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Grottke O, Afshari A, Ahmed A, Arnaoutoglou E, Bolliger D, Fenger-Eriksen C, von Heymann C. Clinical guideline on reversal of direct oral anticoagulants in patients with life threatening bleeding. Eur J Anaesthesiol 2024; 41:327-350. [PMID: 38567679 DOI: 10.1097/eja.0000000000001968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Anticoagulation is essential for the treatment and prevention of thromboembolic events. Current guidelines recommend direct oral anticoagulants (DOACs) over vitamin K antagonists in DOAC-eligible patients. The major complication of anticoagulation is serious or life-threatening haemorrhage, which may necessitate prompt haemostatic intervention. Reversal of DOACs may also be required for patients in need of urgent invasive procedures. This guideline from the European Society of Anaesthesiology and Intensive Care (ESAIC) aims to provide evidence-based recommendations and suggestions on how to manage patients on DOACs undergoing urgent or emergency procedures including the treatment of DOAC-induced bleeding. DESIGN A systematic literature search was performed, examining four drug comparators (dabigatran, rivaroxaban, apixaban, edoxaban) and clinical scenarios ranging from planned to emergency surgery with the outcomes of mortality, haematoma growth and thromboembolic complications. The GRADE (Grading of Recommendations, Assessment, Development and Evaluation) methodology was used to assess the methodological quality of the included studies. Consensus on the wording of the recommendations was achieved by a Delphi process. RESULTS So far, no results from prospective randomised trials comparing two active comparators (e.g. a direct reversal agent and an unspecific haemostatic agent such as prothrombin complex concentrate: PCC) have been published yet and the majority of publications were uncontrolled and observational studies. Thus, the certainty of evidence was assessed to be either low or very low (GRADE C). Thirty-five recommendations and clinical practice statements were developed. During the Delphi process, strong consensus (>90% agreement) was achieved in 97.1% of recommendations and consensus (75 to 90% agreement) in 2.9%. DISCUSSION DOAC-specific coagulation monitoring may help in patients at risk for elevated DOAC levels, whereas global coagulation tests are not recommended to exclude clinically relevant DOAC levels. In urgent clinical situations, haemostatic treatment using either the direct reversal or nonspecific haemostatic agents should be started without waiting for DOAC level monitoring. DOAC levels above 50 ng ml-1 may be considered clinically relevant necessitating haemostatic treatment before urgent or emergency procedures. Before cardiac surgery under activated factor Xa (FXa) inhibitors, the use of andexanet alfa is not recommended because of inhibition of unfractionated heparin, which is needed for extracorporeal circulation. In the situation of DOAC overdose without bleeding, no haemostatic intervention is suggested, instead measures to eliminate the DOACs should be taken. Due to the lack of published results from comparative prospective, randomised studies, the superiority of reversal treatment strategy vs. a nonspecific haemostatic treatment is unclear for most urgent and emergency procedures and bleeding. Due to the paucity of clinical data, no recommendations for the use of recombinant activated factor VII as a nonspecific haemostatic agent can be given. CONCLUSION In the clinical scenarios of DOAC intake before urgent procedures and DOAC-induced bleeding, practitioners should evaluate the risk of bleeding of the procedure and the severity of the DOAC-induced bleeding before initiating treatment. Optimal reversal strategy remains to be determined in future trials for most clinical settings.
