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Mekaj YH, Mekaj AY, Duci SB, Miftari EI. New oral anticoagulants: their advantages and disadvantages compared with vitamin K antagonists in the prevention and treatment of patients with thromboembolic events. Ther Clin Risk Manag 2015; 11:967-77. [PMID: 26150723 PMCID: PMC4485791 DOI: 10.2147/tcrm.s84210] [Citation(s) in RCA: 274] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Despite the discovery and application of many parenteral (unfractionated and low-molecular-weight heparins) and oral anticoagulant vitamin K antagonist (VKA) drugs, the prevention and treatment of venous and arterial thrombotic phenomena remain major medical challenges. Furthermore, VKAs are the only oral anticoagulants used during the past 60 years. The main objective of this study is to present recent data on non-vitamin K antagonist oral anticoagulants (NOACs) and to analyze their advantages and disadvantages compared with those of VKAs based on a large number of recent studies. NOACs are novel direct-acting medications that are selective for one specific coagulation factor, either thrombin (IIa) or activated factor X (Xa). Several NOACs, such as dabigatran (a direct inhibitor of FIIa) and rivaroxaban, apixaban and edoxaban (direct inhibitors of factor Xa), have been used for at least 5 years but possibly 10 years. Unlike traditional VKAs, which prevent the coagulation process by suppressing the synthesis of vitamin K-dependent factors, NOACs directly inhibit key proteases (factors IIa and Xa). The important indications of these drugs are the prevention and treatment of deep vein thrombosis and pulmonary embolisms, and the prevention of atherothrombotic events in the heart and brain of patients with acute coronary syndrome and atrial fibrillation. They are not fixed, and dose-various strengths are available. Most studies have reported that more advantages than disadvantages for NOACs when compared with VKAs, with the most important advantages of NOACs including safety issues (ie, a lower incidence of major bleeding), convenience of use, minor drug and food interactions, a wide therapeutic window, and no need for laboratory monitoring. Nonetheless, there are some conditions for which VKAs remain the drug of choice. Based on the available data, we can conclude that NOACs have greater advantages and fewer disadvantages compared with VKAs. New studies are required to further assess the efficacy of NOACs.
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Affiliation(s)
- Ymer H Mekaj
- Institute of Pathophysiology, Faculty of Medicine, University of Prishtina, Prishtina, Kosovo ; Department of Hemostasis and Thrombosis, National Blood Transfusion Center of Kosovo, Prishtina, Kosovo
| | - Agon Y Mekaj
- Clinic of Neurosurgery, Faculty of Medicine, University of Prishtina, Prishtina, Kosovo, Prishtina, Kosovo
| | - Shkelzen B Duci
- Clinic of Plastic and Reconstructive Surgery, Faculty of Medicine, University of Prishtina
| | - Ermira I Miftari
- The Hospital and University Clinical Service of Kosovo, Prishtina, Kosovo
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102
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Trujillo T, Dobesh PP. Clinical use of rivaroxaban: pharmacokinetic and pharmacodynamic rationale for dosing regimens in different indications. Drugs 2015; 74:1587-603. [PMID: 25178252 PMCID: PMC4180907 DOI: 10.1007/s40265-014-0278-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Target-specific oral anticoagulants have become increasingly available as alternatives to traditional agents for the management of a number of thromboembolic disorders. To date, the direct Factor Xa inhibitor rivaroxaban is the most widely approved of the new agents. The dosing of rivaroxaban varies and adheres to specific schedules in each of the clinical settings in which it has been investigated. These regimens were devised based on the results of phase II dose-finding studies and/or pharmacokinetic modeling, and were demonstrated to be successful in randomized, phase III studies. In most cases, the pharmacodynamic profile of rivaroxaban permits once-daily dosing. A once-daily dose is indicated for the prevention of venous thromboembolism (VTE) in patients undergoing hip or knee replacement surgery, the long-term prevention of stroke in patients with non-valvular atrial fibrillation, and the long-term secondary prevention of recurrent VTE. Twice-daily dosing is required in the acute phase of treatment in patients with VTE and in the combination of rivaroxaban with standard single or dual antiplatelet therapy for secondary prevention after acute coronary syndrome events. This article reviews the empirical and clinical rationale supporting the dose regimens of rivaroxaban in each clinical setting.
