How does coumadin effect aspirin use?

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bvdr

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Hi,

I've been watching for quite a while to see if this would be mentioned but no luck so far.

For arthritis, I have taken 2gm to 4gm of aspirin on a daily basis for many many years. Sometimes when the arthritis simmers down I can go without it for weeks or months but then I end up back on it again.

Why aspirin? It works better than anything else I have ever used. It is also very very cheap. At times I use prilosec if I feel like I'm developing any irritation and if my ears start ringing I reduce the dose. I'm 54 and this has worked well since I was a teen-ager.

Now however, I have this history of atrial fib. I have valve replacement in my near future and believe it or not my main concern is what will I do about mixing coumadin and aspirin. I've never bled with aspirin but I had problems after only 6 days on celebrex a few weeks ago. I can gain up to ten lbs. of fluid after a few days on motrin, anaprox, lodine or so many of the others.

Does anyone have any experience with this? Thanks for any input............Betty(bvdr)
 
Hi Betty,

I had AVR surgery 3 years ago, and I have been on a Coumadin and Enteric,(coated), aspirin routine since surgery. There are many doctors that recommend the combination of Coumadin and Aspirin routine. I take my Coumadin and a 325 mg Aspirin daily, and have not had any problems.

You should consult your doctor about this, and also do some seaches on the Web for Coumadin and Aspirin.

Hope I have helped in some way,
Rob


For Example;

Can low dose anticoagulation with warfarin and/or aspirin be effective in
the primary prevention of ischemic heart disease in men at high risk?


Appraised by: Deb Bynum, MD


Date: Feb 11, 1998


Clinical Bottom Lines:


1) Low dose anticoagulation with warfarin (with a mean INR of 1.47) reduced
all ischemic heart disease events (fatal and nonfatal) from 12.4% in
patients not on warfarin (on aspirin alone or placebo) to 9.8% in patients
on warfarin for a RRR of 21% (p=.02). This effect was primarily due to a
39% RRR in fatal events (4.8% of patients not on warfarin had a fatal IHD
event compared to 2.9% patients on warfarin). This also accounted for an
overall decrease in all cause mortality from 13.9% in patients not on
warfarin to 11.6% -- a RRR of 17%. The effect of warfarin on nonfatal IHD
events was not significant.


2) The use of aspirin (with or without warfarin) was associated with a 20%
decrease in all IHD events (p=.04) from 11.8% in patients not on aspirin to
9.5% in those on aspirin. However, in contrast to warfarin, there was no
difference in the rate of fatal IHD events (3.7% on aspirin vs 3.3% not on
Aspirin). Nonfatal IHD events however were decreased from 8.5% to 5.8% with
the use of aspirin (RRR 32%). There was no difference in all cause
mortality between patients taking aspirin and those not on aspirin.


3) Warfarin and aspirin increased the risk of hemorrhagic and fatal
strokes. Patients on warfarin had a slight increase in the rate of strokes
from any cause (2.7% to 3.1%) and a small increase in hemorrhagic strokes
from 0.2% to 0.5%. Aspirin was associated with a slight increase in
hemorrhagic strokes from 0.1% to 0.6%, but a decrease in thrombotic strokes
from 2.0% to 1.3% -- therefore there was no difference in the rate of
strokes from any cause with aspirin (2.9% vs 3.0%).


4) There was an increased risk of ruptured aortic or dissecting aneurysm in
patients on warfarin (15 patients) vs those not on warfarin (3 patients), p
=.01.


5) There was a small but significant increased risk of major and minor
bleeding episodes in patients on warfarin, however the risk was not
significantly different than the rates seen with aspirin alone.


The Evidence: Randomised, blinded trial comparing patients on low dose
warfarin, low dose aspirin, warfarin plus aspirin, or placebo alone with a
primary endpoint of ischemic heart disease events (deaths from coronary
causes or MI); Stroke and overall mortality were secondary endpoints. The
patient population consisted of men at increased risk for heart disease,
but no prior history of MI or strokes.







warfarin + warfarin aspirin placebo
aspirin



IHD (n=1277) (n=1268) (n=1268) (n=1272)



All 71 (8.7%) 83 83 107
(10.3%) (10.2%) (13.3%)



Fatal 24 (3.0%) 19 36 (4.4%) 34 (4.2%)
(2.4%)



Nonfatal 47 (5.8%) 64 47 (5.8 73 (9.0%)
(8.0%) %)



Stroke



All cause 29 (3.6%) 22 18 (2.2%) 26 (3.2%)
(2.7%)



Thrombotic 11 (1.4%) 15 10 (1.2%) 18 (2.2%)
(1.9%)



Hemorrhagic 7 (0.9%) 1 (0.1%) 2 (0.2%) 0



Fatal 12 (1.5%) 5(0.6%) 2 (0.2%) 1 (0.1%)



Total 103 (12.4%) 95 113 110
Mortality (11.4%) (13.6%) (13.1%)







Comments:


1) Potential limitations to applying this to clinical practice include
difficulty and cost of following patients on warfarin and issues of
compliance. The authors point out that the process may be easier and safer
with having the goal INR of 1.5.


