New Oral Anticoagulants: A review

Previously, we had only Warfarin but now, we have four new drugs for the treatment of Atrial Fibrillation, the NOACs
Dr. Kajal Ganguly

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Dr.Kunal Jhaveri

Today we have one of the leading interventional cardiologist from the city of Kolkata, Dr. Kajal Ganguly. He is currently associated as a professor and head of the department of Cardiology from NRS Medical College and he is also serving as a consultant interventional cardiologist from the Grater City of Kolkata. So today sir is present 01:00 for giving key insights on atrial fibrillation and its major complication of stroke in which the oral anticoagulants are used and now the oral anticoagulation also has been revolving from the older side to the newer generation of oral anticoagulants. So sir what is your key insight on this particular therapy segment of atrial fibrillation and the role of the oral anticoagulants in the stroke prevention atrial fibrillation?

Dr. K. Ganguly

<See as age increases, the chances of atrial fibrillation increases. See in the age of round about 50 chance is almost 5%. As the man grows or woman grows in 80 years this chance is almost 50% and in untreated atrial fibrillation, the chance of stroke in elderly population is as high as 50%. So it must be treated. So we have different modalities of treatment. Previously we had only warfarin that was of drug, now we have four drugs, newer drugs, NOACs are available 02:00 and that should be selected judiciously in patients with atrial fibrillation. Today, we shall mostly discuss nonvalvular atrial fibrillation. So if you see the NOACs, these are four basically that include Pradaxa, rivaroxaban, edoxaban, and apixaban, these are the four drugs. Now, among the four drugs, dabigatran that is the Pradaxa came first, almost four years back we have been using it. Now the drawback of Pradaxa is that it is available at 110 mg. The patients with high comorbidities and elderly age group will frequently use 110 mg twice daily. Otherwise, they have seen other high group of patients that is the 150 mg twice daily, it should be used. The chances of cerebral stroke is little 03:00 higher compared to similar dose of warfarin, but the difficulty is that recently we have got the antidote for this Pradaxa that is dabigatran, but that is not widely available and the chances of stroke and gastrointestinal hemorrhage is also higher. I have used dabigatran antidote in two or three cases. Results are of course pretty fine. Now, if the patient has got renal dysfunction, that is if the creatinine clearance is less than 30 you cannot use this dabigatran. There the role of apixaban and rivaroxaban can be given, but the trial of this rivaroxaban that is the rocket trial they have shown the chances of cerebral hemorrhage is higher in rivaroxaban compared to warfarin. Apixaban is also used in clinical practice with a dose of 5 mg twice daily 04:00 or 2.5 mg twice daily, it can be used up to the renal clearance of 30. So in patients who have got real renal compromise, that is the creatinine clearance is less than 30, they have got no option apart from warfarin. So that is the drug in advanced renal failure. These drugs are widely available, now the difficulty is that as the patient has got to take regularly, cost is little higher, so those patients who have AF, they have got other comorbidities, so other drugs have to used along with this NOAcs, so the cost is little higher and other antidote for this rivaroxaban, apixaban, edoxaban is not freely available. They are also in the investigational stage. That is the direct thrombin detoxifier inhibitor is the dabigtran, others are factor X inhibitor 05:00. So these are we have been using in clinical practice depending on the cases and other comorbidities.

Dr.Kunal Jhaveri

So, I think Dr. Kajal Ganguly has given very brief but very in detail and valuable opinions on the role of NOACs as well as the NOACs are better as compared to the older generation of oral anticoagulants for the stroke prevention in atrial fibrillation. Sir, with these notes we are ending our discussion and thanks a lot for providing your valuable opinion and comments on this.