Prescriber decision support of New Oral Anticoagulants (NOACs)
The aim of this guidance is to summarise and compare NOACs and support prescriber decisions. NICE
has issued guidance and endorsements on the specific uses of: Apixaban (Eliquis®), dabigatran
(Pradaxa®), rivaroxaban (Xarelto®) and edoxaban (Lixiana®).
The decision about whether to start treatment with warfarin or a NOAC should be made after
an informed discussion between the prescriber and the patient about the relative risks and
benefits of each agent.
If a NOAC is recommended, establish the principal reason of this suggestion over alternative first line
anticoagulant agents. There are many factors to consider when recommending an anticoagulant. For
example drug interactions, indications, bleeding risk, falls risk, lifestyle issues, alcohol consumption,
poor compliance, failure to comply with monitoring arrangements etc. This guidance aims to provide
prescribers a personalised approach to selecting anticoagulant therapy for their patients.
INR control
Optimal INR control is defined as TTR ≥65%. Factors to consider in improving TTR:

Patient education

Concordance – identify patients with poor compliance by comparing recommended dose over 3-6
months with quantity of prescription issued

Inconvenient or inappropriate monitoring arrangements – confirm suitability of arrangements for
each patient

Consider domiciliary monitoring arrangements for patients with reduced mobility

Alcohol consumption

Drug interactions
Take action to minimise the effect of any factors that can adversely affect INR control. For all patients
deemed to have previously failed on warfarin therapy, establish all the relevant anticoagulant treatment
history. Confirm the evidence to support proposed reason for treatment failure. For example:

Failed monitoring arrangements – did the patient attend an anticoagulation monitoring service?

Labile INR – did the patient achieve a therapeutic INR?

Bleeding complications – was the bleed major/minor? Confirm INR at time of bleed.

Drug interactions – any change to concurrent therapy should be considered.

Serious ADR – was this documented in patient records?

Severe alopecia – was the patient offered alternative VKA agents?
Key points: Warfarin
 Warfarin has been prescribed for over 50 years and it remains an established, costeffective option for anticoagulation in patients
 The benefits of NOACs over warfarin decline as the Time in Therapeutic Range (TTR) of
warfarin increases
 INR gives clinicians a guide to patient compliance
 Effective and well known antidote with vitamin K should a severe bleed occur whilst
being treated.
 All NOACs are licensed for prevention of stroke in non valvular atrial fibrillation
plus at least one additional risk factor. Warfarin can be used with no additional risk
factors.
 Warfarin is licensed for use without additional risk factors present.
 Unlike NOACs, warfarin may be considered in those patients with mechanical heart
valve, valvular disease and/or hepatic impairment.
 Warfarin - time to peak effect ranges from 3-5 days.
 Warfarin is known to interact with certain foods e.g. cranberry, alcohol and other foods
containing high amounts of vitamin K.
 Patients may have difficulty around INR monitoring
Key points: NOACs
 No requirement for INR monitoring.
 NOACs provide immediate anti-coagulant effect (time to peak effect ranges from 14 hours).
 NOACs currently have no known food interactions.
 Monitor Hb, LFTs and renal function at least annually (More frequent renal function
needed in patients at high risk)
 The sole responsibility of anticoagulation remains with the prescriber without the
support of anticoagulation clinic services.
 NOACs have shorter half-life and missed doses may result in more time without any
anticoagulation and greater risk of thromboembolic complications.
 Difficult to monitor compliance.
 Each NOAC has a higher acquisition cost than warfarin.
 No published systematic clinical studies on the reversal of the anticoagulant effects
of the drugs.
 Renal function should be assessed and monitored using Cockcroft and Gault
formula - CrCL. Especially in patients with extreme BMI.
Patients for consideration of NOAC

Poor INR control on warfarin. INR not well controlled defined as one INR above 8 or 2 readings outside the range of 1.8-5 in a six month period in line with the NORCOM algorithm.
Exclude all reasons for poor INR control despite good compliance before considering NOAC.

Significant difficulties with INR monitoring and/or accessing anticoagulant clinics that raises safety concerns. Exclude alternatives such as community anticoagulant services, domiciliary
monitoring/input or self-testing.

