1
|
Goodman SG, Roy D, Pollack CV, Leblanc K, Kwaku KF, Barnes GD, Bonaca MP, True Hills M, Campello E, Fanikos J, Connors JM, Weitz JI. Current Gaps in the Provision of Safe and Effective Anticoagulation in Atrial Fibrillation and the Potential for Factor XI-Directed Therapeutics. Crit Pathw Cardiol 2024; 23:47-57. [PMID: 38381695 PMCID: PMC11191052 DOI: 10.1097/hpc.0000000000000351] [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] [Indexed: 02/23/2024]
Abstract
The global prevalence of atrial fibrillation is rapidly increasing, in large part due to the aging of the population. Atrial fibrillation is known to increase the risk of thromboembolic stroke by 5 times, but it has been evident for decades that well-managed anticoagulation therapy can greatly attenuate this risk. Despite advances in pharmacology (such as the shift from vitamin K antagonists to direct oral anticoagulants) that have increased the safety and convenience of chronic oral anticoagulation in atrial fibrillation, a preponderance of recent observational data indicates that protection from stroke is poorly achieved on a population basis. This outcomes deficit is multifactorial in origin, stemming from a combination of underprescribing of anticoagulants (often as a result of bleeding concerns by prescribers), limitations of the drugs themselves (drug-drug interactions, bioaccumulation in renal insufficiency, short half-lives that result in lapses in therapeutic effect, etc), and suboptimal patient adherence that results from lack of understanding/education, polypharmacy, fear of bleeding, forgetfulness, and socioeconomic barriers, among other obstacles. Often this adherence is not reported to treating clinicians, further subverting efforts to optimize care. A multidisciplinary, interprofessional panel of clinicians met during the 2023 International Society of Thrombosis and Haemostasis Congress to discuss these gaps in therapy, how they can be more readily recognized, and the potential for factor XI-directed anticoagulants to improve the safety and efficacy of stroke prevention. A full appreciation of this potential requires a reevaluation of traditional teaching about the "coagulation cascade" and decoupling the processes that result in (physiologic) hemostasis and (pathologic) thrombosis. The panel discussion is summarized and presented here.
Collapse
Affiliation(s)
- Shaun G. Goodman
- From the Division of Cardiology, St Michael’s Hospital, Peter Munk Cardiac Centre, University Health Network, University of Toronto, Toronto, ON, Canada
- Canadian VIGOUR Centre and Division of Cardiology, University of Alberta, Edmonton, AB, Canada
| | - Denis Roy
- Department of Medicine and Research Center, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Charles V. Pollack
- Department of Emergency Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Kori Leblanc
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Kevin F. Kwaku
- Department of Medicine, Geisel School of Medicine at Dartmouth, Hanover, NH
| | - Geoffrey D. Barnes
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI
| | - Marc P. Bonaca
- Division of Cardiology, CPC Clinical Research, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | | | - Elena Campello
- Department of Medicine, General Internal Medicine and Thrombotic and Hemorrhagic Diseases Unit, Padova University Hospital, Padova, Italy
| | - John Fanikos
- Department of Pharmacy, Brigham and Women’s Hospital
| | - Jean M. Connors
- Hematology Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
| | - Jeffrey I. Weitz
- Department of Medicine, McMaster University, Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| |
Collapse
|
2
|
Gosselin L, Vilcu AM, Souty C, Steichen O, Launay T, Conte C, Saint-Salvi B, Turbelin C, Sarazin M, Blanchon T, Hanslik T, Lapeyre-Mestre M, Rossignol L. Prevalence and bleeding risk associated with the concomitant use of direct oral anticoagulants and antiarrhythmic drugs in patients with atrial fibrillation, based on the French healthcare insurance database. Eur J Clin Pharmacol 2023:10.1007/s00228-023-03501-8. [PMID: 37184597 DOI: 10.1007/s00228-023-03501-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 04/26/2023] [Indexed: 05/16/2023]
Abstract
