51
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Eikelboom JW, Weitz JI. ‘Real world’ use of non-vitamin K antagonist oral anticoagulants (NOACs): Lessons from the Dresden NOAC Registry. Thromb Haemost 2017; 113:1159-61. [DOI: 10.1160/th15-02-0158] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 02/20/2015] [Indexed: 11/05/2022]
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Darwiche W, Bejan-Angoulvant T, Angoulvant D, Babuty D, Fauchier L. Risk of myocardial infarction and death in patients with atrial fibrillation treated with dabigatran or vitamin K antagonists. Thromb Haemost 2017; 116:1150-1158. [DOI: 10.1160/th16-06-0483] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 08/12/2016] [Indexed: 11/05/2022]
Abstract
SummaryThe safety of dabigatran versus adjusted-dose vitamin K antagonist (VKA) treatment is the subject of debate. We evaluated the risk of myocardial infarction (MI) or mortality in patients with atrial fibrillation (AF) treated in clinical practice with dabigatran or a VKA. We performed a meta-analysis of observational studies that included an adjusted or matched analysis and reported MI, or death in AF patients treated with dabigatran or a VKA. Ten published analyses met the inclusion criteria. Of the 539,559 patients, 17,365 (3%) patients were on dabigatran 110 mg twice daily (bid), 150,948 (28%) were on dabigatran 150 mg bid, and 371,246 (69%) were on VKA. Adjusted risk for MI versus VKA was 0.71 (0.47–1.07; p=0.10) in patients starting oral anticoagulant (OAC) treatment with dabigatran 110 mg, 0.82 (0.71–0.96; p=0.01) in patients starting dabigatran 150 mg, 1.40 (1.04–1.88; p=0.03) in patients switching OAC treatment to dabigatran 110 mg, and 1.28 (0.88–1.87; p=0.19) in patients switching OAC treatment to dabigatran 150 mg, with statistical homogeneity in each subgroup. Risk of death was consistently lower in patients treated with dabigatran 110 mg (HR 0.79; 0.65–0.96; p=0.02) or 150 mg (HR 0.65; 0.57–0.73; p<0.00001) versus VKA. In conclusion, dabigatran use, as currently prescribed in routine practice for AF patients, was associated with a lower risk of MI in OAC-naïve patients treated with dabigatran 150 mg compared with VKA, and a higher risk of MI in patients switching from VKA to dabigatran 110 mg. Risk of death was lower in AF patients treated with either dose of dabigatran versus VKA.
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53
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Tham MY, Ye Q, Ang PS, Fan LY, Yoon D, Park RW, Ling ZJ, Yip JW, Tai BC, Evans SJ, Sung C. Application and optimisation of the Comparison on Extreme Laboratory Tests (CERT) algorithm for detection of adverse drug reactions: Transferability across national boundaries. Pharmacoepidemiol Drug Saf 2017; 27:87-94. [PMID: 29108136 DOI: 10.1002/pds.4340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 09/25/2017] [Accepted: 09/27/2017] [Indexed: 11/07/2022]
Abstract
PURPOSE The Singapore regulatory agency for health products (Health Sciences Authority), in performing active surveillance of medicines and their potential harms, is open to new methods to achieve this goal. Laboratory tests are a potential source of data for this purpose. We have examined the performance of the Comparison on Extreme Laboratory Tests (CERT) algorithm, developed by Ajou University, Korea, as a potential tool for adverse drug reaction detection based on the electronic medical records of the Singapore health care system. METHODS We implemented the original CERT algorithm, comparing extreme laboratory results pre- and post-drug exposure, and 5 variations thereof using 4.5 years of National University Hospital (NUH) electronic medical record data (31 869 588 laboratory tests, 6 699 591 drug dispensings from 272 328 hospitalizations). We investigated 6 drugs from the original CERT paper and an additional 47 drugs. We benchmarked results against a reference standard that we created from UpToDate 2015. RESULTS The original CERT algorithm applied to all 53 drugs and 44 laboratory abnormalities yielded a positive predictive value (PPV) and sensitivity of 50.3% and 54.1%, respectively. By raising the minimum number of cases for each drug-laboratory abnormality pair from 2 to 400, the PPV and sensitivity increased to 53.9% and 67.2%, respectively. This post hoc variation, named CERT400, performed particularly well for drug-induced hepatic and renal toxicities. DISCUSSION We have demonstrated that the CERT algorithm can be applied across national boundaries. One modification (CERT400) was able to identify adverse drug reaction signals from laboratory data with reasonable PPV and sensitivity, which indicates potential utility as a supplementary pharmacovigilance tool.
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Affiliation(s)
- Mun Yee Tham
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore
| | - Qing Ye
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore.,Genome Institute of Singapore, Agency for Science and Technology, Singapore
| | - Pei San Ang
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore
| | - Liza Y Fan
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore.,Genome Institute of Singapore, Agency for Science and Technology, Singapore
| | - Dukyong Yoon
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Republic of Korea.,Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon, Republic of Korea
| | - Rae Woong Park
- Department of Biomedical Informatics, Ajou University School of Medicine, Suwon, Republic of Korea.,Department of Biomedical Sciences, Ajou University Graduate School of Medicine, Suwon, Republic of Korea
| | - Zheng Jye Ling
- Academic Informatics Office, National University Health System, Singapore
| | - James W Yip
- Academic Informatics Office, National University Health System, Singapore
| | - Bee Choo Tai
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Stephen Jw Evans
- Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Cynthia Sung
- Vigilance and Compliance Branch, Health Sciences Authority, Singapore.,Health Services and Systems Research, Duke-NUS Medical School, Singapore
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54
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Miller CS, Dorreen A, Martel M, Huynh T, Barkun AN. Risk of Gastrointestinal Bleeding in Patients Taking Non-Vitamin K Antagonist Oral Anticoagulants: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2017; 15:1674-1683.e3. [PMID: 28458008 DOI: 10.1016/j.cgh.2017.04.031] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 03/13/2017] [Accepted: 04/09/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Non-vitamin K antagonist oral anticoagulants (NOACs) are convenient and effective in the prevention and treatment of venous thromboembolism and the prevention of stroke in patients with atrial fibrillation. However, these drugs have been associated with an increased risk of gastrointestinal (GI) bleeding. We conducted a systematic review and meta-analysis to determine the risk of GI bleeding in patients receiving these drugs. METHODS We searched the EMBASE, Medline, Cochrane, and ISI Web of knowledge databases through January 2016 for randomized trials that compared NOACs with conventional anticoagulants for approved indications. We conducted a meta-analysis, reporting odds ratios (ORs) with 95% confidence intervals (CIs). The primary outcome was major GI bleeding. Secondary outcomes included clinically relevant nonmajor bleeding and upper and lower GI bleeding. We performed a priori subgroup analyses by individual drug. RESULTS Our analysis included a total of 43 randomized trials, comprising 166,289 patients. There was no difference between NOACs and conventional anticoagulants in the risk of major bleeding (1.5% vs 1.3%, respectively; OR, 0.98; 95% CI, 0.80-1.21), clinically relevant nonmajor bleeding (0.6% vs 0.6%, respectively; OR, 0.93; 95% CI, 0.64-1.36), upper GI bleeding (1.5% vs 1.6%, respectively; OR, 0.96; 95% CI, 0.77-1.20), or lower GI bleeding (1.0% vs 1.0%, respectively; OR, 0.88; 95% CI, 0.67-1.15). Dabigatran (2.0% vs 1.4%, respectively; OR, 1.27; 95% CI, 1.04-1.55) and rivaroxaban (1.7% vs 1.3%, respectively; OR, 1.40; 95% CI, 1.15-1.70) were associated with increased odds of major GI bleeding compared with conventional anticoagulation, whereas no difference was found for apixaban (0.6% vs 0.7%, respectively; OR, 0.81; 95% CI, 0.64-1.02) or edoxaban (1.9% vs 1.6%, respectively; OR, 0.93; 95% CI, 0.78-1.11). These subgroup findings were not observed in other sensitivity analyses. CONCLUSIONS In a systematic review and meta-analysis, we found risk of major GI bleeding to be similar between NOACs and conventional anticoagulation. Dabigatran and rivaroxaban, however, may be associated with increased odds of major GI bleeding. Further high-quality studies are needed to characterize GI bleeding risk among NOACs.
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Affiliation(s)
- Corey S Miller
- Internal Medicine Residency Training Program, Department of Medicine, McGill University, Montreal, Canada
| | - Alastair Dorreen
- Division of Gastroenterology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Myriam Martel
- Department of Epidemiology and Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Thao Huynh
- Division of Cardiology, McGill University Health Center, McGill University, Montreal, Canada
| | - Alan N Barkun
- Department of Epidemiology and Biostatistics and Occupational Health, McGill University, Montreal, Canada; Division of Gastroenterology, McGill University Health Center, McGill University, Montreal, Canada.
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55
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Arora A, Jalali RK, Vohora D. Relevance of the Weber effect in contemporary pharmacovigilance of oncology drugs. Ther Clin Risk Manag 2017; 13:1195-1203. [PMID: 28979130 PMCID: PMC5602442 DOI: 10.2147/tcrm.s137144] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Numerous reporting biases have been known to affect spontaneous reporting databases. The Weber effect, which constitutes a peak in adverse event (AE) reporting of a drug at the end of second year after regulatory approval followed by a continuous decline thereafter, has been considered an important bias for a long time. The existence of this bias in AE reporting of oncology drugs remains an underevaluated area, prompting a targeted examination. Methods The US Food and Drug Administration (USFDA) Adverse Event Reporting System (FAERS) was studied for AE reporting patterns of 5 years of 15 new molecular entities (NMEs) and biologics used in oncology. This 5-year period started from the USFDA date of approval for the NMEs and biologics. The number of AEs reported for each of the drugs was plotted against time (years). The AE reporting patterns were specifically examined for the existence of the Weber effect. In addition, AE reporting rate patterns of 5 years of seven NMEs and biologics used in oncology were examined. Results A total of 50,630 AE reports were logged in to the FAERS for all 15 drugs examined for AE reporting patterns. We observed five distinct AE reporting patterns for 15 drugs; however, none of the AE patterns were identical to the Weber effect. We did not observe a consistent AE reporting rate pattern for the seven drugs examined for AE reporting rates. With the exception of one drug (cetuximab), none of the drugs exhibited a second-year peak in AE reporting rates. This peak was not followed by continuous decline in AE reporting rate thereafter. Conclusion This study does not support the existence of the Weber effect in AE reporting of oncology drugs. The contemporary AE reporting of oncology drugs does not exhibit a consistent pattern.
