Paper Example on Preventing Strokes: Anticoagulant Therapy Explained

Introduction

Heart diseases like atrial fibrillation and ischemic heart disease are some of the risk factors of stroke. Other risk factors include high blood pressure, diabetes mellitus, alcohol, and tobacco consumption, hormone replacement, and dyslipidaemia. Stroke affects the arteries causing disabilities and, in some cases, death. To prevent strokes, anticoagulant therapy is used. Coumadin (warfarin) and pradaxa (dabigatran) are common anticoagulants used to prevent strokes in people. The purpose of the review is to find out which anticoagulant is the most effective when used in patients suffering from a stroke. The review will be guided by a PICOT question containing the patients suffering from a stroke, the two medications being compared, expected outcomes, and a time frame.

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PICOT Question

The PICOT question: Do patients suffering from a stroke (P) who take Coumadin (I) experience fewer re-occurrences in strokes (O) compared to those who take Pradaxa (C) within five years (T).

Review of Search History

Patients who have suffered from stroke take medication that will reduce the chances of getting re-current stroke episodes as well as help them avert complications that may arise from the stroke they suffered. From research, Coumadin has been the preferred medication. It has also been effective in promoting the health of people who have suffered from a stroke. In the recent past, newer medication like Praxada has been introduced and is a better alternative to Coumadin.

From the evidence presented in the literature review, the two medications are analyzed in terms of their outcomes while making reference to stroke patients. A comparison of Coumadin and Praxada is necessary since it will provide an insight on the pros and cons of the two medications, The focus is, however, narrowed to the health of the patients who will use the medicines.

Terms Used

Stroke - a medical condition where the movement of blood is inhibited to the brain and within the brain.

(Warfarin) and Praxada (Dabigatran) - medications for people who are suffering from a stroke which work by inhibiting the coagulation of blood in the arteries.

Anti-coagulation - having the ability to prevent blood from clotting.

Articles Used

The articles used for the first assignment were four. For Assignment Two, ten articles were presented in the research matrix. The paper will make extensive use of ten articles that contain evidence of the two drugs and their effectiveness towards managing the re-occurrence of strokes in patients who have suffered from a stroke.

Literature Review

Cairns et al. (2011) discussed the guidelines for atrial fibrillation as provided by Canadian cardiovascular society. The guidelines are focused on the prevention of stroke. According to the author, atrial fibrillation is responsible for 4.5% of the stroke rate every year, where the patients either get permanent disability or die. The tests that can be used to predict stroke include the CHADS2 index and the HAS-BLED score for the bleeding risks.

Using Vitamin K reduces the risk of stroke by 64% while using aspirin reduces the risk by 19%. Coumadin therapy is found to be a suitable form of medication for stroke. When Coumadin therapy is combined with another drug like aspirin, the effectiveness of the drug is reduced since there is more bleeding and less effectiveness. However, when clopidogrel is used with aspirin in Coumadin therapy, it produces more positive results compared to aspirin alone. Praxada is considered a newer form of stroke medication (Cairns et al., 2011).

Depending on the dosage of the medication, Praxada is as effective as Coumadin (Cairns et al., 2011). In analyzing the outcomes of stroke medication, it is significant to analyze the risk factors of stroke. Fuentes et al. (2014) handle the guidelines for the preventative treatment of ischemic stroke.

In summary, the risk factors of ischemic stroke include blood pressure, consumption of alcohol and tobacco, cardio-embolic diseases, hormone replacement therapy (HRT), sleep apnea syndrome, and many other factors. The conclusions of the paper show that lifestyle changes and pharmacological treatment for the risk factors of stroke are effective in preventing ischemic stroke (Fuentes et al., 2014). Coumadin and Praxada also have an impact on the quality of life, as shown from a RE-LY sub-study (Monz et al., 2013).

The study analyzes the effect of Coumadin and Praxada on the quality of life of the patients. The RE-LY study compared the effects of Coumadin and different dosages of Praxada. From the results of the study, 110 mg of Praxada consumed twice daily was found to be as effective as Coumadin and caused less bleeding (Monz et al., 2013).

However, 150mg of Praxada was more effective but caused a risk of major bleeding. Coumadin was also associated with dietary and lifestyle limitations as well as frequent monitoring (Monz et al., 2013). Stambler (2013), Wisloff et al. (2014), and Yu (2018) cement the discussion made by Monz as they directly compare the traditional stroke prevention medications with newer stroke medications.

They show that the novel oral anticoagulants (NOACs), including Praxada, apixaban, rivaroxaban, and edoxaban, have become more effective alternatives to the traditional Coumadin. In terms of cost, the newer drugs are more affordable compared to Coumadin (Wisloff, 2014). Despite the advantages that are gathered from the NOACs, there is a limitation to their use in certain patient populations.

McConeghy (2014) reports the fatality of using Praxada by presenting data of the adverse bleeding reports. According to the analysis, there had been 9029 adverse cases resulting from Praxada, while Coumadin had 2038 reports. Some of the adverse effects were fatal to the patients (McConeghy, 2014).

King et al. (2015) discuss the Praxada at length, where they show the factors that affect the safety and efficacy of the drug. Such factors include patient age adherence, weight, renal function, conmitant disease states, and concurrent drug therapy. Pradaxa is consumed orally and does not warrant regular monitoring when used.

