Understanding Rare Blood Clotting Disorders (Drs. Bartholomew and Gomes 05/01/14)
Thursday, May 1, 2014 - Noon
When you cut or injure yourself, your body stops the bleeding by forming a blood clot (coagulation). Normal coagulation is important during an injury, as it helps stop the bleeding and starts the healing process. However, when your blood clots too much, it is referred to as a hypercoagulable state which can be dangerous to your health. Pulmonary embolisms or deep vein thrombosis (DVT) are two examples of conditions caused by blood clotting disorders. Dr. Bartholomew and Dr. Gomes answer your questions about blood clotting disorders.
Factor V Leiden
JimH: I am a 55 year old male with Factor V from one parent. I have never had a blood clot, but due for a colonoscopy. My question is will it be safe to stop my low dose aspirin for six days prior to the colonoscopy.
Marcelo_Gomes,_MD: Yes, it is safe to stop aspirin for a colonoscopy. There is no formal recommendation to prescribe aspirin to patients who have the Factor V Leiden mutation.
JonathanK: I have had bare metal stents and now I need another stent due to restenosis. Since that time I found I have Factor V Leiden homozygous gene mutation. I am wondering if stent is the best option - or bypass surgery - or medicated stent or bare metal again?
Marcelo_Gomes,_MD: I don't think the Factor V Leiden has anything to do with stent restenosis. Presuming the stents are in the coronary arteries.
John_Bartholomew,_MD: Factor V Leiden patients generally develop blood clots in the veins or lungs and not arteries.
Momx3: I would like to understand Leiden Factor V better. I had a blood clot during my first pregnancy and my daughters have been tested and are considered to have Heterozygous Leiden Factor V. How does this increase chance of blood clots? They are both in their 20s. OBGYN is aware of this and has determined type of birth control based on this concern - again, how great an increase is the likelihood of blood clots by taking birth control pills? [My apologies for misspellings]
Marcelo_Gomes,_MD: Factor V Leiden is the most common inherited predisposition for blood clots in veins worldwide. The name leiden comes from the University of Leiden in the Netherlands where it was described. It is present in about 5% of the US population; it mildly increases the risk of venous thrombosis. However, in women who have Factor V Leiden the use of estrogen containing birth control pills increases the risk of blood clots much more significantly.
John_Bartholomew,_MD: If your daughters decide to use birth control pills, they must be made aware of signs and symptoms of blood clots (DVTs or PE) and seek medical attention immediately if these were to develop. I suggest they talk to their gynecologist about this.
Clotter: Are there any studies that a Factor V Leiden mutation carrier can join? What is the outlook for 'new' generation blood thinners becoming approved for FVL carrier who has had a cerebral sinus thrombosis? I started taking oral birth control to regulate heavy frequent periods three weeks prior to suffering a cerebral sinus thrombosis. Can't I just stop taking the birth control (I have stopped, of course)? How big is the risk of getting another clot if I stop taking Warfarin?
Marcelo_Gomes,_MD: There are no ongoing studies with Factor V Leiden carriers. The new oral anticoagulants are not typically recommended for patients with cerebral sinus thrombosis. Patients with these conditions are typically treated with warfarin for at least six months. The total duration of treatment will depend on the causes of the thrombosis.
DebNsatx: Thank you for having this web chat. My question is whether you see patients having lupus anticoagulant syndrome with another disease like, Fibromuscular Dysplasia (FMD). And is Antiphospholipid Syndrome a progressive disease with age? Thank you for your responses.
John_Bartholomew,_MD: Yes - we see patients with both of these conditions. We have clinics that specialize in both FMD and antiphospholipid syndrome. Like any condition the antiphospholipid syndrome can be progressive but can usually be managed with anticoagulation and aggressive risk factor modification. That means diet, exercise, no smoking, and control of cardiovascular risk factors such as hypertension, diabetes, cholesterol and weight.
TimTom25: I have mild Hemophilia and Factor VIII deficiency - I am being evaluated for heart surgery and wonder if a team works with the heart surgeons to decrease any complications I may have for surgery.
