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Harmouche E, Stueve P, Howland MA, Su MK. Massive Apixaban Overdose Confirmed with Blood Concentrations and Managed Without Bleeding: A Single Case Report. J Pharm Pract 2024; 37:761-765. [PMID: 37227108 DOI: 10.1177/08971900231177570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Background: Acute overdoses of apixaban, and other direct oral anticoagulants are relatively uncommon. The number of direct oral anticoagulants prescriptions in the United States is increasing, however reports on patient outcomes after documented overdose are sparse. Case report: A 76-year-old man with a past medical history of atrial fibrillation and taking apixaban 5 mg twice daily presented to the emergency department 10 hours after reportedly ingesting 60-70 of his pills. He was alert and had a normal physical examination. Blood tests demonstrated an INR of 12, platelets of 161 000 cells/mm3, hemoglobin 9.7 g/dL, and creatinine 1.81 mg/dL. He received 60 g of activated charcoal and 4 units of fresh frozen plasma prophylactically. Initial blood apixaban concentration was 4 000 ng/mL. Repeat blood apixaban concentrations were 3 000 ng/mL and 2 200 ng/mL at 7 and 14 hours, respectively (thrapeutic range 91-321 ng/mL for a 5 mg twice daily dose). The hybrid anti-factor Xa activity did not correlate with blood apixaban concentrations. Apixaban elimination followed first-order kinetics with an apparent elimination half-life of 14 hours in the presence of impaired renal function. He did not have any minor or major bleeding events.
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Affiliation(s)
- Elie Harmouche
- Department of Emergency Medicine, Division of Medical Toxicology, Maimonides Medical Center, Brooklyn, NY, USA
| | - Peter Stueve
- Department of Emergency Medicine, Lincoln Medical Center, Bronx, NY, USA
| | - Mary Ann Howland
- St. John's University College of Pharmacy and Health Sciences, Jamaica, NY, USA
- New York City Poison Control Center, Department of Health and Mental Hygiene, New York, NY, USA
| | - Mark K Su
- New York City Poison Control Center, Department of Health and Mental Hygiene, New York, NY, USA
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2
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Pathan S, Genco AT. Apixaban-Associated Intracranial Hemorrhage in a Patient With Elevated International Normalized Ratio. J Pharm Pract 2024; 37:500-508. [PMID: 36493421 DOI: 10.1177/08971900221144125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2024]
Abstract
Apixaban has been associated with prolongation of the international normalized ratio (INR), but data surrounding the extent of elevation and its clinical significance are limited. Due to interaction between apixaban and the prothrombin assay, elevations in INR in patients receiving apixaban are common and not always grounds for concern. However, in high risk patients, elevations can represent a need for closer monitoring. This case summarizes an 82-year-old woman with a history of atrial fibrillation and left middle cerebral artery strokes with no residual deficits. She presented with right-sided hemiparesis and aphasia and underwent a mechanical thrombectomy with TICI 2b recanalization of a left M1 occlusion. Post-thrombectomy, she was found to have a left atrial thrombus and 10 days later was started on apixaban 5 mg twice daily. On the fourth day of apixaban therapy, she experienced an INR increase to 2.3, prompting initiation of a vitamin K challenge for nutritional deficiency. Despite initial improvement, her INR increased to 2.7 a week after apixaban was initiated, coinciding with a decline in mental status and an apixaban peak level of 435.6 ng/mL (reference range 91-321 ng/mL). A computed tomography (CT) scan of her head showed new intracranial hemorrhage in the area of her previous infarction, prompting apixaban reversal with andexanet alfa. Unfortunately, the patient expired. This case report highlights the importance and difficulty in performing therapeutic drug monitoring in patients receiving oral anti-factor Xa inhibitors, revealing a downside to administration of high-risk medications that do not have readily available monitoring.
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Affiliation(s)
- Sophia Pathan
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew T Genco
- Department of Pharmacy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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3
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Hamidi R, Sowa A, Halperin-Goldstein S, Puthenpura V, Prozora S. Intentional overdose of rivaroxaban and alcohol: A case report. Pediatr Blood Cancer 2023; 70:e29969. [PMID: 36094312 DOI: 10.1002/pbc.29969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2022] [Revised: 08/26/2022] [Accepted: 08/13/2022] [Indexed: 02/06/2023]
Affiliation(s)
- Rohaum Hamidi
- Department of Pediatrics, Yale New Haven Children's Hospital, 1 Park Street, New Haven, Connecticut, USA
| | - Anna Sowa
- Department of Pediatrics, Yale New Haven Children's Hospital, 1 Park Street, New Haven, Connecticut, USA.,Department of Pediatric Hematology & Oncology, Yale University School of Medicine, 333 Cedar St, New Haven, Connecticut, USA
| | - Sofia Halperin-Goldstein
- Department of Pediatrics, Yale New Haven Children's Hospital, 1 Park Street, New Haven, Connecticut, USA
| | - Vidya Puthenpura
- Department of Pediatrics, Yale New Haven Children's Hospital, 1 Park Street, New Haven, Connecticut, USA.,Department of Pediatric Hematology & Oncology, Yale University School of Medicine, 333 Cedar St, New Haven, Connecticut, USA
| | - Stephanie Prozora
- Department of Pediatrics, Yale New Haven Children's Hospital, 1 Park Street, New Haven, Connecticut, USA.,Department of Pediatric Hematology & Oncology, Yale University School of Medicine, 333 Cedar St, New Haven, Connecticut, USA
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4
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Daei M, Abbasi G, Khalili H, Heidari Z. Direct oral anticoagulants toxicity in children: an overview and practical guide. Expert Opin Drug Saf 2022; 21:1183-1192. [PMID: 35924671 DOI: 10.1080/14740338.2022.2110236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION By increasing use of direct oral anticoagulants (DOACs) in adults and children, gradual increase in the number of intentional or unintentional DOAC poisonings among children is suspected in the near future. Hence, clinicians and pharmacists need to be familiar with the clinical features and management of DOAC-toxicity among pediatric population. AREAS COVERED This article provides an overview and practical guide to DOAC-toxicity in pediatrics according to the available clinical evidence. EXPERT OPINION Based on limited available data, accidental pediatric ingestion of DOACs can be managed by supportive care in most cases. However, serious toxicity may occur following massive overdose, in presence of underlying disorders (renal or hepatic dysfunction) and concurrent anticoagulant therapy. Activated charcoal is recommended for known recent ingestion of DOACs (within 2-4 hours) to reduce the gastrointestinal absorption. Supportive interventions including local hemostatic measures and volume resuscitation are the cornerstone of management of bleeding. Vitamin K and fresh frozen plasma are ineffective for DOAC reversal and thus are not recommended. Currently, safety and efficacy data regarding the use of specific reversal agents (including idarucizumab and andexanet alfa) and 3-factor or 4-factor prothrombin complex concentrate (PCC) or activated PCC (aPCC) among children with DOAC-associated bleeding are lacking.
