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Listigovers A, Lento C, Wilson DJ. Distinct antithrombin activation modes for fondaparinux and natural heparins detected using millisecond hydrogen deuterium exchange and collision induced unfolding. Int J Biol Macromol 2024; 273:132868. [PMID: 38838881 DOI: 10.1016/j.ijbiomac.2024.132868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 02/23/2024] [Accepted: 06/01/2024] [Indexed: 06/07/2024]
Abstract
Low molecular weight heparin and synthetic mimetics such as fondaparinux show different binding kinetics, protease specificity, and clinical effects. A combination of allosteric and template-mediated bridging mechanisms have been proposed to explain the differences in rate acceleration and specificity. The difficulty in working with heterogeneous heparin species has rendered a crystallographic interpretation of the differences in antithrombin activation between mimetics and natural heparin inaccessible. In this study, we examine the allosteric changes in antithrombin caused by binding fondaparinux, enoxaparin and depolymerized natural heparins using millisecond hydrogen deuterium exchange mass spectrometry (TRESI-HDX MS) and relate these conformational changes to complex stability in the gas phase using collision induced unfolding (CIU). This exploration reveals that in addition to the dynamic changes caused by fondaparinux, long chain heparins reduce structural flexibility proximal to Arg393, the cleavable residue in the reactive centre loop of the protein. These local changes in protein dynamics are associated with an increase in overall complex stability that increases with heparin chain length. Ultimately, these results shed light on the molecular mechanisms underlying differences in activity and specificity between heparin mimetics and natural heparins.
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Affiliation(s)
- Alex Listigovers
- Department of Chemistry, York University, Toronto M3J 1P3, Canada
| | - Cristina Lento
- Department of Chemistry, York University, Toronto M3J 1P3, Canada
| | - Derek J Wilson
- Department of Chemistry, York University, Toronto M3J 1P3, Canada.
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2
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Huo S, Cheng J. Rivaroxaban plus aspirin vs. dual antiplatelet therapy in endovascular treatment in peripheral artery disease and analysis of medication utilization of different lesioned vascular regions. Front Surg 2023; 10:1285553. [PMID: 38026492 PMCID: PMC10665835 DOI: 10.3389/fsurg.2023.1285553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Background In the management of Peripheral Arterial Disease (PAD), the administration of anticoagulant or antiplatelet agents is imperative. The use of Dual Antiplatelet Therapy (DAPT) in conjunction with rivaroxaban has shown potential in mitigating adverse outcomes. Given the heterogeneity in the pathology of lower limb arteries, there is a compelling case for individualized treatment strategies. Methods In a single-center retrospective study on pharmacotherapy for peripheral artery disease, patients were treated with either aspirin combined with rivaroxaban or aspirin coupled with clopidogrel. The primary efficacy outcome encompassed a composite of increases in the Rutherford classification, acute limb ischemia, amputations due to vascular causes, target lesion revascularization, myocardial infarction, ischemic stroke, and cardiovascular death. The primary safety outcome was major bleeding, as defined by the Thrombolysis in Myocardial Infarction (TIMI) criteria; meanwhile, major bleeding as categorized by the International Society on Thrombosis and Haemostasis (ISTH) served as a secondary safety outcome. The study differentiated between two subgroups: patients with only above-the-knee and below-the-knee arterial lesions. Results From January 2016 to December 2021, 455 patients received either clopidogrel plus aspirin or rivaroxaban plus aspirin following endovascular treatment (EVT). The rivaroxaban group (n = 220) exhibited a lower incidence of primary efficacy outcomes [49.1% vs. 60.4%, hazard ratio (HR) 0.77, P = 0.006] but had more TIMI major bleeding events (5.9% vs. 2.1%, HR 2.6, P = 0.04). ISTH major bleeding events did not show a significant difference, though a higher percentage of rivaroxaban patients discontinued medication due to bleeding (10% vs. 4.7%, HR 2.2, P = 0.03). In the above-the-knee arterial disease subgroup, the rivaroxaban group demonstrated a lower incidence of primary efficacy outcomes (28.2% vs. 45.2%, HR 0.55, P = 0.02). In the below-the-knee arterial disease subgroup, no significant difference was observed in the occurrence of primary efficacy events between the two groups (58.7% vs. 64.8%, HR 0.76, P = 0.14). Conclusion Rivaroxaban plus aspirin improved outcomes compared to DAPT in patients with lower extremity artery disease. Similar findings were observed in the above-the-knee artery lesion-only group. However, in the below-the-knee artery lesion-only group, rivaroxaban plus aspirin did not surpass DAPT in efficacy. Regarding safety, rivaroxaban plus aspirin exhibited higher bleeding risks and more frequent treatment discontinuation than aspirin combined with clopidogrel.
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Affiliation(s)
| | - Jun Cheng
- Department of Vascular Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Yamada N, Fukuda I, Nakamura M, Takayama M, Maeda H, Yamashita T, Ikeda T, Mo M, Yamazaki T, Okumura Y, Hirayama A. Prognostication of Patients with Pulmonary Thromboembolism with and without Residual Deep Vein Thrombosis: A Subanalysis of the J'xactly Study. Ann Vasc Dis 2023; 16:181-188. [PMID: 37779650 PMCID: PMC10539124 DOI: 10.3400/avd.oa.22-00111] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 06/04/2023] [Indexed: 10/03/2023] Open
Abstract
Objectives: It is unclear whether patients with acute pulmonary thromboembolism (PE) with and without residual deep vein thrombosis (DVT) have different prognoses, and there is debate over whether inferior vena cava filters (IVCFs) should be used in conjunction with oral anticoagulants in patients with venous thromboembolism (VTE). Materials and Methods: The J'xactly involved 1,016 patients and was a multicenter, prospective, observational research. In this subanalysis, 419 patients with PE with or without residual DVT who received rivaroxaban with or without IVCFs between February 2016 and April 2018 in Japan were examined. Results: Of 419 patients with PE, 320 had residual DVT. There was no difference between the groups with and without DVT in terms of the percentage of patients who experienced symptomatic PE recurrence (2.8% [9/320] vs. 3.0% [3/99]) or who died from VTE-related complications (0.9% [3/320] vs. 1.0% [1/99]). The percentages of patients with symptomatic PE recurrence were 0% and 3.2%, and the percentages of patients who died from VTE-related causes were 0% and 1.1%, respectively, in the groups with (n=39) and without (n=281) IVCF, albeit not being statistically different. Conclusion: Patients with PE with and without residual DVT did not have a different incidence of symptomatic PE recurrence. These results require additional study to be confirmed.
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Affiliation(s)
- Norikazu Yamada
- Department of Cardiology, Kuwana City Medical Center, Kuwana, Mie, Japan
| | - Ikuo Fukuda
- Department of Cardiology, Keimeikai Yokawa Hospital, Miki, Hyogo, Japan
| | | | - Morimasa Takayama
- Department of Cardiology, Sakakibara Heart Institute, Fuchu, Tokyo, Japan
| | - Hideaki Maeda
- Department of Heart and Vascular Center, Ukima Central Hospital, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Yokohama, Kanagawa, Japan
| | - Tsutomu Yamazaki
- Innovation and Research Support Center, International University of Health and Welfare, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Atsushi Hirayama
- Department of Cardiology, Osaka Police Hospital, Osaka, Osaka, Japan
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Migita S, Okumura Y, Fukuda I, Nakamura M, Yamada N, Takayama M, Maeda H, Yamashita T, Ikeda T, Mo M, Yamazaki T, Hirayama A. Rivaroxaban treatment for asymptomatic venous thromboembolism: insights from the J'xactly study. Thromb J 2023; 21:88. [PMID: 37599351 PMCID: PMC10440934 DOI: 10.1186/s12959-023-00528-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 08/02/2023] [Indexed: 08/22/2023] Open
Abstract
BACKGROUND An established treatment strategy for asymptomatic pulmonary embolism (PE) or deep vein thrombosis (DVT) remains uncertain in Japan; therefore, in this study, we clarify the characteristics and outcomes of symptomatic compared to asymptomatic patients with PE or DVT. METHODS This prospective, multicenter sub-analysis of the J'xactly study in Japan included 1,016 patients (mean age, 68; 41% male) with venous thromboembolism (VTE) treated with rivaroxaban. RESULTS Asymptomatic PE patients (47% of PE patients) were more likely to have active cancer and asymptomatic proximal DVT at lower severity than symptomatic PE patients, despite no differences in age, sex, or the proportion receiving intensive 30 mg/day-rivaroxaban. Patients with asymptomatic DVT (34% of DVT patients) were older, had higher rates of female sex, active cancer, and distal DVT, and received shorter, less intense rivaroxaban treatment. Incidences did not differ between asymptomatic and symptomatic PE patients for recurrent symptomatic VTE (hazard ratio [HR], 0.60; 95% confidence interval [CI], 0.22-1.62; P = 0.31) or major bleeding (HR, 0.68; 95% CI, 0.20-2.33; P = 0.58), nor between asymptomatic and symptomatic DVT patients for recurrent symptomatic VTE (HR, 0.56; 95% CI, 0.23-1.40; P = 0.21) and major bleeding (HR, 1.47; 95% CI, 0.54-3.97; P = 0.45). CONCLUSIONS The real-world composite adverse event rate for treatment with rivaroxaban, as physician-adjusted for dose and duration, was similar for asymptomatic and symptomatic patients regardless of the presence of PE or DVT, suggesting a favorable safety profile for potential rivaroxaban treatment for asymptomatic VTE.
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Affiliation(s)
- Shohei Migita
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Ohyaguchi-kamicho, Itabashi-ku, Tokyo, 173-8610, Japan.
| | - Ikuo Fukuda
- Department of Cardiology, Keimeikai Yokawa Hospital, Miki, Japan
| | | | - Norikazu Yamada
- Department of Cardiology, Kuwana City Medical Center, Kuwana, Japan
| | | | - Hideaki Maeda
- Department of Heart and Vascular Center, Ukima Central Hospital, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Yokohama, Japan
| | - Tsutomu Yamazaki
- Innovation and Research Support Center, International University of Health and Welfare, Tokyo, Japan
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Oride T, Sawada K, Shimizu A, Kinose Y, Takiuchi T, Kodama M, Hashimoto K, Kobayashi E, Nakatani E, Kimura T. Clinical trial assessing the safety of edoxaban with concomitant chemotherapy in patients with gynecological cancer-associated thrombosis (EGCAT study). Thromb J 2023; 21:57. [PMID: 37183245 PMCID: PMC10184411 DOI: 10.1186/s12959-023-00500-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 05/03/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Gynecological cancer is one of the highest risk factors for cancer-associated thrombosis (CAT). Although low-molecular-weight heparin (LMWH) is recommended as an anticoagulant for treating CAT, recent studies have shown that direct oral anticoagulants (DOACs) are an acceptable alternative. Patients with cancer require a series of chemotherapies concomitantly with DOAC administration; however, the extent to which these drugs influence DOAC blood concentrations is unknown. In this study, we measured the plasma concentration of edoxaban during chemotherapy for gynecological cancers to determine its safety. METHODS Patients histologically diagnosed with ovarian or uterine corpus cancer and CAT were recruited after primary surgery and before the initiation of postoperative adjuvant chemotherapy, including paclitaxel. Patients were administered edoxaban (30 or 60 mg) orally for CAT. The plasma concentrations of edoxaban and active factor Xa were determined and their percentage change before and after chemotherapy was calculated. Additionally, blood coagulation tests were analyzed. RESULTS Sixteen patients with gynecological cancer (12 with ovarian cancer and 4 with uterine corpus cancer) were enrolled. Among these, 15 samples were collected one day after chemotherapy initiation. During chemotherapy, the trough concentration of edoxaban changed from 17.6 ± 10.6 to 20.0 ± 15.6 ng/ml, and the mean percentage change in edoxaban concentration was 14.5%. Therefore, the trough concentrations of edoxaban, which represent excretion capacity, were not significantly increased by chemotherapy with paclitaxel. The area under the plasma edoxaban concentration-time curve and the active factor Xa concentration were also unaffected. CONCLUSION Patients with CAT and ovarian or uterine corpus cancer administered edoxaban orally showed no significant increase in the trough concentration of edoxaban while undergoing chemotherapy. This suggests the safety of edoxaban use during the treatment of gynecological cancers. TRIAL REGISTRATION EGCAT study; Japan Registry of Clinical Trials, jRCTs051190024.
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Affiliation(s)
- Tadashi Oride
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-15, Yamada-Oka, Suita City, Osaka, Japan
| | - Kenjiro Sawada
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-15, Yamada-Oka, Suita City, Osaka, Japan.
| | - Aasa Shimizu
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-15, Yamada-Oka, Suita City, Osaka, Japan
| | - Yasuto Kinose
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-15, Yamada-Oka, Suita City, Osaka, Japan
| | - Tsuyoshi Takiuchi
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-15, Yamada-Oka, Suita City, Osaka, Japan
| | - Michiko Kodama
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-15, Yamada-Oka, Suita City, Osaka, Japan
| | - Kae Hashimoto
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-15, Yamada-Oka, Suita City, Osaka, Japan
| | - Eiji Kobayashi
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-15, Yamada-Oka, Suita City, Osaka, Japan
| | - Eiji Nakatani
- Graduate School of Public Health, Shizuoka Graduate University of Public Health, Shizuoka, Japan
| | - Tadashi Kimura
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-15, Yamada-Oka, Suita City, Osaka, Japan
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Nakamura M, Fukuda I, Yamada N, Takayama M, Maeda H, Yamashita T, Ikeda T, Mo M, Yamazaki T, Okumura Y, Hirayama A. Duration of Initial Intensive Rivaroxaban Therapy for Patients With Venous Thromboembolism - Subanalysis of the J'xactly Study. Circ Rep 2023; 5:144-151. [PMID: 37025939 PMCID: PMC10072900 DOI: 10.1253/circrep.cr-23-0008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/16/2023] [Accepted: 02/19/2023] [Indexed: 04/08/2023] Open
Abstract
Background: Rivaroxaban, a direct oral anticoagulant, is used as a first-line treatment to prevent venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). However, whether 21 days is optimal for the initial treatment duration has not been investigated. Methods and Results: In this subanalysis of the prospective multicenter observational J'xactly study, which included 1,039 Japanese patients with acute symptomatic/asymptomatic DVT/PE who were prescribed rivaroxaban, the VTE recurrence rate and incidence of bleeding complications were assessed in 667 patients who underwent intensive rivaroxaban treatment (15 mg, twice daily) for a short (1-8 days), intermediate (9-16), or standard (17-24) duration. The short treatment duration group showed a tendency for increased VTE recurrence/aggravation compared with the standard treatment duration group (6.10% vs. 2.60% per patient-year). The intermediate treatment duration group showed a higher incidence of bleeding events than the standard treatment duration group (9.34% vs. 2.16% per patient-year), without major differences in patient characteristics between the groups. Conclusions: In this subanalysis of the real-world observational J'xactly study of VTE treatment and prevention in Japanese patients with acute symptomatic/asymptomatic DVT/PE, the standard initial intensive rivaroxaban treatment duration (17-24 days) appeared to be safe and effective, providing important insights into the clinical outcomes of the initial rivaroxaban treatment duration in this population.
