- Drug Interactions and Stroke: Can Blood Thinners Cause Strokes?
- Clots and Bleeds: The Two Types of Stroke
- Ischemic Stroke
- Hemorrhagic Stroke
- Transient Ischemic Attack (TIA)
- How Blood Thinners for Stroke Can Save the Day…
- …or Blood Thinners for Stroke Can Worsen the Problem
- Stroke Recovery Is a Delicate Process That Requires a Team of Professionals
- Understanding AFib: Blood thinners simplified
- Can This Common Blood-Thinner Prevent Stroke?
- Preventive Treatment: Anticoagulant Pros and Cons
- Atrial Fibrillation Anticoagulants: Warfarin
- Atrial Fibrillation Anticoagulants: New Options
- Watchman Device Succeeds in Stroke Prevention
- What is the Watchman?
- Why is it Needed?
- Advantages Over Warfarin
- A Life-Changing Device
- Technology Fuels Stroke Prevention Efforts
- How do they work?
- How do I take them?
- Are there any interactions?
- Are there any side effects?
- Lifestyle changes
- Related information
- Blood-thinning medication and stroke
- Warfarin (Coumadin® and others)
Drug Interactions and Stroke: Can Blood Thinners Cause Strokes?
Tuesday, January 15th, 2019
Nearly 800,000 people suffer a stroke every single year in the United States and stroke is the fourth leading cause of death in the United States . Many stroke survivors are prescribed blood thinners and other medications to prevent another, future stroke.
Common blood thinners have proven to be effective for minimizing risk of stroke associated with blood clots, but they also come with their own set of risks that are important to understand before starting treatment.
Unfortunately, blood thinners can reduce the risk of clot-related stroke only to increase the risk of stroke related to bleeding and blood vessel rupture. To prevent unwanted complications from blood thinners, patients may need to make lifestyle and adjustments moving forward.
Understanding the different types of stroke, their treatments, and any potential complications can empower individuals and their loved ones to prevent a second stroke in the future.
Clots and Bleeds: The Two Types of Stroke
A stroke is generally either caused by a clot that is preventing blood from flowing properly to a portion of the brain, or by a leaking or ruptured blood vessel that is causing blood to flow into surrounding brain tissue. The three types of stroke an individual is ly to suffer are ischemic stroke, hemorrhagic stroke, and Transient Ischemic Attack (TIA).
Ischemic strokes are by far the most common type of stroke, representing nearly 90 percent of all stroke cases today. An ischemic stroke is the result of reduced or blocked blood flow to the brain due to a clot in a blood vessel.
This obstruction of blood flow is caused by fatty deposits along the lining of vessels walls. These fatty deposits generally lead to one of two major types of blood flow obstruction: cerebral thrombosis and cerebral embolism.
A thrombotic stroke is the result of an artery that supplies blood to the brain being fully or partially clogged.
An embolic stroke is also caused by a blocked artery, however, in an embolic stroke, the clot develops at a different location in the circulatory system (often near the heart), breaks free, travels through the bloodstream, and eventually becomes lodged in a blood vessel.
While ischemic strokes are tied to the disruption of blood flow to the brain due to clots, hemorrhagic strokes are the result of a blood vessel within the brain rupturing and causing internal bleeding.
Hemorrhagic strokes are less common than ischemic strokes, accounting for approximately 13 percent of all stroke cases. When a blood vessel ruptures and leaks blood into the brain, this hemorrhaging puts enormous pressure on surrounding tissues.
Common conditions such as high blood pressure and aneurysms (abnormal bulges in weakened arteries that are susceptible to leaking or bursting) are common causes of hemorrhagic stroke.
Small clusters of abnormal blood vessels, known collectively as an arteriovenous malformation (AVM), can also rupture and bleed into surrounding brain tissue.
Transient Ischemic Attack (TIA)
A Transient Ischemic Attack (TIA), commonly known as a “mini stroke,” is caused by temporarily disrupted blood flow to the brain as the result of a clot and has symptoms similar to an ischemic stroke.
However, a TIA does not generally result in permanent brain damage and the episode itself is usually short (less than five minutes).
A TIA is often seen as a warning sign that someone is at risk of suffering a major stroke in the near future.
After suffering a stroke or a TIA, a survivor is ly to be prescribed an array of medications to reduce stroke risk moving forward. Blood thinners are frequently prescribed to minimize the risk of clot-related strokes, but it is important to be apprised of risks and lifestyle adjustments inherent to taking blood thinners regularly, in order to do so safely and to maximum benefit.
