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Gritsch D, Gonzalez Castro LN. Relevant pharmacologic interactions in the concurrent management of brain tumor-related epilepsy and venous thromboembolism: a systematic review. J Neurooncol 2022; 157:285-296. [PMID: 35312937 DOI: 10.1007/s11060-022-03984-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/05/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Co-administration of direct oral anticoagulants (DOACs) with antiepileptic drugs (AEDs) is increasingly common in brain tumor patients. We therefore performed a systematic review of the current evidence for potential drug interactions between DOACs and AEDs in this patient population. METHODS We conducted a systematic review of the literature via PubMed according to PRISMA guidelines (last accessed December 15, 2021). Included were clinical studies and case reports, written in English language and published between 2010 and 2021, that investigated concurrent clinical use of AEDs with DOACs for any indication. Non-English articles, articles not related to our research question, review articles and commentaries were excluded. Full-text articles were evaluated for possible confounding factors and results were summarized using a data table highlighting the key characteristics of each article. RESULTS We identified a total of 122 unique articles, of which 27 were deemed relevant to our research question. Of these, 8 articles were clinical studies (n = 295,415 patients) and 19 were case reports (n = 25 patients). Only 3 clinical studies and 2 case reports reported interactions between AEDs and DOACs in patients with active cancer and none reported interactions in patients with brain tumors. CONCLUSION We have identified low (class IV) level evidence of potential drug interactions between DOACs and AEDs. Even though there is no current report of interactions in brain tumor patients, neuro-oncology providers should be aware of the emerging evidence regarding drug interactions between DOACs and AEDs and take this into consideration when concurrently prescribing these to patients.
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Affiliation(s)
- David Gritsch
- Mayo Clinic Scottsdale: Mayo Clinic Arizona, Phoenix, AZ, USA.
| | - L Nicolas Gonzalez Castro
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
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103
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Liu J, Elsamadisi P, Philips E, Bauer KA, Eche IM. Four-factor prothrombin complex concentrate plus andexanet alfa for reversal of factor Xa inhibitor-associated bleeding: Case series. Am J Health Syst Pharm 2022; 79:1323-1329. [PMID: 35291008 DOI: 10.1093/ajhp/zxac079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To manage factor Xa (FXa) inhibitor-associated bleeding, andexanet alfa or 4-factor prothrombin concentrate (4F-PCC) has been used to restore hemostasis. However, literature on the outcomes for patients who received both andexanet alfa and 4F-PCC is limited. SUMMARY We report a case series of 5 patients who received andexanet alfa plus 4F-PCC for reversal of FXa inhibitor-associated bleeding. Patients were included in this case series if they received both andexanet alfa and 4F-PCC for reversal of FXa inhibitor-associated bleeding. They were followed to either discharge or death, and in-hospital complications related to concurrent use of andexanet alfa and 4F-PCC were documented. We report an incidence of thromboembolism of 40% (2 of 5 cases) and an in-hospital mortality rate of 60% (3 of 5 cases). Taking these cases together with those in the existing literature, we found a total of 23 reported cases of safety outcomes with andexanet alfa plus 4F-PCC. The overall incidence of thromboembolism was 35% (8 of 23 cases). CONCLUSION This case series adds to the limited literature describing the outcomes for patients receiving andexanet alfa plus 4F-PCC. We encourage other institutions to report safety data on administering both agents.
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Affiliation(s)
- JiTong Liu
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Pansy Elsamadisi
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Eli Philips
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kenneth A Bauer
- Division of Hematology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ifeoma M Eche
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Cohen AT, Lewis M, Connor A, Connolly SJ, Yue P, Curnutte J, Alikhan R, MacCallum P, Tan J, Green L. Thirty‐day mortality with andexanet alfa compared with prothrombin complex concentrate therapy for life‐threatening direct oral anticoagulant‐related bleeding. J Am Coll Emerg Physicians Open 2022; 3:e12655. [PMID: 35280921 PMCID: PMC8898077 DOI: 10.1002/emp2.12655] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 12/22/2021] [Accepted: 12/28/2021] [Indexed: 11/10/2022] Open
Affiliation(s)
- Alexander T. Cohen
- Department of Haematological Medicine Guy's and St Thomas’ Hospitals London UK
| | | | | | - Stuart J. Connolly
- Population Health Research Institute McMaster University Hamilton Ontario Canada
| | - Patrick Yue
- Portola Pharmaceuticals, Inc. now Alexion Pharmaceuticals, Inc. South San Francisco California USA
| | - John Curnutte
- Portola Pharmaceuticals, Inc. now Alexion Pharmaceuticals, Inc. South San Francisco California USA
| | - Raza Alikhan
- University Hospital of Wales, Cardiff and Vale University Health Board Cardiff UK
| | - Peter MacCallum
- Haemostasis and Transfusion Barts Health NHS Trust London UK
- Wolfson Institute of Preventive Medicine Queen Mary University of London London UK
| | - Joachim Tan
- Population Health Research Institute St George's, University of London London UK
| | - Laura Green
- Haemostasis and Transfusion Barts Health NHS Trust London UK
- Blizard Institute Queen Mary University of London London UK
- NHS Blood and Transplant London UK
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105
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Navin SF, Nardolillo J, Stambaugh A, Young C, Nguyen P, Apodaca M. Pharmacist monitoring of direct oral anticoagulants for American Indians and Alaska Natives in the outpatient setting. J Am Pharm Assoc (2003) 2022; 62:598-603. [PMID: 34728162 DOI: 10.1016/j.japh.2021.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 10/11/2021] [Accepted: 10/12/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) call into question the role of traditional pharmacist-run clinics, and few studies have described the incorporation of DOAC's into traditional anticoagulation management services (AMS) OBJECTIVE: To describe the incorporation of DOACs into a pharmacist-run AMS for American Indian and Alaska Native (AI/AN) patients and determine outcomes related to adherence, follow-up, and pharmacist interventions. PRACTICE DESCRIPTION Traditional AMS embedded in ambulatory clinic. Warfarin managed by pharmacists under a collaborative practice agreement with supervising physician. PRACTICE INNOVATION DOACs incorporated into AMS by transitioning warfarin patients to rivaroxaban and apixaban and managing new patients with DOAC. Follow-up occurred via phone call and at longer intervals. EVALUATION METHODS Single-center, retrospective, observational analysis of AI/AN patients who were followed up by pharmacy AMS. The outcomes measured include adherence to DOAC therapy, number of telephonic encounters versus face-to-face visits, frequency of follow-up, types of interventions made at each visit, and an estimate of face-to-face clinic time savings. RESULTS A total of 50 patients were included for analysis. The average medication possession ratio was 91%. The majority of visits occurred over the phone (59%), and most follow-up visits occurred every 3 months (62%). The top 3 most frequent interventions were adherence education, initial DOAC education, and education on use of nonsteroidal anti-inflammatory drugs. PRACTICE IMPLICATIONS Traditional AMS can evolve by incorporating DOACs and maintaining follow-up. CONCLUSION Pharmacist monitoring of DOACs may promote high levels of adherence and lead to time savings by reducing the amount of time spent in traditional AMS.
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Meißler S, Braun-Dullaeus R, Hansen M, Meyer F. [What the (general and abdominal) surgeon should know about thrombosis prophylaxis]. Chirurg 2022; 93:676-686. [PMID: 35147727 PMCID: PMC9246816 DOI: 10.1007/s00104-021-01568-6] [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] [Accepted: 12/18/2021] [Indexed: 01/19/2023]
Abstract
A persisting problem in the clinical operative routine is surgery-associated venous thromboembolisms with the possible complications. The competent and reliably realized prophylaxis of thromboembolism is part of the original and elementary tasks of the surgeon, both the operator as well as the clinically active physician. Many preventive approaches were developed and established in the daily management but a residual risk for development of thrombosis still remains. Under this aspect a search was carried out particularly with respect to scientific literature with review and guideline character on the topic of risk stratification, prophylactic procedures in general and for specific indications.
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Affiliation(s)
- Saskia Meißler
- Klinik für Kardiologie und Angiologie, Universitätsklinikum Magdeburg A.ö.R., Magdeburg, Deutschland
| | - Rüdiger Braun-Dullaeus
- Klinik für Kardiologie und Angiologie, Universitätsklinikum Magdeburg A.ö.R., Magdeburg, Deutschland
| | - Michael Hansen
- Klinik für Kardiologie und Angiologie, Universitätsklinikum Magdeburg A.ö.R., Magdeburg, Deutschland
| | - Frank Meyer
- Klinik für Allgemein‑, Viszeral‑, Gefäß- und Transplantationschirurgie, Universitätsklinikum Magdeburg A.ö.R., Magdeburg, Deutschland.
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Reversal of factor Xa inhibitors associated intracranial haemorrhage at a tertiary medical centre. Blood Coagul Fibrinolysis 2022; 33:261-265. [DOI: 10.1097/mbc.0000000000001128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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108
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Tasaki D, Arai H, Yokoyama K, Yoshizaki T. Therapeutic-Dose Warfarin (International Normalized Ratio >1.6) Plus Aspirin Improved Long-Term Patency of Saphenous Vein Graft without Bleeding Complication. Ann Thorac Cardiovasc Surg 2022; 28:63-71. [PMID: 35034937 PMCID: PMC8915932 DOI: 10.5761/atcs.oa.21-00236] [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] [Indexed: 11/16/2022] Open
Abstract
Purpose: Saphenous vein graft (SVG) is the most commonly used conduits in coronary artery bypass grafting (CABG), but the disadvantage of SVG is its tendency for progressive failure. We hypothesized that therapeutic-dose warfarin (international normalized ratio [INR] >1.6) plus aspirin improve SVG patency. This study aimed to evaluate the factors contributing to SVG patency. Methods: Since 2010–2020, 199 patients who underwent isolated CABG using SVG were divided into two groups according to their INR values in the first year: group T (INR >1.6) and group L (INR <1.6). Results: Group T had 162 SVGs (105 patients) and group L had 151 SVGs (94 patients). The 1-, 4-, and 7-year SVG patency rates were higher in group T than in group L (99%, 96%, and 92% vs. 93%, 86%, and 79%, respectively; p = 0.00378). The 1-, 4-, and 7-year freedom from repeat-revascularization was higher in group T than in group L (100%, 100%, and 99% vs. 98%, 95%, and 87%, respectively; p = 0.0264). Multivariate analysis showed that therapeutic-dose warfarin (p = 0.00204) and target vessel diameter (p <0.0001) were independent risk factors of SVG occlusion. Conclusion: Therapeutic-dose warfarin (INR >1.6) plus aspirin after CABG improved the long-term patency of SVG and decreased repeat-revascularization rate.
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Affiliation(s)
- Dai Tasaki
- Department of Cardiovascular Surgery, Musashino Red Cross Hospital, Tokyo, Japan
| | - Hirokuni Arai
- Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kenji Yokoyama
- Department of Cardiovascular Surgery, Musashino Red Cross Hospital, Tokyo, Japan
| | - Tomoya Yoshizaki
- Department of Cardiovascular Surgery, Musashino Red Cross Hospital, Tokyo, Japan
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The VKORC1 and CYP2C9 gene variants as pharmacogenetic factors in acenocoumarol therapy in Serbian patients - consideration of hypersensitivity and resistance. SRP ARK CELOK LEK 2022. [DOI: 10.2298/sarh211118013r] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Introduction/Objective. Coumarin therapy represents one of the best models
for applying pharmacogenetics. The contribution of factors influencing
coumarin therapy can vary significantly between ethnic groups, which
justifies conducting population-specific studies. The aim of this study was
to analyze the influence of the most important genetic factors (VKORC1 and
CYP2C9 genes) that affect coumarin therapy in patients from Serbia.
