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Doctors' Answers to "Frequently Asked Questions" - Coumadin

These comments are made for the purpose of discussion and should NOT be used as recommendations for or against therapies or other treatments. An individual patient is always advised to consult their own physician.

[posted 09/24/2000]
Question: Will undergo surgery to replace mitral valve shortly. Will most likely have to have an artificial valve. Will have to be on coumadin the rest of my life with the artificial valve. Will I be able to get pregnant being on coumadin? I was told about a drug called Haprenol? or something like that. Any help would be appreciated.

Answer: Pregnancy with coumadin is possible, but we usually use heparin or low molecular weight heparin. You might want to discuss this with a high risk ob/gyn specialist they can give you the details, but this is able to be done.

[posted 08/13/2000]
Question: Hello Sir
A close relative of mind had a St. Jude valve replacement and is currently balancing out the blood thinner readings. Knowing my friend, he probably did not disclose the fact that he smokes marijuana, usually once or twice a day! Considering this fact, is there any contraindications when prescribed coumadin and routinely using marijuana!

Thank you and keep informing us with your knowledge!

Answer: Not usually.

[posted 04/27/2000]
Question: My mother was recently hospitalized for atrial fib.
Upon her release her cardiologist prescribed several medications.
Coumadin was one of them, somewhere along the line she heard that
Coumadin was like rat poison in when ingested in large quantities
a person would hemmorhage just as a rat would. She is very concerned
about this. If possible could you please tell me what exactly is
in Coumadin? If not, where can I go to find out what is
in it. Tahnk you for your time. Looking forward to hearing from you.

Answer: PLenty of information on the site as well as the FAQs. Coumadin is used for rodent poisoning,but at 50-1000 times the dosage that humans receive. She will need regular testing of her levels which her physician will do depending on the variability that she exhibits. She needs to avoid any aspirin or non-steroidal anti-inflammatories(motrin, aleve and the like). If she starts/stops any medication she needs to let her md know so that her levels can be checked. If she sees any bleeding she should call her md. Her blood will still clot, but in a different manner and a different speed.

[posted 03/2/2000]
Question: I had surgery in 1997 to repair a tear in my left leg(quadricep). Aproximately 3 months later I developed and neglected a blood clot. A DVT. I was hospitalized and given Heprin. I was put on Coumadin and I am still on it. Will I have to be on it for life? Are there herbs to take as an alternative? I have read about Horse Chestnut. What is a greenfilter and can it help me? I had a venus dopler about a year ago and the clot was still present, although reduced.

Answer: Unless there is an underlying mechanism causing the recurrance of clots, most physicians would stop the coumadin after six months regardless of whether there is residual clot on the ultrasound. There will be a risk of reoccurance with this, less if you take an aspirin once a day, but acceptable considering the risk of coumadin for bleeding. If you have a reoccurance off the coumadin, most would recommend long term coumadin. Horse chestnut is for chronic venous stasis , I have not seen studies on DVT per se. A greenfilter is placed in the inferior vena cava to stop the clots from migrating to the lung. This is used in patients who cannot use coumadin(immediately post neurosurgery for example). If you have not had a pulmonary emboli, of little use currently.

[posted 01/27/2000]
Question: I happened upon your site while looking for references for my patients. Thank you for your rational responses regarding warfarin and green leafy vegetables. It is much safer and easier for the clinician to adjust the warfarin dose to the patient's diet (assuming a consistent amount of vegetable intake) than it is to expect a person to radically change their diet and avoid common foods, putting themselves at risk for deficiencies in vitamins and nutrients other than vitamin K. Just a few comments on some related issues that have come up on your site with frequency: I have had patients who have had bleeding problems when they took more than 100% of the RDA of vitamin E in addition to their normal dietary intake while on warfarin. Conversely, I have had patients who have dropped their INRs after eating garbonzo beans (chickpeas) or drinking UNFILTERED tea(especially green tea).
By the way, anyone taking a multivitamin should check the label for vitamin K content every time they buy a new bottle. Companies often change the amounts and even types of vitamins in their tablets, sometimes without any notice to the consumer. And different companies have different mixes. I have had 2 patients come in with low INRs, apparently related to addition of vitamin K to the vitamin brand that they had been taking for years.
Speaking of vitamin companies, several of them have gone into the herbal business. Many of the herbs contain natural coumarins or have anti-platelet activity. Since the FDA hasn't started regulating the concentration or purity of herbals, the actual strengths of these substances can vary widely from company to company, and even from lot to lot from the same company. Have you noticed any increase in INR variability or bleeding events in your patients that take herbal supplements?

Answer: Occasionally,the hard part is getting the history since they often do not consider that these are "medicines" or could have any effect on their life. Thanks for the note.

[posted 01/20/2000]
Question: Anti-inflamatory medication? Because I take Warfarin, I know that I am very limited in what NSAIDS I can take, and that steroids are not an option. My doctor recently placed my on VIOXX which I discontinued after several days of excalating stomach distress - nausea, reflux, milk diarrhia, and gas. Sorry about my spelling. Can you suggest any medication that would not be in conflict with the Warfarin?? Thank you for your advice. And, I will let my doctor know tomorrow that I have discontinued the Vioxx.

