Warfarin supply disruption: what to do?

[Dustin]

It is not my intention to scare the valvers on this board, but I was wondering what to do when warfarin "runs out" temporarily, say months. Would aspirin, lovenox, or any sort of alternative be suitable to make it through months? Is there any sort of food that would increase the INR? Your views are very much appreciated.

 

[hensylee]

it has become such a widely used medicine. It has created special labs, extra jobs - I doubt they would ever let it run out. If it did, there would be another on its heels. Yes, aspirin, other meds and greens would probably do the trick - or close.

 

[Guest]

One of the things that would argue against a severe shortage in the US at least is that most people purchase warfarin with insurance that limits them to a 30 to 90 day supply. These companies will not allow purchases too early. This prevents hoarding which is a big factor in shortages.

Aspirin is only about 20% as effective as warfarin at preventing clots in atrial fibrillation - probably about the same in mechanical valves but it has never been tested. Any herbs or foods are probably less than that. Greens are anti-warfarin so that would not be the answer.

Heparin and derivatives like Lovenox are a possibility but they have to be injected.

It is not just warfarin that is in danger -- it is all medications. We are so dependent on computers to supply medications to hospitals and pharmacies "just in time" that there is no tolerance (sorry engineers) in the system. A fire at a manufacturer's plant could create a months-long shortage of a drug and all of its alternatives by the domino effect. Look at what happened during the hurricaines.

 

[RCB]

We all remember the toilet paper shortage of the '70s

We all remember the toilet paper shortage of the '70s

Al, is right again- many of us remember the T-paper shortage started just by people saying there was a shortage. I have wonder about other drugs like Insulin, heart meds and psych. drug that even being off a few hours can cause big problems and harder to manufacture then warfarin(remember you could always go to your local farm supply where they buy rat killer by the pallet ). Let face it, the whole country depends on the drug industry. As
Ross and others will tell you, try getting along without O2 for even 10 mins .

 

[geebee]

Right now my SO is dealing with low supplies of Primatene. I do not know if it is local or not. Personally I think it is due to a attempt to hike the price. When items are missing from shelves, people will pay any price, especially if it is something you need to breathe.

Don't get me wrong, it's not that he can't find it at all; it's just that some places don't have it.

 

[Dustin]

One of the things that would argue against a severe shortage in the US at least is that most people purchase warfarin with insurance that limits them to a 30 to 90 day supply. These companies will not allow purchases too early. This prevents hoarding which is a big factor in shortages.

Aspirin is only about 20% as effective as warfarin at preventing clots in atrial fibrillation - probably about the same in mechanical valves but it has never been tested. Any herbs or foods are probably less than that. Greens are anti-warfarin so that would not be the answer.

Heparin and derivatives like Lovenox are a possibility but they have to be injected.

It is not just warfarin that is in danger -- it is all medications. We are so dependent on computers to supply medications to hospitals and pharmacies "just in time" that there is no tolerance (sorry engineers) in the system. A fire at a manufacturer's plant could create a months-long shortage of a drug and all of its alternatives by the domino effect. Look at what happened during the hurricaines.

Yesterday evening I watched this documentary on Belgium TV reporting about Omega 3 fatty acids, also referred to as "fish oil." To my surprise it was claimed that substantial fish oil in your diet may cause higher anticoagulation. Have you come across this before?

The funny part was that someone said to smell like a fish when taking fish oil in large quantities.

 

[tommy]

My cardio suggested that I take fish oil to raise my HDL. He didn't mention anticoagulation.

 

[Dustin]

My cardio suggested that I take fish oil to raise my HDL. He didn't mention anticoagulation.

Fish oil interaction with warfarin.

