Direct Oral Anticoagulants and Their Reversal Agents – Current Options
In the last 10 years, the options for anticoagulant therapy have expanded with the introduction of direct oral anticoagulants (DOACs). It appears that DOACs may soon replace warfarin in the first line of prevention of venous thromboembolism, not only due to their clinical advantages but also thanks to newly available reversal agents that can be administered in case of major bleeding in patients taking DOACs. A recently published review article summarizes the current situation in this area.
Benefits of DOACs
Registered DOACs include the direct thrombin inhibitor dabigatran and the factor X inhibitors rivaroxaban, apixaban, and edoxaban. They are increasingly used in the prophylaxis of venous thromboembolism and the prevention of stroke in patients with non-valvular atrial fibrillation. Their advantages include a rapid onset of action, predictable therapeutic response without the need for regular monitoring, and a lower risk of interactions with other drugs, foods, or herbal products.
Reversal Agents
Studies have shown a lower incidence of bleeding with DOACs compared to warfarin; however, major bleeding remains a significant concern during their administration because, if not immediately and effectively managed, it is associated with significant morbidity and mortality. In patients on warfarin, major bleeding can be stopped by administering vitamin K. Similarly, in patients treated with DOACs, in case of life-threatening bleeding or risky surgery, it is necessary to administer a reversal agent that quickly inhibits their efficacy. Such agents are gradually coming to market. So far, two have been approved – idarucizumab for the reversal of dabigatran's effect and andexanet alfa for the reversal of rivaroxaban and apixaban's effect. Currently, the development of a third reversal agent, ciraparantag, which could have universal effects against all DOACs, is underway.
Conclusion
Today, DOACs are coming to the forefront in clinical practice for anticoagulant therapy. Due to their proven superior efficacy, good safety profile, and other benefits over traditional anticoagulants like warfarin, and also because of the availability of reversal agents that quickly suppress their anticoagulant effect when needed, they are likely to soon replace traditional anticoagulants.
(zza)
Source: Kustos S. A., Fasinu P. S. Direct-acting oral anticoagulants and their reversal agents − an update. Medicines (Basel) 2019 Oct 15; 6 (4): 103, doi: 10.3390/medicines6040103.
Did you like this article? Would you like to comment on it? Write to us. We are interested in your opinion. We will not publish it, but we will gladly answer you.