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Sandhu RK, Islam S, Dover D, Andrade JG, Ezekowitz J, McAlister FA, Hawkins NM, Kaul P. Real world Data on the Concurrent Use of P-glycoprotein or Cytochrome 3A4 Drugs and Non-vitamin K Antagonist Oral Anticoagulants in Non-Valvular Atrial Fibrillation. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 8:195-201. [PMID: 33480405 DOI: 10.1093/ehjqcco/qcab002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/01/2021] [Accepted: 01/06/2021] [Indexed: 12/18/2022]
Abstract
AIM To determine the concurrent use of P-glycoprotein (P-gp) or Cytochrome (CYP) 3A4 drugs and non-vitamin K antagonist oral anticoagulants (NOACs) among non-valvular AF (NVAF) patients in clinical practice. METHODS AND RESULTS Administrative databases identified all adults (≥ 18 years) with incident or prevalent NVAF who initiated a NOAC in an outpatient or inpatient setting, between July 2012-March 2019 in Alberta, Canada. Concurrent use was defined as a P-gp or CYP3A4 dispensation in the 100 days prior to and overlapping NOAC dispensation. The P-gp and CYP3A4 drugs were categorized into 3 groups and drug-drug interactions classified according to the 2018 European Heart Rhythm Association practical guide. Time-varying Cox models calculated crude hazard ratio (HR) of outcomes at 1-year. A total of 642,255 NOAC dispensations occurred for 36,566 NVAF patients. Of these, 71,643 (11.2%) had a concurrent dispensation of an interacting P-gp or CYP3A4 drug. Overall, the drug-drug interaction was defined as contraindicated in 2.5%, avoid/caution in 2.3%, and for another 6.7% should require a dose adjustment. When all drug-drug interactions were considered, inappropriate NOAC prescribing occurred in 63% (n = 45,080) of dispensations. There was a significantly higher risk of death (HR 1.58, 1.47-1.70) for a drug-drug interaction but not for stroke (p = 0.89) or major bleeding risk (p = 0.13). CONCLUSIONS The concurrent use of P-gp or CYP3A4 drugs and NOACs was uncommon but important since almost two-thirds of patients with drug-drug interactions had inappropriate NOAC dosing and a higher risk of death. More attention to this issue is needed.
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Affiliation(s)
- Roopinder K Sandhu
- Division of Cardiology, University of Alberta, Edmonton, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
| | | | - Douglas Dover
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
| | - Jason G Andrade
- Dvision of Cardiology, University of British Columbia, Vancouver, Canada
| | - Justin Ezekowitz
- Division of Cardiology, University of Alberta, Edmonton, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
| | - Finlay A McAlister
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada.,Division of General Medicine, University of Alberta, Edmonton, Canada
| | | | - Padma Kaul
- Division of Cardiology, University of Alberta, Edmonton, Canada.,Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada
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Wetmore JB, Yan H, Herzog CA, Weinhandl E, Reyes JL, Roetker NS. CKD Progression in Medicare Beneficiaries With Nonvalvular Atrial Fibrillation Treated With Apixaban Versus Warfarin. Am J Kidney Dis 2021; 78:180-189. [PMID: 33421454 DOI: 10.1053/j.ajkd.2020.12.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 12/24/2020] [Indexed: 12/17/2022]
Abstract
RATIONALE & OBJECTIVE Comparing kidney disease progression among patients treated with direct oral anticoagulants (DOACs) versus warfarin has not been well studied. We hypothesized that apixaban would be associated with lower risks of progression of chronic kidney disease (CKD) and progression to incident kidney failure than warfarin in patients with atrial fibrillation (AF). STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Medicare recipients with stage 3, 4, or 5 CKD and incident AF who received a new prescription for apixaban or warfarin from 2013 through 2017. EXPOSURE Apixaban or warfarin. OUTCOMES Progression to incident kidney failure or, separately, to a more advanced stage of CKD. ANALYTICAL APPROACH Marginal structural cause-specific proportional hazards models with inverse probability weighting to estimate marginal hazard ratios (HRs) for each outcome. HRs compared apixaban to warfarin in intention-to-treat and censored-at-drug-switch analyses. RESULTS 12,816 individuals met inclusion criteria (50.3% received apixaban; 49.7% received warfarin). After weighting, the mean age of the cohort was 80 ± 7 years, 51% were women, and 88% were White. Approximately 84% had stage 3, 15% had stage 4, and 1% had stage 5 CKD. In the intention-to-treat analysis, apixaban, relative to warfarin, was associated with an HR of developing incident kidney failure of 0.98 (95% confidence interval [CI], 0.79-1.22) and of CKD stage progression of 0.90 (95% CI, 0.82-0.99). Corresponding HRs for censored-at-drug-switch analyses were 0.81 (95% CI, 0.56-1.17) and 0.81 (95% CI, 0.70-0.92). Results were similar for a series of subgroup and sensitivity analyses. LIMITATIONS CKD was defined based on diagnosis codes from claims; findings may not be generalizable to non-Medicare CKD populations. CONCLUSIONS Apixaban, compared with warfarin, was associated with lower risk of CKD stage progression, but not with incident kidney failure.
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Affiliation(s)
- James B Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN; Division of Nephrology, Hennepin County Medical Center and Department of Medicine, University of Minnesota, Minneapolis, MN.
| | - Heng Yan
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
| | - Charles A Herzog
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN; Division of Cardiology, Hennepin County Medical Center, and Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Eric Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN; Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, MN
| | - Jorge L Reyes
- Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Nicholas S Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN
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Jurin I, Lucijanić M, Šakić Z, Hulak Karlak V, Atić A, Magličić A, Starčević B, Hadžibegović I. Patterns of anticoagulation therapy in atrial fibrillation: results from a large real-life single-center registry. Croat Med J 2021. [PMID: 33150762 PMCID: PMC7684544 DOI: 10.3325/cmj.2020.61.440] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Aim To investigate the differences in the characteristics and clinical outcomes of recently diagnosed patients with atrial fibrillation (AF) receiving different types of anticoagulants in a real-life setting. Methods We retrospectively analyzed the charts of 1000 consecutive patients with non-valvular AF diagnosed and referred for hospitalization at our institution from 2013 to 2018. Results Over the observed period, the frequency of direct oral anticoagulation (DOAC) therapy use significantly increased (P = 0.002). Patients receiving warfarin had more unfavorable thromboembolic and bleeding risk factors than patients receiving DOAC. Predetermined stroke and major bleeding risks were similarly distributed among the dabigatran, rivaroxaban, and apixaban groups. Patients receiving warfarin had shorter time-to-major bleeding (TTB), time to thrombosis (TTT), and overall survival (OS) than patients receiving DOACs. After adjustment for factors unbalanced at baseline, the warfarin group showed significantly shorter OS (hazard ratio 2.27, 95% confidence interval 1.44-3.57, P < 0.001], while TTB and TTT did not significantly differ between the groups. Only 37% of patients on warfarin had optimal dosing control, and they did not differ significantly in TTB, TTT, and OS from patients on DOACs. Conclusion Warfarin and DOACs are administered to different target populations, possibly due to socio-economic reasons. Patients receiving warfarin rarely obtain optimal dosing control, and experience significantly shorter survival compared with patients receiving DOACs.
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Affiliation(s)
| | | | | | | | | | | | | | - Irzal Hadžibegović
- Irzal Hadžibegović, Department for Cardiovascular Diseases, University Hospital Dubrava, Avenija Gojka Šuška 6, 10000 Zagreb, Croatia,
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Capiau A, De Backer T, Grymonprez M, Lahousse L, Van Tongelen I, Mehuys E, Boussery K. Appropriateness of direct oral anticoagulant dosing in patients with atrial fibrillation according to the drug labelling and the EHRA Practical Guide. Int J Cardiol 2020; 328:97-103. [PMID: 33279589 DOI: 10.1016/j.ijcard.2020.11.062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 11/11/2020] [Accepted: 11/25/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND This study aimed to evaluate the prevalence of potential drug-drug interactions (DDIs) and the appropriateness of direct oral anticoagulant (DOAC) dosing according to both the Summary of Product Characteristics (SmPC) and the European Heart Rhythm Association (EHRA) Practical Guide in a 'real-world' sample of non-valvular atrial fibrillation (NVAF) patients. METHODS AND RESULTS Data of a cross-sectional observational study in a primary care sample of 654 long-term DOAC users were used for this sub-analysis. A total of 262 potential DDIs were identified in 220 patients (33.6%). Pharmacodynamic DDIs were present in 163 patients (24.9%) and pharmacokinetic DDIs in 82 patients (12.5%). One-third of patients (33.8%) received reduced DOAC dose. According to the dosing recommendations in the SmPC, 81.7% of DOACs were dosed appropriately. According to the EHRA recommendations, 76.6% of DOACs were dosed appropriately. Dosing recommendations were consistent for 90.7% of patients, with both the SmPC and EHRA Practical Guide considering DOACs dosed appropriately in 74.5% of patients, overdosed in 7.8%, underdosed in 7.6% and contraindicated in 0.8%. However, for the remaining 9.3% dosing recommendations differed between SmPC and EHRA. CONCLUSIONS This 'real-world' analysis of DOAC dosing demonstrated that in about one-third of NVAF patients potential DDIs were present. In 18.3% and 23.4% of patients, DOACs were dosed inappropriately according to the SmPC and EHRA Practical Guide respectively. In almost 10% of the study population dosing advice was inconsistent between both references. More research is needed to ensure appropriate DOAC dosing in this 'grey zone' population.
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Affiliation(s)
- Andreas Capiau
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium.
| | - Tine De Backer
- Department of Cardiology, Heart Centre, Ghent University Hospital, C. Heymanslaan 10, 9000 Ghent, Belgium; Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, C. Heymanslaan 10, 9000 Ghent, Belgium
| | - Maxim Grymonprez
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Lies Lahousse
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Inge Van Tongelen
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Els Mehuys
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
| | - Koen Boussery
- Pharmaceutical Care Unit, Faculty of Pharmaceutical Sciences, Ghent University, Ottergemsesteenweg 460, 9000 Ghent, Belgium
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Chong J, Chen H, Dai D, Wang S, Zhou Q, Liu J, Lü Y, Wu H, Du M, Chen F, Jiang H, Zhou Y, Yang J. Effects of ticagrelor on the pharmacokinetics of rivaroxaban in rats. PHARMACEUTICAL BIOLOGY 2020; 58:630-635. [PMID: 32633174 PMCID: PMC7470163 DOI: 10.1080/13880209.2020.1785510] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/08/2020] [Accepted: 06/16/2020] [Indexed: 06/11/2023]
Abstract
CONTEXT Rivaroxaban and ticagrelor are two common drugs for the treatment of atrial fibrillation and acute coronary syndrome. However, the drug-drug interaction between them is still unknown. OBJECTIVE To investigate the effects of ticagrelor on the pharmacokinetics of rivaroxaban in rats both in vivo and in vitro. MATERIALS AND METHODS A sensitive and reliable UPLC-MS/MS method was developed for the determination of rivaroxaban in rat plasma. Ten Sprague-Dawley rats were randomly divided into ticagrelor pre-treated group (10 mg/kg/day for 14 days) and control group. The pharmacokinetics of orally administered rivaroxaban (10 mg/kg, single dose) with or without ticagrelor pre-treatment was investigated with developed UPLC-MS/MS method. Additionally, Sprague-Dawley rat liver microsomes were also used to investigate the drug-drug interaction between these two drugs in vitro. RESULTS The C max (221.34 ± 53.33 vs. 691.18 ± 238.31 ng/mL) and the AUC(0-t) (1060.97 ± 291.21 vs. 3483.03 ± 753.83 μg·h/L) of rivaroxaban increased significantly (p < 0.05) with ticagrelor pre-treatment. The MRT(0-∞) of rivaroxaban increased from 4.41 ± 0.79 to 5.97 ± 1.11 h, while the intrinsic clearance decreased from 9.93 ± 2.55 to 2.89 ± 0.63 L/h/kg (both p < 0.05) after pre-treated with ticagrelor. Enzyme kinetic study indicated that ticagrelor decreased rivaroxaban metabolic clearance with the IC50 value of 14.04 μmol/L. CONCLUSIONS Our in vivo and in vitro results demonstrated that there is a drug-drug interaction between ticagrelor and rivaroxaban in rats. Further studies need to be carried out to verify whether similar interactions truly apply in humans and whether these interactions have clinical significance.
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Affiliation(s)
- Jia Chong
- Division of Cardiology, Internal Medicine Department, Beijing Hospital, Beijing, P.R. China
| | - Hao Chen
- Division of Cardiology, Internal Medicine Department, Beijing Hospital, Beijing, P.R. China
| | - Dapeng Dai
- Beijing Institute of Geriatrics, Beijing Hospital, Beijing, P.R. China
| | - Shuanghu Wang
- The Laboratory of Clinical Pharmacy, The People’s Hospital of Lishui, Lishui, P.R. China
| | - Quan Zhou
- The Laboratory of Clinical Pharmacy, The People’s Hospital of Lishui, Lishui, P.R. China
| | - Junpeng Liu
- Division of Cardiology, Internal Medicine Department, Beijing Hospital, Beijing, P.R. China
| | - You Lü
- Division of Cardiology, Internal Medicine Department, Beijing Hospital, Beijing, P.R. China
| | - Hualan Wu
- Division of Cardiology, Internal Medicine Department, Beijing Hospital, Beijing, P.R. China
| | - Minghui Du
- Division of Cardiology, Internal Medicine Department, Beijing Hospital, Beijing, P.R. China
| | - Feifei Chen
- The Laboratory of Clinical Pharmacy, The People’s Hospital of Lishui, Lishui, P.R. China
| | - Hui Jiang
- The Laboratory of Clinical Pharmacy, The People’s Hospital of Lishui, Lishui, P.R. China
| | - Yunfang Zhou
- The Laboratory of Clinical Pharmacy, The People’s Hospital of Lishui, Lishui, P.R. China
| | - Jiefu Yang
- Division of Cardiology, Internal Medicine Department, Beijing Hospital, Beijing, P.R. China
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106
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Emergent reversal of oral factor Xa inhibitors with four-factor prothrombin complex concentrate. Am J Emerg Med 2020; 38:2641-2645. [DOI: 10.1016/j.ajem.2020.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/15/2020] [Accepted: 08/05/2020] [Indexed: 12/20/2022] Open
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Ajam T, Cumpian TL, Tilkens BL, Jahangir IA, Frost J, Ceretto C, Jahangir A. Non-vitamin K antagonist oral anticoagulants for stroke prevention in atrial fibrillation: safety issues in the elderly. Expert Rev Clin Pharmacol 2020; 13:1309-1327. [PMID: 33107345 DOI: 10.1080/17512433.2020.1842191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used for stroke prevention in patients with atrial fibrillation (AF). Since NOACs are predominantly used in the elderly with AF at high risk for stroke and bleeding and with comorbidities requiring polypharmacy, it is important to assess their safety and efficacy in this population. AREAS COVERED We review changes in pharmacokinetics and pharmacodynamics observed with senescence and the effect on NOACs and drug and food interactions. We also provide an update on challenges related to NOAC use in situations that increases the risk for bleeding or require temporary discontinuation and address practical issues in the elderly AF patients managed on NOACs. Clinical studies and trials with cardiovascular outcomes reported from January 1990 to August 2020 were identified through the Medline database using PubMed, Cochrane Library, and EMBASE database. EXPERT OPINION NOACs are highly effective in preventing stroke in AF patients with non-inferior or superior efficacy to warfarin, with reduced risk of major bleeding. However, in the older-elderly, evidence comes mainly from observational studies or extrapolation from studies in populations with minimal functional limitations or comorbidities. The high upfront cost and out-of-pocket expense for copayment or deductibles also limit the use of this effective therapy in a substantial number of patients. The cost reduction may further improve long-term use for NOACs in stroke prevention in elderly patients with AF.
