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Escal J, Lanoiselée J, Poenou G, Zufferey P, Laporte S, Mismetti P, Delavenne X. Latest advances in the reversal strategies for direct oral anticoagulants. Fundam Clin Pharmacol 2024; 38:674-684. [PMID: 38350629 DOI: 10.1111/fcp.12992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/27/2023] [Accepted: 01/24/2024] [Indexed: 02/15/2024]
Abstract
BACKGROUND Since the late 2000s, Europe has granted approval for various thrombotic risk-related uses of direct oral anticoagulants (DOACs). Unlike traditional anticoagulants, DOACs do not necessitate routine coagulation monitoring. Nevertheless, clinical practice often encounters bleeding events associated with these medications, making the need for effective reversal strategies evident. OBJECTIVES The study aims to take stock of current reversal strategies for DOACs, with a particular emphasis on the latest compounds that have been developed or are currently under development. METHODS For obtaining information regarding the ongoing reversal strategies and the compounds under development, we referred to ClinicalTrials website, PubMed, and Google Scholar. RESULTS In 2024, two specific antidotes to DOACs have already received approval when reversal of anticoagulation is needed owing to life-threatening or uncontrolled bleeding: idarucizumab that reverses the effects of dabigatran, and andexanet alfa, designed to counteract activated factor X inhibitors such as apixaban and rivaroxaban. Furthermore, ciraparantag, a potential universal reversal agent, is currently in advanced stages of clinical development. Concerns remain regarding the safety of specific reversal agents, especially concerning the risk of thrombosis. Additionally, the cost of these antidotes remains high. Consequently, nonspecific strategies to counteract anticoagulant medications, including activated charcoal, hemodialysis, and concentrates of coagulation factors, still have utility. CONCLUSION With the validation of specific and nonspecific antidotes, DOACs could supplant traditional oral anticoagulants. This progress represents a significant advancement in anticoagulation therapy. However, ongoing research is crucial to address remaining safety concerns of the specific reversion agents of DOACs in clinical practice.
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Affiliation(s)
- Jean Escal
- Pharmacology and Toxicology Laboratory, INSERM, SAINBIOSE U1059, Saint-Étienne University Hospital, Jean Monnet University, Saint-Etienne, France
| | - Julien Lanoiselée
- Department of Anesthesia and Intensive Care, Saint-Étienne University Hospital, Saint-Etienne, France
| | - Géraldine Poenou
- Innovation and Pharmacology Clinical Research Unit, INSERM, SAINBIOSE U1059, Saint-Étienne University Hospital, Jean Monnet University, Saint-Etienne, France
| | - Paul Zufferey
- Department of Anesthesia and Intensive Care, Saint-Étienne University Hospital, Saint-Etienne, France
| | - Silvy Laporte
- Innovation and Pharmacology Clinical Research Unit, INSERM, SAINBIOSE U1059, Saint-Étienne University Hospital, Jean Monnet University, Saint-Etienne, France
| | - Patrick Mismetti
- Vascular and Therapeutic Medicine Department, INSERM, SAINBIOSE U1059, Saint-Étienne University Hospital, Jean Monnet University Saint-Étienne, Saint-Etienne, France
| | - Xavier Delavenne
- Pharmacology and Toxicology Laboratory, INSERM, SAINBIOSE U1059, Saint-Étienne University Hospital, Jean Monnet University, Saint-Etienne, France
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Skripka AI, Krupenin PM, Kozhanova ON, Kudryavtseva AA, Fedina LV, Akmalova KA, Bochkov PO, Sokolova AA, Napalkov DA, Sychev DA. The impact of ABCB1, CYP3A4 and CYP3A5 gene polymorphisms on apixaban trough concentration and bleeding risk in patients with atrial fibrillation. Drug Metab Pers Ther 2024; 39:89-97. [PMID: 38943286 DOI: 10.1515/dmpt-2024-0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 06/03/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVES Apixaban, a direct oral anticoagulant, is increasingly used worldwide for the treatment and prevention of venous thromboembolism and ischemic stroke in patients with nonvalvular atrial fibrillation (AF). Obviously, one of the ways to enhance effectiveness and safety of drug therapy is a personalized approach to therapy, which involves pharmacogenetic and pharmacokinetic tests. The study aims to investigate the effect of CYP3A4*22, CYP3A5*3 and ABCB1 polymorphisms on the pharmacokinetics of apixaban and the risk of bleeding. METHODS A total of 84 patients were enrolled in this prospective observational study. All patients received apixaban 5 or 2.5 mg twice daily. Real-time polymerase chain reaction was used to evaluate single-nucleotide polymorphisms of the ABCB1 gene (rs1045642 and rs4148738), CYP3A4*22 (rs35599367) C>T, CYP3A5*3 (rs776746) A>G. A plasma trough concentration/dose (C/D) ratio was used as a pharmacokinetic index. RESULTS The C/D ratio was higher in patients aged >80 years (F(1)=11.209, p=0.00124) and was affected by serum creatinine (>133 μmol/L, F(1)=6.7, p=0.01124). ABCB1 (rs1045642 and rs4148738), CYP3A5 (rs776746) and CYP3A4 (rs35599367) polymorphisms did not show a correlation with C/D ratio of apixaban. Multivariate logistic regression analyses showed that none of the clinical or genetic factors predicted the fact of bleeding. CONCLUSIONS We report no significant association between ABCB1 gene polymorphisms (rs1045642 and rs4148738), CYP3A4*22 (rs35599367) C>T, CYP3A5*3 (rs776746) A>G and bleeding events on apixaban treatment. Complementing the existing criteria with pharmacogenetic and pharmacokinetics information for the patients with AF will enable further individualization of apixaban.
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Affiliation(s)
- Alena I Skripka
- Department of Faculty Therapy N1, 68477 I.M. Sechenov First Moscow State Medical University (Sechenov University) , Moscow, Russian Federation
| | - Pavel M Krupenin
- Department of Neurology, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
- Department of Neurology, University of Kentucky Medical Center, Lexington, KY, USA
| | - Olga N Kozhanova
- Department of Faculty Therapy N1, 68477 I.M. Sechenov First Moscow State Medical University (Sechenov University) , Moscow, Russian Federation
| | - Anna A Kudryavtseva
- Department of Faculty Therapy N1, 68477 I.M. Sechenov First Moscow State Medical University (Sechenov University) , Moscow, Russian Federation
| | - Ludmila V Fedina
- Department of Personalized Medicine, Research Center, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
- City Clinical Hospital named after S.S. Yudin, Moscow, Russian Federation
| | - Kristina A Akmalova
- Department of Personalized Medicine, Research Center, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Pavel O Bochkov
- Department of Personalized Medicine, Research Center, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Anastasiya A Sokolova
- Department of Faculty Therapy N1, 68477 I.M. Sechenov First Moscow State Medical University (Sechenov University) , Moscow, Russian Federation
| | - Dmitriy A Napalkov
- Department of Faculty Therapy N1, 68477 I.M. Sechenov First Moscow State Medical University (Sechenov University) , Moscow, Russian Federation
| | - Dmitriy A Sychev
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
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Grottke O, Afshari A, Ahmed A, Arnaoutoglou E, Bolliger D, Fenger-Eriksen C, von Heymann C. Clinical guideline on reversal of direct oral anticoagulants in patients with life threatening bleeding. Eur J Anaesthesiol 2024; 41:327-350. [PMID: 38567679 DOI: 10.1097/eja.0000000000001968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Anticoagulation is essential for the treatment and prevention of thromboembolic events. Current guidelines recommend direct oral anticoagulants (DOACs) over vitamin K antagonists in DOAC-eligible patients. The major complication of anticoagulation is serious or life-threatening haemorrhage, which may necessitate prompt haemostatic intervention. Reversal of DOACs may also be required for patients in need of urgent invasive procedures. This guideline from the European Society of Anaesthesiology and Intensive Care (ESAIC) aims to provide evidence-based recommendations and suggestions on how to manage patients on DOACs undergoing urgent or emergency procedures including the treatment of DOAC-induced bleeding. DESIGN A systematic literature search was performed, examining four drug comparators (dabigatran, rivaroxaban, apixaban, edoxaban) and clinical scenarios ranging from planned to emergency surgery with the outcomes of mortality, haematoma growth and thromboembolic complications. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to assess the methodological quality of the included studies. Consensus on the wording of the recommendations was achieved by a Delphi process. RESULTS So far, no results from prospective randomised trials comparing two active comparators (e.g. a direct reversal agent and an unspecific haemostatic agent such as prothrombin complex concentrate: PCC) have been published yet and the majority of publications were uncontrolled and observational studies. Thus, the certainty of evidence was assessed to be either low or very low (GRADE C). Thirty-five recommendations and clinical practice statements were developed. During the Delphi process, strong consensus (>90% agreement) was achieved in 97.1% of recommendations and consensus (75 to 90% agreement) in 2.9%. DISCUSSION DOAC-specific coagulation monitoring may help in patients at risk for elevated DOAC levels, whereas global coagulation tests are not recommended to exclude clinically relevant DOAC levels. In urgent clinical situations, haemostatic treatment using either the direct reversal or nonspecific haemostatic agents should be started without waiting for DOAC level monitoring. DOAC levels above 50 ng ml-1 may be considered clinically relevant necessitating haemostatic treatment before urgent or emergency procedures. Before cardiac surgery under activated factor Xa (FXa) inhibitors, the use of andexanet alfa is not recommended because of inhibition of unfractionated heparin, which is needed for extracorporeal circulation. In the situation of DOAC overdose without bleeding, no haemostatic intervention is suggested, instead measures to eliminate the DOACs should be taken. Due to the lack of published results from comparative prospective, randomised studies, the superiority of reversal treatment strategy vs. a nonspecific haemostatic treatment is unclear for most urgent and emergency procedures and bleeding. Due to the paucity of clinical data, no recommendations for the use of recombinant activated factor VII as a nonspecific haemostatic agent can be given. CONCLUSION In the clinical scenarios of DOAC intake before urgent procedures and DOAC-induced bleeding, practitioners should evaluate the risk of bleeding of the procedure and the severity of the DOAC-induced bleeding before initiating treatment. Optimal reversal strategy remains to be determined in future trials for most clinical settings.
