Warfarin is an anticoagulation medicine that is one of the most widely prescribed medicines in the world. It is sold under a variety of brand names, the best known of them being Coumadin in the US. Warfarin is used widely for people with blood clotting disorders. Millions of people are prescribed warfarin as their doctors claim it will help to keep them free from blood clots. Often they are placed on this medication after a DVT (deep vein thrombosis) in a leg or pulmonary clots in their lungs. Warfarin probably is a reasonable short-term quick-fix for abnormal blood clots, but long-term warfarin usage has some significant risks.
Long-term warfarin usage is tied to increased arterial calcification, osteoporosis, and cardiovascular disease. Perversely, it clogs up the circulatory system and could actually increase the risk of dangerous clots over time. A more comprehensive anticoagulation program that reduces or eliminates the use of warfarin by adjusting diet and adding certain supplements might achieve a better long-term outcome with reduced risk of both blood clots and abnormal bleeding plus reduced risk of the related cardiovascular and bone health problems that warfarin can exacerbate.
A few years ago, Dr. William Davis, a well known cardiologist and author of the best-selling book Wheat Belly: Lose the Wheat, Lose the Weight, and Find Your Path Back To Health, cited a simple example of how warfarin can severely raise the risk of heart attack by causing greatly accelerated cardiovascular calcification:
Quoted from Warfarin is scary stuff:
Gilbert is a 58-year old high school science teacher.
When I first met Gil, he’d been having bouts of atrial fibrillation and had required various medications to suppress recurrences of the rhythm. However, because his rhythm proved somewhat difficult to control, his electrophysiologist (heart rhythm specialist) prescribed warfarin to reduce the risk of stroke. With atrial fibrillation, because of blood stagnation (in the left atrial appendage) in the heart, there is a stroke risk of approximately 8% per year. Warfarin reduces this risk substantially, to about 2%.
I met Gil because he had a cholesterol disorder. In my practice, the first step in gauging the implications of a lipid or lipoprotein disorder is to obtain a heart scan. If the heart scan score is zero, great. It means that we have plenty of time to treat the disorder since risk for cardiovascular events is near zero also; it means less intensive efforts are necessary. But if the heart scan score is, say, 1200, then an aggressive approach in short order is required, since the risk for heart attack may as high as 20-25% per year, even in the absence of symptoms.
Gil’s heart scan score: 787–high and posing a risk for heart attack of about 5-10% per year without preventive efforts. Gil did indeed prove to have a complex lipoprotein disorder, as well as high blood pressure, vitamin D deficiency, and several other potential contributors to coronary plaque.
Gil did just about everything right: He exercised, followed the recommended diet, achieved better than the Track Your Plaque 60-60-60, lost 18 lbs of abdominal fat.
Gil’s rhythm stabilized for several months, only to have atrial fibrillation break through again. So Gil’s electrophysiologist re-prescribed warfarin.
18 months later, Gil’s 2nd heart scan score: 1410–a near doubling.
Davis believes it is the warfarin that greatly aggravated the heart scan calcium score. Warfarin displaces calcium from the bones and that calcium ends up somewhere, most often on the inside of blood vessels and the heart where it greatly raises the risks of cardiovascular disease and consequent early death. And this is one of the major reasons why anybody prescribed warfarin should be looking hard for alternatives that would help reduce dangerous side effects and allow lowering the dosage of warfarin or discontinuing it entirely. In Gil’s case, the drug Pradaxa (generic Dabigatran) might be an option as it has been approved in some locations for use in reducing clotting risk related to atrial fibrillation. However, as with most drugs, it has risks of its own.
Clotting Is Normal and Safe Until It Gets Out of Control
In medical writings discussing clotting disorders, you’ll often see mention of “thrombosis”. Any time you see “thrombosis” simply think of it as doctor-speak for a clot that has occurred inside a blood vessel.
Clotting is a normal process of the body. It’s important to stop blood loss so that damaged tissues can be repaired. The body normally produces many tiny clots to stop bleeding not only in cuts and bruises but even within blood vessels and internal organs. This normally create no problems as they are so small that are reabsorbed over time or they pass through blood vessels and organs without causing any damage.
