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Wang L, Luo Z, Yang L, Li W. The Effectiveness and Safety of Rivaroxaban and Edoxaban in the Treatment of Lower Extremity Deep Vein Thrombosis. Ann Vasc Surg 2024; 108:246-256. [PMID: 38960092 DOI: 10.1016/j.avsg.2024.04.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/11/2024] [Accepted: 04/08/2024] [Indexed: 07/05/2024]
Abstract
INTRODUCTION Deep vein thrombosis (DVT) is a medical condition characterized by forming a blood clot, or thrombus, in one of the deep veins, typically in the legs. It is a type of venous thromboembolism, which refers to the formation of blood clots in the veins. It is caused by Virchow's triad (stasis, hypercoagulation, and endothelial injury). OBJECTIVE Our main objective is to explore the effectiveness and safety of rivaroxaban and edoxaban in treating lower extremity DVT. METHODS We conducted a retrospective study involving 406 patients subjected to DVT treatment using direct oral anticoagulants (edoxaban and rivaroxaban) at our hospital. We recruited adult patients (aged 18 years and more) diagnosed with lower extremity DVT and received treatment with either rivaroxaban or edoxaban as the primary anticoagulant therapy for DVT. We excluded patients who received treatment with other anticoagulant medications (warfarin and heparin) as the primary therapy for DVT. RESULTS The groups showed statistically significant differences in red blood cell count and hemoglobin levels, with the edoxaban group having high values. However, the 2 groups observed no statistically significant differences in creatinine clearance, white blood cell count, platelet count, C-reactive protein, and D-dimer levels. The difference in the incidence of pulmonary embolism between the 2 groups was statistically significant (P value < 0.001). The edoxaban group had fewer pulmonary embolism patients than the rivaroxaban group. The reduction in recurrent thrombosis was significantly higher in the rivaroxaban group compared to the edoxaban group. There were no significant differences in the major bleeding at various sites across the 2 treatment groups (P > 0.05). CONCLUSIONS Rivaroxaban's pharmacokinetic profile includes rapid absorption and a relatively short half-life. It means that once administered, rivaroxaban quickly reaches its peak concentration in the blood and is subsequently eliminated from the body within a relatively short period. Edoxaban's pharmacokinetic profile may include slower absorption and a longer half-life than rivaroxaban. It can result in a slower rate of achieving peak concentration and a more prolonged presence in the bloodstream. These results emphasize the need for careful consideration of anticoagulant therapy in patients with underlying cancer and underscore the importance of managing risks while providing adequate anticoagulation to prevent thrombotic events.
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Affiliation(s)
- Liang Wang
- Department of Interventional Vascular Surgery, Chengdu First People's Hospital, Chengdu, Sichuan.
| | - Zeen Luo
- Department of Interventional Vascular Surgery, Chengdu First People's Hospital, Chengdu, Sichuan
| | - Long Yang
- Department of Interventional Vascular Surgery, Chengdu First People's Hospital, Chengdu, Sichuan
| | - Weiye Li
- Department of Interventional Vascular Surgery, Chengdu First People's Hospital, Chengdu, Sichuan
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Zhen S, Chu F, Kodesh A, Kim J. Ischaemic stroke in a patient with non-valvular atrial fibrillation (NVAF) despite non-vitamin K oral anticoagulant (NOAC) therapy. BMJ Case Rep 2024; 17:e258761. [PMID: 38199668 PMCID: PMC10806926 DOI: 10.1136/bcr-2023-258761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Abstract
Primary stroke prevention in non-valvular atrial fibrillation (NVAF) is primarily with non-vitamin K oral anticoagulant (NOAC) therapy. However, 20-36% of ischaemic strokes seem to occur in patients with atrial fibrillation while already on anticoagulation. We present a case of an ischaemic stroke in an elderly female in her 70s with medical history significant for hypertension and NVAF. She had a CHA2DS2-VASc score of 3 and was on apixaban for thromboprophylaxis. She presented with neurological deficits consistent with a left middle cerebral artery stroke, confirmed via head imaging; the most likely stroke aetiology was determined to be cardioembolic in the setting of NVAF. She was treated with continuation of her apixaban at the same dosage She displayed improved function, although with residual expressive aphasia at her 2-month neurology follow-up. Cardioembolic ischaemic stroke in NVAF despite current NOAC therapy does not have current management guidelines.