Patients in whom warfarin is unsuitable due to contraindications or intolerance, e.g. alopecia rather than bleeding, could be offered a NOAC. However, NOACs are not suitable alternatives
in patients with bleeding complications associated with warfarin treatment, contraindication to warfarin due to high bleeding risk, poor compliance with warfarin therapy, trivial ADR, a history of
alcohol abuse or drug overdose
All patients started on a NOAC should be provided with a NOAC alert card by the initiating clinician.
GPs and Community Pharmacies can obtain supplies from the Medicines Management Team.
2
Apixaban1
Dabigatran2
Rivaroxaban3
Edoxaban4
Direct factor Xa inhibitor
Direct thrombin inhibitor
Direct factor Xa inhibitor
Direct factor Xa inhibitor
Licensed




Indications1,2,3,4
Prevention of stroke and systemic embolism in adult patients with non-valvular atrial fibrillation (NVA) (with at least one additional risk factor) – Apixaban, Dabigatran, Rivaroxaban, Edoxaban
Treatment and prevention of VTE - Apixaban, Dabigatran, Rivaroxaban, Edoxaban
Prevention of venous thromboembolism after hip or knee replacement – Apixaban, Dabigatran, Rivaroxaban
Prevention of atherothrombotic events after ACS – Rivaroxaban only
NICE Technology Appraisals and Barnsley traffic light status
TA275 (Prevention of stroke and systemic embolism
in NVAF)5
TA341 (Treatment and prevention of VTE)6
TA245 (Prevention of VTE after hip or knee
replacement)7
TA249 (Prevention of stroke and systemic
embolism in NVAF)8
TA327 (Treatment and prevention of VTE)9
TA157 (Prevention of VTE after hip or knee
replacement)10
TA256 (Prevention of stroke and systemic embolism
in NVAF)11
TA287 (Treatment and prevention of VTE)12
TA170 (Prevention of VTE after hip or knee
replacement)13
TA355 (Prevention of stroke and systemic embolism
in NVAF)15
TA354 (Treatment and prevention of VTE)16
TA335 (Prevention of atherothrombotic events after ACS)14
Dose
Prophylaxis of stroke and VTE in AF:
Adults: 5mg twice daily
2.5mg twice daily if:
 CrCL 15-29mL/min - 2.5mg twice daily
 Patients with 2 or more of the following:
-age >80 yrs
-body weight <60kg
-serum Cr >133micromole/L
Treatment and prevention of VTE:
Treatment: 10 mg twice a day for 7 days,
followed by 5 mg twice a day for at least
3 months.
Prevention: 2.5 mg twice a day for patients
having completed 6 months treatment for DVT
or PE
Prophylaxis of stroke and VTE in AF:
Adults<80 yrs:150mg twice daily
Age≥80 yrs or taking verapamil: 110mg twice
daily
Treatment and prevention of VTE:
150 mg twice daily (110mg twice a day if over
80 years or taking verapamil) following
treatment with a parenteral anticoagulant for at
least 5 days.
For both indications, consider 110 mg twice
daily if:
Low thromboembolic risk & high bleeding risk
age 75-80 yrs
patients with gastroesophageal reflux,
oesophagitis or gastritis
body weight <50kg
CrCL 30-50mL/min
Prophylaxis of stroke and VTE in AF:
20mg once daily
15mg once daily when CrCL is 15-49 mL/min
Treatment and prevention of VTE:
15mg twice a day for 21 days then 20mg daily
(min. 3/12 max. 6/12)
CrCL 15-49 mL/min - 15mg twice a day for 21
days then 15mg daily (If risk of bleeding > risk
of recurrent DVT & PE)
Prophylaxis of stroke and VTE in AF:
60mg once daily
Treatment and prevention of VTE:
60mg once daily following treatment with a
parenteral anticoagulant for at least 5 days.
For both indications give a dose of 30 mg
once daily in the following patient groups:
 people with renal impairment
 low body weight (60 kg or less)
 concomitant use of potent P‑glycoprotein
inhibitors (ciclosporin, dronedarone,
erythromycin, ketoconazole)
Drug Interactions (Please note: This list is not exhaustive. Refer to SPC for full information)
Use with caution with any medication known to increase the risk of bleeding
 Avoid concomitant use with inhibitors of
 Verapamil, quinidine, ketoconazole,
both CYP3A4 and P-gp e.g. ketoconazole,
itraconazole, voriconazole or HIV protease
inhibitors.
 Caution with strong CYP3A4 inducers e.g.
rifampicin, phenytoin, carbamazepine,
phenobarbital or St. John's Wort as they may
lead to reduced apixaban concentrations.
clarithromycin, rifampicin, phenytoin and
carbamazepine.
 SSRIs and SNRIs increased the risk of
bleeding in RE-LY17 in all treatment groups.
 Concomitant treatment with systemic and
ketoconazole, cyclosporine, itraconazole,
tacrolimus and dronedarone is
contraindicated.
 Avoid concomitant treatment with strong
 Inhibitors of CYP3A4 and P-gp – ketoconazole,
inhibitors of both CYP3A4 and P-gp e.g.
ketoconazole, itraconazole, voriconazole or
HIV protease inhibitors.
 Caution with strong CYP3A4 inducers e.g.
rifampicin, phenytoin, carbamazepine,
phenobarbital or St. John's Wort as they may
lead to reduced rivaroxaban concentrations.
 Caution with dronedarone.
itraconazole, voriconazole and posaconazole,
HIV protease inhibitors (e.g. ritonavir),
erythromycin, diltiazem, naproxen, verapamil,
amiodarone, quinidine, dronedarone,
clarithromycin, ticagrelor, tacrolimus.
 Inducers of CYP3A4 and P-gp – rifampicin,
phenytoin, carbamazepine, phenobarbital, St.
John’s Wort.
 Anticoagulants, platelet aggregation inhibitors
and NSAIDs.
3
Apixaban
Dabigatran
Rivaroxaban
Contraindications (Please note: This list is not exhaustive. Refer to relevant SPC and MHRA





