Direct oral anticoagulants (DOACs)

1. .
Direct Oral Anticoagulants
(DOACs)
Anwer Ghani
FIBMS
Iraq

2. Direct oral anticoagulants (DOACs) have quickly become attractive
alternatives to the long‐standing standard of care in
anticoagulation, vitamin K antagonist.
Since the first approval in 2010, DOACs have emerged as leading
therapeutic alternatives that provide both clinicians and patients
with more effective, safe, and convenient treatment options in
thromboembolic settings.

3. Direct oral anticoagulants (DOACs)—dabigatran (Pradaxa),
rivaroxaban (Xarelto), apixaban (Eliquis), edoxaban (Savaysa), and
betrixaban (Bevyxxa) are anticoagulation pharmacotherapy used
for the prevention of thrombosis in several cardiovascular contexts.
DOACs are categorized into 2 main classes: oral direct factor Xa
inhibitors (ie, rivaroxaban, apixaban, edoxaban, and betrixaban)
and direct thrombin inhibitors (ie, dabigatran).

4. DOACs are relatively new agents demonstrating superiority or
noninferiority to prior standards of care, anticoagulation with
vitamin K antagonists (VKA; ie, warfarin), or low‐molecular‐weight
heparins (LMWHs), in reducing risk of thromboembolic
complications with similar or reduced bleeding risk.
Advantages of DOACs compared with VKAs include fewer
monitoring requirements, less frequent follow‐up, more immediate
drug onset and offset effects.
DOAC prescriptions exceeded those for warfarin by 2013, with
apixaban being the most frequently prescribed DOAC for patients
with nonvalvular atrial fibrillation (NVAF).

5. Dabigatran, rivaroxaban, apixaban, and edoxaban are approved
for the lowering the risk of stroke and embolism in NVAF as well as
deep vein thrombosis and pulmonary embolism
treatment/prophylaxis.

6. Unique indications include betrixaban for prophylaxis of venous
thromboembolism (VTE) in hospitalized patients for an acute
medical illness, and rivaroxaban in combination with aspirin to
reduce major cardiovascular events in patients with chronic
coronary artery disease (CAD) or peripheral artery disease.

7. AF and PCI
Dual therapy: rivaroxaban (15 mg ) and a P2Y12 inhibitor (
clopidogrel) or
Triple therapy with rivaroxaban 2.5 mg twice daily plus DAPT
lower bleeding risk in comparison to triple therapy (VKA at
standard AF dosing, aspirin, and clopidogrel but similar thrombotic
events.
Dabigatran (150 mg twice‐daily) same.

8. AF and Artificial Heart Valves
VKA remains the preferred agent for this patient population .
bioprosthetic: acceptable (need study).

9. Atrial Fibrillation With Stable Coronary Disease
The rivaroxaban monotherapy arm was noninferior than
combination ( DOAC+AP) in cardiovascular efficacy measures and
superior in reducing major bleeding. combination

10. Cancer‐Associated Thromboembolism
DOAC are not inferior than LMWH in treatment and prevention of
VTE in cancer patient.

11. CKD
all are renal excretion.
Apixoban is the least.
Dose reduction if: age>65, wt<60 and scr>1.5.

12. THANKS
REFERENCE
https://www.ahajournals.org/doi/full/10.1161/JAHA.120.017559