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Peetermans M, Pollack C, Reilly P, Liesenborghs L, Jacquemin M, Levy JH, Weitz JI, Verhamme P. Idarucizumab for dabigatran overdose. Clin Toxicol (Phila) 2016; 54:644-6. [DOI: 10.1080/15563650.2016.1187737] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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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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Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer EAM, Ozier Y, Riddez L, Schultz A, Vincent JL, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20:100. [PMID: 27072503 PMCID: PMC4828865 DOI: 10.1186/s13054-016-1265-x] [Citation(s) in RCA: 597] [Impact Index Per Article: 74.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/11/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.
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Affiliation(s)
- Rolf Rossaint
- />Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Bertil Bouillon
- />Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne-Merheim Medical Centre, Ostmerheimer Strasse 200, 51109 Cologne, Germany
| | - Vladimir Cerny
- />Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, 40113 Usti nad Labem, Czech Republic
- />Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesiology and Intensive Care, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, QE II Health Sciences Centre, 10 West Victoria, 1276 South Park St., Halifax, NS B3H 2Y9 Canada
| | - Timothy J. Coats
- />Emergency Medicine Academic Group, University of Leicester, University Road, Leicester, LE1 7RH UK
| | - Jacques Duranteau
- />Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Cedex France
| | - Enrique Fernández-Mondéjar
- />Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, ctra de Jaén s/n, 18013 Granada, Spain
| | - Daniela Filipescu
- />Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, 022328 Bucharest, Romania
| | - Beverley J. Hunt
- />King’s College, Departments of Haematology, Pathology and Lupus, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- />Department of Traumatology, General and Teaching Hospital Celje, Oblakova 5, 3000 Celje, Slovenia
| | - Giuseppe Nardi
- />Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, 00152 Rome, Italy
| | - Edmund A. M. Neugebauer
- />Faculty of Health - School of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Yves Ozier
- />Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Louis Riddez
- />Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
| | - Arthur Schultz
- />Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Jean-Louis Vincent
- />Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Donat R. Spahn
- />Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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Management of direct oral anticoagulants-associated bleeding in the trauma patient. Curr Opin Anaesthesiol 2016; 29:220-8. [DOI: 10.1097/aco.0000000000000294] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abo-Salem E, Becker RC. Reversal of novel oral anticoagulants. Curr Opin Pharmacol 2016; 27:86-91. [PMID: 26939028 DOI: 10.1016/j.coph.2016.02.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 01/30/2016] [Accepted: 02/12/2016] [Indexed: 01/08/2023]
Abstract
The development of a new generation of non-vitamin K oral anticoagulants represents a potential breakthrough in the management of patients with thrombotic diseases, disorders and conditions. While a large and growing body of evidence from large-scale clinical trials and registries supports a favorable safety profile, having a means to rapidly reverse their anticoagulant effects represents an unmet need among practicing clinicians. Several targeted reversal agents are currently in development and the early results are promising. Idarucizumab is a monoclonal antibody that can immediately and specifically reverse dabigatran. Andexanet alfa is a recombinant modified factor Xa that can bind and reverse oral and parenteral factor Xa inhibitors, including rivaroxaban, apixaban and edoxaban, and low molecular weight heparin. Aripazine is a small molecule that can reverse the action of factor Xa inhibitors and possibly dabigatran as well through non-covalent binding and charge-charge interactions.
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Affiliation(s)
- Elsayed Abo-Salem
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Heart, Lung and Vascular Institute, Cincinnati, OH, USA
| | - Richard C Becker
- Division of Cardiovascular Health and Disease, University of Cincinnati College of Medicine, Heart, Lung and Vascular Institute, Cincinnati, OH, USA.
