Novel Oral Anticoagulants (NOACs) Prescriber Update 2013 Indications/Contraindications Indications Orthopedic VTE Prophylaxis VTE Treatment Stroke Prevention for non-valvular AF Contraindications 150 mg BID for CrCl 30 ml/min 75 mg BID for CrCl 15-30 ml/min **This dose has not been studied** 1. Need for chronic rifampin therapy 2. CrCl <15 ml/min Xarelto (rivaroxaban) 10 mg daily for CrCl 30 ml/min 15 mg BID x 21 days, then 20 mg daily for CrCl 30 ml/min 20 mg daily for CrCl >50 ml/min 15 mg daily for CrCl 30-50 ml/min 1. Need for chronic interacting drugs* 2. Moderate-severe liver disease (Child-Pugh score B or C) 3. CrCl <30 ml/min Eliquis (apixaban) 5 mg BID; 2.5 mg BID if any 2 of the following: age 80, weight 60 kg, SCr 1.5 1. Need for chronic interacting drugs* 2. Severe hepatic impairment * See below for list of interacting drugs
Adverse Reactions/Warnings/Precautions Xarelto (rivaroxaban) Adverse Reactions 1. Bleeding a) overall same as warfarin b) GIB c) ICH 2. Dyspepsia Bleeding a) overall same as warfarin b) GIB c) ICH Warnings/Precautions Use with caution in the following patient populations: 1. Elderly (age 75 years) 2. Renal dysfunction (CrCl <30 ml/min) 3. History of GI disease, particularly GIB Use with caution in the following patient populations: 1. Elderly (age 75 years) 2. Renal dysfunction (CrCl <50 ml/min) Eliquis (apixaban) Bleeding a) overall same as warfarin b) GIB c) ICH
Drug Interactions **Please note: This is not a comprehensive list, and drug interaction reports are constantly evolving. Always check a drug interaction database or call the Thrombosis Service, and one of our pharmacists will be happy to assist you. Drugs that anti-thrombotic effect Action Drugs that anti-thrombotic effect Action If CrCl 30-50 ml/min: Dronedarone dabigatran dose to 75 mg BID If CrCl <30 ml/min: Amiodarone Clarithromycin Dronedarone Quinidine Tacrolimus Verapamil Rifampin Do Not Use
Drugs that anti-thrombotic effect Action Drugs that anti-thrombotic effect Action Clopidogrel Conivaptan Itraconazole Ritonavir Xarelto (rivaroxaban) Amiodarone Azithromycin Clarithromycin Diltiazem Dronedarone Erythromycin Felodipine If CrCl <50 ml/min: Fluconazole Posaconazole Quinidine Ranolazine Tacrolimus Verapamil Voriconazole Carbamazepine Phenytoin Rifampin St John s Wort Do Not Use Eliquis (apixaban) Clarithromycin Itraconazole Ritonavir If already on apixaban 2.5 mg BID and need any of the above drugs Decrease apixaban dose to 2.5 mg BID Carbamazepine Phenytoin Rifampin St John s Wort Do Not Use
Transitions From warfarin to NOAC From NOAC to warfarin For CrCl 50 ml/min: start warfarin 3 days before d/c dabigatran Parenteral Anti-thrombotics d/c warfarin and start dabigatran as soon as INR < 2 For CrCl 30-50 ml/min: start warfarin 2 days before d/c dabigatran For CrCl 15-30 ml/min: start warfarin 1 day before d/c dabigatran Parenteral to NOAC: d/c parenteral agent and start NOAC at the same time as the next parenteral dose is due Xarelto (rivaroxaban) d/c warfarin and start rivaroxaban as soon as INR < 3 Rivaroxaban affects INR; d/c rivaroxaban and then start parenteral anti-thrombotic + warfarin at the same time the next rivaroxaban dose is due NOAC to Parenteral: d/c NOAC and give parenteral agent at the same time the next NOAC dose is due Eliquis (apixaban) d/c warfarin and start apixaban as soon as INR < 2 Apixaban affects INR; d/c apixaban and then start parenteral anti-thrombotic + warfarin at the same time the next apixaban dose is due
Monitoring Laboratory Baseline and periodic SCr/calculated CrCl for all NOACs Dabigatran prolongs aptt and TT Rivaroxaban prolongs PT/INR, increases anti-xa level Provide qualitative assessment only Apixaban prolongs PT/INR, increases anti-xa level Drug Interactions Procedures Adverse Effects All NOACs: bleeding Dabigatran: dyspepsia Clinical Follow-up/Resources Thrombosis Service Consult Service Pharmacist provides education, individualized therapy decision, insurance/copay verification Thrombosis Service Clinical Follow-up Pharmacist will follow-up with NOAC patient periodically by phone to assess correct dosing, drug interactions, peri-procedural plans, adverse effects, continued access to drug Thrombosis Service Resources http://healthcare.utah.edu/thrombosis/noac.html If you have additional questions about the novel oral anticoagulants, feel free to contact the University of Utah Thrombosis Service at 801-585-3713 or 801-213-9150 and one of our pharmacists will be happy to assist you! Copyright 2013 - The University of Utah Health Care - All Rights Reserved Information on this website is provided for general guidance. University of Utah Health Care Thrombosis Service does not diagnose, treat medical conditions, or prescribe medications or treatments online via this website. Always consult with your health care provider before beginning or altering your medication and for questions regarding your personal health situation, and guidance of your medical care and medication management. Do not rely on information from this website as an alternative to medical advice from your healthcare provider.