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Affiliation(s)
- Toby Trujillo
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Mail Stop C238, 12850 E. Montview Blvd. V20-1217, Aurora, CO, 80045, USA,
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103
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Beyer-Westendorf J, Siegert G. Of men and meals. J Thromb Haemost 2015; 13:943-5. [PMID: 25880707 DOI: 10.1111/jth.12973] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 04/12/2015] [Indexed: 02/02/2023]
Abstract
Rivaroxaban is increasingly used to treat patients with acute venous thromboembolism (VTE), a potentially life-threatening condition. Because absorption of rivaroxaban decreases from nearly 100% to 66% under fasting conditions, it is recommended that VTE patients take rivaroxaban with a meal. However, this recommendation is based on preclinical pharmacokinetic (PK) studies in healthy volunteers. So far, no clinical evidence is available to support this recommendation. We describe a case of a compliant young patient who developed recurrent pulmonary embolism during rivaroxaban treatment. PK studies provided evidence that malabsorption of rivaroxaban 20 mg due to irregular intake of meals during shift work was the leading cause of recurrent pulmonary embolism. When the patient was instructed to take rivaroxaban with a regular meal, peak plasma concentrations increased from 115 to 318 ng mL(-1) (+ 176%). Consequently, the importance of taking rivaroxaban with food may have a greater clinical relevance than data from preclinical PK studies suggest.
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Affiliation(s)
- J Beyer-Westendorf
- Center for Vascular Diseases and Medical Clinic III, University Hospital 'Carl Gustav Carus', Technische Univesität, Dresden, Germany
| | - G Siegert
- Institute of Clinical Chemistry and Laboratory Medicine, University Hospital 'Carl Gustav Carus', Technische Univesität, Dresden, Germany
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104
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Dias JD, Norem K, Doorneweerd DD, Thurer RL, Popovsky MA, Omert LA. Use of Thromboelastography (TEG) for Detection of New Oral Anticoagulants. Arch Pathol Lab Med 2015; 139:665-73. [PMID: 25927150 DOI: 10.5858/arpa.2014-0170-oa] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT The clinical introduction of new oral anticoagulants (NOACs) has stimulated the development of tests to quantify the effects of these drugs and manage complications associated with their use. Until recently, the only treatment choices for the prevention of venous thromboembolism in orthopedic surgical patients, as well as for stroke and systemic embolism in patients with atrial fibrillation, were vitamin K antagonists, antiplatelet drugs, and unfractionated and low-molecular-weight heparins. With the approval of NOACs, treatment options and consequent diagnostic challenges have expanded. OBJECTIVE To study the utility of thromboelastography (TEG) in monitoring and differentiating between 2 currently approved classes of NOACs, direct thrombin inhibitors (dabigatran) and factor Xa inhibitors (rivaroxaban and apixaban). DESIGN Blood samples from healthy volunteers were spiked with each NOAC in both the presence and absence of ecarin, and the effects on TEG were evaluated. RESULTS Both the kaolin test reaction time (R time) and the time to maximum rate of thrombus generation were prolonged versus control samples and demonstrated a dose response for apixaban (R time within the normal range) and dabigatran. The RapidTEG activated clotting time test allowed the creation of a dose-response curve for all 3 NOACs. In the presence of anti-Xa inhibitors, the ecarin test promoted significant shortening of kaolin R times to the hypercoagulable range, while in the presence of the direct thrombin inhibitor only small and dose-proportional R time shortening was observed. CONCLUSIONS The RapidTEG activated clotting time test and the kaolin test appear to be capable of detecting and monitoring NOACs. The ecarin test may be used to differentiate between Xa inhibitors and direct thrombin inhibitors. Therefore, TEG may be a valuable tool to investigate hemostasis and the effectiveness of reversal strategies for patients receiving NOACs.