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Affiliation(s)
| | - Ikuo Fukuda
- Department of Cardiology, Keimeikai Yokawa Hospital Miki Japan
| | - Norikazu Yamada
- Department of Cardiology, Kuwana City Medical Center Kuwana Japan
| | | | - Hideaki Maeda
- Department of Heart and Vascular Center, Ukima Central Hospital Tokyo Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute Tokyo Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine Tokyo Japan
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital Yokohama Japan
| | - Tsutomu Yamazaki
- Innovation and Research Support Center, International University of Health and Welfare Tokyo Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine Tokyo Japan
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Migita S, Okumura Y, Fukuda I, Nakamura M, Yamada N, Takayama M, Maeda H, Yamashita T, Ikeda T, Mo M, Yamazaki T, Hirayama A. Relationship between baseline D-dimer and prognosis in Japanese patients with venous thromboembolism: Insights from the J'xactly study. Front Cardiovasc Med 2023; 10:1074661. [PMID: 36844735 PMCID: PMC9949378 DOI: 10.3389/fcvm.2023.1074661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 01/18/2023] [Indexed: 02/11/2023] Open
Abstract
Background D-dimer is a biomarker of fibrin production and degradation, and changes in D-dimer concentration suggest fibrin clot formation, which is associated with thromboembolism and hypercoagulable states. Thus, an elevated D-dimer concentration could be a useful prognostic predictor for patients with venous thromboembolism (VTE). Methods and results In this subanalysis of the J'xactly study, a prospective multicenter study conducted in Japan, we examined the clinical outcomes of 949 patients with VTE stratified by baseline D-dimer concentration. The median D-dimer concentration was 7.6 μg/ml (low D-dimer group: <7.6 μg/ml [n = 473, 49.8%]; high D-dimer group: ≥7.6 μg/ml [n = 476, 50.2%]). The mean age of the patients was 68 years, and 386 patients (40.7%) were male. Compared with the low D-dimer group, the high D-dimer group had more frequent pulmonary embolism with or without deep vein thrombosis (DVT), proximal DVT, atrial fibrillation, or diabetes mellitus, and underwent intensive treatment with 30 mg/day rivaroxaban. The incidence of composite clinically relevant events (recurrence or exacerbation of symptomatic VTE, acute coronary syndrome [ACS], ischemic stroke, death from any cause, or major bleeding) was higher in the high D-dimer group than in the low D-dimer group (11.1% vs. 7.5% per patient-year; hazard ratio, 1.46; 95% confidence interval, 1.05-2.04; p = 0.025). There was no significant difference between the high and low D-dimer groups in the incidence of VTE (2.8% vs. 2.5% per patient-year, respectively; p = 0.788), ACS (0.4% per patient-year vs. not observed, respectively; p = 0.078), or major bleeding (4.0% vs. 2.1% per patient-year, respectively; p = 0.087), but there was a significant difference in the incidence of ischemic stroke (1.0% per patient-year vs. not observed, respectively; p = 0.004). Conclusion Elevated D-dimer concentration may be an important prognostic predictor in Japanese patients with VTE.Clinical Trial Registration: UMIN CTR, UMIN000025072 (https://www.umin.ac.jp/ctr/index.htm).
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Affiliation(s)
- Shohei Migita
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan,*Correspondence: Yasuo Okumura,
| | - Ikuo Fukuda
- Department of Cardiology, Keimeikai Yokawa Hospital, Miki, Japan
| | | | - Norikazu Yamada
- Department of Cardiology, Kuwana City Medical Center, Kuwana, Japan
| | | | - Hideaki Maeda
- Department of Heart and Vascular Center, Ukima Central Hospital, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Yokohama, Japan
| | - Tsutomu Yamazaki
- Innovation and Research Support Center, International University of Health and Welfare, Tokyo, Japan
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Mo M, Fukuda I, Nakamura M, Yamada N, Takayama M, Maeda H, Yamashita T, Ikeda T, Yamazaki T, Okumura Y, Hirayama A. Effectiveness and safety of the direct oral anticoagulant in acute distal deep vein thrombosis: From the prospective multicenter observational study, J'xactly, in Japan. Phlebology 2023; 38:4-15. [PMID: 36433754 DOI: 10.1177/02683555221141310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We assessed the effectiveness and safety of rivaroxaban in patients with isolated distal deep vein thrombosis (IDDVT). METHODS Symptomatic venous thromboembolism (VTE) and major bleeding were assessed. RESULTS Of 1016 patients with acute symptomatic/asymptomatic DVT and/or pulmonary embolism treated with rivaroxaban, 288 had IDDVT and 294 had proximal DVT (pDVT). The IDDVT group had fewer patients on the higher rivaroxaban dose (30 mg/day) (42.7% vs. 66.0%) and a shorter treatment duration (135.5 vs 369.5 days) than the pDVT group. VTE recurrence occurred in 14 and 11 patients with IDDVT and pDVT, respectively (2.89% vs. 2.29% per patient-year; p = 0.534). Major bleeding was less frequent in the IDDVT group (1.55% vs. 4.53% per patient-year; p = 0.044). Comparable effectiveness and safety were observed with 15 and 30 mg/day rivaroxaban in the IDDVT group. CONCLUSIONS Short-term, low-dose rivaroxaban seems safe and effective for IDDVT treatment.
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Affiliation(s)
- Makoto Mo
- Department of Cardiovascular Surgery, 73663Yokohama Minami Kyosai Hospital, Yokohama, Japan
| | - Ikuo Fukuda
- Department of Cardiology, Keimeikai Yokawa Hospital, Miki, Japan
| | | | - Norikazu Yamada
- Department of Cardiology, 38153Kuwana City Medical Center, Kuwana, Japan
| | - Morimasa Takayama
- Department of Cardiology, 26383Sakakibara Heart Institute, Fuchu, Japan
| | - Hideaki Maeda
- Division of Cardiovascular Surgery, 38113Nihon University School of Medicine, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, 36591Toho University Faculty of Medicine, Tokyo, Japan
| | - Tsutomu Yamazaki
- Innovation and Research Support Center, 34804International University of Health and Welfare, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, 38113Nihon University School of Medicine, Tokyo, Japan
| | - Atsushi Hirayama
- Department of Cardiology, 38420Osaka Police Hospital, Osaka, Japan
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Shim CY, Seo J, Kim YJ, Lee SH, De Caterina R, Lee S, Hong GR. Efficacy and safety of edoxaban in patients early after surgical bioprosthetic valve implantation or valve repair: A randomized clinical trial. J Thorac Cardiovasc Surg 2023; 165:58-67.e4. [PMID: 33726903 DOI: 10.1016/j.jtcvs.2021.01.127] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 01/28/2021] [Accepted: 01/28/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Early warfarin anticoagulation is recommended in patients undergoing surgical bioprosthetic valve implantation or valve repair. It is unclear whether non-vitamin K antagonist oral anticoagulants can be a full alternative to warfarin. This study aimed to compare efficacy and safety of edoxaban with warfarin in patients early after surgical bioprosthetic valve implantation or valve repair. METHODS The Explore the Efficacy and Safety of Edoxaban in Patients after Heart Valve Repair or Bioprosthetic Valve Replacement study was a prospective, randomized (1:1), open-label, clinical trial conducted from December 2017 to September 2019. Patients were randomly assigned to receive edoxaban (60 mg or 30 mg once daily) or warfarin for the first 3 months after surgical bioprosthetic valve implantation or valve repair. The primary efficacy outcome was a composite of death, clinical thromboembolic events, or asymptomatic intracardiac thrombosis. The primary safety outcome was the occurrence of major bleeding. RESULTS Of 220 participants, 218 (109 per group) were included in the modified intention-to-treat analysis. The primary efficacy outcome occurred in 4 patients (3.7%) taking warfarin and none taking edoxaban (risk difference, -0.0367; 95% confidence interval, -0.0720 to -0.0014; P < .001 for noninferiority). The primary safety outcome occurred in 1 patient (0.9%) taking warfarin and 3 patients (2.8%) taking edoxaban (risk difference, 0.0183; 95% confidence interval, -0.0172 to 0.0539; P = .013 for noninferiority). CONCLUSIONS Edoxaban is noninferior to warfarin for preventing thromboembolism and is potentially comparable for risk of major bleeding during the first 3 months after surgical bioprosthetic valve implantation or valve repair.
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Affiliation(s)
- Chi Young Shim
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jiwon Seo
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Jin Kim
- Department of Radiology, Research Institute of Radiological Science, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seung Hyun Lee
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Raffaele De Caterina
- Cardio-Thoracic and Vascular Department, Pisa University Hospital and University of Pisa, Pisa, Italy
| | - Sak Lee
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
| | - Geu-Ru Hong
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, Korea.
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Yamashita T, Fukuda I, Nakamura M, Yamada N, Takayama M, Maeda H, Ikeda T, Mo M, Yamazaki T, Okumura Y, Hirayama A. Clinical Outcome After Discontinuation of Anticoagulation Therapy in Japanese Patients With Venous Thromboembolism ― Insights From the J’xactly Study ―. Circ Rep 2022; 4:371-377. [PMID: 36032386 PMCID: PMC9360983 DOI: 10.1253/circrep.cr-22-0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 06/03/2022] [Accepted: 06/13/2022] [Indexed: 11/09/2022] Open
Abstract
Background: Rivaroxaban, a direct oral anticoagulant, is used as first-line treatment to prevent venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE). However, the frequency of rivaroxaban discontinuation and the subsequent clinical outcomes remain unclear. Methods and Results: The study was a subanalysis of the prospective, multicenter, observational J’xactly study, conducted in Japan, and included patients who underwent anticoagulant discontinuation without major bleeding and recurrent VTE. The modified intention-to-treat population (n=1,016) included 579 patients (57%) who underwent anticoagulant discontinuation during a mean follow-up period of 20.2 months (mean [±SD] anticoagulation period 6.9±6.2 months). Patients were divided into 3 groups: those with active cancer, those without active cancer and a transient risk factor for VTE, and those without active cancer or a transient risk factor and/or with previous VTE (unprovoked group). After discontinuation, VTE recurrence occurred in 4.1% of patients, with an annual incidence of 4.6%/year and an increased tendency in the unprovoked group; major bleeding occurred in 8 patients (1.4%; annual incidence 1.1%/year), of whom half were in the cancer group. Conclusions: This analysis of a real-world observational study provides data on VTE recurrence after rivaroxaban discontinuation, which will facilitate anticoagulant discontinuation according to individual risk-benefit considerations.
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Affiliation(s)
| | - Ikuo Fukuda
- Department of Cardiovascular Surgery, Suita Tokushukai Hospital
| | | | | | | | - Hideaki Maeda
- Division of Cardiovascular Surgery, Nihon University School of Medicine
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital
| | - Tsutomu Yamazaki
- Innovation and Research Support Center, International University of Health and Welfare
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
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11
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Fukamachi D, Okumura Y, Fukuda I, Nakamura M, Yamada N, Takayama M, Maeda H, Yamashita T, Ikeda T, Mo M, Yamazaki T, Hirayama A. Characteristics and clinical outcomes of Japanese patients with venous thromboembolism receiving under-dose rivaroxaban: subanalysis of J'xactly. Curr Med Res Opin 2022; 38:1059-1068. [PMID: 35502571 DOI: 10.1080/03007995.2022.2070379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Rivaroxaban is commonly prescribed to prevent venous thromboembolism (VTE). Although lower than standard dosages (under-dosing) may be administered in the real-world setting, data on subsequent clinical outcomes in Japanese patients are lacking. METHODS The prospective, multicenter, observational J'xactly study enrolled patients with acute symptomatic/asymptomatic deep vein thromboses (DVT), pulmonary embolism (PE), or both, who were prescribed rivaroxaban. This subanalysis investigated patient characteristics and outcomes associated with rivaroxaban under-dosing. RESULTS Among 1016 evaluable patients, 667 (65.6%) received an initial standard dosage of rivaroxaban (30 mg/day) and 349 (34.4%) received an initial under-dosage (20 mg/day, n = 22; 15 mg/day, n = 282; and 10 mg/day, n = 45). Those receiving an under-dose had significantly lower body weight and slower pulse rate compared with the standard-dose group regardless of DVT or PE status. Under-dosing was common for distal DVTs, but less frequent for massive/submassive PEs. There were no differences between under-dose and standard-dose groups in the incidences of recurring symptomatic VTEs (DVT: 1.77% vs. 3.35% per patient-year, p = .138; PE: 0.84% vs. 2.84% per patient-year, p = .208) or major bleeding (DVT: 3.55% vs. 3.41% per patient-year, p = .960; PE: not observed vs. 2.83% per patient-year, p = .132). CONCLUSIONS In the real-world setting, rivaroxaban under-dosing for patients with VTE occurred in those with lower body weight, slower pulse rate, distal DVT, or non-massive PEs. There were no statistically significant differences in the clinical outcomes for patients received under-dose of rivaroxaban at the discretion of the physicians in the clinical practice compared with those received standard dose of rivaroxaban.
