"pill-in-the-pocket" use of anticoagulant - AF Association

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"pill-in-the-pocket" use of anticoagulant


Preliminary research the "pill-in-the-pocket" use of anticoagulant for people with AF. I guess we can forgive journalists for calling anticoagulants "blood thinners" - but it is amazing this research made it to mainstream media. There was no control group, and the study involved only 100 patients over just 18 months. Participants were also a fairly select group of AF patients (age 45-78 with "significant stroke risk" who monitor their pulse very diligently). It is encouraging that not a single participant in their study had a stroke using this treatment approach, but it's also hard to draw strong conclusions given the very preliminary nature of the research - let's hope to see more substantial studies in future. I do find it interesting that this treatment option is being investigated, though, as it's precisely the approach my own electrophysiologist recommended for me several years ago - 



33 Replies

To me this would be like sleeping out next to the open stable door, ready to close it if you hear the horse bolt out!

Pill in the pocket for drugs like flecainide - fine.    I get an AF episode and flec stops it.  

But anticoagulants?     I get a stroke and ...........too late I would think.

For me this survey shows how effective NOACs are, protecting the plucky 100 for the most likely time they would have a stroke - ie during an AF episode.    But risky nevertheless, I would have thought.


I agree completely with ACN above. People will do anything for a grant and such reports are in my view dangerous as they encourage some already misguided people to risk their future.  Maybe of we did have some moderation on this forum these sorts of posts (the original one yesterday) may not make it into our impressionable minds.

notkidding in reply to BobD

Not a fan of "moderating" (censoring) differing points-of-view on the forum; rather, let's have the different views - with possible associated risks/benefits - and then each adult on the forum can decide what he/she will do.

Kodaska in reply to notkidding

Agreed.  The tone here is refreshingly respectful, with only the slightest flaming, and that rare.  Off-topic posts can be surprisingly helpful, though not in keeping with the stated purpose of the forum.

This worries me. As I can wake up in AF it is obvious that I don't know when it starts. I was fitted with  a 7 day monitor, that sort that works all the time so you don't have to trigger it. It showed that I had a 36hr episode which I didn't know about as I had not recorded anything in the event diary. 

I'll stay with the 2x daily Pradaxa.

Hennerton in reply to jennydog

Jennydog, I don't imagine you would be assessed and offered this type of treatment in the first place. Surely patients would be selected for it, depending on the type of AF they have? Seems reasonable to me that someone with a once or twice a year AF could benefit from this method.

I'd also like to add that the danger of the stroke is when you are back in NSR after an AF episode because that is when the blood starts to flow normally again and when any clots may decide to start their journey.

PeterWh in reply to Alan_G

Don't know where you got this from but it is contrary to what I read about a year ago. That said if there is a clot in the heart then it can be ejected whether you are in AF or flip back into NSR. It can be released from the pool as or soon after going back into NSR so it is theoretically possible that the number of occurrences could be slightly higher but there's no research that I have to support this although my gut feeling is that this the case  also need to remember about the atrial appendage's contribution and affect.

A logical thought is that if a very small clot does form in the heart then, if it is not ejected because of pooling, the clot could become bigger.

Alan_G in reply to PeterWh

You just seem to be echoing what I said, but in more detail.

Ialla in reply to Alan_G

This is what my EP told me.

It seemed to me that the participants had infrequent episodes or had had ablation so I do think this research may be of interest long term but comparisons are required so it does seem very loose research.

One of the reasons that there may have been a lack of control group is that I doubt whether they could have had a high risk group and got the study past an ethics committee for not offering any treatment, which leaves the only comparison to be that of those taking daily ACs.

After reading Malcom Kendrick's 'Doctoring Data' I have become very cynical about research studies so agree with Bob regarding chasing grants and I think peer pressure to 'get published' is also a strong incentive.   

