Safe physical activity while on coumadin

August 15, 2012 2:57 PM

How cautious do I need to be with physical activity while on blood thinners (coumadin/warfarin)?

I was diagnosed with a deep-vein thrombosis (DVT) in my left leg three months ago and now another blood clot has appeared in my right leg. The doctors don't know what's going on with me yet, but I will be taking coumadin/warfarin for at least three to six more months, and possibly indefinitely. It could even be for the rest of my life. Coumadin is a blood thinner, which means blood doesn't clot as quickly as normal. People on the drug tend to bruise more easily, and cuts can take longer to stop bleeding. They say injuries that might otherwise be minor can be more dangerous, even fatal, for people on coumadin. So recommended physical exercise include low-key activities such as walking and swimming.

I like to walk the dog, and I swim once a week, but I don't want to spend possibly the rest of my life like a delicate flower. How careful do I really need to be?

From my online research, it seems what I really have to worry about is a head injury. So I'll faithfully wear a helmet when riding a bike and stay clear of swinging baseball bats. But what about other activities?

1) What if I'm playing volleyball or ultimate frisbee and throw myself on the grass for a save or a catch?

2) What if I'm playing a friendly game of basketball and accidently get an elbow in the eye?

3) What if I fall off my bike and bang up my body?

Maybe I'll bruise more easily, but I can handle bruises. Is there any greater risk than that? If so, what merits a call to the doctor or a trip to the emergency room?

I realize the best person to ask these questions to is my doctor, but it's hard to get more out of him than a general warning to be careful and avoid risks. At the same time, I see severely restricting my physical activity as risky in its own right because of the dangers of an inactive lifestyle (increased likelihood of heart disease, diabetes, etc.). Being less active is also bringing down my mood, mental health, and quality of life.

So to conclude, please help me realistically assess the dangers of different physical activities while on coumadin. I don't want to take foolish risks, but I also don't want my treatment to unnecessarily weigh me down.

posted by Leontine to health & fitness (9 answers total)

How careful do I really need to be?

Isn't this something you should ask your doctor about? I mean, if this is true...

it's hard to get more out of him than a general warning to be careful and avoid risks.

...then get a different doctor.
posted by valkyryn at 3:01 PM on August 15, 2012 [1 favorite]

When my mom was on Coumadin after surgery, her doctor put it this way: hiking through a local park is fine, back country hiking might not be. Likewise, biking around town is probably fine, downhill mountain biking is right out.

Not only will you bruise easily, but 1) you'll bleed a lot from minor cuts and 2) you may not stop bleeding on your own, so you'll want to avoid situations where you'll be far from medical attention or where it's more than likely that you would suffer "minor" cuts and bruises.
posted by Oktober at 3:03 PM on August 15, 2012 [2 favorites]

I'm not on blood thinners, but I do have a bleeding disorder. I've generally been advised to avoid contact sports and adventure activities where there's an elevated risk for serious injury (especially blows to the head or chest), but that non-contact/non-adventure activities and fitness are totally fine (e.g., basketball and rock climbing BAD, yoga and weights GOOD).

Also, I presume you've already been warned about taking other medications that will thin your blood further. If not, you must avoid NSAIDS for pain or inflammation, whether OTC (namely, ibuprofen, aspirin, and naproxen) or Rx, unless you have your doctor's OK. On a practical level, this means for day-to-day pain management, your OTC option is basically Tylenol. Note that many herbal supplements are also blood thinners, and should similarly be avoided.
posted by scody at 3:18 PM on August 15, 2012

Be specific with your doctor (though it sounds like getting a new one is probably in order) about the kinds of things you want to do. I have a medical condition that is rare in people as young as me; my doctors repeatedly told me I could do "whatever you want to do, within reason". When I'd ask them, "So, can I play softball with my school's intramural team?" they'd look startled and say it was probably not a good idea. "Okay, my friends are going indoor rock-climbing next weekend. Can I join them?" "Uh...."
Doctors who frequently treat with Coumadin are probably used to seeing older patients and are thus just not used to thinking about the risks a younger, more active person would want to take. The more specific you are with them, the better an answer you're likely to get.
posted by katemonster at 5:19 PM on August 15, 2012

Based on an unexplained DVT in a 30yo in the family:

1 - get a doctor who knows about warfarin therapy. A lot of DVT/warfarin expertise exists with community nurses, too.
2 - be prepared for up to a few months during which you'll have to eat a relatively constant diet and have a lot of blood draws whilst your warfarin dose gets adjusted. The therapeutic range is very narrow and varies a lot person-to-person. It can also be very tiring.
3 - consider a medic alert or obvious identifier that you're on anti-coagulants, in case of accident.
4 - You'll bruise like anything, and you might want to lay in a stock of small elastic bandages and thick gauze to mop up the blood from trivial cuts. Elevation is your friend.
5 - You do want to avoid impact activities where internal bruising or bleeding might be a possibility, because you won't see it or feel any different for a dangerously long time. But swimming, on road cycling, running, gym work and long walks were all fine: better than fine actually, and good for post-DVT blood vessel growth.
posted by cromagnon at 5:30 PM on August 15, 2012

