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Agewall S. New data on NOVEL ORAL ANTICOAGULANT, SGLT2i, lipid treatment and genetics. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2024; 10:83-84. [PMID: 38366031 DOI: 10.1093/ehjcvp/pvae005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 01/17/2024] [Indexed: 02/18/2024]
Affiliation(s)
- Stefan Agewall
- Institute of Clinical Sciences, Karolinska Institute of Danderyd, Stockholm Sweden
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Shaikh F, Wynne R, L. Castelino R, Inglis SC, Davidson PM, Ferguson C. Direct oral anticoagulant use in hospitalized patients with atrial fibrillation across body mass index categories: design and rationale for a retrospective cohort study. Ther Adv Drug Saf 2024; 15:20420986241227014. [PMID: 38300763 PMCID: PMC10823844 DOI: 10.1177/20420986241227014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/03/2024] [Indexed: 02/03/2024] Open
Abstract
Background Atrial fibrillation (AF) and obesity are common conditions globally; yet, there remains suboptimal pharmacological management contributing to high rates of hospitalization in patients with AF. The altered pathophysiology of both obese and underweight individuals may influence the pharmacology of medications, including those used to manage AF. This, in turn, increases the risk of adverse events and impacts patient risk for stroke and rehospitalization. Despite the well-established complications of obesity, research investigating the relationship between obesity and AF is scant. Objectives The primary aim of this study is to describe cardiovascular-related hospitalization in AF patients according to BMI categories. A secondary aim is to describe anticoagulant and antiarrhythmic prescribing practice patterns in patients with AF, according to the BMI category. Design A retrospective, exploratory descriptive observational cohort study, using routinely collected electronic medical record data from five public hospitals within a single health district, with a population dominantly that is culturally and linguistically diverse, and has a low socioeconomic status. Methods and analysis Data extraction will include a 24-month period (January 2017 to December 2018) with a 12-month follow-up. All adult (⩾18 years) patients at discharge diagnosed with AF, prescribed any oral anticoagulant and/or oral rate/rhythm control agent, will be eligible for inclusion. Ethics and dissemination Ethics approval from the health district and the University of Wollongong has been granted. Findings will seek to demonstrate associations between management strategies and patient outcomes, as well as describe patterns of acute care management from prescribers. These data will be used to inform and generate hypotheses for large-scale studies examining the impact of body weight on anticoagulation prescribing at national and global scales.
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Affiliation(s)
- Fahad Shaikh
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Rochelle Wynne
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
- The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Ronald L. Castelino
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pharmacy Department, Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, Australia
| | - Sally C. Inglis
- Improving Palliative, Aged and Chronic Care through Clinical Research and Translation (IMPACCT), University of Technology Sydney, Sydney, NSW, Australia
| | | | - Caleb Ferguson
- Centre for Chronic & Complex Care Research, Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, Australia
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
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Shaikh F, Wynne R, Castelino RL, Inglis SC, Davidson PM, Ferguson C. Practices, beliefs, and attitudes of clinicians in prescribing direct oral anticoagulants for obese adults with atrial fibrillation: a qualitative study. Int J Clin Pharm 2023:10.1007/s11096-023-01583-z. [PMID: 37253952 PMCID: PMC10228882 DOI: 10.1007/s11096-023-01583-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 03/24/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) and obesity affect over 60 and 650 million people, respectively. AIM This study aimed to explore clinician practices, beliefs, and attitudes towards the use of direct oral anticoagulants (DOACs) in obese adults (BMI ≥ 30 kg/m2) with AF. METHOD Semi-structured interviews via video conference were conducted with multidisciplinary clinicians from across Australia, with expertise in DOAC use in adults with AF. Clinicians were invited to participate using purposive and snowball sampling techniques. Data were analysed in NVIVO using thematic analysis. RESULTS Fifteen clinicians including cardiologists (n = 5), hospital and academic pharmacists (n = 5), general practitioners (n = 2), a haematologist, a neurologist and a clinical pharmacologist participated. Interviews were on average 31 ± 9 min. Key themes identified were: Health system factors in decision-making Disparities between rural and metropolitan geographic areas, availability of health services, and time limitations for in-patient decision-making, were described; Condition-related factors in decision-making Clinicians questioned the significance of obesity as part of decision-making due to the practical limitations of dose modification, and the rarity of the extremely obese cohort; Decision-making in the context of uncertainty Clinicians reported limited availability, reliability and awareness of primary evidence including limited guidance from clinical guidelines for DOAC use in obesity. CONCLUSION This study highlights the complexity of decision-making for clinicians, due to the limited availability, reliability and awareness of evidence, the intrinsic complexity of the obese cohort and limited guidance from clinical guidelines. This highlights the urgent need for contemporary research to improve the quality of evidence to guide informed shared decision-making.
