Adding Herbal Products to Direct-Acting Oral Anticoagulants Can Be Fatal

Direct-acting oral anticoagulants (DOACs) are used to prevent and treat systemic and cerebral embolisms in patients with non-valvular atrial fibrillation (NV-AF). The use of DOACs with herbal products without consulting healthcare professionals increases the possibility of drug–herb interactions and their adverse effects. An 80-year-old man on dabigatran with a known history of NV-AF presented with a 1-day history of haematemesis and black stool which began 3 days after he had started taking a boiled mixture of ginger and cinnamon. The patient was hypotensive and treated as a case of gastrointestinal bleeding and haemorrhagic shock. Despite continuous aggressive resuscitation measures including administration of a reversal agent for dabigatran, we were unable to control bleeding and the patient died within 24 hours. The interaction of ginger and cinnamon with dabigatran led to fatal bleeding. LEARNING POINTS: Direct-acting oral anticoagulants (DOACs) are frequently prescribed for patients with non-valvular atrial fibrillation. Combining herbal products (ginger and cinnamon) with DOACs can be fatal. Physicians should alert patients and caregivers about dangerous combinations and interactions.