Why Warfarin, Apixaban, Dabigatran, or Rivaroxaban???

I'm at a loss to understand why GPs and cardiologists have a preference for one or the other of the anticoagulants. Warfarin is more or less understandable based on history and familiarity and ease of tracking effectiveness. It's also understandable why many patients, including myself, don't want to take it.

For me it's mainly because I don't believe my lifestyle can accommodate the strict regime of diet and testing which Warfarin would require.

The others three remain more of a mystery. My GP favoured Apixaban but didn't fully explain why, then the cardiologist switched me to Rivaroxaban based on guidelines of the European Heart Rhythm Association.

Because I also have heart disease I was initially taken off Aspirin. Now the cardiologist wants me to take aspirin again. Reason being that the action of the aspirin and the rivaroxaban is different and I need both because of the heart disease.

There was also confusion with differing views about the interaction of any of the NOACS with Carbamazepine which I have to take. The cardiologist believes, based on the European guidelines, that the Rivaroxaban is the safest option. ie: Carbamazepine reduces the effectiveness of Rivaroxaban, but not as much as the it reduces the effectiveness of the other two.

NOW, my question is

What are you taking and do you know the reasoning behind it? Has your GP or cardiologist explained why you're on that particular product and not another? And if you have heart disease are you also on aspirin?

22 Replies

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  • Can you define what you understand about or are including in the term "heart disease?" It is something of a catch all phrase that people use to cover everything from congenital structural abnormalities to coronary artery disease. The treatments can be quite different.

  • 'Heart disease' is a term my cardiologist used when explaining why he wanted me to go back onto aspirin. As far as I know, I have a narrowing somewhere in the heart where they can't put a stent, which results in me having quite frequent angina.

    This is a bit of an aside, but these days it's mostly exertional angina. However there were several years when I would wake with angina 3 to 4 times a week, at around 2am in the morning. No one could isolate the reason why. Strangely, the night time angina ceased within a short time of my AF events commencing in late 2011. I feel there has to be a connection, and I've mentioned it to a few docs but usually only get condescending smiles.

    I hope that answers your question.

  • For years warfarin was the only option as we all know and frankly I never understand this business about life style etc and I have been on it for ten years and never had a problem. According to my yellow book I am in range about 85% of the time at least and never watch my diet or make any concession to warfarin. BUT I know that we are all different and these NOACS offer many people a life line to protection which was not previously available. Warfarin and NOACs work on different parts of the clotting process by the way.

    So which to prescribe? As you mention, rivaroxaban seems to have become the gold standard NOAC and is the one mostly used in UK at least from what little I know. I think dabagtran got a bad press in USA which put a few people off.

    Aspririn is not an anticoagulant it is an anti-platelet so in simple terms anticoagulants slow the clotting process and anti-platelets make the blood flow more smoothly. If there are structural defects, artificial valves, stents or anything similar in your system then aspirin is helpful. It is not much good in prevention of strokes which is why you need anticoag but very useful in treatment of both strokes and non electrical heart problems.

    I think that GPs in UK are beginning to get their heads round prescribing NOACs and rivaroxaban in particular but local budgets and costs rear their ugly heads. My local GP friend tells me that his practice (he is senior partner) is now moving away from warfarin to rivaroxaban since they can see the long term benefits for both patients and the practice but not all GPs are so enlightened.

    Bob

  • Thanks for that Bob.

    Regarding lifestyle my GP advised me to take rivaroxiban rather than warfarin because in her opinion she thought that it would be a waste of NHS money taking the warfarin option as I like a few glasses of wine with my evening meal. She was of the opinion that alcohol would nullify the effect of warfarin and it would not be still effective as an agent in preventing blood clots (Doe's anyone know if this is true?).

    She also thought that warfarin monitoring might possibly restrict any long term travel plans which I might have made to escape the British winter

    I myself think that rivaroxiban is a better choice instead of fitting my life around monitoring

    As we all now know AF in itself is not life threatening if the clots are controlled

    So I suppose that any decision of which drugs to take depends on what type of lifestyle you want to live and what is more suitable for you personally.

    As you know everyone has their own preferences and I am just grateful to be given a choice

    Keep well everyone and I hope that everything goes well for you all and keep the positiveness going

  • I think that alcohol increases the effect of warfarin actually not nullifies it so where that idea came from is strange. One would not prescribe warfarin for an alcoholic due to the increased risk of bleeding. (not that I am suggesting that a couple of glasses of wine makes an alcoholic in which case I am.) I do notice that my INR is slightly higher in summer when I drink two glasses before dinner than in winter when I may not bother.

