1
|
Chiang YJ, Hu YC, Chiang BL. A significant improvement of thromboses treated by a new oral anticoagulant in an 11-year-old girl with systemic lupus erythematosus associated antiphospholipid syndrome: A case report. Lupus 2021; 30:1338-1341. [PMID: 34000880 DOI: 10.1177/09612033211016096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Pediatric venous thrombosis is associated with a variety of chronic diseases. Antiphospholipid syndrome (APS) is one of them and is commonly related to systemic lupus erythematosus (SLE). Warfarin is the mainstream of anticoagulation treatment in pediatric APS currently but it needs close monitoring and frequent dose adjustment. New oral anticoagulants (NOAC) is one of the innovative options in recent years but there is a lack of report in secondary prevention of deep vein thrombosis (DVT), especially pediatric APS. Herein we reported the significant therapeutic effect of edoxaban in a 11-year-old girl of newly diagnosed SLE and APS, who had deep vein thrombosis as the initial presentation.
Collapse
Affiliation(s)
- Yen-Jung Chiang
- Department of Pediatrics, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Ya-Chiao Hu
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Bor-Luen Chiang
- Department of Pediatrics, National Taiwan University Hospital, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| |
Collapse
|
2
|
Ioppolo AM, Longobardo L, D'Isa S, De Gregorio P, Manfredi M, De Cesare NB. An Uncommon Case of Spontaneous Hemopericardium in a Patient Treated with Rivaroxaban. J Cardiovasc Echogr 2020; 29:180-182. [PMID: 32090001 PMCID: PMC7011493 DOI: 10.4103/jcecho.jcecho_57_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
We describe a case of an 88-year-old woman with a severe bluntly ematic pericardial effusion. Radiological and laboratory examinations excluded all the most common causes of hemopericardium, and the diagnosis of spontaneous hemopericardium associated with the treatment with rivaroxaban was made. This is the first case report describing a hemopericardium in a patient treated with rivaroxaban who did not take other herbal products or drugs that may significantly increase rivaroxaban blood levels. This report emphasizes the need for the careful use of new oral anticoagulants, and the importance of taking in mind uncommon side effects. Spontaneous hemopericardium should be considered in these patients.
Collapse
Affiliation(s)
- Anna Maria Ioppolo
- Department of Clinical and Experimental Medicine, Section of Cardiology, Policlinico San Marco, Corso Europa, Zingonia BG, Messina, Italy
| | - Luca Longobardo
- Department of Clinical and Experimental Medicine - Section of Cardiology, University of Messina, Policlinico G. Martino, Messina, Italy
| | - Salvatore D'Isa
- Department of Clinical and Experimental Medicine, Section of Cardiology, Policlinico San Marco, Corso Europa, Zingonia BG, Messina, Italy
| | - Paola De Gregorio
- Department of Clinical and Experimental Medicine, Section of Cardiology, Policlinico San Marco, Corso Europa, Zingonia BG, Messina, Italy
| | - Mariella Manfredi
- Department of Clinical and Experimental Medicine, Section of Cardiology, Policlinico San Marco, Corso Europa, Zingonia BG, Messina, Italy
| | - Nicoletta Bianca De Cesare
- Department of Clinical and Experimental Medicine, Section of Cardiology, Policlinico San Marco, Corso Europa, Zingonia BG, Messina, Italy
| |
Collapse
|
3
|
Gui YY, Zou S, Yang WL, Gong SZ, Cen ZF, Xie ZH, Cui KJ. The impact of renal function on efficacy and safety of new oral anticoagulant in atrial fibrillation patients: A systemic review and meta-analysis. Medicine (Baltimore) 2019; 98:e18205. [PMID: 31770278 PMCID: PMC6890294 DOI: 10.1097/md.0000000000018205] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND AND OBJECTIVES This meta-analysis was to investigate the efficacy and safety of new oral anticoagulant (NOAC) in atrial fibrillation (AF) patients with renal function insufficiency, and to explore whether renal decline occurs in AF patients with NOAC and its impact on outcomes. METHODS AND RESULTS In AF patients with mild renal insufficiency, the NOAC was associated with significantly lower rates of stroke (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.67-0.91; P < .05). Lower rates of bleeding were significantly observed in NOAC group (OR, 0.85; 95% CI, 0.75-0.97; P < .05). In AF patients with moderate renal impairment, similar results were revealed (OR for stroke or systemic embolism, 0.80; 95% CI, 0.67-0.95, P < .05; OR for major bleeding, 0.78; 95% CI, 0.59-1.03; P = .07). During the follow-up, pooled data revealed that NOAC showed a less renal toxicity, but the difference did not reach statistical significance (creatinine clearance decline: -0.12 mL/min [-0.84, 0.61 mL/min]). We have revealed that the NOACs were associated with significantly lower rates of stroke or systemic embolism (hazard ratio [HR], 0.66; 95% CI, 0.42-0.89; P < .05) and lower rates of bleeding (HR, 0.93; 95% CI, 0.70-1.16; P = .153) in AF patients with worsening renal function. CONCLUSIONS NOAC may have the potentiality to be at least as effective as warfarin and may equal safety outcomes in AF patients with renal impairment. Renal decline during therapeutics may be less likely happened in NOAC than warfarin dose. NOAC may reveal good efficacy and safety outcomes in these scenarios. Further detailed research is needed to gain more clear profile on this new anticoagulant.
