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De Simone B, Chouillard E, Podda M, Pararas N, de Carvalho Duarte G, Fugazzola P, Birindelli A, Coccolini F, Polistena A, Sibilla MG, Kruger V, Fraga GP, Montori G, Russo E, Pintar T, Ansaloni L, Avenia N, Di Saverio S, Leppäniemi A, Lauretta A, Sartelli M, Puzziello A, Carcoforo P, Agnoletti V, Bissoni L, Isik A, Kluger Y, Moore EE, Romeo OM, Abu-Zidan FM, Beka SG, Weber DG, Tan ECTH, Paolillo C, Cui Y, Kim F, Picetti E, Di Carlo I, Toro A, Sganga G, Sganga F, Testini M, Di Meo G, Kirkpatrick AW, Marzi I, déAngelis N, Kelly MD, Wani I, Sakakushev B, Bala M, Bonavina L, Galante JM, Shelat VG, Cobianchi L, Mas FD, Pikoulis M, Damaskos D, Coimbra R, Dhesi J, Hoffman MR, Stahel PF, Maier RV, Litvin A, Latifi R, Biffl WL, Catena F. The 2023 WSES guidelines on the management of trauma in elderly and frail patients. World J Emerg Surg 2024; 19:18. [PMID: 38816766 PMCID: PMC11140935 DOI: 10.1186/s13017-024-00537-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/26/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND The trauma mortality rate is higher in the elderly compared with younger patients. Ageing is associated with physiological changes in multiple systems and correlated with frailty. Frailty is a risk factor for mortality in elderly trauma patients. We aim to provide evidence-based guidelines for the management of geriatric trauma patients to improve it and reduce futile procedures. METHODS Six working groups of expert acute care and trauma surgeons reviewed extensively the literature according to the topic and the PICO question assigned. Statements and recommendations were assessed according to the GRADE methodology and approved by a consensus of experts in the field at the 10th international congress of the WSES in 2023. RESULTS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage, including drug history, frailty assessment, nutritional status, and early activation of trauma protocol to improve outcomes. Acute trauma pain in the elderly has to be managed in a multimodal analgesic approach, to avoid side effects of opioid use. Antibiotic prophylaxis is recommended in penetrating (abdominal, thoracic) trauma, in severely burned and in open fractures elderly patients to decrease septic complications. Antibiotics are not recommended in blunt trauma in the absence of signs of sepsis and septic shock. Venous thromboembolism prophylaxis with LMWH or UFH should be administrated as soon as possible in high and moderate-risk elderly trauma patients according to the renal function, weight of the patient and bleeding risk. A palliative care team should be involved as soon as possible to discuss the end of life in a multidisciplinary approach considering the patient's directives, family feelings and representatives' desires, and all decisions should be shared. CONCLUSIONS The management of elderly trauma patients requires knowledge of ageing physiology, a focused triage based on assessing frailty and early activation of trauma protocol to improve outcomes. Geriatric Intensive Care Units are needed to care for elderly and frail trauma patients in a multidisciplinary approach to decrease mortality and improve outcomes.
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Affiliation(s)
- Belinda De Simone
- Department of Emergency Minimally Invasive Surgery, Academic Hospital of Villeneuve St Georges, Villeneuve St Georges, France.
- Department of General Minimally Invasive Surgery, Infermi Hospital, AUSL Romagna, Rimini, Italy.
- General Surgery Department, American Hospital of Paris, Paris, France.
| | - Elie Chouillard
- General Surgery Department, American Hospital of Paris, Paris, France
| | - Mauro Podda
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | - Nikolaos Pararas
- 3rd Department of Surgery, Attikon General Hospital, National and Kapodistrian University of Athens (NKUA), Athens, Greece
| | | | - Paola Fugazzola
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
| | | | | | - Andrea Polistena
- Department of Surgery, Policlinico Umberto I Roma, Sapienza University, Rome, Italy
| | - Maria Grazia Sibilla
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vitor Kruger
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Gustavo P Fraga
- Division of Trauma Surgery, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - Giulia Montori
- Unit of General and Emergency Surgery, Vittorio Veneto Hospital, Via C. Forlanini 71, 31029, Vittorio Veneto, TV, Italy
| | - Emanuele Russo
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Tadeja Pintar
- UMC Ljubljana and Medical Faculty Ljubljana, Ljubljana, Slovenia
| | - Luca Ansaloni
- New Zealand Blood Service, Christchurch, New Zealand
| | - Nicola Avenia
- Endocrine Surgical Unit - University of Perugia, Terni, Italy
| | - Salomone Di Saverio
- General Surgery Unit, Madonna del Soccorso Hospital, AST Ascoli Piceno, San Benedetto del Tronto, Italy
| | - Ari Leppäniemi
- Division of Emergency Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Andrea Lauretta
- Department of Surgical Oncology, Centro Di Riferimento Oncologico Di Aviano IRCCS, Aviano, Italy
| | - Massimo Sartelli
- Department of General Surgery, Macerata Hospital, Macerata, Italy
| | - Alessandro Puzziello
- Dipartimento di Medicina, Chirurgia e Odontoiatria, Campus Universitario di Baronissi (SA) - Università di Salerno, AOU San Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Paolo Carcoforo
- Department of Surgery, Unit of General Surgery, University Hospital of Ferrara and University of Ferrara, Ferrara, Italy
| | - Vanni Agnoletti
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Luca Bissoni
- Department of Anesthesia, Level I, Trauma Center, Bufalini Hospital, Cesena, Italy
| | - Arda Isik
- Istanbul Medeniyet University, Istanbul, Turkey
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Ernest E Moore
- Ernest E Moore Shock Trauma Center at Denver Health, University of Colorado, Denver, CO, USA
| | - Oreste Marco Romeo
- Bronson Methodist Hospital/Western Michigan University, Kalamazoo, MI, USA
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al‑Ain, United Arab Emirates
| | | | - Dieter G Weber
- Department of General Surgery, Royal Perth Hospital and The University of Western Australia, Perth, Australia
| | - Edward C T H Tan
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ciro Paolillo
- Emergency Department, Ospedale Civile Maggiore, Verona, Italy
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Fernando Kim
- University of Colorado Anschutz Medical Campus, Denver, CO, 80246, USA
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Isidoro Di Carlo
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Adriana Toro
- Department of Surgical Sciences and Advanced Technologies, General Surgery Cannizzaro Hospital, University of Catania, Catania, Italy
| | - Gabriele Sganga
- Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University, Rome, Italy
| | - Federica Sganga
- Department of Geriatrics, Ospedale Sant'Anna, Ferrara, Italy
| | - Mario Testini
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Giovanna Di Meo
- Department of Precision and Regenerative Medicine and Ionian Area, Unit of Academic General Surgery, University of Bari "A. Moro", Bari, Italy
| | - Andrew W Kirkpatrick
- Departments of Surgery and Critical Care Medicine, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Frankfurt, Germany
| | - Nicola déAngelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | | | - Imtiaz Wani
- Department of Surgery, Government Gousia Hospital, DHS, Srinagar, India
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Miklosh Bala
- Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Luigi Bonavina
- Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Joseph M Galante
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of California Davis, Sacramento, CA, USA
| | - Vishal G Shelat
- Department of General Surgery, Tan Tock Seng Hospital, Novena, Singapore
| | - Lorenzo Cobianchi
- Unit of General Surgery I, IRCCS San Matteo Hospital of Pavia, University of Pavia, Pavia, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Francesca Dal Mas
- Department of Management, Ca' Foscari University of Venice, Venice, Italy
- Collegium Medicum, University of Social Sciences, Łodz, Poland
| | - Manos Pikoulis
- Department of Surgical Science, Unit of Emergency Surgery, University of Cagliari, Cagliari, Italy
| | | | - Raul Coimbra
- Riverside University Health System Medical Center, Riverside, CA, USA
| | - Jugdeep Dhesi
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Melissa Red Hoffman
- Department of Surgery, University of North Carolina, Surgical Palliative Care Society, Asheville, NC, USA
| | - Philip F Stahel
- Department of Surgery, Brody School of Medicine, East Carolina University, Greenville, NC, USA
| | - Ronald V Maier
- Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - Andrey Litvin
- Department of Surgical Diseases No. 3, Gomel State Medical University, University Clinic, Gomel, Belarus
| | - Rifat Latifi
- University of Arizona, Tucson, AZ, USA
- Abrazo Health West Campus, Goodyear, Tucson, AZ, USA
| | - Walter L Biffl
- Division of Trauma/Acute Care Surgery, Scripps Clinic Medical Group, La Jolla, CA, USA
| | - Fausto Catena
- Department of General and Emergency Surgery, Bufalini Hospital-Level 1 Trauma Center, AUSL Romagna, Cesena, Italy
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2
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Mangion K, Vella K, Gatt A, Vella AM, Borg M, Borg-Aquilina D, Douxfils J, Camilleri L, Riva N. A comparative in vitro study of the anticoagulant effect of branded versus generic rivaroxaban. Thromb Res 2024; 235:41-51. [PMID: 38295600 DOI: 10.1016/j.thromres.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 12/04/2023] [Accepted: 01/22/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Several generic formulations of rivaroxaban were recently marketed to be used interchangeably with their branded equivalent. However, there have been no previously published studies that directly compared the in vitro anticoagulant effect of branded vs. generic rivaroxaban. The aim of this in vitro study was to compare the effects of three raw rivaroxaban materials, obtained from the branded (Xarelto®) and two generic (Rivarolto® and Rivaroxaban Sandoz®) rivaroxaban formulations on an array of coagulation assays. METHODS A pool of normal plasma was spiked with several concentrations of the three rivaroxaban (range 50-750 ng/ml). The concentrations were assessed with a rivaroxaban calibrated anti-Xa assay and confirmed by ultra-high-performance liquid chromatography-mass spectrometry coupled with tandem mass spectrometry (UHPLC-MS/MS). The following assays were performed: Prothrombin time (PT), activated Partial Thromboplastin time (aPTT), Diluted Russell's Viper Venom Test (dRVVT), Thrombin time (TT), Clauss Fibrinogen, Factor VII, VIII and IX assays, and thromboelastography. RESULTS The results obtained by the three rivaroxaban at similar concentrations were comparable. Increasing concentrations of the three rivaroxaban showed a strong positive correlation with the PT, aPTT and dRVVT assays (r > 0.95, p < 0.01 for all), and a strong negative correlation with the Factors assays (r < -0.95, p < 0.01 for all). TT and Clauss Fibrinogen were not affected by rivaroxaban. No significant difference was identified in the mean assays' results obtained by the three rivaroxaban. CONCLUSION This study showed that the branded and generic rivaroxaban exert an identical in vitro anticoagulant effect across a wide range of concentrations.