Answer: Any Non-steroidal anti-inflammatory will cause a potential interaction. We tend to use suldinac but, it is not without risk.

[posted 01/19/2000]
Question: My father had aortic valve replacement surgery Nov 1,1999 and began Coumadin about 3 days later. Ever since it has been a rollercoaster ride trying to regulate is INR. His cardiologist adjusts the dosage about weekly still and we can't figure out why it goes from perfect one week to 8.9 the next with no change in diet. Also he began coughing up blood a few days ago. Is that something that the doctor should look into or is it normal when your INR is that high? He is wondering if this is normal to have such a problem to regulate this drug? Needless to say he is tired of being stuck all the time. Please give us some insight on this.

Answer: Unless he is changing other medications, it is usually not a big deal to regulate.

[posted 01/12/2000]
Question: I had aortic composite graft surgery in November of 1999.Since I have a mechanical valve the dotor put me on 5mg.of coumadin a day. My question is that I have been waterskiing for about 30 yrs. If I ski conservatively and on smooth water I very seldom fall. I hate to give up skiing if the risk is very small for problems relating to the comadin. Iwould like your opinion.

Answer: There is a risk of bleeding post-trauma that you can't avoid. Carry some ice in the boat to help the clotting if you do have a more serious fall and don't ski stupid. You will be at risk but minimal.

[posted 11/30/1999]
Question: I would like to know what the standard of care is regarding a patient on coumadin undergoing oral surgery (for gingivitis)Is it always held, and if so for how long?

Answer: This would depend a lot on why they are on the coumadin. Usually for low risk patients(atrial fibrillation etc.) we stop it 3-4 days prior to any oral procedures. For high risk patients(metal valves, etc) we stop it 2 days prior to dental procedures. Since the gum is accesable, pressure can be applied and stop bleeding in the event there is excessive bleeding. So, it is less of a bleeding risk than an internal procedure like a biopsy.

[posted 08/27/1999]
Question: i am a 38 yr old female that has had aortic vavle replacement in feb.1998 i take 10mg coumadin a day.. i have very very bad leg cramps when i lie down.. i have told my doctor about this and he has given me k+ and quinine and this has done no good.. i know i have to take the coumadin but just to see when i skip my coumadin my legs do not cramp.. they hurt so bad that it feels like the veins are jumping around when they hurt and i dont know what to do about this thank you

Answer: This is really a large dosage of coumadin, what is your INR?

[posted 08/19/1999]
Question: I am on Coumadin and Aspirin for TIA's. What product are OK for use to treat sinus headache, running nose, watery eyes while on these medicines? What about the common cold--what products would be OK for use while on Coumadin/Aspirin?

Answer: You should always check with your doctor. Antihistamines should be ok, but any drug addition to your current drug list can change metabolism and require closer monitoring of the coumadin(INR) levels.

[posted 10/16/1999]
Question: Do I need to temporarily stop my patients' coumadin before dental procedures? If so, how soon in advance of the dental procedure. Does it depend on why they are on coumadin therapy as to whether it is safe to stop coumadin for the procedure. For example, the patient that is on coumadin for atrial fib versus a patient on coumadin for a left venticle thrombus? Should the patient with the thrombus be managed in the hospital? Appreciate any guidance or articles that you could direct me to. Thanks, Tonya FNP

Answer: Yes, usually four days is sufficient. Cleaning alone does not usually require this unless there is a history of excessive post cleaning bleeding(usually only seen with severe gum disease). This is never done in the hospital, if there is a severe risk-subcutaneous low molecular weight heparin or regular heparin can be used for the gap. But, rarely a problem.

[posted 09/28/1999]
Question: My mother just recently had a greenfield vena cava filter implanted. The doctors deemed this necessary after finding a blood clot in her pelvis, and a few emboli in her lungs....she had been on heparin shortly after they found the clot in her pelvis. She was told at first she would need to be on coumadin for about 6 months, now they tell her it will be necessary to take it for the rest of her life. She is not elderly (only 47) and walks daily, so inactivity is not a problem. She also currently has a colostomy bag due to complications of another surgery. She is schuduled for reversal in 3 weeks. My questions are: is it really necessary for her to be on coumadin for the rest of her life and should she be taking blood thinners before this upcoming major surgery?

Answer: Depends a lot on why the doctors thought she should be on coumadin, that is what was the cause of the clot? The filter will work to "catch " emboli from below,although after a few years there are reports of bypass veins growing and allowing repeat emboli. I'll need to know the reason for the emboli. As to the surgery, it should be stopped 4-6 days prior to surgery.

