Probable Interaction Between Warfarin and Inhaled and Oral Administration of Cannabis

2019 ◽  
Vol 33 (6) ◽  
pp. 915-918 ◽  
Author(s):  
Amy Hsu ◽  
Nathan A. Painter
Keyword(s):  
Case Reports ◽  
Middle Eastern ◽  
Signs And Symptoms ◽  
International Normalized Ratio ◽  
Cannabis Use ◽  
Bleeding Complications ◽  
Close Monitoring ◽  
Interaction Probability ◽  
Probable Interaction

Objective: To report a probable interaction between warfarin and edible cannabis that resulted in an elevated international normalized ratio (INR) without bleeding complications. Case Summary: A 35-year-old Middle Eastern male on warfarin long term with an INR goal of 2.5 (accepted range: 2.0-3.0). The patient has generally been stable on warfarin 10 mg daily from 2010 to 2018, until INR suddenly increased to 7.2 following 1 month of edible cannabis ingestion and cannabis smoking. Patient denied any signs and symptoms of bleeding. No other reasonable causes of the elevation in INR were apparent. The patient was advised to hold 2 doses of warfarin and discontinue cannabis use. The INR dropped below 4 upon discontinuation of cannabis with dose adjustments to warfarin. Discussion: The elevation in INR can be explained by the inhibition of CYP2C9 by cannabis use causing decreased metabolism of warfarin. The interaction between warfarin and cannabis was determined to be probable using the Horn Drug Interaction Probability Scale. Conclusions: There are no previous reports of interactions between edible cannabis and warfarin, with very few case reports describing the interaction with other forms of cannabis. Close monitoring of INR in patients with concomitant cannabis is recommended for proper warfarin management.

Inductive Effect of a Ritonavir-Containing Hepatitis C Treatment Regimen on Warfarin in a Patient—A Case Report

2018 ◽  
Vol 32 (4) ◽  
pp. 470-473 ◽  
Author(s):  
Audrey C. Rosene ◽  
Jaymee L. Gaspar
Keyword(s):  
Hepatitis C ◽  
Treatment Regimen ◽  
Case Reports ◽  
Warfarin Dose ◽  
International Normalized Ratio ◽  
Close Monitoring ◽  
Anticoagulation Management ◽  
Hepatitis C Treatment ◽  
History Of ◽  
Repeated Use

The warfarin management strategy for a mechanical mitral valve patient initiated on a ritonavir-based hepatitis C treatment regimen is described. A 62-year-old male with a past medical history of hepatitis C genotype 1a and stable warfarin dose history was initiated on a concomitant Viekira Pak® (VP) regimen containing ritonavir. Prior to initiation of the VP for hepatitis C treatment, the patient was stable on a warfarin dose of 40 mg/wk for 5 months. During treatment with VP, the patient experienced a markedly decreased international normalized ratio (INR) and warfarin requirements ultimately increased 125% from baseline (90 mg/wk). Effective anticoagulation management throughout and surrounding the treatment period for hepatitis C involved frequent warfarin dose adjustments, including preemptive changes, close monitoring, and repeated use of enoxaparin to ensure adequate thrombotic prophylaxis. This is believed to be the first reported case describing the management of warfarin in a patient with hepatitis C who received VP and required a drastically increased weekly warfarin dose. The possible mechanisms suggestive of this interaction and similar case reports in the literature are discussed.

Transient Elevation of International Normalized Ratio During Cisplatin-Based Chemotherapy in Patients Who are Taking Warfarin

2011 ◽  
Vol 45 (10) ◽  
pp. 1308-1308 ◽  
Author(s):  
Ryoichi Yano ◽  
Tetsuji Kurokawa ◽  
Hideaki Tsuyoshi ◽  
Akiko Shinagawa ◽  
Yoko Sawamura ◽  
...  
Keyword(s):  
International Normalized Ratio ◽  
Target Range ◽  
Probability Scale ◽  
Common Drug ◽  
Case Summary ◽  
The Common ◽  
Transient Elevation ◽  
Interaction Probability ◽  
Antineoplastic Chemotherapy ◽  
Probable Interaction

