THE OFFICIAL NEWS SOURCE OF ACR CONVERGENCE 2022 • NOVEMBER 10-14



Comfort level about warfarin replacements still low

Few rheumatologists prescribe direct oral anticoagulants, but these new agents have replaced warfarin in a growing portion of the rheumatologic patient community.

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Kerry Stone, MD

“The direct oral anticoagulants are something cardiologists and hematologists have gotten pretty comfortable with, but rheumatologists haven’t branched out into using them,” said Kerry Stone, MD, Einstein Medical Center. “I don’t have any patients I prescribe them for, but I certainly have patients who are on them. We all see these agents on a regular basis, but management of these medications is still a bit outside our specialty and our comfort zone.”

Dr. Stone will moderate a clinical symposium that poses an important question for rheumatologists: Can We Replace Warfarin? An Update on the Direct Oral Anticoagulants from 9:00 –10:00 am today. Direct oral anticoagulants have become widely used by both cardiologists and hematologists for atrial fibrillation (AF) and venous thrombosis. And while AF is not a condition rheumatologists treat, thrombosis is a frequent complication of a number of rheumatic diseases. That potential use makes direct oral anticoagulants both attractive and challenging for rheumatologists.

The FDA approved the first direct oral anticoagulants in the late 1990s, Dr. Stone said. They were widely hailed as potential replacements for warfarin, the tried and true anticoagulant loved — and hated — by both patients and providers.

Warfarin can be a highly effective anticoagulant for both acute and chronic use. But despite its recognized effectiveness, warfarin remains difficult to take, difficult to monitor, and difficult to regulate.

Warfarin carries multiple dietary restrictions, interacts with multiple drugs, and requires regular intrusive monitoring. Patients may need weekly blood draws while warfarin levels are being titrated. Even if there are no complications, patients can look forward to monthly blood draws for the duration of therapy, often for the rest of their lives.

“We thought that oral agents would have eliminated warfarin by now, but their utility has been a little more limited,” Dr. Stone said. “Currently, they are used mostly for cardiovascular indications, which is outside our area of specialty. At the same time, they would be very useful for patients with hypercoagulable states who need lifelong anticoagulation. But they have not become routinely used in rheumatology. We don’t know much about direct oral anticoagulants and have not become very comfortable using them.”

That lack of knowledge and lack of comfort can combine to create a gap in practice. Many patients enter the rheumatology practice already taking direct oral anticoagulants for a pre-existing cardiovascular condition. Rheumatologists need to understand the implications of these agents, Dr. Stone said:

  • Are there potential interactions with rheumatologic agents?
  • How might these agents affect rheumatologic disease?
  • Can rheumatologists use direct oral anticoagulants to treat clots seen in lupus and other familiar disorders?
  • Might they be effective in treating the recurrent thromboembolic disease so often seen in patients with anti-phospholipid antibody syndrome?

Another concern for rheumatology is how to monitor the effectiveness of these direct acting anticoagulants and how to reverse these agents if a patient has bleeding problems or needs surgery.

“You don’t have the familiar INR test to guide therapy.” Dr. Stone said. “We are still working in conjunction with cardiologists and hematologists who are much more familiar with these agents. But the reality is that these agents are gaining in popularity and gaining acceptance throughout medicine. And they are new since many of us trained. It is important for us to learn about them, how they impact the diseases we treat and, most of all, whether they are something that we will be using more routinely in the future.”