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Goriacko P, Yaghdjian V, Koleilat I, Sinnett M, Shukla H. The Use of Idarucizumab for Dabigatran Reversal in Clinical Practice: A Case Series. P & T : A PEER-REVIEWED JOURNAL FOR FORMULARY MANAGEMENT 2017; 42:699-703. [PMID: 29089726 PMCID: PMC5642159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE To describe the use of idarucizumab (Praxbind, Boehringer Ingelheim) in routine clinical practice at a large urban academic medical center. SUMMARY Seven total doses of idarucizumab were administered to six unique patients from October 31, 2015, to October 31, 2016. The reversal agent was used in conjunction with local bleeding control measures, blood product transfusions, and acid-suppressive therapy. In 86% of cases, idarucizumab administration resulted in a successful cessation of bleeding by clinical assessment. Two patients expired due to coexisting conditions. Idarucizumab was administered to patients with normal baseline coagulation tests in 43% of cases. No adverse reactions related to idarucizumab were reported. CONCLUSIONS Idarucizumab administration resulted in successful resolution of bleeding by clinical assessment. The therapy for acute bleeding with use of dabigatran (Pradaxa, Boehringer Ingelheim) remains supportive care, in addition to idarucizumab in cases of severe or uncontrolled bleeding. Development of institution-specific protocols and better guidance for using baseline coagulation tests are needed.
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Evaluation of dabigatran, rivaroxaban and apixaban target-specific assays in a multicenter French study. Thromb Res 2017; 158:126-133. [DOI: 10.1016/j.thromres.2017.09.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 08/08/2017] [Accepted: 09/01/2017] [Indexed: 01/04/2023]
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De Vlieger J, Dietvorst S, Demaerel R, Verhamme P, Nuttin B, Vanassche T. Neurosurgery in a patient at peak levels of rivaroxaban: taking into account all factors. Res Pract Thromb Haemost 2017; 1:296-300. [PMID: 30046700 PMCID: PMC6058271 DOI: 10.1002/rth2.12035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 07/13/2017] [Indexed: 11/20/2022] Open
Abstract
We present a patient who underwent urgent neurosurgery for acute onset paraplegia due to a spontaneous subdural spinal hematoma less than 5 hours after she had taken rivaroxaban. The Key Clinical Question was whether early high-risk surgery on a patient taking direct oral anticoagulants is feasible. Prothrombin complex concentrate (PCC) and tranexamic acid were administered and perioperative hemostasis was good. There is scant data on neurosurgical procedures performed within 12 hours after the intake of a direct oral anticoagulant. With the hemostatic support of high-dose PCC, early surgery after administration of rivaroxaban seems feasible in case of an emergency indication, but should only be considered when delaying surgery is esteemed hazardous to the patient. More experience is needed to allow balancing risks and benefits of urgent vs delayed intervention and on the optimal hemostatic support in the absence of a specific antidote.
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Affiliation(s)
- Jan De Vlieger
- Department of NeurosurgeryUniversity Hospitals LeuvenLeuvenBelgium
| | - Sofie Dietvorst
- Department of NeurosurgeryUniversity Hospitals LeuvenLeuvenBelgium
| | - Rik Demaerel
- Department of NeurosurgeryUniversity Hospitals LeuvenLeuvenBelgium
| | - Peter Verhamme
- Department of Cardiovascular SciencesUniversity Hospitals LeuvenLeuvenBelgium
| | - Bart Nuttin
- Department of NeurosurgeryUniversity Hospitals LeuvenLeuvenBelgium
| | - Thomas Vanassche
- Department of Cardiovascular SciencesUniversity Hospitals LeuvenLeuvenBelgium
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Major publications in the critical care pharmacotherapy literature: January-December 2016. J Crit Care 2017; 43:327-339. [PMID: 28974331 DOI: 10.1016/j.jcrc.2017.09.178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 08/10/2017] [Accepted: 09/21/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE To summarize select critical care pharmacotherapy guidelines and studies published in 2016. SUMMARY The Critical Care Pharmacotherapy Literature Update (CCPLU) Group screened 31 journals monthly for relevant pharmacotherapy articles and selected 107 articles for review over the course of 2016. Of those included in the monthly CCPLU, three guidelines and seven primary literature studies are reviewed here. The guideline updates included are as follows: hospital-acquired pneumonia and ventilator-associated pneumonia management, sustained neuromuscular blocking agent use, and reversal of antithrombotics in intracranial hemorrhage (ICH). The primary literature summaries evaluate the following: dexmedetomidine for delirium prevention in post-cardiac surgery, dexmedetomidine for delirium management in mechanically ventilated patients, high-dose epoetin alfa after out-of-hospital cardiac arrest, ideal blood pressure targets in ICH, hydrocortisone in severe sepsis, procalcitonin-guided antibiotic de-escalation, and empiric micafungin therapy. CONCLUSION The review provides a synopsis of select pharmacotherapy publications in 2016 applicable to clinical practice.
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Kaatz S, Bhansali H, Gibbs J, Lavender R, Mahan CE, Paje DG. Reversing factor Xa inhibitors - clinical utility of andexanet alfa. J Blood Med 2017; 8:141-149. [PMID: 28979172 PMCID: PMC5602457 DOI: 10.2147/jbm.s121550] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Approximately half of patients started on an oral anticoagulant in the USA now receive one of the newer direct oral anticoagulants (DOACs). Although there is an approved reversal agent for the direct thrombin inhibitor dabigatran, a specific reversal agent for the anti-factor Xa (FXa) DOACs has yet to be licensed. Unlike the strategy to reverse the only oral direct thrombin inhibitor with idarucizumab, which is a humanized monoclonal antibody fragment, a different approach is necessary to design a single agent that can reverse multiple anti-FXa medications. Andexanet alfa is a FXa decoy designed to reverse all anticoagulants that act through this part of the coagulation cascade including anti-FXa DOACs, such as apixaban, edoxaban and rivaroxaban, and indirect FXa inhibitors such as low-molecular-weight heparins. This narrative reviews the development of andexanet alfa and explores its basic science, pharmacokinetics/pharmacodynamics, animal models, and human studies.
