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American Journal of Medicine
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American Journal of Medicine
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For clinicians to use these new anticoagulant agents there are several other considerations to be aware of (Figure 21):
These agents should not be used with individuals with severe renal impairment or a creatinine clearance <30 mL/min. In my opinion these agents should be safe overall in individuals aged 80 years and older; however there may be some older patients, particularly those with fluctuations in kidney function, where use of these new anticoagulants seems too problematic.
What about use of these new anticoagulants combined with antiplatelet agents? This is another area that needs better understanding. Clearly combining any anticoagulant with an antiplatelet agent is going to increase the risk of hemorrhage. Although drug interactions are incredibly decreased compared to warfarin, there will still be some risk. The best rule is to read the package insert – that is literally what we do in our clinic to stay up to date in this particular area.
We are learning about the call for urgent reversal in the patient with trauma. My only counter-argument to the lack of the antidote for these new agents is that I think we all believe that we are doing something beneficial to counter the anticoagulation in patients on warfarin when we give vitamin K and fresh frozen plasma. However I am not certain that that really translates into an altered endpoint or outcome for the patients, until or unless we succeed in lowering the INR, and I think we clearly need more information in this area.
In the atrial fibrillation trials there was some concern about thrombotic risk when stopping one of these agents. Again, having looked at the data, it appears that this is more of a case of managing transition from one of these new agents back to warfarin. The important point is not to have an aggressive approach to getting these patients back onto therapeutic warfarin, and it is really the failure to properly make this smooth transition that explains the increase in stroke that has been seen in the atrial fibrillation trials when the patients were transitioned from one of the new agents back to warfarin.Hylek E. Am J Med 2013; published on-line at http://education.amjmed.com/00000.