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Rivaroxaban: Expanded Role in Cardiovascular Disease Management-A Literature Review. Cardiovasc Ther 2021; 2021:8886210. [PMID: 33505518 PMCID: PMC7810545 DOI: 10.1155/2021/8886210] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/22/2020] [Accepted: 01/04/2021] [Indexed: 01/20/2023] Open
Abstract
Direct oral anticoagulants (DOACs) are widely used for the prevention of stroke in nonvalvular atrial fibrillation, treatment of deep venous thrombosis and pulmonary embolism, and as prophylaxis after hip and knee surgery after approval by the Food and Drug Administration. In the last decade, DOACs were studied for various indications; this review is focused on rivaroxaban, a factor Xa inhibitor, which is used in an expanded evidence-based fashion for coronary artery disease, peripheral artery disease, heart failure, malignancy, and prophylaxis of deep venous thrombosis in acute medical illnesses.
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Knotts TL, Mousa SA. Anticoagulation in Venous Thromboembolism Prophylaxis in Medically Ill Patients: Potential Impact of NOACs. Am J Cardiovasc Drugs 2019; 19:365-376. [PMID: 30809772 DOI: 10.1007/s40256-019-00329-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
While substantial evidence supports the use of standard-duration injectable anticoagulants for venous thromboembolism (VTE) prophylaxis, consensus is mixed about which agents may be preferred in acutely ill patients with ongoing need of VTE prophylaxis past the first 10-day duration of hospital stay and post-discharge. Non-vitamin K antagonist oral anticoagulants (NOACs) provide Factor Xa inhibition to prevent the thrombin generation essential in thromboembolism development, but evidence for the efficacy and safety of most NOACs is conflicting regarding extended-duration prophylaxis. Enoxaparin, a preferred injectable anticoagulant in standard-duration VTE prophylaxis, has shown an increased risk of major bleeding events when used in extended-duration prophylaxis, which outweighs its benefit. Rivaroxaban has demonstrated efficacy in extended-duration prophylaxis, but both rivaroxaban and apixaban have shown increased risks of major bleeding. Betrixaban remains the only NOAC approved in the USA for extended-duration VTE prophylaxis, and it demonstrates efficacy, with fewer adverse effects than other NOACs. This review evaluates the appropriateness of different NOAC agents compared with current therapies for the extended-duration VTE prophylaxis setting in medically ill populations.
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Affiliation(s)
- Tara L Knotts
- The Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, 1 Discovery Drive, Rensselaer, NY, 12144, USA
| | - Shaker A Mousa
- The Pharmaceutical Research Institute, Albany College of Pharmacy and Health Sciences, 1 Discovery Drive, Rensselaer, NY, 12144, USA.
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Sex differences in risk of incident venous thromboembolism in heart failure patients. Clin Res Cardiol 2018; 108:101-109. [DOI: 10.1007/s00392-018-1329-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/16/2018] [Indexed: 01/11/2023]
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Cimminiello C, Prandoni P, Agnelli G, Di Minno G, Polo Friz H, Scaglione F, Boracchi P, Marano G, Harenberg J. Thromboprophylaxis with enoxaparin and direct oral anticoagulants in major orthopedic surgery and acutely ill medical patients: a meta-analysis. Intern Emerg Med 2017; 12:1291-1305. [PMID: 28756546 DOI: 10.1007/s11739-017-1714-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/24/2017] [Indexed: 11/25/2022]
Abstract
Subjects undergoing major orthopedic surgery and acutely ill hospitalized medical patients represent a population at medium-high risk for venous thromboembolism (VTE). They are treated with low molecular weight heparin (LMWH) and direct oral anticoagulants [DOACs] for VTE prevention. We conducted a meta-analysis of phase III randomized clinical trials evaluating LMWH enoxaparin versus DOACs for prophylaxis of VTE by combining studies including patients undergoing elective total hip and knee replacement surgery, and acutely ill hospitalized medical subjects. Studies were searched using PubMed, MEDLINE, and EMBASE databases until December 2016. Differences in clinical outcomes for efficacy and safety endpoints between treatment groups were expressed as risk differences with 95% confidence intervals (95% CI), using random effects regression models. Fourteen RCTs were considered (60,467 subjects). Overall mortality, symptomatic deep venous thrombosis, non-fatal pulmonary embolism (PE) major bleeding (MB) and clinically relevant non-major bleeding (CRNMB) are not different between treatment regimens. Treatment with LMWH enoxaparin is associated with a lower risk of fatal PE plus VTE-related death compared therapy with DOACs (RD = 0.040%, 95% CI 0.001-0.080%, p = 0.0434). Subgroup analysis shows an incidence of MB (RD = 0.181%, 95% CI 0.029-0.332%, p = 0.0033) and CRNMB (RD = 0.546%, 95% CI 0.009-1.082%, p = 0.0462) in patients treated with 40 mg OD enoxaparin compared to DOACs. In major orthopedic surgery and acutely ill hospitalized medical patients, DOACs do not offer clear advantages in terms of clinical efficacy compared to enoxaparin. The advantage of the latter in terms of major and CRNMB, when used at a dose of 40 mg, is statistically significant, but small in terms of clinical relevance.
