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Acton EK, Hennessy S, Gelfand MA, Leonard CE, Bilker WB, Shu D, Willis AW, Kasner SE. Thinking Three-Dimensionally: A Self- and Externally-Controlled Approach to Screening for Drug-Drug-Drug Interactions Among High-Risk Populations. Clin Pharmacol Ther 2024; 116:448-459. [PMID: 38860403 PMCID: PMC11262479 DOI: 10.1002/cpt.3310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/06/2024] [Indexed: 06/12/2024]
Abstract
The global rise in polypharmacy has increased both the necessity and complexity of drug-drug interaction (DDI) assessments, given the growing potential for interactions involving more than two drugs. Leveraging large-scale healthcare claims data, we piloted a semi-automated, high-throughput case-crossover-based approach for drug-drug-drug interaction (3DI) screening. Cases were direct-acting oral anticoagulant (DOAC) users with either a major bleeding event during ongoing dispensings for potentially interacting, enzyme-inhibiting antihypertensive drugs (AHDs) (Study 1), or a thromboembolic event during ongoing dispensings for potentially interacting, enzyme-inducing antiseizure medications (ASMs) (Study 2). 3DI detection was based on screening for additional drug exposures that served as acute outcome triggers. To mitigate direct effects and confounding by concomitant drugs, self-controlled estimates were adjusted using negative cases (external "control" DOAC users with the same outcomes but co-dispensings for non-interacting AHDs or ASMs). Signal thresholds were set based on P-values and false discovery rate q-values to address multiple comparisons. Study 1: 285 drugs were examined among 3,306 episodes. Self-controlled assessments with q-value thresholds yielded 9 3DI signals (cases) and 40 DDI signals (negative cases). External adjustment generated 10 3DI signals from the P-value threshold and no signals from the q-value threshold. Study 2: 126 drugs were examined among 604 episodes. Assessments with P-value thresholds yielded 3 3DI and 26 DDI signals following self-control, as well as 4 3DI signals following adjustment. No 3DI signals met the q-value threshold. The presented self- and externally-controlled approach aimed to advance paradigms for real-world higher order drug interaction screening among high-susceptibility populations with pre-existent DDI risk.
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Affiliation(s)
- Emily K. Acton
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
| | - Sean Hennessy
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, US
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
| | - Michael A. Gelfand
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, US
| | - Charles E. Leonard
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, US
| | - Warren B. Bilker
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
| | - Di Shu
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
| | - Allison W. Willis
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, US
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, US
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, US
| | - Scott E. Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, US
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2
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Ferreira LO, Oldemburg RAL, Leitão Filho JM, Cerveira RA, Vasconcelos VW, da Costa GE, Rodrigues RDR, Lopes DCF. Andexanet Alfa versus Four-Factor Prothrombin Complex Concentrate for the Reversal of Factor Xa (FXa) Inhibitor-Associated Intracranial Hemorrhage: A Systematic Review of Retrospective Studies. J Clin Med 2024; 13:3077. [PMID: 38892788 PMCID: PMC11173120 DOI: 10.3390/jcm13113077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Revised: 04/03/2024] [Accepted: 04/04/2024] [Indexed: 06/21/2024] Open
Abstract
Background/Objectives: There are limited data on the risks and benefits of using Andexanet alfa (AA) compared with four-factor prothrombin complex concentrate (4F-PCC) for the reversal of factor Xa inhibitor-associated intracranial hemorrhage (ICH). Our aim was to describe a compilation of the information available in the literature to date. Methods: PubMed, Embase, Web of Science (Clarivate Analytics) and the Cochrane Central Register of Controlled Trials were searched until December 2023. Following the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)" guidelines, our systematic literature review included studies that were retrospective in design and evaluated both drugs to control bleeding and complications (death and thromboembolic events). Two researchers re-examined the studies for relevance, extracted the data and assessed the risk of bias. No meta-analyses were performed for the results. Results: In this limited patient sample, we found no differences between published articles in terms of neuroimaging stability or thrombotic events. However, some studies show significant differences in mortality, suggesting that one of the AAs may be superior to 4F-PCC. Conclusions: Our qualitative analysis shows that AA has a better efficacy profile compared with 4F-PCC. However, further studies monitoring these patients and a multicenter collaborative network dedicated to this topic are needed.
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Affiliation(s)
- Luan Oliveira Ferreira
- Department of Anesthesiology, João de Barros Barreto University Hospital, Belém 66073-000, Brazil; (R.A.L.O.); (J.M.L.F.); (V.W.V.); (G.E.d.C.)
| | - Ricardo Andres León Oldemburg
- Department of Anesthesiology, João de Barros Barreto University Hospital, Belém 66073-000, Brazil; (R.A.L.O.); (J.M.L.F.); (V.W.V.); (G.E.d.C.)
| | - João Monteiro Leitão Filho
- Department of Anesthesiology, João de Barros Barreto University Hospital, Belém 66073-000, Brazil; (R.A.L.O.); (J.M.L.F.); (V.W.V.); (G.E.d.C.)
| | - Rodrigo Arcoverde Cerveira
- Division of Immunology & Allergy, Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, SE-171 76 Stockholm, Sweden;
- Center for Molecular Medicine, Karolinska Institutet, Karolinska University Hospital, SE-171 76 Stockholm, Sweden
| | - Victoria Winkler Vasconcelos
- Department of Anesthesiology, João de Barros Barreto University Hospital, Belém 66073-000, Brazil; (R.A.L.O.); (J.M.L.F.); (V.W.V.); (G.E.d.C.)
| | - Giovana Escribano da Costa
- Department of Anesthesiology, João de Barros Barreto University Hospital, Belém 66073-000, Brazil; (R.A.L.O.); (J.M.L.F.); (V.W.V.); (G.E.d.C.)
| | - Roseny dos Reis Rodrigues
- Department of Anesthesiology, São Paulo University, São Paulo 05403-010, Brazil;
- Intensive Care Department, Albert Einstein Hospital, São Paulo 05652-900, Brazil
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3
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White CM, Caroti KS, Bessada Y, Hernandez AV, Baker WL, Dobesh PP, van Haalen H, Rhodes K, Coleman CI. Andexanet alfa versus PCC products for factor Xa inhibitor bleeding: A systematic review with meta-analysis. Pharmacotherapy 2024; 44:394-408. [PMID: 38721837 DOI: 10.1002/phar.2925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/12/2024] [Accepted: 04/12/2024] [Indexed: 06/11/2024]
Abstract
Previous meta-analyses assessed andexanet alfa (AA) or prothrombin complex concentrate (PCC) products for the treatment of Factor Xa inhibitor (FXaI)-associated major bleeding. However, they did not include recent studies or assess the impact of the risk of bias. We conducted a systematic review with meta-analysis on the effectiveness of AA versus PCC products for FXaI-associated major bleeding, inclusive of the studies' risk of bias. PubMed and Embase were searched for comparative studies assessing major bleeding in patients using FXaI who received AA or PCC. We used the Methodological Index for NOn-Randomized Studies (MINORS) checklist and one question from the Joanna Briggs Institute (JBI) Critical Appraisal of Case Series tool to assess the risk of bias. Random-effects meta-analyses were performed to provide a pooled estimate for the effect of AA versus PCC products on hemostatic efficacy, in-hospital mortality, 30-day mortality, and thrombotic events. Low-moderate risk of bias studies were meta-analyzed separately, as well as combined with high risk of bias studies. Eighteen comparative evaluations of AA versus PCC were identified. Twenty-eight percent of the studies (n = 5) had low-moderate risk and 72% (n = 13) had a high risk of bias. Studies with low-moderate risk of bias suggested improvements in hemostatic efficacy [Odds Ratio (OR) 2.72 (95% Confidence Interval (CI): 1.15-6.44); one study], lower in-hospital mortality [OR 0.48 (95% CI: 0.38-0.61); three studies], and reduced 30-day mortality [OR 0.49 (95% CI: 0.30-0.80); two studies] when AA was used versus PCC products. When studies were included regardless of the risk of bias, pooled effects showed improvements in hemostatic efficacy [OR 1.36 (95% CI: 1.01-1.84); 12 studies] and reductions in 30-day mortality [OR 0.53 (95% CI: 0.37-0.76); six studies] for AA versus PCC. The difference in thrombotic events with AA versus PCC was not statistically significant in the low-moderate, high, or combined risk of bias groups. The evidence from low-moderate quality real-world studies suggests that AA is superior to PCC in enhancing hemostatic efficacy and reducing in-hospital and 30-day mortality. When studies are assessed regardless of the risk of bias, the pooled hemostatic efficacy and 30-day mortality risk remain significantly better with AA versus PCC.
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Affiliation(s)
- C Michael White
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Hartford Hospital Health Outcomes, Policy and Evidence Synthesis Group, Hartford, Connecticut, USA
| | - Kimberly Snow Caroti
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Hartford Hospital Health Outcomes, Policy and Evidence Synthesis Group, Hartford, Connecticut, USA
| | - Youssef Bessada
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
| | - Adrian V Hernandez
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Hartford Hospital Health Outcomes, Policy and Evidence Synthesis Group, Hartford, Connecticut, USA
- Unidad de Revisiones Sistemáticas y Meta-análisis (URSIGET), Vicerrectorado de Investigación, Universidad San Ignacio de Loyola, Lima, Peru
| | - William L Baker
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Hartford Hospital Health Outcomes, Policy and Evidence Synthesis Group, Hartford, Connecticut, USA
| | - Paul P Dobesh
- University of Nebraska Medical Center College of Pharmacy, Omaha, Nebraska, USA
| | | | - Kirsty Rhodes
- Medical and Payer Evidence, BioPharmaceuticals Medical, AstraZeneca, Cambridge, UK
| | - Craig I Coleman
- University of Connecticut School of Pharmacy, Storrs, Connecticut, USA
- Hartford Hospital Health Outcomes, Policy and Evidence Synthesis Group, Hartford, Connecticut, USA
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Alkhezi OS, Buckley LF, Fanikos J. Trends in Oral Anticoagulant Use and Individual Expenditures Across the United States from 2014 to 2020. Am J Cardiovasc Drugs 2024; 24:433-444. [PMID: 38583107 DOI: 10.1007/s40256-024-00638-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND Landmark clinical trials have expended the indications for the direct oral anticoagulants (DOACs), but contemporary data on usage and expenditure patterns are lacking. OBJECTIVE This study aimed to assess annual trends in oral anticoagulant (OAC) utilization and expenditure across the United States (US) from 2014 to 2020. METHODS We utilized the Medical Expenditure Panel Survey (MEPS) to study the trends of use and expenditures of warfarin, dabigatran, rivaroxaban, apixaban, and edoxaban between 2014 and 2020 in the US. Survey respondents reported OAC use within the past year, which was verified against pharmacy records. Payment information was obtained from the respondent's pharmacy and was categorized as third-party or self/out-of-pocket. Potential indications and medical conditions of interest for OAC therapy were identified from respondent-reported medical conditions. We estimated the national number of OAC users and total expenditures across age, sex, race, ethnicity, insurance, and medical condition subgroups. Trends of OAC users' characteristics, expenditure, and number of prescriptions were evaluated using the Mann-Kendall test for trends. RESULTS Between 2014 and 2020, the number of warfarin users decreased from 3.8 million (70% of all OAC users) to 2.2 million (p = 0.007) [29% of all OAC users], while the number of DOAC users increased from 1.6 million (30% of all OAC users) to 5.4 million (p = 0.003) [70% of all OAC users]. The total expenditure of OACs in the US increased from $3.4 billion in 2014 to $17.8 billion in 2020 (p = 0.003), which was driven by the increase in DOAC expenditures (p = 0.003). CONCLUSIONS DOACs have replaced warfarin as the preferred OAC in the US. The increased costs associated with DOAC use may decline when generic formulations are approved.
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Affiliation(s)
- Omar S Alkhezi
- Department of Pharmacy Practice, College of Pharmacy, Qassim University, Qassim, Saudi Arabia.
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA.
| | - Leo F Buckley
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
| | - John Fanikos
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, USA
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Germini F, Chan NC. Patterns and Persistence of Anticoagulant Use in the Treatment of Venous Thromboembolism: Insights from South Korea. Thromb Haemost 2024; 124:163-165. [PMID: 37463605 DOI: 10.1055/a-2131-7066] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Affiliation(s)
- Federico Germini
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Noel C Chan
- Division of Hematology and Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Yoon D, Jeong HE, Choi S, Shin JY, Bang SM. Dynamic Patterns and Persistence of Anticoagulation Therapy in Patients with Venous Thromboembolism in South Korea: A Nationwide Cohort Study. Thromb Haemost 2024; 124:152-162. [PMID: 37285903 PMCID: PMC10824586 DOI: 10.1055/a-2107-0815] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/22/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Venous thromboembolism (VTE) is associated with increased morbidity, mortality, and health care expenditure. However, the comprehensive utilization of anticoagulation therapy in patients with VTE, especially regarding active cancer, in real-world practice remains unclear. OBJECTIVE To describe the prescription, persistence, and patterns of anticoagulation therapy among patients with VTE stratified according to active cancer. METHODS Using Korean nationwide claims data, we identified an incident, treatment-naïve cohort of patients with VTE from 2013 to 2019 and classified them according to the presence/absence of active cancer. We explored the secular trends, treatment patterns (e.g., discontinuation, interruption, and switch), and persistence of anticoagulation therapy. RESULTS There were 48,504 and 7,255 patients without and with active cancer, respectively. Non-vitamin K antagonist oral anticoagulants (NOACs) were the most common anticoagulant in both groups (65.1 and 57.9%, respectively). The prescription of NOACs increased steeply over time, regardless of active cancer, whereas parenteral anticoagulants (PACs) plateaued and warfarin decreased sharply. A heterogeneous pattern was observed between the groups without and with active cancer (3-month persistence was 60.8, 62.9, 57.2, and 3.4%, respectively; 6-month persistence was 42.3, 33.5, 25.9, and 1.2% vs. 9.9%). Median durations of continuous anticoagulant therapy for warfarin, NOAC, and PAC were 183, 147, and 3 days in nonactive cancer patients, and 121, 117, and 44 days in active cancer patients. CONCLUSION Our findings suggest that there were substantial differences in persistence, patterns, and patient characteristics of anticoagulant therapy based on index anticoagulant and active cancer.
