Sermo Anticoagulation, Anti-platelet, and Thrombolytic Conversation Overview

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Time Period: Key Contact: Date: 02/1/2009 01/31/2010 Joe Walsh, jwalsh@sermo.com 03/04/2010

OBJECTIVES:

Analyze 12 months of Sermo physician conversation about blood clotting, anticoagulation, anti-platelet, and thrombolytic treatments in order to:

Examine which issues are discussed most frequently. Analyze how physicians feel about the mostdiscussed issues. Explore which brands and therapies are most discussed by physicians. Understand how discussions have changed over time.

2009 Sermo, Inc. Confidential

KEY FINDINGS (category):

AMBIGUITY UNDERSCORES TREATMENT DECISIONS:

Unlike discussion of other ailments in the Sermo community, physician conversation about clotting treatment points to a high degree of ambiguity in treatment decisions. As one physician summarizes, there is rarely a clear answer as to what the best course of action is for DVT/clotting issues

RISK MANAGEMENT IS KEY:

Physicians are extremely focused on risk-management when assessing anticoagulant, anti-platelet, and thrombolytic treatment, regardless of the associated underlying condition. Risk of bleeding weighs heavily on the conversation, which includes frequent requests for advice regarding risk vs. benefit tradeoffs in specific patient cases.

PCPs AND CARDIOLOGISTS DRIVE DISCUSSION:

PCPs and Cardiologists are most involved in the clotting conversation on Sermo, followed by Emergency Medical Physicians, Hematologists, and OBGYNs. Although surgery drives significant share of discussion, surgeons themselves generate only 3.8% of the overall clotting dialogue.

KEY FINDINGS (category):

SURGICAL LOGISTICS DRIVE HIGH INTEREST:

Surgery is the most-discussed associated condition or context, as physicians request and provide opinions on how to manage anticoagulant and anti-platelet treatment pre- and post- surgery, including approaches to bridge therapy.

STROKE RISK WEIGHS ON THE CONVERSATION:

Stroke conversation highlights a struggle to weigh the risk of stroke against the risk of bleeding. Physicians struggle to balance risks is particularly acute in the case of stroke prevention, where risk is difficult to quantify.

THERE IS ROOM FOR INNOVATION IN THE ANTICOAGULANT CATEGORY:

Physicians are open to new anticoagulant treatment options. Existing treatments have recognized weaknesses, and physicians do not seem to have strong loyalty to existing options. New treatments will have to prove themselves on the basis of safety and cost in order to overcome potential objections.

KEY FINDINGS (pharmaceuticals):

COUMADIN
By far the most-discussed anticoagulant, Coumadins weakness is physicians overwhelming concern about risk of bleeding, particularly when used simultaneously with anti-platelet medications, including ASA. Cost is a recognized though littlementioned benefit, and side effects (which plague consumer conversation about Coumadin), are rarely discussed.

PLAVIX
Physicians frequently weigh risk of bleeding against risk of stroke, and note that joint Plavix-ASA treatment makes it difficult to get a handle on bleeding risk. Stroke is much more discussed in conjunction with Plavix than are cardiac conditions.

HEPARIN
The logistics of bridge therapy are frequently discussed, particularly among surgical candidates already using Coumadin. Cost is a recognized advantage over Lovenox.

LOVENOX
Logistics drive conversation, both in terms of Lovenoxs use as a bridge therapy and in the case of pregnant patients. Lovenoxs high cost/lack of coverage is a noted challenge for some physicians.

KEY FINDINGS (pharmaceuticals):

THROMBOLYTICS
Not a favored method of treatment, use of thrombolytics is discussed in extremely ambiguous or contentious cases. Stroke drives much of the existing conversation, followed by treatment of PE (led by one particular debate about the appropriateness of thrombolytics to treat a large, central PE).

XARELTO
High expectations characterize conversation about Xarelto, and physicians note that oral administration without required monitoring will be a powerful combination for patient compliance. However, safety data is needed, and cost could be a hurdle.

EFFIENT
Conversation volume is low because physicians appear to be waiting for more clinical outcome data, particularly in light of concern about higher risk of bleeding. Physicians are, however, keen on having more choice in anti-platelet treatments, particularly as this may put pricing pressure on Plavix.

CONTENTS

Data & Topic Overview Physician Engagement Category Themes Patients Co-morbid Conditions Medications Key Findings

THE CONVERSATION:
The following analysis covers 5,047 comments about clotting, anticoagulant, antiplatelet, and thrombolytic treatments, generated by 1,672 physicians from 2/09-1/10.

