Fruits

[pellicle]

A discussion started tonight about Mango and its potential to influence INR ... as this was "new to me" (eating a bit of fresh mango during summer, typically no more than one per day) I thoght this was interesting as I'd never found any effect ...

A quick google revealed this study:

https://journals.sagepub.com/doi/10.1177/0897190014544823

A Comprehensive Review of Potential Warfarin-Fruit Interactions​

Daryl A. Norwood, PharmD [email protected], Crystal K. Parke, PharmD, and Leonard R. Rappa, PharmD, BCPPView all authors and affiliations
Volume 28, Issue 6

Purpose:​

The aim of this review is to discuss possible interactions that may occur between warfarin and fruit products.​

Methods:​

A literature search was conducted using the search terms: “warfarin (Coumadin®) and fruit interactions, warfarin and fruit, warfarin and fruit juice, case reports and clinical trials”.​

Results:​

A total of 23 citations (15 case reports and 7 controlled clinical trials) were reviewed. The majority of cases involved cranberry products, while pomegranate juice, avocado, grapefruit juice, mango, and papain were also implicated in reports of suspected warfarin-fruit interactions. Cranberry juice was also the most frequently studied fruit product. Other fruit products evaluated with warfarin in controlled clinical trials were cranberry concentrate and grapefruit juice.​

Conclusion:​

Although a number of case reports have been published that suggest warfarin has the potential to interact with several fruit products, it is difficult to determine their relevance, as scientific evidence is scarce. Until further information is available, clinicians may want to encourage patients to consume cranberry products and grapefruit juice in small to moderate quantities and to inquire about the recent consumption of mangos, pomegranate juice, and avocados when taking a dietary history or when assessing possible causes for international normalized ratio (INR) instability.​

I can't read the body, but according to Googles citation of that study:

Mangos contain varying amounts of vitamin A which may inhibit CYP2C19, an enzyme involved in the metabolism of warfarin's R-isomer. It has been suggested that large doses of vitamin A can increase the anticoagulant effect of warfarin​

Seems a bit stringy to me ... the study has in its citations (presumably about mango and Vitamin A points here (but is unavailable to me).

The "aware" reader will know already of the dangers of Grapefruit and the suggestions also of Cranberry.

HTH

 

[treichert0312]

Haha an “aware” reader. I have been eating avacado toast without concern. We’ll see what the INR says - but confounded with antibiotics.

 

[ncw3642]

Yeah.. not giving up my Guac but good to know .

 

[pellicle]

Guac

had to google that, thought it may have been an exotic fruit I hadn't heard of

;-)

 

[ncw3642]

had to google that, thought it may have been an exotic fruit I hadn't heard of

;-)

For the sake of hitting my daily target.. it sure is. Helps balance the margarita… right?

 

[pellicle]

Morning

I have been eating avacado toast without concern.

Yeah.. not giving up my Guac

the following is well worth watching, but its not about INR nor about Vitamin K. Instead its about scientific method and questioning what stands out to you as being "iffy" and then following up with some testing.




We can all INR test here (notable exceptions excluded) and so all that remains is to conduct a reasonable trial that repeats things over time. Not just a week of (say) daily testing, but perhaps a week here and there ... I mean iff you want to really know exactly how much vitamin K is needed for you on your dose to make a difference to your INR and over what duration and how transient it is. Lots of good pointers in James's above test. There is no reason why anyone here can't do exactly that with Vitamin K and foods.

However Avocado has only 21µg per half of a fruit, meanwhile Brussels sprouts per cup cooked is about 110µg. I believe that moving upwards of 100µg per serving will have some observable (although minor) influence on your INR.

For anyone interested but feeling they lack the "rigor" of good experimental design feel free to follow up here with discussion on exactly that (the more heads involved the better). Myself I've not got sufficient interest to do it for myself because I'm more interested in other problems.

Best Wishes

PS; for the interested this "mashup" of the above is pretty funny

 

[pellicle]

Helps balance the margarita… right?

