Dabigatran: A new oral anticoagulant. Guidelines to follow in oral surgery procedures. A systematic review of the literature

Patient perception and treatment convenience of dabigatran versus vitamin K antagonist when used for stroke prophylaxis in atrial fibrillation: Real-world Evaluation of Long-term Anticoagulant Treatment Experience (RE-LATE) study

Purpose

Dabigatran is a direct thrombin inhibitor approved for stroke prophylaxis in patients with non-valvular atrial fibrillation (NVAF). Real-world data about patient preference, satisfaction and convenience in patients in Asia are not available. The study aimed to explore the perception of patients with newly diagnosed NVAF regarding dabigatran versus vitamin K antagonists (VKAs), when used for stroke prevention.

Patients and methods

This was a multinational, multicentre, non-interventional study involving 49 sites across 5 countries in South East Asia and South Korea where 934 patients newly diagnosed with NVAF were initiated on either dabigatran (N=591) or VKA (N=343). Data were collected at baseline and over two follow-up visits across 6 months. Treatment satisfaction and patient convenience were evaluated using the Perception on Anticoagulant Treatment Questionnaire-2 (PACT-Q2).

Results

The mean age of the patients was 65.9±10.4 years, and 64.2% were male. Mean CHA₂DS₂-VASc score was 2.4±1.5, and mean HAS-BLED score was 1.2±0.9. At baseline, patients initiated on dabigatran had higher stroke risk, bleeding risk, creatinine clearance and proportion of patients with concomitant illnesses compared with patients initiated on VKAs. Treatment convenience was perceived to be significantly better with dabigatran versus VKAs at visits 2 and 3 (p=0.0423 and 0.0287, respectively). Treatment satisfaction was significantly better with dabigatran compared with VKAs at visit 3 (p=0.0300).

Conclusion

In this study, dabigatran is associated with better patient perception in terms of treatment convenience and satisfaction compared with VKAs when used for stroke prevention in newly diagnosed NVAF patients from South East Asia and South Korea.

Trial registration number

NCT02849509.

Plain language summary

Patient satisfaction with dabigatran versus VKAs in South East Asia. Patients with atrial fibrillation are at high risk of stroke and require anticoagulants for stroke prevention. Two such anticoagulants are dabigatran and VKAs. We wanted to compare the extent of satisfaction and treatment convenience among newly diagnosed patients with atrial fibrillation from the South East Asian region when they were given either dabigatran or VKAs. Consenting patients filled out a standardised questionnaire called the PACT-Q2 over three visits after they were started on either dabigatran (591 patients) or VKAs (343 patients). We found that satisfaction and convenience were significantly higher when patients received dabigatran than when they received VKAs.

Quantification of CYP3A and Drug Transporters Activity in Healthy Young, Healthy Elderly and Chronic Kidney Disease Elderly Patients by a Microdose Cocktail Approach

Background: Ageing and chronic kidney disease (CKD) affect pharmacokinetic (PK) parameters. Since mechanisms are related and remain unclear, cytochrome P450 (CYP) 3A and drug transporter activities were investigated in the elderly with or without CKD and compared to healthy adults using a microdose cocktail. Methods: Healthy young participants (n = 20), healthy elderly participants (n = 16) and elderly patients with CKD (n = 17) received, in study period 1, a single dose of microdose cocktail probe containing 30 µg midazolam, 750 µg dabigatran etexilate, 100 µg atorvastatin, 10 µg pitavastatin, and 50 µg rosuvastatin. After a 14-day wash-out period, healthy young participants continued to study period 2 with the microdose cocktail plus rifampicin. PK parameters including area under the plasma concentration-time curve (AUC), maximum plasma drug concentration (C_max), and half-life were estimated before making pairwise comparisons of geometric mean ratios (GMR) between groups. Results: AUC and C_max GMR (95% confidence interval; CI) of midazolam, a CYP3A probe substrate, were increased 2.30 (1.70-3.09) and 2.90 (2.16-3.88) fold in healthy elderly and elderly patients with CKD, respectively, together with a prolonged half-life. AUC and C_max GMR (95%CI) of atorvastatin, another CYP3A substrate, was increased 2.14 (1.52-3.02) fold in healthy elderly and 4.15 (2.98-5.79) fold in elderly patients with CKD, indicating decreased CYP3A activity related to ageing. Associated AUC changes in the probe drug whose activity could be modified by intestinal P-glycoprotein (P-gp) activity, dabigatran etexilate, were observed in patients with CKD. However, whether the activity of pitavastatin and rosuvastatin is modified by organic anion transporting polypeptide 1B (OATP1B) and of breast cancer resistance protein (BCRP), respectively, in elderly participants with or without CKD was inconclusive. Conclusions: CYP3A activity is reduced in ageing. Intestinal P-gp function might be affected by CKD, but further confirmation appears warranted. Clinical Trial Registration:http://www.thaiclinicaltrials.org/ (TCTR 20180312002 registered on March 07, 2018).

