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Palareti G, Santagata D, De Ponti C, Ageno W, Prandoni P. Anticoagulation and compression therapy for proximal acute deep vein thrombosis. VASA 2024. [PMID: 39017921 DOI: 10.1024/0301-1526/a001138] [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: 07/18/2024]
Abstract
The treatment of proximal deep vein thrombosis (DVT) of the lower limbs includes an initial management phase, covering the first 1 to 3 weeks, a primary treatment phase, lasting a minimum of 3 months, and a secondary treatment phase for those patients requiring continuing anticoagulation beyond the first 3 to 6 months. During the initial phase most patients with DVT can be managed as outpatients. Exclusion criteria for home treatment include high risk of bleeding, limb threatening DVT or other conditions requiring hospitalisation. Anticoagulant drugs represent the mainstay of treatment and include parenteral drugs such as unfractionated heparin or low molecular weight heparin, and oral drugs such as the vitamin K antagonists and the direct oral anticoagulants (DOACs). DOACs are currently recommended as the first line of treatment for proximal DVT of the lower limbs, with no preference for one DOAC over another. Factors to consider when choosing the anticoagulant strategy include, among others, renal and liver function, underlying diseases such as cancer or the antiphospholipid syndrome, and patient preferences. Indefinite duration of anticoagulation beyond the first 3 to 6 months is recommended for patients with unprovoked DVT and patients with permanent, chronic risk factors. Two DOACs, namely apixaban and rivaroxaban, can be administered at low doses for the secondary prevention of DVT. Elastic compression stockings (ECS) have been used for decades in patients with proximal DVT with the aim of counteracting the venous hypertension generated by the vascular disorder and reducing leg edema and to prevent the post-thrombotic syndrome.
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Affiliation(s)
| | - Davide Santagata
- Dipartimento di Medicina e Chirurgia, University of Insubria, Varese, Italy
| | - Chiara De Ponti
- Dipartimento di Medicina e Chirurgia, University of Insubria, Varese, Italy
| | - Walter Ageno
- Dipartimento di Medicina e Chirurgia, University of Insubria, Varese, Italy
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Wang X, Ma Y, Hui X, Li M, Li J, Tian J, Wang Q, Yan P, Li J, Xie P, Yang K, Yao L. Oral direct thrombin inhibitors or oral factor Xa inhibitors versus conventional anticoagulants for the treatment of deep vein thrombosis. Cochrane Database Syst Rev 2023; 4:CD010956. [PMID: 37058421 PMCID: PMC10105633 DOI: 10.1002/14651858.cd010956.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
BACKGROUND Deep vein thrombosis (DVT) is a condition in which a clot forms in the deep veins, most commonly of the leg. It occurs in approximately one in 1000 people. If left untreated, the clot can travel up to the lungs and cause a potentially life-threatening pulmonary embolism (PE). Previously, a DVT was treated with the anticoagulants heparin and vitamin K antagonists. However, two forms of direct oral anticoagulants (DOACs) have been developed: oral direct thrombin inhibitors (DTIs) and oral factor Xa inhibitors, which have characteristics that may be favourable compared to conventional treatment, including oral administration, a predictable effect, lack of frequent monitoring or dose adjustment and few known drug interactions. DOACs are now commonly being used for treating DVT: recent guidelines recommended DOACs over conventional anticoagulants for both DVT and PE treatment. This Cochrane Review was first published in 2015. It was the first systematic review to measure the effectiveness and safety of these drugs in the treatment of DVT. This is an update of the 2015 review. OBJECTIVES: To assess the effectiveness and safety of oral DTIs and oral factor Xa inhibitors versus conventional anticoagulants for the long-term treatment of DVT. