Novel oral anticoagulants and the 73rd anniversary of historical warfarin.

The last 70 years of Warfarin use has been associated with extreme problems. The Novel Oral Anticoagulants (NOACs) are not well utilized in patients with Atrial Fibrillation (AF). We thought to excavate the clinical utility of NOACs and provide some insights into their usefulness as suitable alternatives to Warfarin. Methods: The main objective is to raise awareness of clinicians regarding the underutilized NOACs and shed light on concerns surrounding their utility as suitable alternatives to Warfarin. We searched the literature for recent meta-analysis about NOACs. Results: The choice between the four NOACs depends largely on the cost and patient’s preferences rather on their safety profile. They were better when compared with Warfarin, nevertheless; no head-to-head comparison was performed between NOACs members. The selection of one NOAC over the others rely on patients characteristics (age), cost, insurance coverage, dosing interval (once versus twice) and renal status. One more obstacle to utilization of NOACs is the reversal of bleeding. Discussion: There are three integrated grey areas for suitability to NOAC required to be discussed and argued in light of all of the trials, meta-analysis and pharmaceutical-race. The first is relevant to patient in term of demographics (e.g. age), co-morbidities (e.g. chronic kidney disease), degree of renal impairment (creatinine clearance > 30 mL/min), adherence to daily dosing and risk of bleeding. Most patients with AF are having comorbidities with problematic poly-pharmacy issues. The second is implications of cost and insurance coverage on NOAC selection which is considered highly significant for clinicians. The third is relevant to each NOAC pharmacokinetic and pharmacodynamics profile as dosing interval. Conclusion: The messages taken from this overview is to encourage utility of NOACs in daily clinical practice, evaluate the patient preferences, consider cost and insurance coverage and select a NOAC over Warfarin when the overall clinical judgment is optimal.