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Carlin S, Eikelboom J. Restarting Anticoagulation After Major Bleeding in Patients With Atrial Fibrillation. Can J Cardiol 2024:S0828-282X(24)00019-9. [PMID: 38215970 DOI: 10.1016/j.cjca.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/04/2024] [Indexed: 01/14/2024] Open
Affiliation(s)
- Stephanie Carlin
- Thrombosis Service, Hamilton General Hospital, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
| | - John Eikelboom
- Thrombosis Service, Hamilton General Hospital, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada
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2
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Carlin S, Bond A, Gross P, Bell A, Douketis J, Geerts W, Galanaud JP. Initiation of anticoagulation in atrial fibrillation by primary care physicians: Results of a telephone survey. Thromb Res 2021; 202:176-181. [PMID: 33872825 DOI: 10.1016/j.thromres.2021.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/31/2021] [Accepted: 04/05/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are prescribed for over 80% of patients who start anticoagulant therapy for a new diagnosis of atrial fibrillation (AF). Inappropriate DOAC prescriptions are associated with increased mortality. However, limited data exist as to what proportion of primary care physicians (PCPs) initiate anticoagulation in patients with new AF and the extent of their DOAC knowledge. MATERIAL AND METHODS We conducted a telephone survey of randomly selected PCPs in Ontario, Canada. Our primary objective was to determine the percentage of PCPs who initiate anticoagulation in new AF patients and the proportion of patients they initiate on DOACs. Our secondary objectives were to assess PCPs' knowledge about DOACs and to identify educational opportunities to address any knowledge gaps. RESULTS Our survey included 50 respondents. After making a new AF diagnosis, 66% of PCPs stated that they usually initiate anticoagulation themselves and 84% prescribed a DOAC at least 75% of the time. Potential DOAC knowledge gaps included: administration considerations, off-label dosing, concomitant use of acetylsalicylic acid (ASA) in stable coronary artery disease (CAD) and use in valvular AF. CONCLUSION Most PCPs initiate anticoagulants for AF and prescribe DOACs for the vast majority of new patients. PCPs were well versed in certain aspects of DOAC prescribing, however, a number of knowledge gaps were identified. PCPs may benefit from targeted education in these areas to improve patient outcomes in AF.
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Affiliation(s)
- Stephanie Carlin
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; Leslie Dan Faculty of Pharmacy, 144 College St, University of Toronto, Ontario M5S 3M2, Canada.
| | - Alison Bond
- Department of Pharmacy, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, Ontario M4N 3M5, Canada; Leslie Dan Faculty of Pharmacy, 144 College St, University of Toronto, Ontario M5S 3M2, Canada
| | - Peter Gross
- Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada
| | - Alan Bell
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Ontario M5G 1V7, Canada
| | - James Douketis
- Department of Medicine, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada
| | - William Geerts
- Department of Medicine, University of Toronto, 6 Queen's Park Crescent West, Toronto, Ontario M5S 3H2, Canada
| | - Jean-Philippe Galanaud
- Department of Medicine, University of Toronto, 6 Queen's Park Crescent West, Toronto, Ontario M5S 3H2, Canada
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Haché J, Bonsu KO, Chitsike R, Nguyen H, Young S. Assessment of a Pharmacist-Led Direct Oral Anticoagulant Monitoring Clinic. Can J Hosp Pharm 2021; 74:7-14. [PMID: 33487649 PMCID: PMC7801335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are recommended as first-line therapy for treatment and prevention of venous thromboembolism (VTE) and prevention of stroke related to nonvalvular atrial fibrillation. Recent publications have suggested incorporating DOAC monitoring into anticoagulant management clinics. The Eastern Health Adult Outpatient Thrombosis Service (Newfoundland and Labrador) includes a pharmacist-led DOAC monitoring clinic that uses standardized evidence-based care processes. OBJECTIVES To describe a new pharmacist-led DOAC monitoring clinic and to assess patients' adherence to medication therapy, adherence to guideline-recommended frequencies for blood work, and adverse and non-adverse events. METHODS This retrospective chart review involved patients who attended their first visit to the DOAC clinic between October 10, 2017, and May 31, 2018. Patients were followed until November 30, 2018. Data were abstracted from electronic hospital records and the provincial pharmacy network. Descriptive statistics were used to analyze the data: categorical variables were presented as frequencies and percentages; continuous variables were analyzed and presented as means with standard deviations and, where applicable, as medians with interquartile ranges. RESULTS Forty-seven patients, who attended a total of 74 clinic visits, were included. Twenty-eight patients (60%) were adherent to their DOAC therapy. All patients had blood work completed before each clinic appointment. The mean time between the first and second sets of blood tests was 6.2 (standard deviation [SD] 1.4) months and between the second and third sets of blood tests was 5.1 (SD 1.0) months. There were no episodes of VTE or major bleeding. There was 1 cerebrovascular accident (3.2 events per 100 person-years, 95% confidence interval [CI] 0.2-15.7) and 5 episodes of clinically relevant non-major bleeding (12.8 events per 100 person-years, 95% CI 4.1-30.1). Pharmacists identified 51 issues at the clinic appointments, of which 48 were medication-related. Referral to the Thrombosis Service physician was required to resolve 8 (16%) of the issues identified. A brief discussion between the Thrombosis Service physician and pharmacist was required to resolve 30 (59%) of the issues, with 13 (25%) resolved by the pharmacist alone. CONCLUSIONS This study described the implementation and outcomes of a novel pharmacist-led DOAC clinic. Clinic patients underwent blood work at recommended intervals and received guidance on adherence and adverse events; as such, patients had follow-up that aligned with guideline recommendations.
