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Adelakun AR, Turgeon RD, De Vera MA, McGrail K, Loewen PS. Oral anticoagulant switching in patients with atrial fibrillation: a scoping review. BMJ Open 2023; 13:e071907. [PMID: 37185198 PMCID: PMC10151984 DOI: 10.1136/bmjopen-2023-071907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION Oral anticoagulants (OACs) prevent stroke in patients with atrial fibrillation (AF). Several factors may cause OAC switching. OBJECTIVES To examine the phenomenon of OAC switching in patients with AF, including all available evidence; frequency and patterns of switch, clinical outcomes, adherence, patient-reported outcomes, reasons for switch, factors associated with switch and evidence gaps. DESIGN Scoping review. DATA SOURCES MEDLINE, Embase and Web of Science, up to January 2022. RESULTS Of the 116 included studies, 2/3 examined vitamin K antagonist (VKA) to direct-acting OAC (DOAC) switching. Overall, OAC switching was common and the definition of an OAC switch varied across. Switching from VKA to dabigatran was the most prevalent switch type, but VKA to apixaban has increased in recent years. Patients on DOAC switched more to warfarin than to other DOACs. OAC doses involved in the switches were hardly reported and patients were often censored after the first switch. Switching back to a previously taken OAC (frequently warfarin) occurred in 5%-21% of switchers.The risk of ischaemic stroke and gastrointestinal bleeding in VKA to DOAC switchers compared with non-switchers was conflicting, while there was no difference in the risk of other types of bleeding. The risk of ischaemic stroke in switchers from DOAC versus non-switchers was conflicting. Studies evaluating adherence found no significant changes in adherence after switching from VKA to DOAC, however, an increase in satisfaction with therapy were reported. Reasons for OAC switch, and factors associated with OAC switch were mostly risk factors for stroke and bleeding. Clinical outcomes, adherence and patient-reported outcomes were sparse for switches from DOACs. CONCLUSIONS OAC switching is common in patients with AF and patients often switch back to an OAC they have previously been on. There are aspects of OAC switching that have received little study, especially in switches from DOACs.
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Affiliation(s)
- Adenike R Adelakun
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Science, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Ricky D Turgeon
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Science, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mary A De Vera
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Science, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Kimberlyn McGrail
- Centre for Health Services and Policy Research, The University of British Columbia, Vancouver, British Columbia, Canada
- School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter S Loewen
- Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia, Canada
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Science, The University of British Columbia, Vancouver, British Columbia, Canada
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Bouillon K, Baricault B, Semenzato L, Botton J, Bertrand M, Drouin J, Dray-Spira R, Weill A, Zureik M. Association of Statins for Primary Prevention of Cardiovascular Diseases With Hospitalization for COVID-19: A Nationwide Matched Population-Based Cohort Study. J Am Heart Assoc 2022; 11:e023357. [PMID: 35699173 PMCID: PMC9238639 DOI: 10.1161/jaha.121.023357] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Background There is little evidence on the relationship between statin use and the risk of hospitalization attributable to COVID‐19. Methods and Results The French National Healthcare Data System database was used to conduct a matched‐cohort study. For each adult aged ≥40 years receiving statins for the primary prevention of cardiovascular diseases, one nonuser was randomly selected and matched for year of birth, sex, residence area, and comorbidities. The association between statin use and hospitalization for COVID‐19 was examined using conditional Cox proportional hazards models, adjusted for baseline characteristics, comorbidities, and long‐term medications. Its association with in‐hospital death from COVID‐19 was also explored. All participants were followed up from February 15, 2020, to June 15, 2020. The matching procedure generated 2 058 249 adults in the statin group and 2 058 249 in the control group, composed of 46.6% of men with a mean age of 68.7 years. Statin users had a 16% lower risk of hospitalization for COVID‐19 than nonusers (adjusted hazard ratio [HR], 0.84; 95% CI, 0.81–0.88). All types of statins were significantly associated with a lower risk of hospitalization, with the adjusted HR ranging from 0.75 for fluvastatin to 0.89 for atorvastatin. Low‐ and moderate‐intensity statins also showed a lower risk compared with nonusers (HR, 0.78 [95% CI, 0.71–0.86] and HR, 0.84 [95% CI, 0.80–0.89], respectively), whereas high‐intensity statins did not (HR, 1.01; 95% CI, 0.86–1.18). We found similar results with in‐hospital death from COVID‐19. Conclusions Our findings support that the use of statins for primary prevention is associated with lower risks of hospitalization for COVID‐19 and of in‐hospital death from COVID‐19.
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Affiliation(s)
- Kim Bouillon
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products Saint-Denis France
| | - Bérangère Baricault
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products Saint-Denis France
| | - Laura Semenzato
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products Saint-Denis France
| | - Jérémie Botton
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products Saint-Denis France.,Faculty of Pharmacy Paris-Saclay University Châtenay-Malabry France
| | - Marion Bertrand
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products Saint-Denis France
| | - Jérôme Drouin
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products Saint-Denis France
| | - Rosemary Dray-Spira
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products Saint-Denis France
| | - Alain Weill
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products Saint-Denis France
| | - Mahmoud Zureik
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products Saint-Denis France.,Paris-Saclay University UVSQ CESP-Inserm, Anti-infective evasion and pharmacoepidemiology Montigny le Bretonneux France
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Billioti de Gage S, Bertrand M, Grimaldi S, Zureik M. Intravitreal anti-VEGF use in France: a cross-sectional and longitudinal Nationwide observational study. Acta Ophthalmol 2022; 100:e502-e511. [PMID: 34126649 PMCID: PMC9291173 DOI: 10.1111/aos.14929] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 05/20/2021] [Indexed: 12/20/2022]
Abstract
Purpose To describe the sociodemographic, medical and management characteristics of patients using intravitreal (IVT) anti‐vascular endothelial growth factors (VEGF) in France. Methods An observational study was conducted in patients treated with IVT ranibizumab or aflibercept, aged 18 years or older using the French National Health Insurance Databases covering 99% of the French population. Patients currently treated in 2018 were included in a cross‐sectional approach to describe treatment history over the previous 6 years. Patients newly treated between 2014 and 2018 were included in a longitudinal approach to describe treatment management during up to 6 years of follow‐up. Sociodemographic characteristics and medical history were described in both populations. The analyses were performed at the patient level, as no distinction between the eyes could be made. Results A total of 224 775 current users of IVT anti‐VEGF in 2018 (mean age 78.1 ± 11.3 years, 60% female) and 330 969 new users between 2014 and 2018 (mean age 75.9 ± 12.0 years, 59% female) were included. In both populations cardiovascular comorbidities or risk factors were frequent and the main treatment indications were age‐related macular degeneration and diabetic macular oedema. Among current users of IVT anti‐VEGF in 2018, the mean number of years receiving a treatment was 2.9 ± 2.0 years, with a mean of 13.7 ± 11.8 dispensations. In the longitudinal approach, a 26% increase in IVT anti‐VEGF initiation was observed between 2014 and 2018. For new users, the mean number of years receiving a treatment was 1.6 ± 1.6 and 67% had at least three dispensations within the first three months. A treatment interruption was observed for 83% of new users and occurred on average of 6.1 ± 8.1 months after initiation. The mean number of dispensations was 4.8 ± 2.8 in the first year and 2.2 ± 2.9 in the second year. The mean number of eye monitoring examinations was 6.5 ± 4.7 in the first year and 4.6 ± 4.4 in the second year. Conclusion This study described the real‐world conditions of IVT anti‐VEGF dispensing at the entire French population scale. Less frequent dispensations and surveillance examinations were observed than in monthly schemes applied in registration trials for IVT anti‐VEGF. These results may indicate a lack of systematic monitoring associated with fewer injections and/or clinicians’ preference for more flexible and personalized injection schemes than those originally recommended.
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Affiliation(s)
- Sophie Billioti de Gage
- EPI‐PHARE (French National Agency for Medicines and Health Products Safety (ANSM) and French National Health Insurance (CNAM)) Saint‐Denis France
| | - Marion Bertrand
- EPI‐PHARE (French National Agency for Medicines and Health Products Safety (ANSM) and French National Health Insurance (CNAM)) Saint‐Denis France
| | | | - Mahmoud Zureik
- EPI‐PHARE (French National Agency for Medicines and Health Products Safety (ANSM) and French National Health Insurance (CNAM)) Saint‐Denis France
- University Paris‐Saclay UVSQ, University Paris‐Sud, Inserm Anti‐Infective Evasion and Pharmacoepidemiology, CESP Montigny le Bretonneux France
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Welsh RC, Dehghani P, Lopes R, Wojdyla DM, Aronson R, Granger CB, Windecker S, Vora AN, Vinereanu D, Halvorsen S, Parkhomenko A, Mehran R, Alexander JH, Goodman S. Impact of prior oral anticoagulant use and outcomes on patients from secondary analysis in the AUGUSTUS trial. Open Heart 2022; 9:openhrt-2021-001892. [PMID: 35172988 PMCID: PMC8852719 DOI: 10.1136/openhrt-2021-001892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/11/2022] [Indexed: 11/28/2022] Open
Abstract
Objective Managing antithrombotic therapy in patients with atrial fibrillation (AF) and an acute coronary syndrome (ACS) and/or percutaneous coronary intervention (PCI) is challenging and can be affected by prior oral anticoagulant (OAC) treatment. We examined the relationship between prior OAC use and outcomes in the AUGUSTUS trial. Methods This prespecified secondary analysis is from AUGUSTUS, an open-label, 2-by-2 factorial, RCT to evaluate the safety of apixaban versus vitamin K antagonist (VKA) and aspirin versus placebo in patients with AF and ACS and/or PCI. The primary endpoint, major or clinically relevant non-major bleeding and clinical outcomes were compared in patients receiving (n=2262) or not receiving (n=2352) an OAC prior to enrolment. Results Patients with prior OAC use had more comorbidities, higher CHA2DS2-VASC and HAS-BLED scores, and were more likely enrolled following elective PCI. There was no difference in major or clinically relevant non-major bleeding with or without prior OAC (30 days: 5.1% vs 5.9% (adjusted HR (aHR) 0.82, 95% CI 0.63 to 1.06); 180 days: 13.5% vs 13.5% (aHR 0.98, 95% CI 0.83 to 1.16)). Patients with prior OAC use had a lower risk of death or ischaemic events (30 days: 1.7% vs 2.8% (aHR 0.61, 95% CI 0.41 to 0.92); 180 days: 5.4% vs 7.6% (aHR 0.70, 95% CI 0.55 to 0.88)). No interactions between randomised treatment (apixaban vs VKA, aspirin vs placebo) and prior OAC status were observed for outcomes, apart from apixaban (vs VKA) being associated with a lower risk of myocardial infarction with prior OAC use (180 days: 2.0% vs 3.7% (aHR 0.56, 95% CI 0.33 to 0.91(). Conclusions In AUGUSTUS, prior OAC use was associated with fewer ischaemic events but not more bleeding. In patients with AF and ACS and/or undergoing PCI, clinicians can be assured that the trial results can be applied to patients regardless of their prior OAC status. Trial registration number NCT02415400.
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Affiliation(s)
- Robert C Welsh
- Cardiac Sciences, University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Payam Dehghani
- Medicine, Regina Qu'Appelle Health Region, Regina, Saskatchewan, Canada
| | - Renato Lopes
- Cardiology, Duke Clinical Research Institute and Duke University School of Medicine, Durham, North Carolina, USA
| | - Daniel M Wojdyla
- Cardiology, Duke Clinical Research Institute and Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Stephan Windecker
- Department of Cardiology, Swiss Cardiovascular Center, Bern, Switzerland
| | - Amit N Vora
- Cardiology, Pinnacle Heart and Vascular Institue, Harrisburg, Pennsylvania, USA
| | - Dragos Vinereanu
- Cardiology, Carol Davila University of Medicine and Pharmacy, Bucuresti, Romania
| | - Sigrun Halvorsen
- Cardiology, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Alexander Parkhomenko
- Cardiology, National Scientific Center Academician M D Strazhesko Institute of Cardiology of the National Academy of Medical Sciences of Ukraine, Kiiv, Ukraine
| | - Roxana Mehran
- Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - John H Alexander
- Cardiology, Duke Clinical Research Institute and Duke University School of Medicine, Durham, North Carolina, USA
| | - Shaun Goodman
- Canadian Heart Research Centre, Toronto, Ontario, Canada.,Terrence Donnelly Heart Centre, St Michael's Hospital, Toronto, Ontario, Canada
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Laurendeau C, Goudemand J, Trossaert M, Polack B, Varin R, Godard C, Hadim F, Detournay B. Costs and management of patients with hemophilia A in France: the Hemraude study. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2022; 23:23-32. [PMID: 34236542 DOI: 10.1007/s10198-021-01339-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 06/15/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE The Hemraude study was conducted to describe the profile of patients with HA, disease management, and economic burden in a collective perspective. METHODS This retrospective study was conducted using the French administrative healthcare claims database SNIIRAM/SNDS. Male patients treated for hemophilia A with a long-term illness (ALD) status or invalidity were included in the study between January 1, 2016 and December 31, 2017. Patients were classified in six treatment groups: no treatment, on-demand FVIII, prophylactic FVIII, FVIII in immune tolerance induction (ITI) protocol, on-demand bypassing agents, and prophylactic bypassing agents. Patients treated with FVIII in ITI protocol and those treated with bypassing agents are deemed to have developed inhibitors. HA patients were compared to a control population without coagulation disorder and matched (ratio 1:3) on age and sex. RESULTS A total of 4172 patients were included in the analysis, aged on average 35.2 years, 5.3% had HIV infection, and 8.8% had hepatitis B or C. In 2017, half of the patients received no treatment for HA, 46.7% were treated with FVIII (25% on demand, 20.6% with prophylaxis, and 1.1% ITI), 1.5% with bypassing agents. Patients treated with prophylactic treatments, either inhibitor or non-inhibitor, were less likely to be hospitalized for severe bleeding compared to patients receiving on-demand treatments. The average annual costs for HA management per patient were 72,209.60 €. The highest costs were observed in patients treated with FVIII in ITI protocol and those receiving prophylactic bypassing agents. CONCLUSION Direct costs of HA treatments for HA may be very high especially in the small percentage of patients developing inhibitors or treated with ITI protocol.
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Affiliation(s)
- C Laurendeau
- Cemka, 43, Boulevard Maréchal Joffre, 92340, Bourg-la-Reine, France
| | - J Goudemand
- Department of Hemostasis and Transfusion, Lille University Hospital, Lille, France
| | - M Trossaert
- Hematology Department, University Hospital, Nantes, France
| | - B Polack
- Laboratory TIMC-IMAG, UMRS 5525, Hematology Department, University Hospital, CNRS University Grenoble-Alpes, Grenoble, France
| | - R Varin
- Clinical Pharmacy Department, University Hospital, Rouen, France
| | | | | | - B Detournay
- Cemka, 43, Boulevard Maréchal Joffre, 92340, Bourg-la-Reine, France.
