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Schaefer JK, Barnes GD. Are the Direct Oral Anticoagulants Better for Patients with Low Time in the Therapeutic Range on Vitamin K Antagonist Therapy? Thromb Haemost 2024. [PMID: 38823378 DOI: 10.1055/s-0044-1787299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2024]
Affiliation(s)
- Jordan K Schaefer
- Division of Hematology/Oncology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - Geoffrey D Barnes
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, United States
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2
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Sulaiman KA, Aljuhani O, Alkofide H, Aljohani MA, Badreldin HA, Al Harbi M, Aquil G, Alhajaji R, Alqahtani RA, Babonji A, Altuwayr M, Alshehri AA, Alfaifi M, Alharthi AF, Alzahrani M, Al Sulaiman T, Alqahtani N, Alshahrani WA, Al Katheri A, Albekairy AM. Evaluation of Apixaban standard dosing in underweight patients with non-valvular atrial fibrillation: a retrospective cohort study. Thromb J 2024; 22:43. [PMID: 38778323 PMCID: PMC11110266 DOI: 10.1186/s12959-024-00613-8] [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: 11/01/2023] [Accepted: 05/07/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Recent guidelines recommend using direct oral anticoagulants (DOACs) as first-line agents in patients with non-valvular atrial fibrillation (NVAF). Research is currently investigating the use of Apixaban in underweight patients, with some results suggesting altered pharmacokinetics, decreased drug absorption, and potential overdosing in this population. This study examined the effectiveness and safety of standard Apixaban dosing in adult patients with atrial NVAF weighing less than 50 kg. METHODS This is a retrospective cohort study conducted at King Abdulaziz Medical City (KAMC); adult patients with a body mass index (BMI) below 25 who received a standard dose of Apixaban (5 mg twice daily) were categorized into two sub-cohorts based on their weight at the time of Apixaban initiation. Underweight was defined as patients weighing ≤ 50 kg, while the control group (Normal weight) comprised patients weighing > 50 kg. We followed the patients for at least one year after Apixaban initiation. The study's primary outcome was the incidence of stroke events, while secondary outcomes included bleeding (major or minor), thrombosis, and venous thromboembolism (VTE). Propensity score (PS) matching with a 1:1 ratio was used based on predefined criteria and regression model was utilized as appropriate. RESULTS A total of 1,433 patients were screened; of those, 277 were included according to the eligibility criteria. The incidence of stroke events was lower in the underweight than in the normal weight group at crude analysis (0% vs. 9.1%) p-value = 0.06), as well in regression analysis (OR (95%CI): 0.08 (0.001, 0.76), p-value = 0.002). On the other hand, there were no statistically significant differences between the two groups in the odds of major and minor bleeding (OR (95%CI): 0.39 (0.07, 2.03), p-value = 0.26 and OR (95%CI): 1.27 (0.56, 2.84), p-value = 0.40, respectively). CONCLUSION This exploratory study revealed that underweight patients with NVAF who received standard doses of Apixaban had fewer stroke events compared to normal-weight patients, without statistically significant differences in bleeding events. To confirm these findings, further randomized controlled trials with larger sample sizes and longer observation durations are required.
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Affiliation(s)
- Khalid Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia.
- College of Pharmacy, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, Riyadh, 11426, Saudi Arabia.
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
- Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia.
- Saudi Society for Multidisciplinary Research Development and Education (SCAPE Society), Riyadh, Saudi Arabia.
| | - Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Hadeel Alkofide
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Drug Regulation Research Unit, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Manal A Aljohani
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Hisham A Badreldin
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, Riyadh, 11426, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Mahasen Al Harbi
- Pharmaceutical Care Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Ghalia Aquil
- Pharmaceutical Care Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
| | - Raghad Alhajaji
- Public Health Department, Makkah Health Affairs, Makkah, Saudi Arabia
- Primary Health Department, Makkah Health Cluster, Makkah, Saudi Arabia
| | - Rahaf A Alqahtani
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Alaa Babonji
- Pharmaceutical Care Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | | | - Asma A Alshehri
- Pharmaceutical care departments, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Mashael Alfaifi
- Pharmaceutical Services Administration, King Saud Medical City, Riyadh, Saudi Arabia
| | | | - Mohammed Alzahrani
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, Riyadh, 11426, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Tareq Al Sulaiman
- Department of Orthopedic Surgery, Imam Abdulrahman Al Faisal Hospital, Riyadh, Saudi Arabia
| | | | - Walaa A Alshahrani
- College of Pharmacy, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, Riyadh, 11426, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia
| | - Abdulmalik Al Katheri
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, Riyadh, 11426, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Abdulkareem M Albekairy
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, Ministry of National Guard Health Affairs (MNGHA), King Saud bin Abdulaziz University for Health Sciences, PO Box 22490, Riyadh, 11426, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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Treacy J, Morrato EH, Horne R, Wolf MS, Bakhai A, Wilson MC, Lightowler M, Guerler S, Jokinen J. Behavioral Science: Enhancing Our Approach to the Development of Effective Additional Risk Minimization Strategies. Drug Saf 2024:10.1007/s40264-024-01420-w. [PMID: 38594553 DOI: 10.1007/s40264-024-01420-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2024] [Indexed: 04/11/2024]
Abstract
Additional risk minimization strategies may be required to assure a positive benefit-risk balance for some therapeutic products associated with serious adverse drug reactions/risks of use, without which these products may be otherwise unavailable to patients. The goals of risk minimization strategies are often fundamentally to influence the behavior of healthcare professionals (HCPs) and/or patients and can include appropriate patient selection, provision of education and counselling, appropriate medication use, adverse drug reaction monitoring, and adoption of other elements to assure safe use, such as pregnancy prevention. Current approaches to additional risk minimization strategy development rely heavily on information provision, without full consideration of the contextual factors and multi-level influences on patient and HCP behaviors that impact adoption and long-term adherence to these interventions. Application of evidence-based behavioral science methods are urgently needed to improve the quality and effectiveness of these strategies. Evidence from the fields of adherence, health promotion, and drug utilization research underscores the value and necessity for using established behavioral science frameworks and methods if we are to achieve clinical safety goals for patients. The current paper aims to enhance additional risk minimization strategy development and effectiveness by considering how a behavioral science approach can be applied, drawing from evidence in understanding of engagement with pharmaceutical medicines as well as wider public health interventions for patients and HCPs.
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Affiliation(s)
| | - Elaine H Morrato
- Parkinson School of Health Sciences and Public Health, Loyola University Chicago, Chicago, IL, USA
| | - Robert Horne
- Spoonful of Sugar Ltd, University College London Business Company, Brighton and Hove, UK
| | - Michael S Wolf
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Ameet Bakhai
- The Royal Free and University College Medical School, London, UK
| | | | - Mark Lightowler
- Centre for Pharmaceutical Medicine Research, Institute of Pharmaceutical Science, King's College London, London, UK
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4
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Pacchiarini MC, Regolisti G, Greco P, Di Motta T, Benigno GD, Delsante M, Fiaccadori E, Di Mario F. Treatment of dabigatran intoxication in critically ill patients with Acute Kidney Injury: The role of Sustained Low-Efficiency Dialysis. Int J Artif Organs 2023; 46:574-580. [PMID: 37853619 DOI: 10.1177/03913988231204516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
The use of dabigatran in patients with non-valvular atrial fibrillation (AF) has widely increased in the last decades, due to its positive effects in terms of safety/efficacy. However, because of the risk of major bleeding, a great degree of attention has been suggested in elderly patients with multiple comorbidities. Notably, dabigatran mainly undergoes renal elimination and dose adjustment is recommended in patients with Chronic Kidney Disease (CKD). In this regard, the onset of an abrupt decrease of kidney function may further affect dabigatran pharmacokinetic profile, increasing the risk of acute intoxication. Idarucizumab is the approved antagonist in the case of dabigatran-associated major bleeding or concomitant need of urgent surgery, but its clinical use is limited by the lack of data in patients with Acute Kidney Injury (AKI). Thus, the early start of Extracorporeal Kidney Replacement Therapy (EKRT) could be indicated to remove the drug and to reverse the associated excess anticoagulation. Sustained Low-Efficiency Dialysis (SLED) could represent an effective therapeutic option to reduce the dabigatran plasma levels rapidly while avoiding post-treatment rebound. We present here a case series of three AKI patients with acute dabigatran intoxication, effectively and safely resolved with a single SLED session.
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Affiliation(s)
- Maria Chiara Pacchiarini
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Giuseppe Regolisti
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
- UO Clinica e Immunologia Medica, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Paolo Greco
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Tommaso Di Motta
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Giuseppe Daniele Benigno
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Marco Delsante
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Francesca Di Mario
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
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de Souza Furtado P, Agnes Silva Camargo de Oliveira A, Santiago Rodrigues P, Rita Santiago de Paula Gonçalves A, Raphaella Autran Colaço A, Pinheiro da Costa S, Muniz da Paz M, Wetler Meireles Carreiros Assumpção P, Pereira Rangel L, Simon A, Almada do Carmo F, Mendes Cabral L, Cunha Sathler P. In vivo evaluation of time-dependent antithrombotic effect of rivaroxaban-loaded poly(lactic-co-glycolic acid)/sodium lauryl sulfate or didodecyl dimethylammonium bromide nanoparticles in Wistar rats. Eur J Pharm Biopharm 2023; 190:184-196. [PMID: 37517449 DOI: 10.1016/j.ejpb.2023.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/27/2023] [Indexed: 08/01/2023]
Abstract
Rivaroxaban (RVX), an oral direct factor Xa inhibitor, is being explored as an alternative to traditional anticoagulans. However, RVX still faces pharmacokinetic limitations and adverse effects, highlighting the need for more effective formulations. In this regard, pharmaceutical nanotechnology, particularly the use of polymeric nanoparticles (PNPs), offers a promising approach for optimizing RVX delivery. This study aimed to develop and physicochemically characterize RVX-loaded poly(lactic-co-glycolic acid) (PLGA)/sodium lauryl sulfate (SLS) or didodecyl dimethylammonium bromide (DMAB) nanoparticles, and also evaluate their pharmacological and toxicological profiles as a potential therapeutic strategy. The PNPs exhibited sizes below 300 nm and spherical morphology, with both negative and positive surface charges, according to surfactant used. They demonstrated high encapsulation efficiency and suitable yields, as well as rapid initial liberation followed by sustained release in different pH environments. Importantly, in vivo evaluations revealed a time-dependent antithrombotic effect surpassing the free form of RVX when administered orally in SLS or DMAB PNP. No hemolytic or cytotoxic effects were observed at various concentrations of the PNPs. Interestingly, the PNPs did not induce hemorrhagic events or cause liver enzyme alterations in vivo. These findings suggest that RVX-loaded SLS or DMAB PNPs are promising innovative therapeutic alternatives for the treatment of thromboembolic diseases.
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Affiliation(s)
- Priscila de Souza Furtado
- Universidade Federal do Rio de Janeiro, LabHEx, Faculdade de Farmácia, Ilha do Fundão, CEP 21941-902, Rio de Janeiro, RJ, Brazil
| | | | - Pryscila Santiago Rodrigues
- Universidade Federal do Rio de Janeiro, LabHEx, Faculdade de Farmácia, Ilha do Fundão, CEP 21941-902, Rio de Janeiro, RJ, Brazil
| | | | - Anna Raphaella Autran Colaço
- Universidade Federal do Rio de Janeiro, LabHEx, Faculdade de Farmácia, Ilha do Fundão, CEP 21941-902, Rio de Janeiro, RJ, Brazil
| | - Sandro Pinheiro da Costa
- Universidade Federal do Rio de Janeiro, LabHEx, Faculdade de Farmácia, Ilha do Fundão, CEP 21941-902, Rio de Janeiro, RJ, Brazil
| | - Mariana Muniz da Paz
- Universidade Federal do Rio de Janeiro, LBT, Faculdade de Farmácia, Ilha do Fundão, CEP 21941-902, Rio de Janeiro, RJ, Brazil
| | | | - Luciana Pereira Rangel
- Universidade Federal do Rio de Janeiro, LBT, Faculdade de Farmácia, Ilha do Fundão, CEP 21941-902, Rio de Janeiro, RJ, Brazil
| | - Alice Simon
- Universidade Federal do Rio de Janeiro, LabTIF, Faculdade de Farmácia, Ilha do Fundão, CEP 21941-902, Rio de Janeiro, RJ, Brazil
| | - Flávia Almada do Carmo
- Universidade Federal do Rio de Janeiro, LabTIF, Faculdade de Farmácia, Ilha do Fundão, CEP 21941-902, Rio de Janeiro, RJ, Brazil
| | - Lucio Mendes Cabral
- Universidade Federal do Rio de Janeiro, LabTIF, Faculdade de Farmácia, Ilha do Fundão, CEP 21941-902, Rio de Janeiro, RJ, Brazil
| | - Plínio Cunha Sathler
- Universidade Federal do Rio de Janeiro, LabHEx, Faculdade de Farmácia, Ilha do Fundão, CEP 21941-902, Rio de Janeiro, RJ, Brazil.