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Affiliation(s)
- Simon Zhen
- Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Fion Chu
- Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Afek Kodesh
- Internal Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Jisoon Kim
- Internal Medicine, Montefiore Medical Center, Bronx, New York, USA
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Gennaro N, Ferroni E, Zorzi M, Denas G, Pengo V. ISCHEMIC STROKE AND MAJOR BLEEDING WHILE ON DIRECT ORAL ANTICOAGULANTS IN NAÏVE PATIENTS WITH ATRIAL FIBRILLATION: IMPACT OF RESUMPTION OR DISCONTINUATION OF ANTICOAGULANT TREATMENT. A population-based study. Int J Cardiol 2024; 394:131369. [PMID: 37722453 DOI: 10.1016/j.ijcard.2023.131369] [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: 04/12/2023] [Revised: 09/05/2023] [Accepted: 09/15/2023] [Indexed: 09/20/2023]
Abstract
AIMS We assessed the cumulative incidence of recurrent stroke, major bleeding and all-cause mortality associated with restarting antithrombotic treatment, in patients experiencing an anticoagulation-related event (stroke or major bleeding), occurred during anticoagulation therapy for AF. METHODS AND RESULTS We performed a retrospective population-based analysis on linked claims data of patients resident in the Veneto Region, treated with DOACs for AF and discharged (2013-2020) from the hospital for stroke, intracranial haemorrhage (ICH), and major bleeding. To adjust for competing risk of death and reduce confounding, we started the follow up after a 120-days blanking period, counting events in patients resuming oral anticoagulation versus those that did not. Risks of all-cause mortality, ischemic stroke (IS)intracranial haemorrhage (ICH), and other major bleeding events (MB) were estimated with multivariable Cox proportional hazard models and propensity score to adjust for differences in baseline characteristics. Overall, 1029 patients (mean age 77 years) were included in the final cohort: 23% experienced an IS, 18% an ICH, and 59% MB. Of these, 77% resumed anticoagulation. The cumulative incidence of events was significantly lower in patients resuming therapy. In the multivariable analysis considering age, sex and propensity score as covariates, resumption of anticoagulation significantly reduced the risk of a cumulative event (HR 0.45, 95%CI 0.35-0.57, p < 0.01). Stratifying for the index event, among patients with IS (92% resumed therapy), we observed a risk reduction of 81%; in patients with ICH (64% resumed therapy), we observed a risk reduction of 64% and for patients with MB (76% resuming therapy), we observed a risk reduction of 49%. CONCLUSIONS In patients with AF who experienced an anticoagulation-related event, resuming oral anticoagulation was associated with better outcomes for all-cause mortality and subsequent events as compared with patients who did not resume treatment.
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Affiliation(s)
- N Gennaro
- Epidemiological Department (SER), Azienda Zero of theVeneto Region. Padua. Italy
| | - E Ferroni
- Epidemiological Department (SER), Azienda Zero of theVeneto Region. Padua. Italy
| | - M Zorzi
- Epidemiological Department (SER), Azienda Zero of theVeneto Region. Padua. Italy
| | - G Denas
- Cardiology Clinic, Department of Cardiac. Thoracic, Vascular Sciences and Public Health. Padua University Hospital. Padua. Italy
| | - V Pengo
- Cardiology Clinic, Department of Cardiac. Thoracic, Vascular Sciences and Public Health. Padua University Hospital. Padua. Italy; Arianna Foundation on Anticoagulation. Bologna, Italy.
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4
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Duong E, Lin M, Hodgson M, Jickling G, George-Phillips K, Bungard TJ. Choice of Oral Anticoagulant: Outcomes in Atrial Fibrillation Patients Post-Stroke Despite Direct Oral Anticoagulant Use. CJC Open 2023; 5:603-610. [PMID: 37720181 PMCID: PMC10502439 DOI: 10.1016/j.cjco.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 05/03/2023] [Indexed: 09/19/2023] Open
Abstract
Background For patients with atrial fibrillation who have an ischemic stroke or transient ischemic attack (TIA) despite taking direct oral anticoagulants (DOACs), the optimal strategy for ongoing anticoagulation is unknown. Methods Using provincial administrative databases in Alberta, Canada, we compared anticoagulant use before/after the breakthrough stroke/TIA and assessed recurrence of stroke/TIA or bleeding, with consideration of medication adherence. Adherence was defined as the proportion of days covered (PDC) being ≥ 80%. Results Among 985 patients, the median age was 80 years (interquartile range 13), with a mean CHADS2 score of 1.7± 1 prior to the index event. Patients were followed for a median of 643 days (interquartile range 836). Following the index stroke/TIA event, 623 patients (63%) filled a prescription for the same DOAC regimen, 83 (8%) filled a prescription for a different dose, 155 (16%) switched DOAC agents, 51 (5%) switched to warfarin, and 73 (7%) filled no oral anticoagulant prescription. Patients who kept the same regimen more commonly had TIA index events (59%); patients who changed dose or drug more often had stroke index events (55%-78%). During follow-up, 135 (14%) had stroke/TIA recurrence, and 46 (5%) had bleeding; rates of each did not differ between prescribing patterns. Post-index event, the proportion of patients with a proportion of days covered ≥ 80% improved from 55% to 80%. Conclusions Although most maintained the same DOAC regimen after stroke/TIA, rates of recurrent stroke/TIA and bleeding were similar across prescribing patterns. Stroke/TIA severity may have influenced prescribing practices. DOAC prescription adherence improved poststroke/TIA and signals an opportunity for optimization in patients with atrial fibrillation.
