Blood thinners and exercise

Contents

Blood Clot FAQs – Follow Up Care

Q. What about that swelling/pain/ache still have?

A. If you have had a Deep Vein Thrombosis (DVT), it is common to have residual swelling in the leg after the initial treatment. Graduated compression stockings help increase blood flow in the legs and reduce the swelling.

After a Pulmonary Embolism (PE), shortness of breath and mild pain or pressure in the area affected by the PE are common. Pain may occur in response to physical activity or taking a deep breath and may be present for months or years after the PE. Shortness of breath should decrease with time and exercise.

Q. After having a DVT or a PE, what is the likelihood of developing another one?

A. The majority of patients do not suffer a recurrence. However, their risk is higher than for the general population. The degree of increased risk depends upon individual circumstances such as location of the clot, number of prior clots, and underlying medical conditions.

Q. If I have a DVT in a particular place in the calf, does scarring predispose this site for a new DVT?

A. Yes.

Q. What are the warning signs of a new DVT?

A. Swelling and pain. It often feels like a persistent “charlie horse,” or cramping in the calf. A sensation of fullness/pressure/swelling/tightness occurs, especially when going from sitting to standing. It is also described as an odd pulling sensation or tingling that doesn’t go away.

Q. How do I know it isn’t simply a pulled muscle?

A. A pulled calf muscle usually gets better in a day or two.

Q. Once you’ve had a DVT, should you have follow-up ultrasounds?

A. No, not unless a new DVT is suspected.

Q. What are the warning signs of a new PE?

A. Shortness of breath, fainting, or chest pains (particularly pains that worsen with coughing or change in position) are the three most worrisome signs.

Q. If I’m no longer taking anticoagulants, and I suspect a new clot, should I take Coumadin until I can seek medical attention?

A. No. Contact your doctor.

Q. What tests should I have after I stop taking Coumadin?

A. None.

Q. Should I take aspirin after stopping Coumadin?

A. Only if your doctor prescribes it.

Q. Is it necessary to be weaned gradually off Coumadin?

A. No.

Q. If I have cancer, should I take prophylactic anticoagulants?

A. Discuss this with your doctor.

Q. Once I’ve had a PE or DVT, if I’m ever hospitalized, should I tell the doctors?

A. Yes, immediately.

Q. Should I tell my dentist I’m on anticoagulants?

A. Definitely tell the dentist when you make the appointment. Every dentist handles the issue of anticoagulants differently.

Q. Is it OK to exercise?

A. Moderate exercise such as walking or swimming is recommended. A return to your normal exercise routine depends on your physical condition before the clot and the severity and location of your clots.

Q. How important is exercise in rehabilitation for a PE or DVT?

A. It is essential, within the constraints of your physical condition. Exercise increases circulation, reduces symptoms of venous insufficiency, and will make you feel invigorated. Aerobic exercise may increase lung function after a PE.

Q. I had a DVT. Should I refrain from crossing my legs?

A. Yes. Crossing your legs interferes with circulation.

Q. How long should I sit at one time?

A. No more than two hours at a time.

Q. Is it OK to travel?

A. Yes. In an automobile, stop every hour or so and walk for several minutes. On a plane, try to sit where you can stretch your legs (aisle seat, exit aisle, bulkhead seats, business class, etc.). Periodically, get up and walk the aisle(s) for several minutes. It is also a good idea to wear compression stockings when traveling.

For Patients

What do I need to know?

If you have experienced deep vein thrombosis (DVT) or pulmonary embolism (PE), there are many things you need to know.

1. Information is available

Know there are resources which can help you better understand and manage your condition. You may wish to begin with:

2. Length of treatment

Know how long you should be treated with a blood thinner. Length of treatment can vary from a few months to long-term over many years and is determined by factors your doctor will discuss with you. If you don’t know your treatment plan, ask: ‘How long should I be on a blood thinner?’.

3. Know about your blood thinning medication.

There are multiple blood thinners, both injectible and oral. A comparison of oral blood thinners is available to help you discuss options with your doctor.

If you take Coumadin® (warfarin):
Know your target INR

Know what your target level of blood thinning (INR) should be.

Vitamin K foods and warfarin

Know that foods containing Vitamin K can influence warfarin and learn the implications this has for your diet. Be aware that you should eat relatively even amounts of vitamin K containing foods throughout the week. It is not necessary to avoid them altogether. Rather, consistency is key.

Medications and warfarin

Know that many medications can influence the blood thinning effect of warfarin (Coumadin®). If you start or stop a medication, consult with your doctor about getting an INR check approximately 3 to 5 days after the change and again in another 7 to 10 days to ensure your INR is stable.

Home INR testing

Know that self-testing with an INR home-monitor is possible. Such testing is reliable and often reimbursed by insurance companies. Learn more about home INR testing and ask your doctor if you are a candidate for home monitoring.

If you take Eliquis® (apixaban), Pradaxa® (dabigatran), or Xarelto® (rivaroxaban):
Understand how to take the medication correctly

These drugs vary in dosing and other characteristics. Make sure you understand how to take the specific drug you are prescribed. Know:

  • Should the drug should be taken with or without food?
  • How often should it be taken? (for example, once a day or twice a day)
  • Should it be taken at a particular time of day?
  • What do I do if I miss a dose?

