Millions of Americans who have or are at high risk for heart disease regularly take anti-platelet drugs or anticoagulant drugs, the latter commonly called blood thinners, which are prescribed to help prevent blood clots that can lead to serious complications such as stroke or heart attack.
But what if someone also has hemophilia or another type of bleeding disorder? Can they safely take an anticoagulant or an anti-platelet agent? How do doctors decide whether or not to prescribe one of these medications? For answers to these and other questions, we spoke to two of the co-authors of a 2022 paper on managing coronary artery disease in patients with hemophilia.
“Deciding whether to start these agents in someone with a bleeding disorder is always challenging,” says Andrew D. Leavitt, M.D., director of the University of California San Francisco’s (UCSF) program for noncancerous blood disorders and medical director of the UCSF Adult Hemophilia Treatment Center. “The patient and their doctor must balance the risk of a serious bleeding complication against that of a serious clotting complication such as heart attack or stroke.”
What Are Anticoagulants Prescribed For?
While they’re commonly called blood thinners, anticoagulants do not actually thin the blood. Instead, they work by decreasing the blood’s ability to clot. Patients are prescribed anticoagulants for a variety of reasons, with the strength/dose of the medication depending on the reason they are prescribed, says Jacob Mayfield, M.D., Chief Fellow in the Division of Cardiology at the University of Washington Medical Center in Seattle.
“For example, people who have coronary artery disease, or plaque buildup in the blood vessels that feed their hearts, may need to take anti-platelet medications ranging from low-dose aspirin on the weaker end to clopidogrel (Plavix), ticagrelor (Brilinta), or prasugrel (Effient) on the stronger end of the spectrum,” Mayfield says. All of these medications make platelets less sticky and can reduce the risk of heart attack in people at risk. They may also be used for a period of time after heart stenting procedures to protect the stent until the body can coat it in a layer of its own cells.
“People with other conditions like atrial fibrillation, deep vein thrombosis, or pulmonary embolism may be prescribed anticoagulants such as warfarin (Coumadin), apixaban (Eliquis), or rivaroxaban (Xarelto), which work by reducing or blocking natural substances that aid in blood clotting,” Mayfield adds. In rare cases, he says, these medications may be combined with drugs that work on platelets, such as aspirin or clopidogrel. As one might imagine, combining these agents increases the bleeding risk.
Making the Decision
When evaluating whether it’s safe for a patient with hemophilia (or another bleeding disorder) to take an anticoagulant, what factors do hematologists take into consideration?
“For people with mild bleeding disorders, blood thinners may be considered with caution,” Leavitt says. “For others with very severe bleeding disorders, the medication would only be prescribed if they were at very high risk of having a serious clotting problem.” When this is the case, Leavitt says, extra treatment for the bleeding disorder (such as clotting factor administration) may be needed to reduce or normalize the bleeding risk for the duration of blood thinner treatment. He adds that other factors that affect this decision are age, risk of falling, and the presence of other medical conditions.
If an anticoagulant is recommended, Leavitt says doctors will often suggest one that can be reversed in the case of a serious bleeding problem. “This is a very patient-specific decision, and no rules apply to all,” he adds. “Patients should be supported in making complex decisions like this by hematologists and cardiologists at a center where they have expertise in both.” Patients with hemophilia can locate expert hemophilia treatment centers by visiting the Centers for Disease Control and Prevention website.
“It’s important to emphasize a cautious, collaborative approach among the patient, their hematologist, and whoever is recommending anticoagulant/antiplatelet therapy, often a cardiologist,” Mayfield adds. “The key is understanding the individual and excellent communication among the patient and their care team.”
The Power of Prevention
Because people with bleeding disorders are living longer due to advances in bleeding disorders treatment, the burden of diseases associated with aging, such as heart disease, is increasing, Mayfield says. But having a bleeding disorder makes treating heart disease and stroke much more complicated.
For this reason, he says, it’s crucial to focus on heart disease prevention: maintaining a normal weight, eating a heart-healthy diet (such as the Mediterranean diet), not smoking, and working with a primary care provider to identify and treat high cholesterol and diabetes.
“Even more than for the average person, prevention is the best medicine,” he says.