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Affiliation(s)
- Tarek Ajam
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers , Milwaukee, WI, USA
| | - Tabitha L Cumpian
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers , Milwaukee, WI, USA.,Center for Advanced Atrial Fibrillation Therapies , Milwaukee, WI USA
| | - Blair L Tilkens
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers , Milwaukee, WI, USA
| | | | - Jared Frost
- Pharmacy Services, Advocate Aurora Health , Milwaukee, WI, USA
| | - Cheryl Ceretto
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers , Milwaukee, WI, USA.,Center for Advanced Atrial Fibrillation Therapies , Milwaukee, WI USA
| | - Arshad Jahangir
- Aurora Cardiovascular and Thoracic Services, Aurora Sinai/Aurora St. Luke's Medical Centers , Milwaukee, WI, USA.,Center for Advanced Atrial Fibrillation Therapies , Milwaukee, WI USA
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Highsmith EA, Morton C, Varnado S, Donahue KR, Sulhan S, Lista A. Outcomes Associated With 4-Factor Prothrombin Complex Concentrate Administration to Reverse Oral Factor Xa Inhibitors in Bleeding Patients. J Clin Pharmacol 2020; 61:598-605. [PMID: 33094836 DOI: 10.1002/jcph.1779] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 10/19/2020] [Indexed: 12/20/2022]
Abstract
Compared with vitamin K antagonists (VKAs), oral factor Xa inhibitors are associated with at least equivalent efficacy and a lower incidence of major bleeding. Despite this benefit, bleeding remains the most common adverse event. Prior to the approval of andexanet alfa, alternative agents such as 4-factor prothrombin complex concentrate (4F-PCC) were utilized for reversal. This was a retrospective, descriptive study conducted on patients 18 years of age or older who received 4F-PCC for reversal of oral factor Xa inhibitors-associated bleeding. Patients were excluded if they received a VKA or dabigatran in the previous 48 hours. A subgroup analysis comparing 4F-PCC with andexanet alfa was conducted on patients who met the inclusion and exclusion criteria of the ANNEXA-4 trial. The primary end point of this study was to evaluate the incidence of hemostasis and associated dosing strategies in patients receiving 4F-PCC for reversal of oral factor Xa inhibitors-associated bleeding. Thirty-eight patients were included, and 28 patients (74%) achieved hemostasis. The median dose of 4F-PCC was 50 units/kg. In patients who achieved hemostasis, the median dose was 50 units/kg, and in those who failed to reach hemostasis, a median dose of 30 units/kg was seen. Within the subgroup analysis, there was no difference in overall rates of hemostasis between the 4F-PCC and andexanet alfa groups. Remaining a reasonable option to utilize for reversal of oral factor Xa inhibitors is 4F-PCC, especially when andexanet alfa is unavailable, with 50 units/kg appearing to be the most effective dose to achieve hemostasis. Further studies are needed to determine a preferential agent.
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Gorczyca I, Jelonek O, Uziębło-Życzkowska B, Chrapek M, Maciorowska M, Wójcik M, Błaszczyk R, Kapłon-Cieślicka A, Gawałko M, Budnik M, Tokarek T, Rajtar-Salwa R, Bil J, Wojewódzki M, Szpotowicz A, Bednarski J, Bakuła-Ostalska E, Tomaszuk-Kazberuk A, Szyszkowska A, Wełnicki M, Mamcarz A, Wożakowska-Kapłon B. Trends in the Prescription of Non-Vitamin K Antagonist Oral Anticoagulants for Atrial Fibrillation: Results of the Polish Atrial Fibrillation (POL-AF) Registry. J Clin Med 2020; 9:jcm9113565. [PMID: 33167503 PMCID: PMC7694480 DOI: 10.3390/jcm9113565] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/30/2020] [Accepted: 11/03/2020] [Indexed: 12/25/2022] Open
Abstract
Background: Current guidelines do not suggest in which groups of patients with atrial fibrillation (AF) individual non-vitamin K antagonist oral anticoagulants (NOACs) should be used for the prevention of thromboembolic complications. The aim of this study was to evaluate the frequency of use of apixaban, dabigatran, and rivaroxaban, and attempt to identify factors predisposing their administration. Methods: The Polish Atrial Fibrillation (POL-AF) registry is a prospective, non-interventional study, including consecutive patients with AF hospitalized in ten Polish cardiology centers during the period ranging from January to December 2019. In this study, all patients were treated with NOACs. Results: Among the 2971 patients included in the analysis, 40.4% were treated with rivaroxaban, 32% with apixaban, and 27.6% with dabigatran. The mean age of the total population was 72 ± 11.5 years and 43% were female. A reduced dose of NOAC was used in 35% of patients treated with apixaban, 39.7% of patients treated with dabigatran, and 34.4% of patients treated with rivaroxaban. Independent predictors of the use of apixaban were previous bleeding (OR 2.37, CI 1.67–3.38), GFR < 60 mL/min (OR 1.38, CI 1.25–1.64), heart failure (OR 1.38, CI 1.14–1.67) and age (per 5 years) (OR 1.14, CI 1.09–1.19). GFR < 60 mL/min (OR 0.79, CI 0.66–0.95), female (OR 0.8, CI 0.67–0.96) and age (per 5 years) (OR 0.95, CI 0.91–0.99) diminished the chance of using dabigatran. Previous bleeding (OR 0.43, CI 0.28–0.64), vascular disease (OR 0.84, CI 0.70–0.99), and age (per 5 years) (OR 0.94, CI 0.90–0.97) diminished the chance of choosing rivaroxaban. Conclusions: In hospitalized patients with AF, the most frequently chosen NOAC was rivaroxaban. Apixaban was chosen more often in patients after bleeding, and in those who were advanced in years, with heart failure and impaired renal function. Impaired renal function and female gender were factors that diminished the chance of using dabigatran. Previous bleeding and vascular disease was the factor that diminished the chance of using rivaroxaban. Dabigatran and rivaroxaban have been used less frequently in elderly patients.
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Affiliation(s)
- Iwona Gorczyca
- Collegium Medicum, The Jan Kochanowski University, 25-369 Kielce, Poland; (I.G.); (O.J.); (B.W.-K.)
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
| | - Olga Jelonek
- Collegium Medicum, The Jan Kochanowski University, 25-369 Kielce, Poland; (I.G.); (O.J.); (B.W.-K.)
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
| | - Beata Uziębło-Życzkowska
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland;
- Correspondence: ; Tel.: +48-261-816-376
| | - Magdalena Chrapek
- Faculty of Natural Sciences, The Jan Kochanowski University, 25-369 Kielce, Poland;
| | - Małgorzata Maciorowska
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, 04-141 Warsaw, Poland;
| | - Maciej Wójcik
- Department of Cardiology, Medical University of Lublin, 20-059 Lublin, Poland; (M.W.); (R.B.)
| | - Robert Błaszczyk
- Department of Cardiology, Medical University of Lublin, 20-059 Lublin, Poland; (M.W.); (R.B.)
| | - Agnieszka Kapłon-Cieślicka
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.K.-C.); (M.G.); (M.B.)
| | - Monika Gawałko
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.K.-C.); (M.G.); (M.B.)
| | - Monika Budnik
- 1st Chair and Department of Cardiology, Medical University of Warsaw, 02-097 Warsaw, Poland; (A.K.-C.); (M.G.); (M.B.)
| | - Tomasz Tokarek
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland; (T.T.); (R.R.-S.)
| | - Renata Rajtar-Salwa
- Department of Cardiology and Cardiovascular Interventions, University Hospital, 30-688 Krakow, Poland; (T.T.); (R.R.-S.)
| | - Jacek Bil
- Department of Invasive Cardiology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, 02-507 Warsaw, Poland; (J.B.); (M.W.)
| | - Michał Wojewódzki
- Department of Invasive Cardiology, Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of Interior and Administration, 02-507 Warsaw, Poland; (J.B.); (M.W.)
| | - Anna Szpotowicz
- Department of Cardiology, Regional Hospital, 27-400 Ostrowiec Swiętokrzyski, Poland;
| | - Janusz Bednarski
- Department of Cardiology, St John Paul II Western Hospital, 05-825 Grodzisk Mazowiecki, Poland; (J.B.); (E.B.-O.)
| | - Elwira Bakuła-Ostalska
- Department of Cardiology, St John Paul II Western Hospital, 05-825 Grodzisk Mazowiecki, Poland; (J.B.); (E.B.-O.)
| | - Anna Tomaszuk-Kazberuk
- Department of Cardiology, Medical University, 15-276 Bialystok, Poland; (A.T.-K.); (A.S.)
| | - Anna Szyszkowska
- Department of Cardiology, Medical University, 15-276 Bialystok, Poland; (A.T.-K.); (A.S.)
| | - Marcin Wełnicki
- 3rd Department of Internal Diseases and Cardiology, Warsaw Medical University, 02-091 Warsaw, Poland; (M.W.); (A.M.)
| | - Artur Mamcarz
- 3rd Department of Internal Diseases and Cardiology, Warsaw Medical University, 02-091 Warsaw, Poland; (M.W.); (A.M.)
| | - Beata Wożakowska-Kapłon
- Collegium Medicum, The Jan Kochanowski University, 25-369 Kielce, Poland; (I.G.); (O.J.); (B.W.-K.)
- 1st Clinic of Cardiology and Electrotherapy, Swietokrzyskie Cardiology Centre, 25-736 Kielce, Poland
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Lee JY, Oh IY, Lee JH, Kim SY, Kwon SS, Yang HJ, Kim YK, Bang SM. The increased risk of bleeding due to drug-drug interactions in patients administered direct oral anticoagulants. Thromb Res 2020; 195:243-249. [DOI: 10.1016/j.thromres.2020.07.054] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 07/21/2020] [Accepted: 07/30/2020] [Indexed: 11/25/2022]
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111
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Izumi C, Eishi K, Ashihara K, Arita T, Otsuji Y, Kunihara T, Komiya T, Shibata T, Seo Y, Daimon M, Takanashi S, Tanaka H, Nakatani S, Ninami H, Nishi H, Hayashida K, Yaku H, Yamaguchi J, Yamamoto K, Watanabe H, Abe Y, Amaki M, Amano M, Obase K, Tabata M, Miura T, Miyake M, Murata M, Watanabe N, Akasaka T, Okita Y, Kimura T, Sawa Y, Yoshida K. JCS/JSCS/JATS/JSVS 2020 Guidelines on the Management of Valvular Heart Disease. Circ J 2020; 84:2037-2119. [DOI: 10.1253/circj.cj-20-0135] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kiyoyuki Eishi
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Kyomi Ashihara
- Department of Cardiology, Tokyo Women’s Medical University Hospital
| | - Takeshi Arita
- Division of Cardiovascular Medicine Heart & Neuro-Vascular Center, Fukuoka Wajiro
| | - Yutaka Otsuji
- Department of Cardiology, Hospital of University of Occupational and Environmental Health
| | - Takashi Kunihara
- Department of Cardiac Surgery, The Jikei University School of Medicine
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Toshihiko Shibata
- Department of Cardiovascular Surgery, Osaka City University Postgraduate of Medicine
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
| | - Masao Daimon
- Department of Clinical Laboratory/Cardiology, The University of Tokyo Hospital
| | | | | | - Satoshi Nakatani
- Division of Health Sciences, Osaka University Graduate School of Medicine
| | - Hiroshi Ninami
- Department of Cardiac Surgery, Tokyo Women’s Medical University
| | - Hiroyuki Nishi
- Department of Cardiovascular Surgery, Osaka General Medical Center
| | | | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | | | - Kazuhiro Yamamoto
- Division of Cardiovascular Medicine, Endocrinology and Metabolism, Faculty of Medicine, Tottori University
| | | | - Yukio Abe
- Department of Cardiology, Osaka City General Hospital
| | - Makoto Amaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masashi Amano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kikuko Obase
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Minoru Tabata
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Takashi Miura
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | | | - Mitsushige Murata
- Department of Laboratory Medicine, Tokai University Hachioji Hospital
| | - Nozomi Watanabe
- Department of Cardiology, Miyazaki Medical Association Hospital
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Takatsuki Hospital
| | - Takeshi Kimura
- Department of Cardiology, Kyoto University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Kiyoshi Yoshida
- Department of Cardiology, Sakakibara Heart Institute of Okayama
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112
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Herold J, Bauersachs R. [How to anticoagulate elderly and fragile patients?]. Dtsch Med Wochenschr 2020; 145:1562-1568. [PMID: 33080644 DOI: 10.1055/a-1200-7895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Risks of thrombosis, bleeding and renal impairment are increasing with age. The efficacy and safety of the direct oral anticoagulants (DOACs) in fragile patients (age > 75 years and/or creatinine clearance levels < 50 ml/min and/or body weight below 50 kg) with indication for anticoagulation is one of the most challenging topic in cardiovascular medicine. New registry data from subgroup analyses of landmark studies and registries point towards to superiority of DOACs. This article summarizes new insights and describes pathways for anticoagulation in fragile patients.
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Affiliation(s)
- Joerg Herold
- Klinikum Darmstadt, Klinik für Gefäßmedizin-Angiologie
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113
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Patti G, Haas S. Non-Vitamin K Antagonist Oral Anticoagulants and Factors Influencing the Ischemic and Bleeding Risk in Elderly Patients With Atrial Fibrillation: A Review of Current Evidence. J Cardiovasc Pharmacol 2020; 77:11-21. [PMID: 33060545 PMCID: PMC7774815 DOI: 10.1097/fjc.0000000000000927] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 10/04/2020] [Indexed: 10/31/2022]
Abstract
ABSTRACT Non-vitamin K antagonist oral anticoagulants (NOACs) are a widely prescribed treatment to prevent stroke in patients with nonvalvular atrial fibrillation, and a therapy and preventative measure to prevent recurrences following venous thromboembolism. Optimal use of NOACs requires a thorough knowledge of the pharmacology of these drugs, as well as an understanding of patient factors affecting their use. The 4 NOACs-dabigatran, apixaban, edoxaban, and rivaroxaban are available in a range of doses suitable for differing indications and with a variety of dose reduction criteria. Identification of the correct dose is one of the key challenges in the individualization of treatment. Elderly patients with atrial fibrillation are at a greater risk of both ischemic and bleeding events than younger patients. Consequently, it is essential to achieve balance in anticoagulation strategies. Medication adherence to NOACs is important for safe and effective treatment, particularly in elderly populations. A growing body of evidence shows that once-daily dosing improves adherence and persistence to therapy, without having an impact on bleeding risk.
