The Changing Face of Medicine

In textbooks, we read about old drugs that are no longer used, and occasionally, attendings will talk about medications that were around when they learned anesthesia. My fellow residents and I always share a glance when an attending reminisces about thiopental, an anesthetic no longer manufactured, or the days of halothane (or for some, even earlier inhaled anesthetics). How quaint, we think, that our teachers know so much about drugs we'll never see again.

But I'm starting to realize, the way medicine changes, I might soon fall into the category of physicians who walk about drugs "we used to use." Back in 2009, I wrote a blog about warfarin. For decades, the blood thinner was used to prevent clot formation and decrease risk of thromboembolic stroke in patients with atrial fibrillation. In medical school and residency, we spend a lot of time thinking about warfarin, reviewing the evidence for its use, stratifying patient risk, checking its efficacy in patients taking it, educating family members and caregivers, seeing its unfortunate complications of hemorrhage, reversing supratherapeutic numbers, and instructing patients on when to stop it before surgery. We have pounded in our head the goal INRs for atrial fibrillation versus mechanical heart valve. We learn its half life, its interactions with leafy greens, its mechanism of action, the way to tweak its dosing (3mg on MWF, 2.5mg on TThSSu).

But soon that all might be unnecessary. Newer anticoagulants, anti-thrombin inhibitors like dabigatran and and factor Xa inhibitors like apixaban and rivaroxaban, may soon make warfarin obsolete. With increasing evidence that its efficacy and complications may make it a reasonable alternative to warfarin as well as significant advantages for patient convenience, they may soon be the preferred agent for atrial fibrillation. I'm sure more anticoagulants are on the market. I can only imagine that in a few years, medical students will learn and read about warfarin as if it were a medicine of the past, a quaint and outdated drug that required close monitoring of INR, adjustment for dietary changes, and the need for "coumadin clinics." They will think me ancient because I spent so much of my training using a drug that's been replaced by something much simpler and safer.