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Kelly K, Blanck LM, Lim K, Norman A, Roberto CV, Assifi MM, Wright GP, Chung M. Apixaban for Extended Thromboprophylaxis After Oncologic Resection: Outcomes and Cost Analysis. Am Surg 2023; 89:5428-5435. [PMID: 36782104 DOI: 10.1177/00031348231156778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
BACKGROUND Patients undergoing oncologic resection are at risk of developing venous thromboembolism (VTE), and this can lead to increased morbidity and hospital costs. Low-molecular weight heparin (LMWH) is recommended as extended thromboprophylaxis (ETP) in high-risk patients and has been shown to reduce rates of VTE. METHODS This is a retrospective review of consecutive patients undergoing resection for oncologic indications at a single institution from May 2016 to May 2019. This study evaluated the use of apixaban as ETP at discharge. The primary outcomes were deep vein thrombosis (DVT), pulmonary embolism (PE), or mesenteric/portal venous thromboembolism at 30, 60, and 90 days postoperatively. RESULTS A total of 600 patients were included; 449 patients received no ETP, and 151 patients received apixaban. PE occurred in 1.1, 1.6, and 2.3% of patients without ETP and 0, 0, and .7% of patients in the apixaban group (at 30, 60, and 90 days; P = .338, P = .201, and P = .306, respectively). DVT occurred in 1.8, 2.1, and 2.8% of patients without ETP and 0, 0, and 1.4% in the apixaban group (P = .211, P = .121, and P = .535, respectively). The total cost, including ETP and readmission for VTE, per patient was US $5.51 more in the apixaban group. CONCLUSION Apixaban therapy for ETP did not produce a statistically significant reduction in VTE events in our patients. Future studies should include more patients in a prospective multicenter trial.
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Affiliation(s)
- Kathrine Kelly
- General Surgery Residency, Spectrum Health, Grand Rapids, MI, USA
| | - Lauren M Blanck
- Michigan State College of Human Medicine, Grand Rapids, MI, USA
| | - Kelvin Lim
- Michigan State College of Human Medicine, Grand Rapids, MI, USA
| | - Alexa Norman
- Michigan State College of Human Medicine, Grand Rapids, MI, USA
| | | | - M Mura Assifi
- General Surgery Residency, Spectrum Health, Grand Rapids, MI, USA
- Michigan State College of Human Medicine, Grand Rapids, MI, USA
- Spectrum Health, Grand Rapids, MI, USA
| | - G Paul Wright
- General Surgery Residency, Spectrum Health, Grand Rapids, MI, USA
- Michigan State College of Human Medicine, Grand Rapids, MI, USA
- Spectrum Health, Grand Rapids, MI, USA
| | - Mathew Chung
- General Surgery Residency, Spectrum Health, Grand Rapids, MI, USA
- Michigan State College of Human Medicine, Grand Rapids, MI, USA
- Spectrum Health, Grand Rapids, MI, USA
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2
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Determination of the solubility of rivaroxaban (anticoagulant drug, for the treatment and prevention of blood clotting) in supercritical carbon dioxide: Experimental data and correlations. ARAB J CHEM 2022. [DOI: 10.1016/j.arabjc.2022.104421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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3
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Thromboprophylaxis and clinical outcomes in moderate COVID-19 patients: A comparative study. Res Social Adm Pharm 2022; 18:4048-4055. [PMID: 35864037 PMCID: PMC9288247 DOI: 10.1016/j.sapharm.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/28/2022] [Accepted: 07/10/2022] [Indexed: 01/08/2023]
Abstract
Background Many thrombotic complications are linked to coronavirus disease 2019 (COVID-19). Antithrombotic treatments are important for prophylaxis against these thrombotic events. Objectives This study was designed to compare enoxaparin and rivaroxaban as prophylactic anticoagulants in moderate cases of COVID-19 in terms of efficacy, safety, and clinical outcomes. Methods The study involved 124 patients with moderate COVID-19 (pneumonia without hypoxia) divided into two groups. The first group (G1) comprised 66 patients who received enoxaparin subcutaneously at a dose of 0.5 mg/kg every 12 h until discharge from the hospital. The second group (G2) comprised 58 patients who received oral rivaroxaban at a dose of 10 mg once daily until discharge from the hospital. The outcomes evaluated in this study were as follows: intermediate care unit (IMCU) duration, the number of patients transferred from the IMCU to the intensive care unit (ICU), ICU duration, the total length of hospital stay, in-hospital mortality, and thrombotic and bleeding complications. Results No significant differences in IMCU duration (p = 0.39), ICU duration (p = 0.96), and total length of hospital stay (p = 0.73) were observed between the two groups. The percentage of patients requiring ICU admission after hospitalization was 21.2% in G1 and 22.4% in G2 (p = 0.87). The mortality rate was 12.1% in G1 and 10.3% in G2 (p = 0.76). The proportion of patients who had thrombotic complications was 9.1% in G1 and 12.1% in G2 (p = 0.59). The incidence of mild bleeding was 3% in G1 and 1.7% in G2 (p = 0.64). Conclusion Either enoxaparin or rivaroxaban may be used as thromboprophylaxis agents in managing patients with moderate COVID-19. Either medication has no clear advantage over the other.
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4
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Spyropoulos AC, Raskob GE, Cohen AT, Ageno W, Weitz JI, Spiro TE, Lu W, Lipardi C, Albers GW, Elliott CG, Halperin JL, Hiatt WR, Maynard G, Steg PG, Sugarmann C, Barnathan ES. Association of Bleeding Severity with Mortality in Extended Thromboprophylaxis of Medically Ill Patients in the MAGELLAN and MARINER Trials. Circulation 2022; 145:1471-1479. [PMID: 35389229 DOI: 10.1161/circulationaha.121.057847] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Extended thromboprophylaxis has not been widely implemented in acutely ill medical patients due to bleeding concerns. The MAGELLAN and MARINER trials evaluated whether rivaroxaban compared with enoxaparin or placebo could prevent venous thromboembolism (VTE) without increased bleeding. We hypothesized that patients with major bleeding (MB) but not those with non-major clinically relevant bleeding (NMCRB), would be at an increased risk of all-cause mortality (ACM). Methods: We evaluated all bleeding events in patients taking at least one dose of study drug and their association with ACM in 4 mutually exclusive groups: (1) no bleeding, or first event was (2) NMCRB, (3) MB, or (4) trivial bleeding. Using a Cox proportional hazards model adjusted for differences in baseline characteristics associated with ACM, we assessed the risk of ACM after such events. Results: Compared to patients with no bleeding, the risk of ACM for patients with NMCRB was not increased in MARINER (HR 0.43, p=0.235) but was increased in MAGELLAN (HR 1.74 p=0.021). MB was associated with a higher incidence of ACM in both studies, while trivial bleeding was not associated with ACM in either study. Conclusions: Patients with MB had an increased risk of ACM, while NMCRB was not consistently associated with an increased risk of death. These results inform the risk-benefit calculus of extended thromboprophylaxis in medically ill patients.
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Affiliation(s)
- Alex C Spyropoulos
- The Feinstein Institute for Medical Research, Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lenox Hill Hospital, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY
| | - Gary E Raskob
- Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Alexander T Cohen
- Department of Hematological Medicine, Guys and St Thomas/NHS Foundation Trust, King's College London, London, UK
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy and University of Insubria, Varese, Italy
| | - Jeffrey I Weitz
- McMaster University, and the Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | | | - Wentao Lu
- Biostatistics Department, Janssen Research and Development LLC, Raritan, NJ
| | - Concetta Lipardi
- Cardiovascular Clinical Development, Janssen Research and Development, LLC, Raritan, NJ
| | - Gregory W Albers
- Director Stanford Stroke Center, Stanford Medical Center, Stanford University, Palo Alto, CA
| | - C Gregory Elliott
- Departments of Medicine, University of Utah and Intermountain Healthcare, Salt Lake City, UT
| | | | - William R Hiatt
- Division of Cardiology, University of Colorado School of Medicine, and CPC Clinical Research, Aurora, CO
| | | | - P Gabriel Steg
- Université de Paris, INSERM UMR-1148 F- 75018 Paris, and Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, Paris, France
| | - Chiara Sugarmann
- Cardiovascular Clinical Development, Janssen Research and Development, LLC, Raritan, NJ
| | - Elliot S Barnathan
- Cardiovascular Clinical Development, Janssen Research and Development, LLC, Raritan, NJ
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5
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Chindamo MC, Paiva EF, Carmo Jr PRD, Rocha ATC, Marques MA. Desafios da profilaxia estendida do tromboembolismo venoso em pacientes clínicos e cirúrgicos. J Vasc Bras 2022; 21:e20210195. [PMID: 35836745 PMCID: PMC9250351 DOI: 10.1590/1677-5449.202101951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 04/06/2022] [Indexed: 12/05/2022] Open
Abstract
Patients hospitalized for acute medical and surgical illnesses are at risk of developing venous thromboembolism (VTE) during hospitalization and after discharge. Extended pharmacological prophylaxis beyond the hospital stay is recommended for patients undergoing surgeries at high risk for VTE and for selected groups of hospitalized medical patients. This practice involves several challenges, from identification of at-risk populations eligible for extended prophylaxis to choice of the most appropriate anticoagulant and definition of the ideal duration of use. This review will present the main VTE risk assessment models for hospitalized medical and surgical patients, the current recommendations for use of extended prophylaxis, and its limitations and benefits.
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Affiliation(s)
| | | | | | | | - Marcos Arêas Marques
- Universidade do Estado do Rio de Janeiro, Brasil; Universidade Federal do Estado do Rio de Janeiro, Brasil
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6
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Chindamo MC, Paiva EF, Carmo Jr PRD, Rocha ATC, Marques MA. Challenges of extended venous thromboembolism prophylaxis in medical and surgical patients. J Vasc Bras 2022. [DOI: 10.1590/1677-5449.202101952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Patients hospitalized for acute medical and surgical illnesses are at risk of developing venous thromboembolism (VTE) during hospitalization and after discharge. Extended pharmacological prophylaxis beyond the hospital stay is recommended for patients undergoing surgeries at high risk for VTE and for selected groups of hospitalized medical patients. This practice involves several challenges, from identification of at-risk populations eligible for extended prophylaxis to choice of the most appropriate anticoagulant and definition of the ideal duration of use. This review will present the main VTE risk assessment models for hospitalized medical and surgical patients, the current recommendations for use of extended prophylaxis, and its limitations and benefits.
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Affiliation(s)
| | | | | | | | - Marcos Arêas Marques
- Universidade do Estado do Rio de Janeiro, Brasil; Universidade Federal do Estado do Rio de Janeiro, Brasil
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7
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Ahuja T, Raco V, Papadopoulos J, Green D. Antithrombotic Stewardship: Assessing Use of Computerized Clinical Decision Support Tools to Enhance Safe Prescribing of Direct Oral Anticoagulants in Hospitalized Patients. J Patient Saf 2021; 17:e1057-e1061. [PMID: 30252771 DOI: 10.1097/pts.0000000000000535] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Prescribing patterns for oral anticoagulants in patients with nonvalvular atrial fibrillation and venous thromboembolism is shifting from vitamin K antagonists, such as warfarin to the direct oral anticoagulants (DOACs), such as dabigatran, rivaroxaban, and apixaban. Although many hospital systems have implemented clinical decision support or enhanced monitoring for patients prescribed warfarin, there is limited evidence to suggest similar levels of enhanced monitoring for DOACs. The antithrombotic stewardship team at our institution developed guidelines and implemented computerized clinical decision support (CCDS) tools to enhance medication and patient safety related to the DOACs. We sought to assess the safety and effectiveness of these CCDS tools available to clinicians upon DOAC prescription in hospitalized patients. We performed a retrospective review of 121 patients who received at least two doses of a DOAC from January 2013 to July 2014. We assessed dosing of the DOAC according to the CCDS provided upon order entry. Adherence to CCDS was 80% (n = 24), 75% (n = 46), and 87% (n = 27) in the dabigatran, apixaban, and rivaroxaban group, respectively. Our data demonstrate that implementing CCDS for DOACs into the electronic medical record may ensure safe prescribing of high-risk medications.
