1
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Hunt AR, Coffeen SN, Shiltz DL, Ice C, Parker J. Factor VIII Inhibitor Bypassing Activity (FEIBA) Reversal for Apixaban and Rivaroxaban in Patients With Acute Intracranial and Nonintracranial Hemorrhage. Ann Pharmacother 2021; 55:1455-1466. [PMID: 33843267 DOI: 10.1177/10600280211004583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The clinical use of factor VIII inhibitor bypassing activity (FEIBA) for factor Xa (FXa) inhibitor reversal is derived from small studies with notable variation in patient eligibility for use, dosage regimens, concurrent supportive care, and outcome measures. Consequently, additional effectiveness and safety data are warranted to expand the literature evaluating FEIBA for FXa inhibitor reversal. OBJECTIVE This study sought to determine the incidence of observed effective hemostasis within 24 hours of post-FEIBA® administration as well as in-hospital and 30-day post-discharge incidences of thromboembolic event (TEE) and mortality between apixaban and rivaroxaban in the intracranial hemorrhage (ICH) and non-ICH populations. METHODS This case series evaluated patients between January 1, 2014 through July 1, 2019 who received at least one FEIBA® dose for apixaban or rivaroxaban reversal secondary to acute ICH or non-ICH. Patient demographics, FEIBA® dosages, adjunct treatments, effectiveness, and safety outcomes were retrospectively collected from electronic medical record review. Modified hemostasis outcomes, adapted from criteria previously published by Sarode et al., TEE, and mortality between apixaban and rivaroxaban in the ICH and non-ICH populations were evaluated. RESULTS Among the 104 patients evaluated, 62 received apixaban and 42 rivaroxaban. Thirty apixaban and 25 rivaroxaban users experienced ICH, whereas 32 apixaban and 17 rivaroxaban users experienced non-ICH. Among the combined ICH and non-ICH populations, effective hemostasis occurred in 89%, TEE in 8%, and mortality in 13%. No statistically significant differences were observed within ICH and non-ICH populations receiving apixaban or rivaroxaban regarding effective hemostasis, TEE, or mortality. CONCLUSION AND RELEVANCE The combined ICH and non-ICH overall rates of effective hemostasis, TEE, and mortality were comparable to preexisting studies of FEIBA for factor Xa inhibitor reversal. The limitations inherent to the study design warrant a randomized controlled trial with an active comparator to confirm these observations.
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Affiliation(s)
- Aleah R Hunt
- Spectrum Health Butterworth Hospital, Grand Rapids, MI, USA
| | | | - Dane L Shiltz
- Ferris State University College of Pharmacy, Big Rapids, MI, USA
| | - Calvin Ice
- Spectrum Health Butterworth Hospital, Grand Rapids, MI, USA
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2
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Shah NM, Chong SE, Yusoff SM, Mazlan MZ, Johan KB, Azman N, Lim JA, Mohamad SM, Noordin SS, Ghaffar ZA, Hassan MH, Zabidi MA, Rahim NAA. Recombinant activated factor VII (rFVIIa) in refractory haemorrhage for non-haemophiliacs: an eleven-year single-centre experience. BMC HEMATOLOGY 2018; 18:34. [PMID: 30498571 PMCID: PMC6251212 DOI: 10.1186/s12878-018-0126-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Accepted: 10/17/2018] [Indexed: 11/12/2022]
Abstract
Background Massive bleeding is one of the commonest salvageable causes of death. The search for an ideal haemostatic agent during massive bleeding is still ongoing. One of the novel haemostatic medications is recombinant activated factor VII (rFVIIa). To date, the usage of rFVIIa during massive haemorrhage among non-haemophiliac patients remains off-label. The aim of this study is to report our experience in using rFVIIa to treat refractory bleeding. Methods Medical records of all patients treated with rFVIIa for massive bleeding over an eleven-year period in a single institution were recorded. Treatment indications, 24-h and 30-day mortality, changes in transfusion needs and coagulation profiles after rFVIIa administration were analysed. Results rFVIIa were administered in 76 patients. Of these, 41 (53.9%) were non-surgical bleeding, followed by 22 patients (28.9%) with trauma, other surgery bleedings in 9 patients (11.8%) and 4 patients (5.4%) with peripartum haemorrhage. Total survival rate was 78.9% within 24 h and 44.7% over 30 days. Among all these patients who had received rFVIIa due to life-threatening haemorrhage, blood and blood product requirements were significantly reduced (P < 0.001), and the coagulation profiles improved significantly (P < 0.05). Two patients with preexisting thromboembolism were given rFVIIa due to intractable bleeding, both survived. No thromboembolic events were reported after the administration of rFVIIa. Conclusions rFVIIa significantly improved coagulation parameters and reduced blood product requirements during refractory haemorrhage. Additionally, usage of rFVIIa in trauma and peripartum haemorrhage patients yield better outcomes than other groups of patients. However, the overall mortality rate remained high.
