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When it comes to blood thinners, follow the money

What is your first reaction to the multitude of ads seen every day on television for new medications? It could be curiosity. Will this new medication help my family or me? But be careful. The question you should be asking is "from where does the money come?"

There are big bucks to be made when a new medication comes to market. Clever commercials grab our attention. They relay the magic of their pill by showing happy, healthy customers jogging in parks, laughing with friends, and even holding hands in bathtubs or on mountaintops. Who wouldn't be interested?

Here is the cautionary tale of a kind of new medication that might impact you or a loved one.

I recently received a letter from the manufacturer of a medication called Eliquis. The company is getting ready to begin a television advertising blitz, and they wanted doctors to be in-the-know before the commercials began. This new blood thinner, used most commonly to prevent blood clots that can be caused by atrial fibrillation, is one of four new medications that the FDA has approved for its specific condition.

It is meant to replace Warfarin, an inexpensive, generic blood thinner. There is a good reason to find an alternative to warfarin for many people.  Warfarin, the generic form of Coumadin, is a pain to use for both the doctor and the patient. When someone goes on it, they need a weekly blood test until the proper dose can be individualized. Plus, it was once the main ingredient in rat poison, which is not especially appealing!

For this reason, the holy grail that cardiologists have sought to find is a medication that does not involve frequent blood tests, and now we have not just Eliquis, but four other options to choose from.

The first of these medications cleared to be on the market by the FDA was Pradaxa, and recently it has received a lot of bad press.  A report in the British Medical Journal suggested that the manufacturer of this medication might have fudged data and cut corners in the race to get FDA approval more quickly.  Why? The first product on the market has a big advantage.  As the first approved blood thinner for atrial fibrillation to not require regular blood tests, it was on the fast track toward acceptance. Being first has really paid off; sales for Pradaxa were $1.66 billion in 2013.

The second product to market was Xarelto. It is already well into a direct-to-consumer campaign. But there can be a downside to such a high profile.  One commercial on television last week for Xarelto was followed minutes later by another ad for the same medication, this one from an attorney looking for clients suggesting that they sue the company because of increased risks of bleeding… which brings me back to the letter I received the other week.  Eliquis is the third one to hit the market, and the company that makes it clearly senses an opportunity.

Why do pharma companies feel the need to begin a campaign directed at consumers?  Because they truly believe that the medication is better, and want to inform the public? Perhaps, but one cannot deny the financial stakes as well. The winner of this competition will likely dominate the market to prevent stroke from atrial fibrillation, and is estimated to bring in as high as $9 billion in sales.

Are these drugs actually better than warfarin, which has been the standard of care for 60 years? The color green clouds the issue, and until more information emerges over time, I would suggest taking the following issues into consideration:

  1. Are you on other medications that have drug interactions with warfarin? The new anticoagulants have the advantage of not having as many interactions.

  2. How much will it cost out of pocket per month? The new medications, which are not available in a    generic form, are often formidably expensive, and may not be covered by your insurance

  3. Is the lack of an antidote to reverse the bleeding effects of the new medications a deal breaker for you? You need to wait 24-48 hours for the effects to wear off from all of the new blood thinners if you should need emergency surgery. Warfarin, on the other hand, has an antidote.

  4. Do you mind the inconvenience (required of warfarin) of having to get a weekly blood test until your blood thinning is just perfect? Beginning warfarin is akin to what happened with Goldilocks and the three bears. Your blood cannot be too thin, or too thick. It has to be just right. It can take a month or two for your doctor to find the right dosage, and after that time your blood will still need to be checked once per month

  5. Will you need to stop other blood thinners that work very differently, such as aspirin or Plavix?  Neither of these blood thinners is especially effective to prevent stroke when you have atrial fibrillation, so it is important to understand the differences between these blood thinners as you make this decision.

  6. Do you get squeamish when your blood is drawn, or have tiny little veins that make it hard to have blood tests?  If so, warfarin may not be for you.

If you are starting on blood thinners this year, it is important to have a conversation about these alternatives with your doctor, as you now have many choices.  If you are already on one of these medications, it is never too late to ask questions. If you happen to stumble upon two bath tubs on a mountain top, enjoy!


Dr. David Becker is a board certified cardiologist with Chestnut Hill Temple Cardiology in Flourtown, Pa. and has been in practice for 25 years. In 1993, after extensive research, Dr. Becker launched Healthy Change of Heart™, an innovative 10-week program designed to reverse heart disease and improve quality of life through diet, exercise, and stress management. Since then, thousands of patients have participated in the program, achieving significant results in improving cardiac wellness.