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Affiliation(s)
- João D Dias
- From Clinical Marketing, Haemonetics SA, Signy, Switzerland (Dr Dias); Operations Department (Ms Norem) and Scientific Research & Biomedical (Dr Doorneweerd), Haemonetics Corporation, Rosemont, and Medical Affairs, Haemonetics Corporation, Chicago (Dr Omert), Illinois; Hospital Division (Dr Thurer) and Medical Affairs (Dr Popovsky), Haemonetics Corporation, Braintree, Massachusetts; and Department of Surgery, Einstein Medical Center, Philadelphia, Pennsylvania (Dr Omert). Dr Omert is now with Acquired Bleeding, CSL Behring, King of Prussia, Pennsylvania
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105
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Vranckx P, Leebeek FWG, Tijssen JGP, Koolen J, Stammen F, Herman JPR, de Winter RJ, van T Hof AWJ, Backx B, Lindeboom W, Kim SY, Kirsch B, van Eickels M, Misselwitz F, Verheugt FWA. Peri-procedural use of rivaroxaban in elective percutaneous coronary intervention to treat stable coronary artery disease. The X-PLORER trial. Thromb Haemost 2015; 114:258-67. [PMID: 25925992 DOI: 10.1160/th15-01-0061] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 03/04/2015] [Indexed: 12/12/2022]
Abstract
Patients on rivaroxaban requiring percutaneous coronary intervention (PCI) represent a clinical conundrum. We aimed to investigate whether rivaroxaban, with or without an additional bolus of unfractionated heparin (UFH), effectively inhibits coagulation activation during PCI. Stable patients (n=108) undergoing elective PCI and on stable dual antiplatelet therapy were randomised (2:2:2:1) to a short treatment course of rivaroxaban 10 mg (n=30), rivaroxaban 20 mg (n=32), rivaroxaban 10 mg plus UFH (n=30) or standard peri-procedural UFH (n=16). Blood samples for markers of thrombin generation and coagulation activation were drawn prior to and at 0, 0.5, 2, 6-8 and 48 hours (h) after start of PCI. In patients treated with rivaroxaban (10 or 20 mg) and patients treated with rivaroxaban plus heparin, the levels of prothrombin fragment 1 + 2 at 2 h post-PCI were 0.16 [0.1] nmol/l (median) [interquartile range, IQR] and 0.17 [0.2] nmol/l, respectively. Thrombin-antithrombin complex values at 2 h post-PCI were 3.90 [6.8]µg/l and 3.90 [10.1] µg/l, respectively, remaining below the upper reference limit (URL) after PCI and stenting. This was comparable to the control group of UFH treatment alone. However, median values for thrombin-antithrombin complex passed above the URL with increasing tendency, starting at 2 h post-PCI in the UFH-alone arm but not in rivaroxaban-treated patients. In this exploratory trial, rivaroxaban effectively suppressed coagulation activation after elective PCI and stenting.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - F W A Verheugt
- Prof. Freek W. A. Verheugt MD, PhD, Department of Cardiology, Heartcenter, Oosterpark 9, AC Amsterdam 1091, the Netherlands, Tel.: + 31 20 5993421, Fax: +31 20 5993997, E-mail: f. w.
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106
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Sidharta PN, Dietrich H, Dingemanse J. Investigation of the effect of macitentan on the pharmacokinetics and pharmacodynamics of warfarin in healthy male subjects. Clin Drug Investig 2015; 34:545-52. [PMID: 24861134 DOI: 10.1007/s40261-014-0207-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND OBJECTIVES Macitentan is a novel dual endothelin receptor antagonist recently approved for the treatment of pulmonary arterial hypertension (PAH). Warfarin, an anticoagulant often prescribed to patients with PAH, has a narrow therapeutic index and is prone to potential interactions with drugs. This study assessed the effects of macitentan on the pharmacokinetics and pharmacodynamics of single-dose warfarin in healthy subjects. METHODS This was a randomised, open-label, single-centre, two-way crossover (treatment A followed by treatment B, or vice versa), phase I study in 14 healthy male subjects. Treatment A was a loading dose of macitentan 30 mg on Day 1 followed by 10 mg once daily for 8 days, with a single 25 mg dose of warfarin on Day 4. Treatment B was a single dose of warfarin on Day 1. Blood samples were assessed for warfarin pharmacokinetics (R- and S-warfarin) and pharmacodynamics [international normalised ratio (INR) and factor VII]. Plasma trough concentrations of macitentan and its active metabolite (ACT-132577) and the safety and tolerability of each treatment were also assessed. RESULTS Plasma concentrations of R- and S-warfarin were similar in both treatment periods. Warfarin did not affect the mean trough plasma concentrations of macitentan or ACT-132577. Macitentan did not affect the pharmacodynamics of warfarin; the mean INR and factor VII activity versus time profiles were similar with and without macitentan. CONCLUSIONS The absence of effect of macitentan on the pharmacokinetics and pharmacodynamics of a single dose of warfarin suggests that both drugs can be concomitantly administered without need for dose adjustment.