Buckley MS, Goff AD, Knapp WE. (2004)

Shawnee Mission Medical Center, Shawnee Mission, KS of Arizona, Tucson, AZ 85724, USA. [email protected]

OBJECTIVE: To report a case of elevated international normalized ratio (INR) in a patient taking fish oil and warfarin. CASE SUMMARY: A 67-year-old white woman had been taking warfarin for 1(1/2) years due to recurrent transient ischemic attacks. Her medical history included hypothyroidism, hyperlipidemia, osteopenia, hypertension, and coronary artery disease. She also experienced an inferior myocardial infarction in 1995 requiring angioplasty, surgical repair of her femoral artery in 1995, and hernia repair in 1996. This patient has her INR checked in the anticoagulation clinic and is followed monthly by the clinical pharmacist. Prior to the interaction, her INR was therapeutic for 5 months while she was taking warfarin 1.5 mg/d. The patient admitted to doubling her fish oil dose from 1000 to 2000 mg/d. Without dietary, lifestyle, or medication changes, the INR increased from 2.8 to 4.3 within 1 month. The INR decreased to 1.6 one week after subsequent fish oil reduction, necessitating a return to the original warfarin dosing regimen. DISCUSSION: Fish oil supplementation could have provided additional anticoagulation with warfarin therapy.Fish oil, an omega-3 polyunsaturated fatty acid, consists of eicosapentaenoic acid and docosahexaenoic acid. This fatty acid may affect platelet aggregation and/or vitamin K-dependent coagulation factors. Omega-3 fatty acids may lower thromboxane A(2) supplies within the platelet as well as decrease factor VII levels. Although controversial, this case report illustrates that fish oil can provide additive anticoagulant effects when given with warfarin. CONCLUSIONS: This case reveals a significant rise in INR after the dose of concomitant fish oil was doubled. Patients undergoing anticoagulation therapy with warfarin should be educated about and monitored for possible drug-herb interactions. Pharmacists can play a crucial role in identifying possible drug interactions by asking patients taking warfarin about herbal and other alternative medicine product use.

Source:
http://www.ncbi.nlm.nih.gov/entrez/..._uids=14742793&query_hl=2&itool=pubmed_docsum


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Unfortunately, this does not show whether fish oil itself increases the INR for those who do not take any anti-coagulation. But then again, the title says interaction with warfarin.

 

[Guest]

I tend to discount these 1 patient reports of things that cause an interaction. Why has nobody discovered this before? We all know about how easy it is to throw warfarin off. There is tremendous pressure on young faculty members to publish articles and having a "first of its kind" seems like a real triumph. Lets see if someone else finds the same thing.

 

[RCB]

Gee- Maybe they should study me!

Gee- Maybe they should study me!

I tend to discount these 1 patient reports of things that cause an interaction. Why has nobody discovered this before? We all know about how easy it is to throw warfarin off. There is tremendous pressure on young faculty members to publish articles and having a "first of its kind" seems like a real triumph. Lets see if someone else finds the same thing.

I agree! I'll give you a one pt. case study. Pt. was on 1000 mg. fish oil
a day. When his kidney specialist suggest that fish oil was so good, the pt. should take it 4 times a day. Pt. complied and within two weeks, observed a strange metalic taste in pt.'s mouth. Then pt. read where some studies were
showing fish oil could make people with A-Fib have more problems. Pt. returned to 1000 mg a day of fish oil after a 6 week trail. Pt. home tests and remaine in range, with no adjustments to warfarin dosage in spite of increase in fish oil supplements. Pt. was me and all the above case cited above show some people react differently to different chemical- The medical community
has know this for over 100 years or more. Publish or Perish is the name of the game at these institutions of "Higher Learning"!

 

[Dustin]

I tend to discount these 1 patient reports of things that cause an interaction. Why has nobody discovered this before? We all know about how easy it is to throw warfarin off. There is tremendous pressure on young faculty members to publish articles and having a "first of its kind" seems like a real triumph. Lets see if someone else finds the same thing.

Agreed. Low hanging fruit is gone, and scientists all over the world have to work much harder to find something revolutionary, hence rushed papers with a too small sample size. Anway, real breakthroughs will make it prime time and we'll know about them soon enough.

