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NOACs (Non-vitamin K antagonist oral anticoagulant)
- Non valvular atrial fibrillation :
Reduce the risk of stroke and systemic embolism
Reduce the risk of stroke and systemic embolism
- For risk of recurrent DVT or PE
-- NOACs 都不用監測
-- Dabigatran 有 Idarucizumab + 可以洗腎
-- 10a 不能靠洗腎
-- Coagulant FXa (recombinant), inactivated (andexanet alfa)
for rivaroxaban or apixaban
Direct thrombin inhibitors - Dabigatran
Oral direct thrombin inhibitor
Monitoring with standard coagulation tests during therapeutic use is not required.
Prothrombin time and the activated PTT are insensitive to the activity of dabigatran,
whereas the thrombin clotting time is typically overly sensitive
For practical purposes, a normal thrombin time
excludes a significant coagulopathy due to dabigatran.
If available, a diluted thrombin time is even more specific.
Only about 15% to 20% of absorbed dabigatran is metabolized,
and the remainder is excreted unchanged in the urine.
It is therefore important to maintain urinary output in patients.
Idarucizumab (Praxbind®)
PCC (four-factor PCC) may reverse the anticoagulative effect of dabigatran
whereas fresh frozen plasma does not
Hemodialysis can be effective with removal of 60% or more of the drug within 2 hours;
however, hemodialysis should be performed only if idarucizumab is not available
Factor xa inhibitor, Rivaroxaban, apixaban, and edoxaban
These FXa inhibitors have predictable pharmacologic properties
and do not require routine laboratory monitoring.
Standard coagulation tests is variable and not reliable.
The preferred most clinically available test is
drug level using the anti–FXa activity assay
calibrated for the specific oral FXa inhibitor used.
Discontinuation of the drug for at least 24 hours
could be sufficient when there is no imminent need for reversal,
as in elective or nonurgent procedures
Renal impairment and the elderly, additional time for clearance would be required before
Increased risk of stroke or other thrombotic event
when rivaroxaban is suddenly discontinued in patients
with nonvalvular atrial fibrillation.
When possible, another anticoagulant should be substituted.
Coagulant FXa (recombinant),
inactivated (andexanet alfa) for rivaroxaban or apixaban
Adverse effect : thromboembolic events, infusion-related reactions
Due to high plasma protein binding,
FXa inhibitors are not readily removed by dialysis
Administration of activated charcoal within 2 hours of taking an oral anticoagulant
may adsorb the drug from the intestines before it reaches the plasma.
* 在各個大型 clinical trial 的表現 :
- 高劑量 Dabigatran, Apixaban 預防 stroke 優於 wafarin
- 黑字都是 non inferior to wafarin
- 只有高劑量 Dabigatran, Rivaroxaban 在 GI bleeding 劣於 wafarin
只有 Dabigatran 可以洗腎
- 低腎臟排除 : warfarin (少於1%), apixaban (27%), rivaroxaban (36%)
- 中高腎臟排除 : dabigatran (80%), edoxaban (50%)
- 低血液透析排除 : warfarin (少於1%), apixaban (7%), rivaroxaban (少於1%), edoxaban (9%)
- 中高血液透析排除：dabigatran (50~60%)
- 用在腎功能不佳病人 : Dabigatran 最差
- 最佳選擇是 Apixaban ( 記得調整劑量 )
- Rivaroxaban, Edoxaban 也都可以選 ( 記得調整劑量 )
腎功能不全病人使用需注意出血風險
* 問 : 停藥到下次給藥, 是什麼意思 ?
以Apixaban BID (每天兩次) 為例, Apixaban 轉換為Enoxaparin (LMWH) 時
Apixaban停藥後, 須等到原訂下一次給藥時, 才能使用 Enoxaparin
http://jerryljw.blogspot.tw/2016/06/updated-european-heart-rhythm.html
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