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EDUCATION IN THE MANAGEMENT OF BLEEDING

A practical, evidence-based guide for front-line physicians on how to Treat the Bleed

Which medications are classified as DOACs and what are their characteristics?

  • Direct Oral Anticoagulants (DOACs) bind specifically to a factor in the coagulation pathway to inactivate them. They are generally oral medications that do not require monitoring for anticoagulation and have similar efficacy to warfarin.
    • Other names: NOACs (“new” OACs), TSOACs (“target-specific” OACs)
  • Current DOACs are broadly divided into two categories:
    • Direct thrombin inhibitors (inhibit factor 2): dabigatran
    • Factor Xa inhibitors (inhibit activated factor 10): apixaban, edoxaban, rivaroxaban

DOAC Figure Q1

  • General indications:
    • Prevention of stroke and embolism in atrial fibrillation patients
      • Should NOT be used for prevention in patients with mechanical prosthetic heart valves
    • Acute and extended treatment of venous thromboembolism (VTE)
    • Prevention of VTE post-operatively (generally total knee or hip arthroplasty)

 

Direct Thrombin Inhibitors

Factor Xa Inhibitors

Dabigatran

Apixaban

Edoxaban

Rivaroxaban

Time to Peak Onset

0.5-2 hours

3-4 hours

1-2 hours

2-4 hours

Half-life

12-14 hours

>24 hours if CrCl <30 mL/min

8-15 hours

10-14 hours

5-9 hours

9-13 hours if elderly

Drug Interactions

P-glycoprotein

CYP3A4

P-glycoprotein

P-glycoprotein

CYP3A4

P-glycoprotein

Renal Excretion

80%

25%

50%

33%

References:

  1. Brnjac E, Lin Y, Selby R. Chapter 2: Routine Coagulation Tests, Bloody Easy Coagulation Simplified (Second Edition). Ontario Regional Blood Coordinating Network. 2019.
  2. Shih AW, Crowther MA. Reversal of Direct Oral Anticoagulants: A Practical Approach. Hematology Am Soc Hematol Educ Program. 2016;612-619.
  3. Spahn DR, Beer JH, Borgeat A, et al. NOACs in Anesthesiology. Transfus Med Hemother. 2019;46:282-293.
  4. Eliquis® (Apixaban) Product Monograph, Pfizer Canada ULC. October 7, 2019.
  5. Lixiana® (Edoxaban) Product Monograph, Servier Canada Inc. July 26, 2017.
  6. Pradaxa® (Dabigatran) Product Monograph, Boehringer Ingelheim Canada Ltd. March 23, 2020.
  7. Xarelto® (Rivaroxaban) Product Monograph, Bayer Inc. September 20, 2019.
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A practical, evidence-based guide for front-line physicians on how to treat acquired bleeding