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, CENTRAL, MEDLINE, Embase and CINAHL databases and the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 1 March 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) in which people with a DVT, confirmed by standard imaging techniques, were allocated to receive an oral DTI or an oral factor Xa inhibitor compared with conventional anticoagulation or compared with each other for the treatment of DVT. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were recurrent venous thromboembolism (VTE), recurrent DVT and PE. Secondary outcomes included all-cause mortality, major bleeding, post-thrombotic syndrome (PTS) and quality of life (QoL). We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS We identified 10 new studies with 2950 participants for this update. In total, we included 21 RCTs involving 30,895 participants. Three studies investigated oral DTIs (two dabigatran and one ximelagatran), 17 investigated oral factor Xa inhibitors (eight rivaroxaban, five apixaban and four edoxaban) and one three-arm trial investigated both a DTI (dabigatran) and factor Xa inhibitor (rivaroxaban). Overall, the studies were of good methodological quality. Meta-analysis comparing DTIs to conventional anticoagulation showed no clear difference in the rate of recurrent VTE (odds ratio (OR) 1.17, 95% confidence interval (CI) 0.83 to 1.65; 3 studies, 5994 participants; moderate-certainty evidence), recurrent DVT (OR 1.11, 95% CI 0.74 to 1.66; 3 studies, 5994 participants; moderate-certainty evidence), fatal PE (OR 1.32, 95% CI 0.29 to 6.02; 3 studies, 5994 participants; moderate-certainty evidence), non-fatal PE (OR 1.29, 95% CI 0.64 to 2.59; 3 studies, 5994 participants; moderate-certainty evidence) or all-cause mortality (OR 0.66, 95% CI 0.41 to 1.08; 1 study, 2489 participants; moderate-certainty evidence). DTIs reduced the rate of major bleeding (OR 0.58, 95% CI 0.38 to 0.89; 3 studies, 5994 participants; high-certainty evidence). For oral factor Xa inhibitors compared with conventional anticoagulation, meta-analysis demonstrated no clear difference in recurrent VTE (OR 0.85, 95% CI 0.71 to 1.01; 13 studies, 17,505 participants; moderate-certainty evidence), recurrent DVT (OR 0.70, 95% CI 0.49 to 1.01; 9 studies, 16,439 participants; moderate-certainty evidence), fatal PE (OR 1.18, 95% CI 0.69 to 2.02; 6 studies, 15,082 participants; moderate-certainty evidence), non-fatal PE (OR 0.93, 95% CI 0.68 to 1.27; 7 studies, 15,166 participants; moderate-certainty evidence) or all-cause mortality (OR 0.87, 95% CI 0.67 to 1.14; 9 studies, 10,770 participants; moderate-certainty evidence). Meta-analysis showed a reduced rate of major bleeding with oral factor Xa inhibitors compared with conventional anticoagulation (OR 0.63, 95% CI 0.45 to 0.89; 17 studies, 18,066 participants; high-certainty evidence). AUTHORS' CONCLUSIONS: The current review suggests that DOACs may be superior to conventional therapy in terms of safety (major bleeding), and are probably equivalent in terms of efficacy. There is probably little or no difference between DOACs and conventional anticoagulation in the prevention of recurrent VTE, recurrent DVT, pulmonary embolism and all-cause mortality. DOACs reduced the rate of major bleeding compared to conventional anticoagulation. The certainty of evidence was moderate or high.