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Cada DJ, Kim AP, Baker DE. Idarucizumab. Hosp Pharm 2016; 51:256-262. [PMID: 38745579 PMCID: PMC11089633 DOI: 10.1310/hpj5103-256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are sent in print and are also available on-line. Monographs can be customized to meet the needs of a facility. A drug class review is now published monthly with The Formulary Monograph Service. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, contact Wolters Kluwer customer service at 866-397-3433. The March 2016 monograph topics are necitumumab, talimogene laherparepvec, asfotase alfa, trabectedin, and osimertinib. The Safety MUE is on patiromer.
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Affiliation(s)
- Dennis J Cada
- Drug Information Resident, College of Pharmacy, Washington State University Spokane
| | - Anne P Kim
- Drug Information Resident, College of Pharmacy, Washington State University Spokane
| | - Danial E Baker
- Drug Information Center, and College of Pharmacy, Washington State University Spokane. The authors indicate no relationships that could be perceived as a conflict of interest
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Lohrmann GM, Atwal D, Augoustides JG, Askar W, Patel PA, Ghadimi K, Makar G, Gutsche JT, Shamoun FE, Ramakrishna H. Reversal Agents for the New Generation of Oral Anticoagulants: Implications for the Perioperative Physician. J Cardiothorac Vasc Anesth 2016; 30:823-30. [PMID: 27080265 DOI: 10.1053/j.jvca.2016.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Indexed: 11/11/2022]
Affiliation(s)
| | - Danish Atwal
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Wajih Askar
- Department of Anesthesiology, Mayo Clinic, Scottsdale, AZ
| | - Prakash A Patel
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Kamrouz Ghadimi
- Divisions of Cardiothoracic Anesthesiology and Critical Care, Duke University Medical Center, Durham, NC
| | - Gerges Makar
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Fadi E Shamoun
- Division of Cardiovascular Diseases, Mayo Clinic, Scottsdale, AZ
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Prothrombin Complex Concentrate Is Effective in Treating the Anticoagulant Effects of Dabigatran in a Porcine Polytrauma Model. Anesthesiology 2015; 123:1350-61. [DOI: 10.1097/aln.0000000000000863] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Abstract
Background
In the event of trauma, emergency reversal of anticoagulation therapy may be required. However, no specific reversal agents are routinely available for the direct oral anticoagulants such as dabigatran. The authors investigated four-factor prothrombin complex concentrate (PCC) for treating dabigatran-induced anticoagulation in a porcine polytrauma model.
Methods
Dabigatran etexilate was given orally for 3 days and intravenously on day 4 to 32 pigs. Animals were randomized 1:1:1:1 to PCC (25, 50, or 100 U/kg) or saline. Study medication was administered 12 min after bilateral femur fractures and blunt liver injury. The primary endpoint was blood loss at 300 min.
Results
The mean plasma concentration of dabigatran was 487 ± 161 ng/ml after intravenous administration. Blood loss was 3,855 ± 258 ml in controls and 3,588 ± 241 ml in the PCC25 group. In the PCC50 and PCC100 groups, blood loss was significantly lower: 1,749 ± 47 ml and 1,692 ± 97 ml, respectively. PCC50 and PCC100 effectively reduced dabigatran’s effects on coagulation parameters, whereas control and (to a lesser extent) PCC25 animals developed severe coagulopathy. Sustained increases in endogenous thrombin potential occurred with PCC50 and PCC100.
Conclusion
Four-factor PCC (50 or 100 U/kg) is effective in reducing blood loss in dabigatran-anticoagulated pigs, but higher doses may induce a procoagulant state.
