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Kee YK, Jeon HJ, Oh J, Yoo TH, Kang D, Lee J, Shin DH. Direct oral anti-Xa anticoagulants versus warfarin in newly diagnosed atrial fibrillation and CKD: the Korean National Health Insurance Data. Front Med (Lausanne) 2023; 10:1212816. [PMID: 37786900 PMCID: PMC10541953 DOI: 10.3389/fmed.2023.1212816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/28/2023] [Indexed: 10/04/2023] Open
Abstract
Introduction Despite the benefits of direct oral anti-Xa anticoagulants (DOACs), the risk-benefit profile of DOAC therapy compared to warfarin therapy in patients with non-valvular atrial fibrillation (AF) and chronic kidney disease (CKD), including end-stage renal disease (ESRD), is uncertain. Methods We conducted a retrospective study using the Korea National Health Insurance Database from 2013 to 2018. We evaluated patients with incident non-valvular AF and CKD. The primary and secondary effectiveness outcomes were ischemic stroke and all-cause mortality. The primary safety outcomes included intracranial hemorrhage, gastrointestinal bleeding, and extracranial or unclassified major bleeding. Results Among the 1,885 patients evaluated, 970 (51.5%) initiated warfarin therapy, and 915 (48.5%) initiated DOAC therapy. During a mean follow-up period of 23.8 months, there were 293 and 214 cases of ischemic stroke and all-cause death, respectively. Kaplan-Meier survival analysis showed significantly lower all-cause mortality in DOAC users than in warfarin users. In multivariate Cox regression analyses, DOAC therapy had a hazard ratio for all-cause mortality of 0.41 (95% CI, 0.30-0.56; p < 0.001) compared to warfarin therapy. Additionally, DOAC therapy significantly reduced intracranial hemorrhage and gastrointestinal bleeding. Discussion Our study demonstrates that DOAC therapy has a better risk-benefit profile than warfarin therapy in patients with AF and CKD. Further well-designed clinical trials are needed to clarify the benefits of DOACs in this patient population.
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Affiliation(s)
- Youn Kyung Kee
- Department of Internal Medicine, College of Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Hee Jung Jeon
- Department of Internal Medicine, College of Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea
| | - Jieun Oh
- Department of Internal Medicine, College of Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea
| | - Tae-Hyun Yoo
- Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Republic of Korea
| | - Dongwoo Kang
- Data Science Team, Hanmi Pharm. Co., Ltd., Seoul, Republic of Korea
| | - Jungkuk Lee
- Data Science Team, Hanmi Pharm. Co., Ltd., Seoul, Republic of Korea
| | - Dong Ho Shin
- Department of Internal Medicine, College of Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, Republic of Korea
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Alshogran OY. Warfarin Dosing and Outcomes in Chronic Kidney Disease: A Closer Look at Warfarin Disposition. Curr Drug Metab 2019; 20:633-645. [PMID: 31267868 DOI: 10.2174/1389200220666190701095807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 04/02/2019] [Accepted: 06/12/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Chronic Kidney Disease (CKD) is a prevalent worldwide health problem. Patients with CKD are more prone to developing cardiovascular complications such as atrial fibrillation and stroke. This warrants the use of oral anticoagulants, such as warfarin, in this population. While the efficacy and safety of warfarin in this setting remain controversial, a growing body of evidence emphasizes that warfarin use in CKD can be problematic. This review discusses 1) warfarin use, dosing and outcomes in CKD patients; and 2) possible pharmacokinetic mechanisms for altered warfarin dosing and response in CKD. METHODS Structured search and review of literature articles evaluating warfarin dosing and outcomes in CKD. Data and information about warfarin metabolism, transport, and pharmacokinetics in CKD were also analyzed and summarized. RESULTS The literature data suggest that changes in warfarin pharmacokinetics such as protein binding, nonrenal clearance, the disposition of warfarin metabolites may partially contribute to altered warfarin dosing and response in CKD. CONCLUSION Although the evidence to support warfarin use in advanced CKD is still unclear, this synthesis of previous findings may help in improving optimized warfarin therapy in CKD settings.