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Billioti de Gage S, Bertrand M, Grimaldi S, Zureik M. Risk of Myocardial Infarction, Stroke, or Death in New Users of Intravitreal Aflibercept Versus Ranibizumab: A Nationwide Cohort Study. Ophthalmol Ther 2022; 11:587-602. [PMID: 35072917 PMCID: PMC8927514 DOI: 10.1007/s40123-021-00451-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/23/2021] [Indexed: 01/26/2023] Open
Abstract
Introduction The risk of thromboembolic events or death in patients treated with intravitreal anti-vascular endothelial growth factor (IVT anti-VEGF) is poorly described on a large scale and by molecule. This study aimed to assess the risk of myocardial infarction (MI), stroke, or death in new users of IVT aflibercept versus ranibizumab in real-world practice. Methods A nationwide cohort study using the French National Health Insurance databases covering 99% of the French population was conducted in patients aged 18 years or older who initiated IVT therapy with ranibizumab or aflibercept between 2014 and 2018. Patients were followed for up to 6 years until December 31, 2019. The risks of MI, stroke, and death were compared in new aflibercept versus ranibizumab users using Kaplan–Meier and multivariate Cox proportional hazards models adjusted on sociodemographic characteristics and cardiovascular disease or risk factors. Subgroup analyses were performed according to history of ischemic heart disease or stroke, diabetes, indication for treatment, sex, age, and number of IVT anti-VEGF injections. Results When compared to new users of ranibizumab (n = 174,794, mean age 76.0 ± 11.9 years, 59.2% female), new users of aflibercept (n = 76,242, mean age 76.6 ± 11.2 years, 59.2% female) did not have an increased risk of MI (n = 1523 incident MI, adjusted hazard ratio [aHR] 1.00; 95% CI 0.89–1.11), stroke (n = 2306 incident strokes, aHR 1.03; 95% CI 0.95–1.13), or death (n = 4135 deaths, aHR 0.98; 95% CI 0.92–1.05). However, a small but non-statistically significant increase in the risk of stroke was observed in new users of aflibercept versus ranibizumab among patients with diabetes (aHR 1.15; 95% CI 0.98–1.35), particularly those with diabetic macular edema (aHR 1.20; 95% CI 1.00–1.44). The remaining subgroup analyses did not change the results. Conclusion Aflibercept and ranibizumab appear to have similar safety profiles with respect to the risk of MI, stroke, or death under real-world conditions of use. Supplementary Information The online version contains supplementary material available at 10.1007/s40123-021-00451-1.
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Affiliation(s)
- Sophie Billioti de Gage
- EPI-PHARE (French National Agency for Medicines and Health Products Safety (ANSM) and French National Health Insurance (CNAM)), 143/147 Boulevard Anatole France, 93 285, Saint-Denis, France.
| | - Marion Bertrand
- EPI-PHARE (French National Agency for Medicines and Health Products Safety (ANSM) and French National Health Insurance (CNAM)), 143/147 Boulevard Anatole France, 93 285, Saint-Denis, France
| | - Sébastien Grimaldi
- Ophthalmologic Center, 24/26 Boulevard Aristide Briand, 86 100, Châtellerault, France
| | - Mahmoud Zureik
- EPI-PHARE (French National Agency for Medicines and Health Products Safety (ANSM) and French National Health Insurance (CNAM)), 143/147 Boulevard Anatole France, 93 285, Saint-Denis, France.,University Paris-Saclay, UVSQ, University Paris-Sud, Inserm, Anti-Infective Evasion and Pharmacoepidemiology, CESP, 78 180, Montigny le Bretonneux, France
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Bouillon K, Baricault B, Botton J, Jabagi MJ, Bertrand M, Semenzato L, Le Vu S, Drouin J, Dray-Spira R, Weill A, Zureik M. Effectiveness of BNT162b2, mRNA-1273, and ChAdOx1-S vaccines against severe covid-19 outcomes in a nationwide mass vaccination setting: cohort study. BMJ MEDICINE 2022; 1:e000104. [PMID: 36936561 PMCID: PMC9978755 DOI: 10.1136/bmjmed-2021-000104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 05/11/2022] [Indexed: 11/07/2022]
Abstract
Objective To estimate the effectiveness of the three covid-19 vaccines by Pfizer-BioNTech (BNT162b2), Moderna (mRNA-1273), and Oxford-AstraZeneca (ChAdOx1-S) in people after receiving two doses. Design Cohort study. Setting Nationwide, population based data in France, from the French National Health Data System (Système National des Données de Santé), between 27 December 2020 and 30 April 2021. Participants Adults aged ≥50 years receiving a first dose of BNT162b2, mRNA-1273, or ChAdOx1-S were randomly selected (1:1) and matched on the date of vaccination with one unvaccinated control. Individuals were matched on year of birth, sex, region of residence, and residence in a nursing home (for individuals aged ≥75 years). All individuals were followed up until 20 August 2021. Main outcome measures Primary outcome measure was vaccine effectiveness estimated at least 14 days after the second dose against covid-19 related hospital admission using Cox proportional hazards models adjusted for baseline characteristics and comorbidities. Vaccine effectiveness against covid-19 related death in hospital was also investigated. Results 11 256 832 vaccinated individuals were included in the study (63.6% (n=7 161 658) with the BNT162b2 vaccine, 7.6% (n=856 599) with the mRNA-1273 vaccine, and 28.8% (n=3 238 575) with the ChAdOx1-S vaccine), along with 11 256 832 matched unvaccinated controls. During follow-up (up to 20 August 2021), 43 158 covid-19 related hospital admissions and 7957 covid-19 related deaths in hospital were registered. Compared with unvaccinated controls, vaccine effectiveness of two doses against covid-19 related hospital admission was 91% (95% confidence interval 91% to 92%), 95% (93% to 96%), and 91% (89% to 94%) for the BNT162b2, mRNA-1273, and ChAdOx1-S vaccines, respectively. Similar results were observed for vaccine effectiveness of two doses against covid-19 related deaths in hospital (BNT162b2, 91% (90% to 93%); mRNA-1273, 96% (92% to 98%); and ChAdOx1 nCoV-19, 88% (68% to 95%)). At 5-6 months after receiving the second dose of vaccine, effectiveness remained high at 94% (92% to 95%) for the BNT162b2 vaccine and 98% (93% to 100%) for the mRNA-1273 vaccine. Vaccine effectiveness of ChAdOx1-S estimated at 3-4 months was 90% (63% to 97%). All three vaccines remained effective at the time of circulation of the delta variant of SARS-CoV-2 between 1 July and 20 August 2021 (effectiveness between 89% and 95%). Conclusions These findings provide evidence indicating that two doses of ChAdOx1-S is as effective as two doses of mRNA vaccines in France against the alpha and delta variants of SARS-CoV-2. The effectiveness of ChAdOx1-S should be further examined with a longer follow-up and in the light of the circulation of new SARS-CoV-2 variants of concern.
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Affiliation(s)
- Kim Bouillon
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products, Saint-Denis, France
| | - Bérangère Baricault
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products, Saint-Denis, France
| | - Jérémie Botton
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products, Saint-Denis, France
- Faculty of Pharmacy, Paris-Saclay University, Châtenay-Malabry, France
| | - Marie-Joëlle Jabagi
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products, Saint-Denis, France
| | - Marion Bertrand
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products, Saint-Denis, France
| | - Laura Semenzato
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products, Saint-Denis, France
| | - Stéphane Le Vu
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products, Saint-Denis, France
| | - Jérôme Drouin
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products, Saint-Denis, France
| | - Rosemary Dray-Spira
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products, Saint-Denis, France
| | - Alain Weill
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products, Saint-Denis, France
| | - Mahmoud Zureik
- EPI-PHARE Scientific Interest Group in Epidemiology of Health Products, Saint-Denis, France
- CESP-Inserm, Anti-infective evasion and pharmacoepidemiology, Paris-Saclay University, UVSQ, Montigny le Bretonneux, France
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Escobar C, Barrios V, Lip GYH, Amin AN, Auladell-Rispau A, Santero M, Salazar J, Requeijo C. Effectiveness and Safety of Dabigatran Compared to Vitamin K Antagonists in Non-Asian Patients with Atrial Fibrillation: A Systematic Review and Meta-Analysis. Clin Drug Investig 2021; 41:941-953. [PMID: 34643934 DOI: 10.1007/s40261-021-01091-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND OBJECTIVE Real-life data about the use of dabigatran in patients with non-valvular atrial fibrillation are warranted. The objective of this systematic review and meta-analysis was to assess the effectiveness and safety of dabigatran, globally and stratified by dose (110/150 mg twice daily), vs vitamin K antagonists in non-Asian patients with non-valvular atrial fibrillation from "real-world" studies. METHODS A systematic review was performed according to Cochrane methodological standards. The results were reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses Statement) statement. The ROBINS-I tool was used to assess bias risk. MEDLINE and EMBASE, from inception up to May 2021, using appropriate controlled vocabulary and free search terms, were searched. RESULTS: A total of 34 studies, corresponding to 37 articles involving 1,600,722 participants (1,154,283 exposed to vitamin K antagonists and 446,439 to dabigatran) were eligible for this review. Dabigatran 150 mg reduced the risk of ischemic stroke compared with vitamin K antagonists, with a 14% risk reduction (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.74-0.98). Globally, dabigatran reduced the risk of all-cause mortality compared with vitamin K antagonists (HR 0.76, 95% CI 0.69-0.84), with a greater effect observed with dabigatran 150 mg (HR 0.65, 95% CI 0.58-0.73). There was a trend towards a lower risk of myocardial infarction with dabigatran 150 mg (HR 0.86, 95% CI 0.71-1.04). Regarding the primary safety outcomes, dabigatran (either at a dose of 150 mg or 110 mg) reduced the risk of major bleeding compared with vitamin K antagonists (HR 0.77, 95% CI 0.70-0.83), as well as the risk of intracranial bleeding (HR 0.44, 95% CI 0.39-0.50) and fatal bleeding (HR 0.76, 95% CI 0.60-0.95), but with a slight increase in gastrointestinal bleeding risk (HR 1.16, 95% CI 1.08-1.26). CONCLUSIONS Dabigatran has a favorable impact on effectiveness and safety outcomes compared with vitamin K antagonists in real-world populations.
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Affiliation(s)
- Carlos Escobar
- Servicio de Cardiología, Hospital Universitario La Paz, Paseo de la Castellana 261, 28046, Madrid, Spain.
| | - Vivencio Barrios
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Gregory Y H Lip
- University of Liverpool and Liverpool Heart and Chest, Liverpool, UK
| | - Alpesh N Amin
- Department of Medicine, School of Medicine, University of California Irvine, Irvine, CA, USA
| | - Ariadna Auladell-Rispau
- Grup de Recerca d'Epidemiologia Clínica i Serveis Sanitaris, Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Marilina Santero
- Grup de Recerca d'Epidemiologia Clínica i Serveis Sanitaris, Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Josefina Salazar
- Grup de Recerca d'Epidemiologia Clínica i Serveis Sanitaris, Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Carolina Requeijo
- Grup de Recerca d'Epidemiologia Clínica i Serveis Sanitaris, Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), Barcelona, Spain
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9
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Inappropriate Use of Oral Antithrombotic Combinations in an Outpatient Setting and Associated Risks: A French Nationwide Cohort Study. J Clin Med 2021; 10:jcm10112367. [PMID: 34072261 PMCID: PMC8198137 DOI: 10.3390/jcm10112367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 05/20/2021] [Accepted: 05/25/2021] [Indexed: 12/28/2022] Open
Abstract
With the increase in prevalence of cardiovascular diseases, multimorbidity, and medical progress, oral antithrombotic (AT) combinations are increasingly prescribed. The aims of this study were to estimate the incidence of oral AT combinations, their appropriateness (defined as indications compliant with guidelines), and the related risk of major bleeding (i.e., leading to hospitalization) or death, among new users. We conducted a 5-year historical cohort study, using the French national healthcare database, including all individuals ≥ 45 years old with a first delivery of oral ATs between 1 January 2013 and 31 December 2017. The cumulative incidence of oral AT combinations was estimated with the Fine and Gray method, taking into account the competitive risk of death. We compared the cumulative incidence of major bleeding according to the type of oral AT treatment initiated at study entry (monotherapy or oral AT combinations). During the study period, 22,220 individuals were included (mean (SD) age 68 (12) years). The cumulative incidence of oral AT combinations at 5 years was 27.8% (95% confidence interval (CI) 26.8–28.9). Overall, 64% of any oral AT combinations did not comply with guidelines. The cumulative incidence of major bleeding and death in the whole cohort at 5 years was 4.1% (95% CI 3.7–4.6) and 10.8% (95% CI 10.1–11.6), respectively. Risk of major bleeding increased among individuals with oral AT combinations versus oral AT monotherapy at study entry (subdistribution hazard ratio sHR: 2.16 (1.01–4.63)); with no difference in terms of death. The use of oral AT combinations among oral AT users is frequent, often inappropriately prescribed, and associated with an increased risk of major bleeding.
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10
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Weaver J, Shoaibi A, Truong HQ, Larbi L, Wu S, Wildgoose P, Rao G, Freedman A, Wang L, Yuan Z, Barnathan E. Comparative Risk Assessment of Severe Uterine Bleeding Following Exposure to Direct Oral Anticoagulants: A Network Study Across Four Observational Databases in the USA. Drug Saf 2021; 44:479-497. [PMID: 33651368 PMCID: PMC7994226 DOI: 10.1007/s40264-021-01060-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 10/26/2022]
Abstract
BACKGROUND Antithrombotic therapies are associated with an increased bleeding risk. Abnormal uterine bleeding data have been reported in clinical trials of patients with venous thromboembolism (VTE), but data are limited for patients with atrial fibrillation (AF). OBJECTIVE Using real-world data from four US healthcare databases (October 2010 to December 2018), we compared the occurrence of severe uterine bleeding among women newly exposed to rivaroxaban, apixaban, dabigatran, and warfarin stratified by indication. METHODS To reduce potential confounding, patients in comparative cohorts were matched on propensity scores. Treatment effect estimates were generated using Cox proportional hazard models for each indication, in each database, and only for pairwise comparisons that met a priori study diagnostics. If estimates were homogeneous (I2 < 40%), a meta-analysis across databases was performed and pooled hazard ratios reported. RESULTS Data from 363,919 women newly exposed to a direct oral anticoagulant or warfarin with a prior diagnosis of AF (60.8%) or VTE (39.2%) were analyzed. Overall incidence of severe uterine bleeding was low in the populations exposed to direct oral anticoagulants, although relatively higher in the younger VTE population vs the AF population (unadjusted incidence rates: 2.8-33.7 vs 1.9-10.0 events/1000 person-years). In the propensity score-matched AF population, a suggestive, moderately increased risk of severe uterine bleeding was observed for rivaroxaban relative to warfarin [hazard ratios and 95% confidence intervals from 0.83 (0.27-2.48) to 2.84 (1.32-6.23) across databases with significant heterogeneity], apixaban [pooled hazard ratio 1.45 (0.91-2.28)], and dabigatran [2.12 (1.01-4.43)], which were sensitive to the time-at-risk period. In the propensity score-matched VTE population, a consistent increased risk of severe uterine bleeding was observed for rivaroxaban relative to warfarin [2.03 (1.19-3.27)] and apixaban [2.25 (1.45-3.41)], which were insensitive to the time-at-risk period. CONCLUSIONS For women who need antithrombotic therapy, personalized management strategies with careful evaluation of benefits and risks are required. CLINICALTRIALS. GOV REGISTRATION NCT04394234; registered in May 2020.