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Affiliation(s)
- Xiaoqin Wang
- Michael G DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Canada
| | - Yanfang Ma
- School of Chinese Medicine, Hong Kong Baptist University, Hong Kong Special Administrative Region, China
| | - Xu Hui
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Meixuan Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Jing Li
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Jinhui Tian
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Qi Wang
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Peijing Yan
- Department of Epidemiology and Health Statistics, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Jianfeng Li
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Ping Xie
- Department of Cardiology, Gansu Provincial Hospital, Lanzhou, China
| | - Kehu Yang
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, China
- Evidence-Based Social Science Research Center, School of Public Health, Lanzhou University, Lanzhou, China
| | - Liang Yao
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Canada
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Maximiliano CL, Jaime GC, Erika MH. Rivaroxaban plus aspirin versus acenocoumarol to manage recurrent venous thromboembolic events despite systemic anticoagulation with rivaroxaban. Thromb Res 2023; 222:43-48. [PMID: 36565679 DOI: 10.1016/j.thromres.2022.12.008] [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: 08/02/2022] [Revised: 12/09/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The evaluation and management of patients who sustain recurrent thromboembolic events while taking therapeutic anticoagulation have not been well characterized; moreover, there has been no systematic review or randomized trial focused on treating patients with recurrent deep vein thrombosis (DVT) and pulmonary embolism (PE) during anticoagulant treatment. Therefore, we developed a pilot trial to compare rivaroxaban plus aspirin versus acenocoumarol in patients with recurrent venous thromboembolism despite ongoing anticoagulation with rivaroxaban. MATERIALS AND METHODS The study was a multicenter, randomized clinical trial. We randomly assigned patients with objectively documented recurrent venous thromboembolism to receive rivaroxaban (20 mg once a day) plus aspirin (300 mg once a day) or an adjusted dose of acenocoumarol. The study was designed to evaluate the incidence of recurrent thromboembolic events (recurrent ipsilateral or contralateral DVT, PE, ischemic stroke, and myocardial infarction) and hemorrhagic events. RESULTS A total of 58 patients were randomized: 28 were allocated to the rivaroxaban plus aspirin group and 30 to the acenocoumarol group. After 90 days of follow-up, three recurrent thromboembolic events (primary outcome) occurred in the acenocoumarol group - two DVTs and one ischemic stroke - and zero events in the rivaroxaban plus aspirin group (risk ratio [RR] 0.15; 95 % confidence interval [CI] 0.008-2.83; P = 0.20). Minor bleeding occurred in five patients in the acenocoumarol group and zero in the rivaroxaban plus aspirin group (RR 0.09; 95 % CI 0.005-1.68; p = 0.10). There was one non-fatal gastrointestinal major bleed in the rivaroxaban plus aspirin group. CONCLUSIONS In this pilot study, there were no significant differences in any outcome assessed; however, recurrent thromboembolic events and minor bleeding events occurred numerically less frequently in the rivaroxaban plus aspirin group. These data suggest the need to carry out more extensive randomized studies with sufficient statistical power to clarify these results.
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Affiliation(s)
- Correa Lara Maximiliano
- Centro Medico Nacional "La Raza", Instituto Mexicano del Seguro Social, Mexico City, Mexico; Environmental Toxicology Laboratory, Instituto Politécnico Nacional, Mexico.
| | - García Chavez Jaime
- Centro Medico Nacional "La Raza", Instituto Mexicano del Seguro Social, Mexico City, Mexico
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Ortel TL, Neumann I, Ageno W, Beyth R, Clark NP, Cuker A, Hutten BA, Jaff MR, Manja V, Schulman S, Thurston C, Vedantham S, Verhamme P, Witt DM, D Florez I, Izcovich A, Nieuwlaat R, Ross S, J Schünemann H, Wiercioch W, Zhang Y, Zhang Y. American Society of Hematology 2020 guidelines for management of venous thromboembolism: treatment of deep vein thrombosis and pulmonary embolism. Blood Adv 2020; 4:4693-4738. [PMID: 33007077 PMCID: PMC7556153 DOI: 10.1182/bloodadvances.2020001830] [Citation(s) in RCA: 588] [Impact Index Per Article: 147.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 07/27/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE), which includes deep vein thrombosis (DVT) and pulmonary embolism (PE), occurs in ∼1 to 2 individuals per 1000 each year, corresponding to ∼300 000 to 600 000 events in the United States annually. OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH) intend to support patients, clinicians, and others in decisions about treatment of VTE. METHODS ASH formed a multidisciplinary guideline panel balanced to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process, including updating or performing systematic evidence reviews. The panel prioritized clinical questions and outcomes according to their importance for clinicians and adult patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to assess evidence and make recommendations, which were subject to public comment. RESULTS The panel agreed on 28 recommendations for the initial management of VTE, primary treatment, secondary prevention, and treatment of recurrent VTE events. CONCLUSIONS Strong recommendations include the use of thrombolytic therapy for patients with PE and hemodynamic compromise, use of an international normalized ratio (INR) range of 2.0 to 3.0 over a lower INR range for patients with VTE who use a vitamin K antagonist (VKA) for secondary prevention, and use of indefinite anticoagulation for patients with recurrent unprovoked VTE. Conditional recommendations include the preference for home treatment over hospital-based treatment for uncomplicated DVT and PE at low risk for complications and a preference for direct oral anticoagulants over VKA for primary treatment of VTE.
