recent developments in new oral anticoagulants eric watts basildon hospital

Recent Developments InNew Oral Anticoagulants

Eric WattsBasildon Hospital

Recent Developments In New Oral AnticoagulantsEric Watts, Basildon HospitalEric Watts, Basildon Hospital

Recent Developments In New Oral AnticoagulantsEric Watts, Basildon Hospital


Prevention of Atrial Fibrillation-Related Stroke


Background - AF

Warfarin is effective, 2/3 risk reduction for CVA

Better than maximal antiplatelet therapy

Cumbersome to use

Discontinuation rates high

Many patients have inadequate control

Several drug interactions


Dabigatran etexilate Oral prodrug –rapidly converted to Dabigatran

Predictable bioavailbility

80% renal excretion

½ life 12-17 hrs

“does not require regular monitoring”


3 groups “well balanced”

Mean age 71

63% male

Mean CHADS score 2.1

CCF

Hypertension

Age

Diabetes

Patient Baseline Characteristics


Warfarin …………………….4.13% pa

Dabigatran 110mg ……...…3.75% pa .ns

Dabigatran 150mg …………3.64% pa .ns

Mortality


Myocardial Infarction

Warfarin ……………….0.53 %

Dabigatran 110mg ...…0.72 % p= 0.07

Dabigatran 150mg ……0.74% p= 0.048

Is the antithrombin effect cardioprotective?


Major Bleeding

Warfarin…………….3.36 %

Dabigatran 110 ……2.71 %, p=0.003

Dabigatran 150 ……3.11% n.s.

Life threatening, intracranial Minor bleeding higher with warfarin

More major GI bleeding with 150 Dabigatran


Haemorrhagic Stroke

Warfarin …………................. 0.38%

Dabigatran 110mg ………... 0.12%

Dabigatran 150mg ……….… 0.10%

NNT = 370

“significant”


GI bleeding & discomfort

Discontinuation

Warfarin ……………….……. 10.2%pa

Dabigatran 110mg ……...…..14.5% pa

Dabigatran 150mg …………..15.5% pa


Can we Rely on RE-LY

Fairly good INR control -64% (Rosendal) for warfarin to be equally effective – 74%

No hepatic toxicity

Does have some interactions –P-glycoprotein inhibitors verapamil, amioderone & quinidine

Lower dose for renal patients ?

Risk stratification for GI pathologies


Can we Rely on RE-LY

Is selective antithrombin activity a mixed blessing?

“Because of Dabigatran’s twice daily dosing & greater risk of non haemorrhagic side effects patients already taking warfarin with excellent INR control have little to gain by switching”

“in contrast, many other patients who have atrial fibrillation and at least one additional risk factor for stroke could benefit from Dabigatran”


Efficacy Outcomes Apixaban Enoxaparin

Intended treatment period no. / total no. (%) no. /total no. (%)

All VTE and death from any cause 104 / 1157 (9.0) 100 / 1130 (8.8)

Major VTE and death from any cause 26 / 1269 (2.0) 20 / 1216 (1.6)

Symptomatic VTE and VTE-related death 19 / 1599 (1.2) 13 / 1596 (0.8)


From Xarelto’s Website


From Xarelto’s Website

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2011 & beyond ?????

New drugs licensed

Costs will need to be competitive

NICE recommendation clinical & cost effectiveness

Warfarin wobblers & patients on interacting drugs may be changed over

No INR monitoring

More complex patients e.g. VR may stay on warfarin for the benefit of monitoring


The future of anticoagulant services ?

There will still be a need for clinicians with specialist knowledge & experience

Diagnosing & initiating treatment for DVT has been developed by many anticoagulant nurses where this service works well it will probably be maintained

Some old drugs are still in use despite the introduction of modern alternatives (UFH)


‘Clunky’ GP contracts raise questions on quality 8 October 2009 | By Sally Gainsbury

There are huge variations in what different PCTs pay for the same services, yet there is no detectable correlation between cost and quality or patient satisfaction. Sally Gainsbury looks at why commissioning has not yet addressed these stark contrasts

If you have ever attended a conference on making NHS commissioning “world class” the dominant theme will have been primary care trusts getting to grips with their hospitals. You hear less, if anything, about what PCTs are doing to improve the value for money of their primary care contracts with GPs.

There are huge variations in what different PCTs payfor the same services, yet there is no detectable correlation between cost and quality nor patient satisfaction.

Sally Gainsbury asks why has commissioning not yet addressed these stark contrasts ?

From the Health Service Journal


From the Health Service Journal

‘Clunky’ GP contracts raise questions on quality 8 October 2009 | By Sally Gainsbury

Ms Helen Northall says the absence of a value for money focus in primary care is evident in the results of Primary Care Commissioning’s latest benchmarking survey, which found huge and persistent variations in what PCTs pay for ostensibly the same thing.


Discussion Points

A “tighter” control with Dabigatran gives fewer bleeds ?

The bleeds only need supportive treatment?


Basildon Costs

Pradaxa - both 75mg and 110mg are £48.30 for 60 – 80p each

Xarelto is £47.40 for 30 tablets …….. £1.59 each

recent developments in new oral anticoagulants eric watts basildon hospital

Documents

recent developments

basildon hospital warfarin

dabigatran slide

pa slide

significant slide

ns mortality slide

xareltos website slide

regular monitoring slide