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Affiliation(s)
- Claudio Cimminiello
- Studies and Research Center of the Italian Society of Angiology and Vascular Patholog (Società Italiana di Angiologia e Patologia Vascolare, SIAPAV), via Gorizia 22, 20144, Milan, Italy
| | - Paolo Prandoni
- Vascular Medicine Unit, Department of Cardiothoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Piazzale Menghini 1, 06100, Perugia, Italy
| | - Giovanni Di Minno
- Department of Clinical and Experimental Medicine, Federico II, University Hospital, Via S. Pansini 5, Naples, Italy
| | - Hernan Polo Friz
- Department of Medicine, Vimercate Hospital, Azienda Ospedaliera di Desio e Vimercate, via Santi Cosma e Damiano 10, 20871, Vimercate, Italy.
| | - Francesco Scaglione
- Department of Oncology and Onco-Hematology, University of Milan, Via Vanvitelli 32, 20129, Milan, Italy
| | - Patrizia Boracchi
- Laboratory of Medical Statistics, Department of Clinical Sciences and Community Health, Epidemiology and Biometry G. A. Maccacaro, University of Milan, Via C. Vanzetti 5, 20133, Milan, Italy
| | - Giuseppe Marano
- Laboratory of Medical Statistics, Department of Clinical Sciences and Community Health, Epidemiology and Biometry G. A. Maccacaro, University of Milan, Via C. Vanzetti 5, 20133, Milan, Italy
| | - Job Harenberg
- Medical Faculty Mannheim, Ruprecht-Karls University Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
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Agnelli G, Gallus A, Lassen M, Prins M, Renfurm R, Kashiwa M, Turpie A, Eriksson B. Darexaban (YM150) versus enoxaparin for the prevention of venous thromboembolism after total hip arthroplasty: a randomised phase IIb dose confirmation study (ONYX-3). Thromb Haemost 2017; 111:213-25. [DOI: 10.1160/th13-04-0296] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 09/13/2013] [Indexed: 01/23/2023]
Abstract
SummaryThis double-blind, double-dummy, randomised, phase IIb study (NCT00902928) evaluated different dosing regimens of darexaban compared with enoxaparin (randomised 1:1:1:1:1 to 15 mg twice daily [bid], 30 mg once daily [qd], 30 mg bid or 60 mg qd or enoxaparin 40 mg qd) in patients undergoing elective total hip arthroplasty. Patients, investigators, pharmacists and sponsor were all blinded to treatment allocation. Darexaban administration started 6-10 hours (h) post-surgery. Enoxaparin 40 mg qd administration started 12 ± 2 h before surgery. Treatment continued for 35 days. Bilateral venography was performed on Day 10 ± 2. The primary efficacy outcome was total VTEs (composite of proximal/distal deep-vein thrombosis, pulmonary embolism) or death, at Day 12. Total VTE rates were similar across all groups. There was no apparent difference in efficacy between onceand twice-daily darexaban (odds ratio [OR] 1.00; 95% confidence interval [CI] 0.71–1.42; p=0.988), or total daily dose (30 mg/day vs 60 mg/day; OR 0.81; 95% CI 0.57–1.15; p=0.244). There was no significant difference in major and/or clinically relevant non-major bleeding between darexaban qd or bid, or between total daily doses of 30 mg or 60 mg, and also for any dosing regimen of darexaban vs enoxaparin. Darexaban was well tolerated, without signs of liver toxicity. In conclusion, darexaban, administered qd or bid, and at total daily doses of 30 mg or 60 mg, appears to be effective for VTE prevention and was well tolerated. Data suggest no significant differences between a once- or twice-daily dosing regimen.
