Clinical implications, benefits and pitfalls of using and reversing non-vitamin K antagonist oral anticoagulants

INTRODUCTION: The use of non-Vitamin K antagonist oral anticoagulant (NOAC) drugs is increasingly common in clinical practice. As compared to vitamin K antagonists they are more straightforward to initiate, require no hematological monitoring and offer potentially more stable therapeutic indices. Concern has been raised with regard to their safety profiles particularly in the context of acute reversal in major bleeding. Further issues pertain to patient concordance. Areas covered: This review article aims to provide an overview of the current evidence relating to NOAC safety as well as the management of NOAC-related major bleeding with particular emphasis on reversal agents in use and in development following a selective literature review. Second, the effects of medication concordance and dosing regimens on NOAC efficacy will be considered. Expert commentary: The short half-lives and low overall bleeding risk of NOACs is likely to mean that specific reversal agents in development are infrequently required and costly with associated practicality issues with their use in clinical emergencies. Concern regarding patient concordance can be practicably addressed with appropriate medication, dosing regimen and patient selection and continuous education with active, informed patient involvement in the decision-making process.