Posts Tagged ‘Warfarin’

Dabigatran approved!

October 21, 2010

For the first time in nearly 50 years, patients with Atrial Fibrillation (A-Fib) have a new blood thinning option: Dabigatran. The talk is already starting about how this could replace Warfarin (which is really RAT POISON… we’re just given it in doses too small to kill us!)

One can hope, but there is still a lot that we need to learn about the drug. The US Food and Drug Administration has approved it only as a preventive for stroke caused by A-Fib. Will it even work for anything else? The odds are that it will, but it still needs to be tested. How are people with mechanical valves going to react to it? Somebody’s going to have to take a deep breath and test it. Yet another problem is the cost. Dabigatran is estimated to cost $8 to $12 per day; Warfarin has been around so long that the cost is a pittance. But that is just the cost of the drug – with Warfarin, you also get the required monitoring, in the form of the INR Test. Dabigatran doesn’t require monitoring. Does the cost of Warfarin plus the cost of the test plus supplies make its cost roughly equal with Dabigatran?

There’s another major drawback for certain CHDers: Dabigtran is currently not recommended for “patients with the presence of a severe heart-valve disorder.” That sounds like Tricuspid Atresia patients, Hypoplastic Left Heart Syndrome patients, and those with several other defects are out of luck. Perhaps it is not for us because of lack of testing; if that is the case, the recommendation may change in the future.

At the moment, Dabigatran looks like a drug with a limited potential. Hopefully real world experience will change this.

Let’s do it again!

June 24, 2010

“All this has happened before; and it will happen again.”Battlestar Galactica

I’ll give you three guesses to figure out what I have been doing today.

Today, I went to the doctor’s office to have blood drawn; I bought medication;  and I bought groceries. The groceries I don’t mind – we all have to eat, of course. But since I am on a blood thinning medication (Warfarin) I have to go in every so often and have my INR number checked. Warfarin is a delicate drug – it’s really rat poison – and it seems to be able to go up and down on its own. Tie your shoes, the number goes up. Cross your legs, it goes back down. It seems like anything can affect it.

So you must have your Prothrombin Time (PT) checked. The results are given as the INR Number (which stands for International Normalized Ratio.) If the INR falls within you Therapeutic Range, everything is good. If it doesn’t… your doctor is going to adjust your medication and you’ll have to have a retest, usually in two weeks. My INR number has been riding a rollercoaster lately, and I’m feeling like a pin cushion.

If you are lucky, you can do the test at home. You test your blood much as a diabetic would, only you are looking for the INR number, not a Blood Sugar level.  I haven’t been lucky – My hemoglobin is too high, and it makes the testing machine go crazy. So I have to drive 20 miles for the privilege of having a needle stuck in my arm.

My medications tend to make my head spin, too. I take 14 different medications a day, and if I could figure a way to get the same amount of pills for each prescription, I think I could figure a way to refill them all at once. But no – some of them are 30 day prescriptions; a couple are 60 day; and a few are 90 day prescriptions. I think I go to the Drug Store every two weeks! It’s not difficult (if you keep close track of when you need refill and prescription renewals) but is sure is inconvenient!

This probably sounds like a whine, and it very well could be – it seems that as soon as I get through one “cycle” of refills or blood draws, it’s time for another. And my heart problems aren’t going away, so I’ll be doing this forever. But doing these things are extremely important, and they allow me to live my life. I enjoy life – I just get frustrated at the repetition.

But it is an important part of not giving up. These drugs and the blood tests allow me to do things like go to Houston for Hearts Re-United 2010. I recently got a new laptop bag, and one of the things that was important to me was to get one that had plenty of room for medication. The old one didn’t, and trips longer than 4 days required some creative packing on my part. (NEVER pack your medication in your checked baggage if you are flying. If you go to Detroit and your bag goes to Dallas, you’re in trouble!)

So yes, I’ll whine a little about blood tests and prescription refills – but I’ll still do it. I’m having too much fun to let my bum heart win!

A Replacement for Warfarin?

March 22, 2010

A lot of people dislike Warfarin. Also known by its brand name Coumadin, it is the most prescribed anticoagulant (Blood thinner) in North America. If you can get past the fact that you are taking something that is also used as rat poison, the constant monitoring and dosage adjustments are a pain in the butt. Every six weeks you must have a blood test, and it reacts with nearly everything. Other medications and even your choice of foods can make the drug more or less effective. This requires you to adjust your medication and have another blood test. It’s enough to make you yell!

But there are two new anticoagulants being developed that could replace Warfarin. The first is Dabigatran, which is marketed in Europe as Pradaxa. Dabigatran was approved for use in Europe and Canada in 2008 and is currently being considered here in the United States by the Food and Drug Administration.

