Ask Dr. Stephan Moll

These questions have been submitted by folks on the mailing list and answered by Dr. Moll, Director of the Thrombophilia Program at the Carolina Cardiovascular Biology Center, Department of Medicine, Division of Hematology-Oncology, UNC Chapel Hill (North Carolina, USA). Why am I doing this?

63. Various questions II

Q1: "My Gyn said one of the most common things for factor V Leiden was that we have a higher rate of fluctuations with our INR while on coumadin®."

A1: I have never heard, read, or observed that and I believe this is false information. The way factor V and factor V Leiden function in the body and in the lab test tube when determining the INR, I can not imagine any reason why INRs should fluctuate more in patients with factor V Leiden.

Q2: "I have had two pleural effusions and my doctor says that he thinks they are related to my having factor V Leiden. Have you heard of others who get pleural effusions due to FVL? I also have lupus anticoagulant."

A2: Patients with pulmonary embolism sometimes develop a pleural effusion (= fluid around the lung) because the outer layer of the lung (= pleura) gets irritated (inflamed) due to the PE. Since patients with factor V Leiden have an increased risk for PE, this could be the link between pleural effusion and FVL. However, in the absence of a PE, I do not see how factor V Leiden and pleural effusion could be connected. However, patients with lupus anticoagulant can have a variety of autoimmune inflammatory problems, such as arthritis, pleuritis (= inflammation of the pleura) or pericarditis (= inflammation of the outer layer of the heart). These inflammations often lead to fluid excretion (joint, pleural or pericardial effusion). The lupus anticoagulant appears to be a more likely explanation for the above patient's 2 episodes of pleural effusion.

Q3: "I am a 37 year old female who had a minor surgery that went bad fast. I ended up having a PE. I have been tested to be positive for factor V Leiden mutation, resistance to protein C, and anticardiolipin antibodies. Does the fact that I have 3 abnormalities increase my risks of re-occurrence of clots?"

A3: The above patient likely does not have 3, but only 2 clotting abnormalities. There are 2 ways to test for the factor V Leiden mutation: (a) with a genetic test, and (b) with a functional, coagulation test called APC resistance test - see Q/A 31.

The risk of recurrent venous clot in patients whose first venous clot was spontaneous, i.e. not triggered by surgery or trauma, and who have no detectable clotting disorder (thrombophilia) is 20-25 % over the 5 years following discontinuation of warfarin. The risk of recurrence is not significantly higher in patients who are heterozygous for factor V Leiden (also see Q/A 9). However, the risk is significantly higher in patients who have the antiphospholipid antibody syndrome (patients with repeatedly clearly positive anticardiolipin antibody levels of at least moderate levels).

Q4: "I am a 57 year old male with factor V Leiden. At 30 years old I had a pulmonary embolism and have since had several other clots. Because coumadin has numerous side effects, is there any other solution, or another medication that can be taken without being at risk for bleeding if you fall, get hit, or undergo operation?

A4: No, there is no other solution. There are presently only 2 types of blood thinners, that can be taken as tablets: the group of drugs called coumarins (warfarin, phenprocoumon, acenocoumarol) and indandiones (Anisindione = Miradon®, Phenindione). Both drug types thin the blood and put patients at risk for bleeding. Compared to warfarin, the risk of bleeding with heparin and low molecular weight heparin is similar; however, heparins do not exist as tablets, just as drugs to be injected under the skin. The new oral blood thinner Exanta® (=Ximelagatran; see Q/A 2) may come onto the market in 2005 (if the FDA approves it); FDA approval may occur in 2004. Studies published so far show that it has a similar risk of bleeding as warfarin.

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