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Affiliation(s)
- Jenna Haché
- , BSc(Biochem), BSc(Pharm), RPh, is with Eastern Health and with the School of Pharmacy, Memorial University of Newfoundland and Labrador, St John's, Newfoundland and Labrador
| | - Kwadwo Osei Bonsu
- , BSc(Pharm), PhD, is with the School of Pharmacy, Memorial University of Newfoundland and Labrador, St John's, Newfoundland and Labrador
| | - Rufaro Chitsike
- , MD, MMed(Haem), is with Eastern Health and with the School of Pharmacy, Memorial University of Newfoundland and Labrador, St John's, Newfoundland and Labrador
| | - Hai Nguyen
- , PhD, is with the School of Pharmacy, Memorial University of Newfoundland and Labrador, St John's, Newfoundland and Labrador
| | - Stephanie Young
- , BSc(Pharm), ACPR, PharmD, MSc(Med), is with Eastern Health and with the School of Pharmacy, Memorial University of Newfoundland and Labrador, St John's, Newfoundland and Labrador
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Insights Into Direct Oral Anticoagulant Therapy Implementation of Stroke Survivors with Atrial Fibrillation in an Ambulatory Setting. J Stroke Cerebrovasc Dis 2020; 30:105530. [PMID: 33333334 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/25/2020] [Accepted: 12/01/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES To describe how stroke survivors with atrial fibrillation implement direct oral anticoagulant treatment and propose appropriate metrics to describe adherence. MATERIALS AND METHODS Stroke patients with atrial fibrillation electronically recorded their self-administered direct oral anticoagulants (apixaban, dabigatran, edoxaban, rivaroxaban) during a 6-month observation phase after hospitalisation for ischemic stroke. Taking and timing adherence, correct dosing days, drug holidays, time of the day and day of the week subsets, dose-to-dose intervals and longest intervals between two consecutive doses were calculated from electronic monitoring data to describe and discuss the implementation phase of adherence. RESULTS Data from 41 patients were analysed. Median age was 77 (IQR = 69-84), 63.4% were male and the majority suffered a mild stroke (median NIHSS: 1). Mean taking and timing adherence exceeded 90%. Correct dosing occurred in 86.6% of the days. Seven patients (17.1%) had intake pauses of three or more consecutive days. Patients with twice-daily regimen (70.7%) had higher taking adherence in the morning than in the evening (94.4% versus 89.9%; p = 0.001). No therapy- or anamneses-related characteristic was associated with taking adherence. CONCLUSIONS Although adherence to direct oral anticoagulants of stroke patients with atrial fibrillation exceeded 90%, deviant intake patterns such as drug holidays and missed evening doses were common and raise concerns. Appropriate adherence metrics calculated from electronic monitoring data may guide healthcare professionals elucidating patient-tailored adherence-enhancing interventions. ClinicalTrials.gov registration number: NCT03344146.
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5
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El Hussein MT, Cuncannon A. DARE to Prescribe: Strategy to Guide Direct Oral Anticoagulant Therapy. J Nurse Pract 2020. [DOI: 10.1016/j.nurpra.2020.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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6
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Creatinine monitoring patterns in the setting of direct oral anticoagulant therapy for non-valvular atrial fibrillation. J Thromb Thrombolysis 2020; 48:500-505. [PMID: 31111434 DOI: 10.1007/s11239-019-01883-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Guidelines and experts note that patients with atrial fibrillation require regular renal function monitoring to ensure safe use of direct oral anticoagulants (DOACs). Insufficient monitoring could lead to inappropriate dosing and adverse events. Our objective was to describe the frequency of insufficient creatinine monitoring among patients on DOACs, and to describe clinical factors associated with insufficient monitoring. We hypothesized that renal impairment would be associated with insufficient monitoring. A retrospective cohort study was performed with data from the Michigan Anticoagulant Quality Improvement Initiative. Patients were included if they initiated DOAC therapy for stroke prevention related to atrial fibrillation, remained on therapy for ≥ 1 year, and had baseline creatinine and weight measurements. Creatinine clearance (CrCl) was calculated via Cockcroft-Gault equation. Our outcome was the presence of insufficient creatinine monitoring, defined as: < 1 creatinine level/year for patients with CrCl > 50, or < 2 creatinine levels/year for patients with CrCl ≤ 50. Multivariable analysis was done via logistic regression. Study population included 511 patients. In overall, 14.0% of patients received insufficient monitoring. Among patients with CrCl > 50, 11.5% had < 1 creatinine level/year. Among patients with CrCl ≤ 50, 27.1% received < 2 creatinine levels/year. Baseline renal dysfunction was associated with a higher likelihood of insufficient creatinine monitoring (adjusted odds ratio 3.64, 95% confidence interval 1.81-7.29). This shows a significant gap in the monitoring of patients on DOACs-patients with renal impairment are already at higher risk for adverse events. Future studies are needed to describe the barriers in monitoring these patients and to identify how to optimally address them.
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7
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Bo M, Marchionni N. Practical use of Direct Oral Anti Coagulants (DOACs) in the older persons with atrial fibrillation. Eur J Intern Med 2020; 71:32-38. [PMID: 31740104 DOI: 10.1016/j.ejim.2019.10.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 09/16/2019] [Accepted: 10/22/2019] [Indexed: 02/06/2023]
Abstract
Direct Oral Anticoagulants (DOACs) consistently demonstrated a greater net clinical benefit compared to Vitamin K Antagonists (VKAs) also in persons aged 75 years and over, who account for the largest proportion of AF patients; however, major uncertainties in DOACs prescription have to do with this age group. In this review, persistent uncertainties and implications of frailty and geriatric syndromes on DOACs prescription, and practical use of DOACs in real-world older persons, and will be discussed.
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Affiliation(s)
- Mario Bo
- Section of Geriatric, Department of Medical Sciences, AOU Città della Salute e della Scienza, Molinette, Turin, Italy.
| | - Niccolò Marchionni
- University of Florence, Head, Division of General Cardiology, Director, Cardiothoracovascular Department, AOU Careggi, Florence, Italy
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8
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Kim PY, Di Giuseppantonio LR, Wu C, Douketis JD, Gross PL. An assay to measure levels of factor Xa inhibitors in blood and plasma. J Thromb Haemost 2019; 17:1153-1159. [PMID: 30985986 DOI: 10.1111/jth.14451] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/15/2019] [Accepted: 04/04/2019] [Indexed: 11/30/2022]
Abstract
Essentials Direct oral anticoagulants (DOAC) are used for stroke and venous thromboembolism prevention. We report a new assay that measures anti-factor Xa DOAC levels in plasma and whole blood. Rivaroxaban and apixaban can be accurately quantified below trough levels. The ease and accuracy of the assay demonstrate its potential for point-of-care applications. BACKGROUND Rivaroxaban and apixaban are the most commonly used anti-factor (F) Xa direct oral anticoagulants (DOAC), with indications for prevention of stroke in nonvalvular atrial fibrillation as well as treatment and prevention of venous thromboembolism. However, lacking is accessibility to a detection method that is able to quantify low levels of anti-FXa DOACs. OBJECTIVE We report a new assay that measures anti-FXa DOAC levels in plasma and whole blood. METHODS This is achieved by the use of a prothrombin derivative that is labeled with a fluorescent probe (Flu-II), which then acts as the macromolecular substrate to measure residual FXa activity. The Flu-II cleavage is then initiated by the addition of a solution containing FXa, FVa, and phospholipid vesicles composed of 75% PC and 25% PS (PCPS) vesicles with calcium, in the presence of hirudin to prevent feedback activity by the native thrombin generated. The Flu-II cleavage is monitored by fluorescence in real time where the initial rate of fluorescence change is inversely proportional to DOAC levels. RESULTS In plasma systems, the assay demonstrates dose-response between 0 and 5 nmol/L rivaroxaban and between 0 and 10 nmol/L apixaban. Corn trypsin inhibitor did not affect this assay. With individual plasma samples, the assay showed excellent consistency and reproducibility. From 2 μL of whole blood, the assay showed dose-response between 0 and 2 nmol/L of DOACs in the final mixture of 100 μL, thus representing up to 100 nmol/L in circulating blood. CONCLUSION The assay is ideal for rapidly and accurately measuring DOAC levels in plasma and blood, demonstrating its potential for point-of-care applications.
