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Jones H, De Simone N, Webb C. Laboratory-guided repeat dosing of idarucizumab for dabigatran reversal. Clin Toxicol (Phila) 2023; 61:622-623. [PMID: 37668187 DOI: 10.1080/15563650.2023.2254055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/25/2023] [Accepted: 08/25/2023] [Indexed: 09/06/2023]
Affiliation(s)
- Heather Jones
- Department of Pathology, University of TX Southwestern Medical Center, Dallas, TX, USA
| | - Nicole De Simone
- Department of Pathology, University of TX Southwestern Medical Center, Dallas, TX, USA
| | - Christopher Webb
- Department of Pathology, University of TX Southwestern Medical Center, Dallas, TX, USA
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White K, Faruqi U, Cohen A(AT. New agents for DOAC reversal: a practical management review. THE BRITISH JOURNAL OF CARDIOLOGY 2022; 29:1. [PMID: 35747314 PMCID: PMC9196076 DOI: 10.5837/bjc.2022.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Bleeding is the commonest and most concerning adverse event associated with anticoagulants. Bleeding, depending on the severity, is managed in various ways, and for severe or life-threatening bleeding, specific antidotes are indicated and recommended. This review provides guidance relating to specific direct oral anticoagulant (DOAC) reversal agents, the antidotes. We discuss their indications for use, dosing, and potential side effects.
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Affiliation(s)
- Katie White
- Haematology Clinical Fellow Department of Haematological Medicine, Guys and St Thomas’ NHS Foundation Trust, King’s College London, Westminster Bridge Road, London, SE1 7EH
| | - Uzma Faruqi
- Haematology Specialist Registrar Department of Haematological Medicine, Guys and St Thomas’ NHS Foundation Trust, King’s College London, Westminster Bridge Road, London, SE1 7EH
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Kulesh AA, Syromyatnikova LI. Oral anticoagulant therapy in patients after intracerebral hemorrhage. NEUROLOGY, NEUROPSYCHIATRY, PSYCHOSOMATICS 2020. [DOI: 10.14412/2074-2711-2020-3-4-10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- A. A. Kulesh
- Acad. E.A. Vagner Perm State Medical University, Ministry of Health of Russia
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Pasea L, Chung SC, Pujades-Rodriguez M, Shah AD, Alvarez-Madrazo S, Allan V, Teo JT, Bean D, Sofat R, Dobson R, Banerjee A, Patel RS, Timmis A, Denaxas S, Hemingway H. Bleeding in cardiac patients prescribed antithrombotic drugs: electronic health record phenotyping algorithms, incidence, trends and prognosis. BMC Med 2019; 17:206. [PMID: 31744503 PMCID: PMC6864929 DOI: 10.1186/s12916-019-1438-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 10/01/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Clinical guidelines and public health authorities lack recommendations on scalable approaches to defining and monitoring the occurrence and severity of bleeding in populations prescribed antithrombotic therapy. METHODS We examined linked primary care, hospital admission and death registry electronic health records (CALIBER 1998-2010, England) of patients with newly diagnosed atrial fibrillation, acute myocardial infarction, unstable angina or stable angina with the aim to develop algorithms for bleeding events. Using the developed bleeding phenotypes, Kaplan-Meier plots were used to estimate the incidence of bleeding events and we used Cox regression models to assess the prognosis for all-cause mortality, atherothrombotic events and further bleeding. RESULTS We present electronic health record phenotyping algorithms for bleeding based on bleeding diagnosis in primary or hospital care, symptoms, transfusion, surgical procedures and haemoglobin values. In validation of the phenotype, we estimated a positive predictive value of 0.88 (95% CI 0.64, 0.99) for hospitalised bleeding. Amongst 128,815 patients, 27,259 (21.2%) had at least 1 bleeding event, with 5-year risks of bleeding of 29.1%, 21.9%, 25.3% and 23.4% following diagnoses of atrial fibrillation, acute myocardial infarction, unstable angina and stable angina, respectively. Rates of hospitalised bleeding per 1000 patients more than doubled from 1.02 (95% CI 0.83, 1.22) in January 1998 to 2.68 (95% CI 2.49, 2.88) in December 2009 coinciding with the increased rates of antiplatelet and vitamin K antagonist prescribing. Patients with hospitalised bleeding and primary care bleeding, with or without markers of severity, were at increased risk of all-cause mortality and atherothrombotic events compared to those with no bleeding. For example, the hazard ratio for all-cause mortality was 1.98 (95% CI 1.86, 2.11) for primary care bleeding with markers of severity and 1.99 (95% CI 1.92, 2.05) for hospitalised bleeding without markers of severity, compared to patients with no bleeding. CONCLUSIONS Electronic health record bleeding phenotyping algorithms offer a scalable approach to monitoring bleeding in the population. Incidence of bleeding has doubled in incidence since 1998, affects one in four cardiovascular disease patients, and is associated with poor prognosis. Efforts are required to tackle this iatrogenic epidemic.