2) Caution needed in patients with poorly controlled hypertension who seem
to be at increased risk for strokes. The increased risk of aneurysms on
warfarin raises concerns for need for screening prior to starting treatment
which could be costly.


3) BIG POINT: need to weigh costs and benefits. The results are mainly
given as relative risk reduction-- overall 5 IHD events could be avoided by
treating 1000 men with warfarin and aspirin for one year ( or 3 events with
warfarin alone, 3 with aspirin alone). In other words, the NNT with
warfarin and aspirin to prevent on IHD event is 21. But, the all cause
mortality in the placebo group was 13.1% compared to 12.4% in the warfarin
plus aspirin group for an ARR of 0.7% -- The NNT for all cause mortality is
therefore 143 ! -- Is this worth the cost and risk??


4) Although aspirin alone decreased the risk for nonfatal IHD events, there
was still no difference in fatal IHD events and no difference in overall
mortality -- these results are in agreement with prior studies
demonstrating no overall benefit for the use of aspirin in primary
prevention of IHD.


5) Other potential problems with the study -- large rate of withdrawal,
loss of blinding due to minor bleeding events, limited patient population
(men only), an overall incidence of IHD that was less than anticipated, and
the potential bias of self selection in the initial process.


Reference: Thrombosis prevention trial: randomised trial of low-intensity
oral anticoagulation with warfarin and low-dose aspirin in the primary
prevention of ischemic heart disease in men at increased risk. Lancet 1998:
351: 233-41.
 
You are taking way more than the dose of warfarin for preventing heart attack. Eventually this will erode the lining of your stomach and start a bleed. You will probably have to be hospitalized. One aspirin tablet per day will not cause much harm But 2 to 3 Gm per day will get you eventually. This was the dose they used to use before Mortin came out. This is the reason for the warning against aspirin on warfarin prescription containers.
 
So, I guess the ASA will have to go.

So, I guess the ASA will have to go.

Thanks for the good input from both of you. It looks like I will have to use something other than aspirin for arthritis then since what I take is certainly not low dose. I think it may even be a good idea to make the change now so I won't have to tackle more than one major problem at a time.

Al, I've spent some time on your web site but I plan on becoming a more frequent visitor. Thanks again for the imput...............Betty(bvdr)

Al, one more question for you. My H&H runs high for a woman- my hemoglobin is usually around 16.1 and Hct. around 49. Does that make any difference in dosing with coumadin?.................thanks again..........Betty
 
There are many other options for arthritis these days. Most of the new anti-inflammatory drugs like Vioxx, Celebrex and Bextra work real well and are a much better choice for your arthritis than plain old aspirin. Aspirin will blow the top out of the lab machine when they check your INR if you take much of it with coumadin.
Talk to your doctor about trying some of these before you have surgery and then you will both know what works for you the next time you have a flare-up of arthritis.


Lettitia
 
Vioxx interfered with Joe's INR, and also caused him to retain 10 pounds of ugly fluid.

Not something he would like to take again, especially with CHF.
 
Betty

Betty

You are from the ones who were put on the asprin or coated asprin regiment. My mother was one also, RA, or rhuematoid arthritis. She was on the asprin regiment for years. By the time the new meds came along. she was suffering complications from RA. She has the disease all her life. So there are, like has been mentioned here, other new inflammatory meds, be sure to talk to the doctor throughly about the coumadin situation and he/she should medicate you accordingly. And make sure the cario doctor is up to speed on any and all med changes. You take care and keep hanging in there.

Caroline
09-13-01
Aortic valve replacement
St. Jude's valve
 
Betty,

I don't think that the high H & H will affect the warfarin dosing. One thing that it could make a difference with would be the finger-stick testing methods.

The only one that I am thoroughly familiar with is CoaguChek. This will not test with a hematocrit above 52%. It will not give a false test, the test will simply not run. This is because the test depends on the blood flowing up a tube. A high hematocrit means literally that your blood is too thick and it will not flow up the tube. I would make sure of a testing method's limitations before purchasing one.

The hematocrit, like all blood test numbers, is constantly changing, so it could reach 52 or it could go down.

If a person smokes, the hematocrit will creep up over time.
 
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