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Diesveld MME, Pijnenburg DWMJ, Weersink RA, Barzel I, Drenth JPH, Lisman T, Metselaar HJ, Monster-Simons MH, Mulder MB, Okel E, Taxis K, Borgsteede SD. Recommendations for the safe use of direct oral anticoagulants in patients with cirrhosis based on a systematic review of pharmacokinetic, pharmacodynamic and safety data. Eur J Clin Pharmacol 2024; 80:797-812. [PMID: 38430266 DOI: 10.1007/s00228-024-03648-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 02/03/2024] [Indexed: 03/03/2024]
Abstract
PURPOSE The popularity of direct oral anticoagulants (DOACs) is increasing among patients with cirrhosis. Cirrhosis has a major impact on the pharmacokinetics of drugs, potentially increasing adverse events. Safe use of drugs in cirrhosis requires a diligent risk-benefit analysis. The aim of this study is to develop practice recommendations for safe use of DOACs in cirrhosis based on a systematic review of pharmacokinetic, pharmacodynamic and safety data. METHODS We conducted a systematic literature search to identify studies on pharmacokinetics, pharmacodynamics and safety of DOACs in cirrhosis. Data were collected and presented in summary tables by severity of cirrhosis using the Child-Turcotte-Pugh (CTP) classification. A multidisciplinary expert panel evaluated the results and classified the DOACs according to safety. RESULTS Fifty four studies were included. All DOACs were classified as 'no additional risks known' for CTP A. For CTP B, apixaban, dabigatran and edoxaban were classified as 'no additional risks known'. Apixaban and edoxaban showed fewer adverse events in patients with cirrhosis, while dabigatran may be less impacted by severity of cirrhosis based on its pharmacokinetic profile. Rivaroxaban was classified as 'unsafe' in CTP B and C based on significant pharmacokinetic alterations. Due to lack of data, apixaban, dabigatran and edoxaban were classified as 'unknown' for CTP C. CONCLUSION DOACs can be used in patients with CTP A cirrhosis, and apixaban, dabigatran and edoxaban can also be used in CTP B. It is recommended to avoid rivaroxaban in CTP B and C. There is insufficient evidence to support safe use of other DOACs in CTP C cirrhosis.
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Affiliation(s)
| | | | - Rianne A Weersink
- Deventer Hospital, Department of Clinical Pharmacy, Deventer, The Netherlands
- Radboud University Medical Center, Department of Pharmacy, Nijmegen, The Netherlands
| | - Ina Barzel
- Erasmus University Medical Center, Department of Hospital Pharmacy, Rotterdam, The Netherlands
| | - Joost P H Drenth
- Radboud University Medical Center, Department of Gastroenterology, Nijmegen, The Netherlands
| | - Ton Lisman
- University of Groningen, University Medical Center Groningen, Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Groningen, The Netherlands
| | - Herold J Metselaar
- Erasmus University Medical Center, Department of Gastroenterology and Hepatology, Rotterdam, The Netherlands
| | - Margje H Monster-Simons
- Dutch Medicines Evaluation Board, Utrecht, The Netherlands
- University of Groningen, Department of Clinical Pharmacy and Pharmacology, Groningen, The Netherlands
| | - Midas B Mulder
- Erasmus University Medical Center, Department of Hospital Pharmacy, Rotterdam, The Netherlands
| | - Eline Okel
- Pharmacy Zorgapotheken Flevoland, Almere, The Netherlands
| | - Katja Taxis
- University of Groningen, Groningen Research Institute of Pharmacy, Unit of Pharmacotherapy, -Epidemiology & -Economics, Groningen, The Netherlands
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Simaan N, Metanis I, Honig A, Hallevi H, Filioglo A, Mendel R, Barnea R, Naftali J, Auriel E, Aladdin S, Orion D, Dally N, Leker RR, Molad J. Efficacy and safety of Apixaban in the treatment of cerebral venous sinus thrombosis: a multi-center study. Front Neurol 2024; 15:1404099. [PMID: 38817547 PMCID: PMC11137185 DOI: 10.3389/fneur.2024.1404099] [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: 03/20/2024] [Accepted: 05/01/2024] [Indexed: 06/01/2024] Open
Abstract
Background Information regarding the safety and efficacy of specific direct oral anticoagulants (DOAC) in the treatment of cerebral sinus and venous thrombosis (CSVT) is scarce. Apixaban is one of the most frequently prescribed DOACs. Therefore, we aimed to compare the safety and efficacy of Apixaban with those of vitamin k antagonists (VKA) in patients with CSVT. Methods Prospective CSVT databases from seven academic medical centers were retrospectively analyzed. Patients treated with Apixaban were compared to those treated with VKA. Data on demographics, clinical presentations, risk factors, radiological and outcome parameters were studied. Results Overall, 403 patients were included in the analysis. Of them, 48 (12%) were treated with Apixaban, and 355 (88%) were treated with VKA. Rates of coagulopathies were significantly higher in the VKA-treated patients but no other differences between the groups were found in baseline characteristics and underlying etiology. No significant differences were found between groups in efficacy or safety parameters including the rates of recanalization, favorable outcomes, one-year mortality, seizures, intracranial hemorrhage or CSVT recurrences. Conclusion Our data suggests that Apixaban may be safe and effective for patients with CSVT. These results should be tested in prospective randomized clinical studies.
