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Doctors' Answers to "Frequently Asked Questions" - Coumadin
Coumadin and Vitamin E [posted
Answer: Polio does not affect the heart, the virus lives in the spinal cord and causes de-enervation of the muscle, which the heart does not have. There should be no problem with Vit E and the coumadin. As to the ginko, I have no information. Just watch your pt/INR, closely after starting it.
Coumadin Alternatives [posted
Answer: Maybe, maybe not. But, if you are getting a valve replaced, you have few/little option. While it is a pain to get regular testing, it is the only way to decrease the risk of bleeding or insufficient anticoagulation.
Coumadin Side Effects [posted
Answer: Coumadin (warfarin) has generally few side effects. It should not be used during pregnancy due to birth defects. There are occasional severe cases of skin necrosis, also a strange phenomenon called purple toe syndrome wherein the feet (generally) develop tender purple spots. There is a long list of occasionally reported items, but generally not enough to discuss. The biggest risk is excessive bleeding and interaction with drug metabolism causing other drugs concurrently being taken to rise/fall out of therapeutic range.
Coumadin [posted 8/13/98]
Answer: As long as you take regular dosages, you can take most medications with coumadin without problem. The problem arises if you take a large dose one day (or for a week) and then none for a while. The dosage of coumadin can be adjusted for almost any metabolic problem as long as the problem is relatively fixed.
Coumadin Levels [posted 8/11/98]
Answer: I think you are referring to the INR rather than the protime. A higher INR necessitates a lowering of the coumadin, a low INR raising the dosage. The level of the INR depends a lot on why he is taking coumadin - the higher the INR the "thinner" his blood.
Coumadin [posted 8/6/98]
Answer: I'm kind of baffled concerning your coumadin needs. This is a large dosage - depending on where your doctor wants to keep your INR. Are you taking other medications that are competing with the coumadin? This is peculiar and needs further evaluation by your doctor.
Coumadin and Atrial Fibrillation
Answer: Coumadin will usually have some effect for 4-5 days after cessation depending on the initial INR and the patient's metabolism. If the death was due to an embolic event from the heart thrown to the brain - possibly.
Hair Loss from Coumadin [posted
Answer: Are you taking any other medications? Because coumadin is pretty risk free, I suspect another medication, like a beta blocker is the culprit. However, I know of no interaction with zinc in coumadin action and I don't think zinc would be of any use. Women do have good responses to topical minoxidil. If you can't eliminate the drug, try this.
Loss of Taste and Coumadin
Answer: Taste like any sensory nervous input is prone to degradation with age. Sight and hearing have obvious decline with aging. However, taste and smell do as well. While different medications can affect taste/smell, I wouldn't expect the effect to last more than a couple of weeks after the drug is discontinued. I have not had any patients complain of loss of taste with coumadin, but anything is possible. There are clinics that can quantify your taste/smell ability and loss. I have not been impressed that they offer good treatment alternatives.
Coumadin [posted 7/21/98]
Answer: Would certainly be uncommon. I'd have him see a Rheumatologist (arthritis specialist) to find the cause. I strongly doubt that it is the coumadin.
Coumadin and Tylenol [posted
Answer: There was one article that studied patients who presented to the hospital with high levels of PT or INR. This is a selected group of patients and a study has not been done prospectively looking at this problem. My own read is that these patients had liver problems, either caused by the Tylenol or accelerated by Tylenol since Tylenol can damage the liver in large doses. Clinically, I have never been impressed with any interaction and one would expect to see something in 20 years with all the tylenol that my patients take. I would continue to take tylenol with coumadin until further studies are done. Limit the dosage to 6-8 per day. If you have any history of liver disease do not take the tylenol until further studies are done. This has received far too much publicity without any critical analysis of the study.
Coumadin and hair loss/thinning
Answer: I have never heard of it as a problem. I haven't seen it in my patients. You might want to call the company - they might have an idea. It is Dupont: 302-992-4240.
Better, safer, natural alternatives
Answer: Sounds like you need a new doctor. Assuming that she had an artificial valve replacement, she will need to be on coumadin for her lifetime. There is no alternative nor herbal remedy that will be effective to prevent the possible strokes. If she had a porcine valve, this is not the case. Nausea, dizziness, and weakness are rarely due to the coumadin. Her other problems probably are. I would convey my concern and your need to switch physicians unless they can be addressed. Usually, one can keep the INR about 2.5 without major problems, but I do not know her specifics. A second opinion may be of help.
Answer: I doubt it is coumadin. You might try to selectively stop the lipitor and triamterene(with your doctor's knowledge). There really is no other drug than coumadin. Aspirin can be used but may not work. Ticlid is available but can be toxic and expensive.
Answer: Sorry to shock you, but I stand by my opinion. It really doesn't matter clinically as long as the intake doesn't vary a great deal from day to day. Large intakes followed by abstinence could cause problems. Try it and see. In theory it matters, in practice rarely.
Answer: Don't seem to be any other than the yearly risk of bleeding-- currently around 5-10%.
