Direct-Acting Oral Anticoagulants

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This issue will review the evidence supporting DOACs and their place in therapy for: 1) atrial fibrillation (AF); 2) the acute treatment and long-term secondary prevention of deep vein thrombosis (DVT) and pulmonary embolism (PE); and 3) DVT and PE prevention after major orthopedic surgery and in medically ill patients. The differences among DOACs will be highlighted (eg, side effect profiles, dosing considerations and drug interactions), and DOACs will be compared with warfarin for conditions where both are indicated. Bleeding management and the use of reversal agents will also be addressed.

For more than 50 years, vitamin K antagonists (VKAs) such as warfarin were the only oral anticoagulant options for patients with blood clotting disorders. In 2010, dabigatran (Pradaxa®) – a direct thrombin inhibitor – became the first approved agent from the next generation of oral anticoagulants. Over the next 7 years, 4 factor Xa inhibitor oral anticoagulants were FDA approved. These include rivaroxaban (Xarelto®), apixaban (Eliquis®), edoxaban (Savaysa™), and most recently, betrixaban (Bevyxxa®). Early on, this generation of oral anticoagulants was referred to as NOACs (Novel Oral AntiCoagulants). However, the Institute For Safe Medication Practices (ISMP) issued a safety alert because “NoAC” was interpreted as “no anticoagulation” in a patient at high risk of stroke. The ISMP designated “NoAC” a potentially dangerous abbreviation and discourages its use. Today, the acronym DOAC, for Direct-acting Oral AntiCoagulant, is the abbreviation most widely used to distinguish these medications from warfarin.

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