The danger from clots largely comes from when they grow large enough to block healthy blood flow and particularly if they break loose in big chunks and then travel throughout the body and lodge somewhere else blocking blood flow. This is more likely to happen in microscopic blood vessels, but the danger from a clot is much worse when it blocks a larger blood vessel. When this happens, parts of the body that are deprived of ample blood flow are often damaged severely. Most people are aware that blood carries oxygen and nutrients that cells need to survive. But blood is also a means to eliminate buildups of metabolic products that can harm cells. The bloodstream takes such substances to the kidney and liver where they can be processed into waste products or transformed into useful or at least less harmful substances.
Doctors and biomedical researchers often discuss ischemia and reperfusion injuries to tissues deprived of blood flow. Ischemia refers to an abnormal slowing or cessation of blood supply to tissues. Reperfusion refers to the blood flow being restored after a period of ischemia. Both can produce significant damage to tissues and both are major reasons for why clots are so dangerous. While it may seem counterintuitive that restoring blood flow could cause further damage, this happens because the restored blood flow often brings with it a barrage of inflammatory cytokines, free radicals, and oxidized biochemicals that further damage tissue already weakened by the ischemia.
Why Doctors Prescribe Warfarin and Anticoagulants
The best way to prevent ischemia and reperfusion damage is to prevent any interruption of blood flow in the first place. Once a patient has experienced an abnormal blood clot, doctors generally regard this patient as at high risk for further clots unless they can explain away the clot as being caused by some unusual event such as an injury or surgery. If they can’t find a good explanation like that, doctors will generally run a series of tests looking for genetic and immune markers that are commonly found in people with high clotting risk. If they find some of these risk factors, they are likely to prescribe warfarin or other anticoagulants on a long-term basis for years or more. Often they will tell such patients they must continue to use these drugs “for life”.
How Warfarin Prevents Clots
Many people call warfarin a “blood thinner” but that’s a misnomer. It doesn’t actually change the viscosity of blood. Instead, it works by interfering with vitamin K metabolism in the liver involved in producing various clotting proteins, particularly prothrombin (factor II) and factor VII. By decreasing the available amount of these proteins, the body’s ability to create blood clots is reduced. But prothrombin and factor VII are just two of the many clotting proteins involved in a clot.
Other anticoagulation drugs target other clotting proteins or enzymes involved in the clotting process. For instance, heparin as its low molecular weight derivatives (enoxaparin, tinzaparin, dalteparin) are widely used as injection anticoagulants that operate on the antithrombin III enzyme which then inactivates the thrombin and factor Xa clotting proteins.
Injections are obviously not ideal, so warfarin which can be taken orally as small pills has an advantage over heparins. Unfortunately, warfarin works inconsistently in large part because it is a vitamin K antagonist that interacts with the vitamin K in a person’s diet. Because of this interaction, many patients require diet modifications and frequent testing to safely use warfarin. Without such changes, patients may experience their clotting profiles varying from high risk for clotting to high risk for bleeding and spend little time in the safe therapeutic zone.
Starting Warfarin Risky, Often Requires Concurrent Injection Anticoagulation
It takes about a day for the anticoagulation effect of warfarin to become apparent in test results. But reaching therapeutic range for the drug often takes several days. During this initial use, patients often must use injection anticoagulants such as heparin because warfarin actually causes a rapid drop in the anticoagulation protein C that can trigger extensive clotting if the prothrombin and factor VII protein levels have not decreased enough to prevent this effect.
During this initial period, patients are often tested daily to measure their INR, the International Normalized Ratio representing how slowly or quickly their blood clots. INR 1.0 is supposed to be “normal”, but of course as with most tests there is some variation from person to person and test to test. Typical people not on an anticoagulation regime have INR tests ranging from 0.8 to 1.2. For people who have not experienced abnormal clotting while taking warfarin, doctors often aim for an INR therapeutic range of 2.0 to 2.5. That means that blood will take about two to two and a half times longer than “normal” to clot.
Maintenance of Warfarin Dosage
Many health clinics and hospitals have a “Coumadin Clinic” or “Anticoagulation Services” group that monitors patients who are taking warfarin. Usually this consists of a pharmacist and a doctor who are experienced in managing the usage of the drug and advising patients on diet, medications, and health concerns impacted by warfarin. Warfarin interacts with many medications. Often other doctors are poorly informed on these interactions and will prescribe medications that may be dangerous for patients using warfarin. As a result, the anticoagulation experts typically advise any changes in medication and diet should be checked with them. The essential message from them is “do not completely trust other doctors” because they have seen many patients injured by prescriptions that should never have been written for them. Dangerous drugs for warfarin patients even include over-the-counter medications such as ibuprofen, aspirin, and other NSAIDs painkillers as they all increase the risk of gastrointestinal bleeding. Yet most doctors regard them as being very safe and many not stop to consider that they could trigger dangerous bleeding in a patient taking warfarin or other anticoagulation medication.
