Appropriate use of NOAC in patient with major bleeding risk

Risk of stroke to rise when controlling dose without referring to evidences

When unavoidably controlling dose, the choice of drug is gravely important

Images of NOAC products released in Korean market

As the prescription cases of new oral anti-coagulant (NOAC) have been accumulating, the prescribers are paying a closer attention on adequately prescribing for patients with high risk of bleeding.

 

HAS-BLED score, the most well known scoring system for measuring major bleeding risk, indicates patients scoring over three are equivalent to tripling the major bleeding risk of patients scoring zero to one.

 

Especially because the ratio of patients with atrial fibrillation scoring HAS-BLED over three has been rising constantly, the bleeding control during an anti-coagulant treatment became a significant factor.

 

Data on patients with atrial fibrillation in Korea shows the ratio of elderly patients aged over 80 is noticeably growing.

 

And the risk of major bleeding has heightened even more as the ratio of patients with other underlying diseases like hypertension, diabetes and heart failure is increasing sharply.

 

A study found patients who scored over three in HAS-BLED took approximately 40 percent of total patients who have been diagnosed with atrial fibrillation in 2006, but the figure rose up to 60 percent in 2015.

 

The average score also climbed from 2.07 in 2006 to 2.75 in 2015.

 

Considering various factors, atrial fibrillation patient with high risk of bleeding has to use controlled dose of NOAC according to the guideline.

 

Patients showing creatinine clearance (CrCl) of less than 50 mL/ min would be prescribed with Xarelto (rivaroxaban) 15 mg (low-dose).

 

And Eliquis (apixaban) and Lixiana (edoxaban) would be prescribed in 2.5 mg and 30 mg doses, respectively, depending on body weight and age as well as the patients’ renal function.

 

Professor Kim Namho of internal medicine department at Wonkwang University Hospital commented, “An elderly female patient aged about 80 and underweight at around 40 kg would be considered high risk when treating anti-coagulation.

 

But a patient manifesting CrCl of over 50 mL/ min or at the borderline, prescribing the indicated dose may not be advisable.

 

And cases of using low-dose NOAC have been reported in one out of two atrial fibrillation patients.” The professor added, “If the dose control is inevitably needed for the patients’ condition, basing it on evidences collected so far would be crucial.

 

As real world data on Korean patients have been accumulated, the prescribers should refer to the evidences accordingly when prescribing the right drug in right dose.” Meanwhile, the renal function may start to fail irreversibly depending on the age or heart function of the patient.

 

As the renal function heavily affects bleeding, the next issue to be addressed and explored would be which NOAC to use in atrial fibrillation patient with expected failure or already low renal function.