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International Journal of General Medicine, Drugs in Context

Clinical Articles, News & Views

NOACs for stroke prevention in AF

Novel oral anticoagulants (NOACs) reduced stroke risk in the elderly population with atrial fibrillation (AF), and overcome many of the disadvantages of warfarin, according to a study1 published recently in the International Journal of General Medicine.

The authors reviewed the efficacy and safety of dabigatran etexilate, rivaroxaban, and apixaban, in addition to warfarin and aspirin, for prevention of stroke in patients with AF, focusing on the elderly population. Results of clinical trials demonstrate that the efficacy of NOACs for stroke prevention in patients with AF is as good as or better than that of warfarin, they say.

NOACs may be suitable alternatives to warfarin for stroke prevention in older patients due to several advantages, the authors say, including “a faster onset of action, few drug or food interactions, and no requirement for regular monitoring”. However, dose adjustments may be required for certain patients, such as those with severe renal impairment or in the setting of drug interactions, they add.

The reduction in stroke risk with NOACs must be balanced against the increased risk of bleeding in older patients, as well as potential challenges related to drug interactions and monitoring requirements, the authors say. They also warn that an antidote to reverse the anticoagulant effect of NOACs does not currently exist. Elderly patients must be evaluated carefully for impaired renal function which may increase the risk of bleeding, they conclude.

Although dabigatran, rivaroxaban and apixaban have advantages over warfarin, they also bring new therapeutic dilemmas, says another study2 published recently in Drugs in Context.

Consideration of similarities and critical differences, including the effect of organ dysfunction on drug disposition, drug–drug interaction potential, and other patient-centered factors is essential for selecting the best antithrombotic therapy for the patient, say the authors. It is also important to understand the impact of unanswered questions about these agents on the individual patient when deciding to use a new agent instead of warfarin, they add.

Compared with warfarin, these new agents have a more predictable pharmacodynamic response and fewer major clinically relevant drug–drug interactions, say the authors, having few, if any, food–drug interactions, and infrequent or no need for routine laboratory monitoring. However, these agents also bring new disadvantages, particularly lack of clearly defined reversal strategies, inability to effectively monitor patient response, and higher cost, they add.

Selection of the most appropriate oral antithrombotic agent for a given patient is dependent on clinician knowledge of the similarities and critical differences between the available antithrombotic medications, they conclude.


1. Yates SW. Novel oral anticoagulants for stroke prevention in atrial fibrillation: a focus on the older patient. Int J Gen Med 2013;6:167–80.

2. Kalus JS. Antithrombotic alternatives for stroke prevention in atrial fibrillation: critical differences and remaining questions. Drugs Context 2013;212251.

Published on: April 26, 2013

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    None Found


  • ArrhythmiaAlliance
  • Stars
  • Anticoagulation Europe
  • Atrial Fibrillation Association

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