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Affiliation(s)
- Dongwon Yoon
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
| | - Han Eol Jeong
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
| | - Songhwa Choi
- Medical Affairs, Pfizer Korea Ltd., Seoul, South Korea
| | - Ju-Young Shin
- School of Pharmacy, Sungkyunkwan University, Suwon, South Korea
- Department of Biohealth Regulatory Science, Sungkyunkwan University, Suwon, South Korea
- Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Sciences and Technology, Sungkyunkwan University, Seoul, South Korea
| | - Soo-Mee Bang
- Division of Hemato-Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
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Xu Y, Zhang L, Dou X, Dong Y, Guo X. Physiologically based pharmacokinetic modeling of apixaban to predict exposure in populations with hepatic and renal impairment and elderly populations. Eur J Clin Pharmacol 2024; 80:261-271. [PMID: 38099940 PMCID: PMC10847219 DOI: 10.1007/s00228-023-03602-4] [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: 09/25/2023] [Accepted: 12/02/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Apixaban is a factor Xa inhibitor with a limited therapeutic index that belongs to the family of oral direct anticoagulants. The pharmacokinetic (PK) behavior of apixaban may be altered in elderly populations and populations with renal or hepatic impairment, necessitating dosage adjustments. METHODS This study was conducted to examine how the physiologically based pharmacokinetic (PBPK) model describes the PKs of apixaban in adult and elderly populations and to determine the PKs of apixaban in elderly populations with renal and hepatic impairment. After PBPK models were constructed using the reported physicochemical properties of apixaban and clinical data, they were validated using data from clinical studies involving various dose ranges. Comparing predicted and observed blood concentration data and PK parameters was utilized to evaluate the model's fit performance. RESULTS Doses should be reduced to approximately 70% of the healthy adult population for the healthy elderly population to achieve the same PK exposure; approximately 88%, 71%, and 89% of that for the elderly populations with mild, moderate, and severe renal impairment, respectively; and approximately 96%, 81%, and 58% of that for the Child Pugh-A, Child Pugh-B, and Child Pugh-C hepatic impairment elderly populations, respectively to achieve the same PK exposure. CONCLUSION The findings indicate that the renal and hepatic function might be considered for apixaban therapy in Chinese elderly patients and the PBPK model can be used to optimize dosage regimens for specific populations.
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Affiliation(s)
- Yichao Xu
- Center of Clinical Pharmacology, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Lei Zhang
- Department of Pharmacy, the Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaofan Dou
- Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yongze Dong
- Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xiangchai Guo
- Center for Plastic & Reconstructive Surgery, Department of Orthopedics, Zhejiang Provincial People's Hospital (Affiliated People's Hospital), Hangzhou Medical College, Hangzhou, Zhejiang, China.
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Alalawneh M, Rachid O, Abdallah I, Mahfouz A, Elewa H, Danjuma MIM, Mohamed AE, Awaisu A. Trends in prescribing and outcomes in obese versus non-obese patients receiving rivaroxaban therapy: an observational study using real-world data. Eur J Clin Pharmacol 2023; 79:1675-1685. [PMID: 37816816 PMCID: PMC10663176 DOI: 10.1007/s00228-023-03572-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 09/17/2023] [Indexed: 10/12/2023]
Abstract
PURPOSE To investigate real-world prescribing trends and clinical outcomes based on body mass index (BMI) categorization in patients who received rivaroxaban therapy. METHODS This was a retrospective cohort study involving all patients who received rivaroxaban therapy across all Hamad Medical Corporation (HMC) hospitals from 2015 to 2020. RESULTS The number of patients initiated on rivaroxaban therapy significantly increased from 152 (3.3%) in 2015 to 1342 (28.9%) in 2020 (p <0.001). Within BMI categories, a similar increasing trend was observed in underweight, normal, and overweight patients, while from 2018 to 2020, there was a decreasing trend in rivaroxaban prescribing in all obese classes. The prevalence rate of all-cause mortality differed significantly between the BMI groups, with the highest mortality being among morbidly obese patients (BMI ≥ 40 kg/m2) (p< 0.001). On the other hand, no significant differences were found between the BMI groups in terms of bleeding, pulmonary embolism, deep vein thrombosis and stroke incidences. Multivariate logistic regression analyses showed that the likelihood of all-cause mortality was significantly higher in overweight and all categories of obese patients compared to underweight patients: overweight (OR: 5.3, 95% CI: 2.3-11.9, p< 0.001); obese class 1 (OR: 5.4, 95% CI: 2.3 - 12.2, p< 0.001); obese class 2 (OR: 6.5, 95% CI: 2.7 - 15.6, p< 0.001); and obese class 3 (OR: 3.7, 95% CI: 1.6 - 8.7, p = 0.003). CONCLUSIONS Rivaroxaban prescribing has significantly increased over the years across general population, with a noticeable decline in obese population during the last few years (from 2018 onwards). Furthermore, an appreciable association was evident between all-cause mortality and BMI of these patients.
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Affiliation(s)
- Majdoleen Alalawneh
- College of Pharmacy, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Ousama Rachid
- College of Pharmacy, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Ibtihal Abdallah
- Clinical Pharmacy Services, Hamad General Hospital, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | - Ahmed Mahfouz
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | - Hazem Elewa
- College of Pharmacy, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Mohammed Ibn-Mas'ud Danjuma
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
- College of Medicine, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Asmaa Ezzeldin Mohamed
- Clinical Pharmacy Services, Hamad General Hospital, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | - Ahmed Awaisu
- College of Pharmacy, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar.
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Arora P, Muehrcke M, Russell M, Ghanekar S. Utilization outcomes of direct oral anticoagulants in Medicare patients. Res Social Adm Pharm 2023; 19:1424-1431. [PMID: 37429747 DOI: 10.1016/j.sapharm.2023.07.002] [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: 12/19/2022] [Revised: 04/19/2023] [Accepted: 07/02/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE To compare the adherence, persistence, discontinuation and switching rates of direct oral anticoagulants (DOACs) for Medicare patients with non-valvular atrial fibrillation (NVAF) or venous thromboembolism (VTE). METHODS This was retrospective observational cohort study design. Medicare Part D claims files were used for the study duration (2015-2018). Inclusion-exclusion criteria were applied to identify the NVAF and VTE sample using dabigatran, rivaroxaban, apixaban, edoxaban and warfarin during the identification period (2016-2017). Outcomes of adherence, persistence, time to non-persistence and time to discontinuation were assessed in those who did not switch the index drug in the follow-up period (365 days from the index date). Switching rates were assessed in those who switched the index drug at least once in the aforementioned follow-up period. Descriptive statistics were conducted for all the outcomes, and comparisons were made using t-tests, chi-square, and ANOVA. Logistic regression was conducted to compare the odds of being adherent and the odds of switching in NVAF and VTE patient cohorts. RESULTS Of all the DOACs, patients with NVAF or VTE were most adherent to apixaban (PDC = 76.88). Among all the DOACs, non-persistence and discontinuation rates were highest for warfarin. Majority of the switches were reported from dabigatran to other DOAC and to apixaban from other DOAC. Despite the better utilization outcomes reported for apixaban users, Medicare plans covered rivaroxaban favorably. It was associated with the lowest mean amount paid by the patient (NVAF: $76; VTE: $59), and the highest mean amount paid by the plans (NVAF: $359; VTE: $326). CONCLUSION Medicare plans need to consider adherence, persistence, discontinuation and switching rates of DOACs to make the coverage decisions.
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Affiliation(s)
- Prachi Arora
- College of Pharmacy and Health Sciences, Butler University, 4600 Sunset Ave, Indianapolis, IN, 46208, USA.
| | - Maria Muehrcke
- College of Pharmacy and Health Sciences, Butler University, 4600 Sunset Ave, Indianapolis, IN, 46208, USA.
| | - Molly Russell
- College of Pharmacy and Health Sciences, Butler University, 4600 Sunset Ave, Indianapolis, IN, 46208, USA.
| | - Saurabh Ghanekar
- Resultant, 111 Monument Circle, Suite 202, Indianapolis, IN, 46204, USA.
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Fermann GJ, Cash BD, Coelho‐Prabhu N, Maegele M, Bingisser R, Sehgal V, Cohen AT, Golden AH, Russo J, Price M, Mangel A, Koch B, Christoph MJ, Milling TJ. Definition of factor Xa inhibitor-related, life-threatening gastrointestinal bleeding and guidance on when to use reversal therapy: A Delphi panel. J Am Coll Emerg Physicians Open 2023; 4:e13043. [PMID: 37794950 PMCID: PMC10545659 DOI: 10.1002/emp2.13043] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 08/11/2023] [Accepted: 08/31/2023] [Indexed: 10/06/2023] Open
Abstract
Objective To define and contextualize life-threatening gastrointestinal (GI) bleeding in the setting of factor Xa (FXa) inhibitor therapy and to derive a consensus-based, clinically oriented approach to the administration of FXa inhibitor reversal therapy. Methods We convened an expert panel of clinicians representing specialties in emergency medicine, gastroenterology, vascular medicine, and trauma surgery. Consensus was reached among the clinician panelists using the Delphi technique, which consisted of 2 survey questionnaires followed by virtual, real-time consensus-building exercises. Results Hypovolemia and hemodynamic instability were considered the most important clinical signs of FXa inhibitor-related, life-threatening GI bleeds. Clinician panelists agreed that potentially life-threatening GI bleeding should be determined on the basis of hemodynamic instability, signs of shock, individual patient characteristics, and clinical judgment. Last, the panel agreed that all patients with life-threatening, FXa inhibitor-associated GI bleeding should be considered for FXa inhibitor reversal therapy; the decision to reverse FXa inhibition should be individualized, weighing the risks and benefits of reversal; and when reversal is elected, therapy should be administered within 1 h after initial emergency department evaluation, when possible. Conclusions Consensus-based definitions of life-threatening GI bleeding and approaches to FXa inhibitor reversal centered on hemodynamic instability, signs of shock, individual patient characteristics, and clinical judgment. The results from this Delphi panel may inform clinical decision-making for the treatment of patients experiencing GI bleeding associated with FXa inhibitor use in the emergency department setting.
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Affiliation(s)
- Gregory J. Fermann
- Department of Emergency MedicineUniversity of CincinnatiCincinnatiOhioUSA
| | - Brooks D. Cash
- Division of Gastroenterology, Hepatology, and NutritionUniversity of Texas Health Science Center at Houston‐McGovern Medical SchoolHoustonTexasUSA
| | | | - Marc Maegele
- Department of Trauma and Orthopedic SurgeryCologne‐Merheim Medical CenterInstitute of Research in Operative MedicineUniversity Witten‐HerdeckeCologneGermany
| | - Roland Bingisser
- Department of Emergency MedicineUniversitätsspital BaselBaselSwitzerland
| | - Vinay Sehgal
- Department of GastroenterologyUniversity College Hospital LondonLondonUK
| | - Alexander T. Cohen
- Department of Haematological MedicineGuy's and St. Thomas’ HospitalLondonUK
| | | | - Jon Russo
- RTI Health SolutionsResearch Triangle ParkNorth CarolinaUSA
| | - Mark Price
- RTI Health SolutionsResearch Triangle ParkNorth CarolinaUSA
| | - Allen Mangel
- RTI Health SolutionsResearch Triangle ParkNorth CarolinaUSA
| | - Bruce Koch
- AstraZenecaMedical AffairsWilmingtonDelawareUSA
| | | | - Truman J. Milling
- Departments of Neurology and of Surgery and Perioperative CareDell Medical SchoolAustinTexasUSA
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11
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Singer AJ, Concha M, Williams J, Brown CS, Fernandes R, Thode HC, Kirchman M, Rabinstein AA. Treatment of Factor-Xa Inhibitor-associated Bleeding with Andexanet Alfa or 4 Factor PCC: A Multicenter Feasibility Retrospective Study. West J Emerg Med 2023; 24:939-949. [PMID: 37788035 PMCID: PMC10527834 DOI: 10.5811/westjem.60587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/06/2023] [Accepted: 07/20/2023] [Indexed: 10/04/2023] Open
Abstract
Background: There are no randomized trials comparing andexanet alfa and 4 factor prothrombin complex concentrate (4F-PCC) for the treatment of factor Xa inhibitor (FXa-I)-associated bleeds, and observational studies lack important patient characteristics. We pursued this study to demonstrate the feasibility of acquiring relevant patient characteristics from electronic health records. Secondarily, we explored outcomes in patients with life-threatening FXa-I associated bleeds after adjusting for these variables. Methods: We conducted a multicenter, chart review of 100 consecutive adult patients with FXa-I associated intracerebral hemorrhage (50) or gastrointestinal bleeding (50) treated with andexanet alfa or 4F-PCC. We collected demographic, clinical, laboratory, and imaging data including time from last factor FXa-I dose and bleed onset. Results: Mean (SD) age was 75 (12) years; 34% were female. Estimated time from last FXa-I dose to bleed onset was present in most cases (76%), and patients treated with andexanet alfa and 4F-PCC were similar in baseline characteristics. Hemostatic efficacy was excellent/good in 88% and 76% of patients treated with andexanet alfa and 4F-PCC, respectively (P = 0.29). Rates of thrombotic events within 90 days were 14% and 16% in andexanet alfa and 4F-PCC patients, respectively (P = 0.80). Survival to hospital discharge was 92% and 76% in andexanet alfa and 4F-PCC patients, respectively (P = 0.25). Inclusion of an exploratory propensity score and treatment in a logistic regression model resulted in an odds ratio in favor of andexanet alfa of 2.01 (95% confidence interval 0.67-6.06) for excellent/good hemostatic efficacy, although the difference was not statistically significant. Conclusion: Important patient characteristics are often documented supporting the feasibility of a large observational study comparing real-life outcomes in patients with FXa-I-associated bleeds treated with andexanet alfa or 4F-PCC. The small sample size in the current study precluded definitive conclusions regarding the safety and efficacy of andexanet alfa or 4F-PCC in FXa-I-associated bleeds.
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Affiliation(s)
- Adam J Singer
- Renaissance School of Medicine at Stony Brook University, Department of Emergency Medicine, Stony Brook, New York,
| | - Mauricio Concha
- Sarasota Memorial Hospital, Department of Neuroscience, Sarasota, Florida
| | - James Williams
- Meritus Health, Department of Emergency Medicine, Hagerstown, Maryland
| | - Caitlin S Brown
- Mayo Clinic-Rochester, Department of Pharmacy, Rochester, Minnesota
| | - Rafael Fernandes
- Renaissance School of Medicine at Stony Brook University, Department of Emergency Medicine, Stony Brook, New York
| | - Henry C Thode
- Renaissance School of Medicine at Stony Brook University, Department of Emergency Medicine, Stony Brook, New York
| | - Marylin Kirchman
- Sarasota Memorial Hospital, Department of Neuroscience, Sarasota, Florida
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12
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Giorgio K, Walker RF, MacLehose RF, Herrera DA, Wang W, Alonso A, Zakai NA, Lutsey PL. Venous thromboembolism mortality and trends in older US adults, 2011-2019. Am J Hematol 2023; 98:1364-1373. [PMID: 37366276 PMCID: PMC10529371 DOI: 10.1002/ajh.26996] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/18/2023] [Accepted: 06/07/2023] [Indexed: 06/28/2023]
Abstract
Venous thromboembolism (VTE) affects 1.2 million people per year in the United States. With several clinical changes in diagnosis and treatment approaches in the past decade, we evaluated contemporary post-VTE mortality risk profiles and trends. Incident VTE cases were identified from the 2011-2019 Medicare 20% Sample, which is representative of nearly all Americans aged 65 and older. The social deprivation index was linked from public data; race/ethnicity and sex were self-reported. The all-cause mortality risk 30 days and 1 year after incident VTE was calculated in demographic subgroups and by prevalent cancer diagnosis status using model-based standardization. Risks for major cancer types, risk differences by age, sex, race/ethnicity, and socio-economic status (SES), and trends over time are also reported. The all-cause mortality risk among older US adults following incident VTE was 3.1% (95% CI 3.0-3.2) at 30 days and 19.6% (95% CI 19.2-20.1) at 1 year. For cancer-related VTE events, the age-sex-race-standardized risk was 6.0% at 30 days and 34.7% at 1 year. The standardized 30-day and 1-year risks were higher among non-White beneficiaries and among those with low SES. One-year mortality risk decreased 0.28 percentage points per year (95% CI 0.16-0.40) on average across the study period, with no trend observed for 30-day mortality risk. In sum, all-cause mortality risk following incident VTE has decreased slightly in the last decade, but racial and socio-economic disparities persist. Understanding patterns of mortality among demographic subgroups and in cancer-associated events is important for targeting efforts to improve VTE management.
