What is so new about the new generation of anticoagulation drugs? No side effects or reaction with other drugs, no INR monitoring and easy management are just the top-of- the list advantages of these new drugs over the age-old heparin and warfarin, says Dr. JS Hiremath in an interview with Dr. Manish Verma. “Atrial fibrillation, venous thromboembolism, pulmonary embolism are a few heart diseases which require use of anticoagulation drugs.” “While Dabigatran , rivaroxaban, apixaban and edoxaban, all new anticoagulation drugs, have done well in the trials, there would be preference for one drug over another in specific situations.” “For instance, rivaroxaban or apixaban would be the best choice for renal dysfunction while Dabigatran 150 mg for stroke prevention.” Dr. Hiremath cites ‘people living longer’ as a reason for more incidence of atrial fibrillation, a condition in which heart beats out of rhythm. “For patients of STEMI, ACE inhibitors, specifically ramipril remains the drug of choice. And in specific cases of intractable cough where ramipril cannot be used, which is the case with 15-20% patients, valsartan- an ARB can be used.”

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Complete Transcript:

Dr. Manish Verma You recently spoke at the congress on new arrival anticoagulants. For many years, heparin and warfarin has been synonymous with anticoagulation, but now we have an armamentarium of newer anticoagulants. What is your take on that? How they are going to affect the management of the patient’s who needed anticoagulation in Cardiology.
Dr. JS Hiremath Phenomenally, because non-valvular atrial fibrillation is on the grow in our country, all over the world and after almost 55 years,we have something which is challenging the old treatment. They are smooth by way of side effects,easy to manage, very short-acting and there are so many advantages of the newer anticoagulants that we have to change our mind sets and shift to the newer ones for non-valvular atrial fibrillation, venous thromboembolism, pulmonary embolism, so this shift will take place.
Dr. Manish Verma You were specifically mentioning about non-valvular indications. What is about the valvular indications? What does their study say?
Dr. JS Hiremath Valvular is still the domain of the warfarin or Coumadin derivatives. These newer anticoagulants are not tried in valvular atrial fibrillation or they are contraindicated in prosthetic valves, so it is a non-valvular atrial fibrillation and related thromboembolism.
Dr. Manish Verma There were few studies on acute coronary syndrome says that, can u please tell us more about that?
Dr. JS Hiremath It is still budding actually. Rivaroxaban especially can be used more for acute coronary syndromes as compared to other, but it is yet to be approved by the FDA and yet to be practiced by all of us, but I would say that Dabigatran has a longest experience for systemic stroke prevention. Apixaban, edoxaban and rivaroxaban are almost reaching there 02:00 and we will see that in the years to come, we will be talking mainly about these rather than the old warfarins.
Dr. Manish Verma What is your take on the agents. There are many agents, so is it one is better than the other or all are same or how do you …..?
Dr. JS Hiremath Once a day advantage is with rivaroxaban. All trials are very robust. They have done more than for 15,000 to 18,000 patients. So, there is a little to choose between one from the other, but if you have highest chance of stroke and less chance of bleed, I would put Dabigatran 150 mg as the drug of choice. If you have renal dysfunction then I would put rivaroxaban or apixaban is slightly better and edoxaban is making the entry too.
Dr. Manish Verma You also mentioned that atrial fibrillation is increasing in Indians as well and any particular reason for that or any particular way to detect it and how the physician should be carefully looking for it?
Dr. JS Hiremath I think it is just improved longevity and probably more awareness as well. It was a disease which was thought to be of old age and was probably getting neglected. As we have done these trials even in Dabigatran trials, other trials, we have been involved as Indian patient and we see the number is not small at all and so we have a large population which is now beyond 60 to 65 years of age. Hypertension is rampaging. People are living longer and that is why I think this is going to be a real problem. It is already a real problem for India too.
Dr. Manish Verma So that brings to a very interesting point. Most of the elderly have a lot of other comorbidities.
Dr. JS Hiremath Yes.
Dr. Manish Verma And when we add any new drug, which actually there are chances that may interact with other medicines as well. So, any word of caution on oral anticoagulants specifically in elderly.
Dr. JS Hiremath No. No. In fact that is the USP, because these drugs hardly interact with any other drugs.There is no food-drug interaction like warfarin. There is no drug-drug interaction. So, in fact with comorbidities except maybe the very end-stage renal dysfunction, these are very good agents to be used in these conditions.
Dr. Manish Verma Any particular thing regarding monitoring of them because warfarin used to require a lot of monitoring?
Dr. JS Hiremath That is the main one of the strong points that it does not require monitoring. We have been getting fed up with monitoring the prothrombin time INRs of individuals, the lab inconsistency, the cost involved and the complications related to warfarin based on INR management, but all this is sort of gotten rid of by these new agents. No monitoring requires, fixed oral dose and you just feel very safe with them actually.