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Affiliation(s)
- Karl Mangion
- Department of Applied Biomedical Science, Faculty of Health Sciences, University of Malta, Msida, Malta.
| | - Kevin Vella
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta.
| | - Alex Gatt
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta; Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.
| | - Amy Marie Vella
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta.
| | - Marica Borg
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta.
| | - Denise Borg-Aquilina
- National Blood Transfusion Service & Mater Dei Hospital Blood Bank, Msida, Malta.
| | - Jonathan Douxfils
- University of Namur, Faculty of Medicine, Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium; Qualiblood s.a., Qualiclinics, Namur, Belgium.
| | - Liberato Camilleri
- Department of Statistics & Operations Research, Faculty of Science, University of Malta, Msida, Malta.
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.
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Divsalar B, Kalantari T, Mohebbi S, Bahmanimehr A, Shahsavani A, Borhani-Haghighi A. Comparison of Commercial Low Molecular Weight Heparin and Homemade Anti-Xa Calibrators to a Commercial Specific Anti-Xa Calibrator for Plasma Rivaroxaban Quantification by Anti-Xa Oral Anticoagulant Plasma Concentration Chromogenic Assay. Lab Med 2022. [DOI: 10.1093/labmed/lmac137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Abstract
Objective
The main concern about measuring the concentration of rivaroxaban by anti-Xa assay in some laboratories is the lack of a commercial specific calibrator in emergencies. Therefore, this study aimed at providing a homemade anti-Xa calibrator and commercial low molecular weight heparin (LMWH) anti-Xa calibrator.
Methods
The anti-Xa plasma concentration of rivaroxaban was measured in 70 patients using a commercial specific anti-Xa calibrator, a commercial LMWH anti-Xa calibrator, and a homemade anti-Xa calibrator.
Results
We demonstrated a significant correlation and agreement (P < .001) between LMWH-calibrated anti-Xa and the commercial specific calibrator. A significant correlation (P < .001) was found between homemade calibrated anti-Xa made by normal pooled plasma and that calibrated with a commercial specific drug. The nonspecific homemade and LMWH calibrators had excellent agreement (P < .001) and can be used interchangeably.
Conclusion
Our data showed that for estimating rivaroxaban concentrations, the LMWH calibrator could be used as an alternative calibrator in the anti-Xa assay.
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Affiliation(s)
- Bita Divsalar
- Division of Hematology and Blood Banking, Department of Laboratory Sciences, School of Paramedical Sciences, Shiraz University of Medical Sciences , Shiraz , Iran
- Diagnostic Laboratory Sciences and Technology Research Center, School of Paramedical Sciences, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Tahereh Kalantari
- Division of Hematology and Blood Banking, Department of Laboratory Sciences, School of Paramedical Sciences, Shiraz University of Medical Sciences , Shiraz , Iran
- Diagnostic Laboratory Sciences and Technology Research Center, School of Paramedical Sciences, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Soheila Mohebbi
- Division of Hematology and Blood Banking, Department of Laboratory Sciences, School of Paramedical Sciences, Shiraz University of Medical Sciences , Shiraz , Iran
- Diagnostic Laboratory Sciences and Technology Research Center, School of Paramedical Sciences, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Ardeshir Bahmanimehr
- Thalassemia and Hemophilia Genetic, PND Research Center, Dastgheib Hospital, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Amin Shahsavani
- Thalassemia and Hemophilia Genetic, PND Research Center, Dastgheib Hospital, Shiraz University of Medical Sciences , Shiraz , Iran
- Hematology Research Center, Shiraz University of Medical Sciences , Shiraz , Iran
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4
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Ghodsi A, Etemad L, Dadpour B, Mostafazadeh B, Moshiri M. Conservative management of massive rivaroxaban overdose: A case report and literature review. Clin Case Rep 2021; 9:e05023. [PMID: 34765205 PMCID: PMC8572343 DOI: 10.1002/ccr3.5023] [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: 08/13/2021] [Revised: 09/23/2021] [Accepted: 10/08/2021] [Indexed: 11/12/2022] Open
Abstract
In the cases of acute rivaroxaban overdose, conservative management without prothrombin complex concentrate or other coagulation factors may be sufficient if renal function is normal and there is no bleeding.
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Affiliation(s)
- Alireza Ghodsi
- Student Research CommitteeFaculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Leila Etemad
- Pharmaceutical Research CenterPharmaceutical Technology InstituteMashhad University of Medical SciencesMashhadIran
| | - Bita Dadpour
- Medical Toxicology Research Center, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
| | - Babak Mostafazadeh
- Toxicological Research CenterShahid Beheshti University of Medical SciencesTehranIran
- Department of Forensic Medicine and ToxicologyFaculty of MedicineShahid Beheshti University of Medical SciencesTehranIran
| | - Mohammad Moshiri
- Medical Toxicology Research Center, Faculty of MedicineMashhad University of Medical SciencesMashhadIran
- Department of Clinical Toxicology and PoisoningFaculty of MedicineImam Reza (p) HospitalMashhad University of Medical SciencesMashhadIran
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Lin S, Hoffman R, Nabriski O, Moreinos D, Dummer PMH. Management of patients receiving novel antithrombotic treatment in endodontic practice: Review and clinical recommendations. Int Endod J 2021; 54:1754-1768. [PMID: 33894015 DOI: 10.1111/iej.13533] [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: 03/13/2020] [Accepted: 04/19/2021] [Indexed: 11/27/2022]
Abstract
Cardiovascular diseases are a major component of non-communicable diseases and death, with thrombosis constituting the most common underlying pathosis of the three major cardiovascular disorders: ischaemic heart disease (acute coronary syndrome), stroke and venous thromboembolism (VTE). The introduction of direct oral anticoagulants (DOACs) in recent years has necessitated a more complex approach to periprocedural and perioperative anticoagulation management and the need for revised management strategies and protocols. Currently, patients taking classic oral anticoagulants are advised to stop taking the drugs and have their INR values checked 72 h prior to dental surgery (e.g., apical surgery, tooth extraction, and periodontal surgery) and checked again 24 h prior to the procedure to ensure it is within the therapeutic range. However, the current incorporation of these novel DOACs in routine medical practice requires changes in the way patients are managed preoperatively in dentistry, and specifically in endodontic surgery. The methodology applied in this review included searching for relevant articles in the PubMed database using keywords listed in the Entree Terms databases. Articles published on human blood clotting mechanism, antithrombotic drugs, as well as treatment guidelines and recommendations for dentistry were retrieved. In addition, textbooks and guidelines that may not have surfaced in the online search were searched manually. The aim of this paper was to review the mechanisms of action of classic and novel antithrombotic medications and their impact on endodontic treatment and the management of local haemostasis in endodontics.
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Affiliation(s)
- Shaul Lin
- Department of Endodontic, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,The Israeli National Center for Trauma & Emergency Medicine Research, Gertner Institute, Tel Hashomer, Israel
| | - Ron Hoffman
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel.,Department of Hematology, Rambam Health Care Campus, Haifa, Israel
| | - Omri Nabriski
- Department of Endodontic, Rambam Health Care Campus, Haifa, Israel
| | - Daniel Moreinos
- Department of Endodontic, Rambam Health Care Campus, Haifa, Israel.,The Ruth and Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Paul M H Dummer
- School of Dentistry, College of Biomedical Sciences and Life Sciences, Cardiff University, Cardiff, UK
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Wu X, Wang L, Peng Y, Wu F, Cao J, Chen X, Wu W, Yang H, Xing M, Zhu Y, Shi Y, Zhuang S. Quantitative analysis of direct oral anticoagulant rivaroxaban by terahertz spectroscopy. Analyst 2020; 145:3909-3915. [PMID: 32301471 DOI: 10.1039/d0an00268b] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Rivaroxaban, as a direct oral anticoagulant, has been widely used in the treatment and prevention of thrombosis disease (TD). However, even if the same dose of rivaroxaban is taken, different pathophysiological characteristics of TD patients determine the differences in plasma concentrations between individuals, leading to the difficulties of dosage selection and plasma concentration control. Conventional rivaroxaban detection methods, including prothrombin time method, anti-Xa assay and liquid chromatography-tandem mass spectrometry (LC-MS/MS), are not widely used in clinical practice due to the limitations of accuracy, speed and cost. Here, we present a simple quantitative detection method for rivaroxaban by terahertz (THz) spectroscopy. Combining density functional theory (DFT) method and THz spectroscopy, the THz absorption peaks of rivaroxaban and the corresponding low-frequency vibrational modes are studied theoretically and experimentally. We find linear relationships between the amplitudes of these characteristic peaks and the concentrations of rivaroxaban. Based on these linear functions, we can analyse the rivaroxaban concentration with a detection time of 1 minute per test and the lowest detection limit of 2 μmol mL-1. As compared to Raman spectroscopy method (its detection limit is about 80 μmol mL-1), our method has more potential and is practical for the clinical quantitative detection of rivaroxaban as well as other direct oral anticoagulants.
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Affiliation(s)
- Xu Wu
- Terahertz Technology Innovation Research Institute, Shanghai Key Lab of Modern Optical System, Terahertz Science Cooperative Innovation Center, University of Shanghai for Science and Technology, Shanghai, P. R. China.
