Warfarin versus DOACS

Following the subconjunctival haemorrhage I got from taking Apixaban for a week, my GP has asked me if I would “like to try” warfarin as an alternative. This is, according to her, less likely to produce an eye bleed. I’m very dubious about this claim which conflicts with what I have read. Has anyone been transferred from a DOAC to warfarin for this reason or know anything about the issue?

[BobD Volunteer]

Warfarin has been used for seventy years ( I think President Isenhower was one early recipient) and provided that INR is kept in order (between 2 and 3 ) is inherently safe. The best advice I can give is make the warfarin dose suit your diet rather than the other way round as the actual amount you take is of little consequence, only the resulting INR. For example my very stable INR is attained on 4mg yet I know of others who to attain the same level take 15mgs . Never "chase" INR with violent switches, rather do it gradually. Whilst 3 may be an upper target 5 should not be dangerous according to the leading UK expert on the subject when he presented at our conference a few years ago.

[Hidden]

This is only a decision you can make, but I think you know that. The boffins suggest that Apixaban is a marginally better option than Warfarin but the difference is minuscule. Most are aware of the benefits of taking a DOAC rather than a Warfarin, but for me the deciding factor was diet. As Bob rightly says, doses should suit diet but pre-pandemic I was a bit of a globe trotter which can make diet a bit more difficult to manage. All I can say is that even with having had 2 bloodshot eyes in 7 years, I have absolutely no plans to change. I wish you luck with your dilemma…..

[Threecats]

Hi, I don’t know about switching from DOAC to warfarin but I have an elderly relative (86) who has been on warfarin for 9 years now since being hospitalised with AF and heart failure. She’s had no eye bleed issues at all. The only drawback is, as Bob says, making sure your INR stays at the target level which, for my relative, meant a few trips up and down to the surgery initially to get the dose right but now she’s at a dose that keeps her levels at or around 2.5, she only has checks about four times a year. Again, echoing Bob, any changes in dose need to be slow and gradual.

[Hidden]

Hi,

TO ANSWER YOUR QUESTION ....NO! But...... I've been on Warfarin for 12 years and like BobD, have a very stable INR. I have my own self testing device with the support of my surgery and my very constant INR is achieved on 4.4 mg per day. I have no bleed problems, no bruising problems but if I accidently graze or give myself a minor cut arising from a moment of carelessness then I bleed fairly quickly. I still lead a normal life, drive a bus, drink alcohol and eat virtually anything I want. I follow a diet - not because of Warfarin - but because I use it as a mechanism to help control my AF. When I am at work in my work bag I also keep a mini first aid kit to use if I give myself a knock. The biggest feature of Warfarin is ..... WHATEVER YOU EAT OR DRINK DO IT CONSISTENTLY AND IN SMALLISH QUANTITIES. I might add that in the good old days before CoVid I used to holiday in Australia and take all my stuff with me and have no problems whatsoever.

I would add that I have even had to stop Warfarin and restart it again to enable two procedures to take place. One was a head scan and the other - much more demanding - was knee replacement surgery. No problems at all.

Warfarin is certainly not the demon that many people and healthcare professionals like to portray and for many who cannot take these new anticoagulents it is an AC of choice. That said of course, there equally are many that cannot take Warfarin either because of issues trying to stabilise their INR. From an NHS point of view it is claimed to be a lower cost drug than the new ones but I've not seen any costings on this, just read reports.

John

[Hidden in reply to Hidden]

Very interesting reply. I'm going to be referred to an anticoagulation clinic to discuss the possibility of warfarin and, hopefully, to find the cause of the problem. I have a friend who has been taking warfarin for a heart condition- not AF- for years without problems; If they recommend it then I'm willing to give it a shot.

[Hidden in reply to Hidden]

Hi Samazeuilh,

If recommended it is worth giving it a try. I forgot to say that I have also had cataract surgery on both eyes ( 2018 for the left and 2021 for the right) on neither occasion did I stop Warfarin and had no problems. I mentioned about my stability .... my test periods now are every 10 weeks. However, because I think this is a bit long and because I have the technology I do test at home about every 5 weeks just for peace of mind.

I would think initially, if it is recommended and you give it a go, your AC Clinic will start you on it and check you probably every 2 weeks for quite a while until you demonstrate what your INR readings will trend. First up, it will take a few weeks to get your INR up into whatever is decided is your theraputic range, so just go with the flow. For me I am usually steady in the range of 2.4 to 2.7. When you first start they will have to determine a theraputic range ( an INR range and a target INR). What this is can vary according to your condition. For me with paroxysmal AF ( and no other issues) the range is between 2.0 and 3.0 with my target being 2.5.

TBH, I seldom hit the target of 2.5, and often for mysterious reasons sometimes my INR will jump to 3.3 or higher and other times just as mysteriously it will fall to 1.8 or a tad lower. So long as your clinic are told what is going on ( by you) neither is a big deal. It is unlikely that you will be perfect but it is all very manageable. The thing is when you get these weird swings do make sure your clinic is aware and KEEP CALM AND CARRY ON. Never hit the panic button. Warfarin can be your forever friend.

You might find it useful to search the NHS website and explore what they say about warfarin and food and drink. But, in any case your clinic will advise you.

John

[mhoam]

Hi, when I started with PAF about 10 years ago, the only option was Warfarin. The newer DOACS were not available. However I was also on other medications for an auto-immune problem. This meant I was never able to establish a stable INR despite weekly visits to the Warfarin clinic, which was a real burden. Eventually I was advised to stop trying Warfarin as I was still relatively young then I have been on Apixaban for about 2 years now without any problems.

In short, your experience on Warfarin will depend a lot on both your diet and any other medical conditions/treatments.

Hope this helps

[Slipware]

I have taken warfarin for 9 years now, I did have a hyphema, a bleed inside the eye a few years ago, even though my INR was on target. We can get a bleed on any anticoagulant. I choose warfarin over all the 'new anticoagulants' because I’m in charge and control of it. I’ve tried Apixaban and Dabigitran. Tried and trusted Warfarin for me.

[Harrycat]

I have used warfarin for 10 years and had no problems, Check INR regularly with the practice nurse, sometimes need to alter the dose, but otherwise no broblems.

[Mira265]

Hi BobHaving been on Warfarin for several years I have never had an eye bleed or any other symptons. I prefer to have checkups that is why I continue to take Warfarin.