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Affiliation(s)
- Laura Pasea
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
| | - Sheng-Chia Chung
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
| | | | - Anoop D Shah
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
- Department of Clinical Pharmacology, University College London Hospital NHS Foundation Trust, London, UK
| | - Samantha Alvarez-Madrazo
- Health Data Research UK Scotland, Strathclyde Institute of Pharmacy and Biomedical Sciences, University of Strathclyde, Glasgow, UK
| | - Victoria Allan
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
| | - James T Teo
- Department of Stroke and Neurology, King's College Hospital NHS Foundation Trust, London, UK
| | - Daniel Bean
- Department of Biostatistics and Health Informatics, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - Reecha Sofat
- Department of Clinical Pharmacology, University College London Hospital NHS Foundation Trust, London, UK
| | - Richard Dobson
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
- Department of Biostatistics and Health Informatics, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK
| | - Amitava Banerjee
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
| | - Riyaz S Patel
- Institute of Health Informatics, University College London, London, UK
- Institute of Cardiovascular Science, Faculty of Population Health Sciences, University College London, London, UK
| | - Adam Timmis
- Bart's Heart Centre, Queen Mary University London, London, UK
| | - Spiros Denaxas
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK
- Institute of Health Informatics, University College London, London, UK
| | - Harry Hemingway
- Health Data Research UK, University College London, 222 Euston Road, London, NW1 2DA, UK.
- Institute of Health Informatics, University College London, London, UK.
- The National Institute for Health Research University College London Hospitals Biomedical Research Centre, University College London, London, UK.
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Cost comparison of andexanet versus prothrombin complex concentrates for direct factor Xa inhibitor reversal after hemorrhage. J Thromb Thrombolysis 2019; 49:121-131. [DOI: 10.1007/s11239-019-01973-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Halvorsen S, Storey RF, Rocca B, Sibbing D, Ten Berg J, Grove EL, Weiss TW, Collet JP, Andreotti F, Gulba DC, Lip GYH, Husted S, Vilahur G, Morais J, Verheugt FWA, Lanas A, Al-Shahi Salman R, Steg PG, Huber K. Management of antithrombotic therapy after bleeding in patients with coronary artery disease and/or atrial fibrillation: expert consensus paper of the European Society of Cardiology Working Group on Thrombosis. Eur Heart J 2019; 38:1455-1462. [PMID: 27789570 DOI: 10.1093/eurheartj/ehw454] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 09/11/2016] [Indexed: 01/09/2023] Open
Affiliation(s)
- Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval and University of Oslo, Oslo, Norway
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Rome, Italy
| | - Dirk Sibbing
- Medizinische Klinik und Poliklinik I, Ludwig-Maximilians-Universität, Munich, Germany and DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Munich, Germany
| | - Jurrien Ten Berg
- Department of Cardiology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Erik Lerkevang Grove
- Department of Cardiology, Aarhus University Hospital, and Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Thomas W Weiss
- 3rd Department of Internal Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Montleartstrasse 37, Vienna, A-1160, Austria
| | - Jean-Philippe Collet
- Univ Paris 06 (UPMC), ACTION Study Group, INSERM UMR_S 1166, ICAN, Institut de Cardiologie, Pitié-Salpêtrière Hospital (AP-HP), Paris, France
| | - Felicita Andreotti
- Institute of Cardiology, Catholic University Medical School, Rome, Italy
| | - Dietrich C Gulba
- Clinic for Internal Medicine and Pneumology, Katholisches Klinikum Oberhausen GmbH, St. Marien Hospital, Oberhausen, Germany
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, United Kingdom; and Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Denmark
| | - Steen Husted
- Medical Department, Region Hospital West, Herning/Holstebro