How Blood Thinners for Stroke Can Save the Day…
After a transient ischemic attack (TIA) or a ischemic stroke, many patients are prescribed medications designed to prevent blood clots, such as anticoagulants or antiplatelets. Antiplatelet and anticoagulation medications are the two most commonly prescribed blood thinners for stroke patients.
These medications prevent blood clots by interfering with the blood’s natural ability to clot. Traveling through our bloodstream are microscopic cells known as platelets. After a cut, the average person may begin to bleed a bit, but the rate of bloodletting will slow down fairly quickly, due to the aforementioned platelets sticking to one another.
The phenomenon of platelets sticking together is what we understand to be clotting. Antiplatelets (also known as platelet aggregation inhibitors) minimize the risk of potentially dangerous blood clots forming by disrupting the clotting process.
Common antiplatelet medications currently on the market include aspirin, dipyridamole, clopidogrel, or one of the above combined with aspirin, a medication many of us take for headaches that has antiplatelet properties.
Anticoagulant medications are designed to inhibit the blood from clotting quickly by inhibiting blood proteins associated with coagulation. Common anticoagulant blood thinners for stroke include heparin, dabigatran, rivaroxaban, apixaban, edoxaban, and warfarin.
As one would imagine, blood thinners make patients taking them more prone to bleeding and, therefore, these medications often require lifestyle adjustments to prevent injury and excessive bleeding.
Additionally, it’s absolutely necessary to inform a medical professional you are taking a blood thinner for stroke prior to surgery or any medical treatment.
Statins are not on the blood thinners list, but drugs to lower cholesterol are commonly prescribed alongside blood thinners after a stroke. Remember, fatty deposits in the blood vessels (a common symptom of high cholesterol) can become or compound the damage of clots that cause stroke.
Similarly, high triglycerides are linked to arteriosclerosis, or the buildup of plaque in the arteries, another risk factor for stroke. Studies have also shown that EPA, an omega-3 fatty acid found in in fish oil, may reduce the risk of stroke for high-risk patients.
Fish oil supplements are often taken following a stroke and some studies have even shown that fish oil consumed within 5 hours of suffering a stroke may minimize brain damage.
…or Blood Thinners for Stroke Can Worsen the Problem
Blood thinners are commonly prescribed for stroke survivors at risk of dangerous blood clots.
Unfortunately, the blood thinners used to prevent such blood clots can increase the risk of bleeding in the brain, a cause of hemorrhagic stroke.
Furthermore, many common blood thinners may interact with other over-the-counter medications, common supplements, and prescriptions, reducing their effectiveness and setting the stage for potentially dangerous side effects.
Non-vitamin K oral anticoagulants (NOACs) are common blood thinners used to prevent stroke risk associated with blood clotting.
A recent study determined there was an increased risk of bleeding associated with NOACs, especially when taken with commonly prescribed medications amiodarone, fluconazole, rifampin and phenytoin.
The researchers found the interaction with Lipitor to be particularly worrisome, considering that Lipitor is frequently prescribed to address the high cholesterol associated with stroke risk.
Some common blood thinners may even interact negatively with everyday foods: turmeric, the kitchen spice, has been shown to increase the risk of bleeding when combined with some anticoagulant drugs. While the average spice rack turmeric contains only a small amount of curcumin, a known anticoagulant ingredient, the larger capsules sold as supplements can contain up to 2000 mg of curcumin per dose.
Many common blood thinners can lose efficacy due to interactions with supplements, diets, or other medications. Vitamin K plays a central role in the body’s clotting process and vitamin K antagonists (As) warfarin are designed to slow down the anticoagulation properties of Vitamin K.
A patient’s dosage of an anticoagulant is generally determined after a doctor learns their activity level, diet, other medications, family history, and other factors. Regular blood tests during drug therapy are used to fine-tune the dosage and establish a patient’s international normalised ratio (INR).
The INR illustrates how long it takes for a person’s blood to clot and will determine the appropriate dosage of blood thinners. That said, fluctuations in dietary vitamin K levels can reduce the effectiveness of such medications.
A diet high in foods that are rich with Vitamin K may require a patient to take a higher dosage. Unfortunately, many patients don’t know which foods are sources of Vitamin K.
Some of the common foods rich in vitamin K that patients should be aware of are: Kale, collard greens, spinach, broccoli, beef liver, pork chops, chicken, green beans, prunes, kiwi, soybeans, green peas, avocados, and cheese.
