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Harskamp RE, Teichert M, Lucassen WAM, van Weert HCPM, Lopes RD. Impact of Polypharmacy and P-Glycoprotein- and CYP3A4-Modulating Drugs on Safety and Efficacy of Oral Anticoagulation Therapy in Patients with Atrial Fibrillation. Cardiovasc Drugs Ther 2019; 33:615-623. [PMID: 31520256 PMCID: PMC6904377 DOI: 10.1007/s10557-019-06907-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE To study whether polypharmacy or drug-drug interactions have differential effect on safety and efficacy in patients treated with direct oral anticoagulants (DOACs) versus warfarin. METHODS We performed a systematic review and meta-analysis of studies that randomized patients with atrial fibrillation to DOACs or warfarin stratified by the number of concomitant drugs. Outcomes included stroke or systemic embolism (SE), all-cause mortality, major bleeding, and intracranial hemorrhage. Risk ratios (RR) were calculated and Mantel-Haenszel random effects were applied. RESULTS Two high-quality studies were eligible, including 32,465 participants who received apixaban, rivaroxaban, or warfarin, with a median follow-up of 1.9 years. Of participants, 29% used < 5 drugs, 55% used 5-9 drugs, and 16% used ≥ 10 drugs. Drugs interacting with DOACs (P-glycoprotein/CYP3A4) were used by 6460 (20%) of patients. Patients with higher number of drugs (0-4 vs 5-9 vs ≥ 10) had higher rates of mortality (5.8%, 7.9%, 10.0%) and major bleeding (3.4%, 4.8%, 7.7%). Comparative efficacy or safety of DOACs versus warfarin was not affected by polypharmacy status or P-glycoprotein/CYP3A4 inhibitor use. However, the presence of polypharmacy (p = 0.001) or glycoprotein/CYP3A4-modulating drugs (p = 0.03) was correlated with increased risk of major bleeding when compared with warfarin. Overall, DOAC use was associated with a lower risk of stroke/SE (RR, 0.84; 95%CI, 0.74-0.94), all-cause mortality (RR, 0.91; 95%CI, 0.84-0.98), and intracranial hemorrhage (RR, 0.51; 95%CI, 0.38-0.70) compared with warfarin. CONCLUSIONS DOACs were more effective than warfarin, and at least as safe. Polypharmacy was associated with adverse outcomes and attenuated the advantage in risk of major bleeding among rivaroxaban users, particularly in the presence of P-glycoprotein/CYP3A4-modulating drugs.
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Affiliation(s)
- Ralf E Harskamp
- Department of General Practice, Amsterdam UMC, Amsterdam Public Health and Amsterdam Cardiovascular Sciences Research Institutes, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.
| | - Martina Teichert
- Department of Clinical Pharmacy and Toxicology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Wim A M Lucassen
- Department of General Practice, Amsterdam UMC, Amsterdam Public Health and Amsterdam Cardiovascular Sciences Research Institutes, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Henk C P M van Weert
- Department of General Practice, Amsterdam UMC, Amsterdam Public Health and Amsterdam Cardiovascular Sciences Research Institutes, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA
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Sriperumbuduri S, Dent R, Malcolm J, Hiremath S, Klein R, White CA, Brown PA, Akbari A. Accurate GFR in obesity-protocol for a systematic review. Syst Rev 2019; 8:147. [PMID: 31228953 PMCID: PMC6588895 DOI: 10.1186/s13643-019-1052-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/26/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Obesity is increasing globally. Chronic kidney disease (CKD) is strongly associated with obesity. Kidney function is commonly estimated with equations using creatinine (such as CKD-EPI equation) which is a product of muscle metabolism. Decisions about categorizing CKD, planning modality of renal replacement therapies, and adjusting dosages of medications excreted by the kidneys are done using these equations. However, it is not well appreciated that creatinine-based equations may not accurately estimate kidney function in obese individuals. We plan a systematic review of diagnostic studies which will compare estimating equations to actual measured kidney function. METHODS We will systematically search electronic bibliographic databases including MEDLINE, EMBASE, and the Cochrane Library with no restrictions on language or specific dates. The search terms will be adapted for the different databases using a combination of Medical Subject Heading and relevant keywords contained in titles and abstracts. Our preliminary search strategy using Cochrane, MEDLINE, and EMBASE databases have identified 190, 1246, and 1660 citations, respectively. For all studies selected, we will extract information on general study characteristics, study participant (age, sex, ethnicity, weight, height, BMI, BSA), type and protocol of reference standard utilized, the index test studied, the methodology of measurement of index test, categories of GFR, the proportion of eGFR within 10, 20, 30, 40, and 50% of measured GFR, and bias between eGFR and measured GFR. If the quality of methods and risk of bias are adequate, we will perform a meta-analysis. We will assess the heterogeneity using the χ 2 and the I 2 statistics to examine whether the estimates from studies included could be pooled. Sensitivity and multivariate meta-regression analyses will be performed to assess the effects of clinical factors and socio-demographic characteristics reported in included studies on the meta-analytic estimates. All analysis will be performed using the Comprehensive Meta-analysis software. DISCUSSION This systematic review might help to inform clinicians on the best equation to use in patients with obesity and CKD for staging of CKD and for medication dosing. If no equation is deemed suitable, this review will form a basis for future studies of GFR in obese individuals. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018104345.
