What are the contraindications to blood thinners, including anticoagulants (Anti-Coagulants) like warfarin (Coumadin)?

Contraindications to Blood Thinners

Absolute contraindications to blood thinners include active major bleeding, recent intracranial hemorrhage, severe uncontrolled hypertension, severe uncompensated coagulopathy, severe platelet dysfunction, persistent severe thrombocytopenia (<20,000/μL), and high-risk invasive procedures in critical sites. 1

Absolute Contraindications

Blood thinners, including anticoagulants like warfarin (Coumadin), should not be administered in the following situations:

1. Active major bleeding:

   • Active bleeding in critical sites (intracranial, pericardial, retroperitoneal, intraocular, intra-articular, intraspinal) 1
   • Any serious or potentially life-threatening bleeding not reversible with medical or surgical intervention 1

2. Severe cardiovascular conditions:

   • Severe, uncontrolled malignant hypertension 1
   • Pericarditis 1
   • Dissecting aorta 2

3. Coagulation disorders:

   • Severe, uncompensated coagulopathy (e.g., liver failure) 1
   • Severe platelet dysfunction or inherited bleeding disorder 1
   • Persistent severe thrombocytopenia (<20,000/μL) 1

4. Procedural contraindications:

   • Recent or planned surgery of the central nervous system or eye 2
   • Traumatic surgery resulting in large open surfaces 2
   • High-risk invasive procedures including lumbar puncture, spinal anesthesia, and epidural catheter placement 1

5. Pregnancy-related (specific to warfarin):

   • Pregnancy (except in women with mechanical heart valves) 2
   • Threatened abortion, eclampsia, and preeclampsia 2

Relative Contraindications

These situations require careful risk-benefit assessment before initiating anticoagulation:

1. Lesions with bleeding risk:

   • Intracranial or spinal lesions at high risk for bleeding 1
   • Active peptic or GI ulceration at high risk of bleeding 1

2. Recent bleeding events:

   • Active but non-life-threatening bleeding (e.g., trace hematuria) 1
   • Intracranial or CNS bleeding within past 4 weeks 1
   • Major surgery or serious bleeding within past 2 weeks 1

3. Hematologic issues:

   • Persistent thrombocytopenia (<50,000/μL) 1
   • Platelet count <150,000/μL 1

4. Patient-specific factors:

   • End-of-life/hospice care 1
   • Very limited life expectancy with no palliative benefit 1
   • Patient preference or refusal 1
   • Nonadherence to dosing schedule, follow-up, or monitoring 1
   • History of falls or high risk for falls 1

Special Considerations for Direct Oral Anticoagulants (DOACs)

DOACs have additional contraindications:

• Concurrent use of potent P-glycoprotein or CYP3A4 inhibitors or inducers 1
• Active mucosal bleeding or tumors 1
• Serious nausea/vomiting precluding adequate oral intake 1
• Obesity (BMI >40 kg/m² or weight >120 kg) 1

Clinical Pitfalls to Avoid

1. Not recognizing relative vs. absolute contraindications:

   • Some contraindications are temporary and may resolve, allowing anticoagulation to be initiated later 1
   • Regular reassessment of contraindications is recommended 1

2. Misinterpreting laboratory findings:

   • A prolonged aPTT is not a contraindication in patients with lupus inhibitor or lupus anticoagulant 1
   • Antiphospholipid antibodies are actually associated with increased thrombosis risk 1

3. Overlooking alternative options:

   • When anticoagulation is contraindicated but needed, consider inferior vena cava filter placement 1
   • Once bleeding risk is reduced, anticoagulation should be resumed if possible 1

4. Failure to distinguish between therapeutic and prophylactic dosing:

   • Some contraindications apply only to therapeutic doses and not prophylactic doses 1

Blood thinners require careful patient selection and monitoring to balance the risk of thrombosis against the risk of bleeding. Regular reassessment of contraindications is essential, as many are temporary and may resolve over time.