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Affiliation(s)
- Fahad Shaikh
- School of Nursing, Faculty of Science, Medicine & Health, University of Wollongong, Wollongong, NSW, Australia.
| | - Rochelle Wynne
- School of Nursing, Faculty of Science, Medicine & Health, University of Wollongong, Wollongong, NSW, Australia
- The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Ronald L Castelino
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pharmacy Department, Blacktown Hospital, Western Sydney Local Health District, Blacktown, NSW, Australia
| | - Sally C Inglis
- Improving Palliative, Aged and Chronic Care Through Clinical Research and Translation (IMPACCT), University of Technology Sydney, Sydney, NSW, Australia
| | | | - Caleb Ferguson
- School of Nursing, Faculty of Science, Medicine & Health, University of Wollongong, Wollongong, NSW, Australia
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Rivaroxaban Monotherapy for Atrial Fibrillation and Coronary Artery Disease in Underweight/Obese Patients: Evidence Is Needed. JACC. ASIA 2022; 2:894-896. [PMID: 36713757 PMCID: PMC9877208 DOI: 10.1016/j.jacasi.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Erstad BL, Barletta JF. Dilemmas Related to Direct-Acting Oral Anticoagulant Administration in Patients With Extreme Obesity. Ann Pharmacother 2022; 57:727-737. [PMID: 36258660 DOI: 10.1177/10600280221130456] [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: 11/16/2022] Open
Abstract
OBJECTIVE The objective of the study was to discuss the controversies surrounding the use and dosing of direct-acting oral anticoagulants (DOACs) in obese patients recognizing the limitations of the existing evidence base that preclude strong recommendations. DATA SOURCES A literature search of MEDLINE was performed (2020 to end August 2022) subsequent to recent guidelines using the following search terms: direct acting anticoagulants, obesity, rivaroxaban, apixaban, edoxaban, dabigatran, dabigatran etexilate, and clinical practice guidelines. STUDY SELECTION AND DATA ABSTRACTION English-language studies and those conducted in adults were selected. DATA SYNTHESIS The available randomized studies evaluating DOACs had relatively small numbers of patients with more extreme forms of obesity (body mass index [BMI] > 40 kg/m2) and none of the larger studies had a specific focus on dosing DOACs in obese patients. Recent guidelines by the International Society on Thrombosis and Haemostasis (ISTH) have specific recommendations for dosing DOACs in obesity. There are pharmacokinetic/pharmacodynamic and observational studies published before and after the ISTH guidelines with a focus on DOAC dosing in obese patients that generally support the recommendations in the guidelines, but most involved small numbers of patients usually with BMIs <45 kg/m2. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This review discusses DOAC dosing in obesity with important considerations for clinicians related to DOAC choice and dosing. CONCLUSIONS Dosing alterations of DOACs do not appear to be necessary when used for either prophylaxis or treatment in patients with BMIs up to approximately 45 to 50 kg/m2, but research is needed for BMIs >50 kg/m2.
