EHRA Practical Guide to NOACs available free
The second update of the original European Heart Rhythm Association (EHRA) practical guide on the use of the new oral anticoagulants (NOACs) in patients with atrial fibrillation provides primary care a useful document to use in every day practice. Nigel Rowell, a member of the ESC Scientific Document Group that drafted the latest guide, provides some background on the development of the latest update.
The updated EHRA guide provides GPs with specific practical advice on a range of issues on the NOACs including patient eligibility, start up, adherence, switching and many others. Although we have entered an era of safer and more effective stroke prevention with NOACs, health professionals always feel responsible when a bleed occurs on an anticoagulant and this guide will minimise that risk.
The intention of the new EHRA guide is to make it as practical as possible. As well as updating all sections of the guide, there is a new chapter on frailty.
One of the great successes of the introduction of these drugs has been the platform with which to spread the whole anticoagulation message. As anticoagulation rates continue to rise (now exceeding 73% in the UK), it was clear from the pattern of emergency admissions, particularly with AKI, that guidance on NOACs would find a useful place in management of atrial fibrillation for all physicians whether they are GPs, haematologists, cardiologists, stroke physicians or many of the other professionals who come across this common condition.
I was asked to head up the chapter on initial start-up and management and my contribution was edited by Lien Desteghe from Hasselt University in Belgium. The timeline was fairly tight – to have an initial draft within 6 weeks for review and editing, with the final work complete by February and publication in March 2018.
One feature of the use of NOACS has been relative underdosing. For instance, low dose apixaban (2.5 mg bd) represented only 4% of the population in the landmark ARISTOTLE trial,1 but roughly 35% of the current UK prescribing of apixaban is at this lower dose according to the GARFIELD Registry data.2 Yao et al.3 have shown is that if you do not use the dose in the trials, you do not get the stroke prevention that was seen in the trials. And neither does the lower dose reduce GI bleeding as presumably the prescriber was hoping. I have termed under-dosing of NOACs “The New Aspirin” and hope that this trend will reverse over time as confidence increases with what are safer and equally effective drugs compared to warfarin.
One of the discussion points as the guide was developed was whether to change the term NOAC (novel oral anticoagulant) to DOAC (direct oral anticoagulant). My view here prevailed as the last thing GPs like is constantly changing the abbreviations and terms for things (I have still not forgiven the change to furosemide!).
The guide follows on from EHRA guidance that NOACs should be used in preference to vitamin K antagonists as the side-effect and mortality data is advantageous especially with regard to intracranial haemorrhage.4 However, caution is needed in renal impairment when the SPC should be adhered to.
Key practice points for NOACs
- Granger C, Alexander J, McMurray J, et al. Apixaban versus warfarin in patients with atrial fibrillation. New Engl J Med 2011;365:981-992.
- GARFIELD registry at www. garfieldregistry.org
- Yao X, Shah ND, Sangaralingham LR, et al. Non-vitamin K antagonist oral anticoagulant dosing in patients with atrial fibrillation and renal dysfunction. J Am Coll Cardiol2017;69(23):2779-2790.
- Ruff CT, Giuglano RP, Braunwald E, et al. Comparison of the efficacy and safety of new oral anticoagulants with warfarin in patients with atrial fibrillation: a meta-analysis of randomised trials. Lancet2014;383(9921):955-62.
Steffel J, et al. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J 2018;39(16):1330-93. https://academic.oup.com/eurheartj/article/39/16/1330/4942493