1
|
Diesveld MME, Pijnenburg DWMJ, Weersink RA, Barzel I, Drenth JPH, Lisman T, Metselaar HJ, Monster-Simons MH, Mulder MB, Okel E, Taxis K, Borgsteede SD. Recommendations for the safe use of direct oral anticoagulants in patients with cirrhosis based on a systematic review of pharmacokinetic, pharmacodynamic and safety data. Eur J Clin Pharmacol 2024; 80:797-812. [PMID: 38430266 DOI: 10.1007/s00228-024-03648-y] [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: 12/22/2023] [Accepted: 02/03/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE The popularity of direct oral anticoagulants (DOACs) is increasing among patients with cirrhosis. Cirrhosis has a major impact on the pharmacokinetics of drugs, potentially increasing adverse events. Safe use of drugs in cirrhosis requires a diligent risk-benefit analysis. The aim of this study is to develop practice recommendations for safe use of DOACs in cirrhosis based on a systematic review of pharmacokinetic, pharmacodynamic and safety data. METHODS We conducted a systematic literature search to identify studies on pharmacokinetics, pharmacodynamics and safety of DOACs in cirrhosis. Data were collected and presented in summary tables by severity of cirrhosis using the Child-Turcotte-Pugh (CTP) classification. A multidisciplinary expert panel evaluated the results and classified the DOACs according to safety. RESULTS Fifty four studies were included. All DOACs were classified as 'no additional risks known' for CTP A. For CTP B, apixaban, dabigatran and edoxaban were classified as 'no additional risks known'. Apixaban and edoxaban showed fewer adverse events in patients with cirrhosis, while dabigatran may be less impacted by severity of cirrhosis based on its pharmacokinetic profile. Rivaroxaban was classified as 'unsafe' in CTP B and C based on significant pharmacokinetic alterations. Due to lack of data, apixaban, dabigatran and edoxaban were classified as 'unknown' for CTP C. CONCLUSION DOACs can be used in patients with CTP A cirrhosis, and apixaban, dabigatran and edoxaban can also be used in CTP B. It is recommended to avoid rivaroxaban in CTP B and C. There is insufficient evidence to support safe use of other DOACs in CTP C cirrhosis.
Collapse
Affiliation(s)
| | | | - Rianne A Weersink
- Deventer Hospital, Department of Clinical Pharmacy, Deventer, The Netherlands
- Radboud University Medical Center, Department of Pharmacy, Nijmegen, The Netherlands
| | - Ina Barzel
- Erasmus University Medical Center, Department of Hospital Pharmacy, Rotterdam, The Netherlands
| | - Joost P H Drenth
- Radboud University Medical Center, Department of Gastroenterology, Nijmegen, The Netherlands
| | - Ton Lisman
- University of Groningen, University Medical Center Groningen, Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Groningen, The Netherlands
| | - Herold J Metselaar
- Erasmus University Medical Center, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands
| | - Margje H Monster-Simons
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands
- University of Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Midas B Mulder
- Erasmus University Medical Center, Department of Hospital Pharmacy, Rotterdam, The Netherlands
| | - Eline Okel
- Pharmacy Zorgapotheken Flevoland, Almere, The Netherlands
| | - Katja Taxis
- University of Groningen, Groningen Research Institute of Pharmacy, Unit of Pharmacotherapy, -Epidemiology & -Economics, Groningen, The Netherlands
| | | |
Collapse
|
2
|
Sinha T, Kaur M, Mayow AH, Soe TM, Khreis K, Chaudhari SS, Kholoki S, Hirani S. Effectiveness of Direct Oral Anticoagulants and Vitamin K Antagonists in Preventing Stroke in Patients With Atrial Fibrillation and Liver Cirrhosis: A Systematic Review and Meta-Analysis. Cureus 2024; 16:e62606. [PMID: 39027793 PMCID: PMC11257023 DOI: 10.7759/cureus.62606] [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] [Accepted: 06/17/2024] [Indexed: 07/20/2024] Open
Abstract
Patients with atrial fibrillation and concurrent liver cirrhosis have been excluded from major clinical trials evaluating direct oral anticoagulants (DOACs) due to safety concerns. This has led to uncertainty regarding the optimal anticoagulant therapy in this population at high risk of thromboembolic events. We conducted a systematic review and meta-analysis to compare the effectiveness and safety of DOACs versus vitamin K antagonists (VKAs) in patients with atrial fibrillation and liver cirrhosis. Databases including Embase, MEDLINE/PubMed, and Web of Science were searched for relevant studies. The primary effectiveness outcome was stroke or systemic embolism, and the safety outcome was major bleeding events. A total of 10 studies were included in the meta-analysis. Compared to VKAs, the use of DOACs was associated with a significantly lower risk of stroke or systemic embolism (RR: 0.78, 95% CI: 0.65-0.92, p=0.005). The risk of all-cause mortality was comparable between the two groups (RR: 0.89, 95% CI: 0.74-1.07, p=0.23). Notably, DOACs demonstrated a significantly lower risk of major bleeding events (RR: 0.67, 95% CI: 0.61-0.73, p<0.01) compared to VKAs. This meta-analysis suggests that DOACs may be a favorable alternative to VKAs for the prevention of thromboembolic events in patients with atrial fibrillation and liver cirrhosis, with a lower risk of stroke or systemic embolism and major bleeding. However, further research is needed to establish optimal dosing strategies and assess the safety and efficacy of DOACs in patients with advanced liver disease.
Collapse
Affiliation(s)
- Tanya Sinha
- Internal Medicine, Tribhuvan University, Kathmandu, NPL
| | - Mandeep Kaur
- Hospital Medicine, HCA Capital Regional Medical Center, Tallahassee, USA
| | - Abshiro H Mayow
- Medicine, St. George's University School of Medicine, Chicago, USA
| | - Thin M Soe
- Medicine, University of Medicine 1, Yangon, Yangon, MMR
| | | | - Sandipkumar S Chaudhari
- Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, USA
- Family Medicine, University of North Dakota School of Medicine and Health Sciences, Fargo, USA
| | - Samer Kholoki
- Internal Medicine, La Grange Memorial Hospital, Chicago, USA
| | | |
Collapse
|
3
|
Marongiu F, Ruberto MF, Barcellona D. Is anticoagulative therapy in systemic sclerosis to be reconsidered? JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2024; 9:81-85. [PMID: 38910594 PMCID: PMC11188846 DOI: 10.1177/23971983241256250] [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: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 06/25/2024]
Abstract
Systemic sclerosis is a rare disease with a high mortality rate. It is a multisystem connective tissue disease due to endothelial autoimmune activation along with tissue and vascular fibrosis, inducing vasculopathy, with an angiogenesis wasting. The endothelial damage provokes platelet activation and immune cell adhesion. The detachment of endothelial cells leads to the interaction of platelets and collagen present in the exposed subendothelial layer. This provokes the activation of several coagulative factors, inducing a pro-thrombotic condition by thrombin generation, which converts fibrinogen into fibrin. Moreover, thrombin has other functions, such as the induction of hyperplasia in smooth muscle cells and fibroblasts, thereby favouring fibrosis. An increased risk of venous thromboembolism has been found in systemic sclerosis, whereas pulmonary hypertension may be due to the obstruction of small pulmonary arteries. Pulmonary veno-occlusive disease may also occur. Warfarin showed inconsistent results, while the outcomes of a randomised, placebo-controlled clinical trial on apixaban versus placebo are still awaited. A new anticoagulation strategy based on anti-factor XI drugs is being developed, with the aim of achieving optimal anticoagulation along with a low risk of bleeding. The molecule types under investigation in this category include monoclonal antibodies, small molecules, natural inhibitors, antisense oligonucleotides, and aptamers. Patients with systemic sclerosis may be ideal candidates for clinical trials planned to analyse the efficacy and safety of these molecules.
Collapse
Affiliation(s)
- Francesco Marongiu
- Department of Medical Sciences and Public Health, Hemostasis and Thrombosis Unit, University of Cagliari and AOU of Cagliari, Cagliari, Italy
| | - Maria Filomena Ruberto
- Department of Medical Sciences and Public Health, Hemostasis and Thrombosis Unit, University of Cagliari and AOU of Cagliari, Cagliari, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, Hemostasis and Thrombosis Unit, University of Cagliari and AOU of Cagliari, Cagliari, Italy
| |
Collapse
|
4
|
Chow MM, Chua DJ, Wong VS, How SY, Koh SK, Tay XY, Lee LH. Drug-related problems associated with direct oral anticoagulants: an observational cross-sectional study of medical record review by pharmacists in a large teaching hospital. Res Pract Thromb Haemost 2024; 8:102354. [PMID: 38487677 PMCID: PMC10937962 DOI: 10.1016/j.rpth.2024.102354] [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: 09/27/2023] [Revised: 01/26/2024] [Accepted: 02/09/2024] [Indexed: 03/17/2024] Open
Abstract
Background Prescribing DOACs presents with challenges in the elderly and patients with renal and hepatic impairment. To mitigate safety risks, pharmacists have a role in detection, prevention, and resolution of DOAC-associated drug-related problems (DRPs). Objectives To identify the types of DOAC-associated DRPs in patients on DOAC therapy and factors that predispose patients to DOAC-associated DRPs. Methods An observational cross-sectional study was conducted in SGH from January 1, 2017, to May 31, 2019, on patients prescribed with a DOAC (rivaroxaban, dabigatran, and apixaban). Data were electronically extracted for patient demographics, clinical characteristics, and details of DOAC-related DRPs identified by pharmacists. Matching of DRP group to non-DRP group at a ratio of 1:2 based on gender, race, and DOAC was performed. The DRP group included patients with detected DRPs while non-DRP group included patients without them. Descriptive analysis was used to summarize patient characteristics and types of DOAC-associated DRPs. In the matched population, conditional logistic regression was used to calculate unadjusted (UOR) and adjusted odds (AOR) ratio to detect association of DOAC-associated DRPs with age, renal function, ≥2 comorbidities, and DOAC indication (atrial fibrillation [AF] vs venous thromboembolism). Results A total of 8432 patients prescribed DOACs were analyzed, which consisted of 827 (9.8%) and 7602 (90.2%) patients with DRPs and no DRPs, respectively. The top DOAC-associated DRP was inappropriate drug regimen (n = 487, 60.1%). After matching, 2403 patients were analyzed, consisting of 801 patients from DRP group and 1602 from non-DRP group. Factors associated with DOAC-associated DRPs were statistically significant for renal function at creatinine clearance (CrCl) of >30 to 50 mL/min/1.73 m2 (AOR: 1.42; 95% CI: 1.14-1.76; P = .002), 15 to 30 mL/min/1.73 m2 (OR: 1.94; 95% CI: 1.42-2.66; P < .001), and <15 mL/min/1.73m2 (OR: 2.35; 95% CI: 1.13-4.88; P = .022), respectively, compared with a CrCl of >50 mL/min/1.73 m2 and DOAC indication for AF (AOR: 1.84; 95% CI: 1.47-2.30; P < .001) compared with venous thromboembolism. Conclusion Inappropriate drug regimen was the most common DOAC-associated DRP. Impaired renal function and patients with AF increased the likelihood of DOAC-associated DRPs.
