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Hwang YJ, Chang HY, Metkus T, Andersen KM, Singh S, Alexander GC, Mehta HB. Risk of Major Bleeding Associated with Concomitant Direct-Acting Oral Anticoagulant and Clopidogrel Use: A Retrospective Cohort Study. Drug Saf 2024; 47:251-260. [PMID: 38141156 PMCID: PMC10942724 DOI: 10.1007/s40264-023-01388-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND AND AIM Combined anticoagulant-antiplatelet therapy is often indicated in adults with cardiovascular disease and atrial fibrillation or venous thromboembolism. The study aim was to assess the comparative risk of bleeding between rivaroxaban and apixaban when combined with clopidogrel. METHODS We conducted a retrospective cohort study of commercially insured US adults newly treated with a combination of rivaroxaban+clopidogrel or apixaban+clopidogrel (2015-2018) using Merative™ Marketscan Research Databases. We used propensity score-based inverse probability of treatment weighting (IPTW) to balance the treatment groups. Weighted Cox proportional hazards regression was used to estimate the risk of major bleeding. RESULTS The study cohort included 2895 rivaroxaban+clopidogrel users and 3628 apixaban+clopidogrel users. The median (range) duration of follow up was 61 (73) days. Rivaroxaban+clopidogrel users had a similar risk of major bleeding compared with apixaban+clopidogrel users (IPTW incidence rate per 100 person-years 7.96 vs 7.38; IPTW hazard ratio [HR] 1.13 [95% CI 0.78-1.63]). In the subcohort of adults who were treated with DOAC or clopidogrel monotherapy prior to the combined therapy, the risk of major bleeding did not differ by the drug of monotherapy (IPTW HR for rivaroxaban+clopidogrel group: 0.66 [95% CI 0.33-1.32]; IPTW HR for apixaban+clopidogrel group: 1.10 [95% CI 0.55-2.23]) CONCLUSIONS: In our study of commercially insured US adults, the concomitant use of rivaroxaban+clopidogrel and apixaban+clopidogrel conferred a similar risk of major bleeding. DOAC versus clopidogrel monotherapy prior to the concomitant therapy did not influence the risk of major bleeding.
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Affiliation(s)
- Y Joseph Hwang
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA.
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, 2024 E. Monument Street, 2-300A, Baltimore, MD, 21287, USA.
| | - Hsien-Yen Chang
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Janssen Scientific Affairs LLC, Titusville, NJ, USA
| | - Thomas Metkus
- Divisions of Cardiology and Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kathleen M Andersen
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sonal Singh
- UMass Chan Medical School, Worcester, MA, USA
| | - G Caleb Alexander
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins University, 2024 E. Monument Street, 2-300A, Baltimore, MD, 21287, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Hemalkumar B Mehta
- Center for Drug Safety and Effectiveness, Johns Hopkins University, Baltimore, MD, USA
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Li D, Liu Y, Song Y, Wen A. Antithrombotic therapy for secondary prevention of unprovoked venous thromboembolism: a systematic review and network meta-analysis of randomized controlled trials. Ann Med 2022; 54:253-261. [PMID: 35023788 PMCID: PMC8759723 DOI: 10.1080/07853890.2022.2026002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Extended antithrombotic treatment is recommended for secondary prevention of unprovoked venous thromboembolism (VTE), however, there is no consensus on which antithrombotic strategy is preferable. AIM To compare the efficacy and safety of different antithrombotic strategies for secondary prevention unprovoked VTE. METHODS Cochrane Central Register of Controlled Trials, Embase, and MEDLINE were systematically searched from inception to 22 July 2020 for randomized controlled trials (RCTs) that compared the efficacy and/or safety of extended antithrombotic strategies including aspirin, warfarin and direct oral anticoagulants (DOACs) for secondary prevention of unprovoked VTE. The primary outcome was risk of major bleeding and the secondary outcomes were risks of recurrent VTE and all-cause death. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using pairwise and network meta-analysis with random effect. Possible ranking of extended antithrombotic strategies was plotted using the surface under the cumulative ranking curve and mean ranks. RESULTS Seventeen RCTs met the inclusion criteria, and meta-analysis results showed that warfarin was associated with significantly higher risk of major bleeding than placebo/observation (OR 2.71, 95% CI 1.32-5.55) or apixaban (OR 10.65, 95% CI 1.06-107.13). Apixaban and low-apixaban were the top two strategies according to the ranking of major bleeding. Warfarin (OR 0.25, 95%CI 0.13-0.49), rivaroxaban (OR 0.18, 95%CI 0.03-0.90), apixaban (OR 0.18, 95%CI 0.04-0.85) and low-apixaban (OR 0.18, 95%CI 0.04-0.82) were related to significantly lower risk than placebo/observation; edoxaban was non-inferior to warfarin on the risk of recurrent VTE. Furthermore, apixaban was linked with significantly lower risk of all-cause death than placebo/observation (OR 0.29, 95% CI 0.09-0.88). CONCLUSION Apixaban showed superiority to other antithrombotic strategies on major bleeding and all-cause death for secondary prevention of unprovoked VTE. Further studies are warranted owing to the limited number of studies and positive cases.Key messagesAll antithrombotic strategies including warfarin, DOACs and aspirin were superior to placebo/observation on recurrent VTE for secondary prevention of unprovoked VTE.Apixaban demonstrated lower risk of major bleeding than warfarin, and lower risk of all-cause death than placebo/observation.Further research about the efficacy and safety of antithrombotic treatments for secondary prevention of unprovoked VTE is warranted.
