Integrating Novel Oral Anticoagulants Into Clinical Practice

Samuel Z. Goldhaber, MD; Seth Bilazarian, MD


January 09, 2014

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ENGAGE-AF, Another NOAC on the Block

Samuel Z. Goldhaber, MD: Hello. This is Dr. Sam Goldhaber, for on Medscape. I am here with Dr. Seth Bilazarian, a good friend and colleague who also writes many columns for on Medscape.

We are going to talk about the ENGAGE-AF trial[1] with edoxaban and how this fits into our multitude of choices for stroke prevention in atrial fibrillation (AF). Seth, you were an investigator in ENGAGE.

Seth Bilazarian, MD: I was, yes.

Dr. Goldhaber: Could you tell us about the bottom line of the ENGAGE trial -- the largest trial ever of stroke prevention in AF?

Dr. Bilazarian: The fourth novel oral anticoagulant (NOAC) was just presented. We just heard the data. Two doses of edoxaban were tested: a 30-mg dose and a 60-mg dose. The 60-mg dose was found to be noninferior for efficacy and superior for safety. So, we now have a fourth NOAC. I was excited to have a conversation with you about how we should integrate this. (Editor's Note: Edoxaban is investigational at this time; dabigatran, rivaroxaban, and apixaban are approved by the US Food and Drug Administration.)

It's funny that we are still calling them NOACs, now that we have had dabigatran for more than 3 years. Here at the meetings, there is a lot of enthusiasm and discussion about NOACs. Is this the end of warfarin now that we will have a fourth drug? I don't know the answer to that, but I'm interested in having a conversation with you about it.

It appears to me that these data are very strong, although unlike the apixaban data, we did not see a mortality benefit. That may be a slight marketing edge for that drug over the other NOACs.[2,3,4] However, these drugs all are as good as or better than warfarin. All seem to be superior with respect to safety, particularly for intracranial hemorrhage, which is a dreaded complication of anticoagulation.


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