Coumadin and Vitamin E [posted 1/13/99]
Question: I have been taking coumadin for several years and am currently taking 7.5 mg daily. I have had open heart surgery to remove the back of my heart, a 4 level bypass, and insert a ventricular defibrillator. I have also had 2 major strokes (the first at age 38), hence the coumadin. In spite of this I feel my health is currently good. I exercise (aerobic) every day, eat correctly and would like to be more in control of my health. I heard about the wonderful effects of Vitamin E but have heard that it is contra-indicated when taking coumadin. Is this true? I have also heard that it is beneficial to take ginko buloba to improve brain circulation, but care must be exercised when taking coumadin. Can you give me some more information on this? I am a male, 57 years old and have been blessed with very good care. I would just like to be able to take things more into my own hands. Also, I recovered from a severe case of polio as a child and wondered about the effects of polio on the heart since it is a muscle as well.

Answer: Polio does not affect the heart, the virus lives in the spinal cord and causes de-enervation of the muscle, which the heart does not have. There should be no problem with Vit E and the coumadin. As to the ginko, I have no information. Just watch your pt/INR, closely after starting it.

Coumadin Alternatives [posted 11/11/98]
Question: I am getting ready to have AVR. I have been very concerned about living on Coumadin. I have had two doctors tell me not to dwell on this because Coumadin should be replaced within 3 to 5 years. Is this true? If so with what and how will it work?

Answer: Maybe, maybe not. But, if you are getting a valve replaced, you have few/little option. While it is a pain to get regular testing, it is the only way to decrease the risk of bleeding or insufficient anticoagulation.

Coumadin Side Effects [posted 8/13/98]
Question: What are the common side effects of coumadin? It was prescribed for my father-in-law after he had a light stroke 5 months ago.

Answer: Coumadin (warfarin) has generally few side effects. It should not be used during pregnancy due to birth defects. There are occasional severe cases of skin necrosis, also a strange phenomenon called purple toe syndrome wherein the feet (generally) develop tender purple spots. There is a long list of occasionally reported items, but generally not enough to discuss. The biggest risk is excessive bleeding and interaction with drug metabolism causing other drugs concurrently being taken to rise/fall out of therapeutic range.

Coumadin [posted 8/13/98]
Question: I have been taking Coumadin for approximately eight months. I have just gotten permission from my doctor to resume taking Vitamine E and Calcium. What is your opinion of Grape Seed Extract? Would it be safe to take with Coumadin? I am a 56 year old female. I am taking Coumadin because of vasculitis.

Answer: As long as you take regular dosages, you can take most medications with coumadin without problem. The problem arises if you take a large dose one day (or for a week) and then none for a while. The dosage of coumadin can be adjusted for almost any metabolic problem as long as the problem is relatively fixed.

Coumadin Levels [posted 8/11/98]
Question: My father is on coumadin and has asked me to ask for information regarding the level. His doctor wants his pro time between 2 and 3. Yesterday it was 3.1. With the pro time increasing, he wants to know if the coumadin needs to be reduced or increased to keep pro time below 3.

Answer: I think you are referring to the INR rather than the protime. A higher INR necessitates a lowering of the coumadin, a low INR raising the dosage. The level of the INR depends a lot on why he is taking coumadin - the higher the INR the "thinner" his blood.

Coumadin [posted 8/6/98]
Question: I am a 50 year old male. In January 1996 I had a St. Jude aortic valve implant. I was prescribed coumadin. The doses have ranged from 10 to 15 mg/day. I have been tested regularly, but have continued to fluctuate from too high to too low. Several weeks ago I passed out (1-3 minutes) after severe leg pain and was hospitalized. A Brain Scan, CT Scan, and Lung scan all were negative. INR=1 in the emergency room. They kept me on heparin while they waited 4 days for coumadin to come up to INR=1.9. What can I do to avoid another vacation?

Answer: I'm kind of baffled concerning your coumadin needs. This is a large dosage - depending on where your doctor wants to keep your INR. Are you taking other medications that are competing with the coumadin? This is peculiar and needs further evaluation by your doctor.

Coumadin and Atrial Fibrillation [posted 7/31/98]
Question: If a patient has been on coumadin for several years and is taken off, cold turkey (not reduced), and just stopped for five days and on the 6th day the patient suffers "sudden death" caused by atrial fibrillation would taking him off coumadin have been the cause?

Answer: Coumadin will usually have some effect for 4-5 days after cessation depending on the initial INR and the patient's metabolism. If the death was due to an embolic event from the heart thrown to the brain - possibly.

Hair Loss from Coumadin [posted 7/30/98]
Question: My cardiologist has put me on coumadin because of an irregular heartbeat and told me that I have to take this the rest of my life. Aspirin will not suffice. I am a woman, 54, and since I have been on this, I have been losing significant amounts of hair daily. I would like to find an alternative to coumadin, perhaps using vitamin/mineral therapy. I have read that vitamin E thins the blood and that zinc deficiency can cause a hair loss. Is the coumadin interfering in the body's ability to use the zinc in my current supplements and in my diet? I am taking 300% of the RDA of zinc and 100% of RDA of vitamin E. If there in no alternative to stopping the coumadin, can larger doses of zinc help stop the hair loss? Do other vitamins or minerals play an important part in hair loss?

