New Kids on the Block

Hospitals Collect Valuable Experiences with New Anticoagulant

In February, a patient was sent to Thomas Jefferson University Hospital in Philadelphia and was about to get a spinal injection for pain management. The patient had been assessed and it was noted that he was on a drug called Pradaxa, but no one thought much of it at the time—that is, until the anesthesiologist saw the newly approved anticoagulant on the patient’s list of medications.

“The anesthesiologist said, ‘This is sort of a funny drug,’ looked it up and said, ‘Oh, this is Pradaxa, this is an anticoagulant,’ so they stopped the procedure,” recalls Dr. Merli, Jefferson’s chief medical officer, who oversees patient drug safety. “If you look at the package insert for Pradaxa, it tells you that if you’re going to do spinal anesthesia or access the spine, you need to be off the drug at least 72 hours.”

Pradaxa, the brand name for dabigatran, was approved nine months ago and has been in use at hospitals across America for only a few months. But there already are potentially valuable experiences—some cautionary—to be shared by those who have added it to their formularies.

The bottom line, experts say, is that hospitalists have to educate themselves about the new drugs so that they are armed with the information needed to decide which patients to treat with which drugs. There also might be a certain amount of “unlearning” that will have to take place, because what applies to warfarin might not apply to the new drugs.

“Providers are just absolutely in tune with an obtaining INR [international normalized ratio] value and knowing that what that means in terms of anticoagulation [on warfarin]. Unfortunately, providers try to extrapolate that same interpretation to dabigatran. [But] the INR is not at all sensitive to the effects,” Dr. Pendleton says.

When one patient was about to be transferred to the University of Utah Medical Center with life-threatening bleeding complications, an outside hospital “just mentioned in passing that the patient was on dabigatran, but were falsely reassured that the INR value was not super-therapeutic.” So hospitals, he notes, need to have ideal laboratory tests in place to assess patients’ anticoagulation levels.

As dabigatran, and other new anticoagulants, come into wider use, it will be important for hospitals to share their experiences so that, collectively, patients will benefit, Dr. Pendleton says. His university’s thrombosis service Web page (www.healthcare.utah.edu/thrombosis) has links to information about the new drugs.

“I think that if hospitals pool together, people aren’t having to reinvent the wheel at the local level,” he says, “but there are resources available to help.”—TC