In the United States, there are currently four direct oral anticoagulants (DOACs). All four DOACs are approved for the treatment of venous thromboembolism (VTE) and nonvalvular atrial fibrillation (NVAF), among other indications.1-4 Despite differences in pharmacology, pharmacokinetics, and clinical trial efficacy and safety data, current guidelines do not prefer a specific DOAC. Given the lack of guideline-based recommendations for a particular DOAC, clinicians are frequently left without clear guidance of the most appropriate DOAC for a particular patient beyond the preferences of an insurance company or the availability of manufacturers’ coupons. After a careful analysis of the existing data, a very strong case can be made to make apixaban (Eliquis) the preferred DOAC for both VTE and NVAF.
What is the role of DOACs versus warfarin in VTE and NVAF?
For the treatment of venous thromboembolism (VTE), the CHEST 2016 guidelines recommend any of the four DOACs over warfarin therapy for long-term anticoagulation therapy in patients without cancer (grade 2B).5 The guidelines do not specifically endorse any DOAC, although a table is provided that outlines factors that may influence the selection of a “preferred” anticoagulant. For example, patients wanting to avoid parenteral therapy may prefer rivaroxaban or apixaban because dabigatran and edoxaban require five to ten days of parenteral therapy prior to initiation.
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