I think they work well together ... .... what would be the result of substituting Grapefruit for Lemon on that?

 

[Superman]

Haha an “aware” reader. I have been eating avacado toast without concern. We’ll see what the INR says - but confounded with antibiotics.

Interesting. And here I am happy to have a, “Can’t eat avocado” to go along with my, “Won’t eat avocado.”

I think it’s a texture thing with me. Not a fan.

 

[Chuck C]

I'll continue to eat my guacamole and let the tortilla chips fall where they may.

On a serious note, I've been eating avocados for years. I'll have some weeks in which I eat them daily and some weeks where I don't eat any at all. I've never noticed any effect on my INR. If it is moving things, I don't think by much.

 

[Chuck C]

the study has in its citations (presumably about mango and Vitamin A points here (but is unavailable to me).

I was able to get the abstract. Only n=13 study. The page won't link, due to a subscription, so I'll clip and paste. Just case studies. In my view, this is very low level of evidence and can't really be used to draw any meaningful conclusions.
Lots to criticize here. How about this?
"The majority of patients reported a daily mango intake of 1–3, 2–3, and 5–6 mangos 2 days to 1 month prior to the anticoagulation clinic appointment."
OK, so how many were in each category? And the categories overlap? But 4 mangos per day is excluded from the categories? Just, odd.
It would be easy enough to conduct a RCT. But, I doubt anyone has the motivation to do such a study.

Interaction between Warfarin and Mango Fruit​

Abstract

TO THE EDITOR: Many drugs, dietary supplements, and foods are known to interact with warfarin. Most warfarin–food interactions are related with the vitamin K content of nutrients (e.g., vegetables), interfering with its therapeutic safety and efficacy. The mango (Mangifera indica) is an Anacardiaceae native to southern Asia. The mango is one of the most common orchard or backyard trees in Puerto Rico. The fruit is commercially grown in 4 municipalities on the island and harvested between March and November, peaking during the months of May and July.1 Mango fruit comes in a variety of sizes and shapes. Much of the varieties cultivated in Puerto Rico are oval, round, heart, or kidney-shaped, with its size fluctuating between a small melon to a large avocado. It is preferably consumed for its pleasant sweet flavor and high vitamin A, C, and fiber content. Mango possesses antiviral, antiparasitic, antitussive, laxative, and stomachic properties, among others.2-5 More recently, studies6,7 involving an aqueous extract of M. indica called Vimang have reported analgesic, antiinflammatory, and antioxidant activity. We report a possible interaction between mango fruit and warfarin. Case Reports. Thirteen male patients aged 56–85 years were found to have increased international normalized ratios (INRs) after mango fruit ingestion. Indication for chronic anticoagulation therapy varied among patients: atrial fibrillation (31%), recurrent deep-venous thrombosis (15%), heart valve replacement (31%), and others (23%). The majority of patients reported a daily mango intake of 1–3, 2–3, and 5–6 mangos 2 days to 1 month prior to the anticoagulation clinic appointment. No other factors for increased INR (e.g., confusion about warfarin dose, changes in other medications or diet, heart failure decompensation, alcohol intake) were identified on interview. The average INR increase in these patients was 38%. The difference between the INR at baseline and after mango intake was statistically significant (p < 0.001). No bleeding episodes resulted from the supratherapeutic INR found after mango ingestion. After identification of mango fruit as a possible cause of supratherapeutic INR, patients were instructed to stop mango ingestion for 2 weeks. The average measured INR in the 13 patients decreased by 17.7% after mango fruit was discontinued (Table 1). Patients denied changes in their drug regimen and reported a consistency in the intake of vitamin K–containing food, as well as good compliance with all other medications. These patients also denied the use of health-food supplements and vitamins during this period. Rechallenge with mango fruit was performed in 2 of the 13 patients (Table 2). Patients were told to eat the same amount of mango fruit they were eating before the increase in the INR was observed. Although the INR value increased after rechallenge, these 2 patients reported less mango ingestion than previously taken (2 mangos daily and 3 mangos in 1 week vs. 6 mangos daily and 1–2 mangos per day, respectively). After a MEDLINE search (1966–August 2001) no other case reports of a drug–food interaction between warfarin and mango fruit were found in the literature. Other possible causes for increased INR were ruled out before identifying mango fruit as the only recent dietary change in the patients’ regimen. Discussion. The vitamin content of a medium-sized mango (130 g without seed) is: vitamin A 8061 IU, vitamin C 57 mg, vitamin B6 0.28 mg, vitamin B1 0.12 mg, and folate 29 μg, among others.8 Although the exact mechanism for this interaction is unknown, there are literature reports9 suggesting that concomitant administration of warfarin and vitamin A can cause an increased anticoagulant effect when large doses of vitamin A are given. Vitamin A has several important functions in the body. It is known to play an essential role in the function of the retina, growth and differentiation of epithelial tissue, and is also required for growth of bone, reproduction, and embryonic development. Although the term vitamin A has been used to denote specific chemical compounds, like retinol, it has also been used for compounds with the biological properties of retinol.10 Yamazaki and Shimada11 investigated the effects of retinoic acid and retinol in the xenobiotic oxidations catalyzed by human cytochrome P450 enzymes. That study showed that retinol and retinoid acid were strong inhibitors for xenobiotic oxidations catalyzed by recombinant CYP2C19, the hepatic enzyme responsible for the metabolism (7-hydroxylation) of the warfarin R-isomer. Inhibition of CYP2C19 would lead to a moderate increase in warfarin concentrations