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Affiliation(s)
- Daisuke Fukamachi
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Ikuo Fukuda
- Department of Cardiovascular Surgery, Suita Tokushukai Hospital, Suita, Japan
| | - Mashio Nakamura
- Department of Internal Medicine, Pediatrics and Cardiology, Nakamura Medical Clinic, Kuwana, Japan
| | - Norikazu Yamada
- Department of Cardiology, Kuwana City Medical Center, Kuwana, Japan
| | | | - Hideaki Maeda
- Division of Cardiovascular Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Yokohama, Japan
| | - Tsutomu Yamazaki
- Innovation and Research Support Center, International University of Health and Welfare, Tokyo, Japan
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12
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Choffat D, Farhoumand PD, Jaccard E, de la Harpe R, Kraege V, Benmachiche M, Gerber C, Leuzinger S, Podmore C, Truong MK, Dumans-Louis C, Marti C, Reny JL, Aujesky D, Rakovic D, Limacher A, Rossel JB, Baumgartner C, Méan M. Risk stratification for hospital-acquired venous thromboembolism in medical patients (RISE): Protocol for a prospective cohort study. PLoS One 2022; 17:e0268833. [PMID: 35609087 PMCID: PMC9128957 DOI: 10.1371/journal.pone.0268833] [Citation(s) in RCA: 4] [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: 11/06/2021] [Accepted: 05/09/2022] [Indexed: 12/04/2022] Open
Abstract
Background Hospital-acquired venous thromboembolism (VTE) is one of the leading preventable causes of in-hospital mortality. However, its risk assessment in medically ill inpatients is complicated due to the patients’ heterogeneity and complexity of currently available risk assessment models (RAMs). The simplified Geneva score provides simplicity but has not yet been prospectively validated. Immobility is an important predictor for VTE in RAMs, but its definition is inconsistent and based on subjective assessment by nurses or physicians. In this study, we aim to prospectively validate the simplified Geneva score and to examine the predictive performance of a novel and objective definition of in-hospital immobilization using accelerometry. Methods and analysis RISE is a multicenter prospective cohort study. The goal is to recruit 1350 adult inpatients admitted for medical illness in three Swiss tertiary care hospitals. We collect data on demographics, comorbidities, VTE risk and thromboprophylaxis. Mobility from admission to discharge is objectively measured using a wrist-worn accelerometer. Participants are followed for 90 days for the occurrence of symptomatic VTE (primary outcome). Secondary outcomes are the occurrence of clinically relevant bleeding, and mortality. The evolution of autonomy in the activities of daily living, the length of stay, and the occurrence of readmission are also recorded. Time-dependent area under the curve, sensitivity, specificity, and positive and negative predictive values are calculated for each RAM (i.e. the simplified and original Geneva score, Padua, and IMPROVE score) with and without the objective mobility measures to assess their accuracy in predicting hospital-acquired VTE at 90 days. Ethics and expected impact The ethics committee approved the protocol and the study was registered on ClinicalTrials.gov as NCT04439383. RISE has the potential to optimize VTE risk stratification, and thus to improve the quality of care of medically hospitalized patients.
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Affiliation(s)
- Damien Choffat
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- * E-mail:
| | - Pauline Darbellay Farhoumand
- Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - Evrim Jaccard
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Roxane de la Harpe
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Vanessa Kraege
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Malik Benmachiche
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Christel Gerber
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Salomé Leuzinger
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Clara Podmore
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Minh Khoa Truong
- Division of Pneumology, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Céline Dumans-Louis
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Christophe Marti
- Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - Jean-Luc Reny
- Division of General Internal Medicine, Department of Medicine, Geneva University Hospitals (HUG), Geneva, Switzerland
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Damiana Rakovic
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - Jean-Benoît Rossel
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
- CTU Bern, University of Bern, Bern, Switzerland
| | - Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marie Méan
- Division of Internal Medicine, Department of Medicine, Lausanne University Hospital (CHUV), Lausanne, Switzerland
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Oyakawa T, Fukumitsu M, Ebihara A, Shiga T. Relevance of Non-Bridging Therapy with Heparin during Temporary Interruption of Direct Oral Anticoagulants in Patients with Cancer-Associated Venous Thromboembolism. Ann Vasc Dis 2022; 15:121-125. [PMID: 35860816 PMCID: PMC9257392 DOI: 10.3400/avd.oa.22-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/21/2022] [Indexed: 12/01/2022] Open
Abstract
Objectives: To evaluate the relevance of non-bridging therapy with unfractionated heparin during the temporary, pre-procedural interruption of direct oral anticoagulants (DOACs) in patients with cancer-associated venous thromboembolism (VTE). Materials and Methods: This retrospective study included 142 patients with cancer and VTE who required temporary interruption of DOACs before invasive procedures. Data, including rates of VTE recurrence, non-major bleeding, and major bleeding, were compared between patients who received or not received alternative therapy with unfractionated heparin during interruption. Results: Sixty-eight patients were prescribed heparin, while 74 were not. There were no differences in age, body mass index, white blood cell count, hemoglobin level, or platelet count between the groups. VTE recurrence was observed in four (6%) and one (1%) patient in the heparin bridging and non-bridging groups, respectively (risk ratio [RR]: 4.4, 95% confidence interval [CI]: 0.50–38.0, p=0.19). Non-major bleeding occurred in three (4%) and two (3%) patients in the bridging and non-bridging groups (RR: 1.6, 95%CI: 0.28–9.48, p=0.67), while major bleeding occurred in 0 (0%) and three patients (4%) (p=0.25), respectively. Conclusion: Our findings confirm the relevance of non-bridging therapy with unfractionated heparin for reducing VTE risk during DOAC interruption in patients with cancer.
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Affiliation(s)
- Takuya Oyakawa
- Department of Onco-Cardiology/Cardiovascular Medicine, The Cancer Institute Hospital of Japanese Foundation for Cancer Research
| | - Masafumi Fukumitsu
- Department of Onco-Cardiology/Cardiovascular Medicine, The Cancer Institute Hospital of Japanese Foundation for Cancer Research
| | - Aya Ebihara
- Department of Clinical Examination Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research
| | - Taro Shiga
- Department of Onco-Cardiology/Cardiovascular Medicine, The Cancer Institute Hospital of Japanese Foundation for Cancer Research
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14
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Comparison of Enoxaparin and Rivaroxaban in the Prophylaxis of Deep Venous Thrombosis in Arthroplasty. Emerg Med Int 2021; 2021:2945978. [PMID: 34824871 PMCID: PMC8610719 DOI: 10.1155/2021/2945978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/10/2021] [Accepted: 11/01/2021] [Indexed: 11/17/2022] Open
Abstract
Background Pulmonary embolism is a serious early complication of arthroplasty procedures that can develop after deep venous thrombosis. The present study aimed to compare rivaroxaban and enoxaparin in terms of preventing DV and PE, and also in this study, we compared the complications due to these drugs in patients undergoing elective arthroplasty. Materials and Methods 214 patients were divided into three groups based on their treatment regimens. In group I, enoxaparin was used, in group II, rivaroxaban was used, and in group III, enoxaparin was used throughout hospitalization, and after hospital discharge, rivaroxaban was used. These three groups were compared according to the occurrence of deep venous thrombosis, pulmonary embolism, and major and minor complications. Results Major postoperative complications occurred in 5, 15, and 6 patients in group I, II, and III, respectively. Minor postoperative complications occurred in 10, 24, and 11 patients in group I, II, and III, respectively. No significant difference was found among the three groups. Deep venous thrombosis or pulmonary embolism was not observed in any patient. Conclusion Rivaroxaban was found to be as effective as enoxaparin in the prevention of deep venous thrombosis and other complications after arthroplasty. Moreover, oral rivaroxaban provided greater ease of use compared to subcutaneous enoxaparin. Based on these findings, we consider that rivaroxaban could be an effective alternative to enoxaparin.
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15
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Zhang L, Li M, Zhu Y, Shi Z, Zhang W, Gao B, Li L, Fang Z, Yang G, Han W, Wang L, Yin L, Ke X, Yue J, Gu Z, Liu Z. Efficacy and safety of rivaroxaban in patients with inferior vena cava filter placement without anticoagulation contraindications (EPICT): a prospective randomised controlled trial study protocol. BMJ Open 2021; 11:e045530. [PMID: 34697109 PMCID: PMC8547359 DOI: 10.1136/bmjopen-2020-045530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Inferior vena cava (IVC) filters are commonly used in patients with venous thromboembolism to prevent fatal pulmonary embolism, but the thrombosis risk increases after filter placement. Warfarin is a widely anticoagulant, but long-term monitoring and dose adjustments are required. Anticoagulation with rivaroxaban is more straightforward as it dose not require laboratory monitoring. This study compares the efficacy and safety of rivaroxaban and warfarin as an in anticoagulation therapy for patients with IVC filter placement. METHODS AND ANALYSIS This is a multicentre, randomised controlled trial. In total, 200 patients with deep vein thrombosis (DVT) with IVC filter implantation from 10 hospitals will be recruited. The patients will be randomised to the experimental group (rivaroxaban) or the control group (nadroparin overlapped with warfarin). The primary outcomes include death of any cause, pulmonary embolism (PE)-related death, bleeding and recurrent PE/DVT. The secondary outcomes include the percentage of other vascular events, IVC filter retrieval failure and net clinical benefits. This study aims to provide reliable, verification for the efficacy and safety of rivaroxaban antithrombotic therapy after IVC filter placement. ETHICS AND DISSEMINATION The study was approved by the Human Research Ethics Committee of the Second Affiliated Hospital of Zhejiang University School of Medicine (approval number: (2019) 295). The results will be disseminated through presentations at scientific conferences and publications in peer-reviewed journals TRIAL REGISTRATION NUMBER: NCT04066764.
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Affiliation(s)
- Libin Zhang
- Vascular Surgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Miaomiao Li
- Vascular Surgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Yuefeng Zhu
- Vascular Surgery, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Zhenyu Shi
- Vascular Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Wan Zhang
- Vascular Surgery, Huadong Hospital Affiliated to Fudan University, Shanghai, China
| | - Bin Gao
- Vascular Surgery, Shanghai Fifth People's Hospital, Shanghai, China
| | - Lubin Li
- Vascular Surgery, Qindao University Medical College Affiliated Yantai Yuhuangding Hospital, Yantai, Shandong, China
| | - Zhengdong Fang
- Vascular Surgery, Anhui Provincial Hospital, Hefei, Anhui, China
| | - Guangwei Yang
- Vascular Surgery, Zhejiang Provincial People's Hospital, Hangzhou, Zhejiang, China
| | - Wei Han
- Vascualr Surgery, Zhejiang Xiaoshan Hospital, Hangzhou, Zhejiang, China
| | - Linjun Wang
- Vascular Surgery, Third Peoplles Hospital of Hangzhou, Hangzhou, Zhejiang, China
| | - Li Yin
- Vascular Surgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Xueying Ke
- Vascular Surgery, Zhejiang University School of Medicine Sir Run Run Shaw Hospital, Hangzhou, Zhejiang, China
| | - Jianing Yue
- Vascular Surgery, Zhongshan Hospital Fudan University, Shanghai, China
| | - Zheng Gu
- Department of Clinical Medicine Engineering, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China
| | - Zhenjie Liu
- Vascular Surgery, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang, China
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16
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Hara N, Watanabe K, Miyazaki R, Nakamura T, Lee T, Nagata Y, Nozato T, Miyamoto T, Obayashi T, Ashikaga T. Administration of Direct Oral Anticoagulant Immediately after Unfractionated Heparin Bolus for the Treatment of Intermediate-High-Risk Pulmonary Thromboembolism. Ann Vasc Dis 2020; 13:370-376. [PMID: 33391553 PMCID: PMC7758599 DOI: 10.3400/avd.oa.20-00079] [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] [Indexed: 11/13/2022] Open
Abstract
Objective: This study aims to evaluate the efficacy and safety of direct oral anticoagulants (DOACs) after unfractionated heparin (UFH) bolus for the treatment of intermediate-high-risk pulmonary embolism. Materials and Methods: On the basis of initial treatment, 81 patients were divided into two groups: DOAC after UFH bolus infusion group (group D; n=32) and conventional therapy group (group C; n=49). The frequency of recurrence of venous thromboembolism (VTE) and bleeding within 6 months were compared. In addition, hospitalization length and thrombus reduction rate in the pulmonary artery on computed tomography (CT) at the chronic phase were assessed. Results: Recurrence of VTE was found in one (3.1%) and three patients (6.1%) (P=1.00) in groups D and C, respectively, whereas no bleeding events was found in group D and 8.2% of patients in group C (P=0.15). Group D showed shorter hospitalization (7.2±2.3 days) than group C (15.7±9.9 days; P<0.001). In the subset of patients with serial CT assessment (group D, n=20; group C, n=38), almost all thrombus of pulmonary artery were disappeared and the thrombus reduction rates were similar between the two groups (group D, 99.5%; group C, 97.1%; P=0.59). Conclusion: DOAC administration immediately after UFH bolus treatment has the same efficacy and safety, whereas hospitalization days were significantly shorter than the conventional treatment group.
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Affiliation(s)
- Nobuhiro Hara
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Keita Watanabe
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Ryoichi Miyazaki
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Tomofumi Nakamura
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Tetsumin Lee
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Yasutoshi Nagata
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Toshihiro Nozato
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Takamichi Miyamoto
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
| | - Toru Obayashi
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan.,Department of Clinical Engineering, Gunma Paz College, Takasaki, Gunma, Japan
| | - Takashi Ashikaga
- Department of Cardiology, Japanese Red Cross Musashino Hospital, Tokyo, Japan
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Baumgartner C, Klok FA, Carrier M, Limacher A, Moor J, Righini M, Beer JH, Peluso M, Rakovic D, Huisman MV, Aujesky D. Clinical Surveillance vs. Anticoagulation For low-risk patiEnts with isolated SubSegmental Pulmonary Embolism: protocol for a multicentre randomised placebo-controlled non-inferiority trial (SAFE-SSPE). BMJ Open 2020; 10:e040151. [PMID: 33444199 PMCID: PMC7678381 DOI: 10.1136/bmjopen-2020-040151] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION The clinical significance of subsegmental pulmonary embolism (SSPE) is currently unclear. Although growing evidence from observational studies suggests that withholding anticoagulant treatment may be a safe option in selected patients with isolated SSPE, most patients with this condition receive anticoagulant treatment, which is associated with a 90-day risk of recurrent venous thromboembolism (VTE) of 0.8% and major bleeding of up to 5%. Given the ongoing controversy concerning the risk-benefit ratio of anticoagulation for isolated SSPE and the lack of evidence from randomised-controlled studies, the aim of this clinical trial is to evaluate the efficacy and safety of clinical surveillance without anticoagulation in low-risk patients with isolated SSPE. METHODS AND ANALYSIS SAFE-SSPE (Surveillance vs. Anticoagulation For low-risk patiEnts with isolated SubSegmental Pulmonary Embolism, a multicentre randomised placebo-controlled non-inferiority trial) is an international, multicentre, placebo-controlled, double-blind, parallel-group non-inferiority trial conducted in Switzerland, the Netherlands and Canada. Low-risk patients with isolated SSPE are randomised to receive clinical surveillance with either placebo (no anticoagulation) or anticoagulant treatment with rivaroxaban. All patients undergo bilateral whole-leg compression ultrasonography to exclude concomitant deep vein thrombosis before enrolment. Patients are followed for 90 days. The primary outcome is symptomatic recurrent VTE (efficacy). The secondary outcomes include clinically significant bleeding and all-cause mortality (safety). The ancillary outcomes are health-related quality of life, functional status and medical resource utilisation. ETHICS AND DISSEMINATION The local ethics committees in Switzerland have approved this protocol. Submission to the Ethical Committees in the Netherlands and Canada is underway. The results of this trial will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT04263038.