Dr. Manish Verma We have talked about lot of benefits, but many people say that there are no antidotes as of now. So, you are taking care, the patient is bleeding, what should a physician do to manage it?
Dr. JS Hiremath The anti-roads are not required, in fact, because the pharmacokinetics, pharmacodynamics is so safe and because we know that a certain drug level will be achieved and that is why this monitoring is probably not required and also they are short acting. So, if there is a life threatening emergency of bleeding, the patient is already on novac and meets with a road traffic accident which needs hyper-acute management.Then, it will be dealt with ever, but if you have a little time then all you have to do is stop one dose and by the time the next dose come probably you are ready to operate the patient that short-acting period also helps in these individuals.
Dr. Manish Verma Thank you so much for your clear answer and guidance on the role of newer arrival anticoagulants. Any final word from you on that?
Dr. JS Hiremath Yeah, I think we have hit with the discovery almost after 55 years and all that we have to do is change your mind sets and get into the new drugs which will help the society to reduce a life threatening and probably nerve shuttering complication like a stroke.
Dr. Manish Verma Thank you so much sir. Now this brings to us to a second topic today, which we wanted to discuss with you. Most of the patients who develop ST-elevation MI during the chronic phase during the rehabilitation phase, they generally receive four drugs. One of them is renin-angiotensin receptor blockers. So, what is your take on that. We have primarily two forms of therapy, one is largely by continuing the ACE inhibitor category and second is largely by continuing the ARBs and within then there are various drugs. So, before we go to individual drugs on those categories, what is your take on the large as a whole. In which situation which to be preferred any choices,or all are same, or …..?
Dr. JS Hiremath The traditional wisdom, I think ACE inhibitors no doubt and largest of course experience is with ramipril and that still remains my drug of choice for somebody who has had ST-elevation MI.Before he goes home, we need to put him on ramipril a good dose. I end up building them up to almost 10 mg despite a normal blood pressure and we realized that that kind of gives the longest advantage to the patient as far as for future events are concerned and morbidity and other things are concerned. Definitely, this is as I said traditional wisdom coming from our literature as well. The only place, where I feel is for some reason we cannot give ramipril, where there is intractable cough or some other reason why we cannot use then the only ARB that can be used is valsartan and I tend to use it whenever ramipril cannot be used but either which way I feel that ACE inhibitor in this particular indication still scores over ARBs and I am still as I said may be a little old fashion in this way, but I do not easily switch to an ARB when a post-MI patient comes to us and more the LV dysfunction, more it is indicated.
Dr. Manish Verma If a patient comes to you is already on anti-hypertensive and is already taking losartan if the patient develops an ST-elevation MI despite being on the drug on the second day when the revascularization priority is already taken care of and now we are preparing the patient to go back to the normal life. In that situation, would you continue with the ARB or you switch to ACE??
Dr. JS Hiremath I switch. Actually yes. Because this is certainly not from the literature. This comes more from experience and I feel I would be happiest when I switch to ACE inhibitor because that is where it has the best indication. Otherwise, ARBs are crawling up and trying to take away some indications of ACE inhibitors.
Dr. Manish Verma You mentioned about cough, how frequently you see in your practice on ACE inhibitors because you are putting almost all the patients of post MI situation on ACE. In terms of percentage if I have to ask you. What percentage of patients. Is it something which has to be worried so frequently??
Dr. JS Hiremath Yes. Actually, I feel that cough develops almost in 15% to 20% of the patients; however; withdrawal of ACE inhibitors is required in single digit number. So, I would say about 8% to 9%, one would be withdrawn off ramipril or other ACE inhibitors if because of intractable cough, but other than that, we have not seen so much of angioneurotic edemas and other thing. The only probable problem with the ACE inhibitors is the intractable cough and as I said the withdrawal of therapy takes place only in single digit number and it all depends on also a little convincing the patient, making him understand the importance of the drug. These small things also help actually to retain the patient on ACE inhibitor.
Dr. Manish Verma Any indication where you think that ARBs will score over ACE in a patient who is post-MI other than if he has intractable cough other than that any other things?
Dr. JS Hiremath Nothing that I can think of really, not from my own experience and not from the literature.
Dr. Manish Verma Thank you so much sir. It was really exiting talking to you and it is the knowledge which you provided is going to be really helpful for the audience. Thank you so much sir.
Dr. JS Hiremath Thank you.

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