Blood thinners

 
Column by Chris DeWald
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Blood thinners are commonly used in the prevention of strokes. This is especially important for people who have suffered a first stroke, as they have an increased risk of suffering a second one. In fact, about 30 percent of all strokes in a given year are repeat strokes. Thus, stroke survivors must be diligent about stroke prevention. However, even if you have never suffered a stroke, but are at risk of getting one, you are likely to be taking a blood thinner.

I remember the days at Augusta Health becoming aware of thinners. I am on Warfarin, and we shall discuss this later in the article. My first contact with a thinner was the nurse feeding my IV with a thinner called Heparin. Before the IV introduction, they had to inject it into my stomach for a faster effect. I was told that they were going to transfer Heparin over to Coumadin (Warfarin). This was for the rest of my life as the benefits of Warfarin outweighed the adverse effects. I heard the adverse effects more clearly, and I feel most of the panic is unnecessary for some of us. I had to watch an in house Coumadin Movie that scared the nine lives out of me. No more Vitamin K ingestion as it reduces the strength of the Coumadin/Warfarin. Also once a month or more I would have to undergo blood tests to determine the amount of thinner in my bloodstream. Too little does no good, too much and I could die. Gee, seems I have motivation for getting my blood drawn.

There are other thinners out there on the market.

Aggrenox
This medication is a combination of aspirin and extended-release dipyridamole. Almost 40 percent of patients on this medication report feeling a headache. Other common side effects include abdominal pain, indigestion and diarrhea.
What to watch out for: You should stop taking Aggrenox and go to your doctor or to an emergency room if you find black or tarry-appearing stools, as this is a sign of intestinal bleeding.

Aspirin
Aspirin can irritate the stomach and intestines and cause indigestion, nausea, and vomiting. The “enteric coated,” or EC, form of aspirin is gentler on the intestines and produces milder side effects. Other less common side effects of aspirin include difficulty breathing and intestinal bleeding.
What to watch out for: If you find black or tarry-looking stools this is a sign of intestinal bleeding. This, and any other forms of abnormal bleeding should prompt you to stop taking aspirin and to go to the nearest emergency room. Also go to the emergency room if you develop difficulty breathing while on aspirin. You should never give your children aspirin as they can develop a serious and often fatal disease called Reye’s Syndrome.

Coumadin
Also known as Warfarin, this medication is used to prevent strokes in people who suffer from atrial fibrillation, people who suffer blood clotting disorders, and people who have mechanical heart valves. Coumadin can cause serious bleeding. To avoid this, people who take this medication must have routine blood testing to monitor their INR, or International Normalized Ratio. This is an international measure of coagulation which attributes a value of 1.0 to people with a normal ability to clot. As the INR increases, it reflects that a person is less likely to form blood clots. Patients with atrial fibrillation must maintain an INR of 2-3 in order to effectively decrease their risk of stroke.
Coumadin works by decreasing the amount of vitamin K available for use in the body, which in turn reduces the efficiency of blood clot formation by the body. This is why you should monitor your intake of foods that are rich in vitamin K. Consuming too much of these foods can prevent Coumadin from working properly and may leave you temporarily at a high risk of stroke. Some foods with high vitamin K content include spinach, lettuce, alfalfa sprouts, asparagus, broccoli, cauliflower, and cabbage. Doctors recommend that you eat the same amounts of these food items every day in order to maintain a steady level of vitamin K in your body. This will both ensure that Coumadin works properly, and that you will have a low risk of dangerous bleeding while you take Coumadin.
What to watch out for: By far the most common side effect of Coumadin is abnormal and sometimes profuse bleeding. Often the abnormal bleeding can occur inside the eye, and in the intestines. Because of this, people who take Coumadin must monitor stool color and seek medical attention if stools become black or tarry-appearing. Of course, bleeding and easy bruising can occur anywhere in the body.

