Nevertheless, an unscheduled PT test performed in the ER during her second visit provided markedly different results indicating a prolonged coagulation time despite no known changes to the patient's medication regimen or diet.
As a result of the results of the PT test performed in the ER, her physician lowered her daily dosage of Coumadin to 2 milligrams per day, with instructions to repeat PT testing weekly for the time being. Four days later, the patient returned to the ER complaining of excessive bleeding from the nose and gums (on flossing) again, despite following her physician's instructions to decrease her Coumadin dosage.
Administration of intravenous saline and elevation of the affected extremities again resolved her symptoms, but this time, she was admitted to the hospital for observation and more extensive testing scheduled by her cardiologist for the nest day.
Resolution:
While interviewing the patient and her family in great detail the next day, her physician inquired again into every over-the-counter (OTC) medication taken since her return from Europe and again reviewed dietary guidelines intended to avoid unintended interference with the desired effects her Coumadin regimen. The interview failed to disclose any medication interactions or dietary issues. Only after the interview concluded, did the patient ask "Doctor, does it matter what kind of tea I drink?" On the physician's subsequent inquiry, the patient disclosed that she had begun drinking Ginseng tea that a friend in...
The physician advised that Ginseng has been shown, in at least one study, to decrease the effectiveness of Coumadin's anticoagulant effects.
The physician then inquired more particularly into whether the patient had taken any other natural remedies" and stressed the importance of considering any and all types of dietary changes, including any so-called "naturopathic" products. The patient then related that the same person who had provided the Ginseng tea had also suggested
Ginkgo Biloba and St. John's Wart for "mood elevation." According to the patient, she first began taking those two herbal agents shortly after her first visit to the ER, specifically because she was depressed over the recurrence of her DVT symptoms.
After reiterating his instructions about avoiding "any and all" dietary changes without first consulting him, he instructed the patient to discontinue the Ginseng tea, St.
John's Wart, and the Ginkgo Biloba, the last of which, in particular, has specifically been linked to increasing the effect of blood thinning medications like Coumadin, resulting in excessive bleeding. Following her discharge the next day, the patient was returned to her previous 2.5mg/day dosage of Coumadin without subsequent medical incident. She is presently looking forward to her next European trip in July of 2008.
