When a patient is on a blood thinner, why do they have to stop it a few days before having a procedure?


Today’s question comes from Terry Fletcher who is the producer of the CodeCast podcast. She is an expert medical coder and builder. She has a whole series of episodes about different ways that doctors, hospitals, and insurance companies use coding and billing services. I highly recommend you take a listen.


The website is www.terryfletcher.net/podcasts


Terry recorded a question for me to answer. Let’s have a listen:


Terry, thank you for sending in that question because so many people are taking blood thinners or have family members who take them every day.


Coumadin, also called warfarin, is one of the most common blood thinning medications in the world. Millions of people take it daily to prevent blood clots.


Let me first tell you a little bit about the history of Coumadin. Coumadin is actually derived from a chemical called coumarin. Coumarin is an active ingredient used in rat poison. It was used as a commercial pesticide. The way that works is it blocks the vitamin K in the coagulation cascade. Vitamin K is necessary to help the blood clot properly. For example, if you cut your finger, within a few minutes the bleeding will stop as long as you have adequate platelets, vitamin K in your body, and all the other necessary ingredients.


When people have a heart attack or stroke, it is due to a blood clot. In those situations, we know that there blood is too thick. This will automatically cause them to be at a higher risk of having another heart attack or another stroke. That’s why we add Coumadin to act as a blood thinner by blocking the vitamin K pathway.


Coumadin has been used for decades because it’s cheap and effective. However, sometimes it’s too effective. People who are on this medication or other blood thinners often complain about excessive bleeding and bruising even from simple injuries.


For example, if somebody bumps their knee on the edge of a table, they may not consider that a serious injury. However in the ER I see these people several hours later because the knees swells up with a large amount of blood which then has to be drained out.


People in blood thinners often have big bruises on their abdomen or their back or their arms. Whatever they have to get blood drawn, they regret it because it causes a lot of excessive bleeding. So the blood thinners definitely save their lives because it reduces the risk of heart attack and stroke. However, the downside is that the blood is just too thin.


People who have been on Coumadin for years can still have some side effects. This can include spontaneous bleeding from the gums, bleeding in the urine, bloody stools, persistent nose bleeding, and vomiting blood.


If somebody is scheduled for a wisdom tooth extraction, shoulder surgery, or any type of invasive procedure, the surgeon or the dentist or the specialist wants to avoid excessive bleeding. In that case, the surgeon will notify the primary care doctor or the cardiologist that they are scheduled for surgery and the patient needs to be aware of when to stop the Coumadin and when to resume it.


The question that Terry was asking is why do we stop the medication about 3 days before an invasive procedure. The reason is that it takes about 3 days for the vitamin K to be depleted in the body when you start Coumadin. So that means it takes about 3 days for the Coumadin to wear off and the blood to become thick again back to its previous consistency.


Now as soon as the procedure is over, the surgeon or the dentist will recommend the patient to resume the Coumadin based on the instructions from their family doctor.


The dilemma is that if somebody is taking this medication to prevent a stroke and they have to have a surgery where they are off the medication, there’s a chance they could develop a stroke or some other blood clot either during or after surgery. So there’s that period of time where the person is unprotected because they don’t have a blood thinning medication on board.


With Coumadin you have to check the INR or the PT value at least monthly. Oftentimes people are checked more often especially because Coumadin interacts with a lot of antibiotics, anesthesiology and even vegetables.


There are other blood thinning medications that don’t have the same monitoring requirements as Coumadin. Common ones include aspirin, Plavix, Eliquis, and Xarelto. The benefit of these medications is that you don’t need to monitor the blood.


The downside to some of these medications is the cost. Not every insurance plan will cover them and they are not approved for all of the conditions that Coumadin may be approved for. Each medication has an effect but also a side effect. In these cases, I strongly recommend that you talk with your pharmacist and your family doctor or cardiologist about the different options available with blood thinning medications.


So again want to thank Terry from the CodeCast podcast. You can visit her website https://www.terryfletcher.net/podcasts/


I love to receive questions from my listeners so I can answer them on my show. It helps me to make the content relevant and more interesting.


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