Management of Non-Vitamin K Antagonist Oral Anticoagulants in the Perioperative Setting

Table 2

Summary of the main studies leading to approved indications of NOACs.

Clinical context	NOAC	Other anticoagulant	Conclusion (NOACs versus other drugs)
VTE^0 prophylaxis after orthopedic surgery
RE-MODEL	Dabigatran etexilate 150 or 220 mg OD	Enoxaparin 40 mg OD SC^5	Same efficacy and safety profile after TKR^1
RE-NOVATE II	Dabigatran etexilate 220 mg OD	Enoxaparin 40 mg OD SC	Same profile in term of safety and bleeding after THR^2
RECORD	Rivaroxaban 10 mg OD	Enoxaparin 40 mg OD SC	More effective, without increasing major bleeding after THR/TKR
ADVANCE II	Apixaban 2.5 mg BID	Enoxaparin 40 mg OD SC	More effective without increased bleeding after TKR
ADVANCE III	Apixaban 2.5 mg BID	Enoxaparin 40 mg OD SC	Lower rate of VTE without increased bleeding after THR
Non-valvular atrial fibrillation
RE-LY^3	Dabigatran etexilate 110 mg or 150 mg BID	Adjusted dose warfarin (INR 2-3)	Efficacy superior for the prevention of stoke with a similar rate of major bleeding
ROCKET-AF^4	Rivaroxaban daily dose 20 mg	Adjusted dose warfarin	Non-inferiority, no significant difference in term of bleeding
ARISTOTLE	Apixaban 5 mg BID	Adjusted dose warfarin (INR 2-3)	Superior in preventing stroke or systemic embolism, less bleeding and lower mortality
VTE Treatment
RE-COVER II	Dabigatran etexilate 150 mg BID after 5–11 days of LMWH^6 or UFH^7	Warfarin	Similar effect on VTE recurrence, lower risk of bleeding for the treatment of acute VTE
EINSTEIN	Rivaroxaban 15 mg BID for 3 weeks following by 20 mg OD	Enoxaparin SC following by vitamin K antagonist	Simple, single drug approach. Improve benefit-to-risk of anticoagulation
Acute coronary syndrome
ATLAS ACS	Rivaroxaban 2.5 BID	Placebo	Reduced the composite endpoint of death from cardiovascular causes, myocardial infarction or stroke. No increase of fatal bleeding.

VTE: venous thromboembolism, ¹TKR: total knee replacement, ²THR: total hip replacement, ³RE-LY: Randomized Evaluation of Long-Term Anticoagulation therapy, ⁴ROCKET-AF: Rivaroxaban Once Daily Oral, Direct factor Xa Inhibition Compared with Vitamin K antagonism for Prevention of Stroke and Embolism in Atrial Fibrillation, ⁵SC: Subcutaneously, ⁶LMWH: low molecular weight heparin, ⁷UFH: unfractionated heparin.