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Update on Oral Anticoagulants

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					Recent Developments In
New Oral Anticoagulants

         Eric Watts
      Basildon Hospital
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital

Prevention of Atrial Fibrillation-Related Stroke
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital

Prevention of Atrial Fibrillation-Related Stroke
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital

Prevention of Atrial Fibrillation-Related Stroke
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital

Prevention of Atrial Fibrillation-Related Stroke
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital

Prevention of Atrial Fibrillation-Related Stroke
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital




  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
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital




  Dabigatran etexilate
   Oral prodrug –rapidly converted to Dabigatran
   Predictable bioavailbility
   80% renal excretion
   ½ life 12-17 hrs
   “does not require regular monitoring”
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital




  Patient Baseline Characteristics
   3 groups “well balanced”
   Mean age 71
   63% male
   Mean CHADS score 2.1
   CCF
   Hypertension
   Age
   Diabetes
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital




  Mortality


   Warfarin …………………….4.13% pa
   Dabigatran 110mg ……...…3.75% pa .ns
   Dabigatran 150mg …………3.64% pa .ns
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital




   Myocardial Infarction

    Warfarin ……………….0.53 %
    Dabigatran 110mg ...…0.72 % p= 0.07
    Dabigatran 150mg ……0.74% p= 0.048




    Is the antithrombin effect cardioprotective?
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital




 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
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital




  Haemorrhagic Stroke

   Warfarin …………................. 0.38%
   Dabigatran 110mg ………... 0.12%
   Dabigatran 150mg ……….… 0.10%


   NNT = 370
   “significant”
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital




  GI bleeding & discomfort

  Discontinuation
   Warfarin ……………….……. 10.2%pa
   Dabigatran 110mg ……...…..14.5% pa
   Dabigatran 150mg …………..15.5% pa
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital




  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
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital




  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”
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital




   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)
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital




  From Xarelto’s Website
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital




  From Xarelto’s Website

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Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital




  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
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital




  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)
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital

                                                             From the Health Service Journal




 „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 ?
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital

                                                   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.
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital




  Discussion Points

   A “tighter” control with Dabigatran gives fewer bleeds ?
   The bleeds only need supportive treatment?
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital
Recent Developments In New Oral Anticoagulants
Eric Watts, Basildon Hospital




  Basildon Costs

   Pradaxa - both 75mg and 110mg are £48.30 for 60 – 80p
    each
   Xarelto is £47.40 for 30 tablets …….. £1.59 each

				
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posted:12/3/2011
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