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Zheng Y, Mostamand S. Nutrition in children with exocrine pancreatic insufficiency. Front Pediatr 2023; 11:943649. [PMID: 37215591 PMCID: PMC10196508 DOI: 10.3389/fped.2023.943649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 04/18/2023] [Indexed: 05/24/2023] Open
Abstract
Exocrine pancreatic insufficiency (EPI) is a condition defined as pancreatic loss of exocrine function, including decreased digestive enzymes and bicarbonate secretion, which leads to maldigestion and malabsorption of nutrients. It is a common complication in many pancreatic disorders. If left undiagnosed, EPI can cause poor digestion of food, chronic diarrhea, severe malnutrition and related complications. Nutritional status and fat-soluble vitamins should be carefully assessed and monitored in patients with EPI. Early diagnosis of EPI is clinically important for appropriate nutritional support and initiating pancreatic enzyme replacement therapy (PERT) which could significantly improve patient outcomes. The evaluation of nutritional status and related unique management in children with EPI will be discussed in this review.
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Affiliation(s)
- Yuhua Zheng
- Gastroenterology, Hepatology and Nutrition, Children’s Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - Shikib Mostamand
- Gastroenterology, Hepatology, and Nutrition, Stanford Children’s Health & Stanford University School of Medicine, Palo Alto, CA, United States
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Lukas JG, Reichert MJ, Jones GM. Use of Prothrombin Complex Concentrate in Oral Anticoagulant-Associated Major Bleeding. Crit Care Nurs Q 2022; 45:167-179. [PMID: 35212656 DOI: 10.1097/cnq.0000000000000399] [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: 11/26/2022]
Abstract
Severe bleeding remains the most significant adverse effect associated with both warfarin and the direct oral anticoagulant agents. Due to the life-threatening nature of these bleeds, knowledge and understanding of agents that are able to rapidly overcome the anticoagulation effects of these medications is paramount to their use. Worldwide, the most commonly used agent for this indication is prothrombin complex concentrate (PCC). This review summarizes the evidence on the use of PCC in this population and provides practical information regarding patient-specific administration considerations.
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Affiliation(s)
- Jack G Lukas
- Department of Pharmacy, Methodist University Hospital, Memphis, Tennessee (Drs Lukas, Reichert, and Jones); and College of Pharmacy (Drs Lukas, Reichert, and Jones) and College of Medicine (Dr Jones), University of Tennessee Health Science Center, Memphis
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McKinney AL, Dailey LM, McMillen JC, Rowe AS. Impact of Obesity on Warfarin Reversal With Fixed-Dose Factor VIII Inhibitor Bypassing Activity (aPCC). Ann Pharmacother 2020; 55:856-862. [PMID: 33094635 DOI: 10.1177/1060028020968049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Data are limited addressing anticoagulant reversal in obese patients using activated prothrombin complex concentrate (aPCC). OBJECTIVE Assess the impact of obesity on INR reversal with fixed aPCC dosing. METHODS Institutional review board-approved, retrospective cohort conducted in a large academic medical center. Patients 18 years or older who received fixed-dose aPCC for warfarin-associated hemorrhage were included. Patients who received aPCC for any other indications or who had no follow-up INR after aPCC administration were excluded. Patients with an INR of 5 or greater received 1000 units aPCC, whereas those with INR less than 5 received 500 units aPCC, per institutional protocol. Patients were stratified into obese and nonobese based on body mass index. Primary end point was INR reversal, defined as repeat INR of 1.4 or less within 4 hours following aPCC treatment, without a repeated dose. Secondary end points included percentage change in INR, proportion of patients requiring an additional dose of aPCC, bleeding complications, thrombotic complications, hospital length of stay, and in-hospital mortality. RESULTS 259 patients were included, of whom 83 were obese (32%). A significantly higher proportion of nonobese patients achieved an INR of 1.4 or less within 4 hours of treatment (169 [96.02%] vs 69 [83.13%]; P = 0.0004). There were no differences in any secondary end points. CONCLUSION AND RELEVANCE When fixed-dose aPCC is used for warfarin reversal, obesity is associated with a significantly lower rate of INR reversal, without increased bleeding. This study adds to the limited amount of literature on aPCC dosing in obesity.
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Affiliation(s)
| | | | | | - A Shaun Rowe
- The University of Tennessee Health Science Center College of Pharmacy, Knoxville, TN, USA
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4
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Zhou E, Lord A, Boehme A, Henninger N, de Havenon A, Vahidy F, Ishida K, Torres J, Mistry EA, Mac Grory B, Sheth KN, Gurol ME, Furie K, Elkind MSV, Yaghi S. Risk of Ischemic Stroke in Patients With Atrial Fibrillation After Extracranial Hemorrhage. Stroke 2020; 51:3592-3599. [PMID: 33028172 DOI: 10.1161/strokeaha.120.029959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Anticoagulation therapy not only reduces the risk of ischemic stroke in atrial fibrillation (AF) but also predisposes patients to hemorrhagic complications. There is limited knowledge on the risk of first-ever ischemic stroke in patients with AF after extracranial hemorrhage (ECH). METHODS We conducted a retrospective study using the California State Inpatient Database including all nonfederal hospital admissions in California from 2005 to 2011. The exposure variable was hospitalization with a diagnosis of ECH with a previous diagnosis of AF. The outcome variable was a subsequent hospitalization with acute ischemic stroke. We excluded patients with stroke before or at the time of ECH diagnosis. We calculated adjusted hazard ratios for ischemic stroke during follow-up and at 6-month intervals using Cox regression models adjusted for pertinent demographics and comorbidities. In subgroup analyses, subjects were stratified by primary ECH diagnosis, severity/type of ECH, age, CHA2DS2-VASc score, or the presence/absence of a gastrointestinal or genitourinary cancer. RESULTS We identified 764 257 patients with AF (mean age 75 years, 49% women) without a documented history of stroke. Of these, 98 647 (13%) had an ECH-associated hospitalization, and 22 748 patients (3%) developed an ischemic stroke during the study period. Compared to patients without ECH, subjects with ECH had ≈15% higher rate of ischemic stroke (overall adjusted hazard ratio, 1.15 [95% CI, 1.11-1.19]). The risk appeared to remain elevated for at least 18 months after the index ECH. In subgroup analyses, the risk was highest in subjects with a primary admission diagnosis of ECH, severe ECH, gastrointestinal-type ECH, with gastrointestinal or genitourinary cancer, and age ≥60 years. CONCLUSIONS Patients with AF hospitalized with ECH may have a slightly elevated risk for future ischemic stroke. Particular consideration should be given to the optimal balance between the benefits and risks of anticoagulation therapy and the use of nonanticoagulant alternatives, such as left atrial appendage closure in this vulnerable population.
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Affiliation(s)
- Eric Zhou
- NYU Grossman School of Medicine, New York, NY (E.Z.)
| | - Aaron Lord
- Department of Neurology, NYU Langone Health, New York, NY (A.L., K.I., J.T., S.Y.)
| | - Amelia Boehme
- Department of Neurology, Vagelos College of Physicians and Surgeons (A.B., M.S.V.E.), Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health (A.B., M.S.V.E.), Columbia University, New York, NY
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Medical Center, Worcester (N.H.)
- Department of Psychiatry, University of Massachusetts, Worcester (N.H.)
| | - Adam de Havenon
- Departments of Neurology, University of Utah Medical Center, Salt Lake City (A.d.H.)
| | - Farhaan Vahidy
- Center for Outcomes Research, The Houston Methodist Neurological Institute, TX (F.V.)
| | - Koto Ishida
- Department of Neurology, NYU Langone Health, New York, NY (A.L., K.I., J.T., S.Y.)
| | - Jose Torres
- Department of Neurology, NYU Langone Health, New York, NY (A.L., K.I., J.T., S.Y.)
| | - Eva A Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN (E.A.M.)
| | - Brian Mac Grory
- Department of Neurology, Brown University, Providence, RI (B.M.G., K.F.)
| | - Kevin N Sheth
- Department of Neurology, Yale University, New Haven, CT (K.N.S.)
| | - M Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (M.E.G.)
| | - Karen Furie
- Department of Neurology, Brown University, Providence, RI (B.M.G., K.F.)
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons (A.B., M.S.V.E.), Columbia University, New York, NY
- Department of Epidemiology, Mailman School of Public Health (A.B., M.S.V.E.), Columbia University, New York, NY
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Health, New York, NY (A.L., K.I., J.T., S.Y.)
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Abstract
This article explores how to prevent and manage complications of dentoalveolar surgery. Many complications are avoidable. Surgical skills and knowledge of anatomy play an important role in prevention of complications. Prevention starts with detailed history and physical examination of the patient. Key to perioperative management of patients is risk assessment. Without a proper history and physical examination, the clinician is unable to assess the risk of performing surgery and anesthesia for each patient. Some illnesses and medications increase the risk of complications. The following complications are discussed: alveolar osteitis, displacement, fracture, hemorrhage, infection, nonhealing wound, oroantral communication, swelling, and trismus.
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Affiliation(s)
- Patrick J Louis
- Department of Oral and Maxillofacial Surgery, University of Alabama at Birmingham, 1919 7th Avenue South, SDB 419, Birmingham, AL 35294, USA.
