Edoxaban

[Barb1]

In 2 weeks I am due to have my second Total Hip Replacement. I am on warfarin (previously on Dabigatran) since a clot was discovered in the left atrial appendage. My EP thinks that it is timely, as I have to come off warfarin for the op, to switch me to a NOAC, namely Edoxaban. But he says it is up to my surgeon to advise as to how many doses I should miss and when to restart. My surgeon has never even heard of NOACs, so I am appealing to this forum for advice. I would like to be prepared for my pre op assessment on the 8th. Thank you.

[GazzaD57]

I am amazed your surgeon hasn't heard of them, they aren't that new. I am on one for clots and AF called Apixaban and haven't had any issues at all.

[Rusty8 in reply to GazzaD57]

Sorry to jump in but I noticed you are on apixaban I've not been able to see anyone else on it .i am a kidney transplant patient so unable to take certain drugs but the renal consultant is now saying that one is ok My levels on warfarin have never been ok since taking them must be 3years now but gp is against them

I don't know what to do have you had any problems also are your blood levels monitored thank you June

[Barb1 in reply to Rusty8]

Rusty, I am about to go on Edoxaban not Apixaban and I would except my kidney fct to be monitored not blood levels.

[PeterWh in reply to Rusty8]

There are a lot on here who are on apixaban. Make sure you have full set of bloods before you start including kidney, liver and thyroid. Then possibly further tests at 4 to 6 weeks and the 3 months. Then probably 6 or 9 months. Because of you history they may want to do additional.

[Auriculaire in reply to PeterWh]

Can Apixaban alter thyroid levels? My TSH has gone up out of range since I have been on it. I have not had such a large jump for years.

[Barb1 in reply to Auriculaire]

I haven't heard of it.

[GazzaD57 in reply to Rusty8]

Never had any issues on Apixaban. No blood level monitoring.

[PeterWh in reply to GazzaD57]

Have you had organ function tests. Often this gets missed.

[PeterWh]

Not surprised about surgeon not knowing the full things about NOACs nor about how long to stop NOACs or warfarin because it is a specialised area that they don't too often come across. I am surprised about EP and certainly when I had an angiogram my heart consultant had me injecting clexane to bridge before and after procedure so as to minimise the stroke risks when warfarin was stopped and then restarted on evening of same day. Older basis used to be stopping but no bridging.

Also he said always have bridging for operations and procedures (I had one a short time previously at another hospital where warfarin was stopped but no bridging.

[Barb1]

Thank you Peter Wh. Yes, I know about warfarin and ops. What I don't know is about NOACs.

[Goldfish_]

This is the Guys and St Thomas protocol - stopping edoxaban 48hr preop (irrespective of renal function) and deltaparin bridging

guysandstthomas.nhs.uk/reso...

I can't see why this should affect the decision about using a NOAC, which should be made in good time preoperatively.

There is a query though in that you previously had a clot on dabigatran, so ?safety of changing back to a NOAC again. Not an obvious decision to me (although dabigatran is not a great NOAC in my opinion and needs twice daily dosing so compliance more likely to be a problem), but there has not been shown to be a definite benefit for warfarin over dabigatran , although data on switching anticoag is small ncbi.nlm.nih.gov/pubmed/197...

Dave

[Barb1 in reply to Goldfish_]

Thank you. I have printed this to take with me. When I was changed from Dabigatran to warfarin it was 2 weeks before I was properly anti coagulated. This could have been when the clot happened. I will be having a TOE 3 months after starting Edoxaban.

[PeterWh in reply to Barb1]

This endorses the view and practical of the local Anticoagulation service run by the CCG which covers 4 hospitals. When I was switched from apixaban to warfarin it was overlapped. I started warfarin on a Monday evening but continued to take apixaban every morning and evening. I had the apixaban on the Friday morning and the second blood test later that morning and it was a surprise to them that my INR was already up at 2.2 so they then told me to stop taking the apixaban. They said most of the apixaban would be out of my system by the Saturday evening. Effectively four or five days of overlap.

[Finvola]

I'm surprised that your EP had no advice regarding Edoxaban and surgery, although can understand why the final decision would be left to the surgeon. It beggars belief that you are left wondering about something so vital to your health. I had a quick search and found the article below which suggests stopping Edoxaban for 48 hours before major surgery.

In your position I would light a fire under these guys and get some advice from them. I seem to remember an article about surgery and the other 3 NOAC's and will try to find it for comparison.

ncbi.nlm.nih.gov/pubmed/258...

[Finvola in reply to Finvola]

This is the article regarding the three older NOAC's and is a bit out of date but gives the general idea. Does your Health Trust not have similar published protocols?

networks.nhs.uk/nhs-network...

[Barb1 in reply to Finvola]

I will look. It does appear though that I should have renal fct test before starting the NOAC though (and not just after.)

[Finvola in reply to Barb1]

Yes, renal function should be tested beforehand - I was checked before starting Apixaban and have annual checks (I had to ask for them to be done).

[PeterWh in reply to Finvola]

Same for me. However I was told that 2nd test should be at approx 4 to 8 weeks then again at 3 to 4 months then annually.

[PeterWh in reply to Finvola]

I couldn't get the above link to work but this one does:

networks.nhs.uk/nhs-network...

[Barb1 in reply to Finvola]

Thank you. I have printed this as well.

[Hidden]

You can read more information on edoxaban and other anticoagulant options in our booklet "A Guide for Patients prescribed oral anticoagulant therapy". heartrhythmalliance.org/fil...

There is also a factsheet on edoxaban, which can be found here: heartrhythmalliance.org/fil...

If you would like paper copies of this information, perhaps to give to your EP, please email me with your address, and I will gladly send them to you.

Regards - Rachel - AF Association, Patient Services Associate.

[Barb1 in reply to Hidden]

Very useful, thank you.