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6
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Bartholomew RR, Noble BN, Stanislaw JJ, Viehmann M, Herink MC, Furuno JP. Frequency and clinical outcomes of pharmacist-driven switching from warfarin to direct oral anticoagulants in an underserved patient population: A retrospective cohort study. Am J Health Syst Pharm 2023; 80:S103-S110. [PMID: 36525478 DOI: 10.1093/ajhp/zxac375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023] Open
Abstract
PURPOSE Direct oral anticoagulant (DOAC) medications have improved safety, efficacy, and laboratory monitoring requirements compared to warfarin. However, available data are limited on the frequency and clinical outcomes of pharmacist-driven warfarin-to-DOAC switches. We aimed to quantify the frequencies and rationale of warfarin-to-DOAC switches in an underserved population. We also assessed clinical outcomes and compliance with recommended laboratory monitoring after switches. METHODS This retrospective cohort study included adult (age 18 years or older) patients on warfarin who were assessed by a clinical pharmacist for switch appropriateness to a DOAC. Study data were collected via manual chart review and included demographics, comorbid illnesses, switch status, the rationale for or against switching, incidence of thromboses and bleeds within 6 months of the switch assessment, and the time to the first complete blood count and renal and hepatic function tests after the switch. Statistical analysis utilized descriptive statistics, including the mean and SD, median and interquartile range, and frequencies and percentages. RESULTS Among 189 eligible patients, 108 (57%) were switched from warfarin to a DOAC. The primary rationales for switching were less monitoring (64%) and labile international normalized ratio (32%). The main reason against switching was DOAC inappropriateness (53%), such as in morbid obesity (14%). Patient preference was commonly cited in both groups (54% and 36%, respectively). The overall incidence of thrombotic events (9%) and bleeds (15%) after switch assessment was low. Laboratory monitoring after switches was consistent with current recommendations. CONCLUSION No increase in harm was observed 6 months after switch assessment when pharmacists at a family medicine clinic switched underserved patients from warfarin to DOACs.
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Affiliation(s)
- Rebekah R Bartholomew
- Pharmacy Services, Neighborhood Health Center Tanasbourne Medical & Dental Clinic, Hillsboro, OR, USA
| | - Brie N Noble
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, OR, USA
| | - Jennifer J Stanislaw
- Pharmacy Services, Family Medicine at Richmond Clinic, Oregon Health & Science University, Portland, OR
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, OR, USA
| | - Megan Viehmann
- Pharmacy Services, Family Medicine at Richmond, Oregon Health & Science University, Portland, OR, USA
| | - Megan C Herink
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, OR, USA
| | - Jon P Furuno
- Department of Pharmacy Practice, Oregon State University College of Pharmacy, Portland, OR, USA
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7
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Sugimoto M, Murata M, Kawai T. Assessment of delayed bleeding after endoscopic submucosal dissection of early-stage gastrointestinal tumors in patients receiving direct oral anticoagulants. World J Gastroenterol 2023; 29:2916-2931. [PMID: 37274799 PMCID: PMC10237096 DOI: 10.3748/wjg.v29.i19.2916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 04/03/2023] [Accepted: 04/24/2023] [Indexed: 05/16/2023] Open
Abstract
Delayed bleeding is a major and serious adverse event of endoscopic submucosal dissection (ESD) for early-stage gastrointestinal tumors. The rate of post-ESD bleeding for gastric cancer is higher (around 5%-8%) than that for esophagus, duodenum and colon cancer (around 2%-4%). Although investigations into the risk factors for post-ESD bleeding have identified several procedure-, lesion-, physician- and patient-related factors, use of antithrombotic drugs, especially anticoagulants [direct oral anticoagulants (DOACs) and warfarin], is thought to be the biggest risk factor for post-ESD bleeding. In fact, the post-ESD bleeding rate in patients receiving DOACs is 8.7%-20.8%, which is higher than that in patients not receiving anticoagulants. However, because clinical guidelines for management of ESD in patients receiving DOACs differ among countries, it is necessary for endoscopists to identify ways to prevent post-ESD delayed bleeding in clinical practice. Given that the pharmacokinetics (e.g., plasma DOAC level at both trough and Tmax) and pharmacodynamics (e.g., anti-factor Xa activity) of DOACs are related to risk of major bleeding, plasma DOAC level and anti-FXa activity may be useful parameters for monitoring the anti-coagulate effect and identifying DOAC patients at higher risk of post-ESD bleeding.
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Affiliation(s)
- Mitsushige Sugimoto
- Department of Gastroenterological Endoscopy, Tokyo Medical University Hospital, Tokyo 160-0023, Japan
| | - Masaki Murata
- Department of Gastroenterology, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
| | - Takashi Kawai
- Department of Gastroenterological Endoscopy, Tokyo Medical University Hospital, Tokyo 160-0023, Japan
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Hagedorn JC, Yates SG, Chen J, Adkins BD. Direct Oral Anticoagulants: How Do These Drugs Work, How to Monitor, and What Is Their Role in Orthopaedic Surgery. J Am Acad Orthop Surg 2023; 31:e347-e355. [PMID: 36862808 DOI: 10.5435/jaaos-d-21-00807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 01/19/2023] [Indexed: 03/04/2023] Open
Abstract
Postoperative venous thromboembolism is a major adverse event associated with orthopaedic surgery. With the addition of perioperative anticoagulation and antiplatelet therapy, the rates of symptomatic venous thromboembolism have dropped to 1% to 3%, and as such, practicing orthopaedic surgeons must be familiar with these medications, including aspirin, heparin, or warfarin, and the use of direct oral anticoagulants (DOACs). DOACs are increasingly being prescribed due to their predictable pharmacokinetics and increased convenience, as they do not require routine monitoring, and 1% to 2% of the general population is currently anticoagulated. Although the introduction of DOACs has yielded additional treatment options, this has also led to confusion and uncertainty regarding treatment, specialized testing, and when and what reversal agents are appropriate. This article provides a basic overview of DOAC medications, their suggested use in the perioperative setting, effects on laboratory testing, and consideration for when and how to use reversal agents in orthopaedic patients.
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Affiliation(s)
- John C Hagedorn
- From the Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX (Hagedorn II, and Chen), and Department of Pathology, University of Texas Southwestern, Division of Transfusion Medicine and Hemostasis, Dallas, TX (Yates, and Adkins)
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9
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Yagi T, Mannheimer B, Reutfors J, Ursing J, Giunta DH, Kieler H, Linder M. Bleeding events among patients concomitantly treated with direct oral anticoagulants and macrolide or fluoroquinolone antibiotics. Br J Clin Pharmacol 2023; 89:887-897. [PMID: 36098510 PMCID: PMC10092847 DOI: 10.1111/bcp.15531] [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: 02/23/2022] [Revised: 08/11/2022] [Accepted: 08/19/2022] [Indexed: 01/18/2023] Open
Abstract
Fluoroquinolones and macrolides may, due to a potential drug-drug interaction, increase the concentration of any concomitantly administered direct oral anticoagulant (DOAC) and thereby increase the risk of severe bleeding. However, clinical evidence for such an effect is scarce. The present study aimed to evaluate the association between the use of fluoroquinolones or macrolides and bleeding events in patients with concomitant DOAC use. This was a nationwide cohort study including 19 288 users of DOACs in 2008-2018 using information from Swedish national health registers. We compared the incidence of bleeding events associated with use of fluoroquinolones or macrolides using doxycycline as a negative control. Cox regression was used to calculate crude and adjusted hazard ratios (aHRs) in time windows of various length of follow-up after the start of antibiotic use. The incidence rates for fluoroquinolones and macrolides ranged from 12 to 24 and from 12 to 53 bleeding events per 100 000 patients in the investigated time windows. The aHRs (95% confidence interval) for use of fluoroquinolones and macrolides were 1.29 (0.69-2.44) and 2.60 (0.74-9.08) at the concomitant window, 1.31 (0.84-2.03) and 1.79 (0.75-4.29) at 30 days, and 1.34 (0.99-1.82) and 1.28 (0.62-2.65) at 150 days, respectively. With regard to fluoroquinolones, the present study suggests that the risk of bleeding when combined with DOACs, if any, is small. Codispensation of macrolides in patients on DOACs was not associated with an increased risk of bleeding. However, due to the small number of macrolide users, the results must be interpreted with caution.
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Affiliation(s)
- Tatsuya Yagi
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Buster Mannheimer
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Johan Reutfors
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Ursing
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Diego Hernan Giunta
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Helle Kieler
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marie Linder
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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10
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To Measure or Not to Measure: Direct Oral Anticoagulant Laboratory Assay Monitoring in Clinical Practice. Adv Hematol 2023; 2023:9511499. [PMID: 36875183 PMCID: PMC9977549 DOI: 10.1155/2023/9511499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 01/28/2023] [Accepted: 02/07/2023] [Indexed: 02/24/2023] Open
Abstract
The need for therapeutic drug monitoring of direct oral anticoagulants (DOACs) remains an area of clinical equipoise. Although routine monitoring may be unnecessary given predictable pharmacokinetics in most patients, there may be altered pharmacokinetics in those with end organ dysfunction, such as those with renal impairment, or with concomitant interacting medications, at extremes of body weight or age, or in those with thromboembolic events in atypical locations. We aimed to assess real-world practices in situations in which DOAC drug-level monitoring was used at a large academic medical center. A retrospective review of the records of patients who had a DOAC drug-specific activity level checked from 2016 to 2019 was included. A total of 119 patients had 144 DOAC measurements (apixaban (n = 62) and rivaroxaban (n = 57)). Drug-specific calibrated DOAC levels were within an expected therapeutic range for 110 levels(76%), with 21 levels (15%) above the expected range and 13 levels (9%) below the expected range. The DOAC levels were checked in the setting of an urgent or emergent procedure in 28 patients (24%), followed by renal failure in 17 patients (14%), a bleeding event in 11 patients (9%), concern for recurrent thromboembolism in 10 patients (8%), thrombophilia in 9 patients (8%), a history of recurrent thromboembolism in 6 patients (5%), extremes of body weight in 7 patients (5%), and unknown reasons in 7 patients (5%). Clinical decision making was infrequently affected by the DOAC monitoring. Therapeutic drug monitoring with DOACs may help predict bleeding events in elderly patients, those with impaired renal function, and in the event of an emergent or urgent procedure. Future studies are needed to target the select patient-specific scenarios where monitoring DOAC levels may impact clinical outcomes.
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Turcato G, Zaboli A, Bonora A, Ricci G, Zannoni M, Maccagnani A, Zorzi E, Pfeifer N, Brigo F. Analysis of Clinical and Laboratory Risk Factors of Post-Traumatic Intracranial Hemorrhage in Patients on Direct Oral Anticoagulants with Mild Traumatic Brain Injury: An Observational Multicenter Cohort. J Emerg Med 2023; 64:1-13. [PMID: 36658008 DOI: 10.1016/j.jemermed.2022.09.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 07/25/2022] [Accepted: 09/04/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Assessing the risk of intracranial hemorrhage (ICH) in patients with a mild traumatic brain injury (MTBI) who are taking direct oral anticoagulants (DOACs) is challenging. Currently, extensive use of computed tomography (CT) is routine in the emergency department (ED). OBJECTIVE This study aims to investigate whether the clinical and laboratory characteristics presented at the ED evaluation can also estimate the risk of post-traumatic ICH in DOAC-treated patients with MTBI. METHODS A retrospective observational study was conducted in three EDs in Italy from January 1, 2016 to March 15, 2020. All patients treated with DOACs who were evaluated for an MTBI in the ED were enrolled. The primary outcome of the study was the presence of post-traumatic ICH in the head CT performed in the ED. RESULTS Of 930 patients on DOACs with MTBI who were enrolled, 6.8% (63 of 930) had a post-traumatic ICH and 1.5% (14 of 930) were treated with surgery or died as a result of the ICH. None of the laboratory factors were associated with an increased risk of ICH. On multivariate analysis, previous neurosurgical intervention, major trauma dynamic, post-traumatic loss of consciousness, post-traumatic amnesia, Glasgow Coma Scale score of 14, and evidence of trauma above the clavicles were associated with a higher risk of post-traumatic ICH. The net clinical benefit provided by risk factor assessment appears superior to the strategy of performing CT on all DOAC-treated patients. CONCLUSIONS Assessment of the clinical characteristics presented at ED admission can help identify DOAC-treated patients with MTBI who are at risk of ICH.