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Affiliation(s)
- Patricia N Sidharta
- Department of Clinical Pharmacology, Actelion Pharmaceuticals Ltd, Gewerbestrasse 16, Allschwil, Switzerland
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107
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Brinkman HJM. Global assays and the management of oral anticoagulation. Thromb J 2015; 13:9. [PMID: 25762867 PMCID: PMC4355453 DOI: 10.1186/s12959-015-0037-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 01/12/2015] [Indexed: 12/12/2022] Open
Abstract
Coagulation tests range from global or overall tests to assays specific to individual clotting factors and their inhibitors. Whether a particular test is influenced by an oral anticoagulant depends on the principle of the test and the type of oral anticoagulant. Knowledge on coagulation tests applicable in monitoring status and reversal of oral anticoagulation is a prerequisite when studying potential reversal agents or when managing anticoagulation in a clinical setting. Specialty tests based on the measurement of residual activated factor X (Xa) or thrombin activity, e.g., are highly effective for determining the concentration of the new generation direct factor Xa- and thrombin inhibitors, but these tests are unsuitable for the assessment of anticoagulation reversal by non-specific prohemostatic agents like prothrombin complex concentrate (PCC) and recombinant factor VIIa (FVIIa). Global coagulation assays, in this respect, seem more appropriate. This review evaluates the current status on the applicability of the global coagulation assays PT, APTT, thrombin generation and thromboelastography in the management of oral anticoagulation by vitamin K antagonists and the direct factor Xa and thrombin inhibitors. Although all global tests are influenced by both types of anticoagulants, not all tests are useful for monitoring anticoagulation and reversal thereof. Many (pre)analytical conditions are of influence on the assay readout, including the oral anticoagulant itself, the concentration of assay reagents and the presence of other elements like platelets and blood cells. Assay standardization, therefore, remains an issue of importance.
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Affiliation(s)
- Herm Jan M Brinkman
- Department of Plasma Proteins, Sanquin Research, Plesmanlaan 125, 1066 CX Amsterdam, The Netherlands
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108
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Management of dabigatran-induced bleeding with continuous venovenous hemodialysis. Int J Hematol 2015; 101:594-7. [DOI: 10.1007/s12185-015-1739-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 01/06/2015] [Accepted: 01/15/2015] [Indexed: 01/23/2023]
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109
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Zalpour A, Oo TH. Clinical utility of apixaban in the prevention and treatment of venous thromboembolism: current evidence. DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:2181-91. [PMID: 25395835 PMCID: PMC4226443 DOI: 10.2147/dddt.s51006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Anticoagulation with heparin and vitamin K antagonist has been the mainstay of prevention and treatment of venous thromboembolism (VTE) for many years. In recent years, novel oral anticoagulants such as dabigatran etexilate (a direct thrombin inhibitor) and rivaroxaban, apixaban, and edoxaban (a direct factor Xa inhibitor) have emerged for the prevention and treatment of VTE. Novel oral anticoagulants have been shown to be noninferior to vitamin K antagonist or heparin in the prevention and treatment of VTE. This review specifically examines the role of apixaban in the prevention and treatment of VTE based on the available literature. The management of apixaban in the perioperative setting is also explored because some patients on apixaban may require surgical intervention. Finally, we discuss the management of apixaban-induced major bleeding complications, the relevance of drug–drug interactions, and patient education.