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Affiliation(s)
- Ankur Arora
- School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India.,Medical Affairs and Clinical Research, Sun Pharmaceutical Industries Limited, Gurgaon, Haryana, India
| | - Rajinder K Jalali
- School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India.,Medical Affairs and Clinical Research, Sun Pharmaceutical Industries Limited, Gurgaon, Haryana, India
| | - Divya Vohora
- School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India
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56
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Walsh M, Fritz S, Hake D, Son M, Greve S, Jbara M, Chitta S, Fritz B, Miller A, Bader MK, McCollester J, Binz S, Liew-Spilger A, Thomas S, Crepinsek A, Shariff F, Ploplis V, Castellino FJ. Targeted Thromboelastographic (TEG) Blood Component and Pharmacologic Hemostatic Therapy in Traumatic and Acquired Coagulopathy. Curr Drug Targets 2017; 17:954-70. [PMID: 26960340 PMCID: PMC5374842 DOI: 10.2174/1389450117666160310153211] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 10/13/2015] [Accepted: 12/15/2015] [Indexed: 12/17/2022]
Abstract
Trauma-induced coagulopathy (TIC) is a recently described condition which traditionally has been diagnosed by the common coagulation tests (CCTs) such as prothrombin time/international normalized ratio (PT/INR), activated partial thromboplastin time (aPTT), platelet count, and fibrinogen levels. The varying sensitivity and specificity of these CCTs have led trauma coagulation researchers and clinicians to use Viscoelastic Tests (VET) such as Thromboelastography (TEG) to provide Targeted Thromboelastographic Hemostatic and Adjunctive Therapy (TTHAT) in a goal directed fashion to those trauma patients in need of hemostatic resuscitation. This review describes the utility of VETs, in particular, TEG, to provide TTHAT in trauma and acquired non-trauma-induced coagulopathy.
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Affiliation(s)
- Mark Walsh
- Memorial Hospital of South Bend, South Bend, Indiana 46601, USA.
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Hellenbart EL, Faulkenberg KD, Finks SW. Evaluation of bleeding in patients receiving direct oral anticoagulants. Vasc Health Risk Manag 2017; 13:325-342. [PMID: 28860793 PMCID: PMC5574591 DOI: 10.2147/vhrm.s121661] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are recognized by evidence-based treatment guidelines as the first-line option for the treatment of venous thromboembolism and prevention of stroke and systemic embolism in nonvalvular atrial fibrillation. As use of these anticoagulants has become favored over the past several years, reported bleeding-related adverse drug events with these agents has increased. In randomized clinical trials, all DOACs have a reduced risk for intracranial hemorrhage, while major and other bleeding results have varied among the agents compared to vitamin K antagonists. We have reviewed the bleeding incidence and severity from randomized and real-world data in patients receiving DOACs in an effort to provide the clinician with a critical review of bleeding and offer practical considerations for avoiding adverse events with these anticoagulants.
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Affiliation(s)
| | | | - Shannon W Finks
- University of Tennessee College of Pharmacy, Memphis, TN, USA
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58
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Vornicu O, Larock AS, Dincq AS, Douxfils J, Dogné JM, Mullier F, Lessire S. Idarucizumab for the treatment of hemorrhage and dabigatran reversal in patients requiring urgent surgery or procedures. Expert Opin Biol Ther 2017; 17:1275-1296. [DOI: 10.1080/14712598.2017.1349749] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Ovidiu Vornicu
- Department of Anesthesiology, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Anne-Sophie Larock
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Department of Pharmacy, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Anne-Sophie Dincq
- Department of Anesthesiology, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| | - Jonathan Douxfils
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Université de Namur, Namur, Belgium
| | - Jean-Michel Dogné
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Université de Namur, Namur, Belgium
| | - François Mullier
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Hematology Laboratory, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Sarah Lessire
- Department of Anesthesiology, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Université de Namur, Namur, Belgium
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59
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Feagins LA. Management of Anticoagulants and Antiplatelet Agents During Colonoscopy. Am J Med 2017; 130:786-795. [PMID: 28344132 DOI: 10.1016/j.amjmed.2017.01.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 01/31/2017] [Accepted: 01/31/2017] [Indexed: 01/14/2023]
Abstract
Colonoscopy frequently is performed for patients who are taking aspirin, nonsteroidal anti-inflammatory drugs, antiplatelet agents, and other anticoagulants. These colonoscopies often involve polypectomy, which can be complicated by bleeding. The risks of precipitating thromboembolic complications if anticoagulants are stopped must be weighed against the risk of postpolypectomy bleeding if these agents are continued. This article systematically reviews the management of anticoagulation during elective and emergency colonoscopy. For patients undergoing colonoscopic polypectomy, the overall risk of postpolypectomy bleeding is <0.5%. Risk factors for postpolypectomy bleeding include large polyp size and anticoagulant use, especially warfarin and thienopyridines. For patients who do not stop aspirin or other nonsteroidal anti-inflammatory drugs prior to colonoscopy, the rate of postpolypectomy bleeding is not significantly different from that for patients who do not take those medications. For patients who continue thienopyridines and undergo polypectomy, the risk of delayed postpolypectomy bleeding is approximately 2.4%. Even for patients who interrupt warfarin, the risk of postpolypectomy bleeding is increased. The direct oral anticoagulants (direct thrombin inhibitors and factor Xa inhibitors) have a rapid onset and offset of action, and periprocedural bridging generally is not necessary. For the thienopyridines, warfarin, and the direct oral anticoagulants, the decision to interrupt or continue these agents for endoscopy will involve considerable exercise of clinical judgment.
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Affiliation(s)
- Linda Anne Feagins
- Divisions of Gastroenterology and Hepatology, VA North Texas Health Care System, Dallas and the University of Texas Southwestern Medical Center at Dallas.
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60
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Novel Oral Anticoagulants in the Peri-Endoscopic Period. Cardiol Rev 2017; 25:223-229. [PMID: 28604566 DOI: 10.1097/crd.0000000000000149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Millions of patients in the United States are currently prescribed some form of anticoagulation therapy. Recently, novel oral anticoagulants (NOACs), including direct thrombin inhibitors and direct factor Xa inhibitors, have begun to replace warfarin as the drugs of choice for anticoagulation. As the use of these medications becomes more widespread, it is increasingly important for gastroenterologists to understand the risks associated with performing endoscopic procedures on patients who are taking NOACs. In this review, we provide an overview of the NOACs and current guidelines from international societies regarding the management of patients scheduled to undergo endoscopic procedures who are prescribed these medications. Finally, we offer a perspective on future studies required to adequately investigate and characterize the effects that these drugs have on a patient's risk for bleeding in the peri- and/or postprocedural timeframes.
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61
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Di Minno MND, Ambrosino P, Di Minno A, Tremoli E, Di Minno G. The risk of gastrointestinal bleeding in patients receiving dabigatran etexilate: a systematic review and meta-analysis of the literature. Ann Med 2017; 49:329-342. [PMID: 28084107 DOI: 10.1080/07853890.2016.1268710] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Evidence on the risk of gastrointestinal (GI) bleeding associated with dabigatran etexilate (DE) is contrasting. We performed a meta-analysis of literature to address this issue. METHODS AND RESULTS Studies on GI bleeding risk in patients receiving DE or vitamin-K antagonists (VKA) were systematically searched. Twenty-three studies (26 datasets) showed no difference in the GI bleeding risk between the 250,871 patients treated with DE and the 460,386 receiving VKA (OR: 1.052, 95% CI: 0.815, 1.359). Similar results were obtained when pooling together adjusted ORs/HRs, obtained by means of multivariate analysis (OR: 1.06, 95% CI: 0.914, 1.222). Compared with VKA, DE use was associated with a significantly lower risk of upper GI (OR: 0.742, 95% CI: 0.569, 0.968), but not of lower GI bleedings (OR: 1.208, 95% CI: 0.902, 1.619). Furthermore, no significant difference in the GI bleeding risk was found when data on DE 110 mg and DE 150 mg twice-daily were separately compared with VKA. CONCLUSIONS No difference in GI bleeding risk was found between DE and VKA. These results were confirmed for both dosages of DE and when specifically analyzing lower GI bleeding. In contrast, the risk of upper GI bleeding was lower with DE than with VKA. KEY MESSAGES No difference in the risk of gastrointestinal (GI) bleeding can be found between dabigatran etexilate (DE) and vitamin K-antagonists (VKA). These results are confirmed for both dosages of DE. The risk of upper GI bleeding is lower with DE than with VKA.
