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Hassanzadeh TE, Hohmann C, Culmsee C. Impact of a DSS-supported medication review on the safety of drug therapy and quality of life in patients with antithrombotic therapy. Front Pharmacol 2024; 15:1194201. [PMID: 38846096 PMCID: PMC11153675 DOI: 10.3389/fphar.2024.1194201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 04/17/2024] [Indexed: 06/09/2024] Open
Abstract
Polypharmacy is common among patients with antithrombotic medication, giving rise to concerns about Drug-Related Problems (DRPs). Therefore, these patients would benefit from a Medication Review (MR) along with pharmacist counselling to reduce the risks accompanying polymedication. This prospective study presents a concept for MRs that are applicable in German community pharmacies and can efficiently support pharmacist counselling and improve the safety of drug therapy. As this is a major challenge in everyday pharmacy practice, we used a Decision Support System (DSS) to evaluate its ability to support the process of pharmacist-led MRs. The primary endpoint was the impact of a community pharmacist on the reduction of DRPs. We investigated the impact of the interventions resulting from MRs on patients taking at least one antithrombotic drug as part of their polymedication regimen. Secondary endpoints were the reduction in the number of patients with bleeding risks and the improvement of patients' Quality of Life (QoL) and therapy adherence. Furthermore, the DSS used in the study was controlled for correct data assessment and plausibility of data. We selected adult patients who were taking no less than three different medications for long-term treatment, at least one of which had to be an antithrombotic drug, and who were customers in one of eight selected pharmacies over a period of 6 months. Data from 87 patients were analyzed with DSS-support. A total of 234 DRPs were identified by the pharmacist (2.7 DRPs per patient). MR reduced DRPs by 43.2% which, resulting to a reduction of 1.2 DRPs per patient. The intervention also led to a significant improvement in the patients' QoL (assessed via EQ-5D-5L questionnaire; p < 0.001) and enhanced therapy adherence (assessed via A14 questionnaire; p < 0.001). The control of correct data assessment (with 93.8% concordance) and plausibility of data (with 91.7% concordance) of the DSS software were conducted by an external auditor. No significant effect was found for overall bleeding risk. The results of this study indicate that DSS-supported and structured MR conducted by pharmacists can contribute to a reduction in DRPs and significantly improve patient's QoL and adherence to treatment.
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Affiliation(s)
- Tanja Elnaz Hassanzadeh
- Pharma4u GmbH, Munich, Germany
- Institute for Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, University of Marburg, Marburg, Germany
| | - Carina Hohmann
- Department of Pharmacy, Klinikum Fulda gAG, Fulda, Germany
| | - Carsten Culmsee
- Institute for Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, University of Marburg, Marburg, Germany
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Coumau C, Gaspar F, Terrier J, Schulthess-Lisibach A, Lutters M, Le Pogam MA, Csajka C. Drug-drug interactions with oral anticoagulants: information consistency assessment of three commonly used online drug interactions databases in Switzerland. Front Pharmacol 2024; 15:1332147. [PMID: 38633615 PMCID: PMC11022661 DOI: 10.3389/fphar.2024.1332147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 03/15/2024] [Indexed: 04/19/2024] Open
Abstract
Background: Toxicity or treatment failure related to drug-drug interactions (DDIs) are known to significantly affect morbidity and hospitalization rates. Despite the availability of numerous databases for DDIs identification and management, their information often differs. Oral anticoagulants are deemed at risk of DDIs and a leading cause of adverse drug events, most of which being preventable. Although many databases include DDIs involving anticoagulants, none are specialized in them. Aim and method: This study aims to compare the DDIs information content of four direct oral anticoagulants and two vitamin K antagonists in three major DDI databases used in Switzerland: Lexi-Interact, Pharmavista, and MediQ. It evaluates the consistency of DDIs information in terms of differences in severity rating systems, mechanism of interaction, extraction and documentation processes and transparency. Results: This study revealed 2'496 DDIs for the six anticoagulants, with discrepant risk classifications. Only 13.2% of DDIs were common to all three databases. Overall concordance in risk classification (high, moderate, and low risk) was slight (Fleiss' kappa = 0.131), while high-risk DDIs demonstrated a fair agreement (Fleiss' kappa = 0.398). The nature and the mechanism of the DDIs were more consistent across databases. Qualitative assessments highlighted differences in the documentation process and transparency, and similarities for availability of risk classification and references. Discussion: This study highlights the discrepancies between three commonly used DDI databases and the inconsistency in how terminology is standardised and incorporated when classifying these DDIs. It also highlights the need for the creation of specialised tools for anticoagulant-related interactions.
