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Elsadig AE, M. Muddath AR, Elamin EM, MA Shrif NE, Waggiallah HA. Effect of CYP2C9*2 and VKORC-1639G/A Polymorphisms on Warfarin Doses Requirements in Sudanese Patients. INT J PHARMACOL 2022. [DOI: 10.3923/ijp.2022.1366.1373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Alwhaibi A, Alenazi M, Alwagh F, Al-Ghayhab A, Alghadeer S, Bablghaith S, Wajid S, Al-Arifi M. Does Ramadan fasting disrupt international normalised ratio control in warfarin-treated medically stable patients? Int J Clin Pract 2021; 75:e14796. [PMID: 34482618 DOI: 10.1111/ijcp.14796] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 09/02/2021] [Indexed: 12/29/2022] Open
Abstract
AIM Warfarin is commonly used in patients with thrombotic diseases. This study aimed to evaluate the impact of Ramadan fasting on warfarin efficacy by investigating international normalised ratio (INR) stability in medically stable patients. METHODS A retrospective observational study was conducted at King Khalid University Hospital during Ramadan 2016 on fasting adult patients aged above 18 years and receiving warfarin. The INR values during pre-Ramadan, Ramadan and post-Ramadan periods were collected after satisfying the inclusion criteria. Time within the therapeutic range (TTR) during the whole period was estimated using the conventional method. RESULTS In total, 101 patients were included in the study. The mean age (SD) was 55.8 ± 15.5 years, and 52.4% were females. The target INR range for 62.4% was 2-3, while 37.6% had a target INR range of 2.5-3.5. An upward trend in the proportion of patients with therapeutic INR was noticed during Ramadan (59.4%) as compared to pre- (56.4%) and post-Ramadan periods (53.5%) respectively. Additionally, the proportions of patients with supratherapeutic and sub-therapeutic INR were the highest and lowest, 23% and 24% respectively post-Ramadan as compared to other periods. Based on target INR categorisation, achieving therapeutic INR during Ramadan was more feasible with the low INR (2-3) compared to the high INR (2.5-3.5) target patients, 63.5% vs 52.6% respectively. TTR estimation revealed 62.4% and 37.6% of the patients had good and poor, respectively, anticoagulation status throughout the study period. CONCLUSION Despite the changes in mean INR and proportion of patients with therapeutic INR during Ramadan compared to other non-fasting months, our results confirmed that short-term fasting during Ramadan has no significant influence on INR stability and, consequently, therapeutic efficacy in warfarin-treated medically stable patients.
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Affiliation(s)
| | - Miteb Alenazi
- Pharmacy Department, King Saud University Medical City (KSUMC), Riyadh, Saudi Arabia
| | - Fouzia Alwagh
- Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | | | - Sultan Alghadeer
- Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia
- Department of Basic Sciences, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
| | - Salmeen Bablghaith
- Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Syed Wajid
- Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia
| | - Mohamed Al-Arifi
- Department of Clinical Pharmacy, King Saud University, Riyadh, Saudi Arabia
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Hyperthyroidism in severe mitral regurgitation post mechanical mitral valve replacement: the effect on warfarin anticoagulation. Cardiovasc Endocrinol Metab 2021; 10:146-148. [PMID: 34113800 DOI: 10.1097/xce.0000000000000233] [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: 05/20/2020] [Accepted: 07/27/2020] [Indexed: 11/25/2022]
Abstract
A 24-year-old male patient came to the emergency room with melena, gum bleeding and nosebleeds. This patient has a history of mechanical prosthetic mitral valve replacement for severe mitral regurgitation (MR) and consumed warfarin irregularly, but did not come back for regular check-up. Investigations showed greatly increased thyroid function and international normalised ratio (INR) was 15.8. Patients were diagnosed with thyroid storm and bleeding due to prolongation of INR. His hyperthyroid state might have caused increased rate of degradation of vitamin K-dependent clotting factor thereby increased sensitivity to warfarin. Concomitant acute decompensated heart failure, thrombocytopenia and hypoalbuminemia also contributed to his risk of bleeding. Treatment included anti-thyroid therapy as well as warfarin reversal therapy by stopping warfarin, low-dose intravenous vitamin K due to his mechanical prosthetic valve and fresh frozen plasma. In conclusion, hyperthyroidism could increase the response to warfarin so close monitoring is needed to balance the risk of bleeding and thromboembolism.