Pradaxa also has fewer drug interactions compared to Coumadin. Bleeding that results from the use of Praxada can be managed separately for each patient who has those effects. A patient using Praxada who experiences bleeding should be assessed in terms of the intensity in bleeding, degree of coagulation, risk of thromboembolic events, and renal function (King et al., 2015).

In Asians with nonvalvular atrial fibrillation, Praxada was found that it did not increase the risk of gastrointestinal bleeding when compared to Coumadin in a study of a total of 19853 patients (Chan et al., 2016). The most desirable outcomes for stroke survivors is when they come out alive and have evaded recurrent stroke or being hospitalized for complications resulting from their strokes (Xian et al., 2015). The success of an anti-coagulant to a stroke patient depends on the recurrent strokes that they may get and the number of times they get hospitalized.

Strengths and Gaps in Review

The strengths of the review are the sources that have been used. All the sources are credible and show present data that has been carefully studied and reviewed. Another strength lies in the elaborate application of the data that has been collected from the various articles. The gaps that are found in the data may be a result of the limited information gathered from the articles that have been used for the review.

Conclusion

From the research provided in various articles, it is evident that the two medications, Coumadin and Pradaxa, are effective medications used for patients suffering from a stroke. The pros and cons of the two medications have been assessed by many scholars to compare the effects of the two for the patients suffering from a stroke. Coumadin has been used for a longer time compared to Pradaxa. Praxada, on its part, is found to bring forth more pros than cons as noted herein and is, therefore, the best choice for stroke patients.

References

Cairns, J. A., Connolly, S., McMurtry, S., Stephenson, M., Talajic, M., & CCS Atrial Fibrillation Guidelines Committee. (2011). Canadian Cardiovascular Society Atrial Fibrillation Guidelines 2010: Prevention of Stroke and Systemic Thromboembolism in Atrial Fibrillation and Flutter. Canadian Journal of Cardiology, 27(1), 74-90. https://www.onlinecjc.ca/action/showPdf?pii=S0828-282X%2810%2900008-5

Chan, Y. H., Yen, K. C., See, L. C., Chang, S. H., Wu, L. S., Lee, H. F., ... & Kuo, C. T. (2016). Cardiovascular, Bleeding, and Mortality Risks of Dabigatran in Asians with Nonvalvular Atrial Fibrillation. Stroke, 47(2), 441-449. https://www.ahajournals.org/doi/pdf/10.1161/STROKEAHA.115.011476

Fuentes, B., Gallego, J., Gil-Nunez, A., Morales, A., Purroy, F., Roquer, J., & de Lecinana, M. A. (2014). Guidelines for the Preventive Treatment of Ischemic Stroke and TIA (II). Recommendations. According to Aetiological Sub-type. Neurologia (English Edition), 29(3), 168-183. https://www.sciencedirect.com/science/article/pii/S2173580812001836

King, A. E., Szarlej, D. K., & Rincon, F. (2015). Dabigatran-associated Intracranial Hemorrhage: Literature Review and Institutional Experience. The Neurohospitalist, 5(4), 234-244. https://journals.sagepub.com/doi/abs/10.1177/1941874415569069

McConeghy, K. W., Bress, A., Qato, D. M., Wing, C., & Nutescu, E. A. (2014). Evaluation of Dabigatran Bleeding adverse reaction Reports in the FDA adverse event reporting System during the First Year of approval. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy, 34(6), 561-569. https://accpjournals.onlinelibrary.wiley.com/doi/full/10.1002/phar.1415

Monz, B. U., Connolly, S. J., Korhonen, M., Noack, H., & Pooley, J. (2013). Assessing the impact of Dabigatran and Warfarin on Health-related Quality of Life: Results from a RE-LY sub-study. International Journal of Cardiology, 168(3), 2540-2547. https://www.sciencedirect.com/science/article/abs/pii/S0167527313004786

Stambler, B. S. (2013). A New Era of Stroke Prevention in Atrial Fibrillation: Comparing a New Generation of Oral Anticoagulants with Warfarin. International Archives of Medicine, 6, and 46. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3829372/

Wisloff, T., Hagen, G., & Klemp, M. (2014). An Economic Evaluation of Warfarin, Dabigatran, Rivaroxaban, and Apixaban for Stroke Prevention in Atrial Fibrillation. Pharmacoeconomics, 32(6), 601-612. https://link.springer.com/article/10.1007/s40273-014-0152-z

Xian, Y., Wu, J., O'Brien, E. C., Fonarow, G. C., Olson, D. M., Schwamm, L. H., Bhatt, D. L., Smith, E. E., Suter, R. E., Hannah, D., Lindholm, B., Maisch, L., Greiner, M. A., Lytle, B. L., Pencina, M. J., Peterson, E. D., & Hernandez, A. F. (2015). Real World effectiveness of Warfarin among Ischemic Stroke Patients with Atrial Fibrillation: An Observational Analysis from Patient-Centered Research into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) study. BMJ (Clinical research ed.), 351, h3786. https://doi.org/10.1136/bmj.h3786

Yu, Y. B., Liu, J., Fu, G. H., Fang, R. Y., Gao, F., & Chu, H. M. (2018). Comparison of Dabigatran and Warfarin used in Patients with Non-valvular Atrial Fibrillation: Meta-analysis of Random Control Trial. Medicine, 97(46), e12841. https://doi.org/10.1097/MD.0000000000012841