Ray: Talking about anticoagulants creates controversy. Those that take Coumadin/Warfarin believe it is the best/safest. Same thing with those that take the New/Novel Oral Anticoagulants like Pradaxa/Dabigatran. I take Pradaxa, but I will lay out all the issues.

Please understand that there are studies that conflict with each other. There is also a tendency not to report adverse events with old medicines like Warfarin.

There was a flurry of deaths reported with Pradaxa. It turned out that there were many cases where Pradaxa was prescribed to elderly patients who had kidney/renal problems that caused bleeding. So it was prescribed properly.

Some facts: Pradaxa causes more GI bleeds, but less brain bleeds than Warfarin.

There is no antidote for Pradaxa, although they are very close. However, Warfarin is not as easily reversed as people would have you believe. Many doctors think it is better not to have a brain bleed first (by taking Pradaxa) and that the GI bleeds are less dangerous.

Fact: All anticoagulants make you bleed, and if you at risk for bleeds, they all have potential for bad outcomes. But so many, many more people are saved from having strokes, than have bleeds. Coumadin prevents at least 70% of strokes, and Pradaxa about 93%.

Warfarin is hard to adjust for many people, If you are one of those people, Pradaxa is for you. Some people test INR at home and do quite well. I observational trials, overall, Pradaxa did better for preventing strokes. 35% better. Some people claim if they are in INR range 90% of the time, they get fewer strokes than with Pradaxa.

Another way of looking at the bleed numbers is that Warfarin definitely causes more deaths for those that are properly prescribed their anticoagulant because there are many more people on Warfarin and because Warfarin causes more brain bleeds.

Question: How often is your INR tested? Your numbers are good, but if you only go once a month, maybe your INR is not always in range.

My EP believes Pradaxa is better for preventing strokes and should be safe for me. Since I don't want to have a brain bleed or stroke, I am going with the numbers.

petey

I meant "So it was prescribed IMPROPERLY".

When I was in the hospital last week because of a stroke, I discussed with the doctors, Coumadin, vs the never anti coagulants. They all didn't like the newer drugs because they cannot control bleeds as well as they can with Coumadin.

I think Peteys answer is excellent and extremely fair. Thats what I love about this site; as far as I can tell no question is left unanswered and no bickering just people helping people. That says a lot. Thanks to you all.

Ray, you said recently i was told that there is lot more deaths due to bleeding in warafin compared to padraxa .

A lot more is relative and scary. Dr. John M. wrote an article well worth reading on December 18th of last year on the Medscape website titled:

Novel Oral Anticoagulants vs Warfarin: The Truth is Relative
(To read the whole article Google the exact title above)

This is his summary to the article:

The two approaches to anticoagulation in patients with AF have been studied head-to-head in thousands of patients in trials that measured hard outcomes. Strokes, bleeds, and deaths are easy to count. Division is easy. So is subtraction.

In the outcomes that matter to the patient who sits across from us, the two classes of drugs perform nearly identicallythat is, if you count greater than 99% the same.

This doesn't mean novel anticoagulants are bad drugs or that I recommend stopping them. It simply means they are clinically equivalent to warfarin. And, therefore, at the current premium, these drugs are grossly overvalued.

To be fair, NOAC drugs have some practical advantages, like convenience, lack of dietary interactions, and fewer drug-drug interactions. And not all patients do well with warfarin. For these patients, NOAC drugs may be an alternative. (See footnote.) What's more, if one is willing to pay for convenience and absolute differences of less than 1%, then that is his or her choice.

To put in my 2 cents worth I think being within your individual therapeutic range is extremely important (the longer the better. I self-manage so I can test whenever I feel the need or once a week whatever comes first). I believe I read somewhere that the TTR (Therapeutic Time in Range) for warfarin in studies is around 68% and thats what was compared to the NOACs. Maybe, maybe not who knows for sure. Important is to know ALL BLOOD THINNERS ARE DANGEROUS DRUGS but taken correctly they inhibit strokes so take them seriously.

