Warfarin with Cannabidiol Interaction Details
Brand Names Associated with Warfarin
- Coumadin®
- Jantoven®
- Warfarin
Brand Names Associated with Cannabidiol
- Cannabidiol
- Epidiolex®
Medical Content Editor Dr. Brian Staiger, PharmD
Last updated
Nov 07, 2023
Interaction Effect
Increased warfarin exposure and risk of increased INR and bleeding
Interaction Summary
Coadministration of cannabidiol (CYP2C9 inhibitor) is predicted to cause a clinically significant interaction with CYP2C9 substrates (eg, warfarin). A 46-year-old man required a nearly 20% warfarin dose reduction to maintain an INR within the goal range after starting therapy with cannabidiol . If warfarin is coadministered with therapeutic or recreational cannabinoids, monitor warfarin closely . Consider decreasing the warfarin dose and measure INR within 3 days of coadministration of cannabidiol .
Severity
Major
Onset
Delayed
Evidence
Probable
How To Manage Interaction
Coadministration of cannabidiol is predicted to cause a clinically significant interaction with CYP2C9 substrates (eg, warfarin).If warfarin is coadministered with therapeutic or recreational cannabinoids, monitor warfarin closely . Consider decreasing the warfarin dose and measure INR within 3 days of coadministration of cannabidiol .
Mechanism Of Interaction
Inhibition of CYP2C9-mediated metabolism of warfarin by cannabidiol
Literature Reports
A) A 46-year-old man treated with stable warfarin doses for DVT (INR goal 2 to 3) was initiated on cannabidiol initial dosage of 5 mg/kg/day in divided doses, titrated weekly to a final daily maintenance dose of 20 mg/kg for treatment-resistant complex partial seizures. Concomitant medications included stable doses of carbamazepine, lacosamide, levetiracetam, acetaminophen, atorvastatin, azelastine nasal spray, carvedilol, cetirizine, fluticasone nasal spray, folic acid, topical ketoconazole, methotrexate, montelukast, mupirocin, mycophenolic acid, omeprazole, prednisone, ranitidine, and tramadol. His warfarin dosage was 80 mg/week during 7 clinic visits over 5 months prior to cannabidiol initiation with INR ranging from 1.7 to 3.3. His INR at the time of cannabidiol initiation was 3.1 however over multiple weeks during cannabidiol dose titration, an increase in INR was observed necessitating a dosage adjustment after weeks 1 and 2 of cannabidiol use; highest INR was 3.5. A nearly 20% warfarin dosage reduction to 65 mg/week resulted in a sustained therapeutic INR with no reported bleeding. The Drug Interaction Probability Scale (DIPS) score for this interaction was rated as 4 (possible) .
Warfarin Overview
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Warfarin is used to prevent blood clots from forming or growing larger in your blood and blood vessels. It is prescribed for people with certain types of irregular heartbeat, people with prosthetic (replacement or mechanical) heart valves, and people who have suffered a heart attack. Warfarin is also used to treat or prevent venous thrombosis (swelling and blood clot in a vein) and pulmonary embolism (a blood clot in the lung). Warfarin is in a class of medications called anticoagulants ('blood thinners'). It works by decreasing the clotting ability of the blood.
Cannabidiol Overview
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Cannabidiol is used to control seizures in adults and children 1 year of age and older with Lennox-Gastaut syndrome (a disorder that begins in early childhood and causes seizures, developmental delays, and behavioral issues), Dravet syndrome (a disorder that begins in early childhood and causes seizures and later may lead to developmental delays and changes in eating, balance, and walking), or tuberous sclerosis complex (TSC; a genetic condition that causes tumors to grow in many organs). Cannabidiol is in a class of medications called cannabinoids. It is not known exactly how cannabidiol works to prevent seizure activity.
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Definitions
Severity Categories
Contraindicated
These drugs, generally, should not be used together simultaneously due to the high risk of severe adverse effects. Combining these medications can lead to dangerous health outcomes and should be strictly avoided unless otherwise instructed by your provider.
Major
This interaction could result in very serious and potentially life-threatening consequences. If you are taking this drug combination, it is very important to be under close medical supervision to minimize severe side effects and ensure your safety. It may be necessary to change a medication or dosage to prevent harm.
Moderate
This interaction has the potential to worsen your medical condition or alter the effectiveness of your treatment. It's important that you are monitored closely and you potentially may need to make adjustments in your treatment plan or drug dosage to maintain optimal health.
Minor
While this interaction is unlikely to cause significant problems, it could intensify side effects or reduce the effectiveness of one or both medications. Monitoring for changes in symptoms and your condition is recommended, and adjustments may be made if needed to manage any increased or more pronounced side effects.
Onset
Rapid: Onset of drug interaction typically occurs within 24 hours of co-administration.
Delayed: Onset of drug interaction typically occurs more than 24 hours after co-administration.
Evidence
Level of documentation of the interaction.
Established: The interaction is documented and substantiated in peer-reviewed medical literature.
Theoretical: This interaction is not fully supported by current medical evidence or well-documented sources, but it is based on known drug mechanisms, drug effects, and other relevant information.
How To Manage The Interaction
Provides a detailed discussion on how patients and clinicians can approach the identified drug interaction as well as offers guidance on what to expect and strategies to potentially mitigate the effects of the interaction. This may include recommendations on adjusting medication dosages, altering the timing of drug administration, or closely monitoring for specific symptoms.
It's important to note that all medical situations are unique, and management approaches should be tailored to individual circumstances. Patients should always consult their healthcare provider for personalized advice and guidance on managing drug interactions effectively.
Mechanism Of Interaction
The theorized or clinically determined reason (i.e., mechanism) why the drug-drug interaction occurs.
Disclaimer: The information provided on this page is for informational purposes only and should not be considered medical advice. Always consult with a qualified healthcare professional regarding your specific circumstances and medical conditions.
Where Does Our Information Come From?
Information for our drug interactions is compiled from several drug compendia, including:
The prescribing information for each drug, as published on DailyMED, is also used.
Individual drug-drug interaction detail pages contain references specific to that interaction. You can click on the reference number within brackets '[]' to see what reference was utilized.
The information posted is fact-checked by HelloPharmacist clinicians and reviewed quarterly.