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Advantages and disadvantages of oral anticoagulants (warfarin versus direct oral anticoagulants*)

Advantages and disadvantages of oral anticoagulants (warfarin versus direct oral anticoagulants*)
  Warfarin Direct oral anticoagulants*
Dosing

Once-daily dosing may be more convenient.

Anticoagulant intensity may be titrated if needed for patients who require a higher INR.		 May require more frequent dosing.
Dietary restrictions Need to ensure relatively constant level of vitamin K intake. None. Rivaroxaban doses ≥15 mg should be taken with food.
Monitoring therapy PT/INR monitoring is required, which entails regular visits to a facility for most patients (point-of-care devices may be an option for some). Not required; however, nonadherence will not be as readily apparent. It may be reasonable to obtain drug levels in some settings (eg, altered gastrointestinal anatomy) to ensure that the drug is being absorbed.
Drug interactions Many. Rivaroxaban and apixaban interact with CYP-3A4 and P-glycoprotein inhibitors or inducers; edoxaban and dabigatran interact with P-glycoprotein inducers or inhibitors.
Time in therapeutic range Approximately 65% based on clinical trials. Expected to be superior to warfarin, although therapeutic ranges have not been established.
Reversal agent(s) Several available (eg, vitamin K, FFP, PCC). For dabigatran: idarucizumab; for direct factor Xa inhibitors: andexanet alfa or PCC. Activated charcoal may be used to remove unabsorbed drug if the last ingestion was recent. Hemodialysis may be used to remove dabigatran from the circulation.
Monitoring drug activity after reversal PT/INR can be used. TT can be used for dabigatran; anti-factor Xa activity can be used for apixaban.
Effect of comorbid conditions May increase fracture risk, especially in individuals with underlying osteoporosis. Kidney function affects pharmacokinetics; dosing unclear in those with obesity.
The factors listed may be considered in making decisions regarding choice of oral anticoagulant, but these must be considered together with clinical information regarding efficacy and toxicity in specific medical conditions. Refer to the UpToDate topic reviews on specific medical conditions for clinical data and expert opinion regarding the choice of oral anticoagulants. Refer to UpToDate topics on warfarin and direct thrombin and factor Xa inhibitors for further details on administration of these agents and management of bleeding associated with their use. Refer to UpToDate tables on drug interactions and the drug interaction program for descriptions of drug interactions with agents described herein.

FFP: fresh frozen plasma; INR: international normalized ratio; PCC: prothrombin complex concentrates; PT: prothrombin time; rFVIIa: recombinant activated factor VII; TT: thrombin time; VTE: venous thromboembolism.

* Direct oral anticoagulants include direct thrombin inhibitors (eg, dabigatran) and direct factor Xa inhibitors (eg, apixaban, edoxaban, rivaroxaban).
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