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Novel oral anticoagulants: clinical pharmacology, indications and practical considerations

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Abstract

Background

Novel oral anticoagulants are approved in several indications: rivaroxaban, apixaban, and dabigatran for the prevention of venous thromboembolism after elective hip or knee replacement surgery, and edoxaban for hip or knee replacement surgery and hip fracture surgery (in Japan only); rivaroxaban for the treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE), and prevention of recurrent DVT and PE; and rivaroxaban, apixaban, and dabigatran for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation. These agents overcome some limitations of traditional anticoagulants, are suggested to have no requirement for routine coagulation monitoring, and are administered orally. Rivaroxaban, apixaban, and dabigatran have different pharmacological characteristics, and guidance is needed on optimum doses and dosing intervals and the effects of renal or hepatic impairment, age, food, and other drugs. Dabigatran has stricter prescribing advice than rivaroxaban or apixaban for patients with moderate-to-severe renal impairment. All three drugs have restrictions on use in patients with hepatic impairment. Apixaban requires twice-daily dosing in all indications, whereas rivaroxaban and dabigatran are dosed once- or twice-daily depending on indication. Although head-to-head comparisons are lacking, the novel oral anticoagulants may show favorable cost–benefit relations compared with traditional vitamin K antagonists or no therapy.

Aim

This review summarizes the pharmacology of rivaroxaban, apixaban, edoxaban, and dabigatran, and the indications for which they are approved. Issues regarding the optimization of the use of these anticoagulants for the management of thromboembolic disorders will also be discussed.

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Acknowledgements

The authors would like to acknowledge Li Wan, who provided editorial support with funding from Bayer HealthCare Pharmaceuticals and Janssen Scientific Affairs, LLC.

Conflicts of interest

S.H. has received scientific grants from Merck KGaA, and The Medicines Company and has received honoraria for lectures from Merck KGaA and LEO Pharmaceuticals. J.G. has no disclosures to declare.

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Authors and Affiliations

  1. Goethe University Frankfurt, Frankfurt am Main, Germany

    Sebastian Harder & Jochen Graff

  2. Institute of Clinical Pharmacology, University Hospital, Theodor Stern Kai 7, 60590, Frankfurt am Main, Germany

    Sebastian Harder

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  1. Sebastian Harder
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  2. Jochen Graff
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Correspondence to Sebastian Harder.

Additional information

After this article was accepted, rivaroxaban received a ‘positive opinion’ from the Committee for Medicinal Products for Human Use (CHMP) regarding its use (2.5 mg twice daily in combination with standard antiplatelet therapy) for the prevention of atherothrombotic events after an acute coronary syndrome in adult patients.

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Harder, S., Graff, J. Novel oral anticoagulants: clinical pharmacology, indications and practical considerations. Eur J Clin Pharmacol 69, 1617–1633 (2013). https://doi.org/10.1007/s00228-013-1510-z

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