Coumadin versus Pradaxa

Coumadin (Warfarin) is a blood anticoagulant which prevents clotting by inhibiting Vitamin K dependent clotting factors.  It is taken orally and becomes effective after several days of administration when the Vitamin K dependent clotting factors have been depleted.  It is inexpensive and has been used for years to prevent clots from forming in patients with the irregular heart rhythm known as atrial fibrillation.  These clots can form in the chambers of the heart and break off and travel to the brain causing embolic strokes.

Coumadin is additionally used to prevent recurrent blood clots in patients who have had phlebitis (or inflammation of a blood vessel) and in certain postoperative conditions such as joint replacements. Physicians monitor your ability to clot by drawing blood for a test called “the prothrombin time or INR (International Normalized Ratio).  The blood can be drawn from a vein and sent to a lab or performed by a finger stick method in a doctor’s office.  Based on the blood test result we adjust your medication dose up or down. Coumadin’s effect on blood clotting can be easily affected by certain foods rich in Vitamin K (green leafy vegetables in particular) and by medicines which either enhance or limit Coumadin’s effect on clotting.

The major complication of Coumadin is excessive bleeding. We stop the bleeding by administering Vitamin K and infusing blood products intravenously containing active blood clotting factors.

Pradaxa and the new wave of direct thrombin inhibitors that are now being released are designed to do the same job as Coumadin without requiring monitoring by blood test of your ability to clot. This new class of medications should have many fewer interactions with food and other prescription and over the counter medicines. Its two major drawbacks are bleeding and expense.  The drug was tested extensively in Europe and proved to be safe but it has been on the US market for less than six months. While Coumadin costs pennies per tablet, Pradaxa costs about $300 per month. It requires taking a pill twice per day.

It is clear that thrombin inhibitors like Pradaxa will one day replace Coumadin. For now I prefer to have other physicians’ patients use it and compile a safety record before I try it on my patients. We know the pros and cons of Coumadin.  Let Pradaxa survive the test of use on the US market, and time, and show a clear cut safety advantage before giving it to our patients locally.

Fight Doctor – A Rich Experience in a Non-Traditional M.D. Role

I received a phone call from the Broward Sheriff’s Office Police Athletic League Youth Boxing Program asking if I would help them out on short notice and be the fight physician at their large youth boxing tournament. Their usual physician, a member of the Boxing Hall of Fame, had another commitment.  He was willing to train me in advance and show me the ropes on the day of the event but had to leave before the matches got started.

State law and the Boxing Authority require a physician to be at ring side and perform the pre and post fight exams.  I have worked with athletes in contact sports at all levels during my 32 years of medical practice but have no experience with boxing. It had been years since I have worked on a sideline so there was a bit of anxiety over wanting to have the skills, experience and expertise to help them and be able to make judgments and decisions that would help not hurt the participants.  I agreed to meet the fight doctor.

To help me with the project I enlisted my niece, a medical student who had just completed her second year and happens to be a fifth degree black belt in one of the karate disciplines. She was thrilled with idea.  We filled out applications and were accepted into the US Olympic program boxing medical team.  We then did a literature search to bring ourselves up to date on the latest articles on evaluation of head trauma in competitive youth sports.  Then, with some trepidation, it was off to Deerfield Beach High School and the bouts.

The Broward Sheriffs had done a remarkable job of transforming a gym into a regulation boxing ring with seating for about 1,000 people. As the fighters marched into the training room, we performed the fight physicals on enthusiastic and polite 8-14 year olds.  It was an opportunity for a medical student, my niece, to examine healthy patients for a change and be exposed to an unusual area of medicine that is certainly not discussed in the four year curriculum.

Dr. Allen Fields, a surgeon by training and board member of the Association of Professional Fight Doctors, was on hand to explain our duties and the fine points.  This gentleman, in his mid- seventies, clearly had the trust and respect of all those in the boxing program. Despite his easy going down to earth manner, it was apparent he was current and up to date in his knowledge of the medical aspects of evaluating and treating athletes at all levels of competition.  He is a source of experience and knowledge that my niece and I took full advantage of.

When the physicals were completed, we were off to ringside where we met numerous champions and Olympic boxing team members who were present to assist in the program. We were shown to our ringside seats. The National Anthem was played by a saxophone player and the show began. The referee prepped the first boxers, turned to the judges and timer and then turned to the fight doctors and asked our permission to begin the match.

At the conclusion of each bout, the participants shook hands and hugged. When the decision was announced it was difficult to distinguish the winner from the other boxer. There were no losers. The sportsmanship and camaraderie instilled in these youngsters by their coaches was apparent.  As they left the ring, we met them at courtside for the post fight checkup followed by a handshake and a hug.

The adults organizing and supervising the tournament could not have been warmer or nicer. These were high risk disadvantaged children using “Gloves Instead of Guns.”  They were expected to excel in school, be disciplined and play by the rules.   Six hours later the last bout was completed.  All the participants fared well with no injuries and no need for our intervention.  I can not express just how appreciative all the organizers and participants in this event were for my niece and I spending a day with them so that their tournament could take place.

It’s a funny thing; I think my niece and I are far richer for the experience and exposure to these wonderful volunteers trying to give these kids an opportunity to succeed in their lives. It was a pleasure to again see the value of a physician in the society working with healthy individuals in a nontraditional role. For as much as we gave, we received much more in return.