John_Bartholomew,_MD: I would recommend you be seen by a hematologist that has expertise in hemophilia. It seems as though you have hemophilia A and I would strongly suggest this consultation before surgery. The hematologist should communicate his or her concerns and recommendations about the surgery to the surgeon.
mathisfun: I was diagnosed with a pulmonary embolism in 10/01. At this time it was discovered I had Factor V Leiden. I had been taking Premphase, hormone replacement therapy for menopause symptoms, for about a year before this. My doctors believe that this was a provoked embolism. Since this incident, I have been on Warfarin and get monthly blood draws to monitor my INR (PT). My doctor believes I will need to be on this for the rest of my life with monthly blood draws. Is this true? I understand there are alternate drugs but they are not reversible. I also have had bouts of diverticulitis for which I have been hospitalized. I also have been treated for dermatomyositis but this is in remission right now. I am 66 years old and try to eat a healthy lifestyle which includes a lot of green vegetables with vitamin K. My INR ratings fluctuate depending on my food consumption. Any advice you have for better management of my Factor V would be greatly appreciated. Thanks
John_Bartholomew,_MD: I understand your doctors feel your pulmonary embolism (PE) was provoked by your hormone therapy. I also understand you have Factor V Leiden. The current American College of Chest Physicians guidelines do not recommend lifelong anticoagulation for patients with Factor V Leiden. If you are no longer on hormone therapy, it would seem to me you no longer need anticoagulation unless there are other reasons that I do not know. For my patients on Coumadin who eat a lot of green vegetables, I advise them to be consistent in their diet and try to eat the same amount every day to regulate their INR. It is true that the new oral anticoagulants have no food - food interactions. That is what lends to their popularity - however as you pointed out - there is no antidote.
Ingrid52: My little nephew was diagnosed with Inherited Thrombophilia Vein Thrombosis. What is the treatment? If he has it should all relatives get tested - including aunts and cousins?
John_Bartholomew,_MD: There are a number of different inherited thrombophilia conditions. It would depend on which inherited thrombophilia condition he has. I normally do not recommend all family members be tested for thrombophilia, but do make each individual aware of the signs and symptoms of blood clots.
DebraK: My mother who is 79 has Thalassemia anemia with a high white count of 28,000. She recently had a blood transfusion which brought her red count up to 8.1 from 6.9, but the high white count has me confused. I feel that there is an underline condition going on and I can't seem to get the doctor to do a bone marrow bios to explain the high white count. The doctor did rule out leukemia. Can you explain to me what other things should I be looking for.
Marcelo_Gomes,_MD: There are several bone marrow disorders that could cause high white blood counts. I agree with your concern, and suggest that your mother consult with a different Hematologist for a second opinion.
John_Bartholomew,_MD: I would definitely agree for a second opinion. There are other reasons for elevated WBC - such as infection - which must be ruled out.
DebNsatx: Thank you Doctors for doing this web chat. My question is if you have been diagnosed with Lupus Anticoagulant about ten years ago and now are in your 50's as to whether or not you would advise your patients to have a colonoscopy or not? Keep in mind I have no symptoms of having any problems with my colon, but it just seems that most folks always end up having a polyp or two removed when they have this procedure done. I am currently on Coumadin and I know it is risky to be off of it for a procedure so I was wanting to know your opinions on this matter. Have a colonoscopy and if so , what type to get because I've heard of a virtual colonoscopy vs. the regular type. Can you give me the pros and cons of getting it done or not. Thank you for your responses.
John_Bartholomew,_MD: In our clinic, we schedule patients almost daily for invasive procedures despite the fact they are on blood thinners. We generally recommend a bridging process. In your case we would stop Coumadin five days before the procedure and begin a parenteral anticoagulant such as low molecular weight heparin, fondaparinux, or heparin approximately 36 hours after stopping Coumadin. We then stop the parenteral anticoagulant one - two days before the colonoscopy depending on what agent you are on. Following the procedure, we bridge you back to Coumadin. I think it is safe to do this - given you are now at the age when this should be done - under the guidance of a physician familiar with bridging therapy.
DebNsatx: When you have lupus anticoagulant syndrome and are taking Coumadin for your condition, do you believe it is OK for home monitoring to check your INR and PT levels? About two years ago, I was going forward for the home monitoring but once they checked my health history and found that I had lupus anticoagulant syndrome, they said I was not eligible with that condition. Your opinions of home monitoring with this condition, a good idea or not? And why or why not ? Thank You!
