Warfarin or one of the new DOACs?

[MainlyMyself]

I have chronic AF since I was diagnosed in 2013 and probably long before. I have had two GI bleeds; one in 2008 caused by helicobachter pylori in my stomach and one in 2014 caused by 4 ulcers in my duodenum. Because of these bleeds I am concerned to move from warfarin until the replacement DOAC has an equally effective reversal agent. Does anyone have any reassurance to offer on this?

[CDreamer]

Yes. Hospitals have reversal agents isbtweb.org/isbt-working-pa...

Also I am much happier on an anticoagulant that has a short 12 hour half life and is not affected by food interactions or dependant upon INR staying in range. Others may have different views. I guess we trust what we know and have experience of.

I would point out that reversal of Wafarin is not that easy and takes time, as I seem to remember one forum member blogged about having had an unfortunate experience.

There are also dressings you can buy which you can keep at home which help to stem bleeds but of course it’s the bleeds we can’t see that we need to be concerned about.

I take Apixaban and have done for nearly 9 years now, Dabigatran before that. Apixaban seems to be the anticoagulant with the least affects and seems to have the best outcomes regarding brain bleeds which to be honest is the one we all fear.

Hope that helps.

[ozziebob in reply to CDreamer]

Thanks for your helpful reply.

Just one thing re your comment about Apixaban re least brain bleeds, is that with full awareness of the German research on DOACs that was Posted on the Forum recently? pubmed.ncbi.nlm.nih.gov/347...

This study seems to show that Edoxaban is the safest of all DOACs re strokes, and just as good as Apixaban re brain bleeds.

It is very confusing to me as Edoxaban has had some pretty negative mentions on the Forum in relation to the current switching to Edoxaban for cost reasons.

Maybe not so bad after all?

Any further thoughts would be very welcome.

Bob

[MainlyMyself in reply to CDreamer]

Thank you, that is very helpful indeed

[Mazza23]

I had a gi bleed two weeks ago caused by an ulcer this turned out a blessing in disguise as they found I have early stage stomach cancer that they are hopeful they can remove I have been on apixaban nearly 10 years but have had to stop it before surgery on my cardiologist advice because if I have another bleed they won’t do the surgery on the 18th of may

[rothwell in reply to Mazza23]

I have been on Apixaban for 5 years. Last September I was knocked over by a car in Madrid which caused a brain injury. I had a skull fracture and a bleed on the brain. The Apixaban was stopped for 10 days. I’m not sure when the brain bleed actually stopped but a brain scan 5 days after the accident revealed that there was no longer a brain bleed and I was allowed to fly home.

[MainlyMyself in reply to rothwell]

I am so relieved for you. thank you for taking the time to reply.

[northernsoul1]

When I moved from Warfarin it was like getting my life back, constant blood tests and an inability to eat certain things such as green leafy vegetables which offer huge health benefits in themselves became a thing of the past. Take the plunge.

[Thomas45 in reply to northernsoul1]

It is a myth that you can't eat green leafy vegetables when on Warfarin. As long as you have a regular diet your dose is adjusted to take account of the vegetables. Ii eat a largely vegetarian diet, plus fish. Some days I'll have 7 or more different vegetables. As for testing I have my own Coaguchek meter. .

[BobD Volunteer in reply to northernsoul1]

Sorry but I have been on warafin since 2004 and never changed my diet. I really don't understand people who say this. So long as you eat a regular diet with plenty of Vit K all the time, the dosage matches you diet and your INR stays stable. I have found illness has more affect on INR than diet and like Thomas I self test with a better than 85% record of compliance. (I only bother to test once a month unless I have been ill. )

[sunlovah in reply to BobD]

Is the brain bleeding risk the same on Warfarin also, long shit i know but...if I'm unable to tolerate DOACS would there be a biological reason ref medication, that my system might handle Warfarin . Last chance saloon...

[BobD Volunteer in reply to sunlovah]

MY understanding is that apixaban has a slightly better profile in that respect for those over 80 years old but otherwise no real difference for any of the DOACs.

[sunlovah in reply to BobD]

Thank you for your reply. Tried 5 variables DOACS, even 2.5 mg apixaban x 2 daily still causes pain/discomfort, guessing Warfarin may do the same.

[BobD Volunteer in reply to sunlovah]

Must be you I'm afraid 19 years of warfarin =zero problems apart from slightly brittle nails.

[MainlyMyself in reply to BobD]

The more one researches these things the more complicated it becomes. Thanks for this overview.

[MainlyMyself in reply to northernsoul1]

Thanks, that is worth considering.

