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Pozzi A, Lucà F, Gelsomino S, Abrignani MG, Giubilato S, Di Fusco SA, Rao CM, Cornara S, Caretta G, Ceravolo R, Parrini I, Geraci G, Riccio C, Grimaldi M, Colivicchi F, Oliva F, Gulizia MM. Coagulation Tests and Reversal Agents in Patients Treated with Oral Anticoagulants: The Challenging Scenarios of Life-Threatening Bleeding and Unplanned Invasive Procedures. J Clin Med 2024; 13:2451. [PMID: 38730979 PMCID: PMC11084691 DOI: 10.3390/jcm13092451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/22/2024] [Accepted: 04/07/2024] [Indexed: 05/13/2024] Open
Abstract
In clinical practice, the number of patients treated with direct oral anticoagulants (DOACs) has consistently increased over the years. Since anticoagulant therapy has been associated with an annual incidence of major bleeding (MB) events of approximately 2% to 3.5%, it is of paramount importance to understand how to manage anticoagulated patients with major or life-threatening bleeding. A considerable number of these patients' conditions necessitate hospitalization, and the administration of reversal agents may be imperative to manage and control bleeding episodes effectively. Importantly, effective strategies for reversing the anticoagulant effects of DOACs have been well recognized. Specifically, idarucizumab has obtained regulatory approval for the reversal of dabigatran, and andexanet alfa has recently been approved for reversing the effects of apixaban or rivaroxaban in patients experiencing life-threatening or uncontrolled bleeding events. Moreover, continuous endeavors are being made to develop supplementary reversal agents. In emergency scenarios where specific reversal agents might not be accessible, non-specific hemostatic agents such as prothrombin complex concentrate can be utilized to neutralize the anticoagulant effects of DOACs. However, it is paramount to emphasize that specific reversal agents, characterized by their efficacy and safety, should be the preferred choice when suitable. Moreover, it is worth noting that adherence to the guidelines for the reversal agents is poor, and there is a notable gap between international recommendations and actual clinical practices in this regard. This narrative review aims to provide physicians with a practical approach to managing specific reversal agents.
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Affiliation(s)
- Andrea Pozzi
- Cardiology Division Valduce Hospital, 22100 Como, Italy;
| | - Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy (C.M.R.)
| | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University Hospital, 6229 HX Maastricht, The Netherlands
| | | | - Simona Giubilato
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy;
| | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy (C.M.R.)
| | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy;
| | - Giorgio Caretta
- Sant’Andrea Hospital, ASL 5 Regione Liguria, 19124 La Spezia, Italy;
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 97100 Lamezia, Italy;
| | - Iris Parrini
- Cardiology Department, Mauriziano Hospital, 10128 Torino, Italy;
| | - Giovanna Geraci
- Cardiology Unit, S. Antonio Abate Hospital, ASP Trapani, 91016 Erice, Italy;
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy;
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy;
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Fabrizio Oliva
- Cardiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy;
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2
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Pacchiarini MC, Regolisti G, Greco P, Di Motta T, Benigno GD, Delsante M, Fiaccadori E, Di Mario F. Treatment of dabigatran intoxication in critically ill patients with Acute Kidney Injury: The role of Sustained Low-Efficiency Dialysis. Int J Artif Organs 2023; 46:574-580. [PMID: 37853619 DOI: 10.1177/03913988231204516] [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] [Indexed: 10/20/2023]
Abstract
The use of dabigatran in patients with non-valvular atrial fibrillation (AF) has widely increased in the last decades, due to its positive effects in terms of safety/efficacy. However, because of the risk of major bleeding, a great degree of attention has been suggested in elderly patients with multiple comorbidities. Notably, dabigatran mainly undergoes renal elimination and dose adjustment is recommended in patients with Chronic Kidney Disease (CKD). In this regard, the onset of an abrupt decrease of kidney function may further affect dabigatran pharmacokinetic profile, increasing the risk of acute intoxication. Idarucizumab is the approved antagonist in the case of dabigatran-associated major bleeding or concomitant need of urgent surgery, but its clinical use is limited by the lack of data in patients with Acute Kidney Injury (AKI). Thus, the early start of Extracorporeal Kidney Replacement Therapy (EKRT) could be indicated to remove the drug and to reverse the associated excess anticoagulation. Sustained Low-Efficiency Dialysis (SLED) could represent an effective therapeutic option to reduce the dabigatran plasma levels rapidly while avoiding post-treatment rebound. We present here a case series of three AKI patients with acute dabigatran intoxication, effectively and safely resolved with a single SLED session.
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Affiliation(s)
- Maria Chiara Pacchiarini
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Giuseppe Regolisti
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
- UO Clinica e Immunologia Medica, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
| | - Paolo Greco
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Tommaso Di Motta
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Giuseppe Daniele Benigno
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Marco Delsante
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
| | - Francesca Di Mario
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Parma, Italy
- Scuola di Specializzazione in Nefrologia, Università di Parma, Parma, Italy
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3
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Givens G, Neu D, Marler J. The Risk of Major Bleeding With Apixaban Administration in Patients With Acute Kidney Injury. Ann Pharmacother 2022:10600280221129831. [PMID: 36239322 DOI: 10.1177/10600280221129831] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Apixaban is eliminated by the kidneys and in acute kidney injury (AKI) there is potential for an increase in apixaban exposure and bleeding events. In one instance, data have shown higher than normal bleed risk in patients with AKI, unless calibrated anti-factor Xa monitoring is used, which is not widely available. OBJECTIVE To evaluate bleeding with apixaban administration to hospitalized patients with an AKI in an unmonitored real-world scenario. METHODS We conducted a retrospective study of patients admitted to a large urban academic teaching hospital from April 2015 to March 2022, who received apixaban for venous thromboembolism or nonvalvular atrial fibrillation (NVAF). The primary outcome evaluated major bleeding when apixaban was administered to patients with or without an AKI. RESULTS A total of 232 patients were evaluated (116 per group). Most patients (79.7%) were on apixaban for NVAF, 32.7% had chronic kidney disease, 58.2% were on a medication increasing bleed risk, and HAS-BLED score was a median of 2 in both groups. No differences were noted between groups for bleeding (AKI group 7.8% vs non-AKI 3.4%; P = 0.15), and on regression analysis, coadministration of a P2Y12 inhibitor was predictive of major bleeding (odds ratio = 5.9; 95% confidence interval = 1.4-23.6). CONCLUSION AND RELEVANCE Although no differences between groups were noted, apixaban use in the AKI group resulted in a higher than normally reported incidence of apixaban-associated major bleeding, and concomitant antiplatelet use increased bleed risk as well. Cautious use of apixaban and further investigation with larger studies are warranted in this area.
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Affiliation(s)
- Gabrielle Givens
- Department of Pharmacy, Veterans Affairs Hospital, Memphis, TN, USA
| | - Daniel Neu
- Department of Pharmacy, Veterans Affairs Hospital, Memphis, TN, USA
| | - Jacob Marler
- Department of Pharmacy, Veterans Affairs Hospital, Memphis, TN, USA.,Department of Clinical Pharmacy, The University of Tennessee Health Science Center, Memphis, TN, USA
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4
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Salter B, Crowther M. A Historical Perspective on the Reversal of Anticoagulants. Semin Thromb Hemost 2022; 48:955-970. [PMID: 36055273 DOI: 10.1055/s-0042-1753485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
There has been a landmark shift in the last several decades in the management and prevention of thromboembolic events. From the discovery of parenteral and oral agents requiring frequent monitoring as early as 1914, to the development of direct oral anticoagulants (DOACs) that do not require monitoring or dose adjustment in the late 20th century, great advances have been achieved. Despite the advent of these newer agents, bleeding continues to be a key complication, affecting 2 to 4% of DOAC-treated patients per year. Bleeding is associated with substantial morbidity and mortality. Although specific reversal agents for DOACs have lagged the release of these agents, idarucizumab and andexanet alfa are now available as antagonists. However, the efficacy of these reversal agents is uncertain, and complications, including thrombosis, have not been adequately explored. As such, guidelines continue to advise the use of nonspecific prohemostatic agents for patients requiring reversal of the anticoagulant effect of these drugs. As the indications for DOACs and the overall prevalence of their use expand, there is an unmet need for further studies to determine the efficacy of specific compared with nonspecific pro-hemostatic reversal agents. In this review, we will discuss the evidence behind specific and nonspecific reversal agents for both parenteral and oral anticoagulants.
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Affiliation(s)
- Brittany Salter
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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5
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Abstract
Anticoagulant and antiplatelet drugs target a specific portion of the coagulation cascade or the platelet activation and aggregation pathway. The primary toxicity associated with these agents is hemorrhage. Understanding the pharmacology of these drugs allows the treating clinician to choose the correct antidotal therapy. Reversal agents exist for some of these drugs; however, not all have proven patient-centered outcomes. The anticoagulants covered in this review are vitamin K antagonists, heparins, fondaparinux, hirudin derivatives, argatroban, oral factor Xa antagonists, and dabigatran. The antiplatelet agents reviewed are aspirin, adenosine diphosphate antagonists, dipyridamole, and glycoprotein IIb/IIIa antagonists. Additional notable toxicities are also reviewed.
