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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 156] [Impact Index Per Article: 156.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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2
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 42] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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3
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Hindley B, Lip GYH, McCloskey AP, Penson PE. Pharmacokinetics and pharmacodynamics of direct oral anticoagulants. Expert Opin Drug Metab Toxicol 2023; 19:911-923. [PMID: 37991392 DOI: 10.1080/17425255.2023.2287472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 11/21/2023] [Indexed: 11/23/2023]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) have overtaken vitamin K antagonists to become the most widely used method of anticoagulation for most indications. Their stable and predictable pharmacokinetics combined with relatively simple dosing, and the absence of routine monitoring has made them an attractive proposition for healthcare providers. Despite the benefits of DOACs as a class, important differences exist between individual DOAC drugs in respect of their pharmacokinetic and pharmacodynamic profiles with implications for dosing and reversal in cases of major bleeding. AREAS COVERED This review summarizes the state of knowledge relating to the pharmacokinetics of dabigatran (factor IIa/thrombin inhibitor) and apixaban, edoxaban and rivaroxaban (factor Xa) inhibitors. We focus on pharmacokinetic differences between the drugs which may have clinically significant implications. EXPERT OPINION Patient-centered care necessitates a careful consideration of the pharmacokinetic and pharmacodynamic differences between DOACs, and how these relate to individual patient circumstances. Prescribers should be aware of the potential for pharmacokinetic drug interactions with DOACs which may influence prescribing decisions in patients with multiple comorbidities. In order to give an appropriate dose of DOAC drugs, accurate estimation of renal function using the Cockcroft-Gault formula using actual body weight is necessary. An increasing body of evidence supports the use of DOACs in patients who are obese, and this is becoming more routine in clinical practice.
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Affiliation(s)
- B Hindley
- Pharmacy Department, Aintree University Hospital, Liverpool, UK
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - G Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - A P McCloskey
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - P E Penson
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
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Hamidi R, Sowa A, Halperin-Goldstein S, Puthenpura V, Prozora S. Intentional overdose of rivaroxaban and alcohol: A case report. Pediatr Blood Cancer 2023; 70:e29969. [PMID: 36094312 DOI: 10.1002/pbc.29969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 08/26/2022] [Accepted: 08/13/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Rohaum Hamidi
- Department of Pediatrics, Yale New Haven Children's Hospital, 1 Park Street, New Haven, Connecticut, USA
| | - Anna Sowa
- Department of Pediatrics, Yale New Haven Children's Hospital, 1 Park Street, New Haven, Connecticut, USA.,Department of Pediatric Hematology & Oncology, Yale University School of Medicine, 333 Cedar St, New Haven, Connecticut, USA
| | - Sofia Halperin-Goldstein
- Department of Pediatrics, Yale New Haven Children's Hospital, 1 Park Street, New Haven, Connecticut, USA
| | - Vidya Puthenpura
- Department of Pediatrics, Yale New Haven Children's Hospital, 1 Park Street, New Haven, Connecticut, USA.,Department of Pediatric Hematology & Oncology, Yale University School of Medicine, 333 Cedar St, New Haven, Connecticut, USA
| | - Stephanie Prozora
- Department of Pediatrics, Yale New Haven Children's Hospital, 1 Park Street, New Haven, Connecticut, USA.,Department of Pediatric Hematology & Oncology, Yale University School of Medicine, 333 Cedar St, New Haven, Connecticut, USA
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5
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Transferability of Published Population Pharmacokinetic Models for Apixaban and Rivaroxaban to Subjects with Obesity Treated for Venous Thromboembolism: A Systematic Review and External Evaluations. Pharmaceutics 2023; 15:pharmaceutics15020665. [PMID: 36839986 PMCID: PMC9967935 DOI: 10.3390/pharmaceutics15020665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/03/2023] [Accepted: 02/14/2023] [Indexed: 02/18/2023] Open
Abstract
Apixaban and rivaroxaban have first-line use for many patients needing anticoagulation for venous thromboembolism (VTE). The pharmacokinetics of these drugs in non-obese subjects have been extensively studied, and, while changes in pharmacokinetics have been documented in obese patients, data remain scarce for these anticoagulants. The aim of this study was to perform an external validation of published population pharmacokinetic (PPK) models of apixaban and rivaroxaban in a cohort of obese patients with VTE. A literature search was conducted in the PubMed/MEDLINE, Scopus, and Embase databases following the PRISMA statement. External validation was performed using MonolixSuite software, using prediction-based and simulation-based diagnostics. An external validation dataset from the university hospitals of Brest and Rennes, France, included 116 apixaban pharmacokinetic samples from 69 patients and 121 rivaroxaban samples from 81 patients. Five PPK models of apixaban and 16 models of rivaroxaban were included, according to the inclusion criteria of the study. Two of the apixaban PPK models presented acceptable performances, whereas no rivaroxaban PPK model did. This study identified two published models of apixaban applicable to apixaban in obese patients with VTE. However, none of the rivaroxaban models evaluated were applicable. Dedicated studies appear necessary to elucidate rivaroxaban pharmacokinetics in this population.