4. Know how to recognize abnormal bleeding

All blood thinners increase bleeding risk. Know the signs and symptoms of bleeding.

5. Keep follow-up appointments. Review your treatment plan annually.

If you are on a blood thinning medication (anticoagulant) long-term, review with your doctor each year whether continuation is still the right thing to do. Have a dialogue with your doctor which reviews how well you have tolerated therapy and what new published research studies might influence your treatment plan.

6. Compression stockings

Know that compression stockings (when individually fitted) may make your leg feel better. They are beneficial to treat long-term leg pain and swelling that sometimes follows DVT. A detailed guide to compression stocking use after DVT is available.

7. Medical care and support

Know what medical center and what doctor to turn to for state-of-the-art medical treatment and advice. There are unfortunately very few in-person local support groups for persons affected by blood clots, but be sure to ask your doctor if any are available in your area. We have complied a list of support resources.

8. Pregnancy

For women of childbearing age who have experienced clots: For most women, it is safe to get pregnant again, but special blood-thinning treatment may be needed during pregnancy. Consult with your doctor about clot prevention during pregnancy.

9. Clinical trials

Consider participating in a clinical research study. Greater participation in clinical trials means faster answers to research questions, which can lead to better diagnosis and treatment options for persons affected by blood clots and clotting disorders.

10. Symptoms and risk factors

If you have experienced a blood clot, you are at higher risk for developing a future clot. Know your risk factors and the symptoms of DVT and pulmonary embolism. Be aware that the symptoms of a future clot may not be identical in presentation to what you experienced in the past. If you suspect a clot, don’t delay in seeking medical care.

Deep Vein Thrombosis (DVT):

A clot that typically is in one leg (can also occur in unusual sites, such as veins in the arm, abdomen or around the brain). Symptoms range from mild to severe; may involve the foot, ankle, calf, whole leg or arm. The classic symptoms are:

  • Pain
  • Swelling
  • Discoloration (bluish or reddish)
  • Warmth

Pulmonary Embolism (PE):

A blood clot in the lungs. The classic symptoms are:

  • Shortness of breath
  • Chest pain (may be worse with deep breath)
  • Unexplained cough (may cough up blood)
  • Unexplained rapid heart rate

Know your risk for clots is increased if you…

  • have major surgery or trauma
  • are hospitalized
  • are overweight
  • are immobile
  • are on birth control pill, patch or ring
  • are on hormone replacement therapy
  • are pregnant
  • smoke
  • have a family history of deep vein thrombosis or pulmonary embolisms
  • have an inherited or acquired blood clotting disorder
  • have cancer
  • have an inflammatory disorder, such as lupus, rheumatoid arthritis, inflammatory bowel disease

A more detailed discussion of symptoms, including subtle symptoms can be found on the Clot Connect patient blog.

A series of videos for patients called “DVT and PE: What Patients Need to Know” can be found on this website here.Clot Connect has a comprehensive brochure, “Deep vein thrombosis (DVT) and Pulmonary embolism (PE): Information for newly diagnosed patients”, found here.

Blood Thinners and Dental Care

Many dental patients are taking “blood thinner” medications for various medical conditions to prevent the formation of potentially harmful blood clots . However, these medications interfere with the body’s normal clotting mechanism to stop blood flow at a site of tissue injury, which is of concern to dentists for procedures that cause bleeding.

There are two main processes by which the body normally forms a blood clot. The first involves small blood cells called platelets which clump together at the wound to form a plug which slows the flow of blood through the vessel and forms a matrix. The next phase is coagulation when proteins in the blood interact with each other to fill in the spaces between the platelets, stabilize the clot, and make it more solid until bleeding stops.

Antiplatelet medication target the first phase of clot formation by preventing platelets from sticking to each other and to the blood vessel walls. Aspirin does this by creating permanent changes in the platelets which last throughout the lifetime of the platelet (7-10 days) which can only be reversed as the body produces new platelets that have not been exposed to the medication.

Anticoagulant medications inhibit the second phase of clotting by blocking production or the function of proteins that stabilize the clot (anticoagulation). For warfarin, it takes several days after the starting of medication to reach full anticoagulation effect, and several days after the medication is stopped for the anticoagulation to stop. In addition many foods and other medications can affect warfarin by either increasing or decreasing activity, therefore the physician needs to frequently monitor (with blood test – See Box to right) for too little or too much anticoagulation activity. There are newer anticoagulants such as Pradaxa (dabigatran), Xarelto (rivaroxaban) and Eliquis (apixaban), which do not need as much time as warfarin to reach full anticoagulation effect, and also to stop that effect when discontinued. However, their anticoagulation activity cannot be monitored as easily as warfarin. Lovenox (enoxaparin) is used to prevent PE and DVT, and is given through self-injection.

Some Dental Procedures
Associated with Bleeding
Dental prophylaxis (teeth cleaning)
Scaling and root planning (deep teeth cleaning)
Periodontal (gum) surgery
Tooth extractions
Dental implant placement
Biopsies

Preparations for dental procedure

Most of the time bleeding from dental procedures is not difficult to control and stop, even in patients who are taking blood thinners. However, both the effect of these medicines on clotting and the potential for bleeding from dental procedures varies between each patient. Therefore, for each procedure and patient, the risk of bleeding from the dental procedure must be weighed against the risk of harmful blood clot formation from altering the dose or discontinuing the medication.