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Affiliation(s)
- Gianni Turcato
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Arian Zaboli
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Antonio Bonora
- Department of Emergency Medicine, Policlinico Univeristario di Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Giorgio Ricci
- Department of Emergency Medicine, Hospital Civile Maggiore, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Massimo Zannoni
- Department of Emergency Medicine, Hospital Civile Maggiore, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Antonio Maccagnani
- Department of Emergency Medicine, Policlinico Univeristario di Verona, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Elisabetta Zorzi
- Department of Cardiology and Intensive Care Cardiology, Girolamo Fracastoro Hospital of San Bonifacio, Azienda Ospedaliera Scaligera, San Bonifacio, Verona, Italy
| | - Norbert Pfeifer
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano, Italy
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Sin CF, Wong KP, Wong TF, Siu CW, Yap DYH. Plasma apixaban levels in Chinese patients with chronic kidney disease-Relationship with renal function and bleeding complications. Front Pharmacol 2022; 13:928401. [PMID: 36569289 PMCID: PMC9772439 DOI: 10.3389/fphar.2022.928401] [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: 04/25/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
Introduction: Accumulation of apixaban in plasma is a major concern in patients with chronic kidney disease (CKD). Studies that investigated plasma apixaban level in CKD patients and its association with clinically significant events are scarce. Methods: Patients with CKD Stage 1-4 who were taking apixaban, either 2.5 mg BD or 5 mg BD were recruited. The peak and trough plasma apixaban level were measured after 2 h and 12 h of last dose respectively. The results were correlated with renal function and clinical events during the period of follow-up from 1 January 2018 to 31 October 2021. Results: 141 patients (CKD Stage 1, n = 12; Stage 2, n = 74; Stage 3, n = 48, stage 4, n = 7) were included for analysis. The plasma peak and trough apixaban were significantly higher in patients with CKD stage 3 when compared with those having CKD stage 2 and 1 (peak levels: 223.4 ± 107.8 ng/ml vs. 161.0 ± 55.2 ng/ml vs. 126.6 ± 30.2 ng/ml; trough levels: 118.3 ± 67.9 ng/ml vs. 81.2 ± 33.0 ng/ml vs. 51.9 ± 31.1 ng/ml, p < 0.05 or all) in patients taking 5 mg BD. Plasma trough apixaban level was negatively correlated with eGFR in patients taking 5 mg BD (r 2 = -0.174, p < 0.001) and 2.5 mg BD (r 2 = -0.215, p < 0.05). The plasma peak and trough apixaban level correlated with PT (r 2 = 0.065, p = 0.003 and r 2 = 0.096, p < 0.01 respectively). Multivariate analysis showed that plasma trough apixaban levels were associated with the risk of bleeding complications (Odd ratio: 1.011, 95% CI:1.002-1.021, p = 0.023). Conclusion: The plasma apixaban level shows a trend of increase with worsening renal function, and an increase in the plasma apixaban level is suggestive of an increased risk of bleeding complications in patients with CKD. Further large-scale prospective studies are needed to evaluate relationship between plasma apixaban level and renal function as well as safety outcome in CKD patients. Moreover, the role of drug level monitoring should be prospectively evaluated for dosage optimization and the minimization of bleeding risks in CKD patients.
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Affiliation(s)
- Chun-fung Sin
- Department of Pathology, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Ka-ping Wong
- Department of Pathology, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Tsz-fu Wong
- Department of Pathology, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Chung-wah Siu
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China
| | - Desmond Y. H. Yap
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Pokfulam, Hong Kong SAR, China,*Correspondence: Desmond Y. H. Yap,
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Moorthamers S, Mattar N, Frezals L, Preseau T, Gazagnes MD. Thrombolysis in an Acute Ischemic Stroke Patient on Direct Anticoagulant Therapy Outside of the Traditional Time Window: A Case Report. Cureus 2022; 14:e29673. [PMID: 36321003 PMCID: PMC9614184 DOI: 10.7759/cureus.29673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2022] [Indexed: 11/11/2022] Open
Abstract
A stroke is a life-threatening medical condition that could be disabling if left untreated. Intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) can be effective when initiated in an acute stroke, but their benefit is time-dependent and their use may be restricted by contraindications (CIs) such as anticoagulation therapy. The critical therapeutic time window, which was previously limited to 4.5-6 hours, is now extended to 24 hours in selected patients due to the development of advanced neuroimaging techniques. Herein, we discuss the case of a 50-year-old patient on rivaroxaban who developed acute ischemic stroke (AIS) and was treated successfully with intravenous recombinant tissue plasminogen activator thrombolysis more than six hours after the time he was last seen well (LSW). Our case demonstrates the importance of advanced neuroimaging techniques in identifying AIS candidates for IVT and/or MT with late or unknown time windows as well as the importance of case-by-case assessment when challenged by theoretical contraindications for thrombolysis.
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Sun B, Yew PY, Wen YF, Chi CL, Straka RJ. Comparison of the Warfarin Dosing and Outcomes in Hmong Versus East Asians Patients: Real-World Data From an Integrated Healthcare System. Cureus 2022; 14:e28905. [PMID: 36249660 PMCID: PMC9549258 DOI: 10.7759/cureus.28905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2022] [Indexed: 11/30/2022] Open
Abstract
Background Previous research predicted that Hmong, an understudied East Asian subpopulation, might require significantly lower warfarin doses than East Asian patients partially due to their unique genetic and clinical factors. However, such findings have not been corroborated using real-world data. Methods This was a retrospective cohort study of Hmong and East Asian patients receiving warfarin. Warfarin stable doses (WSD) and time to the composite outcome, including international normalized ratio (INR) greater than four incidences or major bleeding within six months of warfarin initiation, were compared. Results This cohort study included 55 Hmong and 100 East Asian patients. Compared to East Asian patients, Hmong had a lower mean WSD (14.5 vs. 20.4 mg/week, p<0.05). In addition, Hmong had a 3.1-fold (95% CI: 1.1-9.3, p<0.05) higher hazard of the composite outcome. Conclusion Using real-world data, significant differences in warfarin dosing and hazard for the composite outcome of INR>4 and major bleeding were observed between Hmong and East Asian patients. These observations further underscore the importance of recognizing subpopulation-based differences in warfarin dosing and outcomes.
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15
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Sin CF, Wong KP, Wong HM, Siu CW, Yap DYH. Plasma Rivaroxaban Level in Patients With Early Stages of Chronic Kidney Disease-Relationships With Renal Function and Clinical Events. Front Pharmacol 2022; 13:888660. [PMID: 35662694 PMCID: PMC9157352 DOI: 10.3389/fphar.2022.888660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 05/02/2022] [Indexed: 12/04/2022] Open
Abstract
Introduction Drug accumulation of rivaroxaban is a concern in patients with chronic kidney disease (CKD). Data regarding the plasma rivaroxaban levels in early CKD patients and its relationship with clinical events is lacking. Methods Early CKD patients (Stage 1-3) with atrial fibrillation who received rivaroxaban (15 or 20 mg daily) were recruited. Plasma rivaroxaban levels were measured at 2 hours (peak) and 24 hours (trough) after drug administration, and correlated with eGFR and clinically significant events during the follow-up period (1 January 2018 to 31 October 2021). Results Ninety-two patients were included (CKD stage 1 n=10, stage 2 n=53, stage 3 n=29). Plasma trough levels in patients with stage 3 CKD were significantly higher than those with stage 2 and 1 CKD (66.0±34.9 ng/ml vs. 35.7 ± 24.7 ng/ml vs. 34.7 ± 26.2 ng/ml, respectively, p=0.005), and showed inverse relationship with eGFR (r=0.391, p=0.001) in patients receiving 20 mg daily. The plasma trough rivaroxaban level correlated with PT and APTT (r = 0.650 and 0.44, respectively, p<0.001 for both). Plasma trough rivaroxaban level in those with bleeding were higher than those who did not (59.9 ± 35.6 ng/ml vs. 41.1 ± 29.2 ng/ml, p=0.011), and multivariate analysis suggested that plasma trough rivaroxaban level was associated with the rate of bleeding complications (OR: 1.020, 95% CI 1.002-1.038, p=0.028). Conclusion Plasma trough rivaroxaban levels correlated with renal function in early CKD patients, and its measurement may help dosage optimization in patients with renal impairment. Moreover, our data suggests that there may be an association between plasma trough rivaroxaban level and the rate of bleeding complication.
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Affiliation(s)
- Chun-Fung Sin
- Department of Pathology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Ka-Ping Wong
- Department of Pathology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Hoi-Man Wong
- Department of Pathology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Chung-Wah Siu
- Division of Cardiology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Desmond Y. H. Yap
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, Hong Kong SAR, China
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Dingus SJ, Smith AR, Dager WE, Zochert S, Nothdurft SA, Gulseth MP. Comparison of Managing Factor Xa Inhibitor to Unfractionated Heparin Transitions by aPTT Versus a Treatment Guideline Utilizing Heparin Anti-Xa Levels. Ann Pharmacother 2022; 56:1289-1298. [PMID: 35499336 DOI: 10.1177/10600280221090211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND There are inadequate data on the optimal strategy for transitioning factor Xa inhibitors (FXai; apixaban, rivaroxaban) to unfractionated heparin (UFH) infusions. OBJECTIVE In patients transitioning from an FXai to an UFH infusion, this study compared the safety and efficacy of monitoring UFH infusions using an activated partial thromboplastin time (aPTT) titration scale versus utilizing an UFH-calibrated anti-Xa titration scale aided by a novel institutional guideline. METHODS A retrospective cohort analysis was conducted on adult patients transitioning from an FXai to an UFH infusion at 2 medical centers from June 1, 2018, to November 1, 2020. One institution utilized aPTT while the other institution primarily used UFH-calibrated anti-Xa. The primary endpoint was a composite of death, major bleeding, or new thrombosis during the hospitalization with a planned noninferiority analysis. Secondary outcomes were also collected including the amount and duration of UFH administered between cohorts. RESULTS The incidence rate of the primary composite endpoint was 6.3% in the anti-Xa group and 11% in the aPTT group (P < 0.001 for noninferiority, P = 0.138 for superiority) meeting noninferiority criteria. No statistical differences were seen in new thrombosis, major bleeding, or any bleeding. CONCLUSION AND RELEVANCE This represents the first report of a comparison between aPTT versus anti-Xa monitoring in relation to clinical outcomes for patients transitioning from an FXai to an UFH infusion. A transition guideline primarily utilizing an UFH-calibrated anti-Xa assay appears to be a safe alternative to aPTT monitoring and can aid facilities in the management of patients during these complex transitions.
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Affiliation(s)
- Scott J Dingus
- Department of Pharmacy, Platte Health Center Avera, Platte, SD, USA
| | - Alex R Smith
- Department of Pharmaceutical Services, Sanford USD Medical Center, Sioux Falls, SD, USA
| | - William E Dager
- Department of Pharmacy, UC Davis Medical Center, Sacramento, CA, USA
| | - Sara Zochert
- Department of Pharmaceutical Services, Sanford USD Medical Center, Sioux Falls, SD, USA
| | - Salli A Nothdurft
- Department of Pharmaceutical Services, Sanford USD Medical Center, Sioux Falls, SD, USA
| | - Michael P Gulseth
- Department of Pharmaceutical Services, Sanford USD Medical Center, Sioux Falls, SD, USA
- Department of Internal Medicine, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, USA
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MacDougall C, Canonica T, Keh C, P. Phan BA, Louie J. Systematic review of drug–drug interactions between rifamycins and anticoagulant and antiplatelet agents and considerations for management. Pharmacotherapy 2022; 42:343-361. [DOI: 10.1002/phar.2672] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Conan MacDougall
- Department of Clinical Pharmacy University of California San Francisco School of Pharmacy San Francisco California USA
| | - Theora Canonica
- Department of Clinical Pharmacy San Francisco Veterans' Affairs Medical Center San Francisco California USA
| | - Chris Keh
- Division of Infectious Disease University of California, San Francisco San Francisco California USA
| | - Binh An P. Phan
- Division of Cardiology San Francisco General Hospital University of California, San Francisco San Francisco California USA
| | - Janice Louie
- Division of Infectious Diseases San Francisco Department of Public Health Tuberculosis Clinic University of California, San Francisco San Francisco California USA
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Abstract
Patients with advanced liver disease who are not taking vitamin K antagonists often have an elevated international normalized ratio, potentially due to vitamin K deficiency and the decreased synthesis of clotting factors by the liver. It is possible that vitamin K deficiency is due to dietary deficiency, impaired absorption in the small intestine, or both. This has led to the practice of the administration of phytonadione to limit the risks of bleeding in these patients. However, phytonadione is available in different formulations with varying pharmacokinetics and there is a paucity of data in the literature to guide optimal management. The routine use of phytonadione to correct INR in cirrhotic patients not taking warfarin should be avoided due to the lack of proven benefits. However, intravenous phytonadione may be considered in actively bleeding or critically ill patients with vitamin K deficiency. Oral formulation is unlikely to be absorbed in cirrhotic patients and should be avoided.