Marcelo_Gomes,_MD: Some patients with lupus anticoagulant may be safely monitored by portable INR devices. However, this decision must be done on an individual basis. It is true that the lupus anticoagulant sometimes makes the INR results inaccurate in some portable devices.
DebNsatx: Is it a good idea to take Foltx- B6 and B12 if you have Lupus Anticoagulant? Your opinions are greatly appreciated.
John_Bartholomew,_MD: There is no data to suggest those vitamins are necessary because of lupus anticoagulant.
MTHFR (methylenetetrahydrofolate reductase)
CharleneNY: Do you specialize in MTHFR, dna mutation? I am homozygous and recently diagnosed. I would like to know the implications, if I should be on special diet, if there are supplements that would help?
John_Bartholomew,_MD: Yes - we specialize in MTHFR. We are generally only concerned if you have a significantly elevated fasting homocysteine level. There is no specific diet recommended other than low salt, low fat.
Marcelo_Gomes,_MD: I wonder why you were tested for the MTHFR.
sydneysmom: I have the MTHFR gene mutation as well. What does that gene affect?
John_Bartholomew,_MD: Many physicians feel that MTHFR is important in the development of blood clots. This was based on earlier studies. Currently, unless you have a significantly elevated fasting homocysteine level, we are not concerned about MTHFR. In fact we do not routinely test for this in patients with clotting conditions.
Blood Clots: DVT (Deep Vein Thrombosis) and Pulmonary Embolism (PE)
victoria1102: Hello Dr. Bartholomew. I have a question regarding DVT. I'm a generally healthy 36 yr. old woman. I went to the ER for a pulling/spasm leg pain in both legs, due to an incident a week before. I was running fast and all of a sudden felt a "Charlie horse" feeling in both legs. It continued for about a little over a week. Finally I went to the ER and was told I pulled a muscle. I asked for an ultrasound to rule out DVT. The doctor was hesitant to but he ordered one. Well the ultrasound showed a "probable non occlusive thrombus". Was put on Xarelto for roughly three mo. Had a repeat ultrasound done and it had not gotten better or worse. An oncologist is ordering blood work to check for clotting disorder. Could PAD or my running incident have caused this? No family history of DVT. Should I be under the care of a vascular surgeon as well as an oncologist? Waiting two more weeks to get blood work done. Doctor said to wait until my blood is back to normal. I've never had DVT before I'm concerned.
John_Bartholomew,_MD: I would question whether you had other reasons for the blood clot. Are you on hormone therapy? Currently pregnant? Strong family history of blood clots? Recent surgery or trauma? Or long airplane trips or auto trips? I don't like the terminology "probable thrombus". I think it reasonable to see a vascular surgeon, vascular medicine specialist, or hematologist to find out why you had the blood clot. If the blood clot was in your left leg, I would ask the doctor whether or not you have a condition called May Thurner Syndrome. I agree with seeing another specialist to clarify these issues.
WestonMom: I was lucky enough to survive a calf DVT and huge saddle PE three years ago this week when a great CCF doctor believed me in the ER when I said, "I think I have a pulmonary embolism". I was tested for all genetic possibilities except one, which wasn't possible since I was on warfarin. All negative. Should I get off warfarin to test for that possibility? Any new tests/genes in the past three years? I’m still on warfarin since there wasn't an obvious reason why this happened and I have some other health issues that don't keep me as mobile as I would like. I monitor my INR at home, and am very aware of food and drug interactions, so I keep it stable. How many people stay on it for life after a single incident (albeit a very serious one in my mid-40's)? Any new alternative anticoagulants to warfarin, specifically for DVT/PE? What's coming down the pike that you're excited about? Any correlation between being on warfarin and decreased arthritis/autoimmune symptoms (or just me)? Thank you!
Marcelo_Gomes,_MD: Patients on warfarin cannot be tested accurately for protein S and protein C levels. In your case, given the fact that your pulmonary embolism was life threatening, I would agree with your doctors and keep you on anticoagulation indefinitely. I would not stop Coumadin to do blood testing for protein C and protein S. If you are stable on Coumadin as you suggest, then I would not recommend changing that treatment for a new oral anticoagulant. There are no new genetic tests for clotting disorders over the last three years. I am not aware of any correlation between warfarin and autoimmune symptoms. One other option for testing proteins C or S - is to test your parents as these are genetically transmitted - so you would not have to stop your Coumadin.