INR
The INR is shorthand for “International Normalized Ratio.” It is the primary method that health care providers use to measure the degree of anticoagulation for taking Coumadin (warfarin). For most medical conditions, the expected range for anticoagulation as measured by the INR is 2.0 – 3.5. An INR of 2.0 roughly means that a person taking this drug takes twice as long to clot than a normal individual.

Your dentist will want you to provide a thorough and complete medical history. Factors that he/she may ask you to provide include: all medical conditions (e.g: heart disease, irregular heartbeat, stroke, liver disease, kidney disease, history of blood clots); all current medications; name of your physician; purpose of antiplatelet and/or anticoagulation therapy medications; anticipated time that you will be on these medications; the results of any monitoring of the effects of these agents (blood test results); and any problems that you have had with your medicines. Your dentist may run some tests before your treatment and consult with your physician before doing the dental procedure. They may do the dental procedure in one of 3 ways: 1) continue taking the medications as normal; 2) change the dose or type of medications or; 3) stop the medication before the procedure. Furthermore, precautions may be made before, during and after the dental procedure to reduce the risk of significant oral bleeding. Do not discontinue or alter your medications without the advice of your physician and dentist.

QUESTIONS AND ANSWERS ABOUT BLOOD THINNER MEDICATIONS

Q: Is it necessary to check my clotting times before a dental appointment.
A: Depending upon the type of medication you are taking and the type of dental procedure that is to be performed, you may need to obtain specific blood tests that your dentist or physician orders shortly before your dental procedure. This will give your doctor an idea of how your medication is affecting your ability to clot after the procedure.

Q: Why not stop my blood thinners before dental care just to be safe?
A: There are cases that have shown that the risks of discontinuing these medications can be very dangerous, and many studies have proven that serious bleeding from most dental procedures, even while taking these medications, is very uncommon. Additionally, bleeding can be controlled in the dental office in many ways (pressure, stitches, medications, socket packing, etc.). Therefore, even with surgical procedures these important medications are seldom stopped, except in certain patients who have a high risk of bleeding. On the rare occasion when it is recommended that a medication be discontinued or changed, this decision is typically made by discussion between your dentist and physician. They will determine when and for how long any medication should be discontinued and when it should be resumed. These order should be followed explicitly.

Q: What measures can I take to minimize bleeding after a dental procedure?
A: Most invasive dental procedures result in bleeding that is well controlled if simple procedures are followed. For example, after surgical treatment applying firm pressure on the bleeding sites for 30 minutes with moist gauze or tea bags will usually stop the bleeding. Patients should refrain from spitting, rinsing, using a straw, drinking hot beverages, and smoking for at least the first 24 hours. Also, patients should avoid eating hard or sharp foods (such as pretzels, chips, nuts) for the first two to three days. Your dentist may also prescribe certain medications that can help minimize bleeding. Follow the instructions given to you by your dentist.

Q: At what point do I seek help for oral bleeding and whom should I contact?
A: If at any time you have a concern regarding bleeding after surgery, you should feel free to contact your dentist. If all the local precautions described above are taken and there is significant blood loss; meaning non-stop bleeding for more than several hours, or the formation of a very large blood clot (a “liver clot”), then you clearly should seek help. Your dentist should provide you with a means of contact after hours (i.e.: office or cell phone number, on-call pager), and failing that, you should visit your local emergency room.

Q: What other precautions should I take if I am on blood thinners?
A: If you are prescribed any new medication (prescribed and over-the-counter) while taking blood thinner, make sure your prescribing doctor understands that you are on blood thinner medications. Your pharmacy will also check for drug interactions, and if you have any doubts, consult your physician/ dentist to ensure there is no conflict. Be aware also that over-the-counter medications such as Motrin, Advil and Aleve, can increase the antiplatelet effects. Additionally “herbal” or “non-traditional” medications can interfere with, or increase the effects of your anticoagulant medications.

Additional Information May be Obtained from the American Heart Association

Prepared by J. Napenas and the AAOM Web Writing Group
Prepared 5 May, 2015

The information contained in this monograph is for educational purposes only. This information is not a substitute for professional medical advice, diagnosis, or treatment. If you have or suspect you may have a health concern, consult your professional health care provider. Reliance on any information provided in this monograph is solely at your own risk.

Xarelto and Sex

Editorial Note: This extraordinary post from Spiros might help explain the very similar problems that follow SSRIs, Finasteride, and Isotretinoin. There have been several other reports to RxISK of comparable problems on rivaroxaban – Xarelto. This drug causes many more problems than the sexual one described here. We would be interested to hear from anyone else suffering from this or other problems. The main source of information on the sexual problems is Spiros’s website listed below.

Injury and Insult

I was prescribed Xarelto (rivaroxaban) for deep vein thrombosis (DVT) following a treatment with heparin injections.

DVT was caused by immobility after a fibula fracture. The fracture was the injury.

At the time, the doctors did not warn me about the risk of DVT, not even following a visit to the emergency department 2 weeks after the fracture with an extremely swollen lower extremity. The result was that my residual oedema and discomfort was misdiagnosed later as lymphoedema by a physical therapist and I had physiotherapy, and only after 1 year following the fracture, when the oedema was still unresolved and I visited ortho Dr No 6, was I instructed to have a vein ultrasound which revealed extensive femoral and popliteal DVT. The failure to alert me about the risk of DVT, the ensuing non-diagnoses and the misdiagnosis, was the insult to injury No 1.

