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
- 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)
- Prevention of stroke and embolism in atrial fibrillation patients
|
|
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:
- Brnjac E, Lin Y, Selby R. Chapter 2: Routine Coagulation Tests, Bloody Easy Coagulation Simplified (Second Edition). Ontario Regional Blood Coordinating Network. 2019.
- Shih AW, Crowther MA. Reversal of Direct Oral Anticoagulants: A Practical Approach. Hematology Am Soc Hematol Educ Program. 2016;612-619.
- Spahn DR, Beer JH, Borgeat A, et al. NOACs in Anesthesiology. Transfus Med Hemother. 2019;46:282-293.
- Eliquis® (Apixaban) Product Monograph, Pfizer Canada ULC. October 7, 2019.
- Lixiana® (Edoxaban) Product Monograph, Servier Canada Inc. July 26, 2017.
- Pradaxa® (Dabigatran) Product Monograph, Boehringer Ingelheim Canada Ltd. March 23, 2020.
- Xarelto® (Rivaroxaban) Product Monograph, Bayer Inc. September 20, 2019.