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

2. Eric Watts, Basildon Hospital

3. Eric Watts, Basildon Hospital

6. Prevention of Atrial Fibrillation-Related Stroke

7. Prevention of Atrial Fibrillation-Related Stroke

8. Prevention of Atrial Fibrillation-Related Stroke

9. Prevention of Atrial Fibrillation-Related Stroke

10. Prevention of Atrial Fibrillation-Related Stroke

15. 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

16. Dabigatran etexilate Oral prodrug –rapidly converted to Dabigatran
Predictable bioavailbility
80% renal excretion
½ life hrs
“does not require regular monitoring”

18. Patient Baseline Characteristics
3 groups “well balanced”
Mean age 71
63% male
Mean CHADS score 2.1
CCF
Hypertension
Age
Diabetes

20. Mortality
Warfarin …………………….4.13% pa
Dabigatran 110mg ……...…3.75% pa .ns
Dabigatran 150mg …………3.64% pa .ns

21. Myocardial Infarction
Warfarin ……………….0.53 %
Dabigatran 110mg ...…0.72 % p= 0.07
Dabigatran 150mg ……0.74% p= 0.048
Is the antithrombin effect cardioprotective?

22. 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

23. Haemorrhagic Stroke Warfarin …………................. 0.38%
Dabigatran 110mg ……… %
Dabigatran 150mg ……….… 0.10%
NNT = 370
“significant”

24. GI bleeding & discomfort
Discontinuation
Warfarin ……………….……. 10.2%pa
Dabigatran 110mg ……...…..14.5% pa
Dabigatran 150mg …………..15.5% pa

26. 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

27. 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”

28. Efficacy Outcomes
Apixaban
Enoxaparin
Intended treatment period
no. / total no. (%)
no. /total no. (%)
All VTE and death from any cause
104 / (9.0)
100 / (8.8)
Major VTE and death from any cause
26 / (2.0)
20 / (1.6)
Symptomatic VTE and VTE-related death
19 / (1.2)
13 / (0.8)

31. From Xarelto’s Website

32. From Xarelto’s Website
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34. 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

35. 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)

36. 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 ?

37. 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.

38. Discussion Points
A “tighter” control with Dabigatran gives fewer bleeds ?
The bleeds only need supportive treatment?

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