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Affiliation(s)
| | | | - Joseph Gibbs
- Department of Internal Medicine, Henry Ford Hospital, Detroit, MI
| | - Robert Lavender
- Division of General Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR
| | - Charles E Mahan
- University of New Mexico, Presbyterian Healthcare Services, Albuquerque, NM
| | - David G Paje
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
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Ebner M, Birschmann I, Peter A, Härtig F, Spencer C, Kuhn J, Blumenstock G, Zuern CS, Ziemann U, Poli S. Emergency Coagulation Assessment During Treatment With Direct Oral Anticoagulants. Stroke 2017; 48:2457-2463. [DOI: 10.1161/strokeaha.117.017981] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 07/11/2017] [Accepted: 07/12/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Matthias Ebner
- From the Department of Internal Medicine and Cardiology, Charité University Medicine Berlin–Campus Virchow Klinikum, Germany (M.E.); Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.); Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., F.H., C.S., U.Z., S.P.), Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry of the Department of
| | - Ingvild Birschmann
- From the Department of Internal Medicine and Cardiology, Charité University Medicine Berlin–Campus Virchow Klinikum, Germany (M.E.); Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.); Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., F.H., C.S., U.Z., S.P.), Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry of the Department of
| | - Andreas Peter
- From the Department of Internal Medicine and Cardiology, Charité University Medicine Berlin–Campus Virchow Klinikum, Germany (M.E.); Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.); Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., F.H., C.S., U.Z., S.P.), Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry of the Department of
| | - Florian Härtig
- From the Department of Internal Medicine and Cardiology, Charité University Medicine Berlin–Campus Virchow Klinikum, Germany (M.E.); Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.); Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., F.H., C.S., U.Z., S.P.), Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry of the Department of
| | - Charlotte Spencer
- From the Department of Internal Medicine and Cardiology, Charité University Medicine Berlin–Campus Virchow Klinikum, Germany (M.E.); Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.); Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., F.H., C.S., U.Z., S.P.), Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry of the Department of
| | - Joachim Kuhn
- From the Department of Internal Medicine and Cardiology, Charité University Medicine Berlin–Campus Virchow Klinikum, Germany (M.E.); Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.); Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., F.H., C.S., U.Z., S.P.), Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry of the Department of
| | - Gunnar Blumenstock
- From the Department of Internal Medicine and Cardiology, Charité University Medicine Berlin–Campus Virchow Klinikum, Germany (M.E.); Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.); Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., F.H., C.S., U.Z., S.P.), Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry of the Department of
| | - Christine S. Zuern
- From the Department of Internal Medicine and Cardiology, Charité University Medicine Berlin–Campus Virchow Klinikum, Germany (M.E.); Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.); Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., F.H., C.S., U.Z., S.P.), Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry of the Department of
| | - Ulf Ziemann
- From the Department of Internal Medicine and Cardiology, Charité University Medicine Berlin–Campus Virchow Klinikum, Germany (M.E.); Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.); Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., F.H., C.S., U.Z., S.P.), Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry of the Department of
| | - Sven Poli
- From the Department of Internal Medicine and Cardiology, Charité University Medicine Berlin–Campus Virchow Klinikum, Germany (M.E.); Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Bad Oeynhausen, Ruhr University, Bochum, Germany (I.B., J.K.); Department of Neurology and Stroke, and Hertie Institute for Clinical Brain Research (M.E., F.H., C.S., U.Z., S.P.), Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry of the Department of
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Sennesael AL, Exner T, Chatelain B, Lessire S, Larock AS, Vancraeynest C, Pochet L, Dogné JM, Spinewine A, Mullier F, Douxfils J. An optimized dRVVT-based assay to estimate the intensity of anticoagulation in patients treated with direct oral anticoagulants. Thromb Res 2017; 157:29-37. [DOI: 10.1016/j.thromres.2017.06.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2017] [Revised: 06/16/2017] [Accepted: 06/27/2017] [Indexed: 11/27/2022]
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Colombini MP, Derogis PBMC, de Aranda VF, de Campos Guerra JC, Hamerschlak N, Mangueira CLP. Comparison of different laboratory tests in the evaluation of hemorrhagic risk of patients using rivaroxaban in the critical care setting: diagnostic accuracy study. Thromb J 2017; 15:21. [PMID: 28814943 PMCID: PMC5557535 DOI: 10.1186/s12959-017-0140-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Accepted: 06/26/2017] [Indexed: 01/19/2023] Open
Abstract
Background Rivaroxaban is a direct oral anticoagulant designed to dispense with the necessity of laboratory monitoring. However, monitoring rivaroxaban levels is necessary in certain clinical conditions, especially in the critical care setting. Methods This is a diagnostic accuracy study evaluating sensitivity and specificity of prothrombin time (PT), activated partial thromboplastin time (aPTT), and Dilute Russell viper venom time (dRVVT), to evaluate the hemorrhagic risk in patients taking rivaroxaban. The study used a convenience sample of 40 clinically stable patients using rivaroxaban to treat deep vein thrombosis or atrial fibrillation admitted in a private hospital in Brazil, compared to a group of 60 healthy controls. The samples from patients were collected two hours after the use of the medication (peak) and two hours before the next dose (trough). Results The correlation with the plasmatic concentration measured by anti-FXa assay was higher for PT and dRVVTS. The PT and aPTT tests presented higher specificity, while dRVVT was 100% sensible. Conclusions There was a strong correlation between the tests and the plasma concentration of the drug. Additionally, our results demonstrated the potential use of dRVVT as a screening test in the emergency room and the need of a second test to improve specificity.
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Affiliation(s)
- Marjorie Paris Colombini
- Department of Diagnostic and Preventive Medicine and Clinical Laboratory, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Valdir Fernandes de Aranda
- Department of Diagnostic and Preventive Medicine and Clinical Laboratory, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - João Carlos de Campos Guerra
- Department of Diagnostic and Preventive Medicine and Clinical Laboratory, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Nelson Hamerschlak
- Department of Hematology, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Studt JD, Alberio L, Angelillo-Scherrer A, Asmis LM, Fontana P, Korte W, Mendez A, Schmid P, Stricker H, Tsakiris DA, Wuillemin WA, Nagler M. Accuracy and consistency of anti-Xa activity measurement for determination of rivaroxaban plasma levels. J Thromb Haemost 2017; 15:1576-1583. [PMID: 28574652 DOI: 10.1111/jth.13747] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Indexed: 12/18/2022]
Abstract
Essentials Accurate determination of anticoagulant plasma concentration is important in clinical practice. We studied the accuracy and consistency of anti-Xa assays for rivaroxaban in a multicentre study. In a range between 50 and 200 μg L-1 , anti-Xa activity correlated well with plasma concentrations. The clinical value might be limited by overestimation and intra- and inter-individual variation. SUMMARY Background Determining the plasma level of direct oral anticoagulants reliably is important in the work-up of complex clinical situations. Objectives To study the accuracy and consistency of anti-Xa assays for rivaroxaban plasma concentration in a prospective, multicenter evaluation study employing different reagents and analytical platforms. Methods Rivaroxaban 20 mg was administered once daily to 20 healthy volunteers and blood samples were taken at peak and trough levels (clinicaltrials.gov NCT01710267). Anti-Xa activity was determined in 10 major laboratories using different reagents and analyzers; corresponding rivaroxaban plasma concentrations were measured by high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS). Findings Overall Pearson's correlation coefficient of anti-Xa levels and HPLC-MS results was 0.99 for Biophen® Heparin (95% CI, 0.99, 0.99), Biophen® DiXaI (95% CI, 0.99, 0.99) and STA® anti-Xa liquid (95% CI, 0.99, 1.00). Correlation was lower in rivaroxaban concentrations below 50 μg L-1 and above 200 μg L-1 . The overall bias of the Bland-Altman difference plot was 14.7 μg L-1 for Biophen Heparin, 17.9 μg L-1 for Biophen DiXal and 19.0 μg L-1 for STA anti-Xa liquid. Agreement between laboratories was high at peak level but limited at trough level. Conclusions Anti-Xa activity correlated well with rivaroxaban plasma concentrations, especially in a range between 50 and 200 μg L-1 . However, anti-Xa assays systematically overestimated rivaroxaban concentration as compared with HPLC-MS, particularly at higher concentrations. This overestimation, coupled with an apparent interindividual variation, might affect the interpretation of results in some situations.
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Affiliation(s)
- J-D Studt
- Division of Haematology, University Hospital and University of Zurich, Zurich, Switzerland
| | - L Alberio
- Service and Central Laboratory of Haematology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - A Angelillo-Scherrer
- Department of Haematology, Inselspital, Bern University Hospital, Berne, Switzerland
- Department of Clinical Research, University of Bern, Berne, Switzerland
| | | | - P Fontana
- Division of Angiology and Haemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - W Korte
- Institute for Clinical Chemistry and Haematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - A Mendez
- Centre for Laboratory Medicine, Cantonal Hospital Aarau, Aarau, Switzerland
| | - P Schmid
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, Lucerne, Switzerland
| | - H Stricker
- Division of Surgery, Regional Hospital La Carita, Locarno, Switzerland
| | - D A Tsakiris
- Diagnostic Haematology, University Hospital of Basel, Basel, Switzerland
| | - W A Wuillemin
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, Lucerne, Switzerland
- Department of Clinical Research, University of Berne, Berne, Switzerland
| | - M Nagler
- Department of Haematology, Inselspital, Bern University Hospital, Berne, Switzerland
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, Lucerne, Switzerland
- Department of Clinical Research, University of Berne, Berne, Switzerland
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Moss AS, Dimitropoulous G, Lip GYH. Clinical implications, benefits and pitfalls of using and reversing non-vitamin K antagonist oral anticoagulants. Expert Rev Hematol 2017; 10:833-845. [PMID: 28741391 DOI: 10.1080/17474086.2017.1358085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The use of non-Vitamin K antagonist oral anticoagulant (NOAC) drugs is increasingly common in clinical practice. As compared to vitamin K antagonists they are more straightforward to initiate, require no hematological monitoring and offer potentially more stable therapeutic indices. Concern has been raised with regard to their safety profiles particularly in the context of acute reversal in major bleeding. Further issues pertain to patient concordance. Areas covered: This review article aims to provide an overview of the current evidence relating to NOAC safety as well as the management of NOAC-related major bleeding with particular emphasis on reversal agents in use and in development following a selective literature review. Second, the effects of medication concordance and dosing regimens on NOAC efficacy will be considered. Expert commentary: The short half-lives and low overall bleeding risk of NOACs is likely to mean that specific reversal agents in development are infrequently required and costly with associated practicality issues with their use in clinical emergencies. Concern regarding patient concordance can be practicably addressed with appropriate medication, dosing regimen and patient selection and continuous education with active, informed patient involvement in the decision-making process.
