Anticoagulation
Corey Diamond, PharmD
In January 2024, the Journal of the American College of Cardiology published a systematic review that included a detailed examination of randomized controlled trials exploring the efficacy and safety of direct oral anticoagulants (DOACs) and when they should not be considered standard treatment. The authors also delved into instances when DOACs have demonstrated their worth and highlighted the ambiguous terrain where further research is needed.
Summary of major findings
DOACs may not offer the same level of effectiveness or safety as the current standard of care in cases involving mechanical heart valves, thrombotic antiphospholipid syndrome, and AFib linked to rheumatic heart disease. Moreover, in conditions such as embolic stroke of undetermined source, DOACs fail to deliver a net benefit.
In both AFib (excluding mechanical heart valves or rheumatic source) and venous thromboembolism, apixaban, rivaroxaban, edoxaban, and dabigatran all have demonstrable safety and efficacy compared to vitamin K antagonists, which are the standard of care. The anticoagulation indications for which DOACs should not be used as the standard of care can be seen in the table on the following page. The table also summarizes evidence and recommendations for DOAC use in indications when strong caution is warranted.
Gray areas
The review also addresses the uncertainty that clouds the efficacy of DOACs in addressing left ventricular thrombus, catheter-associated deep vein thrombosis, adult congenital heart disease, splanchnic vein thrombosis, and cerebral venous sinus thrombosis.
For these indications, the authors recommend discussing the uncertainty of the evidence with the patient if DOACs are to be considered. They also recommend strong caution against using DOACs in patients who are pregnant or breastfeeding. Furthermore, DOACs should be used with caution in patients with end stage renal disease, as these patients were excluded from major clinical trials.
“Results reviewed here have significant implications for optimizing anticoagulation therapy and improving patient outcomes in clinical practice. In some conditions, the safety and efficacy of DOACs remain uncertain caused by the lack or flaws of RCTs, necessitating immediate definitive trials,” said El Bèze and colleagues. ■