Two Cases of Acute Direct Oral Anticoagulant Overdose Without Adverse Effect

Management of Patients Receiving Anticoagulation Therapy in Dental Practice: A Systematic Review

BACKGROUND

Anticoagulant drugs are a valuable tool for minimizing thrombotic risks in at-risk patients. The purpose of this study is to conduct a literature review highlighting the management of these drugs during daily clinical dental practice.

MATERIALS AND METHODS

We limited our search to English-language papers published between 1 January 1989, and 7 March 2024, in PubMed, Scopus and Web of Science that were relevant to our topic. In the search approach, the Boolean keywords "anticoagulant AND dentistry" were used.

RESULTS

Twenty-five clinical trials were included for final review from 623 articles obtained from the databases Web of Science (83), PubMed (382), and Scopus (158), eliminating duplicates and 79 off-topic items, resulting in 419 articles after removing 315 entries and confirming eligibility. Overall, these studies support the use of local hemostatic measures to manage the risk of bleeding in patients on anticoagulant therapy undergoing dental procedures and highlight the importance of greater education and collaboration among healthcare professionals.

CONCLUSIONS

Research and clinical investigation have improved understanding and management of dental procedures in patients undergoing anticoagulant or antiplatelet therapy. Hemostatic agents, clinical protocols, risk factors, and continuous education are essential for navigating the complexities of anticoagulant therapy, ensuring optimal outcomes and enhancing patient well-being.

Massive Apixaban Overdose Confirmed with Blood Concentrations and Managed Without Bleeding: A Single Case Report

Background: Acute overdoses of apixaban, and other direct oral anticoagulants are relatively uncommon. The number of direct oral anticoagulants prescriptions in the United States is increasing, however reports on patient outcomes after documented overdose are sparse. Case report: A 76-year-old man with a past medical history of atrial fibrillation and taking apixaban 5 mg twice daily presented to the emergency department 10 hours after reportedly ingesting 60-70 of his pills. He was alert and had a normal physical examination. Blood tests demonstrated an INR of 12, platelets of 161 000 cells/mm3, hemoglobin 9.7 g/dL, and creatinine 1.81 mg/dL. He received 60 g of activated charcoal and 4 units of fresh frozen plasma prophylactically. Initial blood apixaban concentration was 4 000 ng/mL. Repeat blood apixaban concentrations were 3 000 ng/mL and 2 200 ng/mL at 7 and 14 hours, respectively (thrapeutic range 91-321 ng/mL for a 5 mg twice daily dose). The hybrid anti-factor Xa activity did not correlate with blood apixaban concentrations. Apixaban elimination followed first-order kinetics with an apparent elimination half-life of 14 hours in the presence of impaired renal function. He did not have any minor or major bleeding events.

Apixaban overdose in children: case report and proposed management. A brief communication from the Pediatric and Neonatal Thrombosis and Hemostasis SSC of ISTH

Background

Direct oral anticoagulants are commonly prescribed for adults and increasingly also for children requiring anticoagulation therapy. While household medications should not be accessible to children, accidental, and intentional overdoses occur.

Key Clinical Question

How should apixaban overdose in children be managed?.

Clinical Approach

We present a case of an accidental overdose with the factor Xa antagonist apixaban in a young child and propose an approach to the management of cases of apixaban overdose in children.

Conclusion

Given the increasing use of direct oral anticoagulants, it is important to have an approach to the management of overdose of these medications.

Direct oral anticoagulants toxicity in children: an overview and practical guide

INTRODUCTION

By increasing use of direct oral anticoagulants (DOACs) in adults and children, gradual increase in the number of intentional or unintentional DOAC poisonings among children is suspected in the near future. Hence, clinicians and pharmacists need to be familiar with the clinical features and management of DOAC-toxicity among pediatric population.

AREAS COVERED

This article provides an overview and practical guide to DOAC-toxicity in pediatrics according to the available clinical evidence.

EXPERT OPINION

Based on limited available data, accidental pediatric ingestion of DOACs can be managed by supportive care in most cases. However, serious toxicity may occur following massive overdose, in presence of underlying disorders (renal or hepatic dysfunction) and concurrent anticoagulant therapy. Activated charcoal is recommended for known recent ingestion of DOACs (within 2-4 hours) to reduce the gastrointestinal absorption. Supportive interventions including local hemostatic measures and volume resuscitation are the cornerstone of management of bleeding. Vitamin K and fresh frozen plasma are ineffective for DOAC reversal and thus are not recommended. Currently, safety and efficacy data regarding the use of specific reversal agents (including idarucizumab and andexanet alfa) and 3-factor or 4-factor prothrombin complex concentrate (PCC) or activated PCC (aPCC) among children with DOAC-associated bleeding are lacking.