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Affiliation(s)
- Nurfatin Mohd Shah
- 1Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia
| | - Soon Eu Chong
- 1Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia.,3Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, KTN Malaysia
| | - Syahirah Mohamed Yusoff
- 1Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia
| | - Mohd Zulfakar Mazlan
- 2School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, KTN Malaysia.,3Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, KTN Malaysia
| | - Khairul Bariah Johan
- 3Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, KTN Malaysia.,5Department of Pharmacy, Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, KTN Malaysia
| | - Nizuwan Azman
- 1Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia
| | - Jo Anne Lim
- 4Department of Internal Medicine, Hospital Sultan Abdul Halim, 08000 Sungai Petani, KDH Malaysia
| | - Siti Mardhiana Mohamad
- 1Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia
| | - Siti Salmah Noordin
- 1Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia
| | - Zainab Abdul Ghaffar
- 6Integrative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia
| | - Mohd Hasyizan Hassan
- 2School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, KTN Malaysia.,3Hospital Universiti Sains Malaysia, 16150 Kubang Kerian, KTN Malaysia
| | - Muhammad Azrul Zabidi
- 1Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia
| | - Nur Arzuar Abdul Rahim
- 1Regenerative Medicine Cluster, Advanced Medical and Dental Institute, Universiti Sains Malaysia, 13200 Kepala Batas, PNG Malaysia
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3
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Di Fusco SA, Lucà F, Benvenuto M, Iorio A, Fiscella D, D'Ascenzo F, Madeo A, Colivicchi F, Di Lenarda A, Gulizia MM. Major bleeding with old and novel oral anticoagulants: How to manage it. Focus on reversal agents. Int J Cardiol 2018; 268:75-79. [DOI: 10.1016/j.ijcard.2018.05.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/19/2018] [Accepted: 05/18/2018] [Indexed: 12/13/2022]
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4
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Abstract
Intracerebral hemorrhage (ICH) is a subset of stroke due to spontaneous bleeding within the parenchyma of the brain. It is potentially lethal, and survival depends on ensuring an adequate airway, proper diagnosis, and early management of several specific issues such as blood pressure, coagulopathy reversal, and surgical hematoma evacuation for appropriate patients. ICH was chosen as an Emergency Neurological Life Support (ENLS) protocol because intervention within the first hours may improve outcome, and it is critical to have site-specific protocols to drive care quickly and efficiently.
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5
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Xia ZN, Zhou Q, Zhu W, Weng XS. Low molecular weight heparin for the prevention of deep venous thrombosis after total knee arthroplasty: A systematic review and meta-analysis. Int J Surg 2018; 54:265-275. [DOI: 10.1016/j.ijsu.2018.04.059] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 03/23/2018] [Accepted: 04/28/2018] [Indexed: 11/26/2022]
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6
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Fernandes CJCDS, Alves Júnior JL, Gavilanes F, Prada LF, Morinaga LK, Souza R. New anticoagulants for the treatment of venous thromboembolism. J Bras Pneumol 2017; 42:146-54. [PMID: 27167437 PMCID: PMC4853069 DOI: 10.1590/s1806-37562016042020068] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 03/22/2016] [Indexed: 12/21/2022] Open
Abstract
Worldwide, venous thromboembolism (VTE) is among the leading causes of death from cardiovascular disease, surpassed only by acute myocardial infarction and stroke. The spectrum of VTE presentations ranges, by degree of severity, from deep vein thrombosis to acute pulmonary thromboembolism. Treatment is based on full anticoagulation of the patients. For many decades, it has been known that anticoagulation directly affects the mortality associated with VTE. Until the beginning of this century, anticoagulant therapy was based on the use of unfractionated or low-molecular-weight heparin and vitamin K antagonists, warfarin in particular. Over the past decades, new classes of anticoagulants have been developed, such as factor Xa inhibitors and direct thrombin inhibitors, which significantly changed the therapeutic arsenal against VTE, due to their efficacy and safety when compared with the conventional treatment. The focus of this review was on evaluating the role of these new anticoagulants in this clinical context.
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Affiliation(s)
| | | | | | - Luis Felipe Prada
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | | | - Rogerio Souza
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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7
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Gulati D, Dua D, Torbey MT. Hemostasis in Intracranial Hemorrhage. Front Neurol 2017; 8:80. [PMID: 28360881 PMCID: PMC5351795 DOI: 10.3389/fneur.2017.00080] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 02/24/2017] [Indexed: 01/12/2023] Open
Abstract
Spontaneous non-traumatic intracerebral hemorrhage (ICH) is associated with high morbidity and mortality throughout the world with no proven effective treatment. Majority of hematoma expansion occur within 4 h after symptom onset and is associated with early deterioration and poor clinical outcome. There is a vital role of ultra-early hemostatic therapy in ICH to limit hematoma expansion. Patients at risk for hematoma expansion are with underlying hemostatic abnormalities. Treatment strategy should include appropriate intervention based on the history of use of antithrombotic use or an underlying coagulopathy in patients with ICH. For antiplatelet-associated ICH, recommendation is to discontinue antiplatelet agent and transfuse platelets to those who will undergo neurosurgical procedure with moderate quality of evidence. For vitamin K antagonist-associated ICH, administration of 3-factor or 4-factor prothrombin complex concentrates (PCCs) rather than fresh frozen plasma to patients with INR >1.4 is strongly recommended. For patients with novel oral anticoagulant-associated ICH, administering activated charcoal to those who present within 2 h of ingestion is recommended. Idarucizumab, a humanized monoclonal antibody fragment against dabigatran (direct thrombin inhibitor) is approved by FDA for emergency situations. Administer activated PCC (50 U/kg) or 4-factor PCC (50 U/kg) to patients with ICH associated with direct thrombin inhibitors (DTI) if idarucizumab is not available or if the hemorrhage is associated with a DTI other than dabigatran. For factor Xa inhibitor-associated ICH, administration of 4-factor PCC or aPCC is preferred over recombinant FVIIa because of the lower risk of adverse thrombotic events.
