AF Association

Warfarin preferred to NOACs ?

My GP asked if I would like to switch from Warfarin to a NOAC. I said no.

I have taken warfarin for 8 years. I self test with the Coagucheck system and do not attend the surgery for monitoring. Since I started testing twice a week, more than 90% of my INR readings are in range. I find it very simple to do the test, probably no more difficult than testing blood sugar.

My advised range is 2 - 3.. I can fine tune to keep in range 2.5 to 3 fairly easily. If my medication changes I am able to adjust the dose of warfarin if needed, and feel confident to do this without seeking advice, much as diabetics adjust their insulin.

I know that no tests are required for NOACs. In a way, I see that as a disadvantage, because there seems to be no way for the patient to achieve the level of anticoagulation he/she wants. I prefer my readings in range but closer to 3 than to 2.

Does anybody else feel the same or am I missing some fundamental point about how NOACs are used or how they work?

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I'm inclined to agree with you although from time to time I do wonder whether I would be better off on a NOAC. I also self test. As the saying goes ' if it ain't broke why fix it '

Sandra

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My EP changed me to Apixaban from Warfarin because he said it was less likely to cause a intracranial bleed. I had told him that such a bleed was my only real concern, even if fairly unlikely.

Please check this for yourself because I am NOT medical, just quoting what I was told at the time a few years ago.

But that is why I changed, not because of no testing, or ease of use.

Koll

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The cardiologist who prescribed Apixaban for me said he preferred it as it had the lowest bleed factor of anything available then - in 2013.

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Yes Finvola same for me, my Cardiologist always uses Apixaban!

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The whole point of DOACs is that no testing is required. They work-- end of story. At a recent meeting Prof Camm commented that DOACs were safer and more effective at stroke prevention than warfarin. That said and with my in range level of circa 85% + as well I am in no hurry to change a habit of fifteen plus years when Warfarin has so little impact on my life..

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medscape.com/viewarticle/88...

Not convinced that is the end of the story Bob

Suspect further real world problems as above will emerge with time. Without a test how can we be confident the dose is correct?

Are patients on NOACs managed or monitored in some way over time?

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If you were starting out taking an anticoagulant now Bob, which would you choose? Sorry if this is an unfair question!

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Fair question Mrspat. Probably Rivaroxban to be honest. No real reason I can give, just a feeling from what I hear and read.

Badger DOACs' (They are no longer new so not NOACs please) need regular renal and liver function tests. Most of the problems reported ( and few in UK by the way) are due to lack of testing.

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Thanks Bob. DOACs it is then!

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I have changed from warfarin to apixaban. I also self tested and was able to keep in range nearly all of the time but only because I juggled my diet and sometimes doses.I thought I was fine on warfarin and wouldnt ask to change but my EP put me on apixaban following an aborted ablation. He had had to reverse the warfarin with a massive dose of vit k. Afterwards he wanted me to be anticoagulated quickly so put me on apixaban as there is no loading period. I have stayed on apixaban and am amazed at how much better I feel psychologically'. Because there is no testing ,AF is no longer at the front of my mind. I didnt realise how much I thought about it before. I have had quite a few minor operations recently and havnt had to worry about building up INR levels afterwards. Just 1 day of apixaban and I am protected again.

I agree it is a little unnerving that there is no test to see if all is well but I am just going to trust that it is! X

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agree Deodette- I was surprised at how not having the worry of being in range makes such a difference

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I agree absolutely Badger! I've had to come off it twice, for a CT Scan and knee replacement surgery. No way would I come off Warfarin, unless it was critical that I did so. Must say the switching warfarin on and off was far less of an issue than the PT following knee replacement - that was a challenge.

Like you I self test with my Coaguchek, and on occasions I self dose too or vary my own warfarin doses too. No sweat! I'm in range around 92% if not more.

John

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Completely disagree. Loathed the whole concept of INR and testing. It makes me feel like a patient and not a person.

