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Comment & Response |

Fish Oils and Bleeding—Where Is the Evidence?—Reply

Dima M. Qato, PharmD, MPH, PhD1,2; G. Caleb Alexander, MD, MS3,4
[+] Author Affiliations
1Department of Pharmacy Systems, Outcomes and Policy, University of Illinois at Chicago, College of Pharmacy, Chicago
2Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago
3Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, Maryland
4Center for Drug Safety and Effectiveness, Johns Hopkins School of Public Health, Baltimore, Maryland
JAMA Intern Med. 2016;176(9):1406-1407. doi:10.1001/jamainternmed.2016.3971.
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In Reply Dr Harris, who owns a company that produces an assay to assess ω-3 levels, asserts that the potential increased bleeding risk associated with the concurrent use of ω-3 fish oils and warfarin is a legend that is not evidence based. The evidence he provides to support this assertion is derived from studies that took place among postsurgical patients that are underpowered to detect such an association.

In contrast to these studies, several case reports demonstrate extremely elevated international normalized ratios and increased bleeding risk associated with the use of ω-3 fish oils with warfarin.1,2 These findings are consistent with both in vitro and in vivo animal and human studies suggesting the anticoagulant effects of these drugs.1,2 Micromedex, the drug compendium and the source for our data on potential drug-drug interactions, acknowledges the lack of well-controlled clinical trials and lists the use of ω-3 fish oils in combination with warfarin as a potentially major, or life-threatening, drug interaction due to increased bleeding risk.3

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September 1, 2016
William S. Harris, PhD
1Department of Internal Medicine, Sanford School of Medicine, University of South Dakota, Sioux Falls
JAMA Intern Med. 2016;176(9):1405-1406. doi:10.1001/jamainternmed.2016.3968.
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