Even more alarming is the that so few patients are aware of the potentially dangerous interactions with anticoagulants.
According to a study by the Intermountain Medical Center: “Researchers found that of 35 patients combining warfarin with supplements, more than half (54 percent) were unaware of potential interactions.
Researchers also found that of the 100 most-used supplements, 69 percent interfere with the effectiveness of warfarin.”
Additionally, stroke survivors who have been prescribed statins may develop a coenzyme Q10 (CoQ10) deficiency and begin taking a CoQ10 supplement. Unfortunately, studies have shown that CoQ10 supplements can reduce the effectiveness of blood thinners.
Beginning a CoQ10 supplement while taking a common blood thinners may increase the chances of developing a potentially life-threatening blood clot.
There are many potential side effects of blood thinners and all stroke survivors should consult their doctor before changing their diet or beginning a drug regimen, prescription or otherwise.
Stroke Recovery Is a Delicate Process That Requires a Team of Professionals
According to the Center for Disease Control and Prevention (CDC), someone suffers a stroke every 40 seconds in the United States. After a stroke, survivors may begin taking one or more medications for the purpose of decreasing stroke risk, including blood thinners.
While anticoagulant and antiplatelet medications may decrease the risk of ischemic stroke, the associated dietary and pharmaceutical complications may reduce the effectiveness of other medication and even increase the chances of bleeding and hemorrhagic stroke.
To minimize these risks, stroke survivors may need to make rather substantial lifestyle and dietary changes.
The stroke recovery process is often challenging for stroke survivors. Fortunately, a team of doctors, caregivers, and stroke rehab professionals can all play a role in minimizing the burden of stroke rehabilitation.
Here at Saebo, we are committed to stroke support and recovery for all survivors and their families. Saebo offers a wide range of products that combine cutting-edge technology with evidence-based rehabilitation techniques.
Our offerings and network of Saebo-trained therapists can help you or a loved one to obtain all the necessary tools to maximize stroke recovery.
All content provided on this blog is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment.
Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 immediately.
Reliance on any information provided by the Saebo website is solely at your own risk.
Understanding AFib: Blood thinners simplified
For those patients with atrial fibrillation (AFib) at high risk of having a stroke, drugs that reduce the blood’s ability to clot are quite effective.
In most cases, these blood thinners effectively eliminate the risk of having a type of stroke that frequently occurs with this heart condition.
At the same time, excessive bleeding is a serious side effect of these medications and requires that they be used carefully.
In earlier posts, we met George H., a 71-year old retired engineer.
After years of experiencing episodes of a rapid heart rate, George was diagnosed with AFib during a doctor’s visit. Sent to the emergency room for further evaluation, he was at first reassured that he wasn’t having a heart attack.
After a review of his stroke risk, the ER physician prescribed Eliquis (generic name: apixaban), a strong blood thinner.
A week later, however, George was startled to find blood in his stool and naturally worried that his bleeding was serious. Luckily, he quickly went to urgent care where blood tests for anemia were stable.
A few days later, a colonoscopy revealed bleeding from his hemorrhoids, a startling, but more mild problem rather than something more ominous. He was annoyed, however, that no one had told him that abnormal bleeding was a frequent side effect of blood thinners: the price to pay for protection from a stroke.
The blood’s ability to clot is miraculous. It is critical to human survival; without this well-tuned system of blood clotting, we would die from minor injuries.
In AFib, however, drugs are given to intentionally impair the blood’s ability to clot. The upper chambers of the heart (the atria) do not beat properly in AFib, which allows small blood clots to form on the inner walls of the heart. These blood clots can then fall off and travel to the brain where they block off an artery supplying oxygen and nutrients to the brain, resulting in a stroke.
Strokes can be mild or temporary, or so severe that major disability or death occurs. Without blood thinners, the risk of someone with AFib having a stroke averages about 2.3 percent per year or 20 percent over 10 years. As we talked about previously, the trade-off of preventing these strokes is major bleeding, which occurs in 2 percent of patients annually taking blood thinners.
What type of blood thinner is best?
There are four groups of drugs that block blood clotting. While all these drugs can be used to prevent strokes in people with AFib, each has its advantages and disadvantages.
- Warfarin (brand name Coumadin) was until 2012 the standard oral blood thinner for AFib. Stronger than aspirin, it knocks out special proteins in the blood needed for clots to form. Warfarin is inexpensive, but can be a hassle because it requires precise dosing and careful monitoring with frequent lab tests. Excessive doses can be dangerous. Currently, 20 percent of patients with AFib are prescribed warfarin.