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Affiliation(s)
- Oliver Grottke
- From the Department of Anaesthesiology, RWTH Aachen University Hospital, Pauwelsstrasse, Aachen, Germany (OG), Department of Paediatric and Obstetric Anaesthesia, Juliane Marie Centre, Rigshospitalet; & Department of Clinical Medicine, Copenhagen University, Denmark (AA), Department of Anaesthesia and Critical Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester (AA), Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (AA), Department of Anaesthesiology, Larissa University Hospital, Larissa, Greece (EA), Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse, Basel, Switzerland (DB), Department of Anaesthesiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard, Aarhus, Denmark (CF-E) and Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Landsberger Allee, Berlin, Germany (CvH)
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Salaun A, de Maistre E, Daller M, Sombrun C, Chagué F, Bichat F, Rochette L, Danchin N, Fauchier L, Zeller M, Cottin Y. Acute coronary syndrome in patients treated by vitamin K antagonists or non-vitamin K antagonist oral anticoagulants: Proposed management algorithm for the first 48hours. Arch Cardiovasc Dis 2024; 117:351-357. [PMID: 38644068 DOI: 10.1016/j.acvd.2024.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/22/2024] [Accepted: 02/26/2024] [Indexed: 04/23/2024]
Abstract
Around 10% of patients with acute coronary syndrome are treated by vitamin K antagonists or non-vitamin K antagonist oral anticoagulants for various indications. The initial management of these patients is highly complex, and new guidelines specify that, only during percutaneous coronary intervention, a bolus of unfractionated heparin is recommended in one of the following circumstances: (1) if the patient is receiving a non-vitamin K antagonist oral anticoagulant; or (2) if the international normalized ratio is<2.5 in a patient being treated with a vitamin K antagonist. In this review, we report on five key messages essential for the management of these patients. There are no randomized studies to date, and we propose two diagnostic and/or therapeutic decision algorithms. However, randomized studies are needed to validate these strategies.
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Affiliation(s)
- Alexandre Salaun
- Department of Cardiology, Dijon Bourgogne University Hospital, 21000 Dijon, France
| | - Emmanuel de Maistre
- Haematology Laboratory, Haemostasis Unit, Dijon Bourgogne University Hospital, 21000 Dijon, France
| | - Marlène Daller
- Department of Cardiology, Dijon Bourgogne University Hospital, 21000 Dijon, France
| | - Chan Sombrun
- Department of Cardiology, Dijon Bourgogne University Hospital, 21000 Dijon, France
| | - Frédéric Chagué
- Department of Cardiology, Dijon Bourgogne University Hospital, 21000 Dijon, France
| | - Florence Bichat
- Department of Cardiology, Dijon Bourgogne University Hospital, 21000 Dijon, France
| | - Luc Rochette
- EA 7460, PEC2, University of Burgundy, 21000 Dijon, France
| | - Nicolas Danchin
- Department of Cardiology, Hôpital Européen Georges-Pompidou, 75015 Paris, France
| | - Laurent Fauchier
- Department of Cardiology, University Hospital of Trousseau and François Rabelais University, 37170 Chambray-lès-Tours, France
| | | | - Yves Cottin
- Department of Cardiology, Dijon Bourgogne University Hospital, 21000 Dijon, France.
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Baturina O, Chashkina M, Andreev D, Mirzaev K, Bykova A, Suvorov A, Yeryshova D, Suchkova S, Sychev D, Syrkin A. Pharmacokinetic and Pharmacogenetic Predictors of Major Bleeding Events in Patients with an Acute Coronary Syndrome and Atrial Fibrillation Receiving Combined Antithrombotic Therapy. J Pers Med 2023; 13:1371. [PMID: 37763139 PMCID: PMC10532904 DOI: 10.3390/jpm13091371] [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: 07/24/2023] [Revised: 08/30/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
Objective: This study's objective was to evaluate the effects of pharmacokinetic and pharmacogenetic factors on major bleeding in patients with ACS and non-valvular AF receiving combined antithrombotic therapy consisting of rivaroxaban, clopidogrel, and aspirin as part of dual or triple therapy. Methods: A prospective observational study was conducted in two PCI centers in Moscow, the Russian Federation, from 2017 to 2018. One hundred patients with ACS and AF were enrolled. Prospective follow-ups continued for 12 months. Results: A total of 36 patients experienced bleeding events, with 10 experiencing major bleeding based on the BARC scale and 17 experiencing major bleeding based on the ISTH scale. The following predictors associated with an increased number of major bleeding events were identified: for the ISTH scale, a Css min. of rivaroxaban of >137 pg/mL (5.94 OR, (95% CI, 3.13-12.99; p < 0.004)) and carriage of the T allelic variant polymorphism ABCB1 rs4148738 (8.97 OR (95% CI, 1.48-14.49; p < 0.017)), as well as for the BARC scale (5.76 OR (95% CI, 2.36-9.87; p < 0.018)). Conclusions: Measuring residual steady-state rivaroxaban concentrations and determining the carriage of the T allelic variant polymorphism ABCB1 rs4148738 may be applicable to high-risk patients for subsequent antithrombotic therapy modification.
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Affiliation(s)
- Olga Baturina
- Cardiology, Functional and Ultrasound Diagnostics Department, N.V. Sklifosovskiy Institute of Clinical Medicine, Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation, Moscow 119048, Russia; (O.B.); (D.A.); (A.B.); (D.Y.); (S.S.); (A.S.)
| | - Maria Chashkina
- Cardiology, Functional and Ultrasound Diagnostics Department, N.V. Sklifosovskiy Institute of Clinical Medicine, Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation, Moscow 119048, Russia; (O.B.); (D.A.); (A.B.); (D.Y.); (S.S.); (A.S.)
| | - Denis Andreev
- Cardiology, Functional and Ultrasound Diagnostics Department, N.V. Sklifosovskiy Institute of Clinical Medicine, Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation, Moscow 119048, Russia; (O.B.); (D.A.); (A.B.); (D.Y.); (S.S.); (A.S.)
| | - Karin Mirzaev
- Clinical Pharmacology and Therapy Department B.E. Votchal, Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow 125993, Russia; (K.M.); (D.S.)
| | - Alexandra Bykova
- Cardiology, Functional and Ultrasound Diagnostics Department, N.V. Sklifosovskiy Institute of Clinical Medicine, Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation, Moscow 119048, Russia; (O.B.); (D.A.); (A.B.); (D.Y.); (S.S.); (A.S.)
| | - Alexandr Suvorov
- World-Class Research Center “Digital Biodesign and Personalized Healthcare”, Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation, Moscow 119048, Russia;
| | - Daria Yeryshova
- Cardiology, Functional and Ultrasound Diagnostics Department, N.V. Sklifosovskiy Institute of Clinical Medicine, Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation, Moscow 119048, Russia; (O.B.); (D.A.); (A.B.); (D.Y.); (S.S.); (A.S.)
| | - Svetlana Suchkova
- Cardiology, Functional and Ultrasound Diagnostics Department, N.V. Sklifosovskiy Institute of Clinical Medicine, Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation, Moscow 119048, Russia; (O.B.); (D.A.); (A.B.); (D.Y.); (S.S.); (A.S.)
| | - Dmitry Sychev
- Clinical Pharmacology and Therapy Department B.E. Votchal, Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation, Moscow 125993, Russia; (K.M.); (D.S.)
| | - Abram Syrkin
- Cardiology, Functional and Ultrasound Diagnostics Department, N.V. Sklifosovskiy Institute of Clinical Medicine, Sechenov First Moscow State Medical University, Ministry of Health of the Russian Federation, Moscow 119048, Russia; (O.B.); (D.A.); (A.B.); (D.Y.); (S.S.); (A.S.)
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Botrel T, Cunat S, Helms J, Lemarié J, Gaillon J, Préau S, Favory R, Thille AW, Boissier F, Maury E, Joffre J, Ait-Oufella H. Extracranial anticoagulant related bleedings admitted to intensive care units: a French multicenter retrospective study. Crit Care 2023; 27:312. [PMID: 37559102 PMCID: PMC10411017 DOI: 10.1186/s13054-023-04605-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/07/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Anticoagulants are widely used but can lead to iatrogenic events such as bleeding. Limited data exists regarding the characteristics and management of patients admitted to intensive care units (ICU) for severe anticoagulant-related extracranial bleeding. METHODS A retrospective observational study was conducted in five French ICUs. From January 2007 to December 2018, all patients aged over 18 years admitted to ICU for extracranial bleeding while receiving therapeutic anticoagulation were included. RESULTS 486 patients were included, mainly male (61%) with an average age of 73 ± 13 years. Most patients had comorbidities, including hypertension (68%), heart disease (49%) and diabetes (33%). Patients were treated by vitamin K antagonists (VKA, 54%), heparins (25%) and direct oral anticoagulants (DOAC, 7%). The incidence of patients admitted to ICU for anticoagulant-related bleeding increased from 3.2/1000 admissions in 2007 to 5.8/1000 in 2018. This increase was particularly high for DOAC class. Upon admission, patients exhibited severe organ failure, as evidenced by a high SOFA score (7 ± 4) and requirement for organ support therapies such as vasopressors (31.5%) and invasive mechanical ventilation (34%). Adherence to guidelines for the specific treatment of anticoagulant-related bleeding was generally low. ICU mortality was 27%. In multivariate analysis, five factors were independently associated with mortality: chronic hypertension, need for vasopressors, impaired consciousness, hyperlactatemia and prolonged aPTT > 1.2. CONCLUSION Anticoagulant-related extracranial bleeding requiring ICU admission is a serious complication responsible for organ failure and significant mortality. Its incidence is rising. The therapeutic management is suboptimal and could be improved by educational programs.