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Affiliation(s)
- Maryam Daei
- Faculty of Pharmacy, Alborz University of Medical Sciences, Alborz, Iran
| | - Golnaz Abbasi
- Faculty of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hossein Khalili
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Zinat Heidari
- Department of Clinical Pharmacy, Faculty of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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5
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Delrue M, Chevillard L, Stépanian A, Dragoni A, Camoin-Jau L, Voicu S, Malissin I, Deye N, Gainnier M, Siguret V, Mégarbane B. Case series of massive direct oral anticoagulant ingestion-Treatment and pharmacokinetics data. Eur J Clin Invest 2022; 52:e13746. [PMID: 35000196 DOI: 10.1111/eci.13746] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/19/2021] [Accepted: 01/05/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOAC) are widely used due to favourable benefit/risk ratio. However, consequences of massive ingestion have been poorly investigated. OBJECTIVES We aimed to report outcome and pharmacokinetic parameters in patients who massively ingested DOACs. METHODS We conducted a 5-year cohort study including consecutive massive DOAC ingestion patients admitted to two critical care departments. Patients were managed in accordance with standards of care. We collected the main history, clinical, laboratory, management and outcome data. The time-course of plasma DOAC concentrations measured using specific assays was modelled. RESULTS Twelve patients (3F/9M; age, 55 years [41-63], median [25th-75th percentiles]) were included. Ingestions involved rivaroxaban (n = 7), apixaban (n = 3) and dabigatran (n = 2), with presumed doses of 9.4-fold [5.0-22.0] the full daily dose. Six patients received activated charcoal but no antidote nor blood-derived product. No bleeding was observed. One patient died due to refractory cardiogenic shock related to bisoprolol co-intoxication. Highest observed peak plasma concentrations were 1720 ng/ml (rivaroxaban), 750 ng/ml (apixaban) and 644 ng/ml (dabigatran). Times to reach DOAC concentration below 50 ng/ml were ~20-45 h (rivaroxaban), ~125 h (apixaban) and ~30-50 h (dabigatran). Elimination half-lives were 2.5-25.5 h (rivaroxaban), 22.0 and 36.5 h (apixaban), and 5.8 and 15.5 h (dabigatran), with substantial interindividual variability and prolongation in case of cardiovascular failure related to co-intoxicants. Charcoal administration, even if delayed, may have contributed to limit toxicity, possibly by reducing absorption and/or enteroenteric recycling. CONCLUSION No bleeding was observed in this series of massive DOAC ingestions despite elevated plasma concentrations. No patient required specific haemostatic agents. Charcoal administration should be considered to limit toxicity.
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Affiliation(s)
- Maxime Delrue
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
| | - Lucie Chevillard
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France.,INSERM, UMRS-1144, Paris University, Paris, France
| | - Alain Stépanian
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
| | - Alessandra Dragoni
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France
| | | | - Sébastien Voicu
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France.,INSERM, UMRS-1144, Paris University, Paris, France
| | - Isabelle Malissin
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France.,INSERM, UMRS-1144, Paris University, Paris, France
| | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France
| | - Marc Gainnier
- Department of Critical Care, APHM, la Timone Hospital, Marseille, France
| | - Virginie Siguret
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France.,INSERM, UMRS-1140, Paris University, Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France.,INSERM, UMRS-1144, Paris University, Paris, France
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6
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Ansari U, Asghar Z, Oswald M, Ng H. Apixaban-Induced Hepatotoxicity. Cureus 2022; 14:e23879. [PMID: 35402115 PMCID: PMC8985735 DOI: 10.7759/cureus.23879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 11/05/2022] Open
Abstract
Apixaban is widely used to prevent and manage thromboembolic disease. Due to it being fairly new in the market, we are still understanding its complete risk profile. We present a case of a 61-year-old female with no prior history of liver disease, who developed severe transaminitis shortly after the initiation of apixaban and started trending down after its discontinuation.