Is it necessary to alter anticoagulation therapy for tooth extraction in patients taking direct oral anticoagulants?

BACKGROUND

The number of patients using direct oral anticoagulants (DOACs) instead of vitamin K antagonists (VKA) is increasing and there is limited data on the safety of tooth extractions in patients taking DOACs. The aim of this study was to compare the amount of bleeding (AOB) and postoperative complications after tooth extractions between patients taking VKAs and patients taking DOACs without altering the anticoaguation therapy.

MATERIAL AND METHODS

The study consisted of four groups: Direct thrombin inhibitor group, factor Xa inhibitor group, warfarin group and a control group. A single tooth was extracted in each patient and routine coagulation test values were recorded prior to extraction. AOB was measured for 20 minutes after tooth extraction. The patients were evaluated on 2nd and 7th days after extraction for bleeding. Status of bleeding was classified as no bleeding, mild bleeding controlled by gauze pads, moderate bleeding controlled by hemostatic agents and severe bleeding required hospitalization. Analysis of variance, chi square test and correlation analysis were used for statistical analysis of data.

RESULTS

A total of 84 patients (48 male, 36 female) were included in this study. The mean age of patients was 57 (38-87) years. Mean AOB was 1388.6±913.0, 1909.29±1063.1, 3673±1415.4, 1593.33±672.5 mg for direct thrombin inhibitor, factor Xa inhibitor, warfarin and control groups respectively. Mean AOB was significantly higher for warfarin group, compared to other groups (p<0.05). The number of patients showing mild and moderate bleeding was significantly higher in warfarin group compared to other groups on the 2nd postextraction day (p=0.001). No bleeding was occurred in control group on 2nd and 7th postextraction days and no bleeding was occurred in direct thrombin inhibitor group on 7th postextraction day. The number of bleeding events among groups was not statistically significant on 7th postextraction day (p=0.251).

CONCLUSIONS

Patients taking warfarin had more bleeding compared to patients taking direct oral anticoagulants after tooth extractions. In patients taking direct oral anticoagulants simple tooth extractions can be safely carried out without altering the anticaogulant regimen with the use of local hemostatic agents.

Dentists' Knowledge, Attitude and Practice in Treating Patients Taking Oral Antithrombotic Medications - A Survey

INTRODUCTION

India lists high on patients suffering from diabetes, hypertension, stroke and myocardial infarction. Hence, a large proportion of the population is on long term Oral Antithrombotic Medications (OAM). Though several guidelines exist on dental management of these patients, previous surveys have shown variation among the dentists.

AIM

The purpose of this study was to assess the knowledge, attitude and practice of dentists in Chennai, India, towards dental management of patients taking OAM using a questionnaire survey.

MATERIALS AND METHODS

The survey was conducted among 256 dentists in Chennai, India using a printed questionnaire containing 16 questions, at their university location. Descriptive statistical analysis was used to analyze the data.

RESULTS

Of the final population of dentists who were included in the survey (n =212), majority of them were aware about drugs such as warfarin and aspirin compared to other newer drugs (dabigatran, rivaroxaban). Most participants took physician's opinion before proceeding with any invasive dental procedure and thromboembolic events were their major concern while treating patients on OAM.

CONCLUSION

The survey revealed dentists are knowledgeable about management of patients on OAM. However, they tend to overestimate the bleeding risk, thus being cautious in their treatment approach. Based on the results of the study, the authors suggest that continuing dental education programs and further training on management of such medically complex patients will be beneficial in order to provide optimum dental care to people taking OAM.