The relative cost of the novel replacements for Coumadin should consider the $90 per month Coumadin co pay. That is the cost of monthly anti coagulation clinic visits in my area. This is the anti coagulation clinic rice bowl. They don't want to lose that.

I have used both Pradaxa & Warfarin – I took Pradaxa for 6 months from Aug ‘11-Jan ’12 and have been taking Warfarin for the last 3 months following heart surgery to replace my aortic valve & which included the Cox IV maze procedure to restore sinus rhythm which has been successful.  I had no adverse affects from Pradaxa but found dosing twice a day inconvenient.

 

 Re Warfarin I self test once a week and over 3 months I have only been slightly out of rang twice. My range is 2-3. One time I was @ 3.2 & the other @ 1.8. I eat & drink whatever I like & adjust my dosage if & when required.

 

My daily dosage is currently 2mg. It has never been greater than 2.5mg. I call in my INR weekly to my doctor but use an online calculater to adjust my dosage if necessary. This calculator has proven 100% reliable for me.

http://www.pace-med-apps.com/CoumCalc.htm

 

I much prefer Warfarin as I am able to adjust my dosage as needed – I eat & drink whatever I like so no advantage here to the new anticoagulants. My dosage is very low and my INR is consistently 2.2 – 2.5. Equally important I am able to also take any vitamins or pharmaceutical drug that may cause blood thinning & adjust my Warfarin dosage accordingly.

 

For me no antidote re bleeding, the relatively short time (under 3 years) the new anticoagulants have been on the market are major negatives. I believe 3 years is the minimum time necessary to se what adverse events are reported that are not found from FDA approval trials.

So the debate continues with emerging anticoagulants to replace warfarin. Some clinicians clearly want black and white answer and that is where the problem lies. All three new anticoagulants have positive and negatives to them and so does warfarin? So how does a clinician balance the risks and benefits?

I think we should go back and revisit the definition of evidence-based medicine where "patients" are put at the centre of all clinical decision making. Why not present the data to the patient and let them make the decision? I fail to grasp the need to jump on the bandwagon of the new anticoagulants too quickly. If patients are well managed on warfarin and happy about it then perhaps new agents may add any superior advantage.

 Recently, we discussed pros and cons of dabigatran (and yes MI risk is there!) to a 83 year old man and his spouse. The patient has MCI and was well managed on warfarin; after explaining risks and benefits of each agent, the couple were happy to continue with warfarin. On contrary, another elderly gentleman with Parkinson's decided to go with dabigatran because he was sick of INR testing. 

 We should provide the patient with all information (takes extra 5 minutes) and let them make the decision; after all, that is why are in the health profession, to "help" our patients to manage their health, not to be their parents!

 

Patient perspective:  over the past four years, I was put on warfarin for pre- and post-ablation anti-coagulation (durations were 3-6 months for each of my three procedures).  I had problems staying within INR therapeutic range and various side-effects that impacted my quality of life and work.  Also, the INR testing was  time-consuming, as the Anti-Coagulation Clinic requires an appointment. 

About three months ago, three months after my third ablation, I started rivaroxiban, as prescribed by my EP (the local cardiologist refused to prescribe it for unstated reasons).  For the first three days, I had a pretty bad headache, but since then I've had no discernable side-effects.   Taking the pill once/day is not hard to remember.  Also, I'm relieved not to have to worry about food interactions or being out of INR range.  My main concern, as a very active endurance athlete, is the lack of antidote.  Any idea if and when an antidote will be developed?

Dr Ansell's argument centered around non-compliance with medication regimen is a compelling one.  The most common cause of medication failure overall is that the patient is simply not taking it, due to costs, forgetfulness, lack of insight about their disease and the importance of the medication, fear of the medication, or even obstinance.  Any oral competitor that is a once daily regimen can compete with warfarin's administration advantage.  However, the lack of the physician being able to document compliance with INR results and the lack of an available antidote are negatives that cannot be ignored.  There is a place for all of these medications.  It's just that time and good science will be required to identify how to best prescribe them.

The choice of anticoagulant needs to be individualized and whether or not an INR is required should not determine the need for monitoring. Some physicians might find the new anticoagulants attractive because they can write a prescription and feel their job is done. No more pesty INR's to deal with! However we know that 50% of the time, patients do not take medications as prescribed. Patients who have their anticoagulation monitored by an Anticoagulation Service receive the benefit of ongoing patient education including the reinforcement of the risks of non adherence, the monitoring of drug interactions with prescribed and OTC medications such as NSAID's and ASA, monitoring for signs and sypmtoms of bleeding, the need to discontinue anticoagulation prior to certain but not all procedures, the best way to do so, etc. When deciding which anticoagulant to prescribe many factors should be considered including renal function, liver function, history of bleeding, compliance, cost, follow up, and patient preference. It is always prudent to make thoughtful decisions when choosing to start and/or change anticoagulants and to continually monitor patients receiving any of these benefial but potentially dangerous medications.

I have change my patients to the newer anticoagulants if their time in range is less than 60% and they have adequate renal functions.  Warfarin benefit is tied to time in range while the newer agents do not vary as much.  I have personally been on warfarin and dabigatran.  Dabigatran gave my some minor bleeding side effects and I currently back on warfairn.  All these agents are good if we do the correct patient selection.

With an increasing number of choices available to us, we should be able to lower our threshold for prescribing anticoagulation, particularly for at risk patients with atrial fibrillation.  We'll have the opportunity to "personalize" our anticoagulant choice if we wish.  It's important to remember that all of the novel agents, so far, have a lower risk of intracranial hemorrhage than warfarin.  And some have superiority to warfarin for stroke reduction in AF.  But the most important point is to ensure that all patients for whom anticoagulation is indicated receive it, unless the bleeding risk is extraordinarily high.--SZG