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Affiliation(s)
- Eric Duong
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Mu Lin
- Data and Research Services, Alberta Strategy for Patient-Oriented Research Support Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Mathew Hodgson
- Pharmacy Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Glen Jickling
- Division of Neurology, Faculty of Medicine & Dentistry, Stroke Program, University of Alberta, Edmonton, Alberta, Canada
| | | | - Tammy J. Bungard
- Division of Cardiology, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
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5
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Jethwa TE, Moran KM, Maniaci MJ. Medication non-adherence as a cause of apixaban failure in venous thromboembolism: The importance of pharmacist medication reconciliation. Clin Case Rep 2022; 10:e05338. [PMID: 35140953 PMCID: PMC8811178 DOI: 10.1002/ccr3.5338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/05/2022] [Accepted: 01/17/2022] [Indexed: 11/09/2022] Open
Abstract
Venous thromboembolism is often treated with direct oral anticoagulants. In order for direct oral anticoagulants to be effective, patients must adhere to a specific dosing strategy. We report a case of apixaban failure, the clinical workup that ensued, and the eventual discovery of unsuccessful medication adherence as the cause.
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Affiliation(s)
- Trisha E Jethwa
- Department of Family MedicineMayo Clinic in FloridaJacksonvilleFloridaUSA
| | - Kaitlin M Moran
- Department of Internal MedicineMayo Clinic in FloridaJacksonvilleFloridaUSA
| | - Michael J Maniaci
- Department of Internal MedicineMayo Clinic in FloridaJacksonvilleFloridaUSA
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6
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Haraguchi Y, Nakamura K, Inoue M, Sasaki T, Minami K, Yoshimura S, Naito S. Antiphospholipid Syndrome Diagnosed as a Result of the Occurrence of an Ischemic Stroke After a Successful Catheter Ablation of Atrial Fibrillation and Continuous Direct Oral Anticoagulants. Int Heart J 2022; 63:153-158. [DOI: 10.1536/ihj.21-475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
| | - Kohki Nakamura
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Mitsuho Inoue
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Takehito Sasaki
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | - Kentaro Minami
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
| | | | - Shigeto Naito
- Division of Cardiology, Gunma Prefectural Cardiovascular Center
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7
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Aziz AA, Christmas D. Acute Mesenteric Ischemia in a Chronically Anticoagulated Patient With Atrial Fibrillation: Anticoagulation Reversal, Management and Preventing Recurrence. Cureus 2022; 14:e21642. [PMID: 35233319 PMCID: PMC8881081 DOI: 10.7759/cureus.21642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2022] [Indexed: 11/05/2022] Open
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Aplin M, Andersen A, Brandes A, Dominguez H, Dahl JS, Damgaard D, Iversen HK, Iversen KK, Nielsen E, Risum N, Schmidt MR, Andersen NH. Assessment of patients with a suspected cardioembolic ischemic stroke. A national consensus statement. SCAND CARDIOVASC J 2021; 55:315-325. [PMID: 34470566 DOI: 10.1080/14017431.2021.1973085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Several cardiovascular, structural, and functional abnormalities have been considered as potential causes of cardioembolic ischemic strokes. Beyond atrial fibrillation, other sources of embolism clearly exist and may warrant urgent action, but they are only a minor part of the many stroke mechanisms and strokes that seem to be of embolic origin remain without a determined source. The associations between stroke and findings like atrial fibrillation, valve calcification, or heart failure are confounded by co-existing risk factors for atherosclerosis and vascular disease. In addition, a patent foramen ovale which is a common abnormality in the general population is mostly an innocent bystander in patients with ischemic stroke. For these reasons, experts from the national Danish societies of cardiology, neurology, stroke, and neuroradiology sought to develop a consensus document to provide national recommendations on how to manage patients with a suspected cardioembolic stroke. Design: Comprehensive literature search and analyses were done by a panel of experts and presented at a consensus meeting. Evidence supporting each subject was vetted by open discussion and statements were adjusted thereafter. Results: The most common sources of embolic stroke were identified, and the statement provides advise on how neurologist can identify cases that need referral, and what is expected by the cardiologist. Conclusions: A primary neurological and neuroradiological assessment is mandatory and neurovascular specialists should manage the initiation of secondary prophylactic treatment. If a cardioembolic stroke is suspected, a dedicated cardiologist experienced in the management of cardioembolism should provide a tailored clinical and echocardiographic assessment.