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Affiliation(s)
- Christine Baumgartner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Marc Carrier
- Department of Medicine, The Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | | | - Jeanne Moor
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Marc Righini
- Division of Angiology and Haemostasis, Geneva University Hospital, University of Geneva, Geneva, Switzerland
| | - Jürg-Hans Beer
- Department of Internal Medicine, Cantonal Hospital of Baden, Baden, Switzerland
| | - Martina Peluso
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Damiana Rakovic
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Eichinger S, Lin M, Shi M, Grosso MA, Kyrle PA. Recurrent venous thromboembolism during anticoagulation with edoxaban or warfarin: A post hoc analysis of the Hokusai-VTE trial. Thromb Res 2020; 195:209-214. [DOI: 10.1016/j.thromres.2020.07.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 07/02/2020] [Accepted: 07/10/2020] [Indexed: 10/23/2022]
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19
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Okumura Y, Fukuda I, Nakamura M, Yamada N, Takayama M, Maeda H, Yamashita T, Ikeda T, Mo M, Kobayashi T, Niwa A, Matsuo H, Yokoi H, Koga M, Yamazaki T, Hirayama A. A Multicenter Prospective Observational Cohort Study to Investigate the Effectiveness and Safety of Rivaroxaban in Japanese Venous Thromboembolism Patients (The J'xactly Study). Circ J 2020; 84:1912-1921. [PMID: 32981924 DOI: 10.1253/circj.cj-20-0636] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND There is insufficient real-world data on the current status of Japanese patients with venous thromboembolism (VTE) or its treatment and prevention with rivaroxaban.Methods and Results:In this multicenter, prospective, observational study conducted in Japan, 1,039 patients with acute symptomatic/asymptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) with or without DVT prescribed rivaroxaban were enrolled at 152 institutions and observed for a median of 21.3 months. Mean age was 68.0±14.7 years, mean body weight was 60.3±14.1 kg, 59.0% were females, and 19.0% had active cancer. Incidences of recurrence or aggravation of symptomatic VTE (primary effectiveness outcome) and major bleeding (principal safety outcome) were 2.6% and 2.9% per patient-year, respectively. These outcomes did not differ between patients with DVT and those with PE (primary effectiveness outcome: 2.6% vs. 2.5% per patient-year, P=0.810; principal safety outcome: 3.5% vs. 2.4% per patient-year, P=0.394). The incidence of composite clinically relevant events, including recurrence or aggravation of symptomatic VTE, acute coronary syndrome, ischemic stroke, all-cause death, or major bleeding events, was 9.2% per patient-year. Multivariate analysis revealed that male sex, being underweight, having active cancer, chronic heart and lung disease, and previous stroke were independent determinants for composite clinically relevant events. CONCLUSIONS In Japanese clinical practice, a single-drug approach with rivaroxaban was demonstrated to be a valuable treatment for a broad range of VTE patients.
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Affiliation(s)
- Yasuo Okumura
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
| | - Ikuo Fukuda
- Department of Cardiovascular Surgery, Hirosaki University
| | | | | | | | - Hideaki Maeda
- Division of Cardiovascular Surgery, Nihon University School of Medicine
| | | | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital
| | | | | | | | | | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Tsutomu Yamazaki
- Innovation and Research Support Center, International University of Health and Welfare
| | - Atsushi Hirayama
- Division of Cardiology, Department of Medicine, Nihon University School of Medicine
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20
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Sorgi MW, Roach E, Bauer SR, Bass S, Militello M, Welch S, Lam S, Reddy AJ, Torbic H. Effectiveness and Safety of Twice Daily Versus Thrice Daily Subcutaneous Unfractionated Heparin for Venous Thromboembolism Prophylaxis at a Tertiary Medical Center. J Pharm Pract 2020; 35:190-196. [PMID: 33016183 DOI: 10.1177/0897190020961210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The direct comparison of twice daily (BID) and thrice daily (TID) dosing of subcutaneous low dose unfractionated heparin (LDUH) for venous thromboembolism (VTE) prophylaxis in a mixed inpatient population is not well-studied. OBJECTIVE This study evaluated the effectiveness and safety of BID compared to TID dosing of LDUH for prevention of VTE. METHODS Retrospective, single-center analysis of patients who received LDUH for VTE prophylaxis between July and September 2015. Outcomes were identified by ICD-9 codes. A matched cohort was created using propensity scores and multivariate analysis was conducted to identify independent risk factors for VTE. The primary outcome was incidence of symptomatic VTE. RESULTS In the full cohort, VTE occurred in 0.71% of patients who received LDUH BID compared to 0.77% of patients who received LDUH TID (p = 0.85). There was no difference in major (p = 0.85) and minor (p = 0.52) bleeding between the BID and TID groups. For the matched cohort, VTE occurred in 1.4% of BID patients and 2.1% of TID patients (p = 0.32). Major bleed occurred in 0.36% of BID patients and 0.52% of TID patients (p = 0.7), while a minor bleed was seen in 3.4% of BID patients and 2.1% of TID patients (p = 0.13). Personal history of VTE (p = 0.002) and weight (p = 0.035) were independently associated with increased risk of VTE. CONCLUSION This study did not demonstrate a difference in effectiveness or safety between BID and TID dosing of LDUH for VTE prevention.
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Affiliation(s)
- Meghan W Sorgi
- EHP Pharmacy Management, Cleveland Clinic, Independence, OH, USA
| | - Erin Roach
- Department of Pharmacy, Carolinas Medical Center, Charlotte, NC, USA
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Stephanie Bass
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | | | - Sarah Welch
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Simon Lam
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
| | - Anita J Reddy
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Heather Torbic
- Department of Pharmacy, Cleveland Clinic, Cleveland, OH, USA
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21
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Anticoagulation in Italian patients with venous thromboembolism and thrombophilic alterations: findings from START2 register study. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2020; 18:486-495. [PMID: 32955425 DOI: 10.2450/2020.0091-20] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/30/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Randomised control trials have assessed the efficacy and safety of direct oral anticoagulants in the prophylaxis and treatment of venous thromboembolism (VTE). Positive but limited results have been reported in patients with inherited thrombophilia. Using an Italian, multicentre, prospective registry of consecutive patients presenting with symptomatic, acute VTE, we aimed to assess which factors are involved in making the choice of the drug that best fits the patient's risk profile in a large real-world setting of VTE patients. MATERIALS AND METHODS We investigated 4,866 VTE patients who took oral anticoagulants in the period between 2012 and April 2018 to prevent a new thromboembolic episode. RESULTS The large majority of patients who underwent thrombophilic screening, regardless of the results obtained, were prescribed direct oral anticoagulants rather than conventional anticoagulant therapy (p<0.001). During anticoagulation, bleeding events occurred more frequently in patients on conventional anticoagulant therapy (4.2%) than in those receiving direct oral anticoagulants (1.8%) and an increase in bleeding events was observed in patients who tested positive at the thrombophilic screening. Overall, a higher number of recurrent VTE was observed in patients not screened for thrombophilia (n=36; 1.7%) than in those screened (n=20; 0.7%; adjusted odds ratio: 2.2; 95% confidence interval: 1.2-4.1). DISCUSSION The present data confirm previous findings from other post-marketing registries and suggest that the choice of oral anticoagulation is strongly driven by patients' characteristics and VTE manifestations. Factors leading to the prescription of thrombophilic screening may identify a patient with a lower risk of VTE recurrence during anticoagulation.
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22
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Tang Y. Score confidence intervals and sample sizes for stratified comparisons of binomial proportions. Stat Med 2020; 39:3427-3457. [DOI: 10.1002/sim.8674] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 03/25/2020] [Accepted: 06/03/2020] [Indexed: 11/10/2022]
Affiliation(s)
- Yongqiang Tang
- Tesaro Department of Biometrics 1000 Winter Street Waltham MA USA
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23
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Bolten SN, Knoll AS, Li Z, Gellermann P, Pepelanova I, Rinas U, Scheper T. Purification of the human fibroblast growth factor 2 using novel animal-component free materials. J Chromatogr A 2020; 1626:461367. [PMID: 32797846 DOI: 10.1016/j.chroma.2020.461367] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/11/2020] [Accepted: 06/22/2020] [Indexed: 11/17/2022]
Abstract
This paper analyzes the use of animal-component free chromatographic materials for the efficient purification of the human fibroblast growth factor 2 (hFGF-2). hFGF-2 is produced in Escherichia coli and purified via three different chromatography steps, which include a strong cation exchange chromatography as a capture step, followed by heparin affinity chromatography and an anion exchange chromatography as a polishing step. The affinity chromatography step is based on the animal-derived material heparin. Chemically produced ligands provide a viable alternative to animal-derived components in production processes, since they are characterized by a defined structure which leads to reproducible results and a broad range of applications. The alternative ligands can be assigned to adsorber of the mixed-mode chromatography (MMC) and pseudo-affinity chromatography. Eight different animal-component free materials used as adsorbers in MMC or pseudo-affinity chromatography were tested as a substitute for heparin. The MMCs were cation exchangers characterized with further functional residues. The ligands of the pseudo-affinity chromatography were heparin-like ligands which are based on heparin's molecular structure. The alternative methods were tested as a capture step and in combination with another chromatographic step in the purification procedure of hFGF-2. In each downstream step purity, recovery and yield were analysed and compared to the conventional downstream process. Two types of MMC - the column ForesightTM NuviaTM cPrimeTM from Bio-Rad Laboratories and the column HiTrapTM CaptoTM MMC from GE Healthcare Life Sciences - can be regarded as effective animal-component free alternatives to the heparin - based adsorber.
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Affiliation(s)
- Svenja Nicolin Bolten
- Institute of Technical Chemistry, Leibniz University of Hannover, Callinstraße 5, Hannover 30167, Germany
| | - Anne-Sophie Knoll
- Institute of Technical Chemistry, Leibniz University of Hannover, Callinstraße 5, Hannover 30167, Germany
| | - Zhaopeng Li
- Institute of Technical Chemistry, Leibniz University of Hannover, Callinstraße 5, Hannover 30167, Germany
| | - Pia Gellermann
- Institute of Technical Chemistry, Leibniz University of Hannover, Callinstraße 5, Hannover 30167, Germany
| | - Iliyana Pepelanova
- Institute of Technical Chemistry, Leibniz University of Hannover, Callinstraße 5, Hannover 30167, Germany
| | - Ursula Rinas
- Institute of Technical Chemistry, Leibniz University of Hannover, Callinstraße 5, Hannover 30167, Germany; Helmholtz Centre for Infection Research, Inhoffenstraße 7, Braunschweig 38124, Germany
| | - Thomas Scheper
- Institute of Technical Chemistry, Leibniz University of Hannover, Callinstraße 5, Hannover 30167, Germany.
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24
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Xiong W, Zhao Y, Xiong Y, Xu M, Pudasaini B, Du H, Guo X. Coagulation factor IV is an indicator of symptomatic pulmonary embolism in patients with primary lung cancer. CLINICAL RESPIRATORY JOURNAL 2019; 14:124-131. [PMID: 31747482 DOI: 10.1111/crj.13109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Revised: 11/14/2019] [Accepted: 11/15/2019] [Indexed: 12/24/2022]
Affiliation(s)
- Wei Xiong
- Department of Respiratory Medicine Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine Shanghai China
| | - Yunfeng Zhao
- Department of Respiratory Medicine Punan Hospital, Pudong New District Shanghai China
| | - Yifan Xiong
- Shanghai Jincai North Secondary School Shanghai China
| | - Mei Xu
- Department of Pediatrics Community Health Service Center of North Bund Shanghai China
| | - Bigyan Pudasaini
- Department of Internal Medicine Columbia Bainuo Clinic Shanghai China
| | - He Du
- Shanghai Pulmonary Hospital Affiliated to Tongji University School of Medicine Shanghai China
| | - Xuejun Guo
- Department of Respiratory Medicine Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine Shanghai China
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25
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Cormican D, Morkos MS, Winter D, Rodrigue MF, Wendel J, Ramakrishna H. Acute Perioperative Pulmonary Embolism-Management Strategies and Outcomes. J Cardiothorac Vasc Anesth 2019; 34:1972-1984. [PMID: 31883768 DOI: 10.1053/j.jvca.2019.11.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 11/12/2019] [Indexed: 12/20/2022]
Affiliation(s)
- Daniel Cormican
- Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA; Division of Critical Care Medicine, Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA
| | - Michael S Morkos
- Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA
| | - Daniel Winter
- Department of Anesthesiology, Northwestern Medicine, Chicago, IL
| | - Marc F Rodrigue
- Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA
| | - Justin Wendel
- Department of Anesthesiology, Allegheny Health Network, Pittsburgh, PA
| | - Harish Ramakrishna
- Division of Cardiovascular and Thoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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26
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Moll F, Baumgartner I, Jaff M, Nwachuku C, Tangelder M, Ansel G, Adams G, Zeller T, Rundback J, Grosso M, Lin M, Mercur MF, Minar E. Edoxaban Plus Aspirin vs Dual Antiplatelet Therapy in Endovascular Treatment of Patients With Peripheral Artery Disease: Results of the ePAD Trial. J Endovasc Ther 2019; 25:158-168. [PMID: 29552984 PMCID: PMC5862321 DOI: 10.1177/1526602818760488] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Purpose: To report a randomized study that investigated the safety (risk of major bleeds) and potential efficacy of edoxaban, an oral anticoagulant that targets the major components of arterial thrombi, to prevent loss of patency following endovascular treatment (EVT). Methods: Between February 2012 and June 2014, 203 patients who underwent femoropopliteal EVT were randomized to receive aspirin plus edoxaban or aspirin plus clopidogrel for 3 months in the Edoxaban in Peripheral Arterial Disease (ePAD) study (ClinicalTrials.gov identifier NCT01802775). Randomization assigned 101 patients (mean age 68.0±10.4 years; 67 men) to the edoxaban group and 102 patients (mean age 66.7±8.6 years; 78 men) to the clopidogrel group. The primary safety endpoint was bleeding as classified by the TIMI (Thrombolysis in Myocardial Infarction) criteria and ISTH (International Society of Thrombosis and Hemostasis) criteria; the efficacy endpoint was the rate of restenosis/reocclusion. Results: There were no major or life-threatening bleeding events in the edoxaban group, while there were 2 major and 2 life-threatening bleeding events in the clopidogrel group by the TIMI criteria. By the ISTH classification, there was 1 major and 1 life-threatening bleeding event vs 5 major and 2 life-threatening bleeding events, respectively [relative risk (RR) 0.20, 95% confidence interval (CI) 0.02 to 1.70]. The bleeding risk was not statistically different with either treatment when assessed by TIMI or ISTH. Following 6 months of observation, there was a lower incidence of restenosis/reocclusion with edoxaban compared with clopidogrel (30.9% vs 34.7%; RR 0.89, 95% CI 0.59 to 1.34, p=0.643). Conclusion: These results suggest that patients who have undergone EVT have similar risks for major and life-threatening bleeding events with edoxaban and aspirin compared with clopidogrel and aspirin. The incidence of restenosis/reocclusion events, while not statistically different, was lower with edoxaban and aspirin, but an adequately sized trial will be needed to confirm these findings.
