New Anticoagulants Promising but Problematic

The introduction of new anticoagulants continues to occur at an accelerating pace. For several decades, surgeons simply needed to have adequate knowledge of heparin and warfarin in order to appropriately take care of patients. Direct thrombin inhibitors (bivalirudin, dabigatran, etc.) and direct Xa inhibitors (rivaroxaban) are being used with increasing frequency. An "adequate" knowledge of anticoagulation must now include these newer agents.

On the one hand, the search for improved anticoagulants has allowed us to overcome several of the shortcomings of warfarin – namely, a more consistent response profile and decreased need for monitoring. On the other, these agents do not yet have the widespread understanding that the old stalwarts do. Every midlevel surgical resident knows how to dose heparin and how to reverse warfarin, but many practicing surgeons have never heard of rivaroxaban or dabigatran until they are forced to operate on a patient who is taking them.

Dr. Ravi Rajani

Furthermore, it is important to remember that these newer anticoagulants have been FDA approved for very specific indications only. We are starting to see off-label use of dabigatran as an end-all substitute for warfarin, without the evidence to really support it as such. Until we have more experience with these agents, their usage should be reserved for approved indications only.

Articles such as this one are invaluable resources for educating surgeons about the newer agents and reminding everyone about their current indications.

Dr. Ravi Rajani is assistant professor of surgery at Emory University and director of vascular and endovascular surgery at Grady Memorial Hospital, both in Atlanta. He said he had no relevant disclosures.