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Affiliation(s)
- Matteo Nicola Dario Di Minno
- a Department of Advanced Biomedical Sciences, Division of Cardiology , Federico II University , Naples , Italy.,b Centro Cardiologico Monzino, IRCCS , Milan , Italy
| | - Pasquale Ambrosino
- c Department of Clinical Medicine and Surgery , Federico II University , Naples , Italy
| | | | - Elena Tremoli
- b Centro Cardiologico Monzino, IRCCS , Milan , Italy
| | - Giovanni Di Minno
- c Department of Clinical Medicine and Surgery , Federico II University , Naples , Italy
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62
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Nyeland ME, Laursen MV, Callréus T. Evaluating the effectiveness of risk minimisation measures: the application of a conceptual framework to Danish real-world dabigatran data. Pharmacoepidemiol Drug Saf 2017; 26:607-614. [PMID: 28397317 DOI: 10.1002/pds.4203] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Revised: 02/10/2017] [Accepted: 03/05/2017] [Indexed: 01/16/2023]
Abstract
PURPOSE For both marketing authorization holders and regulatory authorities, evaluating the effectiveness of risk minimization measures is now an integral part of pharmacovigilance in the European Union. The overall aim of activities in this area is to assess the performance of risk minimization measures implemented in order to ensure a positive benefit-risk balance in patients treated with a medicinal product. METHODS Following a review of the relevant literature, we developed a conceptual framework consisting of four domains (data, knowledge, behaviour and outcomes) intended for the evaluation of risk minimization measures put into practice in the Danish health-care system. For the implementation of the framework, four classes of monitoring variables can be named and defined: patient descriptors, performance-related indicators of knowledge, behaviour and outcomes. RESULTS We reviewed the features of the framework when applied to historical, real-world data following the introduction of dabigatran in Denmark for the prophylactic treatment of patients with non-valvular atrial fibrillation. CONCLUSIONS The application of the framework provided useful graphical displays and an opportunity for a statistical evaluation (interrupted time series analysis) of a regulatory intervention. © 2017 Commonwealth of Australia. Pharmacoepidemiology & Drug Safety © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
| | | | - Torbjörn Callréus
- Danish Medicines Agency, Copenhagen, Denmark.,Copenhagen Center for Regulatory Science, Copenhagen, Denmark
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63
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Abstract
The standard of care for oral anticoagulation therapy has primarily been warfarin, which is limited by its indirect mechanism-of-action, variable kinetics, tolerability, and routine monitoring concerns. The direct-acting oral anticoagulants (DOACs) have predictable pharmacokinetics and pharmacodynamics, and improved safety and efficacy compared to warfarin for the prevention of stroke in patients with nonvalvular atrial fibrillation and prevention or management of venous thromboembolism. Consequential bleeding is a concern with all anticoagulants. Vitamin K is not a rapid reversal agent for warfarin; rather it facilitates synthesis of new vitamin K-dependent clotting factors, which can take longer than 24 h. Other nonspecific agents, including recombinant activated factor VII, three- and four-factor prothrombin complex concentrates (PCC), and activated PCC or Factor Eight Inhibitor Bypassing Activity (FEIBA®), are options based on clinical need. Specific agents to quickly reverse the effects of DOACs have been under development, and idarucizumab, a monoclonal antibody fragment that rapidly binds dabigatran, has been approved for clinical use in cases of dabigatran-related life-threatening bleeding, or if a dabigatran-treated patient needs emergency surgery or an invasive procedure. Idarucizumab specifically and rapidly reverses dabigatran-induced anticoagulation as measured by established coagulation assays. However, this does not guarantee complete hemostasis, especially if a patient has underlying comorbidities such as renal or liver disease, or has experienced recent trauma that requires urgent surgery. In these cases, concomitant supportive therapy and/or administration of concentrated clotting factors may be considered. Emerging data from ongoing trials and clinical experience will further inform providers regarding optimal approaches for anticoagulation reversal.
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Affiliation(s)
- William E Dager
- a Department of Pharmaceutical Services , University of California, Davis Medical Center , Sacramento , CA , US
| | - Linda Banares
- b Department of Clinical Sciences , Touro University California, College of Pharmacy , Vallejo , CA , US
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64
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Cheung KS, Leung WK. Gastrointestinal bleeding in patients on novel oral anticoagulants: Risk, prevention and management. World J Gastroenterol 2017; 23:1954-1963. [PMID: 28373761 PMCID: PMC5360636 DOI: 10.3748/wjg.v23.i11.1954] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 01/18/2017] [Accepted: 03/02/2017] [Indexed: 02/06/2023] Open
Abstract
Novel oral anticoagulants (NOACs), which include direct thrombin inhibitor (dabigatran) and direct factor Xa inhibitors (rivaroxaban, apixaban and edoxaban), are gaining popularity in the prevention of embolic stroke in non-valvular atrial fibrillation as well as in the prevention and treatment of venous thromboembolism. However, similar to traditional anticoagulants, NOACs have the side effects of bleeding, including gastrointestinal bleeding (GIB). Results from both randomized clinical trials and observations studies suggest that high-dose dabigatran (150 mg b.i.d), rivaroxaban and high-dose edoxaban (60 mg daily) are associated with a higher risk of GIB compared with warfarin. Other risk factors of NOAC-related GIB include concomitant use of ulcerogenic agents, older age, renal impairment, Helicobacter pylori infection and a past history of GIB. Prevention of NOAC-related GIB includes proper patient selection, using a lower dose of certain NOACs and in patients with renal impairment, correction of modifiable risk factors, and prescription of gastroprotective agents. Overt GIB can be managed by withholding NOACs followed by delayed endoscopic treatment. In severe bleeding, additional measures include administration of activated charcoal, use of specific reversal agents such as idarucizumab for dabigatran and andexanent alfa for factor Xa inhibitors, and urgent endoscopic management.
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Clinically relevant non-major bleeding with oral anticoagulants: non-major may not be trivial. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2017; 16:387-391. [PMID: 28488972 DOI: 10.2450/2017.0335-16] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 01/17/2017] [Indexed: 01/05/2023]
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Lauw MN, Eikelboom JW, Coppens M, Wallentin L, Yusuf S, Ezekowitz M, Oldgren J, Nakamya J, Wang J, Connolly SJ. Effects of dabigatran according to age in atrial fibrillation. Heart 2017; 103:1015-1023. [PMID: 28213368 DOI: 10.1136/heartjnl-2016-310358] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 01/02/2017] [Accepted: 01/03/2017] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE The prevalence of atrial fibrillation (AF) and the risk of stroke and bleeding vary according to age. To estimate effects of dabigatran, compared with warfarin, on stroke, bleeding and mortality in patients with AF in the Randomized Evaluation of Long-Term Anticoagulant Therapy (RE-LY) trial according to age, we analysed treatment effects using age as a continuous variable and using age categories. METHODS RE-LY included 10 855 (59.9%) patients aged <75 years, 4231 patients (23.4%) aged 75-79 years, 2305 (12.7%) aged 80-84 years and 722 (4.0%) aged ≥85 years at baseline. RESULTS Benefits of dabigatran versus warfarin regarding stroke (HR range 0.63 (95% CI 0.46 to 0.86) to 0.70 (0.31 to 1.57) for dabigatran 150 mg twice daily), HR range 0.52 (0.21 to 1.29) to 1.08 (0.73 to 1.60) for dabigatran 110 mg twice daily) and intracranial bleeding were maintained across all age groups (interaction p values all not significant). There was a highly significant interaction (p value interaction <0.001) between age and treatment for extracranial major bleeding, with lower rates with both doses of dabigatran compared with warfarin in younger patients (HR 0.78 (0.62 to 0.97) for 150 mg twice daily, HR 0.72 (0.57 to 0.90) for 110 mg twice daily) but similar (HR 1.50 (1.03 to 2.18) for 110 mg twice daily) or higher rates (HR 1.68 (1.18 to 2.41) for 150 mg twice daily) in older patients (≥80 years). CONCLUSION Effects of dabigatran compared with warfarin on stroke prevention and intracranial bleeding are consistent across all age groups. Effects of dabigatran on extracranial major bleeding are age dependent, supporting selection of dabigatran 110 mg twice daily for elderly patients (age ≥80 years). TRIAL REGISTRATION NUMBER Clinical trial registration number: https://clinicaltrials.gov NCT00262600.
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Affiliation(s)
- Mandy N Lauw
- McMaster University and Hamilton Health Sciences, Population Health Research Institute, Hamilton, Ontario, Canada.,Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - John W Eikelboom
- McMaster University and Hamilton Health Sciences, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Michiel Coppens
- McMaster University and Hamilton Health Sciences, Population Health Research Institute, Hamilton, Ontario, Canada.,Department of Vascular Medicine, Academic Medical Center, Amsterdam, The Netherlands
| | - Lars Wallentin
- Department of Medical Sciences, Clinical Research Center, University of Uppsala, Uppsala, Sweden
| | - Salim Yusuf
- McMaster University and Hamilton Health Sciences, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Michael Ezekowitz
- Jefferson Medical College and Lankenau Medical Center, Philadelphia, Pennsylvania, USA.,Cardiovascular Research Foundation, New York, New York, USA
| | - Jonas Oldgren
- Department of Medical Sciences, Clinical Research Center, University of Uppsala, Uppsala, Sweden
| | - Juliet Nakamya
- McMaster University and Hamilton Health Sciences, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jia Wang
- McMaster University and Hamilton Health Sciences, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Stuart J Connolly
- McMaster University and Hamilton Health Sciences, Population Health Research Institute, Hamilton, Ontario, Canada
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Affiliation(s)
- Audrey L Gassman
- From the Division of Bone, Reproductive, and Urologic Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD
| | - Christine P Nguyen
- From the Division of Bone, Reproductive, and Urologic Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD
| | - Hylton V Joffe
- From the Division of Bone, Reproductive, and Urologic Products, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD
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Becattini C, Franco L, Beyer-Westendorf J, Masotti L, Nitti C, Vanni S, Manina G, Cattinelli S, Cappelli R, Sbrojavacca R, Pomero F, Marten S, Agnelli G. Major bleeding with vitamin K antagonists or direct oral anticoagulants in real-life. Int J Cardiol 2017; 227:261-266. [DOI: 10.1016/j.ijcard.2016.11.117] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 11/06/2016] [Indexed: 10/20/2022]
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Sauter TC, Melis C, Hautz WE, Ricklin ME, Exadaktylos AK. Direct new oral anticoagulants: follow-up, guidelines and bleeding complications in general practice-a survey of Swiss general internal medicine practitioners. SPRINGERPLUS 2016; 5:2030. [PMID: 27995007 PMCID: PMC5126033 DOI: 10.1186/s40064-016-3722-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 11/21/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND The present study investigated how much Swiss general internal medicine practitioners (GPs) know about new direct oral anticoagulants (NOACs), particularly the relevant guidelines, follow-up tests, dosing adjustments, indications and complications. We conducted a paper-based survey of GPs, performed in Bern, Switzerland. Our questionnaire assessed the physicians' preference for NOACs rather than vitamin K antagonists (VKA), prevalence and choice of NOAC, clinical follow-up including follow-up blood testing, and bleeding complications. RESULTS 53 GPs participated in our pilot investigation. They treated 32.7% ± 19 of their patients requiring oral anticoagulation with NOACs. New patients who had started oral anticoagulation received NOACs from 49 GPs (92.5%) but most GPs would not switch patients from existing VKA therapy to NOACs. Clinical controls are scheduled by a majority of GPs (67.9%) at least every 3 months; creatinine and haemoglobin are monitored by most GPs (51 (96.2%) and 39 (73.6%), respectively). In the preceding 2 years, GPs had seen 1.9 ± 2.87 bleeding complications in patients with NOACs. 0.5 ± 0.95 (range 0-5) of these required hospital treatment. CONCLUSION NOACs are broadly accepted by investigated Swiss GPs as the first choice for patients newly requiring oral anticoagulation. This was in preference to VKAs and especially if recommended by a haematologist or cardiologist. As, in our population, only about two-thirds of GPs adhere to recommendations on clinical and blood test follow-ups, further efforts to implement follow-up guidelines seem necessary. Further research in a large representative GP population is recommended; this should compare NOACs and VKAs. Bleeding complications were rare in our population and could mostly be handled without hospital admission.
