Conversion Between Anticoagulants
European Heart Rhythm Association (EHRA): 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation (Steffel et al, EP Europace 2021)
This updated guidance, published by the EHRA in 2021, provides evidence-based recommendations for the use of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF), including eligibility assessment; monitoring; transitioning between other anticoagulants and DOACs; possible drug-drug interactions (DDIs); dosing adjustments in the elderly, in patients with hepatic or renal impairment, or based on body weight; management of DOAC-associated bleeding (including use of reversal agents); and periprocedural management considerations for elective or emergency procedures (including ablation and cardioversion). Special considerations for DOAC use during the COVID-19 pandemic are also included. Sample pathways to help guide decision-making are included for various clinical scenarios.
Non-vitamin K Antagonist Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: Safety Issues in the Elderly (Ajam et al, Expert Rev Clin Pharmacol 2020)
This article reviews the use of direct oral anticoagulants (DOACs) in elderly patients with atrial fibrillation (AF), high risk of stroke and bleeding, and comorbidities requiring polypharmacy. The safety, efficacy, pharmacokinetics, pharmacodynamics, drug-drug interactions, and drug-food interactions of DOACs are described. Clinical studies, guidelines for the management of AF, and expert consensus statements of US and European societies of cardiovascular diseases and cardiac electrophysiology are also reviewed. The article addresses specific challenges with the use of DOACs, including bleeding management and reversal, switching between anticoagulants (vitamin K antagonists and DOACs), and use of DOACs in patients with AF and renal impairment.
Transition of Anticoagulants 2019
This 4-page wall chart was designed to help guide the transition between anticoagulants (includes oral and injectable anticoagulants).
American Heart Association (AHA): Management of Patients on Non-Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association (Raval et al, Circulation 2017)
This scientific statement from the AHA describes the management of direct oral anticoagulants (DOACs) in patients needing interruption or reversal of anticoagulation because of an acute bleed or procedural intervention, including in patients undergoing cardioversion or ablation. Sample pathways for these scenarios are provided. The pharmacology, potential drug-drug interactions (DDIs), and reversal of individual DOACs are compared, and guidance on transitioning between oral anticoagulants, based on the prescribing information of individual DOACs, are included.
American College of Cardiology (ACC): Practical Management of Anticoagulation in Patients With Atrial Fibrillation (Kovacs et al, J Am Coll Cardiol [JACC] 2015)
Includes considerations for the management of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF) that are based on the consensus recommendations of experts from multiple specialties as part of the ACC’s Anticoagulation Initiative. Topics include initiation and interruption of anticoagulation, quality of anticoagulation care, management of major and minor bleeding (including when and how to use reversal agents [sample pathway included]), and treatment of special populations, such as those with various comorbid cardiovascular diseases (including those with stents) and those undergoing ablation or cardioversion. Comparisons of the risks and benefits of DOACs, dosing considerations in patients with hepatic or renal impairment, and potential drug-drug interactions are provided, along with periprocedural considerations and guidance on transitioning between anticoagulants. A list of topics to cover in patient education encounters is also provided.
University of Washington School of Medicine (2015): Conversions (“Switching”) Among the Oral Anticoagulants
This is a 1-page guide to switching between oral anticoagulants (includes vitamin K antagonists and DOACs).