Direct oral anticoagulants: what can we learn?
Francesco Marongiu1, Doris Barcellona2
1Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
Abstract:
Direct oral anticoagulants (DOACs) represent an innovation because they avoid periodic laboratory monitoring, and also reduce cerebral bleeding. An examination of the performance of DOACs versus warfarin in randomized clinical trials dedicated to atrial fibrillation would reveal the poor performance of warfarin because the percentage of major bleeding is always above 3%; however, the percentage of major bleeding is less than half of that when the management is done in anticoagulation clinics (ACs). Several years ago, a common opinion was that ACs would disappear as soon as DOACs enter the market. We proposed then that ACs could be transformed into thrombosis centres (TCs) because we envisaged many new activities in terms of diagnostic tools and therapeutic choices. After the introduction of DOACs, the role of the ACs has been re-evaluated because their role may be crucial in selecting both the most appropriate diagnostic approach and the best therapeutic option (including anti-vitamin K drugs) for the single patient. TCs can organize a regular follow-up to improve patient adherence to DOACs. Marketing might have a role in the decision making of the single doctor. Efforts should be made for limiting the relationships between doctors and pharmaceutical companies. It seems reasonable to better prepare doctors, during their university courses, for them to develop a greater scientific culture that would enable them to critically read clinical studies and acquire an independent opinion. Ideally, an expert in haemostasis and thrombosis should handle new and old anticoagulants.
Insights
Direct oral anticoagulants (DOACs) offer improved safety and efficacy over warfarin, particularly in managing atrial fibrillation. Anticoagulation clinics (ACs) remain vital for optimizing patient care and adherence to these novel therapies.
Area of Science:
- Cardiology
- Pharmacology
- Clinical Medicine
Background:
- Direct oral anticoagulants (DOACs) offer advantages over warfarin, including reduced bleeding risk and avoidance of routine laboratory monitoring.
- Warfarin's performance in atrial fibrillation trials shows high major bleeding rates (>3%), significantly improved in anticoagulation clinic (AC) settings.
- The advent of DOACs prompted re-evaluation of ACs' role, suggesting transformation into thrombosis centers (TCs).
Purpose of the Study:
- To re-evaluate the evolving role of anticoagulation clinics (ACs) in the era of direct oral anticoagulants (DOACs).
- To explore the potential for ACs to evolve into thrombosis centers (TCs) offering expanded diagnostic and therapeutic services.
- To emphasize the importance of specialized care in optimizing anticoagulant therapy and patient adherence.
Main Methods:
- Comparative analysis of randomized clinical trials comparing DOACs and warfarin in atrial fibrillation.
- Review of the current literature and expert opinion on the management of anticoagulation.
- Discussion of the evolving landscape of anticoagulant therapy and the role of specialized clinics.
Main Results:
- DOACs demonstrate superior safety profiles compared to warfarin, with significantly lower major bleeding rates.
- Anticoagulation clinics (ACs) play a crucial role in improving patient outcomes and adherence, even with DOACs.
- Specialized centers (TCs) can enhance diagnostic capabilities and therapeutic decision-making for complex anticoagulation management.
Conclusions:
- Anticoagulation clinics (ACs) are essential for optimizing the use of both DOACs and traditional anticoagulants.
- The transformation of ACs into thrombosis centers (TCs) is a logical progression to meet the growing needs of anticoagulated patients.
- Enhanced medical education focusing on critical appraisal of studies and fostering scientific independence is crucial for healthcare providers managing anticoagulation.
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