Interactions of Warfarin and Herbs, Dietary Supplements, Foods & Vitamins

There is limited evidence on the exact effect herbs, dietary supplements, foods, and vitamins have on warfarin. They may potentially affecting the effectiveness of warfarin by altering the clearance/metabolism of warfarin through various pathways, reducing the absorption of warfarin, containing warfarin constituents themselves, inhibiting the synthesis of vitamin K-dependent coagulation factors, increasing the dietary intake of vitamin K and reducing the effectiveness of warfarin, or inhibiting/decreasing the platelet function. The safest is to avoid all herbal and dietary supplements, of course except foods, unless their physicians approve. However, if herbal and dietary supplements are taken regularly on a daily basis, they pose less of a problem than if taken off and on. The following interaction chart is intended as a quick reference to highlight potential interactions between warfarin and commonly known herbal, dietary supplements, foods, and vitamins. Most of the potential interactions stated in the following chart have no published human case reports of an interaction with warfarin, and caution with using these supplements in combination with warfarin is warranted. **Most of the uses of various supplements stated in the following interaction chart are insufficient of evidence. More evidence is needed to rate the effectiveness of the supplements for their respective uses.

Warfarin Interaction Chart with Herbs, Dietary Supplements & Foods 1, 2, 3, 4

Herb/Supplement/ Food/ Vitamin Agar Agrimony Alcohol (acute) Alcohol (chronic) Alfalfa (Medicago sativa) Algin Aloe Anise (Aniseed) Arnica (Wolf bane) Artemesia Asafoetida Avocado Barley Bishops weed (Bergapten) Bitter Orange Black cohosh (cimicifuga racemosa) Bladderwrack (Fucus, Kelp) Blond psyllium Herbal/Supplemental/Vitamin Uses Potential Interactio n INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR Mechanism May absorption of warfarin May be a coagulant May warfarin metabolism when consumed excessively May warfarin metabolism by inducing CYP enzyme INR May contain warfarin constituents INR May be due to the Vitamin K content in herb May absorption of warfarin May absorption of warfarin May contain warfarin constituents May contain warfarin constituents May contain warfarin constituents May contain warfarin constituents May warfarin metabolism May absorption of warfarin May contain warfarin constituents May warfarin metabolism (P450 3A4 inhibitor) May warfarin metabolism (P450 3A4 inhibitor) May contain salicylates constituents May have anticoagulant effects May absorption of warfarin

To curb appetite & promote weight loss. To treat winter colds, fevers, diarrhea, sores, blemishes & pimples. To stop bleeding in Chinese herbal medicine. To treat disorders related to the digestive tract and the kidneys. To lower cholesterol & blood pressure. To reduce the amount of heavy chemicals taken up by the body. To treat osteoarthritis, bowel diseases, fever, itching, inflammation, stomach ulcers, diabetes & asthma. As a digestive aid and anti-flatulence agent. To relieve coughs & colds. To prevent insomnia. Used in homeopathic preparations to treat sore muscles & bruises. To treat malaria & bacterial/fungal/viral infections. To treat bronchitis, H1N1 swine flu, asthma & digestive disorders. To lower blood sugar, blood pressure & cholesterol. To promote weight loss & treat diarrhea and stomach pain. To treat digestive disorders, asthma, angina, kidney stones & as a diuretic. To improve appetite, and in contrast, also used for weight loss. To treat upset stomach & nasal congestion To treat symptoms of menopause, premenstrual syndrome, painful menstruation, acne, osteoporosis & induce labor. To treat thyroid disorders, obesity, arthritis, joint pain, arteriosclerosis, digestive disorders, heartburn, constipation, bronchitis, emphysema, UTI & anxiety. As a laxative & for softening stools.

