1
|
Ura H, Matsuoka N, Kubota K, Sadamoto K. Trends in prescription of anti-seizure medications in Japan between 2018 and 2021: A retrospective study using the National Database Open Data Japan. Epilepsy Behav 2024; 159:109949. [PMID: 39121754 DOI: 10.1016/j.yebeh.2024.109949] [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: 05/06/2024] [Revised: 06/13/2024] [Accepted: 07/14/2024] [Indexed: 08/12/2024]
Abstract
PURPOSE This retrospective study aimed to analyze anti-seizure medication (ASM) prescription trends in Japan, particularly among older adults and women of childbearing age, to inform future treatment strategies and optimize ASM selection criteria. METHODS Data were extracted from the National Database Open Data Japan for fiscal years (FY) 2018-2021, covering prescriptions across sex and 5-year age groups. We conducted data imputation for prescriptions under 1,000 units to maintain anonymity, calculated the estimated number of patients using standard adult maintenance doses, and adjusted for pediatric dosing using Augsberger's formula. RESULTS Our analysis revealed a 7.6% increase in ASM usage, with a notable shift from older to newer ASMs, such as levetiracetam (LEV) and lamotrigine (LTG). LEV and LTG prescriptions increased by 26.7% and 15.0% from FY 2018 to FY 2021, respectively, whereas older ASMs such as phenytoin, declined. Sex-specific analysis showed a higher LTG prescription rate among women, especially in adolescent and young adult cohorts, where the female-to-male prescription ratio increased from 1.65 to 1.85. Valproate (VPA) and LEV accounted for 57.0% of ASM prescriptions in older adults. The number of inpatient LTG prescriptions was notably lower than that of outpatient LTG prescriptions across age groups. Pediatric use of generics was lower than that in other age groups. CONCLUSION This study revealed that newer ASMs are being used increasingly, with a significant proportion of VPA continuously prescribed among women of childbearing age. In older adults, VPA and LEV accounted for more than half of the ASM prescriptions. These findings are crucial for developing future treatment strategies and improving the ASM selection criteria.
Collapse
Affiliation(s)
- Hiroyuki Ura
- Department of Clinical Pharmacy, Shonan University of Medical Science, Yokohama, Japan; Department of Pharmacy Services, Shiomidai Hospital, Yokohama, Japan.
| | - Noriko Matsuoka
- Department of Pharmacy Services, Nippon Medical School Musashi Kosugi Hospital, Kawasaki, Japan
| | - Kiyoshi Kubota
- Department of Clinical Pharmacy, Shonan University of Medical Science, Yokohama, Japan
| | - Kiyomi Sadamoto
- Department of Clinical Pharmacy, Shonan University of Medical Science, Yokohama, Japan
| |
Collapse
|
2
|
Acton EK, Hennessy S, Gelfand MA, Leonard CE, Bilker WB, Shu D, Willis AW, Kasner SE. Direct-Acting Oral Anticoagulants and Antiseizure Medications for Atrial Fibrillation and Epilepsy and Risk of Thromboembolic Events. JAMA Neurol 2024; 81:835-844. [PMID: 38976246 PMCID: PMC11231911 DOI: 10.1001/jamaneurol.2024.2057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 04/17/2024] [Indexed: 07/09/2024]
Abstract
Importance Direct-acting oral anticoagulants (DOACs) are commonly prescribed with antiseizure medications (ASMs) due to concurrency of and the association between atrial fibrillation (AF) and epilepsy. However, enzyme-inducing (EI) ASMs may reduce absorption and accelerate metabolism of DOACs, potentially lowering DOAC levels and elevating thromboembolism risk. Objective To assess the rates of thromboembolic and major bleeding events in adults with AF and epilepsy dispensed DOACs and EI ASMs vs DOACs with non-EI ASMs. Design, Setting, and Participants This active-comparator, new-user cohort study included US health care data from the Clinformatics Data Mart database from October 2010 to September 2021 for a nationally representative population of adults with AF and epilepsy. Exposure Evaluations included episodes of contiguous coadministration of DOACs for AF with EI ASMs (exposed) or non-EI ASMs (referent) for epilepsy. Main Outcomes and Measures Thromboembolic events (primary outcome) and major bleeding events (secondary outcome) were identified based on a series of validated, diagnosis-based coding algorithms. Data-adaptive, high-dimensional propensity score matching was used to control for observed confounders and proxies for unobserved confounders. Adjusted hazard ratios (AHRs) were estimated using Cox proportional hazards regression models with robust variance estimators to account for clustering within matched pairs. Results This study included 14 078 episodes (median age, 74 [IQR, 67-81]; 52.4% female) and 14 158 episodes (median age, 74 [IQR, 67-81]; 52.4% female) of incident DOAC and ASM use that met eligibility criteria for assessment of thromboembolic and major bleeding outcomes, respectively. Incidence was 88.5 per 1000 person-years for thromboembolic events and 68.3 per 1000 person-years for bleeding events. Compared with use of non-EI ASMs, use of EI ASMs with DOACs was not associated with a difference in risk of thromboembolic events (AHR, 1.10; 95% CI, 0.82-1.46) but was associated with a reduction in risk of major bleeding events (AHR, 0.63; 95% CI, 0.44-0.89). Conclusions and Relevance In this cohort study, EI ASMs were not associated with alteration in DOAC efficacy. Further research is needed on the reduction in bleeding risk associated with EI ASMs, as this may suggest that pharmacokinetic interactions are associated with lowering DOAC levels without negating therapeutic effects.
