Review
Novel oral anticoagulants: What dermatologists need to know

A presentation on novel oral anticoagulants was given by Dr Mostaghimi at the 72nd Annual Meeting of the American Academy of Dermatology in Denver, Colorado on March 22, 2014.
https://doi.org/10.1016/j.jaad.2014.11.013Get rights and content

The development of novel oral anticoagulants provides clinicians and patients a welcome alternative to the challenges of warfarin therapy. Dermatologists must be aware of the potential impact of novel oral anticoagulants on their surgical and medical practice. This review provides a concise summary of the novel oral anticoagulants for dermatologists with particular emphasis on: (1) the pharmacokinetic properties of these drugs and how they differ from warfarin, (2) suggested management during cutaneous surgery, (3) adverse drug interactions with commonly prescribed medications in dermatology, and (4) potential use within dermatology for treatment of disorders of cutaneous thrombosis.

Section snippets

Mechanism and pharmacokinetics

Although warfarin inhibits synthesis of activated vitamin K, the NOACs directly inhibit activated coagulation factors. Dabigatran inhibits thrombin (factor IIa) whereas rivaroxaban and apixaban inhibit factor Xa (Fig 1). Unlike warfarin, these drugs act independently of the vitamin K pathway and are advantageous in that they have predictable pharmacokinetics between individuals and do not require therapeutic monitoring.13 Compared with warfarin, which has a prolonged half-life and delayed peak

Surgical management

The impact of NOACs on patients undergoing dermatologic surgery is currently unknown. Before the late 1990s, anticoagulation therapy was routinely interrupted for cutaneous surgery given the perceived risk of serious bleeding with surgery. However, when the first study to systematically examine the risk of bleeding on warfarin was performed, there was not a significantly increased risk of bleeding in the warfarin group,37 a finding replicated by several subsequent studies.38, 39 In the largest

New oral anticoagulants and thrombotic disorders of the skin

There are many cutaneous manifestations of thrombotic diseases, including purpura, purpura fulminans, livedo reticularis, livedo vasculopathy, and chronic venous ulcers.51 The presence of these signs may reflect an underlying inherited or acquired hypercoagulable state that could potentially be treated by one of the NOACs. In a recent case series, 3 patients with livedoid vasculopathy were treated successfully with rivaroxaban 10 mg once daily without any complications or recurrence of livedoid

Summary

The new oral anticoagulants are an exciting development and have multiple advantages when compared with warfarin. However, they are not perfect; current limitations of these medications include a reduced ability to closely monitor their therapeutic activity and an inability to quickly reverse their activity in the setting of a catastrophic bleed. There are limited data regarding their safety in the perioperative period, but given their similar risk of bleeding relative to warfarin in clinical

References (52)

  • T.E. Warkentin et al.

    Recombinant factor VIIa (rFVIIa) and hemodialysis to manage massive dabigatran-associated postcardiac surgery bleeding

    Blood

    (2012)
  • F. Schiele et al.

    A specific antidote for dabigatran: functional and structural characterization

    Blood

    (2013)
  • J.S. Bordeaux et al.

    Prospective evaluation of dermatologic surgery complications including patients on multiple antiplatelet and anticoagulant medications

    J Am Acad Dermatol

    (2011)
  • O. Kovich et al.

    Thrombotic complications related to discontinuation of warfarin and aspirin therapy perioperatively for cutaneous operation

    J Am Acad Dermatol

    (2003)
  • A.C. Spyropoulos et al.

    How I treat anticoagulated patients undergoing an elective procedure or surgery

    Blood

    (2012)
  • E. Ing et al.

    New oral anticoagulants and oculoplastic surgery

    Can J Ophthalmol

    (2014)
  • K.H. Liesenfeld et al.

    Population pharmacokinetic analysis of the oral thrombin inhibitor dabigatran etexilate in patients with non-valvular atrial fibrillation from the RE-LY trial

    J Thromb Haemost

    (2011)
  • L.A. Thornsberry et al.

    The skin and hypercoagulable states

    J Am Acad Dermatol

    (2013)
  • R.E. Fremont et al.

    Clinical observations on use of warfarin (Coumadin) sodium, a new anticoagulant

    JAMA

    (1957)
  • M. Pirmohamed

    Warfarin: almost 60 years old and still causing problems

    Br J Clin Pharmacol

    (2006)
  • D.N. Juurlink

    Drug interactions with warfarin: what clinicians need to know

    CMAJ

    (2007)
  • W.L. Baker et al.

    Meta-analysis to assess the quality of warfarin control in atrial fibrillation patients in the United States

    J Manag Care Pharm

    (2009)
  • N. Oake et al.

    Frequency of adverse events in patients with poor anticoagulation: a meta-analysis

    CMAJ

    (2007)
  • E. Kargi et al.

    Complications of minor cutaneous surgery in patients under anticoagulant treatment

    Aesthetic Plast Surg

    (2002)
  • P.M. Mannucci et al.

    Old and new anticoagulant drugs: a minireview

    Ann Med

    (2011)
  • S.J. Connolly et al.

    Dabigatran versus warfarin in patients with atrial fibrillation

    N Engl J Med

    (2009)

    • Cited by (0)

    Funding sources: None.

    Conflicts of interest: None declared.

    View full text
    Copyright © 2014 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.