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7
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Kim B, Jang S, Lee YJ, Park N, Cho YU, Park CJ. The rivaroxaban-adjusted normalized ratio: use of the prothrombin time to monitor the therapeutic effect of rivaroxaban. Br J Biomed Sci 2019; 76:122-128. [DOI: 10.1080/09674845.2019.1605648] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- B Kim
- Department of Laboratory Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Republic of Korea (South Korea)
| | - S Jang
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea (South Korea)
- Asan Clinical Research Center, Seoul, Republic of Korea (South Korea)
| | - YJ Lee
- Asan Clinical Research Center, Seoul, Republic of Korea (South Korea)
| | - N Park
- Asan Clinical Research Center, Seoul, Republic of Korea (South Korea)
| | - YU Cho
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea (South Korea)
| | - CJ Park
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea (South Korea)
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8
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Bae J, Kim H, Kim W, Kim S, Park J, Jung DI, Yu D. Therapeutic monitoring of rivaroxaban in dogs using thromboelastography and prothrombin time. J Vet Intern Med 2019; 33:1322-1330. [PMID: 30859645 PMCID: PMC6524124 DOI: 10.1111/jvim.15478] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 02/26/2019] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND The chromogenic anti-Xa assay, the gold standard for monitoring the anti-Xa effect of rivaroxaban, is not available as a cage-side diagnostic test for use in a clinical setting. HYPOTHESIS/OBJECTIVES To evaluate clinical modalities for measuring the anticoagulant effects of rivaroxaban using a point-of-care prothrombin time (PT) and thromboelastography (TEG). ANIMALS Six healthy Beagle dogs. METHODS Prospective, experimental study. Four different doses of rivaroxaban (0.5, 1, 2, and 4 mg/kg) were administered PO to dogs. Single PO and 3 consecutive dosing regimens also were assessed. Plasma rivaroxaban concentration was determined using a chromogenic anti-Xa assay, point-of-care PT, and TEG analysis with 4 activators (RapidTEG, 1 : 100 tissue factor [TF100], 1 : 3700 tissue factor [TF3700], and kaolin), and results were compared. Spearman correlation coefficients were calculated between ratios (peak to baseline PT; peak reaction time [R] of TEG to baseline [R] of TEG) and anti-Xa concentration. RESULTS Anti-Xa concentration had a significant correlation with point-of-care PT (R = 0.82, P < .001) and RapidTEG-TEG, TF100-TEG, and TF3700-TEG (R = 0.76, P < .001; R = 0.82, P < .001; and R = 0.83, P < .001, respectively). CONCLUSIONS AND CLINICAL IMPORTANCE Overall, a 1.5-1.9 × delay in PT and R values of TEG 3 hours after rivaroxaban administration is required to achieve therapeutic anti-Xa concentrations of rivaroxaban in canine plasma. The R values of TEG, specifically using tissue factors (RapidTEG, TF100, TF3700) and point-of-care PT for rivaroxaban can be used practically for therapeutic monitoring of rivaroxaban in dogs.
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Affiliation(s)
- Junwoo Bae
- College of Veterinary Medicine, Chonnam National University, Gwangju, Republic of Korea
| | - Hyunwoo Kim
- College of Veterinary Medicine, Chonnam National University, Gwangju, Republic of Korea
| | - Woosun Kim
- College of Veterinary Medicine, Chonnam National University, Gwangju, Republic of Korea
| | - Suhee Kim
- National Institute of Animal Science, Rural Development Administration, Wanju, Republic of Korea
| | - Jinho Park
- College of Veterinary Medicine, Chonbuk National University, Iksan, Republic of Korea
| | - Dong-In Jung
- College of Veterinary Medicine, Gyeongsang National University, Jinju, Republic of Korea
| | - Dohyeon Yu
- College of Veterinary Medicine, Gyeongsang National University, Jinju, Republic of Korea
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9
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Wu HD, Cao HY, Song ZK, Yang S, Tang ML, Liu Y, Qin L. Considerations for routine coagulation monitoring with rivaroxaban: A case report and review of the literature. World J Clin Cases 2019; 7:382-388. [PMID: 30746380 PMCID: PMC6369389 DOI: 10.12998/wjcc.v7.i3.382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/04/2018] [Accepted: 12/21/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Rivaroxaban is a non-vitamin K antagonist oral anticoagulant that does not require coagulation monitoring based on current recommendations. Our goal is to explore whether routine coagulation monitoring should not be required for all patients receiving oral rivaroxaban, what relationship between routine coagulation abnormalities and bleeding, and how to deal with the above clinical situations through our case and review of the literature.
CASE SUMMARY We report a 67-year-old woman with a history of atrial fibrillation who presented to the hospital with worsening dyspnea and cough. Based on electrocardiogram, venous compression ultrasonography, and computed tomography pulmonary angiography, the diagnosis of atrial fibrillation, deep venous thrombosis, and acute pulmonary embolism was confirmed. Her coagulation assays and renal function were normal on admission; she was not underweight, did not have a history of hemorrhagic disease, and her CHA2DS2-VAS, HAS-BLED, and simplified Pulmonary Embolism Severity Index scores were 3, 0, and 0, respectively. Oral rivaroxaban (15 mg twice daily) was administered. The following day, she presented gastrointestinal and gum bleeding, combined with coagulation abnormalities. Following cessation of rivaroxaban, her bleeding stopped and tests improved over the next 2 d. Rivaroxaban was begun again 3 d after recovery. However, she again presented with gastrointestinal and gum bleeding and the abnormal tests, and the therapy was discontinued. At 30-d follow-up after discharge, she presented normal coagulation tests without bleeding.
CONCLUSION Although current guidelines recommend that using non-vitamin K antagonist oral anticoagulants including rivaroxaban do not require coagulation monitoring, a small number of patients may develop routine coagulation test changes and bleeding during rivaroxaban therapy, especially in the elderly. Clinicians should pay attention to these patients and further obtain evidence in practice.
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Affiliation(s)
- Hai-Di Wu
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Hong-Yan Cao
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Zi-Kai Song
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Shuo Yang
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Ming-Long Tang
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Yang Liu
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Ling Qin
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
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Rivaroxaban dose adjustment using thrombin generation in severe congenital protein C deficiency and warfarin-induced skin necrosis. Blood Adv 2019; 2:142-145. [PMID: 29365322 DOI: 10.1182/bloodadvances.2017012047] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 12/13/2017] [Indexed: 01/29/2023] Open
Abstract
Key Points
Rivaroxaban was efficacious and safe in a child with protein C deficiency to prevent the recurrence of skin necrosis or venous thrombosis. The dosage of direct oral anticoagulants in children with thrombophilia is unclear; a thrombin generation assay may be useful to adjust it.
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11
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Huang JH, Lin YK, Chung CC, Hsieh MH, Chiu WC, Chen YJ. Factors That Determine the Prothrombin Time in Patients With Atrial Fibrillation Receiving Rivaroxaban. Clin Appl Thromb Hemost 2018; 24:188S-193S. [PMID: 30244598 PMCID: PMC6714846 DOI: 10.1177/1076029618800830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Rivaroxaban, a direct factor Xa inhibitor, is widely used to reduce the chance of stroke
in patients with atrial fibrillation (AF). It is not clear why the prothrombin time (PT)
of the international normalized ratio (INR) fails to correlate with treatment using
rivaroxaban in patients with AF. In this study, patient characteristics, the rivaroxaban
dosage, AF type, drug history, biochemical properties, and hematological profiles were
assessed in patients treated with rivaroxaban. In 69 patients with AF receiving
rivaroxaban, 27 (39.1%) patients had a normal INR (≤1.1, group 1), 27 (39.1%) patients had
a slightly prolonged INR (1.1∼1.5, group 2), and 15 (21.7%) patients had a significantly
prolonged INR (>1.5, group 3). Group 1 patients had a higher incidence of a stroke
history than did patients in group 2 (P = .026) and group 3
(P = .032). We scored patients with a persistent AF pattern (1 point),
paroxysmal AF pattern (0 point), renal function (ie, the creatinine clearance rate in
mL/min/1.73 m2 of >60 as 0 points, of 30∼60 as 1 point, and of <30 as 2
points), and no history of stroke (1 point), and we found that group 3 had a higher score
than groups 2 or 1 (2.9 ± 0.8, 2.4 ± 0.7, and 2 ± 0.7, respectively; P
< .05). There were similar incidences of bleeding, stroke, and unexpected
hospitalizations among the 3 groups. The PT of the INR is determined by multiple variables
in patients with AF receiving rivaroxaban. Rivaroxaban-treated patients with AF having
different INR values may have similar clinical outcomes.
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Affiliation(s)
- Jen-Hung Huang
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yung-Kuo Lin
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Chih Chung
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ming-Hsiung Hsieh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wan-Chun Chiu
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, Taiwan
| | - Yi-Jen Chen
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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12
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Abstract
RATIONALE Rivaroxaban is a non-vitamin K antagonist oral anticoagulant. Current recommendations state that coagulation monitoring is not required, and neither the dose nor dosing interval requires adjustment in response to changes in coagulation parameters when rivaroxaban is used for approved indications. Guidelines mainly discuss the indications for rivaroxaban and non-vitamin K antagonist oral anticoagulants in general; they offer less guidance regarding how to use these medications in specific clinical situations to bridge the gulf between guidelines and clinical practice. PATIENT CONCERNS An 88-year-old man with a long history of atrial fibrillation presented to the hospital with worsening dyspnea and chest pain. Significantly, he had an estimated glomerular filtration rate of 46.7 mL/min. He was prescribed oral rivaroxaban 20 mg once daily. After 7 days, the patient complained of maroon colored stools. DIAGNOSIS Laboratory investigations revealed that the patient's prothrombin time (PT) and activated partial thromboplastin time (aPTT) were elevated. Rivaroxaban induced gastrointestinal bleeding was suspected. INTERVENTIONS Rivaroxaban was discontinued and routine coagulation tests were monitored daily. OUTCOMES Two days following the discontinuation of the drug, the bleeding was controlled and hemoglobin was normal, but the PT and aPTT remained abnormal. On the third day after discontinuing rivaroxaban, the patient experienced sudden syncope and pulselessness and expired. LESSONS This case indicates that in real-world situations, a small number of patients may develop changes in both PT and aPTT during rivaroxaban therapy. Therefore, coagulation monitoring should be considered in patients with risk factors for bleeding, such as elderly patients with renal insufficiency.
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Thom I, Cameron G, Robertson D, Watson HG. Measurement of rivaroxaban concentrations demonstrates lack of clinical utility of a PT, dPT and APTT test in estimating levels. Int J Lab Hematol 2018; 40:493-499. [PMID: 29718586 DOI: 10.1111/ijlh.12846] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 03/14/2018] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Rivaroxaban concentrations were measured in 127 inpatient samples using an HPLC-MS/MS assay. METHODS We compared this measurement with a calibrated anti-Xa assay and performed PT, aPTT and dilute PT tests to assess the value of clot-based assays in clinical decision-making. RESULTS The correlation between the anti-Xa assay and the HPLC-MS/MS at therapeutic concentrations was strong (R2 = 0.98). The PT, RecombiPlasTin 2G, and aPTT, Actin FS, showed a linear dose-response but poor correlation (R2 = 0.32 and 0.44, respectively) and at dilutions of 1 in 150 to 1 in 750 the dilute PT assay also showed poor correlation with rivaroxaban concentrations measured by specific assays. A normal PT or aPTT alone did not identify a likely safe rivaroxaban concentration to allow surgery or invasive procedures, but the combination of normal PT and aPTT identified a group of patients with rivaroxaban levels less than 90 ng/mL. Combined normal PT and aPTT had specificity and sensitivity of 0.97 (95% CI 0.92-0.99) and 0.37 (95% CI 0.1-0.74) for a rivaroxaban concentration < 32 ng/mL. CONCLUSIONS The PT and aPTT show poor correlation with rivaroxaban levels measured by calibrated anti-Xa and HPLC-MS/MS assays. A normal combined PT and APTT identified low rivaroxaban levels with high specificity but lacked sensitivity. The dPT assay at several dilutions could not be used to quantify rivaroxaban in clinical samples. The utility of these PT, aPTT and dilute PT assays in a clinical setting is very limited, and results generated must be interpreted with caution.