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Affiliation(s)
- Thomas L Ortel
- Division of Hematology, Department of Medicine, Duke University, Durham NC
| | | | - Walter Ageno
- Department of Medicine and Surgery, University of Insurbria, Varese, Italy
| | - Rebecca Beyth
- Division of General Internal Medicine, Department of Medicine, University of Florida, Gainesville, FL
- Malcolm Randall Veterans Affairs Medical Center, Gainesville, FL
| | - Nathan P Clark
- Clinical Pharmacy Anticoagulation Service, Kaiser Permanente, Aurora, CO
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Barbara A Hutten
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam Cardiovascular Sciences, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Veena Manja
- University of California Davis, Sacramento, CA
- Veterans Affairs Northern California Health Care System, Mather, CA
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
- Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
| | | | - Suresh Vedantham
- Division of Diagnostic Radiology, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Peter Verhamme
- KU Leuven Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Daniel M Witt
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, UT
| | - Ivan D Florez
- Department of Pediatrics, University of Antioquia, Medellin, Colombia
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Ariel Izcovich
- Internal Medicine Department, German Hospital, Buenos Aires, Argentina; and
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Stephanie Ross
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Yuqing Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
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Abstract
About 1.4 British million people are at risk of strokes due to non-valvular atrial fibrillation (AF) necessitating long-term anticoagulation. The vitamin K antagonist, warfarin, has a long half-life and narrow therapeutic range necessitating regular monitoring and is a common cause of iatrogenic hospital admission. Direct-acting oral anticoagulants (DOACs), dabigatran, rivaroxaban, apixaban and edoxaban are not required to have monitoring but are sensitive to changes in renal function and are associated with poorer adherence. There are good grounds to believe that DOACs are not always superior to warfarin in routine practice particularly with an older population. Much higher levels of therapeutic effectiveness can be achieved using a simple genotype guidance to identify those who are highly sensitive and by adoption of home monitoring. These adjustments could make warfarin the preferred drug for most people and would reduce the dramatic rise in health service expenditure.
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Affiliation(s)
- John Burn
- Institute of Genetic Medicine, Newcastle Univerisity, Centre for Life, Newcastle upon Tyne, UK
| | - Munir Pirmohamed
- Department of Molecular & Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
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6
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Palareti G, Antonucci E, Migliaccio L, Erba N, Marongiu F, Pengo V, Poli D, Testa S, Tosetto A, Tripodi A, Moia M. Vitamin K antagonist therapy: changes in the treated populations and in management results in Italian anticoagulation clinics compared with those recorded 20 years ago. Intern Emerg Med 2017; 12:1109-1119. [PMID: 28501909 PMCID: PMC5691104 DOI: 10.1007/s11739-017-1678-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2017] [Accepted: 05/04/2017] [Indexed: 11/26/2022]
Abstract
Vitamin K antagonists (VKA) are the most widely used anticoagulants in the world. An appropriate management of treated patients is crucial for their efficacy and safety. The prospective, observational, multicenter, inception-cohort FCSA-START Register, a branch of START Register (NCT02219984) included VKA-treated patients managed by centers of Italian Federation of anticoagulation clinics (AC). Baseline patient characteristics and data during treatment were analyzed and compared with those of ISCOAT study, performed by the Federation and published in 1996/7. 5707 naïve patients [53% males, mean age 73.0 years (28.1% >80 years)], 61.6% treated for atrial fibrillation (AF), and 28.0% for venous thromboembolism were included. During the 8906 patient-years (pt-yrs) of observation, 123 patients had major bleeding (MB) (1.38% pt-yrs; fatal: 0.11% pt-yrs), while non-major clinically relevant bleeds were 144 (1.62% pt-yrs). Bleeding was more frequent in elderly (≥70 years; p = 0.04), and during initial 3-month therapy (p = 0.02). Bleeding rate was 2.5% pt-yrs for temporally related INR results <3.0, increasing to 12.5% for INR ≥ 4.5. Thrombotic events were 47 (0.53% pt-yrs; 4 fatal 0.04% pt-yrs). Compared with ISCOAT-1996/7 results, patients older than 80 y are increased from 8 to 28% (p < 0.01), and those treated for AF are increased from 17 to 61%. The quality of anticoagulation control and incidence of MB are not different. However, thrombotic complications fell drastically from 3.5 to 0.53% pt-yrs (p < 0.01), with lower mortality (p = 0.01). VKA-treated patients monitored in Italian AC have good clinical results, with low bleeding and thrombotic complications rates. Important changes in the treated population and improvement in thrombotic complications are detected compared with the ISCOAT-1996/7 study.
