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Thursday, December 16, 2010

Isn't Coumadin supposed to be dead?

Coumadin - the drug Cardiologists love to hate.

Ever since I was a medical student, I've be amazed what patients requiring Coumadin have to go through. Coumadin (warfarin) is a blood thinner, ie it keeps the blood from clotting. It is used for many conditions - atrial fibrillation, after placement of metallic heart valves, blood clots in the legs or lungs and many other conditions.

Its action is very dependent on diet, its very effected by the amount of vitamin K ingested. Therefore, patients must have frequent blood tests to ensure the level of their blood thinnest is safe (level of anti-coagulation). We use the INR to measure this. An INR of 1 is normal. For atrial fibrillation, we aim for an INR 2-3. For other conditions, we aim for an INR of 2.5-3.5. Keeping patients within this narrow therapeutic window can be difficult. Too low, patients blood and clot - in atrial fibrillation this increases the risk of a stroke. Too high, patients can spontaneously bleed. Therefore, patients need to have their blood tested at least one a month. If the levels are off and adjustments in dosage need to be made, patients may need weekly blood tests. This is a big deal for patients who need this medication indefinitely.

For years, I've been looking forward to a new medication for patient with atrial fibrillation to take Coumadin's place. I envisioned that all my patients would be immediately switched to this drug. I thought we would be able to close the Coumadin Clinic which we run in my office (15-25 patients come through this clinic on a daily basis).

Well, that time is here. But, the reality of American medicine is keeping my above dream from becoming a reality. Dabigatran (Pradaxa) has been released. It is a new class of medications called factor Xa inhibitors). Clinical trials have shown that it works better than Coumadin. It reduces strokes and other embolic and reduces significant major bleeding events. Also, its absorption is consistent and not effected by diet. Therefore, as long as it is taken morning and night, NO blood tests are required.

So, why are so few of my patients jumping on the dabagatran bandwagon? $$$$$ Coumadin, specifically generic warfarin, cost pennies. Depending on my patients insurance plan, Pradaxa costs $90-300/month.

So we have a medication that works better and is safer but is not being used because insurance companies will not pay for it.

My hope for 2011 is that more of my patients will be able to be afford this new Rx. As more and more Factor Xa inhibitors come to the market (at least 3-4 are in the works), market forces will push down the price making each Rx cheaper.

If you are interested about leaning more about this new Rx, please talk to your physician.


  1. Coumadin is definitely a nightmare for those of us who have (or have had) atrial fibrillation. In my case, INR testing once a month was not enough--I had it weekly, sometimes twice a week--and was still never stable (for genetic reasons). Pradaxa (and the coming Xarelto and others) are the holy grail for patients who are like I was. Cost was originally an issue, but I've been hearing from patients that their doctors have provided vouchers from BI, the manufacturer, helping them afford Pradaxa. Ask your BI rep about this. It's been a lifesaver for those I've heard from.

    Mellanie True Hills

  2. Thanks Mellanie. We have received some vouchers from BI. The Rx is still quite expensive. I do hope the price will decrease, more insurance companies will make it Tier 1 or 2 and more of my patients begin to use this impressive new Rx