Treatment and Medications
When treating a blood clot, physicians use medications that thin the blood called anticoagulants or blood thinners. This type of medication disrupts the formation of clotted blood in the vessels and doesnâ€™t allow for the formation of a Deep Vein Thrombosis (DVT) or Pulmonary Embolism (PE). There are a number of different anticoagulants that can be used to achieve this, however, they vary dramatically in monitoring, price, effectiveness and convenience
Low Molecular Weight Heparins
These medications may be referred to as Innohep (tinzaparin), Lovenox (enoxaparin) and Fragmin (dalteparin). These medications are often the first medications used in the hospital during DVT or PE Diagnosis. (referring to the metabolism and elimination of the drug). These medications are effective but require self injection daily if used in an outpatient setting. Patients who are confined to a wheelchair or bed rest during times of illness are often given this medication to prevent a blood clot in leg or lung.
This medication may be referred to as Coumadin and is an oral medication. Until recently warfarin was the most prescribed anticoagulant used for outpatient treatment of DVT. Warfarin has a variety of dosage strengths that need to be adjusted based on the results of regular INR blood tests. This blood test is used to analyze the degree of coagulation in the blood (how thin it is). The optimal INR range while using Coumadin is 2.0 to 3.0, but this number may be difficult to achieve, especially early in the treatment process. Blood tests for INR are completed weekly early in the treatment cycle and then may be extended to bi-weekly or monthly. While many patients are treated successfully with this medication, physicians today often opt for newer more consistent oral anticoagulants. This is the only oral medication used for patients with mechanical heart valves.
New Oral Anticoagulants (NOACs)
These may be refered to as Pradaxa (dabigatran), Eliquis (Apixaban), and Xarelto (Rivaroxaban). These medications are currently the frontline treatment for DVT and PE. They are taken either once or twice daily every day and do not require regular INR monitoring. The medication is eliminated through the kidneys, therefore, physicians will complete a blood test annually for creatinine levels to ensure proper kidney function. In Canada, Xarelto is currently the only one of these medications indicated for PE and DVT treatment. The dosage is 30 mg for 3 weeks followed by 20 mg for the duration of treatment. These medications do not have a a counteracting agent, which is a minor drawback.
Risks of Treatment
Due to the nature of treatment and hindering the coagulation ability of a patientâ€™s blood, there are a number of risks that are associated with the use of blood thinning treatments. Bleeding is the major risk and can occur without trauma or blood thinners can exacerbate bleeding due to trauma. A patient should be aware of this and seek Emergency Medical attention if excessive bleeding occurs. We use The Outpatient Bleeding Risk Index (OBRI) to evaluate risk. When taking an anticoagulant patients should avoid binges of alcohol use and keep daily quantities to less than 2 units. Anti-inflammatory medication such as Advil, Aspirin and Aleve should not be used as they have anticoagulant properties. Patients should try to avoid dangerous activities during the course of their treatment to minimize risk. Bruising is also common during anti coagulation treatment. Spontaneous bruising should be reported to the doctor and patients should seek emergency medical attention for bruising that increases in size quickly.
There are a number of naturopathic remedies that can have an effect on anti coagulation treatment- for example Omega 3 Fish Oil. Patients should indicate what holistic treatment they are using as it may hinder the activity of the anticoagulant.
Surgery or Dental Work
During surgery patients are susceptible to major bleeding. The degree of bleeding depends on if the surgery is considered major or minor. In order to avoid dangerous excessive bleeding an anticoagulant regimen may be stopped from before to after the surgery. This process is referred to as Ã¢â‚¬Å“BridgingÃ¢â‚¬Â. Bridging is different for the type of procedure and the type of medication used. Please note that bridging may involve a temporary switch to low molecular weight heparin from Warfarin or NOACs before and after surgery.
Unprovoked: Treatment duration is longer in patients with no known cause for their DVT or PE. A spontaneous DVT or PE may be indicative of a genetic disease or disorder that makes the patient more susceptible to blood clots. These patients are treated for a minimum of 1 year and are often treated for the rest of their life. Family history is helpful in confirming a genetic thrombotic disease connection. Genetic testing can be completed at specialized thrombosis clinics but this is not a consideration until after 1 year of treatment because treatment would need to be temporarily ceased.
Provoked: Provoked DVT and PE treatment time is 3-6 months. Possibility of recurrence of DVT and PE increase every year, therefore, treatment may be continued for a year or longer in higher risk individuals. Frequently, we are asked about repeat testing and imaging after the treatment course to ensure resolution of the blood clot in leg or lung. DVT and PE symptoms are caused directly by the blood clot, therefore, without symptoms repeat ultra sounds and CT scans are not necessary. Individuals receiving treatment must remain patient as returning to a regular routine may take some time. Pain and swelling may dissipate slowly in some and very quickly in others. Post Thrombotic syndrome is a possibility in patients after a DVT where symptoms proceed after treatment. If symptoms of DVT proceed for several months then consult your doctor. Patients should be seen for regular follow ups during treatment.