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Affiliation(s)
| | - Robert Dent
- Department of Medicine, Division of Endocrinology, University of Ottawa, Ottawa, Canada
| | - Janine Malcolm
- Kidney Research Centre, Division of Nephrology, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON K1H 7W9 Canada
| | - Swapnil Hiremath
- Department of Medicine, Division of Nephrology, The Ottawa Hospital, Ottawa, Canada
- Kidney Research Centre, Division of Nephrology, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON K1H 7W9 Canada
| | - Ran Klein
- Department of Medicine, Division of Nuclear Medicine, University of Ottawa, Ottawa, Canada
| | - Christine A. White
- Department of Medicine, Division of Nephrology, Queen’s University, Kingston, Canada
| | - Pierre Antoine Brown
- Department of Medicine, Division of Nephrology, The Ottawa Hospital, Ottawa, Canada
- Kidney Research Centre, Division of Nephrology, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON K1H 7W9 Canada
| | - Ayub Akbari
- Department of Medicine, Division of Nephrology, The Ottawa Hospital, Ottawa, Canada
- Kidney Research Centre, Division of Nephrology, Department of Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON K1H 7W9 Canada
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Mahmood M, Lip GY. Anticoagulantes orales no dependientes de la vitamina K para pacientes con fibrilación auricular e insuficiencia renal grave. Rev Esp Cardiol 2018. [DOI: 10.1016/j.recesp.2018.03.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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4
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Nonvitamin K Oral Anticoagulants in Patients With Atrial Fibrillation and Severe Renal Dysfunction. ACTA ACUST UNITED AC 2018; 71:847-855. [PMID: 29958809 DOI: 10.1016/j.rec.2018.05.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 03/12/2018] [Indexed: 12/17/2022]
Abstract
Both atrial fibrillation (AF) and chronic kidney disease (CKD) are highly prevalent, especially with increasing age and associated comorbidities, such as hypertension, diabetes, heart failure, and vascular disease. The relationship between both AF and CKD seems to be bidirectional: CKD predisposes to AF while onset of AF seems to lead to progression of CKD. Stroke prevention is the cornerstone of AF management, and AF patients with CKD are at higher risk of stroke, mortality, cardiac events, and bleeding. Stroke prevention requires use of oral anticoagulants, which are either vitamin K antagonists (eg, warfarin), or the nonvitamin K antagonist oral anticoagulants (NOACs). While NOACs have been shown to be effective in mild-to-moderate renal dysfunction, there are a paucity of data regarding NOACs in severe and end-stage renal dysfunction. This review first discusses the evidence for NOACs in CKD. Second, we summarize the current knowledge regarding the efficacy and safety of NOACs to prevent AF-related stroke and systemic embolism in severe and end-stage renal disease.