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Affiliation(s)
- Frans Moll
- 1 Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Iris Baumgartner
- 2 Cardiovascular Research Cluster, Universität Bern, Switzerland
| | - Michael Jaff
- 3 Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | | | - Marco Tangelder
- 1 Department of Vascular Surgery, University Medical Center Utrecht, the Netherlands
| | - Gary Ansel
- 5 Vascular Services, Ohio Health Heart & Vascular Physicians, Columbus, OH, USA
| | - George Adams
- 6 Cardiovascular and Peripheral Vascular Research, Rex Hospital University of North Carolina Health System, Raleigh, NC, USA
| | - Thomas Zeller
- 7 Department of Angiology, Universitäts Herzzentrum, Bad Krozingen, Germany
| | - John Rundback
- 8 Interventional Institute, Holy Name Medical Center, Teaneck, NJ, USA
| | | | - Min Lin
- 4 Daiichi Sankyo Pharma Development, Edison, NJ, USA
| | | | - Erich Minar
- 9 Internal Medicine, Medical University Vienna, Austria
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27
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Takai S, Nakanishi N, Yokota I, Imai K, Yamada A, Kawasaki T, Okada T, Sawada T, Fujita H, Matoba S. Clot regression effects of rivaroxaban in the treatment of venous thromboembolism in patients with cancer (CRERIT-VTE cancer): study protocol. BMJ Open 2019; 9:e031698. [PMID: 31694850 PMCID: PMC6858172 DOI: 10.1136/bmjopen-2019-031698] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Anticoagulant therapy in patients with cancer with venous thromboembolism (VTE) increases the risk of both VTE recurrence and haemorrhagic complication. Direct oral anticoagulants (DOACs) have been shown to be effective in preventing VTE recurrence, and comparable to conventional therapy in preventing VTE recurrence in patients with advanced cancer. Rivaroxaban is a DOAC that causes thrombus regression, possibly through a profibrinolytic effect. Thrombus regression with initial treatment is essential for VTE patients. However, the thrombolytic effect of DOAC for VTE patients with cancer has not been fully examined. Therefore, in this study, we investigate the thrombolytic effect of rivaroxaban in patients with cancer who develop VTE. METHODS AND ANALYSIS This study is a single-arm, open-label, prospective interventional study. Forty patients aged from 20 to 75 years old at the time of consent who have been diagnosed with acute VTE and have active cancer are included. Patients are excluded if they have received thrombolytic therapy, have creatinine clearance of less than 30 mL/min, have expected a life expectancy of less than 6 months or have deep vein thrombosis limited to the distal lower leg. Eligible patients receive standard treatment with rivaroxaban (15 mg two times daily for 3 weeks, followed by 15 mg QD). The primary study endpoint is clot regression ratio as evaluated by contrast-enhanced CT imaging. CT imaging is obtained at baseline, 21±4 and 90±14 days after the start of rivaroxaban treatment. Secondary endpoints are the recurrence of VTE and haemorrhagic complications. ETHICS AND DISSEMINATION This study was approved by the institutional review board of the Kyoto Prefectural University of Medicine. Study results will be disseminated through peer-reviewed journals.Trial registration numberUMIN000027793.
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Affiliation(s)
- Shigeki Takai
- Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Naohiko Nakanishi
- Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Isao Yokota
- Biostatistics, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kojiro Imai
- Medical Innovation and Translational Medical Science, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Ayumu Yamada
- The Center for Quality Assurance in Research and Development, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takanori Kawasaki
- Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takashi Okada
- Cardiovascular Medicine, Kyoto City Hospital, Kyoto, Japan
| | - Takahisa Sawada
- Cardiovascular Medicine, Kyoto First Red Cross Hospital, Kyoto, Japan
| | - Hiroshi Fujita
- Cardiovascular Medicine, Kyoto Second Red Cross Hospital, Kyoto, Japan
| | - Satoaki Matoba
- Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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28
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Pina LM, Dong X, Zhang L, Samtani MN, Michelson AD, Justino H, Bonnet D, Harris KC, Jefferies J, McCrindle BW, Li JS. Rivaroxaban, a direct Factor Xa inhibitor, versus acetylsalicylic acid as thromboprophylaxis in children post-Fontan procedure: Rationale and design of a prospective, randomized trial (the UNIVERSE study). Am Heart J 2019; 213:97-104. [PMID: 31132584 DOI: 10.1016/j.ahj.2019.04.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Accepted: 04/16/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Fontan procedure is the final step of the 3-stage palliative procedure commonly performed in children with single ventricle physiology. Thrombosis remains an important complication in children after this procedure. To date, guideline recommendations for the type and duration of thromboprophylaxis after Fontan surgery are mainly based on extrapolation of knowledge gained from adults at risk for thrombosis in other clinical settings. Warfarin is being used off-label, and because of its multiple interactions with other drugs and food, a new alternative is highly desirable. Rivaroxaban, a direct Factor Xa inhibitor with a predictable pharmacokinetic profile, is a candidate to address this medical need. STUDY DESIGN The UNIVERSE study is a prospective, open-label, active-controlled, multicenter study in children 2 to 8 years of age who have single ventricle physiology and had the Fontan procedure within the 4 months preceding enrollment. This study consists of 2 parts. In Part A, rivaroxaban pharmacokinetics, pharmacodynamics, safety, and tolerability are assessed to validate the pediatric dosing selected. In Part B, safety and efficacy of rivaroxaban versus acetylsalicylic acid are evaluated for thromboprophylaxis in children post-Fontan procedure. Children in each part will receive study drug for 12 months. Part A has been completed with 12 children enrolled. Enrollment into Part B is currently ongoing. CONCLUSIONS The UNIVERSE study aims to provide dosing, pharmacokinetics/pharmacodynamics, safety, and efficacy information on the use of rivaroxaban, an oral anticoagulant, versus acetylsalicylic acid, an antiplatelet agent, in children with single ventricle physiology after the Fontan procedure.
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Affiliation(s)
| | - Xiangwen Dong
- Janssen Research and Development, LLC., Raritan, NJ 08869
| | - Liping Zhang
- Janssen Research and Development, LLC., Raritan, NJ 08869
| | | | | | | | | | - Kevin C Harris
- Children's Heart Centre, BC Children's Hospital, Vancouver, BC V6H 3N1, Canada
| | - John Jefferies
- The Heart Institute, Cincinnati Children's Hospital Medical Centre, Cincinnati, OH 45229
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29
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Oyakawa T, Muraoka N, Iida K, Kusuhara M, Mori K. Use of direct oral anti-coagulants for the treatment of venous thromboembolism in patients with advanced cancer: a prospective observational study. Int J Clin Oncol 2019; 24:876-881. [PMID: 30756270 DOI: 10.1007/s10147-019-01415-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 02/06/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND The efficacy of direct oral anti-coagulants (DOACs) for the treatment of venous thromboembolism (VTE) in Japanese patients with advanced cancer is largely unknown. METHODS This prospective single-center observational study enrolled Japanese patients with unresectable advanced cancer who started DOAC treatment for new-onset VTE between December 2015 and May 2018. Patients were followed for 3 months to evaluate bleeding and VTE recurrences. The primary study endpoint was major and non-major bleeding. RESULTS One hundred and forty-five of 147 enrolled patients were analyzed. Of these, 8 [5.5%, 95% confidence interval (CI) 2.8-10.5] and 29 patients (20%, 95% CI 14.3-27.2) experienced major and non-major bleeding, respectively. Patients with bleeding were more likely to have a poor performance status (PS) [hazard rate (HR) 2.04, 95% CI 1.15-3.63] and more frequent use of non-steroidal anti-inflammatory drugs (NSAIDs) (HR 2.75, 95% CI 1.62-4.67) relative to those without bleeding. In a multivariate analysis, combined DOAC and NSAID use correlated significantly with bleeding (odds ratio 4.63, 95% CI 1.70-12.9, p = 0.003). Among 105 of 145 patients included in the VTE recurrence assessment, 9 experienced a VTE recurrence (8.6%, 95% CI 4.6-15.5). CONCLUSIONS Our findings confirm the risk of bleeding during DOAC treatment for VTE in Japanese patients with advanced cancer, particularly those with poor PS and those using NSAIDs. The risk of bleeding in these patients may be reduced by avoiding the combined use of DOACs and NSAIDs.
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Affiliation(s)
- Takuya Oyakawa
- Division of Cardiology, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan.
| | - Nao Muraoka
- Division of Cardiology, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Kei Iida
- Division of Cardiology, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Masatoshi Kusuhara
- Research Institute, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
| | - Keita Mori
- Clinical Research Promotion Unit, Clinical Research Support Center, Shizuoka Cancer Center, 1007 Shimonagakubo, Nagaizumi-cho, Sunto-gun, Shizuoka, 411-8777, Japan
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30
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Oyakawa T, Muraoka N, Iida K, Kusuhara M. Effect of Switching from the Initial Direct Oral Anticoagulant to Another One on Exacerbation of Venous Thromboembolism in Patients with Cancer: A Retrospective Study. Ann Vasc Dis 2018; 11:531-534. [PMID: 30637010 PMCID: PMC6326063 DOI: 10.3400/avd.oa.18-00072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective: To determine the effect of switching from the initial direct oral anticoagulant (DOAC) to another DOAC on exacerbation of deep vein thrombosis (DVT). Materials and Methods: We retrospectively reviewed the data of patients with advanced cancer who experienced exacerbated DVT during initial treatment with DOAC due to new venous thromboembolism (VTE). After switching to another DOAC for VTE recurrence, changes in the thrombus and bleeding were evaluated for 3 months. Eighteen patients met these criteria. We compared the effect of anticoagulant switching on the switched-drug group in those 18 patients with the effect of no anticoagulant switching on the single-drug group of patients (n=78) with a similar background. Results: The recurrence rate of VTE in the switched-drug group was 6%. Non-major bleeding occurred in 11% of patients. Recurrent VTE occurred in 6% of patients in both the switched-drug and single-drug groups, respectively [risk ratio (RR): 0.9, 95% confidence interval (CI): 0.11–7.6]. Non-major bleeding occurred in 11% and 14% of patients in the switched-drug and single-drug groups, respectively (RR: 0.79, 95%CI: 0.19–3.2). Conclusion: Switching DOAC may be a treatment option for exacerbation of DVT in patients with advanced cancer.
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Affiliation(s)
- Takuya Oyakawa
- Division of Cardiology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Nao Muraoka
- Division of Cardiology, Shizuoka Cancer Center, Shizuoka, Japan
| | - Kei Iida
- Division of Cardiology, Shizuoka Cancer Center, Shizuoka, Japan
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31
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Ohmori H, Nakamura M, Kada A, Saito AM, Sanayama Y, Shinagawa T, Fujita H, Wakisaka A, Maruhashi K, Okumura A, Takizawa N, Murata H, Inoue M, Kaneko H, Taniguchi H, Kawasaki M, Sano N, Akaboshi S, Tanuma N, Sone S, Kumode M, Takechi T, Koretsune Y, Sumimoto R, Miyanomae T. Multicenter, Open-Label, Randomized Controlled Trial of Warfarin and Edoxaban Tosilate Hydrate for the Treatment of Deep Vein Thrombosis in Persons with Severe Motor Intellectual Disabilities. Kurume Med J 2018; 65:11-16. [PMID: 30158356 DOI: 10.2739/kurumemedj.ms651003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Sudden death in patients with severe motor and intellectual disabilities (SMID) is sometimes caused in part by pulmonary thromboembolism (PTE), and deep venous thrombosis (DVT) has drawn attention as a possible embolic source. Warfarin, which is a conventional therapeutic agent, is not easy to control appropriately, and daily management can be especially difficult in SMID patients. On the other hand, edoxaban tosilate hydrate, which has been newly approved for insurance coverage for the treatment of DVT, is not listed in the Guidelines for the Diagnosis, Treatment and Prevention of Pulmonary Thromboembolism and Deep Vein Thrombosis (DVT-PTE guidelines). The aim of this study is to evaluate the efficacy and safety of anticoagulation therapy (warfarin vs. edoxaban) in DVT treatment in SMID patients by means of an open-label, randomized controlled trial. The primary endpoint is the incidence of hemorrhagic events during 12 months of follow up.