Hypersensitivity
A lesion or condition, if considered a
significant risk factor for major bleeding
Active bleeding
Hepatic disease associated with
coagulopathy and clinically relevant
bleeding risk
Anticoagulant in use (except during
switching -see
below) CrCL<15mL/min








Hypersensitivity
A lesion or condition, if considered a
significant risk factor for major bleeding
Active bleeding
Hepatic disease or impairment expected to
impact survival
Anticoagulant in use (except during switching see
below)
Concomitant treatment with
systemic ketoconazole,
cyclosporine, itraconazole,
tacrolimus and dronedarone
CrCL<30mL/min
Prosthetic heart valves







alert18
Edoxaban
for full information)
Hypersensitivity
A lesion or condition, if considered a
significant risk factor for major
bleeding
Active bleeding
Hepatic disease associated with
coagulopathy and clinically relevant
bleeding risk
Anticoagulant in use (except during switching
-see
below)
Pregnancy and breast feeding
CrCL<15mL/min







Hypersensitivity
A lesion or condition, if considered a
significant risk factor for major
bleeding
Active bleeding
Hepatic disease associated with
coagulopathy and clinically relevant
bleeding risk
Anticoagulant in use (except during
switching)
Pregnancy and breast feeding
Patients with prosthetic heart valves
Pregnancy
Not recommended
Not recommended
Contraindicated in pregnancy and breastfeeding
Contraindicated in pregnancy and
breastfeeding
Contraindicated
Not studied therefore not recommended
Not studied therefore not recommended
Not studied – not recommended
Not studied – not recommended
Not studied – not recommended
Swallow whole - opening capsules may increase risk
of bleeding and should not be done.19
Take with food to increase absorption.
Can be crushed and put through NG tube if
required. 19
No specific instructions.
Not suitable for compliance aids.
Shelf-life of 3 years and no special storage
requirement – can be used in compliance aids.
No special storage instructions – can be used in
compliance aids.
Twice daily dosing. Missed dose may be taken up to
6 hours prior next scheduled dose. If within 6 hours
of next dose, the missed dose should be omitted.
May support concordance – once daily dosing.
Missed dose should be taken immediately and
then continued on the following day with once a
day dosing. Do not double dose within the same
day to make up for missed dose.
Missed dose should be taken immediately and
then be continued the following day with the
once-daily intake as recommended. The patient
should not take double the prescribed dose on
the same day to make up for a missed dose.
Mechanical heart valves
Not studied therefore not recommended
Valvular disease
Not studied – not recommended
Administration
No special direction. Can be crushed and
dispersed in 5% dextrose in water (D5W), water,
apple juice or apple puree and administered
immediately. Apixaban can be crushed and
suspended in 60 mL of water or D5W and given
immediately through a nasogastric tube .19
Requirement for compliance aid
Shelf-life of 3 years and no special storage
requirement – can be used in compliance aids.
Missed dose
Twice daily dosing. Missed dose should be taken
immediately and then continued with twice a day
as before. Do not double dose within the same
day to make up for a missed dose.
NOACs have shorter half-life therefore missed doses may result in more time without any anticoagulation and greater risk of thromboembolic complications. Warfarin has a longer half-life and once a day dosing.
Reversibility
There is currently no antidote to apixaban.
Haemodialysis will clear dabigatran and
currently there is no antidote.
Haemodialysis will not clear rivaroxaban and
currently there is no antidote. Data suggest
reversibility with prothrombin complex concentrate
(PCC) has been successful.
