<p>There is such a wide range of backgrounds and experience in the Parent Cafe - I hope that someone (an MD, RN, pharmacist, patient, etc.) can provide some information on these anticoagulants. </p>
<p>We have a family friend in her late 20s who had a pulmonary embolism last week. She’s undergoing tests to find the cause. She’s debating between warfarin, which requires frequent doctor visits and some lifestyle changes (particularly diet), and xarelto. My husband is an MD and blanched at the idea of xarelto, which apparently can’t be reversed in case of a major bleeding event. </p>
<p>Like so many young people, she’s not really plugged in to a great medical practice, though she was treated at a major medical center. She doesn’t have an MD she knows well. I thought it might be helpful if folks here could suggest questions or concerns to mention to her specialists, reading/resources for a layperson, etc. If you’ve had experience taking either med, that could be helpful as well. I’m not asking for medical advice, but if you know something helpful about either drug that might aid in her decision, I’ll pass it on to her. Many thanks.</p>
<p>Warfarin has been used since the beginning of time, and is a known quantity. I would never want to be a guinea pig on a new drug like Xarelto. </p>
<p>I don’t know what major diet changes are necessary with warfarin, other than grapefruit juice and some prescription drugs. Herbal supplements are also sometimes a problem. Warfarin is metabolized by a liver enzyme called CYP3A4. If you look up CYP3a4 inducers and CYP3A4 inhibitors, the inhibitors will increase warfarin levels and the inducers will lower it. </p>
<p>Warfarin takes longer to work, but that’s the only disadvantage compared to Xarelto based on my brief review of Xarelto. My opinion is to stick with warfarin. What does the doctor say?</p>
<p>If possible, use brand Coumadin rather than generic warfarin. My family miner had really uneven pro times on generic but was fine on brand. And fwiw, a colleague, a physician, had afib and was switched from Coumadin to xarelto. He stroked out. Funeral was a month ago.</p>
<p>Thank you, collegealum! Our friend seems to think that warfarin, though slightly less expensive, will be costlier in the long run because of more MD visits for monitoring. She has insurance but is going to be out of pocket for quite a bit. I get the impression that the MD has left it up to her - here are the benefits, here are the drawbacks. I agree with you that staying with a tried and true drug makes much more sense, especially if the new drug has such an enormous drawback.</p>
<p>and jym - wow! what an awful outcome for your colleague - sorry. I’ll pass along your comment about your family member’s experience with coumadin.</p>
<p>It seems to say there is no difference in safety between brand and generic warfarin, although there can be differences in patient reaction from one kind or another (even one generic to another.)</p>
<p>edit: I’m reading more about Xarelto, and it seems like it may have a significantly larger dosing safety margin (therapeutic index) compared to warfarin, although I can’t find the actual numbers. What this means is that there is a wider range of drug concentrations which are safe. </p>
<p>While my husband was on warfarin he was able to monitor his own blood levels at home. He had a test kit and called in the results. She may want to ask her doctor about doing that. It was cheaper and far more convenient than running to the lab.</p>
<p>People often refer to warfarin as “rat poison” and badmouth it. But it actually works in rats like it does in humans - it thins the blood. Rats would die because they would overdose on the stuff and have internal bleeding. It will not hurt humans if properly prescribed and monitored. She may want to consider being tested for compatibility. My husband had a genetic factor that made the dosages hard to set - the insurance company did the DNA analysis for that at no charge to him.</p>
<p>The are dietary restrictions, mostly green vegetables and some fruits. Those can be found online and the doctor may also provide a list.</p>
<p>Can she set up a program with her doctor where he/she puts in future lab orders so she only has to stop in for a blood draw versus seeing the doctor EVERY time. If there needs to be a dose adjustment then the Dr. can call it in. You can find home blood pressure monitors like Omron online for $40-60 (I have model BP710 and it is simple to use and has been accurate) . Many pharmacies and large chain grocery stores offer free blood pressure checks) It is critical that she keeps up with monitoring her blood thinner dose. My Dad chose not to keep up with his blood checks and kept taking his high dose. The result was not good. </p>
<p>I think collegealum314 has a good point when they suggested to be aware of the inducers and inhibitors of CYP3A4. (My body does not properly metabolize some of the CYP substrates so I am sensitive to the topic)</p>
<p>Working in cardiology for years, I have never heard a mention of generic warfarin vs brand name being an issue with effectiveness. However, generic med problems can occasionally crop up, so would not rule it out. </p>
<p>Interesting about the CYP3A4. Agree about the rat poison analogy. </p>
<p>The dietary precautions with warfarin are mostly related to the vitamin K amounts in green vegetables, as Vitamin K is an anecdote to warfarin, and eating irregularly will cause blood levels to fluctuate. You can google for lists that give Vitamin K amounts in various foods. Often the teaching is done in terms of avoiding green vegetables. However dosing can be adjusted for green vegetable intake, however it needs to be consistent, with the same intake of Vitamin K on most days. A spinach salad one day a week, not so good. A daily salad, dosing can be adjusted. But even if sick, that spinach or an equivalent amount of another vegetable needs to be taken in broth or whatever, otherwise, again, blood levels will vary to excess. </p>
<p>Many clinics have an RN who runs the anti coagulation clinic, and after the lab level is obtained, by phone, dosages are adjusted without seeing a physician. </p>
<p>I don’t know as much about zarelto, but with some of the new anticoagulants, the effectiveness of the anti clotting therapy is greater than with warfarin, though am unsure of this point with pulmonary embolism. The new anti coagulants disappear from the body faster, but have no anecdote, useful for dental work or surgical procedures. Warfarin is slow to leave the system, but has an antidote in case of accident or injury-Vitamin K.</p>
