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Gochnauer B, Rodino A, Russell S, Bradley K. A Pilot Study Describing DOAC Level Results and Association With Clinical Outcomes. J Pharm Pract 2024:8971900241262363. [PMID: 38884944 DOI: 10.1177/08971900241262363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Purpose: Describe direct oral anticoagulant (DOAC) level ordering and interpretation practices in association with clinical outcomes at a vascular medicine clinic. Methods: This study was a retrospective, observational study including patients who had a DOAC level ordered and assessed while on DOAC therapy. The primary outcome was the proportion of DOAC levels within previously reported ranges. Secondary outcomes included thrombotic events, major and clinically relevant non-major bleeding events, and the proportion of DOAC level results which prompted a change in the therapeutic plan. Results: A total of 43 patients who had a DOAC level ordered while on DOAC therapy were included in the study. More patients were on apixaban than other DOACs, and the most common indication for anticoagulation was deep vein thrombosis (DVT) or pulmonary embolism (PE). The most common reasons for ordering DOAC levels included history of gastric bypass (n = 20) and drug-drug interactions (n = 8). Most patients on apixaban had in-range levels (n = 24) compared to out of-range levels (5 patients). More patients on rivaroxaban had a level out-of-range (n = 10) than in-range (n = 4). One patient had a DVT, resulting in hospitalization and change in DOAC therapy. Two patients had bleeding events, with 1 hospitalization and change in DOAC therapy. DOAC level results also prompted changes in therapeutic plans for 9 of the patients. Conclusion: DOAC level results did not always correlate with expected outcomes, and further research is warranted to clarify which clinical situations may benefit from ordering DOAC levels.
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Affiliation(s)
- Brittni Gochnauer
- Ambulatory Clinical Pharmacist, The University of Kansas Health System, Kansas City, KS, USA
| | - Anne Rodino
- Ambulatory Clinical Pharmacist Practitioner, UNC Health Rex, Raleigh, NC, USA
| | - Sarah Russell
- Ambulatory Clinical Pharmacist Practitioner, UNC Health Rex, Raleigh, NC, USA
| | - Kristin Bradley
- Ambulatory Clinical Pharmacist Practitioner, UNC Health Rex, Raleigh, NC, USA
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2
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Harrington LB, Benz L, Haneuse S, Johnson E, Coleman KJ, Courcoulas AP, Li RA, Theis MK, Cooper J, Chin PL, Grinberg GG, Daigle CR, Chang JH, Um SS, Yenumula PR, Getty JZ, Arterburn DE. Bariatric Surgery and the Long-Term Risk of Venous Thromboembolism: A Population-Based Cohort Study. Obes Surg 2024; 34:2017-2025. [PMID: 38689074 DOI: 10.1007/s11695-024-07236-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 04/05/2024] [Accepted: 04/16/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE Bariatric surgery is associated with a greater venous thromboembolism (VTE) risk in the weeks following surgery, but the long-term risk of VTE is incompletely characterized. We evaluated bariatric surgery in relation to long-term VTE risk. MATERIALS AND METHODS This population-based retrospective matched cohort study within three United States-based integrated health care systems included adults with body mass index (BMI) ≥ 35 kg/m2 who underwent bariatric surgery between January 2005 and September 2015 (n = 30,171), matched to nonsurgical patients on site, age, sex, BMI, diabetes, insulin use, race/ethnicity, comorbidity score, and health care utilization (n = 218,961). Follow-up for incident VTE ended September 2015 (median 9.3, max 10.7 years). RESULTS Our population included 30,171 bariatric surgery patients and 218,961 controls; we identified 4068 VTE events. At 30 days post-index date, bariatric surgery was associated with a fivefold greater VTE risk (HRadj = 5.01; 95% CI = 4.14, 6.05) and a nearly fourfold greater PE risk (HRadj = 3.93; 95% CI = 2.87, 5.38) than no bariatric surgery. At 1 year post-index date, bariatric surgery was associated with a 48% lower VTE risk and a 70% lower PE risk (HRadj = 0.52; 95% CI = 0.41, 0.66 and HRadj = 0.30; 95% CI = 0.21, 0.44, respectively). At 5 years post-index date, lower VTE risks persisted, with bariatric surgery associated with a 41% lower VTE risk and a 55% lower PE risk (HRadj = 0.59; 95% CI = 0.48, 0.73 and HRadj = 0.45; 95% CI = 0.32, 0.64, respectively). CONCLUSION Although in the short-term bariatric surgery is associated with a greater VTE risk, in the long-term, it is associated with a substantially lower risk.
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Affiliation(s)
- Laura B Harrington
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Ste. 1600, Seattle, WA, 98101, USA.
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, 98195, USA.
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, 91101, USA.
| | - Luke Benz
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Sebastien Haneuse
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, 02115, USA
| | - Eric Johnson
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Ste. 1600, Seattle, WA, 98101, USA
| | - Karen J Coleman
- Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
| | - Anita P Courcoulas
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, 15213, USA
| | - Robert A Li
- Kaiser Permanente Northern California, Oakland, CA, 94611, USA
| | - Mary Kay Theis
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Ste. 1600, Seattle, WA, 98101, USA
| | - Julie Cooper
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Ste. 1600, Seattle, WA, 98101, USA
| | - Philip L Chin
- Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
| | - Gary G Grinberg
- Kaiser Permanente Northern California, Oakland, CA, 94611, USA
| | - Christopher R Daigle
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Ste. 1600, Seattle, WA, 98101, USA
| | - Julietta H Chang
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Ste. 1600, Seattle, WA, 98101, USA
| | - Scott S Um
- Kaiser Permanente Southern California, Pasadena, CA, 91101, USA
| | | | | | - David E Arterburn
- Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave., Ste. 1600, Seattle, WA, 98101, USA
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle, WA, 98104, USA
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3
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Dvořáčková E, Pilková A, Matoulek M, Slanař O, Hartinger JM. Bioavailability of Orally Administered Drugs After Bariatric Surgery. Curr Obes Rep 2024; 13:141-153. [PMID: 38172482 DOI: 10.1007/s13679-023-00548-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2023] [Indexed: 01/05/2024]
Abstract
PURPOSE OF REVIEW Oral drug absorption after bariatric surgery is likely to be altered, but the impact of different bariatric surgery procedures on individual drugs is not uniform. The aim of this article is to describe factors influencing the bioavailability of orally administered drugs after bariatric surgery and to provide readers with practical recommendations for drug dosing. We also discuss the medications that may be harmful after bariatric surgery. RECENT FINDINGS The fundamental factors for enteral drug absorption are the production of gastric acid; the preserved length of the intestine, i.e., the size of the absorption surface and/or the preserved enterohepatic circulation; and the length of common loop where food and drugs are mixed with digestive enzymes and bile acids. Bypassing of metabolizing enzymes or efflux pumps and changes in intestinal motility can also play an important role. Significant changes of drug absorption early after the anatomic alteration may also be gradually ameliorated due to gradual intestinal adaptation. The most affected drugs are those with low or variable bioavailability and those undergoing enterohepatic circulation. Attention should also be paid to oral drug formulations, especially in the early postoperative period, when immediate-release and liquid formulations are preferred. The changes in oral bioavailability are especially clinically meaningful in patients treated with drugs possessing narrow therapeutic index (e.g., oral anticoagulants, levothyroxine, and anticonvulsants) or in acute conditions (e.g., anti-infectives); nevertheless, it may also influence the therapeutic value of chronic therapy (e.g., antidepressants. antihypertensives, antiplatelets, statins, PPIs, contraceptives, and analgesics); therapeutic effect of chronic therapy is further influenced by pharmacokinetic alterations resulting from weight loss. Therapeutic drug monitoring, periodical clinical evaluation, and adequate dose adjustments are necessary. Due to safety reasons, patients should avoid oral bisphosphonates, regular use of non-steroidal anti-inflammatory drugs, and, if possible, corticosteroids after bariatric surgery.
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Affiliation(s)
- Eliška Dvořáčková
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
- Department of Clinical Pharmacy, Hospital Na Františku, Prague, Czech Republic
| | - Alena Pilková
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Martin Matoulek
- Third Internal Department of Endocrinology and Metabolism, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Ondřej Slanař
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Jan Miroslav Hartinger
- Institute of Pharmacology, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic.
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Nicol C, Jacquot J, Chebane L, Combret S, Pecquet PE, Massy N, Bagheri H. [Bariatric surgery and drugs: Review of the literature and Adverse Drug Reactions analysis in French National Pharmacovigilance Database]. Therapie 2024:S0040-5957(24)00033-7. [PMID: 38458944 DOI: 10.1016/j.therap.2024.02.003] [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: 12/29/2023] [Revised: 02/09/2024] [Accepted: 02/22/2024] [Indexed: 03/10/2024]
Abstract
INTRODUCTION Bariatric surgery is the only treatment for severe obesity (BMI>35kg/m2) currently recognized as effective both in achieving tangible and lasting weight loss, and in improving obesity-related comorbidities such as type 2 diabetes, hypertension, and cardiovascular complications. Bariatric surgery, like any other surgery of the digestive tract, can have an impact on nutrient absorption, as well as on drug absorption. The literature on drug management in bariatric surgery patients concerned mainly of case reports and retrospective studies involving a small number of patients. No official guidelines are available. METHODS We conducted a literature search on the consequences of bariatric surgery in terms of drug bioavailability and/or effect. The Medline® (PubMed) database was searched using the following keywords: "bariatric surgery", "bioavailability", "gastric bypass", and "obesity". We completed this review with an analysis of reports of adverse drug reactions (ADRs) in post-bariatric surgery patients for obesity registered in the National pharmacovigilance database (PVDB). We selected all cases with the mention of "bariatric surgery and/or gastrectomy" as "medical history". After reading the cases, we excluded those in which the patient had undergone surgery for an indication other than obesity, where the route of administration was other than oral, and cases in which ADRs resulted from voluntary overdose, attempted suicide, allergy, switch to Levothyrox® new formulation, meningioma under progestative drugs, inefficacy related to generic substitution and medication error. RESULTS The literature search identified mainly "case report" about the impact of bariatric surgery on so-called "narrow therapeutic window" drugs. We identified 66 informative cases out of a total of 565 cases selected (11%) in the PVDB. Nevertheless, the information does not allow a clear relationship between the occurrence of the ADR and the influence of bariatric surgery. CONCLUSION There is a lack of official information and/or recommendations on medication use in subjects who have undergone bariatric surgery. Apart from under-reporting, ADRs reports remain largely uninformative. Health professional and patients would be awareness for improving, quantitatively and qualitatively the reporting of ADRs in this population.
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Affiliation(s)
- Carole Nicol
- Service de pharmacologie médicale, centre de pharmacovigilance de Toulouse, CIC1436, faculté de médecine, CHU de Toulouse, 31000 Toulouse, France
| | - Julien Jacquot
- Service de pharmacologie médicale, centre de pharmacovigilance de Toulouse, CIC1436, faculté de médecine, CHU de Toulouse, 31000 Toulouse, France
| | - Leila Chebane
- Service de pharmacologie médicale, centre de pharmacovigilance de Toulouse, CIC1436, faculté de médecine, CHU de Toulouse, 31000 Toulouse, France
| | - Sandrine Combret
- Centre régional de pharmacovigilance de Bourgogne, CHU de Dijon, 21000 Dijon, France
| | - Pauline-Eva Pecquet
- Service de pharmacologie clinique, centre de pharmacovigilance d'Amiens, CHU d'Amiens, 80000 Amiens, France
| | - Nathalie Massy
- Centre régional de pharmacovigilance de Rouen, CHU de Rouen, 76000 Rouen, France
| | - Haleh Bagheri
- Service de pharmacologie médicale, centre de pharmacovigilance de Toulouse, CIC1436, faculté de médecine, CHU de Toulouse, 31000 Toulouse, France.