Insult and Injury 2

Three weeks following the heparin injections I switched to Xarelto, as the doctor upped the heparin dosage to a very high level for my weight (I was 65 kgs and I was prescribed a dosage for someone who is 100 kgs) which resulted in lightheadedness, listlessness and inability to concentrate.

About two weeks into Xarelto, and in a matter of 2-5 days, everything about my sexuality changed drastically. Spontaneous erections disappeared and nocturnal/morning erections became extremely feeble and shortlived (when, previously, morning erections were so strong so that often I would have to spend time waiting them out in order to urinate despite the strong need for urination). Reaching and holding a half-baked erection required great effort and it would go down immediately after discontinuing stimulation.

Takers of SSRIs describe genital numbness. In my case there is no genital numbness—If I pinch myself I do feel pain—but lack of sexual sensation and sensitivity. Another strange symptom I have been having, which is especially noticeable when sitting or lying down, is a “trembling” sensation, as if a low-intensity electric current is running through my penis. Moreover, sometimes, following an orgasm there is a lasting feeling of discomfort in the genital area, bordering on mild pain.

Interest in the opposite sex disappeared completely. Seeing a woman was like seeing a painting or a landscape; the aesthetic value was completely dissociated from triggering any sort of desire. Sexual stimulation resulted in very feeble erections with premature ejaculation and pleasureless orgasm. The hedonic aspect of the orgasm was not much different to urination—no pleasure at all. In short, serious erectile dysfunction of abrupt onset accompanied by a complete loss of libido and muted orgasms. For me, it could be summed up as chemical castration and it was experienced as some sort of weird altered state of consciousness, that of a totally desexualized being. This was the insult to injury No 2.

The Problem Deepens

I did not like it one bit, but I was convinced that my deep vein thrombosis was a very serious issue and the only way to fight it was to continue taking the blood thinners (little did I know then that, most likely, the blood thinners I was prescribed to take could have little to no effect due to my extremely delayed diagnosis of a year after the acute DVT phase).

Initially I thought that, since there was no such side effect listed in the patient information leaflet, and I could not find any related information or similar experience by someone else on the Internet, then it must be a temporary issue, which would resolve after discontinuing the drug.

Unfortunately, as it transpired later, that was not the case. The symptoms persist until now 2 years after discontinuing Xarelto in very much the same way as they originally appeared. There were no periods or instances where the symptoms subsided (and this is one more counter-argument to the fatuous suggestions by some ignorant health professionals of a “psychological” problem).

I even tried abstaining from orgasm for two weeks as an experiment. Before Xarelto, when I had done something similar, it required a great deal of effort and self-discipline in order to maintain the abstention. Now, it was as if I was not abstaining from anything. In fact, it was the opposite, sexual stimulation was a like a chore, which I carried out in order to confirm that, at least on a “technical” level, an orgasm was feasible, no matter the quality and pleasure that may or may not be derived from it. And when I broke the two-week “fast”, the results were bathetic. It was equally difficult, if not even more so, to reach some sort of half-baked erection which resulted in a quick pleasureless orgasm. This, coming as a sharp contrast to what it would have been like before Xarelto.

Consulting Doctors – More Insults

I mentioned the sexual side-effects to 5 different vascular surgeons (including the well-known British physician Stephen Black); they did not have a clue. One told me that I could switch to a different drug and others said I should see a urologist/andrologist.

I visited 5 urologists and 1 endocrinologist. The urologists saw my hormone and blood works and they concluded that there was nothing wrong there; hence, for them, the issue is “psychological”. The endocrinologist concurred and declined to see the data I had from pharmacovigilance databases where similar issues were reported. He persisted that since the hormone tests did not show anything, then it must be psychological. As if hormone tests and the current state of medical science can detect everything that could go wrong in one’s body. Another urologist I visited said that science does not know all the chemical paths relating to sexuality, so it is possible that the medication affected one of those. Good luck to me with discovering it. At that point, it dawned on me that no doctor would bother with something that was not or could not be documented with current diagnostic tools, let alone research it.

To quote from another post regarding encountering doctors, “the drug has damaged you in a way that is evident only to you who live it on your skin, and not because you are an imaginary madman, but because there are not, to date, diagnostic tools capable of highlighting the damage that you are suffering.”

The above fact, and the attitude of doctors to dismiss the issues as purely psychological, was the insult to injury No 3.

Research

As a result, I had to do the research myself. To start with, I wrote an article on my thrombosis site about the sexuality-related issues with Xarelto which I kept updating as new findings presented themselves.

Some of my first findings were similar issues reported in pharmacovigilance databases as well as the fact that Xarelto is facing numerous law suits for “failing to provide adequate warnings about its serious side effects to patients and doctors”. On March 25th, 2019, they settled for $775 million to get paid out to victims.

