Friday, September 28, 2012


The first decade of the 21st century had seen the proliferation of a whole host of new anti-coagulants, which were touted as an alternative to the famous rat poison, warfarin. These new groups, some of whose names I have difficulty pronouncing, I often call the -xatans, and the - gatrans. They include dabigatran, apixaban, rivaroxaban, etc., etc. They are all either factor Xa inhibitors or direct thrombin inhibitors. They are expensive ( obviously more expensive than warfarin, which is dirt cheap ). After all these years of trials, what is their role. I suppose, their role in preventing DVT is established. Dabigatran's role in stroke prevention is also FDA approved, but I must say that my own reading tells me that the 110mg dose does carry with it an increase risk of bleebing, which is of great concern for us.
Well, Dr Andras Komosci and colleagues at University of Pecs, Hungary, did a meta-analysis of 7 large scale randomised, placebo control clinical trials on these -xabans and - gartrans, and their role in Acute Coronary Syndrome ( ACS ) management. These new anti-coagulants were use on top of anti-platelet agents. The meta-analysis involved about 31,000 patients with enrolled in these trials from Jan 2000 till Dec 2011. In their meta-analysis, they found that although there was a mild to modest benefit, in terms of ischemic symptom improvement, there was no benefit in death, because, the ischemic symptom benefits were greatly outpaced by a nearly 3x increase risk of bleeding.
Overall, looks like the new anti-coagulants ( factor Xa inhibitors and the direct thrombin inhibitors ), works and does reduce thrombus and ischemia, but have this problem of bleeding, at their current recommended dose. If you try and reduce the dose, to lower bleeding, it may not work so well to reduce thrombus formation. So basically much more work needs to be done.
Besides, it is also much more expensive.

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