Heartfelt with Dr Melissa Walton-ShirleyView all posts »
Dabigatran (Pradaxa) thus far: Still your "new best friend"?Apr 17, 2011 08:46 EDT
There are times when you instantly "fall in love" or "fall in like" with a new significant other or a potential friend. Will you make plans for another lunch date or a movie, or will you find that you can't wait to pay the tab and get back to work? My experience with dabigatran (Pradaxa, Boehringer Ingelheim) as "my new best friend" in the anticoagulation world has been largely positive, but there have been some bobbles along the way.
What I like about Pradaxa:
1. Getting to turn off the heparin the moment the pill is swallowed and allowing those afib patients to go home without an (enoxaparin) Lovenox bridge.
2. Starting patients in the office on Pradaxa without having to admit the patient for IV or sub-Q anticoagulation.
3. Untethering the patient from the monthly pilgrimage to the protime clinic.
4. Feeling less anxious about intracranial bleeding with Pradaxa vs (warfarin) Coumadin.
5. The (what I am sure is a short-term flurry of) samples available prior to asking the patient to make the switch.
6. How interested the reps are in side effects, adverse events, and ease of reporting.
What I DON'T like about Pradaxa:
1. Occasional GI upset.
2. Worrying about what the exact GFR is in the elderly (so I've ordered a few 24-hour urines just to be certain of how to dose it).
3. Trusting the 75-mg dose. An 89-year-old female suffered a small stroke about three weeks after I switched her, resulting in diplopia. I have a feeling I underestimated her GFR.
4. How uncomfortable surgeons, especially neurosurgeons, are with estimating the necessary time to be off it prior to surgery.
5. How it came to market without an exact measurement tool of anticoagulation status.
6. The absolutely ridiculous cost.
7. The occasional mistakes I see others make with it, like forgetting to stop the heparin when it's started or starting heparin when the patient is on it. Pradaxa doesn't yet catch the same attention as the words "warfarin or Coumadin" do on an MAR.
8. Handling the anticoagulation for a STEMI while on dabigatran. Funny, I really haven't dealt with that one yet in all these months.
9. Twice-daily dosing.
The most concerning issue with dabigatran involves the particular patient that frequently suffers a TIA or small CVA whenever their INR is less than 2.0. I'm not certain it's really as good an option as warfarin for those folks when it comes to the occasional necessary interruptions in life. I like knowing exactly when to bridge with enoxaparin and the comfort of being able to say, "Your INR is 2.0, so you are safe. You can stop your Lovenox." Case in point: 80-year-old with upcoming neurosurgery. The neurosurgeon had no prior experience with it. "Three to five days" of interruption is the standard answer. Well, is it three or is it five? Is their GFR 29 or is it 40? I don't like that gray zone. Will he bleed if it's three days off or will he stroke if it's five days off without a bridge? For most patients, it's not critical; for some, it is, such as if someone is going to be operating on your spinal cord and you are a patient with a penchant for frequent TIAs.
I already had a potential "mini Pradaxa disaster." An ENT called me to say that my patient's nose was "smashed all over his face." This 86-year-old who would never come to protime clinic with afib and a history of transient aphasia fell headlong onto his porcelain sink. So what's a girl to do with this gentleman? I had just talked him into starting Pradaxa, and when I did, I confess there were "high fives" all around in the protime clinic. We held it for five days, then operated, and he did fine, but not without a little nail-chewing on my behalf. For those few days, I felt as if my patient and I had been pushed out on a tightrope, notwithstanding my fear of heights, with no INR to hold onto.
So are we better off with or without dabigatran? Trials suggest we are far better off, patients love it, and I love it . . . well, most of the time. However, I wish in our haste to bring it to market, we had applied the same haste to the development of a readily available and easy-to-use measurement tool to confirm the exact status of anticoagulation. As with all anticoagulants, they've been wonderful "friends," but add the wrong circumstances, and they can become your worst enemies. For now, I'm "booking more luncheons" with my "new best friend Pradaxa," but every now and then, I slip back to my "old best friend Coumadin." For the sake of my patients, because they are the individuals we must acknowledge they are, I'm still trying to balance my relationships with both.