accrossthepond: Sounds like you are doing your own dosage management. I bet the doctors union had a fit. Somehow, I doubt that will fly in this country (the US) .. so let's ask ----

Is there anyone here who does at home INR testing??? If so do you determine your own dosage of Coumadin ???

Hi Paul: I was having my primary care doc follow my coumadin and they also refused to give me a standing order at a lab for INR. I contacted my Cardio and he called in a 6 month standing order which was way more convenient for me and appeared to cut out "the middle man". Most recently, I changed primary care doctors (very happy with my new doc!) and they do the finger stick coagulation check in the office. I really like that since the result is immediate and they can discuss dosage changes and other aspects with me immediately. I think DS member Steve09 does his own coagulation monitoring at home with a machine. Hopefully he will chime in on this post :)

Carrie:
Does your new doc try to charge your insurance company $300.00 for an office visit to do the finger stick (gee Paul you are SUCH a cynic!). What machine does he use. In al seriousness, how does he bill it? (after all those test strips cost about a buck).

Paul: So far, I have only been there twice and each has been an office visit. The coagulation check has been done within the office visit. I havent received a bill yet to determine cost. When I went to Quest Labs by way of my Cardio standing order, it costs me $10.00 so I imagine the cost will be similar. I have a high deductible health plan and I tend not to see extremely high cost insurance billing. My cost is probably the actual cost of things, rather an an inflated insurance billing.

Carrie: I just reviewed my bills from the lab:

They charge $25.00 for the puncture, and $35.00 for the actual INR test, my resulting charge after insurance is $3.07. Next time you visit the doc, take a look at the meter, thanks.

Acrossthepond: The NOACs don't prevent strokes by the same action as Coumadin, so INR isn't relevant.

Anyone who is on Pradaxa and who has a good health plan, Pradaxa is $30 a month with the savings card. In my case, I have Blue Cross Blue Shield Federal and I only pay $10:

https://www.pradaxa.com/patient-support/pradaxa-prescription-savings-card.html?

petey

Paul, youre right; I am doing self-management. The term self-monitoring is wrong.

Self-monitoring would be having a monitor at home where you can test your INR, then you call the doctor who interprets the results and says what you should do.

Self-management would be having a monitor at home where you can test your INR and you decide what you should do.

Dont most diabetics self-manage? There is no hocus-pocus in determining what amount of blood thinner you should take. My doctor hasnt had any problems with me self-managing my blood thinner. They dont know what I eat or have done to make the INR change but I do. If, for any reason I want to know what my INR is I can test it myself and I know immediately what it is and can act upon those results. I showed my doctor a flow-chart that I made showing what I will do in different situations. For example, it said if my INR is above 6 I would call him and he said, no that was not necessary (only if I was bleeding) and gave me some vitamin K in case it should go too high. Of course, if I have any problems you can bet Ill call! But so far Im right on track (today 2.5! )

In the States Im sure its a completely different situation what with malpractice, suing and stuff like that. I dont suppose its that easy for doctors to let go.

Petey, youre right NOACs inhibit only one factor in the blood thinning cascade where as Coumadin inhibits at least 4 factors which is why so many things can interact with it. Like you said, the blood thinners are very similar in effectiveness which is good. NOACs are cool among other things, because you dont have that worry about INR.

Paul,

If half life is a major concern then you may want to check out xarelto whose half life is 5-9 hrs for young and 11-13 hrs for elderly (65 and over) and once per day. I think you still fall in the young.

An excellent picture and table desribing this is on page 632 of the attached link

http://www.escardio.org/communities/EHRA/publications/novel-oral-anticoagulants-for-atrial-fibrillation/Documents/EHRA-NOAC-Practical-Full-EPEuropace-2013.pdf

opsyn

opsyn: Thank you for posting this excellent reference. While I am not really good at reading medical research literature, I was able to make out some of this and get some value out of it.

My take aways are that there is not real measure of anti coagulation level of the NOAC's at this time (like the INR). The INR is useless with the NOAC's. Given the short half life of Pradaxa and Apaxiban (12 hrs), they may be compared favorably with the reversal of Coumadin with vitamin K which may take at least 24 hours. However, there still is a plasma replacement approach with Coumadin that can take effect much more rapidly. But, a lower level of spontaneous bleed is expected from the NOAC's.

Right now there is rather limited response repertoire available for the NOAC's in the event of an emergency bleed (like an auto accident or emergency surgery i.e. ruptured appendix). In these situations, waiting 12-24 hours may not be an option.

OPSYN isn't your ablation coming up soon? Do you have a date yet?

I talked to the Couagu Check people this morning. As I suspected, they do not do self management(patient deciding what dosage of Coumadin to take) in the United States. They do self monitoring. You do the test at home and call, fax or website the data to them. They then fax to your doctor who decides what to do. However, they indicated that Medicare and many insurance companies do pay for their service. This is similar to another service I investigated a few months ago PTINR.

You Swiss have a better system -- cut out two middle men( persons).

Oh, okay, sorry to hear that. I'm sure you'll find what's best for you though!

There are tests for Pradaxa:

1) Thrombin Time (TT) test. activated Partial Thromboplastin Time
2) (aPTT)
3) Ecarin Clotting Time (ECT)
4) Calibrated Hemoclot Thrombin Inhibitor assay (HYPHEN BioMed, Neuville-sur-Oise, France): diluted Thrombin Time (dTT).


petey

Re: Reversal Agent for Pradaxa. There actually is one (actually an "antidote"). It isn't approved yet. It is a protein. It's called aDabi-Fab.


Another point. They just don't watch you die with Pradaxa. This is what they can do-

To manage bleeding in patients receiving PRADAXA

Apply the same measures as for patients treated with vitamin K antagonists, excluding vitamin K application.

Dialysis is an additional option to eliminate PRADAXA from the blood plasma.

Discontinue PRADAXA

Investigate the source of bleeding

Maintain adequate diuresis before initiation of standard treatments:

1.Surgical hemostasis
2.Blood volume replacement (e.g. fresh whole blood or fresh frozen plasma)
3.Application of factor concentrates (Please note: while there is some experimental evidence to support the role of these agents, limited clinical evidence is available)

a) Prothrombin complex concentrates (PCC) (e.g. nonactivated or activated)

b) Recombinant activated factor VIIa (rFVIIa)

c) Platelet concentrates may be considered when thrombocytopenia is present or long-acting antiplatelet drugs (e.g. acetylsalicylic acid or clopidogrel) have been used
.

Eliminate PRADAXA via dialysis, constant hemoperfusion, or emergency charcoal filtration.


NOTE: 80% of Pradaxa is eliminated in 12-14 hours. If you hadn't taken your last dose for 11 hours, it will reverse quicker than Coumadin (1-3 hours without intervention). Coumadin gradually builds up and gradually gets out of your system.

Just wanted to set the record straight. :-)

petey

Gang,

For those of you living in the DC area...did you see the story in the Washington Post about the dude on blood thinners who died? 63 year old (O'Brien was his name, I think), was involved in a road rage incident. Got one punch to the head. Felt ok after the fight, then within the hour got a TERRIBLE headache. Died 10 days later. They said the blood thinner caused a brain bleed. That is SO scary. I do recall when I was on blood thinners after my ablation that the hospital said "if you are involved in any kind of car accident, go to the hospital." Of course as we age, we need these blood thinners to keep us from stroke, but that was just such a sad story.

Bill