Episode 112: Dabigatran versus Warfarin, James versus Mike, Right versus Wrong

In episode 112, Mike and James discuss the who, what, why, where and when of dabigatran in atrial fibrillation. We look at the data, and then discuss what we as individuals would do when making a decision between dabigatran and warfarin. At the end we both agree to disagree with the fact that we agree to disagree.

Show notes

The full content of this Podcast, including the audio file, is available to Premium Members only. Click to find out the benefits of having a Premium Membership.

Why Get A Premium Membership ?

Comments

Dabigatran

What about compliance issues with Dabigatran? My concern is that is some patients without monitoring may be more likely to start missing doses and therefore have worse outcomes. IE just like we see happen with statins and non-compliance

Also no easy antedote for bleeding.

peter loewen

I used the sparc calculator for a newly diagnosed afib and talked about dabigatran being a little better than the warfarin with the patient, but I didn't have the exact numbers. I emailed Peter about it and he said he was going to try to work on it over holiday. Solid podcast. In the states the 110mg isn't even available and I couldn't understand why... it's just as effective and safer... I guess my problem is trying to understand the FDA.

long term

Loved this discussion in the podcast. My one problem with any new LIFELONG drug is not the quality or power of the study, but the duration. Anticoagulation is a lifelong committment. Right now, we know that warfarin is safe on a lifelong basis, although it is inconvenient. This is one situation where it would be essential to wait a good 5 years to see if we start knocking off people unexpectedly over time, especially with the MI trend data. We don't want to see another rofecoxib or (insert any weight loss drug name here) repeated...

Dabigatran reversal

Is there a way to reverse the anticoagulation with Dabigatran? That is the concern I have hear from colleagues in Anesthesia and Heme? Do you just have your patient sign a contract stating they will never have a car accident or need emergency surgery before taking the drug?

Dabigatran reversal

From the Anesthesia point of view, the above comment is very much the point. It seems irresponsible to put out a drug, especially an anticoagulant, that has no reversal agent and no reliable and accurate way to measure its activity level. I know they spin that as an advantage, "not needing monitoring", but the fact is they have no test available. This is the same lack of forethought as the introduction of drug eluting stents. Patients need roughly one year on Plavix and ASA before reliable endotheliazation occurs. If you take someone off the drugs for surgery and see the ST segments starting to rise intra-op, well good luck. They need a fast trip to an interventional cath lab, not something that is available in all centers. A bit less greed in the pursuit of The Next Big Thing and a bit more responsibility, please.

your colleagues at TI say http://ti.ubc.ca/letter80

Licensing of dabigatran 150 mg BID for atrial fibrillation is premature, pharmacologically irrational and unsafe for many patients.
The optimal dose of dabigatran for non-valvular atrial fibrillation is not yet clear.
An independent audit of RE-LY is needed to check for irregularities in conduct, sources of bias and the cause of the unusually high incidence of intracranial hemorrhage in the warfarin arm.
An independently conducted double-blind RCT comparing dabigatran with warfarin in patients with non-valvular atrial fibrillation is required.
Taking antiplatelet drugs in combination with oral anticoagulants doubles the incidence of major bleeding events.

Do you guys care to comment
andrew