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Perri L, Loffredo L, Violi F. Should all acutely ill medical patients be treated with antithrombotic drugs? Thromb Haemost 2017; 109:589-95. [DOI: 10.1160/th12-11-0860] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Accepted: 01/09/2013] [Indexed: 01/20/2023]
Abstract
SummaryAfter reports from observational studies suggesting an association between acutely ill medical patients and venous thromboembolism (VTE), interventional trials with anticoagulants drugs have demonstrated a significant reduction of VTE during and immediately after hospitalisation. Although several guidelines suggest the clinical relevance of reducing this outcome, there is a low tendency to use anticoagulants in patients hospitalised for acute medical illness. We speculated that such underuse may be dependent on a low perception that patients included in the trials are actually at risk of thromboembolism. Therefore, the aim of this study was to analyse the clinical settings included in the interventional trials and their relationship with thrombotic risk. Analysis of interventional trials revealed that the majority of patients included in the trials (about 80%) were affected by heart failure, acute respiratory syndrome or infections. Among these three illnesses, literature data shows an association with venous thrombosis only in patients with acute infections; this finding was, however, supported only by retrospective study. On the contrary, there is scarce or no evidence that heart failure and acute respiratory syndrome are associated with venous thrombosis. These data underscore the need of better defining the thrombotic risk profile of acutely ill medical patients included in interventional trials with anticoagulants.
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Venous thromboembolism prophylaxis in medically ill patients: a mixed treatment comparison meta-analysis. J Thromb Thrombolysis 2017; 45:36-47. [DOI: 10.1007/s11239-017-1562-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Isnard R, Bauer F, Cohen-Solal A, Damy T, Donal E, Galinier M, Hagège A, Jourdain P, Leclercq C, Sabatier R, Trochu JN, Cohen A. Non-vitamin K antagonist oral anticoagulants and heart failure. Arch Cardiovasc Dis 2016; 109:641-650. [PMID: 27836786 DOI: 10.1016/j.acvd.2016.08.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2016] [Revised: 07/14/2016] [Accepted: 08/05/2016] [Indexed: 12/31/2022]
Abstract
Thromboembolism contributes to morbidity and mortality in patients with heart failure (HF), and atrial fibrillation (AF) is one of the main factors promoting this complication. As they share many risk factors, HF and AF frequently coexist, and patients with both conditions are at a particularly high risk of thromboembolism. Non-vitamin K antagonist oral anticoagulants (NOACs) are direct antagonists of thrombin (dabigatran) and factor Xa (rivaroxaban, apixaban and edoxaban), and were designed to overcome the limitations of vitamin K antagonists. Compared with warfarin in non-valvular AF, NOACs demonstrated non-inferiority with better safety, most particularly for intracranial haemorrhages. Therefore, the European Society of Cardiology guidelines recommend NOACs for most patients with non-valvular AF. Subgroups of patients with both AF and HF from the pivotal studies investigating the safety and efficacy of NOACs have been analysed and, for each NOAC, results were similar to those of the total analysis population. A recent meta-analysis of these subgroups has confirmed the better efficacy and safety of NOACs in patients with AF and HF - particularly the 41% decrease in the incidence of intracranial haemorrhages. The prothrombotic state associated with HF suggests that patients with HF in sinus rhythm could also benefit from treatment with NOACs. However, in the absence of clinical trial data supporting this indication, current guidelines do not recommend anticoagulant treatment of patients with HF in sinus rhythm. In conclusion, recent analyses of pivotal studies support the use of NOACs in accordance with their indications in HF patients with non-valvular AF.
