Baby aspirin for afib


Better Blood Thinners, Less Aspirin in Atrial Fibrillation Guidelines

The new blood thinners do not interact with foods, a big advantage for patients because they won’t have to restrict their diets.

“The only thing holding me back from switching more of my patients to these newer blood thinners is the cost,” Day confides. “For too many of my patients the cost of these newer medications is prohibitively expensive.”

Less Aspirin, Less Bleeding for People With Atrial Fibrillation

One big change is the recommendation to use less aspirin. Aspirin is now not recommended for anticoagulation to prevent stroke in patients who have afib.

“Studies have shown that aspirin does very little to lower stroke risk in afib patients, while at the same time being associated with a bleeding risk as high as some of the newer anticoagulant agents,” says Hugh Calkins, MD, professor of medicine and director of the Cardiac Arrhythmia Service at Johns Hopkins Medicine in Baltimore.

“In the old days aspirin was considered important for stroke prevention. New knowledge and reanalysis of prior studies reveals that aspirin does little to nothing to reduce stroke risk in this setting,” notes Dr. Calkins.

Ablation by the Right Doc at the Right Facility

The procedure known as radio-frequency ablation stops abnormal electrical signals from forming in the heart, where they can cause the abnormal rhythm of afib.

Patients are having catheter ablation with increased frequency, says Calkins. “This is consistent with multiple studies and clinical experience, which have shown that catheter ablation is more effective than antiarrhythmic drug therapy,” he explains.

Patient health outcomes depend on getting the best surgeon and the best facility, according to Dr. Day. “If catheter ablations can be performed by experienced cardiologists at experienced centers, then the outcomes of ablation are generally superior to medical treatment of afib.”

“Unfortunately, the outcomes with catheter ablation just have not been nearly as good at the smaller community hospitals,” he adds. “For catheter ablation of afib it is best to stick to the large, high-volume, experienced hospitals.”

RELATED: 10 Things Your Doctor Won’t Tell You Before Surgery

Better Atrial Fibrillation Risk Assessment

The newer afib risk calculator is more complex than the older one, says Day. Previously, the health risks that counted were congestive heart failure, high blood pressure, age, diabetes, and stroke. In contrast, the new risk calculator uses all of these and other factors to more accurately predict patients’ risks.

What the new afib risk calculator uses to help determine the best treatment options:

  • Congestive heart failure: 1 point
  • High blood pressure: 1 point
  • Age 75 or higher: 1 point
  • Diabetes: 1 point
  • Stroke or TIA (transient ischemic attack): 2 points
  • Vascular disease: 1 point
  • Age 65 or higher: 1 point
  • Being female: 1 point

If your score is two or higher, you need a potent blood thinner. “As you can see, if you are a woman and are 65 or older, then you automatically require a potent blood thinner,” says Day.

How to Lower Your Afib Risk

What can people do now to lower their risk?

“First, don’t acquire risk factors that cause stroke,” says cardiologist T. Jared Bunch, MD, a columnist at Everyday Health.

“The ones we can do something about are high blood pressure and diabetes. Lifestyle changes such as daily exercise, weight loss, and a whole-foods, plant-based diet can lower your risk of developing high blood pressure and diabetes significantly,” says Dr. Bunch. He directs heart rhythm research at Intermountain Medical Center Heart Institute, in Murray, Utah and was not involved in the afib guidelines revisions.

Getting good sleep also comes into the picture. Bunch says, “If a person snores, has daytime fatigue, or needs a daytime nap, they need to be screened for sleep apnea. Sleep apnea is a very common condition in our country and increases risk of high blood pressure, weight gain, atrial fibrillation, and metabolic syndrome.”

More antidotes for newer blood thinners

New medications add advantages to treatments that help prevent stroke, pulmonary embolism, and deep-vein thrombosis.

Published: September, 2018

Image: © Mohammed Haneefa Nizamudeen/Getty Images

The wait is over for an antidote to stop rare uncontrolled bleeding linked to some newer blood thinners. The FDA approved andexanet alfa (AndexXa) on May 3, 2018. It’s the first and only antidote to reverse bleeding in people taking apixaban (Eliquis), rivaroxaban (Xarelto), or edoxaban (Savaysa).

Another newer blood thinner — dabigatran (Pradaxa) — already has an approved antidote called idarucizumab (Praxbind). A dose of vitamin K is used to reverse the action of warfarin (Coumadin), a blood thinner used routinely for more than half a century and, until recently, the only such option for most people.