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Affiliation(s)
- Hiromitsu Ohmori
- Department of Pediatrics, National Hospital Organization Yanai Medical Center.,Clinical Research Center, National Hospital Organization Nagoya Medical Center
| | - Mashio Nakamura
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine
| | - Akiko Kada
- Clinical Research Center, National Hospital Organization Nagoya Medical Center
| | - Akiko M Saito
- Clinical Research Center, National Hospital Organization Nagoya Medical Center
| | - Yoshitami Sanayama
- Department of Pediatrics, National Hospital Organization Shimoshizu Hospital
| | - Tomoe Shinagawa
- Department of Pediatrics, National Hospital Organization Aomori Hospital
| | - Hiroshi Fujita
- Department of Pediatrics, National Hospital Organization Aomori Hospital
| | - Akiko Wakisaka
- Department of Pediatrics, National Hospital Organization Iou Hospital
| | - Keiko Maruhashi
- Department of Pediatrics, National Hospital Organization Iou Hospital
| | - Akiko Okumura
- Department of Pediatrics, National Hospital Organization Toyama Hospital
| | - Noboru Takizawa
- Department of Pediatrics, National Hospital Organization Toyama Hospital
| | - Hiroaki Murata
- Department of Pediatrics, National Hospital Organization Mie Hospital
| | - Michiko Inoue
- Department of Pediatrics, National Hospital Organization Minami-Okayama Medical Center
| | - Hideo Kaneko
- Department of Clinical Research, National Hospital Organization Nagara Medical Center
| | - Hidekazu Taniguchi
- Department of Pediatric Neurosurgery, National Hospital Organization Shikoku Medical Center for Children and Adults
| | - Masayuki Kawasaki
- Department of Respiratory Medicine, National Hospital Organization Omuta Hospital
| | - Nozomi Sano
- Department of Pediatrics, National Hospital Organization Minami-Kyushu Hospital
| | - Shinjiro Akaboshi
- Department of Pediatrics, National Hospital Organization Tottori Medical Center
| | - Naoyuki Tanuma
- Department of Pediatrics, Tokyo Metropolitan Fuchu Medical Center for the Disabled
| | - Sui Sone
- Department of Pediatrics, Tokyo Metropolitan Higashiyamato Medical Center for Developmental/Multiple Disabilities
| | - Masao Kumode
- Department of Pediatrics, Biwako Gakuen Kusatsu Medical and Welfare Center
| | - Tomoki Takechi
- Department of Pediatrics, National Hospital Organization Kochi Hospital
| | - Yukihiro Koretsune
- Director General, National Hospital Organization Osaka National Hospital
| | - Ryo Sumimoto
- Department of Surgery, National Hospital Organization Yanai Medical Center
| | - Takeshi Miyanomae
- Department of Pediatrics, National Hospital Organization Minami Kyoto Hospital
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Bolten SN, Rinas U, Scheper T. Heparin: role in protein purification and substitution with animal-component free material. Appl Microbiol Biotechnol 2018; 102:8647-8660. [PMID: 30094590 PMCID: PMC6153649 DOI: 10.1007/s00253-018-9263-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 07/20/2018] [Accepted: 07/21/2018] [Indexed: 01/27/2023]
Abstract
Heparin is a highly sulfated polysaccharide which belongs to the family of glycosaminoglycans. It is involved in various important biological activities. The major biological purpose is the inhibition of the coagulation cascade to maintain the blood flow in the vasculature. These properties are employed in several therapeutic drugs. Heparin’s activities are associated with its interaction to various proteins. To date, the structural heparin-protein interactions are not completely understood. This review gives a general overview of specific patterns and functional groups which are involved in the heparin-protein binding. An understanding of the heparin-protein interactions at the molecular level is not only advantageous in the therapeutic application but also in biotechnological application of heparin for downstreaming. This review focuses on the heparin affinity chromatography. Diverse recombinant proteins can be successfully purified by this method. While effective, it is disadvantageous that heparin is an animal-derived material. Animal-based components carry the risk of contamination. Therefore, they are liable to strict quality controls and the validation of effective good manufacturing practice (GMP) implementation. Hence, adequate alternatives to animal-derived components are needed. This review examines strategies to avoid these disadvantages. Thereby, alternatives for the provision of heparin such as chemical synthesized heparin, chemoenzymatic heparin, and bioengineered heparin are discussed. Moreover, the usage of other chromatographic systems mimetic the heparin effect is reviewed.
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Affiliation(s)
- Svenja Nicolin Bolten
- Institute of Technical Chemistry, Leibniz University of Hannover, Callinstraße 5, 30167, Hannover, Germany
| | - Ursula Rinas
- Institute of Technical Chemistry, Leibniz University of Hannover, Callinstraße 5, 30167, Hannover, Germany
- Helmholtz Centre for Infection Research, Inhoffenstraße 7, 38124, Braunschweig, Germany
| | - Thomas Scheper
- Institute of Technical Chemistry, Leibniz University of Hannover, Callinstraße 5, 30167, Hannover, Germany.
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Okumura Y, Fukuda I, Nakamura M, Yamada N, Takayama M, Maeda H, Yamashita T, Ikeda T, Mo M, Yamazaki T, Hirayama A. Design and rationale for the Japanese Registry of Rivaroxaban Effectiveness & Safety for the Prevention of Recurrence in Patients with Deep Vein Thrombosis and Pulmonary Embolism (J'xactly) study. BMJ Open 2018; 8:e020286. [PMID: 29934383 PMCID: PMC6020936 DOI: 10.1136/bmjopen-2017-020286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Rivaroxaban, a factor Xa inhibitor used as a direct oral anticoagulant, is beneficial over warfarin in terms of food-drug interactions and the need for therapeutic monitoring in patients with acute venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism. Because there is little data regarding VTE treatment in Japan, a real-world survey of Japanese patients being treated with rivaroxaban for VTE is needed. METHODS AND ANALYSIS The Japanese Registry of Rivaroxaban Effectiveness & Safety for the Prevention of Recurrence in Patients with Deep Vein Thrombosis and Pulmonary Embolism has been established to investigate the clinical outcomes of rivaroxaban for the initial treatment and prevention of symptomatic recurrent VTE in Japanese patients with acute symptomatic/asymptomatic VTE. 150 institutions in Japan will enrol patients in the study; the target enrolment is 1000. All patients will be followed up two times a year for at least 18 months and up to 3 years after their enrolment. The primary outcome is symptomatic recurrent VTE occurring during the study period. The principal safety outcome is clinically relevant bleeding (ie, major bleeding or clinically relevant non-major bleeding) occurring during treatment. A clinical events committee will adjudicate all outcomes. ETHICS AND DISSEMINATION The study protocol has been approved by the Nihon University Itabashi Hospital, Clinical Research Ethics Committee and all local institutional ethics committees of the participating hospitals. Findings of the study will be presented in scientific sessions and will be published in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT03091621,UMIN000025072; Pre-results.
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Affiliation(s)
- Yasuo Okumura
- Division of Cardiology, Nihon University Itabashi Hospital, Tokyo, Japan
| | - Ikuo Fukuda
- Department of Cardiovascular Surgery, Hirosaki University, Graduate School of Medicine, Aomori, Japan
| | - Mashio Nakamura
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Norikazu Yamada
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | | | - Hideaki Maeda
- Division of Cardiovascular, Respiratory and General Surgery, Nihon University School of Medicine, Tokyo, Japan
| | - Takeshi Yamashita
- Department of Cardiovascular Medicine, The Cardiovascular Institute, Tokyo, Japan
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Makoto Mo
- Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital, Kanagawa, Japan
| | - Tsutomu Yamazaki
- Clinical Research Support Center, The University of Tokyo Hospital, Tokyo, Japan
| | - Atsushi Hirayama
- Division of Cardiology, Nihon University Itabashi Hospital, Tokyo, Japan
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Collet JP, Berti S, Cequier A, Van Belle E, Lefevre T, Leprince P, Neumann FJ, Vicaut E, Montalescot G. Oral anti-Xa anticoagulation after trans-aortic valve implantation for aortic stenosis: The randomized ATLANTIS trial. Am Heart J 2018; 200:44-50. [PMID: 29898848 DOI: 10.1016/j.ahj.2018.03.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 03/03/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Antithrombotic treatment regimen following transcatheter aortic valve replacement (TAVR) is not evidence-based. Apixaban, a non-vitamin K direct anticoagulant (NOAC) was shown to be superior to VKA and superior to aspirin to prevent cardioembolic stroke in non-valvular atrial fibrillation. It may have the potential to reduce TAVR-related thrombotic complications including subclinical valve thrombosis along with a better safety than the standard of care. DESIGN ATLANTIS is a multicenter, randomized, phase IIIb, prospective, open-label, superiority study comparing standard of care (SOC Group) versus an apixaban-based strategy (Anti-Xa Group) after successful TAVR (ClinicalTrials.gov NCT 02664649). Randomization is stratified according to the need for chronic anticoagulation therapy for a reason other than the TAVR procedure. In the experimental arm, patients receive 5 mg bid of apixaban or a reduced dose of 2.5 mg bid according to the drug label or when apixaban is combined with antiplatelet therapy. In the control arm, patients receive VKA therapy if there is an indication for oral anticoagulation or antiplatelet therapy alone (single or dual) or the combination of both if needed. The primary study end point is the composite of all-cause death, TIA/stroke, myocardial infarction, symptomatic valve thrombosis, pulmonary embolism, deep venous thrombosis, systemic embolism, life-threatening, disabling or major bleeding, according to the Valve Academic Research Consortium definitions. CONCLUSIONS ATLANTIS tests the superiority of an apixaban-based strategy versus the recommended standard of care strategy to reduce the risk of post-TAVR thromboembolic and bleeding complications in an all comer population.
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Xiong W, Zhao Y, Xu M, Guo J, Pudasaini B, Wu X, Liu J. The relationship between tumor markers and pulmonary embolism in lung cancer. Oncotarget 2018; 8:41412-41421. [PMID: 28575869 PMCID: PMC5522295 DOI: 10.18632/oncotarget.17916] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/01/2017] [Indexed: 11/25/2022] Open
Abstract
Background Tumor markers (TMs) and D-Dimer are both hallmarks of severity and prognosis of lung cancer. Tumor markers could be related to pulmonary embolism (PE) in lung cancer. Results The number of abnormal tumor markers of lung cancer patients with pulmonary embolism (3.9 ± 1.1vs1.6 ± 0.6,P 0.005) was more than that in patients without pulmonary embolism. TMs panel (P trend < 0.001), CEA (R2 0.735, P0.003) and CYFRA21-1 (R2 0.718, P0.005) were positively correlated with D-Dimer in patients with pulmonary embolism. The multivariate logistic regression analysis showed that, for tumor markers, TMs panel (OR5.98, P < 0.001) had the strongest correlation with pulmonary embolism. The AUC (area under curve) of TMs panel and CEA were 0.82 [95%CI (0.71–0.95), P < 0.001] and 0.71 [95%CI (0.62–0.84), P 0.002] by ROC (receiver operating characteristic) curve analysis, respectively. Materials and Methods Tumor markers were compared between lung cancer patients complicated with pulmonary embolism and those without pulmonary embolism Then the correlation between each tumor marker as well as panel of combined TMs and D-Dimer as well as pulmonary embolism were analyzed for patients with pulmonary embolism. Conclusions There is a relationship between tumor markers and pulmonary embolism in patients with lung cancer. The panel of combined tumor markers is a valuable diagnostic marker for pulmonary embolism in lung cancer.
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Affiliation(s)
- Wei Xiong
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yunfeng Zhao
- Department of Respiratory Medicine, Punan Hospital, Pudong New District, Shanghai, China
| | - Mei Xu
- Department of Respiratory Medicine, Gongli Hospital, Pudong New District, Second Military Medical University, Shanghai, China
| | - Jian Guo
- Department of Pulmonary Function Test, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Bigyan Pudasaini
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xueling Wu
- Department of Respiratory Medicine, Renji Hospital, Jiaotong University School of Medicine, Shanghai, China
| | - Jinming Liu
- Department of Cardio-Pulmonary Circulation, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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Palareti G. Bleeding with anticoagulant treatments. Hamostaseologie 2017; 31:237-42. [DOI: 10.5482/ha-1151] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 06/06/2011] [Indexed: 11/05/2022] Open
Abstract
SummaryAnticoagulation with vitamin K antagonists (VKAs) is effective in the prevention and treatment of thrombotic complications in many clinical conditions, including atrial fibrillation (that represents today the most frequent indication for anticoagulant treatment), venous thromboembolism, acute coronary syndromes and after invasive cardiac procedures. Bleeding is the most important complication of VKAs and a major concern for both physicians and patients, limiting a more widespread prescription of the treatment. As a result, a non negligible proportion of all the subjects who would have a clear clinical indication for anticoagulation do not receive an effective treatment.This review analyses the treatment- and person-associated risk factors for bleeding during VKAs. New oral anticoagulant drugs seems to overcome at least some of the limitations of VKAs. Potentially, they can allow a less demanding and more stable anticoagulant treatment, with less side-effects allowing that more patients can receive an appropriate anticoagulant treatment. Based on the so far available phase III clinical studies, it is possible to assume that these new drugs are associated with a risk of bleeding, that is probably related to the intensity of treatment.