The monitoring generally consists of testing once every one to four weeks if dosage and INR levels have been stable for months. When INR tests show out-of-range results versus the therapeutic range prescribed for a patient, often the patient will be asked to increase or decrease the dosage of warfarin and come back for tests more often. On an outpatient basis, this could be as often as once per day. If the coagulation problems demand more frequent testing than that, it’s likely you’ll be confined to a hospital until the doctors think they have some control over the problems.
Since around 2005, an increasing number of warfarin patients have used at-home testing devices to monitor and report their INR results to their health care providers. Generally such tests involve finger-prick blood drop samples similar to those used for daily monitoring of glucose levels in diabetic patients. Being able to use an at-home testing device can save a lot of hassle and time for those who are able to do it successfully. One of the benefits of this approach is that more frequent testing is possible and if a patient suspects something has gone wrong (missed a dose or took an extra dose, a change in diet, etc.) then it is easier to retest than having to drive to a clinic for a blood draw and waiting a day or so for the results.
Warfarin Patients Must Change Medications Around Surgeries and Dental Work
Patients taking warfarin are often advised to switch to injection anticoagulation and temporarily stop the warfarin if they need surgery or even some kinds of dental work such as deep gum cleaning that can trigger a lot of bleeding. Typically such patients will have to use injection anticoagulation starting two or more days before a procedure, resume the warfarin the day after the procedure, and then continue the injection anticoagulation until the INR test results are again therapeutic. It is not unusual for the total time on the injection anticoagulation drugs to be one week or more before then can be stopped safely. Injection anticoagulation drugs used for this purpose include heparin and low molecular weight variants such as enoxaparin.
Warfarin Dosages Increased For Patients With Higher Clotting Risks
Doctors try to keep the INR at a reading they think balances the risk between abnormal clotting and abnormal bleeding. People who have experienced clots while taking warfarin are often prescribed with higher doses of the medicine to reach INR 2.5 to 3.5. Patients with replacement heart valves may be prescribed even higher dosages to reach INR ranges up to 4.5.
The higher the INR, the slower the clotting. Unfortunately, this also means the risk of abnormal bleeding goes way up. Often this shows up with symptoms such as a person bruising very easily. Unfortunately, this also means elevated risks for dangerous hemorrhages and bleeding strokes.
Anybody taking warfarin should consider modifying their daily activities to avoid injury risks involving exercise (especially contact sports such as football, soccer, basketball, etc.), cuts, and puncture wounds. This is especially true for people who are told to maintain higher INR levels due to clotting or heart valve replacement. Anybody taking warfarin who experiences an injury that could lead to internal bleeding needs to be especially careful to watch for swelling or pooling of blood under the skin and if it appears to seek immediate medical attention.
Warfarin patients are often advised to wear medical advisory bracelets and carry information about their warfarin usage in their wallets and purses. Emergency medical workers need to be able to quickly determine that patients are being treated with warfarin in order to avoid treating them with a drug or medical procedure that could kill them because of high bleeding potential.
Patients also need to take their warfarin at consistent times of the day. Generally it would be better to take divided doses so that there is less of a spike effect from taking it all at once. If you forget a dose, you need to take it as soon as possible before your warfarin levels drop too low and your clotting risk increases as your INR falls out of therapeutic range. Likewise, if you take an extra dose you are at increased risk of bleeding.
Often patients who are taking warfarin find that their INR test results vary dramatically and they have trouble figuring out why this happens. There’s an interesting discussion thread Hawaiian Punch “Don’t Do It” that reveals how confusing this can be. The discussion covers the impact of travel affecting when you take your medicine, changes in diet such as certain kinds of fruit juices increasing or decreasing warfarin activity, and interactions with antibiotics. If you’re taking warfarin, please take a few minutes to read this to understand how puzzling and drastic changes in INR can originate from seemingly “normal” variations in diet, medications, and schedules. For instance, say you’re taking warfarin and take a trip from London to Hawaii for a wedding (throwing your schedule off by several hours) and then proceed to have a few tropical alcoholic beverages at the wedding banquet. You might find yourself in the hospital as a result and at a loss for what happened because you didn’t miss any doses or take any extra doses and didn’t change the foods you are usually eating, either.