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Affiliation(s)
- Ali Zalpour
- Division of Pharmacy - Clinical Programs, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Thein Hlaing Oo
- Section of Thrombosis and Benign Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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110
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Bornkamm K, Harloff A. Safe intravenous thrombolysis in acute stroke despite treatment with rivaroxaban. J Clin Neurosci 2014; 21:2012-3. [DOI: 10.1016/j.jocn.2014.03.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 02/01/2014] [Accepted: 03/08/2014] [Indexed: 01/28/2023]
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111
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Renner TA, Zalunardo MP, Weder W, Spahn DR. Bilateral lung transplantation in a patient receiving rivaroxaban anticoagulation. J Cardiothorac Vasc Anesth 2014; 29:723-6. [PMID: 25440624 DOI: 10.1053/j.jvca.2014.06.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Indexed: 12/12/2022]
Affiliation(s)
- Tobias A Renner
- Institute of Anesthesiology, University and University Hospital Zurich, Switzerland.
| | - Marco P Zalunardo
- Institute of Anesthesiology, University and University Hospital Zurich, Switzerland
| | - Walter Weder
- Division of Thoracic Surgery, University and University Hospital Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Switzerland
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112
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Abstract
Until about 4 years ago, warfarin was the only oral anticoagulant approved in the United States, and switching between oral anticoagulants has become an option since the emergence of the novel oral anticoagulants dabigatran, rivaroxaban, and apixaban. What are the reasons one may switch between the agents and how is this done? Discussed in this article are the 4 agents approved in the United States, their characteristics, reasons one may switch, and methods for conversion. After a thorough search of original trial data and recent expert review articles, we have summarized the most recent recommendations below and briefly discuss upcoming oral anticoagulants that show promise.
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113
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Abstract
OPINION STATEMENT The careful review of drug-drug interactions is vital to the safe prescribing of medications for chronic medical conditions. The elderly population suffers from multiple medical problems, and polypharmacy leads to further morbidity in this vulnerable group of patients. We discuss gastrointestinal conditions such as GERD, peptic ulcer disease, gastroparesis, diarrhea, constipation, irritable bowel syndrome, inflammatory bowel disease, chronic liver disease and the commonly used medications in these conditions. Treatment options must be individualized and tailored to accommodate the underlying pharmacokinetics and known drug-drug interactions. The indication for the use of a therapeutic agent in the elderly and the duration of use must be frequently readdressed to help prevent polypharmacy and adverse drug reactions. Medications should be started at a low dose with careful titration to achieve a clinical response to prevent toxicity. The aim of this article is to increase awareness of important drug-drug interactions of commonly prescribed gastrointestinal medications in the elderly.
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114
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Williams LA, Hunter JM, Marques MB, Vetter TR. Periprocedural management of patients on anticoagulants. Clin Lab Med 2014; 34:595-611. [PMID: 25168945 DOI: 10.1016/j.cll.2014.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Every year, new studies are undertaken to address the complex issue of periprocedural management of patients on anticoagulants and antiplatelet medications. In addition, newer drugs add to the confusion among clinicians about how to best manage patients taking these agents. Using the most recent data, guidelines, and personal experience, this article discusses recommendations and presents simplified algorithms to assist clinicians in the periprocedural management of patients on anticoagulants.
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Affiliation(s)
- Lance A Williams
- Department of Pathology, University of Alabama at Birmingham, 619 19th Street South, WPP230F, Birmingham, AL 35249-7331, USA.
| | - James M Hunter
- Department of Anesthesiology, University of Alabama at Birmingham, 1720 2nd Avenue South, JT926C, Birmingham, AL 35249-6810, USA
| | - Marisa B Marques
- Department of Pathology, University of Alabama at Birmingham, 619 19th Street South, WPP230G, Birmingham, AL 35249-7331, USA
| | - Thomas R Vetter
- Department of Anesthesiology, University of Alabama at Birmingham, 619 19th Street South, JT865, Birmingham, AL 35249, USA
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Martínez-Rubio A, Dan GA, Kaski JC. Rivaroxaban and stroke prevention in patients with atrial fibrillation: new evidence. Expert Rev Cardiovasc Ther 2014; 12:933-47. [DOI: 10.1586/14779072.2014.931223] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Mani H, Lindhoff-Last E. New oral anticoagulants in patients with nonvalvular atrial fibrillation: a review of pharmacokinetics, safety, efficacy, quality of life, and cost effectiveness. DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:789-98. [PMID: 24970997 PMCID: PMC4069048 DOI: 10.2147/dddt.s45644] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Atrial fibrillation (AF) continues to be a leading cause of cerebrovascular morbidity and mortality resulting from cardioembolic stroke. Oral anticoagulation therapy has been shown to decrease the incidence of cardioembolic stroke in patients with AF by more than 50%. Appropriate use of anticoagulation with vitamin K antagonists requires precise adherence and monitoring. A number of factors that potentially induce patients’ dissatisfaction reduce quality of patient life. New direct oral anticoagulants, such as the direct factor Xa inhibitors rivaroxaban, apixaban, edoxaban, and the thrombin inhibitor dabigatran, were developed to overcome the limitations of the conventional anticoagulant drugs. However, models to optimize the benefit of therapy and to ensure that therapy can be safely continued are missing for the new oral anticoagulants. This review will briefly describe the new oral anticoagulants dabigatran, rivaroxaban, apixaban, and edoxaban with focus on their use for prevention of embolic events in AF. Moreover, it will discuss the safety, efficacy, cost data, and benefit for patients’ quality of life and adherence.
