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Hindley B, Lip GYH, McCloskey AP, Penson PE. Pharmacokinetics and pharmacodynamics of direct oral anticoagulants. Expert Opin Drug Metab Toxicol 2023; 19:911-923. [PMID: 37991392 DOI: 10.1080/17425255.2023.2287472] [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: 06/07/2023] [Accepted: 11/21/2023] [Indexed: 11/23/2023]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) have overtaken vitamin K antagonists to become the most widely used method of anticoagulation for most indications. Their stable and predictable pharmacokinetics combined with relatively simple dosing, and the absence of routine monitoring has made them an attractive proposition for healthcare providers. Despite the benefits of DOACs as a class, important differences exist between individual DOAC drugs in respect of their pharmacokinetic and pharmacodynamic profiles with implications for dosing and reversal in cases of major bleeding. AREAS COVERED This review summarizes the state of knowledge relating to the pharmacokinetics of dabigatran (factor IIa/thrombin inhibitor) and apixaban, edoxaban and rivaroxaban (factor Xa) inhibitors. We focus on pharmacokinetic differences between the drugs which may have clinically significant implications. EXPERT OPINION Patient-centered care necessitates a careful consideration of the pharmacokinetic and pharmacodynamic differences between DOACs, and how these relate to individual patient circumstances. Prescribers should be aware of the potential for pharmacokinetic drug interactions with DOACs which may influence prescribing decisions in patients with multiple comorbidities. In order to give an appropriate dose of DOAC drugs, accurate estimation of renal function using the Cockcroft-Gault formula using actual body weight is necessary. An increasing body of evidence supports the use of DOACs in patients who are obese, and this is becoming more routine in clinical practice.
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Affiliation(s)
- B Hindley
- Pharmacy Department, Aintree University Hospital, Liverpool, UK
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
| | - G Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - A P McCloskey
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - P E Penson
- Clinical Pharmacy and Therapeutics Research Group, School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
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2
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Zhou H, Wu M, Yu S, Xia H, Yu W, Huang K, Chen Y. Comparison of the efficacy and safety between rivaroxaban and dabigatran in the treatment of acute portal vein thrombosis in cirrhosis. BMC Gastroenterol 2023; 23:329. [PMID: 37749527 PMCID: PMC10521568 DOI: 10.1186/s12876-023-02960-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/15/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND New oral anticoagulants (NOACs) have been becoming prevalent in recent years and are increasingly used in the treatment of port vein thrombosis. The difference of the efficacy and safety between rivaroxaban and dabigatran remains unclear in the treatment of cirrhotic patients with acute portal vein thrombosis (PVT). METHODS This retrospective study included all consecutive cirrhotic patients with acute portal vein thrombosis in our institute from January 2020 to December 2021. The patients received oral anticoagulation with rivaroxaban or dabigatran. The demographic, clinical, and imaging data of patients were collected. The diagnosis of acute PVT was confirmed by imaging examinations. The severity of liver cirrhosis was assessed using Child-Pugh score and Model for End-Stage Liver Disease (MELD) score. Outcomes included recanalization (complete, partial, and persistent occlusion), liver function, bleedings, and survival. The log-rank test was used to compare Kaplan-Meier distributions of time-to-event outcomes. The Cox proportional hazards model was used to calculate hazard ratios (HRs) with 95% confidence intervals (CIs). RESULTS A total of 94 patients were included, 52 patients (55%) received rivaroxaban and 42 (45%) with dabigatran. The complete and partial recanalization of PVT was observed in 41 patients. There was no significant difference in complete recanalization, partial recanalization, and persistent occlusion between the two groups. With multivariate analysis, D-dimer (HR 1.165, 95% CI 1.036-1.311, p = 0.011) was independent predictors of complete recanalization. The Child-Pugh score (p = 0.001) was significantly improved in both two groups after anticoagulation, respectively. However, there was no difference between the two groups. The probability of survival was 94%, 95% in the rivaroxaban and dabigatran groups (log-rank p = 0.830). Major bleedings were reported in 3 patients (6%) in rivaroxaban group and 1 patient (2%) in dabigatran group (p = 0.646). Six patients (12%) in rivaroxaban group experienced minor bleeding, and five (12%) from dabigatran group (p = 0.691). CONCLUSIONS The efficacy and safety were comparable between rivaroxaban and dabigatran in the treatment of cirrhotic patients with acute portal vein thrombosis. And D-dimer can contribute to the prediction of PVT recanalization in cirrhotic patients.
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Affiliation(s)
- Haonan Zhou
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| | - Mingdong Wu
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| | - Shixiong Yu
- Department of General Surgery, The First Affiliated Hospital of Chongqing Medical and Pharmaceutical College, Chongqing, 400060 People’s Republic of China
| | - Han Xia
- Department of Cardiothoracic Surgery, Second Clinical Hospital, Army Medical University, Chongqing, 400000 People’s Republic of China
| | - Wu Yu
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| | - Kai Huang
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
| | - Yikuan Chen
- Department of Vascular Surgery, The Second Affiliated Hospital of Chongqing Medical University, #76 Linjiang Road, Yuzhong District, Chongqing, 400010 People’s Republic of China
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Seagull FJ, Lanham MS, Pomorski M, Callahan M, Jones EK, Barnes GD. Implementing evidence-based anticoagulant prescribing: User-centered design findings and recommendations. Res Pract Thromb Haemost 2022; 6:e12803. [PMID: 36110900 PMCID: PMC9464620 DOI: 10.1002/rth2.12803] [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: 04/04/2022] [Revised: 07/20/2022] [Accepted: 08/17/2022] [Indexed: 11/08/2022] Open
Abstract
Background Direct oral anticoagulants (DOACs) are widely used medications with an unacceptably high rate of prescription errors and are a leading cause of adverse drug events. Clinical decision support, including medication alerts, can be an effective implementation strategy to reduce prescription errors, but quality is often inconsistent. User‐centered design (UCD) approaches can improve the effectiveness of alerts. Objectives To design effective DOAC prescription alerts through UCD and develop a set of generalizable design recommendations Methods This study used an iterative UCD process with practicing clinicians. In three rapid iterative design and assessment stages, prototype alert designs were created and refined using a test electronic health record (EHR) environment and simulated patients. We identified key emergent themes across all user observations and interviews. The themes and final designs were used to derive a set of design guidelines. Results Our UCD sample comprised 13 prescribers, including advanced practice providers, physicians in training, primary care physicians, and cardiologists. The resulting alert designs embody our design recommendations, which include establishing intended indication, clarifying dosing by renal function, tailoring alert language in drug interactions, facilitating trust in alerts, and minimizing interaction overhead. Conclusions Through a robust UCD process, we have identified key recommendations for implementing medication alerts aimed at improving evidence‐based DOAC prescribing. These recommendations may be applicable to the implementation of DOAC alerts in any EHR systems.
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Affiliation(s)
- F Jacob Seagull
- Center for Bioethics and Social Science in Medicine Michigan Medicine Ann Arbor Michigan USA
| | - Michael S Lanham
- Obstetrics and Gynecology Michigan Medicine Ann Arbor Michigan USA.,Department of Learning Health Sciences Michigan Medicine Ann Arbor Michigan USA.,Menlo Innovations Ann Arbor Michigan USA
| | | | | | | | - Geoffrey D Barnes
- Internal Medicine and Cardiovascular Medicine Michigan Medicine Ann Arbor Michigan USA
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Paparazzo E, Geracitano S, Lagani V, Soraci L, Cozza A, Cosimo S, Morelli F, Corsonello A, Passarino G, Montesanto A. Clinical and Prognostic Implications of Estimating Glomerular Filtration Rate by Three Different Creatinine-Based Equations in Older Nursing Home Residents. Front Med (Lausanne) 2022; 9:870835. [PMID: 35559339 PMCID: PMC9087281 DOI: 10.3389/fmed.2022.870835] [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: 02/07/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
Background According to the international literature, the percentage of nursing home (NH) residents with renal insufficiency is very high, ranging between 22 and 78%. Diminished kidney function represents a risk factor for drug overdosage, adverse drug reactions, end-stage renal disease, disability, morbidity, and mortality. Several studies suggested that screening for chronic kidney disease (CKD) in high-risk and older populations may represent a cost-effective approach to reducing progression to renal failure and CKD mortality. Objective This study aimed (i) to investigate to what extent CKD may be staged interchangeably by three different creatinine-based estimated glomerular filtration rate (eGFR) equations in a sample of older adults living in long-term care facilities; (ii) to investigate factors explaining differences among eGFR equations; and (iii) to compare the predictivity of different creatinine-based eGFR equations with respect to all-cause mortality. Methods A total of 522 residents aged 65 years and older participated in a prospective cohort study of 9 long-term care facilities in Calabria. eGFR was calculated by Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), Berlin initiative study (BIS), and full age spectrum (FAS) equations. Disability in at least one activity of daily living (ADL), depression, cognitive impairment, comorbidity, and malnutrition was considered in the analysis. Statistical analysis was carried out by Bland-Altman analysis, and 2-year mortality was investigated by Kaplan-Meier curves and Cox regression analysis. Results Depending on the adopted equation, the prevalence of NH residents with impaired renal function (eGFR < 60 ml/min/1.73 m2) ranged between 58.2% for the CKD-EPI and 79.1% for the BIS1 equation. The average difference between BIS and FAS was nearly negligible (0.45 ml/min/1.73 m2), while a significant bias was detected between CKD-EPI and BIS and also between CKD-EPI and FAS (6.21 ml/min/1.73 m2 and 6.65 ml/min/1.73 m2, respectively). Although the eGFR study equations had comparable prognostic accuracy in terms of mortality risk, BIS and FAS were able to reclassify NH residents pertaining to a low-risk group with CKD-EPI, and this reclassification improves the discriminative capacity of CKD-EPI with respect to overall mortality. Conclusion Despite the relatively good correlation between eGFRs calculated using all adopted equations, the findings in this study reported clearly demonstrated that CKD-EPI and BIS/FAS equations are not interchangeable to assess eGFR among older people and particularly in institutionalized and frail older subjects.
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Affiliation(s)
- Ersilia Paparazzo
- Department of Biology, Ecology and Earth Sciences, University of Calabria, Rende, Italy
| | - Silvana Geracitano
- Department of Biology, Ecology and Earth Sciences, University of Calabria, Rende, Italy
| | - Vincenzo Lagani
- Institute of Chemical Biology, Ilia State University, Tbilisi, Georgia.,Biological and Environmental Sciences and Engineering Division (BESE), King Abdullah University of Science and Technology (KAUST), Thuwal, Saudi Arabia
| | - Luca Soraci
- Unit of Geriatric Medicine, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
| | - Annalisa Cozza
- Laboratory of Pharmacoepidemiology and Biostatistics, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
| | | | | | - Andrea Corsonello
- Unit of Geriatric Medicine, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy.,Laboratory of Pharmacoepidemiology and Biostatistics, Italian National Research Center on Aging (IRCCS INRCA), Cosenza, Italy
| | - Giuseppe Passarino
- Department of Biology, Ecology and Earth Sciences, University of Calabria, Rende, Italy
| | - Alberto Montesanto
- Department of Biology, Ecology and Earth Sciences, University of Calabria, Rende, Italy
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Rohla M, Pecen L, Cemin R, Patti G, Siller-Matula JM, Schnabel RB, Huber K, Kirchhof P, De Caterina R. Reclassification, Thromboembolic, and Major Bleeding Outcomes Using Different Estimates of Renal Function in Anticoagulated Patients With Atrial Fibrillation: Insights From the PREFER-in-AF and PREFER-in-AF Prolongation Registries. Circ Cardiovasc Qual Outcomes 2021; 14:e006852. [PMID: 34078099 DOI: 10.1161/circoutcomes.120.006852] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND The Cockcroft-Gault formula is recommended to determine a renal indication for dose reduction of dabigatran, edoxaban, and rivaroxaban. Nephrology guidelines now recommend the Modification of Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formulae as more accurate estimates of glomerular filtration rate. METHODS We analyzed anticoagulated patients with atrial fibrillation who were enrolled in the Prevention of Thromboembolic Events - European Registry in Atrial Fibrillation (PREFER in AF). The proportion of patients with dissimilar renal dosing indications was assessed when applying Cockcroft-Gault, MDRD, or CKD-EPI. Thromboembolic and major bleeding events at 1 year were compared in patients in whom Cockcroft-Gault and CKD-EPI provided concordant or discordant results around a threshold of 50 mL/minute. RESULTS Out of 1288 patients with atrial fibrillation with chronic kidney disease in whom Cockcroft-Gault suggested a dose reduction of dabigatran, edoxaban, or rivaroxaban (creatinine clearance ≤50 mL/minutes), 19% and 16% were reclassified to the respective higher doses, and 24% and 23% to the respective lower doses by applying the MDRD and CKD-EPI formulae, respectively. In patients potentially receiving a different dose of dabigatran, edoxaban, or rivaroxaban when using CKD-EPI, we observed an excess of thromboembolic events (4.1% versus 0.8%; odds ratio, 5.5 [95% CI, 1.5-20.8]; P=0.01). Major bleeding rates were nonsignificantly different in the discordance versus concordance group (5.7% versus 2.7%; odds ratio, 2.2 [95% CI, 0.9-5.6]; P=0.09). CONCLUSIONS The MDRD and CKD-EPI formulae suggest a different dosing in up to a quarter of anticoagulated patients with atrial fibrillation. This seems to impact hard outcomes.