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Affiliation(s)
- Oliver Grottke
- From the Department of Anaesthesiology, RWTH Aachen University Hospital, Pauwelsstrasse, Aachen, Germany (OG), Department of Paediatric and Obstetric Anaesthesia, Juliane Marie Centre, Rigshospitalet; & Department of Clinical Medicine, Copenhagen University, Denmark (AA), Department of Anaesthesia and Critical Care, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester (AA), Department of Cardiovascular Sciences, University of Leicester, Leicester, UK (AA), Department of Anaesthesiology, Larissa University Hospital, Larissa, Greece (EA), Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Spitalstrasse, Basel, Switzerland (DB), Department of Anaesthesiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard, Aarhus, Denmark (CF-E) and Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Landsberger Allee, Berlin, Germany (CvH)
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OUP accepted manuscript. Lab Med 2022; 53:349-359. [DOI: 10.1093/labmed/lmac005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Onundarson PT, Palsson R, Witt DM, Gudmundsdottir BR. Replacement of traditional prothrombin time monitoring with the new Fiix prothrombin time increases the efficacy of warfarin without increasing bleeding. A review article. Thromb J 2021; 19:72. [PMID: 34654442 PMCID: PMC8520310 DOI: 10.1186/s12959-021-00327-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 10/06/2021] [Indexed: 12/13/2022] Open
Abstract
The antithrombotic effect of vitamin K antagonists (VKA) depends on controlled lowering of the activity of factors (F) II and X whereas reductions in FVII and FIX play little role. PT-INR based monitoring, however, is highly influenced by FVII, which has the shortest half-life of vitamin K-dependent coagulation factors. Hence, variability in the anticoagulant effect of VKA may be partly secondary to an inherent flaw of the traditional monitoring test itself. The Fiix prothrombin time (Fiix-PT) is a novel test that is only sensitive to reductions in FII and FX and is intended to stabilize the VKA effect. Two clinical studies have now demonstrated that when warfarin is monitored with the Fiix-PT based normalized ratio (Fiix-NR) instead of PT-INR, anticoagulation is stabilized and less testing and fewer dose adjustments are needed. Furthermore, the relative risk of thromboembolism was reduced by 50-56% in these studies without an increase in major bleeding.
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Affiliation(s)
- Pall T Onundarson
- Central Laboratory/Hematology, Landspitali National University Hospital of Iceland and University of Iceland Faculty of Medicine, Hringbraut, 101 Reykjavik, Reykjavik, Iceland.
| | - Ragnar Palsson
- Nephrology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, UT, USA
| | - Brynja R Gudmundsdottir
- Central Laboratory/Hematology, Landspitali National University Hospital of Iceland , Reykjavik, Iceland
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McRae HL, Militello L, Refaai MA. Updates in Anticoagulation Therapy Monitoring. Biomedicines 2021; 9:262. [PMID: 33800804 PMCID: PMC8001784 DOI: 10.3390/biomedicines9030262] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/27/2021] [Accepted: 03/03/2021] [Indexed: 11/29/2022] Open
Abstract
In the past six decades, heparin and warfarin were the primary anticoagulants prescribed for treatment and prophylaxis of venous thromboembolism worldwide. This has been accompanied by extensive clinical knowledge regarding dosing, monitoring, and reversal of these anticoagulants, and the resources required to do so have largely been readily available at small and large centers alike. However, with the advent of newer oral and parenteral anticoagulants such as low molecular weight heparins, factor Xa inhibitors, and direct thrombin inhibitors in recent years, new corresponding practice guidelines have also emerged. A notable shift in the need for monitoring and reversal agents has evolved as well. While this has perhaps streamlined the process for physicians and is often desirable for patients, it has also left a knowledge and resource gap in clinical scenarios for which urgent reversal and monitoring is necessary. An overview of the currently available anticoagulants with a focus on the guidelines and available tests for anticoagulant monitoring will be discussed in this article.
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Affiliation(s)
| | | | - Majed A. Refaai
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, Hemostasis and Thrombosis Unit, University of Rochester Medical Center, Rochester, NY 14642, USA; (H.L.M.); (L.M.)
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Lachuer C, Benzengli H, Do B, Rwabihama JP, Leglise P. Oral anticoagulants: Interventional pharmaceutical study with reminder of good practices, and iatrogenic impact. ANNALES PHARMACEUTIQUES FRANÇAISES 2021; 79:409-417. [PMID: 33516717 DOI: 10.1016/j.pharma.2021.01.004] [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: 08/24/2020] [Revised: 12/04/2020] [Accepted: 01/06/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Study of the impact of geriatricians' training on the improvement of their prescribing practices, and comparison of iatrogenesis between the two classes of oral anticoagulants. MATERIAL AND METHODS Before/after and here/there comparison between a trained prescribers group and a control group, before and after the pharmacist intervention, with comparison of the iatrogenesis of two oral anticoagulant classes. Patients in the acute and post-acute geriatric departments treated with a vitamin K antagonist or a direct oral anticoagulant were included. Criteria for Good practice were rated according to a scale of severity: calculation of a score and a percentage of compliance per patient, and then an average of the percentage of compliance (main criterion) within the populations to be compared. The proportion of iatrogenic elements between the two classes was compared. We used statistical tests (significance threshold of 5%). RESULTS Vitamin K antagonist: a decreasing trend in the control group (P=0.086) and an increasing trend in the trained group (P=0.183) was observed in prescription compliance before/after training. Direct oral anticoagulants: the compliance before/after decreased in the control group (P=0.005) and increased in the trained group (P=0.024). After training, compliance is higher among the group of trained prescribers for both vitamin K antagonist (P=0.018) and direct oral anticoagulant (P=0.003). The proportion of iatrogenic events in the two oral anticoagulants classes was not significantly different. CONCLUSIONS Interest of good practice reminders in the quality of oral anticoagulants prescriptions with no difference in safety of use between the two classes.
