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Vu TT, Gooderham M. Adverse Drug Reactions and Cutaneous Manifestations Associated With Anticoagulation. J Cutan Med Surg 2017. [PMID: 28639463 DOI: 10.1177/1203475417716364] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Anticoagulants are amongst the most commonly prescribed medications worldwide. Although rare, localised and systemic drug reactions have been reported with anticoagulants that can lead to significant morbidity and mortality. Some of the first signs of drug reactions to anticoagulants are cutaneous changes that, when recognised early, can prevent significant complications. Dermatologists should be aware of these changes to make an early and accurate diagnosis. This is particularly important in instances of skin-induced necrosis caused by systemic toxicity to anticoagulants. This review discusses adverse drug reactions to the traditional anticoagulants, warfarin and heparin, and the newer direct oral anticoagulants (DOACs) such as the thrombin inhibitor, dabigatran, and the factor Xa inhibitors, rivaroxaban, apixaban, and edoxaban. In particular, this review provides dermatologists with a framework for early diagnosis and management of patients with drug reactions to anticoagulants and alerts them to potential bleeding complications associated with minor procedures.
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Affiliation(s)
- Trang T Vu
- 1 University of Toronto, Faculty of Medicine, Toronto, ON, Canada
| | - Melinda Gooderham
- 2 Skin Centre for Dermatology, Peterborough, ON, Canada.,3 Probity Medical Research, Waterloo, ON, Canada.,4 Queen's University, Kingston, ON, Canada
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2
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Igarashi Y, Akimoto T, Kobayashi T, Iwazu Y, Miki T, Otani-Takei N, Imai T, Sugase T, Masuda T, Takeda SI, Muto S, Nagata D. Performing Anticoagulation: A Puzzling Case of Cholesterol Embolization Syndrome. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2017; 10:1179547616684649. [PMID: 28469497 PMCID: PMC5398301 DOI: 10.1177/1179547616684649] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 11/21/2016] [Indexed: 12/04/2022]
Abstract
The avoidance of any form of anticoagulation is advised in cases of cholesterol embolization syndrome (CES). We herein describe a case of CES in a man with a history of unprovoked pulmonary embolism for which warfarinization was performed. Despite anecdotal reports of successful anticoagulation in CES patients with certain indications, irreversible renal failure, which was sufficiently severe to require chronic hemodialysis, eventually developed in our patient. Our results emphasize the pitfalls of this procedure, which imply its limited feasibility and safety. Several therapeutic concerns associated with this case are also discussed.
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Affiliation(s)
- Yusuke Igarashi
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Takahisa Kobayashi
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Yoshitaka Iwazu
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Takuya Miki
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Naoko Otani-Takei
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Toshimi Imai
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Taro Sugase
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Takahiro Masuda
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Shin-Ichi Takeda
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Shigeaki Muto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Japan
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4
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Kim H, Zhen DB, Lieske JC, McBane RD, Grande JP, Sandhu GS, Melduni RM. Treatment of Cholesterol Embolization Syndrome in the Setting of an Acute Indication for Anticoagulation Therapy. J Med Cases 2014; 5:376-379. [PMID: 25197328 DOI: 10.14740/jmc1804w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Cholesterol embolization syndrome (CES) is a complication sometimes occurring after invasive endovascular procedures. CES is characterized by release of cholesterol crystals and particles from atheromatous plaques, which can occlude distal vessels and induce an inflammatory response, resulting in end-organ damage. We report the case of a 66-year-old man who presented with an acute ST-elevation myocardial infarction. An intra-aortic balloon pump was placed due to hemodynamic instability following percutaneous coronary intervention. Ten weeks after discharge, he presented with signs and symptoms of CES (e.g., livedo reticularis, acrocyanosis, acute renal failure), and a new left ventricular apical thrombus. Withdrawal of anticoagulation is often recommended in the setting of CES, on the presumption that anticoagulants favor plaque hemorrhage and subsequent cholesterol micro-embolization. Because of the potential disastrous consequences of an embolus, the patient was anticoagulated with warfarin concurrently with corticosteroids to suppress the inflammatory response to cholesterol crystals. His renal function continued to improve and was discharged without the need for dialysis. This case illustrates that anticoagulation therapy in CES is feasible and appears to be safe in patients with a coexisting urgent indication for anticoagulation.
