Use of Non-Vitamin K Antagonist Oral Anticoagulants in Special Patient Populations with Nonvalvular Atrial Fibrillation: A Review of the Literature and Application to Clinical Practice

Abstract

Atrial fibrillation is a commonly encountered arrhythmia associated with increased risk for thromboembolic events. Anticoagulation is necessary to decrease the risk of ischemic stroke. Traditionally, warfarin has been the only oral pharmacotherapeutic option for long-term anticoagulation in patients with nonvalvular atrial fibrillation (NVAF). Recently, non-vitamin K antagonist oral anticoagulants (NOAC), including dabigatran, rivaroxaban, apixaban, and edoxaban, have become available as alternatives for warfarin in the prevention of stroke in patients with NVAF. Recently published atrial fibrillation guidelines contain new recommendations for risk stratification tools in determining the need for anticoagulant therapy and incorporate NOAC pharmacotherapy options for stroke prevention in patients with NVAF. NOACs offer several advantages over warfarin, including the elimination of routine laboratory monitoring, fewer drug and food interactions, and rapid therapeutic onset and offset. However, the lack of antidote in the case of serious bleeding and lack of data for long-term use in patient populations at risk for bleeding is problematic. Older adults are at high risk for thromboembolic and bleeding events as a result of anticoagulation and require special consideration when selecting anticoagulant therapy. The risk of drug accumulation and bleeding is concerning in the presence of renal impairment. The objective of this review is to provide the clinician with an update on the use of NOACs for NVAF, focusing on older adults and patients with renal impairment in light of recently published atrial fibrillation guidelines. Available data on using NOACs in coronary artery stenting, cardioversion, and ablation are also reviewed.

Drug interactions with aprepitant or fosaprepitant: Review of literature and implications for clinical practice

“…48,49 Moderate CYP3A4 inhibitors should be avoided in patients with renal impairment receiving rivaroxaban due to increased bleeding risk unless the benefit outweighs the potential risk. 48,50 Since aprepitant is a moderate inhibitor of CYP3A4, a theoretical interaction between aprepitant and rivaroxaban exists. Recommendations for apixaban are limited to strong CYP3A4 inhibitors only.…”

Thrombocytopenia Induced by Direct Oral Anticoagulants: a Clinical Case and Literature Review

“…Дабигатран -прямой блокатор тромбина, введенный в клиническую практику для профилактики тромбоэмболических осложнений у больных с ФП, для неотложной терапии и вторичной профилактики тромбоза глубоких вен и тромбоэмболии легочной артерии, послеоперационной тромбопрофилактики и гепарин-индуцированной тромбоцитопении [19] В редких случаях дабигатран может вызвать тромбоцитопению (1% случаев), хотя основной механизм этого осложнения остается неясным [20]. Национальная база данных итальянского лекарственного агентства, содержащая все сообщения о побочных осложнениях дабигатрана, зафиксировала семь случаев развития тромбоцитопении.…”

Changes in primary care management of atrial fibrillation patients following the shift from warfarin to non-vitamin K antagonist oral anticoagulants: a Norwegian population based study

“…Warfarin and other vitamin K antagonists were traditionally established as effective treatments, reducing the risk of stroke by about two-thirds [3]. In recent years, four non-vitamin K antagonist oral anticoagulants (NOACs) (apixaban, dabigatran, edoxaban, and rivaroxaban) have been introduced as replacements for warfarin in patients with AF; they reduce routine laboratory monitoring, have fewer drug and food interactions, and have a more rapid onset and offset of action compared with warfarin [4][5][6][7][8][9][10][11]. The body of evidence from clinical trials and meta-analyses has shown similar or superior efficacy of NOACs in stroke prevention compared with warfarin and an association with a similar or reduced risk of bleeding [4,6,[8][9][10][11][12][13].…”