<p>How long will the patient be on an anticoagulant? The dietary restrictions and concentration monitoring may be more tolerable if it is only for a couple months instead of indefinitely.</p>
<p>I’m on warfarin and will be for the rest of my life (Factor V Leiden deficiency combined with heart attack triggered by massive blockages and resulting stents). </p>
<p>I go to a local lab for the INR blood testing – they send the results to the doc and the doc/physician’s asst calls me the next day. I have a standing order for testing at the lab, though my cardiologist told me earlier this week that she would try to get me set up for DIY home testing (similar to diabetes monitoring), which would give me instant results. At the beginning, I went in to the dr’s office for the testing, which was more costly. The doctor’s office copay and lab fee was ~$45. My copay at the local lab is $2.21. Warfarin costs me $20 for a 90 day supply. It comes in 5 mg and 1 mg tablets and I have both so that we can adjust the dose as needed.</p>
<p>Once I got out of the hospital after the heart attack, we were testing my blood once a week. Now it’s once a month unless we have to tweak the dose, in which case I may go to the lab two weeks in a row. I see my primary 3-4 times a year, but never for just dealing with warfarin/coumadin issues/testing.</p>
<p>As far as Vitamin K goes, what my doc said follows GreatLakesMom’s advice – keep the Vitamin K intake consistent from day to day. My biggest issue with coumadin is that I bruise VERY easily – I get bruises and have no idea how they happened. This is magnified for me because I’m also on Plavix and 81 mg aspirin – so three blood thinners tends to have that effect.</p>
<p>I was pretty concerned about this regimen when I started – but now it’s routine. One thing I would recommend that anyone who is on warfarin should have a medical bracelet or a list of medications in his/her wallet in case of emergency. I have a list in a small pouch inside my pocketbook which lists my entire pharmacopeia, all my docs and medical history (which is long and complicated). DH carries the same list in case I am not able to communicate, and I have him listed as my ICE contact on my cellphone.</p>
<p>One thing about new drugs–they are rigorously tested by the FDA, but the populations used aren’t large enough to detect whether a small minority of people will have very bad side effects. There is no way to know until the drug is used by the general population. This is why I would avoid new drugs unless there is a good reason.</p>
<p>I knew there would be expertise here! Thank you all so much for taking the time to respond - I’ll forward this thread. I truly appreciate your help.</p>
<p>My husband was on warfarin for several years after a blood clot. When they ran a scan at M D Anderson a couple of years ago, they discovered he had thrown a clot in his lungs while on warfarin. They immediately took him off warfarin and put him on lovenox. Horribly expensive (I tell people it must be made of unicorn blood) but it had certain benefits such as less accidental bleeding, less tracking, and, the biggest benefit for someone going through extensive medical treatment, being able to stop it the day before an invasive procedure (warfarin is 10 days). After a year and a half on Lovenox, M D Anderson sent him to their blood specialist to get some tests done to see if he had to stay on a blood thinner for life. Turns out he does, but the haematologist did not want him back on warfarin. He changed him to Xarelto. Costs more than warfarin but much cheaper than lovenox. He has been on it since November. </p>
<p>We are very happy with the change. It seems like the best of both worlds between warfarin (lots of constant tracking and blood tests and he was always covered in bruises and cuts and scars from bumping into things) and lovenox (was 2 shots a day and he had a black and blue tummy and knots from the shots, plus it cost thousands). With Xeralto he does not have to have the close monitoring, does not bleed the same way as warfarin, does not have to avoid any foods, and it is hundreds rather than thousands.We do need to check with the hematologist about how to handle it with an upcoming procedure. We personally do not ever want to go back on the warfarin.</p>
<p>Tell your friend to make sure that she educates herself about the interactions associated with Warfarin or Coumadin. My grandmother died from a medical oversight while on Warfarin. She was prescribed an antibiotic that was contraindicated with the drug and we were told that the visiting clinic would increase the visits while she was on it. They didn’t and, before we were even aware what was happening, my grandmother had a massive cerebral hemorrhage. </p>
<p>I would lean towards the Xarelto. No monitoring and dietary issues go away. Huge for a 20 year old. There are still many drug interactions. Although there is no antidote for overdose it has a half-life of only 5-9 hours (body gets rid of it quickly) versus coumadin at 40-80 hours. The only real problem would be in case of emergency surgery… Coumadin is a difficult drug to dose correctly and requires very careful monitoring.</p>
<p>has anyone else heard of a cardiologist/electrophysiologist recommending taking Zarelto upon experiencing an A-Fib episode? have only had 3 episodes 4-5 yrs ago, none since. not on any anti-coagulant, other than aspirin, but doctor said here take home a sample of Zarelto and if you think you’re having an episode take a pill, as it works within an hour. </p>
<p>I am presently sitting in a continuing Ed seminar given by a professor from the school of pharmacy. He said that the 3 problematic generic versions of a med are for lithium, thyroid Meds and WARFARIN . Wellbutrin had been a problem in the past but has been addressed. There can be differences in the efficacy and side effects. </p>
<p>I just noticed this thread popping up again - thanks for resurrecting it, jym. Good point about problems with generic versions at times. You mention Wellbutrin - I always thought their commercial named the most terrifying list of side effects of any drug on TV.</p>
<p>@myturnnow - I just asked my dh, who is an MD, about xarelto for a-fib. His understanding is that one of its uses is to treat a-fib, but that it’s not meant to be taken in the way you describe (take one if you feel you’re having an episode). It’s one of those you’re-on-it-or-you’re-not meds, in his opinion.</p>
<p>This Is a fascinating presentation I am attending. Pointed out things like generics using different fillers or binders that may use different dyes, lactose, gluten etc that cause effects in patients with sensitivity. </p>