HI all - I haven't been on here in awhile as things have been going smoothly with my Afib, or rather, lack of it. Two ablations and all is good. However, I did end up having to be on Eliquis for reasons that don't matter to this discussion. I have a supplement that I'd like to take that has some Gingko Biloba in it, but want to be sure that's not a problem. I already have been taking some of that for well over a few years, w/o any issues - no bruising, nosebleeds, anything at all that I've noticed. I'd like to take a little more and am unsure how concerning it is, as it has a tendency to naturally thin your blood a little too. Not sure how much it really does.

Does anyone know much about this?

Thanks ~ Barb

Hi Barb - Happy New Year. Glad to see all is going well for you. Are you taking the full dose of Eliquis? Also,
how much ginkgo is in the supplement you're taking?

Jackie

HI Jackie - thank you. Happy New Year to you too!

I am taking 5 mgs twice/day, so yes, I think that is the full dose....

The supplement has a total of 60 mg. of Proteases (Bromelain, Aspergillus, Oryzae var), Quercetin powder, Bilberry extract and Ginkgo Biloba (leaf) extract,.all together. The Gingko is the last item mentioned, so I believe it is the least. I have already been taking this for the past few years with out any issues. I would like to take double the amount....I have to assume that the Ginkgo itself is no more than 20 mgs., as the 60 mgs. is divided up by the 4 different categories (Proteases, Quercetin, Bilberry and Gingko).

Barb

Barb - yes, that's the full dose. Now, this is very important:

If you haven't read my recent post on the nosebleed experience on half-dose of Eliquis... please, definitely read as a reminder for you that you are on a full dose of a very potent blood thinner and you don't want to take anything that would add to that potency. So, I while absolutely love ginkgo biloba and used it daily for many years prior to Eliquis at a dose of 80 mg, I would not consider even half that amount of ginkgo while using any size dose of Eliquis.

Also, the proteases, bromelain,quercetin and bilberry all have blood thinning properties and it's typically mentioned not to use those if on a blood thinner.

While my nosebleed was dramatic in that the volume of blood was so abundant, I did manage to get it under control in a relatively short period of time and I wasn't at all 'panicked' but it definitely was a significant reminder that if a nose capillary rupture could produce that much blood so quickly, I'd hate to see a severe wound from a cut or fall. The other significant factor was that I was at home and actually right outside the bathroom so the sink was only 8 feet away. I immediately thought how fortunate the timing was rather than had I been driving or shopping for food. That would have been quite a mess and inconvenience.

Please be safe, Barb, and stop using that supplement unless your EP or cardiologist says otherwise.

Jackie

HI Jackie - thanks for the information. I won't take any additional gingko then, per your advice. I am going to continue as I have been doing for now, and try to get an appt to see Dr. Natale when he is in the NY area again, for a follow up. I don't know if I would do a Watchman, but the thought is there, as i don't like taking something that has so many precautions...and there are so many health benefits to using things like gingko and other heart healthy supplements. They are having a big symposium on all of this stuff later this week, I believe, so perhaps there will be even more recent info to help make any decisions.

Keep in mind - and please don't take this personally - but age probably does play a factor in how easily someone bleeds, don't you think? Doing things that might aggravate the situation would likely be more of a concern as we get older...just as medication often needs to be reduced as people get older. At least that's what I've read...

All good advice. Thank you Barb

Hi Barb - Yes, that's undoubtedly true that the elderly have more risk of bleeding as mentioned in cautions about GI and brain bleeds when using these anticoagulants that don't have reversal agents.

However, I did do a quick search on the topic and found this quote:

"When we look at patients who are older than 80 or younger than 80 where we had a demarcation for dose reduction, we see that there really is no difference by age category. There is no clear difference in treatment effect based on age," he said. Patients who had two or more of the criteria were eligible for the reduced dose of the anticoagulant. "
[www.medpagetoday.com]

Please be cautious and be well,
Jackie

Chronological age or biological age?

Jackie - Does that apply to their skin being thinner? I would think people with thinner skin (more common as we age) would therefore be more likely to bleed..no? And bruise....

Glad you brought up the reversal agent...is there one yet for Eliquis?

Shannon and I were talking about the Watchman..what are your thoughts on that? Going for another procedure sounds daunting, but having a blood thinner that brings so many concerns is too.

I will be careful...I tend to be a cautious person overall. Thank you for your counsel and advice ~ Barb

Yes there are reversal agents for the new DOAC (direct oral anticoagulation) drugs like Eliquis and Xarelto, but they are VERY new and likely not in stock at every ER department nationwide, nor could you count on emergency physicians being trained on their proper use. Sadly I think we are still a few years away from that not being the case and in the meantime caution is still the word of the day when it comes to DOAC use. At the very least, get a medical bracelet that indicates which anticoagulant you are taking in the event of an emergency.