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Dzeshka MS, Lip GYH. Edoxaban for reducing the risk of stroke and systemic embolism in patients with non-valvular atrial fibrillation. Expert Opin Pharmacother 2015; 16:2661-78. [PMID: 26559069 DOI: 10.1517/14656566.2015.1104301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Oral anticoagulation is central to the management of patients with atrial fibrillation (AF) and at least one additional stroke risk factor. For decades, the vitamin K antagonists (e.g. warfarin) remained the only oral anticoagulant available for stroke prevention in AF. The non-vitamin K oral anticoagulants (NOACs) are now available, and these drugs include the direct thrombin inhibitors and factor Xa inhibitors. The latter class includes edoxaban, which has recently been approved for stroke prevention in AF by the United States Food and Drug Administration and the European Medicine Agency. In line with other NOACs, edoxaban avoids the many limitations of warfarin associated with variability of anticoagulation effect and multiple food and drug interactions. AREAS COVERED In this review, the currently available evidence on edoxaban in patients with non-valvular AF is discussed. The pharmacology, efficacy and safety, and current aspects of use of edoxaban in patients with non-valvular AF for stroke and thromboembolism prevention are reviewed. EXPERT OPINION Phase III trials on edoxaban for stroke prevention in non-valvular AF confirms non-inferiority of edoxaban compared to well-managed warfarin both in terms of efficacy and safety. Currently ongoing and future trials as well as real-world data are warranted to confirm its effectiveness and safety for chronic anticoagulation and improve evidence in other areas which are lacking evidence where NOAC use remains controversial.
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Affiliation(s)
- Mikhail S Dzeshka
- a University of Birmingham Institute of Cardiovascular Sciences, City Hospital , Birmingham B18 7QH , UK.,b Grodno State Medical University , Grodno , Belarus
| | - Gregory Y H Lip
- a University of Birmingham Institute of Cardiovascular Sciences, City Hospital , Birmingham B18 7QH , UK.,c Aalborg Thrombosis Research Unit, Department of Clinical Medicine , Faculty of Health, Aalborg University , Aalborg , Denmark
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Das A, Liu D. Novel antidotes for target specific oral anticoagulants. Exp Hematol Oncol 2015; 4:25. [PMID: 26380149 PMCID: PMC4570637 DOI: 10.1186/s40164-015-0020-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 08/25/2015] [Indexed: 12/27/2022] Open
Abstract
Target specific oral anticoagulants
(dabigatran, rivaroxaban, apixaban, and edoxaban) are changing the landscape of anticoagulation. The major drawback is the absence of an effective antidote for severe bleedings and/or prior to procedures. Currently there are a few promising antidotes undergoing clinical trials. This review summarized the latest development in idarucizumab, andexanet alpha and PER977.
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Affiliation(s)
- Arundhati Das
- Department of Medicine, New York Medical College and Westchester Medical Center, Valhalla, NY 10595 USA
| | - Delong Liu
- Department of Medicine, New York Medical College and Westchester Medical Center, Valhalla, NY 10595 USA ; Henan Cancer Hospital and the Affiliated Cancer Hospital of Zhengzhou University, Zhengzhou, China
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Heidbuchel H, Verhamme P, Alings M, Antz M, Diener HC, Hacke W, Oldgren J, Sinnaeve P, Camm AJ, Kirchhof P. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015; 17:1467-507. [PMID: 26324838 DOI: 10.1093/europace/euv309] [Citation(s) in RCA: 723] [Impact Index Per Article: 80.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Accepted: 02/10/2015] [Indexed: 12/24/2022] Open
Abstract
The current manuscript is an update of the original Practical Guide, published in June 2013[Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-51; Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, et al. EHRA practical guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation: executive summary. Eur Heart J 2013;34:2094-106]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with non-valvular atrial fibrillation (AF). Both physicians and patients have to learn how to use these drugs effectively and safely in clinical practice. Many unresolved questions on how to optimally use these drugs in specific clinical situations remain. The European Heart Rhythm Association set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group defined what needs to be considered as 'non-valvular AF' and listed 15 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 15 topics are (i) practical start-up and follow-up scheme for patients on NOACs; (ii) how to measure the anticoagulant effect of NOACs; (iii) drug-drug interactions and pharmacokinetics of NOACs; (iv) switching between anticoagulant regimens; (v) ensuring adherence of NOAC intake; (vi) how to deal with dosing errors; (vii) patients with chronic kidney disease; (viii) what to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a risk of bleeding?; (xi) management of bleeding complications; (x) patients undergoing a planned surgical intervention or ablation; (xi) patients undergoing an urgent surgical intervention; (xii) patients with AF and coronary artery disease; (xiii) cardioversion in a NOAC-treated patient; (xiv) patients presenting with acute stroke while on NOACs; and (xv) NOACs vs. VKAs in AF patients with a malignancy. Additional information and downloads of the text and anticoagulation cards in >16 languages can be found on an European Heart Rhythm Association web site (www.NOACforAF.eu).
