Qual anticoagulante preferir na TVP (Trombose Venosa Profunda)? Anticoagulantes novos ou Varfarina?

A warfarina (veja posts prévios: Dicas para manejo de anticoagulação com warfarina e CME - Varfarina) tradicionalmente consagrada como principal anticoagulante oral no nosso meio,  compartilha agora espaço com novos anticoagulantes orais anti trombínicos e anti fator Xa (Anticoagulantes direstos).  

O UpToDate em um Practice Changing Uptade dá preferência a eles no tratamento de TVP, exceto em gestantes, pacientes com câncer ativo e insuficiência renal grave. Claro, como sempre, temos que contextualizar para nossa realidade a disponibilidade, custo, preferência do paciente, necessidade de monitorização laboratorial etc.

Agent selection for anticoagulation in venous thromboembolism

Practice Changing UpDate: For long-term anticoagulation for venous thromboembolism in most nonpregnant patients who do not have severe renal insufficiency or active cancer, we suggest a direct oral anticoagulant (ie, apixaban, edoxaban, rivaroxaban, or dabigatran) rather than other agents (Grade 2B). Guidelines for the treatment of acute venous thromboembolism (VTE) were issued by The American College of Chest Physicians (ACCP) [1]. Compared with earlier versions of the guidelines, the direct oral anticoagulants (DOACs) apixaban, edoxaban, rivaroxaban, or dabigatran are now the preferred agents for long-term anticoagulation in patients who are not pregnant and do not have active cancer or severe renal insufficiency. This preference was based upon randomized trials that consistently reported similar efficacy, a lower bleeding risk, and improved convenience when compared with warfarin. We agree with this preference for DOACs in patients with acute VTE, understanding that choosing among anticoagulants frequently depends upon availability and cost as well as patient comorbidities and preferences.

See 'Venous thromboembolism: Long-term anticoagulation, section on 'Selection of agent'.

1. Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e419S. For most non-pregnant patients who do not have severe renal insufficiency (eg, creatinine clearance <30 mL/minute) or active cancer, we suggest a direct oral anticoagulant (ie, apixaban, edoxaban, rivaroxaban, or dabigatran) rather than other agents (Grade 2B). In general, these agents have similar efficacy to warfarin and a lower risk of bleeding; however, access to a reversal agent may be limited. Direct oral anticoagulants are NOT suitable for the treatment of hemodynamically unstable pulmonary embolism (PE), massive iliofemoral deep vein thrombosis (DVT), those who are pregnant, or those with severe renal insufficiency. Dosing of these agents is individualized. (See 'Selection of agent' above and 'Direct thrombin and factor Xa inhibitors' above.)