Patient education: Taking oral medicines for blood clots (The Basics)

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What is a blood clot? — Normally, your body is protected from bleeding because your blood vessels seal over after an injury. The seal is made by proteins and cells in the blood. Sometimes, these proteins and cells can form a larger "clot" that takes up space inside a blood vessel. Blood clots can be dangerous because they can stop blood from flowing. They can also break off and travel in the bloodstream to another part of the body, like the brain or the lungs.

Medicines used for blood clots are also known as "anticoagulants" or "blood thinners." They do not actually thin the blood. They just make the blood less likely to form clots.

You might be prescribed one of these medicines for either of these reasons:

●You had a blood clot – Medicine helps stop the clot from getting worse.

●Your risk of a blood clot is high – Medicine helps prevent new clots from forming.

What are the different oral medicines for blood clots? — "Oral" means that the medicine is taken by mouth. There are several medicines for blood clots that come as pills or capsules. These include:

●Apixaban (brand name: Eliquis)

●Dabigatran (brand name: Pradaxa)

●Edoxaban (brand names: Savaysa, Lixiana)

●Rivaroxaban (brand name: Xarelto)

●Warfarin (brand name: Jantoven, also known as Coumadin in some places)

Each medicine is different. They have different doses. Some are taken once a day, and some twice a day. Some are more expensive than others. And some are more affected by what you eat. The table answers some common questions about the differences (table 1).

Are there other types of medicines for blood clots? — Yes. In some situations, your doctor might prescribe medicine that comes as an injection (shot) instead of a pill. Examples include:

●"Low molecular weight heparins" such as enoxaparin (brand name: Lovenox) and dalteparin (brand name: Fragmin)

●Fondaparinux (brand name: Arixtra)

How should I take my medicine? — It depends on which medicine you take. Your pills will come with specific instructions, and your doctor or pharmacist will talk to you about what you need to do. If you take warfarin, you might also work with an "anticoagulation clinic." People taking warfarin need to have their blood checked, and sometimes, their dose needs to be adjusted.

Here are some general tips:

●Know the strength of your medicine and what the pills look like – The strength of the medicine is given in milligrams ("mg"). If the color, shape, or strength of your pills looks different from the ones you have taken before, check with your doctor or pharmacist.

If you take warfarin, you might be prescribed more than 1 strength. This might happen if you take a different dose depending on the day of the week, or if your dose is changed based on your blood tests. Know the color and number of milligrams (strength) of each warfarin pill you have.

●Take your medicine exactly as instructed – Try to take your medicine at the same time each day (or at the same set of times, if you take it twice a day). In addition:

•Dabigatran should be taken with a full glass of water after a meal.

•In some cases, rivaroxaban should be taken with food. This is explained in the table (table 1).

Do not change your dose or stop your medicine without talking to your doctor. Always refill your prescription before you run out of pills.

If you forget or miss a dose, or accidentally take more than you were supposed to, call your doctor or anticoagulation clinic to find out what to do. The instructions that come with your medicine might tell you what to do if you miss a dose.

●Use a pill box to stay organized – Some people find it helpful to use a weekly pill box with a slot for each day (picture 1). This can help you keep track of your medicine and make sure that you take all of your doses.

One exception is if you take dabigatran. This medicine should not be stored in a pill box. Always keep dabigatran pills in the original bottle or package they came in.

●Get your blood tested – If you take warfarin, you need to have your blood tested to check how your blood is clotting. This test is called a "PT and INR". This is important to make sure that you get the correct dose of warfarin for you. Once you are on a regular dose, you can have a PT and INR test less often, unless your diet changes, you get sick, or you start a new medicine. If your INR result is outside of the range that it should be in (usually between 2 and 3) and you have not received instructions about what to do, call your doctor, pharmacist, or anticoagulation clinic.

If you take apixaban, dabigatran, edoxaban, or rivaroxaban, you do not need regular blood tests to check how the medicine is working. But your doctor might do a blood test once in a while to check your kidneys or liver.

●Check before taking any new medicines – Ask your doctor, pharmacist, or anticoagulation clinic before taking any new medicines. This includes prescription or over-the-counter medicines, herbs, and vitamins. Certain medicines and remedies can change the way that some of these medicines work. In particular, a lot of medicines can affect the way warfarin works, especially vitamin K. So it's very important to check before taking any new medicines or stopping any medicines you already take.

Do not use medicines that contain an "NSAID" for treating pain or fever unless you talk to your doctor first. NSAIDs are a group of medicines that includes aspirin, ibuprofen (sample brand names: Advil, Motrin), and naproxen (sample brand names: Aleve, Naprosyn). They can increase your risk of bleeding, especially if combined with a medicine for blood clots.

