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Health24.com | Blood thinners may have dangerous side effects
Blood-thinning drugs can save your life by preventing a heart attack or stroke caused by artery-blocking blood clots.
But these are powerful drugs, and a pair of new studies detail side effects people need to understand before taking them.
Risk of life-threatening bleeding
The effectiveness of a class of blood thinners called nonvitamin K oral anticoagulants (NOACs) can be significantly altered through interaction with other drugs, the first study reveals.
In some cases, these drug interactions increase a person’s risk of life-threatening bleeding in locations such as the brain and gastrointestinal tract. In other cases, the NOACs’ effectiveness is reduced, robbing patients of some protection against stroke and heart attack.
“NOACs alone do not pose a significant risk of bleeding, but the concurrent use of NOACs with certain drugs that share the same metabolic pathways may cause increased risk of major bleeding,” said study lead researcher Dr Shang-Hung Chang, an associate professor of cardiology with Chang Gung Memorial Hospital in Taoyuan, Taiwan.
Meanwhile, a second study found that blood thinners can greatly increase a person’s risk of finding blood in their urine.
The two studies were published in the Journal of the American Medical Association.
As a result, patients might unnecessarily wind up in the hospital or emergency room, or undergo an unneeded invasive procedure, said senior researcher Dr Robert Nam. He is a professor of surgery and head of genitourinary oncology with Sunnybrook Health Sciences Center in Toronto.
Preventing stroke risk
“Patients and physicians need to discuss this, to try and prevent patients having to be hospitalised or come to the emergency room in the middle of the night,” Nam said.
The first study looked at the bleeding risk associated with NOAC drugs dabigatran (Pradaxa), rivaroxaban (Xarelto) and apixaban (Eliquis).
These drugs are primarily used to prevent risk of stroke in people with atrial fibrillation, an abnormal heart rhythm that can cause blood to pool and clot inside the heart, said Dr Deepak Bhatt. A spokesman for the American Heart Association, he is also executive director of interventional cardiovascular programmes at Brigham and Women’s Hospital’s Heart & Vascular Center in Boston.
NOACs are being used more frequently because they’re easier to use and produce fewer side effects than warfarin, an older anticoagulant that has many food and drug interactions, said Bhatt.
There may be other alternatives in the future. According to Taiwanese scientists a blood thinner blood drug based on venom from the Wagler’s pit viper was effective in mice, and might prove safer than current anti-clotting meds for humans.
Chang and his colleagues also decided to investigate whether NOACs might have previously unknown interactions with other commonly used medications. The team analysed health data on 91 330 Taiwanese patients with atrial fibrillation who were prescribed an NOAC.
The investigators found that bleeding risk increased significantly when NOACs were used in combination with amiodarone, fluconazole, rifampin and phenytoin – four drugs that treat widely different conditions.
Lower risk of bleeding
The researchers also found that other drugs dampened the effectiveness of NOACs, including atorvastatin, digoxin, and erythromycin or clarithromycin.
Bhatt said he’s particularly concerned about the effect of atorvastatin (Lipitor) on NOACs’ effectiveness.
“That’s a very commonly prescribed cholesterol-lowering drug, especially now that it’s generic,” Bhatt said. In fact, the researchers found that atorvastatin was the drug most commonly prescribed alongside an NOAC.
“That’s a big deal because that means all those patients on both drugs have a lower risk of bleeding, but on the flip side then would have a higher risk of stroke,” Bhatt said.
The second study found that people are much more likely to go to the hospital for blood in their urine if they’re taking blood thinners.
Nam and his colleagues examined medical data on 2.5 million Ontario residents, including nearly 809 000 who had been prescribed a blood thinner.
During an average follow-up period of seven years, people on blood thinners were six to 10 times more likely to wind up hospitalised or in the ER complaining of blood in their urine compared with others not taking the drugs, Nam said.
Image credit: iStock
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All Physicians Should Engage In Pharmaceutical Whack-A-Mole: Please Follow Physiatry’s Lead
Medical school prepares physicians to prescribe medications for prevention and treatment of disease, but little to no time is spent teaching something just as important: de-prescribing. In our current system of auto-refills, e-prescriptions, and mindless “check box” EMR medication reconciliation, patients may continue taking medications years after their original prescriber intended them to stop. There is no doubt that many Americans are over-medicated, and the problem compounds itself as we age. Although “no-no” lists for Seniors (a tip of the hat to the American Geriatrics Society “Beers List”) have been published and promoted, many elderly Americans are prescribed medicines known to be of likely harm to them.
You may be surprised to learn that one medical specialty has taken advanced steps to address this problem. Physiatry (also known as Physical Medicine and Rehabilitation or PM&R) is a national leader in pain management education, and is the author and promoter of the majority of continued medical education (CME) courses on reducing opioid prescribing in favor of alternative pain management strategies. But did you also know that most patients who are admitted to an inpatient rehabilitation facility (IRF) are tested on their capability to correctly administer their own medications before they are discharged home?
The MedBox test provides a validated cognitive performance assessment of whether or not an individual can correctly distribute multiple prescription medications into weekly pill boxes as directed on the containers. This is a short video of how the test works, demonstrated by some occupational therapists having a good time with it. In one fell swoop, this test checks vision, reading comprehension, pharmaceutical knowledge, manual dexterity, attention, and short term memory.
This test is very helpful in picking up potential misunderstandings in how prescription meds are to be taken, and identifying cognitive deficits that might preclude accurate self-administration of prescription meds at home. One of our main goals in rehab is to make sure that patients have the skills, assistance, and equipment necessary to thrive at home, so that they can remain hospital-free for as long as possible. To that end, we feel strongly that limiting medications to those only truly necessary, as well as making sure that patients can demonstrate safe-use of their medications (or have a caregiver who can do this for them), can reduce hospital readmission rates, falls, unwanted drug side-effects and accidental drug-drug interactions.
In addition to MedBox testing, physiatrists invite hospital pharmacists to join their weekly patient team conferences. While we discuss patient progress in physical, occupational, and speech therapies, we also review nursing assessments of medication self-administration competency, and ask our pharmacist(s) which medications can potentially be stopped or decreased that week. Rehab physicians (familiar with patient health status, goals, and current complaints) and pharmacists together come up with stop dates and taper regimens at these weekly meetings.
Part of the reason why inpatient rehabilitation has been so successful at reducing hospital readmission rates, in my view, is that we are committed to pharmaceutical whack-a-mole. “Test-driving” patient competency at medication self-administration, in the setting of responsible de-prescribing in a monitored clinical environment, is a highly valuable (though sadly under-reported) benefit of rehabilitation medicine. I hope that my medical and surgical peers will join us physiatrists in combating some of the patient harms that are passively occurring in our healthcare system designed to add, but not subtract, diagnoses and treatments.
