Pumping Marvellous

Warfarin in decline, alternatives on the Up? 

Pulse magazine is reporting that GPs are increasingly prescribing the newer anticoagulant alternatives to warfarin for the prevention of stroke, although their uptake has been slower than expected due to cost concerns.

An analysis of NHS primary care prescribing data for the past three years shows a fourteen-fold increase in the use of the newer anticoagulants dabigatran, rivaroxaban and apixaban in 2012, compared with 2011.

There was also a 9% increase in the use of warfarin from 2011 to 2012, leading experts to conclude that newer anticoagulants are being reserved for patients who are unsuitable for warfarin.

Pulse reported last year that following the NICE approval of dabigatran in March for certain patients with atrial fibrillation, CCGs put restrictions in place to limit use of the drug, with some warning its use as an alternative to warfarin could ramp up primary care drug budgets by as much as 20%.

This looks to have put a lid on demand, alongside concerns about the safety profile of some of the newer alternatives.

The figures from the NHS Information Centre Prescribing and Primary Care Services show that the total number of NHS prescriptions in 2012 for warfarin rose to 10.2 million prescriptions dispensed last year, compared with 9.4 million in 2011.

The total prescribed items for dabigatran – including those prescribed in patients with atrial fibrillation and venous thromboembolism – went up from around 3,200 in 2011, to 48,300 in 2012. Prescriptions for rivaroxaban and apixaban also rose, but their use remains much lower than that of dabigatran.

To read the full article from Pulse click here 

Guest Blog – AF Association (Part 3 of 3)

Atrial Fibrillation Association

So who are the Atrial Fibrillation Association?

The Atrial Fibrillation Association (AFA) is a UK registered charity that focuses on raising awareness of Atrial Fibrillation (AF) by providing information and support materials for patients and medical professionals involved in detecting, diagnosing and managing Atrial Fibrillation. There is now also a sister charity in the US, Atrial Fibrillation Association USA.

AFA works closely with medical professionals, Department of Health, government, NHS Trusts, PCTs, patients, carers, patient support group members and allied groups.

All information booklets published by AFA have been approved by an AF medical panel and endorsed by the Department of Health. The booklets currently available include titles on: Cardioversion of AF, Drug Treatments for AF, Blood Thinning for AF, two Checklists and an AF Patient Information booklet. They are downloadable from the AFA website.

AFA aims to provide support and information on Atrial Fibrillation to those affected by this condition; to advance the education of the medical profession and the general public on the subject of Atrial Fibrillation and to promote research into the management of condition.

The charity is involved in several campaigns for AF and heart rhythm disorders including World Heart Rhythm Week, ACT on AF and Know Your Pulse.

Its website, www.afa-international.org provides a wealth of information for patients and professionals including links to UK and international AF specialists.

A blood clot that forms on the outside of the body over a wound is a good thing. It stops the bleeding if you cut yourself. But a blood clot that forms inside a blood vessel can cut off blood flow to vital organs like the brain or heart. This results in a stroke or heart attack. A clot can also block circulation in the legs or lungs.

If taken properly, blood thinners can help prevent dangerous clots but still allow normal clotting to take place and stop blood flow from an injury.

Examples of blood thinners are:

• Anticoagulants such as warfarin and heparin
• Antiplatelet drugs such as aspirin and clopidogrel

A newer drug called Pradaxa may also be an option to prevent stroke in some people with atrial fibrillation. Regular blood test monitoring is not required with Pradaxa as it is with warfarin.

To make sure your blood thinner medication is both safe and effective, follow these steps.

1. Timing is important

• Take your blood thinner at the same time each day.
• Never skip a dose or take more than your prescribed dose.
• If you miss a dose, take the medicine as soon as you remember.
• If you don’t remember until the next day, call your doctor or anti coag clinic for instructions before taking that day’s dose.

You may find it easier to take your medicine if you use a pill organizer with compartments for each day of the week.

2. Watch for signs of bleeding
A nose bleed or bleeding from a cut are obvious. But more serious bleeding can occur in the brain or digestive track hidden from view.

A head injury can result in bleeding within the brain. This can cause a severe headache or other signs of a stroke. If you hit your head hard then we would suggest you go to Accident and Emergency for a check up or call the Emergency Services.

