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Sbeit W, Basheer M, Shahin A, Khoury S, Msheael B, Assy N, Khoury T. Clinical Predictors of Gastrointestinal Bleeding Source before Computed Tomography Angiography. J Clin Med 2023; 12:7696. [PMID: 38137765 PMCID: PMC10744149 DOI: 10.3390/jcm12247696] [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: 11/08/2023] [Revised: 12/07/2023] [Accepted: 12/13/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Acute gastrointestinal bleeding (GIB) is a commonly encountered medical emergency. In cases of negative endoscopic evaluations, computed tomography angiography (CTA) is usually the next diagnostic step. To date, data regarding positive CTA examinations are lacking. We aimed to assess the clinical and laboratory parameters that predict a positive CTA examination, as demonstrated by the extravasation of contrast material into the bowel lumen. METHODS We performed a single-center retrospective study, including all patients who were admitted with GIB and who underwent CTA. Analysis was performed to compare patients' characteristics, and logistic regression was used to explore parameters associated with a positive CTA. RESULTS We included 154 patients. Of them, 25 patients (16.2%) had active GIB on CTA vs. 129 patients (83.8%) who did not. On univariate analysis, several parameters were positively associated with active GIB, including congestive heart failure (OR 2.47, 95% CI 1.04-5.86, p = 0.04), warfarin use (OR 4.76, 95% CI 1.49-15.21, p = 0.008), higher INR (OR 1.33, 1.04-1.69, p = 0.02), and low albumin level (OR 0.37, 95% CI 0.17-0.79, p = 0.01). On multivariate logistic regression analysis, only high INR (OR 1.34, 95% CI 1.02-1.76, p = 0.03) and low albumin (OR 0.3, 95% CI 0.12-0.7, p = 0.005) kept their positive association with active bleeding, while a high ASA score was negatively associated with an active GIB. CONCLUSIONS We could identify high INR and low albumin as strong predictors of active GIB, as demonstrated by positive CTA. On the other hand, comorbid patients classified by a high ASA score did not experience a higher rate of active GIB.
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Affiliation(s)
- Wisam Sbeit
- Department of Gastroenterology, Galilee Medical Center, Nahariya 221001, Israel; (W.S.); (A.S.); (T.K.)
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Maamoun Basheer
- Department of Gastroenterology, Galilee Medical Center, Nahariya 221001, Israel; (W.S.); (A.S.); (T.K.)
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Amir Shahin
- Department of Gastroenterology, Galilee Medical Center, Nahariya 221001, Israel; (W.S.); (A.S.); (T.K.)
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
| | - Sharbel Khoury
- Department of Radiology, Galilee Medical Center, Nahariya 221001, Israel; (S.K.); (B.M.)
| | - Botros Msheael
- Department of Radiology, Galilee Medical Center, Nahariya 221001, Israel; (S.K.); (B.M.)
| | - Nimer Assy
- Internal Medicine Department, Galilee Medical Center, Nahariya 221001, Israel;
| | - Tawfik Khoury
- Department of Gastroenterology, Galilee Medical Center, Nahariya 221001, Israel; (W.S.); (A.S.); (T.K.)
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel
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Xiao B, Ye Z, Cheng R, Han Z, Wu S, Wang G, Li Z, Liang T, Zhang S, Huang R. Optimal antiplatelet therapy for patients after antiplatelet therapy induced gastrointestinal bleeding: timing. Intern Emerg Med 2023; 18:1385-1396. [PMID: 37195594 DOI: 10.1007/s11739-023-03299-4] [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] [Received: 12/31/2022] [Accepted: 05/02/2023] [Indexed: 05/18/2023]
Abstract
Adjusting antiplatelet strategies after antiplatelet-associated gastrointestinal bleeding (GIB) is a complex clinical challenge. To assess the risk of outcomes at different times of resumption of antiplatelet therapy in an attempt to find the optimal time to resume therapy. The study analyzed consecutive patients with antiplatelet-associated GIB from Beijing Friendship Hospital Information System between October 2019 and June 2022. The primary outcomes were recurrent bleeding, major adverse cardiovascular and cerebrovascular events (MACE), and all-cause death. Multivariate-adjusted Cox proportional hazards models were used to evaluate the risks of these outcomes. The receiver operating characteristic curve was used to find the optimal time to resume treatment. Of the 617 patients with GIB after antiplatelet therapy successfully followed up, the median follow-up was 246 (interquartile range: 120-466) days, most patients (87.36%) interrupted therapy after GIB and 45.22% resumed within 90 days, of which 35.13% resumed within 7 days and 64.87% resumed after 7 days. Resumption therapy had a low risk of recurrent bleeding (uninterrupted as a reference: HR 0.32, 95% CI 0.15-0.67, p = 0.003), MACE (no resumption as a reference: HR 0.66, 95% CI 0.45-0.98, p = 0.037), and all-cause death (no resumption as a reference: HR 0.18, 95% CI 0.08-0.40, p < 0.001). And resuming therapy within 7 days had a lower risk of MACE (HR 0.18, 95% CI 0.08-0.44, p < 0.001) than after 7 days without a significantly higher risk of re-bleeding. The optimal time point for resuming therapy in this study was 8.5 days. Resuming antiplatelet therapy after GIB provides better clinical benefits compared to discontinued and uninterrupted therapy, especially compared with resuming after 7 days, resuming within 7 days is associated with a lower risk of MACE and a less significant increased risk of recurrent bleeding, leading to a higher net clinical benefit. China Clinical Trial Registration: ChiCTR2200064063.
