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In a person with Afib, these “blood-thinning” drugs can prevent a blood clot from forming in the heart, traveling to the brain and causing a stroke. They also can ward off development of blood clots in the veins of the legs (deep vein thromboses) that can move to the lungs and cause a life-threatening pulmonary embolism.
You have a choice between the old standby, warfarin (Coumadin®), or newer medications known as direct oral anticoagulants (DOACs). Each drug has advantages and disadvantages that you should carefully discuss with your physician.
“When you select the drug, from a physician’s point of view, you want to know what caused the blood clot, the properties of each medication, the patient’s preference, what other medications he’s taking, and if he’s had a history of bleeding,” advises Head of Vascular Medicine John R. Bartholomew, MD. “A patient also needs to know whether insurance will cover the newer drugs.”
Warfarin works by inhibiting vitamin K, which your body needs to form clots. Consequently, changes in dietary intake of vitamin K (found in green leafy vegetables, broccoli, cauliflower and other foods) can affect the activity of warfarin. Moreover, a wide array of medications and supplements can interact with warfarin and alter its effects.
Patients taking warfarin must undergo periodic calculations of their international normalized ratio (INR), a measure of how quickly your blood clots. If the INR is too fast, you face a greater risk of blood clots; if it’s too slow, your risk of bleeding increases. Some patients on warfarin require frequent dose adjustments to keep their INR in a healthy, therapeutic range.
The DOACs — apixaban (Eliquis®), dabigatran (Pradaxa®), edoxaban (Savaysa®), and rivaroxaban (Xarelto®) — are given in fixed doses, do not require INR monitoring, have few medication interactions, do not require dietary restrictions, and carry a lower risk of bleeding compared with warfarin, Dr. Bartholomew says.
Plus, compared with warfarin, it’s less complicated to stop DOAC therapy before surgery or other invasive medical procedures and to resume it afterward, notes Head of Cardiac Electrophysiology and Pacing Oussama Wazni, MD.
“More and more physicians are prescribing the DOACs than warfarin for patients who are suitable for them,” he says. “They’re much more convenient, and people just seem to like them better than warfarin.”
Drawbacks of DOACs
Despite their advantages, the DOACs do have some downsides — namely, their higher price. Available as a generic, warfarin costs about $4 to $14 for a 30-day supply, whereas DOAC prices range from upwards of $300 to more than $400 for a 30-day supply. However, as Dr. Bartholomew notes, the expense of traveling to an anticoagulation clinic and any fees you might incur for INR monitoring with warfarin might negate the cost savings of the drug somewhat.
He adds that questions remain about using DOACs in cancer patients, and that warfarin remains the preferred choice for patients with liver disease, kidney failure, mechanical heart valves and certain clotting disorders (thrombophilia).
Factors to consider
Warfarin offers protection for several days, whereas the DOACs have much shorter half-lives. Consequently, if you miss a dose of the newer drugs, especially those taken once a day, you could leave yourself unprotected, Dr. Bartholomew cautions.
“I tell all my patients if you miss a dose, you could easily be in trouble because the half-lives are shorter,” he says. “If you miss warfarin a day or so, you’re probably not going to have a problem, but if you miss a dose of these drugs, they’ll be out of your system pretty quickly. So, if someone has compliance issues, I would not prescribe these drugs.”
Overall, discuss your need for anticoagulation and your choice of anticoagulants with your physician, carefully considering the cost, convenience, safety and other pros and cons.
“If insurance is not an issue, I would encourage patients to take a DOAC, provided they’re appropriate candidates,” Dr. Wazni adds. “And, if the insurance doesn’t pay and they find a good anticoagulation clinic, warfarin is a great medication, but patients have to be a little more vigilant. A lot of patients have stayed on warfarin for many years, and they do fine without any problems.”
What you should do before — and after — you make your decision
Drs. Bartholomew and Wasni recommend the following checklist:
- Before starting therapy with any anticoagulant, tell your doctor about all supplements or medications you take that inhibit blood clotting, such as aspirin, nonsteroidal anti-inflammatory drugs (e.g., Advil®, Motrin® and Aleve®), clopidogrel (Plavix®), prasugrel (Effient®), ticagrelor (Brilinta®) or any medication containing heparin.
- Check with your insurance provider to see which, if any, of the direct oral anticoagulants (DOACs) it covers. Talk to your doctor and pharmacist about available discounts and drug-assistance programs.
- While on anticoagulation therapy, avoid contact sports or other activities that increase your risk of a potentially life-threatening bleeding event.
- Carry a card in your wallet, or wear a bracelet or pendant, identifying which anticoagulant drug you take.
This article originally appeared in Cleveland Clinic Men’s Health Advisor.