my Monty Python moment

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ski girl

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Joined
Sep 14, 2010
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683
Location
Perth, Western Australia
Does anyone remember the Monty Python scene where people are dying at a dinner party and the grim reaper appears and announces the source of the problem - 'it was the salmon mousse'?

Well I had a similar experience this week. I had a blood test for something totally unrelated to warfarin and just because they had a needle in me they decided to test my INR, which I said would be 3.0 +/- 0.1. Imagine my shock when it came back and was 9.0!

I immediately stopped juggling the sharp knives and took my Vit K but I've been wracking my brain trying to figure out what happened - then I saw an article on Yahoo about the dangers of grapefruit juice.

And my Monty Python moment - 'it was the grapefruit juice'!!!!! Last week I bought a huge bottle of it and had a large glass every night, usually washing down my warfarin with it! Oops . . . .
 
Grapefruit juice (and grapefruit, in general) is not a friend for many of us. I am now taking Lipitor (Atorvastatin) because it's part of the stroke protocol, supposedly reducing the risk of stroke for people who've had one (I had a TIA in April), and anything with grapefruit is a strict no-no.

Of course, with an INR of 9.0, you'd have figured out that your INR was too damned high before too long because you'd have been symptomatic fairly soon.

I'm glad that the lab caught it before it could do any damage -- and will continue to avoid Grapefruit. (I live in an area that used to be an orange grove -- if I walk near a tree that looks like it may be growing grapefruit, I'll cross the street and go around it.)
 
I had a blood test for something totally unrelated to warfarin and just because they had a needle in me they decided to test my INR, which I said would be 3.0 +/- 0.1. Imagine my shock when it came back and was 9.0!

I immediately stopped juggling the sharp knives and took my Vit K but I've been wracking my brain trying to figure out what happened - then I saw an article on Yahoo about the dangers of grapefruit juice.

And my Monty Python moment - 'it was the grapefruit juice'!!!!! Last week I bought a huge bottle of it and had a large glass every night, usually washing down my warfarin with it! Oops . . . .

My first reaction with an INR of 9.0 would be test error, especially if I had been within my range for the last few months. I have read about the grapefruit interaction although I have never found it to have a negative effect on my INR. Depending on your internet source, you can read that all citrus products may interact with warfarin, as well as a number of other medications. Like the foods that are very hi in vit K, we only need to monitor our consumption a little, but we do no need to avoid or exclude them from our diet. I enjoyed grapefruit and grapefruit juice for 30 years before learning of a possible interaction....and I have enjoyed them for 15 years after learning of the possible interaction......it's like kale, a serving ever so often is OK, but you don't want to sit down and eat a bushel basket at a sitting.

FWIW, tonite is my nite to cook dinner and I just got back from the store after buying a grapefruit to have for a fruit desert. We normally enjoy a grapefruit half every few weeks.
 
I've found cranberry juice has the same impact for me. I ran an INR that high going through a family size jug in a week or two. Don't do cranberry much anymore. *TMI - Took a trip to urgent care with blood in urine to learn.
 
Interestingly, when the doc took my blood she said she was surprised I didn't bleed more from the needle stick!

Also interestingly, grapefruit is fine, it's the juice that causes the problem. I'll stay away from both for now and have a chat with my cardiologist next time I see him.
 
According to the info that came with my medication, it's the fruit or juice that should be avoided -- but this is probably not a coagulation issue. Dick's observation is also probably right -- if you had a 9.0, you'd have a lot of bleeding at the test site and probably a great deal of bruising where the needle went in. It may have just been test error.

This is just one more reason to have your own meter, and do your own testing. It would have been easy to tell if a 9.0 lab test made sense by testing at home.
 
After I left the hospital (against medical advice!) I went straight home and tested on my home machine. 8.0. Then I went to the hospital my cardio works at, and they re-tested me - also 8.0. No error! Yet still I wasn't spurting blood all over the place.

Pellicle - I have the same thought, if I'm consistent with my grapefruit juice, can I reduce the amount of warfarin I take? I'll be asking . . . . Grapefruit juice is a whole lot better for you than rat poison!!
 
After I left the hospital (against medical advice!) I went straight home and tested on my home machine. 8.0. Then I went to the hospital my cardio works at, and they re-tested me - also 8.0. No error! Yet still I wasn't spurting blood all over the place.

Pellicle - I have the same thought, if I'm consistent with my grapefruit juice, can I reduce the amount of warfarin I take? I'll be asking . . . . Grapefruit juice is a whole lot better for you than rat poison!!

This is interesting. How much grapefruit juice do you think you drank in the week prior to the 8, or 9 INR? I think that relying on grapefruit juice as an anti-coagulant drug might be a no-no.....but who knows, I often use a salad to slightly alter my INR. I don't know if it really works, but it makes me feel good........who wants to be first to try grapefruit juice ACT?
 
Grapefruit juice interacts with many prescriptions, not just warfarin.
At one time, the prescribing leaflet that Bristol-Myers Squibb inserted with Coumadin, the trademarked name of warfarin, specified herbals and other items that can affect the INR, such as licorice or anise, I beleive. The leaflet was overhauled several years ago and that very useful info was deleted. Bad decision!!