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Konstantinidou SK, Argyrakopoulou G, Dalamaga M, Kokkinos A. The Effects of Bariatric Surgery on Pharmacokinetics of Drugs: a Review of Current Evidence. Curr Nutr Rep 2023; 12:695-708. [PMID: 37857987 PMCID: PMC10766679 DOI: 10.1007/s13668-023-00498-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2023] [Indexed: 10/21/2023]
Abstract
PURPOSE OF REVIEW Obesity constitutes a major public health concern and has been recognized as an epidemic. To date, bariatric surgery remains the most effective way for substantial long-lasting weight loss in severe obesity. The purpose of this review is to summarize how the pharmacokinetics of drugs are affected by the most common types of bariatric surgery, i.e., Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG). RECENT FINDINGS Limited data are available regarding the changes in pharmacokinetics of drugs after bariatric surgery. The lack of existing guidelines may lead patients to experience drug toxicity or therapeutic undertreatment. Pharmacokinetic parameters that need to be taken into consideration postoperatively include gastric motility, gastric volume, pH, surface area, bile secretions, carrier proteins, and first-pass metabolism. For drugs with a narrow therapeutic index, other factors need to be monitored closely, including plasma drug levels, patients' clinical outcomes, and laboratory markers. Patients should be followed up frequently and treated in accordance with their response to the drug therapy. Bariatric surgery may affect the pharmacokinetics of various drugs, due to the resultant anatomical changes and the substantial weight loss. Therefore, there is a need to identify those potential changes and adjust patients' medication doses in order to achieve higher efficacy and avoid toxicity.
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Affiliation(s)
- Sofia K Konstantinidou
- First Department of Propaedeutic Internal Medicine, School of Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece.
| | | | - Maria Dalamaga
- Department of Biological Chemistry, School of Medicine, National and Kapodistrian University of Athens, 11527, Athens, Greece
| | - Alexander Kokkinos
- First Department of Propaedeutic Internal Medicine, School of Medicine, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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6
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Abi Mosleh K, Belluzzi A, Salame M, Kendrick ML, Abu Dayyeh BK, McKenzie TJ, Ghanem OM. Long-Term Outcomes of Bariatric Surgery in Patients on Chronic Anticoagulation. Obes Surg 2023; 33:4007-4016. [PMID: 37917392 DOI: 10.1007/s11695-023-06910-x] [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: 08/20/2023] [Revised: 10/11/2023] [Accepted: 10/18/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Approximately 3% of patients undergoing metabolic and bariatric surgery (MBS) are receiving chronic anticoagulation therapy (CAT) prior to operation. The management of these patients is complex, as it involves balancing the potential risk of thrombosis against that of bleeding. Our primary objective is to assess the long-term bleeding risk in patients undergoing MBS. We also aim to observe the trends in anticoagulant dosing after MBS. METHODS A single-center retrospective review of patients who underwent either primary Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) with preoperative CAT between 2008 and 2022 was performed. Data on baseline demographics, indication for anticoagulation, type of CAT, and dosing were collected. Events of bleeding and the CAT at event were subsequently evaluated. RESULTS A total of 132 patients (82 RYGB and 50 SG) initially on CAT were identified, with atrial fibrillation being the most common indication. Incidence of long-term bleeding was significantly higher in the RYGB group (18.3%) compared to the SG group (4%) (p = 0.017) over a total of 5.2 ± 3.8 years. Bleeding marginal ulcer (MU) was the most common cause of bleeding in the RYGB group (13.4%). 84.2% of all bleeding events occurred in patients on chronic Warfarin therapy. CONCLUSION Long-term CAT is associated with an increased risk of bleeding in RYGB patients, particularly MU bleeds. Patients on CAT seeking MBS should be counseled regarding this risk and potential implications. Direct-acting oral anticoagulants offer promise as an alternative to Warfarin in these patients; further research is necessary to better understand their safety.
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Affiliation(s)
- Kamal Abi Mosleh
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Amanda Belluzzi
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Marita Salame
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Michael L Kendrick
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Barham K Abu Dayyeh
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Travis J McKenzie
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA
| | - Omar M Ghanem
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
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7
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Zhang H, Xie H, Wang X, Zhu Z, Duan F. Effectiveness and safety of non-vitamin K antagonist oral anticoagulant in the treatment of patients with morbid obesity or high body weight with venous thromboembolism: A meta-analysis. Medicine (Baltimore) 2023; 102:e35015. [PMID: 37682131 PMCID: PMC10489198 DOI: 10.1097/md.0000000000035015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 08/08/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) poses a significant health risk to patients with morbid obesity or high body weight. Non-vitamin K antagonist oral anticoagulants (NOACs) are emerging treatments, but their effectiveness and safety compared with vitamin K antagonists (VKAs) in this population are yet to be thoroughly studied. METHODS We conducted a systematic review and meta-analysis, adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Four electronic databases were searched for relevant studies comparing the efficacy and safety of NOACs and VKAs in treating patients with VTE with a body mass index > 40 kg/m2 or body weight > 120 kg. Eligible studies were scored for quality using the Newcastle-Ottawa Scale. RESULTS Thirteen studies were included. The meta-analysis results showed that compared to VKAs, NOACs significantly decreased the risk of VTE occurrence (odds ratio = 0.72, 95% CI: 0.57-0.91, I2 = 0%, P < .001) and were associated with a lower risk of bleeding (odds ratio = 0.74, 95% CI: 0.58-0.95, I2 = 0%, P < .05). Subgroup analysis showed that in the cancer patient subgroup, both risks of VTE occurrence and bleeding were lower in the NOAC group than in the VKA group. In patients without cancer, the risk of VTE was significantly lower in the NOAC group. CONCLUSION NOACs appear to be more effective and safer than VKAs in patients with morbid obesity or a high body weight with VTE. However, further large-scale randomized controlled trials are required to confirm these findings.
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Affiliation(s)
- Hongxia Zhang
- Department of Neurology, Sixth Medical Center, General Hospital of The People’s Liberation Army, Haidian District, Beijing, China
| | - Hua Xie
- Healthcare Department 1, Second Medical Center, General Hospital of The People’s Liberation Army, Haidian District, Beijing, China
| | - Xiaoyan Wang
- Department of Neurology, Sixth Medical Center, General Hospital of The People’s Liberation Army, Haidian District, Beijing, China
| | - Zonghong Zhu
- Department of Emergency, Sixth Medical Center, General Hospital of The People’s Liberation Army, Haidian District, Beijing, China
| | - Feng Duan
- Department of Neurology, Sixth Medical Center, General Hospital of The People’s Liberation Army, Haidian District, Beijing, China
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8
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Wołowiec Ł, Kusiak M, Budzyński J, Wołowiec A, Jaśniak A, Wiciński M, Pedrycz-Wieczorska A, Rogowicz D, Grześk G. Therapeutic Drug Monitoring of Direct Oral Anticoagulants in Patients with Extremely Low and High Body Weight-Pilot Study. J Clin Med 2023; 12:4969. [PMID: 37568371 PMCID: PMC10419712 DOI: 10.3390/jcm12154969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
Phase III clinical trials for individual direct oral anticoagulants (DOACs) contained a limited representation of subjects with abnormal body weight, which were mostly limited to a BMI > 40 kg/m2, or body weight > 120 kg for obese subjects, and <50 kg for underweight subjects. Although low or high body weight is not a contraindication to DOACs therapy, it can significantly affect the safety and effectiveness of treatment. Due to the limited amount of clinical data on the use of DOACs in extremely abnormal weight ranges, optimal pharmacotherapy in this group of patients is a matter of controversy. The objective of this study was to evaluate the pharmacokinetics of DOAC properties in patients with abnormal body weight beyond the established cut-off points in the phase III studies for rivaroxaban, apixaban, and dabigatran. In total, 38 patients took DOACs for at least 12 months for non-valvular atrial fibrillation in 2019-2021. Blood samples were collected before the planned intake of the drug and 4 h after its administration. The determined concentrations of DOACs were statistically analyzed in relation to body weight, age, and eGFR (estimated Glomerular Filtration Rate). Among subjects taking apixaban, rivaroxaban, and dabigatran, the smallest representation of patients who achieved therapeutic concentrations were those treated with dabigatran. The population of people with abnormal body weight is a potential risk group of patients, in which some of them do not reach the therapeutic range of DOACs.
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Affiliation(s)
- Łukasz Wołowiec
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Toruń, Poland; (M.K.); (A.J.); (D.R.); (G.G.)
| | - Mateusz Kusiak
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Toruń, Poland; (M.K.); (A.J.); (D.R.); (G.G.)
| | - Jacek Budzyński
- Department of Vascular and Internal Diseases, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Toruń, Poland;
| | - Anna Wołowiec
- Department of Geriatrics, Division of Biochemistry and Biogerontology, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Toruń, Poland;
| | - Albert Jaśniak
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Toruń, Poland; (M.K.); (A.J.); (D.R.); (G.G.)
| | - Michał Wiciński
- Department of Pharmacology and Therapeutics, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Toruń, Poland;
| | | | - Daniel Rogowicz
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Toruń, Poland; (M.K.); (A.J.); (D.R.); (G.G.)
| | - Grzegorz Grześk
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University, 87-100 Toruń, Poland; (M.K.); (A.J.); (D.R.); (G.G.)
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9
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Liu PH, Singal AG, Murphy CC. Stool-Based Tests Mitigate Impacts of COVID-19 on Colorectal Cancer Screening. Clin Gastroenterol Hepatol 2023; 21:1667-1669.e2. [PMID: 36566814 PMCID: PMC9780015 DOI: 10.1016/j.cgh.2022.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/05/2022] [Accepted: 12/08/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Po-Hong Liu
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Amit G Singal
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Caitlin C Murphy
- School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
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10
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Swartz DE, Gupta S. RE: Letter to the Editor "Practical Issues with Using Direct Oral Anticoagulant After Bariatric Metabolic Surgery" Following the Publication of: "30-Day Post-Discharge Prophylaxis with Rivaroxaban Prevents PMVT Following Laparoscopic Sleeve Gastrectomy". Obes Surg 2023:10.1007/s11695-023-06592-5. [PMID: 37084022 DOI: 10.1007/s11695-023-06592-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/05/2023] [Accepted: 04/10/2023] [Indexed: 04/22/2023]
Affiliation(s)
- Daniel E Swartz
- Saint Agnes Care Metabolic and Bariatric Surgery, Saint Agnes Medical Center, 1510 East Herndon Ave., Ste 210, Fresno, CA, 93720, USA.
| | - Sachin Gupta
- California Cancer Associates for Research & Excellence, 7130 N Millbrook Ave, Fresno, CA, 93720, USA
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11
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Hany M, Bedewy AML, Torensma B. Practical Issues with Using Direct Oral Anticoagulant After Bariatric Metabolic Surgery. Obes Surg 2023:10.1007/s11695-023-06591-6. [PMID: 37074527 DOI: 10.1007/s11695-023-06591-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 03/18/2023] [Accepted: 04/05/2023] [Indexed: 04/20/2023]
Affiliation(s)
- Mohamed Hany
- Department of Surgery, Medical Research Institute, Alexandria University, 165 Horreya Avenue, Hadara, 21561, Alexandria, Egypt.