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Elgersma B, Zochert S. Utilization of apixaban anti-Xa levels in transition from apixaban to warfarin in a patient with chronic renal dysfunction. Am J Health Syst Pharm 2021; 79:e104-e109. [PMID: 34864841 PMCID: PMC8690383 DOI: 10.1093/ajhp/zxab469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE The effect of apixaban on anti-factor Xa (anti-Xa) assays and international normalized ratio (INR) complicates transitions between anticoagulant agents. When switching from apixaban to warfarin, the recommendation is to begin both a parenteral anticoagulant and warfarin at the time of the next apixaban dose and to discontinue the parenteral agent when INR is in an acceptable range. This proves challenging in renal dysfunction, as continued presence of apixaban contributes to both a prolonged effect on the INR and continued therapeutic levels of anticoagulation. SUMMARY This case describes the transition of apixaban to warfarin in a patient with acute on chronic kidney disease and recent deep vein thrombosis, utilizing chromogenic apixaban anti-Xa assays to assess the level of anticoagulation and avoid unnecessary parenteral anticoagulation. CONCLUSION Utilization of apixaban anti-Xa levels aided in the transition from apixaban to warfarin in a patient with chronic renal failure and avoided need for parenteral bridging therapy.
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Affiliation(s)
- Brittany Elgersma
- Sanford USD Medical Center, Sioux Falls, SD, USA
- Address correspondence to Dr. Elgersma ()
| | - Sara Zochert
- Sanford USD Medical Center, Sioux Falls, SD, USA
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Hu X, Xu Y, Chen J, Shen Y, Yang D, Hu Y, Jiang B, Lou H, Ruan Z. A validated UPLC-MS/MS method for the determination of CX3002 in human plasma and its application to a pharmacokinetic study. J Chromatogr B Analyt Technol Biomed Life Sci 2021; 1183:122954. [PMID: 34628186 DOI: 10.1016/j.jchromb.2021.122954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/20/2021] [Accepted: 09/22/2021] [Indexed: 11/24/2022]
Abstract
A simple, selective, rapid, and reliable ultra-high performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) method was developed and validated to determine CX3002 in human plasma using CX3002-d3 as the internal standard (IS). After a rapid protein precipitation with acetonitrile (3:1, v/v), the chromatographic separation of CX3002 and IS was performed on a Thermo Hypersil GOLD C18 column (2.1 mm × 50 mm, 1.9 μm) with gradient elution at a flow rate of 0.4 ml/min. Gradient elution was achieved with mobile phase A consisting of water containing 0.1% formic acid and 5 mmol/L ammonium formate and mobile phase B consisting of methanol containing 0.1% formic acid. The detection was performed on AB SCIEX QTRAP® 5500 tandem mass spectrometry in the positive ion mode. Multiple reactions monitoring (MRM) was used for quantitative analysis at transition of m/z 460.3 → 199.3 for CX3002 and m/z 463.3 → 202.3 m/z for IS. The method was fully validated and displayed good linearity over a concentration range of 0.2-400 ng/mL with the correlation coefficient above 0.997. The intra-run and inter-run precision (coefficient of variation, CV) ranged from 0.60%-16.46% and the accuracy bias ranged from -7.09%-9.75%. The mean IS-normalized extraction recovery ranged from 98.30% to 104.52%. The CV(%) of IS-normalized matrix factors at the low and high QC concentration were 4.09% and 1.68%, respectively. The storage stability under different conditions was in accordance with the bioanalytical guidelines. The method was successfully applied to the pharmacokinetic study of CX3002 (30 mg) in healthy Chinese subjects.
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Affiliation(s)
- Xinhua Hu
- Center of Clinical Pharmacology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yichao Xu
- Center of Clinical Pharmacology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Jinliang Chen
- Center of Clinical Pharmacology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yuting Shen
- Center of Clinical Pharmacology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Dandan Yang
- Center of Clinical Pharmacology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yin Hu
- Center of Clinical Pharmacology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Bo Jiang
- Center of Clinical Pharmacology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Honggang Lou
- Center of Clinical Pharmacology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Zourong Ruan
- Center of Clinical Pharmacology, Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
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May JE, Siniard RC, Taylor LJ, Marques MB, Gangaraju R. From Activated Partial Thromboplastin Time to Antifactor Xa and Back Again. Am J Clin Pathol 2021; 157:321-327. [PMID: 34562001 PMCID: PMC8891818 DOI: 10.1093/ajcp/aqab135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/14/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Monitoring is essential to safe anticoagulation prescribing and requires close collaboration among pathologists, clinicians, and pharmacists. METHODS We describe our experience in the evolving strategy for laboratory testing of unfractionated heparin (UFH). RESULTS An intrainstitutional investigation revealed significant discordance between activated partial thromboplastin time (aPTT) and antifactor Xa (anti-Xa) assays, prompting a transition from the former to the latter in 2013. With the increasing use of oral factor Xa inhibitors (eg, apixaban, rivaroxaban, edoxaban, betrixaban), which interfere with the anti-Xa assay, we adapted our protocol again to incorporate aPTT in patients admitted on oral Xa inhibitors who require transition to UFH. CONCLUSIONS Our experience demonstrates key challenges in anticoagulation and highlights the importance of clinical pathologists in helping health systems adapt to the changing anticoagulation landscape.
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Affiliation(s)
- Jori E May
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, USA,Corresponding author: Jori E. May, MD;
| | - Rance Chad Siniard
- Division of Laboratory Medicine, Department of Pathology, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Laura J Taylor
- UAB Coagulation Service, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Marisa B Marques
- Division of Laboratory Medicine, Department of Pathology, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Radhika Gangaraju
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, USA,Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
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22
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Cavaillez T, Weinmann L, Mouton C, Delassasseigne C, Sesay M, Biais M, James C, Roullet S. A retrospective study of indications and consequences of monitoring direct oral anticoagulant plasma concentrations on patient care in a university hospital: The Retro-AOD study. Thromb Res 2021; 206:76-83. [PMID: 34419866 DOI: 10.1016/j.thromres.2021.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 07/31/2021] [Accepted: 08/11/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The use of direct oral anticoagulants (DOAC) is increasing. Specific concentrations are available and have been proven to be reliable and reproducible in optimising patient care. This retrospective, monocentric study aimed to describe the indications and consequences of monitoring DOAC plasma levels on patient care. MATERIALS AND METHODS We collected data of patients hospitalised at the Bordeaux University Hospital between January 2017 and December 2018. These included demographics, indications, type, dose of DOAC, standard coagulation tests, creatinine clearance and DOAC plasma concentration using specifically calibrated rivaroxaban and apixaban anti-Xa and dabigatran anti-IIa assays. The date of last DOAC intake, the time between intake and plasma level measurement were also collected and analysed. RESULTS A total of 2197 DOAC assays in 1488 patients were obtained in various clinical situations: urgent or elective procedures, context of acute renal failure, suspicion or occurrence of ischemic strokes, intra-cranial and other bleeding sites. Interpretation of these assays led physicians to maintain, postpone or cancel invasive and high haemorrhagic risk procedures in 757, 261 and 56 cases respectively. The remaining 1123 assays were associated with no significant modification of patient care. DOAC plasma concentration was ≤30 ng ml-1 (sensitivity 85.4%, specificity 73.6%, positive predictive value 71.1%, negative predictive value 86.7%, AUC 0.81) after a last intake of at least 2 days. CONCLUSIONS Our study is, to date, the largest report of real-life measurement of specific DOAC plasma level at a single institution. Patient care was not modified in more than half of the assays.
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Affiliation(s)
- Thibaud Cavaillez
- CHU Bordeaux, Service d'Anesthésie-Réanimation Tripode, F-33000 Bordeaux, France
| | - Laurent Weinmann
- CHU Bordeaux, Laboratoire d'hématologie, F-33000 Bordeaux, France
| | - Christine Mouton
- CHU Bordeaux, Laboratoire d'hématologie, F-33000 Bordeaux, France
| | | | - Musa Sesay
- CHU Bordeaux, Service d'Anesthésie-Réanimation Tripode, F-33000 Bordeaux, France
| | - Matthieu Biais
- CHU Bordeaux, Service d'Anesthésie-Réanimation Tripode, F-33000 Bordeaux, France; Univ. Bordeaux, INSERM, Biologie des maladies cardiovasculaire, U1034, F-33600 Pessac, France
| | - Chloé James
- CHU Bordeaux, Laboratoire d'hématologie, F-33000 Bordeaux, France; Univ. Bordeaux, INSERM, Biologie des maladies cardiovasculaire, U1034, F-33600 Pessac, France
| | - Stéphanie Roullet
- CHU Bordeaux, Service d'Anesthésie-Réanimation Tripode, F-33000 Bordeaux, France; Univ. Bordeaux, INSERM, Biologie des maladies cardiovasculaire, U1034, F-33600 Pessac, France.
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23
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Piersma‐Wichers M, Elling T, de Vries‐Bots AMB, Kooistra HAM, Meijer K. Convenience and satisfaction in direct oral anticoagulant-treated patients with atrial fibrillation. Res Pract Thromb Haemost 2021; 5:e12577. [PMID: 34430791 PMCID: PMC8371341 DOI: 10.1002/rth2.12577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/18/2021] [Accepted: 07/12/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are the preferred anticoagulants for thromboprophylaxis in atrial fibrillation. We aimed to identify determinants of quality of life related to DOAC treatment to optimize DOAC treatment convenience and satisfaction. METHODS We conducted a cross-sectional study in DOAC users. DOAC treatment-related convenience and satisfaction were measured by Perception of Anticoagulant Treatment Questionnaire. Higher scores are more favorable (range, 0-100). Patient-reported outcome measures and drug- and organization-related factors were collected. Multiple regression analyses were used to evaluate the association between these factors (ie, exposure variables) and DOAC treatment-related convenience and treatment satisfaction (ie, outcome variables). RESULTS Of 1598 patients invited, 1035 responded, and 962 were included. The median convenience score was 98.1 (94.2-100.0), mean satisfaction score 66.5± 14.9. Twenty-four percent felt not well informed at the start of DOAC; 6.9% did not know who to turn to with questions. Multiple regression analyses showed that lacking sense of security, the predefined composite of receiving insufficient information at start of DOAC and/or not knowing who to turn to with questions was associated with lower convenience (regression coefficient, -1.29; 95% confidence interval [CI], -2.16 to -0.41). Bleeding, gastrointestinal complaints, and lower medication adherence were also associated with lower convenience. Missing sense of security (regression coefficient -6.59; 95% CI, -8.94 to -4.24) and bleeding without consultation were associated with lower treatment satisfaction. CONCLUSIONS Accessible interventions to improve DOAC care could be providing more instruction at treatment initiation and ensuring that patients know who to contact in case of problems.
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Affiliation(s)
- Margriet Piersma‐Wichers
- Department of HaematologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
- Certe Thrombosis Service GroningenGroningenthe Netherlands
| | - Tessa Elling
- Department of HaematologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | | | - Hilde A. M. Kooistra
- Department of HaematologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Karina Meijer
- Department of HaematologyUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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24
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Fong AYY, Tiong LL, Tan SSN, Geruka D, Apil GG, Choo CW, Ong TK. Effect of Dabigatran on Clotting Time in the Clotpro Ecarin Clotting Assay: A Prospective, Single-Arm, Open-Label Study. Clin Appl Thromb Hemost 2021; 26:1076029620972473. [PMID: 33284050 PMCID: PMC7724398 DOI: 10.1177/1076029620972473] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Routine coagulation tests do not enable rapid, accurate determination of direct
oral anticoagulant (DOAC) therapy. The ecarin clotting assay (ECA), performed on
the ClotPro viscoelastic testing device, may enable sensitive and specific
detection of dabigatran. We assessed the association between trough plasma
dabigatran concentration and clotting time (CT) in the ClotPro ECA, in patients
with non-valvular atrial fibrillation (NVAF). Each patient provided a single
venous blood sample, ∼1 hour before dabigatran dosing. The study included 118
patients, of whom 64 were receiving dabigatran 110 mg twice daily and 54 were
receiving 150 mg twice daily. ECA CT was moderately correlated with trough
plasma dabigatran concentration (r = 0.80, p < 0.001).
