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• W2340866354 abstract "After the commissioning of new oral anticoagulants for the treatment and prevention of thrombosis, these medications are now widely used within clinical settings. Increasing numbers of patients present to the health services on anticoagulant medications, and it is therefore imperative for surgeons to be aware of the new therapeutic treatments available and how patients will benefit from such interventions. This review highlights the most pertinent learning points for surgeons regarding the indications, pharmacokinetics, and perioperative management of these new oral medications, as a quick reference guide. After the commissioning of new oral anticoagulants for the treatment and prevention of thrombosis, these medications are now widely used within clinical settings. Increasing numbers of patients present to the health services on anticoagulant medications, and it is therefore imperative for surgeons to be aware of the new therapeutic treatments available and how patients will benefit from such interventions. This review highlights the most pertinent learning points for surgeons regarding the indications, pharmacokinetics, and perioperative management of these new oral medications, as a quick reference guide. During the last 5 years, new anticoagulants, such as dabigatran, rivaroxaban, apixaban, and edoxaban, have been used increasingly in the clinical setting, predominantly for the prevention and treatment of thrombosis. Their added benefits mean they have replaced the use of warfarin in many cases. The new oral anticoagulant (NOAC) agents not only have the advantage of fast-onset anticoagulation but also have a fixed anticoagulation effect, allowing administration of specified doses and no routine monitoring. Although much ambiguity remains on the efficacy of novel oral anticoagulants, several randomized controlled trials have shown there is no inferiority in their clinical use compared with standard therapy. The landmark studies highlighting these results include: EINSTEIN DVT,1Bauersachs R. Berkowitz S.D. Brenner B. Buller H.R. Decousus H. Gallus A.S. et al.Oral rivaroxaban for symptomatic venous thromboembolism.N Engl J Med. 2010; 363: 2499-2510Crossref PubMed Scopus (2600) Google Scholar EINSTEIN PE,2Büller H.R. Prins M.H. Lensin A.W. Decousus H. Jacobson B.F. Minar E. et al.Oral rivaroxaban for the treatment of symptomatic pulmonary embolism.N Engl J Med. 2012; 366: 1287-1297Crossref PubMed Scopus (1883) Google Scholar AMPLIFY (Apixaban for the Initial Management of Pulmonary Embolism and Deep-Vein Thrombosis as First-Line Therapy),3Agnelli G. Buller H.R. Cohen A. Curto M. Gallus A.S. Johnson M. et al.Oral apixaban for the treatment of acute venous thromboembolism.N Engl J Med. 2013; 369: 799-808Crossref PubMed Scopus (1655) Google Scholar RE-COVER,4Schulman S. Kearon C. Kakkar A.K. Mismetti P. Schellong S. Eriksson H. et al.Dabigatran versus warfarin in the treatment of acute venous thromboembolism.N Engl J Med. 2009; 361: 2342-2352Crossref PubMed Scopus (2162) Google Scholar ENGAGE AF-TIMI (Effective aNticoaGulation with factor xA next GEneration in Atrial Fibrillation-Thrombolysis In Myocardial Infarction study 48),5Ruff C.T. Giugliano R.P. Antman E.M. Crugnale S.E. Bocanegra T. Mercuri M. et al.Evaluation of the novel factor Xa inhibitor edoxaban compared with warfarin in patients with atrial fibrillation: design and rationale for the Effective aNticoaGulation with factor xA next GEneration in Atrial Fibrillation-Thrombolysis In Myocardial Infarction study 48 (ENGAGE AF-TIMI 48).Am Heart J. 2010; 160: 635-641Abstract Full Text Full Text PDF PubMed Scopus (417) Google Scholar and Hokusai VTE.6Said K. Hokusai-VTE: edoxaban for the treatment of venous thromboembolism.Glob Cardiol Sci Pract. 2013; 2013: 416-420Google Scholar Both EINSTEIN studies looked at the use of rivaroxaban compared with enoxaparin in thromboembolic disease, AMPLIFY compared apixaban with enoxaparin, followed by warfarin, RE-COVER reviewed dabigatran compared with warfarin, and ENGAGE AF-TIMI, and Hokusai VTE matched edoxaban therapy to warfarin treatment in the prevention of atrial fibrillation (AF)-related stokes and recurrent venous thromboembolism, respectively. All these studies show equivocal or reduced rates of stroke7Easton J.D. Lopes R.D. Bahit M.C. Wojdyla D.M. Granger C.B. Wallentin L. et al.Apixaban compared with warfarin in patients with atrial fibrillation and previous stroke or transient ischaemic attack: a subgroup analysis of the ARISTOTLE trial.Lancet Neurol. 