Collapse
Affiliation(s)
| | - Duke J.J. Chua
- Pharmacy Department, Singapore General Hospital, Singapore
| | | | - Sin Y. How
- Pharmacy Department, Singapore General Hospital, Singapore
| | - Sei K. Koh
- Pharmacy Department, Singapore General Hospital, Singapore
| | - Xin Y. Tay
- Pharmacy Department, Singapore General Hospital, Singapore
| | - Lai H. Lee
- Haematology Department, Singapore General Hospital, Singapore
| |
Collapse
|
5
|
Kim H, Song TJ, Yee J, Kim DH, Park J, Gwak HS. ABCG2 Gene Polymorphisms May Affect the Bleeding Risk in Patients on Apixaban and Rivaroxaban. Drug Des Devel Ther 2023; 17:2513-2522. [PMID: 37641689 PMCID: PMC10460569 DOI: 10.2147/dddt.s417096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 08/17/2023] [Indexed: 08/31/2023] Open
Abstract
Purpose Direct oral anticoagulants (DOACs) are widely used for stroke prevention in atrial fibrillation. However, they have a bleeding complication. Breast cancer resistance protein, encoded by ABCG2, is known to be an efflux transporter of apixaban and rivaroxaban among DOACs. This study aimed to investigate the association between gene variants and bleeding complications during treatment with ABCG2 substrates (apixaban and rivaroxaban). Patients and Methods Patients treated with apixaban and rivaroxaban were enrolled from June 2018 to December 2021. Five single nucleotide polymorphisms (SNPs) of ABCG2 were selected. Previously studied genes (ABCB1, CYP3A4, and CYP3A5) were further analyzed as possible confounders. Finally, a total of 16 SNPs were examined in this case-control study. The outcome was defined as major bleeding and clinically relevant non-major bleeding. Two models were constructed using the multivariable analysis. Results Among 293 patients, 64 were cases. The mean age of the patients was 68.8 years, and males comprised 62.5% of the study population. Model I revealed that a history of bleeding, concurrent use of proton pump inhibitor (PPI), ABCG2 rs3114018, and ABCB1 rs1045642 were significantly associated with bleeding complications; the AORs (95% CI) were 6.209 (2.210-17.442), 2.385 (1.064-5.349), 2.188 (1.156-4.142), and 3.243 (1.371-7.671), respectively. Model II showed that modified HAS-BLED score, concurrent use of PPI, ABCG2 rs3114018, and ABCB1 rs1045642 were significantly associated with bleeding complications. Conclusion The modified HAS-BLED score, a history of bleeding, concurrent use of PPI, ABCG2 rs3114018, and ABCB1 rs1045642 were significantly associated with the risk of bleeding complications in patients on apixaban and rivaroxaban, after adjusting for other confounders. These findings can be used to develop individualized treatment strategies for patients taking apixaban and rivaroxaban.
Collapse
Affiliation(s)
- Hamin Kim
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Korea
| | - Tae-Jin Song
- Department of Neurology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jeong Yee
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Korea
| | - Dong-Hyeok Kim
- Department of Cardiology, Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Junbeom Park
- Department of Cardiology, Mokdong Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Hye Sun Gwak
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Korea
| |
Collapse
|
6
|
Ren JW, Zheng X, Han XH. Generic Methods for Simultaneous Analysis of Four Direct Oral Anticoagulants in Human Plasma and Urine by Ultra-High Performance Liquid Chromatography-Tandem Mass Spectrometry. Molecules 2023; 28:molecules28052254. [PMID: 36903499 PMCID: PMC10004761 DOI: 10.3390/molecules28052254] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/28/2023] [Accepted: 02/02/2023] [Indexed: 03/05/2023] Open
Abstract
The new direct oral anticoagulants (DOACs) are increasingly used to treat and prevent thromboembolic disorders, and monitoring concentrations may be valuable in some special scenarios to prevent clinical adverse events. This study aimed to develop generic methods for the rapid and simultaneous analysis of four DOACs in human plasma and urine. Protein precipitation and one-step dilution were used to prepare the plasma and urine; the extracts were injected to ultra-high performance liquid chromatography-tandem mass spectrometry (UPLC-MS/MS) for analysis. Chromatographic separation was performed on an Acquity™ UPLC BEH C18 column (2.1 × 50 mm, 1.7 μm) with gradient elution of 7 min. A triple quadrupole tandem mass spectrometer with an electrospray ionization source was employed to analyze DOACs in a positive ion mode. The methods showed great linearity in the plasma (1~500 ng/mL) and urine (10~10,000 ng/mL) for all analytes (R2 ≥ 0.99). The intra- and inter-day precision and accuracy were within acceptance criteria. The matrix effect and extraction recovery were 86.5~97.5% and 93.5~104.7% in the plasma, while 97.0~101.9% and 85.1~99.5% in the urine. The stability of samples during the routine preparation and storage were within the acceptance criteria of less than ±15%. The methods developed were accurate, reliable, and simple for the rapid and simultaneous measurement of four DOACs in human plasma and urine, and successfully applied to patients and subjects with DOACs therapy for anticoagulant activity assessment.
Collapse
|
7
|
Ivany E, Lotto R, Lip GYH, Lane D. Managing uncertainty: Physicians’ decision-making for stroke prevention for patients with atrial fibrillation and intracerebral haemorrhage. Thromb Haemost 2022; 122:1603-1611. [DOI: 10.1055/a-1789-4824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Background Stroke prevention in patients with atrial fibrillation (AF) post-intracerebral haemorrhage (ICH) is an area of clinical equipoise. Little is known about the tools and processes that physicians use to make decisions regarding anticoagulation in this high-risk patient population.
Objective To explore physicians’ decision-making process regarding stroke prevention in patients with AF and a recent history of ICH.
Method Qualitative study, utilising semi-structured interviews and analysed using Framework analysis.
Results Twenty physicians from five European countries (Austria, France, Germany, Spain, United Kingdom) participated. The over-arching theme ‘Managing uncertainty’, addressed the process of making high-risk clinical decisions in the context of little available robust clinical evidence for best practice. Three sub-themes were identified under the umbrella theme: (1) ‘Computing the Risks’, captured the challenge of balancing the risks of ischaemic stroke with the risk of recurrent ICH in a complex patient population; (2) ‘Patient Factors’ highlighted the influence that patients’ beliefs and previous experience of stroke had on physicians’ decisions; and (3) ‘Making a Decision’ explored the process of reaching a final decision regarding initiation of OAC therapy or not.
Conclusion Physicians described the process of deciding on stroke prevention in patients with AF post-ICH as ‘challenging’ due to considerable ‘clinical equipoise’. Key factors that affected decision-making was patient comorbidities, functional status, and patient willingness to engage with oral anticoagulation therapy. Shared decision-making was believed to be beneficial, but physicians believed that the ultimate responsibility to decide on stroke prevention lay with the clinician.
Collapse
Affiliation(s)
- Elena Ivany
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Robyn Lotto
- Liverpool John Moores University - City Campus, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Gregory YH Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool Institute of Ageing and Chronic Disease, Liverpool, United Kingdom of Great Britain and Northern Ireland
| | - Deirdre Lane
- Liverpool Centre of Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom of Great Britain and Northern Ireland
| |
Collapse
|
8
|
Maduray K, Moneruzzaman M, Changwe GJ, Zhong J. Benefits and Risks Associated with Long-term Oral Anticoagulation after Successful Atrial Fibrillation Catheter Ablation: Systematic Review and Meta-analysis. Clin Appl Thromb Hemost 2022; 28:10760296221118480. [PMID: 35924410 PMCID: PMC9358599 DOI: 10.1177/10760296221118480] [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] [Indexed: 11/19/2022] Open
Abstract
Oral anticoagulation (OAC) prevents thromboembolism yet greatly increases the risk of bleeding, inciting concern among clinicians. Current guidelines lack sufficient evidence supporting long-term OAC following successful atrial fibrillation catheter ablation (CA). A literature search was performed in PubMed, Google Scholar, Medline, and Scopus to seek out studies that compare continued and discontinued anticoagulation in post-ablation Atrial fibrillation (AF) patients. Funnel plots and Egger’s test examined potential bias. Via the random-effects model, summary odds ratios (OR) with 95% confidence intervals (CI) were calculated using RevMan (5.4) and STATA (17.0). Twenty studies, including 22 429 patients (13 505 off-OAC) were analyzed. Stratified CHA2DS2-VASc score ≥2 examining thromboembolic events (TE) favored OAC continuation (OR 1.86; 95% CI: 1.02-3.40; P = .04). Sensitivity analysis demonstrated this association was attenuated. The on-OAC arm had greater incidence of major bleeding (MB) (OR 0.16; 95% CI: 0.08-0.95; P < .00001), particularly intracranial hemorrhage (ICH) and gastrointestinal bleeding (GI); (OR 0.17; 95% CI: 0.08-0.36; P < .00001) and (OR 0.12; 95% CI: 0.04-0.32; P < .0001), respectively. Our findings support sustained anticoagulation in patients with a CHA2DS2-VASc score of ≥2. Due to reduced outcome robustness, physician discretion is still advised.
Collapse
Affiliation(s)
- Kellina Maduray
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, 91623Shandong University, Jinan, China
| | - Md Moneruzzaman
- Department of Physical Medicine and Rehabilitation, 572575Qilu hospital, Cheeloo college of Medicine, Shandong University, Jinan, China
| | - Geoffrey J Changwe
- Department of Cardiothoracic Surgery, 619938National Heart Hospital, Lusaka, Zambia
| | - Jingquan Zhong
- The Key Laboratory of Cardiovascular Remodeling and Function Research, Chinese Ministry of Education, Chinese National Health Commission and Chinese Academy of Medical Sciences, The State and Shandong Province Joint Key Laboratory of Translational Cardiovascular Medicine, Department of Cardiology, Qilu Hospital, Cheeloo College of Medicine, 91623Shandong University, Jinan, China.,Department of Cardiology, Qilu Hospital (Qingdao), Cheeloo College of Medicine, Shandong University, Qingdao, China
| |
Collapse
|
9
|
Tanawuttiwat T, Stebbins A, Marquis-Gravel G, Vemulapalli S, Kosinski AS, Cheng A. Use of Direct Oral Anticoagulant and Outcomes in Patients With Atrial Fibrillation after Transcatheter Aortic Valve Replacement: Insights From the STS/ACC TVT Registry. J Am Heart Assoc 2021; 11:e023561. [PMID: 34970918 PMCID: PMC9075194 DOI: 10.1161/jaha.121.023561] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Clinical evidence on the safety and effectiveness of using direct oral anticoagulants (DOACs) in patients with atrial fibrillation after transcatheter aortic valve replacement (TAVR) remains limited. The aim of this study was to investigate the trends and outcomes of using DOACs in patients with TAVR and atrial fibrillation. Methods and Results Data from the STS/ACC TVT (Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy) Registry was used to identify patients who underwent successful TAVR with preexisting or incident atrial fibrillation who were discharged on oral anticoagulation between January 2013 and May 2018. Patients with a mechanical valve, valve‐in‐valve procedure, or prior stroke within a year were excluded. The adjusted primary outcome was 1‐year stroke events. The adjusted secondary outcomes included bleeding, intracranial hemorrhage, and death. A total of 21 131 patients were included in the study (13 004 TAVR patients were discharged on a vitamin K antagonist and 8127 were discharged on DOACs.) The use of DOACs increased 5.5‐fold from 2013 to 2018. The 1‐year incidence of stroke was comparable between DOAC‐treated patients and vitamin K antagonist‐treated patients (2.51% versus 2.37%; hazard ratio [HR], 1.00; 95% CI, 0.81–1.23) whereas DOAC‐treated patients had lower 1‐year incidence of any bleeding (11.9% versus 15.0%; HR, 0.81; 95% CI, 0.75–0.89), intracranial hemorrhage (0.33% versus 0.59%; HR, 0.54; 95% CI, 0.33–0.87), and death (15.8% versus 18.2%; HR, 0.92; 95% CI, 0.85–1.00). Conclusions In patients with TAVR and atrial fibrillation, DOAC use, when compared with vitamin K antagonists, was associated with comparable stroke risk and significantly lower risks of bleeding, intracranial hemorrhage, and death at 1 year.
