Dabigatran etexilate (Pradaxa) was recently licensed for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (AF). This article in the Drug and Therapeutics Bulletin (DTB) reviews the evidence and its place in therapy, and makes note of the following:

One study found that dabigatran 150mg twice daily was slightly more effective than warfarin in preventing stroke and systemic embolism, and was as likely to cause major bleeding. However, it included some patients who would not be managed with warfarin based on current clinical practice. In addition, the long-term efficacy and safety of dabigatran are unknown.
 

Dabigatran costs more than warfarin and one UK analysis suggests that it may be cost-effective in patients with poor anticoagulation control, but not in those with good anticoagulation control.
 

Dabigatran may be suitable for patients who are considered unsuited to anticoagulation monitoring but are at high risk of stroke (e.g. some older people); those at high risk of drug interactions; or those whose coagulation control is poor (and where all warfarin management strategies have failed).
 

The DTB concludes that given the potential advantages of dabigatran for many patients with AF and the continuing need to provide warfarin therapy for others, “a large-scale disinvestment from anticoagulation services is unlikely to be possible in the foreseeable future. Investment decisions will need to take into account the cost of dabigatran as well the cost of continuing to provide an anticoagulation service.”