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Yee J, Kaide CG. Emergency Reversal of Anticoagulation. West J Emerg Med 2019; 20:770-783. [PMID: 31539334 PMCID: PMC6754204 DOI: 10.5811/westjem.2018.5.38235] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 05/28/2019] [Indexed: 11/23/2022] Open
Abstract
Owing to the propensity of anticoagulated patients to bleed, a strategy for reversal of anticoagulation induced by any of the common agents is essential. Many patients are anticoagulated with a variety of agents, including warfarin, low molecular weight heparin, and the direct oral anticoagulants such as factor Xa and factor IIa inhibitors. Patients may also be using antiplatelet agents. Recommendations to reverse bleeding in these patients are constantly evolving with the recent development of specific reversal agents. A working knowledge of hemostasis and the reversal of anticoagulation and antiplatelet drugs is required for every emergency department provider. This article reviews these topics and presents the currently recommended strategies for dealing with bleeding in the anticoagulated patient.
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Affiliation(s)
- Jennifer Yee
- Wexner Medical Center, The Ohio State University, Department of Emergency Medicine, Columbus, Ohio
| | - Colin G Kaide
- Wexner Medical Center, The Ohio State University, Department of Emergency Medicine, Columbus, Ohio
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Abstract
The appropriate use of medications during Emergency Neurological Life Support (ENLS) is essential to optimize patient care. Important considerations when choosing the appropriate agent include the patient's organ function and medication allergies, potential adverse drug effects, drug interactions and critical illness and aging pathophysiologic changes. Critical medications used during ENLS include hyperosmolar therapy, anticonvulsants, antithrombotics, anticoagulant reversal and hemostatic agents, anti-shivering agents, neuromuscular blockers, antihypertensive agents, sedatives, vasopressors and inotropes, and antimicrobials. This article focuses on the important pharmacokinetic and pharmacodynamics characteristics, advantages and disadvantages and clinical pearls of these therapies, providing practitioners with essential drug information to optimize pharmacotherapy in acutely ill neurocritical care patients.
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Affiliation(s)
- Gretchen M Brophy
- Departments of Pharmacotherapy and Outcomes Science and Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA.
| | - Theresa Human
- Department of Clinical Pharmacy, Barnes-Jewish Hospital, Washington University in St. Louis, St. Louis, MO, USA
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Lindhoff-Last E. Direct oral anticoagulants (DOAC) - Management of emergency situations. Hamostaseologie 2017; 37:257-266. [PMID: 29582928 DOI: 10.5482/hamo-16-11-0043] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The worldwide increase in the aging population and the associated increase in the prevalence of atrial fibrillation and venous thromboembolism as well as the widespread use of direct oral anticoagulants (DOAC) have resulted in an increase of the need for the management of bleeding complications and emergency operations in frail, elderly patients, in clinical practice. When severe bleeding occurs, general assessment should include evaluation of the bleeding site, onset and severity of bleeding, renal function, and concurrent medications with focus on anti-platelet drugs and nonsteroidal anti-inflammatory drugs (NSAID). The last intake of the DOAC and its residual concentration are also relevant. The site of bleeding should be immediately localized, anticoagulation should be interrupted, and local measures to stop bleeding should be taken. In life-threatening bleeding or emergency operations immediate reversal of the antithrombotic effect may be indicated. If relevant residual DOAC-concentrations are expected and surgery cannot be postponed, prothrombin complex concentrate (PCC) and/or a specific antidote should be given. While idarucizumab, the specific antidote for dabigatran, has been recently approved for clinical use, the recombinant factor X protein andexanet alfa, an antidote for the reversal of inhibitors of coagulation factor Xa, and ciraparantag, a universal antidote, are not available. Future cohort studies are necessary to assess the efficacy and safety of specific and unspecific reversal agents in "real-life" conditions. This was the rationale for introducing the RADOA-registry (RADOA: Reversal Agent use in patients treated with Direct Oral Anticoagulants or vitamin K antagonists), a prospective non-interventional registry, which will evaluate the effects of specific and unspecific reversal agents in patients with life-threatening bleeding or emergency operations either treated with DOACs or vitamin K antagonists.
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Levy JH, Ghadimi K, Quinones QJ, Bartz RR, Welsby I. Adjuncts to Blood Component Therapies for the Treatment of Bleeding in the Intensive Care Unit. Transfus Med Rev 2017; 31:258-263. [PMID: 28552276 DOI: 10.1016/j.tmrv.2017.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 04/11/2017] [Accepted: 04/21/2017] [Indexed: 11/19/2022]
Abstract
Patients who are critically ill following surgical or traumatic injury often present with coagulopathy as a component of the complex multisystem dysfunction that clinicians must rapidly diagnose and treat in the intensive care environment. Failure to recognize coagulopathy while volume resuscitation with crystalloid or colloid takes place, or an unbalanced transfusion strategy focused on packed red blood cell transfusion can all significantly worsen coagulopathy, leading to increased transfusion requirements and poor outcomes. Even an optimized transfusion strategy directed at correcting coagulopathy and maintaining clotting factor levels carries the risk of a number of transfusion reactions including transfusion-related acute lung injury, transfusion-related circulatory overload, anaphylaxis, and septic shock. A number of adjunctive strategies can be used either to augment a balanced transfusion approach or as alternatives to blood component therapy. Coupled with an appropriate and timely laboratory testing, this approach can quickly diagnose a patient's specific coagulopathy and work to correct it as quickly as possible, minimizing the requirement of blood transfusion and the pathophysiologic effects of excessive bleeding and fibrinolysis. We will review the literature supporting this approach and provide insight into how these approaches can be best used to care for bleeding patients in the intensive care unit. Finally, the increasing use of several novel oral anticoagulants, novel antiplatelet drugs, and low-molecular weight heparin to clinical practice has complicated the care of the coagulopathic patient when these drugs are involved. Many clinicians familiar with heparin and warfarin reversal are not familiar with the optimal way to reverse the action of these new drugs. Patients treated with these drugs for a wide variety of conditions including atrial fibrillation, stroke, coronary artery stent, deep venous thrombosis, and pulmonary embolism will present for emergency surgery and will require management of pharmacologically induced postoperative coagulopathy. We will discuss optimized strategies for reversal of these agents and strategies that are currently under development.
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Affiliation(s)
- Jerrold H Levy
- Division of Cardiothoracic Anesthesiology, Dept. of Anesthesiology, Duke University, Durham, NC.
| | - Kamrouz Ghadimi
- Division of Cardiothoracic Anesthesiology, Dept. of Anesthesiology, Duke University, Durham, NC
| | - Quintin J Quinones
- Division of Cardiothoracic Anesthesiology, Dept. of Anesthesiology, Duke University, Durham, NC
| | - Raquel R Bartz
- Division of Cardiothoracic Anesthesiology, Dept. of Anesthesiology, Duke University, Durham, NC
| | - Ian Welsby
- Division of Cardiothoracic Anesthesiology, Dept. of Anesthesiology, Duke University, Durham, NC
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Yin EB, Tan B, Nguyen T, Salazar M, Putney K, Gupta P, Suarez JI, Bershad EM. Safety and Effectiveness of Factor VIII Inhibitor Bypassing Activity (FEIBA) and Fresh Frozen Plasma in Oral Anticoagulant-Associated Intracranial Hemorrhage: A Retrospective Analysis. Neurocrit Care 2017; 27:51-59. [DOI: 10.1007/s12028-017-0383-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Nonvitamin K antagonist oral anticoagulant activity: challenges in measurement and reversal. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:273. [PMID: 27659071 PMCID: PMC5034528 DOI: 10.1186/s13054-016-1422-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Four nonvitamin K antagonist oral anticoagulants (NOACs) are approved for the prevention of stroke in patients with nonvalvular atrial fibrillation and for the treatment of venous thromboembolism. These include the direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors rivaroxaban, apixaban, and edoxaban. Bleeding is a complication for all anticoagulants and concerns regarding bleeding risk and the suitability of effective reversal strategies may be a barrier to their prescription. Despite the reduced risk of bleeding compared with vitamin K antagonists, questions persist regarding the management of bleeding related to NOAC use. Main text To date, although a number of assays are responsive to NOACs, no single routine laboratory test has been identified to accurately measure the clinical anticoagulation state of patients on NOACs or established as a reliable predictor of bleeding risk. In addition, the establishment of a reliable human bleeding model to test novel inhibitors of the coagulation cascade has proved challenging. Although routine monitoring of anticoagulant levels is not necessary in patients taking NOACs, anticoagulant reversal and a means of measuring reversal may be required for patients who present with bleeding or require urgent surgery. Prothrombin complex concentrates are pooled plasma products containing varying amounts of inactive vitamin K-dependent clotting factors in addition to vitamin K-dependent proteins and can replenish factors in the intrinsic and extrinsic coagulation cascade, reversing an anticoagulant effect. Only one agent, idarucizumab, has been approved for rapid reversal of dabigatran-induced anticoagulation and one more agent, andexanet alfa, has been submitted for approval to reverse the anticoagulatory effects of direct and indirect factor Xa inhibitors. Conclusions This review discusses the laboratory tests available for assessing anticoagulation, human models of bleeding, and the use of current strategies—including prothrombin complex concentrates for reversal of anticoagulation by NOACs—to manage bleeding in patients.
