1-Other names:
Direct oral anticoagulant(DOACs), non vitamin K antagonist oral anticoagulant(NOACs)
2-Either Direct thrombin inhibitors (dabigatran), anti factorX (Rivaroxaban, apixaban, edoxaban)
Are Contraindicated as follow
3-Contraindicated in Pregnancy and lactation
4-Contraindicated in Mechanical prosthesis and Mitral stenosis (Mitral valve area 1.5 cm2 or less)
5-Contraindicated in the first three months after mitral valve repair or tricuspid valve repair
And contraindicated in the first 3 months after Implantation of mitral or tricuspid tissue valve
6-Contraindicated in liver cirrhosis, Child C
Main points to be considered:
7-The approved one in Chronic kidney disease or dialysis is Apixaban
8-Antidote for dabigatran is Idarucizumab, antidote for Anti Factor X (mainly Rivaroxaban) is andexanet alfa,
you can give 4 factors prothrombin complex concentrate for NOCAs related Bleeding
9-When you switch from Warfarin to NOACs, start NOACs when INR is 2. 5 or less
10-When switch from NOACs to warfarin, give both till INR reach 2 for two consecutive readings
11-As a general rule, NOACs are stopped 2 days before surgery (except for dabigatran in patients with CKD,
will need longer interval)
12-As a general rule, you can restore NOACs 3 days after surgery
13-As a general rule, the risk of GIT Bleeding with NOACs is more than Warfarin except Apixaban 5mg twice or
dabigatran 110 mg twice which have a comparable GIT Bleeding risk similar to Warfarin
14-PTT can be prolonged with dabigatran, and dabigatran is the only one that be be cleared with
dialysis in case of toxicity
15-As a general rule, NOACs are at least as effective as Warfarin and they are more safe as regard Bleeding risk
16-The risk of Hemorrhagic stroke or cerebral hemorrhage is low with all NOCAs when compared to Warfarin
17-The only 2 NOCAs that showed superiority over warfarin in stroke risk reduction are:
apixaban 5 mg twice and Dabigatran 150mg twice
Other NOACs have a comparable stroke risk reduction VS. Warfarin
18-Dabigatran is associated with reduction of vascular mortality, Apixaban is associated with
reduction of all cause mortality,
edoxaban is associated with reduction of Cardiovascular mortality
19-Rivaroxaban should be given with meal
20-Highest renal excretion with dabigatran, lowest renal excretion with apixaban
21-Trials of NOACs with P2 Y12 inhibitors
-Redual PCI(dabigatran)
-Pioneer AF(Rivaroxaban)
-Augustus(apixaban)
-Entrust(Edoxaban) (ongoing)
Trials of NOACs in AFib
-Rely (dabigatran)
-Rocket(Rivaroxaban)
-Aristotle (Apixaban)
-Engage (Edoxaban)
Trials of NOACs in venous thromboembolism
-Recover(Dabigatran)
-Einstein(Rivaroxaban)
-Amplify(Apixaban)
22-No need for concomitant treatment with parenteral anticoagulant upon starting with apixaban or
Rivaroxaban in treatment of Venous thromboembolism
Instead, you can give apixaban 10mg twice for 1 week then 5 mg twice daily thereafter
And Rivaroxaban 15mg twice daily for 3 weeks then 20mg once daily thereafter