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Affiliation(s)
- Bin Xiao
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, No.95, Yong'an Rd, Xicheng District, Beijing, 100050, China
| | - Zhishuai Ye
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, No.95, Yong'an Rd, Xicheng District, Beijing, 100050, China
| | - Rui Cheng
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yongan Road, Beijing, 100050, China
| | - Zhen Han
- Department of Emergency, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Shanshan Wu
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yongan Road, Beijing, 100050, China
| | - Guoxing Wang
- Department of Emergency, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Zeya Li
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, No.95, Yong'an Rd, Xicheng District, Beijing, 100050, China
| | - Tuo Liang
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, No.95, Yong'an Rd, Xicheng District, Beijing, 100050, China
| | - Shutian Zhang
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, No. 95 Yongan Road, Beijing, 100050, China.
| | - Rongchong Huang
- Department of Cardiology, Beijing Friendship Hospital, Capital Medical University, No.95, Yong'an Rd, Xicheng District, Beijing, 100050, China.
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Song XT, Xu WT, Li Y, Qi XS. Management of antiplatelet drugs after gastrointestinal bleeding in patients with cardiovascular disease. Shijie Huaren Xiaohua Zazhi 2022; 30:599-604. [DOI: 10.11569/wcjd.v30.i13.599] [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] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal bleeding (GIB) is one of the common clinical emergencies and is usually caused by the long-term use of antiplatelet drugs. With the increase in the prevalence of cardiovascular disease (CVD), there are a growing number of patients with GIB secondary to antiplatelet drugs. In this setting, the discontinuation and resumption of antiplatelet drugs in patients with GIB who are receiving antiplatelet drugs for CVD has become a hot research topic. This article aims to comprehensively review the management of antiplatelet drugs after GIB in patients with CVD using aspirin or P2Y12 receptor antagonist alone as well as dual antiplatelet therapy (DAPT) to guide clinical practice.
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Affiliation(s)
- Xiao-Ting Song
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China,Graduate School of Dalian Medical University, Dalian 116044, Liaoning Province, China
| | - Wen-Tao Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China,Postgraduate College, Shenyang Pharmaceutical University, Shenyang 110016, Liaoning Province, China
| | - Yang Li
- Department of Cardiology, General Hospital of Northern Theater Command, Shenyang 110016, Liaoning Province, China
| | - Xing-Shun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
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Jia RJ, Wang XP, Zhang ZH, Cui HH, Qin R, Du DY, Liu Y. Effect of Rabeprazole and Rebamipide in the Treatment of Upper Gastrointestinal Hemorrhage Associated with Dual Antiplatelet Therapy in Elderly Patients with Coronary Heart Disease. Clin Appl Thromb Hemost 2022; 28:10760296221130746. [PMID: 36411982 PMCID: PMC9703470 DOI: 10.1177/10760296221130746] [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] [Received: 07/28/2022] [Revised: 09/07/2022] [Accepted: 09/16/2022] [Indexed: 08/27/2023] Open
Abstract
To investigate the therapeutic effect of rabeprazole and rebamipide on patient age over 60 with dual antiplatelet therapy (DAPT)-related upper gastrointestinal hemorrhage following percutaneous coronary intervention (PCI). A total of 360 patients age over 60 undergoing PCI were recruited for antiplatelet therapy involving a combined treatment of aspirin (100 mg/d) and clopidogrel (75 mg/d). The enrolled patients were divided into 4 groups: the control group, the rabeprazole group, the rebamipide group, and the rabeprazole + rebamipide group. The incidence and severity of any upper gastrointestinal hemorrhage and the incidence of major adverse cardiac events (MACEs) were observed 6 months after the operation. The incidence of upper gastrointestinal hemorrhage in the 4 groups was 11.1%, 3.3%, 8.9%, and 1.1%, respectively, and the differences were statistically significant (P < 0.05). On comparing the groups, the differences between the control group and the rabeprazole group, those between the control group and the rabeprazole + rebamipide group, and those between the rebamipide group and the rabeprazole + rebamipide group were found to be statistically significant (P < 0.05). The severity of the upper gastrointestinal hemorrhage in the rabeprazole group and the rabeprazole + rebamipide group was significantly lower than that in the control group. The 4 groups exhibited no significant differences in the incidence of MACEs (P > 0.05). For patients age over 60 receiving DAPT following PCI in our study population, treatment with rabeprazole or a combination of rabeprazole and rebamipide could reduce the risk of upper gastrointestinal hemorrhage, as well as reduce its severity.
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Affiliation(s)
- Rong-Jie Jia
- Department of Gastroenterology and Hepatology, The 305 Hospital of
Chinese PLA, Beijing, China
| | - Xiao-Peng Wang
- Department of Gastroenterology and Hepatology, The 305 Hospital of
Chinese PLA, Beijing, China
| | - Zhen-Hua Zhang
- Department of Gastroenterology and Hepatology, The 305 Hospital of
Chinese PLA, Beijing, China
| | - Hai-Hong Cui
- Department of Gastroenterology and Hepatology, The 305 Hospital of
Chinese PLA, Beijing, China
| | - Rui Qin
- Department of Gastroenterology and Hepatology, The 305 Hospital of
Chinese PLA, Beijing, China
| | - Da-Yong Du
- Department of Cardiology, The 305 Hospital of Chinese PLA, Beijing,
China
| | - Yang Liu
- Department of Cardiology, The 305 Hospital of Chinese PLA, Beijing,
China
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Xuan H, Chen YM, Dai YL, Zhou J, Jiang YF, Zhou YF. Safety and Efficacy of Vitamin K Antagonists vs. Novel Oral Anticoagulants in Patients With Left Ventricular Thrombus: A Meta-Analysis. Front Cardiovasc Med 2021; 8:636491. [PMID: 33996936 PMCID: PMC8118127 DOI: 10.3389/fcvm.2021.636491] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 03/30/2021] [Indexed: 12/01/2022] Open
Abstract
Aims: A meta-analysis was conducted to evaluate the safety and efficacy of novel oral anticoagulants (NOACs) compared with vitamin K antagonists (VKAs) in patients with left ventricular thrombus (LVT). Methods and Results: We searched PubMed, Web of Science, and Cochrane Library for cohort studies comparing the use of VKAs vs. NOACs for the treatment of LVT from the earliest date available to September 30, 2020. The predetermined efficacy and safety outcomes included thromboembolic events, resolution of LVT, clinically significant bleedings, and all-cause death. Fixed-effects model was used to estimate the pooled effects. Publication bias analyses and sensitivity analyses were conducted to check the robustness of results. A total of 6 studies enrolling 837 patients (mean age 60.2 ± 1.6 years; 77.2% were male) were included. We found no significant differences in thromboembolic events [relative risk (RR) 1.69, 95% confidence interval (CI) 0.94–3.06, P 0.08, I2 12.7%], the rate of resolution of thrombus (RR 1.08, 95% CI 0.96–1.21, P 0.21, I2 4.8%), and clinically significant bleedings (RR 0.70, 95% CI 0.37–1.32, P 0.27, I2 0%) between the VKAs and NOACs group. Additionally, no significant difference in all-cause mortality was found between the two groups (RR 1.24, 95% CI 0.79–1.96, P 0.35, I2 0.0%). Sensitivity analyses, using the “1-study removed” method, detected no significant differences. Conclusion: NOACs and VKAs have similar efficacy and safety in treating LVT, prompting the inference that NOACs are the possible alternatives of VKAs in LVT therapy.