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Affiliation(s)
- Miklos Rohla
- 3 Medical Department, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria (M.R., K.H.).,Institute for Cardiometabolic Diseases, Karl Landsteiner Society, St. Pölten, Austria (M.R.)
| | - Ladislav Pecen
- Medical Faculty Pilsen, Charles University, Czech Republic (L.P.)
| | - Roberto Cemin
- Department of Cardiology, San Maurizio Regional Hospital of Bolzano, Italy (R.C.)
| | - Giuseppe Patti
- University of Eastern Piedmont, Maggiore della Carità Hospital of Novara, Italy (G.P.)
| | - Jolanta M Siller-Matula
- Department of Cardiology, Medical University of Vienna, Austria (J.M.S.-M.).,Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Poland (J.M.S.-M.)
| | - Renate B Schnabel
- University Heart Center Hamburg, Clinic for General and Interventional Cardiology, Hamburg, Germany and DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany (R.B.S.)
| | - Kurt Huber
- 3 Medical Department, Cardiology and Intensive Care Medicine, Wilhelminenhospital, Vienna, Austria (M.R., K.H.).,Sigmund Freud University, Medical School, Vienna, Austria (K.H.)
| | - Paulus Kirchhof
- University of Birmingham Institute of Cardiovascular Sciences, University of Birmingham, UHB and SWBH NHS Trusts, United Kingdom (P.K.)
| | - Raffaele De Caterina
- Chair of Cardiology, University of Pisa and Cardiology Division, Pisa University Hospital, Italy (R.D.C.)
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6
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Goutelle S, Bleyzac N, Mioux L, de la Gastine B, Bourguignon L. Estimating renal function when adjusting the dosage of antibiotics: Facts and fables. Infect Dis Now 2021; 51:635-637. [PMID: 33870894 DOI: 10.1016/j.idnow.2021.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/17/2021] [Accepted: 01/21/2021] [Indexed: 11/30/2022]
Affiliation(s)
- S Goutelle
- Service de pharmacie, Hospices Civils de Lyon, groupement hospitalier Nord, Lyon, France; Laboratoire de Biométrie et Biologie Evolutive UMR CNRS 5558 & ISPB, faculté de pharmacie de Lyon, université Lyon, université Lyon 1, Lyon, France.
| | - N Bleyzac
- Service de pharmacie, Hospices Civils de Lyon, groupement hospitalier Nord, Lyon, France
| | - L Mioux
- Service de pharmacie, Hospices Civils de Lyon, groupement hospitalier Nord, Lyon, France
| | - B de la Gastine
- Service de gériatrie, Hospices Civils de Lyon, groupement hospitalier Nord, hôpital Pierre-Garraud, Lyon, France
| | - L Bourguignon
- Service de pharmacie, Hospices Civils de Lyon, groupement hospitalier Nord, Lyon, France; Laboratoire de Biométrie et Biologie Evolutive UMR CNRS 5558 & ISPB, faculté de pharmacie de Lyon, université Lyon, université Lyon 1, Lyon, France
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7
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Kobalava ZD, Shavarov AA, Vatsik-Gorodetskaya MV. Direct Oral Anticoagulants in Patients with Atrial Fibrillation and Renal Dysfunction. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2021. [DOI: 10.20996/1819-6446-2021-02-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Atrial fibrillation and renal dysfunction often coexist, each disorder may predispose to the other and contribute to worsening prognosis. Both atrial fibrillation and chronic kidney disease are associated with increased risk of stroke and thromboembolic complications. Oral anticoagulation for stroke prevention is therefore recommended in patients with atrial fibrillation and decreased renal function. Each direct oral anticoagulant has unique pharmacologic properties of which clinician should be aware to optimally manage patients. The doses of direct oral anticoagulants require adjustment for renal function. There is debate regarding which equation, the Chronic Kidney Disease Epidemiology (CKD-EPI) equation vs. the Cockcroft-Gault equation, should be used to estimate glomerular filtration rate in patients with atrial fibrillation treated with direct oral anticoagulants. Our review tries to find arguments for benefit of direct oral anticoagulants in patients with renal dysfunction.
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Affiliation(s)
- Z. D. Kobalava
- Peoples Friendship University of Russia (RUDN University)
| | - A. A. Shavarov
- Peoples Friendship University of Russia (RUDN University)
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8
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Position paper on the safety/efficacy profile of direct oral anticoagulants in patients with chronic kidney disease. Consensus document from the SIN, FCSA and SISET. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 18:478-485. [PMID: 33000751 DOI: 10.2450/2020.0156-20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 05/26/2020] [Indexed: 12/15/2022]
Abstract
Direct oral anticoagulants (DOAC) are mostly prescribed to prevent cardioembolic stroke in patients with non-valvular atrial fibrillation (AF). An increasing number of guidelines recommend DOAC in AF patients with preserved renal function for the prevention of thromboembolism, and an increased use of DOAC in daily practice has been recorded also in elderly patients. Ageing is associated with a reduction in glomerular filtration rate, and impaired renal function, regardless of the cause, increases the risk of bleeding. Multiple medication use (polypharmacy) for treating superimposed co-morbidities is common in both elderly and chronic kidney disease (CKD) patients and drug-drug interaction may cause accumulation of DOAC, thereby increasing the risk of bleeding. The safety profile of DOAC in patients with CKD has not been defined with any certainty, particularly in those with severely impaired renal function or end stage renal disease. This has been due to the heterogeneity of studies and the relative paucity of data. This document reports the position of three Italian scientific societies engaged in the management of patients with atrial fibrillation who are treated with DOAC and present with CKD.
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Speed V, Green B, Roberts LN, Woolcombe S, Bartoli-Abdou J, Barsam S, Byrne R, Gee E, Czuprynska J, Brown A, Duffy S, Vadher B, Patel R, Scott V, Gazes A, Patel RK, Arya R, Patel JP. Fixed dose rivaroxaban can be used in extremes of bodyweight: A population pharmacokinetic analysis. J Thromb Haemost 2020; 18:2296-2307. [PMID: 32511863 DOI: 10.1111/jth.14948] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/28/2020] [Accepted: 05/26/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Emerging safety and efficacy data for rivaroxaban suggest traditional therapy and rivaroxaban are comparable in the morbidly obese. However, real-world data that indicate pharmacokinetic (PK) parameters are comparable at the extremes of body size are lacking. The International Society of Thrombosis and Haemostasis Scientific and Standardisation Committee (ISTH SSC) suggests avoiding the use of direct oral anticoagulants (DOACs) in patients weighing >120 kg or with a body mass index >40 kg/m2 and gives no recommendation on the use of DOACs in those <50 kg. OBJECTIVES To generate a population PK model to understand the influence of bodyweight on rivaroxaban exposure from clinical practice data. METHOD Rivaroxaban plasma concentrations and patient characteristics were collated between 2013 and 2018 at King's College Hospital anticoagulation clinic. A population PK model was developed using a nonlinear mixed effects approach and then used to simulate rivaroxaban concentrations at the extremes of bodyweight. RESULTS A robust population PK model derived from 913 patients weighing between 39 kg and 172 kg was developed. The model included data from n = 86 >120 kg, n = 74 BMI >40 kg/m2 , and n = 30 <50 kg. A one-compartment model with between-subject variability on clearance and a proportional error model best described the data. Creatinine clearance calculated by Cockcroft-Gault, with lean bodyweight as the weight descriptor in this equation, was the most significant covariate influencing rivaroxaban exposure. CONCLUSIONS Our work demonstrates rivaroxaban can be used at extremes of bodyweight provided renal function is satisfactory. We recommend that the ISTH SSC revises the current guidance with respect to rivaroxaban at extremes of body size.
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Affiliation(s)
- Victoria Speed
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King's College London, London, UK
| | | | - Lara N Roberts
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Sarah Woolcombe
- Department of Oral Surgery, King's College Hospital NHS Foundation Trust, London, UK
| | - John Bartoli-Abdou
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Sarah Barsam
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Rosalind Byrne
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Emma Gee
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Julia Czuprynska
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Alison Brown
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Sinead Duffy
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Bipin Vadher
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Rachna Patel
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Valerie Scott
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Anna Gazes
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Raj K Patel
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Roopen Arya
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Jignesh P Patel
- King's Thrombosis Centre, Department of Haematological Medicine, King's College Hospital NHS Foundation Trust, London, UK
- Institute of Pharmaceutical Science, King's College London, London, UK
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Grandone E, Aucella F, Barcellona D, Brunori G, Forneris G, Gresele P, Marietta M, Poli D, Testa S, Tripodi A, Genovesi S. Position paper on the safety/efficacy profile of Direct Oral Anticoagulants in patients with Chronic Kidney Disease: Consensus document of Società Italiana di Nefrologia (SIN), Federazione Centri per la diagnosi della trombosi e la Sorveglianza delle terapie Antitrombotiche (FCSA) and Società Italiana per lo Studio dell'Emostasi e della Trombosi (SISET). J Nephrol 2020; 34:31-38. [PMID: 32757171 PMCID: PMC7881955 DOI: 10.1007/s40620-020-00768-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/29/2020] [Indexed: 12/20/2022]
Abstract
Direct oral anticoagulants (DOAC) are mostly prescribed to prevent cardioembolic stroke in patients with non-valvular atrial fibrillation (AF). An increasing number of guidelines recommend DOAC in AF patients with preserved renal function for the prevention of thromboembolism and an increased use of DOAC in daily practice is recorded also in elderly patients. Aging is associated with a reduction of glomerular filtration rate and impaired renal function, regardless of the cause, increases the risk of bleeding. Multiple medication use (polypharmacy) for treating superimposed co-morbidities is common in both elderly and chronic kidney disease (CKD) patients and drug-drug interaction may cause accumulation of DOAC, thereby increasing the risk of bleeding. There is uncertainty on the safety profile of DOAC in patients with CKD, particularly in those with severely impaired renal function or end stage renal disease, due to the heterogeneity of studies and the relative paucity of data. This document reports the position of three Italian scientific societies engaged in the management of patients with atrial fibrillation who are treated with DOAC and present with CKD.
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Affiliation(s)
- Elvira Grandone
- Thrombosis and Haemostasis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy.,Ob/Gyn Department of the First I.M. Sechenov, Moscow State Medical University, Moscow, Russia
| | - Filippo Aucella
- Nephrology and Dialysis Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Doris Barcellona
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.,SHRO Temple University, Philadelphia, USA
| | | | - Giacomo Forneris
- Department of Clinical and Biological Sciences, University of Turin, Turin, Italy
| | - Paolo Gresele
- Department of Medicine, Section of Internal and Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Marco Marietta
- Department of Medical and Surgical Sciences, Section of Hematology, University of Modena and Reggio Emilia, Modena, Italy
| | - Daniela Poli
- Center for Atherothrombotic Diseases, Azienda Ospedaliero-Universitaria Careggi, Firenze, Italy
| | - Sophie Testa
- Haemostasis and Thrombosis Center, ASST Cremona, Cremona, Italy
| | - Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Simonetta Genovesi
- University of Milan-Bicocca, Milano, Italy. .,Nephrology Unit, San Gerardo Hospital, Monza, Italy.