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Delrue M, Chevillard L, Stépanian A, Dragoni A, Camoin-Jau L, Voicu S, Malissin I, Deye N, Gainnier M, Siguret V, Mégarbane B. Case series of massive direct oral anticoagulant ingestion-Treatment and pharmacokinetics data. Eur J Clin Invest 2022; 52:e13746. [PMID: 35000196 DOI: 10.1111/eci.13746] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/19/2021] [Accepted: 01/05/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOAC) are widely used due to favourable benefit/risk ratio. However, consequences of massive ingestion have been poorly investigated. OBJECTIVES We aimed to report outcome and pharmacokinetic parameters in patients who massively ingested DOACs. METHODS We conducted a 5-year cohort study including consecutive massive DOAC ingestion patients admitted to two critical care departments. Patients were managed in accordance with standards of care. We collected the main history, clinical, laboratory, management and outcome data. The time-course of plasma DOAC concentrations measured using specific assays was modelled. RESULTS Twelve patients (3F/9M; age, 55 years [41-63], median [25th-75th percentiles]) were included. Ingestions involved rivaroxaban (n = 7), apixaban (n = 3) and dabigatran (n = 2), with presumed doses of 9.4-fold [5.0-22.0] the full daily dose. Six patients received activated charcoal but no antidote nor blood-derived product. No bleeding was observed. One patient died due to refractory cardiogenic shock related to bisoprolol co-intoxication. Highest observed peak plasma concentrations were 1720 ng/ml (rivaroxaban), 750 ng/ml (apixaban) and 644 ng/ml (dabigatran). Times to reach DOAC concentration below 50 ng/ml were ~20-45 h (rivaroxaban), ~125 h (apixaban) and ~30-50 h (dabigatran). Elimination half-lives were 2.5-25.5 h (rivaroxaban), 22.0 and 36.5 h (apixaban), and 5.8 and 15.5 h (dabigatran), with substantial interindividual variability and prolongation in case of cardiovascular failure related to co-intoxicants. Charcoal administration, even if delayed, may have contributed to limit toxicity, possibly by reducing absorption and/or enteroenteric recycling. CONCLUSION No bleeding was observed in this series of massive DOAC ingestions despite elevated plasma concentrations. No patient required specific haemostatic agents. Charcoal administration should be considered to limit toxicity.
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Affiliation(s)
- Maxime Delrue
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
| | - Lucie Chevillard
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France.,INSERM, UMRS-1144, Paris University, Paris, France
| | - Alain Stépanian
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
| | - Alessandra Dragoni
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France
| | | | - Sébastien Voicu
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France.,INSERM, UMRS-1144, Paris University, Paris, France
| | - Isabelle Malissin
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France.,INSERM, UMRS-1144, Paris University, Paris, France
| | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France
| | - Marc Gainnier
- Department of Critical Care, APHM, la Timone Hospital, Marseille, France
| | - Virginie Siguret
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France.,INSERM, UMRS-1140, Paris University, Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France.,INSERM, UMRS-1144, Paris University, Paris, France
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Greenberg SM, Ziai WC, Cordonnier C, Dowlatshahi D, Francis B, Goldstein JN, Hemphill JC, Johnson R, Keigher KM, Mack WJ, Mocco J, Newton EJ, Ruff IM, Sansing LH, Schulman S, Selim MH, Sheth KN, Sprigg N, Sunnerhagen KS. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2022; 53:e282-e361. [PMID: 35579034 DOI: 10.1161/str.0000000000000407] [Citation(s) in RCA: 333] [Impact Index Per Article: 166.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | | | | | | | | | | | | | - William J Mack
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison
| | | | | | - Ilana M Ruff
- AHA Stroke Council Stroke Performance Measures Oversight Committee liaison
| | | | | | | | - Kevin N Sheth
- AHA Stroke Council Scientific Statement Oversight Committee on Clinical Practice Guideline liaison.,AAN representative
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8
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Ha CJ, Harmouche E, Howland MA, Su MK. Two Cases of Acute Direct Oral Anticoagulant Overdose Without Adverse Effect. J Pediatr Hematol Oncol 2022; 44:e447-e449. [PMID: 35200221 DOI: 10.1097/mph.0000000000002263] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/05/2021] [Indexed: 12/24/2022]
Abstract
We report 2 pediatric patients who had acute overdoses of the direct oral anticoagulants medications. Both patients were managed conservatively; neither required reversal agents or blood products nor had any major or minor bleeding events. With therapeutic usage of direct oral anticoagulants, routine coagulation studies typically are considered insufficient measures of anticoagulation and the preferred chromogenic anti-Factor Xa assay is recommended but not widely available. Using a routine hybrid heparin anti-Factor Xa assay, 1 patient demonstrated a strong linear correlation up to a serum rivaroxaban concentration of 940 ng/mL.
