Great blog.  Very thoughtful and balanced presentation of the data.

One clarification to make: the TTR is calculated using a linear interpolation so it does not consider someone out of range until the next INR is draw.  For example, if INR is 3.2 today and next INR is checked in 4 days and is 2.8, the INR is assumed to have gone from 3.1 to 3.0 to 2.9 to 2.8 over the 4 day period and the TTR would be 75% (i.e., 3 days in range and 1 day out of range).

One question: given the short half life of rivoraxaban, are you concerned about the once a day dosing at all?

Thanks. 

Wow, I think that you missed some key points with a weak analysis.

It's clear that Rivaroxaban has a better renal strategy since the approved dose was actually used in the trial, unlike Dabigatran.

Actually, Dabigatran has more troublesome drug-to-drug interactions, such as with anti-arrhythmics like amiodarone.

 You did not even mention the increased rate of dyspepsia since with Dabigatran.

 You also did not mention the recent failed medical prophylaxis trial with Dabigatran or the successful ACS trial with Rivaroxaban.

Clearly, there are not great differences between these two medications in stroke prevention, except for their completely different MOA, but once a day is a big deal. Renal dosing for patients with moderate dysfunction is helpful. Dyspepsia, if avoidable, is also an advantage.

You kept harping on the evening meal.  Rivaroxaban's absorption is affected by food, not the time of day, but only at the 15 & 20mg dose.

Steve, thanks for your comments

I agree that dyspepsia and GI bleeding are Dabigatran's most significant limitation and I think its the most improtant difficulty in choosing the pros and cons of the soon to be 4 drugs for thromboembolic protection in AF.  I thank you for emphasizing that point.

I dont agree based on my reading of the package inserts about the drug interactions of Pradaxa and Xarelto.

I don't agree with your statement:  "It's clear that Rivaroxaban has a better renal strategy since the approved dose was actually used in the trial, unlike Dabigatran"

All the trials did not test patients with the CrCL that was appoved by the FDA. All 3 trials excluded patients with CrCL < 30.  I dont think it makes sense to use either of the 2 new approved drugs with CrCl < 30 since we have no data on those patients.  The specific statement from ROCKET AF supplement on trial EXCLUSION in NEJM is Calculated CLCR <30 mL/min at the screening visit.

 I do think the evening meal issue is significant for my patients - perhaps different for yours - most of my patients do not eat their evening meal at a consistent time each day, so I think this will be a potential problem to monitor with regular discussions at follow-up or ignore and hope for the best, but either way a concern since we have no way to monitor levels - thanks again for your post.

Very imformative, thank you.

I noticed Rivaroxaban attempted the NVAF back in the beginning of 2008.

What are your thoughts on why the FDA has waited so long to approve this medication for indication?