Tgspiro: Dr. John, I'm a 60 year male. Last year I had a PE with massive clots in both lungs, wife was told in ER I wasn't going to make it, they had a heart dr. go through my groin artery to the clots and dissolve them, and I’m here! My question: They do not know where the clots came from, altar sound of legs heart cat scan, and all came back negative, also all blood work showed not justified, and no heredity issues. Put on Coumadin for six months, after two weeks off Coumadin I felt dizzy went to emergency and cat scan showed four really small clots, two in each lung. Another round of blood tests with Dr. Spiro hematology, and a slew of extra blood work, and he said there is nothing to warrant the clots. A round of leg heart ultrasound and nothing. Back on Coumadin, with no answer to my clots forming. Sixty year old male, five miles a day, five days a week on tread mill, a little weights and heavy bag, not over weight. What and why did this happen and from where. Thomas Spiro
John_Bartholomew,_MD: Blood clots are often looked at as hereditary or acquired. It appears you have likely all the appropriate hereditary testing performed. However, this data is not available to me. There are many acquired causes of blood clots including extended travel, trauma, immobilization or surgery. Assuming you had neither a hereditary nor one of those acquired conditions - we use the term unprovoked or idiopathic. I would make sure that you are up to date on age appropriate cancer screening such as recent colonoscopy and prostate exam. I would see an internist and have a complete physical exam as well. In your situation I would recommend indefinite anticoagulation, given your near death experience and now another round of clots. PAD is not an issue here based on your history and ability to run. Patients with PAD usually have problems with walking.
april.c: I have a friend who recently had surgery of his knee and due to having an abnormal blood clotting gene, unaware of this prior to surgery, was found to have DVT with bilateral PE's in which the Dr.'s placed an IVC Filter in him. It has since been removed, one year later. The concern is at what risk is he at to get further bloodclots?
John_Bartholomew,_MD: Your friend is at an increased risk for future blood clots because he or she has already had one blood clot. If he or she is over 40, that increases his or her risk along with being overweight; and having cardiovascular risk factors. Therefore, he or she should let all of his or her physicians know that he or she has had blood clots in the past and he or she should take appropriate precautions if he or she has surgery, takes a long trip, or is immobilized.
J12345: I feel like my case was more severe or different somehow? Central saddle PE's with both bronchi full twice (one year apart - first time Aug '13 undiagnosed during 3rd trimester and 2nd time July '13). Chest pain, sob, presyncopic, etc., at each onset inability to sit up from laying position, vomiting when forced to sit up, extreme severe dizziness. After a few days symptoms barely less, start to walk, after each month, slightly less, etc. In addition, sense of smell/nausea was severe and sound also (radio low for months). (Autonomic failure?) I'm so confused by and most concerned about why my (somewhat positional) dizziness won't go away (especially at night turning head right to left or rolling over)? Also, chest pain, sob, dizziness gets worse before and during my monthly cycle). If anyone could explain at a minimum the dizziness (especially at night and when bending over, sometimes looking up, etc.). Recent echo showed right side in upper normal limits. Please help.
John_Bartholomew,_MD: It sounds like you need to be evaluated further. Elevated levels of Factor VIII can be seen for a number of conditions including a tendency to form blood clots but also in patients with infection or inflammation. We do not get overly concerned about elevated levels of antithrombin. It is the low levels of antithrombine (formally known as antithrombin III) that lead to blood clots. I am not sure how to interpret your echo report. This should be evaluated further given your complaints. We would be happy to see you here.
Bon: My brother has bladder cancer and has been passing blood clots, very painful when this happens. He is no longer seeing his doctor and now has lower back pain too, what is going on we have no answers.
Marcelo_Gomes,_MD: What you are describing with your brother is not related to blood clots inside blood vessels. Bladder cancer may cause injury to the inner lining of the bladder and lead to bleeding and blood in the urine. Depending on the amount of bleeding there might be large blood clots as well. You should contact his urologist.
baileybuttons: Five years ago I developed numerous micro embolisms in both feet, and several in fingers of both hands. After an extensive workup, I was placed on Warfarin, Prevastatin ,Diltiazem, and aspirin 81 mg at that time. I have now been taken of the Warfarin since January of 2012 with no further episodes. My final diagnosis is Vasculitis, and that exposure to cold temperatures caused vasospasms to my digits, causing the embolisms to form. Since I am extremely careful in cold weather now, do I still need to keep taking these three medications for the rest of my life, or can I discontinue them under doctor's supervision one at a time?
