New anti-clotting meds for Atrial fibrulation

[NewGuy]

I’ve been taking Warfarin for 14 years; it keeps my INR in the 2-3 range most of the time. The side effects are a bit of a pain: purple blotches on my right arm, lots of dietary restrictions (floppy greens are restricted, cranberries and a hundred more - it really cuts down on what’s okay). Warfarin is inexpensive but the INR tests can add up - every week in Canada (free) and every two weeks here, my choice - do add up.

 

I asked a BPH doctor about other drug choices. He mentioned perhaps stopping Wararin and start using either 

 

1. Xarelto 20 mg

2. Lixiana 60 mg

3. Pradaxa 150 mg

4, Eliguis 5 mg

 

What are your experiences with these alternatives? Are all available here? Does one get a strong recommendation?

 

One reason I’ve stayed with Warfarin is that the INR test can tell you if you’re in range and a run to the hospital for a b-something shot will bring a too high reading right down.

[Sheryl]

#4 correct  spelling is Eliquis.

 

All 4 of these are in the category of "Non–vitamin K oral anticoagulants" and all 4 are recommended for people with A-fib.

 

Aside from not needing INRs, these drugs are safer because they have a less narrow therapeutic range and so less risk of bleeding (the therapeutic range for warfarin is very, very narrow so hard to get the dose right and easy to be under or over anticoagulated).

 

They do, however, also have a lot of drug interactions (though not quite as bad as warfarin -- and no food restrictions that I know of)

 

HOWEVER they are much, much more expensive. Only one of them has a locally made generic equivalent: Rivoxan is same generic as Xarelto (Rivaroxaban). So out of the 4, this would be the most affordable but it's still going to cost you a lot more than warfarin. Probably even taking the INR cost into account.

 

These articles may be of interest

https://www.uspharmacist.com/article/updated-afib-guidelines-tout-newer-blood-thinners

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4408611/

[NewGuy]

Thanks Sheryl. Lots of reading for me coming up.

[Lorry]

You should be able to get a prescription for Xarelto in Canada, bring as much as possible next time you enter Thailand

[NewGuy]

Thanks Larry, how much there?

[gargamon]

I took someone to the ER(Canada) a few weeks ago and overheard a number of doctors telling a couple of patients that eliquis is the gold standard for a-fib. They indicated it was significantly better than the alternatives.  No periodic blood tests required.

 

It is quite pricey, but if you're over 65, you get reduced prices in Canada, $25 CDN for 3 months worth. Each province has different criteria so the $25 may not be consistent across all of Canada. I checked the goodrx(USA) price and the same 3 months would cost well over $1000US. 

Edited April 27, 2022 by gargamon

[NewGuy]

Gargamon, boy, do I need this feedback. Cheers.

[ozimoron]

This is a very complex subject. What the specialists told me is that there is very little quality research done on warfarin despite it's use over many decades. About three years a go I had an abdominal blood clot in Pattaya and after several weeks of unsuccessful treatment by doctors with antibiotics I took my self back to Australia. In Thailand the doctors insisted that it was a infection but it was correctly diagnosed immediately in hospital in Australia. A week in hospital and many blood tests later they were unable to pinpoint a cause. Because of a family history of stroke and the lack of a cause I was put on indefinite warfarin, dosage between 1 and 2mg daily depending on INR. I returned to Pattaya and had INR tests weekly for a few months, average cost around 1,500 incl. doctors consultation at the hospital.

 

On a return trip to Australia, I saw a specialist again who said I should stay on warfarin rather than one of the newer doacs as warfarin had a lower risk of abdominal clotting. The specialist then told me that the chance of a reocurrence was very low. I bought an INR patient self testing machine and returned to Thailand. Test strips were hard to come by but I had some delivered by Roche in Bangkok.

 

Soon after I returned to Australia because of covid and eventually had an annual review where the haematologist said he'd take me off anti coagulants altogether as i was considered low risk. When I mentioned that I intended to return to Thailand he decided I should keep taking warfarin as there was a risk in Thailand if I had another clot. He offered to change me to eliquis which I accepted. He claimed that the risk of abdominal clots with eliquis was about the same as warfarin but eliquis was safer, despite not having an antidote available because of the short half life whereas warfarin can take days to clear without a vitamin K shot.

 

I found that very few foods actually affected my INR (when on warfarin) and it was easier to regulate my INR by eating more or less greens than it was to change the dose to chase changes in INR. Rarely did I drift out of therapeutic range. I'm much happier taking eliquis but wondering what the cost will be in Thailand. With the PBS scheme in Australia, it is $41 for a month supply, around $100 full price.

[ozfarang]

@ozimoron, ฿3845 for 60 5mg tabs of Eliquis at Medtide

[NewGuy]

Thoughtful, Ozimoron. I’ll need to read again, tomorrow. Thanks Oz guy.

