Health Q&A: shoulder pain causes and taking dabigatran for atrial fibrillation

Dr David Roche / 03 April 2014

Saga Magazine's Dr Roche answers questions about shoulder pain and whether a patient with atrial fibrillation should take Pradaxa or warfarin.



Why does my shoulder still hurt after a fall?

I am in my seventies and three months ago I tripped and fell, banging my arm on the pavement. A doctor examined me and said I had not broken anything or dislocated my shoulder. But it still aches from time to time and I have some restricted movement. Is this to be expected and should it improve with time?

The shoulder has one of the widest range of movements of any joint in the body. To achieve this it is an inherently unstable joint which is held and adjusted in position by a complex arrangement of muscles, tendons and ligaments.As a result it is quite prone to injury and those injuries more commonly affect the soft tissues rather than the bone structure or the joint. It is very likely that these structures are causing your current shoulder pain and restricted movement.

If the shoulder problem is gradually improving then I would not be too concerned, they are always slow to settle. However, if there is increasing stiffness and a reducing range of movement then the shoulder joint needs to be examined more carefully. If a specific diagnosis can be made then a targeted joint injection or a physiotherapy course may be appropriate. Sometimes a ‘frozen shoulder’ or other long-term problem can develop following shoulder injuries and timely intervention through your GP or a physiotherapist can produce a quicker resolution of the problem.

Should I take dabigatran for atrial fibrillation?

I have atrial fibrillation and two slightly damaged valves. I have been prescribed Pradaxa as being safer than warfarin, but I know this drug is controversial as the blood thinning is irreversible. What if I need major surgery later in life or have an accident? It also interacts with many other medicines. Should I ask to go back to using warfarin?

Pradaxa (dabigatran) is one of a group of new blood thinning agents which are used in patients prone to developing blood clots in their blood vessels (thrombosis or embolism).

Atrial fibrillation is an irregular heart rhythm in which patients are known to be more prone to developing blood clots. Typically these result in a stroke but occasionally the blood clot can cause damage elsewhere in the body.

Warfarin has always been the standard treatment for this condition and is given in sufficient doses to make the blood clotting time two or three times longer than normal, thus substantially reducing the chances of a blood clot developing. The new drugs are as effective as warfarin in preventing stroke, with the caveat that as with all new drugs the evidence of effectiveness and safety is still being collected.

The side effects of these drugs are primarily those of major bleeding and, again, the risks of warfarin versus the new drugs is largely similar. Warfarin has a reversing agent available (vitamin k) if bleeding has occurred but it still takes several hours to work.

There is no reversing agent for the new drugs, they have to be left to wear off over time. It is rare for this to be a serious issue for surgery, supportive measures for the bleeding can be used to stabilise the patient until either the effect of warfarin or dabigatran has worn off.

Other drugs can interfere with both groups but as long as care is taken with other prescribing this should not be a problem.

The major difference between warfarin and dabigatran is that warfarin is inherently a less stable drug and needs constant blood test monitoring. This is not necessary for dabigatran. As you can see this is a finely balanced argument and current practice is to use warfarin unless there are specific difficulties controlling it or particular reasons why it might not suit the patient. Dabigatran is then used as an alternative.


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