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Warnings

Platelets are very sensitive and can react to many substances, interfering with their ability to clot or triggering their removal from circulation.  Be sure to tell your doctor if your platelets drop or extra bleeding coincided with any new food, drugs, herbs, supplements, or environmental exposure.  “Several hundred drugs, toxins and herbs have been reported to cause blood abnormalities, and drugs account for 20 - 40% of all instances of cytopenias”1

This page contains some of the most well-known causes of substance-induced thrombocytopenia and associated bleeding. If you suspect that something you are taking, eating, or breathing might be the cause of your low platelets or excessive bleeding and you don’t see the link on this page, try searching the Internet using the terms “substance platelets" or "substance thrombocytopenia" where substance is the suspected item. While there is no guarantee, it is possible that removing or discontinuing the offending substance can have a positive effect on your platelet count.  It is important to communicate with your doctor/healthcare provider as you consider or make changes. 

Drug-induced Thrombocytopenia

When drugs are the cause of low platelets, the disease is called drug-induced thrombocytopenia (DITP).  In some cases, as in chemotherapy drugs, the drop in platelet count is due to changes in the bone marrow.  In other cases antibodies can develop to both the drug and platelets at the same time, causing the platelets to drop.  Sometimes drugs cause a combination of both bone marrow and immune problems.42

DITP is rare, can occur with any medication, and is no more likely in patients with ITP than in others, as far as we know.  However, sometimes patients are misdiagnosed with ITP when a substance they ingested caused their low platelets.  We have also heard from patients who have been diagnosed with ITP and a new drug prompted their platelets to drop further.

In the case of DITP caused by an immune reaction, platelets usually drop within one to two weeks after taking the problem drug.  However, low platelets can occur almost immediately after taking some drugs that interfere with the production of blood clots.  If the drug responsible for low platelets is stopped, platelets may begin to recover in one or two days, but the antibodies to the drug can linger in the blood stream for a very long time and cause future problems.2,42  Often the reaction to the drug is specific and a similar compound can be substituted without ill effect.42 If the suspected drug is stopped and the platelets recover, other drugs are introduced without a problem, other causes of thrombocytopenia are excluded, and the drug is introduced again and the platelets drop, there is a definitive diagnosis of DITP.  If only the first criteria is met, DITP is a possible cause of thrombocytopenia. If all but the last criteria are met, DITP is the probable cause.2

Some drugs have been reported to cause more instances of DITP than others.  Sulfa drugs, vancomycin, penicillin, rifampin, ceftriaxone, trimethoprim/sulfamethoxazole and linezolid (antibiotics), gold salts, valproate (for epilepsy), amrinone (for heart problems), biophosphates (ex. Fosamax), quinidine (for abnormal heart rhythms), carbamazepine (controls seizures), mirtazapine (anti-depressant), oxaliplatin and suramin (chemotherapies), the glycoprotein IIbIIIa inhibitors abciximab, tirofiban and eptifibatide, heparin (anti-clotting agents).and quinine (see below) are particular problems. Be sure to tell your doctor if you are taking any herbal remedies or common non-prescription drugs such as acetaminophen (ex. Tylenol) or ibuprofen (ex: Advil, Motrin) as these can also cause DITP.42,45 There should be a compelling reason for taking any medication and medical attention is needed for any side effect, including bruising/bleeding.

Dr. James George and colleagues at the University of Oklahoma track published reports of drugs that cause low platelets and update a summary list every two years.2 Unfortunately, many instances of DITP are not published, so there is no comprehensive compilation of problem drugs. Visit Dr. George's web site to view his list.

The Blood Center of Southeastern Wisconsin has a test for drug-associated antibodies that can help confirm a diagnosis of DITP.

Quinine: a special case

Quinine is found in some drugs as well as in tonic water, bitter lemon, and bitter melons.  Some people whose low platelets were due to drinking or eating these things have been misdiagnosed as having ITP.

In a study of 343 patients, 28 (8%) were found to have drug-induced thrombocytopenia and 13 of these cases were caused by quinine.  Three of these people had an unnecessary splenectomy.2

Herbs, Food, and Supplements

Some food, herbs, and supplements can reduce the number of platelets for various reasons.  This list includes those substances that have been documented in journal or other articles.  It is not known whether there are few items in this category or if they are underreported. If your platelets drop after taking something new, please notify your doctor.

alcohol3,44 (also called ethanol-induced thrombocytopenia)
aspartame (NutraSweet)5
cow’s milk*6
cranberry Juice*6
erucic acid (in Lorenzo's oil, some rapeseed and mustard oil)46
jui [a Chinese medicinal herbal tea]*7
L-tryptophan*8
lupinus termis bean (cultivated in Egypt, a food protein supplement that contains quinolizidine alkaloids)6
niacin (liver damage due to long exposure) 9
tahini (pulped sesame seeds)*6