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Affiliation(s)
- Giuseppe Patti
- Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy; and
| | - Sylvia Haas
- Formerly Technical University of Munich, Munich, Germany
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114
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Suceveanu AI, Suceveanu AP, Parepa I, Mazilu L, Pantea-Stoian A, Diaconu C, Botea F, Herlea V, Micu SI, Tuta LA, Costea DO, Voinea F. Reducing upper digestive bleeding risk in patients treated with direct oral anticoagulants and concomitant infection with Helicobacter pylori. Exp Ther Med 2020; 20:205. [PMID: 33123234 DOI: 10.3892/etm.2020.9335] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 09/10/2020] [Indexed: 12/12/2022] Open
Abstract
Direct oral anticoagulants (DOACs) such as apixaban or dabigatran are excellent options in preventing embolic cardiovascular events. Observational studies have shown that gastrointestinal bleeding risks produced by DOACs could be lowered when correcting some host co-factors i.e. Helicobacter pylori (HP) infection. The upper digestive bleeding (UDB) rates in patients with DOAC indication and the usefulness of anti-HP therapy addition were compared. An observational retrospective study was conducted of medical records of 260 patients treated with DOACs, 130 of whom were concomitantly treated for HP infection in accordance with Maastricht V/Florence consensus. The severity of bleeding, the complexity of endoscopic treatment required to stop the bleeding, the re-bleeding rates, the surgical treatment indication and the overall mortality rates were compared between the groups. The risk of UDB was higher in HP-untreated patients in both types of DOACs used (respectively 2.08, 2.02). HP-untreated Forrest Ia/Ib/IIa and IIb DOACs patients had more severe bleedings compared with same class of HP-treated patients (P=0.007/0.005; 0.009/0.006; 0.048/0.005, 0.044/0.049, respectively). Endoscopic treatments such as adrenaline injections combined with metallic clip attachments were more frequently mandatory in HP-untreated DOACs patients for classes Ia/b and IIa (respectively, P=0.000/0.001, P=0.003/0.003). The re-bleeding rates were higher in HP-untreated patients with concomitant DOACs (OR 82.5; 95% CI 30.1-121.7; P=0.005). A history of peptic ulcer or UDB was associated with a 2.9-fold higher risk of UDB in HP-untreated compared with HP-treated patients, slightly increased for dabigatran compared with apixaban (RR 3.06, 2.72, P<0.5, respectively). Surgical intervention and the UDB-related mortality rates were higher in HP-untreated patients (P=0.041/0.044, P=0.007, respectively). HP-eradication treatment and bacterial clearance improve the safety profile of DOACs treatment, especially in fragile patients, in whom the UDB rates can be lowered, and the overall outcome can be enhanced by this combined approach.
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Affiliation(s)
- Andra-Iulia Suceveanu
- Department of Gastroenterology, Emergency Hospital of Constanta, Ovidius University, 900527 Constanta, Romania
| | - Adrian-Paul Suceveanu
- Internal Medicine Clinic, Emergency Hospital of Constanta, Ovidius University, 900527 Constanta, Romania
| | - Irinel Parepa
- Department of Cardiology, Emergency Hospital of Constanta, Ovidius University, 900527 Constanta, Romania
| | - Laura Mazilu
- Department of Oncology, Emergency Hospital of Constanta, Ovidius University, 900527 Constanta, Romania
| | - Anca Pantea-Stoian
- Department of Diabetes Mellitus, Clinical Emergency Hospital of Bucharest, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Camelia Diaconu
- Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 'Carol Davila' University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Florin Botea
- Liver Transplant and General Surgery Centre, Fundeni Institute, 022328 Bucharest, Romania
| | - Vlad Herlea
- Department of Pathology, Fundeni Institute, 022328 Bucharest, Romania
| | - Sergiu Ioan Micu
- Department of Gastroenterology, Emergency Hospital of Constanta, Ovidius University, 900527 Constanta, Romania
| | - Liliana Ana Tuta
- Department of Nephrology, Emergency Hospital of Constanta, Ovidius University, 900527 Constanta, Romania
| | - Daniel Ovidiu Costea
- Department of Surgery, Emergency Hospital of Constanta, Ovidius University, 900527 Constanta, Romania
| | - Felix Voinea
- Department of Urology, Emergency Hospital of Constanta, Ovidius University, 900527 Constanta, Romania
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115
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Trends in anticoagulation management services following incorporation of direct oral anticoagulants at a large academic medical center. J Thromb Thrombolysis 2020; 51:1050-1058. [PMID: 33037531 PMCID: PMC7546384 DOI: 10.1007/s11239-020-02286-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2020] [Indexed: 10/25/2022]
Abstract
The introduction of direct oral anticoagulants (DOACs) to the market has expanded anticoagulation options for outpatient use. Routine evaluation by health care professionals is recommended as it is with warfarin, therefore requiring adjustments in practices of anticoagulation management services (AMS). This study aims to describe trends that occurred following the incorporation of DOACs into AMS at a large academic medical center. A retrospective chart review of pharmacist-run AMS was used to compare patients on DOAC therapy versus other types of anticoagulation, including warfarin and parenteral agents. Primary outcomes included trends in the number of unique patients, management encounters, and telephone encounters throughout the study period. Secondary outcomes included trends in new encounters, and changes in patient characteristics, resources utilized, and patient satisfaction scores. A total of 2976 unique patients, 74,582 management encounters, and 13,282 telephone encounters were identified. From study beginning to end, results showed stable numbers of unique patients, an increase in management encounters for the DOAC group and decrease in the other anticoagulants group, and stable numbers of telephone encounters. Additionally, the number of new encounters for both groups increased. Throughout the study, pharmacy resources were reallocated within anticoagulation to adapt to the changing trends and patient satisfaction reached targets. Patients' characteristics remained stable, with the DOAC group having fewer comorbid conditions and concomitant medications that could increase bleed risk. This study showed that by reallocating resources within anticoagulation, AMS can maintain stable patient populations while continuing to expand access and satisfy patients following DOAC inclusion.
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116
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Calkins H, Willems S, Verma A, Schilling R, Hohnloser SH, Okumura K, Nordaby M, Kleine E, Bis B, Gerstenfeld EP. Heparin dosing in uninterrupted anticoagulation with dabigatran vs. warfarin in atrial fibrillation ablation: RE-CIRCUIT study. Europace 2020; 21:879-885. [PMID: 30982849 PMCID: PMC6781146 DOI: 10.1093/europace/euz057] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 03/18/2019] [Indexed: 01/10/2023] Open
Abstract
AIMS To describe heparin dosing requirements in patients who underwent catheter ablation of atrial fibrillation with uninterrupted anticoagulation using dabigatran etexilate (dabigatran) or warfarin to attain therapeutic activated clotting time (ACT) in the RE-CIRCUIT® study. The RE-CIRCUIT study showed significantly fewer major bleeding events in the dabigatran vs. warfarin treatment group. Unfractionated heparin was administered during the procedure to maintain ACT >300 s. METHODS AND RESULTS Patients were randomly assigned to dabigatran 150 mg bid or international normalized ratio-adjusted warfarin. Ablation was performed with uninterrupted anticoagulation and continued for 8 weeks after the procedure. Heparin was administered after placement of femoral sheaths before or immediately after transseptal puncture. Ablation was performed in 635 patients (dabigatran, 317; warfarin, 318); data were available from 396 patients administered heparin (dabigatran, 191; warfarin, 205). Most frequent time window from last dose of study drug to septal puncture was 0 to <4 h in the dabigatran (41.3%) and 16 to <24 h in the warfarin arms (44.7%). Overall mean (standard deviation) heparin dose was similar between the dabigatran and warfarin groups [12 402 (10 721) vs. 11 910 (8359) IU, respectively]. Heparin dosing requirement to reach therapeutic ACT was lowest when time from last dose of dabigatran to septal puncture was 0 to <4 h. CONCLUSION Patients treated with dabigatran required a similar amount of unfractionated heparin as those treated with warfarin to achieve an ACT of >300 s during ablation. More heparin units were required when the time from the last dose of dabigatran to septal puncture increased.
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Affiliation(s)
- Hugh Calkins
- Johns Hopkins Medical Institutions, Baltimore, MD, USA
| | | | - Atul Verma
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Ken Okumura
- Saiseikai Kumamoto Hospital, Cardiovascular Center, Kumamoto, Japan
| | - Matias Nordaby
- Boehringer Ingelheim Pharma, Ingelheim am Rhein, Germany
| | - Eva Kleine
- Boehringer Ingelheim Pharma, Ingelheim am Rhein, Germany
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117
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Holm J, Mannheimer B, Malmström RE, Eliasson E, Lindh JD. Bleeding and thromboembolism due to drug-drug interactions with non-vitamin K antagonist oral anticoagulants-a Swedish, register-based cohort study in atrial fibrillation outpatients. Eur J Clin Pharmacol 2020; 77:409-419. [PMID: 33029651 PMCID: PMC7867544 DOI: 10.1007/s00228-020-03015-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 10/01/2020] [Indexed: 01/14/2023]
Abstract
PURPOSE To study the association between interacting drugs and bleeding or thromboembolism in atrial fibrillation outpatients treated with non-vitamin K antagonist oral anticoagulants (NOACs). METHODS Population-based cohort study of outpatients treated with NOACs in Sweden from 2008 to 2017. Patients with atrial fibrillation and newly initiated NOAC treatment were identified in the Prescribed Drug Register. Comorbidities and outcome data were retrieved from the Patient Register and the Cause of Death Register. Cox-regression analyses were performed to evaluate the primary endpoints any severe bleed and ischemic stroke/transient ischemic attack/stroke unspecified during the first six months of treatment. Secondary endpoints were gastrointestinal bleeding, intracranial bleeding, ischemic stroke, and venous thromboembolism. RESULTS Increased risk of any severe bleed was found when NOAC treatment, and drugs with pharmacodynamic effect on bleeding were combined, compared to NOAC only. An increased risk with these combinations was evident for apixaban (hazard ratio (HR) 1.47; 95% CI 1.33-1.63), rivaroxaban (HR 1.7; 95% CI 1.49-1.92), and dabigatran (HR 1.26; 95% CI 1.05-1.52). For apixaban, there was an increased risk of any severe bleed when combined with CYP3A4 and/or P-glycoprotein (P-gp) inhibitors (HR 1.23; 95% CI 1.01-1.5). The use of inducers of CYP3A4 and/or P-gp was low in this cohort, and effects on ischemic stroke/TIA/stroke unspecified could not be established. CONCLUSION Increased risk of bleeding was seen for pharmacodynamic and pharmacokinetic interactions with NOACs. Prescribers need to be vigilant of the effect of interacting drugs on the risk profile of patients treated with NOACs.
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Affiliation(s)
- Johan Holm
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden. .,Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden.
| | - Buster Mannheimer
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden.,Internal Medicine, Södersjukhuset, Stockholm, Sweden
| | - Rickard E Malmström
- Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Erik Eliasson
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Jonatan D Lindh
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
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118
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Yao X, Inselman JW, Ross JS, Izem R, Graham DJ, Martin DB, Thompson AM, Ross Southworth M, Siontis KC, Ngufor CG, Nath KA, Desai NR, Nallamothu BK, Saran R, Shah ND, Noseworthy PA. Comparative Effectiveness and Safety of Oral Anticoagulants Across Kidney Function in Patients With Atrial Fibrillation. Circ Cardiovasc Qual Outcomes 2020; 13:e006515. [PMID: 33012172 DOI: 10.1161/circoutcomes.120.006515] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with atrial fibrillation and severely decreased kidney function were excluded from the pivotal non-vitamin K antagonist oral anticoagulants (NOAC) trials, thereby raising questions about comparative safety and effectiveness in patients with reduced kidney function. The study aimed to compare oral anticoagulants across the range of kidney function in patients with atrial fibrillation. METHODS AND RESULTS Using a US administrative claims database with linked laboratory data, 34 569 new users of oral anticoagulants with atrial fibrillation and estimated glomerular filtration rate ≥15 mL/(min·1.73 m2) were identified between October 1, 2010 to November 29, 2017. The proportion of patients using NOACs declined with decreasing kidney function-73.5%, 69.6%, 65.4%, 59.5%, and 45.0% of the patients were prescribed a NOAC in estimated glomerular filtration rate ≥90, 60 to 90, 45 to 60, 30 to 45, 15 to 30 mL/min per 1.73 m2 groups, respectively. Stabilized inverse probability of treatment weighting was used to balance 4 treatment groups (apixaban, dabigatran, rivaroxaban, and warfarin) on 66 baseline characteristics. In comparison to warfarin, apixaban was associated with a lower risk of stroke (hazard ratio [HR], 0.57 [0.43-0.75]; P<0.001), major bleeding (HR, 0.51 [0.44-0.61]; P<0.001), and mortality (HR, 0.68 [0.56-0.83]; P<0.001); dabigatran was associated with a similar risk of stroke but a lower risk of major bleeding (HR, 0.57 [0.43-0.75]; P<0.001) and mortality (HR, 0.68 [0.48-0.98]; P=0.04); rivaroxaban was associated with a lower risk of stroke (HR, 0.69 [0.51-0.94]; P=0.02), major bleeding (HR, 0.84 [0.72-0.99]; P=0.04), and mortality (HR, 0.73 [0.58-0.91]; P=0.006). There was no significant interaction between treatment and estimated glomerular filtration rate categories for any outcome. When comparing one NOAC to another NOAC, there was no significant difference in mortality, but some differences existed for stroke or major bleeding. No relationship between treatments and falsification end points was found, suggesting no evidence for substantial residual confounding. CONCLUSIONS Relative to warfarin, NOACs are used less frequently as kidney function declines. However, NOACs appears to have similar or better comparative effectiveness and safety across the range of kidney function.