Marcelo_Gomes,_MD: These medications are usually recommended long term in a situation like yours. I would make sure however, that the diagnosis of vasculitis has been made by a specialist. There are different types of vasculitis with different treatment options. I am not sure what vasculitis you have.
JJCarter: I have venous malformations in my intestines. My doctor put me on plavix and then aspirin. But now he wants me on Xarelto. I am still in afib and aflutter. My doctor wants to put me on Xarelto. What do you think? What is a venous malformation, how serious is it and does it increase my risk for blood clots and bleeding?
Marcelo_Gomes,_MD: Venous malformations in the intestines do increase the risk of GI bleeding. I would not recommend one of the newer anticoagulants, including Xarelto, as there is no antidote for these agents should bleeding occur. If your doctor felt you must be on an anticoagulant other than aspirin or plavix, I would recommend Coumadin.
Protein S Deficiency
MJR1972: I am a 42 year old woman that has been diagnosed with Protein S Blood Clot Deficiency Disorder. There isn't a lot of research that I can understand on this disease. Not many people have Protein S, but I have a real concern there may be a genetic factor linked to my mother and maternal grandmother's cancers that took both their lives at 64 years of age. Is there a possibility Protein S deficiency can be linked to their cancers?
Marcelo_Gomes,_MD: Protein S deficiency has never been linked to any specific cancer types.
Blood Clotting Disorders and Pregnancy
sydneysmom: I am a 40 y/o female with a history of PE, Factor V Leiden Heterozygous, MTHFR, TIA and (1) miscarriage at nine weeks in March of 2011. I had a son who was stillborn at 37 weeks due to blood clots in the placenta on 7/9/13. I was on Lovenox for the entire pregnancy and was switched to Heparin just days before he was stillborn. I suffered the TIA at almost 12 weeks along while pregnant with my son in Jan. of 2013 and was not placed on aspirin nor directed to a hematologist as I was already with MFM at Magee Women's Hospital in Pittsburgh, PA. I am terrified of becoming pregnant again and for my future health as well. Are the tests/studies that can be done to find out if something else is going on? Can I pass my records onto someone for review? I cannot survive another loss and am in need of answers. Please advise via chat or email. Thank you in advance.
Marcelo_Gomes,_MD: Factor V Leiden can be associated with pregnancy complications, but there are other conditions that could have caused the unfortunate and tragic complication that you described. You would have to consult with a Vascular Medicine specialist or Hematologist about specific tests to be ordered (it will depend on what tests may already have been done). I would recommend a second opinion with one of those specialists.
John_Bartholomew,_MD: I would also suggest a lupus anticoagulant profile that includes anti-cardiolipin antibodies; beta2 glycoprotein IgG; and a lupus anticoagulant. These are well known to contribute to maternal fetal problems.
sydneysmom: I was negative for the Lupus anticoagulant.
John_Bartholomew,_MD: I would reinforce what was said before and make sure you see a high risk obstetrician and hematologist.
Anticoagulants – “Blood Thinner” medications
RobertN: My mother is taking Coumadin (blood thinner). If she took this multiple vitamin powder daily ( "All One" for seniors) with these ingredients: Would it be safe with some of these amts. of Ginko,CoQ10, or whatever’s in it ? Appreciate your help greatly, Bob
ROS (Fructo-Oligosaccharides) 1,000mg * Lemon Bioflavonoids (Lemon Fruit) 400mg * Choline (as Choline Bitartrate) 100mg * Lecithin (as Non-GMO Soy Lecithin) 350mg * Guar Gum 300mg * Inositol 100mg * Para Amino Benzoic Acid (PABA) 25 mg * Rutin 25 mg * Hesperidin Complex (Citrus Fruit) 25 mg * Ginko Biloba Extract (24% Flavoneglycosides)(leaf) 25 mg * Glycine 25 mg * CoEnzyme Q-10 15 mg * Reishi Extract 4:1 (fruiting body) 5 mg * Marigold (tagetes Spp.)(flower extract)(containing 5% Lutein) 5 mg * In a base of: Paplin, Betaine HCI, Kelp.