My husband has been on coumadin for 3 years.... he has an auto-immune that makes his blood to thick and caused a stroke at age 37. He has fully recovered but keeping his coumadin regulated has been tricky. No real problems with bleeding from cuts and such (we've been lucky I guess) but we have had to really watch his INR (blood thickness). We ended up buying a home machine, expensive but worth it to keep an eye on things.....it can change overnight. Do get a medic alert bracelet....paramedics will NEED to know that you are on blood thinners in an accident. Watch your intake of greens and vitamin K and follow your Dr's instructions.... Best of luck...
posted by pearlybob at 6:56 PM on August 15, 2012

I would actually recommend talking to a pharmacist about this. A lot of healthcare facilities in the US are moving to a model where pharmacists do all the monitoring and dosage adjustments with warfarin. Pharmacists know a lot about warfarin, and some spend their whole days doing anti-coagulation therapies. It would be worth it to find a pharmacist who could spend a few minutes answering your questions.
posted by CutaneousRabbit at 9:52 PM on August 15, 2012

It seems to me that the clotting disorder is what should be worrying you more than the warfarin. If you have a clot formed somewhere and you take a good fall and it breaks free, that's not a good thing. I would avoid any activity that has a risk of impact until you get everything figured out.

Ask your doctor or pharmacist about foods with Vitamin K and why you should be very careful about them.
posted by gjc at 7:31 AM on August 16, 2012

Obviously, IANYD, but I've been on coumadin for the past eight years as a young adult (and will be for life unless a better medication comes out), so here's what I've learned & what works for me. This also follows the advice of my current hematologist, who I think is fantastic.

1. Stay as active as you like, but don't take stupid risks. What constitutes a "stupid risk" will vary from person to person, but in the past year I've done the following with the full knowledge of my hematologist: backpacking trips at elevation (with others and with a well-stocked first aid kit everyone knew how to use), skydiving, bungee-jumping, lots of skiing (*always* with a helmet), white-water rafting on Class II and III rapids, and lots of surfing (on soft boards). I wouldn't personally choose to play any contact sports, go into a mosh pit at a rock concert, or use a bike for my daily commute here in San Francisco. I'd definitely wear a helmet if I went on rougher rapids or surfed on a hard board.

For me, it comes down to wanting to enjoy life, but knowing that I'm at a greater risk of bleeding internally if I suffer major trauma to my torso or (worse, imo) bleeding cranially if I get a nasty knock to my head. So I watch out for activities that could lead to those sort of issues, and either opt out or approach them very cautiously. Bruises suck, but they fade with time and aren't a major medical risk when you're young and otherwise healthy.

2. Let others around you know what the risks are should you get injured and aren't able to communicate that yourself to them or medical personnel. So my friends, coworkers, and activity partners all get a heads up that I'm on blood thinners, and at a much greater risk to bleed internally or have head trauma from injuries. When I'm traveling or in an area alone, I wear a simple medical bracelet that says I'm on warfarin (since that's the internationally-known generic of coumadin), and lists my history of DVTs and a PE.

3. Pay attention to how much you're bruising and/or bleeding from simple cuts, and keep that in mind for your physical activities. As you've probably realized by now, coumadin is a very finicky medication, and a minor change in your diet can change your PT/INR unexpectedly between blood tests. I nicked my finger last night while chopping vegetables for dinner, and it took quite awhile to stop bleeding - much more than normal for me. So I'm probably running a bit higher than my target INR of 2.5 - 3.0 - which isn't surprising, since, looking back, I haven't been eating as much leafy greens as I normally do. So tonight it's extra spinach, and I'm going to be more mindful of my physical activities and diet until I check my INR next week and see whether I'm a bit high or not. If some *serious* bruising starts occurring then I'll check my INR immediately.

4. Speaking of getting your INR checked, if you end up on coumadin long term, check into getting a personal home-monitoring INR machine - some insurances will pay for it and some won't. My previous insurance didn't, my new insurance did, and it's awesome to have the ability to check your INR quickly & at home rather than dragging yourself to the doctor's or a lab.

Now, to answer your specific concerns (reminder - IANYD):

1. Volleyball and ultimate frisbee sound absolutely fine, although you may get some wicked bruises or abrasions if you throw yourself onto a gym floor for a save. If you end up running into something *hard* by accident while playing, like a fence post to the stomach or whatever, pay attention to how you're feeling and keep an eye out for symptoms of internal bleeding.
2. Again, elbow to the eye sound painful, but not medically dangerous. You'd likely get a nice black eye, though.
3. With bikes, it's a little more dangerous, since you're going at high speeds, generally around hard objects, and, more importantly, there are plenty of cars around you on the roads. I personally wouldn't bike regularly on busy roads or in a city - just too much risk of an idiot driver- but I wouldn't hesitate to go on regular bike trails with a helmet. I've never really done downhill mountain biking, so I'm not keen on picking it up now - I don't feel skilled enough to evaluate the risks and pull back before I put myself in a situation where I might seriously injure myself.
4. If you run into something hard enough with enough force, you might move on from a simple bruise to a hematoma. I got a nasty one this January on my thigh after I tripped and fell against the wooden stairs in my house. It was a *spectacular*, painful bruise that lasted about two months, and the blue coloration and slight sensitivity still hasn't quite gone away eight months later.

Okay, I think that's enough rambling from me. If you've got any questions, feel free to shoot me a memail.
posted by Gori Girl at 8:46 PM on August 16, 2012 [1 favorite]