Collapse
|
4
|
Guo WQ, Chen XH, Tian XY, Li L. Differences In Gastrointestinal Safety Profiles Among Novel Oral Anticoagulants: Evidence From A Network Meta-Analysis. Clin Epidemiol 2019; 11:911-921. [PMID: 31632152 PMCID: PMC6778450 DOI: 10.2147/clep.s219335] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 08/03/2019] [Indexed: 12/21/2022] Open
Abstract
Background There is no consensus at present regarding the differences in the risk of GI bleeding across various NOAC regimens. Therefore, we performed a network meta-analysis to compare the risk of gastrointestinal bleeding after different NOAC regimens. Methods PubMed, Cochrane, Web of Science, Clinicaltrial.gov and Clinicaltrialresults.org were searched for randomized controlled trials (RCTs) assessing gastrointestinal bleeding of all NOAC regimens from inception to January 2018. The primary endpoint was major gastrointestinal (MGI) bleeding. The meta-regression was performed to access the association between the MGI bleeding events and mortality. The network meta-analysis was carried out with the Bayesian random-effect model. Results A total of 25 RCTs, including 139,392 patients, were identified. Meta-regression analysis showed that MGI bleeding was correlated with fatal bleeding events (odds ratios [OR], 1.76; 95% confidence interval [CI], 1.13-2.77], P=0.015). The network meta-analysis results showed that compared to the conventional regimens, rivaroxaban was associated with increased risk of MGI bleeding (OR, 1.37; 95% credible interval [CrI], 1.00-1.85), but not the apixaban (OR, 0.77; 95% CrI, 0.53-1.07]), edoxaban (OR, 0.86; 95%CrI, 0.52-1.18) and dabigatran etexilate (OR, 1.22; 95% CrI, 0.82-1.69). Compared to rivaroxaban, apixaban (OR, 0.56; 95% CrI, 0.35-0.88) and edoxaban (OR, 0.62; 95% CrI, 0.35-0.96) showed a significantly lower risk of MGI bleeding. Apixaban had the highest probability of being the safest option with regard to the risk of MGI bleeding (89.1%), followed by edoxaban (77.4%), conventional therapy (51.4%), dabigatran etexilate (23.8%) and rivaroxaban (8.3%). Conclusion The risk of GI bleeding significantly varies among different NOAC regimens, and evidence shows that apixaban and edoxaban had the most favorable MGI bleeding safety profile, while rivaroxaban and dabigatran etexilate were the least safe.
Collapse
Affiliation(s)
- Wen-Qin Guo
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, People's Republic of China
| | - Xie-Hui Chen
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, People's Republic of China
| | - Xiao-Yuan Tian
- Department of Cardiology, Fuwai Hospital Chinese Academy of Medical Sciences, Shenzhen, People's Republic of China
| | - Lang Li
- Department of Cardiology, The First Affiliated Hospital of Guangxi Medical University, Nanning, People's Republic of China
| |
Collapse
|
5
|
Zhang J, Xu J, Zhang W, Jiang M, Liu J, Xu L, Liu G, Zhao Z. Quality Appraisal of Guidelines on Cancer-Associated Thrombosis Using AGREE II Instrument and Analysis of Current Status of New Oral Anticoagulants. Clin Appl Thromb Hemost 2019; 25:1076029619846562. [PMID: 31025571 PMCID: PMC6714899 DOI: 10.1177/1076029619846562] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Cancer-associated thrombosis (CAT) studies have increased in recent years and the quality of guidelines to guide the clinical practice of CAT prevention and treatment becomes crucial. The therapy status of new oral anticoagulants (NOACs) has been established in some thrombotic diseases, but the evidence for CAT remains unconvincing. The aim of this research is to evaluate the quality of CAT guidelines and discuss the role of NOAC in CAT. A search of articles was performed using PubMed/Medline, Chinese National Knowledge Infrastructure, and other authoritative websites. Search terms included guideline or guidance, consensuses, cancer, and thrombosis. Appraisal of Guidelines for Research & Evaluation II (AGREE II) tool was used to evaluate the qualities of the guidelines. A total of 19 guidelines were screened out and evaluated, of which 8 were recommended, 5 were recommended after revision, and 6 were not recommended. For prevention and treatment of CAT, low-molecular-weight heparin is the most recommended, followed by vitamin K antagonist, unfractionated heparin, fondaparinux, and aspirin. New oral anticoagulant is optional in some cases of CAT treatment. Based on AGREE II assessment tool, the quality of CAT guidelines is inconsistent. Attention should be drawn to the quality of CAT guidelines during clinical practice. The role of NOAC in the treatment of CAT is gradually established but requires more supporting evidence from future clinical trials.
