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Skripka AI, Krupenin PM, Kozhanova ON, Kudryavtseva AA, Fedina LV, Akmalova KA, Bochkov PO, Sokolova AA, Napalkov DA, Sychev DA. The impact of ABCB1, CYP3A4 and CYP3A5 gene polymorphisms on apixaban trough concentration and bleeding risk in patients with atrial fibrillation. Drug Metab Pers Ther 2024; 39:89-97. [PMID: 38943286 DOI: 10.1515/dmpt-2024-0013] [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: 03/03/2024] [Accepted: 06/03/2024] [Indexed: 07/01/2024]
Abstract
OBJECTIVES Apixaban, a direct oral anticoagulant, is increasingly used worldwide for the treatment and prevention of venous thromboembolism and ischemic stroke in patients with nonvalvular atrial fibrillation (AF). Obviously, one of the ways to enhance effectiveness and safety of drug therapy is a personalized approach to therapy, which involves pharmacogenetic and pharmacokinetic tests. The study aims to investigate the effect of CYP3A4*22, CYP3A5*3 and ABCB1 polymorphisms on the pharmacokinetics of apixaban and the risk of bleeding. METHODS A total of 84 patients were enrolled in this prospective observational study. All patients received apixaban 5 or 2.5 mg twice daily. Real-time polymerase chain reaction was used to evaluate single-nucleotide polymorphisms of the ABCB1 gene (rs1045642 and rs4148738), CYP3A4*22 (rs35599367) C>T, CYP3A5*3 (rs776746) A>G. A plasma trough concentration/dose (C/D) ratio was used as a pharmacokinetic index. RESULTS The C/D ratio was higher in patients aged >80 years (F(1)=11.209, p=0.00124) and was affected by serum creatinine (>133 μmol/L, F(1)=6.7, p=0.01124). ABCB1 (rs1045642 and rs4148738), CYP3A5 (rs776746) and CYP3A4 (rs35599367) polymorphisms did not show a correlation with C/D ratio of apixaban. Multivariate logistic regression analyses showed that none of the clinical or genetic factors predicted the fact of bleeding. CONCLUSIONS We report no significant association between ABCB1 gene polymorphisms (rs1045642 and rs4148738), CYP3A4*22 (rs35599367) C>T, CYP3A5*3 (rs776746) A>G and bleeding events on apixaban treatment. Complementing the existing criteria with pharmacogenetic and pharmacokinetics information for the patients with AF will enable further individualization of apixaban.
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Affiliation(s)
- Alena I Skripka
- Department of Faculty Therapy N1, 68477 I.M. Sechenov First Moscow State Medical University (Sechenov University) , Moscow, Russian Federation
| | - Pavel M Krupenin
- Department of Neurology, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russian Federation
- Department of Neurology, University of Kentucky Medical Center, Lexington, KY, USA
| | - Olga N Kozhanova
- Department of Faculty Therapy N1, 68477 I.M. Sechenov First Moscow State Medical University (Sechenov University) , Moscow, Russian Federation
| | - Anna A Kudryavtseva
- Department of Faculty Therapy N1, 68477 I.M. Sechenov First Moscow State Medical University (Sechenov University) , Moscow, Russian Federation
| | - Ludmila V Fedina
- Department of Personalized Medicine, Research Center, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
- City Clinical Hospital named after S.S. Yudin, Moscow, Russian Federation
| | - Kristina A Akmalova
- Department of Personalized Medicine, Research Center, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Pavel O Bochkov
- Department of Personalized Medicine, Research Center, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
| | - Anastasiya A Sokolova
- Department of Faculty Therapy N1, 68477 I.M. Sechenov First Moscow State Medical University (Sechenov University) , Moscow, Russian Federation
| | - Dmitriy A Napalkov
- Department of Faculty Therapy N1, 68477 I.M. Sechenov First Moscow State Medical University (Sechenov University) , Moscow, Russian Federation
| | - Dmitriy A Sychev
- Department of Clinical Pharmacology and Therapy, Russian Medical Academy of Continuous Professional Education, Moscow, Russian Federation
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2
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Onelöv L, Theodorsson E, Božič-Mijovski M, Mavri A. Clot time ratio (CTR) and relation to treatment outcome in patients with atrial fibrillation treated with Rivaroxaban. Thromb J 2024; 22:24. [PMID: 38429728 PMCID: PMC10905907 DOI: 10.1186/s12959-024-00591-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 02/05/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND There are situations where information about the anticoagulant effects of Rivaroxaban could be clinically useful. Methods for measuring Rivaroxaban concentrations are not available at all medical laboratories while the test MRX PT DOAC for measuring the functional effects of Rivaroxaban, in CTR (Clot Time Ratio), can be made available around the clock. The objectives of this study were to investigate CTR in trough and peak samples during Rivaroxaban treatment of atrial fibrillation and to correlate the findings to bleeding episodes. METHODS 3 trough- and 3 peak samples from 60 patients (30 on 20 mg daily and 30 on 15 mg daily) were analyzed with PT DOAC. Patients were monitored for 20 months, and bleeding and thrombotic events were documented. Descriptive statistics were used to summarize the data and non-parametric t-test for comparison between groups. ROC curves for the prediction of DOAC plasma levels > 50 ng/mL as determined with LC-MS/MS and anti-FXa methods were computed. RESULTS There was a significant difference between trough and peak CTR (median CTR 1.33 vs. 3.57, p < 0.001). 