anticoagulant category report

8/2/2019 Anticoagulant Category Report

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Sermo Anticoagulation, Anti-platelet, and

Thrombolytic Conversation Overview

Powered by MotiveQuest

Time Period: 02/1/2009 01/31/2010

Key Contact: Joe Walsh, [email protected]

Date: 03/04/2010


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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 most-

discussed issues.

Explore which brands and therapies are mostdiscussed by physicians.

Understand how discussions have changed over time.

2 2009 Sermo, Inc. Confidential


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KEY FINDINGS (category):

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.

AMBIGUITY UNDERSCORES TREATMENT DECISIONS:Unlike discussion of other ailments in the Sermo community, physician conversation about clotting treatment points to a high degreeof 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

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.


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THERE IS ROOM FOR INNOVATION IN THE ANTICOAGULANT CATEGORY:Physicians are open to new anticoagulant treatment options. Existing treatments have recognized weaknesses, and physicians donot 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.

SURGICAL LOGISTICS DRIVE HIGH INTEREST:Surgery is the most-discussed associated condition or context, as physicians request and provide opinions on how to manageanticoagulant 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 risksis particularly acute in the case of stroke prevention, where risk is difficult to quantify.


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KEY FINDINGS (pharmaceuticals):

COUMADINBy 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 little-mentioned benefit, and side effects (which plague consumer conversation about Coumadin), are rarely discussed.

PLAVIXPhysicians 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.

HEPARINThe 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.


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XARELTOHigh 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.

EFFIENTConversation volume is low because physicians appear to be waiting for more clinical outcome data, particularly in light ofconcern 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.

THROMBOLYTICSNot 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 appropriatenessof thrombolytics to treat a large, central PE).


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CONTENTS

Patients

Physician Engagement

Co-morbid Conditions

Data & Topic Overview

Category Themes

Medications

Key Findings


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THE CONVERSATION:The following analysis covers 5,047 comments about clotting, anticoagulant, anti-platelet, 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.


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CONTEXT:Blood clotting complications and treatment are frequently discussed in the Sermocommunity.

MENTIONS OF SELECTED MEDICAL CONDITIONS: 02/1/2009 01/31/2010 N = 237,857

Note: Comments are not mutually exclusive.

NUMBER OF COMMENTS IN SERMO COMMUNITY

Blood clotting conversation

is defined as mentions of

clotting terminology

(thrombosis, embolism, etc)

as well as anticoagulant,

anti-platelet, andthrombolytic treatment.


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TREND:Conversation volume is stable, with the exception of two extremely high interestSermo Discussions in March and April 2009.

* 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

OFCOMMENTS

Comments

BLOOD CLOTTING COMMENT VOLUME TRENDED: 02/1/2009 01/31/2010 N = 5,047


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CONTENTS

Patients


AssociatedConditions


Category Themes

Medications

Key Findings


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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

NUMBER

OFPHYSICIAN

S

ENGAGEMENT IN THE CLOTTING CONVERSATION

(1-5 comments)

(6+ comments)


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VOLUME BY SPECIALTY:Aside from PCPs, Cardiologists generate high volume of conversation about theclotting topic within the Sermo community.

SHARE OF CLOTTING CONVERSATION BY SPECIALTY:

02/1/2009-01/31/2010 N = 5,047

PERCENTAGE OF COMMENTS

Share of clotting comments

Share of all Sermo comments


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CONTENTS

Patients




Category Themes

Medications

Key Findings


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THEMES:As is typical of Sermo conversations, patient cases drive much discussion, followedby concern about associated conditions and pharmaceutical treatment options.

PATIENTS:

Much of the conversation revolves around

specific patient cases, as physicians seek

and provide counsel on risk management.

ASSOCIATED CONDITIONS:

Surgery, stroke, and pregnancy leadassociated conditions. Risk-management is

of primary importance as physicians discuss

their approaches to managing anticoagulant

and anti-platelet treatment pre- and post-

surgery. 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: Mentions are not mutually exclusive.

