Newer Anticoagulants: What Do We Call Them and How Do They Work?

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The MD Magazine Peer Exchange “Novel Anticoagulation Options: Target-Specific Oral Agents and Their Antidotes” features leading physician specialists discussing key topics in anticoagulation therapy, including the clinical characteristics of current and emerging agents and criteria for use in specific patient populations.

This Peer Exchange is moderated by Peter Salgo, MD, professor of medicine and anesthesiology at Columbia University and an associate director of surgical intensive care at the New York-Presbyterian Hospital in New York City.

The panelists are:

• Scott Kaatz, DO, MSc, Chief Quality Officer at Hurley Medical Center in Flint, Michigan, and clinical associate professor at Michigan State University
• Seth Bilazarian, MD, clinical and interventional cardiologist at Pentucket Medical and instructor of medicine at Harvard Medical School
• Gerald Naccarelli, MD, Bernard Trabin Chair in Cardiology, professor of medicine and chief of the Division of Cardiology at Penn State University School of Medicine, and associate clinical director at Penn State Heart and Vascular Institute in Hershey, Pennsylvania
• Christian T. Ruff, MD, associate physician in the cardiovascular medicine division at Brigham and Women’s Hospital, and assistant professor of medicine at Harvard Medical School in Boston

In this segment of the Peer Exchange, the panelists discuss the nomenclature and terminology used to describe the new class of oral anticoagulants. They also talk about the specific mechanisms of action of some of the newer agents and whether that should be a factor when selecting a medication.

Salgo starts the segment by asking the question, “What is the preferred term when we talk about these agents, is it novel oral anticoagulant, direct oral anticoagulant? Is it something else?”

Bilazarian says that’s an interesting question, due to the lack of a naming convention in medicine for many things (except for generic drugs). Even the term “novel” (as part of the phrase novel oral anticogaulants, or NOAC, which seems to be widely used to describe this class of drugs) may be inappropriate to use as a label the farther out from approval we go. “Maybe we’re at that point now. We’re four years out since the first NOAC, so this is becoming an inappropriate term. I think the term ‘novel’ may also be an impediment to use because there are some patients and physicians who are unwilling to be early adopters,’ he says.

Bilazarian says he prefers to use either “direct oral anticoagulant” or” target-specific oral anticoagulant” as descriptive terms for this drug class.

“My favorite was specific oral direct anticoagulant, because that comes out to be SODA,” says Kaatz.

Moving on to discuss how these anticoagulant drugs work, Bilazarian notes they block specific targets in the coagulation cascade. Three of the four block the factor X and one blocks factor II, its direct thrombin inhibitor.

Salgo asks, “If they’re all attacking different parts of this cascade, how do clinicians should determine which patient gets which agent?”

Ruff says he does not think the mechanism of action is an important factor in choosing the agent. Although there may be differences between the agents or doses (based on the data from the trials), “I don’t think that anybody should select an agent based on whether this one inhibits thrombin or that one inhibits factor Xa. These agents are much more similar to each other than warfarin. So I think they are a class in that we can think about them in the same way and then we can pick a specific one of these four for an individual patient based on the efficacy and safety data, but not the mechanism of action,” he says.