External bleeds aren't what you need to worry about with anticoagulants. Even nosebleeds, which can be dramatic as Jackie described, aren't life threatening. I spent 15 years in EMS and have seen dozens and dozens of severe nose bleeds. I've seen houses that looked like murder scenes due to nosebleeds, especially with people on warfarin and home oxygen (oxygen dries your nasal passages). But not a single one of those nose bleeds warranted priority transport (ie, lights and sirens). The amount of blood loss it takes to become dangerous is far more substantial than most people believe. Trust me, it's a lot more than most people have ever seen and far more than Hollywood would have you believe.

The danger of bleeding with anticoagulants is primarily 1) in the brain and 2) elsewhere internally, usually the GI tract. Bleeding in the brain is a hemorrhagic stroke and it can be every bit as devastating as an embolic stroke (from a clot). In fact, they're often more devastating than embolic strokes. Bleeding elsewhere isn't as dangerous, but can still be life-threatening. You can lose a lot of blood into your GI tract before it even becomes apparent you're bleeding, so that's the danger there. However, bleeding to death is very unlikely as long as you can get medical help promptly.

The third danger, of course, is major trauma -- car accidents, falls, etc. If you manage to lop off a foot with the lawnmower, that's a grievous injury even without anticoagulants, but it becomes more of a concern with them. The bleeding will be more difficult to control, but controlling external bleeding isn't as difficult as people think. If EMS can get to you promptly, they will control external bleeding no matter how severe. I promise you that. And once they get you to a surgeon s/he will stop that bleeding. External bleeding is usually easy to control and not likely to kill you unless it's truly massive. It's the internal bleeding you can't see and surgeons can't get to that's dangerous. And once again, head injury is the big danger here. Avoid falls. Falls in the home cause an astonishing number of serious injuries and deaths every year.


No, there's no reversal agent for Eliquis yet, but my understanding is it's in the FDA approval process and expected to be available soon.

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wolfpack
Yes there are reversal agents for the new DOAC (direct oral anticoagulation) drugs like Eliquis and Xarelto

You sure about that? I thought the Eliquis reversal agent got sent back for further testing last year and hasn't been approved in the US yet.

Barb - Thinner skin for some people is certainly a factor but the main focus of my 'nosebleed' post was just a reminder to those on Eliquis or similar and thinking ahead about what to do if one crops up was my focus. I was home but if away from home, it would have been really messy.

As I commented initially, because some of us live where the climate has turned very frigid, that can certainly dry out nasal membranes as can low household humidity. That was the FYI factor "awareness" tip.

Since you are younger, the consideration for the Watchman is an important one. Yes, it's another procedure but my view is, it's definitely worth doing so you are free from not only the bleeding risk factor if you fall or have a severe accident, but getting the chemical out of your body. Who knows what other long-term side effects might develop?

Check out this info from People's Pharmacy alert on unexpected side effects:
[www.peoplespharmacy.com]

Be well,
Jackie

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Carey

You sure about that? I thought the Eliquis reversal agent got sent back for further testing last year and hasn't been approved in the US yet.

I recall reading an article about the reversal agent for Pradaxa and that it was effective against all the factor Xa anticoagulants. The veracity of the article I can’t speak to. My take on it is that these things are in their nacency and it will be some time before they become as well understood as Vitamin K to reverse Warfarin.

Carey - are you saying that you have seen many cases of Eliquis causing a brain bleed, and therefore a stroke? I would hate to think that the agent that is recommended for avoiding a clot is even more dangerous for potentially causing a stroke in a different way....it sounds like a no-win situation.

Jackie - is the Watchman what Shannon had when he had an issue? I am thinking about it, but with these devices being fairly new, one has to wonder if they are completely safe as well. Ahhh...damn genetics!

~ Barb

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tobherd
Carey - are you saying that you have seen many cases of Eliquis causing a brain bleed, and therefore a stroke? I would hate to think that the agent that is recommended for avoiding a clot is even more dangerous for potentially causing a stroke in a different way....it sounds like a no-win situation.

No, I didn't say that at all.

Carey - can you please clarify what you were saying when you wrote about Eliquis and the brain. It's unclear what your message was.

Thank you ~ Barb

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tobherd
Carey - can you please clarify what you were saying when you wrote about Eliquis and the brain. It's unclear what your message was.

Sorry, I'll try to clarify. I wrote mainly about nose bleeds and such, so please don't mix my comments about that with comments about brain bleeds. Very different things. What I wrote is quoted below with the parts about brain bleeding in bold:

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The danger of bleeding with anticoagulants is primarily 1) in the brain and 2) elsewhere internally, usually the GI tract. Bleeding in the brain is a hemorrhagic stroke and it can be every bit as devastating as an embolic stroke (from a clot). In fact, they're often more devastating than embolic strokes. Bleeding elsewhere isn't as dangerous, but can still be life-threatening. You can lose a lot of blood into your GI tract before it even becomes apparent you're bleeding, so that's the danger there. However, bleeding to death is very unlikely as long as you can get medical help promptly.