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Affiliation(s)
- Deepak Gulati
- Neurology Department, The Ohio State University College of Medicine , Columbus, OH , USA
| | - Dharti Dua
- Neurology Department, The Ohio State University College of Medicine , Columbus, OH , USA
| | - Michel T Torbey
- Neurology Department, The Ohio State University College of Medicine , Columbus, OH , USA
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8
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Dager W, Hellwig T. Current knowledge on assessing the effects of and managing bleeding and urgent procedures with direct oral anticoagulants. Am J Health Syst Pharm 2017; 73:S14-26. [PMID: 27147455 DOI: 10.2146/ajhp150960] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Current knowledge on managing major bleeding events with available hemostatic agents, including their combined use with potential reversal agents, in patients taking direct oral anticoagulant (DOACs) is reviewed. SUMMARY Over the past five years, a new generation of oral agents, the DOACs, has emerged as commonly used anticoagulants for stroke prevention in non-valvular atrial fibrillation, and treatment or secondary prevention of venous thromboembolism. Management of a bleeding event in the setting of DOAC therapy should take into account the relative risks of bleeding and thrombosis, which will determine the degree of anticoagulant reversal required. In the setting of a major (critical) bleeding event associated with notable blood loss, management may include transfusions of blood products to sustain the function of organ systems, and the availability of specific reversal agents will provide additional options for bleeding management. Beyond withholding the DOAC and providing supportive management that addresses any factors contributing to the bleeding event, clinicians may desire to expedite the removal of any anticoagulation effects. In general, this is accomplished by either removing or neutralizing the anticoagulant or by independently establishing hemostasis. CONCLUSION With or without reversal agents, patients may require supportive management such as mechanical pressure, volume support, transfusions of blood products, and, depending on the situation, surgery to repair the bleeding source. Specific reversal agents are currently under development or have recently been approved for the urgent management of bleeding events or the facilitation of invasive procedures in patients receiving DOACs.
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Affiliation(s)
- William Dager
- University of California Davis Medical Center, Sacramento, CA.
| | - Thaddaus Hellwig
- South Dakota State University College of Pharmacy, Sioux Falls, SDSanford USD Medical Center, Sioux Falls, SD
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9
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Yorkgitis BK, Zhang J, Rappold JF. Non-Vitamin K Antagonist Oral Anticoagulants: The Clinician's New Challenge. J Osteopath Med 2016; 115:612-21. [PMID: 26414714 DOI: 10.7556/jaoa.2015.122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Millions of US patients are prescribed oral anticoagulants. Traditionally, oral anticoagulation was achieved with vitamin K antagonists (VKAs). In recent years, non-VKA oral anticoagulants (NOACs) have emerged that provide an effective and convenient alternative to VKAs. These agents possess very different pharmacologic properties from what the medical community has grown accustom to with the VKAs. Thus, a new knowledge base is required for NOACs. One particular challenge with the NOACs is the lack of specific reversal agent, resulting in difficulties correcting the coagulopathy induced by these drugs when needed. A review of the current literature is presented to assist clinicians in gaining knowledge of the NOACs to care for patients.
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10
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Chang Y, Kim YJ, Song TJ. Management of Oral Anti-Thrombotic Agents Associated Intracerebral Hemorrhage. JOURNAL OF NEUROCRITICAL CARE 2016. [DOI: 10.18700/jnc.160082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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11
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Jauch EC, Pineda JA, Hemphill JC. Emergency Neurological Life Support: Intracerebral Hemorrhage. Neurocrit Care 2016; 23 Suppl 2:S83-93. [PMID: 26438461 DOI: 10.1007/s12028-015-0167-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Intracerebral hemorrhage (ICH) is a subset of stroke due to bleeding within the parenchyma of the brain. It is potentially lethal, and survival depends on ensuring an adequate airway, reversal of coagulopathy, and proper diagnosis. ICH was chosen as an Emergency Neurological Life Support protocol because intervention within the first critical hour may improve outcome, and it is critical to have site-specific protocols to drive care quickly and efficiently.
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Affiliation(s)
- Edward C Jauch
- Division of Emergency Medicine and Department of Neurosciences, Medical University of South Carolina, Charleston, USA.
| | - Jose A Pineda
- Department of Pediatrics and Neurology, Washington University School of Medicine, St. Louis, MO, USA
| | - J Claude Hemphill
- Department of Neurology, University of California, San Francisco, USA
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12
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Rodríguez-Reyes H, Arauz-Góngora A, Asensio-Lafuente E, Celaya-Cota MDJ, Cordero-Cabra A, Guevara-Valdivia M, Izaguirre-Avila R, Lara-Vaca S, Mariona-Moreno V, Martínez-Flores E, Nava-Townsend S, Pozas-Garza G, Rodríguez-Diez G. [Multidisciplinary meeting about the use of direct oral anticoagulants in nonvalvular atrial fibrillation]. ARCHIVOS DE CARDIOLOGIA DE MEXICO 2016; 87:124-143. [PMID: 27578566 DOI: 10.1016/j.acmx.2016.06.006] [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: 01/22/2016] [Revised: 06/17/2016] [Accepted: 06/21/2016] [Indexed: 11/27/2022] Open
Abstract
Knowing the real impact of atrial fibrillation in the stroke, the Sociedad Mexicana of Electrofisiología y Estimulación Cardiaca (SOMEEC) had the initiative to develop a multidisciplinary meeting of experts the with the purpose to update the available scientific evidence from clinical practice guidelines, meta-analyses, controlled clinical trials, and complementing with the experience and views of a group of experts. To meet this goal, SOMEEC gathered a group of specialists in the area of cardiology, electrophysiology, neurology and hematology that given their experience in certain areas, they share the scientific evidence with the panel of experts to leave open a discussion about the information presented in this article. This document brings together the best scientific evidence available and aims to be a useful tool in the decision to use of new oral anticoagulants in nonvalvular atrial fibrillation and ischemic heart disease, or relating to the management of patients with stroke or renal failure, and even those that will be submitted to elective surgery and invasive procedures. In the same, they handled comparative schemes of follow-up and treatment which simplifies the decision making by the specialists participants.
