Study ties hospital overdoses to bleeding

Those given too much of two newer blood thinners — low molecular weight heparin

I worked as an orderly in med/surg way back, 1970 - 1973. Heparin was widely used then. Is this some new form of it?

diff subject.....do you have a link to the actual study that put the bite on Naproxen use in patients with one or more cardiac arteries blocked 70+%? Not quite a year ago, if memory serves....tks

I had an elderly neighbor who had been hospitalized for heart trouble. I had cared for him before and after this, purchasing groceries, doing home repairs, joining him for lunch occasionally. After his latest hospital visit, he complained about being given a blood thinner, I think he called it "cumadin". He hated it, bbut took it anyway. I was amazed at how both his appearance and general health decayed so quickly thereafter. Although he had been living at home, he was dead within months. Now, I'm nobody to say that it might not have been "his time", but that medication sure seemed to cause major problems. After a while, all of his clothes were stained with blood. It was sad to watch.

low molecular weight heparin

Low molecular weight heparins are smaller pieces of the heparin molecule that inhibit clotting factor Xa more than factor IIa (thrombin). These drugs are given subcutaneously and can usually be administered in a weight-based dose without subsequent monitoring or dose-adjustment. At a higher dose these drugs are used to treat active thrombotic disease and at lower dose to prevent thrombosis. Three LMW-heparins are widely used in the United States and Canada. They are dalteparin, enoxaparin, and tinzaparin.

more here

http://www.careinternet.com/caregiver/lmwh.php

Heparin was widely used then. Is this some new form of it?

They still use the old unfractionated heparin, but now they also have low molecular weight heparin like Lovenox.

Are you referring to studies of Vioxx that had fewer coronary events in the arm of the study that used naproxen?

not sure, honestly........whichever one it was, it concluded that if you had 1 or more heavily obstructed in CAD, naproxen can kill you. There was at least one thread about it here, likely begun by you.....

I don't remember. Naproxen and the other non-steroidal anti-inflammatory drugs, NSAIDs, reversibly inhibit platelet aggregation, unlike aspirin which irreversibly inhibits platelet aggregation. So if someone takes a daily aspirin for primary or secondary prevention of a myocardial infarction, and they also take daily NSAIDS for chronic pain, they should take the aspirin at least one hour, before taking Advil, naproxen, etc.

Articles like this create more panic than good outcomes IMO. Let's face it, those who have heart attacks are walking a fine line when it comes to therapy. It is important that the damage to their heart tissue is minimized, but it is also important that they are not induced to bleed.

This article seems to touch on the core issues that have been recognized for several decades. I don't consider this ground-breaking and am perfectly happy to see alternatives suggested that can achieve the best balance.

"Even giving the right drug at the right dose increases the risk of bleeding," and giving too low a dose can increase patients' risk for clot-related damage, said Dr. Robert Bonow, a former American Heart Association president." Really?

At high doses, NANSAIDs inhibit the body’s synthesis of prostacyclin, which is a naturally occurring platelet inhibitor. This effect could actually promote heart attacks.

http://www.mc.vanderbilt.edu/reporter/?ID=1898

The effect of a single oral dose of 500 mg naproxen on the synthesis in vivo of thromboxane A2 and prostacyclin was studied in healthy volunteers. The synthesis of the prostanoids was assessed by measuring the urinary excretion of the metabolites 2,3-dinor-TxB2 and 2,3-dinor-6-keto-PGF1 alpha, respectively, using stable isotope dilution assays based on gas chromatography - mass spectrometry. Naproxen caused significant inhibition of the excretion of both metabolites for about two days. The reduction of the thromboxane metabolite was more pronounced (75% inhibition) than that of the prostacyclin metabolite (about 50% inhibition). The data support the idea that naproxen causes reversible inhibition of cyclooxygenase.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2515064&dopt=Abstract

CONCLUSIONS: The regular administration of naproxen 500 mg BID can mimic the antiplatelet COX-1 effect of low-dose aspirin. Naproxen, unlike aspirin, decreased prostacyclin biosynthesis in vivo.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=15037526&dopt=Citation

888888888888888888888888888888888888888888888888888888888

one of the threaded news stories or study about a year ago was interrupted because of an unanticipated negative finding that was risky to some of the patients.......I'm not certain, but I think it was the naproxen, as we were discussing it here on the thread I am thinking of, many folks chimed in, wondering what to do now.

I THINK the (3) above is what is/was behind it, but what was out there at the time included none of the above that I can remember, but it makes sense that this would be esp risky for a heavily obstructed CAD patient.

I take coumadin and I have taken it since 1994. I have never had a serious problem, I have to have regular blood tests to monitor the "protime" of my blood, in other words the clotting level of my blood. Millions of people have been on coumadin over the years and most of them do fine, much better than they would without it. I would have surely suffered a stroke by now if I didn't take it. I would rather bleed to death then to have a stroke, just MO.

