In my previous article Widely Used Anticoagulation Drug Warfarin (Coumadin) More Dangerous Than Commonly Thought, I discussed some coagulation disorders in which the widely prescribed drug warfarin (Coumadin) is used and how it has some very bad long-term side effects. Warfarin fails to fully solve the problem of abnormal clotting particularly in patients who have been taking it for years in whom it may actually aggravate several processes which can increase abnormal blood clotting risk.
Abnormal clotting can show up as DVTs (deep vein thrombosis which typically present as a swelling and painful leg changing colors and feeling warmer than usual), heart attacks, pulmonary embolisms (which are often lethal and the symptoms of which may be confused with a heart attack), strokes, and a variety of less frequent but still dangerous conditions. Warfarin users in some ways are more likely to have these problems if for no other reason than the warfarin interacts with vitamin K levels in a way that can often be difficult to control without additional measures.
Warfarin probably is a reasonable stop-gap measure for treating people at elevated clotting risk, but I personally do not believe it should be used for more than a few weeks on its own without also introducing a variety of other measures designed to help prevent clots. Past experience of many patients using warfarin is that they are much more likely to experience abnormal bleeding and still have abnormal clotting even when taking warfarin precisely because it is highly sensitive to vitamin K in the diet and it only modifies two blood clotting factors, prothrombin (Factor II) and Factor VII, while doing nothing to a myriad other biochemical factors that influence clot development and progression.
For many patients using warfarin, even those with genetic risk factors such as Factor V Leiden, it should be possible over a period of a year or more to eliminate the drug and its dangerous side effects. Careful monitoring of test results, consistent use of supplements that reduce a wide range of clotting risk factors, and for many people some diet changes (particularly reducing carbohydrates) are all necessary for this to be safe and successful.
Unfortunately, not all warfarin patients are candidates for stopping the drug. Dr. William Davis, a cardiologist who often advises the use of supplements over prescription drugs, says that those with artificial heart valve replacements are likely to need to continue to take the drug because their clotting risk is so severe. Even for these people, however, supplements and diet changes are likely to make the anticoagulation effects safer and to reduce some of the side effects of warfarin.
Here I’m going to outline some of the best measures outside of medications that you should discuss with your doctor about how to reduce the risk of side effects from warfarin and possibly, over time, get off of it entirely. I must caution you that although getting off of warfarin is a definite possibility for many people, this is not something you want to do quickly because your body needs time (maybe even over a year) to lower its innate clotting risks affected by some combination of the supplements below before you should risk discontinuing warfarin entirely.
Making Warfarin’s Vitamin K Interaction More Consistent
Warfarin works by interfering with the biological activity of vitamin K. Although vitamin K is fat soluble and therefore should in theory persist longer in the body than many water soluble nutrients, the reality is that most people get too little vitamin K and they tend to eat a “bursty” diet of vitamin K foods. If you eat some tasty kale and a spinach salad one day and then only have a piece of iceberg lettuce on a burger for your greens the next, you are creating peaks and valleys in your circulatory vitamin K levels. What this means is that on the days you eat a lot of vitamin K, the warfarin won’t protect you against abnormal clotting as well. And on the days you eat much less, you are far more likely to see a rise in your INR (clotting time) measurement that means you are a higher risk for abnormal bleeding.
Abnormal bleeding can be just as lethal as abnormal clotting. If there was a way to maintain more consistent levels of vitamin K then warfarin would probably be a safer drug. One step would be to carefully calculate how much vitamin K you get in the foods you eats and to modify or time your diet to keep daily vitamin K intake steady. Unfortunately, this is really not so easy to do as you may not always know what is in the foods you are eating and with people’s busy schedules, a shift of a planned meal by a few hours could still leave you with peaks and valleys in vitamin K.
Fortunately there are practices using supplements that can help stabilize vitamin K. The first one is to get a supply of supplements containing vitamin K2 of both the forms MK4 and MK7 and to take them at a consistent time each day every day with a meal containing fats and apart from any fat-blockers such as fiber and Orlistat that would impede the vitamin K absorption.
MK7 lasts in the body about 24 to 72 hours. Vitamin K1 lasts around 8 hours. MK4 lasts even less time, often stated as “a few hours”, but is more rapidly absorbed by the body than the K1 form commonly found in foods and supplements.
