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Choosing Your Anticoagulant

8/16/2015

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PicturePrescription pill bottle by francesco_rollandin at openclipart.org
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.

3 Comments

Drug Interactions

7/17/2013

3 Comments

 
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
3 Comments

FAQ: How Can I Find The Best Price On A Prescription Medication?

1/19/2013

0 Comments

 
It is common knowledge that certain prescription medications are very expensive.  This is especially true if it is a newer medication or if it doesn't have a generic form.  This doesn't mean that generics are always easy on the pocket book.  Generics can run high as well.  So, how can you find good prices on medications?  What are your options?
  1. Tell your doctor that you need financial help.  Doctors often have samples.  With all of the new anticoagulants on the market, you may be lucky.
  2. Ask your doctor about manufacturer low income programs.  Most manufacturers have some type of financial aid available for those without insurance.
  3. Ask about generics.  Generic warfarin is VERY inexpensive.
  4. Try good old fashioned warfarin rather than newer medications.
  5. While buying from other countries is illegal, the U.S. typically overlooks individuals who purchase abroad.  Make sure that your pharmacy has some accreditation and that they have a real pharmacist that requires a prescription from your doctor.
  6. If you are in the hospital, a social worker may be able to help get that Lovenox prescription filled. When I was being discharged, a social worker came and got my insurance info to confer with my insurance about how I was to get Lovenox.  I didn't have to do a thing.
  7. Write an appeal to the insurance company.
  8. This is my favorite!  Use one of the new, Internet price comparison sites.  I use www.goodrx.com for migraine medication when I have hit my insurance company's maximum for the month.  I have seen the price go from over $200.00 to around $35.00!  They show the prices in your area and provide discount coupons if needed to get the price.

Here are some other interesting thoughts on prescriptions for pulmonary embolism treatment for you. Some people will find certain brands of a generic medication to work better for them.  If this is the case, your doctor can specify on your prescription to ONLY give you a certain brand or to give you any generic BUT a certain brand.  I do that with my Wellbutrin generic.  It was much easier ad cheaper than fighting to use name brand Wellbutrin.  The brands are listed on your prescription bottle or you can often look up a pill online using a search engine and the pill's label, number, color, or markings.

If you need brand name Coumadin or you need another medication like one of the newer anticoagulants and your insurance won't pay, first have your doctor's insurance representative call to ask for an override based on medical need.  If that doesn't work, ask your insurer for the address of the appeals department and write the letter.  Your doctor can help you to make sure you have a solid, well informed letter.
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