All I was saying there is that bleeding in the brain is an especially serious place for a bleed to happen. For example, if a small bleed develops in your intestine, that blood simply mingles with the food you eat and might not even be noticed until you have a medical exam and they detect occult blood in your stool. You might not experience any symptoms at all if the bleed is small enough. But that same amount of blood bleeding in your brain could be catastrophic.

So what's the difference? There are two reasons:

1) Your brain is exquisitely sensitive to lack of blood flow and lack of oxygen. Lack of blood flow to brain tissue results in tissue damage in minutes, and the damage is irreparable if it continues very long at all. Most other organs in your body can withstand lack of blood flow for much longer (hours in the case of non-cardiac muscles, for example). If the lack of blood flow is total, irreparable death of the brain tissue affected will occur in about 5-8 minutes. Whatever that part of the brain did before will be gone. It might be your memories, your ability to speak, your ability to use your left arm, or your ability to swallow. It could be anything and just depends on the part of the brain affected. That's what a stroke is, and whether the lack of blood flow is caused by a clot or by a bleed doesn't matter much. The end result is the same.

2) Unlike your intestines and most other organs in your body, blood in the brain has nowhere to go. Your skull is a closed container and if you're bleeding into it, that creates pressure inside your skull, and the blood also causes irritation and swelling which just adds to the pressure. That increasing pressure can reduce blood flow to the rest of your brain by squeezing arteries off, or even squeezing parts of your brain out the openings in your skull if the pressure becomes high enough. That pressure can be deadly, and largely explains why hemorrhagic strokes tend to be more devastating than embolic strokes.

And finally, you need to keep in mind that all the bad stuff above also happens to people who don't take anticoagulants, don't have afib, and don't fall and hit their head. It just happens sometimes. All we can do is hope we're not one of those unlucky few.

So now that I've filled you with dread about hemorrhagic strokes, what does all this have to do with Eliquis? Frankly, not that much. All the anticoagulants come with a slightly increased risk of bleeding in the brain and elsewhere. Eliquis happens to be on the low end of the scale in that regard, actually. It has about the safest track record with regard to bleeding out of all the anticoagulants.

When you and your doctor decide that you need an anticoagulant, it's a measured judgement of risks. Which risk is greater for you in your current situation? Bleeding from an anticoagulant or stroke from lack of one? For example, right now my biggest risk is clots, not bleeds, so I'm taking Eliquis daily and probably will be for some time. But for the previous two years I wasn't taking any anticoagulant at all because the equation was different and my risk of bleeds was greater than my risk of clots.

I've probably just muddied the waters more for you than clarified, but the takeaway message you get from this is that the threat of blood clots from lack of anticoagulants is probably greater for you than the threat of bleeds from taking them, so you should stick with the Eliquis.

Thank you for clarifying that. I have had two ablations, both with Dr. Natale, and have been Afib free now since the second one, in June 2014. As it was a LAA isolation ablation, your numbers all have to be good to not have to be on a blood thinner. One of my numbers was e on the border..so they had me on the lowest dose of Eliquis. Fast forward to March 2016, and I got walking pneumonia. Was sent for a Cat scan of my abdomen, as I was feeling very nauseas for awhile. They saw a small "wedge shaped" spot in my kidney, and after much discussion and head scratching, decided it was likely a small blood clot. I told them I had a severe muscle pull the year before in that same area..but since they didn't see a shadow, so determined it was probably more recent..... (I still believe that's what it was from, but...). My cardiologist decided that the low dose of Eliquis was not enough, and ramped it up to 5mgs. twice/day instead. I was not..and am not..happy about that.

I'm hoping to get an appt. with Dr. Natale when he is up here in the NY area, to get his opinion and also possibly discuss getting the Watchman..although the thought does scare me. However, I don't like the idea of worrying about a possible brain bleed..aka stroke...and I don't want to worry about any possible drug or vitamin interactions....

I am glad to hear that Eliquis is one of the safer ones...that's a good thing.

Have a good night ~ Barb

Get that appointment with Natale, go with his advice, and don't worry so much about the Eliquis and drugs and vitamins. You'll be fine.

Good advice. Thanks. And yes, I can be a worrier....lol

Be well ~ Barb

Jackie:

I recall that you advocated using an Earthing product, I was on Dr.J. Wright's site and saw this:

If you take a pharmaceutical blood thinner, however, do not use any Earthing product until you consult with your physician. There is the potential for excessive blood thinning. You'll need to monitor your INR closely and, with your doctor, consider lowering your medication dosage. To find Earthing sheets, mats, or bands, contact my staff at 800-228-1507

Liz

Carey:

Are you saying that you are on a blood thinner? So many on this site have had ablations and are on blood thinners. The last time I was on Coumadin I had a problem and had to stop, when I stopped, two weeks later I had a slight nose bleed (I never got them) and coughed up some blood clots.

