Dr Steve Austin, St George's Hospital, London, UK

In this free-access CardioEd resource from the recent Cardiology Update 2016 meeting organised by St George’s University of London, UK, Dr Steve Austin, consultant haemotologist from St George’s University Hospital’s Foundation Trust talks about the use of DOACs and the impact of ‘antidotes’ in the treatment of atrial fibrillation.

The Cardiology Update 2016 meeting focused on heart failure management and stroke prevention in patients with atrial fibrillation.

What impact will having an ‘antidote’ have regarding the use of DOACs in real life clinical practice?

You raise a very important question, what effect having a reversal agent will have on clinical practice, and there are certainly a number of implications.

But the first thing that is important to remember is the Direct Oral Anticoagulants (DOACs), these new agents that we use, basically have a much safer profile than the previous agent – warfarin – than we were using.

And this is so important to appreciate, because people were reluctant to prescribe it without a reversal agent.

So it raises the issue of whether the presence of a reversal agent will actually improve prescribing.

But indeed it probably won’t be used nearly as much as people might think. So the reluctance to prescribe is somewhat influenced by anxiety over bleeding, but the data doesn’t support that.

So the first thing is it might influence people to prescribe a little bit more, because they think there is something they can use. And certainly that is important.

But actually what is really important, that will have a big implication on clinical practice, is certainly that this agent can be used in urgent situations – whether it be in a patient with uncontrolled, life-threatening bleeding, which is a rare problem for these patients on this drug, but it can occur – or whether it can be use to simplify and streamline the management of a patient who requires an urgent procedure or surgery.

So you can imagine if a patient comes in and they have been on dabigatran, which is the one agent that we do have a reversal agent for, if they have been on dabigatran and they can be given the agent and sent off to theatre if they have fractured their hip, for example. There’s no waiting around, or giving them lots of plasma products, or things like that. So it will certainly change that practice.

It will also certainly change the way we think about people who might not have been put on an anticoagulant previously because of problems with bleeding. If they have a very high HAS-BLED score, for example, or whatever tool you’re using to determine bleeding risk. People can be reluctant to put them on anticoagulant.

And so high-risk patients at higher risk of bleeding than the standard patient, people might be more happy to prescribe say dabigatran because there is idarucizumab – a reversal agent. So I think it will slowly influence that.

But beyond that, will influence when these patients have procedures because they come in needing something urgent and they don’t have to wait.

It will reduce bed time, in terms of stays in hospital, because the whole thing will be much less complicated. So there are big implications for clinical practice.

What proportion of AF patients in the UK are now receiving DOAC treatment?
That’s a very important question, and the first thing I would say to you is not enough.

The second thing I say to you is it is completely variable. It depends on what region of the UK we’re talking about.

If we look at the national median from last year’s reports we get around 16 per cent of patients are on DOACs for AF and stroke prevention. That’s versus all the rest being on warfarin.

But that’s not really enough. There is still a proportion of patients who are either not treated at all, or who are on aspirin which we know is not an adequate treatment for stroke prevention.

So basically we need to improve that uptake still, and I hope that over the years to come people will get more confident in the use of these agents, and patients will be put on appropriate preventative strategies.