Shalyn Quigley, PharmD; PGY1 General Practice Resident, Millcreek Community Hospital in Erie, PA
When hemostatic balance is interrupted by stasis, stress, or hypercoagulabilty, patients are at
risk for venous or arterial thrombosis that may require medical prophylaxis or treatment. In the low
shear venous system, thrombi are composed of red blood cells trapped by fibrin and manifest
clinically as deep vein thrombosis (DVT). DVTs can cause post-thrombotic syndrome (PTS) or travel to
the lungs where they become lodged and present as pulmonary embolism (PE). PEs may be one of many
causes of chronic pulmonary hypertension and are known together with DVTs as venous thromboembolism
(VTE). In the high shear arterial circulation, thrombi are primarily platelet aggregates that impede
adequate blood flow and may result in myocardial infarction (MI), ischemic stroke, or limb
If the endothelium of
a blood vessel is damaged (e.g. by a cholesterol plaque), the intrinsic coagulation pathway is
activated to repair the vessel. This trauma also causes the release of tissue factor, which is
responsible for activation of the extrinsic pathway. These two pathways utilize different clotting
factors to reach a common pathway where factor Xa converts prothrombin into thrombin, which
transforms fibrinogen into fibrin.1 Fibrin is
responsible for platelet aggregation which binds platelets together at their GPIIb-IIIa receptors.
These receptors are exposed by platelet activation when thrombin binds to the platelet’s
protease-activated receptors (PARs) or adenosine diphosphate (ADP) binds to P2Y12 receptors. To keep
the clot in place, von Willebrand factor is produced by the damaged vessel and facilitates platelet
Both coagulation and
platelet aggregation are involved in thrombosis; therefore risk factors for various thrombotic
events are evaluated and anticoagulant or antiplatelet agents are prescribed. Warfarin, heparin,
heparin derivatives, aspirin, and clopidogrel have been successful in treating and preventing these
types of events but are limited in their dosage forms, need for monitoring, and efficacy in certain
patient populations. Patients who require rapid reversal of bleeding (i.e. trauma or emergent
surgery), have a genetic predisposition to clopidogrel resistance, or indications for triple
antithrombotic therapy will benefit from new options. Five oral antithrombotic agents (Table 1) have
earned FDA-approval over the past four years. Prasugrel, dabigatran, rivaroxaban, ticagrelor, and
apixaban each offer a unique pharmacologic profile.1 Anticoagulation previously gained versatility with the introduction
of subcutaneous injections; patients could use the medications at home to treat and prevent embolic
events. The low molecular weight heparin enoxaparin has proven efficacy but can still increase a
patient’s risk for heparin-induced thrombocytopenia and fondaparinux, the original factor Xa
inhibitor, is limited by its subcutaneuous route of administration.
approved in 2010 for thrombus prevention in patients with nonvalvular atrial fibrillation (AF). The
first approved oral anticoagulant since warfarin, the direct thrombin inhibitor demonstrated
non-inferiority to warfarin for prevention of stroke and systemic embolism in patients with AF.