PURPOSE Pharmacokinetic interactions exist between apixaban or rivaroxaban, and CYP3A4 and P-glycoprotein inhibitors such as amiodarone, verapamil and diltiazem. We aimed to estimate the prevalence of exposure to this drug-drug association (DDA) and to assess the bleeding risk associated in patients with atrial fibrillation (AF). METHODS We conducted a cohort study using a representative 1/97th sample of the French healthcare insurance database between 2014 and 2019. Patients with AF receiving apixaban or rivaroxaban were included and followed-up until hospitalization for bleeding, death, discontinuation of apixaban or rivaroxaban, exposure to strong CYP3A4 inhibitor, or until December 31st 2019, whichever came first. Primary outcome was hospitalization for bleeding registered as primary diagnosis. The association between the exposure to the DDA and hospitalization for bleeding was evaluated as a time-dependent variable in Cox model. RESULTS Between 2014 and 2019, the AF population under apixaban or rivaroxaban represented 10,392 patients. During the study period, the annual average prevalence of DDA exposure in this population was 38.9%. Among the 10,392 patients, 223 (2.1%) were hospitalized for bleeding, of which 75 (33.6%) received the association and 148 (66.4%) received apixaban or rivaroxaban alone. There was no association between DDA exposure and risk of hospitalization for bleeding (aHR = 1.19, [95% CI: 0.90, 1.58]). Age (HR 1.03 [1.02, 1.05]) and male gender (HR 1.72 [1.28, 2.30]) were associated with an increased risk of hospitalization for bleeding. CONCLUSION Exposure to antiarrhythmic drugs was not associated with an increased risk of hospitalization for bleeding in patients with AF under rivaroxaban or apixaban.
Collapse
Affiliation(s)
- Laëtitia Gosselin
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France.
- Département de Médecine Générale, Université Paris Cité, Paris, France.
| | - Ana-Maria Vilcu
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
| | - Cécile Souty
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
| | - Olivier Steichen
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
- Assistance Publique - Hôpitaux de Paris (APHP), hôpital Tenon, Service de Médecine Interne, Paris, France
| | - Titouan Launay
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
| | - Cécile Conte
- INSERM, Université de Toulouse, Service de Pharmacologie médicale et clinique, CIC 1436, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France
| | - Béatrice Saint-Salvi
- Agence National de Sécurité du Médicaments et des produits de santé, Saint-Denis, 93200, France
| | - Clément Turbelin
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
| | - Marianne Sarazin
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
| | - Thierry Blanchon
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
| | - Thomas Hanslik
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
- Université de Versailles Saint-Quentin-en-Yvelines, UVSQ, UFR de Médecine, Versailles, France
- Assistance Publique - Hôpitaux de Paris (APHP), hôpital Ambroise Paré, Service de Médecine Interne, Boulogne Billancourt, France
| | - Maryse Lapeyre-Mestre
- INSERM, Université de Toulouse, Service de Pharmacologie médicale et clinique, CIC 1436, Centre Hospitalo-Universitaire de Toulouse (CHU Toulouse), Toulouse, France
| | - Louise Rossignol
- Sorbonne Université, INSERM, Institut Pierre Louis d'épidémiologie et de Santé publique (IPLESP), Paris, France
- Département de Médecine Générale, Université Paris Cité, Paris, France
| |
Collapse
|
3
|
Bortman LV, Mitchell F, Naveiro S, Pérez Morales J, Gonzalez CD, Di Girolamo G, Giorgi MA. Direct Oral Anticoagulants: An Updated Systematic Review of Their Clinical Pharmacology and Clinical Effectiveness and Safety in Patients With Nonvalvular Atrial Fibrillation. J Clin Pharmacol 2023; 63:383-396. [PMID: 36433678 DOI: 10.1002/jcph.2184] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
Direct oral anticoagulants have been an increasingly used class of drugs in the setting of nonvalvular atrial fibrillation, defying vitamin K antagonists' monopoly when it comes to anticoagulation due to its several limitations. Direct oral anticoagulants (DOACs) have entered the market as a noninferior and safer option in comparison with vitamin K antagonists, as their respective phase III clinical trials proved. The aim of this article was to update and summarize data on their clinical pharmacology and to review real-world data to know their comparative effectiveness and safety. We performed a systematic review using PubMed, Google Scholar, Embase, and Web of Science as search engines. Regarding pharmacodynamics, there were no substantial changes reported from their original profile. There were many advances in the knowledge about clinical pharmacokinetics of DOACs that have had a direct impact on their clinical use, mainly related to drug-drug interactions. In a real-world setting, DOACs have shown to be noninferior in preventing thromboembolic events compared to vitamin K antagonists. In regards to safety, DOACs have shown a lower bleeding risk relative to warfarin. Comparison between DOACs has demonstrated rivaroxaban to have the highest bleeding risk. Overall, the evidence gathered showed few changes from the original data presented in phase III clinical trials, concluding that their real-world use coincides greatly with them.