28 patients suffered bleeds. Patients on 20 mg Rivaroxaban with bleeds had higher mean peak CTR than patients without bleeds (CTR 4.11 vs. CTR 3.47, p = 0.040). There was no significant difference in mean CTR between patients on 15 mg Rivaroxaban with or without bleeds (CTR 3.81 vs. 3.21, p = 0.803), or when considering all patients (CTR 3.63 vs. 3.56, p = 0.445). Five out of seven patients on Rivaroxaban 20 with mean peak CTR above the dose specific first to third quartile range (Q1-Q3) suffered bleeds, while 7/16 patients with mean peak CTR within, and 1/7 patients with mean peak CTR below the Q1-Q3 suffered bleeds. The area under the ROC curve was > 0.98 at the upper limit of the PT DOAC reference interval and the negative predictive value of PT DOAC for the prediction of DOAC plasma levels > 50 ng/mL was > 0.96. CONCLUSIONS The sample size was too low to draw any firm conclusions but is seems that MRX PT DOAC might be a useful laboratory test in situations where the effect of Rivaroxaban needs evaluation.
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Affiliation(s)
| | | | - Mojca Božič-Mijovski
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Alenka Mavri
- Department of Vascular Diseases, University Medical Centre Ljubljana, Ljubljana, Slovenia
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3
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Talerico R, Pola R, Huisman MV, Klok FA. DOACs plasma levels in relation to clinical outcome. How far have we come? Thromb Res 2023; 225:16-21. [PMID: 36906474 DOI: 10.1016/j.thromres.2023.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/20/2023] [Accepted: 02/28/2023] [Indexed: 03/07/2023]
Affiliation(s)
- Rosa Talerico
- Section of Internal Medicine and Thromboembolic Diseases - Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy; IRCCS San Raffaele, Rome, Italy.
| | - Roberto Pola
- Section of Internal Medicine and Thromboembolic Diseases - Department of Internal Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Menno Volkert Huisman
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, the Netherlands
| | - Frederikus Albertus Klok
- Department of Medicine - Thrombosis and Haemostasis, Leiden University Medical Centre, Leiden, the Netherlands
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4
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Zhang H, Zhang Z, Liu Z, Mu G, Xie Q, Zhou S, Wang Z, Cao Y, Tan Y, Wei X, Yuan D, Xiang Q, Cui Y. Circulating miR-320a-3p and miR-483-5p level associated with pharmacokinetic-pharmacodynamic profiles of rivaroxaban. Hum Genomics 2022; 16:72. [PMID: 36578040 PMCID: PMC9795792 DOI: 10.1186/s40246-022-00445-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 12/15/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Novel biomarkers for personalizing anticoagulation remain undetermined. We aimed to investigate the association of plasma miRNAs with pharmacokinetic-pharmacodynamic (PK-PD) profiles of rivaroxaban. METHODS This is a multicenter, exploratory study of miRNAs in a Chinese population. Healthy volunteers and patients receiving rivaroxaban were enrolled in the study. The area under the plasma concentration-time curve from time 0-t h (AUC0-t) and anti-Xa activity at 3 h (AXA3h) were measured in healthy volunteers, and AXA3h was measured in patients. MiRNAs were detected by miRNA microarray in 26 healthy volunteers with 20 mg rivaroxaban, and quantitative reverse transcription polymerase chain reaction was used to exclude undetectable ones. MiR-320a-3p and miR-483-5p were then quantified in 65 healthy volunteers and 71 patients. MiRNA levels at 3 h were compared between high and low AXA3h or AUC0-t subjects and in matched patients with or without bleeding during follow-up. The miRNA targets were predicted by TargetScan, miRTarBase, and miRDB. Validated genes were included in GO enrichment and KEGG analyses. The protein-protein interaction network was established by STRING and visualized by Cytoscape. RESULTS A total of 136 Chinese subjects completed the study. In healthy volunteers taking 15 mg rivaroxaban, the miR-320a level at 3 h was significantly positively correlated with AXA3h and AUC0-t (r = 0.359, p = 0.025; r = 0.370, p = 0.02, respectively). A positive correlation was also observed between miR-483 and AXA3h or AUC0-t (r = 0.372, p = 0.02; r = 0.523, p = 0.001, respectively). MiR-320a and miR-483 levels at 3 h in the higher AUC0-t group were significantly higher than those at 0 h. MiR-483 levels at 3 h may distinguish healthy volunteers with high or low AXA3h or AUC0-t. In the 10 mg fed subgroup, higher 3 h mir-483 levels were also observed compared with the control group. No significant differences were found in the comparisons among patients. Bioinformatic analysis showed that these miRNAs may play a regulatory role by targeting ABCG2, ITGB3, PTEN, MAPK1/3, etc. CONCLUSIONS: MiR-320a and miR-483 levels were found to be associated with PK and PD profiles of rivaroxaban in healthy Chinese subjects. Further studies are required to verify these findings and explore the mechanisms.