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Bhatt NR, Davis NF, Nolan WJ, Flynn RJ, McDermott T, Thomas AZ, Manecksha RP. Incidence of Visible Hematuria Among Antithrombotic Agents: A Systematic Review of Over 175,000 Patients. Urology 2018; 114:27-32. [PMID: 29191640 DOI: 10.1016/j.urology.2017.11.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 11/05/2017] [Accepted: 11/15/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To determine the probability of visible hematuria with antithrombotic agents and to evaluate association of urologic etiology in antithrombotic-related hematuria. METHODS Preferred Reporting Items in Systematic Reviews and Meta-Analyses guidelines were followed to conduct a systematic review using search engines PUBMED and SCOPUS with the terms "(hematuria) OR (haematuria) OR urinary bleeding)) AND ((anticoagulants) OR anticoagulation) OR noac) OR novel anticoagulants) OR antiplatelet) OR dabigatran) OR rivaroxaban) OR apixaban) OR warfarin) OR aspirin) OR heparin) OR dipyridamole)." Raw data were used to perform a pooled analysis. Chi-square and logistic regression analysis were used for statistical analyses. RESULTS Twenty-two studies describing 175,114 patients met inclusion criteria. Odds ratio of hematuria with warfarin to rivoraxaban was 33 and warfarin to dabigatran was 16. The odds ratio of hematuria for oral anticoagulant (26.7%) to prophylactic parenteral anticoagulant (1.1%) agents was 9.6. Antiplatelet agents are 76 times less likely to cause hematuria compared to anticoagulants. Odds of hematuria with aspirin were 6.7 times the odds with clopidogrel and 3.5 times the odds with ticagrelor. Dabigatran was 198 times more likely to cause major hematuria compared to warfarin, whereas clopidogrel is 1.2 times more likely to cause major hematuria compared to aspirin. Urologic pathology was identified in 44% (234/532) of cases, malignancy in 24%. CONCLUSION Warfarin use poses the greatest risk for hematuria but is unlikely to cause major hematuria, whereas novel antithrombotic agents are more commonly associated with major hematuria. This review further characterizes the risk profile of antithrombotic agents and associated hematuria to equip clinicians with knowledge to choose an appropriate antithrombotic agent in patients with high-risk hematuria.
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Affiliation(s)
- Nikita R Bhatt
- Department of Urology, Tallaght Hospital, Dublin, Ireland
| | - Niall F Davis
- Department of Urology, Tallaght Hospital, Dublin, Ireland
| | | | - Robert J Flynn
- Department of Urology, Tallaght Hospital, Dublin, Ireland
| | - Ted McDermott
- Department of Urology, Tallaght Hospital, Dublin, Ireland
| | - Arun Z Thomas
- Department of Urology, Tallaght Hospital, Dublin, Ireland; Department of Surgery, Trinity College, Dublin, Ireland
| | - Rustom P Manecksha
- Department of Urology, Tallaght Hospital, Dublin, Ireland; Department of Surgery, Trinity College, Dublin, Ireland.
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6
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Bundhun PK, Soogund MZS, Teeluck AR, Pursun M, Bhurtu A, Huang WQ. Bleeding outcomes associated with rivaroxaban and dabigatran in patients treated for atrial fibrillation: a systematic review and meta-analysis. BMC Cardiovasc Disord 2017; 17:15. [PMID: 28056795 PMCID: PMC5216587 DOI: 10.1186/s12872-016-0449-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 12/17/2016] [Indexed: 01/31/2023] Open
Abstract
Background Warfarin is commonly used as a secondary prevention of stroke in patients with atrial fibrillation (AF). However, limitations have been observed even with the use of this medication. Recently, several newer direct oral anticoagulants (DOACs) have been approved for use by the food and drug administrations. Unfortunately, these newer drugs have seldom been compared directly with each other. Therefore, this study aimed to compare the bleeding events associated with rivaroxaban and dabigatran in patients treated for non-valvular AF. Methods EMBASE, Medline (National Library of Medicine) and the Cochrane Central Registry of Controlled Trials were searched for studies comparing rivaroxaban with dabigatran using the terms ‘rivaroxaban, dabigatran and atrial fibrillation’. Primary endpoints