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12
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Abstract
The appropriate use of medications during Emergency Neurological Life Support (ENLS) is essential to optimize patient care. Important considerations when choosing the appropriate agent include the patient's organ function and medication allergies, potential adverse drug effects, drug interactions, and critical illness and aging pathophysiologic changes. Critical medications used during ENLS include hyperosmolar therapy, anticonvulsants, antithrombotics, anticoagulant reversal and hemostatic agents, anti-shivering agents, neuromuscular blockers, antihypertensive agents, sedatives, vasopressors and inotropes, and antimicrobials. This article focuses on the important pharmacokinetic and pharmacodynamics characteristics, advantages and disadvantages, and clinical pearls of these therapies, providing practitioners with essential drug information to optimize pharmacotherapy in acutely ill neurocritical care patients.
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13
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Emergent reversal of vitamin K antagonists: addressing all the factors. Am J Surg 2016; 211:919-25. [PMID: 27046797 DOI: 10.1016/j.amjsurg.2016.02.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 02/03/2016] [Accepted: 02/03/2016] [Indexed: 02/01/2023]
Abstract
BACKGROUND Reversal of warfarin-induced coagulopathy after traumatic injury may be done exclusively with prothrombin complex concentrates (PCCs). No direct comparisons between different PCC regimens exist to guide clinical decision-making. Our institution has used 2 distinct PCC strategies for warfarin reversal; a 3-Factor PCC (Profilnine) combined with activated Factor VII (3F-PCC+rVIIa), and a 4-Factor PCC (Kcentra) given without additional factor supplementation. METHODS Retrospective review of all PCC administrations to trauma patients with acute bleeding who were taking warfarin before injury. Primary endpoints were international normalized ratio (INR) reduction, in-hospital mortality, and diagnosis of deep venous thrombosis (DVT). RESULTS Eighty-seven patients were identified from 2011 to 2015. Fifty-three were treated with 3F-PCC+rVIIa and 34 with 4F-PCC. Patient demographics, injury severity, and presenting laboratory data were similar. The 3F-PCC+rVIIa produced a lower median (IQR) INR postreversal compared with 4F-PCC (.75 (.69, 1.00) vs 1.28 (1.13, 1.36), P<.001). Both regimens were able to obtain an INR lower than 1.5 immediately after administration (3F+rVIIA 93.9% vs 4F 97.1%, P =.51). In the 4F-PCC group, there was a significant decrease in the incidence of DVT (2.9% vs 22.6%), P < .01), and a nonsignificant reduction in mortality (2.9% vs 17.0%, P = .08). CONCLUSIONS Use of 4F-PCC for warfarin reversal after traumatic hemorrhage is associated with a less severe decrease in INR, a significant reduction in DVT rates and a trend toward reduced mortality when compared with similar patients treated with 3F-PCC+rVIIa.
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Mangram A, Oguntodu OF, Dzandu JK, Hollingworth AK, Hall S, Cung C, Rodriguez J, Yusupov I, Barletta JF. Is there a difference in efficacy, safety, and cost-effectiveness between 3-factor and 4-factor prothrombin complex concentrates among trauma patients on oral anticoagulants? J Crit Care 2016; 33:252-6. [PMID: 27021851 DOI: 10.1016/j.jcrc.2016.02.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 01/11/2016] [Accepted: 02/22/2016] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this study was to compare the efficacy, safety, and cost-effectiveness of 3-factor prothrombin complex concentrate (3F-PCC) vs 4-factor prothrombin complex concentrate PCC (4F-PCC) in trauma patients requiring reversal of oral anticoagulants. MATERIALS AND METHODS All consecutive trauma patients with coagulopathy (international normalized ratio [INR] ≥1.5) secondary to oral anticoagulants who received either 3F-PCC or 4F-PCC from 2010 to 2014 at 2 trauma centers were reviewed. Efficacy was determined by assessing the first INR post-PCC administration, and successful reversal was defined as INR less than 1.5. Safety was assessed by reviewing thromboembolic events, and cost-effectiveness was calculated using total treatment costs (drug acquisition plus transfusion costs) per successful reversal. RESULTS Forty-six patients received 3F-PCC, and 18 received 4F-PCC. Baseline INR was similar for 3F-PCC and 4F-PCC patients (3.1 ± 2.3 vs 3.4 ± 3.7, P = .520). The initial PCC dose was 29 ± 9 U/kg for 3F-PCC and 26 ± 6 U/kg for 4F-PCC (P = .102). The follow-up INR was 1.6 ± 0.6 for 3F-PCC and 1.3 ± 0.2 for 4F-PCC (P = .001). Successful reversal rates in patients were 83% for 4F-PCC and 50% for 3F-PCC (P = .022). Thromboembolic events were observed in 15% of patients with 3F-PCC vs 0% with 4F-PCC (P = .177). Cost-effectiveness favored 4F-PCC ($5382 vs $3797). CONCLUSIONS Three-factor PCC and 4F-PCC were both safe in correcting INR, but 4F-PCC was more effective, leading to better cost-effectiveness. Replacing 3F-PCC with 4F-PCC for urgent coagulopathy reversal may benefit patients and institutions.
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Affiliation(s)
| | | | | | | | - Scott Hall
- Department of Pharmacy Services, HonorHealth John C. Lincoln Medical Center.
| | - Christina Cung
- Department of Pharmacy Services, HonorHealth John C. Lincoln Medical Center.
| | - Jason Rodriguez
- Department of Pharmacy Services, HonorHealth John C. Lincoln Medical Center.
| | - Igor Yusupov
- Neurosurgery Department, HonorHealth John C. Lincoln Medical Center.
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Nishimura K, Koga M, Minematsu K, Takahashi JC, Nagatsuka K, Kobayashi J, Toyoda K. Intracerebral hemorrhage in patients after heart valve replacement. J Neurol Sci 2016; 363:195-9. [PMID: 27000250 DOI: 10.1016/j.jns.2016.02.033] [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: 08/25/2015] [Revised: 01/19/2016] [Accepted: 02/15/2016] [Indexed: 10/22/2022]
Abstract
BACKGROUNDS Although prevention of hematoma enlargement and thromboembolic complications is critically important in acute intracerebral hemorrhage (ICH) patients with prosthetic heart valves, clinical data are scarce. The goal of this study was to elucidate patient characteristics, acute treatments, and the clinical course of them. METHODS We investigated a retrospective cohort of consecutive acute ICH patients with prosthetic heart valves. Neurological data, hospital management, hemorrhagic and thromboembolic complications and functional disability/mortality were reviewed. RESULTS We identified 38 patients (27 men; 67.9±16.7 years). The median ICH volume was 22.8 ml. The most frequent location was lobar (50%). All patients with mechanical valves (25/25) and 46% of patients with bioprosthetic valves (6/13) were receiving warfarin at the time of hospital admission. The median anticoagulation withholding period was 2 days in 24 patients who ultimately resumed anticoagulation. Hematoma enlargement within 24 h was observed in eight patients and hemorrhagic complications occurred in three patients. Thromboembolic stroke occurred in four patients. At discharge, death had occurred or severe disability was present in 53% of patients (20/38). CONCLUSIONS Hematoma enlargement, hemorrhagic complications or thromboembolic stroke occurred in a significant number of patients during hospitalization. ICH was a serious complication among patients with valve replacement.
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Affiliation(s)
- Kazutaka Nishimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Masatoshi Koga
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Japan.
| | - Kazuo Minematsu
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan
| | - Jun C Takahashi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Japan
| | - Kazuyuki Nagatsuka
- Department of Neurology, National Cerebral and Cardiovascular Center, Japan
| | - Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Japan
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Limb-threatening Deep Venous Thrombosis Complicating Warfarin Reversal with Three-factor Prothrombin Complex Concentrate: A Case Report. J Emerg Med 2015; 50:28-31. [PMID: 26603365 DOI: 10.1016/j.jemermed.2015.02.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 01/30/2015] [Accepted: 02/17/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Three- and four-factor prothrombin complex concentrates (PCC) are gaining popularity for acute reversal of vitamin K antagonist-associated bleeding. Although acute thrombosis after PCC administration has been described, it seems to be rare. CASE REPORT An 83-year-old woman on warfarin for history of deep venous thrombosis (DVT) presented to the Emergency Department with life-threatening gastrointestinal bleeding, requiring urgent PCC administration. After stabilization, she subsequently developed a new limb-threatening upper-extremity DVT. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: As PCC therapy gains popularity for reversal of anticoagulant-induced bleeding in urgent bleeding scenarios, the emergency physician must be aware of the complications of PCC administration, including new limb-threatening DVT.