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Affiliation(s)
- Naaem Simaan
- Department of Neurology, Ziv Medical Center, Safed, Israel
- The Azrieli Faculty of Medicine, Safed Bar Ilan University, Safed, Israel
| | - Issa Metanis
- Hadassah Departments of Neurology, Hebrew University Medical Center, Jerusalem, Israel
| | - Asaf Honig
- Hadassah Departments of Neurology, Hebrew University Medical Center, Jerusalem, Israel
| | - Hen Hallevi
- Department of Neurology and Stroke, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Faculty of Medicine and Sagol School of Neuroscience, Tel-Aviv University, Tel-Aviv, Israel
| | - Andrei Filioglo
- Hadassah Departments of Neurology, Hebrew University Medical Center, Jerusalem, Israel
| | - Rom Mendel
- Department of Neurology, Assuta Ashdod Medical Center, Ashdod, Israel
| | - Rani Barnea
- Department of Neurology, Rabin Medical Center, Petah Tikva, Israel
| | - Jonathan Naftali
- Department of Neurology, Rabin Medical Center, Petah Tikva, Israel
| | - Eitan Auriel
- Department of Neurology, Rabin Medical Center, Petah Tikva, Israel
| | - Shorooq Aladdin
- Departments of Neurology, Sheba Medical Center, Ramat Gan, Israel
| | - David Orion
- Departments of Neurology, Sheba Medical Center, Ramat Gan, Israel
| | - Najib Dally
- The Azrieli Faculty of Medicine, Safed Bar Ilan University, Safed, Israel
- Department of Hematology, Ziv Medical Center, Safed, Israel
| | - Ronen R. Leker
- Hadassah Departments of Neurology, Hebrew University Medical Center, Jerusalem, Israel
| | - Jeremy Molad
- Department of Neurology and Stroke, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
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Jankowski W, Surov SS, Hernandez NE, Rawal A, Battistel M, Freedberg D, Ovanesov MV, Sauna ZE. Engineering and evaluation of FXa bypassing agents that restore hemostasis following Apixaban associated bleeding. Nat Commun 2024; 15:3912. [PMID: 38724509 PMCID: PMC11082157 DOI: 10.1038/s41467-024-48278-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 04/26/2024] [Indexed: 05/12/2024] Open
Abstract
Direct oral anticoagulants (DOACs) targeting activated factor Xa (FXa) are used to prevent or treat thromboembolic disorders. DOACs reversibly bind to FXa and inhibit its enzymatic activity. However, DOAC treatment carries the risk of anticoagulant-associated bleeding. Currently, only one specific agent, andexanet alfa, is approved to reverse the anticoagulant effects of FXa-targeting DOACs (FXaDOACs) and control life-threatening bleeding. However, because of its mechanism of action, andexanet alfa requires a cumbersome dosing schedule, and its use is associated with the risk of thrombosis. Here, we present the computational design, engineering, and evaluation of FXa-variants that exhibit anticoagulation reversal activity in the presence of FXaDOACs. Our designs demonstrate low DOAC binding affinity, retain FXa-enzymatic activity and reduce the DOAC-associated bleeding by restoring hemostasis in mice treated with apixaban. Importantly, the FXaDOACs reversal agents we designed, unlike andexanet alfa, do not inhibit TFPI, and consequently, may have a safer thrombogenic profile.
