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Fiebig A, Leibl V, Oostendorf D, Lukaschek S, Frömbgen J, Masoudi M, Kremer AE, Strupf M, Reeh P, Düll M, Namer B. Peripheral signaling pathways contributing to non-histaminergic itch in humans. J Transl Med 2023; 21:908. [PMID: 38087354 PMCID: PMC10717026 DOI: 10.1186/s12967-023-04698-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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 11/04/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Chronic itch (chronic pruritus) is a major therapeutic challenge that remains poorly understood despite the extensive recent analysis of human pruriceptors. It is unclear how the peripheral nervous system differentiates the signaling of non-histaminergic itch and pain. METHODS Here we used psychophysical analysis and microneurography (single nerve fiber recordings) in healthy human volunteers to explore the distinct signaling mechanisms of itch, using the pruritogens β-alanine, BAM 8-22 and cowhage extract. RESULTS The mode of application (injection or focal application using inactivated cowhage spicules) influenced the itch/pain ratio in sensations induced by BAM 8-22 and cowhage but not β-alanine. We found that sensitizing pre-injections of prostaglandin E2 increased the pain component of BAM 8-22 but not the other pruritogens. A-fibers contributed only to itch induced by β-alanine. TRPV1 and TRPA1 were necessary for itch signaling induced by all three pruritogens. In single-fiber recordings, we found that BAM 8-22 and β-alanine injection activated nearly all CM-fibers (to different extents) but not CMi-fibers, whereas cowhage extract injection activated only 56% of CM-fibers but also 25% of CMi-fibers. A "slow bursting discharge pattern" was evoked in 25% of CM-fibers by β-alanine, in 35% by BAM 8-22, but in only 10% by cowhage extract. CONCLUSION Our results indicate that no labeled line exists for these pruritogens in humans. A combination of different mechanisms, specific for each pruritogen, leads to itching sensations rather than pain. Notably, non-receptor-based mechanisms such as spatial contrast or discharge pattern coding seem to be important processes. These findings will facilitate the discovery of therapeutic targets for chronic pruritus, which are unlikely to be treated effectively by single receptor blockade.
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Affiliation(s)
- Andrea Fiebig
- Research Group Neuroscience, Interdisciplinary Centre for Clinical Research, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
- Institute of Neurophysiology, Uniklinik RWTH Aachen University, Aachen, Germany
| | - Victoria Leibl
- Institute of Physiology and Pathophysiology, University of Erlangen-Nürnberg, 91054, Erlangen, Germany
| | - David Oostendorf
- Institute of Physiology and Pathophysiology, University of Erlangen-Nürnberg, 91054, Erlangen, Germany
| | - Saskia Lukaschek
- Research Group Neuroscience, Interdisciplinary Centre for Clinical Research, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
- Institute of Neurophysiology, Uniklinik RWTH Aachen University, Aachen, Germany
| | - Jens Frömbgen
- Research Group Neuroscience, Interdisciplinary Centre for Clinical Research, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
- Institute of Neurophysiology, Uniklinik RWTH Aachen University, Aachen, Germany
| | - Maral Masoudi
- Institute of Physiology and Pathophysiology, University of Erlangen-Nürnberg, 91054, Erlangen, Germany
| | - Andreas E Kremer
- Department of Gastroenterology and Hepatology, University Hospital Zürich, University of Zürich, Zurich, Switzerland
| | - Marion Strupf
- Institute of Physiology and Pathophysiology, University of Erlangen-Nürnberg, 91054, Erlangen, Germany
| | - Peter Reeh
- Institute of Physiology and Pathophysiology, University of Erlangen-Nürnberg, 91054, Erlangen, Germany
| | - Miriam Düll
- Institute of Physiology and Pathophysiology, University of Erlangen-Nürnberg, 91054, Erlangen, Germany
- Department of Medicine 1, University Hospital Erlangen and Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Barbara Namer
- Research Group Neuroscience, Interdisciplinary Centre for Clinical Research, Faculty of Medicine, RWTH Aachen University, Aachen, Germany.
- Institute of Neurophysiology, Uniklinik RWTH Aachen University, Aachen, Germany.
- Institute of Physiology and Pathophysiology, University of Erlangen-Nürnberg, 91054, Erlangen, Germany.
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Kumar VS, Puthuran GV, Radhakrishnan N, Kohli P. Reticular epithelial corneal oedema secondary to topical netarsudil drops. Natl Med J India 2023; 36:274-275. [PMID: 38692630 DOI: 10.25259/nmji_675_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Affiliation(s)
| | - George V Puthuran
- Department of Glaucoma, Aravind Eye Hospital, Madurai, Tamil Nadu, India
| | | | - Piyush Kohli
- Department of Vitreoretinal Services, CL Gupta Eye Institute, Moradabad, Uttar Pradesh, India
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Asrani S, Bacharach J, Holland E, McKee H, Sheng H, Lewis RA, Kopczynski CC, Heah T. Fixed-Dose Combination of Netarsudil and Latanoprost in Ocular Hypertension and Open-Angle Glaucoma: Pooled Efficacy/Safety Analysis of Phase 3 MERCURY-1 and -2. Adv Ther 2020; 37:1620-1631. [PMID: 32166538 PMCID: PMC7140751 DOI: 10.1007/s12325-020-01277-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Indexed: 12/22/2022]
Abstract
INTRODUCTION New open-angle glaucoma (OAG) and ocular hypertension (OHT) therapies that reduce treatment burden and improve outcomes relative to currently available agents are needed. Netarsudil, a novel Rho kinase inhibitor approved by the US Food and Drug Administration, reduces intraocular pressure (IOP) by increasing trabecular outflow. Two phase 3 superiority studies compared a fixed-dose combination (FDC) of netarsudil and the prostaglandin latanoprost with each active component for IOP-lowering efficacy. METHODS Pooled efficacy and safety data were analyzed from MERCURY-1 and -2 studies in patients with OAG or OHT. Patients instilled one drop of netarsudil (0.02%)/latanoprost (0.005%) FDC (n = 483), netarsudil (0.02%, n = 499), or latanoprost (0.005%, n = 486) into each eye once-daily between 20:00 and 22:00. IOP was measured at 08:00, 10:00, and 16:00 at weeks 2, 6, and the primary endpoint at month 3. RESULTS Baseline mean diurnal IOP was 23.6, 23.6, and 23.5 mmHg in netarsudil/latanoprost FDC, netarsudil, and latanoprost groups, respectively. Mean diurnal IOP in each group was 15.3, 18.1, and 17.5 mmHg at week 2, 15.7, 18.4, and 17.4 mmHg at week 6, and 15.8, 18.4, and 17.3 mmHg at week 12. The netarsudil/latanoprost FDC met criteria for superiority compared with each active component (p < 0.0001 for all nine time points). At month 3, among patients randomized to netarsudil/latanoprost FDC or latanoprost, 58.4% vs 37.3% (p < 0.0001) achieved IOP ≤ 16 mmHg. Among patients randomized to netarsudil/latanoprost FDC or netarsudil or latanoprost, 30.9% vs 5.9% (p < 0.0001) vs 8.5% (p < 0.0001) achieved at least a 40% reduction from baseline in mean diurnal IOP. Pooled safety results were consistent with individual MERCURY studies. CONCLUSION Once-daily netarsudil/latanoprost FDC produced statistically significant and clinically relevant reductions in mean IOP that were statistically superior to IOP reductions achieved by netarsudil and latanoprost monotherapy. Results of the pooled efficacy and safety analyses were consistent with the individual studies. TRIAL REGISTRATION ClinicalTrials.gov identifiers, NCT02558400 and NCT02674854.
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Affiliation(s)
- Sanjay Asrani
- Duke University School of Medicine, Durham, NC, USA.
| | | | | | | | - Huan Sheng
- Aerie Pharmaceuticals, Inc, Durham, NC, USA
| | - Richard A Lewis
- Aerie Pharmaceuticals, Inc, Durham, NC, USA
- Sacramento Eye Consultants, Sacramento, CA, USA
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Wisely CE, Sheng H, Heah T, Kim T. Effects of Netarsudil and Latanoprost Alone and in Fixed Combination on Corneal Endothelium and Corneal Thickness: Post-Hoc Analysis of MERCURY-2. Adv Ther 2020; 37:1114-1123. [PMID: 31981106 PMCID: PMC7089717 DOI: 10.1007/s12325-020-01227-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION To describe the changes in endothelial cell density (ECD), the coefficient of variation (CV), the percentage of hexagonal cells (%HEX), and central corneal thickness (CCT) following 3 months of therapy with netarsudil 0.02%/latanoprost 0.005% fixed combination, and to compare these changes with those seen with netarsudil 0.02% or latanoprost 0.005% in eyes with ocular hypertension or open-angle glaucoma. METHODS A subset of subjects enrolled in a Phase 3 evaluation of the intraocular pressure-lowering efficacy and safety of netarsudil 0.02%/latanoprost 0.005% fixed combination once daily (QD) versus each of its individual components underwent corneal endothelial cell imaging by specular microscopy and ultrasound pachymetry at baseline and following 3 months of therapy. Images were evaluated in masked fashion at an independent reading center. Changes from baseline to 3 months in ECD, CV, %HEX, and CCT were compared between treatment groups. RESULTS Data from 415 subjects obtained at both baseline and Month 3 were included in this post hoc analysis. Changes from baseline to Month 3 in ECD, CV, and %HEX were clinically insignificant in all three groups, and the changes in the netarsudil/latanoprost fixed combination group demonstrated no statistical difference from those seen in the netarsudil and latanoprost groups. Mean CCT decreased more in the fixed combination group (- 6.4 µm) than in either the netarsudil group (- 3.3 µm, p = 0.0248) or the latanoprost group (- 1.2 µm, p < 0.0001). CONCLUSIONS Netarsudil 0.2%/latanoprost 0.005% fixed combination QD for 3 months in eyes with ocular hypertension or open-angle glaucoma had no clinically significant effects on endothelial cell density or morphology. The significant decrease in CCT in the fixed combination group compared to the two individual component groups may indicate that the potential effects of each drug on CCT are additive, although the magnitude of the observed effects is likely of negligible clinical significance. CLINICALTRIALS. GOV IDENTIFIER NCT02674854.