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Affiliation(s)
- I Thom
- Department of Haematology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - G Cameron
- Rowett Institute, University of Aberdeen, Aberdeen, UK
| | - D Robertson
- Laboratory Medicine IT Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | - H G Watson
- Department of Haematology, Aberdeen Royal Infirmary, Aberdeen, UK
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Lindhoff-Last E. Direct oral anticoagulants (DOAC) - Management of emergency situations. Hamostaseologie 2017; 37:257-266. [PMID: 29582928 DOI: 10.5482/hamo-16-11-0043] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The worldwide increase in the aging population and the associated increase in the prevalence of atrial fibrillation and venous thromboembolism as well as the widespread use of direct oral anticoagulants (DOAC) have resulted in an increase of the need for the management of bleeding complications and emergency operations in frail, elderly patients, in clinical practice. When severe bleeding occurs, general assessment should include evaluation of the bleeding site, onset and severity of bleeding, renal function, and concurrent medications with focus on anti-platelet drugs and nonsteroidal anti-inflammatory drugs (NSAID). The last intake of the DOAC and its residual concentration are also relevant. The site of bleeding should be immediately localized, anticoagulation should be interrupted, and local measures to stop bleeding should be taken. In life-threatening bleeding or emergency operations immediate reversal of the antithrombotic effect may be indicated. If relevant residual DOAC-concentrations are expected and surgery cannot be postponed, prothrombin complex concentrate (PCC) and/or a specific antidote should be given. While idarucizumab, the specific antidote for dabigatran, has been recently approved for clinical use, the recombinant factor X protein andexanet alfa, an antidote for the reversal of inhibitors of coagulation factor Xa, and ciraparantag, a universal antidote, are not available. Future cohort studies are necessary to assess the efficacy and safety of specific and unspecific reversal agents in "real-life" conditions. This was the rationale for introducing the RADOA-registry (RADOA: Reversal Agent use in patients treated with Direct Oral Anticoagulants or vitamin K antagonists), a prospective non-interventional registry, which will evaluate the effects of specific and unspecific reversal agents in patients with life-threatening bleeding or emergency operations either treated with DOACs or vitamin K antagonists.
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15
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[Anticoagulation in geriatric patients with atrial fibrillation : With what and for whom no more?]. Herz 2017; 43:214-221. [PMID: 29260237 DOI: 10.1007/s00059-017-4665-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Based on established risk scores, such as the CHA2DS2-VASc score, the indications for oral anticoagulation are given for patients over 65 years old with atrial fibrillation and even more so for patients over 75 years old. Before beginning anticoagulation a geriatric assessment for evaluation of the cognitive ability, the activities of daily living and the risk of falling should be made because of the known complications of anticoagulation. Geriatric patients with non-valvular atrial fibrillation (AF) are increasingly being treated with non-vitamin K antagonist oral anticoagulants (NOAC) to prevent ischemic stroke. The European Society for Cardiology (ESC) guidelines for the management of AF recommended NOACs as the preferred treatment and vitamin K antagonists (VKA) only as an alternative option. Meanwhile, apixaban, rivaroxaban, and edoxaban as factor Xa inhibitors and dabigatran as a thrombin inhibitor, are more commonly used in clinical practice in patients with AF. Although, these drugs have pharmacodynamics and pharmacokinetic similarities and are often grouped together, it is important to recognize that the pharmacology and dose regimens differ between compounds. Especially in elderly patients the new drugs have interesting advantages compared to VKA, i. e., less drug-drug interactions with concomitant medication and a more favorable risk-benefit ratio mostly driven by the reduction of bleeding. Treatment of anticoagulation in elderly patients requires weighing the serious risk of stroke with an equally high risk of major bleeding and pharmacoeconomic considerations. The easier practicality of NOACs in routine practice must be emphasized as no international normalized ratio (INR) monitoring is necessary and the interruption of treatment for planned interventions is uncomplicated. A regular monitoring of the indications for NOACs is indispensable (as for all other medications). Especially elderly patients have the greatest benefit from NOAC along with a low renal elimination rate and they should certainly not be withheld from elderly patients who have a clear need for oral anticoagulation.
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Ten Cate H, Henskens YM, Lancé MD. Practical guidance on the use of laboratory testing in the management of bleeding in patients receiving direct oral anticoagulants. Vasc Health Risk Manag 2017; 13:457-467. [PMID: 29263674 PMCID: PMC5732550 DOI: 10.2147/vhrm.s126265] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Direct oral anticoagulants (DOACs) have demonstrated a favorable benefit–risk profile in several thromboembolic disorders and are increasingly used in routine clinical practice. A number of real-world studies on DOACs are ongoing, and data published so far have shown broadly similar outcomes to those demonstrated in the respective phase III trials. Despite their beneficial attributes, bleeding risk (as with any other anticoagulants) is often a concern for physicians when prescribing DOACs, particularly in elderly patients, those with significant comorbidities, and other high-risk patient populations. Although the absence of routine coagulation monitoring is an advantage of the DOACs, measuring their anticoagulant effect and/or plasma drug levels may be helpful in certain clinical scenarios to help patient management and improve outcomes. In this paper, practical guidance and recommendations are provided for clinical situations in which the test results may aid clinical decision-making, including patients with life-threatening bleeding events, patients without bleeding but with test results indicating a risk of bleeding, for those patients with a suspected thromboembolism while receiving a DOAC, or prior to patients undergoing elective or urgent surgical procedures. Finally, appropriate monitoring of the DOACs could be of substantial benefit to patients, and there is a high potential for development in this area in the future.
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Affiliation(s)
- Hugo Ten Cate
- Department of Internal Medicine, Cardiovascular Research Institute
| | | | - Marcus D Lancé
- Department of Anaesthesiology, Maastricht University Medical Centre, Maastricht, the Netherlands
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17
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Studt JD, Alberio L, Angelillo-Scherrer A, Asmis LM, Fontana P, Korte W, Mendez A, Schmid P, Stricker H, Tsakiris DA, Wuillemin WA, Nagler M. Accuracy and consistency of anti-Xa activity measurement for determination of rivaroxaban plasma levels. J Thromb Haemost 2017; 15:1576-1583. [PMID: 28574652 DOI: 10.1111/jth.13747] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Indexed: 12/18/2022]
Abstract
Essentials Accurate determination of anticoagulant plasma concentration is important in clinical practice. We studied the accuracy and consistency of anti-Xa assays for rivaroxaban in a multicentre study. In a range between 50 and 200 μg L-1 , anti-Xa activity correlated well with plasma concentrations. The clinical value might be limited by overestimation and intra- and inter-individual variation. SUMMARY Background Determining the plasma level of direct oral anticoagulants reliably is important in the work-up of complex clinical situations. Objectives To study the accuracy and consistency of anti-Xa assays for rivaroxaban plasma concentration in a prospective, multicenter evaluation study employing different reagents and analytical platforms. Methods Rivaroxaban 20 mg was administered once daily to 20 healthy volunteers and blood samples were taken at peak and trough levels (clinicaltrials.gov NCT01710267). Anti-Xa activity was determined in 10 major laboratories using different reagents and analyzers; corresponding rivaroxaban plasma concentrations were measured by high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS). Findings Overall Pearson's correlation coefficient of anti-Xa levels and HPLC-MS results was 0.99 for Biophen® Heparin (95% CI, 0.99, 0.99), Biophen® DiXaI (95% CI, 0.99, 0.99) and STA® anti-Xa liquid (95% CI, 0.99, 1.00). Correlation was lower in rivaroxaban concentrations below 50 μg L-1 and above 200 μg L-1 . The overall bias of the Bland-Altman difference plot was 14.7 μg L-1 for Biophen Heparin, 17.9 μg L-1 for Biophen DiXal and 19.0 μg L-1 for STA anti-Xa liquid. Agreement between laboratories was high at peak level but limited at trough level. Conclusions Anti-Xa activity correlated well with rivaroxaban plasma concentrations, especially in a range between 50 and 200 μg L-1 . However, anti-Xa assays systematically overestimated rivaroxaban concentration as compared with HPLC-MS, particularly at higher concentrations. This overestimation, coupled with an apparent interindividual variation, might affect the interpretation of results in some situations.