were: any bleeding outcomes, intracranial bleeding and gastro-intestinal (GI) bleeding. Secondary outcomes included stroke/systemic embolism (SE)/transient ischemic attack (TIA), venous thromboembolism and mortality. Odds ratios (OR) with 95% confidence intervals (CIs) were calculated. The pooled analyses were carried out with RevMan 5.3 software. All the authors had full access to the data and approved the manuscript as written. Results A total number of 4895 patients were included. This analysis showed that rivaroxaban was not associated with a significantly higher bleeding event when compared to dabigatran (OR: 1.28, 95% CI: 0.95–1.72; P = 0.11). GI bleeding was similarly manifested between these two DOACs (OR: 0.98, 95% CI: 0.43–2.25; P = 0.97). Even if intracranial bleeding was higher with the use of rivaroxaban, (OR: 2.18, 95% CI: 0.51–9.25; P = 0.29), the result was not statistically significant. Moreover, stroke/SE/TIA and venous thromboembolism were also not significantly different (OR: 0.81, 95% CI: 0.53–1.23; P = 0.32) and (OR: 2.06, 95% CI: 0.73–5.82; P = 0.17) respectively. However, even if mortality favored dabigatran (OR: 1.42, 95% CI: 0.99–2.06; P = 0.06), this result only approached statistical significance. Conclusion Head to head comparison showed that rivaroxaban was not associated with significantly higher bleeding events compared to dabigatran. Intracranial bleeding, GI bleeding, stroke/SE/TIA, venous thromboembolism and mortality were also not significantly different between these two DOACs. However, due to the limited number of patients analyzed, and which were mainly obtained from observational studies, this hypothesis might only be confirmed in future randomized trials. Furthermore, the CHADS2-VASC and HAS-BLED score which might play an important role in predicting bleeding risks should also not be ignored.
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Affiliation(s)
- Pravesh Kumar Bundhun
- Institute of Cardiovascular Diseases, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530027, People's Republic of China
| | | | | | - Manish Pursun
- Guangxi Medical University, Nanning, Guangxi, 530027, People's Republic of China
| | - Akash Bhurtu
- Guangxi Medical University, Nanning, Guangxi, 530027, People's Republic of China
| | - Wei-Qiang Huang
- Institute of Cardiovascular Diseases, the First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, 530021, People's Republic of China.
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Rodríguez-Reyes H, Arauz-Góngora A, Asensio-Lafuente E, Celaya-Cota MDJ, Cordero-Cabra A, Guevara-Valdivia M, Izaguirre-Avila R, Lara-Vaca S, Mariona-Moreno V, Martínez-Flores E, Nava-Townsend S, Pozas-Garza G, Rodríguez-Diez G. [Multidisciplinary meeting about the use of direct oral anticoagulants in nonvalvular atrial fibrillation]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2016; 87:124-143. [PMID: 27578566 DOI: 10.1016/j.acmx.2016.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 06/17/2016] [Accepted: 06/21/2016] [Indexed: 11/27/2022] Open
Abstract
Knowing the real impact of atrial fibrillation in the stroke, the Sociedad Mexicana of Electrofisiología y Estimulación Cardiaca (SOMEEC) had the initiative to develop a multidisciplinary meeting of experts the with the purpose to update the available scientific evidence from clinical practice guidelines, meta-analyses, controlled clinical trials, and complementing with the experience and views of a group of experts. To meet this goal, SOMEEC gathered a group of specialists in the area of cardiology, electrophysiology, neurology and hematology that given their experience in certain areas, they share the scientific evidence with the panel of experts to leave open a discussion about the information presented in this article. This document brings together the best scientific evidence available and aims to be a useful tool in the decision to use of new oral anticoagulants in nonvalvular atrial fibrillation and ischemic heart disease, or relating to the management of patients with stroke or renal failure, and even those that will be submitted to elective surgery and invasive procedures. In the same, they handled comparative schemes of follow-up and treatment which simplifies the decision making by the specialists participants.