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Affiliation(s)
- Richard Isnard
- Department of Cardiology, AP-HP, Pitié-Salpêtrière Hospital, Faculty of Medicine Pierre-et-Marie-Curie, University Paris 6, UMRS Inserm-UPMC 1166 and Institute of Cardiometabolism and Nutrition (ICAN), 75013 Paris, France.
| | - Fabrice Bauer
- Department of Cardiology, Inserm U1096, Rouen University Hospital, 76031 Rouen, France
| | - Alain Cohen-Solal
- Department of Cardiology, Paris Diderot University, Sorbonne Paris Centre, UMRS 942, Lariboisière Hospital, 75013 Paris, France
| | - Thibaud Damy
- UPEC, Mondor Amyloidosis Network, Department of Cardiology, AP-HP, Henri-Mondor Teaching Hospital, Inserm U955, DHU ATVB, 94010 Créteil, France
| | - Erwan Donal
- Department of Cardiology, Rennes University Hospital, University of Rennes 1, LTSI, Inserm UMR 1099, University of Rennes 1, 35033 Rennes, France
| | - Michel Galinier
- Équipe 7 « Obésité et Insuffisance Cardiaque : Approches Moléculaires et Cliniques », Inserm UMR 1048 - I2MC, Faculty of Medicine, University Paul-Sabatier - Toulouse 3, 31432 Toulouse, France
| | - Albert Hagège
- Department of Cardiology, AP-HP, Georges-Pompidou European Hospital, Paris Descartes University, PRES Paris Cité, 75015 Paris, France
| | - Patrick Jourdain
- École du Cœur et des Anticoagulants, UTIC, CHR Dubos, 95300 Pontoise, France
| | - Christophe Leclercq
- Department of Cardiology, Rennes University Hospital, CIC-IT, 35033 Rennes, France
| | - Rémi Sabatier
- Department of Cardiology, Caen University Hospital, 14003 Caen, France
| | - Jean-Noël Trochu
- Department of Cardiology and Vascular Diseases, Inserm UMR 1087, CIC 1413, Nantes University, Institut du Thorax, CHU de Nantes, 44093 Nantes, France
| | - Ariel Cohen
- Faculty of Medicine Pierre-et-Marie-Curie, University Paris 6, Department of Cardiology, AP-HP, Saint-Antoine Hospital, 75012 Paris, France
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Warfarin Discontinuation in Patients With Unprovoked Venous Thromboembolism: A Large US Insurance Database Analysis. Am J Ther 2015. [PMID: 26214203 DOI: 10.1097/mjt.0000000000000167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study examined warfarin therapy discontinuation and its risk factors among patients with unprovoked venous thromboembolism (VTE) in the US clinical practice setting. Adult patients with unprovoked VTE were identified from the MarketScan claims database from January 1, 2006 to December 31, 2012. The index date was defined as the date of first VTE diagnosis. Patients were required to have no VTE diagnosis in the 6 months before index date and continuous health plan enrollment for 6 months before and 12 months after the index date. Warfarin discontinuation rates and adjusted hazard ratios (HRs) were reported. Of 21,163 eligible patients, 15,463 were diagnosed with deep vein thrombosis (DVT) only (73.1%), 5027 with pulmonary embolism (PE) only (23.7%), and 673 with DVT and PE (3.2%). The average duration of warfarin therapy was 5.2 months (SD = 3.0). During 1-year follow-up, 21.4% patients discontinued therapy within 3 months, 42.8% within 6 months, and 70.1% within 12 months. PE versus DVT [HR = 0.77, 95% confidence interval (CI) = 0.74-0.80], comorbid atrial fibrillation (HR = 0.73, 95% CI = 0.66-0.81), thrombophilia (HR = 0.62, 95% CI = 0.54-0.71), and age >40 years (41-65 years: HR = 0.86, 95% CI = 0.81-0.91; >65 years: HR = 0.82, 95% CI = 0.77-0.87) were significantly associated with reduced risk of warfarin discontinuation. Alcohol abuse/dependence (HR = 1.36, 95% CI = 1.20-1.55), cancer history (HR = 1.13, 95% CI = 1.07-1.19), bleeding (HR = 1.07, 95% CI = 1.01-1.15), and catheter ablation (HR = 1.10, 95% CI = 1.00-1.20) in the 6 months before index date were significantly associated with increased risk for warfarin discontinuation. In conclusion, nearly 1 of 4 patients with unprovoked VTE discontinued warfarin within 3 months. Three of 4 patients discontinued therapy within 1 year. Younger age and multiple clinical factors are associated with warfarin therapy discontinuation.