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Affiliation(s)
- Thomas C. Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Carlo Melis
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Wolf E. Hautz
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Meret E. Ricklin
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
| | - Aristomenis K. Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse, 3010 Bern, Switzerland
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71
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Chronic anticoagulation in non-valvular atrial fibrillation: Where things stand. Int J Cardiol 2016; 222:615-619. [DOI: 10.1016/j.ijcard.2016.07.271] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/29/2016] [Accepted: 07/30/2016] [Indexed: 11/17/2022]
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Abstract
Direct oral anticoagulants (DOACs) have been marketed in the United States since 2010. While numerous large-scale prospective phase 3 outcomes studies have documented the effectiveness of DOACs for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, the primary safety concern with all of these drugs-as it is with the more established oral anticoagulant warfarin-is the risk of major bleeding. Postmarketing surveillance studies (PMSS) provide the opportunity to evaluate the safety of these recently approved drugs across a spectrum of patients that may be broader than those included in randomized controlled trials. This review will summarize the safety findings of numerous recently performed, large-scale PMSS evaluations, and consider the currently available evidence regarding the risks for bleeding in patients treated with DOACs, in order to give providers and patients additional evidence regarding the safety of DOACs.
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Affiliation(s)
- Todd C Villines
- Department of Medicine, Cardiology Service, Walter Reed National Military Medical Center, Bethesda, MD
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX.
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Dong K, Song Y, Li X, Ding J, Gao Z, Lu D, Zhu Y. Pentasaccharides for the prevention of venous thromboembolism. Cochrane Database Syst Rev 2016; 10:CD005134. [PMID: 27797404 PMCID: PMC6463830 DOI: 10.1002/14651858.cd005134.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common condition with potentially serious and life-threatening consequences. The standard method of thromboprophylaxis uses an anticoagulant such as low molecular weight heparin (LMWH) or warfarin. In recent years, another type of anticoagulant, pentasaccharide, an indirect factor Xa inhibitor, has shown good anticoagulative effect in clinical trials. Three types of pentasaccharides are available: short-acting fondaparinux, long-acting idraparinux and idrabiotaparinux. Pentasaccharides cause little heparin-induced thrombocytopenia and are better tolerated than unfractionated heparin, LMWH and warfarin. However, no consensus has been reached on whether pentasaccharides are superior or inferior to other anticoagulative methods. OBJECTIVES To assess effects of pentasaccharides versus other methods of thromboembolic prevention (thromboprophylaxis) in people who require anticoagulant treatment to prevent venous thromboembolism. SEARCH METHODS The Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (last searched March 2016) and the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 2). The CIS searched trial databases for details of ongoing and unpublished studies. Review authors searched LILACS (Latin American and Caribbean Health Sciences) and the reference lists of relevant studies and reviews identified by electronic searches. SELECTION CRITERIA We included randomised controlled trials on any type of pentasaccharide versus other anticoagulation methods (pharmaceutical or mechanical) for VTE prevention. DATA COLLECTION AND ANALYSIS Two review authors independently selected trials, assessed methodological quality and extracted data in predesigned tables. MAIN RESULTS We included in this review 25 studies with a total of 21,004 participants. All investigated fondaparinux for VTE prevention; none investigated idraparinux or idrabiotaparinux. Studies included participants undergoing abdominal surgery, thoracic surgery, bariatric surgery or coronary bypass surgery; acutely ill hospitalised medical patients; people requiring rigid or semirigid immobilisation; and those with superficial venous thrombosis. Most studies focused on orthopaedic patients. We lowered the quality of the evidence because of heterogeneity between studies and a small number of events causing imprecision.When comparing fondaparinux with placebo, we found less total VTE (risk ratio (RR) 0.24, 95% confidence interval (CI) 0.15 to 0.38; 5717 participants; 8 studies; I2 = 64%; P < 0.00001), less symptomatic VTE (RR 0.15, 95% CI 0.06 to 0.36; 6503 participants; 8 studies; I2 = 0%; P < 0.0001), less total DVT (RR 0.25, 95% CI 0.15 to 0.40; 5715 participants; 8 studies; I2 = 67%; P < 0.00001), less proximal DVT (RR 0.12, 95% CI 0.04 to 0.39; 2746 participants; 7 studies; I2 = 64%; P = 0.0004) and less total pulmonary embolism (PE) (RR 0.16, 95% CI 0.04 to 0.62; 6412 participants; 8 studies; I2 = 0%; P = 0.008) in the fondaparinux group. The quality of the evidence was moderate for total VTE, total DVT and proximal DVT, and high for symptomatic VTE and total PE.When fondaparinux was compared with LMWH, analyses indicated that fondaparinux reduced total VTE and DVT (RR 0.55, 95% CI 0.42 to 0.73; 9339 participants; 11 studies; I2 = 64%; P < 0.0001; and RR 0.54, 95% CI 0.40 to 0.71; 9356 participants; 10 studies; I2 = 67%; P < 0.0001, respectively), and showed a trend toward reduced proximal DVT (RR 0.58, 95% CI 0.33 to 1.02; 8361 participants; 9 studies; I2 = 53%; P = 0.06). Symptomatic VTE (RR 1.03, 95% CI 0.65 to 1.63; 12240 participants; 9 studies; I2 = 35%; P = 0.90) and total PE (RR 1.24, 95% CI 0.65 to 2.34; 12350 participants; 10 studies; I2 = 0%; P = 0.51) indicated no difference between fondaparinux and LMWH. The quality of the evidence was moderate for total VTE, symptomatic VTE, total DVT and total PE, and low for proximal DVT.We showed that fondaparinux increased major bleeding compared with both placebo and LWMH (RR 2.56, 95% CI 1.48 to 4.44; 6659 participants; 8 studies; I2 = 0%; P = 0.0008; moderate-quality evidence; and RR 1.38, 95% CI 1.09 to 1.75; 12,501 participants; 11 studies; I2 = 24%; P = 0.008; high-quality evidence, respectively). All-cause mortality was not different between fondaparinux and placebo or LMWH (RR 0.76, 95% CI 0.48 to 1.22; 6674 participants; 8 studies; I2 = 14%; P = 0.26; moderate-quality evidence; and RR 0.88, 95% CI 0.63 to 1.22; 12,400 participants; 11 studies; I2 = 0%; P = 0.44; moderate-quality evidence, respectively).One study compared fondaparinux with variable and fixed (1 mg per day) doses of warfarin after elective hip or knee replacement surgery and showed no difference in primary and secondary outcomes between fondaparinux and both variable and fixed doses of warfarin. The quality of the evidence was very low. One small study compared fondaparinux with edoxaban in patients with severe renal impairment undergoing lower-limb orthopaedic surgery and reported no thromboembolic events, major bleeding events or deaths in either group. The quality of the evidence was very low. One small study compared fondaparinux with mechanical thromboprophylaxis. Results showed no difference in total VTE and total DVT between fondaparinux and mechanical thromboprophylaxis. This study reported no cases pertaining to the other outcomes of this review. The quality of the evidence was low.There were insufficient studies to permit meaningful conclusions for subgroups of clinical conditions other than orthopaedic surgery. AUTHORS' CONCLUSIONS Moderate to high quality evidence shows that fondaparinux is effective for short-term prevention of VTE when compared with placebo. It can reduce total VTE, DVT, total PE and symptomatic VTE, and does not demonstrate a reduction in deaths compared with placebo. Low to moderate quality evidence shows that fondaparinux is more effective for short-term VTE prevention when compared with LMWH. It can reduce total VTE and total DVT and does not demonstrate a reduction in deaths when compared with LMWH. However, at the same time, moderate to high quality evidence shows that fondaparinux increases major bleeding when compared with placebo and LMWH. Therefore, when fondaparinux is chosen for the prevention of VTE, attention should be paid to the person's bleeding and thrombosis risks. Most data were derived from patients undergoing orthopaedic surgery. Therefore, the conclusion predominantly pertains to these patients. Data on fondaparinux for other clinical conditions are sparse.
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Affiliation(s)
- Kezhou Dong
- The 2nd Jiangsu Province Hospital of TCM, Nanjing University of Chinese MedicineDepartment of RespirationNo.155, Hanzhong RoadNanjingChina
| | - Yanzhi Song
- Shanghai Daopei Hospital, Fudan UniversityShanghaiChina
| | - Xiaodong Li
- BenQ Medical Center, Nanjing Medical UniversityDepartment of RadiotherapyNanjingJiangsu ProvinceChina210019
| | - Jie Ding
- National Institute on Aging, NIHLaboratory of Epidemiology and Population Science7201 Wisconsin Ave, Suite 3C‐309BethesdaMarylandUSAMD 20814
| | - Zhiyong Gao
- Shanghai Daopei Hospital, Fudan UniversityShanghaiChina
| | - Daopei Lu
- Shanghai Daopei Hospital, Fudan UniversityShanghaiChina
| | - Yimin Zhu
- The 2nd Jiangsu Province Hospital of TCM, Nanjing University of Chinese MedicineDepartment of RespirationNo.155, Hanzhong RoadNanjingChina
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Singer AJ, Quinn A, Dasgupta N, Thode HC. Management and Outcomes of Bleeding Events in Patients in the Emergency Department Taking Warfarin or a Non-Vitamin K Antagonist Oral Anticoagulant. J Emerg Med 2016; 52:1-7.e1. [PMID: 27793500 DOI: 10.1016/j.jemermed.2016.09.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 09/08/2016] [Accepted: 09/15/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Most comparisons of bleeding patients who are taking warfarin or a non-vitamin K oral anticoagulant (NOAC) have been limited to admitted patients and major bleeding events in well-controlled, clinical trial settings. OBJECTIVES We describe the clinical characteristics, interventions, and outcomes in patients who are taking warfarin or a NOAC who presented to the emergency department (ED) with any bleeding event. METHODS We conducted a structured, retrospective, observational study of nonvalvular atrial fibrillation, pulmonary embolism, or deep vein thrombosis warfarin- or NOAC-treated patients presenting with any bleeding event to a large, academic ED between January 2012 and March 2015. We used descriptive statistics to summarize baseline characteristics, treatments, and outcomes and performed subgroup analyses based on the type of anticoagulant and site of bleeding. RESULTS The electronic search yielded 95 cases of patients taking a NOAC (i.e., dabigatran [33], rivaroxaban [32], or abixaban [30]) and 342 patients taking warfarin. Reversal agents were rarely used in all anticoagulant groups. Case fatality rates were similar among warfarin- and NOAC-treated patients for gastrointestinal bleeding (7% vs. 7%) and intracranial hemorrhage (18% vs. 4%), respectively. After adjustment for other factors, only intracranial hemorrhage (odds ratio 4.4; 95% confidence interval 1.4-13.3) was associated with mortality. CONCLUSIONS Despite the rare use of reversal strategies, mortality was low and outcomes were comparable among patients with bleeding events presenting to the ED while taking a NOAC compared with warfarin.