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Affiliation(s)
- Wojciech Jankowski
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Stepan S Surov
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Nancy E Hernandez
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Atul Rawal
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Marcos Battistel
- Laboratory of Bacterial Polysaccharides, Division of Bacterial, Parasitic and Allergenic Products, Office of Vaccines Research and Review, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Daron Freedberg
- Laboratory of Bacterial Polysaccharides, Division of Bacterial, Parasitic and Allergenic Products, Office of Vaccines Research and Review, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Mikhail V Ovanesov
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA
| | - Zuben E Sauna
- Hemostasis Branch 1, Division of Hemostasis, Office of Plasma Protein Therapeutics, Office of Therapeutic Products, Center for Biologics Evaluation & Research, US FDA, Silver Spring, MD, USA.
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Reynolds KR, Khosrow-Khavar F, Dave CV. Racial and Ethnic Disparities in Initiation of Direct Oral Anticoagulants Among Medicare Beneficiaries. JAMA Netw Open 2024; 7:e249465. [PMID: 38709533 DOI: 10.1001/jamanetworkopen.2024.9465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2024] Open
Abstract
Importance The influence of race and ethnicity on initiation of direct oral anticoagulants (DOACs) is relatively understudied in Medicare data. Objective To investigate disparities in the initiation of DOACs compared with warfarin by race, ethnicity, and social vulnerability. Design, Setting, and Participants This retrospective cohort study used a 50% sample of Medicare fee-for-service data from January 1, 2010, to December 31, 2019 (mean patient enrollment duration, 7.7 years). Analysis took place between January 2023 and February 2024. A cohort of older adults (aged ≥65 years) with atrial fibrillation who newly initiated warfarin or DOACs (dabigatran, rivaroxaban, apixaban, and edoxaban) was identified. Exposure Patients were classified as non-Hispanic White, non-Hispanic Black, and Hispanic. Main Outcomes and Measures The likelihood of starting use of DOACs compared with warfarin was modeled, adjusting for race, ethnicity, age, sex, county-level social vulnerability, and other clinical factors. Results Among 950 698 anticoagulation initiations, consisting of 680 974 DOAC users and 269 724 warfarin users (mean [SD] age, 78.5 [7.6] years; 52.6% female), 5.2% were Black, 4.3% were Hispanic, and 86.7% were White. During the 10-year study period, DOAC use increased for all demographic groups. After adjustment, compared with White patients, Black patients were 23% less likely (adjusted odds ratio [AOR, 0.77; 95% CI, 0.75-0.79) and Hispanic patients were 13% less likely (AOR, 0.87; 95% CI, 0.85-0.89) to initiate DOAC use. Disparities in DOAC initiation were greatest among Black patients in the earlier years but attenuated during the study period. For instance, in 2010, the OR of Black patients initiating DOACs was 0.54 (95% CI, 0.50-0.57), attenuating linearly over time to 0.69 by 2013 (95% CI, 0.65-0.74) and 0.83 (95% CI, 0.78-0.89) by 2017. By 2019, these differences became nonsignificant (OR, 1.08; 95% CI, 0.99-1.18). Conclusions and Relevance In this cohort study of Medicare patients with atrial fibrillation, Black and Hispanic patients were less likely to initiate DOACs for atrial fibrillation, although these differences diminished over time. Identifying the factors behind these early disparities is crucial for ensuring equitable access to novel therapies as they emerge for Black and Hispanic populations.
