Edoxaban: How Does the Newest Agent Fit into the DOAC Landscape?

Latest advances in the reversal strategies for direct oral anticoagulants

BACKGROUND

Since the late 2000s, Europe has granted approval for various thrombotic risk-related uses of direct oral anticoagulants (DOACs). Unlike traditional anticoagulants, DOACs do not necessitate routine coagulation monitoring. Nevertheless, clinical practice often encounters bleeding events associated with these medications, making the need for effective reversal strategies evident.

OBJECTIVES

The study aims to take stock of current reversal strategies for DOACs, with a particular emphasis on the latest compounds that have been developed or are currently under development.

METHODS

For obtaining information regarding the ongoing reversal strategies and the compounds under development, we referred to ClinicalTrials website, PubMed, and Google Scholar.

RESULTS

In 2024, two specific antidotes to DOACs have already received approval when reversal of anticoagulation is needed owing to life-threatening or uncontrolled bleeding: idarucizumab that reverses the effects of dabigatran, and andexanet alfa, designed to counteract activated factor X inhibitors such as apixaban and rivaroxaban. Furthermore, ciraparantag, a potential universal reversal agent, is currently in advanced stages of clinical development. Concerns remain regarding the safety of specific reversal agents, especially concerning the risk of thrombosis. Additionally, the cost of these antidotes remains high. Consequently, nonspecific strategies to counteract anticoagulant medications, including activated charcoal, hemodialysis, and concentrates of coagulation factors, still have utility.

CONCLUSION

With the validation of specific and nonspecific antidotes, DOACs could supplant traditional oral anticoagulants. This progress represents a significant advancement in anticoagulation therapy. However, ongoing research is crucial to address remaining safety concerns of the specific reversion agents of DOACs in clinical practice.

Predicted effect of ticagrelor on the pharmacokinetics of dabigatran etexilate using physiologically based pharmacokinetic modeling

Dabigatran etexilate (DABE) is a direct oral anticoagulant (DOAC) and may be combined with ticagrelor, a P2Y₁₂ inhibitor with antiplatelet effects. This combination of antiplatelet drugs and anticoagulants would increases the risk of bleeding in patients. In addition, the potential drug interaction may further increase the risk of bleeding. At present, there is scarce research to clarify the results of the interaction between the two. Therefore, we conducted this study to identify the potential impact of ticagrelor on the pharmacokinetics of DABE using physiologically based pharmacokinetic (PBPK) modeling. The models reasonably predicted the concentration-time profiles of dabigatran (DAB), the transformation form after DABE absorption, and ticagrelor. For pharmacokinetic drug-drug interaction (DDI), exposure to DAB at steady state was increased when co-administrated with ticagrelor. The C_max and AUC_0-t of DAB were raised by approximately 8.7% and 7.1%, respectively. Meanwhile, a stable-state ticagrelor co-administration at 400 mg once-daily increased the C_max and AUC_0-t of DAB by approximately 12.8% and 18.8%, respectively. As conclusions, Ticagrelor slightly increased the exposure of DAB. It is possible to safely use ticagrelor in a double or triple antithrombotic regimen containing DABE, only considering the antithrombotic efficacy, but not need to pay much attention on the pharmacokinetic DDI.

Use of DOACs in real-world challenging settings: a Delphi Consensus from Italian cardiologists

BACKGROUND

Direct oral anticoagulants (DOACs) represent the first therapeutic option for stroke prevention in patients with non-valvular atrial fibrillation (AF). However, phase 3 trials that demonstrated higher safety and at least similar efficacy of DOACs compared to Warfarin, included a selected population, not entirely representative of real-world. The present Consensus document was aimed at overcoming the uncertainties about DOAC use in challenging setting where data are conflicting or sparse or where a gap between trials and real world exists.

METHODS

The Delphi method was used to achieve consensus on DOAC use in AF patients throughout 104 Cardiologists in Piedmont, Italy. A questionnaire on 6 commonly encountered clinical settings was administered: 1) the elderly; 2) the "frail" patient; 3) interactions with food/drugs; 4) low-dosages; 5) cancer patients; 6) patients with acute coronary syndrome.

RESULTS

DOAC use over Warfarin was investigated in the elderly population, in the frail patients and in those with cancer, and clinical consensus was reached on its preferential use. Drug interactions should always be considered when a DOAC is prescribed and dosage should respect the Summary of Product Characteristics. No consensus was reached in patients with severe renal impairment and in those with dynamic clinical characteristics ("borderline patients"). DOACs should be considered as the first-line anticoagulation therapy in patients with high intracranial bleeding risk.

CONCLUSIONS

DOACs should represent the first-line anticoagulation therapy in non-valvular AF patients in the majority of challenging settings, underexplored by literature. Caution in their prescription is needed in case of severe renal impairment. Dose choice should follow the SmPC, although this is matter of debate in borderline patients.

[Oral anticoagulation : Current overview and perioperative management in ophthalmic surgery]

Antithrombotic treatment with oral anticoagulants and antiplatelet agents can increase the risk for perioperative bleeding. In contrast to other surgical fields, the optimal perioperative management in ophthalmic surgery has not yet been exactly defined and, thus, is not standardized. In this contribution, we provide an overview of currently available oral anticoagulants and discuss potential strategies for the management of these agents in different ophthalmic surgical procedures.