? dabigatrin or apixaban for Alice

[Marty]

My wife Alice age 85 had refractory afib and has had a pacemaker for five years. No valve problems. I have managed her warfarin therapy, though in her case, I need to report her protimes from our INRatio at regular intervals to her cardiology group. No problems, she is easy to manage stays stable, on 28mg/week between 2.0-3.0 INR. However she sees all the ads and has asked me if she could be switched to one of the new drugs. No more testing and calling in. I am ambivalent and told her I would get some other opinions. Any ideas? Thanks Marty

 

[pellicle]

Hi

My wife Alice age 85 had refractory afib and has had a pacemaker for five years.
... she is easy to manage stays stable, on 28mg/week between 2.0-3.0 INR. However she sees all the ads and has asked me if she could be switched to one of the new drugs. No more testing and calling in.

I don't know if you remember Ross, but I've had a few (just last year) conversations with Ross "off line" about this topic as he was of the view that dabigatran was not good even for its intended market. For the sake of "devils advocate" I dug through some literature on it and found that its only about equal to Warfarin in terms of bleed event data when you take the worst case management scenario of Warfarin. If you compare it to data from better managed groups (like self measurement and better dosing history) then dabigatran comes in significantly worse.

Then there is reversal. I have a friend who is a pharmacist and one of his "customers" switched over a while back. Then had a fall in a supermarket car park and was hospitalised for 3 days simply because he got a nose bleed (landed on his face) which would not stop. They had him on dialysis for a day to speed up the restoration of coagulation, but reversal is a big issue in comparison to Warfarin.

Its lucky they live in a bigger town for the ER there had some experience in what to do with dabigatran.

I say, if it ain't broken don't "fix it" :thumbup:

 

[ElectLive]

You might look here and also the other threads linked (by me) therein: http://www.valvereplacement.org/forums/showthread.php?39921-Pradaxa-Xarelto-Warfarin.

Sorry, I've rambled on and on about this before, just short on time today! :smile2: The short takeaway point, though, seemingly reinforced by FDA and ACC/AHA review, is that patients under good control with Warfarin are unlikely to see benefit (any, little, much, ?) from switching over, and potentially could actually be at higher risk. It's not nearly so simple as that, of course, but the other threads have much more info...

 

[Marty]

I agree Pellicle , we aren't going off warfarin for an xa or thrombin inhibitor. If it aint broke don't fixit! Thanks Marty

 

[Marty]

Hi ElectLive, After going back to the early reviews we decided to stay with warfarin, Thanks Marty

 

[epstns]

Hi ElectLive, After going back to the early reviews we decided to stay with warfarin, Thanks Marty

I'm glad you've made this choice, Marty. If it involved my wife, that is exactly what I would do. I really fear these new meds.

 

[catwoman]

Marty:

Good decision. If it were my huband and stable on warfarin, I'd keep him on it too.

 

[Protimenow]

I agree with everyone else here. The terrible discomfort of a minor lancet stick every week or two shouldn't be that big a deal. (Hell, diabetics u a smaller lancet but test much more frequently). In addition to the pure desire of these great pharmaceutical companies to help keep us poor people from having to test our blood occasionally, if the new drugs are widely adopted, the drugs could be a goldmine for these companies. If not, why would they advertise so damned much?

Personally, I'd rather pay a dime or so a day than what I've heard was $8 or so a day, for a well understood medication with a long history, and one whose effects can be easily reversed.

 

[Stopper]

I agree with everyone. But the only concern to bring up is the increase of incranial hemmorhage (ICH) with warfarin in older patients. I know many older patients are treated sub therapeutically with warfarin to reduce the risk of ICH. If I was stable with warfarin, I would find it hard to switch. If I were to switch, it would be apixaban over dabigatran due to less bleeding, less MI's, and it has all-cause mortality data.

 

[Marty]

I agree. The recommended therapeutic range for Alice is INR 2.0-3.0. I try to keep her close to 2.0.

 

[epstns]

I agree. The recommended therapeutic range for Alice is INR 2.0-3.0. I try to keep her close to 2.0.

And she is really lucky to have you to manage it with her.

 

[Marty]

apixoban vs warfarin

apixoban vs warfarin

I agree with everyone. But the only concern to bring up is the increase of incranial hemmorhage (ICH) with warfarin in older patients. I know many older patients are treated sub therapeutically with warfarin to reduce the risk of ICH. If I was stable with warfarin, I would find it hard to switch. If I were to switch, it would be apixaban over dabigatran due to less bleeding, less MI's, and it has all-cause mortality data.

Article in JAMA March 19,2014
FactorXa Inhibitors vs Warfarin for Preventing Stroke and thromboembolism in Patients with Atrial Fibrillation

Clinical question: Is treatment with factor Xa inhibitors associated with better efficacy and safety compared with warfarin in preventing strokes in afib patients?
Bottom Line: factorXa inhibitors were associated with lower risk of stroke and other systemic embolic events Overall lower risk of intracranial hemorrhage and mortality.
Reduction in major bleeding events.

Thanks, Stopper. If we ever do switch away from warfarin it will be to an Xainhibitor like apixoban.