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Perez-Bernat E, Viñas MªA, Vera M, González-Rico M, Montomoli M, Astudillo-Cortés E, Quevedo-Reina JC, García-Méndez I, Martinez-Losa A, Rama-Arias I, Maldonado-Martín M, Munar MªA, Cerrato AO, Beltrán-Catalán S, Peso GD, Cases A, Górriz JL. Non-valvular atrial fibrillation in patients on peritoneal dialysis, prevalence, treatment and professionals involved. Nefrologia 2024:S2013-2514(24)00066-X. [PMID: 38609756 DOI: 10.1016/j.nefroe.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 06/12/2023] [Indexed: 04/14/2024] Open
Abstract
Atrial fibrillation is the most frequent chronic arrhythmia in patients with chronic kidney disease. Oral anticoagulation with vitamin K antagonists and now direct oral anticoagulants have been and are the fundamental pillars for the prevention of thromboembolic events. However, there are no randomized clinical trials on the risk-benefit profile of oral anticoagulation in patients with chronic kidney disease stage 5 on peritoneal dialysis and there is little evidence in the literature in this population. The objective of our study was to know the prevalence, treatment and professionals involved in the management of atrial fibrillation in peritoneal dialysis patients. For this purpose, we performed a descriptive analysis through a survey sent to different peritoneal dialysis units in Spain. A total of 1,403 patients on peritoneal dialysis were included in the study, of whom 186 (13.2%) had non-valvular atrial fibrillation. In addition, the assessment of the scores of thromboembolic and bleeding risks for the indication of oral anticoagulation was mainly carried out by the cardiologist (60% of the units), as well as its prescription (cardiologist 47% or in consensus with the nephrologist 43%). In summary, patients on peritoneal dialysis have a remarkable prevalence of non-valvular atrial fibrillation. Patients frequently receive oral anticoagulation with vitamin K antagonists, as well as direct oral anticoagulants. The data obtained regarding the scores used for the assessment of thromboembolic and bleeding risk, treatment and involvement by Nephrology indicates that there is a need for training and involvement of the nephrologist in this pathology.
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Affiliation(s)
- Elisa Perez-Bernat
- Servicio de Nefrología, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - M ª Angeles Viñas
- Servicio de Urgencias, Hospital Universitari i Politecnic La Fe, Valencia, Spain
| | - Manel Vera
- Servicio de Nefrología, Hospital Clínic, Barcelona, Spain
| | - Miguel González-Rico
- Servicio de Nefrología, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Marco Montomoli
- Servicio de Nefrología, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | | | | | | | | | - Ines Rama-Arias
- Servicio de Nefrología, Hospital Univesitario de Bellvitge, Barcelona, Spain
| | | | - M ª Antonia Munar
- Servicio de Nefrología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Agustín Ortega Cerrato
- Servicio de Nefrología, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
| | | | - Gloria Del Peso
- Servicio de Nefrología, Hospital Universitario La Paz, Madrid, Spain
| | - Aleix Cases
- Servicio de Nefrología, Hospital Clínic, Barcelona, Spain; Universitat de Barcelona, Barcelona, Spain.
| | - Jose Luis Górriz
- Servicio de Nefrología, Hospital Clínico Universitario de Valencia, Valencia, Spain; Universitat de València, Valencia, Spain
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Yamazoe S, Imai H, Ogawa Y, Kano N, Murase Y, Mamiya K, Ikeda T, Hiramatsu K, Torii J, Kawaguchi K. The effect of off-label use of reduced-dose direct oral anticoagulants therapy in the treatment of pulmonary embolism comparable to standard-dose therapy. Heart Vessels 2024; 39:365-372. [PMID: 38381170 PMCID: PMC10920432 DOI: 10.1007/s00380-023-02339-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 11/08/2023] [Indexed: 02/22/2024]
Abstract
Direct oral anticoagulants (DOACs) have been shown to be effective and safe in preventing pulmonary embolism recurrence. In this single-center retrospective observational study, we aimed to evaluate the efficacy and safety of reduced-dose DOACs in 86 consecutive patients with acute pulmonary embolism. Patients were divided into standard-dose and reduced-dose DOACs groups. Initial clot volume did not significantly differ between the two groups (standard-dose DOACs vs. reduced-dose DOACs, 18.8 [Q1-Q3 7.3-30.8] mL vs. 10.0 [Q1-Q3 3.2-27.9] mL, p = 0.1). Follow-up computed tomography (CT) within 30 days showed a higher rate of clot volume reduction or disappearance in the standard-dose group compared to the reduced-dose group (standard-dose DOACs vs. reduced-dose DOACs, 81.6% vs. 53.9%, p = 0.02). However, at the final follow-up CT, there was no significant difference in clot volume change between the two groups (standard-dose DOACs vs. reduced-dose DOACs, 91.5% vs. 82.0%, p = 0.19). Major bleeding occurred in two patients in the standard-dose group (4.3%) and three patients in the reduced-dose DOACs group (7.7%) (p = 0.5). In conclusion, while standard-dose DOACs demonstrated superior efficacy in early clot reduction, reduced doses of apixaban and edoxaban showed comparable efficacy and safety profiles in long-term treatment of acute pulmonary embolism in certain patients.
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Affiliation(s)
- Shinji Yamazoe
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Hajime Imai
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan.
| | - Yasuhiro Ogawa
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Naoaki Kano
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Yosuke Murase
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Keita Mamiya
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Tomoyo Ikeda
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Kei Hiramatsu
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Jun Torii
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
| | - Katsuhiro Kawaguchi
- Department of Cardiology, Komaki City Hospital, 1-20 Joubushi, Komaki, Aichi, 485-8520, Japan
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Elshaer A, Abraham NS. Management of Anticoagulant and Antiplatelet Agents in Acute Gastrointestinal Bleeding and Prevention of Gastrointestinal Bleeding. Gastrointest Endosc Clin N Am 2024; 34:205-216. [PMID: 38395479 DOI: 10.1016/j.giec.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Managing gastrointestinal bleeding in patients using antithrombotic agents remains challenging in clinical practice. This review article provides a comprehensive and evidence-based approach to managing acute antithrombotic-related gastrointestinal bleeding, focusing on the triage of patients, appropriate resuscitation, and timely endoscopy. The latest clinical practice guidelines are highlighted to guide decisions concerning the use of reversal agents, temporary interruption, and resumption of antithrombotic drugs. Additionally, preventive measures are discussed to lower the risk of future bleeding and minimize complications among patients prescribed antithrombotic drugs.
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Affiliation(s)
- Amany Elshaer
- Department of Internal Medicine, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA
| | - Neena S Abraham
- Department of Internal Medicine, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA; Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ 85259, USA.
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Simard C, Poirier-Blanchette L, Rizzolo A, Cafaro T, Kerzner R, Mantzanis H, Koolian M. Standardized direct oral anticoagulants prescription for treatment of acute venous thromboembolism in the emergency department: A quality improvement initiative. Thromb Res 2024; 236:68-73. [PMID: 38401355 DOI: 10.1016/j.thromres.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/30/2024] [Accepted: 02/14/2024] [Indexed: 02/26/2024]
Abstract
INTRODUCTION Direct oral anticoagulants (DOACs) are commonly used for the treatment and prevention of venous thromboembolism (VTE). However, prescription errors with DOACs can lead to patient dissatisfaction and harm. This study aimed to evaluate the impact of a standardized prescription for DOACs for VTE on prescription appropriateness. MATERIALS AND METHODS The study included patients discharged from the Emergency Department (ED) with a DOAC prescription for an acute VTE. A standardized prescription tool was developed and implemented, and patients were divided into pre- and post-intervention groups. The appropriateness of prescriptions was assessed using the Medication Appropriateness Index (MAI). RESULTS A total of 161 patients with VTE were included in the study. The post-intervention group showed a significant increase in prescriptions with an MAI rating of "appropriate" and a decrease in ratings of "inappropriate." Improvements were observed in loading dose duration, maintenance dose frequency and duration, and inclusion of necessary drug coverage codes. CONCLUSION The implementation of a standardized prescription for DOACs in the management of VTE in the ED significantly improved medication appropriateness and reduced inappropriate prescriptions. Standardized prescriptions have the potential to enhance patient safety and optimize care by providing clear and uniform guidance to healthcare providers. Further research is needed to explore the effectiveness of medication prescription software systems in real-world clinical settings to improve prescribing practices.
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Affiliation(s)
- C Simard
- Division of General Internal Medicine, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Centre of Excellence in Thrombosis and Anticoagulation, Jewish General Hospital, McGill University, Montreal, Quebec, Canada.
| | | | - A Rizzolo
- Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - T Cafaro
- Division of General Internal Medicine, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - R Kerzner
- Department of Pharmacy, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - H Mantzanis
- Department of Pharmacy, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - M Koolian
- Division of General Internal Medicine, Jewish General Hospital, McGill University, Montreal, Quebec, Canada; Centre of Excellence in Thrombosis and Anticoagulation, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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Chen IW, Kao CL, Ho CN, Hung KC. Association between direct oral anticoagulants and risk of gastrointestinal bleeding. Eur J Intern Med 2024; 122:144-145. [PMID: 38388294 DOI: 10.1016/j.ejim.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 02/10/2024] [Indexed: 02/24/2024]
Affiliation(s)
- I-Wen Chen
- Department of Anesthesiology, Chi Mei Medical Center, Liouying, Tainan city, Taiwan
| | - Chia-Li Kao
- Department of Anesthesiology, E-Da Hospital, I-Shou University, Kaohsiung City, Taiwan
| | - Chun-Ning Ho
- Department of Anesthesiology, Chi Mei Medical Center, Tainan city, Taiwan
| | - Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan city, Taiwan.
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Mruthunjaya AKV, Chatelier RC, Torriero AAJ. Calibration-free electrochemical sensor to monitor factor-Xa inhibitors at the point-of-care anticoagulation therapy. Talanta 2024; 270:125593. [PMID: 38159356 DOI: 10.1016/j.talanta.2023.125593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
This article presents a novel proof of concept for the blood plasma quantification of clinically relevant concentrations of direct oral anticoagulants, DOACs, including rivaroxaban and edoxaban, as well as low-molecular-weight heparins, LMWHs, such as enoxaparin and dalteparin, utilising a calibration-free disposable electrochemical sensor with co-facing electrodes. A dose-response curve was generated for rivaroxaban and edoxaban to demonstrate the sensor's ability to detect ≥9.00 ng mL-1 rivaroxaban and quantify it in the 11.0-140 ng mL-1 range. Similarly, the lower detection limit for edoxaban was 12.9 ng mL-1, with a quantification range of 16.8-140 ng mL-1. The significance of this sensor lies in its ability to quantify rivaroxaban and edoxaban below 30 ng mL-1, which is crucial in emergency care centres when patients undergoing DOAC therapy require emergency surgery or reversal of DOACs due to bleeding or ischemic stroke. Furthermore, the sensor can detect ≥0.016 IU mL-1 enoxaparin and ≥0.013 IU mL-1 dalteparin and quantify them in the 0.025-0.75 and 0.019-0.75 IU mL-1 range, respectively. Additionally, a dose-response curve was presented to demonstrate the potential ability of this sensor to quantify factor-Xa inhibitors independently of which DOACs or LMWHs are used. With the assay completed in less than 30 s using a minimal volume of 7 μL sample, the possibility to work at physiological pH and under calibration-free format makes this assay an excellent candidate for point-of-care testing.
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Affiliation(s)
- Ashwin K V Mruthunjaya
- School of Life and Environmental Sciences, Deakin University, Burwood, Victoria, 3125, Australia
| | - Ronald C Chatelier
- School of Life and Environmental Sciences, Deakin University, Burwood, Victoria, 3125, Australia
| | - Angel A J Torriero
- School of Life and Environmental Sciences, Deakin University, Burwood, Victoria, 3125, Australia.
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Polo-García J, Pallares-Carratalá V, Turegano-Yedro M, Romero-Vigara JC, Prieto-Díaz MA, Cinza-Sanjurjo S. [Current situation of direct oral anticoagulants in primary care in Spain: Positioning of SEMERGEN in 2023]. Semergen 2024; 50:102136. [PMID: 38052147 DOI: 10.1016/j.semerg.2023.102136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 10/20/2023] [Indexed: 12/07/2023]
Abstract
Oral anticoagulation is the key to reduce the risk of stroke in atrial fibrillation. Although vitaminK antagonists (VKA) have classically been used for this purpose, they have been largely overcome by direct oral anticoagulants (DOAC), as demonstrated by evidence from clinical trials, real-life and population studies. In fact, all clinical practice guidelines recommend their use preferentially over VKA. However, in Spain the prescription of DOAC is subordinated to an inspection visa that includes the clinical conditions defined in the Therapeutic Positioning Report of the Spanish Medicines Agency, and that still imposes important restrictions on their use, limiting the benefits of using DOACs in patients with atrial fibrillation (AF), and also generating inequalities between the different autonomous communities. In fact, the use of DOAC in Spain is much lower than that observed in neighboring countries. This has made that while in other countries the incidence of ischemic stroke has decreased at the population level, along with a reduction in the cost per patient with AF, in Spain this decrease has been modest. For all these reasons, and for assuring the sustainability of the health care system, we ask for the elimination of the visa so that DOAC can be prescribed according to the recommendations made by the guidelines. In addition, we are also committed to reinforce medical education and decisions made by consensus with the patient, with the primary care physician acquiring a key role in the protection of the patient with AF.
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Affiliation(s)
- J Polo-García
- Medicina Familiar y Comunitaria, Centro de Salud Casar de Cáceres, Casar de Cáceres, Cáceres, España
| | - V Pallares-Carratalá
- Medicina Familiar y Comunitaria, Departamento de Medicina, Universidad JaimeI, Castellón, España.
| | - M Turegano-Yedro
- Medicina Familiar y Comunitaria, Centro de Salud Casar de Cáceres, Casar de Cáceres, Cáceres, España
| | - J C Romero-Vigara
- Medicina Familiar y Comunitaria, Centro de Salud Alfajarín, Alfajarín, Zaragoza, España
| | - M A Prieto-Díaz
- Medicina Familiar y Comunitaria, Centro de Salud Vallobín-La Florida, Oviedo, España
| | - S Cinza-Sanjurjo
- Medicina Familiar y Comunitaria, Centro de Salud Milladoiro, Área de Salud de Santiago de Compostela. Instituto de Investigación en Salud de Santiago de Compostela (IDIS). Centro de Investigación Biomédica en Red-Enfermedades Cardiovasculares (CIBERCV), Santiago de Compostela, La Coruña, España
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Abane C, Gominard P, Hardy J, Alain A, Marcheix PS. Should recommended laboratory-test cut-offs allowing surgery be followed for proximal femoral fractures in patients on direct oral anticoagulant therapy? Orthop Traumatol Surg Res 2024; 110:103819. [PMID: 38278346 DOI: 10.1016/j.otsr.2024.103819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 07/10/2023] [Accepted: 10/11/2023] [Indexed: 01/28/2024]
Abstract
BACKGROUND Proximal femoral fractures (PFFs) in elderly patients must receive prompt surgical treatment. Optimal PFF-surgery timing in patients on direct oral anticoagulant (DOA) therapy is a specific but common clinical issue. Recommendations exist about the anti-Xa or anti-IIa levels and creatinine clearance values required to allow surgery. The objectives of this study in patients older than 75 years who required PFF surgery were to evaluate bleeding when the recommendations were versus were not applied and to assess concordance between DOA-activity-assay results and creatinine clearance used to help determine the wait to surgery. HYPOTHESIS Peri-operative bleeding is more marked when surgery is performed while the DOA is still active. PATIENTS AND METHODS This single-centre, retrospective, comparative, observational study included 87 patients older than 75 years who required arthroplasty or intra-medullary nailing for PFF and were taking DOA therapy. Surgery was performed after versus before the laboratory-test results fell below the recommended cut-offs in 68 patients (Rec+ group) versus 19 patients (Rec- group), respectively. The study outcomes were blood loss estimated using the Mercuriali's formula and the proportion of patients requiring post-operative blood transfusions. RESULTS Mean blood loss was 287.1mL in the Rec+ group and 411.7mL in the Rec- group (p=0.12). Blood transfusions were required by a post-operative haemoglobin level below 0.8g/dL in 11 (16.2%) Rec+ patients and 6 (31.6%) Rec- patients (p=0.2). Concordance was poor between DOA activity and creatinine clearance (Cohen's κ, 0.16; p=0.146). DISCUSSION Peri-operative bleeding was not significantly more severe when PFF surgery was performed while DOA therapy was still active. These data suggest that PFF surgery within 48h may be appropriate in patients older than 75 years on DOA therapy. LEVEL OF EVIDENCE IV; retrospective single-centre study.