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Affiliation(s)
- David B Liss
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University in St. Louis, 660 South Euclid Avenue, CB 8072, St Louis, MO 63110, USA.
| | - Michael E Mullins
- Department of Emergency Medicine, Division of Medical Toxicology, Washington University in St. Louis, 660 South Euclid Avenue, CB 8072, St Louis, MO 63110, USA
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6
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Wahab A, Patnaik R, Gurjar M. Use of direct oral anticoagulants in ICU patients. Part II - Clinical evidence. Anaesthesiol Intensive Ther 2021; 53:440-449. [PMID: 34816706 PMCID: PMC10172943 DOI: 10.5114/ait.2021.110608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 06/08/2021] [Indexed: 11/17/2022] Open
Abstract
During the last decade, utilization of direct oral anticoagulants (DOACs) has increased due to their pharmacokinetic profile and the fact that they are non-inferior to warfarin in the prevention of stroke in patients with atrial fibrillation, as well as for the treatment of venous thromboembolism. However, there are few studies about their use in critically ill patients. This article aims to review available evidence on the use of DOACs in the indicated conditions and anticoagulant management of medical or surgical patients receiving DOAC before intensive care unit (ICU) admission. The rapidly changing pathophysiology and heterogeneous nature of critically ill patients combined with limited evidence often leads to a high degree of individualization of DOAC regimens in ICU patients. This article is the second part of the narrative review series on the use of DOACs in ICU patients, focusing on current "Clinical evidence". "Applied pharma-cology" has been described in the first part.
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Affiliation(s)
- Abdul Wahab
- University of Iowa Hospitals and Clinics, Iowa City, United States
| | - Rupali Patnaik
- Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh, India
| | - Mohan Gurjar
- Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh, India
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7
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Exner T, Rigano J, Favaloro EJ. The effect of DOACs on laboratory tests and their removal by activated carbon to limit interference in functional assays. Int J Lab Hematol 2020; 42 Suppl 1:41-48. [DOI: 10.1111/ijlh.13196] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | - Joseph Rigano
- Haematology Department Alfred Hospital Melbourne Vic. Australia
| | - Emmanuel J. Favaloro
- Laboratory Haematology Institute of Clinical Pathology and Medical Research (ICPMR) NSW Health Pathology Westmead Hospital Sydney NSW Australia
- Sydney Centres for Thrombosis and Haemostasis Westmead Hospital Sydney NSW Australia
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8
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Galassi A, Podda G, Monciino P, Stucchi A, Del Nero A, Cozzolino M. Dabigatran overload in acute kidney injury: haemodialysis or idarucizumab? A case report and proposal for a decisional algorithm. Clin Kidney J 2020; 14:712-714. [PMID: 34101772 PMCID: PMC8173663 DOI: 10.1093/ckj/sfaa011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 01/07/2020] [Indexed: 11/19/2022] Open
Abstract
Dabigatran overload has been reported in acute kidney injury (AKI), leading to occasional major bleeding. Haemodialysis (HD) was the method used for reversing dabigatran anticoagulant effects before the approval of idarucizumab, which is now indicated for dabigatran reversal in major bleeding or surgical emergencies. There have been reports of rebound of dabigatran levels following idarucizumab administration in AKI, requiring HD to achieve effective dabigatran clearance. However, a decisional algorithm to individualize treatments for dabigatran overload seems lacking. We present a case of dabigatran accumulation in obstructive AKI with minor bleeding that was successfully treated with HD and tranexamic acid without using idarucizumab, and propose a decision-making algorithm including different pathways in the management of suspected dabigatran overload in AKI.
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Affiliation(s)
- Andrea Galassi
- Renal Division, Department of Health Sciences, University of Milan, San Paolo Hospital, Milan, Italy.,Renal & Dialysis Unit, San Paolo Hospital, ASST Santi Paolo e Carlo, Milano, Italy
| | - Gianmarco Podda
- Renal Division, Department of Health Sciences, University of Milan, San Paolo Hospital, Milan, Italy.,Internal Medicine Unit III, San Paolo Hospital, ASST Santi Paolo e Carlo, Milano, Italy
| | - Paola Monciino
- Renal Division, Department of Health Sciences, University of Milan, San Paolo Hospital, Milan, Italy.,Renal & Dialysis Unit, San Paolo Hospital, ASST Santi Paolo e Carlo, Milano, Italy
| | - Andrea Stucchi
- Renal & Dialysis Unit, San Paolo Hospital, ASST Santi Paolo e Carlo, Milano, Italy
| | - Alberto Del Nero
- Urology Unit, San Paolo Hospital, ASST Santi Paolo e Carlo, Milan, Italy
| | - Mario Cozzolino
- Department of Health Sciences, University of Milan Ringgold Standard Institution, Milano, Italy
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9
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Nestor MA, Boling B. Reversing Direct Oral Anticoagulants in Acute Intracranial Hemorrhage. Crit Care Nurse 2020; 39:e1-e8. [PMID: 31154337 DOI: 10.4037/ccn2019160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Intracerebral hemorrhage is a major source of morbidity and mortality, accounting for 10% of all strokes. Oral anticoagulation therapy, while necessary to prevent thromboembolic complications, increases the risk of intracerebral hemorrhage and can potentially worsen bleeding in cases of acute hemorrhage. Before the introduction of direct oral anticoagulant agents in 2010, warfarin was the only option for oral anticoagulation. These new agents have an improved safety profile compared with warfarin but require different reversal strategies. Anticoagulation reversal in the setting of acute intracerebral hemorrhage is an evolving field. This article covers the most common direct oral anticoagulant medications, various available anticoagulant reversal strategies, and the latest guidelines for anticoagulation reversal in patients with acute intracranial hemorrhage.
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Affiliation(s)
- Melissa A Nestor
- Melissa A. Nestor is a neurosciences critical care pharmacist at the University of Kentucky, Lexington, Kentucky, with research interests in sepsis, neurologic injury, and ischemic stroke; Bryan Boling is an advanced practice provider with the Department of Anesthesiology, Division of Critical Care at the University of Kentucky
| | - Bryan Boling
- Melissa A. Nestor is a neurosciences critical care pharmacist at the University of Kentucky, Lexington, Kentucky, with research interests in sepsis, neurologic injury, and ischemic stroke; Bryan Boling is an advanced practice provider with the Department of Anesthesiology, Division of Critical Care at the University of Kentucky.
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10
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Rali P, Gangemi A, Moores A, Mohrien K, Moores L. Direct-Acting Oral Anticoagulants in Critically Ill Patients. Chest 2019; 156:604-618. [PMID: 31251908 DOI: 10.1016/j.chest.2019.05.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Revised: 05/02/2019] [Accepted: 05/21/2019] [Indexed: 01/03/2023] Open
Abstract
The direct-acting oral anticoagulants (DOACs) have been increasingly used over vitamin K antagonists in recent years because they do not require monitoring and have an immediate anticoagulation effect. In general, DOACs have exhibited a better safety profile and noninferiority for prophylaxis and treatment of venous thromboembolism (VTE) and stroke prevention in patients with atrial fibrillation compared with vitamin K antagonists in the non-ICU population; whether this finding holds true in patients who are critically ill remains unknown. The current review addresses the role of DOACs in special ICU populations, use of these agents for VTE prophylaxis, perioperative management of DOACs, drug monitoring, and potential drug interactions of DOACs in critically ill patients. Adverse events and available reversal agents for DOACs are also discussed.
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Affiliation(s)
- Parth Rali
- Division of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA
| | - Andrew Gangemi
- Division of Thoracic Medicine and Surgery, Temple University Hospital, Philadelphia, PA
| | - Aimee Moores
- Department of Medicine, Madigan Army Medical Center, Joint Base Lewis-McChord, WA
| | - Kerry Mohrien
- Department of Pharmacy, Temple University Hospital, Philadelphia, PA
| | - Lisa Moores
- Department of Medicine, F. Edward Hebert School of Medicine, The Uniformed Services University of the Health Sciences, Bethesda, MD.
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11
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Effect of an activated charcoal product (DOAC Stop™) intended for extracting DOACs on various other APTT-prolonging anticoagulants. ACTA ACUST UNITED AC 2019; 57:690-696. [DOI: 10.1515/cclm-2018-0967] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 10/02/2018] [Indexed: 11/15/2022]
Abstract
Abstract
Background
The aim of the study was to investigate the specificity of an activated charcoal-based product (DOAC Stop™) initially intended for the specific extraction of direct oral anticoagulants (DOACs) from test plasmas on a range of other anticoagulants.
