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Insight: Top Heart Doctors Fret Over New Blood Thinners
11 Min Read
NEW YORK – For millions of heart patients, a pair of new blood thinners have been heralded as the first replacements in 60 years for warfarin, a pill whose hardships and risks have deterred many from using the stroke-prevention medicine.
But growing complaints of risks and deaths tied to the new crop of drugs have made some top U.S. cardiologists hesitant to prescribe them. Some are proposing a more rigorous monitoring regimen for when they are used.
Most concerns revolve around Pradaxa, a twice daily pill from Boehringer Ingelheim that was approved by the U.S. Food and Drug Administration in October 2010 to prevent strokes in patients with an irregular heartbeat called atrial fibrillation. It was the first new oral treatment for that use since warfarin was introduced in the 1950s.
The good news is you now have an alternative to warfarin, said Dr. Alan Jacobson, director of anti-coagulation services at the Veterans Administration healthcare system in Loma Linda, California. The bad news is you can kill a patient as easily with the new drug as you could with the old drug if it is not handled properly.
The average patient doesnt understand anything about the new drug, or what the risks are, or what other medicines he can or cant take, said Jacobson, citing interactions with common painkillers and other drugs that can alter Pradaxa blood levels.
Doctors have less data and familiarity with Xarelto, which is still being rolled out.
Switching From Warfarin To Rivaroxaban
If you need to switch from warfarin to rivaroxaban, your doctor will advise you when to stop taking warfarin. This will probably be a few days before you start rivaroxaban.
Your doctor or anticoagulant clinic will do a blood test called the international normalised ratio to check how quickly your blood’s clotting.
This is to help decide exactly when you should start taking rivaroxaban.
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What If I Forget To Take It
What you need to do depends on the dose you take.
If you usually take:
- 10mg, 15mg or 20mg once a day take a dose as soon as you remember, unless it’s nearly time for your next one. Take your next dose at the usual time and then carry on as normal. Never take more than 1 dose in a single day.
- 15mg twice a day take a dose as soon as you remember. You can take 2 x 15mg tablets at the same time to get a total of 2 doses in 1 day. Never take more than 2 doses in 1 day.
- 2.5mg twice a day take a dose as soon as you remember, unless it’s nearly time for your next one. Do not take a double dose to make up for a missed one. Take your next dose at the usual time, and then carry on as normal.
It’s very important that you remember to take rivaroxaban every day.
If you forget doses often, it may help to set an alarm to remind you.
You could also ask your pharmacist for advice on other ways to help you remember to take your medicine.
If you’re worried, contact your doctor or pharmacist.
Kidney Disease Affects Response To Blood Thinner
Patients with reduced kidney function may need lower doses of warfarin
American Society of Nephrology
Patients with reduced kidney function require lower doses of the anticoagulant drug warfarin, and may need closer monitoring to avoid serious bleeding complications, suggests a study in the April 2009 issue of the Journal of the American Society of Nephrology .
Among patients who take blood thinner there is a high prevalence of reduced kidney function, ranging from mild to severe. “Although warfarin is very effective in protecting against blood clots it can also cause serious bleeding complications,” commented lead author Nita A. Limdi, PharmD, PhD, of the University of Alabama at Birmingham. “The information in our study may help doctors customize warfarin management in patients with kidney failure and lower the risk of complications,” commented Michael Allon, MD, also of the University of Alabama at Birmingham.
The researchers evaluated responses to warfarin, the most widely used oral anticoagulant drug, in 578 patients. About 60 percent of the patients had normal or mildly reduced kidney function. Another 30 percent had moderate reductions in kidney function, common in older adults. The remaining patients, nearly ten percent, had kidney failure requiring dialysis.
The National Heart Lung and Blood Institute and the National Institute of Neurological Disorders and Stroke provided funding for this study.
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Can I Take Eliquis Once A Day
No, Eliquis needs to be taken twice a day. This helps keep a steady level of the drug in your blood.
Certain other blood thinners can be taken once a day. These include warfarin , rivaroxaban and enoxaparin .
If youre interested in a blood thinner that you take only once a day, talk with your doctor.
Xarelto And Acute Kidney Injuries
One of the severe side effects of Xarelto is that it can cause acute kidney injuries.
In the past few years, medical researchers have recognized a new type of acute kidney injury: Anticoagulant-related nephropathy.2
In anticoagulant-related nephropathy, the tissues in the kidney that strain impurities from the blood to create urine end up hemorrhaging because the blood is so thin.3 The damage from the hemorrhaging leaves blood to build up in the kidney, which can lead to further kidney damage and potentially renal failure.
To potentially make matters worse, newer anticoagulant drugs like Xarelto use a different chemical reaction to thin a patients blood. Called novel oral anticoagulants, or NOACs, these new blood thinners do not rely on vitamin K like earlier drugs did, like warfarin. NOACs also have a faster onset time and are not supposed to need constant medical monitoring.
