Microsoft word - aunt c vitamin k follow-up clarification letter 2-10.doc

MeritCare Medical Center
Aunt Cathy’s Guide to:
Vitamin K --
Focus on the Vitamin K
and Warfarin/Coumadin
Anticoagulant Drugs Issue
Prenatal/Pediatric Nutrition Specialist This paper is in response to the many questions I get from health care professionals about the problem of actual vitamin K insufficiency in many people already using these drugs. It is a follow-up clarification of the drug-nutrient interaction issue only, and it is intended only for health care professionals who have read my more complete paper on many aspects of the vitamin K inadequacy problem: “Aunt Cathy’s Guide to: Vitamin K --New Issues in Cardiovascular Health, Osteoporosis, Cancer of the Liver and Colon, Diabetes, Pregnancy & Varicose Veins. —------------------------------------------------------------------------------ Question 1:
“What should we tell people already on
Coumadin/warfarin regarding vitamin K?”

My Answer:
Here's our problem . overt vitamin K deficiency is (unfortunately) common in this population and quite often unrecognized because it is rarely evaluated, either by lab tests or dietary evaluations. A great many multivitamin supplements do not even include vitamin K because (until recently) it had been assumed to be provided in adequate amounts by intestinal bacteria. It is not even included in the list of nutrients in the “mypyramid.gov” diet information. It is not on our radar. Many health professionals are totally unaware of this. Some automatically tell patients to quit taking their multivitamins without checking to see if the product even contains any vitamin K. This is clearly not benign for many reasons, many of which are explained in another paper: “Aunt Cathy’s Guide: My Current Top Five Easy Ways to Improve Your Family’s Nutrition (subject to change at any moment! ☺)” Back to the topic: Normally dietitians and nurses are dead-set against allowing any actual vitamin deficiency diseases in their patients, and now that we know it is such a big problem, we want to fix it. But we are usually not in control of this situation.
It needs to be corrected because vitamin deficiency hurts people in several different ways, both related to the coagulation issue and also related to a number of other serious complications of inadequacy (arteriocalcinosis, liver and colon cancer, osteoporosis, diabetes, arthritis, etc.) However, if patients are already on this drug
AND they are vitamin K deficient, the doctor
(or PA or NP) has to be the one in charge of
incrementally improving the vitamin K status.
This can be accomplished most effectively (because of consistency) with a regular (daily) supplement. A daily supplement providing the advisable intake is actually recommended by many researchers as a way to minimize the problem of volatility of blood coagulation for people on these medications. It should be pretty easy to do . just walk the amount up incrementally and monitor coagulation while doing it and adjusting the dosage of medication. But if the doctor doesn't "believe in" this new research there is not a thing we can do about it. We can't tell
patients to add a bunch (even a "consistent" bunch) of vitamin K because it might cause
problems for a person whose coagulation balance was calculated counting on a baseline
vitamin K deficiency state.

Question 2:
“What if the person is not yet on Coumadin/warfarin but
he/she may be put on this medication?”
If a person is contemplating going on Coumadin, it is of course safe to beef up their vitamin K intake "up front" to a consistent "assured adequacy" amount. Then the person prescribing it simply sets the new drug prescription based on the underlying consistent and adequate vitamin K status. That would be ideal. (Actually, ideal would be a situation in which nobody had vitamin K insufficiency to begin with. ☺) Nutrition folks and other health care professionals need to have a clear understanding that vitamin K is not a scary nutrient. It is just that there is an important drug/nutrient interaction that needs attention when people are put on that particular drug. We also need to be very aware that low vitamin K can also increase the dangerous volatility of a warfarin patient's blood coagulation. (This is another reason why vitamin K deficiency is NOT benign.) Vitamin K is only a safety issue in relation to folks on this medication. Vitamin K does not "make you" coagulate your blood. It's just a tool (a vitamin cofactor) that needs to be there for normal coagulation to take place. (Other things set coagulation into motion.) There is no upper
level of safety even established for this vitamin in its natural forms (vitamin K-1
philoquinone and vitamin K-2 menaquinone) because no problems have ever been seen
apart from the altered situation that exists when a person is prescribed a warfarin/
Coumadin type of anticoagulant medication. They are of a class called “vitamin K
antagonists” because they exert their influence on the vitamin K piece of the process of
coagulation.
However, all we can really do about vitamin K for
people on warfarin or those about to start warfarin
is to share this new information with the people in
charge of prescribing their medications.

