Perspectives: Patient Management

David Allen Garcia

David Allen Garcia

MD

  • Professor
  • Division of Hematology
  • University of Washington
  • Seattle, WA USA

Anticoagulants and dosing adjustments

The vitamin K antagonists (VKAs) are very effective anticoagulants when used appropriately. However, there are several challenges associated with their use. For one, the therapeutic index with VKAs is very narrow. When you go below the target range, the thrombosis risk rises dramatically and when you go above it, the bleeding risk increases. The therapeutic index may be wider with newer oral anticoagulants than it is with VKAs. It’s not clear whether that’s due to the more predictable pharmacokinetics, the more predictable pharmacodynamics, or some combination.

In the real world, anticoagulants are given to people who are at extremes of weight, extremes of age, and extremes of renal function. When you start to give the drugs to those sorts of people, I see a benefit to being able to adjust the dose of an oral anticoagulant for specific patients based on comorbidities and other factors. This is important especially in the elderly population, which tends to be the group that has atrial fibrillation and is at risk for stroke; there is a large proportion of them who have decreased renal function. And many of these are appropriate candidates for oral anticoagulation. So, I think it would be beneficial to have efficacy and safety data available regarding particular dosing adjustments for anticoagulants in patients who have renal insufficiency to help clinicians make educated treatment decisions.

Welcome to patient management

Welcome to patient management

Oral anticoagulation should consider individual patient differences and needs

About the Coagulation Center

The Coagulation Center is an educational resource for healthcare professionals. Guided by a global editorial board of experts, the Coagulation Center offers a range of clinical perspectives on balancing the benefit and risk of anticoagulation in a rapidly changing landscape. Within the Coagulation Center you will find roundtable discussions on anticoagulation management, materials for patient management including patient case studies, tools to help evaluate bleeding risk and stroke risk, and downloadable resources for your practice.