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Affiliation(s)
- Kamika R Reynolds
- Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
| | - Farzin Khosrow-Khavar
- Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- Department of Biostatistics and Epidemiology, Rutgers School of Public Health, Piscataway, New Jersey
- Rutgers Cancer Institute of New Jersey, New Brunswick
| | - Chintan V Dave
- Center for Pharmacoepidemiology and Treatment Science, Institute for Health, Health Care Policy and Aging Research, Rutgers University, New Brunswick, New Jersey
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers University, Piscataway, New Jersey
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5
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Douros A, Cui Y, Platt RW, Filion KB, Sebastiani G, Renoux C. Effectiveness and safety of direct oral anticoagulants among patients with non-valvular atrial fibrillation and liver disease: A multinational cohort study. Thromb Res 2024; 237:71-78. [PMID: 38552497 DOI: 10.1016/j.thromres.2024.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 03/19/2024] [Accepted: 03/22/2024] [Indexed: 04/29/2024]
Abstract
BACKGROUND AND AIMS The effects of direct oral anticoagulants (DOACs) in patients with non-valvular atrial fibrillation (NVAF) and liver disease remain poorly understood. Our multinational cohort study assessed the effectiveness and safety of DOACs in this high-risk population. METHODS We assembled two population-based cohorts in United Kingdom and in Québec of NVAF patients with liver disease initiating DOACs or vitamin K antagonists (VKAs) between 2011 and 2020. Using an as-treated exposure definition, we compared DOACs to VKAs and apixaban to rivaroxaban. After inverse probability of treatment weighting, Cox proportional hazards models estimated site-specific hazard ratios (HRs) and 95 % confidence intervals (CIs) of ischemic stroke and major bleeding. Site-specific estimates were pooled using random-effects models. Analyses were repeated among NVAF patients with cirrhosis. RESULTS There were 11,881 NVAF patients with liver disease (2683 with cirrhosis). Among those, 8815 initiated DOACs (4414 apixaban, 2497 rivaroxaban) and 3696 VKAs. The HRs (95 % CIs) for DOACs compared to VKAs were 1.01 (0.76-1.34) for ischemic stroke and 0.87 (0.77-0.99) for major bleeding. Results were consistent among patients with cirrhosis. The HRs (95 % CIs) for apixaban compared to rivaroxaban were 0.85 (0.60-1.20) for ischemic stroke and 0.80 (0.68-0.95) for major bleeding. This decreased bleeding risk was not observed among patients with cirrhosis (HR, 1.01; 95 % CI 0.72-1.43). CONCLUSIONS Among NVAF patients with liver disease, DOACs were as effective and slightly safer than VKAs, and apixaban was as effective but safer than rivaroxaban. The safety benefit with apixaban was not present among patients with cirrhosis.
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Affiliation(s)
- Antonios Douros
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada; Department of Medicine, McGill University, Montreal, Québec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Montreal, Québec, Canada; Institute of Clinical Pharmacology and Toxicology, Charité-Universitätsmedizin Berlin, Berlin, Germany.
| | - Ying Cui
- Centre for Clinical Epidemiology, Lady Davis Institute, Montreal, Québec, Canada
| | - Robert W Platt
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Montreal, Québec, Canada; Department of Pediatrics, McGill University, Montreal, Québec, Canada
| | - Kristian B Filion
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada; Department of Medicine, McGill University, Montreal, Québec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Montreal, Québec, Canada
| | - Giada Sebastiani
- Department of Medicine, McGill University, Montreal, Québec, Canada; Division of Gastroenterology and Hepatology, McGill University Health Centre, Montreal, Québec, Canada
| | - Christel Renoux
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Québec, Canada; Department of Medicine, McGill University, Montreal, Québec, Canada; Centre for Clinical Epidemiology, Lady Davis Institute, Montreal, Québec, Canada; Department of Neurology and Neurosurgery, McGill University, Montreal, Québec, Canada
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Potpara T, Grygier M, Häusler KG, Nielsen-Kudsk JE, Berti S, Genovesi S, Marijon E, Boveda S, Tzikas A, Boriani G, Boersma LVA, Tondo C, De Potter T, Lip GYH, Schnabel RB, Bauersachs R, Senzolo M, Basile C, Bianchi S, Osmancik P, Schmidt B, Landmesser U, Döhner W, Hindricks G, Kovac J, Camm AJ. Practical guide on left atrial appendage closure for the non-implanting physician: an international consensus paper. Europace 2024; 26:euae035. [PMID: 38291925 PMCID: PMC11009149 DOI: 10.1093/europace/euae035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/17/2024] [Indexed: 02/01/2024] Open
Abstract
A significant proportion of patients who suffer from atrial fibrillation (AF) and are in need of thromboembolic protection are not treated with oral anticoagulation or discontinue this treatment shortly after its initiation. This undertreatment has not improved sufficiently despite the availability of direct oral anticoagulants which are associated with less major bleeding than vitamin K antagonists. Multiple reasons account for this, including bleeding events or ischaemic strokes whilst on anticoagulation, a serious risk of bleeding events, poor treatment compliance despite best educational attempts, or aversion to drug therapy. An alternative interventional therapy, which is not associated with long-term bleeding and is as effective as vitamin K anticoagulation, was introduced over 20 years ago. Because of significant improvements in procedural safety over the years, left atrial appendage closure, predominantly achieved using a catheter-based, device implantation approach, is increasingly favoured for the prevention of thromboembolic events in patients who cannot achieve effective anticoagulation. This management strategy is well known to the interventional cardiologist/electrophysiologist but is not more widely appreciated within cardiology or internal medicine. This article introduces the devices and briefly explains the implantation technique. The indications and device follow-up are more comprehensively described. Almost all physicians who care for adult patients will have many with AF. This practical guide, written within guideline/guidance boundaries, is aimed at those non-implanting physicians who may need to refer patients for consideration of this new therapy, which is becoming increasingly popular.