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Reddy S, Sharma R, Grotts J, Ferrigno L, Kaminski S. Prophylactic Fresh Frozen Plasma Infusion is Ineffective in Reversing Warfarin Anticoagulation and Preventing Delayed Intracranial Hemorrhage After Falls. Neurohospitalist 2015; 5:191-6. [PMID: 26425246 DOI: 10.1177/1941874414564981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Elderly patients, with considerable fall risk, are increasingly anticoagulated to prevent thromboembolic disease. We hypothesized that a policy of prophylactic fresh frozen plasma (FFP) infusion in patients having falls would reverse vitamin K antagonists (VKAs) and that reversal would decrease delayed intracranial hemorrhage (ICH). METHODS A retrospective review of patients with trauma admitted to a level 2 community trauma center was performed from January 2010 until November 2012. Inclusion criteria were: ground level fall (GLF) with suspected head trauma, on VKA, an international normalized ratio (INR) of >1.5, and a negative head computed tomography (CT). Patients were transfused with FFP to a goal INR of <1.5 while observed. Patients were classified as reversed (REV) if the lowest INR achieved within 4 to 24 hours after initial INR was <1.5 or unreversed (NREV) if lowest INR achieved was >1.5. Chi-square and logistic regression were performed. RESULTS A total of 194 patients met the criteria. In all, 43 (22%) patients were able to be REV, and 151 (78%) patients remained NREV. Unreversed patients were male and younger (P < .05). There was no difference in mean FFP received. Unreversed patients had a higher initial INR of 3.0 compared to REV patients (2.5; P = .018). One patient developed a delayed ICH and belonged to the REV group. CONCLUSION The incidence of delayed hemorrhage was 0.5%. A strategy of prophylactic FFP infusion was ineffective in VKA reversal. We recommend against prophylactic infusion of FFP during a period of observation for patients on VKA with suspected head trauma and a negative initial CT.
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Affiliation(s)
- Subhash Reddy
- Trauma Service, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA
| | - Rohit Sharma
- Trauma Service, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA
| | - Jonathan Grotts
- Trauma Service, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA
| | - Lisa Ferrigno
- Trauma Service, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA
| | - Stephen Kaminski
- Trauma Service, Santa Barbara Cottage Hospital, Santa Barbara, CA, USA
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Karli B, Bartel B, Pavelko R. Reversal Strategies for Intracranial Hemorrhages in Patients Taking Oral Factor Xa Inhibitors. Hosp Pharm 2015; 50:569-77. [PMID: 26448667 DOI: 10.1310/hpj5007-569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Factor Xa (fXa) inhibitors are becoming more common in clinical practice due to a variety of reasons. Unfortunately, limited data are currently available on the safe and efficacious reversal of these agents. This series presents 3 patient cases of intracranial hemorrhage and illustrates the observed effect of different methodologies undertaken in an attempt to reverse the fXa inhibitors implicated. Additionally, a brief review of the current available literature in reversal strategies is provided. The appropriate reversal for fXa inhibitors at this time is unknown. The cases described indicate that the administration of fresh frozen plasma and 4-factor prothrombin complex concentrate may provide minimal benefit in reversing the coagulation abnormalities caused by fXa inhibitors. However, in a life-threatening situation, the addition of these agents should be considered to prevent further progression of the bleed.
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Affiliation(s)
- Betsy Karli
- PGY2 Critical Care Pharmacy Resident, Avera McKennan Hospital and University Health Center , Sioux Falls, South Dakota
| | - Billie Bartel
- Critical Care Clinical Specialist, PGY2 Critical Care Pharmacy Residency Program Director, Assistant Professor, Department of Pharmacy Practice, South Dakota State University College of Pharmacy , Brookings, South Dakota
| | - Rachel Pavelko
- PGY1 Pharmacy Resident, Avera McKennan Hospital and University Health Center , Sioux Falls, South Dakota
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Brown KS, Wickremasingha P, Parasrampuria DA, Weiss D, Kochan J, Dishy V, He L, Shi M. The impact of a three-factor prothrombin complex concentrate on the anticoagulatory effects of the factor Xa inhibitor edoxaban. Thromb Res 2015; 136:825-31. [PMID: 26298619 DOI: 10.1016/j.thromres.2015.07.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 07/08/2015] [Accepted: 07/09/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Edoxaban, a direct factor Xa inhibitor, is a once-daily, non-vitamin K antagonist oral anticoagulant. There is no established method to reverse the activity of non-vitamin K oral anticoagulants in cases of hemorrhage or urgent surgery. This study evaluated the ability of a 3-factor prothrombin complex concentrate (3F-PCC) to reverse the anticoagulatory effects of edoxaban. METHODS In this phase 1 study, 24 healthy subjects were randomly assigned to receive a single dose of 60 or 180mg edoxaban, followed by placebo, 25IU/kg 3F-PCC, or 50IU/kg 3F-PCC. Edoxaban pharmacokinetics and pharmacodynamics, including the primary endpoint of prothrombin time (PT) and endogenous thrombin potential (ETP), were assessed. D-dimer and prothrombin fragment 1 and 2 (F1+2) were also measured. RESULTS Overall, there were no apparent consistent effects of 3F-PCC on edoxaban pharmacokinetics. Administration of 3F-PCC 25 or 50IU/kg with edoxaban 60 or 180mg did not substantially accelerate the return of PT to baseline levels. However, infusion of 3F-PCC 25 and 50IU/kg did substantially accelerate return to baseline of ETP compared with placebo. D-dimer and F1+2 data did not indicate any lasting procoagulant effects of 3F-PCC infusion, although a transient increase in F1+2 was noted during and after 3F-PCC infusion. Edoxaban and 3F-PCC co-administration was well tolerated in normal healthy subjects. CONCLUSIONS There was no apparent reversal of PT prolongation with 3F-PCC following edoxaban infusion, but ETP was completely reversed. Co-administration of 3F-PCC was well tolerated, but a dose-dependent increase in F1+2 may reflect a procoagulant risk.
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Affiliation(s)
- Karen S Brown
- Daiichi Sankyo Pharma Development, Edison, NJ, United States.
| | | | | | | | - Jarema Kochan
- Daiichi Sankyo Pharma Development, Edison, NJ, United States
| | - Victor Dishy
- Daiichi Sankyo Pharma Development, Edison, NJ, United States
| | - Ling He
- Daiichi Sankyo Pharma Development, Edison, NJ, United States
| | - Minggao Shi
- Daiichi Sankyo Pharma Development, Edison, NJ, United States
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New oral anticoagulants - a practical guide. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2015; 12:111-8. [PMID: 26336492 PMCID: PMC4550032 DOI: 10.5114/kitp.2015.52851] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 08/05/2014] [Accepted: 05/22/2015] [Indexed: 01/30/2023]
Abstract
Oral direct inhibitors of thrombin and activated factor Xa are approved as new anticoagulant drugs. In contrast to vitamin K antagonists (VKA) and heparins, the new agents have single targets in the coagulation cascade and more predictable pharmacokinetics, but they lack validated and available antidotes. Unlike VKA, they do not require routine monitoring of coagulation. However, the measurement of their pharmacologic effects might be of value in selected patients. They interfere with the routine coagulation tests, which should be interpreted with caution. Specific tests exist and can be used in case of emergencies. Adequate supportive care and temporary removal of all antithrombotic agents constitute the basis for management of serious bleeding complications. The administration of coagulation factors, such as fresh frozen plasma, prothrombin complex concentrates or recombinant activated FVII, can benefit in life-threatening bleeding or emergency surgery. Specific antidotes for non-vitamin K oral anticoagulants are in clinical development. This review aims at answering in a brief and simplified manner some clinical questions.
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Gomes JA, Ahrens CL, Hussain MS, Winners S, Rasmussen PA, Uchino K. Prehospital Reversal of Warfarin-Related Coagulopathy in Intracerebral Hemorrhage in a Mobile Stroke Treatment Unit. Stroke 2015; 46:e118-20. [DOI: 10.1161/strokeaha.115.008483] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Accepted: 02/25/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Joao A. Gomes
- From the Cerebrovascular Center, Neurological Institute (J.A.G., M.S.H., S.W., P.A.R., K.U.) and Department of Pharmacy (C.L.A.), Cleveland Clinic, OH
| | - Christine L. Ahrens
- From the Cerebrovascular Center, Neurological Institute (J.A.G., M.S.H., S.W., P.A.R., K.U.) and Department of Pharmacy (C.L.A.), Cleveland Clinic, OH
| | - Muhammad Shazam Hussain
- From the Cerebrovascular Center, Neurological Institute (J.A.G., M.S.H., S.W., P.A.R., K.U.) and Department of Pharmacy (C.L.A.), Cleveland Clinic, OH
| | - Stacey Winners
- From the Cerebrovascular Center, Neurological Institute (J.A.G., M.S.H., S.W., P.A.R., K.U.) and Department of Pharmacy (C.L.A.), Cleveland Clinic, OH
| | - Peter A. Rasmussen
- From the Cerebrovascular Center, Neurological Institute (J.A.G., M.S.H., S.W., P.A.R., K.U.) and Department of Pharmacy (C.L.A.), Cleveland Clinic, OH
| | - Ken Uchino
- From the Cerebrovascular Center, Neurological Institute (J.A.G., M.S.H., S.W., P.A.R., K.U.) and Department of Pharmacy (C.L.A.), Cleveland Clinic, OH
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Bordeleau S, Poitras J, Marceau D, Breton C, Beaupré P, Archambault PM. Use of prothrombin complex concentrate in warfarin anticoagulation reversal in the emergency department: a quality improvement study of administration delays. BMC Health Serv Res 2015; 15:106. [PMID: 25880097 PMCID: PMC4365812 DOI: 10.1186/s12913-015-0775-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Accepted: 03/02/2015] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Quick reversal of warfarin anticoagulation is important in life threatening bleeding. The aim of this study is to improve the administration delay when using Prothrombin Complex Concentrate (PCC) for the emergent reversal of warfarin anticoagulation in the emergency department. METHODS An audit and feedback quality improvement project was conducted in three phases: a retrospective audit phase, an analysis and feedback phase and prospective evaluation phase. The charts of all eligible patients in a single Emergency Department (ED) in Québec, Canada, who received PCC since the introduction of this product in 2009 until October 31, 2011, were retrospectively audited. The administration delay of PCC was calculated from the time of prescription to the time of administration. With the data, we determined where improvements could be attained, and jointly with all stakeholders in the ED and the blood bank, we created an action plan to ensure the timely administration of PCC. The action plan was then implemented and a six-month prospective evaluation study was conducted to determine any improvement. RESULTS Seventy-seven charts were reviewed in the retrospective chart audit. The mean administration delay was 73.6 minutes (STD [34.1]) with a median of 70.0 minutes (25-75% IQR [45.0-95.0]). We found that this delay was principally due to the following barriers: communication problems between the ED and the blood bank as well as delivery inefficiencies. An action plan that involved a flowchart to remind all clinicians how to order PCC and a new delivery method from the blood bank to the ED were developed. During the 6 months following the implementation of our action plan, 39 patients received PCC and the mean administration time decreased to 33.2 minutes (STD [14.2])(p < .0001) with a median of 30.0 minutes (25-75% IQR [24.3-38.8]). CONCLUSION By implementing an action plan comprising of a flowchart and a new delivery process, this audit and feedback quality improvement project reduced the administration time of PCC by more than half. Future studies to measure the impact of a similar audit and feedback process involving an action plan in other centers should be conducted before this type of quality improvement process is implemented on wider scale.