Call the emergency services if you are on a blood thinner and you have:

• A severe headache
• A fall or injury to the head
• Confusion, numbness, weakness
• Cough up large amounts of bright red blood
• Vomited blood
• Passed a lot of blood in the stool

Bleeding from the digestive track can occur gradually over time and may not cause pain. Seek immediate medical help if you have any of the following:

• Bright red blood in the stool
• Very dark or black stool
• Blood in the urine
• Bleeding that does not stop
• Bleeding in the mouth after a dental procedure (make sure your dentist is aware you are taking blood thinners before any surgery)

3. Use caution
Be careful with:

• New prescription medicine. Any doctor you see should know that you are taking a blood thinner. Warfarin and other blood thinners can interact with many types of medicine.
• Over-the-counter products. Check with your doctor or pharmacist before taking any non-prescription product, including aspirin, herbal medicine, or vitamins.
• Alcohol. Alcohol increases the effect of blood thinners and raises the risk of bleeding.
• Foods containing vitamin K. Foods that contain vitamin K can interfere with blood thinners. They make warfarin less effective and raise the risk of a blood clot. Vitamin K is found in green and leafy vegetables such as broccoli, lettuce, and spinach. You don’t have to avoid these foods, but keep the amount of vitamin K you eat consistent from day to day.
• Dental visits. Tell your dentist that you are taking a blood-thinning medicine as well as about all your other medicines. He or she may modify certain dental procedures to limit bleeding. Avoid eating hard foods or foods with sharp surfaces for 2 days after a dental procedure.

4. Keep your lab appointments
Doctor and Anti Coagulant Clinic visits for blood tests or lab visits are important when you are on certain blood thinners such as warfarin. Frequent testing is often needed to make adjustments to this medicine.

While taking warfarin, a blood test is used to measure the time it takes blood to clot. It’s called the prothombin time, or “protime.” The result is reported as the INR, which stands for the International Normalized Ratio. The INR is what your doctor uses to monitor the effects of the drug. The goal is to take enough blood thinner to keep the INR in the therapeutic range, which is higher than normal so that clotting is delayed but not prevented.

• When the INR is too low, the risk of a dangerous blood clot is increased.
• When it is too high, the risk of bleeding is increased.

It often takes some time to get the INR into the therapeutic range. INR monitoring may be necessary twice a week or more at first, and then less frequently.

Image via Wikipedia

Interaction between Vitamin K and Warfarin

I think this is a great article on Vitamin K and Warfarin and how it all works. It is taken from a blog on the site Xtend-life.com which is an excellent site where I buy my supplements, namely Total Balance Men and Omega 3 QH Ultra.

It is a conversation between a customer of theirs and Jo their Medical Nutritionsist you gave me this link and it takes you through what you need to know. Ok it talks about there products but this is a conversation between customer and company so you would expect that oh and by the way it is worth looking at their products and probably the most refined you can get.

Michael: asks…

Hi, I just read about your new Multi-Xtra vitamin/mineral supplement. I would like to know if it is safe to take with blood thinners (Warfarin). I saw it has some vitamin K-2 and Green Tea in it. I believe these could interact with Warfarin but I don’t know if the levels are sufficient to do so or if any of the other ingredients are a problem. I already understand that the Total Balance Premium could interact with Warfarin because of some of the ingredients. Please advise. Thanks

Joanna: responds

It is true that you should recognize that there is a relationship between Warfarin and vitamin K, but often the relationship between Warfarin and vitamin K is misunderstood.

First, you should know that your liver needs and uses vitamin K to make blood clotting proteins. In doing so, vitamin K plays a role in your body’s natural clotting process. Warfarin of course works against vitamin K.

Specifically, Warfarin reduces your liver’s ability to use vitamin K to produce normally functioning forms of the blood clotting proteins. By reducing the liver’s ability to use vitamin K to produce normally functioning forms of the blood clotting proteins, Warfarin reduces your risk of forming a blood clot.

It is a common misconception that people on Warfarin should avoid vitamin K. Reducing your vitamin K intake can cause your INR (your International Normalized Ratio) to increase and may make it more difficult to control. Rather than avoiding vitamin K, you should maintain a consistent intake of vitamin K by maintaining a consistent diet and supplement regime. In other words, from week to week, you should eat the same types of foods and take the same dose of your supplement. If your vitamin K intake is consistent then you won’t have any problems with your Warfarin interaction.

