New oral anticoagulants promise to impact hospitalists and their patients—but the question is how much
When the FDA gave the nod to factor Xa-inhibitor rivaroxaban in November for use in treating acute DVT and pulmonary embolism (PE), it was just the latest development in the swiftly evolving world of oral anticoagulants—a world that hospitalists had better get used to living in, and quick.
As many as 80% of the patients that hospitalists encounter are on some kind of anticoagulant, experts say. But the extent to which the emergence of the new drugs— particularly rivaroxaban, which also is approved for stroke prevention in nonvalvular atrial fibrillation (afib) and for DVT and PE prevention in knee and hip replacement patients—will affect the daily routines of hospitalists remains to be seen.
Hospitalists specializing in VTE prevention and vascular experts say that the new drugs will make life simpler for hospitalists in some ways, mainly because for some patients, a pill will replace the injectable enoxaparin that has been used to bridge patients to warfarin. But with more options available, things will become more complicated as well, they say.
Approvals for the new agents, which aim to replace warfarin and its need for constant monitoring and concern over drug and food interactions, have been coming rapid-fire. Along with rivaroxaban in the new oral anticoagulant group are dabigatran, approved in late 2010 for stroke prevention in nonvalvular afib, and apixaban, which is expected to be approved for the same indication this year.
“Of all three drugs, [rivaroxaban] has the broadest indications for use,” said Hiren Shah, MD, assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director of hospital medicine at Northwestern Memorial Hospital in Chicago. “Because of that, it’s likely that it’s going to be the agent that will be adopted much more broadly and more easily than dabigatran.”
But apixaban might come on strong in the U.S. when it’s approved because it shows better promise for patients with renal impairment and has a lower risk of intracranial hemorrhage, says Geno Merli, MD, director of the Jefferson Center for Vascular Disease and chief medical officer at Thomas Jefferson University Hospital in Philadelphia.
“I think the two other [manufacturers] are afraid of apixaban because apixaban’s safety profile was much better,” he says.
Steven Deitelzweig, MD, FACP, SFHM, secretary of the Gulf State chapter of SHM and a DVT prevention specialist at Ochsner Health System New Orleans, says hurdles to adoption of the new agents will include whether a system is integrated and can assure appropriate follow-up and concerns over proper patient selection and cost, as the cost-benefit analyses haven’t been done yet.
“The learning curve, or the adoption curve, is really going to be very variable around the country,” he says.
Experts agree changes are on the way as the new anticoagulants gain more traction. Here are some things they say hospitalists should watch out for.
Care and Discharge
Dr. Shah says the availability of the oral agents will streamline care and discharge of patients.
“The care and coordination process that needs to occur with the use of parenteral agents and warfarin is significantly more complex than the patient education and care coordination that will be required with the new oral anticoagulants,” he says. “That’s where there’s a significant time savings.”