Choosing Wisely Recommendations
Do not measure the international normalized ratio in patients who are taking an anti-Xa inhibitor.
Rationale and Comments
Anti-Xa inhibitors (e.g., rivaroxaban [Xarelto], apixaban [Eliquis]) are commonly prescribed anticoagulants. Their indications include (but are not limited to) reducing the risk of stroke or systemic embolism in patients with nonvalvular atrial fibrillation; treating deep venous thromboembolism and pulmonary embolism; and deep venous thromboembolism prophylaxis. Bleeding is a common complication from anti-Xa inhibitor use that may require reversal with andexanet alfa, prothrombin complex concentrate, or plasma. Although the international normalized ration (INR) is commonly used to measure the anticoagulation effect of vitamin K antagonists (e.g., warfarin), it is insensitive for anti-Xa inhibitors, potentially leading to inappropriate patient management decisions.
Sponsoring Organizations
- American Society for Clinical Laboratory Science
- American Society for Clinical Pathology
Sources
Disciplines
References
- Gosselin RC, Adcock DM, Bates SM, et al. International Council for Standardization in Haematology (ICSH) recommendations for laboratory measurement of direct oral anticoagulants. Thromb Haemost. 2018;118(3):437-450.
- Milling TJ Jr, Frontera J. Exploring indications for the use of direct oral anticoagulants and the associated risks of major bleeding. Am J Manag Care. 2017;23(4 Suppl):S67-S80.
- Cuker A, Burnett A, Triller D, et al. Reversal of direct oral anticoagulants: guidance from the Anticoagulation Forum. Am J Hematol. 2019;94(6):697-709.
