{"id":1379,"date":"2009-12-07T11:00:37","date_gmt":"2009-12-07T16:00:37","guid":{"rendered":"http:\/\/blogs.nejm.org\/cardioexchange\/dabigatran-vs-warfarin-war-or-peace\/"},"modified":"2011-07-19T17:45:15","modified_gmt":"2011-07-19T21:45:15","slug":"dabigatran-vs-warfarin-war-or-peace","status":"publish","type":"post","link":"https:\/\/blogs.nejm.org\/cardioexchange\/2009\/12\/07\/dabigatran-vs-warfarin-war-or-peace\/","title":{"rendered":"Dabigatran vs Warfarin: War or Peace?"},"content":{"rendered":"

CardioExchange Editors: <\/strong> Given the results of both your\u00a0RE-COVER study<\/a> and the recently published RE-LY study<\/a>, should anybody still be using warfarin?<\/p>\n

Goldhaber:<\/strong> Warfarin is not going to fade away into oblivion.\u00a0 Anyone currently stable on warfarin has little reason to abandon this time-tested drug.\u00a0 If once monthly INRs are usually in the therapeutic range, and if there have been no bleeding or clotting complications, why \u201crock the boat\u201d?\u00a0 By the way, warfarin\u2019s fighting back.\u00a0 It\u2019s been around since 1954, so we know all of its potential complications.\u00a0 And it\u2019s inexpensive.\u00a0 With a large ongoing NHLBI trial to test rapid turnaround genetic testing to prescribe a more precise starting dose of warfarin, and with (mostly) insurance-reimbursed point-of-care fingerstick self-testing of INR, effective prescription of warfarin is more widespread now than ever before.\u00a0 Keep in mind that nurse and pharmacist-run Anticoagulation Clinics have also enhanced the safety and efficacy of warfarin prescription.\u00a0Finally, dabigatran has not been tested in important thrombotic conditions such as for prophylaxis against venous thromboembolism during hospitalization for medical illness or for prevention of thrombosis with mechanical prosthetic heart valves.\u00a0 At the moment, dabigatran is not FDA approved for any condition in the United States.\u00a0 And nowhere has it yet received regulatory approval for stroke prevention in atrial fibrillation or for treatment (along with a required initial course of low molecular weight heparin or fondaparinux) for acute venous thromboembolism.<\/p>\n

CardioExchange Editors:<\/strong> If it were to receive FDA approval, what situations would you consider to be prohibitive for dabigatran?
\n
\nGoldhaber:<\/strong> Very few.\u00a0 Inability to comply with a twice daily medication.\u00a0 Renal failure.\u00a0 Gastric discomfort not alleviated by taking dabigatran with food.\u00a0 Keep in mind that a small minority of patients (3%) suffers excruciating gastric discomfort.\u00a0 They can\u2019t tolerate dabigatran and should use warfarin.\u00a0 Contraindications also include any active bleeding condition or bleeding predisposition that would ordinarily prohibit use of warfarin.
\n
\nCardioExchange Editors:<\/strong> Given that\u00a0very few\u00a0patients in RE-COVER had even mild renal dysfunction, how cautious do you think we should be in situations where the creatinine clearance is above 30 but below 50 ml\/minute, knowing that dabigatran is 80% renally excreted?
\n
\nGoldhaber: <\/strong> We need to be cautious using dabigatran in patients with chronic kidney disease, especially the creatinine clearance might drift down below 30 ml\/minute.\u00a0 Major bleeding is an ominous prognostic sign for patients with either arterial or venous thrombotic illness.\u00a0 Patients with renal failure (creatinine clearance <30 ml\/minute) should use warfarin, which is metabolized by the liver, not the kidney.
\n
\nCardioExchange Editors:<\/strong> Although the difference was not statistically significant, people with a prior VTE appeared to do better on warfarin versus dabigatran in RE-COVER.\u00a0 Why might this be the case?
\n
\nGoldhaber:<\/strong> It has been long observed by \u201cblood clot docs\u201d that patients who are established on warfarin and clinically stable have much better control of the INR and far fewer problems than \u201cwarfarin na\u00efve\u201d patients.\u00a0 So, I\u2019d expect that these patients already taking warfarin are, in a sense, pre-selected to do well.\u00a0 All the kinks of anticoagulation have been pretty much been worked out for them.<\/p>\n

Comments are closed on this post, but please join the conversation at our Dabigatran Resource Round-Up<\/a>.<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

CardioExchange Editors: Given the results of both your\u00a0RE-COVER study and the recently published RE-LY study, should anybody still be using warfarin? Goldhaber: Warfarin is not going to fade away into oblivion.\u00a0 Anyone currently stable on warfarin has little reason to abandon this time-tested drug.\u00a0 If once monthly INRs are usually in the therapeutic range, and […]<\/p>\n","protected":false},"author":181,"featured_media":0,"comment_status":"closed","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1,7,16],"tags":[],"class_list":["post-1379","post","type-post","status-publish","format-standard","hentry","category-general","category-prevention","category-vascular"],"_links":{"self":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/1379","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\/181"}],"replies":[{"embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/comments?post=1379"}],"version-history":[{"count":0,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/posts\/1379\/revisions"}],"wp:attachment":[{"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/media?parent=1379"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/categories?post=1379"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/blogs.nejm.org\/cardioexchange\/wp-json\/wp\/v2\/tags?post=1379"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}