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Affiliation(s)
- Thomas Botrel
- Medical Intensive Care Unit, Intensive Care Department, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
| | - Sibylle Cunat
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Service de Médecine Intensive-Réanimation, Nouvel Hôpital Civil, Strasbourg, France
| | - Julie Helms
- Université de Strasbourg (UNISTRA), Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Service de Médecine Intensive-Réanimation, Nouvel Hôpital Civil, Strasbourg, France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative Nanomedicine (RNM), FMTS, Strasbourg, France
| | - Jérémie Lemarié
- Intensive Care Department, Nantes University Hospital, Nantes, France
| | - Jeanne Gaillon
- Intensive Care Department, Nantes University Hospital, Nantes, France
| | - Sébastien Préau
- Intensive Care Department, CHU Lille, Univ. Lille, RID-AGE, INSERM UMR 1167, Institut Pasteur, 59000, Lille, France
| | - Raphael Favory
- Intensive Care Department, CHU Lille, Univ. Lille, RID-AGE, INSERM UMR 1167, Institut Pasteur, 59000, Lille, France
| | - Arnaud W Thille
- Intensive Care Department, Centre Hospitalo-Universitaire de Poitiers, Poitiers, France
- INSERM CIC 1402 (IS-ALIVE Group), Université de Poitiers, Poitiers, France
| | - Florence Boissier
- Intensive Care Department, Centre Hospitalo-Universitaire de Poitiers, Poitiers, France
- INSERM CIC 1402 (IS-ALIVE Group), Université de Poitiers, Poitiers, France
| | - Eric Maury
- Medical Intensive Care Unit, Intensive Care Department, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
- Sorbonne Université, Paris, France
| | - Jérémie Joffre
- Medical Intensive Care Unit, Intensive Care Department, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France
- Sorbonne Université, Paris, France
- Centre de Recherche Saint-Antoine Inserm UMR-S 938, Paris, France
| | - Hafid Ait-Oufella
- Medical Intensive Care Unit, Intensive Care Department, Saint Antoine University Hospital, APHP, Sorbonne University, 75012, Paris, France.
- Centre de Recherche Saint-Antoine Inserm UMR-S 938, Paris, France.
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Baker RI, Gilmore G, Chen V, Young L, Merriman E, Curnow J, Joseph J, Tiao JY, Chih J, McRae S, Harper P, Tan CW, Brighton T, Royle G, Hugman A, Hankey GJ, Crowther H, Boey J, Gallus A, Campbell P, Tran H. Direct oral anticoagulants or vitamin K antagonists in emergencies: comparison of management in an observational study. Res Pract Thromb Haemost 2023; 7:100196. [PMID: 37601024 PMCID: PMC10439397 DOI: 10.1016/j.rpth.2023.100196] [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: 12/04/2022] [Revised: 04/17/2023] [Accepted: 05/11/2023] [Indexed: 08/22/2023] Open
Abstract
Background Restoring hemostasis in patients on oral anticoagulants presenting with major hemorrhage (MH) or before surgical intervention has changed, with the replacement of vitamin K antagonist (VKA) with direct oral anticoagulants (DOACs). Objectives To observe the difference in urgent hemostatic management between patients on VKA and those on DOACs. Methods A multicenter observational study evaluated the variation in laboratory testing, hemostatic management, mortality, and hospital length of stay (LOS) in patients on VKA or DOACs presenting with MH or urgent hemostatic restoration. Results Of the 1194 patients analyzed, 783 had MH (61% VKA) and 411 required urgent hemostatic restoration before surgery (56% VKA). Compared to the international normalized ratio (97.6%), plasma DOAC levels were measured less frequently (<45%), and the time taken from admission for the coagulation sample to reach the laboratory varied widely (median, 52.3 minutes; IQR, 24.8-206.7). No significant plasma DOAC level (<50 ng/mL) was found in up to 19% of patients. There was a poor relationship between plasma DOAC level and the usage of a hemostatic agent. When compared with patients receiving VKA (96.5%) or dabigatran (93.7%), fewer patients prescribed a factor Xa inhibitor (75.5%) received a prohemostatic reversal agent. The overall 30-day mortality for MH (mean: 17.8%) and length of stay (LOS) (median: 8.7 days) was similar between VKA and DOAC patients. Conclusion In DOAC patients, when compared to those receiving VKA, plasma DOAC levels were measured less frequently than the international normalized ratio and had a poor relationship with administering a hemostatic reversal agent. In addition, following MH, mortality and LOS were similar between VKA and DOAC patients.
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Affiliation(s)
- Ross I. Baker
- Western Australia Centre for Thrombosis and Haemostasis, Murdoch University, Perth, Australia
- Perth Blood Institute, Perth, Australia
- Hollywood Hospital Haemophilia Centre, Perth, Australia
| | - Grace Gilmore
- Western Australia Centre for Thrombosis and Haemostasis, Murdoch University, Perth, Australia
- Perth Blood Institute, Perth, Australia
| | - Vivien Chen
- Concord Repatriation General Hospital, Concord Clinical School, Faculty of Health and Medicine, University of Sydney, Sydney, Australia
| | - Laura Young
- Auckland City Hospital, Grafton, Auckland, New Zealand
| | | | | | - Joanne Joseph
- St Vincent’s Hospital and School of Clinical Medicine, Faculty of Medicine and Health, University of New South Wales Sydney, Sydney, Australia
| | - Jim Y. Tiao
- Western Australia Centre for Thrombosis and Haemostasis, Murdoch University, Perth, Australia
- Perth Blood Institute, Perth, Australia
| | - Jun Chih
- Curtin School of Population Health, Perth, Australia
| | - Simon McRae
- Perth Blood Institute, Perth, Australia
- Hollywood Hospital Haemophilia Centre, Perth, Australia
| | - Paul Harper
- Palmerston North Hospital, Palmerston North, New Zealand
| | - Chee W. Tan
- Royal Adelaide Hospital, University of Adelaide, Adelaide, Australia
| | | | | | | | - Graeme J. Hankey
- Perron Institute for Neurological and Translational Science and The University of Western Australia, Perth, Australia
| | | | - Jirping Boey
- Flinders Medical Centre, Flinders University, Adelaide, Australia
| | - Alexander Gallus
- Flinders Medical Centre, Flinders University, Adelaide, Australia
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8
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Kietaibl S, Ahmed A, Afshari A, Albaladejo P, Aldecoa C, Barauskas G, De Robertis E, Faraoni D, Filipescu DC, Fries D, Godier A, Haas T, Jacob M, Lancé MD, Llau JV, Meier J, Molnar Z, Mora L, Rahe-Meyer N, Samama CM, Scarlatescu E, Schlimp C, Wikkelsø AJ, Zacharowski K. Management of severe peri-operative bleeding: Guidelines from the European Society of Anaesthesiology and Intensive Care: Second update 2022. Eur J Anaesthesiol 2023; 40:226-304. [PMID: 36855941 DOI: 10.1097/eja.0000000000001803] [Citation(s) in RCA: 66] [Impact Index Per Article: 66.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND Management of peri-operative bleeding is complex and involves multiple assessment tools and strategies to ensure optimal patient care with the goal of reducing morbidity and mortality. These updated guidelines from the European Society of Anaesthesiology and Intensive Care (ESAIC) aim to provide an evidence-based set of recommendations for healthcare professionals to help ensure improved clinical management. DESIGN A systematic literature search from 2015 to 2021 of several electronic databases was performed without language restrictions. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to assess the methodological quality of the included studies and to formulate recommendations. A Delphi methodology was used to prepare a clinical practice guideline. RESULTS These searches identified 137 999 articles. All articles were assessed, and the existing 2017 guidelines were revised to incorporate new evidence. Sixteen recommendations derived from the systematic literature search, and four clinical guidances retained from previous ESAIC guidelines were formulated. Using the Delphi process on 253 sentences of guidance, strong consensus (>90% agreement) was achieved in 97% and consensus (75 to 90% agreement) in 3%. DISCUSSION Peri-operative bleeding management encompasses the patient's journey from the pre-operative state through the postoperative period. Along this journey, many features of the patient's pre-operative coagulation status, underlying comorbidities, general health and the procedures that they are undergoing need to be taken into account. Due to the many important aspects in peri-operative nontrauma bleeding management, guidance as to how best approach and treat each individual patient are key. Understanding which therapeutic approaches are most valuable at each timepoint can only enhance patient care, ensuring the best outcomes by reducing blood loss and, therefore, overall morbidity and mortality. CONCLUSION All healthcare professionals involved in the management of patients at risk for surgical bleeding should be aware of the current therapeutic options and approaches that are available to them. These guidelines aim to provide specific guidance for bleeding management in a variety of clinical situations.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesiology & Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University Vienna, Austria (SK), Department of Anaesthesia and Critical Care, University Hospitals of Leicester NHS Trust (AAh), Department of Cardiovascular Sciences, University of Leicester, UK (AAh), Department of Paediatric and Obstetric Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (AAf), Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark (AAf), Department of Anaesthesiology & Critical Care, CNRS/TIMC-IMAG UMR 5525/Themas, Grenoble-Alpes University Hospital, Grenoble, France (PA), Department of Anaesthesiology & Intensive Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania (GB), Division of Anaesthesia, Analgesia, and Intensive Care - Department of Medicine and Surgery, University of Perugia, Italy (EDR), Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA (DFa), University of Medicine and Pharmacy Carol Davila, Department of Anaesthesiology & Intensive Care, Emergency Institute for Cardiovascular Disease, Bucharest, Romania (DCF), Department of Anaesthesia and Critical Care Medicine, Medical University Innsbruck, Innsbruck, Austria (DFr), Department of Anaesthesiology & Critical Care, APHP, Université Paris Cité, Paris, France (AG), Department of Anesthesiology, University of Florida, College of Medicine, Gainesville, Florida, USA (TH), Department of Anaesthesiology, Intensive Care and Pain Medicine, St.-Elisabeth-Hospital Straubing, Straubing, Germany (MJ), Department of Anaesthesiology, Medical College East Africa, The Aga Khan University, Nairobi, Kenya (MDL), Department of Anaesthesiology & Post-Surgical Intensive Care, University Hospital Doctor Peset, Valencia, Spain (JVL), Department of Anaesthesiology & Intensive Care, Johannes Kepler University, Linz, Austria (JM), Department of Anesthesiology & Intensive Care, Semmelweis University, Budapest, Hungary (ZM), Department of Anaesthesiology & Post-Surgical Intensive Care, University Trauma Hospital Vall d'Hebron, Barcelona, Spain (LM), Department of Anaesthesiology & Intensive Care, Franziskus Hospital, Bielefeld, Germany (NRM), Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP. Centre - Université Paris Cité - Cochin Hospital, Paris, France (CMS), Department of Anaesthesiology and Intensive Care, Fundeni Clinical Institute, Bucharest and University of Medicine and Pharmacy Carol Davila, Bucharest, Romania (ES), Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz and Ludwig Boltzmann-Institute for Traumatology, The Research Centre in Co-operation with AUVA, Vienna, Austria (CS), Department of Anaesthesia and Intensive Care Medicine, Zealand University Hospital, Roskilde, Denmark (AW) and Department of Anaesthesiology, Intensive Care Medicine & Pain Therapy, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany (KZ)
