A third option for stroke prevention in AF.

Willingness to exercise, or lack thereof
December 2, 2012
Dietary data
April 1, 2013

Great news yesterday. Health Canada approved apixaban (Eliquis) for stroke prevention in atrial fibrillation. http://m.theheart.org/article/1483463.do. It joins dabigatran (Pradax) and rivaroxaban (Xarelto) as oral anticoagulants that do not require blood testing. All three of these are great options for patients and much easier to use than warfarin, which they are meant to replace.

I do not know this drug as well as the other two yet. But it’s initial data are very promising. Less stroke than patients treated on warfarin and a much lower bleeding risk. From what I do know, it looks very promising. I will come up to speed quickly, rest assured!

Warfarin remains a reasonable option for some, and it is the only appropriate option for some patients, e.g. those with mechanical heart valves. But for many patients these new drugs are a great option and much easier to use. These drugs have transformed how we try to prevent stroke in patients with atrial fibrillation.

Any thoughts or experience with these new drugs?? Let me know, leave me a comment!

Until next time,

Dr. John Vyselaar

2 Comments

  1. Anonymous says:

    Have used both Warfarin and Dabigatran. Warfarin definately the more econimical choice but does have draw backs with the constant testing and how easily you can drift off the mark if you are not consistent with your diet.

    Dabigatran is definately much easier to use. Only concern (and albeit small) is what happens if a have a major bleed from and injury (crash), the new drugs are not easily reversed?

    Still a bit confused on the science. If the new drugs are all anticoagulants how do they pose less risk of bleeding?

    Regards,

    Stephen Sutherland

  2. Great questions Stephen. A major injury is bad with any anticoagulant, whether warfarin or one of the new three. For warfarin there are antidotes, but they work slowly, over several hours. Vitamin K takes 2-3 days for full reversal. With the newer agents there are no approved antidotes – conventional treatment (from warfarin) such as FFP and cryoprecipitate may be helpful, but this is not proven. However the drug level declines fairly rapidly, over 1-2 days, so there is little left in the system by the end of day two. All bleeding, such as from an auto crash, is treated roughly the same, with pressure on the site of bleeding and volume replacement (iv fluids, transfusions, etc) being the same regardless of each anticoagulant. So far observational studies have not shown any significant difference in outcomes from major bleeding with warfarin vs the new blood thinners – in fact, in one study, there was a trend towards better outcomes with dabigatran vs warfarin, but as I recall the difference was small.

    You asked about induced bleeding from an accident such as an auto crash, Stephen. As I mentioned this is serious regardless of which anticoagulant you take. The lower risk of bleeding seen with the new anticoagulants refers to spontaneous (non-traumatic) bleeding. Most of these bleeds are treatable, the most serious would be spontaneous intracranial hemorrhage, which is uncommon for all blood thinners, and less with the new ones.

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