Dabigatran has all the appearances of a wonder drug. It has done well in scientific studies: the RE-LY clinical trail shows that it performs better than Warfarin at some dosage levels; the RECOVER study proves that there is no need for the constant monitoring and no food/drug interactions.

If you’re waiting on the other shoe to drop, here it comes: Dabigatran is expensive. Great Britain’s National Health Service pays £4.20 per day for Dabigatran, and about £1 per day for Warfarin.

Ugh. Now that’s a problem.There are several theories that the cost difference can be recouped not only through the savings in monitoring costs, but the costs associated with stroke recovery. The simpler a medical therapy is to use, the more likely someone is to follow the instructions and benefit from it. Warfarin is difficult to maintain, while Dabigatran wouldn’t be. Just take your pill and go about your business.

The other new drug is Betrixaban, which is still being developed. It’s a joint venture between Merck and Co. and Portola, and like Dabigatran requires no monitoring and has almost no interactions. But it is still in Phase 2 testing, a long way from public use. Also, Portola is developing an “off switch”; another drug that can be administered in case of a heavy bleed and deactivate Betrixaban.

The potential market for any company that can develop a Warfarin replacement that has less interaction and less monitoring needs is wide open. Hopefully market forces will not only benefit the companies developing new drugs, but those of us who rely on them.

New Blood Thinners!

September 28, 2009

The European Society of Cardiology held its annual big meeting recently, and the major news revolved around some new blood thinning medication coming to the market.

The two major blood thinners available now are Plavix, manufactured by Bristol-Myers and the second best selling drug in the world, and Coumadin, also known as Warfarin, which has been available for at least fifty years and is considered the “Gold Standard”. If you need to take a blood thinner, odds are you are on one of these two pills.

The new drug Pradaxa was compared to Warfarin and the results were roughly equal, with Pradaxa being slightly better. One advantage to Pradaxa is that the dosage is based on weight, not monthly blood tests, and there are fewer interactions with other foods and drugs. Not getting those pokes would be great!

Brilinta, another new anticoagulant, was tested gainst Plavix and found to be better at reducing heart attacks, strokes, and death. The study also found there were less bleeding problems with Brilinta.

A third drug, Dabigatran, was tested against Cumadin. In that study, Dabigatran seems to outperform Cumadin at higher doses and be roughly equal in lower doses.

All of these drugs are still in the testing phase – so it may be a while (quite a while!) before your doctor offers them to you for your anticoagulation needs.

Pass the plate, gain a little weight. Walk a mile, make your doctor smile!

December 25, 2008

Happy Christmas Day 2008!

Thanks to the economy, this may not have been the most exciting Christmas on record (at least to the retailers) but the important thing is that we are all here!

Today was quiet; my family has our gathering on Christmas Eve. And I love every moment of it… until I step on the scale the next morning.  Then I’m not such a fan. I am so glad that I don’t have a talking scale, because this morning  it would have said “Unnnnh…. Come on, come on, read the dial and get offa me! Whew, that’s better… wait a minute, getting back on isn’t going to give you a lower reading! That’s not gonna wo-UUUHHH!”

There was a lot of options to choose from yesterday; starting with my mom’s barbeque. I can enjoy her barbeque because she uses very little salt, so a good bit of that goes on my plate. I get a little slaw but that’s it; the Vitamin K found in most leafy greens doesn’t get along well with my blood thinner. At least, that’s what I tell myself; I’m also a junk food junkie. My membership in the That’s not Good for Me Club is pretty much honorary these days, but old habits are hard to break.

So far, I’m doing ok – barbecue, rice, some slaw, and a piece of bread. Once I finish, I examine the desert table very carefully. Coconut Pie, Peanut Brittle (Already in individual plastic bags, so it is meant as take-out) an Orange Slice Cake – the candy, not the fruit – and “stickies”. Some people call these “haystacks”; they are Graham Crackers dipped into a Carmel coating and then coated with chopped pecans. When the Carmel coating dries, the pecans will stick to the crackers.

My aunt called and is running late, she sent word just to go ahead and start and she would catch up when she arrived. She walks in the door carrying a large container of thin cookies and a homemade pizza loaf. The cookies are a family favorite, but the pizza loaf… we’ve been having this Christmas gathering for years and I’ve never seen this before! Have you been holding out on us?!?!

She turns the oven to broil and shoves in the pizza loaf, and in a few moments in begins to smell wonderful. Well, I thought I was through eating… but I’ll take a small piece. I really shouldn’t, but it smells so good. Oh. Dear. Heaven. This is delicious. Maybe one more small piece….