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Affiliation(s)
- Catherine J Ha
- Columbia University Vagelos College of Physicians and Surgeons
| | - Elie Harmouche
- Department of Emergency Medicine, Maimonides Medical Center
| | - Mary Ann Howland
- NYC Poison Control Center
- St. John's University College of Pharmacy and Health Professions
| | - Mark K Su
- NYC Poison Control Center
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York City, NY
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9
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Sibon I, Mazighi M, Smadja D. Decision-Making Process for the Management of Acute Stroke in Patients on Oral Anticoagulant: From Guidelines to Clinical Routine. Front Neurol 2022; 12:794001. [PMID: 35069423 PMCID: PMC8766998 DOI: 10.3389/fneur.2021.794001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The occurrence of both ischaemic (IS) and haemorrhagic stroke in patients on anticoagulation is a major issue due to the frequency of their prescriptions in westernised countries and the expected impact of anticoagulant activity on recanalization during an IS or on the outcomes associated with intracerebral haemorrhage (ICH). Several guidelines are available but sometimes differ in their conclusions or regarding specific issues, and their application in routine emergency settings may be limited by particular individual issues or heterogeneous local specificities. Methods: Based on the current guidelines and additional published data, the algorithms proposed in this paper aim to help the decision-making process regarding stroke management in the setting of concurrent anticoagulants by addressing specific clinical situations based on clinical variables commonly encountered in real-world practise. Results: For patients on non-vitamin K oral anticoagulants, reversion can be achieved with specific antidotes, but only idarucizumab, the specific dabigatran antidote, is indicated in both IS and ICH. Due to the low risk of a prothrombotic effect, idarucizumab can be immediately used in IS patients eligible for thrombolysis before the dabigatran concentration is known. To optimise ICH management, the time since symptom onset, with thresholds proposed at 6 and 9 hours based on the expected timing of haematoma expansion, could also to be taken into account. Conclusions: Anticoagulant reversal in patients presenting with a stroke remains a major issue, and algorithms based on a step-by-step approach may be useful for clinical practise. Real-life studies strongly support the benefits of idarucizumab availability in stroke units and emergency departments.
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Affiliation(s)
- Igor Sibon
- Stroke Unit, Department of Neurology, Bordeaux University Hospital, Bordeaux, France
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, University of Paris, Laboratory of Vascular Translational Sciences, Paris, France
| | - Didier Smadja
- Stroke Unit, INSERM U895, Department of Neurology, Centre Hospitalier Sud-Francilien, Paris-Saclay University, Corbeil-Essonnes, France
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10
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Ballerie A, Nguyen Van R, Lacut K, Galinat H, Rousseau C, Pontis A, Nédelec-Gac F, Lescoat A, Belhomme N, Guéret P, Mahé G, Couturaud F, Jégo P, Gouin-Thibault I. Apixaban and rivaroxaban in obese patients treated for venous thromboembolism: Drug levels and clinical outcomes. Thromb Res 2021; 208:39-44. [PMID: 34689080 DOI: 10.1016/j.thromres.2021.10.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/24/2021] [Accepted: 10/12/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOAC) use remains challenging in obese patients treated for Venous-Thrombo-Embolism (VTE) due to the paucity of prospective and dedicated studies. OBJECTIVE To assess rivaroxaban and apixaban concentrations at different time-points after intake, in obese patients followed at a thrombosis center and treated for VTE; to define factors associated with DOAC levels outside the on-therapy ranges; and to evaluate bleeding and thrombosis rates during follow-up. METHODS Observational prospective study in two French University hospitals. Apixaban or rivaroxaban concentrations were measured after the first visit, regardless of last intake in obese patients receiving DOAC for VTE. Concentrations were compared to published reference values for non-obese patients. Demographic, clinical, biological and therapeutic data were collected. Univariate and multivariate analyses were performed to identify factors associated to DOAC concentrations outside the on-therapy ranges. RESULTS Out of the 146 patients included, 22 (15%) had DOAC concentrations outside the on-therapy ranges, mainly in the rivaroxaban group (n = 17). Age ≤ 63 years, use of rivaroxaban and time since last intake ≤8 h were associated with DOAC concentrations outside the on-therapy ranges, in multivariable analysis. During the median follow-up of 16 months, two (1%) patients receiving apixaban had recurrent VTE. No patient had major bleeding, 11 (8%) patients had minor bleeding. CONCLUSION In this specific prospective bi-centric study dedicated to VTE obese patients, use of DOACs at fixed doses led to concentrations similar to those of non-obese patients in a high proportion of patients, without any effect of the BMI, and with risk-benefit profile comparable to non-obese patients.
