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GPs go forth

Call for monitoring of newer oral anticoagulants to help control bleeding risk

GPs should be given tools to monitor on-treatment blood levels of new oral anticoagulants to optimise their safety, US researchers have urged, after new ‘real-world’ data raised concerns about increased risks of bleeding in elderly patients.

The new data are published in two papers in the BMJ this week, looking at gastrointestinal (GI) bleeding with the new non-vitamin K oral anticoagulants (NOACs) dabigatran and rivaroxaban.

One study – which looked at almost 220,000 new users of dabigatran, rivaroxaban or warfarin – found the risk of GI bleeding was increased for the NOACs relative to warfarin after adjusting for patients’ underlying risk, with the increase statistically significant in older patients aged over 75.

For people aged 76, the GI bleeding risk was 2.9 times higher for rivaroxaban users and 2.5 times higher for dabigatran users, relative to patients on warfarin.

The oother analysis of 46,000 new users of these drugs found no difference in GI bleeds with the NOACs relative to warfarin – but the authors warned that, statistically, it was impossible to rule out the possibility of increased risk with the newer drugs.

Writing in an editorial accompanying the papers, Professor Mary Vaughan, from the University of Iowa, and Professor Adam Rose, from Boston University School of Medicine said patients taking NOACs should have their drug levels monitored, at least initially.

They wrote: ‘Given the variability in drug absorption that influences bleeding risk, patients taking newer oral anticoagulants might benefit from some kind of monitoring – perhaps not as frequency as for patients taking warfarin, but at least once or twice to guide decisions about dose.’

BMJ 2015; available online 24 April

Readers' comments (7)

  • Vinci Ho

    Again , like statin,we seem to have questions raised on the issue of these prophylaxis in over 75 years old patients....

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  • overall mortality is lower on new anticoagulants and apixaban(not mentioned) has lower bleeding risk than warfarin and better than warfarin at reducing stroke from AF etc

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  • More bleeds seen with aspirin due to larger volumes taking

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  • Just use warfarin. Duh.

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  • when was the last time you ever saw the HAS-BLED score included when a patient was started on an OAC? CHA2DS-VASC quoted liberally however. HAS-BLED is the better validated score (better predictor of outcomes) but virtually ignored. No internationally consistent guidelines on monitoring INR. No ability to monitor NOAC at all. 80% of the cost of Warfarin therapy in managing the complications. Studies looking at the risk and complications suggest we should take a hard look at the risks and benefits of OAC before embarking on this course. The mortality from thromboembolic stroke is 19%. The mortality from haemorrhagic stroke is 43%. The mortality from "major haemorrhage" (and it has to be pretty major to be considered as major!) is 27%. A little thought perhaps people? It is the patient taking the risk.

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  • Go back to warfarin

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  • Go back to the Ox and Cart

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