Antithrombotic therapy for VTE Disease: CHEST Guideline and Expert Panel Report

This article interested me right from the start because the title involved anticoagulation. Anticoagulation is a huge part of pharmacy and its management is essential for those with a history of cardiac events. Newer oral anticoagulation drugs or non-Vitamin K oral antagonists (NOAC) directly inhibit factor Xa. These drugs have simpler dosing regimens and do not require frequent INR values for monitoring. Their downside though, is the lack of reversal agents. Although, this issue was partially solved by the FDA with the approval of a monoclonal antibody product that has the capability to reverse the effects of a common NOAC: dabigatran. A clinical pharmacist at the University of Utah College of Pharmacy thinks it’s important to note that even without a reversal agent, patients that suffer from bleeding episodes as a result of anticoagulation therapy are better off on these newer agents rather than something more traditional like warfarin. The coordination of care as well as the fact that INR monitoring is not necessary is another positive to NOACs. What are your thoughts? Should we begin to make the transition from warfarin to newer drugs as the first line therapy for patients in need of anticoagulation? What about switching patients that are already receiving warfarin? Are there potential risks to changing drug therapy in this sense? My thoughts include keeping patients on the medications that they’ve been the most compliant or successful with. If a patient doesn’t mind having their INR levels checked and they haven’t had any trouble with warfarin I think it would make the most sense to keep the patient on this medication.

Kearon C, Akl E, Ornelas J. Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest. 2016; 149(2):315-52.

http://journal.publications.chestnet.org/article.aspx?preview=true&articleid=2479255

2 thoughts on “Antithrombotic therapy for VTE Disease: CHEST Guideline and Expert Panel Report”

  1. I think that keeping people on what’s working for them is probably best. However, I think as time goes on physicians should begin leaning towards prescribing Factor Xa inhibitors. It makes sense that these would be used over traditional anticoagulants. But, I do think that it should be explained to patients that a reversal agent is not available and they should be apart of the decision making process.

  2. I agree that in general it is best to maintain patients on the agents that they have found to be effective, even if they are older medications. The NOACs do have other drawbacks as well, including limitations for individuals with renal insufficiency. Most, if not all, of the NOACs require dose adjustments or cannot be used in patients whose CrCl is too low; this is not an issue for warfarin. Another consideration is that in some populations (e.g. those with certain cardiac devices), we do not have data to support the use of newer anticoagulants and/or their use may be risky, because we cannot be entirely sure whether patients are sufficiently anticoagulated. One of the major benefits of using warfarin is that we have a good method of measuring its blood-thinning effect, which we cannot reliably do with the newer agents.

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