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Affiliation(s)
- Claire Coumau
- Centre for Research and Innovation in Clinical Pharmaceutical Sciences, University Hospital and University of Lausanne, Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Frederic Gaspar
- Centre for Research and Innovation in Clinical Pharmaceutical Sciences, University Hospital and University of Lausanne, Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
| | - Jean Terrier
- Division of General Internal Medicine, Geneva University Hospitals, Geneva, Switzerland
- Geneva Platelet Group, Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Clinical Pharmacology and Toxicology Division, Anesthesiology, Pharmacology, Intensive Care and Emergency Medicine Department, Geneva University Hospitals, Geneva, Switzerland
| | | | - Monika Lutters
- Clinical Pharmacy, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Marie-Annick Le Pogam
- Department of Epidemiology and Health Systems, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Chantal Csajka
- Centre for Research and Innovation in Clinical Pharmaceutical Sciences, University Hospital and University of Lausanne, Lausanne, Switzerland
- School of Pharmaceutical Sciences, University of Geneva, Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, University of Lausanne, Lausanne, Switzerland
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Hou Y, Trogdon JG, Freburger JK, Bushnell CD, Halladay JR, Duncan PW, Kucharska-Newton AM. Association of Continuity of Care With Health Care Utilization and Expenditures Among Patients Discharged Home After Stroke or Transient Ischemic Attack. Med Care 2024; 62:270-276. [PMID: 38447009 DOI: 10.1097/mlr.0000000000001983] [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: 03/08/2024]
Abstract
OBJECTIVES To examine the association of prestroke continuity of care (COC) with postdischarge health care utilization and expenditures. STUDY POPULATION The study population included 2233 patients with a diagnosis of stroke or a transient ischemic attack hospitalized in one of 41 hospitals in North Carolina between March 2016 and July 2019 and discharged directly home from acute care. METHODS COC was assessed from linked Centers for Medicare and Medicaid Services Medicare claims using the Modified, Modified Continuity Index. Logistic regressions and 2-part models were used to examine the association of prestroke primary care COC with postdischarge health care utilization and expenditures. RESULTS Relative to patients in the first (lowest) COC quartile, patients in the second and third COC quartiles were more likely [21% (95% CI: 8.5%, 33.5%) and 33% (95% CI: 20.5%, 46.1%), respectively] to have an ambulatory care visit within 14 days. Patients in the highest COC quartile were more likely to visit a primary care provider but less likely to see a stroke specialist. Highest as compared with lowest primary care COC quartile was associated with $45 lower (95% CI: $14, $76) average expenditure for ambulatory care visits within 30 days postdischarge. Patients in the highest, as compared with the lowest, primary care COC quartile were 36% less likely (95% CI: 8%, 64%) to be readmitted within 30 days postdischarge and spent $340 less (95% CI: $2, $678) on unplanned readmissions. CONCLUSIONS These findings underscore the importance of primary care COC received before stroke hospitalization to postdischarge care and expenditures.
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Affiliation(s)
- Yucheng Hou
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Management, Policy and Community Health, School of Public Health, The University of Texas Health Science Center at Houston, Houston, TX
| | - Justin G Trogdon
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Janet K Freburger
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA
| | - Cheryl D Bushnell
- Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC
| | - Jacqueline R Halladay
- Department of Family Medicine, UNC School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Pamela W Duncan
- Department of Internal Medicine, Wake Forest School of Medicine, Winston Salem, NC
| | - Anna M Kucharska-Newton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Epidemiology, College of Public Health, University of Kentucky, Lexington, KY
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Al Rowily A, Baraka MA, Abutaleb MH, Alhayyan AM, Aloudah N, Jalal Z, Paudyal V. Patients' views and experiences on the use and safety of directly acting oral anticoagulants: a qualitative study. J Pharm Policy Pract 2023; 16:58. [PMID: 37127790 PMCID: PMC10150668 DOI: 10.1186/s40545-023-00563-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 04/15/2023] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are considered high-risk medications and used to prevent thromboembolic events and stroke. This study aimed to examine patients' views and experiences of DOACs use and factors that can promote safety associated with DOACs. METHODS In-depth interviews were conducted with adult patients who had been prescribed DOACs, identified and invited by local collaborators in three different tertiary care hospitals in Saudi Arabia. A topic guide developed based on was used to inform the interview. Data were analysed thematically. RESULTS Data saturation was achieved by the ninth participants. Three major themes were identified: (1) factors affecting DOAC's safety from the patients view; (2) barriers to adherence to DOACs and (3) strategies to promote the safety of DOACs. Lack of knowledge of DOACs, using inappropriate sources of information, lack of communication with HCPs, difficulty in having access to DOACs and lack of monitoring were the main factors affecting the safe use of DOACs. Unavailability of the drugs and difficulty in timely getting to hospitals affected adherence. Patients acknowledged difficulties communicating with healthcare professionals, timely access to anticoagulation clinics and in obtaining their DOACs on time. CONCLUSIONS There is a need to develop and evaluate theory-based interventions to promote patient knowledge, understanding and shared decision-making to optimise DOACs use and improve their safety.