BLOOD CLOTTING CONVERSATIONS Comments: 5,047 Unique Physicians: 1,672

Methodological Note: Comments are defined as all original comments and subsequent responses relevant to the topic. Physicians counts the number of unique participants in the discussion.

CONTEXT:
Blood clotting complications and treatment are frequently discussed in the Sermo community.
MENTIONS OF SELECTED MEDICAL CONDITIONS: 02/1/2009 01/31/2010 N = 237,857

Blood clotting conversation is defined as mentions of clotting terminology (thrombosis, embolism, etc) as well as anticoagulant, anti-platelet, and thrombolytic treatment.

Note: Comments are not mutually exclusive.

NUMBER OF COMMENTS IN SERMO COMMUNITY

TREND:
Conversation volume is stable, with the exception of two extremely high interest Sermo Discussions in March and April 2009.
BLOOD CLOTTING COMMENT VOLUME TRENDED: 02/1/2009 01/31/2010 N = 5,047 Comments

* Two-month spike is due to increased conversation about anti platelet and anticoagulant treatment that originated under two consecutive Sermo Discussions, one in March, and one in April.

NUMBER OF COMMENTS

CONTENTS

Data & Topic Overview Physician Engagement Category Themes Patients Associated Conditions Medications Key Findings

PARTICIPATION:
About 10% of physicians involved in the clotting conversation are highly-engaged, contributing to the discussion six or more times over the last 12 months.
PHYSICIAN PARTICIPATION DISTRIBUTION IN THE CLOTTING DISCUSSION: 02/1/09-01/31/10 N = 1,672 Participants ENGAGEMENT IN THE CLOTTING CONVERSATION
(6+ comments)

NUMBER OF PHYSICIANS

(1-5 comments)

VOLUME BY SPECIALTY:
Aside from PCPs, Cardiologists generate high volume of conversation about the clotting topic within the Sermo community.
SHARE OF CLOTTING CONVERSATION BY SPECIALTY: 02/1/2009-01/31/2010 N = 5,047

Share of clotting comments Share of all Sermo comments

PERCENTAGE OF COMMENTS

CONTENTS

Data & Topic Overview Physician Engagement Category Themes Patients Associated Conditions Medications Key Findings

THEMES:
As is typical of Sermo conversations, patient cases drive much discussion, followed by concern about associated conditions and pharmaceutical treatment options.
BLOOD CLOTTING CONVERSATION - TOP THEMES 02/1/2009-01/31/2010; N = 5,047 PATIENTS: Much of the conversation revolves around specific patient cases, as physicians seek and provide counsel on risk management.

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ASSOCIATED CONDITIONS: Surgery, stroke, and pregnancy lead associated conditions. Risk-management is of primary importance as physicians discuss their approaches to managing anticoagulant and anti-platelet treatment pre- and postsurgery. Meanwhile, in the stroke discussion, physicians weigh the risks of stroke with the risk of bleeding. Finally, pregnant women requiring anticoagulant treatment inspire substantial conversation as physicians seek and share advice on which treatments to use, and when.

PHARMACEUTICAL TREATMENTS: Coumadin and Plavix lead conversation, but ASA adds a much-discussed layer of complication and risk.
Note: Comments are not mutually exclusive. Mentions are not mutually exclusive.

PERCENTAGE OF BLOOD CLOTTING COMMENTS

CONTENTS

Data & Topic Overview Physician Engagement Category Themes Patients Associated Conditions Medications Key Findings

PATIENTS:
Seeking and sharing advice regarding particularly thorny or ambiguous cases drives patient mentions.
STATISTICALLY MOST-CORRELATED WORDS IN CONVERSATION ABOUT PATIENTS IN THE CLOTTING DIALOGUE CLOTTING: PATIENT WORD MAP: 02/1/2009-01/31/2010 N = 2,745

THEMES
Anti-platelet Treatment Tests, Diagnostics Risks & Concerns Underlying Conditions Treatment Context Patient Descriptors Situations Results & Testing Anticoagulation Treatment

Methodological Note: The size of the bubble represents the frequency in which the term is mentioned. Terms appear when they have exceeded a correlation threshold based on their prevalence in the clotting patient discussion versus their prevalence throughout the entirety of Sermo discussion.

