James Douketis MD FRCPC, Alan David Bell MD CCFP, John Eikelboom MB BS FRCPC, and Aaron Liew MB BCh MRCPI PhD
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Intent of the article
To compare key features of the new oral anticoagulants (NOACs)—dabigatran, rivaroxaban, and Apixaban, and to address questions that arise when comparing the NOACs.
Main Messages
- All NOACs are at least as effective as warfarin for stroke prevention in patients with non-valvular atrial fibrillation (AF), and are at least as safe in terms of bleeding risk according to 3 large trials.
- Meta-analyses of these trials have shown that, compared with warfarin therapy, NOACs reduced total mortality, cardiovascular mortality, and intracranial bleeding, and there was a trend toward less overall bleeding.
- Practical advantages of NOACs over warfarin include fixed once- or twice-daily oral dosing without the need for coagulation monitoring, and few known or defined drug or food interactions.
- Potential drawbacks of NOACs include:
- A risk of bleeding that might be increased in patients older than 75 years,
- Increased major gastrointestinal bleeding with high-dose dabigatran,
- Increased dyspepsia with dabigatran,
- The lack of a routine laboratory test to reliably measure anticoagulant effect, and
- The lack of an antidote for reversal.
- No direct comparisons of NOACs have been made in randomized controlled trials, and the choice of NOAC is influenced by individual patient characteristics, including risk of stroke or venous thromboembolism (VTE), risk of bleeding, and comorbidity (e.g., renal dysfunction).