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Affiliation(s)
- Tatjana Potpara
- Medical Faculty, University of Belgrade, Belgrade, Serbia
- University Clinical Centre of Serbia, Belgrade, Serbia
| | - Marek Grygier
- 1st Department of Cardiology, Poznan University School of Medical Sciences, Poznan, Poland
| | - Karl Georg Häusler
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | | | - Sergio Berti
- Ospedale del Cuore, Fondazione CNR Regione Toscana G. Monasterio, Pisa, Italy
| | - Simonetta Genovesi
- School of Medicine and Surgery, University of Milano-Bicocca, Nephrology Clinic, Monza, Italy
- Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Eloi Marijon
- Division of Cardiology, European Georges Pompidou Hospital, AP-HP, Paris, France
| | - Serge Boveda
- Cardiology, Heart Rhythm Management Department, Clinique Pasteur, Toulouse, France
- Cardiologie Clinique Pasteur, Brussels University VUB, Brussels, Belgium
| | - Apostolos Tzikas
- Ippokrateio Hospital of Thessaloniki, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Structural and Congenital Heart Disease, European Interbalkan Medical Centre, Thessaloniki, Greece
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Lucas V A Boersma
- Cardiology Department, St. Antonius Hospital Nieuwegein/Amsterdam University Medical Centers, Amsterdam, Netherlands
| | - Claudio Tondo
- Centro Cardiologico Monzino, IRCCS, Department of Clinical Electrophysiology & Cardiac Pacing, Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Tom De Potter
- Cardiovascular Center Aalst, OLV Hospital, Aalst, Belgium
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Renate B Schnabel
- Department of Cardiology, University Heart and Vascular Centre Hamburg, Hamburg, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Rupert Bauersachs
- Cardioangiology Center Bethanien CCB, Frankfurt, Germany
- Center for Vascular Research, Munich, Germany
| | - Marco Senzolo
- Department of Surgery, Oncology and Gastroenterology, University Hospital of Padua, Padua, Italy
| | - Carlo Basile
- Division of Nephrology, Miull General Hospital, Acquaviva delle Fonti, Italy
- EuDial Working Group of the European Renal Association, Acquaviva delle Fonti, Italy
| | - Stefano Bianchi
- Nephrology and Dialysis Unit, ASL Toscana NordOvest, Livorno, Italy
| | - Pavel Osmancik
- Department of Cardiology, University Hospital Kralovske Vinohrady, Charles University, Prague, Czech Republic
| | - Boris Schmidt
- Cardioangiologisches Centrum Bethanien, Agaplesion Markus Krankenhaus, Frankfurt, Germany
| | - Ulf Landmesser
- Department of Cardiology, Angiology, and Intensive Care Medicine, Deutsches Herzzentrum Charité, Charité University Medicine, Berlin
| | - Wolfram Döhner
- Berlin Institute of Health-Center for Regenerative Therapies, Berlin, Germany
- Deutsches Herzzentrum der Charité, Campus Virchow Klinikum, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK)- partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | | | - Jan Kovac
- Leicester NIHR BRU, University of Leicester, Glenfield Hospital, Leicester, UK
| | - A John Camm
- Genetic and Cardiovascular Sciences Institute, Cardiology Academic Group, St. George’s University of London, Cranmer Terrace, London SW190RE, UK
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Senzolo M, Garcia-Pagan JC. A major research gap: The use of anticoagulants in cirrhosis. J Hepatol 2023; 79:1566-1570. [PMID: 37302580 DOI: 10.1016/j.jhep.2023.06.001] [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] [Received: 03/03/2023] [Revised: 05/28/2023] [Accepted: 06/02/2023] [Indexed: 06/13/2023]
Abstract
Historically, anticoagulants were contraindicated in patients with cirrhosis owing to concerns about bleeding risks. However, recent studies have shown that patients with cirrhosis are not naturally anticoagulated and are at increased risk of prothrombotic events, such as portal venous thrombosis. In this article, we review preclinical and clinical data on the effects of anticoagulants in cirrhosis, including their potential benefits in reducing liver fibrosis, portal hypertension, and improving survival. Despite promising preclinical evidence, clinical translation has proven challenging. Nevertheless, we discuss the use of anticoagulation in specific clinical scenarios, such as patients with atrial fibrillation and portal vein thrombosis, and highlight the need for further research, including randomised-controlled trials, to determine the optimal role of anticoagulants in the management of patients with cirrhosis.
