Is there still room for warfarin after the appearance of direct oral anticoagulants?

Abstract

After the appearance of direct oral anticoagulants (DOAC), the use of vitamin K antagonists (VKA) has become more rare, but nevertheless, there are diseases in which they remain indispensable drugs. This review is devoted to VKA and the diseases in which these drugs can be used. The article compares the mechanism of action of VKA and DOAC, discusses methods of monitoring VKA therapy. Among the diseases of non-alternative use of VKA, mechanical prosthetic heart valves, atrial fibrillation in patients with moderate and severe mitral stenosis, antiphospholipid syndrome should be mentioned. Another indication for the appointment of anticoagulants is thrombosis of the left ventricle. In patients who have survived a myocardial infarction complicated by left ventricular thrombosis, anticoagulant treatment should be continued for up to 6 months with repeated imaging control. For this purpose, warfarin is successfully used. Currently, there is insufficient data to recommend the routine use of DOAC in patients with KrCl less than 25–30 ml/min, and in routine practice, warfarin remains the main anticoagulant in such patients. Direct oral anticoagulants have practically not been studied in the so-called special groups of patients: patients with congenital thrombophilia and rare localizations of thrombosis. There were practically no such patients in randomized trials and very little is known about the effectiveness of DOAC, so today warfarin remains the main drug for their treatment. Despite the fact that DOAC has displaced VKA in patients with non-valvular AF, we should not forget that it is VKA that we are obliged to prove the effectiveness of anticoagulants in patients with AF. The article discusses the pharmacogenetics of warfarin in relation to the data of the Russian Federation, as well as the practically important question of the possibility of resuming anticoagulants in patients with bleeding, the results of their own research are presented.