An update of the efficacy and comparative characteristics of direct (new) oral anticoagulants (DOACs)

2021 ◽  
Vol 19 ◽  
Author(s):  
Ozgur Karcioglu ◽  
Sarper Yilmaz ◽  
Göksu Afacan ◽  
Eylem Ersan ◽  
Derya Abuşka ◽  
...  
Keyword(s):  
Clinical Decision Making ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Clinical Decision ◽  
Thrombin Inhibitor ◽  
Decision Making Processes ◽  
Clinical Conditions ◽  
Thrombotic Diseases ◽  
New Generation ◽  
Specific Agent

: Direct (New-generation) Oral Anticoagulants (DOACs) have emerged as effective agents which are used in place of vitamin-K antagonists in treatment and prophylaxis of Venous Thromboembolism (VTE), atrial fibrillation and other thrombotic diseases. Among them, the FIIa-direct thrombin inhibitor dabigatran and FXa inhibitors (rivaroxaban, apixaban, edoxaban) are the most broadly used. Anticoagulant dosing may differ under special considerations. The patients’ physiological reserves, organ functional status and failures should be taken into account in clinical decision-making processes. The advantages and drawbacks of each specific agent should be weighed with special regard to metabolism, pharmacokinetics and pharmacodynamics, along with the efficiency of the agents in different indications. This article aims to review the most recent literature to highlight the usage and efficacy of the agents in different clinical conditions.

scholarly journals Direct oral anticoagulant monitoring: what laboratory tests are available to guide us?

Hematology ◽  
2019 ◽  
Vol 2019 (1) ◽  
pp. 194-197 ◽  
Author(s):  
Ravi Sarode
Keyword(s):  
Clinical Decision Making ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Rapid Assessment ◽  
Clinical Decision ◽  
The United States ◽  
Thrombin Inhibitor ◽  
Thrombin Time ◽  
Clinical Scenarios

Abstract Direct oral anticoagulants (DOACs) are increasingly used in the treatment and prophylaxis of thromboembolism because of several advantages over vitamin K antagonists, including no need for laboratory monitoring. However, it has become increasingly important in certain clinical scenarios to know either actual DOAC concentration (quantitative) or presence of DOAC (qualitative). These clinical conditions include patients presenting with major bleeding or requiring urgent surgery who may need a reversal or hemostatic agent, extremes of body weight, failed therapy, etc. Prothrombin time and activated partial thromboplastin time are variably affected by factor Xa inhibitors (FXaIs) and direct thrombin inhibitor (DTI), respectively, depending on reagents’ sensitivity, and hence, they cannot be relied on confidently. Thrombin time is highly sensitive to very low amounts of DTI; thus, normal value rules out a clinically significant amount. Liquid chromatography mass spectrometry accurately measures DOAC levels but is clinically impractical. Dilute thrombin time and ecarin-based assays using appropriate calibrators/controls provide an accurate DTI level. Anti-Xa assay using corresponding FXaI calibrators/controls provides accurate drug levels. However, these assays are not readily available in the United States compared with some other parts of the world. Heparin assays using anti-Xa activity often have a linear relationship with calibrated FXaI assays, especially at the lower end of on-therapy levels, and they may provide rapid assessment of drug activity for clinical decision making. Currently, there is very limited knowledge of DOAC effect on viscoelastic measurements. Although there is uniformity in expression of DOAC concentrations in nanograms per milliliter, a universal FXaI DOAC assay is urgently needed.

Review of the Target-Specific Oral Anticoagulants in Development for the Treatment and Prevention of Venous Thromboembolism

2016 ◽  
Vol 29 (4) ◽  
pp. 392-405 ◽  
Author(s):  
Sandeep Devabhakthuni ◽  
Connie H. Yoon ◽  
Kathleen J. Pincus
Keyword(s):  
Venous Thromboembolism ◽  
Clinical Decision Making ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Bleeding Risk ◽  
Clinical Decision ◽  
Thrombin Inhibitors ◽  
Direct Thrombin Inhibitors ◽  
Treatment And Prevention

Anticoagulation therapy is often indicated for the treatment and prevention of venous thromboembolism (VTE). Despite advances in anticoagulant management with parenteral anticoagulants and vitamin K antagonists, limitations to their use still exists, leading to investigation of alternative anticoagulants such as factor Xa inhibitors and direct thrombin inhibitors. To date, 3 target-specific oral anticoagulants (TSOACs) are Food and Drug Administration approved; several other agents are currently in development to optimize VTE management and minimize bleeding risks. The objective of this systematic review article is to provide clinicians an overview of the clinical evidence on the investigational TSOACs for the treatment and prevention of VTE. Of the agents in development, edoxaban holds the most promise due to robust data supporting its clinical benefit with a similar bleeding risk to currently approved agents. Clinicians should understand the TSOACs under investigation, since differences in pharmacokinetics and pharmacodynamics may influence clinical decision making and agent selection for management of VTE. Currently, no direct comparisons between TSOACs have been conducted. Agents under investigation have yet to overcome the major limitations of the currently existing TSOACs. Further studies are necessary to clarify which TSOAC agent is best for management of VTE in clinical practice.

