After a clot you have a number of anticoagulants available for treatment.  Currently, there are three anticoagulants that are approved for the treatment of pulmonary embolism and deep vein thrombosis.  These three medications are Lovenox (enxaparin), Coumadin (warfarin), and Xarelto (rivaroxaban).  This article will review what I know about each medication.  Remember to discuss all of your options with your doctor.

Medication Descriptions:
Coumadin is the oldest medication on the list.  It blocks vitamin K.  Each person needs a different amount of Coumadin to achieve a safe range of medication.  This amount of medication changes daily based on diet and other medications.  Patients must eat a consistent amount of vitamin K daily in order to have the right amount of Coumadin.  This medication is very picky.  Too small of a dose raises the risk of clots and too high a dose raises the risk of a bleed.  Because the dosing must be very precise in order to be safe and effective, people who take Coumadin must have routine blood tests.  These tests may be done at home by working with a doctor to purchase a home testing machine or they can be done at a doctors office.

Lovenox is an injection that can be given at home by the patient.  It is self-injected into the fat around the abdomen.  Typically patients will do injections twice a day.  Lovenox doses are much more consistent from patient to patient.  For this reasons you will not need routine blood work done while you are on Lovenox.  Lovenox is much more expensive than Coumadin, but you will not have to pay for weekly blood testing.  Lovenox has no dietary restrictions.  You can eat a massive salad one day and no vitamin K containing foods the next day without having to worry about your medication levels.

Xarelto is the newest of the approved medications.  It is an oral medication.  It has no dietary restrictions.  It also is very consistent from patient to patient so it doesn't require routine blood work.  As it is new, there are no generic versions of this medication.  Payment assistance can be found on the manufacturer's website.  Like Lovenox, Xarelto has no dietary restrictions.

Effectiveness of the Different Anticoagulants:
Studies have shown that all three medications are about equally matched in effectiveness when they are used as directed.  As directed is very important to note.  If you are prone to missing doses, the newer anticoagulants aren't for you.  The new anticoagulants must be taken more frequently and they leave your body quickly.  Missing a dose of medications like Xarelto will put you at a high risk of clotting. Coumadin has similar problems.  If you can't maintain a high enough level of Coumadin, you risk a clot.  If you don't feel that you can track your vitamin K intake or if your INR test results are showing a lot of fluctuations, you may want to ask your doctor about switching to a different medication.

Bleeding Risk:
Coumadin can have a high risk of major bleeds if the blood levels are not kept within range.  This risk goes up with age and with certain health conditions.  Out of the anticoagulants, Coumadin has the highest risk of cranial (head) bleeds.  Coumadin takes 5-7 days to leave your system completely.  If you start to bleed or need surgery an antidote will be needed.  This can cause problems.  Luckily, years of use have established many FDA approved means of reversing Coumadin's anticoagulant effect.

Lovenox has a similar risk of bleeds.  It also takes a number of days to leave the body.  For this reason it should not be used before surgery.  Lovenox also has a number of FDA approved antidotes to reverse bleeding.  Diet and dosing will not impact the bleeding risk.  The biggest risk of bleeding on Lovenox is caused by heparin-induced thrombocytopenia.  If you have ever had heparin-induced thrombocytopenia let your doctor know immediately.

Xarelto has a much lower risk of cranial (head) bleeds than the other two options.  It does carry a higher risk of stomach and intestine bleeds.  Other bleeding risks are the same whether you take Coumadin, Lovenox, or Xarelto.  Xarelto leaves your body quickly.  This can help in a bleeding situation.  Currently there are no FDA approved methods of reversing Xarelto.  There are some unapproved methods that can be used to reverse bleeding.  The FDA is reviewing some possible methods of reversal so there may be an antidote in the near future.  If you are having problems keeping your INR in range, Xarelto may put you at a lower risk of a major bleed.

Other Side Effects:
Everyone's body is different.  You may find that your have side effects other than a bleed.  If you are having something happen that is uncomfortable or unfamiliar I highly recommend talking to your pharmacist and medical team.  Switching medications may make you feel a lot better while keeping you safe.  If you switch and the symptom hasn't gone away, talk to your doctor as you may have another health problem that needs to be addressed.