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Affiliation(s)
- James Weaver
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Azza Shoaibi
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Huy Q Truong
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Leila Larbi
- Janssen Research & Development, LLC, Raritan, NJ, USA
| | - Shujian Wu
- Janssen Research & Development, LLC, Horsham, PA, USA
| | - Peter Wildgoose
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Gowtham Rao
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Amy Freedman
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Lu Wang
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Zhong Yuan
- Janssen Research & Development, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA.
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11
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Lorenzoni V, Pirri S, Turchetti G. Cost-Effectiveness of Direct Non-Vitamin K Oral Anticoagulants Versus Vitamin K Antagonists for the Management of Patients with Non-Valvular Atrial Fibrillation Based on Available "Real-World" Evidence: The Italian National Health System Perspective. Clin Drug Investig 2021; 41:255-267. [PMID: 33587284 PMCID: PMC7946694 DOI: 10.1007/s40261-021-01002-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND OBJECTIVE The increasing availability of real-world evidence (RWE) about safety and effectiveness of direct non-vitamin K oral anticoagulants (DOACs) for the management of atrial fibrillation (AF) offers the opportunity to better understand the clinical and economic implications of DOACs versus vitamin K antagonists (VKAs). The objective of this study was to compare the economic implications of DOACs and VKAs using data from real-world evidence in patients with AF. METHODS A Markov model simulating the lifetime course of patients diagnosed with non-valvular AF was used to evaluate the cost-effectiveness of DOACs (i.e., rivaroxaban, dabigatran and apixaban) versus VKAs from the Italian National Health System (INHS) perspective. The model was made up of data from the literature and a meta-analysis of RWE on the incidence of stroke/systemic embolism (SE), major bleeding (MB), intracranial haemorrhage (ICH) and all-cause mortality (ACM); direct costs included drug costs, costs for drug monitoring, and management of events from official national lists. One-way and probabilistic sensitivity analyses (PSA) were used to assess the robustness of the results. RESULTS Results from the meta-analysis showed that apixaban had a high probability of being the most effective for stroke/SE, MB and ACM. Despite their higher acquisition costs, the cost-effectiveness analysis showed all DOACs involved a saving when compared with VKAs, with per-patient savings ranging between €4647 (rivaroxaban) to €6086 (apixaban). Moreover, all DOACs indicated a gain both in quality-adjusted life-years and life-years. According to PSA, findings related to apixaban were consistent, while for dabigatran and rivaroxaban PSA revealed a higher degree of uncertainty. CONCLUSIONS The beneficial effect of DOACs on containing events showed in RWE had the potential to offset drug-related costs, thus improving the sustainability of treatment for non-valvular AF in daily clinical practice.
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Affiliation(s)
- Valentina Lorenzoni
- Institute of Management, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà, 33, 56127, Pisa, Italy.
| | - Salvatore Pirri
- Institute of Management, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà, 33, 56127, Pisa, Italy
| | - Giuseppe Turchetti
- Institute of Management, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà, 33, 56127, Pisa, Italy
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12
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Domek M, Gumprecht J, Ding WY, Lip GYH, Lane DA. Practice-derived data on non-vitamin K antagonist oral anticoagulant therapy to complement observations from randomized trials. Eur Heart J Suppl 2020; 22:I1-I12. [PMID: 33093817 PMCID: PMC7556745 DOI: 10.1093/eurheartj/suaa100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Anticoagulation is fundamental in the management of patients with atrial fibrillation (AF). The study aims to provide a comparative review of the major phase III randomized clinical trials (RCTs) and real-world data (RWD) from reliable, high-grade Phase IV studies that assess the efficacy and safety of non-vitamin K antagonist oral anticoagulants (NOACs) vs. vitamin K antagonists (VKAs). Observational studies based on nationwide or health insurance database records on the use of NOACs vs. VKAs in patients with AF were included. We performed a comparison of the efficacy and safety characteristics associated with NOACs vs. VKAs in RCTs and RWD. Although RCTs provide strong support for evidence-based practice, RWD may be used to reflect the broader picture of various clinical settings, provide supplementary insight and fulfil knowledge gaps. Both study types confirmed the safety and efficacy of NOACs in preventing stroke and thromboembolism in patients with AF. In comparison to VKAs, NOACs were associated with reduced risk of ischaemic events and lower rates of adverse events such as major bleeding or intracranial haemorrhage. Administration of NOACs might be associated with increased risk of dose-related gastrointestinal bleeding and myocardial ischaemic events, especially in the early treatment period after switching from VKAs. Special care should be taken in challenging clinical situations like severe renal or hepatic impairment when the treatment regimen needs to be considered individually. Randomized clinical trial and RWD studies are complementary and present comparable findings, affirming that NOACs are safe and effective for anticoagulation of patients with AF in daily clinical practice.
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Affiliation(s)
- Magdalena Domek
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Internal Diseases, Diabetology and Nephrology, Medical University of Silesia, Zabrze, Poland
| | - Jakub Gumprecht
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiology, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland
| | - Wern Yew Ding
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Department of Cardiology, Medical University of Silesia, Silesian Centre for Heart Diseases, Zabrze, Poland.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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13
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Wang YP, Kehar R, Iansavitchene A, Lazo-Langner A. Bleeding Risk in Nonvalvular Atrial Fibrillation Patients Receiving Direct Oral Anticoagulants and Warfarin: A Systematic Review and Meta-Analysis of Observational Studies. TH OPEN 2020; 4:e145-e152. [PMID: 32676543 PMCID: PMC7358046 DOI: 10.1055/s-0040-1714918] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/26/2020] [Indexed: 02/07/2023] Open
Abstract
Introduction In randomized trials in atrial fibrillation (AF) patients on direct oral anticoagulants (DOACs) have a lower risk of bleeding compared with warfarin. However, data from randomized trials may not extrapolate to general population. We aimed to determine the risk of bleeding in patients on DOACs in observational studies. Materials and Methods Observational studies from 1990 to January 2019 were included. A pooled effect hazard ratio (HR) was calculated with a random effects model using the generic inverse variance method. Subgroup analyses according to previous anticoagulants exposure, study type, funding source, and DOAC type (direct thrombin inhibitors vs. factor Xa inhibitors) were conducted. Results A total of 35 studies comprising 2,356,201 patients were included. The average pooled HR for observational data was 0.78 (95% confidence interval [CI] 0.71, 0.85). There were no statistically significant differences in pooled HR by previous exposure to anticoagulants, DOAC type (direct thrombin vs. factor Xa inhibitors), study type, and funding source. Among patients receiving factor Xa inhibitors, patients on apixaban had a lower risk of bleeding compared with warfarin (HR 0.60, 95% CI 0.50, 0.71, p < 0.001) in contrast to those on rivaroxaban (HR 0.98, 95% CI 0.91, 1.06, p = 0.60). Conclusion In observational studies, AF patients on DOACs experience less bleeding events compared with warfarin; however, apixaban and dabigatran, but not rivaroxaban, have a lower risk of bleeding than warfarin.
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Affiliation(s)
- Yimin Pearl Wang
- Division of Hematology, Department of Medicine, Western University, London, Ontario, Canada
| | - Rohan Kehar
- Division of Hematology, Department of Medicine, Western University, London, Ontario, Canada
| | - Alla Iansavitchene
- Library Services, London Health Sciences Centre, London, Ontario, Canada
| | - Alejandro Lazo-Langner
- Division of Hematology, Department of Medicine, Western University, London, Ontario, Canada.,Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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14
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Van Ganse E, Danchin N, Mahé I, Hanon O, Jacoud F, Nolin M, Dalon F, Lefevre C, Cotté FE, Gollety S, Falissard B, Belhassen M, Steg PG. Comparative Safety and Effectiveness of Oral Anticoagulants in Nonvalvular Atrial Fibrillation: The NAXOS Study. Stroke 2020; 51:2066-2075. [PMID: 32539675 PMCID: PMC7306262 DOI: 10.1161/strokeaha.120.028825] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: The effects of direct oral anticoagulants in nonvalvular atrial fibrillation should be assessed in actual conditions of use. France has near-universal healthcare coverage with a unified healthcare information system, allowing large population-based analyses. NAXOS (Evaluation of Apixaban in Stroke and Systemic Embolism Prevention in Patients With Nonvalvular Atrial Fibrillation) aimed to compare the safety, effectiveness, and mortality of apixaban with vitamin K antagonists (VKAs), rivaroxaban, and dabigatran, in oral anticoagulant-naive patients with nonvalvular atrial fibrillation. Methods: This was an observational study using French National Health System claims data and including all adults with nonvalvular atrial fibrillation who initiated oral anticoagulant between 2014 and 2016. Outcomes of interest were major bleeding events leading to hospitalization (safety), stroke and systemic thromboembolic events (effectiveness), and all-cause mortality. Four approaches were used for comparative analyses: matching on propensity score (PS; 1:n); as a sensitivity analysis, matching on high-dimensional PS; adjustment on PS; and adjustment on known confounders. For each outcome, cumulative incidence rates accounting for competing risks of death were estimated. Results: Overall, 321 501 patients were analyzed, of whom 35.0%, 27.2%, 31.1%, and 6.6% initiated VKAs, apixaban, rivaroxaban, and dabigatran, respectively. Apixaban was associated with a lower PS–matched risk of major bleeding compared with VKAs (hazard ratio [HR], 0.43 [95% CI, 0.40–0.46]) and rivaroxaban (HR, 0.67 [95% CI, 0.63–0.72]), but not dabigatran (HR, 0.93 [95% CI, 0.81–1.08]). Apixaban was associated with a lower risk of stroke and systemic thromboembolic event compared with VKAs (HR, 0.60 [95% CI, 0.56–0.65]), but not rivaroxaban (HR, 1.05 [95% CI, 0.97–1.15]) or dabigatran (HR, 0.93 [95% CI, 0.78–1.11]). All-cause mortality was lower with apixaban than with VKAs, but not lower than with rivaroxaban or dabigatran. Conclusions: Apixaban was associated with superior safety, effectiveness, and lower mortality than VKAs; with superior safety than rivaroxaban and similar safety to dabigatran; and with similar effectiveness when compared with rivaroxaban or dabigatran. These observational data suggest potentially important differences in outcomes between direct oral anticoagulants, which should be explored in randomized trials.
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Affiliation(s)
- Eric Van Ganse
- PELyon (Pharmaco Epidemiology Lyon), Lyon, France (E.V.G., F.J., M.N., F.D., M.B.).,Department of Respiratory Medicine, Croix Rousse University Hospital, Lyon, France (E.V.G.).,HESPER (Health Services and Performance Research) 7425, University Claude Bernard Lyon 1, Lyon, France (E.V.G.)
| | - Nicolas Danchin
- Hôpital Européen Georges Pompidou, Department of Cardiology, Paris, France (N.D.)
| | - Isabelle Mahé
- Hôpital Louis Mourier, AP-HP, Department of Internal Medicine, Colombes, France (I.M.).,Université de Paris, Department of Innovative Therapies in Haemostasis, INSERM, Paris, France (I.M.)
| | - Olivier Hanon
- Université Paris Descartes, Sorbonne Paris Cité, Equipe d'accueil, 4468, Paris, France (O.H.).,Hôpital Broca, Department of Geriatrics, AP-HP, Paris, France (O.H.)
| | - Flore Jacoud
- PELyon (Pharmaco Epidemiology Lyon), Lyon, France (E.V.G., F.J., M.N., F.D., M.B.)
| | - Maëva Nolin
- PELyon (Pharmaco Epidemiology Lyon), Lyon, France (E.V.G., F.J., M.N., F.D., M.B.)
| | - Faustine Dalon
- PELyon (Pharmaco Epidemiology Lyon), Lyon, France (E.V.G., F.J., M.N., F.D., M.B.)
| | - Cinira Lefevre
- Bristol-Myers Squibb, Rueil-Malmaison, France (C.L., F.-E.C., S.G.)
| | | | - Sabrina Gollety
- Bristol-Myers Squibb, Rueil-Malmaison, France (C.L., F.-E.C., S.G.)
| | | | - Manon Belhassen
- PELyon (Pharmaco Epidemiology Lyon), Lyon, France (E.V.G., F.J., M.N., F.D., M.B.)
| | - Ph Gabriel Steg
- Department of Cardiology, Hôpital Bichat, AP-HP, Paris, France (P.G.S.).,Université de Paris, Paris, France (P.G.S.).,INSERM U-1148, Paris, France (P.G.S.)
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15
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Franchino‐Elder J, Gilligan A, Song X, Hartaigh BO, Henriques C, Sainski‐Nguyen A, Wang C. Comparison of healthcare costs among patients with non‐valvular atrial fibrillation treated with warfarin who switched to a novel oral anticoagulant. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2020. [DOI: 10.1111/jphs.12352] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | | | - Xue Song
- IBM Watson Health Cambridge MA USA
| | | | | | | | - Cheng Wang
- Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield CTUSA
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16
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Risk of Major Gastrointestinal Bleeding With New vs Conventional Oral Anticoagulants: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2020; 18:792-799.e61. [PMID: 31195162 DOI: 10.1016/j.cgh.2019.05.056] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/21/2019] [Accepted: 05/31/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is controversy over whether use of non-vitamin K antagonist oral anticoagulants (NOACs) associates with increased risk of major gastrointestinal bleeding (GIB) compared with conventional therapies (such as vitamin K antagonists or anti-platelet agents). We performed a systematic review and meta-analysis of data from randomized controlled trials and high-quality real-world studies. METHODS We performed a systematic search of the MEDLINE, EMBASE, Cochrane Library, and ClinicalTrials.gov Website databases (through Oct 12, 2018) for randomized controlled trials and high-quality real-world studies that reported major GIB events in patients given NOACs or conventional therapy. Relative risks (RRs) for randomized controlled trials and adjusted hazard ratios (aHRs) for real-world studies were calculated separately using random-effects models. RESULTS We analyzed data from 43 randomized controlled trials (183,752 patients) and 41 real-world studies (1,879,428 patients). The pooled major rates of GIB for patients on NOACs (1.19%) vs conventional treatment (0.92%) did not differ significantly (RR from randomized controlled trials, 1.09; 95% CI, 0.91-1.31 and aHR from real-world studies, 1.02; 95% CI, 0.94-1.10; Pinteraction=.52). Rivaroxaban, but not other NOACs, was associated with an increased risk for major GIB (RR from randomized controlled trials, 1.39; 95% CI, 1.17-1.65 and aHR from real-world studies, 1.14; 95% CI, 1.04-1.23; Pinteraction = .06). Analyses of subgroups, such as patients with different indications, dosage, or follow-up time, did not significantly affect results. Meta-regression analysis failed to detect any potential confounding to impact the primacy outcome. CONCLUSIONS In a systematic review and meta-analysis of data from randomized controlled trials and real-world studies, we confirmed that there is no significant difference in risk of major GIB between patients receiving NOACs vs conventional treatment. Rivaroxaban users had a 39% increase in risk for major GIB.
