The End of Coumadin?

Are we finally seeing the end of Coumadin?  In the 9-15-11 edition of the NEJM, we read the results of the ARISTOTLE trial which demonstrated the superiority of apixaban over coumadin in patient with AFib in preventing stroke.  Apixaban (also known as Eliquis) in an oral Xa inhibitor.  The Averroes study had already shown that in prevented stroke in AFib at 5 mg BID.  Now this ARISTOTLE study shows that it is even better than Coumadin at doing so - with less bleeding and less mortality!

Dabigatran (Pradaxa) is already being given to patients instead of Coumadin for non-valvular AFib.  It's a direct thrombin inhibitor.

Rivaroxaban (Xarelto) is another oral Xa inhibitor (like apixaban) that's been shown to possibly be better than Coumadin for AFib in the ROCKET-AF trial.

Cost?  Well.....Pradaxa will cost patients around $250/month at their local drug store.  Ouch!  That can be a car payment.  That's roughly $8/day, whereas Coumadin can be $1/day or less.  Eliquis will likely be similar.  So the question is how are we going to get patients to pay eight times more than what they are already paying.  Well - in the long run, it's probably is more cost effective, given the blood tests to check the INR and especially if there is truly less bleeding with the newer drugs.  Will Medicare put them on a different schedule?  The less bleeding and the mortality benefit will certainly get their attention.

What about for indications other than AFib?  What about prosthetic valves?  What about other hypercoaguable  states?  PE, DVT, and on and on....  It will be a while before any of these new drugs are FDA approved for use in mechanical valves.  Likely, there will need to be large clinical trials and Europe will try it out first and then we'll see.

Honestly, I am looking forward to saying bye to Coumadin - warfarin - rat poison - whatever you want to call it.  No more checking PT and INR and worrying about the narrow therapeutic range.  Too high?  Too low?  Too many green leafy vegetables - one of the healthiest things you can eat.  What do we do about the cost?  Drug companies need to make millions of dollars.  Insurance companies need to make millions of dollars.  And so patients can't have what doctors want to give them?  C'mon...really?