Collapse
Affiliation(s)
| | | | | | | | | | - Alan Cheng
- Department of Medicine Johns Hopkins University School of Medicine Baltimore MD
| |
Collapse
|
10
|
Sato N, Cameron P, Mclellan S, Beck B, Gabbe B. Association between anticoagulants and mortality and functional outcomes in older patients with major trauma. Emerg Med J 2021; 39:emermed-2019-209368. [PMID: 34610958 DOI: 10.1136/emermed-2019-209368] [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: 12/13/2019] [Accepted: 09/26/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The number of trauma patients taking anticoagulants and antiplatelet agents is increasing as society ages. However, there have been limited and inconsistent reports of the association between anticoagulants and mortality and functional outcomes. This study aimed to quantify the association between anticoagulant/antiplatelet medication at the time of injury and both short-term and longer-term outcomes in older major trauma patients. METHODS This was a population-based registry study using data from the Victorian State Trauma Registry from July 2017 to June 2018. We included patients with major trauma aged 65 years and older. The outcomes of interest were in-hospital mortality, hospital length of stay, intensive care unit length of stay and the Extended Glasgow Outcome Scale (GOS-E) at 6 months after injury. We examined the association between the outcomes and anticoagulants/antiplatelet agents at the time of injury and used multivariable logistic regression models to account for known confounders. RESULTS There were 1323 older adults eligible for inclusion in the study, of which 249 (18.8%) were taking anticoagulants (n=8 were taking both anticoagulants and antiplatelet agents), 380 (28.7%) were taking antiplatelet agents and 694 (52.5%) were not using either. Any anticoagulant use was associated with higher odds of in-hospital mortality (adjusted OR (AOR), 2.38; 95% CI 1.58 to 3.59) compared with not using anticoagulants. No differences were observed in the GOS-E at 6 months after injury between any anticoagulants use, antiplatelet use and no anticoagulant use (anticoagulant AOR, 0.71; 95% CI 0.48 to 1.05, antiplatelet AOR, 1.02; 95% CI 0.73 to 1.42). CONCLUSION Anticoagulant use at the time of injury was associated with higher odds of in-hospital mortality but did not adversely impact functional outcomes at 6 months after injury. These findings demonstrate the importance of seeking an accurate history of anticoagulant use and its indication, as well as the immediate initiation of reversal therapies.
Collapse
Affiliation(s)
- Nobuhiro Sato
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Susan Mclellan
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ben Beck
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Faculty of Medicine, Laval University, Quebec, Québec, Canada
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Health Data Research UK, Swansea University, Swansea, West Glamorgan, UK
| |
Collapse
|
11
|
Lindhoff-Last E, Birschmann I, Kuhn J, Lindau S, Konstantinides S, Grottke O, Nowak-Göttl U, Lucks J, Zydek B, von Heymann C, Sümnig A, Beyer-Westendorf J, Schellong S, Meybohm P, Greinacher A, Herrmann E. Pharmacokinetics of Direct Oral Anticoagulants in Emergency Situations: Results of the Prospective Observational RADOA-Registry. Thromb Haemost 2021; 122:552-559. [PMID: 34256392 PMCID: PMC9113852 DOI: 10.1055/a-1549-6556] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are increasingly used worldwide. Little is known so far about their pharmacokinetics in emergency situations. METHODS A prospective, observational registry was performed to determine the clinical course in consecutive patients with major bleeding or urgent surgery treated with DOACs. In samples collected as part of routine care DOAC drug concentrations were measured using ultraperformance liquid chromatography-tandem mass spectrometry. Anticoagulant intensity at first presentation and drug half-life (t 1/2), tested in repeat samples, were evaluated. RESULTS A total of 140 patients were prospectively included. Pharmacokinetic data were available in 94% (132/140) of patients. Note that 67% (89/132) experienced life-threatening bleeding and 33% (43/132) needed an urgent surgery. For pharmacokinetic analysis a total of 605 blood samples was available. Median concentration on admission was 205 ng/mL for rivaroxaban and 108 ng/mL for apixaban. All treatment groups showed a high variation of drug concentrations at baseline. In rivaroxaban-treated patients t ½ was 17.3 hours (95% confidence interval [CI]: 15.4-19.7) without significant difference in both groups (major bleeding: t ½ 16.7 hours, 95% CI: 14.7-19.3; urgent surgery: t ½ 19.7 hours, 95% CI: 15.2-27.9; p = 0.292). In apixaban-treated patients t ½ was 25.0 hours (95% CI: 22.9-27.6) with a longer t ½ after urgent surgery (t 1/2: 30.8 hours; 95% CI: 26.9-36.4) compared with severe bleeding (t 1/2: 20.8 hours; 95% CI: 18.8-23.2; p < 0.001). CONCLUSION Emergency patients under DOAC treatment show a high variation of anticoagulant concentrations at baseline. Compared with rivaroxaban, apixaban showed a lower median concentration on admission and a longer t ½.
Collapse
Affiliation(s)
- Edelgard Lindhoff-Last
- Coagulation Centre at the Cardiology Angiology Centre Bethanien Hospital (CCB), Frankfurt, Germany,Coagulation Research Centre Bethanien Hospital, Frankfurt, Germany,Address for correspondence Edelgard Lindhoff-Last, MD Cardiology Angiology Center Bethanien Hospital (CCB)Im Prüfling 23, 60389 FrankfurtGermany
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Centre, Ruhr University, Bochum, Germany
| | - Joachim Kuhn
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Centre, Ruhr University, Bochum, Germany
| | - Simone Lindau
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Haemostasis (CTH), Johannes Gutenberg University, Mainz, Germany
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Ulrike Nowak-Göttl
- Institute of Clinical Chemistry, Thrombosis & Haemostasis Treatment Centre, University Hospital, Kiel-Lübeck, Germany
| | - Jessica Lucks
- Coagulation Research Centre Bethanien Hospital, Frankfurt, Germany
| | - Barbara Zydek
- Coagulation Research Centre Bethanien Hospital, Frankfurt, Germany
| | - Christian von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Ariane Sümnig
- Department of Immunology and Transfusion Medicine, Universitätsmedizin, Greifswald, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine 1, Dresden, Germany,Division of Haematology, Dresden University Clinic, Dresden, Germany,Department of Haematology and Oncology, Kings College, London, United Kingdom
| | | | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany,Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Andreas Greinacher
- Department of Immunology and Transfusion Medicine, Universitätsmedizin, Greifswald, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University, Frankfurt, Germany
| | | |
Collapse
|
12
|
Srinivasan S, Ajmal M, Pecci C, Lassar T. Edoxaban in Cardiovascular Disease Management: Review. Br J Clin Pharmacol 2021; 88:535-540. [PMID: 34365675 DOI: 10.1111/bcp.15026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Revised: 07/23/2021] [Accepted: 07/31/2021] [Indexed: 11/30/2022] Open
Abstract
In the past decade, direct oral anticoagulants (DOACs) have transformed the world of anti-thrombotic therapy. Edoxaban is the most recently approved DOAC. Though intended for use primarily in stroke prevention, it has found applications in various other conditions including thromboembolic and peripheral arterial disease. This review aims to provide a detailed outline of the growing indications, evidence for use in special populations, pharmacogenetics, and side effect profile of edoxaban.
Collapse
Affiliation(s)
| | - Muhammad Ajmal
- Sarver Heart Center, University of Arizona, College of Medicine, Tucson, Arizona, USA
| | - Cristina Pecci
- University of Arizona, College of Medicine, Phoenix, Arizona, USA
| | - Tom Lassar
- Sarver Heart Center, University of Arizona, College of Medicine, Tucson, Arizona, USA
| |
Collapse
|
13
|
Škorňová I, Samoš M, Bolek T, Kamenišťáková A, Stančiaková L, Galajda P, Staško J, Kubisz P, Mokáň M. Direct Oral Anticoagulants Plasma Levels in Patients with Atrial Fibrillation at the Time of Bleeding: A Pilot Prospective Study. J Cardiovasc Pharmacol 2021; 78:e122-e127. [PMID: 34173805 DOI: 10.1097/fjc.0000000000001038] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 03/20/2021] [Indexed: 10/21/2022]
Abstract
ABSTRACT Patients with atrial fibrillation (AF) on long-term direct oral anticoagulants (DOACs) may be at higher risk of bleeding because of higher anti-Xa or anti-IIa levels. However, there is no postmarketing study investigating these DOAC plasma levels at the time of bleeding. The aim of this study was to evaluate DOAC levels at the time of a bleeding emergency. We analyzed 5440 patients examined at our Emergency Department in from April 1, 2019, to September 30, 2019. During this period, we prospective identified 105 consecutive patients with bleeding while on long-term antithrombotic therapy; 49 patients had AF on DOACs. We compared DOAC levels in patients who bled against a control sample of 55 patients who tolerated long-term high dose DOAC therapy without any emergency. Samples of these patients were tested with drug-specific anti-Xa chromogenic analysis (rivaroxaban and apixaban) and with Hemoclot Thrombin Inhibitor assay (dabigatran). Dabigatran-treated patients who bled had significantly higher anti-IIa levels when compared with trough (261.4 ± 163.7 vs. 85.4 ± 57.2 ng/mL, P < 0.001) and peak samples of controls (261.4 ± 163.7 vs. 138.8 ± 78.7 ng/mL, P < 0.05). Similarly, there were significantly higher anti-Xa levels in rivaroxaban-treated and apixaban-treated patients with bleeding compared with trough control samples (rivaroxaban: 245.9 ± 150.2 vs. 52.5 ± 36.4 ng/mL, P <0.001 and apixaban: 311.8 ± 142.5 vs. 119.9 ± 81.7 ng/mL, P < 0.001), as well as in apixaban-treated patients when compared with peak control samples (311.8 ± 142.5 vs. 210.9 ± 88.7 ng/mL, P < 0.05). Finally, rivaroxaban anti-Xa levels in patients who bled tended to be higher compared with peak control samples (245.9 ± 150.2 vs. 177.6 ± 38.6 ng/mL, P = 0.13). This observational study showed a significant difference in anti-IIa and anti-Xa plasma levels in patients with AF with bleeding complications compared with those who tolerated long-term high-dose DOAC therapy without bleeding complications.