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New blood-thinning drug ‘less likely to cause bleeding’ than warfarin

“New blood-thinning drugs ‘could be far safer than the commonly-prescribed warfarin’,” reports the Mail Online.

UK researchers looked at what happened to almost 200,000 people taking the anti-clotting drugs warfarin, apixaban, dabigatran and rivaroxaban. Warfarin, the oldest of these drugs, has been used for decades to prevent blood clots, which lead to stroke, heart attack or deep vein thrombosis (DVT).

These drugs are also used in people with an irregular heartbeat (atrial fibrillation) because blood clots are a possible complication of this condition.

However, anticoagulants leave people at risk of dangerous bleeding in the stomach or brain. To avoid this, people taking warfarin have their blood monitored and their medication dose adjusted.

For this study, researchers wanted to compare newer anticoagulants and warfarin for people with and without atrial fibrillation. The results showed that one of these drugs, apixaban, was linked to a lower risk of major bleeding than warfarin, for people with and without atrial fibrillation. Apixaban and dabigatran were also more effective at preventing DVT.

However, low-dose apixaban and rivaroxaban were also linked to a higher risk of death than warfarin. This may be because these drugs were more likely than warfarin to be prescribed to older, less-healthy people.

Finally, it’s worth repeating a quote provided by the Mail Online from the study’s lead author: “It is very important that people should not stop taking their medication before seeing their GP.”

Where did the story come from?

The study was carried out by researchers at the University of Nottingham and was funded by the National Institute for Health Research. It was published in the peer-reviewed British Medical Journal on an open-access basis so is free to read online.

The Mail Online story was generally accurate, although the claim that newer drugs are “far safer” than warfarin may be an overstatement, and the story did not mention the result that people taking warfarin were less likely to die than those taking rivaroxaban or low-dose apixaban.

Also, one of the taglines under the headline claimed: “Nottingham University has discovered a safer type of blood-thinning drug.” While the study authors are based at Nottingham University, they had no role in designing apixaban – that work was done by a pharmaceutical company.

What kind of research was this?

This was a cohort study that used information from 2 NHS databases of general practice records.

This type of research cannot prove that outcomes, such as bleeding, are caused by using one drug rather than another because there are many potentially confounding factors that could be involved. For example, doctors might choose to prescribe one drug rather than another to someone who had a higher risk of having a bleeding episode.

What did the research involve?

Researchers used data from 196,061 people newly prescribed one of the anti-coagulant drugs between 2011 and 2016, registered on 2 GP databases – the Q Research database of 1,457 general practices and the Clinical Practice Research Datalink (CPRD) of 357 practices.

They recorded outcomes including major bleeding that required hospital admission, or led to death, stroke, DVT or death from any cause. They looked separately at figures for people treated for atrial fibrillation and those treated for other reasons.

They tried to account for confounding factors by adjusting their figures for a wide range of factors, including age, sex, ethnicity, deprivation, smoking, alcohol, blood pressure, other illnesses and use of other medicines.

They presented the results for events per 1,000 people per year separately for each database.

What were the basic results?

About half of the people taking anticoagulants were diagnosed with atrial fibrillation (AF), while half took them for other reasons, such as a previous history of clotting.

The results showed:

  • people who took warfarin for any reason were more likely to have a major bleed than those who took apixaban for any reason
  • people taking warfarin had 26.54 major bleeds per 1,000 people per year in the Q Research database and 30.29 in CPRD
  • people taking apixaban had 16.62 major bleeds per 1,000 people per year in the Q Research database and 22.29 in CPRD

There was also a 40% decrease in risk of a major bleed for people without AF taking apixaban (HR 0.60, 95% CI 0.46 to 0.79).

The difference in major bleeding rates between warfarin and dabigatran or rivaroxaban was too small to be statistically significant, for people with or without AF.

However, for death by any cause (all-cause mortality), low doses of 2 of the newer drugs were linked to increases in risk in comparison with warfarin. There was a 29% increase in all-cause mortality risk for rivaroxaban for those with AF (HR 1.29, 95% CI 1.14 to 1.47) and 27% for apixaban for those with AF (HR 1.27, 95% CI 1.12 to 1.45).

Risks of death by any cause for people taking rivaroxaban or low-dose apixaban were also raised compared with warfarin for people without AF.

How did the researchers interpret the results?

The researchers said the study “showed a decreased risk of major bleeding events associated with the use of apixaban compared with warfarin in both patients with atrial fibrillation and without atrial fibrillation”.

While they did not explain their findings on increased death rates, they did say: “A greater proportion of the older patients on apixaban and rivaroxaban may have died while still taking anticoagulants but from age-related causes other than ischaemic stroke or venous thromboembolism.”