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Affiliation(s)
- Paul Y Kim
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
- Department of Medical Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Luca R Di Giuseppantonio
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
- Department of Medical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Chengliang Wu
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James D Douketis
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Peter L Gross
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
- Department of Medical Sciences, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Kawabata M, Goya M, Takahashi Y, Maeda S, Yagishita A, Sekigawa M, Akiyoshi K, Yamamoto T, Koyama T, Hirao K. Excessive Prolongation of Coagulation Time During Treatment With Direct Oral Anticoagulants in Patients With Nonvalvular Atrial Fibrillation. Can J Cardiol 2019; 35:736-743. [PMID: 31151709 DOI: 10.1016/j.cjca.2019.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 01/31/2019] [Accepted: 02/10/2019] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Conventional coagulation assays have poor sensitivity and specificity for assessing the anticoagulant effect of direct oral anticoagulants (DOACs). This study aimed to evaluate the causes and consequences of the excessive prolongation of coagulation time in patients with nonvalvular atrial fibrillation who receive DOACs. METHODS We retrospectively analysed 1521 patients (age, 66 ± 12 years). The prothrombin time (PT) and activated partial thromboplastin time (APTT) were averaged if they were measured more than twice depending on the respective DOAC and dosage across individuals. Excessive coagulation time prolongation was defined as PT or APTT of >2 standard deviations over the median for each DOAC. RESULTS In all, 1913 DOAC cases were found. Excessive prolongation (EP), which was noted in 88 patients (5.8%), was found to be significantly associated with inappropriately high DOAC dosage and body weight (≤ 60 kg). During follow-up (median, 8.9 months), thromboembolisms developed in 10 patients (0.66%) and bleeding events in 85 (5.6%). Bleeding events were significantly higher in patients with excessive prolongation (EP group) than in those without (P = 0.013). Of the 53 patients in the EP group, 15 (28%) were positive for antiphospholipid antibodies, 6 (11%) had inappropriately high prescription dosages, 4 (8%) had coagulation factor deficiencies, and 3 (6%) had severe liver dysfunction. CONCLUSIONS Bleeding event rates were remarkably higher in patients receiving DOACs that caused EP of PT or APTT. Thus, following the current guidelines and administering the recommended dose of DOACs are fundamentally important. Patients with the body weight of <60 kg should be considered for dosage reduction or DOAC withdrawal.
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Affiliation(s)
- Mihoko Kawabata
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan.
| | - Masahiko Goya
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Yoshihide Takahashi
- Advanced Arrhythmia Research, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shingo Maeda
- Advanced Arrhythmia Research, Tokyo Medical and Dental University, Tokyo, Japan
| | - Atsuhiko Yagishita
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masahiro Sekigawa
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kiko Akiyoshi
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Tasuku Yamamoto
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takatoshi Koyama
- Department of Hematology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Kenzo Hirao
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University, Tokyo, Japan
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10
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How I manage anticoagulant therapy in older individuals with atrial fibrillation or venous thromboembolism. Blood 2019; 133:2269-2278. [PMID: 30926593 DOI: 10.1182/blood-2019-01-846048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 03/26/2019] [Indexed: 01/08/2023] Open
Abstract
Anticoagulant therapy is the most effective strategy to prevent arterial and venous thromboembolism, but treating older individuals is challenging, because increasing age, comorbidities, and polypharmacy increase the risk of both thrombosis and bleeding. Warfarin and non-vitamin K antagonist oral anticoagulants are underused and often underdosed in the prevention of stroke in older patients with atrial fibrillation because of concerns about the risk of bleeding. Poor adherence to anticoagulant therapy is also an issue for older patients with atrial fibrillation and those at risk of recurrent pulmonary embolism. In this review, we present 5 clinical cases to illustrate common challenges with anticoagulant use in older patients and discuss our approach to institute safe and effective antithrombotic therapy.
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11
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Huang JH, Lin YK, Chung CC, Hsieh MH, Chiu WC, Chen YJ. Factors That Determine the Prothrombin Time in Patients With Atrial Fibrillation Receiving Rivaroxaban. Clin Appl Thromb Hemost 2018; 24:188S-193S. [PMID: 30244598 PMCID: PMC6714846 DOI: 10.1177/1076029618800830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Rivaroxaban, a direct factor Xa inhibitor, is widely used to reduce the chance of stroke
in patients with atrial fibrillation (AF). It is not clear why the prothrombin time (PT)
of the international normalized ratio (INR) fails to correlate with treatment using
rivaroxaban in patients with AF. In this study, patient characteristics, the rivaroxaban
dosage, AF type, drug history, biochemical properties, and hematological profiles were
assessed in patients treated with rivaroxaban. In 69 patients with AF receiving
rivaroxaban, 27 (39.1%) patients had a normal INR (≤1.1, group 1), 27 (39.1%) patients had
a slightly prolonged INR (1.1∼1.5, group 2), and 15 (21.7%) patients had a significantly
prolonged INR (>1.5, group 3). Group 1 patients had a higher incidence of a stroke
history than did patients in group 2 (P = .026) and group 3
(P = .032). We scored patients with a persistent AF pattern (1 point),
paroxysmal AF pattern (0 point), renal function (ie, the creatinine clearance rate in
mL/min/1.73 m2 of >60 as 0 points, of 30∼60 as 1 point, and of <30 as 2
points), and no history of stroke (1 point), and we found that group 3 had a higher score
than groups 2 or 1 (2.9 ± 0.8, 2.4 ± 0.7, and 2 ± 0.7, respectively; P
< .05). There were similar incidences of bleeding, stroke, and unexpected
hospitalizations among the 3 groups. The PT of the INR is determined by multiple variables
in patients with AF receiving rivaroxaban. Rivaroxaban-treated patients with AF having
different INR values may have similar clinical outcomes.