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7
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Ha CJ, Harmouche E, Howland MA, Su MK. Two Cases of Acute Direct Oral Anticoagulant Overdose Without Adverse Effect. J Pediatr Hematol Oncol 2022; 44:e447-e449. [PMID: 35200221 DOI: 10.1097/mph.0000000000002263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/05/2021] [Indexed: 12/24/2022]
Abstract
We report 2 pediatric patients who had acute overdoses of the direct oral anticoagulants medications. Both patients were managed conservatively; neither required reversal agents or blood products nor had any major or minor bleeding events. With therapeutic usage of direct oral anticoagulants, routine coagulation studies typically are considered insufficient measures of anticoagulation and the preferred chromogenic anti-Factor Xa assay is recommended but not widely available. Using a routine hybrid heparin anti-Factor Xa assay, 1 patient demonstrated a strong linear correlation up to a serum rivaroxaban concentration of 940 ng/mL.
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Affiliation(s)
- Catherine J Ha
- Columbia University Vagelos College of Physicians and Surgeons
| | - Elie Harmouche
- Department of Emergency Medicine, Maimonides Medical Center
| | - Mary Ann Howland
- NYC Poison Control Center
- St. John's University College of Pharmacy and Health Professions
| | - Mark K Su
- NYC Poison Control Center
- Ronald O. Perelman Department of Emergency Medicine, New York University Grossman School of Medicine, New York City, NY
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8
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Current use of rivaroxaban in elderly patients with venous thromboembolism (VTE). J Thromb Thrombolysis 2021; 52:863-871. [PMID: 33674983 DOI: 10.1007/s11239-021-02415-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 12/12/2022]
Abstract
Venous thromboembolism (VTE), which is characterized by pulmonary embolism and deep vein thrombosis, has become a serious public concern. Notably, over half of the patients with VTE are over 70 years of age, but elderly patients are at high risk of anti-coagulation and bleeding, which increase with age. Moreover, risk factors and frailty also show a difference between elderly patients and ordinary patients diagnosed with VTE. Rivaroxaban is a direct inhibitor of activated factor Xa and has the advantage of predictable pharmacodynamics and pharmacokinetics, no coagulation monitoring, and few drug interactions. As a first-line therapy for VTE, this drug is more advantageous than traditional therapy and exhibits good efficacy and safety for ordinary patients. However, the effectiveness and safety of rivaroxaban in elderly patients have not been fully elucidated. This article reviewed the use of rivaroxaban in elderly patients, including drug interactions, monitoring, reversal agents of rivaroxaban, and the use of small dosages of rivaroxaban in elderly patients.
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9
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Renon F, Rago A, Liccardo B, D'Andrea A, Riegler L, Golino P, Nigro G, Russo V. Direct Oral Anticoagulants Plasma Levels Measurement: Clinical Usefulness from Trials and Real-World Data. Semin Thromb Hemost 2021; 47:150-160. [PMID: 33636746 DOI: 10.1055/s-0041-1723770] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Measurement of direct oral anticoagulants (DOACs) activity is not routinely necessary. Indeed, evaluation of DOACs plasmatic concentration is discouraged for the majority of patients, due to the lack of outcome data supporting this approach. Nevertheless, DOAC measurements may be useful in emergency situations such as serious bleeding events, need for urgent invasive procedures, and acute ischemic stroke or in managing anticoagulation in "special populations" not adequately studied in clinical trials, for example the very elderly or those at the extremes of body weight. The aim of this review is to describe and summarize the methods for DOACs activity evaluation and the settings in which their plasma level measurement may be indicated, analyzing indications from scientific societies and evidence from clinical trials, as well as real world data on the usefulness of DOACs plasma levels "monitoring."
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Affiliation(s)
- Francesca Renon
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Anna Rago
- Department of Cardiology, Monaldi Hospital, Naples, Italy
| | | | - Antonello D'Andrea
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore, Italy
| | - Lucia Riegler
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore, Italy
| | - Paolo Golino
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Gerardo Nigro
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Vincenzo Russo
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
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10
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Exploratory Ingestions of Novel Anticoagulants and Antiplatelets: What Is the Risk? Pediatr Emerg Care 2020; 36:283-285. [PMID: 30461669 DOI: 10.1097/pec.0000000000001616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Historically, anticoagulants and antiplatelet agents included warfarin and aspirin, respectively. In recent years, numerous novel anticoagulants (eg, direct thrombin inhibitors and factor Xa inhibitors) as well as the adenosine diphosphate receptor antagonists have increased significantly. Little information on the bleeding risk after exploratory ingestion of these agents is available. The primary purpose of this study is to evaluate the bleeding risk of these agents after an exploratory ingestion in children 6 years or younger. METHODS This retrospective multicenter poison control center study was conducted on calls between 2005 and 2014. The following agents were included: apixaban, clopidogrel, dabigatran, edoxaban, prasugrel, rivaroxaban, or ticagrelor. Bleeding characteristics and treatment rendered were recorded. RESULTS A total of 638 cases were identified. Most cases involved antiplatelet agents. No patient developed any bleeding complication. The administration of charcoal was independent of the amount of drug ingested. CONCLUSION Accidental, exploratory ingestions of these agents seem well tolerated, with no patient developing bleeding complications.
