Cost-effective drug selection: Injectable anticoagulants

Compared to other antithrombotic classes for treatment of acute coronary syndromes (ACS), anticoagulants are relatively inexpensive. Available injectable anticoagulants for treating patients with ACS include unfractionated heparin (UFH), the low molecular weight heparins (LMWHs) enoxaparin and dalteparin, and the direct thrombin inhibitor lepirudin (1-5). Currently, either the LMWHs or UFH are acceptable agents for treating patients with non-ST segment elevation (NSTE) ACS based upon the 2002 American Heart Association (AHA)/American College of Cardiology (ACC) practice guidelines, while enoxaparin is the preferred agent (6). While UFH is the preferred agent for patients with ST segment elevation (STE) ACS, AHA/ACC data suggests that enoxaparin may be a preferred alternative (7,8). Lepirudin, due to its expense (approximately $500-$750 per day), marginal superiority to UFH in clinical trials, and high rate of bleeding complications, is reserved for patients with heparin-induced thrombocytopenia (2,4).