Reactions 1680, p236 - 2 Dec 2017 X S Increased plasma levels of warfarin and intraoperative haemorrhage: 4 case reports In a cross-sectional prospective study, four patients [not all ages and sexes stated] were described, who developed intraoperative haemorrhage (n=3) or increased plasma levels of warfarin (n=1) following interaction between Salvia officinalis [sage] and warfarin (n=1) or fish oil [omega-3 fish oil], warfarin and clopidogrel (n=1) or fish oil and enoxaparin sodium (n=2) [routes not stated; not all dosages and indication stated]. A patient experienced a rise in the plasma levels of warfarin following an interaction between warfarin and Salvia officinalis [not all outcomes stated]. An 82-year-old man with cholecystitis was undergoing an emergency laparoscopic cholecystectomy. He had been using fish oil in the week preceding his surgery. During his hospitalisation, he received warfarin and clopidogrel. Subsequently, his haemoglobin dropped from 13 g/dL to 9 g/dL and intraoperative haemorrhage was suspected. He was treated with two units of packed cells and his condition normalised. The man’s intraoperative haemorrhage was thought to be related a drug interaction between fish oil, warfarin and clopidogrel. A 93-year-old woman with large bowel obstruction underwent an urgent laparoscopic hemicolectomy. She had been using fish oil in the week preceding her surgery. During hospitalisation, she received enoxaparin sodium 20mg daily for prevention of thrombosis. Following the surgery, her haemoglobin dropped from 12 g/dL to 8 g/dL. Intraoperative haemorrhage was suspected, and she was treated with two units of packed cells. The woman’s intraoperative haemorrhage was thought to be related a drug interaction between fish oil and enoxaparin sodium. A 67-year-old man was undergoing laparoscopic sleeve gastrectomy for weight loss. He had been using fish oil in the week preceding his surgery. During hospitalisation, he received preventive enoxaparin sodium 40mg daily pre- operatively. Intraoperative haemorrhage was reported. He underwent haemostasis with staples and surgicell. His bleeding resolved without a drop in haemoglobin. The man’s intraoperative haemorrhage was thought to be related a drug interaction between fish oil and enoxaparin sodium. Author comment: "Eight [Dietary and Herbal Supplements] were involved in potential interactions with anticoagulant or antiplatelet drugs". "[S]age in one patient treated with such medications) may have increased the warfarin plasma level by potentially inhibiting CYP 2C9." "According to the [Drug Interaction Probability Scale], all three of these actual bleeding events were "probably’’ caused by the mentioned [Dietary and Herbal Supplements]–drug interactions." Levy I, et al. Perioperative Risks of Dietary and Herbal Supplements. World Journal of Surgery 41: 927-934, No. 4, Apr 2017. Available from: URL: http:// doi.org/10.1007/s00268-016-3825-2 - Israel 803285088 0114-9954/17/1680-0001/$14.95 Adis © 2017 Springer International Publishing AG. All rights reserved Reactions 2 Dec 2017 No. 1680
Reactions Weekly – Springer Journals
Published: Dec 2, 2017
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