PEBC: What You Need to Know: Direct Oral Anticoagulants (DOACs)

Examples: Rivaroxaban, Apixaban, Dabigratran, Edoxaban

Indications: prevention of stroke in atrial fibrillation, deep vein thrombosis, pulmonary embolism, prophylaxis after hip or knee surgery

Role in Therapy:

less types of bleeding, somewhat less drug interactions and no need for blood monitoring compared to warfarin

Dosing (Atrial Fibrillation):

Rivaroxaban, edoxaban: once daily

Apixaban, dabigatran: twice daily

Rivaroxaban: take with food if dose is 15 or 20 mg *enhances absorption

*Must dose reduce in renal dysfunction

Adverse Effects:

-Bleeding of course! By thinning the blood, each agent has different types of bleeding risks in comparison to warfarin. If bleeding occurs, there are reversal agents (Praxbind (Idarucizumab) for dabigratran, and Andexxa (andexanet alfa) for rivaroxaban, edoxaban & apixaban)

-GI upset and diarrhea with dabigatran

Drug Interactions: Many!

-CYP3A4 and pg-p inhibitors: may increase anticoagulant levels and increase risk of bleeding (common examples are diltiazem, verapamil, ketoconazole, clarithromycin)

-CYP3A4 inducers (phenytoin, carbamazepine): may lead to reduced anticoagulant level --> ineffective treatment may put patients at risk for stroke or deep vein thrombosis

-other agents which increase bleeding such as NSAIDs and antiplatelet agents

Additional: store dabigatran in original containers because of sensitivity to moisture