2012; 11: 503-511Abstract Full Text Full Text PDF PubMed Scopus (230) Google Scholar, 8Halvorsen S. Atar D. Yang H. De Caterina R. Erol C. Garcia D. et al.Efficacy and safety of apixaban compared with warfarin according to age for stroke prevention in atrial fibrillation: observations from the ARISTOTLE trial.Eur Heart J. 2014; 35: 1864-1872Crossref PubMed Scopus (265) Google Scholar arterial embolism,9Lopes R.D. Alexander J.H. Al-Khatib S.M. Ansell J. Diaz R. Easton J.D. et al.Apixaban for reduction in stroke and other ThromboemboLic events in atrial fibrillation (ARISTOTLE) trial: design and rationale.Am Heart J. 2010; 159: 331-339Abstract Full Text Full Text PDF PubMed Scopus (379) Google Scholar, 10Halperin J.L. Hankey G.J. Wojdyla D.M. Piccini J.P. Lokhnygina Y. Patel M.R. et al.Efficacy and safety of rivaroxaban compared with warfarin among elderly patients with nonvalvular atrial fibrillation in the Rivaroxaban Once Daily, Oral, Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation (ROCKET AF).Circulation. 2014; 130: 138-146Crossref PubMed Scopus (302) Google Scholar and bleeding complications with NOACs and significantly reduced rates of intracerebral hemorrhage and overall mortality.11Ruff C.T. Giugliano R.P. Braunwald E. Hoffman E.B. Deenadayalu N. Ezekowitz M.D. et al.Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials.Lancet. 2014; 383: 955-962Abstract Full Text Full Text PDF PubMed Scopus (3316) Google Scholar, 12Hart R.G. Diener H.C. Yang S. Connolly S.J. Wallentin L. Reilly P.A. et al.Intracranial hemorrhage in atrial fibrillation patients during anticoagulation with warfarin or dabigatran: the RE-LY trial.Stroke. 2012; 43: 1511-1517Crossref PubMed Scopus (358) Google Scholar, 13Oldgren J. Alings M. Darius H. Diener H.C. Eikelboom J. Ezekowitz M.D. et al.Risks for stroke, bleeding, and death in patients with atrial fibrillation receiving dabigatran or warfarin in relation to the CHADS2 score: a subgroup analysis of the RE-LY trial.Ann Intern Med. 2011; 155 (W204): 660-667Crossref PubMed Scopus (184) Google Scholar In light of these results, and their fixed anticoagulation effects, the new anticoagulants have become favorable for use in a variety of patient subsets. Currently the new oral anticoagulants hold licences for the following:•Dabigatran for stroke prevention in patients with AF plus one of reduced ejection fraction, coronary heart disease, diabetes, or age <65 years (150 mg, twice daily [BD]), the treatment of deep venous thrombosis (DVT) or pulmonary embolism (PE) after parenteral anticoagulation for 5 to 10 days (150 mg BD), and prevention of venous thromboembolism in elective hip and knee surgery (110 mg, 1-4 hours after surgery, then 220 mg once daily [OD] for 9/7 days, respectively).•Rivaroxaban for the prevention of venous thromboembolism in elective hip or knee surgery (10 mg OD for 35/12 days, respectively), stroke prevention in patients with AF plus one of the following risk factors: congestive heart failure, hypertension, age >75 years, diabetes, or prior stroke (CHADS2 [Congestive heart failure, Hypertension {blood pressure consistently >140/90 mm Hg or treated hypertension on medication}, Age ≥75 years, Diabetes mellitus, Prior Stroke or transient ischemic attack or thromboembolism]) (20 mg OD), and treatment of DVT and PE or prophylaxis after recurrent DVT or PE (15 mg BD for 21 days, then 20 mg OD).•Apixaban for the prevention of stroke in patients with AF plus one CHADS2 risk factor (5 mg BD), prevention of venous thromboembolism in elective hip and knee surgery (2.5 mg BD for 35/12 days, respectively), and treatment of DVT and PE (10 mg BD for 7 days then 5 mg BD), or prophylaxis after recurrent DVT/PE (2.5 mg BD).