- Consultant of Bariatric Surgery at Madina Women's Hospital, Alexandria, Egypt.
| | | | - Bart Torensma
- Clinical Epidemiologist, Leiden University Medical Center (LUMC), Leiden, The Netherlands
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Patel PH, Ho T, Upadhyay SM. A Systematic Review of Warfarin Use in Post-Bariatric Surgery Patients: Cases Compiled From a Literature Review. Ann Pharmacother 2023; 57:193-197. [PMID: 35699512 DOI: 10.1177/10600280221105312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVE The objective of this review was to provide dosing recommendations for percentage change in weekly warfarin dose and rates of thrombotic and bleeding events in patients requiring long-term warfarin therapy after bariatric surgery. DATA SOURCES A comprehensive literature search of PubMed (through April 5, 2021), Cochrane Library, and Google Scholar (through April 5, 2021) databases was completed using the keywords warfarin OR vitamin k antagonist AND bariatric surgery. STUDY SELECTION AND DATA EXTRACTION Retrospective studies and matched-cohort studies evaluating preoperative and postoperative use of warfarin after bariatric surgery for obesity were considered. Weekly dose defined as sum of daily doses of warfarin for 7 consecutive days was a required outcome to be considered in this review. Patients were excluded from review if post-operative dosage change was not reported. DATA SYNTHESIS Six studies were included with a total of 160 patients who met the criteria. A decrease in average warfarin dose was seen in all studies, with the largest decrease occurring at 1 month postsurgery followed by an upward trend toward baseline about 90 days postsurgery. While thrombotic events were observed in none of the patients, there was an increased risk of bleeding in patients, particularly in those who underwent roux-en-y gastric bypass (RYGB) surgery. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE The study provides a specific warfarin dosing titration regimen, as well as embolic and bleed risk in post-bariatric surgery population. CONCLUSIONS Clinicians may consider lowering warfarin weekly dose by about 25% immediately postsurgery, with doses approaching closer to baseline about 90 days postsurgery.
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Affiliation(s)
- Pooja H Patel
- Department of Pharmacy Practice, Texas A&M University, Houston, TX, USA
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13
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Swan D, Thachil J. Challenges in managing patients on anticoagulation: Thrombocytopenia, resumption after bleeding and recurrent thrombosis. J R Coll Physicians Edinb 2022; 52:341-349. [PMID: 36317384 DOI: 10.1177/14782715221134720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Abstract
Prescribing of anticoagulation is increasing worldwide. This is partly reflective of an aging population with cardiovascular comorbidities such as arrhythmias and prosthetic heart valves, alongside improvements in cancer treatments and survival. In this review, we discuss three common challenges faced by clinicians. These concern the management of patients with thrombosis and thrombocytopenia, resumption of anticoagulation in patients with a history of gastrointestinal or intracranial haemorrhage, and how to approach and treat a patient with recurrent thrombosis on anticoagulation. We consider the available evidence including relevant published recommendations and propose practical management suggestions to aid clinicians faced with these dilemmas.
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Affiliation(s)
- Dawn Swan
- Department of Haematology, St James Hospital, Dublin, Ireland
| | - Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, UK
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14
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Amaral FC, Baptista-Silva JC, Nakano LC, Flumignan RL. Pharmacological interventions for preventing venous thromboembolism in people undergoing bariatric surgery. Cochrane Database Syst Rev 2022; 11:CD013683. [PMID: 36413425 PMCID: PMC9680918 DOI: 10.1002/14651858.cd013683.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE), which comprises deep vein thrombosis (DVT) and pulmonary embolism (PE), is the leading cause of preventable death in hospitalised people and the third most common cause of mortality in surgical patients. People undergoing bariatric surgery have the additional risk factor of being overweight. Although VTE prophylaxis in surgical patients is well established, the best way to prevent VTE in those undergoing bariatric surgery is less clear. OBJECTIVES To evaluate the benefits and harms of pharmacological interventions (alone or in combination) on venous thromboembolism and other health outcomes in people undergoing bariatric surgery compared to the same pharmacological intervention administered at a different dose or frequency, the same pharmacological intervention or started at a different time point, another pharmacological intervention, no intervention or placebo. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 1 November 2021. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs in males and females of any age undergoing bariatric surgery comparing pharmacological interventions for VTE (alone or in combination) with the same pharmacological intervention administered at a different dose or frequency, the same pharmacological intervention started at a different time point, a different pharmacological intervention, no treatment or placebo. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. VTE and 2. major bleeding. Our secondary outcomes were 1. all-cause mortality, 2. VTE-related mortality, 3. PE, 4. DVT, 5. adverse effects and 6. quality of life. We used GRADE to assess certainty of evidence for each outcome. MAIN RESULTS We included seven RCTs with 1045 participants. Data for meta-analysis were available from all participants. Four RCTs (597 participants) compared higher-dose heparin to standard-dose heparin: one of these studies (139 participants) used unfractionated heparin (UFH) and the other three (458 participants) used low-molecular-weight heparin (LMWH). One study compared heparin versus pentasaccharide (198 participants), and one study compared starting heparin before versus after bariatric surgery (100 participants). One study (150 participants) compared combined mechanical and pharmacological (enoxaparin) prophylaxis versus mechanical prophylaxis alone. The duration of the interventions ranged from seven to 15 days, and follow-up ranged from 10 to 180 days. Higher-dose heparin versus standard-dose heparin Compared to standard-dose heparin, higher-dose heparin may result in little or no difference in the risk of VTE (RR 0.55, 95% CI 0.05 to 5.99; 4 studies, 597 participants) or major bleeding (RR 1.19, 95% CI 0.48 to 2.96; I2 = 8%; 4 studies, 597 participants; low-certainty) in people undergoing bariatric surgery. The evidence on all-cause mortality, VTE-related mortality, PE, DVT and adverse events (thrombocytopenia) is uncertain (effect not estimable or very low-certainty evidence). Heparin versus pentasaccharide Heparin compared to a pentasaccharide after bariatric surgery may result in little or no difference in the risk of VTE (RR 0.83, 95% CI 0.19 to 3.61; 1 study, 175 participants) or DVT (RR 0.83, 95% CI 0.19 to 3.61; 1 study, 175 participants). The evidence on major bleeding, PE and mortality is uncertain (effect not estimable or very low-certainty evidence). Heparin started before versus after the surgical procedure Starting prophylaxis with heparin 12 hours before surgery versus after surgery may result in little or no difference in the risk of VTE (RR 0.11, 95% CI 0.01 to 2.01; 1 study, 100 participants) or DVT (RR 0.11, 95% CI 0.01 to 2.01; 1 study, 100 participants). The evidence on major bleeding, all-cause mortality and VTE-related mortality is uncertain (effect not estimable or very low-certainty evidence). We were unable to assess the effect of this intervention on PE or adverse effects, as the study did not measure these outcomes. Combined mechanical and pharmacological prophylaxis versus mechanical prophylaxis alone Combining mechanical and pharmacological prophylaxis (started 12 hours before surgery) may reduce VTE events in people undergoing bariatric surgery compared to mechanical prophylaxis alone (RR 0.05, 95% CI 0.00 to 0.89; number needed to treat for an additional beneficial outcome (NNTB) = 9; 1 study, 150 participants; low-certainty). We were unable to assess the effect of this intervention on major bleeding or morality (effect not estimable), or on PE or adverse events (not measured). No studies measured quality of life. AUTHORS' CONCLUSIONS Higher-dose heparin may make little or no difference to venous thromboembolism or major bleeding in people undergoing bariatric surgery when compared to standard-dose heparin. Heparin may make little or no difference to venous thromboembolism in people undergoing bariatric surgery when compared to pentasaccharide. There are inadequate data to draw conclusions about the effects of heparin compared to pentasaccharide on major bleeding. Starting prophylaxis with heparin 12 hours before bariatric surgery may make little or no difference to venous thromboembolism in people undergoing bariatric surgery when compared to starting heparin after bariatric surgery. There are inadequate data to draw conclusions about the effects of heparin started before versus after surgery on major bleeding. Combining mechanical and pharmacological prophylaxis (started 12 hours before surgery) may reduce VTE events in people undergoing bariatric surgery when compared to mechanical prophylaxis alone. No data are available relating to major bleeding. The certainty of the evidence is limited by small sample sizes, few or no events, and risk of bias concerns. Future trials must be sufficiently large to enable analysis of relevant clinical outcomes, and should standardise the time of treatment and follow-up. They should also address the effect of direct oral anticoagulants and antiplatelets, preferably grouping them according to the type of intervention.
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Affiliation(s)
- Fabio Cf Amaral
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jose Cc Baptista-Silva
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Luis Cu Nakano
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
- Cochrane Brazil, Universidade Federal de São Paulo, São Paulo, Brazil
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15
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Erstad BL, Barletta JF. Dilemmas Related to Direct-Acting Oral Anticoagulant Administration in Patients With Extreme Obesity. Ann Pharmacother 2022; 57:727-737. [PMID: 36258660 DOI: 10.1177/10600280221130456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE The objective of the study was to discuss the controversies surrounding the use and dosing of direct-acting oral anticoagulants (DOACs) in obese patients recognizing the limitations of the existing evidence base that preclude strong recommendations. DATA SOURCES A literature search of MEDLINE was performed (2020 to end August 2022) subsequent to recent guidelines using the following search terms: direct acting anticoagulants, obesity, rivaroxaban, apixaban, edoxaban, dabigatran, dabigatran etexilate, and clinical practice guidelines. STUDY SELECTION AND DATA ABSTRACTION English-language studies and those conducted in adults were selected. DATA SYNTHESIS The available randomized studies evaluating DOACs had relatively small numbers of patients with more extreme forms of obesity (body mass index [BMI] > 40 kg/m2) and none of the larger studies had a specific focus on dosing DOACs in obese patients. Recent guidelines by the International Society on Thrombosis and Haemostasis (ISTH) have specific recommendations for dosing DOACs in obesity. There are pharmacokinetic/pharmacodynamic and observational studies published before and after the ISTH guidelines with a focus on DOAC dosing in obese patients that generally support the recommendations in the guidelines, but most involved small numbers of patients usually with BMIs <45 kg/m2. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This review discusses DOAC dosing in obesity with important considerations for clinicians related to DOAC choice and dosing. CONCLUSIONS Dosing alterations of DOACs do not appear to be necessary when used for either prophylaxis or treatment in patients with BMIs up to approximately 45 to 50 kg/m2, but research is needed for BMIs >50 kg/m2.
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Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, The University of Arizona, Tucson, AZ, USA
| | - Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy-Glendale Campus, Midwestern University, Glendale, AZ, USA
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16
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Leong R, Chu DK, Crowther MA, Mithoowani S. Direct oral anticoagulants after bariatric surgery-What is the evidence? J Thromb Haemost 2022; 20:1988-2000. [PMID: 35844166 DOI: 10.1111/jth.15823] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 06/29/2022] [Accepted: 07/13/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Obesity is a global epidemic and bariatric surgery is used with increasing frequency to treat its complications. The extent to which bariatric surgery alters the efficacy, safety, and pharmacokinetics of direct oral anticoagulants (DOACs) is unknown. AIMS In this review, we summarize the evidence supporting the use of DOACs after bariatric surgery and apply our findings to resolve several clinical cases. MATERIALS & METHODS We systematically searched MEDLINE, EMBASE, Cochrane Library, CINAHL and ClinicalTrials.gov from January 1, 2000, to June 15, 2021 for randomized and non-randomized studies evaluating the use of DOACs for any indication after bariatric surgery. Two reviewers independently screened titles, abstracts, and full-text articles. Clinical and pharmacokinetic outcomes were pooled by random-effects meta-analysis with inverse variance weighting. We used the Newcastle-Ottawa scale to assess risk of bias in non-randomized studies and assessed the certainty of evidence with GRADE. RESULTS From 2519 records, we included 28 studies (n = 3229 patients): no randomized trials, 7 cohort studies, 6 case series, and 15 case reports. Incidence rates for arterial thromboembolism, venous thromboembolism and major bleeding were: 0.73 (95% confidence interval [CI]: 0.01-5.10), 2.45 (95% CI: 0.40-7.94), and 3.40 (95% CI: 0.80-9.36) events per 100 patient-years, respectively. The pooled proportion of peak direct oral anticoagulant drug levels within the expected range was 58% (95% CI: 39%-74%). CONCLUSION There appears be substantial risk of DOAC malabsorption after bariatric surgery that could affect clinical outcomes, however the certainty of evidence was very low. PROSPERO CRD42020202636.
