Clinical management of rivaroxaban-treated patients

Abstract

Availability of new anticoagulant drugs, including rivaroxaban, is an important step forward to allow easier, more effective, and safer long-term anticoagulation in patients in whom adequate anticoagulation is currently denied due to the limitations of VKAs. However, given their totally new properties, associated risks, and expected broad clinical use, expert professionals and manufacturers must urgently tackle a series of issues.

Direct oral anticoagulants for secondary prevention in patients with non-valvular atrial fibrillation

“…Very recently, recommendations for the management of DOACs in clinical practice have been made widely available. [25][26][27][28][29] In the context of the acute phase of cardioembolic stroke, recommendations on dabigatran suggest starting it immediately after a TIA, 3-5 days after a clinically mild stroke, after 5-7 days in patients with a stroke of moderate severity, approximately 14 days or more in patients with severe cardioembolic stroke. [25][26][27] Other clinical management experts have made similar suggestions for rivaroxaban.…”

“…Rivaroxaban should be started immediately after a TIA, and between 48 h to 14 days after a stroke, taking into account clinical severity, lesion extension at neuroimaging, and cardiological comorbidity by echocardiography. 29 However, there are no recommendations as to which dosage should be chosen. The acute phase of cardioembolic stroke is a well-recognized period of high risk and the incidence and risk factors of hemor- …”

How to manage new oral anticoagulants in case of surgery

“…When oral treatment cannot be administered immediately after surgery, patients should re-start anticoagulant therapy with LMWH and re-introduce NOACs as soon as possible. [7][8][9][10] …”

“…When surgery cannot be delayed, or in patients requiring surgical approach to stop bleeding, the urgent reversal of NOACs should be performed. [7][8][9][10] The peri-operative management of patients treated with NOACs is summarized in Table 4.…”

“…2 Despite this lack of evidence, practical recommendations for management of NOACs in the peri-procedural setting have been indicated. [7][8][9][10] In patients treated with NOACs and requiring invasive procedures, it is first necessary to clearly identify the level of urgency of the intervention (election, urgency, emergency) and subsequently to consider the following issues:…”