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Affiliation(s)
| | - Antonio Arauz-Góngora
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | | | | | | | - Milton Guevara-Valdivia
- UMAE Hospital de Especialidades «Dr. Antonio Fraga Mouret», Centro Médico Nacional La Raza, Ciudad de México, México
| | - Raúl Izaguirre-Avila
- Departamento de Hematología, Clínica de anticoagulantes, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México
| | - Susano Lara-Vaca
- Servicio de Arritmias, Centro Médico IMSS, León Guanajuato, México
| | | | | | - Santiago Nava-Townsend
- Departamento de Electrocardiología, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México
| | - Gerardo Pozas-Garza
- Instituto de Cardiología y Medicina vascular del TEC de Monterrey, Monterrey, México
| | - Gerardo Rodríguez-Diez
- Departamento de Electrofisiología, Centro Médico Nacional 20 de Noviembre, Ciudad de México, México
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Ruff CT, Ansell JE, Becker RC, Benjamin EJ, Deicicchi DJ, Mark Estes NA, Ezekowitz MD, Fanikos J, Fareed J, Garcia D, Giugliano RP, Goldhaber SZ, Granger C, Healey JS, Hull R, Hylek EM, Libby P, Lopes RD, Mahaffey KW, Mega J, Piazza G, Sasahara AA, Sorond FA, Spyropoulos AC, Walenga JM, Weitz JI. North American Thrombosis Forum, AF Action Initiative Consensus Document. Am J Med 2016; 129:S1-S29. [PMID: 27126598 DOI: 10.1016/j.amjmed.2016.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The North American Thrombosis Forum Atrial Fibrillation Action Initiative consensus document is a comprehensive yet practical briefing document focusing on stroke and bleeding risk assessment in patients with atrial fibrillation, as well as recommendations regarding anticoagulation options and management. Despite the breadth of clinical trial data and guideline recommendation updates, many clinicians continue to struggle to synthesize the disparate information available. This problem slows the uptake and utilization of updated risk prediction tools and adoption of new oral anticoagulants. This document serves as a practical and educational reference for the entire medical community involved in the care of patients with atrial fibrillation.
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Affiliation(s)
- Christian T Ruff
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Jack E Ansell
- Hofstra North Shore/LIJ School of Medicine, Hempstead, NY
| | - Richard C Becker
- University of Cincinnati College of Medicine, University of Cincinnati Medical Center, Ohio
| | - Emelia J Benjamin
- Boston University School of Medicine and Public Health, Boston Medical Center, Boston, Mass
| | | | - N A Mark Estes
- Tufts Medical Center, Tufts University School of Medicine, Boston, Mass
| | - Michael D Ezekowitz
- Lankenau Medical Center, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pa
| | - John Fanikos
- Massachusetts College of Pharmacy, Brigham and Women's Hospital, Northeastern University School of Pharmacy, Boston, Mass
| | - Jawed Fareed
- Loyola University Medical Center, Loyola University Chicago Stritch School of Medicine, Ill
| | - David Garcia
- University of Washington Medical Center, University of Washington School of Medicine, Seattle, Wash
| | - Robert P Giugliano
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Samuel Z Goldhaber
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Christopher Granger
- Duke University Medical Center, Duke University School of Medicine, Durham, NC
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Russell Hull
- Foothills Medical Center, University of Calgary, Alberta, Canada
| | - Elaine M Hylek
- Boston University School of Medicine and Public Health, Boston Medical Center, Boston, Mass
| | - Peter Libby
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Renato D Lopes
- Duke University Medical Center, Duke University School of Medicine, Durham, NC
| | - Kenneth W Mahaffey
- Stanford University Medical Center, Stanford University School of Medicine, Calif
| | - Jessica Mega
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Gregory Piazza
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Arthur A Sasahara
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Farzaneh A Sorond
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | | | - Jeanine M Walenga
- Loyola University Medical Center, Loyola University Chicago Stritch School of Medicine, Ill
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
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Metabolic syndrome, atrial fibrillation, and stroke: Tackling an emerging epidemic. Heart Rhythm 2015; 12:2332-43. [DOI: 10.1016/j.hrthm.2015.06.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Indexed: 12/11/2022]
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Moreno Villar A, Nacle López I, Barbero Hernández MJ, Lizan Tudela L. [Therapeutic equivalence of the new oral anticoagulants]. Semergen 2015; 41:382-6. [PMID: 26146035 DOI: 10.1016/j.semerg.2015.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 04/22/2015] [Accepted: 04/27/2015] [Indexed: 10/23/2022]
Abstract
In an attempt to minimize the economic impact due to the incorporation of innovative drugs, health authorities have promoted and supported the evaluation and market positioning of drugs, as equivalent therapeutic alternatives. This issue has recently gained importance, possibly due to the current economic crisis. The equivalent therapeutic alternatives are justified by the need to compete on price, and by the authorities recommendation to establish therapeutic equivalence, price and financing of medicinal products at the same time. The establishment of the new oral anticoagulants and the equivalent therapeutic alternatives is a problematic issue if it is based on the absence of direct comparisons between different drugs and the questionable methodology used in the current indirect comparisons. Currently, it is difficult to determine when a new oral anticoagulant is more recommendable than others, but efforts are being made in order to propose alternatives for the decision based on patient characteristics.