Collapse
Affiliation(s)
- Jiuxing Zhang
- 1 Department of Pharmacy, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Juan Xu
- 1 Department of Pharmacy, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Wenlong Zhang
- 1 Department of Pharmacy, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Meiting Jiang
- 1 Department of Pharmacy, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Juan Liu
- 1 Department of Pharmacy, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Lei Xu
- 2 Medical Department, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Gaofeng Liu
- 1 Department of Pharmacy, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zhigang Zhao
- 3 Department of Pharmacy, Beijing Tiantan Hospital Affiliated to Capital Medical University, Beijing, China
| |
Collapse
|
6
|
Li YG, Pastori D, Lip GYH. Fitting the right non-vitamin K antagonist oral anticoagulant to the right patient with non-valvular atrial fibrillation: an evidence-based choice. Ann Med 2018; 50:288-302. [PMID: 29608110 DOI: 10.1080/07853890.2018.1460489] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Atrial fibrillation (AF) is the most prevalent arrhythmia and is associated with an increased risk of ischemic stroke (IS) and systemic embolism (SE). Stroke prevention is a key element for the overall management of AF patients. The non-vitamin K antagonist oral anticoagulants (NOACs), such as dabigatran, rivaroxaban, apixaban and edoxaban, are at least as effective as warfarin in reducing IS/SE with a lower rate of major bleeding. Various analyses from the large Phase III randomized trials demonstrated different efficacy and safety of NOACs in specific subgroups of patients. The randomized trials are supplemented by effectiveness and safety data from real-world observational cohorts following the availability of these drugs for use in everyday clinical practice. Given the clinical heterogeneity of AF patients, the available data from trials and real-world studies allow us to fit the right NOAC to the particular patient's characteristics, with the aim of optimizing outcomes for the individual patient. This review article aims to provide a summary of the evidence on the performance of NOACs in AF patients with specific clinical characteristics. Evidence-based suggestions are presented to provide a simple and viable strategy for clinicians for the choice of a particular NOAC. KEY MESSAGE Given the different performance of the new-oral anticoagulants in patients with the different clinical situation, evidence-based choice of fitting the right new-oral anticoagulants to the patients is provided in this review article.
Collapse
Affiliation(s)
- Yan-Guang Li
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,b Department of Cardiology , Chinese PLA General Hospital, Chinese PLA Medical School , Beijing , China
| | - Daniele Pastori
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,c I Clinica Medica, Atherothrombosis Center, Department of Internal Medicine and Medical Specialties , Sapienza University of Rome , Rome, Italy
| | - Gregory Y H Lip
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,d Aalborg Thrombosis Research Unit, Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
| |
Collapse
|
7
|
Wamala H, Scott IA, Caney X. Perioperative management of new oral anticoagulants in patients undergoing elective surgery at a tertiary hospital. Intern Med J 2017; 47:1412-1421. [PMID: 28589690 DOI: 10.1111/imj.13513] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/10/2017] [Accepted: 06/01/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Increasing numbers of patients receiving new oral anticoagulants (NOAC) are undergoing elective surgery. The extent to which perioperative interruption of NOAC therapy and use of bridging heparin are concordant with best evidence is uncertain. AIMS To determine: (i) concordance of NOAC and bridging heparin use with guidelines; and (ii) associations between guideline concordance and patient characteristics, surgical factors and perioperative adverse events. METHODS Retrospective study of consecutive adult patients undergoing elective surgery at a tertiary hospital between 1 January 2014 and 30 June 2015 and were receiving NOAC for at least 3 months prior to surgery. Concordance of perioperative anticoagulation management with hospital guidelines was rated by two independent researchers according to explicit thrombosis and bleeding risk tables. RESULTS One hundred and fifty patients of mean (±SD) age 72.0 (±11.6) years were studied; 75% had atrial fibrillation as NOAC indication. Decision to interrupt anticoagulation in 142 patients was rated guideline-concordant in 59 (41.5%) based on low bleeding risk in all cases and high thrombotic risk in one-third. Concordant decisions were associated with past myocardial infarction (P = 0.009), chronic kidney disease (P = 0.05), use of dabigatran (P = 0.06) and major surgery (P < 0.001). Bridging heparin was prescribed in 51 (35.9%) patients and not prescribed in 91 (64.1%), with 64 (45.1%) decisions rated guideline-discordant comprising 27 decisions to prescribe and 37 not to prescribe. Guideline concordant bridging was associated with chronic kidney disease (P = 0.02); discordant bridging with use of dabigatran (P = 0.04), high thrombotic risk (P = 0.004), past ischaemic stroke (P = 0.07). At 30 days, only one adverse event (major bleed) was noted. CONCLUSION Considerable discordance exists between guideline recommendations and perioperative NOAC management. Assistive tools are required that better align decision-making with current best practice.