A significant change in your intake of vitamin K is what can result in a significant, and potentially dangerous, change in your INR, not your intake of vitamin K alone. For example, if you reduce your amount of vitamin K, your INR will increase, making it more difficult to manage your Warfarin therapy (patients who have a low intake of vitamin K have been found to have more fluctuation in their INR).

So why would a diet LOW in vitamin K make your INR more difficult to manage? Well, suppose you have a diet that is extremely low in vitamin K. Now suppose you eat a spinach salad at dinner one night for example. Spinach salad is high in vitamin K, so you have just increased your vitamin K intake, which represents a huge change in your dietary vitamin K. The result of this will be a significant drop in your INR. Any changes to your vitamin K intake represent fluctuations in your INR.

In order to maintain a consistent intake of vitamin K, keep to a good consistent diet, and the normal regular dosage of your supplement. Remember that the critical consideration in managing Warfarin and vitamin K is keeping the levels of vitamin K constant so your doctor doesn’t have to constantly change your dosage. People and their livers vary in their responses to Warfarin and vitamin K. The key is consistency. If your doctor gives you odd doses of Warfarin, such as 5 mg on Tuesday and Thursday and 2.5 mg on Friday for example, then that is what’s needed to keep your clotting factors constant. So, don’t adjust your vitamin K to your Warfarin.

Now, if you are on Warfarin and only just thinking of taking Total Balance or Multi Xtra, then my advice would be to consult your doctor about your wish to take this supplement simply so that he can then adjust your Warfarin dose accordingly. This is actually a good thing as it is a potential to perhaps lower your Warfarin dose, and discuss with your doctor other more long-term and natural approaches. For example, depending on your exact condition and health status of course, I would highly recommend discussing with your doctor the possibility of looking at not only Total Balance, but also Omega 3/DHAs (high dose fish oil can have a similar blood thinning effect) at 4-6 per day of our brand, plus our Cardio-Klenz supplement which has many cardiovascular benefits as well as helping blood consistency. These would be very beneficial for you and may, along with a good diet, help you to lessen your need for Warfarin at the same time.

If you decided to look at such a regime, and are currently on a normal dosage of Warfarin, my advice would be to start at a lower dose of Total Balance initially:

Total Balance 4-5 per day Premium (3 per day Standard; or 2 of Multi Xtra). Note: If you were not on warfarin you are strongly advised to take the full daily recommended dose right from the outset.

Omega 3/DHAs at 2-3 per day;

Cardio-Klenz at 4 per day.

Then gradually increase these dosages up to the recommended daily dose levels as your Warfarin decreases, if your condition warrants this.

Finally, regarding the other ingredients in Total Balance, such as ginkgo, policosanol, n-acetyl-glucosamine. It is true that, like vitamin K, attention needs to be paid to the dosages. However, again the dosages in Total Balance are all low compared to what would cause interaction. Only excesses in vitamin K, or any of these other ingredients, may potentially cause problems. In the low dosages in Total Balance, and careful dosing of both your medication and supplementation, as suggested above, whilst still on Warfarin, there is no indication of interaction.

I just want to make clear these are the opinions of Xtend-Life and no before you ask I am not in the pay of them, I just think this is a cracking blog post.

Understanding Atrial Fibrillation

At Pumping Marvellous we try to keep things simple as we are patients, however we do know a fair bit about our conditions so we do like to share our experiences with our readers. Sometimes it can become a little technical even for us with the conditions and we may need to use reference points to help us be factual but as stated we try to keep things simple.

Atrial fibrillation is a heart condition that causes episodes of irregular and often abnormally fast heart rate.

A normal heart rate should be between 60 and 100 beats a minute at rest. You can measure your heart rate by feeling the pulse in your wrist or neck. In atrial fibrillation, the heart rate may be over 140 beats a minute.

There are three main types of atrial fibrillation:

* Paroxysmal atrial fibrillation. This comes and goes and usually stops within 48 hours without any treatment.
* Persistent atrial fibrillation. This lasts for longer than seven days (or less when it is treated).
* Longstanding persistent atrial fibrillation. This usually lasts for longer than a year.

What happens

When the heart beats normally, its muscular walls contract (tighten and squeeze) to force blood out and around the body. They then relax, so the heart can fill with blood again. This process is repeated every time the heart beats.

