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Mahieu G, Sennesael AL, Pochet L, Haufroid V, Van Bambeke F, Spinewine A, Elens L. In vitro assessment of the risk of ABCB1-mediated drug-drug interaction between rivaroxaban and tacrolimus in human embryonic kidney 293 recombinant cell lines. Res Pract Thromb Haemost 2024; 8:102521. [PMID: 39228433 PMCID: PMC11369460 DOI: 10.1016/j.rpth.2024.102521] [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: 02/24/2024] [Revised: 07/04/2024] [Accepted: 07/09/2024] [Indexed: 09/05/2024] Open
Abstract
Background In lung transplant patients, direct oral anticoagulants are often taken in combination with immunosuppressive drugs such as tacrolimus. Since tacrolimus is a substrate and inhibitor of the efflux protein ABCB1, also transporting direct oral anticoagulants, a possible drug-drug interaction mediated by competition for this transporter needs to be investigated. Objectives To determine the in vitro effect of tacrolimus on ABCB1-mediated rivaroxaban transport in order to support clinician practice. Methods Recombinant cell line models, based on human embryonic kidney 293 cells, were generated by a stable transfection process to overexpress ABCB1 or not (control cells). The impact of tacrolimus on ABCB1-mediated rivaroxaban transport was assessed by accumulation experiments. Results ABCB1 expression decreased the cellular accumulation of rivaroxaban and tacrolimus at their respective clinically relevant concentrations when compared with control cells. This confirms the involvement of ABCB1 in the active transport of tacrolimus and rivaroxaban. However, tacrolimus had no significant influence on rivaroxaban disposition at those clinically relevant concentrations. Conclusion Our study does not provide evidence for a possible interaction between tacrolimus and rivaroxaban when used together in practice.
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Affiliation(s)
- Gwenaëlle Mahieu
- Pharmacologie Cellulaire et Moléculaire, Louvain Drug Research Institute (LDRI), Université catholique de Louvain (UCLouvain), Brussels, Belgium
- Integrated PharmacoMetrics, PharmacoGenomics and Pharmacokinetics (PMGK) Research Group, Louvain Drug Research Institute (LDRI), Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Anne-Laure Sennesael
- Université catholique de Louvain (UCLouvain), Pharmacy Department, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Centre Hospitalier Universitaire UCL Namur, Namur, Belgium
| | - Lionel Pochet
- Namur Medicine & Drug Innovation Center (NAMEDIC - NARILIS), University of Namur, Namur, Belgium
| | - Vincent Haufroid
- Louvain Centre for Toxicology and Applied Pharmacology, Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain (UCLouvain), Brussels, Belgium
- Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Françoise Van Bambeke
- Pharmacologie Cellulaire et Moléculaire, Louvain Drug Research Institute (LDRI), Université catholique de Louvain (UCLouvain), Brussels, Belgium
| | - Anne Spinewine
- Clinical Pharmacy and Pharmacoepidemiology Research Group, Louvain Drug Research Institute (LDRI), Université catholique de Louvain (UCLouvain), Brussels, Belgium
- Department of Pharmacy, Centre Hospitalier Universitaire (CHU) UCL Namur, Yvoir, Belgium
| | - Laure Elens
- Integrated PharmacoMetrics, PharmacoGenomics and Pharmacokinetics (PMGK) Research Group, Louvain Drug Research Institute (LDRI), Université catholique de Louvain (UCLouvain), Brussels, Belgium
- Louvain Centre for Toxicology and Applied Pharmacology, Institut de Recherche Expérimentale et Clinique (IREC), Université catholique de Louvain (UCLouvain), Brussels, Belgium
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Papakonstantinou PE, Kalogera V, Charitos D, Polyzos D, Benia D, Batsouli A, Lampropoulos K, Xydonas S, Gupta D, Lip GYH. When anticoagulation management in atrial fibrillation becomes difficult: Focus on chronic kidney disease, coagulation disorders, and cancer. Blood Rev 2024; 65:101171. [PMID: 38310007 DOI: 10.1016/j.blre.2024.101171] [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: 01/03/2024] [Revised: 01/11/2024] [Accepted: 01/11/2024] [Indexed: 02/05/2024]
Abstract
Anticoagulation therapy (AT) is fundamental in atrial fibrillation (AF) treatment but poses challenges in implementation, especially in AF populations with elevated thromboembolic and bleeding risks. Current guidelines emphasize the need to estimate and balance thrombosis and bleeding risks for all potential candidates of antithrombotic therapy. However, administering oral AT raises concerns in specific populations, such as those with chronic kidney disease (CKD), coagulation disorders, and cancer due to lack of robust data. These groups, excluded from large direct oral anticoagulants trials, rely on observational studies, prompting physicians to adopt individualized management strategies based on case-specific evaluations. The scarcity of evidence and specific guidelines underline the need for a tailored approach, emphasizing regular reassessment of risk factors and anticoagulation drug doses. This narrative review aims to summarize evidence and recommendations for challenging AF clinical scenarios, particularly in the long-term management of AT for patients with CKD, coagulation disorders, and cancer.
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Affiliation(s)
| | - Vasiliki Kalogera
- Third Cardiology Department, School of Medicine, National and Kapodistrian University of Athens, "Sotiria" Chest Hospital, Mesogeion Ave 152, 11527 Athens, Greece
| | - Dimitrios Charitos
- First Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dimitrios Polyzos
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dimitra Benia
- Cardiology Department, General Hospital-Health Center of Kithira, Aroniadika, 80200 Kithira Island, Greece
| | - Athina Batsouli
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Konstantinos Lampropoulos
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece; School of Medicine, European University of Cyprus, Diogenous 6, 2404 Egkomi, Cyprus
| | - Sotirios Xydonas
- Second Cardiology Department, Evangelismos Hospital, Ipsilantou 45-47, 106 76 Athens, Greece
| | - Dhiraj Gupta
- Department of Cardiology, Liverpool Heart and Chest Hospital, L14 3PE Liverpool, United Kingdom.