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Affiliation(s)
- Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (X.Y., J.W.I., C.G.N., N.D.S., P.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN.,Division of Health Care Policy and Research, Department of Health Sciences Research (X.Y., J.W.I., N.D.S.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN.,Department of Cardiovascular Medicine (X.Y., K.C.S., P.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Jonathan W Inselman
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (X.Y., J.W.I., C.G.N., N.D.S., P.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN.,Division of Health Care Policy and Research, Department of Health Sciences Research (X.Y., J.W.I., N.D.S.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Joseph S Ross
- Department of Internal Medicine, Section of General Internal Medicine, Yale School of Medicine, New Haven, CT (J.S.R.).,Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S.R., N.R.D.)
| | - Rima Izem
- Division of Biometrics and Epidemiology, Children's National Research Institute, Washington, D.C. (R.I.)
| | - David J Graham
- Office of Surveillance and Epidemiology (D.J.G.), Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - David B Martin
- Office of Medical Policy (D.B.M.), Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Aliza M Thompson
- Division of Cardiovascular and Renal Products (A.M.T, M.R.S.), Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Mary Ross Southworth
- Division of Cardiovascular and Renal Products (A.M.T, M.R.S.), Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD
| | - Konstantinos C Siontis
- Department of Cardiovascular Medicine (X.Y., K.C.S., P.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Che G Ngufor
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (X.Y., J.W.I., C.G.N., N.D.S., P.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN.,Division of Biomedical Statistics and Informatics, Department of Health Sciences Research (C.G.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Karl A Nath
- Division of Nephrology and Hypertension (K.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Nihar R Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (J.S.R., N.R.D.)
| | - Brahmajee K Nallamothu
- Division of Cardiovascular Medicine, Department of Internal Medicine (B.K.N.), University of Michigan, Ann Arbor
| | - Rajiv Saran
- Department of Internal Medicine (R.S.), University of Michigan, Ann Arbor
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (X.Y., J.W.I., C.G.N., N.D.S., P.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN.,Division of Health Care Policy and Research, Department of Health Sciences Research (X.Y., J.W.I., N.D.S.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN.,OptumLabs, Cambridge, MA (N.D.S.)
| | - Peter A Noseworthy
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (X.Y., J.W.I., C.G.N., N.D.S., P.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN.,Department of Cardiovascular Medicine (X.Y., K.C.S., P.A.N.), and Department of Internal Medicine, Mayo Clinic, Rochester, MN
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119
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Galdi F, Pedone C, Antonelli Incalzi R. Thromboembolic disease: a geriatric syndrome. JOURNAL OF GERONTOLOGY AND GERIATRICS 2020. [DOI: 10.36150/2499-6564-437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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120
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Nakagawa J, Kinjo T, Iizuka M, Ueno K, Tomita H, Niioka T. Impact of gene polymorphisms in drug-metabolizing enzymes and transporters on trough concentrations of rivaroxaban in patients with atrial fibrillation. Basic Clin Pharmacol Toxicol 2020; 128:297-304. [PMID: 32920985 DOI: 10.1111/bcpt.13488] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/30/2020] [Accepted: 09/04/2020] [Indexed: 11/28/2022]
Abstract
Rivaroxaban is excreted from the body via multiple pathways involving glomerular filtration, drug-metabolizing enzymes and transporters. In this study, we aimed to examine the impact of single nucleotide polymorphisms in P-glycoprotein, breast cancer resistance protein, cytochrome P450 (CYP) 3A5 and CYP2J2 on the pharmacokinetics of rivaroxaban. Eighty-six patients with non-valvular atrial fibrillation (NVAF) undergoing AF catheter ablation were enrolled in this study. In these analyses, the dose-adjusted plasma trough concentration ratio (C0h /D) of rivaroxaban was used as the pharmacokinetic index. The median (quartile range) rivaroxaban C0h /D was 3.39 (2.08-5.21) ng/mL/mg (coefficient of variation: 80.5%). The C0h /D did not differ significantly among ABCB1 c.3435C>T, c.2677G>A/T, c.1236C>T, ABCG2 c.421C>A, CYP3A5*3 and CYP2J2*7 genotypes. Stepwise selection multiple linear regression analysis showed that the estimated glomerular filtration rate was the only independent factor influencing the C0h /D of rivaroxaban (R2 = 0.152, P < 0.001). There was a significant correlation between the C0h of rivaroxaban and prothrombin time (PT) (rho = 0.357, P = 0.001). In patients with NVAF, pharmacokinetic genotype tests are unlikely to be useful for prediction of the C0h of rivaroxaban.
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Affiliation(s)
- Junichi Nakagawa
- Department of Pharmacy, Hirosaki University Hospital, Aomori, Japan
| | - Takahiko Kinjo
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Mei Iizuka
- Department of Pharmacy, Hirosaki University Hospital, Aomori, Japan
| | - Kayo Ueno
- Department of Pharmacy, Hirosaki University Hospital, Aomori, Japan
| | - Hirofumi Tomita
- Department of Cardiology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Takenori Niioka
- Department of Pharmacy, Hirosaki University Hospital, Aomori, Japan.,Department of Pharmaceutical Science, Hirosaki University Graduate School of Medicine, Aomori, Japan
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Microdosed Cocktail of Three Oral Factor Xa Inhibitors to Evaluate Drug-Drug Interactions with Potential Perpetrator Drugs. Clin Pharmacokinet 2020; 58:1155-1163. [PMID: 30828771 DOI: 10.1007/s40262-019-00749-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to prove the suitability of simultaneously administered microdoses of the factor Xa inhibitors (FXaIs) rivaroxaban, apixaban and edoxaban (100 µg in total). To evaluate drug-drug interactions, the impact of ketoconazole, a known strong inhibitor of cytochrome P450 3A4 and P-glycoprotein, was studied. METHODS In a crossover clinical trial, 18 healthy volunteers were randomized to the two treatments using microdoses of rivaroxaban, apixaban and edoxaban alone and when coadministered with ketoconazole. Plasma and urine concentrations of microdosed apixaban, edoxaban and rivaroxaban were quantified using a validated ultra-performance liquid chromatography-tandem mass spectrometry assay with a lower limit of quantification of 2.5 pg/ml. RESULTS The microdosed FXaI cocktail showed similar pharmacokinetic parameters compared with published data, using normal therapeutic doses of each FXaI. Ketoconazole significantly increased exposure, with geometric mean AUC ratios of 1.90 (apixaban), 2.35 (edoxaban) and 2.27 (rivaroxaban). CONCLUSION The microdosed FXaI cocktail approach was able to precisely predict the drug interaction with ketoconazole. This is the first study that has been conducted to evaluate drug-drug interactions with a drug class, and the low administered doses also allow evaluation in vulnerable target populations. STUDY PROTOCOL EudraCT 2016-003024-23.
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Novel Oral Anticoagulants in Renal Transplant Recipients: A Retrospective Cohort Study. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2020; 41:49-55. [PMID: 33011699 DOI: 10.2478/prilozi-2020-0032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
AIM Data on the use of novel anticoagulant drugs (NOACc) in renal transplant recipients is scarce. The aim of our study was to investigate the safety and efficacy of NOACs in renal transplant recipients. MATERIALS AND METHODS In a single-centre retrospective cohort study we assessed adverse reactions, thromboembolic events, and interactions of calcineurin inhibitors in patients treated with NOACs. RESULTS Twenty-three renal transplant recipients were treated with NOACs (70% male), mean age of 65.8 ± 1.8 years. Fourteen (61%) patients were treated with rivaroxaban, apixaban was given to 8 (35%) of our patients, and dabigatran to one patient (4%). The main indications for NOAC therapy was atrial fibrillation in 61% and deep venous thrombosis in 23% of patients. Bleeding occurred in 2 patients (1 treated with rivaroxaban and 1 with dabigatran). None of our patients developed thrombosis while treated with NOAC. During the median follow-up of 24 months graft function, as well as hematological parameters, remained stable in patients that were treated with rivaroxaban and apixaban, while dabigatran was ceased after a month of therapy due to a bleeding event. CONCLUSION Our results show that both rivaroxaban and apixaban are safe and efficient oral anticoagulant drugs in renal transplant patients. Additional studies are needed to prove these results.
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Milling TJ, Pollack CV. A review of guidelines on anticoagulation reversal across different clinical scenarios – Is there a general consensus? Am J Emerg Med 2020; 38:1890-1903. [PMID: 32750627 PMCID: PMC9245126 DOI: 10.1016/j.ajem.2020.05.086] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 04/13/2020] [Accepted: 05/22/2020] [Indexed: 12/23/2022] Open
Affiliation(s)
- Truman J Milling
- Department of Surgery and Perioperative Care, Dell Medical School, Austin, TX, USA; Department of Neurology, Seton Dell Medical School Stroke Institute, Austin, TX, USA
| | - Charles V Pollack
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS, USA.
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Dherange P, Lang J, Qian P, Oberfeld B, Sauer WH, Koplan B, Tedrow U. Arrhythmias and COVID-19: A Review. JACC Clin Electrophysiol 2020; 6:1193-1204. [PMID: 32972561 PMCID: PMC7417167 DOI: 10.1016/j.jacep.2020.08.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 07/31/2020] [Accepted: 08/04/2020] [Indexed: 12/15/2022]
Abstract
Current understanding of the impact of coronavirus disease-2019 (COVID-19) on arrhythmias continues to evolve as new data emerge. Cardiac arrhythmias are more common in critically ill COVID-19 patients. The potential mechanisms that could result in arrhythmogenesis among COVID-19 patients include hypoxia caused by direct viral tissue involvement of lungs, myocarditis, abnormal host immune response, myocardial ischemia, myocardial strain, electrolyte derangements, intravascular volume imbalances, and drug sides effects. To manage these arrhythmias, it is imperative to increase the awareness of potential drug-drug interactions, to monitor QTc prolongation while receiving COVID therapy and provide special considerations for patients with inherited arrhythmia syndromes. It is also crucial to minimize exposure to COVID-19 infection by stratifying the need for intervention and using telemedicine. As COVID-19 infection continues to prevail with a potential for future surges, more data are required to better understand pathophysiology and to validate management strategies.
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Affiliation(s)
- Parinita Dherange
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joshua Lang
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pierre Qian
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Blake Oberfeld
- Division of Cardiovascular Medicine, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - William H Sauer
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bruce Koplan
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Usha Tedrow
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Lupi SM, Baena ARY. Patients Taking Direct Oral Anticoagulants (DOAC) Undergoing Oral Surgery: A Review of the Literature and a Proposal of a Peri-Operative Management Protocol. Healthcare (Basel) 2020; 8:healthcare8030281. [PMID: 32825272 PMCID: PMC7551164 DOI: 10.3390/healthcare8030281] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/17/2020] [Accepted: 08/18/2020] [Indexed: 11/16/2022] Open
Abstract
Patients on anticoagulant therapy for the prevention of cardiovascular accidents present an increased risk of bleeding following dental and oral surgery. Four recently introduced non-vitamin K antagonist oral anticoagulants, namely dabigatran etexilate (direct thrombin inhibitor), rivaroxaban, apixaban, and edoxaban (Xa factor direct inhibitor), are widely spreading for convenience of use compared to the older drug class. Dental management of patients taking these drugs has substantial differences compared to patients on vitamin K antagonist therapy. Anticoagulation is not assessed directly through a hematological test, but indirectly by renal function. The interventions must be scheduled at the time of minimum blood concentration of the drug. Bleeding can occur even after several days following the surgery. The interaction with drugs administered for dental care must be carefully evaluated. The peri-operative diet can influence the risk of bleeding. Local measures favoring coagulation must be adopted. The interventions with higher risk must be divided into multiple less invasive interventions. Although antidotes exist for these drugs, their use does not seem necessary for dental interventions that have been planned optimally. Furthermore, in this review of the literature a decision protocol is proposed for the evaluation of the suspension of the anticoagulant drug before oral surgery. Cessation of any anticoagulant should only be made in consultation with the patient’s general practitioner/cardiologist, who will weigh up the risk of bleeding from the proposed procedure with the risk of thrombosis/stroke in each individual patient.
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Affiliation(s)
- Saturnino Marco Lupi
- Department of Clinical Surgical, Pediatric and Diagnostic Sciences, University of Pavia, 27100 Pavia, Italy
- Correspondence: ; Tel.: +39-382-516-255
| | - Arianna Rodriguez y Baena
- Department of Dentistry, IRCCS San Raffaele Hospital, 20123 Milan, Italy;
- Dental School, Vita Salute University, 20132 Milan, Italy
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Shindo K, Ogino T, Kamiyama K, Fukuda M, Okamura N, Fuchizaki T, Ishizuka T, Ishikawa K, Yamaguchi Y, Muraki T, Tatsuta Y, Sakurai S, Endo H, Ookuma M, Osato T, Nakamura H. Results of Therapy Using Oral Anticoagulants in the Acute Phase after Mechanical Thrombectomy. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 14:481-487. [PMID: 37501765 PMCID: PMC10370943 DOI: 10.5797/jnet.oa.2019-0118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Accepted: 06/09/2020] [Indexed: 07/29/2023]
Abstract
Objective The usage of oral anticoagulants (OACs) in the acute phase of cerebral infarction has increased, but the optimal timing for starting OACs after mechanical thrombectomy (MT) is unclear. We report the usage of OACs after MT at our hospital and evaluated the outcomes. Methods OACs were selected as secondary preventive drugs for 64 patients who underwent MT for anterior circulatory embolism between July 2016 and January 2019. Of the 64 patients, 28 and 36 received direct oral anticoagulants (DOACs) and warfarin (Wf), respectively. We compared the frequency of intracranial hemorrhage in the acute phase and that of recurrent cerebral infarction within 30 days. Results The median diffusion-weighted imaging-Alberta Stroke Program Early Computed Tomography Scores + white matter (DWI-ASPECTS + W) score at admission was 7.5 (IQR 6-9)/8 (IQR, 6-9) in the DOACs group/Wf group. The rate of recanalization with modified thrombolysis in cerebral infarction (TICI) ≥2B by MT was 89.3/80.6%. In patients with subarachnoid hemorrhage (SAH) associated with MT and patients with hemorrhagic transformation (HT) on MRI the next day, administration was started after hemostasis. The median timing of the first anticoagulant administration was 3 (IQR, 2-4)/2 (IQR, 1-4) days. In the case of no HT the next day, the rate of new HT after 1 week was 7.1%/29.1%. In the case of HT the next day, the rate of HT deterioration the next day was 7.1%/16.6%. The percentage of symptomatic bleeding was 0%/2.8%. The percentage of recurrent cerebral infarction within 30 days was 0%/2.8%. Conclusion OACs in the acute phase after MT can be safely used and are expected to be effective at preventing recurrence.
