Effects of oral anticoagulation with various INR levels in deep vein thrombosis cases

Acenocoumarol Pharmacogenetic Dosing Algorithm versus Usual Care in Patients with Venous Thromboembolism: A Randomised Clinical Trial

Patients with venous thromboembolism (VTE) require immediate treatment with anticoagulants such as acenocoumarol. This multicentre randomised clinical trial evaluated the effectiveness of a dosing pharmacogenetic algorithm versus a standard-of-care dose adjustment at the beginning of acenocoumarol treatment. We included 144 patients with VTE. On the day of recruitment, a blood sample was obtained for genotyping (CYP2C9*2, CYP2C9*3, VKORC1, CYP4F2, APOE). Dose adjustment was performed on day 3 or 4 after the start of treatment according to the assigned group and the follow-up was at 12 weeks. The principal variable was the percentage of patients with an international normalised ratio (INR) within the therapeutic range on day 7. Thirty-four (47.2%) patients had an INR within the therapeutic range at day 7 after the start of treatment in the genotype-guided group compared with 14 (21.9%) in the control group (p = 0.0023). There were no significant differences in the time to achieve a stable INR, the number of INRs within the range in the first 6 weeks and at the end of study. Our results suggest the use of a pharmacogenetic algorithm for patients with VTE could be useful in achieving target INR control in the first days of treatment.

Risk factors associated with warfarin overdose and complications related to warfarin overdose in the emergency department

The aim of this study was to investigate risk factors of bleeding and mortality in patients with warfarin overdose (WOD). Totally, 783 patients were included, of which, 272 patients (34.7%) with an INR below 5,364 patients (46.5%) with an INR between 5-10, and 147 patients (18.8%) with an INR of 10 or above. Demographic, clinical, and laboratory findings of the patients were obtained from the Real Life Data Provision Center and Hospital Information Management System. Admittance in autumn (OR = 1.75; p = 0.012), INR = 5-10 (OR = 2.65; p < 0.001), INR ≥ 10 (OR = 9.06; p < 0.001), and antiplatelet use alongside warfarin (OR = 1.93; p < 0.001) were found to be independent risk factors for bleeding in this study. The age (OR= 1.03; p = 0.005), bleeding (OR = 1.69; p = 0.020), primary hypertension (OR = 1.72; p = 0.031), and INR ≥ 10 (OR = 2.02; p = 0.025) were found to be independent risk factors for mortality. The cutoff value for INR in predicting bleeding was found to be >6.35 with 74.2% sensitivity and 72.7% specificity. The significant risk factors were determined in WOD development. INR level, autumn, and antiplatelet use were independently associated with bleeding due to WOD. In addition, bleeding, hypertension and INR levels were independently related to in-hospital-mortality due to WOD.

Is dabigatran considered a cost-effective alternative to warfarin treatment: a review of current economic evaluations worldwide

OBJECTIVE

Dabigatran was the first of a new generation of anticoagulation drugs for the indication of non-valvular atrial fibrillation (AF) to be approved. Evidence show that dabigatran 150 mg twice daily significantly reduces the risk of stroke and systemic embolism (RR = 0.65; p < 0.001) and shows a comparable rate of major bleedings (RR = 0.93; p = 0.32), whereas dabigatran 110 mg twice daily was associated with a comparable rate of stroke and systemic embolism (RR = 0.90; p = 0.30) and a significantly lower rate of major bleedings compared to warfarin treatment (RR = 0.80; p = 0.003). The purpose is to review current economic evaluations of these alternatives for healthcare professionals to include these findings in their decision-making.

METHODS

A systematic literature search identified 43 economic evaluations, of which 10 were included and evaluated according to the Consensus Health Economic Criteria list (CHEC-list) and the Oxford model.

RESULTS

Six economic evaluations concluded that dabigatran was a cost-effective alternative to warfarin. One evaluation concluded the same except when quality in warfarin treatment was excellent, with a mean time in therapeutic range (TTR) > 73%. Three evaluations concluded that dabigatran was a cost-effective alternative to warfarin in patient sub-groups; TTR ≤ 64%, congestive heart failure, hypertension, age ≥ 75, diabetes mellitus, prior stroke or transient ischemic attack (CHADS2 score) ≥3, or a CHADS2 score = 2 unless international normalized ratio (INR) control was excellent, and with high risk of stroke or in a low-quality warfarin treatment. Dabigatran 110 mg twice daily was in general dominated by dabigatran 150 mg twice daily.

LIMITATIONS

The evaluations were not fully homogeneous, as some did not include loss of productivity, costs of dyspepsia, and annual costs of dabigatran patient management.

CONCLUSIONS

In the majority of the economic evaluations, dabigatran is a cost-effective alternative to warfarin treatment. In some evaluations dabigatran is only cost-effective in sub-groups, such as patients with a low TTR-value in warfarin treatment and a CHADS2 score ≥2.

Serum levels of matrix metalloproteinases -1,-2,-3 and -9 in thoracic aortic diseases and acute myocardial ischemia

Background

Matrix metalloproteinases (MMPs) constitute a family of zinc-dependent proteases (endopeptidases) whose catalytic action is the degradation of the extracellular matrix components. In addition, they play the major role in the degradation of collagen and in the process of tissue remodeling. The present clinical study investigated blood serum levels of metalloproteinases- 1, -2, -3 and -9 in patients with acute and chronic aortic dissection, thoracic aortic aneurysm and acute myocardial ischemia compared to healthy individuals.

