Anticoagulation: Updated Guidelines for Outpatient Management

 

Anticoagulation therapy is recommended for preventing, treating, and reducing the recurrence of venous thromboembolism, and preventing stroke in persons with atrial fibrillation. Direct oral anticoagulants are first-line agents for eligible patients for treating venous thromboembolism and preventing stroke in those with nonvalvular atrial fibrillation. Vitamin K antagonists are recommended for patients with mechanical valves and valvular atrial fibrillation. Vitamin K antagonists inhibit the production of vitamin K-related factors and require a minimum of five days overlap with parenteral anticoagulants, whereas direct oral anticoagulants directly inhibit factor II or factor Xa, providing more immediate anticoagulation. The immediate effect of direct oral anticoagulants permits select patients at low risk to initiate treatment in the outpatient setting for venous thromboembolism, including pulmonary embolism. Low-molecular-weight heparin continues to be recommended as a first-line treatment for patients with venous thromboembolism and active cancer, although there is growing evidence of effectiveness for the use of direct oral anticoagulants in this patient population. Validated bleeding risk assessments such as HAS-BLED should be performed at each visit and modifiable factors should be addressed. Major bleeding should be treated with vitamin K and 4-factor prothrombin complex concentrate for patients already being treated with a vitamin K antagonist. Idarucizumab has been effective for reversing the anticoagulant effects of dabigatran, and andexanet alfa has been effective for reversing the effects of rivaroxaban and apixaban.

Vitamin K antagonists (e.g., warfarin [Coumadin]), unfractionated heparin, low-molecular-weight heparin (LMWH), and direct oral anticoagulants are commonly used for the prevention and treatment of systemic embolism associated with atrial fibrillation, stroke, and venous thromboembolism (VTE). LMWH and select direct oral anticoagulants can be used for anticoagulation therapy initiation on an outpatient basis.

WHAT'S NEW ON THIS TOPIC

Compared with vitamin K antagonists, direct oral anticoagulants have fewer overall drug-drug interactions, a comparable (if not lower) bleeding rate, a shorter half-life, and fixed dosing based on indication, drug interactions, and renal or hepatic function.

American Academy of Family Physicians guidelines recommend the use of oral anticoagulants in patients with a CHADS2 score greater than 1 for the prevention of stroke in atrial fibrillation. The American Heart Association/American College of Cardiology/Heart Rhythm Society guidelines recommend a direct oral anticoagulant over a vitamin K antagonist, unless the patient has moderate-to-severe mitral stenosis or a mechanical heart valve.

In May 2018, andexanet alfa (Andexxa) was approved to reverse the anticoagulant effects of rivaroxaban (Xarelto) and apixaban (Eliquis) in patients with life-threatening or uncontrolled bleeding. Optimal dose, duration, need for repeat dosing, and mitigation of thromboembolic risk is yet to be delineated.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Direct oral anticoagulants should be used as first-line agents for the treatment of venous thromboembolism and the prevention of stroke in patients with nonvalvular atrial fibrillation and a CHA2DS2-VASc score of 2 or higher in men and 3 or higher in women.20

C

Consensus guideline on the management of venous thromboembolism and atrial fibrillation

Bleeding risk assessment should be performed and any modifiable risk factors addressed during each visit.1,21

C

Expert opinion and consensus guidelines

Vitamin K antagonists should be used for the prevention of stroke in patients with atrial fibrillation with moderate-to-severe mitral stenosis and a CHA2DS2-VASc score of 2 or higher in men and 3 or higher in women.20,21

C

Consensus guidelines and a two-dose validation study

Low-molecular-weight heparin is recommended as the anticoagulant of choice in patients with cancer and venous thromboembolism; however, direct oral anticoagulants may be appropriate in select situations.1

C

Consensus guideline


CHA2DS2-VASc = congestive heart failure; hypertension; age 75 years or older [doubled]; diabetes mellitus; prior stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65 to 74 years; sex category.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

Direct oral anticoagulants should be used as first-line agents for the treatment of venous thromboembolism and the

The Authors

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PATRICIA WIGLE, PharmD, BCPS, BCACP, FCCP, is a professor in the Division of Pharmacy Practice and Administrative Sciences at the University of Cincinnati (Ohio) and is an ambulatory care clinical pharmacy specialist at The Christ Hospital, Cincinnati....

BRAD HEIN, PharmD, BS, BCPS, is the associate dean for professional education and assessment at the University of Cincinnati and is an internal medicine clinical pharmacy specialist at The Christ Hospital.

CHRISTOPHER R. BERNHEISEL, MD, is the director of the University of Cincinnati/The Christ Hospital Family Medicine Residency Program and is an associate professor in the Department of Family and Community Medicine at the University of Cincinnati.

Address correspondence to Patricia Wigle, PharmD, BCPS, BCACP, FCCP, University of Cincinnati James L. Winkle College of Pharmacy, 3225 Eden Ave., 285 Kowalewski Hall, Cincinnati, OH 45267-0004 (email: patricia.wigle@uc.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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