Management of New Anticoagulants in the ICU

The development of novel anticoagulant drugs, namely factor Xa and factor IIa inhibitors, has proceeded at a remarkable pace over the past 15 years. Because of their ease of administration, predictable pharmacokinetics and pharmacodynamics, and relatively rapid onset and offset, they have begun to supplant warfarin, heparin, and low-molecular-weight heparin in many clinical settings. Unfortunately, their development and usage has far outpaced innovations in monitoring modalities and reversal agents leaving the intensivist with a paucity of tools for managing these drugs and their effects in the acute setting. This article will review four new anticoagulants: fondaparinux, rivaroxaban, argatroban, and dabigatran. For each drug, we will describe the mechanism of action, basic pharmacokinetics, current usages, monitoring techniques, and reversal mechanisms.