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Affiliation(s)
- Russell Leong
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Derek K Chu
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Mark A Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Siraj Mithoowani
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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17
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Outcomes with direct acting oral anticoagulants in patients with a history of bariatric surgery: a retrospective cohort study. Surg Obes Relat Dis 2022. [DOI: 10.1016/j.soard.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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18
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Ramcharitar RK, Man L, Khaja MS, Barnett ME, Sharma A. A Review of the Past, Present and Future of Cancer-associated Thrombosis Management. Heart Int 2022; 16:117-123. [PMID: 36721704 PMCID: PMC9870322 DOI: 10.17925/hi.2022.16.2.117] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 06/14/2022] [Indexed: 12/25/2022] Open
Abstract
Venous thromboembolism (VTE) can have a significant impact on the management, quality of life and mortality of patients with cancer. VTE occurs in 5-20% of patients with cancer, and malignancy is associated with up to 25% of all VTE. It is the second leading cause of death in ambulatory patients with cancer who are receiving chemotherapy. Increased rates of cancer-associated thrombosis are attributed to improved patient survival, increased awareness, surgery, antineoplastic treatments and the use of central venous access devices. Many factors influence cancer-associated thrombosis risk and are broadly categorized into patient-related, cancer-related and treatment-related risks. Direct-acting oral anticoagulants have shown themselves to be at least as effective in preventing recurrent VTE in patients with cancer with symptomatic and incidental VTE. This has led to a change in treatment paradigms so that direct-acting oral anticoagulants are now considered first-line agents in appropriately selected patients. In this article, we review the prior and recent landmark studies that have directed the treatment of cancer-associated thrombosis, and discuss specific factors that affect management as well as future treatment considerations.
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Affiliation(s)
| | - Louise Man
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Minhaj S Khaja
- Department of Radiology and Medical Imaging, University of Virginia, Charlottesville, VA, USA
| | | | - Aditya Sharma
- Department of Medicine, University of Virginia, Charlottesville, VA, USA
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Raithel M, Haibach M, Kremenevski I, Arnold E, Ringwald J. Moderne Antikoagulation mit FXa-Inhibitoren in der Onkologie: Ist die gastrointestinale Blutungsrate (mit)-entscheidend? ZEITSCHRIFT FÜR GASTROENTEROLOGIE 2022; 61:411-419. [PMID: 35878607 DOI: 10.1055/a-1886-4591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
ZusammenfassungDas erhöhte Thrombose- und Blutungsrisiko bei aktiver Tumorerkrankung wird als sog. „thrombo-hämorrhagisches Syndrom“ bezeichnet, welches hohe Anforderungen an die Antikoagulation stellt. Aktuell liegen 4 randomisierte, prospektive Studien zum Einsatz von neuen, nicht Vitamin K-abhängigen oralen Antikoagulantien (NOAK) zur Behandlung von in der Onkologie aufgetretenen venösen Thromboembolien (VTE) vor. Dabei wurden die FXa-Inhibitoren Rivaroxaban, Edoxaban und zweimal Apixaban jeweils in einzelnen Studien gegenüber dem Standardtherapeutikum Dalteparin eingesetzt. Da es keinen direkten Head-to-Head-Vergleich der genannten FXa-Inhibitoren innerhalb einer Studie gibt, wurde zu jedem NOAK die jeweils größte Studie – stets verglichen gegenüber Dalteparin – ausgewertet. Die Studien wurden bzgl. ihrer Wirksamkeit, Sicherheit, fataler Blutungsraten, dem Risiko für gastrointestinale Blutungen (GIB) und sonstiger Unterschiede anhand deskriptiver Statistik analysiert. Unter Dalteparin ergab sich eine mittlere VTE-Rezidivrate von ca. 9% bei einem 6-monatigen Behandlungszeitraum. Alle 3 FXa-Inhibitoren waren gegenüber Dalteparin bezüglich der Wirksamkeit nicht unterlegen. Die VTE-Rezidivrate war bei mit Edoxaban und Apixaban behandelten Patienten um – 2,3% und bei Rivaroxaban um – 5,0% niedriger.Bei der Sicherheit fanden sich – jeweils gegenüber Dalteparin – für Rivaroxaban und Edoxaban eine erhöhte Rate an schweren Blutungen (jeweils +2,4%); insbesondere war hierbei die Zahl GIB deutlich erhöht. Dagegen war für Apixaban die Zahl schwerer Blutungen, wie auch für verschiedene Blutungstypen inkl. GIB, nicht erhöht. In der Apixabanstudie war insgesamt die Rate von schweren GIB, die ca. 50% aller schweren Blutungen ausmachten, und die der klinisch-relevanten nicht schweren Blutungen, am niedrigsten. Die FXa-Inhibitoren sind der Standardtherapie mit Dalteparin in der VTE-Rezidivrate bei onkologischen Patienten nicht unterlegen. Die GIB-Rate scheint ein wichtiger prädiktiver Faktor für die Sicherheit dieser Substanzgruppe zu sein, sodass Tumorlokalisation, gastrointestinale Risikofaktoren und andere individuelle Kriterien in Zukunft stärker bei der Therapieentscheidung für oder gegen einen FXa-Inhibitor berücksichtigt werden sollten.
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Affiliation(s)
| | - Martina Haibach
- Internistische Schwerpunktpraxis (IISP) Onkologie, Erlangen, Germany
| | | | - Erich Arnold
- Malteser Waldkrankenhaus St. Marien gGmbH, Erlangen, Germany
| | - Jürgen Ringwald
- Institut Lütjensee, DRK-Blutspendedienst Nord-Ost gGmbh, Lütjensee, Germany
- Praxis für Transfusionsmedizin, Lütjensee, Germany
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20
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Hwang HG, Kim YK. Pharmacotherapy for pulmonary embolism: new anticoagulants. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2022. [DOI: 10.5124/jkma.2022.65.7.442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Pulmonary embolism is associated with reduced survival and considerable economic burden worldwide. In Korea, the incidence of pulmonary embolism has been gradually increasing. Older individuals are at an increased risk for pulmonary embolism and anticoagulation-related bleeding events. Typically, heparin and vitamin K antagonists are employed to treat pulmonary embolism; however, these agents present numerous limitations. Hence, novel anticoagulants with improved safety and efficacy profiles are urgently needed.Current Concepts: Direct oral anticoagulants (DOACs), including direct thrombin (coagulation factor II) inhibitors and selective inhibitors of coagulation factor Xa, have emerged as alternative agents. Phase III, large-scale clinical trials have revealed that DOACs are non-inferior to standard therapy during initial and long-term treatment of pulmonary embolism, considering the safety profile. Evidence-based clinical guidelines recommend that primary care clinicians employ DOACs over warfarin to achieve anticoagulation.Discussion and Conclusion: For over 70 years, the standard therapy for most patients with pulmonary embolism has involved heparin administration, overlapped and followed by a vitamin K antagonist. Recently developed DOACs against coagulation factor Xa or thrombin might overcome limitations of standard therapy, including the need for injection and regular dose adjustment with laboratory monitoring. These limitations hinder the management of patients with pulmonary embolism and negatively impact the patient’s quality of life. Four DOACs, including apixaban, dabigatran, edoxaban, and rivaroxaban, are currently available for treating pulmonary embolism in Korea, which could simplify the therapeutic strategy.
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21
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Direct oral Xa inhibitors for the treatment of venous thromboembolism after bariatric surgery. Blood Adv 2022; 7:224-226. [PMID: 35640233 PMCID: PMC9841032 DOI: 10.1182/bloodadvances.2021006696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 05/27/2022] [Accepted: 05/27/2022] [Indexed: 01/21/2023] Open
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22
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Absorption of Direct Oral Anticoagulants in Cancer Patients after Gastrectomy. Pharmaceutics 2022; 14:pharmaceutics14030662. [PMID: 35336036 PMCID: PMC8951361 DOI: 10.3390/pharmaceutics14030662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 11/30/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are safe and effective in cancer patients treated for venous thromboembolism (VTE) or atrial fibrillation (AF). Gastrectomy is the treatment of choice in patients with localized upper gastrointestinal cancer. DOACs are absorbed in the upper gastrointestinal tract, but to what extent is unclear. In a retrospective analysis, hospital data were searched for adult patients who underwent gastrectomy for gastroesophageal or pancreatic cancer, and DOAC therapy for VTE or AF after gastrectomy. DOAC blood levels were determined by chromogenic assays before and after administration, and thromboembolic and bleeding complications were recorded. Eleven patients (median age 76 years) received a factor Xa inhibitor (FXaI; apixaban (3), edoxaban (3), rivaroxaban (4)) or the factor IIa inhibitor dabigatran (1) for VTE (7) or AF (4) after gastrectomy. Eight patients on FXaI had anti-Xa (aXa) trough levels within the expected range (ER). In all of them, aXa levels increased upon DOAC administration. Two patients on 30 mg edoxaban had low aXa trough levels. Administration of 20 mg of rivaroxaban resulted in trough levels in the ER in one of them. None of the FXaI patients had thromboembolism, while two experienced bleeding (arterial puncture site, gastrointestinal). One dabigatran AF patient with trough and peak concentrations below the ER had strokes during 110 mg and 150 mg dabigatran administration. While on apixaban, aXa levels were in the ER, and no clinical complications occurred. DOACs, particularly FXaI, were adequately absorbed in cancer patients after gastrectomy. Our observation of recurrent thromboembolic events in a patient treated with dabigatran warrants cautious use in this specific patient population.
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23
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Van der Linden L, Hias J, Vanassche T. The value and limitations of new oral anticoagulant plasma level assessments. Eur Heart J Suppl 2022; 24:A32-A41. [PMID: 35185407 PMCID: PMC8850711 DOI: 10.1093/eurheartj/suab153] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
abstract
The class of new oral anticoagulants (NOACs) has been developed to provide reliable oral anticoagulation without the need for therapeutic drug monitoring. Based on phase I and II trials and pharmacokinetic and pharmacodynamic modeling, fixed drug doses have been selected for large phase III clinical trials for each currently available NOAC. In these trials, the use of the fixed dose without plasma level assessments was shown to be at least as effective and at least as safe as vitamin K antagonists with continuous therapeutic drug monitoring. Real world evidence reaffirms that the use of a fixed NOAC dose without plasma level assessment is safe and effective in a large variety of patients. Nevertheless, measurement of NOAC plasma levels can add information that may be useful in some clinical scenarios. This review discusses the possible use cases, the limitations, and the practical implementation of measuring NOAC plasma concentrations.
