DEAR READER: Plavix is prescribed by physicians to prevent blood clots that could lead to heart attack or stroke in some patients. Prilosec (omeprazole) reduces the incidence of excess stomach acid. In November 2009, the Food and Drug Administration issued a warning to patients not to take one if you are on the other. New research suggests that when Prilosec and Plavix are taken, the ability to block platelet anticlotting may be reduced by almost 50 percent. Plavix alone isn’t capable of producing an anticlotting effect until it is metabolized or converted into an active form with the assistance of the liver enzyme CYP2C19. With the addition of Prilosec, this liver enzyme is blocked, substantially reducing the potential effectiveness of the Plavix.

Once the possible interaction was noted, the FDA requested additional studies from the manufacturer that supported the existence of a significant interaction that could negatively impact a person’s health. As a result, the Plavix label has been updated and now includes warnings regarding the use of Prilosec and other drugs that block the liver enzyme. It is unknown how other proton-pump inhibitors (PPIs) may interfere, but the recommendation is that Nexium, Tagamet and Tagamet HB, Diflucan, Nizoral, VFEND, Intelence, Felbatol, Prozac, Sarafem, Symbyax, Luvox and Ticlid also not be taken with Plavix because of the potential for similar interactions.
Any patient prescribed Plavix who needs medication to control stomach acid should speak with his or her physician for a recommendation of possible substitutes, such as Zantac, Pepcid, Axid and others that do not inhibit the CYP2C19 enzyme. So make a telephone call now or set up an early appointment with your doctor to resolve the issue.

To provide related information, I am sending you a copy of my Health Report “Consumer Tips on Medicine.” Other readers who would like a copy should send a self-addressed stamped No. 10 envelope and a $2 check or money order to Newsletter, P.O. Box 167, Wickliffe, OH 44092, or download an order blank from my Web site, www.AskDrGottMD.com. Be sure to mention the title.

I have talked to several members of the medical community who say that this is primarily due to the medication, orthotricyclin. Manufacturers state that five percent of women taking it will develop a blood clot. To me this still means hundreds of thousands of women are at risk.

Please raise awareness about blood clots and birth control.

DEAR READER:
Consider it done.

For many years now, gynecologists and physicians have known about the risk of developing blood clots because of birth control pills. Any prudent physician will tell all potential users of the risks associated and it is then up to the patient to decide if the medication is worth it.

As for orthotricyclin being the main culprit I cannot comment because I am not a gynecologist and never prescribed birth control pills. However, to the best of my knowledge, all hormonal forms of contraceptives carry the risk of stroke due to blood clot formation.

To give you related information, I am sending you a copy of my Health Report “Contraception”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

When I returned home I saw my physician who was concerned about my kidney at first. I asked for a referral to a specialist who ordered another CT scan. Again, it showed I had a mass on my kidney. I was told that it was under 4 cm so it was caught quite early.

My urologist doesn’t want to do anything about the kidney right now despite the fact he feels it is cancer. He says it may have been there a long time and that these things are usually slow growing. He appears to be more concerned with the blood clots in my lungs.

I am scheduled for a follow up CT scan in 90 days and am looking at surgery sometime this fall.

My concern is that if this is cancer, waiting is just giving it a chance to spread. I would like to have the cancer dealt with right now. My daughter is an RN and agrees with my urologist so I am not sure what to think. Can you help? Does the urologist’s approach seem right to you?

DEAR READER:
I am not a urologist but agree with him.

The blood clots in your lungs are the most serious problem you have. They are more likely to cause immediate problems or even death should they move.

Your kidney tumor on the other hand, was found incidentally; therefore, I assume it was not causing any symptoms. Without the blood clot testing you probably would not have even known you had a kidney tumor until it grew or spread causing symptoms. You are lucky that it was caught early.

Follow your urologist’s advice. Stay on the Coumadin.

To give you related information, I am sending you a copy of my Health Report “Kidney Disorders”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

I have factor V, double genetics which makes me a homozygote. There are many people who have had blood clots and are still under diagnosed for this genetic condition. Many doctors are unaware that it even exists. I was diagnosed after a family doctor recommended I have genetic testing following a blood clot in my leg at age 40. I am now 43 and live knowing the health risks of having homozygous factor V. None of them are good.

I am currently writing a college research paper on factor V and have learned how dangerous it can actually be. Please run a column on this matter to help educate those who have been afflicted by blood clots or have a strong family history such as mine does.

DEAR READER:
You seem to be very familiar and have been well-educated in your condition so please permit me to explain to other readers.

In order to understand the condition we must first know what factor V and homozygote mean.

Homozygote is a term used primarily to explain a genetic condition in which there are two identical copies of one gene. Instead of receiving one copy of that gene from the mother and another from the father, the offspring receives three copies, two from one parent and a one from the other. Often the duplicate genes are fused together.

Factor V is a blood clotting disorder of the factor V Leiden gene that controls fibrin production (a substance that is responsible for aiding blood clotting). Heterozygous factor V is rare, occurring in approximately five percent of the Caucasian population and homozygous is extremely rare, occurring in less than one percent. Both forms are seen even less in Hispanic, Asian, African, and Native American populations.

Factor V can increase the risk of blood clots. Heterozygous factor V can cause a five to seven fold increase, meaning five to seven out of 1000 affected individuals. In the homozygous form this is increased to 25-50 out of 1000 affected individuals. Risk may differ from person to person because of other factors such as hormone use, pregnancy, alcohol, smoking or other factors.

