Chris Holmes, MD, is a hematologist/oncologist at the University of Vermont Medical Center and associate professor in the Larner College of Medicine at UVM.

Chris Holmes, MD, is a hematologist/oncologist at the University of Vermont Medical Center and associate professor in the Larner College of Medicine at UVM.

Now is an exciting time to treat patients who have blood clots. Why? We now have more drug choices approved for treatment.

If you have had a blood clot in the lungs (also known as a pulmonary embolism) or in the legs (also known as venous thrombosis) in the past, your doctor had one path to treat you: a drug called heparin right after the blood clot formed and a drug called warfarin (or Coumadin) for the next many months or years to follow.  This drug combination is effective for the majority of patients and allows your own body to dissolve the clot. They also keep new blood clots from forming (which is known as a recurrence).

The most recent drugs approved are rivoroxaban and dabigatran. These are oral drugs that don’t require that the levels be monitored in the way warfarin does and don’t require injection like heparin drugs do.

What does your doctor consider when deciding which drug (old or new) is right for you? Here’s a checklist:

  1. How much data do we have in your clinical situation? We know that each of the new drugs works just as well as the heparin-warfarin drug combination in preventing a recurrent blood clot from forming after your initial event. However, certain situations weren’t addressed in clinical trials for these new drugs, like whether you are at an extreme of body weight (very fat or very thin).  Also, certain groups of patients, such as those with cancer, were not well represented in the clinical trials, and experts are recommending against the use of the newer drugs in those patients.
  2. What is your risk of bleeding? Your doctor will talk to you about your past bleeding history and assess your ongoing bleeding risk to help decide what drug is right for you. For example, some drugs have a slightly lower bleed risk than others but some seem to be particularly bad at increasing your risk of bleeding from your gastrointestinal tract (or gut).
  3. How well do your kidneys and liver function? Certain drugs are better for you if you have reduced kidney function while others are preferred for reduced liver function.
  4. What works for you: once a day or twice a day drug dosing? This matters because if you are not compliant in taking these new medicines exactly as prescribed, they don’t work as well.  Tell your doctor if there is no way you are going to remember that evening pill—it makes a difference and there are once-a-day options!
  5. What other drugs and herbs are you taking? Some herbs and drugs may further increase your risk of bleeding, while others interact in a negative way with the prescribed blood thinner.
  6. What is your insurance coverage? For some patients, only certain drugs are covered under his or her insurance plan.

Here are some tips for all patients who are taking blood thinners of any kind:

  • Pick a time of day to take the drug with which you can be the most consistent. Timing makes a difference with blood thinners – try to not vary by more than one to two hours from your usual drug dosing time each day;
  • Notify your doctor of new medications and check on interactions with your drug;
  • Talk to your doctor about using herbal medications – they may increase your bleeding risk or decrease the effectiveness of your drug;
  • Never double up if you miss a dose; and
  • Get a pill box no matter what your age!

The Thrombosis and Hemostasis Program at the University of Vermont Medical Center has expertise in treating patients with blood clots and we are happy to help you and your doctor decide which drug is best for you.

Chris Holmes, MD, is a hematologist/oncologist at the University of Vermont Medical Center and associate professor in the Larner College of Medicine at UVM. 

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