Although the novel oral anticoagulants (NOACs) dabigatran (Pradaxa, Boehringer Ingelheim), rivaroxaban (Xarelto, Janssen) and apixaban (Eliquis, Bristol-Myers Squibb) offer alternatives to warfarin to prevent strokes in patients with atrial fibrillation, physicians may still need guidance on how to manage them.

In a review published in the January issue of International Journal of Stroke, a group of researchers led by Emer R. McGrath, MB, of National University of Ireland in Galway discussed some of the challenges involved in managing these medications and offered suggestions for their use.

One recommendation was to use heparin anti-Xa levels to measure anticoagulant activity rather than prothombin time/international normalized ratio. The researchers also offered recommendations on managing the drugs in patients with renal impairment, thrombolysis in patients on NOACs having a stroke, starting NOAC therapy after an ischemic stroke, managing intracerebral hemorrhage (ICH) in patients taking NOACs, starting NOACs after ICH, appropriate antidotes and managing NOACs in patients with both atrial fibrillation and arterial disease.