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GPs face curb on warfarin alternative as CCGs warn of soaring drug bills

Exclusive: GPs face restrictions on their use of the first alternative to warfarin to be approved on the NHS in 50 years, after PCTs and clinical commissioning groups began frantically drawing up prescribing policies to soften the financial impact.

NICE last week gave the green light for GPs to use dabigatran in patients with atrial fibrillation and one additional risk factor for stroke, after evidence it could reduce risk by up to 40% compared with warfarin. But GP commissioners are warning its use as an alternative to warfarin could push up the overall primary care drug budget by as much as 20%, and cost some areas £10m in the new financial year.

CCGs plan emergency measures to limit the impact on the 2012/13 budget, with some to allow GPs only to prescribe the drug to high-risk patients not suitable for warfarin.

The restrictions could turn dabigatran prescribing into a new battleground between CCGs and practices. They could also put CCGs at risk of legal action, particularly with the Government set to insist all drugs recommended in NICE appraisals are included in local formularies within 90 days.

NICE published a final version of its appraisal of dabigatran approving use of the drug after rejecting an appeal by NHS managers, who had argued it would bust drug budgets.

NHS Salford predicted the recommendation would have ‘one of the largest impacts on the NHS to date', but NICE argued it would prove cost-effective in the long term.

Professor Carole Longson, director of the NICE health technology evaluation centre, said: ‘Because dabigatran does not require frequent blood tests it represents a useful alternative for people with atrial fibrillation.'

But leaders of PCTs and CCGs are alarmed at the immediate costs – of around £1,000 extra a year per patient – and the need for wholesale service redesign.

NHS North Yorkshire and York said it faced a £4m financial risk from use of dabigatran, and that it would have to consider decommissioning other services to manage it.

NHS Somerset estimated the prescribing costs of dabigatran would be £9.5m annually – compared with the current £1m for warfarin enhanced services – and plans to give detailed advice to local GPs restricting the drug only to patients at highest risk.

Dr Donal Hynes, PEC chair at NHS Somerset and vice chair of the NHS Alliance, said dabigatran would be a ‘huge cost pressure' and that he planned to restrict GP use to patients who were housebound or had unstable INR levels.

Minutes of the Carlisle locality board warned ‘there is an issue of affordability', and said guidance would be issued to GPs. Dr Peter Weaving, chair of the group and joint chair of Cumbria Clinical Senate, said he hoped local GPs would use the drug only ‘very cautiously': ‘Use of dabigatran as a replacement for warfarin could add 20% to primary care prescribing costs.'



How dabigatran could add to costs


Annual prescribing costs estimated by NHS Somerset (compared with £1m for warfarin services)


Annual cost per patient estimated in Carlisle


Cost per quality-adjusted life year estimated in NICE appraisal


Price per pack assumed in NICE appraisal

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Readers' comments (1)

  • I have Grossly Enlarged L. Atrium. 2 Clots bobbling about inside 8 Jan-2008. Warfarin for Life. MI 4 weeks after that TEE scan I self test INR effectively and report to Warfarin Clinic the result. My AF got progressively worse until Dec 2012 Pacemaker Implant. I have Brady-Tachycardia with my heart stopping at 30bpm and topping out at 130bpm. Amioderone useless and Dangerous Dronederone was far worse. Gosh I'm an OLD MAN too too expensive for NHS to keep me alive. My Cancer in 2009 and Diabetes for 2010 was just not acceptable - far too costly Where is my dabigatran you say - they say we would rather you drop dead. You are costing too much. I am now on waiting list for another Angiogram - I suspect that will be ignored RHS sent me home but sent the man in the next bed for his to Stoke Yes we were both scheduled to have it done on the same day. Due to a cock-up allegedly at RHS lists were cancelled I was already marked up as Nil By Mouth. I got sent home next day my next door bed mate - somewhat younger got his done. Well I have been told unequivacally by a consultant in that Hospital that I have had my "Three Score Years and Ten - What more can you expect" My wife was not thrilled sitting next to me in the consultants room. If You are OVER 65 and hope the NHS will look after you having paid a Lifetime contribution as many have and a darn site more have not DON'T EXPECT the NHS to fund your life and look after you. It will rarely happen. Oh yes I have seen Patients verbally abused and Dignity removed. It is all a case of Gi's a Job I need the money these days Nursing is no longer a vocation the NHS is a Vacation for many. Yes I am Soured by my experience but with-holding drugs like dagabitran is Abuse of Patient Human Rights. That is a phrase I do not normally use or condone. Human rights should only be interpreted as Human beings Respecting other Human beings. Hope I am still around next year to read this page again.

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