Costo-Efectividad Dabogatran

The Relative Cost-Effectiveness of Anticoagulants: Obvious, Except for the Cost and the Effectiveness Jerry Avorn Circulation 2011;123;2519-2521; originally published online May 23, 2011; DOI: 10.1161/CIRCULATIONAHA.111.030148
Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX 72514 Copyright © 2011 American Heart Association. All rights reserved.Print ISSN: 0009-7322. Online ISSN: 1524-4539

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://circ.ahajournals.org/cgi/content/full/123/22/2519

Subscriptions: Information about subscribing to Circulation is online at http://circ.ahajournals.org/subscriptions/ Permissions: Permissions & Rights Desk, Lippincott Williams &Wilkins, a division of Wolters Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Fax: 410-528-8550. E-mail: journalpermissions@lww.com Reprints: Information about reprints can be found online at http://www.lww.com/reprints

Downloaded from circ.ahajournals.org by on July 5, 2011

Editorial
The Relative Cost-Effectiveness of Anticoagulants
Obvious, Exceptfor the Cost and the Effectiveness
Jerry Avorn, MD
he search for a safer and more tolerable anticoagulant alternative to warfarin has been the holy grail of thromboembolic research for decades. With its capacity to reduce the risk of ischemic stroke by nearly two thirds in patients with atrial fibrillation, warfarin remains one of the most powerful preventive tools in all of medicine.1 But inthe 57 years since the drug was introduced, generations of clinicians and patients have become all too familiar with the difficulty of establishing and maintaining an adequate level of the international normalized ratio (INR) in the face of intercurrent illnesses, the use of myriad interacting drugs, and dietary changes. Partly as a result, anticoagulation remains woefully underused in patients forwhom it could do enormous good.2 Sensitive to problems that result from commission more than from omission, physicians often overestimate the likelihood of hemorrhagic complications and underestimate the consequences of failing to prevent embolic events.3

T

Article see p 2562
This is especially true in older patients, whom prescribers excessively perceive to be poor risks foranticoagulation, because they are frail or more likely to fall— even though these are the very patients at highest risk for preventable atrial fibrillation-induced stroke.4 Although there is good evidence that well-run anticoagulation clinics can help patients to hit the sweet spot of an INR of 2 to 3 consistently, most receive warfarin without benefit of such services. As a result, the average patientprescribed warfarin spends a distressingly high proportion of time either over or under the safe INR range. The prospect that pharmacogenetic testing could guide warfarin dosing, although now enshrined in the official labeling for the drug, has not been borne out as a compelling clinical or economic strategy.5 The search for a better alternative to warfarin has had several false starts and blind alleys.One of the most notable of these was ximelagatran, a direct thrombin inhibitor. It had been in use in Europe, but marketing plans in the United States were suspended when it was found to cause potentially fatal hepatotoxicity.6 In 2010, the Food and Drug AdminisThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association. From the Division ofPharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School. Boston, MA. Correspondence to Jerry Avorn, MD, Harvard Medical School, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women’s Hospital, 1620 Tremont St, Suite 3030, Boston, MA 02120. E-mail javorn@medsoc.harvard.edu (Circulation. 2011;123:2519-2521.)...