Marcelo_Gomes,_MD: In general, patients taking Coumadin are advised NOT to take vitamin supplements with herbal medicines (such as the “all One” for seniors) because of the potential risk of medicine interactions and increased risk of bleeding.
liesel: In 2004 I received a bare metal stent in the LDL. Ten hrs. later I had a heart attack. They did an emergency angioplasty through the same groin area and inserted another stent. After a few days, I developed blood clots in my right leg due to the trauma in my groin area. I was on Coumadin for nine months. When the clots were gone Coumadin was discontinued. I had a hard time with Coumadin: constant nose bleeds, etc. In 2006, I was diagnosed with Factor V Leiden homozygote. Most doctors want to put me on lifelong Coumadin. I have been resisting it for ten years. The doctors do agree that I am doing all the right things: eating right, exercising, taking 81 mg Aspirin, Plavix, and 2000 mg Fish Oil. I personally think that so many doctors get all nervous about Factor V and immediately want to put you on a blood thinner for life. My question is about the three new blood thinners on the market. Do you know if there “now” is an antidote for the bleeding?
John_Bartholomew,_MD: There are no antidotes for any of the new oral anticoagulants including Xarelto; Pradaxa; or Eliquis. There is ongoing research and hopes in the new future to have an antidote - but at this time - nothing is available.
cyn2: More physicians are moving away from established blood thinning medications that require constant monitoring to newer medications with less monitoring. Could you discuss the pros and cons. On a personal note, my mother in her eighties is on one of these meds that has been effective, yet she is at high risk for falls and is genetically predisposed to be a "bleeder". My understanding is if she should have bleeding, with these newer drugs it would be hard to stop. Correct, or not? Lastly, my husband died recently from a blood clot on his lung after being put on one these drugs. His kidneys appeared to be effected (reduced urine output). Could this have been a side effect of the drug? (He was near to being put in hospice prior to being put on the drug, so I'm not looking for a cause of death - which was neurological - but I did notice this abrupt change in urine flow, which we had monitored for years, right after starting one of the newer blood thinning drugs.)
Marcelo_Gomes,_MD: Yes it is true that the new oral anticoagulants do not have antidotes. So in case of bleeding their effect cannot be reversed. In general, if a patient has been stable on a "traditional" anticoagulant such as Coumadin, I would not recommend a change to a new oral medicine. With regards to your husband's case, acute renal failure is not a reported side effect of the new oral anticoagulants - however, in patients who have kidney disease, the use of these new oral medicines are contraindicated (withheld) due to a high risk of bleeding.
monica l: I have been on Coumadin for a long time due to Factor V Leiden and now I have afib - I am wondering if Xarelto may be an option for me now that I have afib.
John_Bartholomew,_MD: Xarelto, one of the new medications, does not require monitoring, has few drug-drug interactions, and no food interactions. It has not been tested well in patients that are overweight, have a hereditary clotting problem, or kidney disease. If you have any of these conditions, Coumadin would be the best choice. In addition, Xarelto does not have an antidote therefore, if you are prone to bleeding, it would also not be a good choice.
Isa: Your opinions please: Risks vs. benefit:-LOW dose ELIQUIS vs. XARELTO vs. nothing (watchful waiting!), for preventing future DVT ? (Healthy 74 yr. female (Factor V Leiden; full length clot to femoral junction in 2008 in greater saphenous; less than 2cm thrombus 2011 in left Giacomini vein and similar size left gastrocnemius vein 2012 - all treated six months with poorly tolerated Warfarin/Coumadin, but INRs always perfect! Stable ascending aortic aneurysm 4.3: very early indication of monoclonal CLL - recent blood test.) Bearing in mind ELIQUIS not approved yet for DVT by FDA, how long is the recommended LOW dose treatment? What are the statistics comparing the two drugs for bleeding since no antidote for either drug? What are the statistics for risks (equal or different) on discontinuation especially for strokes? What other side effects are your patients experiencing ?What are the major trials going on now with both new anticoagulants and will Cleveland Clinic be posting updates? Thanks!
