Safety of direct oral anticoagulants versus traditional anticoagulants in venous thromboembolism
Venous thromboembolism (VTE) is a leading cause of morbidity and mortality worldwide. For decades, low molecular weight heparins (LMWH) and vitamin K-antagonists have been the gold standard of anticoagulation for VTE. Recently, direct oral anticoagulants (DOACs) that can be administered in fixed doses, without laboratory monitoring and dose adjustment have revolutionized anticoagulation management in VTE. Here, we report on recent evidence regarding the safety of DOACs compared to traditional anticoagulants in surgical and medical prophylaxis as well as in acute and extended treatments of VTE. Additionally, we provide data on special situations such as elderly, cancer and renal impairment patients. Regarding antithrombotic prophylaxis, data are lacking on DOAC use in general surgical patients, while DOACs appear to be more effective than and as safe as LMWHs in VTE prophylaxis for major orthopedic surgical patients. Whether a medically ill patient may benefit from extended VTE prophylaxis remains unclear. In fact, in these patients, DOACs showed an increased risk of bleeding compared to conventional therapy. In the acute treatment of VTE, DOACs were non-inferior and probably safer than conventional anticoagulation therapy while in the extended VTE treatment DOACs were more effective than placebo or aspirin with a comparable risk of major bleeding. These favorable results were also confirmed in elderly, cancer and renal impairment patients. However, further investigations are needed in order to generalize the safe use of DOACs in these specific subgroups of patients.
KeywordsAnticoagulation Direct oral anticoagulants Low-molecular weight heparin Thromboprophylaxis Venous thromboembolism Vitamin K-antagonists
All the authors have contributed sufficiently to the scientific work and therefore share collective responsibility and accountability for the results.
Compliance with ethical standards
Conflict of interest
Michela Giustozzi, Laura Franco, Maria Cristina Vedovati have no conflicts of interest to disclose. Cecilia Becattini reports lecture fees from Bayer, Boehringer Ingelheim, Bristol Myers Squibb and Daiichi Sankyo. Giancarlo Agnelli reports lecture fees from Bayer, Boehringer Ingelheim, Bristol Myers Squibb and Daiichi Sankyo.
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