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Affiliation(s)
- Hidong Kim
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - David B Zhen
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert D McBane
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph P Grande
- Division of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Gurpreet S Sandhu
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
| | - Rowlens M Melduni
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA
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5
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Dulíček P, Bártová J, Beránek M, Malý J, Pecka M. The Purple Toe Syndrome in Female With Factor V Leiden Mutation Successfully Treated With Enoxaparin. Clin Appl Thromb Hemost 2012; 19:100-2. [DOI: 10.1177/1076029612440033] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Petr Dulíček
- Second Department of Internal Medicine, Department of Hematology, University Hospital and Medical Faculty, Hradec Králové, Czech Republic
| | - J. Bártová
- Second Department of Internal Medicine, Department of Gastroenterology, University Hospital and Medical Faculty, Hradec Králové, Czech Republic
| | - M. Beránek
- Department of Clinical Biochemistry University Hospital and Medical Faculty, Hradec Králové, Czech Republic
| | - J. Malý
- Second Department of Internal Medicine, Department of Hematology, University Hospital and Medical Faculty, Hradec Králové, Czech Republic
| | - M. Pecka
- Second Department of Internal Medicine, Department of Hematology, University Hospital and Medical Faculty, Hradec Králové, Czech Republic
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Ageno W, Gallus AS, Wittkowsky A, Crowther M, Hylek EM, Palareti G. Oral anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e44S-e88S. [PMID: 22315269 PMCID: PMC3278051 DOI: 10.1378/chest.11-2292] [Citation(s) in RCA: 1026] [Impact Index Per Article: 85.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2011] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The objective of this article is to summarize the published literature concerning the pharmacokinetics and pharmacodynamics of oral anticoagulant drugs that are currently available for clinical use and other aspects related to their management. METHODS We carried out a standard review of published articles focusing on the laboratory and clinical characteristics of the vitamin K antagonists; the direct thrombin inhibitor, dabigatran etexilate; and the direct factor Xa inhibitor, rivaroxaban RESULTS The antithrombotic effect of each oral anticoagulant drug, the interactions, and the monitoring of anticoagulation intensity are described in detail and discussed without providing specific recommendations. Moreover, we describe and discuss the clinical applications and optimal dosages of oral anticoagulant therapies, practical issues related to their initiation and monitoring, adverse events such as bleeding and other potential side effects, and available strategies for reversal. CONCLUSIONS There is a large amount of evidence on laboratory and clinical characteristics of vitamin K antagonists. A growing body of evidence is becoming available on the first new oral anticoagulant drugs available for clinical use, dabigatran and rivaroxaban.
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Affiliation(s)
| | | | | | - Mark Crowther
- McMaster University, St. Joseph's Hospital, Hamilton, ON, Canada
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8
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Scherer K, Tsakiris DA, Bircher AJ. Überempfindlichkeits- und allergische Reaktionen auf hämostaseologisch wirksame Medikamente. Hamostaseologie 2010. [DOI: 10.1007/978-3-642-01544-1_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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10
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Weyland P. Warfarin therapy management: tap in to new ways to slow the clot. Nurse Pract 2009; 34:22-29. [PMID: 19240633 DOI: 10.1097/01.npr.0000346589.28196.ec] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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Bassas P, Bartralot R, García-Patos V. Anticoagulation and Antiplatelet Therapy in Dermatology. ACTAS DERMO-SIFILIOGRAFICAS 2009. [DOI: 10.1016/s1578-2190(09)70004-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Bircher AJ, Harr T, Hohenstein L, Tsakiris DA. Hypersensitivity reactions to anticoagulant drugs: diagnosis and management options. Allergy 2006; 61:1432-40. [PMID: 17073874 DOI: 10.1111/j.1398-9995.2006.01227.x] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Anticoagulants, including heparins, coumarins, hirudins, and some of the previously used plasma volume expanders, belong to the most widely used drugs. Hypersensitivity reactions from these agents are uncommon. However, they may have a considerable impact on patient safety and treatment decisions. Therefore, early diagnosis of potentially life-threatening adverse events and identification of alternatives is clinically important. This review contains an update on current knowledge about hypersensitivity reactions caused by the different anticoagulants. In addition, it discusses pathophysiologic mechanisms, diagnostic possibilities, and management options. The most common hypersensitivity reactions are erythematous plaques, occurring with a delay after subcutaneous application of heparins. Seldom they turn into maculopapular exanthema. Other hypersensitivity reactions are rare but may be life-threatening, e.g. skin necrosis because of heparin-induced thrombocytopenia. Skin and provocation tests with immediate and late readings are the most reliable diagnostic tools for heparin- or hirudin-induced urticaria/anaphylaxis or heparin-induced delayed plaques. If necrosis from heparins or coumarins is suspected, skin tests are contraindicated. In anaphylactic reactions caused by dextrans or hydroxyethyl starch skin tests are useless. Most in vitro tests have a low sensitivity and are not generally available. Therefore, in some anticoagulant-associated hypersensitivity reactions detailed allergologic investigation may help to identify safe treatment alternatives. However, several tests may be needed, and the procedures are usually time-consuming.
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Affiliation(s)
- A J Bircher
- Allergy Unit, University Hospital, Basel, Switzerland
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