There is currently no antidote to edoxaban.
Haemodialysis does not significantly contribute to
edoxaban clearance.
4
Apixaban
Dabigatran
Rivaroxaban
Edoxaban
Extremes of BMI
Exposure of NOACs may vary by 20-30% at extremes of bodyweight (<50 kg or >100-120 kg). This may be problematic given the difficulties in monitoring the therapeutic effects. It is recommended that Cockcroft and Gault
formula is used to calculate CrCL to adjust NOAC dosage.
Electronic calculator link - http://www.medicinescomplete.com/mc/bnf/current/PHP18586creatinine-clearance.htm
Cockcroft and Gault formula: CrCL = (140-Age in years) X Weight (kg) X Constant (1.23 in men. 1.04 in women)
Serum creatinine (micromole/litre)
Renal Impairment
Not recommended if CrCL<15mL/min
Contraindicated in CrCL<30mL/min
Use with caution if CrCL 15-29mL/min
CrCl 15-50ml/min reduce dose to 30mg od
Contraindicated in CrCL<15mL/min
Not recommended if CrCl <15ml/min
Patients must have a baseline renal function test before initiating NOAC. Renal function can decline while on treatment hence monitor annually or more often in high risk patients (6 monthly if CrCl30-60ml/min, age>75 years
or fragile. 3 monthly if CrCl 15-30ml/min). Note: In practice eGFR and CrCL are not interchangeable; however for most drugs and for most patients (over 18 years) of average build and height, eGFR could provide some
guidance. The SPC of each NOAC recommends that ‘Cockcroft and Gault’ formula is used for dosing and monitoring.
Hepatic Impairment
Not recommended in severe hepatic impairment. Check
baseline LFTs prior initiation.
Contraindicated in hepatic disease associated with
coagulopathy and clinically relevant bleeding risk.
Not recommended in patients with liver
enzymes >2 upper limit of normal.
Contraindicated in patients with hepatic impairment
or liver disease expected to impact on survival.
Liver function tests should be monitored annually in all patients prescribed a NOAC.
Use with caution as requires hepatic metabolism.
Contraindicated in hepatic disease associated with
coagulopathy and clinically relevant bleeding risk
including cirrhotic with Child Pugh B and C.
Contraindicated in hepatic disease associated
with coagulopathy and clinically relevant
bleeding risk.
Before surgery - If the procedure cannot be delayed the increased risk of bleeding should be assessed against the urgency of the intervention.
Discontinue at least 48 hours prior to elective surgery or
invasive procedures with a moderate or high risk of
bleeding.
Discontinue at least 24 hours prior to elective surgery or
invasive procedures with a low risk of bleeding.
Depending on renal function stop dabigatran 1 - 4
days prior elective surgery or invasive procedure.
If acute, surgery/invasive procedure should be
delayed if possible until at least 12 hours after the
last dose.
If possible, based on the clinical judgement of the
physician, discontinue 24 hours before surgery or
invasive procedure.
If anticoagulation must be discontinued to
reduce the risk of bleeding with surgical or
other procedures, edoxaban should be
stopped as soon as possible and preferably at
least 24 hours before the procedure.
Conversion from warfarin to NOAC
Discontinue warfarin and start rivaroxaban when:
Discontinue warfarin and start edoxaban
-INR ≤3.0 for prevention of stroke and systemic
when the international normalised ratio
embolism.
(INR) is ≤ 2.5.
-INR ≤2.5 for DVT, PE and prevention of recurrence.
Caution: INR values will be falsely elevated after the
intake of rivaroxaban.
NOACs have shorter half-life and converting a NOAC to an alternative NOAC should be theoretically uncomplicated. To date there is little evidence of such practice and it would be advisable to seek advice from specialist
anticoagulant team or GPwSI when necessary.
Discontinue warfarin and start apixaban when the
INR<2.
