Abstract

• Apixaban, edoxaban and rivaroxaban are direct oral anticoagulants that inhibit factor Xa. No routine laboratory tests are available to quantify their anticoagulant effect as of mid-2020, whereas the effect of the standard oral anticoagulant, warfarin, can be easily monitored using the INR.
   
• Data from clinical trials, cohort studies and pharmacovigilance can be used to identify situations that increase the risk of bleeding or thrombosis, some of which involve medication errors. The main situations and errors known to increase the risk of bleeding with xabans are: advanced age; renal or hepatic impairment; low body weight (body mass index (BMI) less than 18.5 kg/m2); certain conditions that increase the likelihood of bleeding; and drug interactions that increase blood xaban levels or involve drugs with additive bleeding effects.
   
• The main situations and errors known to increase the risk of thrombosis with xabans are: missed or delayed doses; drug interactions that lower blood xaban levels or involve drugs with antagonistic effects; a period of under-anticoagulation when switching to a vitamin K antagonist; and, in the case of edoxaban, creatinine clearance greater than 95 ml/min.
   
• In practice, as of mid-2020, when using xabans, it is essential to take into account the situations that increase the risk of bleeding or thrombosis, and to monitor the patient for any change in these risks, such as new comorbidities, new drugs, or discontinued drugs.

©Prescrire 1 October 2020

Source: "Apixaban, edoxaban, rivaroxaban: situations with a high risk of bleeding or thrombosis" Prescrire International 2020; 29 (219): 238-241. Subscribers only.

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