RE-LY: An obituary for Warfarin?

I told an elderly patient last week that “in our lifetime” we might just see a drug that would take the place of Warfarin.  Her eyes sparkled at the thought.  I could imagine her vision of freedom.  No more monthly treks to our clinic to roll the dice.  Like all Warfarin users, she gambles every 4 weeks for a 30-day respite from blood checks.  So often, the players are disappointed, but there is hope today with the new direct  thrombin inhibitor Dabigatran. 

Warfarin dosing is like witchcraft.   The starting dose is a total stab in the dark.   300-pound men take 1.0 mg/day and 88-pound women require 12 mg/day.  The high dose in our clinic currently is 20 mg/day in a gentleman with an ostomy.  Both physicians and patients hate Warfarin and all the hoopla that goes along with it. Without it, scores of humans would be dead of embolic stroke and prosthetic heart valves would have been as useless as DaVinci's helicopter grounded for centuries for lack of fuel.

I had already decided NOT to get my hopes up.  I was stung by Ximelegatran due to transaminase issues.  I was teased by the clopedigrel and aspirin combination pronounced “less effective” than Warfarin, and I do mean a lot less effective. Idraparanux failed with too much bleeding and was sub-q in trial, which would never compete with Warfarin.   There always seems to be a snag and thus it’s been a long good-bye for Warfarin since my first hint of optimism.

 Re-Ly gave us cause for hope again.  The trial design was ample.  It answered all of the basic safety questions.  The right dose was fairly obvious to me, but the researchers are still haggling a bit.  Bleed rates were less than Warfarin at the 110-bid dose.  It did well with aspirin.  Some unanswered  questions include its application in the valvular a-fib patients and of course, the Holy Grail (s) of all anticoagulants:  prosthetic valve patients and pregnant women.   

With the birth of a new technology comes the death of the one that preceded it and the entire community of support that has kept it alive.  I’m hoping to eulogize my Coumadin clinic soon.  I want all of my Protime gals to spend their time shopping ,  and the guys? .... I hope they can tee off at 8 am instead of signing the clipboard at our front desk.  Fingers will be less sore, money will be saved and time will be better spent without Warfarin.

Born via patent in 1948  a product of sweet clover tainted with Penicillin Mold and Aspergillus that  fermented coumarol into Dicoumarol, Warfarin killed thousands of head of cattle before it found application.  The massive hemorrhaging it produced was later applied to rodent control.   It surfaced as a savior of hopeless victims of stroke risk who could tolerate it and a harbinger of death and disability for those who couldn’t.

From the shear inconvenience alone of utilizing  Warfarin, thanks to at least one of the new thrombin inhibitors coming down the pike, I hope I can soon say:  

May Warfarin rest in peace. 

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