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Affiliation(s)
- Simon Bordeleau
- Emergency Medicine Training Program, Département de médecine familiale et médecine d'urgence, Université Laval, Québec, QC, Canada.
| | - Julien Poitras
- Centre de santé et de services sociaux Alphonse-Desjardins (Centre hospitalier affilié universitaire de Lévis), Lévis, QC, Canada.
- Département de médecine familiale et médecine d'urgence, Université Laval, Québec, QC, Canada.
| | - Danièle Marceau
- Centre de santé et de services sociaux Alphonse-Desjardins (Centre hospitalier affilié universitaire de Lévis), Lévis, QC, Canada.
- Blood bank director, Quebec, Province of Quebec, Région 12, Canada.
| | - Carolle Breton
- Transfusion Safety Officer, Quebec, Province of Quebec, Région 12, Canada.
| | - Pierre Beaupré
- Centre de santé et de services sociaux Alphonse-Desjardins (Centre hospitalier affilié universitaire de Lévis), Lévis, QC, Canada.
- Département de médecine familiale et médecine d'urgence, Université Laval, Québec, QC, Canada.
| | - Patrick M Archambault
- Centre de santé et de services sociaux Alphonse-Desjardins (Centre hospitalier affilié universitaire de Lévis), Lévis, QC, Canada.
- Département de médecine familiale et médecine d'urgence, Université Laval, Québec, QC, Canada.
- Division de soins intensifs, Département d'anesthésiologie, Université Laval, Québec, QC, Canada.
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Cao H, Tian Q, Huang Y, Ye S, Xin Y, Lin F, Li C. Biochemical characterization of prothrombin complex concentrates in China. Biologicals 2015; 43:84-91. [PMID: 25648383 DOI: 10.1016/j.biologicals.2015.01.001] [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: 09/17/2014] [Revised: 12/29/2014] [Accepted: 01/12/2015] [Indexed: 10/24/2022] Open
Abstract
Despite increasing use of prothrombin complex concentrates (PCCs), there is little knowledge about the biochemical characterization of Chinese PCCs. Six Chinese PCCs were investigated and compared with PCCs (Octaplex®) from Europe. The levels of coagulation factors and inhibitors were detected. The presence of activated coagulation factors was assessed. Furthermore, their thrombin inhibitory capacities, specific activity and purity were assayed. All above parameters of biochemical properties were statistically analyzed. Chinese PCCs contained FⅡ, Ⅶ, Ⅸ and Ⅹ, protein C, S and Z, heparin and extremely low level antithrombin, as well as Octaplex®. The measured FⅨ activities were similar to those declared, however the measured potency of FⅡ, Ⅶ and Ⅹ greatly exceeded the labeled. Though all preparations were negative for activated coagulation factors in non-activated partial thromboplastin time test, the activated coagulation factor Ⅶ (FⅦa) remained in all PCCs and its content differed greatly. Overall, FⅦa content of Chinese PCCs was higher than that of Octaplex®. Further, Chinese PCCs were inferior to Octaplex® in the thrombin inhibitory capacities, specific activity and purity. In summary, compared with Octaplex®, Chinese PCCs' errors about the labeled activity of coagulation factors and probably high risks of thrombosis should be considered.
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Affiliation(s)
- Haijun Cao
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences & Peking Union Medical College, 610052 Chengdu, China
| | - Qian Tian
- College of Chemical Engineering, Sichuan University, 610065 Chengdu, China
| | - Yun Huang
- School of Materials Science and Engineering, Southwest Petroleum University, 610500 Chengdu, China
| | - Shengliang Ye
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences & Peking Union Medical College, 610052 Chengdu, China
| | - Ye Xin
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences & Peking Union Medical College, 610052 Chengdu, China
| | - Fangzhao Lin
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences & Peking Union Medical College, 610052 Chengdu, China
| | - Changqing Li
- Institute of Blood Transfusion, Chinese Academy of Medical Sciences & Peking Union Medical College, 610052 Chengdu, China.
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24
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Évolution dans la prise en charge des accidents hémorragiques liés aux antivitamines K et traités par du concentré de complexes prothrombiniques : la gestion du traitement médicamenteux par les urgentistes s’est-elle améliorée au fil du temps ? ANNALES FRANCAISES DE MEDECINE D URGENCE 2015. [DOI: 10.1007/s13341-015-0502-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Chu C, Tokumaru S, Izumi K, Nakagawa K. Obesity increases risk of anticoagulation reversal failure with prothrombin complex concentrate in those with intracranial hemorrhage. Int J Neurosci 2014; 126:62-6. [DOI: 10.3109/00207454.2014.993034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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26
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Davis EM, Uhlmeyer EM, Schmidt DP, Schardt GL. Strategies for urgent reversal of target-specific oral anticoagulants. Hosp Pract (1995) 2014; 42:108-25. [PMID: 25485923 DOI: 10.3810/hp.2014.12.1164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The direct thrombin inhibitor dabigatran and factor Xa inhibitors rivaroxaban and apixaban are US Food and Drug Administration (FDA)-approved target-specific oral anticoagulants (TSOACs) that have emerged onto the market for use in some indications similar to those for warfarin; in addition, edoxaban is seeking FDA approval. Similar indications include reducing the risk of stroke and systemic embolism in patients with nonvalvular atrial fibrillation for all 3 agents, for the prevention of deep vein thrombosis that may lead to pulmonary embolism in patients undergoing hip or knee surgery for rivaroxaban and apixaban, and for the treatment and prevention of deep vein thrombosis and pulmonary embolism. As anticoagulants, they are all associated with a risk of bleeding, and, unfortunately, there are no approved antidotes for reversal of these agents. A number of small studies in human subjects and in human/animal models exposed to TSOACs have evaluated the use of activated charcoal, hemodialysis for dabigatran, or clotting factor concentrates for their ability to neutralize the anticoagulant effects or reduce drug concentrations of TSOACs. Clotting factor concentrates that have been used include prothrombin complex concentrates and recombinant factor VII. This review examines studies and case reports evaluating these strategies for expedited or emergent reversal of TSOACs.
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Affiliation(s)
- Estella M Davis
- Associate Professor of Pharmacy Practice, Creighton University School of Pharmacy and Health Professions, Omaha, NE.
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Unold D, Tormey CA. Clinical Applications of 4-Factor Prothrombin Complex Concentrate: A Practical Pathologist's Perspective. Arch Pathol Lab Med 2014; 139:1568-75. [DOI: 10.5858/arpa.2014-0366-rs] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
A 4-factor prothrombin complex concentrate (4F-PCC), containing therapeutic doses of vitamin K–dependent coagulation factors, was recently licensed in the United States for reversal of vitamin K antagonist therapy. However, given the emergence of several oral anticoagulants for which there are no specific reversal agents, and the existence of many other complex bleeding disorders, it is likely that clinicians will seek to use 4F-PCCs for any number of off-label indications. Thus, the goal of this review is to explore practical issues regarding 4F-PCC, with an emphasis on issues relevant to blood bankers and pathologists. Specifically, our aims are to (1) examine the role of 4F-PCC in vitamin K antagonist reversal, (2) review its potential use in the treatment of hemorrhage due to novel oral anticoagulants, and (3) explore potential uses in liver disease, trauma-associated bleeding, and rare coagulopathies. Safety and other practical considerations of 4F-PCCs will also be discussed.