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Affiliation(s)
- Hanxu Zhang
- grid.411472.50000 0004 1764 1621Department of Pharmacy, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034 China ,grid.11135.370000 0001 2256 9319School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Zhuo Zhang
- grid.411472.50000 0004 1764 1621Department of Pharmacy, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034 China
| | - Zhiyan Liu
- grid.411472.50000 0004 1764 1621Department of Pharmacy, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034 China
| | - Guangyan Mu
- grid.411472.50000 0004 1764 1621Department of Pharmacy, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034 China
| | - Qiufen Xie
- grid.411472.50000 0004 1764 1621Department of Pharmacy, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034 China
| | - Shuang Zhou
- grid.411472.50000 0004 1764 1621Department of Pharmacy, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034 China ,grid.11135.370000 0001 2256 9319School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Zhe Wang
- grid.411472.50000 0004 1764 1621Department of Pharmacy, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034 China
| | - Yu Cao
- grid.412521.10000 0004 1769 1119Office of Drug Clinical Trial Management, Affiliated Hospital of Qingdao University, Qingdao, Shandong China
| | - Yunlong Tan
- grid.11135.370000 0001 2256 9319Psychiatry Research Center, Beijing HuiLongGuan Hospital, Peking University, Beijing, China
| | - Xiaohua Wei
- grid.412604.50000 0004 1758 4073Clinical Trial Research Center, Department of Pharmacy, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi China
| | - Dongdong Yuan
- grid.417239.aDepartment of Pharmacy, The 7Th People’s Hospital of Zhengzhou, Zhengzhou, Henan China
| | - Qian Xiang
- grid.411472.50000 0004 1764 1621Department of Pharmacy, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034 China
| | - Yimin Cui
- grid.411472.50000 0004 1764 1621Department of Pharmacy, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, 100034 China ,grid.11135.370000 0001 2256 9319School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China ,grid.11135.370000 0001 2256 9319Institute of Clinical Pharmacology, Peking University, Beijing, China
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5
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Okada T, Yoshimoto T, Wada S, Yoshimura S, Chiba T, Egashira S, Kimura S, Shiozawa M, Inoue M, Ihara M, Toyoda K, Takashima H, Koga M. Intravenous Thrombolysis With Alteplase at 0.6 mg/kg in Patients With Ischemic Stroke Taking Direct Oral Anticoagulants. J Am Heart Assoc 2022; 11:e025809. [PMID: 36129032 PMCID: PMC9673692 DOI: 10.1161/jaha.122.025809] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Background We elucidated the safety of treatment with alteplase at 0.6 mg/kg within 24 hours for patients on direct oral anticoagulants (DOACs) before ischemic stroke onset. Methods and Results Consecutive patients with acute ischemic stroke who underwent intravenous thrombolysis using alteplase at 0.6 mg/kg from 2011 to 2021 were enrolled from our single‐center prospective stroke registry. We compared outcomes between patients taking DOACs and those not taking oral anticoagulants within 48 hours of stroke onset. The primary safety outcome was the rate of symptomatic intracranial hemorrhage with a ≥4‐point increase on the National Institutes of Health Stroke Scale score from baseline. The efficacy outcome was defined as 3‐month modified Rankin Scale score of 0 to 2 after stroke onset. Of 915 patients with acute ischemic stroke who received intravenous thrombolysis (358 women; median age, 76 years; median National Institutes of Health Stroke Scale score, 10), 40 patients took DOACs (6 took dabigatran, 8 took rivaroxaban, 16 took apixaban, and 10 took edoxaban) within 24 hours of onset and 753 patients did not take any oral anticoagulants. The rate of symptomatic intracranial hemorrhage was comparable between patients on DOACs and those not on oral anticoagulants (2.5% versus 2.4%, P=0.95). The rate of favorable outcomes was comparable between the 2 groups (59.4% versus 58.2%, P=0.46), although the admission National Institutes of Health Stroke Scale score was higher in patients on DOACs. No significant differences showed in any intracranial hemorrhage within 36 hours or mortality at 3 months. Conclusions Intravenous thrombolysis would be safely performed for patients on DOACs following the recommendations of the Japanese guidelines. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02251665.