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Rahmat NA, Lip GYH. Monitoring the Effects and Antidotes of the Non-vitamin K Oral Anticoagulants. Arrhythm Electrophysiol Rev 2015; 4:90-5. [PMID: 26835107 PMCID: PMC4711499 DOI: 10.15420/aer.2015.04.02.90] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 06/18/2015] [Indexed: 01/17/2023] Open
Abstract
In the last decade, we have witnessed the emergence of the oral non-vitamin K oral anticoagulants (NOACs), which have numerous advantages compared with the vitamin K antagonists, particularly their lack of need for monitoring; as a result their use is increasing. Nonetheless, the NOACs face two major challenges: the need for reliable laboratory assays to assess their anticoagulation effect, and the lack of approved antidotes to reverse their action. This article provides an overview of monitoring the anticoagulant effect of NOACs and their potential specific antidotes in development.
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Affiliation(s)
- Nur A Rahmat
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
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Werth S, Breslin T, NiAinle F, Beyer-Westendorf J. Bleeding Risk, Management and Outcome in Patients Receiving Non-VKA Oral Anticoagulants (NOACs). Am J Cardiovasc Drugs 2015; 15:235-42. [PMID: 25940651 DOI: 10.1007/s40256-015-0123-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Modern direct-acting anticoagulants are rapidly replacing vitamin K antagonists (VKA) in the management of millions of patients worldwide who require anticoagulation. These drugs include agents that inhibit activated factor X (FXa) (such as apixaban and rivaroxaban) or thrombin (such as dabigatran), and are collectively known today as non-VKA oral anticoagulants (NOACs). Since bleeding is the most common and most dangerous side effect of long-term anticoagulation, and because NOACs have very different mechanisms of action and pharmacokinetics compared with VKA, physicians are naturally concerned about the lack of experience regarding frequency, management and outcome of NOAC-associated bleeding in daily care. This review appraises trial and registry (or "real-world") data pertaining to bleeding complications in patients taking NOACs and VKA and provides practical recommendations for the management of acute bleeding situations.
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Weitz JI, Pollack CV. Practical management of bleeding in patients receiving non-vitamin K antagonist oral anticoagulants. Thromb Haemost 2015; 114:1113-26. [PMID: 26155974 DOI: 10.1160/th15-03-0222] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 05/26/2015] [Indexed: 12/21/2022]
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used in the prevention and treatment of venous thromboembolism and in the prevention of stroke in patients with non-valvular atrial fibrillation. In phase III clinical trials and meta-analyses, the NOACs were at least as effective as vitamin K antagonists (VKAs) and were associated with a similar or lower incidence of major bleeding, including consistent and significant decreases in intracranial bleeding, although with an increase in gastrointestinal bleeding for some agents compared with VKAs. Subsequent real-world evidence supports these outcomes. Despite this, physicians have concerns about serious bleeding or emergencies because there are no specific reversal agents for the NOACs. However, in clinical trials, patients receiving NOACs generally had similar or better outcomes after these events than those taking VKAs. As with any bleeding, anticoagulant-related bleeding should first be stratified according to severity and location; risk can be minimised by ongoing assessment. Management protocols for NOAC-related bleeding are similar to those for VKAs but should take into account the pharmacological profile of the specific drug. Because of their short half-lives, NOAC-related mild bleeding can often be controlled by temporarily withholding treatment. More severe bleeding requires standard escalating haemodynamic support measures, and non-specific reversal agents can be considered in life-threatening situations, based on limited clinical data. Specific and rapid reversal agents are not currently available for any oral anticoagulant and restoration of coagulation may not necessarily lead to better outcomes. Nevertheless, specific NOAC reversal agents are in development and show promise in healthy volunteers.
