You've seen all the commercials, but here's what to know about the medications.
Have you ever wondered why there are so many blood thinner commercials on TV? Pradaxa, Xarelto and Eliquis advertisements flood the airwaves promising to protect you from life-threatening clots while also claiming superiority to a medication many of us remember our grandparents taking, called warfarin. Of course, none of us understood why our grandparents may have been taking warfarin (a medication made from rat poison) in the first place. But the newer blood thinners called NOACs (novel oral anticoagulants) are actually great treatment options for many people with specific medical conditions. So should you pay attention the next time one of these commercials pops up? To clot, or not to clot, that is the question perhaps we should all be asking.
What Is Warfarin?
Warfarin, also called coumadin, is in fact derived from rat poison. Being an animal activist and lover of all animals, I will refrain from expounding on how warfarin went from poisoning rats to being used clinically in patients (I'm not sure I would have gone to that doctor), as I find animal persecution too upsetting. However, a well-written article in Nature Reviews Cardiology explains this evolution. In truth, the medical use of warfarin was revolutionary in both treating and preventing leg and lung clots as well as in effectively decreasing the risk of stroke in patients with either an abnormal heart rhythm, called atrial fibrillation, or in people with abnormal heart valves. However, the drawback of warfarin treatment is that patients require frequent blood tests to ensure proper blood levels, as its therapeutic effect and its bleeding risk can be quickly affected by changes in diet (including alcohol) and by multiple medication interactions (including antibiotics).
What About NOACs?
Pradaxa, Xarelto and Eliquis do not require routine blood tests, are not affected by dietary changes, have fewer drug interactions, and their onsets of action and therapeutic elimination from the body are much quicker than warfarin, therefore making them readily effective and allowing for a safer discontinuation period prior to any procedures. The main downside of these newer blood thinners is their price, as they can be very expensive. Whether it be warfarin, Pradaxa, Xarelto or Eliquis, as the job of all of these medications is to dissolve clots, they all increase one's risk of bleeding. In fact, for people who have specific bleeding problems or who are at higher risk of bleeding due to possible falls on account of balance problems, it may not be safe to initiate or continue treatment with any of these medications. The risk of causing life-threatening bleeds in these people may outweigh the beneficial effects of the treatment. However, in the majority of patients who have medical conditions that warrant these blood thinners, the benefits of being treated with them surely outweigh the slightly increased risk of bleeding.
Who May Need Blood Thinners?
Some of the common medical conditions that benefit from treatment with blood thinners include:
- Atrial fibrillation
- Leg clots (deep vein thrombosis)
- Lung clots (pulmonary embolism)
Atrial fibrillation is an irregular heartbeat that initiates in the upper chambers of the heart. Because this rhythm is chaotic, the top chambers, known as the atria, do not contract effectively and therefore blood can pool and coalesce in them, forming clots. These clots can then be ejected from the heart and travel to various parts of the body such as the brain, causing a stroke. Symptoms of atrial fibrillation include shortness of breath, dizziness, palpitations (feeling like your heart is racing) and chest pain; however, many people who have atrial fibrillation do not have symptoms and, therefore, are unaware they have this condition until it is discovered during a routine physical exam (or, unfortunately, after presenting with a stroke). Risk factors for developing atrial fibrillation include getting older, having high blood pressure, having heart, lung, or thyroid disease, drinking alcohol, having a family history of atrial fibrillation, and sleep apnea. As blood thinners are highly effective in preventing clot formation (and decreasing one's risk of having a stroke) in patients with atrial fibrillation, your physician will likely start you on a blood thinner (unless you have a high risk of bleeding), particularly if you are over the age of 65, have high blood pressure, a history of diabetes, heart disease, or a prior history of having a stroke.
Leg clots, known as deep vein thrombosis, and lung clots, known as pulmonary embolism, should also be treated with any of these blood thinners. The sudden onset of leg swelling, especially if associated with pain, can be very concerning for having a clot in your leg, particularly when the swelling only occurs in one leg and especially after prolonged immobilization, either due to a long car/plane ride or from wearing a cast for a broken bone. People on oral contraceptives are also at risk for developing leg clots, especially if they also smoke. Because the clot can break off and travel to your lungs causing a life-threatening condition called a pulmonary embolism, getting to an emergency room for an ultrasound to rule out a clot is critical. If you do have a clot, starting blood thinners promptly can save your life.
By Dr. Marc Eisenberg
Dr. Marc Sabin Eisenberg, M.D., F.A.C.C. is an associate professor of medicine at Columbia University Medical Center. He is co-author of the book "Am I Dying?!: A Complete Guide to Your Symptoms and What to Do Next" and co-host of the "Am I Dying?!" podcast, which provides light-hearted advice for the hypochondriac in all of us. He writes the "Rounds With Dr. E" column for DoctorOz.com.