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Affiliation(s)
- J-D Studt
- Division of Haematology, University Hospital and University of Zurich, Zurich, Switzerland
| | - L Alberio
- Service and Central Laboratory of Haematology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - A Angelillo-Scherrer
- Department of Haematology, Inselspital, Bern University Hospital, Berne, Switzerland
- Department of Clinical Research, University of Bern, Berne, Switzerland
| | | | - P Fontana
- Division of Angiology and Haemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - W Korte
- Institute for Clinical Chemistry and Haematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - A Mendez
- Centre for Laboratory Medicine, Cantonal Hospital Aarau, Aarau, Switzerland
| | - P Schmid
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, Lucerne, Switzerland
| | - H Stricker
- Division of Surgery, Regional Hospital La Carita, Locarno, Switzerland
| | - D A Tsakiris
- Diagnostic Haematology, University Hospital of Basel, Basel, Switzerland
| | - W A Wuillemin
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, Lucerne, Switzerland
- Department of Clinical Research, University of Berne, Berne, Switzerland
| | - M Nagler
- Department of Haematology, Inselspital, Bern University Hospital, Berne, Switzerland
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, Lucerne, Switzerland
- Department of Clinical Research, University of Berne, Berne, Switzerland
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Ofek F, Bar Chaim S, Kronenfeld N, Ziv-Baran T, Berkovitch M. International Normalized Ratio Is Significantly Elevated With Rivaroxaban and Apixaban Drug Therapies: A Retrospective Study. Clin Ther 2017; 39:1003-1010. [DOI: 10.1016/j.clinthera.2017.04.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 03/29/2017] [Accepted: 04/09/2017] [Indexed: 11/17/2022]
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19
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Bluecher A, Meyer Dos Santos S, Ferreirós N, Labocha S, Meyer Dos Santos IMR, Picard-Willems B, Harder S, Singer OC. Microfluidic coagulation assay for monitoring anticoagulant therapy in acute stroke patients. Thromb Haemost 2017; 117:519-528. [PMID: 28124061 DOI: 10.1160/th16-08-0619] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Accepted: 12/10/2016] [Indexed: 11/05/2022]
Abstract
Reliable detection of anticoagulation status in patients treated with non-vitamin K antagonist oral anticoagulants (NOACs) is challenging but of importance especially in the emergency setting. This study evaluated the potential of a whole-blood clotting time assay based on Surface Acoustic Waves (SAW-CT) in stroke-patients. The SAW-technology was used for quick and homogenous recalcification of whole blood inducing a surface-activated clotting reaction quantified and visualised by real-time fluorescence microscopy with automatic imaging processing. In 20 stroke or transient ischaemic attack (TIA)-patients taking NOACs kinetics of SAW-CT were assessed and correlated to other coagulation parameters (PT, aPTT) and NOAC-plasma concentration measured by tandem mass spectrometry (LC-MS/MS). In 225 emergency patients with suspicion of acute stroke or TIA, SAW-CT values were assessed. Mean (± SD) SAW-CT in non-anticoagulated stroke patients (n=180) was 124 s (± 21). In patients on dabigatran or rivaroxaban, SAW-CT values were significantly higher 2 and 8 hours (h) after intake rising up to 267 seconds (s) (dabigatran, 2 h after intake) and 250 s (rivaroxaban, 8 h after intake). In patients on apixaban, SAW-CT values were only moderately increased 2 h after intake (SAW-CT 153 s). In emergency patients, SAW-CT values were significantly higher in NOAC and vitamin K antagonist (VKA)-treated as compared to non-anticoagulated patients. In conclusion, the SAW-CT assay is capable to monitor anticoagulant level and effect in patients receiving dabigatran, rivaroxaban and the VKA phenprocoumon. It has a limited sensitivity for apixaban-detection. If specific SAW-CT results were used as cut-offs, SAW-CT yields high diagnostic accuracy to exclude relevant rivaroxaban and dabigatran concentrations in stroke-patients.
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Affiliation(s)
| | | | | | | | | | | | | | - Oliver C Singer
- Oliver C. Singer, MD, Department of Neurology, HELIOS HSK Kliniken, Ludwig-Erhard-Str. 100, 65199 Wiesbaden, Germany, Tel.: +49 611 432376, Fax: +49 611 432732, E-mail:
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20
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Zotz RB, Weißbach L. [Monitoring of NOAC]. Med Klin Intensivmed Notfmed 2017; 112:92-98. [PMID: 28083625 DOI: 10.1007/s00063-016-0249-6] [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] [Received: 12/02/2016] [Accepted: 12/09/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Monitoring non-vitamin K antagonist oral anticoagulants (NOAC) is usually not necessary; however, in some patients it may prove beneficial. OBJECTIVES Patient subgroups who may profit from monitoring were identified, and methods of monitoring (including assessment of which coagulation parameters are affected by NOAC) are described. MATERIALS AND METHODS We searched the PubMed database for each of the search terms, "NOAC", "DOAC", "rivaroxaban", "dabigatran", and "apixaban", in combination with one of the terms, "monitoring", "measurement", "measuring", or "assessment". The results were compiled and reviewed. RESULTS Monitoring is most advantageous in emergency cases with severe bleeding where drug activity needs to be assessed. It can also help in deciding for or against lysis therapy after acute stroke in patients taking NOAC. Furthermore, it can also identify compliance problems and help in planning periprocedural management. There are quantitative measurement methods which measure plasma concentrations exactly and qualitative methods which only allow for a rough estimate or a general confirmation of drug activity. Recommended quantitative measurement methods are diluted thrombin time for dabigatran, and anti-factor Xa activity (calibrated) for rivaroxaban and apixaban. CONCLUSIONS Several patient subgroups may profit from monitoring of NOAC plasma concentration. One should, however, take several issues into consideration before measurements, such as the objective of each individual measurement, possible consequences (e. g., dose adjustment), and which measurement method to pick.
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Affiliation(s)
- R B Zotz
- Institut für Laboratoriumsmedizin & Transfusionsmedizin, LBT Zotz/Klimas, Immermannstraße 65a, 40210, Düsseldorf, Deutschland.
| | - L Weißbach
- Institut für Laboratoriumsmedizin & Transfusionsmedizin, LBT Zotz/Klimas, Immermannstraße 65a, 40210, Düsseldorf, Deutschland
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Dosage plasmatique de quatre anticoagulants directs par UHPLC/DAD. TOXICOLOGIE ANALYTIQUE ET CLINIQUE 2016. [DOI: 10.1016/j.toxac.2016.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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22
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Abstract
Patients taking direct oral anticoagulants (DOACs) who then need an emergency invasive procedure require specialized management strategies. Appropriate patient evaluation includes assessment of the current anticoagulation state, including timing of the last dose. DOACs require particular coagulation assays to measure anticoagulation levels accurately, although standard coagulation screening tests may provide qualitative guidance. Specialty societies have endorsed general recommendations for patient management to promote hemostasis in anticoagulated patients requiring surgery or other invasive procedures. These include general stopping rules (such as ≥24 hours for low-risk procedures and ≥48 hours for high-risk surgery with normal renal function) for elective procedures. Bridging therapy when oral anticoagulant treatment is interrupted has recently been questioned, depending on the clinical scenario. Novel agents for the reversal of DOAC-induced anticoagulation have recently been developed. Idarucizumab, a humanized monoclonal antibody fragment that selectively binds dabigatran, was recently approved for clinical use in patients with life-threatening or uncontrolled bleeding, and for patients requiring emergency interventions. Idarucizumab can streamline the pre- and periprocedural anticoagulation management of dabigatran-treated patients, as it provides fast, complete, and sustainable reversibility. Andexanet alfa is an inactive, decoy factor Xa (FXa) molecule that binds FXa inhibitors, and ciraparantag is a synthetic molecule designed to bind fractionated and unfractionated heparins, and each of the currently approved DOACs. As clinical development of the additional anti-FXa-specific anticoagulant reversal agents proceeds, the respective role of each in the management of emergency bleeding events and invasive procedures will be better defined, and it is hoped they will make important contributions to patient care.
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23
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Discontinuation and management of direct-acting anticoagulants for emergency procedures. Am J Emerg Med 2016; 34:14-18. [DOI: 10.1016/j.ajem.2016.09.048] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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24
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Yates SG, Smith S, Tharpe W, Shen YM, Sarode R. Can an anti-Xa assay for low-molecular-weight heparin be used to assess the presence of rivaroxaban? Transfus Apher Sci 2016; 55:212-215. [DOI: 10.1016/j.transci.2016.06.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 04/19/2016] [Accepted: 06/23/2016] [Indexed: 10/21/2022]
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Amiral J, Dunois C, Amiral C, Seghatchian J. Anti-Xa bioassays for the laboratory measurement of direct Factor Xa inhibitors in plasma, in selected patients. Transfus Apher Sci 2016; 55:249-261. [PMID: 27692605 DOI: 10.1016/j.transci.2016.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
In the past decade Direct Oral Anti-Coagulants (DOACs), targeting Thrombin or Factor Xa, have enormously facilitated the daily treatment of all relevant patients, including those requiring lifelong therapy. These DOACs have considerable advantages over the use of oral Vitamin K Antagonist (VKA) treatments, in view of having little interferences with food and other medications and also not requiring adjustment for age, gender or weight, with some well-defined exceptions. In this current What's Happening Section we focus on measurements of DiXaIs in plasma using anti-Xa assays, with the objective of providing a tribute to Professor Michel Meyer Samama, who was not only a real leader in this field but, in the past, both authors benefited from his wisdom, as a teacher who dedicated his scientific and professional life (among many other interests in hemostasis, thrombosis and fibrinolysis) to develop and promote methods and strategies for laboratory monitoring of anticoagulants. This review presents the performance characteristics of the Anti-Factor Xa assays (measuring Factor Xa inhibition by drugs), which are available for measuring Direct Factor Xa Inhibitors in plasma, and show good compliance of the results with the reference LC:MS method (which measures the mass of Direct Factor Xa Inhibitors). We also present the preparation and validation of drug specific plasma calibrators and controls which are requested for drug measurements. These assays are convenient and practical laboratory tools which can be used in any laboratory setting, and meet the requirements of regulatory bodies for making smart, quantitative, sensitive, accurate and ease of use assays for measuring DOACs when needed. The manuscript focuses mainly on the following areas of current interest: interference in coagulation assays; anti-Xa laboratory methods; development of calibrators and controls for DiXaIs; method validation and comparison with reference techniques (LC:MS); regulatory requirements and method registrations; newer clinical applications and experience on DiXaIs with Anti-Xa assays, and future perspectives.
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Affiliation(s)
- Jean Amiral
- Hyphen BioMed, Sysmex Group, Neuville sur Oise, France.
| | - Claire Dunois
- Hyphen BioMed, Sysmex Group, Neuville sur Oise, France
| | - Cédric Amiral
- Hyphen BioMed, Sysmex Group, Neuville sur Oise, France
| | - Jerard Seghatchian
- International Consultancy in Blood Components Quality/Safety Improvement, Audit/Inspection and DDR Strategies, London, UK.
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Egger F, Targa F, Unterholzner I, Grant RP, Herrmann M, Wiedermann CJ. Medication Error When Switching from Warfarin to Rivaroxaban Leading to Spontaneous Large Ecchymosis of the Abdominal and Chest Wall. Clin Pract 2016; 6:873. [PMID: 27777713 PMCID: PMC5067405 DOI: 10.4081/cp.2016.873] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 08/10/2016] [Indexed: 12/18/2022] Open
Abstract
Non-vitamin K oral anticoagulant (NOAC) therapy may be inappropriate if prescription was incorrect, the patient’s physiological parameters change, or interacting concomitant medications are erroneously added. The aim of this report was to illustrate inappropriate NOAC prescription in a 78-year-old woman with non-valvular atrial fibrillation and borderline renal dysfunction who was switched from warfarin to rivaroxaban and subsequently developed bruising with hemorrhagic shock and acute on chronic renal failure. Administration of 4-factor prothrombin complex concentrate effectively reversed coagulopathy and stopped bleeding. Retrospective determination of circulating plasma levels of rivaroxaban and warfarin confirmed that excessive anticoagulation was likely due to warfarin that the patient probably continued to take although rivaroxaban was initiated. Pharmacodynamic interaction between rivaroxaban and warfarin may not only be additive but synergistic. In patients at high risk of complications, judicious prescribing and dosing of NOACs, and regular monitoring of concomitant medications and renal function are highly recommended.