Collapse
Affiliation(s)
- Henry Wamala
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Ian A Scott
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Xenia Caney
- Department of Internal Medicine and Clinical Epidemiology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| |
Collapse
|
8
|
Abstract
Renal insufficiency increases the risk of stroke and bleeding in atrial fibrillation patients. Although vitamin K antagonists reduce the risk of stroke in patients with moderate renal dysfunction, this observation is less clear in patients with renal impairment. Moreover, the risk of bleeding with vitamin K antagonists increases as renal function worsens. Maintaining international normalized ratio values within therapeutic targets is more difficult in patients with renal dysfunction, and those agents may cause warfarin-related nephropathy and vascular calcification. Rivaroxaban is the only nonvitamin K oral anticoagulant with a dose specifically tested in patients with moderate renal insufficiency. Rivaroxaban is effective for the prevention of stroke in atrial fibrillation patients with moderate renal dysfunction, with a lower risk of intracranial and fatal bleeding.
Collapse
Affiliation(s)
- Vivencio Barrios
- Department of Cardiology, University Hospital Ramón y Cajal, School of Medicine, Alcalá University, Madrid, Spain
| | - José Luis Górriz
- Department of Nephrology, Doctor Peset University Hospital, Department of Medicine, University of Valencia, Valencia, Spain
| |
Collapse
|
9
|
Mandernach MW, Beyth RJ, Rajasekhar A. Apixaban for the prophylaxis and treatment of deep vein thrombosis and pulmonary embolism: an evidence-based review. Ther Clin Risk Manag 2015; 11:1273-82. [PMID: 26345156 PMCID: PMC4556259 DOI: 10.2147/tcrm.s68010] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Venous thromboembolism (VTE) results in significant morbidity and mortality. The prevention and treatment of VTE is managed with anticoagulant therapy, historically parenteral anticoagulants such as unfractionated heparin, low molecular weight heparin, and fondaparinux, and oral vitamin K antagonists such as warfarin. In the last few years, several target-specific oral anticoagulants have been developed, including the direct thrombin inhibitor dabigatran and anti-Xa inhibitors rivaroxaban, apixaban, and edoxaban. The target-specific oral anticoagulants have proven to be noninferior to vitamin K antagonists and heparins in the prevention and treatment of VTE. This review will focus on the pharmacology, clinical trial data, and laboratory assessment of apixaban. Moreover, perioperative management, use in special populations, and management of bleeding complications in patients taking apixaban for the prevention and treatment of VTE will also be discussed.