Methods. A retrospective study involving 207 patients on acenocoumarol
therapy was conducted. Genetic analyses were performed by direct sequencing.
Influence on acenocoumarol dose of variants (VKORC1, CYP2C9*2, CYP2C9*3)
causing hypersensitivity and VKORC1 variants causing resistance to
acenocoumarol were analyzed. Multiple regression analysis was used to design
a mathematical model for predicting individual drug dosage based on
clinical-demographic and genetic data. Results. The study confirmed
significant influence of the analyzed genetic factors on acenocoumarol
maintenance dose. We designed mathematical model for predicting individual
acenocoumarol dose and its unadjusted R2 was 61.8. In the testing cohort,
our model gave R2 value of 42.6 and showed better prediction in comparison
with model given by other authors. In the analyzed patients, nine different
variants in the VKORC1 coding region were found. Among carriers of these
variants 78% were completely resistant, and it was not possible to achieve
therapeutic effect even with high doses of acenocoumarol. Conclusions.
Population-specific model for prediction individual dose of acenocoumarol,
may show advantages over protocols that are used in a generalized manner.
Also, VKORC1 variants which cause coumarin resistance should be considered
when planning therapy.
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110
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Choi SW, Kim J, Lee JH, Kim SK, Lee SR, Kim SH, Chae HD. Hormone Therapy in the Era of the COVID-19 Pandemic: A Review. J Menopausal Med 2022; 28:1-8. [PMID: 35534425 PMCID: PMC9086346 DOI: 10.6118/jmm.21036] [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] [Received: 12/17/2021] [Revised: 03/12/2022] [Accepted: 03/13/2022] [Indexed: 11/05/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has impacted the medical, social, and reproductive health of millions of people since its outbreak. The causative virus transmits, reproduces, and manifests through the respiratory tract. COVID-19 can invade any system of the body, including the cardiovascular and endocrine systems, through a secondary immune response. In particular, because the fatality rate is high in those over the age of 50 years, special attention is required during the medical care of this population. However, considering the benefit of therapy and the risk of COVID-19, high-quality evidence regarding individualized management in relation to hormone therapy is still insufficient in the field of gynecology. Furthermore, this review aims to serve as a reference for clinical application by analyzing and summarizing the results of studies reported to date regarding female hormone therapy in the context of the COVID-19 pandemic.
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Affiliation(s)
- Sung Wook Choi
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Juhee Kim
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Hoon Lee
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seul Ki Kim
- Department of Obstetrics and Gynecology, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sa Ra Lee
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Hoon Kim
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hee Dong Chae
- Department of Obstetrics and Gynecology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Carballo Álvarez F, Albillos Martínez A, Llamas Silero P, Orive Calzada A, Redondo-Cerezo E, Rodríguez de Santiago E, Crespo García J. Consensus document of the Sociedad Española de Patología Digestiva on massive nonvariceal gastrointestinal bleeding and direct-acting oral anticoagulants. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2022; 114:375-389. [DOI: 10.17235/reed.2022.8920/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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112
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Kircher CE, Adeoye O. Prehospital and Emergency Department Care of the Patient With Acute Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00052-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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113
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Venous Thromboembolism. Fam Med 2022. [DOI: 10.1007/978-3-030-54441-6_88] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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114
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Oyakawa T, Fukumitsu M, Ebihara A, Shiga T. Relevance of Non-Bridging Therapy with Heparin during Temporary Interruption of Direct Oral Anticoagulants in Patients with Cancer-Associated Venous Thromboembolism. Ann Vasc Dis 2022; 15:121-125. [PMID: 35860816 PMCID: PMC9257392 DOI: 10.3400/avd.oa.22-00005] [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] [Received: 01/11/2022] [Accepted: 04/21/2022] [Indexed: 12/01/2022] Open
Abstract
Objectives: To evaluate the relevance of non-bridging therapy with unfractionated heparin during the temporary, pre-procedural interruption of direct oral anticoagulants (DOACs) in patients with cancer-associated venous thromboembolism (VTE). Materials and Methods: This retrospective study included 142 patients with cancer and VTE who required temporary interruption of DOACs before invasive procedures. Data, including rates of VTE recurrence, non-major bleeding, and major bleeding, were compared between patients who received or not received alternative therapy with unfractionated heparin during interruption. Results: Sixty-eight patients were prescribed heparin, while 74 were not. There were no differences in age, body mass index, white blood cell count, hemoglobin level, or platelet count between the groups. VTE recurrence was observed in four (6%) and one (1%) patient in the heparin bridging and non-bridging groups, respectively (risk ratio [RR]: 4.4, 95% confidence interval [CI]: 0.50–38.0, p=0.19). Non-major bleeding occurred in three (4%) and two (3%) patients in the bridging and non-bridging groups (RR: 1.6, 95%CI: 0.28–9.48, p=0.67), while major bleeding occurred in 0 (0%) and three patients (4%) (p=0.25), respectively. Conclusion: Our findings confirm the relevance of non-bridging therapy with unfractionated heparin for reducing VTE risk during DOAC interruption in patients with cancer.
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Affiliation(s)
- Takuya Oyakawa
- Department of Onco-Cardiology/Cardiovascular Medicine, The Cancer Institute Hospital of Japanese Foundation for Cancer Research
| | - Masafumi Fukumitsu
- Department of Onco-Cardiology/Cardiovascular Medicine, The Cancer Institute Hospital of Japanese Foundation for Cancer Research
| | - Aya Ebihara
- Department of Clinical Examination Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research
| | - Taro Shiga
- Department of Onco-Cardiology/Cardiovascular Medicine, The Cancer Institute Hospital of Japanese Foundation for Cancer Research
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115
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van der Heijden CDCC, Ter Heine R, Kooistra EJ, Brüggemann RJ, Walburgh Schmidt JWJ, de Grouw EPLM, Frenzel T, Pickkers P, Leentjens J. Effects of dalteparin on anti-Xa activities cannot be predicted in critically ill COVID-19 patients. Br J Clin Pharmacol 2021; 88:2982-2987. [PMID: 34965610 PMCID: PMC9305530 DOI: 10.1111/bcp.15208] [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: 05/07/2021] [Revised: 11/21/2021] [Accepted: 12/13/2021] [Indexed: 11/29/2022] Open
Abstract
Critically ill COVID‐19 patients are at high risk of thromboembolic events despite routine‐dosed low‐molecular‐weight heparin thromboprophylaxis. However, in recent randomized trials increased‐intensity thromboprophylaxis seemed futile and possibly even harmful. In this explorative pharmacokinetic (PK) study we measured anti‐Xa activities on frequent timepoints in 15 critically ill COVID‐19 patients receiving dalteparin and performed PK analysis by nonlinear mixed‐effect modelling. A linear one‐compartment model with first‐order kinetics provided a good fit. However, wide interindividual variation in dalteparin absorption (variance 78%) and clearance (variance 34%) was observed, unexplained by routine clinical covariates. Using the final PK model for Monte Carlo simulations, we predicted increased‐intensity dalteparin to result in anti‐Xa activities well over prophylactic targets (0.2‐0.4 IU/mL) in the majority of patients. Therapeutic‐intensity dalteparin results in supratherapeutic anti‐Xa levels (target 0.6‐1.0 IU/mL) in 19% of patients and subtherapeutic levels in 22%. Therefore, anti‐Xa measurements should guide high‐intensity dalteparin in critically ill COVID‐19 patients.
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Affiliation(s)
- Charlotte D C C van der Heijden
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rob Ter Heine
- Department of Pharmacy, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Emma J Kooistra
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Roger J Brüggemann
- Department of Intensive Care, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jesper W J Walburgh Schmidt
- Department of Pharmacy, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Elke P L M de Grouw
- Department of Clinical Chemistry, Radboud University Medical Center, The Netherlands
| | - Tim Frenzel
- Department of Pharmacy, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Pharmacy, Radboud university medical center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Jenneke Leentjens
- Department of Internal Medicine, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
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116
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Lin YS, Lin MS, Wu VCC, Chen YL, Chang JJ, Chu PH, Lip GYH, Chen MC. Differential Presentations of Arterial Thromboembolic Events Between Venous Thromboembolism and Atrial Fibrillation Patients. Front Cardiovasc Med 2021; 8:775564. [PMID: 34938791 PMCID: PMC8685417 DOI: 10.3389/fcvm.2021.775564] [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: 09/14/2021] [Accepted: 11/15/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Atrial fibrillation (AF) and venous thromboembolism (VTE) share several risk factors related to arterial thromboembolism. No study has reported the differential contribution to arterial thromboembolic events and mortality between these two conditions in the same population. We therefore assessed the differential arterial thromboembolic events between AF and VTE. Methods: We included AF and VTE national cohorts derived from Taiwan National Health Insurance Research Database between 2001 and 2013. The eligible population was 314,861 patients in the AF cohort and 41,102 patients in the VTE cohort. The primary outcome was arterial thromboembolic events, including ischemic stroke, extracranial arterial thromboembolism (ECATE) and myocardial infarction (MI). Secondary outcomes were all-cause mortality and cardiovascular death. Results: After a 1:1 propensity matching, 32,688 patients in either group were analyzed. The risk of arterial thromboembolic events was lower in the VTE cohort than that in the AF cohort (subdistribution hazard ratio [SHR], 0.60; 95% confidence interval [CI], 0.57–0.62). The risk of ischemic stroke (SHR, 0.44; 95% CI, 0.42–0.46) and MI (SHR, 0.80; 95% CI, 0.72–0.89) were lower in the VTE cohort, while the risk of ECATE (SHR, 1.23; 95% CI, 1.14–1.33; particularly lower extremities) was higher in the VTE cohort. All-cause mortality rate was higher in the VTE cohort (HR, 1.18; 95% CI, 1.15–1.21) while the risk of cardiovascular death was lower in the VTE cohort (HR, 0.96; 95% CI, 0.93–0.995). Conclusions: Patients with AF had higher risks of arterial thromboembolic events compared to patients with VTE, despite having risk factors in common. The VTE cohort had higher risks of all-cause mortality and ECATE, particularly lower extremity events, compared to AF patients. The differential manifestations of thromboembolism sequelae and mortality between AF and VTE patients merit further investigation.
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Affiliation(s)
- Yu-Sheng Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan.,College of Medicine, Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan City, Taiwan
| | - Ming-Shyan Lin
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Victor Chien-Chia Wu
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
| | - Yung-Lung Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Jung-Jung Chang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Pao-Hsien Chu
- Division of Cardiology, Chang Gung Memorial Hospital, Linkou Medical Center, Taoyuan City, Taiwan
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, Liverpool Heart and Chest Hospital, University of Liverpool, Liverpool, United Kingdom.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
| | - Mien-Cheng Chen
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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117
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Hofer S, Schlimp CJ, Casu S, Grouzi E. Management of Coagulopathy in Bleeding Patients. J Clin Med 2021; 11:jcm11010001. [PMID: 35011742 PMCID: PMC8745606 DOI: 10.3390/jcm11010001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/10/2021] [Accepted: 12/14/2021] [Indexed: 02/06/2023] Open
Abstract
Early recognition of coagulopathy is necessary for its prompt correction and successful management. Novel approaches, such as point-of-care testing (POC) and administration of coagulation factor concentrates (CFCs), aim to tailor the haemostatic therapy to each patient and thus reduce the risks of over- or under-transfusion. CFCs are an effective alternative to ratio-based transfusion therapies for the correction of different types of coagulopathies. In case of major bleeding or urgent surgery in patients treated with vitamin K antagonist anticoagulants, prothrombin complex concentrate (PCC) can effectively reverse the effects of the anticoagulant drug. Evidence for PCC effectiveness in the treatment of direct oral anticoagulants-associated bleeding is also increasing and PCC is recommended in guidelines as an alternative to specific reversal agents. In trauma-induced coagulopathy, fibrinogen concentrate is the preferred first-line treatment for hypofibrinogenaemia. Goal-directed coagulation management algorithms based on POC results provide guidance on how to adjust the treatment to the needs of the patient. When POC is not available, concentrate-based management can be guided by other parameters, such as blood gas analysis, thus providing an important alternative. Overall, tailored haemostatic therapies offer a more targeted approach to increase the concentration of coagulation factors in bleeding patients than traditional transfusion protocols.