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Affiliation(s)
- Alexandra Sophie Moss
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , United Kingdom.,b Cardiology Department , City Hospital , Birmingham , United Kingdom
| | - Gerasimos Dimitropoulous
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , United Kingdom.,b Cardiology Department , City Hospital , Birmingham , United Kingdom
| | - Gregory Y H Lip
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , United Kingdom.,b Cardiology Department , City Hospital , Birmingham , United Kingdom.,c Aalborg Thrombosis Research Unit, Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
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Godier A, Dincq AS, Martin AC, Radu A, Leblanc I, Antona M, Vasse M, Golmard JL, Mullier F, Gouin-Thibault I. Predictors of pre-procedural concentrations of direct oral anticoagulants: a prospective multicentre study. Eur Heart J 2017; 38:2431-2439. [DOI: 10.1093/eurheartj/ehx403] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 06/29/2017] [Indexed: 12/20/2022] Open
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Auer J, Huber K, Granger CB. Interruption of non-vitamin K antagonist anticoagulants in patients undergoing planned invasive procedures: how long is long enough? Eur Heart J 2017; 38:2440-2443. [DOI: 10.1093/eurheartj/ehx416] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Vornicu O, Larock AS, Dincq AS, Douxfils J, Dogné JM, Mullier F, Lessire S. Idarucizumab for the treatment of hemorrhage and dabigatran reversal in patients requiring urgent surgery or procedures. Expert Opin Biol Ther 2017; 17:1275-1296. [DOI: 10.1080/14712598.2017.1349749] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Ovidiu Vornicu
- Department of Anesthesiology, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Anne-Sophie Larock
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Department of Pharmacy, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Anne-Sophie Dincq
- Department of Anesthesiology, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| | - Jonathan Douxfils
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Université de Namur, Namur, Belgium
| | - Jean-Michel Dogné
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Université de Namur, Namur, Belgium
| | - François Mullier
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Hematology Laboratory, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Sarah Lessire
- Department of Anesthesiology, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Université de Namur, Namur, Belgium
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Maegele M, Schöchl H, Menovsky T, Maréchal H, Marklund N, Buki A, Stanworth S. Coagulopathy and haemorrhagic progression in traumatic brain injury: advances in mechanisms, diagnosis, and management. Lancet Neurol 2017; 16:630-647. [PMID: 28721927 DOI: 10.1016/s1474-4422(17)30197-7] [Citation(s) in RCA: 189] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Revised: 05/08/2017] [Accepted: 05/30/2017] [Indexed: 01/28/2023]
Abstract
Normal haemostasis depends on an intricate balance between mechanisms of bleeding and mechanisms of thrombosis, and this balance can be altered after traumatic brain injury (TBI). Impaired haemostasis could exacerbate the primary insult with risk of initiation or aggravation of bleeding; anticoagulant use at the time of injury can also contribute to bleeding risk after TBI. Many patients with TBI have abnormalities on conventional coagulation tests at admission to the emergency department, and the presence of coagulopathy is associated with increased morbidity and mortality. Further blood testing often reveals a range of changes affecting platelet numbers and function, procoagulant or anticoagulant factors, fibrinolysis, and interactions between the coagulation system and the vascular endothelium, brain tissue, inflammatory mechanisms, and blood flow dynamics. However, the degree to which these coagulation abnormalities affect TBI outcomes and whether they are modifiable risk factors are not known. Although the main challenge for management is to address the risk of hypocoagulopathy with prolonged bleeding and progression of haemorrhagic lesions, the risk of hypercoagulopathy with an increased prothrombotic tendency also warrants consideration.
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Affiliation(s)
- Marc Maegele
- Department for Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Center, University Witten/Herdecke, Cologne, Germany; Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany.
| | - Herbert Schöchl
- Department for Anaesthesiology and Intensive Care Medicine, AUVA Trauma Academic Teaching Hospital, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Tomas Menovsky
- Department for Neurosurgery, Antwerp University Hospital, University of Antwerp, Edegem, Belgium
| | - Hugues Maréchal
- Department of Anaesthesiology and Intensive Care Medicine, CRH La Citadelle, Liège, Belgium
| | - Niklas Marklund
- Department of Clinical Sciences, Division of Neurosurgery, University Hospital of Southern Sweden, Lund University, Lund, Sweden
| | - Andras Buki
- Department of Neurosurgery, The MTA-PTE Clinical Neuroscience MR Research Group, Janos Szentagothai Research Center, Hungarian Brain Research Program, University of Pécs, Pécs, Hungary
| | - Simon Stanworth
- NHS Blood and Transplant/Oxford University Hospitals NHS Foundation Trust, University of Oxford, John Radcliffe Hospital, Oxford, UK
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Gosselin RC, Gosselin R, Douxfils J, Adcock D. Clinical pearls: Laboratory assessments of direct oral anticoagulants (DOACS). Hamostaseologie 2017; 37:17-01-0002. [PMID: 28678302 DOI: 10.5482/hamo-17-01-0002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Accepted: 05/05/2017] [Indexed: 11/05/2022] Open
Abstract
Direct oral anticoagulants (DOACS) are being used for stroke prevention in patients with atrial fibrillation as well as for prophylaxis and treatment of venous thromboembolism. Clinicians who treat, or may encounter, patients with DOAC exposure, should be aware of the limitations of coagulation testing in this setting, and seek counsel from their laboratory to understand the effects of DOACS on coagulation results. Generally, assays that employ clot based principles, or methods that require thrombin or Factor Xa activation or substrates may be affected by the presence of DOACS. The clinical laboratory should have an algorithmic testing plan for adequately assessing the presence of all DOACS and readily provide this information to clinicians. We describe Clinical Pearls for DOAC assessment using common and esoteric coagulation testing.
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Affiliation(s)
| | - Robert Gosselin
- Robert C. Gosselin, University of California, Davis Health System - Pathology and Laboratory Medicine, 2315 Stockton Blvd Rm 2P344 Sacramento California 95817, United States, Tel: 916-703-6688, Fax: 916-703-5665, E-Mail:
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217
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Weitz JI, Jaffer IH, Fredenburgh JC. Recent advances in the treatment of venous thromboembolism in the era of the direct oral anticoagulants. F1000Res 2017; 6:985. [PMID: 28713563 PMCID: PMC5490483 DOI: 10.12688/f1000research.11174.1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2017] [Indexed: 12/25/2022] Open
Abstract
The direct oral anticoagulants (DOACs) have now supplanted vitamin K antagonists (VKAs) for the treatment of venous thromboembolism (VTE). The DOACs include dabigatran, which inhibits thrombin, and rivaroxaban, apixaban, and edoxaban, which inhibit factor Xa. The DOACs are as effective for the prevention of recurrence as conventional VTE treatment, consisting of a parenteral anticoagulant followed by a VKA, and are associated with less bleeding. Because of these properties and the convenience of fixed dosing without the need for routine coagulation monitoring, guidelines now recommend DOACs over VKAs for VTE treatment in patients without active cancer. This paper examines the increasing role of the DOACs for VTE treatment.