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Abstract
The recent development of new oral anticoagulants (NOACs) offers the possibility of efficacy, relative safety and convenience compared with warfarin. This could lead to greater patient compliance, with easier management and improved provision of thromboprophylaxis. Safety whilst using NOACs should be focused on bleeding cases, surgery or on the management of patients receiving anticoagulant therapy with concomitant impairment of renal function, especially since many NOACs are dependent on renal excretion. Thus, if the clearance creatinine indicates severe renal impairment, NOACS will be contraindicated or their dose needs to be changed. In patients who need surgery, there are published protocols of management, depending on the severity of the intervention and renal function. In the case of severe hemorrhage, requiring rapid reversal of the anticoagulant effect and in the absence of specific antidotes, alternatives such as one of the nonspecific haemostatic agents must be considered. Clinical evaluation in bleeding situations and a meticulous risk-benefit appraisal for NOACs is needed, and these procoagulant agents and patients must be monitored closely. This article provides an overview of the pharmacology and potential risks, as well as the efficacy and safety of NOACs.
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Affiliation(s)
- Juan Antonio Vílchez
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK and Department of Cardiology and Department of Clinical Analysis, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Pilar Gallego
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK and Department of Hematology and Clinical Oncology, Hospital Universitario Morales Meseguer, Murcia, Spain
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Dudley Road, Birmingham B18 7QH, UK
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Kim MY, Kang HJ, Ryu MS, Kim SW, Ryu YJ, Lee SJ, Lee JH, Chang JH, Hwang JY. A Fatal Case of a Large Abdominal Wall Muscle Hematoma Secondary to Low-Molecular-Weight Heparin Injections. Korean J Crit Care Med 2014. [DOI: 10.4266/kjccm.2014.29.2.126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Mi Yeon Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Hyeon Ju Kang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Min Sun Ryu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Seo Woo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Yon Ju Ryu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Seok Jeong Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jin Hwa Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Jung Hyun Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
| | - Ji Young Hwang
- Department of Radiology, Ewha Medical Center and Ewha Medical Research Institute, Ewha Womans University School of Medicine, Seoul, Korea
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Imberti D, Benedetti R, Ageno W. Prevention of venous thromboembolism in acutely ill medical patients after the results of recent trials with the new oral anticoagulants. Intern Emerg Med 2013; 8:667-72. [PMID: 23857035 DOI: 10.1007/s11739-013-0979-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 07/05/2013] [Indexed: 01/02/2023]
Abstract
Venous thromboembolism (VTE) is a common potentially life-threatening complication in acutely ill medical patients; over 70 % of the fatal episodes of pulmonary embolism during hospitalization occur in non-surgical patients. In the absence of thromboprophylaxis, the incidence of venographically detected deep vein thrombosis is about 15 % in medical patients. Several trials and meta-analyses have clearly demonstrated the prophylactic role of unfractionated heparin, low molecular weight heparin and fondaparinux. Although over the past few years the knowledge of epidemiology, clinical features and prophylaxis in medical patients has significantly improved, there remain a number of controversial areas that require further investigation. Newer VTE risk assessment models have been proposed to select high risk hospitalized medical patients, but they still require external validation; scarce data are available to stratify patients to identify their individual bleeding risk. The optimal duration of thromboprophylaxis in medical patients is still a matter of debate; currently, extended prophylaxis after discharge is not recommended, but it may be required for subgroup of patients with persistently high VTE risk and a negligible risk of bleeding. Based on the results of recent studies, the new oral anticoagulants appear to have a very limited role, if any. However, a better risk stratification of patients who have a persistently increased risk of VTE is warranted to improve the risk to benefit profile of any anticoagulant drug to be used in this setting.