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Affiliation(s)
- He Xuan
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| | - Yi-Ming Chen
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| | - Yun-Lang Dai
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jing Zhou
- Department of Cardiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yu-Feng Jiang
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
| | - Ya-Feng Zhou
- Department of Cardiology, Dushu Lake Hospital Affiliated to Soochow University, Suzhou, China
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Wei ZQ. Digestive system injury induced by drugs for secondary prevention of ischemic stroke. Shijie Huaren Xiaohua Zazhi 2021; 29:81-86. [DOI: 10.11569/wcjd.v29.i2.81] [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] [Indexed: 02/06/2023] Open
Abstract
The recurrence of ischemic stroke can be reduced by active secondary prevention, including antithrombotic, lipid-lowering, antihypertensive, and hypoglycemic treatment. However, long-term use of drugs for secondary prevention can cause damage to the digestive system, reduce patient compliance, increase the recurrence of stroke, and even lead to ulcer bleeding and life-threatening events. It is necessary to early identify populations at a high risk for digestive system injury, understand the adverse reactions of various drugs, and standardize the treatment, which can improve the effect of secondary prevention of ischemic stroke.
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Affiliation(s)
- Zhi-Qiang Wei
- Department of Internal Medicine-Neurology, The Second Hospital of Tianjin Medical University, Tianjin 300211, China
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Bang CS, Joo MK, Kim BW, Kim JS, Park CH, Ahn JY, Lee JH, Lee BE, Yang HJ, Cho YK, Park JM, Kim BJ, Jung HK. The Role of Acid Suppressants in the Prevention of Anticoagulant-Related Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis. Gut Liver 2020; 14:57-66. [PMID: 30974930 PMCID: PMC6974330 DOI: 10.5009/gnl19009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 02/01/2019] [Accepted: 02/13/2019] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Although acid suppressants are widely used for the prevention or treatment of drug-induced upper gastrointestinal bleeding (GIB), evidence regarding the prevention of anticoagulant-related GIB is scarce. The aim of this study was to evaluate the protective effect of acid suppressants against anticoagulant-related GIB. Methods A systematic review was conducted of studies that evaluated the protective effect of acid suppressants against anticoagulant-related GIB found in PubMed, the Cochrane library, Embase, and KoreaMed from the date of database inception to April 2018. Random effect model meta-analyses with sensitivity analyses were conducted. The methodological quality of each included publication was evaluated using the Risk of Bias Assessment Tool for Nonrandomized Studies. Publication bias was assessed. Results In total, six nested case-control or cohort studies were identified and analyzed. Proton-pump inhibitors (PPI) had a protective effect against upper GIB in patients on dicumarinics (risk ratio [RR], 0.56; 95% confidence interval [CI], 0.38 to 0.83; I2, 0%); however, the histamine-2 receptor antagonist did not have the same effect (RR, 0.97; 95% CI, 0.52 to 1.81; I2, 0%). Acid suppressants did not have a protective effect against GIB in patients on dabigatran (hazard ratio, 0.78; 95% CI, 0.44 to 1.37; I2, 81.8%). Conclusions The protective effect of PPIs against dicumarinics-related upper GIB was clear, while there was no evidence supporting the protective effect of acid suppressants against dabigatran-related GIB. However, in the absence of randomized trials demonstrating a lack of bias, solid conclusions cannot be drawn.
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Affiliation(s)
- Chang Seok Bang
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Moon Kyung Joo
- Division of Gastroenterology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Byung-Wook Kim
- Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joon Sung Kim
- Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chan Hyuk Park
- Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea
| | - Ji Yong Ahn
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bong Eun Lee
- Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Hyo-Joon Yang
- Division of Gastroenterology, Department of Internal Medicine and Gastrointestinal Cancer Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yu Kyung Cho
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Myung Park
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Beom Jin Kim
- Department of Internal Medicine, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - Hye-Kyung Jung
- Department of Internal Medicine, Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
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Bouget J, Viglino D, Yvetot Q, Oger E. Major gastrointestinal bleeding and antithrombotics: Characteristics and management. World J Gastroenterol 2020; 26:5463-5473. [PMID: 33024397 PMCID: PMC7520611 DOI: 10.3748/wjg.v26.i36.5463] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/30/2020] [Accepted: 08/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND There are few reports on major gastrointestinal (GI) bleeding among patients receiving an antithrombotic.