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Affiliation(s)
- Gualtiero Palareti
- Cardiovascular Diseases, University of Bologna, Coordinator of the START-Register, Bologna, Italy.
| | - Emilia Antonucci
- Arianna Anticoagulazione Foundation, Via Paolo Fabbri 1/3, 40138, Bologna, Italy
| | - Ludovica Migliaccio
- Arianna Anticoagulazione Foundation, Via Paolo Fabbri 1/3, 40138, Bologna, Italy
| | - Nicoletta Erba
- Dip Medicina di Laboratorio, Patologia Clinica-Merate, Asst Lecco, Lecco, Italy
| | - Francesco Marongiu
- UO Medicina Interna ed Emocoagulopatie, Policlinico Univeristario, Cagliari, Italy
| | - Vittorio Pengo
- Department of Cardiothoracic and Vascular Sciences, University Hospital of Padua, Padua, Italy
| | - Daniela Poli
- Thrombosis Centre, Department Heart and Vessels, University Hospital of Florence, Florence, Italy
| | - Sophie Testa
- Haemostasis and Thrombosis Center, Department of Laboratory Medicine, AO Istituti Ospitalieri, Cremona, Italy
| | - Alberto Tosetto
- Department of Hematology, S. Bortolo Hospital, Vicenza, Italy
| | - Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, IRCCS Cà Granda Maggiore Hospital Foundation, Milan, Italy
| | - Marco Moia
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Department of Clinical Sciences and Community Health, Università degli Studi di Milano, IRCCS Cà Granda Maggiore Hospital Foundation, Milan, Italy
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7
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Almutairi AR, Zhou L, Gellad WF, Lee JK, Slack MK, Martin JR, Lo-Ciganic WH. Effectiveness and Safety of Non-vitamin K Antagonist Oral Anticoagulants for Atrial Fibrillation and Venous Thromboembolism: A Systematic Review and Meta-analyses. Clin Ther 2017; 39:1456-1478.e36. [PMID: 28668628 DOI: 10.1016/j.clinthera.2017.05.358] [Citation(s) in RCA: 105] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 05/16/2017] [Accepted: 05/30/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE The findings from the observational studies comparing the effectiveness and safety of non-vitamin K antagonist oral anticoagulants (NOACs) versus vitamin K antagonists (VKAs) for atrial fibrillation (AF) and venous thromboembolism (VTE) are inconsistent. We conducted separate meta-analyses examining the efficacy/effectiveness and safety of NOACs versus VKAs by disease (AF vs VTE), study design (randomized controlled trials [RCTs] vs observational studies), and NOAC (dabigatran, rivaroxaban, apixaban, and edoxaban). METHODS The main data sources included PubMed/MEDLINE, EMBASE, Web of Science, CINAHL, and Scopus from January 1, 2005, to February 15, 2016. We searched for Phase III RCTs and observational studies comparing NOACs versus VKAs. The primary outcomes were stroke/systemic embolism (SE) for AF; recurrent VTE/fatal pulmonary embolism (PE) for VTE; and major bleeding for both conditions. Secondary outcomes included stroke and myocardial infarction (MI) for AF, recurrent deep vein thrombosis (DVT)/PE for VTE, and mortality, intracranial hemorrhage (ICH), and gastrointestinal bleeding for both conditions. Pooled hazard ratios (HRs) were reported by using inverse variance-weighted random effects models. FINDINGS A total of 13 RCTs and 27 observational studies (AF, n = 32; VTE, n = 8) were included. For AF, dabigatran and VKAs were comparable for stroke/SE risk in 1 RCT (HR, 0.77 [95% CI, 0.57-1.03]) and 6 observational studies (HR, 1.03 [95% CI, 0.83-1.27]). Rivaroxaban had a 20% decreased risk of stroke/SE in 3 RCTs (HR, 0.80 [95% CI, 0.67-0.95]) compared with VKA, but the effect was nonsignificant in 3 observational studies (HR, 0.78 [95% CI, 0.59-1.04]). Apixaban decreased stroke/systemic embolism risk (HR, 0.79 [95% CI, 0.66-0.95]) compared with VKA in 1 RCT, but edoxaban was comparable to VKA (HR, 0.99 [95% CI, 0.77-1.28]) in 1 RCT (no observational studies available for