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Affiliation(s)
- Stefan Hofer
- Department of Anaesthesiology, Westpfalz-Klinikum Kaiserslautern, 67655 Kaiserlautern, Germany
- Correspondence: ; Tel.: +49-631-203-1030
| | - Christoph J. Schlimp
- Department of Anaesthesiology and Intensive Care, AUVA Trauma Hospital Linz, 4010 Linz, Austria;
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Center, 1200 Vienna, Austria
| | - Sebastian Casu
- Emergency Department, Asklepios Hospital Wandsbek, 22043 Hamburg, Germany;
| | - Elisavet Grouzi
- Transfusion Service and Clinical Hemostasis, Saint Savvas Oncology Hospital, 115 22 Athens, Greece;
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118
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Burnett AE. Perioperative consultative hematology: can you clear my patient for a procedure? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:521-528. [PMID: 34889442 PMCID: PMC8791149 DOI: 10.1182/hematology.2021000287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Periprocedural management of antithrombotics is a common but challenging clinical scenario that renders patients vulnerable to potential adverse events such as bleeding and thrombosis. Over the past decade, periprocedural antithrombotic approaches have changed considerably with the advent of direct oral anticoagulants (DOACs), as well as a paradigm shift away from bridging in many warfarin patients. Successfully navigating this high-risk period relies on a number of individualized patient assessments conducted within a framework of standardized, systematic approaches. It also requires a thorough understanding of antithrombotic pharmacokinetics, multidisciplinary coordination of care, and comprehensive patient education and empowerment. In this article, we provide clinicians with a practical, stepwise approach to periprocedural management of antithrombotic agents through case-based examples of relevant clinical scenarios.
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119
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In vivo real-time monitoring of anti-factor Xa level using a microdialysis-coupled microfluidic device. TALANTA OPEN 2021. [DOI: 10.1016/j.talo.2021.100059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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120
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Wiercioch W, Nieuwlaat R, Zhang Y, Alonso-Coello P, Dahm P, Iorio A, Manja V, Mustafa RA, Neumann I, Ortel TL, Rochwerg B, Santesso N, Vesely SK, Akl EA, Schünemann HJ. New methods facilitated the process of prioritizing questions and health outcomes in guideline development. J Clin Epidemiol 2021; 143:91-104. [PMID: 34843861 DOI: 10.1016/j.jclinepi.2021.11.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 11/06/2021] [Accepted: 11/22/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Health guideline development requires sequential prioritization of the guideline topic, questions, and health outcomes. In this paper we report on new approaches for prioritizing questions and outcomes in guidelines. METHODS Ten guideline panels on venous thromboembolism rated potential guideline questions on a 9-point scale according to their overall importance and 6 criteria: common in practice, uncertainty in practice, variation in practice, new evidence available, cost consequences, not previously addressed. We randomized panelists to rate one potential question with and without the 6 criteria. Panelists rated importance of outcomes, defined with health outcome descriptors (HODs), using a 9-point scale, and health utility of outcomes on a visual analogue scale. RESULTS Of 469 potential questions identified, 72.5% were rated as important but not of high priority, and 25.4% as high priority. Each criterion was significantly associated with the overall importance rating. The overall importance rating means were 5.96 (SD 2.38) and 6.53 (SD 2.45) (P = 0.25) for those randomized to rate questions with and without the criteria, respectively. The mean importance rating for 121 outcomes was 6.01 (SD 1.25), with 35.5% rated as critical for decision-making. Panelists provided health utility ratings for 127 outcomes, with a minimum mean rating of 0.12 (SD 0.10) and maximum of 0.91 (SD 0.15). CONCLUSION Our structured process provided information to help explain perspectives of question importance, to facilitate panels' outcome prioritization, and to facilitate decision-making in guideline development.
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Affiliation(s)
- Wojtek Wiercioch
- Michael G. DeGroote Cochrane Canada & McMaster GRADE Centres, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Robby Nieuwlaat
- Michael G. DeGroote Cochrane Canada & McMaster GRADE Centres, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Yuan Zhang
- Michael G. DeGroote Cochrane Canada & McMaster GRADE Centres, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Center, Biomedical Research Institute Sant Pau (IIB Sant Pau-CIBERESP), Barcelona, Spain
| | - Philipp Dahm
- Minneapolis VAMC, Urology Section and University of Minnesota Department of Urology, Minneapolis, Minnesota
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Veena Manja
- Department of Surgery, University of California Davis, California, USA; Department of Medicine, Veterans Affairs Northern California Health Care System, Mather, California
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Division of Nephrology and Hypertension, Department of Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Ignacio Neumann
- Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Thomas L Ortel
- Departments of Medicine and Pathology, Duke University Medical Center, Durham, North Carolina
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Canada
| | - Nancy Santesso
- Michael G. DeGroote Cochrane Canada & McMaster GRADE Centres, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Sara K Vesely
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Elie A Akl
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Internal Medicine, American University of Beirut, Lebanon
| | - Holger J Schünemann
- Michael G. DeGroote Cochrane Canada & McMaster GRADE Centres, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Canada; Institut für Evidence in Medicine, Medical Center & Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Diavati S, Sagris M, Terentes-Printzios D, Vlachopoulos C. Anticoagulation Treatment in Venous Thromboembolism: Options and Optimal Duration. Curr Pharm Des 2021; 28:296-305. [PMID: 34766887 DOI: 10.2174/1381612827666211111150705] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 10/26/2021] [Indexed: 12/24/2022]
Abstract
Venous thromboembolism (VTE), clinically presenting as deep-vein thrombosis (DVT) or pulmonary embolism (PE), constitutes a major global healthcare concern with severe complications, long-term morbidity and mortality. Although several clinical, genetic and acquired risk factors for VTE have been identified, the molecular pathophysiology and mechanisms of disease progression remain poorly understood. Anticoagulation has been the cornerstone of therapy for decades, but there still are uncertainties regarding primary and secondary VTE prevention, as well as optimal therapy duration. In this review we discuss the role of factor Xa in coagulation cascade and the different choices of anticoagulation therapy based on patients' predisposing risk factors and risk of event recurrence. Further, we compare newer agents to traditional anticoagulation treatment, based on most recent studies and guidelines.
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Affiliation(s)
- Stavrianna Diavati
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, Athens. Greece
| | | | | | - Charalambos Vlachopoulos
- First Department of Cardiology, Hippokration Hospital, Medical School, National and Kapodistrian University of Athens, Athens. Greece
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Willeford A, Leiman V, Noel ZR. Impact of a
pharmacist‐to‐dose
direct oral anticoagulant protocol on medication errors at an academic medical center. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2021. [DOI: 10.1002/jac5.1503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Andrew Willeford
- Department of Pharmacy Practice and Science University of Maryland School of Pharmacy Baltimore Maryland USA
- Department of Pharmacy University of Maryland Medical Center Baltimore Maryland USA
| | - Victoria Leiman
- Department of Pharmacy University of Maryland Medical Center Baltimore Maryland USA
| | - Zachary R. Noel
- Department of Pharmacy Practice and Science University of Maryland School of Pharmacy Baltimore Maryland USA
- Department of Pharmacy University of Maryland Medical Center Baltimore Maryland USA
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123
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Hill K, Sucha E, Rhodes E, Bota S, Hundemer GL, Clark EG, Canney M, Harel Z, Wang TF, Carrier M, Wijeysundera HC, Knoll G, Sood MM. Amiodarone, verapamil, or diltiazem use with direct oral anticoagulants and the risk of hemorrhage in older adults. CJC Open 2021; 4:315-323. [PMID: 35386137 PMCID: PMC8978070 DOI: 10.1016/j.cjco.2021.11.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/03/2021] [Indexed: 12/26/2022] Open
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Prévention du risque thromboembolique veineux et surveillance de l’hémostase chez les patients hospitalisés pour COVID-19 : propositions réactualisées (avril 2021). Groupe d’intérêt en hémostase périopératoire (GIHP) et groupe d’étude sur l’hémostase et la thrombose (GFHT). ANESTHÉSIE & RÉANIMATION 2021. [PMCID: PMC8516597 DOI: 10.1016/j.anrea.2021.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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125
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Milling TJ, Refaai MA, Sengupta N. Anticoagulant Reversal in Gastrointestinal Bleeding: Review of Treatment Guidelines. Dig Dis Sci 2021; 66:3698-3714. [PMID: 33403486 PMCID: PMC9245141 DOI: 10.1007/s10620-020-06728-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 11/17/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Patients receiving anticoagulant therapies, such as vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs), commonly experience gastrointestinal (GI) bleeding as a complication and may require anticoagulant reversal prior to endoscopic treatment. Anticoagulant reversal agents include prothrombin complex concentrates (PCCs; including 3 or 4 coagulation factors), plasma, vitamin K, and target-specific DOAC reversal agents (e.g., idarucizumab and andexanet alfa). AIM To review current US, as well as international, guidelines for anticoagulant reversal agents in patients on VKAs or DOACs presenting with GI bleeding prior to endoscopy, guideline-based management of coagulation defects, timing of endoscopy, and recommendations for resumption of anticoagulant therapy following hemostasis. Supporting clinical data were also reviewed. METHODS This is a narrative review, based on PubMed and Internet searches reporting GI guidelines and supporting clinical data. RESULTS GI-specific guidelines state that use of reversal agents should be considered in patients with life-threatening GI bleeding. For VKA patients presenting with an international normalized ratio > 2.5, guidelines recommend PCCs (specifically 4F-PCC), as they may exhibit greater efficacy/safety compared with fresh frozen plasma in reversal of VKA-associated GI bleeding. For DOAC patients, most guidelines recommend targeted specific reversal agents in the setting of GI bleeding; however, PCCs (primarily 4F-PCC) are often listed as another option. Resumption of anticoagulant therapy following cessation of GI bleeding is also recommended to reduce risks of future thromboembolic complications. CONCLUSIONS The utility of anticoagulant reversal agents in GI bleeding is recognized in guidelines; however, such agents should be reserved for use in truly life-threatening scenarios.