AIM To describe clinical characteristics, bleeding locations, management and in-hospital mortality related to these events.
METHODS Over a three-year period, we prospectively identified 1080 consecutive adult patients admitted in two tertiary care hospitals between January 1, 2013 and December 31, 2015 for major GI bleeding while receiving an antithrombotic. The bleeding events were medically validated. Clinical characteristics, causative lesions, management and fatalities were described. The distribution of antithrombotics prescribed was compared across the bleeding lesions identified.
RESULTS Of 576 patients had symptoms of upper GI bleeding and 504 symptoms of lower GI bleeding. No cause was identified for 383 (35.5%) patients. Gastro-duodenal ulcer was the first causative lesion in the upper tract (209 out of 408) and colonic diverticulum the first causative lesion in the lower tract (120 out of 289). There was a larger proportion of direct oral anticoagulant use among patients with lower GI than among those with upper GI lesion locations (P = 0.03). There was an independent association between gastro-duodenal ulcer and antithrombotic use (P = 0.03), taking account of confounders and proton pump inhibitor co-prescription. Pair wise comparisons pointed to a difference between vitamin K antagonist, direct oral anticoagulants, and antiplatelet agents in monotherapy vs dual antiplatelet agents.
CONCLUSION We showed a higher rate of bleeding lesion identification and suggested a different pattern of antithrombotic exposure between upper and lower GI lesion locations and between gastro-duodenal ulcer and other identified upper GI causes of bleeding. Management was similar across antithrombotics and in-hospital mortality was low (5.95%).
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Affiliation(s)
- Jacques Bouget
- EA 7449 REPERES, Pharmacoepidemiology and Health Services Research, Univ Rennes, Rennes 35000, France
| | - Damien Viglino
- Emergency Department and Mobile Intensive Care Unit-HP2 Laboratory INSERM U1042, University Grenoble Alps, La Tronche 38700, France
| | | | - Emmanuel Oger
- EA 7449 REPERES, Université de Rennes 1, Rennes 35000, France
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Bouget J, Balusson F, Viglino D, Roy PM, Lacut K, Pavageau L, Oger E. Major bleeding risk and mortality associated with antiplatelet drugs in real-world clinical practice. A prospective cohort study. PLoS One 2020; 15:e0237022. [PMID: 32764775 PMCID: PMC7413418 DOI: 10.1371/journal.pone.0237022] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Accepted: 07/18/2020] [Indexed: 12/20/2022] Open
Abstract
Background Major bleedings other than gastrointestinal (GI) and intracranial (ICH) and mortality rates associated with antiplatelet drugs in real-world clinical practice are unknown. The objective was to estimate major bleeding risk and mortality among new users of antiplatelet drugs in real-world clinical practice. Methods and findings A population-based prospective cohort using the French national health data system (SNIIRAM), identified 69,911 adults living within five well-defined geographical areas, who were new users of antiplatelet drugs in 2013–2015 and who had not received any antithrombotics in 2012. Among them, 63,600 started a monotherapy and 6,311 a dual regimen. Clinical data for all adults referred for bleeding was collected from all emergency departments within these areas, and medically validated. Databases were linked using common key variables. The main outcome measure was time to major bleeding (GI, ICH and other bleedings). Secondary outcomes were death, and event-free survival (EFS). Hazard ratios (HR) were derived from adjusted Cox proportional hazard models. We used Inverse Propensity of Treatment Weighting as a stratified sensitivity analysis according to the antiplatelet monotherapy indication: primary prevention without cardiovascular (CV) risk factors, with CV risk factors, and secondary prevention. We observed 250 (0.36%) major haemorrhages, 81 ICH, 106 GI and 63 other types of bleeding. Incidences were twice as high in dual therapy as in monotherapy. Compared to low-dose aspirin (≤ 100 mg daily), high-dose (> 100 up to 325 mg daily) was associated with an increased risk of ICH (HR = 1.80, 95%CI 1.10 to 2.95). EFS was improved by high-dose compared to low-dose aspirin (1.41, 1.04 to 1.90 and 1.32, 1.03 to 1.68) and clopidogrel (1.30, 0.73 to 2.3 and 1.7, 1.24 to 2.34) respectively in primary prevention with and without CV risk factors. Conclusion The incidence of major bleeding and mortality was low. In monotherapy, low-dose aspirin was the safest therapeutic option whatever the indication. Trial registration NCT02886533.
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Affiliation(s)
- Jacques Bouget
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
| | - Frédéric Balusson
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
| | - Damien Viglino
- Emergency Department, Grenoble-Alpes University Hospital, Grenoble, France
| | - Pierre-Marie Roy
- Emergency Department, Centre Hospitalier Universitaire, Institut MITOVASC, Université d'Angers, Angers, France.,F-CRIN INNOVTE, France
| | - Karine Lacut
- CIC 1412, Université de Bretagne Loire, Université de Brest, INSERM CIC 1412, CHRU de Brest, Brest, France
| | - Laure Pavageau
- Emergency Department, University Hospital, Nantes, France
| | - Emmanuel Oger
- EA 7449 [Pharmacoepidemiology and Health Services Research] REPERES, Univ Rennes, CHU Rennes, Rennes, France
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Mascolo A, Ruggiero R, Sessa M, Scavone C, Sportiello L, Rafaniello C, Rossi F, Capuano A. Preventable Cases of Oral Anticoagulant-Induced Bleeding: Data From the Spontaneous Reporting System. Front Pharmacol 2019; 10:425. [PMID: 31114497 PMCID: PMC6503045 DOI: 10.3389/fphar.2019.00425] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 04/03/2019] [Indexed: 12/12/2022] Open
Abstract
Background Despite the risk of bleeding is a well-known adverse effect of oral anticoagulants, there is scarce evidence on the preventability of oral anticoagulant-induced bleedings. Therefore, we investigated the potential risk factors related to preventable cases of oral anticoagulant-induced bleedings. Methods We performed a study using Individual Case Safety Reports (ICSRs) with an oral anticoagulant as suspected drug among those reported through the spontaneous reporting system of Campania Region from 1 July 2012 to 31 December 2017. The P-method was used for the preventability assessment of all cases of bleeding. Results In total, 58 cases out of 253 (22.9%) were preventable, and the most reported suspected drug was an indirect oral anticoagulant (warfarin). Sixty-eight critical criteria for preventability were identified, all related to healthcare professionals' practices. The most detected risk factor related to healthcare professionals' practices was the labeled drug-drug interaction for both direct and indirect oral anticoagulants. Conclusion Our findings describe the most reported risk factors for preventability of oral anticoagulant-induced bleedings. These factors may be useful for targeting interventions to improve pharmacovigilance activities in our regional territory and to reduce the burden of medication errors and inappropriate prescription.
