CHOOSING ANTICOAGULATION AGENT
VTE: DOACs (dabigatran, ...
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CHOOSING ANTICOAGULATION AGENT

VTE: DOACs (dabigatran, rivaroxaban, apixaban, edoxaban) > VKA > LMWH

VTE & active malignancy: LMWH or edoxaban (NEJM 2018;378:615) > other DOACs, VKA; apixaban may be > LMWH (ADAM-VTE, ASH 2018); DOAC ppx ↓VTE risk in int/high risk ambulatory pts w/ CA (AVERT NEJM 2019;380:711; CASSINI NEJM 2019;380:720)

VTE & obesity (BMI ≥40, weight ≥120 kg): VKA, LMWH, or rivaroxaban > other DOACs

Recurrent VTE on non-LMWH A/C: switch to LMWH; Recurrent VTE on LMWH: increase LMWH dose

Mechanical valve: VKA; VKA > dabigatran (RE-ALIGN NEJM 2013;369:1206)

Non-valvular AF: DOAC > VKA; Valvular AF: VKA

AF + PCI: dual therapy (P2Y12i + OAC) vs. triple therapy (ASA + P2Y12i + OAC): triple therapy ↑bleeding, ?↓ ischemic events

 • Dual therapy options: (1) P2Y12i (clopidogrel or ticag) + VKA; (2) P2Y12i (clopidogrel) + low

dose rivaroxaban 15mg QD (PIONEER AF NEJM 2016;375:2423: ↓bleeding, similar CV death/MI/CVA; (3) P2Y12i (clopidogrel) + dabigatran 150mg BID (RE-DUAL PCI NEJM 2017;377:1513: ↓bleeding, similar MI/CVA/death/unplanned revascularization

 • If triple therapy chosen, consider transition to dual therapy at 4-6 weeks

APLS: VKA; VKA > rivaroxaban in high-risk APLS (TRAPS Blood 2018;132:1365)

Stable ischemic CAD: very lose dose rivaroxaban (2.5mg BID) + ASA → ↓MACE compared to ASA alone; ↑ major bleeding but no difference in ICH or fatal bleeding



#anticoagulation #indications #selection #pharmacology #management #choosing
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