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Elewa H, Qurishi I, Abouelhassan R, Abou Safrah S, Alhamoud E, Bader L. Effect of SAMe-TT 2R 2 score and genetic polymorphism on the quality of anticoagulation control in Qatari patients treated with warfarin. J Thromb Thrombolysis 2021; 49:659-666. [PMID: 32274641 PMCID: PMC7182538 DOI: 10.1007/s11239-020-02102-x] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
There is no strong evidence on pharmacogenetics role on the quality of INR control after the initiation phase and on the maintenance of stable INR on the long term as measured by the time in therapeutic range (TTR). The benefit of a score such as SAMe-TT2R2 is that it can preemptively guide clinicians on whether to start the patient on warfarin or direct oral anticoagulant. To determine the association between genetic variants in CYP2C9, VKORC1, and CYP4F2 and TTR. To validate SAMe-TT2R2 score predictive ability on the quality of anticoagulation in Qatari patients. This is an observational nested case–control study that was conducted on a cohort of Qatari patients treated with warfarin with previously identified genotype for the CYP2C9, VKORC1, and CYP2F4. The sample size of this cohort was 148 patients. Mean TTR was 62.7 ± 21%. TTR was not significantly different among carriers of the CYP2C9*2 &*3, VKORC1(–1639G>A) or CYP4F2*3 compared to their non-carriers alleles. None of the factors in the SAMe-TT2R2 score had a significant effect on the TTR except for the female gender where TTR was significantly lower in females (n = 89) compared to males (n = 59) (59.6 ± 21% vs. 67.2 ± 20%, p = 0.03). Furthermore, patients with SAMe-TT2R2 score of zero had significantly better TTR compared to those with higher scores (76.5 ± 17% vs. 61.8 ± 21%, p = 0.04). Logistic regression analysis showed that high SAMe-TT2R2 score was the only statistically significant predicting factor of poor INR control (odds ratio (OR) 5.7, 95% confidence interval (CI) 1.1–28.3, p = 0.034). Genetic variants have no contribution to the quality of INR control. SAMe-TT2R2 score was predictive for the poor quality of anticoagulation in a cohort of Qatari patients.
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Affiliation(s)
- Hazem Elewa
- Clinical Pharmacy and Practice Section, College of Pharmacy, QU Health, Qatar University, P.O. Box 2713, Doha, Qatar.
| | - Iqrah Qurishi
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
| | | | | | | | - Loulia Bader
- College of Pharmacy, QU Health, Qatar University, Doha, Qatar
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Fahmi AM, Mohamed A, Elewa H, Saad MO. Preemptive Dose Adjustment Effect on the Quality of Anticoagulation Management in Warfarin Patients With Drug Interactions: A Retrospective Cohort Study. Clin Appl Thromb Hemost 2019; 25:1076029619872554. [PMID: 31482725 PMCID: PMC6829638 DOI: 10.1177/1076029619872554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
One strategy to manage patients on warfarin starting an interacting drug is to increase
the frequency of monitoring. Another strategy is to adjust warfarin dose around the time
patient is started on an interacting medication, which is known as “preemptive warfarin
dose adjustment.” The main objective of this study is to compare preemptive to
nonpreemptive strategy and their impact on the quality of anticoagulation management. This
is a retrospective cohort study performed at the pharmacist-managed anticoagulation clinic
in a tertiary hospital in the State of Qatar. Over a 4-year period, 340 patients were
evaluated, and 58 warfarin–drug interaction encounters were identified. Mean age of the
patients was (57.7 ± 13.7), and 50% of them were females. Preemptive dose adjustment was
used in 17 (29.3%) cases. Incidence of out-of-target international normalized ratio (INR)
was statistically lower in the preemptive arm compared to the control group (41.2% [7/17]
vs 69.2% [27/39], P = .048). Incidence of extreme out-of-target INR was
numerically lower in the preemptive arm compared to the control but did not reach
statistical significance (11.8% [2/17] vs 29.3% [12/41], P = .139).
Change in frequency of INR monitoring was not different between the 2 groups. However,
overall frequency of INR monitoring after onset/discontinuation of interacting medication
increased compared to baseline (7 [9] vs 21 [16] days, P < .001).
