A Mix to Avoid? |

Jef L’Ecuyer September 12, 2016 Heart Health, Vegetables

You might have heard that if you take an anticoagulant (blood thinner), like Coumadin (warfarin), you should stop eating, or at least eat fewer, green vegetables, because they contain too much Vitamin K. But is this really the case?

Before getting right into the topic, let’s review some basics. Firstly, it’s important to note that Coumadin (generic name: warfarin) is an anticoagulant, which means it stops the formation of blood clots and makes blood thinner (less viscous). As for Vitamin K, it helps the process of blood clotting. In other words, warfarin has the opposite effect to Vitamin K.

What is INR (International Normalized Ratio)? And how does it vary?

The INR is a test used by doctors and pharmacists to check the effectiveness of blood thinning medication (Coumadin/warfarin) and to adapt the dosage. Ideally, you should maintain as stable an INR as possible, meaning you should maintain an optimal blood coagulation rate.

Several factors can influence and unbalance this rate, the seven main ones are:

• Travelling
• Moving home
• Depression
• Divorce
• Bereavement
• Malnutrition
• Dementia

Other factors include genetics, diet, adherence to treatment and other medications you may be taking. Natural supplements are included in the list of medicines that can affect INR.

Natural Supplements and Anticoagulation Therapy

For your information, here are a few examples of natural products that could influence your INR more than eating green vegetables:

• Those which increase INR values:
  • Boldo and fenugreek
  • Cranberry juice (in large quantities)
  • Danshen
  • Devil’s Claw
  • Dong Quai
  • Garlic capsules
  • Ginger
  • Ginko biloba
  • Mayweed
  • Papain
  • Vitamin E (in doses larger than 400 units/day)

• Those which reduce INR values:
  • Coenzyme Q10
  • Ginseng
  • Green tea (in large quantities)
  • St. John’s Wort

Always speak to your pharmacist before you start or stop taking a supplement. If you take supplements, make sure you tell your doctor and your pharmacist.

Now that we’re reviewed some basic facts, let’s get to the nitty gritty: diet and its effect on medication! Several vegetables, particularly green ones, contain Vitamin K, in varying quantities. As mentioned earlier, warfarin (Coumadin) is a Vitamin K antagonist. Its presence or absence from the diet can play a role in the medication’s effectiveness.

Why You Shouldn’t Avoid Green Vegetables

Two main reasons can explain why reducing your intake of green vegetables is not necessary, even if you’re going through anticoagulation therapy.

Firstly, despite what you might have heard, the presence of Vitamin K in the diet helps better balance your INR. Indeed, regularly eating vegetables, particularly green ones, helps you to be less sensitive to daily variations in Vitamin K. This is explained by the fact the liver stocks some Vitamin K, because it is a fat soluble vitamin.

For example, if you eat green vegetables every day, your liver stores Vitamin K. If, one day, you have a lower intake of Vitamin K, this will have practically no repercussions. Vitamin K stored in the liver will be used. This way, you can maintain you INR as stable as possible. However, if you never eat green vegetables, you don’t have Vitamin K stores, so if you eat a good amount of green vegetables one day, you’ll experience a “peak” of Vitamin K, which will then destabilize your INR.

Secondly, Vitamin K’s bioavailability depends on several factors like cultivation, storage and cooking of foods. What’s more, we only know the Vitamin K content of around half the food in the North American diet. It’s therefore practically impossible to establish and respect a recommended daily intake of Vitamin K.

For these reasons, we recommend an intake of 1 to 2 portions of green vegetables each day, even for those taking Coumadin. This quantity enables you to have a better control of your medication and to meet the nutritional needs established by Health Canada. What’s more, green vegetables are great for health!

Note: if you are a fan of Asian cuisine and regularly eat natto (a traditional Japanese food made from fermented soya beans), it would be a good idea to avoid it, because it contains a large quantity of Vitamin K (much higher than what is commonly found in vegetables), which can influence your INR.

Main food sources of Vitamin K

So, in answer to the original question, no, it isn’t necessary to avoid green vegetables because the Vitamin K they contain enables a better control of both coagulation and medication. Good to know, those who have the most difficulty managing their INR are often those who do not eat (or do not eat enough) Vitamin K and green vegetables.

Our heart-healthy menus are approved by the nutritionists at EPIC, Montreal Heart Institute’s Center for Preventative Medicine, even for their anticoagulation therapy patients. Why not give them a try to help plan your meals?