Supplement

Uses

Bogbean Bromelain Buchu Burdock Butternut Caffeine Capsicum Cascara Cassia Castor Cats Claw Celery (seed/extract) Chamomile (Matricaria recutita) Chondroitin Chrysin Clove Cod Liver Oil (Fish oil) Co-enzyme Q10 (Ubiquinone) Coffee Charcoal Coltsfoot Cranberry Dandelion

To treat rheumatoid arthritis, loss of appetite & upset stomach. To reduce swelling/inflammation of nose & sinuses. To treat cystitis, urethritis, prostatitis & pyelonephritis. To increase urine flow, kill germs, reduce fever & purify blood. To treat constipation, gallbladder disorders & hemorrhoids. To improve mental alertness. To treat digestive disorders. As a laxative for constipation. To treat digestive disorders, common cold & loss of appetite. Used for birth control, constipation, leprosy & syphilis. To treat osteoarthritis, rheumatoid arthritis & digestive disorders. To treat joint pain, gout, headache, nervousness & exhaustion. To treat digestive disorders, travel sickness, stuffy nose, hay fever, ADHD, restlessness & trouble sleeping. To treat osteoarthritis. To treat anxiety, gout, baldness & erectile dysfunction. To treat upset stomach, diarrhea, hernia & bad breath. To treat high cholesterol, high triglycerides, high blood pressure, heart disease, kidney disease, osteoarthritis & depression. To treat blood vessel conditions such as CHF, angina & high blood pressure. To treat diarrhea. To treat bronchitis, asthma, whooping cough. To prevent and treat UTI. To treat loss of appetite, upset stomach, gallstones, joint pain, muscle aches, eczema & bruises.

Potential Interactio n INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR

Mechanism

May contain warfarin constituents May platelet aggregation May contain warfarin constituents May platelet aggregation May absorption of warfarin May have antiplatelet effects May contain warfarin constituents May absorption of warfarin May contain warfarin constituents May inhibit platelet aggregration May absorption of warfarin May warfarin metabolism (P450 3A4 inhibitor) May contain warfarin constituents May contain warfarin constituents May increase bleeding & chondroitin sulfate is a component of the antithrombotic danaparoid May warfarin metabolism (P450 3A4 inhibitor) Contains eugenol a platelet inhibitor May inhibit platelet aggregration May have Vitamin K-like procoagulant effects. May absorption of warfarin May inhibit platelet aggregration May warfarin metabolism (P450 2C9 inhibitor) INR May contain warfarin constituents INR May be due to the Vitamin K content in herb

Supplement

Uses

Potential Interactio n

Mechanism

Danshen (Salvia miltiorrhiza) Dehydroepiandrosterone (DHEA) Devils Claw Dong Quai (Angelica sinesis)

To treat stroke, angina, menstrual disorders & liver disease. To slow or reverse aging, to improve thinking skills in older people, to slow the progress of Alzheimers disease. As an analgesic in treating gout, arthritis & myalgias. To lower symptoms of menopause, relieves menstrual cramp, and regulates menstrual periods. Combined with other herbs to treat conditions such as high blood pressure, arthritis, allergies and asthma. To treat infections, especially common cold & other upper respiratory infections. To treat infections, fever, upset stomach & cough. To treat constipation. To treat breast pain, osteoporosis, eczema, psoriasis & acne. To treat diabetes, loss of appetite, heartburn, constipation, atherosclerosis, hyperlidemia & promote lactation. To prevent migraine headaches. To treat fever, irregular menstrual periods, arthritis, psoriasis & asthma. To treat GI tract disorders. To treat tuberculosis, prostatis & constipation. To treat hypertension & hyperlipidemia. To prevent coronary heart disease, age-related vascular changes & atherosclerosis. To treat motion/morning sickness, upset stomach, diarrhea, nausea, cough & bronchitis. To enhance memory & improve cognition. Used for stress, to boost immune system, to prevent and treat cold & flu, to improve digestion and for loss of appetite. To improve thinking, concentration, memory, work efficiency, physical stamina & athletic endurance. Uses