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Surely you are better having once a month or in my case every two months blood test which is just a prick in your arm to check that your level is correct??

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Except that it was far more frequent than monthly which is in any case still too often IMO. Sorry, I am not one of those who found it comforting.

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The studies show NOACS are better ONLY for those who are up to 66percent of the time in range on warfarin- above that and warfarin may be better!!You sound as it you have got it sorted on Warfarin!! NOACS are easier if you need to miss a dose for dentistry etc but Warfarin is better than NOACs in some cases so it's an even balance for you!!( personal opinion only here!!)

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To me it is not having the testing that made all the difference. Had a series of infections and anti biotics which messed with my inr, so much happier on my Noacs x

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I think you've got it right, Badger. Warfarin is just as good as NOACs if not better once your time in range exceeds 80-90%. I'm in range 98% of the time and just eat what I want. I find testing empowering - I have control of the situation. If I go for minor surgery I drop my INR to 2, the surgeon's happy and I stay protected. The surgeon I dealt with would have insisted those on NOACs would have had to stop for a day.

The key on warfarin is self-testing and self-management. Then you're running the show.

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Thank you Mark. 98%, wow!

I was very interested in your point about minor surgery. If the surgeon is happy with an INR of 2.0 for minor surgery that would be a big plus.

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this is the crux of the issue: " I know that no tests are required for NOACs. In a way, I see that as a disadvantage, because there seems to be no way for the patient to achieve the level of anti coagulation he/she wants. " As you observed, it's not that you dont have to test -- its that there is no standard test to calibrate whether the drug is keeping the patient in the correct range for protection. DOACs work differently from Warfarin. I personally preferred to try apixaban first .. but there was no way to determine that the drug was performing as needed. That is because patients like me (and many others) -- intestinal surgery, overweight -- were not included in the test trials.

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I am on Pradaxa.....it is mellow and easy and I like to eat a lot of kale and collards so wayfarin would never work for me............

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Thank you everybody for responding. This has been helpful for me.

I suppose it is not a surprise there is no consensus on this. In my opinion (which in truth has never been that humble!), the jury is still out on NOACs.

Each to their own, I prefer to be in control of my medication. While there are obviously some advantages to NOACs, I hope a test equivalent to the INR becomes available soon. I wonder if those who are pleased to have switched will choose not to use it.

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Same here, on Warfarin since 2000 until this year when I started getting TIA'S and the stroke doc said less chance of bleed by going on to Pradaxa and as his knowledge is greater than mine I agreed. I also self tested and kept control whilst on Warfarin without problem but sometimes we do need to take the advice of experts in their field.

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Hi Opal

I remember reading that most brief and minor TIAs in AF patients are not due to emboli from the heart. In that situation, adding an antiplatelet med to AC might protect against further TIAs. That was the advice I was given.

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and what would that be Badger?

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At the time, Aspirin. Perhaps now Clopidogerol would be preferred.

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Thank you for your reply

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might have too much bleeding risk with this Badger

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Sorry. I missed your post, somehow finished up in my spam folder!

But I take your point.

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I used to be on Warfarin but changed to Apixaban, as research shows that you are much less likely to have a stroke whilst on it, and much less likely to have a "brain bleed", which you would be very lucky to survive if on anticoagulants. It has also been proven that your INR stays at 2.5 on the newer coags, that's why they don't check INR. They are so much easier than Warfarin, you don't have to watch what you are eating and drinking whilst on them, and going for blood tests and dosing. Also if you are out of your range on Warfarin and the dose is adjusted it takes 3-4 days for the INR to adjust, scary thinking you are out of range for that length of time ( with blood which is too thick or thin ) ! I am a Nurse myself and frequently seek the opinion of consultants whom I work with ( pick their brains ), and they are all of the opinion that Doacs are far superior to Warfarin! When I told my GP that I wanted to change to Apixaban from Warfarin he tried to dissuade me ( probably because Warfarin costs pennies ), but when I asked him what he would do if he had to go on anticoagulant, he said Apixaban ! I notice through my work that a lot of elderly people take Warfarin, but younger people take a Doac. I think if you've been on Warfarin for years they tend to leave you on it, whereas if you were new to anticoagulant they start you on a Doac.