Vitamin K2 MK7 supplementation at levels around 50 to 150 mcg (micrograms) per day is likely to create a much more stable level of vitamin K in your bloodstream while still allowing warfarin to reduce clotting activity. So when you eat that kale or spinach salad, instead of your vitamin K levels skyrocketing by hundreds of percent perhaps they will go up only 50%. The reverse applies, too, that on days when you don’t eat much vitamin K in your diet you will not see as big of a drop in your blood reserves. Overall, this means that the warfarin dosage you can take probably will need to be a little higher but it will often be more stable and less important to get frequent tests to track the changes.
You might time your vitamin K2 MK4 intake to correspond with a meal containing some fat that also contain the least natural vitamin K of your daily meals. Typical breakfast foods (cereals, milk, toast, eggs, etc.) often don’t have much vitamin K but do have some fat, so taking your vitamin K2 MK4 with this meal might be a good choice. It may be appropriate to take part of your warfarin dosage at the same time as a vitamin K supplement containing K1 or K2 MK4 forms in order to ensure the uptake of the extra vitamin K doesn’t cause an excessively large drop in anticoagulation effect.
You may have to argue with your doctor over the entire concept of vitamin K supplementation for warfarin patients. Many of them are under the mistaken belief that vitamin K supplements are dangerous for warfarin patients. That’s not quite right. What is probably most dangerous is that consuming widely inconsistent amounts of vitamin K which is precisely what is happening due to the varying diet of many or even most people taking warfarin.
If your doctor is not receptive to these ideas, you may want to look for an integrative health care practitioner who is familiar with combining medications and supplements to get a better effect than you are likely to obtain from medicines alone.
Probably the worst long-term problem with warfarin is that by interfering with vitamin K biological activity, it causes calcium to leach out of your bones (raising your risk for osteoporosis) and into your blood. The calcium may attach at a higher than normal rate to the inside of your blood vessels, heart valves, and possibly other non-bone tissues with large enough blood flow volume to keep the calcium coming to the area. In short, this causes vastly increased rates of calcification which can damage heart values, organs with high circulatory volumes such as the liver and kidney, and most obviously all of your blood vessels. Calcification makes them more rigid and creates higher risk for high blood pressure. It’s not far off to say that warfarin causes people to “grow bones in their blood vessels”!
It’s important to keep a watch on your calcium levels in your blood if you are taking warfarin. The body is fairly good at keeping stable levels, but if you see the levels rising or falling much from previous tests it can be a warning sign that something is going wrong with your vitamin K and warfarin interaction.
The danger of aggravated calcification during long-term use of warfarin is so significant that patients should talk with their doctors about getting a CT heart scan with calcium scoring to establish a baseline measurement of calcification and then rechecking to see how the drug over a period of a year or more may be rapidly and measurably worsening the calcification.
It may be also worthwhile to get a bone density measurement, such as a DEXA scan, to monitor for how warfarin may be aggravating bone loss to the degree it triggers osteoporosis. As warfarin is often prescribed in senior citizens who are already at elevated risk for osteoporosis and life-threatening falls and fractures, it is especially important to monitor and reduce the loss of bone integrity caused by this drug.
Other health conditions can exacerbate the displacement of calcium from the bones into the bloodstream. The use of steroid drugs, for instance, can do this. High levels of cortisol, a condition often seen in people under high stress, can also result in numerous health problems including accelerated bone loss that may result in dangerously increased calcification of the cardiovascular system.
It may not be a great idea to take supplemental calcium for warfarin patients as you don’t want to boost the calcium levels too high and make any accelerated arterial calcification problems even worse. It is arguably safer to increase your dosage of vitamin D3 and magnesium, both of which in conjuction with vitamin K help your body to maintain safe levels of calcium and to avoid osteoporosis and arterial calcification. Then after you have some experience with how these and the other supplements below work, you might considering adding small quantities of calcium supplements.
In short, I believe that almost all warfarin patients should be put onto a consistent dose of vitamin D3 and magnesium that is enough to get their vitamin D blood levels up to something in the low end of the optimal range and keeps the calcium levels in the blood stable preferably in the bottom half of the reference range for the calcium test. The few exceptions would be the atypical person who already has adequate levels of both or the handful of people who suffer from illness that is aggravated by vitamin D, for instance very high calcium levels caused by some unusual calcium metabolism.
What are suitable dosages? Unfortunately they vary tremendously based upon diet and individual biology. Some people may attain good healthy vitamin D levels with as little as a couple thousand IU per day of vitamin D3. Many more will need more than 5000 IU per day. A few may need even more than 10,000 IU per day, even though that is regarded as the upper safe limit for vitamin D3 supplementation by the researchers who have studied dosages most carefully. You really need to get vitamin D blood testing to know how your vitamin D levels are and how vitamin D3 supplements work for you.
