Skip to main content

Pickles and warfarin interaction: a case-based review


A 36-year-old woman with a history of lupus and antiphospholipid syndrome controlled by warfarin presented to the hospital with left periorbital ecchymosis. She was found to have an INR of 9 despite maintaining her normal warfarin dose of 12.5 mg/15 mg alternating qd. The only identifiable precipitating factor was that the patient recently stopped eating dill pickles. Limiting dietary vitamin K while on warfarin therapy was once considered best practice. However, studies have demonstrated that maintaining a consistent intake of vitamin K is more important than the quantity. Still, many patients on warfarin remain unaware of which foods contain large amounts of vitamin K and are, therefore, susceptible to bleeding sequelae. Practitioners should be educated to inform patients to consume a steady amount of vitamin K in their diet, identify which foods contain vitamin K, and include pickles on that list.

This is a preview of subscription content, access via your institution.

Data availability

Graphed data available in published work. Exact values available upon request.


  1. Holbrook AM, Pereira JA, Labiris R, McDonald H, Douketis JD, Crowther M, Wells PS (2005) Systematic overview of warfarin and its drug and food interactions. Arch Intern Med 165(10):1095–1106

    Article  CAS  Google Scholar 

  2. Hirsh J, Fuster V, Ansell J, Halperin JL, American Heart Association/American College of Cardiology Foundation (2003) American Heart Association/American College of Cardiology Foundation guide to warfarin therapy. J Am Coll Cardiol 41(9):1633–1652

    Article  CAS  Google Scholar 

  3. Franco V, Polanczyk CA, Clausell N, Rohde LE (2004) Role of dietary vitamin K intake in chronic oral anticoagulation: prospective evidence from observational and randomized protocols. Am J Med 116(10):651–656

    Article  CAS  Google Scholar 

  4. Hirsh J et al (2001) Oral anticoagulants: mechanism of action clinical effectiveness and optimal therapeutic range. Chest 119(suppl 1):8S–21S

    Article  CAS  Google Scholar 

  5. Norwood DA, Parke CK, Rappa LR (2015) A comprehensive review of potential warfarin-fruit interactions. J Pharm Pract 28(6):561–571

    Article  Google Scholar 

  6. Couris RR, Tataronis GR, Dallal GE, Blumberg JB, Dwyer JT (2000) Assessment of healthcare professionals’ knowledge about warfarin-vitamin K drug-nutrient interactions. J Am Coll Nutr 19(4):439–445

    Article  CAS  Google Scholar 

  7. Franchini M, Lippi G (2010) Prothrombin complex concentrates: an update. Blood Transfus 8(3):149–154

    PubMed  PubMed Central  Google Scholar 

  8. Kahlon P, Nabi S, Arshad A, Jabbar A, Haythem A (2016) Warfarin dosing and time required to reach therapeutic international normalized ratio in patients with Hypercoaguable conditions. Turk J Haematol 33(4):299–303

    Article  CAS  Google Scholar 

  9. Kremers RMW, Zuily S, Kelchtermans H, Peters TC, Bloemen S, Regnault V, Hemker HC, de Groot PG, Wahl D, de Laat B (2018) Prothrombin conversion is accelerated in the antiphospholipid syndrome and insensitive to thrombomodulin. Blood Adv 2(11):1315–1324

    Article  CAS  Google Scholar 

  10. Ames PR et al (2011) Increased warfarin consumption and residual fibrin turnover in thrombotic patients with primary antiphospholipid syndrome. Thromb Res 127(6):595–599

    Article  CAS  Google Scholar 

  11. Violi F et al (2016) Interaction between dietary vitamin K intake and anticoagulation by vitamin K antagonists: is it really true?: a systematic review. Medicine (Baltimore) 95(10):e2895

    Article  CAS  Google Scholar 

  12. LeBlanc C et al (2016) Avoidance of vitamin K-rich goods is common among warfarin users and translates into lower usual vitamin K intakes. J Acad Nutr Diet 116(6):1000–1007

    Article  Google Scholar 

  13. Baker J et al (2011) INR goal attainment and oral anticoagulation knowledge of patients enrolled in an anticoagulation clinic in a Veterans Affairs Medical Center. JMCP 17(2):133–142 USDA: United States Department of Agriculture: food data central. Accessed 20 May 2020

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Alexa Rangecroft.

Ethics declarations

Conflict of interest

Alexa Rangecroft has nothing to disclose. Shamit S. Prabhu has nothing to disclose. Dr. Chi-Cheng Huang reports the following interests outside of the submitted work: stock options with the Scientific Advisory Board for Medicus Tek, a role on the Executive Board for Dynamed Plus—EBSCO with no compensation, and compensated personal fees as a Hospital Medicine Editor for Dynamed Plus—EBSCO.

Ethics approval

This manuscript complies with all ethical and procedural requirements.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Rangecroft, A., Prabhu, S.S. & Huang, CC. Pickles and warfarin interaction: a case-based review. Clin Rheumatol 40, 1621–1624 (2021).

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: