General Medical issues thread

[prozac]

The problem with Xarelto is that the effect lasts for 2-3 days

The scenario is this:
Travelling, so thinking of long haul DVT
Take xarelto
Then have a fall while travelling and break a leg/hip or hit the head and get a brain bleed
Problem is Xarelto officially cannot be reversed with a antidote (though the TGA has given provisional approval to a new antidote)
So depending on situation, may not be able to have a corrective surgery for 2 days and /or may have excessive bleeding from the injury.

Whereas, it is better to have an anticoagulant which is not long lasting
Something like Clexane - which hangs around for 12hrs. But its an subcutaneous injectable (like insulin)

When I went on it, the vascular surgeon asked if I did any motorsport to which I responded I rode a motorbike. His reply, "Don't"
So in your scenario above @Quickstatus if you are travelling, take xeralto for potential DVT and then have your fall, but instead of breaking a leg you bump your head causing internal bleeding, you have some serious treatment difficulties.

 

[Quickstatus]

instead of breaking a leg you bump your head causing internal bleeding, you have some serious treatment difficulties.

In my scenario, skiing. Fall, head injury, brain bleed etc etc...
clexane on the other hand, stops working in 12hrs
heparin even better as it can be easily reversed

"dont " as in no more motorsports?

 

[Quickstatus]

Nup.

Yes pros and cons.
I think for those who need it everyday, a single tablet line xarelto where you don't need to test the levels or watch the diet is life changing "However one has to live too" applies here too. But this is different to xarelto vs clexane as a just in case thing

 

[RooFlyer]

The problem with Xarelto is that the effect lasts for 2-3 days

The scenario is this:
Travelling, so thinking of long haul DVT
Take xarelto
Then have a fall while travelling and break a leg/hip or hit the head and get a brain bleed

I take Xarelto for heart arrhythmia and even though I’ve had the ablation procedure, they’ve still kept me on.

Issue is, as you know, that an AF episode can occur in your sleep so you can’t just take one on onset to mitigate the risk of a clot.

The scenario you portray is something that has scared me ever since I’ve been on the drug - must be 9 years now.

clexane on the other hand, stops working in 12hrs
heparin even better as it can be easily reversed

I might ask the question again about whether Xarelto is the one I really need.

 

[love_the_life]

MrLtL is on Amiodarone in addition to an ICD. The drug comes with quite a few possible nasty side effects but at the moment is the only one the cardiologist will use. Certainly has improved the continuing tachycardia. Another ablation was discussed as a possibility but it is not helpful that the cardiologist is currently suspended by AHPRA (nothing to do with his medical competence I can add).

 

[andye]

Anticoagulants are always a trade-off between clotting and bleeding risk.
The pharmacological half-lives are not always helpful (xarelto's is about the same as clexane) as the biological clotting action doesn't completely correlate.

If looking at an oral agent, one could argue that dabigatran is the best as there is an instant reversal agent in event of life-
threatening bleeding. Having said that it's twice a day, has a little more likelihood of intolerance due to indigestion and a higher risk of lower gastrointestinal bleeding (especially in over 70s and at the higher dose)..

Personally, I'd choose dabigatran (Pradaxa) if I had AF (especially after a stroke) and probably if I had DVT. There is an argument that apixaban (Eliquis) is safer in elderly but having looked at the trials in detail I'm not 100% convinced it's better

 

[Pushka]

Yes pros and cons.
I think for those who need it everyday, a single tablet line xarelto where you don't need to test the levels or watch the diet is life changing "However one has to live too" applies here too. But this is different to xarelto vs clexane as a just in case thing

I have a medic alert bracelet which I haven't been wearing. But as I get older it might be an idea to wear it again although

Anticoagulants are always a trade-off between clotting and bleeding risk.
The pharmacological half-lives are not always helpful (xarelto's is about the same as clexane) as the biological clotting action doesn't completely correlate.

If looking at an oral agent, one could argue that dabigatran is the best as there is an instant reversal agent in event of life-
threatening bleeding. Having said that its twice a day, has a little more likelihood of intolerance due to indigestion and a higher risk of lower gastrointestinal bleeding (especially in over 70s and at the higher dose)..

Personality, I'd choose dabigatran (Pradaxa) if I had AF (especially after a stroke) and probably if I had DVT. There is an argument that apixaban is safer in elderly but having looked at the trials in detail I'm not 100% convinced. It's better

thankyou. I might have that discussion next appointment. The non reversal issue has always been a thought.

 

[Quickstatus]

The scenario you portray is something that has scared me ever since I’ve been on the drug - must be 9 years now.

But the scenario is more for someone who does not take anticoags regularly and has one for travelling in case of DVT - my point is that they should also consider the risks that go with anticoagulants.
For most flights where its 12-24hrs only one clexane shot is needed at the airport. By the time you get off the flight the clexane is gone and you can be PFO (pissed and fell over) and you will be OK.
That said most actually dont need to do it even if travelling in LCC Y - if they just follow the airline DVT recommendations.

I might ask the question again about whether Xarelto is the one I really need.

I think chat with your favourite prescriber. Pros and cons to all anticoags. There is no perfect one.
Pradaxa has an TGA approved reversal : "Praxbind"

AFF Grapefruit test: increases pradaxa effect a little

 

[RooFlyer]

But the scenario is more for someone who does not take anticoags regularly and has one for travelling in case of DVT - my point is that they should also consider the risks that go with anticoagulants.

Yes, although I was talking about the general scenario of being on Xeralto and having a bad fall or being in an accident. It would be bad news and this discussion has prompt me to look for alternatives again.

 

[prozac]

Question for the docs. Lady told me she had been taking Prednisone for 4 days to treat sudden hearing loss. When I asked how much, thinking she'd say around 5mg, she told me it was 60mg. I asked if she was taking any insulin during this time and she responded in the negative. Could the pred cause low BP? The local pharmascist came out to help with a cuff and posrtable BP machine which initially showed her BP was low (in the 90s). I made a point of mentioning the pred to the ambos but they seemed to discount it.

For those following. Turns out patient was also taking diuretic and BP meds and this stripped Magnesium and potassium which resulted in feinting. Interesting how things happen.

 

[Quickstatus]

Turns out patient was also taking diuretic and BP meds and this stripped Magnesium and potassium which resulted in feinting.

steroi_s like prednisone often increases Bp because it causes the kidney to retain water and sodium.

The cause of fainting likely to be the diuretic draining the body of water causing the Bp to fall. Fainting in the context of diuretics can be as a result of arrhythmia due to low K or Mg. Low K or Mg does not cause low BP.