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Affiliation(s)
- Davide Imberti
- Internal Medicine Department, Haemostasis and Thrombosis Center, Piacenza Hospital, Via Taverna 49, 29121, Piacenza, Italy,
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Di Nisio M, Porreca E. Prevention of venous thromboembolism in hospitalized acutely ill medical patients: focus on the clinical utility of (low-dose) fondaparinux. DRUG DESIGN DEVELOPMENT AND THERAPY 2013; 7:973-80. [PMID: 24068866 PMCID: PMC3782407 DOI: 10.2147/dddt.s38042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Venous thromboembolism (VTE) is a frequent complication among acutely ill medical patients hospitalized for congestive heart failure, acute respiratory insufficiency, rheumatologic disorders, and acute infectious and/or inflammatory diseases. Based on robust data from randomized controlled studies and meta-analyses showing a reduced incidence of VTE by 40% to about 60% with pharmacologic thromboprophylaxis, prevention of VTE with low molecular weight heparin (LMWH), unfractionated heparin (UFH), or fondaparinux is currently recommended in all at-risk hospitalized acutely ill medical patients. In patients who are bleeding or are at high risk for major bleeding, mechanical prophylaxis with graduated compression stockings or intermittent pneumatic compression may be suggested. Thromboprophylaxis is generally continued for 6 to 14 days or for the duration of hospitalization. Selected cases could benefit from extended thromboprophylaxis beyond this period, although the risk of major bleeding remains a concern, and additional studies are needed to identify patients who may benefit from prolonged prophylaxis. For hospitalized acutely ill medical patients with renal insufficiency, a low dose (1.5 mg once daily) of fondaparinux or prophylactic LMWH subcutaneously appears to have a safe profile, although proper evaluation in randomized studies is lacking. The evidence on the use of prophylaxis for VTE in this latter group of patients, as well as in those at higher risk of bleeding complications, such as patients with thrombocytopenia, remains scarce. For critically ill patients hospitalized in intensive care units with no contraindications, LMWH or UFH are recommended, with frequent and careful assessment of the risk of bleeding. In this review, we discuss the evidence for use of thromboprophylaxis for VTE in acutely ill hospitalized medical patients, with a focus on (low-dose) fondaparinux.
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Affiliation(s)
- Marcello Di Nisio
- Department of Medical, Oral and Biotechnological Sciences, University G D'Annunzio of Chieti-Pescara, via dei Vestini 31, Chieti, Italy.
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Abstract
Nonvalvular atrial fibrillation (AF) confers an increased risk of thromboembolism, with a 5-fold higher risk of ischemic stroke. Oral anticoagulation (OAC) has shown to be highly effective in preventing stroke and mortality compared to placebo and is also used in patients without AF for both treatment and prophylaxis of venous thromboembolism. The OAC halts the coagulation by different mechanisms. Until recently, the only option was the vitamin K antagonists (VKAs), but their inherent limitations have promoted the development of novel oral anticoagulants (NOACs), which may offer efficacious and safer alternatives. Patients should be carefully selected to receive the most suitable treatment for each one. As the VKA efficacy and safety largely rely on the time the patient remains within the therapeutic range, this could be a useful selection criterion. Bleeding remains the main complication of all OACs. Although clinical trials of stroke prevention in AF have shown a significant reduction in hemorrhagic stroke and intracranial bleeding with the NOACs, as prescriptions are increasing, clinicians need to be prepared to accurate management of bleeding complications. Withholding the drug is usually enough for most cases of mild bleeding, but in patients with major, life-threatening bleeding, other measures, such as fluid replacement and blood transfusion, might be necessary while waiting for specific reversal agents that may reach the market soon. In case of acute bleeding, the accurate estimation of anticoagulant effect could also be needed, but the currently available coagulation tests only offer a qualitative measure. While awaiting long-term safety data, the choice between all these available therapies should be based on patient preferences, compliance, and ease of administration as well as on local factors affecting cost-effectiveness. But the increasing variety of therapeutic options when chronic OAC is needed can only improve the provided health care.
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Affiliation(s)
- Pilar Gallego
- 1Department of Hematology and Clinical Oncology, Hospital Universitario Morales, Meseguer, Murcia, Spain
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