PATIENTS:
Advice-seeking (and giving) drives patient discussion as physicians look for second opinions on ambiguous cases. Treating PE patients is top-of-mind.
PATIENTS: PATIENT COMMENTS - THEMES: 02/1/2009-01/31/2010; N = 2,745

Specific patient cases are frequently discussed as physicians seek second opinions, often inspired by disagreement among a physicians own colleagues. The Sermo community helps settle debate about the best course of treatment.
35 yo female c/o 2 wk dull chest pain, intermittent & right calf tenderness, says sx similar to when had postpartum PE last year. Sx were relatively mild then & pt was surprised at the diagnosis. Was on coumadin 6 mo & has been off for a year now. Would you do further workup (CT, angiography)? Her presentation is so unimpressive. Also - in pt with postpartum PE - is workup for thrombophilia necessary, and what is the chance for recurrence when not pregnant, no hormone use? You have a PE, you get admitted. Period. This can be either observational or inpatient treatment. There is no way for you to predict that a 'stable' PE patient might toss another life threatening clot before they have had a chance to start lovenox and coumadin (Yes, it can happen anytime, but it is less with treatment).

Note: Comments are not mutually exclusive.

PERCENTAGE OF PATIENT COMMENTS

CONTENTS

Data & Topic Overview Physician Engagement Category Themes Patients Associated Conditions Medications Key Findings

ASSOCIATED CONDITIONS:
Together, surgery and orthopedic surgery comprise a full quarter of all associated conditions discussed. Stroke and pregnancy are also top-of-mind.
MENTIONS OF ASSOCIATED CONDITIONS: 02/1/09-01/31/10; N = 2,473

Note: Comments are not mutually exclusive.

PERCENTAGE OF ASSOCIATED CONDITION COMMENTS

SURGERY:
Conversation is highly focused on the logistics of managing anticoagulation/anti platelet treatment pre- and post- procedure.
STATISTICALLY MOST-CORRELATED WORDS IN CONVERSATION ABOUT SURGERY IN THE CLOTTING DIALOGUE CLOTTING: SURGERY WORD MAP: 02/1/2009-01/31/2010 N = 489

THEMES
Tests Clotting Conditions Procedure Types Risks & Complications Anticoagulant/Anti platelet Management Anticoagulant/Anti platelet Treatments

Methodological Note: The size of the bubble represents the frequency in which the term is mentioned. Terms appear when they have exceeded a correlation threshold based on their prevalence in the clotting/surgery discussion versus their prevalence throughout the entirety of Sermo discussion.

SURGERY:
Managing the risk of bleeding and swelling is top-of-mind, and physicians are looking for more nuanced approaches to risk assessment.
SURGERY COMMENTS - THEMES: 02/1/2009-01/31/2010; N = 489 SURGERY:

Managing the risk of bleeding dominates discussion. Administration of Plavix, Coumadin, and ASA generate the most concern and uncertainty.
Patients should be risk stratified. There should be multiple options for anticoagulation. All patients don't have the same risk of VTE and/or bleeding. I think the bleeding/ swelling complications are much higher with anticoagulants, and I am not convinced they prevent significant VTE lower death from all causes. I can tell you from my trauma days that I saw death from VTE with or without the anticoagulants, and this increases my bias. This data needs to be confirmed in a community setting by nonpharma people. You might also dissent from the hideous, but widespread, practice of making the Coumadin dose a daily conundrum, as in: Coumadin 2.5 mg on Mon-Wed-Fri, 5 mg on Tues-Thurs-Sat, and Coumadin either 3 mg or 2.5 mg on Sunday, according to the phase of the moon. Why do otherwise sensible doctors become such morons when they prescribe Coumadin?

Note: Comments are not mutually exclusive.

PERCENTAGE OF SURGERY COMMENTS

STROKE:
The struggle to balance the risk of stroke against the risk of bleeding drives discussion.
STATISTICALLY MOST-CORRELATED WORDS IN CONVERSATION ABOUT STROKE IN THE CLOTTING DIALOGUE CLOTTING: STROKE WORD MAP: 02/1/2009-01/31/2010 N = 398

THEMES
Discussion of Causes Testing/Results Associated Conditions Risks & Complications of Treatment Treatment Options Patient Cases

Methodological Note: The size of the bubble represents the frequency in which the term is mentioned. Terms appear when they have exceeded a correlation threshold based on their prevalence in the clotting/stroke discussion versus their prevalence throughout the entirety of Sermo discussion.

