Salvia miltiorrhiza, also known as Danshen (丹参), is a commonly used traditional Chinese medicine for promoting blood circulation and removing blood stasis. The main chemical components of Salvia miltiorrhiza include Tanshinone IIA, Salvianolic acid A, and Salvianic acid A. Although the anticoagulant mechanism of Salvia miltiorrhiza is not yet fully understood, many studies suggest that its effects are primarily due to its antiplatelet activity. With this in mind, it is understandable that there are concerns about its safety and potential for increased bleeding risk when used in conjunction with Western anti-thrombotic medications.

Currently, there is limited research in this area, and the overall quality of the literature is relatively low. Most clinical studies indicate that using Salvia miltiorrhiza alone or in combination with aspirin or oral anticoagulants does not increase the incidence of bleeding events and may even reduce the rate of thromboembolism or cardiovascular events. A nationwide cohort study in China in treatment of Urolithiasis with Salvia miltiorrhiza revealed that the incidence of bleeding was significantly lower among those who took Salvia miltiorrhiza compared to those who did not. Additionally, increasing the dosage of Salvia miltiorrhiza did not elevate the risk of bleeding.

However, among various anti-thrombotic drugs, warfarin poses a higher risk of bleeding, with significant individual variability. Some pharmacokinetic studies suggest that effective components of Salvia miltiorrhiza, such as Tanshinone IIA, Sodium dodecyl sulfonate and Salvianic acid A, might alter the pharmacokinetics of warfarin by increasing its bioavailability or reducing its clearance, thereby enhancing its anticoagulant effect. Therefore, caution is advised when using Salvia miltiorrhiza or other blood-invigorating herbs in patients on warfarin.
Additionally, the most common side effect of aspirin is gastrointestinal bleeding, so it is important to consider whether traditional medicines that promote blood circulation might exacerbate such bleeding or cause other adverse reactions. Due to the low quality of the existing literature, the conclusions above need to be validated through further large-scale, high-quality clinical studies and systematic reviews to confirm the efficacy and safety of combining Salvia miltiorrhiza with anti-thrombotic medications.

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