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Affiliation(s)
| | | | | | - L Lizan Tudela
- Outcomes'10, Universitat Jaume I, Castellón de la Plana, España.
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11
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Veiga Fernández F, Malfeito Jiménez MDR, Barros Cerviño SM, Magariños Losada MDM. [Oral anticogulation for non-valvular atrial fibrilation in the elderly]. Rev Esp Geriatr Gerontol 2015; 50:134-42. [PMID: 25770008 DOI: 10.1016/j.regg.2015.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 01/23/2015] [Accepted: 01/28/2015] [Indexed: 11/26/2022]
Abstract
Anticoagulation in elderly people with non-valvular atrial afibrillation (AF) is a challenge, due to the thromboembolic, as well as the haemorrhagic risks. The correct use of anticoagulants in these patients has shown a higher net clinical benefit when comparing it with a younger population. Non-vitamin K antagonist oral anticoagulants (NOACs) have been compared to oral vitamin K antagonists in several studies that included a sufficient number of elderly people. Favourable results for non-vitamin K antagonist oral anticoagulants were obtained in these studies, making them the preferred treatment for this group of patients. Basing the estimations on indirect comparisons, the ideal anticoagulant and the specific dose for each particular case has been determined. Finally, a new algorithm has been developed that relates these parameters. Geriatric assessment is the key to the indication for an anticoagulation, the type of anticoagulant needed, and also the best way to optimise all the factors for a safe anticoagulation. The arrival of non-vitamin K antagonist oral anticoagulants will enhance the efficient thromboembolic prophylaxis rate in elderly people with AF. This new treatment will remove different controversial prophylaxis, such as antiaggregants.
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12
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Abe J, Umetsu R, Kato Y, Ueda N, Nakayama Y, Suzuki Y, Suzuki T, Nagasawa H, Kinosada Y, Nakamura M. Evaluation of Dabigatran- and Warfarin-Associated Hemorrhagic Events Using the FDA-Adverse Event Reporting System Database Stratified by Age. Int J Med Sci 2015; 12:312-21. [PMID: 25897292 PMCID: PMC4402434 DOI: 10.7150/ijms.10703] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 02/25/2015] [Indexed: 01/23/2023] Open
Abstract
Dabigatran and warfarin are oral anticoagulant drugs widely used for the prevention of stroke in patients with atrial fibrillation. The objective of this study was to evaluate the interaction between aging and dabigatran- and warfarin-induced gastrointestinal (GI) and nervous system hemorrhage using data available in the FDA Adverse Event Reporting System (FAERS) database. We analyzed reports of hemorrhagic events in the GI and nervous system recorded in the FAERS database between 2004 and 2014 using an adjusted reporting odds ratio (ROR). We demonstrated that dabigatran-associated GI hemorrhage was significantly increased in patients over the age of 80 years. The RORs of dabigatran increased with increasing age, although aging had little effect on warfarin-associated GI hemorrhage. The ROR for anticoagulant-associated nervous system hemorrhage was not significantly affected by aging, as compared to GI hemorrhage. Our results indicate that the excretion of dabigatran may be affected by aging, as compared to warfarin, likely due to renal function decline. Our results emphasize the need for physicians to closely monitor GI bleeding in aging patients, because it is closely related to renal function deterioration.