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Affiliation(s)
- Cynthia Abane
- Service d'orthopédie-traumatologie, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - Pierre Gominard
- Service d'orthopédie-traumatologie, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - Jérémy Hardy
- Service d'orthopédie-traumatologie, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - Armand Alain
- Service d'orthopédie-traumatologie, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - Pierre-Sylvain Marcheix
- Service d'orthopédie-traumatologie, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France.
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Al Zaria MH, Buckley LF, Dell'orfano H, Manzo P, Fanikos J. Management of direct oral anticoagulant drug interactions in hospitalized patients. J Thromb Thrombolysis 2024:10.1007/s11239-024-02967-2. [PMID: 38554223 DOI: 10.1007/s11239-024-02967-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/08/2024] [Indexed: 04/01/2024]
Abstract
Moderate-strong CYP3A4 or Pgp inhibitors and inducers alter direct oral anticoagulant (DOAC) pharmacokinetics. Whether the presence of a DOAC drug-drug interaction (DDI) prompts in- hospital changes in management remains unknown. We identified all hospitalized patients at our institution who were admitted with a clinically relevant DOAC DDI from 01/2021 to 06/2021. Clinically relevant DOAC DDIs were defined as those listed in the prescribing information or FDA CYP3A4/Pgp inhibitors clinical indexes. We assessed the prevalence of DOAC DDIs and categorized their management as: drug stopped, drug held, or drug continued. For drugs that were continued we assessed whether the dose of the DOAC or interacting drug was increased, decreased or unchanged during the admission. We ascertained the number of DOAC DDIs that prompted an automated prescribing alert in our electronic health record (EHR). Finally, we conducted a logistic regression model to compare users of DOACs with DDI who had their regimen adjusted versus those without adjustments, focusing on outcomes of rehospitalization and death, adjusting for age and gender. Among 3,725 hospitalizations with a DOAC admission order, 197 (5%) had a clinically relevant DOAC DDI. The DOAC and the interacting drug were continued at discharge for 124 (63%) hospitalizations. The most frequent adjustments were stopping the interacting drug (73%) and stopping the DOAC (15%). Only 7 (4%) of DOAC DDIs prompted an EHR alert. The adjusted odds ratios for rehospitalizations and death, respectively, among patients whose regimens were adjusted compared to those whose were not, were 1.29 (95% CI, 0.67 to 2.48; P = 0.44) and 1.88 (95% CI, 0.91 to 3.89; P = 0.09). Clinically relevant DDIs with DOACs occur infrequently among hospitalized patients and usually are managed without stopping the DOAC. The clinical impact of such DDIs and subsequent adjustments on thrombotic and hemorrhagic outcomes requires further investigation.
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Affiliation(s)
- Mohsen H Al Zaria
- Department of Pharmacy Services, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.
| | - Leo F Buckley
- Department of Pharmacy Services, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Heather Dell'orfano
- Department of Pharmacy Services, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - Peter Manzo
- Department of Pharmacy Services, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
| | - John Fanikos
- Department of Pharmacy Services, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
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10
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Russo V, Caiazza E, Femine FCD, Pezzullo E, Sarpa S, Ianniciello A, Alfredo C, D'Andrea A, Golino P, Nigro G. Predictors of Plasma Levels of Direct Oral Anticoagulants Among Patients with Atrial Fibrillation in Need of Elective Cardiac Procedures. Cardiovasc Drugs Ther 2024:10.1007/s10557-024-07573-1. [PMID: 38507041 DOI: 10.1007/s10557-024-07573-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND The withdrawal timing of direct oral anticoagulants (DOACs) among patients in need of elective invasive surgery is based on DOAC pharmacokinetics in order to perform the procedure out of the DOAC peak plasma concentration. We aimed to investigate the prevalence and predictors of plasma levels of DOACs out of trough range in patients with atrial fibrillation (AF) in need of elective cardiac procedure. MATERIALS AND METHODS We evaluated all consecutive AF patients on DOAC therapy in need of elective cardiac procedure, admitted to our division from January 2022 to March 2022. All patients underwent DOAC plasma dosing the morning of procedure day. They were categorized as in range, above range, and below range, according to the DOAC reference range at the downstream point. The timing of discontinuation of DOAC therapy was considered as appropriate or not, according to the current recommendations. The clinical predictors of out-of-range DOAC plasma levels have been evaluated. RESULTS We included 90 consecutive AF patients (56.6% male, mean age 72.95 ± 10.12 years); 74 patients (82.22%) showed DOAC concentration out of the expected reference range. In half of them (n, 37), the DOAC plasma concentration was below the trough reference range. Of the study population, 17.7% received inappropriate DOAC dosages (10% overdosing, 7% underdosing), and 35.5% had incorrect timing of DOAC withdrawal (26% prolonged, 9.5% shortened). At multivariable analysis, inappropriate longer DOAC withdrawal period (OR 10.13; P ≤ 0.0001) and increased creatinine clearance (OR 1.01; P = 0.0095) were the independent predictors of plasma DOAC levels below the therapeutic trough range. In contrast, diabetes mellitus (OR 4.57; P = 0.001) was the only independent predictor of DOAC plasma level above the therapeutic trough range. CONCLUSION Increased creatinine clearance and inappropriate longer drug withdrawal period are the only independent predictors of DOAC plasma levels below the reference range; in contrast, diabetes is significantly correlated with DOAC plasma levels above the reference.
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Affiliation(s)
- Vincenzo Russo
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, 80136, Naples, Italy.
| | - Eleonora Caiazza
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, 80136, Naples, Italy
| | - Fiorella Chiara Delle Femine
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, 80136, Naples, Italy
| | - Enrica Pezzullo
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, 80136, Naples, Italy
| | - Sara Sarpa
- Clinical Biochemistry Unit, Monaldi Hospital, Naples, Italy
| | - Antonio Ianniciello
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, 80136, Naples, Italy
| | - Caturano Alfredo
- Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | | | - Paolo Golino
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, 80136, Naples, Italy
| | - Gerardo Nigro
- Cardiology Unit, Department of Medical Translational Sciences, University of Campania "Luigi Vanvitelli" - Monaldi Hospital, 80136, Naples, Italy
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Diesveld MME, Pijnenburg DWMJ, Weersink RA, Barzel I, Drenth JPH, Lisman T, Metselaar HJ, Monster-Simons MH, Mulder MB, Okel E, Taxis K, Borgsteede SD. Recommendations for the safe use of direct oral anticoagulants in patients with cirrhosis based on a systematic review of pharmacokinetic, pharmacodynamic and safety data. Eur J Clin Pharmacol 2024:10.1007/s00228-024-03648-y. [PMID: 38430266 DOI: 10.1007/s00228-024-03648-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/03/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE The popularity of direct oral anticoagulants (DOACs) is increasing among patients with cirrhosis. Cirrhosis has a major impact on the pharmacokinetics of drugs, potentially increasing adverse events. Safe use of drugs in cirrhosis requires a diligent risk-benefit analysis. The aim of this study is to develop practice recommendations for safe use of DOACs in cirrhosis based on a systematic review of pharmacokinetic, pharmacodynamic and safety data. METHODS We conducted a systematic literature search to identify studies on pharmacokinetics, pharmacodynamics and safety of DOACs in cirrhosis. Data were collected and presented in summary tables by severity of cirrhosis using the Child-Turcotte-Pugh (CTP) classification. A multidisciplinary expert panel evaluated the results and classified the DOACs according to safety. RESULTS Fifty four studies were included. All DOACs were classified as 'no additional risks known' for CTP A. For CTP B, apixaban, dabigatran and edoxaban were classified as 'no additional risks known'. Apixaban and edoxaban showed fewer adverse events in patients with cirrhosis, while dabigatran may be less impacted by severity of cirrhosis based on its pharmacokinetic profile. Rivaroxaban was classified as 'unsafe' in CTP B and C based on significant pharmacokinetic alterations. Due to lack of data, apixaban, dabigatran and edoxaban were classified as 'unknown' for CTP C. CONCLUSION DOACs can be used in patients with CTP A cirrhosis, and apixaban, dabigatran and edoxaban can also be used in CTP B. It is recommended to avoid rivaroxaban in CTP B and C. There is insufficient evidence to support safe use of other DOACs in CTP C cirrhosis.
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Affiliation(s)
| | | | - Rianne A Weersink
- Deventer Hospital, Department of Clinical Pharmacy, Deventer, The Netherlands
- Radboud University Medical Center, Department of Pharmacy, Nijmegen, The Netherlands
| | - Ina Barzel
- Erasmus University Medical Center, Department of Hospital Pharmacy, Rotterdam, The Netherlands
| | - Joost P H Drenth
- Radboud University Medical Center, Department of Gastroenterology, Nijmegen, The Netherlands
| | - Ton Lisman
- University of Groningen, University Medical Center Groningen, Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Groningen, The Netherlands
| | - Herold J Metselaar
- Erasmus University Medical Center, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands
| | - Margje H Monster-Simons
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands
- University of Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Midas B Mulder
- Erasmus University Medical Center, Department of Hospital Pharmacy, Rotterdam, The Netherlands
| | - Eline Okel
- Pharmacy Zorgapotheken Flevoland, Almere, The Netherlands
| | - Katja Taxis
- University of Groningen, Groningen Research Institute of Pharmacy, Unit of Pharmacotherapy, -Epidemiology & -Economics, Groningen, The Netherlands
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Tripodi A, Clerici M, Scalambrino E, Agosti P, Bucciarelli P, Peyvandi F. How the Hemostasis Laboratory Can Help Clinicians to Manage Patients on Oral Anticoagulants. Mediterr J Hematol Infect Dis 2024; 16:e2024027. [PMID: 38468834 PMCID: PMC10927209 DOI: 10.4084/mjhid.2024.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/14/2024] [Indexed: 03/13/2024] Open
Abstract
Oral anticoagulants are widely used to treat or prevent cardiovascular diseases in millions of patients worldwide. They are the drugs of choice for stroke prevention and systemic embolism in patients with non-valvular atrial fibrillation and prosthetic heart valves, as well as for treatment/prevention of venous thromboembolism. Oral anticoagulants include vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs). The hemostasis laboratory plays a crucial role in the management of treated patients, spanning from dose adjustment based on laboratory testing that applies to VKAs to the measurement of drug concentrations in special situations that apply to DOACs. This article aims to overview how the hemostasis laboratory can help clinicians manage patients on oral anticoagulants. Special interest is devoted to the international normalized ratio, used to manage patients on VKAs and to the measurement of DOAC concentrations, for which the role of the laboratory is still not very well defined, and most interferences of DOACs with some of the most common hemostatic parameters are not widely appreciated.
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Affiliation(s)
- Armando Tripodi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi, Heomophilia and Thrombosis Center, Milan, Italy
| | - Marigrazia Clerici
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi, Heomophilia and Thrombosis Center, Milan, Italy
| | - Erica Scalambrino
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi, Heomophilia and Thrombosis Center, Milan, Italy
| | - Pasquale Agosti
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi, Heomophilia and Thrombosis Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
| | - Paolo Bucciarelli
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi, Heomophilia and Thrombosis Center, Milan, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi, Heomophilia and Thrombosis Center, Milan, Italy
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milano, Italy
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13
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de Lucena LA, Freitas MAA, Souza AKC, Silva CHA, Watanabe JMF, Guedes FL, Almeida JB, de Oliveira RA. Direct oral anticoagulants versus vitamin K antagonists in patients with atrial fibrillation and stage 5 chronic kidney disease under dialysis: A systematic review and meta-analysis of randomized controlled trials. J Thromb Thrombolysis 2024; 57:381-389. [PMID: 38281231 DOI: 10.1007/s11239-023-02945-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND In patients with atrial fibrillation (AF) and normal or slightly impaired renal function, the use of direct oral anticoagulants (DOACs) is preferable to vitamin K antagonists (VKAs). However, in patients undergoing hemodialysis, the efficacy, and safety of DOACs compared with VKAs are still unknown. PURPOSE To review current evidence about the safety and efficacy of DOACs compared to VKAs, in patients with AF and chronic kidney disease under hemodialysis. METHODS We systematically searched PubMed, Scopus, and Cochrane databases for RCTs comparing DOACs with VKAs for anticoagulation in patients with AF on dialysis therapy. Outcomes of interest were: (1) stroke; (2) major bleeding; (3) cardiovascular mortality; and (4) all-cause mortality. Statistical analysis was performed using RevMan 5.1.7 and heterogeneity was assessed by I2 statistics. RESULTS Three randomized controlled trials were included, comprising a total of 383 patients. Of these, 218 received DOACs (130 received apixaban; 88 received rivaroxaban), and 165 were treated with VKAs (116 received warfarin; 49 received phenprocoumon). The incidence of stroke was significantly lower in patients treated with DOACs (4.7%) compared with those using VKAs (9.5%) (RR 0.42; 95% CI 0.18-0.97; p = 0.04; I2 = 0%). However, the difference was not statistically significant in the case of ischemic stroke specifically (RR 0.42; 95% CI 0.17-1.04; p = 0.06; I2 = 0%). As for the major bleeding outcome, the DOAC group (11%) had fewer events than the VKA group (13.9%) but without statistical significance (RR 0.75; 95% CI 0.45-1.28; p = 0.29; I2 = 0%). There was no significant difference between groups regarding cardiovascular mortality (RR 1.23; 95% CI 0.66-2.29; p = 0.52; I2 = 13%) and all-cause mortality (RR 0.98; 95% CI 0.77-1.24; p = 0.84; I2 = 16%). CONCLUSION This meta-analysis suggests that in patients with AF on dialysis, the use of DOACs was associated with a significant reduction in stroke, and a numerical trend of less incidence of major bleeding compared with VKAs, but in this case with no statistical significance. Results may be limited by a small sample size or insufficient statistical power.
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Affiliation(s)
- Larissa A de Lucena
- Department of Health Sciences, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Marcos A A Freitas
- Department of Medicine, State University of Região Tocantina do Maranhão, Department of Medicine, Imperatriz, Brazil
| | - Ana K C Souza
- Department of Health Sciences, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Caroliny H A Silva
- Department of Health Sciences, Federal University of Rio Grande do Norte, Natal, Brazil
| | | | - Felipe L Guedes
- Division of Nephrology, University Hospital Onofre Lopes, Natal, Brazil
| | - Jose B Almeida
- Department of Integrated Medicine, Federal University of Rio Grande do Norte, Nilo Peçanha Avenue, 620, 3rd underground - Petroópolis, Natal, 59012-300, Brazil
| | - Rodrigo A de Oliveira
- Department of Integrated Medicine, Federal University of Rio Grande do Norte, Nilo Peçanha Avenue, 620, 3rd underground - Petroópolis, Natal, 59012-300, Brazil.