In other words, the drugs and their relative benefits and harms may not have been related to the cause of death.


This study adds to evidence that the anticoagulant drug apixaban may cause fewer major bleeding episodes and prevent more DVT than warfarin. The study suggests this is true for people taking anticoagulants for reasons other than atrial fibrillation.

However, the study had many limitations that we must consider.

Because it was an observational study, it cannot prove that apixaban causes fewer major bleeds than warfarin. We would need a randomised controlled trial to prove that. Outside of a randomised trial, doctors are likely to prescribe differently for people at different levels of bleeding risk.

We don’t know the reason why almost half the people in the study were prescribed anticoagulants. We know they were not prescribed them for atrial fibrillation, but the study did not include or examine other possible reasons, or how these might affect bleeding risk.

There was no information about whether people actually took the medicine they were prescribed. We know people are more likely to stop taking warfarin than other types of anticoagulant, and this could affect the mortality figures if people died having discontinued their medicine, perhaps after a bleeding episode.

We don’t know what was behind the difference in mortality figures. Although it’s possible that people who took medicines other than warfarin were older and sicker, that was not fully explained. Also, these confounding factors should have been adjusted for in the analysis.

The bottom line is that apixaban may be the best option for some people, but if you’re taking warfarin and have not had problems with it, you should continue to take it in the way it has been prescribed.

Find out more about anticoagulant medicine.

Analysis by Bazian
Edited by NHS Website

Links to the headlines

New blood-thinning drugs ‘could be far safer than the commonly-prescribed warfarin’

Mail Online, 5 July 2018

Links to the science

Vinogradova Y, Coupland C, Hill T, et al.

Risks and benefits of direct oral anticoagulants versus warfarin in a real world setting: cohort study in primary care

BMJ. Published online June 4 2018

Roughly 50 million Americans take daily low-dose aspirin for cardioprevention, as it is generally perceived as a safe, effective, and inexpensive OTC preventive medication for cardiovascular disease. For patients who have nonvalvular atrial fibrillation (AF), many guidelines recommend aspirin as thromboprophylaxis among those who are not considered to be high risk.
In this context, aspirin represents an “easy” or “soft” anticoagulation option. However, a new article published ahead of print in the European Heart Journal joins a growing chorus of voices suggesting that aspirin may be overused.
Written by cardiac academics from the University of Sydney in Australia, the opinion piece reviewed aspirin’s long history in cardiac prevention. The medication’s initial use grew from the results of the 1989 Physicians Health Study, which showed that aspirin reduced the risk of non-fatal myocardial infarction. However, many do not realize that the study also demonstrated increased intracranial hemorrhage and unchanged mortality in physicians who took daily aspirin.
The authors reviewed the reasons why prescribers might default to daily low-dose aspirin when a prescription anticoagulant is a more appropriate and effective choice. They also presented the evidence behind some key facts:
· As thromboprophylaxis for stroke after AF, aspirin is ineffective and has a risk of bleeding similar to prescription anticoagulants.
· Most updated guidelines now use CHA2DS2-VASc score for risk stratification in AF and can identify truly low-risk patients who require neither aspirin nor an anticoagulant.
· The vast majority of patients with AF have CHA2DS2-VASc scores that support oral anticoagulant prescription.
· Although oral anticoagulants are more costly than aspirin, economic analyses have repeatedly deemed them more cost effective.
The authors strongly recommended that current guidelines remove aspirin as an option for stroke prevention in AF patients who lack the comorbid conditions requiring its use. The United Kingdom’s National Institute for Health and Care Excellence has already made that move, and the FDA issued a statement in May 2014 indicating that current evidence does not support the general use of aspirin for primary prevention of a heart attack or stroke, though the US agency confirmed aspirin’s role in secondary prevention.

Aspirin not an effective treatment for atrial fibrillation, study suggests

New research suggests that aspirin may not be as effective as previously believed for treating patients with atrial fibrillation. In fact, for patients who had a catheter ablation to lower their risk of stroke, the risks of using aspirin may outweigh the benefits.

Share on PinterestNew research suggests that aspirin has ‘little to no benefit’ for treating atrial fibrillation.

Atrial fibrillation (A-fib) is a common heart condition in which the heart beats irregularly. A-fib affects more than 2.7 million people in the United States and, if left untreated, the condition can lead to more serious cardiovascular events – such as stroke, blood clots, or even heart failure.