Methods
Test plasmas were prepared by adding various anticoagulants to pooled normal plasma at concentrations prolonging an activated partial thromboplastin time (APTT) test by a factor of 1.5–3. These plasmas were treated with DOAC Stop™ for 5 and 20 min. Then APTTs were repeated and residual anticoagulant concentrations estimated from dose-response curves.
Results
The activated charcoal (AC)-based product was found to extract DOACs efficiently. It also bound the intravenous anticoagulants argatroban and lepirudin, but it had no effect on heparin, enoxaparin or danaparoid in plasma. Among other APTT-inhibiting agents that might be present in test plasmas from patients, it extracted protamine, aprotinin and polymyxin. It had no effect on annexin V, thrombomodulin, a typical lupus anticoagulant, a factor VIII antibody, activated protein C or its activator, but it did bind some cationic inhibitors of the APTT with molecular weight below approximately 30 kDa.
Conclusions
The AC-based product extracted DOACs efficiently with no effect on heparin-type anticoagulants. It did bind argatroban and hirudin-type anticoagulants, which might occur in plasmas from some inpatients, and APTT results obtained after its use should be interpreted after due consideration of patient medications.
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12
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Shah SB, Pahade A, Chawla R. Novel reversal agents and laboratory evaluation for direct-acting oral anticoagulants (DOAC): An update. Indian J Anaesth 2019; 63:169-181. [PMID: 30988530 PMCID: PMC6423941 DOI: 10.4103/ija.ija_734_18] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Novel oral anticoagulants (NOACs) are no longer "novel" but their reversal agents definitely are. Although NOACs enjoy high clinical efficacy, monitoring and reversal of their effect is a challenge which this review attempts to surmount. Ideally, for NOAC activity measurement, specific anti-Factor IIa levels and anti -Factor Xa levels should be monitored (chromogenic assays), but such tests are not readily available. Modifications of the existing coagulation tests catering to this unmet need for quantification of DOAC activity have been reviewed. The available United States Food and Drug Administration (FDA) approved reversal agents, idarucizumab for dabigatrin and andexanet alfa for anti-Xa direct acting oral anticoagulants have given promising results but are prohibitively priced. Medline, Embase, and Scopus databases were thoroughly searched for clinical trials on laboratory investigations and specific as well as non-specific reversal-agents for DOACs.
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Affiliation(s)
- Shagun B Shah
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, New Delhi, India
| | - Akhilesh Pahade
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, New Delhi, India
| | - Rajiv Chawla
- Department of Anaesthesia, Rajiv Gandhi Cancer Institute and Research Centre, Sector-5, Rohini, New Delhi, India
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13
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Probable drug–drug interaction between dabigatran and quinidine resulting in thrombin time rebound despite multiple idarucizumab doses. Blood Coagul Fibrinolysis 2019; 30:42-46. [DOI: 10.1097/mbc.0000000000000782] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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14
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Major bleeding with old and novel oral anticoagulants: How to manage it. Focus on general measures. Int J Cardiol 2018; 268:80-84. [DOI: 10.1016/j.ijcard.2018.05.061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 05/04/2018] [Accepted: 05/18/2018] [Indexed: 01/07/2023]
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15
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Udayachalerm S, Rattanasiri S, Angkananard T, Attia J, Sansanayudh N, Thakkinstian A. The Reversal of Bleeding Caused by New Oral Anticoagulants (NOACs): A Systematic Review and Meta-Analysis. Clin Appl Thromb Hemost 2018; 24:117S-126S. [PMID: 30176738 PMCID: PMC6714855 DOI: 10.1177/1076029618796339] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
New oral anticoagulants (NOACs; ie, direct thrombin inhibitor [DTI] and factor Xa [FXa] inhibitors) were used as alternatives to warfarin. Specific antidotes (idarucizumab for dabigatran and andexanet alfa for FXa inhibitors) and hemostatic reversal agents were used for lowering bleeding, but their efficacies were still uncertain. The objectives of this study were to estimate and compare the efficacy of NOAC antidotes on bleeding reversal and death. Studies were identified from MEDLINE and Scopus databases until May 2018. Case reports/series and cohorts were selected if they assessed reversal or death rates. Data were independently extracted by 2 reviewers. Individual patient data and aggregated data of outcomes were extracted from case reports/series and cohorts. Binary regression was used to estimate outcome rates, risk ratio (RR) along with 95% confidence interval (CI). Interventions were NOACs and reversal agents (ie, DTI-specific, DTI-standard, FXa-specific, and FXa-standard). Among 220 patients of 93 case reports/series, reversal rates were 95.9%, 77.6%, and 71.5% for DTI-specific, FXa-standard, and DTI-standard. Pooled RRs for DTI-specific and FXa-standard versus DTI-standard, respectively, were 1.34 (CI: 1.13-1.60) and 1.09 (CI: 0.84-1.40). Death rate was 0.18 (CI: 0.06-0.57) times lower in DTI-specific versus DTI-standard. For pooling 10 subcohorts, pooled RRs were 1.08 (CI: 1.00-1.16), 1.29 (CI: 1.20-1.39), and 1.13 (CI: 1.01-1.25) for DTI-specific, FXa-specific, and FXa-standard versus DTI-standard. In conclusion, specific reversal agents might be useful for reversal of bleeding and lowering the risk of death than standard reversal agents. Our findings were based on case reports/series and selected cohorts, further comparative studies are thus needed.
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Affiliation(s)
- Sariya Udayachalerm
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sasivimol Rattanasiri
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Teeranan Angkananard
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Division of Cardiology, Faculty of Medicine, Srinakharinwirot University, Bangkok, Thailand
| | - John Attia
- Centre for Clinical Epidemiology and Biostatistics, Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, New South Wales, Australia.,Hunter Medical Research Institute, New South Wales, Australia
| | - Nakarin Sansanayudh
- Cardiology Unit, Department of Internal Medicine, Phramongkutklao Hospital, Bangkok, Thailand
| | - Ammarin Thakkinstian
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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16
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Thiele T, Selleng K, Greinacher A. Reversal of anticoagulants: an overview of current developments. Thromb Haemost 2017; 113:931-42. [DOI: 10.1160/th14-11-0982] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 02/23/2015] [Indexed: 11/05/2022]
Abstract
SummarySeveral new anticoagulants have entered the clinical arena or are under clinical development. These drugs include indirect (fondaparinux) and direct oral factor Xa inhibitors (rivaroxaban, apixaban, edoxaban, betrixaban), and the direct thrombin inhibitor dabigatran. Especially the oral direct FXa and FIIa inhibitors overcome many of the shortcomings of heparins and vitamin K antagonists (VKAs). They are administered orally at a fixed dose; regular monitoring is not necessary; interaction with other drugs or nutrition occur less than with VKAs and they are at least as effective as VKAs for most indications tested. They are associated with about 50 % less intracranial bleeding than VKAs. Nevertheless, they are still associated with bleeding complications. Bleeding can occur spontaneously or as a result of trauma or urgent surgery. In such situations rapid reversal of the anticoagulant effect is highly desirable. For unfractionated heparin protamine, and for VKAs prothrombin complex concentrates are available as specific antidotes. Under clinical development are: for the direct and indirect FXa inhibitors a modified recombinant FXa (andexanet alpha), which lacks enzymatic activity; and for dabigatran a Fab fragment of a monoclonal antibody (idarucizumab). In addition a small molecule (aripazine) has entered phase I clinical trials, which seems to inhibit nearly all anticoagulants but VKAs and argatroban. This review summarises the current options and strategies in development to antagonise anticoagulants with a focus on the status of the development of antidotes for the oral direct FXa and FIIa inhibitors.
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17
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A case of tumor lysis syndrome and acute renal failure associated with elotuzumab treatment in multiple myeloma. Clin Nephrol Case Stud 2017; 5:78-81. [PMID: 29318105 PMCID: PMC5715206 DOI: 10.5414/cncs109165] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 09/05/2017] [Indexed: 11/18/2022] Open
Abstract
Renal dysfunction is a common comorbidity of multiple myeloma. However, tumor lysis syndrome is a rare cause of renal dysfunction in multiple myeloma. Elotuzumab is a newly US FDA-approved monoclonal antibody used in the treatment of refractory multiple myeloma. To our knowledge, elotuzumab has not been associated with a case of tumor lysis syndrome. We present the case of a patient who developed clinical tumor lysis syndrome 1 week after treatment with elotuzumab accompanied by renal failure with hyperphosphatemia, hyperkalemia, and profound hyperuricemia. His course was further complicated by significant epistaxis from the accumulation of dabigatran in acute renal failure. In spite of treatment with rasburicase and hemodiafiltration, the patient decompensated and eventually died. Risk factors for the development of tumor lysis syndrome in multiple myeloma are discussed.
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Abstract
The use of anticoagulation in the prevention of strokes due to atrial fibrillation or the treatment of venous thromboembolic disease has been on the rise. With the advent and proliferation of direct oral anticoagulation medications, the management of anticoagulation reversal has become increasingly complex, especially when urgent or emergent reversal is required. This review details the commonly used parenteral and oral anticoagulants, the treatment strategies necessary for their reversal, and therapies still in development.