Collapse
Affiliation(s)
- Ingrid Škorňová
- Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Matej Samoš
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic ; and
| | - Tomáš Bolek
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic ; and
| | | | - Lucia Stančiaková
- Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Peter Galajda
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic ; and
| | - Ján Staško
- Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Peter Kubisz
- Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Marián Mokáň
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic ; and
| |
Collapse
|
14
|
Bourdin M, Perrotin D, Mathieu O, Herve T, Depasse F, Lu G, Conley PB, Contant G. Measuring residual anti-Xa activity of direct factor Xa inhibitors after reversal with andexanet alfa. Int J Lab Hematol 2021; 43:795-801. [PMID: 34092030 PMCID: PMC8453859 DOI: 10.1111/ijlh.13591] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 11/28/2022]
Abstract
Introduction Andexanet alfa (AnXa) was developed for anticoagulant effect reversal of direct factor Xa inhibitors (DXaI) (apixaban, rivaroxaban, edoxaban) in emergency situations. Regular anti‐Xa assays are not suitable to evaluate anti‐Xa activity after AnXa administration because of the high sample dilution resulting in the AnXa‐DXaI dissociation which gives inaccurately high DXaI measured concentrations. This study aimed at developing dedicated STA‐Liquid anti‐Xa test set‐ups for accurately measuring DXaI after reversal with AnXa. Methods Modified anti‐Xa test set‐ups, with reduced sample dilution, were developed to overcome regular assays limitations and to improve measured accuracy with results comparable to Portola microplate reference method used in clinical studies. Both regular and optimized assays were used to measure DXaI concentration in AnXa‐containing samples. Quality controls, normal pooled plasma spiked with five DXaI and three AnXa concentrations, samples from DXaI‐treated patients spiked with AnXa and ex vivo healthy volunteers having received both DXaI and AnXa were used. Results The lower limit of quantitation of optimized anti‐Xa assays was <10 ng/mL with CVs ≤10%. DXaI samples containing 300 ng/mL and 1 µmol/L AnXa resulted in DXaI residual concentrations of 29‐72 ng/mL depending on the DXaI (76%‐90% reversal), compared to 20‐28 ng/mL with reference method (92%‐94% reversal) and 135‐165 ng/mL with regular assays (about 50% reversal). Conclusion Modified test set‐ups are automated alternative to reference method with improved precision and reproducibility. They can be run in all laboratories where regular anti‐Xa assays are performed using commercially available reagents.
Collapse
Affiliation(s)
| | | | | | - Tristan Herve
- Diagnostica Stago Clinical and Pharmaceutical Development, Asnières-sur-Seine, France
| | - François Depasse
- Diagnostica Stago Clinical and Pharmaceutical Development, Asnières-sur-Seine, France
| | - Genmin Lu
- Portola, a subsidiary of Alexion, South San Francisco, CA, USA
| | - Pamela B Conley
- Portola, a subsidiary of Alexion, South San Francisco, CA, USA
| | | |
Collapse
|
15
|
Mandibular Fracture in a Patient Taking a Direct Oral Anticoagulant. J Craniofac Surg 2021; 32:1421-1422. [PMID: 33038172 DOI: 10.1097/scs.0000000000007162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT A 74-year-old man presented with hemorrhage from the mandible after an injury caused by a 5 × 3 × 3-cm metal square column flying from a 45-ton press machine that struck the right side of his face. He is a known atrial fibrillation patient and is on rivaroxaban, a direct oral anticoagulant. An approximately 8-cm Y-shaped wound with persistent hemorrhage was observed in the right mandible, and the mandible was displaced between the right mandibular canine and first premolar. Although the patient showed no dyspnea, the sublingual region showed a slight dark purple swelling; fiberoptic nasal intubation was performed. Computed tomography at 3.5 hours after the injury revealed a comminuted fracture of the right mandibular body, edema at the floor of the mouth, nasal cavity, upper pharynx to hypopharynx, and the pharyngeal airway around the endotracheal tube. Open reduction and internal fixation were performed. Rivaroxaban was started again 3 days after surgery.
Collapse
|
16
|
Ayyar VS, Jaiprasart P, Geist B, Huang Devine Z, Case M, Hazra A, Hsu CH, Chintala M, Wang W. Translational PK/PD and model-informed development of JNJ-67842125, a F ab reversal agent for JNJ-64179375, a long-acting thrombin inhibitor. Br J Pharmacol 2021; 178:3943-3958. [PMID: 34008170 DOI: 10.1111/bph.15533] [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] [Received: 05/07/2020] [Revised: 04/30/2021] [Accepted: 05/06/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE Antigen-binding fragment (Fab ) reversal agents were developed to reverse, in bleeding emergency, the long-acting anticoagulant effect of JNJ-64179375 (JNJ-9375), a monoclonal antibody that binds exosite-1 on thrombin. EXPERIMENTAL APPROACH The pharmacokinetic and pharmacodynamic (PK/PD) activities of three reversal agents of varying in vitro binding affinities to JNJ-9375 were characterised in cynomolgus monkeys. The time course of JNJ-9375 anticoagulant activity and reversal effects of each agent were evaluated. A mechanism-based PK/PD model, which integrated free serum concentrations of reversal agent, total and free serum concentrations of JNJ-9375, and thrombin time, was developed to quantitatively relate JNJ-9375 neutralisation to reversal of induced thrombin time prolongation. Model-based allometric scale-up of the lead reversal agent and the PK/PD relationship of JNJ-9375 in healthy volunteers were utilised to predict clinical dosing regimens. KEY RESULTS Lowering of free JNJ-9375 by the reversal agents corresponded with reversal of thrombin time prolongation. Total JNJ-9375 displayed typical mAb clearance at 2.75 ml·day-1 ·kg-1 , whereas reversal agents cleared faster between 1400 and 2400 ml·day-1 ·kg-1 . The model-estimated in vivo KD values for JNJ-9375 reversal agents were 9 nM (ICHB-256), 0.4 nM (ICHB-281) and 13.7 pM (ICHB-164), in rank-ordered agreement of their KD values determined in vitro. The three reversal agents exhibited different neutralisation characteristics in vivo, governed primarily by their binding kinetics to JNJ-9375. The model predicted a priori free JNJ-9375 kinetics after dosing ICHB-164 (JNJ-67842125) and JNJ-9375 under a different regimen. CONCLUSION AND IMPLICATIONS The results enabled selection of JNJ-67842125 as the reversal agent for JNJ-9375.
Collapse
Affiliation(s)
- Vivaswath S Ayyar
- Biologics Development Sciences, Janssen BioTherapeutics, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA.,Clinical Pharmacology and Pharmacometrics, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Pharavee Jaiprasart
- Biologics Development Sciences, Janssen BioTherapeutics, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA.,Clinical Pharmacology and Pharmacometrics, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Brian Geist
- Biologics Development Sciences, Janssen BioTherapeutics, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Zheng Huang Devine
- Cardiovascular and Metabolism, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Martin Case
- New Platforms and Technology, Janssen BioTherapeutics, Janssen Research & Development, LLC, San Diego, California, USA
| | - Anasuya Hazra
- Clinical Pharmacology and Pharmacometrics, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Chyi-Hung Hsu
- Clinical Pharmacology and Pharmacometrics, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Madhu Chintala
- Cardiovascular and Metabolism, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| | - Weirong Wang
- Clinical Pharmacology and Pharmacometrics, Janssen Research & Development, LLC, Spring House, Pennsylvania, USA
| |
Collapse
|
17
|
Mir T, Sattar Y, Attique HB, Hussain T, Alraies MC, Sheikh M, Qureshi WT. Meta-analysis of direct oral anticoagulants compared with vitamin K antagonist for left ventricle thrombus. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 35:141-146. [PMID: 33722539 DOI: 10.1016/j.carrev.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/15/2021] [Accepted: 03/01/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The use of direct oral anticoagulants (DOAC) in preference to vitamin K antagonists (VKA) as a treatment of left ventricle (LV) thrombus is controversial. METHODS Literature search for full-text articles and conference abstracts was performed using PubMed, EMBASE databases search was performed to identify articles that compared use of DOAC vs. VKA in patients with LV thrombus. The primary outcome was composite failure or adverse effects of DOAC and VKA. Other outcomes were resolution of thrombus, systemic thromboembolism, major bleeding, and mortality. Pooled odds ratio (OR) with 95% confidence interval (CI) were computed using random effects model. RESULTS Seven studies with 1003 patients (mean age DOAC = 58.8 years and VKA = 58.9 year, 55.5% males) were included in this study. There were 306 (30.5%) patients that were treated with DOAC and 697 (69.5%) patients were treated with VKA. Overall, there were no significant differences between both agents in terms of composite failure/adverse effects, resolution of thrombus, systemic embolism, major bleeding, or mortality. CONCLUSION In this pooled analysis, outcomes in patients on DOAC were comparable to VKA. The hypothesis generated could suggest DOAC could be used interchangeably with VKA in patients with LV thrombus. Randomized trials are needed for generalization of results.
Collapse
Affiliation(s)
- Tanveer Mir
- Internal Medicine, Detroit Medical Center, Wayne State University. Detroit, MI, USA
| | - Yasar Sattar
- Internal Medicine, Icahn School of Medicine at Mount Sinai, NY, USA
| | | | - Tanveer Hussain
- Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - M Chadi Alraies
- Cardiovascular Medicine, Detroit Medical Center, Wayne State University, Detroit, MI, USA
| | - Mujeeb Sheikh
- Interventional Cardiology, Promedica Toledo Hospital, OH, USA
| | - Waqas T Qureshi
- Division of Cardiology, University of Massachusetts School of Medicine, Worcester, MA, USA.
| |
Collapse
|
18
|
Gedikli Ö, Altay S, Ünlü S, Çakmak HA, Aşkın L, Yanık A, Beşli F, Sinan ÜY, Canpolat U, Şahin M, Pehlivanoğlu S. Real-life data of major and minor bleeding events with direct oral anticoagulants in the one-year follow-up period: The NOAC-TURK study. Anatol J Cardiol 2021; 25:196-204. [PMID: 33690135 DOI: 10.5152/anatoljcardiol.2021.57635] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE This study aimed to evaluate the safety of direct oral anticoagulants (DOACs) in patients with non-valvular atrial fibrillation (NVAF) during daily clinical practice. METHODS This was a prospective study conducted between January 01, 2016, and April 01, 2017, in patients aged ≥18 years with a diagnosis of NVAF. We performed the study in 9 clinical centers from different regions of Turkey, and the mean follow-up period was 12+2 months. We investigated major and minor bleeding events of DOAC. RESULTS A total of 1807 patients with NVAF were enrolled. The mean age of the patients was 73.6±10.2 years, CHA2DS2-VASc score was 3.6±1.4, and HAS-BLED score was 2±1.2. The most frequently prescribed DOAC was dabigatran 110 mg bid in 409 (22.6%) patients. The patients on apixaban 2.5 mg bid were older (p<0.001). Patients on rivaroxaban 15 mg od also had a higher prevalence of chronic renal failure, 46 (16.7%) patients. A total of 205 (11.4%) bleeding events were observed; among these, 34 (1.9%) patients had major bleeding and 171 (9.4%) patients had minor bleeding. The major and minor bleeding events were 2/273 (0.7%) and 30/273 (10.9%) in patients receiving dabigatran 150 mg bid, 13/409 (3%) and 44/409 (10.7%) in patients receiving dabigatran 110 mg bid, 4/385 (1%) and 42/385 (10.9%) in patients receiving rivaroxaban 20 mg od, 8/276 (2.9%) and 27/276 (9.7%) in patients receiving rivaroxaban 15 mg od, 3/308 (0.9%) and 14/308 (4.5%) in patients receiving apixaban 5 mg bid, 4/156 (2.5%) and 14/156 (9%) in patients receiving apixaban 2.5 mg bid, respectively. The total bleeding events were 17 (5.6%) in patients receiving apixaban 5 mg, less than those receiving other DOACs. On multivariate analyses, rivaroxaban 20 mg od (p=0.002), ATRIA and HAS-BLED scores, and peripheral artery disease were independent indicators of bleeding. The most frequent location of major bleeding was the gastrointestinal system (GIS) [17 (0.9%) patients], and the most frequent location of minor bleeding was the gingiva [45 (2.5%) patients]. CONCLUSION This study showed that similar results as the previous real-life study; however, we had some different results, such as the GIS tract bleeding was more frequent in patients receiving dabigatran 110 mg bid. The major and intracranial bleeding events were similar for different DOACs; and among DOACs, only rivaroxaban 20 mg od was associated with a high risk of bleeding.