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Affiliation(s)
- Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Julie Hias
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
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Steele KE, Prokopowicz GP, Canner JP, Harris C, Jurao RA, Kickler TS, Streiff MB, Petty BG. The APB study: apixaban pharmacokinetics in bariatric patients before to 1 year after vertical sleeve gastrectomy or Roux-en-Y gastric bypass. Surg Obes Relat Dis 2021; 18:594-603. [DOI: 10.1016/j.soard.2021.12.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 11/28/2021] [Accepted: 12/21/2021] [Indexed: 11/24/2022]
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25
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Nasser MF, Jabri A, Gandhi S, Rader F. Oral Anticoagulant Use in Morbid Obesity and Post Bariatric Surgery: A Review. Am J Med 2021; 134:1465-1475. [PMID: 34403701 DOI: 10.1016/j.amjmed.2021.07.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 01/06/2023]
Abstract
Bariatric surgery has emerged as a therapy for obesity and the associated comorbidities. Obesity has been shown to be a risk factor for atrial fibrillation as well as venous thromboembolism, both of which are conditions that warrant anticoagulation. There is significant underrepresentation of the morbidly obese population in prospective trials that evaluated direct oral anticoagulants and vitamin K antagonists in atrial fibrillation and venous thromboembolism. We aim to review all the available data that assessed these oral anticoagulants in the morbidly obese population (body mass index >40 kg/m2 and weight >120 kg) and in the post-bariatric surgery population. Our findings suggest that direct oral anticoagulants may be safe and effective for anticoagulation in morbidly obese patients for both atrial fibrillation and venous thromboembolism. However, warfarin is the preferred agent in the post-bariatric surgery population, given the limited number of studies on direct oral anticoagulants in this population. Further adequately powered randomized control trials are needed to confirm the safety and efficacy of these oral anticoagulants in the morbidly obese and post-bariatric surgery population.
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Affiliation(s)
- Mohamed Farhan Nasser
- Heart and Vascular Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Ahmad Jabri
- Heart and Vascular Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Sanjay Gandhi
- Heart and Vascular Center, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio.
| | - Florian Rader
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
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Srivastava K, Patel N, Tabbara M, Liew A, Zaghloul I, Migliore MM, Mekary RA. Thromboembolism, Bleeding, and Mortality Incidence of Direct Oral Anticoagulants Versus Warfarin Postbariatric Surgery. Am J Med 2021; 134:1403-1412.e2. [PMID: 34273283 DOI: 10.1016/j.amjmed.2021.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND There is no randomized controlled trial comparing direct oral anticoagulants (DOACs) and warfarin following bariatric surgery to date. The mortality, thromboembolism, and bleeding risk of DOACs in comparison with warfarin following bariatric surgery remains unclear. We aimed to provide a clinical comparison between DOACs and warfarin for these 3 prespecified outcomes. METHODS A systematic literature search was performed on November 10, 2019, using PubMed, Embase, clinicaltrial.gov, and Cochrane databases. Studies with adult patients who were on either warfarin or DOACs following bariatric surgery and reported the incidence of thromboembolism, bleeding, or mortality were included. Pooled incidence for these prespecified outcomes and its 95% confidence interval (CI) were calculated for each drug separately using the random-effects model, along with a nonadjusted P value comparing the 2 subgroups. RESULTS A total of 11 studies (805 patients) were included. Comparing DOACs to warfarin, the following pooled incidences were observed for mortality (DOACs: 3.0%; 95% CI 0.4%-18.6% versus warfarin: 1.5%; 95% CI 0.8%-2.9%; P value comparing the 2 subgroups = .38), thromboembolism (DOACs: 4.9%; 95% CI 1%-21.1% versus warfarin: 1.5%; 95% CI 0.8%-2.9%; P value = .18), and bleeding (DOACs: 3.9%; 95% CI 0.7%-18.2% versus warfarin: 11.3%; 95% CI 5.7%-21.4%; P value = .23). CONCLUSION The results of our meta-analysis remain hypothesis-generating, providing rationale for future randomized controlled trial design or well-designed comparative observational studies. Currently, it does not support the change in the current recommendation from warfarin to DOACs following bariatric surgery.
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Affiliation(s)
- Krutika Srivastava
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, Mass
| | - Neil Patel
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, Mass
| | - Malek Tabbara
- Department of Surgery, Maniwaki Hospital, McGill University, Montreal, Canada
| | - Aaron Liew
- Portiuncula University Hospital and National University of Ireland Galway, Galway, Ireland
| | - Iman Zaghloul
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, Mass
| | - Mattia M Migliore
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, Mass
| | - Rania A Mekary
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences University, Boston, Mass; Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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27
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Abstract
Venous thromboembolism (VTE), encompassing pulmonary embolism (PE) and deep vein thrombosis (DVT), is encountered commonly. Acute PE may present as a high-risk cardiovascular emergency, and acute DVT can cause acute and chronic vascular complications. The goal of this review is to ensure that cardiologists are comfortable managing VTE-including risk stratification, anticoagulation therapy, and familiarity with primary reperfusion therapy. Clinical assessment and determination of degree of right ventricular dysfunction are critical in initial risk stratification of PE and determination of parenteral versus oral anticoagulation therapy. Direct oral anticoagulants have emerged as preferred first-line oral anticoagulation strategy in VTE scenarios.
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Affiliation(s)
- Abby M Pribish
- Department of Medicine, Division of ADM-Housestaff, Beth Israel Deaconess Medical Center, Harvard Medical School, Deac 311, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Eric A Secemsky
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 4th Floor, 375 Longwood Avenue, Boston, MA 02215, USA
| | - Alec A Schmaier
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 4th Floor, 375 Longwood Avenue, Boston, MA 02215, USA.
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28
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Adverse events in patients taking apixaban or rivaroxaban who have undergone bariatric surgery: a retrospective case series. J Thromb Thrombolysis 2021; 53:601-606. [PMID: 34559367 DOI: 10.1007/s11239-021-02573-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/12/2021] [Indexed: 10/20/2022]
Abstract
Clinical trials comparing direct oral anticoagulants (DOAC) to warfarin excluded patients with a history of bariatric surgery. The anatomic changes from bariatric procedures have several effects on drug absorption which can have serious consequences for these patients. We sought to describe real-world use of DOACs among adults that had a history of bariatric surgery or underwent a bariatric surgery while receiving a DOAC. We conducted a retrospective case series of adult patients, at a large academic medical center, who initiated any DOAC in 2016 thru 2019 and had a history of bariatric surgery or underwent a bariatric surgery while receiving a DOAC. Thrombotic and bleeding events were described using summary statistics and bleeding severity was described using the International Society on Thrombosis and Haemostasis criteria. Twenty-eight patients met the inclusion criteria of having bariatric surgery (Roux-en-Y gastric bypass, sleeve gastrectomy or gastric band) and receiving a DOAC. Twenty (71.4%) were prescribed apixaban and eight (28.6%) were prescribed rivaroxaban. Seven patients (25%) experienced at least one clinically relevant non-major bleeding event, including one patient (3.6%) that had a major bleeding event. Two patients (7.1%) had a thromboembolic event. Coagulation laboratory studies were infrequently performed at the time of the bleeding or clotting events. Among patients with a history of bariatric surgery, use of DOACs were commonly associated with clinically relevant non-major bleeding events and less commonly associated with major bleeding and thromboembolic events. Larger studies may offer further insight into the overall safety and efficacy of DOAC therapy in patients that have undergone bariatric surgery. The specific role of coagulation laboratory studies warrants further evaluation.
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29
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Ryan CT, Santiago A, Tariq N, Lamba HK. Effect of Laparoscopic Sleeve Gastrectomy on Heart Transplant Status in 4 Patients with Left Ventricular Assist Devices. Tex Heart Inst J 2021; 47:284-289. [PMID: 33472222 DOI: 10.14503/thij-19-7161] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Bariatric surgery helps many morbidly obese patients lose substantial weight. However, few data exist on its long-term safety and effectiveness in patients who also have continuous-flow left ventricular assist devices and in whom heart transplantation is contemplated. We retrospectively identified patients at our institution who had undergone ventricular assist device implantation and subsequent laparoscopic sleeve gastrectomy from June 2015 through September 2017, and we evaluated their baseline demographic data, preoperative characteristics, and postoperative outcomes. Four patients (3 men), ranging in age from 32 to 44 years and in body mass index from 40 to 57, underwent sleeve gastrectomy from 858 to 1,849 days after left ventricular assist device implantation to treat nonischemic cardiomyopathy. All had multiple comorbidities. At a median follow-up duration of 42 months (range, 24-47 mo), median body mass index decreased to 31.9 (range, 28.3-44.3) at maximal weight loss, with a median percentage of excess body mass index lost of 72.5% (range, 38.7%-87.4%). After achieving target weight, one patient was listed for heart transplantation, another awaited listing, one was kept on destination therapy because of positive drug screens, and one regained weight and remained ineligible. On long-term follow-up, laparoscopic sleeve gastrectomy appears to be safe and feasible for morbidly obese patients with ventricular assist devices who must lose weight for transplantation consideration. Additional studies are warranted to evaluate this weight-loss strategy after transplantation and immunosuppression.
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Affiliation(s)
- Christopher T Ryan
- Division of Cardiothoracic Transplantation and Mechanical Circulatory Support, Department of Surgery; Baylor College of Medicine, Houston, Texas 77030
| | - Adriana Santiago
- Division of Cardiothoracic Transplantation and Mechanical Circulatory Support, Department of Surgery; Baylor College of Medicine, Houston, Texas 77030
| | - Nabil Tariq
- Bariatric and Metabolic Surgery Center, Department of Surgery; Baylor College of Medicine, Houston, Texas 77030
| | - Harveen K Lamba
- Division of Cardiothoracic Transplantation and Mechanical Circulatory Support, Department of Surgery; Baylor College of Medicine, Houston, Texas 77030
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30
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Wang TF, Carrier M, Fournier K, Siegal DM, Le Gal G, Delluc A. Oral anticoagulant use in patients with morbid obesity: A systematic review and meta-analysis. Thromb Haemost 2021; 122:830-841. [PMID: 34399433 DOI: 10.1055/a-1588-9155] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Obesity is associated with increased risks of atrial fibrillation (AF) and venous thromboembolism (VTE) for which anticoagulation is commonly used. However, data on the efficacy and safety of oral anticoagulants in patients with morbid obesity are limited. METHODS We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs) for AF or VTE in patients with morbid obesity. RESULTS We included 3 randomized controlled trials (5 studies) and 18 observational studies in adult patients with a body weight ≥ 120 kg, body mass index (BMI) ≥ 40 kg/m2 or classified as morbid obesity who received DOACs or VKAs for AF or VTE (N=77,687). The primary efficacy outcome was stroke/systemic embolism or recurrent VTE, and the primary safety outcome was major bleeding. DOACs were associated with a pooled incidence rate of stroke/systemic embolism of 1.16 per 100 person-years, compared to 1.18 with VKAs. The incidence of recurrent VTE on DOACs was 3.83 per 100 person-years, compared to 6.81 on VKAs. In both VTE and AF populations, DOACs were associated with lower risks of major bleeding compared to VKAs. However, all observational studies had moderate to serious risks of bias. CONCLUSIONS Patients with morbid obesity on DOACs had similar risks of stroke/systemic embolism, lower rates of recurrent VTE and major bleeding events compared to those on VKAs. However, the certainty of evidence was low given that studies were mostly observational with high risk of confounding.