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Schweinfurth J, Bauer A, Bauer F, Seibert FS, Rohn B, Seidel M, Bertram S, Stervbo U, Babel N, Westhoff TH. The impact of acute diarrhea on the coagulation status of patients with vitamin K antagonists. Sci Rep 2021; 11:11726. [PMID: 34083692 PMCID: PMC8175677 DOI: 10.1038/s41598-021-91316-x] [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: 07/12/2020] [Accepted: 03/10/2021] [Indexed: 11/25/2022] Open
Abstract
Acute diarrhea is associated with a reduced absorption of both vitamin K antagonists (VKA) and vitamin K itself. To date, the net effect on the coagulation status of subjects with VKA remains elusive. We performed a systematic retrospective single-center analysis using an electronic data extraction approach to identify subjects with plasmatic anticoagulation (either VKA or direct oral anticoagulant (DOAC)) and diarrhea in a German University Hospital over a period of eight years. Acute diarrhea and complete documentation of coagulation status on admission were defined as inclusion criteria, anticoagulation other than VKA/DOAC and obvious inadherence as exclusion criteria. Subjects with VKA/DOAC admitted for hypertension served as control group. Data extraction yielded 356 subjects with gastrointestinal diagnoses and 198 hypertensive subjects, 55 and 83 of whom fulfilled all in- and exclusion criteria. INR values of subjects with VKA were significantly higher in subjects with diarrhea than in hypertensive controls (4.3 ± 3.7 vs. 2.3 ± 0.7, p < 0.001). The distribution of subjects having INR values lower, higher or within the target range differed significantly among groups with a substantially higher prevalence of overanticoagulation in the diarrhea group (46.4% vs. 14.3%, p < 0.001). In a multinomial logistic regression model, acute diarrhea was significantly associated with overanticoagulation (odds ratio 7.2, 95% confidence interval 2.163–23.921; p < 0.001), whereas age, sex, creatinine, and indication of anticoagulation were not (p > 0.05 each). Acute diarrhea is associated with a highly increased risk for overanticoagulation in patients with VKA. Thus, gastroenteritis necessitates a close monitoring of INR in order to identify subjects needing a temporary pause of VKA therapy.
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Affiliation(s)
- Johannes Schweinfurth
- Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Alexander Bauer
- Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Frederic Bauer
- Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Felix Sebastian Seibert
- Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Benjamin Rohn
- Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Maximilian Seidel
- Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Sebastian Bertram
- Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Ulrik Stervbo
- Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Nina Babel
- Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany
| | - Timm Henning Westhoff
- Medical Department I, Marien Hospital Herne, University Hospital of the Ruhr-University Bochum, Hölkeskampring 40, 44625, Herne, Germany.
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Mohammadi K, Kargar M. Sensitivity to warfarin following cardiac surgery. Ther Adv Drug Saf 2018; 9:673-674. [PMID: 30546861 DOI: 10.1177/2042098618804488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Keyhan Mohammadi
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mona Kargar
- Research Center for Rational Use of Drugs, Tehran University of Medical Sciences, No. 92, Karimkhan-e-Zand Blvd. Haft-e-Tir Square, Tehran, Iran
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Eberst G, Lakhzoum W, Tomasini P, Andreotti N, Abcaya J, Mascaux C, Barlesi F. [Autoimmune-related bleeding occurring during combined immunotherapy for lung cancer - Case report]. Rev Mal Respir 2018; 35:974-977. [PMID: 30318433 DOI: 10.1016/j.rmr.2018.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2017] [Accepted: 04/25/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Specific immune-related adverse events in lung cancer treatment are rare and it is important that they are identified as they may have important adverse consequences. We report such a case here. CASE REPORT A Caucasian female diagnosed with KRAS mutant advanced adenocarcinoma of the lung was enrolled in a phase Ib trial assessing the combination of an anti cytotoxic T-lymphocyte- associated protein 4 antibody and a programmed death-Ligand 1 inhibitor. For several years, she had also been taking warfarin for recurrent pulmonary embolism. At day 15 of treatment, she presented with grade 1 haematomas and signs of grade 2 hyperthyroidism. Blood tests revealed a normal number of platelets but an INR increased to 6.5. Thyroid function tests and auto antibodies confirmed the presence of an autoimmune thyroitidis. The study treatment was then stopped and the patient received 1mg/kg of prednisone and 40mg of propranolol. At day 28, the thyroid function and symptoms were normalized. No direct interactions exist between immunotherapy and vitamin K antagonists (VKA) but hyperthyroidism, through pharmacokinetic and metabolic mechanisms, can boost VKA plasma levels and increase INR, leading to hemorrhagic complications. CONCLUSIONS This case emphasizes that special consideration should be given to patients with VKA treatment planned to receive immunotherapy.