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Affiliation(s)
- Jen-Hung Huang
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yung-Kuo Lin
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Cheng-Chih Chung
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Ming-Hsiung Hsieh
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Wan-Chun Chiu
- School of Nutrition and Health Sciences, College of Nutrition, Taipei Medical University, Taipei, Taiwan
| | - Yi-Jen Chen
- Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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13
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Sennesael AL, Larock AS, Devalet B, Mathieux V, Verschuren F, Muschart X, Dalleur O, Dogné JM, Spinewine A. Preventability of serious thromboembolic and bleeding events related to the use of oral anticoagulants: a prospective study. Br J Clin Pharmacol 2018. [PMID: 29522647 DOI: 10.1111/bcp.13580] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
AIMS To determine the preventability of serious adverse drug reactions (ADRs) related to the use of direct oral anticoagulants (DOACs), and to explore contributing factors to preventable ADRs. Results were compared with vitamin K antagonists (VKAs). METHODS We conducted a prospective observational study in the emergency departments of two teaching hospitals from July 2015 to January 2016. Patients admitted with a thrombotic or bleeding event while under DOAC or VKA were included. Four independent reviewers assessed causality, seriousness and preventability of ADRs using pilot-tested scales. For cases of serious and potentially preventable ADRs, we performed semi-structured interviews with general practitioners to identify contributing factors to ADRs. The primary outcome was the proportion of serious ADRs that were potentially preventable. RESULTS The analysis included 46 DOAC and 43 VKA patients (median age 79 years). Gastrointestinal (n = 34) and intracranial (n = 16) bleedings were the most frequent ADRs. Results were that 53% of DOAC- and 61% of VKA-related serious ADRs were deemed potentially preventable. Prescribing issues and inadequate monitoring were frequent for DOAC and VKA respectively. We identified many causes of preventable ADRs that applied to all oral anticoagulants, such as pharmacodynamic drug interactions and lack of communication. CONCLUSIONS More than half of serious ADRs were potentially preventable for both DOACs and VKAs. Interventions focusing on prescribing, patient education and continuity of care should help improve the use of DOACs in practice.
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Affiliation(s)
- Anne-Laure Sennesael
- Louvain Drug Research Institute, Clinical Pharmacy Research Group, Université catholique de Louvain, Brussels, Belgium.,Namur Research Institute for Life Sciences, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, University of Namur, Namur, Belgium
| | - Anne-Sophie Larock
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, Université catholique de Louvain, Yvoir, Belgium
| | - Bérangère Devalet
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Department of Hematology, Université catholique de Louvain, Yvoir, Belgium
| | - Valérie Mathieux
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Department of Hematology, Université catholique de Louvain, Yvoir, Belgium
| | - Franck Verschuren
- Institute of Experimental and Clinical Research, Cliniques Universitaires Saint-Luc, Department of Emergency Medicine, Université catholique de Louvain, Brussels, Belgium
| | - Xavier Muschart
- CHU UCL Namur, Department of Emergency Medicine, Université catholique de Louvain, Yvoir, Belgium
| | - Olivia Dalleur
- Louvain Drug Research Institute, Clinical Pharmacy Research Group, Université catholique de Louvain, Brussels, Belgium.,Cliniques Universitaires Saint-Luc, Department of Pharmacy, Université catholique de Louvain, Brussels, Belgium
| | - Jean-Michel Dogné
- Namur Research Institute for Life Sciences, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, University of Namur, Namur, Belgium
| | - Anne Spinewine
- Louvain Drug Research Institute, Clinical Pharmacy Research Group, Université catholique de Louvain, Brussels, Belgium.,CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Department of Pharmacy, Université catholique de Louvain, Yvoir, Belgium
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14
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Leblanc K, Semchuk WM, Papastergiou J, Snow B, Mandlsohn L, Kapoor V, Guirguis LM, Douketis JD, Geerts W, Gladstone DJ. A pharmacist checklist for direct oral anticoagulant management: Raising the bar. Can Pharm J (Ott) 2018. [PMID: 29531627 DOI: 10.1177/1715163518756926] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Kori Leblanc
- University Health Network (Leblanc), University of Toronto, Toronto.,Leslie Dan Faculty of Pharmacy (Leblanc, Papastergiou), University of Toronto, Toronto.,Regina Qu'Appelle Health Region (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,College of Pharmacy and Nutrition (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,John Papastergiou Pharmacy Ltd. (Papastergiou), Toronto.,Long Term Care Service (Snow), Roulston's Pharmacy, Simcoe.,Green Shield Canada (Mandlsohn), Willowdale.,Vinay Kapoor Drugs Ltd. (Kapoor), Thunder Bay, Ontario.,Faculty of Pharmacy and Pharmaceutical Sciences (Guirguis), University of Alberta.,Department of Medicine (Douketis), McMaster University, Hamilton.,Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Research Institute, Toronto.,Thromboembolism Program (Geerts), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Division of Neurology (Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Department of Medicine (Geerts, Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario
| | - William M Semchuk
- University Health Network (Leblanc), University of Toronto, Toronto.,Leslie Dan Faculty of Pharmacy (Leblanc, Papastergiou), University of Toronto, Toronto.,Regina Qu'Appelle Health Region (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,College of Pharmacy and Nutrition (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,John Papastergiou Pharmacy Ltd. (Papastergiou), Toronto.,Long Term Care Service (Snow), Roulston's Pharmacy, Simcoe.,Green Shield Canada (Mandlsohn), Willowdale.,Vinay Kapoor Drugs Ltd. (Kapoor), Thunder Bay, Ontario.,Faculty of Pharmacy and Pharmaceutical Sciences (Guirguis), University of Alberta.,Department of Medicine (Douketis), McMaster University, Hamilton.,Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Research Institute, Toronto.,Thromboembolism Program (Geerts), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Division of Neurology (Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Department of Medicine (Geerts, Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario
| | - John Papastergiou