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11
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Clinical Implications of Estimating Glomerular Filtration Rate with Three Different Equations Among Older People. Preliminary Results of the Project "Screening for Chronic Kidney Disease among Older People across Europe (SCOPE)". J Clin Med 2020; 9:jcm9020294. [PMID: 31973029 PMCID: PMC7074235 DOI: 10.3390/jcm9020294] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Revised: 01/09/2020] [Accepted: 01/15/2020] [Indexed: 12/17/2022] Open
Abstract
We aimed at investigating to what extent CKD may be staged interchangeably by three different eGFR equations in older people, and evaluating the source of discrepancies among equations in a population of 2257 patients older than 75 years enrolled in a multicenter observational study. eGFR was calculated by CKD-EPI, BIS and FAS equations. Statistical analysis was carried out by Bland–Altman analysis. κ statistic was used to quantify the agreement between equations in classifying CKD stages. The impact of selected variables on the difference among equations was graphically explored. The average difference between BIS and FAS was −0.24 (95% limits of agreement (95%LA = −4.64–4.14) mL/min/1.73 m2. The difference between CKD-EPI and BIS and between CKD-EPI and FAS was 8.97 (95%LA = −2.90–20.84) and 8.72 (95%LA = −2.11–19.56) mL/min/1.73 m2, respectively. As regards CKD stage classification, κ value was 0.47 for both CKD-EPI vs. FAS and CKD-EPI vs. BIS, while BIS and FAS had similar classificatory properties (κ = 0.90). Muscle mass was found related to the difference between CKD-EPI and BIS (R2 = 0.11) or FAS (R2 = 0.14), but not to the difference between BIS and FAS. In conclusion, CKD-EPI and BIS/FAS equations are not interchangeable to assess eGFR among older people. Muscle mass may represent a relevant source of discrepancy among eGFR equations.
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12
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Chan Y, Lee H, Wang C, Chang S, Yeh C, Chao T, Yeh Y, Chen S, Kuo C. Comparisons of Rivaroxaban Following Different Dosage Criteria (ROCKET AF or J-ROCKET AF Trials) in Asian Patients With Atrial Fibrillation. J Am Heart Assoc 2019; 8:e013053. [PMID: 31623498 PMCID: PMC6898830 DOI: 10.1161/jaha.119.013053] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background The ROCKET AF (Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared with Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation) evaluated rivaroxaban (20/15 mg/d) versus warfarin in patients with atrial fibrillation. A separate trial, J‐ROCKET AF (Japanese ROCKET AF), compared rivaroxaban (15/10 mg/d) and warfarin in Japanese patients with atrial fibrillation. Data about rivaroxaban following J‐ROCKET AF criteria compared with warfarin and ROCKET AF dosage were limited. Methods and Results This retrospective study used medical data from a multicenter healthcare provider in Taiwan that included 3162 patients taking rivaroxaban. Among 2320 patients with an estimated glomerular filtration rate (eGFR) ≥50 mL/min per 1.73 m2, 384 and 1936 patients followed the ROCKET AF (20 mg/d) and J‐ROCKET AF (15 mg/d) recommendation, respectively. Among 842 patients with an eGFR <50 mL/min per 1.73 m2, 422 and 420 patients followed the ROCKET AF (15 mg/d) and J‐ROCKET AF (10 mg/d) recommendation, respectively. A total of 2053 patients with atrial fibrillation receiving warfarin were identified. Rivaroxaban following either ROCKET AF or J‐ROCKET AF dosage criteria was associated with a comparable risk of thromboembolism but a lower risk of bleeding than warfarin. For patients with an eGFR ≥50 mL/min per 1.73 m2, risks of clinical events did not differ significantly between the 2 dosage criteria of rivaroxaban. For patients with an eGFR <50 mL/min per 1.73 m2, the ROCKET AF dosage was associated with a higher risk of major bleeding compared with the J‐ROCKET AF dosage (hazard ratio, 2.70; P=0.0445) without significant differences regarding the risk of ischemic events. Conclusions In Asian patients with atrial fibrillation, the J‐ROCKET AF dosage was as effective as the ROCKET AF dosage irrespective of renal function. The risk of major bleeding was lower with the J‐ROCKET AF dosage in patients with an eGFR <50 mL/min per 1.73 m2. Compared with warfarin, rivaroxaban following either dosage criteria was effective and even safer.
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Affiliation(s)
- Yi‐Hsin Chan
- The Cardiovascular DepartmentChang Gung Memorial HospitalLinkou, TaoyuanTaiwan
- College of MedicineChang Gung UniversityTaoyuanTaiwan
- Microscopy Core LaboratoryChang Gung Memorial HospitalLinkou, TaoyuanTaiwan
| | - Hsin‐Fu Lee
- The Cardiovascular DepartmentChang Gung Memorial HospitalLinkou, TaoyuanTaiwan
- College of MedicineChang Gung UniversityTaoyuanTaiwan
- Graduate Institute of Clinical Medical SciencesCollege of MedicineChang Gung UniversityTaoyuanTaiwan
| | - Chun‐Li Wang
- The Cardiovascular DepartmentChang Gung Memorial HospitalLinkou, TaoyuanTaiwan
- College of MedicineChang Gung UniversityTaoyuanTaiwan
| | - Shang‐Hung Chang
- The Cardiovascular DepartmentChang Gung Memorial HospitalLinkou, TaoyuanTaiwan
- College of MedicineChang Gung UniversityTaoyuanTaiwan
- Center for Big Data Analytics and StatisticsChang Gung Memorial HospitalTaoyuanTaiwan
| | - Chih‐Hsin Yeh
- Center for Big Data Analytics and StatisticsChang Gung Memorial HospitalTaoyuanTaiwan
| | - Tze‐Fan Chao
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- Institute of Clinical Medicine, and Cardiovascular Research CenterNational Yang‐Ming UniversityTaipeiTaiwan
| | - Yung‐Hsin Yeh
- The Cardiovascular DepartmentChang Gung Memorial HospitalLinkou, TaoyuanTaiwan
- College of MedicineChang Gung UniversityTaoyuanTaiwan
| | - Shih‐Ann Chen
- Division of CardiologyDepartment of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- Institute of Clinical Medicine, and Cardiovascular Research CenterNational Yang‐Ming UniversityTaipeiTaiwan
| | - Chi‐Tai Kuo
- The Cardiovascular DepartmentChang Gung Memorial HospitalLinkou, TaoyuanTaiwan
- College of MedicineChang Gung UniversityTaoyuanTaiwan
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13
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Simpson BH, Reith DM, Medlicott NJ, Smith AJ. Choice of Renal Function Estimator Influences Adverse Outcomes with Dabigatran Etexilate in Patients with Atrial Fibrillation. TH OPEN 2019; 2:e420-e427. [PMID: 31249970 PMCID: PMC6524914 DOI: 10.1055/s-0038-1676356] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 10/15/2018] [Indexed: 12/12/2022] Open
Abstract
Background
Clinical significance of dosing dabigatran with different estimates of renal function for treatment of atrial fibrillation (AF) is unknown. Renal function is routinely estimated by the chronic kidney disease epidemiology initiative equation (CKD-EPI) and used to guide dosing. The aim of this study was to investigate the risk of adverse outcomes for patients with AF when different estimators of renal function are used.
Material and Methods
AF patient data were extracted from national administrative databases. Renal function was estimated using Cockcroft–Gault, CKD-EPI, and CKD-EPI adjusted for body surface area (CKD-EPI-BSA). Outcomes of cerebrovascular accident (CVA), systemic embolism (SE), and hemorrhage were extracted.
Results
In total, 2,425 patients were identified, of which there were hospitalizations for 138 (5.7%) hemorrhagic events, 45 (1.9%) CVA/SE, and 33 (1.4%) unspecified CVA. The level of agreement between Cockcroft–Gault with CKD-EPI and CKD-EPI-BSA yielded a weighted kappa statistic of 0.47 and 0.71, respectively. CKD-EPI and CKD-EPI-BSA significantly overestimated renal function in elderly patients resulting in higher recommended doses compared with Cockcroft–Gault. The hazard ratio for a hemorrhagic event was 2.32 (95% confidence interval, 1.22–4.42;
p
= 0.01) when a high dose was given compared with normal dose, based on Cockcroft–Gault.
Conclusion
Both CKD-EPI and CKD-EPI-BSA equations significantly overestimated renal function in the elderly population compared with the Cockcroft–Gault equation. This may lead to dose selection errors for dabigatran, particularly for those with severe impairment, increasing the risk of adverse outcome. Hence, CKD-EPI and CKD-EPI-BSA equations should not be substituted for the Cockcroft–Gault equation in the elderly for the purpose of renal dosage adjustments.
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Affiliation(s)
- Bryan H Simpson
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - David M Reith
- Dunedin Medical School, University of Otago, Dunedin, New Zealand
| | | | - Alesha J Smith
- School of Pharmacy, University of Otago, Dunedin, New Zealand
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14
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Affiliation(s)
- David Erskine
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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15
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Almarshad F, Alaklabi A, Bakhsh E, Pathan A, Almegren M. Use of direct oral anticoagulants in daily practice. AMERICAN JOURNAL OF BLOOD RESEARCH 2018; 8:57-72. [PMID: 30697449 PMCID: PMC6334188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 10/19/2018] [Indexed: 06/09/2023]
Abstract
In recent years, the options for anticoagulant therapy have examined new direct oral anticoagulants (DOACs) comprising direct thrombin inhibitors (dabigatran) and direct factor Xa inhibitors (rivaroxaban, apixaban, and edoxaban). These agents represent further progress towards the ideal anticoagulant drug and thus towards a safe and effective antithrombotic therapy. The ideal anticoagulant is oral and has a wide therapeutic range, predictable pharmacokinetics and pharmacodynamics, a rapid onset of action, an available antidote, minimal side effects, and minimal interactions with other drugs or food. This review addresses the practical considerations for physicians in DOAC use, including indication, dosage, monitoring, pharmacokinetic profile, drug-drug interaction, and reversal of direct anticoagulation effects in case of bleeding.
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Affiliation(s)
| | - Ali Alaklabi
- Department of Medicine, King Abdulaziz Medical CityRiyadh, Saudi Arabia
| | - Ebtisam Bakhsh
- College of Medicine, Princess Nourah Bint Abdulrahman UniversityRiyadh, Saudi Arabia
| | - Aslam Pathan
- College of Medicine, Shaqra UniversityShaqra, Saudi Arabia
| | - Mosaad Almegren
- College of Medicine, Al-Imam Mohammad Ibn Saud Islamic UniversityRiyadh, Saudi Arabia
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16
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Discrepancy Between Equations Estimating Kidney Function in Geriatric Care: A Study of Implications for Drug Prescription. Drugs Aging 2018; 36:155-163. [DOI: 10.1007/s40266-018-0618-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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17
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Houlind MB, Petersen KK, Palm H, Jørgensen LM, Aakjær M, Christrup LL, Petersen J, Andersen O, Treldal C. Creatinine-Based Renal Function Estimates and Dosage of Postoperative Pain Management for Elderly Acute Hip Fracture Patients. Pharmaceuticals (Basel) 2018; 11:E88. [PMID: 30231578 PMCID: PMC6160960 DOI: 10.3390/ph11030088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 09/13/2018] [Accepted: 09/14/2018] [Indexed: 12/12/2022] Open
Abstract
Many analgesics and their metabolites are renally excreted. The widely used Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)-estimated glomerular filtration rate (eGFR) equations are not developed for use in the elderly, while the recent Berlin Initiative Study (BIS), Full Age Spectrum (FAS), and Lund-Malmö revised (LMR) equations are. This observational study investigated differences between creatinine-based eGFR equations and how the choice of equation influences dosage of analgesics in elderly (≥70 years) patients admitted with acute hip fracture. eGFR was calculated by the CKD-EPI, BIS, Cockcroft-Gault (CG), FAS, LMR, and Modification of Diet in Renal Disease (MDRD) equations. Standard daily dose for postoperative pain medications ibuprofen, morphine and gabapentin was simulated for each equation according to dosage recommendations in Renbase®. For 118 patients, mean eGFR from the CKD-EPI, BIS, CG, FAS, LMR, and MDRD equations was 67.3 mL/min/1.73 m², 59.1 mL/min/1.73 m², 56.9 mL/min/1.73 m², 60.3 mL/min/1.73 m², 58.9 mL/min/1.73 m², and 79.1 mL/min/1.73 m², respectively (p < 0.0001). Mean difference to CKD-EPI was -10.4 mL/min/1.73 m² to 11.8 mL/min/1.73 m². Choice of eGFR equation significantly influenced the recommended dose (p < 0.0001). Shifting to BIS, FAS, or LMR equations led to a lower recommended dose in 20% to 31% of patients. Choice of eGFR equation significantly influenced dosing of ibuprofen, morphine, and gabapentin.
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Affiliation(s)
- Morten Baltzer Houlind
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
- The Capital Region Pharmacy, Marielundvej 25, 2730 Herlev, Denmark.
- Section of Pharmacotherapy, Department of Drug Design and Pharmacology, University of Copenhagen, Universitetsparken 2, 2100 København Ø, Denmark.
| | - Kristian Kjær Petersen
- Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Fredrik Bajers Vej 7, building A2-206, 9220 Aalborg Ø, Denmark.
| | - Henrik Palm
- Orthopedic Department, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400 København, Denmark.
| | - Lillian Mørch Jørgensen
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
| | - Mia Aakjær
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
- The Capital Region Pharmacy, Marielundvej 25, 2730 Herlev, Denmark.