References

• Nutescu, E. A., Shapiro, N. L., Ibrahim, S., & West, P. (2006). Warfarin and its interactions with foods, herbs and other dietary supplements. Expert opinion on drug safety, 5(3), 433-451.
• OPDQ. (2013). Manuel de nutrition clinique – Traitement anticoagulant et vitamine K. Retrieved from: http://opdq.org/mnc/regime-controle-en-vitamine-k/
• Ordre des Pharmaciens du Québec. (2005). Anticoagulothérapie en milieu ambulatoire. Retrieved from: http://www.opq.org/doc/media/809_38_fr-ca_0_ld_anticoagulotherapie_pharm.pdf
• PENnutrition. (6 octobre 2008). Drug/Nutrient Interactions – Key Practice Points. Retrieved from: http://www.pennutrition.com/KnowledgePathway.aspx?kpid=11728&pqcatid=146&pqid=11785
• Schurgers, L. J., Shearer, M. J., Hamulyák, K., Stöcklin, E., & Vermeer, C. (2004). Effect of vitamin K intake on the stability of oral anticoagulant treatment: dose-response relationships in healthy subjects. Blood, 104(9), 2682-2689.
• Uniprix. (2016). Lexique des médicaments – Coumadin (warfarine). Retrieved from:  https://www.uniprix.com/fr/lexique-medicaments/741/coumadin
• UpToDate. (13 avril 2016). Overview of Vitamin K. Retrieved from http://www.uptodate.com/contents/overview-of-vitamin-k

Author

Member of the Quebec College of Dietitians (ODNQ) and Dietitians of Canada,Jef graduated from McGill University in December 2014. Recently graduated and passionate about culinary arts, Jef poses a simple, effective and practical look at daily meal planning. With this in mind, she works in conjunction with the mission of SOSCuisine…

What foods should I eat or avoid when taking Brilinta?

Medically reviewed by Leigh Ann Anderson, PharmD. Last updated on Nov 2, 2022.

Do not drink grapefruit juice while taking Brilinta (ticagrelor). Grapefruit juice can inhibit (block) one of the enzymes (3A4) needed to break down Brilinta for excretion from the body. Theoretically, drinking grapefruit juice with Brilinta may increase the antiplatelet effect of your medicine and increase the risk for bleeding. Ask your doctor about this possible drug-food interaction.

Brilinta (ticagrelor) is an oral antiplatelet prescription tablet that is usually taken twice a day, in the morning and the evening. It is used with a daily maintenance dose of aspirin. It is approved by the FDA for these uses:

• to reduce the risk of cardiovascular death, a heart attack or stroke in patients with acute coronary syndrome (ACS) or a history of a heart attack. For at least the first 12 months following ACS, it is superior to clopidogrel.
• to reduce the risk of a clot formation in stents of patients who have been stented for treatment of ACS.
• to reduce the risk of a first heart attack or stroke in patients with coronary artery disease (CAD) at high risk for such events.
• to reduce the risk of stroke in patients with acute ischemic stroke (NIH Stroke Scale score ≤5) or high-risk transient ischemic attack (TIA)

Grapefruit juice and Brilinta: Study

In one study, ten healthy volunteers ingested 200 ml of grapefruit juice or water three times a day for 4 days and a single 90 mg dose of ticagrelor on day three.

• The authors concluded that grapefruit juice markedly increased the plasma concentrations and antiplatelet effect of ticagrelor.
• This effect was most likely due to inhibition (blocking) of the CYP3A4-mediated first pass metabolism of ticagrelor mainly at the intestinal level.
• The researchers noted that the use of ticagrelor and grapefruit juice is best to be avoided while the patient is taking this drug.

In general, taking medications at a different time from when you drink grapefruit juice will not prevent the interaction. The effects of grapefruit juice on some medications can last for over 24 hours. Even if you take a medicine that is only given once per day, you should avoid grapefruit and grapefruit juice for the entire treatment period.

Brilinta and vitamin K: Can I eat spinach with Brilinta?

You do not need to worry about eating green leafy vegetables like spinach, broccoli, kale, or other vitamin K-rich foods with Brilinta. You can enjoy these healthy foods while you are taking Brilinta.

Brilinta, an antiplatelet, works differently from warfarin (brand name: Coumadin), an anticoagulant. Vitamin K is an essential part of our body’s blood clotting process. Warfarin effects may be altered by changing levels of vitamin K in your body, but this is not a concern with Brilinta.

What other foods affect Brilinta absorption?

