Blood Thinners and Your Brain
An estimated six million Americans take blood-thinning medications (antithrombotics) on an outpatient basis each year to prevent the formation in arteries and veins of blood clots that, among other effects, can cause serious brain injury or death.
Yet although these drugs are among the most effective therapies available for preventing heart attacks and brain-damaging strokes, they are not without problems. Their side effects and interactions with other drugs and foods can pose a challenge to patients and their doctors, and occasionally may lead to serious health problems.
For example, a new generation of oral anticoagulants—such as rivaroxaban (Xarelto), dabigatran (Pradaxa), and apixaban (Eliquis)—dramatically reduces the risk for strokes caused by blockage of blood flow to the brain. However, they are also linked to greater risk for anticoagulant-associated intracerebral hemorrhage (AAICH, major bleeding from a cerebral blood vessel that causes a dangerous increase in blood pressure within the skull) that can lead to loss of consciousness and death if not successfully treated.
“The new drugs give us more treatment choices, which is exciting,” says Natalia S. Rost, MD, MPH, FAAN, Director of Acute Stroke Services at MGH. “But because they also carry serious risks, they require careful coordination between patients and their doctors to ensure optimal outcomes.”
WHAT YOU CAN DO
The following strategies may help to strengthen the blood/brain barrier:
- Managing health conditions linked to BBB damage. These conditions include high blood pressure, which can lead to stroke, viral infections, inflammation and cerebrovascular disease.
- Getting regular exercise. Animal research suggests that regular exercise can help protect the BBB by making it less permeable.
- Avoiding chemical toxins and pollutants. A number of toxic chemicals—such as polychlorinated biphenyls (PCBs) and the drug ecstasy (MDMA)—can disrupt BBB integrity and cause leakage.
- Reducing levels of cholesterol. Animal studies have linked high-cholesterol diets with disruptions of the BBB.
- Consuming caffeinated beverages. Research suggests that regular consumption of caffeine may help block disruptions in the BBB caused by a high cholesterol diet.
- Preventing traumatic brain injury. Use vehicular seatbelts, wear helmets while bicycling or playing sports, etc.
- Ensuring healthy sleep by setting aside six to eight hours at night for sleep, establishing good sleep habits, and seeking treatment for sleep disorders.
- Maintaining a healthy body weight.
- Eating a nourishing diet. A deficiency of thiamine (vitamin B-1) is associated with a weakened BBB. A well-balanced diet should include plenty of thiamine-rich foods, such as pork, whole grains, sunflower seeds, kale, beans, and peas.
Bleeding Risks
“In fact, although they can be very effective and save many lives, all blood-thinning medications carry the risk of excessive bleeding, which can be especially harmful to the brain, Dr. Rost says. “That is why it’s important to weigh the benefits and risks of drug treatment for each individual patient, and carefully monitor his or her progress.”
A study published Aug. 1, 2014 in the Journal of Neurosurgery has raised concerns about bleeding linked to the newer anticoagulants. While there is an effective way to quickly counteract bleeding caused by older anticoagulants such as warfarin (Coumadin), there “is currently no specific antidote for any of the (newer) agents,” and “no evidence-based strategies that can be used to guide treatment…” of life-threatening hemorrhages linked to them, the researchers said. The mortality rate for AAICH linked to taking these novel anticoagulants is estimated to be 42.3 percent to 67 percent.
“Although overall risk of bleeding tends to be lower with the newer anticoagulants compared to the more established anticoagulants, the absence of antidotes or reversal strategies to address major bleeding when it does occur is a significant problem that should be addressed by researchers and drug companies,” says Dr. Rost.
“To maximize the safety and effectiveness of all blood-thinning medications, it’s important for patients to work closely with their physicians, use the drugs exactly as directed, and learn to recognize problems and seek immediate medical advice if they experience symptoms of possible excessive bleeding (see What You Can Do).”
Two types
Blood-thinning medications come in two forms:
Antiplatelets, which include drugs such as aspirin, clopidogrel, and dipyridamole, limit the clumping together of cell fragments called blood platelets to form a clot. Antiplatelets are often prescribed for people at risk for stroke, and for those who have heart disease or diabetes. Possible side effects include: Greater risk for hemorrhagic stroke (bleeding of a cerebral blood vessel); allergic reaction; gastrointestinal bleeding and/or stomach ulcers; and excessive bleeding from surgery or superficial wounds.
Anticoagulants—which include the older drugs heparin (Hep-Lock®; HepFlush-10®) and warfarin, and the newer medications mentioned above—slow clot formation by targeting proteins in the blood called clotting factors. Anticoagulants can be very effective for people at high risk for stroke or mini-stroke, or those with nonvalvular atrial fibrillation (A-Fib, an irregular heartbeat), deep vein thrombosis (blood clots in the deep veins of the legs), heart valve surgery, and pulmonary embolism (a blood clot in the lungs). Possible side effects include: skin rash; bruising; and serious bleeding in the stomach, intestines, or brain. Some anticoagulants interact with foods, medications, vitamins and supplements and may require careful monitoring.
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