In atrial fibrillation, the upper chambers of the heart (atria) contract randomly and sometimes so fast that the heart muscle cannot relax properly between contractions.

This may lead to a number of problems, including dizziness and shortness of breath. You may also be aware of a fast and irregular heartbeat (palpitations) and feel very tired.

Some people with atrial fibrillation have no symptoms and are completely unaware that their heart rate is not regular.

So why does it happens

Atrial fibrillation occurs when abnormal electrical impulses suddenly start firing in the atria. These impulses override the heart’s natural pacemaker, which can no longer control the rhythm of the heart. This causes you to have a highly irregular pulse rate.

The cause is not fully understood, but it tends to occur in certain groups of people and may be triggered by certain situations, such as drinking excessive amounts of alcohol or smoking.

How common is it?

Atrial fibrillation is the most common heart rhythm disturbance and affects up to 500,000 people in the UK.

Who is affected?

Atrial fibrillation can affect adults of any age, but affects men more than women and becomes more common the older you get. It affects about 10% of people over 75.

Atrial fibrillation is more likely to occur in people with other conditions, such as high blood pressure or atherosclerosis.

It is not common in younger people unless they have a heart condition.

Outlook

Atrial fibrillation is generally not life threatening, but it can be uncomfortable and often needs treating.

Treatment may involve medication to control heart rate and/or rhythm, and medication to prevent stroke.

A healthy lifestyle, regular blood pressure checks and treatment for raised blood pressure can reduce the chances of developing the heart problems that cause atrial fibrillation.

Flying, Travel and Heart Failure

After just being on a Transatlantic flight just over a month ago I thought this little article was quite reassuring for Heart Failure patients. As always consult with your Doctor / Consultant before flying anywhere. It will probably be a stipulation of your medical insurance to get an “ok” from them anyway.

Although this article is focussed on cardiovascular you can relate it to Heart Failure. Look for the highlighted text.

This article is by sify

Most people with cardiovascular diseases who are not critically ill can safely fly, a news report says.

The study, conducted by the British Cardiovascular Society, says that such people can undertake air travel provided they drink plenty of fluids, wear compression stockings and take a blood thinner.

However, the fluid intake should exclude alcohol, tea and coffee.

Consultant cardiologist David Smith of National Health Service (NHS) Foundation and colleagues explain that the main impact of air travel is the inhalation of air with reduced oxygen content in a pressurized environment.

This results in lower circulating oxygen levels in the blood, known as hypobaric hypoxia, says a society release.

Passengers already at high risk of angina, heart failure or abnormal heart rhythms might be adversely affected by hypoxia.

Otherwise, the blood oxygen levels induced by flying appear to have little or no adverse circulatory effects, certainly not for short-and medium-haul flights, for heart patients, the report says.

So what we are saying is that you must take the advice of your Consultant or Doctor. Don’t book until you have had the OK!

Interesting little post about Coenzyme Q10 and its effects on Warfarin

Coenzyme Q10 can be used in the management of mitochondrial disease, heart failure, hypertension, angina and arrhythmias. It is thought to work by being a free-radical scavenger, antioxidant, and membrane stabilizer. Coenzyme Q10 is structurally related to Vitamin K (menaquinone); therefore, it possesses procoagulant properties which will effect your INR if you are taking Warfarin.

If you take Q10 without your clinician knowing and you are prescribed Warfarin talk to them.

Let’s hit the target

As I drove into the Royal Blackburn Hospital and parked up I thought that Pumping Marvellous needed Anti-Coagulation support as I know alot of you out there are on some form of Anti-Coagulation and would probably like to know more about it.

Anyway after hitting my INR of 2.8 which generated a yipeee down the corridor as I really put effort into being within range I have asked Sister Maggs who is actually become a good friend, to help support the patients and pumping marvellous. She has agreed to recieving emails of which she will answer questions on anti-coagulation and especially warfarin management. We will be adding a link to the site to help you communicate with Maggs.

We will also try and bring the Pharmacy into the fold so you can ask questions about your prescribed drugs.

As always we are trying to stay innovative and focussed on bringing targetted patient care to Heart Failure patients.

Cut your salt intake

Ok will all like a bit of salt but too much salt can raise your blood pressure, and this can lead to heart failure or a worsening of the condition.