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Affiliation(s)
- Jeffrey I Weitz
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Iqbal H Jaffer
- Department of Surgery, McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - James C Fredenburgh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
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218
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Stecher A, Vene N, Mavri A, Mijovski MB, Krevel B, Gradišek P. Late rebound of dabigatran levels after idarucizumab reversal in two patients with severe renal failure. Eur J Anaesthesiol 2017; 34:400-402. [DOI: 10.1097/eja.0000000000000617] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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219
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Farge D, Bounameaux H, Brenner B, Cajfinger F, Debourdeau P, Khorana AA, Pabinger I, Solymoss S, Douketis J, Kakkar A. International clinical practice guidelines including guidance for direct oral anticoagulants in the treatment and prophylaxis of venous thromboembolism in patients with cancer. Lancet Oncol 2017; 17:e452-e466. [PMID: 27733271 DOI: 10.1016/s1470-2045(16)30369-2] [Citation(s) in RCA: 264] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 07/13/2016] [Accepted: 07/14/2016] [Indexed: 02/07/2023]
Abstract
Venous thromboembolism (VTE) is the second leading cause of death in patients with cancer. These patients are at an increased risk of developing VTE and are more likely to have a recurrence of VTE and bleeding while taking anticoagulants. Management of VTE in patients with cancer is a major therapeutic challenge and remains suboptimal worldwide. In 2013, the International Initiative on Thrombosis and Cancer (ITAC-CME), established to reduce the global burden of VTE in patients with cancer, published international guidelines for the treatment and prophylaxis of VTE and central venous catheter-associated thrombosis. The rapid global adoption of direct oral anticoagulants for management of VTE in patients with cancer is an emerging treatment trend that needs to be addressed based on the current level of evidence. In this Review, we provide an update of the ITAC-CME consensus recommendations based on a systematic review of the literature ranked according to the Grading of Recommendations Assessment, Development, and Evaluation scale. These guidelines aim to address in-hospital and outpatient cancer-associated VTE in specific subgroups of patients with cancer.
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Affiliation(s)
- Dominique Farge
- Assistance Publique-Hôpitaux de Paris, Internal Medicine: Autoimmune and Vascular Disease Unit, Saint-Louis Hospital, Paris, France; Sorbonne Paris Cité, Paris 7 Diderot University, Paris, France.
| | - Henri Bounameaux
- Division of Angiology and Hemostasis, University Hospitals of Geneva and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin Brenner
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Francis Cajfinger
- Assistance Publique-Hôpitaux de Paris, Service d'oncologie, Hôpital Pitié-Salpêtrière, Paris, France
| | | | - Alok A Khorana
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Internal Medicine, Medical University Vienna, Vienna, Austria
| | - Susan Solymoss
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Ajay Kakkar
- Thrombosis Research Institute, London, UK; University College London, London, UK
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220
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Sabor L, Raphaël M, Dogné JM, Mullier F, Douxfils J. Heparin-calibrated chromogenic anti-Xa assays are not suitable to assess the presence of significant direct factor Xa inhibitors levels. Thromb Res 2017; 156:36-38. [PMID: 28582639 DOI: 10.1016/j.thromres.2017.05.024] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 05/23/2017] [Accepted: 05/24/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Lina Sabor
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Namur Thrombosis and Hemostasis Center (NTHC), Yvoir, Belgium
| | - Mélanie Raphaël
- University of Namur, Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for Life Sciences (NARILIS), Namur, Belgium
| | - Jean-Michel Dogné
- University of Namur, Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for Life Sciences (NARILIS), Namur, Belgium
| | - François Mullier
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Namur Thrombosis and Hemostasis Center (NTHC), Yvoir, Belgium
| | - Jonathan Douxfils
- University of Namur, Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for Life Sciences (NARILIS), Namur, Belgium.
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221
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Monitoring of anticoagulant therapy in cancer patients with thrombosis and the usefulness of blood activation markers. Transfus Apher Sci 2017; 56:279-286. [PMID: 28552490 DOI: 10.1016/j.transci.2017.05.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Thrombotic diseases caused by cancer progression have been reported as one of the major causes of cancer associated morbidity and mortality along with cancer invasiveness and infectious complications. Moreover, anticoagulant therapy with heparin and heparin-like drugs, or vitamin K antagonists, or the Direct Oral Anticoagulants, is seeing an extended application in cancer patients and offers prolonged life expectancy to oncology patients for whom blood activation and thrombotic events have a variable incidence, depending on cancer type. Laboratory tools are highly useful for identifying patients at thrombotic risk through the measurement of blood activation markers and selecting those appropriate for anticoagulant therapy. Among the pathological markers, DDimer or Extracellular Vesicles have the highest diagnostic value in these pathological conditions. Global assays are useful for dosage adjustment, such as assessing either an induced anticoagulant effect or the measurement of drug activity. Various assays are also developed such as platelet aggregometry techniques for evaluating drug induced- aggregates or methods allowing measurement of the drug activity to its targeted coagulation factors such as: heparin to thrombin or Factor Xa; DOACs to Thrombin or Factor Xa (Dabigatran to thrombin and DiXaIs, Rivaroxaban, Apixaban, and Edoxaban, to Factor Xa). Such explorative techniques help to find the right dosage adjustment to protect patients from developing thrombosis without exposing them bleeding. It also permits exploration of unexpected drug behavior in treated patients, to check the right adherence to therapy in long-term anticoagulant protocols, and prevention of bleeding in patients with impaired renal or hepatic function. Complementary use of blood activation markers brings additional information on the curative effects of the anticoagulant therapy, and allows identification of pro-thrombotic activity in the clinically silent state. These issues are concisely addressed below.
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Dubois V, Dincq AS, Douxfils J, Ickx B, Samama CM, Dogné JM, Gourdin M, Chatelain B, Mullier F, Lessire S. Perioperative management of patients on direct oral anticoagulants. Thromb J 2017; 15:14. [PMID: 28515674 PMCID: PMC5433145 DOI: 10.1186/s12959-017-0137-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 05/04/2017] [Indexed: 12/31/2022] Open
Abstract
Direct oral anticoagulants (DOACs) have been licensed worldwide for several years for various indications. Each year, 10-15% of patients on oral anticoagulants will undergo an invasive procedure and expert groups have issued several guidelines on perioperative management in such situations. The perioperative guidelines have undergone numerous updates as clinical experience of emergency management has increased and perioperative studies including measurement of residual anticoagulant levels have been published. The high inter-patient variability of DOAC plasma levels has challenged the traditional recommendation that perioperative DOAC interruption should be based only on the elimination half-life of DOACs, especially before invasive procedures carrying a high risk of bleeding. Furthermore, recent publications have highlighted the potential danger of heparin bridging use when DOACs are stopped before an invasive procedure. As antidotes are progressively becoming available to manage severe bleeding or urgent procedures in patients on DOACs, accurate laboratory tests have become the standard to guide their administration and their actions need to be well understood by clinicians. This review aims to provide a systematic approach to managing patients on DOACs, based on recent updates of various perioperative guidance, and highlighting the advantages and limits of recommendations based on pharmacokinetic properties and laboratory tests.