It came as a surprise to discover that similar issues (especially muted orgasms) were reported by sufferers of post-finasteride syndrome (PFS), post-retinoid sexual dysfunction (PRSD) and post-SSRI sexual dysfunction (PSSD). And there are some papers on Endocrine Journal and the International Journal of Risk & Safety in Medicine making the connection:

  • Post-finasteride syndrome and post-SSRI sexual dysfunction: two sides of the same coin?
  • Enduring sexual dysfunction after treatment with antidepressants, 5α-reductase inhibitors and isotretinoin: 300 cases

Healy make the suggestion on RxISK of nerve damage, and specifically of c-fibers and repeats this in a presentation regarding sexual problems caused by post-SSRI sexual dysfunction. I was particularly touched by a comment to that video which pretty much echoed my own feelings:

…not only do they destroy ability to experience physical affection. They also stop ability to feel love, empathy, compassion, regret, human connection. They make you a shell of a human being. In fact they take away the essential essence of being human. Beyond unconscionable.

To put all this into context, such sexuality-related issues affect the individual on a scale that goes far beyond the sexual plane:

Brain mechanisms involved in fundamental pleasures (food and sexual pleasures) overlap with those for higher-order pleasures (for example, monetary, artistic, musical, altruistic, and transcendent pleasures).

And this is what I can confirm from my experience. For example, I have lost any inspiration in meditating, playing the piano and composing as I used to do, as well as meeting new people and socializing. It is as if the annihilation of the sex-drive—on the level of desire and the physical level—resulted in depriving life of all its sparkle, enthusiasm and motivation, as if I had been transformed into an empty “shell of a human being”—a flat tire if you will. Existence had become a blunt, tasteless, odourless and colourless experience. A highly-pixellated, low-resolution, black-and-white jpeg in a world of 3-D, augmented reality, high-resolution, fast-streaming phantasmagoria.

Perhaps the grand irony of my case is that a legal drug was the cause of major sexual dysfunction without as much as a warning to this effect in the patient information leaflet, despite leading a healthy lifestyle, eating organic, being a non-smoker and non-drinker; whereas, on the other hand, other individuals, who may have been eating junk, smoking, drinking and abusing illegal drugs throughout their lives, had none such issues. The conclusion: legal drugs, although presented as “cures” are potentially much more dangerous than illegal ones and often, much more expensive. In the words of Karl Kraus: “medicine: your money and your life”.

If you too are facing issues with Xarelto, there is a Xarelto Side Effect Support Group on Facebook but there is no group or forum worth mentioning that deals specifically with sexually-related Xarelto side-effects.

So far, 5 people have contacted me through the who had sexuality-related issues (erectile dysfunction, loss of libido). So, for all intents and purposes, that is the main point of reference and up-to-date information for anyone suffering from similar issues. And now, it is this post too.

What Is XARELTO®?

XARELTO® benefits

  • No known dietary restrictions while on XARELTO®

    XARELTO® doesn’t interact with vitamin K like warfarin does. This means you can enjoy leafy green vegetables and other foods high in vitamin K whenever you like—without it interfering with your medication.

  • XARELTO® usage doesn’t require regular blood testing

    Studies show that the effect of XARELTO® on your body’s blood-clotting function is the same regardless of age, race, weight, sex, or dietary changes. If you take XARELTO®, regular blood tests are not needed to see if XARELTO® is working, to check your blood-thinning levels (international normalized ratio, or INR), or to change your medication dose.*

    *Certain patients with impaired kidney function may be monitored by their healthcare professional and have their dose adjusted as necessary.

  • XARELTO® dosing doesn’t require frequent adjustments

    While the dosage is different depending on why you are taking XARELTO®, most people will start and stay on the same dosage. Exceptions include people with kidney problems whose condition may require a dosage adjustment, or people taking XARELTO® to treat a DVT or PE, since the dose changes after 21 days of treatment.

To learn more about how XARELTO® treats and helps prevent blood clots related to a specific condition, select below:

  • Nonvalvular atrial fibrillation (AFib)
  • Deep vein thrombosis (DVT)
  • Pulmonary embolism (PE)
  • Knee- or hip-replacement surgery
  • Coronary artery disease (CAD)
  • Peripheral artery disease (PAD)

Exercise on blood thinner medications- A Physical Therapist Perspective

Blood thinner medications are prescribed to patients who suffer from deep vein thrombosis (blood clot), pulmonary embolism (blood clot has migrated to the lung), claudication (walking induced pain in one or both calves) and ischemic heart diseases. A common belief that these conditions affect the elderly population, however healthy and athletic populations are also at risk of developing the above-mentioned conditions. The concern is whether exercise is helpful. The answer is yes. The following will show you what research are saying about exercise on blood thinner.

Ernst in 1987 looked at the influence of regular physical activity on blood flow. In his 3 month longitudinal study of untrained volunteers performing regular exercise revealed a decreased in their blood viscosity and an improvement in the red cell deformity. That conclusion suggests that physical exercise improved blood fluidity; hence improve blood flow through the process of blood dilution.

El-Sayed in 1998 looks at the effects of exercise and training on blood flow. He indicated that the blood of endurance athlete is more diluted as a result of endurance training. This suggests that exercise and blood thinner medication have a constructive effect the blood flow and oxygen delivery to tissues.

An adaptation to exercise training is an increased in capillary formation and increased blood flow to muscles away from the occlusion. This adaptation allows increased in muscle contraction away from the occlusion, hence improved walking ability.

