Plavix vs Coumadin for Afib in fall risk - interesting case

[winterallsummer]

Hello and thanks in advance for any opinions.  I encountered a patient at a nursing home the other day who was on plavix 75 mg qd for Afib.  I casually mentioned that coumadin may be more appropriate as its pretty well-agreed that it's more efficacious than plavix.  I was told the pt was put on plavix because they were a fall risk, and thus were not considered a candidate for coumadin.  This pt was not in active Afib, at least at that time.

 

My personal opinion based on my knowledge and the study posted below is as such: 

1. Coumadin and plavix have similar/same risk of bleeding, and coumadin is more effective in preventing clotting, so it should still be used in this scenario.

2. If the pt is not a candidate for coumadin based on fall risk, they should not be a candidate for plavix either.

 

What are your alls opinion on this?  I am not one to toy with meds especially in a pt older than the national life expectancy.  However in other, younger patients, had it been my patient, I would have switched him to coumadin irregardless of him being on plavix (unless of course he had some drug interaction, allergy or problem getting INR checked, or if he was often on abx or something that messed up his INR, or had some other indication for plavix such as drug eluding stent; none of which were the case with this patient).  

 

Would anyone have switched this pt to coumadin?  Or left him on plavix?  Or perhaps monotherapy with ASA?  Or just discontinued the med all together?  Interested in any and all opinions as anticoagulants are an interest of mine.  

 

 

http://archinte.jamanetwork.com/article.aspx?articleid=225918

(very good article btw for those interested, comparing ASA vs plavix vs coumadin and dual and triple therapy)

[GetMeOuttaThisMess]

Nevermind the initial posting.  Just keep in mind that studies I've seen reviewed have not shown a statistical benefit with the addition of ASA but DO show a statistically significant risk of bleeds.  Consider excluding reversible causes since you say that the symptoms are apparently intermittent.  What's the QOL, and how does the pt./family feel about the risk?

[winterallsummer]

Yes that is a good point regarding adding ASA to either plavix or coumadin.

 

I am most interested in if 

1. Plavix is ever desirable over Coumadin except in unique circumstances (INR or drug rxn problems, recent stenting, etc)

2. Plavix is in any way less of a bleeding risk than Coumadin

I believe it is generally accepted that coumadin leads to better outcomes regarding decreasing risk of eg CVA as compared to plavix.

 

As far as QOL - the pt is confused but happy, makes needs known, engages in activities, watches TV, has friends at the nursing home (other pts), ambulates with a wheel or geri chair, and is incontinent.  Pt is not really competent to talk about risk.  Family is mostly uninvolved, but for discussion's sake let's assume that their input coincides with most of the family's input at this facility which is that they want you to "do what's best."  

 

Also in a more competent, younger pt would the decision to use plavix over coumadin be any different?  I understand the above question is probably related to d/c'ing anticoags/antiplt's all together vs continuing anything.  

 

Thx for the input.

[GetMeOuttaThisMess]

I have seen a recent trend (own family including a younger brother, 50), who were placed on non-warfarin preparations. Sad to hear about non-family involvement (not uncommon).

[EMEDPA]

a few issues:

1, given the option, ablation for afib (maze procedure) is the way to go vs life-long anticoagulation

2. use chad scoring to determine the need for anticoagulation

3. coumadin is evil. ever looked at what you are not supposed to do on coumadin? long list including ride a bike, use rollerblades, use a ladder, etc

4. new agents,such as eliquis, pradaxa, etc, are even more evil as reversing them is MUCH more difficult AND there is no way to measure how anticoagulated someone is on one of these agents. in fact, use of a new agent is considered a contraindication to giving TPA in the setting of ischemic stroke(found that out last week).

5. I have seen bad side effects from plavix as well. saw one guy with large hemorrhagic blisters in his mouth. we admitted him and stopped the plavix out of fear that he would develop airway obstruction from them...

[GetMeOuttaThisMess]

^^^. Even though unlikely, this is the reason I brought up potential reversible causes. Don't forget alcohol ingestion is a potential source in addition to the more common causes. Unfortunately this case will probably prove to be a primary cardiac based on age.

[Guest JMPA]

coumadin should be used over plavix if no direct contraindication to coumadin. plavix has a long halflife and is more difficult to reverse, thus leading to a greater risk of m&m from a fall and bleed. especially if she is in a nursing home or SNF where the diet and anticoagulant can be controlled. as stated above, there is really limited data on therapeutic controls

[cbrsmurf]

Things to consider:

 

1. What's the CHADS2 or CHADS2-Vasc score of the patient?

2. Anticoag is superior to antiplt therapy (at least double) in CVA prophylaxis in AFib pts.

3. The new factor Xa inhibitors (apixaban, rivaroxaban etc) have a significantly lower risk of intracranial bleeds vs warfarin.

4. Is there comorbid cardiac disease in the patient?  CKD?

 

Also this, from UptoDate:

A risk of falling, with the potential for the development of a subdural hematoma, is often considered a contraindication to the use of anticoagulation in the elderly, although this risk is often overestimated by clinicians [40]. In one study, a history of falls was not an independent predictor of bleeding in patients taking warfarin [41]. In addition, one study that reviewed 49 published anticoagulation studies of patients with atrial fibrillation found that ICH (subdural hematoma or intracerebral hemorrhage) was uncommon [42]. A Markov decision analytic model demonstrated that, regardless of the patient's age or baseline risk of stroke, the risk of falling was not an important factor for determining the optimal antithrombotic therapy (ie, aspirin, warfarin, or no therapy) [43].

The risk of a subdural hematoma from falling is so small that patients with atrial fibrillation with an average risk of stroke (5 percent per year in the absence of anticoagulation) would have to fall approximately 300 times in a year for the risk of anticoagulation to outweigh its benefits [42-44]. (emphasis mine)