Direct Oral Anticoagulants: Practical Management Approaches

Barnes GD, Kurtz B.
Direct Oral Anticoagulants: Unique Properties and Practical Approaches to Management. Heart 2016;Jul 19:[Epub ahead of print].

The following are 10 points to remember from this review about direct oral anticoagulants (DOACs):

  1. Since 2009, four DOACs have been introduced for treatment of venous thromboembolism and stroke prevention in nonvalvular atrial fibrillation (AF).
  2. The four DOACs, including the three factor Xa inhibitors (apixaban, edoxaban, and rivaroxaban) and one direct thrombin inhibitor (dabigatran) provide oral anticoagulation therapy alternatives to vitamin K antagonist (VKA) therapy. The DOACs offer an exciting alternative to warfarin for a variety of thrombotic conditions and have now become the first-line choice for treatment of venous thromboembolism (VTE) and AF.
  3. Certain clinical situations may sway patients and clinicians to favor one oral anticoagulant over another. These are based on both the pharmacokinetic profiles of the medications and the results from randomized trials and real-world observational data.
  4. For example, use of DOACs is contraindicated for patients with mechanical valve replacement. Similarly, extremely limited data exist for the use of DOACs in patients with severe renal insufficiency (Cockcroft-Gault creatinine clearance <15 ml/min or end-stage renal disease). Therefore, warfarin is the preferred agent for these patients.
  5. Certain clinical situations may also favor one DOAC over another. For example, patients with moderate renal function can be treated with one of the factor Xa inhibitors (apixaban, edoxaban, or rivaroxaban). Patients with AF with high stroke risk (e.g., CHADS2 score of 5 or 6) could be treated with dabigatran 150 mg twice daily, as this was the only medication to show a significant reduction in ischemic stroke risk as compared with warfarin in the randomized trials.
  6. For patients with AF at higher risk of bleeding, use of apixaban, edoxaban, or dabigatran 110 mg twice daily (where available) might be preferable given that each of these medications reduced the risk of bleeding as compared with warfarin.
  7. Patients who prefer once-daily dosing will find both edoxaban and rivaroxaban to be more convenient than the twice-daily regimens for apixaban and dabigatran.
  8. Patients looking for single-drug treatment of VTE (especially outpatient treatment) will favor the use of apixaban or rivaroxaban, which do not require 5–10 days of pre-treatment with low molecular weight heparin as is required for dabigatran and edoxaban.
  9. Relevant to the majority of patients is the need for regular, ongoing renal function monitoring. Each of the DOACs is, at least in part, cleared by the kidneys. For that reason, they require periodic assessment of renal function to determine when dose adjustments are necessary or if their use is contraindicated.
  10. Engaging patients in a shared decision-making process to identify the most appropriate anticoagulant and ensuring safe long-term management are essential for high-quality, patient-centered anticoagulant care.

Keywords: Anticoagulants, Antithrombins, Arrhythmias, Cardiac, Atrial Fibrillation, Factor Xa Inhibitors, Heparin, Low-Molecular-Weight, Kidney Failure, Chronic, Primary Prevention, Stroke, Venous Thromboembolism, Vitamin K, Warfarin

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