Ask the Doctors March 2016 Issue

March 2016

I have atrial fibrillation and am on warfarin (Coumadin®). I have kidney insufficiency. Should I be concerned about using new warfarin alternatives?

Cleveland Clinic Dr. Leslie Cho

Heart Advisor Editor-in-Chief Leslie Cho, MD, Co-section head of Preventive Cardiology and Rehabilitation at Cleveland Clinic.

Approved alternatives to Coumadin® (collectively known as NOACs) for anticoagulation in the setting of atrial fibrillation include dabigatran, rivaroxaban, apixaban, and edoxaban. When compared to warfarin they have all been at least as effective at reducing the risk of stroke and blood clots and are associated with similar or lower bleeding complications.

Benefits of these medications as an alternative to Coumadin® include quick onset of drug-thinning effect within hours, lack of dietary restrictions and no requirement for routine laboratory monitoring.

There are some downsides. They have a short life in the body, so taking the medications regularly as prescribed is vital. Except for dabigatran, which has a reversal agent, the other drugs have no available antidote to be used to treat life-threatening bleeds.

These medications are dependent on clearance from the kidneys, and therefore dose adjustment is recommended in patients with reduced kidney function. If the dose of medication is not appropriately reduced in the setting of kidney dysfunction, bleeding risks could increase.

The dosing recommendations vary depending on the drug. In general, doses are reduced if there is moderate impairment of kidney function. Studies show that if the dose is correctly adjusted, individuals with moderate impairment of kidney function can tolerate these medications with similar efficacy and safety. The drugs should not be used at all if there is severe kidney dysfunction, usually defined as a creatinine clearance less than 15 mL/min.

As long as you have no other reasons not to take the drug, your kidney function is not severely impaired and you do not have marked variations in kidney function over time, these medications could be appropriate alternatives for you. Your physician will need to closely monitor your kidney function using a simple calculation while on the medication.

My son and I have high cholesterol. Should my 10-year-old grandson have his cholesterol levels measured?

Cleveland Clinic Dr. Michael Rocco

Michael Rocco, MD, medical director of Cardiac Rehabilitation and Stress Testing at Cleveland Clinic.

There is little disagreement that adults should undergo cholesterol screening. The question of if and when to screen children has been more contentious. Why consider screening at an early age? The U.S. Department of Health and Human Services recently reported that one in five children and adolescents have at least one abnormal cholesterol level (high total, low HDL or high non-HDL cholesterol). Abnormal cholesterol may be acquired and/or inherited. Some of the time it may be related to obesity, sedentary lifestyle and poor diet. Genetic abnormalities known as familial hypercholesterolemia are not uncommon, affecting one in 250 to 500 individuals. Cardiovascular disease (CVD) is rare in children. However, since risk factors such as cholesterol are common and atherosclerosis begins early and progresses with age, an argument can be made for early screening.

An important focus of screening guidelines has been to identify those with inherited disorders. Targeted screening recommends blood tests after the age of 2 years when there is a family history of premature CVD or high cholesterol in parents or grandparents. Early recognition and monitoring does not commit to medications; rather it can help with early initiation of heart-healthy lifestyles.

If there is a family history of high cholesterol or early CVD, I strongly recommend a cholesterol test for your grandson. Evidence is mounting that cholesterol screening in all children and adolescents may be beneficial in helping them enter into adulthood with a lower risk for future heart disease.

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