Dietary Challenges for Warfarin Patients
It is essential to understand that warfarin interacts with vitamin K and therefore consuming drinks and eating foods can cause peaks and valleys in your vitamin K intake or add substances that block or enhance warfarin metabolism. Varying diet is particularly risky for anybody taking warfarin. The key is to try to maintain reasonably stable levels of vitamin K and any substances that may affect warfarin metabolism such as alcohol.
Unfortunately, some doctors and patients have a misconception that this means avoiding vitamin K rich foods altogether. That’s probably not a good idea for most warfarin patients. Long-term use of warfarin contributes to significant health damage via arterial calcification, osteoporosis, and increasing the risk of blood clots because of accelerated damage to the circulatory system. This is directly related to how it interferes with the body’s normal use of vitamin K.
Vitamin K is a very important fat-soluble nutrient. When warfarin was first developed as rat poison and then used as a medicine to prevent clotting, there was little understanding of vitamin K. It wasn’t until 1974 that scientists even understood the precise chemical mechanism for vitamin K’s role in clotting processes.
In recent years, it has become clear that vitamin K is essential to bone health and circulatory system health. It helps control the activity of osteoclasts that break down old bone matter. One of the possible causes of osteoporosis is inadequate vitamin K that results in osteoclasts breaking down old bone faster than osteoblasts can build new bone. The result is that the blood gets loaded with high levels of calcium. The result is accelerated arterial calcification, atherosclerosis, and heart valve damage as the excess calcium lost from the bones ends up on the walls of blood vessels and the heart. This is one of the causes for “hardening of the arteries” as the endothelial lining of the circulatory system literally starts to resemble very thin bone tissue.
There’s growing evidence that people who are deficient in vitamin K are more likely to develop liver and prostate cancers and Alzheimer’s Disease.
Probably the biggest challenge with successfully using warfarin is that the vitamin K intake in the diet of most people is quite variable. It is typical for a person some days to eat little in the way of vitamin K and then another day eat a big salad with lots of vitamin K rich leafy greens. The resulting interaction with the swinging levels of vitamin K and the stable level of warfarin is INR readings that also swing wildly. Thus if you do have to use warfarin for some reason, you need to keep your vitamin K intake consistent to avoid periods of high bleeding and high clotting risks.
It’s probably even advisable to take vitamin K supplements every day consistently and take more warfarin than you would need without them because it will help reduce the day-to-day variation in vitamin K and warfarin-modified INR readings. Another rationale for this is that most food-based vitamin K is in the poorly absorbed and rapidly used K1 (phylloquinone or phytonadione) form, but many supplements including the vitamin K2 forms MK-4 (menaquinone-4 or menatetrenone) and MK-7 (menaquinone-7) that are better absorbed and last longer in the body. Vitamin K2 MK-7 is particularly strong at lasting a long time in the body thereby helping keep vitamin K levels more stable throughout the day. Animal-derived foods and fermented foods are generally richer in vitamkin K2.
Some doctors may consider this advice dangerously wacky and advise their patients taking warfarin to avoid leafy greens. This opinion has increasingly been shown to be a poorly thought out position. Beyond being strong sources of vitamin K, many leafy and dark green vegetables are also a good source of important antioxidants such as vitamins A and C, fiber, and other nutrients such as folic acid, iron, and calcium. Strong vitamin K foods such as kale, collards, and broccoli are also rich in glucosinolates and sulforaphane that have a variety of important health benefits such as reducing the risk of cardiovascular disease, diabetes, and certain bacterial infections and cancers.
Some fruits such as blueberries and cantaloupe are also sources of vitamin K, but at lower levels than in leafy and dark green vegetables.
Meat is generally not a strong source for vitamin K, but organs such as the liver of grazing animals (e.g., cows and pigs) can have very high levels of vitamin K since they eat so much vitamin K rich plant matter as a major component of their daily diets.
Food preparation also affects vitamin K. Heavy cooking tends to destroy it and many other nutrients, so it’s often advisable to consume fruits and veggies raw or lightly cooked if you’re trying to get the most nutritional value out of them.