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Affiliation(s)
- Tzu-Fei Wang
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
| | - Marc Carrier
- Department of Medicine. University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Deborah M Siegal
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
| | - Grégoire Le Gal
- Thrombosis Program, Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Canada.,Clinical Epidemiology Unit, Ottawa Health Research Institute, Ottawa, Canada.,Université de Bretagne Occidentale, Brest, France.,INNOVTE (INvestigation Network On Venous ThromboEmbolism) F-CRIN (French Clinical Research Infrastructure) Network, Saint Etienne, France
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31
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Grześk G, Rogowicz D, Wołowiec Ł, Ratajczak A, Gilewski W, Chudzińska M, Sinkiewicz A, Banach J. The Clinical Significance of Drug-Food Interactions of Direct Oral Anticoagulants. Int J Mol Sci 2021; 22:8531. [PMID: 34445237 PMCID: PMC8395160 DOI: 10.3390/ijms22168531] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 08/05/2021] [Accepted: 08/06/2021] [Indexed: 12/25/2022] Open
Abstract
Cardiovascular diseases are the most common cause of death in the world. For almost 60 years, vitamin K antagonists (VKAs) were the mainstay of anticoagulation therapy, but in recent years direct oral anticoagulants (DOACs) have become the anticoagulant treatment of choice. DOACs were initially considered drugs with no significant food interactions; however, clinical observations from daily practice have proved otherwise as interactions with food ingredients have been reported. Food, dietary supplements or herbs may contain substances that, when administered concomitantly with DOACs, can potentially affect the plasma concentration of the drugs. The aim of this paper was to evaluate the clinical significance of drug-food interactions of DOACs, such as dabigatran, rivaroxaban, apixaban, edoxaban and betrixaban. Patients treated with anticoagulants should avoid products containing St. John's wort and take special care with other food ingredients. As the interest in dietary supplements is on the rise, healthcare providers can contribute to the development of well-designed clinical trials on interactions between DOACs and food, and distribute sufficient knowledge about the proper use of these supplements among patients.
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Affiliation(s)
- Grzegorz Grześk
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Daniel Rogowicz
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Łukasz Wołowiec
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Agnieszka Ratajczak
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Wojciech Gilewski
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
| | - Małgorzata Chudzińska
- Department of Nutrition and Dietetics, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Dębowa 3 Street, 85-626 Bydgoszcz, Poland;
| | - Anna Sinkiewicz
- Department of Otolaryngology, Audiology and Phoniatrics, University Hospital No. 2, Collegium Medicum, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland;
| | - Joanna Banach
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, Ujejskiego 75 Street, 85-168 Bydgoszcz, Poland; (G.G.); (Ł.W.); (A.R.); (W.G.); (J.B.)
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32
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Disparities in Colorectal Cancer Screening Practices in a Midwest Urban Safety-Net Healthcare System. Dig Dis Sci 2021; 66:2585-2594. [PMID: 32816217 DOI: 10.1007/s10620-020-06545-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 08/06/2020] [Indexed: 01/05/2023]
Abstract
AIMS Although colorectal cancer screening (CRC) using stool-based test is well-studied, evidence on fecal immunochemical test (FIT) patterns in a safety-net healthcare system utilizing opportunistic screening is limited. We studied the FIT completion rates and adenoma detection rate (ADR) of positive FIT-colonoscopy (FIT-C) in an urban safety-net system. METHODS We performed a retrospective cross-sectional chart review on individuals ≥ 50 years who underwent CRC screening using FIT or screening colonoscopy, 09/01/2017-08/30/2018. Demographic differences in FIT completion were studied; ADR of FIT-C was compared to that of screening colonoscopy. RESULTS Among 13,427 individuals with FIT ordered, 7248 (54%) completed the stool test and 230 (48%) followed up a positive FIT with colonoscopy. Increasing age (OR 1.01, CI 1.01-1.02), non-Hispanic Blacks (OR 0.87, CI 0.80-0.95, p = 0.002), current smokers (OR 0.84, CI 0.77-0.92, p < 0.0001), those with Medicaid (OR 0.86, CI 0.77-0.96, p = 0.006), commercial insurance (OR 0.85, CI 0.78-0.94, p = 0.002), CCI score ≥ 3 (OR 0.82, CI 0.74-0.91, p < 0.0001), orders by family medicine providers (OR 0.87, CI 0.81-0.94, p < 0.0001) were associated with lower completion of stool test. Individuals from low median household income cities had lower follow-up of positive FIT, OR 0.43, CI 0.21-0.86, p = 0.017. ADR of FIT-C was higher than that of screening colonoscopy. CONCLUSION Adherence to CRC screening is low in safety-net systems employing opportunistic screening. Understanding demographic differences may allow providers to formulate targeted strategies in high-risk vulnerable groups.
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Martin KA, Beyer-Westendorf J, Davidson BL, Huisman MV, Sandset PM, Moll S. Use of direct oral anticoagulants in patients with obesity for treatment and prevention of venous thromboembolism: Updated communication from the ISTH SSC Subcommittee on Control of Anticoagulation. J Thromb Haemost 2021; 19:1874-1882. [PMID: 34259389 DOI: 10.1111/jth.15358] [Citation(s) in RCA: 112] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 04/20/2021] [Accepted: 04/21/2021] [Indexed: 12/27/2022]
Abstract
Although direct-acting oral anticoagulants (DOACs) have widespread first-line use for treatment and prevention of venous thromboembolism (VTE), uncertainty remains regarding their efficacy and safety in patients with obesity. We reviewed available data for use of DOACs for VTE treatment and prevention in patients with obesity, including phase 3, phase 4, meta-analyses, and pharmacokinetic and pharmacodynamics studies. In addition, we reviewed available data regarding DOACs in bariatric surgery. We provide updated guidance recommendations on using DOACs in patients with obesity for treatment and prevention of VTE, as well as following bariatric surgery.
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Affiliation(s)
- Karlyn A Martin
- Division of Hematology/Oncology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division Hematology and Hemostasis, Department of Medicine 1, University Hospital, Technische University Dresden, Dresden, Germany
| | - Bruce L Davidson
- Pulmonary and Critical Care Medicine, Washington State University Elson S Floyd College of Medicine and Providence Health System, Seattle, WA, USA
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Per Morten Sandset
- Department of Hematology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Stephan Moll
- Division of Hematology, Department of Medicine, University of North Carolina, Chapel Hill, NC, USA
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34
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Dahm AEA. Cancer and Thrombosis: New Treatments, New Challenges. Med Sci (Basel) 2021; 9:medsci9020041. [PMID: 34204957 PMCID: PMC8293316 DOI: 10.3390/medsci9020041] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 05/26/2021] [Accepted: 05/29/2021] [Indexed: 12/21/2022] Open
Abstract
The direct-acting oral anticoagulant (DOAC) has become an alternative to low-molecular-weight heparin (LMWH) for treatment and prophylaxis of venous thromboembolism (VTE) in cancer patients. The clinicians are, however, faced with difficult decisions regarding DOAC treatment: Which patients cannot use DOACs? Should incidental VTE be treated similar to symptomatic VTE? Is it safe to give DOACs to patients with gastrointestinal or urogenital cancers? How about drug–drug interactions? Should all cancer patients receive thromboprophylaxis? Is arterial thrombosis a problem? The current article reviews the available literature regarding these questions and aims to provide practical solutions based on data from the clinical trials and new guidelines.
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Affiliation(s)
- Anders Erik Astrup Dahm
- Department of Hematology, Akershus University Hospital, 1478 Lørenskog, Norway;
- Institute of Clinical Medicine, University of Oslo, 0316 Oslo, Norway
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35
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Kingma JS, Burgers DMT, Monpellier VM, Wiezer MJ, Blussé van Oud-Alblas HJ, Vaughns JD, Sherwin CMT, Knibbe CAJ. Oral drug dosing following bariatric surgery: General concepts and specific dosing advice. Br J Clin Pharmacol 2021; 87:4560-4576. [PMID: 33990981 PMCID: PMC9291886 DOI: 10.1111/bcp.14913] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 04/06/2021] [Accepted: 05/01/2021] [Indexed: 11/30/2022] Open
Abstract
Bariatric or weight‐loss surgery is a popular option for weight reduction. Depending on the surgical procedure, gastric changes like decreased transit time and volume and increased pH, decreased absorption surface in the small intestine, decreased exposure to bile acids and enterohepatic circulation, and decreased gastrointestinal transit time may be expected. In the years after bariatric surgery, patients will also substantially lose weight. As a result of these changes, the absorption, distribution, metabolism and/or elimination of drugs may be altered. The purpose of this article is to report the general influence of bariatric surgery on oral drug absorption, and to provide guidance for dosing of commonly used drugs in this special population. Upon oral drug administration, the time to maximum concentration is often earlier and this concentration may be higher with less consistent effects on trough concentrations and exposure. Additionally, prescription of liquid formulations to bariatric patients is supported by some reports, even though the high sugar load of these suspensions may be of concern. Studies on extended‐release medications result in an unaltered exposure for a substantial number of drugs. Also, studies evaluating the influence of timing after surgery show dynamic absorption profiles. Although for this group specific advice can be proposed for many drugs, we conclude that there is insufficient evidence for general advice for oral drug therapy after bariatric surgery, implying that a risk assessment on a case‐by‐case basis is required for each drug.
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Affiliation(s)
- Jurjen S Kingma
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Clinical Pharmacy, Division of Laboratories, Pharmacy, and Biomedical Genetics, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Desirée M T Burgers
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Valerie M Monpellier
- Nederlandse Obesitas Kliniek (Dutch Obesity Clinic), Huis ter Heide, The Netherlands
| | - Marinus J Wiezer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Janelle D Vaughns
- Department of Anesthesia and Pain Medicine, Children's National Health System, Washington, DC, USA.,Division of Clinical Pharmacology, Children's National Health System, Washington, DC, USA
| | - Catherine M T Sherwin
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Catherijne A J Knibbe
- Department of Clinical Pharmacy, St. Antonius Hospital, Nieuwegein, The Netherlands.,Division of Systems Biomedicine & Pharmacology, Leiden Academic Centre for Drug Research, Leiden University, Leiden, the Netherlands
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36
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Abstract
Cardiovascular disease (CVD) remains the leading cause of death in the USA. Several risk factors have been identified, and obesity has become one of prominent concern. Excessive weight is considered a risk factor for CVD based on evidence linking it to a hypercoagulable state. Considering the prevalence of CVD and obesity in the USA, along with the increased risk for thrombus-related events, anticoagulation plays a significant role in prevention and treatment. Direct oral anticoagulants have taken the place of many traditional anticoagulants. Considering the recently approved indications and continued postmarketing studies conducted with rivaroxaban, this updated review provides data on the overall impact of obesity on this compound. This includes data obtained from both healthy obese volunteers and obese patients with various CVD conditions enrolled in rivaroxaban clinical trials, along with data obtained from postmarketing real-world evidence studies. Assessment of the clinical pharmacology and population pharmacokinetics in obese individuals revealed no clinically relevant effects of increased weight. Additionally, subgroup analyses from each of the pivotal phase III trials supporting the current approved labeling also demonstrated consistent efficacy and safety results in obese patients. Lastly, these findings are further supported by several recent real-world evidence studies assessing the continued effectiveness and safety of rivaroxaban. In conclusion, rivaroxaban’s overall pharmacological and clinical profile remained consistent in obese adults when assessed in both drug development and postmarketing studies, supporting the premise that higher weight does not necessitate adjustment in either dose strength or regimen.