Collapse
Affiliation(s)
- Emily K. Acton
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Sean Hennessy
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Charles E. Leonard
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Warren B. Bilker
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Di Shu
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Allison W. Willis
- Center for Real-World Effectiveness and Safety of Therapeutics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Translational Center of Excellence for Neuroepidemiology and Neurology Outcomes Research, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Scott E. Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia
| |
Collapse
|
3
|
Rota E, Immovilli P, Pappalardo I, Risso R, Zuccotti G, Agosti S, Morelli N, Rovere ME, Costa I, D'Orsi ML. Direct Oral Anticoagulants and Concomitant Anti-seizure Medications: A Retrospective, Case-Control Study in a Real-World Setting. Clin Ther 2024; 46:e26-e30. [PMID: 38972763 DOI: 10.1016/j.clinthera.2024.06.002] [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: 10/18/2023] [Revised: 06/02/2024] [Accepted: 06/04/2024] [Indexed: 07/09/2024]
Abstract
PURPOSE Although prescription of direct oral anticoagulants (DOACs) for epileptic patients on anti-seizure medications (ASMs) is on the increase, international guidelines pose strict restrictions because this may lead to pharmacologic interactions. However, current evidence on their clinical relevance remains scanty. This retrospective, case-control study assessed the frequency of ischemic/hemorrhagic events and epileptic seizures involving DOAC-ASM cotherapy in the real world, compared with DOAC and ASM monotherapy, in age- and gender-matched controls. METHODS Data on patients who had been prescribed a concomitant DOAC and ASM therapy for at least 6 months were extracted from the database of the Pharmaceutical Service of the Alessandria Province (Italy). After exclusions, the case group included 124 patients, 44 on valproic acid (VPA) and 80 on levetiracetam (LEV) concomitant with a DOAC, and it was compared with the DOAC-control and ASM-control groups. The clinical and laboratory data were extracted from the electronic archives of the hospitals in the same province. FINDINGS Two (1.6%) ischemic and 2 (1.6%) major hemorrhagic events were observed in the case group. Four (3.2%) ischemic and no hemorrhagic events occurred in the DOAC-control group. There were no statistically significant differences in the ischemic and hemorrhagic events between the case group (patients on concomitant LEV or VPA who were prescribed a DOAC) and the DOAC-control group, and there was no difference in the recurrence rate of epileptic seizures between the case group and the ASM-control group. IMPLICATIONS Although this study has some limits, mainly the small sample size, our findings indicate that neither LEV nor VPA concomitant treatment significantly affects the effects of DOACs in a real-world setting.
Collapse
Affiliation(s)
- Eugenia Rota
- The Neurology Unit, San Giacomo Hospital, ASL Alessandria, Novi Ligure, Italy.
| | - Paolo Immovilli
- The Neurology Unit, Guglielmo da Saliceto Hospital, AUSLPC, Piacenza, Italy
| | - Irene Pappalardo
- The Clinical Neurophysiology and Epilepsy Unit, IRCCS San Martino Hospital, Genova, Italy
| | - Roberta Risso
- The Internal Medicine Unit, M. Ferrero Hospital, ASLCN2, Verduno, Italy
| | | | - Sergio Agosti
- The Cardiology Unit, Micone Hospital, ASL3, Sestri Ponente, Italy
| | - Nicola Morelli
- The Neurology Unit, Guglielmo da Saliceto Hospital, AUSLPC, Piacenza, Italy
| | | | - Ilaria Costa
- The Hospital Pharmacy, ASL Alessandria, Alessandria, Italy
| | | |
Collapse
|
4
|
Stöllberger C, Finsterer J, Schneider B. Interactions between antiepileptic drugs and direct oral anticoagulants for primary and secondary stroke prevention. Expert Opin Drug Metab Toxicol 2024; 20:359-376. [PMID: 38712571 DOI: 10.1080/17425255.2024.2352466] [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: 01/30/2024] [Accepted: 05/03/2024] [Indexed: 05/08/2024]
Abstract
INTRODUCTION Direct oral anticoagulants (DOAC) are the guideline-recommended therapy for prevention of stroke in atrial fibrillation (AF) and venous thromboembolism. Since approximately 10% of patients using antiepileptic drugs (AED) also receive DOAC, aim of this review is to summarize data about drug-drug interactions (DDI) of DOAC with AED by using data from PubMed until December 2023. AREAS COVERED Of 49 AED, only 16 have been investigated regarding DDI with DOAC by case reports or observational studies. No increased risk for stroke was reported only for topiramate, zonisamide, pregabalin, and gabapentin, whereas for the remaining 12 AED conflicting results regarding the risk for stroke and bleeding were found. Further 16 AED have the potential for pharmacodynamic or pharmacokinetic DDI, but no data regarding DOAC are available. For the remaining 17 AED it is unknown if they have DDI with DOAC. EXPERT OPINION Knowledge about pharmacokinetic and pharmacodynamic DDI of AED and DOAC is limited and frequently restricted to in vitro and in vivo findings. Since no data about DDI with DOAC are available for 67% of AED and an increasing number of patients have a combined medication of DOAC and AED, there is an urgent need for research on this topic.
Collapse
|
5
|
Goldstein R, Rabkin N, Buchman N, Jacobs AR, Sandouka K, Raccah B, Fisher Negev T, Matok I, Bialer M, Muszkat M. The Effect of Levetiracetam Compared with Enzyme-Inducing Antiseizure Medications on Apixaban and Rivaroxaban Peak Plasma Concentrations. CNS Drugs 2024; 38:399-408. [PMID: 38520503 PMCID: PMC11026229 DOI: 10.1007/s40263-024-01077-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/25/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND AND OBJECTIVE Post-stroke epilepsy represents an important clinical challenge as it often requires both treatment with direct oral anticoagulants (DOACs) and antiseizure medications (ASMs). Levetiracetam (LEV), an ASM not known to induce metabolizing enzymes, has been suggested as a safer alternative to enzyme-inducing (EI)-ASMs in patients treated with DOACs; however, current clinical guidelines suggest caution when LEV is used with DOACs because of possible P-glycoprotein induction and competition (based on preclinical studies). We investigated whether LEV affects apixaban and rivaroxaban concentrations compared with two control groups: (a) patients treated with EI-ASMs and (b) patients not treated with any ASM. METHODS In this retrospective observational study, we monitored apixaban and rivaroxaban peak plasma concentrations (Cmax) in 203 patients treated with LEV (n = 28) and with EI-ASM (n = 33), and in patients not treated with any ASM (n = 142). Enzyme-inducing ASMs included carbamazepine, phenytoin, phenobarbital, primidone, and oxcarbazepine. We collected clinical and laboratory data for analysis, and DOAC Cmax of patients taking LEV were compared with the other two groups. RESULTS In 203 patients, 55% were female and the mean age was 78 ± 0.8 years. One hundred and eighty-six patients received apixaban and 17 patients received rivaroxaban. The proportion of patients with DOAC Cmax below their therapeutic range was 7.1% in the LEV group, 10.6% in the non-ASM group, and 36.4% in the EI-ASM group (p < 0.001). The odds of having DOAC Cmax below the therapeutic range (compared with control groups) was not significantly different in patients taking LEV (adjusted odds ratio 0.70, 95% confidence interval 0.19-2.67, p = 0.61), but it was 12.7-fold higher in patients taking EI-ASM (p < 0.001). In an analysis in patients treated with apixaban, there was no difference in apixaban Cmax between patients treated with LEV and non-ASM controls, and LEV clinical use was not associated with variability in apixaban Cmax in a multivariate linear regression. CONCLUSIONS In this study, we show that unlike EI-ASMs, LEV clinical use was not significantly associated with lower apixaban Cmax and was similar to that in patients not treated with any ASM. Our findings suggest that the combination of LEV with apixaban and rivaroxaban may not be associated with decreased apixaban and rivaroxaban Cmax. Therefore, prospective controlled studies are required to examine the possible non-pharmacokinetic mechanism of the effect of the LEV-apixaban or LEV-rivaroxaban combination on patients' outcomes.