*allergic or cross-reaction to platelets in those with sensitivities to that substance, similar to drug-induced thrombocytopenia

Environmental Hazards

Exposure to  toxins and household chemicals can cause a drop in platelets in some people.  Below is a list of toxins that have been documented to cause low platelets. You can find more information about environmental medicine and minimizing toxic exposure on Dr. Lisa Nagy's Web site. Check the NIH toxmap for toxic locations near you or local environmental sites such as the Environmental Health Watch

Aromatic hydrocarbons

polyurethane10
toluene methylbenzene (Anisen or Toluol)
(smells like paint thinner, used in the many industrial processes including the production of gasoline and Coca-cola.)11
wood preservatives and solvents12

Insecticides, chlorinated hydrocarbons, and organic phosphorus compounds41

Mycotoxins (toxins that can be produced by molds, yeast, and mushrooms)

mold (can be in the air, on food, or in cardboard)13
P. sorghina (mold on grains)14
trichothecenes (a family of micotoxins)15

Pesticides

Various pesticides increase oxidative stress (implicated in ITP) and can promote platelet destruction in the spleen according to experiments in fish.43

Research and Contacts

Physicians specializing in enviromental medicine may be able to help.  You can find them through the American Academy of Environmental Medicine.  The impact of the environment on autoimmune disease is getting more attention at the National Institute of Environmental Health Science and the press.  Many environmental medicine practitioners recommend using products that are environmental friendly and non-toxic.

(PDSA thanks Dr. Lisa Nagy for help with the environmental hazard list.)

Food and Supplements that Interfere with Platelet Function

This list contains food and supplements that can change the way platelets work and make it more difficult for your blood to clot.  They do not reduce the platelet count unless noted.  A small quantity of these substances will probably be safe and not cause a problem. 

There are many drugs such as Plavix and Coumadin that are designed to interfere with platelet function as well as other drugs such as aspirin that reduce platelet function as a side effect of their other uses.  The food and supplements listed can amplify the effect of these medications. See the results of the  NIH Conference on Dietary Supplements, Coagulation, and Antithrombotic Therapies held January 13-14, 2005, for more information and an extensive bibliography.

Many of the listed substances are also antioxidants or have other properties that promote healing.  A balance is important.  We are publishing this list so you are aware that everyday or easily-available substances can have an effect on platelets, although their anti-clotting action is much weaker than pharmaceuticals. 

If you have a reasonably high platelet count and few bleeding symptoms, many items on this list will not cause problems unless you ingest large quantities.  Ironically, some patients with ITP have a clotting problem and are also taking blood thinners.  Others may have a clotting problem and not know it.  The propensity to clot and medication status are important factors when considering diet choices.  Please discuss any concerns with your doctor.

alcohol (can also reduce the number of platelets)44
aspartame (NutraSweet, can also reduce the number of platelets)16
beer (including non-alcoholic beer)17,18
blueberries19
chocolate (dark)20
coffee21
feverfew22
garlic23
onions24
gingko biloba25
ginger26
ginseng27
green tea28
guarana (a dietary supplement)29
kiwi fruit30
omega 3 fatty acids (hemp seed, fish oil)31, 32
pycnogenol (pine bark extract)33
quercetin, rutin, and related bioflavonoids34, 35
red/purple grape products (grape juice, red wine, raisins, grape seeds)36
red wine37
tomatoes38
vitamin E39
wood ear or cloud ear mushroom (Auricularia auricula-judae, used in Chinese cuisine)40