Collapse
Affiliation(s)
- Molly W Mandernach
- Division of Hematology and Oncology, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Rebecca J Beyth
- Division of Hematology and Oncology, College of Medicine, University of Florida, Gainesville, FL, USA
- North Florida/South Georgia Veterans Health System (NF/SGVHS), Geriatric Research, Education and Clinical Center (GRECC), Gainesville, FL, USA
| | - Anita Rajasekhar
- Division of Hematology and Oncology, College of Medicine, University of Florida, Gainesville, FL, USA
| |
Collapse
|
10
|
Mont L, Marín F, Dalmau FGB, Martínez MS, Cullere JG. Clinical development of rivaroxaban: emerging new clinical evidences? Future Cardiol 2015; 11:565-83. [PMID: 26111102 DOI: 10.2217/fca.15.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Rivaroxaban has proven efficacious in a variety of conditions. In fact, rivaroxaban has been approved for the prevention of venous thromboembolism after elective hip or knee replacement surgery, for the prevention and treatment of deep vein thrombosis and pulmonary embolism, for the prevention of stroke in patients with nonvalvular atrial fibrillation and for the prevention of atherothrombotic events after acute coronary syndrome with elevated cardiac biomarkers. However, clinical development of rivaroxaban is ongoing. Considering published and on-going randomized clinical trials, noninterventional studies and registries, over 275,000 patients are being analyzed. The aim of this review was to update the clinical development of rivaroxaban, including completed and ongoing studies not only randomized clinical trials, but also clinical practice studies.
Collapse
Affiliation(s)
- Luís Mont
- Arrhythmia Section, Institut del Torax, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
| | - Francisco Marín
- Department of Cardiology, Hospital Universitario Virgen de la Arrixaca, Universidad de Murcia, Instituto de Investigación Biosanitaria Virgen de la Arrixaca, IMIB-Arrixaca, Murcia, Spain
| | | | - Marianela Sánchez Martínez
- Cardiovascular Critical Unit, Department of Cardiology. Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | - Jaime Gallego Cullere
- Neurology Department and Stroke Unit, Complejo Hospitalario de Navarra, Pamplona, Spain
| |
Collapse
|
11
|
Cox JL. Effective practical management of patients with atrial fibrillation when using new oral anticoagulants. Ann Med 2015; 47:278-88. [PMID: 25850527 DOI: 10.3109/07853890.2015.1015600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Practical management of stroke prevention in patients with non-valvular atrial fibrillation (AF) requires physicians to find the optimal balance between maximizing prevention of ischaemic stroke and minimizing the risk of bleeding. Vitamin K antagonists have traditionally been used for stroke prevention in patients with AF; however, they have been associated with increased risk of bleeding, particularly intracranial haemorrhage. New oral anticoagulants (OACs) have shown similar efficacy to the vitamin K antagonist warfarin but with a reduced risk of bleeding, particularly life-threatening bleeding such as intracranial haemorrhage. Decisions about which new OAC therapy to use may be influenced by patient characteristics such as age, renal function, co-medication use, and bleeding risk. This review uses a case-based approach to highlight the practical management issues to be considered by the physician when selecting a new OAC for stroke prevention in patients with non-valvular AF.
Collapse
Affiliation(s)
- Jafna L Cox
- Division of Cardiology, Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada; Department of Medicine and Department of Community Health and Epidemiology, Dalhousie University , Halifax, Nova Scotia, Canada; Capital Health, Halifax, Nova Scotia , Canada
| |
Collapse
|
12
|
Cope S, Clemens A, Hammès F, Noack H, Jansen JP. Critical appraisal of network meta-analyses evaluating the efficacy and safety of new oral anticoagulants in atrial fibrillation stroke prevention trials. Value Health 2015; 18:234-249. [PMID: 25773559 DOI: 10.1016/j.jval.2014.10.012] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 10/20/2014] [Accepted: 10/23/2014] [Indexed: 06/04/2023]
Abstract
OBJECTIVES To critically appraise published network meta-analyses (NMAs) evaluating the efficacy or safety of the new oral anticogulants (NOACs) dabigatran, rivaroxaban, and apixaban for the prevention of stroke in patients with nonvalvular atrial fibrillation (AF). METHODS A systematic literature review was performed to identify the relevant NMAs using MEDLINE, EMBASE, Cochrane Library, Database of Abstracts of Reviews of Effects, and Health Technology Assessment. The synthesis studies were evaluated using the "Questionnaire to assess the relevance and credibility of the NMA." RESULTS Eleven NMAs evaluating NOACs among adults with nonvalvular AF were identified. Most NMAs included three large phase III randomized controlled trials, comparing NOACs to adjusted-dose warfarin (Randomized Evaluation of Long-Term Anticoagulation Therapy [RE-LY], Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation [ROCKET-AF], and Apixaban for Reduction of Stroke and Other Thromboembolic Events in Atrial Fibrillation [ARISTOTLE]). The main differences identified related to potential treatment effect modifiers regarding the mean time spent in therapeutic range (TTR) in the warfarin arm, the risk of stroke or systemic embolism across the trials (mean CHADS2 score: C = congestive heart failure, H = hypertension, A = older than age 75 years, D = diabetes mellitus, S2 = prior stroke or history of transient ischemic attack) or primary versus secondary prevention, and type of populations used in the analysis. Kansal et al. [Kansal AR, Sharma M, Bradley-Kennedy C, et al. Dabigatran versus rivaroxaban for the prevention of stroke and systemic embolism in atrial fibrillation in Canada: comparative efficacy and cost-effectiveness. Thromb Haemost 2012;108:672-82] appropriately adjusted the ROCKET-AF TTR to match the RE-LY population on the basis of individual patient data. Meta-regressions are not expected to minimize confounding bias given limited data, whereas subgroup analyses had some impact on the point estimates for the treatment comparisons. CONCLUSIONS Results of the synthesis studies were generally comparable and suggested that the NOACs had similar efficacy, although some differences were identified depending on the outcome. The extent to which differences in the distribution of TTR, CHADS2 score, or primary versus secondary prevention biased the results remains unclear.