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Affiliation(s)
- Osama Y Alshogran
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
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Kamuren Z, Kigen G, Keter A, Maritim A. Characteristics of patients with thromboembolic disorders on warfarin therapy in resource limited settings. BMC Health Serv Res 2018; 18:723. [PMID: 30231891 PMCID: PMC6145184 DOI: 10.1186/s12913-018-3537-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 09/12/2018] [Indexed: 11/28/2022] Open
Abstract
Background Warfarin is a drug with narrow therapeutic index used in the management of thromboembolic disorders. Several factors affect its plasma concentrations with a resultant risk of toxicity. We examined the database of patients on warfarin therapy in order to establish the factors that affect the stability of INR and correlated them to clinical outcomes in resource limited settings. Methods We analysed retrospective data of patients admitted to adult medical wards at Moi Teaching and Referral Hospital (MTRH) in 2015. Inclusion criteria were patients with thromboembolic and related disorders and on warfarin treatment. Derived data included demographics, indications for warfarin use, co-prescribed drugs, co-morbidities, INR measurements, duration of hospital stay and clinical outcomes. Descriptive statistics were used to summarize the data. Pearson’s correlation coefficient was used to assess relationships between duration of hospitalization and number of INR tests. Regression splines were used to capture INR trends during the follow up period. Data was analysed using R v. 3.3.1. Results A total of 310 patients had thromboembolic disorders, out of which 63 met the study criteria. The median age was 48 years, while the mean number of INR measurements was once every four days. Majority of patients did not achieve stable INR values, with only two having consecutive INR values within therapeutic goal. Patients who died had high INR levels. The median duration of hospital stay was 9 days (IQR: 7.0, 16.5). There was a significant correlation between length of stay in hospital and the number of times that INR were measured (Corr = 0.667, p < 0.001). The two most common indications for warfarin were DVT (64.4%) and atrial fibrillation (24.7%). All the patients had one or more comorbid conditions except for 11 with DVT alone, with cardiovascular diseases and infections being the most frequent, and on concomitant medications, majority of which are known to interact with warfarin. Conclusions It was difficult to achieve stable INR under the prevailing conditions despite the frequent tests. The potential factors that may have contributed to the fluctuations include drug-drug interactions, frequency of INR tests, comorbidities and the short duration of hospital stay.
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Affiliation(s)
- Zipporah Kamuren
- Department of Pharmacology and Toxicology, Moi University School of Medicine, P.O. Box 4606, Eldoret, 30100, Kenya.
| | - Gabriel Kigen
- Department of Pharmacology and Toxicology, Moi University School of Medicine, P.O. Box 4606, Eldoret, 30100, Kenya
| | - Alfred Keter
- Academic Model Providing Access to Healthcare, P.O. Box 4606, Eldoret, 30100, Kenya
| | - Alice Maritim
- Department of Pharmacology and Toxicology, Moi University School of Medicine, P.O. Box 4606, Eldoret, 30100, Kenya
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Gong X, Wang H, Yuan Y. Analysis of the first therapeutic-target-achieving time of warfarin therapy and associated factors in patients with pulmonary embolism. Exp Ther Med 2016; 12:2265-2274. [PMID: 27698722 DOI: 10.3892/etm.2016.3610] [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: 02/09/2015] [Accepted: 03/30/2016] [Indexed: 11/06/2022] Open
Abstract
The present study aimed to investigate the factors affecting the first therapeutic-target-achieving (TTA) time of warfarin therapy in patients with acute pulmonary embolism (PTE). Between January 2008 and June 2013, patients with PTE confirmed by transpulmonary arterial enhanced computed tomographic pulmonary angiography or pulmonary ventilation perfusion scanning were included in the present study. Data collected included demographic information, history of tobacco and alcohol intake, basic diseases (stable and unstable hypertension, diabetes, heart failure, cancer/cerebral infarction, old myocardial infarction and atrial fibrillation), liver and kidney function, the haemoglobin and platelet count of the blood, international normalized ratio monitoring, warfarin dosage adjustment and medication combinations. Dynamic changes in international normalized ratio, anticoagulant efficacy, and adverse events within 90 days were monitored and analyzed. Univariate analysis demonstrated that the following factors affect the first TTA time: Initial dose, body mass index (BMI), liver function, heart failure, and the administration of levofloxacin, cephalosporins, and blood circulation-activating drugs. Logistic regression analysis revealed that the following were independent factors of the first TTA time: Initial dose, BMI, liver function, heart failure and levofloxacin. Therefore, the results of the present study demonstrated that various factors may affect the first TTA time of warfarin therapy, including the initial dose, BMI, liver function, heart function and concomitant medication.