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Affiliation(s)
- Katherine Giorgio
- Division of Epidemiology & Community Health; School of Public Health, University of Minnesota, Minneapolis, MN
| | - Rob F. Walker
- Division of Epidemiology & Community Health; School of Public Health, University of Minnesota, Minneapolis, MN
| | - Richard F. MacLehose
- Division of Epidemiology & Community Health; School of Public Health, University of Minnesota, Minneapolis, MN
| | - Diego Adrianzen Herrera
- Division of Hematology/Oncology, Department of Medicine & Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Wendy Wang
- Division of Epidemiology & Community Health; School of Public Health, University of Minnesota, Minneapolis, MN
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Neil A. Zakai
- Division of Hematology/Oncology, Department of Medicine & Department of Pathology and Laboratory Medicine, Larner College of Medicine at the University of Vermont, Burlington, VT
| | - Pamela L. Lutsey
- Division of Epidemiology & Community Health; School of Public Health, University of Minnesota, Minneapolis, MN
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13
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Li M, Li J, Wang X, Hui X, Wang Q, Xie S, Yan P, Tian J, Li J, Xie P, Yang K, Yao L. Oral direct thrombin inhibitors or oral factor Xa inhibitors versus conventional anticoagulants for the treatment of pulmonary embolism. Cochrane Database Syst Rev 2023; 4:CD010957. [PMID: 37057837 PMCID: PMC10103165 DOI: 10.1002/14651858.cd010957.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
BACKGROUND Pulmonary embolism (PE) is a potentially life-threatening condition in which a clot can migrate from the deep veins, most commonly in the leg, to the lungs. Conventional treatment of PE used unfractionated heparin (UFH), low molecular weight heparin (LMWH), fondaparinux, and vitamin K antagonists (VKAs). Recently, two forms of direct oral anticoagulants (DOACs) have been developed: oral direct thrombin inhibitors (DTIs) and oral factor Xa inhibitors. DOACs have characteristics that may be favourable to conventional treatment, including oral administration, a predictable effect, no need for frequent monitoring or re-dosing, and few known drug interactions. This review reports the efficacy and safety of these drugs in the long-term treatment of PE (minimum duration of three months). This is an update of a Cochrane Review first published in 2015. OBJECTIVES: To assess the efficacy and safety of oral DTIs and oral factor Xa inhibitors versus conventional anticoagulants for the long-term treatment of PE. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases, the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov trials registers to 2 March 2022. We checked the reference lists of relevant articles for additional studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which people with a PE confirmed by standard imaging techniques were allocated to receive an oral DTI or an oral factor Xa inhibitor compared with a conventional anticoagulant or compared with each other for the long-term treatment of PE (minimum duration three months). DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were recurrent PE, recurrent venous thromboembolism (VTE), and deep vein thrombosis (DVT). Secondary outcomes were all-cause mortality, major bleeding, and health-related quality of life. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We identified five additional RCTs with 1484 participants for this update. Together with the previously included trials, we have included ten RCTs with a total of 13,073 participants. Two studies investigated an oral DTI (dabigatran) and eight studies investigated oral factor Xa inhibitors (three rivaroxaban, three apixaban, and two edoxaban). The studies were of good methodological quality overall. Meta-analysis showed no clear difference in the efficacy and safety of oral DTI compared with conventional anticoagulation in preventing recurrent PE (odds ratio (OR) 1.02, 95% confidence interval (CI) 0.50 to 2.04; 2 studies, 1602 participants; moderate-certainty evidence), recurrent VTE (OR 0.93, 95% CI 0.52 to 1.66; 2 studies, 1602 participants; moderate-certainty evidence), DVT (OR 0.79, 95% CI 0.29 to 2.13; 2 studies, 1602 participants; moderate-certainty evidence), and major bleeding (OR 0.50, 95% CI 0.15 to 1.68; 2 studies, 1527 participants; moderate-certainty evidence). We downgraded the certainty of evidence by one level for imprecision due to the low number of events. There was also no clear difference between the oral factor Xa inhibitors and conventional anticoagulation in the prevention of recurrent PE (OR 0.92, 95% CI 0.66 to 1.29; 3 studies, 8186 participants; moderate-certainty evidence), recurrent VTE (OR 0.83, 95% CI 0.66 to 1.03; 8 studies, 11,416 participants; moderate-certainty evidence), DVT (OR 0.77, 95% CI 0.48 to 1.25; 2 studies, 8151 participants; moderate-certainty evidence), all-cause mortality (OR 1.16, 95% CI 0.79 to 1.70; 1 study, 4817 participants; moderate-certainty evidence) and major bleeding (OR 0.71, 95% CI 0.36 to 1.41; 8 studies, 11,447 participants; low-certainty evidence); the heterogeneity for major bleeding was significant (I2 = 79%). We downgraded the certainty of the evidence to moderate and low because of imprecision due to the low number of events and inconsistency due to clinical heterogeneity. None of the included studies measured health-related quality of life. AUTHORS' CONCLUSIONS Available evidence shows there is probably little or no difference between DOACs and conventional anticoagulation in the prevention of recurrent PE, recurrent VTE, DVT, all-cause mortality, and major bleeding. The certainty of evidence was moderate or low. Future large clinical trials are required to identify if individual drugs differ in effectiveness and bleeding risk, and to explore effect differences in subgroups, including people with cancer and obesity.
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Affiliation(s)
- Meixuan Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Jing Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Xiaoqin Wang
- Michael G DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Canada
| | - Xu Hui
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Qi Wang
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Shitong Xie
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
- School of Pharmaceutical Science and Technology, Tianjin University, Tianjin, China
| | - Peijing Yan
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Jianfeng Li
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Ping Xie
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Liang Yao
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
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14
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Wang X, Ma Y, Hui X, Li M, Li J, Tian J, Wang Q, Yan P, Li J, Xie P, Yang K, Yao L. Oral direct thrombin inhibitors or oral factor Xa inhibitors versus conventional anticoagulants for the treatment of deep vein thrombosis. Cochrane Database Syst Rev 2023; 4:CD010956. [PMID: 37058421 PMCID: PMC10105633 DOI: 10.1002/14651858.cd010956.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
BACKGROUND Deep vein thrombosis (DVT) is a condition in which a clot forms in the deep veins, most commonly of the leg. It occurs in approximately one in 1000 people. If left untreated, the clot can travel up to the lungs and cause a potentially life-threatening pulmonary embolism (PE). Previously, a DVT was treated with the anticoagulants heparin and vitamin K antagonists. However, two forms of direct oral anticoagulants (DOACs) have been developed: oral direct thrombin inhibitors (DTIs) and oral factor Xa inhibitors, which have characteristics that may be favourable compared to conventional treatment, including oral administration, a predictable effect, lack of frequent monitoring or dose adjustment and few known drug interactions. DOACs are now commonly being used for treating DVT: recent guidelines recommended DOACs over conventional anticoagulants for both DVT and PE treatment. This Cochrane Review was first published in 2015. It was the first systematic review to measure the effectiveness and safety of these drugs in the treatment of DVT. This is an update of the 2015 review. OBJECTIVES: To assess the effectiveness and safety of oral DTIs and oral factor Xa inhibitors versus conventional anticoagulants for the long-term treatment of DVT. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 1 March 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which people with a DVT, confirmed by standard imaging techniques, were allocated to receive an oral DTI or an oral factor Xa inhibitor compared with conventional anticoagulation or compared with each other for the treatment of DVT. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were recurrent venous thromboembolism (VTE), recurrent DVT and PE. Secondary outcomes included all-cause mortality, major bleeding, post-thrombotic syndrome (PTS) and quality of life (QoL). We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We identified 10 new studies with 2950 participants for this update. In total, we included 21 RCTs involving 30,895 participants. Three studies investigated oral DTIs (two dabigatran and one ximelagatran), 17 investigated oral factor Xa inhibitors (eight rivaroxaban, five apixaban and four edoxaban) and one three-arm trial investigated both a DTI (dabigatran) and factor Xa inhibitor (rivaroxaban). Overall, the studies were of good methodological quality. Meta-analysis comparing DTIs to conventional anticoagulation showed no clear difference in the rate of recurrent VTE (odds ratio (OR) 1.17, 95% confidence interval (CI) 0.83 to 1.65; 3 studies, 5994 participants; moderate-certainty evidence), recurrent DVT (OR 1.11, 95% CI 0.74 to 1.66; 3 studies, 5994 participants; moderate-certainty evidence), fatal PE (OR 1.32, 95% CI 0.29 to 6.02; 3 studies, 5994 participants; moderate-certainty evidence), non-fatal PE (OR 1.29, 95% CI 0.64 to 2.59; 3 studies, 5994 participants; moderate-certainty evidence) or all-cause mortality (OR 0.66, 95% CI 0.41 to 1.08; 1 study, 2489 participants; moderate-certainty evidence). DTIs reduced the rate of major bleeding (OR 0.58, 95% CI 0.38 to 0.89; 3 studies, 5994 participants; high-certainty evidence). For oral factor Xa inhibitors compared with conventional anticoagulation, meta-analysis demonstrated no clear difference in recurrent VTE (OR 0.85, 95% CI 0.71 to 1.01; 13 studies, 17,505 participants; moderate-certainty evidence), recurrent DVT (OR 0.70, 95% CI 0.49 to 1.01; 9 studies, 16,439 participants; moderate-certainty evidence), fatal PE (OR 1.18, 95% CI 0.69 to 2.02; 6 studies, 15,082 participants; moderate-certainty evidence), non-fatal PE (OR 0.93, 95% CI 0.68 to 1.27; 7 studies, 15,166 participants; moderate-certainty evidence) or all-cause mortality (OR 0.87, 95% CI 0.67 to 1.14; 9 studies, 10,770 participants; moderate-certainty evidence). Meta-analysis showed a reduced rate of major bleeding with oral factor Xa inhibitors compared with conventional anticoagulation (OR 0.63, 95% CI 0.45 to 0.89; 17 studies, 18,066 participants; high-certainty evidence). AUTHORS' CONCLUSIONS: The current review suggests that DOACs may be superior to conventional therapy in terms of safety (major bleeding), and are probably equivalent in terms of efficacy. There is probably little or no difference between DOACs and conventional anticoagulation in the prevention of recurrent VTE, recurrent DVT, pulmonary embolism and all-cause mortality. DOACs reduced the rate of major bleeding compared to conventional anticoagulation. The certainty of evidence was moderate or high.
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Affiliation(s)
- Xiaoqin Wang
- Michael G DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Canada
| | - Yanfang Ma
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong Special Administrative Region, China
| | - Xu Hui
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Meixuan Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Jing Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Qi Wang
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Peijing Yan
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jianfeng Li
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Ping Xie
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Liang Yao
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
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15
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Konish T, Ono S, Okada A, Matsui H, Tanabe M, Seto Y, Yasunaga H. Comparison of bleeding following gastrointestinal endoscopic biopsy in patients treated with and without direct oral anticoagulants. Endosc Int Open 2023; 11:E52-E59. [PMID: 36644535 PMCID: PMC9839429 DOI: 10.1055/a-1981-2946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 11/15/2022] [Indexed: 11/19/2022] Open
Abstract
Background and study aims Despite the widespread use of direct oral anticoagulants (DOACs), the association between DOAC use and complications (e. g., bleeding) following gastrointestinal endoscopic biopsy remains unclear. This study aimed to evaluate complications after biopsy in patients treated with DOACs in Japan, where biopsies would be generally performed without DOAC withdrawal based on guideline recommendations. Patients and methods Using a Japanese nationwide database, we identified patients taking DOACs who underwent gastrointestinal endoscopic biopsy (n = 2,769, DOAC group) and those not taking DOACs (n = 129,357, control group) from April 2015 to November 2020. We conducted 1:4 propensity score (PS) matching and overlap PS-weighting analyses with adjustment for background characteristics to compare occurrence of post-procedure hemorrhage and stroke within 1 week after biopsy, and thrombin use on the day of biopsy without a diagnosis of hemorrhage. Results In total, 578 patients (0.44 %) developed post-procedure hemorrhage, and 13 patients (0.01 %) developed stroke. The DOAC group had more comorbidities than the control group. The PS matching analysis revealed no significant differences in post-procedure hemorrhage (odds ratio, 1.52 [95 % confidential interval, 0.96-2.41]) or stroke (1.00 [0.21-4.71]), whereas the DOAC group received thrombin more often than the control group (1.60 [1.30-1.95]). The results were equivalent in the overlap PS-weighting analysis. Conclusions The PS analyses showed no significant differences in complications following gastrointestinal endoscopic biopsy between DOAC users and non-users. These results suggest the safety of endoscopic biopsy without DOAC withdrawal although the need for careful hemostasis remains.
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Affiliation(s)
- Takaaki Konish
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Sachiko Ono
- Department of Eat-loss Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akira Okada
- Department of Prevention of Diabetes and Lifestyle-Related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Masahiko Tanabe
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasuyuki Seto
- Department of Breast and Endocrine Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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16
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Lee JH, Lee HH, Park HJ, Kim S, Kim YJ, Lee JS, Kim HC. Venous thromboembolism in patients with idiopathic pulmonary fibrosis, based on nationwide claim data. Ther Adv Respir Dis 2023; 17:17534666231155772. [PMID: 36846942 PMCID: PMC9972056 DOI: 10.1177/17534666231155772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 01/23/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND Idiopathic pulmonary fibrosis (IPF) is a known risk factor for venous thromboembolism (VTE). However, it is currently unknown which factors are associated with an increase of VTE in patients with IPF. OBJECTIVES We estimated the incidence of VTE in patients with IPF and identified clinical characteristics related to VTE in patients with IPF. DESIGN AND METHODS De-identified nationwide health claim data from 2011 to 2019 was collected from the Korean Health Insurance Review and Assessment database. Patients with IPF were selected if they had made at least one claim per year under the J84.1 [International Classification of Diseases and Related Health Problems, 10th Revision (ICD-10)] and V236 codes of rare intractable diseases. We defined the presence of VTE as at least one claim of pulmonary embolism and deep vein thrombosis ICD-10 codes. RESULTS The incidence rate per 1000 person-years of VTE was 7.08 (6.44-7.77). Peak incidence rates were noted in the 50-59 years old male and 70-79 years old female groups. Ischemic heart disease, ischemic stroke, and malignancy were associated with VTE in patients with IPF, with an adjusted hazard ratio (aHR) of 1.25 (1.01-1.55), 1.36 (1.04-1.79), and 1.53 (1.17-2.01). The risk for VTE was increased in patients diagnosed with malignancy after IPF diagnosis (aHR = 3.18, 2.47-4.11), especially lung cancer [hazard ratio (HR) = 3.78, 2.90-4.96]. Accompanied VTE was related to more utilization of medical resources. CONCLUSION Ischemic heart disease, ischemic stroke, and malignancy, especially lung cancer, were related to higher HR for VTE in IPF.