- University Health Network (Leblanc), University of Toronto, Toronto.,Leslie Dan Faculty of Pharmacy (Leblanc, Papastergiou), University of Toronto, Toronto.,Regina Qu'Appelle Health Region (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,College of Pharmacy and Nutrition (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,John Papastergiou Pharmacy Ltd. (Papastergiou), Toronto.,Long Term Care Service (Snow), Roulston's Pharmacy, Simcoe.,Green Shield Canada (Mandlsohn), Willowdale.,Vinay Kapoor Drugs Ltd. (Kapoor), Thunder Bay, Ontario.,Faculty of Pharmacy and Pharmaceutical Sciences (Guirguis), University of Alberta.,Department of Medicine (Douketis), McMaster University, Hamilton.,Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Research Institute, Toronto.,Thromboembolism Program (Geerts), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Division of Neurology (Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Department of Medicine (Geerts, Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario
| | - Blair Snow
- University Health Network (Leblanc), University of Toronto, Toronto.,Leslie Dan Faculty of Pharmacy (Leblanc, Papastergiou), University of Toronto, Toronto.,Regina Qu'Appelle Health Region (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,College of Pharmacy and Nutrition (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,John Papastergiou Pharmacy Ltd. (Papastergiou), Toronto.,Long Term Care Service (Snow), Roulston's Pharmacy, Simcoe.,Green Shield Canada (Mandlsohn), Willowdale.,Vinay Kapoor Drugs Ltd. (Kapoor), Thunder Bay, Ontario.,Faculty of Pharmacy and Pharmaceutical Sciences (Guirguis), University of Alberta.,Department of Medicine (Douketis), McMaster University, Hamilton.,Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Research Institute, Toronto.,Thromboembolism Program (Geerts), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Division of Neurology (Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Department of Medicine (Geerts, Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario
| | - Leilany Mandlsohn
- University Health Network (Leblanc), University of Toronto, Toronto.,Leslie Dan Faculty of Pharmacy (Leblanc, Papastergiou), University of Toronto, Toronto.,Regina Qu'Appelle Health Region (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,College of Pharmacy and Nutrition (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,John Papastergiou Pharmacy Ltd. (Papastergiou), Toronto.,Long Term Care Service (Snow), Roulston's Pharmacy, Simcoe.,Green Shield Canada (Mandlsohn), Willowdale.,Vinay Kapoor Drugs Ltd. (Kapoor), Thunder Bay, Ontario.,Faculty of Pharmacy and Pharmaceutical Sciences (Guirguis), University of Alberta.,Department of Medicine (Douketis), McMaster University, Hamilton.,Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Research Institute, Toronto.,Thromboembolism Program (Geerts), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Division of Neurology (Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Department of Medicine (Geerts, Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario
| | - Vinay Kapoor
- University Health Network (Leblanc), University of Toronto, Toronto.,Leslie Dan Faculty of Pharmacy (Leblanc, Papastergiou), University of Toronto, Toronto.,Regina Qu'Appelle Health Region (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,College of Pharmacy and Nutrition (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,John Papastergiou Pharmacy Ltd. (Papastergiou), Toronto.,Long Term Care Service (Snow), Roulston's Pharmacy, Simcoe.,Green Shield Canada (Mandlsohn), Willowdale.,Vinay Kapoor Drugs Ltd. (Kapoor), Thunder Bay, Ontario.,Faculty of Pharmacy and Pharmaceutical Sciences (Guirguis), University of Alberta.,Department of Medicine (Douketis), McMaster University, Hamilton.,Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Research Institute, Toronto.,Thromboembolism Program (Geerts), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Division of Neurology (Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Department of Medicine (Geerts, Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario
| | - Lisa M Guirguis
- University Health Network (Leblanc), University of Toronto, Toronto.,Leslie Dan Faculty of Pharmacy (Leblanc, Papastergiou), University of Toronto, Toronto.,Regina Qu'Appelle Health Region (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,College of Pharmacy and Nutrition (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,John Papastergiou Pharmacy Ltd. (Papastergiou), Toronto.,Long Term Care Service (Snow), Roulston's Pharmacy, Simcoe.,Green Shield Canada (Mandlsohn), Willowdale.,Vinay Kapoor Drugs Ltd. (Kapoor), Thunder Bay, Ontario.,Faculty of Pharmacy and Pharmaceutical Sciences (Guirguis), University of Alberta.,Department of Medicine (Douketis), McMaster University, Hamilton.,Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Research Institute, Toronto.,Thromboembolism Program (Geerts), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Division of Neurology (Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Department of Medicine (Geerts, Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario
| | - James D Douketis
- University Health Network (Leblanc), University of Toronto, Toronto.,Leslie Dan Faculty of Pharmacy (Leblanc, Papastergiou), University of Toronto, Toronto.,Regina Qu'Appelle Health Region (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,College of Pharmacy and Nutrition (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,John Papastergiou Pharmacy Ltd. (Papastergiou), Toronto.,Long Term Care Service (Snow), Roulston's Pharmacy, Simcoe.,Green Shield Canada (Mandlsohn), Willowdale.,Vinay Kapoor Drugs Ltd. (Kapoor), Thunder Bay, Ontario.,Faculty of Pharmacy and Pharmaceutical Sciences (Guirguis), University of Alberta.,Department of Medicine (Douketis), McMaster University, Hamilton.,Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Research Institute, Toronto.,Thromboembolism Program (Geerts), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Division of Neurology (Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Department of Medicine (Geerts, Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario
| | - William Geerts
- University Health Network (Leblanc), University of Toronto, Toronto.,Leslie Dan Faculty of Pharmacy (Leblanc, Papastergiou), University of Toronto, Toronto.,Regina Qu'Appelle Health Region (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,College of Pharmacy and Nutrition (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,John Papastergiou Pharmacy Ltd. (Papastergiou), Toronto.,Long Term Care Service (Snow), Roulston's Pharmacy, Simcoe.,Green Shield Canada (Mandlsohn), Willowdale.,Vinay Kapoor Drugs Ltd. (Kapoor), Thunder Bay, Ontario.,Faculty of Pharmacy and Pharmaceutical Sciences (Guirguis), University of Alberta.,Department of Medicine (Douketis), McMaster University, Hamilton.,Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Research Institute, Toronto.,Thromboembolism Program (Geerts), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Division of Neurology (Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Department of Medicine (Geerts, Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario
| | - David J Gladstone