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Affiliation(s)
- Adam J Singer
- Department of Emergency Medicine, Stony Brook Medicine, Stony Brook, New York.
| | - Adam Quinn
- Department of Emergency Medicine, Stony Brook Medicine, Stony Brook, New York
| | - Neil Dasgupta
- Department of Emergency Medicine, Stony Brook Medicine, Stony Brook, New York
| | - Henry C Thode
- Department of Emergency Medicine, Stony Brook Medicine, Stony Brook, New York
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Decision-making about the use of non-vitamin K oral anticoagulant therapies for patients with atrial fibrillation. J Thromb Thrombolysis 2016; 41:234-40. [PMID: 26343041 DOI: 10.1007/s11239-015-1276-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Until recently, vitamin K antagonists, warfarin being the most commonly used agent in the United States, have been the only oral anticoagulant therapies available to prevent stroke in patients with atrial fibrillation (AF). In the last 5 years four new, non-vitamin K oral anticoagulants, the so-called NOACs or novel oral anticoagulants, have come to market and been approved by the Federal Drug Administration. Despite comparable if not superior efficacy in preventing AF-related stroke, and generally lower risks of major hemorrhage, particularly intracranial bleeding, the uptake of these agents has been slow. A number of barriers stand in the way of the more widespread use of these novel agents. Chief among them is concern about the lack of antidotes or reversal agents. Other concerns include the need for strict medication adherence, since missing even a single dose can lead to a non-anticoagulated state; out-of-pocket costs for patients; the lack of easily available laboratory tests to quantitatively assess the level of anticoagulant activity when these agents are being used; contraindications to use in patients with severe chronic kidney disease; and black-box warnings about the increased risk of thromboembolic events if these agents are discontinued prematurely. Fortunately, a number of reversal agents are in the pipeline. Three reversal agents, idarucizumab, andexanet alfa, and aripazine, have already progressed to human studies and show great promise as either antidotes for specific drugs or as universal reversal agents. The availability of these reversal agents will likely increase the clinical use of the non-vitamin K oral anticoagulants. In light of the many complex and nuanced issues surrounding the choice of an optimal anticoagulant for any AF patient, a patient-centered/shared decision-making approach will be useful.
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Deville L, Konan M, Hij A, Goldwirt L, Peyrony O, Fieux F, Faure P, Madelaine I, Villiers S, Farge-Bancel D, Frère C. Major bleeding complications in patients treated with direct oral anticoagulants: One-year observational study in a Paris Hospital. Curr Res Transl Med 2016; 64:129-133. [PMID: 27765272 DOI: 10.1016/j.retram.2016.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2016] [Revised: 02/10/2016] [Accepted: 02/12/2016] [Indexed: 12/17/2022]
Abstract
Direct oral anticoagulants (DAOC) are indicated for the treatment of venous thromboembolism and the prevention of stroke or systemic embolism in patients with non-valvular atrial fibrillation. Given their advantages and friendly use for patient, the prescription of long term DOAC therapy has rapidly increased both as first line treatment while initiating anticoagulation and as a substitute to vitamins K antagonist (VKA) in poorly controlled patients. However, DOAC therapy can also be associated with significant bleeding complications, and in the absence of specific antidote at disposal, treatment of serious hemorrhagic complications under DOAC remains complex. We report and discuss herein five cases of major hemorrhagic complications under DOAC, which were reported to the pharmacological surveillance department over one year at Saint-Louis University Hospital (Paris, France). We further discuss the need for careful assessment of the risk/benefit ratio at time of starting DOAC therapy in daily clinical practice.
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Affiliation(s)
- L Deville
- Service de pharmacie, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - M Konan
- Unité de médecine interne et pathologie vasculaire, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 1, avenue Claude-Vellefaux, 75010 Paris, France; Service de médecine interne, CHU de Treichville, Abidjan, Côte d'Ivoire
| | - A Hij
- Unité de médecine interne et pathologie vasculaire, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - L Goldwirt
- Unité de pharmacologie, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - O Peyrony
- Service des urgences, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - F Fieux
- Service de réanimation chirurgicale, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - P Faure
- Service de pharmacie, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - I Madelaine
- Service de pharmacie, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - S Villiers
- Service d'anesthésie réanimation, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - D Farge-Bancel
- Unité de médecine interne et pathologie vasculaire, hôpital Saint-Louis, Assistance publique-Hôpitaux de Paris, 1, avenue Claude-Vellefaux, 75010 Paris, France
| | - C Frère
- Service d'hématologie biologique, CHU Timone, Assistance publique-Hôpitaux de Marseille, 264, rue Saint-Pierre, 13385 Marseille, France; Inserm UMRS 1076, VRCM, Aix-Marseille université, 13385 Marseille, France.
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Villines TC, Peacock WF. Safety of direct oral anticoagulants: insights from postmarketing studies. Am J Emerg Med 2016; 34:9-13. [PMID: 27697441 DOI: 10.1016/j.ajem.2016.09.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Direct oral anticoagulants (DOACs) have been marketed in the United States since 2010. While numerous large-scale prospective phase 3 outcomes studies have documented the effectiveness of DOACs for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, the primary safety concern with all of these drugs-as it is with the more established oral anticoagulant warfarin-is the risk of major bleeding. Postmarketing surveillance studies (PMSS) provide the opportunity to evaluate the safety of these recently approved drugs across a spectrum of patients that may be broader than those included in randomized controlled trials. This review will summarize the safety findings of numerous recently performed, large-scale PMSS evaluations, and consider the currently available evidence regarding the risks for bleeding in patients treated with DOACs, in order to give providers and patients additional evidence regarding the safety of DOACs.
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Affiliation(s)
- Todd C Villines
- Department of Medicine, Cardiology Service, Walter Reed National Military Medical Center, Bethesda, MD
| | - W Frank Peacock
- Department of Emergency, Medicine, Baylor College of Medicine, Houston, TX.
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Nonvitamin K antagonist oral anticoagulant activity: challenges in measurement and reversal. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:273. [PMID: 27659071 PMCID: PMC5034528 DOI: 10.1186/s13054-016-1422-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Four nonvitamin K antagonist oral anticoagulants (NOACs) are approved for the prevention of stroke in patients with nonvalvular atrial fibrillation and for the treatment of venous thromboembolism. These include the direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors rivaroxaban, apixaban, and edoxaban. Bleeding is a complication for all anticoagulants and concerns regarding bleeding risk and the suitability of effective reversal strategies may be a barrier to their prescription. Despite the reduced risk of bleeding compared with vitamin K antagonists, questions persist regarding the management of bleeding related to NOAC use. Main text To date, although a number of assays are responsive to NOACs, no single routine laboratory test has been identified to accurately measure the clinical anticoagulation state of patients on NOACs or established as a reliable predictor of bleeding risk. In addition, the establishment of a reliable human bleeding model to test novel inhibitors of the coagulation cascade has proved challenging. Although routine monitoring of anticoagulant levels is not necessary in patients taking NOACs, anticoagulant reversal and a means of measuring reversal may be required for patients who present with bleeding or require urgent surgery. Prothrombin complex concentrates are pooled plasma products containing varying amounts of inactive vitamin K-dependent clotting factors in addition to vitamin K-dependent proteins and can replenish factors in the intrinsic and extrinsic coagulation cascade, reversing an anticoagulant effect. Only one agent, idarucizumab, has been approved for rapid reversal of dabigatran-induced anticoagulation and one more agent, andexanet alfa, has been submitted for approval to reverse the anticoagulatory effects of direct and indirect factor Xa inhibitors. Conclusions This review discusses the laboratory tests available for assessing anticoagulation, human models of bleeding, and the use of current strategies—including prothrombin complex concentrates for reversal of anticoagulation by NOACs—to manage bleeding in patients.