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Affiliation(s)
- Koichiro Shindo
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Center for Endovascular Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Tatsuya Ogino
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Center for Endovascular Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Mamoru Fukuda
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Naoyasu Okamura
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Tomoki Fuchizaki
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Tomoaki Ishizuka
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Kohei Ishikawa
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Yohei Yamaguchi
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Takeshi Muraki
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Center for Endovascular Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Yasuyuki Tatsuta
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Center for Endovascular Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Suguru Sakurai
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Center for Endovascular Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Hideki Endo
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Center for Endovascular Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
- Department of Neurosurgery, Nakamura Memorial South Hospital, Sapporo, Hokkaido, Japan
| | - Masahiro Ookuma
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Toshiaki Osato
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
| | - Hirohiko Nakamura
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Hokkaido, Japan
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Creeper K, Stafford A, Reynolds S, Samida S, P'Ng S, Glennon D, Seymour H, Grove C. Outcomes and anticoagulation use for elderly patients that present with an Acute Hip Fracture: multi‐centre, retrospective analysis. Intern Med J 2020; 52:418-425. [DOI: 10.1111/imj.15007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/15/2020] [Accepted: 08/04/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Katherine Creeper
- Haematology Department, NedlandsSir Charles Gairdner Hospital Western Australia
- PathWest Laboratory Medicine, Nedlands Western Australia
| | - Andrew Stafford
- School of Pharmacy and Biomedical SciencesCurtin University of Technology Bentley Western Australia
| | - Sophie Reynolds
- Royal Perth Hospital Department of Geriatric Medicine Perth Western Australia
| | - Sapna Samida
- Royal Perth Hospital Department of Geriatric Medicine Perth Western Australia
| | - Stephanie P'Ng
- PathWest Laboratory Medicine, Nedlands Western Australia
- Department of HaematologyFiona Stanley Hospital Murdoch Western Australia
| | - Denise Glennon
- Department of Rehabilitation and Aged CareSir Charles Gairdner Hospital Nedlands Western Australia
| | - Hannah Seymour
- Department of Geriatrics and Aged CareFiona Stanley Hospital Murdoch Western Australia
| | - Carolyn Grove
- Haematology Department, NedlandsSir Charles Gairdner Hospital Western Australia
- PathWest Laboratory Medicine, Nedlands Western Australia
- School of Medicine and PharmacologyUniversity of Western Australia Nedlands Western Australia
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Trani A, Benedetto P, Di Leo F, Baiano A, Esposito A, Menna D, Allegretti A, Cappiello PA, Dell'Edera D. Long term efficacy and safety of rivaroxaban plus cilostazol in the treatment of critical ischemia of the lower limbs in a frail, elderly patient with non valvular atrial fibrillation. J Pharm Health Care Sci 2020; 6:17. [PMID: 32774874 PMCID: PMC7398073 DOI: 10.1186/s40780-020-00173-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 06/18/2020] [Indexed: 11/10/2022] Open
Abstract
Background Many patients with critical lower limb ischemia are not eligible for revascularization procedures. Still, given the emerging role of both platelet and coagulation activation in the formation of arterial thrombi, they may benefit from the novel anticoagulant and antiplatelet drugs. Case presentation We describe the case of a male with critical lower limb ischemia complicated by older age, frailty, polymorbidity and non valvular atrial fibrillation, who was deemed as non eligible for surgery. The patient was successfully treated with the combination of rivaroxaban and cilostazol, and the clinical benefit was maintained throughout 32 months, with no occurrence of major or minor hemorrhagic or thrombotic events. Conclusions To our knowledge, this is the first report on the efficacy and safety of such a combination therapy in critical lower limb ischemia. In a clinical setting in which alternative pharmacological approaches are urgently needed, the association of rivaroxaban and cilostazol warrants further investigations.
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Affiliation(s)
- Antonio Trani
- Vascular and Endovascular Surgery Unit, Cardiovascular Department, San Carlo Hospital Potenza, via Potito Petrone, 85100 Potenza, Italy
| | - Pietro Benedetto
- Vascular and Endovascular Surgery Unit, Cardiovascular Department, San Carlo Hospital Potenza, via Potito Petrone, 85100 Potenza, Italy
| | - Ferdinando Di Leo
- Vascular and Endovascular Surgery Unit, Cardiovascular Department, San Carlo Hospital Potenza, via Potito Petrone, 85100 Potenza, Italy
| | - Angela Baiano
- Vascular and Endovascular Surgery Unit, Cardiovascular Department, San Carlo Hospital Potenza, via Potito Petrone, 85100 Potenza, Italy
| | - Andrea Esposito
- Vascular and Endovascular Surgery Unit, Cardiovascular Department, San Carlo Hospital Potenza, via Potito Petrone, 85100 Potenza, Italy
| | - Danilo Menna
- Vascular and Endovascular Surgery Unit, Cardiovascular Department, San Carlo Hospital Potenza, via Potito Petrone, 85100 Potenza, Italy
| | - Arianna Allegretti
- Cytogenetic and Molecular Genetics Unit, "Madonna delle Grazie" Hospital, 75100 Matera, Italy
| | - Pierluigi Antonino Cappiello
- Vascular and Endovascular Surgery Unit, Cardiovascular Department, San Carlo Hospital Potenza, via Potito Petrone, 85100 Potenza, Italy
| | - Domenico Dell'Edera
- Cytogenetic and Molecular Genetics Unit, "Madonna delle Grazie" Hospital, 75100 Matera, Italy
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Wetmore JB, Roetker NS, Yan H, Reyes JL, Herzog CA. Direct-Acting Oral Anticoagulants Versus Warfarin in Medicare Patients With Chronic Kidney Disease and Atrial Fibrillation. Stroke 2020; 51:2364-2373. [DOI: 10.1161/strokeaha.120.028934] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background and Purpose:
The comparative effectiveness of direct-acting oral anticoagulants, compared with warfarin, for risks of stroke/systemic embolism, major bleeding, or death have not been studied in Medicare beneficiaries with atrial fibrillation and nondialysis-dependent chronic kidney disease.
Methods:
Medicare data from 2011 to 2017 were used to identify patients with stages 3, 4, or 5 chronic kidney disease and new atrial fibrillation who received a new prescription for warfarin, apixaban, rivaroxaban, or dabigatran. We estimated marginal hazard ratios with 95% CIs for the association of each direct-acting oral anticoagulant, compared with warfarin, for the outcomes of interest using inverse-probability-of-treatment weighted Cox proportional hazards models in as-treated and intention-to-treat analyses.
Results:
A total of 22 739 individuals met criteria (46.3% warfarin, 29.6% apixaban, 17.2% rivaroxaban, 6.9% dabigatran). Across the groups of anticoagulant users, mean age was 78.4 to 79.0 years; 50.3% to 51.4% were women, and 80.3% to 82.8% had stage 3 chronic kidney disease. In the as-treated analysis, for stroke/systemic embolism, hazard ratios, all compared with warfarin, were 0.70 (0.51–0.96) for apixaban, 0.80 (0.54–1.17) for rivaroxaban, and 1.15 (0.69–1.94) for dabigatran. For major bleeding, analogous hazard ratios were 0.47 (0.37–0.59) for apixaban, 1.05 (0.85–1.30) for rivaroxaban, and 0.95 (0.70–1.31) for dabigatran. There was no difference in the risk of all-cause mortality between the direct-acting oral anticoagulants and warfarin. Results of the intention-to-treat analysis were similar.
Conclusions:
Apixaban, compared with warfarin, was associated with decreased risk of stroke/systemic embolism and major bleeding; risks for both outcomes with rivaroxaban and dabigatran did not differ from risks with warfarin.
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Affiliation(s)
- James B. Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN (J.B.W., N.S.R., H.Y., C.A.H.)
- Division of Nephrology (J.B.W.), Hennepin County Medical Center and Department of Medicine, University of Minnesota, Minneapolis
| | - Nicholas S. Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN (J.B.W., N.S.R., H.Y., C.A.H.)
| | - Heng Yan
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN (J.B.W., N.S.R., H.Y., C.A.H.)
| | - Jorge L. Reyes
- Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, MN (J.L.R.)
| | - Charles A. Herzog
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, MN (J.B.W., N.S.R., H.Y., C.A.H.)
- Division of Cardiology (C.A.H.), Hennepin County Medical Center and Department of Medicine, University of Minnesota, Minneapolis
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Kow CS, Sunter W, Bain A, Zaidi STR, Hasan SS. Management of Outpatient Warfarin Therapy amid COVID-19 Pandemic: A Practical Guide. Am J Cardiovasc Drugs 2020; 20:301-309. [PMID: 32458370 PMCID: PMC7247959 DOI: 10.1007/s40256-020-00415-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Many healthcare resources have been and continue to be allocated to the management of patients with COVID-19. Therefore, the ongoing care of patients receiving oral anticoagulation with warfarin is likely to be compromised amid this unprecedented crisis. This article discusses a stepwise algorithm for the management of outpatient warfarin therapy. Alternative management strategies are presented and discussed, including alternative pharmacological therapy options and self-monitoring. Our algorithm aims to help clinicians safely optimize the treatment of patients requiring anticoagulation therapy in the context of the global response to the current pandemic.
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Kodani E, Inoue H, Atarashi H, Tomita H, Okumura K, Yamashita T, Origasa H. Predictive ability of creatinine clearance versus estimated glomerular filtration rate for outcomes in patients with non-valvular atrial fibrillation: Subanalysis of the J-RHYTHM Registry. IJC HEART & VASCULATURE 2020; 29:100559. [PMID: 32566722 PMCID: PMC7298529 DOI: 10.1016/j.ijcha.2020.100559] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/01/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Renal impairment is a risk factor for various adverse events, especially for death. In general, creatinine clearance (CrCl) is used for dose-adjustments of many drugs including oral anticoagulants, and estimated glomerular filtration rate (eGFR) is adopted for the diagnosis of chronic kidney disease. Predictive ability of CrCl versus eGFR for outcomes in patients with non-valvular atrial fibrillation (NVAF) remains controversial; therefore, this was compared using data from the J-RHYTHM Registry. METHODS Out of 7406 outpatients with NVAF from 158 institutions, 6004 (age, 69.7 ± 9.9 years; men, 71.2%) having data of CrCl (mL/min, by the Cockcroft-Gault formula), eGFR (mL/min/1.73 m2, by the equations of the Japanese Society of Nephrology), and body surface area (BSA) were analyzed. C-statistics (area under the receiver-operating characteristic curve) of CrCl and eGFR for events were compared by DeLong's test. RESULTS Thromboembolism, major hemorrhage, and all-cause death occurred in 107 (1.8%), 117 (1.9%), and 154 (2.6%) patients during the 2-year follow-up period. C-statistics of CrCl for each event were 0.609 (95% confidence interval, 0.559-0.658), 0.599 (0.548-0.657), and 0.746 (0.706-0.786); and those of eGFR were 0.542 (0.487-0.597), 0.573 (0.519-0.626), and 0.677 (0.631-0.723), respectively. C-statistics of CrCl for thromboembolism and all-cause death were significantly higher than those of eGFR (P < 0.001 for both). These results were consistent when BSA-unadjusted eGFR was used instead of eGFR (P = 0.002 for thromboembolism and P < 0.001 for all-cause death). CONCLUSIONS CrCl was superior to eGFR in the prediction of adverse outcomes, i.e., thromboembolism and all-cause death in Japanese patients with NVAF.
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Affiliation(s)
- Eitaro Kodani
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama-Nagayama Hospital, Tokyo, Japan
| | | | | | - Hirofumi Tomita
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Aomori, Japan
| | - Ken Okumura
- Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Hideki Origasa
- Division of Biostatistics and Clinical Epidemiology, University of Toyama, Toyama, Japan
| | - on behalf of the J-RHYTHM Registry Investigators
- Department of Internal Medicine and Cardiology, Nippon Medical School Tama-Nagayama Hospital, Tokyo, Japan
- Saiseikai Toyama Hospital, Toyama, Japan
- Minamihachioji Hospital, Tokyo, Japan
- Department of Cardiology and Nephrology, Hirosaki University Graduate School of Medicine, Aomori, Japan
- Saiseikai Kumamoto Hospital, Kumamoto, Japan
- The Cardiovascular Institute, Tokyo, Japan
- Division of Biostatistics and Clinical Epidemiology, University of Toyama, Toyama, Japan
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[Second look: practical diagnostic and therapeutic checks in neurorehabilitation]. DER NERVENARZT 2020; 91:324-336. [PMID: 32123934 DOI: 10.1007/s00115-020-00887-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Post-acute inpatient neurorehabilitation facilities are increasingly treating patients who are not only severely ill and multimorbid but who are also referred from non-neurological departments. These patients are still often medically unstable so that the previous diagnostics and treatment must be reevaluated and when necessary adapted or supplemented. Certain interdisciplinary diagnostic and therapeutic problems, such as antithrombotic therapy, regularly reoccur. This article presents these problems in a checklist fashion, which should provide indications in individual cases when previously carried out measures need to be questioned and adapted.
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134
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Crawley RM, Anderson RL. Prevention and Treatment of Bleeding with Direct Oral Anticoagulants. Drugs 2020; 80:1293-1308. [PMID: 32691292 DOI: 10.1007/s40265-020-01345-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Anticoagulant-related bleeding carries considerable morbidity and mortality. Major or life-threatening bleeding is among the most severe of these complications. As the number of patients treated with direct oral anticoagulants (DOACs) continues to increase, so does the number of DOAC-related bleeding events. The incidence of CRNM bleeding related to DOAC therapy ranges from 15 to 18% per 100-year patients, while the incidence of major bleeding ranges from 2.71 to 3.6%. Many of these bleeding events can be prevented with tailored dosing regimens or proper peri-procedural management. When unable to be prevented, DOAC-related bleeding can lead to significant long-term disability or death. Management with newer reversal agents such as andexanet alfa and idarucizumab, as well as prothrombin complex concentrates, may improve outcomes for patients with DOAC-related bleeding. The purpose of this review is to explore strategies for preventing and treating bleeding in patients receiving DOACs for anticoagulant therapy.
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Affiliation(s)
- R Monroe Crawley
- Department of Pharmacy, Huntsville Hospital, 101 Sivley Road, Huntsville, AL, 35801, USA.
| | - Rachel L Anderson
- Department of Pharmacy, Huntsville Hospital, 101 Sivley Road, Huntsville, AL, 35801, USA
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135
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Maura G, Bardou M, Billionnet C, Weill A, Drouin J, Neumann A. Oral anticoagulants and risk of acute liver injury in patients with nonvalvular atrial fibrillation: a propensity-weighted nationwide cohort study. Sci Rep 2020; 10:11624. [PMID: 32669591 PMCID: PMC7363898 DOI: 10.1038/s41598-020-68304-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 06/15/2020] [Indexed: 11/28/2022] Open
Abstract
Insufficient real-world data on acute liver injury (ALI) risk associated with oral anticoagulants (OACs) exist in patients with nonvalvular atrial fibrillation (NVAF). Using the French national healthcare databases, a propensity-weighted nationwide cohort study was performed in NVAF patients initiating OACs from 2011 to 2016, considering separately those (1) with no prior liver disease (PLD) as main population, (2) with PLD, (3) with a history of chronic alcoholism. A Cox proportional hazards model was used to estimate the hazard ratio with 95% confidence interval (HR [95% CI]) of serious ALI (hospitalised ALI or liver transplantation) during the first year of treatment, for each non-vitamin K antagonist (VKA) oral anticoagulant (NOAC: dabigatran, rivaroxaban, apixaban) versus VKA. In patients with no PLD (N = 434,015), only rivaroxaban new users were at increased risk of serious ALI compared to VKA initiation (adjusted HR: 1.41 [1.05–1.91]). In patients with chronic alcoholism history (N = 13,173), only those initiating dabigatran were at increased risk of serious ALI compared to VKA (2.88 [1.74–4.76]) but an ancillary outcome suggested that differential clinical follow-up between groups might partly explain this association. In conclusion, this study does not suggest an increase of the 1-year risk of ALI in NOAC versus VKA patients with AF.