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Affiliation(s)
- Helen Mani
- Johann Wolfgang Goethe-University Hospital Frankfurt/Main, Department of Internal Medicine, Division of Haemostasis, Frankfurt, Germany
| | - Edelgard Lindhoff-Last
- Johann Wolfgang Goethe-University Hospital Frankfurt/Main, Department of Internal Medicine, Division of Haemostasis, Frankfurt, Germany
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117
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Stöllberger C, Finsterer J. Prolonged anticoagulant activity of rivaroxaban in a polymorbid elderly female with non-convulsive epileptic state. Heart Lung 2014; 43:262-3. [PMID: 24794785 DOI: 10.1016/j.hrtlng.2014.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 03/03/2014] [Accepted: 03/04/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES AND BACKGROUND Rivaroxaban, an oral direct factor Xa-inhibitor was non-inferior to adjusted dose warfarin in the prevention of stroke and embolism among patients with atrial fibrillation (AF) in the ROCKET-AF trial and has been approved for stroke prevention in AF. CASE REPORT A 88-years-old female (body-mass-index = 19.95) with AF, hypertension and diabetes mellitus, hospitalized because of heart failure and a non-convulsive epileptic state, was treated by valproate, mirtazepin, nebivolol, digitoxin, lisinopril, gliclazide and amlodipine. Irrespective of renal insufficiency, rivaroxaban 15 mg/d was started. After 3 days rivaroxaban was stopped because of concerns about the bleeding risk. Coagulation tests 28 h after rivaroxaban-intake showed INR 2.26, PT 35%, aPTT 38.3 s and anti-Factor Xa-activity 2.00 U/ml. Explanations for the prolonged anticoagulant activity of rivaroxaban comprise renal failure, the low body-mass-index, the advanced age and drug-drug interactions of rivaroxaban with mirtazepin, valproate and amlodipine. CONCLUSION Health care providers should consider renal function, concomitant medication, polymorbidity and age prior to prescribing rivaroxaban. Care has to be taken when prescribing rivaroxaban to patients who are different from those included in the ROCKET AF trial.
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Affiliation(s)
| | - Josef Finsterer
- Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030 Wien, Austria
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118
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Berndtson AE, Coimbra R. The epidemic of pre-injury oral antiplatelet and anticoagulant use. Eur J Trauma Emerg Surg 2014; 40:657-69. [PMID: 26814780 DOI: 10.1007/s00068-014-0404-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Accepted: 04/09/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND As the population ages, an increasing number of trauma patients are taking antiplatelet and anticoagulant medications (ACAP) prior to their injuries. These medications increase their risk of hemorrhagic complications, particularly intracerebral hemorrhage. Clopidogrel and warfarin are common and their mechanisms well understood, but optimal reversal methods continue to evolve. The novel direct thrombin and factor Xa inhibitors are less well described and do not have existing antidotes. METHODS This article reviews the relevant literature on traumatic outcomes with use of ACAP medications, as well as data on ideal reversal strategies. Suggested algorithms are introduced, and future research directions discussed. RESULTS Although they are beneficial in preventing clot formation, once bleeding occurs ACAP medications contribute to increased morbidity and mortality, particularly in geriatric patient populations. The efficacy of clopidogrel reversal with platelet transfusions and DDAVP remains unclear. Warfarin use is best treated with the algorithm-driven use of plasma, vitamin K, prothrombin complex concentrates (PCCs) and possibly recombinant factor VIIa depending upon specific patient and injury factors. Optimal treatment for direct thrombin and factor Xa inhibitors has yet to be developed, but PCCs are promising for rivaroxaban and apixaban while dabigatran is best treated with medication cessation and the possible addition of activated PCCs or hemodialysis. CONCLUSION New developments in reversal of the ACAP medications are promising, particularly PCCs for warfarin and the factor Xa inhibitors. Function assays and clear antidotes are needed for the thrombin and Xa inhibitors. Research on outcomes and appropriate treatments is actively ongoing.