Discontinue warfarin and start dabigatran when
the INR<2.0.
Caution: INR values will be falsely elevated when
taking dabigatran.
Conversion from NOAC to warfarin/alternative NOAC
Continue with apixaban for at least 2 days after
starting warfarin therapy.
Check INR after 2 days of co-administration. Obtain INR
before next schedule dose of apixaban. Continue coadministration until the INR is >2.0 then discontinue
apixaban.
CrCL ≥50mL/min – Start warfarin 3 days before
discontinuing dabigatran.
CrCL ≥30- <50mL/min – Start warfarin 2 days
before discontinuing dabigatran.
CrCL <30mL/min – not recommended. Consult
haematologist.
Caution: INR values will be falsely elevated. INR
testing should not be performed until dabigatran
has been stopped for at least 2 days.
Co-administer rivaroxaban and warfarin until INR>2.0.
Test INR 24hours after previous dose but prior next
dose of rivaroxaban.
Start warfarin as standard initial dosing followed by
dosing guided by INR testing. Once rivaroxaban is
discontinued, INR testing may be done reliably at least
24hours after the
last dose.
Discontinue dabigatran, rivaroxaban or
apixaban and start edoxaban at the time of
the next dose of the oral anticoagulant.
5
Apixaban
Dabigatran
Rivaroxaban
Edoxaban
Efficacy for stroke prevention in patients with NVAF
20
Superior to warfarin (ARISTOTLE).
Slightly superior to warfarin with 150mg
twice daily dose.
Non-inferior to warfarin with 110mg twice
17
daily dose (RE-LY).
21
Non-inferior to warfarin (ROCKET-AF).
Both once daily doses are non-inferior to
warfarin (ENGAGE AF-TIMI).22
Major bleed risk compared to warfarin in patients with NVAF
Reduced risk (ARISTOTLE)
20
Similar risk with 150mg twice daily
Reduced risk with 110mg twice daily (RE17
LY)
Similar risk (ROCKET-AF)
Reduced risk (ENGAGE AF-TIMI).22
21
Intracranial bleed risk compared to warfarin in patients with NVAF
Reduced risk (ARISTOTLE)
20
21
17
Reduced risk (ROCKET-AF)
Significantly increased risk with 150mg twice
daily.
Similar risk with 110mg twice daily (RE17
LY)
Increased risk (ROCKET-AF)
Reduced risk (RE-LY)
Reduced risk (ENGAGE AF-TIMI).22
Major GI bleed risk compared to warfarin
Similar risk (ARISTOTLE)
20
21
The annualised rate of major GI bleed
was higher with high dose edoxaban than
with warfarin (1.51% vs. 1.23%), but the
rate was lowest with low-dose edoxaban
(0.82%). (ENGAGE AF-TIMI).22
Risk of dyspepsia/ upper GI side effects compared to warfarin in patients with NVAF
Non-reported (ARISTOTLE)
20
Dyspepsia was significantly more common
with both doses of dabigatran (RE-LY)17
Similar risk of dyspepsia (ROCKET-AF)
21
Not reported
Risk of MI compared to warfarin in patients with NVAF
Reduced risk (ARISTOTLE)
20
Statistically significant increased risk (metaanalysis)23
Reduced risk but trend did not reach statistical
21
significance (ROCKET-AF)
No statistical difference.(ENGAGE AFTIMI).22
This information is a summary to guide prescribers – for further information please consult individual SPCs at www.medicines.org.uk
All patients started on a NOAC should be provided with a NOAC alert card by the initiating clinician.
GPs and Community Pharmacies can obtain supplies from the Medicines Management Team.
References
1.
2.
3.
4.
5.
Summary of Product Characteristics. Eliquis® (Apixaban). October 2015. Available at: http://www.medicines.org.uk/emc/history/27220 Accessed <14.10.15>
Summary of Product Characteristics. Pradaxa® (Dabigatran). September 2015. Available at: http://www.medicines.org.uk/emc/medicine/24839 Accessed <14.10.15>
Summary of Product Characteristics. Xarelto® (Rivaroxaban). July 2015. Available at: http://www.medicines.org.uk/emc/medicine/25592 Accessed <14.10.15>
Summary of Product Characteristics. Lixiana® (Edoxaban). July 2015. Available at: http://www.medicines.org.uk/emc/medicine/30506 Accessed <21.10.15>