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Affiliation(s)
- Jang Ho Lee
- Department of Pulmonology and Critical Care
Medicine, Asan Medical Center, University of Ulsan College of Medicine,
Seoul, Republic of Korea
| | - Hoon Hee Lee
- Department of Internal Medicine, Yeosu Jeil
Hospital, Yeosu, Republic of Korea
| | - Hyung Jun Park
- Department of Pulmonology and Critical Care
Medicine, Asan Medical Center, University of Ulsan College of Medicine,
Seoul, Republic of Korea
| | - Seonok Kim
- Department of Clinical Epidemiology and
Biostatistics, Asan Medical Centre, University of Ulsan College of Medicine,
Seoul, Republic of Korea
| | - Ye-Jee Kim
- Department of Clinical Epidemiology and
Biostatistics, Asan Medical Centre, University of Ulsan College of Medicine,
Seoul, Republic of Korea
| | - Jae Seung Lee
- Department of Pulmonology and Critical Care
Medicine, Asan Medical Center, University of Ulsan College of Medicine,
Seoul, Republic of Korea
| | - Ho Cheol Kim
- Department of Pulmonology and Critical Care
Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88
Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Republic of Korea
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17
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Takahashi S, Imura M, Katada J. Epidemiology and Treatment Patterns of Venous Thromboembolism: an Observational Study of Nationwide Time-Series Trends in Japan. Cardiol Ther 2022; 11:589-609. [PMID: 36318364 PMCID: PMC9652174 DOI: 10.1007/s40119-022-00284-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 10/11/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Previous studies on anticoagulation treatment trends have mostly focused on hospitalized patients. This study aimed to clarify the treatment status of patients with venous thromboembolism (VTE) in Japan from 2011 to 2018, including outpatients, and to assess adherence with current guidelines. METHODS Data of inpatients and outpatients who were treated for VTE were extracted from a nationwide claims database (Medical Data Vision Co., Ltd., Tokyo, Japan) and analyzed. RESULTS The study included 79,330 patients with VTE; half were diagnosed during hospitalization for diseases other than VTE. The proportion of outpatient treatment increased significantly from 2015 to 2018 (Cochran-Armitage trend test, P < 0.0001), while 80% were anticoagulated in hospital after pulmonary embolism (PE) diagnosis. The proportion of patients with VTE treated as outpatients was no lower than the proportion of inpatients, even in the presence of active cancer, and there were no clear differences in anticoagulant choices. Treatment with direct oral anticoagulants (DOACs) did not always include the recommended initial intensification therapy. There was wide variation in the duration of DOAC treatment and the median duration of use was shorter than that recommended in VTE treatment guidelines. CONCLUSION While the gradual increase in VTE outpatient treatment appears to be in line with guideline recommendations, PE outpatient treatment could be further facilitated. The large proportion of patients diagnosed with VTE during hospitalization for other conditions suggests the importance of further utilizing in-hospital manuals for thrombosis prevention. The presence or absence of cancer did not appear to affect the basic treatment strategy of anticoagulation for VTE. Future studies are expected to better define the characteristics of patients who can be safely and effectively treated in an outpatient setting, and to examine whether anticoagulation for a shorter treatment period than recommended by the guidelines or DOAC therapy without initial intensification would improve patient outcomes.
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Affiliation(s)
- Shoko Takahashi
- Medical Affairs, Internal Medicine, Pfizer Biopharmaceuticals Group, Pfizer Japan Inc., 3-22-7, Yoyogi, Shibuya-ku, Tokyo, 151-8589, Japan.
| | - Miki Imura
- Medical Affairs, Internal Medicine, Pfizer Biopharmaceuticals Group, Pfizer Japan Inc., 3-22-7, Yoyogi, Shibuya-ku, Tokyo, 151-8589, Japan
| | - Jun Katada
- Medical Affairs, Internal Medicine, Pfizer Biopharmaceuticals Group, Pfizer Japan Inc., 3-22-7, Yoyogi, Shibuya-ku, Tokyo, 151-8589, Japan
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18
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Zhang C, Wang J, Yang Y, Ma EL, Lin HW, Liu BL, Gu ZC. Prescribing Trends of Oral Anticoagulants from 2010 to 2020 in Shanghai, China: A Retrospective Study. Clin Appl Thromb Hemost 2022; 28:10760296221132551. [PMID: 36250531 PMCID: PMC9578173 DOI: 10.1177/10760296221132551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Aim Non-vitamin K antagonist oral anticoagulants (NOACs) were developed as an alternative to warfarin to prevent thromboembolism in patients with atrial fibrillation (AF), prosthetic heart valves, venous thromboembolism (VTE), or other thrombotic disorders. The aim of this study is to explore the trends in prescribing OACs, including warfarin and NOACs, in Shanghai, China. Methods Prescription data of OACs were retrospectively collected from Rx Analysis System from 2010 to 2020 in Shanghai, China. Comparisons were made on the trends of each OACs according to different indications, age groups, and hospital grades. The costs and the contribution of individual OACs were also explored. Results Growing trends in overall prescriptions for OACs were observed. The prescriptions of NOACs were significantly increased since 2016, while the prescriptions of warfarin kept decreasing since 2017. A highly statistically significant increase in prescriptions of Rivaroxaban was observed from 2016 to 2020 (P < .001). Despite the price reduction of rivaroxaban in 2018, the total cost of rivaroxaban continued to rise (P < .001). Rivaroxaban emerged as a preferred NOAC in both indications of AF and VTE, and accounted for more than three-quarters of the total costs for OACs since 2019. Compared with rivaroxaban, the prescription numbers of dabigatran and apixaban were much smaller, and the growth of prescriptions were much slower. Differences in prescribing patterns in different indications, age groups, and grades of hospitals were also founded. Conclusion There has been a rapid increase in the use of OAC over the last 11 years in Shanghai, China. NOACs have been adopted rapidly, and have been gradually replacing warfarin. Warfarin remains the top choice for certain patients with valvular heart disease. Future studies are warranted considering changes in the OAC use in a larger scale, as well as the rationality and its influence factors on OAC use.
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Affiliation(s)
- Chi Zhang
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,School of Medicine, Tongji University, Shanghai, China,Drug Clinical Comprehensive Evaluation Group, Shanghai Pharmaceutical Association, Shanghai, China
| | - Jia Wang
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ya Yang
- Department of Medical Administration, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Er-Li Ma
- Shanghai Pharmaceutical Association, Shanghai, China
| | - Hou-Wen Lin
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,School of Medicine, Tongji University, Shanghai, China
| | - Bing-Long Liu
- Shanghai Pharmaceutical Association, Shanghai, China,Bing-Long Liu, Shanghai Pharmaceutical Association, Shanghai 200040, China.
| | - Zhi-Chun Gu
- Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China,Drug Clinical Comprehensive Evaluation Group, Shanghai Pharmaceutical Association, Shanghai, China,Zhi-Chun Gu, Department of Pharmacy, Ren Ji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China.
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19
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Mertins T, Nilius H, Boss R, Knuchel M, Signorell A, Huber CA, Blozik E, Kremer Hovinga JA, Bachmann LM, Nagler M. Secondary prevention of venous thromboembolism: Predictors and outcomes of guideline adherence in a long-term prospective cohort study. Front Cardiovasc Med 2022; 9:963528. [PMID: 35990937 PMCID: PMC9381867 DOI: 10.3389/fcvm.2022.963528] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 07/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background Prevention of recurrent venous thromboembolism (VTE) is considered a main goal of VTE management. However, the extent to which physicians adhere to the recommendations from evidence-based guidelines is unknown. Aim From a large, prospective clinical cohort, we aimed to (1) quantify the adherence of treatment recommendations to evidence-based guidelines and establish its predictors, and (2) estimate its impact on clinical outcomes and costs in patients with VTE. Methods We included 6'243 consecutive patients with VTE treated at the university outpatient unit. Detailed clinical characteristics and treatment recommendations were recorded. Adherence of treatment recommendations to evidence-based guidelines at risk assessment was assessed in terms of duration of anticoagulant treatment. Data on death were obtained from the Swiss Central Compensation Office. Health care claims data recorded between 2014 and 2019 were retrieved from Helsana, one of the largest Swiss health insurance companies. Results The adherence to evidence-based guidelines was 36.1%. Among patients with non-adherence, overtreatment was present in 70.1%. Significant patient-related predictors of guideline adherence were (a) age above 50 years, (b) male sex, (c) pulmonary embolism, (d) unprovoked VTE, (e) multiple VTE, (f) laboratory tests not ordered, and (g) various cardiovascular comorbidities. Non-adherence was not significantly associated with mortality, hospitalization, admission to nursing home, and costs. Conclusions The adherence to evidence-based guidelines was low, and several unrelated predictors appeared. Although these results need to be confirmed in other settings, they highlight the need for implementation of evidence-based guidelines in clinical practice.
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Affiliation(s)
- Tamara Mertins
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Henning Nilius
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Robin Boss
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Matthias Knuchel
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Andri Signorell
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Carola A. Huber
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
| | - Eva Blozik
- Department of Health Sciences, Helsana Group, Zurich, Switzerland
- Institute of Primary Care, University of Zurich and University Hospital of Zurich, Zurich, Switzerland
| | - Johanna Anna Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Lucas M. Bachmann
- Medignition AG, Research Consultants, University of Zurich, Zurich, Switzerland
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, Bern, Switzerland
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, Bern, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
- *Correspondence: Michael Nagler
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20
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Sharma AE, Khoong EC, Rivadeneira N, Sierra M, Fang MC, Gupta N, Pramanik R, Tran H, Whitezell T, Fontil V, Lee SY, Sarkar U. Warfarin Monitoring in Safety-Net Health Systems: Analysis by Race/Ethnicity and Language Preference. J Gen Intern Med 2022; 37:2703-2710. [PMID: 34993871 PMCID: PMC9411299 DOI: 10.1007/s11606-021-07283-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 11/17/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Racial/ethnic disparities in anticoagulation management are well established. Differences in warfarin monitoring can contribute to these disparities and should be measured. OBJECTIVE We assessed for differences in international normalized ratio (INR) monitoring by race/ethnicity and language preference across safety-net care systems serving predominantly low-income, ethnically diverse populations. DESIGN Cross-sectional analysis of process and safety data shared from the Safety Promotion Action Research and Knowledge Network (SPARK-Net) initiative, a consortium of five California safety-net hospital systems. PARTICIPANTS Eligible patients were at least 18 years old, received warfarin for at least 56 days during the measurement period from July 2015 to June 2017, and had INR testing in an ambulatory care setting at a participating healthcare system. MAIN MEASURES We conducted a scaled Poisson regression for adjusted rate ratio of having at least one INR checked per 56-day time period for which a patient had a warfarin prescription. Adjusting for age, sex, healthcare system, and insurance status/type, we assessed for racial/ethnic and language disparities in INR monitoring. KEY RESULTS Of 8129 patients, 3615 (44%) were female; 1470 (18%), Black/African American; 3354 (41%), Hispanic/Latinx; 1210 (15%), Asian; 1643 (20%), White; and 452 (6%), other. Three thousand five hundred forty-nine (45%) were non-English preferring. We did not observe statistically significant disparities in the rate of appropriate INR monitoring by race/ethnicity or language; the primary source of variation was by healthcare network. Older age, female gender, and uninsured patients had a slightly higher rate of appropriate INR monitoring, but differences were not clinically significant. CONCLUSIONS We did not find a race/ethnicity nor language disparity in INR monitoring; safety-net site was the main source of variation.
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Affiliation(s)
- Anjana E Sharma
- Department of Family and Community Medicine, Center for Excellence In Primary Care, University of California San Francisco, San Francisco, USA.,Center for Vulnerable Populations, University of California San Francisco, San Francisco, CA, USA
| | - Elaine C Khoong
- Center for Vulnerable Populations, University of California San Francisco, San Francisco, CA, USA.,Division of General Internal Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Natalie Rivadeneira
- Division of General Internal Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Maribel Sierra
- Center for Vulnerable Populations, University of California San Francisco, San Francisco, CA, USA
| | - Margaret C Fang
- Division of Hospital Medicine at UCSF Health, Department of Medicine, University of California San Francisco, San Francisco, USA
| | | | | | - Helen Tran
- Los Angeles County Department of Health Services, Charles R. Drew University College of Medicine, Los Angeles, CA, USA
| | | | - Valy Fontil
- Center for Vulnerable Populations, University of California San Francisco, San Francisco, CA, USA.,Division of General Internal Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Shin-Yu Lee
- San Francisco Department of Public Health (SFDPH), San Francisco Health Network (SFHN), San Francisco, USA
| | - Urmimala Sarkar
- Center for Vulnerable Populations, University of California San Francisco, San Francisco, CA, USA. .,Division of General Internal Medicine at Zuckerberg San Francisco General Hospital and Trauma Center, Department of Medicine, University of California San Francisco, San Francisco, USA.
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21
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Costa OS, Connolly SJ, Sharma M, Beyer-Westendorf J, Christoph MJ, Lovelace B, Coleman CI. Andexanet alfa versus four-factor prothrombin complex concentrate for the reversal of apixaban- or rivaroxaban-associated intracranial hemorrhage: a propensity score-overlap weighted analysis. Crit Care 2022; 26:180. [PMID: 35710578 PMCID: PMC9204964 DOI: 10.1186/s13054-022-04043-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/02/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Andexanet alfa is approved (FDA "accelerated approval"; EMA "conditional approval") as the first specific reversal agent for factor Xa (FXa) inhibitor-associated uncontrolled or life-threatening bleeding. Four-factor prothrombin complex concentrates (4F-PCC) are commonly used as an off-label, non-specific, factor replacement approach to manage FXa inhibitor-associated life-threatening bleeding. We evaluated the effectiveness and safety of andexanet alfa versus 4F-PCC for management of apixaban- or rivaroxaban-associated intracranial hemorrhage (ICH). METHODS This two-cohort comparison study included andexanet alfa patients enrolled at US hospitals from 4/2015 to 3/2020 in the prospective, single-arm ANNEXA-4 study and a synthetic control arm of 4F-PCC patients admitted within a US healthcare system from 12/2016 to 8/2020. Adults with radiographically confirmed ICH who took their last dose of apixaban or rivaroxaban < 24 h prior to the bleed were included. Patients with a Glasgow Coma Scale (GCS) score < 7, hematoma volume > 60 mL, or planned surgery within 12 h were excluded. Outcomes were hemostatic effectiveness from index to repeat scan, mortality within 30 days, and thrombotic events within five days. Odds ratios (ORs) with 95% confidence intervals (CI) were calculated using propensity score-overlap weighted logistic regression. RESULTS The study included 107 andexanet alfa (96.6% low dose) and 95 4F-PCC patients (79.3% receiving a 25 unit/kg dose). After propensity score-overlap weighting, mean age was 79 years, GCS was 14, time from initial scan to reversal initiation was 2.3 h, and time from reversal to repeat scan was 12.2 h in both arms. Atrial fibrillation was present in 86% of patients. Most ICHs were single compartment (78%), trauma-related (61%), and involved the intracerebral and/or intraventricular space(s) (53%). ICH size was ≥ 10 mL in volume (intracerebral and/or ventricular) or ≥ 10 mm in thickness (subdural or subarachnoid) in 22% of patients and infratentorial in 15%. Andexanet alfa was associated with greater odds of achieving hemostatic effectiveness (85.8% vs. 68.1%; OR 2.73; 95% CI 1.16-6.42) and decreased odds of mortality (7.9% vs. 19.6%; OR 0.36; 95% CI 0.13-0.98) versus 4F-PCC. Two thrombotic events occurred with andexanet alfa and none with 4F-PCC. CONCLUSIONS In this indirect comparison of patients with an apixaban- or rivaroxaban-associated ICH, andexanet alfa was associated with better hemostatic effectiveness and improved survival compared to 4F-PCC. Trial registration NCT02329327; registration date: December 31, 2014.