•Edoxaban for prevention of stroke and systemic embolic events in patients with AF (60 mg OD) and treatment of DVT or PE and prophylaxis after recurrent DVT/PE (60 mg OD). Dabigatran has also been used in the prevention of venous thromboembolism in elective hip/knee surgery (110 mg 1-4 hours after surgery, then 220 mg OD for 9/7 days, respectively) and rivaroxaban in the prevention of atherosclerotic events after acute coronary syndrome. However, both of these indications are currently off therapeutic licence (Table I).Table IComparison of novel anticoagulants: Mode of action and indication for useVariableDabigatranRivaroxibanApixabanEdoxabanClassDirect thrombin (IIa) inhibitorFactor Xa inhibitorFactor Xa inhibitorDirect inhibitor of factor XaMode of actionDirect, competitive inhibition of free and clot bound thrombinDirect inhibition of free factor Xa and factor Xa bound to prothrombinase complexReversible and selectively inhibits free and clot bound factor XaDirect inhibition of free factor XaIndication/FDA licence (in bold)Stroke prevention in patients with AF + one of reduced ejection fraction, CHD, diabetes, <65 years (150 mg BD)Treatment of DVT or PE after parenteral anticoagulation for 5-10 days (150 mg BD)Prevention of venous thromboembolism in elective hip/knee surgery (110 mg 1-4 hours after surgery, then 220 mg OD 9/7)Stroke prevention in patients with AF + one CHADS2 risk factor (20 mg OD)Treatment of DVT and PE and prophylaxis after recurrent DVT/PE (15 mg BD for 21 days, then 20 mg OD)Prevention of venous thromboembolism in elective hip/knee surgery (10 mg OD for 35/12 days respectively)Prevention of atherothrombotic events in adults after acute coronary syndrome (2.5 mg OD)Stroke prevention in patients with AF + one CHADS2 risk factor (5 mg BD)Prevention of venous thromboembolism in elective hip/knee surgery (2.5 mg BD for 35/12 days, respectively)Treatment of DVT and PE (10 mg BD for 7 days then 5 mg BD), or prophylaxis after recurrent DVT/PE (2.5 mg BD)Prevention of venous thromboembolism (2.5 mg BD)Treatment of DVT or PE and prophylaxis after recurrent DVT/PE (60 mg OD)Prevention of stroke and systemic embolic events in patients with AF (60 mg OD)Dosage (mg)110-2202.5-202.5-530-60ReversalSpecific reversal not available; consider prothrombin complex concentrate or dialysisSpecific reversal not available; consider prothrombin complex concentrate in emergency settingSpecific reversal not available; consider prothrombin complex concentrate in emergency settingSpecific reversal not available; consider prothrombin complex concentrate in emergency settingMonitoringNo routine monitoring requiredNo routine monitoring requiredNo routine monitoring requiredNo routine monitoring requiredPeriprocedural managementDepends on renal function:CrCl > 80 mL/min: stop 24-48 hours beforeCrCl 51-80 mL/min: stop 48-72 hours beforeCrCl 30-50 mL/min: stop 72-96 hours beforeStop at least 24 hours before interventionStop at least 24 hours before interventionStop at least 24 hours before interventionAF, Atrial fibrillation; BD, twice daily; CHADS2, Congestive heart failure, Hypertension (blood pressure consistently >140/90 mm Hg or treated hypertension on medication), Age ≥75 years, Diabetes mellitus, Prior Stroke or transient ischemic attack or thromboembolism; CHD, coronary heart disease; CrCl, creatinine clearance; DVT, deep venous thrombosis; FDA, Food and Drug Administration; OD, once daily; PE, pulmonary embolism. Open table in a new tab AF, Atrial fibrillation; BD, twice daily; CHADS2, Congestive heart failure, Hypertension (blood pressure consistently >140/90 mm Hg or treated hypertension on medication), Age ≥75 years, Diabetes mellitus, Prior Stroke or transient ischemic attack or thromboembolism; CHD, coronary heart disease; CrCl, creatinine clearance; DVT, deep venous thrombosis; FDA, Food and Drug Administration; OD, once daily; PE, pulmonary embolism. It is important to know the contraindications to NOAC therapy, which include:•Recent gastrointestinal bleeding•Malignancy•Recent brain, spine, or ophthalmic surgery•Intracerebral hemorrhage•Varices•Arteriovenous malformations•Concurrent use of other anticoagulants There are further specific contraindications for individual NOACs (Table II).Table IIComparison of novel anticoagulants: Special populationsVariableDabigatranRibaroxibanApixabanEdoxabanCreatinine clearance <15 mL/minNoNoNoNoCreatinine clearance 15-29 mL/minNoReduced dose (50%)Reduced dose (50%)Reduced dose (50%)Moderate to severe hepatic impairmentNoNoNoNoMild hepatic impairment? Reduced doseYes? Reduced doseYesWeight <60 kgYesYesReduced dose (50%)Reduced dose (50%) Open table in a new tab Dabigatran should not be used in those with renal impairment because it is 85% renally excreted.14Berthelot E. Lavenu-Bombled C. Orostegui-Giron L. Desconclois C. Assayag P. Impaired renal function and bleeding in elderly treated with dabigatran.Blood Coagul Fibrinolysis. 