Feature Article

Practical use of the nonvitamin K antagonist oral anticoagulants

Alex Madden, Harry Gibbs



Six cases illustrate some of the practical issues when determining patient suitability for therapy with a nonvitamin K antagonist oral anticoagulant (NOAC), initiating therapy, managing patients undergoing surgery or with bleeding, and switching between different anticoagulants.

Key Points

  • NOACs (nonvitamin K antagonist oral anticoagulants) are an alternative to vitamin K antagonists such as warfarin for: – prevention of stroke in patients with nonvalvular atrial fibrillation and of venous thromboembolism in adults after elective total hip or knee replacement – treatment of deep vein thrombosis (DVT) and pulmonary embolism (PE) and prevention of recurrent DVT and PE.
  • The NOACs dabigatran, apixaban and rivaroxaban differ in their properties, including mode of action and drug interactions; these differences must be taken into account when assessing patient suitability for NOAC therapy.
  • Laboratory monitoring required for NOACs differs significantly from that used for warfarin.
  • Perioperative use of NOACs is common; management differs between agents, depending on their pharmacokinetic and pharmacodynamic properties.

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