Pall T. Onundarson: DOACs – Monitoring, Tailoring Dose and Identifying Problems
Pall T. Onundarson, Professor Emeritus of Hematology at University of Iceland, shared a post on LinkedIn:
“DOACs can be measured and monitored. Yet, in clinical practice, they rarely are.
At Landspitali, we have had DOAC assays available 24/7 for the past 10 years, but clinicians request them almost exclusively in emergencies but not to monitor therapeutic effect. ‘No monitoring needed’ it is claimed.
I feel DOACs should be monitored occasionally for the benefit of patients. Their pharmacokinetics mean they do not require the frequent monitoring needed with VKAs.
But why not identify patients who consistently achieve appropriate drug levels?
And why not offer those whose levels are persistently too high or too low an alternative: a tailored-dose anticoagulant such as warfarin?
I am old enough to remember when the old generation of ‘clotters’ lined up and warned at professional meetings against the one-dose-fits-all strategy. Many are gone now, and in the enthusiasm that followed the DOAC trials, their concerns were largely forgotten. Now, those concerns are resurfacing.
In my view, DOAC levels should be measured periodically; perhaps once or twice a year, when new drugs are prescribed that could interact or if the patient´s condition changes, e.g. heart failure.
DOAC-patients are hopefully having their renal function checked anyway. When levels are unexpectedly high or low, we should ask why and recognize that some patients may benefit from switching to a VKA, where treatment can be individually tailored.”
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