Methods

The blood serum levels of MMP-1, -2, -3 and -9 were calculated in 31 patients with acute aortic dissection, 18 patients with chronic aortic dissection, 18 patients with aortic aneurysm and in 13 patients with acute myocardial ischemia, as well as in 15 healthy individuals who served as the control group. Serum MMP levels were measured by using an ELISA technique.

Results

There were significantly higher levels of MMP-3 in patients with acute myocardial ischemia as compared to acute aortic dissection (17.33 ± 2.03 ng/ml versus 12.92 ± 1.01 ng/ml, p < 0.05). Significantly lower levels of MMP-1 were found in healthy controls compared to all groups of patients (1.1 ± 0.38 ng/ml versus 2.97 ± 0.68 in acute aortic dissection, 3.09 ± 0.98 in chronic dissection, 3.16 ± 0.51 in thoracic aortic aneurysm and 4.58 ± 1.04 in acute myocardial ischemia, p < 0.05). Higher levels of MMP-1 and MMP-3 were detected on males. There was a positive correlation with increasing age (r = 0.38, p < 0.05). In patients operated for acute type A aortic dissection, the levels of MMP-1, MMP-3 and MMP-9 increased immediately after surgery, while the levels of MMP-2 decrease. At 24 hours postoperatively, levels of MMP -1, -2 and -9 are almost equal to the preoperative ones.

Conclusion

Measurement of serum MMP levels in thoracic aortic disease and acute myocardial ischemia is a simple and relatively rapid laboratory test that could be used as a biochemical indicator of aortic disease or acute myocardial ischemia, when evaluated in combination with imaging techniques.

Is any link between inflammation and coronary artery ectasia?

Coronary artery ectasia (CAE) is well-recognized, angiographic finding of abnormal coronary dilatation, and detected in 0.3-5.3% of angiographic studies. The gold standard for diagnosis this type of aneurysm is coronary angiography, which provides information about the size, sample, location and number of aneurysms. Despite growing prevalence in recent years, controversy still exists as to the pathogenetic mechanisms that underlie this entity. An increased incidence of CAE has been reported in several disorders. Examples include atherosclerotic vascular disease, heterozygous familial hypercholesterolemia, usage of substances including herbicide spray, acetylcholinesterase inhibitors and nitrates, previous arterial balloon angioplasty, polyarteritis nodosa and Kawasaki syndrome. In addition, possible factors contributing to CAE are imbalance between matrix metalloproteinase and tissue inhibitor of metalloproteinase, angiotensin converting enzyme genotype, elevated homocysteine levels, cocaine user, smoking, vascular trauma, nitrate use and diabetes. Emerging investigations have pinpointed inflammation as a central process in all stages of atherosclerosis. This inflammatory process culminates in acute thrombotic complications and clinical events, which is involved in different clinical settings of atherosclerotic diseases. Recent data have also showed that CAE is associated with inflammatory response presented as elevated inflammatory cytokines and C-reactive protein. Accordingly, more complete understanding of the pro- and anti-inflammatory circuits that operate during CAE in particular may foster the development of novel therapeutic approaches.

Clinical equivalence of IV paracetamol compared to IV dipyrone for postoperative analgesia after surgery for breast cancer

OBJECTIVE

To assess clinical efficacy of IV paracetamol 1 g and IV dipyrone 1 g on a 24-h dosing schedule in this randomised, double-blinded study of 40 ASA I-III (American Society of Anesthesiologists classification of physical status) patients undergoing surgery for breast cancer.

RESEARCH DESIGN AND METHODS

General anaesthesia using remifentanil and propofol was performed for surgery. The patients were randomly allocated to two groups, receiving infusions of paracetamol 1 g/100 mL (Para Group) or of dipyrone 1 g/100 mL (Dipy Group) 30 min before arrival in the recovery area and every 6 h up to 24 h postoperatively. All patients had unrestricted access to opioid rescue medication via an IV patient-controlled analgesia (PCA) device.

MAIN OUTCOME MEASURES

The primary variables for clinical equivalence were the differences between the mean values for pain scores at rest and pain scores on coughing over 30 h postoperatively. The equivalence margin was determined as +/-10 mm on the visual analogue scale (VAS).

RESULTS

Regarding pain scores at rest, the 90% CI of the mean differences between the treatment groups over 30 h postoperatively was found to be within the predefined equivalence margin [+7.5/-6.2], and the CI values for pain scores on coughing [+7.3/-9.0] were similar. The two groups did not differ in cumulative opioid rescue consumption (Dipy-Group 14.8 +/- 17.7 mg vs. Para Group 12.1 +/- 8.8 mg, p = 0.54) nor in piritramide loading dose (Dipy Group 0.95 +/- 2.8 mg vs. Para Group 1.3 +/- 2.8 mg, p = 0.545). Five patients in the Dipy Group experienced hypotension in contrast to none in the Para Group (p = 0.047). There were no significant between-treatment differences for other adverse events, patient satisfaction scores (p = 0.4) or quality of recovery scores (p = 0.3).

CONCLUSION

IV paracetamol 1 g is clinically equivalent to IV dipyrone 1 g for postoperative analgesia after surgery for breast cancer.