Treatment with novel oral anticoagulants: indications, efficacy and risks.

PURPOSE OF REVIEW: To summarize data relevant to novel oral anticoagulants (nOACs), mainly apixaban, dabigatran and rivaroxaban, as alternatives to vitamin K antagonists (VKAs).

RECENT FINDINGS: RE-LY was the first contemporaneous study to compare a nOAC, dabigatran, with dose-adjusted warfarin, for prevention of stroke and systemic embolism in atrial fibrillation. Since then multiple studies have compared nOACs to warfarin for acute (RE-COVER, RECOVER-II, EINSTEIN-DVT and EINSTEIN-PE) and extended treatment of venous thromboembolism (VTE) (AMPLIFY-EXT, RE-MEDY and RE-SONATE). Additional studies have examined stroke prevention in atrial fibrillation (ARISTOTLE and ROCKET-AF). We do not examine, in depth, use of nOACs in coronary artery disease.

SUMMARY: nOACs are an acceptable alternative to VKAs in certain situations - these are at least as effective as warfarin for secondary prevention of VTE and for prevention of stroke and systemic embolism in patients with atrial fibrillation. These compare favorably with warfarin with respect to their rate of fatal and major bleeding. However, special attention should be given when using these drugs in certain patient populations, in particular in patients with renal insufficiency, those receiving additional antithrombotic therapy, those with questionable compliance, patients of child bearing potential and those with a high risk of gastrointestinal bleeding.