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Affiliation(s)
- Jeremy L Holzmacher
- Center for Trauma and Critical Care, Department of Surgery, George Washington University Medical Center, 2150 Pennsylvania Avenue Northwest, Suite 6B, Washington, DC 20037, USA
| | - Babak Sarani
- Center for Trauma and Critical Care, Department of Surgery, George Washington University Medical Center, 2150 Pennsylvania Avenue Northwest, Suite 6B, Washington, DC 20037, USA.
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19
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Major publications in the critical care pharmacotherapy literature: January-December 2016. J Crit Care 2017; 43:327-339. [PMID: 28974331 DOI: 10.1016/j.jcrc.2017.09.178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 08/10/2017] [Accepted: 09/21/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE To summarize select critical care pharmacotherapy guidelines and studies published in 2016. SUMMARY The Critical Care Pharmacotherapy Literature Update (CCPLU) Group screened 31 journals monthly for relevant pharmacotherapy articles and selected 107 articles for review over the course of 2016. Of those included in the monthly CCPLU, three guidelines and seven primary literature studies are reviewed here. The guideline updates included are as follows: hospital-acquired pneumonia and ventilator-associated pneumonia management, sustained neuromuscular blocking agent use, and reversal of antithrombotics in intracranial hemorrhage (ICH). The primary literature summaries evaluate the following: dexmedetomidine for delirium prevention in post-cardiac surgery, dexmedetomidine for delirium management in mechanically ventilated patients, high-dose epoetin alfa after out-of-hospital cardiac arrest, ideal blood pressure targets in ICH, hydrocortisone in severe sepsis, procalcitonin-guided antibiotic de-escalation, and empiric micafungin therapy. CONCLUSION The review provides a synopsis of select pharmacotherapy publications in 2016 applicable to clinical practice.
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20
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Abuqayyas S, Raju S, Bartholomew JR, Abu Hweij R, Mehta AC. Management of antithrombotic agents in patients undergoing flexible bronchoscopy. Eur Respir Rev 2017; 26:26/145/170001. [PMID: 28724561 DOI: 10.1183/16000617.0001-2017] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 04/09/2017] [Indexed: 12/16/2022] Open
Abstract
Bleeding is one of the most feared complications of flexible bronchoscopy. Although infrequent, it can be catastrophic and result in fatal outcomes. Compared to other endoscopic procedures, the risk of morbidity and mortality from the bleeding is increased, as even a small amount of blood can fill the tracheobronchial tree and lead to respiratory failure. Patients using antithrombotic agents (ATAs) have higher bleeding risk. A thorough understanding of the different ATAs is critical to manage patients during the peri-procedural period. A decision to stop an ATA before bronchoscopy should take into account a variety of factors, including indication for its use and the type of procedure. This article serves as a detailed review on the different ATAs, their pharmacokinetics and the pre- and post-bronchoscopy management of patients receiving these medications.
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Affiliation(s)
- Sami Abuqayyas
- Internal Medicine Institute, Cleveland Clinic, Cleveland, OH, USA.,Both authors contributed equally
| | - Shine Raju
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Both authors contributed equally
| | | | - Roulan Abu Hweij
- Internal Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Atul C Mehta
- Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
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21
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Simon A, Domanovits H, Ay C, Sengoelge G, Levy JH, Spiel AO. The recommended dose of idarucizumab may not always be sufficient for sustained reversal of dabigatran. J Thromb Haemost 2017; 15:1317-1321. [PMID: 28426914 DOI: 10.1111/jth.13706] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Indexed: 08/31/2023]
Abstract
Essentials Reversal of anticoagulant effects of dabigatran may occur despite application of idarucizumab. Monitoring of dabigatran level after antidote application is crucial to detect rebound. Repeated doses of idarucizumab may be necessary in cases of massive dabigatran accumulation. Combination of antidote application and renal replacement therapy may offer additional benefit. SUMMARY Idarucizumab is a monoclonal antibody fragment designed for reversing the anticoagulant effects of dabigatran. Administration is recommended as two intravenous boluses of 2.5 g within 15 min of each other or as a single 5 g bolus. However, in certain situations a second dose of the drug could be necessary. We report the case of a 77-year-old man, treated with dabigatran for paroxysmal atrial fibrillation. He presented at our department with acute renal failure, concomitant massive dabigatran accumulation and subsequent acute gastrointestinal bleeding. Fifty minutes after the administration of idarucizumab, the dabigatran plasma concentration decreased from a peak of 1630 ng ml-1 to a level below the detection limit of 30 ng ml-1 and bleeding stopped. Eight hours after administration, the dabigatran plasma level started to increase up to 1560 ng ml-1 (96% of the maximum value obtained), accompanied by a further drop in hemoglobin. Concomitant hemodialysis and hemofiltration led to a continuous decrease in dabigatran plasma levels. However, sepsis and multiorgan failure ensued, which led to death. With this case report we raise the question of whether massive dabigatran accumulation requires repeated doses of idarucizumab, or alternatively, if the combination of antidote with hemodialysis/renal replacement therapy is advisable in order to remove circulating levels of dabigatran.
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Affiliation(s)
- A Simon
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - H Domanovits
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - C Ay
- Medical University of Vienna, Clinical Division of Hematology and Hemostaseology, Vienna, Austria
| | - G Sengoelge
- Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - J H Levy
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - A O Spiel
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
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22
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Gottlieb M, Khishfe B. Idarucizumab for the Reversal of Dabigatran. Ann Emerg Med 2017; 69:554-558. [DOI: 10.1016/j.annemergmed.2016.11.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Indexed: 10/20/2022]
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23
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Dager W, Hellwig T. Current knowledge on assessing the effects of and managing bleeding and urgent procedures with direct oral anticoagulants. Am J Health Syst Pharm 2017; 73:S14-26. [PMID: 27147455 DOI: 10.2146/ajhp150960] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Current knowledge on managing major bleeding events with available hemostatic agents, including their combined use with potential reversal agents, in patients taking direct oral anticoagulant (DOACs) is reviewed. SUMMARY Over the past five years, a new generation of oral agents, the DOACs, has emerged as commonly used anticoagulants for stroke prevention in non-valvular atrial fibrillation, and treatment or secondary prevention of venous thromboembolism. Management of a bleeding event in the setting of DOAC therapy should take into account the relative risks of bleeding and thrombosis, which will determine the degree of anticoagulant reversal required. In the setting of a major (critical) bleeding event associated with notable blood loss, management may include transfusions of blood products to sustain the function of organ systems, and the availability of specific reversal agents will provide additional options for bleeding management. Beyond withholding the DOAC and providing supportive management that addresses any factors contributing to the bleeding event, clinicians may desire to expedite the removal of any anticoagulation effects. In general, this is accomplished by either removing or neutralizing the anticoagulant or by independently establishing hemostasis. CONCLUSION With or without reversal agents, patients may require supportive management such as mechanical pressure, volume support, transfusions of blood products, and, depending on the situation, surgery to repair the bleeding source. Specific reversal agents are currently under development or have recently been approved for the urgent management of bleeding events or the facilitation of invasive procedures in patients receiving DOACs.
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Affiliation(s)
- William Dager
- University of California Davis Medical Center, Sacramento, CA.
| | - Thaddaus Hellwig
- South Dakota State University College of Pharmacy, Sioux Falls, SDSanford USD Medical Center, Sioux Falls, SD
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24
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Salerno DM, Tsapepas D, Papachristos A, Chang JH, Martin S, Hardy MA, McKeen J. Direct oral anticoagulant considerations in solid organ transplantation: A review. Clin Transplant 2016; 31. [PMID: 27859621 DOI: 10.1111/ctr.12873] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2016] [Indexed: 12/17/2022]
Abstract
For more than 60 years, warfarin was the only oral anticoagulation agent available for use in the United States. In many recent clinical trials, several direct oral anticoagulants (DOACs) demonstrated similar efficacy with an equal or superior safety profile, with some other notable benefits. The DOACs have lower inter- and intrapatient variability, much shorter half-lives, and less known drug-drug and drug-food interactions as compared to warfarin. Despite these demonstrated benefits, the use of DOACs has not gained uniform acceptance because of lack of supportive data in special patient populations, including recipients of solid organ transplants maintained on immunosuppression. This review describes the properties of several novel DOACs including their pharmacology and mechanisms of action as they relate to use among solid organ transplant recipients. We have particularly focused on (i) dosing in patients with impaired renal and hepatic function; (ii) considerations for drug-drug interactions with immunosuppressive medications; and (iii) management of the anticoagulated patients at the time of unplanned surgery. The risks and benefits of the use of DOACs in solid organ transplant recipients should be carefully evaluated prior to the introduction of these agents in this highly distinct patient population.