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Affiliation(s)
- David Unold
- From the Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut (Drs Unold and Tormey); BloodSource, Inc, Mather, California (Dr Unold); and Pathology & Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven, Connecticut (Dr Tormey)
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28
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Yates S, Sarode R. Reversal of Anticoagulant Effects in Patients with Intracerebral Hemorrhage. Curr Neurol Neurosci Rep 2014; 15:504. [DOI: 10.1007/s11910-014-0504-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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29
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Matsushima K, Benjamin E, Demetriades D. Prothrombin complex concentrate in trauma patients. Am J Surg 2014; 209:413-7. [PMID: 25457236 DOI: 10.1016/j.amjsurg.2014.08.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2014] [Revised: 07/30/2014] [Accepted: 08/04/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Despite recent advances, trauma care providers nowadays face a number of coagulopathic patients. Coagulopathy in trauma patients can be secondary to the traumatic insult or therapeutic effect of the anticoagulants including the Vitamin K antagonist. The efficacy of a concentrated product of Vitamin K-dependent coagulation factors, prothrombin complex concentrate (PCC), to reverse coagulopathy has been tested mainly in nontrauma setting. DATA SOURCES Currently available literature on the use of PCC was identified by searches of electronic database. The indications (trauma vs nontrauma) and types of the PCC products (3 vs 4 factors) were also reviewed in each article. CONCLUSIONS There are small studies that show promising results regarding PCC use to reverse the Vitamin K antagonist-related coagulopathy in trauma patients. It remains unanswered whether PCC can be effective as an adjunct in patients who require massive transfusion.
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Affiliation(s)
- Kazuhide Matsushima
- Division of Acute Care Surgery, University of Southern California, 1200 North State Street, Inpatient Tower (C), Room C5L100, Los Angeles, CA 90033, USA.
| | - Elizabeth Benjamin
- Division of Acute Care Surgery, University of Southern California, 1200 North State Street, Inpatient Tower (C), Room C5L100, Los Angeles, CA 90033, USA
| | - Demetrios Demetriades
- Division of Acute Care Surgery, University of Southern California, 1200 North State Street, Inpatient Tower (C), Room C5L100, Los Angeles, CA 90033, USA
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Steiner T, Al-Shahi Salman R, Beer R, Christensen H, Cordonnier C, Csiba L, Forsting M, Harnof S, Klijn CJM, Krieger D, Mendelow AD, Molina C, Montaner J, Overgaard K, Petersson J, Roine RO, Schmutzhard E, Schwerdtfeger K, Stapf C, Tatlisumak T, Thomas BM, Toni D, Unterberg A, Wagner M. European Stroke Organisation (ESO) guidelines for the management of spontaneous intracerebral hemorrhage. Int J Stroke 2014; 9:840-55. [PMID: 25156220 DOI: 10.1111/ijs.12309] [Citation(s) in RCA: 495] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Accepted: 05/23/2014] [Indexed: 01/15/2023]
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) accounted for 9% to 27% of all strokes worldwide in the last decade, with high early case fatality and poor functional outcome. In view of recent randomized controlled trials (RCTs) of the management of ICH, the European Stroke Organisation (ESO) has updated its evidence-based guidelines for the management of ICH. METHOD A multidisciplinary writing committee of 24 researchers from 11 European countries identified 20 questions relating to ICH management and created recommendations based on the evidence in RCTs using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RESULTS We found moderate- to high-quality evidence to support strong recommendations for managing patients with acute ICH on an acute stroke unit, avoiding hemostatic therapy for acute ICH not associated with antithrombotic drug use, avoiding graduated compression stockings, using intermittent pneumatic compression in immobile patients, and using blood pressure lowering for secondary prevention. We found moderate-quality evidence to support weak recommendations for intensive lowering of systolic blood pressure to <140 mmHg within six-hours of ICH onset, early surgery for patients with a Glasgow Coma Scale score 9-12, and avoidance of corticosteroids. CONCLUSION These guidelines inform the management of ICH based on evidence for the effects of treatments in RCTs. Outcome after ICH remains poor, prioritizing further RCTs of interventions to improve outcome.
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Affiliation(s)
- Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany; Department of Neurology, Heidelberg University, Heidelberg, Germany
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Abstract
Acute ischemic stroke is the fourth leading cause of death and the leading cause of disability in the United States. Stroke is a medical emergency. The development of stroke systems of care has changed the way practitioners view and treat this devastating disease. Ample evidence has shown that patients presenting early and receiving intravenous thrombolytic therapy have the best chance for significant improvement in functional outcome, particularly if they are transported to specialized stroke centers. Early detection and management of medical and neurologic complications is key at preventing further brain damage in patients with acute ischemic stroke.
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Affiliation(s)
- Nelson J Maldonado
- Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB302, Houston, TX 77030, USA
| | - Syed O Kazmi
- Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB302, Houston, TX 77030, USA
| | - Jose Ignacio Suarez
- Division of Vascular Neurology and Neurocritical Care, Department of Neurology, Baylor College of Medicine, One Baylor Plaza, MS NB302, Houston, TX 77030, USA.
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Mani H, Lindhoff-Last E. New oral anticoagulants in patients with nonvalvular atrial fibrillation: a review of pharmacokinetics, safety, efficacy, quality of life, and cost effectiveness. DRUG DESIGN DEVELOPMENT AND THERAPY 2014; 8:789-98. [PMID: 24970997 PMCID: PMC4069048 DOI: 10.2147/dddt.s45644] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Atrial fibrillation (AF) continues to be a leading cause of cerebrovascular morbidity and mortality resulting from cardioembolic stroke. Oral anticoagulation therapy has been shown to decrease the incidence of cardioembolic stroke in patients with AF by more than 50%. Appropriate use of anticoagulation with vitamin K antagonists requires precise adherence and monitoring. A number of factors that potentially induce patients’ dissatisfaction reduce quality of patient life. New direct oral anticoagulants, such as the direct factor Xa inhibitors rivaroxaban, apixaban, edoxaban, and the thrombin inhibitor dabigatran, were developed to overcome the limitations of the conventional anticoagulant drugs. However, models to optimize the benefit of therapy and to ensure that therapy can be safely continued are missing for the new oral anticoagulants. This review will briefly describe the new oral anticoagulants dabigatran, rivaroxaban, apixaban, and edoxaban with focus on their use for prevention of embolic events in AF. Moreover, it will discuss the safety, efficacy, cost data, and benefit for patients’ quality of life and adherence.
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Affiliation(s)
- Helen Mani
- Johann Wolfgang Goethe-University Hospital Frankfurt/Main, Department of Internal Medicine, Division of Haemostasis, Frankfurt, Germany
| | - Edelgard Lindhoff-Last
- Johann Wolfgang Goethe-University Hospital Frankfurt/Main, Department of Internal Medicine, Division of Haemostasis, Frankfurt, Germany
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Tilton R, Michalets EL, Delk B, Sutherland SE, Ramming SA. Outcomes Associated With Prothrombin Complex Concentrate for International Normalized Ratio Reversal in Patients on Oral Anticoagulants With Acute Bleeding. Ann Pharmacother 2014; 48:1106-1119. [PMID: 24899340 DOI: 10.1177/1060028014537897] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Management of bleeding in patients on oral anticoagulants (OACs) is crucial in optimizing outcomes. No large studies examine 3-factor prothrombin complex concentrate (PCC) for OAC reversal. OBJECTIVE To assess outcomes after administration of 3-factor PCC for reversal of international normalized ratio (INR). METHOD We conducted an institutional review board-approved retrospective cohort study in all patients admitted to our level II trauma center over a 5-year period from 2007 to 2012 who received PCC for INR reversal and bleeding management. The primary outcome was assessment of efficacy as measured by achievement of INR < 1.5. Secondary objectives were to evaluate: factors associated with achievement of target INR, cessation of bleeding, mortality, outcome differences with or without fresh frozen plasma (FFP) or protocol utilization, safety, and cost. RESULT A total of 403 patients were evaluated. Target INR was achieved in 88.8% of patients and was influenced by baseline INR. Associated factors were younger age (P = 0.02), utilization of the institution's protocol (P < 0.01), and concomitant administration of vitamin K (P < 0.01). Concomitant FFP did not affect achievement. Bleeding cessation occurred in 333 (82.6%) patients, and 68 (16.9%) patients died. Patients who achieved target INR were more likely to have bleeding cessation (P < 0.01). The odds of survival for those who reached target INR was 3.8 times greater (P < 0.01). The incidence of thromboembolism was 3.7%. CONCLUSION Three-factor PCC administration with IV vitamin K was effective for INR reversal and bleeding cessation and should continue to be a mainstay of therapy pending head-to-head outcome and cost comparisons with 4-factor products.
