Direct Oral Anticoagulants for the Management of Thromboembolic Disorders

Abstract

Anticoagulation therapy is central to the management of thromboembolic disorders, and the use of direct oral anticoagulants offers several advantages over standard therapy with parenteral heparins and vitamin K antagonists. In phase III clinical trials, the direct oral anticoagulants (given once or twice daily) all demonstrated favorable benefit-risk profiles compared with conventional standard therapy for the treatment and secondary prevention of venous thromboembolism and for stroke prevention in patients with nonvalvular atrial fibrillation. In clinical practice, many factors may influence overall clinical outcomes in patients receiving anticoagulant therapy, including adherence and persistence to the prescribed therapy, which becomes particularly important during long-term therapy. When choosing an anticoagulant for an individual patient, the pharmacological and clinical profile of the anticoagulant, its dosing regimen, and the patient's clinical characteristics (eg, renal function and comorbidities) and preferences should be considered. This review examines the rationale for and clinical evidence of the selected dosing regimens of the direct oral anticoagulants for the treatment of venous thromboembolism and stroke prevention in nonvalvular atrial fibrillation. The potential influence of dosing strategies (eg, once- or twice-daily dosing) and other factors on patient adherence and therapy persistence are also discussed.

Switching to Another Oral Anticoagulant and Drug Discontinuation Among Elderly Patients With Nonvalvular Atrial Fibrillation Treated With Different Direct Oral Anticoagulants

“…9–14 Further study of DOAC usage patterns among patients with NVAF and across different patient groups is warranted, since suboptimal adherence, interruptions in therapy, and/or discontinuation of DOACs are associated with poor patient outcomes. 17–20,26,27…”

“…16 Furthermore, other real-world studies have provided evidence that continuous adherence to DOACs is essential to maintain stroke risk reduction. 17–20 To gain a greater understanding of the usage patterns of DOACs among elderly patients with NVAF, in this study, we compared the risks of switching to another OAC and discontinuation of DOACs among elderly patients with NVAF who were prescribed rivaroxaban or dabigatran versus apixaban.…”

Comparison of Drug Switching and Discontinuation Rates in Patients with Nonvalvular Atrial Fibrillation Treated with Direct Oral Anticoagulants in the United States

“…Over the last decade, direct oral anticoagulants (DOACs) have been developed with the goal of decreasing stroke and bleeding risk without the inconvenience of continuous monitoring and risks associated with the commonly used oral anticoagulant (OAC) warfarin [ 4 ]. The FDA-approved DOACs include apixaban, rivaroxaban, dabigatran, and edoxaban, all of which have demonstrated similar or superior reduction in stroke risk when compared to warfarin in clinical trials, with all being associated with a significant reduction in the risk of hemorrhagic stroke [ 5 – 8 ].…”

Exploration of adherence and patient experiences with DOACs one year after switching from vitamin-K antagonists- insights from the switching study

“…In phase III clinical trials apixaban dabigatran, edoxaban and rivaroxaban were shown to be at least non-inferior to traditional vitamin-K antagonists (VKAs) such as warfarin [2][3][4][5][6][7][8][9][10][11][12]. Relative advantages of DOACs compared to VKAs include: a predictable pharmacokinetic profile enabling fixed dosing and infrequent laboratory monitoring, limited drug-drug interactions and insignificant drug-food interactions [13]. However, although DOACs may have a lower burden on both patients and healthcare providers, they present new challenges for anticoagulation services.…”