References

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2. George JN, Aster RH, “Drug-induced thrombocytopenia:pathogenesis, evaluation, and management” 2009 American Society of Hematology Education Program Book. 153-8.
3. Latvala J et al. “Excess alcohol consumption is common in patients with cytopenia: studies in blood and bone marrow.” Clin Exp Res. 2004 Apr;28(4):619-24. http://www.ncbi.nlm.nih.gov/pubmed/15100613
5. Roberts HJ.."Aspartame-induced thrombocytopenia." South Med J. 2007 May;100(5):543 http://www.ncbi.nlm.nih.gov/pubmed/17534100
6. Royer DJ et al, “Thrombocytopenia as an adverse effect of complementary and alternative medicines, herbal remedies, supplements, foods, and beverages.” Eur J Haematol.  2010. .http://www.ncbi.nlm.nih.gov/pubmed/20059530
7. Ohmori T et al, “Acute thrombocytopenia induced by jui, a traditional herbal medicine.” J Thromb Haemost. 2004 Aug;2(8):1479-80. http://www.ncbi.nlm.nih.gov/pubmed/15304064
8. Morgan JM et al. “Scleroderma and autoimmune thrombocytopenia associated with ingestion of L-tryptophan.” Br J Dermatol.  1993 May;128(5):581-3.http://www.ncbi.nlm.nih.gov/pubmed/8504054
9. Reimund E et al. “Niacin-induced hepatitis and thrombocytopenia after 10 years of niacin use.” J Clin Gastroenterol. 1994 Apr;18(3):270-1. http://www.ncbi.nlm.nih.gov/pubmed/8034946
10. Michelson AD. Am J Hematol. 1991 Oct;38(2):145-6.”Thrombocytopenia associated with environmental exposure to polyurethane.” http://www.ncbi.nlm.nih.gov/pubmed/1951307
11. Jennings GH et al, “Thrombocytopenic purpura in toluene di-isocyanate workers.” Lancet. 1963 Feb 23;1(7278):406-8.http://www.ncbi.nlm.nih.gov/pubmed/14029047
12. Hay A et al. “Wood preservatives, solvents, and thrombocytopenic purpura.” Lancet. 1991 Sep 21;338(8769):766.http://www.ncbi.nlm.nih.gov/pubmed/1716341
13. Gray MR et al. “Mixed mold mycotoxicosis: immunological changes in humans following exposure in water-damaged buildings.” Arch Environ Health. 2003 Jul;58(7):410-20.http://www.ncbi.nlm.nih.gov/pubmed/15143854
14. Rabie CJ et al. “Onyalai--the possible involvement of a mycotoxin produced by Phoma sorghina in the aetiology.” S Afr Med J. 1975 Sep 20;49(40):1647-50. http://www.ncbi.nlm.nih.gov/pubmed/1080886
15. Parent-Massin D. “Haematotoxicity of trichothecenes.” Toxicol Lett. 2004 Oct 10;153(1):75-81. http://www.ncbi.nlm.nih.gov/pubmed/15342083
16. Pretorius E et al. “Ultrastructural changes to rabbit fibrin and platelets due to aspartame.“ Ultrastruct Pathol. 2007 Mar-Apr;31(2):77-83. http://www.ncbi.nlm.nih.gov/pubmed/17613990
17. Bassus S et al. “Effect of Dealcoholized Beer (Bitburger Drive®) Consumption on Hemostasis in Humans.” Alcoholism: Clinical and Experimental Research Volume 28 Issue 5, Pages 786 – 791 http://www3.interscience.wiley.com/journal/118770401/abstract
18. Mann LB et al. “Effects of ethanol and other constituents of alcoholic beverages on coronary heart disease: a review.” Pathophysiology.  2004 Apr;10(2):105-12. http://www.ncbi.nlm.nih.gov/pubmed/15006416
19. Mazza GJ. “Anthocyanins and heart health.” Ann Ist Super Sanita. 2007;43(4):369-74. http://www.ncbi.nlm.nih.gov/pubmed/18209270
20. Innes AJ et al. “Dark chocolate inhibits platelet aggregation in healthy volunteers.” Platelets. 2003 Aug;14(5):325-7. http://www.ncbi.nlm.nih.gov/pubmed/12944249
21. Natella F et al. “Effect of coffee drinking on platelets: inhibition of aggregation and phenols incorporation.” Br J Nutr. 2008 Dec;100(6):1276-82. http://www.ncbi.nlm.nih.gov/pubmed/18439332
22. Heptinstall S et al. “Parthenolide content and bioactivity of feverfew (Tanacetum parthenium (L..)” J Pharm Pharmacol. 1992 May;44(5):391-5.  http://www.ncbi.nlm.nih.gov/pubmed/1359053
23. Ali M et al. “Antithrombotic activity of garlic: its inhibition of the synthesis of thromboxane-B2 during infusion of arachidonic acid and collagen in rabbits.” Prostaglandins Leukot Essent Fatty Acids. 1990 Oct;41(2):95-9.http://www.ncbi.nlm.nih.gov/pubmed/2274570
24. Osmont KS et al. “Temporal aspects of onion-induced antiplatelet activity.” Plant Foods Hum Nutr. 2003 Winter;58(1):27-40. http://www.ncbi.nlm.nih.gov/pubmed/12859011
