For decades, vitamin K antagonists such as warfarin were the only oral agents available for long-term anticoagulation. Warfarin's variable bioavailability and drug–drug interaction, necessity of regular monitoring of the antithrombotic effect has been a "hard nut to crack" for clinicians for many years. Recent introduction of new anticoagulants (NOACs) means new options in the prevention and treatment of thromboembolic events. Their wide therapeutic window, fewer drug and diet interactions, no need for routine monitoring, more predictable pharmacokinetics present some advantages and tempt clinicians to prescribe NOACs on a large-scale basis.
However, day-to-day practice evokes some uncertainties with the respect to the use of NOACs. Management of new anticoagulants in perioperative setting can be challenging due to lack of data from large randomized studies and little experience of healthcare professionals with these drugs. Availability of a specific antidote offers new possibility in the reversal of oral direct thrombin inhibitor effect but clear guidance in the management of bleeding complications remain an area for improvement. No need for routine laboratory monitoring is viewed as an advantage of NOACs despite that an assessment of the drug concentration or residual activity could be helpful in emergency situations as well as a tool for ensuring compliance with therapy.
The pharmacist has an important role in maintaining the awareness of new agents, its management, adverse effects and educating the patients about their drugs and importance of adherence.
Learning objectives At the end of the seminar participants should be able to:
Explain the differences between anticoagulants, their pharmacodynamics and pharmacokinetics;
Describe the management of different anticoagulants in perioperative settings;
Describe and interpret the laboratory results used to assess anticoagulation effect; and,
Define the possibilities for reversal of anticoagulation effect.