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Affiliation(s)
- Virginie Dubois
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
| | - Anne-Sophie Dincq
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| | - Jonathan Douxfils
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université de Namur, Department of Pharmacy, Faculty of Medecine, Namur, Belgium
| | - Brigitte Ickx
- Université Libre de Bruxelles, Erasme University Hospital,Department of Anesthesiology, Brussels, Belgium
| | - Charles-Marc Samama
- Université Paris Descartes, Cochin University Hospital,Department of Anesthesiology and Intensive Care, Paris, France
| | - Jean-Michel Dogné
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université de Namur, Department of Pharmacy, Faculty of Medecine, Namur, Belgium
| | - Maximilien Gourdin
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| | - Bernard Chatelain
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Yvoir, Belgium
| | - François Mullier
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Yvoir, Belgium
| | - Sarah Lessire
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
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223
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Vosko MR, Bocksrucker C, Drwiła R, Dulíček P, Hauer T, Mutzenbach J, Schlimp CJ, Špinler D, Wolf T, Zugwitz D. Real-life experience with the specific reversal agent idarucizumab for the management of emergency situations in dabigatran-treated patients: a series of 11 cases. J Thromb Thrombolysis 2017; 43:306-317. [PMID: 28210988 PMCID: PMC5337234 DOI: 10.1007/s11239-017-1476-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) have a favorable benefit-risk profile compared with vitamin K antagonists. However, the lack of specific reversal agents has made the management of some patients receiving long-term treatment with NOACs problematic in emergency situations such as major bleeding events or urgent procedures. Idarucizumab, a fully humanized Fab antibody fragment that binds specifically and with high affinity to dabigatran, was recently approved for use in adult patients treated with dabigatran when rapid reversal of its anticoagulant effect is required. Clinical experience with idarucizumab is currently limited. We report 11 real-life clinical cases in which idarucizumab was used after multidisciplinary consultation in a variety of emergency situations including severe postoperative bleeding, emergency high-bleeding-risk surgery (hip/spine surgery and neurosurgery), invasive diagnostic testing (lumbar puncture), intracranial bleeding (pre-pontine subarachnoid hemorrhage and lobar intracerebral hemorrhage) and thrombolysis with recombinant tissue plasminogen activator for acute ischemic stroke. This case series illustrates the role of idarucizumab in improving patient safety in rare emergency situations requiring rapid reversal of the anticoagulant effect of dabigatran, while highlighting the importance of information and education about the availability and appropriate use of this recently approved specific reversal agent.
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Affiliation(s)
- Milan R Vosko
- Department of Neurology 2, Kepler Universitätsklinikum, Med Campus III, Krankenhausstr. 9, 4020, Linz, Austria.
| | | | - Rafał Drwiła
- Department of Anesthesiology and Intensive Care, John Paul II Hospital, Medical College of Jagiellonian University, Krakow, Poland
| | - Petr Dulíček
- Fourth Department of Internal Medicine, Hematology, Hradec Králové Faculty of Medicine, Hradec Králové University Hospital, Hradec Králové, Czech Republic
| | - Tomas Hauer
- Department of Internal Medicine, České Budějovice Regional Hospital, and Faculty of Health and Science, University of South Bohemia, České Budějovice, Czech Republic
| | - Johannes Mutzenbach
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Schlimp
- Department of Anesthesiology and Intensive Care, AUVA Trauma Hospital, Klagenfurt, Austria
| | - David Špinler
- Department of Internal Medicine, Ústí nad Orlicí Hospital, Ústí nad Labem, Czech Republic
- Department of Cardiology, Pardubice Regional Hospital, Pardubice, Czech Republic
| | - Thomas Wolf
- Department of Neurology, Wiener Neustadt Regional Hospital, Wiener Neustadt, Austria
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224
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Prisco D, Ageno W, Becattini C, D'Angelo A, Davì G, De Cristofaro R, Dentali F, Di Minno G, Falanga A, Gussoni G, Masotti L, Palareti G, Pignatelli P, Santi RM, Santilli F, Silingardi M, Tufano A, Violi F. Italian intersociety consensus on DOAC use in internal medicine. Intern Emerg Med 2017; 12:387-406. [PMID: 28191610 DOI: 10.1007/s11739-017-1628-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Accepted: 02/02/2017] [Indexed: 12/15/2022]
Abstract
The direct oral anticoagulants (DOACs) are drugs used in clinical practice since 2009 for the prevention of stroke or systemic embolism in non-valvular atrial fibrillation, and for the treatment and secondary prevention of venous thromboembolism. The four DOACs, including the three factor Xa inhibitors (rivaroxaban, apixaban and edoxaban) and one direct thrombin inhibitor (dabigatran) provide oral anticoagulation therapy alternatives to Vitamin K antagonists (VKAs). Despite their clear advantages, the DOACs require on the part of the internist a thorough knowledge of their pharmacokinetic and pharmacodynamic characteristics to ensure their correct use, laboratory monitoring and the appropriate management of adverse events. This document represents a consensus paper on the use of DOACs by representatives of three Italian scientific societies: the Italian Society of Internal Medicine (SIMI), the Federation of the Associations of Hospital Managers (FADOI), and the Society for the Study of Haemostasis and Thrombosis (SISET). This document formulates expert opinion guidance for pragmatic managing, monitoring and reversing the anticoagulant effect of DOACs in both chronic and emergency settings. This practical guidance may help the internist to create adequate protocols for patients hospitalized ion internal medicine wards, where patients are often elderly subjects affected by poly-morbidities and renal insufficiency, and, thus, require particular attention to drug-drug interactions and peri-procedural protocols.
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Affiliation(s)
- Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.
| | - Walter Ageno
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - Cecilia Becattini
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Perugia, Italy
| | - Armando D'Angelo
- Coagulation Service and Thrombosis Research Unit, Scientific Institute San Raffaele, Milan, Italy
| | - Giovanni Davì
- Clinica Medica, Department of Medicine and Aging Sciences, University of Chieti G.D'Annunzio, Chieti, Italy
| | - Raimondo De Cristofaro
- Institute of Internal Medicine and Geriatrics, Center for Haemorrhagic and Thrombotic Diseases, Haematology, Foundation Policlinico universitario "Agostino Gemelli", Catholic University of the Sacred Heart, Rome, Italy
| | - Francesco Dentali
- Department of Clinical and Experimental Medicine, Insubria University, Varese, Italy
| | - Giovanni Di Minno
- Clinica Medica, Department of Clinical Medicine and Surgery, AOU Policlinico Federico II, Naples, Italy
| | - Anna Falanga
- Department of Immunohematology and Transfusion Medicine, and the Thrombosis and Hemostasis Center, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | | | - Luca Masotti
- Internal Medicine, Santa Maria Nuova Hospital, Florence, Italy
| | | | - Pasquale Pignatelli
- Department of Internal Medicine and Medical Specialties, "La Sapienza" University of Rome, Rome, Italy
| | - Roberto M Santi
- Haemostasis and Thrombosis Unit, Haematology, Az. Osp. "SS.Antonio e Biagio e C. Arrigo", Alessandria, Italy
| | - Francesca Santilli
- Clinica Medica, Department of Medicine and Aging Sciences, University of Chieti G.D'Annunzio, Chieti, Italy
| | - Mauro Silingardi
- Internal Medicine Unit A - Ospedale Maggiore, AUSL Bologna, Bologna, Italy
| | - Antonella Tufano
- Clinica Medica, Department of Clinical Medicine and Surgery, AOU Policlinico Federico II, Naples, Italy
| | - Francesco Violi
- Department of Internal Medicine and Medical Specialties, "La Sapienza" University of Rome, Rome, Italy
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225
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Bertoletti L, Ollier E, Duvillard C, Delavenne X, Beyens MN, De Magalhaes E, Bellet F, Basset T, Mismetti P, Laporte S. Direct oral anticoagulants: Current indications and unmet needs in the treatment of venous thromboembolism. Pharmacol Res 2017; 118:33-42. [DOI: 10.1016/j.phrs.2016.06.023] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 06/22/2016] [Accepted: 06/23/2016] [Indexed: 12/11/2022]
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226
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Van Blerk M, Bailleul E, Chatelain B, Demulder A, Devreese K, Douxfils J, Jacquemin M, Jochmans K, Mullier F, Wijns W, China B, Vernelen K, Soumali MR. Influence of apixaban on commonly used coagulation assays: results from the Belgian national External Quality Assessment Scheme. Int J Lab Hematol 2017; 39:402-408. [DOI: 10.1111/ijlh.12640] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Accepted: 01/16/2017] [Indexed: 12/16/2022]
Affiliation(s)
- M. Van Blerk
- Department of Quality of Medical Laboratories; Scientific Institute of Public Health; Brussels Belgium
| | | | | | | | | | | | | | | | | | - W. Wijns
- EQA Advisory Board; Brussels Belgium
| | - B. China
- Department of Quality of Medical Laboratories; Scientific Institute of Public Health; Brussels Belgium
| | - K. Vernelen
- Department of Quality of Medical Laboratories; Scientific Institute of Public Health; Brussels Belgium
| | - M. R. Soumali
- Department of Quality of Medical Laboratories; Scientific Institute of Public Health; Brussels Belgium
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227
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Abstract
An understanding of how to counteract the anticoagulant effect of direct oral anticoagulants is essential in the event of haemorrhage, emergency surgery and overdose. This review summarizes strategies for the reversal of direct oral anticoagulants, including the use of novel agents.