INR INR INR INR

May contain warfarin constituents May inhibit platelet aggregration May warfarin metabolism (P450 3A4 inhibitor) May warfarin metabolism (P450 2C9 inhibitor) May contain warfarin constituents May inhibit platelet aggregration May warfarin metabolism (P450 3A4 inhibitor) May warfarin metabolism (P450 1A2, 2C9, 3A4 inhibitor) May absorption of warfarin May platelet aggregation May contain warfarin constituents May have antiplatelet effects May inhibit platelet release and aggregration May warfarin metabolism (P450 1A2, 2C9, 3A4 inhibitor) May platelet aggregation & bleeding time May warfarin metabolism (P450 1A2, 2C9, 3A4 inhibitor) May have anticoagulant effects & inhibit platelet aggregration May warfarin metabolism (P450 2C9, 3A4 inhibitor) May inhibit thromboxane synthetase & platelet aggregration Ginkolide B may inhibit platelet activating factor by displacement from its receptor binding sites INR may decrease platelet aggregration INR may antagonize the anticoagulant effects of warfarin

Echinacea (Purple coneflower) Eucalyptus European Buckthorn Evening Primrose Oil Fenugreek Feverfew (Tanacetum parthenium) Flaxseed Fo-Ti Garlic (Allium sativum)

INR INR INR INR INR INR INR INR INR INR INR

Ginger (Zingiber officinale) Gingko biloba (Maidenhair Tree) Ginseng, American (Panax quinquefolinus) Ginseng, Oriental (Panax ginseng) Supplement

INR

Potential Interactio n

Mechanism

Ginseng, Eleuthero or Siberian (Eleutherococcus senticosus) Glucosamine Goldenseal Grapefruit juice Green Tea Guggul Horse chestnut Horseradish Iceland Moss Ipriflavone Karaya Gum Kava Larch Arabinogalactan Licorice ( Glcyrrhiza glabra) Lime Limonene Lovage root Lycium (Chinese Wolfberry) Mango Marshmallow Meadowsweet Melatonin Melilot ( Sweet clover) Supplement

To strengthen the body & increase general resistance to daily stress. To treat high blood pressure, low blood pressure, atherosclerosis & rheumatic heart disease. To treat osteoarthritis, knee pain, back pain & glaucoma. To treat upper respiratory tract infections & digestive disorders. To treat high cholesterol, atherosclerosis, psoriasis, cancer, weight loss & obesity. To improve mental alertness and thinking. To treat weight loss, stomach disorders, headaches & osteoporosis To treat arthritis, high cholesterol atherosclerosis & acne. To treat varicose veins, hemorrhoids & phlebitis. To treat UTI, kidney stones, cough, bronchitis & gout. To treat irritation of mouth & throat, dry cough & common cold To prevent and treat osteoporosis. As a bulk-forming laxative to relieve constipation. To treat anxiety, stress, restlessness & insomnia. To treat common cold, flu, H1N1 (swine) flu & ear infections. To treat stomach ulcers, heartburn, chronic gastritis, sore throat, bronchitis, osteoarthritis, SLE, liver disorders & tuberculosis. To treat severe diarrhea. To treat weight loss, cancer & bronchitis. To treat urinary tract inflammation & kidney stones. To treat diabetes, high blood pressure, fever & malaria. To treat inflammation of respiratory tract, stomach & urinary tract. To treat colds, bronchitis, upset stomach, heartburn & gout. To treat insomnia or sleep problems in children with developmental disorders & blind people. As a diuretic & to relieve symptoms of poor blood circulation. Uses

INR

May inhibit constituents

platelet

aggregration

&

contain

warfarin

INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR Potential Interactio

May contain heparin constituents May warfarin metabolism (P450 3A4 inhibitor) May warfarin metabolism (P450 1A2, 2A6, 3A4 inhibitor) May contain substantial amounts of vitamin K May warfarin metabolism (P450 3A4 inducer) May contain warfarin constituents May contain warfarin constituents May absorption of warfarin May warfarin metabolism (P450 1A2, 2C9 inhibitor) May absorption of warfarin May warfarin metabolism (P450 1A2, 2C9, 3A4 inhibitor) May absorption of warfarin May contain warfarin constituents May inhibit platelet aggregration May warfarin metabolism (P450 3A4 inhibitor) May warfarin metabolism (P450 3A4 inhibitor) May warfarin metabolism (P450 2C9 inducer) May contain warfarin constituents May warfarin metabolism (P450 2C9 inhibitor) May warfarin metabolism (P450 2C9 inhibitor) May absorption of warfarin May contain warfarin constituents May the anticoagulant or antiplatelet effect May prothrombin activity May contain warfarin constituents Mechanism

