Initiation of glucose-lowering drugs reduces the anticoagulant effect of warfarin—But not through altered drug metabolism in patients with type 2 diabetes

Ann-Cathrine Dalgård Dunvald, Flemming Nielsen, Dorte Aalund Olsen, Martin Thomsen Ernst, Louise Donnelly, Enrique Soto-Pedre, Maja Refshauge Kristiansen, Jens Steen Nielsen, Frederik Persson, Kurt Højlund, Jonna Skov Madsen, Jens Søndergaard, Ewan Pearson, Anton Pottegård, Tore Bjerregaard Stage (Lead / Corresponding author)

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Aims: Drug metabolism might be altered in patients with type 2 diabetes. We aimed to evaluate if initiation of glucose-lowering drugs impacts warfarin efficacy and drug metabolism. Methods: First, we conducted a register-based self-controlled cohort study on Danish and Scottish warfarin users. Warfarin efficacy (international normalized ratio [INR]) was compared before and after initiation of glucose-lowering drugs. Second, we conducted a clinical pharmacokinetic trial comprising treatment-naïve type 2 diabetes patients. Patients ingested probe drugs for drug-metabolizing enzymes (the Basel Cocktail) before initiating glucose-lowering treatment, and after 3 and 12 weeks of treatment. Drug metabolism, glycaemic control, and inflammation were assessed on each visit. Results: In the Danish and Scottish cohorts (n = 982 and n = 44, respectively), initiating glucose-lowering drugs reduced warfarin efficacy. INR decreased from 2.47 to 2.21 in the Danish cohort (mean difference −0.26; 95% CI −0.35; −0.17) and from 2.33 to 2.13 in the Scottish cohort (−0.21; 95% CI −0.52; 0.11) after initiation of glucose-lowering treatment. This impact on INR was more pronounced among individuals with stronger effects of glucose-lowering treatment. In the clinical pharmacokinetic trial (n = 10), initiating metformin did not affect drug metabolism after 3 weeks (geometric mean ratio of CYP3A metabolic ratio: 1.12 [95% CI: 0.95; 1.32]) or 12 weeks of metformin treatment. Glycaemic control improved during treatment, while inflammation remained low and unchanged during treatment. Conclusions: In conclusion, initiation of glucose-lowering drugs among chronic warfarin users seems associated with a reduction in INR, particularly among individuals with a large decrease in HbA 1c. This effect seems unrelated to CYP enzyme activity and warfarin drug metabolism.

Original languageEnglish
Pages (from-to)2529-2541
Number of pages13
JournalBritish Journal of Clinical Pharmacology
Issue number8
Early online date26 Mar 2023
Publication statusPublished - Aug 2023


  • clinical pharmacokinetic trial
  • drug-drug interaction
  • inflammation
  • glucose-lowering drugs
  • metformin
  • observational study
  • pharmacokinetic
  • translational research
  • type 2 diabetes
  • drug–drug interaction
  • pharmacokinetics
  • warfarin

ASJC Scopus subject areas

  • Pharmacology (medical)
  • Pharmacology


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