What are the advantages and disadvantages of newer oral anticoagulants for treatment of atrial fibrillation (Afib) (AF)?

Updated: Nov 18, 2019
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD  more...
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There are several advantages of using the newer oral anticoagulants over warfarin, including the following:

  • Predictable pharmacologic profiles with fewer drug–drug interactions, and dietary effects

  • Lower risk of intracranial bleeding

  • Rapid onset and offset of action, with no need for bridging with parenteral anticoagulant therapy during initiation or after interruption

  • No need for periodic INR testing

  • Superiority to warfarin for reducing the risk of thromboembolic events with dabigatran 150 mg BID and apixaban

Disadvantages of the newer oral anticoagulants include the following:

  • Requires strict compliance, because missing even a single dose could result in a period without anticoagulation

  • No FDA-approved reversal agents for rivaroxaban, apixaban, and edoxaban (currently under clinical trials) [92, 93]

  • Limited safety profile data for patients with severe kidney failure

  • No data for their use in the presence of mechanical heart valves (dabigatran was associated with increased risk of thromboembolic complications in patients with mechanical heart valves in the RE-ALIGN trial) or valvular AF, due to hemodynamically significant mitral stenosis

  • No data for their use in pregnant or lactating women, in children, or in patients with a recent stroke (≤7-14 days), reversible causes of AF, severe increase in blood pressure, and significant liver disease

  • Lack of reliable blood tests to ascertain therapeutic effect or toxicity

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