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Affiliation(s)
- Marco Senzolo
- Gastroenterology and Multivisceral Transplant Unit, Azienda Ospedale - Università Padova, Padova, Italy; Department of Surgery, Oncology and Gastroenterology, University of Padova, Padova, Italy; Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Germany.
| | - Juan Carlos Garcia-Pagan
- Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Germany; Barcelona Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut de Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain; CIBEREHD (Centro de Investigación Biomédica en Red Enfermedades Hepáticas y Digestivas), Spain.
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8
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Al Ayoubi F, Al Mashali M, Abdallah MH, Al Sheef M, Owaidah T. Position Statement on In-hospital/Clinic Point-of-care Coagulation Testing for Anticoagulation Monitoring in Saudi Arabia. J Saudi Heart Assoc 2023; 35:290-300. [PMID: 38116402 PMCID: PMC10727136 DOI: 10.37616/2212-5043.1355] [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] [Received: 06/21/2023] [Revised: 09/14/2023] [Accepted: 10/07/2023] [Indexed: 12/21/2023] Open
Abstract
Objectives Hospital overload is a persistent occurrence in daily practice. Interventions such as point-of-care testing (POCT) are needed to alleviate the pressure faced by healthcare providers and administrators. Methods An invited panel of experts from Saudi Arabia was formed under the auspices of the Saudi Heart Association in order to discuss local treatment gaps in the management of patients receiving anticoagulation therapy. This was done in a series of meetings, which resulted in the development of official recommendations for the implementation of POCT for anticoagulation monitoring in the country. Recommendations were based on a comprehensive literature review and international guidelines taking into consideration local clinical practice, clinical gaps, and treatment/testing availabilities. Results Vitamin K antagonist (VKA)-based anticoagulation therapy requires routine monitoring. POCT is a promising model of care for the monitoring of International Normalized Ratio (INR) in patients receiving oral anticoagulation in terms efficacy, safety and convenience. The availability of POC INR testing should not replace the use of standard laboratory anticoagulation monitoring. However, there are several indications for implementing POCTINR monitoring that was agreed upon by the expert panel. POCT for anticoagulation monitoring should primarily be used in the warfarin (or other VKA) monitoring clinic in order to ensure treatment efficiency, cost-effectiveness of care, patient satisfaction, and quality of life improvement. The expert panel detailed the requirements for the establishment of a warfarin (or other VKA) monitoring clinic in terms of organization, safety, quality control, and other logistic and technical considerations. The limitations of POCT should be recognized and recommendations on best practices should be strictly followed. Core laboratory confirmation should be sought for patients with higher INR results (>4.7) on POCT. Proper training, quality control, and regulatory oversight are also critical for preserving the accuracy and reliability of POCT results. Conclusions POCT enables more rapid clinical decision-making in the process of diagnosis (rule-in or rule-out), treatment choice and monitoring, and prognosis, as well as operational decision-making and resource utilization. POCT thus can fulfill an important role in clinical practice, particularly for patients receiving VKAs.
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Affiliation(s)
- Fakhr Al Ayoubi
- College of Medicine, King Saud University Medical City, Riyadh,
Saudi Arabia
| | - Malak Al Mashali
- Head of Point of Care Division, Prince Sultan Military Medical City, Riyadh,
Saudi Arabia
| | | | - Mohamed Al Sheef
- Medical Specialties Department, King Fahad Medical City, Riyadh,
Saudi Arabia
| | - Tarek Owaidah
- King Faisal Specialty Hospital and Al-Faisal University, Riyadh,
Saudi Arabia
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Ahmed T, Messerli AW. Double Trouble: The Challenge of Neuroprotection in Patients with Liver Cirrhosis and Atrial Fibrillation. Am J Cardiovasc Drugs 2023; 23:599-600. [PMID: 37639202 DOI: 10.1007/s40256-023-00608-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Taha Ahmed
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, USA
| | - Adrian W Messerli
- Gill Heart and Vascular Institute, University of Kentucky, Lexington, KY, USA.
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