Slight trends toward increased plasma dabigatran concentration and prolonged ECA
CT were apparent with 150 mg versus the 110 mg dose (differences not
statistically significant). Individuals with creatinine clearance below 50
mL/minute had significantly higher plasma dabigatran concentrations and
significantly prolonged ECA CT versus those with creatinine clearance ≥50
mL/minute. In conclusion, this preliminary study has demonstrated that CT in the
ClotPro ECA reflects the plasma concentration of dabigatran in patients with
NVAF. The ECA could potentially be used to assess the impact of dabigatran on a
patient’s coagulation status.
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Affiliation(s)
- Alan Yean Yip Fong
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia.,Department of Cardiology, Sarawak Heart Center, Kota Samarahan, Sarawak, Malaysia
| | - Lee Len Tiong
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia
| | - Shirley Siang Ning Tan
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia.,Department of Pharmacy, 58986Sarawak General Hospital, Kuching, Sarawak, Malaysia
| | - Dominic Geruka
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia
| | - Gerald Grino Apil
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia
| | - Chee Wei Choo
- Clinical Research Center, 58986Sarawak General Hospital, Institute for Clinical Research, National Institutes of Health, Shah Alam, Malaysia
| | - Tiong Kiam Ong
- Department of Cardiology, Sarawak Heart Center, Kota Samarahan, Sarawak, Malaysia
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25
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Yang P, Li H, Zhang J, Xu X. Research progress on biomarkers of pulmonary embolism. CLINICAL RESPIRATORY JOURNAL 2021; 15:1046-1055. [PMID: 34214256 DOI: 10.1111/crj.13414] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/16/2021] [Accepted: 06/29/2021] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To present a review on the traditional and new biomarkers of pulmonary embolism (PE). DATA SOURCE A systematic search has been carried out using keywords as PE, biomarker, diagnosis and risk stratification. RESULTS The results of this work have been structured into three parts: first, conventional biomarkers for vascular, cardiac and inflammation, including static markers and dynamic markers for measuring the time course; next, a review of new biomarkers in recent years, such as RNAs and markers obtained through proteomics and mass spectrometry; finally, use of new detection methods to directly detect the activity of existing markers, such as the determination of coagulation factor II and plasmin activities based on the proteolytic activation of an engineered zymogen. CONCLUSIONS This work summarized the characteristics of current traditional biomarkers for clinical diagnosis and risk stratification of PE, as well as a series of newly discovered biomarkers obtained through various clinical experimental methods.
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Affiliation(s)
- Pengbo Yang
- Department of Laboratory Medicine, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, China
| | - Hexin Li
- Clinical Biobank, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, China
| | - Junhua Zhang
- The Key Laboratory of Geriatrics, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaomao Xu
- Department of Respiratory and Critical Care Medicine, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, China
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26
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Vu A, Qu TT, Ryu R, Nandkeolyar S, Jacobson A, Hong LT. Critical Analysis of Apixaban Dose Adjustment Criteria. Clin Appl Thromb Hemost 2021; 27:10760296211021158. [PMID: 34075813 PMCID: PMC8175828 DOI: 10.1177/10760296211021158] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Apixaban is indicated for the prevention of ischemic stroke in non-valvular atrial fibrillation (NVAF), as well as for the prevention and treatment of venous thromboembolism (VTE). Dose adjustment is based on age, weight, and serum creatinine in NVAF, while there are no recommended adjustment criteria for VTE. Such adjustment is unconventional compared to other commonly used medications. The objective of this manuscript is to critically analyze each apixaban dosing adjustment criterion and its associated outcomes. PubMed articles from March 2013 to March 2020 were selected with search terms “apixaban,” and “dose adjustment,” “adjustment,” or “adjustment criteria.” Pharmacokinetic studies demonstrated increased apixaban exposure in patients >65 years of age, those with extreme body weights, and those with advanced renal impairment, though post-hemodialysis dosing may off-set the elevated apixaban exposure. However, clinical data show that among patients >75 years, <60 kg, and with estimated glomerular filtration rate <50 mL/min, including those on dialysis, there is no reduction in apixaban safety or efficacy. Published literature describes variable dosing strategies utilized in clinical practice. Overall, apixaban dose adjustment criteria may need to be re-evaluated.
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Affiliation(s)
- Anh Vu
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, CA, USA
| | - Tao T Qu
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, CA, USA
| | - Rachel Ryu
- Department of Pharmacy Practice and Administration, Western University of Health Sciences College of Pharmacy, Pomona, CA, USA
| | - Shuktika Nandkeolyar
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, CA, USA
| | - Alan Jacobson
- Division of Cardiology, Department of Medicine, Loma Linda University Medical Center, CA, USA.,Loma Linda VA Medical Center, CA, USA
| | - Lisa T Hong
- Department of Pharmacy Practice, Loma Linda University School of Pharmacy, CA, USA
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27
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Suzuki K, Katori N, Kimura Y, Terui T, Sunaga H, Kobayashi S, Uezono S. Evaluation of the effect of apixaban using a viscoelastic coagulation assay with Russell's viper venom reagent. JA Clin Rep 2021; 7:42. [PMID: 33956242 PMCID: PMC8102657 DOI: 10.1186/s40981-021-00445-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 04/23/2021] [Accepted: 04/26/2021] [Indexed: 11/20/2022] Open
Abstract
Background Conventional coagulation tests, such as prothrombin time and activated partial thromboplastin time, are not sensitive to anticoagulation by apixaban. We evaluated the antithrombotic effect of apixaban using a Russell viper venom (RVV) test for a patient who underwent posterior spine fusion surgery. Case presentation An 84-year-old man was scheduled for percutaneous posterior spine fusion. He continued apixaban until the night before surgery and resumed it on the first day after surgery. We performed an RVV test as point-of-care coagulation monitoring in combination with chromogenic anti-activated factor X (anti-Xa) activity, prothrombin time, and activated partial thromboplastin time. Clotting time with the RVV test was prolonged according to the anti-Xa activity of apixaban, which was in the therapeutic range during surgery. Conclusions An RVV test might be useful as a point-of-care assay for estimation of the anti-Xa level induced by apixaban during the perioperative period.
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Affiliation(s)
- Kaoru Suzuki
- Department of Anesthesiology, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Nobuyuki Katori
- Department of Anesthesiology, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Yoshihiro Kimura
- Department of Anesthesiology, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Takako Terui
- Department of Anesthesiology, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Hiroshi Sunaga
- Department of Anesthesiology, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Shunsuke Kobayashi
- Department of Orthopedics, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
| | - Shoichi Uezono
- Department of Anesthesiology, The Jikei University School of Medicine, 3-25-8 Nishishinbashi, Minato-ku, Tokyo, 105-8461, Japan
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28
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Zielinski GD, van Rein N, Teichert M, Klok FA, Rosendaal FR, van der Meer FJM, Huisman MV, Cannegieter SC, Lijfering WM. Adherence to direct oral anticoagulant treatment for atrial fibrillation in the Netherlands: A surveillance study. Pharmacoepidemiol Drug Saf 2021; 30:1027-1036. [PMID: 33822401 PMCID: PMC8360064 DOI: 10.1002/pds.5242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 03/30/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Adherence to direct oral anticoagulants (DOACs) in patients with atrial fibrillation in every day practice may be less than in clinical trials. AIMS To assess adherence to DOACs in atrial fibrillation patients in every day practice and identify predictors for non-adherence. METHODS Individual linked dispensing data of atrial fibrillation patients who used DOACs were obtained from the Foundation for Pharmaceutical Statistics covering the Netherlands between 2012 and 2016. One year adherence to DOAC was calculated for initial DOAC as proportion of days covered (PDC) ≥80% and the association between clinical variables and adherence was assessed using logistic regression. In addition, we measured non-persistence, that is, patients who completely stopped their initial DOAC within 1 year follow-up. RESULTS A total of 4797 apixaban-, 20 454 rivaroxaban- and 18 477 dabigatran users were included. The mean age was 69 years (n = 43 910), which was similar for the DOAC types. The overall proportion of patients with PDC ≥80% was 76%, which was highest for apixaban- (87%), followed by dabigatran- (80%) and rivaroxaban (69%) users. Multivariable analyses revealed that age ≤60 years, no concomitant drug use were predictors for non-adherence. Of atrial fibrillation patients who continued treatment, 97% had a PDC ≥80%, compared with only 56% for those who discontinued their DOAC treatment within 1 year. CONCLUSIONS Non-adherence to DOACs was associated with age ≤60 years and no concomitant drugs use. Non-adherence was higher in patients who later discontinued DOAC treatment. Results of our study support research into interventions to improve adherence.
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Affiliation(s)
- Gilda D Zielinski
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Nienke van Rein
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Martina Teichert
- Department of Clinical Pharmacy & Toxicology, Leiden University Medical Center, Leiden, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Frits R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Felix J M van der Meer
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Willem M Lijfering
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
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29
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Galhardo C, Yamauchi LHI, Dantas H, Guerra JCDC. Clinical protocols for oral anticoagulant reversal during high risk of bleeding for emergency surgical and nonsurgical settings: a narrative review. Braz J Anesthesiol 2021; 71:429-442. [PMID: 33887335 PMCID: PMC9373671 DOI: 10.1016/j.bjane.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 02/23/2021] [Accepted: 03/13/2021] [Indexed: 11/29/2022] Open
Abstract
Background and objectives Oral anticoagulants prevent thromboembolic events but expose patients to a significant risk of bleeding due to the treatment itself, after trauma, or during surgery. Any physician working in the emergency department or involved in the perioperative care of a patient should be aware of the best reversal approach according to the type of drug and the patient’s clinical condition. This paper presents a concise review and proposes clinical protocols for the reversal of oral anticoagulants in emergency settings, such as bleeding or surgery. Contents The authors searched for relevant studies in PubMed, LILACS, and the Cochrane Library database and identified 82 articles published up to September 2020 to generate a review and algorithms as clinical protocols for practical use. Hemodynamic status and the implementation of general supportive measures should be the first approach under emergency conditions. The drug type, dose, time of last intake, and laboratory evaluations of anticoagulant activity and renal function provide an estimation of drug clearance and should be taken into consideration. The reversal agents for vitamin K antagonists are 4-factor prothrombin complex concentrate and vitamin K, followed by fresh frozen plasma as a second-line treatment. Direct oral anticoagulants have specific reversal agents, such as andexanet alfa and idarucizumab, but are not widely available. Another possibility in this situation, but with less evidence, is prothrombin complex concentrates. Conclusion The present algorithms propose a tool to help healthcare providers in the best decision making for patients under emergency conditions.
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Affiliation(s)
- Carlos Galhardo
- Hospital São Lucas Copacabana, Departamento de Anestesia, Rio de Janeiro, RJ, Brazil; Instituto Nacional de Cardiologia, Rio de Janeiro, RJ, Brazil.
| | | | - Hugo Dantas
- Clínica de Anestesiologia, Departamento de Anestesia, Salvador, BA, Brazil
| | - João Carlos de Campos Guerra
- Hospital Israelita Albert Einstein, Centro de Oncologia e Hematologia, Setor de Hematologia e Coagulação, Departamento de Patologia Clínica, São Paulo, SP, Brazil
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30
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Camanho LEM, Santos GVD. Rivaroxaban: is it Really Need to Monitor its Anticoagulant Effect in Clinical Practice? INTERNATIONAL JOURNAL OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.36660/ijcs.20200373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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31
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Safety and efficacy of direct oral anticoagulants across body mass index groups in patients with venous thromboembolism: a retrospective cohort design. J Thromb Thrombolysis 2021; 52:567-576. [PMID: 33387202 DOI: 10.1007/s11239-020-02361-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/02/2020] [Indexed: 12/13/2022]
Abstract
Current literature on the safety and efficacy of direct oral anticoagulants (DOACs) in patients of extreme weights are limited, however, they are still being prescribed in these populations. The objective of this study is to describe the safety and efficacy of DOAC therapy in patients of extreme weights for the treatment of venous thromboembolism (VTE) using body mass index (BMI) groups. A multi-site, retrospective cohort design at four hospitals was performed. Patients who experienced an initial VTE between November 2012 and August 2017 and placed on a DOAC were included. Patients were defined as: extremely obese (EO) if BMI ≥ 40 kg/m2, obese if BMI 30-39.9 kg/m2, normal/overweight if BMI 18.5-29.9 kg/m2, and underweight if BMI < 18.5 kg/m2. The primary efficacy outcome of recurrent VTE and primary safety outcome of major bleeding (MB) within 12 months were compared between weights. Univariate statistical tests and multivariate logistic regression analyses were performed. Rates of recurrent VTE showed no significant differences (p = 0.58) across groups; 7.8% (11/142) EO, 4.7% (18/383) obese, 5.2% (27/517) normal/overweight, and 5.9% (1/17) underweight. Proportions of MB were overall significantly different (p = 0.026); 6.3% (9/142) EO, 10.4% (40/383) obese, 10.1% (52/517) normal/overweight, and 29.4% (5/17) underweight. EO and obese patients had similar odds of MB compared to normal/overweight (OR 0.61, 95% CI [0.29, 1.26] and OR 1.04, 95% CI [0.67, 1.61]). Underweight patients showed larger odds of MB compared to normal/overweight (OR 3.73, 95% CI [1.26, 11.0]). This study found that recurrence of VTE was not associated with BMI. However, the proportions of major bleeding were statistically different among the BMI categories.
