Letters Dabigatran v warfarin

Take real world issues into account

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d7716 (Published 13 December 2011) Cite this as: BMJ 2011;343:d7716
  1. Arnold Zermansky, GP and senior research fellow1,
  2. Rani Khatib, senior pharmacist and lecturer1
  1. 1University of Leeds, Leeds, UK
  1. a.g.zermansky{at}leeds.ac.uk

Pink and colleagues’ analysis of the economics of dabigatran is flawed by several real world issues that were not considered.1

Firstly, the price of dabigatran will fall as competitive drugs are licensed.

Secondly, the cost of stopping international normalised ratio (INR) monitoring depends on whether warfarin clinics continue to run but at a lower workload (thereby increasing unit cost) or close completely (allowing resource redeployment).

Thirdly, not all patients with poor adherence to warfarin will have better adherence with dabigatran.

Fourthly the analysis did not adjust for reduction of drug related hospital admissions, cost of transport to clinics, or renally compromised patients staying on warfarin.

Fifthly, some patients currently take (much less effective) aspirin because they will not attend clinics or it is unsafe to vary their warfarin doses. Dabigatran cannot ethically be denied to them.

Sixthly, there is still no satisfactory NHS mechanism for transferring resources from secondary care to the primary care prescribing budget. Without this, warfarin clinic resources may disappear into the secondary care black hole.

Lastly, once sanctioned by the National Institute for Health and Clinical Excellence and publicised (as a breakthrough) by the media, GPs will be overwhelmed by demand for dabigatran, because few patients enjoy regular monitoring.

It would be premature to recommend the wholesale closure of warfarin clinics without more long term safety and efficacy data, but the conclusion that dabigatran is “unlikely to be cost effective in clinics able to achieve good INR control with warfarin” takes insufficient account of actualities.


Cite this as: BMJ 2011;343:d7716


  • Competing interests: None declared.


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