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Affiliation(s)
- Dandan Li
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yi Liu
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yao Song
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Aiping Wen
- Department of Pharmacy, Beijing Friendship Hospital, Capital Medical University, Beijing, China
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Popa P, Iordache S, Florescu DN, Iovanescu VF, Vieru A, Barbu V, Bezna MC, Alexandru DO, Ungureanu BS, Cazacu SM. Mortality Rate in Upper Gastrointestinal Bleeding Associated with Anti-Thrombotic Therapy Before and During Covid-19 Pandemic. J Multidiscip Healthc 2022; 15:2679-2692. [PMID: 36425876 PMCID: PMC9680964 DOI: 10.2147/jmdh.s380500] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 11/09/2022] [Indexed: 08/27/2023] Open
Abstract
INTRODUCTION During the last few years, a progressive higher proportion of patients have had upper gastrointestinal bleeding (UGIB) related to antithrombotic therapy. The introduction of direct oral anticoagulant (DOAC) and COVID-19 pandemic may change the incidence, mortality, and follow-up, especially in patients at high risk of bleeding. PATIENTS AND METHODS We studied the use of anti-thrombotic therapy (AT) in patients with upper gastrointestinal bleeding for 5 years (January 2017-December 2021) including Covid-19 pandemic period (March 2020-December 2021). We analyzed mortality rate, rebleeding rate and need for transfusion in patients with AT therapy compared with those without AT therapy and risk factors for mortality, and also the incidence of gastrointestinal bleeding in patients admitted for COVID-19 infection. RESULTS A total of 824 patients were admitted during Covid-19 pandemic period and 1631 before pandemic period; a total of 426 cases of bleeding were recorded in patients taking antithrombotic therapy and the frequency of antithrombotic therapy in patients with UGIB was higher in pandemic period (24.39% versus 13.8%). Unadjusted mortality was 12.21%, similar with patients with no antithrombotic treatment but age-adjusted mortality was 9.62% (28% lower). The rate of endoscopy was similar but fewer therapeutic procedures were required. Mean Hb level was 10% lower, and more than 60% of patients required blood transfusion. CONCLUSION Mortality was similar compared with patients with no antithrombotic therapy, fewer therapeutic endoscopies were performed and similar rebleeding rate and emergency surgery were noted. Hb level was 10% lower and a higher proportion of patients required blood transfusions. Mortality was higher in DOAC treatment group compared with VKA patients but with no statistical significance. The rate of upper gastrointestinal bleeding in Covid-19 positive hospitalized cases was 0.58%. The mortality risk in multivariate analysis was associated with GB score, with no endoscopy performed, with obscure and variceal bleeding and with LMWH versus VKA therapy.
