Direct oral anticoagulant use in special populations

Area of Science:

• Pharmacology
• Cardiology
• Hematology

Background:

• Direct oral anticoagulants (DOACs) are widely used for venous thromboembolism (VTE) and nonvalvular atrial fibrillation (NVAF).
• Initial trials excluded patients with common comorbidities like obesity, advanced kidney disease, cirrhosis, cancer, and antiphospholipid antibody syndrome.
• Real-world data has emerged on DOAC use in these excluded populations.

Purpose of the Study:

• To review the efficacy and safety of DOACs in patients with common comorbidities typically excluded from pivotal trials.
• To synthesize current evidence on DOAC use in specific high-risk patient groups.

Main Methods:

• Review of retrospective studies, meta-analyses, national databases, and pharmacokinetic data.
• Analysis of DOAC efficacy and safety in patient populations with obesity, advanced chronic kidney disease, cirrhosis, cancer, and antiphospholipid antibody syndrome.

Main Results:

• DOACs demonstrate efficacy and safety in many patients with comorbidities, despite initial trial exclusions.
• Caution or avoidance of DOACs is advised in specific conditions like high-risk antiphospholipid antibody syndrome, advanced cirrhosis, advanced kidney disease, and intact gastrointestinal cancers.
• DOAC use is expanding beyond initial randomized controlled trial criteria.

Conclusions:

• DOACs have transformed anticoagulant management for VTE and NVAF.
• Individualized patient assessment, considering comorbidities and patient preference, is crucial for selecting the appropriate anticoagulant.
• Informed consent is paramount when making decisions about anticoagulant therapy.