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Affiliation(s)
- Truman J. Milling
- Departments of Neurology and Surgery and Perioperative Care, Seton Dell Medical School Stroke Institute, Austin, TX, USA
| | - Majed A. Refaai
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Neil Sengupta
- Section of Gastroenterology Hepatology and Nutrition, The University of Chicago, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL 60637, USA
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126
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Davis SD, Chauv S, Hickman AW, Collingridge DS, Kjerengtroen S, Fontaine GV. High-dose versus low-dose 4-factor prothrombin complex concentrate for factor Xa inhibitor reversal in intracranial hemorrhage. Thromb Res 2021; 208:112-116. [PMID: 34749042 DOI: 10.1016/j.thromres.2021.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/21/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND & PURPOSE 4-factor prothrombin complex concentrate (4FPCC) is used off-label for factor Xa (FXa) inhibitor-associated intracranial hemorrhage (ICH). Guideline recommendations provide various 4FPCC dosing regimens for FXa inhibitor reversal in this setting. We evaluated 4FPCC weight-based dosing and outcomes in FXa inhibitor-associated ICH. METHODS We conducted a multi-center, retrospective, cohort study of ICH patients between July 2017 and February 2020. Patients were greater than 18 years of age, received 4FPCC, and were taking apixaban, rivaroxaban, or edoxaban. Patients were separated into high- (≥35 units/kg) or low-dose (<35 units/kg) 4FPCC groups. The primary outcome was hemostasis achievement. Secondary outcomes included in-hospital mortality, intensive care unit and hospital length of stay, discharge disposition, and thrombotic events. Outcomes were evaluated with binary logistic regression. RESULTS Of 390 patients identified, 89 were included with 74 and 15 in the high- vs low-dose groups, respectively. Mean (SD) age was 76.6 (±10.8) years. Most were taking a FXa inhibitor for atrial fibrillation (76.4%) and apixaban was the most common FXa inhibitor (65.2%). Hemostasis achievement was greater in the high- vs low-dose group (89.2% vs 46.7%; OR 11.2; 95% CI 2.4-52.6, P = 0.002). Thrombotic events were 8.2% and 6.7% in the high vs low-dose groups, respectively (OR 0.8; 95% CI 0.08-8.2, P = 0.87). No statistically significant differences were found in secondary outcomes. CONCLUSION In patients with FXa inhibitor-associated ICH, high-dose 4FPCC was associated with increased odds of hemostasis achievement. There was no difference in thrombotic events.
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Affiliation(s)
- Spencer D Davis
- Department of Pharmacy, Intermountain Medical Center, Murray, UT 84107, United States of America.
| | - Stephanie Chauv
- Department of Pharmacy, Intermountain Medical Center, Murray, UT 84107, United States of America
| | - Abby W Hickman
- Department of Pharmacy, Intermountain Medical Center, Murray, UT 84107, United States of America
| | - Dave S Collingridge
- Office of Research, Intermountain Healthcare, Murray, UT 84107, United States of America
| | - Sara Kjerengtroen
- Department of Pharmacy, Intermountain Medical Center, Murray, UT 84107, United States of America; Nebraska Medicine, Omaha, NE 68105, United States of America
| | - Gabriel V Fontaine
- Department of Pharmacy, Intermountain Medical Center, Murray, UT 84107, United States of America
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Alsubaie NS, Al Rammah SM, Alshouimi RA, Alzahrani MY, Al Yami MS, Almutairi AR, Alfayez OM, Korayem GB, Almohammed OA. The use of direct oral anticoagulants for thromboprophylaxis or treatment of cancer-associated venous thromboembolism: a meta-analysis and review of the guidelines. Thromb J 2021; 19:76. [PMID: 34717653 PMCID: PMC8556878 DOI: 10.1186/s12959-021-00326-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 10/03/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common complication among patients with cancer and is one of the most common causes of increased morbidity and mortality. The use of direct oral anticoagulants (DOACs) for thromboprophylaxis and treatment of cancer-associated venous thromboembolism (CA-VTE) has been evaluated in several randomized clinical trials (RCTs). The aim of this meta-analysis was to assess efficacy and safety of using DOACs for thromboprophylaxis and treatment of CA-VTE and provide a summary for available guidelines' recommendations. METHODS MEDLINE was searched to identify studies evaluating the use of DOACs for thromboprophylaxis or treatment in patients with cancer. Search was limited to peer-reviewed studies published in English. Studies were excluded if they were not RCTs or subgroup analyses of data derived from RCTs, if they did not report efficacy and safety data on patients with active cancer, or if they were published as an abstract. New VTE or VTE recurrence, and major or clinically relevant non-major bleeding (CRNMB) were used to assess the efficacy and safety, respectively. The Mantel-Haenszel random-effects model risk ratios (RRs) and the corresponding 95% confidence intervals (CIs) were calculated to estimate the pooled treatment effects of DOACs. RESULTS Four studies evaluating DOACs use for thromboprophylaxis and four - for treatment of CA-VTE were included. Thromboprophylaxis with DOACs was associated with a significant reduction in the risk of symptomatic VTE (RR = 0.58; 95%CI 0.37,0.91) but with an incremental risk of major bleeding or CRNMB (RR = 1.57; 95%CI 1.10,2.26). CA-VTE treatment with DOACs was linked with a significant reduction in VTE recurrence (RR = 0.62; 95%CI 0.44,0.87) but with an incremental risk of CRNMB (RR = 1.58; 95%CI 1.11,2.24). CONCLUSIONS The DOACs are associated with a lower risk of symptomatic VTE and VTE recurrence, but the risk of bleeding remains a considerable concern. Clinical decisions should be made by assessing individual patient's risk of VTE and bleeding.
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Affiliation(s)
- Norah S Alsubaie
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Shahad M Al Rammah
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Reema A Alshouimi
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Mohammed Y Alzahrani
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Majed S Al Yami
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | | | - Osamah M Alfayez
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Qassim, Buraydah, Saudi Arabia
| | - Ghazwa B Korayem
- Department of Pharmacy Practice, College of Pharmacy, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Omar A Almohammed
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, P.O. Box 2457, Riyadh, 11451, Saudi Arabia.
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128
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Jones AE, Saunders J, Vazquez SR, Fagerlin A, Witt DM. A survey of current anticoagulation patient education practices and development. Thromb Res 2021; 208:11-13. [PMID: 34673367 DOI: 10.1016/j.thromres.2021.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 10/01/2021] [Accepted: 10/05/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Aubrey E Jones
- University of Utah School of Medicine, Department of Population Health, SLC, UT, United States of America.
| | - John Saunders
- University of Utah College of Pharmacy, Department of Pharmacotherapy, SLC, UT, United States of America
| | - Sara R Vazquez
- Thrombosis Service, University of Utah Health, United States of America
| | - Angela Fagerlin
- University of Utah School of Medicine, Department of Population Health, SLC, UT, United States of America
| | - Daniel M Witt
- University of Utah College of Pharmacy, Department of Pharmacotherapy, SLC, UT, United States of America
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129
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Gong X, He Q, Yan J, Chen J, Chen X, Huang M, Li J, Chen P. A drug utilization study of oral anticoagulants in five representative cities of China between 2015 and 2019. J Clin Pharm Ther 2021; 47:38-45. [PMID: 34592785 DOI: 10.1111/jcpt.13538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 09/09/2021] [Accepted: 09/22/2021] [Indexed: 11/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Oral anticoagulants (OACs), including warfarin and newer direct-acting OACs (DOACs), have been used for decades to prevent thromboembolic diseases. A drug utilization study was performed to determine the prescribing patterns of OACs. METHODS Data were extracted from the Cooperation Project of Hospital Prescription Analysis in China. A total of 455,490 prescription records from 43 tertiary hospitals in five cities of China (Beijing, Shanghai, Guangzhou, Hangzhou and Chengdu) were selected for inclusion. Quarterly trends of defined daily doses (DDDs) and defined daily dose cost (DDDC) from 1 January 2015 to 31 December 2019 were calculated. RESULTS AND DISCUSSION Warfarin was the most widely used OAC with DDDs between 189,982 and 176,323 from the first quarter (Q1) of 2015 to the fourth quarter (Q4) of 2019, whereas the use of DOACs increased rapidly during this period. DDDs of rivaroxaban increased from 5409 in Q1 of 2015 to 125,800 in Q4 of 2019, whereas the DDDC declined from 160.5 to 45.7. From Q1 of 2018, rivaroxaban became the most prescribed OAC, surpassing warfarin, in patients diagnosed with deep vein thrombosis. In addition, the DDDs of rivaroxaban exceeded those of warfarin in patients diagnosed with non-valvular atrial fibrillation since the second quarter (Q2) of 2019. DDDs in outpatients and inpatients increased by 80.6% and 71.4%, respectively, and the DDDC for outpatients in Q4 of 2019 was 6.7-fold higher than that in Q1 of 2015. Among patients of all ages, the DDDs in elderly patients increased from 36.8% in Q1 of 2015 to 59.4% in Q4 of 2019. Moreover, the departments of cardiology and cardiothoracic surgery prescribed the majority of the OACs. WHAT IS NEW AND CONCLUSION In this study, we describe OAC prescription patterns in China. DOACs, especially rivaroxaban, contribute to the continuous increase in the use of OACs. In the investigated population of China, outpatients and elderly patients were observed to be administered the highest proportion of DOACs.
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Affiliation(s)
- Xiaojiao Gong
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.,Institute of clinical pharmacology, School of Pharmaceutical sciences, Sun Yat-sen University, Guangzhou, China
| | - Qiuyi He
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiajia Yan
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jie Chen
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiao Chen
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Min Huang
- Institute of clinical pharmacology, School of Pharmaceutical sciences, Sun Yat-sen University, Guangzhou, China
| | - Jingjie Li
- Reproductive Medicine Center, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Pan Chen
- Department of Pharmacy, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Lecumberri R, Jiménez L, Ruiz-Artacho P, Nieto JA, Ruiz-Giménez N, Visonà A, Skride A, Moustafa F, Trujillo J, Monreal M. Prediction of Major Bleeding in Anticoagulated Patients for Venous Thromboembolism: Comparison of the RIETE and the VTE-BLEED Scores. TH OPEN 2021; 5:e319-e328. [PMID: 34568742 PMCID: PMC8459175 DOI: 10.1055/s-0041-1729171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 03/16/2021] [Indexed: 12/15/2022] Open
Abstract
The performance of validated bleeding risk scores in patients with venous thromboembolism (VTE) could be different depending on the time after index event or the site of bleeding. In this study we compared the "classic" Registro Informatizado de Enfermedad TromboEmbólica (RIETE) score and the more recently developed VTE-BLEED score for the prediction of major bleeding in patients under anticoagulant therapy in different time intervals after VTE diagnosis. Out of 82,239 patients with acute VTE, the proportion of high-risk patients according to the RIETE and VTE-BLEED scores was 7.1 and 62.3%, respectively. The performance of both scores across the different study periods (first 30 days after VTE diagnosis, days 31-90, days 91-180, and days 181-360) was similar, with areas under the receiving operating characteristics (ROC) curve (AUC) ranging between 0.69 and 0.72. However, the positive predictive values were low, ranging between 0.6 and 3.9 (better for early major bleeding than for later periods). A sensitivity analysis limited to patients with unprovoked VTE showed comparable results. Both scores showed a trend toward a better prediction of extracranial than intracranial major bleeding, the RIETE score resulting more useful for early extracranial bleeding and the VTE-BLEED for late intracranial hemorrhages. Our study reveals that the usefulness of available bleeding scores may vary depending on the characteristics of the patient population and the time frame evaluated. Dynamic scores could be more useful for this purpose.