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Affiliation(s)
- Takashi Okada
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan.,Department of Neurology and Geriatrics Kagoshima University Graduate School of Medical and Dental Sciences Kagoshima Japan
| | - Takeshi Yoshimoto
- Department of Neurology National Cerebral and Cardiovascular Center Suita Japan
| | - Shinichi Wada
- Department of Medical and Health Information Management National Cerebral and Cardiovascular Center Suita Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Tetsuya Chiba
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Shuhei Egashira
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Shunsuke Kimura
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan.,Division of Stroke Care Unit National Cerebral and Cardiovascular Center Suita Japan
| | - Masafumi Ihara
- Department of Neurology National Cerebral and Cardiovascular Center Suita Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Hiroshi Takashima
- Department of Neurology and Geriatrics Kagoshima University Graduate School of Medical and Dental Sciences Kagoshima Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
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6
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Dinunno CV, Lopez CN, Succar L, Nguyen DT, Graviss EA, Salazar E, Donahue KR. Direct oral to parenteral anticoagulant transitions: Role of factor Xa inhibitor‐specific anti‐
X
a concentrations. Pharmacotherapy 2022; 42:768-779. [DOI: 10.1002/phar.2726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/02/2022] [Accepted: 08/20/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Corey V. Dinunno
- Department of Pharmacy Houston Methodist Hospital Houston Texas USA
| | - Chelsea N. Lopez
- Department of Pharmacy Houston Methodist Hospital Houston Texas USA
| | - Luma Succar
- Department of Pharmacy Houston Methodist Hospital Houston Texas USA
| | - Duc T. Nguyen
- Department of Pathology and Genomic Medicine Houston Methodist Research Institute Houston Texas USA
| | - Edward A. Graviss
- Department of Pathology and Genomic Medicine Houston Methodist Research Institute Houston Texas USA
| | - Eric Salazar
- Department of Pathology University of Texas Health Science Center at San Antonio San Antonio Texas USA
| | - Kevin R. Donahue
- Department of Pharmacy Houston Methodist Hospital Houston Texas USA
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7
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Zhao N, Liu Z, Xie Q, Wang Z, Sun Z, Xiang Q, Cui Y. A Combined Pharmacometrics Analysis of Biomarker Distribution Under Treatment With Standard- or Low-Dose Rivaroxaban in Real-World Chinese Patients With Nonvalvular Atrial Fibrillation. Front Pharmacol 2022; 13:814724. [PMID: 35370683 PMCID: PMC8971662 DOI: 10.3389/fphar.2022.814724] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 02/24/2022] [Indexed: 12/14/2022] Open
Abstract
Background: The rivaroxaban dose regimen for patients with nonvalvular atrial fibrillation (NVAF) is complex in Asia. Given the high interindividual variability and the risk of bleeding caused by rivaroxaban in Asians, the influencing factors and the relationship between outlier biomarkers and bleeding events need exploration. Methods: The integrated pharmacokinetics (PK)/pharmacodynamics (PD) models were characterized based on rich PK/PD data from 304 healthy volunteers and sparse PD [anti-factor Xa activity (anti-Xa) and prothrombin (PT)] data from 223 patients with NVAF. The correlations between PD biomarkers and clinically relevant bleedings in 1 year were explored. The final integrated PK/PD model was used to evaluate the influence of dosage and individual covariates on PD parameters. Results: A two-compartment, linear model with sequential zero-order and first-order absorption was adopted. The dose-specific relative bioavailability (F1), diet status, creatinine clearance, and body mass index (BMI) improved the model fit. The apparent systemic clearance was 7.39 L/h, and the central and peripheral volumes were 10.9 and 50.9 L, respectively. The linear direct-effects model with shape factor plus the additive (and/or proportional) error model described the correlation between anti-Xa/PT and plasma concentration. Bodyweight, total cholesterol (TCHO), and diet status were selected as the covariates of the anti-Xa/PT model. Anti-Xa was more sensitive to the increase in rivaroxaban exposure compared with PT. An elevated bleeding tendency was seen with higher peak anti-Xa and PT. For a typical Chinese patient, the peak anti-Xa value (median (5%–95% PI)) of 20 and 15 mg were 309 ng/ml (139–597 ng/ml) and 296 ng/ml (138–604 ng/ml), both median values were within the expected range. For patients with CrCL 30–49 ml/min, the median peak anti-Xa with recommended 10 mg other than 15 mg were within the expected range. Conclusion: Fixed doses of rivaroxaban could be prescribed for patients with NVAF without adjustment for bodyweight, BMI, and TCHO. Randomized studies should be performed to evaluate the efficacy and safety of low-dose rivaroxaban in Chinese patients with NVAF.