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Affiliation(s)
- Olivia S. Costa
- grid.63054.340000 0001 0860 4915Department of Pharmacy Practice, University of Connecticut School of Pharmacy, 69 North Eagleville Road, Unit 3092, Storrs, CT 06269 USA ,grid.277313.30000 0001 0626 2712Evidence-Based Practice Center, Hartford Hospital, Hartford, CT USA
| | - Stuart J. Connolly
- grid.25073.330000 0004 1936 8227Department of Medicine, McMaster University, 237 Barton St East, Hamilton, ON L8L 2X2 Canada ,grid.415102.30000 0004 0545 1978Population Health Research Institute, Hamilton, ON Canada
| | - Mukul Sharma
- grid.25073.330000 0004 1936 8227Department of Medicine, McMaster University, 237 Barton St East, Hamilton, ON L8L 2X2 Canada ,grid.415102.30000 0004 0545 1978Population Health Research Institute, Hamilton, ON Canada
| | - Jan Beyer-Westendorf
- grid.4488.00000 0001 2111 7257Thrombosis and Anticoagulation Service, Division Hematology and Hemostaseology, Department of Medicine I, Dresden University Hospital, Fetscherstrasse 74, 01307 Dresden, Germany
| | - Mary J. Christoph
- Department of Global Health Economics and Outcomes Research, Alexion, AstraZeneca Rare Disease, 121 Seaport Blvd, Boston, MA 02210 USA
| | - Belinda Lovelace
- Department of Global Health Economics and Outcomes Research, Alexion, AstraZeneca Rare Disease, 121 Seaport Blvd, Boston, MA 02210 USA
| | - Craig I. Coleman
- grid.63054.340000 0001 0860 4915Department of Pharmacy Practice, University of Connecticut School of Pharmacy, 69 North Eagleville Road, Unit 3092, Storrs, CT 06269 USA ,grid.277313.30000 0001 0626 2712Evidence-Based Practice Center, Hartford Hospital, Hartford, CT USA
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22
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Effectiveness and Safety of Nonvitamin K Oral Anticoagulants Rivaroxaban and Apixaban in Patients with Venous Thromboembolism: A Meta-Analysis of Real-World Studies. Cardiovasc Ther 2022; 2022:2756682. [PMID: 35801133 PMCID: PMC9203223 DOI: 10.1155/2022/2756682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/11/2022] [Accepted: 05/20/2022] [Indexed: 11/24/2022] Open
Abstract
Background Rivaroxaban and apixaban are the most widely used nonvitamin K oral anticoagulants (NOACs) in patients with venous thromboembolism (VTE). This meta-analysis evaluates the effectiveness and safety of both NOACs versus standard of care (SoC) in real-world practice. Methods Real-world evidence (RWE) studies were identified through a systematic literature review conducted between January 2012 and July 2020, using Embase, MEDLINE, and the websites of cardiological, hematological, and oncological associations. Eligible RWE studies recruited adult patients with deep vein thrombosis and/or pulmonary embolism and presented a comparison between rivaroxaban and apixaban versus SoC, consisting either of vitamin K antagonists, heparins, or combinations thereof. Hazard ratios (HRs) for the comparison between NOACs and SoC were extracted from the relevant studies or estimated based on the reported binary data. The between-treatment contrasts were reported as HRs with associated 95% confidence intervals. Results A total of 65 RWE studies were identified and considered relevant for the meta-analysis. Compared with SoC, both rivaroxaban and apixaban were associated with reduced risks of recurrent VTE and a lower rate of major bleeding events. Patients treated with rivaroxaban were at a lower risk of all-cause death compared with those receiving SoC (HR = 0.56 [0.39-0.80]), while evidence for apixaban from the identified studies was insufficient to demonstrate a statistically significant change in mortality (HR = 0.66 [0.30-1.47]). Conclusion This analysis indicates that in real-world practice, rivaroxaban and apixaban are associated with a lower risk of recurrent VTE and major bleeding events compared with SoC. Survival benefit in patients treated with rivaroxaban was also observed.
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23
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Chin KY, Pang KL, Wong SK, Chew DCH, Qodriyah HMS. Relationship Amongst Vitamin K Status, Vitamin K Antagonist Use and Osteoarthritis: A Review. Drugs Aging 2022; 39:487-504. [PMID: 35635615 DOI: 10.1007/s40266-022-00945-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 11/28/2022]
Abstract
Vitamin K is essential for the carboxylation of the vitamin K-dependent proteins that are responsible for the suppression of matrix calcification. The use of vitamin K antagonists (VKAs) in patients with cardiovascular diseases could affect protein carboxylation and lead to the development of osteoarthritis (OA). This review aims to summarise the current evidence for the relationship between VKAs and OA. The literature search revealed that in observation studies, good vitamin K status, as reflected by the circulating level or protein carboxylation status of vitamin K, is associated positively with improved joint structural and functional indices and negatively associated with OA incidence. By contrast, in limited retrospective and prospective studies, the use of VKAs is associated positively with OA occurrence and knee/hip replacement. Pharmacological interactions between VKAs and various OA therapeutic agents exist and require careful monitoring and dosing. In conclusion, further epidemiological studies are warranted to verify the relationship between VKA use and OA to strengthen the evidence. Given that VKA use exerts potentially negative effects on joint health, intervention is required to protect the quality of life and mobility of patients.
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Affiliation(s)
- Kok-Yong Chin
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000, Cheras, Malaysia.
| | - Kok-Lun Pang
- Newcastle University Medicine Malaysia, Jalan Sarjana 1, Educity, 79200, Iskandar Puteri, Malaysia
| | - Sok Kuan Wong
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000, Cheras, Malaysia
| | - Deborah Chia Hsin Chew
- Deparment of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, 56000, Cheras, Malaysia
| | - Haji Mohd Saad Qodriyah
- Department of Pharmacology, Faculty of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000, Cheras, Malaysia
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24
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Wetmore JB, Herzog CA, Yan H, Reyes JL, Weinhandl ED, Roetker NS. Apixaban versus Warfarin for Treatment of Venous Thromboembolism in Patients Receiving Long-Term Dialysis. Clin J Am Soc Nephrol 2022; 17:693-702. [PMID: 35470214 PMCID: PMC9269579 DOI: 10.2215/cjn.14021021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 03/04/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES The association of apixaban compared with warfarin for the treatment of venous thromboembolism in patients receiving maintenance dialysis is not well studied. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We conducted a retrospective cohort study of Medicare fee-for-service beneficiaries receiving dialysis using United States Renal Data System data from 2013 to 2018. The study included patients who received a new prescription for apixaban or warfarin following a venous thromboembolism diagnosis. The outcomes were recurrent venous thromboembolism, major bleeding, and death. Outcomes were analyzed using Cox proportional hazards regression for intention-to-treat and censored-at-drug-switch-or-discontinuation analyses. Models incorporated inverse probability of treatment and censoring weights to minimize confounding and informative censoring. RESULTS In 12,206 individuals, apixaban, compared with warfarin, was associated with lower risks of both recurrent venous thromboembolism (hazard ratio [HR], 0.58; 95% confidence interval [95% CI], 0.43 to 0.77) and major bleeding (HR, 0.78; 95% CI, 0.62 to 0.98) in the intention-to-treat analysis over 6 months of follow-up. However, there was no difference between apixaban and warfarin in terms of risk of all-cause death (HR, 1.04; 95% CI, 0.94 to 1.16). Corresponding hazard ratios for the 6-month censored-at-drug-switch-or-discontinuation analysis and for corresponding analyses limited to a shorter (3-month) follow-up were all highly similar to the primary analysis. CONCLUSIONS In a large group of US patients on dialysis with recent venous thromboembolism, we observed that apixaban was associated with lower risk of recurrent venous thromboembolism and of major bleeding than warfarin. There was no observed difference in mortality.
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Affiliation(s)
- James B Wetmore
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota .,Division of Nephrology, Hennepin Healthcare and Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Charles A Herzog
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota.,Division of Cardiology, Hennepin Healthcare, and Department of Medicine, University of Minnesota, Minneapolis, Minnesota
| | - Heng Yan
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
| | - Jorge L Reyes
- Division of Cardiology, University of Minnesota, Minneapolis, Minnesota
| | - Eric D Weinhandl
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota.,Department of Pharmaceutical Care and Health Systems, University of Minnesota, Minneapolis, Minnesota
| | - Nicholas S Roetker
- Chronic Disease Research Group, Hennepin Healthcare Research Institute, Minneapolis, Minnesota
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25
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Response to "An International Consensus List of Potentially Clinically Significant Drug-Drug Interactions in Older People". J Am Med Dir Assoc 2022; 23:521. [PMID: 35026144 DOI: 10.1016/j.jamda.2021.10.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 10/15/2021] [Indexed: 11/23/2022]
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26
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White D, Moore GW, Besser M, MacDonald S, Thomas W. Direct oral anticoagulants-Remove versus Taipan snake venom time for detection of a lupus anticoagulant in patients taking oral direct factor Xa inhibitors. Res Pract Thromb Haemost 2022; 6:e12648. [PMID: 35106431 PMCID: PMC8784856 DOI: 10.1002/rth2.12648] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/18/2021] [Accepted: 11/24/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The optimal method of detecting a lupus anticoagulant (LA) for patients taking direct factor Xa inhibitor (DFXaI) direct oral anticoagulants (DOACs) remains controversial. Methods include charcoal adsorption of the DOACs to allow testing with the activated partial thromboplastin time (APTT) and dilute Russell viper venom time (dRVVT), or use of the DFXaI-insensitive Taipan snake venom time (TSVT) and Ecarin time (ET) assays on neat plasma. OBJECTIVES The objective was to compare the utility of APTT and dRVVT analysis following DOAC Remove against TSVT/ET on untreated plasma for LA detection in spiked plasmas and routine clinical samples for patients on DFXaIs. PATIENTS/METHODS Various LA-negative and LA-positive samples were assayed by APTT, dRVVT, and TSVT/ET, and then separately spiked with rivaroxaban, apixaban, and edoxaban calibrators to a concentration of ~190 ng/ml and the assays repeated on spiked plasma before and after DOAC Remove treatment. Testing of 284 consecutive samples from DFXaI-anticoagulated patients by APTT/dRVVT and TSVT/ET before and after DOAC Remove treatment was undertaken. RESULTS In the spiking model, we found that both TSVT/ET and DOAC Remove strategies generally distinguished LA-negative and LA-positive samples, but some false-positive LA results occurred. In the investigation of 284 consecutive patient samples on DFXaIs, the percentage agreement for LA detection in neat samples tested by TSVT/ET versus APTT and dRVVT after DOAC Remove treatment was 90% (Cohen kappa 0.12). CONCLUSION Our data highlight uncertainty and disagreement for testing LA in patients on DFXaI. Further studies are required.
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Affiliation(s)
- Danielle White
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Gary W Moore
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
- Faculty of Science and Technology Middlesex University London UK
| | - Martin Besser
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Stephen MacDonald
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Will Thomas
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
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Lim KK, Koleva-Kolarova R, Chowienczyk P, Wolfe CDA, Fox-Rushby J. Genetic-guided pharmacotherapy for venous thromboembolism: a systematic and critical review of economic evaluations. THE PHARMACOGENOMICS JOURNAL 2021; 21:625-637. [PMID: 34131314 PMCID: PMC8602036 DOI: 10.1038/s41397-021-00243-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 05/12/2021] [Accepted: 05/19/2021] [Indexed: 12/02/2022]
Abstract
Despite the known contributions of genes, genetic-guided pharmacotherapy has not been routinely implemented for venous thromboembolism (VTE). To examine evidence on cost-effectiveness of genetic-guided pharmacotherapy for VTE, we searched six databases, websites of four HTA agencies and citations, with independent double-reviewers in screening, data extraction, and quality rating. The ten eligible studies, all model-based, examined heterogeneous interventions and comparators. Findings varied widely; testing was cost-saving in two base-cases, cost-effective in four, not cost-effective in three, dominated in one. Of 22 model variables that changed decisions about cost-effectiveness, effectiveness/relative effectiveness of the intervention was the most frequent, albeit of poor quality. Studies consistently lacked details on the provision of interventions and comparators as well as on model development and validation. Besides improving the reporting of interventions, comparators, and methodological details, future economic evaluations should examine strategies recommended in guidelines and testing key model variables for decision uncertainty, to advise clinical implementations.
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Affiliation(s)
- Ka Keat Lim
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- National Institute for Health Research (NIHR) Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
| | - Rositsa Koleva-Kolarova
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Philip Chowienczyk
- Cardiovascular Division, Department of Clinical Pharmacology, King's College London School of Medicine, St Thomas' Hospital, London, UK
| | - Charles D A Wolfe
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- National Institute for Health Research (NIHR) Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (ARC) South London, London, UK
| | - Julia Fox-Rushby
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
- National Institute for Health Research (NIHR) Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK.
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García Rodríguez LA, Cea Soriano L, de Abajo FJ, Valent F, Hallas J, Gil M, Cattaruzzi C, Rodriguez-Martin S, Vora P, Soriano-Gabarró M, Gaist D. Trends in the use of oral anticoagulants, antiplatelets and statins in four European countries: a population-based study. Eur J Clin Pharmacol 2021; 78:497-504. [PMID: 34791521 PMCID: PMC8818635 DOI: 10.1007/s00228-021-03250-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Accepted: 11/07/2021] [Indexed: 11/28/2022]
Abstract
Purpose To evaluate time trends in the prevalence of antithrombotic and statin use in four European countries. Methods Using population-based data from the United Kingdom, Denmark, Spain and Italy between 2010 and 2018, we calculated standardized annual prevalence proportions of antithrombotics and statin use, and changes in prevalence proportions (2018 vs. 2010). Results Prevalence proportion of statins increased from 24.8% to 24.6% (UK), 21.0% to 22.3% (Region of Southern Denmark [RSD]), 12.9% to 14.3% (Udine, Italy), and 20.3% to 23.2% (Spain). Prevalence proportions of antithrombotics declined in all four countries: 18.7% to 15.9% (UK; − 2.8% points), 18.9% to 18.1% (RSD; − 0.8% points), 17.7% to 16.6% (Udine; − 1.1% points) and 15.0% to 13.6% (Spain; − 1.4% points). These declines were driven by reductions in low-dose aspirin use: 15.3% to 8.9% (UK; − 6.4% points), 16.3% to 9.5% (RSD; − 6.8% points), 13.5% to 11.6% (Udine; − 1.9% points), and 10.2% to 8.8% (Spain; − 1.4% points). In the UK, low-dose aspirin use declined from 9.1% to 4.3% (− 4.8% points) for primary CVD prevention, and from 49.6% to 36.9% (− 12.7% points) for secondary prevention. Oral anticoagulant use gradually increased but did not fully account for the decrease in low-dose aspirin use. Conclusions Antithrombotic use in the UK, RSD, Udine and Spain declined between 2010 and 2018, driven by a reduction in use of low-dose aspirin that is not completely explained by a gradual increase in OAC use. Use of statins remained constant in the UK, and increased gradually in the RSD, Udine and Spain. Supplementary Information The online version contains supplementary material available at 10.1007/s00228-021-03250-6.