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Affiliation(s)
| | - Huan Sheng
- Aerie Pharmaceuticals, Inc., Irvine, CA, USA.
| | | | - Terry Kim
- Duke University Eye Center, Durham, NC, USA
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Kahook MY, Serle JB, Mah FS, Kim T, Raizman MB, Heah T, Ramirez-Davis N, Kopczynski CC, Usner DW, Novack GD. Long-term Safety and Ocular Hypotensive Efficacy Evaluation of Netarsudil Ophthalmic Solution: Rho Kinase Elevated IOP Treatment Trial (ROCKET-2). Am J Ophthalmol 2019; 200:130-137. [PMID: 30653957 DOI: 10.1016/j.ajo.2019.01.003] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Revised: 01/03/2019] [Accepted: 01/05/2019] [Indexed: 12/21/2022]
Abstract
PURPOSE To evaluate netarsudil 0.02% ophthalmic solution in patients with open-angle glaucoma (OAG) and ocular hypertension (OHT). DESIGN Double-masked, randomized, multicenter, parallel-group, noninferiority clinical study. METHODS After a washout of all prestudy ocular hypotensive medications, 756 eligible patients with elevated IOP were randomized to receive netarsudil 0.02% once a day (q.d.) (251); netarsudil 0.02% twice a day (b.i.d.) (254); or timolol 0.5% b.i.d. (251) for 12 months, as well as a noninterventional Corneal Observation Study (COS) for patients manifesting cornea verticillata. RESULTS On treatment, mean IOP at 8:00 AM decreased from a baseline IOP of 22.5-22.6 mm Hg to 17.9-18.8 mm Hg, 17.2-18.0 mm Hg, and 17.5-17.9 mm Hg for netarsudil q.d., netarsudil b.i.d., and timolol, respectively, over 12 months. The most frequently reported adverse events (AEs) were ocular, with the most frequent ocular AE being conjunctival hyperemia, with an incidence of 61%, 66%, and 14%, respectively. The next most frequent AEs were corneal deposits (corneal verticillata), with an incidence of 26%, 25%, and 1%, respectively, and conjunctival hemorrhage (typically petechial), with an incidence of 20%, 19%, and 1%, respectively. All 3 AEs were generally scored as mild, with conjunctival hyperemia and/or hemorrhage appearing sporadically during the study. In the observational follow-up component of this study, there was no clinically meaningful impact of corneal verticillata on visual function in affected patients. CONCLUSIONS In this randomized, double-masked trial, once-daily dosing of netarsudil 0.02% was effective, consistently lowering IOP through 12 months, and was tolerated by the majority of patients.
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Affiliation(s)
- Malik Y Kahook
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Janet B Serle
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Terry Kim
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Theresa Heah
- Aerie Pharmaceuticals, Inc, Bedminster, New Jersey, USA; Durham, North Carolina, USA
| | - Nancy Ramirez-Davis
- Aerie Pharmaceuticals, Inc, Bedminster, New Jersey, USA; Durham, North Carolina, USA
| | - Casey C Kopczynski
- Aerie Pharmaceuticals, Inc, Bedminster, New Jersey, USA; Durham, North Carolina, USA
| | | | - Gary D Novack
- PharmaLogic Development, Inc, San Rafael, California, USA; Department of Ophthalmology, University of California Davis School of Medicine, Sacramento, California, USA.
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Christensen JD, Lo Vecchio S, Elberling J, Arendt-Nielsen L, Andersen HH. Assessing Punctate Administration of Beta-alanine as a Potential Human Model of Non-histaminergic Itch. Acta Derm Venereol 2019; 99:222-223. [PMID: 30320870 DOI: 10.2340/00015555-3067] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Janne D Christensen
- Laboratory for Experimental Cutaneous Pain and Itch Research, SMI®, Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Aalborg, Denmark
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Kazierad DJ, Chidsey K, Somayaji VR, Bergman AJ, Calle RA. Efficacy and safety of the glucagon receptor antagonist PF-06291874: A 12-week, randomized, dose-response study in patients with type 2 diabetes mellitus on background metformin therapy. Diabetes Obes Metab 2018; 20:2608-2616. [PMID: 29923286 DOI: 10.1111/dom.13440] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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: 03/01/2018] [Revised: 06/12/2018] [Accepted: 06/15/2018] [Indexed: 12/14/2022]
Abstract
AIMS To conduct a dose-response assessment of the efficacy and safety of the glucagon receptor antagonist PF-06291874 in adults with type 2 diabetes (T2DM) using stable doses of metformin. MATERIALS AND METHODS This randomized, double-blind, statin-stratified, placebo-controlled, 4-arm, parallel-group study was conducted in patients with T2DM who were receiving background metformin. After an 8-week, non-metformin oral antidiabetic agent washout period, 206 patients were randomized to placebo or PF-06291874 (30, 60 or 100 mg once daily) for 12 weeks. Glycosylated haemoglobin (HbA1c), fasting plasma glucose (FPG) and safety endpoints were assessed at baseline and post baseline. RESULTS Dose-dependent mean reductions from baseline in HbA1c for PF-06291874 ranged from -0.67% (-7.29 mmol/mol) to -0.93% (-10.13 mmol/mol), and for FPG from -16.6 to -33.3 mg/dL after 12 weeks of dosing. The incidence of hypoglycaemia was low and was similar between groups receiving PF-06291874 and placebo. Small, non-dose-dependent increases in LDL cholesterol (<10%) and blood pressure (BP) (systolic BP > 2 mm Hg; diastolic BP > 1 mm Hg) were observed with PF-06291874. Modest non-dose-dependent median increases were observed across PF-06291874 groups at 12 weeks for alanine aminotransferase (range, 37.6-48.7 U/L vs placebo) and aspartate aminotransferase (range, 33.3-36.6 U/L vs placebo); these were not associated with bilirubin changes. Small increases were observed in body weight (< 0.5 kg) in each PF-06291874 group vs placebo. CONCLUSIONS In patients with T2DM, PF-06291874 significantly lowered HbA1c and glucose, was well tolerated and carried a low risk of hypoglycaemia. Small, non-dose-related increases in BP, lipids and hepatic transaminases were observed.
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Affiliation(s)
- David J Kazierad
- Internal Medicine Research Unit, Pfizer Inc, Cambridge, Massachusetts
| | - Kristin Chidsey
- Internal Medicine Research Unit, Pfizer Inc, Cambridge, Massachusetts
| | - Veena R Somayaji
- Internal Medicine Research Unit, Pfizer Inc, Cambridge, Massachusetts
| | - Arthur J Bergman
- Internal Medicine Research Unit, Pfizer Inc, Cambridge, Massachusetts
| | - Roberto A Calle
- Internal Medicine Research Unit, Pfizer Inc, Cambridge, Massachusetts
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Two new drugs for glaucoma. Med Lett Drugs Ther 2018; 60:117-20. [PMID: 30036347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Jones RL, Barnett CT, Davidson J, Maritza B, Fraser WD, Harris R, Sale C. β-alanine supplementation improves in-vivo fresh and fatigued skeletal muscle relaxation speed. Eur J Appl Physiol 2017; 117:867-879. [PMID: 28349262 PMCID: PMC5388709 DOI: 10.1007/s00421-017-3569-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 02/11/2017] [Indexed: 11/30/2022]
Abstract
Purpose In fresh muscle, supplementation with the rate-limiting precursor of carnosine, β-alanine (BA), results in a decline in muscle half-relaxation time (HRT) potentially via alterations to calcium (Ca2+) handling. Accumulation of hydrogen cation (H+) has been shown to impact Ca2+ signalling during muscular contraction, carnosine has the potential to serve as a cytoplasmic regulator of Ca2+ and H+ coupling, since it binds to both ions. The present study examined the effect of BA supplementation on intrinsic in-vivo isometric knee extensor force production and muscle contractility in both fresh and fatigued human skeletal muscle assessed during voluntary and electrically evoked (nerve and superficial muscle stimulation) contractions. Methods Twenty-three males completed two experimental sessions, pre- and post- 28 day supplementation with 6.4 g.day−1 of BA (n = 12) or placebo (PLA; n = 11). Isometric force was recorded during a series of voluntary and electrically evoked knee extensor contractions. Results BA supplementation had no effect on voluntary or electrically evoked isometric force production, or twitch electromechanical delay and time-to-peak tension. There was a significant decline in muscle HRT in fresh and fatigued muscle conditions during both resting (3 ± 13%; 19 ± 26%) and potentiated (1 ± 15%; 2 ± 20%) twitch contractions. Conclusions The mechanism for reduced HRT in fresh and fatigued skeletal muscle following BA supplementation is unclear. Due to the importance of muscle relaxation on total energy consumption, especially during short, repeated contractions, BA supplementation may prove to be beneficial in minimising contractile slowing induced by fatigue. Trial registration The trial is registered with Clinicaltrials.gov, ID number NCT02819505.
