Novel Anticoagulant Use for Venous Thromboembolism: A 2013 Update

Many pharmacologic options are available for prevention and treatment of venous thromboembolism (VTE). The anticoagulant selected may vary according the individual patient situation such as the acute versus chronic setting, renal function and indication for either VTE prevention or treatment. Established methods of pharmacologic prophylaxis agents include heparinoids, injectable anti-Xa inhibition and vitamin K antagonists (VKA). The novel anticoagulants have recently been incorporated into orthopedic surgery prophylaxis pathways and can be used for VTE treatment. Chronic VTE management, however, has largely been managed with the use VKA. The advantages of VKA include low cost, familiarity with use, and established protocols to manage catastrophic bleeding. VKA use, however, poses hurdles including the fact that correct dosing can be empiric, the existence of multiple potential medication and dietary interactions, and the possiblity for complications when anticoagulation levels are not well monitored. In contrast, the novel anticoagulants offer ease of dosing, reliable pharmacokinetics and low risk of interactions with other medications or diet. Potential hazards of the novel anticoagulants include high costs, questionable therapeutic benefit in those with poor adherence, a reliance on renal clearance, lack of reliable reversibility in the event of catastrophic bleeding, as well as incomplete familiarity with use by the general practitioner. Although clinical trials demonstrate promise of greater applicability of use of these novel agents, hospital systems will need to simultaneously create a plan for appropriate management of the use of these agents, an anticoagulation stewardship program. As guidelines are adopted to prevent and manage VTE, an appreciation for this new level of complexity is essential.