General Medical issues thread

[Pushka]

I've discussed the reversal issue with the Hematologist. He said the evidence was there seemed less risk of bleeding on the new drugs and while reversal is possible with VitK for warfarin, it wasnt an immediate reversal but over a period of time. X is out of the system within 24 hours and half life in someone with normal creatinine clearance (kidney function) in 8-12 hours. Non reversal certainly is an issue and it's why I wear a medic alert bracelet. If I'm in an accident where I bang my head badly then I'll need a CT whereas people not on the drug don't. So yes. I'm a little paranoid about that. Plus I get random bruises much more easily. I take a prescribed medication to reduce the chance of a gastric bleed. I also rattle when shaken

 

[Quickstatus]

Reversal of warfarin effect can be very rapid with transfusion of donated human plasma or prothrombinex. Vit K is a bit old school and does not lend itself to prompt restart of warfarin. The NOACS are more difficult.
We are seeing more bleeding now with patients in NOAC presenting with gut bleeding. I'm not sure overall significant bleeding (requiring medical attention) is lower or same. My gastro colleagues reckon it's higher. Additionally increasing numbers are on platelet inhibitors. Same colleagues have seen their callbacks increase over the last few years
I don't believe there is such a thing as more anti coagulation with less bleeding even though the manufacturers may think it's possible.i think there is a sweet spot but it will be different for everyone. So why give a similar dose to everyone as suggested by the manufacturers of NOACS like rivaroxaban

 

[Pushka]

I prolly don't need to hear that . If I want to travel I can't really do it on warfarin. Particularly as we don't stay long in one place.

 

[Cynicor]

I prolly don't need to hear that . If I want to travel I can't really do it on warfarin. Particularly as we don't stay long in one place.

That's not really true at all. Option 1- buy your own POC tester. They aren't cheap but (I've seen your trip reports ;P) TBH you can afford it.
option 2 - wait til you stabilse. Most of my patients on it are stable with only monthly testing or less. Keep an eye on your food and alcohol/fluid intakes to not vary it up too much from a normal week and you should be fine for shorter trips.

I don't trust the NOACs at all, the studies seem dodgy and the bleeding risk equal at best, and probably much worse in a well controlled warfarin population (like AU) rather than the USA population who spent 6-% or less time in therapeutic range. (AU studies hit 80+)

 

[Quickstatus]

If I want to travel I can't really do it on warfarin. Particularly as we don't stay long in one place.

Why not??..

The POC (point of care) machine referred to by Cynicor is a finger prick INR test. Works ok but I'm not sure that accurate. INR lab machines are highly and frequently calibrated. Not sure how these are calibrated.
The APS foundation in US do not recommend them
http://www.apsfa.org/fingerstick.htm

 

[Pushka]

I've read the self testers weren't accurate. So if the INR was critical it seems a bit of a risk. My INR when I had the DVT was 1.2 (not on meds) which was the higher end of normal which meant nothing to me at the time but now surprises me.

I don't want to go on shorter trips. I'm off again next week. I love cruises. That means I won't be long enough near a lab to get results. I'm just at the age nearing retirement and thoughts of travel have kept me working until now. I don't want to have to watch my diet other than a normal healthy one. And then there's alcohol.

I know it's all a risk. But if I have to hang around I'd rather be doing what I want to do than just - well, hanging around. I'm probably in denial. . And it's a sucky diagnosis. Like House said.

 

[love_the_life]

I prolly don't need to hear that .......

And neither do I

 

[Pushka]

Why not??..

The POC (point of care) machine referred to by Cynicor is a finger prick INR test. Works ok but I'm not sure that accurate. INR lab machines are highly and frequently calibrated. Not sure how these are calibrated.
The APS foundation in US do not recommend them
INR Finger Stick Machines ~ APS Foundation of America, Inc

So with those issues, it doesnt really work ok then?

I pose the question to Medicoes. Your close blood relative dies on warfarin - cause of death was either stroke (warfarin fail) or brain bleed (warfarin side effect). You then develop a DVt in a rare location 6 weeks later. What drug would you go on? I'm betting, not warfarin.

And neither do I

I'll behave

 

[Princess Fiona]

Reversal of warfarin effect can be very rapid with transfusion of donated human plasma or prothrombinex. Vit K is a bit old school and does not lend itself to prompt restart of warfarin. The NOACS are more difficult.
We are seeing more bleeding now with patients in NOAC presenting with gut bleeding. I'm not sure overall significant bleeding (requiring medical attention) is lower or same. My gastro colleagues reckon it's higher. Additionally increasing numbers are on platelet inhibitors. Same colleagues have seen their callbacks increase over the last few years
I don't believe there is such a thing as more anti coagulation with less bleeding even though the manufacturers may think it's possible.i think there is a sweet spot but it will be different for everyone. So why give a similar dose to everyone as suggested by the manufacturers of NOACS like rivaroxaban

Yes I am definitely seeing this in my work. It is very difficult to treat.

 

[Quickstatus]

I pose the question to Medicoes. Your close blood relative dies on warfarin - cause of death was either stroke (warfarin fail) or brain bleed (warfarin side effect). You then develop a DVt in a rare location 6 weeks later. What drug would you go on? I'm betting, not warfarin.

Understand where you are coming from
How do you know if the alternatives are better.

