Can we finally ditch Coumadin?

[DrMetal]

---

Members don't see this ad.

ACP Journals
Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients With Valvular Atrial Fibrillation


So we can use DOACs now for valvular Afib (See study above), we've been using DOACs for other VTEs, and recently shown to be safe in even cancer-related VTEs. Is there any reason (maybe poor renal function) to continue using warfarin?

 

[thumbz]

INR goals 2.5-3.5 (APLA, mechanical valves) - hopefully this will get studied one day and found non inferior
Compliance (rebound hypercoag status when people go on and off frequently) - no fixing this sadly
Cost - coupon cards have helped a lot with this but I do have some patients who just won't do the $10-$20/mth
History of major bleeds - relative contraindication in my mind (my shop doesn't have the targeted reversal agents - so if someone has a history of a life threatening GI or head bleed they tend to prefer warfarin after a risk/benefit discussion)

I used a DOAC for HIT associated thrombosis just the other day. It's a wonderful new world as I hate warfarin

 

[aafisahar]

ACP Journals
Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients With Valvular Atrial Fibrillation


So we can use DOACs now for valvular Afib (See study above), we've been using DOACs for other VTEs, and recently shown to be safe in even cancer-related VTEs. Is there any reason (maybe poor renal function) to continue using warfarin?

needs to be prospective. tons of **** works in retrospective studies but never pan out in prospective studies.

and you can never overcome the fundamental flaw of retrospective studies, which is bias. for whatever reason, patients were put on DOACs most likely because it was felt they could not tolerate coumadin. you can't escape this ultimate confounder, no matter how much statistical ****ery is done.

 

[Osteoth]

INR goals 2.5-3.5 (APLA, mechanical valves) - hopefully this will get studied one day and found non inferior
Compliance (rebound hypercoag status when people go on and off frequently) - no fixing this sadly
Cost - coupon cards have helped a lot with this but I do have some patients who just won't do the $10-$20/mth
History of major bleeds - relative contraindication in my mind (my shop doesn't have the targeted reversal agents - so if someone has a history of a life threatening GI or head bleed they tend to prefer warfarin after a risk/benefit discussion)

I used a DOAC for HIT associated thrombosis just the other day. It's a wonderful new world as I hate warfarin

What doac is $10/mo? I’ve seen Eliquis and lovenox like $40+ on goodrx

 

[aafisahar]

What doac is $10/mo? I’ve seen Eliquis and lovenox like $40+ on goodrx

Pradaxa lol

 

[thumbz]

What doac is $10/mo? I’ve seen Eliquis and lovenox like $40+ on goodrx

One of our pharmacists is a strait up wizard. We got a patient down to $40 which was not affordable and they worked some sort of voodoo magic and got a month free followed by a $10 copay. I have no doubt it was through some sort of copay assistance program

 

[RheumDoc112]

ACP Journals
Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients With Valvular Atrial Fibrillation


So we can use DOACs now for valvular Afib (See study above), we've been using DOACs for other VTEs, and recently shown to be safe in even cancer-related VTEs. Is there any reason (maybe poor renal function) to continue using warfarin?

Secondary thrombosis prevention in antiphospholipid syndrome.

Pengo, V. et al. Rivaroxaban vs warfarin in high-risk patients with antiphospholipid syndrome. Blood 132, 1365–1371 (2018).

 

[Osteoth]

Pradaxa lol

People give Pradaxa as outpt antcoag?

 

[DrMetal]

I'll answer my own question: we can shed Coumadin when the patents expire on the Doacs, and they become generics. Lipitor use to be really expensive, until the patent ran out on Pfizer, now it's generic atorvastatin and dirt cheap.

 

[ortnakas]

I'll answer my own question: we can shed Coumadin when the patents expire on the Doacs, and they become generics. Lipitor use to be really expensive, until the patent ran out on Pfizer, now it's generic atorvastatin and dirt cheap.

Agreed. I’d rather use NOACs for most things but the majority of my patients are on a fixed income and simply cannot afford it.

 

[tantacles]

People give Pradaxa as outpt antcoag?

Yes. Kaiser has a huge contract with pradaxa and will bridge with enoxaparin after starting it instead of doing warfarin or another doac.

 

[gutonc]

Yes. Kaiser has a huge contract with pradaxa and will bridge with enoxaparin after starting it instead of doing warfarin or another doac.

Which I discovered last week when I saw a new patient transferring from Kaiser for h/o VTE. Since they only had 1 more month of treatment planned, I just left them on it, but it had me scratching my head for awhile until I reached out to a former co-fellow who does heme for Kaiser.

 

[Osteoth]

Yes. Kaiser has a huge contract with pradaxa and will bridge with enoxaparin after starting it instead of doing warfarin or another doac.