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Affiliation(s)
| | - Antonio Arauz-Góngora
- Clínica de Enfermedad Vascular Cerebral, Instituto Nacional de Neurología y Neurocirugía, Ciudad de México, México
| | | | | | | | - Milton Guevara-Valdivia
- UMAE Hospital de Especialidades «Dr. Antonio Fraga Mouret», Centro Médico Nacional La Raza, Ciudad de México, México
| | - Raúl Izaguirre-Avila
- Departamento de Hematología, Clínica de anticoagulantes, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México
| | - Susano Lara-Vaca
- Servicio de Arritmias, Centro Médico IMSS, León Guanajuato, México
| | | | | | - Santiago Nava-Townsend
- Departamento de Electrocardiología, Instituto Nacional de Cardiología «Ignacio Chávez», Ciudad de México, México
| | - Gerardo Pozas-Garza
- Instituto de Cardiología y Medicina vascular del TEC de Monterrey, Monterrey, México
| | - Gerardo Rodríguez-Diez
- Departamento de Electrofisiología, Centro Médico Nacional 20 de Noviembre, Ciudad de México, México
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13
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Yorkgitis BK. Direct oral anticoagulants for venous thromboembolism treatment and prophylaxis. JAAPA 2016; 29:24-9. [PMID: 27359069 DOI: 10.1097/01.jaa.0000488690.65799.b0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Direct oral anticoagulants are a popular option for prevention and treatment of venous thromboembolism. However, they possess significantly different pharmacologic properties from warfarin. This article reviews approved direct oral anticoagulants, their indications, pharmacologic properties, monitoring, and reversal strategies.
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Affiliation(s)
- Brian K Yorkgitis
- Brian K. Yorkgitis practices in the Division of Acute Care Surgery at the University of Florida-Jacksonville. The author has disclosed no potential conflicts of interest, financial or otherwise
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14
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Sié P. Spotlight on idarucizumab and its potential for the reversal of anticoagulant effects of dabigatran. DRUG DESIGN DEVELOPMENT AND THERAPY 2016; 10:1683-9. [PMID: 27274201 PMCID: PMC4876800 DOI: 10.2147/dddt.s94167] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Idarucizumab is the first targeted antidote of dabigatran, a direct oral anticoagulant used for prevention and treatment of venous thromboembolism and prevention of stroke in atrial fibrillation. Idarucizumab is a humanized fragment of a monoclonal antibody, which binds dabigatran reversibly with high affinity and, when administered intravenously, immediately neutralizes its anticoagulant effect. It is rapidly cleared by the kidney with captured dabigatran. In Phase I and II trials, no significant adverse events have been reported. Specifically, idarucizumab has no anticoagulant or procoagulant effect by itself. Idarucizumab is currently being evaluated in an ongoing Phase III trial, in patients treated with dabigatran presenting with severe active bleeding or requiring emergency surgery or an invasive procedure and are at high risk of bleeding. The results of the interim analysis confirm the ability of idarucizumab to neutralize dabigatran instantaneously, without rebound effect, except in rare patients with very high baseline levels of anticoagulant. Although not definitely proving clinical efficacy, due to the noncontrolled design of the trial and the heterogeneity of patient conditions, these promising results on an intermediate criterion with strong rationale have led to the approval of idarucizumab for these indications. However, several questions are unresolved. First, activity measurement of dabigatran in blood, useless in current practice, could be useful to guide the treatment and avoid over- or underutilization of the antidote; but so far, it has not been largely available in real time. Second, the translation of anticoagulant neutralization to an effect on mortality and better outcome is highly dependent on the global management of these patients, especially rapid diagnosis, supportive care, and easy access to antidote administration. Although idarucizumab represents a remarkable achievement in drug design and development, whether it will be an important step toward improved safety of patients treated with dabigatran in the real world will have to be demonstrated in the postmarketing phase.
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Affiliation(s)
- Pierre Sié
- Hematology Laboratory, Academic Hospital of Toulouse, Hospital Rangueil, Toulouse, France
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15
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Christos S, Naples R. Anticoagulation Reversal and Treatment Strategies in Major Bleeding: Update 2016. West J Emerg Med 2016; 17:264-70. [PMID: 27330657 PMCID: PMC4899056 DOI: 10.5811/westjem.2016.3.29294] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 03/01/2016] [Accepted: 03/18/2016] [Indexed: 11/11/2022] Open
Affiliation(s)
- Steve Christos
- Presence Resurrection Medical Center, Department of Emergency Medicine, Chicago, Illinois
| | - Robin Naples
- Lewis Katz School of Medicine at Temple University, Department of Emergency Medicine, Philadelphia, Pennsylvania
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16
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Ruff CT, Ansell JE, Becker RC, Benjamin EJ, Deicicchi DJ, Mark Estes NA, Ezekowitz MD, Fanikos J, Fareed J, Garcia D, Giugliano RP, Goldhaber SZ, Granger C, Healey JS, Hull R, Hylek EM, Libby P, Lopes RD, Mahaffey KW, Mega J, Piazza G, Sasahara AA, Sorond FA, Spyropoulos AC, Walenga JM, Weitz JI. North American Thrombosis Forum, AF Action Initiative Consensus Document. Am J Med 2016; 129:S1-S29. [PMID: 27126598 DOI: 10.1016/j.amjmed.2016.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The North American Thrombosis Forum Atrial Fibrillation Action Initiative consensus document is a comprehensive yet practical briefing document focusing on stroke and bleeding risk assessment in patients with atrial fibrillation, as well as recommendations regarding anticoagulation options and management. Despite the breadth of clinical trial data and guideline recommendation updates, many clinicians continue to struggle to synthesize the disparate information available. This problem slows the uptake and utilization of updated risk prediction tools and adoption of new oral anticoagulants. This document serves as a practical and educational reference for the entire medical community involved in the care of patients with atrial fibrillation.