| | - Gemma Vilahur
- Cardiovascular Research Center, CSIC-ICCC, HSCSP-Barcelona, Spain
| | - Joao Morais
- Department of Cardiology, Leiria Hospital Centre, Portugal
| | - Freek W A Verheugt
- Emeritus Professor of Cardiology, P.C. Hooftstraat 188, CH Amsterdam, 1071, Netherlands
| | - Angel Lanas
- Service of Digestive Diseases. University Hospital. University of Zaragoza. CIBERehd. IIS Aragón. Zaragoza, Spain
| | | | - Philippe Gabriel Steg
- Université Paris-Diderot, Sorbonne Paris Cité, DHU FIRE, AP-HP and INSERM U-1148, all in Paris, France. NHLI, Imperial College, Royal Brompton Hospital, London, UK
| | - Kurt Huber
- 3rd Department of Internal Medicine, Cardiology and Intensive Care Medicine, Wilhelminen Hospital, Montleartstrasse 37, Vienna, A-1160, Austria
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Giannandrea D, Mengoni A, Carluccio E, Ambrosio G. Practical considerations on anticoagulation reversal: spotlight on the reversal of dabigatran. Vasc Health Risk Manag 2019; 15:139-142. [PMID: 31213821 PMCID: PMC6536811 DOI: 10.2147/vhrm.s181806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/03/2019] [Indexed: 11/23/2022] Open
Abstract
Idarucizumab (Praxbind) is a humanized antibody fragment, that reversibly and with high affinityties up dabigatran (Pradaxa). Anticoagulation reversal is achieved immediately, and with no procoagulant effect. It is administered intravenously and clearance is renal. The main clinical application of idarucizumab is to antagonize bleeding related to dabigatran, especially if it occurs at critical sites, such as nervous system (central or peripheral), intraocular, pericardial, retroperitoneal or pulmonary. Other indications are: i) dabigatran-induced anticoagulation reversal in the need for emergency surgery or procedures at high risk of bleeding; and ii) second-line treatment in bleedings that persist despite local hemostasis procedures. In this narrative review, we comprehensively address clinical indications for idarucizumab, summing up evidence derived from a systematic literature review, but also from case reports.
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Affiliation(s)
- David Giannandrea
- Neurology Departement - Stroke Unit, Gubbio/Gualdo Tadino Hospitals, Perugia, Italy.,Association "Naso Sano", Umbria Regional Registry of No-Profit Organization, Corciano, Italy
| | - Anna Mengoni
- Cardiology and Cardiovascular Physiopathology, S. Maria della Misericordia Hospital, USL Umbria 1, Perugia, Italy
| | - Erberto Carluccio
- Cardiology and Cardiovascular Physiopathology, S. Maria della Misericordia Hospital, USL Umbria 1, Perugia, Italy
| | - Giuseppe Ambrosio
- Cardiology and Cardiovascular Physiopathology, S. Maria della Misericordia Hospital, USL Umbria 1, Perugia, Italy
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Agewall S. Anticoagulation, atherosclerosis, and heart failure. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2018; 3:1-2. [PMID: 28062653 DOI: 10.1093/ehjcvp/pvw037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Stefan Agewall
- Editor-in-Chief, Oslo University Hospital Ullevål and Institute of Clinical Sciences, University of Oslo, Oslo, Norway
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Proietti M, Boriani G. Use of idarucizumab in reversing dabigatran anticoagulant effect: a critical appraisal. Ther Clin Risk Manag 2018; 14:1483-1488. [PMID: 30174430 PMCID: PMC6110633 DOI: 10.2147/tcrm.s140377] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Use of non-vitamin K antagonist oral anticoagulants is spreading in the real world. Despite that, a strong need for antidotes/reversal agents is still reported by several physicians. Idarucizumab is a humanized monoclonal antibody fragment that binds specifically to dabigatran. Idarucizumab was approved in 2015 by the US Food and Drugs Administration and European Medicines Agency for reversal of anticoagulation activity in dabigatrantreated patients. This review briefly summarizes the experimental evidence about effectiveness and safety of idarucizumab. Furthermore, we review the current recommendations and experts' point of view about the use of antidotes/reversal agents in patients reporting a major bleeding event.
