AZOLES AND WARFARIN AND OTHER ORAL ANTICOAGULANTS

Case reports describe raised INRs and bleeding when fluconazole, ketoconazole, or itraconazole were given with warfarin. The anticoagulant effects of acenocoumarol, ethyl biscoumacetate, fluindione, phenindione, phenprocoumon, tioclomarol and warfarin can be markedly increased if miconazole is given orally, and bleeding can occur. The interaction can occur with buccal gel, intravaginal miconazole, and in one case, with miconazole cream. Voriconazole decreases the metabolism of warfarin resulting in a doubling of the prothrombin time. Acenocoumarol appears to interact similarly.
Monitor the INR if an azole is given with an oral anticoagulant and adjust the dose accordingly. Oral miconazole, fluconazole and voriconazole interfere with the main metabolic pathway of warfarin (and acenocoumarol) and are therefore likely to interact more frequently than the other azoles.
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