Can somebody explain to me the deal with Eliquis?
Eliquis is one of the new anticoagulants that is starting to take the place of Coumadin. It's a wonderful thing, because Coumadin has to be monitored so carefully with blood tests and interacts with everything. The newer anticoagulants don't need to be monitored in the same way and have lower risk of bleeding. Win-win, right?
Except the problem with Eliquis is that it's not reversible. If you're on Coumadin and you have a big bleed in your head or GI tract, they can give you Vitamin K to reverse it and hopefully stop bleeding. If you're on Eliquis, you just have to wait for it to get out of your system.
I could accept this risk because of the benefits of Eliquis except that there are other newer anticoagulants such as Pradaxa that have lower risk of bleeding, don't need to be monitored, and they are reversible.
I can't figure out why people keep prescribing Eliquis instead of a reversible alternative. It's the most prescribed of the newer anticoagulants, yet I've never heard a physician give a really good reason why they would pick that over something reversible. I casually looked up the literature and I don't see anything compelling there either.
I don't get it. Can somebody please explain this to me?
Kickbacks? Attractive drug reps? Sheer laziness? Ignorance?ReplyDelete
But I really do like my own doctor - really.
Both eliquis and xarelto have reversal agents in clinical trials. I tend to avoid Pradaxa because patients often have trouble swallowing the huge pill. It also has a tendency to cause pill esophagitis.ReplyDelete
Eliquis is also the only one to really show superiority over coumadin as far as bleeding rates as well as CVA prevention.ReplyDelete
In addition, pradaxa got reamed out by the BMJ a few years ago for fudging data and the lawyers went bonkers over it. Pradaxa only relatively recently got a reversal agent so this whole argument was moot until a year ago at best anyway. ANd even if not, reversal in the case of a big bleed doesn't make a big difference clinically unfortunately when the drug is out of the system in 24 hrs anyway.
Now if you needed emergency surgery a reversal agent that worked quickly(within a couple hours or so) would be cool but I don't think the pradaxa reversal agent is that quick.
I use eliquis/xarelto/coumadin and rarely pradaxa in part for those reasons. Never used the newest one(sadevya or some such) because so far I've seen nothing to suggest it's better as far as bleeding or CVA prevention.
And the suggestion of kickbacks/attractive drug reps/laziness is just insulting.
To echo what Kassy said above, the DOACs (Pradaxa, Xarelto, Eliquis) are simpler to take (don't have to do INRs, fewer medication interactions). With respect to the bleeding risk and reversibility, for ICH, the literature shows that once the bleeding happens, the horse is out of the barn; you can reverse warfarin/Pradaxa but it doesn't show a mortality or morbidity benefit (the GI bleeding literature is a little less definitive but trends in a similar direction). Having a reversal agent is a bit of a false comfort.ReplyDelete
I blame the drug reps and Big Pharma.ReplyDelete
-There is less overall bleeding with apixaban and rivaroxaban.ReplyDelete
-If significative bleeding do happen, having an antidote won't help much in most case since the damage is already done by the time they arrive at the hospital (intracranial bleeding, for exemple). Either ways, apixaban's and rivaroxaban's antidotes are coming in the next 1-2 years to answer those clinician's fears, though it probably won't change much the outcome of bleeders.
-Apixaban is also the best tolerated/studied in patients with renal failure, which is a very attractive feature considering that the population anticoagulated is often eldery and at risk.
-Fewer interactions, less labile anticoagulation, less follow-up (but I agree that dabigatran has these too).
(As you probably already know, I would also point out that you don't reverse coumadin with vitamine K when there is an urgent need for reversal (exemple : a life threatening bleeding), since it would take as much time to reverse it that way that it would for the DOAC to be eliminated. But yea, you can speed it up with fresh frozen plasma/beriplex/etc)
A very timely link to Journal Watch from my e-mail earlier this week
OK, this all makes a lot of sense.ReplyDelete
Novel anticoagulants have such a short track record. I don't think they have been on the market long enough to elucidate all the possible adverse reactions. I've been on Coumadin which is cheap effective and reversible. Why enrich Big Pharma when a proven drug is available.ReplyDelete
Remember Dorothy Hammil and all those Viox ads. I stuck with Motrin and that turned out to be a good choice. Just because something is new does not mean it's better than a proven choice
It's worth noting that all of these DOACs have a much shorter half life than coumadin, so the reversability isn't as much of an issue as many make it out to be. In the case of major traima, vitamin K takes between 4-6 hours to reverse coumadin, so I don't see how it's very helpful to these patients, especially when they are likely to get prothrombin concentrate complex in ED anyway. I guess it's more useful to think about for semi-emergent surgery (like appendicectomies), but even then, it takes 24 hours for the DOACs to be out of your system, so I doubt there would be a statistically significant difference between morbidity and mortality her. But I'm a trauma junkie, not a haematologist, so what do I know?ReplyDelete
Eliquis is better for elderly patients. In ARISTOTLE, lower risk of bleeds, lower mortality when used vs warfarin.ReplyDelete
ROCKET, the trial for xarelto, has been plagued by the POC INR readers overestimating patient's INR, meaning a lot of patients were probably subtherapeutic but reported as being therapuetic.