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17
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Oka S, Wakui M, Fujimori Y, Kuroda Y, Nakamura S, Kondo Y, Nakagawa T, Katagiri H, Murata M. Application of clot-fibrinolysis waveform analysis to assessment of in vitro effects of direct oral anticoagulants on fibrinolysis. Int J Lab Hematol 2020; 42:292-298. [PMID: 32078255 DOI: 10.1111/ijlh.13168] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/11/2020] [Accepted: 02/03/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Acceleration of fibrinolysis by direct oral anticoagulants (DOACs) has been reported by several groups, suggesting contribution of not only anticoagulant but also fibrinolytic effects to the therapeutic efficacy. The present study aims to evaluate the usability of clot-fibrinolysis waveform analysis (CFWA) for assessment of in vitro effects of DOACs on fibrinolysis. METHODS The experimental conditions were optimized according to how t-PA concentrations and a time length after t-PA adjustment affect parameters of CFWA. Addition of the activated partial thromboplastin time (APTT) reagent followed by that of calcium and t-PA was done to obtain clotting and fibrinolytic reaction curves which were mathematically differentiated for CFWA (APTT-CFWA). The positive and negative modes of waveforms were defined as the direction toward fibrin generation and that toward fibrin degradation, respectively. The maximum positive and negative values (Maxp 1 and Maxn 1) correspond to the maximum coagulation velocity and the maximum fibrinolysis velocity, respectively. Plasma spiked with each of DOACs (rivaroxaban, apixaban, edoxaban, and dabigatran) was subjected to APTT-CFWA. RESULTS Optimization of t-PA use was based on Maxn 1. Roughly biphasic effects of rivaroxaban and dabigatran but not apixaban or edoxaban on fibrinolysis were observed through Maxn 1 and the fibrinolysis peak time, which was defined as a time length from the time when Maxp 1 (Maxp 1 time) to the time when Maxn 1 appears (Maxn 1 time). CONCLUSION The results suggest the usability of CFWA for assessment of DOAC effects and provide insights into relevance of anticoagulation to therapeutic efficacy and bleeding risk from the perspective of fibrinolysis.
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Affiliation(s)
- Shusaku Oka
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Masatoshi Wakui
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yuta Fujimori
- Office of Clinical Laboratory Technology, Keio University Hospital, Tokyo, Japan
| | - Yuko Kuroda
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Shoko Nakamura
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | - Yoshino Kondo
- Clinical Laboratory, Keio University Hospital, Tokyo, Japan
| | | | | | - Mitsuru Murata
- Department of Laboratory Medicine, Keio University School of Medicine, Tokyo, Japan
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18
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Blin P, Dureau-Pournin C, Bénichou J, Cottin Y, Mismetti P, Abouelfath A, Lassalle R, Droz C, Moore N. Comparative Real-Life Effectiveness and Safety of Dabigatran or Rivaroxaban vs. Vitamin K Antagonists: A High-Dimensional Propensity Score Matched New Users Cohort Study in the French National Healthcare Data System SNDS. Am J Cardiovasc Drugs 2020; 20:81-103. [PMID: 31254174 DOI: 10.1007/s40256-019-00359-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Clinical trials have indicated that the direct-acting oral anticoagulants dabigatran and rivaroxaban have better risk/benefit profiles than do vitamin K antagonists (VKAs) for stroke prevention in non-valvular atrial fibrillation (NVAF). OBJECTIVE Our objective was to compare the 1-year real-life risk of major clinical events with dabigatran or rivaroxaban versus VKAs for NVAF. METHODS This was a high-dimensional propensity score (hdPS)-matched cohort study of new users of dabigatran, rivaroxaban or VKAs for NVAF in the French national healthcare systems database in 2013 followed-up for 1 year [22]. Hazard ratios (HRs) with 95% confidence intervals (CIs) for clinical events and death were determined during exposure. RESULTS In 2013, a total of 103,101 new anticoagulant users had definite NVAF: 44,653 VKA, 27,060 dabigatran, and 31,388 rivaroxaban. In matched populations, HRs were as follows for dabigatran versus VKAs (20,489 per group): stroke and systemic embolism (SSE) 0.75 (95% CI 0.63-0.88), clinically relevant bleeding (CRB) 0.58 (95% CI 0.51-0.66), hemorrhagic stroke (HS) 0.22 (95% CI 0.14-0.36), gastrointestinal bleeding (GIB) 0.98 (95% CI 0.80-1.19), acute coronary syndrome (ACS) 0.79 (95% CI 0.65-0.95), death 0.74 (95% CI 0.67-0.82), composite (any of the above) 0.71 (95% CI 0.66-0.76). For matched rivaroxaban versus VKA (23,053 per group) HRs were as follows: SSE 0.98 (95% CI 0.85-1.14), CRB 0.83 (95% CI 0.75-0.92), HS 0.65 (95% CI 0.49-0.87), GIB 1.08 (95% CI 0.90-1.30), ACS 0.84 (95% CI 0.71-1.00), death 0.77 (95% CI 0.71-0.84), composite 0.84 (95% CI 0.79-0.89). Numbers needed to treat to observe one fewer death were 49 ± 0.05 with dabigatran or rivaroxaban versus VKAs. CONCLUSION Consistent with results from clinical trials and other observational studies, dabigatran and rivaroxaban were at least as effective and safer than VKAs for the prevention of thromboembolic events in NVAF over 1 year in the French population. STUDY REGISTRATION European Medicines Agency EUPAS 13017 (www.encepp.eu) Clinicaltrials.gov id NCT02785354.
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Affiliation(s)
- Patrick Blin
- Bordeaux PharmacoEpi, INSERM CIC 1401 Université de Bordeaux, CHU de Bordeaux, 146 Rue Leo Saignat, 33076, Bordeaux, France
| | - Caroline Dureau-Pournin
- Bordeaux PharmacoEpi, INSERM CIC 1401 Université de Bordeaux, CHU de Bordeaux, 146 Rue Leo Saignat, 33076, Bordeaux, France
| | - Jacques Bénichou
- INSERM U1219, Université de Bordeaux, Bordeaux, France
- CHU de Rouen, Unité de Biostatistique, 1 rue de Germont, 76031, Rouen, France
| | - Yves Cottin
- CHU de Dijon, Service de Cardiologie, 14 rue Gaffarel, 21079, Dijon cedex, France
| | - Patrick Mismetti
- Hôpital Nord, Unité de Recherche Clinique Innovation et Pharmacologie, 120 avenue Albert Raimond, 42055, Saint-Etienne, France
| | - Abdelilah Abouelfath
- Bordeaux PharmacoEpi, INSERM CIC 1401 Université de Bordeaux, CHU de Bordeaux, 146 Rue Leo Saignat, 33076, Bordeaux, France
| | - Regis Lassalle
- Bordeaux PharmacoEpi, INSERM CIC 1401 Université de Bordeaux, CHU de Bordeaux, 146 Rue Leo Saignat, 33076, Bordeaux, France
| | - Cécile Droz
- Bordeaux PharmacoEpi, INSERM CIC 1401 Université de Bordeaux, CHU de Bordeaux, 146 Rue Leo Saignat, 33076, Bordeaux, France
| | - Nicholas Moore
- Bordeaux PharmacoEpi, INSERM CIC 1401 Université de Bordeaux, CHU de Bordeaux, 146 Rue Leo Saignat, 33076, Bordeaux, France.
- INSERM U1219, Université de Bordeaux, Bordeaux, France.
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Başaran Ö, Biteker M. Switching among oral anticoagulants: is it logical? Curr Med Res Opin 2020; 36:177-178. [PMID: 31462076 DOI: 10.1080/03007995.2019.1662196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Özcan Başaran
- Department of Cardiology, Mugla Sitki Kocman University, Education and Research Hospital, Muğla, Turkey
| | - Murat Biteker
- Department of Cardiology, Faculty of Medicine, Mugla Sitki Kocman University, Muğla, Turkey
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Hellfritzsch M, Adelborg K, Damkier P, Paaske Johnsen S, Hallas J, Pottegård A, Grove EL. Effectiveness and safety of direct oral anticoagulants in atrial fibrillation patients switched from vitamin K antagonists: A systematic review and meta-analysis. Basic Clin Pharmacol Toxicol 2020; 126:21-31. [PMID: 31240841 PMCID: PMC6973083 DOI: 10.1111/bcpt.13283] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 06/20/2019] [Indexed: 02/06/2023]
Abstract
A substantial proportion of atrial fibrillation patients initiating direct oral anticoagulants (DOAC) are vitamin K antagonists (VKA)-experienced, for example switchers from VKA to DOAC. With this study, we aimed to summarize available evidence on the effectiveness and safety of DOAC vs VKA in real-life VKA-experienced atrial fibrillation patients. We searched EMBASE, MEDLINE and Cochrane Library systematically for English-language studies indexed any time before October 2018. We included studies of VKA-experienced atrial fibrillation patients initiating DOAC therapy, with continued VKA therapy as comparator. Outcomes included arterial thromboembolism and bleeding. When appropriate, meta-analysis was performed by calculating pooled, weighted and adjusted hazard ratios (aHR) with 95% confidence intervals (CI). Eight cohort studies comparing VKA-experienced DOAC (dabigatran or rivaroxaban) users with continued VKA users were included. When comparing DOAC to VKA, an increased risk of ischaemic stroke and myocardial infarction was found for dabigatran (pooled aHR of 1.61 [95% CI 1.19-2.19, I2 = 65%] and 1.29 [95% CI 1.10-1.52, I2 = 0%], respectively), but not for rivaroxaban. The use of dabigatran in VKA-experienced users was associated with an increased risk of gastrointestinal bleeding (pooled aHR 1.63 [95% CI 1.36-1.94, I2 = 30%]), but a decreased risk of intracranial bleeding (pooled aHR 0.45 [95% CI 0.32-0.64, I2 = 0%]). In conclusion, the use of dabigatran in prior VKA users in clinical practice was associated with a slightly increased risk of arterial thromboembolism and gastrointestinal bleeding, but a decreased risk of intracranial bleeding. Importantly, observational studies of real-life VKA-experienced oral anticoagulant users may be confounded by the reason for switching.
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Affiliation(s)
- Maja Hellfritzsch
- Clinical Pharmacology and Pharmacy, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark
| | - Kasper Adelborg
- Department of Clinical EpidemiologyAarhus University HospitalAarhusDenmark
- Department of Clinical BiochemistryAarhus University HospitalAarhusDenmark
| | - Per Damkier
- Department of Clinical Chemistry and PharmacologyOdense University HospitalOdenseDenmark
- Department of Clinical ResearchUniversity of Southern DenmarkOdenseDenmark
| | - Søren Paaske Johnsen
- Department of Clinical EpidemiologyAarhus University HospitalAarhusDenmark
- Department of Clinical MedicineAalborg University and Aalborg University HospitalAalborgDenmark
| | - Jesper Hallas
- Clinical Pharmacology and Pharmacy, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark
| | - Anton Pottegård
- Clinical Pharmacology and Pharmacy, Department of Public HealthUniversity of Southern DenmarkOdenseDenmark
| | - Erik Lerkevang Grove
- Department of CardiologyAarhus University HospitalAarhusDenmark
- Department of Clinical Medicine, Faculty of HealthAarhus UniversityAarhusDenmark
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21
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ten Berg JM, de Veer A, Oldgren J, Steg PG, Zateyshchikov DA, Jansky P, Seung KB, Hohnloser SH, Lip GY, Nordaby M, Kleine E, Bhatt DL, Cannon CP. Switching of Oral Anticoagulation Therapy After PCI in Patients With Atrial Fibrillation. JACC Cardiovasc Interv 2019; 12:2331-2341. [DOI: 10.1016/j.jcin.2019.08.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 08/23/2019] [Accepted: 08/27/2019] [Indexed: 10/25/2022]
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22
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Briere JB, Wu O, Bowrin K, Millier A, Toumi M, Taieb V, Levy P, Coleman CI. Impact of methodological choices on a meta-analysis of real-world evidence comparing non-vitamin-K antagonist oral anticoagulants with vitamin K antagonists for the treatment of patients with non-valvular atrial fibrillation. Curr Med Res Opin 2019; 35:1867-1872. [PMID: 31328580 DOI: 10.1080/03007995.2019.1647020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: The aim of this study was to investigate the impact of methodological choices in a meta-analysis of real-world evidence (RWE) comparing three non-vitamin-K antagonist oral anticoagulants with vitamin K antagonists (VKAs) for the treatment of patients with non-valvular atrial fibrillation (NVAF). Methods: The meta-analysis was based on a systematic review of RWE studies enrolling incident and prevalent patients aged ≥18 years with NVAF and receiving either rivaroxaban, dabigatran, apixaban or a VKA. Five different scenarios were considered to explore the impact of the initial meta-analysis assumptions: (1) using studies that involved only incident patients; (2) excluding studies that only reported crude values and did not consider any adjustment; (3) including all studies independently of possible database overlap; (4) using studies with data on different dosages for rivaroxaban and dabigatran; and (5) assigning quality weights to studies to assess quality of reporting. These scenarios were run on three outcomes: ischemic stroke (IS), myocardial infarction (MI) and intracranial hemorrhage (ICH). Results: Across all scenarios, rivaroxaban was associated with significantly lower risks of IS and ICH than VKAs. In most scenarios, dabigatran was associated with significantly lower risks of IS and ICH. In all scenarios, apixaban was associated with a significantly lower risk of ICH. Conclusions: Sensitivity analyses showed the impact of similar assumptions was different depending on the outcome and the drug considered. The development of recommendations and guidelines for the inclusion of RWE in meta-analyses could prove useful in evaluating the effectiveness of health care interventions.
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Affiliation(s)
| | - Olivia Wu
- HEHTA, Institute of Health & Wellbeing , Glasgow , UK
| | | | - Aurélie Millier
- HEOR Department, HTA Team, Creativ-Ceutical , Paris , France
| | - Mondher Toumi
- Faculty of Medicine, University of Aix-Marseille , Marseille , France
| | - Vanessa Taieb
- HEOR Department, Evidence Synthesis Team, Creativ-Ceutical , London , UK
| | - Pierre Levy
- Université Paris-Dauphine, PSL Research University, LEDa-LEGOS , Paris , France
| | - Craig I Coleman
- School of Pharmacy, University of Connecticut , Storrs, CT , USA
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Oger E, Botrel MA, Juchault C, Bouget J. Sensitivity and specificity of an algorithm based on medico-administrative data to identify hospitalized patients with major bleeding presenting to an emergency department. BMC Med Res Methodol 2019; 19:194. [PMID: 31627721 PMCID: PMC6798331 DOI: 10.1186/s12874-019-0841-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 09/24/2019] [Indexed: 11/10/2022] Open
Abstract
Background Validation studies on an ICD-10-based algorithm to identify major bleeding events are scarce, and mostly focused on positive predictive values. Objective To evaluate the sensitivity and specificity of an ICD-10-based algorithm in adult patients referred to hospital. Methods This was a cross-sectional, retrospective analysis. Among all hospital stays of adult patients referred to Rennes University Hospital, France, through the emergency ward in 2014, we identified major bleeding events according to an index test based on a list of ICD-10 diagnoses. As a reference, a two-step process was applied: firstly, a computerized request for electronic health records from the emergency ward, using several hemorrhage-related diagnostic codes and specific emergency therapies so as to discard stays with a very low probability of bleeding; secondly, a chart review of selected records was conducted by a medical expert blinded to the index test results and each hospital stay was classified into one of two exclusive categories: major bleeding or no major bleeding, according to pre-specified criteria. Results Out of 16,012 hospital stays, the reference identified 736 major bleeding events and left 15,276 stays considered as without the target condition. The index test identified 637 bleeding events: 293 intracranial hemorrhages, 197 gastrointestinal hemorrhages and 147 other bleeding events. Overall, sensitivity was 65% (95%CI, 62 to 69), and specificity was 99.0%. We observed differential sensitivity and specificity across bleeding types, with the highest values for intracranial hemorrhage. Positive predictive values ranged from 59% for “other” bleeding events, to 71% (95%CI, 65 to 78) for gastrointestinal hemorrhage, and 96% for intracranial hemorrhage. Conclusions Low sensitivity and differential measures of accuracy across bleeding types support the need for specific data collection and medical validation rather than using an ICD-10-based algorithm for assessing the incidence of major bleeding.