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Affiliation(s)
- Nan Zhao
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
| | - Zhongyi Sun
- Shanghai Qiangshi Information Technology Co., Ltd, Shanghai, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- *Correspondence: Yimin Cui, ; Qian Xiang,
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China
- Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University, Beijing, China
- Institute of Clinical Pharmacology, Peking University, Beijing, China
- *Correspondence: Yimin Cui, ; Qian Xiang,
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8
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Ebai FB, Mohiuddin A. Failure of non-vitamin K antagonist oral anticoagulants in preventing stroke in elderly patient: a case report of multiple strokes on standard of care treatment for atrial fibrillation. Arch Clin Cases 2021; 8:1-6. [PMID: 34754932 PMCID: PMC8565703 DOI: 10.22551/2021.30.0801.10177] [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] [Indexed: 11/25/2022] Open
Abstract
Atrial fibrillation (AF) is the most common type of treated heart arrhythmia. Generally, the treatment goals for atrial fibrillation are to reset the rhythm or control the rate and prevent the development and subsequent embolization of atrial thrombi. These thromboembolic events can occur with any kind of atrial fibrillation that is paroxysmal, persistent or permanent. In patients who are candidate for anticoagulation therapy, major practice guideline provides vitamin K antagonist (VKA) oral anticoagulant and non-VKA oral anticoagulants as treatment options. The risk of AF increases with age and despite treatment on standard of care anticoagulation therapy, recrudescent cardioembolic events may still arise especially in the elderly as we will see in this case.
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Affiliation(s)
| | - Azam Mohiuddin
- Nazareth Hospital, Trinity Health Mid-Atlantic, Philadelphia, PA, USA
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9
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Liu XQ, Yin YW, Wang CY, Li ZR, Zhu X, Jiao Z. How to handle the delayed or missed dose of rivaroxaban in patients with non-valvular atrial fibrillation: model-informed remedial dosing. Expert Rev Clin Pharmacol 2021; 14:1153-1163. [PMID: 34058934 DOI: 10.1080/17512433.2021.1937126] [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: 10/21/2022]
Abstract
BACKGROUND Rivaroxaban is an oral anticoagulant widely used for stroke prevention in patients with non-valvular atrial fibrillation (NVAF). During long-term anticoagulant therapy, delayed or missed doses are common. This study aimed to explore appropriate remedial dosing regimens for non-adherent rivaroxaban-treated patients. METHODS Monte Carlo simulation based on a previously established rivaroxaban population pharmacokinetic/pharmacodynamic (PK/PD) model for patients with NVAF was employed to design remedial dosing regimens. The proposed regimens were compared with remedial strategies in the European Heart Rhythm Association (EHRA) guide by assessing deviation time in terms of drug concentration, factor Xa activity, and prothrombin time. RESULTS The proposed remedial dosing regimens were dependent on delay duration. The missed dose should be taken immediately when the delay does not exceed 6 h; a half dose is advisable when the delay is between 6 and 20 h. A missed dose should be skipped if less than 4 h remains before the next dose. The proposed regimens resulted in shorter deviation time than that of the EHRA guide. CONCLUSION PK/PD modeling and simulation provide valid evidence on the remedial dosing regimen of rivaroxaban, which could help to minimize the risk of bleeding and thromboembolism.