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Affiliation(s)
- Géric Maura
- French National Health Insurance (Caisse Nationale de L'Assurance Maladie, Cnam), 50 Avenue du Pr. André Lemierre, 75 986, Paris Cedex 20, France.
| | - Marc Bardou
- Clinical Investigation Center, Clinical Epidemiology/Clinical Trials Unit, Dijon-Bourgogne University Hospital, 21 000, Dijon, France.,Division of Gastroenterology, Dijon-Bourgogne University Hospital, 21 000, Dijon, France
| | - Cécile Billionnet
- French National Health Insurance (Caisse Nationale de L'Assurance Maladie, Cnam), 50 Avenue du Pr. André Lemierre, 75 986, Paris Cedex 20, France
| | - Alain Weill
- EPI-PHARE Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety (ANSM) and French National Health Insurance (CNAM), 93 200, Saint-Denis, France
| | - Jérôme Drouin
- EPI-PHARE Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety (ANSM) and French National Health Insurance (CNAM), 93 200, Saint-Denis, France
| | - Anke Neumann
- EPI-PHARE Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety (ANSM) and French National Health Insurance (CNAM), 93 200, Saint-Denis, France
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136
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Drakopoulou M, Soulaidopoulos S, Oikonomou G, Stathogiannis K, Latsios G, Synetos A, Tousoulis D, Toutouzas K. Novel Perspective for Antithrombotic Therapy in TAVI. Curr Pharm Des 2020; 26:2789-2803. [DOI: 10.2174/1381612826666200413083746] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 03/16/2020] [Indexed: 12/29/2022]
Abstract
:
While surgical aortic valve replacement (SAVR) was for years the only available treatment for symptomatic
aortic stenosis, the introduction of transcatheter aortic valve implantation (TAVI) in 2002 and the improvement
of its technical aspects in the following years, has holistically changed the synchronous therapeutic
approach of aortic valve stenosis. Recent evidence has expanded the indication of TAVI from high to lower surgical
risk populations with symptomatic aortic stenosis. The administration of antithrombotic therapy periprocedurally
and its maintenance after a successful TAVI is crucial for the prevention of complications and affects
postprocedural survival. Randomized controlled trials investigating the appropriate combination and the
duration of antithrombotic treatment after TAVI are for the moment scarce. This review article sheds light on the
underlying pathogenetic mechanisms contributing in periprocedural TAVI thrombotic complications and discuss
the efficacy of current antithrombotic policies as evaluated in randomized trials.
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Affiliation(s)
- Maria Drakopoulou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Stergios Soulaidopoulos
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - George Oikonomou
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Konstantinos Stathogiannis
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - George Latsios
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Andreas Synetos
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
| | - Konstantinos Toutouzas
- First Department of Cardiology, Hippokration Hospital, Medical School of Athens University, Athens, Greece
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137
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Giustozzi M, Acciarresi M, Agnelli G, Caso V, Bandini F, Tsivgoulis G, Yaghi S, Furie KL, Tadi P, Becattini C, Zedde M, Abdul-Rahim AH, Lees KR, Alberti A, Venti M, D'Amore C, Giulia Mosconi M, Anna Cimini L, Bovi P, Carletti M, Rigatelli A, Cappellari M, Putaala J, Tomppo L, Tatlisumak T, Marcheselli S, Pezzini A, Poli L, Padovani A, Vannucchi V, Sohn SI, Lorenzini G, Tassi R, Guideri F, Acampa M, Martini G, Ntaios G, Athanasakis G, Makaritsis K, Karagkiozi E, Vadikolias K, Liantinioti C, Theodorou A, Halvatsiotis P, Mumoli N, Galati F, Sacco S, Tiseo C, Corea F, Ageno W, Bellesini M, Silvestrelli G, Ciccone A, Lanari A, Scoditti U, Denti L, Mancuso M, Ferrari E, Ulivi L, Orlandi G, Giannini N, Tassinari T, Luisa De Lodovici M, Rueckert C, Baldi A, Toni D, Letteri F, Giuntini M, Maria Lotti E, Flomin Y, Pieroni A, Kargiotis O, Karapanayiotides T, Monaco S, Maimone Baronello M, Csiba L, Szabó L, Chiti A, Giorli E, Del Sette M, Imberti D, Zabzuni D, Doronin B, Volodina V, Michel P, Vanacker P, Barlinn K, Barlinn J, Deleu D, Gourbali V, Paciaroni M, Masotti L. Safety of Anticoagulation in Patients Treated With Urgent Reperfusion for Ischemic Stroke Related to Atrial Fibrillation. Stroke 2020; 51:2347-2354. [PMID: 32646335 DOI: 10.1161/strokeaha.120.030143] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The optimal timing for starting oral anticoagulant after an ischemic stroke related to atrial fibrillation remains a challenge, mainly in patients treated with systemic thrombolysis or mechanical thrombectomy. We aimed at assessing the incidence of early recurrence and major bleeding in patients with acute ischemic stroke and atrial fibrillation treated with thrombolytic therapy and/or thrombectomy, who then received oral anticoagulants for secondary prevention. METHODS We combined the dataset of the RAF and the RAF-NOACs (Early Recurrence and Major Bleeding in Patients With Acute Ischemic Stroke and Atrial Fibrillation Treated With Non-Vitamin K Oral Anticoagulants) studies, which were prospective observational studies carried out from January 2012 to March 2014 and April 2014 to June 2016, respectively. We included consecutive patients with acute ischemic stroke and atrial fibrillation treated with either vitamin K antagonists or nonvitamin K oral anticoagulants. Primary outcome was the composite of stroke, transient ischemic attack, symptomatic systemic embolism, symptomatic cerebral bleeding, and major extracerebral bleeding within 90 days from the inclusion. Treated-patients were propensity matched to untreated-patients in a 1:1 ratio after stratification by baseline clinical features. RESULTS A total of 2159 patients were included, 564 (26%) patients received acute reperfusion therapies. After the index event, 505 (90%) patients treated with acute reperfusion therapies and 1287 of 1595 (81%) patients untreated started oral anticoagulation. Timing of starting oral anticoagulant was similar in reperfusion-treated and untreated patients (median 7.5 versus 7.0 days, respectively). At 90 days, the primary study outcome occurred in 37 (7%) patients treated with reperfusion and in 146 (9%) untreated patients (odds ratio, 0.74 [95% CI, 0.50-1.07]). After propensity score matching, risk of primary outcome was comparable between the 2 groups (odds ratio, 1.06 [95% CI, 0.53-2.02]). CONCLUSIONS Acute reperfusion treatment did not influence the risk of early recurrence and major bleeding in patients with atrial fibrillation-related acute ischemic stroke, who started on oral anticoagulant.
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Affiliation(s)
- Michela Giustozzi
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Giustozzi, M. Acciarresi, G.A., V.C., C.B., A.A., M.V., C.D., M.G.M., L.A.C., M.P.)
| | - Monica Acciarresi
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Giustozzi, M. Acciarresi, G.A., V.C., C.B., A.A., M.V., C.D., M.G.M., L.A.C., M.P.)
| | - Giancarlo Agnelli
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Giustozzi, M. Acciarresi, G.A., V.C., C.B., A.A., M.V., C.D., M.G.M., L.A.C., M.P.)
| | - Valeria Caso
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Giustozzi, M. Acciarresi, G.A., V.C., C.B., A.A., M.V., C.D., M.G.M., L.A.C., M.P.)
| | - Fabio Bandini
- Department of Neurology, Ospedale San Paolo, Savona, Italy (F.B.)
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis (G.T.).,Second Department of Neurology, "Attikon" University Hospital, National & KapodistrianUniversity of Athens, School of Medicine, Greece (G.T., C.L.)
| | - Shadi Yaghi
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (S.Y., K.L.F., P.T.)
| | - Karen L Furie
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (S.Y., K.L.F., P.T.)
| | - Prasanna Tadi
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, RI (S.Y., K.L.F., P.T.)
| | - Cecilia Becattini
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Giustozzi, M. Acciarresi, G.A., V.C., C.B., A.A., M.V., C.D., M.G.M., L.A.C., M.P.)
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Arcispedale Santa Maria Nuova, Azienda Unità Sanitaria Locale - IRCCS, Reggio Emilia, Italy (M.Z.)
| | | | - Kennedy R Lees
- School of Medicine, Dentistry and Nursing, University of Glasgow (K.R.S.)
| | - Andrea Alberti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Giustozzi, M. Acciarresi, G.A., V.C., C.B., A.A., M.V., C.D., M.G.M., L.A.C., M.P.)
| | - Michele Venti
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Giustozzi, M. Acciarresi, G.A., V.C., C.B., A.A., M.V., C.D., M.G.M., L.A.C., M.P.)
| | - Cataldo D'Amore
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Giustozzi, M. Acciarresi, G.A., V.C., C.B., A.A., M.V., C.D., M.G.M., L.A.C., M.P.)
| | - Maria Giulia Mosconi
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Giustozzi, M. Acciarresi, G.A., V.C., C.B., A.A., M.V., C.D., M.G.M., L.A.C., M.P.)
| | - Ludovica Anna Cimini
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Giustozzi, M. Acciarresi, G.A., V.C., C.B., A.A., M.V., C.D., M.G.M., L.A.C., M.P.)
| | - Paolo Bovi
- SSO Stroke Unit, UO Neurologia, DAI di Neuroscienze, AOUI Verona, Italy (P.B., M. Carletti, M. Cappellari)
| | - Monica Carletti
- SSO Stroke Unit, UO Neurologia, DAI di Neuroscienze, AOUI Verona, Italy (P.B., M. Carletti, M. Cappellari)
| | - Alberto Rigatelli
- Pronto Soccorso - Ospedale Borgo Trento, DAI emergenza e accettazione, AOUI Verona (A.R.)
| | - Manuel Cappellari
- SSO Stroke Unit, UO Neurologia, DAI di Neuroscienze, AOUI Verona, Italy (P.B., M. Carletti, M. Cappellari)
| | - Jukka Putaala
- Department of Neurology, Helsinki University Central Hospital, Finland (J.P., L.T., T. Tatlisumak)
| | - Liisa Tomppo
- Department of Neurology, Helsinki University Central Hospital, Finland (J.P., L.T., T. Tatlisumak)
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Central Hospital, Finland (J.P., L.T., T. Tatlisumak).,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T. Tatlisumak).,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T. Tatlisumak)
| | - Simona Marcheselli
- Neurologia d'urgenza e Stroke Unit, Istituto Clinico Humanitas, Rozzano, Milano, Italy (S. Marcheselli)
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Italy (A. Pezzini, L. Poli, A. Padovani)
| | - Loris Poli
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Italy (A. Pezzini, L. Poli, A. Padovani)
| | - Alessandro Padovani
- Department of Clinical and Experimental Sciences, Neurology Unit, University of Brescia, Italy (A. Pezzini, L. Poli, A. Padovani)
| | - Vieri Vannucchi
- Internal Medicine, Santa Maria Nuova Hospital, Firenze, Italy (V. Vannucchi, L.M.)
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University School of Medicine, Daegu, South Korea (S.-I.)
| | - Gianni Lorenzini
- SC Medicina e Chirurgia d'Accettazione e d'Urgenza, Ospedale Lotti Pontedera, Azienda USL Toscana Nordovest (G.L.)
| | | | | | | | | | - George Ntaios
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (G.N., G.A., K.M., E.K.)
| | - George Athanasakis
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (G.N., G.A., K.M., E.K.)
| | - Konstantinos Makaritsis
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (G.N., G.A., K.M., E.K.)
| | - Efstathia Karagkiozi
- Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece (G.N., G.A., K.M., E.K.)
| | - Konstantinos Vadikolias
- Department of Neurology, Democritus University of Thrace, University Hospital of Alexandroupolis, Greece (K.V.)
| | - Chrissoula Liantinioti
- Second Department of Neurology, "Attikon" University Hospital, National & KapodistrianUniversity of Athens, School of Medicine, Greece (G.T., C.L.)
| | | | | | - Nicola Mumoli
- Department of Internal Medicine, Ospedale Civile di Livorno, Italy (N.M.)
| | | | - Simona Sacco
- Department of Neurology, University of L'Aquila, Avezzano Hospital, Italy (S.S., C.T.)
| | - Cindy Tiseo
- Department of Neurology, University of L'Aquila, Avezzano Hospital, Italy (S.S., C.T.)
| | - Francesco Corea
- UO Gravi Cerebrolesioni, San Giovanni Battista Hospital, Foligno (F.C.)
| | - Walter Ageno
- Department of Internal Medicine, Insubria University, Varese, Italy (W.A., M.B.)
| | - Marta Bellesini
- Department of Internal Medicine, Insubria University, Varese, Italy (W.A., M.B.)
| | - Giorgio Silvestrelli
- S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Mantova, Italy (G.S., A. Ciccone, A.L.)
| | - Alfonso Ciccone
- S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Mantova, Italy (G.S., A. Ciccone, A.L.)
| | - Alessia Lanari
- S.C. di Neurologia e S.S. di Stroke Unit, ASST di Mantova, Mantova, Italy (G.S., A. Ciccone, A.L.)
| | - Umberto Scoditti
- Stroke Unit, Neuroscience Department, University of Parma, Italy (U.S.)
| | - Licia Denti
- Stroke Unit - Dipartimento Geriatrico Riabilitativo - University of Parma, Italy (L.D.)
| | - Michelangelo Mancuso
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Italy (M.M., E.F., L.U., G.O., N.G., A. Chiti)
| | - Elena Ferrari
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Italy (M.M., E.F., L.U., G.O., N.G., A. Chiti)
| | - Leonardo Ulivi
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Italy (M.M., E.F., L.U., G.O., N.G., A. Chiti)
| | - Giovanni Orlandi
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Italy (M.M., E.F., L.U., G.O., N.G., A. Chiti).,Neurologia, Ospedale Apuano, Massa Carrara, Italy (G.O., M. Giuntini)
| | - Nicola Giannini
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Italy (M.M., E.F., L.U., G.O., N.G., A. Chiti)
| | - Tiziana Tassinari
- Stroke Unit-Department of Neurology, Santa Corona Hospital, Pietra Li-gure (Savona), Italy (T. Tassinari)
| | | | - Christina Rueckert
- Abteilung für Neurologie, Oberschwabenklinik gGmbH, Ravensburg, Germany (C.R.)
| | - Antonio Baldi
- Stroke Unit, Ospedale di Portogruaro, Portogruaro (Venice), Italy (A.B.)
| | - Danilo Toni
- Department of Human Neurosciences,, Sapienza University of Rome, Italy (D.T., F.L., A. Pieroni)
| | - Federica Letteri
- Department of Human Neurosciences,, Sapienza University of Rome, Italy (D.T., F.L., A. Pieroni)
| | | | - Enrico Maria Lotti
- U.O. Neurologia Presidio Ospedaliero di Ravenna Azienda USL della Romagna, Italy (E.M.L.)
| | - Yuriy Flomin
- Stroke and Neurorehabilitation Unit MC 'Universal Clinic 'Oberig' Kyiv, Ukraine (Y.F.)
| | - Alessio Pieroni
- Department of Human Neurosciences,, Sapienza University of Rome, Italy (D.T., F.L., A. Pieroni)
| | | | | | - Serena Monaco
- Stroke Unit, Ospedale Civico, Palermo, Italy (S. Monaco)
| | | | - Laszló Csiba
- Stroke Unit, University of Debrecen, Hungary (M.M.B., L.C., L.S.)
| | - Lilla Szabó
- Stroke Unit, University of Debrecen, Hungary (M.M.B., L.C., L.S.)
| | - Alberto Chiti
- Department of Clinical and Experimental Medicine, Neurological Institute, University of Pisa, Italy (M.M., E.F., L.U., G.O., N.G., A. Chiti).,Stroke Unit, Department of Neurology, Sant'Andrea Hospital, La Spezia, Italy (A. Chiti, E.G.)
| | - Elisa Giorli
- Stroke Unit, Department of Neurology, Sant'Andrea Hospital, La Spezia, Italy (A. Chiti, E.G.)
| | - Massimo Del Sette
- Struttura Complessa di Neurologia, Ospedale Galliera, Genoa, Italy (M.D.S.)
| | - Davide Imberti
- Department of Internal Medicine, Ospedale Civile di Piacenza, Italy (D.I., D.Z.)
| | - Dorjan Zabzuni
- Department of Internal Medicine, Ospedale Civile di Piacenza, Italy (D.I., D.Z.)
| | - Boris Doronin
- Municipal Budgetary Healthcare Institution of Novosibirsk. City Clinical Hospital # 1. Novosibirsk (Russia) at the Novosibirsk State Medical University (Russia) (B.D., V. Volodina)
| | - Vera Volodina
- Municipal Budgetary Healthcare Institution of Novosibirsk. City Clinical Hospital # 1. Novosibirsk (Russia) at the Novosibirsk State Medical University (Russia) (B.D., V. Volodina)
| | - Patrik Michel
- Centre Cérébrovasculaire, Service de Neurologie, Département des Neurosciences Cliniques Centre Hopitalier Universitaire Vaudois, Lausanne (Switzerland) (P.M.)
| | - Peter Vanacker
- Department of Neurology, Born Bunge Institute, Antwerp University Hospital, Antwerp, Belgium (P.V.)
| | - Kristian Barlinn
- Department of Neurology, Dresden University Stroke Center, Germany (K.B., J.B.)
| | - Jessica Barlinn
- Department of Neurology, Dresden University Stroke Center, Germany (K.B., J.B.)
| | - Dirk Deleu
- Department of Neurology, Hamad Medical Corporation, Doha, Qatar (D.D.)
| | | | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M. Giustozzi, M. Acciarresi, G.A., V.C., C.B., A.A., M.V., C.D., M.G.M., L.A.C., M.P.)
| | - Luca Masotti
- Internal Medicine, Santa Maria Nuova Hospital, Firenze, Italy (V. Vannucchi, L.M.)