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Affiliation(s)
- Petrica Popa
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Craiova, Dolj County, Romania
| | - Sevastita Iordache
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Craiova, Dolj County, Romania
| | - Dan Nicolae Florescu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Craiova, Dolj County, Romania
| | - Vlad Florin Iovanescu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Craiova, Dolj County, Romania
| | - Alexandru Vieru
- Gastroenterology Department, Clinical Emergency County Hospital Craiova, Craiova, Dolj County, Romania
| | - Valentin Barbu
- Gastroenterology Department, Clinical Emergency County Hospital Craiova, Craiova, Dolj County, Romania
| | - Maria-Cristina Bezna
- Cardiology Department, Clinical Emergency County Hospital Craiova, Craiova, Romania
| | - Dragos Ovidiu Alexandru
- Department of Medical Informatics and Statistics, University of Medicine and Pharmacy Craiova, Craiova, Dolj County, Romania
| | - Bogdan Silviu Ungureanu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Craiova, Dolj County, Romania
| | - Sergiu Marian Cazacu
- Gastroenterology Department, University of Medicine and Pharmacy Craiova, Craiova, Dolj County, Romania
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Endothelial cell-mediated venous thrombosis. Blood 2022; 140:1459-1460. [PMID: 36173663 DOI: 10.1182/blood.2022017938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 11/20/2022] Open
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Jin MC, Parker JJ, Rodrigues AJ, Ruiz Colón GD, Garcia CA, Mahaney KB, Grant GA, Prolo LM. Development of an integrated risk scale for prediction of shunt placement after neonatal intraventricular hemorrhage. J Neurosurg Pediatr 2022; 29:444-453. [PMID: 35090135 DOI: 10.3171/2021.11.peds21390] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 11/15/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Neonatal intraventricular hemorrhage (IVH) is a major cause of mortality and morbidity, particularly following premature birth. Even after the acute phase, posthemorrhagic hydrocephalus is a long-term complication, frequently requiring permanent ventriculoperitoneal shunt (VPS) placement. Currently, there are no risk classification methods integrating the constellation of clinical data to predict short- and long-term prognosis in neonatal IVH. To address this need, the authors developed a two-part machine learning approach for predicting short- and long-term outcomes after diagnosis of neonatal IVH. Integrating both maternal and neonatal characteristics, they developed a binary classifier to predict short-term mortality risk and a clinical scale to predict the long-term risk of VPS placement. METHODS Neonates with IVH were identified from the Optum Clinformatics Data Mart administrative claims database. Matched maternal and childbirth characteristics were obtained for all patients. The primary endpoints of interest were short-term (30 day) mortality and long-term VPS placement. Classification of short-term mortality risk was evaluated using 5 different machine learning approaches and the best-performing method was validated using a withheld validation subset. Prediction of long-term shunt risk was performed using a multivariable Cox regression model with stepwise variable selection, which was subsequently converted to an easily applied integer risk scale. RESULTS A total of 5926 neonates with IVH were identified. Most patients were born before 32 weeks' gestation (67.2%) and with low birth weight (81.2%). Empirical 30-day mortality risk was 10.9% across all IVH grades and highest among grade IV IVH (34.3%). Among the neonates who survived > 30 days, actuarial 12-month postdiagnosis risk of shunt placement was 5.4% across all IVH grades and 31.3% for grade IV IVH. The optimal short-term risk classifier was a random forest model achieving an area under the receiver operating characteristic curve of 0.882 with important predictors ranging from gestational age to diverse comorbid medical conditions. Selected features for long-term shunt risk stratification were IVH grade, respiratory distress syndrome, disseminated intravascular coagulation, and maternal preeclampsia or eclampsia. An integer risk scale, termed the Shunt Prediction After IVH in Neonates (SPAIN) scale, was developed from these 4 features, which, evaluated on withheld cases, demonstrated improved risk stratification compared with IVH grade alone (Harrell's concordance index 0.869 vs 0.852). CONCLUSIONS In a large cohort of neonates with IVH, the authors developed a two-pronged, integrated, risk classification approach to anticipate short-term mortality and long-term shunt risk. The application of such approaches may improve the prognostication of outcomes and identification of higher-risk individuals who warrant careful surveillance and early intervention.
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Affiliation(s)
- Michael C Jin
- 1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - Jonathon J Parker
- 1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - Adrian J Rodrigues
- 1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - Gabriela D Ruiz Colón
- 1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - Cesar A Garcia
- 1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - Kelly B Mahaney
- 1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
- 2Division of Pediatric Neurosurgery, Stanford Children's Health, Lucile Packard Children's Hospital, Palo Alto, California
| | - Gerald A Grant
- 1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
- 2Division of Pediatric Neurosurgery, Stanford Children's Health, Lucile Packard Children's Hospital, Palo Alto, California
| | - Laura M Prolo
- 1Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
- 2Division of Pediatric Neurosurgery, Stanford Children's Health, Lucile Packard Children's Hospital, Palo Alto, California
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