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Steg PG, Bhatt DL. Viewpoint: a proposal for a simple algorithm for managing oral anticoagulation and antiplatelet therapy in patients with non-valvular atrial fibrillation and coronary stents. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:93-97. [DOI: 10.1177/2048872615610868] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Ph Gabriel Steg
- FACT (French Alliance for Cardiovascular clinical Trials), Hôpital Bichat, France
- Université Paris-Diderot, Sorbonne Paris Cité, France
- INSERM U-1148, France
- NHLI, Imperial College London, UK
| | - Deepak L Bhatt
- Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, USA
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80
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DiSantostefano RL, Berlin JA, Chuang-Stein C, Quartey G, Eichenbaum G, Levitan B. Selecting and Integrating Data Sources in Benefit–Risk Assessment: Considerations and Future Directions. Stat Biopharm Res 2016. [DOI: 10.1080/19466315.2016.1225596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
| | - Jesse A. Berlin
- Department of Epidemiology, Johnson & Johnson, Inc. Titusville, NJ, USA
| | | | - George Quartey
- Genentech Inc., Safety Risk Management, South San Francisco, CA, USA
| | - Gary Eichenbaum
- Johnson & Johnson, Inc. Office of the Chief Medical Safety Officer, New Brunswick, NJ, USA
| | - Bennett Levitan
- Department of Epidemiology, Janssen R&D, LLC, Titusville, NJ, USA
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Abstract
BACKGROUND Recently, a new generation of direct-acting oral anticoagulants (DOACs) with a greater specificity towards activated coagulation factors was introduced based on encouraging results for efficacy and safety in clinical studies. An initial limitation of these new drugs was the absence of an adequate strategy to reverse the effect if a bleeding event occurs or an urgent invasive procedure has to be carried out. MAIN TEXT Specific reversing agents for DOACs have become available, however, and are now evaluated in clinical studies. For the anti-factor Xa agents (rivaroxaban, apixaban, and edoxaban) a number of studies have shown that the administration of prothrombin complex concentrate resulted in a correction of the prolonged prothrombin time and restored depressed thrombin generation after rivaroxaban treatment in a controlled trial in healthy human subjects. In view of the relatively wide availability of prothrombin complex concentrates, this would be an interesting option if the results can be confirmed in patients on oral factor Xa inhibitors who present with bleeding complications. More specific reversal can be achieved with andexanet, a new agent currently in development that competitively binds to the anti-factor Xa agents. For the direct thrombin inhibitor dabigatran, the administration of prothrombin complex concentrates showed variable results in various volunteer trials and efficacy at relatively high doses in animal studies. Recently, a Fab fragment of a monoclonal antibody (idarucizumab) was shown to be an effective reversal agent for dabigatran in human studies. CONCLUSION For the new generation of DOACs, several reversal strategies and specific antidotes are under evaluation, although most interventions need further evaluation in clinical trials.
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Affiliation(s)
- Marcel Levi
- Department of Vascular Medicine, Academic Medical Center (E-2), University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Department of Medicine, University of Amsterdam, Amsterdam, The Netherlands.
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82
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Lip GYH, Keshishian A, Kamble S, Pan X, Mardekian J, Horblyuk R, Hamilton M. Real-world comparison of major bleeding risk among non-valvular atrial fibrillation patients initiated on apixaban, dabigatran, rivaroxaban, or warfarin. A propensity score matched analysis. Thromb Haemost 2016; 116:975-986. [PMID: 27538358 DOI: 10.1160/th16-05-0403] [Citation(s) in RCA: 162] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 07/27/2016] [Indexed: 01/14/2023]
Abstract
In addition to warfarin, there are four non-vitamin K antagonist oral anticoagulants (NOACs) available for stroke prevention in non valvular atrial fibrillation (NVAF). There are limited data on the comparative risks of major bleeding among newly anticoagulated NVAF patients who initiate warfarin, apixaban, dabigatran, or rivaroxaban, when used in 'real world' clinical practice. The study used the Truven MarketScan® Commercial & Medicare supplemental US claims database. NVAF patients aged ≥18 years newly prescribed an oral anticoagulant 01JAN2013-31DEC2014, with a ≥1-year baseline period, were included (study period: 01JAN2012-31DEC2014). Major bleeding was defined as bleeding requiring hospitalisation. Propensity score matching (PSM) was used to balance age, sex, region, baseline comorbidities, and comedications. Cox proportional hazards models were used to estimate the PSM hazard ratio (HR) of major bleeding. Among 45,361 newly anticoagulated NVAF patients, 15,461 (34.1 %) initiated warfarin, 7,438 (16.4 %) initiated apixaban, 17,801 (39.2 %) initiated rivaroxaban, and 4,661 (10.3 %) initiated dabigatran. Compared to matched warfarin initiators, apixaban (HR: 0.53; 95 % CI: 0.39-0.71) and dabigatran (HR: 0.69; 95 % CI: 0.50-0.96) initiators had a significantly lower risk of major bleeding. Patients initiating rivaroxaban (HR: 0.98; 95 % CI: 0.83-1.17) had a non-significant difference in major bleeding risk compared to matched warfarin patients. When comparisons were made between NOACs, matched rivaroxaban patients had a significantly higher risk of major bleeding (HR: 1.82; 95 % CI: 1.36-2.43) compared to apixaban patients. The differences for apixaban-dabigatran and dabigatran-rivaroxaban matched cohorts were not statistically significant. Among newly anticoagulated NVAF patients in the real-world setting, apixaban and dabigatran initiation was associated with significantly lower risk of major bleeding compared to warfarin initiation. When compared to apixaban, rivaroxaban initiation was associated with significantly higher risk of major bleeding.
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Affiliation(s)
- Gregory Y H Lip
- Prof. Gregory Y. H. Lip, University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom, Tel.: +44 121 5075080, Fax: +44 121 554 4083, E-mail: g. y.
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83
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Pharmacogenetics of dabigatran etexilate interindividual variability. Thromb Res 2016; 144:1-5. [DOI: 10.1016/j.thromres.2016.05.025] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 05/02/2016] [Accepted: 05/25/2016] [Indexed: 01/18/2023]
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84
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Yogaratnam D, Ditch K, Medeiros K, Doyno C, Fong JJ. Idarucizumab for Reversal of Dabigatran-Associated Anticoagulation. Ann Pharmacother 2016; 50:847-54. [DOI: 10.1177/1060028016659504] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To review clinical data on idarucizumab for the reversal of dabigatran-associated anticoagulation. Data Sources: Articles for this review were identified via PubMed using the MeSH term dabigatran combined with the keyword idarucizumab. Additional online searches via PubMed and Google Scholar were conducted for both prescribing and cost information. Study Selection and Data Extraction: English-language clinical trials published between 1946 and May 2016 were included for review. Bibliographies of selected articles were also manually reviewed for relevant publications that focused on reversal strategies for dabigatran-associated anticoagulation. Data Synthesis: The safety and tolerability of idarucizumab has been evaluated in 3 phase I clinical trials. The use of idarucizumab for reversing dabigatran-associated anticoagulation is also being evaluated in the phase III RE-VERSE AD study. Interim results of the RE-VERSE AD study have been published. Conclusions: Idarucizumab rapidly neutralizes the anticoagulant effect of dabigatran in healthy volunteers, in patients with life-threatening bleeding, and in patients requiring urgent surgery that cannot be delayed. These observations are largely based on laboratory assessments rather than clinical outcomes. Idarucizumab is well tolerated, and it does not appear to induce procoagulant or immunogenic adverse effects.
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Affiliation(s)
- Dinesh Yogaratnam
- Massachusetts College of Pharmacy and Health Sciences University, Worcester, MA, USA
| | | | | | | | - Jeffrey J. Fong
- Massachusetts College of Pharmacy and Health Sciences University, Worcester, MA, USA
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85
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Management Overview: Taking a Patient with Intracranial Hemorrhage Related to Direct Oral Anticoagulants to the Operating Room. World Neurosurg 2016; 90:262-267. [DOI: 10.1016/j.wneu.2016.02.070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 02/13/2016] [Accepted: 02/15/2016] [Indexed: 11/23/2022]
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86
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Stabile E, Izzo R, Rozza F, Losi MA, Coscioni E, Trimarco B. Real Data on Effectiveness, Tolerability and Safety of New Oral Anticoagulant Agents: Focus on Dabigatran. High Blood Press Cardiovasc Prev 2016; 23:115-22. [PMID: 27207360 DOI: 10.1007/s40292-016-0150-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 03/21/2016] [Indexed: 12/26/2022] Open
Abstract
Vitamin K-dependent antagonists (VKAs) are the most commonly used oral anticoagulants. Non-VKA oral anticoagulants (NOACs), directly target factor IIa (dabigatran) or Xa (rivaroxaban, apixaban, and edoxaban) have predictable pharmacological effects and relatively few drug and food interactions compared with VKA. Among NOACs, dabigatran has been extensively tested for stroke prevention in patients with non-valvular atrial fibrillation eligible for oral anticoagulation with VKA. Dabigatran is at least as effective as warfarin at preventing stroke with advantages of less serious bleeding except for gastrointestinal bleeding, which occurs more often than with warfarin. The findings of dabigatran use in randomized trials, post market registries and specific clinical settings are discussed in this article.
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Affiliation(s)
- Eugenio Stabile
- Division of Cardiology, Department of Advanced Biomedical Sciences, Hypertension Research Centre, University of Napoli "Federico II", Naples, Italy.
| | - Raffaele Izzo
- Division of Cardiology, Department of Advanced Biomedical Sciences, Hypertension Research Centre, University of Napoli "Federico II", Naples, Italy
| | - Francesco Rozza
- Division of Cardiology, Department of Advanced Biomedical Sciences, Hypertension Research Centre, University of Napoli "Federico II", Naples, Italy
| | - Maria Angela Losi
- Division of Cardiology, Department of Advanced Biomedical Sciences, Hypertension Research Centre, University of Napoli "Federico II", Naples, Italy
| | - Enrico Coscioni
- Department of Cardiac Surgery, Azienda Ospedaliera Universitaria San Giovanni di Dio e Ruggi D'aragona, Salerno, Italy
| | - Bruno Trimarco
- Division of Cardiology, Department of Advanced Biomedical Sciences, Hypertension Research Centre, University of Napoli "Federico II", Naples, Italy
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87
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Smythe MA, Forman MJ, Bertran EA, Hoffman JL, Priziola JL, Koerber JM. Dabigatran versus warfarin major bleeding in practice: an observational comparison of patient characteristics, management and outcomes in atrial fibrillation patients. J Thromb Thrombolysis 2016; 40:280-7. [PMID: 25851800 DOI: 10.1007/s11239-015-1213-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Data comparing the patient characteristics, management and outcomes for dabigatran versus warfarin major bleeding in the practice setting are limited. We performed a retrospective single health system study of atrial fibrillation patients with dabigatran or warfarin major bleeding from October 2010 through September 2012. Patient identification occurred through both an internal adverse event reporting system and a structured stepwise data filtering approach using the International Classification of Diseases diagnosis codes. Thirty-five dabigatran major bleeding patients were identified and compared to 70 warfarin major bleeding patients. Intracranial bleed occurred in 4.3 % of warfarin patients and 8.6 % of dabigatran patients. Dabigatran patients tended to be older (79.9 vs. 76 years) and were more likely to have a creatinine clearance of 15-30 mL/min (40 vs. 18.6 %, p = 0.02). Over one-third of dabigatran patients had an excessive dose based on renal function. More dabigatran patients required a procedure for bleed management (37.1 vs. 17.1 %, p = 0.03) and received a hemostatic agent for reversal (11.4 vs. 1.4 %, p = 0.04). Dabigatran patients were twice as likely to spend time in an ICU (45.7 vs. 27.1 %, p = 0.06), be placed in hospice/comfort care (14.3 vs. 7.1 %, p = 0.24), expire during hospitalization (14.3 vs. 7.1 %, p = 0.24), and expire within 30-days (22.9 vs. 11.4 %, p = 0.28). In a single hospital center practice setting, as compared to warfarin, patients with dabigatran major bleeding were more likely to be older, have renal impairment, require a procedure for bleed management and receive a hemostatic agent. Patients with dabigatran major bleeding had an excessive dose for renal function in more than one-third of cases.