- University Health Network (Leblanc), University of Toronto, Toronto.,Leslie Dan Faculty of Pharmacy (Leblanc, Papastergiou), University of Toronto, Toronto.,Regina Qu'Appelle Health Region (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,College of Pharmacy and Nutrition (Semchuk), University of Saskatchewan, Saskatoon, Saskatchewan.,John Papastergiou Pharmacy Ltd. (Papastergiou), Toronto.,Long Term Care Service (Snow), Roulston's Pharmacy, Simcoe.,Green Shield Canada (Mandlsohn), Willowdale.,Vinay Kapoor Drugs Ltd. (Kapoor), Thunder Bay, Ontario.,Faculty of Pharmacy and Pharmaceutical Sciences (Guirguis), University of Alberta.,Department of Medicine (Douketis), McMaster University, Hamilton.,Hurvitz Brain Sciences Program (Gladstone), Sunnybrook Research Institute, Toronto.,Thromboembolism Program (Geerts), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Division of Neurology (Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario.,Department of Medicine (Geerts, Gladstone), Sunnybrook Health Sciences Centre and University of Toronto, Toronto, Ontario
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15
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Wein T, Lindsay MP, Côté R, Foley N, Berlingieri J, Bhogal S, Bourgoin A, Buck BH, Cox J, Davidson D, Dowlatshahi D, Douketis J, Falconer J, Field T, Gioia L, Gubitz G, Habert J, Jaspers S, Lum C, McNamara Morse D, Pageau P, Rafay M, Rodgerson A, Semchuk B, Sharma M, Shoamanesh A, Tamayo A, Smitko E, Gladstone DJ. Canadian stroke best practice recommendations: Secondary prevention of stroke, sixth edition practice guidelines, update 2017. Int J Stroke 2017; 13:420-443. [DOI: 10.1177/1747493017743062] [Citation(s) in RCA: 143] [Impact Index Per Article: 20.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The 2017 update of The Canadian Stroke Best Practice Recommendations for the Secondary Prevention of Stroke is a collection of current evidence-based recommendations intended for use by clinicians across a wide range of settings. The goal is to provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations include those related to diagnostic testing, diet and lifestyle, smoking, hypertension, hyperlipidemia, diabetes, antiplatelet and anticoagulant therapies, carotid artery disease, atrial fibrillation, and other cardiac conditions. Notable changes in this sixth edition include the development of core elements for delivering secondary stroke prevention services, the addition of a section on cervical artery dissection, new recommendations regarding the management of patent foramen ovale, and the removal of the recommendations on management of sleep apnea. The Canadian Stroke Best Practice Recommendations include a range of supporting materials such as implementation resources to facilitate the adoption of evidence to practice, and related performance measures to enable monitoring of uptake and effectiveness of the recommendations. The guidelines further emphasize the need for a systems approach to stroke care, involving an interprofessional team, with access to specialists regardless of patient location, and the need to overcome geographic barriers to ensure equity in access within a universal health care system.
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Affiliation(s)
- Theodore Wein
- McGill University, Canada
- Montreal General Hospital, Canada
| | | | - Robert Côté
- McGill University, Canada
- Montreal General Hospital, Canada
| | - Norine Foley
- Western University, Canada
- workHORSE Consulting, London
| | | | | | | | - Brian H Buck
- Division of Neurology, Department of Medicine, University of Alberta, Canada
| | - Jafna Cox
- Department of Medicine, Dalhousie University, Canada
| | | | | | - Jim Douketis
- Divisions of General Internal Medicine, Hematology and Thromboembolism, McMaster University Department of Medicine, Canada
- Thrombosis Canada, Canada
| | | | - Thalia Field
- Faculty of Medicine, University of British Columbia, Canada
| | - Laura Gioia
- Department of Neurosciences, CHUM-Centre Hospitalier de l’Université de Montréal, Hôpital Notre Dame, Canada
| | - Gord Gubitz
- Department of Medicine, Dalhousie University, Canada
- Queen Elizabeth II Stroke Program, Nova Scotia, Canada
| | - Jeffrey Habert
- Department of Family and Community Medicine, University of Toronto, Canada
| | | | - Cheemun Lum
- Stroke Program, Ottawa Civic Hospital, Canada
| | | | - Paul Pageau
- Department of Emergency Medicine, The University of Ottawa, Canada
| | - Mubeen Rafay
- Winnipeg Children’s Hospital, Canada
- University of Manitoba, Canada
| | | | | | - Mukul Sharma
- Population Health Research Institute, McMaster University, Canada
| | | | | | | | - David J Gladstone
- Sunnybrook Health Sciences Centre, Hurvitz Brain Sciences Program, Sunnybrook Research Institute, Toronto, Canada
- University of Toronto Department of Medicine, Toronto, Canada
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16
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Mohammad I, Korkis B, Garwood CL. Incorporating Comprehensive Management of Direct Oral Anticoagulants into Anticoagulation Clinics. Pharmacotherapy 2017; 37:1284-1297. [DOI: 10.1002/phar.1991] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Insaf Mohammad
- Pharmacy Department; Harper University Hospital, Detroit Medical Center; Detroit Michigan
| | - Bianca Korkis
- Pharmacy Department; Harper University Hospital, Detroit Medical Center; Detroit Michigan
- Department of Pharmacy Practice; Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University; Detroit Michigan
| | - Candice L. Garwood
- Pharmacy Department; Harper University Hospital, Detroit Medical Center; Detroit Michigan
- Department of Pharmacy Practice; Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University; Detroit Michigan
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17
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Bo M, Grisoglio E, Brunetti E, Falcone Y, Marchionni N. Oral anticoagulant therapy for older patients with atrial fibrillation: a review of current evidence. Eur J Intern Med 2017; 41:18-27. [PMID: 28343849 DOI: 10.1016/j.ejim.2017.03.012] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/08/2017] [Accepted: 03/13/2017] [Indexed: 12/11/2022]
Abstract
Atrial fibrillation is more frequent in older patients, who have a higher risk of cardioembolic stroke and thromboembolism. Oral anticoagulant therapy is the standard of treatment for stroke prevention; however, under-prescription is still very common in older patients. The reasons underlying this phenomenon have not been systematically investigated, and true contraindications only partially account for it. An intimate skepticism on the real benefit-risk balance of oral anticoagulant therapy in the oldest patients seems to derive from the fact that most studies supporting it were conducted decades ago and included younger patients, with overall better functional and clinical status. In this review we will focus on the main barriers to anticoagulant therapy prescription in older patients and summarize the available evidences on the efficacy and safety of vitamin K antagonists and direct oral anticoagulants in this population. The encouraging evidence of a higher net clinical benefit of direct oral anticoagulants compared with warfarin should hopefully widen the treatment options also for frail individuals, thereby allowing a greater number of patients to be treated according to current international guidelines.