  • Hi Ozlinda

    There are differences between the NOACs and quite well known, there are several really good papers which have been posted here on the forum, but all of them offer slighter better anti-coagulation, and slightly less bleed risk than warfarin. The interactions with other drugs is more complex, and it seems that your Cardiologist has looked at this and plumped for Rivaroxaban. Lastly of course there is no immediate reversal agent for any of the NOACs yet, but tried and tested medical procedures.

    One quick comment if I may you say " the strict regime of diet and testing which Warfarin would require" There is no strict diet regime, simply avoid cranberry juice, and don't binge on anything, adjust warfarin to your diet NOT your diet to warfarin, yes regular blood testing, and that could be a challenge.

    Everyone has the right to choose whichever anti-coagulant they wish of course, and I support that wholeheartedley, but warfarin sometimes gets an unfair bad press.

    Lastly aspirin does have a place alongside anti-coagulants, usually when there is a presence of what I understand to be "free calcium" Not medically trained but this is like the furring of our kettles (very bad here in London) and aspirin as an anti-platelet will assist to stop the furring up of your arteries and of course preventing further heart disease. But it's very low dose, usually once a day like me, and should only be taken with an anti-coagulant under medical supervision, and never as an anti-coagulant on it's own.

    Be well

    Ian

  • Sorry, just don't agree with the last sentence of your opening paragraph. No problem with diet, I diet but it is to control my AF and nothing to do with warfarin, doesn't stop me enjoying alcohol, going out partying, travelling (to and from Oz), and at 70 I'm still working driving buses - no problems passing my annual PCV licence medical - life is as normal for me now as it was before AF and before being warfarinised !! The only concession is that I bought my own INR testing device and I test now between every 30 and 56 days.

    Also, matter of interest I don't regard AF as a heart disease, it is an arrhythmia and a medical condition.

    John

  • Thanks for your comments AussieJohn. I guess I referred to a perception I have of what would be required - which mightn't be correct. I haven't found any diet triggers for my AF, and I have no wish to make any concessions to warfarin so the NOACS seem best for me and my GP and cardiologist agree..

    Good for you that at 70 you're still enjoying life so fully. I'm 70 too now and doing the same.

    Finally, I don't regard AF as a heart disease either. Perhaps I wasn't clear in what I way saying? It was my cardiologist who said that because I had heart disease, in addition to AF, I should still take a small aspirin dose.

    Cheers, Lynda

  • Hi Lynda,

    Must say, I rather wish I wasn't taking anything at all but - well - perchance to dream :-) I've just changed medical practices and was offered a new NOAC but declined gracefully. I do understand the difficulties warfarin poses for many, many people and its great that this lifeline is now available to those who need it - can only imagine how much it does to restore a degree of quality of life compared to the stresses and dramas associated with warfarin.

    70 eh ! its a magic time of life I reckon and am glad too that you are enjoying yourself - great. I can't wait for the weather to warm up so I can get out on Cornwall's South West Path ... I'm afraid I'm a fair weather walker. Spent too long in the heat down under, can't stand the cold.

    Enjoy yourself.

    John

  • The cold of Cornwall sounds hard to take, I've got to face Canberra weather for a while in June and not looking forward to it at all. My home base is Bundaberg now - reportedly the 4th best climate in the world :-) Hope to make a visit to the UK next year so I'll have to research the climate to find a good time.

    Keep enjoying your fitness and keep travelling as much as you can.

    Lynda

  • I take rivaoxaban as that was the drug of choice at my local health trust at the time I was told. I understand they now use Apixaban quite often too. I am happy with the Rivaoxaban two years in.

    Dee

  • Please can we define 'disease' and 'condition'? Pendantic but vocabulary is important.

    A disease is a particular abnormal, pathological condition that affects part or all of an organism. It is often construed as a medical condition associated with specific symptoms and signs.[1] It may be caused by factors originally from an external source, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune diseases. In humans, "disease" is often used more broadly to refer to any condition that causes pain, dysfunction, distress, social problems, or death to the person afflicted, or similar problems for those in contact with the person. - Wikipedia

    If that doesn't confuse you - I think of disease as 'dis-ease' - which is literally the root of the word. Condition is a general word used to describe a present state of fitness - good condition, poor condition.

    To me the terms are completly interchangeable and it seems the medical fraternity have no precise definition of disease that I can find, please correct me if you can.