Coumadin and Migraines
Answer: I doubt that the coumadin is the culprit. If he were to develop migraines due to the coumadin, I strongly suspect that they would have occurred with the onset of therapy. The fact that he developed them several years later doesn't make any logical sense. Secondly, I must have 200 patients on coumadin and I have never heard one of them complain about headaches. I would focus on the other potential causes for new headaches rather than the coumadin.
Coumadin and Alcohol
Answer: The best way to keep coumadin from causing trouble is to keep your diet, medications, etc. the same from day to day. Changing metabolism of coumadin is responsible for the different levels. As a consequence, it is fairly easy to adjust coumadin for the changes seen with alcohol metabolism if it is fairly regular. Irregular use of alcohol(or other drugs)makes management more difficult. A regular drink is usually easier to compensate for than an occasional drink. I'd stick to his usual regimen.
Answer: Patients who have undergone heart valve repair or replacement are placed on blood-thinner medications to avoid having clots form about these valves. Essentially, these valves are foreign in the body in that they are close to, but not identical to, your natural valves which were replaced. Thus, there is a small but still significant risk for clot formation; thus, you have the need for blood thinners. Coumadin is the agent typically employed for long term blood-thinning or "anticoagulation". This medication works by inhibiting some of the chemicals in your body that are part of clot formation. There is still a large number of other chemicals responsible for forming clots, and therefore, patients on these medications do not have a great deal of bleeding problems assuming that the medication concentration in the blood is not too high. Therefore, your provider must keep your blood level high enough to avoid clot formation but not so high so as to allow for abnormal bleeding to occur. The numbers you describe refer to the blood test used to determine whether you have the right amount of coumadin in your system. There is no "correct range" for this medication because its uses vary, and the desired range of blood test levels varies, as well. You should discuss the desired ranges for your particular needs with your health care provider. Typically, patients with mitral valve replacements are kept with Prothrombin Times (or "PT", the numbers you reported) in the range of 20-25, while patients with aortic valve replacements are kept in the 16-19 range. If the level is too low, the risk of clot formation goes up, while if the "PT" is too high, the risk of bleeding complications goes up. Also keep in mind that the results of your routine blood test is a sample measurement, and that like all other functions in the body, monthly or even weekly variation is normal. Thus, slight variations in your levels are to be expected, and your health care provider will continue to monitor your levels to make sure you stay within your desired range.
Coumadin and diet
Answer: It isn't a big deal about foods. I have received a lot of criticism for this view, but I still stick to it. Green leafy vegetables do contain Vitamin K and large amounts can potentially change your blood results. However, few people eat these amounts and the vegetable intake is only a problem if it varies widely from day to day. In general, these vegetables contain antioxidants that probably improve your health. Consequently, avoiding leafy green vegetables and vegetables in general is not good advice. Rather, ensure that your intake is relatively predictable. Vegetable orgies one week followed by abstinence the next can potentially produce problems, but few follow this type of regimen. Watching different food intake on coumadin is more a theoretical than a practical problem.
Answer: There is a fine line with coumadin between risk and benefit and between too much and too little. An inflamed or irritated area can still bleed if coumadin is normal, but it is less likely if the coumadin is on the low end of "normal" . What have his INR been doing and why is he on coumadin. These are the pertinent questions. If he is on coumadin for less than dramatic reasons(concerning his heart) it might be possible to let the coumadin drift down. The risk here is either a stroke or heart attack. This needs to be discussed with his physician and with another member of the family present to ensure that there is no confusion.
Coumadin and food interaction
Answer: I don't tell my patients to avoid any specific food while on coumadin. I do discuss medical interactions with other medications-- aspirin and other non-steroidal antiinflammatories, etc. I do not limit or restrict their diet in any manner. Reference pharmacology textbooks do reference that foods high in Vitamin K can produce a problem. Clinically this is not seen. Almost all vegetables have Vitamin K and green leafy vegetables the most. However, the health benefits of the antioxidants in vegetables far outweigh any theoretical risk inherent in Vitamin K ingestion.
Answer: I've had a lot of patients on Coumadin and never seen this side effect. There are actually labs which can check your taste. A more common drug to cause change in taste would be digoxin. It is sometimes given in irregular heart beats. Are you on anything besides coumadin?
Answer: Coumadin is a common drug used in anti-coagulation. It really is the only drug that is effective and simple to give. Its major drawback is its tendency to interact with other drugs. Either by changing the liver metabolism of coumadin-affecting the anti-coagulation level, or by affecting the ability of the blood to clot. In general, aspirin and non-steroidals (like Relafen) should be used sparingly, if at all, with coumadin. Coumadin affects the coagulation profile - aspiring and NSAIDS the platelet function.
Coumadin and Vitamin E
Answer: There should be little interaction. However, I would keep my dosage of Vitamin E about the same each day so any side effects can be compensated for in your regular blood testing for coumadin.