Milk Thistle Nattokinase Nettle Noni Juice Onion Pantethine Papain/Papaya

To treat liver disorders, heartburn & diabetes. To treat cardiovascular diseases. To treat urination problems related to BPH. To treat arthritis, diabetes, high blood pressure & heart diseases. To treat digestive disorders & heart and blood vessel problems. To lower cholesterol, prevent inflammation, boost immune system, treat GI diseases & improve energy. To treat herpes zoster, pharyngitis, digestive problems, hay fever & runny nose. To treat UTI, kidney stones, GI disorders & menstrual problems. To treat insomnia, anxiety & relieve symptoms related to narcotic drug withdrawal. To treat heartburn, IBS, common cold, cough, nausea & vomiting. To treat high cholesterol & narrowing of blood vessels. To treat cough & chest congestion. To treat anorexia, indigestion, constipation & fever. To treat high cholesterol, indigestion, cough, asthma & bronchitis. To treat atherosclerosis & high cholesterol. To treat digestive problems & heart and circulation problems. To decrease symptoms of BPH & treat prostate infections. To treat arthritis, GI ulcers & gout. To treat sore throat, cough, IBS & UTI. To treat precancerous mouth lesions, boost immune system, improve memory, increase energy & improve digestion. To treat depression, anxiety, moodiness & menopausal symptoms. To prevent prostate cancer & other types of cancer. Uses

n INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR INR Potential Interactio

May warfarin metabolism (P450 2C9, 3A4 inhibitor) may have thrombolytic activity INR May contain warfarin constituents INR May be due to the Vitamin K content in herb May effectiveness of warfarin. Mechanism unknown May platelet aggregation May platelet aggregation Effect of INR has only been reported in a single case with papaya extract, not with the fruit. May cause gastrointestinal mucous membrane damage and bleeding. May contain warfarin constituents May contain warfarin constituents May warfarin metabolism (P450 1A2, 2C9, 3A4 inhibitor) May inhibit platelet aggregation May contain salicylates constituents & platelet aggregation May contain warfarin constituents May contain warfarin constituents May warfarin metabolism (P450 1A2, 2C9, 3A4 inhibitor) May have antiplatelet effects May warfarin metabolism (P450 1A2, 3A4 inhibitor) May contain warfarin constituents May have anticoagulant effects May inhibit platelet aggregation May absorption of warfarin May contain substantial amounts of vitamin K May effectiveness of warfarin due to the Vitamin K content May warfarin metabolism (P450 1A2, 2C9, 3A4 inducer) May warfarin metabolism (P450 1A2 inhibitor) Mechanism

Parsley Passionflower Peppermint Policosanol Poplar Quassia Red clover (Promensil) Resveratrol Rue Saw palmetto Sea buckthorn Slippery Elm Soy (Milk/Tofu) Spirulina St. Johns Wort Sulforaphane Supplement

Tonka Bean Tragacanth Turmeric Valerian Vinpocetine Vitamin A Vitamin C Vitamin E

Wild Carrot Wild Cherry Wild Lettuce Willow/Wintergreen Woodruff Yarrow

To treat cramps, nausea, cough, spasms & tuberculosis. To treat diarrhea & constipation. To treat heartburn, digestive problems & liver problems. To treat insomnia, anxiety & psychological stress. To enhance memory & prevent Alzheimers disease. To treat vitamin A deficiency, improve visions, treat eye disorders & reduce complications of malaria, HIV & measles in children. To treat and prevent vitamin C deficiency, improve absorption of iron, treat and prevent common cold. To treat Vitamin E deficiency, bladder cancer, Alzheimers disease, dysmenorrheal, premenstrual syndrome, ischemic stroke, male infertility, dementia & Parkinsons disease. To treat kidney stones, bladder problems & gout. To treat colds, whooping cough & bronchitis To treat whooping cough, asthma, insomnia & restlessness. To treat headache, nerve pain, arthritis & menstrual cramp. To treat disorders of lung, stomach, liver, gallbladder & urinary. To treat fever, common cold, hay fever, dysentery & diarrhea.