Suggested recommended limit: 2,000 milligrams per day (less than one teaspoon per day).

Limiting sodium is one of the most important things that people with heart failure can do.

Sodium makes the body hold on to fluid. To pump the added fluid, the heart has to work harder. People with heart failure shouldn’t put this extra strain on their hearts.
Excess fluid can also cause weight gain. Your heart has to work harder when you put on extra weight.
Too much sodium in the diet can worsen symptoms like swelling and shortness of breath. If those symptoms become severe, the person may need to be admitted to the hospital.
Sodium increases blood pressure. High blood pressure constricts the arterioles, making them resistant to blood flow. This makes the heart work progressively harder to pump enough blood to the body’s tissues and organs.

Cut down on table salt now!

Take the salt shaker off the table.
Discuss using salt substitutes with your doctor.
Limit salt in cooking
Avoid any seasonings that taste salty, including:

stock cubes (make your own stock it’s vastly superior)
cooking sherry or cooking wine
chilli sauce
meat tenderizer
seasoning salts
soy sauce
steak sauce
worcestershire sauce

Try substituting salt-free seasonings with lemon juice, vinegar and herbs.

Drain and rinse canned foods before preparing them to remove some of the salt. Tuna can now be purchased in fresh water – avoid the brine.

If you can use fresh fruits and vegetables over canned or frozen versions with added salt.

Shop for canned or frozen foods with no salt added.

Avoid packaged foods such as soups or rice dishes that come with a packet of powdered seasoning.

Avoid all processed convenience foods

Most of us take in more sodium through packaged convenience foods and snacks than by using table salt.

Look for “low-salt” or “low-sodium” labels on cans and packages. This label means the food has 140 milligrams or less sodium per serving. “Very low sodium” means it has 35 mg or less per serving.

“Reduced-salt” or “reduced-sodium” simply means that the product has at least 25 percent less sodium than the original version of the same product.

These foods may still have more sodium than you’re allowed.

Canned soups and dry soup mixes
Canned meats and fish
Ham, bacon and sausage
Salted nuts and peanut butter
Instant cooked cereals
Salted butter and margarine
Processed meats, such as deli items and hot dogs
Prepared baking mixes (pancake, muffin, cornbread, etc.)
Prepackaged frozen dinners (look for options where one serving has less than 400 mg of sodium)
Preseasoned mixes
Snack foods (crisps, snacks, olives, pickles)
Cheese
Tomatoes
Salad dressings
Fast food
Pay attention to your serving sizes.
A 2.5-serving can of soup with 200 mg of sodium per serving actually gives you 500 mg of sodium if you eat the whole thing. That’s a real dent in your 2,000 mg-per-day allowance.

Watch for other forms of sodium.
Read the ingredients. Many foods contain more than one form of sodium, such as

sodium alginate
sodium sulfite
sodium caseinate
disodium phosphate
sodium benzoate
sodium hydroxide
monosodium glutamate or MSG
sodium citrate.
Know what’s in your medicines.

Some medicines are high in sodium, too – always read the sodium content and warnings before taking an over-the-counter medication. Don’t take headache or heartburn medicines that contain sodium carbonate or bicarbonate.

Also be very careful that if you use lo-salt products that are based on “potassium sulphate” this will effect your INR warfarin levels.

Quick Tip on Warfarin and the INR front

I currently have a target INR of 2.5 and I have regulary achieved this when I have my 4 weekly tests at the anti-coag clinic at the Royal Blackburn Hospital. I am 79% in range since I started taking Warfarin which I believe is the top result in the clininc!

There are lots of reason for your INR to fluctuate; diet / exercise etc but there are three very important ones which cause continued instable INR results therefore you need to control these

Alcohol intake – I don’t really drink Alcohol I never really have
Smoking – I use to Smoke but don’t now
Recreational drug use – hand on my heart I don’t do drugs

Reduce your consumption of Alcohol down to a minimum and don’t binge drink – this must be why you are struggling to keep your fluid retention levels under control

Therefore if you haven’t kicked the cigarettes do so – can’t believe you are still smoking with Heart Failure

Recreational drugs are so a complete no no – do I have to explain this?

Be sensible and use your judgement – your Anti-Coagulant Nurse is always there to answer questions.