apixaban/edoxaban). Dabigatran, apixaban, and edoxaban decreased the risk of hemorrhagic stroke, mortality, major bleeding, and ICH by 10% to 71% compared with VKAs but not rivaroxaban. For VTE, NOACs and VKAs were comparable for recurrent VTE/fatal PE/DVT/PE risk in 7 RCTs and 1 observational study. The 7 RCTs demonstrated a 32% to 69% decreased risk of major bleeding for dabigatran, rivaroxaban, and apixaban compared with VKAs. No difference was shown in 1 rivaroxaban observational study (HR, 0.77 [95% CI, 0.40-1.49]) and 1 edoxaban RCT (HR, 0.84 [95% CI, 0.59-1.20]). Except for dabigatran, the NOACs had a 61% to 86% decreased risk of ICH and gastrointestinal bleeding. IMPLICATIONS Overall, NOACs were comparable or superior to VKAs. Although no observational studies are currently available for apixaban/edoxaban, a few notable inconsistencies exist for dabigatran (ischemic stroke, MI) and rivaroxaban (stroke/SE, major bleeding in VTE) between RCTs and observational studies. Individualizing NOAC/VKA therapy based on benefit/safety profiles and patient characteristics is suggested.
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Affiliation(s)
- Abdulaali R Almutairi
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona
| | - Lili Zhou
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona
| | - Walid F Gellad
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; Center for Health Equity Research Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Jeannie K Lee
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona
| | - Marion K Slack
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona
| | - Jennifer R Martin
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona; Arizona Health Sciences Library, University Libraries, University of Arizona, Tucson, Arizona
| | - Wei-Hsuan Lo-Ciganic
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, Arizona.
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8
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Stolk LM, de Vries F, Ebbelaar C, de Boer A, Schalekamp T, Souverein P, Ten Cate-Hoek A, Burden AM. Risk of myocardial infarction in patients with atrial fibrillation using vitamin K antagonists, aspirin or direct acting oral anticoagulants. Br J Clin Pharmacol 2017; 83:1835-1843. [PMID: 28326589 DOI: 10.1111/bcp.13264] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 02/02/2017] [Accepted: 02/04/2017] [Indexed: 01/11/2023] Open
Abstract
AIM Direct-acting oral anticoagulants (DOACs) have become available for the prevention of stroke in patients with atrial fibrillation (AF). Conflicting results have been published on the risk of acute myocardial infarction (AMI) with the use of DOACs in comparison with vitamin K antagonists (VKAs). The objective of the present study was to evaluate the risk of AMI in patients with AF who are exposed to either VKAs, DOACs or low-dose (< 325 mg) aspirin. METHODS We conducted a population-based cohort study using data from the Clinical Practice Research Datalink (2008-2014). The study population (n = 30 146) consisted of all patients ≥18 years with a diagnosis of AF who were new users of VKAs, DOACs (rivaroxaban and dabigatran) or aspirin. Cox proportional hazards models were used to estimate the hazard ratio (HR) of AMI for users of DOACs or aspirin vs. VKA. Adjustments were made for age, gender, lifestyle, risk factors, comorbidity and other drugs. RESULTS The risk of AMI was doubled when we compared current use of DOACs with current use of VKAs [adjusted HR 2.11; 95% confidence interval (CI) 1.08, 4.12] and for current users of aspirin vs. current VKA users (adjusted HR 1.91; 95% CI 1.45, 2.51). CONCLUSIONS There is a twofold increase in the risk of AMI for users of DOACs, in comparison with VKAs, in AF therapy. In addition, the results suggested that in patients with AF, the incidence of AMI is higher during aspirin monotherapy than during the use of VKAs.