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Affiliation(s)
| | - Lucía Cea Soriano
- Department of Public Health and Maternal and Child Health, Faculty of Medicine, Complutense University of Madrid), Madrid, Spain
| | - Francisco J de Abajo
- Clinical Pharmacology Unit, Department of Biomedical Sciences (Pharmacology Section), University Hospital Príncipe de Asturias, University of Alcalá (IRYCIS), Alcalá de Henares, Madrid, Spain
| | - Francesca Valent
- Institute of Hygiene and Clinical Epidemiology, Udine Integrated University Health Unit, Udine, Italy
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Miguel Gil
- División de Farmacoepidemiología Y Farmacovigilancia, Agencia Española de Medicamentos Y Productos Sanitarios, Madrid, Spain
| | - Chiara Cattaruzzi
- Pharmaceutical Service, Udine Integrated University Health Unit, Udine, Italy
| | - Sara Rodriguez-Martin
- Clinical Pharmacology Unit, Department of Biomedical Sciences (Pharmacology Section), University Hospital Príncipe de Asturias, University of Alcalá (IRYCIS), Alcalá de Henares, Madrid, Spain
| | | | | | - David Gaist
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, Odense, Denmark
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29
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Hara N, Lee T, Nozato T, Terui Matsuyama M, Okata S, Nagase M, Mitsui K, Nitta G, Watanabe K, Miyazaki R, Nagamine S, Kaneko M, Nakamura T, Nagata Y, Miyamoto T, Obayashi T, Ashikaga T. Effectiveness and Safety of Direct Oral Anticoagulants vs. Warfarin and Recurrence After Discontinuation in Patients With Acute Venous Thromboembolism in the Real World. Circ J 2021; 86:923-933. [PMID: 34645732 DOI: 10.1253/circj.cj-21-0588] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The efficacy of direct oral anticoagulants (DOACs) compared with warfarin for the treatment of venous thromboembolism (VTE), and the recurrence of VTE after discontinuation of anticoagulation therapy in research are limited.Methods and Results:This retrospective study enrolled 893 patients with acute VTE between 2011 and 2019. The cohort was divided into the transient risk, unprovoked, continued cancer treatment, and cancer remission groups. The following were compared between DOACs and warfarin: composite outcome of all-cause death, VTE recurrence, bleeding and composite outcome of VTE-related death, recurrence and bleeding. In the continued cancer treatment group, more bleeding was seen in warfarin-treated patients than in patients treated with DOACs (53.2% vs. 31.2%, [P=0.048]). In addition, composite outcome of VTE-related death and recurrence after discontinuation of anticoagulation therapy (n=369) was evaluated. The continued cancer treatment group (multivariate analysis: HR: 3.62, 95% CI: 1.84-7.12, P<0.005) and bleeding-related discontinuation of therapy (HR: 2.60, 95% CI: 1.32-5.13, P=0.006) were independent predictors of the event after discontinuation of anticoagulation therapy. VTE recurrence after discontinuation of anticoagulation therapy in the cancer remission group was 1.6% and a statistically similar occurrence was found in the transient risk group (12.4%) (P=0.754). CONCLUSIONS DOACs may decrease bleeding incidence in patients continuing to receive cancer treatment. In patients with bleeding-related discontinuation of anticoagulation therapy, VTE recurrence may increase. Discontinuation of anticoagulant therapy might be a treatment option in patients who have completed their cancer treatment.
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Affiliation(s)
- Nobuhiro Hara
- Department of Cardiology, Japanese Red Cross Musashino Hospital
| | - Tetsumin Lee
- Department of Cardiology, Japanese Red Cross Musashino Hospital
| | | | | | | | - Masashi Nagase
- Department of Cardiology, Japanese Red Cross Musashino Hospital
| | - Kentaro Mitsui
- Department of Cardiology, Japanese Red Cross Musashino Hospital
| | - Giichi Nitta
- Department of Cardiology, Japanese Red Cross Musashino Hospital
| | - Keita Watanabe
- Department of Cardiology, Japanese Red Cross Musashino Hospital
| | | | - Sho Nagamine
- Department of Cardiology, Japanese Red Cross Musashino Hospital
| | - Masakazu Kaneko
- Department of Cardiology, Japanese Red Cross Musashino Hospital
| | | | | | | | - Toru Obayashi
- Department of Cardiology, Japanese Red Cross Musashino Hospital
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30
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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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Tanaka KA, Shettar S, Vandyck K, Shea SM, Abuelkasem E. Roles of Four-Factor Prothrombin Complex Concentrate in the Management of Critical Bleeding. Transfus Med Rev 2021; 35:96-103. [PMID: 34551881 DOI: 10.1016/j.tmrv.2021.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 06/27/2021] [Indexed: 12/19/2022]
Abstract
Four-factor prothrombin complex concentrate (4F-PCC) is the term used to describe a pathogen-reduced, lyophilized concentrate that contains therapeutic amounts of at least 4 coagulation factors: Factor II (FII), Factor VII (FVII), Factor IX (FIX), and Factor X (FX). 4F-PCC has proven to be an effective hemostatic agent compared to plasma transfusion in several prospective randomized trials in acute warfarin reversal. In recent years, 4F-PCC has been used in various acquired coagulopathies including post-cardiopulmonary bypass bleeding, trauma-induced coagulopathy, coagulopathy in liver failure, and major bleeding due to anti-FXa (anti-Xa) inhibitors (eg, rivaroxaban and apixaban). As transfusion of frozen plasma (FP) has not been found efficacious in the above critical bleeding scenarios, there is increasing interest in expanding the use of 4F-PCC. However, efficacy, safety, and clinical implications of expanded use of 4F-PCC have not been fully elucidated. Prothrombin time and international normalized ratio are commonly used to assess dose effects of 4F-PCC. Prothrombin time/international normalized ratio are standardly use for warfarin titration, but they are not suited for real-time monitoring of complex coagulopathies. Optimal dosing of 4F-PCC outside of the current approved use for vitamin K antagonist reversal is yet to be determined. In this review, we will discuss the use of 4F-PCC in four critical bleeding settings: cardiac surgery, major trauma, end-stage liver disease, and oral anti-Xa reversal. We will discuss recent studies in each area to explore the dosing, efficacy, and safety of 4F-PCC.
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Affiliation(s)
- Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, OK, USA.
| | - Shashank Shettar
- Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, OK, USA
| | - Kofi Vandyck
- Department of Anesthesiology, University of Oklahoma College of Medicine, Oklahoma City, OK, USA
| | - Susan M Shea
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ezeldeen Abuelkasem
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Ansell J, Bakhru S, Laulicht BE, Tracey G, Villano S, Freedman D. Ciraparantag reverses the anticoagulant activity of apixaban and rivaroxaban in healthy elderly subjects. Eur Heart J 2021; 43:985-992. [PMID: 34534272 PMCID: PMC8900496 DOI: 10.1093/eurheartj/ehab637] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 08/03/2021] [Accepted: 08/31/2021] [Indexed: 11/13/2022] Open
Abstract
Aims Ciraparantag is a reversal agent for anticoagulants including direct oral anticoagulants. The aim was to evaluate the efficacy and safety of ciraparantag to reverse anticoagulation induced by apixaban or rivaroxaban in healthy elderly adults. Methods and results Two randomized, placebo-controlled, dose-ranging trials conducted in healthy subjects aged 50–75 years. Subjects received apixaban (Study 1) 10 mg orally twice daily for 3.5 days or rivaroxaban (Study 2) 20 mg orally once daily for 3 days. At steady-state anticoagulation subjects were randomized 3:1 to a single intravenous dose of ciraparantag (Study 1: 30, 60, or 120 mg; Study 2: 30, 60, 120, or 180 mg) or placebo. Efficacy was based on correction of the whole blood clotting time (WBCT) at multiple timepoints over 24 h. Subjects and technicians performing WBCT testing were blinded to treatment. Complete reversal of WBCT within 1 h post-dose and sustained through 5 h (apixaban) or 6 h (rivaroxaban) was dose related and observed with apixaban in 67%, 100%, 100%, and 17% of subjects receiving ciraparantag 30 mg, 60 mg, 120 mg, or placebo, respectively; and with rivaroxaban in 58%, 75%, 67%, 100%, and 13% of subjects receiving ciraparantag 30 mg, 60 mg, 120 mg, 180 mg, or placebo, respectively. Adverse events related to ciraparantag were mild, transient hot flashes or flushing. Conclusions Ciraparantag provides a dose-related reversal of anticoagulation induced by steady-state dosing of apixaban or rivaroxaban. Sustained reversal was achieved with 60 mg ciraparantag for apixaban and 180 mg ciraparantag for rivaroxaban. All doses of ciraparantag were well tolerated.
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Affiliation(s)
- Jack Ansell
- Hofstra Northwell School of Medicine, 500 Hofstra Blvd., Hempstead, NY 11549, USA
| | - Sasha Bakhru
- Perosphere Technologies Inc., 108 Mill Plain Rd., Danbury, CT 06811, USA
| | - Bryan E Laulicht
- Landsdowne Laboratories Inc., 1073 N. Benson Rd., Fairfield, CT 06824, USA
| | - Gregory Tracey
- Frontage Clinical Services, Inc., 200 Meadowlands Pkwy, Secaucus, NJ 07094, USA
| | - Stephen Villano
- AMAG Pharmaceuticals, Inc., 1100 Winter St., Waltham, MA 02450, USA
| | - Daniel Freedman
- AMAG Pharmaceuticals, Inc., 1100 Winter St., Waltham, MA 02450, USA
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Risk for stroke and myocardial infarction with abiraterone versus enzalutamide in metastatic prostate cancer patients. ESMO Open 2021; 6:100261. [PMID: 34509804 PMCID: PMC8437777 DOI: 10.1016/j.esmoop.2021.100261] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 07/12/2021] [Accepted: 08/06/2021] [Indexed: 11/23/2022] Open
Abstract
Background Abiraterone and enzalutamide use is associated with significant cardiovascular (CV) morbidity in clinical trials, but the magnitude and clinical relevance of this association in real-world prostate cancer (PC) population remain unknown. Materials and methods We retrospectively reviewed the MarketScan claims databases (1 January 2013 to 30 September 2018) to identify adults with diagnosis of metastatic PC who received treatment with androgen deprivation therapy (ADT) and novel antiandrogen agents (abiraterone or enzalutamide). The primary CV outcome measure was composite outcome of acute myocardial infarction (MI) or stroke. Secondary outcomes were individual risks of MI or stroke. We used an intention-to-treat approach to analyze the CV outcomes associated with drug exposure among patients with metastatic PC. Cox regression model was used to estimate the independent association of two drugs with CV risk after adjustment for age, baseline atrial fibrillation, and Charlson Comorbidity Index. Results A total of 6294 patients with metastatic PC who were treated with ADT and either abiraterone or enzalutamide were included in the final analysis. Of these, 4017 (63.8%) patients used abiraterone and 2217 (32.2%) patients used enzalutamide. During the study period, 255 (6.3%) primary endpoint events occurred, resulting in an incidence rate of 4.3 per 100 patient-years. In multivariable analysis, abiraterone use was associated with a 31% increased risk of MI or stroke compared to enzalutamide (hazard ratio 1.31; 95% confidence interval 1.05-1.63; P = 0.01). The incidence rate was similar in patients who switched initial therapy from abiraterone to enzalutamide or vice versa (5.0 versus 5.6 per 100 patient-years, respectively). Conclusions To our knowledge, this is the first real-world assessment of MI and stroke among metastatic PC patients receiving novel anti-androgens. Our findings of increased MI and stroke risk with abiraterone compared with enzalutamide are consistent with data from clinical trials and suggest that enzalutamide may be preferable for prostate cancer patients at high CV risk. Abiraterone and enzalutamide have comparable efficacy but substantial differences in CV toxicity. We identified metastatic PC patients treated with ADT and abiraterone or enzalutamide from insurance claims-based database. Abiraterone use was associated with a 31% increased risk for MI or stroke when compared to enzalutamide. Enzalutamide may be preferable in patients with baseline high CV risk.
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Zakai NA, Walker RF, MacLehose RF, Koh I, Alonso A, Lutsey PL. Venous thrombosis recurrence risk according to warfarin versus direct oral anticoagulants for the secondary prevention of venous thrombosis. Res Pract Thromb Haemost 2021; 5:e12575. [PMID: 34430789 PMCID: PMC8371351 DOI: 10.1002/rth2.12575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 07/15/2021] [Accepted: 07/21/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) affects nearly 1 million Americans annually, and many benefit from continued anticoagulation after the initial 3- to 6-month treatment period (secondary prevention). OBJECTIVES To determine whether warfarin, apixaban, or rivaroxaban is associated with reduced recurrent VTE hospitalization in the secondary prevention of VTE. PATIENTS/METHODS We performed a retrospective cohort study of participants enrolled in the MarketScan Insurance Database between 2013 and 2017 in those with an incident VTE. In those individuals who continued oral anticoagulation (warfarin, apixaban, or rivaroxaban) beyond 6 months, we determined the relative rate of recurrent VTE hospitalization. RESULTS Among 119 964 individuals with VTE, 25 419 remained on anticoagulation after 6 months and were matched successfully by age, sex, and date. After adjusting for a propensity score, apixaban versus rivaroxaban (hazard ratio [HR], 0.65; 95% confidence interval [CI], 0.45-0.94) and apixaban versus warfarin (HR, 0.68; 95% CI, 0.47-1.00) had a reduced risk of recurrent VTE hospitalization, and rivaroxaban versus warfarin (HR, 1.12; 95% CI, 0.94-1.33) had equivalent rates. For the rivaroxaban versus warfarin comparison there was a significant interaction by renal function (P < .01) where rivaroxaban was associated with a lower risk of recurrent VTE hospitalization (HR, 0.65; 95% CI, 0.41-1.03) in those with kidney disease and increased risk in those without kidney disease (HR, 1.24; 95% CI, 1.02-1.50). CONCLUSIONS These data suggest that apixaban has a lower recurrent VTE hospitalization rate than rivaroxaban during the secondary prevention of VTE, and further study of diverse patient populations, especially by kidney function, is warranted.