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37
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Steffel J, Collins R, Antz M, Cornu P, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Vanassche T, Potpara T, Camm AJ, Heidbüchel H, Lip GYH, Deneke T, Dagres N, Boriani G, Chao TF, Choi EK, Hills MT, Santos IDS, Lane DA, Atar D, Joung B, Cole OM, Field M. 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation. Europace 2021; 23:1612-1676. [PMID: 33895845 DOI: 10.1093/europace/euab065] [Citation(s) in RCA: 423] [Impact Index Per Article: 141.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Jan Steffel
- Department of Cardiology, Division of Electrophysiology, University Heart Center Zurich, Switzerland
| | - Ronan Collins
- Age-Related Health Care, Tallaght University Hospital / Department of Gerontology Trinity College, Dublin, Ireland
| | - Matthias Antz
- Department of Electrophysiology, Hospital Braunschweig, Braunschweig, Germany
| | - Pieter Cornu
- Faculty of Medicine and Pharmacy, Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lien Desteghe
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK
| | - Hein Heidbüchel
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan & Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | | | - Itamar de Souza Santos
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.,Departamento de Clínica Médica, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Boyoung Joung
- Yonsei University College of Medicine, Cardiology Department, Seoul, Republic of Korea
| | - Oana Maria Cole
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mark Field
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
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Briggler R, Matherne E, Johnson C, Boehmer K. Recurrent Thrombi in an Obese Patient With History of Bariatric Surgery Despite Anti-Xa Therapy. J Pharm Pract 2021; 35:811-816. [PMID: 33827312 DOI: 10.1177/08971900211004837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Obesity and gastric bypass surgery can complicate anticoagulation therapy. In general, patients post-bariatric surgery are considered to be at a moderate risk for deep venous thromboembolism or pulmonary embolism. American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists guidelines recommend chemical prophylaxis with unfractionated heparin or low molecular weight heparin after surgery until the patient is fully mobile, and for those who require chronic anticoagulation, the International Society of Thrombosis and Haemostasis recommend warfarin if body mass index (BMI) is above 40 kg/m2 or weight is more than 120 kg. Clinical decision making regarding anticoagulation in the following patient case is complicated by multiple factors, most notably the combination of obesity and history of gastric bypass surgery. This patient failed multiple anticoagulation regimens, with apixaban and rivaroxaban therapies each ending in venous thromboemboli and warfarin leading to subtherapeutic International Normalized Ratio (INR)s despite dose adjustment. However, she is currently therapeutic on the combination of enoxaparin and warfarin as shown by INR and anti-Xa level monitoring. In this case and similar instances, there could be a need for anticoagulant dose adjustments, different INR goals, or a combination of different anticoagulants. Providers should take an individualized approach to patients who have had bariatric surgery with elevated BMI as a key factor in anticoagulant selection.
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Affiliation(s)
- Rachel Briggler
- 15499University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Emma Matherne
- 15499University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Chris Johnson
- Pharmacy Practice, 15499University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
| | - Kaci Boehmer
- Pharmacy Practice, 15499University of Arkansas for Medical Sciences College of Pharmacy, Little Rock, AR, USA
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39
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Yamamura Y, Takeda K, Kawai YK, Ikenaka Y, Kitayama C, Kondo S, Kezuka C, Taniguchi M, Ishizuka M, Nakayama SMM. Sensitivity of turtles to anticoagulant rodenticides: Risk assessment for green sea turtles (Chelonia mydas) in the Ogasawara Islands and comparison of warfarin sensitivity among turtle species. AQUATIC TOXICOLOGY (AMSTERDAM, NETHERLANDS) 2021; 233:105792. [PMID: 33662877 DOI: 10.1016/j.aquatox.2021.105792] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 02/15/2021] [Accepted: 02/20/2021] [Indexed: 06/12/2023]
Abstract
Although anticoagulant rodenticides (ARs) are effectively used for the control of invasive rodents, nontarget species are also frequently exposed to ARs and secondary poisonings occur widely. However, little data is available on the effects of ARs, especially on marine organisms. To evaluate the effects of ARs on marine wildlife, we chose green sea turtles (Chelonia mydas), which are one of the most common marine organisms around the Ogasawara islands, as our primary study species. The sensitivity of these turtles to ARs was assessed using both in vivo and in vitro approaches. We administered 4 mg/kg of warfarin sodium either orally or intravenously to juvenile green sea turtles. The turtles exhibited slow pharmacokinetics, and prolongation of prothrombin time (PT) was observed only with intravenous warfarin administration. We also conducted an in vitro investigation using liver microsomes from green sea turtles, and two other turtle species (softshell turtle and red-eared slider) and rats. The cytochrome P450 metabolic activity in the liver of green sea turtles was lower than in rats. Additionally, vitamin K epoxide reductase (VKOR), which is the target enzyme of ARs, was inhibited by warfarin in the turtles at lower concentration levels than in rats. These data indicate that turtles may be more sensitive to ARs than rats. We expect that these findings will be helpful for sea turtle conservation following accidental AR-broadcast incidents.
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Affiliation(s)
- Yoshiya Yamamura
- Laboratory of Toxicology, Department of Environmental Veterinary Sciences, Faculty of Veterinary Medicine, Hokkaido University, Kita 18 Nishi 9, Kita-ku, Sapporo, 060-0818, Japan
| | - Kazuki Takeda
- Laboratory of Toxicology, Department of Environmental Veterinary Sciences, Faculty of Veterinary Medicine, Hokkaido University, Kita 18 Nishi 9, Kita-ku, Sapporo, 060-0818, Japan
| | - Yusuke K Kawai
- Laboratory of Toxicology, the Graduate School of Veterinary Medicine, Obihiro University of Agriculture and Veterinary Medicine, Nishi-2, 11-banchi, Obihiro, 080-8555, Japan
| | - Yoshinori Ikenaka
- Laboratory of Toxicology, Department of Environmental Veterinary Sciences, Faculty of Veterinary Medicine, Hokkaido University, Kita 18 Nishi 9, Kita-ku, Sapporo, 060-0818, Japan; Water Research Group, Unit for Environmental Sciences and Management, North-West University, Potchefstroom, South Africa
| | - Chiyo Kitayama
- Everlasting Nature of Asia (ELNA), Ogasawara Marine Center, Ogasawara, Tokyo, 100-2101, Japan
| | - Satomi Kondo
- Everlasting Nature of Asia (ELNA), Ogasawara Marine Center, Ogasawara, Tokyo, 100-2101, Japan
| | - Chiho Kezuka
- Kobe Municipal Suma Aqualife Park, Kobe, Hyogo 654-0049, Japan
| | - Mari Taniguchi
- Kobe Municipal Suma Aqualife Park, Kobe, Hyogo 654-0049, Japan
| | - Mayumi Ishizuka
- Laboratory of Toxicology, Department of Environmental Veterinary Sciences, Faculty of Veterinary Medicine, Hokkaido University, Kita 18 Nishi 9, Kita-ku, Sapporo, 060-0818, Japan
| | - Shouta M M Nakayama
- Laboratory of Toxicology, Department of Environmental Veterinary Sciences, Faculty of Veterinary Medicine, Hokkaido University, Kita 18 Nishi 9, Kita-ku, Sapporo, 060-0818, Japan.
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40
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Lee AYY. Web Exclusive. Annals for Hospitalists Inpatient Notes - Direct Oral Anticoagulants in Patients With Cancer-What Hospitalists Need to Know. Ann Intern Med 2021; 174:HO2-HO3. [PMID: 33872545 DOI: 10.7326/m21-0807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Agnes Y Y Lee
- University of British Columbia, BC Cancer, and Vancouver Coastal Health Authority, Vancouver, British Columbia, Canada (A.Y.Y.L.)
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41
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Nasser MF, Khaled Z, Jabri A, Karim S. The importance of use of appropriate anticoagulant in atrial fibrillation after gastric bypass surgery. HeartRhythm Case Rep 2021; 7:354-356. [PMID: 34194978 PMCID: PMC8226277 DOI: 10.1016/j.hrcr.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Mohamed Farhan Nasser
- Heart and Vascular Institute, MetroHealth Medical Center / Case Western Reserve University, Cleveland, Ohio
| | - Zahra Khaled
- Heart and Vascular Institute, MetroHealth Medical Center / Case Western Reserve University, Cleveland, Ohio
| | - Ahmad Jabri
- Heart and Vascular Institute, MetroHealth Medical Center / Case Western Reserve University, Cleveland, Ohio
| | - Saima Karim
- Heart and Vascular Institute, MetroHealth Medical Center / Case Western Reserve University, Cleveland, Ohio
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42
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Abdulrehman J, Selby R, Joundi RA, Yeo E. Peak plasma rivaroxaban levels in patients weighing 120 kg or greater. Thromb Res 2021; 201:15-17. [PMID: 33626462 DOI: 10.1016/j.thromres.2021.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Jameel Abdulrehman
- Division of Hematology, Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada.
| | - Rita Selby
- Department of Laboratory Medicine and Pathobiology & Medicine, University Health Network and Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Raed A Joundi
- Department of Clinical Neurosciences, University of Calgary, AB, Canada
| | - Erik Yeo
- Division of Hematology, Department of Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
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43
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Dobesh PP, Kernan MM, Lueshen JJ. Direct Oral Anticoagulants in the Treatment of Venous Thromboembolism: Use in Patients with Advanced Renal Impairment, Obesity, or Other Weight-Related Special Populations. Semin Respir Crit Care Med 2021; 42:233-249. [PMID: 33601428 DOI: 10.1055/s-0041-1723952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
There are currently more than 7 million patients taking a direct oral anticoagulant (DOAC), with more new prescriptions per year than warfarin. Despite impressive efficacy and safety data for the treatment of venous thromboembolism, patients with obesity or advanced renal impairment represented a small portion of the patients enrolled in the phase 3 clinical trials. Therefore, to evaluate the potential use of DOACs in these special populations, clinicians need to have an understanding of the pharmacokinetics and pharmacodynamics of these agents in these settings. Since data from randomized controlled trials are limited, data from observational trials are helpful in gaining comfort with the use of DOACs in these special populations. Selecting the appropriate dose for each agent is imperative in achieving optimal patient outcomes. We provide an extensive review of the pharmacokinetics, pharmacodynamics, phase 3 clinical trials, and observational studies on the use of DOACs in patients with advanced renal impairment, obesity, or other weight-related special populations to provide clinicians with a comprehensive understanding of the data for optimal drug and dose selection.
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Affiliation(s)
- Paul P Dobesh
- College of Pharmacy, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, Nebraska
| | - Molly M Kernan
- College of Pharmacy, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, Nebraska
| | - Jenni J Lueshen
- College of Pharmacy, University of Nebraska Medical Center, Nebraska Medical Center, Omaha, Nebraska
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44
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Riva N, Ageno W. Direct oral anticoagulants for unusual-site venous thromboembolism. Res Pract Thromb Haemost 2021; 5:265-277. [PMID: 33733025 PMCID: PMC7938617 DOI: 10.1002/rth2.12480] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 12/08/2020] [Accepted: 12/11/2020] [Indexed: 12/25/2022] Open
Abstract
Direct oral anticoagulants (DOACs) are currently the preferred oral anticoagulant treatment for most of the patients with deep vein thrombosis of the lower extremities and/or pulmonary embolism. DOACs have several advantages over vitamin K antagonists, such as availability of fixed dosages, fewer drug interactions, faster onset of action, shorter half-life, and lower risk of major and intracranial bleeding. Although the evidence on the use of DOACs in patients with unusual-site venous thromboembolism (VTE) is limited to a few, small randomized controlled trials, these drugs are increasingly used in clinical practice, and several observational cohort studies have been published recently. This narrative review will describe the latest evidence for the use of the DOACs in patients with thrombosis in atypical locations (splanchnic, cerebral, upper extremity, ovarian, and renal vein thrombosis) and will provide some practical advice for their use in patients with unusual-site VTE.