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Affiliation(s)
- David M Salerno
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, NY, USA
| | - Demetra Tsapepas
- Department of Pharmacy, NewYork-Presbyterian Hospital, New York, NY, USA.,Department of Surgery, Division of Abdominal Transplantation, Columbia University Medical Center, New York, NY, USA
| | | | - Jae-Hyung Chang
- Department of Medicine, Division of Nephrology, Columbia University Medical Center, New York, NY, USA
| | - Spencer Martin
- Department of Pharmacy, Hartford Hospital, Hartford, CT, USA
| | - Mark A Hardy
- Department of Surgery, Division of Abdominal Transplantation, Columbia University Medical Center, New York, NY, USA
| | - Jaclyn McKeen
- Department of Pharmacy, Hackensack University Medical Center, Hackensack, NJ, USA
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25
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Bashir S, Al-Mohammed A, Gupta S. A practical approach to the new oral anticoagulants used for stroke prevention in patients with atrial fibrillation. J R Coll Physicians Edinb 2016; 46:113-118. [PMID: 27929577 DOI: 10.4997/jrcpe.2016.211] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
This review evaluates the research undertaken in the last six years on the use of new oral anticoagulants for stroke prevention in atrial fibrillation and provides evidence-based answers to common clinical questions. Two types of new oral anticoagulants - direct thrombin (IIa) inhibitors, and Xa inhibitors - are currently available. These drugs have similar pharmacokinetics and pharmacodynamics. They are more predictable than, though in many respects comparable to, warfarin. They do not require frequent laboratory tests, nor do they have a narrow therapeutic window. When a patient requires surgery, new oral anticoagulants are easier to manage than warfarin due to their short half-lives. Short half-lives reduce the length of bleeding events. Information obtained from risk calculators such as CHA2DS2-VASc and HAS-BLED should be considered before prescribing. New oral anticoagulants are useful in every day clinical practice, but there are complex factors that should be considered in each patient before prescribing to implement the best practice and achieve the best results.
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Affiliation(s)
- S Bashir
- S Bashir, Department of Cardiology, Castle Hill Hospital, Castle Rd, Cottingham, Yorkshire HU16 5JQ, UK, E-mail
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26
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Porru M, Mameli A, Cianchetti ME, Musu M, Schirru P, Ruberto MF, Barcellona D, Marongiu F. Dabigatran overdose: a case report of acute hepatitis. Extracorporeal treatment. Int J Hematol 2016; 105:532-535. [PMID: 27910004 DOI: 10.1007/s12185-016-2158-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 11/22/2016] [Accepted: 11/24/2016] [Indexed: 12/01/2022]
Abstract
Dabigatran is an oral, direct thrombin inhibitor approved by international regulatory agencies for stroke prevention in patients with paroxysmal or persistent non-rheumatic atrial fibrillation (AF). The benefits of dabigatran are widely described, but its use in the geriatric population is not without risk. Chronic kidney disease is a common comorbidity with AF, and thus frequent checks of renal function in elderly patients are recommended. We report a case of dabigatran intoxication in an elderly man affected by heart failure and worsening renal function, who developed acute hepatitis and coma, which was successfully treated with continuous veno-venous hemodiafiltration. Although extracorporeal therapy has been suggested as a strategy for clearing dabigatran during acute bleeding, this approach may be useful in other dabigatran-related, life-threatening conditions, such as that described in this report.
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Affiliation(s)
- Mariagrazia Porru
- Internal Medicine and Haemocoagulopathies Unit, Azienda Ospedaliero Universitaria (A.O.U.), Presidio "Duilio Casula", University of Cagliari, SS 554, Bivio per Sestu, 09042, Monserrato, Cagliari, Italy
| | - Antonella Mameli
- Internal Medicine and Haemocoagulopathies Unit, Azienda Ospedaliero Universitaria (A.O.U.), Presidio "Duilio Casula", University of Cagliari, SS 554, Bivio per Sestu, 09042, Monserrato, Cagliari, Italy.
| | - Maria E Cianchetti
- Internal Medicine and Haemocoagulopathies Unit, Azienda Ospedaliero Universitaria (A.O.U.), Presidio "Duilio Casula", University of Cagliari, SS 554, Bivio per Sestu, 09042, Monserrato, Cagliari, Italy
| | - Mario Musu
- Intensive Care Unit, Azienda Ospedaliero Universitaria (A.O.U.), Presidio "Duilio Casula", University of Cagliari, Monserrato, Cagliari, Italy
| | - Paola Schirru
- Internal Medicine and Haemocoagulopathies Unit, Azienda Ospedaliero Universitaria (A.O.U.), Presidio "Duilio Casula", University of Cagliari, SS 554, Bivio per Sestu, 09042, Monserrato, Cagliari, Italy
| | - Maria F Ruberto
- Internal Medicine and Haemocoagulopathies Unit, Azienda Ospedaliero Universitaria (A.O.U.), Presidio "Duilio Casula", University of Cagliari, SS 554, Bivio per Sestu, 09042, Monserrato, Cagliari, Italy
| | - Doris Barcellona
- Internal Medicine and Haemocoagulopathies Unit, Azienda Ospedaliero Universitaria (A.O.U.), Presidio "Duilio Casula", University of Cagliari, SS 554, Bivio per Sestu, 09042, Monserrato, Cagliari, Italy
| | - Francesco Marongiu
- Internal Medicine and Haemocoagulopathies Unit, Azienda Ospedaliero Universitaria (A.O.U.), Presidio "Duilio Casula", University of Cagliari, SS 554, Bivio per Sestu, 09042, Monserrato, Cagliari, Italy
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27
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Dhakal P, Rayamajhi S, Verma V, Gundabolu K, Bhatt VR. Reversal of Anticoagulation and Management of Bleeding in Patients on Anticoagulants. Clin Appl Thromb Hemost 2016; 23:410-415. [DOI: 10.1177/1076029616675970] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Bleeding is the most common complication of all anticoagulants. Any bleeding patient on an anticoagulant should be risk-stratified based on hemodynamic instability, source of bleeding, and degree of blood loss. Although minor bleed may be managed with discontinuation of anticoagulant, major bleed may require transfusion of blood products and use of specific antidote. The residual effects of each anticoagulant may be monitored with distinct coagulation assay. Intravenous or oral vitamin K can reverse the effect of warfarin within 24 to 48 hours and is indicated for any bleeding, international normalized ratio of >10 or 4.5 to 10 in patients with other risk factors for bleeding. Fresh frozen plasma or prothrombin complex concentrate (PCC) may be necessary in major bleeding related to warfarin. Protamine sulfate reverses the effect of unfractionated heparin completely and of low-molecular-weight heparin (LMWH) partially. Idarucizumab has recently been approved in United States for dabigatran reversal, whereas andexanet alfa is expected to get approved in the near future for reversal of oral factor Xa inhibitors. The PCC may reverse the effect of rivaroxaban to some extent, but no data are available regarding reversal of apixaban and edoxaban. Aripazine has shown promising results to reverse the effects of LMWH, fondaparinux, and direct oral anticoagulants but is still in the developmental phase.