(unbranded references)

(unbranded references)

BLOOD CLOTTING CONVERSATION - TOP THEMES 02/1/2009-01/31/2010; N = 5,047

PERCENTAGE OF BLOOD CLOTTING COMMENTS



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CONTENTS

Patients




Category Themes

Medications

Key Findings


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PATIENTS:Seeking and sharing advice regarding particularly thorny or ambiguous cases drivespatient mentions.

STATISTICALLY MOST-CORRELATED WORDS IN CONVERSATION ABOUT PATIENTS IN THE CLOTTING DIALOGUE

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.

Anti-platelet Treatment

Tests, Diagnostics

Risks & Concerns

Underlying Conditions

Treatment Context

Patient Descriptors

Situations

Results & Testing

Anticoagulation Treatment

THEMESCLOTTING: PATIENT WORD MAP: 02/1/2009-01/31/2010 N = 2,745


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PATIENTS:Advice-seeking (and giving) drives patient discussion as physicians look for secondopinions on ambiguous cases. Treating PE patients is top-of-mind.

PATIENTS:

Specific patient cases are frequentlydiscussed as physicians seek secondopinions, often inspired by disagreement

among a physicians own colleagues. TheSermo community helps settle debateabout the best course of treatment.

35 yo female c/o 2 wk dull chest pain,intermittent & right calf tenderness, sayssx similar to when had postpartum PElast year. Sx were relatively mild then &pt was surprised at the diagnosis. Wason coumadin 6 mo & has been off for ayear now. Would you do further workup(CT, angiography)? Her presentation isso unimpressive. Also - in pt withpostpartum PE - is workup forthrombophilia necessary, and what is thechance for recurrence when notpregnant, no hormone use?

You have a PE, you get admitted. Period.This can be either observational orinpatient treatment. There is no way foryou to predict that a 'stable' PE patientmight toss another life threatening clotbefore they have had a chance to startlovenox and coumadin (Yes, it canhappen anytime, but it is less withtreatment).


PATIENT COMMENTS - THEMES: 02/1/2009-01/31/2010; N = 2,745

PERCENTAGE OF PATIENT COMMENTS


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CONTENTS

Patients


Associated Conditions


Category Themes

Medications

Key Findings


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ASSOCIATED CONDITIONS:Together, surgery and orthopedic surgery comprise a full quarter of all associatedconditions discussed. Stroke and pregnancy are also top-of-mind.

MENTIONS OF ASSOCIATED CONDITIONS: 02/1/09-01/31/10; N = 2,473


PERCENTAGE OF ASSOCIATED CONDITION COMMENTS


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SURGERY:Conversation is highly focused on the logistics of managing anticoagulation/antiplatelet treatment pre- and post- procedure.

STATISTICALLY MOST-CORRELATED WORDS IN CONVERSATION ABOUT SURGERY IN THE CLOTTING DIALOGUE



threshold based on their prevalence in the clotting/surgery discussion versus their prevalence throughout the entirety of Sermo discussion.

Tests

Clotting Conditions

Procedure Types

Risks & Complications

Anticoagulant/Anti plateletManagement

Anticoagulant/Anti platelet

Treatments

THEMES

CLOTTING: SURGERY WORD MAP: 02/1/2009-01/31/2010 N = 489


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SURGERY:Managing the risk of bleeding and swelling is top-of-mind, and physicians are lookingfor more nuanced approaches to risk assessment.


SURGERY COMMENTS - THEMES: 02/1/2009-01/31/2010; N = 489

PERCENTAGE OF SURGERY COMMENTS

SURGERY:

Managing the risk of bleeding dominatesdiscussion. Administration of Plavix,Coumadin, and ASA generate the most

concern and uncertainty.

Patients should be risk stratified. Thereshould be multiple options foranticoagulation. All patients don't have thesame risk of VTE and/or bleeding.

I think the bleeding/ swellingcomplications are much higher withanticoagulants, and I am not convinced theyprevent significant VTE lower death from allcauses. I can tell you from my trauma daysthat I saw death from VTE with or withoutthe anticoagulants, and this increases mybias. This data needs to be confirmed in acommunity setting by nonpharma people.

You might also dissent from the hideous,

but widespread, practice of making theCoumadin dose a daily conundrum, as in:Coumadin 2.5 mg on Mon-Wed-Fri, 5 mg onTues-Thurs-Sat, and Coumadin either 3 mgor 2.5 mg on Sunday, according to the phaseof the moon. Why do otherwise sensibledoctors become such morons when theyprescribe Coumadin?