Patients included in the approval trial scored a mean 2.1 on the CHADS2 scale for stroke risk in AF
and the warfarin group was within therapeutic range for 64% of the trial. Dyspepsia was reported in
35% of the dabigatran group (24% warfarin group), possibly due to its tartaric acid core.5,9 The pharmacokinetics observed in this trial
allowed for extrapolation of dosing recommendations in patients with severe renal impairment (CrCl
15-30 mL/min). Another trial evaluated patients with AF and mechanical heart valves. Results
indicated an increased risk of thromboembolism and major bleeding with dabigatran when compared to
warfarin.5 Post-marketing reports to the FDA
have demonstrated higher rates of gastrointestinal bleeding and intracranial hemorrhage than had
been identified in clinical trials.10
Rivaroxaban, an oral factor Xa inhibitor, was originally approved with the sole indication
of prevention of VTE in orthopedic surgery patients. Since, it has gained FDA approval for VTE
treatment, recurrent VTE prevention, and stroke and systemic embolism prevention in nonvalvular
atrial fibrillation (AF). The ROCKET AF trial compared the risk of stroke in patients with AF
treated with rivaroxaban or warfarin; patients had a mean CHADS2 score of 3.5 and the warfarin group
was within therapeutic range 55% of the trial. Use is not recommended in patients with creatinine
clearance below 15 mL/min.5
of the next factor Xa inhibitor apixaban introduced a unique claim: superiority to warfarin in
stroke and systemic embolism prevention in nonvalvular AF. The patients in the ARISTOTLE trial
(comparing apixaban to warfarin) had a mean CHADS2 score of 2.1 and the warfarin group was within
the therapeutic range 62% of the trial. Limitations to this option include twice daily dosing and
adjustments for weight (<60 kg) renal function (SCr>1.5), and age (>80 years).4
The new antiplatelet agent prasugrel was
shown to be superior to clopidogrel in reducing cardiovascular (CV) events in patients with acute
coronary syndrome (ACS) managed with percutaneous coronary intervention (PCI). Prasugrel is
contraindicated in patients with a history of transient ischemic attack (TIA) due to an increased
risk of intracranial bleeding. As a result of prasugrel’s irreversible platelet inhibition and
the 7-10 day lifespan of a platelet, prasugrel should be discontinued at least 7 days prior to a
surgical procedure (ex. coronary artery bypass grafting).6
Patients with ACS can also take ticagrelor to reduce
their risk of thrombotic CV events. Results of the PLATO trial indicate that ticagrelor is superior
to clopidogrel in the reduction of stent thrombosis. Patients undergoing surgery should discontinue
ticagrelor therapy at least 5 days prior to the procedure.7 Unlike clopidogrel, neither prasugrel nor ticagrelor rely on CYP2C19
activation of the drug and therefore present viable options for patients exhibiting clopidogrel
resistance secondary to CYP2C19 slow metabolizer phenotypes.6-7
Although these agents are becoming commonly
prescribed, none have the long-term safety or efficacy data of warfarin, heparin, aspirin, or
clopidogrel. Therefore, they are still relatively unpredictable and have no complete antidotes for
reversal in the case of bleeding. The ideal antithrombotic agent would be pharmacodynamically
predictable, potent, low in price, and easy to administer. It would also have a rapid onset and
offset of action,8 such as is being
investigated with the intravenous antiplatelet agent cangrelor.1 While further research is being conducted, we can utilize these new
oral agents in the specific populations they have been studied without the nuisance of
1. Weitz JI, Eikelboom JW, Samama MM. New antithrombotic drugs:
Antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians
evidence-based clinical practice guidelines. Chest. 2012; 141(2_suppl):e120S–e151S.
2. Eikelboom JW,
Hirsh J, Spencer FA, Baglin TP, Weitz JI. Antiplatelet drugs: Antithrombotic therapy and prevention
of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical
practice guidelines. Chest. 2012; 141(2_suppl):e89S-e119S.
3. Xarelto [package insert]. Janssen
Pharmaceuticals, Inc. Titusville, NJ. 2011.
4. Eliquis [package insert].
Bristol-Myers Squibb Company. Princeton, NJ. 2013.
5. Pradaxa [package insert]. Boehringer
Ingelheim Pharmaceuticals, Inc. Ridgefield, CT. 2013.
6. Effient [package insert]. Eli Lilly
and Company. Indianapolis, IN. 2012.
7. Brilinta [package insert].
AstraZeneca LP. Wilmington, DE. 2013.
8. Cattaneo M. Update on antithrombotic
therapy: new P2Y12 inhibitors. Circulation.
2010;121:171-179. doi: 10.1161/CIRCULATIONAHA.109.853069.
9. Hankey GJ, Eikelboom JW. Dabigatran
etexilate: a new oral thrombin inhibitor. Circulation.
2011;123:1436-1450. doi: 10.1161/CIRCULATIONAHA.110.004424.
10. U.S. Food and Drug
Administration. FDA drug safety communication: update on the risk for serious bleeding events with
the anticoagulant Pradaxa (dabigatran). Drug safety and availability. Available from:
http://www.fda.gov/Drugs/DrugSafety/ucm282724.htm. Published November 2, 2012. Accessed January 20,