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The evolution of anticoagulant therapy. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2015; 14:175-84. [PMID: 26710352 DOI: 10.2450/2015.0096-15] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 04/16/2015] [Accepted: 07/16/2015] [Indexed: 02/07/2023]
Abstract
Arterial and venous thromboembolism are leading causes of morbidity and mortality around the world. For almost 70 years, heparins (unfractionated heparin and low molecular weight heparins) and vitamin K antagonists have been the leading therapeutic medical options for the treatment and prevention of thromboembolic disorders. Nevertheless, the many limitations of these traditional anticoagulants have fuelled the search for novel agents over the past 15 years, and a new class of oral anticoagulants that specifically target activated factor X and thrombin has been developed and is now commercially available. In this narrative review, the evolution of anticoagulant therapy is summarised, with a focus on newer oral anticoagulants.
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Caldeira D, Barra M, Ferreira A, Rocha A, Augusto A, Pinto FJ, Costa J, Ferreira JJ. Systematic review with meta-analysis: the risk of major gastrointestinal bleeding with non-vitamin K antagonist oral anticoagulants. Aliment Pharmacol Ther 2015; 42:1239-49. [PMID: 26434935 DOI: 10.1111/apt.13412] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Revised: 07/31/2015] [Accepted: 09/02/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND Gastrointestinal (GI) bleeding is a common complication among anticoagulated patients. Non-vitamin K antagonist oral anticoagulants (NOACs) are associated with increased risk of GI (major and clinically relevant non-major) bleeding. However, more information is needed regarding severe events. AIM To evaluate the risk of NOACs major GI bleeding. METHODS We searched for phase III randomised clinical trials (RCT) evaluating NOACs (apixaban, dabigatran, edoxaban and rivaroxaban) and reporting major GI bleeding events, in MEDLINE, Cochrane Library, SciELO collection and Web of Science databases (July 2015). Meta-analysis was performed to estimate risk ratio (RR) and 95% confidence intervals (95% CIs). Heterogeneity was assessed with the I(2) test. RESULTS A total of 23 studies were included. Among patients with atrial fibrillation, the risk of major GI bleeding was not different between NOACs and vitamin K antagonists (VKA) (RR 1.08, 95% CI 0.85-1.36, I(2) = 78%; 5 RCTs) or acetylsalicylic acid (RR 0.78, 95% CI 0.36-1.72; 1 RCT). Similar results were found for patients undergoing orthopaedic surgery and those with venous thromboembolism. NOACs were not found to increase the risk compared to low-molecular-weight heparin (LWMH) alone (RR 1.42, 95% CI 0.55-3.71, I(2) = 7%; 8 RCTs), the sequential treatment with LMWH-VKA (RR 0.77, 95% CI 0.49-1.21, I(2) = 43%; 7 RCTs) or placebo (RR 1.48, 95% CI 0.15-14.84, I(2) = 21%; 2 RCTs). CONCLUSION Despite previous evidence supporting the association of non-vitamin K antagonist oral anticoagulants and overall GI bleeding, non-vitamin K antagonist oral anticoagulants are not associated with increased risk of major GI bleeding compared to other anticoagulant drugs (with known increased risk of these events).
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Affiliation(s)
- D Caldeira
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal.,Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal.,Cardiology Department, Hospital Garcia de Orta, Almada, Portugal
| | - M Barra
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal
| | - A Ferreira
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal
| | - A Rocha
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal
| | - A Augusto
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal
| | - F J Pinto
- Cardiology Department, Faculty of Medicine, CCUL, CAML, Lisbon, Portugal
| | - J Costa
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal.,Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal.,Center for Evidence-Based Medicine, Faculty of Medicine, University of Lisbon, Lisbon, Portugal.,Portuguese Collaborating Center of the IberoAmerican Cochrane Network, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - J J Ferreira
- Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal.,Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
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