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Affiliation(s)
- X-Y Zhang
- Haematology Specialist Registrar, Department of Haematology, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford
| | - M J Desborough
- Clinical Research Fellow, NHS Blood and Transplant, John Radcliffe Hospital, Oxford, and Oxford Clinical Research in Transfusion Medicine, Nuffield Division of Clinical Laboratory Sciences, University of Oxford, Oxford
| | - S Shapiro
- Consultant Haematologist, Oxford Haemophilia and Thrombosis Centre, Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford OX3 7LE
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228
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Reversal of dabigatran-associated major bleeding with activated prothrombin concentrate: A prospective cohort study. Thromb Res 2017; 152:44-48. [PMID: 28222322 DOI: 10.1016/j.thromres.2017.02.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 02/03/2017] [Accepted: 02/14/2017] [Indexed: 11/20/2022]
Abstract
The reversal of dabigatran-associated major bleeding can now be achieved with the antidote idarucizumab. We evaluated activated prothrombin complex concentrate (aPCC) as an alternative for this purpose. Patients treated with dabigatran and suffering a major bleed were treated as per existing hospital protocol with aPCC. They were subsequently recruited for a 30-day follow-up. Effectiveness was evaluated by the treating physician, using an Assessment Guide. Safety outcomes were arterial or venous thromboembolism or death. A comparison was also made with historic cases with dabigatran-associated major bleeds treated with supportive care, by matching 1:2 for type of bleed, age and sex. We aimed at 32 evaluable cases but the study was prematurely discontinued after 14 cases due to the availability of the approved antidote. The effectiveness of aPCC was assessed as Good in 9 (64%), moderate in 5 (36%) and poor in none. There were no thromboembolic events and one death. In the secondary adjudication of effectiveness, using the same criteria and by the same adjudicators as previously done for the historic cases, the outcome was graded for the current cases versus the historic cases as Good, Moderate, or Poor in 10 (71%) versus 16 (57%), 3 (21%) versus 4 (14%), and 1 (7%) versus 8 (29%), respectively. Although supportive care is sufficient to manage many patients with dabigatran-associated bleeding, aPCC might provide an additional benefit to control life-threatening bleeding in selected cases and does not appear to cause an excess of thromboembolic events.
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229
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Gendron N, Feral-Pierssens AL, Jurcisin I, de Raucourt E, Bouton V, Fischer AM, Lorenceau-Savale C, Lillo-Le Louët A, Smadja DM. Real-world use of idarucizumab for dabigatran reversal in three cases of serious bleeding. Clin Case Rep 2017; 5:346-350. [PMID: 28265404 PMCID: PMC5331231 DOI: 10.1002/ccr3.839] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 10/25/2016] [Accepted: 12/24/2016] [Indexed: 12/24/2022] Open
Abstract
Bleeding is a rare complication of direct oral anticoagulant potentially associated with high mortality rates. Biological monitoring is necessary for more than 24 h after idarucizumab antidote therapy in case of bleeding with dabigatran therapy.
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Affiliation(s)
- Nicolas Gendron
- Hematology Department AP-HP European Hospital Georges Pompidou Paris France; Sorbonne Paris Cite Université Paris Descartes Paris France; Inserm UMR-S1140 Paris France
| | | | - Igor Jurcisin
- Intensive Care Unit AP-HP Beaujon Hospital Paris France
| | | | | | - Anne Marie Fischer
- Hematology Department AP-HP European Hospital Georges Pompidou Paris France; Sorbonne Paris Cite Université Paris Descartes Paris France; Inserm UMR-S970 PARCC Paris France
| | - Camille Lorenceau-Savale
- Department of Gastroenterology and Endoscopy AP-HP European Hospital Georges Pompidou Paris France
| | - Agnès Lillo-Le Louët
- Regional Center of Pharmacovigilance AP-HP European Hospital Georges Pompidou Paris France
| | - David M Smadja
- Hematology Department AP-HP European Hospital Georges Pompidou Paris France; Sorbonne Paris Cite Université Paris Descartes Paris France; Inserm UMR-S1140 Paris France
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230
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Plitt A, Bansilal S. The Nonvitamin K Antagonist Oral Anticoagulants and Atrial Fibrillation: Challenges and Considerations. J Atr Fibrillation 2017; 9:1547. [PMID: 29250278 PMCID: PMC5673394 DOI: 10.4022/jafib.1547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 01/20/2017] [Accepted: 01/23/2017] [Indexed: 01/18/2023]
Abstract
The nonvitamin K antagonist oral anticoagulants (NOACs) dabigatran, rivaroxaban, apixaban, and edoxaban are used for the reduction of the risk of stroke or systemic embolism (SEE) in patients with nonvalvular atrial fibrillation (NVAF). The purpose of this review is to highlight the safety and efficacy results of the pivotal NOAC clinical trials for use in NVAF, discuss some of the unique management challenges in the use of NOACs in special populations, summarize data on emerging and novel indications, and address potential future directions. METHODS A literature search was conducted and to identify relevant clinical trials and studies regarding the use of NOACs for the prevention of stroke or SEE in patients with atrial fibrillation. RESULTS Relative to warfarin, NOACs are as effective or superior in the prevention of stroke or SEE, and are associated with similar or lower rates of major bleeding and significantly decreased rates of intracranial bleeding, but may be associated with a slightly increased risk of gastrointestinal bleeding in patients with AF. The NOACs are not indicated for use and have not been widely tested in AF patients with other cardiovascular conditions. Additional ongoing and planned clinical trials will provide additional information regarding the use of NOACs in these patients. In situations requiring rapid reversal of anticoagulation, the availability of specific antidotes will improve safety and facilitate NOAC use. CONCLUSIONS Use of NOACs in clinical practice requires consideration of patient characteristics as well as potentially required procedures.
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Affiliation(s)
- Anna Plitt
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sameer Bansilal
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY
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Becattini C, Franco L, Beyer-Westendorf J, Masotti L, Nitti C, Vanni S, Manina G, Cattinelli S, Cappelli R, Sbrojavacca R, Pomero F, Marten S, Agnelli G. Major bleeding with vitamin K antagonists or direct oral anticoagulants in real-life. Int J Cardiol 2017; 227:261-266. [DOI: 10.1016/j.ijcard.2016.11.117] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Accepted: 11/06/2016] [Indexed: 10/20/2022]
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Ruff CT, Giugliano RP, Antman EM. Management of Bleeding With Non-Vitamin K Antagonist Oral Anticoagulants in the Era of Specific Reversal Agents. Circulation 2016; 134:248-61. [PMID: 27436881 DOI: 10.1161/circulationaha.116.021831] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Vitamin K antagonists are commonly used by clinicians to provide anticoagulation to patients who have or are at risk of having thrombotic events. In addition to familiarity with the dosing and monitoring of vitamin K antagonists, clinicians are accustomed to using vitamin K if there is a need to reverse the anticoagulant effect of vitamin K antagonists. There are now 4 new non-vitamin K antagonist oral anticoagulants (NOACs) that are attractive alternatives to vitamin K antagonists. Despite similar or lower rates of serious bleeding with NOACs in comparison with warfarin, there is a pressing need for strategies to manage bleeding when it does occur with NOACs and to reverse the pharmacological effect of these agents if needed. Important steps in minimizing bleeding risks with NOACs include dose adjustment of the agents in the setting of renal dysfunction and avoidance of the concomitant use of other antithrombotic agents if feasible. Laboratory measurement of the anticoagulant effect of NOACs is best accomplished with specialized assays, although some of the more widely available coagulation tests can provide information that is potentially useful to clinicians. Nonspecific hemostatic agents such as prothrombin complex concentrates and recombinant factor VIIa can be used to reverse the effect of NOACs. More specific reversing agents include the approved humanized monoclonal antibody fragment idarucizumab for reversing the effects of dabigatran, the investigational factor Xa decoy andexanet alfa, and the synthetic small molecule ciraparantag. Both andexanet and ciraparantag have been reported to reverse the effects of the anti-Xa NOACs (rivaroxaban, apixaban, and edoxaban), and a number of other anticoagulant agents in common clinical use, as well.