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14
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Bo M, Fumagalli S, Degli Esposti L, Perrone V, Dovizio M, Poli D, Marcucci R, Verdecchia P, Reboldi G, Lip GYH, Ungar A, Boccanelli A, Fumagalli C, Marchionni N. Anticoagulation in atrial fibrillation. A large real-world update. Eur J Intern Med 2024; 121:88-94. [PMID: 37879969 DOI: 10.1016/j.ejim.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/03/2023] [Accepted: 10/10/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION In a large nationwide administrative database including ∼35 % of Italian population, we analyzed the impact of oral anticoagulant treatment (OAT) in patients with a hospital diagnosis of non-valvular atrial fibrillation (NVAF). METHODS AND RESULTS Of 170404 OAT-naïve patients (mean age 78.7 years; 49.4 % women), only 61.1 % were prescribed direct oral anticoagulants, DOACs, or vitamin-K antagonists, VKAs; 14.2 % were given aspirin (ASA), and 24.8 % no anti-thrombotic drugs (No Tx). We compared ischemic stroke (IS), IS and systemic embolism (IS/SE), intracranial hemorrhage (ICH), major bleeding (MB), major gastro-intestinal bleeding, all-cause deaths and the composite outcome, across four propensity-score matched treatment cohorts with >15400 patients each. Over 2.9±1.5 years, the incidence of IS and IS/SE was slightly less with VKAs than with DOACs (1.62 and 1.84 vs 1.81 and 1.99 events.100 person-years; HR=0.85, 95%CI=0.76-0.95 and HR=0.87, 95%CI=0.78-0.97). This difference disappeared in a sensitivity analysis which excluded those patients treated with low-dose of apixaban, edoxaban, or rivaroxaban (41.7% of DOACs cohort). Compared with DOACs, VKAs were associated with greater incidence of ICH (1.09 vs 0.81; HR=1.38, 95%CI=1.17-1.62), MB (3.78 vs 3.31; HR=1.14, 95%CI=1.02-1.28), all-cause mortality (9.66 vs 10.10; HR=1.07, 95%CI=1.02-1.11), and composite outcome (13.72 vs 13.32; HR=1.04, 95%CI=1.01-1.08). IS, IS/SE, and mortality were more frequent with ASA or No Tx than with VKAs or DOACs (p<0.001 for all comparisons). CONCLUSIONS Beyond confirming the association with a better net clinical benefit of DOACs over VKAs, our findings substantiate the large proportion of NVAF patients still inappropriately anticoagulated, thereby reinforcing the need for educational programs.
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Affiliation(s)
- Mario Bo
- Section of Geriatrics, Department of Medical Sciences, University of Turin, AOU Città della Salute e della Scienza, Molinette, Turin, Italy
| | - Stefano Fumagalli
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, Florence 50134, Italy.
| | - Luca Degli Esposti
- CliCon Società Benefit Srl, Health, Economics & Outcome Research, Bologna, Italy
| | - Valentina Perrone
- CliCon Società Benefit Srl, Health, Economics & Outcome Research, Bologna, Italy
| | - Melania Dovizio
- CliCon Società Benefit Srl, Health, Economics & Outcome Research, Bologna, Italy
| | - Daniela Poli
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, Florence 50134, Italy
| | - Rossella Marcucci
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, Florence 50134, Italy
| | - Paolo Verdecchia
- Fondazione Umbra Cuore e Ipertensione-ONLUS and Struttura Complessa di Cardiologia, Ospedale S. Maria della Misericordia, Perugia, Italy
| | - Gianpaolo Reboldi
- Department of Medicine and Centro di Ricerca Clinica e Traslazionale (CERICLET), University of Perugia, Italy
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom; Danish Centre for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Andrea Ungar
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, Florence 50134, Italy
| | | | - Carlo Fumagalli
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, Florence 50134, Italy; Department of Advanced Medical and Surgical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, University of Florence, Largo G. Brambilla 3, Florence 50134, Italy
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15
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Khalid SI, Sathianathan S, Thomson KB, McGuire LS, Soni MC, Mehta AI. 5-year stroke rates in nonvalvular atrial fibrillation after watchman compared to direct oral anticoagulants. J Cardiol 2024; 83:163-168. [PMID: 37541428 DOI: 10.1016/j.jjcc.2023.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 07/25/2023] [Accepted: 07/28/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND The WATCHMAN device (Boston Scientific; Marlborough, MA, USA) is noninferior to warfarin in preventing ischemic strokes while reducing bleeding risks associated with long term anticoagulation in nonvalvular atrial fibrillation (AFib). The device's performance compared to direct oral anticoagulants (DOAC) is less well known. OBJECTIVE To compare 5-year major bleeding and ischemic stroke rates in patients with nonvalvular AFib who received a WATCHMAN device or DOAC therapy after a major bleeding event. METHODS This retrospective, multicenter, 1:1 matched cohort study was derived from the PearlDiver Mariner database from 2010 to 2020. Patients with nonvalvular AFib on oral anticoagulation who had a major bleeding event were identified. Those who received either WATCHMAN or DOAC after resolution of the bleeding event were selected. The two groups were exactly matched 1:1 based on various comorbidities. Rates of ischemic stroke, transient ischemic attack (TIA), major bleeding, and hemorrhagic stroke were compared over 5 years. RESULTS Each cohort consisted of 2248 patients after 1:1 matching. The mean CHADS2-VASC score was 4.81 ± 1.25. At 5 years, the WATCHMAN cohort had significantly lower rates of major bleeding events [OR 0.24 (0.21, 0.27)], TIAs [OR 0.75 (0.58, 0.95)], and ischemic strokes [OR 0.72 (0.61, 0.86)]. There was no significant difference in hemorrhagic strokes [OR 1.14 (0.83, 1.58)]. CONCLUSION Even in a high-risk population, the WATCHMAN is comparable to DOAC therapy in the primary prevention of hemorrhagic strokes and may provide benefit in the rates of bleeding events, TIAs, and ischemic strokes.
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Affiliation(s)
- Syed I Khalid
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA.
| | - Shyama Sathianathan
- Department of Internal Medicine, Temple University Hospital, Philadelphia, PA, USA
| | - Kyle B Thomson
- Chicago Medical School, Rosalind Franklin University, North Chicago, IL, USA
| | - Laura Stone McGuire
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Mona C Soni
- Department of Cardiology, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Ankit I Mehta
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
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16
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Gjermeni D, Anfang V, Vetter H, Szabó S, Hesselbarth D, Gauchel N, Siegel PM, Kaier K, Kille A, Franke K, Leggewie S, Trenk D, Duerschmied D, Bode C, Westermann D, Olivier CB. Low on-clopidogrel ADP- and TRAP-6-induced platelet aggregation in patients with atrial fibrillation undergoing percutaneous coronary intervention: an observational pilot study. J Thromb Thrombolysis 2024; 57:361-369. [PMID: 38347374 PMCID: PMC10961278 DOI: 10.1007/s11239-023-02937-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/16/2023] [Indexed: 03/26/2024]
Abstract
High on-clopidogrel platelet reactivity (HPR) associates with ischemic risk in patients after percutaneous intervention (PCI). This study aimed to evaluate the association of HPR as assessed by multiple electrode aggregometry (MEA) with ischemic, thromboembolic, and bleeding risk in patients with atrial fibrillation (AF) undergoing PCI. Patients with AF and an indication for oral anticoagulation (OAC) were included in this prospective cohort study on day 1-3 after PCI. Platelet aggregation [U] was analyzed by MEA. HPR and low platelet reactivity (LPR) were defined as ADP-induced aggregation ≥ 46 U and ≤ 18 U, respectively. TRAP-6-induced aggregation reference was 94-156 U. The primary outcome was time to all-cause death, myocardial infarction, or stroke at 6 months. The secondary outcome was time to non-major clinically relevant bleedings or major bleedings. 159 patients were enrolled between May 2020 and May 2021. The median age was 78 years (interquartile range 72-82) and 111 (70%) were male. Median ADP- and TRAP-induced aggregation were 12 (6-17) and 49 (35-68) U, respectively. 147 (93%) patients had a low overall aggregability. HPR was detected in 2 patients (1%) and 125 (79%) had LPR. ADP-induced aggregation did not significantly associate with the primary outcome (r = 0.081, p = 0.309) but correlated inversely with bleeding risk (r = - 0.201, p = 0.011). HPR status as assessed by MEA among patients with AF after PCI was rare and overall aggregability was low. Conventional cut-off values for HPR might be inappropriate for these patients. ADP-induced aggregation might be helpful to identify patients at risk for bleeding.
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Affiliation(s)
- Diona Gjermeni
- Department of Cardiology and Angiology, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Viktoria Anfang
- Department of Cardiology and Angiology, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Hannah Vetter
- Department of Cardiology and Angiology, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Sofia Szabó
- Department of Cardiology and Angiology, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - David Hesselbarth
- Department of Cardiology and Angiology, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Nadine Gauchel
- Department of Cardiology and Angiology, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Patrick M Siegel
- Department of Cardiology and Angiology, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Klaus Kaier
- Department of Cardiology and Angiology, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alexander Kille
- Department of Cardiology and Angiology, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kilian Franke
- Department of Cardiology and Angiology, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Stefan Leggewie
- Department of Cardiology and Angiology, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dietmar Trenk
- Department of Cardiology and Angiology, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Department of Cardiology, Angiology, Haemostaseology and Medical Intensive Care, Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
- European Center for AngioScience (ECAS) and German Center for Cardiovascular Research (DZHK) Partner Site Heidelberg/Mannheim, Mannheim, Germany
| | - Christoph Bode
- Department of Cardiology and Angiology, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dirk Westermann
- Department of Cardiology and Angiology, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph B Olivier
- Department of Cardiology and Angiology, University Heart Center Freiburg - Bad Krozingen, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
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Sperry JD, Loeb A, Smith MJ, Brighton TB, Ehret JA, Fermo JD, Gentili ME, Lancaster JW, Mazur JN, Spezzano K, Szwak JA. Retrospective, multicenter analysis of the safety and effectiveness of direct oral anticoagulants for the treatment of venous thromboembolism in obesity. J Thromb Thrombolysis 2024:10.1007/s11239-024-02955-6. [PMID: 38409303 DOI: 10.1007/s11239-024-02955-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/04/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are the preferred treatment for venous thromboembolism (VTE). However, DOAC use in patients with a BMI greater than 40 kg/m2 has not been well studied despite the growing prevalence of obesity, and current literature is often underpowered. METHODS This multicenter, retrospective, observational study evaluated patients 18 years and older who received DOACs for acute VTE treatment. Patients receiving DOACs for recurrent VTE or for failure of another agent were excluded. The primary efficacy outcome was recurrent VTE and the primary safety outcome was major bleeding within 12 months (or one month after stopping anticoagulation therapy). A propensity score analysis was performed to balance patient characteristics and evaluate the primary endpoints by BMI group. Time-to-event outcomes were analyzed using weighted Kaplan-Meier curves. RESULTS There were 165 patients with a BMI of at least 40 kg/m2 and 320 patients with a BMI less than 40 kg/m2. The majority received apixaban (373, 77%). Recurrent VTE occurred in 5 (3.0%) and 13 (4.1%) of patients in the higher and lower BMI groups, respectively (adjusted OR: 0.66; 95% CI: 0.16-2.69). Major bleeding occurred in 5 (3.0%) and 15 (4.7%) of patients in the higher and lower BMI groups, respectively (adjusted OR: 1.19; 95% CI: 0.36-3.92). CONCLUSION There was no significant difference in VTE recurrence or major bleeding related to BMI among patients treated with DOACs. This study showed that DOACs may be a safe and effective VTE treatment option in patients with obesity.
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Affiliation(s)
- Jeffrey D Sperry
- UC Health Memorial Hospital, Department of Pharmacy, Colorado Springs, CO, USA
| | - Aletha Loeb
- Department of Pharmacy, University of California, Davis, Sacramento, CA, USA
| | - Melissa J Smith
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Tessa B Brighton
- Department of Pharmacy, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Julie A Ehret
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC, USA
| | - Joli D Fermo
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC, USA
| | - Morgan E Gentili
- Department of Pharmacy Services, Beth Israel Lahey Health, Burlington, MA, USA
| | - Jason W Lancaster
- School of Pharmacy and Pharmaceutical Sciences, Northeastern University, Boston, MA, USA
| | - Jennifer N Mazur
- Department of Pharmacy Services, Medical University of South Carolina, Charleston, SC, USA
| | - Katherine Spezzano
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, KY, USA
| | - Jennifer A Szwak
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD, USA.
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Zhou H, Chen TT, Ye LL, Ma JJ, Zhang JH. Efficacy and safety of direct oral anticoagulants versus low-molecular-weight heparin for thromboprophylaxis after cancer surgery: a systematic review and meta-analysis. World J Surg Oncol 2024; 22:69. [PMID: 38403630 PMCID: PMC10895850 DOI: 10.1186/s12957-024-03341-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 02/14/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) used as an alternative to low-molecular-weight heparin (LMWH) for thromboprophylaxis after cancer surgery for venous thromboembolic events (VTE) remains unclear. This study aimed to investigate the efficacy and safety of DOACs versus LMWH in these patients. MATERIALS AND METHODS A search of EMBASE, MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and Web of Science was carried out and included all randomized controlled trials (RCTs) and observational studies that directly compared DOACs with LMWH for thromboprophylaxis in patients after cancer surgery through July 25, 2023. The primary efficacy and safety outcomes were VTE, major bleeding, and clinically relevant non-major bleeding (CRNMB) within 30 days of surgery. The risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB2) tool for RCTs and ROBINS-I tool for non-randomized studies. This study was registered in PROSPERO (CRD42023445386). RESULTS We retrieved 5149articles, selected 27 for eligibility, and included 10 studies (three RCTs and seven observational studies) encompassing 3054 patients who underwent postoperative thromboprophylaxis with DOACs (41%) or LMWH (59%). Compared to LMWH thromboprophylaxis, DOACs had a comparable risk of VTE (RR:0.69[95% CI:0.46-1.02], I2 = 0%), major bleeding (RR:1.55 [95% CI:0.82-2.93], I2 = 2%), and CRNMB (RR, 0.89 [95% CI, 0.4-1.98], I2 = 31%) during the 30-day postoperative period. Subgroup analysis of VTE and major bleeding suggested no differences according to study type, extended thromboprophylaxis, tumor types, or different types of DOAC. CONCLUSION DOACs are potentially effective alternatives to LMWH for thromboprophylaxis in patients undergoing cancer surgery, without increasing the risk of major bleeding events.
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Affiliation(s)
- Hong Zhou
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Ting-Ting Chen
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Ling-Ling Ye
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350001, Fujian, China
| | - Jun-Jie Ma
- School of Medicine, Huaqiao University, Quanzhou, 362021, Fujian, China.
| | - Jin-Hua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, 350001, Fujian, China.
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Binding C, Blanche P, Lip GYH, Kamper AL, Lee CJY, Staerk L, Gislason G, Torp-Pedersen C, Olesen JB, Bonde AN. Efficacy and safety of oral anticoagulants according to kidney function among patients with atrial fibrillation. Eur Heart J Cardiovasc Pharmacother 2024:pvae016. [PMID: 38402466 DOI: 10.1093/ehjcvp/pvae016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/26/2024]
Abstract
BACKGROUND AND AIMS Patients with severely reduced kidney function have been excluded from randomized controlled trials and data on safety and efficacy of direct oral anticoagulants (DOACs) according to kidney function remain sparse. The aim was to evaluate safety and efficacy of the DOACs across subgroups of kidney function. METHODS Using multiple Danish nationwide registers and laboratory databases, we included patients initiated on oral anticoagulants (OACs) with atrial fibrillation and available creatinine level and followed patients for 2 years to evaluate occurrence of stroke/thromboembolism (TE) and major bleeding. RESULTS Among 26,686 included patients, 3667 (13.7%) had an estimated glomerular filtration rate (eGFR) of 30-49 mL/min/1.73m2 and 596 (2.2%) had an eGFR below 30 mL/min/1.73m2. We found no evidence of differences regarding the risk of stroke/TE between the OACs (p-value interaction>0.05 for all). Apixaban was associated with a lower 2-year risk of major bleeding compared to VKA (risk ratio 0.79, 95% confidence interval (CI) 0.67-0.93), and the risk difference was significantly larger among patients with reduced kidney function (p-value interaction 0.018). Rivaroxaban was associated with higher risk of bleeding compared to apixaban (risk ratio 1.78, 95%CI 1.32-2.39) among patients with eGFR 30-49 mL/min/1.73m2. CONCLUSIONS Overall, we found no differences regarding the risk of stroke/TE, but apixaban was associated with a 21% lower relative risk of major bleeding compared to VKA. This risk reduction was even greater when comparing apixaban and rivaroxaban among patients with eGFR 15-30 mL/min/1.73m2, and when comparing apixaban to dabigatran and rivaroxaban among patients with eGFR 30-49 mL/min/1.73m2.
