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The doctor who said that patients should have their INR checked like Warfarin and that big pharm is to blame for not doing so is not accurate. The doctor doesn't understand the laboratory aspects of the tests and how the specific tests are optimized in the case of Warfarin the PT and in the case of heparin the PTT. There is a variety of reagents that can be used for coagulation testing and sources for tissue thromboplastin can be obtained from lung, heart or brain sources. The sources for the extracts used for the PT are optimized to work best for Warfarin and allows a nice straight linear graph of reactivity that correlates with drug concentration and the PT results in seconds. One wants the PT seconds to be a nice broad range to establish a therapeutic reference range. One does not want a narrow range between therapeutic levels to all of a sudden have critical high levels of PT results. That's an insensitive test. Some tissues used work best for Warfarin. Some places have two different assays for PT when one wants to use the test to check for lupus anticoagulants and not for Warfarin. The other assay is more sensitive in detecting that condition. The INR was devised because the strengths of the reagents varied and they varied because people were using different sources of reagents. Some people wanted weak reagents while other wanted stronger reagents thus one could not use the seconds result but had to convert to more standardized INR. The formula incorporates the strength of the reagent.
The INR as a whole is a much stronger reagent that is being used than with the PTT. The PT time a normal result is usually about 12 seconds whereas a normal PTT the clotting time is normally around 32 seconds. One uses the PT for Warfarin because there are several coagulation factors impacted by the Warfarin such as II, VII, IX and X. So that test takes a hit when using Warfarin. It isn't a good test for Xarelto. The only one Xarelto effects is factor X. The more sensitive of the two would be PTT where it would impact the factor X there.
The PTT is optimized for heparin monitoring and not for Xarelto monitoring. There's other tests like activated anti-Xa assays that again have as a standard heparin standards and results are reported out as heparin units of activity. Some places have modified the test and have set or used Xarelto standards for calibration of activity rather than heparin but those are still far and few mainly because as the paper below states it does not need monitoring.
Mike gave a good response in explaining the concerns about Xarelto.
"Monitoring
No routine coagulation test monitoring is required.
Rivaroxaban and apixaban will lead to mild prolongation of the APTT and PT but these can not be reliably used to confirm or exclude a rivaroxaban or apixaban anticoagulant effect. Rarely there may be a role for using specific anti-Xa assays to assess the anticoagulant effect but evidence is limited – discuss with on call haematologist."
I would keep an open mind about everything until you get the whole picture and listened to all of the doctors and have asked questions about your concerns. One other point is that with head trauma or even without head trauma one worries about bleeding inside the brain which has a high mortality rate when one is on warfarin. It isn't so much outside bleeding. So if she stays on Warfarin then watch out for the falls and head trauma. If the INR is critically high sometimes no trauma is needed and a spontaneous intracerebral bleed can occur.
Good to hear that she is doing better. That's always a good thanksgiving.
The doctor who said that patients should have their INR checked like Warfarin and that big pharm is to blame for not doing so is not accurate. The doctor doesn't understand the laboratory aspects of the tests and how the specific tests are optimized in the case of Warfarin the PT and in the case of heparin the PTT. There is a variety of reagents that can be used for coagulation testing and sources for tissue thromboplastin can be obtained from lung, heart or brain sources. The sources for the extracts used for the PT are optimized to work best for Warfarin and allows a nice straight linear graph of reactivity that correlates with drug concentration and the PT results in seconds. One wants the PT seconds to be a nice broad range to establish a therapeutic reference range. One does not want a narrow range between therapeutic levels to all of a sudden have critical high levels of PT results. That's an insensitive test. Some tissues used work best for Warfarin. Some places have two different assays for PT when one wants to use the test to check for lupus anticoagulants and not for Warfarin. The other assay is more sensitive in detecting that condition. The INR was devised because the strengths of the reagents varied and they varied because people were using different sources of reagents. Some people wanted weak reagents while other wanted stronger reagents thus one could not use the seconds result but had to convert to more standardized INR. The formula incorporates the strength of the reagent.
The INR as a whole is a much stronger reagent that is being used than with the PTT. The PT time a normal result is usually about 12 seconds whereas a normal PTT the clotting time is normally around 32 seconds. One uses the PT for Warfarin because there are several coagulation factors impacted by the Warfarin such as II, VII, IX and X. So that test takes a hit when using Warfarin. It isn't a good test for Xarelto. The only one Xarelto effects is factor X. The more sensitive of the two would be PTT where it would impact the factor X there.
The PTT is optimized for heparin monitoring and not for Xarelto monitoring. There's other tests like activated anti-Xa assays that again have as a standard heparin standards and results are reported out as heparin units of activity. Some places have modified the test and have set or used Xarelto standards for calibration of activity rather than heparin but those are still far and few mainly because as the paper below states it does not need monitoring.