Collapse
Affiliation(s)
- Rachel Goldstein
- Department of Medicine, Faculty of Medicine, Hadassah Medical Center Mt. Scopus, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Clinical Pharmacy, Faculty of Medicine, Institute for Drug Research, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Natalie Rabkin
- Department of Medicine, Faculty of Medicine, Hadassah Medical Center Mt. Scopus, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Clinical Pharmacy, Faculty of Medicine, Institute for Drug Research, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Noa Buchman
- Department of Medicine, Faculty of Medicine, Hadassah Medical Center Mt. Scopus, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Aviya R Jacobs
- Department of Medicine, Faculty of Medicine, Hadassah Medical Center Mt. Scopus, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Khaled Sandouka
- Department of Medicine, Faculty of Medicine, Hadassah Medical Center Mt. Scopus, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Bruria Raccah
- Department of Clinical Pharmacy, Faculty of Medicine, Institute for Drug Research, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Cardiology, Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tamar Fisher Negev
- Department of Clinical Pharmacy, Faculty of Medicine, Institute for Drug Research, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Neurology, Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Matok
- Department of Clinical Pharmacy, Faculty of Medicine, Institute for Drug Research, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Meir Bialer
- School of Pharmacy, Institute for Drug Research, Hebrew University of Jerusalem, Mt Scopus, 91905, Jerusalem, Israel.
- David R. Bloom Center for Pharmaceutical Sciences, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Mordechai Muszkat
- Department of Medicine, Faculty of Medicine, Hadassah Medical Center Mt. Scopus, Hebrew University of Jerusalem, Jerusalem, Israel
| |
Collapse
|
6
|
Cohen H, Mahajna G, Ben-Shushan T, Matok I, Eyal S. The extent of cytochrome P450 3A induction by antiseizure medications: A systematic review and network meta-analysis. Epilepsia 2024; 65:445-455. [PMID: 38010146 DOI: 10.1111/epi.17822] [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: 09/15/2023] [Revised: 10/24/2023] [Accepted: 11/07/2023] [Indexed: 11/29/2023]
Abstract
OBJECTIVE Antiseizure medications (ASMs) are commonly categorized as enzyme-inducers and non-enzyme-inducers based on their propensity to enhance the metabolism of concomitantly administered drugs. This systematic review and network meta-analysis aimed to rank ASMs as cytochrome P450 3A (CYP3A)-inducers based on a comparative assessment of ASM-induced reduction in the concentrations of sensitive substrate drugs. METHODS The protocol was registered with PROSPERO (International Prospective Register of Systematic Reviews; CRD42022335846), and the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) standards were followed. We searched MEDLINE, Embase, and Cochrane until March 14, 2023 without an initial date restriction. Data were additionally obtained via the US Food and Drug Administration database. Studies had to be prospective, with ASM monotherapy for ≥5 days. The primary parameter was the magnitude of change in the area under the concentration-time curve of CYP3A substrates following treatment with the ASM. The standardized mean difference (SMD) was used as the point estimate for the indirect comparisons between ASMs using the pairwise method. Bias risk was assessed using the PKclin tool. RESULTS We identified 14 open-label, fixed-sequence studies with 370 participants. The effect size of 600 mg/day carbamazepine did not differ from those of 300 mg/day phenytoin (SMD = -.06, 95% confidence interval [CI] = -.18 to .07) and 200 mg/day cenobamate (SMD = -.11, 95% CI = -.26 to .04). Carbamazepine at 600 mg/day was the strongest CYP3A-inducer (P-score = .88), followed by carbamazepine 400 mg/day (.83), phenytoin 300 mg/day (.79), and cenobamate 200 mg/day (.73). Eslicarbazepine (800 mg/day) ranked higher than cenobamate 100 mg/day and oxcarbazepine 900 mg/day (.60, .39, and .37, respectively). SIGNIFICANCE Despite the limited number of studies, our network meta-analysis emphasizes that the magnitude of ASM effects on CYP3A substrate metabolism is a dose-dependent continuum. When possible, ASM classification as inducers should apply cutoff values tailored to the outcome. Prescribers should monitor plasma concentrations or clinical effects of CYP3A substrates and consider selecting concomitant medications accordingly.
Collapse
Affiliation(s)
- Hagar Cohen
- Department of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ghadeer Mahajna
- Department of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tomer Ben-Shushan
- Medical Library Authority, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Matok
- Department of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sara Eyal
- Department of Clinical Pharmacy, Faculty of Medicine, School of Pharmacy, Hebrew University of Jerusalem, Jerusalem, Israel
| |
Collapse
|
7
|
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: 231] [Impact Index Per Article: 231.0] [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.
Collapse
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
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
8
|
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: 66] [Impact Index Per Article: 66.0] [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.
