title: Possible warfarin interaction with menthol cough drops.
abstract: OBJECTIVE
  To report a case of possible interaction of menthol cough drops (Halls) with warfarin in a patient awaiting cardioversion.
  
  
  METHODS
  A 57-year-old white male awaiting cardioversion for atrial fibrillation was prescribed warfarin. His dosage was adjusted to 7 mg daily to provide stable international normalized ratio (INR) values of 2.28-2.68. Approximately one week later, his INR fell to 1.45. During a follow-up interview, the patient reported that he experienced a flu-like illness during the previous week and had been using menthol cough drops. No other potential causes for the decreased INR were found. Illness will most often elevate the INR; we therefore concluded that the cough drops were the likely cause of this reaction, and the warfarin dose was increased to 53 mg/wk. After discontinuing use of menthol cough drops, the warfarin dose was returned to the previous amount and the INR remained stabilized.
  
  
  CONCLUSIONS
  An objective causality assessment suggests that the decreased INR was possibly related to the use of menthol cough drops during warfarin therapy. The active ingredient in these cough drops is menthol. Menthol has been shown to affect the pharmacokinetics of other drugs by inducing or inhibiting cytochrome P450 isoenzymes and slowing drug absorption. It is not clear whether these mechanisms played a role in this case. As of January 5, 2005 this is the first case report documenting an interaction between warfarin and cough drops containing menthol.
  
  
  CONCLUSIONS
  This case documents a significant decrease in the INR following the use of menthol cough drops. Patients who are ill have several factors that can potentially affect their INR and should be monitored closely.
authors.affiliation: Madigan Army Medical Center, Tacoma, WA, USA.
authors.forename: Paul J
authors.initials: PJ
authors.lastname: Kassebaum
authors.forename: Don L
authors.initials: DL
authors.lastname: Shaw
authors.forename: Dave J
authors.initials: DJ
authors.lastname: Tomich
mesh_terms: D003371:Cough / Q000097:blood* / Q000188:drug therapy; D004347:Drug Interactions / Q000502:physiology; D006801:Humans; D019934:International Normalized Ratio / Q000379:methods / Q000706:statistics & numerical data; D008297:Male; D008610:Menthol / Q000097:blood* / Q000627:therapeutic use; D008875:Middle Aged; D014859:Warfarin / Q000097:blood* / Q000627:therapeutic use
chemical_list: D008610:Menthol; D014859:Warfarin