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Affiliation(s)
- Abdulrhman Al Rowily
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Birmingham, B15 2TT, UK.
- Pharmaceutical Care Department, King Fahad Military Medical Complex (KFMMC), Medical Department, Ministry of Defence, Dhahran, Saudi Arabia.
| | - Mohamed A Baraka
- College of Pharmacy, Al Ain University, Al Ain, United Arab Emirates
| | - Mohammed H Abutaleb
- Pharmaceutical Care Department, King Fahd Central Hospital, Jazan Health Affairs, Ministry of Health, Jazan, Saudi Arabia
| | | | - Nouf Aloudah
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Zahraa Jalal
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Vibhu Paudyal
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Birmingham, B15 2TT, UK
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Austin JA, Barras M, Woods LS, Sullivan C. AIDH Summit 2022 - The effect of digitisation on the safe management of anticoagulants. Appl Clin Inform 2022; 13:845-856. [PMID: 35896507 PMCID: PMC9474267 DOI: 10.1055/a-1910-4339] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Anticoagulants are high-risk medications and are a common cause of adverse events of hospitalised inpatients. The incidence of adverse events involving anticoagulants has remained relatively unchanged over the past two decades, suggesting novel approaches are required to address this persistent issue. Electronic medication management systems (eMMS) offer strategies to help reduce medication incidents and adverse drug events, yet poor system design can introduce new error types. OBJECTIVE To evaluate the effect of the introduction of an electronic medical record (EMR) on the quality and safety of therapeutic anticoagulation management. METHODS A retrospective, observational pre/post study was conducted, analysing real-world data across five hospital sites in a single health service. Four metrics were compared one year pre- and one year post-EMR implementation. They included clinician-reported medication incidents, toxic pathology results, hospital-acquired bleeding complications (HACs) and rate of heparin-induced thrombocytopenia. Further sub-analyses of patients experiencing HACs in the post-EMR period, identified key opportunities for intervention to maximise safety and quality of anticoagulation within an eMMS. RESULTS A significant reduction in HACs was observed in the post-EMR implementation period (mean (SD) =12.1 (4.4)/month, vs. mean (SD) =7.8 (3.5)/month; p=0.01). The categorisation of potential EMR design enhancements found that new automated clinical decision support or improved pathology result integration would be suitable to mitigate future HACs in an eMMS. There was no significant difference in the mean monthly clinician-reported incident rates for anticoagulants or the rate of toxic pathology results in the pre- versus post-EMR implementation period. A 62.5% reduction in the cases of heparin-induced thrombocytopenia were observed in the post-EMR implementation period. CONCLUSION The implementation of an EMR improves clinical care outcomes for patients receiving anticoagulation. System design plays a significant role in mitigating the risks associated with anticoagulants and consideration must be given to optimising eMMS.
