What are the potential interactions between blood thinners and a supplement containing Pau D'Arco, Licorice (Glycyrrhiza glabra), Anise Seed, Beta-Glucanase, Hemicellulase, and Brevibacillus laterosporus?

From the FDA Drug Label

Botanical (Herbal) Medicines Caution should be exercised when botanical medicines (botanicals) are taken concomitantly with warfarin sodium tablets. Few adequate, well-controlled studies exist evaluating the potential for metabolic and/or pharmacologic interactions between botanicals and warfarin sodium tablets Due to a lack of manufacturing standardization with botanical medicinal preparations, the amount of active ingredients may vary. This could further confound the ability to assess potential interactions and effects on anticoagulation. It is good practice to monitor the patient’s response with additional PT/INR determinations when initiating or discontinuing botanicals Specific botanicals reported to affect warfarin sodium tablets therapy include the following: Bromelains, danshen, dong quai (Angelica sinensis), garlic, Ginkgo biloba, ginseng, and cranberry products are associated most often with an INCREASE in the effects of warfarin sodium tablets. Coenzyme Q10 (ubidecarenone) and St John’s wort are associated most often with a DECREASE in the effects of warfarin sodium tablets. Some botanicals may cause bleeding events when taken alone (e.g., garlic and Ginkgo biloba) and may have anticoagulant, antiplatelet and/or fibrinolytic properties. These effects would be expected to be additive to the anticoagulant effects of warfarin sodium tablets. Conversely, other botanicals may have coagulant properties when taken alone or may decrease the effects of warfarin sodium tablets Some botanicals that may affect coagulation are listed below for reference; however, this list should not be considered all-inclusive. Many botanicals have several common names and scientific names. The most widely recognized common botanical names are listed Botanicals that contain coumarins with potential anticoagulant effects:

• Contains coumarins, has antiplatelet properties, and may have coagulant properties due to possible Vitamin K content. † Contains coumarins and has antiplatelet properties. ‡ Contains coumarins and salicylates. § Contains coumarins and has fibrinolytic properties. ¶ Has antiplatelet and fibrinolytic properties (Dong Quai) (German and Roman) (Northern) weet Clover Bogbean‡Horseradish Sweet Woodruff Boldo Licorice†Tonka Beans Buchu Meadowsweet‡Wild Carrot Capsicum§Nettle Wild Lettuce Cassia† Miscellaneous botanicals with anticoagulant properties: Bladder Wrack (Fucus) Pau d’arco

• Botanicals that contain salicylate and/or have antiplatelet properties: AgrimonyDandelion†Meadowsweet‡ Aloe Gel Feverfew Onion¶ Aspen Garlic¶Policosanol Black Cohosh German Sarsaparilla Poplar Black Haw Ginger Senega Bogbean‡Ginkgo Biloba Tamarind Cassia† Ginseng (Panax)¶ Willow Clove Licorice†Wintergreen Botanicals with fibrinolytic properties: Bromelains Garlic¶Inositol Nicotinate Capsicum§Ginseng Onion¶ (Panax)¶ Botanicals with coagulant properties: AgrimonyMistletoe Goldenseal Yarrow

The botanicals Pau d’arco and Licorice may affect coagulation and have potential anticoagulant effects.

• Pau d’arco is listed as a miscellaneous botanical with anticoagulant properties.
• Licorice is listed as a botanical that contains coumarins with potential anticoagulant effects and has antiplatelet properties. It is recommended to monitor the patient’s response with additional PT/INR determinations when initiating or discontinuing these botanicals, as the effects of these botanicals on warfarin sodium tablets are not well understood and may increase the risk of bleeding 1. Key points to consider:
• Monitor PT/INR: When initiating or discontinuing Pau d’arco or Licorice, monitor the patient’s response with additional PT/INR determinations.
• Bleeding risk: The use of Pau d’arco or Licorice with warfarin sodium tablets may increase the risk of bleeding.
• Lack of standardization: The amount of active ingredients in botanical preparations may vary due to a lack of manufacturing standardization.
• Unclear effects: The effects of Pau d’arco and Licorice on warfarin sodium tablets are not well understood and may be additive to the anticoagulant effects of warfarin sodium tablets. There is no information available on the effects of Wildcrafted Pau D'Arco, Organic Licorice, Organic Anise Seed, Beta-Glucanase, Hemicellulase, and Brevibacillus laterosporus on warfarin sodium tablets, except for Pau d’arco and Licorice. Therefore, it is recommended to exercise caution when using these botanicals with warfarin sodium tablets and to monitor the patient’s response with additional PT/INR determinations 1.

From the Research

I strongly recommend consulting with a healthcare provider before taking Wildcrafted Pau D'Arco, Organic Licorice, Organic Anise Seed, Beta-Glucanase, Hemicellulase, or Brevibacillus laterosporus if you are on blood thinners like warfarin, apixaban, rivaroxaban, or heparin. Several of these supplements may interact with anticoagulant medications.

• Pau D'Arco contains compounds that may have anticoagulant properties themselves, potentially increasing bleeding risk when combined with prescription blood thinners.
• Licorice, as seen in a case study 2, can affect blood pressure and potassium levels, which may complicate anticoagulant therapy, and its components can inhibit the P450 system enzymes that metabolize Warfarin, leading to an elevated risk of gastrointestinal bleeding.
• Anise seed contains compounds that might affect platelet aggregation.
• The enzymes beta-glucanase and hemicellulase don't have well-documented interactions with blood thinners, but any supplement that affects digestion could potentially alter medication absorption.
• Brevibacillus laterosporus, a probiotic-type organism, has limited research regarding drug interactions. The primary concern is that these supplements could either enhance the blood-thinning effect, increasing bleeding risk, or potentially reduce the effectiveness of your prescribed medication. Always inform your healthcare provider about all supplements you're taking, and consider having more frequent INR monitoring if you're on warfarin and decide to use these supplements, as the combination of anticoagulants and antiplatelets can significantly increase the risk of bleeding, as shown in studies such as 3. Additionally, maintaining a high level of physical activity may be beneficial in reducing the risk of major bleeding in elderly patients receiving anticoagulant therapy, as suggested by 4. However, the decision to take any supplements should be made under the guidance of a healthcare provider, weighing the potential benefits against the risks, especially considering the complexity of anticoagulant therapy and the variability in patient response, as discussed in studies like 5 and 6.