An additional note:
This discussion is only about the importance of simple nutritional adequacy of vitamin K in relation to warfarin use. It is not addressing therapeutic applications of high-dose vitamin K as a treatment for warfarin overdose or drug-related bleeding. That intervention is not a nutrition-related use of vitamin K but a pharmacologic use in an acute situation. It is outside of
Another additional note:
There are other types of medications sometimes used to decrease risk of inappropriate blood clotting that do not interact with vitamin K, such as “antiplatelet agents” (some are listed
below.) This is mentioned here to be sure that health care people recognize that inducing vitamin K inadequacy by restricting intake is especially inappropriate when the medication does not operate as a vitamin-K antagonist at all. Antiplatelet Agents
Generic Name
Trade Names
Dipyridamole ER plus aspirin (25mg) Aggrenox

Yet another additional note:
Similarly, the nutritional intervention of decreasing the ratio of omega-6 to omega-3 fats in the diet has the ability to decrease clotting time because it alters the strength of thromboxanes produced. Again, vitamin K is not involved in this effect. Thromboxanes made from the omega-6 fatty acid arachidonic acid (ARA) are much more aggregatory than are those made from the omega-3 fat eicosapentaenoic acid (EPA.) [A good way to remember this is that “the bigger number (that is 6, which is bigger than 3) is associated with the bigger aggregation effect.”] The American diet typically provides about 10 to 20 omega-6 fats for every omega-3 fat. In societies that regularly have intake ratios of about 4 omega-6 fats per omega-3 fat (such as those eating the “Mediterranean Diet,”) the problem of excessive and inappropriate clotting is much less common. It benefits other health parameters as well. While change in the 4:1 ratio
direction has been shown to be an excellent idea overall for general health (including
cardiovascular health,) this form of intervention needs to be discussed with
physicians/Pas/NPs if they are treating a person with any anti-clotting medication.
Actually, the dietary change can sometimes make it unnecessary to be on anti-clotting medications at all, but as before, incorporating this kind of diet change also needs to be
managed by the person prescribing the medication.
FYI: Here's the recommendation from page 2 of my
"Top Five" handout about this:
"The dark leafy veggies are also terrific sources of vitamin K, a nutrient just now being recognized as critical to decrease risk of osteoporosis, cardiovascular disease, kidney stones, liver cancer and arthritis. It is also a nutrient found to be low in the diets of many Americans. It appears that the elderly need more than the current Advisable Intake of 90-120 mcg/day. This information is so new that vitamin K is not even included in many multivitamins currently on the market, and many health professionals will not yet have heard about these new issues. [Vitamin K: The coagulation vitamin that became omnipotent. Thromb Haemost. 2007 Jul;98(1):120-5.] If you are taking medications to prevent blood clots, be sure to show this information to your doctor before adding more vitamin K–rich vegetables to your diet or taking any vitamin K supplements. New research on the relationship between vitamin K and these drugs will result in changes in how we do things. But because the information in support of these changes is very new, it will also be new to many healthcare providers, so I have put a ‘Vitamin K” handout on line that includes all the scientific references and detail. Your doctor would want to read more about it before he/she decides to make any changes in your personal diet or medication regimen." References for this and many other emerging health issues related to vitamin K are included in my paper on MeritCare’s website described earlier: Vitamin K --New Issues in Cardiovascular Health, Osteoporosis, Cancer of the Liver and Colon, Diabetes, Pregnancy & Varicose Veins.

Source: http://www.northtexasgig.com/Files/Nutrition/Aunt%20C%20Vitamin%20K%20follow-up%20clarification%20letter.pdf