Last Monday, the American College of Cardiology and the American Heart Association revised their guidelines for preventing stroke in patients with atrial fibrillation, making the new anticoagulant dabigatran an officially recommended alternative to warfarin. That action followed the FDA’s approval of dabigatran for preventing stroke in patients with atrial fibrillation (AF) last October, and the drug’s entry onto the U.S. market in early November under the trade name Pradaxa.
Patients with AF need daily anticoagulant treatment because of their high risk that a blot clot will form in their quivering heart atrium, enter the circulation, lodge in a cerebral artery, and cause a stroke. Until now, the only anticoagulant available to try to prevent this was warfarin, effective but notoriously hard to maintain at the right dosage and requiring patients to go to an anticoagulation clinic every few weeks to have their warfarin control checked and tweaked. The entry of dabigatran onto the U.S. market and now its designation as an officially-sanctioned alternative to warfarin opens a new anticoagulant era for the growing ranks of AF patients because with dabigatran visits to an anticoagulation clinic aren’t needed.
Last week, at the International Stroke Conference, I spoke with Dr. Margaret C. Fang, an AF specialist and director of the anticoagulation clinic at the University of California, San Francisco. Dabigatran prescriptions to AF patients are already being written by community physicians who may not have a handy warfarin clinic to refer patients to, she told me. “We’re hearing of patients in the community who are now on dabigatran who were never referred to the clinic. I think there will be a lot of enthusiasm in the community” for prescribing dabigatran. Despite directing an anticoagulation clinic that may soon become obsolete as new anticoagulants supplant warfarin, Dr. Fang said that she shared the enthusiasm “because I can see all the bad things that happen with warfarin.”
Last November, I spoke with another arrhythmia expert, Dr. Gordon F. Tomiselli, chief of cardiology at Johns Hopkins in Baltimore, who told me: ”Over the course of the next year, a lot of my patients will change from warfarin. What I hear from patients now who are on warfarin is, ‘When can I start with the new drug so that I can stop the rat poison?’”
It might sound like I’m shilling for the company that makes dabigatran, but I’m not. I have no disclosures, gain nothing from this changing of the anticoagulation guard. But I am impressed by the drug’s data, and by the response it’s received from experts who deal with warfarin and with AF. A new medical era is here. The dabigatranification of AF anticoagulation has begun.
—Mitchel Zoler (on Twitter @mitchelzoler)