 

[carbomedic]

I must admit, thinking about natural disasters concerns me as to warfarin supply, specifically, mine. What's a guy to do?? And your atr right, insurance won't pick up the tab.
How bout, what is the shelf life of warfarin?
I could buy it myself and store it, rotate stock.
Just thinking.

carbo

 

[geebee]

I must admit, thinking about natural disasters concerns me as to warfarin supply, specifically, mine. What's a guy to do?? And your atr right, insurance won't pick up the tab.
How bout, what is the shelf life of warfarin?
I could buy it myself and store it, rotate stock.
Just thinking.

carbo

When I worked at a company a few years back that had a great prescription plan, I ordered my coumadin as soon as they would allow each refill which was always sooner than I really needed it. Over the years I worked there, I ended up with a surplus of about a year's worth of coumadin at the time I left the company. However, I was on Cobra after I left the company and couldn't afford much. I used the supply of coumadin down to the last pill with no variation in quality. Therefore I can tell you it is good for at least one year (and most likely longer).

 

[Guest]

Shelf life in an unknown number. It is tested under artificial conditions to simulate rapid deterioration. Then the company says that it will last at least X years. I know a pharmacist who was in the Army and was responsible for testing anti-nerve agents etc. He said that many of them were just as potent as the day they were made years after the use before date was passed. You can't make a valid conclusion about anything else except that under good storage conditions (not refrigerated for pills) most stuff will last a long time.

Example: Why does bottled water have an expiration date? At what point does it cease to be full strength water? Or do so many contaminants leach out of the bottle that the water becomes toxic?

My neighbor is on oxygen. If there is a big blizzard and the electricity goes off and the Rescue Squad can't get there it is all over.

 

[Ross]

My neighbor is on oxygen. If there is a big blizzard and the electricity goes off and the Rescue Squad can't get there it is all over.

I would hope he's got at least 8 hours of O2 in cylinders just incase. I know I do and get to use them pretty frequently too.

 

[Guest]

I'm sure that he does. Actually he has muscular dystrophy and is having trouble breathing on his own. He needs more that just O2 blowing up his nose. Seems like he deteriorates every week. I wrote this to demonstrate that a warfarin shortage need not be at the forefront of everyone's mind by illustrating that there are more pressing problems.

 

[Ross]

I'm sure that he does. Actually he has muscular dystrophy and is having trouble breathing on his own. He needs more that just O2 blowing up his nose. Seems like he deteriorates every week. I wrote this to demonstrate that a warfarin shortage need not be at the forefront of everyone's mind by illustrating that there are more pressing problems.

Oh i gathered that, it's just that when I see the word Oxygen, my mind goes straight to that part.

 

[Guest]

One of our patients always wants her O - Z - Why -Gun checked.

 

[MikeHeim]

As somebody who works for an unnamed medical device company, I can confirm the earlier statements on shelf life for drugs. A shelf life is picked (not kidding) while the drug is in development based on what the customer would deem as reasonable. The lab will then perform the aging studies and prove out that the drug is effective over that time period. The reason is pretty simple. If you had a container of Drug X that you found in your cabinet five years after purchase and the label said the shelf life was seven years, you would probably have no problem taking the drug for whatever its intended use was. However, if the label said the shelf life was two years, you would throw the bottle away and buy a new one. Obviously most companies would like to have a shelf life of about 30 days so that everyone would have to keep restocking their shelves, but with a shelf life that short, people would get frustrated and find a competitor drug that had a longer shelf life. It's not a coincidence that most drugs (especially OTC), have a shelf life of exactly 1, 2, or 3 years.

 

[RCB]

Boy........

Boy........

As somebody who works for an unnamed medical device company, I can confirm the earlier statements on shelf life for drugs. A shelf life is picked (not kidding) while the drug is in development based on what the customer would deem as reasonable. The lab will then perform the aging studies and prove out that the drug is effective over that time period. The reason is pretty simple. If you had a container of Drug X that you found in your cabinet five years after purchase and the label said the shelf life was seven years, you would probably have no problem taking the drug for whatever its intended use was. However, if the label said the shelf life was two years, you would throw the bottle away and buy a new one. Obviously most companies would like to have a shelf life of about 30 days so that everyone would have to keep restocking their shelves, but with a shelf life that short, people would get frustrated and find a competitor drug that had a longer shelf life. It's not a coincidence that most drugs (especially OTC), have a shelf life of exactly 1, 2, or 3 years.

Ain't that the truth!