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9
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Godon A, Gabin M, Levy JH, Huet O, Chapalain X, David JS, Tacquard C, Sattler L, Minville V, Mémier V, Blanié A, Godet T, Leone M, De Maistre E, Gruel Y, Roullet S, Vermorel C, Samama CM, Bosson JL, Albaladejo P. Management of urgent invasive procedures in patients treated with direct oral anticoagulants: An observational registry analysis. Thromb Res 2022; 216:106-112. [DOI: 10.1016/j.thromres.2022.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 06/07/2022] [Accepted: 06/14/2022] [Indexed: 01/21/2023]
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10
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Kietaibl S, Ferrandis R, Godier A, Llau J, Lobo C, Macfarlane AJ, Schlimp CJ, Vandermeulen E, Volk T, von Heymann C, Wolmarans M, Afshari A. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022; 39:100-132. [PMID: 34980845 DOI: 10.1097/eja.0000000000001600] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia. DESIGN A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline. RESULTS Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%. DISCUSSION Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply. CONCLUSION In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University, Vienna, Austria (SK), Department of Anaesthesiology and Critical Care, Hospital Universitari i Politècnic La Fe, Valencia, Spain (RF), Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris (AG), INSERM UMRS-1140 Paris University, Paris, France (AG), Department of Anaesthesiology and Critical Care, Doctor Peset University Hospital (JL), Department of Surgery, Valencia University, Valencia, Spain (JL), Serviço de Anestesiologia Hospital das Forças Armadas, Pólo Porto, Porto, Portugal (CL), Department of Anaesthesia Pain Medicine and Critical Care, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK (AM), Department of Anaesthesia and Intensive Care Medicine, AUVA Trauma Centre Linz, Linz (CJS); Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria (CJS), Department of Anaesthesia, University Hospitals Leuven. Catholic University of Leuven, Leuven, Belgium (EV), Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar (TV), Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany (CVH), Department of Anaesthesia, Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK (MW), and Department of Pediatric and Obstetric Anesthesia, Juliane Marie Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (AA)
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11
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Lindhoff-Last E, Birschmann I, Kuhn J, Lindau S, Konstantinides S, Grottke O, Nowak-Göttl U, Lucks J, Zydek B, von Heymann C, Sümnig A, Beyer-Westendorf J, Schellong S, Meybohm P, Greinacher A, Herrmann E. Pharmacokinetics of Direct Oral Anticoagulants in Emergency Situations: Results of the Prospective Observational RADOA-Registry. Thromb Haemost 2021; 122:552-559. [PMID: 34256392 PMCID: PMC9113852 DOI: 10.1055/a-1549-6556] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are increasingly used worldwide. Little is known so far about their pharmacokinetics in emergency situations. METHODS A prospective, observational registry was performed to determine the clinical course in consecutive patients with major bleeding or urgent surgery treated with DOACs. In samples collected as part of routine care DOAC drug concentrations were measured using ultraperformance liquid chromatography-tandem mass spectrometry. Anticoagulant intensity at first presentation and drug half-life (t 1/2), tested in repeat samples, were evaluated. RESULTS A total of 140 patients were prospectively included. Pharmacokinetic data were available in 94% (132/140) of patients. Note that 67% (89/132) experienced life-threatening bleeding and 33% (43/132) needed an urgent surgery. For pharmacokinetic analysis a total of 605 blood samples was available. Median concentration on admission was 205 ng/mL for rivaroxaban and 108 ng/mL for apixaban. All treatment groups showed a high variation of drug concentrations at baseline. In rivaroxaban-treated patients t ½ was 17.3 hours (95% confidence interval [CI]: 15.4-19.7) without significant difference in both groups (major bleeding: t ½ 16.7 hours, 95% CI: 14.7-19.3; urgent surgery: t ½ 19.7 hours, 95% CI: 15.2-27.9; p = 0.292). In apixaban-treated patients t ½ was 25.0 hours (95% CI: 22.9-27.6) with a longer t ½ after urgent surgery (t 1/2: 30.8 hours; 95% CI: 26.9-36.4) compared with severe bleeding (t 1/2: 20.8 hours; 95% CI: 18.8-23.2; p < 0.001). CONCLUSION Emergency patients under DOAC treatment show a high variation of anticoagulant concentrations at baseline. Compared with rivaroxaban, apixaban showed a lower median concentration on admission and a longer t ½.
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Affiliation(s)
- Edelgard Lindhoff-Last
- Coagulation Centre at the Cardiology Angiology Centre Bethanien Hospital (CCB), Frankfurt, Germany,Coagulation Research Centre Bethanien Hospital, Frankfurt, Germany,Address for correspondence Edelgard Lindhoff-Last, MD Cardiology Angiology Center Bethanien Hospital (CCB)Im Prüfling 23, 60389 FrankfurtGermany
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Centre, Ruhr University, Bochum, Germany
| | - Joachim Kuhn
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Centre, Ruhr University, Bochum, Germany
| | - Simone Lindau
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Haemostasis (CTH), Johannes Gutenberg University, Mainz, Germany
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Ulrike Nowak-Göttl
- Institute of Clinical Chemistry, Thrombosis & Haemostasis Treatment Centre, University Hospital, Kiel-Lübeck, Germany
| | - Jessica Lucks
- Coagulation Research Centre Bethanien Hospital, Frankfurt, Germany
| | - Barbara Zydek
- Coagulation Research Centre Bethanien Hospital, Frankfurt, Germany
| | - Christian von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - Ariane Sümnig
- Department of Immunology and Transfusion Medicine, Universitätsmedizin, Greifswald, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine 1, Dresden, Germany,Division of Haematology, Dresden University Clinic, Dresden, Germany,Department of Haematology and Oncology, Kings College, London, United Kingdom
| | | | - Patrick Meybohm
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany,Department of Anaesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Andreas Greinacher
- Department of Immunology and Transfusion Medicine, Universitätsmedizin, Greifswald, Germany
| | - Eva Herrmann
- Institute of Biostatistics and Mathematical Modelling, Goethe University, Frankfurt, Germany
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12
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Guía ESC 2020 sobre cardiología del deporte y el ejercicio en pacientes con enfermedad cardiovascular. Rev Esp Cardiol 2021. [DOI: 10.1016/j.recesp.2020.11.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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13
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Jaspers T, Shudofsky K, Huisman MV, Meijer K, Khorsand N. A meta-analysis of andexanet alfa and prothrombin complex concentrate in the treatment of factor Xa inhibitor-related major bleeding. Res Pract Thromb Haemost 2021; 5:e12518. [PMID: 34084991 PMCID: PMC8143276 DOI: 10.1002/rth2.12518] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 11/08/2022] Open
Abstract
Background Andexanet alfa (andexanet) and prothrombin complex concentrate (PCC) are both reversal agents for major bleeding in patients using factor Xa inhibitors (FXaIs). Our aim was to evaluate the current evidence for the effectiveness and safety of andexanet and PCC in a systematic review and meta-analysis. Objectives Primary objective was hemostatic effectiveness. Secondary objectives were thromboembolic event rate and mortality. Methods A systematic review was performed in PubMed and Embase. Studies describing the effectiveness and/or safety of PCC or andexanet in patients with major bleeding using FXaIs were included. Meta-analysis was performed using a random-effects model. Results Seventeen PCC studies, 3 andexanet studies, and 1 study describing PCC and andexanet were included, comprising 1428 PCC-treated and 396 andexanet-treated patients. None of the included studies had control groups, hampering a pooled meta-analysis to compare the two reversal agents. Separate analyses for andexanet and PCC were performed. In subgroup analysis, the pooled proportion of patients with effective hemostasis in studies that used Annexa-4 criteria demonstrated a hemostatic effectiveness of 0.85 (95% confidence interval [CI], 0.80-0.90) in PCC and 0.82 (95% CI, 0.78-0.87) in andexanet studies. The pooled proportion of patients with thromboembolic events was 0.03 (95% CI, 0.02-0.04) in PCC and 0.11 (95% CI, 0.04-0.18) in andexanet studies. Conclusion Based on the available evidence with low certainty from observational studies, PCC and andexanet demonstrated a similar, effective hemostasis in the treatment of major bleeding in patients using FXaIs. Compared to PCC, the thromboembolic event rate appeared higher in andexanet-treated patients.