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Affiliation(s)
- Prajwal Dhakal
- Department of Medicine, Michigan State University, East Lansing, MI, USA
| | - Supratik Rayamajhi
- Department of Medicine, Michigan State University, East Lansing, MI, USA
| | - Vivek Verma
- Department of Radiation Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Krishna Gundabolu
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Vijaya R. Bhatt
- Department of Internal Medicine, Division of Hematology-Oncology, University of Nebraska Medical Center, Omaha, NE, USA
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28
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Wang L, Xie Y, Pan H. Management of Major Bleeding Related to Novel Oral Anticoagulant Agents Use in Frail Elderly Adults. J Am Geriatr Soc 2016; 64:e105-e107. [PMID: 27685081 DOI: 10.1111/jgs.14400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Lihong Wang
- First Affiliated Hospital College of Medicine, University of Zhejiang, Zhejiang, China
| | - Yalin Xie
- Hangzhou Tumor Hospital, Zhejiang, China
| | - Huiyun Pan
- First Affiliated Hospital College of Medicine, University of Zhejiang, Zhejiang, China
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29
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Marino KK, Santiago RA, Dew RB, Berliner N, Connors JM, Connell NT, Tucker JK. Management of Dabigatran-Associated Bleeding with Two Doses of Idarucizumab Plus Hemodialysis. Pharmacotherapy 2016; 36:e160-e165. [DOI: 10.1002/phar.1830] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Kaylee K. Marino
- Department of Pharmacy; Brigham and Women's Faulkner Hospital; Jamaica Plain Massachusetts
| | - Raul A. Santiago
- Department of Pharmacy; Brigham and Women's Faulkner Hospital; Jamaica Plain Massachusetts
| | - Richard B. Dew
- Department of Pharmacy; Brigham and Women's Faulkner Hospital; Jamaica Plain Massachusetts
| | - Nancy Berliner
- Department of Medicine; Division of Hematology; Brigham and Women's Hospital; Boston Massachusetts
| | - Jean M. Connors
- Department of Medicine; Division of Hematology; Brigham and Women's Hospital; Boston Massachusetts
| | - Nathan T. Connell
- Department of Medicine; Division of Hematology; Brigham and Women's Hospital; Boston Massachusetts
| | - John Kevin Tucker
- Department of Medicine; Division of Nephrology; Brigham and Women's Faulkner Hospital; Jamaica Plain Massachusetts
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30
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Crapelli GB, Bianchi P, Isgrò G, Biondi A, de Vincentiis C, Ranucci M. A Case of Fatal Bleeding Following Emergency Surgery on an Ascending Aorta Intramural Hematoma in a Patient Taking Dabigatran. J Cardiothorac Vasc Anesth 2016; 30:1027-31. [DOI: 10.1053/j.jvca.2015.10.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Indexed: 01/16/2023]
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31
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Yogaratnam D, Ditch K, Medeiros K, Doyno C, Fong JJ. Idarucizumab for Reversal of Dabigatran-Associated Anticoagulation. Ann Pharmacother 2016; 50:847-54. [DOI: 10.1177/1060028016659504] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To review clinical data on idarucizumab for the reversal of dabigatran-associated anticoagulation. Data Sources: Articles for this review were identified via PubMed using the MeSH term dabigatran combined with the keyword idarucizumab. Additional online searches via PubMed and Google Scholar were conducted for both prescribing and cost information. Study Selection and Data Extraction: English-language clinical trials published between 1946 and May 2016 were included for review. Bibliographies of selected articles were also manually reviewed for relevant publications that focused on reversal strategies for dabigatran-associated anticoagulation. Data Synthesis: The safety and tolerability of idarucizumab has been evaluated in 3 phase I clinical trials. The use of idarucizumab for reversing dabigatran-associated anticoagulation is also being evaluated in the phase III RE-VERSE AD study. Interim results of the RE-VERSE AD study have been published. Conclusions: Idarucizumab rapidly neutralizes the anticoagulant effect of dabigatran in healthy volunteers, in patients with life-threatening bleeding, and in patients requiring urgent surgery that cannot be delayed. These observations are largely based on laboratory assessments rather than clinical outcomes. Idarucizumab is well tolerated, and it does not appear to induce procoagulant or immunogenic adverse effects.
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Affiliation(s)
- Dinesh Yogaratnam
- Massachusetts College of Pharmacy and Health Sciences University, Worcester, MA, USA
| | | | | | | | - Jeffrey J. Fong
- Massachusetts College of Pharmacy and Health Sciences University, Worcester, MA, USA
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32
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Sodha NR, Sellke FW. Reversal of Dabigatran with Idarucizumab. Expert Rev Cardiovasc Ther 2016; 14:889-93. [PMID: 27362456 DOI: 10.1080/14779072.2016.1203253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION The use of novel oral anticoagulants such as dabigatran has been increasing over the last five years. Indicated for use in the prevention of thromboembolic complications from non-valvular atrial fibrillation and for the treatment and prevention of venous thromboembolic disease, dabigatran is increasingly encountered clinically. Lack of an efficacious reversal agent has been a challenge for increased clinical 10 adoption, and for management of patients with bleeding complications while taking dabigatran, or those requiring urgent procedures while taking dabigatran. Idarucizumab, a monoclonal antibody fragment, has recently been approved for use to reverse anticoagulation with dabigatran in patients with serious bleeding. AREAS COVERED Herein we discuss the development and early clinical data evaluating the use of idarucizumab for dabigatran reversal. Expert commentary: Idarucizumab has been shown to be an efficacious reversal agent for patients receiving dabigatran. The drug provides a novel and clinically useful agent for patients with significant bleeding while receiving dabigatran, or those needing urgent invasive procedures.
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Affiliation(s)
- Neel R Sodha
- a Division of Cardiac Surgery, Alpert Medical School , Brown University , Providence , RI , USA
| | - Frank W Sellke
- a Division of Cardiac Surgery, Alpert Medical School , Brown University , Providence , RI , USA
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33
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Use of Continuous Renal Replacement Therapy for Removal of Dabigatran in a Patient in Need of Emergent Surgery. Case Rep Crit Care 2016; 2016:9692568. [PMID: 27313909 PMCID: PMC4899578 DOI: 10.1155/2016/9692568] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2016] [Revised: 04/22/2016] [Accepted: 04/28/2016] [Indexed: 01/07/2023] Open
Abstract
Purpose. To report the ability to remove serum dabigatran using continuous renal replacement therapy (CRRT) in a patient with life-threatening bleeding. Summary. A 77-year-old female with history of atrial fibrillation who takes dabigatran for stroke prevention presented with abdominal pain. Patient was found to have bleeding and possible mesenteric ischemia and was taken to the operating room and had continued bleeding postoperatively. CRRT was initiated for the removal of any remaining dabigatran, with serum dabigatran levels collected to evaluate removal of dabigatran with CRRT. This patient had an increased dabigatran level prior to intervention, which decreased to an undetectable level after use of CRRT. Greater than 80% of the drug was removed due to 4 hours of CRRT and residual kidney function. Reversal of dabigatran is an area of current research with recent FDA approval of idarucizumab for use. Conclusion. Bleeding may occur as a result of the use of dabigatran and change in patient's clinical condition. Use of CRRT may be an option in removing serum dabigatran in the case of a life-threatening bleed.
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Peetermans M, Pollack C, Reilly P, Liesenborghs L, Jacquemin M, Levy JH, Weitz JI, Verhamme P. Idarucizumab for dabigatran overdose. Clin Toxicol (Phila) 2016; 54:644-6. [DOI: 10.1080/15563650.2016.1187737] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Green B, Mendes RA, Van der Valk R, Brennan PA. Novel anticoagulants - an update on the latest developments and management for clinicians treating patients on these drugs. J Oral Pathol Med 2016; 45:551-6. [PMID: 27028407 DOI: 10.1111/jop.12441] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2016] [Indexed: 12/13/2022]
Abstract
There are several novel anticoagulant agents that are being increasingly used as an alternative to warfarin, with these drugs being reported to be at least as effective if not better. Their increased use means that oral care clinicians should have a sound understanding of the mechanism of action, pharmacology, reversal strategies and management of bleeding in patients taking these drugs. Surprisingly, there is little published in the current literature specific to professionals involved in oral health care. In this review, we provide an overview of these drugs and discuss the management of patients who need an oral procedure based on currently available literature and clinical trials.
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Affiliation(s)
- Ben Green
- Department of Gastroenterology, Torbay Hospital, Torquay, UK
| | - Rui Amaral Mendes
- Department of Oral and Maxillofacial Medicine and Diagnostic Sciences, School of Dental Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Ruben Van der Valk
- Department of Oral and Maxillofacial Surgery, Queen Alexandra Hospital, Portsmouth, UK
| | - Peter A Brennan
- Department of Oral and Maxillofacial Surgery, Queen Alexandra Hospital, Portsmouth, UK
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AlTurki A, Proietti R, Birnie DH, Essebag V. Management of antithrombotic therapy during cardiac implantable device surgery. J Arrhythm 2016; 32:163-9. [PMID: 27354859 PMCID: PMC4913137 DOI: 10.1016/j.joa.2015.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 12/03/2015] [Accepted: 12/08/2015] [Indexed: 01/10/2023] Open
Abstract
Anticoagulants are commonly used drugs that are frequently encountered during device placement. Deciding when to halt or continue the use of anticoagulants is a balance between the risks of thromboembolism versus bleeding. Patients taking warfarin with a high risk of thromboembolism should continue to take their warfarin without interruption during device placement while ensuring their international normalized ratio remains below 3. For patients who are taking warfarin and have low risk of thromboembolism, either interrupted or continued warfarin may be used, with no evidence to clearly support either strategy. There is little evidence to support continuing direct acting oral anticoagulants (DOACs) for device implantation. The timing of halting these medications depends largely on renal function. If bleeding occurs, warfarin׳s anticoagulation effect is reversible with vitamin K and activated prothrombin complex concentrate. There are no DOAC reversal agents currently available, but some are under development. Regarding antiplatelet agents, aspirin alone can be safely continued while clopidogrel alone may also be continued, but with a slightly higher bleeding risk. Dual antiplatelet therapy for bare-metal stent/drug-eluting stent implanted within 4 weeks/6 months, respectively, should be continued due to high risk of stent thrombosis; however, if they are implanted after this period, then clopidogrel can be halted 5 days before the procedure and resumed soon after, while aspirin is continued. If the patient is taking both aspirin and warfarin, aspirin should be halted 5 days prior to the procedure, while warfarin is continued.