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Affiliation(s)
- Ryan Tilton
- Mission Health System Department of Pharmacy, Asheville, NC, USA
| | - Elizabeth Landrum Michalets
- Mission Health System Department of Pharmacy, Asheville, NC, USA University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Bethany Delk
- University of Virginia Health System Department of Pharmacy, Charlottesville, VA, USA
| | | | - Scott A Ramming
- Mission Health System and Carolina Mountain Emergency Medicine, Asheville, NC, USA
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Parand A, Honar N, Aflaki K, Imanieh MH, Haghighat M, Cohan N, Haghpanah S, Marietta M, Serati Z, Haghbin S, Karimi M. Management of Bleeding in Post-liver Disease, Surgery and Biopsy in Patients With High Uncorrected International Normalized Ratio With Prothrombin Complex Concentrate: An Iranian Experience. IRANIAN RED CRESCENT MEDICAL JOURNAL 2014; 15:e12260. [PMID: 24693388 PMCID: PMC3955503 DOI: 10.5812/ircmj.12260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Revised: 08/13/2013] [Accepted: 11/18/2013] [Indexed: 12/13/2022]
Abstract
Background: To evaluate the efficacy of prothrombin complex concentrate (PCC) in the management of bleeding in patients with liver disease and patients undergoing surgery or biopsy who had a high uncorrected international normalized ratio (INR). Objectives: In this study, we examined an Iranian sample and investigated the efficacy of PCC to manage bleeding in patients with liver disease and also patients with high uncorrected INR who were scheduled for surgery or biopsy. Materials and Methods: A total of 25 patients including 16 patients with post-liver disease bleeding (group 1) and 9 patients with high uncorrected INR who were scheduled for surgery or biopsy (group 2) were enrolled. All patients were treated with 25 IU/kg PCC, and efficacy was defined as any reduction in or cessation of bleeding episodes and correction of INR before surgery or biopsy. The patients were also evaluated for any adverse effects. Results: INR decreased significantly in both groups of patients, with no bleeding episodes during or after the study in group 1 and during or after surgery/biopsy in group 2. All patients tolerated the therapy well without any significant adverse effects. Conclusions: The efficacy of PCC therapy was satisfactory in this study. PCC therapy in patients with liver disease and patients undergoing surgery or biopsy seems to be effective and safe, and may be a good treatment strategy for these patients, if fresh frozen plasma or vitamin K are not effective.
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Affiliation(s)
- Alireza Parand
- Iranian Hospital, Dubai, UAE
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Naser Honar
- Pediatrics Gastroenterology Department, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Khashayar Aflaki
- Pediatric Intensive Care Unit, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Mohammad Hadi Imanieh
- Pediatrics Gastroenterology Department, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Mahmood Haghighat
- Pediatrics Gastroenterology Department, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Nader Cohan
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Sezaneh Haghpanah
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Marco Marietta
- Department of Hematology, University Hospital of Modena, Modena, Italy
| | - Zahra Serati
- Pediatric Intensive Care Unit, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Saeedeh Haghbin
- Pediatric Intensive Care Unit, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Mehran Karimi
- Hematology Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Corresponding Author: Mehran Karimi, Department of Pediatric Hematology-Oncology, Hematology Research Center, Nemazee Hospital, Shiraz University of Medical Sciences, Postal code: 7193711351, Shiraz, IR Iran, Tel/Fax: +98-7116473239, E-mail:
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Reversal of Coagulopathy Using Prothrombin Complex Concentrates is Associated with Improved Outcome Compared to Fresh Frozen Plasma in Warfarin-Associated Intracranial Hemorrhage. Neurocrit Care 2014; 21:397-406. [DOI: 10.1007/s12028-014-9972-0] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Straznitskas A, Giarratano M. Emergent Reversal of Oral Anticoagulation: Review of Current Treatment Strategies. AACN Adv Crit Care 2014. [DOI: 10.4037/nci.0000000000000000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Andrew Straznitskas
- Andrew Straznitskas is PGY2 Emergency Medicine Pharmacy Resident, Department of Pharmacy Services, Tampa General Hospital, Tampa, Florida.Melissa Giarratano is Clinical Pharmacist – Neurology Critical Care, Department of Pharmacy Services, Tampa General Hospital, 1 Tampa General Circle, Tampa, FL 33601
| | - Melissa Giarratano
- Andrew Straznitskas is PGY2 Emergency Medicine Pharmacy Resident, Department of Pharmacy Services, Tampa General Hospital, Tampa, Florida.Melissa Giarratano is Clinical Pharmacist – Neurology Critical Care, Department of Pharmacy Services, Tampa General Hospital, 1 Tampa General Circle, Tampa, FL 33601
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Oramasionwu CU, Bailey SC, Duffey KE, Shilliday BB, Brown LC, Denslow SA, Michalets EL. The association of health literacy with time in therapeutic range for patients on warfarin therapy. JOURNAL OF HEALTH COMMUNICATION 2014; 19 Suppl 2:19-28. [PMID: 25315581 DOI: 10.1080/10810730.2014.934934] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Patients on warfarin therapy need to achieve and maintain anticoagulation control in order to experience the benefits of treatment while minimizing bleeding risk. Low health literacy skills may hinder patients' ability to use and adhere to warfarin in a safe and effective manner. The authors conducted this study to evaluate the relationship between health literacy and anticoagulation control among patients on chronic warfarin therapy. Participants were recruited from 2 diverse anticoagulation clinics in North Carolina. Time in therapeutic range (TTR) for warfarin therapy was used as a measure of anticoagulation control. Health literacy was assessed using the short form of the Test of Functional Health Literacy in Adults (S-TOFHLA). Of the 198 study participants, 51% had limited health literacy (S-TOFHLA score of 0-90) and 33% had poor anticoagulation control (TTR<50%). Participants with limited health literacy were less likely to correctly answer warfarin-related knowledge questions. Limited health literacy was significantly associated with TTR<50% (adjusted odds ratio=2.34, 95% CI [1.01, 5.46]). Findings indicate that limited health literacy is associated with poor anticoagulation control for patients on warfarin therapy. Lack of medication understanding may hinder the safe and effective use of this narrow therapeutic index drug.
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Affiliation(s)
- Christine U Oramasionwu
- a Division of Pharmaceutical Outcomes and Policy , University of North Carolina , Chapel Hill , North Carolina , USA
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Reversal of Novel Anticoagulants: Role of Clotting Factors and Complex Concentrates. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2013. [DOI: 10.1007/s40138-013-0026-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Präklinische Gabe von Prothrombinkomplex-Konzentrat PPSB bei Schädel-Hirn-Trauma unter oraler Antikoagulation. Notf Rett Med 2013. [DOI: 10.1007/s10049-013-1758-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Cao H, Li C, Huang Y, Ye S, Liu B, Wang Z, Du X, Zhang X, Lin F. Influence of washing conditions on effective components of prothrombin complex concentrates. Prep Biochem Biotechnol 2013; 44:164-81. [PMID: 24152102 DOI: 10.1080/10826068.2013.803479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In order to increase the yield of prothrombin complex concentrates (PCCs) and to reduce their associated thrombotic risks, the influence of washing conditions on the yield, purity, and balance of coagulation factors (FII, FVII, FIX, and FX), and inhibitor proteins (PC, PS, PZ, and AT [antithrombin]) in PCCs was investigated by orthogonal testing, in which three variables (sodium citrate, NaCl, and pH) and their three levels were selected. It was found that AT yield and purity were extraordinarily low, and at lower NaCl content, the general yield, purity, and balance were higher, lower, and better, respectively; however, the results became contrary at higher NaCl. Moreover, within the investigated levels, NaCl was the first determinant for the yield except AT and the purity except FVII, PC, PS, and AT. Sodium citrate was the first determinant for AT yield and FVII, PS, and AT purity. The yield except FII, PS, and AT decreased and the purity except PC increased with increase of sodium citrate content. Just for PC purity, pH was the first determinant. The effect with pH fluctuation on the yield and purity was characteristically unobvious. The outcome undoubtedly supplies the guidance to further improve PCCs.
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Affiliation(s)
- Haijun Cao
- a Institute of Blood Transfusion , Chinese Academy of Medical Sciences & Peking Union Medical College , Chengdu , China
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Frumkin K. Rapid reversal of warfarin-associated hemorrhage in the emergency department by prothrombin complex concentrates. Ann Emerg Med 2013; 62:616-626.e8. [PMID: 23829955 DOI: 10.1016/j.annemergmed.2013.05.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 05/23/2013] [Accepted: 05/29/2013] [Indexed: 10/26/2022]
Abstract
Life-threatening warfarin-associated hemorrhage is common, with a high mortality. In the United States, the most commonly used therapies--fresh frozen plasma and vitamin K--are slow and unpredictable and can result in volume overload. Outside of the United States, prothrombin complex concentrates are often used instead; these pooled plasma products reverse warfarin anticoagulation in minutes rather than hours. This article reviews the literature relating to warfarin reversal with fresh frozen plasma, prothrombin complex concentrates, and recombinant factor VIIa and provides elements for a management protocol based on this literature.
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Affiliation(s)
- Kenneth Frumkin
- Emergency Medicine Department, Naval Medical Center Portsmouth, VA.
