Your Good Health: Anticoagulation drugs raise bleeding concerns

Dear Dr. Roach: My 32-year-old son has been on Xarelto for a deep vein thrombosis for about two months now. I was with him when he hit his head hard on the door hatch of his SUV two days ago. He has no symptoms, but I am still so concerned. He is in a hotel room for the week by himself for school. Should he have a scan to make sure he is OK? What should we do? Does he need to visit the emergency room?

C.H.

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Xarelto is a medication that makes it harder for the blood to clot. It is given to people with inappropriate blood-clotting, such as the deep vein thrombosis (clot) your son had two months ago.
Ideally, the dose of the medication would bring the body back to perfect balance, with no increased risk of clotting or bleeding. In practice, things may not work perfectly.

People can still get clots despite taking Xarelto, warfarin or other drugs. More frequently, people can have bleeding episodes, which can be mild or severe. Among the most dangerous forms of excess bleeding is inside the head, where there is very limited room. A lot of bleeding inside the head will compress the brain, and in some cases can lead to a devastating stroke.

For this reason, even mild head trauma that would otherwise be passed as low-risk is usually evaluated with a CT scan. The vast majority of these will be negative. People your son’s age are less likely to have bleeding.

In studies, the risk of bleeding from head trauma in people on anticoagulation ranged from three per cent to nine per cent. Many of the people in the studies were older (the average age was the 70s) and were seen in the emergency room. Someone in your son’s position is at lower risk, especially two weeks out, and especially with no symptoms.

Against that low risk is the fact that he is alone, where he might not be able to get help if he suddenly developed symptoms.

It is always difficult to make judgments about very-low-risk events that are potentially catastrophic. The downside of a CT scan is a modest amount of radiation and a few hundred dollars (that’s the price I was quoted for people without insurance), although an ER visit is much more expensive. Since I can’t give specific medical advice, I’d suggest your son talk to the person who prescribed the Xarelto.

Dear Dr. Roach: I am an 81-year-old woman and, in late August, I will be a teacher’s aide with first- and second-graders, some of whom may not be vaccinated. The MMR vaccine was not available when I was a child, and I don’t remember having those diseases. Is there a test to check on my immunity? Should I get the MMR, or am I needlessly worrying?

S.W.

More than 99 per cent of people born before 1957 had measles, mumps and rubella, and neither booster vaccines nor blood tests to prove immunity are recommended, as immunity after these illnesses is considered lifelong.

The danger of having unvaccinated children in school is that they may get one of these diseases. Measles, as an example, may be infectious for up to four days before the disease can be diagnosed.

I strongly support proof of vaccination for children in school from the standpoint of public health, with the only exception being medical necessity. When there is greater than two per cent noncompliance with vaccination, outbreaks of the disease may spread. This is what we are seeing in several parts of the U.S., with many more areas at risk.

Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers can email questions to ToYourGoodHealth@med.cornell.edu

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