Question

Please explain why the Health Care Provider would prescribe Warfarin instead of Dabigatran or Rivaroxaban to a patient who was recently diagnosed with Paroxsymal Atrial Fibrillation. The patient states " I don't want to take rat poison ". How should the nurse practitioner respond ? For complete credit please list the risks and benefits to each drug.

Answer 1

Paroxysmal Atrial Fibrillation

Paroxysmal refers to sudden attack or intensification of symptoms. Paroxysmal Atrial Fibrillation is an abnormal heart rhythm/ cardiac arrhythmia that involves the two upper chambers or atria of the heart.

Warfarin: Warfarin is an Anticoagulant, usually sold under the name Coumadin, used for the prophylaxis of thrombosis and embolism in many disorders. Warfarin can be used for preventing stroke in people with Atrial Fibrillation.

Warfarin is a blood thinner and it is a Vitamin K antagonist, resulting in failure of activation of certain clotting factors , thus affecting clot formation.  

'Warfarin as rat poison ' and response of healthcare provider:

During 1940s , when Warfarin invented, it is experimented in rats and found to be lethal to rsts. Then certain rat poison companies added Warfarin in high dose to the product, so that the rat bleed to death. But other experiments conducted in human beings showed  Warfarin is useful in humans to prevent blood clots and very effective in preventing stroke . Since that Warfarin is used for the prophylaxis and treatment of thrombus formation.

Response: Healthcare Provider can tel the patient that , " I respect your autonomy to reject a drug, but same time I want you to understand the risks and benefits of Warfarin and other anticoagulant drugs .

Warfarin is one of the drug of choice for preventing stroke in patients with Atrial Fibrillation and thrombus formation in patient, who have Deep vein thrombosis and Pulmonary embolism. A high lethal dose of it , was used in rat poison, but it discovered that in 1950s , this drug is useful and very effective in human beings , since then it is used as an effective Anticoagulant drug, but ignorant people say ' it as rat poison'.

Dabigatran: It is an Anticoagulant medication that helps to prevent stroke and it is used in certain surgeries like hip or knee replacement surgeries to prevent thrombus formation . It can used as an alternative to Warfarin except in heart valve problem . FDA approved it on 2010.

Risks: Sudden stoppage of Dabigatran ( Pradaxa) can increase the risk of bleeding. If there is any abnormal bleeding, Pradaxa may increase it. There is an increased chance of GI bleeding. Those patients, who have following condition can't take Dabigatran, such as:

* Who have allergic reaction to the drug

* who have kidney problem , peptic ulcer or GI bleeding

* who are planning to have a valve replacement surgery

* Who take any Non steroidal Anti-inflammatory drug, that may increase chance of GI bleeding.

Rivaroxaban : Is also an Anticoagulant , used in Atrial Fibrillation and to prevent Deep vein thrombosis in hip or knee replacement surgeries and Pulmonary embolism. It is also recommended as an alternative to Warfarin .

Risks

It thought to be safer than Warfarin, but studies show that low dose of Rivaroxaban is associated with higher risk of death.  

* Sudden stoppage of the drug may cause high risk for death.

* Bloody black and tarry stools as a result of GI bleeding, heavy menstrual bleeding, muscle spasm, peeling of skin, pink or brown urine , headache are the side effect of Rivaroxaban ( Xarelto).

* It should be taken by patients, who have renal or hepatic problems, Geriatric patients, artificial valves, GI bleeding etc.

* It increases the risk of Myocardial infarction

Why Warfarin...?

Even if Warfarin also possess risk of GI bleeding, head ache , joint pain etc. It is safe for the patients , who have a history of valve replacement, or planning for a valve replacement surgery, minor kidney or liver problem, Geriatric patients, than DOAcs ( Direct oral Anticoagulants) such as Dabigatran and Rivaroxaban.