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STROKE:The struggle to balance the risk of stroke against the risk of bleeding drivesdiscussion.

STATISTICALLY MOST-CORRELATED WORDS IN CONVERSATION ABOUT STROKE IN THE CLOTTING DIALOGUE



threshold based on their prevalence in the clotting/stroke discussion versus their prevalence throughout the entirety of Sermo discussion.

THEMES

Discussion of Causes

Testing/Results

Associated Conditions

Risks & Complications ofTreatment

Treatment Options

Patient Cases

CLOTTING: STROKE WORD MAP: 02/1/2009-01/31/2010 N = 398


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STROKE:Physicians struggle to nail down the risk vs. benefit calculation when dealing withstroke patients. There is a need for more data on the subject.


STROKE COMMENTS - THEMES: 02/1/2009-01/31/2010; N = 398

PERCENTAGE OF STROKE COMMENTS

STROKE:

Striking an appropriate balance between risk of

bleeding and risk of stroke is the highestpriority. Plavix, ASA, and Coumadin are the

primary variables in this calculation, and arethus at the center of stroke conversation.

From a neurologic standpoint, the risk ofPlavix plus ASA causing intracerebralbleeding is more then their benefit inreducing the risk of ischemic stroke. AddingWarfarin to such a combination is notjustifiable.

For ischemic strokes in particular, thegeneral rule is prophylactic Lovenox andfull-dose aspirin, but no Plavix unless theyneed to be on it (in which case aspirin isn'tgiven). The reason for Lovenox is somerandomized data suggesting a marginaldecrease in DVT and presumably PE, thoughthis may be balanced by a marginal increase

in bleeding complications. I believe theFASTER trial (and EXPRESS, though this didnot explicitly look at ASA + Plavix vs ASA)found a trend towards better outcomes forASA and Plavix. Apparently there have beenproposals to study this issue in depth, butthe NINDS and drug companies are notinterested for now since the likely benefitwill be small.


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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.

RISKS & COMPLICATIONS:

More data is needed, as is more understandingof existing guidelines relating to the risks vs.the benefits of clotting treatment.

FDA has published an alert which does NOTmandate any change in prescriptionguidelines, but which advocate risk benefitanalysis before prescribing PPIs to patientswho require Plavix. (So it is up to your

clinical judgment.) My personal bias (basedon the very limited data) is that I will keeppatients who have a history of confirmedUGI bleeds or have high risk UGI bleedingsources on PPIs, but I will switch to Protonixif possible.

I would take issue with the extremepositions that have been taken on both sidesof the arguement here - there are somepeople for whom the risk of anticoagulationoutweighs the benefits and there are even

more people out there who are being harmedby not being anticoagulated. Physiciansinvolved in taking care of pts really need todo a careful reading of the ACCP guidelinesas well as the article describing in orthopedicpts the use of aspirin combined withmechanical prophylaxis which is one of thefew articles out there indicating that this isan acceptable strategy....


RISK & COMPLICATION COMMENTS - THEMES: 02/1/2009-01/31/2010; N = 902

PERCENTAGE OF RISKS & COMPLICATIONS COMMENTS


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CONTENTS

Patients




Category Themes

Medications

Key Findings


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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


PERCENTAGE OF PHARMACEUTICAL TREATMENT COMMENTS


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PHARMACEUTICAL SENTIMENT:Speculation about Xarelto makes it a standout. The promise of oral and non-monitored is powerful, but physicians need proof of safety and are sensitive to cost.

The net sentiment and volume ofconversation about the most-

mentioned treatments is illustrated at

left.

Net sentiment is calculated as thenet result of all positive mentions minus

negative mentions of a particular

treatment.

Because physicians often discussanticoagulant, 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 themost-discussed four treatments shows

a high degree of parity.

Xarelto is a standout becausephysicians are intrigued by the

promise of more alternatives.

Effient trails in sentiment becausephysicians say they need more clinical

outcome data to be comfortable with it.

