Dan shen (Salvia miltiorrhiza), a Chinese herb, was associated with increased warfarin activity in two cases.1 , 2 Although warfarin acts differently from ticlopidine, both affect parameters of bleeding. Until more is known, people taking ticlopidine should use dan shen only under close medical supervision. Sage (Salvia officinalis), a plant relative of dan shen found in the West, has not been not associated with interactions involving warfarin.
Ginseng (Panax ginseng) was associated with a decrease in warfarin activity in a case study.3 This report suggests that ginseng may affect parameters of bleeding. Therefore, people taking ticlopidine should consult with a physician knowledgeable about botanical medicines before taking Asian ginseng or eleuthero/Siberian ginseng (Eleutherococcus senticosus).
Devil’s claw (Harpagophytum procumbens) was associated with purpura (bleeding under the skin) in a patient treated with warfarin.4 As with dan shen, until more is known, people taking ticlopidine should avoid taking devil’s claw concurrently.
Garlic (Allium sativum) has been shown to help prevent atherosclerosis (hardening of the arteries), perhaps by reducing the ability of platelets to stick together.5 Interfering with the action of platelets results in an increase in the tendency toward bleeding6 and in theory could dangerously enhance the effect of ticlopidine. Standardized extracts of garlic have been associated with bleeding in people only on rare occasions.7 People taking ticlopidine should consult with a doctor before taking products containing standardized extracts of garlic or eating more than one clove of garlic daily.
Ginkgo extracts may reduce the ability of platelets to stick together, possibly increasing the tendency toward bleeding.8 In a rat study, a high intake of ginkgo increased the action of ticlopidine in a way that could prove dangerous if the same effect occurred in people.9 Standardized extracts of ginkgo have been associated with two cases of spontaneous bleeding, although the ginkgo extracts were not definitively shown to be the cause of the problem.10 , 11 People taking ticlopidine should use ginkgo extracts only under the supervision of a doctor.
Although there are no specific studies demonstrating interactions with platelet inhibitors, the following herbs contain coumarin-like substances that may cause bleeding and therefore interact with ticlopidine. These herbs include dong quai, fenugreek, horse chestnut, red clover, sweet clover, and sweet woodruff.
Like ticlopidine, salicylates interfere with the action of platelets. Various herbs, including meadowsweet (Filipendula ulmaria), poplar (Populus tremuloides), willow (Salix alba), and wintergreen (Gaultheria procumbens) contain salicylates. Though similar to aspirin, plant salicylates have been shown to have different actions in test tube studies.12 Furthermore, salicylates are poorly absorbed and likely do not build up to levels sufficient to cause negative interactions that aspirin might cause.13 No reports have been published of negative interactions between salicylate-containing plants and aspirin or aspirin-containing drugs.14 Therefore concerns about combining salicylate-containing herbs and any drug remain theoretical, and the risk of causing bleeding problems may be low.
Ginseng (Panax ginseng) was associated with a decrease in warfarin activity in a case study.15 This report suggests that ginseng may affect parameters of bleeding. Therefore, people taking ticlopidine should consult with a physician knowledgeable about botanical medicines before taking Asian ginseng or eleuthero/Siberian ginseng (Eleutherococcus senticosus).
Ginger has been shown to reduce platelet stickiness in test tubes. Although there appear to be no reports of interactions with platelet inhibiting drugs, people should talk with a healthcare professional if they are taking a platelet inhibitor and wish to use ginger.16
1. Yu CM, Chan JCN, Sanderson JE. Chinese herbs and warfarin potentiation by “danshen.” J Intern Med 1997;241:337–9.
2. Tam LS, Chan TYK, Leung WK, Critchley JAJH. Warfarin interactions with Chinese traditional medicines: Danshen and methyl salicylate medicated oil. Aust NZ J Med 1995;25:258.
3. Janetzky K, Morreale AP. Probable interaction between warfarin and ginseng. Am J Health Syst Pharm 1997;54:692–3.
4. Shaw D, Leon C, Kolev S, Murray V. Traditional remedies and food supplements: a 5-year toxicological study (1991–1995). Drug Saf 1997;17:342–56.
5. Rose KD, Croissant PD, Parliment CF, Levin MB. Spontaneous spinal epidural hematoma with associated platelet dysfunction from excessive garlic ingestion: A case report. Neurosurgery 1990;26:880–2.
6. Gadkari JV, Joshi VD. Effect of ingestion of raw garlic on serum cholesterol level, clotting time and fibrinolytic activity in normal subjects. J Postgrad Med 1991;37:128–31.
7. Burnham BE. Garlic as a possible risk for postoperative bleeding. Plast Reconst Surg 1995;95:213.
8. Kleijnen J, Knipschild P. Ginkgo biloba. Lancet 1992;340:1136–9.
9. Kim YS, Pyo MK, Park KM. Antiplatelet and antithrombotic effects of a combination of ticlopidine and Ginkgo biloba ext (EGb 761). Thromb Res 1998;91:33–8.
10. Rosenblatt M, Mindel J. Spontaneous hyphema associated with ingestion of Ginkgo biloba extract. N Engl J Med 1997;336:1108.
11. Rowin J, Lewis SL. Spontaneous bilateral subdural hematoma with chronic Ginkgo biloba ingestion. Neurology 1996;46:1775–6.
12. Wichtl M, Bisset NG, eds. Herbal Drugs and Phytopharmaceuticals Stuttgart: Medpharm GmBH Scientific Publishers. 1994.
13. Janssen PL, Katan MB, van Staveren WA, et al. Acetylsalicylate and salicylates in foods. Cancer Lett 1997:114(1–2):163–4.
14. McGuffin M, Hobbs C, Upton R, Goldberg A, eds. American Herbal Product Association’s Botanical Safety Handbook. Boca Raton, FL: CRC Press, 1997, 154–5.
15. Janetzky K, Morreale AP. Probable interaction between warfarin and ginseng. Am J Health Syst Pharm 1997;54:692–3.
16. Newall CA, Anderson LA, Phillipson JD. Herbal Medicines: A Guide for Health-Care Professionals. London: The Pharmaceutical Press, 1996, 135–7.
Last Review: 02-05-2013
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