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Affiliation(s)
- Rebecca Louise Jones
- Musculoskeletal Physiology Research Group, Sport, Health and Performance Enhancement (SHAPE) Research Centre, School of Science and Technology, Nottingham Trent University, Erasmus Darwin Building, Clifton Lane, Clifton, Nottingham, NG11 8NS, UK
| | - Cleveland Thomas Barnett
- Musculoskeletal Physiology Research Group, Sport, Health and Performance Enhancement (SHAPE) Research Centre, School of Science and Technology, Nottingham Trent University, Erasmus Darwin Building, Clifton Lane, Clifton, Nottingham, NG11 8NS, UK
| | - Joel Davidson
- Musculoskeletal Physiology Research Group, Sport, Health and Performance Enhancement (SHAPE) Research Centre, School of Science and Technology, Nottingham Trent University, Erasmus Darwin Building, Clifton Lane, Clifton, Nottingham, NG11 8NS, UK
| | - Billy Maritza
- Musculoskeletal Physiology Research Group, Sport, Health and Performance Enhancement (SHAPE) Research Centre, School of Science and Technology, Nottingham Trent University, Erasmus Darwin Building, Clifton Lane, Clifton, Nottingham, NG11 8NS, UK
| | - William D Fraser
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
- Norfolk and Norwich University Hospital, Norwich, Norfolk, UK
| | | | - Craig Sale
- Musculoskeletal Physiology Research Group, Sport, Health and Performance Enhancement (SHAPE) Research Centre, School of Science and Technology, Nottingham Trent University, Erasmus Darwin Building, Clifton Lane, Clifton, Nottingham, NG11 8NS, UK.
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Sasaki M, Ishii N, Kikuchi Y, Kudoh Y, Sugiyama R, Hasebe M. [Occupational exposures among nurses caring for chemotherapy patients -Quantitative analysis of cyclophosphamide and α-fluoro-β-alanine in urine]. Sangyo Eiseigaku Zasshi 2016; 58:164-172. [PMID: 27488511 DOI: 10.1539/sangyoeisei.2016-005-e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES The aim of this study was to measure the antineoplastic drug content in urine and verify the situation of occupational exposure of the antineoplastic drug among nurses who care for patients undergoing chemotherapy. METHODS Ten female nurses who were caring for patients receiving chemotherapy were the subjects of this study. Urine samples were collected over 24-hour periods, and each sample was analyzed. The excretion of cyclophosphamide (CP) and α-fluoro-β-alanine (FBAL) were measured in the urine of the 10 nurses. CP and FBAL were detected separately using gas chromatography tandem mass spectrometry (GC-MSMS) methods (Exposure Control, the Netherlands). RESULT CP was detected in 24 urine samples of 9 nurses. The total amount of CP excreted ranged from 5.4 to 44.2 ng/24-hours. The mean amount of CP excreted per nurse was 16.8 ng/24-hours. No significant difference was observed between the hospital I and II. FBAL was not detected in any of the urine samples. CP was detected in the urine of the nurses prior to their work shift. Moreover, CP was detected in the urine of the nurses who were not caring for patients in the intravenous drip of CP. There was most what answered that there was hair loss in health condition. CONCLUSION The results reveal that almost all nurses were exposed to cyclophosphamide. Even when the patient in the intravenous drip of CP was not being cared for, it became clear that exposure by CP existed. As the route of the exposure to CP, the inhalation or dermal absorption can be considered. To ensure minimum exposed to antineoplastic drugs, suitable personal protective equipment needs to be equipped also of various scenes of caring for chemotherapy patients. Moreover, it is important to keep an eye on the monitoring of the antineoplastic drug in the environment and a nurse's health condition periodically going forward.
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Lancha Junior AH, Painelli VDS, Saunders B, Artioli GG. Nutritional Strategies to Modulate Intracellular and Extracellular Buffering Capacity During High-Intensity Exercise. Sports Med 2016; 45 Suppl 1:S71-81. [PMID: 26553493 PMCID: PMC4672007 DOI: 10.1007/s40279-015-0397-5] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intramuscular acidosis is a contributing factor to fatigue during high-intensity exercise. Many nutritional strategies aiming to increase intra- and extracellular buffering capacity have been investigated. Among these, supplementation of beta-alanine (~3–6.4 g/day for 4 weeks or longer), the rate-limiting factor to the intramuscular synthesis of carnosine (i.e. an intracellular buffer), has been shown to result in positive effects on exercise performance in which acidosis is a contributing factor to fatigue. Furthermore, sodium bicarbonate, sodium citrate and sodium/calcium lactate supplementation have been employed in an attempt to increase the extracellular buffering capacity. Although all attempts have increased blood bicarbonate concentrations, evidence indicates that sodium bicarbonate (0.3 g/kg body mass) is the most effective in improving high-intensity exercise performance. The evidence supporting the ergogenic effects of sodium citrate and lactate remain weak. These nutritional strategies are not without side effects, as gastrointestinal distress is often associated with the effective doses of sodium bicarbonate, sodium citrate and calcium lactate. Similarly, paresthesia (i.e. tingling sensation of the skin) is currently the only known side effect associated with beta-alanine supplementation, and it is caused by the acute elevation in plasma beta-alanine concentration after a single dose of beta-alanine. Finally, the co-supplementation of beta-alanine and sodium bicarbonate may result in additive ergogenic gains during high-intensity exercise, although studies are required to investigate this combination in a wide range of sports.
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Affiliation(s)
- Antonio Herbert Lancha Junior
- Laboratory of Applied Nutrition and Metabolism, School of Physical Education and Sport, University of São Paulo, Av. Mello de Moraes, 65 Butanta, São Paulo, SP, 05508-030, Brazil.
| | - Vitor de Salles Painelli
- Laboratory of Applied Nutrition and Metabolism, School of Physical Education and Sport, University of São Paulo, Av. Mello de Moraes, 65 Butanta, São Paulo, SP, 05508-030, Brazil
| | - Bryan Saunders
- Laboratory of Applied Nutrition and Metabolism, School of Physical Education and Sport, University of São Paulo, Av. Mello de Moraes, 65 Butanta, São Paulo, SP, 05508-030, Brazil
| | - Guilherme Giannini Artioli
- Laboratory of Applied Nutrition and Metabolism, School of Physical Education and Sport, University of São Paulo, Av. Mello de Moraes, 65 Butanta, São Paulo, SP, 05508-030, Brazil
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Pollack CV, Reilly PA, Eikelboom J, Glund S, Verhamme P, Bernstein RA, Dubiel R, Huisman MV, Hylek EM, Kamphuisen PW, Kreuzer J, Levy JH, Sellke FW, Stangier J, Steiner T, Wang B, Kam CW, Weitz JI. Idarucizumab for Dabigatran Reversal. N Engl J Med 2015; 373:511-20. [PMID: 26095746 DOI: 10.1056/nejmoa1502000] [Citation(s) in RCA: 1061] [Impact Index Per Article: 117.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Specific reversal agents for non-vitamin K antagonist oral anticoagulants are lacking. Idarucizumab, an antibody fragment, was developed to reverse the anticoagulant effects of dabigatran. METHODS We undertook this prospective cohort study to determine the safety of 5 g of intravenous idarucizumab and its capacity to reverse the anticoagulant effects of dabigatran in patients who had serious bleeding (group A) or required an urgent procedure (group B). The primary end point was the maximum percentage reversal of the anticoagulant effect of dabigatran within 4 hours after the administration of idarucizumab, on the basis of the determination at a central laboratory of the dilute thrombin time or ecarin clotting time. A key secondary end point was the restoration of hemostasis. RESULTS This interim analysis included 90 patients who received idarucizumab (51 patients in group A and 39 in group B). Among 68 patients with an elevated dilute thrombin time and 81 with an elevated ecarin clotting time at baseline, the median maximum percentage reversal was 100% (95% confidence interval, 100 to 100). Idarucizumab normalized the test results in 88 to 98% of the patients, an effect that was evident within minutes. Concentrations of unbound dabigatran remained below 20 ng per milliliter at 24 hours in 79% of the patients. Among 35 patients in group A who could be assessed, hemostasis, as determined by local investigators, was restored at a median of 11.4 hours. Among 36 patients in group B who underwent a procedure, normal intraoperative hemostasis was reported in 33, and mildly or moderately abnormal hemostasis was reported in 2 patients and 1 patient, respectively. One thrombotic event occurred within 72 hours after idarucizumab administration in a patient in whom anticoagulants had not been reinitiated. CONCLUSIONS Idarucizumab completely reversed the anticoagulant effect of dabigatran within minutes. (Funded by Boehringer Ingelheim; RE-VERSE AD ClinicalTrials.gov number, NCT02104947.).
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Affiliation(s)
- Charles V Pollack
- From Pennsylvania Hospital, Philadelphia (C.V.P.); Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT (P.A.R., R.D., B.W.); McMaster University (J.E., J.I.W.) and Thrombosis and Atherosclerosis Research Institute (J.I.W.) - both in Hamilton, ON, Canada; Boehringer Ingelheim Pharma, Biberach (S.G., J.S.) and Ingelheim (J.K.), Klinikum Frankfurt Höchst, Frankfurt am Main, and Heidelberg University Hospital, Heidelberg (T.S.) - all in Germany; University of Leuven, Leuven, Belgium (P.V.); Northwestern University, Chicago (R.A.B.); Leiden University Medical Center, Leiden (M.V.H.), and University Medical Center Groningen, Groningen, (P.W.K.) - both in the Netherlands; Boston University School of Medicine, Boston (E.M.H.); Duke University Medical Center, Durham, NC (J.H.L.); Brown Medical School and Rhode Island Hospital, Providence, RI (F.W.S.); and Tuen Mun Hospital, Tuen Mun, NT, Hong Kong (C.-W.K.)
