Anticoagulant

[Kristin391]

I am on coumadin secondary to atrial fib/flutter and prosthetic valve.  I have heard there is a new drug on the market that requires less monitoring and is safer to use.  What can you tell me about that?  Also, whenever I have a procedure done for whatever reason there is always the issue of coming off of coumadin and going back on.  Sometimes, they require me to be hospitalized early and go on heparin and one other time they merely had be take fragmin for a few days and go off coumadin. What is the best practice at your center.  Of course, I am concerned about thrombus formation etc.

What is your experience with home INR monitoring?  It would appear to be good thing, less cost etc.  If that is the case, then why isn't being used?  Are the monitors reliable?

[Cleveland Clinic]

Kristin,

The drug you are referring to is an oral direct thrombin inhibitor called ximelagatran.

Earlier this year, a study was published in the lancet that compared the drug to coumadin in the atrial fibrillation population. The conclusion of this study was that the drug was noninferior to coumadin. There were several critiques of the study design, and concerns about potential heaptic toxicity of the drug.  There is no data about using the drug with artificial valves, and the overall consensus is thaqt more work needs to be done before it becomes routine to use this agent.

There is also no conclusive data for using low molecular weight heparins for artificial valves.  Generally, our practice involves the type of valve and other patient charateristics (ejection fraction, diabetes, etc..) in the descision how to manage a hiatus of anticoagulation.

Home INR monitoring would require purchase of the machines and agents to do the monitoring. there is some question about reliabilitiy, but cost would be exceedingly high given the frequencyh of checks required by most people in steady state.

hope this helps.

good luck

[White Raven]

My husband has been self-testing on the ProTime Microcoagulation Monitor at home since March 2001.  He tests weekly. Not all insurance cover the monitor and supplies, but many do if the need can be proven.  Medicare now covers self-testing at home, and they require that participants test weekly.  There are now four monitors that are approved for home testing.  Our monitor is easy, safe, and takes about 6 minutes to do a test from start to finish.  Training is provided and the procedure is almost as easy as the procedure that diabetics use for home testing of insulin levels.  If you were to pay for the supplies yourself, the cost on one test would be about $9.00.  

A recent issue of Anticoagulation forum stated that 6,000,000. people worldwide are on anticoagulants.  100,000. of these self-test.  85,000. of these people live in Germany.  Perhaps the reason that there are so few people self-testing in the US is that most doctors and medical people don't know of the point-of-care monitors, or have not had experience with them and therefore don't trust them.  This seems surprising because so many doctors and cardiology practices use monitors to set up "Coumadin Clinics" in their offices.  Reliability data is available for all of the monitors, and some experts contend that the monitors are more reliable that lab tests.  Lab tests have many more variables to control.  I believe that self-testing is a wave of the future, but then....It did take many years and a leap of faith for the medical profession to approve home testing for diabetics.  NOTE: I am a retired educator, with no monitary interest in, or stock holdings of self-testing monitors or the companies that manufacture them, or the distributors who provide them.  My vested interest is my husband and his continued well-being.

[Kristin391]

I have done extensive research on these monitors.  It is very incovenient and costly to have blood drawn and run in a lab not to mention the feedback from them to me about what to do next.  I am very capable of self testing and most insurance companies are covering the costs.  These meters are very expensive right now to cover the R and D costs that went into the approval process etc.  Once the price comes down to be comparable glucometers, I am sure most will be doing self testing.  You can keep a tighter control etc.  The Dr. said that there isn't much testing once a steady state is reached but I am all over the board and have to test weekly.  There was one week I had to go every day to get it under control so that is why I am asking.

Thanks for all the information.  Germany provides much better health care support that us Americans have...

[White Raven]

Kristen: we should compare notes.  I have collected three notebooks full of articles on anticoagulation and home testing.
I agree with your comments, but I believe that the home monitors will continue to increase in cost, not because of R&D, but because of demand. There are 22,500 Medicare eligible people, and this itself should drive the price up.  The ProTime Monitor was approved for home testing in August 1997, and I believe the cost was less than $1,000.  When we bought out monitor, it was $1,200. and in three years the cost has become $2,000. But, for those who are not on medicare and are not covered by insurance the monitor people have many choices, including refurbished units, and financing.  Of the forty or fifty people that I correspond with on valvereplacement.com who have either Coaguchek or ProTime monitors, at least 10 paid for their own monitor, and continue to pay for their supplies. Everyone that I know who has a monitor swears by it.  It does give peace of mind.

I hope you resolve your concerns very soon and that a monitor is in your future.