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11
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Klaassen ILM, Zuurbier CCM, Hutten BA, van den Bos C, Schouten AYN, Stokhuijzen E, van Ommen CH. Venous Thrombosis in Children with Acute Lymphoblastic Leukemia Treated on DCOG ALL-9 and ALL-10 Protocols: The Effect of Fresh Frozen Plasma. TH OPEN 2019; 3:e109-e116. [PMID: 31249990 PMCID: PMC6524923 DOI: 10.1055/s-0039-1688412] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 03/08/2019] [Indexed: 01/19/2023] Open
Abstract
Background
Venous thromboembolism (VTE) is an important complication for treatment of acute lymphoblastic leukemia (ALL) in children. Especially, ALL treatment, with therapeutics such as asparaginase and steroids, increases the thrombotic risk by reduction in procoagulant and anticoagulant proteins. Replacement of deficient natural anticoagulants by administration of fresh frozen plasma (FFP) may have a preventive effect on the occurrence of VTE.
Methods
We retrospectively analyzed all consecutive children (≤18 years) with ALL, treated on the Dutch Childhood Oncology Group (DCOG) ALL-9 and ALL-10 protocols at the Emma Children's Hospital Academic Medical Center between February 1997 and January 2012, to study the effect of FFP on VTE incidence, antithrombin and fibrinogen plasma levels, and VTE risk factors.
Results
In total, 18/205 patients developed VTE (8.8%; 95% confidence interval [CI]: 4.9–12.7%). In all patients, VTE occurred after asparaginase administration. In total, 82/205 patients (40%) received FFP. FFP supplementation did not prevent VTE or alter plasma levels of antithrombin or fibrinogen. In the multivariate analysis, VTE occurred significantly more frequently in children ≥12 years (odds ratio [OR]: 3.89; 95% CI: 1.29–11.73) and treated according to the ALL-10 protocol (OR: 3.71; 95% CI: 1.13–12.17).
Conclusion
FFP supplementation does not seem to be beneficial in the prevention of VTE in pediatric ALL patients. In addition, age ≥12 years and treatment according to the DCOG ALL-10 protocol with intensive and prolonged administration of asparaginase in combination with prednisone are risk factors. There is a need for effective preventive strategies in ALL patients at high risk for VTE.
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Affiliation(s)
- Irene L M Klaassen
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Department of Vascular Medicine, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Charlotte C M Zuurbier
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Barbara A Hutten
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Cor van den Bos
- Department of Pediatric Oncology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - A Y Netteke Schouten
- Department of Pediatric Oncology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands.,Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | - Eva Stokhuijzen
- Department of Pediatric Hematology, Emma Children's Hospital, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - C Heleen van Ommen
- Department of Pediatric Hematology, Erasmus Medical Center/Sophia Children's Hospital, Rotterdam, The Netherlands
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12
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Mullins ME, Fishburn SJ. Comment on: "Drugs That Can Kill a Toddler with One Tablet or Teaspoonful: A 2018 Updated List". Clin Drug Investig 2019; 39:821-822. [PMID: 31203504 DOI: 10.1007/s40261-019-00815-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Michael E Mullins
- Section of Medical Toxicology, Division of Emergency Medicine, Washington University School of Medicine, Campus Box 8072, 660 S. Euclid Avenue, St Louis, MO, 63110, USA.
| | - Steven J Fishburn
- Section of Medical Toxicology, Division of Emergency Medicine, Washington University School of Medicine, Campus Box 8072, 660 S. Euclid Avenue, St Louis, MO, 63110, USA
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13
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Cuker A, Burnett A, Triller D, Crowther M, Ansell J, Van Cott EM, Wirth D, Kaatz S. Reversal of direct oral anticoagulants: Guidance from the Anticoagulation Forum. Am J Hematol 2019; 94:697-709. [PMID: 30916798 DOI: 10.1002/ajh.25475] [Citation(s) in RCA: 182] [Impact Index Per Article: 36.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 03/22/2019] [Accepted: 03/25/2019] [Indexed: 01/17/2023]
Abstract
Two specific reversal agents for direct oral anticoagulants (DOACs) have been approved in the United States: idarucizumab for dabigatran reversal and andexanet alfa for apixaban and rivaroxaban reversal. Non-specific prohemostatic agents such as prothrombin complex concentrate (PCC) and activated PCC have also been used for DOAC reversal. The goal of this document is to provide comprehensive guidance from the Anticoagulation Forum, a North American organization of anticoagulation providers, regarding use of DOAC reversal agents. We discuss indications for reversal, provide guidance on how the individual reversal agents should be administered, and offer suggestions for stewardship at the health system level.