Objective: To report 2 cases of a probable interaction between cisplatin and warfarin. Case Summary: Two cases of transient elevation of international normalized ratio (INR) during Irinotecan (60 mg/m2 on days 1, 8, and 15) plus cisplatin (60 mg/m2 on day 1) chemotherapy with concomitant warfarin are presented. In both cases, warfarin dosages were stable at the therapeutic target range prior to initiation of chemotherapy. Granisetron hydrochloride (3 mg on days 1, 6, and 15) and dexamethasone (13.2 mg on day 1 and 6.6 mg on days 2, 3, 8, and 15) were used prior to irinotecan administration in both patients. In addition, aprepitant was administered to both patients for 3–5 days with cisplatin. One of these patients also received aprepitant with irinotecan on days 8 and 15. During chemotherapy, INR was transiently elevated almost 1.5-fold over baseline level on day 3. This variation did not occur in subsequent irinotecan cycles on days 8 and 15. The timing of these increases was similar in each of the cycles. Discussion: Cisplatin was the common drug in the cases presented and therefore could be related to the INR elevations. To our knowledge, these are the first reports of an Interaction between warfarin and irinotecan-cisplatin chemotherapy, but reports of a similar interaction with chemotherapy including platinum derivatives exist. Use of the Horn Drug Interaction Probability Scale indicated a probable interaction between warfarin and cisplatin. Conclusions: Cisplatin might affect the anticoagulation function of warfarin. Careful INR monitoring is necessary during antineoplastic chemotherapy with cisplatin in patients taking warfarin.

scholarly journals Challenges in Management of Bartholin gland Leiomyoma: A Case Report

2020 ◽  
Author(s):  
Angela Vinturache ◽  
Lamiese Ismail ◽  
Stephen Damato ◽  
Hooman Soleymani Maid
Keyword(s):  
Case Report ◽  
Case Reports ◽  
Symptom Control ◽  
Clinical Signs ◽  
Signs And Symptoms ◽  
Postoperative Recovery ◽  
Long Term Follow Up ◽  
Vulvar Mass

Abstract Background: Leiomyomas are uncommon vulvar neoplasms often misdiagnosed as other Bartholin gland pathology. Due to their rarity and the absence of guidelines, their diagnosis and management remain challenging, largely based on expert opinion and evidence from case reports. Case Presentation: This case report describes a 44-year-old woman presenting with accelerating growth of a vulvar mass. Based on clinical signs and symptoms, the initial diagnosis was Bartholin cyst. Surgical excision was provided for symptom control and aesthetic reasons. The histopathologic diagnosis was vulvar leiomyoma. The postoperative recovery was complicated by secondary haematoma and dehiscence of the surgical site. There was no recurrence at two years follow up. Therefore, we discuss the dilemma posed by physical examination of a vulvar mass, the challenges of the management, and report on secondary morbidity and long-term follow up, aspects of care for patients with vulvar pathology not commonly addressed in the literature. Conclusions: Bartholin gland neoplasms are rare tumors, commonly misdiagnosed as Bartholin’s cysts. Excision is the treatment of choice. Short time follow up allows prompt management of potential postoperative complications. Continuing long term follow up is recommended due to recurrence risk.

scholarly journals Anosmia and Ageusia as Initial or Unique Symptoms after SARS-COV-2 Virus Infection

2020 ◽  
Author(s):  
Calixto Machado ◽  
Joel Victor Gutierrez
Keyword(s):  
Case Reports ◽  
Signs And Symptoms ◽  
World Health ◽  
Upper Respiratory Tract ◽  
Prodromal Phase ◽  
The Common ◽  
Health Organization ◽  
Tract Infections ◽  
Post Infectious

