DOACs and “newer” hemophilia therapies in COVID‐19: Reply

Abstract

We thank the authors for their insightful thoughts on the consideration of anticoagulants and treatment for hemophilia A and B during the COVID‐19 pandemic. They highlight some important practical points that certainly should be adopted by the thrombosis and hemostasis community in the current situation of restricted mobility, which reduces the possibility for patients to access general practitioners and hospitals. In relation to the use of direct oral anticoagulants (DOACs), the authors suggest to consider the current crisis as an opportunity to switch patients receiving vitamin K antagonists (VKA) to a DOAC as long as it is within the indication (excluding patients with mechanical heart valves or antiphospholipid syndrome). In addition, we think this may be an opportunity to consider DOACs for indications such as unusual‐site thromboses like cerebral venous thrombosis and noncirrhotic portal vein thrombosis, where DOACs have been trialed but not yet been accepted for widespread use.1.Lurkin A. Derex L. Fambrini A. et al.Direct oral anticoagulants for the treatment of cerebral venous thrombosis.Cerebrovasc Dis. 2019; 48: 32-37Crossref PubMed Scopus (21) Google Scholar, 2.Naymagon L. Tremblay D. Zubizarreta N. et al.The efficacy and safety of direct oral anticoagulants in noncirrhotic portal vein thrombosis.Blood Adv. 2020; 4: 655-666Crossref PubMed Scopus (45) Google Scholar Another area, where this is similarly relevant is patients who have an underlying malignancy who may be receiving chemotherapy or their treatment may have been withheld due to the pandemic from concerns of immunosuppression. Although, low molecular weight heparin is the drug of choice in patients with cancer, recent trials have clearly shown equal efficacy for DOACs and low molecular weight heparin in these patients and appropriate patients (except those with gastrointestinal and genitourinary cancers) may be considered for DOACs treatment of cancer‐associated thrombosis.3.Key N.S. Khorana A.A. Kuderer N.M. et al.Venous thromboembolism prophylaxis and treatment in patients with cancer: ASCO clinical practice guideline update.J Clin Oncol. 2020; 38: 496-520Crossref PubMed Scopus (659) Google Scholar, 4.Raskob G.E. van Es N. Verhamme P. et al.Edoxaban for the treatment of cancer‐associated venous thromboembolism.N Engl J Med. 2018; 378: 615-624Crossref PubMed Scopus (965) Google Scholar, 5.Young A.M. Marshall A. Thirlwall J. et al.Comparison of an oral factor Xa inhibitor with low molecular weight heparin in patients with cancer with venous thromboembolism: results of a randomized trial (SELECT‐D).J Clin Oncol. 2018; 36: 2017-2023Crossref PubMed Scopus (762) Google Scholar, 6.Agnelli G. Becattini C. Meyer G. et al.Caravaggio investigators. apixaban for the treatment of venous thromboembolism associated with Cancer.N Engl J Med. 2020; 382: 1599-1607Crossref PubMed Scopus (431) Google Scholar DOAC are certainly of more practical use than VKA especially during COVID‐19 pandemic because they do not need laboratory monitoring. In addition, they proved safer than VKA in terms of incidence of intracranial bleeding, although it must be emphasized, contrary to what Hermans and Lambert implied in their letter, that they did not prove safer than VKA in terms of incidence of bleeding in other sites (especially gastrointestinal), which may be severe enough to require transfusion of blood products. We do, however, advice caution (not avoidance) with DOACs in patients admitted with COVID‐19 illness (who can continue to take oral medications) for the following reasons•Interactions with antiretroviral drugs should be taken into account since some of these drugs have been considered in the treatment of COVID‐19 pneumonia. We usually check with https://www.hiv‐druginteractions.org/ to ensure co‐prescription is safe•Those who may have unstable kidney function need to be closely monitored when they develop critical illness due to the renal excretion of DOACs and likelihood of accumulation The authors also highlight the importance of extended half‐life hemophilia products and emicizumab in the management of patients with hemophilia in the COVID‐19 pandemic era. Once again, this approach is very advantageous and in keeping with the international guidance of “social distancing” wherein patients do not have to attend hospitals and can have the protection of higher trough factor levels (with extended half‐life hemophilia products) and possibly less bleeding than the conventional therapies. Once the efforts of the selfless medical community all around the world get on top of the pandemic soon, it is important that we retrospectively analyze the lessons learned from our change of practice in these extenuating circumstances and use them to benefit the thrombosis and hemostasis community in the future. JT has received honoraria from Bayer, BMS‐Pfizer, Daichii‐Sankyo, Boehringer, Mitsubishi, Novo Nordisk, Octapharma, Novartis, Amgen, Norgine, Alexion, Sobi, CSL‐Behring. Others declare no conflicts of interest. J Thachil and M Cattaneo drafted the response; all authors agreed and approved the final manuscript.