Marcelo_Gomes,_MD: If you have recently been diagnosed with chronic lymphocytic leukemia - CLL - the current guidelines by the American Society of Clinical Oncology recommend against the use of any of the new oral anticoagulants for treatment of blood clots in general.
DebNsatx: What is the longest documented case that a person has been on Coumadin and is it true that the risks of increased spontaneous bleeding goes up with age while on this medication?
Marcelo_Gomes,_MD: I have seen a patient on Coumadin for 60 years. Yes - it is true the risk of bleeding increases with age.
Tom724: I am 70 yr. old male with Factor V. I take Warfarin. What are pros cons of going to some of the newer thinners? Recommendation?
John_Bartholomew,_MD: Please see previous answers above.
EveretL: I have atrial fib. Some time ago had a DVT but I think it was related to a long trip. Which do you recommend: Pradaxa, Xarelto or Eliquis for this? My doctor talked to me about Coumadin - but would rather take one of the other blood thinners. Your thoughts on them?
John_Bartholomew,_MD: All three drugs are approved for atrial fibrillation. Some of the new drugs are taken twice a day whereas one is daily. Otherwise they are all quite similar in their prevention of stroke and bleeding risk.
CindyH: I had a Greenfield filter placed in 2005 after suffering from numerous DVT's and pulmonary embolisms. I was diagnosed with a Factor V Leiden deficiency and placed on Coumadin. I still keep getting blood clots even on Coumadin. My doctor said that my current filter maybe is not working. Would they take out the filter and then replace it? What happens when Coumadin does not work for someone?
Marcelo_Gomes,_MD: Your question and case seem quite complicated, and I am afraid I cannot provide a straight answer without learning more details. The biggest question is whether you are truly “forming new clots” or whether there are old clots that never “went away”. If your filter was placed in 2005, it is likely a permanent filter, so it could not be removed. If Coumadin is really not working to prevent more blood clots, there are other anticoagulants that could be used instead.
John_Bartholomew,_MD: I would check with your physicians to make sure it is a permanent filter. There are some retrievable filters from that time, and on occasion even though it has been nine years - it may still be able to be removed. IVC filters are in themselves a reason for forming blood clots. One other option for your physician is to measure Factor II and X levels to make sure you are adequately anticoagulated on Coumadin.
nojoro: In 1998 I was I was taking hormone replacement. I had DVT and PE. Diagnosis Factor V Leiden. Immediately stopped Hormone replacement. Had Greenfield filter installed. Discharged on Coumadin. After 10 yrs. hematologist said I could get off Coumadin and take a 325mg aspirin. If I ever get another episode, its Coumadin for life. My question: I'm off hormones, I have a filter, can I discontinue the aspirin. I'm worried about its effect on my stomach.
Marcelo_Gomes,_MD: I would agree with the decision to stop anticoagulation as long as you do not take HRT anymore. It is uncertain whether aspirin reduces risk of blood clots related to the filter. But - it is true that patients who have an IVC filter are somewhat more likely to develop DVT of the legs.
nojoro: Did I understand correctly? If I have a filter, I'm more likely to develop DVT in the leg? What can I do about that?
John_Bartholomew,_MD: Yes - there does appear to be an increased risk of blood clot in the legs due to presence of filter. This is based on an article in NEJM looking at 400 patients. There was approximately a 20% risk for lower extremity clot due to presence of filter. I suggest that you wear compression stockings and watch your weight, remain physically active and control any cardiovascular risk factors if those are present. If you are hospitalized for any reason, make sure your doctors know of the filter and they should use prophylaxis to prevent leg clots from forming.
Homocysteine – C reactive Protein - Fibrinogen
SandiT: If I have a high fibrinogen level and high CRP and homocysteine - what are the treatments? Does this put me at risk for heart disease?
Marcelo_Gomes,_MD: High crp and elevated homocysteine have been associated with heart disease. However, treatment for homocysteine does not seem to reduce that risk. You first need to make sure your homocysteine was measured while fasting because false positive results may happen after a meal.
John_Bartholomew,_MD: I would also make sure that your B12 and folic acid levels are normal because they can be associated with elevated homocysteine levels. To reduce your risk of cardiovascular disease, I would make sure your weight is ideal; you follow a low salt, low fat diet; exercise regularly; maintain your blood pressure and ensure your cholesterol is well controlled.
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