Exercise is shown to increase the production of nitric oxide within the capillaries, which is impaired in patient with diabetes type II, high blood pressure, heart disease and obesity. The nitric oxide is responsible for opening up the size of capillaries, resulting in increase blood flow hence facilitate oxygen delivery.

As exercise has increase benefit for patient taking blood thinner medication, it also has risk associated with it. Excessive bleeding is a risk to take seriously. Though the risk of bleeding is most of the time non-threatening such a cut from shaving, but it takes about 20 minutes to stop the bleeding. That can be annoying. Hence be careful with activities of daily living that may put you at risk. However, extreme sports such as football, basketball, soccer, rugby, mountain biking, skiing and so forth put you at high risk of life-threatening bleeding. Such sports are best left alone. Running, walking, stationary biking are safe to enjoy. Even outside biking is safe as long as you use the protective equipments to prevent damage to the skin or bone fracture.

By Raj Issuree, MPT

Ernst E. Influence of regular physical activity on blood rheology. Eur Heart J 1987; 8 Suppl G: 59-62

El-Sayed MS. Effects of exercise and training on blood rheology. Sports Med 1998; 26(5): 281-92

Stewart KJ, Hiatl WR et al. Exercise training for claudication. NEJM 2020; 347: 1941-1951

Related Article — Exercising While Taking Blood Thinners

Related Article — Exercise on blood thinner medications

Related Article — Blood Thinners and Exercise

Staying Active and Healthy with Blood Thinners – Transcript

Special Report: Blood Thinner Medications

Narrator: Recently, your doctor has prescribed a blood-thinning drug, like Warfarin, for you. And you probably have lots of questions. Well, sit back and relax as over the next few minutes we’ll attempt to address some of your concerns and answer many of the questions you may have about the drugs. We’ll also introduce you to a strategy for incorporating your blood thinner medication into your daily life. We refer to it as the B.E.S.T., or BEST strategy. So you’ve recently been prescribed blood thinner pills. Perhaps you’ve been wondering what these drugs do and why you need to take them. Starting on blood thinners may feel like getting behind the wheel of a car for the first time. You may feel anxious, but rest assured that you are not alone. Each year, nearly two million people just like you start taking blood thinner medicine.

Now let’s talk about the drugs themselves. What are blood thinners? What do they do? And why are they used? First the drugs are referred to as anticoagulants. This term can best be understood if we break it up into two parts. First, “anti” means against or to prevent. Second, “coagulant” refers to the process by which a substance, like your blood, forms a clot or a blockage. Blood clots are the clumps that occur when the blood hardens and changes from a liquid to a solid. Normally, clots develop to help stop bleeding after you’ve been cut or injured. If you’ve been cut, a clot will usually form that will help stop the bleeding, but not all clots are desirable.

Some clots can form inside your bloodstream. When this happens, the results can be dangerous to your health. So blood thinner pills, also known as anticoagulants, work to help prevent your blood from clotting. This is important because your clinician believes that you are at risk for having a blood clot form in your bloodstream. If the clot breaks loose and gets stuck in a vital blood vessel, it can block the blood flow to important organs in your body, like the heart, brain, or lungs. If a blood clot travels to your heart, you can have a heart attack. If it travels to your brain, it can cause a stroke. If it goes to your lungs, it can cause what’s known as a pulmonary embolism, or a blood clot in the lungs. All of these conditions are serious and can lead to death. So taking a blood thinner can possibly save your life.

There are several reasons why your clinician may have put you on a blood thinner. Some of the most common reasons are: An abnormal heart rhythm called atrial fibrillation; heart attack; stroke; deep vein thrombosis or DVT; pulmonary embolism or PE; or because you’ve had recent surgery. Because blood thinner medicine keeps your blood from clotting, it also increases the chances that you could bleed too much. So if you use this drug, it is important that you also be careful in your daily activities. Be careful when doing activities that might put you at risk for getting a cut or bruise. Even a small cut can bleed more than normal because you are taking a blood thinner. Avoid high-risk sports and other potentially dangerous activities. However, you can still enjoy many of the same activities you engaged in before you started taking blood thinner pills. You just need to be a little more cautious. Don’t be afraid to discuss your concerns and ask questions of your clinician. He or she can help make sure you take this medicine safely.

Like most medicines, blood thinner pills can have side effects. Some of these may include bruising easily or having your gums bleed from brushing your teeth. If you find any unusual bleeding, let your clinician know right away. You should try to be careful in your daily activities and avoid injury as much as possible. If by chance you do injure yourself, whether it be from a fall or hard bump to the head, call your clinician right away. You may have a busy life, but that shouldn’t stop you from following a regular schedule to take your medication. Even at work, there are ways to remember to take your medicine. You might want to carry a pill container with you and wear a digital watch with an alarm. There are many things you can do to remind yourself to take a pill at the same time each and every day. You can also get family and friends to help remind you until it becomes a habit for you. Either way, it is important to remember to take your medication exactly as your doctor prescribed.

For your own safety, you should also consider wearing a medical alert bracelet or carrying a wallet card as a way to let others know that you are on blood thinner medication in case you can’t. It is also important not to make major changes in your diet or start a weight-loss plan without first consulting your clinician. The foods and drinks that you consume can affect how well your blood thinner pills work. For instance, your clinician might want you to be careful about the things you eat or drink that are high in vitamin “K” because it can interfere with the way some blood thinners work. Vitamin “K” is found in many green leafy vegetables, but also in other kinds of foods and in vitamins and herbal nutritional supplements. The most important thing is to remember to keep your diet consistent. Try to eat the same kinds of foods and the same amounts of those foods on a regular basis.