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Affiliation(s)
- Casper Binding
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
- Department of Cardiology, Aalborg Universitetshospital, Denmark
| | - Paul Blanche
- Department of Public Health, Section of Biostatistics, University of Copenhagen, 1014 Copenhagen K, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Anne-Lise Kamper
- Department of Nephrology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Christina J Y Lee
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
| | - Laila Staerk
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
- Department of Cardiovascular Epidemiology and Research, The Danish Heart Foundation, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
- Department of Cardiology, Nordsjællands Hospital, Denmark
| | - Jonas Bjerring Olesen
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
| | - Anders Nissen Bonde
- Department of Cardiology, Copenhagen University Hospital Herlev and Gentofte, 2900 Hellerup, Denmark
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20
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Maytal A, Naidorf Rosenblatt H, Rotem R, Segev F. Effect of direct oral anticoagulants on bleeding during and after cataract surgery. Int Ophthalmol 2024; 44:100. [PMID: 38376717 PMCID: PMC10879357 DOI: 10.1007/s10792-024-02944-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 12/07/2023] [Indexed: 02/21/2024]
Abstract
PURPOSE To assess the risk for intraoperative and postoperative ocular bleeding associated with direct oral anticoagulant treatment in patients undergoing phacoemulsification surgery. METHODS Consecutive patients had phacoemulsification and intraocular lens implantation while taking uninterrupted direct oral anticoagulants (dabigatran, rivaroxaban, or apixaban). Gender and age-matched patients without antithrombotic therapy were used as the control group. Patients were examined one week postoperatively. Intraoperative and postoperative hemorrhagic and non-hemorrhagic complications were assessed. RESULTS Forty patients (56 eyes) on direct oral anticoagulants and 120 patients (172 eyes) without anticoagulation, at a mean age of 77 years, had phacoemulsification. There was no significant difference between the groups in the rate of intraoperative and postoperative bleeding. One eye (1.8%) in the treatment group and 3 eyes (1.7%) in the control group had hyphema (p = 0.72). No patient had thromboembolic event during or after surgery. CONCLUSIONS Cataract surgery was safely performed while continuing direct oral anticoagulation.
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Affiliation(s)
- Anat Maytal
- Department of Ophthalmology, Meir Medical Center, Meir Hospital, 59 Tchernichovsky St, 4428164, Kfar Saba, Israel.
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | | | - Reut Rotem
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Fani Segev
- Department of Ophthalmology, Assuta-Samson Medical Center, Ashdod, Israel
- Joyce and Irwing Goldman Medical School, Ben-Gurion University, Beer-Sheva, Israel
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21
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Efros O, Berman A, Kenet G, Lubetsky A, Doron A, Shlomai G, Klang E, Soffer S, Barda N, Leibowitz A. Elevated International Normalized Ratio and Mortality in Hospitalized Patients Treated with Direct Oral Anticoagulants. Am J Med 2024; 137:147-153.e2. [PMID: 37926222 DOI: 10.1016/j.amjmed.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/21/2023] [Accepted: 10/17/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are associated with a prolongation of the prothrombin time and an increased international normalized ratio (INR). The clinical significance of these changes is unclear. This study aimed to examine the association between an elevated INR on admission and in-hospital death and long-term survival in patients treated with DOACs. METHODS Data were retrospectively retrieved from records of hospitalized patients at the Sheba Medical Center between November 2008 and July 2023. Patients were selected based on DOAC treatment, coagulation profile, and INR test done within 48 hours of hospitalization. The outcomes were in-hospital mortality and mortality in the year following hospitalization. RESULTS The study included 11,399 hospitalized patients treated with DOACs. Patients with elevated INR had a 180% higher risk of in-hospital mortality (adjusted odds ratio 2.80; 95% confidence interval, 2.30-3.39) and a 57% increased risk of death during the following year (adjusted hazard ratio 1.57; 95% confidence interval, 1.44-1.71). Similar results were observed in subgroup analyses for each DOAC. CONCLUSIONS An elevated INR on admission is associated with a higher risk for in-hospital death and increased risk for mortality during the first year following hospitalization in hospitalized patients treated with DOACs. This highlights that elevated INR levels in patients on DOACs should not be dismissed as laboratory variations due to DOAC treatment, as they may serve as a prognostic marker.
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Affiliation(s)
- Orly Efros
- National Hemophilia Center and Thrombosis & Hemostasis Institute, Sheba Medical Center, Ramat Gan, Israel; School of Medicine, Faculty of Medicine, Tel Aviv University, Israel.
| | - Aya Berman
- Dan Petah-Tikva District at Clalit Health Services, Petah-Tikva, Israel; Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Gili Kenet
- National Hemophilia Center and Thrombosis & Hemostasis Institute, Sheba Medical Center, Ramat Gan, Israel; School of Medicine, Faculty of Medicine, Tel Aviv University, Israel; Amalia Biron Research Institute of Thrombosis & Hemostasis
| | - Aharon Lubetsky
- National Hemophilia Center and Thrombosis & Hemostasis Institute, Sheba Medical Center, Ramat Gan, Israel; School of Medicine, Faculty of Medicine, Tel Aviv University, Israel
| | - Alon Doron
- School of Medicine, Faculty of Medicine, Tel Aviv University, Israel
| | - Gadi Shlomai
- School of Medicine, Faculty of Medicine, Tel Aviv University, Israel; The Division of Endocrinology, Diabetes, and Metabolism; Department of Internal Medicine "D" and Hypertension Unit
| | - Eyal Klang
- School of Medicine, Faculty of Medicine, Tel Aviv University, Israel; Arc Innovation Center, Sheba Medical Center, Ramat-Gan, Israel
| | - Shelly Soffer
- Ben-Gurion University of the Negev, Be'er Sheva, Israel; Internal Medicine B, Assuta Medical Center, Ashdod, Israel
| | - Noam Barda
- Arc Innovation Center, Sheba Medical Center, Ramat-Gan, Israel; Software and Information Systems Engineering; Epidemiology, Biostatistics and Community Health Services, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Avshalom Leibowitz
- School of Medicine, Faculty of Medicine, Tel Aviv University, Israel; Department of Internal Medicine "D" and Hypertension Unit
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22
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Yang C, Khan F, MacDonald C, Guglielmo J, Lo M, Young R, Banez MT, Huang L, Nguyen R, Kang S, Saunders IM. Characterization of direct oral anticoagulants use in adult hematopoietic stem cell transplant recipients. J Thromb Thrombolysis 2024; 57:293-301. [PMID: 37932590 PMCID: PMC10869366 DOI: 10.1007/s11239-023-02902-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2023] [Indexed: 11/08/2023]
Abstract
Direct oral anticoagulants (DOACs) for venous thromboembolism (VTE) treatment are of interest in oncology due to ease of administration and lack of need for therapeutic monitoring compared to other anticoagulants. Data supporting their use in patients with hematologic malignancies post-hematopoietic stem cell transplant (HCT) are limited. The purpose of the study is to characterize DOAC use in HCT patients. This multicenter, retrospective cohort analysis included allogeneic and autologous HCT recipients. The primary outcome was major bleeding. Secondary outcomes included clinically relevant non-major bleeding (CRNMB)/minor bleeding and VTE recurrence. Of 126 patients, 91 (72.2%) patients received an autologous HCT, and 35 (27.8%) patients received an allo-HCT. No major bleeding occurred in either transplant recipient groups. In autologous HCT recipients, CRNMB/minor bleeding occurred in four (4.4%) patients and VTE recurrence occurred in one (1.1%) patient. For allogeneic HCT recipients, CRNMB/minor bleeding occurred in five (14.3%) patients and VTE recurrence occurred in two (5.7%) patients. For patients that experienced a CRNMB, five (100%) of the allogeneic HCT and two (50%) of the autologous HCT recipients were thrombocytopenic at the time of bleeding. Only 38.5% of patients who experienced a drug-drug interaction requiring DOAC dose adjustment received the appropriate dose adjustment. DOACs were associated with low rates of recurrent VTE and no major bleeding events, similar to published data on DOAC use in the general cancer patient population. This suggests that DOACs may be safe therapeutic options with proactive management of drug interactions and careful monitoring for bleeding events, especially in the allogeneic HCT population where minor bleeding rates were slightly higher.
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Affiliation(s)
- Claire Yang
- UC Davis Medical Center, 3651 Business Drive, Suite 100, Sacramento, CA, 95820, USA.
| | | | | | - Julie Guglielmo
- UC Davis Medical Center, 3651 Business Drive, Suite 100, Sacramento, CA, 95820, USA
| | - Mimi Lo
- UC San Francisco Medical Center, San Francisco, USA
| | | | | | - Lily Huang
- UC Davis Medical Center, 3651 Business Drive, Suite 100, Sacramento, CA, 95820, USA
| | - Rosalyn Nguyen
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, USA
| | - Stephen Kang
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, USA
| | - Ila M Saunders
- UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, USA
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23
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Dietrich F, Polymeris AA, Albert V, Engelter ST, Hersberger KE, Schaedelin S, Lyrer PA, Arnet I. Intake reminders are effective in enhancing adherence to direct oral anticoagulants in stroke patients: a randomised cross-over trial (MAAESTRO study). J Neurol 2024; 271:841-851. [PMID: 37831125 PMCID: PMC10827905 DOI: 10.1007/s00415-023-12035-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOAC) effectively prevent recurrent ischaemic events in atrial fibrillation (AF) patients with recent stroke. However, excellent adherence to DOAC is mandatory to guarantee sufficient anticoagulation as the effect quickly subsides. AIM To investigate the effect of intake reminders on adherence to DOAC. METHODS MAAESTRO was a randomised, cross-over study in DOAC-treated AF patients hospitalised for ischaemic stroke. Adherence was measured by electronic monitoring for 12 months. After an observational phase, patients were randomised to obtain an intake reminder either in the first or the second half of the subsequent 6-month interventional phase. The primary outcome was 100%-timing adherence. Secondary outcomes were 100%-taking adherence, and overall timing and taking adherence. We analysed adherence outcomes using McNemar's test or mixed-effects logistic models. RESULTS Between January 2018 and March 2022, 130 stroke patients were included, of whom 42 dropped out before randomisation. Analysis was performed with 84 patients (mean age: 76.5 years, 39.3% women). A 100%-timing adherence was observed in 10 patients who were using the reminder, and in zero patients without reminder (p = 0.002). The reminder significantly improved adherence to DOAC, with study participants having 2.7-fold increased odds to achieve an alternative threshold of 90%-timing adherence (OR 2.65; 95% CI 1.05-6.69; p = 0.039). A similar effect was observed for 90%-taking adherence (OR 3.06; 95% CI 1.20-7.80; p = 0.019). Overall timing and taking adherence increased significantly when using the reminder (OR 1.70; 95% CI 1.55-1.86, p < 0.01; and OR 1.67; 95% CI 1.52-1.84; p < 0.01). CONCLUSION Intake reminders increased adherence to DOAC in patients with stroke attributable to atrial fibrillation. TRIAL REGISTRATION ClinicalTrials.gov: NCT03344146.
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Affiliation(s)
- Fine Dietrich
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056, Basel, Switzerland.
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Petersgraben 4, 4051, Basel, Switzerland
| | - Valerie Albert
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056, Basel, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Petersgraben 4, 4051, Basel, Switzerland
- Neurology and Neurorehabilitation, University Department of Geriatric Medicine Felix Platter, University of Basel, Burgfelderstrasse 101, 4055, Basel, Switzerland
| | - Kurt E Hersberger
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056, Basel, Switzerland
| | - Sabine Schaedelin
- Clinical Trial Unit, Department of Clinical Research, University Hospital Basel and University of Basel, Schanzenstrasse 55, 4056, Basel, Switzerland
| | - Philippe A Lyrer
- Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Petersgraben 4, 4051, Basel, Switzerland
| | - Isabelle Arnet
- Pharmaceutical Care Research Group, Department of Pharmaceutical Sciences, University of Basel, Klingelbergstrasse 50, 4056, Basel, Switzerland
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Suzuki Y, Kikura M, Kawashima S, Kimura T, Nakajima Y. Andexanet alpha-induced heparin resistance treated by nafamostat mesylate in a patient undergoing total aortic arch repair for Stanford type A acute aortic dissection: a case report. JA Clin Rep 2024; 10:6. [PMID: 38285208 PMCID: PMC10825097 DOI: 10.1186/s40981-024-00690-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 01/13/2024] [Accepted: 01/16/2024] [Indexed: 01/30/2024] Open
Abstract
BACKGROUND Andexanet alfa, an anti-Xa inhibitor antagonist, induces heparin resistance. Here, we report a case of successful management of cardiopulmonary bypass with andexanet alfa-induced heparin resistance using nafamostat mesylate. CASE PRESENTATION An 84-year-old female, with Stanford type A acute aortic dissection, underwent an emergency surgery for total aortic arch replacement. Andexanet alfa 400 mg was administered preoperatively to antagonize edoxaban, an oral Xa inhibitor. Heparin 300 IU/kg was administered before cardiopulmonary bypass, and the activated clotting time (ACT) was 291 s. The ACT was 361 s after another administration of heparin 200 IU/kg. According to our routine therapy for heparin resistance, an initial dose of nafamostat mesylate 10 mg was administered intravenously, followed by a continuous infusion of 20-30 mg/h. The ACT was prolonged to 500 s, and cardiopulmonary bypass was successfully established thereafter. CONCLUSIONS This case report presents the successful management of cardiopulmonary bypass with andexanet alfa-induced heparin resistance using nafamostat mesilate. This report presents the successful management of cardiopulmonary bypass with andexanet alfa-induced heparin resistance using nafamostat mesilate.
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Affiliation(s)
- Yasuhito Suzuki
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Shizuoka, Japan.
| | - Mutsuhito Kikura
- Department of Anesthesiology, Hamamatsu Rosai Hospital, Japan Organization of Occupational Health and Safety, Shizuoka, Japan
| | - Shingo Kawashima
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Tetsuro Kimura
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Shizuoka, Japan
| | - Yoshiki Nakajima
- Department of Anesthesiology and Intensive Care, Hamamatsu University School of Medicine, Shizuoka, Japan
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25
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Ciou WS, Wang CC, Lin FJ, Chao TF, Lin SY. Comparison of different direct oral anticoagulant regimens in atrial fibrillation patients with high bleeding risk. Heart Rhythm 2024:S1547-5271(24)00079-1. [PMID: 38266751 DOI: 10.1016/j.hrthm.2024.01.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 01/09/2024] [Accepted: 01/16/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND The optimal dose of direct oral anticoagulants (DOACs) to prevent ischemic stroke (IS) and systemic thromboembolism (STE) in atrial fibrillation (AF) patients with a predisposing bleeding risk remains unclear. OBJECTIVE The purpose of this study was to compare the effectiveness and safety of different DOAC dosage regimens in AF patients with high bleeding risk but low thrombosis risk. METHODS This retrospective observational study was conducted with the National Health Insurance claims database in Taiwan to include AF patients aged 20 up to 75 years, under DOAC therapy, with CHA2DS2-VASc score of 1 for males and 2 for females and HAS-BLED score ≥3. Standard-dose regimen was defined as dabigatran 300 mg, rivaroxaban 20 mg, apixaban 10 mg, or edoxaban 60 mg per day. Any other lower-dose regimen were defined as the low-dose regimen. The primary outcomes were IS and major bleeding (MB). The secondary outcomes were STE, gastrointestinal bleeding, intracranial hemorrhage, and cardiovascular death. RESULTS A total of 964 patients were included (52.1% standard-dose regimen). Median HAS-BLED score was 3 [interquartile range 3-3]. Compared with standard-dose group, patients in the low-dose group had a significantly increased risk of IS (adjusted hazard ratio [aHR] 5.13; 95% confidence interval 1.37-19.22) and STE (aHR 3.14 [1.05-9.37]) but similar risk of MB (aHR 0.45 [0.12-1.67]). The risks of other hemorrhage and cardiovascular death were similar between the 2 dose groups. CONCLUSION Among patients with a predominant bleeding risk but relatively low thrombosis risk, the low-dose DOAC regimen is not a more appropriate selection than standard-dose regimen.
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Affiliation(s)
- Wei-Siang Ciou
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Chi-Chuan Wang
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Fang-Ju Lin
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan; Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, and Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shin-Yi Lin
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan; School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan.
