1
|
Simon SJ, Patell R, Zwicker JI, Kazi DS, Hollenbeck BL. Venous Thromboembolism in Total Hip and Total Knee Arthroplasty. JAMA Netw Open 2023; 6:e2345883. [PMID: 38039005 PMCID: PMC10692868 DOI: 10.1001/jamanetworkopen.2023.45883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/23/2023] [Indexed: 12/02/2023] Open
Abstract
Importance The optimal pharmacologic thromboprophylaxis agent after total hip and total knee arthroplasty is uncertain and consensus is lacking. Quantifying the risk of postoperative venous thromboembolism (VTE) and bleeding and evaluating comparative effectiveness and safety of the thromboprophylaxis strategies can inform care. Objective To quantify risk factors for postoperative VTE and bleeding and compare patient outcomes among pharmacological thromboprophylaxis agents used after total hip and knee arthroplasty. Design, Setting, and Participants This retrospective cohort study used data from a large health care claims database. Participants included patients in the United States with hip or knee arthroplasty and continuous insurance enrollment 3 months prior to and following their surgical procedure. Patients were excluded if they received anticoagulation before surgery, received no postsurgical pharmacological thromboprophylaxis, or had multiple postsurgery thromboprophylactic agents. In a propensity-matched analysis, patients receiving a direct oral anticoagulant (DOAC) were matched with those receiving aspirin. Exposures Aspirin, apixaban, rivaroxaban, enoxaparin, or warfarin. Main Outcomes and Measures The primary outcome was 30-day cumulative incidence of postdischarge VTE. Other outcomes included postdischarge bleeding. Results Among 29 264 patients included in the final cohort, 17 040 (58.2%) were female, 27 897 (95.2%) had inpatient admissions with median (IQR) length of stay of 2 (1-2) days, 10 948 (37.4%) underwent total hip arthroplasty, 18 316 (62.6%) underwent total knee arthroplasty; and median (IQR) age was 59 (55-63) years. At 30 days, cumulative incidence of VTE was 1.19% (95% CI, 1.06%-1.32%) and cumulative incidence of bleeding was 3.43% (95% CI, 3.22%-3.64%). In the multivariate analysis, leading risk factors associated with increased VTE risk included prior VTE history (odds ratio [OR], 5.94 [95% CI, 4.29-8.24]), a hereditary hypercoagulable state (OR, 2.64 [95% CI, 1.32-5.28]), knee arthroplasty (OR, 1.65 [95% CI, 1.29-2.10]), and male sex (OR, 1.34 [95% CI, 1.08-1.67]). In a propensity-matched cohort of 7844 DOAC-aspirin pairs, there was no significant difference in the risk of VTE in the first 30 days after the surgical procedure (OR, 1.14 [95% CI, 0.82-1.59]), but postoperative bleeding was more frequent in patients receiving DOACs (OR, 1.36 [95% CI, 1.13-1.62]). Conclusions and Relevance In this cohort study of patients who underwent total hip or total knee arthroplasty, underlying patient risk factors, but not choice of aspirin or DOAC, were associated with postsurgical VTE. Postoperative bleeding rates were lower in patients prescribed aspirin. These results suggest that thromboprophylaxis strategies should be patient-centric and tailored to individual risk of thrombosis and bleeding.