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Affiliation(s)
- Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory MedicinePerelman School of Medicine, University of Pennsylvania Philadelphia Pennsylvania
| | - Allison Burnett
- Department of Pharmacy Practice and Administrative Sciences, University of New Mexico Health Sciences Center Albuquerque New Mexico
| | | | - Mark Crowther
- Department of MedicineMcMaster University Hamilton Ontario Canada
| | - Jack Ansell
- Department of Medicine, Zucker School of Medicine at Hofstra/Northwell Hempstead New York
| | | | - Diane Wirth
- Department of Cardiology, Grady Memorial Hospital Atlanta Georgia
| | - Scott Kaatz
- Division of Hospital MedicineHenry Ford Hospital Detroit Michigan
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14
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Doyle AJ, Crowley MP, Hunt BJ. Perioperative management of antithrombotic treatment in children. Paediatr Anaesth 2019; 29:405-413. [PMID: 30848062 DOI: 10.1111/pan.13511] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 09/12/2018] [Accepted: 09/18/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Andrew J Doyle
- Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Maeve P Crowley
- Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Beverley J Hunt
- Thrombosis & Haemophilia Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
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15
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Model-based meta-analysis to evaluate optimal doses of direct oral factor Xa inhibitors in atrial fibrillation patients. Blood Adv 2019; 2:1066-1075. [PMID: 29760204 DOI: 10.1182/bloodadvances.2017013805] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 03/03/2018] [Indexed: 01/13/2023] Open
Abstract
The noninferiority of direct oral factor Xa (FXa) inhibitors (rivaroxaban, apixaban, and edoxaban) in treatment of atrial fibrillation were demonstrated compared with warfarin by several large clinical trials; however, subsequent meta-analyses reported a higher risk of major bleeding with rivaroxaban than with the other FXa inhibitors. In the present study, we first estimated the changes of prothrombin time (PT) in 5 randomized trials based on reported population pharmacokinetic and pharmacodynamic models and then carried out a model-based meta-analysis to obtain models describing the relationship between PT changes and the event rates of ischemic stroke/systemic embolism (SE) and of major bleeding. By using the models, we simulated the optimal therapeutic doses for each FXa inhibitor. It was suggested that dose reduction of rivaroxaban from the current 20 mg/d to 10 mg/d would decrease patient deaths from major bleeding (hazard ratio [HR], 0.69; 95% confidence interval [CI], 0.64-0.74) with little increase in those for ischemic stroke/SE (HR, 1.11; 95% CI, 1.07-1.20). The overall decrease in the mortality caused by both events was estimated as 5.81 per 10 000 patient-years (95% CI, 3.92-8.16), with an HR of 0.87 (95% CI, 0.83-0.91). For apixaban and edoxaban, no distinct change in the overall mortality was simulated by dose modification. This study suggested that the current dose of rivaroxaban might be excessive and would need to be reduced to decrease the excess risk of major bleeding.
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16
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Wu HD, Cao HY, Song ZK, Yang S, Tang ML, Liu Y, Qin L. Considerations for routine coagulation monitoring with rivaroxaban: A case report and review of the literature. World J Clin Cases 2019; 7:382-388. [PMID: 30746380 PMCID: PMC6369389 DOI: 10.12998/wjcc.v7.i3.382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/04/2018] [Accepted: 12/21/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Rivaroxaban is a non-vitamin K antagonist oral anticoagulant that does not require coagulation monitoring based on current recommendations. Our goal is to explore whether routine coagulation monitoring should not be required for all patients receiving oral rivaroxaban, what relationship between routine coagulation abnormalities and bleeding, and how to deal with the above clinical situations through our case and review of the literature.
CASE SUMMARY We report a 67-year-old woman with a history of atrial fibrillation who presented to the hospital with worsening dyspnea and cough. Based on electrocardiogram, venous compression ultrasonography, and computed tomography pulmonary angiography, the diagnosis of atrial fibrillation, deep venous thrombosis, and acute pulmonary embolism was confirmed. Her coagulation assays and renal function were normal on admission; she was not underweight, did not have a history of hemorrhagic disease, and her CHA2DS2-VAS, HAS-BLED, and simplified Pulmonary Embolism Severity Index scores were 3, 0, and 0, respectively. Oral rivaroxaban (15 mg twice daily) was administered. The following day, she presented gastrointestinal and gum bleeding, combined with coagulation abnormalities. Following cessation of rivaroxaban, her bleeding stopped and tests improved over the next 2 d. Rivaroxaban was begun again 3 d after recovery. However, she again presented with gastrointestinal and gum bleeding and the abnormal tests, and the therapy was discontinued. At 30-d follow-up after discharge, she presented normal coagulation tests without bleeding.
CONCLUSION Although current guidelines recommend that using non-vitamin K antagonist oral anticoagulants including rivaroxaban do not require coagulation monitoring, a small number of patients may develop routine coagulation test changes and bleeding during rivaroxaban therapy, especially in the elderly. Clinicians should pay attention to these patients and further obtain evidence in practice.
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Affiliation(s)
- Hai-Di Wu
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Hong-Yan Cao
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Zi-Kai Song
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Shuo Yang
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Ming-Long Tang
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Yang Liu
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Ling Qin
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
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17
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Male C, Thom K, O'Brien SH. Direct oral anticoagulants: What will be their role in children? Thromb Res 2019; 173:178-185. [DOI: 10.1016/j.thromres.2018.06.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 06/16/2018] [Accepted: 06/26/2018] [Indexed: 01/01/2023]
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18
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Carr BM, Roy DJ, Bangh SA, Hellmich TR, Walker LE. Anti-factor Xa Monitoring and Activated Charcoal for a Pediatric Patient With Rivaroxaban Overdose. Clin Pract Cases Emerg Med 2018; 2:247-250. [PMID: 30083644 PMCID: PMC6075494 DOI: 10.5811/cpcem.2018.5.38373] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 01/13/2023] Open
Abstract
Rivaroxaban, an oral anticoagulant, directly inhibits factor Xa (FXa). A 35-month-old boy was brought to the emergency department 15 minutes after ingesting 200 mg of rivaroxaban (16 mg/kg). Activated charcoal (AC) was administered; the patient was observed with monitoring of plasma anti-FXa levels and discharged the following day after an uneventful hospital observation. We identified two case series and seven case reports of potentially toxic rivaroxaban ingestion in the literature. No serious adverse effects were reported. The present case is the first reported use of anti-FXa monitoring after rivaroxaban ingestion. The magnitude of the effect of AC administration in this patient is unclear.