- Section of Pharmacotherapy, Department of Drug Design and Pharmacology, University of Copenhagen, Universitetsparken 2, 2100 København Ø, Denmark.
| | - Lona Louring Christrup
- Section of Pharmacotherapy, Department of Drug Design and Pharmacology, University of Copenhagen, Universitetsparken 2, 2100 København Ø, Denmark.
| | - Janne Petersen
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Enterance B, 2nd floor, 1014 København, Denmark.
| | - Ove Andersen
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
- Emergency Department, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 436, 2650 Hvidovre, Denmark.
| | - Charlotte Treldal
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
- The Capital Region Pharmacy, Marielundvej 25, 2730 Herlev, Denmark.
- Section of Pharmacotherapy, Department of Drug Design and Pharmacology, University of Copenhagen, Universitetsparken 2, 2100 København Ø, Denmark.
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18
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Okumura Y, Fukuda I, Nakamura M, Yamada N, Takayama M, Maeda H, Yamashita T, Ikeda T, Mo M, Yamazaki T, Hirayama A. Design and rationale for the Japanese Registry of Rivaroxaban Effectiveness & Safety for the Prevention of Recurrence in Patients with Deep Vein Thrombosis and Pulmonary Embolism (J'xactly) study. BMJ Open 2018; 8:e020286. [PMID: 29934383 PMCID: PMC6020936 DOI: 10.1136/bmjopen-2017-020286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Rivaroxaban, a factor Xa inhibitor used as a direct oral anticoagulant, is beneficial over warfarin in terms of food-drug interactions and the need for therapeutic monitoring in patients with acute venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism. Because there is little data regarding VTE treatment in Japan, a real-world survey of Japanese patients being treated with rivaroxaban for VTE is needed. METHODS AND ANALYSIS The Japanese Registry of Rivaroxaban Effectiveness & Safety for the Prevention of Recurrence in Patients with Deep Vein Thrombosis and Pulmonary Embolism has been established to investigate the clinical outcomes of rivaroxaban for the initial treatment and prevention of symptomatic recurrent VTE in Japanese patients with acute symptomatic/asymptomatic VTE. 150 institutions in Japan will enrol patients in the study; the target enrolment is 1000. All patients will be followed up two times a year for at least 18 months and up to 3 years after their enrolment. The primary outcome is symptomatic recurrent VTE occurring during the study period. The principal safety outcome is clinically relevant bleeding (ie, major bleeding or clinically relevant non-major bleeding) occurring during treatment. A clinical events committee will adjudicate all outcomes. ETHICS AND DISSEMINATION The study protocol has been approved by the Nihon University Itabashi Hospital, Clinical Research Ethics Committee and all local institutional ethics committees of the participating hospitals. Findings of the study will be presented in scientific sessions and will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03091621,UMIN000025072; Pre-results.
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Affiliation(s)
- Yasuo Okumura
- Division of Cardiology, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Ikuo Fukuda
- Department of Cardiovascular Surgery, Hirosaki University, Graduate School of Medicine, Aomori, Japan
| | - Mashio Nakamura
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Norikazu Yamada
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | | | - Hideaki Maeda
- Division of Cardiovascular, Respiratory and General Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Kanagawa, Japan
| | - Tsutomu Yamazaki
- Clinical Research Support Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Atsushi Hirayama
- Division of Cardiology, Nihon University Itabashi Hospital, Tokyo, Japan
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19
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Mohebbi N. [The Multimorbid Patient: Use of New Oral Anticoagulants in Patients with Chronic Kidney Disease]. PRAXIS 2018; 107:683-687. [PMID: 29921184 DOI: 10.1024/1661-8157/a003005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
The Multimorbid Patient: Use of New Oral Anticoagulants in Patients with Chronic Kidney Disease Abstract. Increasing life expectancy in Western countries is associated with a high prevalence of multiple chronic diseases which is defined by the term "multimorbidity". Many of these patients suffer from chronic kidney disease (CKD) and thrombogenic comorbidities such as atrial fibrillation with the need for oral anticoagulation. For decades vitamin K antagonists have been exclusively prescribed for oral anticoagulation. However, due to altered pharmacokinetics and bioavailability of these drugs in CKD, a significant risk of bleeding exists. The introduction of direct oral anticoagulants as a new and promising alternative to vitamin K antagonists was -especially for CKD patients - highly anticipated. However, data from randomized studies are missing for older patients with advanced CKD. Consequently, a careful evaluation of the risk-benefit ratio is recommended for this sensitive patient population.
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Affiliation(s)
- Nilufar Mohebbi
- 1 Klinik für Nephrologie, Universitätsspital Zürich und Praxis und Dialysezentrum Zürich-City
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20
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Shinoda N, Mori M, Tamura S, Korosue K, Kose S, Kohmura E. Risk of Recurrent Ischemic Stroke with Unintended Low-Dose Oral Anticoagulant Therapy and Optimal Timing of Review. J Stroke Cerebrovasc Dis 2018; 27:1546-1551. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/23/2017] [Accepted: 01/01/2018] [Indexed: 12/13/2022] Open
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21
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Shroff GR, Stoecker R, Hart A. Non-Vitamin K-Dependent Oral Anticoagulants for Nonvalvular Atrial Fibrillation in Patients With CKD: Pragmatic Considerations for the Clinician. Am J Kidney Dis 2018; 72:717-727. [PMID: 29728318 DOI: 10.1053/j.ajkd.2018.02.360] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 02/22/2018] [Indexed: 01/27/2023]
Abstract
Management of atrial fibrillation (AF) in patients with advanced chronic kidney disease (CKD) poses a complex conundrum because of higher risks for both thromboembolic and bleeding complications compared to the general population. This makes it particularly important for clinicians to carefully weigh the risks versus benefits of anticoagulation therapy to determine the individualized net clinical benefit for every patient. During the past few years, 4 non-vitamin K-dependent oral anticoagulant (NOAC) agents have supplemented warfarin in the therapeutic armamentarium for the prevention of systemic thromboembolism in nonvalvular AF. However, the use of NOACs in CKD specifically mandates a nuanced understanding due to their varying dependence on renal clearance, with resultant safety implications related to either underdosing (thromboembolism) or excessive drug exposure (bleeding). This pragmatic review highlights unique considerations pertaining to accurate estimation and temporal monitoring of kidney function in the context of NOAC use with specific clinical deliberations and variables when determining whether an NOAC is appropriate for a patient with CKD. The dependence of NOACs on renal clearance and several troubling safety signals in the published literature suggest that it is vital for nephrologists to be active members of a multidisciplinary team caring for these high-risk patients with CKD and AF.
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Affiliation(s)
- Gautam R Shroff
- Division of Cardiology, Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, MN; University of Minnesota Medical School, Minneapolis, MN.
| | - Rachel Stoecker
- Department of Pharmacy, Hennepin County Medical Center, Minneapolis, MN
| | - Allyson Hart
- Division of Nephrology, Department of Internal Medicine, Hennepin County Medical Center, Minneapolis, MN; University of Minnesota Medical School, Minneapolis, MN
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22
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Olivera P, Gabilondo M, Constans M, Tàssies D, Plensa E, Pons V, Las Heras G, Jiménez C, Campoy D, Bustins A, Oliver A, Marzo C, Canals T, Varela A, Sorigue M, Sánchez E, Ene G, Perea G, Vicente L, López M, Cerdá M, Johansson E, Aguinaco MR, Santos N, Mateo J, Reverter JC, Moya Á, Santamaría A. Tromboc@t Working Group recommendations for management in patients receiving direct oral anticoagulants. Med Clin (Barc) 2018; 151:210.e1-210.e13. [PMID: 29602444 DOI: 10.1016/j.medcli.2018.01.022] [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: 08/07/2017] [Revised: 01/07/2018] [Accepted: 01/25/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND AND OBJECTIVES In recent years, direct oral anticoagulants (DOACs) have become an alternative to vitamin K antagonists (VKA) for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation (NVAF) as well as for prevention and treatment of deep venous thrombosis. Pivotal trials have demonstrated non-inferiority and potential superiority compared to warfarin, which increases the options of anticoagulant treatment. In our setting, the Anticoagulant Treatment Units (ATUs) and Primary Care Centres (PCCs) play an important role in the education, follow-up, adherence control and management in special situations of anticoagulated patients. These considerations have motivated us to elaborate the present consensus document that aims to establish clear recommendations that incorporate the findings of scientific research into clinical practice to improve the quality of care in the field of anticoagulation. MATERIAL AND METHODS A group of experts from the Catalan Thrombosis Group (TROMBOC@T) reviewed all published literature from 2009 to 2016, in order to provide recommendations based on clinical evidence. RESULTS As a result of the project, a set of practical recommendations have been established that will facilitate treatment, education, follow-up and management in special situations of anticoagulated patients with ACODs. CONCLUSIONS Progressive increase in the use of DOACs calls for measures to establish and homogenise clinical management guidelines for patients anticoagulated with DOACs in ATUs and PCCs.
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Affiliation(s)
- Pável Olivera
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Miren Gabilondo
- Departamento de Hematología, Hospital Universitario Araba Txagorritxu, Vitoria, España
| | - Mireia Constans
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Dolors Tàssies
- Unidad de Hemostasia y Trombosis, Departamento de Hemoterapia y Hemostasia (ICMHO), Hospital Clínic, Barcelona, España
| | - Esther Plensa
- Departamento de Hematología, Consorci Sanitari del Maresme, Mataró, España
| | - Verónica Pons
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Germán Las Heras
- Departamento de Hematología, Parc Sanitari Sant Joan de Déu, Sant Boi de Llobregat, España
| | - Carmen Jiménez
- Departamento de Hematología, Hospital del Mar , Barcelona, España
| | - Desirée Campoy
- Departamento de Hematología, Hospital Universitari Sagrat Cor, Barcelona, España
| | - Anna Bustins
- Departamento de Hematología, Hospital Universitari Doctor Josep Trueta, Girona, España
| | - Artur Oliver
- Departamento de Hematología, Fundació Puigvert, Barcelona, España
| | - Cristina Marzo
- Departamento de Hematología, Hospital Universitari Arnau de Vilanova, Lleida, España
| | - Tania Canals
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Anna Varela
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Marc Sorigue
- Unidad de Trombosis y Hemostasia, Hospital Universitari Germans Trias i Pujol, Badalona, España
| | - Eva Sánchez
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Gabriela Ene
- Departamento de Hematología, Hospital Sant Joan de Déu de Martorell , España
| | - Granada Perea
- Departemento de Hematología, Corporació Sanitaria Parc Taulí, Sabadell, España
| | - Laura Vicente
- Departamento de Hematología, Consorci Sanitari de Terrasa - Hospital de Terrasa, , España
| | - Meritxell López
- Departamento de Hematología, Hospital Universitario Mútua Terrassa, España
| | - María Cerdá
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Erik Johansson
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - M Reyes Aguinaco
- Departamento de Hematología, Hospital Universitari Joan XXIII , Tarragona, España
| | - Nazly Santos
- Departamento de Hematología, Hospital Universitari Arnau de Vilanova, Lleida, España
| | - José Mateo
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | - Ángel Moya
- Unidad de Arritmias, Departamento de Cardiología, Hospital Universitari Vall d' Hebron, Barcelona, España
| | - Amparo Santamaría
- Unidad de Trombosis y Hemostasia, Departamento de Hematología, Hospital Universitari Vall d' Hebron, Barcelona, España.