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Dabigatran (Pradaxa): deep vein thrombosis and pulmonary embolism. Warfarin remains the standard drug. Prescrire Int 2015; 24:150. [PMID: 26436165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Not more effective than warfarin in three "non-inferiority" trials. Less bleeding but more acute coronary events with dabigatran, and still no antidote.
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Ameri AA. [Advantages of NOAKs validated in clinical routine]. MMW Fortschr Med 2015; 157:70. [PMID: 26012835 DOI: 10.1007/s15006-015-3091-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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15
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Sacristán M, Varela A, Pedrosa MM, Burbano C, Cuadrado C, Legaz ME, Muzquiz M. Determination of β-N-oxalyl-L-α,β-diaminopropionic acid and homoarginine in Lathyrus sativus and Lathyrus cicera by capillary zone electrophoresis. J Sci Food Agric 2015; 95:1414-1420. [PMID: 24954190 DOI: 10.1002/jsfa.6792] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 05/27/2014] [Accepted: 06/16/2014] [Indexed: 06/03/2023]
Abstract
BACKGROUND Lathyrus species as legumes represent an alternative protein source for human and animal nutrition. Heavy consumption of these species can lead to lathyrism, caused by the non-protein amino acid β-N-oxalyl-l-α,β-diaminopropionic acid (β-ODAP). Currently, there is no well-defined level below which β-ODAP is considered non-toxic. In this work, the β-ODAP content was determined in L. sativus and L. cicera samples to assess their potential toxicity. Homoarginine is another non-protein amino acid found in Lathyrus spp. with interesting implications for human and animal nutrition. RESULTS The level of β-ODAP found in these two species ranged from 0.79 to 5.05 mg g(-1). The homoarginine content of the samples ranged from 7.49 to 12.44 mg g(-1). CONCLUSION This paper describes an accurate, fast and sensitive method of simultaneous detection and quantification of β-ODAP and homoarginine by capillary zone electrophoresis in L. cicera and L. sativus seeds. Moreover, several methods of extraction were compared to determine the highest performance.
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Affiliation(s)
- Mara Sacristán
- Dpto. Tecnología de Alimentos, SGIT-INIA, Apdo. 8111, 28080, Madrid, Spain
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Abstract
OBJECTIVES To determine the real world safety of dabigatran or rivaroxaban compared with warfarin in terms of gastrointestinal bleeding. DESIGN Retrospective cohort study. SETTING Large administrative database of commercially insured people in United States from 1 October 2010 through 31 March 2012. PARTICIPANTS Enrollees with a prescription of warfarin, dabigatran, or rivaroxaban between 1 October 2010 and 31 March 2012, who were aged 18 years or older, had continuous enrollment and no oral anticoagulant use during the six months before the entry date, with known age and sex, and with no gastrointestinal bleeding for at least six months before the cohort entry date. The final study sample of 46,163 patients included 4907 using dabigatran, 1649 using rivaroxaban, and 39,607 using warfarin. MAIN OUTCOME MEASURE Time to gastrointestinal bleeding. Hazard ratios were derived from Cox proportional hazard models with propensity score weighting and robust estimates of errors. RESULTS Dabigatran users tended to be older (dabigatran v rivaroxaban v warfarin: 62.0 v 57.6 v 57.4 years) and more likely to be male (69% v 49% v 53%). The rate of gastrointestinal bleeding was highest among dabigatran users and lowest among rivaroxaban users (dabigatran v rivaroxaban v warfarin: 9.01 v 3.41 v 7.02 cases per 100 person years). After adjustment for potentially confounding covariates, there was no evidence of a statistically significant difference in the risk of gastrointestinal bleeding between dabigatran and warfarin users (adjusted hazard ratio 1.21, 95% confidence interval 0.96 to 1.53) or between rivaroxaban and warfarin users (0.98, 0.36 to 2.69). CONCLUSIONS Although rates of gastrointestinal bleeding seem to be similar in this commercially insured sample of adults in the United States, we cannot rule out as much as a 50% increase in the risk of gastrointestinal bleeding with dabigatran compared with warfarin or a more than twofold higher risk of bleeding with rivaroxaban compared with warfarin.
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Affiliation(s)
- Hsien-Yen Chang
- Department of Health Policy and Management, Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Meijia Zhou
- Department of Epidemiology, Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Wenze Tang
- Department of Epidemiology and Biostatistics, Milken Institute School of Public Health, The George Washington University, Washington, DC 20052, USA
| | - G Caleb Alexander
- Department of Epidemiology, Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD 21205, USA
| | - Sonal Singh
- Department of Epidemiology, Center for Drug Safety and Effectiveness, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA Division of General Internal Medicine, Johns Hopkins Medicine, Baltimore, MD 21205, USA
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Abraham NS, Singh S, Alexander GC, Heien H, Haas LR, Crown W, Shah ND. Comparative risk of gastrointestinal bleeding with dabigatran, rivaroxaban, and warfarin: population based cohort study. BMJ 2015; 350:h1857. [PMID: 25910928 PMCID: PMC4413863 DOI: 10.1136/bmj.h1857] [Citation(s) in RCA: 258] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine the real world risk of gastrointestinal bleeding associated with the use of the novel oral anticoagulants dabigatran and rivaroxaban compared with warfarin. DESIGN Retrospective, propensity matched cohort study. SETTING Optum Labs Data Warehouse, a large database including administrative claims data on privately insured and Medicare Advantage enrollees. PARTICIPANTS New users of dabigatran, rivaroxaban, and warfarin from 1 November 2010 to 30 September 2013. MAIN OUTCOME MEASURES Incidence rates (events/100 patient years) and propensity score matched Cox proportional hazards models were used to estimate rates of total gastrointestinal bleeds, upper gastrointestinal bleeds, and lower gastrointestinal bleeds for the novel oral anticoagulants compared with warfarin in patients with and without atrial fibrillation. Heterogeneity of treatment effect related to age was examined using a marginal effects model. RESULTS The incidence of gastrointestinal bleeding associated with dabigatran was 2.29 (95% confidence interval 1.88 to 2.79) per 100 patient years and that associated with warfarin was 2.87 (2.41 to 3.41) per 100 patient years in patients with atrial fibrillation. In non-atrial fibrillation patients, the incidence of gastrointestinal bleeding was 4.10 (2.47 to 6.80) per 100 patient years with dabigatran and 3.71 (2.16 to 6.40) per 100 patient years with warfarin. With rivaroxaban, 2.84 (2.30 to 3.52) gastrointestinal bleeding events per 100 patient years occurred in atrial fibrillation patients (warfarin 3.06 (2.49 to 3.77)/100 patient years) and 1.66 (1.23 to 2.24) per 100 patient years in non-atrial fibrillation patients (warfarin 1.57 (1.25 to 1.99)/100 patient years). In propensity score matched models, the risk of gastrointestinal bleeding with novel oral anticoagulants was similar to that with warfarin in atrial fibrillation patients (dabigatran v warfarin, hazard ratio 0.79 (0.61 to 1.03); rivaroxaban v warfarin, 0.93 (0.69 to 1.25)) and in non-AF patients (dabigatran v warfarin, hazard ratio 1.14 (0.54 to 2.39); rivaroxaban v warfarin, 0.89 (0.60 to 1.32)). The risk of gastrointestinal bleeding increased after age 65, such that by age 76 the risk exceeded that with warfarin among atrial fibrillation patients taking dabigatran (hazard ratio 2.49 (1.61 to 3.83)) and patients with and without atrial fibrillation taking rivaroxaban (2.91 (1.65 to 4.81) and 4.58 (2.40 to 8.72), respectively). CONCLUSIONS The risk of gastrointestinal bleeding related to novel oral anticoagulants was similar to that for warfarin. Caution should be used when prescribing novel oral anticoagulants to older people, particularly those over 75 years of age.
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Affiliation(s)
- Neena S Abraham
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, 13400 East Shea Boulevard, Scottsdale, AZ, 85259, USA Division of Health Care Policy and Research, Department of Health Services Research, Mayo Clinic, Rochester, MN, USA Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Sonal Singh
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and Center for Drug Safety and Effectiveness, Baltimore, MD, USA
| | - G Caleb Alexander
- Division of General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and Center for Drug Safety and Effectiveness, Baltimore, MD, USA
| | - Herbert Heien
- Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | - Lindsey R Haas
- Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
| | | | - Nilay D Shah
- Division of Health Care Policy and Research, Department of Health Services Research, Mayo Clinic, Rochester, MN, USA Mayo Clinic Robert D and Patricia E Kern Center for the Science of Health Care Delivery, Rochester, MN, USA
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Brais C, Larochelle J, Turgeon M, Tousignant A, Blais L, Perreault S, Farand P, Letemplier G, Beauchesne M. Patterns of oral anticoagulants use in atrial fibrillation. J Popul Ther Clin Pharmacol 2015; 22:e90-e95. [PMID: 25715385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Novel oral anticoagulants are available for the management of atrial fibrillation and are considered more convenient to use than warfarin. OBJECTIVE The main objective of this study was to describe patterns of oral anticoagulant use in the 6 months period following the availability of dabigatran at our hospital. METHODS A cross-sectional study was conducted in a single University hospital in the province of Québec, Canada. Medical records of subjects on oral anticoagulants for atrial fibrillation that were hospitalized between October 1st, 2011 and March 31th, 2012 were reviewed. Type of use (prevalent, incident and switch) and patient's characteristics of warfarin and dabigatran users were compared using Chi-squared and T-tests. RESULTS In the 6-month period following dabigatran availability in the hospital, 59 patients (13%) were on dabigatran and 388 (87%) on warfarin. Mean CHADS2 score, mean age and mean number of chronic medications were lower in the dabigatran group. The percentage of patients with coronary artery disease was lower and renal function was higher in the dabigatran group. CONCLUSION Dabigatran use remained low in the first 6 months period following the approval of dabigatran at our hospital, which could be explained by limited data on the efficacy and safety of this agent in subjects with multiple comorbidities.