Collapse
|
9
|
Ranzato F, Roberti R, Deluca C, Carta M, Peretti A, Polo D, Perini F, Russo E, Di Gennaro G. Pilot study on the probability of drug-drug interactions among direct oral anticoagulants (DOACs) and antiseizure medications (ASMs): a clinical perspective. Neurol Sci 2024; 45:277-288. [PMID: 37548755 PMCID: PMC10761387 DOI: 10.1007/s10072-023-06992-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 07/29/2023] [Indexed: 08/08/2023]
Abstract
BACKGROUND There is little and controversial information about changes in plasma concentrations (PCs) or clinical events during coadministration of antiseizure medications (ASMs) and direct oral anticoagulants (DOACs). We aimed to explore possible determinants of dosage class among DOACs trough PCs when ASMs are co-administered and the relative risks. We also provided some clinical examples of patients' management. METHODS Data on adult patients concomitantly treated with ASMs (grouped in enzyme-inducing [I-ASMs], non-inducing [nI-ASMs], and levetiracetam [LEV]) and DOACs with at least one measurement of DOACs' PC were retrospectively collected. The role of DOAC-ASM combinations in predicting PC class (ranging from I at ischemic/thromboembolic risk to IV at increased bleeding risk) was investigated by an ordered logit model, and the marginal probabilities of belonging to the four dosage classes were calculated. RESULTS We collected 46 DOACs' PCs out of 31 patients. There were 5 (10.9%) determinations in class I (4 out of 5 with concomitant I-ASMs) and 5 (10.9%) in class IV. The rivaroxaban/I-ASM combination was associated with lower DOAC dosages than rivaroxaban/LEV (OR: 0.00; 95% CI: 0.00-0.62). Furthermore, patient's probability of being in class I was approximately 50% with the rivaroxaban/I-ASM combination, while apixaban, dabigatran, and edoxaban had the highest cumulative probability of being in class II or III despite the ASM used. CONCLUSION These preliminary results confirm the reduction of DOAC's PC by I-ASMs and suggest a better manageability of apixaban, dabigatran, and edoxaban independently from the concomitant ASM, whereas rivaroxaban seems the most liable to PC alterations with I-ASMs.
Collapse
Affiliation(s)
- Federica Ranzato
- Regional Epilepsy Center, Neurology Unit, San Bortolo Hospital, Vicenza, Italy
| | - Roberta Roberti
- Science of Health Department, School of Medicine, Magna Graecia University of Catanzaro, Via T. Campanella, 115, 88100, Catanzaro, Italy
| | - Cristina Deluca
- Stroke Unit, Neurology, San Bortolo Hospital, Vicenza, Italy
| | | | - Alessia Peretti
- Regional Epilepsy Center, Neurology Unit, San Bortolo Hospital, Vicenza, Italy
| | - Diana Polo
- Regional Epilepsy Center, Neurology Unit, San Bortolo Hospital, Vicenza, Italy
| | - Francesco Perini
- Regional Epilepsy Center, Neurology Unit, San Bortolo Hospital, Vicenza, Italy
- Stroke Unit, Neurology, San Bortolo Hospital, Vicenza, Italy
| | - Emilio Russo
- Science of Health Department, School of Medicine, Magna Graecia University of Catanzaro, Via T. Campanella, 115, 88100, Catanzaro, Italy.
| | - Gianfranco Di Gennaro
- Science of Health Department, School of Medicine, Magna Graecia University of Catanzaro, Via T. Campanella, 115, 88100, Catanzaro, Italy
| |
Collapse
|
10
|
Abou Kaoud M, Nissan R, Segev A, Sabbag A, Orion D, Maor E. Levetiracetam Interaction with Direct Oral Anticoagulants: A Pharmacovigilance Study. CNS Drugs 2023; 37:1111-1121. [PMID: 37991705 DOI: 10.1007/s40263-023-01052-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Levetiracetam is widely used in post-stroke epilepsy. However, it is suspected to possess P-glycoprotein (P-gp) induction properties, and therefore, a potentially significant interaction with direct oral anticoagulants (DOACs). We aimed to search for ischemic stroke signals with levetiracetam and the DOACs. METHODS In this retrospective pharmacovigilance study, we used the FAERS database to identify ischemic stroke events associated with DOACs and concomitant use of levetiracetam. We evaluated disproportionate reporting by the adjusted reporting odds ratio (adjROR) and the lower bound of the shrinkage 95% confidence interval. When shrinkage is positive, an increased risk of a specific adverse event occurrence is emphasized over the sum of the individual risks when these same drugs are used separately. RESULTS We identified 1841 (1.5%), 3731 (5.3%), 338 (4.9%), and 1723 (1.3%) ischemic stroke reports with apixaban, dabigatran, edoxaban, and rivaroxaban, respectively. The adjROR of the interaction effect was 3.57 (95% CI 2.81-4.58) between DOACs and levetiracetam. The shrinkage analysis detected an interaction between each of the DOACs and levetiracetam. The logistic model and shrinkage analysis failed to detect an interaction when queried for hemorrhagic stroke. A significant signal in the classical enzyme inducer, carbamazepine, strengthened our results (adjROR; 8.47, 95% CI 5.37-13.36). CONCLUSIONS Our study shows a strong signal for the levetiracetam interaction with the DOACs. Our findings suggest implementation of a drug monitoring strategy.
Collapse
Affiliation(s)
- Mohammed Abou Kaoud
- Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel.
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Ran Nissan
- Division of Clinical Pharmacy, Institute of Drug Research, Faculty of Medicine, Hebrew University, Jerusalem, Israel
- Pharmacy Services, Belinson Hospital, Rabin Medical Center, Petach Tikva, Israel
| | - Amitai Segev
- Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avi Sabbag
- Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Orion
- Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Elad Maor
- Chaim Sheba Medical Center, Tel Hashomer, Ramat Gan, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
11
|
Goldstein R, Jacobs AR, Zighan L, Gronich N, Bialer M, Muszkat M. Interactions Between Direct Oral Anticoagulants (DOACs) and Antiseizure Medications: Potential Implications on DOAC Treatment. CNS Drugs 2023; 37:203-214. [PMID: 36869199 DOI: 10.1007/s40263-023-00990-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2023] [Indexed: 03/05/2023]
Abstract
The use of direct oral anticoagulants (DOACs) is increasing because of their superior efficacy and safety compared with vitamin K antagonists. Pharmacokinetic drug interactions, particularly those involving cytochrome P450- mediated metabolism and P-glycoprotein transport, significantly affect the efficacy and safety of DOACs. In this article, we assess the effects of cytochrome P450- and P-glycoprotein-inducing antiseizure medications on DOAC pharmacokinetics in comparison to rifampicin. Rifampicin decreases to a varying extent the plasma exposure (area under the concentration-time curve) and peak concentration of each DOAC, consistent with its specific absorption and elimination pathways. For apixaban and rivaroxaban, rifampicin had a greater effect on the area under the concentration-time curve than on peak concentration. Therefore, using peak concentration to monitor DOAC concentrations may underestimate the effect of rifampicin on DOAC exposure. Antiseizure medications that are cytochrome P450 and P-glycoprotein inducers are commonly used with DOACs. Several studies have observed a correlation between the concomitant use of DOACs and enzyme-inducing antiseizure medications and DOAC treatment failure, for example, ischemic and thrombotic events. The European Society of Cardiology recommends avoiding this combination, as well as the combination of DOACs with levetiracetam and valproic acid, owing to a risk of low DOAC concentrations. However, levetiracetam and valproic acid are not cytochrome P450 or P-glycoprotein inducers, and the implications of their use with DOACs remain to be elucidated. Our comparative analysis suggests DOAC plasma concentration monitoring as a possible strategy to guide dosing owing to the predictable correlation between DOACs' plasma concentration and effect. Patients taking concomitant enzyme-inducing antiseizure medications are at risk for low DOAC concentrations and subsequently, treatment failure and thus can benefit from DOAC concentration monitoring to prophylactically identify this risk.
