1. You can never be too Thin…. An Update on NOACs
Adam M. Levine, DO, FACC
Clinical Assistant Professor of Medicine
RowanSOM
September 10th, 2016
No disclosures relevant to this topic

3. Objectives Discuss current therapeutic targets for oral anticoagulants
Discuss novel oral anticoagulant specifics
How to convert from one to another
Discuss the use of triple therapy
Non-anticoagulant stoke prevention?

4. NOACs Atrial Fibrillation – Non-valvular
Not intended for Mechanical heart valves or Severe MS
Deep Venous Thrombosis/Pulmonary Embolus
Acute coronary syndrome??

5. NOACs
Edoxaban – Nov 28, 2013

6. Drugs Dabigatran Rivaroxaban Apixaban Edoxaban Target Factor IIa
Factor Xa
Half life
14-17 Hrs
5-9 Hrs
8-13 Hrs
9-11 Hrs
Time to Peak
2-3 Hrs
0.5-3 Hrs
3 Hrs
1.5 Hrs
Bioavailable
6.5%
80%
66%
50%
Excretion
Renal 80%
Renal 66%
Renal 50%
Renal 45%
Interactions
P-gly
Dual*
Reversal
Idarucizumab
PCC, FVIIa?
PCC
Strong P-gly and CYP3A4 inhibitors: ketoconazole, itraconazole, lopinavir/ritonavir, indinavir, conivaptan
Strong P-gly and CYP3A4 inducers: carbamazepine, phenytoin, rifampin, St. John’s wart
*Inhibitors increase bleeding, inducers decrease efficacy
PCC- Prothrombin Complex Concentrate

7. Drug Specifics Dabigatran Rivaroxaban – give with meal Dose
DVT – 150mg BID, paraenteral anticoag for 5-10 days
Afib – 150mg BID, (75mg BID CrCl 15-30)
Rivaroxaban – give with meal
DVT – 15 mg BID x 21 days, then 20 mg daily
Afib – 20 mg daily (15mg daily CrCl 15-50)

8. Drug Specifics Apixaban Edoxaban Dose
DVT – 10 mg BID x 7 days, then 5 mg BID, no renal adjustment
Afib – 5 mg BID, (2.5mg BID if 2 of the 3, Cr>1.5, >80 yo, <60 kg), can give for CrCl < 15
Edoxaban
DVT – 60 mg daily, paraenteral anticoag for 5-10 days, 30mg if <60 kg or CrCl 15-50
Afib – 60 mg daily, avoid if CrCl > 95, 30 mg if CrCl

9. Idarucizumab
Aug 6, 2015

10. Warfarin vs. NOACs Dabigatran Rivaroxaban Apixaban Edoxaban
All Mortality
Non-Inferior
Superior
Bleeding
Stroke
Ischemic
Yes No
Hemorrhagic

11. Warfarin vs. NOACs

12. Dialysis
“…2014 AHA, ACC, and HRS guidelines endorse warfarin as 1st line therapy in patients with CKD 4-5. Similarly the European Heart Rhythm Association …… refrain from NOAC use in CrCl < 30..”

13. NOAC vs. Aspirin
March 3, 2011

14. CHEST 2016 For VTE without cancer For VTE with cancer
Recommend NOAC over VKA or LMWH (Grade 2B)
For VTE with cancer
Recommend LMWH over VKA (2B) or NOAC (2C)

15. There and Back again How to convert from Warfarin
Dabigatran : Start when INR <2.0
Rivaroxaban: Start when INR <3.0
Apixaban: Start when INR <2.0
Edoxaban: Start when INR <2.5
How to convert to Warfarin
Coadminister for 2 to 3 days prior to stopping NOAC
If using dabigatran and CrCl<30, consider 1 day
Alternative: Use paraenteral (heparin/LMWH) while awaiting theraputic INR

16. To BRIDGE or Not? Exlusion: Mechanical valves,
Aug 27, 2015
Exlusion: Mechanical valves,
high risk surgeries, recent stroke
or bleed, CrCl<30, Plt <100,000

17. Surgical Clearance All drugs have slightly different recommendation
Rule of thumb – hold for 48 hours prior to surgery, restart as soon as possible
Hold longer if high risk bleeding operation
Intracranial, intraspinal, intrathoracic, retroperitoneal

18. CHADS2 or CHA2DS2 VASc?

19. CHADS2 or CHA2DS2 VASc?
CHA2DS2 VASc currently recommended for routine risk stratification
Identifies more clearly low, intermediate and higher risk for systemic embolization
Reclassifies people who definitely do not need anticoagulation, but will increase the number who will

20. Alternative to OAC for AFib

21. Alternative to OAC for AFib

22. Alternative to OAC for AFib

23. Acute Coronary Syndrome
Decreased primary endpoint of death from CV cause,
MI, or Stroke however increased major bleeding
Apixaban post ACS had no efficacy and increased bleeding
regardless of single or dual antiplatlet therapy.

24. Triple Therapy post stenting

26. Triple Therapy post stenting

27. Guidelines 2014
After coronary revascularization in patients with CHA2DS2-VASc score ≥2, it may be reasonable to use clopidogrel concurrently with oral anticoagulants but without aspirin
(Class IIb, LOE B)

29. Stenting in Afib Use bare metal stent when able
Shortest duration of triple therapy as possible
Avoid NOACs
Use Clopidogrel
For CHA2DS2 VASc 0-1, don’t anticoagulate
Consider lower target INR

30. Summary
Individualize patient treatment Dosing is different for DVT/PE than AFib Know how to switch agents Avoid new drugs for now when triple therapy is needed
Thank you!!!!