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Affiliation(s)
- Flavio Egger
- Department of Internal Medicine, Central Hospital of Bolzano , BZ, Italy
| | - Federica Targa
- Department of Clinical Pathology, Central Hospital of Bolzano , BZ, Italy
| | - Ivan Unterholzner
- Department of Internal Medicine, Central Hospital of Bolzano , BZ, Italy
| | - Russell P Grant
- Center for Esoteric Testing, Laboratory Corporation of America® Holdings , Burlington, NC, USA
| | - Markus Herrmann
- Department of Clinical Pathology, Central Hospital of Bolzano , BZ, Italy
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Measurement of Non-Vitamin K Antagonist Oral Anticoagulants in Patient Plasma Using Heptest-STAT Coagulation Method. Ther Drug Monit 2016; 37:375-80. [PMID: 25525760 DOI: 10.1097/ftd.0000000000000157] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Non-vitamin K antagonist oral anticoagulants (NOACs) are approved for several indications for prophylaxis of thromboembolism at fixed oral doses. The analysis of NOAC activity/concentration may be required in special patient populations. Heptest coagulation assay determines both factor Xa and thrombin inhibitors. The objective of investigations is to analyze the effects of both groups of NOACs on this assay. METHODS The performance of a modified Heptest-STAT clotting assay was compared with specific chromogenic substrate assays for factor Xa (Coamatic, HemosIL) and thrombin (direct thrombin inhibitor assay and S2238 chromogenic assays) for the determination of rivaroxaban, apixaban, and dabigatran in plasma from patients on treatment. RESULTS For rivaroxaban (n = 74), the concentrations (mean and SD) of Heptest-STAT versus Coamatic and HemosIL assays were 179.3 ± 85.8 ng/mL versus 199.3 ± 105.7 ng/mL and 212.4 ± 115.9 ng/mL (P < 0.0001), and for apixaban (n = 26) 232.8 ± 10.0 ng/mL versus 178.4 ± 64.4 ng/mL (P < 0.0001) and 182.1 ± 73.1 ng/mL (P = 0.0002). For dabigatran (n = 74), the values of Heptest-STAT were 92.3 ± 65.0 ng/mL versus 124.3 ± 85.6 ng/mL (direct thrombin inhibitor assay, P < 0.0001) and 107.5 ± 59.7 ng/mL (S2238 assay, P = 0.0015), respectively. The values of the intraclass coefficient of correlation ranged from 0.64 to 0.91 (Bland-Altman analysis). CONCLUSIONS The objective of the study was achieved by demonstrating a high correlation of the Heptest-STAT coagulation assay with chromogenic assays for factor Xa inhibiting NOACs and acceptably good correlation with thrombin inhibiting NOACs in plasma samples of patients on treatment.
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Yang VK, Cunningham SM, Rush JE, de Laforcade A. The use of rivaroxaban for the treatment of thrombotic complications in four dogs. J Vet Emerg Crit Care (San Antonio) 2016; 26:729-36. [DOI: 10.1111/vec.12466] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 09/16/2014] [Accepted: 10/02/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Vicky K. Yang
- Department of Clinical Sciences; Cummings School of Veterinary Medicine at Tufts University; 200 Westboro Rd North Grafton MA 01536
| | - Suzanne M. Cunningham
- Department of Clinical Sciences; Cummings School of Veterinary Medicine at Tufts University; 200 Westboro Rd North Grafton MA 01536
| | - John E. Rush
- Department of Clinical Sciences; Cummings School of Veterinary Medicine at Tufts University; 200 Westboro Rd North Grafton MA 01536
| | - Armelle de Laforcade
- Department of Clinical Sciences; Cummings School of Veterinary Medicine at Tufts University; 200 Westboro Rd North Grafton MA 01536
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Bahrmann P, Harms F, Schambeck CM, Wehling M, Flohr J. [New oral anticoagulants for prophylaxis of stroke. Results of an expert conference on practical use in geriatric patients]. Z Gerontol Geriatr 2016; 49:216-26. [PMID: 26861870 DOI: 10.1007/s00391-016-1027-z] [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] [Received: 10/19/2015] [Revised: 12/28/2015] [Accepted: 01/13/2016] [Indexed: 10/22/2022]
Abstract
Geriatric patients with non-valvular atrial fibrillation (AF) are increasingly being treated with novel oral anticoagulants (NOAC) to prevent ischemic stroke. This article highlights the outcome of an expert meeting on the practical use of NOAC in elderly patients. An interdisciplinary group of experts discussed the current situation of stroke prevention in geriatric patients and its practical management in daily clinical practice. The topic was examined through focused impulse presentations and critical analyses as the basis for the expert consensus. The key issues are summarized in this paper. The European Society of Cardiology (ESC) guidelines from 2012 for the management of patients with non-valvular AF recommend NOAC as the preferred treatment and vitamin K antagonists (VKA) only as an alternative option. Currently, the NOAC factor Xa inhibitors apixaban and rivaroxaban and the thrombin inhibitor dabigatran are more commonly used in clinical practice for patients with AF. Although these drugs have many similarities and are often grouped together it is important to recognize that the pharmacology and dose regimes differ between compounds. Especially n elderly patients NOAC drugs have some advantages compared to VKA, e.g. less drug-drug interactions with concomitant medication and a more favorable risk-benefit ratio mostly driven by the reduction of bleeding. Treatment of anticoagulation in geriatric patients requires weighing the serious risk of stroke against an equally high risk of major bleeding and pharmacoeconomic considerations. Geriatric patients in particular have the greatest benefit from NOAC, which can also be administered in cases of reduced renal function. Regular control of the indications is indispensable, as also for all other medications of the patient. The use of NOAC should certainly not be withheld from geriatric patients who have a clear need for oral anticoagulation.
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Affiliation(s)
- Philipp Bahrmann
- Institut für Biomedizin des Alterns, Friedrich-Alexander-Universität Erlangen-Nürnberg, Kobergerstr. 60, 90419, Nürnberg, Deutschland.
| | - Fred Harms
- European Health Care Foundation, Zug, Schweiz
| | | | - Martin Wehling
- Institut für Experimentelle und Klinische Pharmakologie und Toxikologie, Medizinische Fakultät Mannheim, Ruprecht-Karls-Universität, Heidelberg, Deutschland
| | - Jürgen Flohr
- Allgemeinmedizinische Gemeinschaftspraxis, Leipzig, Deutschland
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Palareti G, Poli D. The challenges and limitations of widespread direct oral anticoagulant treatment: practical suggestions for their best use. Expert Rev Cardiovasc Ther 2015; 14:163-76. [DOI: 10.1586/14779072.2016.1115344] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Levy JH, Spyropoulos AC, Samama CM, Douketis J. Direct oral anticoagulants: new drugs and new concepts. JACC Cardiovasc Interv 2015; 7:1333-51. [PMID: 25523529 DOI: 10.1016/j.jcin.2014.06.014] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 05/20/2014] [Accepted: 06/13/2014] [Indexed: 10/24/2022]
Abstract
Direct oral anticoagulants (DOACs) are approved for multiple thromboembolic disorders and provide advantages over existing agents. As with all anticoagulants, management protocols for the eventuality of bleeding are important. Randomized phase III studies generally show that DOACs have a similar risk of clinically relevant bleeding compared with standard anticoagulants, with reductions in major bleeding in some cases. This may be particularly important in patients with atrial fibrillation, for whom the rate of intracranial hemorrhage was approximately halved with DOACs compared with warfarin. Conversely, the risk of gastrointestinal bleeding may be increased. Specific patient characteristics, such as renal impairment, comedications, and particular aspects of each drug, including the proportion eliminated by the kidneys, must be taken into account when assessing the risk of bleeding. Although routine coagulation monitoring of DOACs is not required, it may be useful under some circumstances. Of the traditional clotting assays, a sensitive and calibrated prothrombin time may be useful for detecting the presence or absence of clinically relevant factor Xa inhibitor concentrations (rivaroxaban or apixaban), but specific anti-factor Xa assays can measure drug levels quantitatively. For dabigatran, the results of an activated partial thromboplastin time test may exclude a clinically relevant pharmacodynamic effect, but a calibrated dilute thrombin time assay can be used for quantification of drug levels. In the event of mild or moderate bleeding, normal hemostatic support measures are recommended. For life-threatening bleeding, use of nonspecific prohemostatic agents may be considered, although clinical evidence is scarce. Specific antidotes are in development.