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Affiliation(s)
- Christian T Ruff
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Jack E Ansell
- Hofstra North Shore/LIJ School of Medicine, Hempstead, NY
| | - Richard C Becker
- University of Cincinnati College of Medicine, University of Cincinnati Medical Center, Ohio
| | - Emelia J Benjamin
- Boston University School of Medicine and Public Health, Boston Medical Center, Boston, Mass
| | | | - N A Mark Estes
- Tufts Medical Center, Tufts University School of Medicine, Boston, Mass
| | - Michael D Ezekowitz
- Lankenau Medical Center, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pa
| | - John Fanikos
- Massachusetts College of Pharmacy, Brigham and Women's Hospital, Northeastern University School of Pharmacy, Boston, Mass
| | - Jawed Fareed
- Loyola University Medical Center, Loyola University Chicago Stritch School of Medicine, Ill
| | - David Garcia
- University of Washington Medical Center, University of Washington School of Medicine, Seattle, Wash
| | - Robert P Giugliano
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Samuel Z Goldhaber
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Christopher Granger
- Duke University Medical Center, Duke University School of Medicine, Durham, NC
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Russell Hull
- Foothills Medical Center, University of Calgary, Alberta, Canada
| | - Elaine M Hylek
- Boston University School of Medicine and Public Health, Boston Medical Center, Boston, Mass
| | - Peter Libby
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Renato D Lopes
- Duke University Medical Center, Duke University School of Medicine, Durham, NC
| | - Kenneth W Mahaffey
- Stanford University Medical Center, Stanford University School of Medicine, Calif
| | - Jessica Mega
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Gregory Piazza
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Arthur A Sasahara
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Farzaneh A Sorond
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | | | - Jeanine M Walenga
- Loyola University Medical Center, Loyola University Chicago Stritch School of Medicine, Ill
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
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17
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In vitro reversal of supratherapeutic rivaroxaban levels with coagulation factor concentrates. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2016; 14:481-6. [PMID: 27177413 DOI: 10.2450/2016.0205-15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 02/09/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND A bleeding patient undergoing therapy with new oral anticoagulants is every clinician's nightmare as no specific reversal agent is available yet. This in vitro study investigated the effect of prothrombin complex concentrate (PCC), recombinant activated factor VII (rFVIIa) and activated prothrombin complex concentrate (aPCC) on supratherapeutic rivaroxaban concentrations using standard laboratory parameters (prothrombin time [PT], activated partial thromboplastin time [aPTT] and PT ratio) and thromboelastometry (clotting time [CT]). MATERIALS AND METHODS Blood samples from 10 healthy volunteers were collected and spiked with a supratherapeutic dose of rivaroxaban. Afterwards PCC, rFVIIa and aPCC were added in two doses. The laboratory parameters were measured and thromboelastometry was performed. RESULTS The addition of the reversal agents had the following statistically significant effects (all p<0.01): +25 IU/kg PCC: CT -15 s, aPTT +5 s; +50 IU/kg PCC: aPTT +11 s; +90 μg rFVIIa: CT -141 s; +25 IU/kg aPCC: CT -142 s, aPTT -9 s, PT ratio +14%, PT -10.5 s; +50 IU/kg aPCC: CT -118 s, aPTT -7 s, PT ratio +17%, PT -12.2 s. DISCUSSION rFVIIa and aPCC, but not PCC, appear to shorten coagulation times significantly in standard laboratory and thromboelastometry assays. These results need confirmation through evaluation of these agents in the clinical setting.
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Nagakari K, Emmi M, Iba T. Prothrombin Time Tests for the Monitoring of Direct Oral Anticoagulants and Their Evaluation as Indicators of the Reversal Effect. Clin Appl Thromb Hemost 2016; 23:677-684. [PMID: 26984934 DOI: 10.1177/1076029616638506] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION The prompt assessment and the reversal of direct oral anticoagulants (DOACs) are urgent matters in the emergency care setting. Thus, we planned to elucidate the adequate prothrombin time (PT) test for the evaluation of the anticoagulant effects of various DOACs. METHODS The anticoagulant effects of rivaroxaban, apixaban, and edoxaban were measured with 3 PT tests (Triniclot PT Excel S, Neoplastin R, and Thromborel S). Human plasma was spiked with each DOAC at a range of 0 to 1000 ng/mL, and the PT was measured using each PT test. In another series, the reversal effect of either 4-factor prothrombin complex concentrate (PCC) or activated PCC (aPCC) was evaluated with each PT test. RESULTS All PT reagents correlated with the concentrations of each DOAC, however, the reactivity was considerably different between the DOACs and the PT tests. A prolonged PT with DOACs was reversed both by PCC and aPCC in a dose-dependent manner; however, Triniclot PT Excel S showed reprolongation of the PT with a higher dose of PCC. CONCLUSION The proper choice of PT test is necessary for the assessments of the anticoagulant activity of DOACs. It is also important to understand the different characteristics of each PT test for the assessment of the reversal effects of PCC.
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Affiliation(s)
- Kunihiko Nagakari
- 1 Department of Surgery, Juntendo University Urayasu Hospital, Urayasu, Japan
| | - Mari Emmi
- 2 Scientific and Technical Support Department, Kyowa Medex Co, Ltd, Tokyo, Japan
| | - Toshiaki Iba
- 3 Department of Emergency and Disaster Medicine, Juntendo University School of Medicine, Bunkyo-ku, Japan
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Bernardi E, Carbone G, Dentali F. How to manage patients on rivaroxaban in the emergency department: a statement of the Italian society of emergency medicine advisory board. Eur J Emerg Med 2015; 23:320-9. [PMID: 26351974 DOI: 10.1097/mej.0000000000000322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Rivaroxaban, a new oral anticoagulant, has been approved in many countries and its everyday use in clinical practice is increasing. Thus, the chances for an emergency physician to encounter rivaroxaban-treated patients in emergency situations have increased. Here, the authors address the main issues in terms of the prescription of rivaroxaban and the management of these patients in cases of minor or major bleeding, urgent surgery, atrial fibrillation requiring cardioversion, acute ischemic stroke, ST-elevation myocardial infarction, and new onset of atrial fibrillation in recent ST-elevation myocardial infarction. The recommendations reached are based on a literature review and a panel discussion of the advisory board of SIMEU, the Italian Society of Emergency Medicine.