Mike gave a good response in explaining the concerns about Xarelto.
"Monitoring
No routine coagulation test monitoring is required.
Rivaroxaban and apixaban will lead to mild prolongation of the APTT and PT but these can not be reliably used to confirm or exclude a rivaroxaban or apixaban anticoagulant effect. Rarely there may be a role for using specific anti-Xa assays to assess the anticoagulant effect but evidence is limited – discuss with on call haematologist."
I would keep an open mind about everything until you get the whole picture and listened to all of the doctors and have asked questions about your concerns. One other point is that with head trauma or even without head trauma one worries about bleeding inside the brain which has a high mortality rate when one is on warfarin. It isn't so much outside bleeding. So if she stays on Warfarin then watch out for the falls and head trauma. If the INR is critically high sometimes no trauma is needed and a spontaneous intracerebral bleed can occur.
Good to hear that she is doing better. That's always a good thanksgiving.
Thanks. I read lawyers working on the Xarelto cases said patients should be monitored, not a doctor. Anyway, I have to run and make sure an ambulance brings her home from the hospital and I need to talk to the social workers about getting the visiting nurses and home health aids in the house to help me with her. Take care, thanks for all the advice.
It isn't like with Warfarin. the INR is used to monitor that the drug concentration is in the therapeutic level and the dose is admitted.
The patient taking Xarelto is evaluated for contraindications for use of Xarelto which includes bleeding associated with clotting disorders. Their general coagulation status is evaluated which includes a PT and a PTT along with other tests that might be relevant like fibrinogen and D-dimer tests. It's an overall assessment of hemostasis that might be done before and during treatment with Xarelto but it isn't like with Warfarin. Maybe that is what the doctor is talking about or the lawyers.
There are congenital bleeding disorders out there such as Von Willebrand disease and Glanzmann thrombasthenia that one has to watch out for. Regular tests for hemostasis might not yield abnormal tests for those conditions.
Why is your mom on Warfarin? Depending on the condition treated, for many patients there are several newer anticoagulants available with lower bleeding risk and that don't require any dietary monitoring or adjustment either. They aren't cheap like Warfarin, but there are patient assistance programs to help those who can't afford them. Something to look into if you haven't already.
I agree. I was on Warfarin for several years, but the twice monthly blood draws that were necessary to get my INR is acceptable ranges was extremely inconvenient. I switched to Xarelto and life is definitely easier since I have to be on an anti coagulant for life. It is VERY expensive, but there are programs that will help pay for the cost.
I agree. I was on Warfarin for several years, but the twice monthly blood draws that were necessary to get my INR is acceptable ranges was extremely inconvenient. I switched to Xarelto and life is definitely easier since I have to be on an anti coagulant for life. It is VERY expensive, but there are programs that will help pay for the cost.
None of the programs pay for government assisted payments. Medicare and Medicaid
This was not the question. The alternatives are extremely expensive. Coumadin (warfarin) has been around for as long as I have been practicing, over 50 years
It is very safe, especially when monitored and food and drug input is checked
We can afford the alternatives, but MrsM made he own decision (not influenced by pharmacist me) to go on warfarin and have INR checked at local hosp every 6 weeks to avoid her spending the increased money for the newer drugs, AND being tossed into the Medicare doughnut hole where most of her meds will have to cost more
More to OP's point, vitamin K is an "antidote" for warfarin. At the present time, there is no antidote for the high priced alternatines
OP's mother will do much better because Vit K is available
That is correct and Mike is wrong, as usual. He posted here promoting an ancient and relatively risky medication not to help the OP, but simply to argue with me.
Thanks for all the replies! I am happy to report the hospital got my mom's warfarin reversed and her INR is 1 now and the hospital doctor wanted to send her home today! It's amazing how she was diagnosed so fast, reversed so fast, all in about 24 hours. The (hospital) doctor suggested maybe she shouldn't be on warfarin anymore (she has a-fib), and go on a newer anti-coagulant like Eliquis, so I said when Xarelto became available it wasn't recommended for anyone over 75 yrs old (I don't know about Eliquis), and I reminded him about all the Xarelto lawsuits. I read documentation on some of the lawsuits and the lawyers were saying Xarelto patients should have their INR checked like Warfarin patients do, but big pharma charges more money for Xarelto by claiming INR testing is not needed.
Anyway, I explained to him she has taken warfarin successfully for years and this is the first time she experienced internal bleeding, probably due to a drastic diet change when she was coughing and wheezing. Additionally she strained herself on Wednesday because of constipation problems and coughing, so the bleeding occurred in a pelvic muscle. After I explained what happened to her, he agreed the change of diet and pressure being put on her pelvic muscles were probably to blame. Interesting how one poster here pointed out maybe her pelvic muscle bleed had nothing to do with her warfarin.