- Direct oral anticoagulants work in a way that is similar to warfarin, but don’t need monitoring or special dosage adjustments. Their big advantage is simplicity, although they are expensive ($400 per month). They also wear off very quickly if a dose is missed. These drugs include apixaban (brand name Eliquis, 26 percent of patients with AFib use this drug), rivaroxaban (Xarelto, 15 percent ), and dabigatran (Pradaxa, 5 percent).
- Aspirin interferes with small blood cells known as platelets to reduce blood clotting. Taken by 3 percent of AFib patients, aspirin and drugs similar to aspirin are weaker in protecting against strokes.
- Heparins, injected drugs used by 1 percent of AFib patients, are useful for urgent blood thinning.
Research suggests that about 10 percent of AFib patients don’t need blood thinners because their risk of having a stroke is so low. National data also suggests that an additional 20 percent of AFib patients are not taking a blood thinner when they should be. Remember, without protection from a blood thinner, these patients are at risk for preventable strokes.
If you or someone you know has AFib, it is critical to have a discussion with a doctor about the potential benefits of taking a blood thinner.
This is the third in a series of blog posts called Understanding AFib to help patients with atrial fibrillation live healthier lives.
Next, I'll discuss drugs that slow down the heart so that patients with AFib can function better. George H. is an actual patient with some details altered to protect his confidentiality.
Estimates of blood thinner use come from IQVIA’s National Disease and Therapeutic Index.
Randall Stafford, MD, PhD, is a professor of medicine at Stanford and practices primary care internal medicine. Stafford and Stanford cardiologist Paul Wang, MD, lead an American Heart Association effort to improve stroke prevention decision-making in atrial fibrillation.
Illustration by National Institutes of Health
Can This Common Blood-Thinner Prevent Stroke?
One of the most frightening aspects of atrial fibrillation — the most common kind of arrhythmia, or irregular heartbeat — is the risk of a life-threatening stroke.
During atrial fibrillation, the heart’s two small upper chambers — or atria — beat chaotically, increasing the risk of blood clots. If a clot breaks free and travels to the brain, you can suffer a stroke, which can be fatal.
People with atrial fibrillation are five times more ly to have a stroke than those who don’t have the condition. In fact, one in four strokes in people over age 80 is a direct result of atrial fibrillation. That makes stroke prevention a key part of atrial fibrillation treatment.
Stephen Kopecky, MD, professor of medicine at the Mayo Clinic, says that when working with patients who have atrial fibrillation, the biggest hurdle is deciding whether to prescribe an anticoagulant — a medication to prevent blood clots from forming. Because the average age of an atrial fibrillation patient is 76, the risk of stroke has to be weighed against the risk of bleeding. After that, he says, the decisions get easier.
Preventive Treatment: Anticoagulant Pros and Cons
Anticoagulants, commonly called blood thinners, are drugs that slow the clotting of blood, so they help prevent blood clots from forming and traveling to the brain, to reduce stroke risk.
If your doctor is concerned about your stroke risk, the first line of preventive treatment is medication. Since the 1950s, warfarin (Coumadin, Jantoven) has been the most widely used anti-coagulant. Newer anti-coagulants include Eliquis (apixaban), Pradaxa (dabigatran), and Xarelto (rivaroxaban).
Because most people with atrial fibrillation are older, various factors need to be considered. Dr. Kopecky says the risks for stroke are higher in those who have diabetes, high blood pressure, or have experienced heart failure, making an anticoagulant an important part of overall treatment in these cases.
Kopecky says fragile patients who fall and are at increased risk of problems from internal and external bleeding, or those who can’t remember to take medication as prescribed, probably shouldn’t be taking an anticoagulant. For them, he says, it’s probably wise to simply recommend an aspirin every day. Aspirin reduces the risk of stroke by 20 percent; anticoagulants reduce that risk by 80 percent.
For atrial fibrillation patients who have equal risks of bleeding and stroke, doctor and patient should make an informed decision together factors such as lifestyle, diet, physical activity, access to clinics and doctors, work, and travel.
“Every patient is an individual,” says Andrew K. Krumerman, MD, a cardiologist at Montefiore Medical Center and associate professor of clinical medicine at Albert Einstein College of Medicine in New York City.
“The decision about what medication to take should not be dictated by what you read in the media or what you hear from pharmaceutical companies, but by a long conversation between patient and doctor,” he says.