Answer: Are you taking any other medications? Because coumadin is pretty risk free, I suspect another medication, like a beta blocker is the culprit. However, I know of no interaction with zinc in coumadin action and I don't think zinc would be of any use. Women do have good responses to topical minoxidil. If you can't eliminate the drug, try this.

Loss of Taste and Coumadin [posted 7/30/98]
Question: I took Coumadin because I had arrhythmia. I underwent Cardioversion and now I have a normal heart rhythm. I stopped taking Coumadin on advice or permission of my doctor. I feel that Coumadin was responsible for a loss or perversion of taste. I no longer take it. It has been about 3 weeks since my last dosage. It is difficult to tell whether my taste has really improved. What are the statistics on this? I am 73 and have lost a lot of weight with intent. However, I want to taste again. Could this be genetic? My Dad talked about it before he died at 75. He said he could taste the first four bites or so, but he was on medication for high blood pressure. I understand that a side effect of blood pressure reducing pills is loss of taste. I used to take Vasotec. That loss of taste is shown to be a side effect with that drug. I have not taken it for a good length of time. With my loss of weight I have normal blood pressure.

Answer: Taste like any sensory nervous input is prone to degradation with age. Sight and hearing have obvious decline with aging. However, taste and smell do as well. While different medications can affect taste/smell, I wouldn't expect the effect to last more than a couple of weeks after the drug is discontinued. I have not had any patients complain of loss of taste with coumadin, but anything is possible. There are clinics that can quantify your taste/smell ability and loss. I have not been impressed that they offer good treatment alternatives.

Coumadin [posted 7/21/98]
Question: My husband has been on Coumadin, following the installation of a stent. He is 62 years old and still active. The effects he's been noticing are: At therapeutic levels of Coumadin, (the levels some doctors insist on) he experiences joint pain, which interferes with his sleep as well as his activity level. If the level drops too low, (below 13) he experiences atrial fibrillation. I have not seen any information that mentioned the joint pain as a side effect. Have you heard of this before? His other medications have not been changed recently. He is considering a bypass.

Answer: Would certainly be uncommon. I'd have him see a Rheumatologist (arthritis specialist) to find the cause. I strongly doubt that it is the coumadin.

Coumadin and Tylenol [posted 7/17/98]
Question: Recently I was told that there was a news article warning people on coumadin not to take tylenol. I can't find any information on this.

Answer: There was one article that studied patients who presented to the hospital with high levels of PT or INR. This is a selected group of patients and a study has not been done prospectively looking at this problem. My own read is that these patients had liver problems, either caused by the Tylenol or accelerated by Tylenol since Tylenol can damage the liver in large doses. Clinically, I have never been impressed with any interaction and one would expect to see something in 20 years with all the tylenol that my patients take. I would continue to take tylenol with coumadin until further studies are done. Limit the dosage to 6-8 per day. If you have any history of liver disease do not take the tylenol until further studies are done. This has received far too much publicity without any critical analysis of the study.

Coumadin and hair loss/thinning
Question: Has there been any connection reported between Coumadin and hair loss/thinning? If so, what can be done to prevent/counteract this?

Answer: I have never heard of it as a problem. I haven't seen it in my patients. You might want to call the company - they might have an idea. It is Dupont: 302-992-4240.

Better, safer, natural alternatives to Coumadin
Questions: My wife underwent open heart surgery in November 1995. She also has a pacemaker(second one)having had the first one implanted at a relatively young age. Since her open heart surgery (to correct a left mitral valve prolapse, and in so doing, having an annuloplasty performed), her cardiologist (not the surgeon) has had her on Coumadin, and as far as we know her current INR is 3.1. There are some symptoms that would indicate excessive Coumadin levels for her. I repeat, for her. I remark this, because in spite of these apparent side effects, her cardiologist seems strictly focused on the attainment of the INR number no matter what. Yet, everything that we read indicates that these symptoms are indicative of an excessive Coumadin dosage. Her symptoms (that we are concerned could be due to excessive Coumadin) are: 1. Even small wounds take longer than average to heal. 2. In some instances, she may have suffered a small cut or scratch, and is unaware that she is bleeding until someone else points it out to her. 3. Recently, she has been experiencing nausea, dizziness, and weakness. 4. Also recently, when nurses or hospital technicians drew blood, the needle punctures caused later subcutaneous bruising or bleeding over areas of up to 2 inches by 4 inches. As is typical of medical practice today, most treatments are "managed by the numbers", so regardless of our growing concerns as expressed to my wife's cardiologist, all he seems to focus on is the INR number. It is almost as if he believes that IF her INR number is numerically correct (although we understand that 3.1 may be somewhat too high for the AVERAGE patient and evidently definitely too high for my wife)then, all of her health parameters will somehow fall into place. Are there alternatives to this approach to treatment, and should not a more integrative or holistic assessment of each specific patient be taken as a starting point, rather than simply utilizing what (to us) appears to be an increasingly coarse and imprecise (even clumsy and dangerous) method of treatment? Are there other newer drugs or natural medicines that can safely accomplish the same intended results?

