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Dr Helen Webberley MBChB MRCGP MFSRH
GMC no 3657058
NOACs. The ark to steer us through the stormy seas of anticoagulation?
NOACs is an acronym for ‘novel oral anticoagulants’. Anticoagulants are sometimes referred to as ‘blood thinning’ agents or even more cryptically, ‘rat poison’! Although these descriptions are not really accurate.
For many years the medical profession has relied upon warfarin to provide ‘blood thinning’ for those patients who have developed, or are at risk of developing, blood clots.
Blood clots in the legs (DVTs) can typically develop in smokers, in women on the oral contraceptive pill, patients who are bedbound, following long-haul flights, or just spontaneously.
Occasionally these blood clots can break off and fly up to the lungs, called pulmonary embolism, causing blockage to the arteries in the lungs and lung tissue death. This causes severe sharp pain in the affected lung, breathlessness and even death in a few.
Blood clots can also form in the chambers of the hearts in patients with an abnormal heart rhythm called atrial fibrillation (AF). In these patients there is a high risk (1 in 20 per year) of the blood clots flying up into the brain causing stroke. This can have catastrophic consequences for the individual concerned, who may be completely paralysed on one side, unable to speak and swallow and may even cause death. The neurological complications are often irreversible.
It is very important therefore to identify and treat those patients at risk of developing blood clots.
For decades, warfarin has been the standard accepted treatment for these patients.
Warfarin acts by interfering with the formation of certain (vitamin K – dependent) clotting factors by the liver. This has the effect of slowing down the clotting process making patients less likely to form clots. The downside of this of course, is that patients may bleed or haemorrhage more easily.
The problem with warfarin is that it has to be very carefully monitored with frequent blood tests and doctor appointments, some patients are allergic to it, many patients don’t achieve stable blood tests (if at all) making them either susceptible to clots or haemorrhage and patient compliance is often poor. Warfarin therapy may also take several days before therapeutic ranges are reached.
The NOACs are a recent and very welcome addition to the armoury.
They include the drugs apixiban, rivaroxaban and dagibatran. Their pharmacological profile is very predictable, meaning that they don’t have to be closely monitored with blood tests, they work quickly and their effect wears off quickly and they have roughly the same risk profile as warfarin.
They are however much more expensive and not so well studied and unlike warfarin, there isn’t an immediate antidote available if haemorrhage should occur, although intravenous clotting factors can reverse their effects in the emergency setting.
There is a general feeling in primary care that these types of new drugs should be started and monitored in hospital environments, but actually there is no reason at all why GPs can’t do this.
Where NOACs are likely to be most valuable is in the long-term treatment of recurrent thrombosis and the prevention of stroke in patients with AF.
This latter condition has always been a bit of a minefield, the risk of stroke versus the risk of haemorrhage, either in the brain or from the gut.
However recent very large meta analyses (reviews of many studies) have shown that NOACs are superior to warfarin in preventing stroke and systemic embolisation and even more importantly, a halving of intracranial haemorrhage (a complication of warfarin therapy) with corresponding lower mortality.
Other studies have shown that aspirin (previously the mainstay of stroke prevention in AF), has little or no benefit and that patients should be properly anticoagulated, but warfarin has until now, been the only option.
With the development of NOACs there are now other strategies that can be considered and NOACs are much more likely to be acceptable and convenient for patients in the long term.
Dr.Helen Webberley in the news!
GP Dr Helen Webberley has treated many patients with the symptoms of carbon monoxide poisoning and warns of the damage that long-term exposure to the gas can lead to.
She said: “People should not think there is a safe level of poisoning, as exposure to the gas over time, even at a low level, can lead to brain damage.
“Everyone must be vigilant to symptoms which include dizziness, headaches, breathlessness and loss of consciousness.”
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