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26
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Lyu SQ, Zhu J, Wang J, Wu S, Zhang H, Shao XH, Yang YM. The efficacy and safety of direct oral anticoagulants compared with vitamin K antagonist in patients with hypertrophic cardiomyopathy and atrial fibrillation. Thromb J 2024; 22:2. [PMID: 38166972 PMCID: PMC10759476 DOI: 10.1186/s12959-023-00562-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 11/13/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The benefit-risk profile of direct oral anticoagulants (DOAC) therapy in patients with hypertrophic cardiomyopathy (HCM) and atrial fibrillation (AF) has not been well established yet. This study aimed to evaluate the efficacy and safety of DOAC compared with vitamin K antagonists (VKA) in patients with HCM and AF. METHODS PubMed, EMBASE, the Cochrane Library, and clinicaltrials.gov were searched to identify studies comparing DOAC with VKA in patients with HCM and AF. The primary endpoint was thromboembolic events. The relative risks and standard errors were pooled by random-effect models using the generic inverse variance method. RESULTS Seven observational studies involving 9395 patients were included in this meta-analysis. Compared to the VKA group, the DOAC group displayed a similar risk of thromboembolic events [RR (95%CI): 0.93 (0.73-1.20), p = 0.59] and ischemic stroke [RR (95%CI): 0.65 (0.33-1.28), p = 0.22]. The incidence of major bleeding was comparable between the two groups [RR (95%CI): 0.75 (0.49-1.15), p = 0.19]. Meanwhile, DOAC therapy was superior to VKA therapy in reducing the incidences of all-cause death [RR (95%CI): 0.44 (0.35-0.55), p < 0.001], cardiovascular death [RR (95%CI): 0.41 (0.22-0.75), p = 0.004], and intracranial hemorrhage [RR (95%CI): 0.42 (0.24-0.74), p = 0.003]. CONCLUSION In patients with HCM and AF, DOAC therapy was similar to VKA therapy in reducing the risk of thromboembolic events, without increasing bleeding risk. In addition, the DOAC group displayed significant advantages in reducing mortality and intracranial hemorrhage compared with the VKA group. Further randomized controlled trials are needed to provide more evidence for DOAC therapy in this population.
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Affiliation(s)
- Si-Qi Lyu
- Emergency Center, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Zhu
- Emergency Center, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Juan Wang
- Emergency Center, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuang Wu
- Emergency Center, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Han Zhang
- Emergency Center, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Xing-Hui Shao
- Emergency Center, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yan-Min Yang
- Emergency Center, National Clinical Research Center of Cardiovascular Diseases, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Nwanosike EM, Merchant HA, Sunter W, Ansari MA, Conway BR, Hasan SS. Direct oral anticoagulants and the risk of adverse clinical outcomes among patients with different body weight categories: a large hospital-based study. Eur J Clin Pharmacol 2024; 80:163-173. [PMID: 37978999 PMCID: PMC10781787 DOI: 10.1007/s00228-023-03593-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 11/05/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVE Through predictable pharmacokinetics-including a convenient fixed-dose regimen, direct oral anticoagulants (DOACs) are preferred over previous treatments in anticoagulation for various indications. However, the association between higher body weight and the risk of adverse consequences is not well studied among DOAC users. We aim to explore the association of body weight and adverse clinical outcomes in DOAC users. METHODS A total of 97,413 anonymised DOAC users in a tertiary care setting were identified following structured queries on the electronic health records (EHRs) to extract the feature-rich anonymised dataset. The prepared dataset was analysed, and the features identified with machine learning (ML) informed the adjustments of covariates in the multivariate regression analysis to examine the association. Kaplan-Meier analysis was performed to evaluate the mortality benefits of DOACs. RESULTS Among DOAC users, the odds of adverse clinical outcomes, such as clinically relevant non-major bleeding (CRNMB), ischaemic stroke, all-cause mortality, and prolonged hospital stay, were lower in patients with overweight, obesity, or morbid obesity than in patients with normal body weight. The odds of ischaemic stroke (OR 0.42, 95% CI: 0.36-0.88, p = 0.001) and all-cause mortality (OR 0.87, 95% CI: 0.81-0.95, p = 0.001) were lower in patients with morbid obesity than in patients with normal body weight. In the Kaplan-Meier analysis, apixaban was associated with a significantly lower rate of mortality overall and in obesity and overweight subgroups than other DOACs (p < 0.001). However, rivaroxaban performed better than apixaban in the morbid obesity subgroup (p < 0.001). CONCLUSION This study shows the positive effects of DOAC therapy on clinical outcomes, particularly in patients with high body weight. However, this still needs validation by further studies particularly among patients with morbid obesity.
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Affiliation(s)
- Ezekwesiri Michael Nwanosike
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH, UK
| | - Hamid A Merchant
- Department for Bioscience, School of Health, Sport and Bioscience, the University of East London, London, E16 2RD, UK
| | - Wendy Sunter
- Calderdale and Huddersfield Pharmacy Services, Anticoagulation Services, Calderdale and Huddersfield NHS Foundation Trust Hospitals, Lindley, Huddersfield, HD3 3EA, UK
| | - Muhammad Ayub Ansari
- School of Computing and Engineering, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH, UK
| | - Barbara R Conway
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH, UK
| | - Syed Shahzad Hasan
- Department of Pharmacy, School of Applied Sciences, University of Huddersfield, Queensgate, Huddersfield, HD1 3DH, UK.
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Kyriakoulis I, Adamou A, Stamatiou I, Chlorogiannis DD, Kardoutsos I, Koukousaki D, Ntaios G. Efficacy and safety of direct oral anticoagulants vs vitamin K antagonists in patients with atrial fibrillation and end-stage renal disease on hemodialysis: A systematic review and meta-analysis. Eur J Intern Med 2024; 119:45-52. [PMID: 37648582 DOI: 10.1016/j.ejim.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/02/2023] [Accepted: 08/22/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND The prevalence of atrial fibrillation (AF) in individuals with end-stage renal disease (ESRD) on chronic hemodialysis is increasing. The optimal anticoagulant choice in this population is unclear since these patients were excluded from the pivotal randomized controlled trials (RCTs) of direct oral anticoagulants (DOACs) vs. vitamin K antagonists (VKAs) in the general AF population. We aimed to assess the efficacy and safety of DOACs vs. VKAs in patients with AF and ESRD on chronic hemodialysis through a systematic review and meta-analysis of all available evidence. PATIENTS/METHODS We performed a systematic search in MEDLINE and Scopus for RCTs or observational studies of patients with AF and ESRD on chronic hemodialysis who were treated with DOACs or VKAs. The outcomes of interest included ischemic stroke, the composite of ischemic stroke or systemic embolism, major bleeding, gastrointestinal bleeding, minor bleeding events and all-cause mortality. RESULTS Among 397 studies identified from the literature search, six studies (three RCTs and three observational studies) were included in the meta-analysis. Compared with VKA-treated patients, those treated with DOACs had similar risk of ischemic stroke (RR:0.76, 95% CI:0.41-1.41), ischemic stroke or systemic embolism (RR:0.65, 95% CI:0.38-1.10), major bleeding (RR:0.79, 95% CI:0.49-1.28) and all-cause death (RR:0.79, 95% CI:0.56-1.12). The risk of gastrointestinal bleeding was lower in DOAC- vs VKA-treated patients in three eligible observational studies (RR:0.73, 95% CI: 0.54-0.99, I2 = 79%) but this was not confirmed in two eligible RCTs (RR:0.69, 95% CI: 0.33-1.43, I2 = 0%). CONCLUSIONS Among AF patients with ESRD on chronic hemodialysis, the risk of ischemic stroke, ischemic stroke or systemic embolism, minor bleeding, major bleeding, and all-cause mortality is similar in patients treated with DOACs compared to VKAs. Given that the meta-analysis of RCTs on gastrointestinal bleeding did not confirm the results of the meta-analysis of the observational studies, it cannot be concluded that gastrointestinal bleeding is lower among DOAC-treated patients. PROTOCOL REGISTRATION PROSPERO CRD42023391966.
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Affiliation(s)
- Ioannis Kyriakoulis
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Anastasia Adamou
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Iliana Stamatiou
- Department of Internal Medicine, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | | | - Ioannis Kardoutsos
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Despoina Koukousaki
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
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Frenzel L, Decaux O, Macro M, Belhadj-Merzoug K, Manier S, Touzeau C, Leleu X, Frère C, Lecompte T, Perrot A, Avet-Loiseau H, Moreau P, Chalayer E. Venous thromboembolism prophylaxis and multiple myeloma patients in real-life: Results of a large survey and clinical guidance recommendations from the IFM group. Thromb Res 2024; 233:153-164. [PMID: 38064842 DOI: 10.1016/j.thromres.2023.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/30/2023] [Accepted: 11/20/2023] [Indexed: 01/01/2024]
Abstract
Venous thromboembolism (VTE) remains a critical issue in the management of patients with multiple myeloma (MM), particularly when immunomodulatory drugs (IMiDs) combined with dexamethasone therapy are being prescribed as first-line and relapse therapy. One possible explanation for the persistent high rates of VTE, is the use of inappropriate thromboprophylaxis strategies for patients starting antimyeloma treatment. To tackle the issue, the Intergroupe francophone du myélome (IFM) offered convenient guidance for VTE thromboprophylaxis in MM patients initiating systemic therapy. This guidance is mainly supported by the results of a large survey on the clinical habits regarding VTE of physicians who are substantially involved in daily care of MM patients. VTE prophylaxis should be considered for all patients treated with IMiDs in combination with dexamethasone, in the absence of significant comorbidities, such as renal failure or bleeding risk. Anticoagulant should be preferred to antiplatelet agents for thromboprophylaxis. Despite the absence of large randomized controlled trials comparing those attitudes/options, available data on direct oral anticoagulants, which are already used in daily management of MM patients, are consistent with their potential usefulness for VTE prophylaxis in such patients. However, in order to implement a personalized continuous improvement strategy, clinicians must to be organized to collect all the data regarding this management. In other situations, thromboprophylaxis should be evaluated by using risk models and after careful evaluation of the risk/benefit ratio.
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Affiliation(s)
- Laurent Frenzel
- Service d'Hématologie Adulte et unité d'hémostase clinique, Hôpital Necker, Institut IMAGINE - INSERM U 1163/CNRS ERL 8254, Paris, France.
| | | | - Margaret Macro
- Institut d'Hématologie de Basse Normandie (IHBN), CHU Côte de Nacre, Caen, France
| | | | - Salomon Manier
- Hematology department, CHU Lille, Lille University, INSERM UMR-S1277, Lille, France
| | - Cyrille Touzeau
- Department of Hematology, University Hospital Hôtel-Dieu, 44093 Nantes, France; Centre de Recherche en Cancérologie et Immunologie Intégrée Nantes Angers, INSERM UMR 1307, CNRS UMR 6075, Nantes, France
| | - Xavier Leleu
- Hématologie Biologique, Hôpital Pontchaillou University Hospital of Rennes, Rennes, France
| | - Corinne Frère
- Service d'Hématologie Biologique, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France
| | | | - Aurore Perrot
- Institut Universitaire du Cancer de Toulouse-Oncopole and Centre de Recherches en Cancerologie de Toulouse Institut National de la Sante et de la Recherche Medicale, Toulouse, France
| | - Hervé Avet-Loiseau
- Institut Universitaire du Cancer de Toulouse-Oncopole and Centre de Recherches en Cancerologie de Toulouse Institut National de la Sante et de la Recherche Medicale, Toulouse, France
| | - Philippe Moreau
- Department of Hematology, University Hospital Hôtel-Dieu, 44093 Nantes, France; Centre de Recherche en Cancérologie et Immunologie Intégrée Nantes Angers, INSERM UMR 1307, CNRS UMR 6075, Nantes, France
| | - Emilie Chalayer
- Hématologie clinique, Institut de Cancérologie Hématologie Universitaire, CHU St Etienne Unité INSERM SAINBIOSE, U1059, Université Jean Monnet, St-Etienne, France
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Svaguša T, Šimić S, Grabant F, Kereš T, Čančarević O, Paić F, Grizelj D, Blivajs A, Bulum T, Prkačin I. Comparison of vitamin K and non-vitamin K oral anticoagulants and the bleeding frequency in the emergency department. High Blood Press Cardiovasc Prev 2024; 31:23-30. [PMID: 38190093 DOI: 10.1007/s40292-023-00616-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 11/27/2023] [Indexed: 01/09/2024] Open
Abstract
INTRODUCTION Safety studies of anticoagulant therapy have so far been conducted on many subjects in controlled conditions (i.e., clinically monitored) and demonstrated the noninferiority of new ones over old anticoagulant drugs. Data on the propositions for the presence of symptoms and signs of bleeding among various anticoagulants in the emergency department indicate that these data do not match the data published so far. AIM The aim of the study was to investigate the differences in the frequency of bleeding and bleeding-related symptoms as a reason for emergency department attendance in patients on anticoagulant therapy. METHODS The study included patients from the emergency department of University Hospital for one year, who were on anticoagulant therapy and who met the inclusion criteria. Out of a total of 595 patients, 409 were on warfarin (68.74%), and the rest were taking direct oral anticoagulants (DOAC): dabigatran 71 (11.93%), rivaroxaban 66 (11.09%) and apixaban 49 (8.23%). RESULTS Out of 409 patients taking warfarin, 34.4% were adequately anticoagulated with the frequency of bleeding 13.7%, while in 57.2% of patients, PT INR was higher than the reference values with the frequency of bleeding 15.0%. A comparison between all DOAC groups and adequately anticoagulated warfarin patients in the frequency of bleeding and bleeding-related symptoms as a reason for emergency attendance yielded a difference that was marginally statistically significant (Pearson Chi-Square = 7.554, p = 0.052). CONCLUSION Monitoring the frequency of bleeding and bleeding-related symptoms in patients on oral anticoagulant therapy as a reason for emergency department attendance may be a new safety and efficacy factor in real-life patient scenarios.
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Affiliation(s)
- Tomo Svaguša
- Department of Cardiovascular Diseases, University Hospital Dubrava, 10000, Zagreb, Croatia
| | - Stjepan Šimić
- Department of Diabetes, Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Dugi dol 4a, 10000, Zagreb, Croatia
| | - Filip Grabant
- School of Medicine, University of Zagreb, Dugi dol 4a, Zagreb, Croatia
| | - Tatjana Kereš
- School of Medicine, University of Zagreb, Dugi dol 4a, Zagreb, Croatia
- Department of Intensive Care Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Ognjen Čančarević
- Department of Cardiovascular Diseases, University Hospital Dubrava, 10000, Zagreb, Croatia
| | - Frane Paić
- School of Medicine, University of Zagreb, Dugi dol 4a, Zagreb, Croatia
| | - Danijela Grizelj
- Department of Cardiovascular Diseases, University Hospital Dubrava, 10000, Zagreb, Croatia
| | - Aleksandar Blivajs
- Department of Cardiovascular Diseases, University Hospital Dubrava, 10000, Zagreb, Croatia
| | - Tomislav Bulum
- Department of Diabetes, Vuk Vrhovac University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Merkur University Hospital, Dugi dol 4a, 10000, Zagreb, Croatia.