Answer: Sounds like you need a new doctor. Assuming that she had an artificial valve replacement, she will need to be on coumadin for her lifetime. There is no alternative nor herbal remedy that will be effective to prevent the possible strokes. If she had a porcine valve, this is not the case. Nausea, dizziness, and weakness are rarely due to the coumadin. Her other problems probably are. I would convey my concern and your need to switch physicians unless they can be addressed. Usually, one can keep the INR about 2.5 without major problems, but I do not know her specifics. A second opinion may be of help.

Question: I've had three strokes, and I am a 61 yr. old male. My Dr. at Watson Clinic in Lakeland, Fl. has prescribed coumadin, lipitor, and triamterene. He assures me that these meds do not cause increased irritability, nervousness, or listlessness. Yet, I am experiencing all of these problems. I have talked with other coumadin users who also experience these problems. Are these side effects of the drug? Is another drug just as effective? What are my options?

Answer: I doubt it is coumadin. You might try to selectively stop the lipitor and triamterene(with your doctor's knowledge). There really is no other drug than coumadin. Aspirin can be used but may not work. Ticlid is available but can be toxic and expensive.

Question: I was shocked to read your advice that green leafy vegetables are of no concern to someone taking coumadin. My 73 year-old mother is taking the drug, and she was told by several physicians to limit her intake of foods (many of them green & leafy vegetables) that are rich in vitamin K and can reduce the drug's effectiveness.

Answer: Sorry to shock you, but I stand by my opinion. It really doesn't matter clinically as long as the intake doesn't vary a great deal from day to day. Large intakes followed by abstinence could cause problems. Try it and see. In theory it matters, in practice rarely.

Question: I have been taking Coumadin for the past eight years. I am 34 years old, and I am concerned with the long term usage of the medication. Can you please inform me of the long term side effects or symptoms that can be caused by Coumadin.

Answer: Don't seem to be any other than the yearly risk of bleeding-- currently around 5-10%.

Coumadin and Migraines
Question: I have a customer that has been on Coumadin Therapy for several years and is starting to get migraine headaches. In product information it mentions that headaches are a possible side effect. I have not been able to find anymore information to confirm that it is possible the coumadin is causing the effects, and the customer has lost a number of days of work because of them. What possible change in therapy could be instigated, or what type of treatment could I suggest to his physician?

Answer: I doubt that the coumadin is the culprit. If he were to develop migraines due to the coumadin, I strongly suspect that they would have occurred with the onset of therapy. The fact that he developed them several years later doesn't make any logical sense. Secondly, I must have 200 patients on coumadin and I have never heard one of them complain about headaches. I would focus on the other potential causes for new headaches rather than the coumadin.

Coumadin and Alcohol
Question: My 76 year old father has been on Coumadin for about four months as a result of blood clots in his leg(post surgery side effect). He has long enjoyed one scotch and soda each evening before dinner. Just one and no more. His surgeon said this would be OK with the Coumadin. His regular Doctor is saying no more than one drink per week. We are confused. I hate to see him lose this small pleasure in life if it is not necessary.

Answer: The best way to keep coumadin from causing trouble is to keep your diet, medications, etc. the same from day to day. Changing metabolism of coumadin is responsible for the different levels. As a consequence, it is fairly easy to adjust coumadin for the changes seen with alcohol metabolism if it is fairly regular. Irregular use of alcohol(or other drugs)makes management more difficult. A regular drink is usually easier to compensate for than an occasional drink. I'd stick to his usual regimen.

Question: I have been taking coumadin for 5 years after mechanical aorta and mitrol valve replacement. Each month I get a blood test for pro-time. I have been told that my readings vary between 19 and 23. Can you tell me what the safe reading ranges are and what are the consequences for falling outside the safe region on either end.

Answer: Patients who have undergone heart valve repair or replacement are placed on blood-thinner medications to avoid having clots form about these valves. Essentially, these valves are foreign in the body in that they are close to, but not identical to, your natural valves which were replaced. Thus, there is a small but still significant risk for clot formation; thus, you have the need for blood thinners. Coumadin is the agent typically employed for long term blood-thinning or "anticoagulation". This medication works by inhibiting some of the chemicals in your body that are part of clot formation. There is still a large number of other chemicals responsible for forming clots, and therefore, patients on these medications do not have a great deal of bleeding problems assuming that the medication concentration in the blood is not too high. Therefore, your provider must keep your blood level high enough to avoid clot formation but not so high so as to allow for abnormal bleeding to occur. The numbers you describe refer to the blood test used to determine whether you have the right amount of coumadin in your system. There is no "correct range" for this medication because its uses vary, and the desired range of blood test levels varies, as well. You should discuss the desired ranges for your particular needs with your health care provider. Typically, patients with mitral valve replacements are kept with Prothrombin Times (or "PT", the numbers you reported) in the range of 20-25, while patients with aortic valve replacements are kept in the 16-19 range. If the level is too low, the risk of clot formation goes up, while if the "PT" is too high, the risk of bleeding complications goes up. Also keep in mind that the results of your routine blood test is a sample measurement, and that like all other functions in the body, monthly or even weekly variation is normal. Thus, slight variations in your levels are to be expected, and your health care provider will continue to monitor your levels to make sure you stay within your desired range.