STROKE:
Physicians struggle to nail down the risk vs. benefit calculation when dealing with stroke patients. There is a need for more data on the subject.
STROKE: STROKE COMMENTS - THEMES: 02/1/2009-01/31/2010; N = 398

Striking an appropriate balance between risk of bleeding and risk of stroke is the highest priority. Plavix, ASA, and Coumadin are the primary variables in this calculation, and are thus at the center of stroke conversation.
From a neurologic standpoint, the risk of Plavix plus ASA causing intracerebral bleeding is more then their benefit in reducing the risk of ischemic stroke. Adding Warfarin to such a combination is not justifiable. For ischemic strokes in particular, the general rule is prophylactic Lovenox and full-dose aspirin, but no Plavix unless they need to be on it (in which case aspirin isn't given). The reason for Lovenox is some randomized data suggesting a marginal decrease in DVT and presumably PE, though this may be balanced by a marginal increase in bleeding complications. I believe the FASTER trial (and EXPRESS, though this did not explicitly look at ASA + Plavix vs ASA) found a trend towards better outcomes for ASA and Plavix. Apparently there have been proposals to study this issue in depth, but the NINDS and drug companies are not interested for now since the likely benefit will be small.

Note: Comments are not mutually exclusive.

PERCENTAGE OF STROKE COMMENTS

RISKS & COMPLICATIONS:

The difficulty in balancing risks of bleeding with the benefits of anti-clotting treatment (particularly in cases of stroke, cardiac conditions, and pregnancy) is clear.
RISK & COMPLICATION COMMENTS - THEMES: 02/1/2009-01/31/2010; N = 902 RISKS & COMPLICATIONS:

More data is needed, as is more understanding of existing guidelines relating to the risks vs. the benefits of clotting treatment.
FDA has published an alert which does NOT mandate any change in prescription guidelines, but which advocate risk benefit analysis before prescribing PPIs to patients who require Plavix. (So it is up to your clinical judgment.) My personal bias (based on the very limited data) is that I will keep patients who have a history of confirmed UGI bleeds or have high risk UGI bleeding sources on PPIs, but I will switch to Protonix if possible. I would take issue with the extreme positions that have been taken on both sides of the arguement here - there are some people for whom the risk of anticoagulation outweighs the benefits and there are even more people out there who are being harmed by not being anticoagulated. Physicians involved in taking care of pts really need to do a careful reading of the ACCP guidelines as well as the article describing in orthopedic pts the use of aspirin combined with mechanical prophylaxis which is one of the few articles out there indicating that this is an acceptable strategy....

Note: Comments are not mutually exclusive.

PERCENTAGE OF RISKS & COMPLICATIONS COMMENTS

CONTENTS

Data & Topic Overview Physician Engagement Category Themes Patients Associated Conditions Medications Key Findings

PHARMACEUTICAL TREATMENTS:
Coumadin and Plavix dominate the conversation. Thrombolytics trail at a distance.
MENTIONS OF PHARMACEUTICAL TREATMENTS: 02/1/2009-01/31/2010; N = 2,045

Note: Comments are not mutually exclusive.

PERCENTAGE OF PHARMACEUTICAL TREATMENT COMMENTS

PHARMACEUTICAL SENTIMENT:
Speculation about Xarelto makes it a standout. The promise of oral and nonmonitored is powerful, but physicians need proof of safety and are sensitive to cost.
PHARMACEUTICAL TREATMENT VOLUME vs. SENTIMENT: 02/1/2009-01/31/2010; N = 2,045 The net sentiment and volume of conversation about the mostmentioned treatments is illustrated at left. Net sentiment is calculated as the net result of all positive mentions minus negative mentions of a particular treatment. Because physicians often discuss anticoagulant, anti-platelet, and thrombolytic treatment in ambiguous or difficult patient cases, and because physicians rarely seem to be loyal to a particular treatment, conversation is not very positive. Sentiment expressed toward the most-discussed four treatments shows a high degree of parity. Xarelto is a standout because physicians are intrigued by the promise of more alternatives. Effient trails in sentiment because physicians say they need more clinical outcome data to be comfortable with it. PERCENTAGE OF PHARMACEUTICAL COMMENTS

NET SENTIMENT OF COMMENTS

PHARMACEUTICAL TREATMENT:
Treatment conversation focuses heavily on risk management and dosage decisions.
STATISTICALLY MOST-CORRELATED WORDS IN CONVERSATION ABOUT PHARMACEUTICAL TREATMENTS CLOTTING: TREATMENT WORD MAP: 02/1/2009-01/31/2010 N = 2,045

THEMES
Treatment Usage Patient Cases Conflicting and Complementary Therapies Dosage Decisions Risk vs. Benefits Underlying Conditions Testing/Results

Methodological Note: The size of the bubble represents the frequency in which the term is mentioned. Terms appear when they have exceeded a correlation threshold based on their prevalence in the clotting/treatment discussion versus their prevalence throughout the entirety of Sermo discussion.