The most common route for treating patients with A-fib is prescribing anticoagulants, or blood thinners. Some people with A-fib may also have a catheter ablation – a medical procedure that uses energy to damage a small part of heart tissue, thus stopping abnormal electrical signals from traveling through the heart.

Some of the risks entailed by cardiac catheter ablation include bleeding or blood vessel damage. On the plus side, the long-term risk of stroke in patients with A-fib who have undergone the surgery is lower than in patients who did not have an ablation.

However, as Dr. Jared Bunch – the lead author of the new research – explains, when patients with A-fib have had an ablation and also have a low risk of stroke, physicians prefer to treat them with aspirin instead of blood thinners in order to further reduce the risk of stroke.

In the new study, Dr. Bunch and his colleagues examine the effect of long-term aspirin use on patients with A-fib who underwent an ablation.

Putting their new research into perspective, Dr. Bunch explains, “What was unknown was if aspirin was a safe and effective stroke prevention treatment after an ablation in lower-risk AF patients. Traditionally, lower-risk AF patients have been treated with aspirin without significant supportive data.”

In fact, the American College of Cardiologists report that more than 1 in 3 patients with A-fib who have an “intermediate-to-high” risk of stroke are treated with aspirin instead of oral blood thinners, even when medical guidelines advise the use of anticoagulants.

The results of the new study were presented at Heart Rhythm 2017, the Heart Rhythm Society’s 38th Annual Scientific Sessions, held in Chicago, IL.

Aspirin has ‘little to no benefit for stroke prevention’ in patients with A-fib

The study examined 4,124 patients with A-fib over a period of 3 years. The participants had a low risk of stroke, and they had undergone catheter ablation.

Dr. Bunch and colleagues found that patients who were prescribed aspirin were significantly more likely to have gastrointestinal and genitourinary bleeding than those who took anticoagulants such as warfarin, or compared with those who did not receive any treatment.

The study’s lead author reports on the findings:

“In both the general and medical communities, aspirin therapy is perceived to reduce risks, it’s easy to prescribe, and it’s available worldwide over-the-counter. There’s always been little evidence to support its use for stroke prevention in AF patients. This study continues to show that aspirin has little to no benefit for stroke prevention in AF patients and when used in low-risk patients it significantly increases a patient’s bleeding risk.”

Dr. Jared Bunch

Additionally, the study emphasizes aspirin’s lack of benefit for patients with A-fib who had catheter ablation, as well as the increased risk of bleeding that comes with aspirin use, particularly when the risk of stroke is reduced by the surgery.

Dr. Bunch further comments on the significance of the results, saying, “Aspirin is widely considered a healthy therapy to lower risk of heart disease Like all therapies, it has significant risks, including major bleeding. Unfortunately, after careful study, it doesn’t significantly lower stroke risk in most AF patients. Since stroke is the most feared complication of AF, we need to continue to study all available therapies to understand the most effective and safest treatment choices and how to use them after ablation.”

Learn why larger women are almost three times more likely to have A-fib.

Which Blood Thinner Is Right for You?

Atrial fibrillation, also known as Afib, is a quivering or irregular heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure and other heart-related complications. According to the American Heart Association, at least 2.7 million Americans are living with Afib.

Afib has long been treated with the blood thinner Coumadin, also known as warfarin, which the FDA approved in 1954. However, newer blood thinners, or anticoagulants, to treat Afib have been introduced in the last decade, including Xarelto (rivaroxaban) and Eliquis (apixaban).

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According to University of Michigan Frankel Cardiovascular Center cardiologist Geoffrey Barnes, M.D., M.Sc., many patients wonder: Does newer mean better? Not always, he says. “Choosing between medications such as Coumadin, Xarelto or Eliquis depends on the individual patient’s needs and preferences.”

All blood-thinning medicines slow the formation of blood clots, preventing complications such as valve obstruction and blood clots that travel to the brain and cause stroke.

But, says Barnes, “there are advantages and disadvantages to each.”

The FDA approved Xarelto and Eliquis nearly 10 years ago to prevent stroke and systemic blood clots in patients with Afib and for the treatment and prevention of deep vein thrombosis and pulmonary embolism. Many Afib patients are now choosing Xarelto or Eliquis over Coumadin.

Barnes explains the pros and cons of these medications.

Coumadin vs. Xarelto/Eliquis

Dosage and monitoring

Coumadin: The right dose of Coumadin varies by patient and can depend on diet, age and other medications a patient takes. The dosing is a delicate balance: Too much can increase bleeding, and too little might not reduce the risk of stroke. For this reason, blood levels need to be checked regularly.

