Choosing an Anticoagulant for Afib

Sarah Spinler, PharmD, professor of clinical pharmacy at the Philadelphia College of Pharmacy, explains why some patients with atrial fibrillation should be prescribed a new oral anticoagulant (NOAC) instead of warfarin.

As the mainstay atrial fibrillation treatment, warfarin has proven to be a highly effective therapy, but it does have several limitations, including dietary effects, drug-drug interactions, and a need for regular international normalized ratio (INR) monitoring.

Patients with well-managed warfarin may not see a big benefit when switching to a NOAC, Dr. Spinler notes. However, patients with nonvalvular atrial fibrillation (NVAF) who are unable to maintain a therapeutic INR level with warfarin should be prescribed a direct thrombin or factor Xa inhibitor, such as dabigatran, apixaban, and rivaroxaban, Dr. Spinler recommends.

Reduced doses of direct thrombin or factor Xa inhibitors may also be appropriate for patients with NVAF and moderate to severe chronic kidney disease with CHA2DS2-VASc scores of 2 or greater.

NOACs also tend to require fewer dosing changes, Dr. Spinler notes.