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Affiliation(s)
- Brendan M Carr
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
| | - David J Roy
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota.,Mayo Clinic, Pharmacy Services, Rochester, Minnesota
| | - Stacey A Bangh
- Hennepin County Medical Center, Minneapolis, Minnesota.,Minnesota Poison Control System, Minneapolis, Minnesota
| | | | - Laura E Walker
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
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19
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Ilicki J, Höjer J, Djärv T. Massive apixaban overdose – A comparison of three cases. Am J Emerg Med 2018; 36:891-893. [DOI: 10.1016/j.ajem.2017.09.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 09/15/2017] [Accepted: 09/19/2017] [Indexed: 11/16/2022] Open
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20
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Uzunget SC, Evrin T, Uzunget SB, Ertürk ZK, Akıncıoğlu E, Özdemir S, Korkmaz A. Evaluation of activated charcoal and lipid emulsion treatment in model of acute rivaroxaban toxicity. Am J Emerg Med 2018; 36:1346-1349. [PMID: 29395759 DOI: 10.1016/j.ajem.2017.12.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Revised: 12/13/2017] [Accepted: 12/13/2017] [Indexed: 12/20/2022] Open
Abstract
AIM Reducing or reversing the toxicity effects of new oral anticoagulants is an important question.The purpose of the present study is to evaluate the effect of lipid emulsion (LE) and Activated Charcoal (AC) therapy on the intoxication of rivaroxaban, on mice. METHODS Adult male Balb/c mice weighing approximately 30g were used in the study. Seven groups were assigned, with six mice in each group. Groups were defined; given only rivaroxaban, given only LE, given only AC, after the administration of rivaroxaban LE applied group in the 1st hour, after the administration of rivaroxaban LE applied group in the 3rd hour, after the administration of rivaroxaban AC applied group in the1st hour, after the administration of rivaroxaban AC applied group in the 1st hour and LE applied group in the 3rd hour. PT and Anti-Factor Xa activity were measured in all blood samples from subjects. RESULTS A statistically significant difference was found when all groups were compared in terms of mean PT values and Anti-FactorXa values. However, no statistically significant difference was found in the mean PT and Anti-FactorXa values when only rivaroxaban administrated group and after the administration of rivaroxaban LE and/or AC applied groups were compared one to one. No deaths occurred in groups during the observation. CONCLUSION Although the administration of either AC or LE alone or in combination resulted in a decrease in the mean values of PT and anti-Factor Xa, in case of rivaroxaban toxicity, but one-to-one comparison of the groups was not statistically significant.
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Affiliation(s)
- Sinan Cem Uzunget
- Department of Emergency Medicine, Ufuk University Faculty of Medicine, Ankara, Turkey.
| | - Togay Evrin
- Department of Emergency Medicine, Ufuk University Faculty of Medicine, Ankara, Turkey
| | | | - Zamir Kemal Ertürk
- Department of Emergency Medicine, Ufuk University Faculty of Medicine, Ankara, Turkey
| | - Egemen Akıncıoğlu
- Department of Pathology, Ufuk University Faculty of Medicine, Ankara, Turkey
| | - Saffet Özdemir
- Department of Emergency Medicine, Ufuk University Faculty of Medicine, Ankara, Turkey
| | - Atila Korkmaz
- Department of Emergency Medicine, Ufuk University Faculty of Medicine, Ankara, Turkey.
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21
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Levine M, Beuhler MC, Pizon A, Cantrel FL, Spyres MB, LoVecchio F, Skolnik AB, Brooks DE. Assessing Bleeding Risk in Patients With Intentional Overdoses of Novel Antiplatelet and Anticoagulant Medications. Ann Emerg Med 2017; 71:273-278. [PMID: 29032872 DOI: 10.1016/j.annemergmed.2017.08.046] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 08/05/2017] [Accepted: 08/16/2017] [Indexed: 10/18/2022]
Abstract
STUDY OBJECTIVE In recent years, the use of novel anticoagulants and antiplatelet agents has become widespread. Little is known about the toxicity and bleeding risk of these agents after acute overdose. The primary objective of this study is to evaluate the relative risk of all bleeding and major bleeding in patients with acute overdose of novel antiplatelet and anticoagulant medications. METHODS This study is a retrospective study of acute ingestion of apixaban, clopidogrel, ticlopidine, dabigatran, edoxaban, prasugrel, rivaroxaban, and ticagrelor reported to 7 poison control centers in 4 states during a 10-year span. The prevalence of bleeding for each agent was calculated, and hemorrhage was classified as trivial, minor, or major. RESULTS A total of 322 acute overdoses were identified, with the majority of cases involving clopidogrel (260; 80.7%). Hemorrhage occurred in 16 cases (4.9%), including 7 cases of clopidogrel, 6 cases of rivaroxaban, 2 cases of dabigatran, and 1 case of apixaban. Most cases of hemorrhage were classified as major (n=9). Comparing the novel anticoagulants with the P2Y12 receptor inhibitors, the relative risk for any bleeding with novel anticoagulant was 6.68 (95% confidence interval 2.63 to 17.1); the relative risk of major bleeding was 18.1 (95% confidence interval 3.85 to 85.0). CONCLUSION Acute overdose of novel anticoagulants or antiplatelet agents is associated with a small risk of significant hemorrhage. The risk is greater with the factor Xa inhibitors and direct thrombin inhibitors than with the P2Y12 receptor antagonists.