Collapse
Affiliation(s)
- Ömer Gedikli
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayıs University; Samsun-Turkey
| | - Servet Altay
- Department of Cardiology, Faculty of Medicine, Trakya University; Edirne-Turkey
| | - Serkan Ünlü
- Department of Cardiology, Faculty of Medicine, Gazi University, Ankara-Turkey
| | | | - Lütfü Aşkın
- Department of Cardiology, Faculty of Medicine, Adıyaman University; Adıyaman-Turkey
| | - Ahmet Yanık
- Department of Cardiology, Samsun Education and Research Hospital; Samsun-Turkey
| | - Feyzullah Beşli
- Department of Cardiology, Faculty of Medicine, Harran University; Şanlıurfa-Turkey
| | - Ümit Yaşar Sinan
- Institute of Cardiology, Faculty of Medicine, İstanbul University; İstanbul-Turkey
| | - Uğur Canpolat
- Department of Cardiology, Faculty of Medicine, Hacettepe University, Ankara-Turkey
| | - Mahmut Şahin
- Department of Cardiology, Faculty of Medicine, Ondokuz Mayıs University; Samsun-Turkey
| | - Seçkin Pehlivanoğlu
- Department of Cardiology, Faculty of Medicine, Başkent University, İstanbul-Turkey
| |
Collapse
|
19
|
Hanna F, Hyppa A, Prakash A, Vithanarachchi U, Dawar HU, Sanga Z, Olabode G, Crisp H, Khalafallah AA. Real-World Data on Characteristics and Management of Community Patients Receiving Anticoagulation Therapy Who Presented with Acute Bleeding to the Emergency Department at a Regional Australian Hospital: A Prospective Observational Study. Mediterr J Hematol Infect Dis 2021; 13:e2021017. [PMID: 33747398 PMCID: PMC7938926 DOI: 10.4084/mjhid.2021.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/05/2021] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To study patients receiving anticoagulants with or without antiplatelet therapy presenting at a regional Australian hospital with bleeding. The main aims are to explore: (1) patients' characteristics and management provided; (2) association between the type of anticoagulant and antiplatelet agent used and the requirement of reversal; (3) and the length of hospital stay (LoS) in conjunction with bleeding episode and management. METHODS A prospective cross-sectional review of medical records of all patients who presented at a tertiary referral centre with bleeding while receiving anticoagulation therapy between January 2016 and June 2018. Data included: patients, demographics, investigations (kidney and liver function tests, coagulation profile, FBC), LoS, bleeding site, type of and reason for anticoagulation therapy, and management provided. Data analysis included descriptive statistics, χ2 association, and regression models. RESULTS Among the 144 eligible patients, 75 (52.1%) were male, and the mean age was 76 years (SD=11.1). Gastrointestinal tract bleeding was the most common (n=48, 33.3%), followed by epistaxis (n=32, 22.2%). Atrial fibrillation was the commonest reason for anticoagulation therapy (n=65, 45.1%). Warfarin was commonly used (n=74, 51.4%), followed by aspirin (n=29, 20.1%), rivaroxaban (n=26, 18.1%), and apixaban (n=12, 8.3%). The majority had increased blood urea nitrogen (n=67, 46.5%), while 58 (40.3%) had an elevated serum creatinine level, and 59 (41.0%) had a mild reduction in eGFR. Thirty-five of the warfarinised patients (47.3%) had an INR above their condition's target range despite normal liver function. Severe anaemia (Hb<80g/L) was reported in 88 patients (61.1%). DOACs were associated with a reduced likelihood of receiving reversal (B= -1.7, P=<.001), and with a shorter LoS (B= -4.1, P=.046) when compared with warfarin, LMWH, and antiplatelet therapy. CONCLUSION Warfarin use was common among patients who presented with acute bleeding, and the INR in many warfarinised patients exceeded the target for their condition. DOACs were associated with a reduced likelihood of receiving reversal and a shorter LoS than warfarin, LMWH, which might support a broader application of DOACs into community practice.
Collapse
Affiliation(s)
- Fayez Hanna
- Faculty of Health Sciences, Launceston, University of Tasmania, Tasmania, 7249, Australia
- Department of Haematology, Specialist Care Australia, Launceston, Tasmania, 7250 Australia
| | - Annemarie Hyppa
- Department of Haematology, Specialist Care Australia, Launceston, Tasmania, 7250 Australia
- Medical School, University of Saarland, Homburg, Germany
| | - Ajay Prakash
- Faculty of Health Sciences, Launceston, University of Tasmania, Tasmania, 7249, Australia
- Department of Haematology, Specialist Care Australia, Launceston, Tasmania, 7250 Australia
| | - Usira Vithanarachchi
- Faculty of Health Sciences, Launceston, University of Tasmania, Tasmania, 7249, Australia
- Department of Haematology, Specialist Care Australia, Launceston, Tasmania, 7250 Australia
| | - Hizb U Dawar
- Augusta Medical Centre, Lenah Valley 7008, Tasmania, Australia
| | - Zar Sanga
- Augusta Medical Centre, Lenah Valley 7008, Tasmania, Australia
| | - George Olabode
- Launceston General Hospital, Launceston, Tasmania, 7250 Australia
| | - Hamish Crisp
- Launceston General Hospital, Launceston, Tasmania, 7250 Australia
| | - Alhossain A. Khalafallah
- Faculty of Health Sciences, Launceston, University of Tasmania, Tasmania, 7249, Australia
- Department of Haematology, Specialist Care Australia, Launceston, Tasmania, 7250 Australia
| |
Collapse
|
20
|
Rech MA, Masic D, Hammond DA. Four-factor Prothrombin Complex Concentrate for Reversal of Factor Xa Inhibitors versus Warfarin in Life-threatening Bleeding. West J Emerg Med 2021; 22:163-169. [PMID: 33856296 PMCID: PMC7972353 DOI: 10.5811/westjem.2020.11.47931] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 11/11/2020] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Factor Xa (fXa) inhibitor reversal for life-threatening bleeding is controversial due to a lack of high-quality evidence. The purpose of this study was to determine the hemostatic efficacy of four-factor prothrombin complex concentrate (4F-PCC) for the reversal of fXa inhibitors compared to warfarin for life-threatening bleeding. METHODS This was a multicenter, retrospective cohort study at two academic medical centers between January 1, 2014-December 31, 2019, which included patients who presented to the emergency department with a life-threatening bleed necessitating anticoagulation reversal with 4F-PCC. The primary endpoint was achievement of hemostatic efficacy after 4F-PCC administration. RESULTS Of the 525 patients who had an order for 4F-PCC during the study period, 148 patients met the criteria for inclusion (n = 48 fXa inhibitor group; n = 100 warfarin group). Apixaban (52.1%) and rivaroxaban (45.8%) were the most commonly used fXa inhibitors. Effective hemostasis was similar between groups (79.2% fXa inhibitor group vs 85% warfarin group, p = 0.38). This was consistent across all types of bleeding. Thrombotic events were rare in both groups (2% vs 3%). CONCLUSION This multicenter, retrospective cohort study demonstrated that using 4F-PCC for treatment of life-threatening bleeding produced effective hemostasis in patients on fXa inhibitors and warfarin.
Collapse
Affiliation(s)
- Megan A Rech
- Loyola University Medical Center, Department of Pharmacy, Maywood, Illinois.,Stritch School of Medicine, Loyola University Chicago, Department of Emergency Medicine, Maywood, Illinois
| | - Dalila Masic
- Loyola University Medical Center, Department of Pharmacy, Maywood, Illinois
| | - Drayton A Hammond
- Rush University Medical Center, Department of Pharmacy, Chicago, Illinois.,Rush Medical College, Department of Internal Medicine, Chicago, Illinois
| |
Collapse
|
21
|
Abstract
Atrial fibrillation (AF) is the most common cardiac arrythmia and a major cause of stroke, heart failure, sudden death, and cardiovascular morbidity. AF increases risk of thromboembolic stroke via stasis in the left atrium and subsequent embolization to the brain. In patients with acute ischemic stroke, it is essential that clinicians undertake careful investigation to search for AF. In these patients, up to 23.7% eventually are found to have underlying AF. Oral anticoagulation is effective in prevention of strokes secondary to AF, reducing overall stroke numbers by approximately 64%. Left atrial appendage occlusion is promising for prevention of stroke in AF.
Collapse
Affiliation(s)
- Hani Essa
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK
| | - Andrew M Hill
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Department of Medicine for Older People, St Helens and Knowsley Teaching Hospitals NHS Trust, Marshalls Cross Road, St Helens, Liverpool WA9 3DA, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Thomas Drive, Liverpool L14 3PE, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Sondra Skovvej, 15, Aalborg 9000, Denmark.
| |
Collapse
|
22
|
Wiggins BS, Dixon DL, Neyens RR, Page RL, Gluckman TJ. Select Drug-Drug Interactions With Direct Oral Anticoagulants: JACC Review Topic of the Week. J Am Coll Cardiol 2020; 75:1341-1350. [PMID: 32192661 DOI: 10.1016/j.jacc.2019.12.068] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 12/18/2019] [Accepted: 12/23/2019] [Indexed: 01/08/2023]
Abstract
Millions of individuals in the United States require long-term treatment with an oral anticoagulant. For decades, vitamin K antagonists were the only oral option available; however, they have a number of well-known limitations. Introduction of the direct oral anticoagulants (DOACs) has long been considered a major therapeutic advance, largely because they lack the need for therapeutic monitoring. Despite this, DOACs, like vitamin K antagonists, can still cause major and clinically relevant nonmajor bleeding, even when used appropriately. Drug-drug interactions (DDIs) involving the DOACs represent an important contributor to increased bleeding risk. Awareness of these DDIs and how best to address them is of critical importance in optimizing management while mitigating bleeding risk. This review provides an overview of DOAC metabolism, the most common drugs likely to contribute to DOAC DDIs, their underlying mechanisms, and how best to address them.
Collapse
Affiliation(s)
- Barbara S Wiggins
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, South Carolina.
| | - Dave L Dixon
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond Virginia
| | - Ron R Neyens
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, South Carolina
| | - Robert L Page
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy, Aurora, Colorado
| | - Ty J Gluckman
- Center for Cardiovascular Analytics, Research and Data Science (CARDS), Providence Heart Institute, Providence St. Joseph Health, Portland, Oregon
| |
Collapse
|
23
|
Toorop MMA, Lijfering WM, Scheres LJJ. The relationship between DOAC levels and clinical outcomes: The measures tell the tale. J Thromb Haemost 2020; 18:3163-3168. [PMID: 32979033 PMCID: PMC7756566 DOI: 10.1111/jth.15104] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/26/2020] [Accepted: 09/14/2020] [Indexed: 12/14/2022]
Abstract
Direct oral anticoagulants (DOACs) are increasingly used for treatment and prevention of thromboembolic diseases, used in fixed dose regimens. Although their safety and efficacy profiles are considered optimal, clinical events still occur. Given that anticoagulation treatment is a delicate balance between clotting and bleeding, it is possible that an optimal target spot exists where the effect of anticoagulation achieves both the lowest possible risk of bleeding and thrombosis. Other currently available anticoagulants (ie, vitamin K antagonists and heparins) provide important clues for this. If such a target spot exists, tailored DOAC therapy may further benefit patients. This opinion article summarizes the current available evidence that suggests that such a tailored strategy could work. It also describes research suggestions for conducting studies in patient populations such as patients with extremes of body weight or impaired kidney function to evaluate whether tailored treatment with DOACs could lead to better patient outcomes.
