Caregiving and Blood Thinners

Caregiving and Blood Thinners

Author: Mark Parkinson BsPharm:  President  AFC-CE

Credit Hours 1 - Approximate time required: 60 min.

 

Educational Goal

Teach about Antiplatelet and Anticoagulant therapies.

Educational Objectives

• Provide a brief overview of the blood clotting process.
• List symptoms of internal bleeding
• Teach about antiplatelet medications.
• Teach about anticoagulant medications.

Procedure:

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Disclaimer

   The information presented in this activity is not meant to serve as a guideline for patient management. All procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this article should not be used by care providers without evaluation of their patients’ Doctor. Some conditions and possible contraindications may be of concern. All applicable manufacturers’ product information should be reviewed before use. The author and publisher of this continuing education program have made all reasonable efforts to ensure that all information contained herein is accurate in accordance with the latest available scientific knowledge at the time of acceptance for publication. Nutritional products discussed are not intended for the diagnosis, treatment, cure, or prevention of any disease.

 

 

Caregiving and Blood Thinners

 

When I was operating my own adult foster care homes there was one medication that constantly resulted in uncomfortable questions for county health officials, Warfarin (Coumadin). Warfarin is comely known as a blood thinner, we called it the bruiser medication. Blood thinners reduce the chances of dangerous internal blood clots that can cause a lot of damage. They also make it easier for minor cuts and abrasions to bleed profusely on the inside and outside. If an elderly resident bumped into the door a little too hard, a rather large bruise would inevitably form. It made it look like we took a bat and beat up the resident. Not a good look for a care home. It always resulted in abuse questions. Blood thinners are a high maintenance drug class that requires the In-Home caregiver to manage the patient and medication- carefully. 

 

What are blood thinners?

I don’t know how everyday names for drug classes get started. They are often just flat-out wrong. Blood thinners don’t actually thin the blood. They are medications that make it harder for the body to form blood clots (coagulation). There are two types of so-called blood thinners that work in different ways to prevent dangerous emboli from forming. They are antiplatelet and anticoagulant therapies. 

 

Coagulation, or the blood clotting process

To help you understand blood thinners, let’s review how blood clots. The clot formation process is surprisingly complex. It involves multiple cells and blood factors that are constantly flowing through the bloodstream. When a blood vessel is damaged blood platelets are activated. They stick together at the site of the damage and form a weak plug. The plug is strengthened by clotting factors also flowing in the blood. Fibrin a special clotting factor that comes together and forms a mesh of fibers. The fibers act like the glue that holds the platelets, red and white blood cells, and other clotting proteins together and a clot is formed. 

 

For a visual explanation see this video. 

https://www.youtube.com/watch?v=--bZUeb83uU

 

Antiplatelet

Blood platelets are fragments of white blood cells and they flow through our blood. Having the shape of a plate they are designed to stick together at the site of cell damage in response to activating chemical signals. After they are activated, they change shape by growing tendrils that help them form a plug. After they stick together, other reactions occur, and a clot forms. The antiplatelet medication interferes with the chemical cascade of reactions between platelets, thus inhibiting a clot from forming. In laymen's terms, it makes the platelets less sticky. 

Common Antiplatelet medications are 

• Aspirin
• Clopidogrel (Plavix)
• Dipyridamole
• Ticlopidine (Ticlid)

 

Anticoagulant

Anticoagulant medications target the clotting factors, proteins made in the liver that are essential in forming a clot. These clotting factors cannot function without Vitamin K. Anticoagulant medication such as warfarin and heparin compete with Vitamin K and slow down the clotting process. Anticoagulants are more powerful at sopping clot formation than antiplatelet therapy. 

Common Anticoagulation medications are

• Warfarin (Coumadin ,Jantoven)
• Heparins (Lovenox, Fragmin) 
• Dabigatran (Pradaxa)
• Rivaroxaban (Xarelto)
• Apixaban (Eliquis)

 

Why take blood thinners?