Direct oral anticoagulants – new challenge for laboratory medicine

2015 ◽  
Vol 51 (3) ◽  
pp. 221-228
Author(s):  
Anna Raszeja-Specht ◽  
Anna Michno
Keyword(s):  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Thrombin Inhibitors ◽  
Thrombin Inhibitor ◽  
Direct Thrombin Inhibitors ◽  
Factor X ◽  
Clotting Time ◽  
Coagulation Tests ◽  
New Generation

A new generation of oral anticoagulants, direct thrombin or activated factor X inhibitors gradually replaces the existing antithrombotic agents, administered parenterally (heparin) or orally (vitamin K antagonists). Currently, the most widely used class of direct oral anticoagulants (DOACs) are the direct thrombin inhibitor dabigatran and rivaroxaban, apixaban and edoxaban – Xa inhibitors. Although previous reports suggested that DOACs therapy does not require laboratory screening, recently the new indications for monitoring and the types of laboratory tests used in the evaluation of the effectiveness of treatment have been updated. To quantify the activity of direct thrombin inhibitors a dilute thrombin clotting time (dTT) or ecarin clotting time (ECT) is recommended. The effect of rivaroxaban and apixaban can be determined by anti-Xa activity assay when calibrated with a rivaroxaban and apixaban standard. Observed changes in routine coagulation tests such as activated partial thromboplastin time (APTT), and prothrombin time (PT), with varying degrees of severity, can only be an indicator of an additional screening, which is the emergency clinical interventions.

scholarly journals Net clinical benefit of anticoagulation therapy in the elderly patients with atrial fibrillation

2018 ◽  
Vol 88 (2) ◽  
Author(s):  
Lorenzo Palleschi ◽  
Eleonora Nunziata
Keyword(s):  
Atrial Fibrillation ◽  
Vitamin K ◽  
Clinical Decision Making ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Clinical Decision ◽  
The Elderly ◽  
Thromboembolic Disease ◽  
Net Clinical Benefit

Old age remains one of the strongest risk factors for stroke in patients with atrial fibrillation (AF). Oral anticoagulation (OAC) is the most effective way to prevent thromboembolic disease in patients with atrial fibrillation (AF). Until few years ago, aspirin and vitamin-K antagonists (VKAs) were the primary agents used to prevent thromboembolic disease in patients with AF. The approval of non–vitamin K oral anticoagulants (NOACs) has now expanded the range of therapeutic agents available to providers. The authors highlight practical considerations regarding the selection and use of OAC in older adults to aid clinical decision making.

How to Evaluate Clinically Relevant Literature: Five Simple Rules for the Practicing Clinician in Stroke Neurorehabilitation

2020 ◽  
Author(s):  
Jonathan Sanching Tsay ◽  
Carolee Winstein
Keyword(s):  
Clinical Decision Making ◽  
Relevant Literature ◽  
Clinical Decision ◽  
Balance Sheets ◽  
Neural Connections ◽  
Recovery Processes ◽  
Immediate Recovery ◽  
Simple Rules ◽  
Busy Clinician ◽  
New Generation

Neurorehabilitation relies on core principles of neuroplasticity to activate and engage latent neural connections, promote detour circuits, and reverse impairments. Clinical interventions incorporating these principles have been shown to promote recovery while demoting compensation. However, many clinicians struggle to find evidence for these principles in our growing but nascent body of literature. Regulatory bodies and organizational balance sheets further discourage evidence-based, methodical, time-intensive, and efficacious interventions because practical needs often outweigh and dominate clinical decision making. Modern neurorehabilitation practices that result from these pressures favor strategies that encourage compensation over those that promote recovery. With a focus on helping the busy clinician evaluate the rapidly growing literature, we put forth five simple rules that direct clinicians toward intervention studies that value more enduring but slower biological recovery processes over the more alluring practical and immediate “recovery” mantra. Filtering emerging literature through this critical lens has the potential to change practice and lead to more durable long-term outcomes. This perspective is meant to serve a new generation of mechanistically minded clinicians, students, and trainees poised to not only advance our field but to also erect policy changes that promote recovery-based care of stroke survivors.