Your Brilinta (ticagrelor) dose can be taken with or without food. Food (other than grapefruit or grapefruit juice) will not affect how well your medication works or the maximum amount that is absorbed. However, be sure to take your medication at the same time each day, only as directed by your doctor.

Bottom Line

• You may need to avoid grapefruit juice while taking Brilinta. One study showed that grapefruit juice can more than double Brilinta (ticagrelor) exposure. This can lead to a greater effect on antiplatelet inhibition and theoretically could increase your risk for bleeding. Speak to your doctor about this possible interaction if you consume grapefruit juice regularly or on a daily basis.
• Green leafy vegetables can still be consumed safely with Brilinta as this drug does not affect the vitamin K clotting factors.
• Brilinta (ticagrelor) is manufactured by AstraZeneca and was first approved by the FDA in July 2011.

References

• Holmberg M, et al. Grapefruit juice markedly increases the plasma concentrations and antiplatelet effects of ticagrelor in healthy subjects. Br J Clin Pharmacol. 2013 Jun; 75(6): 1488–1496. Doi: 10.1111/bcp.12026
• Brilinta (ticagrelor) [package insert]. Wilmington, DE: AstraZeneca Pharmaceuticals LP; 2020 https://www.azpicentral.com/brilinta/brilinta.pdf
• Brilinta Approved in the US to Reduce the Risk of Stroke in Patients with an Acute Ischemic Stroke or High-Risk Transient Ischemic Attack Drugs.com. Accessed Nov. 11, 2020 at https://www.drugs.com/newdrugs/brilinta-approved-us-reduce-risk-stroke-patients-acute-ischemic-stroke-risk-transient-ischemic-5379.html

Related medical questions

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Drug information

• Brilinta Information for Consumers
• Brilinta Information for Healthcare Professionals
  (includes dosage details)
• Side Effects of Brilinta
  (detailed)

Related support groups

• Brilinta
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Medical Disclaimer

Warfarex analogues.

Prices for analogues in pharmacies

The above list of analogues of drugs, in which substitutes for Warfarex are indicated, is the most suitable, since they have the same composition of active ingredients and match the indications for use

To compile a list of cheap analogues of expensive drugs, we use prices that we are provided with more than 10,000 pharmacies throughout Russia. The database of drugs and their analogues is updated daily, so the information provided on our website is always up-to-date as of the current day. If you have not found the analogue you are interested in, please use the search above and select the medicine you are interested in from the list. On the page of each of them you will find all possible options for analogues of the desired medicine, as well as prices and addresses of pharmacies in which it is available.

To find an inexpensive analogue of a drug, a generic or a synonym, we first of all recommend paying attention to the composition, namely to the same active ingredients and indications for use. The same active ingredients of the drug will indicate that the drug is a synonym for the drug, a pharmaceutical equivalent or a pharmaceutical alternative. However, do not forget about the inactive components of similar drugs, which can affect safety and efficacy. Do not forget about the advice of doctors, self-medication can harm your health, so always consult a doctor before using any medication.

On the websites below you can find prices for Varfarex and find out about availability in a pharmacy nearby

Varfarex instructions

Composition ) 1mg/3mg/ 5mg.

Pharmacological group

Indirect anticoagulant.

Pharmacological properties

Pharmacodynamics

The anticoagulant effect usually occurs within 24 hours after taking warfarin. However, the maximum anticoagulant effect occurs after 72–96 hours. The duration of action of a single dose of racemic warfarin is 2 to 5 days. The effect of warfarin may become more pronounced as the effects of daily maintenance doses overlap.

Anticoagulants do not have a direct effect on the formed thrombus and do not eliminate ischemic tissue damage. However, once a thrombus has formed, the goal of anticoagulant treatment is to prevent further expansion of the formed thrombus and to prevent secondary thromboembolic complications, which can lead to serious and possibly life-threatening consequences.

Pharmacokinetics

Warfarin is a racemic mixture of R and S enantiomers. The S-enantiomer exhibits 2-5 times greater anticoagulant activity than the R-enantiomer in humans, but usually has a faster clearance.

Indications

Prevention and treatment of diseases caused by the formation of blood clots:

– deep vein thrombosis;

– pulmonary thromboembolism;

– atrial fibrillation;

– myocardial infarction;

– for prosthetic heart valves.