We have a winner! Thank you...great post and I wholeheartedly agree with all you say. People who experience AMI are already at risk. It is not easy to treat everyone and expect a 100% full recovery without any complications.

Thanks for the links. Happy New Year!

Articles like this create more panic than good outcomes IMO.

I respectfully disagree. When I was an intern and resident, everyone was given the same loading dose as a bolus and started on the same unfractionated heparin IV rate. After I read that heparin was supposed to be dosed according to patient weight, etc., and I wrote appropriate orders, I was looked at like I had two heads.

IMHO, someone with acute symptoms is not going to worry about a heparin overdose.

My mother suffered a stroke about a year ago and they put her on blood thinners (the name "coumadin" sounds familiar). Any way she "sprung a leak" one day and lost a lot of blood before any of the nurses noticed. She was rushed to the hospital where they gave her transfusions. It was bad enough that my sister gave them the DNR order if she went into cardiac arrest but she never got that bad. She complained about how cold the refrigerated blood felt but the additional oxygen it carried made her as alert as she had been in months. They took her off the blood thinners, at least temporarily.

She's still with us today and has improved to as good as she's going to get.

So what are the effects of Ibuprofen and the 81 mg aspirin?

Psychotherapy on the Road to ... Where?

Researchers Demonstrate Single Molecule Absorption Spectroscopy

FReepmail me if you want on or off my health and science ping list.

So what are the effects of Ibuprofen and the 81 mg aspirin? Please accept my apology for the extensive references, but some folks might find them useful. Happy New Year!

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Volume 345:1809-1817		December 20, 2001		Number 25

Cyclooxygenase Inhibitors and the Antiplatelet Effects of Aspirin

Francesca Catella-Lawson, M.D., Muredach P. Reilly, M.D., Shiv C. Kapoor, Ph.D., Andrew J. Cucchiara, Ph.D., Susan DeMarco, R.N., Barbara Tournier, R.N., Sachin N. Vyas, Ph.D., and Garret A. FitzGerald, M.D.


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Editorial

by Crofford, L. J.

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ABSTRACT

Background Patients with arthritis and vascular disease mayreceive both low-dose aspirin and other nonsteroidal antiinflammatorydrugs. We therefore investigated potential interactions betweenaspirin and commonly prescribed arthritis therapies.

Methods We administered the following combinations of drugsfor six days: aspirin (81 mg every morning) two hours beforeibuprofen (400 mg every morning) and the same medications inthe reverse order; aspirin two hours before acetaminophen (1000mg every morning) and the same medications in the reverse order;aspirin two hours before the cyclooxygenase-2 inhibitor rofecoxib(25 mg every morning) and the same medications in the reverseorder; enteric-coated aspirin two hours before ibuprofen (400mg three times a day); and enteric-coated aspirin two hoursbefore delayed-release diclofenac (75 mg twice daily).

Results Serum thromboxane B₂ levels (an index of cyclooxygenase-1activity in platelets) and platelet aggregation were maximallyinhibited 24 hours after the administration of aspirin on day6 in the subjects who took aspirin before a single daily doseof any other drug, as well as in those who took rofecoxib oracetaminophen before taking aspirin. In contrast, inhibitionof serum thromboxane B₂ formation and platelet aggregation byaspirin was blocked when a single daily dose of ibuprofen wasgiven before aspirin, as well as when multiple daily doses ofibuprofen were given. The concomitant administration of rofecoxib,acetaminophen, or diclofenac did not affect the pharmacodynamicsof aspirin.

Conclusions The concomitant administration of ibuprofen butnot rofecoxib, acetaminophen, or diclofenac antagonizes theirreversible platelet inhibition induced by aspirin. Treatmentwith ibuprofen in patients with increased cardiovascular riskmay limit the cardioprotective effects of aspirin.

Source Information

From the EUPenn Group of Investigators at the Center for Experimental Therapeutics (F.C.-L., S.D., B.T., G.A.F.), the Division of Cardiology (M.P.R.), and the General Clinical Research Center (F.C.-L., S.C.K., A.J.C., S.N.V., G.A.F.), University of Pennsylvania School of Medicine, Philadelphia.

Address reprint requests to Dr. FitzGerald at the University of Pennsylvania School of Medicine, 153 Johnson Pavilion, 3620 Hamilton Walk, Philadelphia, PA 19104-6084, or at garret{at}spirit.gcrc.upenn.edu.

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Related Letters:

Cyclooxygenase Inhibitors and the Antiplatelet Effects of Aspirin
Burnakis T. G., McQuillan A., Eikelboom J. W., Catella-Lawson F., Reilly M. P., FitzGerald G. A.
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N Engl J Med 2002; 346:1589-1590, May 16, 2002. Correspondence

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There are also reported cases where herbal remedies such as ginseng, a blood thinner, were taken by the patient before surgery and the surgeon then had an emergency on his hands.