Collapse
Affiliation(s)
- Shannon Cope
- Mapi, Health Economics and Outcomes Research, Toronto, ON, Canada.
| | - Andreas Clemens
- Corporate Division Medicine, TA Cardiology, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany; Center of Thrombosis and Hemostasis, University Medical Center Mainz, Mainz, Germany
| | | | - Herbert Noack
- Medical Data Services, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | | |
Collapse
|
13
|
Tran H, Joseph J, Young L, McRae S, Curnow J, Nandurkar H, Wood P, McLintock C. New oral anticoagulants: a practical guide on prescription, laboratory testing and peri-procedural/bleeding management. Australasian Society of Thrombosis and Haemostasis. Intern Med J 2015; 44:525-36. [PMID: 24946813 DOI: 10.1111/imj.12448] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2013] [Accepted: 03/19/2014] [Indexed: 01/08/2023]
Abstract
New oral anticoagulants (NOAC) are becoming available as alternatives to warfarin to prevent systemic embolism in patients with non-valvular atrial fibrillation and for the treatment and prevention of venous thromboembolism. An in-depth understanding of their pharmacology is invaluable for appropriate prescription and optimal management of patients receiving these drugs should unexpected complications (such as bleeding) occur, or the patient requires urgent surgery. The Australasian Society of Thrombosis and Haemostasis has set out to inform physicians on the use of the different NOAC based on current available evidence focusing on: (i) selection of the most suitable patient groups to receive NOAC, (ii) laboratory measurements of NOAC in appropriate circumstances and (iii) management of patients taking NOAC in the perioperative period, and strategies to manage bleeding complications or 'reverse' the anticoagulant effects for urgent invasive procedures.
Collapse
Affiliation(s)
- H Tran
- Haemostasis Thrombosis Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | | | | | | | | | | | | | | |
Collapse
|
14
|
Lee MJ, Jang HM, Jeong WK, Bang OY. The Need for a Coagulation Assay after Initiation of New Oral Anticoagulants in Patients with Renal Dysfunction: A Case Report. J Clin Neurol 2014; 11:395-7. [PMID: 25749821 PMCID: PMC4596111 DOI: 10.3988/jcn.2015.11.4.395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2013] [Revised: 01/15/2014] [Accepted: 01/17/2014] [Indexed: 01/25/2023] Open
Abstract
Background Dabigatran etexilate, a new oral anticoagulant, was recently approved as an efficacious alternative to warfarin for the prevention of first and recurrent stroke in patients with nonvalvular atrial fibrillation. Limited data are available for dabigatran use in patients with a creatinine clearance rate (CrCL) of 15-30 mL/min. Furthermore, current guidelines do not recommend frequent blood monitoring after dabigatran use. We report herein a patient with severe renal dysfunction who exhibited profound coagulopathy after 2 days of dabigatran use. Case Report An 87-year-old woman was admitted for altered mental status and left-side weakness. She was diagnosed with right middle cerebral artery infarction. The baseline assessment revealed a serum creatinine concentration of 1.29 mg/dL and a CrCL of 27.2 mL/min. Dabigatran therapy was started 5 weeks after admission at a dosage of 110 mg twice daily. After 2 days of dabigatran use, the patient developed multiple bruises and evidence of upper-gastrointestinal bleeding. Laboratory tests demonstrated a severe coagulopathy, with a prothrombin time of 85.9 sec, an international normalized ratio of 11.36, an activated partial thromboplastin time of 119.2 sec, and a thrombin time of 230.8 sec. Serial assessment of the patient's renal function revealed substantial fluctuation of the CrCL (range, 17.9-26.5 mL/min). Conclusions The present case emphasizes the need for frequent checking of renal function and assessment using coagulation assays after commencing dabigatran therapy in patients with moderate-to-severe renal impairment.