Answer: Coumadin (warfarin) was invented at the University of Wisconsin in 1949. It was initially used as a mammalian pesticide since excessive anticoagulation will produce bleeding leading to shock and death. Most current pesticides use a slightly different chemical that has a time release characteristic rather than a one dose effect. However, this drug has been used extensively since the early 1950's in humans for anticoagulation. Close monitoring is required with the use of this drug to ensure that the right dose is administered. This drug interferes with Vitamin K. Consequently, any change in Vitamin K intake can change the dosage of coumadin. I couldn't find a history of the animal pesticides. However, it is manufactured by Dupont: # 302-992-5000. They are usually very helpful.
Answer: Coumadin rarely causes side effects. Why is she taking the drug? I suspect the medical condition that requires her to take the drug is the reason that she feels so poorly. There is no logical reason that her physician would suddenly start the drug without a change in her cardiac rhythm. I suspect that her rhythm is changed resulting in the change in her affect.
Answer: There are several reasons to take coumadin. However, these should be discussed with the patient and the risks and benefits should be explained. There is always a risk of bleeding with coumadin. Your husband needs to understand why he is taking this drug and what benefit the physician expects. Usually blood tests are not done until the patient is on the drug for a week or so. Then they should be done regularly (depending on how much variation is seen in his test from weekly to every 2 months).
Answer: There are a lot of medicines to avoid or to be careful taking with coumadin, but green vegetables are not one of them.
Answer: Green leafy vegetables are of no concern. There are many medications which can interact and any new medication should be discussed closely with your physician and pharmacist to determine the effect. For practical purposes, regular monitoring will reduce the risk of bleeding, which is about 5-10% per year.
Coumadin & Floxin
Answer: Coumadin(warfarin) is an anti-coagulant used in a variety of situations to decrease the ability of the body to form clots. It acts on different "factors" in the blood necessary to start the coagulation cascade. These factors are made in the liver. Consequently, any drug that is metabolized in the liver can affect the level of coumadin in the body and the subsequent INR. INR is a measure of the decreased coagulation ability of the blood. Coumadin was initially discovered at the University of Wisconsin as a rat poison. As you can see too much of this drug will ruin your whole day. Therefore, it is very important that all your physicians and your pharmacist know that you are on coumadin. In general, antibiotics must be followed extremely closely to avoid either too much or too little coumadin. Floxin(ofloxacin) belongs to a class of drugs called quinolones. These drugs in general increase the effect of coumadin;that is, taking floxin will require your coumadin dose to be decreased. However, this is a very individual effect and must be watched by more regular blood tests to test the effect of coumadin while and immediately after taking the antibiotic.
Coumadin & Alcohol
Answer: Usually, a moderate amount will not drastically affect the PT level.
Coumadin & Glucose Level
Answer: Not usually.
Coumadin & Diet
Answer: Unless you suddenly started large doses of coumadin probably not. There are several possible interactions between diet and coumadin; but, it usually doesn't have a major effect like this unless there is a drastic change in your vegetable intake(particularly leafy, green vegetables). In clinical practice, most patients don't have these major dietary shifts. Other drug interactions are the most probably cause.
Coumadin's Side Effects
Answer: Not usually.
Coumadin & Artificial Aortic
Answer: Could be a lot of different reasons. Something is changing your liver metabolism or your diet is increasing in Vitamin K. Any of several drugs could cause this. I wouldn't spend a lot of time trying to figure it out unless it is markedly variable.
Strange Side Effects
Answer: None of my patients report this side effect. Also, I looked too and didn't find any reports. You might contact the manufacturer Dupont 619-457-2553.
Answer: There is an increased risk of stroke if you continue to have episodic atrial fibrillation. Coumadin will be the best drug; although, aspirin has an effect in decreasing stroke. If you were 80, I'd recommend the aspirin; but, you have a lot of years for a stroke to affect you. Another alternative would be to eliminate the A Fib with a drug like amiodarone which I would try if you haven't . It is pretty clear the digoxin isn't working. Another alternative are beta-blockers; but, they are less likely to work.
Answer: Coumadin, as you know, is a form of blood thinner, in that
it affects blood clotting function, making the patient less likely to form abnormal clots.
The uses of this medication are many, ranging from clots in the leg veins or lung,
abnormal heart rhythm, to genetic/inborn clotting problems. Close follow up to check blood
levels of the medication is essential to avoid the most common side effect- that of
bleeding from high coumadin levels in the blood. Your husbands symptoms definitely
warrant further investigation. As you mentioned, he is not taking any other medications,
and there appeared to be a relationship between his being off the medication and symptom
improvement. It may be that there truly is a relationship, but one instance of symptom
improvement with one instance of drug removal may not necessarily be grounds to assume a
cause and effect relationship. That is to say, perhaps there are other reasons for why
there appeared to be a time related relationship when the drug was stopped, but the
symptom improvement was not due to removal of the drug itself. The Physicians Desk
Reference lists as rare side effects of coumadin (in addition to bleeding with high
levels) nausea, rash, diarrhea, and possibly priapism (persistent and painful penile
erection). Although there is always the possibility that the medication is indeed causing
your husbands symptoms, given the side effects listed for coumadin, further
investigation into other causes for the symptoms should be pursued. A visit to your health
care provider, even if it means repeating the symptom complex to him or her, may be
beneficial. Persistence of symptoms over time may provide additional insight for your
provider into what some of the possible causes are.
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