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Affiliation(s)
- Christian T Ruff
- From TIMI Study Group, Cardiovascular Medicine Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
| | - Robert P Giugliano
- From TIMI Study Group, Cardiovascular Medicine Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Elliott M Antman
- From TIMI Study Group, Cardiovascular Medicine Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
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234
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Abstract
Patients taking direct oral anticoagulants (DOACs) who then need an emergency invasive procedure require specialized management strategies. Appropriate patient evaluation includes assessment of the current anticoagulation state, including timing of the last dose. DOACs require particular coagulation assays to measure anticoagulation levels accurately, although standard coagulation screening tests may provide qualitative guidance. Specialty societies have endorsed general recommendations for patient management to promote hemostasis in anticoagulated patients requiring surgery or other invasive procedures. These include general stopping rules (such as ≥24 hours for low-risk procedures and ≥48 hours for high-risk surgery with normal renal function) for elective procedures. Bridging therapy when oral anticoagulant treatment is interrupted has recently been questioned, depending on the clinical scenario. Novel agents for the reversal of DOAC-induced anticoagulation have recently been developed. Idarucizumab, a humanized monoclonal antibody fragment that selectively binds dabigatran, was recently approved for clinical use in patients with life-threatening or uncontrolled bleeding, and for patients requiring emergency interventions. Idarucizumab can streamline the pre- and periprocedural anticoagulation management of dabigatran-treated patients, as it provides fast, complete, and sustainable reversibility. Andexanet alfa is an inactive, decoy factor Xa (FXa) molecule that binds FXa inhibitors, and ciraparantag is a synthetic molecule designed to bind fractionated and unfractionated heparins, and each of the currently approved DOACs. As clinical development of the additional anti-FXa-specific anticoagulant reversal agents proceeds, the respective role of each in the management of emergency bleeding events and invasive procedures will be better defined, and it is hoped they will make important contributions to patient care.
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235
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Discontinuation and management of direct-acting anticoagulants for emergency procedures. Am J Emerg Med 2016; 34:14-18. [DOI: 10.1016/j.ajem.2016.09.048] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Shapiro S, Bhatnagar N, Khan A, Beavis J, Keeling D. Idarucizumab for dabigatran overdose in a child. Br J Haematol 2016; 180:457-459. [DOI: 10.1111/bjh.14371] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Susan Shapiro
- Oxford Haemophilia and Thrombosis Centre; Oxford University Hospitals NHS Foundation Trust; Oxford Comprehensive Biomedical Resource Centre*; Oxford UK
| | - Neha Bhatnagar
- Department of Paediatric Haematology; John Radcliffe Hospital; Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - Asif Khan
- Department of Haematology; Royal Berkshire Hospital; Reading UK
| | - James Beavis
- Haemostasis Laboratory; Churchill Hospital; Oxford University Hospitals NHS Foundation Trust; Oxford UK
| | - David Keeling
- Oxford Haemophilia and Thrombosis Centre; Oxford University Hospitals NHS Foundation Trust; Oxford Comprehensive Biomedical Resource Centre*; Oxford UK
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Abstract
The group of new oral anticoagulants or NOACs, now termed direct oral anticoagulants or DOACs, with their favourable results from large scale phase III clinical trials, represent a major advancement and expanded armamentarium in antithrombotic therapy. Dabigatran, rivaroxaban, apixaban and edoxaban are now in clinical routine use for prevention and treatment of arterial and venous thrombotic diseases as addressed in their clinical trials. Usage of the DOACs is expected to increase as clinicians gain more experience and reassurance with data from the real world studies which are generally consistent with that from clinical trials. Development of specific antidotes in management of bleeding complications and development of coagulation assays for their plasma levels will further boost the confidence in the DOACs. Nonetheless, there are still limitations associated with the DOACs. Many patients in need of anticoagulant therapy for indications not studied in the clinical trials will not be eligible for treatment with a DOAC. Conditions where more data is required include DOACs use in the paediatric age group, patients with atrial fibrillation and valvular heart disease, thrombosis associated with the anti-phospholipid syndrome and cancer associated thrombosis. The affordability and access to these drugs may pose an issue for many patients under healthcare systems not providing for these medications. With four new anticoagulants coming onboard very quickly, the focus has shifted to the practical approach and management in real life as many clinicians are not yet familiar with the DOACs. Clinicians need to be educated on how to manage this new class for drugs, from choosing the appropriate drug to prevention and managing bleeding complications as a lack of knowledge and understanding in these drugs will lead to inappropriate use and compromise on patient safety.
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Affiliation(s)
- Lai Heng Lee
- Department of Haematology, Singapore General Hospital, 20, College Road, Academia Level 3, Singapore, 169856 Singapore
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238
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Abstract
OPINION STATEMENT Direct oral anticoagulants (DOAC) are an attractive therapeutic option for anticoagulant treatment in the setting of venous thromboembolism or non-valvular atrial fibrillation. These drugs overall appear to have a lower risk of life-threatening hemorrhage than the vitamin K antagonists. In addition, they demonstrate more predictable and stable pharmacokinetics. Measurement of the degree of anticoagulation is desirable in patients with DOAC-associated hemorrhage, but commonly available coagulation assays show poor sensitivity for degree of DOAC effect. DOAC-specific tests are time consuming and not widely available. All coagulation tests should be interpreted considering the timing of last intake and renal function. When life-threatening bleeding occurs, hemostasis should be restored as rapidly as possible. Non-specific prohemostatic drugs may have a role in DOAC reversal, and specific antidotes are at different stages of development. In this review, we provide a summary of DOAC characteristics and an overview of the different therapeutic options available for DOAC reversal.
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Blickstein D, Younes S, Nakav S. Attempted suicide with rivaroxaban. Ann Hematol 2016; 95:2093-2094. [DOI: 10.1007/s00277-016-2816-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 08/31/2016] [Indexed: 01/12/2023]
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Trikha R, Kowey PR. Practical Considerations for the Nonvitamin K Antagonist Oral Anticoagulants. Cardiology 2016; 136:115-124. [PMID: 27595409 DOI: 10.1159/000447530] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Accepted: 06/10/2016] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Dabigatran, rivaroxaban, apixaban, and edoxaban are nonvitamin K antagonist oral anticoagulants (NOACs) approved for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). Phase-3 clinical trials demonstrated NOACs were as effective as warfarin in the prevention of stroke or systemic embolism and associated with decreased incidences of intracranial bleeding. Additionally, NOACs provide quicker onset of action, simpler dosing, more predictable pharmacokinetic profiles, and decreased food and drug interactions compared with warfarin. Despite the advantages of NOACs, the lack of knowledge may limit their use in clinical practice. METHODS A search was performed on the terms 'atrial fibrillation' and 'dabigatran', 'apixaban', 'edoxaban', or 'rivaroxaban' to identify relevant papers; large randomized clinical trials, meta-analyses, and treatment guideline recommendations were given preference. Searches to identify registries, treatment guidelines, and meta-analyses relevant to patient subgroups were also employed. RESULTS Dosing recommendations, initiation of treatment, and applications in patients who undergo NVAF procedures, have mechanical heart valves, or experience other cardiovascular conditions such as myocardial infarction, previous stroke, and valvular heart disease are summarized. The NOAC-specific reversal approaches are also discussed. CONCLUSIONS Several important factors should be considered regarding the adequate use of NOACs, especially in patients with renal impairment or cardiovascular conditions other than NVAF.
