Cinnamon and warfarin interaction

Discussion #1

This week we are discussing Gami, who presents to the clinic for primary care. She is a 48-year -old female, whose history includes Type 2 DM, memory deficits. She is treating the Type 2 DM with cassia cinnamon is also prescribed Aricept and Coumadin.

Additional subjective data would include dates of diagnosis of current disease processes, pain scale, any adverse events, full surgical history, medical history including why she is being prescribed Coumadin, social history, familial history of disease, mental issues, ethnic considerations, nutritional information, and economic factors that may affect compliance. Objective data should include a full head to toe exam, blood work including A1C, vital signs, BMI, thorough wound check and foot care as well as a memory examination, dosages of all medications. It is important to gather as much relevant information as possible during the initial history and visit in order to be able to constructively evaluate the current treatment and what plan of care may be necessary with these factors included (HealthyPeople.gov, 2018).

Taking a position on the patients use of alternative supplements as the only treatment of a chronic serious disease such as type 2 DM can be a delicate balance of looking at the patient’s preferences and safety and efficacy. Using cassia cinnamon to treat Type II diabetes has been studied in several scholarly articles and show improvement in A1C results. I would monitor her more closely if she insists on using cassia cinnamon exclusively treating her type 2 DM. Cassia cinnamon is contraindicated in people with an allergy to cinnamon or Peru balsam and should be used with caution in patients with hepatic disease as it may cause toxicity and also affect blood glucose (Kwak, Park, & Kwon, 2017). The patient should have INR, platelet counts and closely monitor for signs and symptoms of a declining state of dementia (Wilson, Shannon, & Sheilds, 2015).

Due the patient’s history of type 2 DM , I would assess her lab results – A1C, fasting blood glucose, CMP, CBC, liver and kidney function and overall health and my first choice drug would be a prescription for Metformin 500 mg, PO, BID , with meals (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017). The decision is based on evidence that an additional drug should be added to the regimen of treatment with the cassis cinnamon, based on evidence and trials and regulations, unlike the cassis cinnamon alone, which is not regulated by the FDA(Woo & Robinson , 2014). Metformin is classified as antidiabetic, its mechanism of action is a binding of insulin to the receptors and potentiates insulin action, improves tissue sensitivity to insulin, and is effective in lowering serum glucose (Wilson, Shannon, & Sheilds, 2015). Metformin is 50-60% absorbed in the systemic circulation, is not metabolized, eliminate in urine, and has a half-life of 6.2-17.6 hours. Contraindications include hypersensitivity to metformin, hepatic or cardiopulmonary insufficiency and most serious cardiac issues, DKA, renal disease and impairment with creatinine clearance of 1.5 md/dl, and should be stopped 48 hours prior to surgery (Wilson, Shannon, & Sheilds, 2015). Metformin does carry a black box warning of being associated with potentially fatal lactic acidosis (Wilson, Shannon, & Sheilds, 2015).

Educating the patient on proper diet, exercise, taking all medications as prescribed and notifying the HCP of any side effects or missed doses as well as monitoring BG and moderate use of alcohol. Signs and symptoms of hypoglycemia and lactic acidosis should be given with a return demonstration (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2017). Patient should also be made aware of bleeding precautions (Wilson, Shannon, & Sheilds, 2015). Follow up appointments every three months should be adhered to.

Discussion #2

Is there any additional subjective or objective information you need for this client? Explain.

I would obtain a full set of vital signs and request a complete copy of her medical records from her former primary care provider (PCP). I would conduct a head to toe assessment and review her past medical and surgical history. I would inquire about her family medical history, history of smoking, alcohol use, and illicit drug use. Additional information needed from her previous PCP includes asking how long she has been diagnosed and taking the prescribed medications as well as how long she has been taking the supplements. I would also inquire about what diagnosis requires the use of the Coumadin and the dose. Has she had any recent lab work to check her PT INR or noted any excessive bleeding or bruising? I would inquire about any other medications she is taking for DMII, if any, and how blood sugars are controlled (i.e. diet, exercise)? I would also ask if the Cassia Cinnamon is the only medication she is using currently for diabetes. I would ask how often she checks her glucose levels at home and if she has an appropriate meter or test strips. I would also ask about any new or existing issues or problems she has noticed. I would discuss why she takes Ginseng and Aricept and the dosages of both.

What would be your position on the Ms. GMs use of alternative supplements for her diabetes and memory? Explain and include contraindications, if any.

I would advise Ms. GM to discontinue the use of Ginseng and Cassia Cinnamon because of the interactions with Coumadin and glucose levels. The Ginseng interacts with Coumadin causing increase or decrease on coagulations and interacts with insulin causing hypoglycemia in people with diabetes (Ginseng, 2018). There have also been reported potential interactions between cinnamon and warfarin and are labeled as significant, which means there is an increased risk of an interaction occurring and are not recommended for use together. Cassia cinnamon contains high levels of coumarins which are likely toxic in high doses (Kawatra & Rajagopalan, 2015).