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Affiliation(s)
- A E Berndtson
- Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, University of California San Diego, 200 West Arbor Drive, Mail Code 8896, San Diego, CA, 92103, USA
| | - R Coimbra
- Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, University of California San Diego, 200 West Arbor Drive, Mail Code 8896, San Diego, CA, 92103, USA.
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Ing E, Douketis J. New oral anticoagulants and oculoplastic surgery. Can J Ophthalmol 2014; 49:123-7. [PMID: 24767215 DOI: 10.1016/j.jcjo.2013.11.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 10/23/2013] [Accepted: 11/14/2013] [Indexed: 02/08/2023]
Abstract
The use of oral anticoagulants is increasing because of the rising prevalence of atrial fibrillation and other cardiovascular diseases that occur in an aging population. In the last decade, several new oral anticoagulants have emerged, comprising the direct thrombin inhibitor dabigatran and the factor Xa inhibitors apixaban and rivaroxaban. Although these new anticoagulants may not affect clear corneal cataract surgery, their use will impact the management of patients having eyelid, orbital, and nasolacrimal procedures. The objective of this review is to provide a concise and practical approach to the perioperative management of patients who require an oculoplastic procedure and are receiving these new anticoagulants.
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Affiliation(s)
- Edsel Ing
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont.
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, Ont
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Ramisetti NR, Kuntamukkala R. Development and validation of a stability indicating LC-PDA-MS/MS method for separation, identification and characterization of process related and stress degradation products of rivaroxaban. RSC Adv 2014. [DOI: 10.1039/c4ra00744a] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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121
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Rachidi S, Aldin ES, Greenberg C, Sachs B, Streiff M, Zeidan AM. The use of novel oral anticoagulants for thromboprophylaxis after elective major orthopedic surgery. Expert Rev Hematol 2013; 6:677-95. [PMID: 24219550 PMCID: PMC4124620 DOI: 10.1586/17474086.2013.853430] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Venous thromboembolism is a common cause of morbidity and mortality among patients undergoing elective orthopedic surgery. Due to the high incidence of venous thromboembolism in this setting, perioperative anticoagulation is the recommended approach for thromboprophylaxis. Low molecular weight heparin (LMWH), fondaparinux and warfarin are the agents commonly used for thromboprophylaxis. The well-recognized limitations of warfarin and the inconvenience and discomfort associated with the subcutaneous administration of low molecular weight heparin and fondaparinux inspired intense investigation to develop novel oral anticoagulants (NOACs) with more predictable pharmacokinetics, fewer drug interactions and no need for regular laboratory monitoring. Three NOACs have been demonstrated to be effective for thromboprophylaxis after total hip arthroplasty (THA) and total knee arthroplasty (TKA) in large randomized controlled trials. Here we review the pharmacology of rivaroxaban, dabigatran, and apixaban, summarize the major clinical trials of these agents in thromboprophylaxis after THA and TKA, and discuss the clinical factors to be considered by providers when selecting a NOAC for their patients.
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Affiliation(s)
- Saleh Rachidi
- Department of Microbiology and Immunology, Medical University of South Carolina, Charleston, SC, USA
| | - Ehab Saad Aldin
- Department of Internal Medicine, Good Samaritan Hospital, Baltimore, MD, USA
| | - Charles Greenberg
- Division of Hematology/Oncology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Barton Sachs
- Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Michael Streiff
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Amer M Zeidan
- Division of Hematology, Department of Medicine, Johns Hopkins University, Baltimore, MD, USA
- Department of Oncology, Johns Hopkins University, The Sidney Kimmel Comprehensive Cancer Center, 1650 Orleans Street, CRB1, Room 186, Baltimore, MD, USA
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