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Affiliation(s)
- Alice Ballerie
- Department of Internal Medicine and Clinical Immunology, Rennes University Hospital, Rennes, France; Univ Rennes, Rennes University Hospital, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, Rennes, France
| | - Rémi Nguyen Van
- Department of Internal Medicine and Clinical Immunology, Rennes University Hospital, Rennes, France
| | - Karine Lacut
- Department of Internal Medecine and Chest Diseases, Brest University Hospital, Bretagne Occidentale University, EA 3878, CIC INSERM 1412, Brest, FCRIN INNOVTE, France
| | - Hubert Galinat
- Hematology Laboratory, Brest University Hospital, Bretagne Occidentale University, EA 3878, Brest, France
| | - Chloé Rousseau
- Clinical Investigation Center INSERM 1414, Department of Clinical Pharmacology, Rennes University Hospital, F-35033, France
| | - Adeline Pontis
- Hematology Laboratory, Rennes University Hospital, Rennes, France
| | | | - Alain Lescoat
- Department of Internal Medicine and Clinical Immunology, Rennes University Hospital, Rennes, France; Univ Rennes, Rennes University Hospital, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, Rennes, France
| | - Nicolas Belhomme
- Department of Internal Medicine and Clinical Immunology, Rennes University Hospital, Rennes, France
| | - Pierre Guéret
- Hematology Laboratory, Rennes University Hospital, Rennes, France
| | - Guillaume Mahé
- Vascular Medicine Unit, Rennes University Hospital, INSERM CIC 1414, Clinical Investigation Center, Univ Rennes, M2S - EA 7470, F-35033 Rennes, France
| | - Francis Couturaud
- Department of Internal Medecine and Chest Diseases, Brest University Hospital, Bretagne Occidentale University, EA 3878, CIC INSERM 1412, Brest, FCRIN INNOVTE, France
| | - Patrick Jégo
- Department of Internal Medicine and Clinical Immunology, Rennes University Hospital, Rennes, France; Univ Rennes, Rennes University Hospital, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, Rennes, France
| | - Isabelle Gouin-Thibault
- Univ Rennes, Rennes University Hospital, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail) - UMR_S 1085, Rennes, France; Hematology Laboratory, Rennes University Hospital, Rennes, France.
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11
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Hoegberg LCG, Shepherd G, Wood DM, Johnson J, Hoffman RS, Caravati EM, Chan WL, Smith SW, Olson KR, Gosselin S. Systematic review on the use of activated charcoal for gastrointestinal decontamination following acute oral overdose. Clin Toxicol (Phila) 2021; 59:1196-1227. [PMID: 34424785 DOI: 10.1080/15563650.2021.1961144] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION The use of activated charcoal in poisoning remains both a pillar of modern toxicology and a source of debate. Following the publication of the joint position statements on the use of single-dose and multiple-dose activated charcoal by the American Academy of Clinical Toxicology and the European Association of Poison Centres and Clinical Toxicologists, the routine use of activated charcoal declined. Over subsequent years, many new pharmaceuticals became available in modified or alternative-release formulations and additional data on gastric emptying time in poisoning was published, challenging previous assumptions about absorption kinetics. The American Academy of Clinical Toxicology, the European Association of Poison Centres and Clinical Toxicologists and the Asia Pacific Association of Medical Toxicology founded the Clinical Toxicology Recommendations Collaborative to create a framework for evidence-based recommendations for the management of poisoned patients. The activated charcoal workgroup of the Clinical Toxicology Recommendations Collaborative was tasked with reviewing systematically the evidence pertaining to the use of activated charcoal in poisoning in order to update the previous recommendations. OBJECTIVES The main objective was: Does oral activated charcoal given to adults or children prevent toxicity or improve clinical outcome and survival of poisoned patients compared to those who do not receive charcoal? Secondary objectives were to evaluate pharmacokinetic outcomes, the role of cathartics, and adverse events to charcoal administration. This systematic review summarizes the available evidence on the efficacy of activated charcoal. METHODS A medical librarian created a systematic search strategy for Medline (Ovid), subsequently translated for Embase (via Ovid), CINAHL (via EBSCO), BIOSIS Previews (via Ovid), Web of Science, Scopus, and the Cochrane Library/DARE. All databases were searched from inception to December 31, 2019. There were no language limitations. One author screened all citations identified in the search based on predefined inclusion/exclusion criteria. Excluded citations were confirmed by an additional author and remaining articles were obtained in full text and evaluated by at least two authors for inclusion. All authors cross-referenced full-text articles to identify articles missed in the searches. Data from included articles were extracted by the authors on a standardized spreadsheet and two authors used the GRADE methodology to independently assess the quality and risk of bias of each included study. RESULTS From 22,950 titles originally identified, the final data set consisted of 296 human studies, 118 animal studies, and 145 in vitro studies. Also included were 71 human and two animal studies that reported adverse events. The quality was judged to have a Low or Very Low GRADE in 469 (83%) of the studies. Ninety studies were judged to be of Moderate or High GRADE. The higher GRADE studies reported on the following drugs: paracetamol (acetaminophen), phenobarbital, carbamazepine, cardiac glycosides (digoxin and oleander), ethanol, iron, salicylates, theophylline, tricyclic antidepressants, and valproate. Data on newer pharmaceuticals not reviewed in the previous American Academy of Clinical Toxicology/European Association of Poison Centres and Clinical Toxicologists statements such as quetiapine, olanzapine, citalopram, and Factor Xa inhibitors were included. No studies on the optimal dosing for either single-dose or multiple-dose activated charcoal were found. In the reviewed clinical data, the time of administration of the first dose of charcoal was beyond one hour in 97% (n = 1006 individuals), beyond two hours in 36% (n = 491 individuals), and beyond 12 h in 4% (n = 43 individuals) whereas the timing of the first dose in controlled studies was within one hour of ingestion in 48% (n = 2359 individuals) and beyond two hours in 36% (n = 484) of individuals. CONCLUSIONS This systematic review found heterogenous data. The higher GRADE data was focused on a few select poisonings, while studies that addressed patients with unknown and or mixed ingestions were hampered by low rates of clinically meaningful toxicity or death. Despite these limitations, they reported a benefit of activated charcoal beyond one hour in many clinical scenarios.