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Affiliation(s)
- Mark Aplin
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Axel Brandes
- Department of Cardiology, Odense University Hospital, Odense, Denmark.,Department of Internal Medicine - Cardiology, University Hospital of Southern Denmark - Esbjerg, Esbjerg, Denmark
| | - Helena Dominguez
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Jordi S Dahl
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Dorte Damgaard
- Department of Neurology, Aarhus University Hospital, Aarhus N, Denmark
| | - Helle K Iversen
- Department of Neurology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kasper K Iversen
- Department of Cardiology, Herlev-Gentofte Hospital, Herlev, Denmark
| | - Edith Nielsen
- Department of Neuroradiology, Aarhus University Hospital, Aarhus N, Denmark
| | - Niels Risum
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Michael R Schmidt
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Niels H Andersen
- Department of Cardiology, Odense University Hospital, Odense, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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Arena AW, Hussein A, Kurkowski EJ, Kulkarni ML. Can't Dissolve Me Now: A COVID-19 Provoked Venous Thromboembolism Breaks Through Apixaban: Case Report. Clin Pract Cases Emerg Med 2021; 5:202-205. [PMID: 34437005 PMCID: PMC8143841 DOI: 10.5811/cpcem.2021.3.50505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/05/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Coronavirus disease 2019 (COVID-19) is a multisystem process with a growing evidence of its endotheliopathy effects, with subsequent hypercoagulability states. CASE REPORT WWe present an emergency department case of a COVID-19-provoked deep venous thrombosis and pulmonary embolism without a history of venous thromboembolism (VTE), with extension of the VTE despite adherence to apixaban. CONCLUSION This case demonstrates the importance of further research and protocols for optimal dosage and treatment to prevent worsening VTE in COVID-19 patients.
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Affiliation(s)
- Alexander W Arena
- St. John's Riverside Hospital, Department of Emergency Medicine, Yonkers, New York
| | - Ahmad Hussein
- St. John's Riverside Hospital, Department of Emergency Medicine, Yonkers, New York
| | - Ellen J Kurkowski
- St. John's Riverside Hospital, Department of Emergency Medicine, Yonkers, New York
| | - Miriam L Kulkarni
- St. John's Riverside Hospital, Department of Emergency Medicine, Yonkers, New York
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10
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Mazahreh F, Habash F, López-Candales A. Venous Thromboembolism While on Anticoagulation With Apixaban. Cureus 2021; 13:e15189. [PMID: 34178510 PMCID: PMC8218250 DOI: 10.7759/cureus.15189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2021] [Indexed: 12/04/2022] Open
Abstract
Venous thromboembolism (VTE) is a common condition whose pathophysiology is explained by Virchow's triad with stasis, hypercoagulability, and endothelial injury. Direct oral anticoagulants (DOACs) showed non-inferiority when compared with conventional treatment using subcutaneous low molecular weight heparin (LMWH) and warfarin, but treatment failure is a concern and remains a challenge for physicians. In our case report, we present a patient who had VTE in the form of a saddle pulmonary embolus while on apixaban.