Preemptive strategy was shown in our study to decrease incidence of the out-of-target INR
visits, although patients remained in need for close monitoring.
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Affiliation(s)
| | - Adham Mohamed
- 1 Al Wakra Hospital, Hamad Medical Corporation, Al Wakra, Qatar
| | - Hazem Elewa
- 2 Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, Doha, Qatar
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Paravattil B, Elewa H. Approaches to Direct Oral Anticoagulant Selection in Practice. J Cardiovasc Pharmacol Ther 2018; 24:1074248418793137. [PMID: 30092658 DOI: 10.1177/1074248418793137] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Direct oral anticoagulants (DOACs) carry many advantages over warfarin and are now considered first line or an alternative for mnay thromboembolic disorders. With the emergence of 5 DOAC agents to the market as well as the accumulating evidence gathered from head-to-head comparisons between the agents, we attempt to provide direction for clinicians when selecting the most appropriate DOAC agent. Important aspects such as efficacy, safety, cost effectiveness, approved indications, and other drug-related factors will be addressed to highlight the major similarities and diversities among the DOACs. When considering the safety profile of DOACs, evidence points toward apixaban as the safest followed by dabigatran and then rivaroxaban. On the other hand, dabigatran currently has the only approved antidote, idarucizumab. According to the approved DOAC indications, rivaroxaban may be favorable in European countries given its additional indication for secondary prevention of myocardial infarction. Following rivaroxaban, dabigatran and apixaban have the largest number of approved indications and lastly comes edoxaban and then betrixaban. For patients with renal impairment, betrixaban is the safest option, followed by apixaban and edoxaban, then rivaroxaban and lastly dabigatran. When considering DOAC dosing, rivaroxaban, edoxaban, and betrixaban are mainly dosed once daily compared to dabigatran and apixaban, which are dosed twice daily. However, rivaroxaban and betrixaban must be administered with food, which adds another level of complexity to the DOAC dosing. Lastly, taking into consideration drug interactions, dabigatran, edoxaban, and betrixaban have the least amount of interactions compared to apixaban and rivaroxaban. Each DOAC has its own set of features that makes it better suited than others based on the exact clinical situation. Therefore, no conclusion can be drawn to the most superior DOAC based on the aspects discussed in this review.
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Affiliation(s)
- Bridget Paravattil
- 1 Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, Doha, Qatar
| | - Hazem Elewa
- 1 Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, Doha, Qatar
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Manzoor BS, Walton SM, Sharp LK, Galanter WL, Lee TA, Nutescu EA. High number of newly initiated direct oral anticoagulant users switch to alternate anticoagulant therapy. J Thromb Thrombolysis 2018; 44:435-441. [PMID: 29027097 DOI: 10.1007/s11239-017-1565-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Real-world evidence focusing on medication switching patterns amongst direct oral anticoagulant (DOACs) has not been well studied. The objective of this study is to evaluate patterns of prescription switching in non-valvular atrial fibrillation (NVAF) patients initiated on a DOAC and previously naïve to anticoagulation (AC) therapy. Data was obtained from Truven Health MarketScan® Commercial and Medicare Supplemental database (2009-2013). AC naïve (those without prior anticoagulant use) NVAF patients initiated on a DOAC, with 6 months of continuous health plan enrollment before and after treatment initiation and maintained on continuous therapy for a minimum of 6 months were included. Of 34,022 AC naïve NVAF patients initiating a DOAC, 6613 (19.4%) patients switched from an index DOAC prescription to an alternate anticoagulant and 27,409 (80.6%) remained on the DOAC [age: 68.5 ± 11.7 vs. 67.1 ± 12.7 years, p < 0.001; males: 3781 (57.2%) vs. 17,160 (62.6%), p < 0.001]. Amongst those that switched medication, 3196 (48.3%) did so within the first 6 months of therapy. Overall, 2945 (44.5%) patients switched to warfarin, 2912 (44.0%) switched to another DOAC and 756 (11.4%) switched to an injectable anticoagulant. The highest proportion of patients switched from dabigatran to warfarin (N = 2320; 42.5%) or rivaroxaban (N = 2252; 41.3%). The median time to switch from the index DOAC to another DOAC was 309.5 days versus 118.0 days (p < 0.001) to switch to warfarin. In NVAF patients newly initiated on DOAC therapy, one in five patients switch to an alternate anticoagulant and one of every two patients do so within the first 6 months of therapy. Switching from an initial DOAC prescription to traditional anticoagulants occurs as frequently as switching to an alternate DOAC.
