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Practical Considerations on the Use of

Novel Oral Anticoagulants (NOACs) in

Stroke Patients with Non-valvular AF

AHS-NNI Neuroscience Forum 2017

18 February 2017

Hobart Ng Tsai, PharmDSenior Pharmacist (Inpatient)

Khoo Teck Puat Hospital

Content Outline

• Brief review of NOACs mechanism of action and characteristics

• Warfarin vs. NOAC in AF patients, when do I choose what?

• What do I do on follow-up visits?

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Brief Review of NOACsPharmacology and Properties

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http://ijri.org/article.asp?issn=0971-3026;year=2015;volume=25;issue=4;spage=375;epage=379;aulast=Laroia;type=3

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5Heidbuchel H. et al. Europace. 2015;17(10):1467-507.

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Warfarin vs. NOACsWhen to choose what

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7Granger CB, Circulation. 2012;125(1):159-64. Compiled data from randomized controlled trials on warfarin vs. NOACs

In summary, NOACs are as efficacious or more efficacious than and have same

rate or less rate of bleeding compared to warfarin

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Forest plot depicting the hazard ratio for each pairwise propensity‐matched medication

comparison (dabigatran, rivaroxaban, and apixaban each vs warfarin) for stroke and systemic

embolism (S/SE), ischemic stroke, and hemorrhagic stroke.

Xiaoxi Yao et al. J Am Heart Assoc 2016;5:e003725. Real-world data on warfarin vs. NOAC

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Forest plot depicting the hazard ratio for each pairwise propensity‐matched medication

comparison (dabigatran, rivaroxaban, and apixaban each vs warfarin) for major, intracranial,

and gastrointestinal bleeding.

Xiaoxi Yao et al. J Am Heart Assoc 2016;5:e003725. Real-world data on warfarin vs. NOAC

Real-world data show that the results on efficacy and safety of NOACs from clinical

trials are seem to be preserved in practice.

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• 2016 ESC AF Guidelines:

“When oral anticoagulation is initiated in a

patient with AF who is eligible for a NOAC, a

NOAC is recommended in preference to a

Vitamin K antagonist.” (IA)

However, the question remains…who should

be on warfarin? Who should be on a NOAC?

Warfarin vs. NOACs

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Valvular AF or AF with moderate or severe rheumatic mitral stenosis

• Warfarin

Patients on warfarin with TTR >70%

• Warfarin

Warfarin vs. NOACs

http://www.cthsurgery.com/mitral-valve-replacement.html

http://www.medscape.com/viewarticle/862369#vp_2

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Warfarin vs. NOACs

Renal impairment (CrCl <50 ml/min) but not on dialysis

• Apixaban (unless CrCl <25ml/min)

• Rivaroxaban (unless CrCl <30 ml/min)

Dialysis patients

• Warfarin

http://renaltreatment.com/chronic-renal-failure/

http://www.kidneyfailureweb.com/dialysis-knowledge/1248.html

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Warfarin vs. NOACs

Older patients (≥ 75 years old)

• Apixaban

High risk for Gastrointestinal Bleeding

• Apixaban

• Dabigatran 110mg twice daily

http://blogs.nejm.org/now/index.php/gastrointestinal-bleeding/2015/02/06/

http://www.eu-patient.eu/News/News-Archive/EPF-position-on-the-rights-and-needs-of-older-patients/

• What about drug interactions?

Some medications such as rifampicin, anti-

epileptics, and HIV protease inhibitors, are

contraindicated with some NOACs.

It’s best to check with a pharmacist.

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Warfarin vs. NOACs

https://janaburson.wordpress.com/2014/03/25/drug-interactions-with-methadone/

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What to do on follow-up visits?What do I monitor?

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• Assess for the following:

Adherence

Thromboembolism/Bleeding

Concomitant medications

Hemoglobin and renal function

Monitoring Parameters

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• How often to assess renal function

CrCl/10 = frequency in months on how often

to check renal function

E.g. CrCl = 50 ml/min

CrCl/10 = 50/10 = 5 months

*Check renal function at least every 5 months

Monitoring Parameters

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• Yao X, Abraham NS, Sangaralingham LR, et al. Effectiveness and Safety of Dabigatran,

Rivaroxaban, and Apixaban Versus Warfarin in Nonvalvular Atrial Fibrillation. J Am Heart Assoc.

2016;5(6)

• Schneeweiss S, Gagne JJ, Patrick AR, Choudhry NK, Avorn J. Comparative efficacy and safety

of new oral anticoagulants in patients with atrial fibrillation. Circ Cardiovasc Qual Outcomes.

2012;5(4):480-6.

• Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial

fibrillation developed in collaboration with EACTS: The Task Force for the management of atrial

fibrillation of the European Society of Cardiology (ESC)Developed with the special contribution

of the European Heart Rhythm Association (EHRA) of the ESCEndorsed by the European

Stroke Organisation (ESO). Eur Heart J. 2016;

• Heidbuchel H, Verhamme P, Alings M, et al. Updated European Heart Rhythm Association

Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-

valvular atrial fibrillation. Europace. 2015;17(10):1467-507.

• Diener HC, Aisenberg J, Ansell J, et al. Choosing a particular oral anticoagulant and dose for

stroke prevention in individual patients with non-valvular atrial fibrillation: part 1. Eur Heart J.

2016;

• Diener HC, Aisenberg J, Ansell J, et al. Choosing a particular oral anticoagulant and dose for

stroke prevention in individual patients with non-valvular atrial fibrillation: part 2. Eur Heart J.

2016;

References

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Extra Slides

24Diener HC,et al. Eur Heart J. 2016

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25Diener HC,et al. Eur Heart J. 2016