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Thomas Dr., L14 3PE Liverpool, United Kingdom; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Selma Lagerløfs Vej 249, 9260 Gistrup, Aalborg, Denmark.
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3
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Gowers BTV, Greenhalgh MS, Dyson K, Iyengar KP, Jain VK, Adam RF. The importance of perioperative optimisation to facilitate safe regional anaesthesia and their improved outcomes in fracture neck of femur patients. J Perioper Pract 2023; 33:82-88. [PMID: 34957869 DOI: 10.1177/17504589211064042] [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: 11/15/2022]
Abstract
BACKGROUND Hip fractures are common presentations to orthopaedic departments, and their surgical management often results in blood transfusions. Compared with general anaesthesia, regional anaesthesia reduces the need for transfusions and mortality in the wider surgical population. AIMS In hip fracture patients, our primary outcome measure was to examine any relationship between anaesthetic modality and transfusion rates. The secondary outcome measure was to assess the relationship between anaesthetic modality and one-year mortality. METHODS A retrospective cohort study of 280 patients was carried out in 2017 and 2018. Data were collected from patient records, local transfusion laboratory and the national hip fracture database. RESULTS A total of 59.6% had regional and 40.4% general anaesthesia. Regional anaesthesia patients were younger with fewer comorbidities (p < .05). About 19.8% regional and 34.5% general anaesthesia patients received transfusions (odds ratio (OR) = 0.47, p < .05); 13.6% were taking anticoagulants and were less likely to receive a regional anaesthetic (31.6% versus 64%, OR = 0.26, p < .05). One-year mortality was 27% for regional and 37% for general anaesthetic patients (OR = 0.64, p = .09). CONCLUSION Regional anaesthesia halved the risk of blood transfusion. Anticoagulated patients were 74% less likely to receive regional anaesthetics, but had no additional transfusion risk. With optimisation, a larger proportion of patients could have regional anaesthesia.
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Affiliation(s)
| | | | - Kathryn Dyson
- Trauma and Orthopaedics, Health Education North West, Manchester, UK
| | | | - Vijay K Jain
- Department of Orthopaedics, Atal Bihari Vajpayee Institute of Medical Sciences, New Delhi, India
| | - Riad F Adam
- Trauma and Orthopaedics, Southport and Ormskirk Hospital NHS Trust, Southport, UK
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4
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Duffy S. Understanding patient assessment and treatment in deep vein thrombosis. Nurs Stand 2022; 37:71-75. [PMID: 36278279 DOI: 10.7748/ns.2022.e12050] [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] [Accepted: 10/03/2022] [Indexed: 06/16/2023]
Abstract
Deep vein thrombosis (DVT) commonly develops in the deep veins of the legs, but it can potentially form in any part of the body. There are several risk factors associated with DVT including prolonged immobility, malignancy, recent surgery and family history. One of the main risks of DVT is that the thrombus that has formed in a vein may travel through the body and become lodged in the pulmonary system, causing a pulmonary embolism, which is life-threatening. In the UK, specialist services and diagnostic pathways have been developed to speed up the diagnosis and treatment of DVT, many of which are now nurse-led. This article uses a case study to outline the assessment of patients with suspected DVT and the treatment of patients with a confirmed diagnosis of DVT.
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Affiliation(s)
- Sinead Duffy
- King's College Hospital NHS Foundation Trust, London, England
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Ren K, Gong H, Huang J, Liu Y, Dong Q, He K, Tian L, Zhang F, Yu A, Wu C. Thrombolytic and anticoagulant effects of a recombinant staphylokinase-hirudin fusion protein. Thromb Res 2021; 208:26-34. [PMID: 34688099 DOI: 10.1016/j.thromres.2021.10.005] [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: 06/13/2021] [Revised: 09/28/2021] [Accepted: 10/08/2021] [Indexed: 11/26/2022]
Abstract
A pure recombinant staphylokinase-hirudin fusion protein (SFH) was obtained by recombinant genetic engineering and purification techniques. The thrombolytic and anticoagulant activities of SFH were investigated using in vitro coagulation models and chromogenic assays. The results showed that intact SFH had targeted thrombolytic activity, and gained anticoagulant activity when cleaved by FXa. In addition, we investigated the pharmacodynamics of SFH in vivo using a variety of animal models, including a rat inferior vena cava thrombosis model, a rat coronary thrombosis model, a rabbit carotid artery thrombosis model and a canine coronary thrombosis model. We found that SFH had an obvious thrombolytic effect and could prevent and reduce re-embolization after thrombolysis and reduce the serious bleeding side effects caused by the combination of thrombolytic and anticoagulant drugs. The results suggest that SFH can be used for thrombolytic therapy in thromboembolic diseases.
