Life with anticoagulation

Anticoagulants are medicines used to prevent harmful blood clots. The most commonly used medicine is Warfarin but there are others, e.g. Acenocoumarol (Sinthrome) and directoral anticoagulants (DOACs). Apixaban, rivaroxaban, and dabigatran* are the most commonly prescribed DOACs. Direct oral anticoagulants are used for the prevention of stroke, trans-ischaemic attacks (TIA’s), venous thromboembolic event (VTE), primarily deep vein thrombosis (DVT), and non-valvular atrial fibrillation (AF).

*Please note there are regular additions to the group of direct oral anticoagulants as new drugs are developed.

DOACs are used mainly in two situations:

• To prevent further clotting (thrombosis) when a blood clot has already formed and caused a problem – such as when a clot has formed in the legs (deep vein thrombosis) or a clot has travelled to the lungs (pulmonary embolus).
• To prevent clotting when you are at risk of forming a blood clot – such as following certain surgical procedures and some medical conditions.

When a blood vessel is damaged by a cut or injury, a blood clot forms to seal the wound to stop the bleeding. If this did not occur, bleeding would not stop. So the ability for blood to clot is life-saving. However, clots can be serious if they occur in places where they should not.

Blood clots (or thromboses) developing inside a vein or artery when there is no injury can be life-threatening. In these situations, the clot can block the blood vessel and cut off the blood supply to the surrounding tissue, or prevent blood flow through the vessel, thereby causing swelling and pain. Sometimes the clot can move to the lungs (pulmonary embolus) or brain (stroke).

A blood clot can develop suddenly and unpredictably, or as a consequence of several factors. For example, if you are less mobile after surgery then blood may pool in the lower leg veins causing deep vein thrombosis.

Sometimes they can occur in unusual places, due to multiple factors such as poor blood flow, injury to blood vessels or an increased tendency to form blood clots.

DOACs interrupt part of the complex systems involved in the formation of blood clots. They cause the blood to take longer to clot. They DO NOT dissolve clots. There is a chemical process in everyone’s body which breaks down the clots already formed, over a period of time – usually a couple of months. DOACs protect you from further clots while your body performs this process.

Before starting you on a DOAC your Doctor or anticoagulation specialist nurse will take a blood sample to check how well your kidneys and liver are working and also check your full blood count. Once you have started the DOAC these tests may then need repeating every three months and then every year your specialist will advise you how frequently you will require monitoring blood tests.

IT IS VERY IMPORTANT YOU ATTEND FOR YOUR BLOOD TESTS AS REQUESTED.

The duration of treatment depends on the condition for which you are being treated, and the circumstances behind the diagnosis, and any risk factors for bleeding that you may have.

For example:

• unprovoked above knee DVT orPE maybe lifelong
• provoked above knee DVT orPE 3 months & review
• AF lifelong unless circumstances change
• recurrent DVT orPE lifelong

Commencing a DOAC will be discussed with you by a doctor, or a nurse specialist. Once it has been decided to commence a DOAC, you will be seen by the anticoagulant nurse specialists, either in clinic or on the ward. You will be given advice verbally; and an Alert Card for your purse/wallet.

Remember to always inform any health professional that you are taking anticoagulants, e.g. dentists, GPs, chiropodists, pharmacists, practice nurses, or other hospitals.

The dose of DOAC prescribed is dependent upon which one you are commenced on and why you are taking it. However, you must take your DOAC at the same time each day as a missed dose may increase your chance of a clot forming. If you miss a dose – take the dose as soon as you remember (if within 6 hours of the usual time that you take your tablet). Otherwise miss the dose and continue as normal the next day.

Do not double up on your dose or take any extra tablets, and do not run out of tablets. Further tablets should be obtained from your GP.

If you take more than you prescribed dose you may have an increased risk of bleeding and should contact your GP or Specialist Nurse immediately.

The most common side effect of anticoagulation is a tendency to bruise and bleed. If you knock yourself you will bruise easily, but if you have any unexplained bruising, consult your anticoagulant nurse/GP.

Also if you observe any:

• nose bleeds, bleeding from gums
• coughing up or vomiting blood
• red or black stools, pink or brown urine or menstrual flow or vaginal bleeding that is heavier than normal

If you cut yourself, press firmly for 5-10 minutes and the bleeding should stop, if not seek medical advice.

If bleeding is excessive or prolonged (20-30 minutes), attend A&E.

If you suffer a significant injury to your head, attend A&E, even if you feel well.

If you experience dizziness, feeling tired all the time, experience weakness or sudden severe headaches, or experience vomiting that that has an aroma of and looks coffee grounds contact your anticoagulant nurse or GP.

You should seek medical advice immediately.

There are limited and in some cases no antidotes/ reversal agents for some of the direct oral anticoagulants therefore, the sooner you seek advice, the earlier intervention and review of your medication can take place.

Do not take aspirin or anti-inflammatory medications, e.g. Nurofen/Brufen/Ibuprofen/Naproxen/Diclofenac (Voltarol): unless prescribed by a doctor.

Please discuss any herbal medications or vitamin supplements you may wish to commence prior to commencing them with your GP or anticoagulant nurse, or pharmacist.

You must inform your GP or health care practitioner who monitors your anticoagulation if you are started on any new medication. You should always carry your alert card with you and inform any health care professional that you take an anticoagulant.

If you are unsure or you are commenced on any new medications speak with your pharmacist, GP or anticoagulant nurse.

If you require any injections, for holidays; or tetanus or flu/pneumonia injections, please have them as advised. However, you should inform the person administering your vaccinations that you are taking an anticoagulant medication.