PHARMACEUTICAL TREATMENT VOLUME vs. SENTIMENT: 02/1/2009-01/31/2010; N = 2,045

NETSENTIMENTOFCOMM

ENTS

PERCENTAGE OF PHARMACEUTICAL COMMENTS


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PHARMACEUTICAL TREATMENT:Treatment conversation focuses heavily on risk management and dosage decisions.



threshold based on their prevalence in the clotting/treatment discussion versus their prevalence throughout the entirety of Sermo discussion.

Treatment Usage

Patient Cases

Conflicting andComplementary Therapies

Dosage Decisions

Risk vs. Benefits


Testing/Results

THEMES

STATISTICALLY MOST-CORRELATED WORDS IN CONVERSATION ABOUT PHARMACEUTICAL TREATMENTS

CLOTTING: TREATMENT WORD MAP: 02/1/2009-01/31/2010 N = 2,045


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DOSAGE & LOGISTICS:Conversation about dosage and the logistics of managing pharmaceutical treatmentfocus on Coumadin and Plavix administration.

CLOTTING: DOSAGE/LOGISTICS WORD MAP:

02/1/2009-01/31/2010 N = 744

Testing/Results/Treatment

ASA Therapy

Risk Concerns

Additional Considerations


Pharmaceutical Treatments

THEMES



threshold based on their prevalence in the dosage/logistics discussion versus their prevalence throughout the entirety of Sermo discussion.


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DOSAGE & LOGISTICS:Managing anticoagulant and anti-platelet treatment pre- and post- surgicalprocedures is a major source of concern and requests for advice.

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, likeit or not. Would d/c plavix and bridge withLMWH. Nothing wrong with iv heparinexcept you have to keep giving it and testingfor PTT, actually costs more than LMWH.

I do not stop Plavix, ASA or Coumadin forEGD or colonoscopy...in any patient. I do nothesitate to do polypectomies or appropriatebiopsies and I have not had to operate or re-scope a patient for bleeding. This has beenmy practice for over 30 years, over 15, 000scopes. It is dangerous for the patient withCAD, PAD or CVD on these agents for goodreason, to stop them.

I always call the cardiologist and let themmake the call Keep in mind that even if it isan emergency that has to be dealt withwithin the first 1-3 months post stent, mostcardiologists here would STILL notrecommend to stop the antiplatelet drug:They leave it up to the surgeon/anesthesiologist so that if there is acardiovascular event they can defendthemselves.

DOSAGE/LOGISTICS COMMENTS - THEMES: 02/1/2009-01/31/2010; N = 744

PERCENTAGE OF DOSAGE/LOGISTICS COMMENTS



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COUMADIN:Managing bleeding risk is top-of-mind, particularly when used with both Plavix andASA.


COUMADIN COMMENTS - THEMES: 02/1/2009-01/31/2010; N = 966

PERCENTAGE OF COUMADIN COMMENTS

COUMADIN:

Managing the risk of bleeding drivestremendous volume of conversation,particularly when Coumadin is

administered jointly with Plavix and/or ASA.

Side effects are rarely mentioned.

Mortality from stent thrombosis in theLAD distribution is about 40-50%. Iwould not stop plavix before 12 monthsare up. He clearly should be on all threeagents during the initial year. If the stent

is well opposed and gets endothelialized,it's probably safe to continue just ASAand coumadin after that.

I'm a fairly agressive endoscopist asfar as what size and type of polyp I willremove. A 3-4 sessile polyp, that is likelybenign - has a good chance of bleeding ifyou are on ASA and Plavix. I'm not surewhat a little coumadin would do on topof that!

The more complicated theanticoagulation becomes, the better thechance of something going wrong.NSAIDs, except Tylenol, are to onedegree or another platelet antagonists ofvariable duration. If you already have apatient on both coumadin and plavix,that patient is right at the edge ofbleeding.


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PLAVIX:Physicians struggle to weigh risk of bleeding against stroke prevention, particularlywhen considering joint Plavix-ASA treatment.

PLAVIX:

Managing risk of bleeding is of primaryimportance, as is the decision to add ASAto Plavix treatment.

From a neurologic standpoint, the riskof Plavix plus ASA causing intracerebralbleeding is more then their benefit inreducing the risk of ischemic stroke.