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Affiliation(s)
- Tessa Jaspers
- Department of Clinical Pharmacy and Pharmacology University Medical Centre Groningen Groningen The Netherlands
| | - Kimberly Shudofsky
- Department of Hospital Pharmacy Viecuri Medical Center Venlo The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis Leiden University Medical Center Leiden The Netherlands
| | - Karina Meijer
- Department of Hematology University Medical Center Groningen Groningen The Netherlands
| | - Nakisa Khorsand
- Department of Hospital Pharmacy OLVG Amsterdam The Netherlands
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14
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Pelliccia A, Sharma S, Gati S, Bäck M, Börjesson M, Caselli S, Collet JP, Corrado D, Drezner JA, Halle M, Hansen D, Heidbuchel H, Myers J, Niebauer J, Papadakis M, Piepoli MF, Prescott E, Roos-Hesselink JW, Graham Stuart A, Taylor RS, Thompson PD, Tiberi M, Vanhees L, Wilhelm M. 2020 ESC Guidelines on sports cardiology and exercise in patients with cardiovascular disease. Eur Heart J 2021; 42:17-96. [PMID: 32860412 DOI: 10.1093/eurheartj/ehaa605] [Citation(s) in RCA: 714] [Impact Index Per Article: 238.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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15
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Steffel J, Collins R, Antz M, Cornu P, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Vanassche T, Potpara T, Camm AJ, Heidbüchel H, Lip GYH, Deneke T, Dagres N, Boriani G, Chao TF, Choi EK, Hills MT, Santos IDS, Lane DA, Atar D, Joung B, Cole OM, Field M. 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients with Atrial Fibrillation. Europace 2021; 23:1612-1676. [PMID: 33895845 DOI: 10.1093/europace/euab065] [Citation(s) in RCA: 444] [Impact Index Per Article: 148.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Affiliation(s)
- Jan Steffel
- Department of Cardiology, Division of Electrophysiology, University Heart Center Zurich, Switzerland
| | - Ronan Collins
- Age-Related Health Care, Tallaght University Hospital / Department of Gerontology Trinity College, Dublin, Ireland
| | - Matthias Antz
- Department of Electrophysiology, Hospital Braunschweig, Braunschweig, Germany
| | - Pieter Cornu
- Faculty of Medicine and Pharmacy, Research Group Clinical Pharmacology and Clinical Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Lien Desteghe
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiology I - Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK
| | - Hein Heidbüchel
- Cardiology, Antwerp University and University Hospital, Antwerp, Belgium.,Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Thomas Deneke
- Clinic for Interventional Electrophysiology, Heart Center RHÖN-KLINIKUM Campus Bad Neustadt, Bad Neustadt an der Saale, Germany
| | - Nikolaos Dagres
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan & Institute of Clinical Medicine and Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan
| | - Eue-Keun Choi
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | | | - Itamar de Souza Santos
- Centro de Pesquisa Clínica e Epidemiológica, Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil.,Departamento de Clínica Médica, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg Thrombosis Research Unit, Aalborg University, Aalborg, Denmark
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ullevål, Oslo, Norway.,Institute of Clinical Sciences, University of Oslo, Oslo, Norway
| | - Boyoung Joung
- Yonsei University College of Medicine, Cardiology Department, Seoul, Republic of Korea
| | - Oana Maria Cole
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Mark Field
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Liverpool Heart & Chest Hospital, Liverpool, UK
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16
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Renon F, Rago A, Liccardo B, D'Andrea A, Riegler L, Golino P, Nigro G, Russo V. Direct Oral Anticoagulants Plasma Levels Measurement: Clinical Usefulness from Trials and Real-World Data. Semin Thromb Hemost 2021; 47:150-160. [PMID: 33636746 DOI: 10.1055/s-0041-1723770] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Measurement of direct oral anticoagulants (DOACs) activity is not routinely necessary. Indeed, evaluation of DOACs plasmatic concentration is discouraged for the majority of patients, due to the lack of outcome data supporting this approach. Nevertheless, DOAC measurements may be useful in emergency situations such as serious bleeding events, need for urgent invasive procedures, and acute ischemic stroke or in managing anticoagulation in "special populations" not adequately studied in clinical trials, for example the very elderly or those at the extremes of body weight. The aim of this review is to describe and summarize the methods for DOACs activity evaluation and the settings in which their plasma level measurement may be indicated, analyzing indications from scientific societies and evidence from clinical trials, as well as real world data on the usefulness of DOACs plasma levels "monitoring."
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Affiliation(s)
- Francesca Renon
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Anna Rago
- Department of Cardiology, Monaldi Hospital, Naples, Italy
| | | | - Antonello D'Andrea
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore, Italy
| | - Lucia Riegler
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore, Italy
| | - Paolo Golino
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Gerardo Nigro
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Vincenzo Russo
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
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17
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Lindhoff-Last E, Herrmann E, Lindau S, Konstantinides S, Grottke O, Nowak-Goettl U, Lucks J, Zydek B, Heymann CV, Birschmann I, Sümnig A, Beyer-Westendorf J, Schellong S, Meybohm P, Greinacher A. Severe Hemorrhage Associated With Oral Anticoagulants. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:312-319. [PMID: 32605708 DOI: 10.3238/arztebl.2020.0312] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 11/01/2019] [Accepted: 03/09/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Few data have been published to date on outcomes after the common clinical experience of severe hemorrhage in orally anticoagulated patients. METHODS A prospective, multicenter observational study was carried out to investigate outcomes and management in a series of consecutive patients who sustained a severe hemorrhage under treatment with vitamin K antagonists (VKA) or direct oral anticoagulant drugs (DOAC). The primary endpoint was in-hospital death up to and including day 30 after hospital admission. The secondary endpoints were the duration of bleeding, in-hospital death due to hemorrhage (as defined by the study physician examining the patient's records), the use of antagonists, the extent of supportive measures used to stop the hemorrhage, and an assessment of causality. Consecutive patients were recruited until a predefined number of patients was reached in both groups. RESULTS Among 193 patients with severe hemorrhage, 97 had been taking a VKA, and 96 had been taking a DOAC. 13.0 % (95% confidence interval [8.6; 18.5]; 25/193) of the overall group patients died in the first 30 days after hospital admission, including 17.5% ([10.6; 26.6]; 17/97) in the VKA group and 8.3% ([3.7; 15.8]; 8/96) in the DOAC group (p = 0.085). The median duration of bleeding was 19.8 hours in the VKA group and 27.8 hours in the DOAC group (p = 0.632). The in-hospital mortality due to hemorrhage was higher in the VKA group than in the DOAC group (15.5% [15/97] versus 4.2% [4/97]; p = 0.014). Only the use of prothrombin complex concentrates (PCCs) lowered the median duration of hemorrhage in the two patient groups. In 35% (68/193) of the patients, the hemorrhage was caused by an external influence, most commonly a fall. CONCLUSION The in-hospital mortality was higher among patients treated with VKA than among patients treated with DOAC, although the difference failed to reach statistical significance.
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Affiliation(s)
- Edelgard Lindhoff-Last
- Coagulation Center and Research Center, Cardioangiology Center Bethanien Hospital (CCB), Frankfurt/Main; Institute of Biostatistics und Mathematical Modelling, Goethe University, Frankfurt; Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt/Main; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz, Mainz; Department of Anesthesiology, RWTH Aachen University Hospital, Aachen; Department of Clinical Chemistry, Thrombosis and Hemostasis Unit, University Hospital of Kiel and Lübeck, Kiel; Research Center of the Cardioangiology Center Bethanien Hospital (CCB), Frankfurt/Main; Department of Anesthesiology, Intensive Care and Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin; Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Ruhr University Bochum, Bochum; Department of Immunology and Transfusion medicine, University Medicine Greifswald, Greifswald; Thrombosis Research Unit, Center for Internal Medicine 1, Department of Hematology, University Hospital Dresden, Dresden, Germany, and Department of Haematology and Oncology, Kings College London, England; Medical Department 2, Municipal Hospital Dresden-Friedrichstadt, Dresden; Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, and Department of Anesthesiology, University Hospital Würzburg, Würzburg; Department of Immunology and Transfusion Medicine, University Medicine Greifswald, Greifswald
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19
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Lapina NS, Alekseeva AA, Vershinina AD, Khruleva NS, Zlobina DS, Koroleva LY. [Gastrointestinal Bleeding in Patients with Coronary Heart Disease: Preventive Options]. ACTA ACUST UNITED AC 2020; 60:125-135. [PMID: 33155951 DOI: 10.18087/cardio.2020.7.n942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 02/17/2020] [Indexed: 11/18/2022]
Abstract
Extensive use of antithrombotic drugs (ATD) in patients with ischemic heart disease (IHD), on the one hand, provides a considerable decrease in the risk for development of life-threatening cardiovascular complications but on the other hand, is associated with a risk of gastrointestinal bleedings (GIB), which may develop in 0.5-1.0 % of patients. In such cases, the major measures for prevention of GIB are strict adherence to indications for the ATD treatment, detection and analysis of risk factors for GIB and their elimination as far as feasible. For evaluation of GIB risk in patients with IHD, the PRECISE-DAPT and DAPT, HAS-BLED scales should be used. If the risk factors are non-modifiable the therapeutic tactics for further management of these patients should be strictly individual with determining the nature of damage, degree of a risk for present and possible complications, and the range of required therapeutic and diagnostic measures. The use of ATD requires monitoring of the patient's condition to timely detect and treat GI complications.
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Affiliation(s)
- N S Lapina
- Privolzhsky Research Medical University of the Ministry of Health of Russia, Nizhny Novgorod
| | - A A Alekseeva
- Privolzhsky Research Medical University of the Ministry of Health of Russia, Nizhny Novgorod
| | - A D Vershinina
- Privolzhsky Research Medical University of the Ministry of Health of Russia, Nizhny Novgorod
| | - N S Khruleva
- Privolzhsky Research Medical University of the Ministry of Health of Russia, Nizhny Novgorod
| | - D S Zlobina
- Privolzhsky Research Medical University of the Ministry of Health of Russia, Nizhny Novgorod
| | - L Yu Koroleva
- Privolzhsky Research Medical University of the Ministry of Health of Russia, Nizhny Novgorod
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20
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Cafuir L, Cheng E, Kempton C. Outcomes of direct oral anticoagulant- and warfarin-associated hemorrhage: A single center retrospective cohort study. Thromb Res 2020; 189:128-131. [DOI: 10.1016/j.thromres.2019.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 08/13/2019] [Accepted: 09/02/2019] [Indexed: 10/26/2022]
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Martínez de Narvajas Urra I, Daroca Pérez R, Arnedo Hernández S. Prothrombin complex use in patients treated with direct-acting oral anticoagulants. Med Clin (Barc) 2020; 156:193-194. [PMID: 32165003 DOI: 10.1016/j.medcli.2020.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 12/22/2019] [Accepted: 01/09/2020] [Indexed: 10/24/2022]
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22
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An Update on the Reversal of Non-Vitamin K Antagonist Oral Anticoagulants. Adv Hematol 2020; 2020:7636104. [PMID: 32231703 PMCID: PMC7097770 DOI: 10.1155/2020/7636104] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 08/26/2019] [Accepted: 09/25/2019] [Indexed: 12/19/2022] Open
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) include thrombin inhibitor dabigatran and coagulation factor Xa inhibitors rivaroxaban, apixaban, edoxaban, and betrixaban. NOACs have several benefits over warfarin, including faster time to the achieve effect, rapid onset of action, fewer documented food and drug interactions, lack of need for routine INR monitoring, and improved patient satisfaction. Local hemostatic measures, supportive care, and withholding the next NOAC dose are usually sufficient to achieve hemostasis among patients presenting with minor bleeding. The administration of reversal agents should be considered in patients on NOAC's with major bleeding manifestations (life-threatening bleeding, or major uncontrolled bleeding), or those who require rapid anticoagulant reversal for an emergent surgical procedure. The Food and Drug Administration (FDA) has approved two reversal agents for NOACs: idarucizumab for dabigatran and andexanet alfa for apixaban and rivaroxaban. The American College of Cardiology (ACC), American Heart Association (AHA), and Heart Rhythm Society (HRS) have released an updated guideline for the management of patients with atrial fibrillation that provides indications for the use of these reversal agents. In addition, the final results of the ANNEXA-4 study that evaluated the efficacy and safety of andexanet alfa were recently published. Several agents are in different phases of clinical trials, and among them, ciraparantag has shown promising results. However, their higher cost and limited availability remains a concern. Here, we provide a brief review of the available reversal agents for NOACs (nonspecific and specific), recent updates on reversal strategies, lab parameters (including point-of-care tests), NOAC resumption, and agents in development.
