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Ginger-Associated Overanticoagulation by Phenprocoumon

Physician, Department of Clinical Pharmacology, Institute for Pharmacology and Toxicology, University Hospital Tübingen, Tübingen, Germany

Eberhard Brosi, MD

Internist, Private Practice Internal Medicine, Überlingen, Germany

Richard Fux, MD

Physician, Department of Clinical Pharmacology, Institute for Pharmacology and Toxicology, University Hospital Tübingen

Klaus Mörike, MD

Clinical Pharmacologist, Lecturer, Department of Clinical Pharmacology, Institute for Pharmacology and Toxicology, University Hospital Tübingen

Christoph H Gleiter, MD

Clinical Pharmacologist, Professor, Department of Clinical Pharmacology, Institute for Pharmacology and Toxicology, University Hospital Tübingen

Reprints: Christoph H Gleiter MD, Institut für Pharmakologie und Toxikologie, Abteilung Klinische Pharmakologie, Universitätsklinikum Tübingen, Otfried-Müller-Str. 45, D-72076 Tübingen, Germany, fax 49-7071-295035, christoph.gleiter{at}med.unituebingen.de

OBJECTIVE: To report a case of ginger-phenprocoumon interaction resulting in an elevated international normalized ratio (INR) and epistaxis.

CASE SUMMARY: A 76-year-old white European woman on long-term phenprocoumon therapy with an INR within the therapeutic range began using ginger products. Several weeks later, she developed an elevated INR up to 10 and epistaxis. The INR returned to the normal range after ginger was stopped and vitamin K₁ was given.

DISCUSSION: There have been a number of investigations resulting in conflicting opinions on the effect of ginger on hemostasis, specifically, platelet inhibition. Nevertheless, based on these investigations, recommendations have been issued to refrain from ingesting ginger and other herbals like garlic or ginkgo biloba in situations where bleeding may be critical. An objective causality assessment revealed that the adverse drug event as a result of the phenprocoumon and ginger interaction was probable.

CONCLUSIONS: As of writing, this was the first case report that may support an interaction between an oral anticoagulant and ginger together with a brief review of the literature on ginger and hemostasis. As this interaction was observed only by chance, this case highlights the importance of self-control of anticoagulation with coumarins particularly for the detection of unknown interactions.

Key Words: ginger, phenprocoumon, vitamin K antagonists

Published Online, December 19, 2003. www.theannals.com, DOI 10.1345/aph.1D225

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