Direct oral anticoagulants: integration into clinical practice

Abstract

The introduction of direct oral anticoagulants (OACs) for the treatment and prevention of thromboembolic disease represents a shift from the traditional vitamin K antagonist-based therapies, which have been the mainstay of treatment for almost 60 years. A challenge for hospital formularies will be to manage the use of direct OACs from hospital to outpatient settings. Three direct OACs—apixaban, dabigatran and rivaroxaban—are widely approved across different indications, with rivaroxaban approved across the widest breadth of indications. A fourth direct OAC, edoxaban, has also completed phase III trials. Implementation of these agents by physicians will require an understanding of the efficacy and safety profile of these drugs, as well as an awareness of renal function, comedication use, patient adherence and compliance. Optimal implementation of direct OACs in the hospital setting will provide improved patient outcomes when compared with traditional anticoagulants and will simplify the treatment and prevention of thromboembolic diseases.

Pediatric Cardiac Intensive Care Society 2014 Consensus Statement

“…In adult studies, NOACs have been demonstrated to be efficacious and in the United States are approved for the use in stroke prevention from atrial fibrillation, the treatment of acute deep vein thrombosis (DVT), secondary prevention of DVT, DVT prevention post elective knee and hip surgery (80), and in the treatment of acute pulmonary embolus (81,82).…”

Use of direct oral anticoagulants in thromboembolic disease

“…Edoxaban elimination is only slightly dependent on CYP3A4 mechanisms and is mostly mediated by P-gp. 16 Dabigatran is dependent on P-gp …”

The Direct Oral Anticoagulants Apixaban, Rivaroxaban, and Edoxaban

“…In fact, after major elective orthopedic surgery the incidence of a VTE is estimated to be 40% -60% if anticoagulant therapy is not applied. 1 Conditions such as cardiac arrhythmias also require anticoagulant intervention. Atrial fibrillation (AF) is the most common cardiac arrhythmia.…”

“…For this reason they require constant monitoring and dose adjustments. 1 The disadvantage of parenteral agents is their expense and their inability to be given orally. This prevents them from being a long term solution, however because they act quickly they can be used as an anticoagulant bridge until the slower acting VKA can take effect.…”