Herbs and supplements can change how medicines for blood clots work. For example, ginkgo, green tea, and garlic pills can increase the risk of bleeding with warfarin, and you should avoid these. Talk with your doctor or anticoagulation clinic before taking any herbs or supplements. Also, make sure that any doctor or dentist you see knows that you take a medicine for blood clots, and which one you take. That way, they can check whether the new medicine might change the way it works.

●Follow instructions about diet – If you are taking apixaban, dabigatran, edoxaban, or rivaroxaban, there are a few rules about diet. Eat a regular, nutritious diet. If you take apixaban or rivaroxaban, do not drink a lot of grapefruit juice. There is more information about diet and these medicines in the table (table 1).

If you take warfarin, you need to eat about the same amount of vitamin K from foods every day. Do not take vitamin K supplements unless your doctor tells you to. Vitamin K affects how warfarin works. Some leafy green and other vegetables are high in vitamin K. The table lists the amount of vitamin K in foods (table 2).

●If you get sick, tell your doctor – If you have vomiting, diarrhea, a fever, or an infection, or if you cannot eat, tell your doctor. If you take warfarin, you might need a blood test and/or a change in dose. If you cannot keep down the pills, you might need a different type of medicine for blood clots that comes as a shot.

●Wear a medical alert tag – Always wear a bracelet, necklace, or alert tag (or carry a wallet card) that warns people that you take a medicine for blood clots and the name of the medicine. That way, if you are in an accident and are unable to explain your condition, people will know how to care for you. Your alert tag should also have the name and phone number of an emergency contact person.

●If you might get pregnant, talk to your doctor – These medicines are not recommended during pregnancy. If you could get pregnant, talk to your doctor about birth control options. It's also important to tell your doctor right away if you get pregnant while taking one of these medicines.

What are the risks of these medicines? — The major risk is bleeding. It's important to protect yourself from getting injured.

Bleeding can happen after an injury, but sometimes bleeding happens without an injury. If you have any signs of bleeding, get treatment as soon as possible.

How can I lower my risk of bleeding? — The following are things that you can do to lower your risk.

Avoid injuries:

●Avoid doing things that could lead to a fall. Examples include walking on slippery surfaces or climbing on a high stool.

●Avoid sports that might cause injury.

●Use care when handling sharp tools that could cut you, or avoid them when possible. Examples include sharp knives, saws, and straight-edge razors.

Protect yourself:

●Always use a seatbelt in the car, if you are the driver or a passenger.

●Always wear a helmet if you ride a bicycle or motorcycle.

●Avoid drinking a lot of alcohol. If you do drink, limit yourself to no more than 1 to 2 servings per day. A serving is equal to 1 beer (12 ounces), 1 glass of wine (5 ounces), or 1 shot of liquor (1.5 ounces).

●If you get nosebleeds, use a humidifier when the air is dry. You can also try putting petroleum jelly (Vaseline) in your nose. Don't pick your nose.

Communicate with your doctors:

●If you need surgery, tell the surgeon and anesthesiologist that you are taking a medicine for blood clots. Tell them which medicine you take.

●Whenever you start a new medicine or stop taking a current one, contact your doctor or anticoagulation clinic. This is true for prescriptions as well as over-the-counter medicines.

How can I stop bleeding if it does happen? — There are some things that you can do to stop minor bleeding if it happens. These are listed in the table (table 3).

When should I call for help? — Get emergency help right away (in the US and Canada, call 9-1-1) if you:

●Have a serious accident, fall, hit your head, or get another serious injury that could cause bleeding

●Have a severe headache or pass out

●Have trouble talking, weakness, or loss of function of 1 of your arms or legs

●Have severe bleeding

Call your doctor right away if you:

●Took more medicine than you were supposed to.

●Have any of these signs of abnormal bleeding:

•Bowel movements that look dark black or tarry

•Vomiting blood or something that looks like coffee grounds

•Nosebleeds or any bleeding that does not stop with the advice above

•Heavy menstrual periods or bleeding between periods

•Dark red or brown urine

•Any of the symptoms above that are not severe enough to call 9-1-1

You should also tell your doctor if you:

●Bleed from your gums after brushing your teeth

●Have more bruising than usual after a minor injury

●Have diarrhea, vomit, or are unable to eat for more than 24 hours

●Have a fever (temperature higher than 100.4°F or 38°C)

●Cannot take your medicine for any reason, or miss 1 or more doses of your medicine

For more detailed information about your medicines, ask your doctor or pharmacist for the patient handout from Lexicomp available through UpToDate. It explains how to use each medicine, describes its possible side effects, and lists other medicines or foods that can affect how it works.

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Patient education: Taking oral medicines for blood clots (The Basics)