Collapse
Affiliation(s)
- Rachel Goldstein
- Department of Medicine, Faculty of Medicine, Hadassah Medical Center Mt. Scopus, Hebrew University of Jerusalem, Jerusalem, Israel
- Division of Clinical Pharmacy, Faculty of Medicine, Institute for Drug Research, School of Pharmacy, The Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Pharmaceutics ,Faculty of Medicine, Ein Kerem, Institute for Drug Research, School of Pharmacy, Hebrew University of Jerusalem, 91120, Jerusalem, Israel
| | - Aviya R Jacobs
- Department of Medicine, Faculty of Medicine, Hadassah Medical Center Mt. Scopus, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Lana Zighan
- Department of Medicine, Faculty of Medicine, Hadassah Medical Center Mt. Scopus, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Naomi Gronich
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Clalit Health Services, Haifa, Israel
- Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Meir Bialer
- Department of Pharmaceutics ,Faculty of Medicine, Ein Kerem, Institute for Drug Research, School of Pharmacy, Hebrew University of Jerusalem, 91120, Jerusalem, Israel.
- David R. Bloom Center for Pharmacy, The Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Mordechai Muszkat
- Department of Medicine, Faculty of Medicine, Hadassah Medical Center Mt. Scopus, Hebrew University of Jerusalem, Jerusalem, Israel
| |
Collapse
|
12
|
Gritsch D, Gonzalez Castro LN. Relevant pharmacologic interactions in the concurrent management of brain tumor-related epilepsy and venous thromboembolism: a systematic review. J Neurooncol 2022; 157:285-296. [PMID: 35312937 DOI: 10.1007/s11060-022-03984-y] [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: 02/14/2022] [Accepted: 03/05/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Co-administration of direct oral anticoagulants (DOACs) with antiepileptic drugs (AEDs) is increasingly common in brain tumor patients. We therefore performed a systematic review of the current evidence for potential drug interactions between DOACs and AEDs in this patient population. METHODS We conducted a systematic review of the literature via PubMed according to PRISMA guidelines (last accessed December 15, 2021). Included were clinical studies and case reports, written in English language and published between 2010 and 2021, that investigated concurrent clinical use of AEDs with DOACs for any indication. Non-English articles, articles not related to our research question, review articles and commentaries were excluded. Full-text articles were evaluated for possible confounding factors and results were summarized using a data table highlighting the key characteristics of each article. RESULTS We identified a total of 122 unique articles, of which 27 were deemed relevant to our research question. Of these, 8 articles were clinical studies (n = 295,415 patients) and 19 were case reports (n = 25 patients). Only 3 clinical studies and 2 case reports reported interactions between AEDs and DOACs in patients with active cancer and none reported interactions in patients with brain tumors. CONCLUSION We have identified low (class IV) level evidence of potential drug interactions between DOACs and AEDs. Even though there is no current report of interactions in brain tumor patients, neuro-oncology providers should be aware of the emerging evidence regarding drug interactions between DOACs and AEDs and take this into consideration when concurrently prescribing these to patients.
Collapse
Affiliation(s)
- David Gritsch
- Mayo Clinic Scottsdale: Mayo Clinic Arizona, Phoenix, AZ, USA.
| | - L Nicolas Gonzalez Castro
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, 02215, USA
| |
Collapse
|
13
|
Candeloro M, Eikelboom JW, Chan N, Bhagirath V, Douketis JD, Schulman S. Carbamazepine, phenytoin, and oral anticoagulants: Drug-drug interaction and clinical events in a retrospective cohort. Res Pract Thromb Haemost 2022; 6:e12650. [PMID: 35224414 PMCID: PMC8851583 DOI: 10.1002/rth2.12650] [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: 10/21/2021] [Revised: 11/26/2021] [Accepted: 12/01/2021] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Carbamazepine and phenytoin are potent inducers of enzymes that metabolize oral anticoagulants. OBJECTIVES To determine the clinical impact of drug-drug interactions between these anticonvulsants and oral anticoagulants, and whether they affect the treatment with direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs). MATERIAL AND METHODS Data on patients cotreated with carbamazepine or phenytoin and an oral anticoagulant were retrospectively retrieved from medical records from 2011 to 2020. Outcomes were time in therapeutic range (TTR), DOAC levels, thromboembolic events, major bleeding, and all-cause mortality. RESULTS Among 85 patients (37% female, median age 68 years) treated with carbamazepine (n = 43 [51%]) or phenytoin (n = 42 [49%]), 53 (62%) were initially treated with VKAs and 32 (38%) with DOACs. TTR in VKA patients was 63%, which improved in year 2. Four of seven trough and five of 12 peak DOAC plasma levels were lower than expected. The incidence rate (95% confidence interval) per 100 person-years for thromboembolism was 3.6 (3.1-4.2) for VKA patients and 4.4 (3.5-5.6) for DOAC patients; for major bleeding 1.8 (1.5-2.1) and 1.5 (1.2-1.9), and for all-cause mortality 3.6 (3.1-4.2) and 1.5 (1.2-1.9), respectively. Incidence rates between VKAs and DOACs and between carbamazepine and phenytoin were similar. CONCLUSION There was a high incidence of thromboembolism in patients cotreated with anticoagulants and carbamazepine or phenytoin. The incidence rates of thrombotic and bleeding events were similar between VKA and DOAC patients. DOAC levels were lower than expected in 47% of cases tested, without correlation with clinical outcomes.