The body puts a lot of effort into blood clotting to seal up damaged blood vessels. Why would you want to prevent that from happening? Not all blot clots are beneficial. There are times when they form in the wrong places. As a result and an embolus is formed that blocks off blood flow in a blood vessel. If that clot forms in the lungs a pulmonary embolism is formed. If it forms in the brain a stroke happens. If it forms in the heart muscle a heart attack occurs. All are life-threatening. In addition, clots can form in the veins of our extremities and a potentially painful deep vein thrombosis (DVT) occurs. Unwanted clotting can also occur with the irregular heart rhythms of atrial fibrillation (Afib), after surgeries, or when medical devices are implanted. Some of these clots can break away and travel to the lungs, heart, or brain. To prevent unwanted coagulation in these and other at-risk groups, doctors will prescribe blood thinners. Unfortunately for these patients they now have to worry about normal cuts and bruises.  For patients on long-term therapy (even low-dose aspirin), it becomes a balancing act between wanted and unwanted blood clotting. Caregivers find themselves with the extra work of monitoring the blood-thinning therapy and managing lifestyles to reduce and prevent harm.   

 

Caregiving and blood thinners

In-home caregivers are in the powerful position of being with the patient more than any other medical care provider. They have more influence on the day-to-day activities of the patient than even the doctor. As such they are in the best position to ensure patient adherence to therapy (both drug and lifestyle alterations) and monitor for side effects.  

Sometimes though our medical system treats In-home caregivers as if they were glorified babysitters or are just invisible to prescribers. There are those who seem to think that In-Home caregivers are unwilling or unable to follow therapeutic instructions. Regardless of the perception of others, In-Home caregivers have got to step up and insert themselves in such a way that important instructions are communicated to them. If you don’t the doctor, pharmacist, nurse, or therapist will give the information to the patient or whoever drove them to the medical appointment. They will assume that the patient will pass on the information and instructions to the caregiver correctly. Yeah right, like that is one activity that will never go astray. 

Regarding the above, I was going to list all the lifestyle changes that will be required by the various blood thinner therapies but realized that would be a lengthy list indeed. It would be more advantageous for In-home caregivers to get the specific requirement of therapy straight from the prescriber. 

In general, those instructions would include. 

• No alcohol
• No smoking
• Don’t start new medications, herbals, or supplements without talking to your healthcare provider. That especially includes NSAIDs and aspirin which have anti-blood-clotting qualities. You might have to switch to Acetaminophen (Tylenol, APAP) for “as needed” pain therapy. 
• Never double a dose because you missed a dose.
• Tell anyone giving the patient medical or dental care that they are on blood thinners.
• Take blood thinners exactly as prescribed.
• Monitor for signs of bruising or bleeding even in normal activities like brushing or flossing teeth.
• Control strenuous activities but retain an active lifestyle.
• Follow dietary guidelines that are laid out in blood thinner therapy. 

The Signs and Symptoms of Bleeding

Once the therapy has been established and the correct lifestyle choices have been received the next thing for In-Home caregivers is to monitor the patient for the signs and symptoms of bleeding. There is always the chance of the current medication dose working too good, the patient springs a leak through accident, injury or that something (food, drug, or herb) has added to the blood-thinning effects of the medication. 

Watch for

• Severe bleeding, including heavier than normal menstrual bleeding
• Pink, red, or brown urine
• Black or bloody stool
• Severe headache or stomach pain
• Joint pain, discomfort, or swelling, especially after an injury
• Vomiting of blood or material that looks like coffee grounds
• Coughing up blood
• Bruising that develops without an injury
• Dizziness or weakness
• Vision changes
• Head injury, even if you're not bleeding
• Bleeding from the gums after brushing the teeth
• Diarrhea, vomiting, or inability to eat for more than 24 hours

If any of the above occur, call the doctor. In the case of severe bleeding, call 911 and tell them that blood thinners are involved. 

 

Note to caregivers 

If despite your best efforts significant bruising occurs, I would suggest that you let any visiting medical professional, government regulator, family member, or another significant visitor that the bruises were from blood thinner therapy. Do it in such a way that it does not appear that you are covering up abusive caregiving. And of course, notify the doctor. The therapy might have to be adjusted. 