Magnesium dosages vary on a lot based upon the form of the supplement. Magnesium citrate is reputed to be more bioavailable than some other forms, for instance. Magnesium deficiency is fairly common, so unless you have test data that says otherwise I’d assume that you probably could benefit from at least 400 mg to 500 mg of magnesium supplements each day.
Controlling Blood Lipids, Inflammation, and Oxidation
High cholesterol is widely called a huge risk to people’s health. But why is this? It is not that cholesterol in and of itself is bad. Clearly, low cholesterol levels can lead to depression, suicidality, and hormonal abnormalities. This has been noticed in many patients taking statins to lower their cholesterol levels. Low cholesterol produced by the use of statin drugs also tends to produce low CoQ10 enzyme levels that endanger cardiac function and can cause chronic pain and muscle weakness.
Moreover, not all forms are cholesterol are equal. HDL cholesterol helps to transport fatty acids back to the liver, LDL helps to distribute them throughout the body. HDL is often called “good” cholesterol and LDL “bad” cholesterol. This is overly simplistic. You need both.
Even LDL cholesterol itself is complicated to evaluate. First of all, standard lipid blood tests only estimate LDL cholesterol and can be off substantially versus a direct measurement. Secondly, not all LDL cholesterol is the same. Some LDL cholesterol molecules are small and dense and others are big and fluffy. The small dense LDL variety is much more dangerous because it is likely to punch through endothelial linings in your blood vessels and trigger inflammation and repair processes that aggravate atherosclerosis.
Instead of focusing so much on cholesterol levels and INR test results as many doctors do in warfarin patients, I view it as more accurate to consider the overall viscosity and ease of flow of the blood in terms of how blood lipids and other factors such as oxidation and inflammation influence blood flow. If you have a lot of fats in your blood, the blood is likely to be more viscous and resistant to easy flow. If you have a lot of inflammatory cytokines in your blood, it likely the inflammation will affect the way your blood vessel operate both in terms of narrowing down the spaces through which blood flows and also making the endothelial linings of the blood vessels more subject to damage that will lead to atherosclerosis.
To have healthy blood vessels and blood flow, you need to keep blood viscous, keep inflammation levels low, and keep oxidative damage to your body low so that it doesn’t aggravate inflammation.
Thus for this class of concerns, I’d recommend supplementation with large dosage omega 3 fatty acids such as fish oil, carnitine supplements to help shuttle fatty acids into your mitochondria where they can be burned for an energy supply, and amla extracts to fight one of the major cardiovascular risk factors observed via the C Reactive Protein test.
Immediate release niacin (nicotinic acid which is a form of vitamin B3) is another good supplement for lowering LDL cholesterol and raising HDL cholesterol levels. If you take it with food, you are less likely to get the unpleasant but harmless red flushing and itching effect. Niacinamide and inositol hexanicotinate are two other common forms of vitamin B3, but they do not appear to have much if any effect on altering blood lipid levels. Extended release niacin in some people can cause liver damage, so I’d recommend trying the immediate release form first starting around 250 mg to 500 mg with each of the two biggest meals of the day. Watch your liver test results before greatly ramping up the dosages from there.
I do not recommend statins as a first option for anybody. If you have tried other means to lower your LDL cholesterol including those listed in this article and still the results are not good enough, consider trying red yeast rice supplements first. They include active ingredient basically the same as statins but are believed to be less likely to cause statin-induced muscle damage and abnormal hormone levels that can leave people so sick they are bedridden or may attempt suicide. If you try statins or red yeast rice, please add some CoQ10 to your supplementation program as both will reduce the amount of CoQ10 your body produces because they lower production of intermediate compounds on the way to both cholesterol and CoQ10.
Oxidation occurs all the time but particularly when your body is generating a supply of energy to be used by its cells. There is no way to completely stop oxidation. The key is to pump your body full of enough antioxidants that the free radicals are turned from dangerous reactive substances into more inert ones so that the body can repair the damage they cause at a more rapid rate than it accumulates. For this, I’d recommend high dosage vitamin E containing mixed tocopherols and tocotrienols, CoQ10 (preferably ubiquinol or a water soluble formula such as QGel), idebenone (a synthetic analogue of CoQ10 that is an even better antioxidant than CoQ10 itself), and a good solid dose of multivitamins containing vitamins A (preferably in beta carotene form that doesn’t interfere with vitamin D), B complex vitamins, and vitamin C. I’d also recommend supplementation with N-acetylcysteine as it helps the body build up strong levels of glutathione which is a very important antioxidant. Greet tea extracts, particularly those with high levels of EGCG, are also a good option.