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Affiliation(s)
- Jodie Ann Austin
- Centre for Health Services Research, The University of Queensland Faculty of Medicine, Herston, Australia
| | - Michael Barras
- School of Pharmacy, The University of Queensland Faculty of Health and Behavioural Sciences, Woolloongabba, Australia.,Department of Pharmacy, Princess Alexandra Hospital, Woolloongabba, Australia
| | - Leanna Sarah Woods
- Centre for Health Services Research, The University of Queensland, Herston, Australia.,Digital Health Cooperative Research Centre, Sydney, Australia
| | - Clair Sullivan
- Centre for Health Services Research, The University of Queensland Faculty of Medicine, Herston, Australia.,Digital Metro North, Royal Brisbane and Women's Hospital, Herston, Australia
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Al Rowily A, Aloudah N, Jalal Z, Abutaleb MH, Paudyal V. Views, experiences and contributory factors related to medication errors associated with direct oral anticoagulants: a qualitative study with physicians and nurses. Int J Clin Pharm 2022; 44:1057-1066. [PMID: 35731467 PMCID: PMC9393124 DOI: 10.1007/s11096-022-01448-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 06/14/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) have become preferable for the management of thromboembolic events. Recent publications have however identified high volume of medication errors related to DOACs. There is limited literature on why and how such errors occur or happen in clinical practice. AIM This study aimed to explore views, experiences, contributory factors related to DOACs medication errors from the perspectives of healthcare professionals. METHOD Semi-structured interviews using online videoconferencing were conducted with physicians and nurses from tertiary care hospitals in three different regions in Saudi Arabia. Questions included views, experiences and perceived factors contributing to errors. Interviews were transcribed verbatim and were thematically analyzed using MAXQDA Analytics Pro 2020 (VERBI Software). RESULTS The semi-structured interviews (n = 34) included physicians (n = 20) and nurses (n = 14) until data saturation was achieved. The analysis identified five themes: Factors related to healthcare professionals (e.g. knowledge, confidence and access to guidelines); Factors related to patients (e.g. comorbidity, polypharmacy, medication review, and communication barriers); Factors related to organization (e.g. guidelines, safety culture and incidents reporting system); Factors related to the DOACs medications (e.g. lack of availability of antidotes and dosing issues); and Strategies for error prevention/mitigation (e.g. the need for professional training and routine medication review). CONCLUSION Healthcare professionals identified errors in relation to DOACs as multifactorial including their own and patient lack of knowledge, lack of clinical guidelines and organizational factors including safety culture. Medication review and reconciliation on discharge were key strategies suggested to reduce DOACs related errors. These strategies support the role of pharmacists as direct patients care providers to minimize DOACs errors.
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Affiliation(s)
- Abdulrhman Al Rowily
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Birmingham, B15 2TT, UK. .,Pharmaceutical Care Department, King Fahad Military Medical Complex (KFMMC), Medical Department, Ministry of Defense, Dhahran, Saudi Arabia.
| | - Nouf Aloudah
- Department of Clinical Pharmacy, College of Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Zahraa Jalal
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Birmingham, B15 2TT UK
| | - Mohammed H. Abutaleb
- Pharmaceutical Care Department, King Fahad Central Hospital, Jazan Health Affairs, Ministry of Health, Jazan, Saudi Arabia
| | - Vibhu Paudyal
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Birmingham, B15 2TT UK
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7
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Al Rowily A, Jalal Z, Price MJ, Abutaleb MH, Almodiaemgh H, Al Ammari M, Paudyal V. Prevalence, contributory factors and severity of medication errors associated with direct-acting oral anticoagulants in adult patients: a systematic review and meta-analysis. Eur J Clin Pharmacol 2021; 78:623-645. [PMID: 34935068 PMCID: PMC8926953 DOI: 10.1007/s00228-021-03212-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 08/28/2021] [Indexed: 10/30/2022]
Abstract
PURPOSE This study aimed to estimate the prevalence, contributory factors, and severity of medication errors associated with direct acting oral anticoagulants (DOACs). METHODS A systematic review and meta-analysis were undertaken by searching 11 databases including Medline, Embase, and CINHAL between January 2008 and September 2020. The pooled prevalence of errors and predictive intervals were estimated using random-effects models using Stata software. Data related to error causation were synthesised according to Reason's accident causation model. RESULTS From the 5205 titles screened, 32 studies were included which were mostly based in hospitals and included DOAC treatment for thromboembolism and atrial fibrillation. The proportion of study population who experienced either prescription, administration, or dispensing error ranged from 5.3 to 37.3%. The pooled percentage of patients experiencing prescribing error was 20% (95% CI 15-25%; I2 = 96%; 95% PrI 4-43%). Prescribing error constituted the majority of all error types with a pooled estimate of 78% (95%CI 73-82%; I2 = 0) of all errors. The common reported causes were active failures including wrong drug, and dose for the indication. Mistakes such as non-consideration of renal function, and error-provoking conditions such as lack of knowledge were common contributing factors. Adverse events such as potentially fatal intracranial haemorrhage or patient deaths were linked to the errors but causality assessments were often missing. CONCLUSIONS Despite their favourable safety profile, DOAC medication errors are common. There is a need to promote multidisciplinary working, guideline-adherence, training, and education of healthcare professionals, and the use of theory-based and technology-facilitated interventions to minimise errors and maximise the benefits of DOACs usage in all settings. PROTOCOL A protocol developed as per PRISMA-P guideline is registered under PROSPERO ID = CRD42019122996.
