Provoked clots may make the case to come off blood thinners
DEAR DR. ROACH: I would like your opinion about staying on blood thinners for the rest of my life. In July, a CT scan showed a small blood clot in my lowerleft lung. This was an indirect the result of a Grade 3 hamstring pull suffered while jogging. I am now on 20 milligrams Xarelto daily.
My doctor said that I would need to stay on blood thinners for the rest of my life because in 2010 I had a DVT and blood clots in both lungs as a side effect of birth control pills. (At that time, I took Coumadin for six months.)
I am 63, exercise daily, maintain a 1,200-calorie diet and take no other medications. After the current blood clot is reabsorbed into my bloodstream, I want to stop taking Xarelto. Is that advisable or do I really need to be on this medication for life? — E.D.
ANSWER: There is not a clear right or wrong answer to your question. My guess is that if you saw 10 hematologists with expertise in managing people with blood-clotting issues, eight of them would tell you to stay on some kind of anticoagulant — both warfarin (Coumadin) and rivaroxaban (Xarelto) reduce your body’s ability to make clots — but two would not. There is much room for judgment in medical decision-making, and the patient’s desires need to be factored in.
In your case, you could make an argument that both of your clotting events were “provoked,” meaning there was some identifiable reason for them. In the first case, the risk was eliminated by stopping the oral contraceptives; in the second, it was due to a muscular injury (perhaps you were on bed rest for a period of time afterward, which is a clear risk factor). These factors argue against the necessity for lifelong anticoagulation.
On the other hand, a history of blood clots means there is damage to those deep blood vessels. Even though the body partially heals them, you are always at higher risk for developing a clot. Also, a blood clot in the lung (pulmonary embolus) is potentially life-threatening, and two pulmonary emboli is generally an accepted indication for lifelong anticoagulation.
I have seen people go to doctor after doctor until they get the opinion they want. That’s a mistake, in my view (and I’m not saying you are doing that). Rather, I’d recommend going back to the doctor who has recommended the longterm Xarelto and ask what she or he thinks the risks and benefits are, and explain your reasons for wanting to avoid the medication.
Finally, do you really mean 1,200 calories? That’s not enough for most people.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or request an order form of available health newsletters at 628 Virginia Dr., Orlando, Fla., 32803. Health newsletters may be ordered from www.rbmamall.com.