2014; 25: 618-620Google Scholar There are no trials to show its effect with mild hepatic impairment, but it is again contraindicated in moderate to severe hepatic impairment. Rivaroxaban is also contraindicated in patients with a creatinine clearance <15 mL/min, but is tolerated in the elderly and those with a weight of <60 kg. Apixaban should be used with caution in all of the special populations and avoided in those with severe renal and hepatic impairment. A 50% dose reduction should be considered in patients who weigh <60 kg and are aged >80 years. Edoxaban should be prescribed at 30 mg (50% reduction) in patients with moderate renal impairment and weight <60 kg and avoided in severe renal impairment (creatinine clearance <15 mL/min). Owing to their pharmacokinetics, there are few suitable reversal therapies in the setting of acute bleeding.15Christersson C. Wallentin L. Andersson U. Alexander J.H. Ansell J. De Caterina R. et al.D-dimer and risk of thromboembolic and bleeding events in patients with atrial fibrillation–observations from the ARISTOTLE trial.J Thromb Haemost. 2014; 12: 1401-1412Crossref PubMed Scopus (71) Google Scholar, 16Hylek E.M. Held C. Alexander J.H. Lopes R.D. De Caterina R. Wojdyla D.M. et al.Major bleeding in patients with atrial fibrillation receiving apixaban or warfarin: The ARISTOTLE Trial (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation): predictors, characteristics, and clinical outcomes.J Am Coll Cardiol. 2014; 63: 2141-2147Abstract Full Text Full Text PDF PubMed Scopus (261) Google Scholar Thus, the same protocol as for major bleeding on warfarin must be adhered to: discontinue the drug, apply manual compression, maintain blood pressure, surgical or radiological intervention, if appropriate, and replace blood products with or without prothrombin complex concentrate. It is possible to administer activated charcoal if the anticoagulant was taken ≤2 hours of the bleeding, and hemodialysis may be an option with dabigatran only. Tranexamic acid should also be considered after the result of the CRASH-2 (Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage) trial.17Keeling D. Cotter F. Management of bleeding in patients taking FXa and FIIa inhibitors.Br J Haematol. 2013; 160: 1-2Crossref Scopus (7) Google Scholar, 18Shakur H. Roberts I. Bautista R. Caballero J. Coats T. Dewan Y. et al.Effects of tranexamic acid on death, vascular occlusive events, and blood transfusion in trauma patients with significant haemorrhage (CRASH-2): a randomised, placebo-controlled trial.Lancet. 2010; 376: 23-32Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar After increasing use of dabigatran, the United States Food and Drug Administration recently approved Praxbind (idarucizumab; Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, Conn) in October 2015. This is a specific reversal agent licensed for emergency surgery/urgent procedures or in life-threatening or uncontrolled bleeding. Three trials have included 283 patients, and a serum dose reduction of dabigatran was observed in all cases. A fourth trial in 123 patients with uncontrolled bleeding showed that dabigatran was reversed in 89%.19Idarucizumab (Praxbind)–an antidote for dabigatran.Med Lett Drugs Ther. 2015; 57: 157-158Google Scholar Other target-specific reversal agents are currently being developed, such as “Andexanet Alfa” for the reversal of both apixaban and rivaroxaban. However, idarucizumab is currently the only licensed therapy.20Siegal D.M. Curnutte J.T. Connolly S.J. Lu G. Conley P.B. Wiens B.L. et al.Andexanet alfa for the reversal of factor Xa inhibitor activity.N Engl J Med. 2015; 373: 2413-2424Crossref PubMed Scopus (786) Google Scholar Surgical teams are frequently encountering patients on anticoagulant therapy before the intervention. It is therefore important to be fluent with the management of anticoagulation before an operative procedure. Warfarin has a half-life of 20 to 60 hours and, consequently, a very unpredictable profile. This was reproduced in the RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) study, where only one in 10 patients was suitable for surgery 48 hours after stopping warfarin.21Connolly