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Affiliation(s)
- Xiaowei Gong
- Department of Respiratory Disease and Critical Care Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, P.R. China
| | - Haiyan Wang
- Department of Respiratory Disease and Critical Care Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, P.R. China
| | - Yadong Yuan
- Department of Respiratory Disease and Critical Care Medicine, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei 050000, P.R. China
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Self TH, Owens RE, Sakaan SA, Wallace JL, Sands CW, Howard-Thompson A. Effect of diseases on response to vitamin K antagonists. Curr Med Res Opin 2016; 32:613-20. [PMID: 26695107 DOI: 10.1185/03007995.2015.1134464] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The purpose of this review article is to summarize the literature on diseases that are documented to have an effect on response to warfarin and other VKAs. METHODS We searched the English literature from 1946 to September 2015 via PubMed, EMBASE, and Scopus for the effect of diseases on response vitamin K antagonists including warfarin, acenocoumarol, phenprocoumon, and fluindione. DISCUSSION Among many factors modifying response to VKAs, several disease states are clinically relevant. Liver disease, hyperthyroidism, and CKD are well documented to increase response to VKAs. Decompensated heart failure, fever, and diarrhea may also elevate response to VKAs, but more study is needed. Hypothyroidism is associated with decreased effect of VKAs, and obese patients will likely require higher initial doses of VKAs. CONCLUSION In order to minimize risks with VKAs while ensuring efficacy, clinicians must be aware of the effect of disease states when prescribing these oral anticoagulants.
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Affiliation(s)
- Timothy H Self
- a Methodist University Hospital, Clinical Pharmacist , Memphis , TN , USA
| | - Ryan E Owens
- b Methodist University Hospital , Memphis , TN , USA
| | - Sami A Sakaan
- a Methodist University Hospital, Clinical Pharmacist , Memphis , TN , USA
| | | | - Christopher W Sands
- d Methodist University Hospital, Methodist Inpatient Physicians , Memphis , TN , USA
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Fung E, Kurella Tamura M. Epidemiology and Public Health Concerns of CKD in Older Adults. Adv Chronic Kidney Dis 2016; 23:8-11. [PMID: 26709057 PMCID: PMC4693627 DOI: 10.1053/j.ackd.2015.10.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Revised: 10/13/2015] [Accepted: 10/14/2015] [Indexed: 01/29/2023]
Abstract
CKD is increasingly common in older adults. Estimating the glomerular filtration rate can be challenging in this population, with sarcopenia affecting the accuracy of various formulae. Competing risks of death influence the risk of progression to end-stage kidney disease. In managing CKD in this population, one must take into consideration other comorbidities including assessment of geriatric syndromes. More research is still needed to guide medical management in this heterogeneous population.
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Affiliation(s)
- Enrica Fung
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; and VA Palo Alto Geriatric Research and Education Clinical Center, Palo Alto, CA
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, CA; and VA Palo Alto Geriatric Research and Education Clinical Center, Palo Alto, CA.
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Abstract
In the setting of end-stage kidney disease, the incidence and risk for thrombotic events are increased and use of anticoagulants is common. The incidence of bleeding, however, is also a frequent issue and creates additional challenges in the management of anticoagulation therapy. Patients with end-stage renal disease are typically excluded from large clinical trials exploring the use of anticoagulants, which limits our knowledge of optimal management approaches. Furthermore, varying degrees of renal failure in addition to conditions that alter the pharmacokinetics of various anticoagulants or pharmacodynamic response may warrant alternative approaches to dosing. This review will explore systemic chronic anticoagulation therapy in the setting of chronic kidney disease where hemodialysis is required. Agents discussed include vitamin K antagonists, low-molecular-weight heparins, fondaparinux, oral factor Xa antagonists, and direct thrombin inhibitors. Clinical challenges, approaches to dosing regimens, and tools for measuring responses and reversal will be explored.
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Affiliation(s)
- William E Dager
- Department of Clinical Pharmacy, University of California, San Francisco, San Francisco, California.,Departments of Medicine and Pharmaceutical Services, Davis Medical Center, University of California Davis School of Medicine, Sacramento, California.,Department of Pharmacy, Touro Vallejo School of Pharmacy, Vallejo, California
| | - Laura V Tsu
- Department of Pharmacy Practice, Midwestern College of Pharmacy, Glendale, Arizona
| | - Tiffany K Pon
- Department of Clinical Pharmacy, School of Pharmacy, University of California San Francisco, San Francisco, California
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Fever as a Risk Factor for Increased Response to Vitamin K Antagonists: A Review of the Evidence and Potential Mechanisms. Thromb Res 2015; 135:5-8. [DOI: 10.1016/j.thromres.2014.10.015] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 09/19/2014] [Accepted: 10/14/2014] [Indexed: 11/19/2022]
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