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Direct Oral Anticoagulants

  • Natalie S. Evans
Chapter

Abstract

Four direct oral anticoagulants (DOACs)—dabigatran, a direct thrombin inhibitor, and the direct factor Xa inhibitors rivaroxaban, apixaban, and edoxaban—have been approved for prevention of stroke in non-valvular atrial fibrillation and treatment of venous thromboembolism (VTE). All except edoxaban also are approved to prevent VTE in hip and knee replacement surgery. In the atrial fibrillation trials, the DOACs were non-inferior to warfarin dose-adjusted to international normalized ratio (INR) 2.0–3.0 in preventing stroke, with similar or better safety profiles. Rates of intracranial hemorrhage were lower for the DOACs. Results were similar in the VTE trials, with similar or better efficacy and safety. Because of their beneficial pharmacokinetic and pharmacodynamics profiles, the DOACs do not require routine monitoring. A reversal agent, idarucizumab, is approved for patients on dabigatran with serious bleeding or in need of an urgent invasive procedure. A reversal agent for the factor Xa inhibitors has been studied but is not yet approved. To date, data on use of the DOACs in patients with cancer or thrombophilia or at extremes of weight are sparse, as few of these patients were included in the published DOAC trials. Further, the role of anticoagulation with DOACs such as rivaroxaban in patients with stable atherosclerotic vascular disease has been revisited with recent data from COMPASS, but additional studies are still needed to define its exact utility.

Keywords

Anticoagulant reversal Anticoagulants Atrial fibrillation Stroke Deep vein thrombosis Direct oral anticoagulants Malignancy Novel anticoagulants Obesity Perioperative anticoagulation management Prevention Pulmonary embolism Thrombophilia Venous thromboembolism Warfarin 

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Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Department of Cardiovascular Medicine, Section of Vascular MedicineCleveland ClinicClevelandUSA

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