Collapse
Affiliation(s)
- Myrthe M. A. Toorop
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Willem M. Lijfering
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Luuk J. J. Scheres
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Internal MedicineRadboud University Medical CenterNijmegenThe Netherlands
| |
Collapse
|
24
|
Wu Z, Ma Y. Hypersensitivity Reaction from Rivaroxaban. Am J Med Sci 2020; 361:679-680. [PMID: 33773756 DOI: 10.1016/j.amjms.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 10/29/2020] [Accepted: 11/03/2020] [Indexed: 02/05/2023]
Affiliation(s)
- ZhouPeng Wu
- Department of vascular surgery, West China Hospital, 37 GuoXue Alley, Chengdu 610041, Sichuan Province, China
| | - Yukui Ma
- Department of vascular surgery, West China Hospital, 37 GuoXue Alley, Chengdu 610041, Sichuan Province, China.
| |
Collapse
|
25
|
Kampouraki E, Abohelaika S, Avery P, Biss T, Murphy P, Wynne H, Kamali F. Elderly people are inherently sensitive to the pharmacological activity of rivaroxaban: implications for DOAC prescribing. J Thromb Thrombolysis 2020; 52:170-178. [PMID: 33131001 PMCID: PMC8282548 DOI: 10.1007/s11239-020-02326-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/26/2020] [Indexed: 11/29/2022]
Abstract
According to both trial and clinical data on direct oral anticoagulants (DOACs) elderly patients are at greatest risk of bleeding. It is unclear whether age intrinsically affects anticoagulation response. To investigate the age-related sensitivity to DOACs, we compared the pharmacological activity of the direct factor Xa inhibitor, rivaroxaban, between young and elderly subjects ex-vivo. 36 fit elderly and 30 fit young subjects [median (IQR) age: 83(75–87) vs 30(26–38) years] provided a blood sample. Clotting parameters were measured in the resultant plasma samples incubated with rivaroxaban (100–500 ng/ml). Parametric, non-parametric tests and regression lines adjusted for rivaroxaban concentration and baseline values were used to compare data. Rivaroxaban produced a greater prolongation of both Prothrombin Time (PT) and modified Prothrombin Time (mPT) (both p < 0.001) in the elderly compared to young subjects (with difference in mean PT increasing from 1.6 to 6.1s and for mPT from 23.5 to 71.1s at 100 ng/ml and 500 ng/ml plasma rivaroxaban concentration, respectively). Factor X and factor II activity was significantly lower in the elderly in the presence of rivaroxaban (p < 0.001 for both). Rivaroxaban prolonged time-based parameters and suppressed the amount of thrombin generation to a significantly greater extent in the elderly compared to young subjects [%change from baseline for Endogenous Thrombin Potential (ETP): − 35.0 ± 4.4 vs − 29.8 ± 7.4 nM*min; p = 0.002]. The use of validated DOAC assays will be of considerable benefit for monitoring elderly patients who, because of their increased sensitivity to rivaroxaban, may require lower doses of the drug for therapeutic anticoagulation.
Collapse
Affiliation(s)
- Emmanouela Kampouraki
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Salah Abohelaika
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Peter Avery
- School of Mathematics, Statistics and Physics, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Tina Biss
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Paul Murphy
- Department of Hematology, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Hilary Wynne
- Older People's Medicine, Freeman Hospital, Newcastle Upon Tyne, United Kingdom
| | - Farhad Kamali
- Translational and Clinical Research Institute, Newcastle University, and Newcastle upon Tyne Hospitals, NHS Foundation Trust, NE1 7RU, Newcastle upon Tyne, United Kingdom.
| |
Collapse
|
26
|
Anticoagulation Therapy for Patients With New-Onset Postoperative Atrial Fibrillation After Noncardiac Surgery: Must Do, May Do, or Don't Do? Can J Cardiol 2020; 37:359-361. [PMID: 33065203 DOI: 10.1016/j.cjca.2020.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 10/07/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022] Open
|
27
|
Ebraheem M, Alzahrani I, Crowther M, Rochwerg B, Almakadi M. Extended DOAC therapy in patients with VTE and potential risk of recurrence: A systematic review and meta-analysis. J Thromb Haemost 2020; 18:2308-2317. [PMID: 32510840 DOI: 10.1111/jth.14949] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 05/25/2020] [Accepted: 05/27/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Guidelines recommend at least 3 months of anticoagulation for venous thromboembolism (VTE). Evidence supporting indefinite anticoagulation exists in certain conditions; however, for many patients, uncertainty regarding when to discontinue anticoagulation persists. OBJECTIVE We aimed to investigate the efficacy and safety of extended direct oral anticoagulants (DOAC) therapy in patients with VTE and clinical uncertainty regarding extended anticoagulation. METHODS We searched EMBASE, MEDLINE, PubMed, and Cochrane Central Register of Controlled Trials databases for randomized control trials examining extended anticoagulation with DOACs as compared to non-extended therapy for the treatment of VTE. RESULTS Of 560 citations identified by the search, three studies were eligible. Extended anticoagulation reduced VTE recurrence (relative risk [RR] 0.18, 95% confidence interval [CI] 0.12 to 0.25), and mortality (RR 0.39, 95% CI 0.19 to 0.80) with a low total number of deaths in the DOAC group (n = 12) versus placebo (n = 18). Extended anticoagulation increased clinically relevant non-major bleedings (RR 2.51, 95% CI 1.37 to 4.59). There was no difference in rates of major bleeding (RR 1.87, 95% CI 0.19 to 17.85); however, there was a low number of major bleeding events in both DOAC (n = 9) and placebo groups (n = 4). The results were mostly driven by one study (AMPLIFY-EXT), with significant heterogeneity between studies noticed when assessing bleeding outcomes. CONCLUSION Extended DOAC therapy for 1 year in patients with clinical uncertainty for ongoing anticoagulation can reduce VTE recurrence and mortality; however, it could increase clinically relevant non-major bleeding events.
Collapse
Affiliation(s)
| | | | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Bram Rochwerg
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Department of Critical Care, McMaster University, Hamilton, ON, Canada
| | | |
Collapse
|
28
|
Saglietto A, D'Ascenzo F, Errigo D, Leonardi S, Dewilde WJ, Conrotto F, Omedè P, Montefusco A, Angelini F, De Filippo O, Bianco M, Gallone G, Bruno F, Zaccaro L, Giannini F, Latib A, Colombo A, Costa F, De Ferrari GM. Antithrombotic strategies in patients needing oral anticoagulation undergoing percutaneous coronary intervention: A network meta‐analysis. Catheter Cardiovasc Interv 2020; 97:581-588. [DOI: 10.1002/ccd.29192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 07/06/2020] [Accepted: 07/19/2020] [Indexed: 12/31/2022]
Affiliation(s)
- Andrea Saglietto
- Division of Cardiology, Department of Medical Science University of Turin Turin Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Science University of Turin Turin Italy
| | - Daniele Errigo
- Division of Cardiology, Department of Medical Science University of Turin Turin Italy
| | - Sergio Leonardi
- Coronary Care Unit University of Pavia and Fondazione IRCCS Policlinico S. Matteo Pavia Italy
| | | | - Federico Conrotto
- Division of Cardiology, Department of Medical Science University of Turin Turin Italy
| | - Pierluigi Omedè
- Division of Cardiology, Department of Medical Science University of Turin Turin Italy
| | - Antonio Montefusco
- Division of Cardiology, Department of Medical Science University of Turin Turin Italy
| | - Filippo Angelini
- Division of Cardiology, Department of Medical Science University of Turin Turin Italy
| | - Ovidio De Filippo
- Division of Cardiology, Department of Medical Science University of Turin Turin Italy
| | - Matteo Bianco
- Department of Cardiology San Luigi Gonzaga University Hospital Turin Italy
| | - Guglielmo Gallone
- Division of Cardiology, Department of Medical Science University of Turin Turin Italy
| | - Francesco Bruno
- Division of Cardiology, Department of Medical Science University of Turin Turin Italy
| | - Lorenzo Zaccaro
- Division of Cardiology, Department of Medical Science University of Turin Turin Italy
| | - Francesco Giannini
- Interventional Cardiology Unit GVM Care and Research Maria Cecilia Hospital Cotignola Italy
| | - Azeem Latib
- Department of Cardiology Montefiore Medical Center Bronx New York USA
| | - Antonio Colombo
- Interventional Cardiology Unit GVM Care and Research Maria Cecilia Hospital Cotignola Italy
| | - Francesco Costa
- Department of Clinical and Experimental Medicine, Policlinic "G. Martino" University of Messina Messina Italy
| | | |
Collapse
|
29
|
Tan TSE, Cheong SCW, Tan TJ. Clinics in diagnostic imaging (201). Small bowel intramural haematoma induced by anticoagulation therapy with associated reactive ileus. Singapore Med J 2019; 60:566-573. [PMID: 31781781 DOI: 10.11622/smedj.2019147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A 74-year-old woman receiving long-term anticoagulation with warfarin for chronic atrial fibrillation presented with severe acute abdominal pain, diarrhoea and vomiting. Initial laboratory workup revealed a deranged coagulation profile. Computed tomography of the abdomen and pelvis demonstrated spontaneous distal jejunal intramural haematoma with associated reactive ileus. No overt pneumatosis intestinalis, intraperitoneal free gas or haemoperitoneum was seen. Based on clinical and imaging findings, a diagnosis of over-anticoagulation complicated by small bowel intramural haematoma was made. The patient was managed non-operatively with analgesia, cessation of warfarin and reversal therapy with vitamin K. Warfarin therapy was recommenced upon resolution of symptoms and optimisation of coagulation status. The clinical presentation, radiological features and overall management of anticoagulation-induced bleeding are further discussed in this article.
Collapse
Affiliation(s)
| | | | - Tien Jin Tan
- Department of Radiology, Changi General Hospital, Singapore
| |
Collapse
|
30
|
Novel oral anticoagulants in cataract surgery-moving towards a national consensus regarding perioperative continuation. Eye (Lond) 2019; 33:1820. [PMID: 31285572 DOI: 10.1038/s41433-019-0527-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/18/2019] [Indexed: 11/09/2022] Open
|
31
|
Christensen H, Cordonnier C, Kõrv J, Lal A, Ovesen C, Purrucker JC, Toni D, Steiner T. European Stroke Organisation Guideline on Reversal of Oral Anticoagulants in Acute Intracerebral Haemorrhage. Eur Stroke J 2019; 4:294-306. [PMID: 31903428 DOI: 10.1177/2396987319849763] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 04/03/2019] [Indexed: 12/20/2022] Open
Abstract
The aim of the present European Stroke Organisation guideline document is to provide clinically useful evidence-based recommendation on reversal of anticoagulant activity VKA (warfarin, phenprocoumon and acenocoumarol), direct factor II (thrombin) inhibitors (dabigatran etexilat) and factor-Xa-inhibitors (apixaban, edoxaban and rivaroxaban) in patients with acute intracerebral haemorrhage. The guideline was prepared following the Standard Operational Procedure for a European Stroke Organisation guideline document and according to GRADE methodology. As a basic principle, we defined use of oral anticoagulation pragmatically: oral anticoagulation use is assumed by positive medical history unless relevant anticoagulant activity is regarded unlikely by medical history or has been ruled out by laboratory testing. Overall, we strongly recommend using prothrombin complex over no treatment and fresh-frozen plasma in patients on VKA plus vitamin K. We further strongly recommend using idarucizumab in patients on dabigatran and make a recommendation for andexanet alfa in patients on rivaroxaban and apixaban over no treatment. We make a weak recommendation on using high-dose prothrombin complex concentrate (50 IU/kg) for all patients taking edoxaban and for patients on rivaroxaban or apixaban in case andexanet alfa is not available. We recommend against using tranexamic acid and rFVIIa, outside of trials. The presented treatment recommendations aim to normalise coagulation, there is no or only indirect data on effects on functional outcome or mortality, and only little data from randomised controlled trials.
