Anti-coagulation and travel

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ATHENS1964

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Joined
Oct 19, 2019
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448
I would like to share some thoughts about medicines when you travel, I will tell you what is happening in Greece and I would like to know what applies in other countries eg UK-France -Germany-USA etc.
Ιn Greece the only anticoagulant drug that is available is acenocoumarol (name of the drug Sintrom) no warfarin is available at all. The box with 20 pills of 4 mg is a cheap drug of 2.5 euros, and you can buy it from the pharmacy without a prescription. If anyone from the forum travels to Greece and has a problem, they can contact me for any help. Another way to feel safe is to mail to the hotel where you will be staying a box of your medicines also if traveling with friends give the traveler a quantity.
I say that because you will not find warfarin anywhere and the change to another drug is difficult, also if you visit any hospital they will serve you only with asenocoumarol or with anticoagulant injections.
Please know if the brand name of the drug acenocoumarol is available in Europe and how I could get it if I lose my medicine or stay there long enough.
 
first: acenocoumarol
OMG you poor bastard ... that is evil stuff and I've never once met anyone who has had a consistent INR on it because the half life is so short.

I say that because you will not find warfarin anywhere and the change to another drug is difficult,

well actually its reasonably straight forward to switch, and there are guides, the biggest problem is that basically you simply can't get a steady INR with acenocoumarol because of its half life. This is why its basically not used in modern medicine outside places like Greece, Slavic countries, India and South America.

I travelled extensively with warfarin (indeed in Finland I could even get the same maker of warfarin; Marevan) and having my coagucheck with me made testing anywhere a breeze.

Indeed this video was taken in Finland


and this one in Australia while visiting a mate
https://www.valvereplacement.org/threads/freedom-to-roam-or-unusual-inr-testing-locations.877523/
Greece is (still) an EU country ... I can't see why you can't get Marevan there if I can get it in Finland
 
Here is an excellent example of why I can never recommend anyone go on Acenocoumarol.

https://www.revespcardiol.org/en-co...arin-articulo-S1885585715003485?redirect=true
They write
However, VKAs are not exactly equivalent. Genetic polymorphisms are affected differently according to the type of VKA. The CYP2C9 isoenzyme would appear to be more important for warfarin clearance than for acenocoumarol or phenprocoumon clearance.1 Although warfarin is the most widely used VKA, in some countries, acenocoumarol or phenprocoumon are used.​
In Spain, the most widely used VKA is acenocoumarol. However, most of the available evidence on the efficacy and safety of VKAs is derived from warfarin. The results obtained with this VKA have in general been extrapolated to the other VKAs.​

So extrapolated means "guessed at"

Lets dive into this a bit: first the basis of their test is so pathetic that no actuary would accept it :

The objective of the present analysis was to determine whether there were differences in the clinical profile, anticoagulation control, and thromboembolic/bleeding events according to type of VKA. A total of 1524 patients were included. Of these, 79 (5.2%) were taking warfarin (1127 international normalized ratio [INR] assessments; 14.4±0.12 assessments/patient) and the rest were taking acenocoumarol (94.8%).​

so absolutely statistically insignificant number of participants for comparison.

Then we get to the key point of "time in range" Their (seemingly this is good enough) time in range was for acenocoumarol:



Variable​
Acenocoumarol (n=1445)​
Warfarin (n=79)​
P​
Time in therapeutic range (direct method), %​
61.1±0.5964.3±2.0.57
Time in therapeutic range (Rosendaal method), %​
67.9±0.5868.3±2.1.72

absolutely miserable times in range and made to look better by comparing it to substandard times in range of warfarin. Time in theraputic range for warfarin should be in the high 80's for a clinic and for a self manager in the 90's. I myself am on average 95% in range.

Worse (and undiscussed) is that on Acenocoumarol the half life is around 8 hours, so a missed dose will have you absolutely un-anticoagulated for a day. << Not ideal

They say themselves:
In terms of efficacy and safety, no randomized trials have compared these 2 alternatives.​

so why would you even pick the drug? I can only assume because its a national health system and the government saves money in the short term.