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Affiliation(s)
- Jeffrey I Weitz
- Dr. Jeffrey Weitz, Thrombosis and Atherosclerosis Research Institute, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada, Tel.: +1 905 574 8550, Fax: +1 905 575 2646, E-mail:
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69
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Trends in the development of oral anticoagulants. Ther Deliv 2015; 6:685-703. [DOI: 10.4155/tde.15.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Anticoagulation remains the therapy of choice for the prevention and treatment of venous and arterial thromboembolic disorders which can cause major organ damage or death. Heparins represent the antithrombotic drugs of choice in short and medium-term prophylaxis and therapy of thromboembolic diseases. Fondaparinux, a synthetic and structural analog of the antithrombin-binding pentasaccharide domain of heparin, has selective anti-Xa activity and longer half-life. However, anticoagulants are poorly absorbed by oral route because of their high molecular weight, hydrophilicity and negative charges. Long-term anticoagulation therapy is problematic because of side effects and frequent monitoring. Formulation approaches are particularly promising.
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Sticherling C, Marin F, Birnie D, Boriani G, Calkins H, Dan GA, Gulizia M, Halvorsen S, Hindricks G, Kuck KH, Moya A, Potpara T, Roldan V, Tilz R, Lip GY, Gorenek B, Indik JH, Kirchhof P, Ma CS, Narasimhan C, Piccini J, Sarkozy A, Shah D, Savelieva I. Antithrombotic management in patients undergoing electrophysiological procedures: a European Heart Rhythm Association (EHRA) position document endorsed by the ESC Working Group Thrombosis, Heart Rhythm Society (HRS), and Asia Pacific Heart Rhythm Society (APHRS). ACTA ACUST UNITED AC 2015; 17:1197-214. [DOI: 10.1093/europace/euv190] [Citation(s) in RCA: 134] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Wolberg AS, Rosendaal FR, Weitz JI, Jaffer IH, Agnelli G, Baglin T, Mackman N. Venous thrombosis. Nat Rev Dis Primers 2015; 1:15006. [PMID: 27189130 DOI: 10.1038/nrdp.2015.6] [Citation(s) in RCA: 206] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Venous thromboembolism (VTE) encompasses deep-vein thrombosis (DVT) and pulmonary embolism. VTE is the leading cause of lost disability-adjusted life years and the third leading cause of cardiovascular death in the world. DVT leads to post-thrombotic syndrome, whereas pulmonary embolism can cause chronic pulmonary hypertension, both of which reduce quality of life. Genetic and acquired risk factors for thrombosis include non-O blood groups, factor V Leiden mutation, oral contraceptive use, hormone replacement therapy, advanced age, surgery, hospitalization and long-haul travel. A combination of blood stasis, plasma hypercoagulability and endothelial dysfunction is thought to trigger thrombosis, which starts most often in the valve pockets of large veins. Animal studies have revealed pathogenic roles for leukocytes, platelets, tissue factor-positive microvesicles, neutrophil extracellular traps and factors XI and XII. Diagnosis of VTE requires testing and exclusion of other pathologies, and typically involves laboratory measures (such as D-dimer) and diagnostic imaging. VTE is treated with anticoagulants and occasionally with thrombolytics to prevent thrombus extension and to reduce thrombus size. Anticoagulants are also used to reduce recurrence. New therapies with improved safety profiles are needed to prevent and treat venous thrombosis. For an illustrated summary of this Primer, visit: http://go.nature.com/8ZyCuY.