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Affiliation(s)
- Keyun Ren
- School of Chemical Engineering and Technology, Tianjin University, Tianjin 300072, PR China; Beijing Institute of Radiation Medicine, Beijing 100850, PR China
| | - Hao Gong
- The Innovative Drug R & D Center of Wuhan Junke-Optical Valley, Wuhan, Hubei 430072, PR China
| | - Junjie Huang
- The Innovative Drug R & D Center of Wuhan Junke-Optical Valley, Wuhan, Hubei 430072, PR China
| | - Yubin Liu
- Beijing Institute of Radiation Medicine, Beijing 100850, PR China
| | - Qiaoyan Dong
- Beijing Institute of Radiation Medicine, Beijing 100850, PR China
| | - Kun He
- The Innovative Drug R & D Center of Wuhan Junke-Optical Valley, Wuhan, Hubei 430072, PR China
| | - Lvming Tian
- The Innovative Drug R & D Center of Wuhan Junke-Optical Valley, Wuhan, Hubei 430072, PR China
| | - Fan Zhang
- The Innovative Drug R & D Center of Wuhan Junke-Optical Valley, Wuhan, Hubei 430072, PR China
| | - Aiping Yu
- Beijing Institute of Radiation Medicine, Beijing 100850, PR China
| | - Chutse Wu
- School of Chemical Engineering and Technology, Tianjin University, Tianjin 300072, PR China; Beijing Institute of Radiation Medicine, Beijing 100850, PR China.
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Barriers and facilitators for optimizing oral anticoagulant management: Perspectives of patients, caregivers, and providers. PLoS One 2021; 16:e0257798. [PMID: 34587197 PMCID: PMC8480846 DOI: 10.1371/journal.pone.0257798] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 09/10/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Oral anticoagulants (OACs) are very commonly prescribed for prevention of serious vascular events, but are also associated with serious medication-related bleeding. Mitigation of harm is believed to require high-quality OAC management. This study aimed to identify barriers and facilitators for optimal OAC management from the perspective of patients, caregivers and healthcare providers. METHODS Using a qualitative descriptive study design, we conducted five focus groups, three with patients and caregivers and two with health care providers, in two health regions in Southwestern Ontario. An expert facilitator led the discussions using a semi-structured interview guide. Each session was digitally recorded, transcribed verbatim and anonymized. Transcripts were analyzed in duplicate using conventional content analysis. RESULTS Forty-two (19 patients, 7 caregivers, and 16 providers including physicians, nurses and pharmacists) participated. More than half of the patients received OAC for the treatment of venous thromboembolism (57.9%) and the majority (94.7%) were on chronic therapy (defined as >3 years). Data analysis organized codes describing barriers and facilitators into 4 main themes-medication-related, patient-related, provider-related, and system-related. Barriers highlighted were problems with medication access due to cost, patient difficulties with adherence, knowledge and adjusting their lifestyles to OAC therapy, provider expertise, time for adequate communication amongst providers and their patients, and health care system inadequacies in supporting communications and monitoring. Facilitators identified generally addressed these barriers. CONCLUSIONS Many barriers to optimal OAC management exist even in the era of DOACs, many of which are amenable to facilitators of improved care coordination, patient education, and adherence monitoring.
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Demonstration of proof-of-concept of StrokeShield system for complete closure and occlusion of the left atrial appendage for non-valvular atrial fibrillation therapy. PLoS One 2021; 16:e0253299. [PMID: 34157041 PMCID: PMC8219146 DOI: 10.1371/journal.pone.0253299] [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: 02/20/2021] [Accepted: 06/01/2021] [Indexed: 11/29/2022] Open
Abstract
In the US, the most significant morbidity and mortality associated with non-valvular atrial fibrillation (NVAF) is embolic stroke, with 90% of thrombus originating from the left atrial appendage (LAA). Anticoagulation is the preferred treatment for the prevention of stroke in NVAF patients, but clinical studies have demonstrated high levels of non-compliance and increased risk of bleeding or ineligibility for anticoagulation therapy, especially in the elderly population where the incidence of NVAF is highest. Alternatively, stroke may be preventing using clinically approved surgical and catheter-based devices to exclude or occlude the LAA, but these devices continue to be plagued by peri-device leaks and thrombus formation because of residual volume. To overcome these limitations, Cor Habere (Louisville, KY) and the University of Louisville are developing a LAA closure device (StrokeShield) that completely occludes and collapses the LAA to minimize the risk of stroke. The StrokeShield device is a collapsible occluder (nitinol reinforced membrane) that completely covers the LAA orifice with an expandable conical coil anchor that attaches to the myocardium. The device is designed for catheter-based delivery and expands to completely occlude the LAA orifice and collapse the LAA. The primary advantages of the StrokeShield system are a completely sealed LAA (no peri-device flow or residual space) and smooth endothelialized connection to the left atrial wall with minimal risk of cardiac bleeding and tamponade. We tested proof-of-concept of a prototype StrokeShield device in acute (n = 2) and chronic 60-day (n = 2) healthy canine models. Acute results demonstrated that the conical coil securely attached to the myocardium (5N pull-out force) and the Nitinol umbrella fully deployed and covered the LAA ostium. Results from the chronic implants demonstrated long-term feasibility of device placement with no procedural or device-related intra- or post-operative complications, secure placement and correct positioning of the device with no device migration. The device successfully occluded the LAA ostium and collapsed the LAA with no interference with the mitral valve, circumflex coronary artery, or pulmonary veins. Necropsy demonstrated no gross signs of thrombus or end-organ damage and the device was encapsulated in the LAA. Histology demonstrated mature neointima covering the device with expected foreign body inflammatory response. These early positive results will help to guide the iterative design process for the continued development of the StrokeShield system.