DOSAGE & LOGISTICS:

Conversation about dosage and the logistics of managing pharmaceutical treatment focus on Coumadin and Plavix administration.
CLOTTING: DOSAGE/LOGISTICS WORD MAP: 02/1/2009-01/31/2010 N = 744

THEMES Testing/Results/Treatment ASA Therapy Risk Concerns Additional Considerations Underlying Conditions Pharmaceutical Treatments

Methodological Note: The size of the bubble represents the frequency in which the term is mentioned. Terms appear when they have exceeded a correlation threshold based on their prevalence in the dosage/logistics discussion versus their prevalence throughout the entirety of Sermo discussion.

DOSAGE & LOGISTICS:

Managing anticoagulant and anti-platelet treatment pre- and post- surgical procedures is a major source of concern and requests for advice.
DOSAGE/LOGISTICS COMMENTS - THEMES: 02/1/2009-01/31/2010; N = 744 DOSAGE & LOGISTICS:

Concern about bleeding risk related to surgical procedures drives dosage conversation. Physicians need second opinions for peace of mind.
The ASA effect is there for several days, like it or not. Would d/c plavix and bridge with LMWH. Nothing wrong with iv heparin except you have to keep giving it and testing for PTT, actually costs more than LMWH. I do not stop Plavix, ASA or Coumadin for EGD or colonoscopy...in any patient. I do not hesitate to do polypectomies or appropriate biopsies and I have not had to operate or rescope a patient for bleeding. This has been my practice for over 30 years, over 15, 000 scopes. It is dangerous for the patient with CAD, PAD or CVD on these agents for good reason, to stop them. I always call the cardiologist and let them make the call Keep in mind that even if it is an emergency that has to be dealt with within the first 1-3 months post stent, most cardiologists here would STILL not recommend to stop the antiplatelet drug: They leave it up to the surgeon/ anesthesiologist so that if there is a cardiovascular event they can defend themselves.

Note: Comments are not mutually exclusive.

PERCENTAGE OF DOSAGE/LOGISTICS COMMENTS

COUMADIN:
Managing bleeding risk is top-of-mind, particularly when used with both Plavix and ASA.
COUMADIN: COUMADIN COMMENTS - THEMES: 02/1/2009-01/31/2010; N = 966

Managing the risk of bleeding drives tremendous volume of conversation, particularly when Coumadin is administered jointly with Plavix and/or ASA. Side effects are rarely mentioned.
Mortality from stent thrombosis in the LAD distribution is about 40-50%. I would not stop plavix before 12 months are up. He clearly should be on all three agents during the initial year. If the stent is well opposed and gets endothelialized, it's probably safe to continue just ASA and coumadin after that. I'm a fairly agressive endoscopist as far as what size and type of polyp I will remove. A 3-4 sessile polyp, that is likely benign - has a good chance of bleeding if you are on ASA and Plavix. I'm not sure what a little coumadin would do on top of that! The more complicated the anticoagulation becomes, the better the chance of something going wrong. NSAIDs, except Tylenol, are to one degree or another platelet antagonists of variable duration. If you already have a patient on both coumadin and plavix, that patient is right at the edge of bleeding.

Note: Comments are not mutually exclusive.

PERCENTAGE OF COUMADIN COMMENTS

PLAVIX:
Physicians struggle to weigh risk of bleeding against stroke prevention, particularly when considering joint Plavix-ASA treatment.
PLAVIX: PLAVIX COMMENTS - THEMES: 02/1/2009-01/31/2010; N =790

Managing risk of bleeding is of primary importance, as is the decision to add ASA to Plavix treatment.
From a neurologic standpoint, the risk of Plavix plus ASA causing intracerebral bleeding is more then their benefit in reducing the risk of ischemic stroke. Everyone of my hip fx pts is on Plavix. I just do the surgery as soon as they are medically cleared. If you get bleeding problems just give some FFP and be prepared to transfuse. A patient bleeding from excess Plavix effect does not have a bleeding problem that will respond to FFP. The problem is that the platelets have been poisoned. The best treatment would be platelet transfusion, so that there are some unpoisoned platelets in play. However, many blood banks have criteria for platelet transfusion, and the first person you speak to may well object to transfusing platelets to someone with a normal platelet count. You will save time and aggravation if you ask your friendly (honest!) neighborhood hematologist to support you on this to the Blood Bank.

Note: Comments are not mutually exclusive. Note: Comments are not mutually exclusive.