S.J. Ezekowitz M.D. Yusuf S. Eikelboom J. Oldgren J. Parekh A. et al.Dabigatran versus warfarin in patients with atrial fibrillation.N Engl J Med. 2009; 361: 1139-1151Crossref PubMed Scopus (8843) Google Scholar The advantages of using NOACs are their short half-lives and rapid onset of action. They can be discontinued and resumed rapidly in the preoperative and postoperative period, decreasing the window for risk of thromboembolism (Table III).Table IIIComparison of novel anticoagulants: PharmacokineticsVariableDabigatranRivaroxibanApixabanEdoxabanTargetThrombin (IIa)XaXaXaProdrugYesNoNoNoHalf life, hours12-147-111210-14Peak levels, hours1.52-41-21-2DosesBDODBDODExcretion85% renal65% renal25% renal35% renalUse in pregnancy/breast feedingNoNoNoNoInteractionsP-gp inducers: rifampicin—increases risk of stroke/embolismP-gp inhibitors: ketoconazole—increases risk of bleedingCYP3A4 and P-gp inducers: carbamazepine, phenytoin, rifampicin— increases risk of stroke/embolismCYP3A4 and P-gp inhibitors: HIV protease inhibitors, itraconazole, ketoconazole,Reduced renal function: amiodarone, diltiazem, verapamil, erythromycin— increases risk of bleedingCYP3A4 and P-gp inducers: carbamazepine, phenytoin, rifampicin – increases risk of stroke/embolismCYP3A4 and P-gp inhibitors: HIV protease inhibitors, itraconazole, ketoconazole, clarithromycinCYP3A4 and P-gp inducers: carbamazepine, phenytoin, rifampicin – increases risk of stroke/embolismCYP3A4 and P-gp inhibitors: HIV protease inhibitors, itraconazole, ketoconazole, clarithromycinQuinidine, verapamil, and dronedarone to increase edoxaban serum levelsBD, Twice daily; HIV, human immunodeficiency virus; OD, once daily. Open table in a new tab BD, Twice daily; HIV, human immunodeficiency virus; OD, once daily. Understanding the pharmacokinetics will give background and rationale, but in all cases, the NOACs require cessation of treatment 24 hours before surgery, with the exception of dabigatran, which must be adjusted according to renal function (Table I). As long as adequate hemostasis has been achieved postoperatively, novel anticoagulants can be restarted 6 to 8 hours after the intervention.22Daniels P.R. Peri-procedural management of patients taking oral anticoagulants.BMJ. 2015; 351: h2391Crossref PubMed Scopus (36) Google Scholar For those patients at low risk (ie, nonvalvular AF and low CHADS2 score, venous thromboembolism >12 months prior, and bileaflet aortic valve without AF), no bridging therapy is required during the operative period. It may be clinically indicated in moderate to high-risk patients to convert their regular NOAC therapy to a low-molecular-weight heparin (LMWH; enoxaparin) or warfarin. For these cases the following protocol should be followed23Heidbuchel H. Verhamme P. Alings M. Antz M. Diener H.C. Hacke W. et al.Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation.Europace. 2015; 17: 1467-1507Crossref PubMed Scopus (861) Google Scholar, 24Spyropoulos A.C. Douketis J.D. How I treat anticoagulated patients undergoing an elective procedure or surgery.Blood. 2012; 120: 2954-2962Crossref PubMed Scopus (279) Google Scholar, 25Bauer K.A. Pros and cons of new oral anticoagulants.Hematology Am Soc Hematol Educ Program. 2013; 2013: 464-470Crossref PubMed Scopus (170) Google Scholar:•Dabigatran and apixaban should be discontinued 12 hours before the first dose of enoxaparin.•Rivaroxaban, and edoxaban, should be discontinued 24 hours before the first dose of enoxaparin (ie, enoxaparin should be commenced at the same time as the next scheduled NOAC dose). After the procedure, enoxaparin can be converted to regular NOAC therapy once adequate hemostasis has been achieved. For this, the enoxaparin must be discontinued and the NOAC therapy recommenced at the same time as the next scheduled LMWH dose. For conversion to warfarin, the NOAC should be discontinued once the patient's international normalized ratio is in the therapeutic range. Apixaban must also be continued for a further 2 days after the therapeutic range is reached. In the case of dabigatran, conversion to warfarin however is slightly more complex:•Creatine clearance ≥50 mL/min—commence warfarin 3 days before discontinuing dabigatran.