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Affiliation(s)
- Nicoletta Riva
- Department of Pathology, Faculty of Medicine and SurgeryUniversity of MaltaMsidaMalta
| | - Walter Ageno
- Department of Medicine and SurgeryUniversity of InsubriaVareseItaly
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45
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Wadsworth D, Sullivan E, Jacky T, Sprague T, Feinman H, Kim J. A review of indications and comorbidities in which warfarin may be the preferred oral anticoagulant. J Clin Pharm Ther 2021; 46:560-570. [PMID: 33393699 DOI: 10.1111/jcpt.13343] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/16/2020] [Indexed: 02/06/2023]
Abstract
WHAT IS KNOWN AND OBJECTIVE Direct oral anticoagulants (DOACs) are increasingly prescribed instead of warfarin for chronic anticoagulation for ease of dosing, fewer interactions, and less stringent monitoring. However, it is important to consider indications and comorbidities for which warfarin is still the preferred anticoagulant. This review aims to capture these clinical scenarios in which warfarin may still be preferred over DOACs. METHODS We undertook a comprehensive literature search using the PubMed database. Key search terms were based on DOAC clinical trial exclusion criteria, as well as indications and conditions in which the use of DOACs for anticoagulation has suggested harm. Society guidelines and tertiary literature were used to inform expert opinion where necessary. Studies were included if they investigated the use of DOACs or warfarin in the identified indications or conditions. RESULTS AND DISCUSSION Currently, evidence for the use of warfarin over DOACs for anticoagulation is strongest for patients with prosthetic valves, antiphospholipid syndrome, or a high risk of gastrointestinal bleeding. For several clinical situations, including mitral stenosis, obesity, altered gastrointestinal anatomy, pulmonary arterial hypertension, renal or hepatic impairment, and left ventricular thrombus, evidence is lacking but may eventually support the use of DOACs. Depending on indication and condition, appropriateness of DOAC use may vary by agent. WHAT IS NEW AND CONCLUSION New evidence continues to support new indications and conditions in which DOACs may be appropriate to use for anticoagulation. There are key clinical scenarios, however, in which emerging literature continues to support warfarin as the preferred anticoagulant.
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Affiliation(s)
- Daniel Wadsworth
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Emma Sullivan
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Thomas Jacky
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Taylor Sprague
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Hannah Feinman
- The University of North Carolina Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Jennifer Kim
- Cone Health Department of Internal Medicine, Greensboro, NC, USA
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46
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Bartlett MA, Mauck KF, Stephenson CR, Ganesh R, Daniels PR. Perioperative Venous Thromboembolism Prophylaxis. Mayo Clin Proc 2020; 95:2775-2798. [PMID: 33276846 DOI: 10.1016/j.mayocp.2020.06.015] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 04/09/2020] [Accepted: 06/10/2020] [Indexed: 12/17/2022]
Abstract
Venous thromboembolism (VTE) is a preventable cause of postoperative morbidity and mortality; however, audits suggest that the use of thromboprophylaxis is underused. In this review, we describe our approach to prevention of postoperative VTE and provide guidance on how to formulate an optimal VTE prophylaxis plan. We recommend that all patients undergo thrombosis- and bleeding-risk assessment as part of their preoperative evaluation. The risk of thrombosis can be estimated based on patient- and procedure-specific factors, using validated risk-assessment models such as the Caprini score. There are no validated models to predict perioperative bleeding; however, several risk factors have been proposed. Patients should ambulate early and frequently after surgery. We recommend no additional prophylaxis in patients at very low risk of VTE (Caprini score 0). Patients at low risk of VTE (Caprini 1 to 2) are recommended to receive either mechanical or pharmacological prophylaxis. Patients at moderate (Caprini 3 to 4) to high risk of VTE (Caprini ≥5) are recommended pharmacological prophylaxis either alone or combined with mechanical prophylaxis. Patients at high risk of bleeding should receive mechanical prophylaxis until their risk of bleeding is reduced and pharmacological prophylaxis can be reconsidered. Populations for which the Caprini score has not been validated (such as orthopedic surgery) are recommended prophylaxis based on individual and procedure-specific risk factors. Prophylaxis is typically continued until the patient is ambulatory or until hospital dismissal; however, longer durations can be considered in certain circumstances (high-risk patients undergoing malignant abdominopelvic operations, bariatric operations, and certain orthopedic operations).
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Affiliation(s)
- Matthew A Bartlett
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN.
| | - Karen F Mauck
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | | | - Ravindra Ganesh
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Paul R Daniels
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
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47
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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.
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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
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48
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Hendricks AK, Zieminski JJ, Yao X, Dunlay SM, Sangaralingham LR, O'Meara JG, Herrin TR, Nei SD. Safety and Efficacy of Oral Anticoagulants for Atrial Fibrillation in Patients After Bariatric Surgery. Am J Cardiol 2020; 136:76-80. [PMID: 32941819 DOI: 10.1016/j.amjcard.2020.09.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 09/04/2020] [Accepted: 09/09/2020] [Indexed: 12/14/2022]
Abstract
Anticoagulation management is challenging in bariatric surgery patients, due to altered gastrointestinal anatomy and potentially reduced absorption. Few studies have evaluated clinical outcomes in this population. The objective of this study was to compare the efficacy and safety of oral anticoagulants in patients with and without a history of bariatric surgery. A retrospective, matched cohort study was conducted, utilizing data from the OptumLabs Data Warehouse. Patients ≥18 years old, with nonvalvular atrial fibrillation (NVAF), and treated with an oral anticoagulant between January 1, 2010 and December 31, 2018 were included. Outcomes were compared between bariatric and nonbariatric surgery patients. Secondary analysis compared warfarin to the direct oral anticoagulants (DOAC) in the bariatric cohort. The primary efficacy outcome was the rate of ischemic stroke and systemic embolism and the primary safety outcome was major bleeding. A total of 1,673 bariatric surgery and 155,619 nonbariatric surgery patients were identified. There was no significant difference in the rate of ischemic stroke or systemic embolism (0.83 vs 1.32 per 100 person years; Hazard ratio [HR] 0.62, 95% confidence interval [CI] 0.31 to 1.22; p = 0.17) or major bleeding (5.30 vs 4.87 per 100 person years; HR 1.05, 95% CI 0.80 to 1.37; p = 0.73) between bariatric and nonbariatric surgery patients. In bariatric surgery patients alone, efficacy and safety were similar with warfarin compared with the DOACs. Results of this study suggest that bariatric surgery patients are not at an increased thrombotic or bleeding risk when using oral anticoagulants for NVAF. DOACs may be a reasonable alternative to warfarin.
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Affiliation(s)
- Abby K Hendricks
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905.
| | - Joseph J Zieminski
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905
| | - Xiaoxi Yao
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota
| | - Shannon M Dunlay
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Division of Health Care Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Optum Labs, Cambridge, Minnesota
| | - John G O'Meara
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905
| | - Theocles R Herrin
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota; Optum Labs, Cambridge, Minnesota
| | - Scott D Nei
- Department of Pharmacy, Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905
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49
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McBane RD, Torres Roldan VD, Niven AS, Pruthi RK, Franco PM, Linderbaum JA, Casanegra AI, Oyen LJ, Houghton DE, Marshall AL, Ou NN, Siegel JL, Wysokinski WE, Padrnos LJ, Rivera CE, Flo GL, Shamoun FE, Silvers SM, Nayfeh T, Urtecho M, Shah S, Benkhadra R, Saadi SM, Firwana M, Jawaid T, Amin M, Prokop LJ, Murad MH. Anticoagulation in COVID-19: A Systematic Review, Meta-analysis, and Rapid Guidance From Mayo Clinic. Mayo Clin Proc 2020; 95:2467-2486. [PMID: 33153635 PMCID: PMC7458092 DOI: 10.1016/j.mayocp.2020.08.030] [Citation(s) in RCA: 75] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/04/2020] [Accepted: 08/26/2020] [Indexed: 12/16/2022]
Abstract
A higher risk of thrombosis has been described as a prominent feature of coronavirus disease 2019 (COVID-19). This systematic review synthesizes current data on thrombosis risk, prognostic implications, and anticoagulation effects in COVID-19. We included 37 studies from 4070 unique citations. Meta-analysis was performed when feasible. Coagulopathy and thrombotic events were frequent among patients with COVID-19 and further increased in those with more severe forms of the disease. We also present guidance on the prevention and management of thrombosis from a multidisciplinary panel of specialists from Mayo Clinic. The current certainty of evidence is generally very low and continues to evolve.
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Key Words
- aptt, activated thromboplastin time
- covid-19, coronavirus disease 2019
- dic, disseminated intravascular coagulation
- doac, direct oral anticoagulant
- dvt, deep venous thrombosis
- icu, intensive care unit
- lmwh, low-molecular-weight heparin
- or, odds ratio
- pe, pulmonary embolism
- pt, prothrombin time
- sars-cov, severe acute respiratory syndrome coronavirus
- sc, subcutaneously
- vte, venous thromboembolism
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Affiliation(s)
- Robert D McBane
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Victor D Torres Roldan
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Alexander S Niven
- Division of Pulmonary and Critical Care, Center for Sleep Medicine, Mayo Clinic, Rochester, MN
| | - Rajiv K Pruthi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN; Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | - Ana I Casanegra
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Lance J Oyen
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | - Damon E Houghton
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Ariela L Marshall
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN; Division of Hematology, Mayo Clinic, Rochester, MN
| | - Narith N Ou
- Department of Pharmacy, Mayo Clinic, Rochester, MN
| | | | - Waldemar E Wysokinski
- Gonda Vascular Center, Mayo Clinic, Rochester, MN; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | | | - Candido E Rivera
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, FL
| | - Gayle L Flo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Fadi E Shamoun
- Department of Cardiovascular Medicine, Mayo Clinic, Scottsdale, AZ
| | - Scott M Silvers
- Department of Emergency Medicine, Mayo Clinic, Jacksonville, FL
| | - Tarek Nayfeh
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Meritxell Urtecho
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Sahrish Shah
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Raed Benkhadra
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Samer Mohir Saadi
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Mohammed Firwana
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Tabinda Jawaid
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Mustapha Amin
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | - M Hassan Murad
- Evidence-based Practice Center and Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN.
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How I treat obese patients with oral anticoagulants. Blood 2020; 135:904-911. [PMID: 31978224 DOI: 10.1182/blood.2019003528] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 01/13/2020] [Indexed: 11/20/2022] Open
Abstract
Obesity has become a major threat to health worldwide. The prevalence of obesity is rapidly increasing, so much so that the World Health Organization has declared obesity as a global epidemic. Obesity is associated with multiple health problems, including venous thromboembolism and atrial fibrillation, both of which are treated with anticoagulation. However, obesity and treatments for obesity such as bariatric surgery can influence absorption, excretion, pharmacokinetics, and pharmacodynamics of various anticoagulants. This results in uncertainty regarding the best antithrombotic strategies in this population, particularly in the morbidly obese. In the recent years, several studies have attempted to investigate anticoagulation use in this population and provided more insight. Herein, we present 4 cases of anticoagulant use in the obese to illustrate the common challenges faced by clinicians and discuss our approach. Whenever possible, we provide a review of the literature and base our recommendations on the best available evidence.
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