Benner’s Framework and Clinical Decision-Making in the Critical Care Environment

2016 ◽  
Vol 30 (1) ◽  
pp. 52-57 ◽  
Author(s):  
Kristi J. Stinson
Keyword(s):  
Decision Making ◽  
Critical Care ◽  
Clinical Experience ◽  
Strong Correlation ◽  
Clinical Decision Making ◽  
Clinical Decision ◽  
Decision Making Process ◽  
Clinical Experiences ◽  
Care Environment ◽  
Decision Making Processes

Completed as part of a larger dissertational study, the purpose of this portion of this descriptive correlational study was to examine the relationships among registered nurses’ clinical experiences and clinical decision-making processes in the critical care environment. The results indicated that there is no strong correlation between clinical experience in general and clinical experience in critical care and clinical decision-making. There were no differences found in any of the Benner stages of clinical experience in relation to the overall clinical decision-making process.

scholarly journals The Severity of Intracranial Hemorrhages Measured by Free Hemoglobin in the Brain Depends on the Anticoagulant Class: Experimental Data

2017 ◽  
Vol 2017 ◽  
pp. 1-4 ◽  
Author(s):  
Kyle M. Ware ◽  
Douglas L. Feinstein ◽  
Israel Rubinstein ◽  
Prudhvi Battula ◽  
Jose Otero ◽  
...  
Keyword(s):  
Vitamin K ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Factor Xa ◽  
Hemoglobin Concentration ◽  
Thrombin Inhibitor ◽  
Free Hemoglobin ◽  
Intracranial Hemorrhages ◽  
The Brain

Background and Purpose. Anticoagulant therapy is broadly used to prevent thromboembolic events. Intracranial hemorrhages are serious complications of anticoagulation, especially with warfarin. Direct oral anticoagulants reduce but do not eliminate the risk of intracranial hemorrhages. The aim of this study is to determine the degree of intracranial hemorrhage after application of anticoagulants without additional triggers. Methods. Rats were treated with different anticoagulant classes (vitamin K antagonists, heparin, direct thrombin inhibitor, and factor Xa inhibitor). Brain hemorrhages were assessed by the free hemoglobin concentration in the brain parenchyma. Results. Vitamin K antagonists (warfarin and brodifacoum) significantly increased free hemoglobin in the brain. Among direct oral anticoagulants, thrombin inhibitor dabigatran also significantly increased free hemoglobin in the brain, whereas treatment with factor Xa inhibitor rivaroxaban did not have significant effect on the free hemoglobin concentration. Conclusions. Our data indicates that the severity of brain hemorrhages depends on the anticoagulant class and it is more pronounced with vitamin K antagonists.

scholarly journals Update on Edoxaban for the Prevention and Treatment of Thromboembolism: Clinical Applications Based on Current Evidence

2015 ◽  
Vol 2015 ◽  
pp. 1-19 ◽  
Author(s):  
Ali Zalpour ◽  
Thein Hlaing Oo
Keyword(s):  
Vitamin K Antagonists ◽  
Dabigatran Etexilate ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Factor Xa ◽  
Coagulation Factors ◽  
Current Evidence ◽  
Thrombin Inhibitor ◽  
Prevention And Treatment ◽  
Financial Impacts

Vitamin K antagonists (VKA) and heparins have been utilized for the prevention and treatment of thromboembolism (arterial and venous) for decades. Targeting and inhibiting specific coagulation factors have led to new discoveries in the pharmacotherapy of thromboembolism management. These targeted anticoagulants are known as direct oral anticoagulants (DOACs). Two pharmacologically distinct classes of targeted agents are dabigatran etexilate (Direct Thrombin Inhibitor (DTI)) and rivaroxaban, apixaban, and edoxaban (direct oral factor Xa inhibitors (OFXaIs)). Emerging evidence from the clinical trials has shown that DOACs are noninferior to VKA or low-molecular-weight heparins in the prevention and treatment of thromboembolism. This review examines the role of edoxaban, a recently approved OFXaI, in the prevention and treatment of thromboembolism based on the available published literature. The management of edoxaban in the perioperative setting, reversibility in bleeding cases, its role in cancer patients, the relevance of drug-drug interactions, patient satisfaction, financial impacts, and patient education will be discussed.

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