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Affiliation(s)
- Xiao-Qin Liu
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Yi-Wei Yin
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Chen-Yu Wang
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zi-Ran Li
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.,Department of Pharmacy, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiao Zhu
- School of Pharmacy, University of Otago, Dunedin, New Zealand
| | - Zheng Jiao
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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10
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Škorňová I, Samoš M, Bolek T, Kamenišťáková A, Stančiaková L, Galajda P, Staško J, Kubisz P, Mokáň M. Direct Oral Anticoagulants Plasma Levels in Patients with Atrial Fibrillation at the Time of Bleeding: A Pilot Prospective Study. J Cardiovasc Pharmacol 2021; 78:e122-e127. [PMID: 34173805 DOI: 10.1097/fjc.0000000000001038] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 03/20/2021] [Indexed: 10/21/2022]
Abstract
ABSTRACT Patients with atrial fibrillation (AF) on long-term direct oral anticoagulants (DOACs) may be at higher risk of bleeding because of higher anti-Xa or anti-IIa levels. However, there is no postmarketing study investigating these DOAC plasma levels at the time of bleeding. The aim of this study was to evaluate DOAC levels at the time of a bleeding emergency. We analyzed 5440 patients examined at our Emergency Department in from April 1, 2019, to September 30, 2019. During this period, we prospective identified 105 consecutive patients with bleeding while on long-term antithrombotic therapy; 49 patients had AF on DOACs. We compared DOAC levels in patients who bled against a control sample of 55 patients who tolerated long-term high dose DOAC therapy without any emergency. Samples of these patients were tested with drug-specific anti-Xa chromogenic analysis (rivaroxaban and apixaban) and with Hemoclot Thrombin Inhibitor assay (dabigatran). Dabigatran-treated patients who bled had significantly higher anti-IIa levels when compared with trough (261.4 ± 163.7 vs. 85.4 ± 57.2 ng/mL, P < 0.001) and peak samples of controls (261.4 ± 163.7 vs. 138.8 ± 78.7 ng/mL, P < 0.05). Similarly, there were significantly higher anti-Xa levels in rivaroxaban-treated and apixaban-treated patients with bleeding compared with trough control samples (rivaroxaban: 245.9 ± 150.2 vs. 52.5 ± 36.4 ng/mL, P <0.001 and apixaban: 311.8 ± 142.5 vs. 119.9 ± 81.7 ng/mL, P < 0.001), as well as in apixaban-treated patients when compared with peak control samples (311.8 ± 142.5 vs. 210.9 ± 88.7 ng/mL, P < 0.05). Finally, rivaroxaban anti-Xa levels in patients who bled tended to be higher compared with peak control samples (245.9 ± 150.2 vs. 177.6 ± 38.6 ng/mL, P = 0.13). This observational study showed a significant difference in anti-IIa and anti-Xa plasma levels in patients with AF with bleeding complications compared with those who tolerated long-term high-dose DOAC therapy without bleeding complications.
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Affiliation(s)
- Ingrid Škorňová
- Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Matej Samoš
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic ; and
| | - Tomáš Bolek
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic ; and
| | | | - Lucia Stančiaková
- Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Peter Galajda
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic ; and
| | - Ján Staško
- Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Peter Kubisz
- Department of Hematology and Blood Transfusion, National Centre of Hemostasis and Thrombosis, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic
| | - Marián Mokáň
- Department of Internal Medicine I, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovak Republic ; and
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Metze M, Klöter T, Stöbe S, Rechenberger B, Siegemund R, Siegemund T, Laufs U, Petros S, Pfrepper C. Plasma levels do not predict thrombin generation in patients taking direct oral anticoagulants. Int J Lab Hematol 2021; 43:1539-1548. [PMID: 34097808 DOI: 10.1111/ijlh.13618] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/04/2021] [Accepted: 05/14/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The antithrombotic effect of direct oral anticoagulants (DOAC) in specific clinical scenarios is difficult to assess. OBJECTIVE This study aimed to evaluate the effect of DOAC on thrombin generation (TG) in relation to their plasma level. METHODS Eighty patients newly started on anticoagulation were included, 20 patients for each DOAC-apixaban, edoxaban, rivaroxaban, and dabigatran. Plasma was sampled before DOAC (baseline), at plasma peak time, 6 and 12 hours after starting DOAC for quantification of drug levels and TG. RESULTS The baseline TG before DOAC intake showed inter-individual variability. All DOACs significantly prolonged lag time (LT) and time to peak (TTP), but did not change endogenous thrombin potential (ETP). Anti-Xa inhibitors but not dabigatran reduced thrombin peak, but the effect of apixaban at plasma peak was less pronounced (factor 1.6). LT and TTP prolongation of dabigatran was lower compared to anti-Xa inhibitors. All DOACs showed a nonlinear dose-response relationship, with the greatest antithrombotic effect at lower DOAC plasma levels. The inhibition of TG parameters between baseline and peak was parallel between individual patients but the coefficient of variation of TG was lower compared to drug levels. CONCLUSION The antithrombotic effect at DOAC peak plasma level measured by TG depends on the patient-specific baseline TG level and the drug-specific inhibition by the particular DOAC. Although peak plasma levels have a high variability, the variation of TG is lower compared to drug levels. Therefore, TG assays may be superior to plasma levels in the assessment of the intensity of anticoagulation.