n INR INR INR INR INR INR INR INR INR INR INR INR INR INR

May contain warfarin constituents May absorption of warfarin May platelet aggregation May warfarin metabolism (P450 3A4 inhibitor) May have antiplatelet effects May warfarin metabolism (P450 2C9 inhibitor) May effectiveness of warfarin. However, in recent studies, no effect was found with doses up to 1000mg per day. May platelet aggregration & antagonize the effects of vitaminK dependent clotting factors. Dose-dependent and significant with doses > 800 units/day. May contain warfarin constituents May warfarin metabolism (P450 3A4 inhibitor) May contain warfarin constituents May contain salicylates constituents May contain warfarin constituents May be a coagulant

References
1. Nutescu EA, Shapiro NL, Ibrahim S, West P. Warfarin and its interactions with foods, herbs and other dietary supplements. Expert Opin. Drug Saf. (2006) 5(3): 433-451. 2. Jensen B. Herbal Drug Interaction Chart. July 2003. 3. Find a Vitamin Supplements. WebMD, LLC, 2005 2011. http://www.webmd.com/vitamins-supplements. Accessed 10 November 2011. 4. Alternative Nature Online Herbal. Karen Bergeron, Alternative Nature Enterprise, 1997 2011. http://www.altnature.com/gallery/index.html. Accessed 10 November 2011.

Interactions of warfarin and dietary vitamin K

Warfarin is affected by vitamin K. A high vitamin K intake in patients diet can affect the body response to warfarin and lower the INR result. When a patient begins warfarin therapy, baseline education should include information on vitamin K-rich sources. A chart or leaflet identifying foods high in vitamin K can be a helpful reference for the patient. The primary sources of vitamin K-containing foods are dark green vegetables and oils.1 To avoid the risks of INR fluctuation at subsequent visits, it is necessary to advise patients to take a consistent and stable vitamin K diet. Counseling patients on avoidance of vitamin K foods is not recommended as this may prevent intake of other essential vitamins and minerals in the foods.1 It would be the best to advise patients to keep a consistent amount of vitamin K consumption throughout the week by selecting 2 or 3 days that allow the patient to eat 1 2 servings of vitamin-containing foods.1 However, for those patients that are vegetarians or insist on eating vegetables everyday, they can be suggested to take vitamin K-containing foods consistently everyday without exceeding the recommended servings and they must be emphasized on avoiding sudden and drastic changes in vegetables intake. Below is the recommended servings based on vitamin K content: 2, 3 Level High Medium Low Vitamin K content > 100 mcg 25 100 mcg 0 24 mcg Recommended No. of serving(s) per day No more than 1 serving No more than 3 servings No limit

The vitamin K content of common foods (vegetables, fats and oils, beverages, meats, fruits, nuts, grain products and legumes, and dairy products) is shown in the following tables.

