DEAR DR. ROACH: In November 1997, while traveling, I had a pulmonary embolism. I was treated with urokinase to the lungs and a vena cava filter was placed. In November 2006, I had a CT scan of my abdomen. The report says there is an IVC filter in place. A posterior limb appears to have extended beyond the caval wall consistent with perforation. I am now seeing ads on TV that people with an IVC filter should be concerned and that the Food and Drug Administration considers them dangerous. I am 62 years old and never had any problem. Should I be concerned? Are there any studies being done on the long-term effects of these filters? β H.L.
ANSWER: The inferior vena cava is the large vein that receives blood from the legs, pelvis and abdominal organs and returns it to the heart. A blood clot in the legs or pelvis must pass through the vena cava if it is going to the lungs, a potentially life-threatening complication called pulmonary embolism (an embolus is any foreign material, such as cholesterol, blood clot or air that moves from one part of the body to another). The IVC filter was designed to capture the clot, preventing it from going to the lung. Over time, the body dissolves the clot on its own.
The vena cava filter is an alternative to anticoagulation, such as warfarin (Coumadin) or a newer agent like rivaroxaban (Xarelto). The vena cava filter often is used in people who will need anticoagulation forever; this can be due to recurrent clots, an unmodifiable risk factor or sometimes a life-threatening clot (what it sounds like yours was). Compared with not getting treatment, both anticoagulation and IVC filters are effective, reducing the risk of pulmonary embolism to about 2 percent per year.
There are complications of IVC filters, including penetration of the IVC wall by the filter legs, which is what your CT scan shows. In most people, this doesnβt cause problems, although it can rarely cause bleeding or injury to the bowel wall. Other complications include the filter moving into the chest, fracture and infection, all of which happen less than 1 percent of the time. The filter itself can cause a blood clot, at a rate of 1 to 2 percent per year. Because any IVC filter does affect blood flow, there is a small increase in the rate of blood clots below the filter (in the legs or pelvis), but these are still protected from going into the heart.
The complication rate needs to be compared against the alternatives, including doing nothing and using anticoagulation. For most people with a long-term need for treatment to prevent blood clots, IVC filters are a reasonable choice.
DEAR DR. ROACH: I take omeprazole 40 mg. My new gastroenterologist just changed the dose to 20 mg. Unfortunately, just before this, I had ordered a 90-day supply of the 40-mg capsules. I pulled apart one of the capsules and found that it contains granules, not powder. Can I just divide the granules? I would hate to throw away all the 40-mg pills. β H.B.S.
ANSWER: Without a coating, omeprazole is destroyed in the stomach, so manufacturers use a coating to delay absorption until the medicine reaches the intestine. Prilosec OTC tablets cannot be broken. If the capsules you have contain granules, itβs likely that the granules themselves are coated, so you could divide the contents into two. However, you should speak to your pharmacist to be sure.
DEAR DR. ROACH: I am a 67-year-old woman in excellent health except for having rheumatoid arthritis, which does not restrict me. I exercise daily, and Iβm not overweight. My bone scans are very good. My gynecologist, whom I had been seeing for over 20 years and who specialized in menopausal women, recently retired.
She strongly recommended that I continue her prescribed hormone replacement therapy, which I have been on since menopause for hot flashes. At my request, Iβm on the lowest dose of progesterone and a patch. There is no family history of breast or other cancers, no heart disease, blood clots or osteoporosis.
My plan was to see my internist for any gynecological issues as opposed to finding another gynecologist. She tactfully questioned why I am on HRT at all due to the associated risks. I explained that my previous doctor had been a strong advocate and believed that the positive benefits outweighed the risks in my case. My gynecologist had felt that HRT helps to keep all organs healthy: mental acuity, bones, heart, etc. I have read up on this topic, but Iβm unsure as to what to do. β M.Z.
ANSWER: HRT has risks and benefits, and a personβs personal and family history, as well as her preferences, need to guide the decision. You are taking an estrogen patch, about which our data is less certain.
Combined estrogen and progestin treatment is associated with a small increase in the rate of breast cancer and a larger increase in risk of blood clotting, but it brings a benefit in hip fractures and colon cancer. There is no good evidence that HRT protects against or increases risk for dementia.
The effect on heart disease is more controversial, with some data showing that women younger than 60 (especially those who begin HRT at onset of menopause) had no harm and some possible benefit from HRT, whereas those who began HRT over 60 showed an increase in heart disease risk.
As a woman ages, her risk for heart disease increases, and the potential for harm likely also increases.
Most authorities feel that short-term HRT is a reasonable option for women around the time of menopause. However, you are more than a decade past menopause, and I would not recommend continuing the HRT. At this point, you are using it to prevent disease, and there isnβt enough evidence to support that.
DEAR DR. ROACH: Ten years ago, I had an embolism and have been on blood thinners ever since. The levels are checked monthly by bloodwork. I feel I should be supporting our local Red Cross blood clinic. Is it safe for me to be a blood donor? β J.V.
ANSWER: The Red Cross, like most blood suppliers, does not accept blood donation from people taking anticoagulants, like the warfarin (Coumadin) you probably are taking. Thatβs also the case with newer anticoagulants, such as dabigatran (Pradaxa), rivaroxaban (Xarelto) or enoxaparin (Lovenox). People taking aspirin or Plavix may donate blood. There are other medications that can prevent people from giving blood, such as finasteride (Proscar or Propecia).
I admire your spirit. If your meds preclude you from donating your blood, you can help by donating your time to your favorite blood bank, or perhaps someone reading this column will be inspired to help save a life by donating blood in your place today.