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Management of direct factor Xa inhibitor-related major bleeding with prothrombin complex concentrate: a meta-analysis. Blood Adv 2020; 3:158-167. [PMID: 30658963 DOI: 10.1182/bloodadvances.2018024133] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Accepted: 11/03/2018] [Indexed: 01/12/2023] Open
Abstract
A targeted antidote for reversal of direct factor Xa (FXa) inhibitors is now available for clinical use in the United States, but it is costly and has limited availability. In a systematic review, we evaluated the safety and effectiveness of 4-factor prothrombin complex concentrate (4F-PCC) as an alternative for managing direct FXa inhibitor-related major bleeding. A systematic literature search was conducted using Medline, Embase, and the Cochrane Register of Controlled Trials up to September 2018. No comparative studies were found. Ten case series with 340 patients who received PCC for direct FXa inhibitor-related major bleeding were included. The pooled proportion of patients with effective management of major bleeding was 0.69 (95% confidence interval [CI], 0.61-0.76) in 2 studies using the International Society on Thrombosis and Haemostasis (ISTH) criteria and 0.77 (95% CI, 0.63-0.92) in 8 studies that did not use the ISTH criteria; all-cause mortality was 0.16 (95% CI, 0.07-0.26), and thromboembolism rate was 0.04 (95% CI, 0.01-0.08). On the basis of evidence with very low certainty from single-arm case series, it is difficult to determine whether 4F-PCC in addition to cessation of direct oral FXa inhibitor is more effective than cessation of direct oral FXa inhibitor alone in patients with direct FXa inhibitor-related major bleeding.
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Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Collins R, Camm AJ, Heidbüchel H. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J 2019; 39:1330-1393. [PMID: 29562325 DOI: 10.1093/eurheartj/ehy136] [Citation(s) in RCA: 1278] [Impact Index Per Article: 255.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The current manuscript is the second update of the original Practical Guide, published in 2013 [Heidbuchel et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF) and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. The European Heart Rhythm Association (EHRA) set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group identified 20 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 20 topics are as follows i.e., (1) Eligibility for NOACs; (2) Practical start-up and follow-up scheme for patients on NOACs; (3) Ensuring adherence to prescribed oral anticoagulant intake; (4) Switching between anticoagulant regimens; (5) Pharmacokinetics and drug-drug interactions of NOACs; (6) NOACs in patients with chronic kidney or advanced liver disease; (7) How to measure the anticoagulant effect of NOACs; (8) NOAC plasma level measurement: rare indications, precautions, and potential pitfalls; (9) How to deal with dosing errors; (10) What to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a potential risk of bleeding; (11) Management of bleeding under NOAC therapy; (12) Patients undergoing a planned invasive procedure, surgery or ablation; (13) Patients requiring an urgent surgical intervention; (14) Patients with AF and coronary artery disease; (15) Avoiding confusion with NOAC dosing across indications; (16) Cardioversion in a NOAC-treated patient; (17) AF patients presenting with acute stroke while on NOACs; (18) NOACs in special situations; (19) Anticoagulation in AF patients with a malignancy; and (20) Optimizing dose adjustments of VKA. Additional information and downloads of the text and anticoagulation cards in different languages can be found on an EHRA website (www.NOACforAF.eu).
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Affiliation(s)
- Jan Steffel
- Department of Cardiology, University Heart Center Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Peter Verhamme
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | | | | | - Lien Desteghe
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Karl Georg Haeusler
- Center for Stroke Research Berlin and Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Ronan Collins
- Age-Related Health Care & Stroke-Service, Tallaght Hospital, Dublin Ireland
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK, and Imperial College
| | - Hein Heidbüchel
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,Antwerp University and University Hospital, Antwerp, Belgium
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Four-factor Prothrombin Complex Concentrate for the Management of Patients Receiving Direct Oral Activated Factor X Inhibitors. Anesthesiology 2019; 131:1153-1165. [DOI: 10.1097/aln.0000000000002910] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Factor Xa inhibitors prevent thrombosis but are associated with severe or life-threatening bleeding. Here, the authors present data on four-factor prothrombin complex concentrates in management of anticoagulation-associated bleeding and restoring hemostasis, including recent results from the UPRATE study.
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Vigué B, Samama CM. Prise en charge hémostatique des hémorragies cérébrales sous anticoagulants oraux. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
L’hématome intracrânien spontané a un pronostic clinique sévère. Le devenir des patients dépend de l’efficacité de la prise en charge initiale. L’importance du saignement, le volume de l’hématome et son évolution sont les facteurs principaux qui contrôlent mortalité et morbidité. Les traitements anticoagulants oraux, antivitamines K (AVK) et anticoagulants oraux directs (AOD), favorisent l’expansion de l’hématome. La correction rapide de l’hémostase permet le contrôle partiel de l’hématome. Alors que la réversion des AVK par les concentrés de complexe prothrombinique (CCP) a fait l’objet de recommandations bien diffusées, l’attitude thérapeutique reste peu codifiée avec les AOD, alliant l’utilisation de l’idarucizumab pour le dabigatran et des CCP pour les anti-Xa qui n’ont, pour l’instant, pas d’antidote.
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27
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Kozieł M, Ding WY, Kalarus Z, Lip GYH. Considerations when restarting anticoagulants in patients with atrial fibrillation after bleeding. Expert Rev Hematol 2019; 12:845-855. [PMID: 31334670 DOI: 10.1080/17474086.2019.1647779] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Introduction: Oral anticoagulants (OACs) are established treatments to reduce thromboembolic risk in patients with atrial fibrillation (AF). Due to their mechanisms of action, they are associated with increased bleeding risk. Evaluation with bleeding risk scores may be useful to identify patients at high risk. However, the approach in patients who have suffered a recent bleeding event while on OACs is a contentious issue. If a decision is made to re-initiate OACs, the optimal timing for this remains controversial. Areas covered: Bleeding risk scores were designed to evaluate risk in patients with AF and indications for OACs. Some practical schemes were created to manage bleeding in this population. The types of bleeding were classified as minor, major non-life-threatening and major life-threatening bleeding. In AF patients suffering from severe acute bleeding, it is recommended to withhold OACs until the underlying cause is identified and treated. Each case will require an individualized decision to restarting OAC therapy after consideration of the risks, benefits, alternatives and patient's choice in the matter. Expert opinion: Management of major bleeding and restarting OACs in patients with a recent major bleeding poses a special challenge due to high bleeding and thrombotic risk. This will be discussed in this review.
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Affiliation(s)
- Monika Kozieł
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases , Zabrze , Poland
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK
| | - Zbigniew Kalarus
- Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases , Zabrze , Poland
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK.,Department of Cardiology, Congenital Heart Diseases and Electrotherapy, Medical University of Silesia, Silesian Centre for Heart Diseases , Zabrze , Poland.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University , Aalborg , Denmark
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Deutsch D, Romegoux P, Boustière C, Sabaté JM, Benamouzig R, Albaladejo P. Clinical and endoscopic features of severe acute gastrointestinal bleeding in elderly patients treated with direct oral anticoagulants: a multicentre study. Therap Adv Gastroenterol 2019; 12:1756284819851677. [PMID: 31244894 PMCID: PMC6580723 DOI: 10.1177/1756284819851677] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 04/29/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The aim of the study was to describe the clinical and endoscopic characteristics and management of severe acute gastrointestinal (GI) bleeding in patients treated with direct oral anticoagulants (DOACs). METHODS Patients hospitalized for severe GI bleeding under DOAC therapy were identified in 36 centres between June 2013 and March 2016. Clinical outcomes including re-bleeding, major cerebral and cardiovascular events or all-cause mortality were assessed initially and 30 days after admission. RESULTS A total of 59 patients with anonymized detailed endoscopy reports for severe GI bleeding were considered. Mean age was 79.3 ± 10.0 years and 61.3% of patients were men. Patients had histories of hypertension (65.6%), heart failure (29.5%), coronary artery disease (27.9%), stroke (19.7%) and peripheral vascular disease (36.1%). Life-threatening bleeding was observed in 42.6%. Mean number of packed red blood cells transfused was 3.4 (range 1-31). Aetiology of bleeding (identified in 66.2% of cases) was peptic gastroduodenal ulcers (22%), diverticula (11.9%), angiodysplasia (8.5%), colorectal neoplasia (5.1%) and anorectal causes (5.1%). Endoscopic haemostasis was performed in 37.7% of patients. A low haemoglobin level was predictive of life-threatening bleeding and death in multivariate analysis. All-cause mortality rate at day 30 was 11.8%. CONCLUSIONS In this cohort of elderly patients with multiple comorbidities treated with DOACs, the main cause of severe acute GI bleeding was peptic gastroduodenal ulcer and mortality was high.
