Warfarin versus Apixaban

[Bee-Honest]

I have been on Warfarin for 16 years, due to PAF, and have it well under control, told I have 100% rating by the Warfarin Clinic Nurse, I only have to attend every 3 months, and my readings are always 2.5. About 7 years ago I had a minor stroke, lost the power of my right arm for about an hour. A CT scan showed it had left a small part of the left hand side of my brain damaged, no other visible damage, possibly a little dizzy when bending over for any length of time. I was put on a low dose Aspirin along with Warfarin, I queried this recently and was told my need is greater than the possible risks that go along with taking both.

However at a recent visit to a Cardiologist, following up a 5 day AF attack, which reverted into SR on its own, he said he thinks I would be better off on Apixaban, less likely to have "a bleed". I am somewhat concerned about being on a drug that is not monitored and having spoken to a couple of " health people" I am not convinced it is in my best interest to change. Looking for advice please.

[CDreamer]

Apixaban - read the literature on bleed risk.

Doesn’t need monitoring as it isn’t a VitK antagonist - it works on a completely different part of the clotting process. No diet restrictions, no monitoring, a reported lower cranial bleed risk - what’s not to like?

Do your research and then discuss with your doctor. I know some people seem to like the monitoring but for me too many uncertaintys and restrictions with Wafarin

[Bee-Honest in reply to CDreamer]

Thanks for your speedy reply. Will discuss with my GP.

[CDreamer in reply to Bee-Honest]

Not all GPs are up to date, some are biased against and some don’t like it as they see it as more expensive so do your own research before you see your GP and bear those factors in mind.

[Chris1945 in reply to CDreamer]

This is all very interesting for me as only last month I asked my GP re changing from Warfarin to Apixaban and his response was that in the event of a 'catastrophic bleed' from whatever reason, there was an 'antidote' injection of vitamin K available to help but not so in the case of Apixaban, does anyone know if this is a fact or my GP taking the 'easy option'?

[Hidden in reply to Chris1945]

Well, yes, Warfarin's effect can be reduced by vitamin K. But it's quite slow (taking hours or days) and will not be of much benefit in the event of a 'catastrophic bleed'.

[Chris1945 in reply to Hidden]

Thanks Rellim2, cynic that I am, I'm wondering if Apixaban is more expensive than Warfarin hence his hesitancy to even try it!

[CDreamer in reply to Chris1945]

That could be but I think GPs are uneducated about modern DOACs and just don’t have the experience. In a catastrophic bleed it really wouldn’t matter if it was Wafarin or Apixaban is what I was told by an A&E doctor and at least Apixaban half life is 12 hours.

Certainly about 5 years ago it was reported on this site that GPs were very resistant because of the expense but if you take into consideration the cost of INR clinics and testing?

[Hidden in reply to Chris1945]

More expensive? Very much so!

Hard to say how expensive Warfarin is. The pills are cheap but what's the cost of testing INR?

Some of us - as mentioned by 10gingercats and doodle68 - lack a sense of protection when taking Warfarin.

[seasider18 in reply to Hidden]

NHS testing at surgeries is estimated at £10/12 a time. My local surgery gives each patient seven minutes and if your late you've missed your turn.

It must be quite profitable as in some towns (Brighton for example) testing has been taken over by pharmacies.

[Hidden in reply to seasider18]

Thanks for that.

But what's the average number of tests per person per year? Obviously it can be as low as four for the stable, but sometimes, prior to a procedure, you need to have weekly tests (and my surgery insisted on taking blood from a vein, not a quick finger stab) to prove a level INR. It can be a few weeks of testing if INR is wandering.

[seasider18 in reply to Hidden]

My local surgery has 300 patients on warfarin. Some are self testing and phone their results in at an appointed time. One nurse spends a Monday afternoon on it and two nurses spend nearly all day Wednesday doing it.

[Hidden in reply to Chris1945]

Lot more expensive

[MarkS in reply to Chris1945]

There is an antidote to warfarin that is effective in about 10 mins (PCC). It is held in all hospitals and air ambulances. You would have to wait for 24 hours for an NOAC to stop being effective.

Warfarin costs are about half of an NOAC. See "Well-managed warfarin is superior to NOACs":

cfp.ca/content/61/1/23.full

[Bee-Honest in reply to MarkS]

I was told by a surgeon in an ENT ward that he could easily inject me to thicken my blood in an emergency when on Warfarin but not on Abixaban. I had a terrible nosebleed, worse of course because of Warfarin and Aspirin. Had to be in ENT for 24 hours to let my blood clot.

[CDreamer in reply to MarkS]

Surely for the 2x daily dose it is 12 hours?

My neighbour had a bad bleed recently which wouldn’t initially but did after 12 hours - she was on Apixaban, as am I. And there are processes in A&E which could address a bleed, if considered essential.

[MarkS in reply to CDreamer]

Unfortunately no. According to the FDA, accessdata.fda.gov/drugsatf...

in section 5.2, bleeding, "There is no established way to reverse the anticoagulant effect of apixaban, which can be

expected to persist for about 24 hours after the last dose, i.e., for about two half-lives."

[YvonneWilson in reply to Chris1945]

I recently had to have emergency op for a fractured femur. It took 36 hours on a vitamin k drip before my blood was at a level whereby they could operate. (I'm pleased to report now been switched to Rivaroxaban!)