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Affiliation(s)
- Emmanuel Oger
- Univ Rennes, EA 7449 REPERES [Pharmacoepidemiology and Health Services Research], Rennes, France.
| | - Marie-Anne Botrel
- Univ Rennes, EA 7449 REPERES [Pharmacoepidemiology and Health Services Research], Rennes, France
| | | | - Jacques Bouget
- Univ Rennes, EA 7449 REPERES [Pharmacoepidemiology and Health Services Research], Rennes, France
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Bellin A, Berto P, Themistoclakis S, Chandak A, Giusti P, Cavalli G, Bakshi S, Tessarin M, Deambrosis P, Chinellato A. New oral anti-coagulants versus vitamin K antagonists in high thromboembolic risk patients. PLoS One 2019; 14:e0222762. [PMID: 31589620 PMCID: PMC6779249 DOI: 10.1371/journal.pone.0222762] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 09/06/2019] [Indexed: 11/19/2022] Open
Abstract
Background Oral anticoagulant therapy (VKA) is nowadays the mainstay of treatment in primary and secondary stroke prevention in patients with atrial fibrillation. Given the limited risk-benefit ratio of vitamin K antagonists, pharmacological research has been directed towards the development of products that could overcome these limits, new oral anticoagulants were recently introduced: dabigatran, rivaroxaban, apixaban, and edoxaban. Aim Scope of the present study was to examine patterns of use, effectiveness, safety and mean annual cost per patient of anticoagulant treatment for non-valvular AF in real clinical practice. Methods A retrospective observational cohort study, by using administrative databases (drugs, hospitalizations, clinical visits, lab tests, population registry), was conducted in the Local Health Unit (LHU) of Treviso, Italy, from January 1, 2012 to December 31, 2016. Results 5597 subjects were selected, 2171 of which satisfied all inclusion criteria. In particular 1355 patients were treated with VKA, 577 patients were treated with NOAC, and 239 patients were treated initially with VKA and subsequently switched to NOAC (switch group). NOAC treatment showed to be superior to VKA and this superiority was statistically significant on both end-points: patients in the NOAC group reported less cardiovascular events (9,9%) and less bleeding episodes (5,5%) versus VKA patients (14,6% and 11,4%; p<,0001 and p = 0,0049, respectively). The mean cost per patient per year was respectively € 1323,9 for patients treated with NOAC versus € 1003,3 for patients treated with VKA. Cost difference appears to be largely driven by drug cost (€ 767,9 for NOAC versus € 17,7 for VKA patients) and by specialist visits and laboratory tests (€ 318,4 for NOAC versus € 733,4 for VKA patients). Conclusion In this retrospective real-world study treatment with NOAC showed to be associated with significant reductions of CV events and bleeding events compared to VKA use, albeit at a higher NHS’ direct cost per patient/year, mainly due to higher drug therapy cost.
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Affiliation(s)
| | - Patrizia Berto
- Analytica-Laser, a Certara company, Londra, United Kingdom
| | | | - Aastha Chandak
- Analytica-Laser, a Certara company, Londra, United Kingdom
| | | | | | - Sumeet Bakshi
- Analytica-Laser, a Certara company, Londra, United Kingdom
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Blin P, Fauchier L, Dureau-Pournin C, Sacher F, Dallongeville J, Bernard MA, Lassalle R, Droz-Perroteau C, Moore N. Effectiveness and Safety of Rivaroxaban 15 or 20 mg Versus Vitamin K Antagonists in Nonvalvular Atrial Fibrillation. Stroke 2019; 50:2469-2476. [PMID: 31390972 PMCID: PMC6727926 DOI: 10.1161/strokeaha.119.025824] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Supplemental Digital Content is available in the text. We compared the 1-year safety and effectiveness of rivaroxaban 15 mg (R15) or rivaroxaban 20 mg (R20) to vitamin K antagonists (VKAs) in patients with nonvalvular atrial fibrillation.
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Affiliation(s)
- Patrick Blin
- From the Bordeaux PharmacoEpi, INSERM CIC1401, CHU de Bordeaux, Université de Bordeaux, France (P.B., C.D.-P., M.-A.B., R.L., C.D.-P., N.M.)
| | - Laurent Fauchier
- Hôpital Trousseau-CHU de Tours, Service de cardiologie, Faculté de Médecine, Université François Rabelais, France (L.F.)
| | - Caroline Dureau-Pournin
- From the Bordeaux PharmacoEpi, INSERM CIC1401, CHU de Bordeaux, Université de Bordeaux, France (P.B., C.D.-P., M.-A.B., R.L., C.D.-P., N.M.)
| | - Frédéric Sacher
- IHU Liryc, Electrophysiology and Heart Modeling Institute, Fondation Bordeaux Université/Bordeaux University Hospital (CHU), Electrophysiology and Ablation Unit, Centre de recherche Cardio-Thoracique de Bordeaux, INSERM U1045, Université de Bordeaux, France (F.S.)
| | - Jean Dallongeville
- Institut Pasteur de Lille, Inserm U744, Unité d'Epidémiologie et de Santé Publique, France (J.D.)
| | - Marie-Agnès Bernard
- From the Bordeaux PharmacoEpi, INSERM CIC1401, CHU de Bordeaux, Université de Bordeaux, France (P.B., C.D.-P., M.-A.B., R.L., C.D.-P., N.M.)
| | - Regis Lassalle
- From the Bordeaux PharmacoEpi, INSERM CIC1401, CHU de Bordeaux, Université de Bordeaux, France (P.B., C.D.-P., M.-A.B., R.L., C.D.-P., N.M.)
| | - Cécile Droz-Perroteau
- From the Bordeaux PharmacoEpi, INSERM CIC1401, CHU de Bordeaux, Université de Bordeaux, France (P.B., C.D.-P., M.-A.B., R.L., C.D.-P., N.M.)
| | - Nicholas Moore
- From the Bordeaux PharmacoEpi, INSERM CIC1401, CHU de Bordeaux, Université de Bordeaux, France (P.B., C.D.-P., M.-A.B., R.L., C.D.-P., N.M.).,INSERM U1219, Université de Bordeaux, France (N.M.)
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26
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Major ischaemic and bleeding risks following current drug-eluting stent implantation: Are there differences across current drug-eluting stent types in real life? Arch Cardiovasc Dis 2019; 112:469-484. [DOI: 10.1016/j.acvd.2019.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/14/2019] [Accepted: 04/02/2019] [Indexed: 02/07/2023]
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Marietta M, Banchelli F, Pavesi P, Manotti C, Quintavalla R, Sinigaglia T, Guazzaloca G, Pattacini C, Urbinati S, Malavasi VL, Boriani G, Voci C, D'Amico R, Magrini N. Direct oral anticoagulants vs non-vitamin K antagonist in atrial fibrillation: A prospective, propensity score adjusted cohort study. Eur J Intern Med 2019; 62:9-16. [PMID: 30635146 DOI: 10.1016/j.ejim.2018.12.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 12/11/2018] [Accepted: 12/20/2018] [Indexed: 01/22/2023]
Affiliation(s)
- Marco Marietta
- Hematology Unit, Azienda Ospedaliero-Universitaria, Modena, Italy.
| | | | | | - Cesare Manotti
- Department of Internal Medicine, Azienda Ospedaliero-Universitaria di Parma, Italy
| | - Roberto Quintavalla
- Department of Internal Medicine, Azienda Ospedaliero-Universitaria di Parma, Italy
| | - Tiziana Sinigaglia
- Cardiovascular Medicine Unit, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Giuliana Guazzaloca
- Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | | | - Stefano Urbinati
- Cardiology Department, Bellaria Hospital, AUSL of Bologna, Italy
| | - Vincenzo Livio Malavasi
- Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Diagnostics, Clinical and Public Health Medicine, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Claudio Voci
- Servizio Strutture, Tecnologie e Sistemi Informativi, Regione Emilia-Romagna, Bologna, Italy
| | - Roberto D'Amico
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Italy
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Escobar C, Martí-Almor J, Pérez Cabeza A, Martínez-Zapata MJ. Anticoagulantes orales directos frente a antagonistas de la vitamina K en pacientes con fibrilación auricular de la práctica clínica: revisión sistemática y metanálisis. Rev Esp Cardiol 2019. [DOI: 10.1016/j.recesp.2018.02.023] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Blin P, Dureau‐Pournin C, Cottin Y, Bénichou J, Mismetti P, Abouelfath A, Lassalle R, Droz C, Moore N. Comparative Effectiveness and Safety of Standard or Reduced Dose Dabigatran vs. Rivaroxaban in Nonvalvular Atrial Fibrillation. Clin Pharmacol Ther 2019; 105:1439-1455. [DOI: 10.1002/cpt.1318] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 10/30/2018] [Indexed: 01/26/2023]
Affiliation(s)
- Patrick Blin
- Bordeaux PharmacoEpiINSERM CIC1401Université de BordeauxCHU de Bordeaux Bordeaux France
| | | | - Yves Cottin
- Service de CardiologieCHU de Dijon Dijon France
| | - Jacques Bénichou
- INSERM U1219Université de Bordeaux Bordeaux France
- CHU de RouenUnité de Biostatistique Rouen France
| | - Patrick Mismetti
- Unité de Recherche Clinique Innovation et PharmacologieHôpital Nord Saint‐Etienne France
| | - Abdelilah Abouelfath
- Bordeaux PharmacoEpiINSERM CIC1401Université de BordeauxCHU de Bordeaux Bordeaux France
| | - Regis Lassalle
- Bordeaux PharmacoEpiINSERM CIC1401Université de BordeauxCHU de Bordeaux Bordeaux France
| | - Cécile Droz
- Bordeaux PharmacoEpiINSERM CIC1401Université de BordeauxCHU de Bordeaux Bordeaux France
| | - Nicholas Moore
- Bordeaux PharmacoEpiINSERM CIC1401Université de BordeauxCHU de Bordeaux Bordeaux France
- INSERM U1219Université de Bordeaux Bordeaux France
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Jabagi MJ, Vey N, Goncalves A, Le Tri T, Zureik M, Dray-Spira R. Evaluation of the Incidence of Hematologic Malignant Neoplasms Among Breast Cancer Survivors in France. JAMA Netw Open 2019; 2:e187147. [PMID: 30657534 PMCID: PMC6484549 DOI: 10.1001/jamanetworkopen.2018.7147] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Breast cancer survivors are at an increased risk of developing certain types of hematologic malignant neoplasm after diagnosis. OBJECTIVE To estimate the incidence of various types of hematologic malignant neoplasm in breast cancer survivors, both in absolute terms and in association with the general population. DESIGN, SETTING, AND PARTICIPANTS This nationwide cohort study conducted in France used data from the French National Health Data System, a database that contains all of French residents' health-related expenses. All French women aged 20 to 85 years with an incident breast cancer diagnosis between July 1, 2006, and December 31, 2015, were included (n = 439 704) and followed up until hematologic malignant neoplasm occurrence, death, loss of follow-up, or December 31, 2016, whichever came first. Comparisons were made with all French women in the general population who were registered in the French general health insurance program each year from January 1, 2007, and December 31, 2016. Data analysis was performed from January 23, 2018, to May 25, 2018. MAIN OUTCOMES AND MEASURES Main outcomes were incident hematologic malignant neoplasm cases occurring at least 6 months after breast cancer diagnosis. The various types of hematologic malignant neoplasm considered were acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), myeloproliferative neoplasms (MPNs), multiple myeloma (MM), Hodgkin lymphoma or non-Hodgkin lymphoma (HL/NHL), and acute lymphoblastic leukemia or lymphocytic lymphoma (ALL/LL). Incidence of these various types was estimated among breast cancer survivors and compared with the incidence in women in the general population. RESULTS The 439 704 women in the study had a median (interquartile range [IQR]) age of 59 (50-69) years and were followed up for a median (IQR) duration of 5 (2.8-7.5) years. Overall, 3046 cases of hematologic malignant neoplasm occurred: 509 cases (16.7%) of AML (crude incidence rate [CIR] per 100 000 person-years, 24.5; 95% CI, 22.4-26.8), 832 cases (27.3%) of MDS (CIR, 40.1; 95% CI, 37.4-42.9), and 267 cases (8.8%) of MPN (CIR, 12.8; 95% CI, 11.4-14.5). Lymphoid neoplasm cases included 420 cases (13.8%) of MM (CIR, 20.3; 95% CI, 18.4-22.3), 912 cases (29.9%) of HL/NHL (CIR, 44.4; 95% CI, 41.1-50.0), and 106 cases (3.5%) of ALL/LL (CIR, 5.1; 95% CI, 4.2-6.2). Compared with the general population, breast cancer survivors had statistically significantly higher incidence of AML (standardized incidence rate ratio [SIRR], 2.8; 95% CI, 2.5-3.2) and MDS (SIRR, 5.0; 95% CI, 4.4-5.7) and, to a lesser extent, MM (SIRR, 1.5; 95% CI, 1.3-1.7]) and ALL/LL (SIRR, 2.0; 95% CI, 1.3-3.0). CONCLUSIONS AND RELEVANCE The finding that AML and MDS still occur among breast cancer survivors today, and that ALL/LL and MM may also be of concern, merits the continuous monitoring of hematologic malignant neoplasms and the thorough investigations into their underlying mechanisms.