Reducing Excess Clotting Proteins
People who have high levels of the clotting protein fibrinogen are more likely to experience abnormal clots. Lowering your levels of fibrinogen can be accomplished with a variety of proteolytics such as bromelain and nattokinase. Other proteolytics such as serrapeptase may also help, but nattokinase is much better studied for managing clotting problems.
Two variants of pine bark extracts known as Pycnogenol and Enzogenol have scientific evidence backing up their ability to lower fibrinogen levels significantly. One person I know tried proteolytics including nattokinase, serrapeptase, and bromelain for a few years with mixed success as indicated by no more clots (even after discontinuing warfarin) but still higher than optimal fibrinogen levels. Upon trying supplements that included Pycnogenol, this person noticed a very strong and obvious effect that resulted in significantly lower fibrinogen levels. Enzogenol has been studied for lowering C Reactive Protein and fibrinogen in smokers and is believed to work similarly to Pycnogenol even though the source is a different species of pine bark. There’s reason to believe it should work well in non-smokers, too.
Homocysteine is a toxic byproduct of various reactions in the body. High levels of homocysteine are correlated with worse cardiovascular health. As it is believed much of this is due to damage to the endothelial linings of blood vessels, it is likely high homocysteine could contribute to elevated clotting risk. For those attempting to lower homocysteine, often the supplements TMG (trimethylglycine), vitamin B12, vitamin B6, and folate are highly advised.
I’d recommend the methylcobalamin fom of of vitamin B12 as the body has an easier time utilizing it than the cyanocobalamin form common in most multivitamins. Cyanocobalamin may also leave behind traces of cyanide that you would not get from methylcobalamin. Some people cannot convert cyanocobalamin into the biologically active methylcobalamin form, so that’s another reason to pick methylcobalamin.
P5P (pyridoxal 5 phosphate) is a better form of vitamin B6 than the usual pyrixodine that also has anti-glycating properties that help to reduce the damaging crosslinking of sugar molecules with proteins. High dosages of pyridoxine over longer periods can cause neuropathic pain, but this hasn’t been observed with P5P or another vitamin B6 variant known as pyridoxamine which is common on poulty. Unfortunately, the FDA in its corrupt zeal to pump up big pharmaceutical company profits at the expense of citizen’s health banned the sale of pyridoxamine to benefit a company that wants to use it a new drug for diabetics because it works so well at prevent glycation.
Folic acid is the most common form of folate in supplements, but methylfolate is a superior form. The concerns about poor conversion of folic acid to active methylfolate are similar to those about cynanocobalamin to methylcobalamin. Methylfolate is also called 5-MTHF or 5-methyltetrahydrofolate.
Vitamin B2 (riboflavin) and magnesium are also important for helping the body to convert unhealthy homocysteine to beneficial biochemicals. You can probably get enough vitamin B2 from a quality multivitamin, but are likely to get more in a B complex vitamin than a general multivitamin. The magnesium needed is more than you’d get from a general multivitamin so it is likely best to supplement with dedicated magnesium supplements such as magnesium citrate as discussed above with regards for controlling the body’s calcium usage.
Low levels of the amino acid taurine are also tied to high levels of homocysteine. So it might be worthwhile to add 500 mg to 1000 mg of taurine to your supplementation program if you have homocysteine levels above the upper limit of the optimal range which is around 8 umol/L.
Finally, the nutrient choline can be converted into TMG by the body. Choline is regarded as a promising natural supplement for helping both brain and liver health, so it may be worth adding more of this into your diet or supplementation program, too.
Improving Circulatory Health
The supplements pomegranate and GliSODin both help widen up blood vessels and improve the health of endothelial linings. Thus they are likely to be beneficial for people at high risk of clotting or most people taking warfarin because bigger blood vessel openings are less likely to get plugged up by the typical small clots forming in your body.
Pretty much any other supplement that has scientific evidence of being an antioxidant or anti-inflammatory is going to be somewhat beneficial for reducing clotting risk. Curcumin, lycopene, Nexrutine, nettle leaf and stinging nettle extracts, 5-LOXIN and boswellia, and many more are likely to help some. However, I think for cost and benefit reasons you should start with the supplements I mentioned earlier in this article. Many of the other supplements have other properties that are extremely helpful for other conditions such as opposing the development of Alzheimer’s Disease and prostate cancer or fighting chronic joint pain, so if those are concerns for you then I’d suggest investigating the supplements mentioned in this paragraph further.
