Direct Oral Anticoagulant Use: A Practical Guide to Common Clinical Challenges

Abstract

Direct oral anticoagulants ( DOAC s) have quickly become attractive alternatives to the long‐standing standard of care in anticoagulation, vitamin K antagonist. DOAC s are indicated for prevention and treatment of several cardiovascular conditions. Since the first approval in 2010, DOAC s have emerged as leading therapeutic alternatives that provide both clinicians and patients with more effective, safe, and convenient treatment options in thromboembolic settings. With the expanding role of DOAC s, clinicians are faced with increasingly complex decisions relating to appropriate agent, duration of treatment, and use in special populations. This review will provide an overview of DOAC s and act as a practical reference for clinicians to optimize DOAC use among common challenging scenarios. Topics addressed include (1) appropriate indications; (2) use in patients with specific comorbidities; (3) monitoring parameters; (4) transitioning between anticoagulant regimens; (5) major drug interactions; and (6) cost considerations.

Edoxaban versus Warfarin in Patients with Atrial Fibrillation at the Extremes of Body Weight: An Analysis from the ENGAGE AF-TIMI 48 Trial

“…3 However, detailed data on the pharmacokinetics and pharmacodynamics of specific NOAC agents at the extremes of body weight are very limited and the need for additional assessments has been stressed. 3,10,11 The aim of the present posthoc analysis of the ENGAGE AF-TIMI 48 trial 9,10 was to analyze the pharmacokinetics, pharmacodynamics, and clinical outcome in patients treated with edoxaban versus warfarin at extremes of body weight (!120 kg, 55 kg), as compared with a middle body weight group, since for these patient subgroups multiple prior expert consensus statements/guidance documents stated that data were too sparse to recommend NOACs.…”

Targeting multiple enzymes in vitamin K metabolism for anticoagulation

“…These drugs, however, have a narrow therapeutic window and require frequent anticoagulation monitoring and dose adjustments. To overcome these problems, direct oral anticoagulants (DOACs) targeting factor Xa and thrombin have been developed, with the advantages of less monitoring, fixed dosing, predictable responses, and fewer food interactions 1 . The efficacy and safety of DOACs, however, have yet to be demonstrated for a number of specific conditions 2 .…”

A 78-Year-Old Man with a Pulmonary Embolism Who Developed Skin Necrosis 7 Days After Treatment with the Direct Oral Anticoagulant Factor Xa Inhibitor Apixaban

“…In late 2010, a new class of anticoagulants known as direct oral anticoagulants (DOAC) was introduced as an alternative to conventional anticoagulation therapy [ 1 ]. DOACs have proven to be equal or superior to conventional therapy for preventing stroke in nonvalvular atrial fibrillation, with similar efficacy for prevention and treatment of venous thromboembolism [ 1 , 2 ].…”

“…In late 2010, a new class of anticoagulants known as direct oral anticoagulants (DOAC) was introduced as an alternative to conventional anticoagulation therapy [ 1 ]. DOACs have proven to be equal or superior to conventional therapy for preventing stroke in nonvalvular atrial fibrillation, with similar efficacy for prevention and treatment of venous thromboembolism [ 1 , 2 ]. This new class has clear advantages over warfarin, with better pharmacodynamics and pharmacokinetic properties, less drug-drug interactions, and no requirement for frequent coagulation test monitoring [ 2 , 3 ].…”