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Affiliation(s)
- Marco Proietti
- Department of Neuroscience, I Istituto di Ricerche Farmacologiche "Mario Negri", Milan, Italy.,Institute of Cardiovascular Sciences, Universit of Birmingham, Birmingham, UK.,Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy
| | - Giuseppe Boriani
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy,
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Gremmel T, Niessner A, Domanovits H, Frossard M, Sengölge G, Steinlechner B, Sycha T, Wolzt M, Pabinger I. Non-vitamin K antagonist oral anticoagulants in patients with an increased risk of bleeding. Wien Klin Wochenschr 2018; 130:722-734. [PMID: 30128955 PMCID: PMC6290726 DOI: 10.1007/s00508-018-1381-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Accepted: 07/30/2018] [Indexed: 12/24/2022]
Abstract
The non-vitamin K antagonist oral anticoagulants (NOACs) have considerably changed clinical practice and are increasingly being used as an alternative to vitamin K antagonists (VKAs) for 3 main reasons: 1) an improved benefit-risk ratio (in particular lower rates of intracranial bleeding), 2) a more predictable effect without the need for routine monitoring, and 3) fewer food and drug interactions compared with VKAs. Currently, there are four NOACs available: the factor Xa inhibitors apixaban, edoxaban, and rivaroxaban, and the thrombin inhibitor dabigatran. This consensus paper reviews the properties and usage of NOACs in a number of high-risk patient populations, such as patients with chronic kidney disease, patients ≥80 years of age and others and provides guidance for the use of NOACs in patients at risk of bleeding.
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Affiliation(s)
- Thomas Gremmel
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria. .,Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria.
| | - Alexander Niessner
- Department of Internal Medicine II, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Hans Domanovits
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Martin Frossard
- Department of Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Gürkan Sengölge
- Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Barbara Steinlechner
- Department of Anesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Sycha
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Michael Wolzt
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Ingrid Pabinger
- Department of Internal Medicine I, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
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A practical guide on how to handle patients with bleeding events while on oral antithrombotic treatment. Neth Heart J 2018; 26:341-351. [PMID: 29740754 PMCID: PMC5968004 DOI: 10.1007/s12471-018-1117-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Bleeding is a feared complication in patients who are treated with antithrombotic therapy (oral anticoagulation or antiplatelet therapy). Management of antithrombotic therapy after bleeding poses a dilemma where restarting the crucial medication could lead to recurrent bleeding, while interrupting or even discontinuing treatment could increase the thrombotic risk. In this review, we provide recommendations regarding the treatment of patients with a bleeding event while on oral antithrombotic therapy, based on the literature and expert opinion.