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Affiliation(s)
- Lotte C G Hoegberg
- Department of Anesthesiology, The Danish Poisons Information Centre, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Greene Shepherd
- Division of Practice Advancement and Clinical Education, UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust and King's Health Partners, London, UK.,Clinical Toxicology, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jami Johnson
- Oklahoma Center for Poison and Drug Information, University of Oklahoma College of Pharmacy, Oklahoma City, OK, USA
| | - Robert S Hoffman
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - E Martin Caravati
- Division of Emergency Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Wui Ling Chan
- Department of Emergency Medicine, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Silas W Smith
- Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine, NYU Grossman School of Medicine, New York, NY, USA
| | - Kent R Olson
- California Poison Control System, San Francisco Division, University of California, San Francisco, California
| | - Sophie Gosselin
- Emergency Department CISSS Montérégie Centre, Greenfield Park, Canada.,Centre antipoison du Québec, Québec, Canada.,Department of Emergency Medicine, McGill Faculty of Medicine, Montreal, Canada
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12
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Grześk G, Rogowicz D, Wołowiec Ł, Ratajczak A, Gilewski W, Chudzińska M, Sinkiewicz A, Banach J. The Clinical Significance of Drug-Food Interactions of Direct Oral Anticoagulants. Int J Mol Sci 2021; 22:8531. [PMID: 34445237 PMCID: PMC8395160 DOI: 10.3390/ijms22168531] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/25/2022] Open
Abstract
Cardiovascular diseases are the most common cause of death in the world. For almost 60 years, vitamin K antagonists (VKAs) were the mainstay of anticoagulation therapy, but in recent years direct oral anticoagulants (DOACs) have become the anticoagulant treatment of choice. DOACs were initially considered drugs with no significant food interactions; however, clinical observations from daily practice have proved otherwise as interactions with food ingredients have been reported. Food, dietary supplements or herbs may contain substances that, when administered concomitantly with DOACs, can potentially affect the plasma concentration of the drugs. The aim of this paper was to evaluate the clinical significance of drug-food interactions of DOACs, such as dabigatran, rivaroxaban, apixaban, edoxaban and betrixaban. Patients treated with anticoagulants should avoid products containing St. John's wort and take special care with other food ingredients. As the interest in dietary supplements is on the rise, healthcare providers can contribute to the development of well-designed clinical trials on interactions between DOACs and food, and distribute sufficient knowledge about the proper use of these supplements among patients.
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Affiliation(s)
- Grzegorz Grześk
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Daniel Rogowicz
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Łukasz Wołowiec
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Agnieszka Ratajczak
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Wojciech Gilewski
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Małgorzata Chudzińska
- Department of Nutrition and Dietetics, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Dębowa 3 Street, 85-626 Bydgoszcz, Poland;
| | - Anna Sinkiewicz
- Department of Otolaryngology, Audiology and Phoniatrics, University Hospital No. 2, Collegium Medicum, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland;
| | - Joanna Banach
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
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13
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Non-Linear Pharmacokinetics of Oral Roscovitine (Seliciclib) in Cystic Fibrosis Patients Chronically Infected with Pseudomonas aeruginosa: A Study on Population Pharmacokinetics with Monte Carlo Simulations. Pharmaceutics 2020; 12:pharmaceutics12111087. [PMID: 33198319 PMCID: PMC7696167 DOI: 10.3390/pharmaceutics12111087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/06/2020] [Accepted: 11/10/2020] [Indexed: 11/17/2022] Open
Abstract
Roscovitine (Seliciclib), a new protein kinase inhibitor, was administered orally to adult patients with cystic fibrosis for the first time in the ROSCO-CF trial, a dose-escalation, phase IIa, randomized, controlled trial. Extensive pharmacokinetic sampling was performed up to 12 h after the first oral dose. Roscovitine and its main metabolite M3 were quantified by liquid chromatography coupled with tandem mass spectrometry. The pharmacokinetics analyses were performed by non-linear mixed effects modelling. Monte Carlo simulations were performed to assess the impact of dose on the pharmacokinetics of oral roscovitine. Twenty-three patients received oral doses ranging from 200 to 800 mg of roscovitine and 138 data points were available for both roscovitine and M3 concentrations. The pharmacokinetics was best described by a two-compartment parent-metabolite model, with a complex saturable absorption process modelled as the sum of Gaussian inverse density functions. The Monte Carlo simulations showed a dose-dependent and saturable first-pass effect leading to pre-systemic formation of M3. The treatment with proton-pump inhibitors reduced the rate of absorption of oral roscovitine. The pharmacokinetics of oral roscovitine in adult patients with cystic fibrosis was non-linear and showed significant inter-individual variability. A repeat-dose study will be required to assess the inter-occasional variability of its pharmacokinetics.