Vegetables
Vegetables are one of the important food groups to watch for vitamin K content. Green leafy vegetables are high in vitamin K. Many other vegetables have a medium amount of vitamin K.4, 5
Vegetable Vegetable Preparation Frozencookedboileddrainedwithout salt Asparagus Cookedboileddrained Canneddrained solids Snapgreencannedregular packeddrained solids Snapgreencookedboileddrainedwithout salt Snapyellowcookedboileddrainedwithout salt Snapyellowcannedregular packeddrained solids Kidneyredmature seedscookedboiledwithout salt Kidneyredmature seedscanned Cookedboileddrainedwithout salt Cookedboileddrainedwithout salt Frozenchoppedcookedboileddrainedwithout salt Raw Frozencookedboileddrainedwithout salt Cookedboileddrainedwithout salt Cookedboileddrainedwithout salt Chinese (pak-choi)cookedboileddrainedwithout salt Raw Savoyraw Redraw Juicecanned Cookedboileddrainedwithout salt Frozencookedboileddrainedwithout salt Raw Cannedregular packeddrained solids Frozencookedboileddrainedwithout salt Cookedboileddrainedwithout salt Raw Cookedboileddrainedwithout salt Celery Raw Coleslaw Collards Fast foods Frozenchoppedcookedboileddrainedwithout salt Cookedboileddrainedwithout salt With peelraw Cucumber Peeledraw Eggplant Endive Garlic Cookedboileddrainedwithout salt Raw Raw Serving size 1 cup 4 spears 4 spears 4 spears 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 carrot 1 cup 1 cup 1 cup 1 cup 1 cup 1 stalk 1 cup 1 stalk cup 1 cup 1 cup 1 large 1 cup 1 large 1 cup 1 cup 1 cup 1 clove Estimate d weight (g) 180 60 60 72 135 125 125 135 177 256 144 156 184 188 155 156 150 170 70 70 70 236 156 146 110 72 146 180 124 100 150 37.5 120 40 99 170 190 301 104 280 119 99 50 3 Vitamin K (mcg) 144 48 30.4 29.7 52.5 20 20 13.4 14.9 11 697 220.1 162.1 89.4 299.9 218.9 163.1 57.8 53.2 48.2 26.7 36.6 21.4 19.9 14.5 9.5 14.3 21.4 17.1 15.5 56.7 14.2 35.2 11.7 70.2 1059.4 836 49.4 17.1 20.2 8.6 2.9 115.5 0.1 Level High Medium Medium Medium Medium Low Low Low Low Low High High High Medium High High High Medium Medium Medium Medium Medium Low Low Low Low Low Low Low Low Medium Low Medium Low Medium High High Medium Low Low Low Low High Low

Beans

Beet Greens Broccoli Brussel Sprouts

Cabbage

Carrots

Cauliflower

Vegetable Kale

Vegetable Preparation Frozencookedboileddrainedwithout salt Cookedboileddrainedwithout salt Butterheadraw Icebergraw Green leafraw Cos or romaineraw Sproutedraw Sproutedcookedboileddrained without salt Whiteraw Whitecookedboileddrainedwithout salt Canned drained solids Shiitakecookedwithout salt Soup/creamcannedwith equal volume of low fat milk Soup/creamcannedwith equal volume water Greencookedboileddrainedwithout salt Spring or scallionsraw

Serving size 1 cup 1 cup 1 head 1 head 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 whole 1 cup 1 cup 10 sprigs 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 pepper 1 pepper 1 large 1 medium cup 1 cup 1 cup 1 cup 1 cup 1 potato 1 potato 1 potato 1 potato 1 potato 1 cup 1 cup 1 cup 1 cup 1 cup

Lettuce

Mung Beans

Mushrooms

Mustards Onions Parsley Peas

Peppers

Cookedboileddrainedwithout salt Raw Raw Greencanned drained solidsunprepared Greenfrozencookedboileddrainedwithout salt Sweetgreencookedboileddrainedwithout salt Sweetgreenraw Sweetredraw Sweetredcookedboileddrainedwithout salt Hot chiligreenraw Hot chiliredraw Fast foodsfrench fried in vegetable oil Fast foodshashed brown Mashedhome preparedwhole milk & margarine added Hashed brownhome prepared Sweetcannedvacuum pack Sweetcannedsyrup packdrained solids Sweetcookedbaked in skinwithout salt Sweetcookedboliedwithout skin Bakedflesh and skinwithout salt Boiledcooked without skinfleshwithout salt Boiledcooked in skinfleshwithout salt Cannedwithout salt Cookedboileddrainedwithout salt Cannedsolids and liquids Dried Mature cookedboiledwithout salt