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Affiliation(s)
- Mario Bo
- Section of Geriatrics and Bone Metabolic Diseases, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Enrica Grisoglio
- Section of Geriatrics and Bone Metabolic Diseases, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Enrico Brunetti
- Section of Geriatrics and Bone Metabolic Diseases, Department of Medical Sciences, University of Turin, Turin, Italy.
| | - Yolanda Falcone
- Section of Geriatrics and Bone Metabolic Diseases, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Niccolò Marchionni
- Division of Geriatric Cardiology and Medicine, University of Florence, Florence, Italy
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18
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Chan NC, Eikelboom JW, Weitz JI. Evolving Treatments for Arterial and Venous Thrombosis: Role of the Direct Oral Anticoagulants. Circ Res 2017; 118:1409-24. [PMID: 27126650 DOI: 10.1161/circresaha.116.306925] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 04/02/2016] [Indexed: 01/23/2023]
Abstract
The direct oral anticoagulants (DOACs) represent a major advance in oral anticoagulant therapy and have replaced the vitamin K antagonists as the preferred treatment for many indications. By simplifying long-term anticoagulant therapy and improving its safety, the DOACs have the potential to reduce the global burden of thrombosis. Postmarketing studies suggest that the favorable results achieved with DOACs in the randomized controlled trials can be readily translated into practice, but highlight the need for appropriate patient, drug and dose selection, and careful follow-up. Leveraging on their success to date, ongoing studies are assessing the utility of DOACs for the prevention of thrombosis in patients with embolic stroke of unknown source, heart failure, coronary artery disease, peripheral artery disease, antiphospholipid syndrome, and cancer. The purpose of this article is to (1) review the pharmacology of the DOACs, (2) describe the advantages of the DOACs over vitamin K antagonists, (3) summarize the experience with the DOACs in established indications, (4) highlight current challenges and limitations, (5) highlight potential new indications; and (6) identify future directions for anticoagulant therapy.
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Affiliation(s)
- Noel C Chan
- From the Population Health Research Institute (N.C.C., J.W.E.) and Department of Medicine (J.W.E., J.I.W.), McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.W.E., J.I.W.); and Department of Medicine, Monash University, Clayton, Victoria, Australia (N.C.C.).
| | - John W Eikelboom
- From the Population Health Research Institute (N.C.C., J.W.E.) and Department of Medicine (J.W.E., J.I.W.), McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.W.E., J.I.W.); and Department of Medicine, Monash University, Clayton, Victoria, Australia (N.C.C.)
| | - Jeffrey I Weitz
- From the Population Health Research Institute (N.C.C., J.W.E.) and Department of Medicine (J.W.E., J.I.W.), McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.W.E., J.I.W.); and Department of Medicine, Monash University, Clayton, Victoria, Australia (N.C.C.)
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19
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Direct oral anticoagulant use and the incidence of bleeding in the very elderly with atrial fibrillation. J Thromb Thrombolysis 2017; 42:573-8. [PMID: 27520093 DOI: 10.1007/s11239-016-1410-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Atrial fibrillation (AF) is a major risk factor for stroke in the elderly population. The use of anticoagulation in patients with AF greatly reduces the risk for stroke, but results in an increased risk of bleeding. Over the past several years, direct oral anticoagulants (DOACs, dabigatran, rivaroxaban, and apixaban) have been used in place of warfarin for stroke prevention in AF. We conducted a retrospective cohort study to assess the safety of DOACs in very elderly patients (75+) managed in a health care system encompassing both community and academic settings. We found that 36 % of patients had moderate to severe renal failure (estimated glomerular filtration rate <59 ml/min/1.73 m(2)) at the time of DOAC initiation. 142 patients were followed for a mean of 2.56 years, and five experienced a major bleeding episode while on anticoagulation, for a rate of 1.37 per 100 person years. All major bleeding episodes were associated with a decline in GFR compared to baseline. There were 12 non-major bleeding episodes reported. HAS-BLED scores were similar for those patients who experienced bleeding complications compared to those who did not. 21 % of patients were prescribed an inappropriately low dose of DOAC based on approved recommendations. DOACs appear to be a safe form of anticoagulation in very elderly patients with AF. However, the decline in GFR among patients with major bleeding highlights the importance of routine renal function monitoring.
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20
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Abstract
Patients with derangements of secondary hemostasis resulting from inherited or acquired thrombophilias are at increased risk of venous thromboemboli (VTE). Evaluation of a patient with suspected VTE proceeds via evidence-based algorithms that involve computing a pretest probability based on the history and physical examination; this guides subsequent work-up, which can include D dimer and/or imaging. Testing for hypercoagulable disorders should be pursued only in patients with VTE with an increased risk for an underlying thrombophilia. Direct oral anticoagulants are first-line VTE therapies, but they should be avoided in patients who are pregnant, have active cancer, antiphospholipid antibody syndrome, severe renal insufficiency, or prosthetic heart valves.
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Affiliation(s)
- Marie A Hollenhorst
- Internal Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Elisabeth M Battinelli
- Division of Hematology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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21
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Conway SE, Hwang AY, Ponte CD, Gums JG. Laboratory and Clinical Monitoring of Direct Acting Oral Anticoagulants: What Clinicians Need to Know. Pharmacotherapy 2017; 37:236-248. [DOI: 10.1002/phar.1884] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Susan E. Conway
- Department of Pharmacy: Clinical and Administrative Sciences; University of Oklahoma College of Pharmacy; Oklahoma City Oklahoma
| | - Andrew Y. Hwang
- Department of Pharmacotherapy and Translational Research; University of Florida College of Pharmacy; Gainesville Florida
| | - Charles D. Ponte
- Departments of Clinical Pharmacy and Family Medicine; West Virginia University Schools of Pharmacy and Medicine; Morgantown West Virginia
| | - John G. Gums
- Department of Pharmacotherapy and Translational Research; University of Florida College of Pharmacy; Gainesville Florida
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22
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Witt DM, Hansen AL. Non-Vitamin K Anticoagulant Dose Selection: It's Best to Read and Follow the Directions. J Am Coll Cardiol 2016; 68:2605-2607. [PMID: 27978943 DOI: 10.1016/j.jacc.2016.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2016] [Revised: 10/06/2016] [Accepted: 10/11/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Daniel M Witt
- Department of Pharmacotherapy, University of Utah College of Pharmacy, Salt Lake City, Utah.
