Measurement and reversal of the direct oral anticoagulants.
Direct oral anticoagulants (DOACs) offer noninferior efficacy and improved safety compared to vitamin K antagonists (VKAs) for the prevention and treatment of venous thromboembolism and for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation. Unlike VKAs, DOACs do not require routine laboratory monitoring of anticoagulant effect and dose adjustment. In certain situations, however, laboratory assessment of anticoagulant effect may be desirable. Here we review the utility of currently available assays for assessment of DOAC effect and recommend an optimal assessment strategy for each drug, including calibrated dilute thrombin time or ecarin-based assays for dabigatran and calibrated anti-Xa activity assays for the factor Xa inhibitors. We also discuss reversal strategies, both specific and nonspecific, for each drug, including the preferential use of idarucizumab for the reversal of dabigatran and two agents, andexanet and ciraparantag, currently under development for the reversal of rivaroxaban, apixaban, and edoxaban.
Division of Hematology, Department of Medicine, University of Washington, 1100 Fairview Ave N D5-100, Seattle, WA 98109, USA. Electronic address: bts99@uw.edu.
Bethany T
BT
Samuelson
Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, PA 19104, USA. Electronic address: adam.cuker@uphs.upenn.edu.
Adam
A
Cuker
D000284:Administration, Oral; D000925:Anticoagulants / Q000008:administration & dosage* / Q000009:adverse effects*; D000991:Antithrombins / Q000494:pharmacology / Q000627:therapeutic use; D001777:Blood Coagulation / Q000187:drug effects*; D001780:Blood Coagulation Tests; D000069604:Dabigatran / Q000494:pharmacology / Q000627:therapeutic use; D065427:Factor Xa Inhibitors / Q000494:pharmacology / Q000627:therapeutic use; D006801:Humans; D019934:International Normalized Ratio; D000069552:Rivaroxaban / Q000494:pharmacology / Q000627:therapeutic use
D000925:Anticoagulants; D000991:Antithrombins; D065427:Factor Xa Inhibitors; D000069552:Rivaroxaban; D000069604:Dabigatran
Apixaban; DOACs; Dabigatran; Edoxaban; Measurement; Reversal; Rivaroxaban