Coumadin and diet
Question: I am searching for a list of foods to avoid while taking Coumadin.

Answer: It isn't a big deal about foods. I have received a lot of criticism for this view, but I still stick to it. Green leafy vegetables do contain Vitamin K and large amounts can potentially change your blood results. However, few people eat these amounts and the vegetable intake is only a problem if it varies widely from day to day. In general, these vegetables contain antioxidants that probably improve your health. Consequently, avoiding leafy green vegetables and vegetables in general is not good advice. Rather, ensure that your intake is relatively predictable. Vegetable orgies one week followed by abstinence the next can potentially produce problems, but few follow this type of regimen. Watching different food intake on coumadin is more a theoretical than a practical problem.

Question: I am asking a question in regards to my father (67) who is taking coumadin due to 3 heart attacks in one night 2 years ago. For 6 to 8 months, he has been spitting up blood. He has his blood check any where from every 2 weeks to 4 weeks. He started spitting up blood again, and his PT was checked and this was OK. He was sent to an ear/nose/throat doctor who said it could possibly be his coumadin, even though his PT is O.K. Is this serious, and could he started bleeding and not stop? He said the blood could be coming from the back of the tongue.

Answer: There is a fine line with coumadin between risk and benefit and between too much and too little. An inflamed or irritated area can still bleed if coumadin is normal, but it is less likely if the coumadin is on the low end of "normal" . What have his INR been doing and why is he on coumadin. These are the pertinent questions. If he is on coumadin for less than dramatic reasons(concerning his heart) it might be possible to let the coumadin drift down. The risk here is either a stroke or heart attack. This needs to be discussed with his physician and with another member of the family present to ensure that there is no confusion.

Coumadin and food interaction
Question: The question was asked "Specifically, which foods must he stay away from..." This is the exact question I went on-line to have answered and it was completely evaded. This is of great importance to me. So you can understand my disappointment when you responded "green Leafy vegetable are of no concern". Well, exactly what is? There is definitely a warning about consuming certain foods, especially those high in vitamin K.

Answer: I don't tell my patients to avoid any specific food while on coumadin. I do discuss medical interactions with other medications-- aspirin and other non-steroidal antiinflammatories, etc. I do not limit or restrict their diet in any manner. Reference pharmacology textbooks do reference that foods high in Vitamin K can produce a problem. Clinically this is not seen. Almost all vegetables have Vitamin K and green leafy vegetables the most. However, the health benefits of the antioxidants in vegetables far outweigh any theoretical risk inherent in Vitamin K ingestion.

Question: I am just a little guy, a patient on Coumadin, 73, under a physician's care. I have lost 100 pounds in the last year and feel great. I exercise by swimming and my Doctor is pleased. I have a problem which does not worry him. He says it is very common. My heart beat is not totally in rhythm. I get these short circuits and don't even notice it, but my heart beat is not totally rhythmic. To lessen the chances of clots forming he has prescribed Coumadin and I am monitored closely. My problem is a possible side effect. It bothers me. It doesn't really bother my Doctor. This side effect is perversion of taste. I just can't taste things like I used to. I ate a hamburger for the first time in a year, and I couldn't taste it. I could have been eating anything.

Answer: I've had a lot of patients on Coumadin and never seen this side effect. There are actually labs which can check your taste. A more common drug to cause change in taste would be digoxin. It is sometimes given in irregular heart beats. Are you on anything besides coumadin?

Question: I am taking coumadin daily (5 mg daily and 7.5 mg on Sundays) and recently had Relafen prescribed by another doctor. I just read that certain anti-inflammatory drugs don't go well with coumadin. Please advise whether I may be running into a problem.

Answer: Coumadin is a common drug used in anti-coagulation. It really is the only drug that is effective and simple to give. Its major drawback is its tendency to interact with other drugs. Either by changing the liver metabolism of coumadin-affecting the anti-coagulation level, or by affecting the ability of the blood to clot. In general, aspirin and non-steroidals (like Relafen) should be used sparingly, if at all, with coumadin. Coumadin affects the coagulation profile - aspiring and NSAIDS the platelet function.

Coumadin and Vitamin E
Question: What dosage of Vitamin E can be considered safe when taking Coumadin anti-coagulant medication?

Answer: There should be little interaction. However, I would keep my dosage of Vitamin E about the same each day so any side effects can be compensated for in your regular blood testing for coumadin.

Question: I recall being told that Coumadin was formerly used as rat poison. Is this true? If so, where can I find more information on the history of this drug?