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Affiliation(s)
| | | | | | - David Green
- Division of hematology, Department Medicines, NYU Langone Health, New York, New York
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8
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Lipardi C, Elliott CG, Sugarmann CL, Haskell L, Spyropoulos AC, Raskob GE, Xu J, Lu W, Marsigliano J, Spiro T, Yuan Z, Wu S, Barnathan ES. Risk of Severe Bleeding With Extended Rivaroxaban to Prevent Venous Thromboembolism in Acute Medically Ill Patients With Bronchiectasis. Clin Appl Thromb Hemost 2021; 27:10760296211053316. [PMID: 34719984 PMCID: PMC8559236 DOI: 10.1177/10760296211053316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Bronchiectasis is a chronic inflammation of the bronchi with recurrent infections and hemoptysis. The MAGELLAN study compared oral rivaroxaban, 10 mg once daily (QD), for 35 ± 4 days with subcutaneous enoxaparin 40 mg QD for 10 ± 4 days followed by placebo for 25 ± 4 days to prevent venous thromboembolism in patients hospitalized with an acute medical illness. MAGELLAN included a subset of patients with bronchiectasis. In a post hoc analysis, we evaluated the incidence and severity of pulmonary bleeding in patients with bronchiectasis who were hospitalized for an acute medical illness. This analysis included MAGELLAN patients diagnosed with bronchiectasis at baseline. Patients were evaluated by treatment group for International Society on Thrombosis and Haemostasis major bleeding, non-major clinically relevant (NMCR) bleeding, and the composite of the 2 (ie, clinically relevant bleeding). Results: Medically ill patients with bronchiectasis were randomized to rivaroxaban (n = 60) or enoxaparin/placebo (n = 61). There were 2 fatal pulmonary bleeds and 1 fatal gastrointestinal bleed in the rivaroxaban arm and no fatal or major bleeding in the enoxaparin/placebo arm. The incidence of major bleeding was 5% in the rivaroxaban arm. One NMCR bleed occurred in the rivaroxaban arm and 2 NMCR bleeds occurred in the enoxaparin/placebo arm. The incidence of clinically relevant bleeding was 6.7% versus 3.3% in the rivaroxaban and enoxaparin/placebo groups, respectively (relative risk = 2.06 [95% confidence interval: 0.351-12.046]). Conclusion: In-patients hospitalized with bronchiectasis and an acute medical illness, clinically relevant bleeding, including fatal pulmonary hemorrhage, occurs more frequently with extended rivaroxaban thromboprophylaxis than with enoxaparin followed by placebo.
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Affiliation(s)
| | | | | | - Lloyd Haskell
- 6808Janssen Research and Development, LLC, Raritan, NJ, USA
| | - Alex C Spyropoulos
- 232890The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, NY, USA.,68477I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Gary E Raskob
- Hudson College of Public Health, 51166University of Oklahoma Health Sciences Center, OK, USA
| | - Jianfeng Xu
- 6808Janssen Research and Development, LLC, Raritan, NJ, USA
| | - Wentao Lu
- 6808Janssen Research and Development, LLC, Raritan, NJ, USA
| | | | | | - Zhong Yuan
- 6808Janssen Research and Development, LLC, Titusville, NJ, USA
| | - Shujian Wu
- 6808Janssen Research and Development, LLC, Horsham, PA, USA
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9
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Lee JJ, Memar Montazerin S, Shojaei F, Chi G. Current Opinion on the use of Direct Oral Anticoagulants for the Prophylaxis of Venous Thromboembolism among Medical Inpatients. Ther Clin Risk Manag 2021; 17:471-487. [PMID: 34079269 PMCID: PMC8165214 DOI: 10.2147/tcrm.s271439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Accepted: 05/12/2021] [Indexed: 01/09/2023] Open
Abstract
Venous thromboembolism (VTE) is a known cause of morbidity and mortality, especially among acutely ill medical patients. Although VTE prophylaxis is part of post-discharge clinical care in surgical patients, there is controversy regarding its use in acutely ill medical patients and the current guideline statements suggest against its routine use. Recent clinical trials (APEX, MAGELLAN and MARINER) compared the safety and efficacy of direct oral anticoagulants (including betrixaban and rivaroxaban) with the standard of the care, enoxaparin, to identify the risk–benefit tradeoff. In this review, we summarized the key findings from these trials and substudies and recent updates in society guidelines regarding VTE prevention. In addition, we discussed the potential barriers, cost-effectiveness, and COVID-19 with respect to the implementation of extended-duration or post-discharge usage of direct oral anticoagulants.
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Affiliation(s)
- Jane J Lee
- Baim Institute for Clinical Research, Boston, MA, USA
| | - Sahar Memar Montazerin
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Fahimehalsadat Shojaei
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Gerald Chi
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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10
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Raskob GE, Spyropoulos AC, Cohen AT, Weitz JI, Ageno W, De Sanctis Y, Lu W, Xu J, Albanese J, Sugarmann C, Weber T, Lipardi C, Spiro TE, Barnathan ES. Association Between Asymptomatic Proximal Deep Vein Thrombosis and Mortality in Acutely Ill Medical Patients. J Am Heart Assoc 2021; 10:e019459. [PMID: 33586478 PMCID: PMC8174250 DOI: 10.1161/jaha.120.019459] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Asymptomatic proximal deep vein thrombosis (DVT) is an end point frequently used to evaluate the efficacy of anticoagulant thromboprophylaxis in medical patients. Recently, the clinical relevance of asymptomatic DVT has been challenged. Methods and Results The objective of this study was to evaluate the relationship between asymptomatic proximal DVT and all-cause mortality (ACM) using a cohort analysis of a randomized trial for the prevention of venous thromboembolism (VTE) in acutely ill medical patients. Patients who received at least 1 dose of study drug and had an adequate compression ultrasound examination of the legs on either day 10 or day 35 were categorized into 1 of 3 cohorts: no VTE, asymptomatic proximal DVT, or symptomatic DVT. Cox proportional hazards model, with adjustment for significant independent predictors of mortality, were used to compare the incidences of ACM. Of the 7036 patients, 6776 had no VTE, 236 had asymptomatic DVT, and 24 had symptomatic VTE. The incidence of ACM was 4.8% in patients without VTE. Both asymptomatic proximal DVT (mortality, 11.4%; hazard ratio [HR], 2.31; 95% CI, 1.52-3.51; P<0.0001) and symptomatic VTE (mortality, 29.2%; HR, 9.42; 95% CI, 4.18-21.20; P<0.0001) were independently associated with significant increases in ACM. The analysis was post hoc, and ultrasound results were not available for all patients. Adjustment for baseline variables significantly associated with ACM may not fully compensate for differences. Conclusions Asymptomatic proximal DVT is associated with higher ACM than no VTE and remains a relevant end point to evaluate the efficacy of anticoagulant thromboprophylaxis in medical patients. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00571649.
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Affiliation(s)
- Gary E Raskob
- Hudson College of Public HealthUniversity of Oklahoma Health Sciences Center Oklahoma City OK
| | - Alex C Spyropoulos
- The Feinstein Institutes for Medical Research and Zucker School of Medicine at Hofstra/Northwell Anticoagulation and Clinical Thrombosis Services Department of Medicine Northwell Health at Lenox Hill Hospital New York NY
| | - Alexander T Cohen
- Department of Hematological Medicine Guys and St Thomas/NHS Foundation Trust, King's College London London United Kingdom
| | - Jeffrey I Weitz
- McMaster University, and the Thrombosis and Atherosclerosis Research Institute Hamilton Ontario Canada
| | - Walter Ageno
- Department of Medicine and Surgery University of Insubria Varese Italy
| | | | - Wentao Lu
- Biostatistics Department Janssen Research and Development LLC Raritan NJ
| | - Jianfeng Xu
- Biostatistics Department Janssen Research and Development LLC Raritan NJ
| | - John Albanese
- Cardiovascular Clinical Development Janssen Research and Development, LLC Raritan NJ
| | - Chiara Sugarmann
- Cardiovascular Clinical Development Janssen Research and Development, LLC Raritan NJ
| | - Traci Weber
- Cardiovascular Clinical Development Janssen Research and Development, LLC Raritan NJ
| | - Concetta Lipardi
- Cardiovascular Clinical Development Janssen Research and Development, LLC Raritan NJ
| | | | - Elliot S Barnathan
- Cardiovascular Clinical Development Janssen Research and Development, LLC Raritan NJ
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11
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Spyropoulos AC, Lipardi C, Xu J, Lu W, Suh E, Yuan Z, Levitan B, Sugarmann C, De Sanctis Y, Spiro TE, Barnathan ES, Raskob GE. Improved Benefit Risk Profile of Rivaroxaban in a Subpopulation of the MAGELLAN Study. Clin Appl Thromb Hemost 2020; 25:1076029619886022. [PMID: 31746218 PMCID: PMC7019408 DOI: 10.1177/1076029619886022] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Acutely ill medical patients are at risk of venous thromboembolism (VTE) and VTE-related
mortality during hospitalization and posthospital discharge, but widespread adoption of
extended thromboprophylaxis has not occurred. We analyzed a subpopulation within the
MAGELLAN study of extended thromboprophylaxis with rivaroxaban to reevaluate the benefit
risk profile. We identified 5 risk factors for major and fatal bleeding after a clinical
analysis of the MAGELLAN study and analyzed efficacy and safety with these patients
excluded (n = 1551). Risk factors included: active cancer, dual antiplatelet therapy at
baseline, bronchiectasis/pulmonary cavitation, gastroduodenal ulcer, or bleeding within 3
months before randomization. We evaluated efficacy, safety, and benefit risk using
clinically comparable endpoints in the subpopulation. At day 10, rivaroxaban was
noninferior to enoxaparin (relative risk [RR] = 0.82, 95% confidence interval [CI] =
0.58-1.15) and at day 35 rivaroxaban was significantly better than enoxaparin/placebo (RR
= 0.68, 95% CI = 0.53-0.88) in reducing VTE and VTE-related death. Major bleeding was
reduced at day 10 (RR = 2.18, 95% CI = 1.07-4.44 vs 1.19, 95% CI = 0.54-2.65) and at day
35 (2.87, 95% CI = 1.60-5.15 vs 1.48, 95% CI = 0.77-2.84) for MAGELLAN versus this
subpopulation, respectively. The benefit risk profile was favorable in this subpopulation
treated for 35 days, with the number needed to treat ranging from 55 to 481 and number
needed to harm from 455 to 1067 for all pairwise evaluations. Five exclusionary criteria
defined a subpopulation of acutely ill medical patients with a positive benefit risk
profile for in-hospital and extended thromboprophylaxis with rivaroxaban.
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Affiliation(s)
- Alex C Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA.,The Feinstein Institute for Medical Research, Manhasset, NY, USA.,Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lenox Hill Hospital, NY, USA
| | | | - Jianfeng Xu
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Wentao Lu
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Eunyoung Suh
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Zhong Yuan
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | | | | | - Yoriko De Sanctis
- Clinical Development, Pharmaceuticals, Bayer U.S. LLC, Whippany, NJ, USA
| | - Theodore E Spiro
- Clinical Development, Pharmaceuticals, Bayer U.S. LLC, Whippany, NJ, USA
| | | | - Gary E Raskob
- College of Public Health, The University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
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12
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Spyropoulos AC, Lipardi C, Xu J, Peluso C, Spiro TE, De Sanctis Y, Barnathan ES, Raskob GE. Modified IMPROVE VTE Risk Score and Elevated D-Dimer Identify a High Venous Thromboembolism Risk in Acutely Ill Medical Population for Extended Thromboprophylaxis. TH OPEN 2020; 4:e59-e65. [PMID: 32190813 PMCID: PMC7069762 DOI: 10.1055/s-0040-1705137] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 01/27/2020] [Indexed: 12/19/2022] Open
Abstract
An individualized approach to identify acutely ill medical patients at increased risk of venous thromboembolism (VTE) and a low risk of bleeding to optimize the benefit and risk of extended thromboprophylaxis (ET) is needed. The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) VTE risk score has undergone extensive external validation in medically ill patients for in-hospital use and a modified model was used in the MARINER trial of ET also incorporating an elevated D-dimer. The MAGELLAN study demonstrated efficacy with rivaroxaban but had excess bleeding. This retrospective analysis investigated whether the modified IMPROVE VTE model with an elevated D-dimer could identify a high VTE risk subgroup of patients for ET from a subpopulation of the MAGELLAN study, which was previously identified as having a lower risk of bleeding. We incorporated the modified IMPROVE VTE score using a cutoff score of 4 or more or 2 and 3 with an elevated D-dimer (>2 times the upper limit of normal) to the MAGELLAN subpopulation. In total, 56% of the patients met the high-risk criteria. In the placebo group, the total VTE event rate at Day 35 was 7.94% in the high-risk group and 2.83% for patients in the lower-risk group. A reduction in VTE was observed with rivaroxaban in the high-risk group (relative risk [RR]: 0.68, 95% confidence interval [CI]: 0.51-0.91, p = 0.008) and in the lower-risk group (RR: 0.69, 95% CI: 0.40 -1.20, p = 0.187). The modified IMPROVE VTE score with an elevated D-dimer identified a nearly threefold higher VTE risk subpopulation of patients where a significant benefit exists for ET using rivaroxaban.