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Affiliation(s)
- Leo M Stolk
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Frank de Vries
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, the Netherlands.,MRC Life-course Epidemiology Unit, University of Southampton, Southampton, UK.,Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
| | - Chiel Ebbelaar
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
| | - Anthonius de Boer
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
| | - Tom Schalekamp
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
| | - Patrick Souverein
- Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
| | - Arina Ten Cate-Hoek
- Department Internal Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Andrea M Burden
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, the Netherlands.,Utrecht Institute for Pharmaceutical Sciences, Division of Pharmacoepidemiology & Clinical Pharmacology, Utrecht University, Utrecht, the Netherlands
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9
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Long B, Koyfman A. Best Clinical Practice: Controversies in Outpatient Management of Acute Pulmonary Embolism. J Emerg Med 2016; 52:668-679. [PMID: 28007362 DOI: 10.1016/j.jemermed.2016.11.020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/21/2016] [Accepted: 11/05/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Pulmonary embolism (PE) is a common condition managed in the emergency department (ED), with a wide range of morbidity and mortality. Patients are classically admitted for treatment and monitoring of anticoagulation. OBJECTIVE We sought to evaluate the controversy concerning outpatient therapy for patients with acute PE and investigate the feasibility, safety, and efficacy of outpatient management. DISCUSSION Patients with venous thromboembolism have historically been admitted for treatment and monitoring for concern of worsening disease or side effects of anticoagulation (bleeding). More than 90% of EDs admit patients with PE in the United States. However, close to 50% of patients may be appropriate for discharge and outpatient therapy. The published literature suggests that outpatient treatment is safe, feasible, and efficacious, with similar rates of recurrent venous thromboembolism and all-cause mortality, especially with novel oral anticoagulants. Multiple scoring criteria can be used, including the Pulmonary Embolism Severity Index (PESI), simplified PESI, Hestia criteria, Geneva Prognostic Score, European Society of Cardiology guidelines, Global Registry of Acute Coronary Events, and Aujesky score. Simplified PESI and the European Society of Cardiology guidelines have high-quality evidence, sufficient sensitivity, and ease of use for the ED. Patients considered for outpatient therapy should possess low hemorrhage risk, adequate social situation, negative biomarkers, ability to comply, and no alternate need for admission. CONCLUSIONS Patients with acute PE are often admitted in the United States, but a significant proportion may be appropriate for discharge. Patients with low risk for adverse events according to clinical scoring criteria, adequate follow-up, ability to comply, and no other need for admission can be discharged with novel oral anticoagulant therapy.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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10
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Raschi E, Bianchin M, Ageno W, De Ponti R, De Ponti F. Risk-Benefit Profile of Direct-Acting Oral Anticoagulants in Established Therapeutic Indications: An Overview of Systematic Reviews and Observational Studies. Drug Saf 2016; 39:1175-1187. [PMID: 27696300 PMCID: PMC5107188 DOI: 10.1007/s40264-016-0464-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Since 2008, the direct-acting oral anticoagulants (DOACs) have expanded the therapeutic options of cardiovascular diseases with recognized clinical and epidemiological impact, such as non-valvular atrial fibrillation (NVAF) and venous thromboembolism (VTE), and also in the preventive setting of orthopedic surgical patients. The large body of evidence, not only from pivotal clinical trials but also from 'real-world' postmarketing observational findings (e.g. analytical epidemiological studies and registry data) gathered to date allow for a first attempt at verifying a posteriori whether or not the pharmacological advantages of the DOACs actually translate into therapeutic innovation, with relevant implications for clinicians, regulators and patients. This review aims to synthesize the risk-benefit profile of DOACs in the aforementioned consolidated indications through an 'evidence summary' approach gathering the existent evidence-based data, particularly systematic reviews with meta-analyses of randomized controlled trials, as well as observational studies, comparing DOACs with vitamin K antagonists. Clinical evidence will be discussed and compared with major international guidelines to identify whether an update is needed. Controversial clinically relevant safety issues will be also examined in order to highlight current challenges and unsettled questions (e.g. actual bleeding risk in susceptible populations). It is anticipated that the large number of publications on NVAF or VTE (44 systematic reviews with meta-analyses and 12 observational studies retained in our analysis) suggests the potential existence of overlapping studies and calls for common criteria to qualitatively and quantitatively assess discordances, thus guiding future research.
