The new anticoagulants: an update

In recent years, the so-called new oral anticoagulants and later direct-acting oral anticoagulants have gradually been incorporated into clinical practice, progressively displacing traditional anticoagulants.

Today, these direct-acting anticoagulants account for more than a quarter of the anticoagulant treatments in our country, although their main limitation lies in the economic field. These new drugs are expensive, especially considering the number of people who need anticoagulants. In fact, more than one million people in Spain need them just to treat arrhythmias and atrial fibrillation, a fact that constitutes a considerable health expenditure.

The new anticoagulants are easy to administer because they are stable and do not require monitoring. In addition, it is worth mentioning that the first investigations into its operation have shown effective results in terms of hemorrhagic safety and anti-thrombus, so that the initial expectations are being fulfilled.

Areas to be explored

On the other hand, it should be noted that a pending problem, which is the lack and need for a specific antidote that allows better performance in the face of hemorrhagic problems, seems to have been solved.

On the negative side, it should be noted that while we are getting used to these products and their convenience, new research and evidence are appearing that point out apparently conflicting points.

The most novel aspect -in my opinion- of these studies is the finding that, when blood levels of these new anticoagulants are assessed, in most individuals who have had a rethrombosis or embolism despite taking them correctly, their levels both at the end of the day and before administering the next dose are lower than in patients who have not had problems with rethrombosis.

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However, these are preliminary studies and need to be extended, although it seems to be demonstrated that not all people will benefit equally from the same doses of the drug, but that it would be necessary to dose them and establish individualized doses.

This does not imply the need to carry out exhaustive monitoring, since these are stable drugs and once the appropriate dose has been established no further controls should be made, although it is recommended to make a general analysis and at least control visits every six months.

It should also be mentioned that these anticoagulants have been shown to be less efficient in patients with metallic valve prostheses, although this is a small group of patients.

Finally, some studies indicate that there are thrombi in the atrial appendage and left atrium in patients affected by atrial fibrillation, despite receiving these anticoagulants.

This could raise doubts about possible cardioversions without transesophageal echocardiography in these patients.

Finally and in conclusion, it should be mentioned that these direct-acting anticoagulants represent a great advance, although there are still areas to be seen and explored and they may not be equally effective for all patients.

For more information on the new anticoagulants, consult a Hematology specialist.