Collapse
Affiliation(s)
- Mi Ji Lee
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Min Jang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Woo Kyo Jeong
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
| |
Collapse
|
15
|
Jarungsuccess S, Taerakun S. Cost-utility analysis of oral anticoagulants for nonvalvular atrial fibrillation patients at the police general hospital, Bangkok, Thailand. Clin Ther 2014; 36:1389-94.e4. [PMID: 25267360 DOI: 10.1016/j.clinthera.2014.08.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 08/12/2014] [Accepted: 08/26/2014] [Indexed: 11/25/2022]
Abstract
PURPOSE The genetic polymorphism was one of the major considerations for adjusting doses of warfarin in Thai individuals. As a result, new oral anticoagulants (NOACs) were introduced to achieve therapeutic goals in stroke prevention in atrial fibrillation (SPAF) patients. However, a cost-utility analysis in a population-specific model was lacking in Thailand. This study was performed to determine which NOACs yielded population-specific, cost-effective results for SPAF compared with warfarin from both governmental and societal perspectives in Thailand. METHODS A simplified Markov health state model was constructed to calculate the lifetime cost, life-years saved, and quality-adjusted life-years (QALYs) gained. Asia-specific clinical event parameters were defined from systematic searches of PubMed. Cost and utility input was obtained from hospital based data collection. FINDINGS Although NOACs produced more life-years saved and QALYs gained resulting from the base-case versus warfarin, the lifetime costs of new alternatives increased to >1.4 times the comparative cost of warfarin. This caused an incremental cost-effective ratio that exceeded Thailand's cost-effectiveness threshold. The probabilistic sensitivity analysis denoted the robustness of our model and revealed that dose-adjusted warfarin was the most cost-effective option in >99% of iterations. NOACs produced cost-effective results when the medication unit cost was decreased by at least 85%. IMPLICATIONS According to the results of this first cost-utility analysis in Thailand, warfarin is still the most cost-effective medication for SPAF from any perspective in Thailand at the threshold recommended by our health technology assessment guidelines.
Collapse
Affiliation(s)
| | - Satadon Taerakun
- Pharmacy Department, Police General Hospital, Bangkok, Thailand.
| |
Collapse
|
16
|
Lu Y, Branstad R, Karim RM, Asinger RW. Consideration of clinical variables for choosing new anticoagulant alternatives to warfarin for the management of non-valvular atrial fibrillation. J Clin Pharm Ther 2014; 39:628-36. [PMID: 25252149 DOI: 10.1111/jcpt.12207] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Accepted: 08/21/2014] [Indexed: 12/19/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Patients with non-valvular atrial fibrillation (NVAF) are at risk for stroke and systemic embolism (SSE), and this risk can be decreased with adjusted-dose warfarin. Warfarin, however, is cumbersome to use and requires at least monthly laboratory monitoring. Three new oral anticoagulants (NOACs) that are less cumbersome have been approved as alternatives to warfarin for SSE prevention in NVAF. Selecting a patient-specific alternative to warfarin can be confusing for pharmacists and clinicians. This review details clinical parameters to consider when choosing an alternative to warfarin for a specific patient and summarizes them in a Comparison Table. METHODS Using available clinical evidence from pivotal trials, US FDA- and Health Canada-approved prescribing information and post-marketing observations, this review provides a summary of important clinical variables for clinicians to consider when choosing patient-centred anticoagulant alternatives to warfarin for prevention of SSE in NVAF. RESULTS AND DISCUSSION Dabigatran, rivaroxaban and apixaban are approved alternatives to warfarin for primary and secondary prevention of SSE in patients with NVAF. Additionally, apixaban has also been compared to aspirin in patients with NVAF that were considered unsuitable for vitamin K antagonist therapy. Prospective consideration of age, weight, hepatic function, renal function and drug interactions are important clinical parameters to consider when selecting patient-centred alternatives to adjusted-dose warfarin. WHAT IS NEW AND CONCLUSION Several NOACs are now alternatives to warfarin for SSE prevention in NVAF but require providers to make a shift in strategy from tailoring anticoagulant dose based on anticoagulant effect to selection of the anticoagulant based on clinical variables that affect anticoagulant exposure. These variables and their interactions should be considered in choosing an alternative to warfarin and are summarized in a simple table comparing the new anticoagulants.