•Creatine clearance 30 to 50 mL/min—commence warfarin 2 days before discontinuing dabigatran. It is, however, important to consider in these cases if bridging therapy is required. Multiple studies have shown there are similar rates of thrombotic complications after bridging and cessation of treatment but up to fivefold increases in major bleeding risk.26Vanassche T. Lauw M.N. Connolly S.J. Eikelboom J.W. Heparin bridging in peri-procedural management of new oral anticoagulant: a bridge too far?.Eur Heart J. 2014; 35: 1831-1833Crossref PubMed Scopus (9) Google Scholar, 27Healey J.S. Eikelboom J. Douketis J. Wallentin L. Oldgren J. Yang S. et al.Periprocedural bleeding and thromboembolic events with dabigatran compared with warfarin: results from the Randomized Evaluation of Long-Term Anticoagulation Therapy (RE-LY) randomized trial.Circulation. 2012; 126: 343-348Crossref PubMed Scopus (464) Google Scholar, 28Healey J.S. Brambatti M. Periprocedural management of oral anticoagulation in patients with atrial fibrillation: approach in the era of new oral anticoagulants.Can J Cardiol. 2013; 29: S54-S59Abstract Full Text Full Text PDF Scopus (13) Google Scholar, 29Liew A. Douketis J. Perioperative management of patients who are receiving a novel oral anticoagulant.Intern Emerg Med. 2013; 8: 477-484Crossref PubMed Scopus (40) Google Scholar The half-life of LMWH is also similar to that of the NOAC therapies; therefore, bridging therapy may actually be irrelevant.30Nascimento T. Birnie D.H. Healey J.S. Verma A. Joza J. Bernier M.L. et al.Managing novel oral anticoagulants in patients with atrial fibrillation undergoing device surgery: Canadian survey.Can J Cardiol. 2014; 30: 231-236Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar Although the new oral anticoagulants provide a more predicable anticoagulant profile and do not require monitoring, it is possible to review their effects with routine laboratory coagulation screens.31Baglin T. Hillarp A. Tripodi A. Elalamy I. Buller H. Ageno W. Measuring oral direct inhibitors (ODIs) of thrombin and factor Xa: a recommendation from the Subcommittee on Control of Anticoagulation of the Scientific and Standardisation Committee of the International Society on Thrombosis and Haemostasis.J Thromb Haemost. April 11, 2013; https://doi.org/10.1111/jth.12149Crossref Scopus (223) Google Scholar A summary of these tests can be found in Table IV.Table IVMonitoring of new oral anticoagulant (NOAC) therapiesNoDabigatranRivaroxibanApixabanEdoxabanAPTTSensitive (concentration – response relationship)At peak levels APTT is increased 1.5-1.8 timesSensitive (concentration – response relationship)At peak levels APTT increased by 1.5-2 timesSensitive (concentration – response relationship)At peak levels APTT increased by 1.2 timesSensitive (concentration – response relationship)At peak levels APTT is increased 1.3 timesPTInsensitiveQuick type PT may be useful, but generally insensitiveSensitiveAt peak levels PT increased by 2.9 timesSensitiveAt peak levels PT increased by 2 foldTTSensitive (concentration – response relationship)Sensitive through therapeutic range but results extremely variable.InsensitiveInsensitiveFibrinogenLevels affected but not relative to doseN/AN/AN/AAntithrombin/factor X assaysInsensitiveSensitive to anti-factor Xa; insensitive to antithrombinSensitive to anti-factor Xa; insensitive to antithrombinSensitive to anti-factor Xa; insensitive to antithrombinAPTT, Activated partial thromboplastin time; N/A, not applicable; PT, prothrombin time; TT, thrombin time. Open table in a new tab APTT, Activated partial thromboplastin time; N/A, not applicable; PT, prothrombin time; TT, thrombin time. With such value-added benefits, the new oral anticoagulants are here to stay. Consultants and trainees are therefore likely to encounter increasing numbers of patients on NOAC therapies and should be confident in their use. Table I, Table II, Table III highlight this key information, as a summary guide for future reference. Conception and design: KH, AH Analysis and interpretation: Not applicable Data collection: KH Writing the article: KH, RL Critical revision of the article: KH, RL, AH Final approval of the article: KH, RL, AH Statistical analysis: Not applicable Obtained funding: Not applicable Overall responsibility: AH" @default.
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• W2340866354 title "Quick reference guide to the new oral anticoagulants" @default.
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