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American Journal of Medicine
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American Journal of Medicine
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So how do we pull together all the results reviewed in this summary of the clinical trials of the NOACs (Figure 26)?
The current standard for the treatment of VTE would start with therapy with injectable heparin (UFH or, more commonly, LMWH) for the first 5 to 7 days, followed by overlapping transitioning to oral warfarin. Now, however, the trials of these NOACs have demonstrated some alternatives.
When approved for VTE, we could use LMWH initially, followed by dabigatran. Or we could use rivaroxaban initially and during long-term treatment – as this treatment strategy has now been approved for use. And if and when it is approved for long-term treatment, we could then use apixaban as an alternative to rivaroxaban.
At the present, the only real options are the treatments that have been approved, and this means the standard care (LMWH followed by warfarin) or rivaroxaban. These options are reviewed in some detail in the presentation by Dr Hylek.
In summary, we have evidence from the randomized clinical trials with the NOACs that these agents – dabigatran, rivaroxaban, and apixaban – are at least as effective and at least as safe as warfarin for the prevention of recurrent VTE, and they substantially enhance convenience for patients.
I believe that the option to treat patients upfront with one of these NOACs is absolutely game-changing in taking the management of this disease to the next level: We now have several highly attractive options for therapies to tackle the burden of morbidity and mortality due to VTE, because when I see a patient presenting to the clinic or the emergency room with VTE, I can now start treatment with a pill. Eikelboom J. Am J Med 2013; published on-line at http://education.amjmed.com/00000.