Understanding the Risks and Benefits of Blood Thinners: A Comprehensive Guide

For Larry Bordeaux, aged 65, prescription blood thinners became a vital part of his life after he began experiencing life-threatening clots following a surgery in 2010. He attributes these life-saving drugs to preventing further complications, recognizing the necessity of daily doses to avert the rapid development of clots when he must temporarily cease taking them for certain procedures. Residing in Havelock, North Carolina, Bordeaux is acutely aware of the delicate balance needed while on anticoagulants, such as the increased risk of uncontrolled bleeding.

Since commencing this medication, Bordeaux has encountered several complications, including a significant hematoma, where blood collects outside the vessels, and gastrointestinal bleeding. “Even with something like a simple fall, if the blood thinner [dose] is not correct, I could bleed out,” Bordeaux explained. He has joined efforts with the National Blood Clot Alliance, a nonprofit striving to minimize deaths and complications from blood clots and mitigate adverse events related to blood thinners.

Bordeaux is one among over 8 million individuals in the United States prescribed blood thinners, often due to post-operative clot development. Others use these drugs to manage conditions like atrial fibrillation, a heart rhythm disorder increasing clot formation risk. While blood clotting is crucial to stop bleeding, excessive clot formation can obstruct blood flow, potentially causing embolisms, heart attacks, or strokes. Blood thinners interfere with the natural clotting process, though they are linked to myriad unintended bleeding incidents leading to numerous hospitalizations each year. A report in the American Journal of Medicine highlights that these events cost the healthcare system more than $2.5 billion annually.

“Though they reduce stroke and embolism risk, they also cause bleeding,” stated Dr. Samin Sharma, director at the Cardiovascular Clinical Institute, Mount Sinai Fuster Heart Hospital, NYC. “Studies reveal a reduction in ischemic stroke risk, but the hemorrhagic stroke risk slightly elevates.” (Ischemic strokes stem from blockages, while hemorrhagic strokes result from bleeds.)

President Donald Trump has remarked on the risks of blood thinners like aspirin, which he takes daily, noting, “I take the larger one, but I’ve done it for years, and what it does do is it causes bruising,” in a conversation with The Wall Street Journal.

Dr. Pieter Cohen from Harvard University, who explored emergency room visits due to blood thinners, identified stomach or wider gastrointestinal tract bleeding as the main issue. Bordeaux faced a large hematoma post a bike accident. “Many of these individuals need hospitalization to stabilize the situation or require transfusions,” Cohen noted, emphasizing the seriousness these situations entail. Uncontained, rapid gastrointestinal bleeds can lead to disability or death.

Patients on anticoagulants risk serious bleeding from minor cuts, nosebleeds, blood in urine and rare instances of brain or lung hemorrhages. “Anticoagulants raise the likelihood of significant blood loss, needing transfusions, and worsening outcomes,” explained Arthur Allen, a clinical pharmacist and the Anticoagulation Forum’s president-elect advocating for preventive measures against severe bleeds.

Advocates argue the need for educating patients and families about the potential risks associated with anticoagulants. As Leslie Lake of the National Blood Clot Alliance mentioned, “Bleeding events aren’t rare occurrences; they happen frequently and are often brushed aside as common complications rather than preventable harms.” Research indicates that nearly half of such adverse events could be avoided.

Introducing New Blood Thinner Classes

Blood thinners have traditionally posed significant risks. For nearly 60 years, warfarin was the primary choice, initially created as rat poison. It requires frequent blood tests to monitor dosage due to its inconsistent effects. “Warfarin was notoriously challenging; it required constant monitoring and blood tests ranging from weekly to monthly,” stated Allen.

In 2010, a new era began with direct oral anticoagulants (DOACs) like apixaban (Eliquis), dabigatran (Pradaxa), edoxaban (Savaysa), and rivaroxaban (Xarelto). These drugs, proven safer and more consistent in trials, have not significantly lowered incidences in practice. Over 300,000 annual emergency department visits for bleeding still occur among anticoagulant users.

The limited monitoring needed compared to warfarin sometimes leads to inadequate oversight, according to Allen. The potential for aggravated bleeding exists if blood thinners are prescribed for too long or combined with other medications like antiplatelet drugs, often used post-cardiac events. “Some estimates suggest that a third of anticoagulant users are simultaneously on antiplatelet agents, frequently unnecessarily,” stated Allen, highlighting the need for guidelines that restrict such combinations to time-limited prescriptions.

Companies like Daiichi Sankyo, which produces Savaysa, stress awareness of treatment-related bleeding risks. Johnson & Johnson, the maker of Xarelto, advises patients to consult healthcare providers on the benefits and risks of all medications. Although Bristol Myers Squibb and Boehringer Ingelheim (makers of Eliquis and Pradaxa) did not comment, their websites acknowledge bleeding risks.

Combining blood thinners with over-the-counter anti-inflammatories like aspirin, which also increases bleeding risk, is another issue. A study in Michigan showed that one-third of patients on blood thinners for conditions like atrial fibrillation or venous thromboembolism also used aspirin regularly. “Without proper education, this can lead to serious adverse events,” noted Dr. Sabine von Preyss-Friedman, promoting patient awareness.

Careful Monitoring and New Approaches

A necessary consideration for using even newer generation blood thinners is correctly prescribing dosage tailored to individual needs. Factors like kidney function, body weight, and age-related fall risks must be accounted for over time. “Apixaban’s typical dose is 5 mg twice daily, but it should be halved for patients over 80,” Cohen elaborated.

So, can more bleeding incidents be avoided? While primary care doctors widely prescribe blood thinners, experts like Allen advocate for better training among vascular medicine specialists to reduce dosing errors. Dr. Sharma emphasized evaluating each patient’s bleeding risk against stroke threats. “If bleeding risks outweigh the stroke threat, it might be prudent to refrain from prescribing the drugs,” he suggested.

Hospitals increasingly turn to predictive models assessing patients’ bleeding and stroke risks to aid these decisions. Professor Toby Trujillo at the University of Colorado Anschutz mentioned emerging AI tools to refine dosing, connect patients with specialists, and prioritize those needing expert care. “Systems like DOAC Dashboard can highlight patients needing specialist attention due to medication interactions or dosage concerns,” Trujillo suggested.

New treatment avenues are also being explored, including ablation procedures to address atrial fibrillation and upcoming blood thinners targeting Factor XIa proteins involved in clotting to reduce bleeding risks. Trujillo noted, “These newer medications offer promising efficacy in clot prevention while potentially minimizing bleeding risks.”

Whether through innovative medication or improved management practices, reducing dangers associated with blood thinners could result in preventing countless adverse events and supporting affected individuals and families. Von Preyss-Friedman concurred, affirming, “Better control could substantially reduce emergency visits, gastrointestinal bleeds, and severe injuries.”