Collapse
Affiliation(s)
- Samantha J Simon
- Research Department, New England Baptist Hospital, Boston, Massachusetts
| | - Rushad Patell
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jeffrey I Zwicker
- Hematology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dhruv S Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Brian L Hollenbeck
- Research Department, New England Baptist Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
2
|
Cohen O, Levy-Mendelovich S, Budnik I, Ludan N, Lyskov SK, Livnat T, Avishai E, Efros O, Lubetsky A, Lalezari S, Misgav M, Brutman-Barazani T, Kenet G, Barg AA. Management of surgery in persons with hemophilia A receiving emicizumab prophylaxis: data from a national hemophilia treatment center. Res Pract Thromb Haemost 2023; 7:102178. [PMID: 37876894 PMCID: PMC10593567 DOI: 10.1016/j.rpth.2023.102178] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 07/06/2023] [Accepted: 07/09/2023] [Indexed: 10/26/2023] Open
Abstract
Background Persons with hemophilia A may require surgical procedures. Real-world data on invasive procedures in persons with hemophilia A receiving emicizumab prophylaxis are limited. Objectives To evaluate the safety of invasive procedures in persons with hemophilia A receiving emicizumab prophylaxis and their outcomes in a longitudinally followed cohort. Methods Data from medical records of persons with hemophilia A with and without factor VIII (FVIII) inhibitors longitudinally followed at our tertiary center, who received emicizumab prophylaxis and underwent all types of invasive procedures, were retrieved. Outcomes of interest were bleeding and thrombotic complications. Results Overall, 35 patients underwent 56 invasive procedures, 18 (32.1%) were major. The median age was 36.3 years (IQR, 8.8-55.9 years); 12 patients (34.3%) were younger than 18 years at the time of procedure; 17 (48.6%) were patients with FVIII inhibitors. Among major procedures, orthopedic surgeries prevailed. All patients who underwent major procedures received factor replacement with either recombinant activated factor VII (patients with inhibitors) or FVIII (patients without inhibitors). Factor concentrates were administered prior to 32 (84.2%) of the minor procedures. Repeated doses were given according to international expert opinion recommendations and patients' condition.There were 7 bleeding events in 6 patients, 5 were major bleeds, including 1 patient who underwent a minor procedure without factor replacement. None of the patients experienced a thrombotic complication. Conclusion Invasive procedures can be performed safely in patients receiving emicizumab prophylaxis with close surveillance after surgery. Factor concentrates may be advised in selected patients undergoing minor procedures.
Collapse
Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Sarina Levy-Mendelovich
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Sheba Talpiot Medical leadership program, Sheba Medical Center, Tel Hashomer, Israel
| | - Ivan Budnik
- Division of Hematology/Oncology, Department of Internal Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Noa Ludan
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Tami Livnat
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Einat Avishai
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orly Efros
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aharon Lubetsky
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shadan Lalezari
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Mudi Misgav
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tami Brutman-Barazani
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gili Kenet
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Assaf A. Barg
- National Hemophilia Center, Institute of Thrombosis and Hemostasis, Sheba Medical Center, Tel-HaShomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
3
|
Comparative Effectiveness and Safety of Drug Prophylaxis for Prevention of Venous Thromboembolism After Total Knee Arthroplasty. J Arthroplasty 2017. [PMID: 28634095 DOI: 10.1016/j.arth.2017.05.042] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Rates of venous thromboembolism in contemporary studies of primary total knee arthroplasty (TKA) have been reported to be as high as 3.5%. Although drug prophylaxis is effective, the best option among these regimens is not well established. The purpose of this study was to evaluate the comparative effectiveness and safety of aspirin, low-molecular-weight heparin, synthetic pentasaccharide factor Xa inhibitors, and vitamin K antagonist. METHODS Data were from a US total joint replacement registry, with 30,499 patients receiving unilateral TKA from May 16, 2006, to December 31, 2013. Patients received either aspirin (324-325 mg daily), enoxaparin (40-60 mg daily), fondaparinux (2.5 mg daily), or warfarin (all doses) and were followed up 90 days postoperatively on several outcomes: deep vein thrombosis, pulmonary embolism, major bleeding, wound complications, infection, and death. RESULTS There was no evidence that fondaparinux, enoxaparin, or warfarin were superior to aspirin in the prevention of pulmonary embolism, deep vein thrombosis, or venous thromboembolism or that aspirin was safer than these alternatives. However, enoxaparin was found to be as safe as aspirin with respect to bleeding, and fondaparinux was as safe as aspirin for risk of wound complications. CONCLUSION Among TKA patients, we did not find evidence for decreased effectiveness or increased safety with use of aspirin, but enoxaparin had comparable safety to aspirin for bleeding and fondaparinux had comparable safety to aspirin for wound complications.