Here is a brief list of some common vegetables to show there is a wide variation in vitamin K content:
- Kale (boiled and drained) around 1062 to 1147 mcg per 1 cup (130 grams)
- Collards (boiled and drained) around 836 to 1059 mcg per 1 cup (170 grams)
- Spinach (cooked, boiled, or canned) around 889 to 1027 mcg per 1 cup (around 180 to 214 grams)
- Broccoli (cooked, boiled, and drained) around 220 mcg per 1 cup (156 grams)
- Spinach (raw) around 145 mcg per 1 cup (30 grams)
- Broccoli (raw) around 89 mcg per 1 cup (88 grams)
- Iceberg Lettuce around 130 mcg per 1 head (539 grams)
For more details and a wider range of foods, see the USDA’s Nutrient Database.
The USDA recommends a minimum daily intake of 80 to 120 micrograms of vitamin K per day. However, this is generally recognized as not enough to realize the full potential health benefits of vitamin K. Many supplements include 1000 mcg or more of vitamin K in various forms.
Does Warfarin Really Solve the Clotting Problem?
Initially, it’s probably safest to use injection anticoagulants and warfarin if a person has developed a clot and does not yet know how to prevent another one from occurring without such drugs. But because of the long-term risks of low vitamin K levels, patients who can manage a more complicated diet and supplement regime may be better served long-term by using diet and supplements rather than warfarin.
Most doctors would say that warfarin is the “standard of care” for people with abnormally high risk of blood clotting. That they dole out millions of prescriptions for it every year adds to this perception.
However, there is no single reason for why people suffer abnormal blood clots. When you actually investigate all the factors that can affecting clotting, it becomes clear that warfarin is really more of a quick-fix that doesn’t do much of anything to address most of the root causes for abnormal clotting. As such, even a patient on warfarin who is often testing in or near therapeutic range can still develop dangerous clots. This is why I’d advise anybody prescribed warfarin to immediately demand comprehensive testing to look for root causes for their clotting problems.
Such tests should include the following at a bare minimum:
- antiphospholipid antibodies (cardiolipin and lupus anticoagulant tests)
- Factor V Leiden
- Protein S
- Protein C
Antiphospholipid antibodies can can elevated clotting risk. There are two main types. Cardiolipin antibodies are one type, the other is the poorly named “Lupus anticoagulant” condition in which the body makes antibodies against anti-clotting proteins. It got that unfortunate name because it was first identified in patients with lupus, but the condition occurs in many people who do not have lupus. These kinds of clotting related antibody conditions can come and go. Sometimes an immune system reaction to some environmental factor such as an infection or toxin triggers them, other times there is no apparent cause.
Factor V Leiden is a very common genetic disorder especially in people with European ancestry, possibly around 5% of the US and Canadian Caucasian population has it. Many have it heterozygously, causing have of their Factor V clotting proteins to be made in a fashion that they cannot be inactivated. But it is much more dangerous to have it homozygously, causing all the Factor V to have this defect.
Protein S and Protein C deficiencies can lead to increased risk of clots (thrombosis) and pulmonary embolism, but they are probably less common than Factor V Leiden.
It’s possible to have combinations of these conditions, they are not mutually exclusive. The more conditions, the more likely you are to have elevated clotting risk.
Often the above tests plus diagnostic imaging (ultrasounds, X-rays, CAT scans, MRI scans, etc.) are all a doctor will order when a patient is found to have a clot. They want to know where the clot is, how big it is, and if there are any clear signs of a genetic or immune driven clotting problems. However, they often do not consider that there are wide range of other contributing factor for clots that should also be investigated. As a general rule, if you have experienced an abnormal blood clot that landed you in a hospital or resulted in the use of any kind of anticoagulation drug, you should also be asking your doctors to get you tested for a wide range of other conditions that affect cardiovascular and immune system health. Clotting risk is likely to be aggravated by anything that clogs up blood vessels, makes them inflexible or rigid, triggers high levels of inflammation or oxidation especially if it has potential to damages organs with complex circulatory systems (brain, kidney, liver). Additionally, it has been noted that some kinds of chronic infections may trigger chronic inflammation and oxidation that could increase clotting risk if they are not resolved.