The older blood thinner drugs like warfarin have been known to cause anticoagulant-related nephropathy in approximately one in five patients.4 Some studies indicate that NOACs like Xarelto decrease this risk.5 However, researchers admit that more studies need to be done.6
One clinical trial has been formed to monitor the kidney function of a cohort of 40 patients taking Xarelto for six months.7 Results, however, have not yet been released.
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Hopes For A Third New Drug
Warfarin thins the blood by blocking Vitamin K, while Pradaxa directly inhibits thrombin – a protein involved in clotting. Xarelto and Eliquis – which Bristol-Myers is developing with Pfizer Inc – interferes with a protein called Factor Xa.
Richard Purkiss, an analyst with Atlantic Equities, sees the new blood clot drugs reaching combined global annual sales of $10 billion for stroke prevention and other uses, with Eliquis commanding up to a 60 percent market share, based on data showing it was more effective and safer than warfarin, including less bleeding and risk of death from all causes.
Neither Pradaxa nor Xarelto were able to claim both superiority and better safety than warfarin, or reduced risk of death.
Only 25 percent of Eliquis is eliminated by the kidneys – and the rest by the liver – which some doctors say could make it more appropriate than Pradaxa or Xarelto for older patients and those with kidney problems. The FDA is expected to make a decision on Eliquis by June 28.
Michael Liss, portfolio manager at American Century Investments, predicts Eliquis will overtake Pradaxa and Xarelto within six months after it is introduced. He expects it to capture peak annual sales of up to $4 billion, with Pradaxa and Xarelto dividing up another $3 billion.
These are people whose kidneys are already damaged … and even at the smaller dose , you risk overdosing yourself, Bauer said.
FRAIL ELDERLY CANARY IN COAL MINE
Antiplatelet Medications And How To Take Them
Aspirin
Aspirin is often used to treat pain and reduce fever, but it is also an antiplatelet and in low doses, it can help to prevent blood clots.
After a stroke or TIA, its likely that youll be prescribed a daily dose of aspirin to begin with. Sometimes this is combined with clopidogrel. However, in the long term, your prescription is likely to change to clopidogrel alone, or aspirin and dipyridamole together, unless theres a reason why you cant take one of them. In that case, you may be given aspirin on its own, or dipyridamole on its own.
Aspirin can sometimes irritate your stomach, but taking it with food can help to prevent this. You should also make sure that you drink plenty of water so that you dont become dehydrated. Follow the instructions in the leaflet or label that comes with your medicine.
Aspirin is not suitable for everyone. If you have liver or kidney problems, asthma, a blood-clotting disorder or if youve ever had an ulcer in your stomach you may not be able to take it. Its not usually prescribed if youre pregnant and you wont be able to take it if youre allergic to other nonsteroidal anti-inflammatory drugs like ibuprofen or naproxen. These drugs can interact with aspirin, so you should check with your doctor before taking them.
Clopidogrel
Dipyridamole
Dipyridamole is also known by the brand name Persantin. It’s an antiplatelet drug that is often prescribed with aspirin. You may be given a tablet that combines both aspirin and dipyridamole.
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What To Do In Case Of Overdose
If you think youve taken too much of this drug, call your doctor. They may recommend that you take activated charcoal. This should only be done under the supervision of your doctor.
You can also call the American Association of Poison Control Centers at 800-222-1222 or use their online tool if youve taken too much Eliquis. But if your symptoms are severe, call 911 or your local emergency number, or go to the nearest emergency room right away.
Which Blood Thinner Is Best For You
Its hard to say one is better or worse, because there isnt that much data comparing them to one anotherweve mainly compared them against warfarin, says Jonathan Halperin, M.D., a professor of cardiology at the Icahn School of Medicine at Mount Sinai in New York City.
But there are differences you may want to ask your doctor about. For instance, apixaban was associated with the lowest risk of major bleeding in a 2016 study published in the journal Chest, and the lowest risk of gastrointestinal bleeding in elderly adults compared with dabigatran and rivaroxaban in a study published in the journal Gastroenterology in 2017.
Dabigatran carries an approximately 10 percent risk of heartburn so severe that patients have to switch drugs, Noseworthy says. And it cant be crushed, a problem if you have difficulty taking pills.
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Eliquis For Treating Dvt And Pe
Eliquis is FDA-approved to treat deep vein thrombosis and pulmonary embolism .
A DVT is a blood clot that forms in a vein deep inside your body and blocks blood flow. DVTs most commonly occur in a vein in your leg, but they can also occur in your arm. A PE is a blood clot that blocks blood flow to your lungs. It usually occurs when a DVT gets dislodged and travels through your veins to your lungs.
Eliquis treats DVT and PE by stopping these types of blood clots from getting bigger. This allows your body to break down and clear the clot.
Effectiveness for treating DVT and PE
In a clinical study, Eliquis was found to be effective for treating DVT and PE. In this study, Eliquis was compared with enoxaparin plus warfarin .
Enoxaparin and warfarin are effective anticoagulants that are commonly used to treat blood clots. Enoxaparin is given by injection, and warfarin is taken by mouth. Warfarin takes a few days to build up its effect, so enoxaparin is given along with warfarin for the first few days of treatment.