Collapse
Affiliation(s)
- Lucia Victoria Bortman
- Department of Pharmacology, School of Medicine, Instituto Universitario CEMIC, Buenos Aires, Argentina
| | - Florencia Mitchell
- Department of Pharmacology, School of Medicine, Instituto Universitario CEMIC, Buenos Aires, Argentina
| | - Sofia Naveiro
- Department of Pharmacology, School of Medicine, Instituto Universitario CEMIC, Buenos Aires, Argentina
| | - Juana Pérez Morales
- Department of Pharmacology, School of Medicine, Instituto Universitario CEMIC, Buenos Aires, Argentina
| | - Claudio Daniel Gonzalez
- Department of Pharmacology, School of Medicine, Instituto Universitario CEMIC, Buenos Aires, Argentina.,Health Economics and Technology Assessment, Unit. Instituto Universitario CEMIC, Buenos Aires, Argentina
| | - Guillermo Di Girolamo
- Department of Pharmacology, School of Medicine, Universidad de Buenos Aires, Buenos Aires, Argentina.,Instituto Alberto C. Taquini de Investigaciones en Medicina Traslacional (IATIMET), Universidad de Buenos Aires - CONICET, Facultad de Medicina, Buenos Aires, Argentina
| | - Mariano Anibal Giorgi
- Department of Pharmacology, School of Medicine, Instituto Universitario CEMIC, Buenos Aires, Argentina.,Health Economics and Technology Assessment, Unit. Instituto Universitario CEMIC, Buenos Aires, Argentina
| |
Collapse
|
4
|
Group based trajectory modeling to assess adherence to oral anticoagulants among atrial fibrillation patients with comorbidities: a retrospective study. Int J Clin Pharm 2022; 44:966-974. [PMID: 35776377 DOI: 10.1007/s11096-022-01417-4] [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: 12/23/2021] [Accepted: 04/19/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Poor adherence to oral anticoagulants is a significant problem in atrial fibrillation (AF) patients with comorbidities as it increases the risk for cardiac and thromboembolic events. AIM The primary objective was to evaluate adherence to direct oral anticoagulants (DOACs) or warfarin using group-based trajectory modeling (GBTM). The secondary objective was to identify the predictors of adherence to oral anticoagulants. Finally, to report the drug interactions with DOACs/warfarin. METHOD This retrospective study was conducted among continuously enrolled Medicare Advantage Plan members from January 2016-December 2019. AF patients with comorbid hypertension, diabetes and hyperlipidemia using warfarin/DOACs were included. Monthly adherence to DOAC/warfarin was measured using proportion of days covered (PDC) and then modeled in a logistic GBTM to identify the distinct patterns of adherence. Logistic regression model was conducted to identify the predictors of adherence to oral anticoagulants adjusting for all baseline characteristics. Concomitant use of DOACs/warfarin with CYP3A4,P-gp inhibitors were measured. RESULTS Among 317 patients, 137 (43.2%) and 79 (24.9%) were DOAC, and warfarin users, respectively. The adherence trajectory model for DOACs included gradual decline (40.4%), adherent (38.8%), and rapid decline (20.8%). The adherence trajectories for warfarin adherence included gradual decline (8.9%), adherent (59.4%), and gaps in adherence (21.7%). Predictors of adherence included type of oral anticoagulant, stroke risk score, low-income subsidy, and baseline PDC. CYP3A4,P-gp drugs were co-administered with DOACs /warfarin resulting in adverse events. CONCLUSION Adherence to oral anticoagulants is suboptimal. Interventions tailored according to past adherence trajectories may be effective in improving patient's adherence.
Collapse
|