More? I think you guys are trying to kill me, but hand me some before I pass!  Yes, that one right there, please!

And so on, until this morning, when the scale gave me the bad news. I hate pizza loaf! It is an abomination, and a pox upon my house! Keep it away from me!

Well, it is dreary and rainy today. Weather does funny things; after it rains, I can hear the train whistle blow as it passes through town, five miles away. I normally can’t hear that sound. Inclement weather will also cause your weight to go up. I’m sure that’s the problem… right doc?

‘Till next time!

Don’t be a tough guy!

December 21, 2008

I can guarantee that this Christmas is going to be better than last Christmas!

Last December 10, I had my pacemaker replaced. The battery was running dry, so it was a simple procedure – the operation only took about 45 minutes. After they released me later that day, the hospital staff instructed me to resume taking my medications (including Warfarin) that night.

In retrospect, the Warfarin might have been resumed a bit too soon. My pacemaker is implanted in my left abdomen, just beneath the rib cage. In a few days I had developed a bruise that ran from the incision down to my waist, and stretched from my navel to the small of my back.

And if that wasn’t bad enough, the painkillers weren’t working. Medical personnel will often ask you to rate your pain on a scale of 0 to 10, with 0 being “I don’t hurt a bit.” and 10 being “I hurt too much to die!” They had prescribed Lortab, but I learned that Lortab makes me sleepy, and that’s about it. My pain level was 8+, and I spent most of my waking hours sitting in a wooden straight backed chair.

“Wouldn’t you be more comfortable in a recliner, or on the sofa?” a lot of people asked me, and I’m sure that I would have. But getting seated and getting back up bothered me so much, it was much easier to stick with my wooden chair. At least I could reach a light to read and could see the TV. That’s about all there was to do.

I got an appointment to see my Cardiologist on the 19th… pretty quickly for a doctor’s appointment, but that’s forever when you are hurting. The staff did the blood pressure check, the PulseOx, and then the doctor came in.

“Let me see this bruise you were telling me about,” he asked. I took my shirt off.

“Yowsa!” he said when he saw my king sized bruise. I wondered if that was a recognized diagnostic term.

My doc is on the ball. I left his office with a prescription for a stronger painkiller and another week’s worth of antibiotics just in case. Since I had my new pacemaker implanted at the hospital, the pacemaker team sent someone up to examine me, also. “We’re going to have to rethink our anticoagulant therapy procedures, that’s for sure,” he said.

The new painkillers helped almost immediately, but it was about a month before I felt completely human again, and a six weeks before the pacemaker replacement was just an unpleasant memory.

If you are having heart surgery or any number of cardiac procedures, there is going to be some pain involved, and you may just have to put up with it for a little while. But you shouldn’t just HURT, not to the point that you can’t even sit in a padded chair. That’s the time when you don’t need to be the toughest guy on the planet; call your doctor and get some help.

Brrr!

October 20, 2008

Dad-gummit, I hate cold weather!

After I got up this morning and ate breakfast, I checked the thermometer before going outside to walk. The temperature was 48.

Now I know some of you are gonna laugh and even might be saying “The guy is a WIMP!” I’ll admit to it. I do not like cold weather. Some of it is Cyanosis, but it never really hit me until after I started taking Warfarin.

Warfarin is an anticoagulant, which means it slows down the clotting agents in your blood. One of the side effects is a tendency to feel cooler, so when it starts getting cold, it takes me a couple of days to get used to it. My joints tend to creak and hurt for a day or so, so I just take it easy until I get used to the cooler weather. And actually, I don’t think that’s caused by my heart. A few years ago I fell flat on my back on a cement surface.  I hit the ground so hard my teeth rattled, and I’ve had little aches and pains when the weather turns cold since then. I think all my bones got rattled that day.

Back to Warfarin… Warfarin stands for the Wisconsin Alumni Research Foundation, who helped develop the drug, and you may know it better by the brand name: It is usually sold as Coumadin.

It was discovered in the 1920’s completely by accident. Cattle were suddenly dying… a small injury would cause a tremendous amount of bleeding, and the animal would bleed to death. Even stranger, a healthy cow would just suddenly fall over dead, and when they cut him open to try to find the problem, they discovered that the cow had massive internal bleeding. Finally, it was determined that all of the sick cows had eaten a certain type of sweet clover. Cows had been eating clover since there was clover, what was causing the problem?

It was determined that the problem wasn’t the clover itself, it was storing it. Clover that had been stored under the right conditions developed a mold. The mold itself wasn’t poisonous, but it prevented blood from clotting when eaten.