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Affiliation(s)
- Alex C. Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, The Feinstein Institute for Medical Research and Department of Medicine, Anticoagulation and Clinical Thrombosis Services Northwell Health at Lenox Hill Hospital, New York, New York, United States
| | - Concetta Lipardi
- Janssen Research & Development, LLC, Raritan, New Jersey, United States
| | - Jianfeng Xu
- Janssen Research & Development, LLC, Raritan, New Jersey, United States
| | - Colleen Peluso
- Janssen Research & Development, LLC, Raritan, New Jersey, United States
| | - Theodore E. Spiro
- Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S. LLC, Whippany, New Jersey, United States
| | - Yoriko De Sanctis
- Thrombosis and Hematology Therapeutic Area, Clinical Development, Pharmaceuticals, Bayer U.S. LLC, Whippany, New Jersey, United States
| | | | - Gary E. Raskob
- College of Public Health, The University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, United States
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SARS-CoV-2 and venous thromboembolic disease. Not everything is new. ANGIOLOGIA 2020. [DOI: 10.20960/angiologia.00173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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14
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Vandenbriele C, Van der Linden L, Vanassche T, Verhamme P. Intermittent pneumatic compression on top of pharmacological thromboprophylaxis in intensive care: added value or added cost? J Thorac Dis 2019; 11:1734-1737. [PMID: 31285861 DOI: 10.21037/jtd.2019.05.31] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | | | - Thomas Vanassche
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
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15
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Chindamo MC, Marques MA. Role of ambulation to prevent venous thromboembolism in medical patients: where do we stand? J Vasc Bras 2019; 18:e20180107. [PMID: 31360151 PMCID: PMC6636813 DOI: 10.1590/1677-5449.180107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/19/2019] [Indexed: 11/22/2022] Open
Abstract
Venous thromboembolism (VTE) encompasses the spectrum of manifestations of deep venous thrombosis and/or pulmonary embolism and is a common, serious, and preventable complication in hospitalized patients. Although immobility plays an important role in determining VTE risk in medical patients, no clear and uniform criteria exist to guide clinicians in assessing immobility. The variation in the descriptions that do exist makes it difficult to interpret and compare the results of randomized clinical trials with respect to the influence of different levels of immobility on the magnitude of VTE risk and the role that early ambulation as an isolated factor plays in prevention of such events. Understanding these limitations is a prerequisite for the proper use and interpretation of VTE risk assessment tools and for indicating the best strategy for preventing venous thrombosis in hospitalized medical patients. The objective of this study was to review the main evidence reported in the literature on the role of ambulation in prevention of VTE.
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Affiliation(s)
- Maria Chiara Chindamo
- Universidade Federal do Rio de Janeiro – UFRJ, Departamento de Clínica Médica, Rio de Janeiro, RJ, Brasil.
- Rede D’Or São Luiz, Hospital Barra D’Or, Serviço de Clínica Médica, Rio de Janeiro, RJ, Brasil.
| | - Marcos Arêas Marques
- Universidade do Estado do Rio de Janeiro – UERJ, Hospital Universitário Pedro Ernesto, Rio de Janeiro, RJ, Brasil.
- Universidade Federal do Estado do Rio de Janeiro – UNIRIO, Hospital Universitário Gaffrée e Guinle, Rio de Janeiro, RJ, Brasil.
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Raymundo SRDO, Lobo SMA, Hussain KMK, Hussein KG, Secches IT. What has changed in venous thromboembolism prophylaxis for hospitalized patients over recent decades: review article. J Vasc Bras 2019; 18:e20180021. [PMID: 31191626 PMCID: PMC6542320 DOI: 10.1590/1677-5449.002118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 11/13/2018] [Indexed: 11/21/2022] Open
Abstract
Venous thromboembolism (VTE) is a common disease with high rates of morbidity and mortality and is considered the number one cause of avoidable mortality among hospitalized patients. Although VTE incidence is extremely high in all countries and there is ample evidence that thromboprophylaxis inexpensively reduces the rate of thromboembolic complications in both clinical and surgical patients, a great deal of doubt remains with respect to patient safety with this type of intervention and in relation to the ideal thromboprophylaxis methods. Countless studies and evidence-based recommendations confirm the efficacy of prophylaxis for prevention of VTE and/or patient deaths, but it remains underutilized to this day. This article presents a wide-ranging review of existing prophylaxis methods up to the present, from guidelines and national and international studies of thromboprophylaxis.
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Affiliation(s)
- Selma Regina de Oliveira Raymundo
- Faculdade Regional de Medicina de São José do Rio Preto – FAMERP, Hospital de Base, São José do Rio Preto, SP, Brasil.
- Hospital Austa, São José do Rio Preto, SP, Brasil.
| | - Suzana Margareth Ajeje Lobo
- Faculdade Regional de Medicina de São José do Rio Preto – FAMERP, Hospital de Base, São José do Rio Preto, SP, Brasil.
| | | | - Kassim Guzzon Hussein
- Faculdade de Medicina em São José do Rio Preto – FACERES, São José do Rio Preto, SP, Brasil.
| | - Isabela Tobal Secches
- Faculdade de Medicina em São José do Rio Preto – FACERES, São José do Rio Preto, SP, Brasil.
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Ramacciotti E, Fareed J. Rivaroxaban for post-discharge thromboprophylaxis: the MARINER trial. INT ANGIOL 2018; 37:427-430. [DOI: 10.23736/s0392-9590.18.04069-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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18
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Cohoon KP, De Sanctis Y, Haskell L, McBane RD, Spiro TE. Rivaroxaban for thromboprophylaxis among patients recently hospitalized for acute infectious diseases: a subgroup analysis of the MAGELLAN study. J Thromb Haemost 2018; 16:1278-1287. [PMID: 29753308 DOI: 10.1111/jth.14146] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Indexed: 08/31/2023]
Abstract
Essentials Net benefit of venous thromboprophylaxis (VTE) in patients hospitalized for infections is unknown. MAGELLAN trial subgroup analysis was performed for patients hospitalized for acute infectious diseases. At day 35, prolonged rivaroxaban prophylaxis reduced VTE compared to enoxaparin (4.2% vs. 6.6%). Rivaroxaban prophylaxis reduced VTE in patients hospitalized for active lung infections. SUMMARY Background Despite the well-established association between infection and venous thromboembolism (VTE), there are few data specifically assessing the efficacy and safety of the VTE prophylaxis strategies for patients hospitalized for acute infectious diseases. Objectives To estimate the incidence of VTE and bleeding outcomes, comparing prolonged prophylaxis with rivaroxaban 10 mg daily for 35 days with enoxaparin 40 mg daily for 10 days. Patients/Methods A subgroup analysis of patients hospitalized for acute infectious diseases in the MAGELLAN trial was performed. The primary efficacy outcome was the composite of asymptomatic proximal or symptomatic VTE at days 10 and 35. The principal safety outcome was the composite of major or clinically relevant non-major bleeding. Results Three thousand one hundred and seventy-three patients with acute infectious diseases leading to hospitalization were randomized to either rivaroxaban (n = 1585) or enoxaparin/placebo (n = 1588), and received at least one dose of study medication. At day 10, primary composite efficacy outcomes did not differ between prophylaxis strategies (rivaroxaban, 2.7%; and enoxaparin, 3.7%). At day 35, there were fewer VTE events with rivaroxaban (4.2%) than with enoxaparin (6.6%) (relative risk [RR] 0.64; 95% confidence interval [CI] 0.45-0.92). Patients with pulmonary infections randomized to rivaroxaban had a lower incidence of VTE both at 10 days (RR 0.50, 95% CI 0.28-0.90) and at 35 days (RR 0.54, 95% CI 0.33-0.87). Primary safety outcome events were increased with rivaroxaban (RR 2.42, 95% CI 1.60-3.66). Conclusions Prolonged rivaroxaban prophylaxis reduced the incidence of VTE in patients hospitalized for acute infectious diseases, particularly those involving the lungs. Efficacy benefits were, in part, offset by bleeding outcomes. ClinicalTrials.gov Number: NCT 00571649.
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Affiliation(s)
- K P Cohoon
- Department of Cardiovascular Diseases and Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | | | - L Haskell
- Janssen Research & Development LLC, Raritan, NJ, USA
| | - R D McBane
- Department of Cardiovascular Diseases and Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
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19
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Cave B, Hough A, Dobesh PP. Extended Venous Thromboembolism Prophylaxis in Medically Ill Patients. Pharmacotherapy 2018. [PMID: 29543384 DOI: 10.1002/phar.2102] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Brandon Cave
- Fort Loudoun Medical Center; Lenoir City Tennessee
| | - Augustus Hough
- West Palm Beach Veterans Affairs Medical Center; West Palm Beach Florida
| | - Paul P. Dobesh
- College of Pharmacy; University of Nebraska Medical Center; Omaha Nebraska
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20
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Siliste R, Antohi E, Pepoyan S, Nakou E, Vardas P. Anticoagulation in heart failure without atrial fibrillation: gaps and dilemmas in current clinical practice. Eur J Heart Fail 2018; 20:978-988. [DOI: 10.1002/ejhf.1153] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 12/31/2017] [Accepted: 01/15/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
| | - Elena‐Laura Antohi
- Department of Cardiology Emergency Cardiovascular Disease Institute ‘Prof. Dr. C.C. Iliescu’ Bucharest Romania
| | - Sergey Pepoyan
- Department of Cardiology Yerevan State Medical University (YSMU), University Clinical Hospital Yerevan Armenia
| | - Eleni Nakou
- Department of Cardiology Heraklion University Hospital Crete Greece
| | - Panos Vardas
- Department of Cardiology Heraklion University Hospital Crete Greece
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Abstract
Anticoagulation pharmacy has been dramatically altered with US Food and Drug Administration (FDA) approval of 5 direct oral anticoagulants, 1 novel reversal agent and, a second designated for fast-track approval. Trial data surrounding current trends in anticoagulant choice for VTE, reversal, and bridging are constantly redefining practice. Extended therapy for unprovoked VTE has expanded to include low-dose direct oral anticoagulants, aspirin, and the use of the HERDOO2 system to identify women who can stop anticoagulant therapy without increased risk of recurrent VTE. Trends in thromboprophylaxis include extended duration low-dose direct oral anticoagulants to prevent VTE in high-risk patients.
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Affiliation(s)
- Margaret Smith
- General Surgery Residency, Department of Surgery, University of Michigan, 2207 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA
| | - Glenn Wakam
- General Surgery Residency, Department of Surgery, University of Michigan, 2207 Taubman Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA
| | - Thomas Wakefield
- Section of Vascular Surgery, Department of Surgery, University of Michigan, 5463 Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA
| | - Andrea Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, 5372 Cardiovascular Center, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5867, USA.
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22
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Pabinger I, Riedl J. Direct oral anticoagulants: now also for prevention and treatment of cancer-associated venous thromboembolism? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2017; 2017:136-143. [PMID: 29222248 PMCID: PMC6142595 DOI: 10.1182/asheducation-2017.1.136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Data on specific studies in cancer patients using direct oral anticoagulants (DOACs) for the prevention and treatment of venous thromboembolism (VTE) are still scarce. For preventing VTE with DOACs, current experience is still very limited, so definite conclusions cannot yet be drawn. However, DOACs have so far been compared with vitamin K antagonists (VKAs) in patients with acute VTE in 5 studies, and several hundreds of patients included in these studies had either active cancer, a history of cancer, or a new occurrence of cancer during the course of disease. Meta-analyses have revealed an at least similar efficacy and safety profile of DOACs compared with VKAs. A number of studies of cancer patients investigating primary prevention and treatment are underway, and some will be finalized soon. Nevertheless, we might need further trials, specifically on the prevention of VTE in patients who are at particularly high risk. This article also includes a personal opinion on the use of DOACs in cancer patients. In conclusion, the currently available data show that DOACs might be safe and efficacious in the treatment of VTE, however, this has yet to be proven in specifically designed trials in patients with cancer. With regard to prevention, thus far, even less data exist, and the outcomes of the ongoing studies have to be evaluated before DOACs may be used for primary prevention.
