Blood Thinner Can Be Risky

When 85-year-old Laker sportscaster Chick Hearn fell at home recently, hitting his head on concrete, he began hemorrhaging. Surgeons were unable to save him because pooled blood had damaged his brain.

Like hundreds of thousands of Americans, Hearn took the blood-thinner Coumadin to protect against a stroke. But Coumadin makes bleeding hard to stop and, as a result, falls become riskier.

Although brain injury is always a problem--especially for an elderly person whose blood vessels already are fragile--”certainly it would be made worse being on anticoagulants,” said Dr. Jack Patterson, Hearn’s cardiologist.

Coumadin, the brand name for the oral drug warfarin, interferes with various chemicals in the blood that make it clot. It’s a big-selling drug, with annual sales of $553 million for Coumadin and its generic last year, according to IMS Health, a healthcare information company. No other anticoagulant works in quite the same way; aspirin, for example, interferes with blood platelets’ ability to stick together.

It’s an essential medication for patients at high risk for blood clots in the heart, legs or lungs, which can eventually lodge in the brain, causing a stroke. Those include patients like Hearn, who took the anticoagulant for atrial fibrillation, a rhythm abnormality in which the heart’s upper chambers, or atria, quiver but don’t pump blood, creating the risk that sluggish blood could clump and travel to the brain.

Coumadin is also prescribed for patients whose faulty heart valves have been replaced with metallic valves, those with knee or hip replacements, those who previously had a stroke from a clot (as opposed to a stroke caused by a hemorrhage), and those who have had clots in the legs that broke off and lodged in the lungs.

The biggest downside to the blood-thinner is that patients have a 2% to 3% annual risk of serious bleeding, said Dr. Lawrence L.K. Leung, chief of hematology at Stanford University Medical School. A fall or head trauma can exacerbate bleeding. But often the patients who most need Coumadin to prevent strokes and heart attacks are frail, have existing orthopedic problems or take other medications that can interfere with balance.

“If there’s one medication that I dislike and am always hesitant in using, it’s Coumadin,” said Dr. P.K. Shah, chairman of cardiology at Cedars-Sinai Medical Center. “But unfortunately, when it’s needed, there is no substitute, and that is a real problem. The pharmaceutical industry has not been successful so far in finding a safer, hassle-free alternative.”

About 10% of patients on the medication have nosebleeds, Leung said. Bleeding can occur in any joint or tissue, and some patients find blood in the stool, a sign of bleeding in the stomach and intestines, or in the urine, a sign of spontaneous bleeding in the kidneys. Only about 0.5% of patients have serious bleeding inside the skull, he said.

The drug also poses a very small risk of necrosis, a type of gangrene in skin of the chest and arms.

Patients must have their blood tested frequently to avoid excessive thinning. Once they’re stabilized, they’re tested every two to four weeks to measure how long it takes their blood to clot. Patients need to be careful about potential interactions with prescription and over-the-counter medications, as well as some vitamins. For example, antibiotics, aspirin and some nonsteroidal anti-inflammatory drugs other than ibuprofen and naproxen, can overly thin their blood. Barbiturates and foods high in Vitamin K, like broccoli and spinach, can make them less sensitive to Coumadin. If they must undergo surgery, their doctors stop the drug beforehand, then carefully resume it after surgery.

Patients taking anticoagulants typically are advised to avoid activities that put them at risk of major injury--like contact or competitive sports--and to watch out for slippery floors. But, Shah said, “you cannot put a shield around your body. You’re always taking a certain amount of risk.” He noted that many patients take the medication without experiencing problems.

Dr. Asher Taban, the neurosurgeon who operated on Hearn, said the sportscaster suffered from small bruises that are typical of patients on Coumadin and that he reportedly told his wife the morning of his injury that he wanted to stop taking the drug.

But Patterson, a private cardiologist in the San Fernando Valley who had treated Hearn for about a decade, said the sportscaster had never before had any major bleeding problems with Coumadin.

Although patients sometimes express fear about taking it, he said, those with atrial fibrillation and no other heart disease have a 5% chance of suffering a stroke each year; Coumadin reduces that risk to less than 1%.

“It would be a shame if people who need Coumadin stopped taking Coumadin,” Patterson said.

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Who Needs It

Despite its risks, Coumadin (warfarin) is an essential drug for four types of patients, doctors say:

* Those who have a heart rhythm problem called atrial fibrillation. (Laker broadcaster Chick Hearn took it for that reason.)

* Those who have suffered a stroke caused by clots.

* Those with clots in the legs that traveled to the lung.

* Those who have undergone hip or knee replacement.