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14
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Radaelli F, Fuccio L, Paggi S, Bono CD, Dumonceau JM, Dentali F. What gastroenterologists should know about direct oral anticoagulants. Dig Liver Dis 2020; 52:1115-1125. [PMID: 32532603 DOI: 10.1016/j.dld.2020.04.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 04/24/2020] [Accepted: 04/26/2020] [Indexed: 12/11/2022]
Abstract
Direct oral anticoagulants are being increasingly used in patients with non-valvular atrial fibrillation and venous thromboembolism, due to their improved efficacy/ safety ratio, a predictable anticoagulant effect without need for routine coagulation monitoring, and fewer food and drug interactions compared with vitamin K antagonists. Gastrointestinal bleeding remains a serious complication, whose management is challenging for gastroenterologists due to the lack of a standardized clinical approach. Clinical experience on periendoscopic management of these drugs is still limited and there is a paucity of clinical data supporting guidelines recommendations', and this ultimately turns out in different, unsubstantiated and potentially harmful practices of patient management. Present study will provide a thorough revision on the risk of GI bleeding for DOAC therapy and the identification of patient risk factors to individualize treatment. Moreover, the approach to management of DOACs in case of bleeding complications is discussed, and an algorithm of different strategies in presence or not of plasma level measurement is proposed. Finally the periendoscopic management for elective procedures will be reviewed, at the light of the guideline recommendations and new evidences from observational studies.
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Affiliation(s)
- F Radaelli
- Gastroenterology Department, Valduce Hospital, Como, Italy.
| | - L Fuccio
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - S Paggi
- Gastroenterology Department, Valduce Hospital, Como, Italy
| | - C Del Bono
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - J M Dumonceau
- Gastroenterology Service, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - F Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
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15
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Baugh CW, Levine M, Cornutt D, Wilson JW, Kwun R, Mahan CE, Pollack CV, Marcolini EG, Milling TJ, Peacock WF, Rosovsky RP, Wu F, Sarode R, Spyropoulos AC, Villines TC, Woods TD, McManus J, Williams J. Anticoagulant Reversal Strategies in the Emergency Department Setting: Recommendations of a Multidisciplinary Expert Panel. Ann Emerg Med 2019; 76:470-485. [PMID: 31732375 DOI: 10.1016/j.annemergmed.2019.09.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/30/2019] [Accepted: 09/03/2019] [Indexed: 12/12/2022]
Abstract
Bleeding is the most common complication of anticoagulant use. The evaluation and management of the bleeding patient is a core competency of emergency medicine. As the prevalence of patients receiving anticoagulant agents and variety of anticoagulants with different mechanisms of action, pharmacokinetics, indications, and corresponding reversal agents increase, physicians and other clinicians working in the emergency department require a current and nuanced understanding of how best to assess, treat, and reverse anticoagulated patients. In this project, we convened an expert panel to create a consensus decision tree and framework for assessment of the bleeding patient receiving an anticoagulant, as well as use of anticoagulant reversal or coagulation factor replacement, and to address controversies and gaps relevant to this topic. To support decision tree interpretation, the panel also reached agreement on key definitions of life-threatening bleeding, bleeding at a critical site, and emergency surgery or urgent invasive procedure. To reach consensus recommendations, we used a structured literature review and a modified Delphi technique by an expert panel of academic and community physicians with training in emergency medicine, cardiology, hematology, internal medicine/thrombology, pharmacology, toxicology, transfusion medicine and hemostasis, neurology, and surgery, and by other key stakeholder groups.
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Affiliation(s)
| | - Michael Levine
- Department of Emergency Medicine, Keck School of Medicine at the University of Southern California, Los Angeles, CA
| | - David Cornutt
- Department of Emergency Medicine, Regional West Health Systems, Scottsbluff, NE
| | - Jason W Wilson
- Department of Emergency Medicine, Tampa General Hospital, Tampa, FL
| | - Richard Kwun
- Department of Emergency Medicine, Swedish/Mill Creek, Everett, WA
| | - Charles E Mahan
- Presbyterian Healthcare Services, University of New Mexico College of Pharmacy, Albuquerque, NM
| | - Charles V Pollack
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA
| | - Evie G Marcolini
- Department of Medicine, Section of Emergency Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH
| | | | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX
| | - Rachel P Rosovsky
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, MA
| | - Fred Wu
- Department of Emergency Medicine, University of California San Francisco-Fresno, Fresno, CA
| | - Ravi Sarode
- Department of Pathology and Internal Medicine (Hematology/Oncology), University of Texas Southwestern Medical Center, Dallas, TX
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Todd C Villines
- Department of Medicine, University of Virginia Health System, Charlottesville, VA
| | | | - John McManus
- Department of Emergency Medicine, Augusta University, Augusta, GA
| | - James Williams
- Department of Emergency Medicine, Covenant Medical Center, Lubbock, TX.
