Anticoagulation: Past, Present, and Future Therapies

Blood clots may cause as many as one-in-four deaths worldwide each year. Approximately, 100,000–300,000 patients die annually from clots in the United States alone, with potentially another 600,000 nonfatal cases. The economic toll is staggering; the United States may lose about $10 billion each year to such afflictions, though it could represent a nearly $55 billion market for drug developers. As more anticoagulants are brought to market, the list of potential indications approved by the Food and Drug Administration (FDA) and off-label use have expanded considerably. Anticoagulation therapy is now offered to those at risk for myocardial infarction, stroke, transient ischemic attack (TIA), and venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). In addition, anticoagulants are now commonly utilized in cases of atrial fibrillation, heart valve replacement, thrombophilia, prolonged immobility, and procoagulant diseases, such as cancer. This chapter discusses key attributes of anticoagulation agents, including their pharmacokinetics, pharmacodynamics, dosing considerations, significant drug interactions, monitoring parameters, and unique considerations for special patient populations. The chapter also provides an overview for converting between anticoagulants, currently available reversal agents, and future directions in anticoagulation therapy and research.