- School of Medicine, University of Zagreb, Dugi dol 4a, Zagreb, Croatia.
| | - Ingrid Prkačin
- School of Medicine, University of Zagreb, Dugi dol 4a, Zagreb, Croatia
- Department of Internal Medicine, University Hospital Merkur, Zagreb, Croatia
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Alharbi A, Mhanna M, Alyosif M, Pena C, Jabr A, Alsughayer A, Alfatlawi H, Safi M, Aldhafeeri A, Patel N, Khuder S, Eltahawy E. Safety and Efficacy of Direct Oral Anticoagulant in Addition to Antiplatelet Therapy After Acute Coronary Syndrome: A Systemic Review and Meta-analysis of 53,869 Patients. Clin Ther 2024; 46:e1-e6. [PMID: 37880055 DOI: 10.1016/j.clinthera.2023.09.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 08/17/2023] [Accepted: 09/29/2023] [Indexed: 10/27/2023]
Abstract
INTRODUCTION Significant progress has been made in the management of patients with acute coronary syndrome (ACS) during the past few decades. However, the role of direct oral anticoagulants (DOACs) in post-ACS prophylactic therapy remains unknown. This study aims to assess the efficacy and safety of DOACs plus antiplatelet treatment (APT) after ACS. METHODS A systematic literature search was conducted to identify randomized clinical trials comparing DOACs plus APT with APT alone after ACS. The primary efficacy end points were cardiovascular mortality, myocardial infarction, all-cause mortality, and stroke and systemic embolization (SSE). The primary safety end point was major bleeding. The random-effects model was used to calculate relative risk (RR) and corresponding 95% CIs. RESULTS Nine trials with a total of 53,869 patients were identified, with 33,011 (61.2%) in the DOACs plus APT group and 20,858 (38.8%) in the APT alone group. The use of DOACs did not decrease the risk of cardiovascular death (RR = 0.87; 95% CI, 0.75-1.01; P = 0.08; I2 = 0%) or myocardial infarction (RR = 0.90; 95% CI, 0.80-1.02; P = 0.10; I2 = 6%). However, the risk of SSE was significantly lower in patients who received DOACs plus APT compared with APT alone (RR = 0.67; 95% CI, 0.50-0.90; P = 0.008). Moreover, all-cause mortality was significantly lower in the DOACs plus APT group (RR = 0.83; 95% CI, 0.71-98; P = 0.03; I2 = 0%). However, the risk of major bleeding was significantly higher in patients treated with DOACs plus APT compared with APT alone (RR = 2.53; 95% CI, 1.96-3.26; P < 0.01; I2 = 0%), as was the risk of nonmajor bleeding (RR = 2.27; 95% CI, 1.51-3.41; P < 0.01). IMPLICATIONS DOACs plus APT for the prevention of left ventricular thrombus in patients with ACS were associated with a lower risk of SSE and all-cause mortality but increased the risk of major and nonmajor bleeding. The benefits and risks of this approach should be weighed based on a patient's individual clinical characteristics.
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Affiliation(s)
- Abdulmajeed Alharbi
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio.
| | - Mohammed Mhanna
- Division of Cardiology, Department of Medicine, University of Iowa, Iowa City, Iowa
| | - Mohammed Alyosif
- Department of Cardiology, University of Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Clarissa Pena
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Abed Jabr
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Anas Alsughayer
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Halah Alfatlawi
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Mohammad Safi
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Abdulaziz Aldhafeeri
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Neha Patel
- Department of Internal Medicine, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
| | - Sadik Khuder
- Department of Medicine, Statistics, and Public Health, College of Medicine and Life Sciences, The University of Toledo, Toledo, Ohio
| | - Ehab Eltahawy
- Department of Cardiology, University of Toledo College of Medicine and Life Sciences, Toledo, Ohio
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Navalha DDP, Felix N, Nogueira A, Clemente M, Marinho AD, Ferreira ROM, Pasqualotto E, Dagostin CS, Pinto LCS, Fernandes GC. Direct oral anticoagulants versus vitamin K antagonists in patients with atrial fibrillation on chronic hemodialysis: a meta-analysis of randomized controlled trials. Int Urol Nephrol 2023:10.1007/s11255-023-03889-3. [PMID: 38153665 DOI: 10.1007/s11255-023-03889-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 11/14/2023] [Indexed: 12/29/2023]
Abstract
PURPOSE Patients with atrial fibrillation (AF) and end-stage renal disease on chronic hemodialysis are at risk for thromboembolic and bleeding events. We aimed to perform a meta-analysis to evaluate the safety and efficacy of direct oral anticoagulants (DOACs) compared with vitamin K antagonists (VKAs) in this population. METHODS We systematically searched PubMed, Excerpta Medica Database (EMBASE) and Cochrane Library for randomized controlled trials (RCTs) comparing DOACs with VKAs in patients with AF on chronic hemodialysis from inception to February 2023 in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Outcomes were reported using risk ratios (RRs) with 95% confidence intervals (CIs). Statistical analyses were performed using R version 4.2.2. RESULTS We selected three RCTs including 341 patients, of whom 176 (51.6%) were randomized to DOACs. Follow-up ranged from 174 days to 3.38 years. There was no significant difference between groups in terms of cardiovascular mortality (RR 1.34; 95% CI 0.69-2.60; p = 0.39), all-cause mortality (RR 0.96; 95% CI 0.72-1.27; p = 0.77), ischemic/uncertain type of stroke or transient ischemic attack (RR 0.50; 95% CI 0.19-1.35; p = 0.17), or major or life-threatening bleeding (RR 0.70; 95% CI 0.39-1.25; p = 0.22). CONCLUSION In this meta-analysis of three RCTs, no significant difference was observed between DOACs and VKAs in cardiovascular mortality, all-cause mortality, ischemic/uncertain type of stroke or transient ischemic attack, or major or life-threatening bleeding in patients with AF on chronic hemodialysis.
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Affiliation(s)
| | - Nicole Felix
- Federal University of Campina Grande, Campina Grande, Brazil
| | - Alleh Nogueira
- Bahiana School of Medicine and Public Health, Salvador, Brazil
| | | | - Alice D Marinho
- Federal University of the State of Rio de Janeiro, Rio de Janeiro, Brazil
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Ueda K, Inokoshi M, Kubota K, Yamaga E, Minakuchi S. Factors influencing postoperative bleeding after dental extraction in older adult patients receiving anticoagulation therapy. Clin Oral Investig 2023; 28:22. [PMID: 38147161 DOI: 10.1007/s00784-023-05424-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 11/21/2023] [Indexed: 12/27/2023]
Abstract
OBJECTIVES To investigate factors influencing postoperative bleeding occurrence after dental extraction in older patients receiving anticoagulation therapy. MATERIALS AND METHODS This retrospective study included patients aged ≥ 65 years receiving one of the following anticoagulants: apixaban, edoxaban, rivaroxaban, and warfarin. Patients who underwent one to multiple tooth extractions in the geriatric dentistry clinic at Tokyo Medical and Dental University Hospital between August 1, 2016, and November 30, 2020, were included. The outcome variable was postoperative bleeding occurrence. Logistic regression analysis was performed with the following ten factors as explanatory variables: age, sex, maximum systolic blood pressure during the extraction, type of local anesthesia, vertical incision, osteotomy, usage of surgical splints, the mesiodistal width of the extracted tooth on a radiograph, use of antiplatelet agents, and history of diabetes requiring medication. RESULTS Among 395 participants (mean age, 82.3 ± 6.5 years) included in this study, 75 patients experienced postoperative bleeding after tooth extraction. Logistic regression analysis revealed that the odds ratios for the vertical incision (18.400, p < 0.001), osteotomy (3.630, p = 0.00558), usage of surgical splints (1.860, p = 0.0395), and the mesiodistal width of the extracted tooth on a radiograph (1.060, p = 0.0261) were statistically significant. CONCLUSIONS For dental extraction in older patients receiving anticoagulants, postoperative bleeding is more likely to occur in patients with vertical incision, osteotomy, and posterior or multiple tooth extractions. CLINICAL RELEVANCE Dentists should consider suturing and adjunctive hemostatic procedures for patients undergoing vertical incision, osteotomy, and multiple tooth extractions while receiving anticoagulation therapy to minimize the risk of postoperative bleeding.
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Affiliation(s)
- Kaori Ueda
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan
| | - Masanao Inokoshi
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan.
| | - Kazumasa Kubota
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan
- Kubota Dental Clinic, 1-16-2 Iguchi, Mitaka, Tokyo, 181-0011, Japan
| | - Eijiro Yamaga
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan
| | - Shunsuke Minakuchi
- Department of Gerodontology and Oral Rehabilitation, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo, Tokyo, 113-8549, Japan
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Geng Y, Meng C, Gao T, Li S, Bi L, Wang Y, Zhang P. Efficacy and Safety of Direct Oral Anticoagulants in Pediatric Venous Thromboembolism: A Systematic Review and Meta-Analysis. Indian J Pediatr 2023:10.1007/s12098-023-04952-8. [PMID: 38117441 DOI: 10.1007/s12098-023-04952-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 10/05/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVES To assess the efficacy and safety of direct oral anticoagulants (DOACs) in comparison to standard-of-care (SOC) anticoagulants in the management and prophylaxis of thromboembolic events in pediatric populations. METHODS A comprehensive search of electronic databases was conducted to identify relevant studies published between January 1, 2015, and December 18, 2022. A meta-analysis was undertaken to evaluate the effect of DOACs on clinically significant endpoints, employing trial-level data with harmonized endpoint definitions. The primary outcome was venous thromboembolism (VTE). Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. The study was registered with INPLASY (2022120065). RESULTS Three studies encompassing 934 subjects were included. The incidence of VTE was reduced in patients administered DOACs compared to those on SOC anticoagulants (OR 0.41 [95% CI 0.19-0.93], I² = 0%, P = 0.03). No significant differences were observed between the DOAC and SOC groups in all-cause mortality (OR 0.50 [95% CI 0.07-3.59], I² = 0%, P = 0.35) or serious adverse events (OR 0.75 [95% CI 0.50-1.12], I² = 0%, P = 0.16). The risk of major bleeding (OR 0.50 [95% CI 0.13-1.87], I² = 44%, P = 0.30) and clinically relevant non-major bleeding (OR 1.23 [95% CI 0.50-3.00], I² = 0%, P = 0.65) exhibited no significant differences between the groups. CONCLUSIONS DOACs are associated with a reduced risk of VTE in pediatric patients without increasing the risk of bleeding, all-cause mortality, or serious adverse events when compared to SOC anticoagulants. DOACs may be an alternative for the treatment and prevention of thromboembolic events in the pediatrics.
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Affiliation(s)
- Yu Geng
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China
| | - Chang Meng
- Department of Emergency, Emergency General Hospital, Beijing, China
| | - Tong Gao
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China
| | - Siyuan Li
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China
| | - Lei Bi
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China
| | - Yintang Wang
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China.
| | - Ping Zhang
- Department of Cardiology, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, NO. 168 Litang Road, Changping District, Beijing, 102218, P. R. China.
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Al-Hussainy N, Kragholm KH, Lundbye-Christensen S, Torp-Pedersen C, Pareek M, Therkelsen SK, Lip GYH, Riahi S. Gastrointestinal bleeding with direct oral anticoagulants in patients with atrial fibrillation and anaemia. Thromb Res 2023; 232:62-69. [PMID: 37939578 DOI: 10.1016/j.thromres.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 10/10/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023]
Abstract
INTRODUCTION A high risk of gastrointestinal bleeding has been reported with the use of some direct oral anticoagulants (DOACs). This risk may be of particular concern in individuals with associated anaemia. The aim of this study is to investigate potential differences in the risks of gastrointestinal bleeding and stroke among the four available DOACs in patients with atrial fibrillation (AF) and moderate or severe anaemia. MATERIALS AND METHODS All Danish patients diagnosed with incident AF who had a baseline haemoglobin measurement and subsequently initiated DOAC therapy between 2012 and 2021 were identified through administrative registries. Only patients with moderate or severe anaemia (N = 7269) were included and evaluated regarding the risk of hospitalization for gastrointestinal bleeding and stroke. Standardized absolute 1-year risks of stroke and gastrointestinal bleeding were calculated from multivariable Cox regression analyses. DOACs were compared pairwise RESULTS: Compared with apixaban, both dabigatran and rivaroxaban were associated with a significantly increased risk of gastrointestinal bleeding with standardized 1-year risk ratios of 1.73 (95 % confidence interval [CI], 1.10-2.35) and 1.56 (95 % CI, 1.18-1.93), respectively, while no significant difference was seen in the comparison of apixaban with edoxaban 1.32 (95 % CI, 0.41-2.32). No significant differences in gastrointestinal bleeding were observed with pairwise comparisons of dabigatran, rivaroxaban and edoxaban. Finally, no significant difference in stroke risk among the four DOACs was observed. CONCLUSION In AF patients with moderate or severe anaemia, apixaban was associated with a significantly lower risk of gastrointestinal bleeding than dabigatran and rivaroxaban. No significant difference in stroke risk was observed across all four available DOACs.
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Affiliation(s)
- Nour Al-Hussainy
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark.
| | - Kristian Hay Kragholm
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Unit of Clinical Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Lundbye-Christensen
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Unit of Clinical Biostatistics and Epidemiology, Aalborg University Hospital, Aalborg, Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology, North Zealand Hospital, Hillerød, Denmark; Department of Public Health, University of Copenhagen, Denmark
| | - Manan Pareek
- Department of Cardiology, North Zealand Hospital, Hillerød, Denmark; Center for Translational Cardiology and Pragmatic Randomized Trials, Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | | | - Gregory Y H Lip
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
| | - Sam Riahi
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark; Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
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Umashankar K, Mammi M, Badawoud E, Tang Y, Zhou M, Borges JC, Liew A, Migliore M, Mekary RA. Efficacy and Safety of Direct Oral Anticoagulants (DOACs) Versus Warfarin in Atrial Fibrillation Patients with Prior Stroke: a Systematic Review and Meta-analysis. Cardiovasc Drugs Ther 2023; 37:1225-1237. [PMID: 35467313 DOI: 10.1007/s10557-022-07336-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/14/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this meta-analysis was to compare efficacy and safety of direct oral anticoagulants (DOACs) to warfarin for secondary stroke prevention among adult patients with atrial fibrillation and prior stroke. METHODS Major repositories were screened for randomized controlled trials (RCTs), RCT subgroups, and observational studies (OBSs, divided in claims and non-claims). Occurrences of ischemic stroke or transient ischemic attack, systemic embolism, all-cause mortality, intracranial hemorrhage (ICH), and major bleeding were outcomes of interest. Hazard ratios (HRs) and their confidence intervals (95%CIs) were pooled using random-effects models for each study design. Claims studies were analyzed separately from non-claims, while RCT subgroups were grouped with OBSs (non-claims) as the randomization was broken. RESULTS Of 8647 articles, 20 were included (one RCT, six RCT subgroups, nine claims, and four non-claims). Comparing DOACs to warfarin, pooled HRs (95%CI) were consistently in favor of DOACs although some did not reach statistical significance: for ischemic stroke, 0.84 (0.66-1.07) in claims; 0.90 (0.77-1.06) in non-claims and RCT subgroups; for systemic embolism, 0.77 (0.62-0.96) in claims; 0.86 (0.77-0.96) in non-claims and RCT subgroups; for all-cause mortality, 0.57 (0.33-0.99) in claims; 0.87 (0.79-0.96) in non-claims and RCT subgroups; for ICH, 0.72 (0.39-1.33) in claims; 0.51 (0.38-0.67) in non-claims and RCT subgroups; and for major bleeding, 0.86 (0.71-1.03) in claims; 0.90 (0.76-1.08) for non-claims and RCT subgroups. CONCLUSION DOACs were associated with better efficacy and safety profiles than warfarin in atrial fibrillation patients with prior stroke, more specifically a lower risk of systemic embolism, all-cause mortality, and ICH.
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Affiliation(s)
- Kandavadivu Umashankar
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Marco Mammi
- Neurosurgery Unit, Santa Croce e Carle Hospital, Cuneo, Italy
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ebtissam Badawoud
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Yuzhi Tang
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Mengqi Zhou
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Jorge C Borges
- Division of Cardiology, Department of Internal Medicine, Texas Tech University Health Sciences Center (TTUHSC), Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Aaron Liew
- Portiuncula University Hospital and National University of Ireland Galway (NUIG), Galway, Ireland
| | - Mattia Migliore
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA
| | - Rania A Mekary
- School of Pharmacy, Massachusetts College of Pharmacy and Health Sciences (MCPHS) University, Boston, MA, USA.
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Research Faculty, Harvard Medical School, Brigham and Women's Hospital (CNOC), 179 Longwood Avenue, Boston, MA, 02115, USA.