 

From Aspirin to Warfarin- all the details

The following are some specific instructions and details that I think are important for caregivers to know. 

Low dose aspirin- 

• 81 mg therapy is roughly about ¼ of a regular strength aspirin. To save money you could break up a regular aspirin, but I would not recommend it. It’s time-consuming and messy. It would also require a new prescription from the doctor to do so.
• There is a possible rebound effect if therapy is stopped. That means there is an increased chance of adverse events occurring. Counsel with the doctor about how to taper off if therapy is temporarily halted or discontinued. 
• If there is a constant upset stomach, counsel with the doctor about switching to enteric-coated aspirin.
• Along with the regular side effects, aspirin can cause tinnitus or ringing in the ears. Periodically question the patient about their hearing.  

Antiplatelet medications-

• Gastrointestinal bleeding is the most common adverse event associated with any antiplatelet agent. If there are signs of blood in the stools suspect a Peptic ulcer and counsel with the doctor about such. The most prevalent sign of a peptic ulcer is a painful stomach. Remember you don’t have to diagnose a condition you just have to suspect it and bring it to the doctor’s attention. 
• Several medications in this group may cause hypotension. Watch for dizziness upon standing or sitting up. 
• Sudden stopping of some of these medications may increase the risk of heart attacks and strokes. If a patient wants to stop, find out why. If the patient is serious about stopping completely, notify the doctor of the patient’s desires and tell the patient that sudden stopping may cause serious problems. Missing a dose here or there is not a big problem, just as long as the refusal is documented and doesn’t happen too often. 

Anticoagulant medications

• Dabigatran (Pradaxa), Divaroxaban (Xarelto), and Apixaban (Eliquis) all are newer medications that have less interaction with food and drugs. As a result, they do not require frequent blood tests to adjust the dose. But they are more expensive, and the blood-thinning effect does not last as long. They may take twice a day dosing and refusing the medication may have more health risks than other blood-thinning drugs. 
• Headaches, dizziness, and bowel or bladder dysfunction may occur in the elderly
• Cold intolerance may increase. 
• Heparin takes a lot of skill to administer and monitor. They are usually reserved for hospital or advanced nursing facilities. In-home caregivers most likely will not have to deal with these meds. If you do have to deal with them, get plenty of training and nursing delegation even if you are just monitoring the patient. 

Warfarin

Warfarin is a vitamin K antagonist. It blocks the action of vitamin K in the liver thus preventing the production of clotting factors. It has been prescribed since the 1960s, so it has been approved for several disease conditions. It is also inexpensive, so you are likely to see it use in your home. 

Unfortunately, many things can interfere with warfarin’s function in the body. Drugs, food, herbs, and supplements can cause a change in warfarin’s effect, both increasing and decreasing. Due to this variability, a periodic blood test will be required called the International Normalized Ratio (INR) to ensure warfarin’s safe use. It measures the time it takes for blood to clot or the prothrombin time, or just protime (PT). At first, the tests will be frequent, daily, or multiple times in a week. If the INR is too low, blood clots will not be prevented, but if the INR is too high, there is an increased risk of bleeding. Once therapy has been normalized and the variabilities of the patient’s life controlled, the test will most likely become monthly or longer. 

 

Note to caregivers

There may be times when the dose of warfarin will change a lot. Normally you throw away the old medication when a dose is changed. That is not necessarily the case in warfarin. You can also crush and cut warfarin tablets. You might be able to take advantage of ½ tablets in dosage changes to use up old meds and save money. Get permission from the doctor before crushing or breaking tabs

 

 

Controlling variability is where the In-Home caregiver comes into play. It is very important for conditions for the patient to remain the same. Follow medication orders religiously, strictly control PRN (as needed) medications and keep meticulous MARS records and be very aware of foods that affect vitamin K levels and interfere with warfarin’s metabolism. 

