I have an uncle that has just retired as a GP, a couple of months ago we were discussing the things that we thought would change before I retired.
Here are some of my mystic predictions
- Actually thrombolysising strokes in the UK
- Finding out more about syndrome X and finding out exactly how being fat causes diabetes
- I don't think I'll be using much Warfarin in 10 years time.
Warfarin is an annoying drug. The thing is that it's useful, it saves lives. If you have Atrial Fibrillation warfarin will stop you having a stroke. But we all process warfarin differently - for instance I may need 3mg a day to thin my blood, but you may need 10mg. Also lots of medications interact with wafarin - some do, make it more effective, some make it less effective.
So you need lots of monitoring to keep an eye on Warfarin, you have to go to Warfarin clinic every so often and record your results in your yellow book. Sometimes if you drink more than you normally do, or even eat lots of cranberries you find out that your blood isn't clotting enough.
We don't use Warfarin as much as we should - if we follow the guidelines, but lets face it that's because putting older people who fall over a lot on Warfarin is clearly a dumb idea.
So if we could have something that did the job of Warfarin but had less risk of the blood not clotting properly then it would be great. Obviously Warfarin has to stop clotting a little bit, so that will cause some risk of bleeding. The problems with warfarin occur when the clotting is stopped too much, so the bleeding occurs too easily.
If we could have something with a narrower theraputic window that would be just fantastic. We have injectable once daily varieties of Heparin, which are useful but lets face it rather expensive. Especially if you need a District Nurse to give the injection. We probably could teach patients to inject themselves though..
Well, so far so good. There's a study in the NEJM which indicates that there may be something new on the horizon. I consider this A Good Thing. I expect their will be problems with it soon enough. There always is with new drugs that look really good at the start.
Here's a link to the abstract : LINK
Looking at the trial in more detail there's one rather obvious thing that strikes be - this isn't blinded. If there's one thing that annoys me is when people go to all the trouble of doing a trial but design it in a silly way. Of course they tried to analyse it separately and minimise the risk, and of course there are various reasons why randomising Warfarin is difficult. But I still think it would be possible.
And for hevens sake we have blinding for a reason! It's standard practice. So why abandon it just because it's tricky.
Otherwise it's a well conducted study with impressive results. We'll have to see how useful Dabigatran turns out to be, and whether or not it starts being used clinically.
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