I am aware the love for Novel Oral Anticoagulants (NOACs) is growing and that warfarin is falling out of favour, especially in the setting of stroke prevention in atrial fibrillation or in the management of venous thromboembolism. But hear me out on this one. Warfarin should stay and here’s why.
This year for Hypertension Awareness Month and World Hypertension Day (May 17), I want to discuss about the role of single pill combination in the management of hypertension. Single Pill Combination has been consistently recommended in various Hypertension Guidelines to assist with blood pressure control. However, there is no great resource to guide available options of single pill combination in Ontario.
A patient was presented at the ER with an unprovoked deep vein thrombosis (DVT). It was eventually assessed to require indefinite oral anticoagulation therapy. He was started on rivaroxaban, a NOAC (novel oral anticoagulant). Rivaroxaban as well as other NOACs are recommended in the latest Chest guidelines as first line treatment options for venous thromboembolism disease. But the provincial drug plan does not recognize this update yet and is set up such that warfarin is the preferred agent for long term anticoagulation therapy. NOACs would only be reimbursed for the initial 6 months if treating conditions such as DVT.
When a new medication is available, there is often a lot of excitement and hype about how a new option may bring hope to a medical condition. The new medication may offer breakthrough in improving important clinical outcomes (e.g. improving survival, preventing disease complications and significantly offering better quality of life for patients). But before we jump on the bandwagon to start prescribing a new medication, here are few considerations the sales rep may not be quick to highlight or share.
I am often intrigued to connect with clinicians who have various opinions on medications. In particular to GI motility agents, we often discuss the safety profile of domperidone vs. metoclopramide. They are both dopamine antagonists; one main difference is that domperidone works peripherally whereas metoclopramide can cross blood brain barriers and exert some central system effects. The other difference is that domperidone is not commercially available in United States but only via a special access mechanism. As such, there may be more documented clinical evidence and experience with metoclopramide than with domperidone.
ISMP Canada has developed the 5 questions that each patient should ask about medications? Of the 5 questions, I find that proper use is one that tends to be most difficult to communicate clearly and succinctly. How to take your medication? Do you take it with food? Without food? What does it mean to take it on an empty stomach? Can you take it with dairy products? Or mix with supplements and alcohol?
Many people find drug interactions a difficult concept to grasp. And many people assume the only way to manage a drug interaction is to avoid the combination. Often time, it is impractical, nor is it necessary. We do need to actively understand how to best manage the interaction based on many factors including the patient’s specific factors, the indications of the medications, the risk of side effects as well as the potential of the drug interactions. But first, we need to understand what type of interactions we are dealing with.