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Affiliation(s)
- Rahul Trikha
- Lankenau Institute for Medical Research, Wynnewood, Pa., USA
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241
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Abstract
Idarucizumab (Praxbind(®)), a humanized monoclonal antibody, is a specific reversal agent for the direct oral thrombin inhibitor dabigatran, available as its prodrug dabigatran etexilate (Pradaxa(®)). Idarucizumab is approved in several countries (including the USA, the EU, Canada and Australia) for use in adult patients on dabigatran when the reversal of its anticoagulant effects is required for emergency surgery/procedures or in the event of life-threatening or uncontrolled bleeding. In the ongoing pivotal RE-VERSE AD trial in these populations (n = 90), intravenous idarucizumab 5 g reversed dabigatran-induced prolongation of dilute thrombin time (dTT) and ecarin clotting time (ECT) within minutes. The median maximum percentage reversal was 100 % for both assays (primary endpoint). Idarucizumab normalized dTT and ECT in 88-98 % of patients who had elevated levels at baseline. After idarucizumab administration, bleeding stopped in 97 % of evaluable patients in the bleeding cohort within 24 h (median time to cessation of bleeding was 11.4 h), and the rate of normal intraoperative haemostasis was 92 % in the surgical cohort. Idarucizumab was generally well tolerated. In conclusion, idarucizumab is a unique and specific treatment option for the reversal of the anticoagulant effects of dabigatran in adult patients requiring emergency procedures or in the event of life-threatening or uncontrolled bleeding.
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242
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Peetermans M, Pollack C, Reilly P, Liesenborghs L, Jacquemin M, Levy JH, Weitz JI, Verhamme P. Idarucizumab for dabigatran overdose. Clin Toxicol (Phila) 2016; 54:644-6. [DOI: 10.1080/15563650.2016.1187737] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Direct-Acting Oral Anticoagulants: Practical Considerations for Emergency Medicine Physicians. Emerg Med Int 2016; 2016:1781684. [PMID: 27293895 PMCID: PMC4884797 DOI: 10.1155/2016/1781684] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/11/2016] [Accepted: 03/29/2016] [Indexed: 01/01/2023] Open
Abstract
Nonvalvular atrial fibrillation- (NVAF-) related stroke and venous thromboembolism (VTE) are cardiovascular diseases associated with significant morbidity and economic burden. The historical standard treatment of VTE has been the administration of parenteral heparinoid until oral warfarin therapy attains a therapeutic international normalized ratio. Warfarin has been the most common medication for stroke prevention in NVAF. Warfarin use is complicated by a narrow therapeutic window, unpredictable dose response, numerous food and drug interactions, and requirements for frequent monitoring. To overcome these disadvantages, direct-acting oral anticoagulants (DOACs)—dabigatran, rivaroxaban, apixaban, and edoxaban—have been developed for the prevention of stroke or systemic embolic events (SEE) in patients with NVAF and for the treatment of VTE. Advantages of DOACs include predictable pharmacokinetics, few drug-drug interactions, and low monitoring requirements. In clinical studies, DOACs are noninferior to warfarin for the prevention of NVAF-related stroke and the treatment and prevention of VTE as well as postoperative knee and hip surgery VTE prophylaxis, with decreased bleeding risks. This review addresses the practical considerations for the emergency physician in DOAC use, including dosing recommendations, laboratory monitoring, anticoagulation reversal, and cost-effectiveness. The challenges of DOACs, such as the lack of specific laboratory measurements and antidotes, are also discussed.
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244
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Levy JH, Hunt BJ. Edoxaban in the secondary prevention of VTE. Lancet Haematol 2016; 3:e208-e209. [PMID: 27132692 DOI: 10.1016/s2352-3026(16)00037-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Accepted: 03/11/2016] [Indexed: 06/05/2023]
Affiliation(s)
- Jerrold H Levy
- Duke University School of Medicine, Duke University Medical Center, 2301 Erwin Road, 5691H HAFS, Box 3094, Durham, NC 27710, USA.
| | - Beverley J Hunt
- King's College and Guy's & St Thomas' NHS Foundation Trust, London, UK
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245
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Lim HY, Ho P. Direct Oral Anticoagulants in Dental Patients Including the Frail Elderly Population. Dent J (Basel) 2016; 4:E7. [PMID: 29563449 PMCID: PMC5851203 DOI: 10.3390/dj4010007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 02/11/2016] [Accepted: 03/14/2016] [Indexed: 12/24/2022] Open
Abstract
Direct oral anticoagulants (DOACs) have led to a paradigm shift in the field of anticoagulation, providing safe and convenient anticoagulation without the need for regular blood testing. Currently, there are three major DOACs available-Factor Xa inhibitors (apixaban and rivaroxaban) and direct thrombin inhibitors (dabigatran)-that are available for use in atrial fibrillation and venous thromboembolism. While these agents have been shown to be as effective as warfarin, with a similar or better bleeding profile, there remains some concern of the use of these drugs in vulnerable populations, such as the frail elderly patients; particularly since reversal agents and drug monitoring are not routinely available. We aim to provide a review of the use of DOACs and the impact of DOACs on dental treatment in the elderly population.
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Affiliation(s)
- Hui Yin Lim
- Department of Haematology, Northern Health, 185 Cooper Street, Epping VIC 3076, Australia.
- Department of Haematology, Austin Health, Studley Road, Heidelberg VIC 3084, Australia.
| | - Prahlad Ho
- Department of Haematology, Northern Health, 185 Cooper Street, Epping VIC 3076, Australia.
- Department of Haematology, Austin Health, Studley Road, Heidelberg VIC 3084, Australia.
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Amin A. Choosing Non-Vitamin K Antagonist Oral Anticoagulants: Practical Considerations We Need to Know. Ochsner J 2016; 16:531-541. [PMID: 27999513 PMCID: PMC5158161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND Warfarin is a well-established agent for use in the prevention of stroke or systemic embolic event (SEE) in patients with nonvalvular atrial fibrillation (NVAF) and for the treatment of venous thromboembolism (VTE). However, management of patients requiring oral anticoagulation with warfarin can be complicated by the need for frequent monitoring, drug-drug and drug-food interactions, and a variable response based on genetic polymorphisms. The non-vitamin K antagonist oral anticoagulants (NOACs) were developed as alternatives to warfarin; they do not require routine monitoring and have predictable pharmacokinetics, fewer drug-drug interactions, and limited drug-food interactions. Four NOACs-dabigatran, rivaroxaban, apixaban, and edoxaban-have received approval from the US Food and Drug Administration for the prevention of stroke or SEE in NVAF and for the treatment of VTE. Selecting the most appropriate agent for each patient should be done in consideration of patient preferences and characteristics, including renal function, bleeding risk, and the need for other medications. METHODS A search was performed on the terms atrial fibrillation and venous thromboembolism with individual terms dabigatran, apixaban, edoxaban, or rivaroxaban to identify relevant manuscripts; large randomized clinical trials, metaanalyses, and treatment guideline recommendations were given preference. Searches to identify registries, treatment guidelines, and metaanalyses relevant to specific subgroups were also used. RESULTS NOACs are effective in reducing the risk of stroke or SEE in patients with NVAF and are associated with fewer incidents of intracranial bleeding vs warfarin. CONCLUSION NOACs provide a convenient and safe alternative to warfarin and may result in improved therapeutic outcomes for patients with NVAF or VTE. The use of NOACs in other indications and patient populations is under investigation, and clinical trials investigating their use in acute coronary syndrome, medically ill patients, percutaneous coronary intervention, cardioversion, catheter ablation, coronary arterial disease, and heart failure have been announced.
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Affiliation(s)
- Alpesh Amin
- Department of Medicine, Hospitalist Program, University of California, Irvine School of Medicine, Irvine, CA
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