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Affiliation(s)
- C Lachuer
- Pharmacy, Hôpital Joffre-Dupuytren, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 1, rue Eugène Delacroix, 91210 Draveil, France.
| | - H Benzengli
- Pharmacy, Hôpital Joffre-Dupuytren, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 1, rue Eugène Delacroix, 91210 Draveil, France.
| | - B Do
- Pharmacy, Hôpital Henri Mondor, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 51, Avenue du Maréchal de Lattre de Tassigny, 94010 Créteil, France.
| | - J-P Rwabihama
- Geriatric Department, Hôpital Joffre-Dupuytren, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 1, rue Eugène Delacroix, 91210 Draveil, France.
| | - P Leglise
- Pharmacy, Hôpital Joffre-Dupuytren, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, 1, rue Eugène Delacroix, 91210 Draveil, France.
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Oladosu FA, Tu FF, Garrison EF, Dillane KE, Roth GE, Hellman KM. Low Serum Naproxen Concentrations Are Associated with Minimal Pain Relief: A Preliminary Study in Women with Dysmenorrhea. PAIN MEDICINE 2020; 21:3102-3108. [PMID: 32488234 DOI: 10.1093/pm/pnaa133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Incomplete pain relief after administration of nonsteroidal anti-inflammatory drugs (NSAIDs) is common, but it is unknown whether malabsorption or heightened metabolism contributes to NSAID resistance. To explain the etiology of NSAID resistance, we evaluated naproxen absorption and metabolism in relation to pain relief in a pilot study of women with dysmenorrhea. METHODS During menses, participants completed before and after naproxen ingestion pain assessments. Analgesic effectiveness was calculated as a percent change in pain rating before and after naproxen administration. To evaluate the impact of malabsorption, the correlation between analgesic effectiveness and serum naproxen was analyzed. To identify whether hypermetabolism contributes to NSAID resistance, we also analyzed the metabolite O-desmethylnaproxen. RESULTS Serum naproxen and O-desmethylnaproxen concentrations of the dysmenorrheic cohort (N = 23, 126 ± 10 µg/mL, 381 ± 56 ng/mL) and healthy controls (N = 12, 135 ± 8 µg/mL, 355 ± 58 ng/mL) were not significantly different (P > 0.05), suggesting that menstrual pain does not affect drug absorption and metabolism. However, nine dysmenorrhea participants had levels of analgesic effectiveness <30%. Among dysmenorrheic women, analgesic effectiveness was correlated with serum naproxen (r = 0.49, P = 0.019) and O-desmethylnaproxen (r = 0.45, P = 0.032) concentrations. After controlling for other gynecological diagnoses, a multivariate model analysis confirmed that lower serum naproxen concentrations were associated with reduced pain relief (P = 0.038). CONCLUSIONS Our preliminary findings suggest that poor drug absorption contributes to ineffective pain relief in dysmenorrheic women. Future studies should explore whether malabsorption contributes to NSAID resistance for other pain conditions.
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Affiliation(s)
- Folabomi A Oladosu
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem & Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Frank F Tu
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem & Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Ellen F Garrison
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, Ilinois, USA
| | - Katlyn E Dillane
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, Ilinois, USA
| | - Genevieve E Roth
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, Ilinois, USA
| | - Kevin M Hellman
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem & Pritzker School of Medicine, University of Chicago, Chicago, Illinois, USA
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