Multifocal and Recurrent Subarachnoid Hemorrhage Due to an Herbal Supplement Containing Natural Coumarins

Friedman, Jonathan A.; Taylor, Stacy; McDermott, Wayne T.; Alikhani, Puya

doi:10.1007/s12028-007-0075-z

Cited by 11 publications

(19 citation statements)

References 11 publications

(10 reference statements)

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“…Some reviews listed Red clover as having the potential to increase the risk of bleeding or potentiate the effects of warfarin, based on the fact that Red clover inhibited CYP2C9 and contained natural coumarins [107]. But there was only one case report support this statement A 53-year-old woman developed spontaneous subarachnoid hemorrhage when she was taking warfarin with herbal supplements containing Red clover, Chinese Angelica, Ginseng, and others for 4 months [108]. With this case reports, it is not possible to identify which, if any, of these constituents in the herbal supplements might have contribution to the hemorrhage.…”

Section: Resultsmentioning

confidence: 99%

Updates on the Clinical Evidenced Herb‐Warfarin Interactions

Zhang

Zuo

2014

Evidence-Based Complementary and Alternative Medicine

102

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Increasing and inadvertent use of herbs makes herb-drug interactions a focus of research. Concomitant use of warfarin, a highly efficacious oral anticoagulant, and herbs causes major safety concerns due to the narrow therapeutic window of warfarin. This paper presents an update overview of clinical findings regarding herb-warfarin interaction, highlighting clinical outcomes, severity of documented interactions, and quality of clinical evidence. Among thirty-eight herbs, Cannabis, Chamomile, Cranberry, Garlic, Ginkgo, Grapefruit, Lycium, Red clover, and St. John's wort were evaluated to have major severity interaction with warfarin. Herbs were also classified on account of the likelihood of their supporting evidences for interaction. Four herbs were considered as highly probable to interact with warfarin (level I), three were estimated as probable (level II), and ten and twenty-one were possible (level III) and doubtful (level IV), respectively. The general mechanism of herb-warfarin interaction almost remains unknown, yet several pharmacokinetic and pharmacodynamic factors were estimated to influence the effectiveness of warfarin. Based on limited literature and information reported, we identified corresponding mechanisms of interactions for a small amount of “interacting herbs.” In summary, herb-warfarin interaction, especially the clinical effects of herbs on warfarin therapy should be further investigated through multicenter studies with larger sample sizes.

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Section: Resultsmentioning

confidence: 99%

Updates on the Clinical Evidenced Herb‐Warfarin Interactions

Zhang

Zuo

2014

Evidence-Based Complementary and Alternative Medicine

102

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“…These could include minor adverse events such as purpura 96 and gum bleeding 146 to major events such as cerebrocranial bleeding that led to death 114,149 . Herbs or dietary supplements that were reported to result in haemorrhage include: consumption of bilberry fruit, 60 cranberry juice, 83–86 ginger, 111 Ginkgo biloba, 114 Chinese wolfberry, 73,74 Japanese food, 124 PC‐SPES nutritional supplement, 140 pomegranate juice, 143 grapefruit juice, 121 red clover, 97 vitamin E, 40 St John's wort 152 and wormwood 166 as well as herbs such as Danshen, 93 Dong quai, 97 Devil's claw, 96 Quilingao, 146 Shengmai‐yin 149 and ginseng 97 . One case report also described an elderly individual who developed multiple haematoma after the application of a chamomile based skin lotion 67 .…”

Section: Discussionmentioning

confidence: 99%

Warfarin and food, herbal or dietary supplement interactions: A systematic review