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138
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Wongcharoen W, Pacharasupa P, Norasetthada L, Gunaparn S, Phrommintikul A. Anti-Factor Xa Activity of Standard and Japan-Specific Doses of Rivaroxaban in Thai Patients With Non-Valvular Atrial Fibrillation. Circ J 2020; 84:1075-1082. [PMID: 32461505 DOI: 10.1253/circj.cj-20-0056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Recommended rivaroxaban doses for stroke prevention in atrial fibrillation (SPAF) are 20 and 15 mg/day in patients with normal and reduced renal function, respectively, but lower doses (15 and 10 mg) have been tested and approved in Japan. It is not known whether 15 and 10 mg rivaroxaban are appropriate in other Asian populations. This study compared the anti-Factor Xa (FXa) activity of 20 and 15 mg rivaroxaban in Thai patients with normal renal function and 15 and 10 mg rivaroxaban in patients with reduced renal function.Methods and Results:Sixty non-valvular atrial fibrillation patients receiving rivaroxaban (mean [±SD] age 69.3±9.1 years, mean creatinine clearance 59.2±22.7 mL/min) were enrolled. The anti-FXa activity of standard rivaroxaban and Japan-specific doses was measured at peak and trough concentrations. Median anti-FXa activity at peak concentrations was significantly higher for the standard than Japan-specific dose. Median anti-FXa activity measured at the trough was significantly higher for the standard dose only in those with impaired renal function. A higher proportion of patients receiving the Japan-specific rather than standard dose had anti-FXa activity at peak concentrations within the expected range (87.7% vs. 64.4%; P=0.001). One-third of those receiving the standard dose had anti-FXa activity higher than the expected range. CONCLUSIONS A significantly higher proportion of Thai patients receiving the Japan-specific dose of rivaroxaban had anti-FXa activity at peak concentrations within the expected range.
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Affiliation(s)
- Wanwarang Wongcharoen
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
| | - Phongsathon Pacharasupa
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
| | - Lalita Norasetthada
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
| | - Siriluck Gunaparn
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
| | - Arintaya Phrommintikul
- Division of Cardiology, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University
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139
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Gautier N, Pirson A, Lechat JP, Van Der Linden P. Impact of direct oral anticoagulant therapy on operative delay, blood loss, transfusion and postoperative morbidity mortality in hip fracture patient, an observational study. Thromb Res 2020; 194:165-167. [PMID: 32788110 DOI: 10.1016/j.thromres.2020.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/15/2020] [Accepted: 06/12/2020] [Indexed: 01/20/2023]
Affiliation(s)
- Nicolas Gautier
- Department of Anesthesiology, Grand Hôpital de Charleroi, Notre Dame, Grand'Rue 3, Charleroi 6000, Belgium.
| | - Anne Pirson
- Department of Anesthesiology, Grand Hôpital de Charleroi, Notre Dame, Grand'Rue 3, Charleroi 6000, Belgium.
| | - Jean-Paul Lechat
- Department of Anesthesiology, Grand Hôpital de Charleroi, Notre Dame, Grand'Rue 3, Charleroi 6000, Belgium.
| | - Philippe Van Der Linden
- Department of Anesthesiology, Grand Hôpital de Charleroi, Notre Dame, Grand'Rue 3, Charleroi 6000, Belgium.
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Lorusso R, Miceli A, Gelsomino S, Lio A, Parise O, Montisci A, Vizzardi E, Pacini D, Di Bartolomeo R, Renzulli A, Serraino FG, Comoglio C, Liberi R, Martinelli G, Sciangula A, Mazzola A, Faragalli F, De Bonis M, Taramasso M, Alfieri O, Caimmi P, Micalizzi E, Mercogliano D, Demicheli G, Celiento M, Bortolotti U, Solinas M, Glauber M. Mitral Valve Replacement With a Third-Generation Porcine Valve: An Italian Multicentered Study. Ann Thorac Surg 2020; 109:1865-1872. [DOI: 10.1016/j.athoracsur.2019.08.111] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 06/23/2019] [Accepted: 08/08/2019] [Indexed: 10/25/2022]
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Bhardwaj P, Petersen LB, Binko TS, Petersen JR, Fornitz GG. Slightly elevated international normalized ratio predicts bleeding episodes in patients treated with direct oral anticoagulants. J Int Med Res 2020. [PMCID: PMC7294381 DOI: 10.1177/0300060519894439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Patients treated with direct oral anticoagulants (DOACs) are at increased bleeding risk. It is therefore of increasing interest to identify predictors of bleeding episodes to increase safety during treatment with DOACs. Methods This retrospective cohort study systematically reviewed medical records of 235 patients treated with either apixaban, rivaroxaban or dabigatran for non-valvular atrial fibrillation or venous thromboembolism and collected data on the international normalized ratio (INR) and all bleeding episodes. Results INR ≥ 1.5 was significantly associated with increased risk of minor and major bleeding events in patients treated with direct factor Xa inhibitors. This association was not present in patients treated with dabigatran. However, a high negative predictive value was identified for INR < 1.5 for all drugs. The relative risks of bleeding episodes in patients with INR ≥ 1.5 and INR < 1.5 were 5.1 and 0.20, respectively. Conclusions Our results demonstrate a strong correlation between INR and risk of bleeding episodes during DOAC treatment. INR < 1.5 was a strong negative predictor for low bleeding risk independent of indication or choice of drug, and INR ≥ 1.5 was associated with increased risk of bleeding episodes in patients treated with direct factor Xa-inhibitors.
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Affiliation(s)
- Priya Bhardwaj
- Department of Cardiology, Slagelse Hospital, Region Seeland – Denmark
| | | | - Tomas Sorm Binko
- Department of Cardiology, Amager Hospital, Capital Region – Denmark
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Chrysohoou C, Magkas N, Antoniou CK, Manolakou P, Laina A, Tousoulis D. The Role of Antithrombotic Therapy in Heart Failure. Curr Pharm Des 2020; 26:2735-2761. [PMID: 32473621 DOI: 10.2174/1381612826666200531151823] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/27/2020] [Indexed: 12/24/2022]
Abstract
Heart failure is a major contributor to global morbidity and mortality burden affecting approximately 1-2% of adults in developed countries, mounting to over 10% in individuals aged >70 years old. Heart failure is characterized by a prothrombotic state and increased rates of stroke and thromboembolism have been reported in heart failure patients compared with the general population. However, the impact of antithrombotic therapy on heart failure remains controversial. Administration of antiplatelet or anticoagulant therapy is the obvious (and well-established) choice in heart failure patients with cardiovascular comorbidity that necessitates their use, such as coronary artery disease or atrial fibrillation. In contrast, antithrombotic therapy has not demonstrated any clear benefit when administered for heart failure per se, i.e. with heart failure being the sole indication. Randomized studies have reported decreased stroke rates with warfarin use in patients with heart failure with reduced left ventricular ejection fraction, but at the expense of excessive bleeding. Non-vitamin K oral anticoagulants have shown a better safety profile in heart failure patients with atrial fibrillation compared with warfarin, however, current evidence about their role in heart failure with sinus rhythm is inconclusive and further research is needed. In the present review, we discuss the role of antithrombotic therapy in heart failure (beyond coronary artery disease), aiming to summarize evidence regarding the thrombotic risk and the role of antiplatelet and anticoagulant agents in patients with heart failure.
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Affiliation(s)
- Christina Chrysohoou
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - Nikolaos Magkas
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | | | - Panagiota Manolakou
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - Aggeliki Laina
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
| | - Dimitrios Tousoulis
- First Department of Cardiology, 'Hippokration' Hospital, University of Athens, Medical School, Athens, Greece
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143
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Li Y, Du L, Tang X, Chen Y, Mei D. Laboratory monitoring of rivaroxaban in Chinese patients with deep venous thrombosis: a preliminary study. BMC Pharmacol Toxicol 2020; 21:38. [PMID: 32466800 PMCID: PMC7257180 DOI: 10.1186/s40360-020-00414-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 05/12/2020] [Indexed: 12/02/2022] Open
Abstract
Background Rivaroxaban, a novel oral anticoagulant drug, is widely used in clinical practice. There is no standardized laboratory monitoring for rivaroxaban, and its plasma concentration in Chinese patients with deep vein thrombosis is unclear. The rivaroxaban concentrations in human plasma and determine the steady-state concentration of rivaroxaban in patients with deep vein thrombosis are needed. Methods An ultra-high-performance liquid chromatography with mass spectrometric detection method was developed. Chromatographic separation was performed on a Waters BEH C18 column with isocratic elution using a mobile phase composed of acetonitrile and water. Quantitation of the analytes was performed using positive ionization mode and mass transitions of m/z 437.3 → m/z 145.0 and m/z 440.1 → m/z 145.0 for rivaroxaban and the internal standard, respectively. Blood samples were collected at 0 h and 2 h after patients took rivaroxaban for 7 days or more. Results The method was validated over the concentration range of 0.5 ~ 400 ng•mL− 1 with a very low limit of quantification of 0.5 ng·mL− 1, and the intra- and inter-day precision (RSD%) were < 15%. The range of the steady state concentration in patients that took 15 mg rivaroxaban twice daily, 10 mg twice daily, 20 mg once daily, 15 mg once daily, and 10 mg once daily were 168.5 ~ 280.1 ng•mL− 1, 74.2 ~ 271.4 ng•mL− 1, 25.7 ~ 306.8 ng•mL− 1, 24.5 ~ 306.4 ng•mL− 1, and 15.4 ~ 229.2 ng•mL− 1, respectively. Conclusions The plasma rivaroxaban concentration in patients who took 10 mg rivaroxaban twice daily fluctuated less than that in patients who took 20 mg rivaroxaban once daily. The plasma concentration can be used for therapeutic drug monitoring for rivaroxaban.
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Affiliation(s)
- Ying Li
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.,Department of Pharmacy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Liping Du
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Xiaowan Tang
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yuexin Chen
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| | - Dan Mei
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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Meuris B, Borger MA, Bourguignon T, Siepe M, Grabenwöger M, Laufer G, Binder K, Polvani G, Stefano P, Coscioni E, van Leeuwen W, Demers P, Dagenais F, Canovas S, Theron A, Langanay T, Roussel JC, Wendler O, Mariscalco G, Pessotto R, Botta B, Bramlage P, de Paulis R. Durability of bioprosthetic aortic valves in patients under the age of 60 years - rationale and design of the international INDURE registry. J Cardiothorac Surg 2020; 15:119. [PMID: 32460798 PMCID: PMC7251702 DOI: 10.1186/s13019-020-01155-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/10/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is an ever-growing number of patients requiring aortic valve replacement (AVR). Limited data is available on the long-term outcomes and structural integrity of bioprosthetic valves in younger patients undergoing surgical AVR. METHODS The INSPIRIS RESILIA Durability Registry (INDURE) is a prospective, open-label, multicentre, international registry with a follow-up of 5 years to assess clinical outcomes of patients younger than 60 years who undergo surgical AVR using the INSPIRIS RESILIA aortic valve. INDURE will be conducted across 20-22 sites in Europe and Canada and intends to enrol minimum of 400 patients. Patients will be included if they are scheduled to undergo AVR with or without concomitant root replacement and/or coronary bypass surgery. The primary objectives are to 1) determine VARC-2 defined time-related valve safety at one-year (depicted as freedom from events) and 2) determine freedom from stage 3 structural valve degeneration (SVD) presenting as morphological abnormalities and severe haemodynamic valve degeneration at 5 years. Secondary objectives include the assessment of the haemodynamic performance of the valve, all stages of SVD, potential valve-in-valve procedures, clinical outcomes (in terms of New York Heart Association [NYHA] function class and freedom from valve-related rehospitalisation) and change in patient quality-of-life. DISCUSSION INDURE is a prospective, multicentre registry in Europe and Canada, which will provide much needed data on the long-term performance of bioprosthetic valves in general and the INSPIRIS RESILIA valve in particular. The data may help to gather a deeper understanding of the longevity of bioprosthetic valves and may expand the use of bioprosthetic valves in patients under the age of 60 years. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03666741 (registration received September, 12th, 2018).
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Affiliation(s)
- Bart Meuris
- Cardiac Surgery, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | | | | | - Matthias Siepe
- Heart Center University of Freiburg, Freiburg and Bad Krozingen, Germany
| | | | | | - Konrad Binder
- Heart Center University St. Pölten, St. Pölten, Austria
| | | | | | - Enrico Coscioni
- University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | | | | | | | - Sergio Canovas
- Hospital University Virgen de la Arrixaca, Murcia, Spain
| | | | | | | | - Olaf Wendler
- King's College Hospital NHS Foundation Trust, London, UK
| | | | | | - Beate Botta
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
| | - Peter Bramlage
- Institute for Pharmacology and Preventive Medicine, Cloppenburg, Germany
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145
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Simultaneous determination of Rivaroxaban and TAK-438 in rat plasma by LC-MS/MS: application to pharmacokinetic interaction study. Bioanalysis 2020; 12:11-22. [PMID: 31849262 DOI: 10.4155/bio-2019-0130] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Aim: A sensitive and reliable LC-MS/MS method has been established and validated to the quantitation of rivaroxaban (RIV) and TAK-438 in rat plasma using carbamazepine as internal standard. Results: The procedure of method validation was conducted according to the guidelines of EMA and US FDA. At the same time, the method was applied to pharmacokinetic interactions study between RIV and TAK-438 for the first time. When RIV and TAK-438 co-administration to rats, main pharmacokinetic parameters of TAK-438 like AUC(0-t), AUC(0-∞) and Cmax had statistically significant increase. The main pharmacokinetic parameters of RIV have no statistically significant difference (p > 0.05) when co-administered except for t1/2 (p < 0.01). Conclusion: The results indicated that drug-drug interactions occurred between RIV and TAK-438 when co-administered to rats.