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12
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Lee JM, Joung B, Cha MJ, Lee JH, Lim WH, Kim TH, Shin SY, Uhm JS, Lim HE, Kim JB, Kim JS. 2018 KHRS Guidelines for Stroke Prevention Therapy in Korean Patients with Nonvalvular Atrial Fibrillation. ACTA ACUST UNITED AC 2018. [DOI: 10.3904/kjm.2018.93.2.87] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Lu G, Pine P, Leeds JM, DeGuzman F, Pratikhya P, Lin J, Malinowski J, Hollenbach SJ, Curnutte JT, Conley PB. Andexanet alfa effectively reverses edoxaban anticoagulation effects and associated bleeding in a rabbit acute hemorrhage model. PLoS One 2018; 13:e0195122. [PMID: 29590221 PMCID: PMC5874076 DOI: 10.1371/journal.pone.0195122] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 03/17/2018] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Increasing use of factor Xa (FXa) inhibitors necessitates effective reversal agents to manage bleeding. Andexanet alfa, a novel modified recombinant human FXa, rapidly reverses the anticoagulation effects of direct and indirect FXa inhibitors. OBJECTIVE To evaluate the ability of andexanet to reverse anticoagulation in vitro and reduce bleeding in rabbits administered edoxaban. MATERIALS AND METHODS In vitro studies characterized the interaction of andexanet with edoxaban and its ability to reverse edoxaban-mediated anti-FXa activity. In a rabbit model of surgically induced, acute hemorrhage, animals received edoxaban vehicle+andexanet vehicle (control), edoxaban (1 mg/kg)+andexanet vehicle, edoxaban+andexanet (75 mg, 5-minute infusion, 20 minutes after edoxaban), or edoxaban vehicle+andexanet prior to injury. RESULTS Andexanet bound edoxaban with high affinity similar to FXa. Andexanet rapidly and dose-dependently reversed the effects of edoxaban on FXa activity and coagulation pharmacodynamic parameters in vitro. In edoxaban-anticoagulated rabbits, andexanet reduced anti-FXa activity by 82% (from 548±87 to 100±41 ng/ml; P<0.0001), mean unbound edoxaban plasma concentration by ~80% (from 100±10 to 21±6 ng/ml; P<0.0001), and blood loss by 80% vs. vehicle (adjusted for control, 2.6 vs. 12.9 g; P = 0.003). The reduction in blood loss correlated with the decrease in anti-FXa activity (r = 0.6993, P<0.0001) and unbound edoxaban (r = 0.5951, P = 0.0035). CONCLUSION These data demonstrate that andexanet rapidly reversed the anticoagulant effects of edoxaban, suggesting it could be clinically valuable for the management of acute and surgery-related bleeding. Correlation of blood loss with anti-FXa activity supports the use of anti-FXa activity as a biomarker for assessing anticoagulation reversal in clinical trials.
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Affiliation(s)
- Genmin Lu
- Portola Pharmaceuticals Inc., South San Francisco, CA, United States of America
| | - Polly Pine
- Portola Pharmaceuticals Inc., South San Francisco, CA, United States of America
| | - Janet M. Leeds
- Portola Pharmaceuticals Inc., South San Francisco, CA, United States of America
| | - Francis DeGuzman
- Portola Pharmaceuticals Inc., South San Francisco, CA, United States of America
| | - Pratikhya Pratikhya
- Portola Pharmaceuticals Inc., South San Francisco, CA, United States of America
| | - Joyce Lin
- Portola Pharmaceuticals Inc., South San Francisco, CA, United States of America
| | - John Malinowski
- Portola Pharmaceuticals Inc., South San Francisco, CA, United States of America
| | | | - John T. Curnutte
- Portola Pharmaceuticals Inc., South San Francisco, CA, United States of America
| | - Pamela B. Conley
- Portola Pharmaceuticals Inc., South San Francisco, CA, United States of America
- * E-mail:
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Katritsis GD, Katritsis DG. Management of Complications in Anticoagulated Patients with Atrial Fibrillation. Arrhythm Electrophysiol Rev 2017; 6:167-178. [PMID: 29326831 PMCID: PMC5739886 DOI: 10.15420/aer.2017.23.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 07/27/2017] [Indexed: 12/23/2022] Open
Abstract
Oral anticoagulation is mandatory for patients at high risk of thromboembolism, but the risk of bleeding should also be taken into account. Direct oral anticoagulants are now recommended for non-valvular AF as a potential alternative to warfarin. In this article we discuss methods to assess the anticoagulant effect of these agents, specific and general antidotes, and management of complications such as embolic and haemorrhagic stroke, and significant bleeding.