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Affiliation(s)
- Ramón Lecumberri
- Hematology Service, Clínica Universidad de Navarra, IdISNA, Pamplona; CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Laura Jiménez
- Deparment of Internal Medicine, Hospital Virgen de la Luz, Cuenca, Spain
| | - Pedro Ruiz-Artacho
- Deparment of Internal Medicine, Interdisciplinar Teragnosis and Radiosomics Research Group (INTRA-Madrid), Instituto de Salud Carlos III, University of Navarra, Clínica Universidad de Navarra, CIBERES, Madrid, Spain
| | - José Antonio Nieto
- Deparment of Internal Medicine, Hospital Virgen de la Luz, Cuenca, Spain
| | - Nuria Ruiz-Giménez
- Department of Internal Medicine, Hospital Universitario de La Princesa, Madrid, Spain
| | - Adriana Visonà
- Department of Vascular Medicine, Ospedale Castelfranco Veneto, Castelfranco Veneto, Italy
| | - Andris Skride
- Department of Cardiology, Ospedale Pauls Stradins Clinical University Hospital, Riga Stradiņš University, Riga, Latvia
| | - Fares Moustafa
- Department of Emergency, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Javier Trujillo
- Department of Internal Medicine, Hospital General Universitario Santa Lucía, Universidad Católica de Murcia, Murcia, Spain
| | - Manuel Monreal
- Department of Internal Medicine, Instituto de Salud Carlos III, Universidad Católica de Murcia, Hospital Germans Trias i Pujol, CIBERES, Badalona (Barcelona), Madrid, Spain
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Lotfi T, Hajizadeh A, Moja L, Akl EA, Piggott T, Kredo T, Langendam MW, Iorio A, Klugar M, Klugarová J, Neumann I, Wiercioch W, Leontiadis GI, Mbuagbaw L, Turgeon AF, Meerpohl J, Stevens A, Brozek J, Santesso N, Pottie K, Dewidar O, Flottorp SA, Karpusheff J, Saz-Parkinson Z, Rojas MX, Parmelli E, Chu DK, Tugwell P, Welch V, Avey MT, Brignardello-Petersen R, Mathew JL, Munn Z, Nieuwlaat R, Ford N, Qaseem A, Askie LM, Schünemann HJ. A taxonomy and framework for identifying and developing actionable statements in guidelines suggests avoiding informal recommendations. J Clin Epidemiol 2021; 141:161-171. [PMID: 34562579 DOI: 10.1016/j.jclinepi.2021.09.028] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/06/2021] [Accepted: 09/17/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To propose a taxonomy and framework that identifies and presents actionable statements in guidelines. STUDY DESIGN AND SETTING We took an iterative approach reviewing case studies of guidelines produced by the World Health Organization and the American Society of Hematology to develop an initial conceptual framework. We then tested it using randomly selected recommendations from published guidelines addressing COVID-19 from different organizations, evaluated its results, and refined it before retesting. The urgency and availability of evidence for development of these recommendations varied. We consulted with experts in research methodology and guideline developers to improve the final framework. RESULTS The resulting taxonomy and framework distinguishes five types of actional statements: formal recommendations; research recommendations; good practice statements; implementation considerations, tools and tips; and informal recommendations. These statements should respond to a priori established criteria and require a clear structure and recognizable presentation in a guideline. Most importantly, this framework identifies informal recommendations that differ from formal recommendations by how they consider evidence and in their development process. CONCLUSION The identification, standardization and explicit labelling of actionable statements according to the framework may support guideline developers to create actionable statements with clear intent, avoid informal recommendations and improve their understanding and implementation by users.
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Affiliation(s)
- Tamara Lotfi
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton ,ON, Canada; Michael G. DeGroote Cochrane Canada and GRADE Centre, McMaster University, Hamilton , ON, Canada
| | - Anisa Hajizadeh
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton ,ON, Canada
| | - Lorenzo Moja
- Department of Health Product Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Elie A Akl
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton ,ON, Canada; Michael G. DeGroote Cochrane Canada and GRADE Centre, McMaster University, Hamilton , ON, Canada; Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Thomas Piggott
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton ,ON, Canada
| | - Tamara Kredo
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa; Clinical Pharmacology, Department of Medicine, Stellenbosch University, Cape Town, South Africa
| | - Miranda W Langendam
- Amsterdam University Medical Centers, location Academic Medical Center, University of Amsterdam, Amsterdam Public Health research institute, Amsterdam, The Netherlands
| | - Alfonso Iorio
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton ,ON, Canada; Department of Medicine, McMaster University, Hamilton ,ON, Canada
| | - Miloslav Klugar
- The Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech CEBHC: JBI Centre of Excellence, Masaryk University GRADE Centre); Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic
| | - Jitka Klugarová
- The Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech CEBHC: JBI Centre of Excellence, Masaryk University GRADE Centre); Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic
| | - Ignacio Neumann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton ,ON, Canada; Department of Internal Medicine, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton ,ON, Canada; Michael G. DeGroote Cochrane Canada and GRADE Centre, McMaster University, Hamilton , ON, Canada
| | | | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton ,ON, Canada; Biostatistics Unit/The Research Institute, St Joseph's Healthcare, Hamilton ,ON, Canada
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, Québec City ,QC, Canada; Population Health and Optimal Health Practices Research Unit, CHU de Québec - Université Laval Research Center, Québec City ,QC, Canada
| | - Joerg Meerpohl
- Institute for Evidence in Medicine, Medical Center & Faculty of Medicine, University of Freiburg, Freiburg, Germany; Cochrane Germany, Cochrane Germany Foundation, Freiburg, Germany
| | - Adrienne Stevens
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton ,ON, Canada; Michael G. DeGroote Cochrane Canada and GRADE Centre, McMaster University, Hamilton , ON, Canada
| | - Jan Brozek
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton ,ON, Canada; Michael G. DeGroote Cochrane Canada and GRADE Centre, McMaster University, Hamilton , ON, Canada
| | - Nancy Santesso
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton ,ON, Canada; Michael G. DeGroote Cochrane Canada and GRADE Centre, McMaster University, Hamilton , ON, Canada
| | - Kevin Pottie
- School of Epidemiology and Public Health, University of Ottawa, Canada; Departments of Family Medicine and Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute, Ottawa, Canada; Departments of Family Medicine and Epidemiology and Community Medicine, University of Ottawa
| | - Omar Dewidar
- School of Epidemiology and Public Health, University of Ottawa, Canada; Departments of Family Medicine and Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute, Ottawa, Canada; Departments of Family Medicine and Epidemiology and Community Medicine, University of Ottawa
| | - Signe A Flottorp
- Norwegian Institute of Public Health, Oslo, Norway; University of Oslo, Oslo, Norway
| | | | - Zuleika Saz-Parkinson
- Instituto de Salud Carlos III, Agencia de Evaluación de Tecnologías Sanitarias. Madrid, Spain
| | - María X Rojas
- Department of Clinical Epidemiology and Public Health, Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau)
| | - Elena Parmelli
- European Commission, Joint Research Centre (JRC), Ispra, Italy
| | - Derek K Chu
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton ,ON, Canada; Department of Medicine, McMaster University, Hamilton ,ON, Canada
| | - Peter Tugwell
- School of Epidemiology and Public Health, University of Ottawa, Canada; Departments of Family Medicine and Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute, Ottawa, Canada; Departments of Family Medicine and Epidemiology and Community Medicine, University of Ottawa
| | - Vivian Welch
- School of Epidemiology and Public Health, University of Ottawa, Canada; Departments of Family Medicine and Epidemiology and Community Medicine, University of Ottawa; Bruyère Research Institute, Ottawa, Canada; Departments of Family Medicine and Epidemiology and Community Medicine, University of Ottawa
| | | | | | - Joseph L Mathew
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Zachary Munn
- Joanna Briggs Institute Faculty of Health and Medical Sciences The University of Adelaide, Australia
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton ,ON, Canada
| | - Nathan Ford
- Department of HIV, Hepatitis and Sexually Transmitted Infections, World Health Organization, Geneva, Switzerland
| | - Amir Qaseem
- American College of Physicians, Philadelphia, PA, USA
| | - Lisa M Askie
- Quality Assurance of Norms and Standards Department, Science Division, World Health Organization, Geneva, Switzerland
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton ,ON, Canada; Michael G. DeGroote Cochrane Canada and GRADE Centre, McMaster University, Hamilton , ON, Canada; Department of Medicine, McMaster University, Hamilton ,ON, Canada; Dipartimento di Scienze Biomediche Humanitas University, Milan, Italy.
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Stevens VM, Trujillo TC, Kiser TH, MacLaren R, Reynolds PM, Mueller SW. Retrospective Comparison of Andexanet Alfa and 4-Factor Prothrombin Complex for Reversal of Factor Xa-Inhibitor Related Bleeding. Clin Appl Thromb Hemost 2021; 27:10760296211039020. [PMID: 34541920 PMCID: PMC8642040 DOI: 10.1177/10760296211039020] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
The aim of this retrospective study was to compare andexanet alfa and 4-factor
prothrombin complex (4F-PCC) for reversal of factor Xa (FXa)-inhibitor bleeding.
Patients that received andexanet alfa for reversal were included. An equivalent
number of patients administered 4F-PCC for FXa-inhibitor bleeding were randomly
selected as historical controls. The primary outcome was effective hemostasis
achievement within 12 h, defined using ANNEXA-4 criteria. Thromboembolic events
and mortality within 30 days were also evaluated. A total of 32 patients were
included. Baseline characteristics were not statistically different between
andexanet alfa (n = 16) and 4F-PCC (n = 16). Intracranial bleeding was the
primary reversal indication in 43.8% versus 62.5% of patients, respectively.
Effective hemostasis was reached in 75.0% of andexanet alfa patients compared to
62.5% of 4F-PCC patients (P = .70). Thromboembolic events
occurred in 4 (25.0%) patients and 3 (18.8%) patients, respectively
(P = .99). Mortality incidence was 12.5% and 31.3%,
respectively (P = .39). Andexanet alfa and 4F-PCC attained
hemostasis in a majority of patients. A high, but a similar rate of
thromboembolic events was seen with both treatments. Prospective studies are
needed to elucidate comparative risks and benefits of the 2 agents.
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Affiliation(s)
- Victoria M Stevens
- 15503University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 22095Aurora, CO, USA
| | - Toby C Trujillo
- 15503University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 22095Aurora, CO, USA
| | - Tyree H Kiser
- 15503University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 22095Aurora, CO, USA
| | - Robert MacLaren
- 15503University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 22095Aurora, CO, USA
| | - Paul M Reynolds
- 15503University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 22095Aurora, CO, USA
| | - Scott W Mueller
- 15503University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, 22095Aurora, CO, USA
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Abdoellakhan RA, Khorsand N, Ter Avest E, Lameijer H, Faber LM, Ypma PF, Nieuwenhuizen L, Veeger NJGM, Meijer K. Fixed Versus Variable Dosing of Prothrombin Complex Concentrate for Bleeding Complications of Vitamin K Antagonists-The PROPER3 Randomized Clinical Trial. Ann Emerg Med 2021; 79:20-30. [PMID: 34535300 DOI: 10.1016/j.annemergmed.2021.06.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 06/07/2021] [Accepted: 06/17/2021] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE To determine if a fixed dose of 1000 IU of 4-factor prothrombin complex concentrate (4F-PCC) is as effective as traditional variable dosing based on body weight and international normalized ratio (INR) for reversal of vitamin K antagonist (VKA) anticoagulation. METHODS In this open-label, multicenter, randomized clinical trial, patients with nonintracranial bleeds requiring VKA reversal with 4F-PCC were allocated to either a 1,000-IU fixed dose of 4F-PCC or the variable dose. The primary outcome was the proportion of patients with effective hemostasis according to the International Society of Thrombosis and Haemostasis definition. The design was noninferiority with a lower 95% confidence interval of no more than -6%. When estimating sample size, we assumed that fixed dosing would be 4% superior. RESULTS From October 2015 until January 2020, 199 of 310 intended patients were included before study termination due to decreasing enrollment rates. Of the 199 patients, 159 were allowed in the per-protocol analysis. Effective hemostasis was achieved in 87.3% (n=69 of 79) in fixed compared to 89.9% (n=71 of 79) in the variable dosing cohort (risk difference 2.5%, 95% confidence interval -13.3 to 7.9%, P=.27). Median door-to-needle times were 109 minutes (range 16 to 796) in fixed and 142 (17 to 1076) for the variable dose (P=.027). INR less than 2.0 at 60 minutes after 4F-PCC infusion was reached in 91.2% versus 91.7% (P=1.0). CONCLUSION The large majority of patients had good clinical outcome after 4F-PCC use; however, noninferiority of the fixed dose could not be demonstrated because the design assumed the fixed dose would be 4% superior. Door-to-needle time was shortened with the fixed dose, and INR reduction was similar in both dosing regimens.