However, Barnes says, “Coumadin stays in your system longer than Xarelto or Eliquis, so if you miss a day or two, it isn’t a big problem, although a patient’s blood levels still need to be tested on a daily basis.”

Xarelto/Eliquis: “These anticoagulants do not require frequent blood tests, but a periodic check of your kidney function is important,” Barnes says. “Xarelto and Eliquis work quickly but also leave the system quickly, so if a patient forgets to take their daily medication, there could be serious complications.”

While Xarelto is taken once a day, Eliquis is taken twice a day, increasing the risk of patients missing their second dose.

Interactions with food and other meds

Coumadin: Coumadin is highly susceptible to interactions with food and other medications. The drug requires patients to have regular blood tests and to watch their intake of vitamin K, which is found in foods such as spinach, kale and chard.

Too much vitamin K in the blood can lessen Coumadin’s effectiveness. “Quickly cutting back on vitamin K can put patients at risk for bleeding complications,” Barnes says.

Xarelto/Eliquis: These anticoagulants aren’t subject to the same concerns about food and medication interactions as Coumadin is, because they are not cleared by the liver.

“Instead, they are cleared by the kidneys, which can lead to complications for patients with kidney issues,” Barnes says. “Patients with Afib are susceptible to kidney issues.”

Reversing the drugs’ effects

Coumadin: Coumadin is considered completely reversible in the case of life-threatening or uncontrolled bleeding. A patient can get an infusion of anti-clotting factors to reverse the effects of Coumadin, although the effects are not immediate.

Xarelto/Eliquis: A new reversal agent known as Andexxa, recently approved by the FDA, immediately reverses the effects of these blood thinners. However, Andexxa is not readily available at all hospitals, Barnes says.

There may also be a reduced need to reverse the effects of Xarelto and Eliquis, as these medications are less likely than Coumadin to cause severe bleeding (e.g., bleeding in the brain).

Cost considerations

Coumadin: Cost often influences patients deciding on a medication. While Coumadin is considerably less expensive than the newer brands, it requires regular blood tests, which are a cost consideration.

Xarelto/Eliquis: These new medications do not require routine lab monitoring as with Coumadin, but they are significantly more expensive and patients may pay higher medication copays, depending on insurance coverage.

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“At U-M, we believe all patients on anticoagulants should be monitored, not just those on Coumadin,” Barnes says. For this reason, U-M offers its monitoring service to all patients on anticoagulants.

“Patients benefit when they have a knowledgeable anticoagulation provider, such as a pharmacist or nurse, to contact with questions and to ensure they are not having difficulty taking their anticoagulant regularly,” he says.

While the newer medications provide doctors with more options for Afib patients in the prevention of stroke, Barnes advises interested patients to speak with a health care professional to find out which medication is best for them.

Blood Thinner Pills: Your Guide to Using Them Safely

The Agency for Healthcare Research and Quality offers a free booklet and a video about blood thinner medicines. Staying Active and Healthy with Blood Thinners, a 10-minute video, features easy-to-understand explanations of how blood thinners work and why it’s important to take them correctly. Blood Thinner Pills: Your Guide to Using Them Safely, a 24-page booklet, explains how these pills can help prevent dangerous blood clots from forming and what to expect when taking these medicines.

  • Video—Staying Active and Healthy with Blood Thinners
  • Booklet—Blood Thinner Pills: Your Guide to Using Them Safely

Video—Staying Active and Healthy with Blood Thinners

People often worry about how routine medicines like blood thinner pills will affect their lifestyles. With a few simple steps, taking a blood thinner can be safe and easy. In fact, more than 2 million people take blood thinners every day to keep them from developing dangerous blood clots. Staying Active and Healthy with Blood Thinners is a 10-minute video that shows how small changes in daily routines can help people take blood thinners safely.

What is a blood thinner? What does it do? Why it is helpful? These questions are answered in this video, which features easy-to-understand explanations of how blood thinners work and why it’s important to take them correctly. It also introduces BEST, an easy way to remember how to fit blood thinner medication into daily life.

Be Careful
Eat Right
Stick to a Routine
Test Regularly

  • View the video: Staying Active and Healthy with Blood Thinners 8 minutes, 29 seconds. .
  • Vea el video: Manténgase activo y saludable con los diluyentes de la sangre 11 minutes, 51 seconds. .

Booklet—Blood Thinner Pills: Your Guide to Using Them Safely

Blood Thinner Pills: Your Guide to Using Them Safely is an easy-to-read booklet that educates people about blood thinners. It offers basic information about the medication, including reasons why a clinician might prescribe it. It also includes tips on diet, medicines and foods to avoid, important precautions for some daily activities, and when to seek help.

