Diving with Factor V Leiden and Anticoagulants

[DiverJohnATL]

As an ER doc, I'd be happier if my patients stayed on Coumadin. We can measure the degree of anticoagulation easily, and we can reverse it. The newer medications are far more difficult to assess, in terms of the degree of anticoagulation any given patient is experiencing, and reversing their effect is more difficult. Yeah, monitoring Coumadin is a pain, and dosage has to be individualized, and every other medication in the universe changes it -- but at least we can KNOW how bad the situation is that we are dealing with, and we have effective and readily available methods for reversing the action of the drug.

I'm learning to hate the new ones.

As a pulmonary-critical care NP I see a great number of pulmonary embolisms and dvts in the ICUs where I mainly practice. While the new drugs such as Xarelto and Pradaxa have no reversal agents we as a practice (18 MD/26 NP-PA's) routinely use Xarelto (the only other oral anti coag approved) for our patients for not only DVT/PTE but any patient requiring long term oral anti coagulation. We made the switch about a year ago as a practice following a large study and discussion at our journal club that came out either in NEJM or CHEST can't remember which which looked at risk of death vs serious bleeding between Coumadin and Xarelto. While Coumadin has "reversal agents" we as practitioners know it takes time and it's not instant. The study showed that risk of serious bleed requiring hospitalization was greater with xarelto than Coumadin, however......the risk of death from bleeding was greater with Coumadin than xarelto. Usually when we tell our patients the evidence they choose the Xarelto. No monitoring tests. No dietary restrictions. No reversal agent except time, which as I recall the study showed 18h to be an effective amount for reversal.

I can try to find the article if you desire it's probably still in my email as a link

John

 

[tracydr]

The halftime for Xarelto is only about 12 hours. When I get my new providers assigned in NC, I'm going to ask about switching.
i have to keep my INR above 3.0 due to anticardiolipin syndrome. I have read there is very little increased risk of head bleeds with my disease until INR is more than 3.5.
im waiting on my home INR machine. My doctor has had me taking a little extra Coumadin for increased joint and muscle pain which has worked pretty well to keep my INR around 2.7.

 

[medtechdvr]

I don't know if this will help but I thought I'd share my experience.

I was 33 when I had a sudden onset of Vertebral Arterial Dissection (bleed in the blood vessel) leading to a clot around the medula oblong (no risk factors, no hypertension, no smoking etc.). I was in the hospital for a week and placed on Coumadin for about 6 months & after my MRI was clear, aspirin for another 3 months. Before that I was doing Tech and Cave dives. I didn't go back to diving until I was off the Coumadin but I went back to diving while on Aspirin.

 

[scuba5150]

The halftime for Xarelto is only about 12 hours. When I get my new providers assigned in NC, I'm going to ask about switching.
i have to keep my INR above 3.0 due to anticardiolipin syndrome. I have read there is very little increased risk of head bleeds with my disease until INR is more than 3.5.
im waiting on my home INR machine. My doctor has had me taking a little extra Coumadin for increased joint and muscle pain which has worked pretty well to keep my INR around 2.7.

Dr. Tracy brings up the good point about the level of anticoagulation. Patients are anti-coagulated at different levels depending on their condition - e.g. a patient on coumadin because of atrial fibrillation will be at a lower level of anticoagulation that a patient taking coumadin because of a heart valve replacement. So wouldn't part of the decision about diving safely on anticoagulants depend on the level of a patient's anticoagulant therapy?

And, as previously noted, one of coumadin's advantages is that it's relatively easy to get the INR value versus the newer drugs that don't have reliable tests to determine the degree of anticoagulation.