Other Things to Continue:
If you have other health issues let your doctor know.  Pregnancy, cancer, kidney or liver problems, and other health issues can change which medication is recommended for your situation.

Anticoagulants are a life saving class of medications that can help you to survive blood clots.  When used correctly they are very safe.  Very few people will have a life threatening bleed.  For most people the risks of a clot far outweigh the risks of a bleed.  While you will hear law firms advertising law suits against the newer anticoagulants, they are proving to be very safe and effective medications.  Your doctor can review your options with you.  Ask lots of questions and feel free to ask multiple pharmacists or doctors.  These professionals are the best source of information about medications.

Many supplements interact with anticoagulants.  These reactions may make the medications less effective or may increase the risk of bleeding.  This post has links to places where you can get information on drug/natural supplement interactions.  Make sure to check for interactions, talk to your pharmacist, and talk with your doctor before adding or removing supplements from your treatment plan.  This will help you prepare for possible problems.

From Health Notes:

• Warfarin (Coumadin)
• Lovenox
• Heparin
• Xarelto

Other reliable references:

• The Mayo Clinic
• Medline Plus

Today, we will learn about some of the risks of natural medications and supplements.  Before we get to that topic, I want to review the answers to the questions that I posted in the last entry.  Let's review the different mystery substances:

Substance #1 is warfarin (coumadin).
This substance was discovered when a farmer noticed his cows were bleeding more than a healthy cow should bleed.  He did some research and found out that the cows had consumed a large amount of a certain plant while munching the grass in their pasture.  This natural substance is very effective at preventing clots and is still used for this purpose to this day.

Substance #2 is water.
This substance is fine when taken in certain amounts.  It is very effective in preventing clots and often recommended by doctors.  If the patient takes too much of this substance he or she will suffer muscle contractions, headache, seizures, nausea, and unresponsiveness.  If this overdose is not addressed, it will lead to coma and death.

Substance #3 is aspirin.
This substance is starting to show promise as a means to prevent pulmonary embolism.  Although the research is conflicting, some doctors are recommending that patients use this substance.  This substance increases the risk of fatal bleeding.  Other side effects of this substance include vomiting, stomach pain, hives, rash, facial swelling, difficulty breathing, fast heart rate, fast breathing, clammy skin, loss of hearing, and death.

As you can see, anything that you put into your body can have side effects.  It doesn't matter if the substance is over the counter or if it is a prescription.  As a patient it is important to read the labels and talk to medical professionals.  For natural substances you will need to dig a little deeper to find information.  It is much more difficult to find the side effects profile of natural supplements.  When the information does show up, it is even more difficult to know if you can trust the source.

Some Supplements Are Dangerous
Although many sources will tell you that supplements have no side effects because they are not medicine, this is not the case.  Supplements are medicine and they do have side effects.  In the last two weeks articles have come out about the dangers of some very common supplements.  I wanted to share this information because the dangerous supplements are often used by blood clot patients.

Fish Oil May Cause Bleeding And May Increase The Risk Of Aggressive Prostate Cancer
While we often hear that omega fatty acids are healthy, research is beginning to show that they may only be healthy when they are consumed as fish rather than fish oil.  The UK Daily Mail  reported on July 10, 2013, that omega-3 fatty acid fish oil supplements may increase the risk of aggressive prostate cancer by 70%.  Aggressive prostate cancer is fairly rare, however, if you are male, you may wish to reconsider using fish oil as a post clot preventative.  Another problem with fish oil is that it does not mix well with anticoagulation therapy (blood thinners).  If you are on anticoagulation therapy, fish oil raises the risk of suffering a major bleed.