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Affiliation(s)
| | - Alex C Spyropoulos
- Hofstra North Shore/LIJ School of Medicine at Lenox Hill Hospital, Manhasset, New York
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Spiller HA, Mowry JB, Aleguas A, Griffith JRK, Goetz R, Ryan ML, Bangh S, Klein-Schwartz W, Schaeffer S, Casavant MJ. An Observational Study of the Factor Xa Inhibitors Rivaroxaban and Apixaban as Reported to Eight Poison Centers. Ann Emerg Med 2015; 67:189-95. [PMID: 26298448 DOI: 10.1016/j.annemergmed.2015.07.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 06/29/2015] [Accepted: 07/07/2015] [Indexed: 12/17/2022]
Abstract
STUDY OBJECTIVE Rivaroxaban and apixaban are part of a new group of oral anticoagulants targeting factor Xa and approved by the Food and Drug Administration in 2011 and 2012. These oral anticoagulants are administered at fixed daily doses, without the need for laboratory-guided adjustments. There are limited data available on supratherapeutic doses or overdose of the oral Xa inhibitors. This study characterizes the clinical effect in patients exposed to rivaroxaban and apixaban. METHODS A retrospective study collected data from 8 regional poison centers covering 9 states. Cases were initially identified by a search of the poison centers' databases for case mentions involving a human exposure to Xarelto, rivaroxaban, Eliquis, or apixaban. Inclusion criteria included single-substance exposure. Exclusion criteria were animal exposure, polysubstance exposure, or information call. Data for the study were collected by individual chart review, including case narratives, and compiled into a single data set. RESULTS There were 223 patients: 124 (56%) were female patients, mean age was 60 years, and 20 were children younger than 12 years (9%). One hundred ninety-eight patients ingested rivaroxaban (89%) and 25 ingested apixaban (11%). Dose was reported in 182 rivaroxaban patients, with a mean dose of 64.5 mg (range 15 to 1,200 mg), and in 21 apixaban patients, with a mean dose of 9.6 mg (range 2.5 to 20 mg). For rivaroxaban, prothrombin time was measured in 49 patients (25%) and elevated in 7; partial thromboplastin time, measured in 49 (25%) and elevated in 5; and international normalized ratio, measured in 61 (31%) and elevated in 13. For apixaban, prothrombin time was measured in 6 patients (24%) and elevated in none; partial thromboplastin time, measure in 6 (24%) and elevated in none; and international normalized ratio, measured in 5 patients (20%) and elevated in none. Bleeding was reported in 15 patients (7%): 11 rivaroxaban and 4 apixaban. The site of bleeding was gastrointestinal (8), oral (2), nose (1), bruising (1), urine (1), and subdural (1). The subdural bleeding occurred after fall and head injury. All cases with bleeding involved long-term ingestions. Coagulation test results were normal in most patients with bleeding: prothrombin time 5 of 6 (83%), partial thromboplastin time 5 of 6 (83%), and international normalized ratio 5 of 9 (55%). Blood products were used in 7 rivaroxaban patients (1 suicide) and 3 apixaban patients. No bleeding or altered coagulation test results occurred in children, which all involved a one-time ingestion. All 12 suicide attempts involved rivaroxaban: altered coagulation test results occurred for 5 patients (42%), no bleeding occurred in any suicide attempt patient, 1 patient was treated with fresh frozen plasma (international normalized ratio 12.47), and dose by patient history did not predict risk of altered coagulation or bleeding. Two rivaroxaban patients experienced elevation of hepatic transaminase levels greater than 1,000 U/L. CONCLUSION Bleeding after Xa inhibitor ingestion as a single agent is uncommon. Prothrombin time, partial thromboplastin time, or international normalized ratio may be elevated in a minority of cases but appears unreliable to measure risk of bleeding. Massive acute ingestion in suicide attempt may result in significant anticoagulation. Single exploratory ingestion by children was not associated with toxicity.
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Affiliation(s)
- Henry A Spiller
- Central Ohio Poison Center, Nationwide Children's Hospital, Columbus, OH; Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH.
| | - James B Mowry
- Indiana Poison Center, Indiana University Health Methodist Hospital, and the Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Alfred Aleguas
- Florida Poison Information Center-Tampa, Tampa General Hospital, Tampa, FL
| | - Jill R K Griffith
- College of Pharmacy, Ohio State University, Columbus, OH; Mount Carmel Medical Center West, Columbus, OH
| | - Robert Goetz
- Cincinnati Drug & Poison Information Center, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | - Stacey Bangh
- Minnesota Poison Control System, Hennepin County Medical System, Minneapolis, MN
| | - Wendy Klein-Schwartz
- Maryland Poison Center and the University of Maryland School of Pharmacy, Baltimore, MD
| | - Scott Schaeffer
- Oklahoma Center for Poison & Drug Information, Oklahoma City, OK
| | - Marcel J Casavant
- Central Ohio Poison Center, Nationwide Children's Hospital, Columbus, OH; College of Pharmacy, Ohio State University, Columbus, OH; Ohio State University College of Medicine, Columbus, OH
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Rahmat NA, Lip GYH. Monitoring the Effects and Antidotes of the Non-vitamin K Oral Anticoagulants. Arrhythm Electrophysiol Rev 2015; 4:90-5. [PMID: 26835107 PMCID: PMC4711499 DOI: 10.15420/aer.2015.04.02.90] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Accepted: 06/18/2015] [Indexed: 01/17/2023] Open
Abstract
In the last decade, we have witnessed the emergence of the oral non-vitamin K oral anticoagulants (NOACs), which have numerous advantages compared with the vitamin K antagonists, particularly their lack of need for monitoring; as a result their use is increasing. Nonetheless, the NOACs face two major challenges: the need for reliable laboratory assays to assess their anticoagulation effect, and the lack of approved antidotes to reverse their action. This article provides an overview of monitoring the anticoagulant effect of NOACs and their potential specific antidotes in development.
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Affiliation(s)
- Nur A Rahmat
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, UK
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Postoperative Bleeding After Administration of a Single Dose of Rivaroxaban to a Patient Receiving Antiretroviral Therapy. DRUG SAFETY - CASE REPORTS 2015; 2:11. [PMID: 27747723 PMCID: PMC5005638 DOI: 10.1007/s40800-015-0014-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
A 62-year-old man was admitted to hospital for elective revision of a left total hip arthroplasty. His history was significant for human immunodeficiency virus (HIV) infection for which he was taking the following antiretroviral agents (ARVs): etravirine, ritonavir, darunavir, raltegravir and tenofovir/emtricitabine. Rivaroxaban 10 mg daily was commenced on the second postoperative day for venous thromboembolism (VTE) prophylaxis. Approximately 24 h later, the patient developed hypotension and anaemia, accompanied by thigh swelling due to bleeding at the surgical site. Fluid resuscitation was commenced with red cell transfusion. The prothrombin time (PT) was prolonged at 24.3 (10.6–15.3) s, and a rivaroxaban level taken 24 h after administration was 75 ng/mL. Rivaroxaban was ceased, the PT normalised within 24 h of stopping the drug, and the patient made an uneventful recovery. None of the other coadministered drugs are known to interact with rivaroxaban, or are likely to, based on their metabolic pathways. Rivaroxaban, a substrate for cytochrome P450 (CYP) 3A4 and P-glycoprotein (P-gp), is contraindicated in patients concomitantly treated with strong inhibitors of both these systems, e.g. protease inhibitors (PIs) such as ritonavir (based on in vitro data and a pharmacokinetic study in healthy volunteers). No published data are available on the PI darunavir, a moderate inhibitor; however, concomitant use with rivaroxaban should also be avoided. A prolonged PT and a rivaroxaban trough level greater than eight times that predicted from pharmacokinetic modelling suggests that bleeding was due to increased exposure to rivaroxaban, probably due to an interaction with ritonavir and darunavir. This is supported by a Drug Interaction Probability Scale (DIPS) score of 8. An interaction between a single dose of rivaroxaban and ARVs may be clinically significant; therefore, the patient’s medication history should be extensively evaluated to identify any potential interactions.
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Weitz JI, Pollack CV. Practical management of bleeding in patients receiving non-vitamin K antagonist oral anticoagulants. Thromb Haemost 2015; 114:1113-26. [PMID: 26155974 DOI: 10.1160/th15-03-0222] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 05/26/2015] [Indexed: 12/21/2022]
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) are increasingly used in the prevention and treatment of venous thromboembolism and in the prevention of stroke in patients with non-valvular atrial fibrillation. In phase III clinical trials and meta-analyses, the NOACs were at least as effective as vitamin K antagonists (VKAs) and were associated with a similar or lower incidence of major bleeding, including consistent and significant decreases in intracranial bleeding, although with an increase in gastrointestinal bleeding for some agents compared with VKAs. Subsequent real-world evidence supports these outcomes. Despite this, physicians have concerns about serious bleeding or emergencies because there are no specific reversal agents for the NOACs. However, in clinical trials, patients receiving NOACs generally had similar or better outcomes after these events than those taking VKAs. As with any bleeding, anticoagulant-related bleeding should first be stratified according to severity and location; risk can be minimised by ongoing assessment. Management protocols for NOAC-related bleeding are similar to those for VKAs but should take into account the pharmacological profile of the specific drug. Because of their short half-lives, NOAC-related mild bleeding can often be controlled by temporarily withholding treatment. More severe bleeding requires standard escalating haemodynamic support measures, and non-specific reversal agents can be considered in life-threatening situations, based on limited clinical data. Specific and rapid reversal agents are not currently available for any oral anticoagulant and restoration of coagulation may not necessarily lead to better outcomes. Nevertheless, specific NOAC reversal agents are in development and show promise in healthy volunteers.
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Affiliation(s)
- Jeffrey I Weitz
- Dr. Jeffrey Weitz, Thrombosis and Atherosclerosis Research Institute, 237 Barton Street East, Hamilton, ON, L8L 2X2, Canada, Tel.: +1 905 574 8550, Fax: +1 905 575 2646, E-mail:
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Antoniou S. Rivaroxaban for the treatment and prevention of thromboembolic disease. J Pharm Pharmacol 2015; 67:1119-32. [DOI: 10.1111/jphp.12387] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 12/21/2014] [Indexed: 12/26/2022]
Abstract
Abstract
Objectives
A number of direct oral anticoagulants are now available and offer alternative strategies for anticoagulation therapy. Rivaroxaban, a direct oral Factor Xa inhibitor, is approved for use across several thromboembolic indications. This article aims to provide an overview of the key pharmacological characteristics of rivaroxaban and the rationale and evidence for the use of different dose regimens across its licenced indications, and offer practical guidance to healthcare professionals on responsible use. References were sourced via PubMed searches using the search string (rivaroxaban AND (pharmacokinetics OR pharmacodynamics OR (clinical studies) OR (drug interaction)) NOT review NOT (children OR pediatrics OR paediatrics OR adolescent)).
Key findings
Rivaroxaban exhibits predictable pharmacokinetics and pharmacodynamics, and thus does not require routine coagulation monitoring, unlike vitamin K antagonists (e.g. warfarin). Rivaroxaban also has a lower potential for drug–drug and food–drug interactions compared with warfarin; however, co-administration with strong inhibitors of both cytochrome P450 3A4 and P-glycoprotein is not recommended. The data indicate that dose adjustment is not necessary for age, gender or body weight. The dosing regimens of rivaroxaban vary depending on the indication, and phase III studies have demonstrated a favourable benefit–risk profile of rivaroxaban compared with traditional standard of care.
Summary
Rivaroxaban may offer an anticoagulant option that could simplify and improve the management of patients with thromboembolic disorders.