It is important to tell each of your clinicians about the medicines you are taking or want to take. This includes all medicines that other doctors prescribe or ones that you might buy over the counter at your neighborhood drugstore or supermarket. Also, if your medications change, be sure to tell your clinician. Be especially careful about taking aspirin. Talk to your doctor about taking aspirin as it can further reduce your blood’s ability to clot and you can bleed too much. For more details about the foods and other substances that you should limit or avoid, or anything else that you should or shouldn’t do while taking blood thinners, see or talk with your clinician. It is recommended that you talk to your clinician about your intake of alcoholic beverages, as they may interfere with your medication and its overall effectiveness. Just because you are taking a blood thinner doesn’t mean that you have to drastically alter your daily life or stop doing the things that you really enjoy. Just a few changes in your daily schedule and routine are all that’s really needed.

We hope this video helped shed some light on what a blood-thinning drug is, what it does, and how it can help you. We’ve explained why your doctor may have prescribed it, and we’ve shared a number of things to keep in mind. Remember that clinicians are there to answer any questions you might have about taking your blood thinner pills. And keep in mind, there are four simple points of being careful, eating right, sticking to a routine, and testing regularly. By doing these things, you are sure to have success in integrating your blood thinner therapy into your daily life. Thanks for watching.

A Heart Healthy Tip: How to Safely Start an Exercise Routine After A DVT or PE

By Stephanie Lew, PT, DPT
Originally from The Beat – Spring 2016

People who are diagnosed with a pulmonary embolism (PE- a blood clot in the lungs) or deep vein thrombosis (DVT – a blood clot in the deep veins, typically in the legs) often have a lot of questions about when it is safe to start exercising, what exercises are safe for them to do, and what symptoms (if any) they might experience upon return to exercise.

Resuming a regular exercise program after having a PE or DVT is important, not only for your overall cardiovascular health, but also to help prevent another PE or DVT from happening. Since everyone’s PE or DVT are different, there is no one answer about when it is safe to start exercising again, so make sure you speak with your healthcare provider before starting any exercise program.

If you’ve recently been diagnosed with a PE, you may feel short of breath, have chest pain, and/or become easily fatigued when you start exercising. Following a DVT, your leg may be swollen, tender, red, or hot to the touch. These symptoms should improve over time, and exercise often helps. Walking and exercise are safe to do, but be sure to listen to your body to avoid overexertion.

If you are new to physical activity or just want to ease back into a routine after having a PE or DVT, we suggest starting with a beginner walking routine. To start, choose a route that is close to home, relatively flat, and has plenty of places to rest along the way (for example, a local park or shopping mall). You want to warm-up first by walking slowly for 5 minutes, then increase your activity each week as follows:

Week 1 – Walk for 5 minutes at a comfortable pace, 3-4 times per day
Week 2 – Walk for 10 minutes, 3 times per day
Week 3 – Walk for 15 minutes 2 times per day
Week 4 – Walk for 30 minutes, once daily

Your goal is to walk for 30 to 45 minutes, 5 to 7 days per week.

Strength training is also an important part of maintaining your overall health. It is safe to return to your routine if you already have a strength training program. If you want to begin weight training, and have never used weights before, it is recommended that you seek professional advice. Ask your primary care physician for a referral to a professional who can create an individualized strength training program for you.

Exercise is an important part of a heart-healthy lifestyle, and can not only help prevent another DVT or PE, but also a variety of other thrombotic diseases such as heart attack and stroke.

Keep These Tips in Mind If You Take Any Blood Thinner

1. Don’t double up on doses. Ask your doctor what you should do if you accidentally miss a dose of your blood thinner.

2. Be more careful when you exercise or are doing activities. “Even a trivial cut is going to bleed a lot on these medications,” says Molly Cooke, MD, of the University of California, San Francisco.

3. Wear gloves when you use sharp objects like scissors, knives, and gardening tools.

4. Switch to an electric razor.

5. Wear shoes as often as possible — always when you mow the lawn or garden.

6. Use a soft toothbrush and waxed dental floss to clean your teeth.

7. If your doctor says you can do sports like biking or skiing, wear a helmet. But “tackle football is out,” says Natalie Evans, MD, of the Cleveland Clinic — even with a helmet.

8. Wear a medical alert bracelet in case you’re in an accident and can’t talk. Keep a note in your wallet, purse, or phone that lists the medications you take.

9. If you fall or get hit hard, call your doctor or go to the hospital right away, even if there’s no blood. A bruise anywhere on your body means you’re bleeding beneath the skin. And a head injury can cause bleeding under your skull.

10. Make sure any doctor who prescribes medication for you knows you’re taking a blood thinner. Ask them to look up the drug interactions. For warfarin (Coumadin) especially, the list is long. It may be hard to remember them all without looking.

11. Don’t take over-the-counter medicines, vitamins, or supplements unless you check with your doctor first. Your blood thinner may not work right with them. For example, aspirin, ibuprofen, and naproxen can make you bleed more. Even common products like Pepto-Bismol can cause bleeding.