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Affiliation(s)
- Beenish S Manzoor
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA
| | - Surrey M Walton
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Lisa K Sharp
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - William L Galanter
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA
- Department of Academic Internal Medicine & Geriatrics, College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Todd A Lee
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Edith A Nutescu
- Department of Pharmacy, Systems Outcomes and Policy, College of Pharmacy, University of Illinois at Chicago, 833 South Wood St, PHARM 227 (MC 871), Chicago, IL, 60612, USA.
- Center for Pharmacoepidemiology and Pharmacoeconomic Research, College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA.
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Elewa H, El-Makaty H, Ali Z. Appropriateness of Dabigatran and Rivaroxaban Prescribing in Qatar: A 5-Year Experience. J Cardiovasc Pharmacol Ther 2017; 23:155-161. [DOI: 10.1177/1074248417731536] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hazem Elewa
- Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, Doha, Qatar
| | - Honain El-Makaty
- Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, Doha, Qatar
| | - Zainab Ali
- Clinical Pharmacy and Practice Section, College of Pharmacy, Qatar University, Doha, Qatar
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Chang C, Hoyos M, Owusu Y, Elewa H. Direct Oral Anticoagulant Use in Atypical Thrombosis-Related Conditions. Ann Pharmacother 2017; 52:185-197. [PMID: 28918657 DOI: 10.1177/1060028017731850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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8
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Elewa H, Jalali F, Khudair N, Hassaballah N, Abdelsamad O, Mohammed S. Evaluation of pharmacist-based compared to doctor-based anticoagulation management in Qatar. J Eval Clin Pract 2016; 22:433-8. [PMID: 26766552 DOI: 10.1111/jep.12504] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/04/2015] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES For over 60 years, warfarin has been the mainstay anticoagulant used in the outpatient setting for the prevention and treatment of a wide variety of thromboembolic clinical conditions. Guidelines recommend that health care providers managing oral anticoagulation therapy should do so in a systematic and coordinated fashion. Studies have shown that, when compared to traditional doctor-based anticoagulation management, pharmacist-managed anticoagulation services can improve patient outcomes. The first pharmacist-based anticoagulation clinic in Qatar was launched in 2013 at Alwakra Hospital. The primary objective of this research was to evaluate the impact of pharmacist versus doctor-based anticoagulation management on the percentage time under therapeutic INR (International Normalized Ratio; TTR), INR within therapeutic range and the extreme out of range INRs. METHOD A retrospective cohort study was designed to compare the anticoagulation control of pharmacist-based warfarin clinic to the usual doctor-care. RESULTS Data from 278 patients taking warfarin (78 managed at pharmacist and 200 at doctor-based clinic) were evaluated. Subjects followed at the pharmacist-based clinic had a superior TTR compared to those managed at the doctor-based clinic (81.8% vs. 69.8%, P < 0.001). Additionally, the percentage of visits within therapeutic range were significantly higher in the pharmacist's group compared to doctor's group (76.5% vs. 71.2%, P = 0.011). At the same time, percentage of visits with extreme subtherapeutic INR was reduced in the pharmacist-managed clinic (5.17% vs. 7.05%, P = 0.007) CONCLUSIONS: Our study indicates that pharmacist-based anticoagulation has better INR control when compared to the traditional anticoagulation management. Pharmacist-managed anticoagulation clinics should be considered and supported for warfarin management.
