Efficacy and safety of novel anticoagulants compared with established agents

Venous Thromboembolism Prophylaxis in Patients Treated for Acute Lymphoblastic Leukemia: A Comprehensive Systematic Review and Meta-Analysis

Acute lymphoblastic leukemia (ALL) is a common malignancy in children, often treated with intensive chemotherapy regimens. Venous thromboembolism (VTE) poses a significant risk during ALL treatment, leading to suboptimal outcomes. Thromboprophylaxis is crucial in mitigating this risk, but its efficacy and safety remain uncertain. This systematic review and meta-analysis aimed to evaluate the effectiveness of thromboprophylaxis in reducing VTE incidence during ALL treatment, focusing on antithrombin, apixaban, and enoxaparin. A systematic literature search adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed. Randomized controlled trials (RCTs) investigating thromboprophylaxis in ALL were included. Data extraction and quality appraisal were performed independently by three authors. Meta-analysis was conducted using Review Manager software. Three RCTs met the inclusion criteria. Apixaban, enoxaparin, and antithrombin were assessed in these trials. Meta-analysis revealed significantly reduced odds of VTE with thromboprophylaxis compared to standard care (odds ratio (OR): 0.47, 95% confidence interval (CI) 0.29-0.75; relative risk (RR): 0.52, 95% CI 0.33-0.83). However, no significant difference in bleeding risk was observed (OR: 1.33, 95% CI 0.42-4.21; RR: 1.32, 95% CI 0.43-4.07). Heterogeneity among studies was moderate. This study showed that thromboprophylaxis with apixaban, enoxaparin, or antithrombin significantly reduces VTE incidence during ALL treatment. Despite some limitations, including heterogeneity and potential biases, these findings support the adoption of tailored thromboprophylaxis strategies to improve outcomes in ALL patients. Further research is warranted to optimize these approaches and address remaining uncertainties.

Direct-Acting Oral Anticoagulants and Their Reversal Agents-An Update

Background: Over the last ten years, a new class of drugs, known as the direct-acting oral anticoagulants (DOACs), have emerged at the forefront of anticoagulation therapy. Like the older generation anticoagulants, DOACs require specific reversal agents in cases of life-threatening bleeding or the need for high-risk surgery. Methods: Published literature was searched, and information extracted to provide an update on DOACS and their reversal agents. Results: The DOACs include the direct thrombin inhibitor—dabigatran, and the factor Xa inhibitors—rivaroxaban, apixaban, edoxaban, and betrixaban. These DOACs all have a rapid onset of action and each has a predictable therapeutic response requiring no monitoring, unlike the older anticoagulants, such as warfarin. Two reversal agents have been approved within the last five years: idarucizumab for the reversal of dabigatran, and andexanet alfa for the reversal of rivaroxaban and apixaban. Additionally, ciraparantag, a potential “universal” reversal agent, is currently under clinical development. Conclusions: A new generation of anticoagulants, the DOACs, and their reversal agents, are gaining prominence in clinical practice, having demonstrated superior efficacy and safety profiles. They are poised to replace traditional anticoagulants including warfarin.

A Review on the New and Old Anticoagulants

Anticoagulants serve as the primary strategy for the prevention and treatment of both arterial and venous thromboembolism. Anticoagulants disrupt coagulation by interfering at various points in the coagulation cascade. This class of medications does not lyse clots that already exist; rather, it prevents thrombus formation and prevents or slows the extension of an existing clot. For decades, the standard therapy for patients requiring oral anticoagulation was warfarin. However, due to some of the shortcomings of warfarin, including the need for continuous routine monitoring, longtime onset and offset of anticoagulation effect, major food and drug interactions, and high incidence of bleeding, newer agents, termed direct oral anticoagulants, or DOACs were developed. This article will provide a review of clinically important information regarding the most commonly used anticoagulants and their reversal agents.

Anticoagulants: A Review of the Pharmacology, Dosing, and Complications

Anticoagulants remain the primary strategy for the prevention and treatment of thrombosis. Unfractionated heparin, low molecular weight heparin, fondaparinux, and warfarin have been studied and employed extensively with direct thrombin inhibitors typically reserved for patients with complications or those requiring intervention. Novel oral anticoagulants have emerged from clinical development and are expected to replace older agents with their ease of use and more favorable pharmacodynamic profiles. Hemorrhage is the main concerning adverse event with all anticoagulants. With their ubiquitous use, it becomes important for clinicians to have a sound understanding of anticoagulant pharmacology, dosing, and toxicity.

Treatment of pulmonary embolism: anticoagulation, thrombolytic therapy, and complications of therapy

During the last two decades, considerable progress in technology and clinical research methods have led to advances in the approach to the diagnosis, prevention, and treatment of acute venous thromboembolism (VTE). Despite this, however, the diagnosis is often delayed and preventive methods are often ignored. Thus, the morbidity and mortality associated with VTE remain high. The therapeutic approach to acute VTE is discussed in this article, with a particular focus on the intensive care unit setting.