12. Ask your doctor if it’s safe to have alcohol. An occasional drink is probably fine, but it’s best to be sure.

13. Call your doctor if you can’t eat for several days, or you’re vomiting or you get diarrhea that lasts more than a day. You may not have the right amount of medicine in your system.

Jenny’s Journey

  • Heart and Vascular Health
  • Heart Health
  • Stroke

Tips to Live Well (and Safely) with Blood Thinners

Heart Health News Summer 2019 Mar 1, 2016

Are you or a loved one among the two to three million Americans taking blood-thinning medications (also called anticoagulants)? These lifesaving drugs prevent blood clots from forming, growing or moving to critical areas in your body that could block blood flow.

If your body is at risk for forming a blood clot that could lead to stroke or a heart attack, your doctor may prescribe a blood thinner. People with atrial fibrillation often need these. Atrial fibrillation, a common irregular heartbeat often call A-Fib, is a leading risk factor for stroke. It can cause blood to collect in the heart and potentially form a clot, which can travel to the brain and cause a stroke.

People with carotid artery disease also often are prescribed blood thinners. The carotid arteries in your neck carry blood to the head and brain. If a carotid artery becomes blocked by a clot, a stroke occurs. Blood-thinning medicines also are recommended for people who have had a stroke or heart attack or who have heart rhythm or heart valve problems.

Anticoagulant drugs come in pill form or sometimes injections. Common types are:

Your doctor will help decide if you need an anticoagulant and which blood thinner is right for you.

Be on the Alert for Bleeding

The lifesaving potential of blood thinners must be balanced with the risk of their biggest side effect: internal or external bleeding. If you cut yourself while shaving, get a cut on your finger from a kitchen knife or gardening tool, or fall and bump your head, the blood thinner slows your body’s ability to clot and stop bleeding at a normal rate. Nosebleeds also are more common for people who take blood thinners. Many times, this is more of an annoyance than a threat to your safety.

Even though these minor bleeds may be a nuisance, it is extremely important to continue taking your medicine as directed by your physician. The blood thinner is protecting you from developing dangerous or life-threatening blood clots.

If you have a more serious bleed — perhaps a significant fall or injury that could cause internal bleeding in the head or stomach — you should call your doctor or seek medical attention immediately. Warning signs of abnormal bleeding include:

  • Bleeding that doesn’t stop in 10 minutes
  • Coughing or throwing up blood
  • Dark-colored urine or black stools
  • Bloody diarrhea or bleeding hemorrhoids
  • Severe pain in your head or abdomen
  • Unexplained bleeding from the gums and nose
  • Bruising with no apparent cause
  • A heavier-than-normal menstrual period or bleeding between periods
  • Red or black-and-blue marks on your skin that get larger
  • Dizziness or fatigue
  • Chest pain or trouble breathing
  • Allergic reactions such as rash, itching or swelling

The lifesaving potential of blood thinners must be balanced with the risk of their biggest side effect: internal or external bleeding.

Take Common-sense Precautions

You can still do most activities you enjoy while you’re taking blood thinners. Consider taking some common-sense precautions, however:

  • Avoid high-risk sports that expose you to cuts, scrapes and excessive bruising.
  • If you do sports activities, wear protective gear, such as a bicycle helmet or protective pads for knees and elbows.
  • Wear gloves while working in the yard.
  • Trim fingernails and toenails carefully.
  • Use a soft toothbrush and wax-coated floss.
  • Avoid going barefoot or trimming calluses or corns on your feet.
  • Use an electric razor rather than a razor blade.

If you have a minor bleed, there are several over-the-counter products to help stop bleeding. Special bandages, wound dressings, powders and gels are available at most pharmacies or online.

Follow Safe Practices

Getting the right dosage of a blood thinner is extremely important. Too much puts you at risk for bleeding and too little puts you at risk for stroke. If you are taking an anticoagulant, follow these guidelines:

  • Tell anyone who is providing medical or dental care for you that you’re taking a blood thinner.
  • Carry an ID card or wear a medical-alert bracelet that says you take an anticoagulant.

And if that anticoagulant is warfarin:

  • Closely follow your doctor’s recommendations for regular lab testing while taking warfarin, to ensure that you are taking the best, most effective dosage for you.
  • Eat a consistent diet, with consistent amounts of vitamin K. Vitamin K helps your blood clot and could affect how warfarin works. Talk to your doctor before making significant changes in your diet.

Tell your doctor about all medicines you take to help avoid interactions. This includes over-the-counter medicines, supplements or herbal remedies. Do not start taking any new medicines unless you check with your doctor first.

Common medications that interfere with the work of anticoagulants include:

  • Antibiotics
  • Heart medicines
  • Cimetidine (treats excess stomach acid and peptic ulcers)
  • Aspirin or other anti-inflammatory drugs such as ibuprofen, naproxen, ketoprofen or other arthritis medicines
  • Drugs for depression, cancer, HIV (protease inhibitors), diabetes, seizures, gout, high cholesterol or thyroid replacement
  • Vitamins containing vitamin K or herbal products such as ginkgo, Co-Q10, garlic or St. John’s wort

Source: American Heart Association; National Blood Clot Alliance; National Heart, Lung, and Blood Institute

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