• Mochamad Djunaedi Department of Comunity Pharmacy, Faculty of Pharmacy, Universitas Airlangga, Surabaya, Indonesia.
  • Syed Azhar Syed Sulaiman Department of Comunity Pharmacy, Faculty of Pharmacy, Universitas Airlangga, Surabaya, Indonesia.



Supplement, Herbal medicine, Warfarin, International normalized ratio monitoring


Objective: The supplements and herbal medicines used should be monitored in a patient taking warfarin, to achieve the goal of warfarin anticoagulation. This study aims to evaluate the impacts of the supplement and the herbs used on the performance of anticoagulation.

Methods: There were 214 eligible patients for having CHADS2 score >2 registered at warfarin-medication therapy adherence clinic coordinated by Cardiac Hospitals in Malaysia in 2012 included for this study. They have been assessed using a trained pharmacist regarding the safety and efficacy of warfarin as per guideline.

Results: Supplements and herbs are commonly used by the patient (61.2%) who is taking warfarin. Some patients (23%) have decided not to use or stop using it after being consulted by the pharmacist. Some are even starting to use it (37%). Effects of supplements and herbal medicines were found to decrease in the International normalized ratio (INR) reading as 33%, increasing in 37% the INR reading. Further, pharmacist action is to do a dose adjustment to reach INR in the therapeutic range 2.0–3.0. Supplements consumed as categorized as phytomedicine-containing herbs, such as Omega3 and glucosamine. Whereas herbs used as beetle leaves and the product of extracted herbs, for example, Gingko biloba, Cordyceps, etc.

Conclusion: Monitoring by pharmacist is needed to achieve the goal of warfarin as well as to minimize the INR out of therapeutic. The use of herbal and supplement is found to be a factor contributes to the performance of anticoagulation control which has been successfully achieved 71.2%.


Sellers MB, Newby LK. Atrial fibrillation, anticoagulation, fall risk, and outcomes in elderly patients. Am Heart J 2011;161:241-6.

Witt DM, Sadler MA, Shanahan RL, Mazzoli G, Tillman DJ. Effect of a centralized clinical pharmacy anticoagulation service on the outcomes of anticoagulation therapy. Chest 2005;127:1515-22.

Hirsh J, Fuster V, Ansell J, Halperin JL, American Heart Association, American College of Cardiology Foundation, et al. American heart association/American college of cardiology foundation guide to warfarin therapy. Circulation 2003;107:1692-711.

Alhusban A, Fagan SC. Secondary prevention of stroke in the elderly: A review of the evidence. Am J Geriatr Pharmacother 2011;9:143-52.

Colalto C. Herbal interactions on absorption of drugs: Mechanisms of action and clinical risk assessment. Pharmacol Res 2010;62:207-27.

Morgan CL, McEwan P, Tukiendorf A, Robinson PA, Clemens A, Plumb JM. Warfarin treatment in patients with atrial fibrillation: Observing outcomes associated with varying levels Of INR control. Thromb Res 2009;124:37-41.

Bodack MI. A Warfarin-induced subconjunctival hemorrhage. Optometry 2007;78:113-8.

Fuster V, Rydén LE, Cannom DS, Crijns HJ, Curtis AB, Ellenbogen KA, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation. Executive summary: A report of the American college of cardiology/American heart association task force on practice guidelines and the European society of cardiology committee for practice guidelines. J Am Coll Cardiol 2006;48:854-906.

Freestone B, Rajaratnam R, Hussain N, Lip GY. Admissions with atrial fibrillation in a multiracial population in Kuala Lumpur, Malaysia. Int J Cardiol 2003;91:233-8.

Louis KM, Martineau J, Rodrigues I, Fournier M, Berbiche D, Blais N, et al. Primary care practices and determinants of optimal anticoagulation management in a collaborative care model. Am Heart J 2010;159:183-9.

Lane DA, Ponsford J, Shelley A, Sirpal A, Lip GY. Patient knowledge and perceptions of atrial fibrillation and anticoagulant therapy: Effects of an educational intervention programme. The west Birmingham atrial fibrillation project. Int J Cardiol 2006;110:354-8.

Haq AH, Rahman SS, Othman NA, Izam TM, Esa RS. Protocol: Warfarin Medication Therapy Adherence Clinic. Malaysia: Pharmaceutical Services Division Ministry of Health Malaysia; 2010.

Lwanga SK, Lameshow L. Sample Size Determination in Health Studies. (1st Printed). Geneva: World Health Organization; 1991. p. 30.

Gage BF, Waterman AD, Shannon W, Boechler M, Rich MW, Radford MJ, et al. Validation of clinical classification schemes for predicting stroke: Results from the national registry of atrial fibrillation. JAMA 2001;285:2864-70.

Fang MC, Chen J, Rich MW. Atrial fibrillation in the elderly. Am J Med 2007;120:481-7.

Coppens M, Eikelboom J, Hart R, Yusuf S, Lip GY, Dorian P, et al. The CHA2DS2-VASC score identifies AF patients with A CHADS2 score Of 0 Or 1 treatted with antiplatelet therapy who Are Unlikeliy to benefit from oral anticoagulant therapy. J Am Coll Cardiol 2012;59 13 Suppl: E570.

Garcia DA. Benefits and risks of oral anticoagulation for stroke prevention in nonvalvular atrial fibrillation. Thromb Res 2012;129:9-16.

Camm AJ, Kirchhof P, Lip GY, Schotten U, Savelieva I, Ernst S, et al. Guidelines for the management of atrial fibrillation: The task force for the management of atrial fibrillation of the European society of cardiology (ESC). Eur Heart J 2010;31:2369-429.

Gan GG, Teh A, Goh KY, Chong HT, Pang KW. Racial background is a determinant factor in the maintenance dosage of warfarin. Int J Hematol 2003;78:84-6.

Rosendaal FR, Cannegieter SC, van der Meer FJ, Briët E. A method to determine the optimal intensity of oral anticoagulant therapy. Thromb Haemost 1993;69:236-9.

Matalqah LM, Radaideh KM, Sulaiman SA, Hassali MA, Kader MA. Relationship between patients’ warfarin knowledge and anticoagulation control result of validated tool in Malaysia. J Pharm Biomed Sci 2013;30:967-74.

Hisham SA, Wu PY, Loong LS, Choong CC, Loh CF, Nor M. Study on factors affecting overwarfarinization in in-patient hospital universiti Kebangsaan Malaysia (HUKM). Malays J Pharm Sci 2005;3:72.

Witt DM, Delate T, Clark NP, Garcia DA, Hylek EM, Ageno W, et al. Nonadherence with INR monitoring and anticoagulant complications. Thromb Res 2013;132:e124-30.

Fugh-Berman A. Herb-drug interactions. Lancet 2000;355:134-8.

Paeng CH, Sprague M, Jackevicius CA. Interaction between warfarin and cranberry juice. Clin Ther 2007;29:1730-5.

Gage BF, Fihn SD, White RH. Management and dosing of warfarin therapy. Am J Med 2000;109:481-8.



How to Cite

Djunaedi, M., and S. Azhar Syed Sulaiman. “THE PHARMACIST’S ASSESSMENT ON PATIENTS WHO CONSUME SUPPLEMENTS AND HERBAL WHILE UNDERGOING WARFARIN THERAPY”. Asian Journal of Pharmaceutical and Clinical Research, vol. 11, no. 13, Apr. 2018, pp. 49-54, doi:10.22159/ajpcr.2018.v11s1.26566.



Original Article(s)