Management of Patients Treated with Direct Oral Anticoagulants in Clinical Practice and Challenging Scenarios

It is well established that direct oral anticoagulants (DOACs) are the cornerstone of anticoagulant strategy in atrial fibrillation (AF) and venous thromboembolism (VTE) and should be preferred over vitamin K antagonists (VKAs) since they are superior or non-inferior to VKAs in reducing thromboembolic risk and are associated with a lower risk of intracranial hemorrhage (IH). In addition, many factors, such as fewer pharmacokinetic interactions and less need for monitoring, contribute to the favor of this therapeutic strategy. Although DOACs represent a more suitable option, several issues should be considered in clinical practice, including drug-drug interactions (DDIs), switching to other antithrombotic therapies, preprocedural and postprocedural periods, and the use in patients with chronic renal and liver failure and in those with cancer. Furthermore, adherence to DOACs appears to remain suboptimal. This narrative review aims to provide a practical guide for DOAC prescription and address challenging scenarios.

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References

Fanola C, Ruff C, Murphy S, Jin J, Duggal A, Babilonia N . Efficacy and Safety of Edoxaban in Patients With Active Malignancy and Atrial Fibrillation: Analysis of the ENGAGE AF - TIMI 48 Trial. J Am Heart Assoc. 2018; 7(16):e008987. PMC: 6201390. DOI: 10.1161/JAHA.118.008987. View

Leiss W, Mean M, Limacher A, Righini M, Jaeger K, Beer H . Polypharmacy is associated with an increased risk of bleeding in elderly patients with venous thromboembolism. J Gen Intern Med. 2014; 30(1):17-24. PMC: 4284255. DOI: 10.1007/s11606-014-2993-8. View

De Luca L, Rubboli A, Bolognese L, Gonzini L, Urbinati S, Murrone A . Antithrombotic management of patients with acute coronary syndrome and atrial fibrillation undergoing coronary stenting: a prospective, observational, nationwide study. BMJ Open. 2020; 10(12):e041044. PMC: 7757435. DOI: 10.1136/bmjopen-2020-041044. View

van Breugel H, Parise O, Nieman F, Accord R, Luca F, Lozekoot P . Does sinus rhythm conversion after cardiac surgery affect postoperative health- related quality of life?. J Cardiothorac Surg. 2016; 11(1):75. PMC: 4855340. DOI: 10.1186/s13019-016-0459-2. View

Mocini D, Di Fusco S, Mocini E, Donini L, Lavalle C, Lenarda A . Direct Oral Anticoagulants in Patients with Obesity and Atrial Fibrillation: Position Paper of Italian National Association of Hospital Cardiologists (ANMCO). J Clin Med. 2021; 10(18). PMC: 8468506. DOI: 10.3390/jcm10184185. View

Lip G, Banerjee A, Boriani G, Chiang C, Fargo R, Freedman B . Antithrombotic Therapy for Atrial Fibrillation: CHEST Guideline and Expert Panel Report. Chest. 2018; 154(5):1121-1201. DOI: 10.1016/j.chest.2018.07.040. View

Ungar L, Rodriguez F, Hellkamp A, Becker R, Berkowitz S, Breithardt G . Patient-Reported Satisfaction and Study Drug Discontinuation: Post-Hoc Analysis of Findings from ROCKET AF. Cardiol Ther. 2019; 8(2):283-295. PMC: 6828909. DOI: 10.1007/s40119-019-00146-6. View

Douketis J, Healey J, Brueckmann M, Eikelboom J, Ezekowitz M, Fraessdorf M . Perioperative bridging anticoagulation during dabigatran or warfarin interruption among patients who had an elective surgery or procedure. Substudy of the RE-LY trial. Thromb Haemost. 2014; 113(3):625-32. DOI: 10.1160/TH14-04-0305. View

Boriani G, Savelieva I, Dan G, Deharo J, Ferro C, Israel C . Chronic kidney disease in patients with cardiac rhythm disturbances or implantable electrical devices: clinical significance and implications for decision making-a position paper of the European Heart Rhythm Association endorsed by the Heart Rhythm.... Europace. 2015; 17(8):1169-96. PMC: 6281310. DOI: 10.1093/europace/euv202. View

10.