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Affiliation(s)
- Alisa S Wolberg
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, 819 Brinkhous-Bullitt Building, Chapel Hill, North Carolina 27599-7525, USA.,McAllister Heart Institute, University of North Carolina at Chapel Hill, USA
| | - Frits R Rosendaal
- Department of Clinical Epidemiology and Department of Thrombosis and Hemostasis, Leiden University Medical Center, The Netherlands.,K.G. Jensen Thrombosis Research and Expertise Center, University of Tromsø, Norway
| | - Jeffrey I Weitz
- Department of Medicine and Department of Biochemistry and Biomedical Sciences, McMaster University, and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Iqbal H Jaffer
- Department of Medicine and Department of Biochemistry and Biomedical Sciences, McMaster University, and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Giancarlo Agnelli
- Division of Internal and Cardiovascular Medicine, Stroke Unit, University of Perugia, Italy
| | - Trevor Baglin
- Department of Haematology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Nigel Mackman
- Department of Pathology and Laboratory Medicine, University of North Carolina at Chapel Hill, 819 Brinkhous-Bullitt Building, Chapel Hill, North Carolina 27599-7525, USA.,McAllister Heart Institute, University of North Carolina at Chapel Hill, USA.,K.G. Jensen Thrombosis Research and Expertise Center, University of Tromsø, Norway.,Department of Medicine, University of North Carolina at Chapel Hill, USA
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Hobl EL, Jilma B. Towards the development of specific antidotes: Idarucizumab for reversal of dabigatran effects. Thromb Haemost 2015; 113:1162-3. [PMID: 25926042 DOI: 10.1160/th15-04-0324] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 04/20/2015] [Indexed: 11/05/2022]
Affiliation(s)
| | - Bernd Jilma
- Bernd Jilma, MD, Department of Clinical Pharmacology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria, Tel.: +43 1 40400 29900, Fax: +43 1 40400 29980, E-mail:
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McGovern TR, McNamee JJ, Malabanan C, Fouad MA, Patel N. Use of 4-factor prothrombin complex concentrate in the treatment of a gastrointestinal hemorrhage complicated by dabigatran. Int J Emerg Med 2015; 8:10. [PMID: 25918557 PMCID: PMC4401481 DOI: 10.1186/s12245-015-0059-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 04/07/2015] [Indexed: 01/19/2023] Open
Abstract
Target-specific oral anticoagulants (TSOACs) provide patients and healthcare providers with an alternative to vitamin K antagonists (VKA). The TSOACs are of similar or superior efficacy to warfarin, but unlike VKAs, there are no approved ‘antidotes’ for rapid reversal of life-threatening bleeding on therapy. We report here the case of an 83-year-old gentleman, who presented to the emergency department with severe gastrointestinal hemorrhage and coagulopathy (hemoglobin: 5.3 g/dL and INR: 2.2) while on the direct thrombin inhibitor dabigatran. His coagulopathy reversed rapidly after administration of 4-factor prothrombin complex concentrate (4 F-PCC), and after initial administration of 2 units of packed red blood cells, no further product transfusions were required. He was discharged 4 days later without further complications.
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Affiliation(s)
- Terrance R McGovern
- Department of Emergency Medicine, St. Joseph's Regional Medical Center, 703 Main Street, Paterson, NJ 07503 USA
| | - Justin J McNamee
- Department of Emergency Medicine, St. Joseph's Regional Medical Center, 703 Main Street, Paterson, NJ 07503 USA
| | - Christopher Malabanan
- Department of Pharmacy, St. Joseph's Regional Medical Center, 703 Main Street, Paterson, NJ 07503 USA
| | - Mohamed A Fouad
- Department of Pharmacy, St. Joseph's Regional Medical Center, 703 Main Street, Paterson, NJ 07503 USA
| | - Nilesh Patel
- Department of Emergency Medicine, St. Joseph's Regional Medical Center, 703 Main Street, Paterson, NJ 07503 USA
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