title: Probable interaction between warfarin and torsemide.
abstract: OBJECTIVE
  To report a case in which the anticoagulation effect of warfarin appeared to be potentiated by torsemide, possibly due to an interference of metabolism through competition for the CYP2C9 isoenzyme and protein-binding displacement of warfarin.
  
  
  METHODS
  A 43-year-old Hispanic female with congestive heart failure, hypothyroidism, anemia, atrial fibrillation, and a mitral mechanical valve replacement was effectively anticoagulated with a target international normalized ratio (INR) of 2.5-3.5 on a warfarin regimen of 50-52.5 mg/wk. One week following the initiation of torsemide 40 mg in the morning and 20 mg in the afternoon, a marked increase in the INR occurred (6.2), requiring a warfarin dosage reduction. Subsequent titrations over a 3-week period eventually resulted in the achievement of a therapeutic INR (from 3.3 to 2.9) with a new warfarin regimen of 47.5 mg/wk.
  
  
  CONCLUSIONS
  Both torsemide and warfarin are highly protein-bound to albumin and are major substrates for the CYP2C9 isoenzyme. Competition by multiple drugs for metabolism via CYP2C9 may decrease the clearance of the drugs from systemic circulation. Addition of a drug with high protein binding may result in the displacement of other drugs that circulate highly protein-bound. Therefore, it is possible that the addition of torsemide may potentiate the anticoagulant effect of warfarin by (1) competition for metabolism through CYP2C9, with a decrease in the clearance of warfarin, and (2) protein-binding displacement of warfarin from albumin, transiently potentiating anticoagulant activity. An objective causality assessment revealed that the interaction was probable. Cardiology records confirmed the absence of fluid and heart failure status changes; therefore, these were ruled out as potential etiologies. No levothyroxine dosage changes occurred over the previous 14 months; thus, this also was ruled out as a possible etiology.
  
  
  CONCLUSIONS
  To our knowledge, an interaction between warfarin and torsemide has not been previously reported. While further research should be done to confirm this interaction, practitioners should be made aware of its possibility.
authors.affiliation: College of Pharmacy, University of Oklahoma Health Sciences Center, Oklahoma City, OK Clinical Pharmacy Specialist, Oklahoma City Veterans Affairs Medical Center, Oklahoma City, OK 73104, USA. jennifer.bird@va.gov
authors.forename: Jennifer
authors.initials: J
authors.lastname: Bird
authors.forename: Carlos
authors.initials: C
authors.lastname: Carmona
mesh_terms: D000328:Adult; D000925:Anticoagulants / Q000008:administration & dosage / Q000009:adverse effects* / Q000494:pharmacology; D001189:Aryl Hydrocarbon Hydroxylases / Q000187:drug effects / Q000378:metabolism; D001667:Binding, Competitive / Q000187:drug effects; D065729:Cytochrome P-450 CYP2C9; D004232:Diuretics / Q000494:pharmacology*; D004305:Dose-Response Relationship, Drug; D005260:Female; D006801:Humans; D019934:International Normalized Ratio; D011485:Protein Binding / Q000187:drug effects; D013449:Sulfonamides / Q000494:pharmacology*; D000077786:Torsemide; D014859:Warfarin / Q000008:administration & dosage / Q000009:adverse effects* / Q000493:pharmacokinetics
chemical_list: D000925:Anticoagulants; D004232:Diuretics; D013449:Sulfonamides; D014859:Warfarin; C450260:CYP2C9 protein, human; D065729:Cytochrome P-450 CYP2C9; D001189:Aryl Hydrocarbon Hydroxylases; D000077786:Torsemide