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Affiliation(s)
- Ingrid Pabinger
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Julia Riedl
- Clinical Division of Haematology and Haemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
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23
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Mahan CE, Burnett AE, Fletcher ML, Spyropoulos AC. Extended thromboprophylaxis in the acutely ill medical patient after hospitalization - a paradigm shift in post-discharge thromboprophylaxis. Hosp Pract (1995) 2017; 46:5-15. [PMID: 29171776 DOI: 10.1080/21548331.2018.1410053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Venous thromboembolism (VTE) is a significant healthcare burden with approximately 900,000 events annually in the United States, over half of which are healthcare-associated. This number is anticipated to double by 2050. Group prophylaxis strategies confined to the inpatient setting appear to have minimal impact on the reduction of post-discharge VTE in medically ill patients due to shortened lengths of stay and a heterogenous population that includes patients at low risk for VTE. In accordance with current guideline recommendations, very few (<5%) medically ill patients are discharged with extended prophylaxis, which potentially creates a clinical gap for at-risk patients as VTE risk has been shown to persist for up to 90 days. Initial studies of extended thromboprophylaxis in acutely ill medical patients with enoxaparin, rivaroxaban and apixaban showed little to no benefit towards VTE reduction that was consistently outweighed by increased bleeding. The more recent APEX study that compared betrixaban to enoxaparin in an enriched patient population at high-risk for VTE was the first study of extended thromboprophylaxis that showed similar efficacy in VTE prevention without an increase in major bleeding. Based on the APEX results, betrixaban recently gained FDA approval for extended thromboprophylaxis in acutely ill medical patients. Recognition that up to half of medically ill patients are not at sufficient risk to warrant thromboprophylaxis has driven extensive research towards development of scientifically derived and validated VTE risk assessment models intended to identify patients who do not warrant prophylaxis, as well as those at high risk who may derive benefit from extended thromboprophylaxis. This article will review prior and ongoing extended thromboprophylaxis studies, VTE and bleed risk assessment models, incorporation of biomarkers in VTE risk assessment and key issues in the paradigm shift towards individualized VTE prophylaxis in acutely ill medical patients.
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Affiliation(s)
- Charles E Mahan
- a Hospital Pharmacy , Presbyterian Healthcare Services, University of New Mexico , Albuquerque , NM , USA
| | - Allison E Burnett
- b Hospital Pharmacy , University of New Mexico Health Sciences Center , Albuquerque , NM , USA
| | - Meghan L Fletcher
- b Hospital Pharmacy , University of New Mexico Health Sciences Center , Albuquerque , NM , USA
| | - Alex C Spyropoulos
- c Hofstra Northwell School of Medicine, Department of Medicine , Northwell Health System at Lenox Hill Hospital , New York , NY , USA
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Hull RD, Schellong SM, Tapson VF, Monreal M, Samama MM, Chen M, Deslandes B, Turpie AGG, Yusen RD. Impact of age on the efficacy and safety of extended-duration thromboprophylaxis in medical patients. Thromb Haemost 2017; 110:1152-63. [DOI: 10.1160/th13-02-0170] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 08/13/2013] [Indexed: 11/05/2022]
Abstract
SummaryThe EXCLAIM study enrolled hospitalised acutely ill medical patients with age >40 years and recently-reduced mobility into a trial of extended-duration anticoagulant thromboprophylaxis. This post-hoc analysis evaluated the impact of age on patient outcomes. After completion of open-label therapy with enoxaparin 40 mg once-daily (10 ± 4 days), eligible patients underwent randomisation to receive double-blind therapy of enoxaparin (n=2,975) or placebo (n=2,988) for 28 ± 4 days. During follow-up, the venous thromboembolism (VTE) risk increased with age in both treatment groups. In patients with age >75 years, those who received extended-duration enoxaparin had lower incidence of VTE (2.5% vs 6.7%; absolute difference [AD] [95% confidence interval]: −4.2% [−6.5, −2.0]), proximal deep-vein thrombosis (2.5% vs 6.6%; AD −4.1 % [−6.2, −2.0]), and symptomatic VTE (0.3% vs 1.5%; AD −1.2% [−2.2, −0.3]), in comparison to those who received placebo. In patients with age ≤75 years, those who received enoxaparin had reduced VTE (2.4% vs 2.8%; AD −0.4% [−1.5, 0.7]) and symptomatic VTE (0.2% vs 0.7%; AD −0.6% [−1.0, −0.1]) in comparison to those who received placebo. In both age subgroups, patients who received enoxaparin had increased rates of major bleeding versus those who received placebo: age >75 years (0.6% vs 0.2%; AD +0.3% [−0.2, 0.9], respectively); age ≤75 years (0.7% vs 0.2%; AD +0.5% [0.1, 0.9]). Patients in both age subgroups that received enoxaparin had similar low bleeding rates (0.6% and 0.7%, respectively). VTE risk increased with age, though the bleeding risk did not. Patients with age >75 years had a more favourable benefit-to-harm profile than younger patients.
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Cohen A, Dobromirski M. The use of rivaroxaban for short- and long-term treatment of venous thromboembolism. Thromb Haemost 2017; 107:1035-43. [DOI: 10.1160/th11-12-0859] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 02/04/2012] [Indexed: 12/22/2022]
Abstract
SummaryVenous thromboembolism (VTE) is a major healthcare concern and affects more than 1.6 million individuals each year worldwide. Long-term complications include recurrent VTE, chronic thromboembolic pulmonary hypertension and post-thrombotic syndrome. Rivaroxaban is an oral, direct factor Xa inhibitor that has advantages over traditional VTE therapies, including minimal drug and food interactions and no requirement for routine coagulation monitoring. It is currently approved for VTE prevention in adult patients undergoing elective hip or knee replacement surgery. This review evaluates the potential clinical implications of the multicentre, randomised EINSTEIN studies (EINSTEIN DVT and EINSTEIN EXT), which investigated rivaroxaban for the treatment and prevention of recurrent VTE. In EINSTEIN DVT, rivaroxaban was non-inferior to the standard of care (enoxaparin plus a vitamin K antagonist) for recurrent VTE in patients with acute deep-vein thrombosis (DVT) without pulmonary embolism (PE). In EINSTEIN EXT, extended-duration rivaroxaban had superior efficacy to placebo in patients with confirmed DVT or PE who had received 6–12 months of prior VTE treatment. Rivaroxaban was associated with an acceptable safety profile in both studies. The net clinical benefit (efficacy and safety end-points combined) of rivaroxaban was significantly greater than its comparators. The EINSTEIN studies are the first demonstration that a single drug - rivaroxaban - can be effective for both the initial treatment of DVT and prevention of recurrent VTE. Moreover, the simple, once-daily oral administration of rivaroxaban could potentially improve adherence to extended-duration VTE treatment compared with the current standard of care in individuals with confirmed DVT or PE.
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Granziera S, Cohen AT. VTE primary prevention, including hospitalised medical and orthopaedic surgical patients. Thromb Haemost 2017; 113:1216-23. [DOI: 10.1160/th14-10-0823] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 02/23/2015] [Indexed: 11/05/2022]
Abstract
summaryPrimary prevention is the key to managing a significant proportion of the burden of venous thromboembolism (VTE), defined as deep venous thrombosis (DVT) or pulmonary embolism (PE). This is because VTE may lead to sudden death or are often misdiagnosed and therefore treatment is not feasible. Primary prevention usually commences in hospital as VTE following hospitalisation adds to the significant disease burden worldwide. Numerous medical, surgical and other risk factors have been recognised and studied as indications for prophylaxis. The risk of VTE continues following admission to hospital with a medical or surgical condition, usually long after discharge and therefore prolonged primary prophylaxis is often recommended. Clinical and observational studies in surgical patients show this risk extends for months and perhaps more than one year, for medical patients the risk extends for at least several weeks. For the specific groups of patients at higher risk of developing VTE primary prevention, either pharmaceutical or mechanical, is recommended. The aim of this review is to describe the population at risk, the main related risk factors and the approach to thromboprophylaxis in different populations.
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Yang X, Zhang H, Kong F, Wang G, Gu Q, Zhao Z, Li T, Ren M, Li Z, Guo Y. Effect of Huisheng oral solution on coagulation function in perioperative period in patients with primary lung cancer. J Thorac Dis 2017; 9:1891-1902. [PMID: 28839987 PMCID: PMC5542976 DOI: 10.21037/jtd.2017.06.64] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 06/01/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND The incidence of venous thromboembolism (VTE) is about 4-10% in lung cancer patients. Huisheng oral solution (HSOS) has been previously demonstrated to inhibit carageenan induced acute thrombosis in rats, reduce the incidence of thrombosis in the lungs and mesentery of tumor-bearing mice and inhibit tumor cell metastasis. The purpose of this study was to assess the anticoagulant effect of HSOS in lung cancer patients in the perioperative period. METHODS This study was a multicenter, randomized, single-blind, blank-controlled clinical trial. A total of patients at five hospitals in Hebei Province, China were included. The patients were randomly divided into study group or control group according to random number table. The primary outcome was the blood test indices in both groups. The study group was given oral HSOS (20 mL, bid) from admission until 24 h before surgery. If no active bleeding was observed, the patients were given oral HSOS (20 mL, tid) from 24 h to 24 d postoperatively. The patients in the study group did not receive any other anticoagulation therapy during the study period and the control group only underwent surgery. The study protocol was approved by the local ethics committee of principal investigator hospital. Blood samples were taken at admission (before therapy), 24 h, 72 h, 10 d (before discharge) and 24 d (first visit after discharge) after surgery. Routine blood tests [red blood cell (RBC) count, white blood cell (WBC) count, hemoglobin (HGB), and platelet (PLT) count] and coagulation function test [prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), fibrinogen (FIB), and plasma D-dimer] were performed. The changes in outcome measures over time were analyzed by repeated measures analysis of variance to compare the differences between groups and between different time points and assess the impact of tumor stage and mode of surgery on them. All tests were two-tailed, and P values <0.05 were considered statistically significant. RESULTS The results differed between different tumor stage groups. In stage III-IV group, there was no significant difference in various indices between the study group and control group. In stage I-II group, there was significant difference in hemoglobin (P=0.004), platelet count (P=0.007), fibrinogen (P=0.046), and plasma D-dimer (24 d: P=0.032) between two groups. Fibrinogen reach the peak 72 h after surgery, and other indices reach the peak 7-10 d postoperatively and declined one month after surgery, and the decline tendency was different between two groups. In addition, no adverse drug reaction was observed in both the study group and control group. CONCLUSIONS HSOS (20 mL, tid) is of good safety profile and does not increase the risk of bleeding. With its unique characteristic of convenience for being taken, HSOS (20 mL, tid) could be a proper treatment for lung cancer patients in the perioperative period.
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Affiliation(s)
| | - Helin Zhang
- The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Fanyi Kong
- Cangzhou Central Hospital, Cangzhou 061001, China
| | - Guochen Wang
- North China University of Science and Technology Affiliated Hospital, Tangshan 063000, China
| | - Qianyu Gu
- Fourth Hospital of Hebei Medical University, Tumor Hospital of Hebei Province, Shijiazhuang 050000, China
| | - Zheng Zhao
- Handan Central Hospital, Handan 056001, China
| | - Tiezhi Li
- The Second Hospital of Hebei Medical University, Shijiazhuang 050000, China
| | - Mingming Ren
- Cangzhou Central Hospital, Cangzhou 061001, China
| | - Zuosheng Li
- North China University of Science and Technology Affiliated Hospital, Tangshan 063000, China
| | - Yang Guo
- Fourth Hospital of Hebei Medical University, Tumor Hospital of Hebei Province, Shijiazhuang 050000, China
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Extended-duration versus short-duration pharmacological thromboprophylaxis in acutely Ill hospitalized medical patients: a systematic review and meta-analysis of randomized controlled trials. J Thromb Thrombolysis 2016; 43:291-301. [DOI: 10.1007/s11239-016-1461-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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29
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Ye F, Bell LN, Mazza J, Lee A, Yale SH. Variation in Definitions of Immobility in Pharmacological Thromboprophylaxis Clinical Trials in Medical Inpatients: A Systematic Review. Clin Appl Thromb Hemost 2016; 24:13-21. [PMID: 28301904 DOI: 10.1177/1076029616677802] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Although immobility is a common risk factor for venous thromboembolism (VTE) in medical inpatients, lack of a consistent definition of this term may limit accurate assessment of VTE risk for thromboprophylaxis. OBJECTIVE To examine various definitions of immobility used in recent pharmacological thromboprophylaxis clinical trials. DATA SOURCES PubMed and relevant references from articles/reviews from 2008 to 2016 were searched. Randomized controlled trials (RCTs) and other clinical studies involving adult hospitalized medical patients in acute care hospital settings that used the term immobility were selected. Two investigators independently abstracted data in duplicate, and accuracy was checked by a third investigator. RESULTS Twenty-one clinical studies were included. There was heterogeneity among individual VTE risk factors, with respect to the definition of immobility in medical inpatients in these trials. Thirteen studies utilized objective criteria to define "immobility" including duration (12 studies) and distance or time walked (6 studies). In contrast, 7 studies focused principally on subjective definitions (ie, describing the nature of immobility rather than specifying its quantitative measurement). Three RCTs vaguely defined the level of patient's immobility after hospitalization. CONCLUSION Despite the well-known effectiveness of pharmacological thromboprophylaxis for the prevention of VTE in acutely ill medical patients, there is no current consensus on how to define immobility. The heterogeneous nature of definitions of immobility has led to uncertainty about the importance of immobility in VTE risk assessment models. Although clinical studies have incorporated varying definitions of immobility into their inclusion criteria, immobility as a specific VTE risk factor has not been clearly defined.
