Which Blood Thinner Is Right for You?
New drugs offer alternatives to Coumadin, but there are pros and cons to all
Why, I wondered, would anyone choose one of the new blood thinners when Coumadin has a track record of safety and a remedy to stop bleeding in emergencies? I thought the only issue was: Cut out leafy green veggies and get a monthly (or even weekly) blood test or run the risk of uncontrolled bleeding in an emergency.
In fact, the answer is much more complicated, as we've explored on MedShadow, a site I founded.
The Blood Thinner That Fights Heart Attacks and Strokes
For decades, doctors would prescribe Coumadin (warfarin), an anticoagulant also called a blood thinner, for those at high risk of a heart attack or stroke.
Everyone knew the drawbacks: constant blood tests, cutting out spinach and other leafy green veggies and maybe some bruising. Since Coumadin activates in the liver, those with compromised livers may not be candidates for the drug.
Coumadin works by slowing how quickly vitamin K creates clots in the body. Since vitamin K is crucial for forming blood clots, slowing it greatly decreases the risk for heart attack, stroke or pulmonary embolism (a blood clot that reaches the lungs). Generally those on Coumadin avoid veggies in which vitamin K is naturally available, such as kale, collard greens, spinach, brussels sprouts and broccoli.
Pluses and Minuses of Coumadin
Coumadin, however, has another problem. It can interact with other frequently prescribed drugs and some common herbal remedies. Check with your doctor before taking it with antibiotics and antifungal drugs, birth control pills, common over-the-counter pain remedies such as aspirin and Advil or Aleve and acid-reflux treatments including Pepcid and Zantac. Also ask about Co-Q10, St. John’s wort and ginseng.
The big benefit to Coumadin? It’s effective and there’s a reversal drug, Kcentra, that emergency rooms stock.
New Drugs to Prevent Strokes
With all the negative aspects to Coumadin, there was great interest when the Food and Drug Administration (FDA) approved five new drugs in quick succession for stroke prevention: Plavix (clopidogrel), Xarelto (rivaroxaban), Pradaxa (dabigatran), Eliquis (apixaban) and Savaysa (edoxaban).
The newer drugs have a significant advantage over Coumadin: Routine blood testing is not necessary and there are fewer drug interactions (more on that below). Also, because they work differently than Coumadin, eating vitamin K-rich foods isn’t an issue.
But be warned: These drugs (except Pradaxa) have no reversal agent for excessive bleeding or the need for urgent surgery. If an accident were to happen or if a drug interaction caused bleeding, stopping the blood flow could be difficult and — though unlikely — could risk death.
Why New Meds May Be Better — or Worse
Why would the FDA approve new drugs that have no reversal agent when Coumadin is available? After reviewing studies, the FDA concluded that there is value to having alternatives to Coumadin and the risks of life-threatening bleeding are very small.
When comparing Pradaxa, Xarelto and Eliquis, the research showed that the new drugs were either equal or superior to Coumadin in preventing strokes and other blood clots. The agency determined that “all three drugs caused fewer intracranial hemorrhages than warfarin. For these reasons, it was clear that these drugs were worthy of approval, even in the absence of a reversal agent.”
These next-generation blood thinners do have some side effect risks though, such as indigestion, upset stomach or stomach pain and bruising as well as the chance of an allergic reaction — hives, a rash, itching or swelling of the tongue. Also, these drugs work within your kidneys, so those with limited kidney function might not be candidates. Each of the drugs works slightly differently, so ask your doctor which might be best for you.
See our article on MedShadow for more information on drug interactions.
More Details on Plavix
Plavix has some specific problems and has been reviewed after approval by the FDA at least two times. In November 2015, the FDA determined that use of Plavix does not increase or decrease risk of death, which calls into question its effectiveness. It may lower risk of stroke and heart attack, so don’t stop taking it, the FDA says. But discuss the FDA’s concerns with your doctor.
In 2009, the FDA cautioned that Plavix should not be taken with heartburn medications known as PPIs (proton pump inhibitors) since they make Plavix less effective. Among the drugs to avoid taking with Plavix are Nexium, Prilosec and Tagamet. In the same notice, the FDA also cautioned against taking the antidepressant Prozac (fluoxetine), several antifungal medications, an anti-seizure drug and an HIV drug.
Anyone using blood thinners should alert doctors before any scheduled surgery. As we always say at MedShadow, take any drug for the shortest time and in the lowest dosage advisable. Discussing which drugs can be stopped is just as important as which drugs need to be taken for continued good health.