Which blood thinner do I choose?

After syncopal episodes caused by asystole accompanied by bradycardia I got an emergency pacemaker Aug. 1. Two weeks later I was in the hospital for pericarditis. This week I learned that now I've started having afib for up to 4 hours at a time, with 11 episodes over two days. My doctor gave me 3 booklets and said I should choose which blood thinner to take: Warfarin, Apixaban, or Rivaroxaban. I also have Stage 3 kidney disease caused by hyperoxaluria so I asked my nephrologist and he said he would rule out Rivaroxaban. I'm leaning toward Apixaban because the booklet said that I would need to be careful about the consistency with which I ate cruciferous vegetables (such as cauliflower and brussel sprouts and cabbage) with warfarin. These are virtually the only vegetables I can eat because of the hyperoxaluria, and consistency in eating is difficult for me.  From what I've read, Apixaban seems to be slightly better than warfarin in stroke prevention and bleeding but is more expensive. However, my doctor said there isn't a reversal mechanism for Apixaban on the market yet. How big of a concern should this be for someone who, although relatively young at 63, has a mild gait abnormality, is pretty clumsy, and has had multiple concussions from bad falls from the bradycardia prior to the pacemaker. Any help in stacking up the pros and cons of these medications from those using them would be helpful.

10 Comments

Difficult choice

by IAN MC - 2018-10-11 05:32:05

As there have been no clinical trials comparing the newer blood thinners it is impossible to say which is best without any evidence to back it up.

As you admit to being clumsy and prone to suffering concussions if I were you the most important considerations are :-

-  the risks of suffering a bleed, particularly around the brain

- is there an antidote to switch off the drug if you do have an accident or need surgery. ?

Warfarin has the advantage  of having a well-tested antidote ( Vitamin K or something similar ) but has other disadvantages which probably mean that I would only consider one of the newer ones but I need to qualify that statement in view of your medical history.

I was under the impression that , a few months ago, the F.D.A. approved an antidote ( Andexxa) which works for Apixaban and the other new blood thinners  BUT I don't know if it has been launched yet or not. 

You don't say which country you are in but you definitely need to find out if there is an antidote available where you live.  If there isn't , my decision would be to start on warfarin until an antidote is available for the newer ones and I would then switch to ......probably apixaban ...as it seems to be as good as any and MAY have a lower incidence of G.I. bleeds ; but I say that without any trial comparative evidence and it is  a big BUT .

You also need to confirm that apixaban is OK to take if you have kidney disease. This is a slight worry with warfarin.

Best of luck

Ian

 

 

Odd question

by AgentX86 - 2018-10-11 10:28:51

Not yours. Your doctor went to school for a decade to understand these sorts of decisions. I'd think he'd have the answer or at least give you all of the pros/cons to make this decision.

Anyway, I'd go the Eliquis (apixaban) route. I *hated* being on warfarin. Eliquis is a lot more expensive but doesn't have nearly the same bleeding problem as rat poison. There is now a reversal agent but it's absurdly expensive right now and thus may not be universally available. I was supposed to be in all high level trauma centers by now but EMTs won't likely be carrying it for some time.

pharmacist?

by Tracey_E - 2018-10-11 10:56:38

Maybe a pharmacist can give you some insights and help you decide. I've found them more helpful talking about side effects and restrictions than the doctors. It's odd that your doctor didn't have the conversation with you rather than sending you out with homework. There are other medications such as beta blocker that can be used for afib rather than blood thinners. Is that an option?

Tracey / Tumbleweed

by IAN MC - 2018-10-11 12:45:35

Tracey : You seem to have a  misunderstanding of the roles of beta-blockers and blood thinners in a-fib. One cannot be a substitute for the other.

Beta-blockers can actually treat a-fib largely by reducing heart-rate , blood-thinners are used to help prevent the formation of blood-clots ( always a risk in a-fib ) and hence help prevent strokes.

I am not at all surprised that the Dr is passing the decision back to Tumbleweed . Drs attempt to measure the risk of a stroke in individual patients and also the risk of them having a bleed. They follow well-known formulas and allocate individual scores for each risk.

