Best Practices: New Treatment for Pulmonary Embolism

From the New England Journal of Medicine, April 5th 2012--


For decades, Coumadin has been used to keep the blood thinned in people who have had blood clots in the heart, lungs, and legs. Coumadin is very tricky: once a week to once a month, blood levels must be drawn, and adjustments made to insure a person has 'enough' Coumadin to keep the blood thinned, but not too much so that it could cause massive bleeding and death.


Entire "Coumadin" clinics with full time staff have been set up to 'monitor' these thousands of patients to insure they receive safe amounts of Coumadin. However Coumadin is the same chemical used to kill rats and mice! So, we're giving people rat kill to keep them safe from dying of blood clots. There MUST be a better answer.


Several new drugs are on the market now, most having their initial studies and FDA indications for Atrial Fibrilliation-where the heart quivers, instead of squeezes evenly and regularly, and has a high rate of causing clots to form in the chambers of the heart. Those clots are then pumped into the circulation where they can be trapped in the brain (stroke), the small vessels that feed the heart muscle (heart attack), or to the lungs (Pulmonary Embolism).


Science is science, and if we're thinning blood in the heart, and preventing clots, then it follows we could do that in the lungs, or elsewhere. So, a study was done proving that a new drug called Xarelto, with a chemical name of Rivaroxaban, could, in an open-label study of 4,832 adults with symptomatic Pulmonary Embolism (PE), be 50% safer and as effective as Coumadin.


The 4,832 patient study was published in the New England Journal of Medicine in April 2012, on pages 1287-1297, proving that Xarleto was safer than Coumadin, required NO blood testing, and best of all Xarleto has less than 50% of the death rate associated with Coumadin use, whether we looked at 3, 6, or 12 month periods. 


As mentioned, instead of getting stuck every week, every two weeks, or once a month- no lab tests are required-meaning Xarleto is FAR SAFER than Coumadin, and does not go too low or too high in blood levels in the body. It's time you or your loved one got off the rat poison and got on safer Xarleto for the conditions described-including Symptomatic PE (where the person is very tired, or short of breath, or their chest hurts when they breath).

Newer, Safer Treatment for Stroke Prevention

From an article in the November 1st 2010, Annals of Internal Medicine: There's now a More Cost Effective, Better, Newer, Widely Studied, and already in use in Europe for years, medication: Dabigatran (Pradaxa), that is a MUCH safer treatment in preventing stroke and heart attack, in people with atrial fibrillation, (A-Fib), which is better than 'standard' warfarin (Coumadin), in use in the U.S. for decades. (Atrial Fibrillation, typically called A-Fib, is when the top two chambers of the heart beat irregularly, and due to this quivering, can cause a blood clot to form, and then flow to a small vessel in the heart or brain causing a heart attack or stroke). Many of us, count me in, NEVER liked the idea of prescribing patients the active ingredient in RAT POISON (warfarin) for people with A-Fib. There HAD to be a better, safer answer! There now is!


Best of all, patients on Dabigatran will NOT need the constant weekly to monthly blood draws that Warfarin patients required. They won't need to change the dose based on foods, other medications, or changes in blood levels of Warfarin, like Warfarin patients MUST constantly do.


Too bad for those folks running large and expensive clinics to 'monitor' blood levels of Coumadin. They can close those expensive clinics, stop wasting time, manpower, and money doing and redoing lab tests, advising folks into constantly changing their dosage, and those clinics can stop burning millions of dollars to make sure patients received enough 'rat poison' to thin their blood, but not enough kill them. With these 'no-longer' necessary lab tests gone- those same funds (insurers had been paying labs to perform) can be used to pay for the safer therapy. It's about time!


Dabigatran's 150mg twice daily dosing is simple and reasonable. Another plus, while Coumadin reduced the chance of a person throwing a clot and causing a heart attack or stroke, it could also thin the blood too much, and cause a hemorrhagic stroke. These strokes happened way too often, in about 1.2% of those using Coumadin. The chance, in a recent study, showed hemorrhagic stroke in only 0.3% of those on Dabigatran (an occurrance 4 times less than that of Warfarin). Safety and efficacy!


The only hurdle remaining: Dabigatran's $13/day cost versus a dollar a day for Warfarin. But, as we mentioned: no more expensive blood tests, no more 'monitoring fees', no more dosage adjustments every week or two for Coumadin, and a huge reduction in ICU and Nursing Home costs for hemorrhagic stroke patients who 'bled out' on Coumadin and face a lifetime of suffering. From a safety standpoint: insurance companies NEED to replace Warfarin (rat poison) with Dabigatran. From an efficacy point(it works better and easier), insurance companies NEED to replace Warfarin, in favor of Dabigatran. From a monitoring standpoint: there are NO labs with Dabigatran, with Warfarin- those labs NEVER end.


The truth needs to be told: when a patient would have a sudden rise or fall in their 'rat poison' dose (Coumadin), they'd have daily lab tests, sometimes for weeks. Those lab costs, and the human costs: of losing work, of driving to and from the lab, some people dying or being injured for life from a motor vehicle accident (when they could have avoided the trip if they were on Dabigatran), and quality of life issues relating to getting daily labs done, and the anxiety of awaiting test results, AND the costs of a provider closely following those tests, and calling and reviewing the results, and reviewing the plan, burned massive time and the human energy of provider and patient alike. That series of worries and nightmares can be over!


Collectively, we need to remind insurers- our premiums are for our benefit-not theirs. Those premiums are meant to pay for necesary services and treatments, with the BEST outcomes and SAFETY records. Those funds are to provide services to the policy holders- with a small profit for the insurance company- not greedly levels of profits- or millions in pay for executives.


In the meantime: do not be intimidated or discouraged in requesting coverage for this safe drug for you or for your family members. It's time we end the use of 'rat poison' to treat A-Fib. It's time, it's safe, and Dabigatran (Pradaxa) can do much good. At Abobe Family Practice, we're discusing this important news, and changing our patients over, at their next follow-up visit, to the newer, safer Dabigatran treatment. We're here, in everything we do, to advocate for our patients, and insure they get the latest and safest treatment.


Over the years, we've filed hundreds of appeals to get our patients the treatments they need and deserve! If you're not bringing your family to see us, perhaps you should. It's about time!

"Silent" Cerebral Emboli May Hasten Dementia

From the American Journal of Psychiatry,(Association of Cerebral Emboli with Accelerated Cognitive Deterioration in Alzheimer's Disease and Vascular Dementia) March 1st 2012: Patients with Vascular Dementia and Alzheimer's Dementia often share a common brain injury--multiple small blood clots in the brain.


Called 'spontaneous' cerebral emboli, these small blood clots were found in 43% of patients with Alzheimer's and in 45% of those with Vascular Dementia. Scores in all patients with Alzheimer's and Vascular Dementias who had emboli had a more rapid deterioration than those without. Over a 2 year period, those with emboli had mental deterioration of 6.9 points on a 30 point scale, versus 2.4 points in those without emboli.


Unfortunately, in many areas of medicine we can image, examine, test and find abnormalities. We can then finely catagorize these abnormalities, but there are, at times, no treatments available. The 'spontaneous' nature of these clots eludes treatment, and eludes scientific work-up of potential causes. The sadest part: families have loved ones with the abnormal changes, and all they can do is wait for the deterioration to occur.


But it's this exact frustration which causes talented people in medicine and science to collaborate with others to find a treatment.