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Interactive Learning : Ask the Doctor

 

Ask the Doctor Live Chat Transcript - Wednesday, December 19

 

Dr. Suman Rathbun

Associate Professor of Medicine at the University of Oklahoma Health Sciences Center

Venous Disease CoalitionEducation Committee

 

 

Moderator- VDF: Welcome to VDF's Live Chat! Thank you for joining us today, you may now submit your questions for Dr. Rathbun.


Sandy: How often does one need to check their INR* levels if on coumadin? Is there a home testing system instead of going to a clinic?

Speaker- Dr. Rathbun: Thank you Sandy for your question. Typically, the INR should be checked at regular intervals and no less than every 3 to four weeks. If variable, the INR should be checked weekly to ensure safety. There are two home systems available: the Coagucheck and the ProTime system. Both are easy to use but are expensive to purchase. In addition, the reagents for each test are required, so there is not a great cost savings compared with going to the clinic. In addition, Medicare will not pay for these systems if coumadin is prescribed for DVT. It will only pay for those with atrial fibrillation.

*INR stands for International Normalized Ratio and is used to determine the clotting tendency of blood.


Amanda: I had a blood clot in July of 2006 and would like to know what the chances of a reoccurrence are. Also, is it normal to still have some numbness in the leg the clot was in?

Speaker- Dr. Rathbun: Thank you Amanda for your question. Your chances of getting a second blood clot are influenced by your risk factors for the first clot. If your clot was due to surgery or hormone therapy and these factors are no longer present, your chance of another clot is low. However, if your clot was out of the blue, further investigation is required to see if you have some inherited risk. This requires blood testing. To answer your second question, some people will continue to have pain and numbness for many months after a clot. This is usually due to post-phlebitic syndrome which can cause swelling, heaviness and numbness in the leg. Use of a prescription compression stocking can minimize these symptoms.


Moderator- VDF: This next question was e-mailed to us ahead of time: How long will leg pain associated with DVT last for?

Speaker- Dr. Rathbun: Leg pain from DVT can last months or even years. DVT can damage of the valves of the veins causing post-thrombotic syndrome. People often complain of heaviness, swelling, and aching of the legs especially with prolonged standing. Use of a compression stocking can minimize these symptoms. If persistent and troublesome, there are specialized treatments to re-open the veins that are still blocked.  These should be in consultation with an interventional radiologist who is trained in this procedure. Unfortunately, once damage, the venous valves cannot be repaired.


Moderator- VDF: This next question as also e-mailed to us ahead of time: I am 22 years old and about two years ago I got a blood clot in my left leg and I have recently been told that I will be on coumadin for the rest of my life? This scares me since I want to have children so my question is are there any new medicine that I can take that are safe when I want to get pregnant and is it safe to be on coumadin while pregnant?

Speaker- Dr. Rathbun: Currently there are no new medicines that have been tested for prevention of blood clots during pregnancy. However, the good news is that there are standard treatments with low-molecular-weight heparin or regular heparin that have been safely in many women during pregnancy. Coumadin should not be used during pregnancy due to the risk of birth defects. Typically, a pregnant woman will take a daily heparin shot for the duration of her pregnancy and can resume coumadin after delivery. This regimen has been found to be safe both during pregnancy and for those women that choose to breastfeed.


Sandy: My husband recently had a free floating DVT in the groin area after having knee surgery. He is a fit 35 year old. After 3 months of coumadin, they are taking him off and have not scheduled him to have his leg re-scanned. Is it recommended to have an additional scan to make sure the clot is dissolving? He still has some calf and leg pain.  Thanks.

Speaker- Dr. Rathbun: The practice of re-scanning prior to discontinuing coumadin is variable. If your husband is still have pain and swelling in his leg, it is probably worthwhile to re-scan. It is not unusual for the clot, now scar, to still be seen even 6 months to a year after the original clot. However, if he still have significant clot in his leg, his physician may choose to continue coumadin for an additional 3 months. There are some studies that show having a large amount of clot left after treatment of coumadin may predict a higher rate of a second clot. Staying on coumadin may obviate this.