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Pérez Cabeza AI, Chinchurreta Capote PA, González Correa JA, Ruiz Mateas F, Rosas Cervantes G, Rivas Ruiz F, Valle Alberca A, Bravo Marqués R. Discrepancias entre el empleo de las ecuaciones MDRD-4 IDMS y CKD-EPI en vez de la de Cockcroft-Gault en la determinación de la posología de los anticoagulantes orales directos en pacientes con fibrilación auricular no valvular. Med Clin (Barc) 2018; 150:85-91. [DOI: 10.1016/j.medcli.2017.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2017] [Revised: 05/29/2017] [Accepted: 06/01/2017] [Indexed: 01/15/2023]
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Dinsa H, Nedi T, Berha AB. Concordance between modification of diet in renal disease, chronic kidney disease epidemiology collaboration and Cockcroft-Gault equations in patients with chronic kidney disease at St. Paul's hospital millennium medical college, Addis Ababa, Ethiopia. BMC Nephrol 2017; 18:368. [PMID: 29262858 PMCID: PMC5738756 DOI: 10.1186/s12882-017-0783-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 12/07/2017] [Indexed: 01/13/2023] Open
Abstract
Background The most commonly used glomerular filtration rate estimating equations for drug dosing are Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations. However there is still a concern about whether to use MDRD and CKD-EPI interchangeably with CG for drug dosage adjustment. Methods The study was initiated to determine the concordance between MDRD, CKD-EPI and CG equations and associated factors in patients with chronic kidney disease at Saint Paul’s Hospital Millennium Medical College (SPHMMC). This was a cross sectional study which involved patient chart review and physicians self-administered questionnaire. Serum creatinine level ≥ 1.2 mg/dL was used as a cutoff point in pre-selection of patients. The correctness of the drug dose prescribed for the level of renal function were compared to the drug database (Lexi-Comp) available through Up-to-date version 21.2. Results Among the total of 422 patients, 249 (59%) were males. Mean age of patients was 46.09 years. The use of MDRD equation for drug dose adjustment by physicians working in the renal clinic of SPHMMC was six out of nine physicians. The Pearson correlation coefficient between the CG with MDRD and CKD-EPI equations was r = 0.94, P < 0.001 and r = 0.95, P < 0.001, respectively. The concordance between the CG with MDRD and CKD-EPI equations for FDA assigned kidney function categories was 73.7%, Kappa = 0.644 and 74.9%, Kappa = 0.659, respectively. Concordance between the CG with MDRD and CKD-EPI equations for the drug dosing recommendation was 89.6%, kappa = 0.782 and 92%, kappa = 0.834, respectively. Age > 70 years was associated with discordance between CG and MDRD equations for drug dosing recommendation whereas serum creatinine 1.2–3.5 mg/dL, weight < 61 Kg and age > 70 years were associated with discordance between the CG with MDRD and CKD-EPI equations for FDA assigned kidney function categories. However, none of the factors associated with discordance between CG and CKD-EPI for drug dosing. Conclusion MDRD equation can be used interchangeably with CG equation for drug dosing recommended in all adult patients between the age of 18 and 70 years. CKD-EPI can be used interchangeably with CG in all adult Ethiopian patients with CKD. Electronic supplementary material The online version of this article (10.1186/s12882-017-0783-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hunduma Dinsa
- Department of Pharmacy, College of Medicine and Health Sciences, Ambo University, Ambo, Ethiopia
| | - Teshome Nedi
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia
| | - Alemseged Beyene Berha
- Department of Pharmacology and Clinical Pharmacy, School of Pharmacy, College of Health Sciences, Addis Ababa University, P.O. Box 9086, Addis Ababa, Ethiopia.
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Delanaye P, Guerber F, Scheen A, Ellam T, Bouquegneau A, Guergour D, Mariat C, Pottel H. Discrepancies between the Cockcroft-Gault and Chronic Kidney Disease Epidemiology (CKD-EPI) Equations: Implications for Refining Drug Dosage Adjustment Strategies. Clin Pharmacokinet 2017; 56:193-205. [PMID: 27417226 DOI: 10.1007/s40262-016-0434-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The dosages of many medications require adjustment for renal function. There is debate regarding which equation, the Chronic Kidney Disease Epidemiology (CKD-EPI) equation vs. the Cockcroft-Gault (CG) equation, should be recommended to estimate glomerular filtration rate. METHODS We used a mathematical simulation to determine how patient characteristics influence discrepancies between equations and analyzed clinical data to demonstrate the frequency of such discrepancies in clinical practice. In the simulation, the modifiable variables were sex, age, serum creatinine, and weight. We considered estimated glomerular filtration rate results in mL/min, deindexed for body surface area, because absolute excretory function (rather than per 1.73 m2 body surface area) determines the rate of filtration of a drug at a given plasma concentration. An absolute and relative difference of maximum (±) 10 mL/min and 10 %, respectively, were considered concordant. Clinical data for patients aged over 60 years (n = 9091) were available from one hospital and 25 private laboratories. RESULTS In the simulation, differences between the two equations were found to be influenced by each variable but age and weight had the biggest effect. Clinical sample data demonstrated concordance between CKD-EPI and CG results in 4080 patients (45 %). The majority of discordant results reflected a CG result lower than the CKD-EPI equation. With aging, the CG result became progressively lower than the CKD-EPI result. When weight increased, the opposite occurred. DISCUSSION The choice of equation for excretory function adjustment of drug dosage will have different implications for patients of different ages and body habitus. CONCLUSIONS The optimum equation for drug dosage adjustment should be defined with consideration of individual patient characteristics.
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Affiliation(s)
- Pierre Delanaye
- Division of Nephrology, Dialysis and Transplantation, CHU Sart Tilman, University of Liège (ULg-CHU), 4000, Liège, Belgium.
| | | | - André Scheen
- Division of Clinical Pharmacology, Center for Interdisciplinary Research on Medicines, University of Liège, Liège, Belgium
| | - Timothy Ellam
- Sheffield Kidney Institute, Northern General Hospital and Department of Infection, Immunity and Cardiovascular Science, University of Sheffield, Sheffield, UK
| | - Antoine Bouquegneau
- Division of Nephrology, Dialysis and Transplantation, CHU Sart Tilman, University of Liège (ULg-CHU), 4000, Liège, Belgium
| | - Dorra Guergour
- Biochemistry Laboratory, Grenoble University Hospital, Grenoble, France
| | - Christophe Mariat
- Division of Nephrology, Dialysis, Transplantation and Hypertension, CHU Hôpital Nord, University Jean Monnet, PRES Université de LYON, Saint-Etienne, France
| | - Hans Pottel
- Department of Public Health and Primary Care, KU, Leuven Kulak, Kortrijk, Belgium
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Okumura Y, Yokoyama K, Matsumoto N, Tachibana E, Kuronuma K, Oiwa K, Matsumoto M, Kojima T, Hanada S, Nomoto K, Arima K, Takahashi F, Kotani T, Ikeya Y, Fukushima S, Itoh S, Kondo K, Chiku M, Ohno Y, Onikura M, Hirayama A, the SAKURA AF Registry Investigators. Current use of direct oral anticoagulants for atrial fibrillation in Japan: Findings from the SAKURA AF Registry. J Arrhythm 2017; 33:289-296. [PMID: 28765759 PMCID: PMC5529323 DOI: 10.1016/j.joa.2016.11.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 10/27/2016] [Accepted: 11/15/2016] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Large-scale investigations on the use of oral anticoagulants including direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) have not included Japanese patients. METHODS We established the multicenter SAKURA AF Registry to support prospective observational research on the status of anticoagulation treatment, especially with DOAC, for AF in Japan. We enrolled 3266 AF patients treated with warfarin (n=1577) or any of 4 DOACs (n=1689) from 63 institutions (2 cardiovascular centers, 13 affiliated hospitals or community hospitals, and 48 private clinics) in the Tokyo area. RESULTS We conducted our first analysis of the registry data, and although we found equivalent mean age between the DOAC and warfarin users (71.8±9.5 vs. 72.3±9.4 years, p=0.2117), we found a slightly lower risk of stroke (CHADS2 score of 0 or 1 [46.9% vs. 39.4%, p<0.0001]) and significantly better creatinine clearance in DOAC users (70.4±27 vs. 65.6±25.7 mL/min, p<0.0001). Importantly, we documented under-dosing in 32% of warfarin users and inappropriate-low-dosing in 19.7-27.6% of DOAC users. CONCLUSIONS Our initial analysis of the SAKURA AF Registry data clarified the real-world use of anticoagulants, which includes DOACs and warfarin in Japan. The DOAC users were at a lower risk for stroke than the warfarin users. In 20-30% of DOAC users, the dose was inappropriately reduced.
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Affiliation(s)
- Yasuo Okumura
- Division of Cardiology, Nihon University Itabashi Hospital, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
| | | | - Naoya Matsumoto
- Department of Cardiology, Nihon University Hospital, Tokyo, Japan
| | | | | | - Koji Oiwa
- Yokohama Chuo Hospital, Kanagawa, Japan
| | | | | | - Shoji Hanada
- Asakadai Central General Hospital, Saitama, Japan
| | | | - Ken Arima
- Kasukabe Municipal Hospital, Saitama, Japan
| | | | | | | | | | | | | | | | | | | | - Atsushi Hirayama
- Division of Cardiology, Nihon University Itabashi Hospital, 30-1 Ohyaguchi-kamicho, Itabashi-ku, Tokyo 173-8610, Japan
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Molteni M, Bo M, Di Minno G, Di Pasquale G, Genovesi S, Toni D, Verdecchia P. Dabigatran etexilate: appropriate use in patients with chronic kidney disease and in the elderly patients. Intern Emerg Med 2017; 12:425-435. [PMID: 28439778 DOI: 10.1007/s11739-017-1660-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 03/29/2017] [Indexed: 12/16/2022]
Abstract
Dabigatran etexilate (DE) is a direct thrombin inhibitor, which has been approved for the treatment of non-valvular atrial fibrillation (AF), and for the prevention and treatment of venous thromboembolism (VTE). Despite large randomized clinical trials and independent observational studies providing robust data concerning DE safety and efficacy, some physicians still perceive mild-to-moderate renal impairment and old age as a relative contraindication to its use. In this article, we review the available scientific evidence supporting the use of DE in these clinical situations. Patients with AF and chronic kidney disease (CKD) are per se at high risk of stroke, bleeding and mortality. Although there is evidence of clinical benefit of anticoagulation in these patients, anticoagulant therapy requires caution and demands careful clinical monitoring, regardless of the drug used. In patients with no contraindication to its use, the clinical benefit of DE versus warfarin is independent of renal function. The elderly with AF are frequently undertreated because of the perception of high bleeding risk and limited clinical benefit. However, the clinical benefit of anticoagulation is independent of patient age, and age per se should not represent a contraindication to anticoagulation. DE has been extensively studied in the elderly, both in randomized clinical trials and in observational studies: DE 150 mg BID should not be used in patients 80 years of age or older, while DE 110 mg BID is as safe as warfarin. Intracranial haemorrhages reduction by DE compared with warfarin is preserved in the elderly. Therefore, mild and moderate CKD and being elderly should not deter physicians from prescribing DE. Furthermore, the availability of a specific antidote is expected to improve the safety of the use of DE in clinical practice.
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Affiliation(s)
- Mauro Molteni
- Internal Medicine, Vimercate Hospital, Vimercate, MB, Italy.
| | - Mario Bo
- Geriatrics and Bone Metabolic Diseases Division, Città della Salute e della Scienza-Molinette University Hospital, Turin, Italy
| | - Giovanni Di Minno
- Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Naples, Italy
| | | | - Simonetta Genovesi
- Nephrology Unit, Department of Medicine and Surgery, San Gerardo Hospital, University of Milano-Bicocca, Monza, MB, Italy
| | - Danilo Toni
- Department of Neurology and Psychiatry, Policlinico Umberto I Hospital, Sapienza University of Rome, Rome, Italy
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Frain B, Castelino R, Bereznicki LR. The Utilization of Antithrombotic Therapy in Older Patients in Aged Care Facilities With Atrial Fibrillation. Clin Appl Thromb Hemost 2017; 24:519-524. [PMID: 28068791 DOI: 10.1177/1076029616686421] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Oral anticoagulants are essential drugs for the prevention of thromboembolic events in patients with atrial fibrillation (AF). Anticoagulants are, however, commonly withheld in older people due to the risk and fear of hemorrhage. Although the underutilization of anticoagulants in patients with AF has been demonstrated internationally, few studies have been conducted among aged care residents. The aim of this study was to determine the utilization of anticoagulants among people with AF residing in aged care facilities. We performed a non-experimental, retrospective analysis designed to evaluate antithrombotic usage in patients with AF in Australia residing in aged care facilities, using data collected by pharmacists while performing Residential Medication Management Reviews (RMMRs). The utilization of antithrombotic therapy and the appropriateness of therapy were determined based on the CHADS2, CHA2DS2-VASc, and HAS-BLED risk stratification schemes in consideration of documented contraindications to treatment. Predictors of anticoagulant use were determined using multivariate logistic regression. A total of 1952 RMMR patients with AF were identified. Only 35.6% of eligible patients (CHADS2 score ≥2 and no contraindications to anticoagulants) received an anticoagulant. As age increased, the likelihood of receiving an anticoagulant decreased and the likelihood of receiving an antiplatelet or no therapy increased. In patients at high risk of stroke (CHADS score ≥2), utilization of anticoagulants dropped by 19.7% when the HAS-BLED score increased from 2 to 3, suggesting that physicians placed a heavier weighting on bleeding risk rather than stroke risk. Prescribing of anticoagulants was influenced to a greater extent by bleeding risk than it was by the risk of stroke. Further research investigating whether the growing availability of direct oral anticoagulants influences practice in this patient population is needed.