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Affiliation(s)
- Brian L Erstad
- Department of Pharmacy Practice and Science, The University of Arizona, Tucson, AZ, USA
| | - Jeffrey F Barletta
- Department of Pharmacy Practice, College of Pharmacy-Glendale Campus, Midwestern University, Glendale, AZ, USA
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Al Sulaiman K, Badreldin HA, Korayem GB, Alenazi AA, Alsuwayyid F, Alrashidi A, Alhijris M, Almutairi F, Alharthi F, Vishwakarma R, Al Shaya O, Al Amri A, Tayyab S, Al Bekairy AM, Aljuhani O. Evaluation of Apixaban safety and effectiveness in morbidly obese patients with atrial fibrillation: a retrospective cohort study. Thromb J 2022; 20:25. [PMID: 35501916 PMCID: PMC9063081 DOI: 10.1186/s12959-022-00379-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 03/31/2022] [Indexed: 11/23/2022] Open
Abstract
Background The benefit of apixaban to reduce stroke risk in morbidly obese patients with nonvalvular atrial fibrillation (AF) is still undetermined. The International Society of Thrombosis and Hemostasis recommends avoiding the use of direct oral anticoagulants (DOAC)s in morbidly obese patients (body mass index > 40 or weight > 120 kg) because of limited clinical data. This exploratory study aims to evaluate the effectiveness and safety of using apixaban in morbidly obese (body mass index (BMI) ≥ 40) patients with AF. Methods An exploratory retrospective cohort study was conducted at a single-center, including adult patients with non-valvular AF using apixaban between 01/01/2016 and 31/12/2019. Patients were excluded if they were known to have liver cirrhosis Child-Pugh C, mechanical valve, serum creatinine > 1.5 mg/dL, follow up < 3 months, or using apixaban with a dose of ≤5 or > 10 mg/day. Included patients were categorized into two groups based on their BMI (BMI<40 Vs. BMI ≥ 40). The primary outcome was all thrombotic events, while the secondary outcomes were major and minor bleeding after apixaban initiation. Propensity score (PS) matching was used (1:1 ratio) based on the patient’s age, gender, and HAS-BLED score. Results A total of 722 patients were eligible; 254 patients were included after propensity score matching based on the selected criteria. The prevalence of all thrombotic events was similar between the two groups in the first year of apixaban initiation (OR (95%CI): 0.58 (0.13, 2.5), p-value = 0.46). In addition, the odds of developing major and minor bleeding were not statistically significant between the two groups (OR (95%CI): 0.39 (0.07, 2.03), p-value = 0.26 and OR (95%CI): 1.27 (0.56, 2.84), p-value = 0.40), respectively). Conclusion This exploratory study showed similar effectiveness and safety of apixaban use in both morbid and non-morbid obese patients with non-valvular AF. However, a larger randomized controlled trial with a longer follow-up period needs to confirm our findings.
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Singh B, Pai P, Kumar H, George S, Mahapatra S, Garg V, Gupta GN, Makineni K, Ganeshwala G, Narkhede P, Naqvi SMH, Gaurav K, Hukkeri MYK. Expert Recommendations on the Usage of Non-vitamin K Antagonist Oral Anticoagulants (NOACs) from India: Current Perspective and Future Direction. Cardiol Ther 2022; 11:49-79. [PMID: 35137335 PMCID: PMC8933593 DOI: 10.1007/s40119-022-00254-w] [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: 10/27/2021] [Indexed: 11/18/2022] Open
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs) are a new class of anticoagulant drugs used in the prevention and treatment of venous thromboembolism (VTE) and atrial fibrillation (AF). Anticoagulation requires the integration of the correct type and dose of oral anticoagulants based on patient characteristic, and therefore therapy needs to be individualized for each patient. Growing scientific evidence from studies on NOACs has led to a better understanding of their benefits and safety. A large amount of available data creates a necessity for an adaptable practical document for the usage of NOACs in India. The current consensus, developed by experts from India, aims to give recommendations on various frequently raised clinical questions with regards to NOACs and its usage. This practical document provides a platform upon which future guidelines, policies, training, and education for the use of NOACs can be tailored.
