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Comparison of the New Blood Thinners for Atrial Fibrillation

by Dr. Sharon Orrange on February 12, 2014 at 11:22 am

Coumadin (warfarin) has been the mainstay of treatment for stroke prevention in folks with atrial fibrillation. When the atrium is fibrillating, and losing its atrial kick, there is a higher risk of clot forming in the atrium which will break off into the ventricle, then head to your brain and cause a stroke.

For that reason, we treat some folks with atrial fibrillation with blood thinners to prevent that stroke risk. Major changes have occurred in this area where newer more convenient anticoagulants (blood thinners) have emerged. This new group of 4 meds saves you from having blood tests routinely to check your levels, which is called having your “INR” checked. So are these newer agents worth it, and is one better than the other?

Here is what you need to know:

  • The four new players: rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Lixiana) and dabigatran (Pradaxa). Xarelto, Eliquis and Lixiana are what are called factor Xa inhibitors and Pradaxa is a thrombin inhibitor.
  • Compared to warfarin (Coumadin) these four newer anticoagulants result in less major bleeding or intracranial hemorrhage but slightly more gastrointestinal bleeding. Generally, the newer anticoagulants are considered safer than Coumadin because of this smaller risk of bleeding into the brain.
  • The risk of stroke if you have atrial fibrillation is lower on the newer anticoagulants than Coumadin, so all four of these medications appear slightly safer than coumadin.
  • There are no comparisons yet of these 4 new blood thinners to each other. So whether you use Xarelto, Eliquis, Pradaxa or Lixiana may depend on cost to you. These four medications are expensive because they are newer brand name drugs.
  • These four meds are more similar than they are different so which one you use will come down to cost, whether once a day or twice a day dosing is easier, and if you have kidney problems, one may be better than the other.
  • In addition to being slightly safer than Coumadin, the newer anticoagulants are more convenient (you don’t have to have blood tests to check your levels), you won’t have dietary restrictions, and there are fewer drug-to-drug interactions.
  • One downside: If you take a new anticoagulant (not warfarin) is there is no way to reverse the blood thinner effects. In other words, there is no antidote yet, unlike with Coumadin where we can give Vitamin K to reverse its effects.

Safer, maybe slightly better, but more expensive.

What do you think?

Dr O.

Pradaxa, Xarelto, and Eliquis are currently available, and may cost from just under to just over $300 per month. All three have manufacturer co-pay cards (for insured patients) and assistance programs (for uninsured patients) available. Lixiana (edoxaban) is currently approved in Japan, and as of January 2014 the manufacturer has submitted an application to the FDA for approval in the US.

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