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Affiliation(s)
- Neil A. Zakai
- Department of MedicineLarner College of Medicine at the University of VermontBurlingtonVermontUSA
- Department of Pathology and Laboratory MedicineLarner College of Medicine at the University of VermontBurlingtonVermontUSA
| | - Rob F. Walker
- Division of Epidemiology and Community HealthSchool of Public HealthUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Richard F. MacLehose
- Division of Epidemiology and Community HealthSchool of Public HealthUniversity of MinnesotaMinneapolisMinnesotaUSA
| | - Insu Koh
- Department of Pathology and Laboratory MedicineLarner College of Medicine at the University of VermontBurlingtonVermontUSA
| | - Alvaro Alonso
- Department of EpidemiologyRollins School of Public HealthEmory UniversityAtlantaGeorgiaUSA
| | - Pamela L. Lutsey
- Division of Epidemiology and Community HealthSchool of Public HealthUniversity of MinnesotaMinneapolisMinnesotaUSA
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Haykal T, Deliwala SS, Ortel TL. Is the use of warfarin becoming obsolete? J Community Hosp Intern Med Perspect 2021; 11:418-419. [PMID: 34234920 PMCID: PMC8118434 DOI: 10.1080/20009666.2021.1918474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Tarek Haykal
- Division of Hematology, Department of Medicine, Duke University, Durham, NC, USA, .,Department of Medicine, Michigan State University at Hurley Medical Center, Flint, MI, USA.,Division of Hematology, Department of Medicine, Duke University, Durham, NC, USA.,Department of Pathology, Duke University, Durham, NC, USA
| | - Smit S Deliwala
- Division of Hematology, Department of Medicine, Duke University, Durham, NC, USA, .,Department of Medicine, Michigan State University at Hurley Medical Center, Flint, MI, USA.,Division of Hematology, Department of Medicine, Duke University, Durham, NC, USA.,Department of Pathology, Duke University, Durham, NC, USA
| | - Thomas L Ortel
- Division of Hematology, Department of Medicine, Duke University, Durham, NC, USA, .,Department of Medicine, Michigan State University at Hurley Medical Center, Flint, MI, USA.,Division of Hematology, Department of Medicine, Duke University, Durham, NC, USA.,Department of Pathology, Duke University, Durham, NC, USA
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Beyer-Westendorf J, Marten S, Tittl L, Naue C, Bornhäuser M. Venous Thromboembolism Therapy with Apixaban in Daily Care Patients: Results from the Dresden NOAC Registry. TH OPEN 2021; 5:e143-e151. [PMID: 33969261 PMCID: PMC8096533 DOI: 10.1055/s-0041-1728675] [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: 04/23/2020] [Accepted: 02/23/2021] [Indexed: 12/23/2022] Open
Abstract
The effectiveness and safety of venous thromboembolism (VTE) treatment with apixaban, demonstrated in phase III trials, need to be confirmed in daily care.
Using data from the prospective, noninterventional cross-indication
Dresden NOAC Registry
we evaluated rates of VTE recurrence and bleeding complications during apixaban treatment of VTE patients. For this analysis, we only included patients with acute VTE who started apixaban within 14 days after diagnosis and who were enrolled within these 14 days. Patient characteristics, treatment persistence, and clinical outcomes were assessed.
Between August 1st, 2014 and October 31, 2018, 352 patients with apixaban treatment for acute VTE were enrolled. During treatment (median exposure 13.7 ± 9.8 months; median follow-up 21.7 ± 6.1 months) rates of recurrent VTE and International Society on Thrombosis and Haemostasis major bleeding were 1.3/100 pt.years (95% confidence interval or CI 0.4–3.0) and 1.5/100 pt.years (0.6–3.3), respectively. At 6 months. 68.6% of patients were still taking apixaban, 23.9% had a scheduled end of treatment, 6.3% were switched to other anticoagulants, and the remaining 2.3% had unplanned complete discontinuation of anticoagulation. Of the 188 patients stopping apixaban, 12 (6.4%) experienced a recurrent VTE (six pulmonary embolisms ± deep vein thrombosis, six deep vein thrombosis; mean time between stopping anticoagulation and VTE recurrence 5.2 ± 4.1 months [range 14–417 days]). Our findings suggest that, in daily care, apixaban demonstrated high effectiveness, safety, and persistence in the treatment of acute VTE with low rates of unplanned discontinuation.
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Affiliation(s)
- Jan Beyer-Westendorf
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, University Hospital "Carl Gustav Carus" Dresden, Dresden, Germany.,Kings Thrombosis Service, Department of Hematology, Kings College, London, United Kingdom
| | - Sandra Marten
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, University Hospital "Carl Gustav Carus" Dresden, Dresden, Germany
| | - Luise Tittl
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, University Hospital "Carl Gustav Carus" Dresden, Dresden, Germany
| | - Christiane Naue
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, University Hospital "Carl Gustav Carus" Dresden, Dresden, Germany
| | - Martin Bornhäuser
- Thrombosis Research Unit, Division Hematology, Department of Medicine I, University Hospital "Carl Gustav Carus" Dresden, Dresden, Germany
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MacLehose RF, Zakai NA, Walker RF, Alonso A, Adams T, Lutsey PL. Impact of oral anticoagulant choice for the secondary prevention of venous thromboembolism on the risk of inpatient bleeding. Res Pract Thromb Haemost 2021; 5:e12514. [PMID: 33977213 PMCID: PMC8105158 DOI: 10.1002/rth2.12514] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 02/07/2021] [Accepted: 03/05/2021] [Indexed: 12/28/2022] Open
Abstract
Background Randomized trials suggest that direct oral anticoagulants (DOACs) are at least as effective as warfarin for primary treatment of VTE and that bleeding risk may be lower for some DOACs relative to warfarin. However, there is very little information regarding potential bleeding risks for DOACs versus warfarin in secondary prevention of VTE. Objective The aim of this study was to compare rates of bleeding events resulting in inpatient admissions between individuals taking apixaban, rivaroxaban, and warfarin for secondary prevention of VTE during the period 2013-2017. Methods We used the IBM MarketScan Commercial Claims and Encounters Database and Medicare Supplemental and Coordination of Benefits Database (IBM Watson Health, Ann Arbor, MI) to establish a retrospective cohort. Initial venous thrombolism events were defined from medical claims, and follow-up for this cohort began 6 months after the initial event. Bleeding events resulting in inpatient admission were identified from claims data over the subsequent year of secondary prevention. Results A total of 69 264 individuals were identified for the cohort, with 567 bleeding events. The crude rate of bleeding was highest among warfarin users (1.47/100 person-years; 95% confidence interval [CI], 1.24-1.74) and lower among those on either apixaban (1.00/100 person-years; 95% CI, 0.65-1.54) or rivaroxaban (0.84/100 person-years; 95% CI, 0.66-1.08). In multivariable adjusted Cox models, those on apixaban (hazard ratio [HR], 0.80; 95% CI, 0.50-1.29) and rivaroxaban (HR, 0.81; 95% CI, 0.59-1.09) had somewhat lower rates of bleeding events relative to those on warfarin. Conclusions We found modest evidence of decreased risk of bleeding for apixaban and rivaroxaban. These estimates were relatively imprecise.
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Affiliation(s)
- Richard F MacLehose
- Division of Epidemiology and Community Health University of Minnesota Minneapolis MN USA
| | - Neil A Zakai
- Department of Medicine Department of Pathology & Laboratory Medicine Larner College of Medicine at the University of Vermont Colchester VT USA
| | - Rob F Walker
- Division of Epidemiology and Community Health University of Minnesota Minneapolis MN USA
| | - Alvaro Alonso
- Department of Epidemiology Rollins School of Public Health Emory University Atlanta GA USA
| | - Terrence Adams
- Department of Pharmaceutical Care & Health Systems University of Minnesota Minneapolis MN USA
| | - Pamela L Lutsey
- Division of Epidemiology and Community Health University of Minnesota Minneapolis MN USA
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Stubblefield WB, Kline JA. Outpatient treatment of emergency department patients diagnosed with venous thromboembolism. Postgrad Med 2021; 133:11-19. [PMID: 33840338 DOI: 10.1080/00325481.2021.1916299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Venous thromboembolism (VTE) includes the diagnosis of either deep venous thrombosis (DVT) and/or pulmonary embolism (PE). This review discusses an evidence-based approach to the outpatient treatment of VTE in the emergency care setting. Main findings: The majority of patients diagnosed with VTE in the acute care setting are at low risk for an adverse event. Outpatient treatment for patients deemed low-risk by validated clinical decision tools leads to safe, efficacious, patient-centered, and cost-effective care. From a patient perspective, outpatient treatment of VTE can been simplified by the use of direct oral anticoagulant (DOACs) medications, and is supported by clinical trial evidence, and clinical practice guidelines from international societies. Outpatient treatment of patients with DVT has been more widely accepted as a best practice, while adoption of outpatient treatment of low-risk patients with acute PE has lagged. Many acute care clinicians remain wary of discharging patients with PE, concerned about drug access, adherence, and follow-up. Patients with VTE should be risk stratified identically as emerging evidence has demonstrated efficacy and safety in the interdependence of acute care protocols for the outpatient treatment of low-risk DVT and PE. Clinicians who practice in the acute care setting should be comfortable with risk stratification, anticoagulation, and discharge of low-risk VTE.
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Affiliation(s)
- William B Stubblefield
- Department of Emergency Medicine, Vanderbilt University Medical Center Nashville United States
| | - Jeffrey A Kline
- Department of Emergency Medicine, Indiana University School of Medicine, USA
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Porres-Aguilar M, Hoeper MM, Rivera-Lebron BN, Heresi GA, Mukherjee D, Tapson VF. Direct oral anticoagulants in chronic thromboembolic pulmonary hypertension. J Thromb Thrombolysis 2021; 52:791-796. [PMID: 33835334 DOI: 10.1007/s11239-021-02445-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 11/27/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) represents the later stage consequence of at least one or more unresolved episodes of acute pulmonary embolism; thus, indefinite anticoagulation is strongly recommended by current practice guidelines. Historically, vitamin K antagonists have been widely used in these patients. However, recent data indicate a shift toward direct oral anticoagulants (DOACs), despite lack of data on the safety and efficacy in this patient population. Herein, we briefly discuss the current rationale for oral anticoagulation use in CTEPH, addressing important issues and controversies involved with the use of DOACs, opening a strategy for further clinical research in the field of oral anticoagulation.
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Affiliation(s)
- Mateo Porres-Aguilar
- Division of Hospital Medicine, Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA.
- Division of Hospital Medicine, Department of Medicine, Sierra Providence Healthcare and Hospitals, El Paso, TX, USA.
| | - Marius M Hoeper
- Department of Respiratory Medicine, Hannover Medical School and German Center of Lung Research (DZL), Hannover, Germany
| | - Belinda N Rivera-Lebron
- Division of Pulmonary and Critical Care Medicine, University of Pittsburgh Medical Center (UPMC), Pittsburgh, PA, USA
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases, Department of Medicine, Texas Tech University Health Sciences Center at El Paso, El Paso, TX, USA
| | - Victor F Tapson
- Division of Pulmonary and Critical Care Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA
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40
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Magavern EF, Kaski JC, Turner RM, Drexel H, Janmohamed A, Scourfield A, Burrage D, Floyd CN, Adeyeye E, Tamargo J, Lewis BS, Kjeldsen KP, Niessner A, Wassmann S, Sulzgruber P, Borry P, Agewall S, Semb AG, Savarese G, Pirmohamed M, Caulfield MJ. The Role of Pharmacogenomics in Contemporary Cardiovascular Therapy: A position statement from the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2021; 8:85-99. [PMID: 33638977 DOI: 10.1093/ehjcvp/pvab018] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/05/2021] [Accepted: 02/24/2021] [Indexed: 12/14/2022]
Abstract
There is a strong and ever-growing body of evidence regarding the use of pharmacogenomics to inform cardiovascular pharmacology. However, there is no common position taken by international cardiovascular societies to unite diverse availability, interpretation and application of such data, nor is there recognition of the challenges of variation in clinical practice between countries within Europe. Aside from the considerable barriers to implementing pharmacogenomic testing and the complexities of clinically actioning results, there are differences in the availability of resources and expertise internationally within Europe. Diverse legal and ethical approaches to genomic testing and clinical therapeutic application also require serious thought. As direct-to-consumer genomic testing becomes more common, it can be anticipated that data may be brought in by patients themselves, which will require critical assessment by the clinical cardiovascular prescriber. In a modern, pluralistic and multi-ethnic Europe, self-identified race/ethnicity may not be concordant with genetically detected ancestry and thus may not accurately convey polymorphism prevalence. Given the broad relevance of pharmacogenomics to areas such as thrombosis and coagulation, interventional cardiology, heart failure, arrhythmias, clinical trials, and policy/regulatory activity within cardiovascular medicine, as well as to genomic and pharmacology subspecialists, this position statement attempts to address these issues at a wide-ranging level.
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Affiliation(s)
- E F Magavern
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Department of Clinical Pharmacology, Cardiovascular Medicine, Barts Health NHS Trust, London, UK
| | - J C Kaski
- Molecular and Clinical Sciences Research Institute, St George's, University of London, United Kingdom
| | - R M Turner
- The Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - H Drexel
- Vorarlberg Institute for Vascular Investigation & Treatment (VIVIT), Feldkirch, A Private University of the Principality of Liechtenstein, Triesen, FL.,Drexel University College of Medicine, Philadelphia, USA
| | - A Janmohamed
- Department of Clinical Pharmacology, St George's, University of London, United Kingdom
| | - A Scourfield
- Department of Clinical Pharmacology, University College London Hospital Foundation Trust, UK
| | - D Burrage
- Whittington Health NHS Trust, London, UK
| | - C N Floyd
- King's College London British Heart Foundation Centre, School of Cardiovascular Medicine and Sciences, London, UK.,Department of Clinical Pharmacology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - E Adeyeye
- Department of Clinical Pharmacology, Cardiovascular Medicine, Barts Health NHS Trust, London, UK
| | - J Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Universidad Complutense, Madrid, Spain
| | - B S Lewis
- Cardiovascular Clinical Research Institute, Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Keld Per Kjeldsen
- Department of Cardiology, Copenhagen University Hospital (Amager-Hvidovre), Copenhagen, Denmark.,Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
| | - A Niessner
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna
| | - S Wassmann
- Cardiology Pasing, Munich, Germany and University of the Saarland, Homburg/Saar, Germany
| | - P Sulzgruber
- Medical University of Vienna, Department of Medicine II, Division of Cardiology
| | - P Borry
- Center for Biomedical Ethics and Law, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium.,Leuven Institute for Human Genetics and Society, Leuven, Belgium
| | - S Agewall
- Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - A G Semb
- Preventive Cardio-Rheuma clinic, department of rheumatology, innovation and research, Diakonhjemmet hospital, Oslo, Norway
| | - G Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - M Pirmohamed
- The Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, UK.,Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK.,Liverpool Health Partners, Liverpool, UK
| | - M J Caulfield
- William Harvey Research Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Navas-Blanco JR, Martini A, Fabbro M. Expert Consensus Decision Pathway of the American College of Cardiology on Management of Bleeding in Patients With Oral Anticoagulants: A Review of the 2020 Update for Perioperative Physicians. J Cardiothorac Vasc Anesth 2021; 35:2471-2479. [PMID: 33726942 DOI: 10.1053/j.jvca.2021.02.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 02/05/2021] [Accepted: 02/07/2021] [Indexed: 11/11/2022]
Abstract
The use and evolution of oral anticoagulation therapies continue to advance for multiple reasons, including a growing segment of older patients with associated chronic prothrombotic illnesses including cardiovascular, pulmonary, hematologic and oncologic conditions. Correlated to this increased use of oral anticoagulants is bleeding complications associated with their use. Based on these trends, it is expected that perioperative physicians will be facing more and more of these patients requiring scheduled, urgent or emergent surgical procedures During May 2020, the American College of Cardiology updated its Expert Consensus Decision Pathway devoted to the approach of bleeding in patients on oral anticoagulants. This updated version emphasized the expanding role of the direct-acting oral anticoagulants in other conditions beyond nonvalvular atrial fibrillation, such as venous thromboembolism. Several details discussed within this most recent update are pertinent to perioperative physicians, who frequently deal with bleeding in the setting of anticoagulation. The purpose of this narrative review is to highlight and expand on these salient points because they relate to perioperative management.
