From the Guidelines
New anticoagulants, also known as direct oral anticoagulants (DOACs), are now the preferred first-line agents for most patients requiring anticoagulation therapy, as they have an improved efficacy/safety ratio and a predictable anticoagulant effect without the need for routine coagulation monitoring 1. The main DOACs include apixaban (Eliquis), rivaroxaban (Xarelto), edoxaban (Savaysa), and dabigatran (Pradaxa).
- Apixaban is typically dosed at 5mg twice daily (reduced to 2.5mg twice daily in certain patients with renal impairment, low weight, or advanced age).
- Rivaroxaban is usually given as 20mg once daily with food (15mg daily with renal impairment).
- Edoxaban is dosed at 60mg once daily (30mg with renal impairment or low weight),
- while dabigatran is given as 150mg twice daily (110mg twice daily in elderly or those with renal impairment) 1. These medications don't require routine blood monitoring like warfarin does, have fewer food and drug interactions, and offer more predictable anticoagulation. They're effective for stroke prevention in atrial fibrillation, treatment of venous thromboembolism, and post-surgical thromboprophylaxis. However, they're contraindicated in patients with mechanical heart valves, severe renal impairment, and certain other conditions. Specific reversal agents now exist for emergencies: idarucizumab for dabigatran and andexanet alfa for factor Xa inhibitors. DOACs work by directly inhibiting specific coagulation factors rather than affecting multiple points in the coagulation cascade like warfarin. The 2018 European Heart Rhythm Association practical guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation provides a unified way of informing physicians on the use of NOACs, including practical answers to 20 clinical scenarios, based on available and updated knowledge 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Overview of New Anticoagulants
- New anticoagulants, also known as direct oral anticoagulants (DOACs), have emerged as alternatives to vitamin K antagonists for the prevention of stroke in patients with non-valvular atrial fibrillation (NVAF) 2.
- Four DOACs are currently available: dabigatran, rivaroxaban, apixaban, and edoxaban, each with different dosing regimens and characteristics 2, 3.
Dosing Regimens and Adherence
- Edoxaban and rivaroxaban are administered once daily, while dabigatran and apixaban are administered twice daily 2.
- The selection of these dosage regimens is largely based on studies for the prevention or treatment of venous thromboembolism or acute coronary syndrome 2.
- Some studies have found that a once-daily dosing regimen leads to better adherence and persistence to therapy, although other studies have not found increased adherence among once-daily regimens 2.
Effectiveness and Safety of DOACs
- DOACs have been proven non-inferior or superior to warfarin in preventing stroke and systemic embolism, with a lower risk of major hemorrhage, in patients with NVAF 4, 5.
- Direct comparisons of effectiveness and safety of treatment with apixaban, dabigatran, and rivaroxaban in atrial fibrillation have shown a favorable bleeding risk profile for dabigatran and apixaban in standard dose, and for apixaban in reduced dose 4.
- No differences in effectiveness were found among the three DOACs, although further studies are needed to confirm these findings 4.
Management and Reversal of Anticoagulation
- Validated bleeding risk assessments, such as HAS-BLED, should be performed at each visit, and modifiable factors should be addressed 3.
- Major bleeding should be treated with vitamin K and 4-factor prothrombin complex concentrate for patients already being treated with a vitamin K antagonist, while idarucizumab and andexanet alfa have been effective for reversing the anticoagulant effects of dabigatran and rivaroxaban/apixaban, respectively 3.
- Clinical experience with apixaban outside of clinical trials has been limited, and there is currently little evidence to guide the management of bleeding or invasive procedures in patients taking apixaban, although a consensus guide has been written to serve as a guide for healthcare practitioners prescribing apixaban 6.