Choosing patients for NOAC treatment: what to take into account?

Currently, several oral anticoagulant drugs are available to treat and prevent thrombotic and thromboembolic states – warfarin, dabigatran,

rivaroxaban, and apixaban. In a number of indications, there are options to choose from; at other times, the preference of one

approach is more favourable – both in terms of higher efficacy and better safety, or sometimes the choice is limited to one anticoagulant

only. An example when any anticoagulant can be chosen is the prevention of stroke in an otherwise uncompromised patient; when there

is a high risk of thromboembolic stroke, dabigatran at a higher dose will most likely be preferred. By contrast, dabigatran cannot be used

in the presence of moderate to severe reduction in glomerular filtration rate, and it is necessary to choose from xabans or, in terminal

renal failure, warfarin is the only option. Similarly, dabigatran is not suitable in a patient with coronary involvement or a high risk of acute

coronary event. However, in a patient with a higher risk of bleeding, particularly gastrointestinal bleeding, administration of apixaban or

warfarin is an optimal option. With a higher risk of both cerebrovascular ischaemic event and gastrointestinal bleeding, apixaban is again

most advantageous. In another indication, e.g. in thromboembolic event prophylaxis in patients after surgeries on major weight-bearing

joints, rivaroxaban or apixaban are preferred. In the situation when an anticoagulant for treating acute phlebothrombosis is being chosen,

it has to be taken into account whether we want to choose a one-drug strategy from the beginning – then rivaroxaben or apixaban is the

option, or whether to initiate treatment with low-molecular-weight heparin and to administer an oral anticoagulant only in the subacute

phase – then dabigatran or warfarin is the option. Other specific situations and reasons for preference are discussed in this review paper.

Keywords: dabigatran, rivaroxaban, apixaban, atrial fibrillation, phlebothrombosis, pulmonary embolism