Emergency Department Management of Patients Taking Direct Oral Anticoagulant Agents

Points and Pearls Excerpt

• DOACs offer potential benefits over warfarin and other oral anticoagulants, including less need for monitoring and dietary restrictions, as well as the potential for reduced bleeding complications.
• Dabigatran works by direct thrombin inhibition; rivaroxaban, apixaban, edoxaban, and betrixaban all work by factor Xa inhibition.
• DOACs have a much shorter half-life than warfarin.
• Prehospital care providers should ask patients about their use of anticoagulants, including the name of the drug, the dose, and the time the last dose was taken.

Most Important References

• Schulman S, Kearon C, Kakkar AK, et al. Dabigatran versus warfarin in the treatment of acute venous thromboembolism. N Engl J Med. 2009;361(24):2342-2352. (Randomized controlled trial; 2539 patients)
• Patel MR, Mahaffey KW, Garg J, et al. Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. N Engl J Med. 2011;365(10):883-891. (Randomized controlled trial; 14,264 patients) 
• Granger CB, Alexander JH, McMurray JJV, et al. Apixaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2011;365(11):981-992. (Randomized controlled trial; 18,201 patients)
• Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2013;369(22):2093-2104. (Randomized controlled trial; 21,105 patients)
• Cohen AT, Harrington RA, Goldhaber SZ, et al. Extended thromboprophylaxis with betrixaban in acutely ill medical patients. N Engl J Med. 2016;375(6):534-544. (Randomized controlled trial; 7513 patients)
• Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest. 2016;149(2):315-352. (Guidelines statement) 
• Tomaselli GF, Mahaffey KW, Cuker A, et al. 2017 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants: a report of the American College of Cardiology task force on expert consensus decision pathways. J Am Coll Cardiol. 2017;70(24):3042-3067. (Guidelines statement)
• Pollack CV, Reilly PA, Eikelboom J, et al. Idarucizumab for dabigatran reversal. N Engl J Med. 2015;373(6):511-520. (Prospective cohort; 90 patients)