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Who May Benefit from Direct Oral Anticoagulant Level Monitoring? A Systematic Literature Review

1OLVG, Laboratory of Hematology and Clinical Chemistry, Amsterdam, the Netherlands, 2Maastricht UMC, Central Diagnostic Laboratory, Units for Hemostasis and Transfusion, Maastricht, the Netherlands, 3Amsterdam UMC, University of Amsterdam, Department of Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam, the Netherlands, 4Amsterdam UMC, University of Amsterdam, Department of Clinical Chemistry, Amsterdam, the Netherlands

Abstract Number: PB0647

Meeting: ISTH 2020 Congress

Theme: Diagnostics and OMICs » Laboratory Diagnostics

Background: Direct oral anticoagulants (DOACs) are frequently used due to their rapid action, fixed dosing schedule and limited interactions. The question for which patients DOAC level monitoring might be beneficial, is still unanswered.

Aims: We performed a literature search to evaluate whether DOAC monitoring of at risk patients could be beneficial in comparison to no monitoring at all.

Methods: We systematically searched the Pubmed and Medline databases for DOAC studies (Dabigatran, Edoxaban, Rivaroxaban, Apixaban or Betrixaban) in combination with at risk patients suffering from bleeding or thrombotic complications published in the past 5 years. Relatively new literature was searched as discussion about monitoring patients under DOACs due to bleeding or thrombotic adverse events only started recently. The patient groups were selected based on indication of DOAC use (i.e. atrial fibrillation/venous thromboembolism) and other possible vulnerable groups of anticoagulant users. Special attention was given to DOAC monitoring studies.

Results: From 474 studies, 50 met the inclusion criteria (only 5 showed data on monitoring). Different characteristics were identified:

  • Population demographics: body mass index(10%), age(10%)
  • Specific clinical conditions: chronic kidney disease(10%), liver disease(4%), pregnancy(2%), atrial fibrillation(28%), cancer(10%) or venous thromboembolism(4%)
  • High risk interventions: before surgery(4%) or admission to an emergency room(2%)

Recommendations which might be of practical value were extracted from 8 studies (16%) :

  • Monitor renal function using the Cockroft-Gault formula every 3-6 months depending on degree of renal failure (chronic kidney disease study).
  • Measure DOAC level once within the first 3 months after therapy has started (non-valvular atrial fibrillation study).
  • Routine monitoring without an indication did not show beneficial effects (monitoring study).

Conclusions: There is limited evidence to properly answer whether active monitoring of DOAC levels in at risk patients would result in less thrombotic or bleeding complications.

To cite this abstract in AMA style:

Vicente-Steijn R, Henskens YMC, Coppens M, Middeldorp S, Stroobants AK. Who May Benefit from Direct Oral Anticoagulant Level Monitoring? A Systematic Literature Review [abstract]. Res Pract Thromb Haemost. 2020; 4 (Suppl 1). https://abstracts.isth.org/abstract/who-may-benefit-from-direct-oral-anticoagulant-level-monitoring-a-systematic-literature-review/. Accessed October 1, 2023.

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