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Affiliation(s)
- Michael Metze
- Department of Cardiology, Medical Department IV, University Hospital Leipzig, Leipzig, Germany
| | - Tristan Klöter
- Department of Cardiology, Medical Department IV, University Hospital Leipzig, Leipzig, Germany
| | - Stephan Stöbe
- Department of Cardiology, Medical Department IV, University Hospital Leipzig, Leipzig, Germany
| | | | | | | | - Ulrich Laufs
- Department of Cardiology, Medical Department IV, University Hospital Leipzig, Leipzig, Germany
| | - Sirak Petros
- Medical ICU, University Hospital Leipzig, Leipzig, Germany.,Division of Hemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
| | - Christian Pfrepper
- Division of Hemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
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Zhao N, Xiang Q, Liu Z, Zhao X, Cui Y. Pharmacokinetic-Pharmacodynamic Analysis' Role in Design of Phase ⅠClinical Trials of Anticoagulant Agents: A Systematic Review. Expert Rev Clin Pharmacol 2020; 13:1191-1202. [PMID: 33023366 DOI: 10.1080/17512433.2020.1831914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION There remains an unmet need for better anticoagulants. The phase I clinical trial is of great significance in the development of anticoagulants, and the design is special. This system review aims to provide insights for the design of future phase I clinical trials of anticoagulants. AREAS COVERED We searched the database PubMed and ClinicalTrail.gov website, to collate the phase I clinical trial of anticoagulants in healthy people. The study protocol, inclusion-exclusion criteria, safety, and pharmacodynamic indexes were reviewed. EXPERT OPINION New anticoagulants under development focused on inhibiting one or more than one serine proteases within the coagulation cascade. Agents targeting intrinsic factors are in the pipeline of the drug development. The enrollment eligibility criteria have more restrictions on laboratory tests, medical history, or medication history related to bleeding and coagulation; more precautions were taken to assess and minimize the risk of hemorrhagic events. Pharmacodynamics markers were evaluated as a surrogate marker of anticoagulation potency to guide further dose selection in drug's development. In future, the positive control study can be applied in phase I studies of new anticoagulants with appropriate pharmacodynamics markers, which can provide more favorable information on making 'go/no' decision in drug development.
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Affiliation(s)
- Nan Zhao
- Department of Pharmacy, Peking University First Hospital , Beijing, People's Republic of China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University , Beijing, People's Republic of China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital , Beijing, People's Republic of China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital , Beijing, People's Republic of China
| | - Xia Zhao
- Department of Pharmacy, Peking University First Hospital , Beijing, People's Republic of China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital , Beijing, People's Republic of China.,Department of Pharmacy Administration and Clinical Pharmacy, School of Pharmaceutical Sciences, Peking University , Beijing, People's Republic of China
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13
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Different Coagulation Indicators in Predicting Clinical Outcomes for Patients With Direct Oral Anticoagulants: A Systematic Review and Meta-analysis. Clin Ther 2020; 42:2066-2081.e9. [PMID: 32900534 DOI: 10.1016/j.clinthera.2020.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/18/2020] [Accepted: 08/03/2020] [Indexed: 11/23/2022]
Abstract
PURPOSE There are many anticoagulant test indexes available for direct oral anticoagulants (DOACs), but how to select the appropriate index and the index cutoff values are still controversial. This is the first study, to our knowledge, to assess the association of different coagulation indicators with clinical outcomes among DOACs using a meta-analysis of observational studies. METHODS A medical literature search was conducted using PubMed, Web of Science, EMBASE, ClinicalTrials.gov, and the Cochrane Library from inception to February 2020. Studies that reported relationships between coagulation indexes and clinical outcomes or the diagnostic value of coagulation assays were included in the analysis. FINDINGS A total of 17 articles (7 meta-analyses and 10 systematic reviews) from 8904 citations were included in the analysis. In the analysis of bleeding events with coagulation indexes for DOACs, for peak prothrombin time level (cutoff value of 19-25 s), the pooled results found a sensitivity of 0.61 (95% CI, 0.44-0.75) and a specificity of 0.71 (95% CI, 0.49-0.86). For rivaroxaban, the trough anti-factor Xa concentration (AXA-C) (cutoff value of 400-500 ng/mL) had a sensitivity of 0.53 (95% CI, 0.16-0.87) and a specificity of 0.87 (95% CI, 0.71-0.94), with a diagnostic odds ratio of 7 (95% CI, 2-32). For apixaban, trough AXA-C had a sensitivity of 0.85 (95% CI, 0.60-0.96) and a specificity of 0.83 (95% CI, 0.52-0.95). The AUC of the AXA-C peak was higher than that of the trough AXA-C for apixaban, with a higher sensitivity and specificity. Compared with trough concentration of anti-factor IIa for dabigatran, the peak concentration had a higher specificity (98%) at the cutoff value of 484 ng/mL. In the analysis of thromboembolic events with coagulation indexes for DOACs, peak and trough prothrombin time values were not typically correlated with subsequent symptomatic venous thromboembolism, without a sensitivity or specificity higher than 90%. Trough AXA-C had a sensitivity of 100% and but a low specificity (<50%) for rivaroxaban-apixaban. Trough AXA-C had a sensitivity of 100% and a specificity of 32% with a cutoff value of 108 ng/mL for dabigatran. IMPLICATION Peak prothrombin time (19-25 s) and AXA-C had a better predictive value on bleeding outcomes for rivaroxaban and apixaban, whereas peak concentration of anti-factor IIa activity can be an indicator for dabigatran. Coagulation indexes might not be a good indicator of thromboembolic events of DOACs. Because the limited studies focused on association of coagulation indicators and clinical outcomes, more studies are needed to verify this in the future.