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Safety, pharmacokinetics, and reversal of apixaban anticoagulation with andexanet alfa. Blood Adv 2017; 1:1827-1838. [PMID: 29296829 DOI: 10.1182/bloodadvances.2017007112] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Accepted: 08/07/2017] [Indexed: 02/06/2023] Open
Abstract
Direct factor Xa (FXa) inhibitors lack a specific reversal agent for emergencies such as major bleeding or urgent surgery. Andexanet alfa, a modified, catalytically inactive, recombinant human FXa derivative, reverses anticoagulant effect by binding and sequestering FXa inhibitors. This original report of safety and dose-finding, phase 1 and 2 randomized, double-blind, placebo-controlled studies, investigated various doses of andexanet in healthy volunteers. Phase 1 evaluated the safety and pharmacokinetics of andexanet (n = 24) or placebo (n = 8). In phase 2, andexanet (n = 36) or placebo (n = 18) was administered following steady-state apixaban dosing (5 mg twice daily for 6 days); safety, pharmacokinetics, and pharmacodynamics were assessed. Andexanet plasma concentration increased proportionally with dose, with rapid elimination (terminal elimination half-life, 4.35-7.5 hours). Following apixaban treatment, andexanet rapidly (≤2 minutes) and dose dependently reduced unbound apixaban concentration vs placebo (51% to 89% vs 5% reduction; all P < .05), decreased anti-FXa activity (67.8% to 95.0% vs 7.1% reduction; all P < .05), and restored thrombin generation in 67% to 100% vs 6% of subjects (all P < .01), maintaining these effects during continuous 45- and 120-minute infusions. Andexanet was well tolerated. Nine subjects had mild/moderate infusion reactions not associated with hemodynamic changes or respiratory compromise that generally resolved without intervention or dose reduction. There were no thrombotic events or other serious safety issues. In conclusion, andexanet reversed apixaban-mediated effects on pharmacodynamic markers of anticoagulation in healthy volunteers within minutes after administration and for the duration of infusion. This trial was registered at www.clinicaltrials.gov as #NCT01758432.
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur Heart J 2016; 37:2893-2962. [PMID: 27567408 DOI: 10.1093/eurheartj/ehw210] [Citation(s) in RCA: 4683] [Impact Index Per Article: 585.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Abstract
OPINION STATEMENT Direct oral anticoagulants (DOAC) are an attractive therapeutic option for anticoagulant treatment in the setting of venous thromboembolism or non-valvular atrial fibrillation. These drugs overall appear to have a lower risk of life-threatening hemorrhage than the vitamin K antagonists. In addition, they demonstrate more predictable and stable pharmacokinetics. Measurement of the degree of anticoagulation is desirable in patients with DOAC-associated hemorrhage, but commonly available coagulation assays show poor sensitivity for degree of DOAC effect. DOAC-specific tests are time consuming and not widely available. All coagulation tests should be interpreted considering the timing of last intake and renal function. When life-threatening bleeding occurs, hemostasis should be restored as rapidly as possible. Non-specific prohemostatic drugs may have a role in DOAC reversal, and specific antidotes are at different stages of development. In this review, we provide a summary of DOAC characteristics and an overview of the different therapeutic options available for DOAC reversal.