SARS-CoV-2 (CoV-2) is a coronavirus which is causing the actual COVID-19 pandemic. The disease caused by 2019 new coronavirus (2019-nCoV) was named coronavirus disease-19 (COVID-19) by the World Health Organization in February 2020. Primary non-specific reported symptoms of 2019-nCoV infection at the prodromal phase are malaise, fever, and dry cough. The most commonly reported signs and symptoms are fever (98%), cough (76%), dyspnea (55%), and myalgia or fatigue (44%). Nonetheless, recent reports suggest an association between COVID-19 and altered olfactory and taste functions, although smell seems to be more affected than taste. These associations of smell and taste dysfunctions and CoV-2 are consistent with case reports describing a patient with SARS with long term anosmia after recovery from respiratory distress, with the observation that olfactory function is commonly altered after infection with endemic coronaviruses, and with data demonstrating that intentional experimental infection of humans with CoV-299 raises the thresholds at which odors can be detected. Post-viral anosmia and is one of the leading causes of loss of sense of smell in adults, accounting for up to 40% cases of anosmia. Viruses that give rise to the common cold are well known to cause post-infectious loss, and over 200 different viruses are known to cause upper respiratory tract infections. I reviewed the possible mechanisms of smell and taste loss in COVID-19. I concluded that since the existence of such a relationship is likely, it is highly recommended that those patients who experience complications such as smell and/or taste loss, even as unique symptoms, should be considered as potential SARS-CoV-2 virus carriers.

Possible Amiodarone−Warfarin Interaction: A Reemphasis on a Potentially Dangerous Drug−Drug Interaction

2007 ◽  
Vol 20 (6) ◽  
pp. 469-473
Author(s):  
Roda Plakogiannis ◽  
Regina Ginzburg
Keyword(s):  
Potent Inhibitor ◽  
Warfarin Dose ◽  
International Normalized Ratio ◽  
Warfarin Interaction ◽  
Bleeding Complications ◽  
Cytochrome P450 Enzyme ◽  
Close Monitoring ◽  
Probability Scale ◽  
P450 Enzyme ◽  
Cytochrome P450 Enzyme System

This article reports two patients with delayed amiodarone— warfarin interaction resulting in a significant elevation in the international normalized ratio. One patient developed episodes of nosebleeds. Amiodarone is a potent inhibitor of the cytochrome P450 enzyme system. Warfarin undergoes metabolism via the same isoenzyme, potentially leading to prolongation of elevated international normalized ratio levels. A decrease in the warfarin dose is thus warranted when coadministered with amiodarone to circumvent the potential danger of this interaction, which can go unnoticed because several weeks of therapy may be necessary to discern an elevated international normalized ratio. The Naranjo probability scale indicated a possible relationship between the elevated international normalized ratio levels and the coadministration of amiodarone and warfarin. With the coadministration of warfarin and amiodarone, frequent and close monitoring of warfarin is paramount, especially in the initial weeks of therapy, in an effort to prevent supratherapeutic international normalized ratios and bleeding complications.

Phenelzine and Morphine Drug-Drug Interaction? A Literature Review

2020 ◽  
pp. 089719002097075
Author(s):  
Ryan J. Beechinor ◽  
Rachel Tyson ◽  
Mary E. Roth
Keyword(s):  
Drug Interaction ◽  
Case Report ◽  
Single Case ◽  
Case Reports ◽  
Signs And Symptoms ◽  
Human Studies ◽  
Close Monitoring ◽  
Review Articles ◽  
Drug Drug Interaction

The objectives of this manuscript are to describe a case report of a patient whose phenelzine maintenance therapy was discontinued due to concern for a phenelzine-morphine drug interaction, to review the available literature regarding the potential for this drug-drug interaction, and provide recommendations for this clinical scenario. A PubMed/MEDLINE literature search was conducted and all publications determined to be relevant to this case report were included. Literature describing in vitro data, case reports/human studies, and review articles concerning the interaction between morphine and monoamine oxidase inhibitors (MAOIs) were included. A total of 14 publications pertinent to the potential phenelzine-morphine interaction were included in this review including 5 in vitro studies, 4 human studies, and 6 review articles detailing the drug interaction profile between opioids and antidepressants. Of these publications, only a single case report of a potential drug interaction between morphine and phenelzine was identified. The literature suggesting a drug interaction between morphine and phenelzine is limited. The combination of phenelzine and morphine, with close monitoring for signs and symptoms of serotonin syndrome, is reasonable for patients with appropriate indications for both agents.