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Brandao GMS, Junqueira DR, Rollo HA, Sobreira ML. Pentasaccharides for the treatment of deep vein thrombosis. Cochrane Database Syst Rev 2017; 12:CD011782. [PMID: 29199766 PMCID: PMC6486040 DOI: 10.1002/14651858.cd011782.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Standard treatment of deep vein thrombosis (DVT) is based on antithrombotic therapy, initially with parenteral administration of unfractionated heparin or low molecular weight heparins (LMWH) for five to seven days, then subsequent long-term therapy with oral vitamin K antagonists (e.g. warfarin). Pentasaccharides are novel anticoagulants that may be favourable over standard therapy due to their predictable effect, no need for frequent monitoring or re-dosing, and few known drug interactions. Heparin-induced thrombocytopenia, a harmful effect of heparins, appears to be rare during treatment with pentasaccharides. OBJECTIVES To assess the efficacy and harms of pentasaccharides for the treatment of deep vein thrombosis. SEARCH METHODS The Cochrane Vascular Information Specialist (CIS) searched the Specialised Register (22 March 2017) and the Cochrane Central Register of Controlled Trials (CENTRAL) (2017, Issue 2) (searched 22 March 2017). We searched clinical trials databases for details of ongoing or unpublished studies and the reference lists of relevant articles for additional citations. SELECTION CRITERIA We included randomised controlled trials in which people 18 years of age or older with a DVT confirmed by standard imaging techniques were allocated to receive a pentasaccharide (fondaparinux, idraparinux, or idrabiotaparinux) for the treatment of DVT in comparison with standard therapy or other treatments. DATA COLLECTION AND ANALYSIS We extracted data characterising the included trials according to the methods, participants, interventions, and outcomes. We assessed risk of bias using Cochrane's 'Risk of bias' tool and employed the GRADE methodology to evaluate the quality of the evidence.The main primary outcome for efficacy was recurrent venous thromboembolism (VTE), and the main primary outcome for harm was major and clinically relevant bleeding. Since our outcomes were dichotomous, we calculated the risk ratio (RR) with a 95% confidence interval (CI). We combined the effects of different comparisons through a meta-analysis using a fixed-effect model. MAIN RESULTS We included five randomised controlled trials of 6981 participants comparing pentasaccharides with standard therapy or other pentasaccharides. The quality of the evidence varied depending on the outcome and was judged as of moderate to very low quality. We downgraded the quality of the evidence due to risk of bias or imprecision, or both.Two studies evaluated fondaparinux, at doses of 5.0 mg, 7.5 mg, and 10.0 mg, plus vitamin K antagonist in comparison with standard therapy. A meta-analysis of these two studies showed no clear difference in the risk of recurrent VTE (RR 0.80, 95% CI 0.43 to 1.47; 2658 participants); moderate-quality evidence. The frequencies of major bleeding were similar between interventions in the initial period of treatment (approximately five days) (RR 1.15, 95% CI 0.39 to 3.44; 2645 participants) and at three months' follow-up (RR 1.05, 95% CI 0.64 to 1.71; 2645 participants). We judged the quality of the evidence as moderate.One study (757 participants) compared idrabiotaparinux (3.0 mg) with idraparinux (2.5 mg) and demonstrated no clear difference in the risk of recurrent VTE at six months' follow-up (RR 0.72, 95% CI 0.31 to 1.69); low-quality evidence. Major bleeding during the initial treatment period was not reported. Major bleeding at six-month follow-up was less frequent in participants receiving idrabiotaparinux versus participants treated with idraparinux (RR 0.21, 95% CI 0.06 to 0.71); low-quality evidence.The effect of an initial treatment with LMWH followed by three months of idraparinux (10 mg) showed no clear difference from standard therapy for risk of recurrent VTE (RR 1.51, 95% CI 0.26 to 8.90; 263 participants); very low-quality evidence; one study. Major bleeding during the initial treatment period was not reported. The frequency of major and other clinically relevant bleeding at three months' follow-up ranged from 2% to 15% in participants receiving LMWH and increasing doses of idraparinux of 2.5 mg, 5 mg, 7.5 mg, or 10 mg. When dosage groups were combined, there was no clear difference in major plus other clinically relevant bleeding or in major bleeding alone between the idraparinux treatment group and the standard therapy group (RR 1.30, 95% CI 0.70 to 2.40; 659 participants; RR 3.76, 95% CI 0.50 to 28.19; 659 participants, respectively); very low-quality evidence.One study (2904 participants) compared idraparinux (2.5 mg) to standard therapy. There was no clear difference in the risk of recurrent VTE at three months' follow-up (RR 0.98, 95% CI 0.64 to 1.48); low-quality evidence. Major bleeding during the initial treatment period was not reported. Major bleeding at three months of follow-up appeared to be similar in the idraparinux group and the standard therapy group (RR 0.71, 95% CI 0.34 to 1.47); very low-quality evidence. AUTHORS' CONCLUSIONS We found moderate-quality evidence that the effects of fondaparinux at doses of 5.0 mg, 7.5 mg, and 10.0 mg plus vitamin K antagonist are similar in terms of recurrent VTE and risk of major bleeding compared with standard treatment for DVT.Low-quality evidence suggests equal efficacy of idraparinux at 2.5 mg and the equimolar dose of 3.0 mg of idrabiotaparinux with regard to recurrent VTE, but a higher frequency of major bleeding was observed in participants treated with idraparinux.We judged evidence on the effectiveness of idraparinux compared with standard therapy, with or without initial treatment with LMWH, and on associated bleeding risk to be low to very low quality, therefore we have very limited confidence in the estimated effects.The observed similar effectiveness in terms of recurrent DVT and harmful effects in terms of bleeding risk with fondaparinux plus vitamin K antagonist compared to standard treatment for DVT suggest that it may be an alternative to conventional anticoagulants for the treatment of DVT in certain circumstances.
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Affiliation(s)
- Gustavo MS Brandao
- Faculdade de Medicina de BotucatuDepartment of Surgery and OrthopedicsAv. Professor Montenegro Distrito de Rubiao Junior s/nBotucatuSPBrazil18618‐970
| | - Daniela R Junqueira
- University of AlbertaFaculty of Dentistry and Medicine8215 112 St NWSuite #1702, College PlazaEdmontonAlbertaCanadaT6G 2C8
| | - Hamilton A Rollo
- Faculdade de Medicina de BotucatuDepartment of Surgery and OrthopedicsAv. Professor Montenegro Distrito de Rubiao Junior s/nBotucatuSPBrazil18618‐970
| | - Marcone L Sobreira
- Faculdade de Medicina de BotucatuDepartment of Surgery and OrthopedicsAv. Professor Montenegro Distrito de Rubiao Junior s/nBotucatuSPBrazil18618‐970
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Cohen A, Dobromirski M. The use of rivaroxaban for short- and long-term treatment of venous thromboembolism. Thromb Haemost 2017; 107:1035-43. [DOI: 10.1160/th11-12-0859] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 02/04/2012] [Indexed: 12/22/2022]
Abstract
SummaryVenous thromboembolism (VTE) is a major healthcare concern and affects more than 1.6 million individuals each year worldwide. Long-term complications include recurrent VTE, chronic thromboembolic pulmonary hypertension and post-thrombotic syndrome. Rivaroxaban is an oral, direct factor Xa inhibitor that has advantages over traditional VTE therapies, including minimal drug and food interactions and no requirement for routine coagulation monitoring. It is currently approved for VTE prevention in adult patients undergoing elective hip or knee replacement surgery. This review evaluates the potential clinical implications of the multicentre, randomised EINSTEIN studies (EINSTEIN DVT and EINSTEIN EXT), which investigated rivaroxaban for the treatment and prevention of recurrent VTE. In EINSTEIN DVT, rivaroxaban was non-inferior to the standard of care (enoxaparin plus a vitamin K antagonist) for recurrent VTE in patients with acute deep-vein thrombosis (DVT) without pulmonary embolism (PE). In EINSTEIN EXT, extended-duration rivaroxaban had superior efficacy to placebo in patients with confirmed DVT or PE who had received 6–12 months of prior VTE treatment. Rivaroxaban was associated with an acceptable safety profile in both studies. The net clinical benefit (efficacy and safety end-points combined) of rivaroxaban was significantly greater than its comparators. The EINSTEIN studies are the first demonstration that a single drug - rivaroxaban - can be effective for both the initial treatment of DVT and prevention of recurrent VTE. Moreover, the simple, once-daily oral administration of rivaroxaban could potentially improve adherence to extended-duration VTE treatment compared with the current standard of care in individuals with confirmed DVT or PE.
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Antonucci E, Lip G, Testa S, Guazzaloca G, Falanga A, Pengo V, Poli D, Palareti G. The SAME-TT2R2 score predicts the quality of anticoagulation control in patients with acute VTE. Thromb Haemost 2017; 115:1101-8. [DOI: 10.1160/th15-10-0830] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 01/18/2016] [Indexed: 01/01/2023]
Abstract
SummaryThe SAMe-TT2R2 score has recently been proposed to predict the quality of vitamin K antagonist (VKA) anticoagulation control in patients with atrial fibrillation. We aimed at investigating whether the score is effective also in patients with venous thromboembolism (VTE). Patients included in the START-Register because started VKA therapy for a recent VTE episode and with > 3 months follow-up were analyzed. The score was calculated using the baseline patient’s characteristics present in the electronic database of the registry, where all INR results were also available and analysed to calculate the time in therapeutic range (TTR). A total of 1308 patients (53.4 % female, median age 68 years) were analysed. During 998 patient-years followup, the median TTR was 63 %. The maximum score in the patients was 4, with 70 % of them having 0–1. INR controls within range (2.0–3.0) were significantly less prevalent in patients with score ≥ 2 vs 0–1 score (58.5 ± 20 % vs 61.5 ± 19 %, respectively, p = 0.046). Patients with score ≥ 2 vs 0–1 had a highly significant lower TTR during the first 3 months of therapy (53 ± 26 % and 61 ± 26 %, respectively; p=0.0001), difference mainly due to more time spent below 2.0 INR (38 ± 28 % vs 31.3 ± 26.7 %, respectively; p=0.0001). In conclusion, the study proved, for the first time, that the SAMe-TT2R2 score is useful to predict among VTE patients those who will have good (score 0–1) or less good (score ≥ 2) VKA anticoagulation control. The score can help decision-making in everyday clinical practice, especially when choosing between VKA and non-vitamin K antagonists direct anticoagulants.Note: The review process for this paper was fully handled by Christian Weber, Editor in Chief.
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Ageno W, Beyer-Westendorf J. Benefit–risk profile of non-vitamin K antagonist oral anticoagulants in the management of venous thromboembolism. Thromb Haemost 2017; 113:231-46. [DOI: 10.1160/th14-06-0484] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 09/03/2014] [Indexed: 12/23/2022]
Abstract
SummaryThe prevention and treatment of venous thromboembolism (VTE) remains a clinical challenge, primarily owing to drawbacks associated with the use of heparins and vitamin K antagonists (VKAs). These and other factors, including a growing elderly population, mean that VTE presents a continuing burden to patients and physicians. Anticoagulant therapy is a fundamental approach for VTE management. Non- VKA oral anticoagulants, including the factor Xa inhibitors apixaban, edoxaban and rivaroxaban, and the thrombin inhibitor dabigatran, have been studied in phase III trials across a spectrum of thromboembolic disorders. These agents offer simplified care, with similar or improved efficacy and safety outcomes compared with heparins and vitamin K antagonists. There are several factors a physician must consider when prescribing an anticoagulant. An important consideration with all anticoagulant use is bleeding risk, especially in high-risk groups such as the elderly or those with renal impairment or cancer. In orthopaedic patients, other risks include a need for surgical revision or blood transfusion, or wound complications. Therefore, the clinical benefits of an anticoagulant should ideally be balanced with any risks associated with the therapy. Quantitative benefit–risk assessments are lacking, and owing to differences in trial design the non-VKA oral anticoagulants cannot be compared directly. Based on trial and “reallife” data, this review will summarise the clinical data for the non-VKA oral anticoagulants in the prevention and treatment of VTE, focusing on the balance between the benefits and risks of anticoagulation with these drugs, and their potential impact on VTE management.
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Abellás M, Menéndez A, Morillo R, Jara-Palomares L, Barrios D, Nieto R, Barbero E, Corres J, Ruiz-Artacho P, Jiménez D. Clinical Characteristics and Prognosis of Pulmonary Embolism Caused by Economy Class Syndrome. ACTA ACUST UNITED AC 2017. [DOI: 10.1016/j.arbr.2017.07.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Enea I, Roncon L, Gulizia MM, Azzarito M, Becattini C, Bongarzoni A, Casazza F, Cuccia C, D’Agostino C, Rugolotto M, Vatrano M, Vinci E, Fenaroli P, Formigli D, Silvestri P, Nardi F, Vedovati MC, Scherillo M. ANMCO Position Paper: the use of non-vitamin K dependent new oral anticoagulant(s) in pulmonary embolism therapy and prevention. Eur Heart J Suppl 2017; 19:D293-D308. [PMID: 28751847 PMCID: PMC5526474 DOI: 10.1093/eurheartj/sux026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The new oral anticoagulants (NOACs) have radically changed the approach to the treatment and prevention of thromboembolic pulmonary embolism. The authors of this position paper face, in succession, issues concerning NOACs, including (i) their mechanism of action, pharmacodynamics, and pharmacokinetics; (ii) the use in the acute phase with the 'double drug single dose' approach or with 'single drug double dose'; (iii) the use in the extended phase with demonstrated efficacy and with low incidence of bleeding events; (iv) the encouraging use of NOACs in particular subgroups of patients such as those with cancer, the ones under- or overweight, with renal insufficiency (creatinine clearance > 30 mL/min), the elderly (>75 years); (v) they propose a possible laboratory clinical pathway for follow-up; and (vi) carry out an examination on the main drug interactions, their potential bleeding risk, and the way to deal with some bleeding complications. The authors conclude that the use of NOACs both in the acute phase and in the extended phase is equally effective to conventional therapy and associated with fewer major bleeding events, which make their use in patients at higher risk of recurrences safer.