[Meat Pie 47]

I take Xarelto but I get those purple spots on my arms as well

[Sheryl]

1 hour ago, ozimoron said:

This is a very complex subject. What the specialists told me is that there is very little quality research done on warfarin despite it's use over many decades. About three years a go I had an abdominal blood clot in Pattaya and after several weeks of unsuccessful treatment by doctors with antibiotics I took my self back to Australia. In Thailand the doctors insisted that it was a infection but it was correctly diagnosed immediately in hospital in Australia. A week in hospital and many blood tests later they were unable to pinpoint a cause. Because of a family history of stroke and the lack of a cause I was put on indefinite warfarin, dosage between 1 and 2mg daily depending on INR. I returned to Pattaya and had INR tests weekly for a few months, average cost around 1,500 incl. doctors consultation at the hospital.

 

On a return trip to Australia, I saw a specialist again who said I should stay on warfarin rather than one of the newer doacs as warfarin had a lower risk of abdominal clotting. The specialist then told me that the chance of a reocurrence was very low. I bought an INR patient self testing machine and returned to Thailand. Test strips were hard to come by but I had some delivered by Roche in Bangkok.

 

Soon after I returned to Australia because of covid and eventually had an annual review where the haematologist said he'd take me off anti coagulants altogether as i was considered low risk. When I mentioned that I intended to return to Thailand he decided I should keep taking warfarin as there was a risk in Thailand if I had another clot. He offered to change me to eliquis which I accepted. He claimed that the risk of abdominal clots with eliquis was about the same as warfarin but eliquis was safer, despite not having an antidote available because of the short half life whereas warfarin can take days to clear without a vitamin K shot.

 

I found that very few foods actually affected my INR (when on warfarin) and it was easier to regulate my INR by eating more or less greens than it was to change the dose to chase changes in INR. Rarely did I drift out of therapeutic range. I'm much happier taking eliquis but wondering what the cost will be in Thailand. With the PBS scheme in Australia, it is $41 for a month supply, around $100 full price.

It will be at least the full Australian price, maybe more since it has to be imported.

 

The least expensive of the new drugs will be Rivoxan (locally made generic equivalent to Xarelto).

 

Studies show that Xarelto and Eliquis are about equally effective. However risk of bleeding is higher with Xarelto and of all the drugs in this class Eliquis seems safest.

 

 

 

 

[ozimoron]

5 minutes ago, Sheryl said:

It will be at least the full Australian price, maybe more since it has to be imported.

 

The least expensive of the new drugs will be Rivoxan (locally made generic equivalent to Xarelto).

 

Studies show that Xarelto and Eliquis are about equally effective. However risk of bleeding is higher with Xarelto and of all the drugs in this class Eliquis seems safest.

That's in line with the advice i received. Eliquis has a lower risk of abdominal clots than Rivaroxaban which was the alternative I was offered. I was originally leaning toward that as it was daily but a urologist pointed out that twice daily Eliquis (Apixaban) means a lower half life. My initial concern was the lack of a fast and cheap antidote as is available for warfarin. I'm no doctor but listened carefully to the opinions of several specialists.

Edited April 27, 2022 by ozimoron

[NewGuy]

^{Good to read. Too bad there’s no absolute truth. I’ll call for prices tomorrow.}

[NancyL]

The lack of an antidote should be a consideration.  A husband of a suffered several bad cuts when a glass door at a shop broke while he was entering the shop.  He was taken to Chiang Mai Ram Hospital for but treatment was delayed for nearly two hours while they phoned around and finally located the antidote for the Xarelto, prescribed by a doctor at that hospital.  Mind you, this is in Chiang Mai where there are numerous hospitals and it still took this long to find the antidote.

 

It seems to be that if a doctor at a hospital is prescribing a non-vitamin K blood thinner, they should have the antidote stocked in their pharmacy.

[Sheryl]

3 hours ago, NancyL said:

The lack of an antidote should be a consideration.  A husband of a suffered several bad cuts when a glass door at a shop broke while he was entering the shop.  He was taken to Chiang Mai Ram Hospital for but treatment was delayed for nearly two hours while they phoned around and finally located the antidote for the Xarelto, prescribed by a doctor at that hospital.  Mind you, this is in Chiang Mai where there are numerous hospitals and it still took this long to find the antidote.

 

It seems to be that if a doctor at a hospital is prescribing a non-vitamin K blood thinner, they should have the antidote stocked in their pharmacy.

The antidote for Xarelto and Eliquis (Andexanet ) is not yet approved by the Thai FDA, much less is there any registered brand of it in country. In fact it is quite new, and was approved in the US only in 2018. I'm surprised the hospital managed to locate it at all.

[NewGuy]

The lack of an antidote is my big concern; I’ve need a vitamin K shot before - easy.