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Hi D

I think what you say is true for most patients. I also think it may not be true for all patients. Did you have a chance to read the report at the link I put in the first post. Clearly some of us are confident in adjusting our dose of warfarin and are a little sceptical about generalising from risk/benefit to large population groups, to what is best for an individual.

Do you remember how the medical establishment told us all that saturated fats were killing many of us with heart attacks. Now increasing numbers of cardiologists, mine included, say that for the majority, that is complete nonsense. Unfortunately, in the meantime,many patients may have died as a result of the transfats in the original polyunsaturated oils we were encouraged to use.

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Sorry that should have been my post in reply to Bob, seven down. That is where I put the link.

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Oops. That link only works if you are signed up to Medscape, which anyone can do, you don't have to be in health care.

The report is entitled "Inappropriate NOAC dosing common. May be compromising safety".

It contains some alarming comments relating to NOACs but I suspect they are not relevant to the large majority of people on NOACs.

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apparently some GPs have been putting lots of people on the lower dose of NOACS when they should have been on a higher dose!

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Thanks Rosy. Did the report suggest why this was happening? Again, another real world problem by the sounds of it.

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I asked about this- it may be that GPs worry about the bleeding risk but another factor apparently is that there are different ways of measuring renal function and people's weight can be inputted either as 'lean weight' 'actual weight' or 'ideal weight' !! and depending on which you use you get a different result- which puts some people in the range where (below 50) where they should be on the lower dose age!!

Quite tricky!

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Hi All, I've just started on Warfarin 5 weeks ago (solely due to age related CHADSVASC scoring) and am now considered about stabilised with a dose of 4.7mg/day following weekly testing (INR = 2.4 last test). I intend to self-monitor with a Coaguchek shortly with the agreement of my GP. How often should I test when self-monitoring? How sensitive is INR to dietary changes ( e.g. more brocolli / Vitamin K rich food in a week than average?). I rarely drink alcohol apart from when on holiday, celebrations etc. Should I test in reaction to changes to my otherwise regular boring diet?

I was initially recommended Rivaroxaban but deliberated for 12 months before deciding on Warfarin. On-line searches suggested a lot of claims in the US for stomach bleeds etc., plus no "antidote" available atm for NOACS. I know NOACS work in a different way to Warfarin, but how come they are a "one-size-fits-all" solution.

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Hi B

Interesting questions. You may find you get a better response by starting a new thread, maybe you can cut and paste your post and create a new title.

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Will do, thanks.

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No Badger. I totally agree with you. I have been on Warfarin for 30 years and have self-tested over the past few years. I feel much more in control of my INR level (between 3-4) and like you I can regulate my dosage if necessary. Anne

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How do you know if your self testing machine is accurate. Do you get it regulated ?

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I occasionally ask for an INR at the surgery and we do the test on the two machines simultaneously. They use the same machine that I do.

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At the surgery yesterday, my INR was 2.2 on their Coagucheck and 2.3 on mine. Hilary said they calibrate theirs every 6 months with reagent presumably from Roche.

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I have my Coaguchek machine checked twice a year at the anticoagulation clinic as per the NICE guidelines for self-testing.. The machine is checked against a venous sample.Anne

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NOACs work differently to Warfarin.

NOACs target one critical factor of blood clotting, warfarin interferes with vitamin k and at least 6 other blood clotting factors.

Because of this NOACs are predictable, unlike warfarin.

I'd take a noac over warfarin any day thanks

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For me DOACs are preferable every single time. I have only ever taken DOACs - by recommendation from my EP as being more effective, didnt require testing - and as we travelled a lot at that time faffing with coag clinics and diet wasn’t something I was prepared to do.