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Affiliation(s)
- Iolanda Enea
- Emergency Care Department, S. Anna e S. Sebastiano Hospital, Via G. Tescione, 1. 81100 Casert, Italy
| | - Loris Roncon
- Cardiology Department, S. Maria della Misericordia Hospital, Rovigo, Italy
| | - Michele Massimo Gulizia
- Cardiology Department, Garibaldi-Nesima Hospital, Azienda di Rilievo Nazionale e Alta Specializazione “Garibaldi”, Catania, Italy
| | | | - Cecilia Becattini
- Department of Internal and Vascular Medicine, Perugia General Hospital, Perugia, Italy
| | | | | | - Claudio Cuccia
- Cardiology Unit, Poliambulanza Foundation Hospital, Brescia, Italy
| | | | | | - Marco Vatrano
- CCU-Hemodynamics and Interventional Cardiology Department, Civil Pugliese Hospital, Catanzaro, Italy
| | - Eugenio Vinci
- Cardiology-CCU Department, Umberto I Hospital, Siracusa, Italy
| | - Paride Fenaroli
- Nephrology and Dialysis Unit, Salvatore Maugeri Foundation, University of Pavia, Pavia, Italy
| | - Dario Formigli
- Interventional Cardiology-CCU Department, G. Rummo Hospital, Benevento, Italy
| | - Paolo Silvestri
- Interventional Cardiology-CCU Department, G. Rummo Hospital, Benevento, Italy
| | - Federico Nardi
- Cardiology Department, Castelli Hospital, Verbania, Italy
| | - Maria Cristina Vedovati
- Department of Internale and Vascular Medicine, S. Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Marino Scherillo
- Interventional Cardiology-CCU Department, G. Rummo Hospital, Benevento, Italy
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A prospective study of Rivaroxaban for central venous catheter associated upper extremity deep vein thrombosis in cancer patients (Catheter 2). Thromb Res 2017; 162:88-92. [PMID: 28416213 DOI: 10.1016/j.thromres.2017.04.003] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 03/31/2017] [Accepted: 04/03/2017] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Patients with cancer are at increased risk of thrombosis, particularly those with central venous catheter (CVC) placement, which may predispose to the development of upper extremity deep vein thrombosis (UEDVT). Standard treatment includes low molecular weight heparin (LMWH) or LMWH bridged to warfarin. The direct oral anticoagulants (DOACs) have become standard of care for uncomplicated venous thromboembolism (VTE), but research in patients with cancer is ongoing. OBJECTIVES To assess rivaroxaban monotherapy in patients with cancer who develop UEDVT due to CVC for preservation of line function, and safety outcomes of VTE recurrence, bleeding risk and death. MATERIALS AND METHODS Patients ≥18years of age with active malignancy and symptomatic proximal UEDVT with or without pulmonary embolism (PE), associated with a CVC, were eligible. Treatment included rivaroxaban 15mg oral twice daily for 3weeks, followed by 20mg oral daily for 9weeks. Patients were followed clinically for 12weeks to assess for line function, recurrent VTE and bleeding. RESULTS Seventy patients (47 women) were included, with mean age 54.1years. The most common malignancy was breast cancer (41%). Preservation of line function was 100% at 12weeks. The risk of recurrent VTE at 12weeks was 1.43%, with one episode of fatal PE. 9 patients (12.9%) experienced 11 total bleeding episodes. CONCLUSIONS Rivaroxaban showed promise in treating CVC-UEDVT in cancer patients, resulting in preserved line function. However, bleeding rates and a fatal pulmonary embolism on treatment are concerning safety outcomes necessitating further study before rivaroxaban can be recommended.
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Padua prediction score or clinical judgment for decision making on antithrombotic prophylaxis: a quasi-randomized controlled trial. J Thromb Thrombolysis 2017; 42:336-9. [PMID: 27052516 DOI: 10.1007/s11239-016-1358-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The Padua prediction score (PPS) has been suggested as the best available model for the assessment of the risk of venous thromboembolism (VTE) in hospitalized medical patients. The impact of its use in clinical practice has never been prospectively evaluated. According to a quasi-randomized study design, consecutive patients admitted to Internal Medicine Section 1 were allocated to a PPS-based decisional strategy suggesting thromboprophylaxis in patients with PPS score ≥4, and those admitted to Section 2 to a clinical judgment-based strategy. Study patients underwent complete compression ultrasonography of the lower limbs at discharge. The primary outcome was symptomatic or asymptomatic VTE during hospital stay. Secondary outcomes were VTE excluding isolated distal deep vein thrombosis, bleedings, and appropriate thromboprophylaxis. 628 patients were included in the analysis, 235 in the PPS group, and 393 in the clinical judgment group. The two groups differed for length of hospital stay, prevalence of recent trauma or surgery, and stroke. Compared with control, the PPS group had a significantly lower incidence of VTE (8.5 vs. 15.5 %, OR 0.51, 95 % CI 0.30-0.86), also after adjusting for thromboprophylaxis use and patient PPS-risk category (OR 0.54, 95 % CI 0.31-0.94). In conclusion, the use of PPS was associated with a higher rate of appropriate thromboprophylaxis prescription; no significant differences were found in the other secondary outcomes. The use of PPS for the assessment of risk for VTE is associated with a reduced incidence of VTE compared with the clinical judgment. These result needs to be confirmed in future studies.
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Clinical Characteristics and Prognosis of Pulmonary Embolism Caused by Economy Class Syndrome. Arch Bronconeumol 2017; 53:495-500. [PMID: 28366298 DOI: 10.1016/j.arbres.2017.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Revised: 02/15/2017] [Accepted: 02/18/2017] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Clinical presentation and short-term prognosis of patients with travel-associated acute pulmonary embolism (PE) (i.e., economy class syndrome [ECS]) is not well understood. METHODS In this retrospective cohort study of patients with acute PE identified from a single center registry, we assessed the clinical presentation and the association between ECS and the outcomes of all-cause mortality, PE-related mortality, nonfatal venous thromboembolism and nonfatal major bleeding rates through 30days after initiation of PE treatment. RESULTS Of the 2,333 patients with acute symptomatic PE, 124 (5.3%; 95% confidence interval, 4.4-6.3%) had ECS. Patients with ECS were younger and had fewer comorbid diseases (recent bleeding, chronic obstructive pulmonary disease, congestive heart failure), but they presented with more signs of clinical severity (syncope [48% vs. 14%; P<.001], tachycardia [37% vs. 21%; P<.001], right ventricular dysfunction [31% vs. 19%; P<.01] and myocardial injury [57% vs. 28%; P<.001]) compared to those without ECS. Regression analyses showed a significantly lower risk of all-cause mortality for patients with ECS compared to patients without ECS (1.6% vs. 9.6%; P<.01). We did not detect a difference in PE-related mortality at 30days between those with and those without ECS (0.8% vs. 3.1%; P=.18). CONCLUSIONS PE patients with ECS are younger and have fewer comorbid diseases compared to those without ECS. Though they present with more signs of clinical severity, their short-term prognosis is excellent.
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Gouin B, Robert-Ebadi H, Righini M, Blondon M. Pharmacological management of pulmonary embolism. Expert Opin Pharmacother 2017; 18:79-93. [PMID: 27917690 DOI: 10.1080/14656566.2016.1268122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Pulmonary embolism (PE) is a common and potentially severe manifestation of venous thromboembolism. Its management has relied on anticoagulation by vitamin K antagonists (VKA) for the past fifty years. Recently, new alternative drugs have been developed and dramatically modified both the treatment of acute PE and its secondary prevention. Areas covered: This review discusses the contemporary pharmacological treatment for PE, with a focus on anticoagulation options for non-high risk PE. In particular, the advent of direct oral anticoagulants (rivaroxaban, apixaban, edoxaban and dabigatran) and modalities for long-term prevention will be described. Options for anticoagulation for pregnancy-related PE are presented separately. Expert opinion: Direct oral anticoagulants represent the first-line therapy of non-high risk PE, with better risk-benefit ratios compared with VKA due to lower bleeding risks. In specific groups of patients, however, older generations of anticoagulants such as VKA or heparins still play an important role. Multiple alternatives are available for the secondary prevention of PE, with different efficacies in reducing thrombotic risk and bleeding safety profiles.
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Affiliation(s)
- Bobby Gouin
- a Division of Angiology & Hemostasis , Geneva University Hospitals and Faculty of Medicine , Geneva , Switzerland.,b Division of General Internal Medicine , Université de Sherbrooke , Sherbrooke , Canada
| | - Helia Robert-Ebadi
- a Division of Angiology & Hemostasis , Geneva University Hospitals and Faculty of Medicine , Geneva , Switzerland
| | - Marc Righini
- a Division of Angiology & Hemostasis , Geneva University Hospitals and Faculty of Medicine , Geneva , Switzerland
| | - Marc Blondon
- a Division of Angiology & Hemostasis , Geneva University Hospitals and Faculty of Medicine , Geneva , Switzerland
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Trial design: Rivaroxaban for the prevention of major cardiovascular events after transcatheter aortic valve replacement: Rationale and design of the GALILEO study. Am Heart J 2017; 184:81-87. [PMID: 27892890 DOI: 10.1016/j.ahj.2016.10.017] [Citation(s) in RCA: 80] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 10/25/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Optimal antithrombotic treatment after transcatheter aortic valve replacement (TAVR) is unknown and determined empirically. The direct factor Xa inhibitor rivaroxaban may potentially reduce TAVR-related thrombotic complications and premature valve failure. DESIGN GALILEO is an international, randomized, open-label, event-driven, phase III trial in more than 1,520 patients without an indication for oral anticoagulation who underwent a successful TAVR (ClinicalTrials.govNCT02556203). Patients are randomized (1:1 ratio), 1 to 7days after a successful TAVR, to either a rivaroxaban-based strategy or an antiplatelet-based strategy. In the experimental arm, subjects receive rivaroxaban (10mg once daily [OD]) plus acetylsalicylic acid (ASA, 75-100mg OD) for 90days followed by rivaroxaban alone. In the control arm, subjects receive clopidogrel (75mg OD) plus ASA (as above) for 90days followed by ASA alone. In case new-onset atrial fibrillation occurs after randomization, full oral anticoagulation will be implemented with maintenance of the original treatment assignment. The primary efficacy end point is the composite of all-cause death, stroke, myocardial infarction, symptomatic valve thrombosis, pulmonary embolism, deep venous thrombosis, and systemic embolism. The primary safety end point is the composite of life-threatening, disabling, and major bleeding, according to the Valve Academic Research Consortium definitions. CONCLUSIONS GALILEO will test the hypothesis that a rivaroxaban-based antithrombotic strategy reduces the risk of thromboembolic complications post-TAVR with an acceptable risk of bleeding compared with the currently recommended antiplatelet therapy-based strategy in subjects without need of chronic oral anticoagulation.
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Yazıcı S, Kırış T, Sadık Ceylan U, Terzi S, Uzun AO, Emre A, Yeşilçimen K. Relation between dynamic change of red cell distribution width and 30-day mortality in patients with acute pulmonary embolism. CLINICAL RESPIRATORY JOURNAL 2017; 12:953-960. [PMID: 28063201 DOI: 10.1111/crj.12611] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 12/19/2016] [Accepted: 12/29/2016] [Indexed: 12/21/2022]
Abstract
INTRODUCTION AND OBJECTIVES Recent studies suggest that an increase in red cell distribution width (RDW) levels have a better prognostic value than a single measurement. In the current study, we investigated the predictive value of increasing RDW levels for mortality in acute pulmonary emboli (APE) patients. MATERIALS AND METHODS For the study, 199 APE patients who were hospitalized were enrolled. Patients were divided into three groups according to their admission and 24th hour RDW values. Patients for whom both RDW values normal were put in group 1 (normal); patients with admission RDW > 14.5% and decreased 24th hour RDW values were in group 2 (decreased); patients whose 24th hour RDW levels were >14.5% and increased compared to their baseline RDW measurement were in group 3 (increased). Clinical and laboratory findings and 30-day mortality of these groups were compared. RESULTS Mean patient age was 68 ± 16, and 48% of the patients were male. There were 98 patients (49%) in group 1, 59 patients (30%) in group 2, and 42 patients (21%) in group 3. Patients in group 3 were older, had lower eGFR and hemoglobin values, and had higher brain type natriuretic peptide values. Mortality rate was higher in group 3 (0%, 3.4%, 19%, respectively, P < .0001). Increase in RDW was independently related to mortality [HR: 4.9, (95%CI: 1.2-18, P = .02)]. CONCLUSION APE patients with increasing RDW levels have higher mortality rates. Serial measurements of RDW may help us determine patients with high risk for mortality.
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Affiliation(s)
- Selçuk Yazıcı
- Dr.Siyami Ersek Thoracic and Cardiovascular Surgery Center, Department of Cardiology, İstanbul, Turkey
| | - Tuncay Kırış
- Katip Celebi University, Atatürk Training and Research Hospital, Department of Cardiology, İzmir, Turkey
| | - Ufuk Sadık Ceylan
- Dr.Siyami Ersek Thoracic and Cardiovascular Surgery Center, Department of Cardiology, İstanbul, Turkey
| | - Sait Terzi
- Dr.Siyami Ersek Thoracic and Cardiovascular Surgery Center, Department of Cardiology, İstanbul, Turkey
| | - Ahmet Okan Uzun
- Dr.Siyami Ersek Thoracic and Cardiovascular Surgery Center, Department of Cardiology, İstanbul, Turkey
| | - Ayşe Emre
- Dr.Siyami Ersek Thoracic and Cardiovascular Surgery Center, Department of Cardiology, İstanbul, Turkey
| | - Kemal Yeşilçimen
- Dr.Siyami Ersek Thoracic and Cardiovascular Surgery Center, Department of Cardiology, İstanbul, Turkey
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Rivaroxaban versus standard anticoagulation for symptomatic venous thromboembolism (REMOTEV observational study): Analysis of 6-month outcomes. Int J Cardiol 2017; 226:103-109. [DOI: 10.1016/j.ijcard.2016.10.045] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 10/16/2016] [Accepted: 10/17/2016] [Indexed: 11/17/2022]
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Nakamura M, Yamada N, Ito M. Novel Anticoagulant Therapy of Venous Thromboembolism: Current Status and Future Directions. Ann Vasc Dis 2017; 10:92-98. [PMID: 29034033 PMCID: PMC5579781 DOI: 10.3400/avd.ra.17-00015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The first-line treatment of venous thromboembolisms (VTE) is anticoagulant therapy, and unfractionated heparin and warfarin are used in Japan. However, as both drugs require dosage adjustments that are difficult, VTE recurrences occur relatively frequently, and hemorrhagic complications are extremely common. The parenteral factor Xa inhibitor fondaparinux and the direct oral anticoagulants (DOACs) edoxaban, rivaroxaban, and apixaban have recently become available as treatments for VTE in Japan. These novel anticoagulants have more stable effects than traditional therapies and are thus considered safer and more effective than the traditional agents. Especially, DOACs offer improved long-term prevention of recurrence in patients with unprovoked VTE. The initiation of DOAC monotherapy soon after VTE onset leads to shorter hospital stays than required with the older therapies and allows for outpatient treatment. DOACs have additional benefits, such as safer anticoagulant therapy for cancer patients. These novel anticoagulants are extremely promising, but there is a current lack of evidence in areas such as dosing regimens for highly vulnerable patients and dosing for long-term use, and alternative regimens for each DOAC.
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Affiliation(s)
- Mashio Nakamura
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Norikazu Yamada
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
| | - Masaaki Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Mie, Japan
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