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Review
. 2020 Jul 7;9(13):e017559.
doi: 10.1161/JAHA.120.017559. Epub 2020 Jun 15.

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

Ashley Chen  1 , Eric Stecker  2 , Bruce A Warden  3
Affiliations
Review

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

Ashley Chen et al. J Am Heart Assoc. .

Abstract

Direct oral anticoagulants (DOACs) have quickly become attractive alternatives to the long-standing standard of care in anticoagulation, vitamin K antagonist. DOACs are indicated for prevention and treatment of several cardiovascular conditions. Since the first approval in 2010, DOACs 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 DOACs, 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 DOACs 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.

Keywords: anticoagulation; oral direct thrombin inhibitor; oral factor Xa inhibitors; pharmacotherapy.

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Figures

Figure 1
Figure 1. DOAC use in renal insufficiency.
*Apixaban dose adjustments are based on patient serum creatinine, age, and body weight; **rivaroxaban dose adjustments are based on patient indication; ***betrixaban: no dose adjustments provided for hemodialysis patients (has not been studied). CrCl indicates Cockcroft‐Gault creatinine clearance; ESRD, end‐stage renal disease; NVAF, nonvalvular atrial fibrillation; and VTE, venous thromboembolism.
Figure 2
Figure 2. DOAC pharmacokinetic profiles in the extremes of body weight.
AUC indicates area under the curve; Cmax, maximal concentration; and NR, not reported.
Figure 3
Figure 3. DOAC use in extremes of body weight.
*Data not available for rivaroxaban and betrixaban; **avoid unless absolutely necessary; warrants specific laboratory monitoring (refer to Monitoring Parameters for more detail).
See this image and copyright information in PMC

References

    1. Aronis KN, Hylek EM. Evidence gaps in the era of non‐vitamin K oral anticoagulants. J Am Heart Assoc. 2018;7:e007338 DOI: 10.1161/JAHA.117.007338. - DOI - PMC - PubMed
    1. Ruff CT, Giugliano RP, Braunwald E, Hoffman EB, Deenadayalu N, Ezekowitz MD, Camm AJ, Weitz JI, Lewis BS, Parkhomenko A, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta‐analysis of randomised trials. Lancet. 2014;383:955–962. - PubMed
    1. van der Hulle T, Kooiman J, den Exter PL, Dekkers OM, Klok FA, Huisman MV. Effectiveness and safety of novel oral anticoagulants as compared with vitamin K antagonists in the treatment of acute symptomatic venous thromboembolism: a systematic review and meta‐analysis. J Thromb Haemost. 2014;12:320–328. - PubMed
    1. Kapoor A, Ellis A, Shaffer N, Gurwitz J, Chandramohan A, Saulino J, Ishak A, Okubanjo T, Michota F, Hylek E, et al. Comparative effectiveness of venous thromboembolism prophylaxis options for the patient undergoing total hip and knee replacement: a network meta‐analysis. J Thromb Haemost. 2017;15:284–294. - PMC - PubMed
    1. Cohen AT, Harrington RA, Goldhaber SZ, Hull RD, Wiens BL, Gold A, Hernandez AF, Gibson CM. Extended thromboprophylaxis with betrixaban in acutely ill medical patients. N Engl J Med. 2016;375:534–544. - PubMed

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