Cardiomyopathy From Ipecac Administration in Munchausen Syndrome by Proxy

PEDIATRICS ◽  
1993 ◽  
Vol 92 (4) ◽  
pp. 601-603
Author(s):  
JENS GOEBEL ◽  
DAVID A. GREMSE ◽  
MICHAEL ARTMAN
Keyword(s):  
United States ◽  
Case Reports ◽  
Signs And Symptoms ◽  
The United States ◽  
Munchausen Syndrome ◽  
Munchausen Syndrome By Proxy ◽  
Term Basis

In the United States, serum of ipecac is the emetic of choice in poisoning victims if induction of vomiting is indicated. It is readily available without prescription and has been intentionally administered on a long-term basis in cases of self-abuse or abuse by caretakers. Signs and symptoms of chronic ipecac poisoning include protracted vomiting and diarrhea as well as skeletal and cardiac myopathy. We report two cases of ipecac cardiomyopathy due to Munchausen syndrome by proxy (MSBP) in children with longstanding vomiting and diarrhea. CASE REPORTS Case 1 At the age of 29 months, a white, previously healthy boy doveloped appendicitis and underwent appendectomy.

Nortriptyline Cardiac Toxicity Resulting from a Probable Interaction with Telithromycin

2009 ◽  
Vol 44 (5) ◽  
pp. 397-400
Author(s):  
Angela R. Thomason ◽  
Bruce A. Waldrop ◽  
Sherry O. Price
Keyword(s):  
Adverse Effects ◽  
Cardiac Toxicity ◽  
Close Monitoring ◽  
Probability Scale ◽  
Case Summary ◽  
Atrioventricular Nodal Reentry Tachycardia ◽  
Interaction Probability ◽  
Probable Interaction ◽  
Reentry Tachycardia ◽  
New Onset

Objective To report a case of probable nortriptyline toxicity associated with a combination of telithromycin and nortriptyline. Case Summary A 50-year-old white woman was admitted to the hospital with new-onset palpitations after taking 5 days of telithromycin in combination with nortriptyline. On admission her electrocardiograph showed atrioventricular nodal reentry tachycardia. The patient was also hypotensive, with a blood pressure of 90/45 mm Hg. She had been taking nortriptyline 150 mg daily at bedtime for 10 years without complications. The final day of telithromycin therapy was completed, and nortriptyline was discontinued on admission. The tachycardia subsided with a dose of diltiazem. Discussion It is suspected that the cardiovascular symptoms observed in the patient are the result of nortriptyline toxicity caused by inhibition of CYP2D6 by telithromycin. Limited evidence shows that telithromycin may be an inhibitor of CYP2D6. An assessment of causation of the adverse effects using the Drug Interaction Probability Scale suggests a probable interaction between telithromycin and nortriptyline. Conclusion It is recommended that clinicians remain aware of possible interactions between telithromycin and known CYP2D6 substrates such as nortriptyline. Should telithromycin therapy be required, close monitoring of the potential adverse effects and/or plasma drug levels of patients taking interacting drugs is warranted.

scholarly journals Probable Interaction Between Warfarin and the Combination of Remdesivir With Dexamethasone for Coronavirus Disease 2019 (COVID-19) Treatment: A 2 Case Report

2021 ◽  
pp. 089719002110086
Author(s):  
Ronald Patrick Landayan ◽  
Sampson Saint-Felix ◽  
Ashley Williams
Keyword(s):  
Warfarin Therapy ◽  
International Normalized Ratio ◽  
Patient Specific ◽  
Potential Drug Interaction ◽  
Potential Drug ◽  
Specific Goal ◽  
Admission Interview ◽  
Male Patients ◽  
Probable Interaction

Purpose: To describe a potential drug interaction between warfarin and the combination of remdesivir with dexamethasone. Summary: Two male patients, a 71-year-old and 62-year-old presented to the emergency department for symptoms of coronavirus disease 2019 (COVID-19). Both patients were on long-term warfarin therapy with their most recent international normalized ratio (INR) prior to admission within their patient specific goal as managed by their outpatient Pharmacist. In both instances, the patients denied any changes in diet, lifestyle, or missed doses of medications upon admission interview. During admission, both patients experienced a marked elevation in INR within 24 to 48 hours of the initiation of remdesivir with dexamethasone for COVID-19 pneumonia directed therapy. The patients were both eventually stable and were instructed to continue warfarin monitoring and management under the direction of their outpatient Pharmacist upon discharge. Conclusion: The underrecognized but probable interaction between warfarin in conjunction with remdesivir and dexamethasone warrants further analysis.

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.

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