Answer: Coumadin (warfarin) was invented at the University of Wisconsin in 1949. It was initially used as a mammalian pesticide since excessive anticoagulation will produce bleeding leading to shock and death. Most current pesticides use a slightly different chemical that has a time release characteristic rather than a one dose effect. However, this drug has been used extensively since the early 1950's in humans for anticoagulation. Close monitoring is required with the use of this drug to ensure that the right dose is administered. This drug interferes with Vitamin K. Consequently, any change in Vitamin K intake can change the dosage of coumadin. I couldn't find a history of the animal pesticides. However, it is manufactured by Dupont: # 302-992-5000. They are usually very helpful.

Question: My 86 year old aunt has been on Coumadin for the past 6 months and claims she feels like death warmed over since she’s been on this drug. Is there a special diet she should be on? Are there any side affects with this drug? To this point she has been a very healthy person, but for most of her life she has had heart flutter. That is the reason the doctor put her on this drug.

Answer: Coumadin rarely causes side effects. Why is she taking the drug? I suspect the medical condition that requires her to take the drug is the reason that she feels so poorly. There is no logical reason that her physician would suddenly start the drug without a change in her cardiac rhythm. I suspect that her rhythm is changed resulting in the change in her affect.

Question: My husband’s doctor just prescribed "coumadin" for him without even doing a blood test. He is taking a low aspirin dose every day and is leery of taking the coumadin. He is 73 and takes lanoxin and calin.

Answer: There are several reasons to take coumadin. However, these should be discussed with the patient and the risks and benefits should be explained. There is always a risk of bleeding with coumadin. Your husband needs to understand why he is taking this drug and what benefit the physician expects. Usually blood tests are not done until the patient is on the drug for a week or so. Then they should be done regularly (depending on how much variation is seen in his test from weekly to every 2 months).

Question: My mother is currently taking Coumadin. Is there a restriction of green vegetables while on this drug? If so, could you send me a list of the ones she should avoid? The drug has saved her life and stopped her stroking, but she also has bowel problems and must eat a lot of fiber.

Answer: There are a lot of medicines to avoid or to be careful taking with coumadin, but green vegetables are not one of them.

Question: My Dad was prescribed coumadin after his by-pass surgery recently. Specifically, which foods must he stay away from. Green, leafy vegetables is one type, but what else? Should he stay away form Grapefruit?

Answer: Green leafy vegetables are of no concern. There are many medications which can interact and any new medication should be discussed closely with your physician and pharmacist to determine the effect. For practical purposes, regular monitoring will reduce the risk of bleeding, which is about 5-10% per year.

Coumadin & Floxin
Question: Is there any interactions when taking Coumadin and Floxin which would increase the INR level?

Answer: Coumadin(warfarin) is an anti-coagulant used in a variety of situations to decrease the ability of the body to form clots. It acts on different "factors" in the blood necessary to start the coagulation cascade. These factors are made in the liver. Consequently, any drug that is metabolized in the liver can affect the level of coumadin in the body and the subsequent INR. INR is a measure of the decreased coagulation ability of the blood. Coumadin was initially discovered at the University of Wisconsin as a rat poison. As you can see too much of this drug will ruin your whole day. Therefore, it is very important that all your physicians and your pharmacist know that you are on coumadin. In general, antibiotics must be followed extremely closely to avoid either too much or too little coumadin. Floxin(ofloxacin) belongs to a class of drugs called quinolones. These drugs in general increase the effect of coumadin;that is, taking floxin will require your coumadin dose to be decreased. However, this is a very individual effect and must be watched by more regular blood tests to test the effect of coumadin while and immediately after taking the antibiotic.

Coumadin & Alcohol
Question: I am a 23 year old who is on Coumadin for a blood clot in my arm. I know that alcohol can increase the effects of the drug and cause internal bleeding. Is it safe to have a moderate amount of alcohol (2-3 drinks) once a week while on Coumadin or should it be avoided completely?

Answer: Usually, a moderate amount will not drastically affect the PT level.

Coumadin & Glucose Level
Question: Presently my Mother's coumadin dosage has been undergoing change (reduction). Is one's glucose level able to enhance the effect of coumadin?

Answer: Not usually.

Coumadin & Diet
Question: I have been on coumadin for 9 months now for DVT in my left lower leg after a knee replacement. I'm on 10 mg QD. My PT level has been 19-20 without any problems, until last week. My PT was 35.2 and My PTT was 77.1. Now my big question is, could my poor diet and/or eating a lot of grapefruit have any thing to do with such a big change in the levels going sky high so fast. My doctor took me off my coumadin for approx. 5 days and took a blood sample today and wants me to start again tomorrow with 5 mg.

Answer: Unless you suddenly started large doses of coumadin probably not. There are several possible interactions between diet and coumadin; but, it usually doesn't have a major effect like this unless there is a drastic change in your vegetable intake(particularly leafy, green vegetables). In clinical practice, most patients don't have these major dietary shifts. Other drug interactions are the most probably cause.