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Affiliation(s)
- Rahat A Abdoellakhan
- Department of Haematology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | | | - Ewoud Ter Avest
- Department of Emergency Medicine, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Heleen Lameijer
- Department of Emergency Medicine, Medical Center Leeuwarden, Leeuwarden, the Netherlands
| | - Laura M Faber
- Department of Haematology, Rode Kruis Ziekenhuis, Beverwijk, the Netherlands
| | - Paula F Ypma
- Department of Haematology, Hagaziekenhuis, The Hague, the Netherlands
| | | | - Nic J G M Veeger
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Karina Meijer
- Department of Haematology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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How to write a guideline: a proposal for a manuscript template that supports the creation of trustworthy guidelines. Blood Adv 2021; 5:4721-4726. [PMID: 34521104 PMCID: PMC8759117 DOI: 10.1182/bloodadvances.2020003577] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/20/2021] [Indexed: 11/20/2022] Open
Abstract
Trustworthy health guidelines should provide recommendations, document the development process, and highlight implementation information. Our objective was to develop a guideline manuscript template to help authors write a complete and useful report. The McMaster Grading of Recommendations Assessment, Development and Evaluation (GRADE) centre collaborated with the American Society of Hematology (ASH) to develop guidelines for the management of venous thromboembolism. A template for reporting the guidelines was developed based on prior approaches and refined using input from other key stakeholders. The proposed guideline manuscript template includes: 1) title for guideline identification; 2) abstract, including a summary of key recommendations; 3) overview of all recommendations [executive summary]; 4) the main text, providing sufficient detail on the entire process including objectives, background, and methodological decisions from panel selection and conflict of interest management to criteria for updating, as well as supporting information such as links to online (interactive) tables. The template further allows for tailoring to the specific topic, using examples. Initial experience with the ASH guideline manuscript template was positive, and challenges included drafting descriptions of recommendations involving multiple management pathways, tailoring the template for a specific guideline, and choosing key recommendations to highlight. Feedback from a larger group of guideline authors and users will be needed to evaluate its usefulness and refine. The proposed guideline manuscript template is the first detailed template for transparent and complete reporting of guidelines. Consistent application of the template may simplify preparing an evidence-based guideline manuscript and facilitate its use.
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Little DHW, Sutradhar R, Cerasuolo JO, Perez R, Douketis J, Holbrook A, Paterson JM, Gomes T, Siegal DM. Rates of rebleeding, thrombosis and mortality associated with resumption of anticoagulant therapy after anticoagulant-related bleeding. CMAJ 2021; 193:E304-E309. [PMID: 33649169 PMCID: PMC8034308 DOI: 10.1503/cmaj.201433] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND: Data on resuming oral anticoagulants (OACs) after bleeding are primarily from studies involving patients given warfarin, with few data on direct OACs (DOACs). We aimed to characterize prescribing patterns for OACs after OAC-related bleeding and compare the rates of bleeding, thrombosis and mortality in patients who resumed either type of OAC with those who did not. METHODS: We conducted a population-based cohort study of adults aged 66 years or older who were admitted to hospital for bleeding while receiving OACs from Apr. 1, 2012, to Mar. 31, 2017, using linked administrative health databases from Ontario. We used competing risk methods to calculate cause-specific adjusted hazard ratios (HRs) for thrombosis, bleeding and mortality with resumption of OACs adjusted as a time-varying covariate. We determined time to OAC resumption using the Kaplan–Meier method. RESULTS: We included 6793 patients with gastrointestinal (n = 4297, 63.3%), intracranial (n = 805, 11.9%) or other bleeding (n = 1691, 25.0%). At cohort entry, 3874 patients (57.0%) were prescribed warfarin and 2919 patients (43.0%) were prescribed a DOAC. The most common indication for OAC was atrial fibrillation (n = 5557, 81.8%), followed by venous thromboembolism (n = 1367, 20.1%). Oral anticoagulants were resumed in 4792 patients (70.5%) within 365 days of the index bleed. The median time to resumption was 46 (interquartile range 6–550) days. We found that resuming OAC was associated with reduced rates of thrombosis (adjusted HR 0.60, 95% confidence interval [CI] 0.50–0.72) and mortality (adjusted HR 0.54, 95% CI 0.48–0.60), and an increased rate of rebleeding (adjusted HR 1.88, 95% CI 1.64–2.17). INTERPRETATION: We found that resuming OAC is associated with a reduction in thrombosis and mortality but an increase in bleeding. Randomized controlled trials that evaluate the net benefit of strategies for resumption of OAC after a bleeding event are warranted.
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Affiliation(s)
- Derek H W Little
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Rinku Sutradhar
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Joshua O Cerasuolo
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Richard Perez
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - James Douketis
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Anne Holbrook
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - J Michael Paterson
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Tara Gomes
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont
| | - Deborah M Siegal
- Department of Medicine (Little, Douketis, Holbrook) and ICES McMaster (Cerasuolo, Perez), Faculty of Health Sciences, McMaster University, Hamilton, Ont.; ICES Central (Sutradhar, Paterson), Toronto, Ont.; Department of Medicine (Little); Division of Biostatistics (Sutradhar), Dalla Lana School of Public Health; Institute of Health Policy, Management and Evaluation (Paterson); Leslie Dan Faculty of Pharmacy (Gomes), University of Toronto; Unity Health Toronto (Gomes), Toronto, Ont.; Department of Medicine (Siegal), University of Ottawa, Ottawa, Ont.
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Giver J, Dunn AL, Sankar A, Stanek J, Monda K, Canini J, Kerlin BA, Rodriguez V. Drive-through Anticoagulation Clinic During The COVID-19 Pandemic. J Nurse Pract 2021; 18:92-96. [PMID: 34512214 PMCID: PMC8423809 DOI: 10.1016/j.nurpra.2021.08.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
An innovative approach to anticoagulation management during the COVID-19 pandemic was used at our center that allowed patients to stay in their vehicle while our anticoagulation advanced practice registered nurse obtained blood for point-of-care international normalized ratio (INR) testing while education and counseling were completed. A significant improvement in the median percentage of INR within the therapeutic range was observed among the patients who used the drive-through clinic. A small group of patients improved compliance to anticoagulation monitoring. Clinical care models, such as this clinic approach may improve patient compliance and adherence to anticoagulation beyond the pandemic needs.
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Affiliation(s)
- Jean Giver
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus OH
| | - Amy L Dunn
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus OH.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Amanda Sankar
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus OH.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Joseph Stanek
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus OH
| | - Kay Monda
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus OH
| | - Joan Canini
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus OH
| | - Bryce A Kerlin
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus OH.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
| | - Vilmarie Rodriguez
- Division of Hematology/Oncology/BMT, Nationwide Children's Hospital, Columbus OH.,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH
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Smythe MA, Koerber JM, Hoffman JL, Mertz S, Fritsch K, Chehab F, Baalbaki N, Krishnan A. Outcomes of activated prothrombin complex concentrate for direct Xa inhibitor bleeding. Thromb Res 2021; 206:142-144. [PMID: 34481221 DOI: 10.1016/j.thromres.2021.08.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/26/2021] [Accepted: 08/12/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Maureen A Smythe
- Department of Pharmacy Services, Beaumont Hospital, 3601 West 13 Mile Road, MI 48073, USA; Department of Pharmacy Practice, Suite 2190, Wayne State University, 259 Mack Avenue, Detroit, MI 48202, USA.
| | - John M Koerber
- Department of Pharmacy Services, Beaumont Hospital, 3601 West 13 Mile Road, MI 48073, USA; Department of Pharmacy Practice, Suite 2190, Wayne State University, 259 Mack Avenue, Detroit, MI 48202, USA.
| | - Janet L Hoffman
- Department of Pharmacy Services, Beaumont Hospital, 3601 West 13 Mile Road, MI 48073, USA; Department of Pharmacy Practice, Suite 2190, Wayne State University, 259 Mack Avenue, Detroit, MI 48202, USA.
| | - Sean Mertz
- Department of Pharmacy Services, Beaumont Hospital, 3601 West 13 Mile Road, MI 48073, USA.
| | - Karissa Fritsch
- Department of Pharmacy Services, Beaumont Hospital, 3601 West 13 Mile Road, MI 48073, USA.
| | - Fatme Chehab
- Department of Pharmacy Services, Beaumont Hospital, 3601 West 13 Mile Road, MI 48073, USA; Department of Pharmacy Practice, Suite 2190, Wayne State University, 259 Mack Avenue, Detroit, MI 48202, USA.
| | - Nour Baalbaki
- Department of Pharmacy Services, Beaumont Hospital, 3601 West 13 Mile Road, MI 48073, USA; Department of Pharmacy Practice, Suite 2190, Wayne State University, 259 Mack Avenue, Detroit, MI 48202, USA.
| | - Anant Krishnan
- Department of Diagnostic Radiology, Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48073, USA.
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Abstract
Venous thromboembolism (VTE) is increasingly recognised in primary and secondary care practice. The arrival of direct oral anticoagulants (DOACs) has made the management of VTE easier and more convenient. Some patients established on DOACs may need screening for underlying thrombophilias as certain thrombophilic conditions are known to confer a higher thrombosis risk, although the guidelines for when and how to test for a thrombophilia, especially in a patient taking a DOAC, are unclear. This literature review aims to examine when thrombophilia screening should take place in a patient already taking a DOAC, the effect of DOACs on thrombophilia tests, and analyse whether DOACs are safe and effective in both inherited and acquired thrombophilias.
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Affiliation(s)
- Jennifer Darlow
- Manchester Royal Infirmary, Manchester, UK; equal first authors.
| | - Holly Mould
- University of Manchester, Manchester, UK; equal first authors
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139
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Wiethorn EE, Harrison S, Weeda ER, Bell CM. Effectiveness and Safety of Twice- Versus Thrice-Daily Subcutaneous Heparin for Venous Thromboembolism Prophylaxis at a Large Academic Medical Center. Ann Pharmacother 2021; 56:541-547. [PMID: 34459268 DOI: 10.1177/10600280211041380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Dosing variation of subcutaneous unfractionated heparin (UFH) exist for venous thromboembolism prophylaxis (VTEP). OBJECTIVE The purpose of this study was to compare the safety and effectiveness of thrice-daily (TID) versus twice-daily (BID) administration of UFH during a heparin shortage for VTEP. METHODS A single-center retrospective analysis was conducted in patients with orders for BID subcutaneous UFH during a heparin shortage from September 1, 2019, to February 4, 2020. These patients were matched to patients with TID subcutaneous UFH orders from January 1, 2019, to May 31, 2019. The primary outcome was the incidence of deep-vein thrombosis or pulmonary embolism confirmed by imaging during hospitalization. The secondary outcome was the incidence of major or clinically relevant nonmajor bleeding events as defined by International Society on Thrombosis and Haemostasis (ISTH) definitions. RESULTS A total of 277 patients with orders for BID UFH and meeting inclusion criteria were evaluated and matched to patients who received TID UFH. After the exclusion criteria were implemented, 510 patients remained in the TID group. The primary outcome occurred in 4% of patients in the BID group and 3% in the TID group (P = 0.645). Major bleeding or clinically relevant nonmajor bleeding events occurred in 10% of patients in the BID group and 8% in the TID group (P = 0.310). CONCLUSION AND RELEVANCE There was no difference in effectiveness or safety of TID versus BID subcutaneous UFH for VTEP. During a heparin shortage, transitioning patients to BID UFH for VTEP to conserve supply may be considered.