I’d encourage you to request the following tests:
- Vitamin D level
- VAP or NMR cholesterol panel
- CRP (C-Reactive Protein)
- CoQ10 level
- diabetes tests (fasting glucose, fasting insulin, HbA1C)
- inflammatory cytokines panel (IL-1b, IL-6, IL-8, TNF-a, etc.)
- autoimmune disorder tests (e.g., Celiac disease)
- sex hormone tests (DHEA, free and total testosterone, estradiol, SHBG, etc.)
- chronic infection tests (Helicobacter pylori, candida, hepatitis, etc.)
- cancer screening tests (PSA, etc.)
Getting those tests will give you a much more comprehensive set of data to determine factors that you can address to reduce clotting risk. They are also all important measures for general health even if you did not have a clotting problem. The odds are that most of these tests will come back with results that are not blatantly horrible according to most doctors. However, the vast majority of Americans today have very poor levels of vitamin D and the epidemics of obesity and diabetes virtually ensure that for most people some of the other test results will turn out to reveal problems that could be contributing to a tendency to develop abnormal clots.
If you are expected to stay on warfarin for longer than a few months, it is also important to get a baseline of your cardiovascular calcification and recheck it after a year or so on warfarin to understand if the drug is greatly aggravating this problem. A CT heart scan with calcium scoring can be used to check and monitor the impact of the drug. You may find that even the baseline measurement is high and that your doctor may need to rethink the use of warfarin in your case to avoid aggravating your risk for cardiovascular disease.
Importance of Vitamin D
In developed nations, particularly those far from the equator, almost everybody has insufficient levels of vitamin D. Vitamin D is very important to controlling inflammatory conditions and for correct operation of the immune system. It is well known that inflammatory conditions tend to produce tissue damage that can result in clots. It is also well known that infections tend to trigger high levels of inflammation. Consequently, getting your vitamin D levels into the optimal range (generally regarded as around 50 ng/ml to 80 ng/ml) is very important to maintaining clotting risk.
It’s also important because vitamin D is a key ingredient in managing the body’s reserves of calcium. If you have enough vitamin D and vitamin K, your odds are keeping calcium in the bones and avoiding rapid arterial calcification are better.
Achieving optimal vitamin D levels this will almost certainly require supplementation with vitamin D3 for most people. Determining appropriate vitamin D3 dosages is not easy because the response from person to person varies tremendously. However, that said, most adults could stand starting with 5000 IU of vitamin D3 per day for a few months and then retesting to see how things have changed. Based upon this, dosage can be adjusted upwards or downwards.
You want to be cautious about going past 100 ng/ml on your vitamin D test. Actually given the likelihood of high vitamin D boosting blood calcium levels, this is even more important for people taking warfarin as they are at higher risk of calcium leaching out of bones and into the bloodstream. In people without high clotting risk, levels of vitamin D of above 100 ng/ml have been connected with increased risk of heart disease involving calcification damage to the heart valves. I’d suspect, although I haven’t seen any studies to confirm this, that the risk is higher for people on warfarin and therefore they should consider a safe upper limit for vitamin D to be somewhat lower. To be conservative, they might want to aim for the bottom half of the 50 to 80 ng/ml range often considered as optimal and aim not to exceed 65 ng/ml while they are taking warfarin.
Very few people will get anywhere near 100 ng/ml of vitamin D even if supplementing 10,000 IU per day of vitamin D3 for many months. And for some people, getting their 50 to 80 ng/ml target level is going to require even more than 20,000 IU per day of vitamin D3 supplements. I strongly advise anybody who is taking more than 5000 IU per day of vitamin D3 to get tested at least once per year to verify that the dosage is appropriate. And if you’re taking warfarin, you should also be keeping a closer watch on your blood calcium levels, too.
Supplements Important for Warfarin Patients
If you are taking warfarin I would strongly advise you to discuss with your doctor adding low-dosage vitamin K (particularly MK4 and MK7 forms) to help stabilize your coagulation and vitamin K levels to make them less sensitive to dietary impact. This step alone can help reduce the risk of both clots and abnormal bleeding from the diet-interacting variation in the effects of warfarin.
There are also a variety of other supplements that can greatly improve your ability to lower clotting risk while avoiding the dangerous arterial calcification and osteoporosis side effects of warfarin. For more information, see my article Supplements That Can Aid Warfarin Users By Reducing Abnormal Clotting and Bleeding Risks.
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