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Affiliation(s)
- Abdulrhman Al Rowily
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Birmingham, B15 2TT, UK.,Pharmaceutical Care Department, King Fahad Military Medical Complex (KFMMC), Medical Department, Ministry of Defence, Dhahran, Saudi Arabia
| | - Zahraa Jalal
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Malcolm J Price
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK.,NIHR Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Mohammed H Abutaleb
- Pharmaceutical Care Department, King Fahad Central Hospital, Jazan Health Affairs, Ministry of Health, Jazan, Saudi Arabia
| | - Hind Almodiaemgh
- Pharmaceutical Care Department, King Abdulaziz Medical City, King Abdullah International Medical Research Center/King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Maha Al Ammari
- Pharmaceutical Care Department, King Abdulaziz Medical City, King Abdullah International Medical Research Center/King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Vibhu Paudyal
- School of Pharmacy, Institute of Clinical Sciences, College of Medical and Dental Sciences, Sir Robert Aitken Institute for Medical Research, University of Birmingham, Birmingham, B15 2TT, UK.
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Stöllberger C, Finsterer J. Update on drug interactions with non-vitamin-K-antagonist oral anticoagulants for stroke prevention in elderly patients. Expert Rev Clin Pharmacol 2021; 14:569-581. [PMID: 33757376 DOI: 10.1080/17512433.2021.1908124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Introduction: We update the knowledge, since the last review in 2017, about drug-drug interactions (DDI) of non-vitamin-K-antagonist oral anticoagulants (NOAC) in patients ≥75 years.Areas covered: The literature was searched for: 'dabigatran,' 'rivaroxaban,' 'edoxaban,' or 'apixaban' and drugs, affecting platelet function, CYP3A4-, CYP2C9-, or P-Gp-activity. Pharmacodynamic DDI of NOAC with drugs affecting platelet function like nonsteroidal anti-inflammatory drugs and antiplatelet agents occur most frequently. Pharmacokinetic DDI with NOAC were found for 37 of 117 drugs. Reports about DDI with NOAC were found for 51% of P-gp-affecting, 38% for CYP2C9-affecting and 27% for CYP3A4-affecting drugs. Reports about DDI of cardiovascular drugs with NOAC were the most prevalent, followed by anti-infective and nervous system drugs. NOAC plasma levels were measured in retrospective and cohort studies and were associated with concomitant medication. Reports about DDI of NOAC were found in 71 patients ≥75 years.Expert opinion: The knowledge about DDI of NOAC in elderly patients is very limited. Studies should be carried out to investigate the role of drugs potentially interacting with NOAC, which until now have not been investigated. When studying DDI of NOAC, care should be taken to include elderly patients with impaired renal function and patients on polymedication.