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Affiliation(s)
| | - Sarah Harrison
- Medical University of South Carolina, Charleston, SC, USA
| | - Erin R Weeda
- Medical University of South Carolina, Charleston, SC, USA
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140
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Brazeale HS, Fuentes A, Adeola M. Analysis of Direct Oral Anticoagulant Therapy With Concomitant Use of Interacting Antiretroviral Agents. J Pharm Pract 2021; 36:286-294. [PMID: 34392711 DOI: 10.1177/08971900211034258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: A theoretical interaction exists between human immunodeficiency virus (HIV) antiretroviral (ARV) agents and direct oral anticoagulants (DOACs), although the clinical significance is unclear. Objective: This study aimed to assess characteristics, prescribing patterns, and outcomes associated with concomitant therapy. Methods: A single-center, retrospective review was performed on patients older than 18 years prescribed a DOAC for any indication with concurrent interacting ARV(s) from June 2016 through June 2019. The primary endpoint was to assess prescribing and population characteristics. Secondary endpoints were to evaluate safety outcomes, DOAC level monitoring, readmissions, outpatient follow-up, and DOAC modification interventions. Results: Thirty-six patients (72 hospital admissions) were identified. The most common DOAC was apixaban (83.3%) and ARV was ritonavir (50%). Of the 72 encounters, 26 (36.1%) DOACs were dosed appropriately per guideline recommendations. Twenty pharmacy interventions for therapy modification were recognized. Eleven (30.6%) patients experienced bleeding and 2 (5.6%) thrombosis. Of the adverse events, all patients had renal impairment. Conclusions: As DOAC utilization grows, increasing use in HIV could be expected. More frequent adjustment or avoidance is recommended per guidelines. Our data suggest the majority of patients receive CYP3A4-inhibiting regimens. Caution should be employed with renal insufficiencies. Further studies are warranted to assess safety and efficacy within this population.
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Affiliation(s)
- Hayley S Brazeale
- Internal Medicine Clinical Pharmacy Specialist, Department of Pharmacy, 23534Houston Methodist Hospital, Houston, TX, USA
| | - Amaris Fuentes
- System Medication Safety Specialist, System Quality and Patient Safety, 23534Houston Methodist Hospital, Houston, TX, USA
| | - Mobolaji Adeola
- Medication Safety Specialist, Department of Pharmacy, 23534Houston Methodist Hospital, Houston, TX, USA
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141
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Methodology for adaptation of the ASH Guidelines for Management of Venous Thromboembolism for the Latin American context. Blood Adv 2021; 5:3047-3052. [PMID: 34374749 DOI: 10.1182/bloodadvances.2021004268] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/10/2021] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND From 2017 to 2020, the American Society of Hematology (ASH) collaborated with 12 hematology societies in Latin America to adapt the ASH guidelines on venous thromboembolism (VTE). OBJECTIVE To describe the methods used to adapt the ASH guidelines on venous thromboembolism. METHODS Each society nominated 1 individual to serve on the guideline panel. The work of the panel was facilitated by the 2 methodologists. The methods team selected 4 of the original VTE guidelines for a first round. To select the most relevant questions, a 2-step prioritization process was conducted through an on-line survey and then through in-person discussion. During an in-person meeting in Rio de Janeiro, Brazil, from 23 April through 26 April 2018, the panel developed recommendations using the ADOLOPMENT approach. Evidence about health effects from the original guidelines was reused, but important data about resource use, accessibility, feasibility, and impact in health equity were added. RESULTS In the guideline accompanying this paper, Latin American panelists selected 17 questions from an original pool of 49. Of the 17 questions addressed, substantial changes were introduced for 5 recommendations, and remarks were added or modified for 12 recommendations. CONCLUSIONS By using the evidence from an international guideline, a significant amount of work and time were saved; by adding regional evidence, the final recommendations were tailored to the Latin American context. This experience offers an alternative to develop guidelines relevant to local contexts through a global collaboration.
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ASH, ABHH, ACHO, Grupo CAHT, Grupo CLAHT, SAH, SBHH, SHU, SOCHIHEM, SOMETH, Sociedad Panameña de Hematología, SPH, and SVH 2021 guidelines for management of venous thromboembolism in Latin America. Blood Adv 2021; 5:3032-3046. [PMID: 34374748 DOI: 10.1182/bloodadvances.2021004267] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/14/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a common disease in Latin American settings. Implementing international guidelinn Aes in Latimerican settings requires additional considerations. OBJECTIVE The purpose of our study was to provide evidence-based guidelines about managing VTE for Latin American patients, clinicians, and decision makers. METHODS We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE)-ADOLOPMENT method to adapt recommendations from 2 American Society of Hematology (ASH) VTE guidelines (Treatment of VTE and Anticoagulation Therapy). ASH and local hematology societies formed a guideline panel comprised of medical professionals from 10 countries in Latin America. Panelists prioritized 18 questions relevant for the Latin American context. A knowledge synthesis team updated evidence reviews of health effects conducted for the original ASH guidelines and summarized information about factors specific to the Latin American context (ie, values and preferences, resources, accessibility, feasibility, and impact on health equity). RESULTS The panel agreed on 17 recommendations. Compared with the original guideline, 4 recommendations changed direction and 1 changed strength. CONCLUSIONS This guideline adolopment project highlighted the importance of contextualization of recommendations suggested by the changes to the original recommendations. The panel also identified 2 implementation priorities for the region: expanding the availability of home treatment and increasing the availability of direct oral anticoagulants (DOACs). The guideline panel made a conditional recommendation in favor of home treatment for individuals with deep venous thrombosis and a conditional recommendation for either home or hospital treatment for individuals with pulmonary embolism. In addition, a conditional recommendation was made in favor of DOACs over vitamin K antagonists for several populations.
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Benipal H, Holbrook A, Paterson JM, Douketis J, Foster G, Ma J, Thabane L. Derivation and validation of predictors of oral anticoagulant-related adverse events in seniors transitioning from hospital to home. Thromb Res 2021; 206:18-28. [PMID: 34391064 DOI: 10.1016/j.thromres.2021.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/20/2021] [Accepted: 07/29/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Oral anticoagulant (OAC)-related adverse events are high post-hospitalization. We planned to develop and validate a prediction model for OAC-related harm within 30 days of hospitalization. METHODS We undertook a population-based study of adults aged ≥66 years who were discharged from hospital on an OAC from September 2010 to March 2015 in Ontario, Canada. The primary outcome was a composite of time to first hospitalization or emergency department visit for a hemorrhagic or thromboembolic event, or mortality within 30 days of hospital discharge. Cox proportional hazards regression was used to build the model. RESULTS We included 120,721 patients of which 5423 experienced the outcome. Most patients were aged ≥75 years (59.5%) and were female (55.6%). Sixty percent of the cohort had a follow-up visit with a healthcare provider within 7 days of discharge. Patients discharged on a direct acting OAC versus warfarin (apixaban: Hazard Ratio [HR] 0.82, 95% confidence interval [CI] 0.71-0.94; dabigatran: HR 0.73, 95% CI 0.63-0.84; rivaroxaban: HR 0.79, 95% CI 0.71-0.88), were prevalent users of the dispensed OAC versus incident users (HR 0.82, 95% CI 0.69-0.96), had a joint replacement in the past 35 days (HR 0.40, 95% CI 0.33-0.50) or major surgery during index hospital stay (HR 0.69, 95% CI 0.60-0.80) had a lower risk for the outcome. The Cox model was stable with acceptable discrimination but poor goodness-of-fit. CONCLUSIONS A model for OAC-related harm in the early post-discharge period was developed. External validation studies are required to understand the model's poor calibration.
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Affiliation(s)
- Harsukh Benipal
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, 2C Area, Hamilton, Ontario L8S 4K1, Canada.
| | - Anne Holbrook
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, 2C Area, Hamilton, Ontario L8S 4K1, Canada; Division of Clinical Pharmacology & Toxicology, Department of Medicine, McMaster University, SJHH G623, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada.
| | - J Michael Paterson
- ICES, G1 06, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Ontario M5T 3M6, Canada.
| | - James Douketis
- Division of Hematology and Thromboembolism, Department of Medicine, HSC-3V50, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada; Thrombosis and Atherosclerosis Research Institute, David Braley Research Institute C5-121, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada.
| | - Gary Foster
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, 2C Area, Hamilton, Ontario L8S 4K1, Canada; Biostatistics Unit, St Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada.
| | - Jinhui Ma
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, 2C Area, Hamilton, Ontario L8S 4K1, Canada.
| | - Lehana Thabane
- Department of Health Research Methods, Evidence and Impact, McMaster University, 1280 Main Street West, 2C Area, Hamilton, Ontario L8S 4K1, Canada; Biostatistics Unit, St Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, Ontario L8N 4A6, Canada.
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Godon A, Tacquard CA, Mansour A, Garrigue D, Nguyen P, Lasne D, Testa S, Levy JH, Albaladejo P, Gruel Y, Susen S, Godier A. Prevention of venous thromboembolism and haemostasis monitoring in patients with COVID-19: Updated proposals (April 2021): From the French working group on perioperative haemostasis (GIHP) and the French study group on thrombosis and haemostasis (GFHT), in collaboration with the French society of anaesthesia and intensive care (SFAR). Anaesth Crit Care Pain Med 2021; 40:100919. [PMID: 34182166 PMCID: PMC8233055 DOI: 10.1016/j.accpm.2021.100919] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/16/2021] [Indexed: 12/24/2022]
Affiliation(s)
- Alexandre Godon
- Department of Anaesthesiology and Critical Care, Université Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France.
| | - Charles Ambroise Tacquard
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Alexandre Mansour
- Department of Anaesthesiology Critical Care Medicine and Perioperative Medicine, CHU de Rennes, France
| | | | | | - Dominique Lasne
- Department of Haematology Laboratory, Hôpital Necker, AP-HP, Paris, France
| | | | - Jerrold H Levy
- Department of Anaesthesiology, Critical Care, and Surgery, Duke University Hospital, Durham, NC, USA
| | - Pierre Albaladejo
- Department of Anaesthesiology and Critical Care, Université Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
| | - Yves Gruel
- Department of Haematology-Haemostasis, Hôpital Universitaire de Tours, France
| | - Sophie Susen
- Department of Haematology and Transfusion, Université de Lille, Lille, France
| | - Anne Godier
- Department of Anaesthesia and Intensive Care, AP-HP, Hôpital Européen Georges Pompidou, and INSERM UMRS-1140, Université de Paris, France
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145
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Stevens SM, Woller SC, Baumann Kreuziger L, Bounameaux H, Doerschug K, Geersing GJ, Huisman MV, Kearon C, King CS, Knighton AJ, Lake E, Murin S, Vintch JRE, Wells PS, Moores LK. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest 2021; 160:e545-e608. [PMID: 34352278 DOI: 10.1016/j.chest.2021.07.055] [Citation(s) in RCA: 339] [Impact Index Per Article: 113.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 06/11/2021] [Accepted: 07/08/2021] [Indexed: 01/06/2023] Open
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Stevens SM, Woller SC, Baumann Kreuziger L, Bounameaux H, Doerschug K, Geersing GJ, Huisman MV, Kearon C, King CS, Knighton AJ, Lake E, Murin S, Vintch JRE, Wells PS, Moores LK. Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report - Executive Summary. Chest 2021; 160:2247-2259. [PMID: 34352279 DOI: 10.1016/j.chest.2021.07.056] [Citation(s) in RCA: 198] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 07/27/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND This is the second update to the 9th edition of these guidelines. We provide recommendations on 17 PICO (Patients, Interventions, Comparators, Outcomes) questions, four of which have not been addressed previously. METHODS We generate strong and weak recommendations based on high, moderate, and low-certainty evidence, using GRADE methodology. RESULTS The panel generated 29 guidance statements, 13 of which are graded as strong recommendations, covering aspects of antithrombotic management of venous thromboembolism from initial management through secondary prevention and risk reduction of post-thrombotic syndrome. Four new guidance statements are added that did not appear in the 9th edition (2012) or first update (2016). Eight statements have been substantially modified from the first update. CONCLUSION New evidence has emerged since 2016 which further informs the standard of care for patients with venous thromboembolism. Substantial uncertainty remains regarding important management questions, particularly in limited disease and special patient populations.