[10gingercats]

I would not go back to Warfarin and now take Apixaban X twice daily and hardly notice it.

No problems,no testing,no dietary restrictions,no bleeds.no running around abroad trying to find someone to do an INR.,I have had major surgery with Apixaban....only stopped taking it while waiting for the surgery for a short, very short while .

As CDreamer said Apixaban works differently to Warfarin but that is not to say it is not as effective.I feel relaxed taking Apix. in a way I never did with Warfarin. That in itself is worth a lot to me.

[Bee-Honest]

Thanks 10gingercats, good to hear other people's experiences.

[doodle68]

Hi Be-Honest I have read lots of studies on anticoagulants because I was fearful of the prospect of taking them for the rest of my life. In all the studies I have read Apixaban comes out very well and having taken it for almost a year I would not wish to change to anything else.

This is a fairly recent article from the American Journal of Cardiology comparing anticoagulants. ...

[Quote CONCLUSION..

'' Altogether, apixaban had the most favorable effectiveness, safety, and persistence profile''.

sciencedirect.com/science/a...]

All medication carries a risk or has side effects and we all react differently to various medications but after much research, I now feel more at ease taking Apixaban .

[Bee-Honest in reply to doodle68]

Many thanks, this is exactly the kind of information I need to make a decision.

[Hidden]

We are not medically trained Be-Honest, but the general consensus of opinion is that there is not much difference between warfarin and Apixaban in terms of protection against a stroke, However, it is commonly said that Apixaban is less likely to be responsible for an internal bleed compared with warfarin, but as others have said, it is important that you research the facts to satisfy yourself. One thing is for sure, Apixaban offers a much higher degree of freedom even if you have to be sure you take 2 tablets per day!

[Hidden]

One other thing to bear in mind, some are sceptical of some of the reports and studies which have been produced generally because the motives behind some of them are not always clear. The information I based my comments on has come from a variety of EP's, Cardiologist's and other medical professionals who have spoken at various meetings I have attended and who have (to the best of my knowledge) no axe to grind!

[Bee-Honest in reply to Hidden]

Many thanks for replying, all good information. In 16 years I have never forgotten to take my Warfarin, I just hope that continues if I decide to take Apixaban or equivalent.

[MarkS]

Apixaban is only better than warfarin where INR control is poor. In the major Apixaban trial INR control was only a mean 62%. Warfarin has similar effectiveness with INR control (Time in Therapeutic Range or INR) around 70%. If you have excellent control, as you do, then warfarin is superior.

When you add that warfarin's effectiveness can be measured whilst Apixaban's can't (it is not so much that you needn't measure NOAC's effectiveness, there is no easy way of doing it), a very effective reversal agent for warfarin that is commonly held, and cancer risk is reduced by 40% with warfarin, then I would suggest that the case for remaining on warfarin is overwhelming.

[jemurphy in reply to MarkS]

Interested in your reply to Be-Honest on the question of changing from warfarin to apixaban. I too am in that situation and weighing up the pros and cons. You said that apixaban's effectiveness can't be measured. If you self test for warfarin, could you check INR in the same way when starting to take apixaban? There are so many considerations and I too feel confused.

Thanks. Sorry to highjack Be-Honest's post. And good luck Be-Honest.

Jean

[MarkS in reply to jemurphy]

Hi Jean,

No unfortunately. As Apixaban (and all the other NOACs) affect a different clotting path, INR is irrelevant.

To me, the answer of whether to switch or not is fairly straightforward. Can you achieve a time in therapeutic range on warfarin of 70% or more without wild variations? Then best stay with warfarin. Less than 70% then consider switching.

Mark

[jemurphy in reply to MarkS]

Okay, thank you. There is more to this than I thought. Will need to consider carefully before seeing GP tomorrow to discuss changing to apixaban.

Jean

[Bee-Honest in reply to jemurphy]

Hello Jean

There is a lot to consider. All the replies I have received have been excellent and very informative. I have a 100% range on Warfarin, but I know my Cardiologist is concerned about a 'bleed'.

[jemurphy in reply to Bee-Honest]

Yes there is a lot to consider, much more than I thought. And yes the replies have been very informative and have helped me too. My Warfarin range has been good over the last 15 years but has suddenly gone off for some reason. I too have PAF. Will see what my GP thinks tomorrow.

Jean

[Hidden]

I believe there is some research which demonstrates apixaban is better at preventing strokes than warfarin if I can find it i will send you the link ! I would ask your cardiologist about that as well ! It certainly is less risky from a bleed perspective !

Andy

[Bee-Honest]

Thanks to everyone for replying. Your own experiences and information greatly appreciated.

[Sue5453]

I am on apixaban and have been for 1 year and 3 months as I have AF but not had it for a year and 3 months the AF I mean I have found out you carnt have cranberries I read that on line no doctor said anything but it says can corse a bleed so just don’t have or drink anything with it in since I found out but no other problems been fine on it so it works for me

[barbara2]

Apixaban is wonderful… so much easier than warfarin and less worries too.

[Eadaoin]

No question- it is a huge psychological step to move from Warfarin where you regularly know your results to trusting that another anticoagulant is safe. But I did it and moved to Edoxoban a year ago after thoroughly discussing my fears first.