NOACs

Available NOACs

1. Dabigatran (Pradaxa)
2. Rivaroxaban (Xarelto)
3. Apixaban (Eliquis)
4. Edoxaban (Lixiana)

Indications

• Non-valvular Atrial Fibrillation (AF): Prevention of stroke and systemic embolism.
• Venous Thromboembolism (VTE): Treatment and prevention of recurrent deep vein thrombosis (DVT) and pulmonary embolism (PE).
• Post-operative DVT Prevention: Following hip or knee replacement surgery.

Advantages over Warfarin

• Predictable Pharmacokinetics: No need for regular INR monitoring.
• Fewer Dietary Restrictions: Less interaction with food and other medications.
• Rapid Onset of Action: Faster therapeutic effect compared to warfarin.
• Shorter Half-life: Potentially less prolonged effects in case of complications.

NOAC	Dose	PBS Listed Indications	Contraindications
Dabigatran (Pradaxa)	– 150 mg twice daily – 110 mg twice daily (for patients >75 years or with increased bleeding risk)	– Non-valvular AF: Prevention of stroke and systemic embolism – Treatment and prevention of recurrent DVT and PE – Prevention of VTE after hip or knee replacement surgery	– Severe renal impairment (CrCl < 30 mL/min) – Active bleeding – Mechanical prosthetic heart valves – Hypersensitivity to dabigatran
Rivaroxaban (Xarelto) – Take with food to improve absorption.	– 20 mg once daily (with food) – 15 mg once daily (for patients with moderate renal impairment)	– Non-valvular AF: Prevention of stroke and systemic embolism – Treatment and prevention of recurrent DVT and PE – Prevention of VTE after hip or knee replacement surgery	– Severe renal impairment (CrCl < 15 mL/min) – Active bleeding – Hepatic disease with coagulopathy and clinically relevant bleeding risk – Hypersensitivity to rivaroxaban
Apixaban (Eliquis) –	– 5 mg twice daily – 2.5 mg twice daily (for patients >80 years, weight <60 kg, or with serum creatinine >1.5 mg/dL)	– Non-valvular AF: Prevention of stroke and systemic embolism – Treatment and prevention of recurrent DVT and PE – Prevention of VTE after hip or knee replacement surgery	– Severe renal impairment (CrCl < 15 mL/min) – Active bleeding – Hepatic disease with coagulopathy and clinically relevant bleeding risk – Hypersensitivity to apixaban
Edoxaban (Lixiana)	– 60 mg once daily – 30 mg once daily (for patients with renal impairment, low body weight <60 kg, or concomitant use of certain P-gp inhibitors)	– Non-valvular AF: Prevention of stroke and systemic embolism – Treatment and prevention of recurrent DVT and PE	– Severe renal impairment (CrCl < 15 mL/min) – Active bleeding – Hepatic disease with coagulopathy and clinically relevant bleeding risk – Hypersensitivity to edoxaban

General Management of NOAC-related Bleeding

1. Minor Bleeding:
   • Local measures: Compression, ice packs.
   • Discontinue NOAC temporarily.
   • Tranexamic acid if appropriate.
2. Major Bleeding:
   • Hospitalization and supportive care.
   • Administration of specific reversal agents if available.
   • Use of aPCC or PCC.
   • Hemodialysis for dabigatran.
   • Fresh frozen plasma (FFP) if needed.

Dabigatran (Direct Thrombin Inhibitor)

• Tranexamic Acid: 1 gram IV followed by 1 gram infusion over 8 hours.
• Activated Prothrombin Complex Concentrate: Factor eight inhibitor bypassing activity.
• Inactivated PCC: Limited effect.
• Hemodialysis: Removes approximately 60% over 2-3 hours.
  • Should be considered early in acute overdose or hemorrhagic complications.
• Antidote: Idarucizumab (Praxbind).

Apixaban and Rivaroxaban (Direct Xa Inhibitors)

• Tranexamic Acid: 1 gram IV followed by 1 gram infusion over 8 hours.
• Inactivated Prothrombin Complex Concentrate: Effective.
• Dialysis: Not feasible due to high protein binding.