PERCENTAGE OF PLAVIX COMMENTS

HEPARIN:
Debate over the need for bridge therapy drives discussion, as does Heparins benefits regarding physicians ability to control risk of bleeding.
HEPARIN COMMENTS - THEMES: 02/1/2009-01/31/2010; N =258 HEPARIN:

Conversation is driven by best practices to minimizing risk of bleeding and appropriate use of Heparin, including as a bridge therapy.
There are only three types of patients that need a bridge with heparin/Lovenox 1/ patient with mechanical mitral valves (not aortic) 2/ patients with DVT/PE within 6 months 3/ Patients with hypercoagulable states All others can have there AC stopped before sx without the need of a bridge. You can use lovenox, but you can also use heparin at 1/10th the price (with the drawbacks being a higher risk of HIT and twice daily dosing). [Patient] is stuck between bleed and clot, and there is probably no safe middle ground. If any anticoagulant is used, it should be UFH rather than Lovenox, so changes can be made quickly. We got pretty good at knowing how to shut down heparin, reverse it with slow-push protamine sulfate, etc. Lovenox makes us nervous. But still a good drug.

Note: Comments are not mutually exclusive.

PERCENTAGE OF HEPARIN COMMENTS

LOVENOX:
Usage as a bridge therapy and during pregnancy drive discussion and adviceseeking.
LOVENOX: LOVENOX COMMENTS - THEMES: 02/1/09-01/31/10; N =222

Often discussed as bridge therapy for surgical patients on Coumadin, Lovenox is also frequently discussed for use in pregnant patients.
I would use heparin or Lovenox prophylaxis perioperativelly when I did operate. If she continues to bleed and you HAVE to operate you can take her off her coumadin, transition her to full dose heparin, stop for 24 hours while you accomplish surgery and restart post op. Coumadin is a real pain in the ass to keep the INRs in the therapeutic window during pregnancy, but is more or less safe after 13 weeks and before term. Sometimes I have to use this for patients who can not afford Lovenox or are non compliant with heparin i have one right now on lovenox currently 28 weeks, previous pe, almost killed her, she doesn't have a substantial thrombophilia, but still I am keeping her on lovenox until the end.

Note: Comments are not mutually exclusive.

During pregnancy Lovenox until 36 wks, then heparin, stop at first sign contractions or 24h prior to induction if she wants option of epidural anesthetic.

PERCENTAGE OF LOVENOX COMMENTS

THROMBOLYTICS:
Not a favored method of treatment, use of thrombolytics is discussed in extremely THROMBOLYTICS: ambiguous or contentious cases.
Thrombolytics are not frequently discussed, but stroke drives much of the existing conversation, followed by THROMBOLYTICS COMMENTS - THEMES: 02/1/09-01/31/10; N =98 treatment of PE (led by a debate about 51.0% the use of thrombolytics to treat a large, central PE).
This is an 8 hr window that is used with or without IV tPA. However, 3 hr IV tPA is the gold standard for treatment. This case like all tPA cases highlight the archaic modality we have to treat these patients. It is a horrible drug (short timeframe, bad side effects, used infrequently, requires evaluation of MULTIPLE inclusion/exclusion cirteria, requires "stabilizing" of BP which in CVA would be otherwise a bad idea, Etc... for an awful disease. But in the end, right now it is the best we have at the vast majority of institutions. And if you ask most docs, with that devastating a CVA, They'd take that awful drug, so give it and cross your fingers.....
Note: Comments are not mutually exclusive. Note: Comments are not mutually exclusive.

I have never quite understood the explanations in NIND etc how TPA can make things better at 3 months but worse at one month

PERCENTAGE OF THROMBOLYTICS COMMENTS

XARELTO:
Anticipation is high, but benefits of simplicity and patient compliance could be undermined by high cost or insufficient data on safety.
XARELTO: XARELTO COMMENTS - THEMES: 02/1/09-01/31/10; N =87

Interest is high, and while the combination of oral administration and no need for monitoring sounds promising, physicians say they want to know more about risks and cost. Xarelto seems most promising in comparison with Lovenox (due to likely patient compliance advantages), but Coumadins assumed cost advantage will be a sticking point.
This is great if it works. Note also that rivaroxaban (oral factor X inhibitor) is working its way through trials and looks like it works and is much simpler and safer than warfarin. Cost of the drug will be an important factor. Coumadin is cheap... If approved if it works as well as the injectable anti-coagulants, it will likely be a big change to ortho prescribing practices. Now, what happens to this playing field if/when dabigatran, rivaroxaban, and/ orapixaban get approved will be really interesting...

Note: Comments are not mutually exclusive.