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8
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Chen X, Liu Y, Furukawa N, Jin DY, Savage GP, Stafford DW, Suhara Y, Williams CM, Tie JK. A novel vitamin K derived anticoagulant tolerant to genetic variations of vitamin K epoxide reductase. J Thromb Haemost 2021; 19:689-700. [PMID: 33314621 PMCID: PMC7925372 DOI: 10.1111/jth.15209] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 10/20/2020] [Accepted: 11/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Vitamin K antagonists (VKAs), such as warfarin, have remained the cornerstone of oral anticoagulation therapy in the prevention and treatment of thromboembolism for more than half a century. They function by impairing the biosynthesis of vitamin K-dependent (VKD) clotting factors through the inhibition of vitamin K epoxide reductase (VKOR). The challenge of VKAs therapy is their narrow therapeutic index and highly variable dosing requirements, which are partially the result of genetic variations of VKOR. OBJECTIVES The goal of this study was to search for an improved VKA that is tolerant to the genetic variations of its target enzyme. METHODS A series of vitamin K derivatives with benzyl and related side-chain substitutions at the 3-position of 1,4-naphthoquinone were synthesized. The role of these compounds in VKD carboxylation was evaluated by mammalian cell-based assays and conventional in vitro activity assays. RESULTS Our results showed that replacing the phytyl side-chain with a methylene cyclooctatetraene (COT) moiety at the 3-position of vitamin K1 converted it from a substrate to an inhibitor for VKD carboxylation. Strikingly, this COT-vitamin K derivative displayed a similar inhibition potency in warfarin-resistant VKOR mutations whose warfarin resistance varied more than 400-fold. Further characterization of COT-vitamin K for the inhibition of VKD carboxylation suggested that this compound targets multiple enzymes in the vitamin K redox cycle. Importantly, the anticoagulation effect of COT-vitamin K can be rescued with high doses of vitamin K1 . CONCLUSION We discovered a vitamin K analogue that functions as a VKA and is tolerant to genetic variations in the target enzyme.
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Affiliation(s)
- Xuejie Chen
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA
| | - Yizhou Liu
- School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane 4072, Queensland, Australia
| | - Natsuko Furukawa
- Laboratory of Organic Synthesis and Medicinal Chemistry, Department of Bioscience and Engineering, College of Systems Engineering and Science, Shibaura Institute of Technology, 307 Fukasaku, Minuma-ku, Saitama 337-8570, Japan
| | - Da-Yun Jin
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA
| | - G. Paul Savage
- CSIRO Manufacturing, Ian Wark Laboratory, Melbourne 3168, Victoria, Australia
| | - Darrel W. Stafford
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA
| | - Yoshitomo Suhara
- Laboratory of Organic Synthesis and Medicinal Chemistry, Department of Bioscience and Engineering, College of Systems Engineering and Science, Shibaura Institute of Technology, 307 Fukasaku, Minuma-ku, Saitama 337-8570, Japan
| | - Craig M. Williams
- School of Chemistry and Molecular Biosciences, University of Queensland, Brisbane 4072, Queensland, Australia
| | - Jian-Ke Tie
- Department of Biology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina 27599, USA
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Grześk G, Woźniak-Wiśniewska A, Błażejewski J, Górny B, Wołowiec Ł, Rogowicz D, Nowaczyk A. The Interactions of Nintedanib and Oral Anticoagulants-Molecular Mechanisms and Clinical Implications. Int J Mol Sci 2020; 22:ijms22010282. [PMID: 33396592 PMCID: PMC7795697 DOI: 10.3390/ijms22010282] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 12/24/2020] [Accepted: 12/25/2020] [Indexed: 12/13/2022] Open
Abstract
Nintedanib is a synthetic orally active tyrosine kinase inhibitor, whose main action is to inhibit the receptors of the platelet-derived growth factor, fibroblast growth factor and vascular endothelial growth factor families. The drug also affects other kinases, including Src, Flt-3, LCK, LYN. Nintedanib is used in the treatment of idiopathic pulmonary fibrosis, chronic fibrosing interstitial lung diseases and lung cancer. The mechanism of action suggests that nintedanib should be considered one of the potential agents for inhibiting and revising the fibrosis process related to COVID-19 infections. Due to the known induction of coagulation pathways during COVID-19 infections, possible interaction between nintedanib and anticoagulant seems to be an extremely important issue. In theory, nintedanib could increase the bleeding risk, thrombosis and lead to thrombocytopenia. The data from clinical trials on the concomitant use of nintedanib and antithrombotic agents is very limited as this patient group was within the standard exclusion criteria. Nintedanib is an important therapeutic option, despite its interaction with anticoagulants. If anticoagulant therapy is necessary, the more effective and safer option is the concomitant administration of DOACs and nintedanib, especially when drug-monitored therapy will be used in patients at high risk of bleeding complications.
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Affiliation(s)
- Grzegorz Grześk
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 87-100 Toruń, Poland; (G.G.); (A.W.-W.); (J.B.); (B.G.); (Ł.W.); (D.R.)
| | - Anita Woźniak-Wiśniewska
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 87-100 Toruń, Poland; (G.G.); (A.W.-W.); (J.B.); (B.G.); (Ł.W.); (D.R.)
| | - Jan Błażejewski
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 87-100 Toruń, Poland; (G.G.); (A.W.-W.); (J.B.); (B.G.); (Ł.W.); (D.R.)
| | - Bartosz Górny
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 87-100 Toruń, Poland; (G.G.); (A.W.-W.); (J.B.); (B.G.); (Ł.W.); (D.R.)
| | - Łukasz Wołowiec
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 87-100 Toruń, Poland; (G.G.); (A.W.-W.); (J.B.); (B.G.); (Ł.W.); (D.R.)