Collapse
|
4
|
Ficheur G, Caron A, Beuscart JB, Ferret L, Putman S, Beuscart R, Chazard E. The risks of pulmonary embolism and upper gastrointestinal bleeding beyond 35days after total hip replacement for coxarthrosis among middle-aged patients: A cross-over cohort. Prev Med 2016; 93:121-127. [PMID: 27612575 DOI: 10.1016/j.ypmed.2016.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 08/03/2016] [Accepted: 09/05/2016] [Indexed: 11/25/2022]
Abstract
Prophylactic anticoagulation is recommended up to 35days after total hip replacement (THR). Although several observational studies have assessed the incidence of thrombotic events or bleeding events after THR, the corresponding measures of association have never been studied concomitantly. Here, we evaluated the duration of the elevated risks (relative to the baseline risk) of both venous thromboembolic events and bleeding events after THR for coxarthrosis among middle-aged patients. This was a population-based, cross-over cohort study of data extracted from the French national inpatient database between 2007 and 2013. We included middle-aged patients (aged 45 to 69) having undergone THR for coxarthrosis. We compared the numbers of pulmonary embolisms (PEs) (respectively upper gastrointestinal bleedings (UGIBs)) following the THR with the numbers occurring during three unexposed periods one year later. This enabled us to estimate the odds ratio (OR) [95% confidence interval (CI)] for each of six successive 35-day intervals. The study included 108,099 patients. The ORs for PE were respectively 12.4 (95% CI, 8.6-17.8) (absolute risk difference rate per 100,000 (ARD/100,000)=130) and 5.0 (95% CI, 3.4-7.4) (ARD/100,000=52) for the first two 35-day intervals, and the risk was close to 1 thereafter. The risk of UGIB fell quickly, with an OR of 6.5 (95% CI, 4.6-9.1) (ARD/100,000=83) and 0.8 (95% CI, 0.4-1.6) for the first two 35-day intervals, respectively. The majority of UGIBs occurred during the inpatient stay for THR. Among middle-aged patients, the risk of a PE remains elevated beyond 35days after THR for coxarthrosis, whereas the risk of a UGIB remains elevated for the first 35days only.
Collapse
Affiliation(s)
- Grégoire Ficheur
- Univ. Lille EA 2694, CHU Lille, Department of Public Health, F-59000 Lille, France.
| | - Alexandre Caron
- Univ. Lille EA 2694, CHU Lille, Department of Public Health, F-59000 Lille, France
| | | | - Laurie Ferret
- CHU Lille, Department of Pharmacy, F-59000 Lille, France
| | - Sophie Putman
- CHU Lille, Department of Orthopedic Surgery, F-59000 Lille, France
| | - Régis Beuscart
- Univ. Lille EA 2694, CHU Lille, Department of Public Health, F-59000 Lille, France
| | - Emmanuel Chazard
- Univ. Lille EA 2694, CHU Lille, Department of Public Health, F-59000 Lille, France
| |
Collapse
|
5
|
Results of rotational thromboelastometry, coagulation activation markers and thrombin generation assays in orthopedic patients during thromboprophylaxis with rivaroxaban and enoxaparin. Blood Coagul Fibrinolysis 2015; 26:136-44. [DOI: 10.1097/mbc.0000000000000203] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
6
|
Lin CF, Liu JC, Chi NF, Chiu YS, Hsu HS, Chien LN. The effect of osteoarthritis on 1-year risk of ischemic heart disease following total knee arthroplasty. J Arthroplasty 2014; 29:2447-2451.e1. [PMID: 24612737 DOI: 10.1016/j.arth.2014.01.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2013] [Revised: 12/09/2013] [Accepted: 01/27/2014] [Indexed: 02/01/2023] Open
Abstract
To evaluate the long-term risk of ischemic heart disease (IHD) following total knee arthroplasty (TKA), we conducted a retrospective cohort study using data from the National Health Insurance Research Database of Taiwan. We evaluated 3599 primary TKA patients and 14,396 matched control patients. We further classified all patients into those with and without osteoarthritis (OA). The incidence rate of IHD was significantly higher among the TKA patients than among the matched control patients (1.13 vs 0.69 per 1000 person-months, P<.05). However, after controlling for OA, this difference was non-significant (HR=1.18, 95% confidence interval (CI): 0.63-2.20, P>.05). Our study results indicate that underlying OA conditions are predominantly responsible for increased long-term risk of IHD in TKA patients.