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Affiliation(s)
- Farah Mazahreh
- Cardiology, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Fuad Habash
- Cardiology, University of Arkansas for Medical Sciences, Little Rock, USA
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11
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Mahawish KM, Leung A. Failure of dabigatran following idarucizumab and omeprazole administration. Intern Med J 2021; 51:134-135. [PMID: 33572021 DOI: 10.1111/imj.15159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Revised: 03/19/2020] [Accepted: 03/22/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Karim M Mahawish
- Department of Internal Medicine, MidCentral DHB, Palmerston North, New Zealand
| | - Almond Leung
- Department of Internal Medicine, MidCentral DHB, Palmerston North, New Zealand
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12
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Barcellona D, Marongiu F. Thrombosis centres and AVKs monitoring in COVID-19 pandemic. Intern Emerg Med 2020; 15:1365-1368. [PMID: 32686059 PMCID: PMC7369471 DOI: 10.1007/s11739-020-02439-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 07/08/2020] [Indexed: 12/21/2022]
Abstract
Vitamin K-Antagonists (VKAs) are the treatment of choice in patients with indications other than atrial fibrillation and venous thromboembolism. Moreover, some patients still assume VKAs refusing to change their therapy when direct oral anticoagulants (DOACs) are properly indicated. The COVID-19 pandemic has completely changed our lives, nullifying inter-personal relationships to avoid contagion, making difficult the VKAs monitoring. We describe the re-organization of our thrombosis centre (TC) as an example on how to face the emergency due to the COVID-19 pandemic. In the first phase, to avoid overcrowding at the TC, we planned to increase the interval time between INRs checks and to encourage blood sampling at home, especially for elderly patients. Moreover, precise scheduled blood sampling was also organized while telephone and email counselling were guaranteed by two doctors of the TC. In the second phase, to reduce the number of patients who daily attended our TC a switch from VKAs to DOACs was carried out, if no contraindications were identified. In the third phase, to protect patients, healthcare staff and hospital from COVID-19 widespread, telemedicine was strengthened. We tried to extend self-testing at home by means of portable coagulometers to as more patients as possible. To avoid patients staying or coming back to the TC an ad hoc web platform for sending the therapeutic dose adjustment and the next scheduled appointment was developed. The TC re-organization allowed us to monitor anticoagulated patients respecting personal isolation and security measures to avoid possible COVID-19 contagion.
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Affiliation(s)
- Doris Barcellona
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy.
- SHRO, Temple University, Philadelphia, PA, USA.
| | - Francesco Marongiu
- Department of Medical Science and Public Health, University of Cagliari, Cagliari, Italy
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13
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Dreucean D, Nguyen SN, Donahue KR, Salazar E, Ruegger MC. Evaluation of characteristics and dosing regimens in patients with new or recurrent thrombosis on apixaban and rivaroxaban. J Thromb Thrombolysis 2020; 52:161-169. [PMID: 33099722 DOI: 10.1007/s11239-020-02308-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2020] [Indexed: 11/30/2022]
Abstract
Direct factor Xa inhibitors, such as apixaban and rivaroxaban, are widely used for treatment and prevention of venous thromboembolism; however, recent cases of therapeutic failure have been reported. Potential risk factors associated with therapeutic failure such as dose deviations outside of package labeling recommendations, and the use of direct factor Xa-specific inhibitor levels to guide clinical decision making continue to be areas of further investigation. Our study aimed to describe characteristics and dosing regimens in patients on apixaban or rivaroxaban who experienced a new or recurrent thrombosis. We performed a retrospective chart review on 190 patients on either apixaban or rivaroxaban presenting to our institution with new or breakthrough thromboembolism. Evaluation of prescribed anticoagulation regimens compared to package labeling recommendations, direct factor Xa inhibitor-specific anti-Xa levels, anticoagulation interruptions, use of parenteral bridge anticoagulation, final anticoagulation regimen disposition, and thrombosis-associated mortality were recorded. In patients presenting with breakthrough thromboembolism, 78% were on a regimen that matched package labeling recommendations. Anti-Xa levels were documented in 66 patients, the majority of which fell within institutional expected ranges at time of thrombosis. Therapy interruptions immediately prior to thrombosis were observed in 22% of patients and 21% of those patients received parenteral anticoagulation during interruption. Upon discharge, 46% of patients continued the same anticoagulation regimen with no changes. The mortality rate was 6%. In patients who present with new thromboembolism on apixaban or rivaroxaban, a thorough review of risks and benefits should be conducted to mitigate future risk of recurrent thrombosis.
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Affiliation(s)
- Diane Dreucean
- Department of Pharmacy - Houston Methodist Hospital, 6565 Fannin St. DB1-09, Houston, TX, 77030, USA.
| | - Steffany N Nguyen
- Department of Pharmacy - Houston Methodist Hospital, 6565 Fannin St. DB1-09, Houston, TX, 77030, USA
| | - Kevin R Donahue
- Department of Pharmacy - Houston Methodist Hospital, 6565 Fannin St. DB1-09, Houston, TX, 77030, USA
| | - Eric Salazar
- Department of Pathology and Genomic Medicine - Houston Methodist Hospital, 6565 Fannin St, Houston, TX, 77030, USA
| | - Melanie C Ruegger
- Department of Pharmacy - Houston Methodist Hospital, 6565 Fannin St. DB1-09, Houston, TX, 77030, USA
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