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Affiliation(s)
- Bridget Frain
- 1 Unit for Medication Outcomes Research and Education, Division of Pharmacy, School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Ronald Castelino
- 1 Unit for Medication Outcomes Research and Education, Division of Pharmacy, School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
| | - Luke R Bereznicki
- 1 Unit for Medication Outcomes Research and Education, Division of Pharmacy, School of Medicine, Faculty of Health, University of Tasmania, Hobart, Tasmania, Australia
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Fernandez-Prado R, Castillo-Rodriguez E, Velez-Arribas FJ, Gracia-Iguacel C, Ortiz A. Creatinine Clearance Is Not Equal to Glomerular Filtration Rate and Cockcroft-Gault Equation Is Not Equal to CKD-EPI Collaboration Equation. Am J Med 2016; 129:1259-1263. [PMID: 27612441 DOI: 10.1016/j.amjmed.2016.08.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Revised: 08/12/2016] [Accepted: 08/15/2016] [Indexed: 11/30/2022]
Abstract
Direct oral anticoagulants (DOACs) may require dose reduction or avoidance when glomerular filtration rate is low. However, glomerular filtration rate is not usually measured in routine clinical practice. Rather, equations that incorporate different variables use serum creatinine to estimate either creatinine clearance in mL/min or glomerular filtration rate in mL/min/1.73 m2. The Cockcroft-Gault equation estimates creatinine clearance and incorporates weight into the equation. By contrast, the Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations estimate glomerular filtration rate and incorporate ethnicity but not weight. As a result, an individual patient may have very different renal function estimates, depending on the equation used. We now highlight these differences and discuss the impact on routine clinical care for anticoagulation to prevent embolization in atrial fibrillation. Pivotal DOAC clinical trials used creatinine clearance as a criterion for patient enrollment, and dose adjustment and Federal Drug Administration recommendations are based on creatinine clearance. However, clinical biochemistry laboratories provide CKD-EPI glomerular filtration rate estimations, resulting in discrepancies between clinical trial and routine use of the drugs.
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Affiliation(s)
- Raul Fernandez-Prado
- IIS-Fundación Jiménez Díaz-Universidad Autónoma de Madrid, Spain; REDINREN, Madrid, Spain
| | | | | | - Carolina Gracia-Iguacel
- IIS-Fundación Jiménez Díaz-Universidad Autónoma de Madrid, Spain; REDINREN, Madrid, Spain; Fundación Renal Iñigo Alvarez de Toledo-IRSIN, Madrid, Spain
| | - Alberto Ortiz
- IIS-Fundación Jiménez Díaz-Universidad Autónoma de Madrid, Spain; REDINREN, Madrid, Spain; Fundación Renal Iñigo Alvarez de Toledo-IRSIN, Madrid, Spain.
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30
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Cartet-Farnier E, Goutelle-Audibert L, Maire P, De la Gastine B, Goutelle S. Implications of using the MDRD or CKD-EPI equation instead of the Cockcroft-Gault equation for estimating renal function and drug dosage adjustment in elderly patients. Fundam Clin Pharmacol 2016; 31:110-119. [PMID: 27599753 DOI: 10.1111/fcp.12241] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 08/30/2016] [Accepted: 09/02/2016] [Indexed: 11/30/2022]
Abstract
The objectives of this study were to compare the estimations of renal function obtained with six equations, including the Cockcroft-Gault (CG), Modification of Diet in Renal Disease (MDRD), and Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations and to evaluate the implication of using other equations for drug dosing in elderly patients in place of CG. An observational prospective study was conducted over 6 months in two geriatric hospitals with inclusions of all hospitalized inpatients. A list of 36 drugs for which recommendations of dosage adjustment for renal function were mentioned in the manufacturer dosing guidelines was used to compare the implications of using the various equations for drug dosing. A total of 249 patients with a mean age of 83.6 years were included. Mean estimates of renal function from the CG, MDRD, and CKD-EPI equations were 51.3 ± 23.5 mL/min, 72.2 ± 35.2, and 64.3 ± 22.5 mL/min/1.73 m2 , respectively (P < 0.001). Twenty percent of patients had at least one drug for which the dose was not appropriately adjusted to renal function. The use of the MDRD and CKD-EPI equations in place of the CG equation was associated with dosage discrepancy in 20-25% of patients and 15% of drug orders, resulting in potential overdosage in 95% of cases. Use of MDRD or CKD-EPI equations results in higher estimates of renal function and may have important implications for drug dosing decision and drug safety in elderly patients. The best way is to directly measure the drug effect or its concentration when it is possible to do so.
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Affiliation(s)
- Elodie Cartet-Farnier
- Groupement Hospitalier de Gériatrie, Service pharmaceutique, Hospices Civils de Lyon, 136 rue du Commandant Charcot, 69005, Lyon, France
| | - Laetitia Goutelle-Audibert
- Service pharmaceutique, Centre Hospitalier de Saint Laurent de Chamousset, Le Grand Jardin, Chemin du Grand Jardin, 69930, Saint-Laurent de Chamousset, France
| | - Pascal Maire
- Groupement Hospitalier de Gériatrie, Service pharmaceutique, Hospices Civils de Lyon, 136 rue du Commandant Charcot, 69005, Lyon, France.,UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Université Lyon 1, 43 bd du 11 novembre 1918, 69622, Villeurbanne, France
| | - Blandine De la Gastine
- Groupement Hospitalier de Gériatrie, Médecine Gériatrique, Hospices Civils de Lyon, Lyon, France
| | - Sylvain Goutelle
- Groupement Hospitalier de Gériatrie, Service pharmaceutique, Hospices Civils de Lyon, 136 rue du Commandant Charcot, 69005, Lyon, France.,UMR CNRS 5558, Laboratoire de Biométrie et Biologie Evolutive, Université Lyon 1, 43 bd du 11 novembre 1918, 69622, Villeurbanne, France.,Faculté de Pharmacie de Lyon, Université Lyon 1, 8 avenue Rockefeller, 69373, Lyon Cedex 08, France
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Hawkins NM, Jhund PS, Pozzi A, O'Meara E, Solomon SD, Granger CB, Yusuf S, Pfeffer MA, Swedberg K, Petrie MC, Virani S, McMurray JJ. Severity of renal impairment in patients with heart failure and atrial fibrillation: implications for non-vitamin K antagonist oral anticoagulant dose adjustment. Eur J Heart Fail 2016; 18:1162-71. [DOI: 10.1002/ejhf.614] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 05/13/2016] [Accepted: 06/04/2016] [Indexed: 11/06/2022] Open
Affiliation(s)
| | - Pardeep S. Jhund
- BHF Glasgow Cardiovascular Research Centre; University of Glasgow; Glasgow UK
| | - Andrea Pozzi
- BHF Glasgow Cardiovascular Research Centre; University of Glasgow; Glasgow UK
| | | | - Scott D. Solomon
- Division of Cardiovascular Medicine; Brigham and Women's Hospital; Boston MA USA
| | | | - Salim Yusuf
- Population Health Research Institute; McMaster University; Hamilton Canada
| | - Marc A. Pfeffer
- Division of Cardiovascular Medicine; Brigham and Women's Hospital; Boston MA USA
| | | | - Mark C. Petrie
- Scottish National Advanced Heart Failure Service; Golden Jubilee National Hospital; Clydebank Glasgow UK
| | - Sean Virani
- Division of Cardiology; University of British Columbia; Vancouver Canada
| | - John J.V. McMurray
- BHF Glasgow Cardiovascular Research Centre; University of Glasgow; Glasgow UK
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32
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Lau YC, Proietti M, Guiducci E, Blann AD, Lip GY. Atrial Fibrillation and Thromboembolism in Patients With Chronic Kidney Disease. J Am Coll Cardiol 2016; 68:1452-1464. [DOI: 10.1016/j.jacc.2016.06.057] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 06/14/2016] [Indexed: 02/06/2023]
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Drug therapy management in patients with renal impairment: how to use creatinine-based formulas in clinical practice. Eur J Clin Pharmacol 2016; 72:1433-1439. [PMID: 27568310 PMCID: PMC5110609 DOI: 10.1007/s00228-016-2113-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2016] [Accepted: 07/27/2016] [Indexed: 01/26/2023]
Abstract
Purpose The use of estimated glomerular filtration rate (eGFR) in daily clinical practice. Methods eGFR is a key component in drug therapy management (DTM) in patients with renal impairment. eGFR is routinely reported by laboratories whenever a serum creatinine testing is ordered. In this paper, we will discuss how to use eGFR knowing the limitations of serum creatinine-based formulas. Results Before starting a renally excreted drug, an equally effective drug which can be used more safely in patients with renal impairment should be considered. If a renally excreted drug is needed, the reliability of the eGFR should be assessed and when needed, a 24-h urine creatinine clearance collection should be performed. After achieving the best approximation of the true GFR, we suggest a gradual drug dose adaptation according to the renal function. A different approach for drugs with a narrow therapeutic window (NTW) is recommended compared to drugs with a broad therapeutic window. For practical purposes, a therapeutic window of 5 or less was defined as a NTW and a list of NTW drugs is presented. Considerations about the drug dose may be different at the start of the therapy or during the therapy and depending on the indication. Monitoring effectiveness and adverse drug reactions are important, especially for NTW drugs. Dose adjustment should be based on an ongoing assessment of clinical status and risk versus the benefit of the used regimen. Conclusion When determining the most appropriate dosing regimen serum creatinine-based formulas should never be used naively but always in combination with clinical and pharmacological assessment of the individual patient. Electronic supplementary material The online version of this article (doi:10.1007/s00228-016-2113-2) contains supplementary material, which is available to authorized users.
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Egger F, Targa F, Unterholzner I, Grant RP, Herrmann M, Wiedermann CJ. Medication Error When Switching from Warfarin to Rivaroxaban Leading to Spontaneous Large Ecchymosis of the Abdominal and Chest Wall. Clin Pract 2016; 6:873. [PMID: 27777713 PMCID: PMC5067405 DOI: 10.4081/cp.2016.873] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 08/10/2016] [Indexed: 12/18/2022] Open
Abstract
Non-vitamin K oral anticoagulant (NOAC) therapy may be inappropriate if prescription was incorrect, the patient’s physiological parameters change, or interacting concomitant medications are erroneously added. The aim of this report was to illustrate inappropriate NOAC prescription in a 78-year-old woman with non-valvular atrial fibrillation and borderline renal dysfunction who was switched from warfarin to rivaroxaban and subsequently developed bruising with hemorrhagic shock and acute on chronic renal failure. Administration of 4-factor prothrombin complex concentrate effectively reversed coagulopathy and stopped bleeding. Retrospective determination of circulating plasma levels of rivaroxaban and warfarin confirmed that excessive anticoagulation was likely due to warfarin that the patient probably continued to take although rivaroxaban was initiated. Pharmacodynamic interaction between rivaroxaban and warfarin may not only be additive but synergistic. In patients at high risk of complications, judicious prescribing and dosing of NOACs, and regular monitoring of concomitant medications and renal function are highly recommended.
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Affiliation(s)
- Flavio Egger
- Department of Internal Medicine, Central Hospital of Bolzano , BZ, Italy
| | - Federica Targa
- Department of Clinical Pathology, Central Hospital of Bolzano , BZ, Italy
| | - Ivan Unterholzner
- Department of Internal Medicine, Central Hospital of Bolzano , BZ, Italy
| | - Russell P Grant
- Center for Esoteric Testing, Laboratory Corporation of America® Holdings , Burlington, NC, USA
| | - Markus Herrmann
- Department of Clinical Pathology, Central Hospital of Bolzano , BZ, Italy
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Frain BE, Castelino R, Bereznicki L. The Utilization of Antithrombotic Therapy in Older Australians With Atrial Fibrillation. Clin Appl Thromb Hemost 2016; 23:671-676. [DOI: 10.1177/1076029616637184] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
What is known and Objective: Oral anticoagulants are essential drugs for the prevention of thromboembolic events in patients with atrial fibrillation (AF). Anticoagulants are, however, commonly withheld due to a perceived risk of severe adverse events. The underutilization of anticoagulants in patients with AF has been demonstrated internationally, but to date, there are limited data available in the Australian context. The aim of this study was to determine the utilization patterns of anticoagulants (including novel oral anticoagulants) with respect to stroke and bleeding risk among patients with AF within the community. Methods: We performed a nonexperimental, retrospective analysis designed to evaluate antithrombotic usage for AF in Australia. The utilization of antithrombotic therapy and the appropriateness of therapy were determined based on CHADS2, CHA2DS2-VASc and HAS-BLED risk stratification schemes. The presence of documented contraindications was used to determine the appropriateness of antithrombotic therapy. What is new and Conclusion: Anticoagulants were overutilized in patients at low risk of stroke and underutilized in patients at higher risk of stroke. As the HAS-BLED score increased, the likelihood of patients receiving an anticoagulant decreased regardless of CHADS2 or CHA2DS2-VASc scores.