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Affiliation(s)
- Ahmed AlTurki
- McGill University Health Center, Montreal, Quebec, Canada
| | - Riccardo Proietti
- McGill University Health Center, Montreal, Quebec, Canada; Cardiology Department, Luigi Sacco Hospital, Milan, Italy
| | - David H Birnie
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Vidal Essebag
- McGill University Health Center, Montreal, Quebec, Canada; Hôpital Sacré-Coeur de Montréal, Montreal, Quebec, Canada
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Affiliation(s)
- Kelly Byrne
- Department of Anesthesia, Waikato Hospital, Pennbroke Street, Hamilton, New Zealand.
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Thiele T, Kaftan H, Hosemann W, Greinacher A. Hemostatic management of patients undergoing ear-nose-throat surgery. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2015; 14:Doc07. [PMID: 26770281 PMCID: PMC4702056 DOI: 10.3205/cto000122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Perioperative hemostatic management is increasingly important in the field of otolaryngology. This review summarizes the key elements of perioperative risk stratification, thromboprophylaxis and therapies for bridging of antithrombotic treatment. It gives practical advice based on the current literature with focus on patients undergoing ENT surgery.
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Affiliation(s)
- Thomas Thiele
- Institute for Immunology and Transfusion Medicine, Section of Transfusion Medicine, University Medicine of Greifswald, Germany
| | - Holger Kaftan
- Department of Otolaryngology, Head & Neck Surgery, University Medicine of Greifswald, Germany
| | - Werner Hosemann
- Department of Otolaryngology, Head & Neck Surgery, University Medicine of Greifswald, Germany
| | - Andreas Greinacher
- Institute for Immunology and Transfusion Medicine, Section of Transfusion Medicine, University Medicine of Greifswald, Germany
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Awad NI, Brunetti L, Juurlink DN. Enhanced elimination of dabigatran through extracorporeal methods. J Med Toxicol 2015; 11:85-95. [PMID: 25448250 DOI: 10.1007/s13181-014-0448-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Several pharmacokinetic studies have suggested that dabigatran possesses a number of ideal properties for expedited removal via extracorporeal methods. However, this practice has not been prospectively evaluated in patients with life-threatening bleeding or requiring emergency surgery secondary to dabigatran-associated coagulopathy. The purpose of this literature review is to evaluate the published evidence surrounding extracorporeal removal of dabigatran in the setting of emergency surgery or life-threatening bleeding. A query of MEDLINE, Web of Science, International Pharmaceutical Abstracts, and Google Scholar using the terms dabigatran, dabigatran etexilate, hemodialysis, renal replacement therapy, hemorrhage, and atrial fibrillation was used to retrieve relevant literature. Furthermore, a manual search of the references of the identified literature was performed to capture additional data. Current evidence suggests that extracorporeal removal of dabigatran may play a role in the setting of life-threatening bleeding and emergent surgery. Conflicting evidence exists with regard to the potential for redistribution based on serum dabigatran concentrations. In addition, a number of practicalities must be considered before incorporating this technique in the clinical setting. Extracorporeal removal of dabigatran may be a treatment modality in selected patients who require emergency reversal.
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Affiliation(s)
- Nadia I Awad
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, 160 Frelinghuysen Road, Room 423, Piscataway, NJ, USA,
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Prothrombin Complex Concentrate Is Effective in Treating the Anticoagulant Effects of Dabigatran in a Porcine Polytrauma Model. Anesthesiology 2015; 123:1350-61. [DOI: 10.1097/aln.0000000000000863] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Abstract
Background
In the event of trauma, emergency reversal of anticoagulation therapy may be required. However, no specific reversal agents are routinely available for the direct oral anticoagulants such as dabigatran. The authors investigated four-factor prothrombin complex concentrate (PCC) for treating dabigatran-induced anticoagulation in a porcine polytrauma model.
Methods
Dabigatran etexilate was given orally for 3 days and intravenously on day 4 to 32 pigs. Animals were randomized 1:1:1:1 to PCC (25, 50, or 100 U/kg) or saline. Study medication was administered 12 min after bilateral femur fractures and blunt liver injury. The primary endpoint was blood loss at 300 min.
Results
The mean plasma concentration of dabigatran was 487 ± 161 ng/ml after intravenous administration. Blood loss was 3,855 ± 258 ml in controls and 3,588 ± 241 ml in the PCC25 group. In the PCC50 and PCC100 groups, blood loss was significantly lower: 1,749 ± 47 ml and 1,692 ± 97 ml, respectively. PCC50 and PCC100 effectively reduced dabigatran’s effects on coagulation parameters, whereas control and (to a lesser extent) PCC25 animals developed severe coagulopathy. Sustained increases in endogenous thrombin potential occurred with PCC50 and PCC100.
Conclusion
Four-factor PCC (50 or 100 U/kg) is effective in reducing blood loss in dabigatran-anticoagulated pigs, but higher doses may induce a procoagulant state.
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Elad S, Marshall J, Meyerowitz C, Connolly G. Novel anticoagulants: general overview and practical considerations for dental practitioners. Oral Dis 2015; 22:23-32. [DOI: 10.1111/odi.12371] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Revised: 08/20/2015] [Accepted: 09/05/2015] [Indexed: 11/28/2022]
Affiliation(s)
- S Elad
- Division of Oral Medicine; Eastman Institute for Oral Health; University of Rochester Medical Center; Rochester NY USA
- Wilmot Cancer Center; Strong Memorial Hospital; University of Rochester Medical Center; Rochester NY USA
| | - J Marshall
- Division of Oral Medicine; Eastman Institute for Oral Health; University of Rochester Medical Center; Rochester NY USA
| | - C Meyerowitz
- Division of Oral Medicine; Eastman Institute for Oral Health; University of Rochester Medical Center; Rochester NY USA
- Division of General Dentistry; Eastman Institute for Oral Health; University of Rochester Medical Center; Rochester NY USA
| | - G Connolly
- Division of Hematology/Oncology; Department of Medicine; University of Rochester Medical Center; Wilmot Cancer Center; Rochester NY USA
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Sarma A, Giugliano RP. Current and developing strategies for monitoring and reversing direct oral anticoagulants in patients with non-valvular atrial fibrillation. Hosp Pract (1995) 2015; 43:258-67. [PMID: 26559852 DOI: 10.1080/21548331.2015.1103190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE In light of the increasing clinical utilization of the direct oral anticoagulants (DOACs) among patients with non-valvular atrial fibrillation, this review evaluates strategies for monitoring and reversing the anticoagulant effect of these agents. METHODS We summarize the data currently available for laboratory monitoring and reversal of DOACs. Relevant literature was identified using search terms pertaining to oral anticoagulants, reversal agents, and laboratory monitoring using Pubmed, clinicaltrials.gov, and abstracts from recent major cardiovascular meetings. RESULTS Significant user appeal for the DOACs stems from the reliable pharmacokinetics of these agents, which render routine laboratory monitoring unnecessary for general use, as well as lower rates of bleeding as compared to warfarin. However, readily available laboratory tests have not been clinically validated for use with these agents. The ability to measure the anticoagulant effect of a DOAC in selected situations (e.g. serious bleeding, overanticoagulation, emergent procedures, and compliance monitoring) remains an unmet clinical need. Further, there is a paucity of data to guide treatment in patients receiving DOACs who experience a serious hemorrhage. CONCLUSION While evidence-based recommendations cannot be definitively provided for management of DOAC-related bleeding events at present, several targeted reversal agents are currently in development, and hold promise for solving this important clinical problem.