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Affiliation(s)
- Fan Ye
- 1 North Florida Regional Medical Center, UCF COM/HCA GME Consortium Internal Medicine, Gainesville, FL, USA
| | - Lauren N Bell
- 1 North Florida Regional Medical Center, UCF COM/HCA GME Consortium Internal Medicine, Gainesville, FL, USA
| | - Joseph Mazza
- 2 Marshfield Clinic Research Foundation, Marshfield, WI, USA
| | - Arthur Lee
- 3 North Florida Regional Medical Center, The Cardiac and Vascular Institute, Gainesville, FL, USA
| | - Steven H Yale
- 1 North Florida Regional Medical Center, UCF COM/HCA GME Consortium Internal Medicine, Gainesville, FL, USA
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Macbeth F, Noble S, Evans J, Ahmed S, Cohen D, Hood K, Knoyle D, Linnane S, Longo M, Moore B, Woll PJ, Appel W, Dickson J, Ferry D, Brammer C, Griffiths G. Randomized Phase III Trial of Standard Therapy Plus Low Molecular Weight Heparin in Patients With Lung Cancer: FRAGMATIC Trial. J Clin Oncol 2016; 34:488-94. [PMID: 26700124 DOI: 10.1200/jco.2015.64.0268] [Citation(s) in RCA: 128] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2024] Open
Abstract
PURPOSE Venous thromboembolism (VTE) is common in cancer patients. Evidence has suggested that low molecular weight heparin (LMWH) might improve survival in patients with cancer by preventing both VTE and the progression of metastases. No trial in a single cancer type has been powered to demonstrate a clinically significant survival difference. The aim of this trial was to investigate this question in patients with lung cancer. PATIENTS AND METHODS We conducted a multicenter, open-label, randomized trial to evaluate the addition of a primary prophylactic dose of LMWH for 24 weeks to standard treatment in patients with newly diagnosed lung cancer of any stage and histology. The primary outcome was 1-year survival. Secondary outcomes included metastasis-free survival, VTE-free survival, toxicity, and quality of life. RESULTS For this trial, 2,202 patients were randomly assigned to the two treatment arms over 4 years. The trial did not reach its intended number of events for the primary analysis (2,047 deaths), and data were analyzed after 2,013 deaths after discussion with the independent data monitoring committee. There was no evidence of a difference in overall or metastasis-free survival between the two arms (hazard ratio [HR], 1.01; 95% CI, 0.93 to 1.10; P = .814; and HR, 0.99; 95% CI, 0.91 to 1.08; P = .864, respectively). There was a reduction in the risk of VTE from 9.7% to 5.5% (HR, 0.57; 95% CI, 0.42 to 0.79; P = .001) in the LMWH arm and no difference in major bleeding events but evidence of an increase in the composite of major and clinically relevant nonmajor bleeding in the LMWH arm. CONCLUSION LMWH did not improve overall survival in the patients with lung cancer in this trial. A significant reduction in VTE is associated with an increase in clinically relevant nonmajor bleeding. Strategies to target those at greatest risk of VTE are warranted.
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Affiliation(s)
- Fergus Macbeth
- Fergus Macbeth, Jessica Evans, Sheikh Ahmed, and Gareth Griffiths, Wales Cancer Trials Unit; Simon Noble and Kerenza Hood, Cardiff University; David Cohen and Mirella Longo, University of South Wales; Barbara Moore, National Institute for Social Care and Health Research Clinical Research Centre, Cardiff; Gareth Griffiths, University of Southampton, Southampton; Dana Knoyle, Prince Charles Hospital, Merthyr Tydfil; Penella J. Woll, Weston Park Hospital, Sheffield; Wiebke Appel, Royal Preston Hospital, Preston; Jeanette Dickson, Mount Vernon Cancer Center, Northwood; David Ferry, Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Caroline Brammer, Mid Staffordshire Hospital, Stafford, United Kingdom; and Seamus Linnane, Beaumont Hospital, Dublin, Ireland.
| | - Simon Noble
- Fergus Macbeth, Jessica Evans, Sheikh Ahmed, and Gareth Griffiths, Wales Cancer Trials Unit; Simon Noble and Kerenza Hood, Cardiff University; David Cohen and Mirella Longo, University of South Wales; Barbara Moore, National Institute for Social Care and Health Research Clinical Research Centre, Cardiff; Gareth Griffiths, University of Southampton, Southampton; Dana Knoyle, Prince Charles Hospital, Merthyr Tydfil; Penella J. Woll, Weston Park Hospital, Sheffield; Wiebke Appel, Royal Preston Hospital, Preston; Jeanette Dickson, Mount Vernon Cancer Center, Northwood; David Ferry, Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Caroline Brammer, Mid Staffordshire Hospital, Stafford, United Kingdom; and Seamus Linnane, Beaumont Hospital, Dublin, Ireland
| | - Jessica Evans
- Fergus Macbeth, Jessica Evans, Sheikh Ahmed, and Gareth Griffiths, Wales Cancer Trials Unit; Simon Noble and Kerenza Hood, Cardiff University; David Cohen and Mirella Longo, University of South Wales; Barbara Moore, National Institute for Social Care and Health Research Clinical Research Centre, Cardiff; Gareth Griffiths, University of Southampton, Southampton; Dana Knoyle, Prince Charles Hospital, Merthyr Tydfil; Penella J. Woll, Weston Park Hospital, Sheffield; Wiebke Appel, Royal Preston Hospital, Preston; Jeanette Dickson, Mount Vernon Cancer Center, Northwood; David Ferry, Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Caroline Brammer, Mid Staffordshire Hospital, Stafford, United Kingdom; and Seamus Linnane, Beaumont Hospital, Dublin, Ireland
| | - Sheikh Ahmed
- Fergus Macbeth, Jessica Evans, Sheikh Ahmed, and Gareth Griffiths, Wales Cancer Trials Unit; Simon Noble and Kerenza Hood, Cardiff University; David Cohen and Mirella Longo, University of South Wales; Barbara Moore, National Institute for Social Care and Health Research Clinical Research Centre, Cardiff; Gareth Griffiths, University of Southampton, Southampton; Dana Knoyle, Prince Charles Hospital, Merthyr Tydfil; Penella J. Woll, Weston Park Hospital, Sheffield; Wiebke Appel, Royal Preston Hospital, Preston; Jeanette Dickson, Mount Vernon Cancer Center, Northwood; David Ferry, Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Caroline Brammer, Mid Staffordshire Hospital, Stafford, United Kingdom; and Seamus Linnane, Beaumont Hospital, Dublin, Ireland
| | - David Cohen
- Fergus Macbeth, Jessica Evans, Sheikh Ahmed, and Gareth Griffiths, Wales Cancer Trials Unit; Simon Noble and Kerenza Hood, Cardiff University; David Cohen and Mirella Longo, University of South Wales; Barbara Moore, National Institute for Social Care and Health Research Clinical Research Centre, Cardiff; Gareth Griffiths, University of Southampton, Southampton; Dana Knoyle, Prince Charles Hospital, Merthyr Tydfil; Penella J. Woll, Weston Park Hospital, Sheffield; Wiebke Appel, Royal Preston Hospital, Preston; Jeanette Dickson, Mount Vernon Cancer Center, Northwood; David Ferry, Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Caroline Brammer, Mid Staffordshire Hospital, Stafford, United Kingdom; and Seamus Linnane, Beaumont Hospital, Dublin, Ireland
| | - Kerenza Hood
- Fergus Macbeth, Jessica Evans, Sheikh Ahmed, and Gareth Griffiths, Wales Cancer Trials Unit; Simon Noble and Kerenza Hood, Cardiff University; David Cohen and Mirella Longo, University of South Wales; Barbara Moore, National Institute for Social Care and Health Research Clinical Research Centre, Cardiff; Gareth Griffiths, University of Southampton, Southampton; Dana Knoyle, Prince Charles Hospital, Merthyr Tydfil; Penella J. Woll, Weston Park Hospital, Sheffield; Wiebke Appel, Royal Preston Hospital, Preston; Jeanette Dickson, Mount Vernon Cancer Center, Northwood; David Ferry, Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Caroline Brammer, Mid Staffordshire Hospital, Stafford, United Kingdom; and Seamus Linnane, Beaumont Hospital, Dublin, Ireland
| | - Dana Knoyle
- Fergus Macbeth, Jessica Evans, Sheikh Ahmed, and Gareth Griffiths, Wales Cancer Trials Unit; Simon Noble and Kerenza Hood, Cardiff University; David Cohen and Mirella Longo, University of South Wales; Barbara Moore, National Institute for Social Care and Health Research Clinical Research Centre, Cardiff; Gareth Griffiths, University of Southampton, Southampton; Dana Knoyle, Prince Charles Hospital, Merthyr Tydfil; Penella J. Woll, Weston Park Hospital, Sheffield; Wiebke Appel, Royal Preston Hospital, Preston; Jeanette Dickson, Mount Vernon Cancer Center, Northwood; David Ferry, Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Caroline Brammer, Mid Staffordshire Hospital, Stafford, United Kingdom; and Seamus Linnane, Beaumont Hospital, Dublin, Ireland
| | - Seamus Linnane
- Fergus Macbeth, Jessica Evans, Sheikh Ahmed, and Gareth Griffiths, Wales Cancer Trials Unit; Simon Noble and Kerenza Hood, Cardiff University; David Cohen and Mirella Longo, University of South Wales; Barbara Moore, National Institute for Social Care and Health Research Clinical Research Centre, Cardiff; Gareth Griffiths, University of Southampton, Southampton; Dana Knoyle, Prince Charles Hospital, Merthyr Tydfil; Penella J. Woll, Weston Park Hospital, Sheffield; Wiebke Appel, Royal Preston Hospital, Preston; Jeanette Dickson, Mount Vernon Cancer Center, Northwood; David Ferry, Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Caroline Brammer, Mid Staffordshire Hospital, Stafford, United Kingdom; and Seamus Linnane, Beaumont Hospital, Dublin, Ireland
| | - Mirella Longo
- Fergus Macbeth, Jessica Evans, Sheikh Ahmed, and Gareth Griffiths, Wales Cancer Trials Unit; Simon Noble and Kerenza Hood, Cardiff University; David Cohen and Mirella Longo, University of South Wales; Barbara Moore, National Institute for Social Care and Health Research Clinical Research Centre, Cardiff; Gareth Griffiths, University of Southampton, Southampton; Dana Knoyle, Prince Charles Hospital, Merthyr Tydfil; Penella J. Woll, Weston Park Hospital, Sheffield; Wiebke Appel, Royal Preston Hospital, Preston; Jeanette Dickson, Mount Vernon Cancer Center, Northwood; David Ferry, Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Caroline Brammer, Mid Staffordshire Hospital, Stafford, United Kingdom; and Seamus Linnane, Beaumont Hospital, Dublin, Ireland
| | - Barbara Moore
- Fergus Macbeth, Jessica Evans, Sheikh Ahmed, and Gareth Griffiths, Wales Cancer Trials Unit; Simon Noble and Kerenza Hood, Cardiff University; David Cohen and Mirella Longo, University of South Wales; Barbara Moore, National Institute for Social Care and Health Research Clinical Research Centre, Cardiff; Gareth Griffiths, University of Southampton, Southampton; Dana Knoyle, Prince Charles Hospital, Merthyr Tydfil; Penella J. Woll, Weston Park Hospital, Sheffield; Wiebke Appel, Royal Preston Hospital, Preston; Jeanette Dickson, Mount Vernon Cancer Center, Northwood; David Ferry, Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Caroline Brammer, Mid Staffordshire Hospital, Stafford, United Kingdom; and Seamus Linnane, Beaumont Hospital, Dublin, Ireland
| | - Penella J Woll
- Fergus Macbeth, Jessica Evans, Sheikh Ahmed, and Gareth Griffiths, Wales Cancer Trials Unit; Simon Noble and Kerenza Hood, Cardiff University; David Cohen and Mirella Longo, University of South Wales; Barbara Moore, National Institute for Social Care and Health Research Clinical Research Centre, Cardiff; Gareth Griffiths, University of Southampton, Southampton; Dana Knoyle, Prince Charles Hospital, Merthyr Tydfil; Penella J. Woll, Weston Park Hospital, Sheffield; Wiebke Appel, Royal Preston Hospital, Preston; Jeanette Dickson, Mount Vernon Cancer Center, Northwood; David Ferry, Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Caroline Brammer, Mid Staffordshire Hospital, Stafford, United Kingdom; and Seamus Linnane, Beaumont Hospital, Dublin, Ireland
| | - Wiebke Appel
