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Novel Oral Anticoagulants: There's A New Sheriff In Town

Posted Jul 02 2013 3:00am
Up until recently, anyone in need of long term anticoagulation turned to a vitamin K antagonist, warfarin, for outpatient use regardless of whether it was for deep venous thromboembolism, hypercoagulable state, or plain old atrial fibrillation.  When I trained, you told your patients not to eat any vitamin K rich foods.  But if you look at the list, there are a number of vegetables that are really good for you.  So taking warfarin becomes a matter of the tail wagging the dog .

On the other hand, given the advent of home INR monitoring devices, it's time we put the power back in the hands of the patient, empowering him/her to eat healthy & keep track of their INR.  Typically, I then talk to these patients about eating a consistent amount of vitamin K rich foods daily (and to monitor more frequently if they change their dietary habits).  

But a new randomized double-blind study published yesterday in the New England Journal of Medicine suggests that there's a new sheriff in town :  apixiban, a novel oral anticoagulant, was not inferior to traditional vitamin K antagonist, warfarin, over 6 months in preventing pulmonary embolism from deep venous thrombosis.  In fact, without having to worry about vitamin K dietary habits or regular testing, apixiban had similar outcomes to dose-adjusted warfarin.  More importantly, there was no increase in bleeding events (something that was of concern in atrial fibrillation studies comparing NOACs to warfarin).

As the editorialist noted , NOACs have not truly & readily replaced warfarin in all patients for all indications. More importantly, there's also the cost factor to consider.  However, in certain circumstances, it may be time to consider the new sheriff when it comes to preventing pulmonary embolism.  As always, talk this over w/your patient or physician, whichever the case may be.
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