Collapse
Affiliation(s)
- Hanne Christensen
- Department of Neurology, Bispebjerg Hospital & Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte Cordonnier
- Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, Department of Neurology, Université Lille, Lille, France
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, University of Tartu & Tartu University Hospital, Tartu, Estonia
| | - Avtar Lal
- Methodologist, European Stroke Organisation, Basel, Switzerland
| | - Christian Ovesen
- Department of Neurology, Bispebjerg Hospital & Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jan C Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Thorsten Steiner
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany.,Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| |
Collapse
|
32
|
Dubinsky S, Thawer A, McLeod AG, McFarlane TRJ, Emmenegger U. Management of anticoagulation in patients with metastatic castration-resistant prostate cancer receiving abiraterone + prednisone. Support Care Cancer 2019; 27:3209-3217. [PMID: 31073853 DOI: 10.1007/s00520-019-04816-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 04/16/2019] [Indexed: 12/12/2022]
Abstract
PURPOSE Abiraterone has been proven to be an effective agent used in the management of metastatic castration-resistant prostate cancer, significantly improving overall and progression-free survival. Due to the pharmacodynamic and pharmacokinetic properties of abiraterone, concurrent use with anticoagulation may pose a challenge for clinicians. Thrombosis within the cancer setting continues to increase patient mortality; therefore, appropriate anticoagulation through the use of a management algorithm can reduce adverse events and increase quality of life. METHODS A review of the literature was preformed by a medical oncologist, haematologist and pharmacists to identify relevant randomized controlled trials, meta-analyses and retrospective studies. Major society guidelines were reviewed to further aid in developing the anticoagulation protocol for non-valvular atrial fibrillation and venous thromboembolism within this patient population. After reviewing the literature, a clinical framework was designed to aid clinicians in the management of those patients receiving abiraterone concurrently with an anticoagulant. RESULTS In this review, we describe the potential interactions between abiraterone and various anticoagulants and provide management strategies based on the most recent literature for atrial fibrillation, venous thromboembolism and mechanical heart valves to avoid potential drug-drug interactions. CONCLUSION Abiraterone therapy has become a mainstay of the management of advanced prostate cancer and is often used over prolonged years. In this review, we have summarized a framework of how to use abiraterone in men with prostate cancer on anticoagulants. Evidence available to date suggests that patients with an indication for anticoagulation such as atrial fibrillation, venous thromboembolism and mechanical heart valves can be treated safely with abiraterone in the appropriate setting, with appropriate monitoring.
Collapse
Affiliation(s)
- Samuel Dubinsky
- University of Waterloo School of Pharmacy, 10 Victoria St. S, Kitchener, ON, Canada.
| | - Alia Thawer
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Anne G McLeod
- Department of Medicine, Division of Medical Oncology and Hematology, Sunnybrook Hospital, University of Toronto, Toronto, ON, Canada
| | - Thomas R J McFarlane
- University of Waterloo School of Pharmacy, 10 Victoria St. S, Kitchener, ON, Canada.,Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Urban Emmenegger
- Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| |
Collapse
|
33
|
Jolobe OM. Role of atrial cardiomyopathy in guiding choice of antithrombotic therapy. Int J Cardiol 2019; 282:66. [DOI: 10.1016/j.ijcard.2019.01.002] [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: 12/25/2018] [Accepted: 01/02/2019] [Indexed: 11/29/2022]
|
34
|
Mascolo A, Ruggiero R, Sessa M, Scavone C, Sportiello L, Rafaniello C, Rossi F, Capuano A. Preventable Cases of Oral Anticoagulant-Induced Bleeding: Data From the Spontaneous Reporting System. Front Pharmacol 2019; 10:425. [PMID: 31114497 PMCID: PMC6503045 DOI: 10.3389/fphar.2019.00425] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 04/03/2019] [Indexed: 12/12/2022] Open
Abstract
Background Despite the risk of bleeding is a well-known adverse effect of oral anticoagulants, there is scarce evidence on the preventability of oral anticoagulant-induced bleedings. Therefore, we investigated the potential risk factors related to preventable cases of oral anticoagulant-induced bleedings. Methods We performed a study using Individual Case Safety Reports (ICSRs) with an oral anticoagulant as suspected drug among those reported through the spontaneous reporting system of Campania Region from 1 July 2012 to 31 December 2017. The P-method was used for the preventability assessment of all cases of bleeding. Results In total, 58 cases out of 253 (22.9%) were preventable, and the most reported suspected drug was an indirect oral anticoagulant (warfarin). Sixty-eight critical criteria for preventability were identified, all related to healthcare professionals' practices. The most detected risk factor related to healthcare professionals' practices was the labeled drug-drug interaction for both direct and indirect oral anticoagulants. Conclusion Our findings describe the most reported risk factors for preventability of oral anticoagulant-induced bleedings. These factors may be useful for targeting interventions to improve pharmacovigilance activities in our regional territory and to reduce the burden of medication errors and inappropriate prescription.
Collapse
Affiliation(s)
- Annamaria Mascolo
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Pharmacovigilance and Pharmacoepidemiology Regional Centre, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Rosanna Ruggiero
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Pharmacovigilance and Pharmacoepidemiology Regional Centre, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Maurizio Sessa
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Pharmacovigilance and Pharmacoepidemiology Regional Centre, University of Campania "Luigi Vanvitelli", Naples, Italy.,Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Cristina Scavone
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Pharmacovigilance and Pharmacoepidemiology Regional Centre, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Liberata Sportiello
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Pharmacovigilance and Pharmacoepidemiology Regional Centre, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Concetta Rafaniello
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Pharmacovigilance and Pharmacoepidemiology Regional Centre, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Rossi
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Pharmacovigilance and Pharmacoepidemiology Regional Centre, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Annalisa Capuano
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Pharmacovigilance and Pharmacoepidemiology Regional Centre, University of Campania "Luigi Vanvitelli", Naples, Italy
| |
Collapse
|
35
|
Direct Oral Anticoagulants Versus Vitamin K Antagonists in Patients Undergoing Cardioversion for Atrial Fibrillation: a Systematic Review and Meta-analysis. Cardiovasc Drugs Ther 2019; 33:339-352. [DOI: 10.1007/s10557-019-06869-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
36
|
Sumarokov AB, Buryachkovskaya LI, Lomakin NV. Specific Antidotes for Direct Oral Anticoagulants in Life-Threatening Bleeding. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2019. [DOI: 10.20996/1819-6446-2018-14-6-944-950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Review presents data on medicines from the new group of cardiovascular drugs, direct oral anticoagulants (DOACs) inhibitors, as antidotes for DOAC when stopping life-threatening bleeding. DOAC therapy is accorded by hemorrhages with lower frequency than therapy by indirect anticoagulants, but really exist. New antidotes for DOACs are idarucizumab, andexanet, ciraparantag. The need in antidotes for DOAC may suddenly appear in spontaneous bleeding, during surgical operation, invasive procedure, due to trauma, in patients with stroke, kidney or liver failure. Data is given on the frequency of the main types of bleeding while taking new oral anticoagulants. Information concerning use of antidotes for DOACs in bleedings as well as use of non-specific therapy are reviewed.
Collapse
Affiliation(s)
| | | | - N. V. Lomakin
- Central Clinical Hospital of the Presidential Administration of the Russian Federation
| |
Collapse
|
37
|
Hoffman M, Goldstein JN, Levy JH. The impact of prothrombin complex concentrates when treating DOAC-associated bleeding: a review. Int J Emerg Med 2018; 11:55. [PMID: 31179943 PMCID: PMC6326120 DOI: 10.1186/s12245-018-0215-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 11/11/2018] [Indexed: 12/18/2022] Open
Abstract
Background Bleeding complications are a risk associated with all anticoagulants. Currently, the treatment options for the management of direct oral anticoagulant (DOAC)-associated bleeding are limited. Prothrombin complex concentrates (PCCs) have been proposed as a potential therapeutic option, and evidence regarding their use is increasing. Review Many studies supporting PCC have used preclinical models and healthy volunteers; however, more recently, observational studies have further improved insight into current DOAC reversal strategies. Multiple clinical practice guidelines now specifically suggest use of PCCs for this indication. Specific reversal agents for Factor Xa inhibitors may become available in the near future, but data on their efficacy are still emerging. Conclusions Ultimately, a multimodal approach may be the optimal strategy to restore haemostasis in patients presenting with DOAC-associated coagulopathy. Electronic supplementary material The online version of this article (10.1186/s12245-018-0215-6) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Maureane Hoffman
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA.
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, USA
| | - Jerrold H Levy
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
38
|
Dager WE, Roberts AJ, Nishijima DK. Effect of low and moderate dose FEIBA to reverse major bleeding in patients on direct oral anticoagulants. Thromb Res 2018; 173:71-76. [PMID: 30476716 DOI: 10.1016/j.thromres.2018.11.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 10/05/2018] [Accepted: 11/08/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Management of acute, major or life threatening bleeding in the presence of direct acting oral anticoagulants (DOAC) is unclear. In the absence of a specific antidote, or in situations where there is a need for adjunctive therapy, the ideal prothrombin complex concentrate and dose is unclear. The goal of our study was to evaluate the outcomes of our reduced dosing strategy with FEIBA in patients experiencing a DOAC-related bleeding event. DESIGN Retrospective analysis of patients treated with FEIBA for a DOAC-related bleeding event. SETTING Academic medical center PATIENTS: Consecutive patients between May 2011 and April 2017 receiving FEIBA for a DOAC-related bleed INTERVENTIONS: None MEASUREMENTS & MAIN RESULTS: Of the 64 patients included in this analysis, 38 patients received low dose FEIBA (mean 10.0 ± 3.6 units/kg) and 26 received moderate dose (mean 24.3 ± 2.1 units/kg) FEIBA; an additional dose was requested in 6 patients. Six dabigatran patients received idarucizumab. 30 day event rates included 5 thromboembolic events (8%) and 9 (14%) patients expired. Follow-up CT-imaging for ICH, endoscopy/colonoscopy, or interventional radiology exams did not reveal any clinically concerning active bleeding or hematoma expansion except in 2 ICH patients with slight expansion between imaging sessions. CONCLUSIONS Low (<20 units/kg) to moderate (20-30 units/kg) doses of FEIBA, with the option for a repeat dose, may be an effective management strategy for obtaining hemostasis in DOAC-related major bleeding events.