Collapse
Affiliation(s)
- Matteo Candeloro
- Department of Innovative Technologies in Medicine and Dentistry“G. D'Annunzio” UniversityChietiItaly
- Department of Medicine, Thrombosis and Atherosclerosis Research InstituteMcMaster UniversityHamiltonOntarioCanada
| | - John W. Eikelboom
- Department of Medicine, Thrombosis and Atherosclerosis Research InstituteMcMaster UniversityHamiltonOntarioCanada
- Population Health Research InstituteMcMaster UniversityHamiltonOntarioCanada
| | - Noel Chan
- Department of Medicine, Thrombosis and Atherosclerosis Research InstituteMcMaster UniversityHamiltonOntarioCanada
- Population Health Research InstituteMcMaster UniversityHamiltonOntarioCanada
| | - Vinai Bhagirath
- Department of Medicine, Thrombosis and Atherosclerosis Research InstituteMcMaster UniversityHamiltonOntarioCanada
- Population Health Research InstituteMcMaster UniversityHamiltonOntarioCanada
| | - James D. Douketis
- Department of Medicine, Thrombosis and Atherosclerosis Research InstituteMcMaster UniversityHamiltonOntarioCanada
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research InstituteMcMaster UniversityHamiltonOntarioCanada
- Department of Obstetrics and GynecologyI.M. Sechenov First Moscow State Medical UniversityMoscowRussia
| |
Collapse
|
14
|
Vazquez SR, Barnes GD. Anticoagulant drug-drug interactions: Highlighting the need for antithrombotic stewardship and shared decision making. Res Pract Thromb Haemost 2022; 6:e12662. [PMID: 35155978 PMCID: PMC8822260 DOI: 10.1002/rth2.12662] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 01/08/2022] [Indexed: 01/10/2023] Open
Affiliation(s)
- Sara R. Vazquez
- Department of Pharmacy ServicesThrombosis ServiceUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Geoffrey D. Barnes
- Frankel Cardiovascular CenterDepartment of Internal MedicineUniversity of MichiganAnn ArborMichiganUSA
| |
Collapse
|
15
|
Gronich N, Stein N, Muszkat M. Association Between Use of Pharmacokinetic-Interacting Drugs and Effectiveness and Safety of Direct Acting Oral Anticoagulants: Nested Case-Control Study. Clin Pharmacol Ther 2021; 110:1526-1536. [PMID: 34287842 PMCID: PMC9290518 DOI: 10.1002/cpt.2369] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 06/29/2021] [Indexed: 12/29/2022]
Abstract
Concomitant use of direct oral anticoagulants (DOACs) and medications with inhibition/induction effect on P-gp/CYP3A might increase risk of bleeding/treatment failure, respectively. We designed a nested case-control study within a Clalit cohort of patients with atrial fibrillation (AF) and a cohort of patients with venous thromboembolism, new users of a DOAC (January 1, 2010 to August 24, 2020). Propensity scores were constructed from demographic/clinical characteristics, and medications at cohort entry. Each case of: (i) serious bleeding event; (ii) stroke/systemic emboli (SE) in patients with AF; (iii) recurrent thromboembolism in patients with thromboembolism, was matched by age, sex, length of follow-up, year of cohort entry, DOAC type, and DOAC indication, to up to 20 controls. Within 89,284 patients with AF and venous thromboembolism and 126,302 patient-years of follow-up, there were 1,587 serious bleeding events. Risk of serious bleeding increased in association with concurrent prescription of P-gp/CYP3A4 inhibitors. Specifically, higher bleeding risk was associated with dabigatran-verapamil, rivaroxaban-verapamil, and rivaroxaban-amiodarone concurrent prescriptions: adjusted odds ratios (ORs) 2.29 (1.13-4.60), 2.18 (1.07-4.40), and 1.68 (1.14-2.49), respectively. There were 1,116 events of stroke/SE, in 79,302 DOAC-treated patients with AF and 118,124 patient-years of follow-up. Concomitant use of phenytoin, carbamazepine, valproic acid, or levetiracetam was associated with risk for stroke/SE: adjusted OR 2.18 (1.55-3.10). Risk of recurrent venous thromboembolism could not be assessed due to the low number of cases. Concurrent prescriptions of dabigatran or rivaroxaban with verapamil, and of rivaroxaban with amiodarone, are associated with increased risk for serious bleeding. Higher risk for stroke/SE in patients with AF is associated with concurrent prescriptions of DOACs with phenytoin, carbamazepine, valproic acid, or levetiracetam.
Collapse
Affiliation(s)
- Naomi Gronich
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Clalit Health Services, Haifa, Israel.,Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Nili Stein
- Department of Community Medicine and Epidemiology, Lady Davis Carmel Medical Center, Clalit Health Services, Haifa, Israel
| | - Mordechai Muszkat
- Department of Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel.,Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| |
Collapse
|
16
|
Smythe MA, Burns C, Liu Q, Garwood CL. Potential Dexamethasone-Direct Oral Anticoagulant Drug Interaction: Is This a Concern in COVID? Ann Pharmacother 2021; 56:319-329. [PMID: 34137279 DOI: 10.1177/10600280211025042] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE To evaluate the literature on a potential dexamethasone-direct oral anticoagulant (DOAC) drug interaction and provide management considerations with COVID hypercoagulability. DATA SOURCES A search of EMBASE, PubMed, and Google Scholar (January 1990 to May 2021), limited to the English language, using applicable search terms resulted in 137 articles, with 21 relevant articles included. Regulatory agency and clinical guidance documents were also reviewed. STUDY SELECTION AND DATA EXTRACTION Included articles describe in vitro or in vivo animal or human data for dexamethasone induction of cytochrome P450 (CYP) 3A4 or P-glycoprotein (P-gp). DATA SYNTHESIS Dexamethasone has the potential to interact with the DOACs via CYP3A4 and/or P-gp induction. Only apixaban and rivaroxaban have CYP3A4 metabolism. Dexamethasone can increase CYP3A4 activity by up to 70% and reduce the area under the concentration-time curve (AUC) of CYP3A4 substrates by >40%, which is consistent with criteria for a weak CYP inducer. In rodents, dexamethasone P-gp induction is associated with AUC reductions of 20% to 50%. Human data are lacking. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Severe COVID-19 infection is associated with hypercoagulability. Although heparins are the preferred anticoagulants for hospitalized COVID-19 patients, DOACs are being utilized. Dexamethasone is recommended for hospitalized COVID-19 patients requiring supplemental oxygen. The concurrent use of dexamethasone and apixaban or rivaroxaban in such patients carries the potential for reduced anticoagulant effect during a state of heightened thrombotic risk. CONCLUSIONS Concurrent use of dexamethasone and apixaban or rivaroxaban in hospitalized COVID-19 patients with laboratory evidence of COVID coagulopathy should be avoided until higher-quality data are available.