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Moudallel S, van den Bemt BJF, Zwikker H, de Veer A, Rydant S, Dijk LV, Steurbaut S. Association of conflicting information from healthcare providers and poor shared decision making with suboptimal adherence in direct oral anticoagulant treatment: A cross-sectional study in patients with atrial fibrillation. PATIENT EDUCATION AND COUNSELING 2021; 104:155-162. [PMID: 32622691 DOI: 10.1016/j.pec.2020.06.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVE To assess direct oral anticoagulant (DOAC) adherence and to determine possible determinants for suboptimal adherence in Dutch patients with atrial fibrillation (AF). METHODS Cross-sectional study of DOAC users who completed a self-reported questionnaire. Adherence was measured with Morisky8-item Medication Adherence Scale (MMAS-8). Logistic regression analysis was conducted to investigate determinants affecting adherence. RESULTS 398 DOAC users completed the questionnaire (mean age 70.6 ± 9.2years). Approximately one in four patients had suboptimal adherence (MMAS-8 < 8). Multivariable analysis showed that patients who felt to have received conflicting information about the treatment, patients with higher educational level and patients who were not sufficiently involved in the treatment choice had a higher odds of suboptimal adherence. CONCLUSION DOAC adherence was suboptimal. Conflicting information received from different healthcare providers (HCPs), lack of shared decision making and the patients' educational level were determinants negatively affecting DOAC adherence. PRACTICE IMPLICATIONS Efforts towards identifying suboptimally adherent DOAC patients are needed since they are at higher risk to develop thromboembolic events. Adherence counselling should be systematically and repeatedly encouraged and shared decision making should become more mainstream. Moreover, reinforced education of both patients and HCPs combined with interprofessional collaboration are potential solutions to prevent knowledge gaps and communication of conflicting information.
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Affiliation(s)
- Souad Moudallel
- Vrije Universiteit Brussel, Faculty of Medicine and Pharmacy, Centre for Pharmaceutical Research (CePhar), Brussels, Belgium; Department of Clinical Pharmacology and Pharmacotherapy, Universitair Ziekenhuis (UZ) Brussel, Brussels, Belgium.
| | - Bart J F van den Bemt
- Department of Rheumatology and Pharmacy, Sint Maartenskliniek, Nijmegen, the Netherlands
| | - Hanneke Zwikker
- Dutch Institute for Rational Use of Medicine (IVM), Utrecht, the Netherlands
| | - Anne de Veer
- Department of Cardiology, St-Antonius Hospital, Nieuwegein, the Netherlands
| | - Silas Rydant
- Vrije Universiteit Brussel, Faculty of Medicine and Pharmacy, Centre for Pharmaceutical Research (CePhar), Brussels, Belgium; KAVA, Royal Pharmaceutical Society of Antwerp, Antwerp, Belgium
| | - Liset van Dijk
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Stephane Steurbaut
- Vrije Universiteit Brussel, Faculty of Medicine and Pharmacy, Centre for Pharmaceutical Research (CePhar), Brussels, Belgium; Department of Clinical Pharmacology and Pharmacotherapy, Universitair Ziekenhuis (UZ) Brussel, Brussels, Belgium
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Bixby AL, Lichvar AB, Salerno D, Park JM. Use of direct-acting oral anticoagulants in solid organ transplantation: A systematic review. Pharmacotherapy 2020; 41:28-43. [PMID: 33155327 DOI: 10.1002/phar.2485] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/27/2020] [Accepted: 09/10/2020] [Indexed: 12/13/2022]
Abstract
The use of direct-acting oral anticoagulants (DOACs) has increased secondary to the mounting evidence for comparable efficacy and potentially superior safety to vitamin K antagonists (VKAs) in the general population. However, insufficient data regarding DOAC use in solid organ transplant (SOT) recipients and numerous pharmacokinetic and pharmacodynamic considerations limit their use in this highly selected patient population. A systematic review of recent clinical evidence on the safety and efficacy of DOACs compared to VKAs in SOT recipients was conducted. Additional considerations including transplant-specific strategies for DOAC reversal and common pharmacokinetic/pharmacodynamic concerns were also reviewed. Although current evidence is limited to single-center retrospective analyses, DOACs, especially apixaban, appear to be a safe and effective alternative to VKAs for SOT recipients with stable graft function and without drug-drug interactions. Reliable data on DOAC reversal at the time of transplant surgery are lacking, and clinicians should consider idarucizumab, andexanet alfa, and other non-specific reversal agents on an individual patient basis. There is no evidence supporting deviations from the Food and Drug Administration labeling recommendations for DOAC dosing in the setting of drug-drug interactions, obesity, and renal function, especially in patients on hemodialysis.
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Affiliation(s)
- Alexandra L Bixby
- Department of Pharmacy Services, University of Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Alicia B Lichvar
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois, USA.,Department of Surgery, University of Illinois at Chicago College of Medicine, Chicago, Illinois, USA
| | - David Salerno
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Jeong M Park
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA.,Department of Pharmacy Services, Michigan Medicine, Ann Arbor, Michigan, USA
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Velasco-González V, Fernández-Araque A, Sainz-Gil M, Jimeno N, Martín LH, Verde Z. Hydroxychloroquine and Potential Drug Interactions in Older Adults. Arch Bronconeumol 2020; 56:679-681. [PMID: 33994635 PMCID: PMC7528906 DOI: 10.1016/j.arbr.2020.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Verónica Velasco-González
- Department of Nursery, University of Valladolid, Valladolid, Spain
- Recognized research group "Pharmacogenetics, Cancer Genetics, Genetic Polymorphisms and Pharmacoepidemiology", University of Valladolid, Valladolid, Spain
- Institute of Applied Ophthalmobiology, University of Valladolid, Valladolid, Spain
| | - Ana Fernández-Araque
- Recognized research group "Pharmacogenetics, Cancer Genetics, Genetic Polymorphisms and Pharmacoepidemiology", University of Valladolid, Valladolid, Spain
- Department of Nursery, University of Valladolid, Campus Duques de Soria, Soria, Spain
| | - Maria Sainz-Gil
- Recognized research group "Pharmacogenetics, Cancer Genetics, Genetic Polymorphisms and Pharmacoepidemiology", University of Valladolid, Valladolid, Spain
- Centre for Castilla y Leon Pharmacovigilance, Valladolid, Spain
| | - Natalia Jimeno
- Recognized research group "Pharmacogenetics, Cancer Genetics, Genetic Polymorphisms and Pharmacoepidemiology", University of Valladolid, Valladolid, Spain
- Department of Psychiatry, University of Valladolid, Valladolid, Spain
| | - Luis H Martín
- Department of Nursery, University of Valladolid, Valladolid, Spain
- Centre for Castilla y Leon Pharmacovigilance, Valladolid, Spain
| | - Zoraida Verde
- Recognized research group "Pharmacogenetics, Cancer Genetics, Genetic Polymorphisms and Pharmacoepidemiology", University of Valladolid, Valladolid, Spain
- Department of Biochemistry, Molecular Biology and Physiology, University of Valladolid, Campus Duques de Soria, Soria, Spain
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Levito MN, Coons JC, Verrico MM, Szymkowiak A, Legler B, Dueweke EJ, Kane-Gill SL. A Systemwide Approach for Navigating the Dilemma of Oral Factor Xa Inhibitor Interference With Unfractionated Heparin Anti-Factor Xa Concentrations. Ann Pharmacother 2020; 55:618-623. [PMID: 32885997 DOI: 10.1177/1060028020956271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Oral factor Xa inhibitors are known to significantly increase heparin anti-Xa concentrations, which leads to inaccuracies when monitoring intravenous unfractionated heparin (IV UFH). Guidance for managing this laboratory interference is lacking, creating substantial uncertainty in clinical practice. OBJECTIVE To describe a strategy used by a large academic institution for managing the controversy of laboratory interference in the setting of oral factor Xa inhibitor use and provide effectiveness and safety data for this approach. METHODS In December 2016, a new Heparin IV Direct Oral Anticoagulant (DOAC) Interference PowerPlan (a comprehensive order set) was made available in the electronic health record (Cerner, North Kansas City, MO) throughout the health system. We retrospectively examined 169 patients with events reported in the error reporting system, RISKMASTER, and evaluated reports with and without the use of the PowerPlan. Effectiveness was determined through evaluation of thrombosis. The Naranjo criteria for causality were applied to assess thrombotic events. RESULTS Of 56 events that were reported with apixaban when the PowerPlan was not ordered, 4 (7%) thrombotic events occurred within 7 days of UFH initiation. One out of the 4 events (25%) that occurred when the PowerPlan was not appropriately initiated was considered probable using the Naranjo Scale. Three additional events (75%) were possible using the Naranjo Scale. CONCLUSION AND RELEVANCE The Heparin IV DOAC Interference PowerPlan appears to be conducive to positive patient outcomes when evaluating voluntary reported events and may assist clinicians with managing the therapeutic dilemma of this laboratory interference.
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Affiliation(s)
| | - James C Coons
- UPMC Presbyterian-Shadyside, Pittsburgh, PA, USA.,University of Pittsburgh-School of Pharmacy, Pittsburgh, PA, USA
| | | | | | - Brianna Legler
- UPMC Presbyterian-Shadyside, Pittsburgh, PA, USA.,Duquesne University, Pittsburgh, PA, USA
| | | | - Sandra L Kane-Gill
- UPMC Presbyterian-Shadyside, Pittsburgh, PA, USA.,University of Pittsburgh-School of Pharmacy, Pittsburgh, PA, USA
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Ebraheem M, Alzahrani I, Crowther M, Rochwerg B, Almakadi M. Extended DOAC therapy in patients with VTE and potential risk of recurrence: A systematic review and meta-analysis. J Thromb Haemost 2020; 18:2308-2317. [PMID: 32510840 DOI: 10.1111/jth.14949] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 05/25/2020] [Accepted: 05/27/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Guidelines recommend at least 3 months of anticoagulation for venous thromboembolism (VTE). Evidence supporting indefinite anticoagulation exists in certain conditions; however, for many patients, uncertainty regarding when to discontinue anticoagulation persists. OBJECTIVE We aimed to investigate the efficacy and safety of extended direct oral anticoagulants (DOAC) therapy in patients with VTE and clinical uncertainty regarding extended anticoagulation. METHODS We searched EMBASE, MEDLINE, PubMed, and Cochrane Central Register of Controlled Trials databases for randomized control trials examining extended anticoagulation with DOACs as compared to non-extended therapy for the treatment of VTE. RESULTS Of 560 citations identified by the search, three studies were eligible. Extended anticoagulation reduced VTE recurrence (relative risk [RR] 0.18, 95% confidence interval [CI] 0.12 to 0.25), and mortality (RR 0.39, 95% CI 0.19 to 0.80) with a low total number of deaths in the DOAC group (n = 12) versus placebo (n = 18). Extended anticoagulation increased clinically relevant non-major bleedings (RR 2.51, 95% CI 1.37 to 4.59). There was no difference in rates of major bleeding (RR 1.87, 95% CI 0.19 to 17.85); however, there was a low number of major bleeding events in both DOAC (n = 9) and placebo groups (n = 4). The results were mostly driven by one study (AMPLIFY-EXT), with significant heterogeneity between studies noticed when assessing bleeding outcomes. CONCLUSION Extended DOAC therapy for 1 year in patients with clinical uncertainty for ongoing anticoagulation can reduce VTE recurrence and mortality; however, it could increase clinically relevant non-major bleeding events.
