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Health care delivery, economics and global health care
Review
Direct oral anticoagulants versus warfarin: is new always better than the old?
  1. John Burn1 and
  2. Munir Pirmohamed2
  1. 1Institute of Genetic Medicine, Newcastle Univerisity, Centre for Life, Newcastle upon Tyne, UK
  2. 2Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
  1. Correspondence to Dr John Burn; john.burn{at}newcastle.ac.uk

Abstract

About 1.4 British million people are at risk of strokes due to non-valvular atrial fibrillation (AF) necessitating long-term anticoagulation. The vitamin K antagonist, warfarin, has a long half-life and narrow therapeutic range necessitating regular monitoring and is a common cause of iatrogenic hospital admission. Direct-acting oral anticoagulants (DOACs), dabigatran, rivaroxaban, apixaban and edoxaban are not required to have monitoring but are sensitive to changes in renal function and are associated with poorer adherence. There are good grounds to believe that DOACs are not always superior to warfarin in routine practice particularly with an older population. Much higher levels of therapeutic effectiveness can be achieved using a simple genotype guidance to identify those who are highly sensitive and by adoption of home monitoring. These adjustments could make warfarin the preferred drug for most people and would reduce the dramatic rise in health service expenditure.

  • stroke
  • warfarin
  • anticoagulants
  • atrial fibrillation

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http://creativecommons.org/licenses/by/4.0/

https://doi.org/10.1136/openhrt-2017-000712

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    Footnotes

    • Funding No external funding was needed apart from the analysis of anticoagulant adherence. This was commissioned by Roche Diagnostics and donated to the authors for inclusion, with the knowledge of the original analysts.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement No additional data are available.

    • Collaborators Harsh Sheth.

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