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Affiliation(s)
| | - Pauline Romegoux
- Department of Anaesthesiology and Critical Care,
Grenoble-Alpes University Hospital, Grenoble, France
| | | | - Jean-Marc Sabaté
- Department of Gastroenterology, AP-HP Avicenne
Hospital, Paris-13 University, Bobigny, France
| | - Robert Benamouzig
- Department of Gastroenterology, AP-HP Avicenne
Hospital, Paris-13 University, Bobigny, France
| | - Pierre Albaladejo
- Department of Anaesthesiology and Critical Care,
Grenoble-Alpes University Hospital, Grenoble, France
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Favresse J, Hardy M, van Dievoet MA, Sennesael AL, Douxfils J, Samama CM, Vornicu O, Dincq AS, Lessire S, Mullier F. Andexanet alfa for the reversal of factor Xa inhibitors. Expert Opin Biol Ther 2019; 19:387-397. [DOI: 10.1080/14712598.2019.1599355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- J Favresse
- Namur Thrombosis and Haemostasis Center, Hematology Laboratory, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - M Hardy
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Haemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - MA van Dievoet
- St-Luc University Hospital and Catholic University of Louvain, Department of Laboratory Medicine, Hematology Laboratory, Brussels, Belgium
| | - AL Sennesael
- Department of Pharmacy, Namur Thrombosis and Haemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
| | - J Douxfils
- Department of Pharmacy, Namur Thrombosis and Haemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
- Qualiblood s.a., Namur, Belgium
| | - CM Samama
- Department of Anaesthesiology and Intensive Care Medicine, Cochin University Hospital, Paris Descartes University, Paris, France
| | - O Vornicu
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Haemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - AS Dincq
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Haemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - S Lessire
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Haemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - F Mullier
- Namur Thrombosis and Haemostasis Center, Hematology Laboratory, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
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Shin S, Kang H, Lee JW, Kim HG, Choi ES. Epidural hematoma after total knee arthroplasty in a patient receiving rivaroxaban - A case report -. Anesth Pain Med (Seoul) 2019. [DOI: 10.17085/apm.2019.14.1.102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Sojin Shin
- Department of Anesthesiology and Pain Medicine, Nowon Eulji Medical Center, Eulji University College of Medicine, Seoul, Korea
| | - Hyoseok Kang
- Department of Anesthesiology and Pain Medicine, Nowon Eulji Medical Center, Eulji University College of Medicine, Seoul, Korea
| | - Jae Woo Lee
- Department of Anesthesiology and Pain Medicine, Nowon Eulji Medical Center, Eulji University College of Medicine, Seoul, Korea
| | - Hyoung-gyun Kim
- Department of Anesthesiology and Pain Medicine, Nowon Eulji Medical Center, Eulji University College of Medicine, Seoul, Korea
| | - Eun-su Choi
- Department of Anesthesiology and Pain Medicine, Nowon Eulji Medical Center, Eulji University College of Medicine, Seoul, Korea
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Hoffman M, Goldstein JN, Levy JH. The impact of prothrombin complex concentrates when treating DOAC-associated bleeding: a review. Int J Emerg Med 2018; 11:55. [PMID: 31179943 PMCID: PMC6326120 DOI: 10.1186/s12245-018-0215-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 11/11/2018] [Indexed: 12/18/2022] Open
Abstract
Background Bleeding complications are a risk associated with all anticoagulants. Currently, the treatment options for the management of direct oral anticoagulant (DOAC)-associated bleeding are limited. Prothrombin complex concentrates (PCCs) have been proposed as a potential therapeutic option, and evidence regarding their use is increasing. Review Many studies supporting PCC have used preclinical models and healthy volunteers; however, more recently, observational studies have further improved insight into current DOAC reversal strategies. Multiple clinical practice guidelines now specifically suggest use of PCCs for this indication. Specific reversal agents for Factor Xa inhibitors may become available in the near future, but data on their efficacy are still emerging. Conclusions Ultimately, a multimodal approach may be the optimal strategy to restore haemostasis in patients presenting with DOAC-associated coagulopathy. Electronic supplementary material The online version of this article (10.1186/s12245-018-0215-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Maureane Hoffman
- Department of Pathology, Duke University School of Medicine, Durham, NC, USA.
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, USA
| | - Jerrold H Levy
- Department of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, NC, USA
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32
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Sennesael AL, Larock AS, Douxfils J, Elens L, Stillemans G, Wiesen M, Taubert M, Dogné JM, Spinewine A, Mullier F. Rivaroxaban plasma levels in patients admitted for bleeding events: insights from a prospective study. Thromb J 2018; 16:28. [PMID: 30455596 PMCID: PMC6231259 DOI: 10.1186/s12959-018-0183-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Accepted: 08/21/2018] [Indexed: 11/17/2022] Open
Abstract
Background Serious bleeding events have been frequently described in patients taking direct oral anticoagulants (DOAC). In secondary analyses of phase 3 trials, DOAC plasma concentrations were shown to correlate with bleeding outcomes. This study aimed to describe rivaroxaban plasma levels in patients admitted to the emergency department (ED) for bleeding events. For each patient, risk factors for experiencing bleeding events were also investigated. Methods This analysis was part of an observational study conducted in the ED of two teaching hospitals. Plasma samples from 10 rivaroxaban-treated patients admitted for bleeding events were collected. Rivaroxaban plasma concentrations were determined by calibrated chromogenic anti-Xa assay. The measured rivaroxaban levels were then extrapolated at trough using a published population pharmacokinetic (PopPK) model, and compared to on-therapy ranges observed in large clinical trials. For each patient, clinical, medication and ABCB1 genotype data were collected. Results Rivaroxaban measurements varied from 5 to 358 ng/ml, with a post-intake delay ranging from 9 to 38 h. At trough, estimated plasma concentrations were between 12 and 251 ng/ml (median value 94 ng/ml). Four patients had higher-than-expected rivaroxaban levels. Inadequate dose regimen, excessive alcohol consumption and lack of treatment reassessment were observed in several patients. Half of patients were taking ≥1 drug with potential pharmacokinetics interactions (e.g. amiodarone, diltiazem), while half of patients were taking ≥1 drug increasing the risk of bleeding. All 3 patients with available genotyping data and higher-than-expected rivaroxaban levels were heterozygous or homozygous mutated for the ABCB1 1236C > T, 2677G > T, 3435 C > T and rs4148738 single nucleotide polymorphisms (SNP). Conclusions Rivaroxaban patients admitted to the ED for bleeding events showed highly variable plasma concentrations. This analysis underlines the usefulness of rapid DOAC measurement and the value of PopPK models to estimate concentrations at trough in a context where the post-intake delay is unmanageable. Close patient follow-up, including renal function assessment and drug interactions review, is essential for bleeding risk minimization.
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Affiliation(s)
- Anne-Laure Sennesael
- 1Louvain Drug Research Institute, Clinical Pharmacy Research Group, Université catholique de Louvain, Brussels, Belgium.,3Namur Research Institute for LIfe Sciences, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, University of Namur, Namur, Belgium
| | - Anne-Sophie Larock
- 2CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, Université catholique de Louvain, Yvoir, Belgium
| | - Jonathan Douxfils
- 3Namur Research Institute for LIfe Sciences, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, University of Namur, Namur, Belgium
| | - Laure Elens
- 4Louvain Drug Research Institute, Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics, Université catholique de Louvain, Brussels, Belgium
| | - Gabriel Stillemans
- 4Louvain Drug Research Institute, Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics, Université catholique de Louvain, Brussels, Belgium
| | - Martin Wiesen
- 5Center of Pharmacology, Therapeutic Drug Monitoring Unit, University Hospital of Cologne, Cologne, Germany
| | - Max Taubert
- 6Center of Pharmacology, Clinical Pharmacology Unit, University Hospital of Cologne, Cologne, Germany
| | - Jean-Michel Dogné
- 3Namur Research Institute for LIfe Sciences, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, University of Namur, Namur, Belgium
| | - Anne Spinewine
- 1Louvain Drug Research Institute, Clinical Pharmacy Research Group, Université catholique de Louvain, Brussels, Belgium.,2CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, Université catholique de Louvain, Yvoir, Belgium
| | - François Mullier
- 7CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Hematology Laboratory, Université catholique de Louvain, Yvoir, Belgium
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Billoir P, Barbay V, Joly LM, Fresel M, Chrétien MH, Le Cam Duchez V. Anti-Xa Oral Anticoagulant Plasma Concentration Assay in Real Life: Rivaroxaban and Apixaban Quantification in Emergency With LMWH Calibrator. Ann Pharmacother 2018; 53:341-347. [PMID: 30378443 DOI: 10.1177/1060028018811657] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Oral anti-Xa inhibitors have demonstrated noninferiority to vitamin K antagonists (VKAs) for the prevention of stroke in patients with atrial fibrillation and recurrent venous thromboembolism. They are associated with a decrease in major bleeding. In contrast with VKA, no coagulation monitoring is required. However, in clinical practice, determination of drug concentration is sometimes necessary. OBJECTIVE The objective of this study was to evaluate a low-molecular-weight heparin (LMWH) calibrated anti-Xa assay for the quantification of rivaroxaban and apixaban plasma concentration in emergency. METHODS The anti-Xa plasma concentration of rivaroxaban and apixaban were measured in emergency in 210 patients using STA anti-Xa liquid assay. For each plasma concentration <150 ng/mL of rivaroxaban or apixaban, an anti-Xa assay calibrated with LMWH was performed. RESULTS We demonstrated a significant correlation between LMWH anti-Xa activity and rivaroxaban ( R2 = 0.947) or apixaban ( R2 = 0.959) concentration and a significant correlation between rivaroxaban and apixaban plasma concentration ( R2 = 0.972). A LMWH anti-Xa activity <0.50 IU/mL could exclude a plasma concentration of rivaroxaban and apixaban >30 ng/mL and indicate the feasibility of invasive procedure. Conclusion and Relevance: In the absence of a specific test, LMWH-calibrated anti-Xa assay could be used to determine the presence and evaluate the plasma concentration of oral anti-Xa inhibitors. However, these initial findings require confirmation using other chromogenic calibrated oral anti-Xa assays.