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Affiliation(s)
- Marie Joelle Jabagi
- University of Paris Sud, Paris-Saclay University, Paris, France
- Health Product Epidemiology Department, French National Agency for Medicines and Health Products Safety, Saint-Denis, France
| | - Norbert Vey
- Aix-Marseille University, CNRS, Inserm, Institut Paoli-Calmettes, Hematology Department, CRCM, Marseille, France
| | - Anthony Goncalves
- Aix-Marseille University, CNRS, Inserm, Institut Paoli-Calmettes, Medical Oncology Department, CRCM, Marseille, France
| | - Thien Le Tri
- Health Product Epidemiology Department, French National Agency for Medicines and Health Products Safety, Saint-Denis, France
| | - Mahmoud Zureik
- Health Product Epidemiology Department, French National Agency for Medicines and Health Products Safety, Saint-Denis, France
- Versailles Saint-Quentin-en-Yvelines University, Montigny-Le-Bretonneux, AP-HP Hôpital Sainte Perine Hospital, Paris, France
| | - Rosemary Dray-Spira
- Health Product Epidemiology Department, French National Agency for Medicines and Health Products Safety, Saint-Denis, France
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Blin P, Dureau-Pournin C, Cottin Y, Bénichou J, Mismetti P, Abouelfath A, Lassalle R, Droz C, Moore N. Effectiveness and safety of 110 or 150 mg dabigatran vs. vitamin K antagonists in nonvalvular atrial fibrillation. Br J Clin Pharmacol 2018; 85:432-441. [PMID: 30423205 DOI: 10.1111/bcp.13815] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 10/30/2018] [Accepted: 11/08/2018] [Indexed: 12/21/2022] Open
Abstract
AIMS We compared the 1-year safety and effectiveness of dabigatran 110 mg (D110) or 150 mg (D150) twice daily to vitamin K antagonists (VKA) in patients with nonvalvular atrial fibrillation. METHODS New user cohort study of patients dispensed D110 or D150 vs. VKA in 2013 for nonvalvular atrial fibrillation, followed 1 year in the French Système National des Données de Santé (66 million persons). D110 and D150 users were matched 1:1 with VKA users on sex, age, date of first drug dispensing and high-dimensional propensity score. Hazard ratios [HR (95% confidence intervals)] for stroke and systemic embolism (SSE), major bleeding (MB) and death were computed using Cox proportional hazards or Fine and Gray models during exposure. RESULTS In 14 442 matched D110 and VKA patients, mean age 79, 49% male, 91% with CHA2 DS2 -VASc ≥2 and 8% with HAS-BLED score >3, incidence rates of SSE were 1.9% and 2.6% person-years [HR 0.69 (0.56-0.84)], MB 1.8% and 2.9% [0.62 (0.51-0.76)], death 7.2% and 8.6% [0.84 (0.76-0.94)]. In 8389 matched D150 and VKA patients, mean age 67, 67% male, 65% with CHA2 DS2 -VASC ≥2; < 5% HAS-BLED >3, incidence rates were for SSE 1.4% and 1.9% [0.76 (0.56-1.04)], MB 0.6% and 1.9% [0.30 (0.20-0.46)], death 1.6% and 3.6% [0.46 (0.35-0.59)]. Numbers needed to treat to observe one fewer death were 78 for D110, 88 for D150. CONCLUSION In real life D110 and D150 were at least as effective, and safer than VKA.
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Affiliation(s)
- Patrick Blin
- Bordeaux PharmacoEpi, INSERM CIC1401, Université de Bordeaux, CHU de Bordeaux, 33076, Bordeaux, France
| | - Caroline Dureau-Pournin
- Bordeaux PharmacoEpi, INSERM CIC1401, Université de Bordeaux, CHU de Bordeaux, 33076, Bordeaux, France
| | - Yves Cottin
- CHU de Dijon, Service de Cardiologie, 21079, Dijon, France
| | - Jacques Bénichou
- INSERM U1219, Université de Bordeaux, 33076, Bordeaux, France.,CHU de Rouen, Unité de Biostatistique, 76031, Rouen, France
| | - Patrick Mismetti
- Hôpital Nord, Unité de Recherche Clinique Innovation et Pharmacologie, 42055, Saint-Etienne, France
| | - Abdelilah Abouelfath
- Bordeaux PharmacoEpi, INSERM CIC1401, Université de Bordeaux, CHU de Bordeaux, 33076, Bordeaux, France
| | - Regis Lassalle
- Bordeaux PharmacoEpi, INSERM CIC1401, Université de Bordeaux, CHU de Bordeaux, 33076, Bordeaux, France
| | - Cécile Droz
- Bordeaux PharmacoEpi, INSERM CIC1401, Université de Bordeaux, CHU de Bordeaux, 33076, Bordeaux, France
| | - Nicholas Moore
- Bordeaux PharmacoEpi, INSERM CIC1401, Université de Bordeaux, CHU de Bordeaux, 33076, Bordeaux, France.,INSERM U1219, Université de Bordeaux, 33076, Bordeaux, France
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Wakui M, Fujimori Y, Katagiri H, Nakamura S, Kondo Y, Kuroda Y, Nakagawa T, Shimizu N, Murata M. Assessment of in vitro effects of direct thrombin inhibitors and activated factor X inhibitors through clot waveform analysis. J Clin Pathol 2018; 72:244-250. [DOI: 10.1136/jclinpath-2018-205517] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/20/2018] [Accepted: 11/20/2018] [Indexed: 12/14/2022]
Abstract
AimsClot waveform analysis (CWA) has been reported to extend the interpretation of clotting time measurement. The parameters obtained from successive derivatives of the clotting reaction curves reflect the rates of activation of individual coagulation factors, theoretically dissecting the cascade pathway. This study aims to assess the in vitro effects of direct thrombin inhibitors (DTIs) and activated factor X (FXa) inhibitors.MethodsCWA was applied to the activated partial thromboplastin time (APTT) assay of plasma samples spiked with each drug. For CWA of APTT measurement curves (APTT-CWA), the positive mode of clotting reaction curves was defined as the direction towards fibrin generation.ResultsAll the maximum positive values in the successive derivatives were decreased dependently on the concentrations of each drug. Moreover, the negative values in the second and third derivatives appeared putatively due to consumption of thrombin and factor FXa, respectively, to form complexes with plasma serine protease inhibitors. The decrease of the maximum negative values observed dependently on the concentrations of each drug appeared to be consistent with the decreased generation of thrombin and factor FXa. The analysis of Hill coefficients of each drug in the dose–response of changes in the APTT-CWA parameters revealed a difference in anticoagulant cooperativity between DTIs versus FXa inhibitors.ConclusionsThe APTT-CWA demonstrated evidence for the blockade of thrombin-positive feedback by DTIs and FXa inhibitors and that for the differences in anticoagulant cooperativity between them. The results demonstrate the usability of CWA for assessment of anticoagulation and provide insights into direct anticoagulants.
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Cervical cancer screening and subsequent procedures in women under the age of 25 years between 2007 and 2013 in France: a nationwide French healthcare database study. Eur J Cancer Prev 2018; 27:479-485. [DOI: 10.1097/cej.0000000000000360] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Wei AH, Gu ZC, Zhang C, Ding YF, Liu D, Li J, Liu XY, Lin HW, Pu J. Increased risk of myocardial infarction with dabigatran etexilate: fact or fiction? A critical meta-analysis of over 580,000 patients from integrating randomized controlled trials and real-world studies. Int J Cardiol 2018; 267:1-7. [DOI: 10.1016/j.ijcard.2018.05.048] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 04/20/2018] [Accepted: 05/15/2018] [Indexed: 01/20/2023]
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Kirchgesner J, Lemaitre M, Carrat F, Zureik M, Carbonnel F, Dray-Spira R. Risk of Serious and Opportunistic Infections Associated With Treatment of Inflammatory Bowel Diseases. Gastroenterology 2018; 155:337-346.e10. [PMID: 29655835 DOI: 10.1053/j.gastro.2018.04.012] [Citation(s) in RCA: 360] [Impact Index Per Article: 60.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 03/19/2018] [Accepted: 04/06/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS The risk of infection associated with tumor necrosis factor antagonists (anti-TNF) and thiopurines (combination therapy) is uncertain. We assessed the risk of serious and opportunistic infections in patients with inflammatory bowel disease (IBD) treated with thiopurine monotherapy, anti-TNF monotherapy, or combination therapy in a large cohort of patients in France. METHODS We performed a nationwide population-based study of patients (18 years or older) with a diagnosis of IBD in the French national health insurance database; we collected data from January 1, 2009 until December 31, 2014. The risks of serious and opportunistic infections associated with exposure to combination therapy, anti-TNF, and thiopurine monotherapies were compared using marginal structural Cox proportional hazard models adjusted for baseline and time-varying sociodemographic characteristics, medications, and comorbidities. RESULTS Among the 190,694 patients with IBD included in our analysis, 8561 serious infections and 674 opportunistic infections occurred. Compared with anti-TNF monotherapy, combination therapy was associated with increased risks of serious infection (hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.05-1.45) and opportunistic infection (HR, 1.96; 95% CI, 1.32-2.91). Compared with thiopurine monotherapy, anti-TNF monotherapy was associated with increased risks of serious infection (HR, 1.71; 95% CI, 1.56-1.88), mycobacterial infection (HR, 1.98; 95% CI, 1.15-3.40), and bacterial infection (HR, 2.38; 95% CI, 1.23-4.58, respectively). Conversely, anti-TNF monotherapy was associated with decreased risk of opportunistic viral infection compared with thiopurine monotherapy (HR, 0.57; 95% CI, 0.38-0.87). CONCLUSIONS In a nationwide cohort study of patients with IBD in France, we found heterogeneity in risks of serious and opportunistic infections in patients treated with immune-suppressive regimens. These should be carefully considered and weighed against potential benefits for IBD treatment in patient management.
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Affiliation(s)
- Julien Kirchgesner
- Department of Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety, Saint-Denis; UMR-S 1136, INSERM & UPMC Univ Paris 06, Paris; Department of Gastroenterology, AP-HP, Hôpital Saint-Antoine, Paris
| | - Magali Lemaitre
- Department of Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety, Saint-Denis
| | | | - Mahmoud Zureik
- Department of Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety, Saint-Denis; University Versailles St-Quentin-en-Yvelines, Montigny le Bretonneux, France
| | - Franck Carbonnel
- Department of Gastroenterology, AP-HP, Hôpitaux Universitaires Paris Sud, Le Kremlin Bicêtre, France
| | - Rosemary Dray-Spira
- Department of Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety, Saint-Denis.
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Manzoor BS, Walton SM, Sharp LK, Galanter WL, Lee TA, Nutescu EA. High number of newly initiated direct oral anticoagulant users switch to alternate anticoagulant therapy. J Thromb Thrombolysis 2018; 44:435-441. [PMID: 29027097 DOI: 10.1007/s11239-017-1565-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Real-world evidence focusing on medication switching patterns amongst direct oral anticoagulant (DOACs) has not been well studied. The objective of this study is to evaluate patterns of prescription switching in non-valvular atrial fibrillation (NVAF) patients initiated on a DOAC and previously naïve to anticoagulation (AC) therapy. Data was obtained from Truven Health MarketScan® Commercial and Medicare Supplemental database (2009-2013). AC naïve (those without prior anticoagulant use) NVAF patients initiated on a DOAC, with 6 months of continuous health plan enrollment before and after treatment initiation and maintained on continuous therapy for a minimum of 6 months were included. Of 34,022 AC naïve NVAF patients initiating a DOAC, 6613 (19.4%) patients switched from an index DOAC prescription to an alternate anticoagulant and 27,409 (80.6%) remained on the DOAC [age: 68.5 ± 11.7 vs. 67.1 ± 12.7 years, p < 0.001; males: 3781 (57.2%) vs. 17,160 (62.6%), p < 0.001]. Amongst those that switched medication, 3196 (48.3%) did so within the first 6 months of therapy. Overall, 2945 (44.5%) patients switched to warfarin, 2912 (44.0%) switched to another DOAC and 756 (11.4%) switched to an injectable anticoagulant. The highest proportion of patients switched from dabigatran to warfarin (N = 2320; 42.5%) or rivaroxaban (N = 2252; 41.3%). The median time to switch from the index DOAC to another DOAC was 309.5 days versus 118.0 days (p < 0.001) to switch to warfarin. In NVAF patients newly initiated on DOAC therapy, one in five patients switch to an alternate anticoagulant and one of every two patients do so within the first 6 months of therapy. Switching from an initial DOAC prescription to traditional anticoagulants occurs as frequently as switching to an alternate DOAC.
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Affiliation(s)
- Beenish S Manzoor
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA
| | - Surrey M Walton
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Lisa K Sharp
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - William L Galanter
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA
- Department of Academic Internal Medicine & Geriatrics, College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Todd A Lee
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Edith A Nutescu
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA.
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.
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Albaladejo P, Pernod G, Godier A, de Maistre E, Rosencher N, Mas JL, Fontana P, Samama CM, Steib A, Schlumberger S, Marret E, Roullet S, Susen S, Madi-Jebara S, Nguyen P, Schved JF, Bonhomme F, Sié P. Management of bleeding and emergency invasive procedures in patients on dabigatran: Updated guidelines from the French Working Group on Perioperative Haemostasis (GIHP) – September 2016. Anaesth Crit Care Pain Med 2018; 37:391-399. [DOI: 10.1016/j.accpm.2018.04.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 04/17/2018] [Accepted: 04/18/2018] [Indexed: 11/25/2022]
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State of play and future direction with NOACs: An expert consensus. Vascul Pharmacol 2018; 106:9-21. [DOI: 10.1016/j.vph.2018.04.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 03/20/2018] [Accepted: 04/04/2018] [Indexed: 12/17/2022]
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Hersi AS, Alhebaishi YS, Hamoui O, Hassan T, Khalifa Hamad A, Magdy M, Sabbour H, Shaheen S. Practical perspectives on the use of non-vitamin K antagonist oral anticoagulants for stroke prevention in patients with nonvalvular atrial fibrillation: A view from the Middle East and North Africa. J Saudi Heart Assoc 2018; 30:122-139. [PMID: 29910583 PMCID: PMC6000886 DOI: 10.1016/j.jsha.2017.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 05/17/2017] [Accepted: 05/26/2017] [Indexed: 01/18/2023] Open
Abstract
Clinical guidelines for the prevention of stroke in patients with nonvalvular atrial fibrillation (NVAF) are available from several international cardiology associations. Patients with NVAF in the Middle East and North Africa (MENA) region present unique challenges and opportunities related to differences in geography, practice patterns, and patient demographics that are as yet unaddressed in practice guidelines. This review aims to offer a practical perspective on the management of NVAF in patients in MENA and draws on evidence-based guidelines as well as real-world evidence and expert opinion. The literature was searched for relevant original research articles, systematic reviews, meta-analyses, and guideline recommendations addressing the prevention of stroke in patients with NVAF with a focus on issues relevant to the MENA region. Guideline recommendations, best practices, and expert opinion were discussed and agreed on by a working group consisting of cardiologists from across the MENA region. The incidence of stroke secondary to atrial fibrillation in patients across the MENA region is higher than rates reported globally, and this might be attributed to a higher incidence of vascular risk factors and underuse of anticoagulants in patients in the MENA. The available evidence supports the established role of non-vitamin K antagonist oral anticoagulants (NOACs) in the prevention of stroke in patients with NVAF. There is a consistent body of clinical trial and real-world evidence supporting their efficacy for stroke prevention in NVAF, with more favorable bleeding risk profiles relative to vitamin K antagonists, such that guidelines now recommend the use of NOACs in preference over vitamin K antagonists. There are important opportunities to improve the management of NVAF outcomes for patients with NVAF by applying evidence-based guidelines for stroke prevention. Growing experience with NOACs in the MENA region will help guide patient selection and elucidate optimal dosing strategies to maximize the clinical benefits of the NOACs.