In this 6-month study:
- 0.8% of people who took Eliquis had a DVT during treatment
- 1.3% of people who took enoxaparin plus warfarin had a DVT during treatment
- 0.4% of people who took Eliquis died from a blood clot during treatment
- 0.6% of people who took enoxaparin plus warfarin died from a blood clot during treatment
View the drugs prescribing information for more effectiveness information.
Can Rivaroxaban Lead To Anticoagulation
| The safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Listing a study does not mean it has been evaluated by the U.S. Federal Government. Read our disclaimer for details. |
| First Posted : September 14, 2016Results First Posted : June 24, 2020Last Update Posted : July 7, 2020 |
- Study Details
Anticoagulation-Related Nephropathy is a side effect of treatment with blood thinners which leads to kidney dysfunction. A recent review suggests that kidney function should be assessed serially in the first few months of starting a blood thinner. ARN is diagnosed when there is a decline in kidney function after starting the blood thinner and other possible causes of this decline have been excluded. ARN has mainly been studied in relation to the common blood thinner – warfarin, where the prevalence is variable but can be as high as 37% in the patients at highest risk. The risk factors that make this side effect more likely include the presence of pre-existing kidney disease, high blood pressure, older age and diabetes mellitus. Studies have shown that the occurence of ARN can lead to an accelerated progression of pre-existing kidney disease and a 65% increase in the risk of death .
The specific aims of this study will be to –
SIGNIFICANCE
INNOVATION
OBJECTIVES
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Cautions With Other Medicines
Some medicines and supplements can affect rivaroxaban.
This can lead to serious side effects.
Tell your doctor if you’re taking these medicines before starting rivaroxaban:
- any other anticoagulant, such as warfarin or enoxaparin
- drugs to treat fungal or bacterial infections, such as fluconazole, erythromycin or clarithromycin
- drugs to treat HIV, such as ritonavir
- drugs to treat epilepsy, such as carbamazepine or phenytoin
- non-steroidal anti-inflammatory drugs , such as ibuprofen or aspirin
Expert Reaction To Study On Association Between Blood Thinners And Increased Stroke Risk In Over
New research published in the BMJ investigates whether blood thinners may raise stroke risk in over-65s with kidney disease.
An MHRA spokesperson said:
Patient safety is our highest priority and as with all medicines, the safety of blood thinners is kept under constant review.
We are aware of the new study on the use of blood thinners in patients with kidney disease and will review the findings to determine whether they have any implications for the safe use of these medicines.
Any patient who is concerned about their treatment with blood thinners should contact their doctor but continue to take their medicine in the meantime.
Dr Clare J Taylor, General Practitioner and NIHR Academic Clinical Lecturer, University of Oxford, said:
We know that people with atrial fibrillation also called an irregular heart beat are more likely to have a stroke than people without AF. There is a lot of evidence from large clinical trials to show that giving blood thinning treatment to people with AF can significantly reduce their risk of stroke, with a small increased risk of bleeding.
The study by Kumar and colleagues published today in the BMJ looked specifically at people with AF and chronic kidney disease . They compared the number of strokes, bleeds and deaths in people with AF and CKD who were and were not prescribed blood thinning treatment. They found that people treated with blood thinners were more likely to have a stroke and a bleed but were less likely to die.
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I Accidentally Took Two Eliquis Tablets In One Dose What Should I Do
Accidentally taking two Eliquis tablets together is unlikely to cause any problems. If this happens, you should continue with your usual treatment schedule.
In clinical studies, no significant side effects were seen in healthy people who took much higher doses of Eliquis than this.
If youve taken too much Eliquis, talk with your doctor. They may recommend that you take activated charcoal. This should only be done under the supervision of your doctor.
If you have any side effects after taking an extra tablet, or if you take more than two tablets, call your doctor right away. Call 911 or your local emergency number if your symptoms feel life threatening.
How Does This Medication Work What Will It Do For Me
Apixaban belongs to the group of medications called anticoagulants. Anticoagulants prevent harmful blood clots from forming in the blood vessels. They do this by reducing the ability of the blood to clot.
Apixaban is used to prevent blood clots for people who have had total hip replacement or knee replacement surgery. It may also be used to prevent stroke or blood clots in people with atrial fibrillation .
Apixaban is also used to treat and prevent clots from forming in the legs or in the lungs .
This medication may be available under multiple brand names and/or in several different forms. Any specific brand name of this medication may not be available in all of the forms or approved for all of the conditions discussed here. As well, some forms of this medication may not be used for all of the conditions discussed here.
Your doctor may have suggested this medication for conditions other than those listed in these drug information articles. If you have not discussed this with your doctor or are not sure why you are taking this medication, speak to your doctor. Do not stop taking this medication without consulting your doctor.
Do not give this medication to anyone else, even if they have the same symptoms as you do. It can be harmful for people to take this medication if their doctor has not prescribed it.
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