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Affiliation(s)
- Claudia Stöllberger
- 2nd Medical Department with Cardiology and Intensive Care Medicine, Klinik Landstrasse, Wien, Austria
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Spada G, Vighi GV, Pagani S, Vighi GD, Venegoni M, Ruocco M. What are the Characteristics of Patients Experiencing Adverse Drug Reactions to Oral Anticogulants and How Can Such Reactions be Prevented? Curr Drug Saf 2020; 15:38-44. [PMID: 31580253 DOI: 10.2174/1574886314666191003162104] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Oral anticoagulants, including vitamin K inhibitors (VKAs) and direct anticoagulants (DOACs) are important for preventing and treating thromboembolic diseases. However, they are not recommended for use in all patients due to negative side effects and adverse drug reactions (ADRs). Currently, there is a paucity of information about their use in real life. Therefore, the aim of this pilot study is to report on the rate of serious ADRs in oral anticoagulant users, determine patient characteristics associated with increased risk of ADRs, and identify possible management strategies for reducing risk of ADRs within a hospital setting. METHODS Patients admitted to the Internal Medicine Department of the Vimercate Hospital were recruited between November 1, 2015 and October 31, 2016. All patients reporting an ADR associated with anticoagulant use were selected. Demographic, clinical, and observational data were extracted from electronic hospital records, in particular, by the hospital discharge letters and other clinical records. The main outcome of the study was to evaluate the incidence of anticoagulants serious adverse drug reactions conditioning hospital admission, the percentage of preventable reactions, and the determinants of those. RESULTS AND DISCUSSION Of the 2,064 admissions, 102 (4.9%) eligible patients were identified. Age ranged from 60-95 years (mean = 81.9, standard deviation = 6,59) and 47.1% (n=48) were female. Of the 102 cases, 68 used VKAs and 34 used DOACs. The most common admission diagnosis was heart failure following anemia or hemorrhage (56 cases), followed by acute hemorrhage (with or without anemia; 29 cases), and anemia not associated with evident hemorrhage (17cases). The majority of VKA users (n=65, 95.6%) had a high risk of major bleeding. ADRs were found to be preventable in 96% of VKA users and 68% of DOACs users. CONCLUSION This study highlights the large percentage of ADRs from oral anticoagulants that can be avoided with more careful patient management. Periodic check-up of cardiac and renal function, as well as blood count, may be useful for reducing the risk of ADRs, especially in older DOACs users. Further research is needed to get new data to improve the patients monitoring system.
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Affiliation(s)
- G Spada
- Azienda Socio Sanitaria Territoriale Vimercate Hospital, Vimercate, Italy
| | - G V Vighi
- Azienda Socio Sanitaria Territoriale Vimercate Hospital, Vimercate, Italy
| | - S Pagani
- Azienda Socio Sanitaria Territoriale Vimercate Hospital, Vimercate, Italy
| | - G D Vighi
- Azienda Socio Sanitaria Territoriale Vimercate Hospital, Vimercate, Italy
| | - M Venegoni
- Azienda Socio Sanitaria Territoriale Vimercate Hospital, Vimercate, Italy
| | - M Ruocco
- Azienda Socio Sanitaria Territoriale Vimercate Hospital, Vimercate, Italy
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10
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[Pain treatment in old age: special features and recommendations]. Z Gerontol Geriatr 2020; 54:605-610. [PMID: 32681466 DOI: 10.1007/s00391-020-01766-7] [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: 05/10/2020] [Accepted: 06/30/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND For geriatric patients with chronic pain, a comprehensive well-coordinated pain management is pivotal to ensure the best possible pain relief and to minimize as far as possible preventable negative side effects of treatment. OBJECTIVE Description of the difficulties in pain management of geriatric patients with respect to general basic rules that are worth paying attention to and presentation of pharmacological and non-pharmacological treatment options. METHODS This article describes the special features of pain management in older patients and gives recommendations on the use of analgesics and potential drug interactions in geriatric patients with organ dysfunction. Furthermore, individual substance groups are described with respect to their use in geriatric patients based on the recent literature. CONCLUSION The aim of an individualized pain treatment in older and multimorbid patients is the relief of pain to an appropriate level, preservation of mobility, self-reliance and autonomy of each individual. The ability to participate in social activities as well as improvement in the quality of life need to be the focus of pharmacological and non-pharmacological treatment.
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11
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Sennesael AL, Krug B, Sneyers B, Spinewine A. Do computerized clinical decision support systems improve the prescribing of oral anticoagulants? A systematic review. Thromb Res 2020; 187:79-87. [PMID: 31972381 DOI: 10.1016/j.thromres.2019.12.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/13/2019] [Accepted: 12/28/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Serious adverse drug reactions have been associated with the underuse or the misuse of oral anticoagulant therapy. We systematically reviewed the impact of computerized clinical decision support systems (CDSS) on the prescribing of oral anticoagulants and we described CDSS features associated with success or failure. METHODS We searched Medline, Embase, CENTRAL, CINHAL, and PsycINFO for studies that compared CDSS for the initiation or monitoring of oral anticoagulants with routine care. Two reviewers performed study selection, data collection, and risk-of-bias assessment. Disagreements were resolved with a third reviewer. Potentially important CDSS features, identified from previous literature, were evaluated. RESULTS Sixteen studies were included in our qualitative synthesis. Most trials were performed in primary care (n = 7) or hospitals (n = 6) and included atrial fibrillation (AF) patients (n = 9). Recommendations mainly focused on anticoagulation underuse (n = 11) and warfarin-drug interactions (n = 5). Most CDSS were integrated in electronic records or prescribing and provided support automatically at the time and location of decision-making. Significant improvements in practitioner performance were found in 9 out of 16 studies, while clinical outcomes were poorly reported. CDSS features seemed slightly more common in studies that demonstrated improvement. CONCLUSIONS CDSS might positively impact the use of oral anticoagulants in AF patients at high risk of stroke. The scope of CDSS should now evolve to assist prescribers in selecting the most appropriate and tailored medication. Efforts should nevertheless be made to improve the relevance of notifications and to address implementation outcomes.