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Affiliation(s)
- Enrico Bernardi
- aDepartment of Emergency Medicine, ULSS n.7, Pieve di Soligo (TV) bPast President of SIMEU (Società Italiana di Medicina d'Emergenza e Urgenza), the Italian Society of Emergency Medicine. Department of Emergency Medicine and Surgery, Hospital 'Gradenigo', Torino cDepartment of Clinical Medicine, Insubria University, Varese, Italy
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Grandhi R, Newman WC, Zhang X, Harrison G, Moran C, Okonkwo DO, Ducruet AF. Administration of 4-Factor Prothrombin Complex Concentrate as an Antidote for Intracranial Bleeding in Patients Taking Direct Factor Xa Inhibitors. World Neurosurg 2015; 84:1956-61. [PMID: 26341438 DOI: 10.1016/j.wneu.2015.08.042] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 08/12/2015] [Accepted: 08/14/2015] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Direct factor Xa inhibitors rivaroxaban and apixaban are efficacious alternatives to warfarin and confer a lower risk of spontaneous intracranial hemorrhage (ICH); however, they lack a validated reversal strategy. We evaluated the efficacy and safety of 4-factor prothrombin complex concentrate (PCC) administration on rivaroxaban- and apixaban-mediated coagulopathy in patients with traumatic and spontaneous ICH. METHODS Retrospective review of patients presenting with traumatic and spontaneous ICH and concurrent use of rivaroxaban or apixaban. Demographic factors, reason for anticoagulation, hemorrhage type and location, Glasgow coma scale score, and when appropriate, ICH score, were included. Patient charts were reviewed for in-hospital mortality, thromboembolic events, pulmonary complications, worsening of hemorrhage, hemorrhagic complications after neurosurgical intervention, and 90-day modified Rankin scale score. RESULTS Eighteen patients met inclusion criteria; 16 used rivaroxaban and 2 used apixaban. Eight patients presented with traumatic ICH, 8 with hemorrhagic stroke, 1 with subarachnoid hemorrhage, and 1 patient with tumoral hemorrhage. Mean Glasgow coma scale score was 12.6 (range, 6-15) and mean ICH score was 2.3 (range, 0-4). After reversal with PCC, 1 patient (5.6%) demonstrated worsening of ICH on follow-up head computed tomography. PCCs were administered before emergent placement of an external ventricular drain in 1 individual, with no hemorrhagic complications. Six patients (33.3%) experienced in-hospital mortality: family withdrew care in 4 and 2 died due to pneumonia. There was 1 (5.6%) thromboembolic complication. Favorable outcomes at 90 days were seen in 6 patients (33.3%). CONCLUSIONS Despite no studies demonstrating the efficacy of 4-factor PCC administration for reversal of coagulopathy in patients on direct factor Xa inhibitors, our early experience demonstrates it to be safe, yet potentially reducing hemorrhagic complications and hematoma expansion in this critically ill population.
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Affiliation(s)
- Ramesh Grandhi
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA.
| | - W Christopher Newman
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Xiaoran Zhang
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Gillian Harrison
- Department of Neurosurgery, NYU Langone Medical Center, New York, New York, USA
| | - Colleen Moran
- Departments of Anesthesiology and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew F Ducruet
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Untereiner O, Seince PF, Chterev V, Leblanc I, Berroëta C, Bourel P, Philip I. Management of Direct Oral Anticoagulants in the Perioperative Setting. J Cardiothorac Vasc Anesth 2015; 29:741-8. [DOI: 10.1053/j.jvca.2014.12.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2014] [Indexed: 01/22/2023]
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Dzik WH. Reversal of oral factor Xa inhibitors by prothrombin complex concentrates: a re-appraisal. J Thromb Haemost 2015; 13 Suppl 1:S187-94. [PMID: 26149022 DOI: 10.1111/jth.12949] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Oral factor Xa inhibitors are an attractive class of anticoagulants expected to have broad application. Rapid and reliable reversal of the anticoagulant effect is important for patients with bleeding complications or those in need of urgent reversal for procedures. While no specific reversal agent is yet available, multiple published clinical guidelines suggest that four-factor prothrombin complex concentrates (PCC) should be considered when urgent reversal is desired. This presentation updates prior reviews on this topic (Crit Care, 17, 2013, 230; Thromb Haemost, 111, 2014, 189; J Thromb Thrombolysis, 2015, 39, 395); and summarizes more recent evidence in human studies indicating that four-factor PCCs available in North America do not reverse oral factor Xa-inhibitor anticoagulants. New agents on the horizon appear to be far more promising as therapies for reversal or oral factor Xa inhibitors.