 

• If there is a sudden change in INR or it fluctuates ask the pharmacist to review the drug list and prn logs to see if medications are causing the change. 
• Common drugs that can interact with warfarin include:

• • Aspirin or aspirin-containing products
  • Acetaminophen (Tylenol, others) or acetaminophen-containing products
  • Antacids or laxatives
  • Many antibiotics
  • Antifungal medications, such as fluconazole (Diflucan)
  • Cold or allergy medicines
  • Nsaids (Ibuprofen or naproxen sodium)
  • Medications that treat abnormal heart rhythms, such as amiodarone (Pacerone, Nexterone)
  • Sleeping pills
  • Certain medicines used to treat convulsions
  • Corticosteroids or other cortisone-like medicines

• Common supplements that can interact with warfarin include:

• • Coenzyme Q10 (ubiquinone)
  • Dong Quai
  • Garlic
  • Ginkgo biloba
  • Ginseng
  • Green tea
  • St. John's wort
  • Vitamin E

• Common foods and drinks that might interact with warfarin include:

• • Cranberries or cranberry juice
  • Grapefruit
  • Alcohol (including NyQuil and cough syrups)
  • Garlic
  • Black licorice

• Foods that have a lot of Vitamin K. 

• • Green leafy vegetables (Kale has the most)
  • Beets and Beet greens
  • Onions
  • Asparagus 
  • Okra

 

Note to the caregiver 

It will be okay if the patient uses any of the above as long as the caregiver ensures the use is consistent. The INR will pick up any changes and the dose will be adjusted, and conditions will stabilize. One-offs or minor occasional uses of any of the above won’t be a big deal. This is one case where doctors should be notified and consulted before any major change to the patient diet occurs. 

 

Practical Hints For Caregivers

• Contact sports may increase the risk of bleeding. No sword fights or full-contact football contests between the residents of your home, regardless of how entertaining that would be to watch. (just kidding around) Use an electric razor to shave. 
• Use a soft-bristled toothbrush and wax floss. 
• Fall proof the inside and outside of your home. 
• If bleeding occurs apply constant pressure to the wound. If this does not work seek further medical help. 
• Medical alert bracelets may be appropriate to use. 
• The different strengths of warfarin are colored differently to help not make mistakes in dosage. 

 

Conclusion

Blood-thinners are an important but high-maintenance medication that can prevent serious illness and death. They require In-Home caregivers to: 

• Follow prescriber’s instructions faithfully
• Monitor the patient for the signs and symptoms of bleeding
• Help the resident to make the proper lifestyle choices
• Help maintain stability in the variables that can affect blood-thinning therapy. 

Like with many things in life, if the caregiver works at the above list hard it will become a matter of habit and become easy. 

 

As always Good Luck in your caregiving efforts

Mark Parkinson BsPharm

 

References:

1. Warfarin. Drugs.com. https://www.drugs.com/warfarin.html
2. Anti Clotting Agents Explained. https://www.stroke.org/en/life-after-stroke/preventing-another-stroke/anti-clotting-agents-explained
3. Anticoagulants. Texas Heart Institute. https://www.texasheart.org/heart-health/heart-information-center/topics/anticoagulants/
4. Warfarin side effects: Watch for interactions. Mayo Clinic. May 14, 202. https://www.mayoclinic.org/diseases-conditions/deep-vein-thrombosis/in-depth/warfarin-side-effects/ART-20047592?p=1
5. Blood Thinner Basics. WebMD. May 20, 2021. https://www.webmd.com/dvt/dvt-treatment-tips-for-taking-heparin-and-warfarin-safely
6. Blood Thinners. Drugs.com. Nov 1, 2021. https://www.drugs.com/cg/blood-thinners-ambulatory-care.html
7. Chad Shaffer, MD. What are anticoagulants?. The Checkup by Singlecare. May. 5, 2021 https://www.singlecare.com/blog/anticoagulants/
8. A Patient's Guide to Taking Warfarin. American Stroke Association, American Heart Association. Sep 30, 2016 https://www.stroke.org/en/health-topics/arrhythmia/prevention--treatment-of-arrhythmia/a-patients-guide-to-taking-warfarin

 

 

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