Supplements That Increase The Risk Of Bleeding
Supplements can change how the liver creates and processes blood clotting enzymes, change ow much vitamin K is in the body, reduce platelet counts, or decrease thrombin effectiveness.  All of these effects can increase the risk of bleeding, especially if you are on anticoagulation therapy.  In 2010 a study of 100 common herbal remedies was conducted.  It found that 69 out of 100 of the remedies affected how warfarin worked in the body.  If you are on anticoagulation please talk with your pharmacist and physician about mixing herbs and supplements with warfarin.  Here are some of the most common natural supplements that significiantly raise the risk of bleeding and of requiring a blood transfusion:

• Ginko Biloba
• Ginsing
• Garlic
• Fish Oil
• Dong Quai
• Feverfew
• Chamomile
• Ginger
• Nettle
• Cayenne Pepper
• Bromelain

References:
Macrae, F. (2013, July 10). Taking omega-3 fish oil supplements may increase the risk of aggressive prostate cancer by 70%. Mail Online. Retrieved July 17, 2013, from http://www.dailymail.co.uk/health/article-2359466/Taking-omega-3-fish-oil-supplements-increase-risk-aggressive-prostate-cancer-70.html

Story, C. (2013, July 10). Could the Herbs You’re Taking Cause Life-Threatening Bleeding? Renegade Health. Retrieved July 17, 2013, from http://renegadehealth.com/blog/2013/07/10/could-the-herbs-youre-taking-cause-life-threatening-bleeding

U.S. National Library of Medicine. (2012, July 23). Fish oil: MedlinePlus Supplements. MedlinePlus. Retrieved June 3, 2013, from http://www.nlm.nih.gov/medlineplus/druginfo/natural/993.html

Student teaching is over and I am finally getting back to this website.  I want to start by taking a moment to welcome all of the new Clot Spot readers.  Today I want to talk about a new article that was just added to The Clot Spot.  Today I wrote a lengthy post on natural alternatives to warfarin.  It can be found here.  I wrote this article because this is something that feel very strongly about.  I use natural medicine for my migraines under supervision of my doctor.  The supplements were carefully chosen and well researched.  I take them, not because I am afraid of pharmaceutical preventatives, but because those preventatives simply did not work for me.  Before I started taking them, I did a lot of research.  I wanted to know what side effects might occur due to these supplements.  After understanding my risks, I started the supplements.  

I strongly encourage all of you to do this research for both pharmaceutical and natural treatments.  Some natural treatments are more harmful than you can imagine.  There are no requirements for supplement companies to run a disclaimer on their ads or their bottles.  These companies even try to market supplements as a "drug free" alternative.  Natural supplements are drugs.  They have side effects.

I have chosen not to use supplements that will change how my blood clots.  Some of you may choose a different path.  I do not trust my blood to unregulated supplements.  Many of us struggle with different brands of warfarin and those variations are less than 4%!  If 4% bothers your body, imagine what an unregulated variation may do to your body.  Bleeding and clotting are important.  I want to know how much of a substance is in me.  Those natural supplements are chemicals and I want to have them carefully controlled.  I do not want to bleed to death or clot due to variations in dosage.  Also, I want a medication that is well tested.  

Recently, I read an interesting article on this topic at Slate.  I highly recommend it.  It got me thinking a lot about our fear of "chemicals" and "drugs".  

With that article and my recent addition to The Clot Spot, I want to play a guessing game.  I will describe three common substances that can be used to prevent clots; you will guess what they are.  Please leave your guesses in the comments.

Ready?

Substance #1:
This substance was discovered when a farmer noticed his cows were bleeding more than a healthy cow should bleed.  He did some research and found out that the cows had consumed a large amount of a certain plant while munching the grass in their pasture.  This natural substance is very effective at preventing clots and is still used for this purpose to this day.

Substance #2
This substance is fine when taken in certain amounts.  It is very effective in preventing clots and often recommended by doctors.  If the patient takes too much of this substance he or she will suffer muscle contractions, headache, seizures, nausea, and unresponsiveness.  If this overdose is not addressed, it will lead to coma and death.

Substance #3
This substance is starting to show promise as a means to prevent pulmonary embolism.  Although the research is conflicting, some doctors are recommending that patients use this substance.  This substance increases the risk of fatal bleeding.  Other side effects of this substance include vomiting, stomach pain, hives, rash, facial swelling, difficulty breathing, fast heart rate, fast breathing, clammy skin, loss of hearing, and death.

I will be back on to share the answers in a few days.