By Jesse Pines, MD
NOACs, or Novel – or Non-Vitamin-K -- Oral Anti-Coagulants which include apixaban, dabigatran , rivaroxaban, and the most recently approved edoxaban have been on the market now for nearly six years. NOACs are an alternative to warfarin, and are used for the prevention and treatment of thrombosis. This includes stroke prevention in non-valvular atrial fibrillation and treatment for venous thrombo-embolism (VTE) including deep vein thrombosis and pulmonary embolism. As the population ages and the incidence of these conditions rise, it is likely the use NOACs will increase even more in coming years.
However NOACs, similar to warfarin, can cause major bleeding events such as intracranial hemorrhage, bleeding associated with trauma, and gastrointestinal bleeding. Although these events in general tend to occur at lower rates than warfarin, they still can and do occur and emergency physicians need to be prepared to manage them. The problem in NOAC-related bleeding is that it is more difficult to identify the intensity of anticoagulation and many physicians are unfamiliar with ways to manage bleeding, particularly anti-coagulant reversal.
To address this gap in knowledge, the American College of Emergency Physicians (ACEP) has produced a fantastic new webinar, “Clinical Update on NOAC Safety and Reversal”. A link to the website can be found here: http://www.acep.org/noacclinicalupdate/
In the webinar, taught by Dr. Charles V. Pollack, MD, FACEP, FAAEM, the Associate Provost for Innovation in Education and Professor and Senior Advisor for Interdisciplinary Research and Clinical Trials, Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, presents a timely, clinical discussion of recent updates on reversal agents.
The webinar is important for all emergency physicians to watch, and it provides vital information about NOAC safety, and the management of bleeding complications. It provides both a general approach in the ED, and also discusses the use of idarucizumab, the first approved reversal agent, which is useful in the reversal of dabigitran-related bleeding. An interesting podcast series – at total of five -- based off of the “best of” from the Q&A webinar session is also available on the same link.
Dr. Jesse Pines is the Director of the GW Center for Healthcare Innovation and Policy Research (CHIPR) and a Professor of Emergency Medicine and Health Policy at the George Washington University.