Collapse
Affiliation(s)
- Chao-Feng Lin
- Institution of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Internal Medicine, Division of Cardiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Ju-Chi Liu
- Department of Internal Medicine, Division of Cardiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Nai-Fang Chi
- Department of Neurology, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Yen-Shuo Chiu
- Department of Orthopedics, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Han-Shui Hsu
- Institution of Emergency and Critical Care Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Li-Nien Chien
- School of Health Care Administration, Taipei Medical University, Taipei, Taiwan
| |
Collapse
|
7
|
Oberweis BS, Nukala S, Rosenberg A, Guo Y, Stuchin S, Radford MJ, Berger JS. Thrombotic and bleeding complications after orthopedic surgery. Am Heart J 2013; 165:427-33.e1. [PMID: 23453114 DOI: 10.1016/j.ahj.2012.11.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2012] [Accepted: 11/19/2012] [Indexed: 10/27/2022]
Abstract
BACKGROUND Thrombotic and bleeding complications are major concerns during orthopedic surgery. Given the frequency of orthopedic surgical procedures and the limited data in the literature, we sought to investigate the incidence and risk factors for thrombotic (myocardial necrosis and infarction) and bleeding events in patients undergoing orthopedic surgery. METHODS AND RESULTS We performed a retrospective cohort analysis of 3,082 consecutive subjects ≥21 years of age undergoing hip, knee, or spine surgery between November 1, 2008, and December 31, 2009. Patient characteristics were ascertained using International Classification of Diseases, Ninth Revision, diagnosis coding and retrospective review of medical records, and laboratory/blood bank databases. In-hospital outcomes included myocardial necrosis (elevated troponin), major bleeding, coded myocardial infarction, and coded hemorrhage as defined by International Classification of Diseases, Ninth Revision, coding. Of the 3,082 subjects, mean age was 60.8 ± 13.3 years, and 59% were female. Myocardial necrosis, coded myocardial infarction, major bleeding, and coded hemorrhage occurred in 179 (5.8%), 20 (0.7%), 165 (5.4%), and 26 (0.8%) subjects, respectively. Increasing age (P < .001), coronary artery disease (P < .001), cancer (P = .004), and chronic kidney disease (P = .01) were independent predictors of myocardial necrosis, whereas procedure type (P < .001), cancer (P < .001), female sex (P < .001), coronary artery disease (P < .001), and chronic obstructive pulmonary disease (P = .01) were independent predictors of major bleeding. CONCLUSION There is a delicate balance between thrombotic and bleeding events in the perioperative period after orthopedic surgery. Perioperative risk of both thrombosis and bleeding deserves careful attention in preoperative evaluation, and future prospective studies aimed at attenuating this risk are warranted.