You should eat and drink your usual balanced diet.

If you have any diarrhoea or vomiting for more than 24 hours, this can affect your DOAC medication levels you should therefore seek advice from the health care professional who manages your anticoagulation, i.e. the anticoagulant nurse specialist or your GP. You may require an additional blood test.

DOACs are not directly affected by alcohol but exceeding the Department of Health recommended alcoholic units may increase you risk of bleeding and will have a detrimental affect on your general health and well being. The Department of Health recommend:

• men and women not to regularly drink more than 14 units a week
• spread your drinking over three days or more if you drink as much as 14 units a week

With so many drinks and glass sizes, it’s easy to get confused about how many units are in your drink, here are some useful examples:

Can of lager/beer/cider (440ml, ABV 4.5%) = 2 units
Pint of lager/beer/cider (ABV 3.6%) = 2 units
Alcopop (275ml, ABV 5.5%) = 1.5 units
Bottle of lager/beer/cider (330ml, ABV 5%) = 1.7 units
Small glass of red/white/rosé wine (125ml, ABV 12%) = 1.5 units
Large glass of red/white/rosé wine (250ml, ABV 12%) = 3 units
Pint of higher strength lager/beer/cider (ABV 5.2%) = 3 units
Single small shot of spirits (25ml, ABV 40%) = 1 units
Standard glass of red/white/rosé wine (175ml, ABV 12%) = 2.1 units

You can check your units using the unit calculator from Alcohol Change or download a drinks tracker from Drink Aware.

Flying is not advised within the first 3 months of being diagnosed with a thrombosis. If flying, drink plenty of fluids, but avoid alcohol; wear flight stockings, move around and perform ankle/leg exercises. You should always tell your insurance company you have had a blood clot, and/ or if you are taking anticoagulant medication.

If you are taking anticoagulant for a cardiac condition then please speak with your doctor before going abroad or flying.

The use of DOACs is contraindicated in pregnancy. They can affect the development of a baby in the first few weeks, so it is not advised. If you become pregnant whilst taking a DOAC, please consult your GP and anticoagulant nurse urgently.

The combined oral contraceptive pill should be avoided, as should hormone replacement therapy (HRT), after a thrombosis, so seek alternative advice from your GP.

If you are on a DOAC as a long term medication, and wish to become pregnant, it should be planned and discussed with your GP.

You must not stop taking your DOAC without talking to your doctor or anticoagulation nurse specialist as you are at risk of suffering from a stroke or blood clot. No drug means no protection!

You should only stop your medication if medically advised to do so, as with all your other medications.

If you stop your medication after a clot (DVT/PE), please inform doctors if you have any surgery or leg fractures, or hospital admissions or periods of immobility.

Please continue your daily routine and allow the DOAC to fit in with you and not take over your life. In the first 3 months after a blood clot you should avoid contact sports and excessive gym work with heavy weights.

Always tell a work colleague you take an anticoagulant, especially if you are in an industry where accidents can happen – always adhere to the Health and Safety Policy. Take care in the garden with pruning and other sharp objects. Take care with shaving, and maybe consider an electric or battery shaver.

You can drive, but if you have recently had a thrombosis, ensure you can perform an emergency stop, and you are safe and competent to do so. Avoid long distances for the first 3 months, and then ensure you stop regularly to stretch your legs. If you have had an admission with AF or stroke or had any heart surgery, seek medical advice before driving.

After being diagnosed and commenced on treatment with a DOAC, you may still have some swelling, and pain/ache in your leg, or chest pain or breathlessness but this should gradually reduce over the next few weeks. If it persists or worsens, seek medical advice urgently. If diagnosed with a DVT, it is possible for the clot to move to the lungs, so any chest pains or breathlessness shortly after diagnosis, should be treated in A & E immediately.

If you are diagnosed with a DVT, you should be referred to the Orthotics Department for some graduated compression stockings, if appropriate, to ensure you do not develop post-thrombotic syndrome – this is symptoms of pain, swelling, discolouration and leg ulceration. The stockings help to prevent this by promoting good circulation in the legs. They should be worn for 2-5 years or as long as symptoms persist.

Adhere to all the advice and information given, to keep you safe whilst taking an anticoagulant.

Remember:

• attend A&E for any prolonged or excessive bleeding or head injuries
• always seek medical advice for any unusual bruising, or minor bleeds
• always tell health care professionals you are taking an anticoagulant
• drink no more than the Department of Health recommended alcohol allowance, and do not binge drink
• if prescribed any new medication or injections, inform your anticoagulant nurse or medical practitioner
• avoid aspirin and other anti-inflammatory medication, unless specifically prescribed by your doctor
• always use contraception and seek advice before planning a pregnancy.do not run out of your medication; extra tablets can be obtained from your GP
• take the correct dose of DOAC at the time prescribed

Remember to continue with the same dose of DOAC unless advised by your anticoagulant nurse/GP/ or the health care professional who monitors your anticoagulation

For severe, prolonged bleeding or head injuries, attend The Urgent and Emergency Care Centre (A&E).

For all other problems – speak with anticoagulation nurses, GP, or NHS 111..

Anticoagulation Nurses
Telephone: 01709 424016 (please leave a message on the answer machine)

The nurses are available Monday to Friday, except bank holidays, 9am to 5pm.

Phlebotomy Department
Telephone: 01709 424397

The Phlebotomy Department at Rotherham Hospital is open Monday to Friday, except Bank holidays, 7.45am to 4.30pm, via appointments only.

If you are unable to get out of your home, please speak with the anticoagulation nurses / GP