- Fergus Macbeth, Jessica Evans, Sheikh Ahmed, and Gareth Griffiths, Wales Cancer Trials Unit; Simon Noble and Kerenza Hood, Cardiff University; David Cohen and Mirella Longo, University of South Wales; Barbara Moore, National Institute for Social Care and Health Research Clinical Research Centre, Cardiff; Gareth Griffiths, University of Southampton, Southampton; Dana Knoyle, Prince Charles Hospital, Merthyr Tydfil; Penella J. Woll, Weston Park Hospital, Sheffield; Wiebke Appel, Royal Preston Hospital, Preston; Jeanette Dickson, Mount Vernon Cancer Center, Northwood; David Ferry, Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Caroline Brammer, Mid Staffordshire Hospital, Stafford, United Kingdom; and Seamus Linnane, Beaumont Hospital, Dublin, Ireland
| | - Jeanette Dickson
- Fergus Macbeth, Jessica Evans, Sheikh Ahmed, and Gareth Griffiths, Wales Cancer Trials Unit; Simon Noble and Kerenza Hood, Cardiff University; David Cohen and Mirella Longo, University of South Wales; Barbara Moore, National Institute for Social Care and Health Research Clinical Research Centre, Cardiff; Gareth Griffiths, University of Southampton, Southampton; Dana Knoyle, Prince Charles Hospital, Merthyr Tydfil; Penella J. Woll, Weston Park Hospital, Sheffield; Wiebke Appel, Royal Preston Hospital, Preston; Jeanette Dickson, Mount Vernon Cancer Center, Northwood; David Ferry, Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Caroline Brammer, Mid Staffordshire Hospital, Stafford, United Kingdom; and Seamus Linnane, Beaumont Hospital, Dublin, Ireland
| | - David Ferry
- Fergus Macbeth, Jessica Evans, Sheikh Ahmed, and Gareth Griffiths, Wales Cancer Trials Unit; Simon Noble and Kerenza Hood, Cardiff University; David Cohen and Mirella Longo, University of South Wales; Barbara Moore, National Institute for Social Care and Health Research Clinical Research Centre, Cardiff; Gareth Griffiths, University of Southampton, Southampton; Dana Knoyle, Prince Charles Hospital, Merthyr Tydfil; Penella J. Woll, Weston Park Hospital, Sheffield; Wiebke Appel, Royal Preston Hospital, Preston; Jeanette Dickson, Mount Vernon Cancer Center, Northwood; David Ferry, Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Caroline Brammer, Mid Staffordshire Hospital, Stafford, United Kingdom; and Seamus Linnane, Beaumont Hospital, Dublin, Ireland
| | - Caroline Brammer
- Fergus Macbeth, Jessica Evans, Sheikh Ahmed, and Gareth Griffiths, Wales Cancer Trials Unit; Simon Noble and Kerenza Hood, Cardiff University; David Cohen and Mirella Longo, University of South Wales; Barbara Moore, National Institute for Social Care and Health Research Clinical Research Centre, Cardiff; Gareth Griffiths, University of Southampton, Southampton; Dana Knoyle, Prince Charles Hospital, Merthyr Tydfil; Penella J. Woll, Weston Park Hospital, Sheffield; Wiebke Appel, Royal Preston Hospital, Preston; Jeanette Dickson, Mount Vernon Cancer Center, Northwood; David Ferry, Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Caroline Brammer, Mid Staffordshire Hospital, Stafford, United Kingdom; and Seamus Linnane, Beaumont Hospital, Dublin, Ireland
| | - Gareth Griffiths
- Fergus Macbeth, Jessica Evans, Sheikh Ahmed, and Gareth Griffiths, Wales Cancer Trials Unit; Simon Noble and Kerenza Hood, Cardiff University; David Cohen and Mirella Longo, University of South Wales; Barbara Moore, National Institute for Social Care and Health Research Clinical Research Centre, Cardiff; Gareth Griffiths, University of Southampton, Southampton; Dana Knoyle, Prince Charles Hospital, Merthyr Tydfil; Penella J. Woll, Weston Park Hospital, Sheffield; Wiebke Appel, Royal Preston Hospital, Preston; Jeanette Dickson, Mount Vernon Cancer Center, Northwood; David Ferry, Royal Wolverhampton Hospitals National Health Service Trust, Wolverhampton; Caroline Brammer, Mid Staffordshire Hospital, Stafford, United Kingdom; and Seamus Linnane, Beaumont Hospital, Dublin, Ireland
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Focus on direct oral anticoagulants (DOAC) for prophylaxis of venous thrombosis and pulmonary embolism in medically ill patients. Int J Cardiol 2016; 203:454-6. [DOI: 10.1016/j.ijcard.2015.10.204] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2015] [Accepted: 10/25/2015] [Indexed: 11/20/2022]
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Ravikumar R, Lim CS, Davies AH. The Role of New Oral Anticoagulants (NOACs) in Cancer Patients. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 906:137-148. [PMID: 27620312 DOI: 10.1007/5584_2016_112] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
New oral anticoagulants (NOACs) are likely to have a major impact in the next few years, changing clinical practice of anticoagulation therapy. Evidence on its efficacy and superiority to vitamin K antagonists (VKAs) in treating non-cancer patients have been reported in a few clinical trials. However, patients with cancer are complicated by the prothrombotic nature of the disease, need for potentially invasive surgery and interventions, and altered drug handling. This chapter examines the available evidence and guidelines on the use of NOAC in patients with cancer.
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Affiliation(s)
- Raveena Ravikumar
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, Room 4N13C, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK.
| | - Chung Sim Lim
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Alun Huw Davies
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College London, London, UK
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Ramacciotti E, Hoppensteadt D, Fareed J. Betrixaban for VTE Prevention in the Medically Ill Population, the APEX Trial: Good News for This Needy Population? Clin Appl Thromb Hemost 2016; 23:701-702. [PMID: 28294628 DOI: 10.1177/1076029616683805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Eduardo Ramacciotti
- 1 Hospital e Maternidade Dr Christóvão da Gama, Santo André, SP, Brazil.,2 Department of Pathology, Loyola University Chicago, Maywood, IL, USA
| | | | - Jawed Fareed
- 2 Department of Pathology, Loyola University Chicago, Maywood, IL, USA
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Cohen AL, Lim CS, Davies AH. Is there a role yet for new direct oral anticoagulants in cancer patients? Phlebology 2015; 31:157-9. [DOI: 10.1177/0268355515604255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- Abigail L Cohen
- Academic Section of Vascular Surgery, Division of Surgery, Department of Surgery & Cancer, Imperial College London, Charing Cross Hospital, London, UK
| | - Chung S Lim
- Academic Section of Vascular Surgery, Division of Surgery, Department of Surgery & Cancer, Imperial College London, Charing Cross Hospital, London, UK
| | - Alun H Davies
- Academic Section of Vascular Surgery, Division of Surgery, Department of Surgery & Cancer, Imperial College London, Charing Cross Hospital, London, UK
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Mont L, Marín F, Dalmau FGB, Martínez MS, Cullere JG. Clinical development of rivaroxaban: emerging new clinical evidences? Future Cardiol 2015; 11:565-83. [PMID: 26111102 DOI: 10.2217/fca.15.31] [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: 11/21/2022] Open
Abstract
Rivaroxaban has proven efficacious in a variety of conditions. In fact, rivaroxaban has been approved for the prevention of venous thromboembolism after elective hip or knee replacement surgery, for the prevention and treatment of deep vein thrombosis and pulmonary embolism, for the prevention of stroke in patients with nonvalvular atrial fibrillation and for the prevention of atherothrombotic events after acute coronary syndrome with elevated cardiac biomarkers. However, clinical development of rivaroxaban is ongoing. Considering published and on-going randomized clinical trials, noninterventional studies and registries, over 275,000 patients are being analyzed. The aim of this review was to update the clinical development of rivaroxaban, including completed and ongoing studies not only randomized clinical trials, but also clinical practice studies.
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Affiliation(s)
- Luís Mont
- Arrhythmia Section, Institut del Torax, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto de Investigación Biosanitaria Virgen de la Arrixaca, IMIB-Arrixaca, Murcia, Spain
| | | | - Marianela Sánchez Martínez
- Cardiovascular Critical Unit, Department of Cardiology. Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Jaime Gallego Cullere
- Neurology Department and Stroke Unit, Complejo Hospitalario de Navarra, Pamplona, Spain
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Yeh CH, Hogg K, Weitz JI. Overview of the new oral anticoagulants: opportunities and challenges. Arterioscler Thromb Vasc Biol 2015; 35:1056-65. [PMID: 25792448 DOI: 10.1161/atvbaha.115.303397] [Citation(s) in RCA: 124] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 03/05/2015] [Indexed: 01/17/2023]
Abstract
The non-vitamin K antagonist oral anticoagulants (NOACs) are replacing warfarin for many indications. These agents include dabigatran, which inhibits thrombin, and rivaroxaban, apixaban, and edoxaban, which inhibit factor Xa. All 4 agents are licensed in the United States for stroke prevention in atrial fibrillation and for treatment of venous thromboembolism and rivaroxaban and apixaban are approved for thromboprophylaxis after elective hip or knee arthroplasty. The NOACs are at least as effective as warfarin, but are not only more convenient to administer because they can be given in fixed doses without routine coagulation monitoring but also are safer because they are associated with less intracranial bleeding. As part of a theme series on the NOACs, this article (1) compares the pharmacological profiles of the NOACs with that of warfarin, (2) identifies the doses of the NOACs for each approved indication, (3) provides an overview of the completed phase III trials with the NOACs, (4) briefly discusses the ongoing studies with the NOACs for new indications, (5) reviews the emerging real-world data with the NOACs, and (6) highlights the potential opportunities for the NOACs and identifies the remaining challenges.
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Affiliation(s)
- Calvin H Yeh
- From the Thrombosis and Atherosclerosis Research Institute and Departments of Medicine and of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Kerstin Hogg
- From the Thrombosis and Atherosclerosis Research Institute and Departments of Medicine and of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- From the Thrombosis and Atherosclerosis Research Institute and Departments of Medicine and of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada.
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Arcelus JI, Domènech P, Fernández-Capitan MDC, Guijarro R, Jiménez D, Jiménez S, Lozano FS, Monreal M, Nieto JA, Páramo JA. Rivaroxaban in the Treatment of Venous Thromboembolism and the Prevention of Recurrences. Clin Appl Thromb Hemost 2014; 21:297-308. [DOI: 10.1177/1076029614561321] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Anticoagulation therapy is the standard treatment of patients with symptomatic venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism. Until recently, treatment of VTE was based on parenteral or low-molecular-weight heparin for initial therapy (5-10 days) and oral vitamin K antagonists for long-term therapy. Those treatments have some limitations, including parenteral administration (heparins), the need for frequent monitoring and dose adjustments, interactions with several medications, and dietary restrictions (vitamin K antagonists). Rivaroxaban is a new oral direct factor Xa inhibitor with a wide therapeutic window, predictable anticoagulant effect, no food interactions, and few drug interactions. Consequently, no periodic monitoring of anticoagulation is needed, and fixed doses can be prescribed. EINSTEIN program demonstrated that rivaroxaban was as effective as and significantly safer than standard therapy for treatment of VTE. Rivaroxaban was recently authorized so doubts exist about how to use it in daily clinical practice. This document aims to clarify common questions formulated by clinicians regarding the use of this new drug.