25. Dutta-Roy AK et al. “Inhibitory effect of Ginkgo biloba extract on human platelet aggregation.” Platelets. 1999;10(5):298-305. http://www.ncbi.nlm.nih.gov/pubmed/16801106
26. Nurtjahja-Tjendraputra E et al. “Effective anti-platelet and COX-1 enzyme inhibitors from pungent constituents of ginger.” Thromb Res. 2003;111(4-5):259-65.http://www.ncbi.nlm.nih.gov/pubmed/14693173
27. Lau AJ et al. “Antiplatelet and anticoagulant effects of Panax notoginseng: comparison of raw and steamed Panax notoginseng with Panax ginseng and Panax quinquefolium.” J Ethnopharmacol. 2009 Sep 25;125(3):380-6.http://www.ncbi.nlm.nih.gov/pubmed/19665534
28. Babu PV et al. “Green tea catechins and cardiovascular health: an update.” Curr Med Chem. 2008;15(18):1840-50. http://www.ncbi.nlm.nih.gov/pubmed/18691042
29. Braz J et al. “A novel property of an aqueous guaraná extract (Paullinia cupana): inhibition of platelet aggregation in vitro and in vivo.” Med Biol Res. 1988;21(3):535-8.http://www.ncbi.nlm.nih.gov/pubmed/3228635
30. Duttaroy AK, et al. “Effects of kiwi fruit consumption on platelet aggregation and plasma lipids in healthy human volunteers “ Platelets. 2004 Aug;15(5):287-92. http://www.ncbi.nlm.nih.gov/pubmed/15370099
31. Rodriguez-Leyva D et al.  “The cardiac and haemostatic effects of dietary hempseed.” Nutr Metab (Lond). 2010 Apr 21;7(1):32.http://www.ncbi.nlm.nih.gov/pubmed/20409317
32. Phang M et al. “Inhibition of platelet aggregation by omega-3 polyunsaturated fatty acids is gender specific-Redefining platelet response to fish oils.” Prostaglandins Leukot Essent Fatty Acids. 2009 Jul;81(1):35-40. http://www.ncbi.nlm.nih.gov/pubmed/19481915
33. Araghi-Niknam M et al. “Pine bark extract reduces platelet aggregation.” Integr Med. 2000 Mar 21;2(2):73-77. http://www.ncbi.nlm.nih.gov/pubmed/10882879
34. Hubbard GP et al. “Ingestion of quercetin inhibits platelet aggregation and essential components of the collagen-stimulated platelet activation pathway in humans.” J Thromb Haemost. 2004 Dec;2(12):2138-45.http://www.ncbi.nlm.nih.gov/pubmed/15613018
35. Navarro-Núñez L et al. “Differential effects of quercetin, apigenin and genistein on signalling pathways of protease-activated receptors PAR(1) and PAR(4) in platelets.” Br J Pharmacol.  2009 Nov;158(6):1548-56. http://www.ncbi.nlm.nih.gov/pubmed/19814731
36. Vitseva O. “Grape seed and skin extracts inhibit platelet function and release of reactive oxygen intermediates.” J Cardiovasc Pharmacol. 2005 Oct;46(4):445-51. http://www.ncbi.nlm.nih.gov/pubmed/16160595
37. Wu JM et al. “Mechanism of cardioprotection by resveratrol, a phenolic antioxidant present in red wine (Review).” Int J Mol Med. 2001 Jul;8(1):3-17. http://www.ncbi.nlm.nih.gov/pubmed/11408943
38. O'Kennedy N et al. “Effects of tomato extract on platelet function: a double-blinded crossover study in healthy humans." Am J Clin Nutr. 2006 Sep;84(3):561-9. http://www.ncbi.nlm.nih.gov/pubmed/16960170
39. Zingg JM et al. “Non-antioxidant activities of vitamin E.” Curr Med Chem. 2004 May;11(9):1113-33. http://www.ncbi.nlm.nih.gov/pubmed/15134510
40. Tom Volk's Fungus http://botit.botany.wisc.edu/toms_fungi/apr2004.html
41. Mastromatt.eo E. “Hematological Disorders Following Exposure to Insecticides.”Can Med Assoc J. 1964 May 16; 90(20): 1166–1168.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1922786
42. Aster RH, "Drug-induced immune thrombocytopenia" N Engl J Med. 2007 Aug 9;357(6):580-7. http://www.ncbi.nlm.nih.gov/pubmed/17687133
43. Slaninova A et al. "A review: oxidative stress in fish induced by pesticides." Neuro Endocrinol Lett. 2009;30 Suppl 1:2-12.
http://www.ncbi.nlm.nih.gov/pubmed/20027135
44. Ballard HS, "The hematological complications of alcoholism." Alcohol Health and Research World.1997; 21(1):42-52. http://pubs.niaaa.nih.gov/publications/arh21-1/42.pdf
45. Arnold DM et al. "A systematic evaluation of laboratory testing for drug-induced immune thrombocytopenia." J Thromb Haemost. 2012 Nov 3.
http://www.ncbi.nlm.nih.gov/pubmed/23121994
46. Kickler TS et al. “Effect of erucic acid on platelets in patients with adrenoleukodystrophy.” Biochem Mol Med. 1996 Apr;57(2):125-33. http://www.ncbi.nlm.nih.gov/pubmed/8733890