New anticoagulants (blood thinning medication), dabigatran, rivaroxaban and apixaban, have come onto the market since we first interviewed people about their experiences of atrial fibrillation (AF). Designed to reduce the risk of stroke, the medications offer an alternative to warfarin for people with AF. Like all medications, they have both advantages and disadvantages.
Dr Tim Holt discusses the pros and cons of the new anticoagulants.
Attitudes to new medications
At the time of our first interviews, some people were aware that new medications were becoming available and welcomed the possibility of taking a drug which would free them from the constraints of regular blood tests. James had already spoken to his GP about the possibility of taking a new medication, and said “I’d love to be on them because it’d save me going for the [blood] tests.”
Mary said she would consider paying privately to take suitable alternatives, if they were not available on the NHS but were appropriate for her.
Martin was interested in an alternative anticoagulant which did not need monitoring and had no side effects.
Brendan had discussed the newer anticoagulants with his doctor but was happy to stay on warfarin.
Yet some people we talked to were ambivalent or remained wary. Dot had heard of the new medications but felt that taking warfarin and having blood tests now was “a small price to pay” to prevent a stroke. Others expressed concerns, including the cost of the new drugs to the NHS (and whether this would impact upon prescription rates), and problems with the lack of an antidote to reverse the effects of the drug in people with life-threatening bleeding. For Eileen, the new anticoagulants were just “too new for my liking.” She wondered whether the effects of the newer drugs could be reversed in the case of internal bleeding: “they can reverse warfarin; there’s no antidote for the other ones yet.” For the moment, she continued to take warfarin, adding that it was “better the devil you know”.
Anne was also cautious: “there’s always a miracle drug coming onto the market, which a little way down the road, you find has got real problems.” Similarly, Freda did not expect the new drugs to be “miracle cures”.
David X pondered whether new alternatives had been sufficiently trialled, and recognised the role of the National Institute for Health and Care Excellence (NICE) in decision-making.
David Y supported the introduction of new drugs, but believed cost prevented them being more widely available.
Experiences of taking new anticoagulants
We spoke to 4 people who had started taking the new anticoagulants since we first interviewed them. For them, the opportunity to take medication which offered similar protection against stroke as warfarin but without the need for constant monitoring and blood tests was one of the main advantages of the new anticoagulants.
David X’s doctor advised him to start taking rivaroxaban instead of clopidogrel (a drug which reduces the risk of blood clots forming) when he turned 75 because “they believed I need a proper anticoagulation therapy and not just clopidogrel.”
James found it “a pain in the neck” having to go “a couple of times a week” for blood tests in an unsuccessful attempt to get his levels of warfarin right. He said he was “all set towards having another stroke”, when his doctor prescribed rivaroxaban.
After resisting pressure to go on warfarin for years, Elisabeth X finally decided to go on dabigatran to reduce her risk of stroke.
Anne’s doctor recommended rivaroxaban after she experienced problems with warfarin. She has not had an episode of AF since.
One of the key concerns expressed by people taking the new anticoagulants was the increased risk of bleeding and lack of an antidote. As Elisabeth X said: “If I were in say a car crash or had a really serious fall, the risk of bleeding can’t be controlled.”
Dr Tim Holt explains that while bleeding can usually be managed in hospital, unlike warfarin, the new anticoagulants do not have a simple antidote.
Elisabeth X hopes that an antidote will be developed for the new anticoagulants.
David X and James have both had problems with bleeding since taking the new anticoagulants. They are unsure whether this is related to their blood-thinning medication. About 6 months after starting rivaroxaban, David X noticed “there was bleeding subcutaneously (beneath the skin)” on either side of his left ankle which in a short time became “a really big haematoma” on his left thigh.