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Affiliation(s)
- Michael Levine
- Department of Emergency Medicine, Division of Medical Toxicology, University of Southern California, Los Angeles, CA.
| | - Michael C Beuhler
- Department of Emergency Medicine, Division of Medical Toxicology, Carolinas Medical Center, Charlotte, NC
| | - Anthony Pizon
- Department of Emergency Medicine, Division of Medical Toxicology, University of Pittsburgh, Pittsburgh, PA
| | - F Lee Cantrel
- California Poison Control System, San Diego Division, San Diego, CA
| | - Meghan B Spyres
- Department of Emergency Medicine, Division of Medical Toxicology, University of Southern California, Los Angeles, CA
| | - Frank LoVecchio
- Banner Poison & Drug Information Center, Banner University Medical Center-Phoenix, Phoenix, AZ
| | - Aaron B Skolnik
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Daniel E Brooks
- Banner Poison & Drug Information Center, Banner University Medical Center-Phoenix, Phoenix, AZ
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22
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Lai J, Ramai D, Alchi R, Bloomfield D. Anticoagulation therapy for thromboembolism prevention: a case of warfarin-induced skin necrosis in the setting of protein C deficiency. BMJ Case Rep 2017; 2017:bcr-2016-218015. [PMID: 28500260 DOI: 10.1136/bcr-2016-218015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Patients with protein C deficiency are at increased risk for thrombolic diseases. Non-vitamin K antagonist anticoagulant options should be considered in patients with warfarin-induced skin necrosis (WISN) in the setting of protein C. We report a 41-year-old African American male patient with WISN and protein C deficiency who was treated with rivaroxaban followed by dabigatran. After 1 month on rivaroxaban, he began experiencing blood in his stools, unrelenting pain in his lower extremities, found it difficult to obtain medication despite having insurance and as a result did not maintain compliance. He was then assessed at the hospital, symptomatically treated and discharged on dabigatran. After 6 weeks, he reported symptomatic relief and less side effects. This case involved a head-to-head clinical comparison of rivaroxaban and dabigatran as alternatives to warfarin anticoagulation therapy.
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Affiliation(s)
- Jonathan Lai
- Department of Anatomical Sciences, St. George's University School of Medicine, True Blue, Grenada
| | - Daryl Ramai
- Department of Anatomical Sciences, St. George's University School of Medicine, True Blue, Grenada
| | - Ramiz Alchi
- Department of Medicine, Richmond University Medical Center, Staten Island, New York, USA
| | - Dennis Bloomfield
- Department of Medicine, Richmond University Medical Center, Staten Island, New York, USA
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23
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Leikin SM, Patel H, Welker KL, Leikin JB. The X factor: Lack of bleeding after an acute apixaban overdose. Am J Emerg Med 2017; 35:801.e5-801.e6. [DOI: 10.1016/j.ajem.2016.11.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Accepted: 11/10/2016] [Indexed: 11/15/2022] Open
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24
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Raval AN, Cigarroa JE, Chung MK, Diaz-Sandoval LJ, Diercks D, Piccini JP, Jung HS, Washam JB, Welch BG, Zazulia AR, Collins SP. Management of Patients on Non-Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association. Circulation 2017; 135:e604-e633. [PMID: 28167634 DOI: 10.1161/cir.0000000000000477] [Citation(s) in RCA: 156] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Non-vitamin K oral anticoagulants (NOACs) are now widely used as alternatives to warfarin for stroke prevention in atrial fibrillation and management of venous thromboembolism. In clinical practice, there is still widespread uncertainty on how to manage patients on NOACs who bleed or who are at risk for bleeding. Clinical trial data related to NOAC reversal for bleeding and perioperative management are sparse, and recommendations are largely derived from expert opinion. Knowledge of time of last ingestion of the NOAC and renal function is critical to managing these patients given that laboratory measurement is challenging because of the lack of commercially available assays in the United States. Idarucizumab is available as an antidote to rapidly reverse the effects of dabigatran. At present, there is no specific antidote available in the United States for the oral factor Xa inhibitors. Prothrombin concentrate may be considered in life-threatening bleeding. Healthcare institutions should adopt a NOAC reversal and perioperative management protocol developed with multidisciplinary input.
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25
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Krause M, Henningsen A, Torge A, Juhl D, Junker R, Kenet G, Kowalski D, Limperger V, Mesters R, Anonymous, Rocke A, Shneyder M, Clausnizer H, Schiesewitz H, Nowak-Göttl U. Impact of gender on safety and efficacy of Rivaroxaban in adolescents & young adults with venous thromboembolism. Thromb Res 2016; 148:145-151. [DOI: 10.1016/j.thromres.2016.09.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 07/28/2016] [Accepted: 09/11/2016] [Indexed: 12/23/2022]
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26
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Clarke SA, Alsaad AA, Mack A, Phillips MB. Apixaban-induced liver injury. BMJ Case Rep 2016; 2016:bcr-2016-216744. [PMID: 27651407 DOI: 10.1136/bcr-2016-216744] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
An 81-year-old woman with well-controlled hypertension presented to the emergency department with new-onset atrial fibrillation with rapid ventricular response. Treatment for atrial fibrillation was initiated, including rate control and anticoagulation with 5 mg of apixaban two times per day for primary stroke prophylaxis. Three days after initiation of apixaban, the patient noted new-onset abdominal pain, worsening shortness of breath and weakness. Laboratory results showed elevated liver enzymes. Workup for elevated transaminase did not reveal any underlying infectious or autoimmune process. Apixaban, a probable cause for the hepatocellular injury, was discontinued and replaced with intravenous unfractionated heparin to bridge anticoagulation with warfarin. The patient's symptoms resolved as her transaminases improved by discontinuation of apixaban. We illustrate this case of drug-induced hepatotoxicity secondary to treatment with apixaban. It is important for physicians to be aware of this rare adverse effect caused by a widely used novel oral anticoagulant.
