News in the Indications of Direct Oral Anticoagulants According to the American College of Chest Physicians 2016 Guidelines

Background: The 10th edition of the CHEST Guideline and Expert Panel Report for the treatment of venous thromboembolism (VTE) was recently updated with recommendations on both the choice of anticoagulants and the duration of treatment in diverse clinical scenarios. Method: In this paper, we focus on news in the use of direct oral anticoagulants (DOACS), a group of synthetic low molecular weight drugs capable of directly and specifically inhibiting either activated factor X or both free and fibrin-bound thrombin. Results: New to the guidelines is the recommendation of the use of DOACS over vitamin K-antagonists (VKA's) in individuals without cancer who develop VTE. The choice and intensity of anticoagulants is the same for lower and upper extremity thrombosis or for pulmonary embolism. For cancer-related thrombosis low molecular weight heparin is still recommended over the use of VKA's or DOACS, though high quality evidence for this choice is lacking. If therapy is given beyond three months, remaining on the same anticoagulant is suggested. Re-thrombosis while on regular use of DOACs requires switching to low molecular weight heparins at least for one month. Conclusion: Ultimately the choice of anticoagulant will depend on patient-specific factors such as comorbidities, compliance, patient preferences, availability and costs. We address the news in DOAC use in VTE from the perspective of an upper-middle income economy.