There\u2019s an old maxim in medicine that one shouldn\u2019t be the first to prescribe a new drug, nor the last.<\/p>\n
A fascinating debate between Michael Ezekowitz from the U.S. and Felicita Andreotti from Italy highlighted the differences between warfarin and the newer oral anticoagulants (NOACs) apixaban, rivaroxaban, and dabigatran.<\/p>\n
Even Dr. Ezekowitz, the warfarin protagonist for purposes of the debate, had to concede the superiority of the NOACs, now supported as safer and more effective in three clinical trials: RE-LY<\/a>, ROCKET-AF<\/a>, and ARISTOTLE<\/a>. In general, the factor Xa inhibitors prevent ischemic strokes, reduce mortality, and limit the incidence of dreaded intracranial hemorrhage, with less bleeding as well.<\/p>\n How, then, could a cardiologist not rush to the electronic prescription pad and immediately take most patients off warfarin and prescribe NOACs?<\/p>\n Well, for one thing, there\u2019s the cost. True, INR monitoring comes with societal and health care costs, plus the cost of paying for excess strokes. The patient, however, is more concerned with the copay: \u201cDo I have to pay $10 per month for a generic drug or hundreds for a newer medication?\u201d<\/p>\n There\u2019s also the question of patient subgroups. Until we have more information, subgroups such as patients with prosthetic metal valves will need to remain on warfarin. The current lack of a specific drug antidote to the NOACs concerns many observers as well.<\/p>\n I also find intriguing the way statistical data are presented. For example, in the ARISTOTLE trial, death occurred in 3.52% of the apixaban group and 3.94% of the warfarin group. You can declare, then, that by using apixaban instead of warfarin 8 deaths are prevented for every 1000 patients treated. On the other hand, you could say that 96.48% of the apixaban group and 96.06% of the warfarin group didn\u2019t die. Is that really a compelling difference for the individual patient sitting before you in the exam room?<\/p>\n For now, I think I\u2019m going to continue prescribing warfarin for patients who are already well controlled on that medication. For those with poorly controlled INRs or new patients, perhaps the time for NOACs is now.<\/p>\n","protected":false},"excerpt":{"rendered":" There\u2019s an old maxim in medicine that one shouldn\u2019t be the first to prescribe a new drug, nor the last. A fascinating debate between Michael Ezekowitz from the U.S. and Felicita Andreotti from Italy highlighted the differences between warfarin and the newer oral anticoagulants (NOACs) apixaban, rivaroxaban, and dabigatran. Even Dr. Ezekowitz, the warfarin protagonist […]<\/p>\n","protected":false},"author":358,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[495],"tags":[492,363,341,339,326,366,368],"class_list":["post-11295","post","type-post","status-publish","format-standard","hentry","category-anticoagulation-2","tag-anticoagulation","tag-apixaban","tag-atrial-fibrillation","tag-dabigatran","tag-esc","tag-rivaroxaban","tag-warfarin"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/11295","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/users\/358"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=11295"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/11295\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=11295"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=11295"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=11295"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}