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Affiliation(s)
- Annamaria Mascolo
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Pharmacovigilance and Pharmacoepidemiology Regional Centre, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Rosanna Ruggiero
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Pharmacovigilance and Pharmacoepidemiology Regional Centre, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Maurizio Sessa
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Pharmacovigilance and Pharmacoepidemiology Regional Centre, University of Campania "Luigi Vanvitelli", Naples, Italy.,Department of Drug Design and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Cristina Scavone
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Pharmacovigilance and Pharmacoepidemiology Regional Centre, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Liberata Sportiello
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Pharmacovigilance and Pharmacoepidemiology Regional Centre, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Concetta Rafaniello
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Pharmacovigilance and Pharmacoepidemiology Regional Centre, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Rossi
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Pharmacovigilance and Pharmacoepidemiology Regional Centre, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Annalisa Capuano
- Section of Pharmacology "L. Donatelli", Department of Experimental Medicine, Campania Pharmacovigilance and Pharmacoepidemiology Regional Centre, University of Campania "Luigi Vanvitelli", Naples, Italy
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Bertoletti L, Benhamou Y, Béjot Y, Marechaux S, Cheggour S, Aleil B, Lellouche N, Dillinger JG, Delluc A. Direct oral anticoagulant use in patients with thrombophilia, antiphospholipid syndrome or venous thrombosis of unusual sites: A narrative review. Blood Rev 2018; 32:272-279. [DOI: 10.1016/j.blre.2018.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Revised: 12/06/2017] [Accepted: 01/23/2018] [Indexed: 12/19/2022]
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Aguilar-Nájera O, Valdovinos-García LR, Tepox-Padrón A, Valdovinos-Díaz MA. How much does the specialist know about cardiogastroenterology? REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2018; 83:98-105. [PMID: 28823820 DOI: 10.1016/j.rgmx.2017.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 05/30/2017] [Accepted: 06/01/2017] [Indexed: 06/07/2023]
Abstract
INTRODUCTION AND AIMS Cardiovascular disease is a growing public health problem. Forty percent of the general population will suffer from the disease by 2030, consequently requiring antithrombotic therapy. Cardiogastroenterology is a new area of knowledge that evaluates the gastrointestinal effects and complications of antithrombotic therapy. Our aim was to evaluate, through a validated questionnaire, the knowledge held by a group of specialists and residents in the areas of gastroenterology and internal medicine, about pharmacology and drug prescription, as well as gastrointestinal risks and complications, in relation to antithrombotic therapy. PATIENTS AND METHODS A validated questionnaire composed of 30 items was applied to a group of specialists and residents in the areas of gastroenterology and internal medicine. The questions were on indications, pharmacology, evaluation of risks for gastrointestinal bleeding and thromboembolic events, and use of antithrombotic therapy during endoscopic procedures. Sufficient knowledge was defined as 18 or more (≥ 60%) correct answers. RESULTS The questionnaire was answered by 194 physicians: 82 (42%) internal medicine residents and gastroenterology residents and 112 (58%) specialists. Only 40 (20.6%) of the participants had sufficient knowledge of cardiogastroenterology. Residents had a higher number of correct answers than specialists (53 vs. 36%, P<.0001). The gastroenterology residents had more correct answers than the internal medicine residents, gastroenterologists, and internists (70 vs. 53, 40, and 46%, respectively, P<.001). Only residents had sufficient knowledge regarding pharmacology and the use of antithrombotic therapy in endoscopy (P<.0001). All groups had insufficient knowledge in evaluating the risk for gastrointestinal bleeding and thrombosis. CONCLUSIONS Knowledge of cardiogastroenterology was insufficient in the group of residents and specialists surveyed. There is a need for medical education programs on the appropriate use of antithrombotic therapy.
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Affiliation(s)
- O Aguilar-Nájera
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, SSA, Ciudad de México, México
| | - L R Valdovinos-García
- Departamento de Endoscopia Gastrointestinal, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, SSA, Ciudad de México, México
| | - A Tepox-Padrón
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, SSA, Ciudad de México, México
| | - M A Valdovinos-Díaz
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, SSA, Ciudad de México, México.
