Re: Dabigatran etexilate versus warfarin in management of non-valvular atrial fibrillation in UK context: quantitative benefit-harm and economic analyses
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Dabigatran etexilate versus warfarin in management of non-valvular atrial fibrillation in UK context: quantitative benefit-harm and economic analyses
Re: Dabigatran etexilate versus warfarin in management of non-valvular atrial fibrillation in UK context: quantitative benefit-harm and economic analyses
Pink et al's brave economic analysis of the economics of dabigatran is a helpful pointer but is flawed by several real-world issues that are not considered:
1. The price of dabigatran is likely to fall in the medium term as competitive drugs are licensed.
2. The cost saving from not needing INR monitoring will depend upon whether warfarin clinics continue to run but at a lower workload, or close completely. In the former case their unit cost may well rise; in the latter the resource can be redeployed.
3. The need for some patients to continue on warfarin because of impaired renal function is not quantified.
4. Some patients failing to achieve therapeutic INR range on warfarin may be just as non-adherent with dabigatran (though the regimen is simpler to follow).
5. The authors do not indicate whether they have accounted for the cost of transport to clinics.
6. Many frailer patients refuse warfarin because they are unwilling to attend for monitoring; others with cognitive impairment cannot be trusted to adjust their dose in response to INR. These patients currently take aspirin, compared to which dabigatran is likely to be far superior for stroke prevention. It is problematic to deny these patients dabigatran.
7. There has never been a satisfactory mechanism in the NHS for transferring resource from secondary care to the primary care prescribing budget. Without this warfarin clinic resource is likely to disappear into the secondary care black hole.
8. The authors do not indicate any adjustment made for reduction of drug-related admissions.
9. Once sanctioned by NICE and publicised (as a breakthrough, perhaps correctly on this occasion!) by the Daily Mail, GPs will be overwhelmed by demand for dabigatran, because few patients enjoy regular monitoring.
Whilst it would be premature to recommend the wholesale closure of warfarin clinics before there are more long-term safety and efficacy data, we do not think the conclusion that dabigatran is 'unlikely to be cost effective in clinics able to achieve good INR control with warfarin' can be justified without considerable further refinement of the economic model.
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Re: Dabigatran etexilate versus warfarin in management of non-valvular atrial fibrillation in UK context: quantitative benefit-harm and economic analyses
Pink et al's brave economic analysis of the economics of dabigatran is a helpful pointer but is flawed by several real-world issues that are not considered:
1. The price of dabigatran is likely to fall in the medium term as competitive drugs are licensed.
2. The cost saving from not needing INR monitoring will depend upon whether warfarin clinics continue to run but at a lower workload, or close completely. In the former case their unit cost may well rise; in the latter the resource can be redeployed.
3. The need for some patients to continue on warfarin because of impaired renal function is not quantified.
4. Some patients failing to achieve therapeutic INR range on warfarin may be just as non-adherent with dabigatran (though the regimen is simpler to follow).
5. The authors do not indicate whether they have accounted for the cost of transport to clinics.
6. Many frailer patients refuse warfarin because they are unwilling to attend for monitoring; others with cognitive impairment cannot be trusted to adjust their dose in response to INR. These patients currently take aspirin, compared to which dabigatran is likely to be far superior for stroke prevention. It is problematic to deny these patients dabigatran.
7. There has never been a satisfactory mechanism in the NHS for transferring resource from secondary care to the primary care prescribing budget. Without this warfarin clinic resource is likely to disappear into the secondary care black hole.
8. The authors do not indicate any adjustment made for reduction of drug-related admissions.
9. Once sanctioned by NICE and publicised (as a breakthrough, perhaps correctly on this occasion!) by the Daily Mail, GPs will be overwhelmed by demand for dabigatran, because few patients enjoy regular monitoring.
Whilst it would be premature to recommend the wholesale closure of warfarin clinics before there are more long-term safety and efficacy data, we do not think the conclusion that dabigatran is 'unlikely to be cost effective in clinics able to achieve good INR control with warfarin' can be justified without considerable further refinement of the economic model.
Arnold Zermansky, GP and Senior Research Fellow, University of Leeds.
a.g.zermansky@leeds.ac.uk
Rani Khatib, Senior Pharmacist and Lecturer, University of Leeds.
Competing interests: No competing interests