Collapse
|
8
|
Lalmohamed A, Vestergaard P, Cooper C, de Boer A, Leufkens HG, van Staa TP, de Vries F. Timing of Stroke in Patients Undergoing Total Hip Replacement and Matched Controls. Stroke 2012; 43:3225-9. [DOI: 10.1161/strokeaha.112.668509] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Arief Lalmohamed
- From the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, the Netherlands (A.L., A.D.B., H.G.M.L., T.P.V.S., F.D.V.); the Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands (A.L.); Medical Faculty, Aalborg University, Aalborg, Denmark (P.V.); MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, United Kingdom (C.C., T.P.V.S., F.D.V.); Institute of Musculoskeletal
| | - Peter Vestergaard
- From the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, the Netherlands (A.L., A.D.B., H.G.M.L., T.P.V.S., F.D.V.); the Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands (A.L.); Medical Faculty, Aalborg University, Aalborg, Denmark (P.V.); MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, United Kingdom (C.C., T.P.V.S., F.D.V.); Institute of Musculoskeletal
| | - Cyrus Cooper
- From the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, the Netherlands (A.L., A.D.B., H.G.M.L., T.P.V.S., F.D.V.); the Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands (A.L.); Medical Faculty, Aalborg University, Aalborg, Denmark (P.V.); MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, United Kingdom (C.C., T.P.V.S., F.D.V.); Institute of Musculoskeletal
| | - Anthonius de Boer
- From the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, the Netherlands (A.L., A.D.B., H.G.M.L., T.P.V.S., F.D.V.); the Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands (A.L.); Medical Faculty, Aalborg University, Aalborg, Denmark (P.V.); MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, United Kingdom (C.C., T.P.V.S., F.D.V.); Institute of Musculoskeletal
| | - Hubertus G.M. Leufkens
- From the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, the Netherlands (A.L., A.D.B., H.G.M.L., T.P.V.S., F.D.V.); the Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands (A.L.); Medical Faculty, Aalborg University, Aalborg, Denmark (P.V.); MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, United Kingdom (C.C., T.P.V.S., F.D.V.); Institute of Musculoskeletal
| | - Tjeerd P. van Staa
- From the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, the Netherlands (A.L., A.D.B., H.G.M.L., T.P.V.S., F.D.V.); the Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands (A.L.); Medical Faculty, Aalborg University, Aalborg, Denmark (P.V.); MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, United Kingdom (C.C., T.P.V.S., F.D.V.); Institute of Musculoskeletal
| | - Frank de Vries
- From the Division of Pharmacoepidemiology and Clinical Pharmacology, Utrecht Institute of Pharmaceutical Sciences, Utrecht, the Netherlands (A.L., A.D.B., H.G.M.L., T.P.V.S., F.D.V.); the Department of Clinical Pharmacy, University Medical Center Utrecht, Utrecht, The Netherlands (A.L.); Medical Faculty, Aalborg University, Aalborg, Denmark (P.V.); MRC Lifecourse Epidemiology Unit, Southampton General Hospital, Southampton, United Kingdom (C.C., T.P.V.S., F.D.V.); Institute of Musculoskeletal
| |
Collapse
|
9
|
Lowe GDO. Epidemiology of venous thromboembolism: the need for large (including prospective) studies and meta-analyses. J Thromb Haemost 2012; 10:2186-8. [PMID: 22888854 DOI: 10.1111/j.1538-7836.2012.04882.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
10
|
Miesbach W, Seifried E. New direct oral anticoagulants--current therapeutic options and treatment recommendations for bleeding complications. Thromb Haemost 2012; 108:625-32. [PMID: 22782297 DOI: 10.1160/th12-05-0319] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 06/21/2012] [Indexed: 12/22/2022]
Abstract
To date, clinical studies show that the incidence of spontaneous bleeding with new direct oral anticoagulants (DOAs) is comparable to that of established anticoagulants. However, unlike vitamin K antagonists, there are currently no clinically available antidotes or approved reversal agents for new DOAs. Restoring normal coagulation is important in many cases, such as emergency surgeries, serious bleedings, or anticoagulant overdosing. Attempts have been made to restore normal coagulation after treatment with new DOAs using compounds such as recombinant activated factor VII (rFVIIa), prothrombin complex concentrate (PCC), or FEIBA (factor eight inhibitor bypassing activity). Limited pre-clinical data and even less clinical evidence are available on the usefulness of these methods in restoring normal coagulation for the emergency management of critical bleeding episodes. Evaluating the utility of DOAs is further complicated by the fact that it is unknown how predictive established test systems are of the bleeding risks. Clinical practice requires further evaluation of the emergency management options for the new DOAs to define the agents and the doses that are most useful. Furthermore, patients receiving long-term treatment with a DOA are likely to undergo elective surgery at some point, and there is lack of evidence regarding perioperative treatment regimens under such conditions. This review summarises potential bleeding management options and available data on the new DOAs.
Collapse
Affiliation(s)
- Wolfgang Miesbach
- Medical Clinic III, Institute of Transfusion Medicine, University Hospital, Frankfurt/Main, Germany.
| | | |
Collapse
|