How to manage Coumadin while taking NSAIDs?

[Brookwood]

My husband, 39, will have AVR pretty soon, and we are thinking about a mechanical valve. He has arthritis and is taking NSAIDs right now.

This is what I learned recently: Traditional anti-inflammatory drugs, called NSAIDs (nonsteroidal anti-inflammatory drugs) are avoided when taking anticoagulants including coumadin. This is because they impair the action of a major blood clotting element called platelets and because they are associated with ulcer formation in the stomach, esophagus, and small intestines. These associated side effects increase the risk of serious bleeding, especially when taking anticoagulants (blood thinners).

Some over-the-counter pain relievers are NSAIDs, too. These include aspirin, ibuprofen (Advil and Motrin), naproxen sodium (Aleve), and ketoprofen (Orudis KT).

Does that mean we can not choose a mechanical valve? Is it possible to manage Coumadin while taking NSAIDs?

 

[Karlynn]

I would consult with your doctors on this one. Both the cardiologist and the doctor caring for his arthritis. Does he take NSAIDs that are prescribed or is he dosing himself with OTC products?

 

[Brookwood]

He takes the prescribed NSAIDs and Advil.

 

[Guest]

Brookwood,

The information that you have is factual and your concern is real.

NSAIDS do increase the risk of bleeding and ulcers. The worst thing about this is that since they affect platelets, they do not show up in the INR.

Many people, including healthcare professionals, do not understand this. The INR is a test that is designed to measure only a very specific part of the clotting process. It does not equate to the bleeding time -- that measures all factors but is not useful in monitoring warfarin.

If have posted here in the past that naproxen does not seem to have any reports of bleeding with warfarin. However, that does not mean that it wouldn't occur over many years as an arthritis treatment.

If your husband were my patient, I'd advise him to consider a tissue valve. There haven't been any published reports (that I know of) showing that they last as long as mechanical valves but some of my friends who are in a position to know say that the pig valves are lasting in excess of twenty years. This is close to expectations for mechanical valves.

The downside of a tissue valve is that some people develop atrial fibrillation after valve surgery and need to go on warfarin anyhow.

So what is the answer. There is no one "right" answer. You will have to gather as much information as you can and decide how trustworthy the sources are the sources are and then make a decision. Even that may have to be changed while he is "on the table".

My wife calls this "The search for the perfect purse syndrome". You also have to say that "I made the best decision that I could with the information that was available at the time," and not second guess after the surgery. Don't we all at some time wish that we didn't know now what we didn't know then?

 

[ctyguy]

Brookwood....I am 42 and have a mechanical valve, 10 weeks post-op today. I was told by both my cardiologist and PCP to avoid NSAID type otc-medications for long term usage. Acetaminophens like Tylenol are fine but even those they want you to say below 2000mg per day when on Coumadin. I will say however that when I had a bout of pericardial effussion that I could take Advil for a few days to help the inflammation and to stop taking them when the symptoms went away, which for me was about 3 days. I was also told that if my symptoms persisted for more than a week to come back in because they didn't want me on the NSAID meds any longer than that.

I can't speak to arthritis but I know there are plenty of folks with mechanical valves who have arthritis as well. Im sure if you ask your doctor there are other protocols your husband could consider if a mechanical valve is your preferred choice.

 

[Karlynn]

Brookwood - I asked Al to come on and give his opinion. You've heard it from the best Coumadin expert I know. I know it's probably not the answer you were hoping to read.

Does he have any rhythm issues that would cause the doctors to think he may have issues with a-fib post op?

The only other thing I can think of is the On-X valve. They are doing low and no warfarin studies now. Alcapshaw2 has the contact info on that valve, so hopefully he'll be along to help you out.

Best Wishes.

 

[Brookwood]

Thanks for all the information. My husband doesn't have any rhythm issue. Anyway, getting a tissue valve and have ten more years to raise up our two kids is what we can live with. We will meet with the surgeons next week and see what they think.

 

[Bina]

Brookwood,
You have received expert advice from Al Lodwick, hopefully your doctors will help guide you.

 

[Ross]

With luck, he'll get more than ten.

Yes, no guarantees, but I'd start thinking more like 20 before needing another.

 

[Guest]

Surgeons cut. They do not do long-term care. You would do much better (in most cases) to discuss it with a cardiologist or hematologist.

 

[ALCapshaw2]

Brookwood - I asked Al to come on and give his opinion. You've heard it from the best Coumadin expert I know. I know it's probably not the answer you were hoping to read.

Does he have any rhythm issues that would cause the doctors to think he may have issues with a-fib post op?

The only other thing I can think of is the On-X valve. They are doing low and no warfarin studies now. Alcapshaw2 has the contact info on that valve, so hopefully he'll be along to help you out.

Best Wishes.

If you are still interested in a Mechanical Valve, I suggest you look at the relatively New On-X Valves which have several technological improvements over the older designs. See www.onxvalves.com and www.heartvalvechoice.com Contact Catheran Burnett, RN for more information at 888-339-8000 ext. 265 or [email protected] .

The LOW and NO Anticoagulation Studies were made possible by the lower incidence of Clot Formation due to their improved design. While the results of those studies won't be available until 2015 (I think that's the right number), the benefit of Lower Clot formation is realized immediately following implantation. Current protocol calls for anti-coagulation unless the patient qualifies for the study and chooses to participate.

'AL Capshaw'

 

[Kate]

Hi Brookwood,
I got a tissue valve at 38, and it is true that they just don't last as long in younger people. Hard to know for sure with the new versions, but I was told to expect 10 - 12 years with mine (could be more, could be less). The main thing when considering a tissue valve at a younger age is to make sure your husband goes to the best surgeon your insurance will allow. I think the easiest way to do this is to consult the rating of heart hospitals put out by US News and World Report (you can find it on their website) and go to the highest one on the list that you can, if not for this surgery than certainly for his repeat surgeries. After the first surgery, the risks go up and you want to be sure you have the most experienced people possible doing the work. However, with a little luck, there's no reason your husband can't live a normal life span with tissue valves. Best of luck, Kate

 

[aussigal]

I have Arthritis in my spine and used to take NSAIDS before my OHS. I now take Tramadol which doesn't intefere with the Warfarin and INR. I still occaisionally take a NSAID for a headache but only when I dont have any alternatives at home.

My experience.....I tried a NSAID for my back while on wafarin and it did raise my INR so we lowered the dose to compensate...after a month or so I wasnt getting any better pain-relief than with the Tramadol so I chose to go back to the Tramadol.

Just a thought.....it might be a good time for your hubby to try out some non-NSAID meds before he has his OHS to see if any would be a good substitute for him.