This is not a typical case and the formula for measuring the risk of having a bleed probably does not take into account someone with Tumbleweed's background of regular falls and concussion.    I doubt that a pharmacist could add much to the debate as there is no available data.

Ian

Beta blockers

by AgentX86 - 2018-10-11 13:15:06

Blood thinners and beta blockers are entirely different drugs, used for entirely different reasons. Beta blockers put a lid on heart rate to prevent v-tach and v-fib (short term) and cardiomyopathy (long term). Anticoagulants (AKA blood thinners) are used to prevent stroke. Both functions are essential in the treatment of atrial arrhythmias but one doesn't supplant the other.

Thank you!

by Tumbleweed - 2018-10-11 17:50:02

Thank you everyone for the great feedback on this issue. I will probably go with apixaban because of my kidney problems. I found a locator map for the antidote medication, and one of the 10 locations with current availability is 1.5 hours away at a facility where I already see physicians. I certainly hope it becomes more widespread.

 

Warfarin myths

by LondonAndy - 2018-10-11 19:20:54

I don't know enough about the newer anticoagulants, as I have a mechanical heart valve and they are not allowed - normally the only option is Warfarin, or Coumadin as it is also known.  Having been on it for 4 years now I have learnt quite a lot about it.

It is largely a myth that broccoli etc have to be consumed at a consistent level, though it is always possible some are more sensitive to it than others I guess.  Similarly alcohol has a marginal effect.  I eat a variety of vegetables with different meals, depending on mood etc, and have very little change in my blood thickness.  I don't drink alcohol regularly, but when I do I drink between a glass of wine and a bottle, or a pint of beer or 5 or 6.  

How do I know this?  Because best practice is now for patients to have their own hand-held meter that works very similar to blood glucose meters used by diabetics: there is a test strip and you apply a drop of blood, and get your "INR" reading a few seconds later.  Everything is larger than a blood glucose meter: the machine, the strips, and the drop of blood needed.  I test mine once a week usually, as warfarin takes about 3 days to take effect in the bloodstream.  So a change of dose on a Monday won't be fully seen in results until about Thursday, so no point testing sooner.

At first my anti-coagulation clinic told me what dose I needed if I was outside of my range, but after a few weeks I felt confident enough to make minor "course corrections" myself if needed, and these days I only go to the clinic twice a year to confirm the meter is working fine, or when I need more support.  And of course there is an easy and wide known reversal agent in an emergency: vitamin K.

So this is not to say don't go for one of the new ones, which do not require the close monitoring of Warfarin, but if Warfarin has other plus points such as being easier on the kidneys then don't rule it out.

Yes, it is rat poison, and too much of it is dangerous.  But those levels are in a different league, and drinking too much water or inhaling too much oxygen is bad for us too. Perspective.

I agree Andy

by IAN MC - 2018-10-11 19:54:55

Warfarin is the most widely prescribed anti-coagulant in the world and is likely to remain so for some time

 It has been used for over 60 yrs. Millions and millions of people have taken it.  I took it myself without any great problems until an ablation removed my need for it.

I think it is pathetic that many people like to show off their very limited knowledge by saying " rat poison"  every time warfarin is mentioned.

Do the same people realise how little aspirin it takes to kill a cat ?

It is all to do with dosage . If they went into any pharmaceutical research lab , they would be surprised to see how many rats die in dosage tests on all sorts of drugs.

Just a small point ... you suggest that warfarin may be easier on the kidneys . In fact if you have impaired kidney function it is quite important to reduce the warfarin dosage .... so we are back to dosage again !

Cheers

Ian

Thanks Ian

by LondonAndy - 2018-10-11 20:14:46

I agree. I did not mean to imply warfarin is easier on kidneys (I didn't know either way and put 'if') but it was poor wording on my part. Main point intended was that if Tumbleweed thought Warfarin has fewer issues than other options, don't rule it out because of the vegetable issues which are minor.

Research on Warfarin & Kidney Disease

by Tumbleweed - 2018-10-12 16:57:13

I did find a couple of studies that indicated some of the newer blood thinners were better for patients with chronic kidney disease than Warfarin.

It is always a gamble to take new medications, though. It seems like every few weeks, another FDA-approved medication is being withdrawn from the marketplace.

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