Potatoes

Pumpkin Sauerkraut Seaweed Soybean

Estimate d weight (g) 130 130 163 539 55 56 56 104 124 70 156 156 145 248 244 140 100 15 210 160 10 170 160 136 149 149 136 45 45 169 134 72 210 156 255 196 146 156 202 135 136 245 245 236 172

Vitamin K (mcg) 1146.6 1062.1 166.7 129.9 13.3 97.2 57.4 34.3 28.1 0 0 0 0 2.2 2.0 419.3 207 31.1 1.1 0.6 164 62.6 38.4 13.3 11.0 7.3 6.9 6.4 6.3 18.9 15 7.1 12.6 5.8 5.6 5.1 3.4 3.3 4 2.8 2.9 39.2 2.0 30.7 28 33

Level High High High High Low Medium Medium Medium Medium Low Low Low Low Low Low High High Medium Low Low High Medium Medium Low Low Low Low Low Low Low Low Low Low Low Low Low Low Low Low Low Low Medium Low Medium Medium Medium

Vegetable

Vegetable Preparation Frozenchoppedcookedboileddrainedwithout salt Cannedregular pack drained solids Cookedboileddrainedwithout salt Raw Raw Cannedpastewithout salt added Cannedpureewithout salt added Cannedsauce Redriperawyear round average

Serving size 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 tomato 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup

Spinach Swiss Chard

Estimate d weight (g) 190 214 180 30 262 250 245 180 123 240 255 243 248 244 164 144 156

Vitamin K (mcg) 1027.3 987.8 888.5 144.9 299 29.9 8.5 6.9 14.2 9.7 7 6.1 5.6 4 3.7 851 529.3 0.2

Level High High High High High Medium Low Low Low Low Low Low Low Low Low High High Low

Tomatoes

Turnip

Redripecannedpacked in tomato juice Redripecannedstewed Juicecannedwith salt added Soupcannedwith equal volume of low fat milk Soupcannedwith equal volume of water Greenfrozencookedboileddrainedwithout salt Green cookedboileddrainedwithout salt Cookedboileddrainedwithout salt

Fats and Oils

Fats and oils eaten in small amounts are low in vitamin K. However, large amounts can have a medium to high amount of vitamin K. Sometimes, patients may eat more vitamin K than they realize, like when they eat salads that use a lot of oil or mayonnaise such as potato salad or coleslaw.4
Fats and Oils Butter Canola Oil Corn Oil Margarine Mayonnaise Olive Oil Peanut Butter Peanut Oil Safflower Oil Sesame Oil Soybean Oil Serving size 1 cup 1 tablespoon 1 cup 1 tablespoon 1 cup 1 tablespoon 1 cup 1 tablespoon 1 cup 1 tablespoon 1 cup 1 tablespoon 1 cup 1 tablespoon 1 cup 1 tablespoon 1 cup 1 tablespoon 1 cup 1 tablespoon 1 cup 1 tablespoon Vitamin K (mcg) 16 1 55 4 4 Less than 1 211 13 93 6 130 8 2 Less than 1 2 Less than 1 16 1 30 2 431 27 Level Low low Medium Low Low Low High Low Medium low High Low Low Low Low Low Low Low Medium Low High Medium

Beverages
Most beverages are low in vitamin K.4
Beverage Beer Coffee Cola Milk Orange Juice Tea Water Wine Serving size 12 fluid oz. 6 fluid oz. 12 fluid oz. 1 cup 1 cup 6 fluid oz. 8 fluid oz. 3.5 fluid oz. Vitamin K (mcg) Less than 1 Less than 1 Less than 1 Less than 1 Less than 1 Less than 1 Less than 1 Less than 1 Level Low Low Low Low Low Low Low Low