Collapse
Affiliation(s)
- Maureen A Smythe
- Wayne State University, Detroit, MI, USA.,Beaumont Hospital, Royal Oak, MI, USA
| | | | | | - Candice L Garwood
- Wayne State University, Detroit, MI, USA.,Detroit Medical Center, MI, USA
| |
Collapse
|
17
|
Stöllberger C, Finsterer J. Update on drug interactions with non-vitamin-K-antagonist oral anticoagulants for stroke prevention in elderly patients. Expert Rev Clin Pharmacol 2021; 14:569-581. [PMID: 33757376 DOI: 10.1080/17512433.2021.1908124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: We update the knowledge, since the last review in 2017, about drug-drug interactions (DDI) of non-vitamin-K-antagonist oral anticoagulants (NOAC) in patients ≥75 years.Areas covered: The literature was searched for: 'dabigatran,' 'rivaroxaban,' 'edoxaban,' or 'apixaban' and drugs, affecting platelet function, CYP3A4-, CYP2C9-, or P-Gp-activity. Pharmacodynamic DDI of NOAC with drugs affecting platelet function like nonsteroidal anti-inflammatory drugs and antiplatelet agents occur most frequently. Pharmacokinetic DDI with NOAC were found for 37 of 117 drugs. Reports about DDI with NOAC were found for 51% of P-gp-affecting, 38% for CYP2C9-affecting and 27% for CYP3A4-affecting drugs. Reports about DDI of cardiovascular drugs with NOAC were the most prevalent, followed by anti-infective and nervous system drugs. NOAC plasma levels were measured in retrospective and cohort studies and were associated with concomitant medication. Reports about DDI of NOAC were found in 71 patients ≥75 years.Expert opinion: The knowledge about DDI of NOAC in elderly patients is very limited. Studies should be carried out to investigate the role of drugs potentially interacting with NOAC, which until now have not been investigated. When studying DDI of NOAC, care should be taken to include elderly patients with impaired renal function and patients on polymedication.
Collapse
Affiliation(s)
- Claudia Stöllberger
- 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse, Wien, Austria
| | | |
Collapse
|
18
|
Effect of Enzyme-Inducing Antiseizure Medications on the Risk of Sub-Therapeutic Concentrations of Direct Oral Anticoagulants: A Retrospective Cohort Study. CNS Drugs 2021; 35:305-316. [PMID: 33595834 PMCID: PMC8332574 DOI: 10.1007/s40263-021-00795-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/16/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Stroke and thromboembolic events occurring among patients taking direct oral anticoagulants (DOACs) have been associated with low concentrations of DOACs. Enzyme-inducing antiseizure medications (EI-ASMs) are associated with enhanced cytochrome-P450-mediated metabolism and enhanced P-glycoprotein-mediated transport. OBJECTIVE The aim of this study was to evaluate the effect of concomitant EI-ASM use on DOAC peak concentrations in patients treated in clinical care. METHODS We performed a retrospective cohort study of patients treated with DOACs for atrial fibrillation and venous thromboembolic disease in an academic general hospital. In total, 307 patients treated with DOACs between August 2015 and January 2020 were reviewed. Clinical characteristics and peak DOAC plasma concentrations of patients co-treated with an EI-ASM were compared with those of patients not treated with an EI-ASM. An apixaban dose score (ADS) was defined to account for apixaban dosage and the number of apixaban dose-reduction criteria. RESULTS In total, 177 peak DOAC plasma concentrations (including apixaban, rivaroxaban, and dabigatran) from 131 patients were measured, including 24 patients co-treated with an EI-ASM and 107 controls not treated with an EI-ASM. The proportion of patients with DOAC concentrations below the expected range was significantly higher among EI-ASM users than among patients not taking an EI-ASM (37.5 vs. 9.3%, respectively; p = 0.0004; odds ratio 5.82; 95% confidence interval [CI] 2.03-16.66). Most of these patients were treated with apixaban (85%); however, sensitivity analysis results were also significant (p = 0.031) for patients with non-apixaban DOACs. In patients co-treated with apixaban and an EI-ASM, median apixaban peak concentration was 106 ng/mL (interquartile range [IQR] 71-181) compared with 150 ng/mL (IQR 94-222) in controls (p = 0.019). In multivariable analysis, EI-ASM use was associated with 6.26-fold increased odds for apixaban concentration below the expected range (95% CI 2.19-17.90; p = 0.001). Apixaban concentrations were significantly associated with EI-ASM use, moderate enzyme inhibitor use, and ADS. CONCLUSIONS Concurrent EI-ASM and DOAC use presents a possible risk for DOAC concentrations below the expected range. The clinical significance of the interaction is currently unclear.
Collapse
|
19
|
Concomitant Use of Direct Oral Anticoagulants and Antiepileptic Drugs: A Prospective Cohort Study in Patients with Atrial Fibrillation. Clin Drug Investig 2020; 41:43-51. [PMID: 33284370 PMCID: PMC7815539 DOI: 10.1007/s40261-020-00982-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2020] [Indexed: 10/25/2022]
Abstract
BACKGROUND European guidelines do not recommend the use of carbamazepine, levetiracetam, phenobarbital, phenytoin, topiramate and valproic acid in patients taking direct oral anticoagulants (DOACs). Little is known regarding the clinical relevance of the interaction between DOACs and antiepileptic drugs. OBJECTIVES To evaluate the incidence of thromboembolic and bleeding events in patients with non-valvular atrial fibrillation (AF) concurrently treated with DOACs and antiepileptic drugs. METHODS This is a prospective multicentre cohort study of patients with non-valvular AF concurrently treated with DOACs and antiepileptic drugs. The primary outcome was ischaemic stroke/transient ischaemic attack (TIA)/systemic embolism (SE). Secondary outcome was major bleeding (MB). Incidence rates (% patient-year) were evaluated for the study outcomes. RESULTS Overall, 91 patients were included. Mean age was 78 ± 9.5 years, 49.5% were female. Mean CHA2DS2-VASc score was 4.76 ± 1.59 and mean HAS-BLED was 2.67 ± 1.26. Overall, 41, 20, 11, 10 and 9 out of 91 patients were treated with levetiracetam, valproic acid, phenobarbital, carbamazepine and other antiepileptic drugs, respectively. During a median follow-up of 17.5 ± 14.5 months, stroke/TIA/SE occurred in 9 patients (5.7% patient-year) and MB in 3 patients (1.9% patient-year). Ischaemic stroke was fatal in 3 patients (1.9% patient-year) and MB in one patient (0.6% patient-year). CONCLUSION In this cohort, patients with non-valvular AF treated with DOACs and antiepileptic drugs appear to have a relatively high rate of thromboembolic events.
