Features November 2013 Issue

Know the Latest Thinking on Warfarin Alternatives

Three new anticoagulant medications are on the market, but each has its own risks and benefits that you should discuss with your doctor.

For many patients, such as those with irregular heartbeats, or who have survived heart attacks, warfarin (Coumadin) is a well-tolerated and effective protection against the formation of blood clots. But like any medication, it has some drawbacks and isn’t well tolerated by everyone who needs it.

One of the biggest issues with warfarin is that patients must have periodic blood work done to determine whether they need a change in their dosage. Blood is taken, and if it clots too quickly, a higher dose of warfarin is advised; if clotting takes too long, a lower dose is recommended.

Warfarin alternatives that have been approved by the U.S. Food and Drug Administration in recent years do not require regular monitoring. The new drugs include dabigatran (Pradaxa), rivaroxaban (Xarelto), and apixaban (Eliquis).

And while having warfarin alternatives is helpful for patients and doctors seeking options, there are still concerns surrounding these medications, too.

or example, two recent studies found that dabigatran is associated with a slightly elevated risk of heart attack. And a third study found that patients with mechanical valves faced an elevated risk of bleeding complications with dabigatran.

Steven Nissen, MD, Chairman of the Robert and Suzanne Tomsich Department of Cardiovascular Medicine at Cleveland Clinic, says the concerns about dabigatran should be taken seriously, though he notes there are no official warnings about the medication and that it appears to be as safe and effective as warfarin for many patients.

“The story is still incomplete on dabigatran,” he says. “There’s no easy yes-or-no answer on it.”

He adds that the three new warfarin alternatives are also more expensive than warfarin, and that’s not likely to change soon.

“I think if a patient is doing well on warfarin, and doesn’t mind the inconvenience of monitoring, then there’s probably no need for a change,” Dr. Nissen says. “Apixaban may end up being the best of the bunch, but it’s newer, so we don’t have as much experience with it.”

He expects more useful information about all these drugs to emerge in the next few years. Until then, Dr. Nissen advises patients to talk with their doctors about the risks and benefits of their current medications and any alternatives.

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