Everyone of my hip fx pts is on Plavix. Ijust do the surgery as soon as they are

medically cleared. If you get bleedingproblems just give some FFP and beprepared to transfuse.

A patient bleeding from excess Plavixeffect does not have a bleeding problemthat will respond to FFP. The problemis that the platelets have been poisoned.The best treatment would be platelettransfusion, so that there are someunpoisoned platelets in play. However,many blood banks have criteria for

platelet transfusion, and the first personyou speak to may well object totransfusing platelets to someone with anormal platelet count. You will save timeand aggravation if you ask your friendly(honest!) neighborhood hematologist tosupport you on this to the Blood Bank.Note: Comments are not mutually exclusive.

PERCENTAGE OF PLAVIX COMMENTS

PLAVIX COMMENTS - THEMES: 02/1/2009-01/31/2010; N =790



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HEPARIN:Debate over the need for bridge therapy drives discussion, as does Heparinsbenefits regarding physicians ability to control risk of bleeding.


PERCENTAGE OF HEPARIN COMMENTS

HEPARIN COMMENTS - THEMES: 02/1/2009-01/31/2010; N =258 HEPARIN:

Conversation is driven by best practices to

minimizing risk of bleeding and appropriateuse of Heparin, including as a bridge therapy.

There are only three types of patients thatneed a bridge with heparin/Lovenox 1/patient with mechanical mitral valves (notaortic) 2/ patients with DVT/PE within 6months 3/ Patients with hypercoagulable

states All others can have there AC stoppedbefore sx without the need of a bridge.

You can use lovenox, but you can also useheparin at 1/10th the price (with thedrawbacks being a higher risk of HIT andtwice daily dosing).

[Patient] is stuck between bleed and clot,and there is probably no safe middleground. If any anticoagulant is used, itshould be UFH rather than Lovenox, sochanges can be made quickly.

We got pretty good at knowing how to shutdown heparin, reverse it with slow-pushprotamine sulfate, etc. Lovenox makes usnervous. But still a good drug.


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LOVENOX:Usage as a bridge therapy and during pregnancy drive discussion and advice-seeking.


PERCENTAGE OF LOVENOX COMMENTS

LOVENOX COMMENTS - THEMES: 02/1/09-01/31/10; N =222

LOVENOX:Often discussed as bridge therapy forsurgical patients on Coumadin, Lovenox isalso frequently discussed for use in pregnant

patients.

I would use heparin or Lovenoxprophylaxis perioperativelly when I didoperate. If she continues to bleed and youHAVE to operate you can take her off hercoumadin, transition her to full dose

heparin, stop for 24 hours while youaccomplish surgery and restart post op.

Coumadin is a real pain in the ass to keepthe INRs in the therapeutic window duringpregnancy, but is more or less safe after 13weeks and before term. Sometimes I haveto use this for patients who can not affordLovenox or are non compliant withheparin

i have one right now on lovenox currently

28 weeks, previous pe, almost killed her,she doesn't have a substantialthrombophilia, but still I am keeping heron lovenox until the end.

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


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THROMBOLYTICS:Not a favored method of treatment, use of thrombolytics is discussed in extremelyambiguous or contentious cases. THROMBOLYTICS:

Thrombolytics are not frequently

discussed, but stroke drives much of theexisting conversation, followed by

treatment of PE (led by a debate aboutthe use of thrombolytics to treat a large,central PE).

This is an 8 hr window that is usedwith or without IV tPA. However, 3 hrIV tPA is the gold standard fortreatment.

This case like all tPA cases highlightthe archaic modality we have to treatthese patients.

It is a horrible drug (short timeframe,bad side effects, used infrequently,requires evaluation of MULTIPLEinclusion/exclusion cirteria, requires"stabilizing" of BP which in CVA wouldbe otherwise a bad idea, Etc... for anawful disease. But in the end, rightnow it is the best we have at the vast

majority of institutions. And if you askmost docs, with that devastating aCVA, They'd take that awful drug, sogive it and cross your fingers.....