Coumadin's Side Effects
Question: Coumadine has been prescribed after I experienced a vein occlusion behind by eye. Can Coumadine have side effects that make one feel really tired and not well?

Answer: Not usually.

Coumadin & Artificial Aortic Valve
Question: I have an artificial aortic valve and all appears to be going OK, but just recently my INR is going down even though my doctor continues to increase my coumadin. Why is it going down?

Answer: Could be a lot of different reasons. Something is changing your liver metabolism or your diet is increasing in Vitamin K. Any of several drugs could cause this. I wouldn't spend a lot of time trying to figure it out unless it is markedly variable.

Strange Side Effects
Question: I am just a little guy, a patient on Coumadin, 73, under a physician's care. I have lost 100 pounds in the last year and feel great. I mean great. I exercise by swimming and my Doctor is pleased. I have a problem which does not worry him. He says it is very common. My heart beat is not totally in rhythm. I get these short circuits and don't even notice it but my heart beat is not totally rhythmic. To lessen the chances of clots forming he has prescribed Coumadin and I am monitored closely. My problem is a possible side effect. It bothers me. It doesn't really bother my Doctor. And this possible side effect is perversion of taste. I just can't taste things like I used to. I ate a hamburger for the first time in a year, a Burger King, and honestly I couldn't taste it. I could have been eating anything. I buy these sugar-free Jell-O products. I can taste Cherry and Orange and Strawberry real well. I have problems with the taste of chicken, beef, spaghetti, sauces, etc. Somewhere I think I have read about Comedian and the "perversion of taste". I am writing you because I am new to the Web and I have searched and searched and I just can't find this side effect. Serious side effects are in abundance. Perhaps this one just does not merit mentioning. I hope you can help me. I am desperate. I am 73 and now weigh 177. I am proud of this weight loss. Please look into this for me and give me your comments.

Answer: None of my patients report this side effect. Also, I looked too and didn't find any reports. You might contact the manufacturer Dupont 619-457-2553.

Atrial Fibrillation
Question: I have been experiencing atrial fibrillation (episodic every 2-3 months) for about 5 years and since the onset have been taking Lanoxin and seeing my doctor every 6 months for level checks and general check-ups. At my last visit he surprised me by becoming very insistent on my using Coumadin to help prevent a possible stroke. I am questioning whether taking this drug is necessary for me. I am 51 years old and the cause of my fibrillation has not been attributed to any heart disease. Are there alternatives which would work for me, aspirin perhaps?

Answer: There is an increased risk of stroke if you continue to have episodic atrial fibrillation. Coumadin will be the best drug; although, aspirin has an effect in decreasing stroke. If you were 80, I'd recommend the aspirin; but, you have a lot of years for a stroke to affect you. Another alternative would be to eliminate the A Fib with a drug like amiodarone which I would try if you haven't . It is pretty clear the digoxin isn't working. Another alternative are beta-blockers; but, they are less likely to work.

Atrial Fibrillation
Question: My husband has been on Coumadin since September for a clotting problem. Before that time, he was having no noticible problems, but snce has had problems with hyperventilating, chest pains (musculatory, not cardiac), muscle spasms (from the hyperventiting), fatigue, impotence, and many smaller side effects. We have been told that this could not be caused by the drug (he’s not on any others), but the difficulties are more evident when his dosage is high. When he had to go off the drug for clotting factor testing, the symptoms disappeared, and returned when he started it again. Since the clot didn’t cause these, could there be other factors that may have? He’s in his late 30’s, not overweight, but seems to bis n the physical health of one in his fifties with lO0 extra pounds. Would there be anyone doing research on Coumadin who has seen or witnessed any of the above side effects? Where could I find further studies on this drug that would clarify why this could be happening?

Answer: Coumadin, as you know, is a form of “blood thinner”, in that it affects blood clotting function, making the patient less likely to form abnormal clots. The uses of this medication are many, ranging from clots in the leg veins or lung, abnormal heart rhythm, to genetic/inborn clotting problems. Close follow up to check blood levels of the medication is essential to avoid the most common side effect- that of bleeding from high coumadin levels in the blood. Your husband’s symptoms definitely warrant further investigation. As you mentioned, he is not taking any other medications, and there appeared to be a relationship between his being off the medication and symptom improvement. It may be that there truly is a relationship, but one instance of symptom improvement with one instance of drug removal may not necessarily be grounds to assume a cause and effect relationship. That is to say, perhaps there are other reasons for why there appeared to be a time related relationship when the drug was stopped, but the symptom improvement was not due to removal of the drug itself. The Physician’s Desk Reference lists as rare side effects of coumadin (in addition to bleeding with high levels) nausea, rash, diarrhea, and possibly priapism (persistent and painful penile erection). Although there is always the possibility that the medication is indeed causing your husband’s symptoms, given the side effects listed for coumadin, further investigation into other causes for the symptoms should be pursued. A visit to your health care provider, even if it means repeating the symptom complex to him or her, may be beneficial. Persistence of symptoms over time may provide additional insight for your provider into what some of the possible causes are.

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