 

[carolinemc]

I'll continue to eat my guacamole and let the tortilla chips fall where they may.

On a serious note, I've been eating avocados for years. I'll have some weeks in which I eat them daily and some weeks where I don't eat any at all. I've never noticed any effect on my INR. If it is moving things, I don't think by much.

All the things people say you cannot eat, eat it anyway. Just like anything else we eat that is bad for us, just eat in moderation.

 

[Beach77]

I'll continue to eat my guacamole and let the tortilla chips fall where they may.

On a serious note, I've been eating avocados for years. I'll have some weeks in which I eat them daily and some weeks where I don't eat any at all. I've never noticed any effect on my INR. If it is moving things, I don't think by much.

I'm the same Chuck... "I'll have some weeks in which I eat them daily and some weeks where I don't eat any at all. I've never noticed any effect on my INR. If it is moving things, I don't think by much."

 

[V__]

the following is well worth watching, but its not about INR nor about Vitamin K. Instead its about scientific method and questioning what stands out to you as being "iffy" and then following up with some testing.

It's absolutely delightful! A bunch of "obvious" simple explanations turn out to be not quite valid.

 

[pellicle]

It's absolutely delightful! A bunch of "obvious" simple explanations turn out to be not quite valid.

frankly from the first time I became aware of Huberman I was triggered by his appearance and demeanour;

He feels more like a charlatan than a scientist and I can't stand it when someone says "here's the pathway" and "just accept that; despite there being many don't worry your pretty head about it"

Since then I see that so many feel similarly that he even has his own subreddit:





The more things change, the more they stay the same.

Hilarious

 

[Protimenow]

Pellicle used an abbreviation: iff. I don't think this was a typo, and it may be a bit esoteric for some of us.

IFF means 'if, and only if.' When you reread the post that contains this, the context becomes clear.

I don't like avocados. My wife loves them. One day, I'll grow a Hass avocado tree - they seem to do well here. We may get so many that we end up giving them away. But, no tree yet.

 

[pellicle]

Pellicle used an abbreviation: iff. I don't think this was a typo,

Correct

You'll notice that not only is it bold it's also blue

Because it's a hyperlink (the very foundation of the modern internet). Click or tap it and it takes one to the Wikipedia definition for it

 

[Protimenow]

Yes. I noticed that it was blue. And that it was a hyperlink. I just didn't think many people would FOLLOW that link to find out what iff really meant.

 

[pellicle]

. I just didn't think many people would FOLLOW that link to find out what iff really meant.

their loss really