They observe in discussion:
Although the design of our study does not allow determination of the reason for prescribing warfarin or why these differences in prescription vary according to autonomous community, given the difference in half-life of the VKA, the physicians may have switched to warfarin because of inadequate INR control with acenocoumarol.​

Ya think? So Catalonia (which had the highest use of warfarin) may have switched to warfarin because the (largely wealthier) people there were worried about strokes. Possible IMO.

Then they identify what I identified but defend it because "it reflects our malpractice"

The main limitation of this study is the small sample size with warfarin, thereby reducing the statistical power of the comparisons. However, this situation reflects what occurs in clinical practice in Spain, where warfarin use is very limited.

Myself I don't even think its good rat posion because its half life is too short.


Then they write this:
The study was sponsored by Bayer Hispania S.L. The sponsor had no influence on study conduct or data collection and interpretation.​

So the drug company selling them this 5h1t sponsors it? No influence except perhaps to add in that above bit I bolded.

Lastly if you look up the references supporting this drug in their reference section you'll see the author of this papers names come up ... odd isn't it.

Indeed one of their supporting papers wrote this:

https://pubmed.ncbi.nlm.nih.gov/8191397/
Since there is no evidence that acenocoumarol is more efficacious or safer than warfarin, the latter seems to be preferable for patients who are candidate to very prolonged OAT

...and as we're on it for life I'd call that prolonged OAT.

Keep in mind there are many reasnsons why Oral Anticoagulation Therapy are prescribed, many are short term, some are long term. Of the long terms it would include DVT, Stroke history, Atrial Fib and Mechanical Valve Replacement. I would argue of all of those, the only one which will suffer from regular dips in INR is mechanical valve replacement where low INR may well cause thrombosis covering of the valve leading to valvular obstruction by those clots sticking to the leaflet.

I recommend you listen to this:
 
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My question was what does the traveler do in a difficult situation and not which medicine is better. For example if I come to Finland or Australia and I need my medicine what can I do? can I buy it at the pharmacy without a prescription, is the prescription I have from a doctor in my country valid or do I have to go to a hospital?
I also quote 2 links to the so many that circulate for those who compare scientific studies, I just follow the instructions of my doctors.
https://www.rug.nl/research/portal/files/6727335/Beinema_2008_Thromb_Haemostasis.pdf

ACITROM | Comparative Studies - Acenocoumarol vs. Warfarin
 
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My question was what does the traveler do in a difficult situation and not which medicine is better.
my mistake

what I did was go to a pharmacy and buy what I wanted when I was that traveller ... I'd be surprised if warfarin is not available:
I travelled extensively with warfarin (indeed in Finland I could even get the same maker of warfarin; Marevan) and having my coagucheck with me made testing anywhere a breeze.
 
I know for sure that you cannot just walk into a pharmacy in Canada and purchase Warfarin or any other anticoagulant. Need to have a prescription form a Canadian doctor, even if you have a standing order from your regular doctor in your country of origin/permanent residence. In fact, you cannot even get tested in Canada ( granted, I am talking about the province ofManitoba here but would expect it to be pretty much the same in most of the provinces). No pay for the service option like in the USA. Still need to have a Canadian doctor since the results are sent to the physician.
in the US, I could purchase my INR Test through Quest Diagnostics ( one of the major lab chains) for $40 ( cheaper than through my insurance if you factor deductible,etc.), appointment scheduled online, results sent via email. Did that a few times when I did not feel comfortable going to my usual clinic as Covid was beginning to hit my state.

I am currently in Switzerland, will be seeing a GP this coming week. Since the plan is to stay here for 5 years, I will have no choice but switch from Warfarin to Marcoumar commonly used here. I did bring 3 months worth of warfarin though. Been toying with the idea of sourcing Warfarin in France since I am quite happy with it overall and not too keen to start anew.

Sorry for the long and winded response, all I wanted to say that you really need to research whether your country of destination offers “walk in the pharmacy and buy” option. Personally, I would always stock up on my current meds and have them in my carry on bag. Wouldn’t even chance to ship them.
 
For me, once went to other country for 3 months, stayed for 6, ran out of Warfarin, so , as a "visitor" to the country in question, went to a local Dr , paid $50 and got prescription for Warfarin; If the country does not sale Warfarin, then the only option would be to carry with you 6 months supply, tell your local dr you are going away for 6 months and they give you the prescription, thats what i would do, but, we all have different ways to go about things, just a thought
 

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