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146
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Yasaka M, Yokota H, Suzuki M, Yamane T, Ono Y. Incidence Rates of Bleeding and Emergency Surgery Due to Trauma or Fracture Among Japanese Patients with Non-valvular Atrial Fibrillation Receiving Oral Anticoagulation Therapy. Cardiol Ther 2020; 9:189-199. [PMID: 32394292 PMCID: PMC7237605 DOI: 10.1007/s40119-020-00171-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Indexed: 12/01/2022] Open
Abstract
Introduction In patients with nonvalvular atrial fibrillation (NVAF) receiving oral anticoagulants (OACs), reversal of coagulopathy can be achieved with specific reversal drugs such as idarucizumab, which is indicated for use in patients treated with dabigatran for cases of life-threatening or uncontrolled bleeding or during emergency procedures that may cause serious bleeding. This study examined the incidence rate (IR) of emergency surgeries and major bleeding episodes associated with fractures and trauma in Japanese patients with NVAF receiving OACs. Methods This retrospective, non-interventional analysis of health insurance claims was conducted using data from 62,888 OAC-naive adult patients with NVAF who initiated dabigatran, warfarin, apixaban, rivaroxaban, or edoxaban between March 2011 and June 2016. The primary endpoint was overall IR of emergency surgery or major bleeding due to fracture or trauma. Results Overall IR of emergency surgery or major bleeding due to fracture or trauma considering outcomes until OAC discontinuation was 0.489 per 100 patient-years (PY) (95% confidence interval [CI] 0.406–0.572). Considering first OAC exposure only, the IR was 0.483 per 100 PY (95% CI 0.394–0.573). Emergency surgery/major bleeding events due to fracture or trauma was highest in those aged ≥ 75 years (0.611 per 100 PY [95% CI 0.481–0.741]). Conclusions Fewer than one in 200 patients per year with NVAF receiving OACs experience emergency surgeries and major bleeding episodes associated with fractures and trauma; however, the IR of these events is markedly higher in patients of advanced age. Trial registration ClinicalTrials.gov 207, NCT03254147. Patients with an abnormal heart rhythm (nonvalvular atrial fibrillation [NVAF]) have a higher risk of blood clots and stroke (which is when the blood supply to part of the brain is blocked). To reduce these risks, patients can take anticoagulants that slow or prevent the formation of blood clots. However, if the patient needs major emergency surgery or has a severe injury, the anticoagulants can increase their risk of bleeding, which can sometimes be life-threatening. There are drugs (e.g., idarucizumab) that can be used to reverse the effects of anticoagulants in this type of emergency. What we don’t know is how many NVAF patients in Japan who are on anticoagulants have emergency surgeries or major bleeding after an injury, and therefore may require a reversal drug. The authors looked at Japanese health insurance claim data from 62,888 adult patients with NVAF who started taking an anticoagulant. They found that, annually, approximately 0.5% of the patients had emergency surgery or a major bleed associated with a fracture or injury. In very elderly patients (aged at least 75 years), the annual percentage was approximately 0.6%, which was almost double the annual percentage in patients aged less than 65 years. The authors concluded that, even though the number of people requiring a reversal agent are quite small, it is important to have an effective reversal agent for patients on anticoagulants, particularly older patients.
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Affiliation(s)
- Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan.
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Michiyasu Suzuki
- Department of Neurosurgery, Yamaguchi University School of Medicine, 1077-1 Yoshida, Yamaguchi-City, Yamaguchi, 753-0841, Japan
| | - Teiichi Yamane
- Department of Cardiology, Jikei University School of Medicine, 3-25-8, Shinbashi, Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Yasuhisa Ono
- Nippon Boehringer Ingelheim, 2-1-1 Osaki, Shinagawa-ku, Tokyo, 141-6017, Japan
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Kimura S, Emoto A, Yoshimura M, Arimizu K, Kamura T, Sogawa R, Mizuta K, Tagomori Y, Natsuaki M, Kajiwara M, Tsuruoka N, Yakushiji Y, Tanigawa Y, Takamatsu C, Danjo A, Kamohara K, Hirakawa N, Sakaguchi Y, Noguchi M, Noshiro H, Kawaguchi A, Sueoka E, Narisawa Y, Kimura S. Development of an application for management of drug holidays in perioperative periods. Medicine (Baltimore) 2020; 99:e20142. [PMID: 32384497 PMCID: PMC7220215 DOI: 10.1097/md.0000000000020142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/12/2020] [Accepted: 04/03/2020] [Indexed: 11/30/2022] Open
Abstract
Before surgery and other invasive treatments, decisions must be made on whether to discontinue drugs and provide appropriate drug holidays especially for antithrombotic drugs, and this is made difficult by the large number of available drugs and associated guidelines. We have therefore developed an online application for perioperative drug discontinuation and resumption management, named Saga Application for Management of Drug Holidays in PeriOperative Periods (SAMPOP).Multidisciplinary medical staff at Saga University Hospital (SUH) worked together to build an evidence-based Perioperative Drug Discontinuation Management Database (PDDMD) and developed the user-friendly SAMPOP online application via preliminary verification at SUH. From September 2018 to February 2020, 420 medical staff at SUH, including physicians, nurses, and pharmacists, installed and tested SAMPOP.Rate per surgical procedure for forgetting to discontinue antithrombotic drugs preoperatively decreased from 0.18% to 0.09% as of August 2019, 12 months after the introduction of SAMPOP (P = .1359). In addition, six months later, it decreased further to 0.03% as of February 2020 (P = .0436). Forgetting to resume antithrombotic drugs postoperatively decreased from 0.20% to 0.02% as of August 2019, 12 months after the introduction of SAMPOP (P = .0008). There was no case of forgetting to resume the medication in the last 6 months.SAMPOP may be useful for management of drug holidays in the clinic and warrants further evaluation of its safety and efficacy.
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Affiliation(s)
- Sakiko Kimura
- Safety Management Section, Saga University Hospital
- Dep. of Pharmacy, Saga University Hospital
| | | | | | - Kota Arimizu
- Clinical Research Center, Saga University Hospital
| | | | | | - Kikumi Mizuta
- Safety Management Section, Saga University Hospital
- Department of Nursing, Saga University Hospital
| | - Yasuhiro Tagomori
- Safety Management Section, Saga University Hospital
- Department of Nursing, Saga University Hospital
| | - Masahiro Natsuaki
- Div. of Cardiovascular Medicine, Dep. of Internal Medicine, Faculty of Medicine, Saga University
| | - Masataka Kajiwara
- Div. of Cardiovascular Medicine, Dep. of Internal Medicine, Faculty of Medicine, Saga University
| | - Nanae Tsuruoka
- Div. of Gastrointestinal Endoscopy, Dep. of Internal Medicine, Faculty of Medicine, Saga University
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University
| | | | - Chihiro Takamatsu
- Safety Management Section, Saga University Hospital
- Surgical Center, Saga University Hospital
| | - Atsushi Danjo
- Dep. of Oral and Maxillofacial Surgery, Faculty of Medicine, Saga University
| | - Keiji Kamohara
- Dep. of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University
| | - Naomi Hirakawa
- Dep. of Anesthesiology and Critical Care Medicines, Faculty of Medicine, Saga University
| | - Yoshiro Sakaguchi
- Dep. of Anesthesiology and Critical Care Medicines, Faculty of Medicine, Saga University
| | | | | | - Atsushi Kawaguchi
- Clinical Research Center, Saga University Hospital
- Center for Comprehensive Community Medicine, Faculty of Medicine, Saga University
| | - Eisaburo Sueoka
- Dep. of Clinical Laboratory Medicine, Faculty of Medicine, Saga University
| | - Yutaka Narisawa
- Dep. of Pharmacy, Saga University Hospital
- Div. of Dermatology, Dep. of Internal Medicine, Faculty of Medicine, Saga University
| | - Shinya Kimura
- Safety Management Section, Saga University Hospital
- Clinical Research Center, Saga University Hospital
- Division of Hematology, Respiratory Medicine and Oncology, Department of Internal Medicine, Faculty of Medicine, Saga University, Japan
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148
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Kim KS, Song JW, Soh S, Kwak YL, Shim JK. Perioperative management of patients receiving non-vitamin K antagonist oral anticoagulants: up-to-date recommendations. Anesth Pain Med (Seoul) 2020; 15:133-142. [PMID: 33329805 PMCID: PMC7713812 DOI: 10.17085/apm.2020.15.2.133] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 03/05/2020] [Indexed: 01/12/2023] Open
Abstract
Indications of non-vitamin K antagonist oral anticoagulants (NOACs), consisting of two types: direct thrombin inhibitor (dabigatran) and direct factor Xa inhibitor (rivaroxaban, apixaban, and edoxaban), have expanded over the last few years. Accordingly, increasing number of patients presenting for surgery are being exposed to NOACs, despite the fact that NOACs are inevitably related to increased perioperative bleeding risk. This review article contains recent clinical evidence-based up-to-date recommendations to help set up a multidisciplinary management strategy to provide a safe perioperative milieu for patients receiving NOACs. In brief, despite the paucity of related clinical evidence, several key recommendations can be drawn based on the emerging clinical evidence, expert consensus, and predictable pharmacological properties of NOACs. In elective surgeries, it seems safe to perform high-bleeding risk surgeries 2 days after cessation of NOAC, regardless of the type of NOAC. Neuraxial anesthesia should be performed 3 days after cessation of NOACs. In both instances, dabigatran needs to be discontinued for an additional 1 or 2 days, depending on the decrease in renal function. NOACs do not require a preoperative heparin bridge therapy. Emergent or urgent surgeries should preferably be delayed for at least 12 h from the last NOAC intake (better if > 24 h). If surgery cannot be delayed, consider using specific reversal agents, which are idarucizumab for dabigatran and andexanet alfa for rivaroxaban, apixaban, and edoxaban. If these specific reversal agents are not available, consider using prothrombin complex concentrates.
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Affiliation(s)
- Kwang-Sub Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jong Wook Song
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sarah Soh
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Lan Kwak
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jae-Kwang Shim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
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149
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van Til J, Oudshoorn-Groothuis C, Weernink M, von Birgelen C. Heterogeneity in Preferences for Anti-coagulant Use in Atrial Fibrillation: A Latent Class Analysis. PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2020; 13:445-455. [PMID: 32329020 PMCID: PMC7340663 DOI: 10.1007/s40271-020-00420-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Introduction Recent reviews on patients’ preferences towards attributes of oral anti-coagulant therapy have shown that preference for convenience of therapy is heterogeneous. In this study, we used a novel approach—latent class analysis (LCA)—to assess heterogeneity. Methods We developed a health preference survey that consisted of 12 discrete choice questions. The following attributes of convenience were included: intake frequency; need for regular coagulation monitoring; diet or drug interactions; relation between medication and food intake; and pill type. Background questions about gender, age, current therapy [i.e., direct-acting oral anti-coagulant (DOAC) or vitamin K antagonist (VKA)], self-reported medication adherence, and pill burden were included. Mixed logit analysis (MLA) and LCA were performed. The scale-adjusted LCA model with two scale classes and four preference classes emerged as the model with the best fit and interpretability. Results A total of 508 patients with non-valvular atrial fibrillation from five European countries (Germany, Italy, Spain, France, and the UK) were surveyed in August 2017. The most important attributes were need for monitoring (37%) and intake frequency (27%). Patient preferences were significantly influenced by country, gender, and current anti-coagulant therapy. Four different preference classes of patients were identified in the LCA. First, most patients (57%) were in the “no need for regular coagulation monitoring” class. Current DOAC users and patients who were the least adherent to therapy were more likely to prefer no coagulation monitoring. Second, 20% of patients were in the “balanced” class of patients. Current VKA users with moderate adherence were more likely to be in this class. Patients who reported the lowest adherence were most likely in the “once daily, interactions likely” class (16%). Fourth, current VKA users and highly adherent patients were most likely to prefer therapies with a need for regular coagulation monitoring (7%). Conclusions This study demonstrated significant preference heterogeneity among patients with atrial fibrillation and linked these preferences to differences in background characteristics. Country of residence and currently prescribed therapy influenced patient preferences in both the MLA and LCA models. Electronic supplementary material The online version of this article (10.1007/s40271-020-00420-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Janine van Til
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands.
| | - Catharina Oudshoorn-Groothuis
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
| | - Marieke Weernink
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,Municipal Health Services (GGD) Twente, Enschede, The Netherlands
| | - Clemens von Birgelen
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands.,Medical Spectrum Twente, Thorax Centrum Twente, Enschede, The Netherlands
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150
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Interindividual Variability of Apixaban Plasma Concentrations: Influence of Clinical and Genetic Factors in a Real-Life Cohort of Atrial Fibrillation Patients. Genes (Basel) 2020; 11:genes11040438. [PMID: 32316515 PMCID: PMC7230214 DOI: 10.3390/genes11040438] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 04/03/2020] [Accepted: 04/14/2020] [Indexed: 02/06/2023] Open
Abstract
(1) Background: Prescribing apixaban for stroke prevention has significantly increased in patients with non-valvular atrial fibrillation (NVAF). The ABCB1 genotype can influence apixaban absorption and bioavailability. The aim of the present study was to assess the factors that influence apixaban’s plasma level and to establish if a certain relationship has clinical relevance. (2) Methods: Fifty-three NVAF patients were treated with 5 mg apixaban twice/day (70.0 years, range: 65–77, 60.4% men). Trough and peak plasma concentrations of apixaban were determined by liquid chromatography-tandem mass-spectrometry (LC-MS/MS), and ABCB1 genotyping was performed. (3) Results: Apixaban plasma concentrations varied considerably. They were higher in women than in men (311.2 ng/dL vs. 252.2 ng/dL; p = 0.05) and were lower in patients with heart failure (149.4 ng/dL vs. 304.5 ng/dL; p < 0.01). Creatinine clearance was inversely correlated with the apixaban plasma level (Spearman correlation: r = −0.365; p = 0.007 for trough concentrations). No statistically significant differences between the genotypic groups of ABCB1 rs1045642 and ABCB1 rs4148738 were found in the trough or peak apixaban plasma concentrations. (4) Conclusions: Pharmacokinetic parameters are influenced by several clinical factors of which renal function is the major determinant. Plasma concentrations measured in women had higher values than those measured in men, and heart failure was associated with decreased plasma levels of apixaban.
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