Anti coagulation.

[Janna501]

I have yet another question please ! My diagnosis is paroxysmal A fib. Even so , I'm on 20 mg of Rivaroxaban daily. Looking this up, I understand that it protects me from stroke, but also comes with a high risk of internal bleeding, and as yet there is no antidote. Is this essential even though I'm not in permanent A fib ? I read that , while on this drug, something like a car accident or a fall could be fatal. Your opinions please ?

[BobD Volunteer]

Sorry but scare stories do not help anybody so be careful where you look for information.  AF Association website has medically sanctioned information you can trust. . The  truth is that all anticoagulants make blood clot more slowly so they do not as is so often wrongly stated "thin " the blood.  You can't just leak blood in other words but need an injury. Rivaroxaban has a very short half life, i e. it only lasts a short time in your body, say 12 hours which is why you take it twice a day. In the event of an accident there are ways to deal with bleeding such as cell packing transfusions so lack of an antidote is a non event in reality. I hasten to add that when these new drugs first came on the scene I was quite sceptical but the more I researched the more comfortable I became.

Moving on to the question of do you need it? YES. If your stroke risk has been assessed that you need an anticoagulant. the number of times or the length of AF events is not relevant. You have AF therefore you have a stroke risk. Many people who think they only have a few events find that monitoring shows them to have many more than they are aware of and lots of people do not have symptoms and are quite unaware that they have the condition. 

Hope that helps.

Bob

[Janna501 in reply to BobD]

Thank you so much for that Bob, very reassuring,I must say I was getting anxious all over again after what I read, what a minefield this is ....

[caznear68 in reply to Janna501]

Me to Janna501,in the same position as you and about to start rivaroxaban. Had PAF since I was 39 now 67,hate taking meds of any description, Like you, Bobs comments have helped, you are not on your own with the anxiety ,probably half the problem!! take care

[Janna501 in reply to caznear68]

 Thank you for that. You're right about the anxiety, I hope I can get a handle on it , but right now it seems to have taken over my life.

I'm still dithering on whether to go on holiday ! Stupid ....

[caznear68 in reply to Janna501]

oh dear me too, suppose to be going to Teneriffe in 5 weeks, dopey we are don't you think? Not much help to you so sorry for that!

[Janna501 in reply to caznear68]

Yes we are .. I think maybe we need to re read all the positive posts that have been made ..

[Mrspat in reply to BobD]

Rivaroxaban is once a day Bob.

[BobD Volunteer in reply to Mrspat]

I stand corrected on that as I have  never needed to take it being extremely happy and stable on good old fashioned warfarin but everything else is true.

[Kodaska in reply to BobD]

The half-life of rivaroxaban is 5-9 hours in healthy adults age 20-45.  Multiply by 5 and you get the time it takes for the drug to clear your system.  So for this one, it takes 25-45 hours, or 1-2 days.  That is, indeed, a short time, but not when you're bleeding.  That, and the fact that there's no antidote, is why I declined my cardiologist's suggestion to take it.  To each his or her own choice of risk.

[Janna501 in reply to Kodaska]

I appreciate your decision , but aren't you bothered about your great risk of having a stroke ? 

[Kodaska in reply to Kodaska]

While I had active paroxysmal AF, I took Eliquis (apixaban), swallowing those overpriced bits of gold ($23 each, or $47 per DAY) as prescribed.  After my ablation last May, I continued to take it and then after about 6 months, having had no breakthrough arrythmias, I rebelled against the cost.  My cardio suggested Xarelto (rivaroxaban) and when I looked into it, I decided I'd rather take my chances with a stroke than with a bleedout.

My CHADS risk of stroke without an anticoagulant was 2.2%, and with it, 0.8%.  To me, that's small vs. very small, and not particularly compelling.  Then it struck me that the CHADS scores are for people having arrythmias.  No fib, no CHADS score, no need for an anti.

So my situation is different.  My comment above about half-life has to do with the consequences of a bleedout, not the wisdom of taking an anticoagulant.

[PeterWh]

Agree with everything BobD has said.

In addition even if Someone is NOT taking an anticoagulant and they have a major bleed the medics have to stop the bleed by other means - I've the natural clotting process will not work. Those same processes are used on those taking an anticoagulant.

The question of an antidote is a red herring in almost all cases because even though there is an antidote for warfarin it is NOT carried by paramedics in an ambulance nor is it carried in A&E. As one EP said it could take them 2 to 3 hours to get the antidote in which case it would be too late anyway. Also if a blood transfusion is given then that reduces the effect of the anticoagulant.  

[Janna501 in reply to PeterWh]

Thank you also for replying, I'm receiving so much more information and encouragement from this forum than anywhere else ..

[MarkS in reply to PeterWh]

Hi Peter,

Octaplex (Human Prothrombin Complex) which almost instantaneously reverses warfarin is carried on all London Air Ambulances and all rapid response vehicles.

Mark

[R1100S1 in reply to MarkS]

Unfortunately not all of us live in areas with that sort of cover. 

[Kodaska in reply to PeterWh]

Two to three hours sure beats one to two days!

[Beancounter Volunteer]

Hi Janna

BobD has given you loads of great information, just one small correction, you probably take rivaroxban once a day, (it's the others you take twice) and should be with food.

In terms of a reversal agent, it is correct there is not one licensed yet, but it's on final approval with the FDA in the USA and I am told might be as early as this summer for approval.

