Warfarin vs. New anticoagulants?

In my office, when a patient comes to me for the first time, it is my job to try to “steer” them in the right direction in regards to which anticoagulant they should choose to go on.  I always tell them I am only a “guide” but can’t/won’t make the decision for them.  I go through the agents that we have on formulary and the pros and cons of each. It can take some time, as I like to hit the highlights of each agent, and there are many.  Some patients end up staying on aspirin only, some start warfarin, and some start the new anticoagulants. (I am not going to get into why someone would choose which agent on this post)

Warfarin is highly effective for the prevention and/or treatment of most thrombotic disease, but the significant interpatient and intrapatient variability in dose-response, the narrow therapeutic index, and the numerous drug and dietary interactions associated with it have led clinicians, patients, and investigators to search for alternative agents. As of this post, there are four new orally administered anticoagulants. (apixaban, dabigatran, rivaroxaban, and edoxaban)  I have experience with the first 3, as the last one is not on formulary yet.

I always dread the question “What would you do if you were me?” Of course, I try not to answer that, as I don’t want to sway my patients in one direction or the other.  Most of the time, I can give an honest opinion about what agent would be the best option for them. There are many things a practitioner needs to consider when helping a patient choose the appropriate agent for them.  Things to think about are their medical conditions, current medications they take,  their clotting and bleeding risks, compliance with taking medications, ability to get to a lab for draws, intellectual capacity, family support, are they able to see visually, and the list goes on…

So, I guess I am trying to say is that in my world, it’s not a one stop shop for getting warfarin. I DO prescribe other agents. Each one has its place and there are good and bad things about both.  But, I will look at your individual situation/case and derive the best choice for you along with your opinions. Always question your provider if he or she only presents one option for you, as in most cases, there is more than one option!

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