Hope that helps. atp

Just want to throw this out and see if you have heard anything about this...I know Petey will research it.
A few days ago I saw an ad on TV...one of those attorney "if you or a loved one has taken" ...this was pradaxa and suffered a bleed, or HEART ATTACK, to call them. I had not heard that there was any connection with pradaxa and heart attack??? And this is obviously not the most reliable information.
Anyone know anything about this??

This thread seems to be about Warfarin vs. Pradaxa, but it is really about Warfarin vs. the new anticoagulants. Many people can't tolerate Pradaxa because of GI issues, however this doesn't seem to be as prevalent with Xarelto. So my point is that when looking at the new anticoagulants, perhaps look at all of them vs. Warfarin.

I agree that Petey researches everything for us. That's very much appreciated.

I find the longer and longer I go from my ablation, my memory fades and I'm not able to answer questions about the specifics anymore. I guess it's like childbirth, the further away from it you get, your memory fades. Or... I'm just losing my mind. Ha!

acrossthe-
I read Dr. John M's article previously. Just re-read it. I recommend it to all a fibbers. The comments of other doctors following the article were also interesting.
I've been on Warfarin for over 3 years with no side effects, no problems with the dietary restrictions or maintaining a stable INR.
If the cost for the newer drugs were the same as or slightly more than Warfarin I probably would switch to Eliquis. Otherwise a less than 1% difference doesn't balance out the additional cost.

Annette

Agree with Bucco. BTW, many of us pay $10 a month for Pradaxa. I think Eliquis is going to be the big winner because it works a little better than Warfarin with way less bleeds than all of them.

I recommend all the new anticoagulants to agoraphobics who can't make it out their front door to get their INR tests done or answer the front door to get their home testing kit. :-) Joking... but my point is each one of them has benefits and each one of us may take one of the anticoagulants because they work best for us.

In my case, money is not a factor, $10 or $100. Again, my dream in life is not to have a stroke or a brain bleed. If my risk goes down by .999999 of a percent I am going to pay more. Of course I buy lottery tickets where my chances of winning are 1 in 7 million.


petey

Annette you are right, the comments are very interesting. I read them when I read the article in December then there were only about 5 or so now there are 72! Amazing a must read if you want to know what doctors think about the two classes of drugs.

From the comments on the Mandrola post, my take away is this- Many Doctors are emotional about the subject and have wildly differing opinions. Some of them want to stick to their opinions because of their BIG egos.

I will tell you, I thought Dr. Mandrola's post was not one of his best. He is taking the stats from a whole group of people with widely varying CHA2DS2Vasc scores and applying them to everyone. The absolute risk for stroke with a CHADS of 1 is very low for a 1 year period. The absolute risk of stroke for a person with a CHADS of 3 or more is much higher.

So, if you want to be honest about it, the absolute ANNUAL risk for a person with a CHADS of 1 is only 1.3%. You can't move the number that far. If Warfarin reduces that annual risk by 67%, the risk now becomes .871, or a 0.429 percent (less than half of a percent) reduction. But are they telling people not to take Warfarin with a CHADS of 1 because it only has a risk reduction of less than a half of one percent? No! Of course not! I just wanted to point out that annual risk (ABSOLUTE RISK) is so low for CHADS 1 & 2, that, by design, an anticoagulant, like Pradaxa, that reduces stroke by about 93%, can't move the absolute number much further depending on the CHADS scores of those studied. In this case it goes down to .117. Of course, if your CHADS is 5, the numbers move farther. And also remember you are being exposed to these annual risk EVERY year. Although the annual risk is nor additive, you are still exposed, so you want to reduce the number as much as you can.

Please also notice he grouped ALL the new anticoagulants together, even though Pradaxa is much higher in stroke reduction than the other two (Reductions: 35% Pradaxa down to 12% for Xarelto).

Other considerations are things like: Which anticoagulants lessen the chance for calcification? Which ones lessen brain bleeds? Which ones are more convenient? Which one is now being studied because it has proven to stop many types of fibrosis? (They believe that will apply to fibrosis/scarring in the heart and therefore, prevent progression of afib).