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Affiliation(s)
- Ahmad S. Hersi
- King Fahad Cardiac Center, Department of Cardiac Sciences, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | | | - Taher Hassan
- Cardiology Clinics, Al Badriyah Tower, Jeddah, Saudi Arabia
| | - Adel Khalifa Hamad
- Mohammed bin Khalifa Al Khalifa Cardiac Centre, Bahrain Defense Force Hospital, Riffa, Bahrain
| | - Mohamed Magdy
- Critical Care Cardiology and Electrophysiology Departments, Cairo University, Cairo, Egypt
- Electrophysiology Department, Alqassimi Cardiac Center, Sharjah, United Arab Emirates
| | - Hani Sabbour
- Cardiology & Electrophysiology, Cleveland Clinic, Abu Dhabi, United Arab Emirates
- Cardiology Department, Brown University, Warren Alpert School of Medicine, Providence, RI, USA
| | - Sameh Shaheen
- Cardiology Department, Ain-shams University, Cairo, Egypt
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Escobar C, Martí-Almor J, Pérez Cabeza A, Martínez-Zapata MJ. Direct Oral Anticoagulants Versus Vitamin K Antagonists in Real-life Patients With Atrial Fibrillation. A Systematic Review and Meta-analysis. ACTA ACUST UNITED AC 2018; 72:305-316. [PMID: 29606361 DOI: 10.1016/j.rec.2018.03.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 03/02/2018] [Indexed: 12/21/2022]
Abstract
INTRODUCTION AND OBJECTIVES To assess the effectiveness of direct oral anticoagulants vs vitamin K antagonists in real-life patients with atrial fibrillation. METHODS A systematic review was performed according to Cochrane methodological standards. The results were reported according to the PRISMA statement. The ROBINS-I tool was used to assess risk of bias. RESULTS A total of 27 different studies publishing data in 30 publications were included. In the studies with a follow-up up to 1 year, apixaban (HR, 0.93; 95%CI, 0.71-1.20) and dabigatran (HR, 0.95; 95%CI, 0.80-1.13) did not significantly reduce the risk of ischemic stroke vs warfarin, whereas rivaroxaban significantly reduced this risk (HR, 0.83; 95%CI, 0.73-0.94). Apixaban (HR, 0.66; 95%CI, 0.55-0.80) and dabigatran (HR, 0.83; 95%CI, 0.70-0.97) significantly reduced the major bleeding risk vs warfarin, but not rivaroxaban (HR, 1.02; 95%CI, 0.95-1.10), although with a high statistical heterogeneity among studies. Apixaban (HR, 0.56; 95%CI, 0.42-0.73), dabigatran (HR, 0.45; 95%CI, 0.39-0.51), and rivaroxaban (HR, 0.66; 95%CI, 0.49-0.88) significantly reduced the risk of intracranial bleeding vs warfarin. Reduced doses of direct oral anticoagulants were associated with a slightly better safety profile, but with a marked reduction in stroke prevention effectiveness. CONCLUSIONS Data from this meta-analysis suggest that, vs warfarin, the stroke prevention effectiveness and bleeding risk of direct oral anticoagulants may differ in real-life patients with atrial fibrillation.
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Affiliation(s)
- Carlos Escobar
- Departamento de Cardiología, Hospital La Paz, Madrid, Spain.
| | | | | | - M José Martínez-Zapata
- Institut d'Investigació Biomèdica Sant Pau (IIB Sant Pau), CIBER Epidemiología y Salud Pública CIBERESP, Barcelona, Spain
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Bouillon K, Bertrand M, Bader G, Lucot JP, Dray-Spira R, Zureik M. Association of Hysteroscopic vs Laparoscopic Sterilization With Procedural, Gynecological, and Medical Outcomes. JAMA 2018; 319:375-387. [PMID: 29362796 PMCID: PMC5833563 DOI: 10.1001/jama.2017.21269] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
IMPORTANCE Safety of hysteroscopic sterilization has been recently questioned following reports of general symptoms such as allergy, tiredness, and depression in addition to associated gynecological results such as pelvic pain, perforation of fallopian tubes or uterus, and unwanted pregnancy. OBJECTIVE To compare the risk of reported adverse events between hysteroscopic and laparoscopic sterilization. DESIGN, SETTING, AND PARTICIPANTS French nationwide cohort study using the national hospital discharge database linked to the health insurance claims database. Women aged 30 to 54 years receiving a first hysteroscopic or laparoscopic sterilization between 2010 and 2014 were included and were followed up through December 2015. EXPOSURES Hysteroscopic sterilization vs laparoscopic sterilization. MAIN OUTCOMES AND MEASURES Risks of procedural complications (surgical and medical) and of gynecological (sterilization failure that includes salpingectomy, second sterilization procedure, or pregnancy; pregnancy; reoperation) and medical outcomes (all types of allergy; autoimmune diseases; thyroid disorder; use of analgesics, antimigraines, antidepressants, benzodiazepines; outpatient visits; sickness absence; suicide attempts; death) that occurred within 1 and 3 years after sterilization were compared using inverse probability of treatment-weighted Cox models. RESULTS Of the 105 357 women included (95.5% of eligible participants; mean age, 41.3 years [SD, 3.7 years]), 71 303 (67.7% ) underwent hysteroscopic sterilization, and 34 054 (32.3%) underwent laparoscopic sterilization. During the hospitalization for sterilization, risk of surgical complications for hysteroscopic sterilization was lower: 0.13% for hysteroscopic sterilization vs 0.78% for laparoscopic sterilization (adjusted risk difference [RD], -0.64; 95% CI, -0.67 to -0.60) and was lower for medical complications: 0.06% vs 0.11% (adjusted RD, -0.05; 95% CI, -0.08 to -0.01). During the first year after sterilization, 4.83% of women who underwent hysteroscopic sterilization had a higher risk of sterilization failure than the 0.69% who underwent laparoscopic sterilization (adjusted hazard ratio [HR], 7.11; 95% CI, 5.92 to 8.54; adjusted RD, 4.23 per 100 person-years; 95% CI, 3.40 to 5.22). Additionally, 5.65% of women who underwent hysteroscopic sterilization required gynecological reoperation vs 1.76% of women who underwent laparoscopic sterilization (adjusted HR, 3.26; 95% CI, 2.90 to 3.67; adjusted RD, 4.63 per 100 person-years; 95% CI, 3.38 to 4.75); these differences persisted after 3 years, although attenuated. Hysteroscopic sterilization was associated with a lower risk of pregnancy within the first year of the procedure but was not significantly associated with a difference in risk of pregnancy by the third year (adjusted HR, 1.04; 95% CI, 0.83-1.30; adjusted RD, 0.01 per 100 person-years; 95% CI, -0.04 to 0.07). Risks of medical outcomes were not significantly increased with hysteroscopic sterilization compared with laparoscopic sterilization. CONCLUSIONS AND RELEVANCE Among women undergoing first sterilization, the use of hysteroscopic sterilization was significantly associated with higher risk of gynecological complications over 1 year and over 3 years than was laparoscopic sterilization. Risk of medical outcomes was not significantly increased over 1 year or over 3 years. These findings do not support increased medical risks associated with hysteroscopic sterilization.
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Affiliation(s)
- Kim Bouillon
- Department of Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety (ANSM), Saint-Denis, France
| | - Marion Bertrand
- Department of Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety (ANSM), Saint-Denis, France
| | - Georges Bader
- Department of Obstetrics and Gynecology and Reproductive Medicine, Poissy Hospital, Poissy, France
| | - Jean-Philippe Lucot
- Department of Gynecology and Obstetrics, Centre Hospitalier de Bethune, Bethune, France
| | - Rosemary Dray-Spira
- Department of Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety (ANSM), Saint-Denis, France
| | - Mahmoud Zureik
- Department of Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety (ANSM), Saint-Denis, France
- University Versailles St-Quentin-en-Yvelines, Montigny le Bretonneux, France
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Billioti de Gage S, Collin C, Le-Tri T, Pariente A, Bégaud B, Verdoux H, Dray-Spira R, Zureik M. Antidepressants and Hepatotoxicity: A Cohort Study among 5 Million Individuals Registered in the French National Health Insurance Database. CNS Drugs 2018; 32:673-684. [PMID: 29959758 PMCID: PMC6061298 DOI: 10.1007/s40263-018-0537-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Hepatotoxicity may be a concern when prescribing antidepressants. Nevertheless, this risk remains poorly understood for serotonin and noradrenaline reuptake inhibitors (SNRIs: venlafaxine, milnacipran, duloxetine) and 'other antidepressants' (mianserin, mirtazapine, tianeptine and agomelatine), particularly in comparison with selective serotonin reuptake inhibitors (SSRIs: fluoxetine, citalopram, paroxetine, sertraline, fluvoxamine, escitalopram), which are by far the most commonly prescribed antidepressants. OBJECTIVE We quantified the risk of serious liver injury associated with new use of SNRIs and 'other antidepressants' compared with SSRIs in real-life practice. METHODS Based on the French national health insurance database, this cohort study included 4,966,825 individuals aged 25 years and older with a first reimbursement of SSRIs, SNRIs or 'other antidepressants' between January 2010 and June 2015. We compared the risk of serious liver injury within the 6 months following antidepressant initiation according to antidepressant class, with SSRIs as the reference, using an inverse probability-of-treatment-weighted Cox proportional hazard model adjusted for demographic characteristics and risk factors of liver injury. RESULTS We identified 382 serious liver injuries overall (none for milnacipran initiators). Age and gender standardized incidence rates per 100,000 person-years were 19.2 for SSRIs, 22.2 for venlafaxine, 12.6 for duloxetine, 21.5 for mianserin, 32.8 for mirtazapine, 31.6 for tianeptine and 24.6 for agomelatine initiators. Initiation of antidepressants of interest versus SSRIs was not associated with an increased risk of serious liver injury [adjusted hazard ratios (95% confidence interval): venlafaxine 1.17 (0.83-1.64), duloxetine 0.54 (0.28-1.02), mianserin 0.90 (0.58-1.41), mirtazapine 1.17 (0.67-2.02), tianeptine 1.35 (0.82-2.23) and agomelatine 1.07 (0.51-2.23)]. This finding was confirmed by the results of an additional study using a case-time-control design. CONCLUSION These results do not provide evidence of an increased risk of serious liver injury following initiation of SNRIs or 'other antidepressants' compared with SSRIs in real-life practice. This could reflect an inherent lack of difference in risk between the drug classes, or the fact that individuals with higher susceptibility to drug-induced liver injury are not prescribed drugs considered to be more hepatotoxic.
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Affiliation(s)
- Sophie Billioti de Gage
- Department of Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety (ANSM), 143-147 Blvd Anatole France, 93285 Saint-Denis, France ,0000 0001 2106 639Xgrid.412041.2University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, 33000 Bordeaux, France
| | - Cédric Collin
- Department of Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety (ANSM), 143-147 Blvd Anatole France, 93285 Saint-Denis, France
| | - Thien Le-Tri
- Department of Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety (ANSM), 143-147 Blvd Anatole France, 93285 Saint-Denis, France
| | - Antoine Pariente
- 0000 0001 2106 639Xgrid.412041.2University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, 33000 Bordeaux, France
| | - Bernard Bégaud
- 0000 0001 2106 639Xgrid.412041.2University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, 33000 Bordeaux, France
| | - Hélène Verdoux
- 0000 0001 2106 639Xgrid.412041.2University of Bordeaux, Inserm, Bordeaux Population Health Research Center, Team Pharmacoepidemiology, UMR 1219, 33000 Bordeaux, France ,Pôle UNIVA (UNIVersitaire de psychiatrie Adulte), Centre Hospitalier Charles Perrens, 33000 Bordeaux, France
| | - Rosemary Dray-Spira
- Department of Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety (ANSM), 143-147 Blvd Anatole France, 93285 Saint-Denis, France
| | - Mahmoud Zureik
- Department of Epidemiology of Health Products, French National Agency for Medicines and Health Products Safety (ANSM), 143-147 Blvd Anatole France, 93285, Saint-Denis, France. .,University of Versailles Saint-Quentin-en-Yvelines, 78180, Montigny-Le-Bretonneux, France.
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Ikeda T, Yasaka M, Kida M, Imura M. A survey of reasons for continuing warfarin therapy in the era of direct oral anticoagulants in Japanese patients with atrial fibrillation: the SELECT study. Patient Prefer Adherence 2018; 12:135-143. [PMID: 29398909 PMCID: PMC5775732 DOI: 10.2147/ppa.s152584] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
PURPOSE Although warfarin has historically been the standard of care for preventing ischemic stroke in patients with nonvalvular atrial fibrillation (NVAF), the use of direct oral anticoagulants (DOACs) is rapidly increasing. In this study, we examined the demographic and clinical characteristics of patients continuing warfarin therapy and investigated reasons for warfarin continuation. PATIENTS AND METHODS Each study site consecutively registered 10 patients with NVAF who had been taking warfarin for at least 12 months. Demographic and clinical characteristics and international normalized ratio (INR) values were collected from medical records. Physicians responded to questionnaires exploring reasons for continuing warfarin therapy. RESULTS Overall, 313 patients treated with warfarin were registered at 33 sites. Mean ± SD age was 76.4±9.6 years; 62.9% of patients were male. The proportion of patients with INR values in the therapeutic range was 74.6% and 48.8% among patients aged ≥70 years and <70 years, respectively. Over half of the patients (51.4%) had been advised to switch from warfarin to DOACs; the primary physician-reported reason for this recommendation was superior safety and effectiveness. However, patients reported continuing warfarin because of the high price of DOACs (47.2%) and long-term positive experiences with warfarin (31.7%). The remaining 48.6% of patients with NVAF had never been counseled by their physicians about DOACs as an alternative to warfarin. For 76% of these patients, physicians favored warfarin for medical reasons, such as impaired renal function and controlled INR, but in the remaining patients, medical reasons for continuing warfarin were lacking. CONCLUSION Approximately half of the patients in this study were informed of warfarin alternatives primarily for improved efficacy and safety, but elected not to change regimens because of the high price of DOACs and long-term positive experiences with warfarin. In the remaining half, physician preference or specific patient characteristics prevented a change in therapy.