Atrial Fibrillation Anticoagulants: Warfarin
Warfarin is a powerful drug that reduces the chemical reaction of vitamin K in the liver that causes — and lengthens the time it takes for — blood to clot. Its effectiveness depends on the amount of vitamin K in the body.
Vitamin K is found in many leafy green vegetables, such as spinach, Brussels sprouts, and kale.
Warfarin interacts with those vegetables and with various medications, supplements, and over-the-counter drugs, making it vital that people on it be monitored at least once a month. Too much warfarin increases the risk of bleeding, and too little increases the risk of stroke.
No new foods or medicines should be added to or eliminated from your diet without consulting a doctor, and you'll want to seriously limit the amount of alcohol you drink.
Patrick J. Tchou, MD, associate section head of electrophysiology and cardiac pacing in the Robert and Suzanne Tomsich Department of Cardiovascular Medicine, and codirector of the Ventricular Arrhythmia Center at the Cleveland Clinic, says he still considers warfarin to be the gold standard for comparison with other anticoagulants.
But the drawbacks of warfarin, he notes, are that doses have to be individually adjusted, and a patient has to carefully watch levels of vitamin K. If you're able and willing to regularly go for blood level measurement checks and keep in touch with your doctor about any diet or lifestyle changes, warfarin may be a good choice.
Warfarin is inexpensive when covered by insurance. Un some of the newer anticoagulants, warfarin has an antidote for emergency situations, such as during surgery when the drug must be immediately counteracted.
In addition to the risks of internal bleeding, warfarin side effects can include headaches, confusion, weakness, fever, numbness, nausea, and diarrhea. If you experience any of these, contact your doctor immediately because you may need a dose change.
RELATED: I Have Atrial Fibrillation Which New Blood Thinner Should I Take?
Atrial Fibrillation Anticoagulants: New Options
Newer anticoagulants have now been proven to be as effective as warfarin, says Kopecky. According to reports in the September 2011 issue of the New England Journal of Medicine, several important studies showed they're equal or superior at preventing blood clots, as compared with warfarin.
The drugs Pradaxa (dabigatran) and Eliquis (apixaban) are taken in fixed doses twice a day, get into the blood in a matter of hours, and don’t require close monitoring or dietary considerations.
Xarelto (rivaroxaban) is taken in a fixed dose once a day for prevention of stroke in atrial fibrillation. But these aren't advised for anyone with heart valve disease or serious kidney or liver problems.
And un warfarin, they're expensive, and can cost about $3,000 a year. Side effects are similar to those of warfarin.
“As we get to know these drugs better,” says Kopecky, “we’re migrating toward them more.” He said he s to recommend them for patients younger than 65, who are active and have no other health issues. “The only considerations when deciding which medication to put a patient on now,” he says, “are individual safety issues and cost.”
Watchman Device Succeeds in Stroke Prevention
The fifth leading cause of death in the United States, stroke, can occur at any time and any age. The Centers for Disease Control reports that every 40 seconds, someone in the U.S.
suffers a stroke with more than 50 percent of victims ages 65 and older sustaining lifelong disability as a result.
Because the majority of strokes are ischemic strokes, meaning they are caused by blood clots that prevent proper blood flow to the brain, individuals at risk have been treated with blood thinners. Now, physicians have a promising alternative that offers hope for improved stroke prevention.
What is the Watchman?
Designed for use in patients with a history of non-valvular atrial fibrillation who cannot tolerate long-term blood thinners, the Watchman is an implantable, permanent device placed in the heart.
Cardiovascular surgeons implant the Watchman into the left atrial appendage (LAA) through a simple procedure that lasts about an hour. The LAA is targeted by the Watchman because 9 in 10 strokes that occur in patients with non-valvular atrial fibrillation are caused by stroke-causing clots that form in this region.
By blocking off the LAA with the Watchman, doctors have been able to seal off the primary culprit of disabling strokes.
Why is it Needed?
The Watchman device was created for patients who need a safer alternative to blood thinners. People who are doing well with anticoagulant medication, Warfarin, are not ideal candidates for the Watchman. However, there are many patients for whom blood thinners are not recommended.
For example, individuals in industries that pose higher than average injury risk should not take blood thinners. Similarly, people at risk for falling, such as those with movement disorders or senior citizens, should not take blood thinners due to bleeding risk.
The Watchman eliminates the bleeding risks otherwise associated with Warfarin.
Advantages Over Warfarin
Until now, blood thinners have been the only option for patients at risk of stroke, but long-term use of anticoagulants may produce consequences.
