Warfarin alternatives

[Mrspat]

I've been on Warfarin for nearly a year after aortic valve replacement for congenital aortic stenosis. After the operation I had AF but was successfully cardioverted 6 months ago with no apparent relapse.

I would like to discuss alternatives with my GP and/or cardiologist but do not know what local policy is and what it will take to persuade them. I'm aware of the cost issues.

As well as Warfarin I take Bisoprolol and Levothyroxine. The Levothyroxine is because I was on Amiodarone for seven years and it affected my pituitary gland function. This has been discontinued for two months and has affected my INR and thyroid readings. Shortly I will need an operation on my eyelid which may require stopping Warfarin and having heparin injections. Leading up to this, I had infections in the eyelid which were treated with antibiotics, again affecting INR. Also I needed weekly blood tests leading up to the cardioversion.

Everything seems to affect INR. My level was stable for several months but now I'm back to weekly blood checks. I really can't put up with the intrusion. Not sure if I should be on an anticoagulant at all as opposed to aspirin, which worked well for seven years but that's a separate argument.

Would appreciate advice on what to say to the GP/cardiologist about alternatives to

warfarin.

[Hidden]

Dear MrsPat.

I am afraid that the news is not great. There are alternatives to Warfarin as anticoagulants now coming into use but as far as I know they have been approved by NICE for Atrial Fibrilation but not yet for prosthetic heart valves. As you will know, if like me, you have a mechanical aortic valve then you will need anticoagulants for life and I do not doubt that, in time, these alternatives will become available to us but not yet I am afraid. It is true that many other drugs have contraindication with Warfarin but in most cases safe alternative drugs are available or their effect on your INR is predictable and an appropriate adjustment to your Warfarin dose can be made.

I also find that weekly blood tests are a real advantage to manage variations in INR and that is one reason why I obtained a "Coaguchek" instrument and test myself to avoid the intrusion of frequent visits to the GP or hospital. The machines cost £299 at present and you can pay over 24 months with no interest charges, the test is simple to do and the test strips can be obtained on prescription. NICE are currently considering recommending that the machines be issued to long term Warfarin patients on prescription too but their report will not be available until about the middle of next year. Send me a message if you would like more detail about this.

By all means tell your GP how you feel as doctors would be concerned if their patients might stop taking the medication but don't hope for too much.

All the best and do let us know how you get on.

[Mrspat]

Thanks for this message. I missed out an important bit of information: I have a tissue valve. I discussed this with my surgeon and chose this option partly because I did not want to be on warfarin. The reason for my being on Warfarin is (and I'm not entirely clear on this point) is that I had AF. This disappeared after cardioversion 6 months ago and I am not aware that it has returned. I feel really cheated.

My I researches seem to suggest that my clinical history is not shared by many people: congenital aortic stenosis, tissue valve, AF now gone,successful cardioversion so the advice about need for Warfarin in the first place and possible alternatives is hard to come by. I can afford a Coaguchek but need to know whether I am going to be on Warfarin long term.

I would be grateful for any advice about how to discuss this with my GP.

[Hidden]

Hi again.

I think that you need to ask your GP quite simply why are you on Warfarin and will it be for the long term.

If it is because of the tissue valve you are not likely to be on it for life and my earlier comments may not apply but if it is because you have a tendency to suffer AF (which is more common in older people) combined with the valve then maybe you will be but alternatives to Warfarin are then available. Dabigatran is one alternative which is now in common use and is approved for AF sufferers. This does not require blood testing, is less affected by other medicines and you simply take a fixed dose twice per day. Another is Rivaroxaban and another Phenindione (or Sinthrome). Some doctors may be reluctant as they cost a little more than Warfarin but they do save testing for INR and are less intrusive and complicated.

If you have to receive further invasive surgery you are likely to interrupt any anticoagulant medication for a few days and possibly have some "bridging" injections of something similar to Heparin for a short time whichever anticoagulant you are on but this is nothing to fear.

Whatever happens do not let him/her put you on aspirin if you have suffered AF. Many GPs are still doing this and it is now scientifically clear that aspirin does nothing to prevent blood clots and strokes in people suffering AF.

Hope this helps but let me know if you want to discuss it further

[Wagnerm]

I have always found it very worth while discussing anti-coagulation issues with an haematologist. G.Ps are often unaware of alternatives to warfarin.

Incidentally, you do need INR monitoring when on sinthrome.

[Mrspat]

Thank you for these helpful replies.

I have to disagree with you about heparin: I had injections for several days between my operation and discharge. They were painful, unpleasant and left severe bruising for several weeks.

I was thinking about asking for aspirin, though I note your advice. I was on it for seven years after an initial bout of AF which did not recur during that period. I believe it only recurred because the blockage ( congenital sub-aortic membrane) next to the valve became very large. This has now been removed. The valve was almost a secondary issue and would have lasted a bit longer apparently.