Oral anticoagulation: reversing the current view in bleeding events

There are two different types of oral anticoagulation, including vitamin-K antagonists (VKAs), such as warfarin, and the new class of direct oral anticoagulants (DOACs), such as dabigatran, rivaroxaban, apixaban, and endoxaban.1 Until recently, warfarin has been the standard therapy for oral anticoagulation.2 However, according to the most recent CHEST guidelines on antithrombotic therapy for venous thromboembolism (VTE), experts in the field of anticoagulation agreed that DOACs provide advances in efficacy, overall safety, and patient and provider simplicity as the preferred anticoagulant when compared with warfarin in patients without cancer.3 This expert consensus was largely driven by multiple recent, large clinical trials that have established the efficacy and safety of DOACs for stroke prevention and VTE treatment and prevention. Since 2009, four large multicenter, randomized, double-blind, placebo-controlled trials demonstrated that DOACs were noninferior in the prevention of stroke in patients with nonvalvular atrial fibrillation and had a lower risk of bleeding compared with warfarin.4-7 Several other large phase 3 clinical trials have shown that DOACs were noninferior to warfarin regarding acuteVTE treatment and prevention of recurrent VTE. [...]there was no control group in the study; however, the authors acknowledge this limitation and state that it would be unethical to randomly assign patients to a placebo group given there are no approved alternatives to idarucizumab. [...]the REVERSE-AD trial did not evaluate any other specific indications for idarucizumab other than uncontrollable bleeding or need for urgent procedure. Given the recent updates on oral anticoagulation in the literature and findings from multiple large clinical trials showing the efficacy of DOACs, these drugs will become the leaders in antithrombotic therapy. [...]advances in new reversal agents will be a key piece to the puzzle for managing patients treated with DOACs to prevent major bleeding events.