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Velthove KJ, Over J, Abbink K, Janssen MP. Viral Safety of Human Plasma–Derived Medicinal Products: Impact of Regulation Requirements. Transfus Med Rev 2013; 27:179-83. [DOI: 10.1016/j.tmrv.2013.05.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 05/23/2013] [Accepted: 05/24/2013] [Indexed: 01/04/2023]
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Prothrombin complex concentrates to reverse warfarin-induced coagulopathy in patients with intracranial bleeding. Clin Neurol Neurosurg 2013; 115:770-4. [DOI: 10.1016/j.clineuro.2012.07.006] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 05/30/2012] [Accepted: 07/01/2012] [Indexed: 11/23/2022]
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Nitzki-George D, Wozniak I, Caprini JA. Current State of Knowledge on Oral Anticoagulant Reversal Using Procoagulant Factors. Ann Pharmacother 2013; 47:841-55. [DOI: 10.1345/aph.1r724] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE: To discuss current trends and challenges in the use of procoagulants for treating bleeding caused by use of oral anticoagulants. DATA SOURCES: Literature searches of PubMed (MEDLINE), Google, and Medscape were conducted in February 2013. There were no date limitations. Search terms included anticoagulation agents, anticoagulation reversal, anticoagulation reversal agents, apixaban, clinical studies, dabigatran, 3-factor PCCs, 4-factor PCCs, FEIBA, fresh frozen plasma, human studies, pharmacology, prescribing information, rFVIIa, rivaroxaban, vitamin K, and warfarin. DATA SYNTHESIS: Warfarin has been the mainstay for the treatment and prevention of primary and secondary thrombosis in patients with cardiovascular disorders such as atrial fibrillation, deep vein thrombosis, pulmonary embolism, and stroke. Three oral anticoagulants have recently become available in the US: a direct thrombin inhibitor, dabigatran etexilate, and 2 direct factor Xa inhibitors, rivaroxaban and apixaban. Reversal strategies for anticoagulant-associated bleeding are well established for warfarin; however, strategies to stop bleeding in a patient who has taken one of the newer anticoagulants are less clear. In the US, agents available for oral anticoagulant reversal include activated prothrombin complex concentrate (APCC), 3-factor PCCs, and recombinant activated factor VII (rFVIIa). Few studies have evaluated the 3-factor PCCs, and current evidence for APCC and rFVIIa as reversal agents for dabigatran and rivaroxaban is based primarily on laboratory or animal studies, or on small studies in healthy humans and case reports. CONCLUSIONS: Patients contemplating using the new oral anticoagulants should be informed about specific clinical situations that could pose a bleeding risk such as the need for emergency surgery because no reliable antidote is available to stop the bleeding, which could prove fatal.
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Affiliation(s)
- Diane Nitzki-George
- Diane Nitzki-George PharmD, Clinical Specialist, Anticoagulation Clinic, NorthShore University HealthSystem, Glenbrook Hospital, Glenview, IL
| | - Izabela Wozniak
- Izabela Wozniak PharmD, Clinical Specialist, NorthShore University HealthSystem, Evanston Hospital, Evanston, IL
| | - Joseph A Caprini
- Joseph A Caprini MD MS FACS RVT, Clinical Professor of Surgery, Pritzker School of Medicine, The University of Chicago, Chicago, IL
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da Silva IRF, Provencio JJ. Intracerebral hemorrhage in patients receiving oral anticoagulation therapy. J Intensive Care Med 2013; 30:63-78. [PMID: 23753250 DOI: 10.1177/0885066613488732] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intracerebral hemorrhage (ICH) in patients with oral anticoagulation therapy is an increasingly prevalent problem in large part due to the aging population and the increased use of anticoagulants for patients at high risk of thrombosis. Warfarin has been virtually the only outpatient anticoagulant choice until fairly recently. The development of subcutaneously injected heparinoids, and more recently, of direct thrombin inhibitors, has made the treatment and prognostication of ICH in anticoagulated patients more difficult. In this review, we will review the current state of diagnosis, prognostication, and treatment for patients with this often-devastating type of bleeding. We will focus on warfarin therapy, because the preponderance of evidence comes from studies of warfarin treatment. Where there is evidence, we will contrast warfarin with some of the newer treatment modalities. We review the evidence of the 4 major reversal agents for warfarin, vitamin K, prothrombin complex concentrates, activated factor VII, and fresh frozen plasma as well as rational treatment choices. We offer possible treatments for the newer anticoagulants based on the limited evidence available. Finally, we review recommendations from the major societies and studies that support early and aggressive therapies in intensive care units with dedicated neurological specialists.
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Affiliation(s)
| | - J Javier Provencio
- Neurointensive Care Unit, Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA Neuroinflammation Research Center, Cleveland Clinic, Cleveland, OH, USA
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Reversing Dabigatran in Life-Threatening Bleeding Occurring During Cardiac Ablation With Factor Eight Inhibitor Bypassing Activity. Crit Care Med 2013; 41:e42-6. [DOI: 10.1097/ccm.0b013e31827caaa3] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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The clinical use of prothrombin complex concentrate. J Emerg Med 2013; 44:1201-10. [PMID: 23602147 DOI: 10.1016/j.jemermed.2012.12.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Revised: 11/21/2012] [Accepted: 12/19/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND Prothrombin complex concentrate (PCC) is an inactivated concentrate of factors II, IX, and X, with variable amounts of factor VII. Guidelines recommend the use of PCC in the setting of life-threatening bleeds, but little is known on the most effective dosing strategies and how the presenting international normalized ratio affects response to therapy. OBJECTIVES This review aims to highlight available data on monitoring techniques, address shortcomings of currently available data, the reversal of life-threatening and critical bleeds with PCC, and how this product compares to other therapeutic options used in critically ill patients. DISCUSSION PCC has been identified as a potential therapy for critically bleeding patients, but patient-specific factors, product availability, and current data should weigh the decision to use it. Most data exist regarding patients experiencing vitamin K antagonist-induced bleeding, more specifically, those with intracranial hemorrhage. PCC has also been studied in trauma-induced hemorrhage; however, it remains controversial, as its potential benefits have the abilities to become flaws in this setting. CONCLUSION Health care professionals must remain aware of the differences in products and interpret how three- versus four-factor products may affect patients, and interpret literature accordingly. The clinician must be cognizant of how to progress when treating a bleeding patient, propose a supported dosing scheme, and address the need for appropriate factor VII supplementation. At this point, PCC cannot be recommended for first-line therapy in patients with traumatic hemorrhage, and should be reserved for refractory bleeding until more data are available.
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A specific antidote for reversal of anticoagulation by direct and indirect inhibitors of coagulation factor Xa. Nat Med 2013; 19:446-51. [PMID: 23455714 DOI: 10.1038/nm.3102] [Citation(s) in RCA: 520] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Accepted: 01/23/2013] [Indexed: 11/09/2022]
Abstract
Inhibitors of coagulation factor Xa (fXa) have emerged as a new class of antithrombotics but lack effective antidotes for patients experiencing serious bleeding. We designed and expressed a modified form of fXa as an antidote for fXa inhibitors. This recombinant protein (r-Antidote, PRT064445) is catalytically inactive and lacks the membrane-binding γ-carboxyglutamic acid domain of native fXa but retains the ability of native fXa to bind direct fXa inhibitors as well as low molecular weight heparin-activated antithrombin III (ATIII). r-Antidote dose-dependently reversed the inhibition of fXa by direct fXa inhibitors and corrected the prolongation of ex vivo clotting times by such inhibitors. In rabbits treated with the direct fXa inhibitor rivaroxaban, r-Antidote restored hemostasis in a liver laceration model. The effect of r-Antidote was mediated by reducing plasma anti-fXa activity and the non-protein bound fraction of the fXa inhibitor in plasma. In rats, r-Antidote administration dose-dependently and completely corrected increases in blood loss resulting from ATIII-dependent anticoagulation by enoxaparin or fondaparinux. r-Antidote has the potential to be used as a universal antidote for a broad range of fXa inhibitors.
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Hanke AA, Joch C, Görlinger K. Long-term safety and efficacy of a pasteurized nanofiltrated prothrombin complex concentrate (Beriplex P/N): a pharmacovigilance study. Br J Anaesth 2013; 110:764-72. [PMID: 23335567 PMCID: PMC7094476 DOI: 10.1093/bja/aes501] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background The rapid reversal of the effects of vitamin K antagonists is often required in cases of emergency surgery and life-threatening bleeding, or during bleeding associated with high morbidity and mortality such as intracranial haemorrhage. Increasingly, four-factor prothrombin complex concentrates (PCCs) containing high and well-balanced concentrations of vitamin K-dependent coagulation factors are recommended for emergency oral anticoagulation reversal. Both the safety and efficacy of such products are currently in focus, and their administration is now expanding into the critical care setting for the treatment of life-threatening bleeding and coagulopathy resulting either perioperatively or in cases of acute trauma. Methods After 15 yr of clinical use, findings of a pharmacovigilance report (February 1996–March 2012) relating to the four-factor PCC Beriplex P/N (CSL Behring, Marburg, Germany) were analysed and are presented here. Furthermore, a review of the literature with regard to the efficacy and safety of four-factor PCCs was performed. Results Since receiving marketing authorization (February 21, 1996), ∼647 250 standard applications of Beriplex P/N have taken place. During this time, 21 thromboembolic events judged to be possibly related to Beriplex P/N administration have been reported, while no incidences of viral transmission or heparin-induced thrombocytopenia were documented. The low risk of thromboembolic events reported during the observation period (one in ∼31 000) is in line with the incidence observed with other four-factor PCCs. Conclusions In general, four-factor PCCs have proven to be well tolerated and highly effective in the rapid reversal of vitamin K antagonists.
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Affiliation(s)
- A A Hanke
- Department of Anesthesiology and Intensive Care, Hannover Medical School, Carl-Neuberg-Str 1, D-30625 Hannover, Germany.
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