DEAR DR. ROACH: I am a 61-year-old male, and I’m currently taking medication for blood pressure, cholesterol and diabetes. Five years ago, I was diagnosed with deep venous thrombosis (a blood clot in my right leg). I was prescribed Coumadin. After taking Coumadin for six months (I never could get the number right), I went to the emergency room, and the doctor there said that the Coumadin wasn’t working. So, he prescribed Eliquis. He told me that I would be taking a blood thinner for the rest of my life.
Recently, my primary health provider changed my doctor, and now this doctor is taking me off of Eliquis. The reason is due to insurance. I guess it’s expensive, and they asked the new doctor if I really needed to be on it.
Should I be concerned about stopping Eliquis after being on it for five years? One doctor says that I’ll be taking it the rest of my life, and now five years later, another doctor is taking me off of it. Something just doesn’t seem right to me. Your opinion on this matter would be sincerely appreciated. — S.F.
ANSWER: I would also be very concerned if I thought my necessary medication was being stopped because an insurance company no longer wanted to pay for it, so I understand exactly why something doesn’t seem right. But the issue may be a medical one, not a financial one.
There is always a trade-off between reducing the risk of another clot with medicine and increasing the risk of serious bleeding. A bleed inside the brain is devastating, just as a blood clot in the lung is.
So, it is possible that the first doctor might have made an error in judgment, and the second doctor might be right that you shouldn’t be on an anticoagulant like warfarin (Coumadin) or apixaban (Eliquis). It takes experience to decide the duration of anticoagulation.
Most people with their first diagnosis of DVT should be on anticoagulation for at least three months, while others are treated for six months up to a year. That decision is based on knowing what caused the blood clot (sometimes it’s unknown), how likely it is for the clot to come back, and how likely a person is to have dangerous bleeding on an anticoagulant.
In general, if there was a provoking factor (like surgery) that has gone away, most people do not need lifelong therapy. However, if the underlying problem is permanent (cancer or a known genetic cause), or if the person had a life-threatening clot, then long-term anticoagulation is almost always recommended.
One blood test that may be helpful in deciding whether you need lifelong treatment is called the D-dimer test. A high D-dimer predicts a greater risk of a recurrent clot. Some experts use this test only in women, as it is less reliable in men, and men are at a higher risk for recurrent clots.
Since I don’t know if there was something (like a long plane flight, surgery or trauma) that precipitated the initial blood clot, nor what your risks for bleeding might be, I recommend you consult with an expert. A general hematologist, or one who specializes in blood-clotting problems, will take a thorough look and provide you with an unbiased opinion on whether you would be better off on the anticoagulant and taking the small risk of serious bleeding, or off of it and taking the small risk of another clot.
You deserve an expert opinion on whether the medical risks outweigh the medical benefits — independent of the financial costs.
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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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