Warfarin vs Novel Anticoagulants
Discussion
Neuro expert in the house? Help needed to understand please!
A close relative with AF has been taking Warfarin for 10-15 years. About 10 days ago he suffered a haemorrhagic stroke. Vit K injection administered within an hour and warfarin stopped. He has had no anti-coag drugs since whilst the consultant decides which NoAc to use.
I understand the benefit of the NoAcs - no need for constant monitoring, shorter anti-coag effect - but what I don't understand is why they are being considered for a patient with a history of haemorrhagic stroke as there is no 'antidote' to stop a bleed.
I'd like to understand so that I can have a sensible, informed discussion with the consultant. Help please?
A close relative with AF has been taking Warfarin for 10-15 years. About 10 days ago he suffered a haemorrhagic stroke. Vit K injection administered within an hour and warfarin stopped. He has had no anti-coag drugs since whilst the consultant decides which NoAc to use.
I understand the benefit of the NoAcs - no need for constant monitoring, shorter anti-coag effect - but what I don't understand is why they are being considered for a patient with a history of haemorrhagic stroke as there is no 'antidote' to stop a bleed.
I'd like to understand so that I can have a sensible, informed discussion with the consultant. Help please?
Not a neurologist but possible that his INR (a surrogate marker /measure of warfarin level) was very high which caused the bleed. The NOAC would keep him in a safe therapeutic window. Restarting an anticoagulant in this scenario would only really be contemplated if the ongoing risk of thrombosis/ embolus is high. Sometimes a tricky call.
Biglips said:
Not a neurologist but possible that his INR (a surrogate marker /measure of warfarin level) was very high which caused the bleed. The NOAC would keep him in a safe therapeutic window. Restarting an anticoagulant in this scenario would only really be contemplated if the ongoing risk of thrombosis/ embolus is high. Sometimes a tricky call.
Hi Biglips and thanks for the reply. He is at high risk of a clot forming because of the AF so he will be given anti-coag meds. What I don't understand is why they would be contemplating giving him an anti-coagulant that doesn't have an antidote. If NOACs maintain a safe therapeutic level of blood 'clotiness' (sorry!) why is warfarin ever prescribed?
Not a v. articulate post - sorry! It has been a long day....
The NOACs are marketed as being at a certain dose to achieve therapeutic range, but as we can't measure it do we really know how anti-coagulated someone is? The half-lives are shorter, true, but that raises the possibility of being subtherapeutic. This is something I grapple with quite regularly.
Throwing something else into the works (as it's only rarely done currently) - what about left atrial appendage occlusion? Left atrial appendage is thought to be the source of most thrombus and I think some of the big centres in Englandshire might be doing this on a select few folk. But that's as far as my knowledge of this goes.
Throwing something else into the works (as it's only rarely done currently) - what about left atrial appendage occlusion? Left atrial appendage is thought to be the source of most thrombus and I think some of the big centres in Englandshire might be doing this on a select few folk. But that's as far as my knowledge of this goes.
LBird said:
Hi Biglips and thanks for the reply.
He is at high risk of a clot forming because of the AF so he will be given anti-coag meds. What I don't understand is why they would be contemplating giving him an anti-coagulant that doesn't have an antidote. If NOACs maintain a safe therapeutic level of blood 'clotiness' (sorry!) why is warfarin ever prescribed?
Not a v. articulate post - sorry! It has been a long day....
Warfarin still used as it is cheap.......He is at high risk of a clot forming because of the AF so he will be given anti-coag meds. What I don't understand is why they would be contemplating giving him an anti-coagulant that doesn't have an antidote. If NOACs maintain a safe therapeutic level of blood 'clotiness' (sorry!) why is warfarin ever prescribed?
Not a v. articulate post - sorry! It has been a long day....
Wrt an antidote in the event of intracranial haemorrhage it is usually self determining regardless of antidote unless you are already in hospital when immediate CT and then reversal is an option. Usually Either brisk and fatal immediately or stops spontaneously and then reversal reduces further bleed risk.
As mentioned by others warfarin is cheap, but a bit crude - it's basically rat poison. I was on it for 30 years and getting the INR rate right is a bit of a black art.
For the last 10 years I've had one of more versions of this device...
https://shop.coaguchek.com/buy/?utm_source=bing&am...
... you have to purchase the machine, but the consumables are available on prescription. Saves a lot of messing blood test wise and gives peace of mind.
Generally warfarin is consistent, my doc's were loathed to start moving me to the newer anti-coags... the Vit-K is also useful if something goes pear shaped / you need surgery as it acts pretty quickly.
RTS
For the last 10 years I've had one of more versions of this device...
https://shop.coaguchek.com/buy/?utm_source=bing&am...
... you have to purchase the machine, but the consumables are available on prescription. Saves a lot of messing blood test wise and gives peace of mind.
Generally warfarin is consistent, my doc's were loathed to start moving me to the newer anti-coags... the Vit-K is also useful if something goes pear shaped / you need surgery as it acts pretty quickly.
RTS
Pradaxa, the first to market NOAC, currently has a fast-track licensing process for its antidote, and it's looking good. Personally I'd take Pradaxa or Elliquis immediately, as efficacy is well proven and short half-life will be as effective as antidote if there's problems in the real world.
A much better decision than unstable warfarin or, worst still, ineffective asparin.
A much better decision than unstable warfarin or, worst still, ineffective asparin.
Sorry no help for the original poster you need to speak to an experienced elderly care consultant.
They will pick the least worse option - risks with all.
Personally I am very cynical about the NOAC's due to some major issues.
Firstly if you have a significant bleed on one of these it is very difficult to reverse.
Warfarin much simpler to reverse and quicker.
Also the idea that they don't need monitoring does not really make sense.
It seems to be a marketing tool - of the major three in the UK most labs can indirectly measure 2 of them.
The idea that a 60kg women needs the same dose as a 110kg man .....
They will pick the least worse option - risks with all.
Personally I am very cynical about the NOAC's due to some major issues.
Firstly if you have a significant bleed on one of these it is very difficult to reverse.
Warfarin much simpler to reverse and quicker.
Also the idea that they don't need monitoring does not really make sense.
It seems to be a marketing tool - of the major three in the UK most labs can indirectly measure 2 of them.
The idea that a 60kg women needs the same dose as a 110kg man .....
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