| | - Alisyn L Hansen
- Associated Regional and University Pathologists Family Health Clinic, University of Utah College of Pharmacy, Salt Lake City, Utah
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23
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Massaro A, Giugliano RP, Norrving B, Oto A, Veltkamp R. Overcoming global challenges in stroke prophylaxis in atrial fibrillation: The role of non-vitamin K antagonist oral anticoagulants. Int J Stroke 2016; 11:950-967. [DOI: 10.1177/1747493016660106] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 05/16/2016] [Indexed: 01/04/2023]
Abstract
Atrial fibrillation is the world's most common sustained cardiac arrhythmia and is associated with a significantly increased risk of stroke. The global burden of atrial fibrillation is rising, commensurate with the ageing population. Well-controlled vitamin K antagonist-based anticoagulation has been shown to reduce the risk of stroke secondary to atrial fibrillation by two-thirds. However, patients with atrial fibrillation have frequently been denied anticoagulation because of a variety of perceived risks related to bleeding, falls, chronological age, and poor compliance. Even when vitamin K antagonists are used, maximum benefit and safety are only delivered when high quality control of therapy (TTR > 70%) is achieved, which has proven remarkably difficult in many health-care systems and amongst many patient groups. The non-vitamin K antagonist oral anticoagulants (NOACs) offer solutions to many of the challenges of achieving widespread, safe, and effective anticoagulation for stroke prophylaxis in atrial fibrillation, yet their uptake into routine clinical practice remains variable. The evidence supporting their more widespread use to overcome the challenges of stroke prophylaxis for atrial fibrillation is reviewed in this article.
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Affiliation(s)
- Ayrton Massaro
- Department of Neurology, Hospital Sirio-Libanes, São Paulo, Brazil
- Neurovascular Research Unit, Brain Institute of Rio Grande do Sul (BraIns), PUCRS, Porto Alegre – RS – Brazil
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bo Norrving
- Department of Clinical Neuroscience (B.N.), Section of Neurology, Lund University, Lund, Sweden
| | - Ali Oto
- Faculty of Medicine, Department of Cardiology, Hacettepe University, Ankara, Turkey
| | - Roland Veltkamp
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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24
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Solomon JM, Hume AL. Direct Oral Anticoagulants: A Patient-centered Review. J Nurse Pract 2016. [DOI: 10.1016/j.nurpra.2016.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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25
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Abdou JK, Auyeung V, Patel JP, Arya R. Adherence to long-term anticoagulation treatment, what is known and what the future might hold. Br J Haematol 2016; 174:30-42. [DOI: 10.1111/bjh.14134] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- John K. Abdou
- Institute of Pharmaceutical Science; King's College London; London UK
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital Foundation NHS Trust, Denmark Hill; London UK
| | - Vivian Auyeung
- Institute of Pharmaceutical Science; King's College London; London UK
| | - Jignesh P. Patel
- Institute of Pharmaceutical Science; King's College London; London UK
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital Foundation NHS Trust, Denmark Hill; London UK
| | - Roopen Arya
- King's Thrombosis Centre; Department of Haematological Medicine; King's College Hospital Foundation NHS Trust, Denmark Hill; London UK
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26
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Leong-Sit P, Healey JS. A New, Simplified Measure of Anticoagulation Control With Warfarin: Potential Role in the Direct Oral Anticoagulant Era. Can J Cardiol 2016; 32:1203.e5-1203.e7. [PMID: 26922290 DOI: 10.1016/j.cjca.2015.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2015] [Revised: 11/26/2015] [Accepted: 11/26/2015] [Indexed: 10/22/2022] Open
Affiliation(s)
| | - Jeffrey S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada.
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27
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Sweis R, Biller J. Practical Guide to Direct New Oral Anticoagulant Use for Secondary Stroke Prevention in Atrial Fibrillation. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:24. [PMID: 26909818 DOI: 10.1007/s11936-016-0446-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OPINION STATEMENT Anticoagulation remains the optimal treatment choice for secondary stroke prevention of AF. The vitamin K antagonists (VKAs) have been the choice of treatment for the last 60 years, but the new oral anticoagulants are now a safe option for treatment of non-valvular AF (NVAF) in the right patient population, taking into account age, renal function, bleeding risk, cardiovascular comorbidities, cost, and drug interactions.
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Affiliation(s)
- Rochelle Sweis
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, USA.
| | - José Biller
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Chicago, IL, USA.
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AlTurki A, Proietti R, Birnie DH, Essebag V. Management of antithrombotic therapy during cardiac implantable device surgery. J Arrhythm 2016; 32:163-9. [PMID: 27354859 PMCID: PMC4913137 DOI: 10.1016/j.joa.2015.12.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Revised: 12/03/2015] [Accepted: 12/08/2015] [Indexed: 01/10/2023] Open
Abstract
Anticoagulants are commonly used drugs that are frequently encountered during device placement. Deciding when to halt or continue the use of anticoagulants is a balance between the risks of thromboembolism versus bleeding. Patients taking warfarin with a high risk of thromboembolism should continue to take their warfarin without interruption during device placement while ensuring their international normalized ratio remains below 3. For patients who are taking warfarin and have low risk of thromboembolism, either interrupted or continued warfarin may be used, with no evidence to clearly support either strategy. There is little evidence to support continuing direct acting oral anticoagulants (DOACs) for device implantation. The timing of halting these medications depends largely on renal function. If bleeding occurs, warfarin׳s anticoagulation effect is reversible with vitamin K and activated prothrombin complex concentrate. There are no DOAC reversal agents currently available, but some are under development. Regarding antiplatelet agents, aspirin alone can be safely continued while clopidogrel alone may also be continued, but with a slightly higher bleeding risk. Dual antiplatelet therapy for bare-metal stent/drug-eluting stent implanted within 4 weeks/6 months, respectively, should be continued due to high risk of stent thrombosis; however, if they are implanted after this period, then clopidogrel can be halted 5 days before the procedure and resumed soon after, while aspirin is continued. If the patient is taking both aspirin and warfarin, aspirin should be halted 5 days prior to the procedure, while warfarin is continued.
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Affiliation(s)
- Ahmed AlTurki
- McGill University Health Center, Montreal, Quebec, Canada
| | - Riccardo Proietti
- McGill University Health Center, Montreal, Quebec, Canada; Cardiology Department, Luigi Sacco Hospital, Milan, Italy
| | - David H Birnie
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Vidal Essebag
- McGill University Health Center, Montreal, Quebec, Canada; Hôpital Sacré-Coeur de Montréal, Montreal, Quebec, Canada
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