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15
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Affiliation(s)
- Robert Diep
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA.
| | - David Garcia
- Division of Hematology, Department of Medicine, University of Washington, Seattle, WA, USA
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16
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Sarode R. Direct oral anticoagulant monitoring: what laboratory tests are available to guide us? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:194-197. [PMID: 31808890 PMCID: PMC6913449 DOI: 10.1182/hematology.2019000027] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Direct oral anticoagulants (DOACs) are increasingly used in the treatment and prophylaxis of thromboembolism because of several advantages over vitamin K antagonists, including no need for laboratory monitoring. However, it has become increasingly important in certain clinical scenarios to know either actual DOAC concentration (quantitative) or presence of DOAC (qualitative). These clinical conditions include patients presenting with major bleeding or requiring urgent surgery who may need a reversal or hemostatic agent, extremes of body weight, failed therapy, etc. Prothrombin time and activated partial thromboplastin time are variably affected by factor Xa inhibitors (FXaIs) and direct thrombin inhibitor (DTI), respectively, depending on reagents' sensitivity, and hence, they cannot be relied on confidently. Thrombin time is highly sensitive to very low amounts of DTI; thus, normal value rules out a clinically significant amount. Liquid chromatography mass spectrometry accurately measures DOAC levels but is clinically impractical. Dilute thrombin time and ecarin-based assays using appropriate calibrators/controls provide an accurate DTI level. Anti-Xa assay using corresponding FXaI calibrators/controls provides accurate drug levels. However, these assays are not readily available in the United States compared with some other parts of the world. Heparin assays using anti-Xa activity often have a linear relationship with calibrated FXaI assays, especially at the lower end of on-therapy levels, and they may provide rapid assessment of drug activity for clinical decision making. Currently, there is very limited knowledge of DOAC effect on viscoelastic measurements. Although there is uniformity in expression of DOAC concentrations in nanograms per milliliter, a universal FXaI DOAC assay is urgently needed.
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Affiliation(s)
- Ravi Sarode
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX
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17
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Suwa M, Morii I, Kino M. Rivaroxaban or Apixaban for Non-Valvular Atrial Fibrillation - Efficacy and Safety of Off-Label Under-Dosing According to Plasma Concentration. Circ J 2019; 83:991-999. [PMID: 30918237 DOI: 10.1253/circj.cj-18-1282] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Practice-based investigations on direct oral anticoagulant (DOAC) treatment for non-valvular atrial fibrillation (NVAF) have shown that off-label under-dosing is increasingly becoming an issue. Here, we investigate the significance of drug monitoring to prevent undesirable under-dosing with DOAC. Methods and Results: In 255 outpatients with NVAF undergoing treatment with rivaroxaban or apixaban we estimated the cut-offs for bleeding events using drug plasma concentration (PC) data 3 h after drug treatment, that is, at the peak level. Furthermore, we evaluated the appropriateness of labeled and off-label dosing implemented for 348 patients using the obtainable PC threshold. A total of 73 off-label under-dose users of rivaroxaban (37% of all users and 63% of lower dose users) had acceptable peak PC (155-400 ng/mL). Additionally, 46 off-label under-dose users of apixaban (31% of all users and 55% of lower dose users) received appropriate doses according to peak PC threshold (90-386.4 ng/mL). These off-label under-dose users reported no bleeding or thromboembolic events during follow-up. CONCLUSIONS Anticoagulation monitoring enables personalized and appropriate off-label under-dosing in NVAF patients on rivaroxaban or apixaban through the measurement of peak PC during DOAC use.
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Affiliation(s)
| | - Isao Morii
- Department of Cardiology, Hokusetsu General Hospital
| | - Masaya Kino
- Department of Cardiology, Hokusetsu General Hospital
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Patel JP, Byrne RA, Patel RK, Arya R. Progress in the monitoring of direct oral anticoagulant therapy. Br J Haematol 2019; 184:912-924. [DOI: 10.1111/bjh.15756] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Jignesh P. Patel
- Department of Haematological Medicine; King's Thrombosis Centre; King's College Hospital Foundation NHS Trust; London UK
- Institute of Pharmaceutical Science; King's College London; London UK
| | - Rosalind A. Byrne
- Department of Haematological Medicine; King's Thrombosis Centre; King's College Hospital Foundation NHS Trust; London UK
| | - Raj K. Patel
- Department of Haematological Medicine; King's Thrombosis Centre; King's College Hospital Foundation NHS Trust; London UK
| | - Roopen Arya
- Department of Haematological Medicine; King's Thrombosis Centre; King's College Hospital Foundation NHS Trust; London UK
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