Kan Sulandırıcı İlaçlar: Yan Etkiler, INR ve Kanama Riski

What are blood thinners and what are they used for?

There can be many different rhythm disturbances in the heart. One of the most common of these is AF (atrial fibrillation). In AF, the upper chambers of the heart, namely the atria, do not contract; their movements decrease. Blood located in a motionless place is prone to clotting. This clot forming in the heart is dangerous; one day, it may fall from its location—namely the pouch in the left atrium—and travel to the brain via blood vessels through the pumping effect of the heart, blocking the vessels and cutting off blood flow. This is a very common cause of suffering a stroke. Moreover, compared to other causes of stroke, the probability of leaving a severe disability is higher. For this reason, most patients diagnosed with AF are given one of the medications that prevent blood clotting. These are called “blood-thinning medications” among laypeople. Their medical name is “oral anticoagulants” and there are two main types (according to active ingredients): Warfarin and NOACs. There are also four types of NOACs: Dabigatran, rivaroxaban, apixaban, and edoxaban. These drugs are also used in cases of clot formation in the leg veins (deep vein thrombosis; DVT) and clot migration to the pulmonary artery (pulmonary embolism). The drug called Warfarin is also used in those with mechanical artificial valves to prevent the valve from being covered by a clot. Medications called Aspirin, clopidogrel, prasugrel, and ticagrelor are also known as blood thinners. However, these are a different type (antiplatelet) of blood-thinning medications; they are used not in AF, but in patients who have had a stent placed or have undergone bypass surgery due to vascular occlusion and are the subject of another article.

What is a blood thinner injection?

Injectable anticoagulant medications are preferred in cases where oral tablets cannot be used or for adjusting the blood-thinning status before and after any surgery. These drugs can be used as a substitute for anticoagulant medications; they cannot be used in place of antiplatelet drugs such as Aspirin and clopidogrel.

What are the side effects of blood thinners?

The most important side effect, as one might expect, is bleeding. The cause of bleeding in some patients is a high dose of medication, while in others, it is due to another underlying issue that creates a predisposition to bleeding, such as a vascular rupture. In some, bleeding occurs due to other rare reasons. Bleeding can be mild or severe, and it can occur as external or internal bleeding. The most common types of significant bleeding are stomach and brain hemorrhages. The probability of these hemorrhages occurring varies for everyone, but on average, it is seen in 2% of patients. Other common side effects include allergy, jaundice, indigestion, stomach pain, nausea, vomiting, and dizziness. Refraining from using the medication out of fear of bleeding risks can mean being exposed to a much higher probability (greater than 2%) of clot formation and, consequently, problems such as stroke.

What should people taking blood thinners be aware of?

It should be known what to do when bleeding occurs (for example, applying pressure to the bleeding site to stop the bleeding).
The relevant doctor must be informed before any procedure or surgery associated with bleeding, including tooth extraction.
Contact sports and activities that can cause serious trauma, such as football, basketball, and boxing, should be avoided.
Care should be taken while moving, considering the possibility of falling (for example, not walking with hands in pockets).
Leather gloves should be worn when engaging in certain tasks such as gardening.
An electric shaver should be preferred instead of a razor blade.
Similarly, attention should be paid to actions encountered in life that carry a risk of bleeding.

What are the signs and symptoms of bleeding?

Directly visible bleeding (gum bleeding, nosebleeds, etc.)
Spontaneous bruising on the skin
Urine being red or darker in color
Stool being black, sticky, and tar-like
Coughing up bloody phlegm
Vomiting in red or brown color
Severe and persistent headache or dizziness
Sudden onset of pain or swelling

What should be done in case of bleeding?

If the bleeding is in a location where pressure can be applied, it should be stopped by pressing with a clean and dry cloth by hand. The patient should inform their doctor immediately and should not hesitate to go to the emergency room.

What is INR and when is it done?

INR is a test that indicates how long it takes for blood to clot. The higher the value, the longer it takes for blood to clot. However, it is a test specific to warfarin; it is not related to any other blood thinners, including NOACs.

Should blood-thinning medications be discontinued before tooth extraction or implant surgery?

All dental procedures, including tooth extractions and implants, should be performed without discontinuing blood-thinning medications. The bleeding time will be prolonged, but this is not worse than the formation of a clot in the heart. Bleeding can be controlled by applying a long tampon (pressure) or by suturing. However, for those using warfarin, the INR should not be unnecessarily high; in this case, it is preferred for the INR value to be close to the lower limit, yet still within the normal range. For more details regarding tooth extraction and blood-thinning medications, you can read our relevant article.

Do blood thinners interact with other medications?

If a doctor is going to prescribe a different medication for any reason, the patient should inform their doctor that they are taking blood thinners. This is because some medications interact with blood thinners, either reducing or increasing each other’s effects. This can result in blood clots or bleeding. Antibiotics and pain relievers are particularly important. If a pain reliever is needed, those containing paracetamol should be preferred. Most other pain relievers, especially those known as NSAIDs, weaken the stomach lining, increasing the risk of stomach bleeding associated with blood thinners, and are not recommended for patients taking blood thinners unless absolutely necessary.

If foods with blood-thinning properties are consumed frequently, is there a need to take blood-thinning medication?

No food should be used as a substitute for blood thinners. Their effects are neither strong nor easily controlled. They can also interact with blood thinners and increase the risk of bleeding.

Are leafy green foods prohibited for people taking blood-thinning medication?

Vitamin K, found in leafy green foods (lettuce, spinach, etc.), only reduces the effect of warfarin. This is because warfarin exerts its effect via vitamin K. However, this does not mean that leafy green foods are forbidden. Plants, thanks to the other vitamins they contain, are essential for a healthy lifestyle. The important thing is to ensure that even with warfarin interaction, these foods are consumed regularly and in certain amounts to maintain a balanced drug interaction. Other blood thinners (dabigatran, rivaroxaban, apixaban, and edoxaban) do not interact with leafy green foods.

If severe bleeding occurs due to blood-thinning medication, is there an alternative treatment?

If the bleeding is caused by a problem that can be corrected, then the issue is resolved and further bleeding is prevented. For example, enlarged capillaries in the nose can be cauterized, or intestinal polyps can be removed via endoscopy. Thus, treatment is provided, and the medication can be safely restarted. However, sometimes the cause of the bleeding is either unclear or cannot be easily resolved. In this case, both the patient and the doctor may be reluctant to restart the blood-thinning medication due to the fear that “bleeding might occur again.” Yet, this time, the risk of a clot forming inside the heart arises. Today, the LAA closure procedure is recommended for patients facing this dilemma. Thanks to this technology, in most cases, the patient is freed from the risk of bleeding associated with blood-thinning medication while also preventing the formation of clots within the heart.

Blood-Thinning Medications and Bleeding