Heparin
Heparin is usually given in the hospital directly into a blood vessel (i.e., intravenously) in order to prevent blood clot formation, and to enhance the body’s ability to break down existing blood clots. For heparin to work safely, blood must be drawn periodically in order to make sure that its levels fall within a safe margin. The blood test performed to do this is called the partial thromboplastin time or PTT. The main side effects of heparin are bleeding and easy bruising. Irritation at the site of the injection can also occur. In some rare instances heparin can cause an allergic reaction.
What to watch out for: The most common and dangerous side effect of heparin is abnormal bleeding. Therefore, you must be on the lookout for black stools, which reflect intestinal bleeding, or for orange, pinkish or smoke-colored urine, as this indicates there is blood in the urine.

Lovenox
Lovenox, also called enoxaparin, is a form of heparin called fractionated heparin. Lovenox does not require monitoring of its blood levels and it can be injected intramuscularly. People with chronic kidney disease should not use Lovenox as poor kidney function makes Lovenox accumulate in the blood. The side effects of Lovenox include skin irritation at the site of injection and nausea.
What to watch out for: Rarely people develop an allergic reaction to Lovenox and develop a rash. If severe, the reaction can cause swelling on the hands and lips, and difficulty breathing. If you develop any of these symptoms while on Lovenox you should go to an emergency room. For further symptoms (bleeding) caused by abnormal reactions to Lovenox please refer to the “what to watch out for” section under heparin (above.)

Plavix
Common side effects of Plavix include stomach pain, muscle aches, dizziness, and headache. Easy bruising and nose bleeds can also occur. People who have stomach ulcers might develop intestinal bleeding, which can be life threatening.
What to watch out for: if you find black or tarry-looking stools this is a sign of intestinal bleeding. This and any other forms of abnormal bleeding should prompt you to discontinue the medication and to go to the nearest emergency room.

I have said earlier, I am on Warfarin and maintain anywhere between a 2.0 and a 3.0 INR. I test locally once a month to insure I am flowing correctly. I have heard all different types of rumors concerning Warfarin and bleeding. Yes, you can and will bleed more if cut as the clotting factor has been lowered.

I have found a website that tells me the risk of most foods containing vitamin K. Some listed shall surprise you. This site also list if they are high or low in Vitamin K content. I suggest you go peek at it.

www.drgourmet.com/warfarin/vitaminkcontent.pdf.

Now, why am I on this story? It is very important this time of year for us on blood thinners. The nose is a part of the body rich in blood vessels (vascular) and is situated in a vulnerable position as it protrudes on the face. As a result, trauma to the face can cause nasal injury and bleeding. The bleeding may be profuse, or simply a minor complication. Nosebleeds can occur spontaneously when the nasal membranes dry out and crack. This is common in dry climates, or during the winter months when the air is dry and warm from household heaters. People are more susceptible to bleeding if they are taking medications which prevent normal blood clotting warfarin (Coumadin), aspirin, or any anti-inflammatory medication]. In this situation, even a minor trauma could result in significant bleeding.

The incidence of nosebleeds is higher during the colder winter months when upper respiratory infections are more frequent, and the temperature and humidity fluctuate more dramatically. In addition, changes from a bitter cold outside environment to a warm, dry, heated home results in drying and changes in the nose which will make it more susceptible to bleeding. Nosebleeds also occur in hot dry climates with low humidity, or when there is a change in the seasons.

　

What precautions can you take to prevent nose bleeding?

The most common cause of a nose bleeds is drying of the nasal membranes. If you are prone to recurrent nosebleeds, it is often helpful to try lubricating the nose with an ointment of some type. This can be applied gently with a Q-tip or your fingertip up inside the nose, especially on the middle portion (the septum). Many patients use A & D ointment, Mentholatum, Polysporin/Neosporin ointment, or Vaseline. Saline mist nasal spray is often helpful (Ocean Spray). I use a combination of saline solution spray and Vaseline. I would watch on the method of application. I use my finger as a q-tip and my spasms might not be a good idea.

Check with your physician on this. For those using a CPAP or BiPAP device, this is very important to keep the nasal areas moist. Starting a bleed in the nose is detrimental for then trying to use your CPAP or BIPAP. It is a great way to check out the CO2 relief valves, but hard to clean the mask afterwards. Trust me on this.

  

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