October 22nd, 2010

What Do I Plan to Do with Dabigatran?

1. Discuss its pros (no need for INR monitoring, less bleeding than coumadin) and cons (cost, dyspepsia) with my atrial fibrillation patients

2. Avoid its use in patients with renal dysfunction (CrCl  <60), liver disease, pregnancy or stroke within the past 6 months

3. Lament the absence of the INR monitoring requirement, which I currently use to (a) check on patient compliance with medication; (b) assess the adequacy of anticoagulation (especially in patients near the extremes of weight); and (c) detect potential drug interactions (although purportedly rare)

4. Worry that (a) the patient given dabigatran because of probable noncompliance with INR monitoring won’t comply with a twice daily drug regimen; and (b) I can’t reverse dabigatran’s effects when the patient has a major bleeding episode

5. Wait to see (a) whether future studies show a higher risk of MI with dabigatran than coumadin (as noted in RE-LY) and (b) if dabigatran is as effective as coumadin in patients with mechanical valves

6. Hide when the patient (or insurance company) gets the bill for the medication (estimated cost: ~$7,000 to $9,000 per patient-year, which is 4 to 5 times the cost of coumadin, even taking into account the increased physician and laboratory costs required to monitor INR).

Comments are closed on this post, but please join the conversation at our Dabigatran Resource Round-Up.

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