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Health Column: Are new drugs better for atrial fibrillation?

Phil Mohler, M.D.
MOHLER’S MEDICATION MAXIMS
Free Press Health Columnist

For 50 years, warfarin (Coumadin) has been the mainstay in preventing strokes for patients with atrial fibrillation (an irregular heartbeat).

Recently three new drugs — two of them “X” drugs — have hit the market: Pradaxa, Xarelto and Eliquis.

Let’s call them, New Oral AntiCoagulants (NOACs).



They have been heavily marketed to the general public and physicians as the modern alternative to “outdated and inconvenient warfarin (rat poison).”

“The goal of all three NOACs and warfarin is to prevent clots from forming in the fibrillating heart, breaking off and going to the brain, resulting in a stroke.”

The goal of all three NOACs and warfarin is to prevent clots from forming in the fibrillating heart and breaking off and going to the brain, resulting in a stroke. The NOACs and warfarin all increase the risk of bleeding, both in the gut and in the brain. So how do the new drugs stack up against warfarin?



Effectiveness: There are no head-to-head studies between the three NOACs, as no pharma company wants its product to be shown inferior to a brand-name competitor. A recent review of all the NOAC studies in “The Lancet,” a British medical journal, showed new anticoagulants are equally effective as warfarin in preventing strokes caused by clots.

Side-Effects: Patients taking NOACs had fewer episodes of hemorrhage into the brain, but more episodes of gastrointestinal bleeding.

What are the other pros and cons of these medicines?

The advantages of the new anticoagulants are quicker onset of action, hours rather than days for warfarin, no effect of kale, spinach and other veggies on effectiveness as there is with warfarin, fewer drug interactions with NOACs than with warfarin, and no need to monitor blood tests as the dosing with NOACs is fixed.

One of the downsides with these new drugs is that a missed dose quickly results in a situation where there may be no anticoagulant effect, as opposed to warfarin, where a single missed dose will have much less effect. Not only is there is no need to monitor the degree of anticoagulation, there is no method to monitor the degree of anticoagulation with NOACs. The other significant disadvantage with the NOACs is that there is no antidote if the patient starts bleeding or needs to have an unplanned surgical procedure. The anticoagulant effects of warfarin, on the other hand, are fairly quickly reversed with Vitamin K.

Finally, Pradaxa, Xarelto and Eliquis are all pricey, at around $300 per month.

Generic warfarin costs $10-15 per month and with a $50 protime or two per month is still more economical.

My Take: This is a treatment decision that you should make with your physician.

If you are taking warfarin and your blood tests are stable, stick with warfarin.

If you have difficulty remembering to take medications more than once a day, then sticking with warfarin or switching to Xarelto (also once a day) is probably wiser than going with Eliquis or Pradaxa, both twice a day medications.

If you have significant liver or kidney disease, warfarin may be the best choice.

As with all new drugs, avoid being one of the first million patients to consume the new product. Wait until we really figure out how and when to use the new drug and what the unusual side-effects are.

GJ Free Press health columnist Dr. Mohler has practiced family medicine in Grand Junction for 39 years. He has a particular interest in pharmaceutical education. Phil works part-time for Rocky Mountain Health Plans. Email him at pjmohler@bresnan.net.


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