* 1 fluid oz. = approx. 29.5 ml

Meats
Meat is low in vitamin K.4
Meat Bacon Beef Beef Liver Chicken Chicken Liver Duck Fish Lamb Pork Shrimp Turkey (dark meat) Turkey (light meat) Venison Serving size 1 cup (diced) 1 cup (diced) 1 cup (diced) 1 cup (diced) 1 cup (diced) 1 cup (diced) 1 cup (diced) 1 cup (diced) 1 cup (diced) 1 cup (diced) 1 cup (diced) 1 cup (diced) 1 cup (diced) Vitamin K (mcg) Less than 1 2 5 3 3 6 Less than 1 6 Less than 1 Less than 1 5 Less than 1 2 Level Low Low Low Low Low Low Low Low Low Low Low Low Low

Nuts
Nuts have a low to medium amount of vitamin K.4
Nut Almonds Cashews Hazelnuts Macadamia Peanuts Pecans Pistachios Walnuts Serving size 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup Vitamin K (mcg) Less than 1 45 16 Less than 1 Less than 1 3 17 3 Level Low Medium Low Low Low Low Low Low

Fruits
Most fruits are low in vitamin K.4
Fruit Apple Banana Blueberries Cantaloupe Grapefruit Grapes Lemon Lime Mango** Orange Peach Pear Raspberries Strawberries Watermelon Serving size 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup Vitamin K (mcg) 3 Less than 1 28 4 Less than 1 23 Less than 1 Less than 1 7 Less than 1 4 7 10 3 Less than 1 Level Low Low Medium Low Low Medium Low Low Low Low Low Low Low Low Low

**Mango has been associated with an increased INR in 13 patients, with a rechallenge in 2 patients showing similar results. Patients were consuming 1 6 mangos per day for 2 days to 1 month before the INR was tested. INR values decreased in all 13 patients after discontinuing mango ingestion. The mechanism for this interaction has been theorized to be related to the high amount of vitamin A in mangos, which inhibits P450 2C9 enzyme and decreasing warfarin metabolism. It is prudent to advise patients to limit their intake of mangos, or alternatively, keep a consistent weekly intake, to minimize INR fluctuation.2

Grain Products and Legumes

Bread, grain products such as oatmeal and rice, and legumes such as beans and lentils, are low in vitamin K.4
Grain Product and Legume Bagel (plain) Beans (black) Beans (white) Bread (assorted) Flour (white) Flour (whole wheat) Lentils (cooked) Oatmeal Pasta Rice (brown) Rice (white) Rice (wild) Serving size 1 each 1 cup 1 cup 1 slice 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup Vitamin K (mcg) 1 3 6 Less than 1 Less than 1 2 3 1 Less than 1 1 Less than 1 Less than 1 Level Low Low Low Low Low Low Low Low Low Low Low Low

Dairy Products
Dairy products are low in vitamin K.4
Dairy Product Cheese Cream Egg (cooked) Eggs (cooked) Ice Cream (chocolate) Ice Cream (vanilla) Milk (2%) Milk (non-fat) Milk (whole) Yogurt Serving size 1 cup 1 cup 1 (large) 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup 1 cup Vitamin K (mcg) 3 8 1 4 Less than 1 Less than 1 Less than 1 Less than 1 Less than 1 Less than 1 Level Low Low Low Low Low Low Low Low Low Low

References
1. Nutescu EA, Shapiro NL, Ibrahim S, West P. Warfarin and its interactions with foods, herbs and other dietary supplements. Expert Opin. Drug Saf. (2006) 5(3): 433-451. 2. Warren Grant Magnuson Clinical Center, National Institute of Health. Important Information to know when you are taking: Coumadin and Vitamin K. December 2003. 3. Stony Brook University Medical Center. Food Interactions with Warfarin. 7 January 2009. 4. University Health Care Thrombosis Service. Vitamin K Content of Common Foods. http://healthcare.utah.edu/Thrombosis/patients/warfarin/WarfarinGuide_vitaminK.pdf. Accessed 11 November 2011. 5. USDA National Nutrient Database for Standard Reference, Release 23. U.S. Department of Agriculture. http://www.ars.usda.gov/SP2UserFiles/Place/12354500/Data/SR23/nutrlist/sr23a430.pdf. Accessed 11 November 2011. HELP ME TO REMOVE / ADD IN ANYTHING U TINK IS NECESSARY