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Affiliation(s)
- Juan I. Arcelus
- Department of Surgery, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | - Pere Domènech
- Haemostasis and Thrombosis Department. Bellvitge's University Hospital. Hospitalet de Llobregat, Barcelona, Spain
| | | | - Ricardo Guijarro
- Internal Medicine Department, Regional University Hospital of Malaga (Carlos Haya Hospital), Málaga, Spain
| | - David Jiménez
- Respiratory Department, Ramon y Cajal Hospital, Alcala de Henares University, Madrid, Spain
| | - Sonia Jiménez
- Emergency Department, Hospital Clínic and IDIBAPS, Barcelona, Spain
| | | | - Manel Monreal
- Internal Medicine Department, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - José A. Nieto
- Internal Medicine Service, Hospital Virgen de la Luz, Cuenca, Spain
| | - José A. Páramo
- Hematology Service, Clínica Universidad de Navarra, Pamplona, Spain
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Al-Hilal TA, Alam F, Park JW, Kim K, Kwon IC, Ryu GH, Byun Y. Prevention effect of orally active heparin conjugate on cancer-associated thrombosis. J Control Release 2014; 195:155-61. [DOI: 10.1016/j.jconrel.2014.05.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2014] [Revised: 05/08/2014] [Accepted: 05/16/2014] [Indexed: 12/11/2022]
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Mebazaa A, Spiro TE, Büller HR, Haskell L, Hu D, Hull R, Merli G, Schellong SW, Spyropoulos AC, Tapson VF, De Sanctis Y, Cohen AT. Predicting the risk of venous thromboembolism in patients hospitalized with heart failure. Circulation 2014; 130:410-8. [PMID: 24970782 DOI: 10.1161/circulationaha.113.003126] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Whether heart failure (HF) increases the risk of venous thromboembolism (VTE) is not well established. In the phase III MAGELLAN (Multicenter, rAndomized, parallel Group Efficacy and safety study for the prevention of venous thromboembolism in hospitalized medically iLL patients comparing rivaroxabAN with enoxaparin) trial, extended-duration rivaroxaban was compared with standard-duration enoxaparin followed by placebo for VTE prevention in 8101 hospitalized acutely ill patients with or without HF. The aim of this analysis was to evaluate the relationship between HF severity and the risk of VTE in MAGELLAN patients. METHODS AND RESULTS Hospitalized patients diagnosed with HF were included according to New York Heart Association class III or IV at admission (n=2593). HF severity was determined by N-terminal probrain natriuretic peptide (NT-proBNP) plasma concentrations (median 1904 pg/mL). Baseline plasma D-dimer concentrations ranged from 0.6 to 1.7 μg/L for the less and more severe HF subgroups. Patients with more severe HF had a greater incidence of VTE versus patients with less severe HF, with a significant trend up to Day 10 (4.3% versus 2.2%; P=0.0108) and Day 35 (7.2% versus 4.1%; P=0.0150). Multivariable analysis confirmed that NT-proBNP concentration was associated with VTE risk up to Day 10 (P=0.017) and D-dimer concentration with VTE risk up to Day 35 (P=0.005). The association between VTE risk and HF severity that was observed in the enoxaparin/placebo group was not seen in the extended-duration rivaroxaban group. CONCLUSIONS Patients with more severe HF, as defined by high NT-proBNP plasma concentration, were at increased risk of VTE. NT-proBNP may be useful to identify high short-term risk, whereas elevated D-dimer may be suggestive of high midterm risk. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00571649.
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Affiliation(s)
- Alexandre Mebazaa
- From Université Paris Diderot, PRES Sorbonne Paris Cité and Department of Anesthesiology and Critical Care Medicine, Saint Louis Lariboisière University Hospitals, U942 Inserm, Paris, France (A.M.); Bayer HealthCare Pharmaceuticals Inc, Montville, NJ (T.E.S., Y.D.S.); Academic Medical Center, Amsterdam, The Netherlands (H.R.B.); Janssen Research & Development LLC, Raritan, NJ (L.H.); People's Hospital of Peking University, Beijing, China (D.H.); Foothills Hospital, Calgary, Alberta, Canada (R.H.); Thomas Jefferson Medical Center, Philadelphia, PA (G.M.); Dresden-Friedrichstadt Hospital, Dresden, Germany (S.W.S.); Hofstra North Shore-LIJ School of Medicine, Manhasset, NY (A.C.S.); Duke University Medical Center, Durham, NC (V.F.T.); and King's College Hospital, London, UK (A.T.C.).
| | - Theodore E Spiro
- From Université Paris Diderot, PRES Sorbonne Paris Cité and Department of Anesthesiology and Critical Care Medicine, Saint Louis Lariboisière University Hospitals, U942 Inserm, Paris, France (A.M.); Bayer HealthCare Pharmaceuticals Inc, Montville, NJ (T.E.S., Y.D.S.); Academic Medical Center, Amsterdam, The Netherlands (H.R.B.); Janssen Research & Development LLC, Raritan, NJ (L.H.); People's Hospital of Peking University, Beijing, China (D.H.); Foothills Hospital, Calgary, Alberta, Canada (R.H.); Thomas Jefferson Medical Center, Philadelphia, PA (G.M.); Dresden-Friedrichstadt Hospital, Dresden, Germany (S.W.S.); Hofstra North Shore-LIJ School of Medicine, Manhasset, NY (A.C.S.); Duke University Medical Center, Durham, NC (V.F.T.); and King's College Hospital, London, UK (A.T.C.)
| | - Harry R Büller
- From Université Paris Diderot, PRES Sorbonne Paris Cité and Department of Anesthesiology and Critical Care Medicine, Saint Louis Lariboisière University Hospitals, U942 Inserm, Paris, France (A.M.); Bayer HealthCare Pharmaceuticals Inc, Montville, NJ (T.E.S., Y.D.S.); Academic Medical Center, Amsterdam, The Netherlands (H.R.B.); Janssen Research & Development LLC, Raritan, NJ (L.H.); People's Hospital of Peking University, Beijing, China (D.H.); Foothills Hospital, Calgary, Alberta, Canada (R.H.); Thomas Jefferson Medical Center, Philadelphia, PA (G.M.); Dresden-Friedrichstadt Hospital, Dresden, Germany (S.W.S.); Hofstra North Shore-LIJ School of Medicine, Manhasset, NY (A.C.S.); Duke University Medical Center, Durham, NC (V.F.T.); and King's College Hospital, London, UK (A.T.C.)
| | - Lloyd Haskell
- From Université Paris Diderot, PRES Sorbonne Paris Cité and Department of Anesthesiology and Critical Care Medicine, Saint Louis Lariboisière University Hospitals, U942 Inserm, Paris, France (A.M.); Bayer HealthCare Pharmaceuticals Inc, Montville, NJ (T.E.S., Y.D.S.); Academic Medical Center, Amsterdam, The Netherlands (H.R.B.); Janssen Research & Development LLC, Raritan, NJ (L.H.); People's Hospital of Peking University, Beijing, China (D.H.); Foothills Hospital, Calgary, Alberta, Canada (R.H.); Thomas Jefferson Medical Center, Philadelphia, PA (G.M.); Dresden-Friedrichstadt Hospital, Dresden, Germany (S.W.S.); Hofstra North Shore-LIJ School of Medicine, Manhasset, NY (A.C.S.); Duke University Medical Center, Durham, NC (V.F.T.); and King's College Hospital, London, UK (A.T.C.)
| | - Dayi Hu
- From Université Paris Diderot, PRES Sorbonne Paris Cité and Department of Anesthesiology and Critical Care Medicine, Saint Louis Lariboisière University Hospitals, U942 Inserm, Paris, France (A.M.); Bayer HealthCare Pharmaceuticals Inc, Montville, NJ (T.E.S., Y.D.S.); Academic Medical Center, Amsterdam, The Netherlands (H.R.B.); Janssen Research & Development LLC, Raritan, NJ (L.H.); People's Hospital of Peking University, Beijing, China (D.H.); Foothills Hospital, Calgary, Alberta, Canada (R.H.); Thomas Jefferson Medical Center, Philadelphia, PA (G.M.); Dresden-Friedrichstadt Hospital, Dresden, Germany (S.W.S.); Hofstra North Shore-LIJ School of Medicine, Manhasset, NY (A.C.S.); Duke University Medical Center, Durham, NC (V.F.T.); and King's College Hospital, London, UK (A.T.C.)
| | - Russell Hull
- From Université Paris Diderot, PRES Sorbonne Paris Cité and Department of Anesthesiology and Critical Care Medicine, Saint Louis Lariboisière University Hospitals, U942 Inserm, Paris, France (A.M.); Bayer HealthCare Pharmaceuticals Inc, Montville, NJ (T.E.S., Y.D.S.); Academic Medical Center, Amsterdam, The Netherlands (H.R.B.); Janssen Research & Development LLC, Raritan, NJ (L.H.); People's Hospital of Peking University, Beijing, China (D.H.); Foothills Hospital, Calgary, Alberta, Canada (R.H.); Thomas Jefferson Medical Center, Philadelphia, PA (G.M.); Dresden-Friedrichstadt Hospital, Dresden, Germany (S.W.S.); Hofstra North Shore-LIJ School of Medicine, Manhasset, NY (A.C.S.); Duke University Medical Center, Durham, NC (V.F.T.); and King's College Hospital, London, UK (A.T.C.)
| | - Geno Merli
- From Université Paris Diderot, PRES Sorbonne Paris Cité and Department of Anesthesiology and Critical Care Medicine, Saint Louis Lariboisière University Hospitals, U942 Inserm, Paris, France (A.M.); Bayer HealthCare Pharmaceuticals Inc, Montville, NJ (T.E.S., Y.D.S.); Academic Medical Center, Amsterdam, The Netherlands (H.R.B.); Janssen Research & Development LLC, Raritan, NJ (L.H.); People's Hospital of Peking University, Beijing, China (D.H.); Foothills Hospital, Calgary, Alberta, Canada (R.H.); Thomas Jefferson Medical Center, Philadelphia, PA (G.M.); Dresden-Friedrichstadt Hospital, Dresden, Germany (S.W.S.); Hofstra North Shore-LIJ School of Medicine, Manhasset, NY (A.C.S.); Duke University Medical Center, Durham, NC (V.F.T.); and King's College Hospital, London, UK (A.T.C.)
| | - Sebastian W Schellong
- From Université Paris Diderot, PRES Sorbonne Paris Cité and Department of Anesthesiology and Critical Care Medicine, Saint Louis Lariboisière University Hospitals, U942 Inserm, Paris, France (A.M.); Bayer HealthCare Pharmaceuticals Inc, Montville, NJ (T.E.S., Y.D.S.); Academic Medical Center, Amsterdam, The Netherlands (H.R.B.); Janssen Research & Development LLC, Raritan, NJ (L.H.); People's Hospital of Peking University, Beijing, China (D.H.); Foothills Hospital, Calgary, Alberta, Canada (R.H.); Thomas Jefferson Medical Center, Philadelphia, PA (G.M.); Dresden-Friedrichstadt Hospital, Dresden, Germany (S.W.S.); Hofstra North Shore-LIJ School of Medicine, Manhasset, NY (A.C.S.); Duke University Medical Center, Durham, NC (V.F.T.); and King's College Hospital, London, UK (A.T.C.)
| | - Alex C Spyropoulos
- From Université Paris Diderot, PRES Sorbonne Paris Cité and Department of Anesthesiology and Critical Care Medicine, Saint Louis Lariboisière University Hospitals, U942 Inserm, Paris, France (A.M.); Bayer HealthCare Pharmaceuticals Inc, Montville, NJ (T.E.S., Y.D.S.); Academic Medical Center, Amsterdam, The Netherlands (H.R.B.); Janssen Research & Development LLC, Raritan, NJ (L.H.); People's Hospital of Peking University, Beijing, China (D.H.); Foothills Hospital, Calgary, Alberta, Canada (R.H.); Thomas Jefferson Medical Center, Philadelphia, PA (G.M.); Dresden-Friedrichstadt Hospital, Dresden, Germany (S.W.S.); Hofstra North Shore-LIJ School of Medicine, Manhasset, NY (A.C.S.); Duke University Medical Center, Durham, NC (V.F.T.); and King's College Hospital, London, UK (A.T.C.)
| | - Victor F Tapson
- From Université Paris Diderot, PRES Sorbonne Paris Cité and Department of Anesthesiology and Critical Care Medicine, Saint Louis Lariboisière University Hospitals, U942 Inserm, Paris, France (A.M.); Bayer HealthCare Pharmaceuticals Inc, Montville, NJ (T.E.S., Y.D.S.); Academic Medical Center, Amsterdam, The Netherlands (H.R.B.); Janssen Research & Development LLC, Raritan, NJ (L.H.); People's Hospital of Peking University, Beijing, China (D.H.); Foothills Hospital, Calgary, Alberta, Canada (R.H.); Thomas Jefferson Medical Center, Philadelphia, PA (G.M.); Dresden-Friedrichstadt Hospital, Dresden, Germany (S.W.S.); Hofstra North Shore-LIJ School of Medicine, Manhasset, NY (A.C.S.); Duke University Medical Center, Durham, NC (V.F.T.); and King's College Hospital, London, UK (A.T.C.)
| | - Yoriko De Sanctis
- From Université Paris Diderot, PRES Sorbonne Paris Cité and Department of Anesthesiology and Critical Care Medicine, Saint Louis Lariboisière University Hospitals, U942 Inserm, Paris, France (A.M.); Bayer HealthCare Pharmaceuticals Inc, Montville, NJ (T.E.S., Y.D.S.); Academic Medical Center, Amsterdam, The Netherlands (H.R.B.); Janssen Research & Development LLC, Raritan, NJ (L.H.); People's Hospital of Peking University, Beijing, China (D.H.); Foothills Hospital, Calgary, Alberta, Canada (R.H.); Thomas Jefferson Medical Center, Philadelphia, PA (G.M.); Dresden-Friedrichstadt Hospital, Dresden, Germany (S.W.S.); Hofstra North Shore-LIJ School of Medicine, Manhasset, NY (A.C.S.); Duke University Medical Center, Durham, NC (V.F.T.); and King's College Hospital, London, UK (A.T.C.)
| | - Alexander T Cohen
- From Université Paris Diderot, PRES Sorbonne Paris Cité and Department of Anesthesiology and Critical Care Medicine, Saint Louis Lariboisière University Hospitals, U942 Inserm, Paris, France (A.M.); Bayer HealthCare Pharmaceuticals Inc, Montville, NJ (T.E.S., Y.D.S.); Academic Medical Center, Amsterdam, The Netherlands (H.R.B.); Janssen Research & Development LLC, Raritan, NJ (L.H.); People's Hospital of Peking University, Beijing, China (D.H.); Foothills Hospital, Calgary, Alberta, Canada (R.H.); Thomas Jefferson Medical Center, Philadelphia, PA (G.M.); Dresden-Friedrichstadt Hospital, Dresden, Germany (S.W.S.); Hofstra North Shore-LIJ School of Medicine, Manhasset, NY (A.C.S.); Duke University Medical Center, Durham, NC (V.F.T.); and King's College Hospital, London, UK (A.T.C.)