The holy grail - proper anti coagulation without bleeding is difficult to achieve. Everyone has a sweet spot that is variable. At least with warfarin you can adjust dose and measure effect. Rivaroxaban. well everyone seems to be on a similar or same dose. You can't have 80% of a pill

But the NOAC are easier - same dose, no limitations on diet no tests. Studies say same bleeding but coal face experience say otherwise.

Additionally we have seen rivaroxaban and other NOAC fail - have changed to warfarin for these serious/recurrent clotters. In fact an APS patient with severe PAD this week changed to warfarin and still clotting the fempop at INR 3.5.
PAD = peripheral arterial disease

....

Re APS: severe clotters sometimes get methylprednisolone and plaquenil. Non PBS Rituximab 4 week course at $4K is experimental

 

[Pushka]

Understand where you are coming from
How do you know if the alternatives are better.

The holy grail - proper anti coagulation without bleeding is difficult to achieve. Everyone has a sweet spot that is variable. At least with warfarin you can adjust dose and measure effect. Rivaroxaban. well everyone seems to be on a similar or same dose. You can't have 80% of a pill

But the NOAC are easier - same dose, no limitations on diet no tests. Studies say same bleeding but coal face experience say otherwise.

Additionally we have seen rivaroxaban and other NOAC fail - have changed to warfarin for these serious/recurrent clotters. In fact an APS patient with severe PAD this week changed to warfarin and still clotting the fempop at INR 3.5.
PAD = peripheral arterial disease

....

Re APS: severe clotters sometimes get methylprednisolone and plaquenil. Non PBS Rituximab 4 week course at $4K is experimental

Yes - I'm on plaquenil as well. For SLE - which caused the APS.

That's worrying to be clotting at 3.5 INR. Mums target range was 2.5. I suspect it wasn't high enough. Yes - 20 mg seems the standard dose for X.

I'll just go with what I'm on. Just over a year and no issues. Fingers crossed.

 

[Princess Fiona]

So with those issues, it doesnt really work ok then?

I pose the question to Medicoes. Your close blood relative dies on warfarin - cause of death was either stroke (warfarin fail) or brain bleed (warfarin side effect). You then develop a DVt in a rare location 6 weeks later. What drug would you go on? I'm betting, not warfarin.


I'll behave

I'd ask lots of questions but ultimately I would do exactly the same as you Pushka and take the advice of my treating Specialist.

 

[Pushka]

I'd ask lots of questions but ultimately I would do exactly the same as you Pushka and take the advice of my treating Specialist.

Yes. It's all a mere mortal can do.

 

[Milboo]

Also you need to figure out where all your iron has gone.

Likely to be dietary deficiency as I don't eat much meat or green leafy vegetables. My fridge after shopping today shows an attempt to change this.

ETA- thanks Quickstatus for comment on the infusion. Will head back to my GP and enquire as this chronic exhaustion is not fun.

 

[cove]

Anyone in our group been using a heart drug called Inpler where the 50 mg and 25 mg are the same price so you cut the tablet in half? I was switched to this one about a month and a half ago and it took a while for my body to get used to the change. Now the side effects seem to be close to zero so happy days.

 

[Pushka]

Had to share this. I'm on another forum in a specific thread on APS and the admin people have contact with Prof Hughes who discovered this auto immune disease in the 1980's. I posed the question about recurrences once on Anticoagulants and plaquenil.

Brain fog - I misspelt my tag name. Puska. Good grief. But Prof Hughes actually replied to my question in a YouTube clip yesterday.

He does talk only about warfarin. Maybe I'll reconsider at next appointment in May.

https://youtu.be/feW2SQOdrvs

 

[Quickstatus]

Likely to be dietary deficiency as I don't eat much meat or green leafy vegetables. My fridge after shopping today shows an attempt to change this.

ETA- thanks Quickstatus for comment on the infusion. Will head back to my GP and enquire as this chronic exhaustion is not fun.

Here is a good link about iron infusions. It's so much easier than taking Iron tablets. Of course the cause of the Iton deficiency should be elucidated as well. If indeed it's iron deficiency then Hb will elevate and feel normal in about 2-3 days.
Iron Infusion with ferric carboxymaltose (FCM) | Fact Sheets

Cause of iron defiance anaemia:
Losing iron (bleeding)
Not eating enough iron (diet)
Not absorbing enough iron ( mal absorption)
Enough iron but spread too thinly (pregnancy)

......
Other interesting sites for drug information
nps.org.au
pbs.gov.au - good place to see if there is a cheaper generic brand and prices

 

[Cynicor]

I love my infusions. I barely bother with tablets, especially with my patient population.

Infuse once and basically done for a year or so, it's great. Cheaper too!

 

[whatmeworry]

2 thirds of all Cancers are DNA replication errors.

What triggered Ms Woolley's cancer is not known, but a landmark study published on Friday shows that about two-thirds of all cancers are caused by random errors made during normal cell division.
"Our research has broken the paradigm that most cancers are environmental or inherited," said Assistant Professor Cristian Tomasetti of the Johns Hopkins University school of medicine.

The study reviewed 32 types of cancer and found that about 66 per cent of cancer mutations result from random DNA copying errors, 29 per cent can be attributed to lifestyle or environmental factors and the remaining 5 per cent are inherited.

Two-thirds of all cancers caused by DNA replication errors, landmark study shows

 

[Quickstatus]

Interesting and very debatable. What are the assumptions of the study?. How do they know that a random copying error is not environmental or inherited??. Let's read the actual article. I find journalists don't do a accurate job at all.