In addition to bleeding risks, Warfarin use can lead to partial or total resistance.
Individuals who become resistant to Warfarin do not experience the same blood thinning benefits as others even when prescribed the maximum dose. Additionally, the Watchman is a better option because:
- 99 percent of patients no longer have to take blood thinners for life
- A one-time procedure provides permanent results
- Reduces or eliminates the need for blood tests and dietary restrictions associated with blood thinner treatments
Additionally, patients who have difficulty maintaining compliance with anticoagulant regimens or those who are already on medications that increase bleeding risk may be good candidates for the Watchman.
A Life-Changing Device
Patients are already praising the Watchman and the physicians who created it after experiencing an improved quality of life. A 74-year-old Connecticut resident, Russell Bonaccorso, was on a blood-thinner treatment for more than a decade before receiving the Watchman.
During this time, he experienced episodes of life-threatening internal bleeding, which required immediate medical intervention and hospitalization. At times, he would lose so much blood that his vision would rapidly decline.
Even when he wasn’t experiencing a medical emergency, he was constantly afraid of falling or cutting himself because of the bleeding risks.
Since the Watchman was implanted, Bonaccorso has been able to enjoy a life without side effects, he and feels he is 30 years younger. To his surprise, he felt well enough to return to work after being retired for five years. Bonaccorso is now able to enjoy normal activities and has regained his independence.
Technology Fuels Stroke Prevention Efforts
The Watchman is one example of how technology is being used to tackle complex medical concerns. Long-term research being conducted on the Watchman has thus far revealed positive results during five-year follow up. the pacemaker, the Watchman may become a go-to prevention method for at-risk patients in the future.
If you have any questions about the Watchman or any other cardiovascular-related technology, feel free to contact us at 770-962-0399 or visit us online today.
These drugs are also called “blood thinners.” They don’t actually thin your blood. But they can help prevent clots from forming.
- apixaban (Eliquis)
- dabigatran (Pradaxa)
- edoxaban (Lixiana)
- rivaroxaban (Xarelto)
- warfarin (Coumadin)
- Generic names are listed first.
- Canadian brand names are in brackets.
- This list doesn’t include every brand name.
- If your prescription isn’t listed, your pharmacist is the best source for more information.
How do they work?
Blood clots (or coagulates) to stop bleeding. If clots get into your blood vessels, they can cause a heart attack or stroke. Anticoagulants prevent blood clots. They can’t break up clots that have already formed. But they may prevent existing clots from getting bigger
Blood thinners are taken by people:
- with artificial heart valves
- with atrial fibrillation (irregular heartbeat)
- who have had a heart attack
- who have heart diseases, such as cardiomyopathy
- who are at risk of developing blood clots
Listen to Dr. Paul Dorian and Dr. Jeff Nagge explain blood thinners, INR testing (if you are on warfarin) and healthy eating while on warfarin in these videos.
How do I take them?
Anticoagulants can be taken as tablets, given by injection or by IV drip.
- Warfarin is a tablet.
- Its full effects are seen after two or three days.
- Heparin is given by IV or injection.
- It takes effect very quickly.
Are there any interactions?
Some medications can stop your heart medicine from working properly. They may even cause other health problems.
Blood thinners can alter your routine.
You may need regular blood tests.
- This will make sure your blood isn’t too thin (which can lead to bleeding) or too thick (which can lead to clots).
Try to avoid cutting yourself.
- Use an electric shaver and soft-bristled toothbrush.
- Floss gently.
- Wear gloves while gardening.
Avoid large helpings of dark leafy vegetables. Including:
- Kale, collard or beet greens, spinach and Brussels sprouts.
Do not take your medication with grapefruit juice.
Blood thinners interact with many common drugs. Always tell your healthcare provider or pharmacist about any other medications you are taking. These include:
- non-prescription drugs
- creams or ointments
- over-the-counter or natural health products
- alternative therapies
- vitamins, minerals or supplements
- herbal remedies
- homeopathic medicines
- traditional remedies, such as Chinese medicines
- amino acids or essential fatty acids
Are there any side effects?
Because blood thinners delay clotting, their biggest side effect is unwanted bleeding.
When to call your doctor: Bleeding can occur in the gums, urinary system or bowels. You might not realize you’re bleeding. Be on the lookout for:
- pink in the sink when brushing your teeth or shaving
- vomit that looks bloody or coffee grounds
- pink or brown urine (pee)
- stool (poop) that’s red or black
Listen to your body. Tell your healthcare provider if you experience any signs of stroke, bleeding or discomfort.
Ways to reduce these side effects:
- Avoid smoking.
- Limit alcohol.
- Tell your dentist you take this drug before a dental cleaning or other work.
- If you need surgery (even a simple procedure), tell your surgeon about your medication.
- Consider delaying non-essential dental or medical procedures.
If you have side effects, talk to your pharmacist or healthcare provider.
Healthy choices can help you manage heart disease. Get practical tips and advice from Heart & Stroke experts on how to get healthy. Learn how to:
Talk to your healthcare provider about the lifestyle changes that will benefit you the most.
Your healthcare provider or pharmacist are your best sources of information. You can also learn more about medications at any of these trusted sites.
Health Canada – Drugs and Health Products
Provides health and medical information for Canadians to maintain and improve their health.
Learn more about:
Your ministry of health also offers health resources in your province or territory. For example, Ontario’s MedsCheck program provides free pharmacist consultations. And British Columbia’s Senior Healthcare web page provides information about important health programs.
Blood-thinning medication and stroke
Similar to rivaroxaban, apixaban makes the blood less ly to clot by blocking a protein (Factor Xa) in the blood. You won't need to have regular blood tests.
Apixaban can be taken with or without food. If you have kidney problems, you will usually be given a reduced dose. Apixaban isn't usually recommended if you are pregnant or breastfeeding. If you're taking any other prescribed medicines or herbal remedies, please check with your doctor whether it is safe to continue doing so.
The main side effects of apixaban are bleeding and anaemia. Seek urgent medical attention if you experience any unusual bleeding.
Dabigatran etexilate (Pradaxa)
Dabigatran etexilate attaches itself to a protein (called thrombin) in your blood, making your blood less ly to form a clot. You should take dabigatran exactly as your doctor prescribes.
If you take dabigatran etexilate, you do not need to have regular blood tests, as it works in a different way to warfarin. However, you may need to have occasional blood tests. Your doctor will tell you when these tests should take place. Dabigatran etexilate is not usually prescribed if you are pregnant or breastfeeding.
Some types of medication can interact with dabigatran etexilate. Check with your doctor or pharmacist if it is safe to take any other prescribed or herbal remedies, such as anti-inflammatory medication or St John’s wort.
Side effects of dabigatran etexilate include bleeding, diarrhoea, indigestion, nausea and stomach pain. You should seek urgent medical attention if you experience any unusual bleeding. If you're having an operation or dental treatment, ensure the medical professionals are aware that you are taking dabigatran etexilate.
Edoxaban, apixaban and rivaroxaban, makes the blood less ly to clot by blocking a blood protein called factor Xa. You won't need to have regular blood tests.
Edoxaban is taken once a day, either with or without food. The drug is not used if you are pregnant or breastfeeding. It can interact with other medicines, although always check with your doctor whether it is safe to continue taking other prescribed medicines or herbal remedies.
The main side effect of edoxaban is bleeding, but patients may also experience nausea or itchiness. Seek urgent medical attention if you experience any unusual bleeding.
Rivaroxaban makes the blood less ly to clot by blocking a protein (Factor Xa) in the blood. This protein plays a key role in the blood clotting process.
It works in a different way to warfarin so you will not need to have regular blood tests. Rivaroxaban should be taken once daily with food, exactly as prescribed by your doctor.
If you have kidney problems, you will usually be given a reduced dose.
Rivaroxaban is not usually recommended to be used if you are pregnant or breastfeeding.
Ask your doctor whether it is safe to take Rivaroxaban with any other prescribed medicines or herbal remedies you may be taking.
Side effects of rivaroxaban include bleeding, constipation, diarrhoea, dizziness and fainting. You should seek urgent medical attention if you experience any unusual bleeding, high temperature or rash.
Warfarin works by changing the way your liver uses vitamin K. Vitamin K plays an important role in the blood-clotting process. It helps to produce a protein called prothrombin, which helps your blood to clot. Warfarin slows down the way vitamin K is made, which increases the time it takes for your blood to clot.
Warfarin is given in tablet form and the dose needs to be tailored to you individually. This is because people respond to warfarin differently and it is not easy to predict. It should be taken at the same time every day.
You need to have regular blood tests if you take warfarin, to make sure that your blood is not becoming too thin. The test checks how quickly your blood clots at a particular stage in the process and compares it to a normal sample.
The result is called the international normalised ratio (INR). INR is expressed as a number. A normal INR value for blood (when you are not taking anticoagulants) is around one.
