Deciding Which Anticoagulant Is Best for You
If you need to take an anticoagulant medication to prevent blood clots, you may be faced with a choice between warfarin and the newer class of novel oral anticoagulants (NOACs), including dabigatran (Pradaxa), rivaroxaban (Xarelto), apixaban (Eliquis), and edoxaban (Savaysa). Some of the factors that need to be considered when choosing the best drug for you include effectiveness, bleeding risks, convenience, and cost.
Effectiveness
“Anticoagulants have two primary uses: to prevent a stroke in patients with atrial fibrillation (primary prevention), and to prevent a clot from getting larger in patients who have a blood clot (secondary prevention),” explains Maria DeSancho, MD, MSc, associate professor of clinical medicine at Weill Cornell Medicine.
Clinical trials have shown that warfarin and NOACs are similar in effectiveness.
WHAT YOU SHOULD KNOW
If you take an anticoagulant, be alert for symptoms of bleeding, which include:
▶ Weakness, unsteady gait, garbled speech, confusion, or severe headache (possible signs of bleeding in the brain)
▶ Black or bloody stools, vomiting blood or a substance that looks like coffee grounds, blood in your urine (possible signs of bleeding in the GI tract)
▶ Nosebleeds that don’t stop
▶ Bruises in unusual places, such as the abdomen or torso
Bleeding Risks
The flip side to anticoagulants’ ability to prevent blood clots is the risk of internal bleeding: Two locations of major concern for bleeding are the brain and the gastrointestinal (GI) tract.
“For warfarin, there is an antidote that can stop bleeding. At this time, Pradaxa is the only NOAC that has an antidote, which needs to be administered intravenously,” says Dr. DeSancho.
Studies have shown that NOACs cause fewer intracranial hemorrhages (brain bleeds) than warfarin and Pradaxa and Xarelto have a higher risk of gastrointestinal bleeds.
Dr. DeSancho also stresses the importance of exercising caution with any anticoagulant among women of childbearing age: “NOACs cannot be taken during pregnancy or if breast feeding, and warfarin cannot be taken during pregnancy. And, all anticoagulants can cause very heavy menstrual periods.”
Also, recognize that you need to stay active to reduce the risk of blood clots, even though your risk of bleeding increases when taking an anticoagulant: “You can live a normal life, but restrict activities that could cause bleeds, such as contact sports or other activities associated with a higher risk of head injury,” advises Dr. DeSancho.
Convenience
If you take warfarin, you need frequent blood tests, usually every two to four weeks, to monitor your international normalized ratio (INR) level, which measures the rate at which your blood clots. Some patients find the need for regular blood tests to be inconvenient, difficult to manage, or unpleasant.
“Close monitoring is required because many factors, including diet, alcohol consumption, other medications, including over-the-counter drugs and supplements, and other health conditions, can affect the INR,” says Dr. DeSancho. Regarding diet, Dr. DeSancho notes that it is a myth that patients cannot eat foods containing vitamin K, such as spinach, kale, and other green, leafy vegetables, if they take warfarin. She explains that the key is keeping vitamin K intake consistent, so that it doesn’t cause variations in the INR.
Most patients find taking NOACs more convenient. “No monitoring is required, so it’s easier for patients and doctors,” says Dr. DeSancho. In the event of a blood clot requiring treatment, she says that NOACs work more quickly than warfarin and don’t require overlapping of medications, whereas warfarin needs to overlap with a short-acting anticoagulant, such as low-molecular-weight heparin, for about five days until warfarin takes effect.
Cost
Dr. DeSancho says that, for many patients, cost is a significant factor in their choice of an anticoagulant.
Warfarin, which is a generic medication, costs $20 or less a month at most pharmacies. However, frequent blood tests may add to out-of-pocket costs.
NOACs are much more costly; a one-month prescription can cost $400 or more if you have no insurance. If you do have insurance, copays vary depending on your policy. Some drug manufacturers have patient assistance programs (PAPs); for example, you may be able to get your medication at reduced or no cost if you are eligible. If you and your doctor determine that a NOAC is the best choice for you, check with the drug manufacturers to find out more about PAPs.
Finally, regardless of which anticoagulant you choose, take it as directed to ensure you’re getting the best protection the medication can provide.
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