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Affiliation(s)
- Jose R Navas-Blanco
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
| | - Adriana Martini
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL
| | - Michael Fabbro
- Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL.
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Maughan BC, Frueh L, McDonagh MS, Casciere B, Kline JA. Outpatient Treatment of Low-risk Pulmonary Embolism in the Era of Direct Oral Anticoagulants: A Systematic Review. Acad Emerg Med 2021; 28:226-239. [PMID: 32779290 DOI: 10.1111/acem.14108] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/27/2020] [Accepted: 08/07/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Clinical guidelines have supported outpatient treatment of low-risk pulmonary embolism (PE) since 2014, but adoption of this practice has been slow. Direct oral anticoagulant (DOAC) therapy for venous thromboembolism (VTE) is now as common as vitamin K antagonist treatment, but data are sparse regarding outcomes for patients with low-risk PE treated with DOACs as outpatients. We conducted a systematic review of literature on outcomes of outpatient management for PE, including comparisons to inpatient treatment and differences by anticoagulant class. METHODS We searched Medline, Embase, PubMed, CENTRAL, clinicaltrials.gov, and ICTRN for studies published from January 1980 through February 2019 using a predefined strategy developed with a medical librarian. We included English-language randomized controlled trials (RCTs) and prospective nonrandomized trials (NRTs) of adult patients diagnosed with acute, symptomatic PE, and discharged from the emergency department or within 48 hours. Our primary outcome included four major adverse outcomes (all-cause mortality, PE-related mortality, recurrent VTE, and major bleeding) within 30 and 90 days. A preplanned subanalysis of high-quality studies assessed outcomes associated with different anticoagulation treatment classes. RESULTS Our initial search identified 6,818 records, of which 12 studies (four RCT, eight NRT) with a total of 3,191 patients were included in the review. All RCTs and six NRTs were determined to have low to moderate risk of bias and were classified as high quality. Outpatients in these studies (n = 1,814) had rates of 90-day major adverse outcomes below 1%, including all-cause mortality (0.7%, 95% confidence interval [CI] = 0.4% to 1.2%), PE-related mortality (0.06%, 95% CI = 0.01% to 0.3%), recurrent VTE (0.8%, 95% CI = 0.5% to 1.4%), and major bleeding (0.8%, 95% CI = 0.5% to 1.4%). Exploratory analysis revealed no association between anticoagulant treatment class and rates of major adverse outcomes. CONCLUSION Among patients with low-risk PE treated as outpatients, few patients experienced major adverse outcomes such as mortality, recurrent VTE, or major bleeding within 90 days.
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Affiliation(s)
- Brandon C. Maughan
- From the Department of Emergency Medicine Oregon Health & Science University School of Medicine Portland ORUSA
| | - Lisa Frueh
- and the Department of Social and Behavioral Sciences Harvard TS Chan School of Public Health Boston MAUSA
| | - Marian S. McDonagh
- the Department of Medical Informatics and Clinical Epidemiology Oregon Health & Science University School of Medicine Portland ORUSA
| | - Bryan Casciere
- From the Department of Emergency Medicine Oregon Health & Science University School of Medicine Portland ORUSA
| | - Jeffrey A. Kline
- and the Department of Emergency Medicine Indiana University School of Medicine Indianapolis INUSA
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43
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Samuelson Bannow BT, Chi V, Sochacki P, McCarty OJT, Baldwin MK, Edelman AB. Heavy menstrual bleeding in women on oral anticoagulants. Thromb Res 2021; 197:114-119. [PMID: 33212377 PMCID: PMC7775335 DOI: 10.1016/j.thromres.2020.11.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 10/19/2020] [Accepted: 11/07/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although heavy menstrual bleeding (HMB) is a known complication of anticoagulant therapy, rates of HMB in users of the direct oral anticoagulants (OACs) apixaban and rivaroxaban are largely unknown. METHODS We performed a retrospective cohort study of menstruating women prescribed rivaroxaban, apixaban and warfarin over a six-year period (2012-2018). The primary outcome was HMB requiring medical or surgical intervention. We used descriptive statistics and logistic regression to evaluate associations between OAC type, age, history of HMB, and the primary outcome. RESULTS We identified 195 women of reproductive-age with a new therapeutic OAC prescription (62 on rivaroxaban, 54 on apixaban, 79 on warfarin). A minority (26/195, 13.3%) had a documented history of HMB, including 9 rivaroxaban users, 7 apixaban users and 10 warfarin users but most women (117/195, 60%) had no menstrual history documented. One third of subjects (64/195) required treatment for HMB within 6 months of starting OAC therapy. After controlling for a history of HMB, rivaroxaban users were 1.4 times more likely to require treatment as compared to users of other OACs. DISCUSSION We found an association between rates of HMB necessitating medical or surgical intervention and rivaroxaban use. We also found that the majority of women did not have a documented menstrual history, suggesting that many providers do not inquire about menstrual bleeding when starting OAC therapy. Menstruating women, particularly those with a history of HMB, may be at increased risk for HMB necessitating medical treatment depending on the type of OAC used.
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Affiliation(s)
- Bethany T Samuelson Bannow
- The Hemophilia Center at OHSU, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA; Knight Cancer Institute, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA.
| | - Vivia Chi
- OHSU School of Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | | | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Maureen K Baldwin
- Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
| | - Alison B Edelman
- Department of Obstetrics and Gynecology, Oregon Health & Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239, USA
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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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Pakanati KC, Siddamreddy S, Nalleballe K, Thombre V, Sheng S, Veerapaneni K, Yadala S, Kapoor N, Dandu V, Avula A, Meegada S, Bere P. Industry payments to hospitalist physicians: a 5-year analysis of the Open Payments programme from 2014 to 2018. Intern Med J 2020; 50:1547-1550. [PMID: 33354878 DOI: 10.1111/imj.15116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/21/2020] [Accepted: 07/22/2020] [Indexed: 11/27/2022]
Abstract
We analysed Open Payments programme data (https://openpaymentsdata.cms.gov) on industry-to-physician payments to hospitalists for the years 2014 to 2018. Payments to hospitalists increased by 106.5% from 2014 to 2018 with food and beverage (38.5%) and compensation for services other than consulting (24.3%) being the highest-paid categories. Industry payment to hospitalists was highly skewed with top 10 hospitalists receiving more than 30% of the total payments during the study period. The most common drugs associated with payments were anticoagulant medications (apixaban and rivaroxaban). Industry seems to be spending a significant amount of money to increase awareness of medications among hospitalists. Identification of these trends and potential motives of industry spending is critical to address any potential physician bias.
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Affiliation(s)
- Krishna C Pakanati
- Department of Internal Medicine, Envision Physician Services, Plantation, Florida, USA
| | - Suman Siddamreddy
- Department of Internal Medicine, Baptist Health Program, North Little Rock, Arkansas, USA
| | - Krishna Nalleballe
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Vaishali Thombre
- Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Sen Sheng
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Karthika Veerapaneni
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Sisira Yadala
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Nidhi Kapoor
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Vasuki Dandu
- Department of Internal Medicine, Baptist Health Program, North Little Rock, Arkansas, USA
| | - Akshay Avula
- Department of Internal Medicine, Staten Island University Hospital, Staten Island, New York, USA
| | - Sreenath Meegada
- Department of Internal Medicine, UT Health Science Center, Longview, Texas, USA
| | - Praveen Bere
- Department of Internal Medicine, Desert Regional Medical Center, Palm Springs, California, USA
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Cattaneo D, Formenti T, Gidaro A, Merlo A, Gervasoni C. Use of Direct Oral Anticoagulants in People Living with HIV: A Single-Center Experience. Semin Thromb Hemost 2020; 46:999-1001. [PMID: 33368115 DOI: 10.1055/s-0040-1718398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Dario Cattaneo
- Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy.,Unit of Clinical Pharmacology, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Tiziana Formenti
- Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
| | - Antonio Gidaro
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Luigi Sacco Hospital Milan, Milan, Italy
| | - Andrea Merlo
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Luigi Sacco Hospital Milan, Milan, Italy
| | - Cristina Gervasoni
- Gestione Ambulatoriale Politerapie (GAP) Outpatient Clinic, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy.,Department of Infectious Diseases, ASST Fatebenefratelli Sacco University Hospital, Milan, Italy
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Li R, Yuan M, Cheng J, Yu S, Wei W, Fu W, Prandoni P, Chen Y. Risk of post-thrombotic syndrome after deep vein thrombosis treated with rivaroxaban versus vitamin-K antagonists: A systematic review and meta-analysis. Thromb Res 2020; 196:340-348. [DOI: 10.1016/j.thromres.2020.09.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/27/2020] [Accepted: 09/11/2020] [Indexed: 11/25/2022]
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48
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Management of isolated distal deep-vein thrombosis with direct oral anticoagulants in the RIETE registry. J Thromb Thrombolysis 2020; 52:532-541. [PMID: 33247808 DOI: 10.1007/s11239-020-02347-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2020] [Indexed: 12/14/2022]
Abstract
Isolated distal deep-vein thrombosis (DVT, infra-popliteal DVT without pulmonary embolism) is a common presentation of venous thromboembolism (VTE), but was an exclusion criterion from the pivotal trials that validated the use of direct oral anticoagulants (DOACs) for VTE management. Using data from the international RIETE registry, we analyzed and compared trends in DOACs prescription between January 2011 and June 2019 in patients with distal vs. proximal DVT. We also assessed DOACs' prescriptions and compared the outcomes (VTE recurrence, bleeding and death) of distal DVT patients treated with DOACs vs. those on vitamin K antagonists (VKAs). 2308 patients with distal DVT and 11,364 patients with proximal DVT were included in the current analysis. DOACs were more frequently prescribed in patients with distal than proximal DVT (25% vs. 16%, p < 0.001). DOACs use increased sharply during the observation period (P < 0.001 for trend). In 2018, 56% of patients with distal DVT received DOACs. Distal DVT patients treated with rivaroxaban or edoxaban received the dose recommended for VTE management in most (> 85%) cases. Patients treated with apixaban were older, more likely to have underlying conditions than patients treated with rivaroxaban and, in most cases (> 75%), did not receive the recommended 1-week loading dose for acute VTE management. Outcomes between distal DVT patients treated with VKAs or DOACs appeared to be similar. In patients with distal DVT, DOACs have become the most common anticoagulant regimen. Specific trials are needed to determine the optimal DOACs dose regimen for treatment of distal DVT.
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McMahon P, Reichman M, Dodelzon K. Bleeding risk after percutaneous breast needle biopsy in patients on anticoagulation therapy. Clin Imaging 2020; 70:114-117. [PMID: 33157367 DOI: 10.1016/j.clinimag.2020.09.014] [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: 05/14/2020] [Revised: 09/07/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
Image-guided core needle biopsy (CNB) is the standard of care procedure for tissue diagnosis of suspicious breast lesions. While complications are exceedingly rare, the most common complications include bleeding and hematoma formation. With an increasing number of patients on anticoagulation therapy (AT), it is important to determine whether continuation of these medications during CNB increases bleeding risk. While previous studies have demonstrated the safety in continuation of AT during CNB, American College of Radiology (ACR) guidelines recommend practitioners decide whether cessation is necessary on a case-by-case basis as this may put patients at risk for thromboembolic events. The purpose of this review is to analyze the literature on anticoagulation and bleeding risk during CNB to guide clinical practice.
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Affiliation(s)
- Paige McMahon
- Weill Cornell Medicine, 1300 York Avenue, New York, NY, 10065, USA.
| | - Melissa Reichman
- Weill Cornell Medicine, Department of Radiology, 525 East 68th street, New York, NY 10065, USA.
| | - Katerina Dodelzon
- Weill Cornell Medicine, Department of Radiology, 525 East 68th street, New York, NY 10065, USA.
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Lutsey PL, MacLehose RF, Claxton JS, Walker RF, Adam TJ, Alonso A, Zakai NA. Impact of oral anticoagulation choice on healthcare utilization for the primary treatment of venous thromboembolism. Vasc Med 2020; 25:549-556. [PMID: 32716254 DOI: 10.1177/1358863x20940388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Little is known about the impact of oral anticoagulation (OAC) choice on healthcare encounters during venous thromboembolism (VTE) primary treatment. Among anticoagulant-naïve patients with VTE, we tested the hypotheses that healthcare utilization would be lower among users of direct OACs (DOACs; rivaroxaban or apixaban) than among users of warfarin. MarketScan databases for years 2016 and 2017 were used; healthcare utilization was identified in the first 6 months after initial VTE diagnoses. The 23,864 patients with VTE had on average 0.2 ± 0.5 hospitalizations, spent 1.3 ± 5.2 days in the hospital, had 5.7 ± 5.1 outpatient encounters, and visited an emergency department 0.4 ± 1.1 times. As compared to warfarin, rivaroxaban and apixaban were associated with fewer hospitalizations, days hospitalized, outpatient office visits, and emergency department visits after accounting for age, sex, comorbidities, and medications. Hospitalization rates were 24% lower (incidence rate ratio (IRR): 0.76; 95% CI: 0.69, 0.83) with rivaroxaban and 22% lower (IRR: 0.78; 95% CI: 0.71, 0.87) with apixaban, as compared to warfarin (IRR: 1.00 (reference)). Healthcare utilization was similar between apixaban and rivaroxaban users. Patients with VTE prescribed rivaroxaban and apixaban had lower healthcare utilization than those prescribed warfarin, while there was no difference when comparing apixaban to rivaroxaban. These findings complement existing literature supporting the use of DOACs over warfarin.
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Affiliation(s)
- Pamela L Lutsey
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Richard F MacLehose
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - J'Neka S Claxton
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Rob F Walker
- Division of Epidemiology & Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Terrence J Adam
- Department of Pharmaceutical Care and Health Systems, College of Pharmacy, University of Minnesota, Minneapolis, MN, USA
| | - Alvaro Alonso
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Neil A Zakai
- Department of Medicine & Department of Pathology and Laboratory Medicine, Division of Hematology/Oncology, Larner College of Medicine at the University of Vermont, Burlington, VT, USA
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