Select to download print version of the guide .

This guide is also available in Spanish .


About Your Blood Thinner
How to Take Your Blood Thinner
Check Your Medicine
Using Other Medicines
Talk to Your Other Doctors
Possible Side Effects
Stay Safe While Taking Your Blood Thinner
Food and Your Blood Thinner
Blood Tests

About Your Blood Thinner

Your doctor has prescribed a medicine called a blood thinner to prevent blood clots. Blood clots can put you at risk for heart attack, stroke, and other serious medical problems. A blood thinner is a kind of drug called an anticoagulant (an-te-ko-AG-u-lent). “Anti” means against and “coagulant” means to thicken into a gel or solid.

Blood thinner drugs work well when they are used correctly. To help you learn about your medicine, your doctor has given you this booklet to read.

Depending on where you receive care, you may be seen by a doctor, nurse, physician’s assistant, nurse practitioner, pharmacist, or other health care professional. The term “doctor” is used in this booklet to refer to the person who helps you manage your blood thinner medicine.

You and your doctor will work together as a team to make sure that taking your blood thinner does not stop you from living well and safely. The information in this booklet will help you understand why you are taking a blood thinner and how to keep yourself healthy. Please take time to read all of the information in this booklet.

There are different types of blood thinners. The most common blood thinner that doctors prescribe is warfarin (Coumadin®, COU-mad-din). Your doctor may also discuss using one of the newer blood thinners depending on your individual situation.

Tell your doctor if you are pregnant or plan to get pregnant. Many blood thinners can cause birth defects or bleeding that may harm your unborn child.

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How to Take Your Blood Thinner

Always take your blood thinner as directed. For example, some blood thinners need to be taken at the same time of day, every day.

Never skip a dose, and never take a double dose.

If you miss a dose, take it as soon as you remember. If you don’t remember until the next day, call your doctor for instructions. If this happens when your doctor is not available, skip the missed dose and start again the next day. Mark the missed dose in a diary or on a calendar.

A pillbox with a slot for each day may help you keep track of your medicines.

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Check Your Medicine

Check your medicine when you get it from the pharmacy.

  • Does the medicine seem different from what your doctor prescribed or look different from what you expected?
  • Does your pill look different from what you used before?
  • Are the color, shape, and markings on the pill the same as what you were given before?

If something seems different, ask the pharmacist to double check it. Many medication errors are found by patients.

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Using Other Medicines

Tell your doctor about every medicine you take. The doctor needs to know about all your medicines, including medicines you used before you started taking a blood thinner.

Other medicines can change the way your blood thinner works. Your blood thinner can also change how other medicines work.

It is very important to talk with your doctor about all the medicines you take, including other prescription medicines, over-the-counter medicines, vitamins, and herbal products.

Products that contain aspirin may lessen the blood’s ability to form clots and may increase your risk of bleeding when you also are taking a blood thinner. If you are taking a blood thinner, talk to your doctor before taking any medication that has aspirin in it.

Medicines you get over the counter may also interact with your blood thinner. Following is a list of some common medicines that you should talk with your doctor or pharmacist about before using.

Pain relievers, cold medicines, or stomach remedies, such as:

  • Advil®
  • Aleve®
  • Alka-Seltzer®
  • Excedrin®
  • ex-lax®
  • Midol®
  • Motrin®
  • Nuprin®
  • Pamprin HB®
  • Pepto Bismol®
  • Sine-Off®
  • Tagamet HB®
  • Tylenol®

Vitamins and herbal products, such as:

  • Centrum®, One a Day®, or other multivitamins.
  • Garlic.
  • Ginkgo biloba.
  • Green tea.

Talk to your doctor about every medication and over-the-counter product that you take.

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Talk to Your Other Doctors

Because you take a blood thinner, you will be seen regularly by the doctor who prescribed the medicine. You may also see other doctors for different problems. When you see other doctors, it is very important that you tell them you are taking a blood thinner. You should also tell your dentist and the person who cleans your teeth.

If you use different pharmacies, make sure each pharmacist knows that you take a blood thinner.

Blood thinners can interact with medicines and treatments that other doctors might prescribe for you. If another doctor orders a new medicine for you, tell the doctor who ordered your blood thinner because dose changes for your blood thinner may be needed.

Tell all your doctors about every medication and over-the-counter product that you take.