Collapse
|
20
|
Scholz I, Liakoni E, Hammann F, Grafinger KE, Duthaler U, Nagler M, Krähenbühl S, Haschke M. Effects of Hypericum perforatum (St John's wort) on the pharmacokinetics and pharmacodynamics of rivaroxaban in humans. Br J Clin Pharmacol 2020; 87:1466-1474. [PMID: 32959922 DOI: 10.1111/bcp.14553] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 08/28/2020] [Accepted: 09/09/2020] [Indexed: 12/30/2022] Open
Abstract
AIMS To investigate the influence of a cytochrome P450 CYP3A4 and efflux transporter P-glycoprotein (P-gp) inducing Hypericum perforatum extract on the pharmacokinetics and pharmacodynamics of rivaroxaban. METHODS Open-label, nonrandomized, sequential treatment interaction study. Following CYP3A4 and P-gp phenotyping using low-dose midazolam and fexofenadine, 12 healthy volunteers received a single oral dose of 20 mg rivaroxaban and rivaroxaban plasma concentrations and inhibition of the activated coagulation factor X (factor Xa) activity were measured prior to and up to 48 h postdosing. The procedures were repeated after 2 weeks' treatment with the H. perforatum extract. RESULTS The geometric mean ratios for the area under the concentration-time curve and Cmax of rivaroxaban after/before induction with the H. perforatum extract were 0.76 (90% confidence interval [CI] 0.70, 0.82) and 0.86 (90% CI 0.76, 0.97), respectively. Inhibition of factor Xa activity was reduced with a geometric mean area under the effect-time curve ratio after/before induction of 0.80 (90% CI 0.71, 0.89). No clinically significant differences were found regarding Tmax (median 1.5 vs 1 h, P = .26) and terminal elimination half-life (mean 10.6 vs 10.8 h, P = .93) of rivaroxaban. The H. perforatum extract significantly induced CYP3A4 and P-gp activity, as evidenced by phenotyping. CONCLUSION The CYP3A4/P-gp inducing H. perforatum extract caused a decrease of rivaroxaban exposure with a proportional decrease of the pharmacodynamic effect. Although the data do not justify a contraindication for the combination or a systematic adjustment of rivaroxaban dosage, avoidance of the combination or laboratory monitoring should be considered in patients taking hyperforin-containing H. perforatum extracts with rivaroxaban.
Collapse
Affiliation(s)
- Irene Scholz
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Institute of Pharmacology, University of Bern, Switzerland
| | - Evangelia Liakoni
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Institute of Pharmacology, University of Bern, Switzerland
| | - Felix Hammann
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Institute of Pharmacology, University of Bern, Switzerland
| | - Katharina Elisabeth Grafinger
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Institute of Pharmacology, University of Bern, Switzerland
| | - Urs Duthaler
- Division of Clinical Pharmacology & Toxicology, University Hospital Basel, Switzerland.,Department of Biomedicine, University of Basel, Switzerland
| | - Michael Nagler
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, Switzerland
| | - Stephan Krähenbühl
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Division of Clinical Pharmacology & Toxicology, University Hospital Basel, Switzerland.,Department of Biomedicine, University of Basel, Switzerland
| | - Manuel Haschke
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Institute of Pharmacology, University of Bern, Switzerland
| |
Collapse
|
21
|
Gueta I, Schacham YN, Markovits N, Halkin H, Loebstein R. Uninterrupted direct oral anticoagulant treatment during acute illness: Impact on clinical outcomes. Thromb Res 2020; 196:457-462. [PMID: 33065411 DOI: 10.1016/j.thromres.2020.09.034] [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: 04/19/2020] [Revised: 09/08/2020] [Accepted: 09/28/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Uninterrupted drug therapy during acute illness is often associated with pharmacokinetic and pharmacodynamic variations. Among warfarin treated patients, these changes are reflected in the INR. However, in the case of direct oral anticoagulants (DOACs), given that routine laboratory monitoring is not recommended, these changes may result in unforeseen thromboembolic or bleeding events. OBJECTIVES To determine the rate of thromboembolic (TEE) and bleeding events associated with uninterrupted DOAC compared to warfarin treatment during acute illness. METHODS A retrospective cohort study of patients treated with DOACs or warfarin, both at steady state, who were hospitalized for acute illness. Primary outcome was any TEE or major bleeding requiring re-hospitalization within one month from discharge. Secondary outcome was a composite of major bleeding and clinically relevant non-major bleeding (CRNMB) events. RESULTS A total of 410 patients continued oral anticoagulant treatment during their hospitalization, of whom 191 (46.6%) were on DOACs and 219 (53.4%) on warfarin, with a total of 18 (4.4%) events. Rates of TEE and major bleeding events did not differ between DOACs and warfarin treated patients (0.9% vs. 0.5% and 0.5% vs. 1%, respectively). Similarly, rate of secondary outcome was comparable between DOACs (4.7%) and warfarin (2.7%, p = 0.29). Sub-analyses demonstrated significantly higher rates among rivaroxaban (10.4%) treated patients compared to warfarin (p = 0.03). CONCLUSION Uninterrupted treatment with DOACs during acute illness is not associated with increased risk for re-hospitalizations due to bleeding or thromboembolic events compared to warfarin. Our results suggest a higher bleeding rate among rivaroxaban treated patients at high bleeding risk.
Collapse
Affiliation(s)
- Itai Gueta
- Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel; Department of Medicine A, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Yehoshua Nadav Schacham
- Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel
| | - Noa Markovits
- Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hillel Halkin
- Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ronen Loebstein
- Institute of Clinical Pharmacology and Toxicology, Sheba Medical Center, Tel Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|