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Affiliation(s)
- Hazem Elewa
- College of Pharmacy, Qatar University, Doha, Qatar
| | | | - Nada Khudair
- College of Pharmacy, Qatar University, Doha, Qatar
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Brown JD, Shewale AR, Dherange P, Talbert JC. A Comparison of Oral Anticoagulant Use for Atrial Fibrillation in the Pre- and Post-DOAC Eras. Drugs Aging 2016; 33:427-36. [DOI: 10.1007/s40266-016-0369-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Halperin JL, Dorian P. Trials of novel oral anticoagulants for stroke prevention in patients with non-valvular atrial fibrillation. Curr Cardiol Rev 2014; 10:297-302. [PMID: 24821657 PMCID: PMC4101192 DOI: 10.2174/1573403x10666140513104523] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 02/06/2013] [Accepted: 02/08/2014] [Indexed: 11/22/2022] Open
Abstract
Patients with non-valvular atrial fibrillation (AF) face an increased risk of stroke compared with those in normal sinus rhythm. The vitamin K antagonist warfarin, available for over half a century, is highly effective in reducing the risk of stroke in patients with AF, but it is a difficult drug to use properly. As a result, it is challenging to keep the anticoagulant effect of warfarin in the desired range. Newer oral anticoagulants (NOACs) that directly inhibit Factor IIa (thrombin) or Factor Xa provide reliable anticoagulation when administer in fixed oral doses without routine coagulation monitoring. This manuscript will review in detail the pivotal trials of these NOACs that led to their approval as well as comment on the factors that should influence their selection.
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Affiliation(s)
| | - Paul Dorian
- Cardiovascular Institute, Mount Sinai Medical Center, Fifth Avenue at 100th Street, New York, NY 10029-6574, USA.
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Mohanty BD, Looser PM, Gokanapudy LR, Handa R, Mohanty S, Choi SS, Goldman ME, Fuster V, Halperin JL. Controversies regarding the new oral anticoagulants for stroke prevention in patients with atrial fibrillation. Vasc Med 2014; 19:190-204. [PMID: 24879715 DOI: 10.1177/1358863x14532869] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Increasing use of the new oral anticoagulants (NOACs) – dabigatran, rivaroxaban, and apixaban – has prompted considerable discussion in the medical community even as warfarin remains the mainstay of therapy. This article raises 10 controversial issues regarding the use of NOACs for stroke prevention in patients with atrial fibrillation, and offers a review of the latest available evidence. We provide a brief overview of the mechanism and dosing of these drugs, as well as a summary of the key clinical trials that have brought them into the spotlight. Comparative considerations relative to warfarin such as NOAC safety, efficacy, bleeding risk, reversibility, drug-transitioning and use in patients well controlled on warfarin are addressed. Use in select populations such as the elderly, those with coronary disease, renal impairment, or on multiple anti-platelet drugs is also discussed. Finally, we consider such specific issues as comparative efficacy, off-label use, cost, rebound and management during events. Ultimately, the rise of the NOACs to mainstream use will depend on further data and clinical experience amongst the medical community.
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Affiliation(s)
- Bibhu D Mohanty
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA
| | - Patrick M Looser
- Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | | | - Rishi Handa
- Department of Medicine, Morristown Medical Center, Morristown, NJ, USA
| | - Sudipta Mohanty
- University of Pittsburgh, School of Medicine, Pittsburgh, PA, USA
| | - Sharon S Choi
- Department of Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - Martin E Goldman
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA
| | - Valentin Fuster
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA
| | - Jonathan L Halperin
- Zena and Michael A Wiener Cardiovascular Institute, Mount Sinai Heart Hospital, New York, NY, USA
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Abstract
Contemporary management of acute coronary syndromes (ACS) has evolved to include rapid revascularization, potent antithrombotic, and antiplatelets, all of which reduce the risk of ischemic complications. Despite these advances, recurrent ischemic and bleeding event rates are still substantial. This increased risk post-percutaneous coronary intervention (PCI) has been the seminal event leading to recent clinical trials evaluating more potent antiplatelet drugs (prasugrel, ticagrelor, and protease-activated receptor-1 [PAR-1] inhibitors) and novel oral anticoagulants (NOAC). Ideally, an effective anticoagulation regimen adequately reduces the incidence of recurrent ischemia and limits iatrogenic bleeding. In this review, we will discuss the advances in ACS pharmacotherapy, review the recent trials evaluating these drugs, and discuss the major dilemmas in interpreting and implementing their findings.
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