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Affiliation(s)
| | - Ali A Alsaad
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Anwar Mack
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael B Phillips
- Department of Internal Medicine, Mayo Clinic, Jacksonville, Florida, USA
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27
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Blickstein D, Younes S, Nakav S. Attempted suicide with rivaroxaban. Ann Hematol 2016; 95:2093-2094. [DOI: 10.1007/s00277-016-2816-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 08/31/2016] [Indexed: 01/12/2023]
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28
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Egger F, Targa F, Unterholzner I, Grant RP, Herrmann M, Wiedermann CJ. Medication Error When Switching from Warfarin to Rivaroxaban Leading to Spontaneous Large Ecchymosis of the Abdominal and Chest Wall. Clin Pract 2016; 6:873. [PMID: 27777713 PMCID: PMC5067405 DOI: 10.4081/cp.2016.873] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 08/10/2016] [Indexed: 12/18/2022] Open
Abstract
Non-vitamin K oral anticoagulant (NOAC) therapy may be inappropriate if prescription was incorrect, the patient’s physiological parameters change, or interacting concomitant medications are erroneously added. The aim of this report was to illustrate inappropriate NOAC prescription in a 78-year-old woman with non-valvular atrial fibrillation and borderline renal dysfunction who was switched from warfarin to rivaroxaban and subsequently developed bruising with hemorrhagic shock and acute on chronic renal failure. Administration of 4-factor prothrombin complex concentrate effectively reversed coagulopathy and stopped bleeding. Retrospective determination of circulating plasma levels of rivaroxaban and warfarin confirmed that excessive anticoagulation was likely due to warfarin that the patient probably continued to take although rivaroxaban was initiated. Pharmacodynamic interaction between rivaroxaban and warfarin may not only be additive but synergistic. In patients at high risk of complications, judicious prescribing and dosing of NOACs, and regular monitoring of concomitant medications and renal function are highly recommended.
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Affiliation(s)
- Flavio Egger
- Department of Internal Medicine, Central Hospital of Bolzano , BZ, Italy
| | - Federica Targa
- Department of Clinical Pathology, Central Hospital of Bolzano , BZ, Italy
| | - Ivan Unterholzner
- Department of Internal Medicine, Central Hospital of Bolzano , BZ, Italy
| | - Russell P Grant
- Center for Esoteric Testing, Laboratory Corporation of America® Holdings , Burlington, NC, USA
| | - Markus Herrmann
- Department of Clinical Pathology, Central Hospital of Bolzano , BZ, Italy
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29
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Barton J, Wong A, Graudins A. Anti-Xa activity in apixaban overdose: a case report. Clin Toxicol (Phila) 2016; 54:871-873. [DOI: 10.1080/15563650.2016.1204453] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- James Barton
- Monash Clinical Toxicology, Program of Emergency Medicine, Monash Health, Victoria, Australia
| | - Anselm Wong
- Monash Clinical Toxicology, Program of Emergency Medicine, Monash Health, Victoria, Australia
- School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Andis Graudins
- Monash Clinical Toxicology, Program of Emergency Medicine, Monash Health, Victoria, Australia
- School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
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30
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Repplinger DJ, Hoffman RS, Nelson LS, Hines EQ, Howland M, Su MK. Lack of significant bleeding despite large acute rivaroxaban overdose confirmed with whole blood concentrations. Clin Toxicol (Phila) 2016; 54:647-9. [PMID: 27251583 DOI: 10.1080/15563650.2016.1187736] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Since intentional overdose with rivaroxaban is expected to lead to significant coagulopathy and bleeding, prophylactic reversal has been suggested. We report a single massive ingestion confirmed by a blood concentration that was managed with expectant therapy alone. CASE REPORT A 71-year-old man with atrial fibrillation, aortic valve replacement, and congestive heart failure presented to the emergency department after an intentional ingestion of 97 (1940 mg total) rivaroxaban tablets in a suicide attempt. Initial laboratories revealed: PT, 60.2 s; INR 7.2; aPTT, 55.7 s; BUN 28 mg/dL; and creatinine 1.2 mg/dL. A whole-blood rivaroxaban concentration obtained on hospital-day three was 160 ng/mL. The patient was admitted for continued observation and the coagulation markers trended downward with no major bleeding events. No reversal agents or blood products were given during his hospitalization. CONCLUSION In the setting of a single, acute rivaroxaban overdose, with normal renal function, and no active bleeding, conservative therapy alone may be sufficient.
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Affiliation(s)
- Daniel J Repplinger
- a Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine , New York University School of Medicine , New York , NY , USA ;,b New York City Poison Control Center , New York , NY , USA
| | - Robert S Hoffman
- a Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine , New York University School of Medicine , New York , NY , USA ;,b New York City Poison Control Center , New York , NY , USA
| | - Lewis S Nelson
- a Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine , New York University School of Medicine , New York , NY , USA ;,b New York City Poison Control Center , New York , NY , USA
| | - Elizabeth Q Hines
- a Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine , New York University School of Medicine , New York , NY , USA ;,b New York City Poison Control Center , New York , NY , USA
| | - MaryAnn Howland
- a Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine , New York University School of Medicine , New York , NY , USA ;,b New York City Poison Control Center , New York , NY , USA ;,c Health Sciences , St. John's University College of Pharmacy , Jamaica , NY , USA
| | - Mark K Su
- a Division of Medical Toxicology, Ronald O. Perelman Department of Emergency Medicine , New York University School of Medicine , New York , NY , USA ;,b New York City Poison Control Center , New York , NY , USA
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