NOAC use 筆記Pei-shen Wu, MD

Version 2015.10.27

Important facts

• Asians have higher TIA/CVA events with Afib than other ethnic groups

• Aspirin isn’t better than placebo in Afib-related CVA prevention

• NOACs have rapid onset, short half-life– No need for monitoring– Can be taken in fixed regimen– But strict drug adherence is VERY important

Nomenclature

• Factor IIa– Dabigatran etexilate (Pradaxa)

• Factor Xa– Rivaroxaban (Xarelto)– Apixaban (Eliquis)– Edoxaban (Lixiana)

Special aspects - 1• Pradaxa 80% renal excretion, others mostly hepatic

elimination– Thus in hepatic failure use LMWH or VKA instead– NOAC can’t be used in pregnant women

• Xarelto bioavail nearly 100% if taken with food

• NOAC + NSAID or Platelet inhibitors 60% increase in bleeding risk

• Triple anticoag (NOAC + Aspirin + Plavix) should be minimized/avoid as possible x2 bleeding risk

• Prosthetic values: VKA is better than NOAC !!

Special aspects - 2

• Cardioversion under NOAC is acceptable• Stroke– tPA within 4.5hrs is against NOACs (48hrs within

last dose)– Hemorrhagic stroke: re-establish NOAC at least

10-14 days after onset– Ischemic stroke: 1-3-6-14 days rule• TIA = 1d, small = 3d, moderate = 6d, large = 14d

When to stop?

• Consider renal function and Rx (Pradaxa)• Low risk OP trough concent. restart 6

hrs after hemostasis• High risk OP stop >48hrs restart 6-8 hrs

after hemostasis

Forgotten dose??

• For QD regimen retake within 12 hrs• For BID retake within 6 hrs

• If beyond that window then skip dose !!

Shifting from VKA

• d/c VKA till INR<2 take NOAC• Start VKA till INR>2 then d/c NOAC