過去文獻指出某些水果可能影響warfarin 療效， 因此本文目的為蒐集目前與warfarin 具潛在交互作用之水果與其製品資料，並提供臨床建議。本研究搜尋PubMed、Embase、華藝線上圖書館、Micromedex、Lexicomp 和中西藥交互作用資訊網至2020 年3 月31 日，以warfarin 與8 種水果為關鍵字，採交集方式進行檢索。經2 位作者獨立篩選並討論後共納入32 篇文獻，包含22 篇個案報告與10 篇臨床試驗。Warfarin 與葡萄柚、蔓越莓、石榴、芒果、木瓜、櫻桃及其製品併用可能延長國際標準化比值 (international normalized ratio, INR) 數值，且葡萄柚萃取物、蔓越莓汁、石榴汁和櫻桃曾有出血事件報導，建議儘量避免併用。避免食用大量芒果和櫻桃，木瓜可選擇成熟者較為安全。Warfarin 與酪梨、諾麗果汁併用可能降低INR 數值，若遇此情形需停止食用酪梨與諾麗果，並考慮增加warfarin 劑量，若栓塞風險高者，可評估是否需短暫使用heparin，待INR 數值回升，避免發生栓塞事件。使用warfarin 期間若發生INR 波動，可考慮瞭解病人是否食用上述與warfarin 具潛在交互作用的水果與其製品。

Certain fruits have been reported that might affect the warfarin effect. This study aims to evaluate existing data regarding the interaction between warfarin and fruits and provide clinical suggestions. A literature search of PubMed, Embase, Airiti Library, Micromedex, Lexicomp, and Drug-Herb Interaction website until March 31, 2020 was conducted. The search strategy was to unionize synonymous words then separately intersect keywords of 8 fruits. The search results were independently screened and discussed by 2 authors. Thirty-two relevant articles were included for review, which consisted of 22 case reports and 10 clinical trials. Grapefruit, cranberry, pomegranate, mango, papaya, or cherry might increase the international normalized ratio (INR) value. Grapefuit extract, cranberry juice, pomegranate juice, or cherry have all been reported for bleeding events. It is recommended to avoid the combination of warfarin with grapefruit extract, cranberry products, pomegranate juice, large amounts of mangoes, and cherries. Ripe papaya is safer than unripe. Avocado or noni juice might reduce INR value and recommended to avoid the combination. Unfortunately, if the combination causes INR decrease, stop fruit intake and consider increasing warfarin dose. If the patient has a high risk of embolism, it may consider admitted to the hospital and treated with intravenous heparin after INR stable. If patients have unexplained INR fluctuations, it is necessary to consider whether there is an interaction between fruit and warfarin, especially during the particular fruit season.

Summited for publication: 2020.2.21; Accepted for publication: 2020.6.14