PERCENTAGE OF XARELTO COMMENTS

EFFIENT:
Skepticism keeps conversation volume low, as physicians await more clinical outcome data.
EFFIENT: EFFIENT COMMENTS - THEMES: 02/1/09-01/31/10; N =70

Conversation volume is low because physicians appear to be waiting for more clinical outcome data, particularly in light of concern about higher risk of bleeding. Physicians are, however, keen on having more choice in anti platelet treatments, particularly as this may put pricing pressure on Plavix.
It will take a while before using it-plavix is very effective and it will be some time before the masses start Effient and report start to come in on possible problems--prob start after 6 months. Good to have choice, but Plavix is tried and true. Safety is first concern. The impressive data to me from the TRITON trial was the 50% reduction in stent thrombosis, and the lower event rates (nonfatal MI's) , esp. in diabetics. The ideal pt. to me is those younger pt. with DM, or diffuse CAD, and those with complex lesions and multiple/longer stents. Thus, PPI's should be avoided in patients on Plavix -- may open a door to increase prescribing of Lilly's new drug, prasugrel, once it's on the market

Note: Comments are not mutually exclusive. Note: Comments are not mutually exclusive.

PERCENTAGE OF EFFIENT COMMENTS

CONTENTS

Data & Topic Overview Physician Engagement Category Themes Patients Associated Conditions Medications Key Findings

KEY FINDINGS (category):

AMBIGUITY UNDERSCORES TREATMENT DECISIONS:

Unlike discussion of other ailments in the Sermo community, physician conversation about clotting treatment points to a high degree of ambiguity in treatment decisions. As one physician summarizes, there is rarely a clear answer as to what the best course of action is for DVT/clotting issues

RISK MANAGEMENT IS KEY:

Physicians are extremely focused on risk-management when assessing anticoagulant, anti-platelet, and thrombolytic treatment, regardless of the associated underlying condition. Risk of bleeding weighs heavily on the conversation, which includes frequent requests for advice regarding risk vs. benefit tradeoffs in specific patient cases.

PCPs AND CARDIOLOGISTS DRIVE DISCUSSION:

PCPs and Cardiologists are most involved in the clotting conversation on Sermo, followed by Emergency Medical Physicians, Hematologists, and OBGYNs. Although surgery drives significant share of discussion, surgeons themselves generate only 3.8% of the overall clotting dialogue.

KEY FINDINGS (category):

SURGICAL LOGISTICS DRIVE HIGH INTEREST:

Surgery is the most-discussed associated condition or context, as physicians request and provide opinions on how to manage anticoagulant and anti-platelet treatment pre- and post- surgery, including approaches to bridge therapy.

STROKE RISK WEIGHS ON THE CONVERSATION:

Stroke conversation highlights a struggle to weigh the risk of stroke against the risk of bleeding. Physicians struggle to balance risks is particularly acute in the case of stroke prevention, where risk is difficult to quantify.

THERE IS ROOM FOR INNOVATION IN THE ANTICOAGULANT CATEGORY:

Physicians are open to new anticoagulant treatment options. Existing treatments have recognized weaknesses, and physicians do not seem to have strong loyalty to existing options. New treatments will have to prove themselves on the basis of safety and cost in order to overcome potential objections.

KEY FINDINGS (pharmaceuticals):

COUMADIN
By far the most-discussed anticoagulant, Coumadins weakness is physicians overwhelming concern about risk of bleeding, particularly when used simultaneously with anti-platelet medications, including ASA. Cost is a recognized though littlementioned benefit, and side effects (which plague consumer conversation about Coumadin), are rarely discussed.

PLAVIX
Physicians frequently weigh risk of bleeding against risk of stroke, and note that joint Plavix-ASA treatment makes it difficult to get a handle on bleeding risk. Stroke is much more discussed in conjunction with Plavix than are cardiac conditions.

HEPARIN
The logistics of bridge therapy are frequently discussed, particularly among surgical candidates already using Coumadin. Cost is a recognized advantage over Lovenox.

LOVENOX
Logistics drive conversation, both in terms of Lovenoxs use as a bridge therapy and in the case of pregnant patients. Lovenoxs high cost/lack of coverage is a noted challenge for some physicians.

KEY FINDINGS (pharmaceuticals):

THROMBOLYTICS
Not a favored method of treatment, use of thrombolytics is discussed in extremely ambiguous or contentious cases. Stroke drives much of the existing conversation, followed by treatment of PE (led by one particular debate about the appropriateness of thrombolytics to treat a large, central PE).

