May 05 2014

goldman

Welcome to the clot club part 2 - Xarelto no bust, and thankfuly no slip-ups!

Posted at 3:14 am under Uncategorized

This is a continuation of sorts from my April 16 posting when at that time I was diagnosed with DVT. Last week I met with a vascular specialist at my hospital for an approximately two-week followup from the “incident” and to discuss the prescription of Xarelto and blood thinners in general.

Let me begin by saying that I had one of the most enjoyable visits to the hospital, any hospital ever. I was arriving yet again with my wife and 10-year old son in tow and some trepidation from the memory of my last Xarelto-based visit. Whereas the last visit involved several hours captive in the ER and my blood pressure sky high, this visit ended after 45 minutes with me feeling completely informed, my blood pressure at a cool 120/80, and reassurance that recovery was on track and we had made the best decision possible. My visit entailed meeting with Ann Pianca, a nurse practioner who was so knowledgeable about blood clots and the various prescription drug therapies, and so good at explaining them, that I was somewhat blown away. Made me think, “Man — if the doctors and surgeons at this hospital (Lahey Hospital in Burlington MA by the way) would only emulate Ann, Lahey would be number 1, rather than number 4, in the Boston area.”

My posts sometimes tend to the long side. For this reason I will cut to the chase for other blood thinner consumers or potential users reading this post that depending on your personal health history and body chemistry, if you are thinking about taking or are prescribed Rivaroxaban because you are a “good fit” for this medication– I can assure you that you have or will have made an excellent choice. So there you have it. If you want to exit this blog before getting drawn down the drain of my ramblings, do so now; I bear you no ill will, and wish you the speediest and nicest recoveries possible. I tip my hat and bid you adieu.

For those achillesblog gluttons of punishment that want to hear more, read on!

From the moment Ms. Pianca entered the examining room, to the moment we left I felt like I/we were being handled and informed by a real professional. She started out the conversation by advising us exactly how long we would be with her and what to expect from this visit. I interjected that my goals with the visit were three-fold: 1) To find out how long I would need to be on blood thinning medication, 2) Learn more about Xeralto, and 3) If I didn’t like what I heard to determine the fastest and most efficient means possible to switch medication.

Ann assured me that all my goals would be met, and more. She proceeded to outline the basics of the human circulatory system, explaining blood flow as we learned in high school and college anatomy classes. She explained why clots happen and how they are treated, the anti clotting mechanisms of Xeralto and Cumadin, since those are the two main thinning medications that are prescribed. There are several other medications, but some have more risky side effects, and/or are less well known. In any event for a person of my age (52) and health history (healthy except for the ATR and some previous high blood pressure and high cholesterol) those are the two choices. For people with more complicated situations, for example cancer, diabetes, older, etc. the other medications come into play.

One of my main concerns with Rivaroxaban is the known non-reversal component. This means that the anti-clotting features have no known way to be stopped. Where cumadin can be counteracted with vitamin K, Xeralto continues to work its “charm”. The implication is that if one is to suffer a traumatic injury while on Xeralto — one is going to bleed. The big concern is with internal injuries. This was the main reason I was planning on getting off Xeralto once I returned to driving. So I had been watching the calendar, relieving my wife of (some) of the many doctors and hospital visits that she has had to drive me to, and I figured that while I am non-driving less likely I will suffer a bleeding type injury. I had been thinking up to this point that I was going to switch to Cumadin, until I talked it out with Ann. It’s a bit complicated, and I will try to relay accurately what she told me, but the reader is advised with the usual caveats: do your own research, be your own best patient advocate, and make the decision that you feel most comfortable with. I can only relay my experience and contentment with sticking on Xeralto, but your situation may differ.