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Affiliation(s)
- Scott M Stevens
- Department of Medicine, Intermountain Healthcare, Murray, UT
| | - Scott C Woller
- Department of Medicine, Intermountain Healthcare, Murray, UT.
| | | | - Henri Bounameaux
- Department of Medicine, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Kevin Doerschug
- Department of Internal Medicine, University of Iowa College of Medicine, Iowa City, IA
| | - Geert-Jan Geersing
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | | | - Christopher S King
- Advanced Lung Disease and Transplant Clinic, Inova Fairfax Hospital, Falls Church, VA
| | | | - Erica Lake
- Essentia Institute of Rural Health, Duluth, MN
| | - Susan Murin
- University of California Davis School of Medicine, Davis, CA
| | - Janine R E Vintch
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Philip S Wells
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Lisa K Moores
- Department of Medicine, F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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147
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Atchinson PRA, Hatton CJ, Roginski MA, Backer ED, Long B, Lentz SA. The emergency department evaluation and management of massive hemoptysis. Am J Emerg Med 2021; 50:148-155. [PMID: 34365064 DOI: 10.1016/j.ajem.2021.07.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 06/09/2021] [Accepted: 07/11/2021] [Indexed: 10/20/2022] Open
Abstract
INTRODUCTION Massive hemoptysis is a life-threatening emergency that requires rapid evaluation and management. Recognition of this deadly condition, knowledge of the initial resuscitation and diagnostic evaluation, and communication with consultants capable of definitive management are key to successful treatment. OBJECTIVE The objective of this narrative review is to provide an evidence-based review on the management of massive hemoptysis for the emergency clinician. DISCUSSION Rapid diagnosis and management of life-threatening hemoptysis is key to patient survival. The majority of cases arise from the bronchial arterial system, which is under systemic blood pressure. Initial management includes patient and airway stabilization, reversal of coagulopathy, and identification of the source of bleeding using computed tomography angiogram. Bronchial artery embolization with interventional radiology has become the mainstay of treatment; however, unstable patients may require advanced bronchoscopic procedures to treat or temporize while additional information and treatment can be directed at the underlying pathology. CONCLUSION Massive hemoptysis is a life-threatening condition that emergency clinicians must be prepared to manage. Emergency clinicians should focus their management on immediate resuscitation, airway preservation often including intubation and isolation of the non-bleeding lung, and coordination of definitive management with available consultants including interventional radiology, interventional pulmonology, and thoracic surgery.
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Affiliation(s)
- Patricia Ruth A Atchinson
- Department of Emergency Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, United States of America
| | - Colman J Hatton
- Dartmouth-Hitchcock Medical Center, Section of Critical Care Medicine, Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, United States of America
| | - Matthew A Roginski
- Department of Emergency Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, United States of America
| | - Elliot D Backer
- Dartmouth-Hitchcock Medical Center, Section of Critical Care Medicine, Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH, United States of America
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, San Antonio, TX, United States of America
| | - Skyler A Lentz
- Division of Emergency Medicine and Pulmonary Disease and Critical Care Medicine, The University of Vermont Larner College of Medicine, Burlington, VT, United States of America.
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Pearson LN, Johnson SA, Greene DN, Chambliss AB, Farnsworth CW, French D, Herman DS, Kavsak PA, Merrill AE, Lo SYM, Lyon ME, SoRelle JA, Schmidt RL. Side-Effects of COVID-19 on Patient Care: An INR Story. J Appl Lab Med 2021; 6:953-961. [PMID: 33760097 PMCID: PMC8083676 DOI: 10.1093/jalm/jfab025] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/15/2021] [Indexed: 01/07/2023]
Abstract
Background Numerous studies have documented reduced access to patient care due to the COVID-19 pandemic including access to a diagnostic or screening tests, prescription medications, and treatment for an ongoing condition. In the context of clinical management for venous thromboembolism, this could result in suboptimal therapy with warfarin. We aimed to determine the impact of the pandemic on utilization of International normalized ratio (INR) testing and the percentage of high and low results. Methods INR data from 11 institutions were extracted to compare testing volume and the percentage of INR results ≥3.5 and ≤1.5 between a pre-pandemic period (January-June 2019, period 1) and a portion of the COVID-19 pandemic period (January-June 2020, period 2). The analysis was performed for inpatient and outpatient cohorts. Results Testing volumes showed relatively little change in January and February, followed by a significant decrease in March, April and May, and then returned to baseline in June. Outpatient testing showed a larger percentage decrease in testing volume compared to inpatient testing. At 10 of the 11 study sites we observed an increase in the percentage of abnormal high INR results as test volumes decreased, primarily among outpatients. Conclusion The COVID-19 pandemic impacted INR testing among outpatients which may be attributable to several factors. Increased supratherapeutic INR results during the pandemic period when there was reduced laboratory utilization and access to care is concerning because of the risk of adverse bleeding events in this group of patients. This could be mitigated in the future by offering drive through testing and/or widespread implementation of home INR monitoring.
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Affiliation(s)
- Lauren N Pearson
- Department of Pathology, University of Utah, Salt Lake City, UT, USA
| | - Stacy A Johnson
- Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Dina N Greene
- Kaiser Permanente Washington, Washington, Renton, WA, USA
| | - Allison B Chambliss
- Department of Pathology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Christopher W Farnsworth
- Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO, USA
| | - Deborah French
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel S Herman
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
| | - Anna E Merrill
- Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Martha E Lyon
- Department of Pathology and Laboratory Medicine, Saskatchewan Health Authority, Saskatoon, Saskatchewan, CA, USA
| | - Jeffrey A SoRelle
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert L Schmidt
- Department of Pathology, University of Utah, Salt Lake City, UT, USA
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149
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Hitchcock ZR, Smith SD, Le LT, Lees LR, Brandt MD. A Retrospective Review of Four-Factor Prothrombin Complex Concentrate for Factor Xa Inhibitor-Related Bleedings. J Pharm Pract 2021; 36:221-226. [PMID: 34231410 DOI: 10.1177/08971900211026839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The use of factor Xa inhibitors has grown in popularity; however, the risk of major bleeding events requires for the appropriate reversal agent. The recent approved agent for factor Xa inhibitor reversal, andexanet alfa, has limited clinical efficacy and safety data, and it can be a financial burden on healthcare systems due to its high cost. Four-factor prothrombin complex concentrate (4F-PCC) has been utilized off label in patients with factor Xa inhibitor-related bleedings. Objective: The aim of this study was to assess the safety and efficacy of 4F-PCC in managing factor Xa inhibitor-related bleedings. METHODS This is an observational, retrospective review of 4F-PCC usage in treating factor Xa inhibitor-related bleeds from May 2014 to December 2018 at a single health system. Efficacy was evaluated using the assessment criteria described by Sarode et al. Secondary outcomes analyzed included thromboembolic events, length of stay, mortality, and discharge disposition. RESULTS Fifty-nine patient charts were reviewed, and 48 patients were included in the study analysis. The administration of 4F-PCC achieved effective hemostasis in 33 patients (68%), and effective hemostasis was achieved in 12 patients (86%) who had intracranial hemorrhage and did not receive any surgical intervention. Thromboembolic events occurred in 4 patients within 30 days from 4F-PCC use. A majority of patients (85.4%) were discharged from the hospital to home or long-term care; 7 patients (14.6%) expired in the hospital. CONCLUSION Efficacy was achieved in over half of the patient population in this cohort who received 4F-PCC for factor Xa inhibitor-related bleeding events.
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Affiliation(s)
- Zachary R Hitchcock
- Pharmacy Department at CoxHealth South National Avenue, Springfield, MO, USA
| | - Spencer D Smith
- Pharmacy Department at CoxHealth South National Avenue, Springfield, MO, USA
| | - Lamanh T Le
- Pharmacy Department at CoxHealth South National Avenue, Springfield, MO, USA
| | - Lauren R Lees
- Pharmacy Department at CoxHealth South National Avenue, Springfield, MO, USA
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Dietrich SK, Mixon MA, Rech MA. Fixed-dose prothrombin complex concentrate for emergent warfarin reversal among patients with intracranial hemorrhage. Am J Emerg Med 2021; 49:326-330. [PMID: 34224954 DOI: 10.1016/j.ajem.2021.06.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/24/2021] [Accepted: 06/13/2021] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION Four-factor prothrombin complex concentrate (4PCC) is the preferred reversal agent for warfarin reversal, although the ideal dose is unknown. Fixed-dose 4PCC offers simplified dosing compared to standard-dosing algorithms with potentially lower risks of thromboembolic complications given lower doses are typically utilized. METHODS Retrospective, observational, multicentered, pre- post- study of patients who received 4PCC for warfarin reversal among four hospitals within the same regional health system. Standard-dose patients received variable doses ranging from 25 to 50 units/kg based on total body weight and initial INR and fixed-dose patients received 2000 units. The primary outcome was achievement of a target INR ≤ 1.4 on the first post-4PCC INR result. RESULTS After exclusions, 48 and 42 patients were analyzed in the standard-dose and fixed-dose groups, respectively. There was no difference in the ability to achieve a target INR of ≤1.4 (82.6% vs 81.5%, p = 0.14). Both groups received the same median dose of 2000 units, although fixed-dose patients actually received a higher weight-based dose than standard-dose patients (27 units/kg vs 24.5 units/kg). CONCLUSION A fixed-dose 4PCC regimen of 2000 units among patients with ICH was as effective as standard-dose 4PCC for INR reversal among patients with ICH. However, fixed-doses of 2000 units at times exceeded standard 4PCC doses which may be contradictory to the goals of fixed-dose 4PCC for warfarin reversal.
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Affiliation(s)
- Scott K Dietrich
- University of of Colorado Health- North, Department of Pharmacy, Fort Collins, CO, United States of America.
| | - Mark A Mixon
- University of of Colorado Health- North, Department of Pharmacy, Fort Collins, CO, United States of America
| | - Megan A Rech
- Loyola University Medical Center, Department of Pharmacy, United States of America; Department of Emergency Medicine, Stritch School of Medicine, Loyola University of Chicago, United States of America
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