I urge anyone with a strong family history of blood clots or those individuals who develop clots before the age of 40 to see a hematologist for further testing. There are certain measures that need to be taken prior to surgery, hospitalization and other situations.

Thank you for writing and informing others of this potentially life-threatening condition. Because it is rare, it may be, as you say, under diagnosed and word needs to get out to those who suffer from chronic or recurring blood clots.

To give you related information, I am sending you a copy of my Health Report “Blood — Donations and Disorders”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

Because I did not understand why this was happening, I made an appointment with a hematologist (blood specialist). She took blood samples and did a genetic profile. Everything came back negative or normal. She concluded that I now have naturally “clotty” blood and I would have to live with it. There was no identifiable cause.

So now, Dr. Gott, my questions to you are: why, after 58 years of being a “normal blood clotter“, did the above happen to me? Will I really have to be on Coumadin for the rest of my life? Should the VA doctors be doing or have done more for me? Your opinions are appreciated.

DEAR READER:
I don’t know why your blood is now clotting in a dangerous fashion. Your hematologist appears to have run extensive tests and ruled out any genetic factors and disorders as the cause. Therefore, you will need to continue the Coumadin for the rest of life. If you were to discontinue it, you would run a very high risk of developing more pulmonary emboli (blood clots in the lungs). You would also be at higher risk for heart attack and stroke if the clots broke off and were carried to your heart or brain. Sticky blood is especially dangerous and your physicians have taken appropriate steps to normalize your blood and reduce your risk of serious consequences.

Another option to explore, albeit unlikely, is lung cancer. In my practice I have seen several cases where pulmonary emboli were the only symptoms of lung cancer. If you wish to explore this option, I recommend you see a pulmonologist (lung specialist). He or she will most likely take a medical history, do an examination and order some imaging studies of your lungs.

Let me know what happens.

To give you related information, I am sending you a copy of my Health Report “Pulmonary Disease”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

In 1997 I was short of breath, had stress tests and a heart catheter which indicated an 80% blockage in one artery and 50% in the other two. In the artery blocked 80%, I had angioplasty and a stent put in. Relief was immediate.

I felt fine until recently. I have arthritis and attributed the pain my left shoulder and upper arm to that. It started approximately two or three months ago. About three weeks ago I experienced extreme shortness of breath, weakness and fatigue. At the hospital I was diagnosed with blood clots in both my lungs associated with a low INR. I was in the hospital for six days on a course of Coumadin and shots of Lovinox. I was discharged when my INR reached 2.1. I take 10 mg Coumadin daily and felt fine for about a week. Then back to the ER with shortness of breath. Tests showed no clots but my INR had fallen to 1.7. I then consulted with my heart doctor and he ordered another stress test. Again everything was fine.

This leaves me in a dilemma. Chest X-rays and CT scans show nothing relative to the lungs and the stress test shows nothing relative to the heart. However, I still continue to be extremely short of breath, fatigued and weak. As far as I know, I was never diagnosed with asthma or emphysema. I used to be a heavy smoker (2 packs per day), but I stopped more than 12 years ago.

Please give me your expert thoughts on this. Should I opt for a second opinion at a place like the Mayo or Cleveland Clinics?

DEAR READER: Yours is a complicated ailment. For example, why did you develop blood clots in your lungs? Could this be a symptom related to a primary lung disorder or a clotting disorder?

Based on the information you gave, I am fairly confident you have a clotting disorder. Your INR (International Normalized Ratio, higher numbers mean less clotting ability, lower numbers mean more clotting ability) is abnormal despite treatment with an anti-coagulant. I recommend you make an appointment with a blood disorder specialist (hematologist). Bring your lab work and test results with you to the appointment. This will provide background information and aid the specialist in his diagnosis. He or she may choose to order more specific tests. If this specialist doesn’t find anything abnormal, I believe that a visit to a top-notch medical facility is entirely appropriate.

You need to know why you developed blood clots and why your INR is consistently low. In other words, your doctors may be treating your symptoms instead of searching for the cause. This needs to be remedied. Let me know how this turns out.

To give you related information, I am sending you a copy of my Health Report “Blood — Donations and Disorders”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.

When I visited my heart specialist following my surgery and told him about the situation, he would only say it was anxiety. He continued to ignore my list of incidences and maintained it was anxiety. I have had anxiety before on various occasions such as when my car was totaled but I never had to stop and take deep breaths. I explained that this only began after my stent surgery and that I thought it was something other than anxiety.

Should I ask for a second opinion or is this normal after receiving a stent? Do I just have to live with it?

I have had a “chemical” thallium chloride stress test. To quote from my family doctor’s report it said “No definite evidence for ischemia on today’s examination”. I hope this helps you to help me.

DEAR READER:
Shortness of breath can be a sign of ineffective contractions of the heart muscle, known as congestive heart failure. It can also reflect anemia and lung problems such as blood clots, emphysema and other disorders. Although your heart workup was normal, I believe that you need further testing and agree that a second opinion is in order. Ask your family doctor to refer you to an internal medicine specialist.

To give you related information, I am sending you a copy of my Health Report “Coronary Artery Disease”. Other readers who would like a copy should send a self-addressed, stamped number 10 envelope and $2 to Newsletter, PO Box 167, Wickliffe, OH 44092. Be sure to mention the title.