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Udayachalerm S, Rattanasiri S, Angkananard T, Attia J, Sansanayudh N, Thakkinstian A. The Reversal of Bleeding Caused by New Oral Anticoagulants (NOACs): A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2018; 24:117S-126S. [PMID: 30176738 PMCID: PMC6714855 DOI: 10.1177/1076029618796339] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
New oral anticoagulants (NOACs; ie, direct thrombin inhibitor [DTI] and factor Xa [FXa] inhibitors) were used as alternatives to warfarin. Specific antidotes (idarucizumab for dabigatran and andexanet alfa for FXa inhibitors) and hemostatic reversal agents were used for lowering bleeding, but their efficacies were still uncertain. The objectives of this study were to estimate and compare the efficacy of NOAC antidotes on bleeding reversal and death. Studies were identified from MEDLINE and Scopus databases until May 2018. Case reports/series and cohorts were selected if they assessed reversal or death rates. Data were independently extracted by 2 reviewers. Individual patient data and aggregated data of outcomes were extracted from case reports/series and cohorts. Binary regression was used to estimate outcome rates, risk ratio (RR) along with 95% confidence interval (CI). Interventions were NOACs and reversal agents (ie, DTI-specific, DTI-standard, FXa-specific, and FXa-standard). Among 220 patients of 93 case reports/series, reversal rates were 95.9%, 77.6%, and 71.5% for DTI-specific, FXa-standard, and DTI-standard. Pooled RRs for DTI-specific and FXa-standard versus DTI-standard, respectively, were 1.34 (CI: 1.13-1.60) and 1.09 (CI: 0.84-1.40). Death rate was 0.18 (CI: 0.06-0.57) times lower in DTI-specific versus DTI-standard. For pooling 10 subcohorts, pooled RRs were 1.08 (CI: 1.00-1.16), 1.29 (CI: 1.20-1.39), and 1.13 (CI: 1.01-1.25) for DTI-specific, FXa-specific, and FXa-standard versus DTI-standard. In conclusion, specific reversal agents might be useful for reversal of bleeding and lowering the risk of death than standard reversal agents. Our findings were based on case reports/series and selected cohorts, further comparative studies are thus needed.
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Affiliation(s)
- Sariya Udayachalerm
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sasivimol Rattanasiri
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Teeranan Angkananard
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Division of Cardiology, Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand
| | - John Attia
- Centre for Clinical Epidemiology and Biostatistics, Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, New South Wales, Australia
| | - Nakarin Sansanayudh
- Cardiology Unit, Department of Internal Medicine, Phramongkutklao Hospital, Bangkok, Thailand
| | - Ammarin Thakkinstian
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Abstract
Widespread use of anticoagulant drugs for treatment and -prevention of thromboembolic events means it is common to encounter patients requiring reversal of anticoagulation for management of bleeding or invasive procedures. While supportive and general measures apply for patients on all agents, recent diversification in the number of licensed agents makes an understanding of drug-specific reversal strategies essential. Recognising effects upon, and limitations of, laboratory measures of coagulation also plays an important role. An understanding of reversal strategies alone is insufficient to competently care for patients who may require anticoagulation reversal. It is also necessary to reduce the need for reversal through correct prescribing and by employing appropriate periprocedural bridging strategies for elective and semi-elective procedures. Finally, consideration of whether and when to reintroduce an anticoagulant drug following reversal is important not only to balance bleeding and thrombotic risks for individual patients but also for timely management of discharge.
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Affiliation(s)
- Sally Thomas
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, UK
- Department of Haematology, Royal Hallamshire Hospital, Sheffield, UK
| | - Michael Makris
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
- Department of Haematology, Royal Hallamshire Hospital, Sheffield, UK
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36
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Collet JP, Berti S, Cequier A, Van Belle E, Lefevre T, Leprince P, Neumann FJ, Vicaut E, Montalescot G. Oral anti-Xa anticoagulation after trans-aortic valve implantation for aortic stenosis: The randomized ATLANTIS trial. Am Heart J 2018; 200:44-50. [PMID: 29898848 DOI: 10.1016/j.ahj.2018.03.008] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 03/03/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Antithrombotic treatment regimen following transcatheter aortic valve replacement (TAVR) is not evidence-based. Apixaban, a non-vitamin K direct anticoagulant (NOAC) was shown to be superior to VKA and superior to aspirin to prevent cardioembolic stroke in non-valvular atrial fibrillation. It may have the potential to reduce TAVR-related thrombotic complications including subclinical valve thrombosis along with a better safety than the standard of care. DESIGN ATLANTIS is a multicenter, randomized, phase IIIb, prospective, open-label, superiority study comparing standard of care (SOC Group) versus an apixaban-based strategy (Anti-Xa Group) after successful TAVR (ClinicalTrials.gov NCT 02664649). Randomization is stratified according to the need for chronic anticoagulation therapy for a reason other than the TAVR procedure. In the experimental arm, patients receive 5 mg bid of apixaban or a reduced dose of 2.5 mg bid according to the drug label or when apixaban is combined with antiplatelet therapy. In the control arm, patients receive VKA therapy if there is an indication for oral anticoagulation or antiplatelet therapy alone (single or dual) or the combination of both if needed. The primary study end point is the composite of all-cause death, TIA/stroke, myocardial infarction, symptomatic valve thrombosis, pulmonary embolism, deep venous thrombosis, systemic embolism, life-threatening, disabling or major bleeding, according to the Valve Academic Research Consortium definitions. CONCLUSIONS ATLANTIS tests the superiority of an apixaban-based strategy versus the recommended standard of care strategy to reduce the risk of post-TAVR thromboembolic and bleeding complications in an all comer population.
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Laroche JP, Becker F, Schved JF. [Direct oral anticoagulants (DOACS): A necessary focus]. JOURNAL DE MEDECINE VASCULAIRE 2018; 43:198-205. [PMID: 29754730 DOI: 10.1016/j.jdmv.2018.02.005] [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: 12/29/2017] [Accepted: 02/24/2018] [Indexed: 06/08/2023]
Abstract
In 2008, we decided to enter the era of direct oral anticoagulants (DOACS). Was that the right decision to make? The answer will depend on how well we meet the conditions of proper use. This means avoiding underdosing and overdosing as well as understanding how DOACS were validated so that our prescriptions fulfill their role in the management of thrombotic disease.
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Affiliation(s)
- J P Laroche
- Service de médecine vasculaire, hôpital Saint-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France; Médecine vasculaire, médipôle, 1139, chemin du Lavarin, 84000 Avignon, France.
| | - F Becker
- Médecin vasculaire, 40, chemin des Favrands, 74400 Chamonix-Mont-Blanc, France
| | - J F Schved
- Département d'hématologie biologique, hôpital Saint-Éloi, CHU de Montpellier, 80, avenue Augustin-Fliche, 34295 Montpellier cedex 5, France
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Salazar Adum JP, Golemi I, Paz LH, Diaz Quintero L, Tafur AJ, Caprini JA. Venous thromboembolism controversies. Dis Mon 2018; 64:408-444. [PMID: 29631864 DOI: 10.1016/j.disamonth.2018.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
| | - Iva Golemi
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Luis H Paz
- Department of Medicine, John H. Stroger Jr. Hospital of Cook County, Chicago, IL
| | - Luis Diaz Quintero
- Department of Medicine, NorthShore University HealthSystem, Evanston, IL
| | - Alfonso J Tafur
- Cardiovascular Section, NorthShore University HealthSystem, 2650 Ridge Ave, Evanston, IL 60201.
| | - Joseph A Caprini
- The University of Chicago Pritzker School of Medicine, Chicago, IL
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39
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Management of the Trauma Patient on Direct Oral
Anticoagulants. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0253-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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40
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Solbeck S, Jensen AS, Maschmann C, Stensballe J, Ostrowski SR, Johansson PI. The anticoagulant effect of therapeutic levels of dabigatran in atrial fibrillation evaluated by thrombelastography (TEG ®), Hemoclot Thrombin Inhibitor (HTI) assay and Ecarin Clotting Time (ECT). Scandinavian Journal of Clinical and Laboratory Investigation 2018; 78:25-30. [PMID: 29304563 DOI: 10.1080/00365513.2017.1408138] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Monitoring the effect of dabigatran (Pradaxa®) is challenging. The aim of this study was to evaluate if thrombelastography reaction time (TEG® R) could detect the anticoagulant effect of dabigatran showing a correlation between TEG® R, Hemoclot Thrombin Inhibitor (HTI) assay and Ecarin Clotting Time (ECT) in patients with non-valvular atrial fibrillation (NVAF). Blood samples from 35 AF patients receiving either 110 mg (n 19) or 150 mg (n 16) dabigatran twice daily were analyzed with TEG®, HTI and ECT 2-3 h after dabigatran intake. All patients had prolonged TEG® R. The patients receiving dabigatran 110 mg ×2 had a TEG® R mean 14.2 min (range 9.1-25), a mean dabigatran concentration measured by HTI of 268.5 ng/mL (range 54-837 ng/mL) and by ECT of 355.7 ng/mL (range 40-1020 ng/mL). The corresponding numbers for patients receiving dabigatran 150 mg ×2 were TEG® R mean of 12.5 min (range 9.2-23.2 min), mean dabigatran concentration of 179.2 ng/mL by HTI (range 26-687 ng/mL) and by ECT 225.1 ng/mL (range 42-1020 ng/mL). The two dosage groups had comparable anticoagulation demonstrated by equally prolonged TEG® R (p = .909), HTI (p = .707) and ECT (p = .567). No difference in creatinine levels in the two dosage groups was observed (p = .204) though patients with dabigatran concentration >400 ng/mL had significantly higher creatinine levels (p = .001). Large individual variation of the anticoagulant response was observed. Some patients had TEG® R values up to three times upper normal limit with immediate risk of bleeding. Our data indicate that TEG® R reflected dabigatran levels in NVAF patients and that TEG® R correlated to HTI and ECT.
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Affiliation(s)
- Sacha Solbeck
- a Section for Transfusion Medicine, Capital Region Blood Bank , Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark
| | | | - Christian Maschmann
- c Emergency Department & Department of Anesthesia and Intensive Care , Copenhagen University Hospital Bispebjerg , Copenhagen , Denmark
| | - Jakob Stensballe
- a Section for Transfusion Medicine, Capital Region Blood Bank , Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark.,d Department of Anaesthesiology, Centre of Head and Orthopaedics , Copenhagen University Hospital, Rigshospitalet , Copenhagen , Denmark
| | - Sisse Rye Ostrowski
- a Section for Transfusion Medicine, Capital Region Blood Bank , Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark
| | - Pär I Johansson
- a Section for Transfusion Medicine, Capital Region Blood Bank , Rigshospitalet, Copenhagen University Hospital , Copenhagen , Denmark.,e Department of Surgery , University of Texas Health Medical School , Houston , TX , USA
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41
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Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition). Reg Anesth Pain Med 2017; 43:225-262. [DOI: 10.1097/aap.0000000000000700] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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