I have never quite understood theexplanations in NIND etc how TPA canmake things better at 3 months butworse at one month


PERCENTAGE OF THROMBOLYTICS COMMENTS

THROMBOLYTICS COMMENTS - THEMES: 02/1/09-01/31/10; N =98

51.0%



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XARELTO:Anticipation is high, but benefits of simplicity and patient compliance could beundermined by high cost or insufficient data on safety.


PERCENTAGE OF XARELTO COMMENTS

XARELTO COMMENTS - THEMES: 02/1/09-01/31/10; N =87

XARELTO:Interest is high, and while the combinationof oral administration and no need formonitoring sounds promising, physicians

say they want to know more about risksand cost. Xarelto seems most promising incomparison with Lovenox (due to likely

patient compliance advantages), butCoumadins assumed cost advantage will

be a sticking point.

This is great if it works. Note also thatrivaroxaban (oral factor X inhibitor) isworking its way through trials and lookslike it works and is much simpler andsafer than warfarin.

Cost of the drug will be an importantfactor. Coumadin is cheap...

If approved if it works as well as theinjectable anti-coagulants, it will likelybe a big change to ortho prescribingpractices.

Now, what happens to this playing fieldif/when dabigatran, rivaroxaban, and/orapixaban get approved will be reallyinteresting...


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EFFIENT:Skepticism keeps conversation volume low, as physicians await more clinicaloutcome data.

EFFIENT:

Conversation volume is low becausephysicians appear to be waiting for moreclinical outcome data, particularly in light of

concern about higher risk of bleeding.

Physicians are, however, keen on havingmore choice in anti platelet treatments,particularly as this may put pricing pressureon Plavix.

It will take a while before using it--plavix is very effective and it will be some

time before the masses start Effient andreport start to come in on possibleproblems--prob start after 6 months.

Good to have choice, but Plavix is triedand true. Safety is first concern.

The impressive data to me from theTRITON trial was the 50% reduction instent thrombosis, and the lower eventrates (nonfatal MI's) , esp. in diabetics.The ideal pt. to me is those younger pt.with DM, or diffuse CAD, and those withcomplex lesions and multiple/longerstents.

Thus, PPI's should be avoided inpatients on Plavix -- may open a door toincrease prescribing of Lilly's new drug,prasugrel, once it's on the market


PERCENTAGE OF EFFIENT COMMENTS

EFFIENT COMMENTS - THEMES: 02/1/09-01/31/10; N =70



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CONTENTS

Patients




Category Themes

Medications

Key Findings


40/46


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.

AMBIGUITY UNDERSCORES TREATMENT DECISIONS:Unlike discussion of other ailments in the Sermo community, physician conversation about clotting treatment points to a high degreeof 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

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.


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THERE IS ROOM FOR INNOVATION IN THE ANTICOAGULANT CATEGORY:Physicians are open to new anticoagulant treatment options. Existing treatments have recognized weaknesses, and physicians donot 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.

SURGICAL LOGISTICS DRIVE HIGH INTEREST:Surgery is the most-discussed associated condition or context, as physicians request and provide opinions on how to manageanticoagulant 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 risksis particularly acute in the case of stroke prevention, where risk is difficult to quantify.


42/46


COUMADINBy 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 little-mentioned benefit, and side effects (which plague consumer conversation about Coumadin), are rarely discussed.

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

HEPARINThe 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.


43/46


XARELTOHigh 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.

EFFIENTConversation volume is low because physicians appear to be waiting for more clinical outcome data, particularly in light ofconcern 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.

THROMBOLYTICSNot 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 appropriatenessof thrombolytics to treat a large, central PE).


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APPENDIX


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CLOTTING FLAGS:Relevant conversations are identified by mention of clotting complications,anticoagulant, anti platelet, and thrombolytic treatments.

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

Clotting

Embolism

Clots

Thrombosis

Coumadin

Plavix

tPA

Effient

Pulmonary Embolism

VTE

DVT

D-Dimer

INR

Anticoagulant

Anti-platelet

ALL SERMO COMMENTS PARTIAL CLOTTINGSTRING

CLOTTINGCOMMENTS

Terminology

Treatments

Complications

Diagnostics

Drug Types


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FULL BLOOD CLOTTING FLAGS:The following string of words and phrases captured clotting, anticoagulant, anti-platelet, 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")

anticoagulant category report

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