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Affiliation(s)
- Emanuel Raschi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio, 48, I-40126, Bologna, Italy
| | - Matteo Bianchin
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio, 48, I-40126, Bologna, Italy
| | - Walter Ageno
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Roberto De Ponti
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - Fabrizio De Ponti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio, 48, I-40126, Bologna, Italy.
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11
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Loffredo L, Violi F, Perri L. Sex related differences in patients with acute venous thromboembolism treated with new oral anticoagulants. A meta-analysis of the interventional trials. Int J Cardiol 2016; 212:255-8. [DOI: 10.1016/j.ijcard.2016.03.086] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 03/17/2016] [Accepted: 03/19/2016] [Indexed: 10/22/2022]
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12
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Palareti G, Poli D. The challenges and limitations of widespread direct oral anticoagulant treatment: practical suggestions for their best use. Expert Rev Cardiovasc Ther 2015; 14:163-76. [DOI: 10.1586/14779072.2016.1115344] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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13
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14
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Kolinsky DC, Schwarz ES. Are New Oral Anticoagulants Safer Than Vitamin K Antagonists in the Treatment of Venous Thromboembolism? Ann Emerg Med 2015; 67:455-7. [PMID: 26440492 DOI: 10.1016/j.annemergmed.2015.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Daniel C Kolinsky
- Division of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Evan S Schwarz
- Division of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO
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15
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Zalpour A, Oo TH. Update on Edoxaban for the Prevention and Treatment of Thromboembolism: Clinical Applications Based on Current Evidence. Adv Hematol 2015; 2015:920361. [PMID: 26351456 PMCID: PMC4553175 DOI: 10.1155/2015/920361] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 06/18/2015] [Accepted: 06/21/2015] [Indexed: 11/21/2022] Open
Abstract
Vitamin K antagonists (VKA) and heparins have been utilized for the prevention and treatment of thromboembolism (arterial and venous) for decades. Targeting and inhibiting specific coagulation factors have led to new discoveries in the pharmacotherapy of thromboembolism management. These targeted anticoagulants are known as direct oral anticoagulants (DOACs). Two pharmacologically distinct classes of targeted agents are dabigatran etexilate (Direct Thrombin Inhibitor (DTI)) and rivaroxaban, apixaban, and edoxaban (direct oral factor Xa inhibitors (OFXaIs)). Emerging evidence from the clinical trials has shown that DOACs are noninferior to VKA or low-molecular-weight heparins in the prevention and treatment of thromboembolism. This review examines the role of edoxaban, a recently approved OFXaI, in the prevention and treatment of thromboembolism based on the available published literature. The management of edoxaban in the perioperative setting, reversibility in bleeding cases, its role in cancer patients, the relevance of drug-drug interactions, patient satisfaction, financial impacts, and patient education will be discussed.
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Affiliation(s)
- Ali Zalpour
- University of Texas MD Anderson Cancer Center, 1400 Pressler Avenue, Unit 1465, FCT 13.5021, Houston, TX 77030, USA
| | - Thein Hlaing Oo
- Section of Thrombosis & Benign Hematology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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