In talking to healthcare leaders about drug utilization, I’ve fielded many questions concerning the application of clinical evidence to specific drugs and drug categories. I address one popular topic below.
DEAR PROCURED HEALTH: Heparin is much less expensive than bivalirudin. What evidence can I use to support standardizing to it as our primary anticoagulant for percutaneous coronary intervention (PCI)? – HOPING FOR HEPARIN
DEAR HOPING FOR HEPARIN:
For health systems that have not yet set policies on appropriate use of heparin vs. bivalirudin for PCI, some compelling new evidence makes now the perfect time to start the conversation with your physicians.
In particular, exciting results from a recent trial show that heparin and bivalirudin have similar efficacy and safety outcomes.1 A few details to note:
- The study is robust in terms of design and number of patients. The randomized controlled trial included ~6,000 patients with acute coronary syndromes in Sweden.
- Glycoprotein IIb/IIIa inhibitors were administered to less than 3% of patients in each group. Consistent with evidence that routine GPI use contributes to higher bleeding risk2 without improving outcomes,3,4 only emergent, unplanned use was included.
- A radial-artery approach was used in ~90% of patients. While this is typical in some parts of Europe and Asia, current adoption of radial access is estimated to be ~30% in the US.5
- ~95% of patients were also treated with high-potency dual antiplatelet therapy. Organizations standardizing to heparin should also consider concurrent use of a high-potency P2Y12 such as prasugrel or ticagrelor.
There was no statistically significant difference between heparin and bivalirudin as measured by outcomes of death, myocardial infarction, or bleeding at 30 and 180 days, including in patients with comorbidities such as diabetes or renal failure. Knowing that the lack of difference could be related to the above factors, hospitals should take a look at their overall PCI practice when considering standardization to heparin.
Procured Health’s online Pharmacy solution applies the power of evidence to help health systems optimize costs and improve patient care. To learn more, email [email protected].
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4 "Routine upstream initiation vs deferred selective use of glycoprotein IIb/IIIa inhibitors in acute coronary syndromes: the ACUITY Timing trial." Stone GW, Bertrand ME, Moses JW, et al. JAMA, (2/2007)
5 "Radial access adoption in the United States"