  • Totally agree with this one. The structural heart abnormality that I was born with is classified as a disease by some (congenital heart disease). For over 50 years it caused no problems at all, was asymptomatic and did not progress. Doesn't fit into the wikipedia definition.

    To my mind, a disease is something that's acquired. It is often used in a perjorative sense. People born with cleft palate or club feet aren't classified as having a disease, just because they have a birth defect.

  • G'day CDreamer,

    Yes, I was across the dis - ease bit from other readings. When admitted to A & E and diagnosed with AF I was kept in until all manner of tests including ECG and ultrasound my Cardio guy said no sign of heart disease, no other problems, no issues with arteries, some minor change to left /right atria (can't remember now which one). So no disease may well be supported for my case because my heart reverted to NSR on its own when I presented for cardioversion. Ablation was discussed at a later time but I rejected it unless as a last resort instead went for the diet option and medication to control AF - which has been successful. So, that's where my words came from, my cardio guy. So I can't really help with correcting you.

  • That's interesting CDreamer. When I was diagnosed with hypertension 2 years ago and was very cross at the idea of having to take medication at all, let alone for life [I was 70 at the time] my dr, trying to pacify me somewhat, said to think of hypertension as a 'condition' - not a disease. Never was quite sure what she meant!

  • Hi I'm 46 have ischaemic heart disease ,coronary stent and am on aspirin for this,I am on warfarin for my AF as the EP prefers it to the NOACs as the he feels there is still a lot unknown regarding their interactions with aspirin and he feels warfarin is more suitable for me because of this . He wanted me to continue my aspirin because of my heart disease. x

  • Thanks everyone for the replies. I can't comment on the dis-ease discussions, other than to say I certainly didn't mean to suggest that my AF was a disease. The disease reference related to other problems I have which caused the cardiologist to recommend aspirin, as well as the rivaroxaban I'm now taking for the AF.

    The other comments were informative and thought provoking. There's obviously few hard and fast rules, and many differing opinions in the medical fraternity about these drugs. My GP probably summed it up when he said we're sailing unchartered waters.

    Which got me thinking about other analogies. How about this :-)

    The AF patient is on the river bank. Behind him/her a big crocodile is coming out of the water. Ahead is a mine field. Standing by is an EP, several cardiologists and several GPs. The EP says 'don't worry about the mine field, I can shoot the croc'.

    The cardiologists and GPs say not to depend on the EP, he sometimes misses, so best to start across the mine field. Then they all make different suggestions about which path to take. :-)

    Seriously, I know it's a hard job to weight up the risks and benefits. We've already got examples just in this short discussion of one specialist (mine) who thinks it's best to take aspirin with rivaroxaban if the there's concurrent heart disease, and another (basia12) whose specialist opts for warfarin and aspirin because he believes there's too much unknown about interaction between the NOACs and aspirin.

    The main thing I've felt very grateful for is that my GP and specialists have mostly been prepared to explain and discuss their sometimes differing viewpoints. And I'm grateful for the wealth of information sources on the internet, including this forum. At the end of the day it's ME who makes the final decision about what medications I use.

  • LOVE that Lynda. Some years ago at one of our conferences a doctor was talking about a patient making the choice for ablation and using the same idea said that if you were being chased by a lion towards a river full of crocodiles there came a point when the crocs looked the best bet.

    Bob

  • It is simple the guidlines I am told is warfarin in the first instance it is the cheapest despite adding the costs incurred for monitoring. I didn't want it either because of taking time off of work especially when you first start taking it as visits are more frequent. However the deal I made with my gp was I would try it and now I go every two months as my inr is steady. Also I like the fact that I am being monitored unlike the new drugs which are not. The convience of the new drugs I agree are fine but I eat what I want avoid cranberries but still have vegrtables. I am happy to forfeit that to know I have protection. Hope that helps chris

  • Can I ask what it is about cranberries that makes them incompatible with certain medicines?

  • When going for my start on Warfarin the lead coag nurse told me that a recent study in the US came to the conclusion that cranberries are not a no no. However there are other studies that say cranberries (in any form) are a NO. NICE however still say NO cranberry. Don't know who is right but not taking any chances (even though I love cranberries)!!!

  • Hi There. I have just started Riveroxiban this morning and I also have heart disease. I was already taking aspirin and the gp decided to leave me on it along with the riveroxiban. If I understood him correctly it is because one covers for stroke and the other covers the heart. I think that, like you I am also on other medications and this must give some GP'S problems when they are making your medication "fit". Bob

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