Now I don't know what her cardiologist will decide to do with her warfarin(he didn't visit her in the hospital yesterday or today), so the doctor and I agreed she should stay in the hospital overnight and maybe her cardiologist would drop in and see her tomorrow. Now I'm worried because her INR is 1 and I don't want her to have a stroke, so I will ask the doctor or her cardiologist what they are going to do about it tomorrow. I'm also worried about what happens if she gets constipated and keeps coughing at home to strain herself again and I hope it doesn't delay her healing or make it worse.
The doctor said I must take very good care of her, otherwise she wouldn't have reached 92 years old! Part of the reason is I do research to try to keep her healthy, and I deeply appreciate what the posters here contribute to help everyone stay healthy, thank you again!
BTW, my mom has fallen three times and hit her head, twice on concrete, after she fell on my sidewalk she was taken to the hospital and needed stitches to close her scalp wound because warfarin made her bleed more than normal.. Another time I was getting her out of bed and she tipped over on me while I was holding her and she slammed her temple into her night table, bleeding profusely, and needed stitches again. The third time I pushed her out of the way of a falling weed wacker, she falls and hits her head on the concrete basement floor, no bleeding that time. I think she has nine lives, poor thing, she is so sweet and I feel so bad for her.
I would recommend Eliquis over Xarelto without question. When I was faced with a blood thinner decision 3 years ago as a result of persistent afib, I learned all about the tired old standby Warfarin and was introduced to the option of the NOACs. After extensive research, Eliquis clearly stood out as the option to go with. That is what they recommended in the hospital and I've used it for 3 years. It has done what it is supposed to do, with no perceptible side effects. And no Warfarin style worries or complications.
Now, I'm 72 and not 92 and don't know for sure whether that would make a difference. Hopefully not, and once that is confirmed, I would end that Warfarin risk and hassle for good.
Thanks for all the replies! I am happy to report the hospital got my mom's warfarin reversed and her INR is 1 now and the hospital doctor wanted to send her home today! It's amazing how she was diagnosed so fast, reversed so fast, all in about 24 hours. The (hospital) doctor suggested maybe she shouldn't be on warfarin anymore (she has a-fib), and go on a newer anti-coagulant like Eliquis, so I said when Xarelto became available it wasn't recommended for anyone over 75 yrs old (I don't know about Eliquis), and I reminded him about all the Xarelto lawsuits. I read documentation on some of the lawsuits and the lawyers were saying Xarelto patients should have their INR checked like Warfarin patients do, but big pharma charges more money for Xarelto by claiming INR testing is not needed.
Anyway, I explained to him she has taken warfarin successfully for years and this is the first time she experienced internal bleeding, probably due to a drastic diet change when she was coughing and wheezing. Additionally she strained herself on Wednesday because of constipation problems and coughing, so the bleeding occurred in a pelvic muscle. After I explained what happened to her, he agreed the change of diet and pressure being put on her pelvic muscles were probably to blame. Interesting how one poster here pointed out maybe her pelvic muscle bleed had nothing to do with her warfarin.
Now I don't know what her cardiologist will decide to do with her warfarin(he didn't visit her in the hospital yesterday or today), so the doctor and I agreed she should stay in the hospital overnight and maybe her cardiologist would drop in and see her tomorrow. Now I'm worried because her INR is 1 and I don't want her to have a stroke, so I will ask the doctor or her cardiologist what they are going to do about it tomorrow. I'm also worried about what happens if she gets constipated and keeps coughing at home to strain herself again and I hope it doesn't delay her healing or make it worse.
The doctor said I must take very good care of her, otherwise she wouldn't have reached 92 years old! Part of the reason is I do research to try to keep her healthy, and I deeply appreciate what the posters here contribute to help everyone stay healthy, thank you again!
BTW, my mom has fallen three times and hit her head, twice on concrete, after she fell on my sidewalk she was taken to the hospital and needed stitches to close her scalp wound because warfarin made her bleed more than normal.. Another time I was getting her out of bed and she tipped over on me while I was holding her and she slammed her temple into her night table, bleeding profusely, and needed stitches again. The third time I pushed her out of the way of a falling weed wacker, she falls and hits her head on the concrete basement floor, no bleeding that time. I think she has nine lives, poor thing, she is so sweet and I feel so bad for her.
I haven't looked at the chest guidelines for years but that's sort of the gold standard for anticoagulation. at one time, for elderly who had frequent falls and being treated for afib, aspirin was thought to be an alternative. I'm not sure where the thinking is on that now.
even though her INR = 1 are they bridging her with something like enoxaparin or similar, i.e. heparin?
anytime someone is anticoagulated and hit their head they should consider a head CT, that was part of our ER protocol. hope she got the same at the time.
good luck and I hope all turns out well.
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