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Affiliation(s)
| | | | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Critical Care, McMaster University, Hamilton, ON, Canada
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Smith AR, Dager WE, Gulseth MP. Transitioning hospitalized patients from rivaroxaban or apixaban to a continuous unfractionated heparin infusion: A retrospective review. Am J Health Syst Pharm 2020; 77:S59-S65. [PMID: 32719867 DOI: 10.1093/ajhp/zxaa143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To determine a patient's clinical course based on the use of an activated partial thromboplastin time (aPTT) or heparin anti-Xa assay when transitioning from rivaroxaban or apixaban to an unfractionated heparin infusion. METHODS A retrospective chart review was conducted to investigate how unfractionated heparin infusions were managed at a tertiary care hospital in the setting of recent apixaban or rivaroxaban administration. Patients were separated into 2 cohorts based on the chosen heparin infusion monitoring assay: heparin anti-Xa or aPTT. The primary composite outcome was total number of bleeding and thrombotic events; the secondary composite outcome was average incidence of heparin infusion holds and rate changes per patient. RESULTS Data were collected from 76 patients (heparin anti-Xa = 69, aPTT = 7). Due to the limited number of patients within the aPTT cohort, this data was excluded from the analysis, and heparin anti-Xa descriptive statistics were reported without statistical comparisons. In the heparin anti-Xa group, a total of 10 bleeds and 1 thrombus were discovered. Additionally, the average number of infusion holds and rate changes was 0.841 and 2.65 times per patient, respectively, for those patients monitored via heparin anti-Xa assay. CONCLUSION In the presence of a recently administered oral anti-Xa anticoagulant, more down-titrations occurred in the initial 6 hours of the heparin infusion when measuring anti-Xa activity, and most up-titrations occurred after 36 hours. Baseline heparin anti-Xa activity may be a useful tool to identify patients with residual plasma concentrations of apixaban and rivaroxaban to help better individualize heparin therapy.
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Affiliation(s)
- Alex R Smith
- Department of Pharmaceutical Services, Sanford USD Medical Center, Sioux Falls, SD
| | - William E Dager
- Department of Pharmaceutical Services, UC Davis Medical Center, Sacramento, CA
| | - Michael P Gulseth
- Department of Pharmaceutical Services, Sanford USD Medical Center, Sioux Falls, SD
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38
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Rocha AL, Oliveira SR, Souza AF, Travassos DV, Abreu LG, Ribeiro DD, Silva TA. Direct oral anticoagulants in oral surgery: a prospective cohort. ACTA ACUST UNITED AC 2020; 69:384-393. [PMID: 32698567 DOI: 10.23736/s0026-4970.20.04389-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Quantitative assessment of bleeding in dental extractions is rarely reported in the literature. The assessment of bleeding might provide additional evidence to predict and minimize postoperative outcomes. The aim of this study was to evaluate the pattern of bleeding in individuals taking direct oral anticoagulants (DOACs) submitted to dental extractions. METHODS Intraoperative bleeding was evaluated by using total collected bleeding corrected by absorbance reading (dental bleeding score). To monitoring bleeding episodes from the day of surgery, this cohort was followed up until the seventh postoperative day. RESULTS Forty-five procedures were performed in three comparative groups, patients under DOACs, individuals taking vitamin K antagonists (VKAs) and without anticoagulant therapy. No bleeding events were observed in procedures carried out in individuals of the DOAC group. Additional hemostatic measures were required in two procedures in the VKA group and one in the non-anticoagulated group. The dental bleeding scores obtained for the DOAC and VKA groups were similar. CONCLUSIONS Our data suggest that the DOAC therapy did not result in increased bleeding outcomes in this sample.
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Affiliation(s)
- Amanda L Rocha
- Department of Oral Surgery and Pathology, Faculty of Dentistry, Federal University of Minas Gerais, Minas Gerais, Brazil
| | - Sicilia R Oliveira
- Department of Oral Surgery and Pathology, Faculty of Dentistry, Federal University of Minas Gerais, Minas Gerais, Brazil
| | - Alessandra F Souza
- Department of Oral Surgery and Pathology, Faculty of Dentistry, Federal University of Minas Gerais, Minas Gerais, Brazil
| | - Denise V Travassos
- Department of Community and Preventive Dentistry, Faculty of Dentistry, Federal University of Minas Gerais, Minas Gerais, Brazil
| | - Lucas G Abreu
- Department of Pediatric Dentistry and Orthodontics, Faculty of Dentistry, Federal University of Minas Gerais, Minas Gerais, Brazil
| | - Daniel D Ribeiro
- Department of Hematology, Faculty of Medicine, Federal University of Minas Gerais, Minas Gerais, Brazil
| | - Tarcília A Silva
- Department of Oral Surgery and Pathology, Faculty of Dentistry, Federal University of Minas Gerais, Minas Gerais, Brazil -
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40
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Abstract
Abstract
Direct oral anticoagulants (
DOAC
s) have quickly become attractive alternatives to the long‐standing standard of care in anticoagulation, vitamin K antagonist.
DOAC
s are indicated for prevention and treatment of several cardiovascular conditions. Since the first approval in 2010,
DOAC
s have emerged as leading therapeutic alternatives that provide both clinicians and patients with more effective, safe, and convenient treatment options in thromboembolic settings. With the expanding role of
DOAC
s, clinicians are faced with increasingly complex decisions relating to appropriate agent, duration of treatment, and use in special populations. This review will provide an overview of
DOAC
s and act as a practical reference for clinicians to optimize
DOAC
use among common challenging scenarios. Topics addressed include (1) appropriate indications; (2) use in patients with specific comorbidities; (3) monitoring parameters; (4) transitioning between anticoagulant regimens; (5) major drug interactions; and (6) cost considerations.
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Affiliation(s)
| | - Eric Stecker
- Electrophysiology Section Knight Cardiovascular Institute Oregon Health & Science University Portland OR
| | - Bruce A. Warden
- Center for Preventive Cardiology Knight Cardiovascular Institute Oregon Health & Science University Portland OR
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41
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Abstract
Direct oral anticoagulants (DOACs) have quickly become attractive alternatives to the long-standing standard of care in anticoagulation, vitamin K antagonist. DOACs are indicated for prevention and treatment of several cardiovascular conditions. Since the first approval in 2010, DOACs have emerged as leading therapeutic alternatives that provide both clinicians and patients with more effective, safe, and convenient treatment options in thromboembolic settings. With the expanding role of DOACs, clinicians are faced with increasingly complex decisions relating to appropriate agent, duration of treatment, and use in special populations. This review will provide an overview of DOACs and act as a practical reference for clinicians to optimize DOAC use among common challenging scenarios. Topics addressed include (1) appropriate indications; (2) use in patients with specific comorbidities; (3) monitoring parameters; (4) transitioning between anticoagulant regimens; (5) major drug interactions; and (6) cost considerations.
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Affiliation(s)
| | - Eric Stecker
- Electrophysiology SectionKnight Cardiovascular InstituteOregon Health & Science UniversityPortlandOR
| | - Bruce A. Warden
- Center for Preventive CardiologyKnight Cardiovascular InstituteOregon Health & Science UniversityPortlandOR
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Raphael A. Moving towards ideal and appropriate models of anticoagulation management service. Ann Afr Med 2020; 19:153-163. [PMID: 32820726 PMCID: PMC7694708 DOI: 10.4103/aam.aam_30_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 11/12/2019] [Accepted: 02/24/2020] [Indexed: 11/04/2022] Open
Abstract
It is now known that thrombotic disorders such as venous thromboembolism, ischemic stroke, and myocardial infarction contribute significantly to global morbidity and mortality. Anticoagulation service must respond to this new development. Warfarin has continued to provide the backbone for anticoagulation service for decades but with considerable drawbacks. The introduction of nonVitamin K oral anticoagulants (NOACs) has created new challenges. This article seeks to discuss how the establishment of appropriate models of anticoagulation could contain the draw backs of the old anticoagulants and improve on the compliance, availability, affordability, and accessibility of newer anticoagulants. Successful anticoagulation has always been defined by a scientific balancing of the risk of thrombosis and the complication of hemorrhage. To be able to maintain such optimal anticoagulation requires rational drug prescription (physician factor), institutelization of monitoring of therapy (anticoagulation clinic factor) as well as active participation of patients receiving therapy (patient factor). New models of service can be created out of this triad in a bid to replace the old routine medical care model. New models of anticoagulation service should include appropriately trained professionals such as Physicians, Pharmacists, Clinical Pharmacologists, Nurses, and Laboratory Scientists who are knowledgeable in diagnostic, management, and monitoring of anticoagulation. The different models of anticoagulation service discussed in this article clearly demonstrate the need for restructuring of this life saving service particularly in the era of NOAC. Newer models of care that should provide safe, efficacious, and cost-effective services are needed.
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Affiliation(s)
- Anakwue Raphael
- Department of Medicine and University of Nigeria Enugu Campus, Dedicated Anticoagulation Clinic, University of Nigeria Teaching Hospital, Enugu, Nigeria
- Department of Pharmacology and Therapeutics, Faculty of Medicine, University of Nigeria Enugu Campus, Dedicated Anticoagulation Clinic, University of Nigeria Teaching Hospital, Enugu, Nigeria
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43
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Guglielmo N, Orso D, Mestroni R, Montanari G. A Case of Liver Failure Due to Dabigatran Treated with Venovenous Hemodiafiltration and Idarucizumab. Curr Drug Saf 2020; 15:227-230. [PMID: 32576132 DOI: 10.2174/1574886315666200623162926] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 05/07/2020] [Accepted: 05/18/2020] [Indexed: 11/22/2022]
Abstract
Dabigatran etexilate, a direct thrombin inhibitor, was recently introduced in clinical use to prevent thromboembolic events in patients with risk factors (such as non-valvular atrial fibrillation or deep vein thrombosis). Dabigatran is not recommended in patients with creatinine clearance below 30 mL/min. More than 85% of the drug is eliminated by the renal route while the remaining part via the enteral route. Acute renal failure can result in an unexpected increase in serum levels of Dabigatran. In elderly, renal dysfunction, co-morbidity, and concomitant intake of different drugs could make the dosage of Dabigatran challenging. We present a case of an elderly man who suffered a severe accidental dabigatran intoxication with acute liver toxicity recovered after dialytic treatment and Idarucizumab.
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Affiliation(s)
- Nicola Guglielmo
- Department of Emergency Medicine, A.A.S. 2 "Bassa Friulana-Isontina", Ospedale di Latisana, Latisana (UD), Italy
| | - Daniele Orso
- Department of Medicine, University of Udine, Udine, Italy
| | - Rosalba Mestroni
- Department of Medicine, A.A.S. 2 "Bassa Friulana - Isontina", Ospedale di Palmanova, Palmanova (UD), Italy
| | - Giulia Montanari
- Department of Emergency Medicine, A.A.S. 2 "Bassa Friulana-Isontina", Ospedale di Latisana, Latisana (UD), Italy
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Zhang J, Zou L, Liu C, Li C, Wang M, Yang H, Wang Y, Tan Z, Li H, Su F, Zou T, Li K, Wang X, Li Y, Han B, Zhang Z, Zhai Z, Liu X, Xu X, Xiao F. Direct Determination of Coagulation Factor IIa and Plasmin Activities for Monitoring of Thrombotic State. J Appl Lab Med 2020; 5:1265-1276. [PMID: 32529225 DOI: 10.1093/jalm/jfaa060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 03/18/2020] [Indexed: 12/20/2022]
Abstract
Abstract
Background
Current laboratory examinations for hypercoagulable diseases focus on the biomarker content of the activated coagulation cascade and fibrinolytic system. Direct detection of physiologically important protease activities in blood remains a challenge. This study aims to develop a general approach that enables the determination of activities of crucial coagulation factors and plasmin in blood.
Methods
This assay is based on the proteolytic activation of an engineered zymogen of l-phenylalanine oxidase (proPAO), for which the specific blood protease cleavage sites were engineered between the inhibitory and activity domains of proPAO. Specific cleavage of the recombinant proenzyme leads to the activation of proPAO, followed by oxidation and oxygenation of l-phenylalanine, resulting in an increase of chromogenic production when coupled with the Trinder reaction.
