Dr John M

cardiac electrophysiologist, cyclist, learner

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My latest on the NOAC drugs for AFib

March 4, 2017 By Dr John

Three weeks ago I wrote about the growing dominance of the new oral anticoagulant (NOAC) drugs for stroke prevention in patients with atrial fibrillation. (Another common name for these drugs is direct acting oral anticoagulants or DOACs.)

The post generated many comments–some privately and some on the blog.

Your responses induced me to think a bit more about the warfarin-substitute drugs. Thanks for that.

More thinking led to my most recent post on theHeart.org, which is titled: NOACs Are Favored Over Warfarin: I’m (Almost) Okay With That

In this column, which is written for a medical audience, I start by noting the many positives of the new drugs. Then I discuss our collective experience with drugs–also quite positive.

But then I cite reasons for caution.

It turns out there is a lot of nuance to see in the industry-sponsored warfarin vs NOAC studies. Enthusiasm makes it harder to see nuance. What’s more, the dabigatran (RELY), rivaroxaban (ROCKET-AF) and apixaban (ARISTOTLE) trials each suffered from “irregularities.” None of these blemishes were enough to stop FDA approval.

But the NOAC trials have not been independently confirmed. Given the closeness of the results, the complexity of the data and the trials’ irregularities, independent analysis of the data would increase my level of certainty on these new drugs.

Here is a teaser from the column. My editor and I went back and forth on whether this comparison was appropriate.

“My (probabilistic) guess is that time will prove our embrace of the new anticoagulants was the right call. It’s a good bet, but it’s not a sure bet. Many clinicians were quite sure that treating depression in adolescents with paroxetine or high-dose imipramine was beneficial. That was until independent researchers reanalyzed the famous Study 329 and found no evidence of efficacy of the drugs and an increase in harm.[17]

You can decide.

JMM

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Related posts:

  1. 2017 update on the changing use of “blood thinners” for AF
  2. Update: Social justice of AF care, NOAC monitoring, population health and two new podcasts
  3. New post up at Medscape Cardiology: Are novel anticoagulants better than warfarin?
  4. New post up on Trials and Fibrillations…Apixaban (Eliquis) was supposed to beat Pradaxa and Xarelto?

Filed Under: Atrial fibrillation, Dabigatran/Rivaroxaban/Apixaban, Doctoring

John Mandrola, MD

Welcome, Enjoy, Interact. john-mandrola I am a cardiac electrophysiologist practicing in Louisville KY. I am also a husband to a palliative care doctor, a father, a bike racer, and a regular columnist at theHeart.org | Medscape

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Find me on theheart.org | Medscape Cardiology

  • Electrophysiology commentary on Medscape/Cardiology

Mandrola on Medscape

  • My Medscape column on general medical matters

For patients...Educational posts

  • 13 things to know about Atrial Fibrillation — 2014
  • A new cure of AF
  • Adding a new verb to doctoring: To deprescribe is to do a lot
  • AF ablation — 2015 A Cautionary Note
  • AF Ablation in 2012–An easier journey?
  • Atrial Flutter — 15 facts you may want to know.
  • Benign PVCs: A heart rhythm doctor’s approach.
  • Caution with early Cardioversion
  • Decisions of 2 low-risk cases of PAF
  • Defining success in AF ablation in 2014
  • Four commonly asked questions on AF ablation
  • Inflammation and AF — Get off the gas
  • Ten things to expect after AF ablation
  • The medical decsion as a gamble
  • The most important verb in our health crisis
  • Wellness Requires Ownership

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