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Warfarin Institute of America

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GINSENG INTERACTIONS WITH WARFARIN

There are three different species which are referred to as ginseng. These contain more than 20 chemicals known as ginsenosides which have varying degrees of activity. The conditions under which the plant grew causes variations in the amount of activity these ginsenosides contain. When you further complicate this with varying solvents used for extraction, it becomes obvious that it is very difficult to have any standardization among various ginseng products on the market. In fact different batches of the same brand may have varying amounts of activity. There is not even agreement on the definition of what is ginseng, since some authorities do not include Siberian ginseng in this classification

With all of these variables, it is difficult to summarize the effects of ginseng on warfarin. The safest thing to do is to not take ginseng if you are taking warfarin.

Rosado (Cardiology 2003;99:11) reports on a man who had a mechanical aortic valve and added ginseng to his warfarin regimen, For the next three months he needed increasing warfarin doses. His INR was still consistently low. Finally he was admitted to the hospital with acute left-sided heart failure. A workup revealed that there was a blood clot holding the leaflet on his mechanical valve open. He was forced to undergo surgery to have his valve replaced.

This next report does not involve an interaction with warfarin but because it does involve bleeding, I have included it here. Palop-Larrea et al. report the case of a woman who developed a three-week long menstrual bleed after she started taking a compound of ginseng and vitamins to improve her work performance. She had never had any menstrual irregularities previously and had none after she stopped taking the product. She declined to take the product again to determine if the bleeding would recur. Had this person been taking warfarin, it is likely that this would have progressed to a serious situation.

The following was written by one of my students

Of interest regarding ginseng are issues regarding its identity. There are several different species of plants known commonly as ginseng, and each one contains differents constituents in different amounts. These plants include: Panax quinquefolius (American ginseng), Panax ginseng (Oriental ginseng), Panax pseudoginseng var notoginseng (Sanchi ginseng), Eleutherococcus senticosus (Siberian ginseng). (1) Only 25% of products labeled as ginseng actually contain any ginseng (1) The man in the case described above would have been lucky if he had only wasted his money on a bottle that didn't contain any ginseng.

Ginseng is used to provide energy and strength, to treat nervous disorders, chronic fatigue, pain, and nausea. (2) It contains panaxynol and ginsenolides Ro, Rg1, and Rg2. These compounds have been identified as having antiplatelet properties. Panaxynol inhibits the aggregation, release reaction, and thromboxane formation in rabbit platelets while the ginsenolides suppressed the release reaction. (3) There are case reports describing this interaction available in the literature. In this case report the INR decreased, putting the patient at an increased risk of thrombosis.

Case report: (2)

47 year-old male with St.. Jude mechanical heart valve in aortic position; on warfarin since 1990, 5 mg/day with INR between 3-4 over 9 months, began ginseng three times daily and 2 weeks later his INR decreased to 1.5; ginseng was discontinued and the INR increased to 3.3 in 2 weeks; no thrombosis occurred.

References:

1: Miller LG. Herbal medicinals: selected clinical considerations focusing on known or potential drug-herb interactions. Arch Intern Med 1998; 158: 2200-9.

2: Janetzky K, Morreale AP. Probable interaction between warfarin and ginseng. Am J Health-Syst Pharm 1997; 54:692-3.

3:Kuo SC, Teng CM, Ko FN, Chen SC. Antiplatelet components in Panax ginseng. Planta Med 1990; 56:164-7.

4: http://www.micromedex.com Complementary and Alternative Medicine AltMedDex, as seen on March 1, 2001.

An editorial about the lack of concern for manufacturers of these products and their interactions with other medications.

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Last updated November 13, 2004