Tan¹,

Lee

2020

Brit J Clinical Pharma

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Aims To present an updated overview on the safety of concurrent use of food, herbal or dietary supplement and warfarin. Methods A systematic literature review was performed on 5 databases from inception up to 31 December 2019. These interactions were classified depending on the likelihood of interaction and supporting evidences. Results A total of 149 articles describing 78 herbs, food or dietary supplements were reported to interact with warfarin. These reports described potentiation with 45 (57.7%) herbs, food or dietary supplements while 23 (29.5%) reported inhibition and 10 (12.8%) reported limited impact on warfarin pharmacokinetics and pharmacodynamics. Twenty unique herb and dietary supplements also reported to result in minor bleeding events, such as purpura and gum bleeding as well as major events such as intracranial bleeding that led to death. Conclusion While most food, herbs and supplements can be safely taken in moderation, healthcare professionals should be aware of the increased risk of bleeding when taking several food and herbs. These include Chinese wolfberry, chamomile tea, cannabis, cranberry, chitosan, green tea, Ginkgo biloba, ginger, spinach, St. John's Wort, sushi and smoking tobacco. Patients should be counselled to continue to seek advice from their healthcare professionals when starting any new herbs, food or supplement.

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“…[ 4 ] To our knowledge, the only reported case of intracranial bleeding associated with herbal supplements is a nonaneurysmal subarachnoid hemorrhage in a patient taking Red Clover. [ 1 ] The mechanism underlying Red Clover induced coagulopathy is assumed to be due to the coumarin derivatives, hence, the contraindication for its use alongside warfarin; however, in-vitro evidence has shown that it also has negative effects on platelet activity through inhibition of platelet adhesion. [ 2 ]…”

Section: Discussionmentioning

confidence: 99%

“…The literature contains only one case of intracranial bleeding due to Red Clover where a patient suffered a spontaneous, nonaneurysmal subarachnoid hemorrhage. [ 1 ] This case presents a female patient who suffered an acute-on-chronic SDH requiring craniotomy and repeat craniotomy for re-accumulation likely due to Red Clover consumption. It serves to raise awareness of the importance of inquiring about herbal compounds in drug history as a predictor of a patient's surgical bleeding risk.…”

Section: Introductionmentioning

confidence: 99%

Acute-on-chronic subdural hematoma in a patient taking Red Clover herbal supplement: A case report

Hall¹,

Walshe²,

Ajayi³

et al. 2018

Surg Neurol Int

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Background:Herbal supplements are commonly used, however, their side-effect profiles are poorly understood and not subject to the same scrutiny as prescribed medications. Some herbal supplements such as St Johns’ Wort are accepted to interfere with clotting pathways, however others, including Red Clover have theoretical bleeding risks based on coumarin content with very little underlying evidence.Case Description:This case reports a 65-year-old woman who suffered a spontaneous acute-on-chronic subdural hemorrhage with a significant postoperative re-hemorrhage. She had no other risk factors for coagulopathy other than a history of taking Red Clover supplements for postmenopausal symptoms. Her normal INR combined with an intraoperative thromboelastogram confirmed a coagulopathy which was more consistent with anti-platelet effects than coumarin toxicity. After tranexamic acid and platelet transfusions she had no further bleeding and made an uneventful recovery.Conclusion:This case highlights another risk factor for intracranial hemorrhage and the importance of a thorough drug history. The mechanism of Red Clover induced coagulopathy appears to be mediated through anti-platelet actions, which is consistent with in-vitro evidence reporting its role in preventing platelet adhesion.

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Multifocal and Recurrent Subarachnoid Hemorrhage Due to an Herbal Supplement Containing Natural Coumarins

Abstract: We report a 53-year-old woman with spontaneous subarachnoid hemorrhage due to the use of an herbal supplement containing red clover, dong quai, and Siberian ginseng.

Cited by 11 publications

References 11 publications

Updates on the Clinical Evidenced Herb‐Warfarin Interactions

Updates on the Clinical Evidenced Herb‐Warfarin Interactions

Warfarin and food, herbal or dietary supplement interactions: A systematic review

Acute-on-chronic subdural hematoma in a patient taking Red Clover herbal supplement: A case report

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