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Alalawneh M, Rachid O, Abdallah I, Mahfouz A, Elewa H, Danjuma MIM, Mohamed AE, Awaisu A. Trends in prescribing and outcomes in obese versus non-obese patients receiving rivaroxaban therapy: an observational study using real-world data. Eur J Clin Pharmacol 2023; 79:1675-1685. [PMID: 37816816 PMCID: PMC10663176 DOI: 10.1007/s00228-023-03572-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 09/17/2023] [Indexed: 10/12/2023]
Abstract
PURPOSE To investigate real-world prescribing trends and clinical outcomes based on body mass index (BMI) categorization in patients who received rivaroxaban therapy. METHODS This was a retrospective cohort study involving all patients who received rivaroxaban therapy across all Hamad Medical Corporation (HMC) hospitals from 2015 to 2020. RESULTS The number of patients initiated on rivaroxaban therapy significantly increased from 152 (3.3%) in 2015 to 1342 (28.9%) in 2020 (p <0.001). Within BMI categories, a similar increasing trend was observed in underweight, normal, and overweight patients, while from 2018 to 2020, there was a decreasing trend in rivaroxaban prescribing in all obese classes. The prevalence rate of all-cause mortality differed significantly between the BMI groups, with the highest mortality being among morbidly obese patients (BMI ≥ 40 kg/m2) (p< 0.001). On the other hand, no significant differences were found between the BMI groups in terms of bleeding, pulmonary embolism, deep vein thrombosis and stroke incidences. Multivariate logistic regression analyses showed that the likelihood of all-cause mortality was significantly higher in overweight and all categories of obese patients compared to underweight patients: overweight (OR: 5.3, 95% CI: 2.3-11.9, p< 0.001); obese class 1 (OR: 5.4, 95% CI: 2.3 - 12.2, p< 0.001); obese class 2 (OR: 6.5, 95% CI: 2.7 - 15.6, p< 0.001); and obese class 3 (OR: 3.7, 95% CI: 1.6 - 8.7, p = 0.003). CONCLUSIONS Rivaroxaban prescribing has significantly increased over the years across general population, with a noticeable decline in obese population during the last few years (from 2018 onwards). Furthermore, an appreciable association was evident between all-cause mortality and BMI of these patients.
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Affiliation(s)
- Majdoleen Alalawneh
- College of Pharmacy, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Ousama Rachid
- College of Pharmacy, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Ibtihal Abdallah
- Clinical Pharmacy Services, Hamad General Hospital, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | - Ahmed Mahfouz
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | - Hazem Elewa
- College of Pharmacy, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Mohammed Ibn-Mas'ud Danjuma
- Department of Internal Medicine, Hamad General Hospital, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
- College of Medicine, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar
| | - Asmaa Ezzeldin Mohamed
- Clinical Pharmacy Services, Hamad General Hospital, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar
| | - Ahmed Awaisu
- College of Pharmacy, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar.
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Elenjickal EJ, Travlos CK, Marques P, Mavrakanas TA. Anticoagulation in Patients with Chronic Kidney Disease. Am J Nephrol 2023; 55:146-164. [PMID: 38035566 PMCID: PMC10994631 DOI: 10.1159/000535546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 11/27/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Both atrial fibrillation and venous thromboembolism (VTE) are highly prevalent among patients with chronic kidney disease (CKD). Until recently, warfarin was the most commonly prescribed oral anticoagulant. Direct oral anticoagulants (DOACs) have important advantages and have been shown to be noninferior to warfarin with respect to stroke prevention or recurrent VTE in the general population, with lower bleeding rates. This review article will provide available evidence on the use of DOACs in patients with CKD. SUMMARY In post hoc analyses of major randomized studies with DOACs for stroke prevention in atrial fibrillation, in the subgroup of participants with moderate CKD, defined as a creatinine clearance (CrCl) of 30-50 mL/min, dabigatran 150 mg and apixaban were associated with lower rates of stroke and systemic embolism, whereas apixaban and edoxaban were associated with lower bleeding and mortality rates, compared with warfarin. In retrospective observational studies in patients with advanced CKD (defined as a CrCl <30 mL/min) and atrial fibrillation, DOACs had similar efficacy with warfarin with numerically lower bleeding rates. All agents warrant dose adjustment in moderate-to-severe CKD. In patients on maintenance dialysis, the VALKYRIE trial, which was designed initially to study the effect of vitamin K on vascular calcification progression, established superiority for rivaroxaban compared with a vitamin K antagonist (VKA) in the extension phase. Two other clinical trials using apixaban (AXADIA and RENAL-AF) in this population were inconclusive due to recruitment challenges and low event rates. In post hoc analyses of randomized studies with DOACs in patients with VTE, in the subgroup of participants with moderate CKD at baseline, edoxaban was associated with lower rates of recurrent VTE, whereas rivaroxaban and dabigatran were associated with lower and higher bleeding rates, respectively, as compared to warfarin. KEY MESSAGES DOACs have revolutionized the management of atrial fibrillation and VTE, and they should be preferred over warfarin in patients with moderate-to-severe CKD with appropriate dose adjustment. Therapeutic drug monitoring with a valid technique may be considered to guide clinical management in individualized cases. Current evidence questions the need for oral anticoagulation in patients on maintenance dialysis with atrial fibrillation as both DOACs and VKAs are associated with high rates of major bleeding.
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Affiliation(s)
- Elias John Elenjickal
- Division of Nephrology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Québec, Canada
| | - Christoforos K Travlos
- Division of Nephrology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Québec, Canada
| | - Pedro Marques
- Division of Nephrology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Québec, Canada
| | - Thomas A Mavrakanas
- Division of Nephrology, Department of Medicine, McGill University Health Centre and Research Institute, Montreal, Québec, Canada
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Akao M, Inoue H, Yamashita T, Atarashi H, Ikeda T, Koretsune Y, Okumura K, Suzuki S, Tsutsui H, Toyoda K, Hirayama A, Yasaka M, Yamaguchi T, Teramukai S, Kimura T, Morishima Y, Takita A, Shimizu W. Relationship Between Direct Oral Anticoagulant Doses and Clinical Outcomes in Elderly Patients With Non-Valvular Atrial Fibrillation - ANAFIE Registry Sub-Analysis. Circ J 2023; 87:1765-1774. [PMID: 37482411 DOI: 10.1253/circj.cj-23-0143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
BACKGROUND This sub-analysis of the ANAFIE Registry, a prospective, observational study of >30,000 Japanese non-valvular atrial fibrillation (NVAF) patients aged ≥75 years, assessed the prevalence of direct oral anticoagulant (DOAC) under-dose prevalence, identified the factors of under-dose prescriptions, and examined the relationship between DOAC dose and clinical outcomes.Methods and Results: Patients, divided into 5 groups by DOAC dose (standard, over-, reduced, under-, and off-label), were analyzed for background factors, cumulative incidences, and clinical outcome risk. Endpoints were stroke/systemic embolic events (SEE), major bleeding, and all-cause death during the 2-year follow-up. Of 18,497 patients taking DOACs, 20.7%, 3.8%, 51.6%, 19.6%, and 4.3%, were prescribed standard, over-, reduced, under-, and off-label doses. Factors associated with under-dose use were female sex, age ≥85 years, reduced creatinine clearance, history of major bleeding, polypharmacy, antiplatelet agents, heart failure, dementia, and no history of catheter ablation or cerebrovascular disease. After confounder adjustment, under-dose vs. standard dose was not associated with the incidence of stroke/SEE or major bleeding but was associated with a higher mortality rate. Patients receiving an off-label dose showed similar tendencies to those receiving an under-dose; that is, they showed the highest mortality rates for stroke/SEE, major bleeding, and all-cause death. CONCLUSIONS Inappropriate low DOAC doses (under- or off-label dose) were not associated with stroke/SEE or major bleeding but were associated with all-cause death.
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Affiliation(s)
- Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | | | | | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | | | - Ken Okumura
- Division of Cardiology, Saiseikai Kumamoto Hospital Cardiovascular Center
| | | | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, Cerebrovascular Center, National Hospital Organization Kyushu Medical Center
| | - Takenori Yamaguchi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Satoshi Teramukai
- Department of Biostatistics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine
| | - Tetsuya Kimura
- Primary Medical Science Department, Daiichi Sankyo Co., Ltd
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tama Nagayama Hospital
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Truong B, Hornsby L, Fox BI, Chou C, Zheng J, Qian J. Screening for clinically relevant drug-drug interactions between direct oral anticoagulants and antineoplastic agents: a pharmacovigilance approach. J Thromb Thrombolysis 2023; 56:555-567. [PMID: 37563503 DOI: 10.1007/s11239-023-02879-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/29/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Use of direct oral anticoagulants (DOACs) in patients with cancer remains suboptimal due to the concern regarding potential drug-drug interactions (DDIs) with antineoplastic treatments. However, the clinical relevance of these DDIs is unknown. METHODS We conducted a pharmacovigilance study of adverse event (AE) reports from the US Food and Drug Administration Adverse Event Reporting System from 1/1/2004 to 12/31/2021. AE reports containing DOACs and antineoplastic agents with CYP3A4/P-gp inhibitory or inducing activity suggested by published pharmacokinetic studies were included (n = 36,066). The outcomes of interest were bleeding or stroke, identified by MedDRA dictionary version 25.0. We used disproportionality analyses (DPA), logistic regression models (LR), and Multi-item Gamma-Poisson Shrinker (MGPS) (Empirical Bayes Geometric Means (EBGM) and 90% credible intervals (90% CIs)) algorithms to identify the safety signal of DDIs. RESULTS The highest bleeding reporting rates for each drug class were the combination of DOACs with neratinib (39.08%, n = 34), tamoxifen (21.22%, n = 104), irinotecan (20.54%, n = 83), and cyclosporine (19.17%, n = 227). The highest rate of stroke was found for prednisolone (2.43%, n = 113). In the primary analysis, no signal of DDIs by the antineoplastic therapeutic class was detected by MGPS, DPA, and LR approaches. By individual antineoplastic drug, DOACs-neratinib was the only signal detected [EBGM (EB05-EB95) = 2.71 (2.03-3.54)]. CONCLUSION No signal of DDIs between DOACs and antineoplastic agents was detected, except for DOAC-neratinib. Most DDIs between DOACs and antineoplastic agents may not be clinically relevant. The DDIs between DOACs and neratinib should be further examined in future research.
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Affiliation(s)
- Bang Truong
- Department of Health Outcomes Research and Policy, Auburn University Harrison College of Pharmacy, 4306D Walker Building, Auburn, AL, 36849, USA
| | - Lori Hornsby
- Department of Pharmacy Practice, Auburn University Harrison College of Pharmacy, Auburn, AL, USA
| | - Brent I Fox
- Department of Health Outcomes Research and Policy, Auburn University Harrison College of Pharmacy, 4306D Walker Building, Auburn, AL, 36849, USA
| | - Chiahung Chou
- Department of Health Outcomes Research and Policy, Auburn University Harrison College of Pharmacy, 4306D Walker Building, Auburn, AL, 36849, USA
| | - Jingyi Zheng
- Department of Mathematics and Statistics, Auburn University College of Sciences and Mathematics, Auburn, AL, USA
| | - Jingjing Qian
- Department of Health Outcomes Research and Policy, Auburn University Harrison College of Pharmacy, 4306D Walker Building, Auburn, AL, 36849, USA.
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Ishisaka Y, Watanabe A, Takagi H, Steiger D, Kuno T. Anticoagulation in chronic thromboembolic pulmonary hypertension: A systematic review and meta-analysis. Thromb Res 2023; 231:91-98. [PMID: 37839150 DOI: 10.1016/j.thromres.2023.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/31/2023] [Accepted: 10/02/2023] [Indexed: 10/17/2023]
Abstract
INTRODUCTION Life-long anticoagulation is the recommended management for chronic thromboembolic pulmonary hypertension (CTEPH). Evidence regarding the use of direct oral anticoagulants (DOAC) for CTEPH is yet to be established. We performed a systematic review and meta-analysis to clarify the outcomes of CTEPH in patients who used DOAC or vitamin K antagonists (VKA). METHODS We reviewed literature in PubMed and EMBASE through March 2023. We included studies involving patients with CTEPH where DOAC and VKA were compared. We collected data including intervention history for CTEPH, bleeding events, recurrence of VTE (venous thromboembolism), and mortality. We performed a meta-analysis using the Mantel-Haenszel method with a fixed-effects model. RESULTS We included one randomized clinical trial and six observational studies, with a total of 2969 patients. Six studies investigated major bleeding outcomes, and seven investigated all bleeding outcomes. There were no differences in major bleeding (RR 0.59, 95 % CI [0.34-1.02], I2 = 0 %) and all-bleeding (RR 0.87, 95 % CI [0.67-1.13], I2 = 0 %). Based on the five studies we included, DOAC was associated with a lower risk of mortality (RR 0.54, 95 % CI: 0.37-0.79, I2 = 5 %). However, a higher risk of recurrent pulmonary embolism (PE) was seen in three studies (RR 3.80, 95 % CI: [1.93-7.50], I2 = 11 %). No significant differences were noted in terms of VTE. CONCLUSION DOAC compared to VKA was associated with a significantly lower mortality and higher risk of recurrent PE. Since most of the included studies are observational, we must consider the existence of multiple biases and confounding factors.
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Affiliation(s)
- Yoshiko Ishisaka
- Department of Medicine, Mount Sinai Beth Israel, New York, NY, USA
| | | | - Hisato Takagi
- Division of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - David Steiger
- Department of Pulmonary and Critical Care, Icahn School of Medicine at Mount Sinai, Mount Sinai Beth Israel, New York, NY, USA
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA; Division of Cardiology, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY, USA.
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Arora P, Muehrcke M, Russell M, Ghanekar S. Utilization outcomes of direct oral anticoagulants in Medicare patients. Res Social Adm Pharm 2023; 19:1424-1431. [PMID: 37429747 DOI: 10.1016/j.sapharm.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/19/2023] [Accepted: 07/02/2023] [Indexed: 07/12/2023]
Abstract
OBJECTIVE To compare the adherence, persistence, discontinuation and switching rates of direct oral anticoagulants (DOACs) for Medicare patients with non-valvular atrial fibrillation (NVAF) or venous thromboembolism (VTE). METHODS This was retrospective observational cohort study design. Medicare Part D claims files were used for the study duration (2015-2018). Inclusion-exclusion criteria were applied to identify the NVAF and VTE sample using dabigatran, rivaroxaban, apixaban, edoxaban and warfarin during the identification period (2016-2017). Outcomes of adherence, persistence, time to non-persistence and time to discontinuation were assessed in those who did not switch the index drug in the follow-up period (365 days from the index date). Switching rates were assessed in those who switched the index drug at least once in the aforementioned follow-up period. Descriptive statistics were conducted for all the outcomes, and comparisons were made using t-tests, chi-square, and ANOVA. Logistic regression was conducted to compare the odds of being adherent and the odds of switching in NVAF and VTE patient cohorts. RESULTS Of all the DOACs, patients with NVAF or VTE were most adherent to apixaban (PDC = 76.88). Among all the DOACs, non-persistence and discontinuation rates were highest for warfarin. Majority of the switches were reported from dabigatran to other DOAC and to apixaban from other DOAC. Despite the better utilization outcomes reported for apixaban users, Medicare plans covered rivaroxaban favorably. It was associated with the lowest mean amount paid by the patient (NVAF: $76; VTE: $59), and the highest mean amount paid by the plans (NVAF: $359; VTE: $326). CONCLUSION Medicare plans need to consider adherence, persistence, discontinuation and switching rates of DOACs to make the coverage decisions.
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Affiliation(s)
- Prachi Arora
- College of Pharmacy and Health Sciences, Butler University, 4600 Sunset Ave, Indianapolis, IN, 46208, USA.
| | - Maria Muehrcke
- College of Pharmacy and Health Sciences, Butler University, 4600 Sunset Ave, Indianapolis, IN, 46208, USA.
| | - Molly Russell
- College of Pharmacy and Health Sciences, Butler University, 4600 Sunset Ave, Indianapolis, IN, 46208, USA.
| | - Saurabh Ghanekar
- Resultant, 111 Monument Circle, Suite 202, Indianapolis, IN, 46204, USA.
