NOACs in AF: 2018 EHRA practice guide
The 2018 EHRA* practical guide on non–vitamin K antagonist oral anticoagulants (NOACs) in patients with atrial fibrillation (AF) walks clinicians through 20 topics of clinical scenarios, including stroke management, NOAC use in conditions other than AF, and when to measure plasma levels. [Eur Heart J 2018; doi.org/10.1093/eurheartj/ehy136]
The guide was first published in 2013 and updated in 2015. Updates in 2018 include plasma level monitoring.
“For the vast majority of patients, there is no need to measure plasma levels as there is no data to support this approach,” said writing committee chair Dr Jan Steffel from the University Heart Center in Zurich, Switzerland who presented the guide at EHRA 2018. “However, in certain situations, we did feel this may be of use, for example, in cases of severe bleeding, surgeries with high bleeding risk, ischaemic stroke on NOACs, multiple drug-drug interactions, or when treating the very obese or underweight patients.” Measuring plasma concentration however presents a challenge as ranges for trough levels are wide and the peak levels are even wider, Steffel added.
NOACs in CKD, ESRD
All 4 NOACs (dabigatran, rivaroxaban, apixaban, edoxaban) have shown efficacy and safety in patients with mild-to-moderate chronic kidney disease (CKD) vs non-CKD patients. In patients with end-stage renal disease (ESRD) and undergoing dialysis, the use of NOACs remains under study. Also, NOACs are contraindicated in those with hepatic disease associated with coagulopathy and relevant bleeding risk (ie, Child Turcotte-Pugh C cirrhosis). Rivaroxaban is not advised in AF patients with Child B liver cirrhosis, according to the guide.
Monitoring of renal function is recommended at least yearly in patients taking NOACs and frequently in those with impaired renal function (ie, creatinine clearance (CrCL) ≤60mL/min). To determine the frequency of renal function testing in months, CrCL is divided by 10. Patients who are older, frail, or with multiple comorbidities may have to be monitored more frequently, especially if on dabigatran.
The message is ‘do not bridge’
The guide also attempts to clarify a recommendation by the ESC to stop NOACs at least 24 hours prior to an elective surgery, which has led to several time points for when the last dose was taken, (up to 48 hours before surgery). “The take-home message is ‘do not bridge,” said Steffel.
However, for most minor surgical procedures or when bleeding is easily controllable, it is recommended not to interrupt oral anticoagulation. In general, these procedures can be done 12– 24 hours after the last NOAC intake, with NOAC restarted 6 hours later.
In cases of bleeding with NOACs, strategies include waiting until the anticoagulant effect has cleared, or use of the reversal agent idarucizumab for dabigatran for severe cases. Antifibrinolytics (ie, desmopressin, tranexamic acid) may be considered when there is coagulopathy or thrombopathy.
NOACS in CAD, acute stroke
Combined use of an antiplatelet and a NOAC is advised in patients with coronary artery disease (acute coronary syndrome, or those scheduled for PCI with stenting). Individualized treatment is however required.
In patients presenting with an acute stroke while on a NOAC, thrombolytic therapy should be given within 4.5 hours of stroke onset but not in those on full anticoagulation (within 24 hours after last intake of a NOAC). The case may be different for dabigatran due to the availability of the reversal agent idarucizumab. However, more research is required in this complex field,” said Steffel.
An anticoagulation card in different languages comes with the guide detailing important information such as NOAC dosing and timing, and concomitant medication, among others.