Moderator- VDF: This next question was also e-mailed to us ahead of time: When I was 17 year's old and six months pregnant I had a blood clot in my leg while I was in the hospital. I was treated with Lovenox but when I was released from the hospital and I did not go home with any kind of medication. Now I am 21 and am six months pregnant. The doctor has put me on Lovenox for the rest of my pregnancy and I'm concerted about the affect this may have on my baby. Is this life threatening for me or the baby and what are the risks now or during labor?

Speaker- Dr. Rathbun: Being on Lovenox during pregnancy is safe. There is a slight increased risk of bleeding while being a blood thinner, but most pregnant women do very well on this regimen. At the time of the delivery, your doctor may choose to stop the Lovenox a day before delivery or switch you to IV heparin up until the time of delivery. This should be discussed with your ob-gyn ahead of time.


Moderator- VDF: This next question come to us from Renay in Colorado: What herbs facilitate the healing of blood clots and are there herbs that cause clotting?

Speaker- Dr. Rathbun: Thank you Renay for your questions. There is very little known about herbs and clots. We know that herbs that are anti-inflammatory may help with reducing post-thrombotic syndrome after a clot, but there is not much known about which herbs may cause clots. For example, horse chestnut seed extract (VeinLife and other products) have been found to decrease swelling from venous problems short-term but there are no long-term studies. In the absence of FDA approval, I would recommend against the use of herbs.


Moderator- VDF: This next question was also e-mailed to us ahead of time from Jim: I am looking for information on going on vacation to an area that is high altitude, 6000 feet. I have DVT/PE and was on a blood thinner for a year. Now I am only taking daily aspirin and am wondering if it is safe for me to travel for a week in the mountains. Thanks!

Speaker- Dr. Rathbun: Thank you Jim for your question. There is very little known about high altitude and risk of DVT. Most of what we know comes from studies of air travel and these results are conflicting. We know that people who live at high altitudes have not been found to be at higher risk of DVT. However, there have been some laboratory studies that have showed that lower oxygen pressure at high altitudes may cause platelets to be hyperactive and predispose to clots. This is theoretical and has not been tested in patients. If your trip is not longer than a week or so, I would recommend the standard preventive methods for DVT, i.e., stay hydrated, stay active, wear graded compression stockings and avoid leg trauma. If you do have signs and symptoms of DVT, seek care immediately.


Moderator- VDF: This next question was also e-mailed to us ahead of time: If I am on birth control and have been diagnosed with DVT is it safe for me to continue to be on birth control?

Speaker- Dr. Rathbun: If you are on blood thinners, it is safe to stay on your oral contraceptives and especially important since you do not want to become pregnant while taking coumadin. Once your clot has been treated, it will be important not to use hormonal birth control especially orally. There are other contraceptive options including barrier contraception (condoms), IUD, and depot progesterone preparations that carry a less (but still some) risk of clots. The transdermal estrogen products likely have the same risk of clots as oral preparations. These options should be discussed with your doctor.


Sandy: I know someone with a permanent IVC filter to prevent clots from going to the lungs. Can this filter get totally plugged up with clots and if so, what happens?

Speaker- Dr. Rathbun: Permanent IVC filters can have long-term complications. They have been associated both with a higher rate of subsequent DVT in either leg and also will filter thrombosis itself. In fact, some clots may even propagate through the IVC filter and go to the lungs. To prevent this, many recommend that a patient be on coumadin also to prevent filter thrombosis if they can, even if at low doses if there is a bleeding risk. The good news is that the newer filters are made of materials that are less thrombogenic, and likely carry less risk of the filter being clotted up.


Moderator- VDF: Thank you for joining us today! We hope you’ll join us for our next chat on February 20 with Dr. Kenneth Cherry. We wish you and your family a happy and healthy holiday!

Disclaimer

The material provided on VDF's Web site and Live Ask the Doctor chat are for educational purposes only and are not to be used as a substitute for professional medical services or advice. For more information, please read VDF's important disclaimer.