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Eur J Cardiothorac Surg 2016; 50:e1-e88. [DOI: 10.1093/ejcts/ezw313] [Citation(s) in RCA: 602] [Impact Index Per Article: 75.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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Kirchhof P, Benussi S, Kotecha D, Ahlsson A, Atar D, Casadei B, Castella M, Diener HC, Heidbuchel H, Hendriks J, Hindricks G, Manolis AS, Oldgren J, Popescu BA, Schotten U, Van Putte B, Vardas P, Agewall S, Camm J, Baron Esquivias G, Budts W, Carerj S, Casselman F, Coca A, De Caterina R, Deftereos S, Dobrev D, Ferro JM, Filippatos G, Fitzsimons D, Gorenek B, Guenoun M, Hohnloser SH, Kolh P, Lip GYH, Manolis A, McMurray J, Ponikowski P, Rosenhek R, Ruschitzka F, Savelieva I, Sharma S, Suwalski P, Tamargo JL, Taylor CJ, Van Gelder IC, Voors AA, Windecker S, Zamorano JL, Zeppenfeld K. 2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS. Europace 2016; 18:1609-1678. [PMID: 27567465 DOI: 10.1093/europace/euw295] [Citation(s) in RCA: 1305] [Impact Index Per Article: 163.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Stefan Agewall
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John Camm
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gonzalo Baron Esquivias
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Werner Budts
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Scipione Carerj
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Filip Casselman
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Antonio Coca
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raffaele De Caterina
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Spiridon Deftereos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Dobromir Dobrev
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - José M Ferro
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gerasimos Filippatos
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Donna Fitzsimons
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Bulent Gorenek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Maxine Guenoun
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stefan H Hohnloser
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Philippe Kolh
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Gregory Y H Lip
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Athanasios Manolis
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - John McMurray
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Ponikowski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Raphael Rosenhek
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Frank Ruschitzka
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Irina Savelieva
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Sanjay Sharma
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Piotr Suwalski
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Juan Luis Tamargo
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Clare J Taylor
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Isabelle C Van Gelder
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Adriaan A Voors
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Stephan Windecker
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Jose Luis Zamorano
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
| | - Katja Zeppenfeld
- The disclosure forms of all experts involved in the development of these guidelines are available on the ESC website http://www.escardio.org/guidelines
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Diener HC, Kleinschnitz C. Non-Vitamin K Oral Anticoagulants in Stroke Patients: Practical Issues. J Stroke 2016; 18:138-45. [PMID: 27165264 PMCID: PMC4901954 DOI: 10.5853/jos.2016.00157] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 03/08/2016] [Accepted: 03/20/2016] [Indexed: 01/17/2023] Open
Abstract
Non-vitamin-K oral anticoagulants (NOACs) represent a major advance in the prevention of stroke in patients with atrial fibrillation (AF), offering a similar, if not superior, efficacy and safety profile and several practical advantages over oral vitamin K antagonists (VKAs). The rapid onset of action of the NOACs, their relatively short half-live, and the availability of specific reversal agents may be advantageous when managing acute ischemic strokes, and in the post-stroke, post-transient ischemic attack, and post-intracranial hemorrhage settings. In this review article, we offer practical guidance on the use of NOACs in these settings, focusing on managing the acute event and on initiating or resuming anticoagulation for secondary prevention. We also assess the use of NOACs to prevent stroke and bleeding in patients with AF who have chronic kidney disease, are elderly, or cognitively impaired, and we offer guidance on optimizing the use of NOACs and VKAs in these patient groups in the absence of evidence-based guidelines.
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Proietti M, Lip GYH. Edoxaban in venous thromboembolism and stroke prevention: an appraisal. Vasc Health Risk Manag 2016; 12:45-51. [PMID: 27013883 PMCID: PMC4778780 DOI: 10.2147/vhrm.s81569] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Oral anticoagulation is the therapeutic cornerstone in preventing thromboembolic risk in both atrial fibrillation (AF) and venous thromboembolism (VTE). After decades of the sole therapeutic oral anticoagulation option being warfarin, the introduction of non-vitamin K antagonist oral anticoagulants has heralded a new era. Edoxaban is the latest addition to these available for clinical use. Edoxaban was as effective and safer than warfarin in preventing thromboembolic risk in AF patients. Similarly, edoxaban effectiveness and safety was evident when treating VTE patients to prevent recurrent VTE or VTE-related death. Therefore, edoxaban represents a valuable alternative in treating thromboembolic risk for AF and VTE patients.
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Affiliation(s)
- Marco Proietti
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK; Department of Internal Medicine and Medical Specialties, Sapienza-University of Rome, Rome, Italy
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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