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New drugs help keep blood flowing smoothly

Dr. Amgad Makaryus, chairman of the Department of

Dr. Amgad Makaryus, chairman of the Department of Cardiology at Nassau University Medical Center, poses for a portrait in his East Meadow office. (April 16, 2013) Credit: Barry Sloan

For decades, preventing blood clots has been practically synonymous with taking Coumadin, or its generic version, warfarin. That has meant frequent blood tests to make sure levels of the drug are correct, as well as worry about excessive bleeding if you are injured.

Now, a new generation of prescription blood thinners is on the market. They offer freedom from getting poked in the arm on a regular basis, but they're expensive and not always covered by insurance -- and they come with a risk of their own.

Here's what you need to know about blood thinners:




People take blood thinners when blood clots -- clumps of debris in the bloodstream -- are a possibility. Dr. Stephen Green, associate chairman of cardiology at North Shore University Hospital in Manhasset, says this includes people with atrial fibrillation (an irregular heartbeat), artificial heart valves, coronary stents and a number of rare hereditary conditions, as well as those who've had a problem with clots.

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Though blood normally clots to stop bleeding after a cut or an injury, unneeded clotting in other parts of the body poses life-threatening risks as clots migrate through the bloodstream, possibly leading to a heart attack, stroke or pulmonary embolism (clot in the lungs).





Blood thinners use different approaches to prevent the formation of clots.

* Anti-platelet blood thinners work by blocking platelets in the blood from clotting. These medications include aspirin, Plavix (clopidogrel), Effient (prasugrel), Brilinta (ticagrelor) and others.

* Anticoagulants affect the proteins that cause clotting. They include Coumadin (warfarin) and a new generation of alternatives -- Pradaxa (dabigatran), Xarelto (rivaroxaban) and Eliquis (apixaban).

The drugs can boost the risk for severe bleeding, which means that people taking them must be super cautious about preventing injuries. "I tell people there are risks, benefits and alternatives to explore," Green said. "With respect to atrial fibrillation patients, in whom these agents are most commonly indicated, it's a discussion of the risks of the disease, usually a stroke or mini-stroke, versus the risks of the agents, usually bleeding. In general, the patients are elderly and may have risks of falling as well as other issues."





Pradaxa, Xarelto and Eliquis have gotten plenty of attention because they don't require the monthly blood tests that people taking Coumadin must undergo.

But there's a negative that goes with that positive: No antidote for the new drugs -- what doctors refer to as a reversal agent -- is available to quickly stop their effect in someone who's bleeding heavily. Coumadin, by comparison, does have an antidote.

Green said it may be years before it's possible to quickly reverse the effects of the new drugs. Still, he said, "rarely is there a need to rapidly counteract the agents."





Costs for Pradaxa and Xarelto range from about $165 to $270 a month, though it could be less depending on insurance coverage, according to Dr. Amgad Makaryus, an assistant professor at Hofstra North Shore-LIJ School of Medicine and chairman of the cardiology department at Nassau University Medical Center in East Meadow. The third drug, Eliquis, was approved by the U.S. Food and Drug Administration just a few months ago, and some drugstores don't carry it yet. Its price is expected to be similar to the other newer drugs.

By contrast, warfarin "costs about $4 per month plus the cost of blood testing, about $20 per blood test," Makaryus said.

Physicians suspect that some insurers will refuse to cover the high cost of the newer-generation drugs. Green said that though insurers are concerned about cost, in terms of preventing blood clots in people with atrial fibrillation specifically, "the newer agents are as good and perhaps better than warfarin in terms of effectiveness."





"It's important to confer with your doctor about the use of blood thinners, especially if they're being used with aspirin, which can heighten the bleeding problem," said Dr. Lloyd D. Lense, an associate professor of clinical medicine at Stony Brook University. "Other nonsteroidal anti-inflammatory drugs can contribute to bleeding, as can disorders like kidney disease and liver disease."

Herbal medications also can cause problems when taken with blood thinners, he said.

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