Direct-Acting Oral Anticoagulants
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For more than 50 years, vitamin K antagonists such as warfarin
were the only oral anticoagulation option for patients with
blood clotting disorders. Dabigatran (Pradaxa®), an oral direct
thrombin (factor IIa) inhibitor, finally broke onto the scene with
FDA approval in October 2010 as the first of the next generation
of oral anticoagulants.Since that time, 3 additional oral anticoagulants
have been approved in the US. Rivaroxaban (Xarelto®),
apixaban (Eliquis®), and the very recently approved edoxaban
(SavaysaTM) are oral direct factor Xa inhibitors that share the
convenient attributes of dabigatran: fixed dosing, no routine
coagulation monitoring (eg, INR testing), and no known dietary
interactions – to name just a few.
This issue will review the evidence supporting these next
generation oral anticoagulants and their place in therapy for
atrial fibrillation (AF), acute treatment and long-term secondary
prevention of deep vein thrombosis (DVT) and pulmonary embolism
(PE), and DVT and PE prophylaxis after major orthopedic surgery. The differences between the agents will be highlighted,as well as comparisons with warfarin for conditions where both are indicated. Educational and counseling tips for pharmacists and other community-based providers will be presented. Finally,
limitations and challenges to the use of the next generation oral anticoagulants will be discussed.
Before we begin, here’s a word on nomenclature. Early on,
this next generation of oral anticoagulants was convincingly called NOACs (Novel Oral AntiCoagulants), but these drugs would not be novel forever. An Institute For Safe Medication Practices (ISMP) safety alert noted that “NoAC” was interpreted as “no anticoagulation” in a patient at high risk of stroke. The ISMP has designated “NoAC” a potentially dangerous abbreviation
and discourages its use. The acronym DOAC for Direct-Acting Oral Anticoagulant provides a reasonably short, easily pronounced, accurately descriptive abbreviation that distinguishes the class from warfarin, which acts indirectly.
Wewill use the term DOAC throughout this issue; but be aware that other acronyms (eg, TSOAC [target-specific oral anticoagulant]) are also
found in the literature and may work their way into clinical practice.
Publication Date: 02/18/2015
Expiration Date: 02/18/2018
CE Credit: 1.5 (0.15 CEU)
Type of Activity: Knowledge-based
This program was developed by The Rx Consultant and published by Continuing Education Network, Inc.
The Rx Consultant accepts no advertising or financial support from the pharmaceutical industry and
is funded solely by the purchase of programs. The Rx Consultant is dedicated to providing unbiased,
balanced information to health care practitioners.
Programs developed by The Rx Consultant are written by health care providers with expertise in the topic
area, peer-reviewed, extensively edited, and fact-checked. This development process was created to insure
that every program presents information that is current, accurate, relevant to "real world" health care
providers, and written in an easy reading, "plain English" style.
Paul B. Shaw, PharmD, BPCS and Nathan Clark, PharmD, FCCP, BCPS
Dr. Shaw and Dr. Clark report no financial or personal relationships with any commercial interest producing, marketing,reselling or distributing a product or service that appears in this issue.
This accredited program is targeted to pharmacists and nurses.
Goals & Objectives
At the conclusion of this program, participants will be able to:
- Name the 2 classes of direct-acting oral anticoagulants (DOACs) and list the agent(s) in each class. Review their indications, contraindications, guideline recommendations, and dosing.
- Discuss the advantages and disadvantages of the DOACs compared with warfarin.
- Discuss DOAC adverse effects and potential drug interactions.
- Counsel patients about signs and symptoms of bleeding, stroke, and venous thromboembolism.
The Rx Consultant is a publication of Continuing Education Network, Inc.
Continuing Education Network, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education as a
provider of continuing pharmacy education.
Continuing Education Network is approved by the California Board of Registered Nursing, Provider Number CEP 13118. Programs approved by CA BRN are accepted by most State Boards of Nursing.
ACPE Universal Activity Number: 0428-0000-15-002-H01-P
Exam & Credit Statement Procedures
Upon successful completion of this program and the post test (70%), 1.5 hours of continuing education credit will be awarded. To receive credit and your exam score, please complete the exam questions and
Editorial and Review Board
Chief Editor and CE Administrator
Terry M. Baker, PharmD
Tracy Farnen, PharmD
James Chan, PharmD, PhD
Pharmacy Quality and Outcomes Coordinator
Associate Clinical Professor
School of Pharmacy
University of California San Francisco
San Francisco, CA
Richard Ron Finley, B.S. Pharm.,R.Ph.
Clinical Pharmacist (volunteer faculty)
University of California, San Francisco (UCSF) Memory and Aging Center
Lecturer (Emeritus) UCSF, Department of Clinical Pharmacy
Health Sciences Clinical Professor, UCSF School of Pharmacy
San Francisco, CA
Ray Dolby Brain Health Center, Sutter Health/CPMC
San Francisco, CA
Consult Pharmacist Aging and Adult Health Services
San Francisco Health Department
San Francisco, CA
Julio R. Lopez, PharmD, FCSHP
Chief of Pharmacy Service
VA Northern California Health Care System
Adjunct Clinical Professor
College of Pharmacy
Assistant Clinical Professor
School of Pharmacy
University of California, San Francisco
San Francisco, CA Adjunct Professor
Thomas J. Long School of Pharmacy
University of the Pacific
Visiting Associate Professor and Lecturer
Samuel Merritt University
Pamela Mausner, MD
Helen Berlie, Pharm.D. CDE, BCACP
Clinical Assistant Professor, Pharmacy Practice
Wayne State University
Ambulatory Care Specialist - Diabetes
Health Centers Detroit Medical Group
Senior Editorial Advisor
Gerard Hatheway, PharmD, PhD
Belinda M. Danielson, RPh
Christopher M. DeSoto, PharmD
Angie S. Graham, PharmD
Cynthia Chan Huang, PharmD, MBA
Fred Plageman, PharmD
Editorial Advisor and Clinical Practice Consultant for Nurse Practitioners
Meuleman, RN, C, MS
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