It took nearly 30 years for all this to be figured out, and at first, it was sold as rat poison. But then someone attempted suicide by ingesting the stuff, but they recovered. After this, studies were done to see if it could be used on humans as a blood thinner, and Dwight Eisenhower was one of the first patients to use it.

Warfarin can be some wicked stuff, and you have to be tested to make sure your dosage isn’t too high or too low. Usually your test is once a month, but if the dose has to be changed, you could need to get tested once a week until the new dose takes effect. Don’t panic, you probably aren’t going to cut your finger and bleed to death, but injuries have to be dealt with right then. More than once I’ve nicked myself while shaving and had to clean up a mess. (If you switch to a “three floating head” type of shaver, shaving cuts shouldn’t be a problem anymore.) Warfarin allows you to live an active healthy life, but the line has to be drawn somewhere. If you’re on a high school football team when you are prescribed the drug, you’ll almost certainly have to turn in your pads. You will bruise too easily. I carry an older cell phone that no one makes a holster any more, so it’s in my pocket. One of my personal signs of too much Warfarin is a bruise where that phone taps my leg as I walk. So you can see it is a powerful drug.

Vitamin K affects and is affected by Warfarin, so you have to be careful about your leafy greens. Don’t stop eating them, and don’t start eating more than you usually do. You just have to learn to be consistent about it. Try to have about the same amount at about the same time each week. If you usually have a salad for lunch on Mondays, Monday just may have to become a Salad For Lunch day.

Don’t be scared of the drug, but have respect for it. Millions of people take it everyday and they live great lives. There is no reason you can’t be one of them.

Not on MY life!!!

October 9, 2008

This is unreal.

My hospital is not going to be doing the prothrombin test anymore: That’s the test of the Warfarin level in my blood that gives me my INR number. And it isn’t really their fault — their accreditation agency told them to stop offering the test. Apparently, if your Hemocrit is above 55%, they have to hand-calculate the results to determine the correct INR. The hand calculation means they can not guarantee the accuracy of the results, and so they ordered the hospital lab not to offer that test anymore.

I’m not mad at the lab techs. They are some of the nicest people I’ve met, and always bend over backwards to help me out or to hurry up the process if I ever need a test rushed. And they can still do the CBC test for me. But I’d really like to talk to someone from the accreditation agency. if you aren’t offering this test to people with a Hemocrit over 55%, what about the patients in the hospital? And if you suddenly can’t speak for the accuracy of the results, then what about all my previous results? I’ve had that test done once a month for SIX YEARS; are those results suddenly no good?

But like I said, I’m not mad at the hospital lab. I’m not mad at the accreditation agency, though if I sat down and asked them some questions, I’d probably be steaming before we were through. You are about to meet the people I am really mad at.

Before I even knew there was a problem, my doctors and nurses in Atlanta learned about it and were trying to work out the problem. One of my Nurses Googled my area and found this group of doctors, who have an office about half a mile from the hospital. She called them, explained the situation, and asked if they would be willing to do the prothrombin test for me.

Now don’t let the fancy name fool you. They aren’t a state agency, what they are is a group of 24 cardiologists who, along with their Nurses and Nurse Practitioners, work at five offices spread throughout the middle part of the state.  So my Nurse asks if they are set up to do a prothrombin test on a patient with a Hemocrit above 55%.

Certainly! came the answer.

Can you do it for a local patient of ours, and forward the results?

Absolutely not.

Before they will do a lab test for me, I would have to transfer all of my cardiac care to them. Look down their list of doctors — there is not a Pediatric Cardiologist in the entire group, much less an Adult Congenital Heart Specialist. But they are arrogant enough to demand that I leave the doctors and nurses that I trust, and who specialize in care for my heart, before they would stick a needle in my arm.

I’ll answer them with the same answer they gave my nurse: Absolutely not.

South Carolina has the highest death rate from heart disease in the country. Heart disease – the problems you have when you age, nasty stuff builds up in your arteries, and you have heart problems because of that. If you have a heart attack followed by a bypass, these are the guys for you. Congenital Heart Defects are pretty consistent throughout the population: 1 in every 125 people have a CHD; slightly more in some areas; slightly less in others. The composition of their staff shows that they are not interested in dealing with Congenital Heart Defects; I guess it just isn’t a “growth industry.”

And that is why I am miffed. They have offices in the larger cities, but they also have some offices in smaller areas. It would be the perfect situation for them to hire a Pediatric Cardiologist and move him/her between these smaller offices, providing good health care to sick kids (and adults) in the rural parts of the state. But it seems that they are chasing the dollar bill. Maybe that heart on their sign should be green, not red.