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Affiliation(s)
- Sotiris Antoniou
- Clinical Pharmacy Department, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
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Sümnig A, Grotevendt A, Westphal A, Fiene M, Greinacher A, Thiele T. Acquired hemophilia with inhibitors presenting as an emergency: misinterpretation of clotting results during direct oral anticoagulation. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:345-8. [PMID: 24875459 DOI: 10.3238/arztebl.2014.0345] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 04/01/2014] [Accepted: 04/01/2014] [Indexed: 11/27/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) were recently introduced and are being increasingly prescribed. Most DOACs alter the values of traditional coagulation tests, such as the international normalized ratio (INR) or the activated partial thromboplastin time (aPTT). Although vitamin K antagonists raise the INR value to an extent that mirrors their anticoagulant effect, DOACs do not, in general, alter standard clotting values in any consistent way. Thus, there is a risk that abnormal INR and aPTT values can be misinterpreted. CASE ILLUSTRATION A woman taking rivaroxaban, a DOAC, presented with ileus and was scheduled for urgent surgery. A prolonged aPTT was, at first, wrongly attributed to rivaroxaban, delaying the correct diagnosis of autoantibody-associated acquired hemophilia (a rare condition with incidence, 1.34-1.48 cases per million people per year). The patient had a history of unusually intense bleeding in the skin and mucous membranes during anticoagulant treatment. Her aPTT had been prolonged even before any anticoagulants were taken. COURSE The operation was delayed to await the elimination of rivaroxaban. The aPTT was still prolonged 24 hours later. The diagnosis of autoantibody-associated acquired hemophilia was suspected and then confirmed by the measurement of a factor VIII residual activity of 1% and the demonstration of factor VIII inhibition at an intensity of 9.2 Bethesda units per mL. CONCLUSION The causes of abnormal clotting test results must be clarified before beginning anticoagulant therapy. Unusually intense bleeding during oral anticoagulation should arouse suspicion of a previously undiagnosed acquired coagulopathy, e.g., antibody-associated acquired hemophilia.
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Affiliation(s)
- Ariane Sümnig
- Institute of Immunology and Transfusion Medicine, University Medicine, Ernst-Moritz-Arndt-University of Greifswald, Institute of Clinical Chemistry and Laboratory Medicine, University Medicine, Ernst-Moritz-Arndt-University of Greifswald, Department of Internal Medicine A, University Medicine, Ernst-Moritz-Arndt-University of Greifswald
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Than H, Loh JBE, Sum CLL, Ng HJ. Clinical utility of anti-Xa monitoring and differential sensitivity of prothrombin time assays: an illustrated case report. J Clin Pathol 2015; 68:318-9. [DOI: 10.1136/jclinpath-2014-202748] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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McRae S. Treatment options for venous thromboembolism: lessons learnt from clinical trials. Thromb J 2014; 12:27. [PMID: 25506267 PMCID: PMC4265350 DOI: 10.1186/s12959-014-0027-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 10/31/2014] [Indexed: 02/06/2023] Open
Abstract
Venous thromboembolism (VTE), comprising deep vein thrombosis and pulmonary embolism, is a common condition associated with a significant clinical and economic burden. Anticoagulant therapy is the mainstay of treatment for VTE, having been shown to reduce the risk of death in patients with pulmonary embolism, and recurrence or extension of thrombi in patients with deep vein thrombosis during the initial treatment period. Long-term anticoagulation is indicated in some individuals with VTE, depending on individual risk of VTE recurrence and anticoagulant-related bleeding. Management of VTE in clinical practice is often complex because patients' characteristics and treatment needs may differ considerably from those encountered in clinical trials. Current guidelines recommend the use of either low molecular weight heparins or fondaparinux overlapping with and followed by a vitamin K antagonist for the initial treatment of VTE, with the vitamin K antagonist continued when long-term anticoagulation is required. These traditional anticoagulants have practical limitations that have led to the development of direct oral anticoagulants that directly target either Factor Xa or thrombin and are administered at a fixed dose without the need for routine coagulation monitoring. This review discusses practical considerations for hospital physicians and haematologists in the management of VTE treatment, including the potential for the direct oral anticoagulants to simplify treatment.
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Affiliation(s)
- Simon McRae
- Department of Haematology, SA Pathology, Royal Adelaide and Queen Elizabeth Hospitals, Frome Rd, Adelaide, SA 5000 Australia
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Harder S. Pharmacokinetic and pharmacodynamic evaluation of rivaroxaban: considerations for the treatment of venous thromboembolism. Thromb J 2014; 12:22. [PMID: 25698904 PMCID: PMC4334601 DOI: 10.1186/1477-9560-12-22] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 10/14/2014] [Indexed: 11/17/2022] Open
Abstract
Patients with deep vein thrombosis or pulmonary embolism are recommended to receive anticoagulation for acute treatment and secondary prevention of venous thromboembolism (VTE). Fast-acting direct oral anticoagulants, with or without parenteral heparin, have the potential to replace vitamin K antagonists in this setting. Rivaroxaban, a direct Factor Xa inhibitor, is approved in the European Union and the United States for the single-drug treatment of deep vein thrombosis and pulmonary embolism and the secondary prevention of recurrent VTE in adults. The approved rivaroxaban dose schedule (15 mg twice daily for 3 weeks followed by 20 mg once daily) was derived based on pharmacological data from the clinical development programme to achieve a strong antithrombotic effect in the acute treatment phase and address the need to balance efficacy and bleeding risk for long-term treatment with a once-daily dose in the maintenance phase. Data from dose-ranging studies, pharmacokinetic modelling and randomised phase III trials support the use of this regimen. Other direct oral anticoagulants have also shown favourable efficacy and safety compared with standard treatment, and apixaban (European Union) and dabigatran (European Union and United States) have been approved in this indication. There are practical aspects to rivaroxaban use that must be considered, such as treatment of patients with renal and hepatic impairment, drug–drug interactions, monitoring of effect and management of bleeding. This review discusses the derivation of the VTE treatment regimen for rivaroxaban, summarises the clinical data for rivaroxaban and other direct oral anticoagulants in VTE treatment, and considers the practical aspects of rivaroxaban use in this setting.
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Affiliation(s)
- Sebastian Harder
- Institute of Clinical Pharmacology, Pharmazentrum Frankfurt, University Hospital, Theodor Stern Kai 7, D-60590 Frankfurt am Main, Germany
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Linkins LA, Moffat K. Monitoring the anticoagulant effect after a massive rivaroxaban overdose. J Thromb Haemost 2014; 12:1570-1. [PMID: 25040104 DOI: 10.1111/jth.12669] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 07/13/2014] [Indexed: 12/17/2022]
Abstract
Rivaroxaban is a direct factor Xa inhibitor approved for prevention of stroke, prevention and treatment of venous thromboembolism and secondary prevention of acute coronary syndrome in many countries. As the use of this agent increases, so does the potential for overdose, both intentional and unintentional. Clinical data on overdoses of rivaroxaban in humans are limited. We report the case of a 42-year-old man who took an overdose of 1400 mg of rivaroxaban and describe how resolution of the anticoagulant effect was monitored using readily available coagulation assays.
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Affiliation(s)
- L-A Linkins
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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Mueck W, Stampfuss J, Kubitza D, Becka M. Clinical pharmacokinetic and pharmacodynamic profile of rivaroxaban. Clin Pharmacokinet 2014; 53:1-16. [PMID: 23999929 PMCID: PMC3889701 DOI: 10.1007/s40262-013-0100-7] [Citation(s) in RCA: 369] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Rivaroxaban is an oral, direct Factor Xa inhibitor that targets free and clot-bound Factor Xa and Factor Xa in the prothrombinase complex. It is absorbed rapidly, with maximum plasma concentrations being reached 2-4 h after tablet intake. Oral bioavailability is high (80-100 %) for the 10 mg tablet irrespective of food intake and for the 15 mg and 20 mg tablets when taken with food. Variability in the pharmacokinetic parameters is moderate (coefficient of variation 30-40 %). The pharmacokinetic profile of rivaroxaban is consistent in healthy subjects and across a broad range of different patient populations studied. Elimination of rivaroxaban from plasma occurs with a terminal half-life of 5-9 h in healthy young subjects and 11-13 h in elderly subjects. Rivaroxaban produces a pharmacodynamic effect that is closely correlated with its plasma concentration. The pharmacokinetic and pharmacodynamic relationship for inhibition of Factor Xa activity can be described by an E max model, and prothrombin time prolongation by a linear model. Rivaroxaban does not inhibit cytochrome P450 enzymes or known drug transporter systems and, because rivaroxaban has multiple elimination pathways, it has no clinically relevant interactions with most commonly prescribed medications. Rivaroxaban has been approved for clinical use in several thromboembolic disorders.
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Affiliation(s)
- Wolfgang Mueck
- Clinical Pharmacology, Bayer Pharma AG, Aprather Weg 18a, 42113, Wuppertal, Germany,
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Martínez-Rubio A, Dan GA, Kaski JC. Rivaroxaban and stroke prevention in patients with atrial fibrillation: new evidence. Expert Rev Cardiovasc Ther 2014; 12:933-47. [DOI: 10.1586/14779072.2014.931223] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Haas S, Bode C, Norrving B, Turpie AGG. Practical guidance for using rivaroxaban in patients with atrial fibrillation: balancing benefit and risk. Vasc Health Risk Manag 2014; 10:101-14. [PMID: 24648742 PMCID: PMC3956810 DOI: 10.2147/vhrm.s55246] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Rivaroxaban is a direct factor Xa inhibitor that is widely available to reduce the risk of stroke or systemic embolism in patients with nonvalvular atrial fibrillation and one or more risk factors for stroke. Rivaroxaban provides practical advantages compared with warfarin and other vitamin K antagonists, including a rapid onset of action, few drug interactions, no dietary interactions, a predictable anticoagulant effect, and no requirement for routine coagulation monitoring. However, questions have emerged relating to the responsible use of rivaroxaban in day-to-day clinical practice, including patient selection, dosing, treatment of patients with renal impairment, conversion from use of vitamin K antagonists to rivaroxaban and vice versa, coagulation tests, and management of patients requiring invasive procedures or experiencing bleeding or an ischemic event. This article provides practical recommendations relating to the use of rivaroxaban in patients with nonvalvular atrial fibrillation, based on clinical trial evidence, relevant guidelines, prescribing information, and the authors' clinical experience.
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Affiliation(s)
- Sylvia Haas
- Technical University Munich, Munich, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology, University of Freiburg, Freiburg, Germany
| | - Bo Norrving
- Department of Clinical Neuroscience, Lund University Hospital, Lund, Sweden
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Samama MM. Coagulation Assays in Patients with New Oral Anticoagulants (NOACs): Why? When? Drug Dev Res 2013. [DOI: 10.1002/ddr.21118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Meyer Michel Samama
- Cochin-Broca-Hôtel Dieu University Hospital; Department of Hematology; Paris France
- Biomnis Laboratory; Ivry-sur-Seine France
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