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19
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[Triple anticoagulant therapy - now what can I give for pain?]. MMW Fortschr Med 2015; 157:17. [PMID: 25743652 DOI: 10.1007/s15006-015-2684-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Steiner T. [Antidote to dabigatran]. MMW Fortschr Med 2015; 157:71. [PMID: 25743679 DOI: 10.1007/s15006-015-2711-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Oberhofer E. [New oral anticoagulants in venous thromboembolism. General practice information on switching, monitoring, pausing]. MMW Fortschr Med 2015; 157:24. [PMID: 25743289 DOI: 10.1007/s15006-015-2575-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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23
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Einecke D. [Fewer strokes, lower mortality. Large general practice studies confirm good safety profile of dabigatran]. MMW Fortschr Med 2014; 156:28-30. [PMID: 25608388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Vaughan Sarrazin MS, Jones M, Mazur A, Chrischilles E, Cram P. Bleeding rates in Veterans Affairs patients with atrial fibrillation who switch from warfarin to dabigatran. Am J Med 2014; 127:1179-85. [PMID: 25107386 PMCID: PMC7437526 DOI: 10.1016/j.amjmed.2014.07.024] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [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] [Received: 07/09/2014] [Revised: 07/16/2014] [Accepted: 07/17/2014] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Clinical trial data suggest that dabigatran and warfarin have similar rates of major bleeding but higher rates of gastrointestinal bleeding. These findings have not been evaluated outside of a clinical trial. We evaluated the relative risks of any, gastrointestinal, intracranial, and other bleeding for Veterans Affairs patients who switched to dabigatran after at least 6 months on warfarin, compared with patients who continued on warfarin. METHODS We used national Veterans Affairs administrative encounter and pharmacy data from fiscal years 2010-2012 to identify 85,344 patients with atrial fibrillation who had been taking warfarin for at least 180 days before June 2011, of whom 1394 (1.7%) received dabigatran (150 mg) during the next 15 months. Dates of the first occurrence of each type of bleed and dates of death from June 2011 to September 2012 were determined. Baseline and time-dependent patient characteristics were identified, including comorbid conditions, stroke and bleeding risk scores, and time in therapeutic range for international normalized ratios. Marginal structural models were used to address selection bias in the longitudinal observational data. Weighted logistic regression models were fit using generalized estimating equations and reflected baseline and time-dependent covariates and weekly indicators of anticoagulant type (warfarin or dabigatran). RESULTS Compared with patients who never used dabigatran, patients who used dabigatran at least once were younger, were more likely to be white, had lower international normalized ratio time in therapeutic range on warfarin, had lower stroke risk scores, and had similar bleeding risk scores. Overall, 10,734 patients experienced bleeding events, including 131 events after dabigatran use. The risk-adjusted rate of any bleeding was higher with dabigatran compared with warfarin, which was largely driven by a 54% higher risk of gastrointestinal bleeding with dabigatran. Rates of intracranial, other bleeding, and death were similar for dabigatran and warfarin. CONCLUSIONS Dabigatran may increase the likelihood of gastrointestinal bleeds.
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Affiliation(s)
- Mary S Vaughan Sarrazin
- Comprehensive Access and Delivery Research and Evaluation Center (CADRE), Iowa City VA Medical Center, Iowa City; Department of Internal Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa, Iowa City.
| | - Michael Jones
- Comprehensive Access and Delivery Research and Evaluation Center (CADRE), Iowa City VA Medical Center, Iowa City; Department of Biostatistics, College of Public Health, University of Iowa, Iowa City
| | - Alexander Mazur
- Department of Internal Medicine, Roy and Lucille J. Carver College of Medicine, University of Iowa, Iowa City
| | | | - Peter Cram
- Department of Medicine, University of Toronto, Toronto, Ont., Canada
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Weisshaar S, Litschauer B, Gouya G, Mayer P, Smerda L, Kapiotis S, Kyrle PA, Eichinger S, Wolzt M. Antithrombotic triple therapy and coagulation activation at the site of thrombus formation: a randomized trial in healthy subjects. J Thromb Haemost 2014; 12:1850-60. [PMID: 25211369 DOI: 10.1111/jth.12726] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [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: 05/27/2014] [Accepted: 09/07/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Patients with acute coronary syndrome and concomitant atrial fibrillation may require antithrombotic triple therapy but clinical evidence of safety and efficacy is poor. We have therefore studied the combination of different antithrombotic medicines for coagulation activation in an in vivo model in the skin microvasculature. METHODS AND RESULTS Platelet activation (β-thromboglobulin [β-TG]) and thrombin generation (prothrombin fragment 1 + 2 [F1+2 ], thrombin-antithrombin complex [TAT]) were studied in an open-label, randomized, parallel group trial in 60 healthy male subjects (n = 20 per group) who received ticagrelor and acetylsalicylic acid (ASA) in combination with dabigatran (150 mg bid), rivaroxaban (20 mg od) or phenprocoumon (INR 2.0-3.0). Coagulation biomarkers in shed blood were assessed at 3 h after monotherapy with the medicines under study, at 3 h after triple therapy dosing and at steady state trough conditions. Single doses of ticagrelor, dabigatran or rivaroxaban caused comparable decreases in shed blood β-TG and were more pronounced than phenprocoumon at an INR of 2.0-3.0. In contrast, thrombin generation was more affected by rivaroxaban and phenprocoumon than by dabigatran. During triple therapy a similarly sustained inhibition of platelet activation and thrombin generation with a maximum decrease of β-TG, F1+2 and TAT at 3 h post-dosing was noted, which remained below pre-dose levels at trough steady state. CONCLUSION A triple therapy at steady state with ticagrelor plus ASA in combination with dabigatran or rivaroxaban is as effective as a combination with phenprocoumon for platelet activation and thrombin generation in vivo.
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Affiliation(s)
- S Weisshaar
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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Douketis J, Bell AD, Eikelboom J, Liew A. Approach to the new oral anticoagulants in family practice: part 1: comparing the options. Can Fam Physician 2014; 60:989-995. [PMID: 25392438 PMCID: PMC4229157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To compare key features of the new oral anticoagulants (NOACs)-dabigatran, rivaroxaban, and apixaban-and to address questions that arise when comparing the NOACs. SOURCES OF INFORMATION PubMed was searched for recent (January 2008 to week 32 of 2013) clinical studies relating to NOAC use for stroke prevention in atrial fibrillation (AF) and for the treatment of acute venous thromboembolism (VTE). MAIN MESSAGE All NOACs are at least as effective as warfarin for stroke prevention in patients with nonvalvular AF, and are at least as safe in terms of bleeding risk according to 3 large trials. Meta-analyses of these trials have shown that, compared with warfarin therapy, NOACs reduced total mortality, cardiovascular mortality, and intracranial bleeding, and there was a trend toward less overall bleeding. Practical advantages of NOACs over warfarin include fixed once- or twice-daily oral dosing without the need for coagulation monitoring, and few known or defined drug or food interactions. Potential drawbacks of NOACs include a risk of bleeding that might be increased in patients older than 75 years, increased major gastrointestinal bleeding with high-dose dabigatran, increased dyspepsia with dabigatran, the lack of a routine laboratory test to reliably measure anticoagulant effect, and the lack of an antidote for reversal. No direct comparisons of NOACs have been made in randomized controlled trials, and the choice of NOAC is influenced by individual patient characteristics, including risk of stroke or VTE, risk of bleeding, and comorbidity (eg, renal dysfunction). CONCLUSION The NOACs represent important alternatives in the management of patients with AF and VTE, especially for patients who have difficulty accessing regular coagulation monitoring. The companion to this article addresses common "what if" questions that arise in the long-term clinical follow-up and management of patients receiving NOACs.
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Affiliation(s)
- James Douketis
- Professor in the Department of Medicine at McMaster University in Hamilton, Ont.
| | - Alan David Bell
- Assistant Professor in the Department of Family and Community Medicine at the University of Toronto in Ontario
| | - John Eikelboom
- Associate Professor in the Department of Medicine at McMaster University
| | - Aaron Liew
- Research fellow in the Department of Medicine at McMaster University
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Lobo R, McCann C, Hussaini A, Meany TB, Kiernan TJ. Left atrial appendage thrombus with resulting stroke post-RF ablation for atrial fibrillation in a patient on dabigatran. Ir Med J 2014; 107:329-330. [PMID: 25551903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Dabigatran etexilate is licensed for use in prevention of deep venous thromboembolism and in prevention of stroke and systemic embolism in nonvalvular atrial fibrillation (AF). It has also been used in patients for other indications as a substitute for warfarin therapy because it requires no monitoring; one group being patients undergoing radiofrequency (RF), ablation for AF, although there have been no consensus guidelines with regards to dosage and timing of dose. We report the case of a patient with documentary evidence of left atrial appendage (LAA) thrombus formation and neurological sequelae post-RF ablation despite being on dabigatran. This case highlights the concern that periprocedural dabigatran may not provide adequate protection from development of LAA thrombus and that a standardised protocol will need to be developed and undergo large multicentre trials before dabigatran can be safely used for patients undergoing RF-ablation.
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Affiliation(s)
- R Lobo
- University Hospital Limerick, Dooradoyle, Co Limerick.