Collapse
Affiliation(s)
- Y Lu
- Hennepin County Medical Center, Minneapolis, MN, USA; University of Minnesota, Minneapolis, MN, USA
| | | | | | | |
Collapse
|
17
|
Lip GYH, Kongnakorn T, Phatak H, Kuznik A, Lanitis T, Liu LZ, Iloeje U, Hernandez L, Dorian P. Cost-effectiveness of apixaban versus other new oral anticoagulants for stroke prevention in atrial fibrillation. Clin Ther 2014; 36:192-210.e20. [PMID: 24508420 DOI: 10.1016/j.clinthera.2013.12.011] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 11/12/2013] [Accepted: 12/17/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Apixaban (5 mg BID), dabigatran (available as 150 mg and 110 mg BID in Europe), and rivaroxaban (20 mg once daily) are 3 novel oral anticoagulants (NOACs) currently approved for stroke prevention in patients with atrial fibrillation (AF). OBJECTIVE The objective of this study was to evaluate the cost-effectiveness of apixaban against other NOACs from the perspective of the United Kingdom National Health Services. METHODS A Markov model was developed to evaluate the pharmacoeconomic impact of apixaban versus other NOACs over a lifetime. Pair-wise indirect treatment comparisons were conducted against other NOACs by using ARISTOTLE (Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation), RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy), and ROCKET-AF (Rivaroxaban Once Daily Oral Direct Factor Xa Inhibition Compared With Vitamin K Antagonism for Prevention of Stroke and Embolism Trial in Atrial Fibrillation) trial results for the following end points: ischemic stroke, hemorrhagic stroke, intracranial hemorrhage, other major bleeds, clinically relevant nonmajor bleeds, myocardial infarction, and treatment discontinuations. Outcomes were life-years, quality-adjusted life years gained, direct health care costs, and incremental cost-effectiveness ratios. RESULTS Apixaban was projected to increase life expectancy versus other NOACs, including dabigatran (both doses) and rivaroxaban. A small increase in therapeutic management costs was observed with apixaban due to projected gains in life expectancy and lower discontinuation rates anticipated on apixaban versus other NOACs through lifetime. The estimated incremental cost-effectiveness ratio was £9611, £4497, and £5305 per quality-adjusted life-year gained with apixaban compared with dabigatran 150 mg BID, dabigatran 110 mg BID, and rivaroxaban 20 mg once daily, respectively. Sensitivity analyses indicated that results were robust over a wide range of inputs. CONCLUSIONS Although our analysis was limited by the absence of head-to-head trials, based on the indirect comparison data available, our model projects that apixaban may be a cost-effective alternative to dabigatran 150 mg BID, dabigatran 110 mg BID, and rivaroxaban 20 mg once daily for stroke prevention in AF patients from the perspective of the United Kingdom National Health Services.
Collapse
Affiliation(s)
- Gregory Y H Lip
- University of Birmingham Centre for Cardiovascular Sciences, City Hospital, Birmingham, United Kingdom.
| | | | | | | | | | - Larry Z Liu
- Pfizer, New York, New York, Weill Medical College of Cornell University, New York, New York
| | | | | | - Paul Dorian
- University of Toronto, St. Michael's Hospital, Toronto, Ontario, Canada
| |
Collapse
|
18
|
Vidal JS, Hanon O. [What is the current use of vitamin K antagonists in the elderly?]. Geriatr Psychol Neuropsychiatr Vieil 2013; 11:17-22. [PMID: 24463060 DOI: 10.1684/pnv.2013.0443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
With the recent marketing of the new oral anticoagulants (NOAC), the future of vitamin k antagonist (VKA) needs to be redefined. VKAs are drugs with a narrow therapeutic margin and a high iatrogenic risk that requires a close biological monitoring. Their efficacy has been proven for atrial fibrillation in numerous populations, especially in the elderly. Their side effects and interactions are well known. The measurement of the level of anticoagulation is possible and reliable using the INR (international normalized ratio) and an antidote is usable in case of emergency. The NOAC are at least as effective as VKA with slightly less side-effects especially cerebral hemorrhage, and they do not require biological monitoring. However, data on efficacy and side-effects of NOAC rely mainly on phase III clinical trials that did not particularly target polypathologic and frail populations. In these populations, we therefore have more "real life" information on VKA than NOAC. But studies on NOAC are currently conducted among these populations. A conservative approach would be to maintain VKA to older patients with stable INR. Lastly VKA are the only anticoagulant usable in case of severe renal failure and valvular fibrillation.
Collapse
Affiliation(s)
| | - Olivier Hanon
- Service de gérontologie, Hôpital Broca, Paris, France
| |
Collapse
|