Review of Direct Oral Anticoagulants and Guide for Effective Drug Utilization

Tigran Khachatryan; Christopher Hauschild; Jason Hoff; Tahmeed Contractor; Arthur Khachatryan; Huyentran Tran; Bert Matsuo; Alan Jacobson; Anthony Hilliard


Am J Cardiovasc Drugs. 2019;19(6):525-539. 

In This Article


The DOACs provide a viable alternative to warfarin for anticoagulation. These medications are generally at least as efficacious and safe as warfarin, and apixaban and edoxaban have been found to be superior. Their predictable pharmacology, less variable anticoagulant effect, and fewer drug–food interactions compared with warfarin have enabled the convenience of fixed dosing without the need for monitoring.

An important limitation of DOACs is that, unlike warfarin, all but apixaban are not approved for patients with end-stage renal disease receiving hemodialysis, as these patients have been excluded from the major trials. Furthermore, DOACs have either not been studied in, or in the case of dabigatran, have shown worse outcomes in, patients with mechanical heart valves, in which setting warfarin remains the mainstay treatment.[30,34] In addition, DOACs should be used with caution in patients receiving CYP- and/or P-gp-inducing or -inhibiting medications as most are metabolized via these pathways. Thus, this review serves as a guide for the selection of DOACs in clinical practice, providing an overview of the mechanism of action of each currently FDA-approved DOAC and their indications and limitations, to aid in effective drug utilization and patient management.