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Capron T, Botto G, Roujon JJ, Miltgen J, Berard H. Drug-induced interstitial lung disease: Indictment for apixaban. Respir Med Res 2023; 84:101024. [PMID: 37734231 DOI: 10.1016/j.resmer.2023.101024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/12/2023] [Accepted: 05/08/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Thibaut Capron
- Cabinet de Pneumologie, Elsan - Polyclinique les Fleurs, Ollioules, France.
| | - Guillaume Botto
- Cabinet de Pneumologie, Elsan - Polyclinique les Fleurs, Ollioules, France
| | | | - Jean Miltgen
- Cabinet de Pneumologie, Elsan - Polyclinique les Fleurs, Ollioules, France
| | - Henri Berard
- Cabinet de Pneumologie, Elsan - Polyclinique les Fleurs, Ollioules, France
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Krečak I, Grohovac D, Vučenović Bašić N, Čeko M, Nižetić K, Sabljić A, Holik H, Galušić D, Zekanović I, Morić Perić M, Periša V, Lucijanić M. Clinical presentation, treatment patterns, and outcomes of pulmonary embolism in patients with chronic myeloproliferative neoplasms. Thromb Res 2023; 231:141-143. [PMID: 36964024 DOI: 10.1016/j.thromres.2023.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 03/08/2023] [Accepted: 03/15/2023] [Indexed: 03/26/2023]
Affiliation(s)
- Ivan Krečak
- Department of Internal Medicine, General Hospital of Šibenik-Knin County, Šibenik, Croatia; Faculty of Medicine, University of Rijeka, Rijeka, Croatia.
| | | | | | - Monika Čeko
- Department of Internal Medicine, General Hospital of Šibenik-Knin County, Šibenik, Croatia
| | - Karla Nižetić
- Department of Internal Medicine, General Hospital of Šibenik-Knin County, Šibenik, Croatia
| | | | - Hrvoje Holik
- Dr. Josip Benčević General Hospital, Slavonski Brod, Croatia; Faculty of Medicine, University of Osijek, Osijek, Croatia
| | - Davor Galušić
- University Hospital Split, Split, Croatia; Faculty of Medicine, University of Split, Split, Croatia
| | | | | | - Vlatka Periša
- Faculty of Medicine, University of Osijek, Osijek, Croatia; University Hospital Osijek, Osijek, Croatia
| | - Marko Lucijanić
- University Hospital Dubrava, Zagreb, Croatia; Faculty of Medicine, University of Zagreb, Zagreb, Croatia
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Wang TF, Hill M, Mallick R, Chaudry H, Unachukwu U, Delluc A, Carrier M. The prevalence of relevant drug-drug interactions and associated clinical outcomes in patients with cancer-associated thrombosis on concurrent anticoagulation and anticancer or supportive care therapies. Thromb Res 2023; 231:128-134. [PMID: 37857226 DOI: 10.1016/j.thromres.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/27/2023] [Accepted: 10/02/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND A main concern in the management of patients with cancer-associated thrombosis (CAT) is drug-drug interactions (DDIs) between anticoagulants and anticancer therapies. Their clinical implications remain unclear. METHODS To quantify the prevalence of DDIs and risks of recurrent venous thromboembolism (VTE) and bleeding events in patients with CAT on anticoagulation, we conducted a retrospective cohort study in patients with CAT on concurrent anticoagulants and anticancer and/or supportive care therapies. All patients were followed for 6 months from CAT diagnosis or until death (whichever occurred first). The primary outcome was the percentage of patients with anticoagulant DDIs classified as risk C, D, or X in Lexicomp® at any time during the 6 months. Secondary outcomes included recurrent VTE and clinically relevant bleeding events. We calculated the 6-month cumulative incidence of outcomes with 95 % confidence interval (CI) and compared those with and without DDIs, considering death as a competing risk. RESULTS Among 267 patients included, 111 (41.6 %) had DDIs with anticoagulants at any time during the study. Those on DOACs at any time had more DDIs compared to LMWH (50.9 % vs 19.3 %, p < 0.0001). The 6-month incidence was 8.2 % (95 % CI 5.3-11.9) for recurrent VTE and 6.7 % (95 % CI 4.2-10.2) for clinically relevant bleeding, with no significant differences between groups with or without DDIs. CONCLUSIONS There are high incidences of DDIs in patients with CAT on anticoagulants, more with DOACs. DDIs classified as risk C, D, or X by Lexicomp® were not associated with recurrent VTE or bleeding events in our cohort.
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Affiliation(s)
- Tzu-Fei Wang
- Department of Medicine, University of Ottawa at The Ottawa Hospital, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | | | - Ranjeeta Mallick
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Hina Chaudry
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Aurélien Delluc
- Department of Medicine, University of Ottawa at The Ottawa Hospital, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Marc Carrier
- Department of Medicine, University of Ottawa at The Ottawa Hospital, Ottawa, ON, Canada; Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Suda S, Iguchi Y, Yagita Y, Kanzawa T, Okubo S, Fujimoto S, Kono Y, Kimura K. Resumption of oral anticoagulation in patients with non-valvular atrial fibrillation after intracerebral hemorrhage: A sub-analysis of the PASTA registry study. J Neurol Sci 2023; 453:120810. [PMID: 37742350 DOI: 10.1016/j.jns.2023.120810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/09/2023] [Accepted: 09/12/2023] [Indexed: 09/26/2023]
Abstract
PURPOSE To investigate the rate and timing of oral anticoagulant (OAC) resumption and its safety in patients after intracerebral hemorrhage (ICH) in current clinical practice in Japan. METHODS We conducted a sub-analysis of the PASTA registry, an observational, multicenter registry of 1043 patients with stroke receiving OACs in Japan, by including patients with ICH on OAC treatment for non-valvular atrial fibrillation (NVAF). The clinical characteristics of the patients in the resumption and non-resumption groups, rate and timing of OAC resumption, its safety, and switching of OACs after ICH were investigated. RESULTS Of the 160 patients (women, n = 52; median age, 77 years) included, OACs were resumed in 108 (68%) at a median of 7 days (interquartile range, 4-11) after acute ICH onset. The non-resumption group had higher rates of hematoma expansion (21.2% vs. 7.4%; P = 0.0118) and modified Rankin Scale (mRS) scores at discharge (4 (Suda et al., 2019; Steiner et al., 2014 [3, 4]) vs. 4 (Suda et al., 2019; Steiner et al., 2014; Pasquini et al., 2014 [3-5]); P = 0.0302}. The resumption rate in the mRS 0-4 group was higher than that in the mRS 5 group (75.2% vs. 46.5%; P = 0.00006). The number of days to resumption after ICH onset was longer in the mRS 5 than that in the mRS 0-4 group (median 12 days vs. 7 days, P = 0.0065). There were no significant differences in new-onset ICH, symptomatic hematoma expansion, or gastrointestinal bleeding between groups (P > 0.05). CONCLUSIONS Early resumption of OAC for NVAF in patients after ICH appeared to be safe. Expected functional outcomes at discharge were associated with OAC resumption and with the timing of resumption. REGISTRATION https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000034958.
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Affiliation(s)
- Satoshi Suda
- Department of Neurology, Nippon Medical School, Tokyo, Japan; Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Saitama, Japan.
| | - Yasuyuki Iguchi
- Department of Neurology, The Jikei University School of Medicine, Tokyo, Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine, Kawasaki Medical School, Okayama, Japan
| | - Takao Kanzawa
- Department of Stroke Medicine, Institute of Brain and Blood Vessels, Mihara Memorial Hospital, Gunma, Japan; Institute of HM Network, Gunyukai Isesaki Clinic, Gunma, Japan
| | - Seiji Okubo
- Department of Cerebrovascular Medicine, NTT Medical Center Tokyo, Tokyo, Japan
| | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University Hospital, Tochigi, Japan
| | - Yu Kono
- Department of Neurology, Fuji City General Hospital, Shizuoka, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
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Kanazawa R, Yoshihara T, Uchida T, Higashida T, Arai N, Ohbuchi H, Takahashi Y. Thromboembolic complications during and after embolization of unruptured aneurysms: A chronological outcome in periprocedural thromboembolic events. Surg Neurol Int 2023; 14:362. [PMID: 37941641 PMCID: PMC10629294 DOI: 10.25259/sni_625_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/13/2023] [Indexed: 11/10/2023] Open
Abstract
Background Ischemic complications develop after elective coil embolization procedures at a certain rate. The prevention of these events has been a longstanding issue for many interventional neuroradiologists. This study aimed to clarify whether procedural ischemic events after unruptured aneurysm embolization decrease over time with perioperative anti-thromboembolic treatment or surgical experience. Methods This study included patients with cerebral aneurysms in our institution between July 2012 and June 2020. Dual-antiplatelet therapy (DAPT) was performed (Phase 1). Thromboembolic events developed at a certain rate; thus, rivaroxaban was administered with single-antiplatelet therapy (SAPT) to improve thromboembolic results (Phase 2), showing better outcomes than in Phase 1. Subsequently, DAPT was administered again (Phase 3). Ischemic complications were evaluated in each phase or compared between the DAPT group and the direct oral anticoagulant (DOAC) with the clopidogrel (DOAC+SAPT) group. Results Relatively, fewer symptomatic ischemic events were noted in Phase 2 or the DOAC+SAPT group, but the outcome was not better in Phase 3 than in Phase 2. Symptomatic complications were more common in Phase 3 than in Phases 1 and 2. Conclusion Ischemic complications occurred at a certain rate after endovascular procedures for unruptured aneurysms. The incidence did not decrease over time; particularly, standard DAPT plus postoperative anti-thromboembolic medication did not adequately decrease complications in Phase 3 compared to Phases 1 and 2. Therefore, accumulated experience or a learning curve could not explain the results. DOAC administration might decrease the risk of these events, but further accumulation of evidence or prospective investigation is warranted.
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Affiliation(s)
| | - Tomoyuki Yoshihara
- Department of Emergency and Critical Care Medicine, Kansai Medical University General Medical Center, Osaka, Japan
| | - Takanori Uchida
- Department of Neurosurgery, Nagareyama Central Hospital, Chiba, Japan
| | | | - Naoyuki Arai
- Department of Neurosurgery, Medical Center Adachi, Tokyo Women’s Medical University, Tokyo, Japan
| | - Hidenori Ohbuchi
- Department of Neurosurgery, Medical Center Adachi, Tokyo Women’s Medical University, Tokyo, Japan
| | - Yuichi Takahashi
- Department of Neurosurgery, Sassa General Hospital, Nishitokyo, Japan
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Lee KH, Hung WT, Huang WY, Ovbiagele B, Lee M. Direct oral anticoagulants compared with other strategies in patients with atrial fibrillation and stroke or transient ischemic attack: Systematic review. J Formos Med Assoc 2023:S0929-6646(23)00407-2. [PMID: 37838540 DOI: 10.1016/j.jfma.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 09/17/2023] [Accepted: 10/03/2023] [Indexed: 10/16/2023] Open
Abstract
BACKGROUND For patients with atrial fibrillation and a prior stroke or transient ischemic attack (TIA), the risk-benefit of direct oral anticoagulants (DOACs) compared to alternative treatment approaches has not been firmly established. We conducted a systematic review of randomized controlled trials (RCTs) to investigate efficacy and safety of DOACs vs warfarin and DOACs vs aspirin or placebo in patients with AF and a prior stroke or TIA. METHODS We searched PubMed, EMBASE, and Cochrane Central Register of Controlled Trials from January 1, 2000, to January 31, 2023, to find RCTs. Risk ratio (RR) with 95 % CI measured the association of DOACs vs warfarin, and DOACs vs aspirin or placebo, with clinical outcomes. Primary efficacy outcome was stroke or systemic embolism and primary safety outcome was ICH. RESULTS We identified 7 RCTs with 19,111 patients with AF and a prior stroke or TIA, of which 5 trials compared DOACs with warfarin and 2 trials compared DOACs vs aspirin or placebo. Compared with warfarin, DOACs were associated with a lower risk of stroke or systemic embolism (RR, 0.85; 95 % CI, 0.75-0.97) and ICH (RR, 0.53; 95 % CI, 0.41-0.68). Compared with aspirin or placebo, DOACs were associated with a reduced risk of stroke or systemic embolism (RR, 0.33; 95 % CI, 0.19-0.58) and risk of ICH did not differ between apixaban and aspirin. CONCLUSIONS This contemporary evaluation of the literature indicates that DOACs, rather than other antithrombotic agents or no treatment, should be used in patients with AF and a prior stroke or TIA.
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Affiliation(s)
- Kuan-Hsin Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi, Taiwan
| | - Wei-Tse Hung
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi, Taiwan.
| | - Wen-Yi Huang
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Keelung Branch, Keelung, Taiwan
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Chiayi, Taiwan
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Darwish G. The Effect of Direct Oral Anticoagulant Therapy (DOACs) on oral surgical procedures: a systematic review. BMC Oral Health 2023; 23:743. [PMID: 37821865 PMCID: PMC10566068 DOI: 10.1186/s12903-023-03427-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 09/19/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) were developed to overcome the drawbacks of oral anticoagulants. However, not much has been discussed about the perioperative management of patients on DOACs during oral surgical procedures. Thus, we aim to determine the risk of perioperative and postoperative bleeding during oral surgical procedures in patients on DOACs. METHODS A detailed literature search was performed to find potentially relevant studies using the Cochrane Library, Clinical Key, ClinicalTrials.gov, Google Scholar, Ovid, ScienceDirect, and Scopus. Every article available for free in English literature for the past 10 years, between 2012 and 2022, was searched. RESULTS A total of 2792 abstracts were selected through a search strategy across various search engines. Based on inclusion and exclusion criteria, eleven clinical studies using DOACs as anticoagulants or studies comparing patients with and without DOACs under oral surgery procedures were found. The results were inconsistent and varied, with a few studies recommending DOAC administration with the bare minimum reported complications and others finding no statistically significant difference between discontinuation or continuation of drugs, especially across basic dental procedures. CONCLUSION Within the limitations of the study, it can be concluded that minor oral surgical procedures are safe for patients on DOAC therapy. However, the continuation or discontinuation of DOACs in patients undergoing oral surgical procedures remains controversial and requires further studies to extrapolate the results.
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Affiliation(s)
- Ghassan Darwish
- Department of Oral and Maxillofacial Surgery, School of Dentistry, King Abdulaziz University, 21589, Jeddah, Saudi Arabia.
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Heuts S, Ceulemans A, Kuiper GJAJM, Schreiber JU, van Varik BJ, Olie RH, Ten Cate H, Maessen JG, Milojevic M, Maesen B. Optimal management of cardiac surgery patients using direct oral anticoagulants: recommendations for clinical practice. Eur J Cardiothorac Surg 2023; 64:ezad340. [PMID: 37812245 PMCID: PMC10585358 DOI: 10.1093/ejcts/ezad340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 09/26/2023] [Accepted: 10/06/2023] [Indexed: 10/10/2023] Open
Abstract
OBJECTIVES Literature is scarce on the management of patients using direct oral anticoagulants (DOACs) undergoing elective, urgent and emergency surgery. Therefore, we summarize the current evidence and provide literature-based recommendations for the management of patients on DOACs in the perioperative phase. METHODS A general literature review was conducted on the pharmacology of DOACs and for recommendations on the management of cardiac surgical patients on DOACs. Additionally, we performed a systematic review for studies on the use of direct DOAC reversal agents in the emergency cardiac surgical setting. RESULTS When surgery is elective, the DOAC cessation strategy is relatively straightforward and should be adapted to the renal function. The same approach applies to urgent cases, but additional DOAC activity drug level monitoring tests may be useful. In emergency cases, idarucizumab can be safely administered to patients on dabigatran in any of the perioperative phases. However, andexanet alfa, which is not registered for perioperative use, should not be administered in the preoperative phase to reverse the effect of factor Xa inhibitors, as it may induce temporary heparin resistance. Finally, the administration of (activated) prothrombin complex concentrate may be considered in all patients on DOACs, and such concentrates are generally readily available. CONCLUSIONS DOACs offer several advantages over vitamin K antagonists, but care must be taken in patients undergoing cardiac surgery. Although elective and urgent cases can be managed relatively straightforwardly, the management of emergency cases requires particular attention.
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Affiliation(s)
- Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Angelique Ceulemans
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Department of Neurology, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Gerhardus J A J M Kuiper
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Jan U Schreiber
- Department of Anaesthesiology and Pain Treatment, Maastricht University Medical Centre+, Maastricht, Netherlands
| | | | - Renske H Olie
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Thrombosis Expertise Centre, Maastricht University Medical Centre+, Maastricht, Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Hugo Ten Cate
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Thrombosis Expertise Centre, Maastricht University Medical Centre+, Maastricht, Netherlands
- Department of Internal Medicine, Section Vascular Medicine, Maastricht University Medical Centre+, Maastricht, Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
| | - Bart Maesen
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre+, Maastricht, Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
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