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13
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How much does the specialist know about cardiogastroenterology? REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2018. [DOI: 10.1016/j.rgmxen.2017.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Li JJ, Wu XY, Chen JL, Chen GR, Xu J, Gu Y, Song HP. Antiplatelet drug ticagrelor delays gastric ulcer healing in rats. Exp Ther Med 2017; 14:3774-3779. [PMID: 29042978 DOI: 10.3892/etm.2017.4955] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 03/24/2017] [Indexed: 02/07/2023] Open
Abstract
Adenosine diphosphate P2Y12 receptor antagonist clopidogrel is not sufficiently safe for the gastric mucosa in patients with high risk of peptic ulcer, since it may impair healing of gastric erosions. However, the safety of the novel P2Y12 receptor antagonist ticagrelor in the gastric mucosa has not been elucidated to date. The present study aimed to examine whether ticagrelor delays gastric ulcer healing and to elucidate the involved mechanisms. Gastric kissing ulcers were produced in rats by luminal application of acetic acid solution, and ticagrelor was administered at dose of 10 or 20 mg/kg/day orally for 7 days. On day 8 after ulcer induction, the ulcer size, mucosal epithelial cell proliferation of the ulcer margin, expression levels of epidermal growth factor (EGF) and vascular endothelial growth factor (VEGF), and signal transduction pathways for cell proliferation and angiogenesis were measured and compared between the ticagrelor-treated and untreated model groups. The results revealed that the ulcer size was significantly greater in the ticagrelor-treated group compared with the model group, while the mucosal epithelial cell proliferation of the ulcer margin was significantly decreased in the ticagrelor-treated group. In addition, ticagrelor significantly decreased the ulcer-stimulated expression levels of EGF, VEGF, phosphorylated extracellular signal-regulated kinase (ERK), phosphorylated P38 mitogen-activated protein kinase and nuclear factor-κB P65 at the ulcer margin (P<0.05). These findings suggested that ticagrelor delayed gastric ulcer healing. Furthermore, the possible mechanisms underlying the effect of ticagrelor were associated with its functions of attenuating the expression levels of VEGF and EGF, as well as suppressing the phosphorylation activation of ERK1/2, P38 and nuclear factor-κB P65. Finally, the gastric epithelial cell proliferation and angiogenesis were also inhibited.
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Affiliation(s)
- Jing-Jing Li
- Department of Pharmacy, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430000, P.R. China
| | - Xin-Ying Wu
- Department of Cardiology, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430000, P.R. China
| | - Jing-Lou Chen
- Department of Pharmacy, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430000, P.R. China
| | - Guan-Rong Chen
- Department of Pharmacy, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430000, P.R. China
| | - Jun Xu
- Department of Pharmacy, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430000, P.R. China
| | - Ye Gu
- Department of Cardiology, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430000, P.R. China
| | - Hong-Ping Song
- Department of Pharmacy, Puai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430000, P.R. China
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Garasto S, Fusco S, Onder G, Sganga F, Mammarella F, Volpato S, Ruggiero C, Abbatecola AM, Lattanzio F, Corsonello A. Inappropriate prescription of low molecular weight heparins for thromboprophylaxis among older hospitalized patients. Aging Clin Exp Res 2017; 29:483-490. [PMID: 27114077 DOI: 10.1007/s40520-016-0571-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 04/11/2016] [Indexed: 01/09/2023]
Abstract
AIM To investigate the prevalence and clinical correlates of overprescribing and underprescribing of low molecular weight heparins (LMWHs) for thromboprophylaxis among older medical inpatients. METHODS Eight hundred seventy six patients (mean age 81.5 ± 7.6 years, female gender 57.2 %) enrolled in a multicenter observational study of seven acute care wards of geriatric medicine in Italy. The risk of venous thromboembolism was ascertained by calculating the Padua score for each patient. Patients receiving appropriate prescription of LMHW during stay were compared to those receiving LMHW with a Padua score <4 (overprescribing group). Similarly, patients with a high thromboembolic risk (Padua score ≥4) but not receiving LMHW (underprescribing group) were compared to patients appropriately not receiving LMHW during stay. Independent correlates of overprescribing and underprescribing were investigated by logistic regression analysis. RESULTS Overall, 42.8 % of patients had a Padua score ≥4. LMWHs were overprescribed in 7.3 % and underprescribed in 25.2 % of patients. The number of lost basic activities of daily living (BADL) (OR = 0.25; 95 % CI 0.15-0.41) and the number of diagnoses (OR = 0.76; 95 % CI 0.61-0.95) were inversely associated with LMWH overprescription. Conversely, older age (75-84 years: OR = 2.39; 95 % CI 1.10-5.19-85 years or more: OR = 3.25, 95 % CI 1.40-7.61), anemia (OR = 1.80, 95 % CI 1.05-3.16), pressure sores (OR = 4.15, 95 % CI 1.20-14.3), number of lost BADL at the admission (OR = 3.92, 95 % CI 2.86-5.37) and number of diagnoses (OR = 1.29, 95 % CI 1.15-1.44) qualified as significant correlates of LMWH underprescription. DISCUSSION Underprescription and, to a lesser extent, overprescription still represent an issue among older medical inpatients. CONCLUSION Implementing risk-stratifying scores into clinical practice may improve appropriateness of LMWHs prescribing during hospitalization.
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Affiliation(s)
- Sabrina Garasto
- Unit of Geriatric Pharmacoepidemiology, Research Hospital of Cosenza, Italian National Research Centre on Aging (INRCA), C. da Muoio Piccolo, 87100, Cosenza, Italy
| | - Sergio Fusco
- Unit of Geriatric Pharmacoepidemiology, Research Hospital of Cosenza, Italian National Research Centre on Aging (INRCA), C. da Muoio Piccolo, 87100, Cosenza, Italy.