At my first INR test after my surgery, I was told not to make sudden changes in my diet without consulting my doctor first. The Coumadin clinic nurse told about a patient who went overboard on a lot of spinach salad or cole slaw within just a few days' time, then had an INR test. Of course, the INR test was lower than usual. The nurse had to play detective, grill the patient as to what might have caused the drop, and voila! the drop was attributed to the sudden change in diet.

FYI: It appears to be more of an urban legend about cranberry juice affecting INR. That pops up every once in a while. But there's plenty of research that disputes any connection.
 
This would also seem to imply that drinking a lot of grapefruit juice would also put anyone not on warfarin at risk of major bleed type events. I wonder how high someone's INR would be that was not taking warfarin, if they drank just two glasses a day.
 
This would also seem to imply that drinking a lot of grapefruit juice would also put anyone not on warfarin at risk of major bleed type events. I wonder how high someone's INR would be that was not taking warfarin, if they drank just two glasses a day.
well I guess its because of the interaction of drugs. So far I have not seen any studies of the INR or people not on warfarin. I would be interested to know what the natural variation is too.
 
I've found cranberry juice has the same impact for me. I ran an INR that high going through a family size jug in a week or two. Don't do cranberry much anymore. *TMI - Took a trip to urgent care with blood in urine to learn.

Sorry you had a trip to the ER.
Go to ACforum.org and when the home page appears look down the left side and access Newletters. Then scroll down to the date Spring 2006 newsletter containing research results about cranberry juice. This site is for medical professionals but the newsletters can be accessed. Very informative site.
 
This would also seem to imply that drinking a lot of grapefruit juice would also put anyone not on warfarin at risk of major bleed type events.

No, it doesn't. I did a bit of research on this some time back for my own info. What the grapefruit juice does is reduce the body's ability to metabolize the warfarin that you are taking. So, the concentration of warfarin in your blood builds up to much higher levels than it would if your body were constantly clearing out the warfarin. So, if you _ARE_ taking warfarin, the effect is similar to taking more of it. If you are _NOT_ taking warfarin, no problem.

FYI: It appears to be more of an urban legend about cranberry juice affecting INR.

Again, I have done a lot of googling about this, and the jury appears to still be out. There are several studies that show no effect on groups of 250 or so folks drinking cranberry juice compared to placebo. There are, however, a few reported cases of individuals with apparent extreme INR sensitivity to cranberry juice. Because of recent identification of genetic markers indicating predisposition to over/under sensitivity/resistance to warfarin (google "warfarin pharmacogenetics" for lots of info) it may simply be that a few folks _MAY_ have some genetic variant that causes some sensitivity to cranberry juice similar to that of grapefruit juice.

Anecdotally, I recently had my own INR jump between 2.7 and 4.6 in 3 days, then back to 2.6 three days later, then back up to 4.5 four days after that, and the only change in my diet was some cranberry juice, about an 8 oz glass per day for the few days preceding the high readings. Although my INR is fairly bouncy to begin with, I do plan to run a somewhat more controlled experiment on myself to see if there is indeed any repeatable relationship that could be attributable to cranberry juice. I do have a home meter and can test frequently to ensure I stay within a reasonably safe range if it does start to climb. I don't recommend others try this, but if I find anything significant, I'll post something back to the forum.


if I'm consistent with my grapefruit juice, can I reduce the amount of warfarin I take?

I have been wondering the same thing, especially since I take a fairly large amount of warfarin for my maintenance dose. If I could substitute grapefruit or cranberry juice for some of the warfarin, I would feel like that would be a bit healthier. Unfortunately, my personal opinion is that even if it did work to some extent, this would be a much more unstable solution to hitting a target INR range, and your INR would be much more variable. The exact percentage of the "active ingredients" in the juice per fluid ounce are not guaranteed to be as consistent as pharmaceutical grade pills like warfarin. Plus, I suspect counting on the buildup of warfarin in the blood as a result of the slowing of the drug metabolization will be more dependent on other factors like daily physical activity - at least more so than taking warfarin alone to achieve the INR. Again, this is just my unsubstantiated personal opinion, although it might be interesting if some brave soul wants to give it a try. I'm _NOT_ going to try it myself, nor would I recommend it without extremely frequent monitoring of your INR.
 
I did some research through Google as well and came to the same conclusion as newmitral. There may be a connection, but it is not dramatic. There is anectdotal evidence, but in most of the cases consumption was much higher than what I would consider normal.

I drink a 6 oz glass of juice every day and rotate through a variety of juice never having the same juice back to back. I include cranberry and have seen no problems. I also eat fruit once a day and rotate through a variety including grapefruit. I don't have them back to back and never more than two grapfruit in a week. I have seen no problems.

IIRC the quantitative range of most INR tests is about 0.5 to 5, so any INR level over about 5 is not "real", but certainly over 5.
 
Yes, I seen a few of those articles last night. It appears that it rarely occurs that cranberry juice or grapefruit juice will affect INR. Except in some isolated cases there is no other explanation. I guess skigirl is somewhat of an anomaly. Most people it occurs to refuse to become an experiment though. I guess she could end up being someone's science project for this if she wished.
 

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