Warfarin Institute of America
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THAT IS A GOOD QUESTION
BUTALBITAL INTERACTIONS WITH WARFARIN (Coumadin, Jantoven)
THIS IS A SLOW-ONSET INTERACTION THAT CAN EVENTUALLY PUT THE PERSON TAKING THIS COMBINATION IN A VERY PRECARIOUS AND DANGEROUS PREDICAMENT. SEVERAL TIMES, I HAVE SEEN THIS CAUSE BLEEDING INTO THE BRAIN
Butalbital causes an induction of the enzyme which metabolizes warfarin (Coumadin, Jantoven) in the liver. This means that over time warfarin (Coumadin, Jantoven) will be metabolized more and more rapidly. Therefore, the warfarin (Coumadin, Jantoven) dose will have to be increased. I have corresponded with someone whose warfarin (Coumadin, Jantoven) dose doubled over the course of five years while taking this combination. The person is now in a predicament. If the combination is continued, the warfarin (Coumadin, Jantoven) dose will continually have to be increased. If the product containing the butalbital is stopped, there is a risk of bleeding because the enzymes will slow their metabolism of warfarin (Coumadin, Jantoven).
I suspect that weaning a patient from this combination will take months because the onset is so slow. They will probably need an INR dose weekly for many months and the warfarin (Coumadin, Jantoven) dose will have to be adjusted downward over this period of time.
Butalbital also has a fairly high addiction potential which is going to make discontinuing it much more difficult.
My recommendation is that physicians should seek every other possibility before placing a patient on this combination. Then there should be careful documentation that no other possibility that was effective. The potential problem should also be carefully discussed with the patient. I think that prescribing this combination is an invitation to disaster.
PHARMACISTS: Your computer should be flagging this interaction every time either of these medications is filled or refilled. Overriding the warning because "the patient has been taking this for a long time," is not acceptable. However, failing to refill the prescription can put the patient at risk of serious hemorrhage or death. You should counsel (and document your action) the patient to seek competent help in dealing with this problem. It may take a combination of an anticoagulation specialist and pain management or psychiatry.
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Last modified April 22, 2006