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Recent Developments In New Oral Anticoagulants Eric Watts Basildon Hospital.

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Presentation on theme: "Recent Developments In New Oral Anticoagulants Eric Watts Basildon Hospital."— Presentation transcript:

1 Recent Developments In New Oral Anticoagulants Eric Watts Basildon Hospital

2 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital

3 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital

4 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital

5 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital

6 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital Prevention of Atrial Fibrillation-Related Stroke

7 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital Prevention of Atrial Fibrillation-Related Stroke

8 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital Prevention of Atrial Fibrillation-Related Stroke

9 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital Prevention of Atrial Fibrillation-Related Stroke

10 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital Prevention of Atrial Fibrillation-Related Stroke

11 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital

12 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital

13 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital

14 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital

15 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital Background - AF Warfarin is effective, 2/3 risk reduction for CVA Better than maximal antiplatelet therapy Cumbersome to use Discontinuation rates high Many patients have inadequate control Several drug interactions

16 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital Dabigatran etexilate Oral prodrug –rapidly converted to Dabigatran Predictable bioavailbility 80% renal excretion ½ life 12-17 hrs does not require regular monitoring

17 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital

18 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital 3 groups well balanced Mean age 71 63% male Mean CHADS score 2.1 CCF Hypertension Age Diabetes Patient Baseline Characteristics

19 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital

20 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital Warfarin …………………….4.13% pa Dabigatran 110mg ……...…3.75% pa.ns Dabigatran 150mg …………3.64% pa.ns Mortality

21 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital Myocardial Infarction Warfarin ……………….0.53 % Dabigatran 110mg...…0.72 % p= 0.07 Dabigatran 150mg ……0.74% p= 0.048 Is the antithrombin effect cardioprotective?

22 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital Major Bleeding Warfarin…………….3.36 % Dabigatran 110 ……2.71 %, p=0.003 Dabigatran 150 ……3.11% n.s. Life threatening, intracranial Minor bleeding higher with warfarin More major GI bleeding with 150 Dabigatran

23 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital Haemorrhagic Stroke Warfarin …………................. 0.38% Dabigatran 110mg ………... 0.12% Dabigatran 150mg ……….… 0.10% NNT = 370 significant

24 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital GI bleeding & discomfort Discontinuation Warfarin ……………….……. 10.2%pa Dabigatran 110mg ……...…..14.5% pa Dabigatran 150mg …………..15.5% pa

25 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital

26 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital Can we Rely on RE-LY Fairly good INR control -64% (Rosendal) for warfarin to be equally effective – 74% No hepatic toxicity Does have some interactions –P-glycoprotein inhibitors verapamil, amioderone & quinidine Lower dose for renal patients ? Risk stratification for GI pathologies

27 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital Can we Rely on RE-LY Is selective antithrombin activity a mixed blessing? Because of Dabigatrans twice daily dosing & greater risk of non haemorrhagic side effects patients already taking warfarin with excellent INR control have little to gain by switching in contrast, many other patients who have atrial fibrillation and at least one additional risk factor for stroke could benefit from Dabigatran

28 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital Efficacy OutcomesApixabanEnoxaparin Intended treatment periodno. / total no. (%) All VTE and death from any cause104 / 1157 (9.0)100 / 1130 (8.8) Major VTE and death from any cause26 / 1269 (2.0)20 / 1216 (1.6) Symptomatic VTE and VTE-related death19 / 1599 (1.2)13 / 1596 (0.8)

29 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital

30 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital

31 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital From Xareltos Website

32 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital From Xareltos Website Post to: Delicious Digg Reddit Facebook StumbleUpon

33 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital

34 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital 2011 & beyond ????? New drugs licensed Costs will need to be competitive NICE recommendation clinical & cost effectiveness Warfarin wobblers & patients on interacting drugs may be changed over No INR monitoring More complex patients e.g. VR may stay on warfarin for the benefit of monitoring

35 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital The future of anticoagulant services ? There will still be a need for clinicians with specialist knowledge & experience Diagnosing & initiating treatment for DVT has been developed by many anticoagulant nurses where this service works well it will probably be maintained Some old drugs are still in use despite the introduction of modern alternatives (UFH)

36 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital Clunky GP contracts raise questions on quality 8 October 2009 | By Sally Gainsbury There are huge variations in what different PCTs pay for the same services, yet there is no detectable correlation between cost and quality or patient satisfaction. Sally Gainsbury looks at why commissioning has not yet addressed these stark contrasts If you have ever attended a conference on making NHS commissioning world class the dominant theme will have been primary care trusts getting to grips with their hospitals. You hear less, if anything, about what PCTs are doing to improve the value for money of their primary care contracts with GPs. There are huge variations in what different PCTs payfor the same services, yet there is no detectable correlation between cost and quality nor patient satisfaction. Sally Gainsbury asks why has commissioning not yet addressed these stark contrasts ? From the Health Service Journal

37 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital From the Health Service Journal Clunky GP contracts raise questions on quality 8 October 2009 | By Sally Gainsbury Ms Helen Northall says the absence of a value for money focus in primary care is evident in the results of Primary Care Commissionings latest benchmarking survey, which found huge and persistent variations in what PCTs pay for ostensibly the same thing.

38 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital Discussion Points A tighter control with Dabigatran gives fewer bleeds ? The bleeds only need supportive treatment?

39 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital

40 Recent Developments In New Oral Anticoagulants Eric Watts, Basildon Hospital Basildon Costs Pradaxa - both 75mg and 110mg are £48.30 for 60 – 80p each Xarelto is £47.40 for 30 tablets …….. £1.59 each


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