Collapse
Affiliation(s)
- W E Dager
- Department of Pharmacy, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA 95817, United States of America.
| | - A J Roberts
- Department of Pharmacy, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA 95817, United States of America
| | - D K Nishijima
- Department of Emergency Medicine, University of California Davis Medical Center, 2315 Stockton Blvd, Sacramento, CA 95817, United States of America
| |
Collapse
|
39
|
Lim JX, Han JX, See AAQ, Lew VH, Chock WT, Ban VF, Pothiawala S, Lim WEH, McAdory LE, James ML, King NKK. External Validation of Hematoma Expansion Scores in Spontaneous Intracerebral Hemorrhage in an Asian Patient Cohort. Neurocrit Care 2018; 30:394-404. [PMID: 30377910 DOI: 10.1007/s12028-018-0631-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Hematoma expansion (HE) occurs in approximately one-third of patients with intracerebral hemorrhage (ICH) and is known to be a strong predictor of neurological deterioration as well as poor functional outcome. This study aims to externally validate three risk prediction models of HE (PREDICT, 9-point, and BRAIN scores) in an Asian population. METHODS A prospective cohort of 123 spontaneous ICH patients admitted to a tertiary hospital (certified stroke center) in Singapore was recruited. Logistic recalibrations were performed to obtain updated calibration slopes and intercepts for all models. The discrimination (c-statistic), calibration (Hosmer-Lemeshow test, le Cessie-van Houwelingen-Copas-Hosmer test, Akaike information criterion), overall performance (Brier score, R2), and clinical usefulness (decision curve analysis) of the risk prediction models were examined. RESULTS Overall, the recalibrated PREDICT performed best among the three models in our study cohort based on the novel matrix comprising of Akaike information criterion and c-statistic. The PREDICT model had the highest R2 (0.26) and lowest Brier score (0.14). Decision curve analyses showed that recalibrated PREDICT was more clinically useful than 9-point and BRAIN models over the greatest range of threshold probabilities. The two scores (PREDICT and 9-point) which incorporated computed tomography (CT) angiography spot sign outperformed the one without (BRAIN). CONCLUSIONS To our knowledge, this is the first study to validate HE scores, namely PREDICT, 9-Point and BRAIN, in a multi-ethnic Asian ICH patient population. The PREDICT score was the best performing model in our study cohort, based on the performance metrics employed in this study. Our findings also showed support for CT angiography spot sign as a predictor of outcome after ICH. Although the models assessed are sufficient for risk stratification, the discrimination and calibration are at best moderate and could be improved.
Collapse
Affiliation(s)
- Jia Xu Lim
- Department of Neurosurgery, National Neuroscience Institute, 11, Jalan Tan Tock Seng, Singapore, 308433, Singapore.,Department of Neurosurgery, Singapore General Hospital, Singapore, Singapore
| | - Julian Xinguang Han
- Department of Neurosurgery, National Neuroscience Institute, 11, Jalan Tan Tock Seng, Singapore, 308433, Singapore.,Department of Neurosurgery, Singapore General Hospital, Singapore, Singapore
| | - Angela An Qi See
- Department of Neurosurgery, National Neuroscience Institute, 11, Jalan Tan Tock Seng, Singapore, 308433, Singapore.,Department of Neurosurgery, Singapore General Hospital, Singapore, Singapore
| | - Voon Hao Lew
- Department of Neurosurgery, National Neuroscience Institute, 11, Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Wan Ting Chock
- Department of Neurosurgery, Singapore General Hospital, Singapore, Singapore
| | - Vin Fei Ban
- Department of Neurosurgery, Singapore General Hospital, Singapore, Singapore
| | - Sohil Pothiawala
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore
| | - Winston Eng Hoe Lim
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore
| | - Louis Elliot McAdory
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore
| | - Michael Lucas James
- Departments of Anesthesiology, Brain Injury Translational Research Center, Duke University, Durham, NC, USA.,Departments of Neurology, Brain Injury Translational Research Center, Duke University, Durham, NC, USA
| | - Nicolas Kon Kam King
- Department of Neurosurgery, National Neuroscience Institute, 11, Jalan Tan Tock Seng, Singapore, 308433, Singapore. .,Department of Neurosurgery, Singapore General Hospital, Singapore, Singapore. .,Duke-NUS Medical School, Singapore, Singapore.
| |
Collapse
|
40
|
Gilligan AM, Franchino-Elder J, Song X, Wang C, Henriques C, Sainski-Nguyen A, Wilson K, Smith DM, Sander S. Comparison of stroke- and bleed-related healthcare resource utilization and costs among patients with newly diagnosed non-valvular atrial fibrillation and newly treated with dabigatran, rivaroxaban, or warfarin. Expert Rev Pharmacoecon Outcomes Res 2018; 19:203-212. [DOI: 10.1080/14737167.2019.1527220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
| | - Jessica Franchino-Elder
- Boehringer-Ingelheim Pharmaceuticals, Inc, Health Economics and Outcomes Research, Ridgefield, CT, USA
| | - Xue Song
- Truven Health Analytics, an IBM Company, Cambridge, MA, USA
| | - Cheng Wang
- Boehringer-Ingelheim Pharmaceuticals, Inc, Health Economics and Outcomes Research, Ridgefield, CT, USA
| | | | | | | | - David M. Smith
- Truven Health Analytics, an IBM Company, Cambridge, MA, USA
| | - Stephen Sander
- Boehringer-Ingelheim Pharmaceuticals, Inc, Health Economics and Outcomes Research, Ridgefield, CT, USA
| |
Collapse
|
41
|
Steiner T, Köhrmann M, Schellinger PD, Tsivgoulis G. Non-Vitamin K Oral Anticoagulants Associated Bleeding and Its Antidotes. J Stroke 2018; 20:292-301. [PMID: 30309225 PMCID: PMC6186922 DOI: 10.5853/jos.2018.02250] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 09/12/2018] [Indexed: 01/12/2023] Open
Abstract
Oral anticoagulant-associated intracerebral hemorrhage (OAC-ICH) accounts for nearly 20% of all ICH. The number of patients with an indication for oral anticoagulant therapy (OAT) increases with increasing age. OAT became less complicate with the introduction of non-vitamin K oral anticoagulants (NOAC) OAT because of easier handling, favorable risk-benefit profile, reduced rates of ICH compared to vitamin K antagonists and no need for routine coagulation testing. Consequently, despite a better safety profile of NOAC the number of patients with OAC-ICH will increase. The mortality and complication rates of OAC-ICH are high and therefore they are the most feared complication of OAT. Immediate normalization of coagulation is the main goal and therefore knowledge of pharmacodynamics and coagulation status is essential. Laboratory measurements of anticoagulant activity in NOAC patients is challenging as specific tests are not widely available. More accessible tests such as the prothrombin time and activated partial thromboplastin time have important limitations. In dabigatran-associated ICH 5 g Idarucizumab should be administered. In rivaroxaban and apixaban-associated ICHs administration of andexanet alpha should be considered. Prothrombin complex concentrate may be considered if andexanet alpha is not available or in case of an ICH associated with edoxaban.
Collapse
Affiliation(s)
- Thorsten Steiner
- Department of Neurology, Frankfurt Hoechst Hospital, Frankfurt, Germany.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Köhrmann
- Department of Neurology, Essen University Hospital, Essen, Germany
| | - Peter D Schellinger
- Department of Neurology, Essen University Hospital, Essen, Germany.,Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| |
Collapse
|
42
|
An Update on the “Novel” and Direct Oral Anticoagulants, and Long-Term Anticoagulant Therapy. Clin Chest Med 2018; 39:583-593. [DOI: 10.1016/j.ccm.2018.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
|
43
|
Coughlin PA, Rudd JHF. Optimizing medical management in peripheral artery disease. Br J Surg 2018; 105:1079-1081. [PMID: 30461003 DOI: 10.1002/bjs.10883] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 03/29/2018] [Indexed: 11/08/2022]
Abstract
Changing times
Collapse
Affiliation(s)
- P A Coughlin
- Division of Vascular and Endovascular Surgery, Addenbrooke's Hospital, Cambridge University Hospital Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - J H F Rudd
- Division of Cardiovascular Medicine, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
| |
Collapse
|
44
|
Rodríguez Padial L, Arias MA, Pachón M, Flores Hernán M, Suárez Fernández C. Hemorragia grave en el paciente anticoagulado. Med Clin (Barc) 2018. [DOI: 10.1016/s0025-7753(18)30668-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
45
|
Jariwala A, Hamman K. Stop Bleeding! Oral Anticoagulation and Options for Reversal. J Nurse Pract 2018. [DOI: 10.1016/j.nurpra.2017.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
46
|
Affiliation(s)
- OMP Jolobe
- Manchester Medical Society, Manchester, UK
| |
Collapse
|
47
|
Jolobe OM. The challenge of coprescription of antiplatelet therapy and oral anticoagulants. Am J Emerg Med 2017; 35:1782-1783. [DOI: 10.1016/j.ajem.2017.05.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 05/21/2017] [Indexed: 11/29/2022] Open
|
48
|
Jolobe OMP. A comparison between vitamin K antagonists and new oral anticoagulants. Br J Clin Pharmacol 2017; 83:2589-2590. [DOI: 10.1111/bcp.13347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 06/02/2017] [Accepted: 06/08/2017] [Indexed: 11/27/2022] Open
|
49
|
Abstract
PURPOSE OF REVIEW The purpose of this review was to offer practical management strategies for when patients receiving direct oral anticoagulants require elective surgery or present with bleeding complications. RECENT FINDINGS Clinical practice guidelines are now available on the timing of periprocedural interruption of treatment with the newer direct oral anticoagulants based on their pharmacodynamics and pharmacokinetics and based on findings from cohort studies and clinical trials. An antibody that reverses the effects of dabigatran is now available, and a factor Xa decoy is being developed as an antidote to apixaban, betrixaban, edoxaban, and rivaroxaban. The timing of interruption of direct oral anticoagulants for elective surgery is based on multiple factors, including pharmacologic properties and interactions, the patient's renal function, and the type of planned surgery. There is little role for low-molecular-weight heparin bridging. Idarucizumab is the treatment of choice for dabigatran-related life-threatening bleeding, while andexanet alfa is being developed to reverse factor Xa inhibitors.
Collapse
|
50
|
Fujiwara Y, Ando H, Ushijima K, Horiguchi M, Yamashita C, Fujimura A. Dosing-time-dependent effect of rivaroxaban on coagulation activity in rats. J Pharmacol Sci 2017; 134:234-238. [PMID: 28844423 DOI: 10.1016/j.jphs.2017.08.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 07/24/2017] [Accepted: 08/02/2017] [Indexed: 12/13/2022] Open
Abstract
The anticoagulant effect of rivaroxaban, a direct inhibitor of activated factor X (FX), might be influenced by its dosing time because the activity of the coagulofibrinolytic system exhibits daily rhythmicity. In rats, FX activity follows a 24-h rhythm with a peak in the middle of the light phase and a trough at the beginning of the dark phase. Consistent with these findings, a single dose of rivaroxaban had a stronger inhibitory effect on FX activity after dosing at the beginning of the light phase than after dosing at the beginning of the dark phase. A similar chronopharmacological effect was seen in a quantitative model of venous stasis thrombosis. In comparison, the dosing time had minimal influence on the pharmacokinetics of rivaroxaban. These data indicate that the anticoagulant effect of rivaroxaban is influenced by the dosing time. Further studies should confirm this finding in a clinical setting.
Collapse
Affiliation(s)
- Yuki Fujiwara
- Division of Clinical Pharmacology, Department of Pharmacology, School of Medicine, Jichi Medical University, Shimotsuke, Japan; Department of Pharmaceutics and Drug Delivery, Faculty of Pharmaceutical Sciences, Tokyo University of Science, Noda, Japan
| | - Hitoshi Ando
- Division of Clinical Pharmacology, Department of Pharmacology, School of Medicine, Jichi Medical University, Shimotsuke, Japan.
| | - Kentaro Ushijima
- Division of Clinical Pharmacology, Department of Pharmacology, School of Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Michiko Horiguchi
- Department of Pharmaceutics and Drug Delivery, Faculty of Pharmaceutical Sciences, Tokyo University of Science, Noda, Japan
| | - Chikamasa Yamashita
- Department of Pharmaceutics and Drug Delivery, Faculty of Pharmaceutical Sciences, Tokyo University of Science, Noda, Japan
| | - Akio Fujimura
- Division of Clinical Pharmacology, Department of Pharmacology, School of Medicine, Jichi Medical University, Shimotsuke, Japan
| |
Collapse
|