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Karetová D, Bultas J. [Extended options of anticoagulant treatment in thromboembolism]. Vnitr Lek 2014; 60:977-984. [PMID: 25600045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Thromboembolic disease (TD) is a relatively common disease with acute risk of death and potential long-term consequences in term of postthrombotic syndrome or chronic pulmonary hypertension. Anticoagulant therapy is the basic therapeutic procedure; thrombolytic therapy and the introduction cava filter are appropriately indicated for individual cases. In past few years, new direct oral anticoagulant drugs (NOAC) have occurred - Xa factor or thrombin inhibitors which have demonstrated the same efficacy and even higher safety in comparison to conventional treatment. In mid 2014, 3 drugs of this group are registered in Czech Republic - rivaroxaban (Xarelto®), dabigatran (Pradaxa®) and apixaban (Eliquis®). These drugs have comparable efficacy and safety but they differ in schedule of dose administration. Rivaroxaban and apixaban can be administered immediately after diagnosis of venous thrombosis or hemodynamically stable pulmonary embolism. LMWH application has to precede few days the administration of dabigatran. Limitation of new drugs is their price. Unavailability of antidotes is temporary because current researches continue to find one for dabigatran and another for both of xabans. Duration of anticoagulant treatment after acute phase depends on the presence of thrombosis risk factors and the individual bleeding risk. Minimal duration of anticoagulant therapy is 3 months, commonly 6-12 months and in high risk patients it is "long term" treatment. Good results of new anticoagulant drugs in trials in term of thromboembolism recurrence prevention may change established habits in TD patients with long term treatment.
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Gorzelak-Pabiś P, Duraj I, Szlagowska L, Ciastkowska A, Broncel M. [Comparison of the safety of rivaroxaban versus dabigatran therapy in patients with persistent atrial fibrillation]. Pol Merkur Lekarski 2014; 37:261-264. [PMID: 25546985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
UNLABELLED For 60 years, vitamin K antagonists have been used in prevention of thromboembolic complications in the course of atrial fibrillation (AF), however such therapy is associated with many inconveniences. New oral anticoagulants (NOAC), rivaroxaban and dabigatran, represent an attractive alternative to VKA. THE AIM OF THE STUDY Yo evaluate the safety of a 6-month therapy with rivaroxaban and dabigatran in patients (pts) with persistent AF. MATERIALS AND METHODS The analysis included 24 pts (14 females, 10 males) with nonvalvular AF and indications for oral anticoagulant therapy (CHA2DS2-VASc > or = 2, HAS-BLED < 3), hospitalized in the Clinic of Internal Diseases and Clinical Pharmacology of the Medical University of Lodz between July 2012 and September 2013. In the group of patients treated chronically with VKA, laboratory tests (GFR, creatinine, ALT AST, coagulation) were performed during their stay in the clinic. The patients were randomly assigned to the treatment with one of the new NOACs, rivaroxaban or dabigatran. After a 6-month period, the patients completed a questionnaire on their general health condition and follow-up laboratory tests were performed. RESULTS In the group of pts. receiving dabigatran INR increased by 23% (p = 0.0002) and APTT prolongation by 91% was noted (p = 0.0004) whereas in the group of pts receiving rivaroxaban an INR increase by 17% (p = 0.04) and APTT prolongation by 32% (p = 0.0043) were observed. After a 6-month therapy, dabigatran prolongs APTT significantly more, as compared to rivaroxaban (p=0.0002). Among patients using dabigatran, 16.7% experienced the following symptoms: abdominal pain, gastritis, nausea. 8.3% patients experienced bleeding from haemorrhoids, easier bruising. In the group of patients receiving rivaroxaban, 16.7% experienced the following symptoms: nosebleeds and easier bruising; 8.3%: bleeding from gums, haematuria. 25%: pruritus, rash: 8.3%. The hazard ratio (HR) for occurrence of dyspeptic symptoms was 1.13 for dabigatran. Minor bleeding is 3.6 times more common when using rivaroxaban. CONCLUSIONS Significant increase of INR and prolongation of APTT are observed after a 6-month therapy with rivaroxaban or dabigatran. Additionally, dabigatran significantly prolongs the prothrombin time. Despite the fact that dabigatran caused larger prolongation of APTT minor bleeding episodes occurred more frequently in patients treated with rivaroxaban. No worsening of kidney or liver function was observed during the 6-month therapy with rivaroxaban or dabigatran. Rywaroxaban more frequently causes minor bleeding, whereas treatment with dabigatran is associated with more frequent gastrointestinal adverse symptoms.
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Affiliation(s)
- Stephanie Coulter
- Center for Women's Heart & Vascular Health, Texas Heart Institute at St. Luke's Episcopal Hospital, 6624 Fannin, Suite 2780, Houston, TX, 77030, USA,
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Derlon V, Corbonnois G, Martin M, Toussaint-Hacquard M, Audibert G. [Hemorrhagic stroke and new oral anticoagulants]. Ann Fr Anesth Reanim 2014; 33:540-547. [PMID: 25282445 DOI: 10.1016/j.annfar.2014.07.003] [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] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The recent release of new oral anticoagulants (NOAC) raises the question of the management of intracranial hemorrhage occurring during treatment with these molecules. Dabigatran, rivaroxaban and apixaban have different pharmacological characteristics that physicians need to know to adjust their prescription to each patient. Studies of efficacy and safety prior to the marketing of these molecules showed a decreased risk of intracranial hemorrhage compared with vitamin K antagonists. However, no reliable data are available regarding the prognosis of these hemorrhages occurring during NOAC treatment. In addition, there is no specific antidote and reversal protocol validated in humans. So, physicians are in a difficult situation when critical bleeding occurs. The timing of recovering normal hemostatic capacity is then a determinant factor of prognosis. Studies in animals or healthy volunteers showed a correction of the biological parameters using prothrombin complex concentrates activated or not, without reducing the volume of hematoma. On this basis, proposals have been issued by the french group of interest for perioperative hemostasis (GIHP) for the management of bleeding under NOAC treatment, which include management of intracranial hemorrhage.
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Affiliation(s)
- V Derlon
- Service d'anesthésie-réanimation, hôpital Central, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France
| | - G Corbonnois
- Service d'anesthésie-réanimation, hôpital Central, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France
| | - M Martin
- Service d'hématologie biologique, CHU de Brabois, 4, rue de Morvan, 54511 Vandœuvre-lès-Nancy cedex, France
| | - M Toussaint-Hacquard
- Service d'hématologie biologique, CHU de Brabois, 4, rue de Morvan, 54511 Vandœuvre-lès-Nancy cedex, France
| | - G Audibert
- Service d'anesthésie-réanimation, hôpital Central, CHU de Nancy, 29, avenue du Maréchal-de-Lattre-de-Tassigny, 54000 Nancy, France.
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Kosiuk J, Koutalas E, Doering M, Nedios S, Sommer P, Rolf S, Darma A, Breithardt OA, Dinov B, Hindricks G, Richter S, Bollmann A. Comparison of dabigatran and uninterrupted warfarin in patients with atrial fibrillation undergoing cardiac rhythm device implantations. Case-control study. Circ J 2014; 78:2402-2407. [PMID: 25253506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND The incidence of postoperative complications following pacemaker or implantable cardioverter-defibrillator implantations in patients treated with new oral anticoagulation agents has not been studied. Here we present a first comparison of complications after cardiac rhythm device (CRD) implantations in patients with atrial fibrillation (AF) treated with dabigatran or uninterrupted warfarin. METHODS AND RESULTS Using a case-control study design, we compared complications within 30 days after 236 CRD procedures performed under uninterrupted warfarin (n=118) or interrupted dabigatran (n=118).There were no significant differences in the baseline characteristics of both groups. In the warfarin group, 9 (8%) pocket hematomas were observed vs. 3 (3%) in the dabigatran group (P=0.075). Two complications in the warfarin group necessitated surgical intervention as opposed to none in the dabigatran group (P=0.156). The postprocedural blood loss expressed as a drop in hemoglobin was significantly greater in the warfarin group (-0.9±0.7 vs. -0.5±0.4 mmol/L, P=0.023). In the dabigatran group, 1 case of transient ischemic attack occurred. The mean time to hospital discharge was shorter in patients treated with dabigatran (2.5±2.3 vs. 3.8±4.1 days, P=0.02). CONCLUSIONS The incidence and severity of bleeding complications may be lower in patients treated with periprocedurally discontinued dabigatran when compared with uninterrupted warfarin therapy. Further evaluation of peri-interventional complications and establishment of an optimal anticoagulation management protocol are needed.
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Steurer J. [New oral anticoagulants are as safe in elderly patients as conventional drugs]. Praxis (Bern 1994) 2014; 103:1032. [PMID: 25146949 DOI: 10.1024/1661-8157/a001749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Johann Steurer
- Horten-Zentrum für praxisorientierte Forschung und Wissenstransfer; Universitätsspital Zürich
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Badal M, Aryal MR, Mege J, Chaudhary A, Donato AA. Evaluation of Trends of Inpatient Hospitalisation for Significant Haemorrhage in Patients Anticoagulated for Atrial Fibrillation before and after the Release of Novel Anticoagulants. Heart Lung Circ 2014; 24:94-7. [PMID: 25108758 DOI: 10.1016/j.hlc.2014.06.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [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: 05/01/2014] [Accepted: 06/20/2014] [Indexed: 11/18/2022]
Abstract
Compared to Vitamin K antagonists (VKA), novel oral anticoagulants (NOACs) appear to be safer in terms of major bleeding risks with added advantage of having fixed dosing schedules when used in patients with non-valvular atrial fibrillation (AF). We sought to study the differences as sources and severity of anticoagulant-associated haemorrhage in patients with AF in the year preceding introduction of NOACs (first cohort) as compared to post approval of the NOACs (second cohort) by retrospectively reviewing the hospital admissions, as well as the pharmacodynamic and pharmacokinetic interactions between time periods. There were 359 patients for the first cohort and 405 patients for the second cohort, including 57 patients prescribed NOACs. There was no significant difference in age, deaths, source of bleeding, or rate of pharmacokinetic or pharmacodynamic interaction between the two time periods. Comparing all VKA patients to patients prescribed NOAC's, there were non-significant but higher rates of intracerebral bleed, significantly higher rates of pharmacokinetic (194 (25.4%) versus 0 (0%), p<.001) and similar rates of pharmacodynamic interactions (505 (66.1%) versus 39 (68.4%), p=.70). Drug-renal interactions were seen in 7 of the 57 (12.3%) NOAC-treated patients, in which all seven had acute renal failure that may have prolonged the effects of the anticoagulants. NOACs hold promise in that drug interactions are far less common than those seen in VKAs, and intracerebral bleeds appear to be less common in randomised trials as well as our review. For patients on dabigatran or rivaroxaban, consideration should be given to serial monitoring of renal function.