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Affiliation(s)
- Anne-Laure Sennesael
- Université catholique de Louvain, Louvain Drug Research Institute, Clinical Pharmacy Research Group, Brussels, Belgium; Université catholique de Louvain, CHU UCL Namur, Department of Pharmacy, Yvoir, Belgium.
| | - Bruno Krug
- Université catholique de Louvain, CHU UCL Namur, Department of Nuclear Medicine, Yvoir, Belgium; Université catholique de Louvain, Institute of Health and Society, Brussels, Belgium
| | - Barbara Sneyers
- Université catholique de Louvain, CHU UCL Namur, Department of Pharmacy, Yvoir, Belgium
| | - Anne Spinewine
- Université catholique de Louvain, Louvain Drug Research Institute, Clinical Pharmacy Research Group, Brussels, Belgium; Université catholique de Louvain, CHU UCL Namur, Department of Pharmacy, Yvoir, Belgium
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12
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Yiu AWP, Lee VW, Ng KK, Bajorek BV. Patient Feedback on a Warfarin Action Plan Used in a Local Australian Physician Practice Setting. Ther Innov Regul Sci 2019:2168479019865900. [PMID: 31426683 DOI: 10.1177/2168479019865900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Warfarin is a high-risk medicine, and older persons (those aged 65 years and older)1,2 who take this therapy need medicines information about it that is at a level which is both understandable and comprehensive to improve their knowledge about the risks and benefits of warfarin therapy.3,4 Therefore, the primary objective of this study was to report patient feedback on a Warfarin Action Plan (WAP) (leaflet) and identify patients' preferences regarding its content and format. The secondary objective was to canvass in-depth feedback regarding the participants' information needs and current information-seeking practices with respect to warfarin therapy. METHOD In an Australian General Practice medical centre setting, a qualitative study comprising 34 individual interviews was conducted. Emergent themes were elicited via a qualitative analysis using manual inductive coding. RESULTS The majority of participants gave very positive feedback on the WAP leaflet, stating that it was a useful and concise resource. In canvasing this feedback, 4 themes emerged: (1) the need for information about warfarin therapy, (2) reliance on doctors and/or pharmacists for information, (3) the need for information to normalize their daily life, and (4) patients and carers acting on the new information. CONCLUSION The WAP is a simple and well-received tool that meets the knowledge and education needs about warfarin therapy for older people and their carers.
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Affiliation(s)
- Angela W P Yiu
- 1 University Technology of Sydney, Sydney, New South Wales, Australia
- 2 Department of Pharmacy, Westmead Hospital, Westmead, New South Wales, Australia
| | - Vincent W Lee
- 3 Department of Renal Medicine, University of Sydney, Sydney, New South Wales, Australia
- 4 Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Kingsley K Ng
- 2 Department of Pharmacy, Westmead Hospital, Westmead, New South Wales, Australia
| | - Beata V Bajorek
- 1 University Technology of Sydney, Sydney, New South Wales, Australia
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13
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Schneider B, Nazarenus D, Stöllberger C. A 79-year-old woman with atrial fibrillation and new onset of heart failure. ESC Heart Fail 2019; 6:570-574. [PMID: 30903653 PMCID: PMC6487709 DOI: 10.1002/ehf2.12435] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 02/26/2019] [Indexed: 12/29/2022] Open
Abstract
As an alternative to oral anticoagulation, percutaneous left atrial appendage (LAA) closure is an increasingly performed procedure to prevent arterial embolism in patients with non‐valvular atrial fibrillation. Besides procedure‐related complications, residual leaks, device‐related thrombus formation, and dislocation of the LAA occluder have been observed during follow‐up. Heart failure as a consequence of interventional LAA closure has not been reported so far. This case report describes a 79‐year‐old lady with permanent non‐valvular atrial fibrillation presenting with New York Heart Association Class IV heart failure. Symptoms had started immediately after attempted LAA closure 11 months before. Transoesophageal echocardiography demonstrated two devices in the LAA, a large peri‐device leak, a mobile LAA thrombus, a right atrial appendage thrombus, and shunting via a patent foramen ovale. Under a maximally tolerated dose of heart failure medication and edoxaban, the patient remains without bleeding or embolism in New York Heart Association Class II. Because of its unique anatomical and endocrine properties, the LAA plays an important role in situations of pressure and volume overload. Interventional LAA closure interacts unfavourably with left atrial compliance and reservoir function. Atrial and brain natriuretic peptide secretion is known to be significantly reduced after LAA closure. Both mechanisms may result in the development of heart failure. Attempted LAA closure—instead of being the solution—may create new serious problems. Development of heart failure should be assessed, and a systematic search for late leaks after LAA closure should be performed in trials investigating safety and efficacy of this intervention.