I am also interested that it seems to me that the US seems much less likely to prescribe ACs anyway than in the UK & Europe - anyone have any ideas as to why?  (Bob?)  I always had the impression that US leant toward over prescribing and were risk averse so if stroke risk is so increased with PAF then how come asprin is still advised on US version of AFA?

BobDVolunteer in reply to CDreamer

CD I suspect that the sad matter of ambulance chasing lawyers so prevalent in USA means that doing nothing is often safer (financially) for the doctor  than prescribing what could be termed a dangerous medicine.  Couldn't possibly be right though could I?

I am in US. My first (and soon discharged) cardiologist told me just to stay on aspirin. But when I saw another cardiologist, was immediately put on AC. There are constant TV and other media ads for AC here.

As a frequent visitor to the US I am familiar with the advertising but that makes even more intriguing that there doesn't seem to be the take up in the US, but I was also aware of the ads for class actions against NOAC manufacturers which abounded when I was last there in 2014, just after I started taking Dabigatran.  I did wonder if the class actions effected prescribing in the US for the NOACs but that wouldn't really explain the difference in medical advice on the web-sites regarding recommending anticoagulation for AFers and the difference between medical opinion between Europe & US?

As you are probably aware, TV advertising for prescription drugs is strictly prohibited in the UK, which in many ways is a good thing but I have to say I learned quite a lot from those ads and it prompted me into doing quite a lot of research!

Not sure which US groups you believe are recommending aspirin? All the major groups I follow recommend warfarin and other AC, using the CHADS or whatever it is called formula. 

AFA - US site was the one that surprised me the most, the impression I had was there was very mixed opinion, so glad you have a good advisory group.  

It is also reading posts on this site, hopefully things have changed now.  

mumknowsbestVolunteer in reply to lorna-doone18

Aspirin is not recommended over here in the prevention of af strokes. 

Very interesting read I will keep an open mind who knows what the future holds for anticoagulant treatment it wasn't that long ago that the new NOAC'S were shunned.

A very interesting concept althought I have travelled in my time from Warfarin to the more modern drugs and back to Warfarin, which I am delighted to confess has served me very well over the years. If I was to make a comparison to a Pill in the Box method, I'm not sure. Having Warfarin in ones system, is like having petrol in the car as opposed to carrying it around in the boot in case it`s required. 

Have a good week. 



I have only had PAF 5 mo, was on low dose sotalol, which left me bradycardic, fatigued and occaisionally dizzy. Finally sought a second opinion and saw an EP as my cardiologist would not consider alternatives. EP explained with my sick sinus node, I might b better off doing pill in pocket with flecanide and metoprolol and life style changes( good diet and drop 40 lb). Ive been drug free 4 days so far(a little scary) but so far so good. I listen to my heart twice a day and its regular. When I have afib its bery pronounced, like gymnastics in my chest so Im comfortable recognizing its presence. This is first time in 5 months I have felt like my old self, praying this is successful. If now, he said flecanide would be daily. Sorry this is so long😉

PeterWh in reply to Hidden

But you won't know if you are having silent episodes or possibly further ones at night.

Hidden in reply to PeterWh

True, guess we are assuming my afib will be as symptomatic as it was the two times it occurred. He did say if I have regular episodes, it would b daily flec+ metoprolol. Im a CHADS score 1, so no anticoag, but in 2 yr I will b 65(hopefully) then I will b a 2 so will get anticoag. That's more frightening that 24 months will make me a higher stroke risk? I would prefer taking anticoag now, but...

PeterWh in reply to Hidden

You can take anticoag so now if you want. 

Hidden in reply to PeterWh

If EP and cardiologist both say I dont need, how am I going to get it ?

AnticoagulateNow in reply to Hidden

You argue that while you understand that lines have to be drawn somewhere in formulating CHADS scores, it's only a guide and 24 months (and counting) will actually make little difference to your risk.   There is no magical visitation from the stroke fairy on the night of your 65th birthday that instantly changes your risk.    And you can say that not having the protection of anti-coagulants is keeping you awake at night with worry.   

