Current Perspective on Use of NOAC in Clinical Practice in India

Oral vitamin K antagonists (VKA) such as warfarin have been the mainstay of therapy for stroke prevention in patients with non valvular atrial fibrillation (NVAF) while low-molecular-weight heparin, fondaparinux and adjusted-dose warfarin or aspirin have been routinely used for thromboembolism (VTE) prophylaxis in patients undergoing total hip or knee replacement. However, VKAs are associated with considerable limitations, including increased risk of bleeding and narrow therapeutic window. Novel oral anticoagulants (NOACs, now referred as Non Vit K dependent oral anticoagulants), including the direct thrombin inhibitor dabigatran and direct Factor Xa inhibitors such as rivaroxaban and apixaban are now approved alternatives to warfarin for prophylaxis of stroke and systemic embolic events (SEE) in patients with NVAF and treatment and prophylaxis of VTE. The efficacy and safety of NOACs have been proven in several clinical trials. The advantages offered by NOACs such as rapid onset and termination of action, predictable anticoagulant effect, less frequent laboratory monitoring make them promising alternatives to warfarin. However, clinicians in India seek more information over the practical aspects that require due consideration to ensure proper use of these drugs. The article addresses some crucial aspects of NOAC therapy such as measurement of anticoagulant effects, transition between different agents, ensuring drug intake compliance, dealing with dosing errors, management of bleeding complications etc based on the guidance offered by the European Heart Rhythm Association in 2013.