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Coumadin : Teenagers
Coumadin® is a powerful drug which, fortunately, can be used safely if carefully administered and monitored. Teenagers will sometimes need Coumadin® treatment, usually following a heart valve replacement. However, administering any chronic medication to an adolescent has some unique challenges, as will be discussed here.
First of all, it is helpful to understand that it is not easy for anyone to consistently administer medications every day for a long period of time. Forgetfullness, lack of organization, busy schedules, distractions, feelings of resentment, lack of interest, and denial can affect anyone taking chronic medications. However, teenagers and children who take chronic medications often have very serious problems with compliance. Teenagers characteristically enter a state of mind where they question authority and seek their identity and separateness. This quest is often complicated by peer pressure and the need to conform to social trends. The average teenager does not want to act or appear different than his/her classmates or friends. It is common that teenagers deny their illness, the need for treatment, and/or the potential complications of stopping treatment. For example, no matter how intelligent or informed, a teenage patient may still refuse to believe that he/she could suffer a stroke by stopping anticoagulant medication.
Parents need to have an increased alertness with teenage children who are taking anticoagulants. A teenage patient may resist initial treatment, or simply rebel by suddenly stopping to take medications such as Coumadin® Despite potentially life threatening consequences, a decision such as this by a teenager is not necessarily an expression of suicide tendencies. However, if repetitive cessations of treatment occur, the situation should be investigated with a trained professional for the possibility of a hidden depression, with suicide tendency.
Be aware that your child may stop taking their medication, or just start skipping doses. As a parent of a teenager on anticoagulation, keep an eye on the number of pills taken on a weekly basis. If problems arise, make sure you watch your child swallow the pills right in front of you. Do not rely solely on their reassurances that the pills were taken. In addition, recheck the blood test results if you question the reliability of your childs answers. If a patient has stopped Coumadin® for more than 3 days, the ProTime/INR will fall down below the results obtained while on treatment.
It may be necessary to have your child separately counseled on the importance of continuing treatment uninterrupted. A private meeting between your child and the treating physician, and/or trained counselor will help in such situations. Be prepared to frequently reinforce the guidelines for taking Coumadin®, as your child will continue to change his/her attitude and compliance over the upcoming years.
Obtaining blood testing on a rebellious teenager can be a problem. Repeated ProTime/INR measurements cannot be done if the patient won't permit someone to draw the blood. This is a delicate area, and requires the parents sensitivity and judgement. Most often, the teenager will comply with blood draws, but not always when asked or expected. Some physicians use a "finger-stick" technique for measuring ProTimes. Check and see if the "slide test" is available in your clinic or region. If so, this might make it less problematic to coax a teenager in for blood testing.
Another of the chief concern for maintaining chronic anticoagulation in a teenager involves contact sports or other vigorous activities. Contact sports such as as football, rugby, gymnastics and downhill skiing are very popular in the adolescent age groups. Peer pressure and social rewards are often motivations for a teenager to participate in these activities. However, contact sports are more hazardous to the patient on anticoagulant medications. Head trauma can induce bleeding inside of the skull, with potential serious consequences. Consider directing your child to sports with less physical contact, such as golfing, tennis, cycling, swimming, etc. There are many other choices that are less dangerous and still very personally rewarding. Strive to build your childs individual self confidence, so that he/she does not rely on acceptance from their sports team to achieve their personal goals and satisfaction.
Even in non-contact sports spontaneous muscle bleeding can occur during periods of vigorous exercise. Symptoms include soreness followed by bruising and/or yellow to purple discoloration in the extremity. Most of these hemorrhages will resolve without treatment. Hemorrhage into joint spaces, such as the knee and hip joint can lead to acute, painfull joint swelling. After a significant bleed into a joint space, needle aspiration should be performed to drain off the blood. Should any of these events occur, the ProTime/INR should be quickly rechecked to verify the level of anticoagulation at the time of the event.
For teenage daughters taking Coumadin®, the potential for pregnancy raises another set of concerns. Coumadin® taken during early pregnancy does cause birth defects. It is paramount that any young woman taking Coumadin® be counseled and informed of the possibility of birth defects should pregancy occur during treatment. A special section of this Learning Center presentation is devoted to the issue of Coumadin® and Pregnancy. In summary, prevention of an inadvertant pregnancy is very, very important. Not every parent wishes to believe that their daughter can or will go against their advice and experiment with sexual relationships. However, the laws of nature are strong, and many adolescents do engage in sexual relations, whether their parents know about it or not. Thus it is very important to take additional precautions in preventing an unwanted or unplanned pregnancy in a patient on Coumadin®. Reconsider the benefits of educating your daughter on both the risks of pregnancy to the fetus and the possible means of effective birth control. Don't rule out birth control if your daughter needs to take Coumadin®. There are now many possible means of birth control, and each should be investigated and strongly encouraged in any young woman taking Coumadin®. Utilize educational services like Planned Parenthood before an accidental pregnancy occurs. Prevention is far better than dealing with the consequences after a pregnancy has occurred.
Whatever strategy you take with your teenage Coumadin® patient, be preparred to reinforce the same concepts and discipline many times. It takes repitition (and time) before a teenager comes to grips with a responsibility of this magnitude. Most teenage patients prove to be very successful Coumadin® recipients, but not without additional time and effort.
Additional Coumadin Sections:
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