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Affiliation(s)
- G Eberst
- Université d'Aix-Marseille, Assistance publique Hôpitaux de Marseille, centre essais précoces en cancérologie de Marseille CLIP2, hôpital La Timone, boulevard Saint-Pierre, 13005 Marseille, France
| | - W Lakhzoum
- Université d'Aix-Marseille, Assistance publique Hôpitaux de Marseille, centre essais précoces en cancérologie de Marseille CLIP2, hôpital La Timone, boulevard Saint-Pierre, 13005 Marseille, France
| | - P Tomasini
- Université d'Aix-Marseille, Assistance publique Hôpitaux de Marseille, centre essais précoces en cancérologie de Marseille CLIP2, hôpital La Timone, boulevard Saint-Pierre, 13005 Marseille, France; Inserm UMR1068, CNRS UMR7258, UM105, université d'Aix-Marseille, predictive oncology laboratory, centre de recherche en cancérologie de Marseille, 13009 Marseille, France
| | - N Andreotti
- Université d'Aix-Marseille, Assistance publique Hôpitaux de Marseille, centre essais précoces en cancérologie de Marseille CLIP2, hôpital La Timone, boulevard Saint-Pierre, 13005 Marseille, France
| | - J Abcaya
- Université d'Aix-Marseille, Assistance publique Hôpitaux de Marseille, centre essais précoces en cancérologie de Marseille CLIP2, hôpital La Timone, boulevard Saint-Pierre, 13005 Marseille, France
| | - C Mascaux
- Université d'Aix-Marseille, Assistance publique Hôpitaux de Marseille, centre essais précoces en cancérologie de Marseille CLIP2, hôpital La Timone, boulevard Saint-Pierre, 13005 Marseille, France; Inserm UMR1068, CNRS UMR7258, UM105, université d'Aix-Marseille, predictive oncology laboratory, centre de recherche en cancérologie de Marseille, 13009 Marseille, France
| | - F Barlesi
- Université d'Aix-Marseille, Assistance publique Hôpitaux de Marseille, centre essais précoces en cancérologie de Marseille CLIP2, hôpital La Timone, boulevard Saint-Pierre, 13005 Marseille, France; Inserm UMR1068, CNRS UMR7258, UM105, université d'Aix-Marseille, predictive oncology laboratory, centre de recherche en cancérologie de Marseille, 13009 Marseille, France.
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Yan YD, Su YJ, Chen BY, Cui JJ, Zhang ZL, Xu Q, Gu ZC. The optimal anticoagulant therapy for mechanical heart valves in a gallbladder cancer patient with hepatic metastases: A case report. Medicine (Baltimore) 2018; 97:e12368. [PMID: 30212998 PMCID: PMC6156055 DOI: 10.1097/md.0000000000012368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
RATIONALE Developing an optimal anticoagulant strategy poses a challenging task in patients with mechanical heart valves (MHVs) throughout their lifetime. We report an optimal anticoagulant therapy in a cancer patient with hepatic metastases after MHV replacement. PATIENT CONCERNS A 68-year-old female with MHVs suffered from gallbladder cancer with hepatic metastases. Her international normalized ratio (INR) fluctuated owing to the declined hepatic function. DIAGNOSES Gallbladder cancer and hepatic metastases, with a history of mechanic aortic valve replacement and mitral valve replacement. INTERVENTIONS Warfarin was discontinued and Vitamin K1 was immediately administrated via intravenous infusion. low-molecular-weight heparin (LMWH) was regarded as a preferable option, and nadroparin at the dosage of 4100IU daily was administered. OUTCOMES No adverse event occurred during the patient's hospitalization and two-week follow up after discharge. LESSONS LMWH may represent a reasonable alternative regarding the inhibition of thrombus and bleeding in MHVs carriers with cancer and hepatic metastases.