| | - Graziano Onder
- Center for Medicine of Aging, Policlinico A. Gemelli, University of Sacro Cuore, Rome, Italy
| | - Federica Sganga
- Center for Medicine of Aging, Policlinico A. Gemelli, University of Sacro Cuore, Rome, Italy
| | - Federica Mammarella
- Center for Medicine of Aging, Policlinico A. Gemelli, University of Sacro Cuore, Rome, Italy
| | - Stefano Volpato
- Department of Science and Medicine, University of Ferrara, Ferrara, Italy
| | - Carmelinda Ruggiero
- Department of Medicine, Institute of Gerontology and Geriatrics, University of Perugia, Perugia, Italy
| | | | - Fabrizia Lattanzio
- Scientific Direction, Italian National Research Center on Aging (INRCA), Ancona, Italy
| | - Andrea Corsonello
- Unit of Geriatric Pharmacoepidemiology, Research Hospital of Cosenza, Italian National Research Centre on Aging (INRCA), C. da Muoio Piccolo, 87100, Cosenza, Italy
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Di Minno MND, Ambrosino P, Di Minno A, Tremoli E, Di Minno G. The risk of gastrointestinal bleeding in patients receiving dabigatran etexilate: a systematic review and meta-analysis of the literature. Ann Med 2017; 49:329-342. [PMID: 28084107 DOI: 10.1080/07853890.2016.1268710] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Evidence on the risk of gastrointestinal (GI) bleeding associated with dabigatran etexilate (DE) is contrasting. We performed a meta-analysis of literature to address this issue. METHODS AND RESULTS Studies on GI bleeding risk in patients receiving DE or vitamin-K antagonists (VKA) were systematically searched. Twenty-three studies (26 datasets) showed no difference in the GI bleeding risk between the 250,871 patients treated with DE and the 460,386 receiving VKA (OR: 1.052, 95% CI: 0.815, 1.359). Similar results were obtained when pooling together adjusted ORs/HRs, obtained by means of multivariate analysis (OR: 1.06, 95% CI: 0.914, 1.222). Compared with VKA, DE use was associated with a significantly lower risk of upper GI (OR: 0.742, 95% CI: 0.569, 0.968), but not of lower GI bleedings (OR: 1.208, 95% CI: 0.902, 1.619). Furthermore, no significant difference in the GI bleeding risk was found when data on DE 110 mg and DE 150 mg twice-daily were separately compared with VKA. CONCLUSIONS No difference in GI bleeding risk was found between DE and VKA. These results were confirmed for both dosages of DE and when specifically analyzing lower GI bleeding. In contrast, the risk of upper GI bleeding was lower with DE than with VKA. KEY MESSAGES No difference in the risk of gastrointestinal (GI) bleeding can be found between dabigatran etexilate (DE) and vitamin K-antagonists (VKA). These results are confirmed for both dosages of DE. The risk of upper GI bleeding is lower with DE than with VKA.
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Affiliation(s)
- Matteo Nicola Dario Di Minno
- a Department of Advanced Biomedical Sciences, Division of Cardiology , Federico II University , Naples , Italy.,b Centro Cardiologico Monzino, IRCCS , Milan , Italy
| | - Pasquale Ambrosino
- c Department of Clinical Medicine and Surgery , Federico II University , Naples , Italy
| | | | - Elena Tremoli
- b Centro Cardiologico Monzino, IRCCS , Milan , Italy
| | - Giovanni Di Minno
- c Department of Clinical Medicine and Surgery , Federico II University , Naples , Italy
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Molteni M, Bo M, Di Minno G, Di Pasquale G, Genovesi S, Toni D, Verdecchia P. Dabigatran etexilate: appropriate use in patients with chronic kidney disease and in the elderly patients. Intern Emerg Med 2017; 12:425-435. [PMID: 28439778 DOI: 10.1007/s11739-017-1660-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 03/29/2017] [Indexed: 12/16/2022]
Abstract
Dabigatran etexilate (DE) is a direct thrombin inhibitor, which has been approved for the treatment of non-valvular atrial fibrillation (AF), and for the prevention and treatment of venous thromboembolism (VTE). Despite large randomized clinical trials and independent observational studies providing robust data concerning DE safety and efficacy, some physicians still perceive mild-to-moderate renal impairment and old age as a relative contraindication to its use. In this article, we review the available scientific evidence supporting the use of DE in these clinical situations. Patients with AF and chronic kidney disease (CKD) are per se at high risk of stroke, bleeding and mortality. Although there is evidence of clinical benefit of anticoagulation in these patients, anticoagulant therapy requires caution and demands careful clinical monitoring, regardless of the drug used. In patients with no contraindication to its use, the clinical benefit of DE versus warfarin is independent of renal function. The elderly with AF are frequently undertreated because of the perception of high bleeding risk and limited clinical benefit. However, the clinical benefit of anticoagulation is independent of patient age, and age per se should not represent a contraindication to anticoagulation. DE has been extensively studied in the elderly, both in randomized clinical trials and in observational studies: DE 150 mg BID should not be used in patients 80 years of age or older, while DE 110 mg BID is as safe as warfarin. Intracranial haemorrhages reduction by DE compared with warfarin is preserved in the elderly. Therefore, mild and moderate CKD and being elderly should not deter physicians from prescribing DE. Furthermore, the availability of a specific antidote is expected to improve the safety of the use of DE in clinical practice.
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Affiliation(s)
- Mauro Molteni
- Internal Medicine, Vimercate Hospital, Vimercate, MB, Italy.