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Affiliation(s)
- Birke Schneider
- Sana Kliniken Lübeck, Kahlhorststrasse 17, Lübeck, D-23562, Germany
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14
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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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15
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Sennesael AL, Larock AS, Devalet B, Mathieux V, Verschuren F, Muschart X, Dalleur O, Dogné JM, Spinewine A. Preventability of serious thromboembolic and bleeding events related to the use of oral anticoagulants: a prospective study. Br J Clin Pharmacol 2018. [PMID: 29522647 DOI: 10.1111/bcp.13580] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
AIMS To determine the preventability of serious adverse drug reactions (ADRs) related to the use of direct oral anticoagulants (DOACs), and to explore contributing factors to preventable ADRs. Results were compared with vitamin K antagonists (VKAs). METHODS We conducted a prospective observational study in the emergency departments of two teaching hospitals from July 2015 to January 2016. Patients admitted with a thrombotic or bleeding event while under DOAC or VKA were included. Four independent reviewers assessed causality, seriousness and preventability of ADRs using pilot-tested scales. For cases of serious and potentially preventable ADRs, we performed semi-structured interviews with general practitioners to identify contributing factors to ADRs. The primary outcome was the proportion of serious ADRs that were potentially preventable. RESULTS The analysis included 46 DOAC and 43 VKA patients (median age 79 years). Gastrointestinal (n = 34) and intracranial (n = 16) bleedings were the most frequent ADRs. Results were that 53% of DOAC- and 61% of VKA-related serious ADRs were deemed potentially preventable. Prescribing issues and inadequate monitoring were frequent for DOAC and VKA respectively. We identified many causes of preventable ADRs that applied to all oral anticoagulants, such as pharmacodynamic drug interactions and lack of communication. CONCLUSIONS More than half of serious ADRs were potentially preventable for both DOACs and VKAs. Interventions focusing on prescribing, patient education and continuity of care should help improve the use of DOACs in practice.
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Affiliation(s)
- Anne-Laure Sennesael
- Louvain Drug Research Institute, Clinical Pharmacy Research Group, Université catholique de Louvain, Brussels, Belgium.,Namur Research Institute for Life Sciences, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, University of Namur, Namur, Belgium
| | - Anne-Sophie Larock
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, Université catholique de Louvain, Yvoir, Belgium
| | - Bérangère Devalet
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Department of Hematology, Université catholique de Louvain, Yvoir, Belgium
| | - Valérie Mathieux
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Department of Hematology, Université catholique de Louvain, Yvoir, Belgium
| | - Franck Verschuren
- Institute of Experimental and Clinical Research, Cliniques Universitaires Saint-Luc, Department of Emergency Medicine, Université catholique de Louvain, Brussels, Belgium
| | - Xavier Muschart
- CHU UCL Namur, Department of Emergency Medicine, Université catholique de Louvain, Yvoir, Belgium
| | - Olivia Dalleur
- Louvain Drug Research Institute, Clinical Pharmacy Research Group, Université catholique de Louvain, Brussels, Belgium.,Cliniques Universitaires Saint-Luc, Department of Pharmacy, Université catholique de Louvain, Brussels, Belgium
| | - Jean-Michel Dogné
- Namur Research Institute for Life Sciences, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, University of Namur, Namur, Belgium
| | - Anne Spinewine
- Louvain Drug Research Institute, Clinical Pharmacy Research Group, Université catholique de Louvain, Brussels, Belgium.,CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, Université catholique de Louvain, Yvoir, Belgium
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