Friday, May 13, 2016

Direct Oral Anticoagulants

Direct Oral Anticoagulants (DOACs)
R.E.B.E.L.EM - May 12, 2016 - By Salim Rezaie - Post Peer Reviewed by Matt Astin
Clinical Take Home Points
  • Apixaban, edoxaban, and rivaroxaban are all Xa inhibitors
  • Dabigatran is a IIa (thrombin) inhibitor
  • It may be possible to discharge patients from the ED with DOACs
    • Acute VTE –> Rivaroxaban and Apixaban are preferred agents
    • Atrial Fibrillation –> No head to head studies but against warfarin, Dabigatran seems to have largest reduction in incidence of stroke (Beware in Renal Failure)
  • Avoid DOACs in cancer patients, pregnant/breast feeding patients, CrCl <30mL/min, platelet count <50 x109, and patients on medications that inhibit or induce hepatic CYP 3A4 Enzymes
  • Life Threatening Bleeding: Give 1g TXA IV + PCC (3 or 4 factor) –> if still bleeding consider VIIa
  • Novel Reversal Agents are available (Andexanet Alfa & Idarucizumab) and show promise in reversing lab values, but it is unclear if they change meaningful patient outcomes