| | - Daniel Rogowicz
- Department of Cardiology and Clinical Pharmacology, Faculty of Health Sciences, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 87-100 Toruń, Poland; (G.G.); (A.W.-W.); (J.B.); (B.G.); (Ł.W.); (D.R.)
| | - Alicja Nowaczyk
- Department of Organic Chemistry, Faculty of Pharmacy, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Toruń, 2 dr. A. Jurasza St., 85-094 Bydgoszcz, Poland
- Correspondence:
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Tyedin AE, Taylor SE, Than J, Al‐Alawi R, O’Halloran E, Chau A. Impact of proactive pharmacist‐assisted warfarin management using an electronic medication management system in Australian hospitalised patients. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2020. [DOI: 10.1002/jppr.1632] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
| | | | - Jenny Than
- Pharmacy Department Austin Health Heidelberg Australia
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11
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Murphy A, Kirby A, Bradley C. Monitoring of atrial fibrillation in primary care patients prescribed direct oral anticoagulants for stroke prevention. Ir J Med Sci 2020; 189:961-966. [PMID: 31900842 DOI: 10.1007/s11845-019-02150-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 11/20/2019] [Indexed: 01/14/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are widely marketed as medicines that do not require routine laboratory monitoring. However, they do have complex pharmacological properties and side effects; hence prescribing and monitoring guidelines, such as the European Heart Rhythm Association (EHRA) guidelines, have emerged. These advocate monitoring for renal and hepatic impairment; bleeding episodes; liver function; co-medication; circulation, and occurrence of side effects. Though 3 to 6 month follow-up is advocated, this is currently not routine, and its implementation creates a potential obligation for general practitioners (GPs) managing atrial fibrillation (AF) patients in the community. AIMS This study investigates the frequency, the type of follow-up, and the factors that influenced follow-up among Irish GPs, who prescribed DOACs to patients with AF, to prevent strokes in 2015. METHODS The frequency and type of follow-up care is estimated, and a count model regression analysis is applied to determine the GP and practice characteristics that are associated with the implementation of follow-up. RESULTS The EHRA guidelines most frequently followed were those pertaining to renal function (82%), bleeding episodes (71%), liver function (69%), circulation (54%), and side effects (55%). The regression analysis revealed that female GPs (P = 0.05) and GPs who follow all seven guidelines (P = 0.06) practice more frequent follow-up while those in training practices (P = 0.09) provide less frequent follow-up. CONCLUSIONS Results show that there was incomplete adherence to the 2013 EHRA prescribing guidelines with only 24% adhering to all seven guidelines, and patient follow-up was less frequent than has been suggested.
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Affiliation(s)
- Aileen Murphy
- Department of Economics, Cork University Business School, University College Cork, Aras na Laoi, Western Rd., Cork, Ireland.
| | - Ann Kirby
- Department of Economics, Cork University Business School, University College Cork, Aras na Laoi, Western Rd., Cork, Ireland
| | - Colin Bradley
- Department of General Practice, School of Medicine, Western Gateway Building, University College Cork, Cork, Ireland
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12
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Price V, Collins M, Eordogh A, Oatley H, Shapiro S. Anticoagulation: supporting safe and optimal primary care prescribing in a rapidly changing field. Br J Haematol 2019; 186:e17-e20. [PMID: 30843185 DOI: 10.1111/bjh.15850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Victoria Price
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Mary Collins
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Agnes Eordogh
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Susan Shapiro
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,NIHR Oxford Biomedical Research Centre, Oxford, UK
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Ng DLC, Gan GG, Chai CS, Chee KH, Tan KL, Tan SB, Bee PC. Comparing quality of life and treatment satisfaction between patients on warfarin and direct oral anticoagulants: a cross-sectional study. Patient Prefer Adherence 2019; 13:1363-1373. [PMID: 31616136 PMCID: PMC6698611 DOI: 10.2147/ppa.s204246] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 03/27/2019] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION AND AIM Patient quality of life (QOL) while on long-term oral anticoagulant therapy has been receiving greater attention in recent years due to the increase in life expectancy brought about by advances in medical care. This study aimed to compare the QOL, treatment satisfaction, hospitalization and bleeding rate in patients on long-term warfarin versus direct oral anticoagulants (DOAC). METHODS This was a cross-sectional study of patients with non-valvular atrial fibrillation (NVAF) or venous thromboembolism (VTE) on long-term anticoagulant therapy attending the cardiology clinic and anticoagulation clinic of the University Malaya Medical Centre from July 1, 2016, to June 30, 2018. Patient QOL was assessed by using the Short Form 12 Health Survey (SF12), while treatment satisfaction was assessed by using the Perception of Anticoagulation Treatment Questionnaire 2 (PACT-Q2). RESULTS A total of 208 patients were recruited; 52.4% received warfarin and 47.6% received DOAC. There was no significant difference in QOL between warfarin and DOAC based on SF12 (physical QOL, P=0.083; mental QOL, P=0.665). Nevertheless, patients in the DOAC group were significantly more satisfied with their treatment compared to the warfarin group based on PACT-Q2 (P=0.004). The hospitalisation rate was significantly higher in the warfarin group than the DOAC group (15.6% versus 3.0%, P=0.002). Clinically relevant minor bleeds and severe bleeding events were non-significantly higher in the warfarin group than the DOAC group (66.7% versus 40.0%, P=0.069). CONCLUSION Compared to warfarin, treatment of NVAF and VTE with DOAC showed comparable QOL, higher treatment satisfaction, lesser hospitalization, and a non-significant trend toward fewer bleeding episodes.