Results
We applied this method to determine the activities of both coagulation factor IIa and plasmin in their physiologically relevant basal state and fully activated state in sodium citrate–anticoagulated plasma respectively. Factor IIa and plasmin activities could be dynamically monitored in patients with thrombotic disease who were taking oral anticoagulants and used for assessing the hypercoagulable state in pregnant women.
Conclusions
The high specificity, sensitivity, and stability of this novel assay not only makes it useful for determining clinically important protease activities in human blood and diagnosing thrombotic diseases but also provides a new way to monitor the effectiveness and safety of anticoagulant drugs.
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Affiliation(s)
- Junhua Zhang
- The Key Laboratory of Geriatrics, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
- Clinical Biobank, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Lihui Zou
- The Key Laboratory of Geriatrics, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Chengyang Liu
- The Key Laboratory of Geriatrics, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Chuanbao Li
- Department of Laboratory Medicine, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Meng Wang
- Department of Laboratory Medicine, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
| | - He Yang
- Department of Respiratory and Critical Care Medicine, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Yan Wang
- Department of Respiratory and Critical Care Medicine, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Zheng Tan
- Department of Respiratory and Critical Care Medicine, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Hexin Li
- Clinical Biobank, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Fei Su
- Clinical Biobank, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Tong Zou
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Kang Li
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Xiaogang Wang
- Department of Traditional Chinese Medicine, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Ying Li
- The Key Laboratory of Geriatrics, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
- Clinical Biobank, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Bingqing Han
- The Key Laboratory of Geriatrics, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
- Clinical Biobank, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Zhu Zhang
- Department of Respiratory and Critical Care Medicine, The China-Japan Friendship Hospital, Beijing, PR China
| | - Zhenguo Zhai
- Department of Respiratory and Critical Care Medicine, The China-Japan Friendship Hospital, Beijing, PR China
| | - Xiangyi Liu
- Department of Clinical Laboratory, Beijing Tongren Hospital, Capital Medical University, Beijing, PR China
| | - Xiaomao Xu
- Department of Respiratory and Critical Care Medicine, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Fei Xiao
- The Key Laboratory of Geriatrics, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
- Clinical Biobank, Beijing Hospital, National Center of Gerontology, Chinese Academy of Medical Sciences, Beijing, PR China
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45
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Abstract
An increasing number of patients are being prescribed direct oral anticoagulants (DOACs), while the patients who remain on warfarin are becoming more complex. There is currently a lack of a standardised anticoagulation review for patients in primary care, resulting in potentially preventable harm events. Our aim was to implement a new service, where a standardised review is carried out by a specialist multidisciplinary secondary care anticoagulation team. Overall, the implementation of a standardised review resulted in better optimisation of anticoagulation management for patients taking either a DOAC or a warfarin. Of the 172 eligible patients prescribed warfarin, 47 (27%) chose to switch a DOAC. The average time in therapeutic range for patients on warfarin before and after the pilot increased from 73.5% to 75%. Of 482 patients taking a DOAC, 35 (7%) were found to be on incorrect dose. In 32 (91%) of 35 patients, the dose was amended after notifying the patient's general practitioner. We also found a significant number of patients inappropriately prescribed concomitant medication such as antiplatelet or non-steroidal anti-inflammatory drugs, potentially putting the patients at an elevated risk of bleeding. While further research is needed; we believe the results of this pilot can be used to help build a case to influence the commissioning of anticoagulation services. Secondary care anticoagulation teams, like our own, may be well-placed to provide or support such services, by working across the primary care and secondary care interface to support our primary care colleagues.
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46
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Li Y, Du L, Tang X, Chen Y, Mei D. Laboratory monitoring of rivaroxaban in Chinese patients with deep venous thrombosis: a preliminary study. BMC Pharmacol Toxicol 2020; 21:38. [PMID: 32466800 PMCID: PMC7257180 DOI: 10.1186/s40360-020-00414-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 05/12/2020] [Indexed: 12/02/2022] Open
Abstract
Background Rivaroxaban, a novel oral anticoagulant drug, is widely used in clinical practice. There is no standardized laboratory monitoring for rivaroxaban, and its plasma concentration in Chinese patients with deep vein thrombosis is unclear. The rivaroxaban concentrations in human plasma and determine the steady-state concentration of rivaroxaban in patients with deep vein thrombosis are needed. Methods An ultra-high-performance liquid chromatography with mass spectrometric detection method was developed. Chromatographic separation was performed on a Waters BEH C18 column with isocratic elution using a mobile phase composed of acetonitrile and water. Quantitation of the analytes was performed using positive ionization mode and mass transitions of m/z 437.3 → m/z 145.0 and m/z 440.1 → m/z 145.0 for rivaroxaban and the internal standard, respectively. Blood samples were collected at 0 h and 2 h after patients took rivaroxaban for 7 days or more. Results The method was validated over the concentration range of 0.5 ~ 400 ng•mL− 1 with a very low limit of quantification of 0.5 ng·mL− 1, and the intra- and inter-day precision (RSD%) were < 15%. The range of the steady state concentration in patients that took 15 mg rivaroxaban twice daily, 10 mg twice daily, 20 mg once daily, 15 mg once daily, and 10 mg once daily were 168.5 ~ 280.1 ng•mL− 1, 74.2 ~ 271.4 ng•mL− 1, 25.7 ~ 306.8 ng•mL− 1, 24.5 ~ 306.4 ng•mL− 1, and 15.4 ~ 229.2 ng•mL− 1, respectively. Conclusions The plasma rivaroxaban concentration in patients who took 10 mg rivaroxaban twice daily fluctuated less than that in patients who took 20 mg rivaroxaban once daily. The plasma concentration can be used for therapeutic drug monitoring for rivaroxaban.
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Affiliation(s)
- Ying Li
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.,Department of Pharmacy, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100021, China
| | - Liping Du
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Xiaowan Tang
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China
| | - Yuexin Chen
- Department of Vascular Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
| | - Dan Mei
- Department of Pharmacy, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100730, China.
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Abstract
PURPOSE OF REVIEW As the prevalence of patients on antithrombotics is increasing, anesthesiologists must have a firm understanding of these medications and considerations for their periprocedural management. This review details up-to-date periprocedural management of direct oral anticoagulants (DOACs). RECENT FINDINGS DOACs have favorable pharmacokinetics including quick onset of action and short half-lives. Periprocedural management of DOACs relies heavily on drug half-life as well as procedural risk of bleeding. Other than a few exceptions, the American College of Cardiologists generally recommends complete clearance of oral anticoagulants prior to high-risk bleeding procedures and partial clearance prior to low-risk bleeding procedures. Procedures with little to no clinical risk of bleeding can be performed without any drug interruption or during trough levels. Exceptions to periprocedural DOAC management pertain to electrophysiology procedures. SUMMARY With the exception of no clinically relevant bleeding risk or certain electrophysiology procedures, DOACs should be discontinued periprocedurally in accordance with bleeding risks and drug's half-life. Bridging is generally not recommended for DOACs.
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Creatinine monitoring patterns in the setting of direct oral anticoagulant therapy for non-valvular atrial fibrillation. J Thromb Thrombolysis 2020; 48:500-505. [PMID: 31111434 DOI: 10.1007/s11239-019-01883-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Guidelines and experts note that patients with atrial fibrillation require regular renal function monitoring to ensure safe use of direct oral anticoagulants (DOACs). Insufficient monitoring could lead to inappropriate dosing and adverse events. Our objective was to describe the frequency of insufficient creatinine monitoring among patients on DOACs, and to describe clinical factors associated with insufficient monitoring. We hypothesized that renal impairment would be associated with insufficient monitoring. A retrospective cohort study was performed with data from the Michigan Anticoagulant Quality Improvement Initiative. Patients were included if they initiated DOAC therapy for stroke prevention related to atrial fibrillation, remained on therapy for ≥ 1 year, and had baseline creatinine and weight measurements. Creatinine clearance (CrCl) was calculated via Cockcroft-Gault equation. Our outcome was the presence of insufficient creatinine monitoring, defined as: < 1 creatinine level/year for patients with CrCl > 50, or < 2 creatinine levels/year for patients with CrCl ≤ 50. Multivariable analysis was done via logistic regression. Study population included 511 patients. In overall, 14.0% of patients received insufficient monitoring. Among patients with CrCl > 50, 11.5% had < 1 creatinine level/year. Among patients with CrCl ≤ 50, 27.1% received < 2 creatinine levels/year. Baseline renal dysfunction was associated with a higher likelihood of insufficient creatinine monitoring (adjusted odds ratio 3.64, 95% confidence interval 1.81-7.29). This shows a significant gap in the monitoring of patients on DOACs-patients with renal impairment are already at higher risk for adverse events. Future studies are needed to describe the barriers in monitoring these patients and to identify how to optimally address them.
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Jeong HC, Kim TE, Shin KH. Quantification of apixaban in human plasma using ultra performance liquid chromatography coupled with tandem mass spectrometry. Transl Clin Pharmacol 2020; 27:33-41. [PMID: 32055579 PMCID: PMC6989270 DOI: 10.12793/tcp.2019.27.1.33] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 03/11/2019] [Accepted: 03/11/2019] [Indexed: 11/19/2022] Open
Abstract
Apixaban, an inhibitor of direct factor Xa, is used for the treatment of venous thromboembolic events or prevention of stroke. Unlike many other anticoagulant agents, it does not need periodic monitoring. However, monitoring is still required to determine the risk of bleeding due to overdose or surgery. Usually, apixaban concentrations are indirectly quantified using an anti-factor Xa assay. However, this method has a relatively narrow analytical concentration range, poor selectivity, and requires an external calibrator. Therefore, the goal of current study was to establish an analytical method for determining plasma levels of apixaban using ultra performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS). To this end, apixaban was separated using 2.5 mM ammonium formate (pH 3.0) (A) and 100% methanol containing 0.1% formic acid (B) using the gradient method with a Thermo hypersil GOLD column. The mass detector condition was optimized using the electrospray ionization (ESI) positive mode for apixaban quantification. The developed method showed sufficient linearity (coefficient of determination [r2 ≥ 0.997]) at calibration curve ranges. The percentage (%) changes in accuracy, precision, and all stability tests were within 15% of the nominal concentration. Apixaban concentration in plasma from healthy volunteers was quantified using the developed method. The mean maximum plasma concentration (Cmax) was 371.57 ng/mL, and the median time to achieve the Cmax (Tmax) was 4 h after administration of 10 mg apixaban alone. Although the results showed low extraction efficiency (~16%), the reproducibility (% change was within 15% of nominal concentration) was reliable. Therefore, the developed method could be used for clinical pharmacokinetic studies.
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Affiliation(s)
- Hyeon-Cheol Jeong
- College of Pharmacy, Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu 41566, Korea
| | - Tae-Eun Kim
- Department of Clinical Pharmacology, Konkuk University Medical Center, Seoul 05030, Republic of Korea
| | - Kwang-Hee Shin
- College of Pharmacy, Research Institute of Pharmaceutical Sciences, Kyungpook National University, Daegu 41566, Korea
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An Update on the Reversal of Non-Vitamin K Antagonist Oral Anticoagulants. Adv Hematol 2020; 2020:7636104. [PMID: 32231703 PMCID: PMC7097770 DOI: 10.1155/2020/7636104] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/26/2019] [Accepted: 09/25/2019] [Indexed: 12/19/2022] Open
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) include thrombin inhibitor dabigatran and coagulation factor Xa inhibitors rivaroxaban, apixaban, edoxaban, and betrixaban. NOACs have several benefits over warfarin, including faster time to the achieve effect, rapid onset of action, fewer documented food and drug interactions, lack of need for routine INR monitoring, and improved patient satisfaction. Local hemostatic measures, supportive care, and withholding the next NOAC dose are usually sufficient to achieve hemostasis among patients presenting with minor bleeding. The administration of reversal agents should be considered in patients on NOAC's with major bleeding manifestations (life-threatening bleeding, or major uncontrolled bleeding), or those who require rapid anticoagulant reversal for an emergent surgical procedure. The Food and Drug Administration (FDA) has approved two reversal agents for NOACs: idarucizumab for dabigatran and andexanet alfa for apixaban and rivaroxaban. The American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Society (HRS) have released an updated guideline for the management of patients with atrial fibrillation that provides indications for the use of these reversal agents. In addition, the final results of the ANNEXA-4 study that evaluated the efficacy and safety of andexanet alfa were recently published. Several agents are in different phases of clinical trials, and among them, ciraparantag has shown promising results. However, their higher cost and limited availability remains a concern. Here, we provide a brief review of the available reversal agents for NOACs (nonspecific and specific), recent updates on reversal strategies, lab parameters (including point-of-care tests), NOAC resumption, and agents in development.
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