Anyway, back to the story about bleeding. Well it turns out that all the blood thinning medications (as far as I know this applies to all of them) have a half-life. Which means that the anti-clotting mechanism lasts only so long, at which point it needs to be re-inforced. By you guessed it - taking more medication :-) Rivaroxaban has a half life of 5 to 13 hours in most people. The implication being that if you do suffer a serious injury - you only have to wait a few hours before the anti-clotting mechanism stops and you can be treated appropriately (e.g. surgery). Cumadin on the other hand, has a much longer half-life - something like 20 to 60 hours. Now cumadin can be counteracted with vitamin K, and this is where I lost Ann a bit. But the vitamin K can’t be administered right away, or its effects don’t take right away, I am a bit hazy on this point. Patients can be treated with plasma infusions, but there are some limitations there as well. The big concern with Xeralto is dealing with head and brain trauma. What I gathered from Ann is that is one risk that can not be circumvented by other means (I’m sure there are other bleeding risks too, but she focused on that one), but as she put it: “Be careful. Wear seatbelts. If you ski, wear a helmut and know that if you hit a tree, well hitting a tree is risky whether on blood thinners or not.”

One of the main benefits to Xeralto over Cumadin is that it’s chemical properties make it a much smoother release into a person’s system. It’s just a pill, once or twice per day, and requires no monitoring. Cumadin requires monitoring which means more visits to the clinic, to assess it’s effective level and the dosing can vary greatly between patients. So after all the discussion of the half lives issue, and ease of use of Xeralto I was whole heartedly convinced to stay the course. I will be on the medication for about three months, at which point I will return for an ultrasound and appointment. One thing that I was surprised to learn - regardless of the ultrasound in three months, I will be taken off the Xeralto. I’m not really sure what happens from there, because Ann told me that once a blood clot forms, it’s much more likely to get them again in the future. So I guess I’d be back on one of the medications if that were to happen.

We ended the visit with a discussion of compression socks - with her telling me that I would need to wear those for two years, once I get out of the boot. Unfortunately the socks are a bit pricey, and not all insurance covers them, and some people can’t stand to wear them regardless.

So that’s my latest clot club update, until around July 11. Happy Healing!

3 responses so far

3 Responses to “Welcome to the clot club part 2 - Xarelto no bust, and thankfuly no slip-ups!”

  1. normofthenorthon 05 May 2014 at 11:47 am 1

    I read up on Warfarin/Coumadin back when I was on it. Like many drugs, “It’s complicated.” Part of what makes introduction and withdrawal (counteracting) complicated is that it (and Vit. K too?) has several different effects, in several different directions! Because of one “paradoxical” effect, a patient in the first day or 3 of it actually has an ELEVATED risk of clotting, and a depressed bleeding risk(!). That’s why W/C patients almost always get Heparin shots for the first few days of the pills, to overpower that dangerous effect.
    I think the complexity comes from the complexity of Vit. K in the body. W/C is a Vit. K antagonist, but it counteracts some of Vit. K’s impacts quickly, and others only after a few days. Not simple, but finally well understood in most medical centers.

  2. goldmanon 05 May 2014 at 12:56 pm 2

    Ah yes, Norm, good that you confirmed the complicated nature of Warfarin. I was afraid I was not conveying the information correctly. I will say that somebody like Ann who met with me last week sure did give me the warm and fuzzy that she knew exactly what she was doing whether she was prescribing Coumadin or any other anti clotting agent. Unfortunately I never really did get that solid of a feeling with any of the three surgeons I met with before the ATR operation, though I think the procedure turned out ok. At least so far it seems ok.

    One thing I forgot to mention was that while a person who has had a blood clot — due to whatever reason: surgery, genes/hereditary, age or whatever — is much more likely to get a clot in the future, the numbers can be reduced (at least according to her). If I recall what she told me: 40% of blood clot patients will develop another clot in the future. But if you wear the compression socks that number is reduced by another 40%, so that you can reduce your odds to 1/6 or so.

  3. serviceson 08 Apr 2019 at 2:41 am 3

    A lot of side effects and warnings. I guess the best variant is to search for the DVT research samples at Seattle Pacific University library. They have the list of Medicine papers.

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