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Prescription drugs
The European Heart Rhythm Association (EHRA) has released a new version of its “practical guide” for the use of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation.
The guide, now in its third edition, gives concrete advice on how to use NOACs in specific clinical situations.
It was published in European Heart Journal and presented at EHRA 2018 in Barcelona, Spain.
The 2018 edition of the guide has several new chapters.
One chapter summarizes the correct dosing of NOACs in conditions other than atrial fibrillation, such as for the prevention of deep vein thrombosis and treatment of venous thromboembolism.
“The dosing for each condition is different, which may lead to confusion, so we have outlined this clearly,” said author Hein Heidbüchel, MD, PhD, of Hasselt University in Hasselt, Belgium.
Another chapter outlines how to use NOACs in particular groups of patients, including those with very low body weight, the very obese, athletes, frail patients in whom there is concern about bleeding, and patients with cognitive impairment who may forget to take their pills.
The guide also includes updated advice on the combined use of antiplatelet agents and NOACs in patients with coronary artery disease, particularly those with an acute coronary syndrome or patients scheduled for percutaneous coronary intervention with stenting.
“We provide guidance around which and how many antiplatelets, for how long, with which NOAC, and at what dose of that NOAC,” Dr Heidbüchel said.
In addition, the guide now includes more scientific evidence on the use of anticoagulants around cardioversion. The document gives detailed advice on what to do in patients on long-term NOAC treatment who need cardioversion, as compared to patients newly diagnosed with atrial fibrillation and started on a NOAC before cardioversion.
Since the previous edition of the guide was published, the first NOAC reversal agent has received market approval. Therefore, the new edition includes advice on how to use this agent, idarucizumab—which reverses the anticoagulant effect of dabigatran—when there is acute bleeding, when urgent surgery is required, or when the patient has a stroke.
The guide also includes advice on andexanet alfa, another reversal agent expected to receive market approval, with the caveat that the instructions on the label should be followed.
Additionally, the guide describes scenarios in which physicians might want to know the NOAC plasma level. One scenario concerns patients undergoing major surgery in whom it is unclear—for example, because of other drugs or renal dysfunction—whether the usual practice of stopping the NOAC 48 hours in advance is sufficient. The plasma level of the NOAC could be measured just before surgery to confirm the anticoagulant effect has waned.
Finally, the chapter on drug-drug interactions has been expanded with anticancer and antiepileptic drugs.
“While this is mostly based on potential pharmacokinetic interactions and case reports, it is the first of its kind,” said author Jan Steffel, MD, of University Heart Center Zurich in Switzerland.
“This is likely to be adapted and become more complete over the years as our experience increases at this new frontier.”
EHRA received unconditional grants from Pfizer/BMS, Daiichi-Sankyo, Boehringer-Ingelheim, and Bayer.