosage that is encountered in any
patients on warfarin therapy who have otherwise been
under good anticoagulant control. As use of dietary
supplements continues to trend upward in recent years, it
is essential for health care professionals to be also aware of
their potential for interactions with drugs including
warfarin.
References
[1] Feldstein AC, Smith DH, Perrin N, Yang X, Simon SR, Krall M, et al.
Reducing warfarin medication interactions: an interrupted time series
evaluation. Arch Intern Med 2006;166:1009–15.
108 T.O. Cheng / International Journal of Cardiology 119 (2007) 107–108
[2] Tindle HA, Davis RB, Phillips RS, Eisenberg DM. Trends in use of
complementary and alternative medicine by US adults: 1997–2002.
Altern Ther Health Med 2005;11:42–9.
[3] Cheng TO. Herbal interactions with cardiac drugs. Arch Intern Med
2000;160:870–1.
[4] Cheng TO. Ask patients which herbal drugs they smoke as well as eat.
West J Med 2000;172:82.
[5] Cheng TO. Ginseng–warfarin interaction. Am Coll Cardiol Curr J Rev
2000;9(1):84.
[6] Cheng TO. Comment: drug–herb interaction. Ann Pharmacother
2001;35:124.
[7] Cheng TO. Herbal interactions with cardiac drugs. Cardiol Rev
2005;22:19–20.
[8] Cheng TO. Herbal interactions with warfarin. South Med J 2005;
98:748.
[9] Cheng TO. Ginseng and other herbal medicines that interact with
warfarin. Int J Cardiol 2005;104:227.
[10] Cheng TO. Danshen: a popular Chinese cardiac herbal drug. J Am Coll
Cardiol 2006;47:1498.
[11] Cheng TO. Danshen: what every cardiologist should know about Chinese
herbal drug. Int J Cardiol 2006;110:411–2.
[12] Cheng TO. Another common herb that patients take but don3t tell their
physicians about. Consultant 2004;44:743.
[13] Cheng TO. Potential interaction between soy milk and warfarin. Am
Fam Phys 2004;70:1231.
[14] Stefanick ML, Anderson GL, Margolis KL, Hendrix SL, Rodabough
RJ, Paskett ED, et al. Effects of conjugated equine estrogens on breast
cancer and mammography screening in postmenopausal women with
hysterectomy. JAMA 2006;295:1647–1657.
[15] Cheng TO. All teas are not created equal. The Chinese green tea and
cardiovascular health. Int J Cardiol 2006;108:301–8.
[16] Cheng TO, Green tea may inhibit warfarin. Int J Cardiol in press.