By Lynn Malec, MD, MSc, and Janice Staber, MD

Your patient with a new blood clot doesn’t want to give herself shots, and the prospect of frequent lab work is going to be a deal-breaker. A direct oral anticoagulant (DOAC) seems like an obvious choice. But what if the patient is significantly obese? Or underweight? What if other aspects of her medical history make you question if a DOAC is the right choice? You are faced with having to ponder the possible dosing options and choices of medications with little guidance from published data or clinical trials on DOACs. You also wonder about bleeding. If the patient bleeds, exactly how will you treat? Are there any laboratory studies to guide management? An Education Program session chaired by Ravi Sarode, MD, of the UT Southwestern Medical Center offers guidance for clinicians on using “DOACs in the Real World.” This session is being offered twice, on Saturday at 7:30 a.m. and again on Sunday at 4:30 p.m. (W311, Level 3, Orange County Convention Center – map it).

DOACs have transformed the management of thrombotic disorders. Their use is gaining momentum in clinical practice for treatment and prevention of venous thromboembolism (VTE) and is now the preferred treatment in atrial fibrillation to re- duce the risk of stroke. With the rise in prescriptions for DOACs, clinicians face the use of these medications in scenarios not investigated in clinical trials. As a result, they frequently encounter uncertainty regarding the optimal use of DOACs and are left wondering what’s best for their patients. Additionally, there is little published data regarding the management of complications of DOACs to guide clinical practice. During this session, three panelists will dive beyond clinical trial data to discuss the use of DOACs in the context of challenges faced in daily real-world practice.

Wondering how to utilize DOACs for primary and secondary prophylaxis? Beverly Hunt of Guy’s & St Thomas’ NHS Foundation Trust London will address the use of DOACs for prevention of hospital-associated VTE in acutely ill medical patients, patients with cancer, and after joint replacements. She will also discuss the use of low-dose DOACs for primary prevention of arterial thrombosis and secondary prevention of arterial and venous clots.

Wondering how monitoring a DOAC may benefit specific patient populations or clinical scenarios? The allure of a DOAC, as compared to a vitamin K antagonist, includes avoidance of routine medication monitoring. This lack of standard monitoring, however, may be a detriment to understanding VTE events that occur on DOACs or therapeutic dosing at the extremes of weight. Sarode will provide expertise regarding the effect of various DOACs on routine coagulation testing and illustrate the principles of various DOAC-specific assays. He will discuss DOAC levels related to efficacy and estimation of DOACs in major bleeding or when there is a need for emergency surgery, to guide administration of specific reversal or nonspecific hemostatic agents.

Wondering how to best treat a patient with DOAC-related bleeding? Although the rates of major bleeding with DOACs are generally lower compared to other anticoagulants, major bleeding remains the main complication of therapy. Deborah Siegal, MD, of McMaster University will round out the DOACs in the Real World session by discussing the evidence on the management of the dreaded complication of anticoagulant use in bleeding. She will provide current evidence supporting the use of specific DOAC reversal agents and prothrombin complex concentrates for patients with bleeding. Additionally, she will identify areas of uncertainty regarding the benefit and possible harm of reversal and hemostatic strategies.

Dr. Malec and Dr. Staber indicated no relevant conflicts of interest.

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