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Affiliation(s)
- Maureen A Smythe
- Department of Pharmaceutical Services, Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI, 48073, USA,
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88
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Mott K, Graham DJ, Toh S, Gagne JJ, Levenson M, Ma Y, Reichman ME. Uptake of new drugs in the early post-approval period in the Mini-Sentinel distributed database. Pharmacoepidemiol Drug Saf 2016; 25:1023-32. [PMID: 27146123 DOI: 10.1002/pds.4013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 02/26/2016] [Accepted: 03/21/2016] [Indexed: 11/10/2022]
Abstract
PURPOSE Several factors limit the statistical power of drug safety surveillance during the early post-approval period, including uptake of the drug and lag in data availability. This study characterized new drug uptake in the Mini-Sentinel Distributed Database and determined statistical power to detect levels of risk in post-launch safety assessments. METHODS The cumulative exposure among initiators of 46 new molecular entities approved from 2008 to 2011 was assessed. Using a Poisson estimation method, minimum incidence rate ratios (IRRs) detectable, with 80% power, were calculated under varying background incidence rates. RESULTS Twelve products (26.1%) had more than 15 000 new users after 2 years. With comparator group incidence rate of 1/1000 person-years, 16 (33.3%) products had enough exposure to detect an IRR of 5 with 24 months of data collected that would be available for assessment at 33 months post-launch. With an incidence rate of 5/1000 person-years, 23 (50%) products had enough exposure to detect an IRR of ≥3 with 2 years of data collected. At 33 months post-launch, only two (4.3%) of the drugs examined had enough data availability to detect IRR of <2, and eight (17.4%) of <3, with a background rate of 1/1000 person-years. CONCLUSION This study highlights the importance of drug uptake and data availability in early post-approval drug safety surveillance in Mini-Sentinel. There is limited ability to detect rate ratios below three for events with background rates of 1/1000 person-years or lower. This is largely due to low product uptake. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Katrina Mott
- CDER Office of Surveillance and Epidemiology, U.S. Food and Drug Administration, Silver Spring, MD, USA.,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - David J Graham
- CDER Office of Surveillance and Epidemiology, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Sengwee Toh
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Joshua J Gagne
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Mark Levenson
- CDER Office of Biostatistics, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Yong Ma
- CDER Office of Biostatistics, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Marsha E Reichman
- CDER Office of Surveillance and Epidemiology, U.S. Food and Drug Administration, Silver Spring, MD, USA
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89
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90
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Grottke O, Aisenberg J, Bernstein R, Goldstein P, Huisman MV, Jamieson DG, Levy JH, Pollack CV, Spyropoulos AC, Steiner T, Del Zoppo GJ, Eikelboom J. Efficacy of prothrombin complex concentrates for the emergency reversal of dabigatran-induced anticoagulation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:115. [PMID: 27125504 PMCID: PMC4850655 DOI: 10.1186/s13054-016-1275-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Dabigatran is effective in decreasing the risk of ischaemic stroke in patients with atrial fibrillation. However, like all anticoagulants, it is associated with a risk of bleeding. In cases of trauma or emergency surgery, emergency reversal of dabigatran-induced anticoagulation may be required. A specific reversal agent for dabigatran, idarucizumab, has been approved by the US Food and Drug Administration. Alternative reversal agents are available, such as prothrombin complex concentrates (PCCs) and activated PCCs (aPCCs). In this review we evaluate the role of PCCs and aPCCs in the reversal of dabigatran anticoagulation and consider which tests are appropriate for monitoring coagulation in this setting. Pre-clinical studies, small clinical studies and case reports indicate that PCCs and aPCCs may be able to reverse dabigatran-induced anticoagulation in a dose-dependent manner. However, dosing based on coagulation parameters can be difficult because available assays may not provide adequate sensitivity and specificity for measuring anticoagulation induced by dabigatran or the countering effects of PCCs/aPCCs. In addition, PCCs or aPCCs can potentially provoke thromboembolic complications. Despite these limitations and the fact that PCCs and aPCCs are not yet licensed for dabigatran reversal, their use appears to be warranted in patients with life-threatening haemorrhage if idarucizumab is not available.
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Affiliation(s)
- Oliver Grottke
- Department of Anesthesiology, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany.
| | - James Aisenberg
- The Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Richard Bernstein
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Patrick Goldstein
- Emergency Department and SAMU, Lille University Hospital, Lille, France
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Dara G Jamieson
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - Jerrold H Levy
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - Charles V Pollack
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Alex C Spyropoulos
- Hofstra North Shore/LIJ School of Medicine, Lenox Hill Hospital, New York, NY, USA
| | | | - Gregory J Del Zoppo
- Departments of Medicine and Neurology, University of Washington, Seattle, WA, USA
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91
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He Y, Wong ICK, Li X, Anand S, Leung WK, Siu CW, Chan EW. The association between non-vitamin K antagonist oral anticoagulants and gastrointestinal bleeding: a meta-analysis of observational studies. Br J Clin Pharmacol 2016; 82:285-300. [PMID: 26889922 DOI: 10.1111/bcp.12911] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 02/12/2016] [Accepted: 02/14/2016] [Indexed: 12/21/2022] Open
Abstract
Particular concerns have been raised regarding the association between non-vitamin K antagonist oral anticoagulants (NOACs) and the risk of gastrointestinal bleeding (GIB); however, current findings are still inconclusive. We conducted a systematic review with a meta-analysis to examine the association between NOACs and GIB in real-life settings. We performed a systematic search of PubMed, EMBASE and CINAHL Plus up to September 2015. Observational studies that evaluated exposure to NOACs reporting GIB outcomes were included. The inverse variance method using the random-effects model was used to calculate the pooled estimates. Eight cohort studies were included in the primary meta-analysis, enrolling 1442 GIB cases among 106 626 dabigatran users (49 486 patient-years), and 184 GIB cases among 10 713 rivaroxaban users (4046 patient-years). The pooled incidence rates of GIB were 4.50 [95% confidence interval (CI) 3.17, 5.84] and 7.18 (95% CI 2.42, 12.0) per 100 patient-years among dabigatran and rivaroxaban users, respectively. The summary risk ratio (RR) was 1.21 (95% CI 1.05, 1.39) for dabigatran compared with warfarin, and 1.09 (95% CI 0.92, 1.30) for rivaroxaban. Subgroup analyses showed a dose-related effect of dabigatran, with a significantly higher risk of GIB for 150 mg b.i.d. (RR = 1.51, 95% CI 1.34, 1.70) but not for 75 mg b.i.d. or 110 mg b.i.d.. In addition, the use of proton pump inhibitors (PPIs)/histamine H2-receptor antagonists (H2RAs) influenced the association in dabigatran users, whereas this effect was modest among rivaroxaban users. In conclusion, our meta-analysis suggested a slightly higher risk of GIB with dabigatran use compared with warfarin, whereas no significant difference was found between rivaroxaban and warfarin for GIB risk.
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Affiliation(s)
- Ying He
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong
| | - Ian C K Wong
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong.,Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Xue Li
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong
| | - Shweta Anand
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong
| | - Wai K Leung
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Chung Wah Siu
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong
| | - Esther W Chan
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong
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92
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Djalali S, Valeri F, Gerber B, Meli DN, Senn O. Anticoagulation Control in Swiss Primary Care: Time in Therapeutic Range Percentages Exceed Benchmarks of Phase III Trials. Clin Appl Thromb Hemost 2016; 23:685-695. [PMID: 27056934 DOI: 10.1177/1076029616642514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In randomized controlled trials, non-vitamin K antagonist oral anticoagulants (NOACs) demonstrated noninferiority to vitamin K antagonists (VKAs) in patients who spent limited time in therapeutic range (TTR). In real-life patients, TTR is known to vary significantly across countries and health-care settings. OBJECTIVE We aim to evaluate the quality of VKA treatment in Swiss primary care (PC) by comparing patients' median TTR to levels achieved in the phase III NOAC trials RE-LY, ROCKET-AF, ARISTOTLE, and ENGAGE-AF-TIMI 48. Patient characteristics affecting TTR control shall be estimated. METHODS This is a retrospective longitudinal study in Swiss PC patients receiving VKA for ≥6 months. We identified patients from the PC research database FIRE (Family medicine International Classification of Primary Care Research using Electronic medical records) and calculated TTR according to Rosendaal formula. Comparative data from NOAC trials were retrieved from medical literature. Linear regression models were used to assess predictors of TTR. RESULTS Primary care encounters of 215 patients were analyzed. Like in the NOAC trials, median observation period was 2.2 years, but patients were older (67.9% vs 38% ≥75 years) and differed in terms of concomitant diseases and drugs. Median TTR was 75% (65% in the NOAC trials). Female sex was independently associated with a lower TTR and significantly modified by increasing age. CONCLUSION Practitioners should consider that patients in NOAC trials are only partly representative of PC patients, particularly in terms of TTR control. Only a minority of the observed patients would require a therapy switch to NOACs due to inadequate TTR. Further research is needed in order to identify specific features of care management that are associated with these outcomes.