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Affiliation(s)
- Diana Leh-Ching Ng
- Department of Medicine, Faculty of Medicine and Health Science, University Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia
| | - Gin-Gin Gan
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
- Correspondence: Gin-Gin GanDepartment of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur50603, MalaysiaTel +60 37 949 2741Fax +60 37 955 6936Email
| | - Chee-Shee Chai
- Department of Medicine, Faculty of Medicine and Health Science, University Malaysia Sarawak, Kota Samarahan, Sarawak, Malaysia
| | - Kok-Han Chee
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Kok-Leng Tan
- Department of Medicine, Faculty of Medicine, University Science Malaysia, Penang, Malaysia
| | - Seng-Beng Tan
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Ping-Chong Bee
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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14
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Tillman BF, Gruber A, McCarty OJT, Gailani D. Plasma contact factors as therapeutic targets. Blood Rev 2018; 32:433-448. [PMID: 30075986 PMCID: PMC6185818 DOI: 10.1016/j.blre.2018.04.001] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Revised: 03/27/2018] [Accepted: 04/06/2018] [Indexed: 12/20/2022]
Abstract
Direct oral anticoagulants (DOACs) are small molecule inhibitors of the coagulation proteases thrombin and factor Xa that demonstrate comparable efficacy to warfarin for several common indications, while causing less serious bleeding. However, because their targets are required for the normal host-response to bleeding (hemostasis), DOACs are associated with therapy-induced bleeding that limits their use in certain patient populations and clinical situations. The plasma contact factors (factor XII, factor XI, and prekallikrein) initiate blood coagulation in the activated partial thromboplastin time assay. While serving limited roles in hemostasis, pre-clinical and epidemiologic data indicate that these proteins contribute to pathologic coagulation. It is anticipated that drugs targeting the contact factors will reduce risk of thrombosis with minimal impact on hemostasis. Here, we discuss the biochemistry of contact activation, the contributions of contact factors in thrombosis, and novel antithrombotic agents targeting contact factors that are undergoing pre-clinical and early clinical testing.
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Affiliation(s)
- Benjamin F Tillman
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Andras Gruber
- Department of Biomedical Engineering, Oregon Health & Sciences University, Portland, OR, USA; Division of Hematology and Medical Oncology School of Medicine, Oregon Health & Sciences University, Portland, OR, USA; Aronora, Inc., Portland, OR, USA
| | - Owen J T McCarty
- Department of Biomedical Engineering, Oregon Health & Sciences University, Portland, OR, USA; Division of Hematology and Medical Oncology School of Medicine, Oregon Health & Sciences University, Portland, OR, USA
| | - David Gailani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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15
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Charlesworth M, Arya R. Direct oral anticoagulants: peri-operative considerations and controversies. Anaesthesia 2018; 73:1460-1463. [DOI: 10.1111/anae.14455] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- M. Charlesworth
- Department of Cardiothoracic Anaesthesia; Wythenshawe Hospital; Manchester University Hospitals NHS Foundation Trust; Manchester UK
| | - R. Arya
- Department of Haematological Medicine; King's College Hospital NHS Foundation Trust; London UK
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16
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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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17
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Sennesael AL, Panin N, Vancraeynest C, Pochet L, Spinewine A, Haufroid V, Elens L. Effect of ABCB1 genetic polymorphisms on the transport of rivaroxaban in HEK293 recombinant cell lines. Sci Rep 2018; 8:10514. [PMID: 30002384 PMCID: PMC6043481 DOI: 10.1038/s41598-018-28622-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 06/18/2018] [Indexed: 12/18/2022] Open
Abstract
Direct oral anticoagulants (DOAC) are substrates for the ABCB1 transporter (also called P-glycoprotein), an active efflux pump. ABCB1 polymorphisms have been previously reported to influence the pharmacokinetics of several drugs such as immunosuppressants and tyrosine kinase inhibitors. Recently, in vivo studies have suggested that genetic variants might contribute to the inter-individual variability in DOAC plasma concentrations. Therefore, we evaluated the in vitro effect of the most common coding ABCB1 single nucleotide polymorphisms (SNP), 1236 C > T-2677G > T-3435C > T, and the coding ABCB1 1199 G > A SNP on the transport activity towards rivaroxaban. HEK293 cells were transfected to overexpress the ABCB1 wild-type (1236C-2677G-3435C, 1199 G) or variant proteins (1236C-2677G-3435T, 1236T-2677T-3435T or 1199 A). ABCB1 expression decreased the intracellular accumulation of rivaroxaban, when compared to control cells. This confirms the involvement of ABCB1 in the active transport of rivaroxaban. However, the ABCB1 1236 C > T-2677G > T-3435C > T and 1199 G > A SNPs had no significant influence on the intracellular accumulation of rivaroxaban when compared to the wild-type protein. These results suggest that the ABCB1 coding SNPs investigated in the present study are unlikely to contribute to the inter-individual variability in rivaroxaban plasma concentrations.