| | - Mario Bo
- Geriatrics and Bone Metabolic Diseases Division, Città della Salute e della Scienza-Molinette University Hospital, Turin, Italy
| | - Giovanni Di Minno
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | | | - Simonetta Genovesi
- Nephrology Unit, Department of Medicine and Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, MB, Italy
| | - Danilo Toni
- Department of Neurology and Psychiatry, Policlinico Umberto I Hospital, Sapienza University of Rome, Rome, Italy
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Di Minno A, Frigerio B, Spadarella G, Ravani A, Sansaro D, Amato M, Kitzmiller JP, Pepi M, Tremoli E, Baldassarre D. Old and new oral anticoagulants: Food, herbal medicines and drug interactions. Blood Rev 2017; 31:193-203. [PMID: 28196633 DOI: 10.1016/j.blre.2017.02.001] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 02/02/2017] [Indexed: 12/21/2022]
Abstract
The most commonly prescribed oral anticoagulants worldwide are the vitamin K antagonists (VKAs) such as warfarin. Factors affecting the pharmacokinetics of VKAs are important because deviations from their narrow therapeutic window can result in bleedings due to over-anticoagulation or thrombosis because of under-anticoagulation. In addition to pharmacodynamic interactions (e.g., augmented bleeding risk for concomitant use of NSAIDs), interactions with drugs, foods, herbs, and over-the-counter medications may affect the risk/benefit ratio of VKAs. Direct oral anticoagulants (DOACs) including Factor Xa inhibitors (rivaroxaban, apixaban and edoxaban) and thrombin inhibitor (dabigatran) are poised to replace warfarin. Phase-3 studies and real-world evaluations have established that the safety profile of DOACs is superior to those of VKAs. However, some pharmacokinetic and pharmacodynamic interactions are expected. Herein we present a critical review of VKAs and DOACs with focus on their potential for interactions with drugs, foods, herbs and over-the-counter medications.
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Affiliation(s)
| | | | - Gaia Spadarella
- Dipartimento di Medicina Clinica e Chirurgia, Università degli Studi di Napoli "Federico II", Naples, Italy.
| | | | | | - Mauro Amato
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.
| | | | - Mauro Pepi
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.
| | - Elena Tremoli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy.
| | - Damiano Baldassarre
- Centro Cardiologico Monzino, IRCCS, Milan, Italy; Dipartimento di Scienze Farmacologiche e Biomolecolari, Università degli Studi di Milano, Milan, Italy.
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Abstract
PURPOSE OF REVIEW To quantify direct oral anticoagulants (DOACs) related gastrointestinal bleeding (GIB), characterize patients at greatest risk and provide a pragmatic approach for the management of these drugs. This review will also summarize risk-management strategies and highlight evolving areas of clinical knowledge. RECENT FINDINGS DOACs permit anticoagulation with predictable dosing without the need for routine serum monitoring. Since their availability on the market, they have quickly emerged as a popular alternative for patients requiring short-term and lifelong anticoagulation. However, they are associated with an increased risk of GIB when compared with warfarin; thus, gastroenterologists must be prepared to manage DOAC-related GIB and prevent drug-related complications. This review will focus on acute and elective periendoscopic DOAC management, high-risk clinical groups for DOAC-related GIB, quantification of DOAC levels, use of reversal agents and minimization of thromboembolic risk associated with temporary interruption. SUMMARY This review will highlight pragmatic strategies for the treatment of DOAC-related bleeding and the prevention of postendoscopic DOAC bleeding. It will address new and evolving areas of periendoscopic management and identify knowledge gaps requiring further research to inform clinical practice.
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Diagnostic and Therapeutic Yield of Endoscopy in Patients with Elevated INR and Gastrointestinal Bleeding. Am J Med 2016; 129:628-34. [PMID: 26714209 DOI: 10.1016/j.amjmed.2015.11.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 11/05/2015] [Accepted: 11/18/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND Gastrointestinal bleeding is a well-known risk of systemic anticoagulation. However, bleeding in the setting of supratherapeutic anticoagulation may have a milder natural history than unprovoked bleeding. It is a common clinical gestalt that endoscopy is common, but bleeding source identification or intervention is uncommon, yet few data exist to inform this clinical impression. Consequently, we sought to examine our institutional experience with gastrointestinal bleeding in the setting of supratherapeutic international normalized ratio (INR) with the aim of identifying predictors of endoscopically identifiable lesions, interventions, and outcomes. METHODS A retrospective review was conducted at a tertiary referral academic medical center to identify patients presenting with gastrointestinal bleeding in the setting of warfarin and a supratherapeutic INR (>3.5) who underwent an endoscopic procedure. Relevant clinical covariates, endoscopic findings, need for intervention, and outcomes were collected by review of the medical record. Logistic regression adjusting for potential confounders identified predictors of endoscopically significant lesions as well as intervention and outcomes. RESULTS A total of 134 patients with INR 3.5 or greater (mean 5.5, range 3.5-17.1) presented with symptoms of gastrointestinal bleeding, most commonly as melena or symptomatic anemia. Antiplatelet agents were used by 54% of patients, and 60% of patients were on concomitant acid suppression on admission. Procedures included esophagogastroduodenoscopy (upper endoscopy; EGD) (n = 128), colonoscopy (n = 73), and video capsule endoscopy (n = 32). Active bleeding at first EGD or colonoscopy was found in only 19 patients (18%), with endoscopic intervention in only 26 patients (25%). At a critical threshold of INR 7.5 at presentation, the likelihood of finding an endoscopically significant lesion fell to <20%. On multivariate logistic regression, concomitant antiplatelet therapy (odds ratio [OR] 2.59; 95% confidence interval [CI], 1.13-5.94), timing of EGD within 12 hours of presentation (OR 3.71; 95% CI, 1.05-13.08), and INR level (OR 0.79; 95% CI, 0.64-0.98) were the only significant independent predictors of identifying a source of bleeding. A risk score incorporating these covariates performed modestly in identifying risk of significant finding on EGD (area under the curve 0.68). We found no association between identification of a significant lesion at EGD and future readmission for gastrointestinal bleeding. CONCLUSION This study demonstrates that the relationship between INR elevation and identification of a bleeding source or endoscopic intervention at EGD are indeed antiparallel. Concomitant antiplatelet therapy increases the likelihood of bleeding source identification and intervention, as does EGD within 12 hours of presentation. However, regardless of source identification or endoscopic intervention, important clinical outcomes were unchanged, suggesting that decisions about endoscopy should be made on a case-by-case basis, particularly in patients with INR > 7.5. Future prospective studies on appropriate indications and timing of endoscopy in such patients are warranted.
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