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Affiliation(s)
- Madan Badal
- Department of Internal Medicine, Reading Health System, West Reading, PA, USA.
| | - Madan Raj Aryal
- Department of Internal Medicine, Reading Health System, West Reading, PA, USA
| | - Joan Mege
- Department of Pharmacy, Reading Health System, West Reading, PA, USA
| | - Ashok Chaudhary
- Department of Cardiology, Thomas Jefferson University Hospital, Philadelphia PA, USA
| | - Anthony A Donato
- Department of Internal Medicine, Reading Health System, West Reading, PA, USA
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Pluym M, Howell G. Management of hemorrhage with the target-specific oral anticoagulants. Hosp Pract (1995) 2014; 42:75-83. [PMID: 25255409 DOI: 10.3810/hp.2014.08.1120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The target-specific oral anticoagulants have recently been introduced as alternatives to warfarin for both prophylactic and therapeutic indications. Although their efficacy and side-effect profiles have been favorable, there is significant concern about management of hemorrhage with these agents as there is no direct reversal agent available. It is important for clinicians to be aware of these agents and the issues that surround them. Most of the management of hemorrhage is based on expert opinion and case reviews. Given the potentially catastrophic consequences of acute hemorrhage while patients are on anticoagulation, specific treatments are needed. Some methods that have been described include activated charcoal, hemodialysis, prohemostatic agents, and transfusions. Target-specific therapies have been shown to be effective in early studies in animal models; however, the effects in humans are still under investigation. More investigation is needed on the management of bleeding complications from target-specific oral anticoagulants.
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Affiliation(s)
- Mark Pluym
- Department of Internal Medicine, University of Missouri-Kansas City, Kansas City, MO.
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Alonso A, Bengtson LGS, MacLehose RF, Lutsey PL, Chen LY, Lakshminarayan K. Intracranial hemorrhage mortality in atrial fibrillation patients treated with dabigatran or warfarin. Stroke 2014; 45:2286-91. [PMID: 24994722 PMCID: PMC4116615 DOI: 10.1161/strokeaha.114.006016] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [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: 05/02/2014] [Accepted: 06/06/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND PURPOSE In randomized trials, patients with atrial fibrillation (AF) receiving dabigatran, a direct oral anticoagulant, had lower risk of intracranial bleeding (ICB) than those on warfarin. However, concerns exist about potential worse outcomes in dabigatran users if bleeding occurs, given the lack of approved reversal agents. Thus, we examined in-hospital mortality in AF patients with ICB being treated with dabigatran versus warfarin in a real-world population in the United States. METHODS We analyzed healthcare utilization claims in the Truven Health Marketscan Research Databases. The study sample included patients with AF admitted to a hospital with a primary diagnosis of ICB. Information on medications, inpatient, and outpatient diagnoses was obtained from available claims. Propensity score-adjusted risk ratios and 95% confidence intervals of in-hospital mortality comparing current users of dabigatran versus warfarin were estimated using relative risk regression. RESULTS Among 2391 AF patients admitted with ICB (2290 on warfarin, 101 on dabigatran), 531 died during their admission. In-hospital mortality was similar in those treated with warfarin (22%) or dabigatran (20%). Compared with warfarin users, the propensity score-adjusted risk ratio (95% confidence interval) of mortality in dabigatran users was 0.93 (0.62-1.37). Associations were similar across different ICB subtypes (intracerebral hemorrhage, subarachnoid hemorrhage, and subdural hematoma). CONCLUSIONS In this sample of AF patients with ICB on oral anticoagulants, dabigatran was not associated with higher in-hospital mortality compared with warfarin. Hence, reluctance to use dabigatran because of a lack of approved reversal agents is not supported by our results.
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Affiliation(s)
- Alvaro Alonso
- From the Division of Epidemiology and Community Health, School of Public Health (A.A., L.G.S.B., R.F.M., P.L.L., K.L.), University of Minnesota, Minneapolis; and Cardiovascular Division, Department of Medicine (L.Y.C.) and Department of Neurology (K.L.), University of Minnesota Medical School, Minneapolis.
| | - Lindsay G S Bengtson
- From the Division of Epidemiology and Community Health, School of Public Health (A.A., L.G.S.B., R.F.M., P.L.L., K.L.), University of Minnesota, Minneapolis; and Cardiovascular Division, Department of Medicine (L.Y.C.) and Department of Neurology (K.L.), University of Minnesota Medical School, Minneapolis
| | - Richard F MacLehose
- From the Division of Epidemiology and Community Health, School of Public Health (A.A., L.G.S.B., R.F.M., P.L.L., K.L.), University of Minnesota, Minneapolis; and Cardiovascular Division, Department of Medicine (L.Y.C.) and Department of Neurology (K.L.), University of Minnesota Medical School, Minneapolis
| | - Pamela L Lutsey
- From the Division of Epidemiology and Community Health, School of Public Health (A.A., L.G.S.B., R.F.M., P.L.L., K.L.), University of Minnesota, Minneapolis; and Cardiovascular Division, Department of Medicine (L.Y.C.) and Department of Neurology (K.L.), University of Minnesota Medical School, Minneapolis
| | - Lin Y Chen
- From the Division of Epidemiology and Community Health, School of Public Health (A.A., L.G.S.B., R.F.M., P.L.L., K.L.), University of Minnesota, Minneapolis; and Cardiovascular Division, Department of Medicine (L.Y.C.) and Department of Neurology (K.L.), University of Minnesota Medical School, Minneapolis
| | - Kamakshi Lakshminarayan
- From the Division of Epidemiology and Community Health, School of Public Health (A.A., L.G.S.B., R.F.M., P.L.L., K.L.), University of Minnesota, Minneapolis; and Cardiovascular Division, Department of Medicine (L.Y.C.) and Department of Neurology (K.L.), University of Minnesota Medical School, Minneapolis
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Ho MH, Ho CW, Cheung E, Chan PH, Hai JJ, Chan KH, Chan EW, Leung GKK, Tse HF, Siu CW. Continuation of dabigatran therapy in "real-world" practice in Hong Kong. PLoS One 2014; 9:e101245. [PMID: 25084117 PMCID: PMC4118845 DOI: 10.1371/journal.pone.0101245] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 06/04/2014] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Dabigatran, an oral direct thrombin inhibitor, possesses several advantages over warfarin that can in principle simplify the management of stroke prevention in atrial fibrillation (AF). Nonetheless it remains unclear whether these advantages can translate to clinical practice and encourage long-term therapy. The objective was to describe long-term dabigatran therapy for stroke prevention in AF and to identify risk factors for discontinuation of therapy. METHODS AND RESULTS We studied 467 consecutive Chinese patients (72 ± 11 years, male: 53.8%) with a mean CHA2DS2-VASc score of 3.6 prescribed dabigatran for stroke prevention in AF from March 2010 to September 2013. Over a mean follow-up of 16 months, 101 patients (21.6%) permanently discontinued dabigatran. The mean time-to-discontinuation was 8 months. The most common reason for discontinuation was dyspepsia (30.7%), followed by other adverse events (17.8%) such as minor bleeding (8.9%), major gastrointestinal bleeding (7.9%), and intracranial hemorrhage (1%). Other reasons included dosing frequency (5.9%), fear of side effects (4.0%), lack of laboratory monitoring (1.0%), and cost (1.0%). Multivariable analysis revealed that low baseline estimated glomerular filtration rate (p = 0.02), absence of hypertension (p = 0.01), and prior use of a proton-pump inhibitor (p = 0.02) and H2-receptor blocker (p = 0.01) were independent predictors of drug discontinuation. In addition, there were altogether 9 ischemic strokes (1.5%/years), 3 intracranial hemorrhages (0.5%/year), and 24 major gastrointestinal bleedings (4.1%/year). CONCLUSION Dabigatran discontinuation is very common amongst Chinese AF patients. This reveals a management gap in the prevention of stroke in AF.