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Affiliation(s)
- W H Dzik
- Blood Transfusion Service, Massachusetts General Hospital, Boston, MA, USA
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Pollack CV, Reilly PA, Bernstein R, Dubiel R, Eikelboom J, Glund S, Huisman MV, Hylek E, Kam CW, Kamphuisen PW, Kreuzer J, Levy JH, Sellke F, Stangier J, Steiner T, Wang B, Weitz JI. Design and rationale for RE-VERSE AD: A phase 3 study of idarucizumab, a specific reversal agent for dabigatran. Thromb Haemost 2015; 114:198-205. [PMID: 26020620 DOI: 10.1160/th15-03-0192] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 05/19/2015] [Indexed: 12/19/2022]
Abstract
Idarucizumab, a Fab fragment directed against dabigatran, produced rapid and complete reversal of the anticoagulation effect of dabigatran in animals and in healthy volunteers. The Study of the REVERSal Effects of Idarucizumab in Patients on Active Dabigatran (RE-VERSE AD™) is a global phase 3 prospective cohort study aimed at investigating idarucizumab in dabigatran-treated patients who present with uncontrollable or life-threatening bleeding, and in those requiring urgent surgery or intervention. We describe the rationale for, and design of the trial (clinicaltrials.gov NCT02104947).
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Affiliation(s)
- Charles V Pollack
- Charles V. Pollack Jr., Department of Emergency Medicine, Pennsylvania Hospital, University of Pennsylvania Health System, 800 Spruce St, Philadelphia, PA 19107, USA, Tel.: +1 215 8297549, Fax: +1 215 8298044, E-mail:
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Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald RL, Mitchell PH, Scott PA, Selim MH, Woo D. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:2032-60. [PMID: 26022637 DOI: 10.1161/str.0000000000000069] [Citation(s) in RCA: 1992] [Impact Index Per Article: 221.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage. METHODS A formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee. RESULTS Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated. CONCLUSIONS Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted. These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage.
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Faraoni D, Levy JH, Albaladejo P, Samama CM. Updates in the perioperative and emergency management of non-vitamin K antagonist oral anticoagulants. Crit Care 2015; 19:203. [PMID: 25925382 PMCID: PMC4414429 DOI: 10.1186/s13054-015-0930-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Perioperative management of patients treated with the non-vitamin K antagonist oral anticoagulants is an ongoing challenge. Due to the lack of good clinical studies involving adequate monitoring and reversal therapies, management requires knowledge and understanding of pharmacokinetics, renal function, drug interactions, and evaluation of the surgical bleeding risk. Consideration of the benefit of reversal of anticoagulation is important and, for some low risk bleeding procedures, it may be in the patient's interest to continue anticoagulation. In case of major intra-operative bleeding in patients likely to have therapeutic or supra-therapeutic levels of anticoagulation, specific reversal agents/antidotes would be of value but are currently lacking. As a consequence, a multimodal approach should be taken which includes the administration of 25 to 50 U/kg 4-factor prothrombin complex concentrates or 30 to 50 U/kg activated prothrombin complex concentrate (FEIBA®) in some life-threatening situations. Finally, further studies are needed to clarify the ideal therapeutic intervention.
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Affiliation(s)
- David Faraoni
- Department of Anesthesiology, Peri-operative and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, 02115, USA.
| | - Jerrold H Levy
- Department of Anesthesiology and Intensive Care, Duke University School of Medicine, Durham, NC, 27710, USA.
| | - Pierre Albaladejo
- Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, Grenoble, 38043, France.
| | - Charles-Marc Samama
- Department of Anesthesiology and Intensive Care Medicine, Assistance Publique- Hôpitaux de Paris, Cochin University Hospital, Paris, 75181, France.
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Hidalgo F, Gómez-Luque A, Ferrandis R, Llau JV, de Andrés J, Gomar C, Sierra P, Castillo J, Torres LM. [Perioperative management of direct oral anticoagulant in emergency surgery and bleeding. Haemostasis monitoring and treatment]. ACTA ACUST UNITED AC 2015; 62:450-60. [PMID: 25702199 DOI: 10.1016/j.redar.2015.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 01/02/2015] [Accepted: 01/09/2015] [Indexed: 10/24/2022]
Abstract
There is an almost unanimous consensus on the management of the direct new oral anticoagulants, dabigatran, rivaroxaban, and apixaban in elective surgery. However, this general consensus does not exist in relation with the direct new oral anticoagulants use in emergency surgery, especially in the bleeding patient. For this reason, a literature review was performed using the MEDLINE-PubMed. An analysis was made of the journal articles, reviews, systematic reviews, and practices guidelines published between 2000 and 2014 using the terms "monitoring" and "reversal". From this review, it was shown that the routine tests of blood coagulation, such as the prothrombin time and activated partial thromboplastin time, have a limited efficacy in the perioperative control of blood coagulation in these patients. There is currently no antidote to reverse the effects of these drugs, although the possibility of using concentrated prothrombin complex and recombinant activated factor vii has been suggested for the urgent reversal of the anticoagulant effect.
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Affiliation(s)
- F Hidalgo
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Clínica Universidad de Navarra, Pamplona, Navarra, España
| | - A Gómez-Luque
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, España.
| | - R Ferrandis
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, España
| | - J V Llau
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, España
| | - J de Andrés
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, Universidad de Valencia, Valencia, España
| | - C Gomar
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España
| | - P Sierra
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Fundación Puigvert (IUNA), Barcelona, España
| | - J Castillo
- Servicio de Anestesiología, Hospital del Mar, Barcelona, España
| | - L M Torres
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Puerta del Mar, Cádiz, España
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Egea-Guerrero JJ, Quintana Díaz M. New oral anticoagulants in severe trauma patients: enemy at the gates? Med Intensiva 2014; 39:167-71. [PMID: 25510394 DOI: 10.1016/j.medin.2014.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Revised: 08/19/2014] [Accepted: 09/10/2014] [Indexed: 12/22/2022]
Abstract
The high incidence of trauma, especially in elderly people anticoagulated with new oral anticoagulants (NOAs), has become a major challenge, particularly in critical situations with life-threatening bleeding. Under these circumstances, urgent NOA reversion becomes mandatory. Prothrombin complex has become a frequent indication in critical situations in which rapid reversal of anticoagulation is needed and where the use of fresh frozen plasma is limited. This study offers our point of view regarding the usefulness of NOAs, not only in the prevention of cardioembolic events but also as regards their emergent reversion in cases of severe bleeding associated to trauma.