Probably the thing that bothered me the most about the post is that he got his Eureka moment from his son. I get newsletters from his own website, and this is what I got from him before the Medscape article came out:

"The discovery felt like a Eureka moment. I ran it by my stats guy--my son--and a couple of colleagues, and they confirmed, that my discovery was truth. I'm working on a post now that discusses the details of how the medical world has been misled about these drugs. Stay tuned."

He got the revelation from his son? Dr. John is becoming more writer and philosopher, and less scientist. As a writer and family man, I think his posts are becoming more literary pieces that are well written and less science. He is also becoming more philosophical (that's good) and I detect some nostalgia plus a deepened appreciation for life and family. You gotta love this guy. They don't teach that in Med school. But the damn numbers don't work. He is playing with those numbers. You can't say the new oral anticoagulants don't move the relative annual risk that much when the relative annual risk isn't that high to begin with!

Can you guess what any doctor with chronic afib would take as an oral anticoagulant when weighing the cost of a new set of golf clubs or having a stroke? I bet I know.

petey

One other thing:

Consider that about 5 million people in the US have afib, most of which have a score of 1 or more (and btw, I hear many stories of people with a score of 0 having strokes), that means for every 1% reduction in strokes, 50,000 people are spared... year after year. In 20 years, that is 1 million people for every 1% reduction. But they aren't important because the absolute risk is only 1%. Or are they? Numbers lie.

Like all drugs, with usage, the price will come down. Research costs work like that. Let's not stop progress.

petey

OK, one more "one other thing":

His post bothers me so much that I have to add a little more. It talks to the point I was making that you can't make statements about patients with a broad range of CHADS scores.

He says:

"Again, our AF patient has a 96.9% chance of not having an embolic event on a NOAC drug and a 96.2% chance of not having one on warfarin."

Wait a minute,... if your CHADS is 1 (consider an anticoagulant), your risk is only 1.3... so your annual chance of not having a stroke is 98.7%. If your CHADS score is 2 (when you MUST take an anticoagulant), your annual chance of not having a stroke is 97.8%... what the what? Why take an anticoagulant at all? Your risk of an anticoagulant bleed is ZERO when not taking an anticoagulant and if your CHADS is 1 or 2, your absolute chance of NOT having a stroke is between 98.7% and 97.8% respectively. Something's not right with his thinking.

Oh, and his math is wrong anyway. He said:

"From Figure 1: There were 31 830 patients treated with NOAC drugs and 25 661 treated with warfarin. There were 186 ICH events in the NOAC group and 317 in the warfarin group. The absolute risk for ICH was 0.58% with NOAC drugs and 1.24% with warfarin. The NOAC drugs prevented 131 ICHs. The absolute difference between the two groups was a mere 0.65%."

1.24% minus .58% is .66%, not 65%. Not a big difference, but when I see math mistakes, it makes me think someone didn't think something out fully, or their predetermined belief (or hypothesis) is showing.

I guess the most troubling thing is that I can't believe doctors are just discovering "absolute risk". We have been trying to beat it into their heads for years to stop all the b.s. and tell us the absolute risks of stroke versus absolute risk of a side effect (or death) from treatment is. And then when they apply it (absolute risk), they don't apply it properly. It can't be, or those with CHADS scores of 1 or 2 SHOULD NOT be on anticoagulation. After all, buying no anticoagulant saves money for the health care system and the chance of a stroke is slim. Explain that to me doctors.

Sorry for beating this dead horse, but my confidence level in what doctors say has dropped so low, it reinforces my belief we have to be our own advocates... particularly when we got higher marks in math then they did in college. Oops. :-)

petey

Thank you so much , now i am royally confused .lol i go once a month and my lowest INR has been 1,9 they increase the dose and i go for weekly INR TEST
ususally it hovers around 2,4 2.6 or 2.9

thanks

ray

Ray: Any anticoagulant works. I don't remember your CHA2DS2Vasc score, but if you tolerate whatever you are taking, stay with it. Don't overthink this stuff. No-one knows for sure what is best for YOU. They haven't done a study or trial on "Ray from L.A. "! petey