Exercise and Weight Loss
Finally, although this is very hard for many people, boosting your exercise levels and eating less fats and carbohydrates is a consistently good suggestion for how to lose weight, lower inflammation, and improve your blood flow. I believe that for most people this is going to take some long-term commitment and effort to achieve, therefore the supplementation program I outlined above is probably more practical to get some substantial effect within the first few months.
Bleeding vs. Clotting Risk Tradeoff
Your doctor and many supplement labels may warn you that even very common supplements such as vitamin E and CoQ10 may increase bleeding risk. For most supplements, that’s overly alarmist especially if you introduce the supplements at the low of their dosage ranges one or two at a time, tell your doctor and warfarin clinic what you are doing, and monitor your INR tests as usual watching for any changes and adjusting the warfarin dosage as needed.
Which is the bigger risk, bleeding or clotting? For people on warfarin, clotting is probably the bigger risk otherwise what would be the point of taking the medication? This is why I say that the “may increase bleeding risks” warnings are probably on the alarmist side.
I don’t believe that any of the supplements I listed above taken in normal dosages by themselves or in conjuction with low dosages of warfarin are likely to cause unusually high bleeding risks. However, if you are foolish enough to down 60 veggie caps of high-potency nattokinase at once, don’t be surprised if you end up with some unusual bleeding. Supplements of often work by tweaking biochemical processes one way or another, but you can turn the tweak into an overly strong push when dosages are way too high.
If you start with the labelled dosages and try to spread out your supplements throughout the day, it’s quite unlikely you will significantly elevate the risk of bleeding to the point that it will be bumping up your INR test results by more than what your warfarin dosage itself is doing. I say this based upon observations that a person who is taking a heavy dosage of the supplements I listed above but is not taking any warfarin at all often sees a high-normal (i.e., upper end of reference range or just above) INR test result but does not notice unusual bleeding or bruising.
INR for patients not on anticoagulation therapy (warfarin, heparin, etc.) is supposed to be between 0.8 to 1.2. Somebody taking a lot of the supplements above but no anticoagulation medications may tend to see INR tests more like 1.1 to 1.3, right around the “high normal” range.
Patients taking warfarin are virtually always going to be told to aim for INR test results above 2.0. Those with very high clotting risks are often guided to INR ranges above 3.0 sometimes even up to around 4.5. Very few will be advised to aim for levels higher than that as most doctors would conclude the risk of abnormal bleeding at that test range would be higher than the risk for abnormal clotting.
What people with high normal INR (i.e., around 1.2) may notice is that their blood seems to flow from cuts or a prick a little more than most people’s blood does. Blood droplets from puncture wounds, such as from a blood glucose test prick, may look “thinner” in the way the blood droplet forms into shape.
These small changes are probably helpful even in people who do not have a high risk of clotting. For somebody who has a history of abnormal clotting the changes are particularly beneficial under typical circumstances. But in the event of a very severe cut or impact injuries, such changes can tip the risk profile to that of excessive bleeding. So to be on the cautious side, you might add a note to your medical documents in your wallet or purse to list the supplements that you take which may have an anticoagulation effect and suggest that emergency medical personnel should consider that they may need to test your INR to determine what to do if your bleeding seems unusual.
Initially when you start supplementation, particularly with vitamin K, you may find that your INR drops some. This may mean you need to take more warfarin for a time.
As you add in more of the supplements discussed above, you may see your INR go up somewhat and if so then it’s likely you’ll need a reduction in your warfarin dosage.
The combination of a more stable INR plus some of the increase in INR being from a mix of supplements rather than from just warfarin alone may lead to reduced risk from both abnormal clotting and bleeding.
It is important to talk with your doctor and warfarin clinic about what you are doing and to introduce the supplements listed above one or two at a time so you and they can understand what the supplements are doing. If you do this, it is unlikely that you will put yourself at high risk of bleeding.
When a well-designed supplement protocol is taken consistently in reasonable dosages and combined with the usual INR monitoring and warfarin dosages adjustment, I think you and your doctor will find that you will improve your control over your risk of abnormal clotting and abnormal bleeding over what you were able to do with conventional use of warfarin and the typical “bursty” low to moderate vitamin K diet that most warfarin patients consume. And you’ll be doing this while also simultaneously lowering your long-term risk of the cardiovascular disease and osteoporosis that long-term warfarin users are likely to suffer if they rely on the drug alone for their coagulation control.
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