Thursday, April 17, 2014

When are treatments equivalent? Dr. John Mandrola and I disagree (a little bit) ....

A few months ago, Dr. John Mandrola, a prolific web-based author who opines on a variety of health related matters, especially those that are heart rhythm related, published the above piece at Medscape Cardiology.

The NOACS are four Novel Oral AntiCoagulant drugs (dabigatran, rivaroxaban, apixaban, and edoxaban) that challenge the well established status quo, warfarin, for the prevention of stroke in patients with a heart rhythm disorder called atrial fibrillation (AF). I've written about AF and the rationale for OACs in this blog here and here. Compared to warfarin, some of these drugs have been shown to prevent strokes (related mostly to clots) without increasing (and in some cases decreasing) the risk of bleeding. The combination of these 2 feats is amazing since they tend to oppose each other. The occasion of Dr. Mandrola’s opinion piece was the recent publication of two meta-analyses of the NAOC drugs versus warfarin: huge superstudies performed by pooling the data from 4 large randomized trials comparing each individual NOAC with warfarin.

I like Dr. Mandrola: I follow him on twitter and I always try to read his work. While I agree with much of what he writes, I cannot agree with his conclusion that the new oral anticoagulants (NOACs) are "equivalent to warfarin", nor that they are "grossly overvalued".

If you or a loved one has atrial fibrillation, this may be of interest to you, but it will be a bit technical. You'll get a chance to see how docs consider high quality data.

Here's a link to his article, which includes links to the relevant meta-analyses of the NOAC drugs. In case you can't get into the article (registering at Medscape with an email address is required and probably worth it), here and here are links to those studies, but I'll only be discussing the first one.

See you in a few days with my thoughts on the matter.

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