Direct Oral Anticoagulants (DOACs) to Prevent Strokes

For years, the only oral anticoagulant available to prevent strokes among those with afib was warfarin (Coumadin®). It works well but can be challenging to take because it requires regular blood tests to ensure you are taking just the right amount. Too much could lead to excess bleeding; too little might not prevent blood clots and thus lead to a stroke. Plus, warfarin has numerous interactions with food and other medications.1

In 2010, the US Food and Drug Administration (FDA) approved dabigatran (Pradaxa®), the first in a new class of oral anticoagulants. This new class is referred to as Direct (or direct-acting) Oral Anticoagulants, often called DOACs. You may also see them referred to as Non-Vitamin K Antagonist (or New or Novel) Oral Anticoagulants (NOACs) or Target-Specific Oral Anticoagulants (TSOACs). However, the terms NOAC and TSOAC are much less commonly used now than the term DOAC.

Since the approval of dabigatran, three other DOACs have been approved: rivaroxaban (Xarelto®), apixaban (Eliquis®), and edoxaban (Savaysa®).

None of the DOACs require regular blood tests or special diets like warfarin does. Studies found that each worked as well or even better than warfarin at preventing strokes and similar events, usually with a lower risk of bleeding.

An analysis of 48 trials of these drugs involving more than 71,000 people found that the DOACs reduced the risk of stroke or similar events by 19 percent more than warfarin. They also reduced the risk of death from any cause by 10 percent more than warfarin. Significantly, the DOACs reduced the risk of bleeding in the brain, a feared complication from anticoagulants, by 52 percent. However, with the DOACs, there was a 25 percent increase in the risk of stomach bleeding.2

DOACs are recommended over warfarin except for those with valvular afib (mechanical heart valves or moderate-to-severe mitral stenosis).3 DOACs should not be used for those with valvular afib.4 DOACs may be acceptable for those with a bioprosthetic heart valve or valve repair three months or more after the procedure.4 Those with kidney and liver disease should be evaluated before starting a DOAC and each year after that.3

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What to Know If You Take a DOAC

  • Testing. Unlike warfarin, you don’t need regular blood tests while taking a DOAC.
  • Bleeding. All anticoagulants increase the risk of bleeding, so report any signs of unusual bleeding to your healthcare provider immediately.
  • Medications. While the DOACs are considered to have fewer drug interactions than warfarin, the European Heart Rhythm Association (EHRA) published a practical guide for healthcare professionals on the use of these medications and recommends caution with or avoidance of the following with DOACs: Amiodarone, dronedarone, quinidine, verapamil, ticagrelor, some antivirals, certain antibiotics (clarithromycin, erythromycin, rifampicin), certain fungistatic drugs (itraconazole, ketoconazole, voriconazole, posaconazole), SSRIs & SNRIs, and naproxen. There are also some cancer and antiepileptic medications to be careful of taking with DOACs.4 Healthcare professionals need to know about any prescription and over-the-counter medications you take. Your pharmacist can help you avoid potentially dangerous medication interactions.
  • Herbal supplements. The European Heart Rhythm Association practical guide recommends avoiding John’s wort with DOACs and using caution with curcumin, echinacea, garlic, ginger, ginkgo biloba, ginseng, green tea, and horse chestnut.4 Healthcare professionals need to know about any supplements you take to avoid dangerous medication interactions.
  • Activities. You may need to avoid activities or sports that could lead to injuries and take great care with activities that could lead to cuts or bleeds that may be difficult to stop. Also, let your doctor know if you have a fall as it could cause internal bleeding. Those on warfarin may also bruise easily.
  • Medical IDs. Since DOACs increase your risk of bleeding, consider wearing a medical ID to alert people that you take a blood thinner.
  • Surgery and procedures. It’s important to let your doctor and dentist know that you’re taking a DOAC as it may increase bleeding during any kind of surgical or dental procedure. For some surgeries, doctors may ask you to discontinue your DOAC for several days to reduce the risk of uncontrolled bleeding. Please discuss this with the doctor who prescribed your DOAC because it may be sufficient to stop just one or two doses since DOACs clear from your system more quickly than warfarin. For emergency surgery or severe bleeding, reversal agents may be used to quickly stop the anti-clotting effects of your DOAC.

To learn more about specific direct oral anticoagulants, click on the links below.

To learn more about how you and your doctor can decide if an oral anticoagulant is appropriate for you, see Anticoagulant Medication to Prevent Strokes

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