Oh interesting.

 

[johnwalldance]

DOACs are still off label for LV thrombus apparently, per cardiology at my institution. Said they'd do coumadin for medicolegal reasons (whether that's valid or not) not enough studies on DOACs yet....

 

[HariboGoldbears]

Yes. Kaiser has a huge contract with pradaxa and will bridge with enoxaparin after starting it instead of doing warfarin or another doac.

Curious what the indications to bridging for dabigatran is. I saw this also in MKSAP, but thought it was an error.

 

[aafisahar]

DOACs are still off label for LV thrombus apparently, per cardiology at my institution. Said they'd do coumadin for medicolegal reasons (whether that's valid or not) not enough studies on DOACs yet....

Ya it's weird, some docs are sticklers for it. I personally don't care, would prefer to use a doac over Coumadin unless absolutely necessary (eg mechanical valves)

 

[DrMetal]

Curious what the indications to bridging for dabigatran is. I saw this also in MKSAP, but thought it was an error.

I can't find a pharmacological reason for bridging with dabigatran; like the other DOACs, its seems to have a fast onset (on the order of a few hours after ingestion?!), it may even be faster.

Now in the hospital everyone's on a heparin drip before starting one of these, so they're already sort of 'bridged'.

 

[gutonc]

Curious what the indications to bridging for dabigatran is. I saw this also in MKSAP, but thought it was an error.

Oddly, it's in Micromedex but not the PI. I wonder if it's a lot of "received wisdom" without actual data. I will cop to not having bothered to look up the original studies on it since I never use it and have no intention of starting now.

 

[turkeyjerky]

Oddly, it's in Micromedex but not the PI. I wonder if it's a lot of "received wisdom" without actual data. I will cop to not having bothered to look up the original studies on it since I never use it and have no intention of starting now.

It's just how the studies for dabigatran were conducted, they all included at least 5 days of bridging. Studies on riv and apix didn't, so they took off and dabi didn't.

 

[DrMetal]

It's just how the studies for dabigatran were conducted, they all included at least 5 days of bridging. Studies on riv and apix didn't, so they took off and dabi didn't.

Wow, how stupid are we?

 

[gutonc]

It's just how the studies for dabigatran were conducted, they all included at least 5 days of bridging. Studies on riv and apix didn't, so they took off and dabi didn't.

That was kind of my assumption.

 

[HemeOncHopeful19]

It's just how the studies for dabigatran were conducted, they all included at least 5 days of bridging. Studies on riv and apix didn't, so they took off and dabi didn't.

Also interesting is that Rivaroxaban and Apixaban have pretty similar half lives but one was studied BID and the other QD so that’s what we do.

 

[aafisahar]

Also interesting is that Rivaroxaban and Apixaban have pretty similar half lives but one was studied BID and the other QD so that’s what we do.

Ya but that's marketing as much as medicine. Xareltos draw is once a day dosing and non inferiority compared to Coumadin. Eliquis is BID and superior to coumadin for bleeding outcomes. In my neck of the words, eliquis has won the doac wars due to this superiority I think.

 

[FutureInternist]

And when can we standardise them as DOACS, rather than NOACs 😏

 

[BorntobeDO?]

Ya but that's marketing as much as medicine. Xareltos draw is once a day dosing and non inferiority compared to Coumadin. Eliquis is BID and superior to coumadin for bleeding outcomes. In my neck of the words, eliquis has won the doac wars due to this superiority I think.

Agreed, still need coumadin for people with intolerances tho, and agree with the above on people who have high risk of bleeding and need something easily reversible. That said, coumadin seems to headed the way of theophyline and the dodo in my mind. Theo is still around, but not used nearly as much.

 

[turkeyjerky]

Ya but that's marketing as much as medicine. Xareltos draw is once a day dosing and non inferiority compared to Coumadin. Eliquis is BID and superior to coumadin for bleeding outcomes. In my neck of the words, eliquis has won the doac wars due to this superiority I think.

Right, but each of the studies so similiar trends in regards to risk of bleed vis a vie warfarin. Difference was apixaban was statistically significant.

 

[gutonc]

Also interesting is that Rivaroxaban and Apixaban have pretty similar half lives but one was studied BID and the other QD so that’s what we do.

Xarelto is 5-9 while apixaban is 10-15 (mean 12), both with similar peak onset times of ~3 hours.

I use apixaban because I KNOW patients are going to skip/miss doses. If they miss a dose of apixaban, they're still at least as well, if not better, anticoagulated than if they took their Xarelto on schedule. If they miss a dose of Xarelto, they're essentially not anticoagulated for a day and a half.

 

[QuizzicalApe]

And when can we standardise them as DOACS, rather than NOACs 😏

I've made the shift because I no longer find them particularly Novel