Deng Y, Tong Y, Deng Y, Zou L, Li S, Chen H . Non-Vitamin K Antagonist Oral Anticoagulants Versus Warfarin in Patients With Cancer and Atrial Fibrillation: A Systematic Review and Meta-Analysis. J Am Heart Assoc. 2019; 8(14):e012540. PMC: 6662149. DOI: 10.1161/JAHA.119.012540. View

11.

Urban P, Mehran R, Colleran R, Angiolillo D, Byrne R, Capodanno D . Defining High Bleeding Risk in Patients Undergoing Percutaneous Coronary Intervention. Circulation. 2019; 140(3):240-261. PMC: 6636810. DOI: 10.1161/CIRCULATIONAHA.119.040167. View

12.

Kuwahara T, Abe M, Yamaki M, Fujieda H, Abe Y, Hashimoto K . Apixaban versus Warfarin for the Prevention of Periprocedural Cerebral Thromboembolism in Atrial Fibrillation Ablation: Multicenter Prospective Randomized Study. J Cardiovasc Electrophysiol. 2016; 27(5):549-54. DOI: 10.1111/jce.12928. View

13.

Capodanno D, Huber K, Mehran R, Lip G, Faxon D, Granger C . Management of Antithrombotic Therapy in Atrial Fibrillation Patients Undergoing PCI: JACC State-of-the-Art Review. J Am Coll Cardiol. 2019; 74(1):83-99. DOI: 10.1016/j.jacc.2019.05.016. View

14.

Rome B, Gagne J, Avorn J, Kesselheim A . Non-warfarin oral anticoagulant copayments and adherence in atrial fibrillation: A population-based cohort study. Am Heart J. 2020; 233:109-121. DOI: 10.1016/j.ahj.2020.12.010. View

15.

Gargiulo G, Goette A, Tijssen J, Eckardt L, Lewalter T, Vranckx P . Safety and efficacy outcomes of double vs. triple antithrombotic therapy in patients with atrial fibrillation following percutaneous coronary intervention: a systematic review and meta-analysis of non-vitamin K antagonist oral anticoagulant-based.... Eur Heart J. 2019; 40(46):3757-3767. DOI: 10.1093/eurheartj/ehz732. View

16.

Lip G, Collet J, Haude M, Byrne R, Chung E, Fauchier L . 2018 Joint European consensus document on the management of antithrombotic therapy in atrial fibrillation patients presenting with acute coronary syndrome and/or undergoing percutaneous cardiovascular interventions: a joint consensus document of the.... Europace. 2018; 21(2):192-193. DOI: 10.1093/europace/euy174. View

17.

Lange U, Nowak G, Bucha E . Ecarin chromogenic assay--a new method for quantitative determination of direct thrombin inhibitors like hirudin. Pathophysiol Haemost Thromb. 2004; 33(4):184-91. DOI: 10.1159/000081506. View

18.

Levin J, Sams J, Tatsuoka C, Cassidy K, Sajatovic M . Use of automated medication adherence monitoring in bipolar disorder research: pitfalls, pragmatics, and possibilities. Ther Adv Psychopharmacol. 2015; 5(2):76-87. PMC: 4521443. DOI: 10.1177/2045125314566807. View

19.

Deshpande C, Kogut S, Willey C . Real-World Health Care Costs Based on Medication Adherence and Risk of Stroke and Bleeding in Patients Treated with Novel Anticoagulant Therapy. J Manag Care Spec Pharm. 2018; 24(5):430-439. PMC: 6387835. DOI: 10.18553/jmcp.2018.24.5.430. View

20.

Kumar S, Lim E, Covic A, Verhamme P, Gale C, Camm A . Anticoagulation in Concomitant Chronic Kidney Disease and Atrial Fibrillation: JACC Review Topic of the Week. J Am Coll Cardiol. 2019; 74(17):2204-2215. DOI: 10.1016/j.jacc.2019.08.1031. View