These four patients are receiving chronic anticoagulation therapy. Read the descriptions of their cases and decide which, if any, of them you would switch to dabigatran.<\/p>\n
<\/strong><\/p>\n Case 1 <\/strong><\/p>\n A 69-year-old man with a history of hypertension and colon cancer was found to be in atrial fibrillation during a preoperative assessment for colon resection. Metoprolol was used to control his heart rate, and he underwent cardioversion guided by transesophageal echocardiography. When atrial fibrillation recurred postoperatively, he was started on warfarin. Multiple attempts at electrical and chemical cardioversion have been unsuccessful. Warfarin maintenance therapy has kept his INR values between 2 and 3. The patient is \u201csick of being poked and prodded\u201d and wants to know whether he can stop the warfarin.<\/p>\n Case 2<\/strong> <\/span><\/p>\n A 53-year-old heart-transplant patient had her post-transplant course complicated by biopsy-induced tricuspid regurgitation. After undergoing tricuspid valve replacement with a mechanical tricuspid valve, she has been maintained on warfarin for several years without complications. She woke up one morning with fever, a headache, confusion, and a diffuse rash on her chest. She was treated for presumptive meningitis until her laboratory values revealed an INR of 11. A head CT scan identified a large frontal intracerebral hemorrhage, and her INR spike was aggressively reversed with vitamin K and fresh frozen plasma. She was monitored with serial echocardiograms and head CTs while off anticoagulation treatment. When she stabilized, warfarin was cautiously resumed.<\/p>\n Case 3 <\/strong><\/p>\n A 33-year-old woman with a history of adriamycin-induced cardiomyopathy, cardiogenic cirrhosis, and atrial fibrillation is maintained on warfarin but is extremely nonadherent to her schedule of INR checks and clinic visits. When measured, her INR values have ranged from 2.0 to 5.6. She has had no major complications from anticoagulation therapy, except for menometrorrhagia.<\/p>\n Case 4 <\/strong><\/p>\n A 35-year-old man has antiphospholipid antibody syndrome and multiple pulmonary emboli despite therapeutic anticoagulation with warfarin and INR values between 3 and 4. His warfarin was discontinued, and he has been maintained on fondaparinux without any further events. The patient\u2019s health insurance does not cover fondaparinux, and he wants to know whether a cheaper alternative is available.<\/p>\n Questions<\/strong><\/p>\n 1) Which of these four patients would you consider switching to dabigatran? Why or why not?<\/p>\n 2) Would you consider cost in each case?<\/p>\n 3) Would the potential for improved quality of life be an adequate reason to switch any of these patients to dabigatran?<\/p>\n