Effect of Quinolones Versus Cefixime on International Normalized Ratio Levels After Valve Replacement Surgery with Warfarin Therapy

Abstract

Background and Objectives: A dispute over interaction of warfarin with two quinolones—i.e., moxifloxacin and levofloxacin—leading to significant increase in international normalized ratio (INR) levels and coagulopathies is currently in debate. The study objective was to compare the INR values due to addition of quinolones and cefixime in warfarin treated patients after replacement of disease valves with metallic valves. Material and Methods: A prospective evaluation of patients who undergone valve replacement surgeries in the cardiology hospital setup in Pakistan during the period 2018–2019 was done, including all those subjects treated concurrently with levofloxacin, moxifloxacin, cefixime, and warfarin for the study. Data organized included demographic information, concurrent medications, and appropriate analytical parameters, especially INR values taken before and within seven days after prescribing three antibiotics in discharged patients who had undergone valve replacement surgeries. Patients for whom laboratory INR values were not given at the time of discharge and with deranged liver function, renal function, low albumin levels, and febrile patients were removed from study. Furthermore, patients were advised on possible food interactions and evaluated to examine if these factors have any possible influence on the interaction being studied. Results: Differences in INR were analyzed statistically by means of SPSS analysis before and after the possible interaction. Following the administration of levofloxacin and moxifloxacin to warfarin therapy, statistical analysis showed remarkable increase in INR (p < 0.001) and no significant change in INR was observed after cefixime treatment (p > 0.05). Conclusion: Results showed that, after adding levofloxacin and moxifloxacin in patients on warfarin, therapy contributed to remarkable increase in INR. However, addition of cefixime prevented frequent coagulopathies; therefore, close monitoring of INR and switching to a safe antibiotic such as cefixime is recommended.

Drug-drug Interactions between Warfarin and Antimicrobials: A Systematic Review

“…A total of 11 studies were included in this review, with 83438 patients on warfarin therapy who received antibiotics. Five studies were casecontrol studies [15,16,17,18,19], five were retrospective cohort studies [20,21,22,23,24], and one was a prospective study [25]. Six studies were conducted in the USA [15,16,20,21,23,24], three in Canada [17,18,19], one in Australia [22], and one in Pakistan [25].…”

“…Five studies were casecontrol studies [15,16,17,18,19], five were retrospective cohort studies [20,21,22,23,24], and one was a prospective study [25]. Six studies were conducted in the USA [15,16,20,21,23,24], three in Canada [17,18,19], one in Australia [22], and one in Pakistan [25]. The follow-up duration ranged from 5 days [16] to 1 year [15].…”

Risiko Kejadian Perdarahan Pasca Rawat Inap pada Penggunaan Bersamaan Warfarin dan Antibiotik

“…Hal yang sama juga dilaporkan terjadi pada penggunaan makrolida secara keseluruhan [10,14]. Antibiotik golongan kuinolon termasuk siprofloksasin dan levofloksasin juga dilaporkan dapat meningkatkan risiko kejadian perdarahan [9,14,32]. Meskipun demikian, masih terdapat perbedaan pendapat mengenai hal ini.…”

CLINICAL PHARMACOLOGY OF FLOROCHINOLONS: A FOCUS ON SAFETY. Review

“…Ìåòàáîë³çì âàðôàðèíó çä³éñíþºòüñÿ ³çîôåðìåíòîì CYP2C9 [13], äîäàâàííÿ ëåâîôëîêñàöèíó äî êîìïëåêñó ë³êóâàííÿ ïàö³ºíò³â, ÿê³ ïðèéìàþòü âàðôàðèí, ñóòòºâî ï³äâèùóº ì³aeíàðîäíå íîðìàë³çîâàíå â³äíîøåííÿ (ÌÍÂ) [30]. Òîìó ñï³ëüíå çàñòîñóâàííÿ ëåâîôëîêñàöèíó ³ç âàðôàðèíîì àñîö³þºòüñÿ ³ç ðèçèêîì êðîâîòå÷³ [28,30].…”

“…Ìîêñèôëîêñàöèí ìåòàáîë³çóºòüñÿ ãëþêóðîíóâàííÿì ³ íå âïëèâຠíà àêòèâí³ñòü ³çîôåðìåíò³â CYP [40]. Îäíàê, ó äåÿêèõ âèïàäêàõ â³äì³÷åíî çì³íè ï³ä 䳺þ ìîêñèôëîêñàöèíó ð³âíÿ ÌÍ ó ïàö³ºíò³â, ÿê³ ïðèéìàþòü âàðôàðèí [15,30].  á³ëüø³é ì³ð³ öå ìîaeíà ïîÿñíèòè âïëèâîì íà çâ'ÿçîê ³ç á³ëêàìè ïëàçìè êðîâ³, îñê³ëüêè âêàçàí³ çì³íè ïåðåâàaeíî â³äì³÷àëîñü ó ïàö³ºíò³â ³ç ã³ïîàëüáóì³íå쳺þ [2].…”