Lu Y, Branstad R, Karim R M, Asinger R W
Hennepin County Medical Center, Minneapolis, MN, USA; University of Minnesota, Minneapolis, MN, USA.
J Clin Pharm Ther. 2014 Dec;39(6):628-36. doi: 10.1111/jcpt.12207. Epub 2014 Sep 24.
Patients with non-valvular atrial fibrillation (NVAF) are at risk for stroke and systemic embolism (SSE), and this risk can be decreased with adjusted-dose warfarin. Warfarin, however, is cumbersome to use and requires at least monthly laboratory monitoring. Three new oral anticoagulants (NOACs) that are less cumbersome have been approved as alternatives to warfarin for SSE prevention in NVAF. Selecting a patient-specific alternative to warfarin can be confusing for pharmacists and clinicians. This review details clinical parameters to consider when choosing an alternative to warfarin for a specific patient and summarizes them in a Comparison Table.
Using available clinical evidence from pivotal trials, US FDA- and Health Canada-approved prescribing information and post-marketing observations, this review provides a summary of important clinical variables for clinicians to consider when choosing patient-centred anticoagulant alternatives to warfarin for prevention of SSE in NVAF.
Dabigatran, rivaroxaban and apixaban are approved alternatives to warfarin for primary and secondary prevention of SSE in patients with NVAF. Additionally, apixaban has also been compared to aspirin in patients with NVAF that were considered unsuitable for vitamin K antagonist therapy. Prospective consideration of age, weight, hepatic function, renal function and drug interactions are important clinical parameters to consider when selecting patient-centred alternatives to adjusted-dose warfarin.
Several NOACs are now alternatives to warfarin for SSE prevention in NVAF but require providers to make a shift in strategy from tailoring anticoagulant dose based on anticoagulant effect to selection of the anticoagulant based on clinical variables that affect anticoagulant exposure. These variables and their interactions should be considered in choosing an alternative to warfarin and are summarized in a simple table comparing the new anticoagulants.
非瓣膜性心房颤动（NVAF）患者存在中风和全身性栓塞（SSE）风险，调整剂量的华法林可降低此风险。然而，华法林使用不便，且至少需要每月进行实验室监测。三种使用更便捷的新型口服抗凝剂（NOACs）已被批准作为华法林的替代药物，用于预防NVAF患者的SSE。为特定患者选择替代华法林的药物可能会让药剂师和临床医生感到困惑。本综述详细介绍了为特定患者选择华法林替代药物时应考虑的临床参数，并将其汇总在一个比较表中。
利用关键试验的现有临床证据、美国食品药品监督管理局（US FDA）和加拿大卫生部批准的处方信息以及上市后观察结果，本综述总结了临床医生在为预防NVAF患者的SSE选择以患者为中心的抗凝剂替代华法林时应考虑的重要临床变量。
达比加群、利伐沙班和阿哌沙班已被批准作为华法林的替代药物，用于NVAF患者SSE的一级和二级预防。此外，在被认为不适合维生素K拮抗剂治疗的NVAF患者中，还将阿哌沙班与阿司匹林进行了比较。在选择以患者为中心的调整剂量华法林替代药物时，前瞻性考虑年龄、体重、肝功能、肾功能和药物相互作用是重要的临床参数。
现在有几种NOACs可作为华法林的替代药物用于预防NVAF患者的SSE，但需要医疗服务提供者从根据抗凝效果调整抗凝剂剂量转变为根据影响抗凝剂暴露的临床变量选择抗凝剂。在选择华法林替代药物时应考虑这些变量及其相互作用，并汇总在一个比较新型抗凝剂的简单表格中。
