With the advent of the
new novel oral anticoagulants (NOACs) and specifically, their role in patients
with atrial fibrillation (AF), the epitaph for warfarin is being written.
Leaving aside AF patients with mechanical prosthetic valves or rheumatic mitral
stenosis, for whom these agents are not indicated, there hardly seems a role
for warfarin in this population any more. In the aftermath of RE-LY (dabigatran vs warfarin), ROCKET AF
(rivaroxaban vs warfarin), ARISTOTLE (apixaban vs warfarin), and ENGAGE
AF (edoxaban vs warfarin), the
reports of these pivotal trials taken individually along with the data from
multiple meta-analyses examining them together clearly show that better
clinical outcomes are obtained with these new agents. All reduce stroke and systemic embolism at
least as well as warfarin; all are superior in reducing hemorrhagic stroke and
intracerebral bleeds than warfarin; some are superior to warfarin in reducing
all strokes and systemic emboli; and dabigatran is superior at specifically
reducing ischemic stroke. Simultaneously, the NOACs (several or all) have reduced mortality versus
warfarin and have reduced major and fatal bleeding versus warfarin. Gastrointestinal bleeding appears higher with the NOACs than warfarin (with the
exception of apixaban in the ARISTOTLE trial) but still with lower fatality.
None of the NOACs require anticoagulant blood test monitoring (in contrast to
warfarin) and all have fewer drug interactions than warfarin. While rivaroxaban requires significant food
intake at the time the dose is taken, none of the NOACs has the multiple food
interactions that can plague warfarin users and warfarin dosing. Additionally, as regards dosing, the options
with the NOACs are limited, and infrequently change over time, which contrasts
dramatically with the picture seen with warfarin. Finally, while the medication cost itself of
any of the NOACs is higher than that of generic warfarin, multiple cost-effectiveness
analyses have shown that when global costs are considered, including
factors associated with laboratory testing, care-related costs of strokes,
systemic emboli, bleeding, and the like, the NOACs are or may be
preferable. And, in my practice, the
higher costs of the NOACs can be lessened by obtaining them through discounted
pharmacy sources (such as at COSTCO) and can be offset by purchasing other
routine items in discount outlets (again, such as COSTCO) where the significant
cost savings on other products purchased can offset higher medication co-pays.
Credits: Dr. James A. Reiffel, MD