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Affiliation(s)
- Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo
| | - Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization, Kyushu Medical Center, Fukuoka
| | - Makoto Kida
- Medical & Development, Bristol-Myers Squibb KK, Tokyo
| | - Miki Imura
- PIH Medical Affairs, Pfizer Japan Inc, Tokyo, Japan
- Correspondence: Miki Imura, PIH Medical Affairs, Pfizer Japan Inc, Shinjuku Bunka Quint Building, 3-22-7, Yoyogi, Shibuya-ku, Tokyo 151-8589, Japan, Tel +81 805 001 3070, Fax +81 35 309 9198, Email
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Peng S, Deger KA, Ustyugova A, Gandhi P, Qiao N, Wang C, Kansal AR. Cost-effectiveness analysis of dabigatran versus rivaroxaban for stroke prevention in patients with non-valvular atrial fibrillation using real-world evidence in elderly US Medicare beneficiaries. Curr Med Res Opin 2018; 34:55-63. [PMID: 28862479 DOI: 10.1080/03007995.2017.1375470] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE Dabigatran and rivaroxaban have been approved by the US FDA to reduce the risk of stroke and systemic embolism in non-valvular atrial fibrillation (NVAF) patients. Newly published real-world evidence based on the US population found that elderly Medicare patients with NVAF treated with rivaroxaban experienced statistically significant increases in intracranial hemorrhage (ICH) and major extracranial bleeding, and statistically nonsignificant decreases in thromboembolic stroke and acute myocardial infarction (AMI) compared with dabigatran. This study assessed the cost-effectiveness of dabigatran vs. rivaroxaban for the treatment of US Medicare NVAF patients. METHODS A previously published Markov model was adapted to compare dabigatran and rivaroxaban. The model considered thromboembolic stroke, bleeding events, and AMI based on the published real-world event risks. Model outputs included clinical event rates, costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). RESULTS Dabigatran patients experienced fewer ICH and major extracranial bleeding events than rivaroxaban patients, but more stroke and AMI events. Dabigatran was found to yield lower costs and higher QALYs than rivaroxaban, with incremental costs of -$3534 and incremental QALYs of 0.004. Results remained consistent in sensitivity analyses, with a positive net monetary benefit (willingness-to-pay thresholds of $50,000 and $100,000 per QALY) for dabigatran over rivaroxaban for all model inputs tested. CONCLUSIONS In this study using US Medicare real-world data, dabigatran was found to dominate rivaroxaban. The analyses were limited by the short follow-up period of the real-world data and results may not be generalizable to other patient populations.
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Affiliation(s)
| | | | | | - Pranav Gandhi
- c Boehringer-Ingelheim Pharmaceuticals Inc. , Ridgefield , CT , USA
| | | | - Cheng Wang
- c Boehringer-Ingelheim Pharmaceuticals Inc. , Ridgefield , CT , USA
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Risk-Benefit Profile of Direct-Acting Oral Anticoagulants in Established Therapeutic Indications: An Overview of Systematic Reviews and Observational Studies. Drug Saf 2017; 39:1175-1187. [PMID: 27696300 PMCID: PMC5107188 DOI: 10.1007/s40264-016-0464-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Since 2008, the direct-acting oral anticoagulants (DOACs) have expanded the therapeutic options of cardiovascular diseases with recognized clinical and epidemiological impact, such as non-valvular atrial fibrillation (NVAF) and venous thromboembolism (VTE), and also in the preventive setting of orthopedic surgical patients. The large body of evidence, not only from pivotal clinical trials but also from ‘real-world’ postmarketing observational findings (e.g. analytical epidemiological studies and registry data) gathered to date allow for a first attempt at verifying a posteriori whether or not the pharmacological advantages of the DOACs actually translate into therapeutic innovation, with relevant implications for clinicians, regulators and patients. This review aims to synthesize the risk–benefit profile of DOACs in the aforementioned consolidated indications through an ‘evidence summary’ approach gathering the existent evidence-based data, particularly systematic reviews with meta-analyses of randomized controlled trials, as well as observational studies, comparing DOACs with vitamin K antagonists. Clinical evidence will be discussed and compared with major international guidelines to identify whether an update is needed. Controversial clinically relevant safety issues will be also examined in order to highlight current challenges and unsettled questions (e.g. actual bleeding risk in susceptible populations). It is anticipated that the large number of publications on NVAF or VTE (44 systematic reviews with meta-analyses and 12 observational studies retained in our analysis) suggests the potential existence of overlapping studies and calls for common criteria to qualitatively and quantitatively assess discordances, thus guiding future research.
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Costa FM, Ferreira J, Mendes M, Carmo J. Dabigatran in real-world atrial fibrillation. Thromb Haemost 2017; 116:754-63. [DOI: 10.1160/th16-03-0203] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/24/2016] [Indexed: 12/16/2022]
Abstract
SummaryIn the RE-LY clinical trial, dabigatran presented a better effectiveness/ safety profile when compared to warfarin. However, clinical trials are not very representative of the real-world setting. We aimed to assess the performance of dabigatran in real-world patients with atrial fibrillation (AF) by means of a systematic review and meta-analysis of observational comparison studies with vitamin K antagonists (VKA). We searched PubMed, Embase and Scopus databases until November 2015 and selected studies according to the following criteria: observational study performed with nonvalvular AF patients; reporting adjusted hazard ratios (HR) of clinical events in a follow-up period; for dabigatran 75 mg, 110 mg or 150 mg versus VKA. Twenty studies were selected which included 711,298 patients, 210,279 of which were treated with dabigatran and the remaining 501,019 with VKA. Ischaemic stroke incidence was of 1.65 /100 patient-years for dabigatran and 2.85/100 patient-years for VKA (HR 0.86, 95 % confidence interval of 0.74–0.99). Major bleeding rate was 3.93/100 patient-years for dabigatran and 5.61/100 patient-years for VKA (0.79, 0.69–0.89). Risk of mortality (0.73, 0.61–0.87) and intracranial bleeding (0.45, 0.38–0.52) were significantly lower in patients treated with dabigatran when compared to patients on VKA. Risk of gastrointestinal (GI) bleeding was significantly higher in patients treated with dabigatran (1.13, 1.00–1.28). No significant difference was observed in risk of myocardial infarction (0.99, 0.89–1.11). In this combined analysis of real-world observational comparison studies with VKA, dabigatran was associated with a lower risk of ischaemic stroke, major bleeding, intracranial bleeding and mortality, higher risk of GI bleeding and a similar risk of myocardial infarction.Supplementary Material to this article is available online at www.thrombosis-online.com.
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Darwiche W, Bejan-Angoulvant T, Angoulvant D, Babuty D, Fauchier L. Risk of myocardial infarction and death in patients with atrial fibrillation treated with dabigatran or vitamin K antagonists. Thromb Haemost 2017; 116:1150-1158. [DOI: 10.1160/th16-06-0483] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 08/12/2016] [Indexed: 11/05/2022]
Abstract
SummaryThe safety of dabigatran versus adjusted-dose vitamin K antagonist (VKA) treatment is the subject of debate. We evaluated the risk of myocardial infarction (MI) or mortality in patients with atrial fibrillation (AF) treated in clinical practice with dabigatran or a VKA. We performed a meta-analysis of observational studies that included an adjusted or matched analysis and reported MI, or death in AF patients treated with dabigatran or a VKA. Ten published analyses met the inclusion criteria. Of the 539,559 patients, 17,365 (3%) patients were on dabigatran 110 mg twice daily (bid), 150,948 (28%) were on dabigatran 150 mg bid, and 371,246 (69%) were on VKA. Adjusted risk for MI versus VKA was 0.71 (0.47–1.07; p=0.10) in patients starting oral anticoagulant (OAC) treatment with dabigatran 110 mg, 0.82 (0.71–0.96; p=0.01) in patients starting dabigatran 150 mg, 1.40 (1.04–1.88; p=0.03) in patients switching OAC treatment to dabigatran 110 mg, and 1.28 (0.88–1.87; p=0.19) in patients switching OAC treatment to dabigatran 150 mg, with statistical homogeneity in each subgroup. Risk of death was consistently lower in patients treated with dabigatran 110 mg (HR 0.79; 0.65–0.96; p=0.02) or 150 mg (HR 0.65; 0.57–0.73; p<0.00001) versus VKA. In conclusion, dabigatran use, as currently prescribed in routine practice for AF patients, was associated with a lower risk of MI in OAC-naïve patients treated with dabigatran 150 mg compared with VKA, and a higher risk of MI in patients switching from VKA to dabigatran 110 mg. Risk of death was lower in AF patients treated with either dose of dabigatran versus VKA.
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Lemaitre M, Kirchgesner J, Rudnichi A, Carrat F, Zureik M, Carbonnel F, Dray-Spira R. Association Between Use of Thiopurines or Tumor Necrosis Factor Antagonists Alone or in Combination and Risk of Lymphoma in Patients With Inflammatory Bowel Disease. JAMA 2017; 318:1679-1686. [PMID: 29114832 PMCID: PMC5818785 DOI: 10.1001/jama.2017.16071] [Citation(s) in RCA: 379] [Impact Index Per Article: 54.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE An increased risk of lymphoma has been reported among patients receiving thiopurines for inflammatory bowel disease (IBD). The risk of lymphoma associated with anti-tumor necrosis factor (TNF) agents either alone or in combination with thiopurines is uncertain. OBJECTIVE To assess the risk of lymphoma associated with thiopurines and anti-TNF agents, used alone or in combination, for the management of IBD. DESIGN, SETTING, AND PARTICIPANTS Nationwide cohort study based on French National Health Insurance databases. Patients aged 18 years or older identified with IBD were included from January 1, 2009, through December 31, 2013, and followed up until December 31, 2015. EXPOSURES At each time of the follow-up, patients were categorized as being exposed to thiopurine monotherapy, anti-TNF monotherapy, or combination therapy, or being unexposed. MAIN OUTCOMES AND MEASURES The primary outcome was incident lymphoma. RESULTS Among the 189 289 patients included (54% women; median age, 43 years [interquartile range, 32-56 years]) and followed up for a median of 6.7 years, 123 069 were never exposed during follow-up, 50 405 were exposed to thiopurine monotherapy, 30 294 to anti-TNF monotherapy, and 14 229 to combination therapy. Overall, 336 lymphoma cases occurred: 220 in unexposed patients (incidence rate [IR] per 1000 person-years, 0.26; 95% CI, 0.23-0.29), 70 in patients exposed to thiopurine monotherapy (IR, 0.54; 95% CI, 0.41-0.67), 32 in patients exposed to anti-TNF monotherapy (IR, 0.41; 95% CI, 0.27-0.55), and 14 in patients exposed to combination therapy (IR, 0.95; 95% CI, 0.45-1.45). In a multivariable Cox model, compared with unexposed patients, the risk of lymphoma was higher among those exposed to thiopurine monotherapy (adjusted hazard ratio [aHR], 2.60; 95% CI, 1.96-3.44; P < .001), anti-TNF monotherapy (aHR, 2.41; 95% CI, 1.60-3.64; P < .001), or combination therapy (aHR, 6.11; 95% CI, 3.46-10.8; P < .001). The risk was higher in patients exposed to combination therapy vs those exposed to thiopurine monotherapy (aHR, 2.35; 95% CI, 1.31-4.22; P < .001) or anti-TNF monotherapy (aHR, 2.53; 95% CI, 1.35-4.77; P < .001). CONCLUSIONS AND RELEVANCE Among adults with IBD, the use of thiopurine monotherapy or anti-TNF monotherapy was associated with a small but statistically significant increased risk of lymphoma compared with exposure to neither medication, and this risk was higher with combination therapy than with each of these treatments used alone. These findings may inform decisions regarding the benefits and risks of treatment.
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Affiliation(s)
- Magali Lemaitre
- Department of Epidemiology, Agence Nationale de Sécurité du Médicament et des produits de santé (ANSM), Saint-Denis, France
| | - Julien Kirchgesner
- Department of Epidemiology, Agence Nationale de Sécurité du Médicament et des produits de santé (ANSM), Saint-Denis, France
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique, UMR_S 1136, F-75012, Paris, France
- Department of Gastroenterology, Hôpital Saint Antoine, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Annie Rudnichi
- Department of Epidemiology, Agence Nationale de Sécurité du Médicament et des produits de santé (ANSM), Saint-Denis, France
| | - Fabrice Carrat
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique, UMR_S 1136, F-75012, Paris, France
- Department of Public Health, Hôpital Saint Antoine, AP-HP, F-75012, Paris, France
| | - Mahmoud Zureik
- Department of Epidemiology, Agence Nationale de Sécurité du Médicament et des produits de santé (ANSM), Saint-Denis, France
| | - Franck Carbonnel
- Department of Gastroenterology, Hôpitaux Universitaires Paris Sud, Assistance Publique-Hôpitaux de Paris, Université Paris-Sud, Le Kremlin Bicêtre, France
| | - Rosemary Dray-Spira
- Department of Epidemiology, Agence Nationale de Sécurité du Médicament et des produits de santé (ANSM), Saint-Denis, France
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Joung B. Real-world Data and Recommended Dosage of Non-vitamin K Oral Anticoagulants for Korean Patients. Korean Circ J 2017; 47:833-841. [PMID: 29171208 PMCID: PMC5711674 DOI: 10.4070/kcj.2017.0158] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 08/08/2017] [Accepted: 08/14/2017] [Indexed: 12/25/2022] Open
Abstract
Regulatory approvals of non-vitamin K antagonist oral anticoagulants (NOACs) have been based on large randomized phase III trials evaluating dabigatran, rivaroxaban, apixaban, or edoxaban relative to warfarin for atrial fibrillation (AF). The results of the trials showed that all NOACs were at least non-inferior to warfarin in the prevention of stroke/thromboembolism and showed lower rates of intracranial bleeding than those associated with warfarin. However, the trials were designed differently, varied in the inclusion/exclusion criteria, and used either one dose or a low/high dose of the NOAC drug. Some of these differences have challenged the ability to directly compare various NOACs, and comparative data on effectiveness and intracranial bleeding are sparse in "real-world" patients. Real-world data complement data from large randomized phase III trials by providing new aspects of the "real-world" absolute risks of ischemic and hemorrhagic stroke associated with NOACs vs. warfarin. Moreover, "real-world" fragile patients might have been included (e.g., patients with increased risk of bleeding, liver disease, and chronic kidney disease), although these patients would be less represented in trials. This paper introduces recently published real-world data of NOACs and further suggests the recommended dosage of NOACs for Korean patients.
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Affiliation(s)
- Boyoung Joung
- Division of Cardiology, Department of Internal Medicine, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Douros A, Renoux C, Coulombe J, Suissa S. Patterns of long-term use of non-vitamin K antagonist oral anticoagulants for non-valvular atrial fibrillation: Quebec observational study. Pharmacoepidemiol Drug Saf 2017; 26:1546-1554. [DOI: 10.1002/pds.4333] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/24/2017] [Accepted: 09/11/2017] [Indexed: 01/16/2023]
Affiliation(s)
- Antonios Douros
- Centre for Clinical Epidemiology; Lady Davis Institute-Jewish General Hospital; Montreal QC Canada
- Department of Epidemiology and Biostatistics; McGill University; Montreal QC Canada
- Institute of Clinical Pharmacology and Toxicology; Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health; Berlin Germany
| | - Christel Renoux
- Centre for Clinical Epidemiology; Lady Davis Institute-Jewish General Hospital; Montreal QC Canada
- Department of Epidemiology and Biostatistics; McGill University; Montreal QC Canada
| | - Janie Coulombe
- Centre for Clinical Epidemiology; Lady Davis Institute-Jewish General Hospital; Montreal QC Canada
- Department of Epidemiology and Biostatistics; McGill University; Montreal QC Canada
| | - Samy Suissa
- Centre for Clinical Epidemiology; Lady Davis Institute-Jewish General Hospital; Montreal QC Canada
- Department of Epidemiology and Biostatistics; McGill University; Montreal QC Canada
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