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Affiliation(s)
- Balbir Singh
- Max Super Speciality Hospital, Saket, New Delhi, India
| | - Paresh Pai
- Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Harish Kumar
- Moorthy Hospital Pvt. Ltd., Trichy, Tamil Nadu, India
| | - Sheeba George
- Sree Mookambika Institute of Medical Sciences, Thiruvananthapuram, Kerala, India
| | | | - Vineet Garg
- Blossoms Hospitals, Agra, Uttar Pradesh, India
| | - G N Gupta
- Gupta Heart and Medical Centre, Gorakhpur, Uttar Pradesh, India
| | - Kiran Makineni
- Kirans Vascular Surgery Centre, Vijayawada, Andhra Pradesh, India
| | | | | | - Syed M H Naqvi
- Dr. Reddy's Laboratories Ltd., 8-2-337, Road No. 3, Banjara Hills, Hyderabad, Telangana, 500034, India
| | - Kumar Gaurav
- Dr. Reddy's Laboratories Ltd., 8-2-337, Road No. 3, Banjara Hills, Hyderabad, Telangana, 500034, India.
| | - Mohammed Y K Hukkeri
- Dr. Reddy's Laboratories Ltd., 8-2-337, Road No. 3, Banjara Hills, Hyderabad, Telangana, 500034, India
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Fender AC, Gawalko M, Dobrev D. Direct oral anticoagulation and severe obesity - One size fits all? IJC HEART & VASCULATURE 2021; 37:100923. [PMID: 34934804 PMCID: PMC8654775 DOI: 10.1016/j.ijcha.2021.100923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Indexed: 01/14/2023]
Abstract
Oral anticoagulation is obligatory in patients with atrial fibrillation (AF) to prevent thromboembolic stroke. Direct direct oral anticoagulants (DOAC) exhibit improved safety over Vitamin K antagonists, but any interference in haemostasis can impact on bleeding. Optimal anticoagulation remains challenging particularly in patients with co-morbidities. International Society of Thrombosis and Haemostasis (ISTH) guidelines recommend avoiding DOAC in patients with severe obesity, and systematic data on individual DOAC drug concentrations, clinical efficacy and safety in relation to body weight are lacking. A new study now provides reassurance that DOAC are safe and effective in a real-world cohort of morbidly obese patients, going some way to fill the knowledge gap pertaining to optimal management of concomitant obesity and AF.
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Affiliation(s)
- Anke C Fender
- Institute of Pharmacology, Medical Faculty, University Duisburg-Essen, Germany
| | - Monika Gawalko
- Institute of Pharmacology, Medical Faculty, University Duisburg-Essen, Germany.,Department of Cardiology, Maastricht University Medical Centre and Cardiovascular Research Institute Maastricht, Maastricht, the Netherlands.,1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Dobromir Dobrev
- Institute of Pharmacology, Medical Faculty, University Duisburg-Essen, Germany
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Direct Oral Anticoagulants in Patients with Obesity and Atrial Fibrillation: Position Paper of Italian National Association of Hospital Cardiologists (ANMCO). J Clin Med 2021; 10:jcm10184185. [PMID: 34575306 PMCID: PMC8468506 DOI: 10.3390/jcm10184185] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 09/11/2021] [Accepted: 09/13/2021] [Indexed: 11/17/2022] Open
Abstract
The use of the direct oral anticoagulants dabigatran, rivaroxaban, apixaban and edoxaban (DOACs) offers some major advantages over warfarin and other vitamin K antagonists (VKAs). One advantage is the possibility to use a fixed dose in normal-weight patients, overweight patients and patients with obesity. However, the "one size fits all" strategy raised a concern regarding the possibility to undertreat patients with a high body mass index. No randomized controlled trials (RCTs) have ever compared VKAs and DOACs in this population. We analyzed data from the literature on DOAC pharmacokinetics and pharmacodynamics, results from the four pivotal phase III trials on non-valvular atrial fibrillation, retrospective observational studies and metanalyses. While we are aware of the limitation imposed by the absence of specific RCTs, we propose the position of the Italian Association of Hospital Cardiologists (ANMCO) on the use of DOACs in patients with obesity based on the existing evidence.
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