In terms of the bleed risk, as people have said there are alternatives to the reversal agents, but regretably you need to focus on the 5 times greater risk of stroke that having paroxysmal AF give you and they are the worst type of strokes as well, all anti-coagulants are a matter of balancing risk of bleed versus risk of stroke for us. Thousands of us are on anti-coagulants, the the stats say the benefits outweigh the risks.

Be well

Ian

[Janna501 in reply to Beancounter]

Thank you for that , and yes , I'm on once a day Rivaroxiban . 

[Alemo27 in reply to Beancounter]

Hi Beancounter 

You and Bob seems to give more info than the doctors.Thank you.My question is about reversal agent, that might be approved soon by FDA. as you said. Where have you got this info?

I have PAF for many years, that "come and go " before I have started to see  cardio doctors. I have been adviced to take bisoprolol,  though my BP always norm. Than was added Xarelto, that has been  switched to Apixaban after ocassional little noce bleed.The anticouggalant must be taken, as Dr.said,to reduce risk of stroke.

Than was added   Amiodorone, that has been replaced on Flecidiane.

.It  suppose for AF prevention.Do not effective.it  does not stop AF ,but produce prearrythmia,I think.

When I feel the heart palpitations started, I usually take Bisoprolol , and if  is not help, take Flecidiane 50mg. Still the AF continue sometimes for a few hours before stop,and  following weakness. Therefore, I am very reluctant to take Flecidiane,providing those  precaution ,that described  by pharm.

Well, should we  wait for reversal agent?

Thank you 

[Beancounter Volunteer in reply to Alemo27]

Hi Alemo

Can I sart with the last question, should you wait for the reversal agent, absolutely NOT.

There are many hundreds of thousands of us out there on Rivaroxyban and Apixiban, two of the new anti-coagulants which do not currently have licensed reversal agents, the whole point is risk mitigation, and the risk of stroke much much outweighs the bleed risk in AF (for most of us and they would tell you if this was not so) so you must be anti-coagulated NOW.

Re the trials, you can google it yourself if you wish, there are at least 3 drugs vying for the market, here is one of them

reuters.com/article/us-heal...

Take those anti-coagulants please.

Be well

Ian

[Alemo27 in reply to Beancounter]

Thank you very much, Inna

[Buffafly]

I hope not, I had a fall in the street today! I spent a happy (hoho) evening in A&E, two x-rays later I am home with some painkillers and a leaflet on head injuries. My cheek, chin and several other parts of my body are turning purple. I guess this is a downside of Rivaroxaban? I must admit to feeling a bit nervous now.....

[EngMac]

Look at post a day ago called "Issues in Anti-coagulation: Managing the Flow".   You will need to log into Medscape to be able to read it.

[Lainie2875]

Trust me you need it, I too have PAF and was taken off anti coagulants which resulted in me having a heart attack!!!! I will take them for ever now happily.

[Janna501]

Glad you are ok. Having read more too, as suggested, it does seems that the benefits are great, but the risks real, until they find an antidote .Will have to unwrap myself from the cotton wool that some of the information makes me want to wrap myself up in ! As a newbee Afib member, I can see I've a way to go before coming to terms with it all. As all you lovely people have said , I must'nt let it rule my life --- not there yet !

[Beancounter Volunteer in reply to Janna501]

Hi Janna

Don't get too hung up on the reversal agent (I know they call it an antidote but anti-coagulation is not snake bite).

As someone has very helpfully posted here, the only time that you are likely to have need of the reversal agent is in a very bad trauma situation, such as a car crash. The risks are really not high at all, although obviously higher than someone without AF.

But they are nothing like the 5 times greater risk of stroke of you have AF, and that's the very worst strokes as well that will either kill or vegetate.

Be well

Ian

[Janna501 in reply to Beancounter]

Thank you for that, it makes sense .

[Paddinton]

Make sure the Patient Alert card is always easy to find for emergency services, just in case

[Janna501]

Yes, I have that , thank you 

[Alan_G]

I had a long chat with my GP about this and it cleared it up in my mind a bit, I believe. Basically, what I understood from it that the risk isn't so much the bleed itself as the body's ability to 'fix' it before it does damage. Being on the anti-coag doesn't increase the risk of a bleed, you will get that if you are inclined, irrespective of whether you are on anti-coags or not. It is the fact that if the bleed does occur, it will continue to flow rather than 'fix' itself. At least that was my understanding of what was said.

[Jfjfern]

Hi everyone I'm 42 year old female should I be on an anticoagulant ? Nobody has ever mentioned this to me before. 

[Elbows in reply to Jfjfern]

Yes, if you have AF and you score on the chadvasc scale taking into account any hasbled readings re risk of a bleed on anti coagulants. Best read up the material on the AFA site and discuss with your GP.

[Bagrat]

caznear68  Janna501   I understand your anxiety about hols but both my husband and I have AF his is permanent and he  has no symptoms, mine Paroxysmal but well controlled. Husband had one episode over fifteen years ago and got no treatment as it resolved spontaneously. A couple of years back he went into AF while we were on Lanzarote on a Friday night. The treatment he got was fantastic including 24 hour holter monitor clexane injections ECGs and echo all on Sat or Sunday so we could fly home on the Monday. The consultant did the echo herself. I hope this positive experience of Spanish hospitals reassures you.  We are on the old fashioned warfarin so I was able to email the manager of the apartment when we returned last year and find health centre that did INR tests if needed which are free on production of EHIC card.

[Janna501 in reply to Bagrat]

Thank you for that, very encouraging .

[caznear68 in reply to Bagrat]

Thanks for those encouraging words Bagrat.