A review of indications and comorbidities in which warfarin may be the preferred oral anticoagulant

Abstract

What is known and objective: Direct oral anticoagulants (DOACs) are increasingly prescribed instead of warfarin for chronic anticoagulation for ease of dosing, fewer interactions, and less stringent monitoring. However, it is important to consider indications and comorbidities for which warfarin is still the preferred anticoagulant. This review aims to capture these clinical scenarios in which warfarin may still be preferred over DOACs. Methods: We undertook a comprehensive literature search using the PubMed database. Key search terms were based on DOAC clinical trial exclusion criteria, as well as indications and conditions in which the use of DOACs for anticoagulation has suggested harm. Society guidelines and tertiary literature were used to inform expert opinion where necessary. Studies were included if they investigated the use of DOACs or warfarin in the identified indications or conditions. Results and Discussion: Currently, evidence for the use of warfarin over DOACs for anticoagulation is strongest for patients with prosthetic valves, antiphospholipid syndrome, or a high risk of gastrointestinal bleeding. For several clinical situations, including mitral stenosis, obesity, altered gastrointestinal anatomy, pulmonary arterial hypertension, renal or hepatic impairment, and left ventricular thrombus, evidence is lacking but may eventually support the use of DOACs. Depending on indication and condition, appropriateness of DOAC use may vary by agent.What is new and conclusion: New evidence continues to support new indications and conditions in which DOACs may be appropriate to use for anticoagulation. There are key clinical scenarios, however, in which emerging literature continues to support warfarin as the preferred anticoagulant.

Diagnostic and Therapeutic Challenges of Cerebral Venous Thrombosis in SARS-CoV-2 Infection: A Case Report and Review of Literature

“…The gold-standard, long-term treatment of CVT is warfarin, with a target INR of 2.0–3.0 [ 4 , 6 ]. Warfarin has been reported to be the most effective anticoagulation therapy, compared to DOACs, in patients with antiphospholipid syndrome, prosthetic valves, and those with high risk of gastrointestinal bleeds [ 26 , 27 ]. For warfarin to be therapeutic, prolonged stays in the hospital are required, with additional long-term outpatient INR monitoring.…”

Direct Oral Anticoagulants and Vitamin K Antagonists: Role in Thrombotic Damage, Safety, and Indications

“…Warfarin remains the least expensive anticoagulant currently available. This could make it a reasonable option for individuals who cannot afford the more costly options [11]. DOACs are considered the first line option in many indications given their predicted pharmacokinetics and pharmacodynamics which minimizes the need for regular drug monitoring compared to warfarin.…”

DOAC — not for everyone, and sometimes at different dose

“…Dabigatran has the highest degree of elimination and is associated with higher bleeding frequency and mortality as compared to warfarin in atrial fibrillation patients on hemodialysis [9]. On the other hand, apixaban with minimal degree of renal elimination [10], may be administered to hemodialysis patients and the bleeding risk may even be reduced as compared to warfarin [11,12]. Based on observational studies, rivaroxaban place is somewhere in between [11,12].…”

“…On the other hand, apixaban with minimal degree of renal elimination [10], may be administered to hemodialysis patients and the bleeding risk may even be reduced as compared to warfarin [11,12]. Based on observational studies, rivaroxaban place is somewhere in between [11,12].…”

“…Further studies are required [11] to determine if DOACs could find place in patients with biological heart valves and individuals after transcatheter aortic valve replacement (TAVR).…”