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Affiliation(s)
- Amy Sarma
- a Cardiology Division , Massachusetts General Hospital , Boston , MA , USA
| | - Robert P Giugliano
- b Department of Medicine, Cardiovascular Division , Brigham and Women's Hospital , Boston , MA , USA.,c TIMI Study Group, Cardiovascular Medicine , Brigham and Women's Hospital , Boston , MA , USA
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Liesenfeld KH, Gruenenfelder F, Clemens A. Enhanced elimination of dabigatran: Identifying the appropriate patient for the use of continuous venovenous hemodialysis instead of intermittent hemodialysis-A simulation analysis. J Clin Pharmacol 2015; 56:597-608. [DOI: 10.1002/jcph.620] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 08/10/2015] [Indexed: 01/01/2023]
Affiliation(s)
- Karl-Heinz Liesenfeld
- Corporate Division Medicine; Translational Medicine and Clinical Pharmacology, Boehringer Ingelheim Pharma GmbH & Co. KG; Biberach Germany
| | - Fredrik Gruenenfelder
- Corporate Division Medicine; TA Cardiology, Boehringer Ingelheim Pharma GmbH & Co. KG; Ingelheim Germany
| | - Andreas Clemens
- The Center for Thrombosis and Hemostasis; University Medical Center Mainz; Mainz Germany
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DeNino WF, Carter CB, Sievert A, Goss A, Toole JM, Mukherjee R, Uber WE. The effect of ultrafiltration with cardiopulmonary bypass on the removal of dabigatran from the circulation of adult pigs. Perfusion 2015; 31:424-30. [DOI: 10.1177/0267659115614640] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Dabigatran etexilate is a direct thrombin inhibitor approved for use in patients with non-valvular atrial fibrillation. There is no currently available pharmacological therapy to reverse this renally cleared anticoagulant. Dabigatran has a low level of plasma protein binding and has been considered dialyzable. We used a pig model with renal artery ligation to exclude intrinsic drug excretion to examine the efficacy of ultrafiltration (UF) during cardiopulmonary bypass (CPB) for dabigatran removal. Method: Dabigatran was intravenously infused (20 mg) in Yorkshire pigs (male, n=7, 70±1 kg) following renal artery ligation. CPB with UF was initiated after heparinization and continued until a total volume of 6 liters of UF effluent was removed. Serial labs, including dabigatran concentration, activated coagulation times (ACT), hematocrit and creatinine were drawn at intervals before the start of CPB and then incrementally during UF (0, 2, 4 and 6 L removed). Hemodialysis (HD) was performed on one animal following UF. Results: Dabigatran concentration (ng/mL) rose from undetectable levels at baseline to 296±70 (p<0.05) at the conclusion of infusion, but dropped significantly upon administration of heparin (178±40, p<0.05). A further decrement in dabigatran concentration was observed from the administration of heparin to the start of CPB (to 135±28, p<0.05). Once on CPB, dabigatran remained stable, with the end UF (eUF) dabigatran concentration being 133±34. Dabigatran concentration in the UF effluent was measured in one animal and was 98.8, with 6 L of effluent having been removed. The total recovery of dabigatran was calculated to be less than 5%. Dabigatran concentrations also did not decrease appreciably with HD on CPB following UF. Conclusions: UF in conjunction with CPB was ineffective at removing dabigatran. Heparin demonstrated a dabigatran-lowering effect, suggesting a possible drug interaction or assay impairment. Based on these findings, emergent cardiac surgery with UF on cardiopulmonary bypass to remove dabigatran is not advisable. Alternative forms of drug removal or reversal must be identified.
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Affiliation(s)
- Walter F. DeNino
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, USA
| | | | - Alicia Sievert
- Perfusion Services, Medical University of South Carolina, Charleston, SC, USA
| | - Ashley Goss
- Boehringer-Ingelheim Inc., Ridgefield, CT, UK
| | - John M. Toole
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Rupak Mukherjee
- Division of Cardiothoracic Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Walter E. Uber
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC, USA
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Comparison of novel oral anticoagulants versus vitamin K antagonists in patients with chronic kidney disease. Curr Opin Nephrol Hypertens 2015; 24:183-92. [PMID: 25636144 DOI: 10.1097/mnh.0000000000000098] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
PURPOSE OF REVIEW Novel oral anticoagulants (NOACs) including apixaban, dabigatran and rivaroxaban have been approved by international regulatory agencies to prevent venous thromboembolism as well as treat atrial fibrillation and venous thromboembolism in individuals with chronic kidney disease (CKD). However, alterations in their metabolism in the setting of CKD may impact their efficacy and lead to an increased risk of bleeding. This review summarizes the current literature on the efficacy and safety of these agents in individuals with moderate CKD. RECENT FINDINGS In clinical trials, the use of the NOACs in patients with moderate CKD has demonstrated efficacy and safety similar to those seen with vitamin K antagonists. However, no universal reversal agent for the anticoagulant effect of the NOACs exists in the setting of bleeding. Limited data have demonstrated that hemodialysis has been effectively used to aid in reversing the effects of dabigatran, and the use of prothrombin complex concentrate has also been used for serious and major adverse bleeding events with some success. SUMMARY As the use of the NOACs in patients with CKD increases, it will be important to monitor their safety, and clinicians who prescribe them should carefully monitor kidney function and recognize the potential for adverse effects.
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King AE, Szarlej DK, Rincon F. Dabigatran-Associated Intracranial Hemorrhage: Literature Review and Institutional Experience. Neurohospitalist 2015; 5:234-44. [PMID: 26425251 PMCID: PMC4572378 DOI: 10.1177/1941874415569069] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Dabigatran etexilate is an oral direct thrombin inhibitor approved for prevention of stroke and systemic embolization in patients with nonvalvular atrial fibrillation and for the treatment of venous thromboembolism. Although dabigatran has a favorable safety profile, predictable pharmacokinetics, fewer drug interactions than warfarin, and does not require monitoring, clinical data regarding dabigatran reversal are limited. In addition, currently available laboratory assays allow measurement of the presence, but not extent, of dabigatran-associated anticoagulation. Patient age, renal function, weight, concurrent drug therapy, adherence, and concomitant disease states can affect dabigatran's efficacy and safety. Management of dabigatran-related intracranial hemorrhage must be approached on a case-by-case basis and include assessment of degree of anticoagulation, severity of hemorrhage, renal function, timing of last dabigatran dose, and risk of thromboembolic events. Initial management includes dabigatran discontinuation and general supportive measures. Oral activated charcoal should be administered in those who ingested dabigatran within 2 hours. Four-factor prothrombin complex concentrates (4PCCs), activated PCC, or recombinant activated factor VII use may be reasonable but is not evidence based. Reserve fresh frozen plasma for patients with dilutional coagulopathy. If readily available, hemodialysis should be considered, particularly in patients with advanced kidney injury or excessive risk of thromboembolic events. More clinical studies are needed to determine a standardized approach to treating dabigatran-associated intracranial hemorrhage. Institutional protocol development will facilitate safe, efficacious, and timely use of the limited management options.
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Affiliation(s)
- Amber E. King
- Department of Pharmacy Practice, Thomas Jefferson University, Jefferson School of Pharmacy, Philadelphia, PA, USA
| | - Dorota K. Szarlej
- Department of Pharmacy, Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Fred Rincon
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson College of Medicine, Philadelphia, PA, USA
- Division of Critical Care and Neurotrauma, Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
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Chai-Adisaksopha C, Hillis C, Lim W, Boonyawat K, Moffat K, Crowther M. Hemodialysis for the treatment of dabigatran-associated bleeding: a case report and systematic review. J Thromb Haemost 2015; 13:1790-8. [PMID: 26270886 DOI: 10.1111/jth.13117] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 08/02/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Dabigatran, a direct thrombin inhibitor, is effective for the treatment of venous thromboembolism and the prevention of stroke and systemic embolism resulting from atrial fibrillation. The most effective way of reversing the anticoagulant effect of dabigatran in patients who have bleeding complications is unknown. OBJECTIVES To document the clinical outcomes of patients undergoing renal replacement therapy (RRT) for dabigatran-associated bleeding. METHODS We searched MEDLINE and EMBASE up to May 2015. Articles were selected if the patients presented with dabigatran-associated bleeding, underwent RRT for dabigatran removal, and reported an effect on bleeding. RESULTS The search yielded 22 studies representing 35 unique patient cases. The median patient age was 74.1 years (range, 56-94 years). Thirteen patients (37.1%) were female, and 32 (91.4%) patients received dabigatran for atrial fibrillation. Twenty-three patients (65.7%) underwent intermittent hemodialysis, 10 patients (28.6%) underwent continuous RRT (CRRT), and two patients underwent both intermittent hemodialysis and CRRT. Following RRT, there were significant reductions in dabigatran concentrations (P = 0.001). Rebound of the dabigatran concentration was reported in 12 (57.1%) patients following cessation of RRT. Hemostasis was reportedly achieved in 24 patients (70.6%), and 10 patients (29.4%) died because of bleeding. CONCLUSIONS In patients with dabigatran-associated bleeding, RRT appears to be effective in reducing dabigatran concentrations, and in case reports this has been associated with a reduction in the duration and/or severity of bleeding. However, a rebound in concentrations may be seen following withdrawal of RRT, suggesting that a prolonged course of RRT may be more effective.
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Affiliation(s)
- C Chai-Adisaksopha
- Department of Internal Medicine, Chiang Mai University, Chiang Mai, Thailand
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
| | - C Hillis
- Department of Oncology, McMaster University, Hamilton, ON, Canada
| | - W Lim
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - K Boonyawat
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - K Moffat
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - M Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada
- Hamilton Regional Laboratory Medicine Program, McMaster University, Hamilton, ON, Canada
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON, Canada
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Normalization of Activated Partial Thromboplastin Time Correlates with Low Levels of Dabigatran in a Patient with Severe Sepsis. Case Rep Crit Care 2015. [PMID: 26221544 PMCID: PMC4499610 DOI: 10.1155/2015/137504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The oral anticoagulant dabigatran etexilate can be a challenge when patients need acute surgery. Sepsis and acute renal failure exacerbate the anticoagulant effect. There is no specific reversal agent for dabigatran etexilate, but it can be removed by hemodialysis. We present a case where a patient treated with dabigatran etexilate was admitted to intensive care unit with severe sepsis and acute renal failure and in need of bilateral lower limp amputation due to ischemia. The patient had severe coagulopathy and was treated with continuous venovenous hemofiltration in attempt to remove dabigatran etexilate before surgery.
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