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Affiliation(s)
- Sima Djalali
- 1 Institute of Primary Care, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Fabio Valeri
- 1 Institute of Primary Care, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Bernhard Gerber
- 2 Department of Hematology, Istituto Oncologico della Svizzera Italiana, Ospedale Regionale Bellinzona e Valli, Bellinzona, Switzerland
| | - Damian N Meli
- 3 General Practice Center Huttwil, Huttwil, Switzerland
| | - Oliver Senn
- 1 Institute of Primary Care, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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93
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Sauter TC, Amylidi AL, Ricklin ME, Lehmann B, Exadaktylos AK. Direct new oral anticoagulants in the emergency department: Experience in everyday clinical practice at a Swiss university hospital. Eur J Intern Med 2016; 29:e13-5. [PMID: 26777104 DOI: 10.1016/j.ejim.2015.12.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 12/11/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Thomas C Sauter
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland.
| | - Anna-Lea Amylidi
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Meret E Ricklin
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Beat Lehmann
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Aristomenis K Exadaktylos
- Department of Emergency Medicine, Inselspital, University Hospital Bern, Freiburgstrasse, 3010, Bern, Switzerland
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94
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Abstract
What has been learned about electronic health data as a primary data source for regulatory decisions regarding the harms of drugs? Observational studies with electronic health data for postmarket risk assessment can now be conducted in Europe and the US in patient populations numbering in the tens of millions compared with a few hundred patients in a typical clinical trial. With standard protocols, results can be obtained in a few months; however, extensive research published by scores of investigators has illuminated the many obstacles that prevent obtaining robust, reproducible results that are reliable enough to be a primary source for drug safety decisions involving the health and safety of millions of patients. The most widely used terminology for coding patient interactions with medical providers for payment has proved ill-suited to identifying the adverse effects of drugs. Directly conflicting results were reported in otherwise similar patient health databases, even using identical event definitions and research methods. Evaluation of some accepted statistical methods revealed systematic bias, while others appeared to be unreliable. When electronic health data studies detected no drug risk, there were no robust and accepted standards to judge whether the drug was unlikely to cause the adverse effect or whether the study was incapable of detecting it. Substantial investment and careful thinking is needed to improve the reliability of risk assessments based on electronic health data, and current limitations need to be fully understood.
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Affiliation(s)
- Thomas J Moore
- Institute for Safe Medication Practices, 101 N. Columbus St, Suite 410, Alexandria, VA, 22214, USA,
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Masotti L, Lorenzini G, Seravalle C, Panigada G, Landini G, Cappelli R, Schulman S. Management of new oral anticoagulants related life threatening or major bleedings in real life: a brief report. J Thromb Thrombolysis 2016; 39:427-33. [PMID: 25048833 DOI: 10.1007/s11239-014-1112-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Although new oral anticoagulants (NOAs) have been marketed in many countries, concern exists about the management of bleedings related to these drugs due to the lack of specific antidotes. The aim of our study was to report on real life management of NOAs-related life-threatening or major bleedings. We report data from consecutive cases of NOAs related major bleedings admitted to 4 hospitals since NOAs became marketed in Italy. We treated 8 patients, 4 males, with mean age 84 ± 7 years, 7 of whom were on dabigatran and one on rivaroxaban. The indication for NOA was atrial fibrillation. All bleedings were spontaneous and involving the gastro-intestinal tract. At the time of bleeding all patients had a drop in hemoglobin levels over 20 g/L. Creatinine clearance was ≤30 mL/min in 4 patients. All patients received general supportive measures, 4 of 8 patients were transfused with packed red cells and one patient received platelet transfusion. Three patients were treated with tranexamic acid and one patient on dabigatran received 4-factor prothrombin complex concentrate (PCC) with bleeding cessation, although coagulation parameters were not corrected. The median time for normalization of coagulation parameters was 3 days (range 1-6 days). All patients were discharged alive and NOAs were discontinued. In NOAs related major gastro-intestinal bleeding general supportive measures seem to be effective for the majority of patients. Despite promoting bleeding cessation, 4-factor PCC does not reverse abnormal coagulation parameters.
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Affiliation(s)
- Luca Masotti
- Internal Medicine, Santa Maria Nuova Hospital, Florence, Italy,
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96
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Ziff OJ, Camm AJ. Individualized approaches to thromboprophylaxis in atrial fibrillation. Am Heart J 2016; 173:143-58. [PMID: 26920607 DOI: 10.1016/j.ahj.2015.10.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Accepted: 10/28/2015] [Indexed: 12/26/2022]
Abstract
Atrial fibrillation (AF) is the most common arrhythmia worldwide. The prevalence of AF in persons older than 55 years is at least 33.5 million globally and is predicted to more than double in the next half-century. Anticoagulation, heart rate control, and heart rhythm control comprise the 3 main treatment strategies in AF. Anticoagulation is aimed at preventing debilitating stroke, systemic embolism, and associated mortality. Historically, anticoagulation in AF was achieved with a vitamin K antagonist such as warfarin, which is supported by evidence demonstrating reduced incident stroke and all-cause mortality. However, warfarin has unpredictable pharmacokinetics with many drug-drug interactions that require regular monitoring to ensure patients remain in the therapeutic anticoagulant range. Non-vitamin K antagonist oral anticoagulants including dabigatran, rivaroxaban, apixaban, and edoxaban provide a possible solution to these issues with their more predictable pharmacokinetics, rapid onset of action, and greater specificity. Results from large randomized, controlled trials indicate that these agents are at least noninferior to warfarin in prevention of stroke. These trials also demonstrate a consistently lower incidence of intracranial hemorrhage, almost always all life-threatening bleeds, and many forms of major bleeds with the possible exception of gastrointestinal and some other forms of mucosal bleeding, compared with warfarin. Patients with AF are a heterogeneous population with diverse risk of stroke and bleeding, and different subgroups respond differently to anticoagulation. Important clinical questions have arisen regarding optimal anticoagulation drug selection in distinct populations such as those with renal impairment, older age, coronary artery disease, and heart failure as well as those at particularly high risk for bleeding or thromboembolism. In this review, treatment strategies in AF management are discussed in the context of different individual subgroups of patients.
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97
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Sweis R, Biller J. Practical Guide to Direct New Oral Anticoagulant Use for Secondary Stroke Prevention in Atrial Fibrillation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:24. [PMID: 26909818 DOI: 10.1007/s11936-016-0446-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OPINION STATEMENT Anticoagulation remains the optimal treatment choice for secondary stroke prevention of AF. The vitamin K antagonists (VKAs) have been the choice of treatment for the last 60 years, but the new oral anticoagulants are now a safe option for treatment of non-valvular AF (NVAF) in the right patient population, taking into account age, renal function, bleeding risk, cardiovascular comorbidities, cost, and drug interactions.
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Affiliation(s)
- Rochelle Sweis
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, USA.
| | - José Biller
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, USA.
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98
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Anklesaria Z, Al-Helou G. The new era of anticoagulation. Surg Neurol Int 2016; 7:22. [PMID: 26981323 PMCID: PMC4774265 DOI: 10.4103/2152-7806.177124] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 12/30/2015] [Indexed: 01/22/2023] Open
Affiliation(s)
- Zafia Anklesaria
- Department of Pulmonary and Critical Care, University of California, Los Angeles CA, USA
| | - Georges Al-Helou
- Department of Pulmonary and Critical Care, George Washington University, Washington, DC, USA
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99
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Novel Oral Anticoagulants and the Risk of Major Hemorrhage in Elderly Patients With Chronic Kidney Disease: A Nested Case-Control Study. Can J Cardiol 2016; 32:986.e17-22. [PMID: 26992571 DOI: 10.1016/j.cjca.2016.01.013] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 01/04/2016] [Accepted: 01/04/2016] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The novel oral anticoagulants, including dabigatran and rivaroxaban, differ in their degree of renal excretion. METHODS We conducted a population-based nested case-control study in patients 66 years and older with chronic kidney disease (CKD) (excluding patients undergoing chronic dialysis) who received an oral anticoagulant between April 2006 and March 2013. We calculated odds ratios for hospitalization with a major hemorrhagic event and receipt of dabigatran, rivaroxaban, or warfarin in the preceding 60 days. We also performed a sensitivity analysis to investigate whether a relationship exists between major hemorrhage and advanced age (age < 80 years or ≥ 80 years). RESULTS We identified 237,409 patients with CKD, 4470 (1.9%) of whom experienced a major hemorrhage. We matched these patients to 14,460 controls. The use of dabigatran or rivaroxaban was not associated with a statistically significant elevated risk of hemorrhage compared with warfarin (adjusted odds ratio [aOR], 1.15; 95% confidence interval [CI], 0.91-1.45 for dabigatran; aOR, 1.22; 95% CI, 0.83-1.79 for rivaroxaban). Our sensitivity analysis found that older age was associated with an increased risk of hemorrhage for patients receiving dabigatran (aOR, 1.41; 95% CI, 1.06-1.88); results were similar but did not reach statistical significance for rivaroxaban (aOR, 1.57; 95% CI, 0.91-2.69). CONCLUSIONS Among elderly patients with CKD, exposure to dabigatran or rivaroxaban was not associated with a statistically significant increased risk of major hemorrhagic events compared with exposure to warfarin.
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100
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Abstract
Atrial fibrillation (AF) is a major risk factor for ischemic stroke. Guidelines recommend anticoagulation for patients with intermediate and high stroke risk (CHA2DS2-VASc score ≥ 2). Underuse of anticoagulants among eligible patients remains a persistent problem. Evidence demonstrates that the psychology of the fear of causing harm (omission bias) results in physicians' hesitancy to initiate anticoagulation and an inaccurate estimation of stroke risk. The American Heart Association (AHA) initiated the Get With The Guidelines-AFIB (GWTG-AFIB) module in June 2013 to enhance guideline adherence for treatment and management of AF. Better quality of care for AF patients can be provided by increasing adherence to anticoagulation guidelines and improving patient compliance with anticoagulation therapy through education and established protocols. Nonvitamin K antagonist oral anticoagulants may facilitate better patient adherence due to ease of administration and reduced monitoring burden. In this review, we discuss the reasons for underuse, omission bias contributing to underuse, and different strategies to address this issue.
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Affiliation(s)
- Ajay Vallakati
- a Division of Cardiovascular Diseases , Metrohealth Medical Center , Cleveland , OH , USA
| | - William R Lewis
- a Division of Cardiovascular Diseases , Metrohealth Medical Center , Cleveland , OH , USA
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