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Is The Young Pharmaceutical Rep Right?

I loved my old status. Perhaps, reveled in it would be a better description. I was a crotchety, generic medicine-only doctor.** Sadly, my status changed today. Dabigatran (brand name Pradaxa) was the culprit.

It was a little nerve racking. I wrote the order, looked at it, thought it out again, talking to myself: “John, are you sure you don’t want to do it the old way? [pause to think] No, I am embracing the new.”  And then, I closed the chart and handed it to the nurse.

“What’s that? Pradaxa?” asked the nurse. “Stop the Lovenox? You sure?” My face must have told the story.

Eight days had passed since dabigatran’s approval. “That’s plenty of time to mourn warfarin’s demise,” I thought. Enough studies, enough blogs — it was time for the rubber to hit the road.

Later that day, to another EP colleague, I asked: “Have you used Pradaxa yet?” He replied: “No, I don’t want to — because THEY want me to.” He must have liked his independent-of-pharma status, too.

For nearly a decade, most electrophysiologists have had the luxury of prescribing primarily generic medicines. When doctors were scolded for overusing expensive medicines, we EPs could sit back, fold our hands behind our heads, and proudly say: “That’s not us — we use only generics.”

But now, for the first time in years, I am compelled to use a drug that a pharmaceutical rep wants me to use. Right or wrong, that change in status tugs at me a bit. I am going to have to learn about PAs (prior authorizations), Medicare-D, and donut holes. That’s sad.

But in the case of dabigatran (Pradaxa) — and we are going to have to call it Pradaxa, because dabigitran is so much more difficult on the vocal cords — the drug rep is likely right.

Pradaxa’s primary strengths (from the 18,000-patient RE-LY trial) are:

  • Fewer strokes.  
  • Less intracranial bleeding.
  • No INRs.
  • No dietary issues.
  • No drug interactions.
  • Blood thinning occurs one hour after a dose–not 3-4 days.  This will result in shorter hospital stays, and AF is the most common cardiac cause of hospitizations.
  • In the RE–LY trial, 12,000 patients took Pradaxa, and they did well. 
  • Pradaxa has been approved in Europe (for treating blood clots in the veins–DVT, VTE) and no significant safety issues have been reported.

There’s very little not to like. A new chapter in doctoring.


**Until Pradaxa’s recent approval, the only commonly prescribed, non-generic CV drug an electrophysiologist used was Pfizer’s class III anti-arrhythmic drug dofetilide. AF ablaters find this drug especially useful.

Disclosure: I turned down an invitation to become a Boehringer Ingelheim-trained “expert” speaker. Primarily because being non-conflicted feels so good.

*This blog post was originally published at Dr John M*

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