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Affiliation(s)
- Anne-Laure Sennesael
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain (UCL), Brussels, Belgium. .,Department of Pharmacy, Namur Research Institute for LIfe Sciences, Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium.
| | - Nadtha Panin
- Louvain Centre for Toxicology and Applied Pharmacology, Institut de Recherche Expérimentale et Clinique, UCL, Brussels, Belgium
| | - Christelle Vancraeynest
- Department of Pharmacy, Namur Research Institute for LIfe Sciences, Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
| | - Lionel Pochet
- Department of Pharmacy, Namur Research Institute for LIfe Sciences, Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
| | - Anne Spinewine
- Clinical Pharmacy Research Group, Louvain Drug Research Institute, Université catholique de Louvain (UCL), Brussels, Belgium.,Department of Pharmacy, NTHC, CHU UCL Namur, Yvoir, Belgium
| | - Vincent Haufroid
- Louvain Centre for Toxicology and Applied Pharmacology, Institut de Recherche Expérimentale et Clinique, UCL, Brussels, Belgium.,Department of Clinical Chemistry, Cliniques Universitaires Saint-Luc, UCL, Brussels, Belgium
| | - Laure Elens
- Louvain Centre for Toxicology and Applied Pharmacology, Institut de Recherche Expérimentale et Clinique, UCL, Brussels, Belgium.,Integrated PharmacoMetrics, PharmacoGenomics and PharmacoKinetics, Louvain Drug Research Institute, UCL, Brussels, Belgium
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18
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Rocca B, Fox KAA, Ajjan RA, Andreotti F, Baigent C, Collet JP, Grove EL, Halvorsen S, Huber K, Morais J, Patrono C, Rubboli A, Seljeflot I, Sibbing D, Siegbahn A, Ten Berg J, Vilahur G, Verheugt FWA, Wallentin L, Weiss TW, Wojta J, Storey RF. Antithrombotic therapy and body mass: an expert position paper of the ESC Working Group on Thrombosis. Eur Heart J 2018; 39:1672-1686f. [PMID: 29509886 DOI: 10.1093/eurheartj/ehy066] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 02/08/2018] [Indexed: 02/11/2024] Open
Affiliation(s)
- Bianca Rocca
- Institute of Pharmacology, Catholic University School of Medicine, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Keith A A Fox
- Centre for Cardiovascular Science, University and Royal Infirmary of Edinburgh, 51 Little France Cres, Edinburgh EH16 4SA, UK
| | - Ramzi A Ajjan
- Leeds Institute for Cardiovascular and Metabolic Medicine, the LIGHT Laboratories, University of Leeds, Leeds LS2?9JT, UK
| | - Felicita Andreotti
- Cardiovascular Department, Catholic University Hospital, Largo A. Gemelli 8, 00168 Rome, Italy
| | - Colin Baigent
- MRC Population Health Research Unit, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Roosevelt Drive, Oxford OX3 7LF, UK
| | - Jean-Philippe Collet
- Institute of Cardiology, Pitié-Salpêtrière Hospital (AP-HP), Sorbonne Université Paris 06 (UPMC), ACTION Study Group, INSERM UMR_S 1166, Groupe Hospitalier Pitié-Salpêtrière, 47-83 Bd de l'hopital, 75013 Paris, France
| | - Erik L Grove
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Palle Juul-Jensens Boulevard 82, 8200 Aarhus; Denmark
| | - Sigrun Halvorsen
- Department of Cardiology, Oslo University Hospital Ulleval and University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Kurt Huber
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna and Sigmund Freud University, Medical School, Kelsenstrasse 2, A-1030 Vienna, Austria
| | - João Morais
- Division of Cardiology, Leiria Hospital Center, R. de Santo André, 2410-197 Leiria, Portugal
| | - Carlo Patrono
- Institute of Pharmacology, Catholic University School of Medicine, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Andrea Rubboli
- Division of Cardiology, Laboratory of Interventional Cardiology, Ospedale Maggiore, Largo Nigrisoli 2, 40133 Bologna, Italy
| | - Ingebjorg Seljeflot
- Department of Cardiology, Center for Clinical Heart Research, Oslo University Hospital Ullevål and University of Oslo, P.O. Box 1171 Blindern, 0318 Oslo, Norway
| | - Dirk Sibbing
- Department of Cardiology, Munich University Clinic, Ludwig-Maximilians-Universität, Munich, Germany
- DZHK (German Center for Cardiovascular Research), partner site Munich Heart Alliance, Marchioninistrasse 15, 81377 Munich, Germany
| | - Agneta Siegbahn
- Department of Medical Sciences, Clinical Chemistry, Uppsala University, 751 85 Uppsala, Sweden
| | - Jurrien Ten Berg
- Department of Cardiology, St Antonius Hospital, Koekoekslaan 1, 3435 CM Nieuwegein, The Netherlands
| | - Gemma Vilahur
- Cardiovascular Science Institute-ICCC, IIB-Sant Pau, CiberCV, Hospital de Sant Pau, Avda. S. Antoni M. Claret 167, 08025 Barcelona, Spain
| | - Freek W A Verheugt
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis (OLVG), Oosterpark 9, 1091 AC Amsterdam, The Netherlands
| | - Lars Wallentin
- Department of Medical Sciences, Cardiology, Uppsala University & Uppsala Clinical Research Center, Uppsala Science Park, MTC, Dag Hammarskjölds väg 14B, SE-752 37 Uppsala, Sweden
| | - Thomas W Weiss
- 3rd Department of Medicine, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Montleartstrasse 37, A-1160 Vienna and Sigmund Freud University, Medical School, Kelsenstrasse 2, A-1030 Vienna, Austria
| | - Johann Wojta
- Department of Internal Medicine II, Medical University Vienna, Vienna, Austria
- Core Facilities, Medical University Vienna, Vienna, Austria
- Ludwig Boltzmann Cluster for Cardiovascular Research, Waehringer Guertel 18-20, A-1090 Vienna, Austria
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Beech Hill Road, Sheffield, South Yorkshire S10 2RX, UK
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19
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Tripodi A, Chantarangkul V, Legnani C, Testa S, Tosetto A. Interlaboratory variability in the measurement of direct oral anticoagulants: results from the external quality assessment scheme. J Thromb Haemost 2018; 16:565-570. [PMID: 29322630 DOI: 10.1111/jth.13949] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Indexed: 01/11/2023]
Abstract