XARELTO
High expectations characterize conversation about Xarelto, and physicians note that oral administration without required monitoring will be a powerful combination for patient compliance. However, safety data is needed, and cost could be a hurdle.

EFFIENT
Conversation volume is low because physicians appear to be waiting for more clinical outcome data, particularly in light of concern about higher risk of bleeding. Physicians are, however, keen on having more choice in anti-platelet treatments, particularly as this may put pricing pressure on Plavix.

APPENDIX

CLOTTING FLAGS:
Relevant conversations are identified by mention of clotting complications, anticoagulant, anti platelet, and thrombolytic treatments.
ALL SERMO COMMENTS PARTIAL CLOTTING STRING
Clotting Terminology Embolism Clots Thrombosis Coumadin Treatments Plavix tPA Effient Pulmonary Embolism Complications VTE DVT Diagnostics Drug Types D-Dimer INR Anticoagulant Anti-platelet

CLOTTING COMMENTS

Note: These are only portions of the larger strings used to capture and filter the Sermo conversation.

FULL BLOOD CLOTTING FLAGS:

The following string of words and phrases captured clotting, anticoagulant, antiplatelet, and thrombolytic comments.
CLOTTING, ANTICOAGULANT, ANTI-PLATELET, THROMBOLYTICS CODE TERMS: ("Antiplatelet" OR "anti platelet" OR "Antiplatelets" OR "anti platelets" OR "platelet" OR "platelets) OR ("Bloodclot" OR "Bloodclots" OR "Clot" OR "Clots" OR "Clotting" OR "Clotted) OR ("Blood thinners" OR "Blood thinner) OR ("Coagulation" OR "Coagulate" OR "Coagulates" OR "Anticoagulants" OR "Anticoagulation" OR "Anti coagulation" OR "Anti coagulants" OR "Anticoagulant" OR "Anti coagulant" OR "coag" OR "coags" OR "anticoag" OR "anticoags" OR "anticoagulated" OR "coagulated) OR ("D-dimer) OR ("DVT" OR "Deep Vein Thrombosis) OR ("Embolus" OR "Embolism" OR "Embolization" OR "Embolisation" OR "Pulmonary Embolism" OR "Paradoxical embolus" OR "emboli" OR "embolized" OR "embolised) OR ("fibrinolysis" OR "fibrin" OR "Factor Ia" OR "fibrinogen) OR ("Pulmonary Embolism" OR "PE) OR ("inr" OR "pr" OR "prothrombin) OR ("Thrombocytosis" OR "myeloproliferative" OR "thrombopoietin" OR "hydroxyurea" OR "anagrelide" OR "Agrylin) OR ("Thrombolysis) OR ("Thrombosis" OR "Venous Thrombosis" OR "VT" OR "Thrombus" OR "Thrombotic" OR "Venous Thromboembolism" OR "Thromboembolism" OR "VTE" OR "DVT" OR "Deep Vein Thrombosis" OR "Arterial Thrombosis" OR "Thrombi" OR "thromboses" OR "thromboembolic) OR ("Vascular Disease" OR "vascular diseases) ("Aggrenox" ) OR ("apixaban) OR ("argatroban") OR ("arixtra" OR "fondaparinux) OR ("Coumadin" OR "Warfarin" OR "cumadin" OR "cumadon) OR ("Coumadin" OR "cumadin" OR "cumadon) OR ("Effient" OR "prasugrel) OR ("Exanta" OR "ximelagatran" ) OR ("Heparin OR "lmwh" OR "ufh") OR ("Lovenox" OR "enoxaparin) OR ("Marcoumar" OR "Marcumar" OR "Falithrom" OR "phenprocoumon) OR ("Phenindione) OR (("Plavix" OR "clopidogrel") AND NOT ("Laundry list of diseases")) OR ("dabigatran" OR "Pradax" OR "Pradaxa) OR ("lepirudin" OR "Refludan) OR ("Sintrom" OR "Sinthrome" OR "acenocoumarol) OR ("Thrombolytic" OR "Thrombolytics" OR "Thrombolitic" OR "antiThrombolytic" OR "antiThrombolytics" OR "tissue plasminogen activator" OR "tpa" OR "alteplase" OR "Activase" OR "reteplase" OR "Retavase" OR "tenecteplase" OR "TNKase" OR "anistreplase" OR "Eminase" OR "streptokinase" OR "Kabikinase" OR "Streptase" OR "urokinase" OR "Abbokinase" OR "antithrombolytics" OR "antithrombolytic) OR ("Warfarin" ) OR ("Xarelto" OR "Rivaroxaban")