I just don’t get why you anyone would choose something so unstable and variable that requires testing over something with less cranial bleed risk and stability?

Each to his or her own though and if it works for you it will the best for you,

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Comparing apples and oranges here. I'm not a medic and won't comment on which is 'better' for anybody but will say that in my view any A-C is better than none, and personal preference will have an effect on how you feel about it that is valuable. If one alternative would worry you, stick with the other.

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I was put straight on to Rivaroxaban when AF was diagnosed and I feel that I was lucky to have avoided the monitoring necessary for Warfarin. My twin brother was on Warfarin and envied my monitoring-free life!

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I'm on Apixaban and know people who are on warfarin. My life is hassle free theirs isn't. NOAC' s make a real difference.

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If you're not happy with anti coag you can change

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I'd love to come off Warfarin and be moved to one of the other named drugs, but when I asked my GP, he said it was better to stay on warfarin because if I bled badly from whatever cause there was a vitamin K injection available to stop bleeding but not the case for the other drugs.....was he just completely fobbing me off as the other drugs are too expensive?

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Depends on the type of bleed he was using as an example, I was told a major bleed such as car accident wouldn’t matter if you were anti coagulated or not as chances are you’d bleed out before ambulance arrived anyway, however minor bleeds that only require stitches or glue stop with firm pressure, it may take slightly longer but they do stop, I think your GP was using worst case scenario in which case is slightly unfair

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Probably, I changed from Warfarin to Apixaban, my GP tried to dissuade me but I insisted. I said " it's my life and I want what I think is best for me " ! It's all bout the money I think!

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I have been on Warfarin since 1992 and my range is 2.5-3.5, 3.0 ideal. I am not stable and have not been for some time now. When I mentioned it possibly when I am 70 as brain bleeds are more likely then. He did say that at the moment stay with what I know. More I think because of my Pulmonary Hypertension moving from mild to severe now. Along with my other problems not helping anything.

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I am very much agree with Badger approach in general, and with diabetic blood test device comparison. I am thinking,it is enough evidence of dangerous side effect from NOACs., that has not pronounce by checking Body, since the pharmaceutical companies have invest so much in it.

Each new medication has to be used by patients for years to proof it benefit. It is history of many med., that was pushed to take. Eventually , were discontinued .

The governments benefit from cutting down the periodic blood tests. The doctors have pushed to prescribe NOACs .

Of course, it needs to be further research done in order to weight the "future benefit" toward existing negative side effects.

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Hi Alemo

I think I must have given the wrong impression. Let me try to clarify this.

For the large majority of people, NOACs ( now called DOACs apparently) are a better choice for people starting anticoagulation.

For those on Warfarin, whose control is good and who like to adjust their dose, and are happy testing, then it seems reasonable to stay on Warfarin.

As Bob pointed out if you take a DOAC, your GP will check kidney and liver function periodically and this is important especially as we get older.

For myself, I am happy to stay on Warfarin for the moment, but I know that one day if I am still on an AC, my GP will take the decision out of my hands.

That is as long as an unknown unknown about DOACs has not come to light in the meantime.

Enough said ?

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Badger, Thank you for reply. I have just read on the web. " Anticoagulation in Atria Fibrillation NOAC's the word " The German notation and comparison with Warfarin. If you ask for DOCS AND NOACs - this will come out.

Very interesting, as much as the disclosure about conflict of interest between pharmaceutical company and Doctor's remuneration.

My concerns ,of course, is the liver ,kidney and renal function .

.And yes, I am getting older - 78. My PAF for years and is not dangerous , but can create clotting. I perfectly control it with Bisoprolol as per needed. Therefore dr. Insist on Abixaban. VERY RELUCTANT.

My recent CT scan have shown benign ( they said) liver hemangioma .That give me

Food for thought.

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One other thing in favour of warfarin which probably trumps all others is that it apparently cuts the risk of cancer by 40%. It would be worth taking for that alone.

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