If you have atrial fibrillation and are on warfarin your blood should be two to three times thinner than normal, so you should have an INR value of between two and three.
You will need to have a blood test at least every week when you first start taking warfarin, as your dose will need to be adjusted to suit you. When your INR is stable, you will probably need a blood test every six to eight weeks.
When you are first prescribed warfarin you may receive a pack which contains a credit-card sized alert card, a yellow booklet and a record card.
Warfarin is not suitable for everyone and should not be taken if you have very high blood pressure or stomach ulcers. It should also be avoided if you are pregnant. The main side effect of warfarin is bleeding.
The most serious type of bleeding is in the brain, though this is very rare. If you experience symptoms of another stroke, you should call 999.
Less common side effects of warfarin include rashes, vomiting and diarrhoea.
Some medicines and supplements such as St John’s wort can interact with warfarin and affect your INR. Always tell your doctor or pharmacist if you are on warfarin before taking any new medication, particularly antibiotics, antidepressants, aspirin, statins, ulcer medicines, or herbal supplements.
Warfarin and food
If you are taking warfarin, you need to be mindful of the foods you are eating. Your warfarin dose is usually adjusted to the level of vitamin K in your diet. So you shouldn’t make sudden changes to the amount of vitamin K that you eat, as this could affect your INR.
This doesn’t mean that you should avoid foods that are high in vitamin K, as these are an important part of a healthy diet. Equally, you shouldn’t change the amount you eat without talking to your anticoagulant specialist first.
Foods that are very high in vitamin K and are most ly to affect your INR are green, leafy vegetables such as spring greens, broccoli, spinach and kale. Olive oil, rapeseed oil, soya oil and soya flour are also high in vitamin K. These can be found in salad dressings, mayonnaise and pre-cooked foods. Keep your intake of vitamin K from these products stable.
It’s best to avoid cranberries and cranberry juice because they can affect the way that warfarin works. Some natural health food products and herbal remedies can also affect warfarin, so check with your pharmacist or doctor before taking anything this.
Alcohol can increase your INR, so you need to keep within the recommended limits.
When you’re taking warfarin, the main things to remember are:
- Eat a healthy diet.
- Keep the amount of vitamin K in your diet the same from week to week.
- Talk to your anticoagulant specialist about any changes you want to make to your diet or weight.
Heparin can be given intravenously or sub-cutaneously, but not by mouth. Heparin is sometimes used to reduce acute stroke damage or stroke risk in hospitalized patients. In addition, heparin may be used in hospitalized stroke patients to reduce the risk of blood clots forming in leg veins.
Warfarin (Coumadin® and others)
Warfarin is an anticoagulant drug (“blood thinner”) which is taken by mouth. Daily use of warfarin can reduce the risk of stroke in certain patients.
For example, many patients with atrial fibrillation (an irregular heartbeat) should be prescribed warfarin.
Use of warfarin requires careful monitoring, and you should closely follow your doctor’s recommendations, including regular blood tests. Let your doctor know if you’re taking any other medications.
Your doctor will start you on a low dose of Coumadin® and will have you see him or someone else to check your blood weekly. You want your blood levels to be within a certain range. The doctor wants you to be right in the middle, so you will have your blood drawn and the doctor will increase or decrease your dose the blood values and where he or she wants you to be.
Patients receiving Coumadin® also need to be very careful about their diet and activities to prevent problems while taking the medication. The levels of the drug in the body can be affected by the amount of vitamin K in your diet. Foods high in vitamin K include leafy green vegetables, green teas, as well as pork and beef liver.
Patients should avoid large amounts of alfalfa, broccoli, asparagus, brussels sprouts, cauliflower, cabbage, kale, spinach, watercress, lettuce and turnip greens. You can still eat these foods, but eat the same amount regularly. For example, don’t eat a plateful of turnips every day for a week and then decide to stop eating them the next week.
Large changes in the amount you eat can cause problems with your treatment.
Also, since Coumadin® is a fairly strong blood thinner, you have a chance of bleeding more than usual with common cuts, scrapes and falls. Use caution walking and with activities that place you at risk to fall or get hurt. Be careful while shaving, because a common cut may take longer to stop bleeding.
Watch for blood in the urine, in the stools, or around the gums when eating and brushing teeth; bleeding from the nose; or bruising easily. If you notice abnormal or excessive bleeding, let your pharmacist and doctor know, and talk with them before you change or take any new medicines.
Lastly, get an identification bracelet or necklace to let people, doctors and dentist know you are taking Coumadin®.