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16
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Kustos SA, Fasinu PS. Direct-Acting Oral Anticoagulants and Their Reversal Agents-An Update. MEDICINES 2019; 6:medicines6040103. [PMID: 31618893 PMCID: PMC6963825 DOI: 10.3390/medicines6040103] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 10/10/2019] [Accepted: 10/14/2019] [Indexed: 12/13/2022]
Abstract
Background: Over the last ten years, a new class of drugs, known as the direct-acting oral anticoagulants (DOACs), have emerged at the forefront of anticoagulation therapy. Like the older generation anticoagulants, DOACs require specific reversal agents in cases of life-threatening bleeding or the need for high-risk surgery. Methods: Published literature was searched, and information extracted to provide an update on DOACS and their reversal agents. Results: The DOACs include the direct thrombin inhibitor—dabigatran, and the factor Xa inhibitors—rivaroxaban, apixaban, edoxaban, and betrixaban. These DOACs all have a rapid onset of action and each has a predictable therapeutic response requiring no monitoring, unlike the older anticoagulants, such as warfarin. Two reversal agents have been approved within the last five years: idarucizumab for the reversal of dabigatran, and andexanet alfa for the reversal of rivaroxaban and apixaban. Additionally, ciraparantag, a potential “universal” reversal agent, is currently under clinical development. Conclusions: A new generation of anticoagulants, the DOACs, and their reversal agents, are gaining prominence in clinical practice, having demonstrated superior efficacy and safety profiles. They are poised to replace traditional anticoagulants including warfarin.
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Affiliation(s)
- Stephanie A Kustos
- Department of Pharmaceutical Sciences, College of Pharmacy & Health Sciences, Campbell University, Buies Creek, NC 27506, USA.
| | - Pius S Fasinu
- Department of Pharmaceutical Sciences, College of Pharmacy & Health Sciences, Campbell University, Buies Creek, NC 27506, USA.
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17
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Rawal A, Ardeshna D, Minhas S, Cave B, Ibeguogu U, Khouzam R. Current status of oral anticoagulant reversal strategies: a review. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:411. [PMID: 31660310 DOI: 10.21037/atm.2019.07.101] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Utilization of direct oral anticoagulants (DOAC) have steadily increased since their approval and are now recommended over warfarin for both stroke prevention in nonvalvular atrial fibrillation and treatment of venous thromboembolism (VTE). With increased DOAC use, the number of major bleeding events requiring medical intervention will continue to rise. Until 2015, warfarin maintained an advantage as the only oral anticoagulant with a specific reversal agent. Since then, idarucizumab has been approved for dabigatran reversal and recently, andexanet alfa was granted approval for the reversal of apixaban or rivaroxaban in patients with life-threatening or uncontrolled bleeding events. Due to the manufacturing practices required to yield these reversal therapies, they are available at high cost to hospital systems and as a result, have been met with resistance. Data exists describing both prothrombin complex concentrates (PCC) and andexanet alfa for DOAC reversal, however, without head-to-head comparison. Until future studies are available, current literature must be critically evaluated to aid in the clinical decision-making process of how to treat patients with life-threatening DOAC-related bleeding.
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Affiliation(s)
- Aranyak Rawal
- Department of Internal Medicine-Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Devarshi Ardeshna
- College of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sheharyar Minhas
- Department of Medicine, Nazareth Hospital, Conshohocken, PA, USA
| | - Brandon Cave
- Department of Pharmacy, Methodist University Hospital, Memphis, TN, USA
| | - Uzoma Ibeguogu
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Rami Khouzam
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN, USA
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18
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Frans G, Meeus P, Bailleul E. Resolving DOAC interference on aPTT, PT, and lupus anticoagulant testing by the use of activated carbon. J Thromb Haemost 2019; 17:1354-1362. [PMID: 31102433 DOI: 10.1111/jth.14488] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 05/08/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) affect laboratory coagulations tests. Activated carbon (AC) can be used for adsorption of DOACs during acute human intoxications. OBJECTIVES This study evaluates whether AC can also be used to resolve DOAC interference on in vitro clotting tests (prothrombin time [PT], activated partial thromboplastin time [aPTT], and lupus anticoagulant [LA] assays). PATIENTS/METHODS Interference on PT, aPTT, Liquid anti-FXa, DTI, and LA screening/confirmation (SCT and dRVVT) was determined by spiking citrated plasma from 5 adult controls with 0, 20, 40, 80, 120, or 160 mg/mL AC. DOAC concentrations, PT, and aPTT were compared before and after AC addition to citrated plasma from patients receiving DOACs (n = 29), low molecular weight heparin (n = 10), and coumarin (n = 10) therapy. Samples from 69 LA screened patients were compared before and after AC addition. RESULTS A concentration of 20 mg/mL AC had the lowest interference and was selected for further experiments. After AC addition, all DOAC concentrations were below the limit of quantification in the 29 treated patients, except for 2 apixaban samples. AC removed DOAC interference on PT and aPTT but had no impact on results obtained during coumarin or low molecular weight heparin therapy. Of 15 LA samples with interference resulting from DOAC therapy, 14 samples became negative and 1 positive after AC addition. Interference from coumarin therapy was not resolved. All 19 LA negative samples remained negative. AC treatment of the negative pooled plasma was required to avoid false-negative LA results in 21 known LA-positive samples. CONCLUSIONS AC selectively removes DOAC interference on PT, aPTT, and LA assays.