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Affiliation(s)
- Bridget Elise Frain
- Division of Pharmacy, Unit for Medication Outcomes Research and Education, Faculty of Health, School of Medicine, University of Tasmania, Hobart, Australia
| | - Ronald Castelino
- Division of Pharmacy, Unit for Medication Outcomes Research and Education, Faculty of Health, School of Medicine, University of Tasmania, Hobart, Australia
| | - Luke Bereznicki
- Division of Pharmacy, Unit for Medication Outcomes Research and Education, Faculty of Health, School of Medicine, University of Tasmania, Hobart, Australia
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Delanaye P, Flamant M, Cavalier É, Guerber F, Vallotton T, Moranne O, Pottel H, Boffa JJ, Mariat C. [Dosing adjustment and renal function: Which equation(s)?]. Nephrol Ther 2015; 12:18-31. [PMID: 26602880 DOI: 10.1016/j.nephro.2015.07.472] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 07/28/2015] [Accepted: 07/29/2015] [Indexed: 12/18/2022]
Abstract
While the CKD-EPI (for Chronic Kidney Disease Epidemiology) equation is now implemented worldwide, utilization of the Cockcroft formula is still advocated by some physicians for drug dosage adjustment. Justifications for this recommendation are that the Cockcroft formula was preferentially used to determine dose adjustments according to renal function during the development of many drugs, better predicts drugs-related adverse events and decreases the risk of drug overexposure in the elderly. In this opinion paper, we discuss the weaknesses of the rationale supporting the Cockcroft formula and endorse the French HAS (Haute Autorité de santé) recommendation regarding the preferential use of the CKD-EPI equation. When glomerular filtration rate (GFR) is estimated in order to adjust drug dosage, the CKD-EPI value should be re-expressed for the individual body surface area (BSA). Given the difficulty to accurately estimate GFR in the elderly and in individuals with extra-normal BSA, we recommend to prescribe in priority monitorable drugs in those populations or to determine their "true" GFR using a direct measurement method.
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Affiliation(s)
- Pierre Delanaye
- Service de néphrologie, dialyse et transplantation, CHU Sart-Tilman, université de Liège, 4000 Liège, Belgique
| | - Martin Flamant
- Service d'explorations fonctionnelles, hôpital Bichat, AP-HP, université Paris Diderot, Paris, France
| | - Étienne Cavalier
- Service de chimie clinique, CHU Sart-Tilman, université de Liège, 4000 Liège, Belgique
| | - Fabrice Guerber
- Laboratoire Oriade-Vizille, 75, chemin de la Terrasse, 38220 Vizille, France
| | - Thomas Vallotton
- Laboratoire Vialle, Bastia et Syndicat des jeunes biologistes médicaux, 20600 BastiaFrance
| | - Olivier Moranne
- EA 2415, biostatistique, épidémiologie et santé publique, institut universitaire de recherche clinique, université de Montpellier, 34093 Montpellier, France
| | - Hans Pottel
- Department of Primary Care and Public Health at Kulak, KU Leuven Kulak, 8500 Kortrijk, Belgique
| | - Jean-Jacques Boffa
- Inserm 1155, service de néphrologie et dialyse, hôpital Tenon, AP-HP, université Pierre-et-Marie-Curie, 75020 Paris, France
| | - Christophe Mariat
- Service de néphrologie, dialyse et transplantation, hôpital Nord, CHU de Saint-Étienne, université Jean-Monnet, 42055 Saint-Étienne, France.
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Barrios V, Górriz JL. Atrial fibrillation and chronic kidney disease: focus on rivaroxaban. J Comp Eff Res 2015; 4:651-64. [PMID: 26388302 DOI: 10.2217/cer.15.44] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Renal insufficiency increases the risk of stroke and bleeding in atrial fibrillation patients. Although vitamin K antagonists reduce the risk of stroke in patients with moderate renal dysfunction, this observation is less clear in patients with renal impairment. Moreover, the risk of bleeding with vitamin K antagonists increases as renal function worsens. Maintaining international normalized ratio values within therapeutic targets is more difficult in patients with renal dysfunction, and those agents may cause warfarin-related nephropathy and vascular calcification. Rivaroxaban is the only nonvitamin K oral anticoagulant with a dose specifically tested in patients with moderate renal insufficiency. Rivaroxaban is effective for the prevention of stroke in atrial fibrillation patients with moderate renal dysfunction, with a lower risk of intracranial and fatal bleeding.
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Affiliation(s)
- Vivencio Barrios
- Department of Cardiology, University Hospital Ramón y Cajal, School of Medicine, Alcalá University, Madrid, Spain
| | - José Luis Górriz
- Department of Nephrology, Doctor Peset University Hospital, Department of Medicine, University of Valencia, Valencia, Spain
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Helldén A, Al-Aieshy F, Bastholm-Rahmner P, Bergman U, Gustafsson LL, Höök H, Sjöviker S, Söderström A, Odar-Cederlöf I. Development of a computerised decisions support system for renal risk drugs targeting primary healthcare. BMJ Open 2015; 5:e006775. [PMID: 26150141 PMCID: PMC4499680 DOI: 10.1136/bmjopen-2014-006775] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To assess general practitioners (GPs) experience from the implementation and use of a renal computerised decision support system (CDSS) for drug dosing, developed for primary healthcare, integrated into the patient's electronic health record (EHR), and building on estimation of the patient's creatinine clearance (ClCG). DESIGN Qualitative research design by a questionnaire and a focus group discussion. SETTING AND PARTICIPANTS Eight GPs at two primary healthcare centres (PHCs). INTERVENTIONS The GP at PHC 1, and the project group, developed and tested the technical solution of the CDSS. Proof-of-concept was tested by seven GPs at PHC 2. They also participated in a group discussion and answered a questionnaire. A web window in the EHR gave drug and dosage in relation to ClCG. Each advice was according to three principles: If? Why? Because. OUTCOME MEASURES (1) The GPs' experience of 'easiness to use' and 'perceived usefulness' at PHC 2, based on loggings of use, answers from a questionnaire using a 5-point Likert scale, and answers from a focus group discussion. (2) The number of patients aged 65 years and older with an estimation of ClCG before and after the implementation of the CDSS. RESULTS The GPs found the CDSS fast, simple and easy to use. They appreciated the automatic presentation of the CICG status on opening the medication list, and the ability to actively look up specific drug recommendations in two steps. The CDSS scored high on the Likert scale. All GPs wanted to continue the use of the CDSS and to recommend it to others. The number of patients with an estimated ClCG increased 1.6-fold. CONCLUSIONS Acceptance of the simple graphical interface of this push and pull renal CDSS was high among the primary care physicians evaluating this proof of concept. The graphical model should be useful for further development of renal decision support systems.
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Affiliation(s)
- Anders Helldén
- Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Fadiea Al-Aieshy
- Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
| | - Pia Bastholm-Rahmner
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Healthcare Development, Public Healthcare Administration, Stockholm County Council, Stockholm, Sweden
| | - Ulf Bergman
- Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lars L Gustafsson
- Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Hans Höök
- Department of Healthcare Development, Public Healthcare Administration, Stockholm County Council, Stockholm, Sweden
| | - Susanne Sjöviker
- Department of Healthcare Development, Public Healthcare Administration, Stockholm County Council, Stockholm, Sweden
| | | | - Ingegerd Odar-Cederlöf
- Department of Clinical Pharmacology, Karolinska University Hospital, Stockholm, Sweden
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
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Stöllberger C, Finsterer J. Rivaroxaban 10mg/d in severe renal failure does not prevent ischemic events in premorbid neurologic disease. Neurol Neurochir Pol 2015; 49:180-2. [PMID: 26048606 DOI: 10.1016/j.pjnns.2015.04.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 04/11/2015] [Indexed: 11/18/2022]
Abstract
BACKGRUND The direct oral anticoagulants (DOAC) are increasingly used for primary and secondary stroke prophylaxis in atrial fibrillation, although their use in patients with renal failure is problematic. CASE REPORT In an 82-years old female with recurrent strokes and atrial fibrillation, the vitamin-K-antagonist was changed to rivaroxaban because of "unstable international normalized ratio (INR) values". Because of renal failure with a creatinine clearance of 32ml/min, a dosage of rivaroxaban 10mg/d was chosen. Eleven days after initiation of rivaroxaban, she was re-hospitalized because of acute onset of right-sided weakness of the upper and lower limbs. CONCLUSIONS In cases of stroke, renal failure and inadequate anticoagulation it is not useful to change from vitamin-K-antagonists to "low dose" DOAC. Diligent investigations for the cause of INR-instability and continuation of vitamin-K-antagonist therapy seem to be more effective and safer since there is the opportunity of monitoring therapy and to avoid under- as well as over-dosage.
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Manzano-Fernández S, Andreu-Cayuelas JM, Marín F, Orenes-Piñero E, Gallego P, Valdés M, Vicente V, Lip GY, Roldán V. Comparación de las ecuaciones de filtrado glomerular estimado para determinar la posología de los nuevos anticoagulantes orales para pacientes con fibrilación auricular. Rev Esp Cardiol 2015. [DOI: 10.1016/j.recesp.2014.06.027] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Chin PKL, Wright DFB, Zhang M, Wallace MC, Roberts RL, Patterson DM, Jensen BP, Barclay ML, Begg EJ. Correlation between trough plasma dabigatran concentrations and estimates of glomerular filtration rate based on creatinine and cystatin C. Drugs R D 2015; 14:113-23. [PMID: 24797400 PMCID: PMC4070467 DOI: 10.1007/s40268-014-0045-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
AIMS Dabigatran is largely cleared by renal excretion. Renal function is thus a major determinant of trough dabigatran concentrations, which correlate with the risk of thromboembolic and haemorrhagic outcomes. Current dabigatran dosing guidelines use the Cockcroft-Gault (CG) equation to gauge renal function, instead of contemporary equations including the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations employing creatinine (CKD-EPI_Cr), cystatin C (CKD-EPI_Cys) and both renal biomarkers (CKD-EPI_CrCys). METHODS A linear regression model including the dabigatran etexilate maintenance dose rate, relevant interacting drugs and genetic polymorphisms (including CES1), was used to analyse the relationship between the values from each renal function equation and trough steady-state plasma dabigatran concentrations. RESULTS The median dose-corrected trough steady-state plasma dabigatran concentration in 52 patients (38-94 years) taking dabigatran etexilate was 60 µg/L (range 9-279). The dose-corrected trough concentration in a patient on phenytoin and phenobarbitone was >3 standard deviations below the cohort mean. The CG, CKD-EPI_Cr, CKD-EPI_Cys and CKD-EPI_CrCys equations explained (R (2), 95 % CI) 32 % (9-55), 37 % (12-60), 41 % (16-64) and 47 % (20-69) of the variability in dabigatran concentrations between patients, respectively. One-way analysis of variance (ANOVA) comparing the R (2) values for each equation was not statistically significant (p = 0.74). DISCUSSION Estimates of renal function using the four equations accounted for 32-47 % of the variability in dabigatran concentrations between patients. We are the first to provide evidence that co-administration of phenytoin/phenobarbitone with dabigatran etexilate is associated with significantly reduced dabigatran exposure.
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Affiliation(s)
- Paul K L Chin
- Department of Clinical Pharmacology, Christchurch Hospital, 2 Riccarton Avenue, Christchurch, 8011, New Zealand,
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Influence of renal function estimation on pharmacokinetic modeling of vancomycin in elderly patients. Antimicrob Agents Chemother 2015; 59:2986-94. [PMID: 25753640 DOI: 10.1128/aac.04132-14] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 03/01/2015] [Indexed: 01/26/2023] Open
Abstract
Vancomycin is a renally excreted drug, and its body clearance correlates with creatinine clearance. However, the renal function estimation equation that best predicts vancomycin clearance has not been established yet. The objective of this study was to compare the abilities of different renal function estimation equations to describe vancomycin pharmacokinetics in elderly patients. The NPAG algorithm was used to perform population pharmacokinetic analysis of vancomycin concentrations in 78 elderly patients. Six pharmacokinetic models of vancomycin clearance were built, based on the following equations: Cockcroft-Gault (CG), Jelliffe (JEL), Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) (both in milliliters per minute per 1.73 m(2)), and modified MDRD and CKD-EPI equations (both in milliliters per minute). Goodness-of-fit and predictive performances of the six PK models were compared in a learning set (58 subjects) and a validation set (20 patients). Final analysis was performed to estimate population parameters in the entire population. In the learning step, the MDRD-based model best described the data, but the CG- and JEL-based models were the least biased. The mean weighted errors of prediction were significantly different between the six models (P = 0.0071). In the validation group, predictive performances were not significantly different. However, the use of a renal function estimation equation different from that used in the model building could significantly alter predictive performance. The final analysis showed important differences in parameter distributions and AUC estimation across the six models. This study shows that methods used to estimate renal function should not be considered interchangeable for pharmacokinetic modeling and model-based estimation of vancomycin concentrations in elderly patients.