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Cohen AT, Spiro TE, Spyropoulos AC, Desanctis YH, Homering M, Büller HR, Haskell L, Hu D, Hull R, Mebazaa A, Merli G, Schellong S, Tapson VF, Burton P. D-dimer as a predictor of venous thromboembolism in acutely ill, hospitalized patients: a subanalysis of the randomized controlled MAGELLAN trial. J Thromb Haemost 2014; 12:479-87. [PMID: 24460645 DOI: 10.1111/jth.12515] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 01/08/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND D-dimer concentrations have not been evaluated extensively as a predictor of increased venous thromboembolism (VTE) risk in acutely ill, hospitalized medical patients. OBJECTIVES To analyze the relationships between D-dimer concentration, VTE and bleeding in the MAGELLAN trial (NCT00571649). PATIENTS/METHODS This was a multicenter, randomized, controlled trial. Patients aged ≥ 40 years, hospitalized for acute medical illnesses with risk factors for VTE received subcutaneous enoxaparin 40 mg once daily for 10 ± 4 days then placebo up to day 35, or oral rivaroxaban 10 mg once daily for 35 ± 4 days. Patients (n = 7581) were grouped by baseline D-dimer ≤ 2 × or > 2 × the upper limit of normal. VTE and major plus non-major clinically relevant bleeding were recorded at day 10, day 35, and between days 11 and 35. RESULTS The frequency of VTE was 3.5-fold greater in patients with high D-dimer concentrations. Multivariate analysis showed that D-dimer was an independent predictor of the risk of VTE (odds ratio 2.29 [95% confidence interval 1.75-2.98]), and had a similar association to established risk factors for VTE, for example cancer and advanced age. In the high D-dimer group, rivaroxaban was non-inferior to enoxaparin at day 10 and, unlike the low D-dimer group, superior to placebo at day 35 (P < 0.001) and days 11-35 (P < 0.001). In both groups, bleeding outcomes favored enoxaparin/placebo. CONCLUSIONS Elevated baseline D-dimer concentrations may identify acutely ill, hospitalized medical patients at high risk of VTE for whom extended anticoagulant prophylaxis may provide greater benefit than for those with low D-dimer concentrations.
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Engbers MJ, Blom JW, Cushman M, Rosendaal FR, van Hylckama Vlieg A. The contribution of immobility risk factors to the incidence of venous thrombosis in an older population. J Thromb Haemost 2014; 12:290-6. [PMID: 24330554 DOI: 10.1111/jth.12480] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 11/25/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Venous thrombosis is common in the older population. Assessment of risk factors is necessary to implement preventive measures. OBJECTIVES We studied the associations between immobility-related risk factors and thrombosis, specifically, hospitalization, surgery, fractures, plaster cast use, minor injuries, and transient immobility at home, in an older population. PATIENTS AND METHODS Analyses were performed in the Age and Thrombosis, Acquired and Genetic risk factors in the Elderly (AT-AGE) study, a two-center population-based case-control study. Consecutive cases aged > 70 years with a first-time thrombosis (n = 401) and control subjects > 70 years old without a history of thrombosis (n = 431) were included. Exclusion criteria were active malignancy and severe cognitive disorders. We calculated odds ratios (OR) with 95% confidence intervals (95% CI) after adjustment for age, sex, body mass index, study center, and population-attributable risks. RESULTS There was a 15-fold (OR 14.8, 95% CI 4.4-50.4) increased risk of thrombosis within 2 weeks after hospital discharge. Surgery (OR 6.6, 95% CI 3.7-11.6), fractures (OR 12.7, 95% CI 3.7-43.7), plaster cast (OR 6.2, 95% CI 2.0-18.9), minor leg injuries (OR 1.9, 95% CI 1.1-3.3), and transient immobility at home (OR 5.0, 95% CI 2.3-11.2) were all associated with thrombosis risk over 3 months. The population-attributable risks for in-hospital immobility was 27%, and for out-of-hospital immobility, 15%. CONCLUSIONS In those > 70 years of age, in-hospital and out-of hospital immobility are strong risk factors for thrombosis. Additional studies on preventive measures during immobilization in this age group should not focus solely on hospital settings.
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Affiliation(s)
- M J Engbers
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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Cove CL, Hylek EM. An updated review of target-specific oral anticoagulants used in stroke prevention in atrial fibrillation, venous thromboembolic disease, and acute coronary syndromes. J Am Heart Assoc 2013; 2:e000136. [PMID: 24152980 PMCID: PMC3835217 DOI: 10.1161/jaha.113.000136] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Christina L Cove
- Department of Cardiovascular Medicine, Boston University School of Medicine, Boston, MA
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Zannad F, Stough WG, Regnault V, Gheorghiade M, Deliargyris E, Gibson CM, Agewall S, Berkowitz SD, Burton P, Calvo G, Goldstein S, Verheugt FW, Koglin J, O'Connor CM. Is thrombosis a contributor to heart failure pathophysiology? Possible mechanisms, therapeutic opportunities, and clinical investigation challenges. Int J Cardiol 2013; 167:1772-82. [DOI: 10.1016/j.ijcard.2012.12.018] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2012] [Accepted: 12/06/2012] [Indexed: 12/21/2022]
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Palladino M, Merli G, Thomson L. Evaluation of the oral direct factor Xa inhibitor – betrixaban. Expert Opin Investig Drugs 2013; 22:1465-72. [DOI: 10.1517/13543784.2013.825605] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Cohen AAT, Rider T. NOACs for thromboprophylaxis in medical patients. Best Pract Res Clin Haematol 2013; 26:183-90. [PMID: 23953906 DOI: 10.1016/j.beha.2013.07.002] [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: 10/26/2022]
Abstract
The risk of venous thrombosis extends for an indeterminate length of time following admission to hospital with a medical or surgical condition. Observational studies in surgery show this risk extends for months and perhaps more than one year, for medical patients the risk extends for at least several weeks. Large bodies of evidence support the heightened risk status of hospitalised surgical and medical patients, and that prophylactic measures significantly reduce the risk of thrombosis. Extending thromboprophylaxis for 4-6 weeks with anticoagulants both old and new has been shown to be efficacious and safe in surgical patients. However in populations of medical patients although prolonged anticoagulant thromboprophylaxis has been shown to be efficacious it also results in more bleeding and the risk benefit is not clear. Hence no therapies are approved for prolonged thromboprophylaxis in medical patients. In this area there have been one phase III study of low molecular weight heparin and two completed phase III studies of NOACs. This article briefly summarises our understanding of the background to preventing venous thromboembolism in hospitalised medical patients and reviews the details of the studies using NOACs.
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The direct factor Xa inhibitor Rivaroxaban reduces platelet activation in congestive heart failure. Pharmacol Res 2013; 74:49-55. [DOI: 10.1016/j.phrs.2013.05.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 05/03/2013] [Accepted: 05/16/2013] [Indexed: 11/22/2022]
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Mohammed I, Syed W, Kowey PR. Oral anticoagulants to reduce the risk of stroke in atrial fibrillation: how should a clinician choose? Clin Cardiol 2013; 36:663-70. [PMID: 23893881 DOI: 10.1002/clc.22173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 06/20/2013] [Indexed: 11/09/2022] Open
Abstract
Atrial fibrillation (AF), a common arrhythmia that occurs with increasing frequency in the aging population, is associated with increased mortality and morbidity. To ensure that patients receive adequate anticoagulant prophylaxis, clinical guidelines for anticoagulation advocate use of validated scoring systems to stratify patients by cardiovascular risk and predict the individual patient's risk of adverse effects of therapy. Recently approved oral anticoagulants-a direct thrombin inhibitor and the factor Xa inhibitors-may offer advantages over the 50-year standard, warfarin, for efficacy, safety, and ease of administration. Clinical trial experience with the newly approved agents and others, yet to be approved, will define their relative value in reducing the risk of thromboembolism associated with AF. This article discusses issues that may help clinicians choose among these newer agents and individualize treatment appropriately.
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Affiliation(s)
- Ilyas Mohammed
- Department of Cardiology (Mohammed), Lankenau Medical Center and Institute for Medical Research, Wynnewood, Pennsylvania
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Innasimuthu AL, Kumar S, Akter S, Borer JS. New oral anticoagulants: great promise for therapeutic advance but great knowledge gaps remain to be filled. Cardiology 2013; 126:41-9. [PMID: 23860301 DOI: 10.1159/000353484] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Accepted: 06/06/2013] [Indexed: 01/22/2023]
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Thomas TF, Ganetsky V, Spinler SA. Rivaroxaban: an oral factor Xa inhibitor. Clin Ther 2013; 35:4-27. [PMID: 23328267 DOI: 10.1016/j.clinthera.2012.12.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 12/07/2012] [Accepted: 12/12/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Currently available anticoagulants utilized for venous thromboembolism (VTE) treatment and prevention and stroke prevention in patients with atrial fibrillation (AF) have proven effectiveness but are not optimally utilized because of barriers such as the need for subcutaneous administration and requisite routine laboratory monitoring. Rivaroxaban, a novel oral Xa inhibitor, is an alternative to standard therapies utilized for VTE prevention after elective orthopedic surgery, primary and secondary stroke prevention in nonvalvular AF, VTE treatment after an acute VTE event, and secondary prevention after the acute coronary syndromes (ACS). OBJECTIVE This article reviews the pharmacology, efficacy, and tolerability of rivaroxaban for VTE prophylaxis in post-orthopedic surgery and medically ill patients, stroke prevention in nonvalvular AF, adjunctive therapy in patients with ACS, and VTE treatment. METHODS International Pharmaceutical Abstracts and EMBASE were searched for English-only clinical trials and reviews published between 1970 and March 15, 2012. PubMed was searched for articles published between 1970 and June 30, 2012. Additional trials and reviews were identified from the citations of published articles. RESULTS Eighty-nine publications were identified: 10 clinical trials and 1 meta-analysis were used to obtain efficacy and tolerability data, and 1 analysis of pooled data from the clinical trials was included; 17 pharmacokinetic, pharmacodynamic, and drug-drug interaction studies were included; and 5 cost-analyses were reviewed. These data showed rivaroxaban to be noninferior to enoxaparin for thromboprophylaxis of VTE after total knee and total hip replacement surgery. It was also shown to be noninferior to vitamin K antagonist therapy for primary and recurrent stroke prevention in nonvalvular AF as well as for the treatment of VTE after an acute deep vein thrombosis or pulmonary embolism. It also showed benefit in lowering the risk for major adverse cardiovascular events after ACS. Differences in major bleeding rates were not statistically significant between rivaroxaban and comparators across the various studies, with the exception of ACS, in which there were higher rates of non-coronary artery bypass graft surgery related bleeding and intracranial hemorrhage. CONCLUSIONS Based on the findings of the studies reported in this review, rivaroxaban is an effective option for the prevention of VTE after orthopedic surgery, stroke prevention for nonvalvular AF, and treatment of VTE. At this time, rivaroxaban cannot be recommended for secondary risk reduction after ACS because of the increased bleeding risk.
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Affiliation(s)
- Tyan F Thomas
- Philadelphia College of Pharmacy, University of the Sciences in Philadelphia, Philadelphia, Pennsylvania.
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Schellong S. Anticoagulation with rivaroxaban: covering a broad spectrum of thromboembolic disease. Expert Rev Cardiovasc Ther 2013; 11:817-28. [DOI: 10.1586/14779072.2013.811979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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