"Please don't refuse me, Mr EP.  My family know I have asked for anti-coagulation and they will never forgive you if you get this wrong."   Say that bit with a smile so you don't sound too threatening!.

Pick up the prescription on the way out......

I am in U.S,. 66 y.o., and on Tikosyn,  having failed 3 previous antiarrhythmics, and having had serious adverse reactions to flecainide and propafenone. My afib has been so symptomatic that it has been impossible to overlook it, but the Tikosyn has been working flawlessly for 3 months now (knock on wood).

After a month on Tikosyn, the doc said I could come off Xarelto, which was a great relief, since I have a small farm and do a lot of work with sharp tools. About a week after I stopped Xarelto, I noticed a big and painful purplish area on my lower leg, which worried me as I had not knowingly bruised or injured it, and I do not normally have discolored or painful legs.  I monitored it carefully and it went away after about 8 days.

My concern is that there might be some sort of rebound effect from going on and off these NOAC's, and that they might cause a hypercoagulation or thrombosis effect for days after you stop them.  I researched a little and did find one reported case, but these drugs are so new there isn't a lot of info.

Has anyone experienced anything like this?

Thomps95 in reply to Franny50

I looked into this issue a bit and found that about 2.6% or 1 in every 38 of all ischemic stokes occurred shortly after OAC discontinuation. Strokes occurring after OAC discontinuation also have higher mortality rates. 

So yes, there are risks of going off and on anticoagulation, with the riskiest period shortly after going off anticoagulation. I assume that when you take anticoagulants, your body adjusts built in mechanisms to keep the blood at an optimum level of coagulation, subtly countering the effects of anticoagulation. So if I were on anticoagulation permanently, and I wanted to stop, I'd be inclined to come off gradually. 

I doubt such a rebound effect would occur for "one-off" PIP intake of anticoagulation, however. I suspect you'd need to be on medication relatively long term for such a rebound effect. But I believe those risks are unknown and it is a very good question to ask. 

Like you, want to see more research, but appreciate your posting

We published a similar abstract at HRS on rhythm-guided anticoagulation and our study as well as the one from UPenn used my AliveCor ECG to check the rhythm for AFib.

Agree with the above - as mentioned, we should take this particular research project with a grain of salt given its tiny sample size and lack of control group - but we do need and want research on this issue - and it's encouraging the work is starting. 

For those who feel good being "protected on anticoagulation" - take a minute to consider that not everyone can tolerate long-term continuous anticoagulants, for various reasons. 

Some pointed out that we "can't know if we are having AF during our sleep" - I agree, but I think this will change soon, probably within 18 months as portable heart devices on the market are improved and become widely available. So to me that is not a good reason to ignore research findings on the issue. 

Another consideration is that anticoagulants are not without risks: the annual risk of *death* from warfarin is 1% (similar to the risk of death racing in the grand prix), let alone the risk of complications of bleeds. Now consider the cumulative risk over 25 years. If researchers can figure out how we can reduce stroke risk while also minimizing the risk of haemorrhage, well, that would be a good outcome. There is a long way to go, but it's nice to see preliminary efforts :) 

souljacs4 in reply to Thomps95

I like the idea of a portable heart device while you sleep.

Thanks for this Thomps95. I am almost free (for 2+yrs anyway) of AF on Flecainide and am therefore happy to go with my cardiologists advice to do Rivaroxaban as a PIP if I have an episode. However, I think my approach would be different if I was in the group who dip in and out of AF and sometimes don't realise it.

Hope you are keeping well yourself.

Just as a general principle, a medication that can be taken when needed as opposed to  being taken continuously has got to be a good thing in my book.  Regardless of whether or not this particular piece of research is flawed, I have to admire the objective.  One day in the future maybe we will all be empowered to manage our own health and have less of a one-size-fits-all approach.

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