Tell your doctor about all your medicines.
Always tell your doctor about all the medicines you are taking. Tell your doctor when you start taking new medicine, when you stop taking a medicine, and if the amount of medicine you are taking changes. When you visit your doctor, bring a list of current medicines, over-the-counter drugs—such as aspirin—and any vitamins and herbal products you take. A personal, medication wallet card can help you keep track of this list. Go to to download a printable wallet card that you can use to record the medicine and other products that you take.

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Possible Side Effects

When taking a blood thinner it is important to be aware of its possible side effects. Bleeding is the most common side effect.

Call your doctor immediately if you have any of the following signs of serious bleeding:

  • Menstrual bleeding that is much heavier than normal.
  • Red or brown urine.
  • Bowel movements that are red or look like tar.
  • Bleeding from the gums or nose that does not stop quickly.
  • Vomit that is brown or bright red.
  • Anything red in color that you cough up.
  • Severe pain, such as a headache or stomachache.
  • Unusual bruising.
  • A cut that does not stop bleeding.
  • A serious fall or bump on the head.
  • Dizziness or weakness.

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Stay Safe While Taking Your Blood Thinner

Call your doctor and go to the hospital immediately if you have had a fall or hit your head, even if you are not bleeding. You can be bleeding but not see any blood. For example, if you fall and hit your head, bleeding can occur inside your skull. Or, if you hurt your arm during a fall and then notice a large purple bruise, this means you are bleeding under your skin.

Because you are taking a blood thinner, you should try not to hurt yourself and cause bleeding. You need to be careful when you use knives, scissors, razors, or any sharp object that can make you bleed.

You also need to avoid activities and sports that could cause injury. Swimming and walking are safe activities. If you would like to start a new activity that will increase the amount of exercise you get every day, talk to your doctor.

You can still do many things that you enjoy. If you like to work in the yard, you still can. Just be sure to wear sturdy shoes and gloves to protect yourself. If you like to ride your bike, be sure you wear a helmet.

Tell others.
Keep a current list of all the medicines you take. Ask your doctor about whether you should wear a medical alert bracelet or necklace. If you are badly injured and unable to speak, the bracelet lets health care workers know that you are taking a blood thinner.

To prevent injury indoors:

  • Be very careful using knives and scissors.
  • Use an electric razor.
  • Use a soft toothbrush.
  • Use waxed dental floss.
  • Do not use toothpicks.
  • Wear shoes or non-skid slippers in the house.
  • Be careful when you trim your toenails.
  • Do not trim corns or calluses yourself.

To prevent injury outdoors:

  • Always wear shoes.
  • Wear gloves when using sharp tools.
  • Avoid activities and sports that can easily hurt you.
  • Wear gardening gloves when doing yard work.

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Food and Your Blood Thinner

If your doctor has prescribed warfarin, the foods you eat can affect how well your blood thinner works for you. High amounts of vitamin K can work against warfarin. Other blood thinners are not affected by vitamin K. Ask your doctor if your diet can affect how well your blood thinner works.

For a list of foods that contain vitamin K, go to and search for vitamin K.

If you are taking a blood thinner, you should avoid drinking alcohol.

Call your doctor if you are unable to eat for several days, for whatever reason. Also call if you have stomach problems, vomiting, or diarrhea that lasts more than 1 day. These problems could affect your blood thinner dose.

Keep your diet the same.
Do not make any major changes in your diet or start a weight loss plan unless you talk to your doctor first.

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Blood Tests

You will have to have your blood tested often if you are taking warfarin. The blood test helps your doctor decide how much medicine you need.

The International Normalized Ratio (INR) blood test measures how fast your blood clots and lets the doctor know if your dose needs to be changed. Testing your blood helps your doctor keep you in a safe range. If there is too much blood thinner in your body, you could bleed too much. If there is not enough, you could get a blood clot.

Regular blood tests are not needed for some of the newer blood thinners.

Too Little Best Range Too much
May cause a blood clot May cause bleeding

Important reminders:

  • Take your blood thinner as directed by your doctor.
  • Go for blood tests as directed.
  • Never skip a dose.
  • Never take a double dose.

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This booklet is based on a product developed by Carla Huber, A.R.N.P., M.S., Cedar Rapids Community Anticoagulation Clinic, Cedar Rapids, Iowa, under AHRQ Grant No. 1 U18 HSO15830-01 to Kirkwood Community College.

This document is in the public domain and may be used and reprinted without special permission. Citation of the source is appreciated.

The name of my blood thinner is: _______________________________


Call your doctor or pharmacy if you have questions about your blood thinner.

