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    FDA Delays Decision on Blood Thinner Eliquis

    One of Three Warfarin Alternatives for Stroke Prevention

    Safety Questions Remain

    Although patients on the new drugs do not have to be monitored as closely as those taking warfarin, safety questions have plagued Pradaxa and Xarelto since they entered the U.S. market.

    In the months after Pradaxa was approved for use in patients with atrial fibrillation, about 500 cases of hemorrhaging were reported, according to the nonprofit group Institute for Safe Medicine Practices.

    Most of these cases occurred among elderly patients.

    Just days ago, the FDA rejected an application to allow Xarelto to be used to treat patients with blocked coronary arteries.

    Reversal Strategy Not Clear

    Cardiologist Vincent Bufalino, MD, who practices in Elmhurst, Ill., says another safety concern has emerged since the new drugs became available.

    The blood thinning action of warfarin can be quickly reversed in patients who suffer bleeds, have accidents, or face emergency surgery by administering vitamin K, which is blocked by the drug, or by giving patients blood-clotting agents.

    But Bufalino says there is no agreed upon way to reverse the action of the new-generation blood thinners.

    "Those of us on the front lines are very aware of this issue," he says. "If a patient has a brain bleed, that is a potential disaster, especially if you can't stop the bleeding."

    Early laboratory studies suggest that some of the strategies used to reverse the blood thinning action of warfarin may also work with the newer drugs.

    But Bufalino tells WebMD that these trials are preliminary and there is, as yet, no consensus on how to best reverse the actions of the new drugs in emergency situations.

    Head-to-Head Studies Needed

    Mount Sinai Medical Center professor of cardiology Roxana Mehran, MD, says the new blood thinners are likely to be game changers for stroke prevention, but she adds that caution is needed when prescribing them to patients at risk for bleeding, such as the elderly.

    There has been speculation, she says, that Eliquis may be the safest of the three drugs for use in these patients, because it works in a new way and is eliminated by the liver.

    But Mehran says head-to-head studies of the three drugs are needed to determine which drug is best for which patients, assuming Eliquis is eventually approved by FDA.

    The statement issued today by Bristol-Myers Squibb and Pfizer noted that the drug makers will continue to work with federal officials.

    "FDA and the companies are committed to working expeditiously to address the outstanding questions and move the application forward," the statement read.

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