[MainlyMyself in reply to northernsoul1]

You make the move sound well worth it. Thanks.

[MainlyMyself in reply to northernsoul1]

I am not finding that aspect of being on warfarin a difficulty, I'm just keen to know if the new er anti-coats work more effectively. Thanks for taking the time to reply

[Ppiman]

I have a feeling that the newer drugs such as apixaban, which I take, are less likely to cause bleeding since they act differently, and their dosage is much easier to decide upon with their lack of need for INR testing. I wouldn't be surprised if your doctor doesn't add in a PPI drug such as lansoprazole to reduce the chance of internal gastric erosions and bleeding, too. That's what I take (well, esomeprazole now).

Steve

[MainlyMyself in reply to Ppiman]

Thanks. This raises the related issue of the long term consequences of taking a PPI like Lansoprazole.

[Ppiman in reply to MainlyMyself]

Rare indeed but if the PPI isn’t needed for acid reflux, I’m not sure I’d be taking one.

Steve

[Mrsvemb]

I take Dabigatran, which has a 12 hour half life. There is a reversal agent called Praxbind should it be necessary. I had some gastric problems caused by Rivaroxaban which caused some minor gastric bleeding. I had gastritis and a gastric ulcer.

Maybe you should take a PPI to protect your stomach. Personally, I can’t tolerate them, but esomeprazole seems to be the most tolerated.

The DOAC’s should be safer for you than warfarin, because of the short half life.

I have googled regarding reversal agents, there is also a reversal agent for Apixaban and Rivaroxaban, but there doesn’t appear to be one for Edoxaban.

[MarkS in reply to Mrsvemb]

PPIs have their own problems with long term use, see: prescqipp.info/umbraco/surf...

"Review long term PPI prescribing to reduce the potential risk of Clostridium difficile, bone fractures and to a lesser extent the risk of higher mortality in older patients, acute interstitial nephritis, community acquired pneumonia, hypomagnesaemia, vitamin B12 deficiency and rebound acid hypersecretion".

If the only way you can take DOACs is with a PPI, I think you would be much better off with alternatives.

Also the apixaban reversal agent is only approved for Gastro-Intestinal problems, and not brain bleeds, unless it is part of a trial, see App 4:

chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/northdevonhealth.nhs.uk/wp-...

[Mrsvemb in reply to MarkS]

It has to be personal choice, weighing up the risks and benefits, with or without something to protect your stomach.

The article is 8 years old and out of date. It suggests Ranitidine as an alternative. This drug was withdrawn about 3 years ago due to causing stomach cancer.

[sunlovah in reply to MarkS]

Agreed been there unknowingly with PPI ,stopped now. Whe you say 'alternatives' are you referring to DOACS or PPI?

[MainlyMyself in reply to sunlovah]

DOACS

[MarkS in reply to sunlovah]

Sorry, I should have been more specific. I mean alternatives to DOACs such as warfarin.

[MainlyMyself in reply to Mrsvemb]

Thank you. very helpful stuff that I can follow up before my GP appt.

[MainlyMyself in reply to Mrsvemb]

Thank you. I can follow this up further.

[MainlyMyself in reply to Mrsvemb]

thanks. I too shall Google for further information.

[Chinkoflight]

The modern DOAC's are designed to do the job more effectively with fewer contra indications hence no need for regular blood tests. As with all things it's a balance of risks, but the evidence suggests they are more effective.Edoxaban is the newest DOAC and doesn't have an antidote. Previous queries suggest it has lower recording of side effects - that's my assessment.

Consider the issue of when is an antidote needed, how will it be accessed, where will it be accessed, and is this in a timely manner? The evidence suggests there is hardly any circumstance when an antidote would be effectively administered to stop a bleed. There are NICE and other papers on this.

Finally cheaper, does not mean, not as good! NICE and the NHS have negotiated a special rate with the manufacturers to supply Edoxaban as part of a stroke reduction strategy over the next two years. The primary aim is to reduce stroke deaths by 6500. (UK)

I have quoted this NICE research on several previous occasions. Most negative comments rarely quote any evidence to substantiate their concerns.

I had a severe stroke, out of the blue. Subsequent investigations have revealed paroxysmal AFib, precisely the reason for increasing uptake of DOAC'S to reduce future strokes. I am delighted to be offered EDOXABAN, it gives me extra confidence moving forward.

Hope this helps. Try to allow evidence from population studies and trials etc to be the most influential rather than well meant I'm sure experiential trials of one presented by individuals. Individual experiences are brilliant when finding coping strategies for issues with health management.

[MainlyMyself]

thank you for this detailed coverage of the key issues