Go for safety, not con­ve­nience in blood thin­ner

Times Colonist - - Life - DR. KEITH ROACH 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

Dear Dr. Roach: I was re­cently di­ag­nosed with atrial fib­ril­la­tion. I re­ceived ex­cel­lent care, and the car­diac doc­tors rec­om­mended a blood thin­ner, with a clear pref­er­ence for apix­a­ban. The pluses of apix­a­ban are no di­etary re­stric­tions re­lated to the med­i­ca­tion and no need for reg­u­lar, fre­quent blood mon­i­tor­ing. I fol­lowed their ad­vice and am now tak­ing it. But I am in­creas­ingly con­cerned about the fact that there is no way to re­verse dam­ag­ing bleed­ing, as there is for war­farin users. The doc­tors have all told me not to fall, be­cause the bleed­ing re­sult­ing from a fall most likely would lead to a de­bil­i­tat­ing stroke or death. I would like your opin­ion on whether it is wise to take the more con­ve­nient apix­a­ban or to stick with war­farin. Anon.

Apix­a­ban (Eliquis) is one of the newer oral an­ti­co­ag­u­lants, which are used in peo­ple who have an in­creased risk of clot, such as peo­ple with atrial fib­ril­la­tion or a his­tory of blood clots. (Peo­ple with me­chan­i­cal heart valves are not can­di­dates for the newer oral an­ti­co­ag­u­lants.) You are cor­rect that they have sev­eral ad­van­tages, but, like war­farin (Coumadin), they still in­crease the risk of bleed­ing. The risk for bleed­ing is about the same, or per­haps a bit lower, in the new an­ti­co­ag­u­lants com­pared with war­farin. War­farin has been in use for decades; it’s good that it has an an­ti­dote, but not good that it needs to be used.

One of the new agents, dabi­ga­tran (Pradaxa), has a spe­cific an­ti­dote. One has been de­vel­oped for apix­a­ban and ri­varox­a­ban (Xarelto), but it has not been ap­proved by the Food and Drug Ad­min­is­tra­tion as of this writ­ing.

It sounds to me like your big­gest con­cern is safety, not con­ve­nience. Right now, con­sid­er­ing apix­a­ban and war­farin, the data show that apix­a­ban has a lower risk of ma­jor and fatal bleed­ing than war­farin does. On the other hand, there is not yet an an­ti­dote for the rare case of a se­ri­ous bleed­ing episode. Nei­ther choice is per­fect, but if the an­ti­dote for apix­a­ban gets ap­proved, that might end up be­ing the safest choice. Dabi­ga­tran has an an­ti­dote avail­able and is a very rea­son­able choice now.

Dear Dr. Roach: How can a pa­tient dif­fer­en­ti­ate fre­quent uri­na­tion caused by an over­ac­tive blad­der from an un­der­ly­ing med­i­cal prob­lem like di­a­betes?

A.L.

Both over­ac­tive blad­der and di­a­betes (both di­a­betes in­sipidus, which is an in­abil­ity to prop­erly con­cen­trate urine, and un­con­trolled di­a­betes mel­li­tus, which causes loss of wa­ter along with sugar) cause ex­cess uri­na­tion. How­ever, in over­ac­tive blad­der, the uri­na­tion may be fre­quent or ur­gent, but usu­ally is in rel­a­tively small vol­umes, whereas in di­a­betes, the uri­na­tion is both fre­quent and in large amounts. The di­ag­no­sis can be sus­pected by this his­tory; how­ever, it’s wise for the physi­cian to ob­tain blood test­ing for di­a­betes in­sipidus (blood sodium level and some­times urine con­cen­tra­tion) and di­a­betes mel­li­tus (blood and urine sugar or blood A1c level) in some­one sus­pected of over­ac­tive blad­der symp­toms.

It’s also ap­pro­pri­ate to look for in­fec­tion, which can cause sim­i­lar symp­toms. In men, con­sid­er­ing prostate en­large­ment is im­por­tant.

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