Which Blood Thinner Works Best For Your AFib?

HYANNIS – Until recently, if you needed a blood thinner to treat atrial fibrillation, orAFib, and prevent a stroke, your physician would likely have prescribedWarfarin, also known as Coumadin, which has been used for more than 50 years.

Now there are four new choices: Eliquis, Pradaxa, Savaysa and Xarelto. Each has its advantages and possible drawbacks, which can leave patients confused.

“There is no such thing as one anti-coagulant fits all, said Cape Cod Hospital cardiologist Mallory Hatfield, MD, FACC. “Each patient must consider lifestyle, your overall health, potential side effects of each drug and their different costs.”

First and foremost, that means talking with your doctor about the risks and benefits of each of these drugs, she said. Here’s a quick guide to get you started.

Warfarin, with a long-proven track record, still has its downsides. It is the only one of the five drugs that requires frequent testing, and patients must avoid many green vegetables that contain Vitamin K, Dr. Hatfield said. The drug can have a harmful impact on liver function and can dangerously interact with other medications, including pain killers and anti-inflammatories.

If cost is an inescapable consideration, Consumer Reports has chosen generic Warfarin as a “best buy” drug. For many, Warfarin may represent less than a $10 out-of-pocket expense monthly, while the newer drugs can cost as much as $340 a month.

But Warfarin’s testing requirement can cost as much as $85 per visit, so your long-term costs could end up being about the same, Dr. Hatfield said.

Studies show that all four of the new anti-coagulants work at least as well as Warfarin, and all are easier to take because they do not require the constant testing. Nor do they require restricting what you can eat.

But they have their own limitations. For example, you cannot take Xeralto if you have an artificial heart value. A study by Cleveland Clinic found thatPradaxa could lead to a slight increase in heart attack risk, even as it works to prevent stroke. The Clinic did not study the other three.

Eliquis (Apixiban) (Eliquis) is the only one of the newer medicines that has been shown in studies to reduce strokes more than Warfarin and cause slightly fewer bleeding episodes, according to Consumer Reports.

Warfarin has one big advantage over the other drugs – a coagulant can be used to stop excessive bleeding. With the newer drugs, if you suffer internal bleeding, a brain hemorrhage or bleeding from an accident, there is no antidote to immediately stem it. In some cases, that has led to deaths.

Still, even when a patient is on Warfarin, the Vitamin K antidote can take up to six hours to take effect, depending on the method of delivery; oral, intravenous, or by injection, said Dr. Hatfield. And because administering the coagulant can increase the risk of clot formation or embolism, it needs to be administered very cautiously.

The manufacturers of the newer drugs are working hard to find a coagulant. In October, the U.S. Food and Drug Administration granted its German manufacturer accelerated approval for a drug called Praxbind to use during emergencies to immediately reverse Pradaxa’s blood-thinning effects. It’s now available in many hospital emergency rooms across the country, including at Cape Cod and Falmouth hospitals, said Dr. Hatfield.

What about aspirin? While aspirin has been shown to prevent some kinds of strokes, in recent years it has lost support within the medical community. Aspirin appears to do “very little to lower stroke risk in atrial fibrillation patients, while at the same time being associated with a bleeding risk as high as some of the newer anticoagulant agents,” electrophysiologist Hugh Calkins, MD, FHRS, of the Heart Rhythm Society explained.

Do you need a blood thinner?

An AFib calculator determines your CHADS2 score, which measures your risk of stroke by assigning value to your existing conditions, explained Dr. Hatfield. The CHADS2 score risk calculator numbers are: