Measurement of non-VKA oral anticoagulants versus classic ones: the appropriate use of hemostasis assays
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REVIEW
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Measurement of non-VKA oral anticoagulants versus classic ones: the appropriate use of hemostasis assays Jonathan Douxfils1, Anne Tamigniau2, Bernard Chatelain2, Catherine Goffinet3, Jean-Michel Dogné1 and François Mullier1,2*
Abstract Traditional anticoagulant agents such as vitamin K antagonists (VKAs), unfractionated heparin (UFH), low molecular weight heparins (LMWHs) and fondaparinux have been widely used in the prevention and treatment of thromboembolic diseases. However, these agents are associated with limitations, such as the need for regular coagulation monitoring (VKAs and UFH) or a parenteral route of administration (UFH, LMWHs and fondaparinux). Several non-VKA oral anticoagulants (NOACs) are now widely used in the prevention and treatment of thromboembolic diseases and in stroke prevention in non-valvular atrial fibrillation. Unlike VKAs, NOACs exhibit predictable pharmacokinetics and pharmacodynamics. They are therefore usually given at fixed doses without routine coagulation monitoring. However, in certain patient populations or special clinical circumstances, measurement of drug exposure may be useful, such as in suspected overdose, in patients experiencing a hemorrhagic or thromboembolic event during the treatment’s period, in those with acute renal failure, in patients who require urgent surgery or in case of an invasive procedure. This article aims at providing guidance on laboratory testing of classic anticoagulants and NOACs. Keywords: Vitamin K antagonist, Dabigatran, Rivaroxaban, Apixaban, Low molecular weight heparin, Enoxaparin, Monitoring, Non-VKA oral anticoagulants
Introduction Anticoagulants are a mainstay of cardiovascular therapy and, until recently, vitamin K antagonists (VKAs) were the only oral anticoagulants available. The knowledge about monitoring and dosing of VKAs in order to maximize their efficacy and minimize hemorrhagic complications has increased considerably since their introduction in 1950s. In addition, the management of VKAs has been optimized with the establishment of anticoagulation clinics, as well as self-monitoring and self-management programs. However, VKAs have still * Correspondence: [email protected] 1 Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium 2 Hematology Laboratory, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), CHU Dinant Godinne UcL Namur, Université Catholique de Louvain, 1, avenue Dr Gaston Therasse, B5530 Yvoir, Belgium Full list of author information is available at the end of the article
strong limitations such as a slow onset and offset of action, the requirement of variable dose regimen, a series of multiple drug-drug interactions and a considerable inter-individual variability. These limitations make coagulation monitoring and frequent dose adjustments necessary to ensure an adequate level of anticoagulation. Unfractionated heparin (UFH) and low
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