NICE TA 275. Apixaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation. February 2013. Available at: http://www.nice.org.uk/guidance/ta275
Accessed <21.10.15>
6
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
NICE TA 341. Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism. June 2015. Available at:
http://www.nice.org.uk/guidance/ta341 Accessed <21.10.15>
NICE TA 245. Apixaban for the prevention of venous thromboembolism after total hip or knee replacement in adults. January 2012. Available at: http://www.nice.org.uk/guidance/ta245
Accessed <21.10.15>
NICE TA 249. Dabigatran etexilate for the prevention of stroke and systemic embolism in atrial fibrillation. March 2012. Available at: http://www.nice.org.uk/guidance/ta249 Accessed
<21.10.15>
NICE TA 327. Dabigatran etexilate for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism. December 2014. Available at:
http://www.nice.org.uk/guidance/ta327 Accessed <21.10.15>
NICE TA 157. Dabigatran etexilate for the prevention of venous thromboembolism after hip or knee replacement surgery in adults. September 2008. Available at:
http://www.nice.org.uk/guidance/ta157 Accessed <21.10.15>
NICE TA 256. Rivaroxaban for the prevention of stroke and systemic embolism in people with atrial fibrillation. May 2012. Available at: http://www.nice.org.uk/guidance/ta256 Accessed
<21.10.15>
NICE TA 287. Rivaroxaban for treating pulmonary embolism and preventing recurrent venous thromboembolism. June 2013. Available at: http://www.nice.org.uk/guidance/ta287
Accessed <21.10.15>
NICE TA 170. Rivaroxaban for the prevention of venous thromboembolism after total hip or total knee replacement in adults. April 2009. Available at:
http://www.nice.org.uk/guidance/ta170 Accessed <21.10.15>
NICE TA 335. Rivaroxaban for preventing adverse outcomes after acute management of acute coronary syndrome. March 2015. Available at: http://www.nice.org.uk/guidance/ta335
Accessed <21.10.15>
NICE TA 355. Edoxaban for preventing stroke and systemic embolism in people with non-valvular atrial fibrillation. September 2015. Available at: http://www.nice.org.uk/guidance/ta355
Accessed <21.10.15>
NICE TA 354. Edoxaban for treating and for preventing deep vein thrombosis and pulmonary embolism. August 2015. Available at: http://www.nice.org.uk/guidance/ta354 Accessed
<21.10.15>
Connolly SJ et al. Dabigatran versus warfarin in patients with atrial fibrillation. N Engl J Med 2009; 361: 1139-115 (RE-LY)
MHRA. Drug Safety Update. Volume 7, Issue 3, October 2013. Available at: https://www.gov.uk/drug-safety-update/new-oral-anticoagulants-apixaban-eliquis-dabigatran-pradaxa-andrivaroxaban-xarelto Accessed <14.10.15>
NEWT Guidelines for administration of medication to patients with enteral feeding tubes or swallowing difficulties. www.newtguidelines.com Accessed <21.10.15>
Granger CB et al. Apixaban versus Warfarin in Patients with Atrial Fibrillation. N Engl J Med 2011; 365: 981-92 (ARISTOTLE)
Patel MR, Mahaffey KW, Garg J et al. Rivaroxaban versus warfarin in Non-valvular Atrial Fibrillation. N Engl J Med 2011;365:883-91 (ROCKET-AF)
Giugliano RP et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med 2013; 369: 2093-104 (ENGAGE AF-TIMI)
Artang R, Rome E, Nielsen JD (2013). Meta-analysis of randomised controlled trials on risk of myocardial infarction from the use of oral direct thrombin inhibitors. Am J Cardiol. Sep 25.
Pii:S0002-9149(13)01709-8. doi: 10.1016/j.amjcard.2013.08.027
Acknowledgements
NHS Liverpool Community Health Medicines Management Team NHS Stockport CCG Medicines Management Team
NHS Trafford CCG Medicines Management Team
NHS Tameside and Glossop CCG Medicines Management Team
This information resource has been adapted from a resource produced by Jimmy Cheung (Support Pharmacist), Greater Manchester Commissioning Support Unit in December 2013.
7