My doctor wants me to take Eliquis, he is the one that also wanted me to take amiodrone, I have been with him for 20 years, but he made a misstep about that drug, I no longer have faith in him and am looking around for a new doc. I have a concern that if I do take Eliquis and have to stop will I throw clots?

Jackie is on Eliquis and had a extreme nose bleed, that wasn't all due to dry nostrils, to me, this is a very scary drug. I recall you saying that people that havn't had an episode of AF for years can still stroke. My brother does not have AF but 3 years ago did have a stroke, so who knows, I guess it is coming down to the point that everyone over 70 should be on a blood thinner then we will have a generation of bleeders.

Liz

Liz - my nosebleed was most likely caused by dry tissue. I’ve upped the humidity... the windows are now misting on the inside and use the Ayr saline gel regularly day and night.

The ENT physician said the nasal blood vessel he saw and treated was enlarged and had ruptured. Now, a month later, all is good. I can actually feel with my finger that it is now flat and smooth. I’m careful with sneezing and also careful when lifting at the gym… make sure I keep my mouth open… to help eliminate nasal pressure buildup.

I started Earthing several years before I began full dose Eliquis in 2014 and now continue with the half dose – still Earthing. The other day, I cut my finger and the bleeding was typical and stopped in normal time so I’m not concerned with the minor stuff. As I said previously... the nosebleed was just really messy and inconvenient timing... glad I was home instead of at the grocery store! If that's the worst thing I have happen, I'll consider myself extremely fortunate.

Jackie

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Elizabeth
Carey:

Are you saying that you are on a blood thinner? So many on this site have had ablations and are on blood thinners. The last time I was on Coumadin I had a problem and had to stop, when I stopped, two weeks later I had a slight nose bleed (I never got them) and coughed up some blood clots.

Yes, I'm on Eliquis. I've also been on Pradaxa in the past. After two weeks I doubt the Coumadin had anything to do with your nose bleed and coughing up clots. And, btw, coughing up blood clots is a serious matter. It should be considered an emergency until proven otherwise and a 911 call wouldn't be unreasonable at all.

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My doctor wants me to take Eliquis, he is the one that also wanted me to take amiodrone, I have been with him for 20 years, but he made a misstep about that drug, I no longer have faith in him and am looking around for a new doc. I have a concern that if I do take Eliquis and have to stop will I throw clots?

Amiodarone does interfere with coumadin, but as long as your INR is being monitored regularly that will be accounted for. When taken with Eliquis it may require a half dose of Eliquis. Both are manageable as long as the person prescribing them is paying attention and knows what they're doing. The bigger concern is that amiodarone is just an awful drug all on its own.

If you have to stop Eliquis for some reason, that's manageable. For example, if it's just for a day or two for a colonoscopy, dental work or such, that's no big deal for most people to just stop it briefly. If it's longer than that, they can bridge you with heparin.

Anticoagulants are nowhere near as scary as strokes, and serious bleeds are really quite rare. If your CHA2DS2-Vasc score is over 2, your risk of stroke is significantly higher than your risk of a serious bleed.

Carey:


(Yes, I'm on Eliquis. I've also been on Pradaxa in the past. After two weeks I doubt the Coumadin had anything to do with your nose bleed and coughing up clots. And, btw, coughing up blood clots is a serious matter. It should be considered an emergency until proven otherwise and a 911 call wouldn't be unreasonable at all.)

I don't agree, Coumadin did have everything to do with what happened to me, this happened to me about 15 years ago, I took Coumadin for probably around 4 weeks, then my eyes got all red, and I got a sack of blood in my thumb. I quit and a few weeks later the above happened, nothing has happened in that way since. I did go to the ER, checked in, sat for a couple of hours without being called and did not have anymore problems so I left.

I also have low platelets, I believe that contributes to having a problem with blood thinners. I understand about the stroke connection, my chad is over 2 because they count my age and that I am a woman, sometimes my BP is a little high in my doctors office, so if gives me a 3, which I don't agree with -- I have read that they no longer count being a woman in chads and all my blood tests have always been very good and younger than my chronological age.

My mother took Coumadin for a number of years, she had to stop because of tarry stools, the Coumadin caused bleeding in her gut., The docs had her stop but she didn't live too much longer after that. I have had episodes of AF for around 20 years, the episodes didn't last longer than 20 hours and the last year they last from 3 hours to 12 hours, my heart rate doesn't go very high.

Liz

I'm not quite sure what we're discussing here.