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Affiliation(s)
- Mei Han Ho
- Cardiology Division, Department of Medicine, Queen Mary Hospital, the University of Hong Kong, Hong Kong SAR, China
| | - Chi Wai Ho
- Cardiology Division, Department of Medicine, Queen Mary Hospital, the University of Hong Kong, Hong Kong SAR, China
| | - Emmanuel Cheung
- Cardiology Division, Department of Medicine, Queen Mary Hospital, the University of Hong Kong, Hong Kong SAR, China
| | - Pak Hei Chan
- Cardiology Division, Department of Medicine, Queen Mary Hospital, the University of Hong Kong, Hong Kong SAR, China
| | - Jo Jo Hai
- Cardiology Division, Department of Medicine, Queen Mary Hospital, the University of Hong Kong, Hong Kong SAR, China
| | - Koon Ho Chan
- Neurology Division, Department of Medicine, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR, China
| | - Esther W. Chan
- Department of Pharmacology and Pharmacy, the University of Hong Kong, Hong Kong SAR, China
| | - Gilberto Ka Kit Leung
- Division of Neurosurgery, Department of Surgery, Li Ka Shing Faculty of Medicine, the University of Hong Kong, Hong Kong SAR, China
| | - Hung Fat Tse
- Cardiology Division, Department of Medicine, Queen Mary Hospital, the University of Hong Kong, Hong Kong SAR, China
| | - Chung Wah Siu
- Cardiology Division, Department of Medicine, Queen Mary Hospital, the University of Hong Kong, Hong Kong SAR, China
- * E-mail:
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Alotaibi G, Alsaleh K, Wu C, Mcmurtry MS. Dabigatran, rivaroxaban and apixaban for extended venous thromboembolism treatment: network meta-analysis. INT ANGIOL 2014; 33:301-308. [PMID: 25056161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
AIM Many new oral anticoagulants (NOACs; dabigatran, rivaroxaban, and apixaban) are currently available to treat thromboembolic disease. There are no head-to-head trials comparing these agents. To assess the efficacy and safety of NOACs for prevention of recurrent venous thromboembolism (VTE), we performed a network meta-analysis. METHODS Medline, Embase, and the Cochrane-controlled trial register were searched, without language restriction, to identify trials. Studies were evaluated according to a priori inclusion criteria and appraised using established internal validity criteria. Adjusted indirect comparisons between agents were performed using well-established methods. RESULTS Three trials meeting inclusion criteria were identified. Direct comparison between apixaban 2.5 mg twice daily (BID) versus apixaban 5 mg BID showed no difference for any outcome. Clinically relevant non-major bleeding occurred less with both apixaban 2.5 mg BID (OR 0.23, 95% CI 0.08-0.62, P=0.004) and apixaban 5 mg BID [OR 0.31, 95% CI 0.11-0.82, P=0.019] compared to rivaroxaban 20 mg daily. Apixaban 2.5 mg BID showed less clinically relevant non-major bleeding than dabigatran 150 mg BID [OR 0.4, 95% CI 0.16-0.9, P=0.04], but not apixaban 5 mg BID. There were no differences between rivaroxaban 20 mg daily and dabigatran 150 mg BID. No differences in risk for recurrent VTE, major bleeding, or mortality were observed for any comparison between any pair of NOACs. CONCLUSION There were no significant differences in risk for recurrent VTE, major bleeding, or all-cause mortality between the NOACs. However, apixaban 2.5 mg BID was associated with less clinically significant non-major bleeding than either rivaroxaban 20 mg daily or dabigatran 150 mg BID.
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Affiliation(s)
- G Alotaibi
- Department of Medicine, University of Alberta, Edmonton, Canada -
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Affiliation(s)
- Thomas J Moore
- Institute for Safe Medication Practices, 200 Lakeside Drive, Suite 200, Horsham, PA 19044, USA
| | - Michael R Cohen
- Institute for Safe Medication Practices, 200 Lakeside Drive, Suite 200, Horsham, PA 19044, USA
| | - Donald R Mattison
- Risk Sciences International, Ottawa, ON, Canada University of Ottawa, Ottawa
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Affiliation(s)
- Blake Charlton
- Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
| | - Rita Redberg
- Department of Medicine, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143, USA
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Dabigatran: gastrointestinal ulcers. Prescrire Int 2014; 23:186. [PMID: 25162095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Dabigatran appears to provoke gastrointestinal ulcers that are all the more likely to bleed as it is an anticoagulant.
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Affiliation(s)
- Stefania Antoniazzi
- Univ Bordeaux, Inserm U657, F33000 Bordeaux, France; Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, University Hospital "Luigi Sacco", Università di Milano, I20157 Milan, Italy.
| | | | - Valentino Conti
- Regional Centre for Pharmacovigilance, Lombardy Region, via Rosellini 17, I20124 Milan, Italy
| | - Emilio Clementi
- Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences, University Hospital "Luigi Sacco", Università di Milano, I20157 Milan, Italy; E. Medea Scientific Institute, I23842 Bosisio Parini, Italy
| | - Francesco Salvo
- Univ Bordeaux, Inserm U657, F33000 Bordeaux, France; CHU Bordeaux, F33000 Bordeaux, France
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Izumikawa K, Inaba T, Mizukawa S, Kawai Y, Sakakihara I, Ishikawa S, Miyoshi M, Wato M, Kawai K. [Two cases of dabigatran-induced esophageal ulcer indicating the usefulness of drug administration guidance]. Nihon Shokakibyo Gakkai Zasshi 2014; 111:1096-1104. [PMID: 24898488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Here we report two cases of dabigatran-induced esophageal ulcer. Case 1 was a 67-year-old man who presented with heartburn that developed a month after dabigatran administration. Case 2 was an 81-year-old woman who presented with epigastralgia that developed within a few days of dabigatran administration. Endoscopic findings were similar in both cases, including shallow esophageal ulcers covered with a thin whitish membrane. The patients were advised to consume the drug with plenty of water during meals and to remain in a sitting position for 30 min after consumption. This method successfully decreased their symptoms and ulcers, indicating that drug administration guidance is extremely effective in managing dabigatran-induced esophageal injury.
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Affiliation(s)
- Koichi Izumikawa
- Department of Gastroenterology, Kagawa Prefectural Central Hospital
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Abstract
Atrial fibrillation increases the risk of stroke, which is a leading cause of death and disability worldwide. The use of oral anticoagulation in patients with atrial fibrillation at moderate or high risk of stroke, estimated by established criteria, improves outcomes. However, to ensure that the benefits exceed the risks of bleeding, appropriate patient selection is essential. Vitamin K antagonism has been the mainstay of treatment; however, newer drugs with novel mechanisms are also available. These novel oral anticoagulants (direct thrombin inhibitors and factor Xa inhibitors) obviate many of warfarin's shortcomings, and they have demonstrated safety and efficacy in large randomized trials of patients with non-valvular atrial fibrillation. However, the management of patients taking warfarin or novel agents remains a clinical challenge. There are several important considerations when selecting anticoagulant therapy for patients with atrial fibrillation. This review will discuss the rationale for anticoagulation in patients with atrial fibrillation; risk stratification for treatment; available agents; the appropriate implementation of these agents; and additional, specific clinical considerations for treatment.
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Affiliation(s)
- Benjamin A Steinberg
- Electrophysiology Section, Duke Clinical Research Institute, Duke University Medical Center, Durham, NC 27715, USA
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Joseph B, Ditillo M, Pandit V, Aziz H, Sadoun M, Hays D, Davis K, Friese R, Rhee P. Dabigatran therapy: minor trauma injuries are no longer minor. Am Surg 2014; 80:E116-E118. [PMID: 24887656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Bellal Joseph
- Division of Trauma, Critical Care, and Acute Care Surgery, University of Arizona, Tucson, Arizona, USA
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Sardar P, Nairooz R, Chatterjee S, Wetterslev J, Ghosh J, Aronow WS. Meta-analysis of risk of stroke or transient ischemic attack with dabigatran for atrial fibrillation ablation. Am J Cardiol 2014; 113:1173-7. [PMID: 24513472 DOI: 10.1016/j.amjcard.2013.12.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Revised: 12/16/2013] [Accepted: 12/16/2013] [Indexed: 11/17/2022]
Abstract
Dabigatran is a novel oral anticoagulant and may be useful during atrial fibrillation (AF) ablation for prevention of thromboembolic events. However, the benefits and adverse effects of periprocedural dabigatran therapy have not been thoroughly evaluated. A meta-analysis was performed to evaluate the efficacy and safety of dabigatran for anticoagulation in AF ablation. PubMed, The Cochrane Library, EMBASE, Web of Science, and CINAHL databases were searched from January 01, 2001 through July 30, 2013. Two reviewers reviewed the studies for inclusion and extracted data from studies comparing dabigatran with warfarin for AF ablation. A total of 5,513 patients undergoing catheter ablation were included in 17 observational studies and 1 randomized trial. Fourteen events of stroke or transient ischemic attacks were reported in the dabigatran group and 4 in the warfarin group (Peto's odds ratio 3.94, 95% confidence interval [CI] 1.54 to 10.08, number needed to harm=284 patients). The risk of all thromboembolic complications was also higher in the dabigatran group compared with the warfarin group (Peto's odds ratio 2.81, 95% CI 1.23 to 6.45). No major differences were observed for the risk of major bleeding (odds ratio 0.99, 95% CI 0.55 to 1.78), pericardial tamponade, and groin hematoma. A lower risk of minor bleeding was observed with dabigatran (odds ratio 0.60, 95% CI 0.41 to 0.87). In conclusion, periprocedural use of dabigatran for AF ablation was related to a higher risk of thromboembolic complications including stroke and transient ischemic attack.
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Affiliation(s)
- Partha Sardar
- Department of Medicine, New York Medical College, New York, New York.
| | - Ramez Nairooz
- Department of Medicine, New York Medical College, New York, New York
| | - Saurav Chatterjee
- Department of Cardiology, St. Luke's-Roosevelt Hospital Center, Columbia University College of Physicians and Surgeons, New York, New York
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Center for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Joydeep Ghosh
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Wilbert S Aronow
- Cardiology Division, New York Medical College, Valhalla, New York
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Bell S, Nand J, Dawes M. Anticoagulation-associated upper gastrointestinal haemorrhage. Intern Med J 2014; 43:952. [PMID: 23919341 DOI: 10.1111/imj.12217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 05/07/2013] [Indexed: 11/29/2022]
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