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Affiliation(s)
- Junko Abe
- 1. Laboratory of Drug Informatics, Gifu Pharmaceutical University ; 2. Medical Database Co., LTD
| | - Ryogo Umetsu
- 1. Laboratory of Drug Informatics, Gifu Pharmaceutical University
| | - Yamato Kato
- 1. Laboratory of Drug Informatics, Gifu Pharmaceutical University
| | - Natsumi Ueda
- 1. Laboratory of Drug Informatics, Gifu Pharmaceutical University
| | - Yoko Nakayama
- 1. Laboratory of Drug Informatics, Gifu Pharmaceutical University
| | - Yukiya Suzuki
- 1. Laboratory of Drug Informatics, Gifu Pharmaceutical University
| | - Toshiyuki Suzuki
- 1. Laboratory of Drug Informatics, Gifu Pharmaceutical University
| | - Hideko Nagasawa
- 3. Laboratory of Pharmaceutical and Medical Chemistry, Gifu Pharmaceutical University
| | - Yasutomi Kinosada
- 4. Department of Biomedical Informatics, Gifu University Graduate School of Medicine, JAPAN
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Hajhosseiny R, Sabir I, Lip GYH. Non-vitamin K antagonist oral anticoagulants in atrial fibrillation and venous thromboembolism: where are we now? Hosp Pract (1995) 2014; 42:153-162. [PMID: 25502139 DOI: 10.3810/hp.2014.10.1152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Four non-vitamin-K antagonist oral anticoagulants (NOACs) are now available and are variously approved for stroke prevention in atrial fibrillation and the management of venous thromboembolism. On the whole, these drugs offer clear benefits over warfarin, overcoming problems with unpredictable individual responses and avoiding the need for frequent and resource-intensive monitoring. Sufficient data are now available to recommend the use of particular NOACs in defined settings. As a group these drugs offer a real alternative to warfarin; their more widespread use for stroke prevention in atrial fibrillation, in the management of venous thromboembolism, and perhaps in other settings promises to bring real clinical gains for at-risk populations worldwide. This review highlights the growing importance of effective anticoagulation therapy at a time when cardiovascular risk profiles are evolving, discusses the relative merits of the NOACs over warfarin, and describes the use of specific agents in specific patient populations.
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Affiliation(s)
- Reza Hajhosseiny
- BHF Centre of Cardiovascular Excellence, St. Thomas Hospital, Westminster Bridge Road, London, UK
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Wung SF. Atrial Fibrillation in the Elderly: Management Strategies to Achieve Performance Measures. AACN Adv Crit Care 2014. [DOI: 10.4037/nci.0000000000000027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Shu-Fen Wung
- Shu-Fen Wung is Associate Professor, The University of Arizona College of Nursing, 1305 N Martin Ave, Tucson, AZ 85721
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15
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Urgent monitoring of direct oral anticoagulants in patients with atrial fibrillation: a tentative approach based on routine laboratory tests. J Thromb Thrombolysis 2014; 38:269-74. [DOI: 10.1007/s11239-014-1082-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Rao MP, Pokorney SD, Granger CB. Atrial fibrillation: a review of recent studies with a focus on those from the duke clinical research institute. SCIENTIFICA 2014; 2014:901586. [PMID: 25215263 PMCID: PMC4152955 DOI: 10.1155/2014/901586] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 06/24/2014] [Indexed: 05/13/2023]
Abstract
Atrial fibrillation is the most common arrhythmia and accounts for one-third of hospitalizations for rhythm disorders in the United States. The prevalence of atrial fibrillation averages 1% and increases with age. With the aging of the population, the number of patients with atrial fibrillation is expected to increase 150% by 2050, with more than 50% of atrial fibrillation patients being over the age of 80. This increasing burden of atrial fibrillation will lead to a higher incidence of stroke, as patients with atrial fibrillation have a five- to sevenfold greater risk of stroke than the general population. Strokes secondary to atrial fibrillation have a worse prognosis than in patients without atrial fibrillation. Vitamin K antagonists (e.g., warfarin), direct thrombin inhibitors (dabigatran), and factor Xa inhibitors (rivaroxaban and apixaban) are all oral anticoagulants that have been FDA approved for the prevention of stroke in atrial fibrillation. This review will summarize the experience of anticoagulants in patients with atrial fibrillation with a focus on the experience at the Duke Clinic Research Institute.
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Affiliation(s)
- Meena P. Rao
- Cardiology Division, Duke University Hospital, 2301 Erwin Road, DUMC 3845, Durham, NC 27710, USA
- *Meena P. Rao:
| | - Sean D. Pokorney
- Cardiology Division, Duke University Hospital, 2301 Erwin Road, DUMC 3845, Durham, NC 27710, USA
| | - Christopher B. Granger
- Cardiology Division, Duke University Hospital, 2301 Erwin Road, DUMC 3845, Durham, NC 27710, USA
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