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Affiliation(s)
- Yi-Dan Yan
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai
| | - Ying-Jie Su
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai
| | - Bo-Ya Chen
- Department of Pharmacy, Zhengzhou University People's Hospital, Zhengzhou, Henan
| | - Jiu-Jie Cui
- Department of Oncology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Zai-Li Zhang
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai
| | - Qi Xu
- Department of Oncology, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai
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Parrett JL, Reaves AB, Self TH, Owens RE. Enzalutamide-warfarin interaction necessitating warfarin dosage adjustment: A case report of successful clinical management. J Clin Pharm Ther 2017; 43:276-279. [PMID: 28901605 DOI: 10.1111/jcpt.12612] [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] [Received: 05/23/2017] [Accepted: 08/02/2017] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Enzalutamide package labeling recommends avoiding concurrent warfarin use due to potential reductions in warfarin concentrations via enzalutamide-associated hepatic enzyme induction. A case of successful management of this interaction via warfarin adjustments is reported. CASE DESCRIPTION A 77-year-old Caucasian male, previously relatively stable on warfarin 42-45 mg weekly, reported to clinic after the recent start of enzalutamide and subsequent hospitalization with a subtherapeutic International Normalized Ratio (INR). A 50% increase in weekly warfarin dose resulted in a therapeutic INR. Enzalutamide was temporarily discontinued, and a 33% weekly warfarin dose decrease resulted in two therapeutic INRs. WHAT IS NEW AND CONCLUSION This is the first case to highlight the clinical significance of this interaction, noting that patients taking enzalutamide may require approximately 30%-50% adjustment in their warfarin dosage to maintain a therapeutic INR.
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Affiliation(s)
- J L Parrett
- Department of Pharmacy, Baptist Health Louisville, Louisville, KY, USA
| | - A B Reaves
- Methodist University Hospital, Memphis, TN, USA
| | - T H Self
- Department of Clinical Pharmacy, University of Tennessee College of Pharmacy, Memphis, TN, USA
| | - R E Owens
- Department of Pharmacy Practice, Wingate University School of Pharmacy, Hendersonville, NC, USA
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Sajawal Ali M, Mba BI, Ciftci FD, Ali AS. Bleeding heart: a case of spontaneous hemopericardium and tamponade in a hyperthyroid patient on warfarin. BMJ Case Rep 2016; 2016:bcr-2016-215731. [PMID: 27413023 DOI: 10.1136/bcr-2016-215731] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We describe the case of an 81-year-old female, diagnosed with hyperthyroidism-related atrial fibrillation. Given her CHA2DS2VASc score of 3, she was started on warfarin for stroke prevention. One month later, she was admitted with cardiac tamponade. This tamponade was suspected to be secondary to hemopericardium, based on the elevated international normalized ratio (INR), drop in haemoglobin and the radiodensity (55 HU) of the pericardial effusion on CT. The patient was a Jehovah's witness who therefore initially refused measures for reversing coagulopathy. Given her coagulopathy and absence of imminent haemodynamic compromise, pericardiocentesis was deferred. Unfortunately, 1 day later, the patient deteriorated rapidly. By the time pericardiocentesis was performed and factor VIIa administered, the patient had already started developing multiple organ failure. She developed cardiac arrest and died 3 days after her admission. Only 10 cases of hemopericardium attributable to warfarin have previously been reported. In this report, we review the literature and also describe how hyperthyroidism most likely predisposed our patient to bleeding complications from warfarin.
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Affiliation(s)
- Muhammad Sajawal Ali
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois, USA
| | - Benjamin I Mba
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois, USA
| | - Farah Diba Ciftci
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, Illinois, USA
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