Contraindications

– bleeding or risk of bleeding in some serious diseases;

– bacterial endocarditis;

– severe liver failure;

– obstructive jaundice;

– severe renal insufficiency;

– diabetes mellitus;

– acute DIC;

– deficiency of proteins C and S;

– hemorrhagic diathesis;

– thrombocytopenia;

– peptic ulcer of the stomach and duodenum in the acute phase;

– stroke;

– chronic alcoholism;

– severe arterial hypertension;

– recent or expected complex surgeries and diagnostic procedures;

– children’s age;

– pregnancy;

– insufficient possibilities for assessing the state of the blood coagulation system using laboratory methods;

– hypersensitivity to the components of the drug.

Method of administration and dosage

Inside, 1 time per day, preferably at the same time of day. The doctor determines the dose, regimen and duration of use of Varfarex for each patient individually, guided by the severity of the disease and the results of blood coagulation monitoring (INR). Do not arbitrarily change the dose or stop treatment with Warfarex without the permission of a doctor.

Initial dose is 2.5–5 mg daily for the first 2 days, then gradually adjusted according to the patient’s individual blood coagulation response (INR). After reaching the desired level of INR (2.0–3.0, and in some cases 3.0–4.5), a maintenance dose is prescribed.

Elderly, debilitated, or at-risk patients should be given lower initial doses and be careful when increasing them. Warfarex is usually not prescribed for children.

At the beginning of treatment, laboratory monitoring of INR is carried out every day, over the next 3-4 weeks, monitoring is carried out 1-2 times a week, later – every 1-4 weeks. More frequent additional monitoring is necessary in cases where the patient’s state of health changes, before a planned operation or other procedure, and also when any other medication is prescribed or canceled.

Overdose

Symptoms of chronic intoxication: bleeding from the gums, epistaxis, excessive menstrual bleeding, heavy or prolonged bleeding with minor superficial injuries, hemorrhages in the skin, blood in the urine and feces, etc.

Treatment: with minor bleeding, it is necessary reduce the dose of the drug or stop treatment for a short time. In case of severe bleeding, transfusion of prothrombin complex factor concentrates, or fresh frozen plasma, or whole blood.

Interaction with other drugs

High levels of vitamin K in foods (spinach, broccoli, lettuce and other leafy vegetables) may reduce the effect of Warfarex. However, you should not change your diet too abruptly, use vitamins and nutritional supplements without consulting a doctor.

Smoking may reduce the anticoagulant effect of the drug.

The effect of Varfarex may change under the influence of a large number of drugs.

NSAIDs, dipyridamole, valproic acid, cytochrome P450 inhibitors, cimetidine, chloramphenicol, laxatives – increase the risk of bleeding. The combined use of these drugs and Warfarex should be avoided (cimetidine can be replaced with ranitidine or famotidine). If treatment with chloramphenicol is necessary, anticoagulant therapy may be temporarily discontinued. Diuretics can reduce the effect of anticoagulants (in the case of a pronounced hypovolemic effect, which can lead to an increase in the concentration of coagulation factors). Weaken the action: barbiturates, vitamin K, glutethimide, griseofulvin, dicloxacillin, carbamazepine, mianserin, paracetamol, retinoids, rifampicin, sucralfate, phenazone, cholestyramine.

Enhances: allopurinol, amiodarone, anabolic steroids (alkylated at C-17), acetylsalicylic acid and other NSAIDs, heparin, glibenclamide, glucagon, danazol, diazoxide, disopyramide, disulfiram, isoniazid, ketoconazole, clarithromycin, clofibrate, levamisole , metronidazole, miconazole, nalidixic acid, nilutamide, omeprazole, paroxetine, proguanil, oral hypoglycemic agents – sulfonamide derivatives, sulfonamides, tamoxifen, thyroxine, quinine, quinidine, fluvoxamine, fluconazole, fluorouracil, quinolones, chloral hydrate, chloramphenicol, cephalosporins, cimetidine, erythromycin, ethacrynic acid, ethanol.

When using Warfarex in combination with the above drugs, it is necessary to monitor the INR at the beginning and end of treatment and, if possible, after 2-3 weeks from the start of therapy. When using drugs that may increase the risk of bleeding due to a decrease in normal coagulation (inhibition of coagulation factors or liver enzymes), the strategy of anticoagulant therapy should be determined by the possibility of laboratory control. If frequent laboratory monitoring is possible, then, if necessary, therapy with such agents, the dose of Varfarex can be reduced by 5-10%. If laboratory control is difficult, then treatment with Warfarex should be discontinued if it is necessary to prescribe these drugs.

Side effects

The most common side effects observed during treatment with anticoagulants are bleeding and hemorrhages in various organs and tissues. The possible risk of developing these side effects can be significantly reduced by strictly following the doctor’s recommendations related to taking Varfarex.