  • My doctor’s contact information is:
  • My pharmacist’s contact information is:



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What are anticoagulants?

These drugs are also called “blood thinners.” They don’t actually thin your blood. But they can help prevent clots from forming.

Anticoagulants include:

  • apixaban (Eliquis)
  • dabigatran (Pradaxa)
  • edoxaban (Lixiana)
  • rivaroxaban (Xarelto)
  • warfarin (Coumadin)

Be aware:

  • Generic names are listed first.
  • Canadian brand names are in brackets.
  • This list doesn’t include every brand name.
  • If your prescription isn’t listed, your pharmacist is the best source for more information.
How do they work?

Blood clots (or coagulates) to stop bleeding. If clots get into your blood vessels, they can cause a heart attack or stroke. Anticoagulants prevent blood clots. They can’t break up clots that have already formed. But they may prevent existing clots from getting bigger

Blood thinners are taken by people:

  • with artificial heart valves
  • with atrial fibrillation (irregular heartbeat)
  • who have had a heart attack
  • who have heart diseases, such as cardiomyopathy
  • who are at risk of developing blood clots

Listen to Dr. Paul Dorian and Dr. Jeff Nagge explain blood thinners, INR testing (if you are on warfarin) and healthy eating while on warfarin in these videos.

How do I take them?

Anticoagulants can be taken as tablets, given by injection or by IV drip.

  • Warfarin is a tablet.
    • Its full effects are seen after two or three days.
  • Heparin is given by IV or injection.
    • It takes effect very quickly.
Are there any interactions?

Some medications can stop your heart medicine from working properly. They may even cause other health problems.

Blood thinners can alter your routine.

You may need regular blood tests.

  • This will make sure your blood isn’t too thin (which can lead to bleeding) or too thick (which can lead to clots).

Try to avoid cutting yourself.

  • Use an electric shaver and soft-bristled toothbrush.
  • Floss gently.
  • Wear gloves while gardening.

Avoid large helpings of dark leafy vegetables. Including:

  • Kale, collard or beet greens, spinach and Brussels sprouts.

Do not take your medication with grapefruit juice.

  • Visit Health Canada to learn more about The Effects of Grapefruit and its Juice on Certain Drugs.

Blood thinners interact with many common drugs. Always tell your healthcare provider or pharmacist about any other medications you are taking. These include:

  • prescriptions
  • non-prescription drugs
  • inhalers
  • creams or ointments
  • over-the-counter or natural health products
  • alternative therapies
  • vitamins, minerals or supplements
  • herbal remedies
  • homeopathic medicines
  • traditional remedies, such as Chinese medicines
  • probiotics
  • amino acids or essential fatty acids
Are there any side effects?

Because blood thinners delay clotting, their biggest side effect is unwanted bleeding.

When to call your doctor: Bleeding can occur in the gums, urinary system or bowels. You might not realize you’re bleeding. Be on the lookout for:

  • pink in the sink when brushing your teeth or shaving
  • vomit that looks bloody or like coffee grounds
  • pink or brown urine (pee)
  • stool (poop) that’s red or black
  • nosebleeds

Listen to your body. Tell your healthcare provider if you experience any signs of stroke, bleeding or discomfort.

Ways to reduce these side effects:

  • Avoid smoking.
  • Limit alcohol.
  • Tell your dentist you take this drug before a dental cleaning or other work.
  • If you need surgery (even a simple procedure), tell your surgeon about your medication.
  • Consider delaying non-essential dental or medical procedures.

If you have side effects, talk to your pharmacist or healthcare provider.

Lifestyle changes

Healthy choices can help you manage heart disease. Get practical tips and advice from Heart & Stroke experts on how to get healthy. Learn how to:

  • eat well
  • get moving
  • maintain a healthy weight
  • stop smoking
  • manage your stress

Talk to your healthcare provider about the lifestyle changes that will benefit you the most.

Related information

Your healthcare provider or pharmacist are your best sources of information. You can also learn more about medications at any of these trusted sites.

Health Canada – Drugs and Health Products
Provides health and medical information for Canadians to maintain and improve their health.

Learn more about:

  • Safe Use of Medicines
  • Safety and Effectiveness of Generic Drugs
  • Buying drugs over the Internet
  • Drug Product Database
  • MedEffect Canada
    Provides safety alerts, public health advisories, warnings and recalls.

Your ministry of health also offers health resources in your province or territory. For example, Ontario’s MedsCheck program provides free pharmacist consultations. And British Columbia’s Senior Healthcare web page provides information about important health programs.

Drug coverage

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