Novel Oral Anticoagulants: Agent Selection and Patient Monitoring
Ensuing the recent approval of novel oral anticoagulant agents (NOACs) in Greece and many other countries for stoke prevention in patients with non-valvular atrial fibrillation (AF), an overview is herein attempted of some practical points concerning their use with regards to agent selection and patient monitoring. There are currently 3 NOACs, dabigatran (a direct thrombin inhibitor), rivaroxaban and apixaban (direct factor Xa inhibitors), among which physicians are called upon to choose if they decide to use these more expensive agents in lieu of the much cheaper classic vitamin K antagonists (VKA), either to initiate or switch anticoagulant therapy in patients with AF. All three NOACs were evaluated in large randomized trials and found to be effective anticoagulants in patients with non-valvular AF, with comparable to or improved efficacy over warfarin, and a significant reduction in intracranial hemorrhage compared to warfarin. There was even a significant (apixaban) or strong trend toward reduction (dabigatran and rivaroxaban) in all-cause mortality. These agents are easier to administer in fixed once or twice daily doses without the need for routine coagulation monitoring. However, in addition to their much higher pricing, it is important to appreciate the potential challenges and limitations posed by their use and to follow recommendations and guidelines, in order to achieve optimal patient outcomes.
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