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Affiliation(s)
- Glynis Frans
- Department of Laboratory Medicine, Onze-Lieve-Vrouw Ziekenhuis, Aalst, Belgium
| | - Peter Meeus
- Department of Laboratory Medicine, Onze-Lieve-Vrouw Ziekenhuis, Aalst, Belgium
| | - Els Bailleul
- Department of Laboratory Medicine, Onze-Lieve-Vrouw Ziekenhuis, Aalst, Belgium
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19
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Lavalle C, Straito M, Caroli A, Piro A, Giunta G, Mariani MV, Fedele F. Rivaroxaban in atrial fibrillation cardioversion: an update. Ther Clin Risk Manag 2019; 15:613-626. [PMID: 31118649 PMCID: PMC6504667 DOI: 10.2147/tcrm.s201162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 04/08/2019] [Indexed: 01/02/2023] Open
Abstract
Currently, atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with a prevalence of about 2–3% in the general population, representing a powerful risk factor for stroke and systemic thromboembolism and increased mortality and morbidity. Restoration of sinus rhythm is an important treatment option in AF and has a high success rate, but there is the need for an effective anticoagulation strategy to reduce the risk of embolic events. Anticoagulation with vitamin K antagonists is often associated with failure to achieving effective international normalized ratio. In this setting, recent data have led to extended approval for rivaroxaban in clinical practice, because it is effective and safe in patients with AF undergoing cardioversion, avoiding additional health costs and related time loss, while improving patient satisfaction. The present report provides an overview of the main randomized controlled trial and the main real-life studies, documenting the use of rivaroxaban in patients with non-valvular AF who underwent the cardioversion procedure. Considering that novel non-vitamin K antagonist oral anticoagulants in left atrial appendage thrombi resolution is still unknown in the real-world practice, the main findings on the use of rivaroxaban in this setting are also discussed.
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Affiliation(s)
- Carlo Lavalle
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Martina Straito
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Annalisa Caroli
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Agostino Piro
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Giuseppe Giunta
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, "Sapienza" University of Rome, Policlinico Umberto I, Rome, Italy
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20
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Effect of an activated charcoal product (DOAC Stop™) intended for extracting DOACs on various other APTT-prolonging anticoagulants. ACTA ACUST UNITED AC 2019; 57:690-696. [DOI: 10.1515/cclm-2018-0967] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 10/02/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Background
The aim of the study was to investigate the specificity of an activated charcoal-based product (DOAC Stop™) initially intended for the specific extraction of direct oral anticoagulants (DOACs) from test plasmas on a range of other anticoagulants.
Methods
Test plasmas were prepared by adding various anticoagulants to pooled normal plasma at concentrations prolonging an activated partial thromboplastin time (APTT) test by a factor of 1.5–3. These plasmas were treated with DOAC Stop™ for 5 and 20 min. Then APTTs were repeated and residual anticoagulant concentrations estimated from dose-response curves.
Results
The activated charcoal (AC)-based product was found to extract DOACs efficiently. It also bound the intravenous anticoagulants argatroban and lepirudin, but it had no effect on heparin, enoxaparin or danaparoid in plasma. Among other APTT-inhibiting agents that might be present in test plasmas from patients, it extracted protamine, aprotinin and polymyxin. It had no effect on annexin V, thrombomodulin, a typical lupus anticoagulant, a factor VIII antibody, activated protein C or its activator, but it did bind some cationic inhibitors of the APTT with molecular weight below approximately 30 kDa.
Conclusions
The AC-based product extracted DOACs efficiently with no effect on heparin-type anticoagulants. It did bind argatroban and hirudin-type anticoagulants, which might occur in plasmas from some inpatients, and APTT results obtained after its use should be interpreted after due consideration of patient medications.
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21
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Use of DOAC Stop for elimination of anticoagulants in the thrombin generation assay. Thromb Res 2018; 170:97-101. [DOI: 10.1016/j.thromres.2018.08.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/20/2018] [Accepted: 08/21/2018] [Indexed: 11/18/2022]
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22
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Carr BM, Roy DJ, Bangh SA, Hellmich TR, Walker LE. Anti-factor Xa Monitoring and Activated Charcoal for a Pediatric Patient With Rivaroxaban Overdose. Clin Pract Cases Emerg Med 2018; 2:247-250. [PMID: 30083644 PMCID: PMC6075494 DOI: 10.5811/cpcem.2018.5.38373] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 01/13/2023] Open
Abstract
Rivaroxaban, an oral anticoagulant, directly inhibits factor Xa (FXa). A 35-month-old boy was brought to the emergency department 15 minutes after ingesting 200 mg of rivaroxaban (16 mg/kg). Activated charcoal (AC) was administered; the patient was observed with monitoring of plasma anti-FXa levels and discharged the following day after an uneventful hospital observation. We identified two case series and seven case reports of potentially toxic rivaroxaban ingestion in the literature. No serious adverse effects were reported. The present case is the first reported use of anti-FXa monitoring after rivaroxaban ingestion. The magnitude of the effect of AC administration in this patient is unclear.
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Affiliation(s)
- Brendan M Carr
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
| | - David J Roy
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota.,Mayo Clinic, Pharmacy Services, Rochester, Minnesota
| | - Stacey A Bangh
- Hennepin County Medical Center, Minneapolis, Minnesota.,Minnesota Poison Control System, Minneapolis, Minnesota
| | | | - Laura E Walker
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
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23
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Levy JH, Douketis J, Weitz JI. Reversal agents for non-vitamin K antagonist oral anticoagulants. Nat Rev Cardiol 2018; 15:273-281. [DOI: 10.1038/nrcardio.2017.223] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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