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Affiliation(s)
- J J Egea-Guerrero
- Unidad de Neurocríticos. Unidad de Gestión Clínica de Cuidados Críticos y Urgencias, Hospital Universitario Virgen del Rocío, Sevilla, España; Instituto de Biomedicina de Sevilla (IBiS)/CSIC/Universidad de Sevilla, Sevilla, España.
| | - M Quintana Díaz
- Departamento de Urgencias, Hospital Universitario La Paz, IdiPAZ, Madrid, España; Unidad de Cuidados Intensivos, Hospital Universitario La Paz, IdiPAZ, Madrid, España
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Yates S, Sarode R. Reversal of Anticoagulant Effects in Patients with Intracerebral Hemorrhage. Curr Neurol Neurosci Rep 2014; 15:504. [DOI: 10.1007/s11910-014-0504-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Lazo-Langner A, Fleet JL, McArthur E, Garg AX. Rivaroxaban vs. low molecular weight heparin for the prevention of venous thromboembolism after hip or knee arthroplasty: a cohort study. J Thromb Haemost 2014; 12:1626-35. [PMID: 25069387 DOI: 10.1111/jth.12675] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2014] [Accepted: 07/14/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Rivaroxaban is increasingly used to prevent venous thromboembolism after hip or knee arthroplasty. Studies evaluating the effectiveness of rivaroxaban compared to low molecular weight heparin after orthopedic surgery in routine practice are scarce. PATIENTS AND METHODS We conducted a retrospective cohort study in 121 hospitals in Ontario, Canada, between 2002 and 2012. We included patients aged 66 years or older (median age 73 years) who received an outpatient prescription for subcutaneous low molecular weight heparin (n = 11 471) or oral rivaroxaban (n = 12 850) on hospital discharge after a total knee or hip arthroplasty. The two coprimary outcomes assessed within 30 days of the prescription date were emergency department visit or hospitalization with venous thromboembolism (either deep vein thrombosis or pulmonary embolism; primary efficacy outcome) and a hospitalization with non-traumatic major hemorrhage (primary safety outcome). RESULTS Rivaroxaban use increased over the study period. Compared to low molecular weight heparin, rivaroxaban was associated with a lower 30-day risk of hospitalization with venous thromboembolism (0.47% vs. 0.81%; relative risk 0.58; 95% confidence interval 0.42-0.81; P = 0.001) with no significant difference in hospitalizations for major bleeding (0.18% vs. 0.20%; relative risk 0.89; 95% confidence interval 0.50-1.59; P = 0.700). CONCLUSIONS In routine practice, anticoagulant prophylaxis with rivaroxaban compared to low molecular weight heparin after hospital discharge from total hip or knee arthroplasty is associated with a lower risk of symptomatic venous thromboembolism with no difference in the risk of bleeding.
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Affiliation(s)
- A Lazo-Langner
- Division of Hematology, Department of Medicine, University of Western Ontario, London, ON, Canada; Department of Epidemiology and Biostatistics, University of Western Ontario, London, ON, Canada; Institute for Clinical Evaluative Sciences - Western (ICES Western), London, ON, Canada
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Stevenson JW, Minns AB, Smollin C, Albertson TE, Cantrell FL, Tomaszewski C, Clark RF. An observational case series of dabigatran and rivaroxaban exposures reported to a poison control system. Am J Emerg Med 2014; 32:1077-84. [DOI: 10.1016/j.ajem.2014.04.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2014] [Revised: 03/23/2014] [Accepted: 04/15/2014] [Indexed: 10/25/2022] Open
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Levy JH. Pharmacology and safety of new oral anticoagulants: the challenge of bleeding persists. Clin Lab Med 2014; 34:443-52. [PMID: 25168936 DOI: 10.1016/j.cll.2014.06.003] [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] [Indexed: 10/25/2022]
Abstract
New oral anticoagulants (NOACs) are increasingly replacing vitamin K antagonists and older parenteral agents in clinical practice. NOACs offer several advantages compared with standard agents, including rapid onset of action, fixed dosing, and no requirement for routine coagulation monitoring. However, like all anticoagulants, NOACs carry a risk of bleeding. Here, we discuss the pharmacology and safety of NOACs, with particular emphasis on the risks of bleeding associated with NOACs versus standard anticoagulants, and we provide an overview of current bleeding management strategies.
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Affiliation(s)
- Jerrold H Levy
- Duke University School of Medicine, Divisions of Cardiothoracic Anesthesiology and Critical Care, Duke University Hospital, 2301 Erwin Road, Durham, NC 27710, USA.
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Affiliation(s)
- Beverley J Hunt
- From King's College London and Guy's and St. Thomas' Trust - both in London
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Harikrishnan P, Palaniswamy C, Aronow WS. Update on pharmacologic therapy for pulmonary embolism. J Cardiovasc Pharmacol Ther 2013; 19:159-69. [PMID: 24177334 DOI: 10.1177/1074248413506612] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Warfarin, unfractionated heparin (UFH), and low-molecular-weight heparins are anticoagulants that have been used for treatment of pulmonary embolism. Currently approved drugs for treatment of venous thromboembolism include UFH, enoxaparin, dalteparin, fondaparinux, warfarin, and rivaroxaban. The advent of newer oral anticoagulants such as rivaroxaban, dabigatran, and apixaban has provided us with alternative therapeutic options for long-term anticoagulation. This article will give an overview of the various anticoagulant drugs, use in various clinical scenarios, data supporting their clinical use, and recommendations regarding duration of anticoagulant therapy.
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Affiliation(s)
- Prakash Harikrishnan
- 1Cardiology Division, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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