Cardiovascular/Direct oral anticoagulant

DOACs

also: apixaban · rivaroxaban · dabigatran · edoxaban

Overview

First-line oral anticoagulation for non-valvular AF and VTE — no routine monitoring (cf. warfarin). Cross-references Haematology.

Mechanism

Direct, reversible inhibition of a single clotting factor. Factor Xa inhibitors ("-xaban": apixaban, rivaroxaban, edoxaban) block Xa. Dabigatran is a direct thrombin (factor IIa) inhibitor.

Indications

Non-valvular AF (stroke prevention, CHA₂DS₂-VASc)
VTE treatment + prevention
VTE prophylaxis post hip/knee replacement

The agents

Apixabanfactor Xa

BD; partly renal

Lowest bleeding profile; usable to lower eGFR.

Rivaroxabanfactor Xa

OD with food

Edoxabanfactor Xa

Dabigatranthrombin (IIa)

mostly renal

Reversal: idarucizumab.

Adverse effects

Bleeding (incl. GI)serious

Anaemiacommon

Dyspepsiacommon

Dabigatran.

Cautions & contraindications

Active major bleedingall

Mechanical heart valve / significant mitral stenosisall

Warfarin required — DOACs contraindicated.

Pregnancypregnancy

Use LMWH instead.

Severe renal impairmentrenal

Dabigatran especially (renal clearance).

Interactions

Strong CYP3A4/P-gp inhibitors/inducers (azoles, rifampicin, carbamazepine)
Other anticoagulants/antiplatelets ↑bleeding

Monitoring & kinetics

Renal function (annually, more if CKD/elderly) — NO routine coagulation monitoring,Reversal: andexanet alfa (Xa), idarucizumab (dabigatran)

Oral, fixed dosing. Renal dose adjustment.

Source: BNF — Direct oral anticoagulants · NICE NG196 — AF