15 Background - AF Warfarin is effective, 2/3 risk reduction for CVA Better than maximal antiplatelet therapyCumbersome to useDiscontinuation rates highMany patients have inadequate controlSeveral drug interactions
16 Dabigatran etexilate Oral prodrug –rapidly converted to Dabigatran Predictable bioavailbility80% renal excretion½ life hrs“does not require regular monitoring”
22 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 warfarinMore major GI bleeding with 150 Dabigatran
26 Can we Rely on RE-LYFairly good INR control -64% (Rosendal) for warfarin to be equally effective – 74%No hepatic toxicityDoes have some interactions –P-glycoprotein inhibitors verapamil, amioderone & quinidineLower dose for renal patients ?Risk stratification for GI pathologies
27 Can we Rely on RE-LYIs selective antithrombin activity a mixed blessing?“Because of Dabigatran’s 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 Efficacy OutcomesApixabanEnoxaparinIntended treatment periodno. / total no. (%)no. /total no. (%)All VTE and death from any cause104 / (9.0)100 / (8.8)Major VTE and death from any cause26 / (2.0)20 / (1.6)Symptomatic VTE and VTE-related death19 / (1.2)13 / (0.8)
34 2011 & beyond ????? New drugs licensed Costs will need to be competitiveNICE recommendation clinical & cost effectivenessWarfarin wobblers & patients on interacting drugs may be changed overNo INR monitoringMore complex patients e.g. VR may stay on warfarin for the benefit of monitoring
35 The future of anticoagulant services ? There will still be a need for clinicians with specialist knowledge & experienceDiagnosing & initiating treatment for DVT has been developed by many anticoagulant nurses where this service works well it will probably be maintainedSome old drugs are still in use despite the introduction of modern alternatives (UFH)
36 From the Health Service Journal ‘Clunky’ GP contracts raise questions on quality 8 October 2009 | By Sally GainsburyThere 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 contrastsIf 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 ?
37 From the Health Service Journal ‘Clunky’ GP contracts raise questions on quality 8 October 2009 | By Sally GainsburyMs Helen Northall says the absence of a value for money focus in primary care is evident in the results of Primary Care Commissioning’s latest benchmarking survey, which found huge and persistent variations in what PCTs pay for ostensibly the same thing.
38 Discussion PointsA “tighter” control with Dabigatran gives fewer bleeds ?The bleeds only need supportive treatment?