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Pirmohamed M, Kamali F, Daly AK, Wadelius M. Oral anticoagulation: a critique of recent advances and controversies. Trends Pharmacol Sci 2015; 36:153-63. [PMID: 25698605 DOI: 10.1016/j.tips.2015.01.003] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 01/18/2015] [Accepted: 01/20/2015] [Indexed: 12/17/2022]
Abstract
There have recently been significant advances in the field of oral anticoagulation, but these have also led to many controversies. Warfarin is still the commonest drug used for clotting disorders but its use is complicated owing to wide inter-individual variability in dose requirement and its narrow therapeutic index. Warfarin dose requirement can be influenced by both genetic and environmental factors. Two recent randomized controlled trials (RCTs) came to different conclusion regarding the utility of genotype-guided dosing; we critically explore the reasons for the differences. The new generation of oral anticoagulants have been demonstrated to be as efficacious as warfarin, but further work is needed to evaluate their safety in real clinical settings.
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Affiliation(s)
- Munir Pirmohamed
- The University of Liverpool, Liverpool L69 3BX, UK; Royal Liverpool and Broadgreen University Hospital National Health Service (NHS) Trust, Prescot Street, Liverpool L7 8XP, UK.
| | - Farhad Kamali
- Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Ann K Daly
- Newcastle University, Newcastle upon Tyne NE2 4HH, UK
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Nomura E, Ohshita T, Imamura E, Wakabayashi S, Kajikawa H, Hosomi N, Matsumoto M. Early Administration of Non-Vitamin K Antagonist Oral Anticoagulants for Acute Ischemic Stroke Patients With Atrial Fibrillation in Comparison With Warfarin Mostly Combined With Heparin. Circ J 2015; 79:862-6. [DOI: 10.1253/circj.cj-14-0793] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Eiichi Nomura
- Department of Neurology, Suiseikai Kajikawa Hospital
- Department of Neurology, Hiroshima City Hiroshima Citizens Hospital
| | | | - Eiji Imamura
- Department of Neurology, Suiseikai Kajikawa Hospital
| | | | | | - Naohisa Hosomi
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences
| | - Masayasu Matsumoto
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences
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Manzano-Fernández S, Andreu-Cayuelas JM, Marín F, Orenes-Piñero E, Gallego P, Valdés M, Vicente V, Lip GYH, Roldán V. Comparison of estimated glomerular filtration rate equations for dosing new oral anticoagulants in patients with atrial fibrillation. ACTA ACUST UNITED AC 2014; 68:497-504. [PMID: 25457087 DOI: 10.1016/j.rec.2014.06.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 06/13/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION AND OBJECTIVES New oral anticoagulants require dosing adjustment according to renal function. We aimed to determine discordance in hypothetical recommended dosing of these drugs using different estimated glomerular filtration rate equations in patients with atrial fibrillation. METHODS Cross-sectional analysis of 910 patients with atrial fibrillation and an indication for oral anticoagulation. The glomerular filtration rate was estimated using the Cockcroft-Gault, Modification of Diet in Renal Disease and Chronic Kidney Disease Epidemiology Collaboration equations. For dabigatran, rivaroxaban, and apixaban we identified dose discordance when there was disagreement in the recommended dose based on different equations. RESULTS Among the overall population, relative to Cockcroft-Gault, discordance in dabigatran dosage was 11.4% for Modification of Diet in Renal Disease and 10% for Chronic Kidney Disease Epidemiology Collaboration, discordance in rivaroxaban dosage was 10% for Modification of Diet in Renal Disease and 8.5% for the Chronic Kidney Disease Epidemiology Collaboration. The lowest discordance was observed for apixaban: 1.4% for Modification of Diet in Renal Disease and 1.5% for the Chronic Kidney Disease Epidemiology Collaboration. In patients with Cockcroft-Gault<60mL/min or elderly patients, discordances in dabigatran and rivaroxaban dosages were higher, ranging from 13.2% to 30.4%. Discordance in apixaban dosage remained<5% in these patients. CONCLUSIONS Discordance in new oral anticoagulation dosages using different equations is frequent, especially among elderly patients with renal impairment. This discordance was higher in dabigatran and rivaroxaban dosages than in apixaban dosages. Further studies are needed to clarify the clinical importance of these discordances and the optimal anticoagulant dosages depending on the use of different equations to estimate renal function.
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Affiliation(s)
- Sergio Manzano-Fernández
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Facultad de Medicina, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
| | - José M Andreu-Cayuelas
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Facultad de Medicina, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
| | - Francisco Marín
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Facultad de Medicina, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
| | - Esteban Orenes-Piñero
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Facultad de Medicina, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
| | - Pilar Gallego
- Servicio de Hematología, Hospital Rafael Méndez, Lorca, Murcia, Spain
| | - Mariano Valdés
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Facultad de Medicina, Universidad de Murcia, Instituto Murciano de Investigación Biosanitaria, Murcia, Spain
| | - Vicente Vicente
- Unidad de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Universidad de Murcia, Murcia, Spain
| | - Gregory Y H Lip
- Haemostasis, Thrombosis and Vascular Biology Unit, University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom.
| | - Vanessa Roldán
- Unidad de Hematología y Oncología Médica, Hospital Universitario Morales Meseguer, Universidad de Murcia, Murcia, Spain
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Management of non-vitamin K antagonist oral anticoagulants in the perioperative setting. BIOMED RESEARCH INTERNATIONAL 2014; 2014:385014. [PMID: 25276784 PMCID: PMC4168027 DOI: 10.1155/2014/385014] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 08/05/2014] [Indexed: 12/29/2022]
Abstract
The field of oral anticoagulation has evolved with the arrival of non-vitamin K antagonist oral anticoagulants (NOACs) including an anti-IIa agent (dabigatran etexilate) and anti-Xa agents (rivaroxaban and apixaban). The main specificities of these drugs are predictable pharmacokinetics and pharmacodynamics but special attention should be paid in the elderly, in case of renal dysfunction and in case of emergency. In addition, their perioperative management is challenging, especially with the absence of specific antidotes. Effectively, periods of interruption before surgery or invasive procedures depend on half-life and keeping a permanent balance between bleeding and thromboembolic risks. In addition, few data regarding the link between plasma concentrations and their effects are provided. Routine laboratory tests are altered by NOACs and quantitative measurements are not widely performed. This paper provides a review on the management of NOACs in the perioperative setting, including the estimation of the bleeding and thrombotic risk, the periods of interruption, the indication of heparin bridging, the usefulness of laboratory tests before surgery or invasive procedure, and the time of resuming. Most data are based on expert's opinions.
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Berthelot E, Lavenu-Bombled C, Orostegui-Giron L, Desconclois C, Assayag P. Impaired renal function and bleeding in elderly treated with dabigatran. Blood Coagul Fibrinolysis 2014; 25:618-20. [DOI: 10.1097/mbc.0000000000000077] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Nomura E, Ohshita T, Imamura E, Wakabayashi S, Kajikawa H, Matsumoto M. Can early effective anticoagulation prevent new lesions on magnetic resonance imaging in acute cardioembolic stroke? J Stroke Cerebrovasc Dis 2014; 23:2099-2104. [PMID: 25106835 DOI: 10.1016/j.jstrokecerebrovasdis.2014.03.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 03/08/2014] [Accepted: 03/21/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The timing of warfarin administration for acute ischemic stroke (AIS) patients with atrial fibrillation (Af) has not been established. We hypothesized that achieving targeted prothrombin time and international normalized ratio (PT-INR) at 2 weeks could prevent AIS patients with Af from developing a new lesion on diffusion-weighted magnetic resonance imaging (DW-MRI). METHODS Of consecutively enrolled AIS patients with Af between 2008 and 2011, we selected the patients who were given warfarin within 2 weeks of admission and had DW-MRI and blood test for PT-INR both on admission and at 2 weeks. Warfarin was started as early as possible and heparin was administered until the targeted PT-INR (2.0-3.0 for patients aged <70 years or 1.6-2.6 for those aged ≥70 years) was achieved. RESULTS One hundred and twenty-three patients were selected, consisting of 88 patients without a new lesion and 35 patients with a new lesion. Patients with a new lesion had a significantly higher median score on National Institutes of Health Stroke Scale (11.0 vs. 5.5, P = .0053), a lower rate of achieving targeted PT-INR at 2 weeks (25.7% vs. 48.9%, P = .0190), and a lower median dosage of warfarin at 2 weeks (2.0 mg vs. 2.5 mg, P = .0209) than patients without a new lesion. Multivariate logistic regression analysis showed that failure to achieve targeted PT-INR (P = .0298) was significantly associated with the occurrence of a new lesion. CONCLUSIONS Our findings suggest that achieving targeted PT-INR at 2 weeks by using warfarin prevents new lesions in AIS patients with Af.
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Affiliation(s)
- Eiichi Nomura
- Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan.
| | - Tomohiko Ohshita
- Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan
| | - Eiji Imamura
- Department of Neurology, Suiseikai Kajikawa Hospital, Hiroshima, Japan
| | | | - Hiroshi Kajikawa
- Department of Neurosurgery, Suiseikai Kajikawa Hospital, Hiroshima, Japan
| | - Masayasu Matsumoto
- Department of Clinical Neuroscience and Therapeutics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
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Preventive strategies against bleeding due to nonvitamin K antagonist oral anticoagulants. BIOMED RESEARCH INTERNATIONAL 2014; 2014:616405. [PMID: 25032218 PMCID: PMC4084591 DOI: 10.1155/2014/616405] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Accepted: 04/14/2014] [Indexed: 01/20/2023]
Abstract
Dabigatran etexilate (DE), rivaroxaban, and apixaban are nonvitamin K antagonist oral anticoagulants (NOACs) that have been compared in clinical trials with existing anticoagulants (warfarin and enoxaparin) in several indications for the prevention and treatment of thrombotic events. All NOACs presented bleeding events despite a careful selection and control of patients. Compared with warfarin, NOACs had a decreased risk of intracranial hemorrhage, and apixaban and DE (110 mg BID) had a decreased risk of major bleeding from any site. Rivaroxaban and DE showed an increased risk of major gastrointestinal bleeding compared with warfarin. Developing strategies to minimize the risk of bleeding is essential, as major bleedings are reported in clinical practice and specific antidotes are currently not available. In this paper, the following preventive approaches are reviewed: improvement of appropriate prescription, identification of modifiable bleeding risk factors, tailoring NOAC's dose, dealing with a missed dose as well as adhesion to switching, bridging and anesthetic procedures.
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Stöllberger C, Finsterer J. Prolonged anticoagulant activity of rivaroxaban in a polymorbid elderly female with non-convulsive epileptic state. Heart Lung 2014; 43:262-3. [PMID: 24794785 DOI: 10.1016/j.hrtlng.2014.03.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 03/03/2014] [Accepted: 03/04/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVES AND BACKGROUND Rivaroxaban, an oral direct factor Xa-inhibitor was non-inferior to adjusted dose warfarin in the prevention of stroke and embolism among patients with atrial fibrillation (AF) in the ROCKET-AF trial and has been approved for stroke prevention in AF. CASE REPORT A 88-years-old female (body-mass-index = 19.95) with AF, hypertension and diabetes mellitus, hospitalized because of heart failure and a non-convulsive epileptic state, was treated by valproate, mirtazepin, nebivolol, digitoxin, lisinopril, gliclazide and amlodipine. Irrespective of renal insufficiency, rivaroxaban 15 mg/d was started. After 3 days rivaroxaban was stopped because of concerns about the bleeding risk. Coagulation tests 28 h after rivaroxaban-intake showed INR 2.26, PT 35%, aPTT 38.3 s and anti-Factor Xa-activity 2.00 U/ml. Explanations for the prolonged anticoagulant activity of rivaroxaban comprise renal failure, the low body-mass-index, the advanced age and drug-drug interactions of rivaroxaban with mirtazepin, valproate and amlodipine. CONCLUSION Health care providers should consider renal function, concomitant medication, polymorbidity and age prior to prescribing rivaroxaban. Care has to be taken when prescribing rivaroxaban to patients who are different from those included in the ROCKET AF trial.
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Affiliation(s)
| | - Josef Finsterer
- Krankenanstalt Rudolfstiftung, Juchgasse 25, 1030 Wien, Austria
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