Essentials Tests for direct oral anticoagulants (DOACs) are not widely applied. These tests are perceived to be difficult to run and subjected to large between-lab variation. We carried out proficiency testing surveys for DOAC testing in Italy. Interlab variability was small and similar to that of the international normalised ratio. SUMMARY Background Tests for direct oral anticoagulants (DOACs) are not widely available. The perception that they are difficult to perform and are subject to large between-laboratory variation makes their implementation difficult. Aims We carried out proficiency-testing surveys for DOACs within the activity of the external quality-assessment scheme of the Italian Federation of Thrombosis Centers. Design Participants were provided with coded freeze-dried plasmas without or with graded concentrations of the three main DOACs, and asked to measure prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time and DOAC concentrations with dedicated tests. The results were centralized for statistical analysis. Results and conclusions All participants (n = 235) reported results for PT and APTT, and approximately one-third reported results for DOAC concentration. PT and APTT showed variable responsiveness to DOACs: PT was more responsive to rivaroxaban than to dabigatran or apixaban. APTT was more responsive to dabigatran than to rivaroxaban or apixaban. The thrombin time ratio (test/normal) was close to unity for plasmas without dabigatran, and was high (i.e. 7.6-fold or 15.4-fold longer than the plasma free from the drug) for plasmas containing dabigatran at low (i.e. 42 ng mL-1 ) or high (i.e. 182 ng mL-1 ) concentration. Dedicated tests were responsive to the respective drugs, and their interlaboratory variability was relatively small (overall coefficients of variation of 8.7%, 8.4% or 10.3% for dabigatran, rivaroxaban and apixaban, respectively) and was comparable to that observed within the same survey for the International Normalized Ratio (i.e. 11.4%). In conclusion, tests for DOAC measurement performed reasonably well in a national quality-control scheme. Regulatory authorities should urgently issue recommendations on their use, and clinical laboratories should make them available.
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Affiliation(s)
- A Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy
- IRCCS Cà Granda Maggiore Hospital Foundation, Milan, Italy
| | - V Chantarangkul
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy
- IRCCS Cà Granda Maggiore Hospital Foundation, Milan, Italy
| | - C Legnani
- Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - S Testa
- Hemostasis and Thrombosis Center, Department of Laboratory Medicine, AO Istituti Ospitalieri, Cremona, Italy
| | - A Tosetto
- Hematology Department, S. Bortolo Hospital, Vicenza, Italy
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20
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Abstract
Anticoagulant drugs are widely used in hospital and community settings. Anticoagulation is the first-line treatment for venous thromboembolism, and anticoagulant drugs have an important role in the treatment and prevention of blood clots. However, maintaining the equilibrium between clotting and bleeding can be challenging and anticoagulants have been identified as a class of drug associated with preventable patient harm. Direct oral anticoagulants (DOACs) have become the first-line treatment for many patients requiring an anticoagulant, removing the burden of frequent tests and the many food and drug interactions associated with vitamin K antagonists such as warfarin sodium. However, DOACs have increased the complexity of decision-making regarding treatment, which also increases the risk of drug errors. This article discusses the uses, modes of action and potential side effects of anticoagulants, to improve nurses' understanding and enable them to have an active role in limiting the risk of harm from these drugs.
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Affiliation(s)
- Emma Gee
- Thrombosis and coagulation, King's College Hospital NHS Foundation Trust, London, England
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21
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Raschi E, Bianchin M, Fantoni C, Ageno W, De Ponti F, De Ponti R. Evolving cardiovascular uses of direct-acting oral anticoagulants: a paradigm shift on the horizon? Intern Emerg Med 2017; 12:923-934. [PMID: 28785902 DOI: 10.1007/s11739-017-1724-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/29/2017] [Indexed: 12/27/2022]
Abstract
Direct-acting oral anticoagulants (DOACs), by virtue of pharmacological properties perceived as innovative, are changing the therapeutic scenario of patients requiring short- and long-term anticoagulation. The evidence gathered so far (from pre-approval pivotal trials to real-world post-marketing observational data) consistently confirms that DOACs are overall comparable to vitamin-K antagonists (VKAs) in terms of safety, efficacy, effectiveness and unequivocally documents a clinically relevant reduced risk of intracranial bleeding in the settings of non-valvular atrial fibrillation (AF) and venous thromboembolism. The following issues are attracting considerable clinical interest: (a) identifying specific subpopulations of patients with AF most likely to benefit from one of these agents (the so-called tailored therapy), and (b) expanding therapeutic indications in emerging diseases characterized by arterial and venous thromboembolic risk. In these scenarios, the risk-benefit profile of DOACs, as compared to VKAs or heparins, is still incompletely characterized. In cardiology, the challenging task of selecting a suitable or even the most appropriate DOAC for patients with AF and a particular phenotype prompted experts to provide suggestions based on careful review of subgroups of patients from pivotal RCTs. However, in the past few months, variegated multicenter trials have been published (RE-CIRCUIT, PIONEER-AF-PCI, GEMINI-ACS-1), with potential influence on clinical practice. Therefore, this review aims to update the latest evidence on the evolving therapeutic uses of DOACs in the cardiovascular area, addressing potential impact for clinicians.
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Affiliation(s)
- Emanuel Raschi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, BO, Italy
| | - Matteo Bianchin
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, BO, Italy
| | - Cecilia Fantoni
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fabrizio De Ponti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, Via Irnerio 48, 40126, Bologna, BO, Italy.
| | - Roberto De Ponti
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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