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British Journal of Haematology Aug 2012Venous thromboembolism (VTE) is effectively treated with anticoagulant therapy. After an initial treatment phase, extended treatment is effective to prevent recurrence... (Review)
Review
Venous thromboembolism (VTE) is effectively treated with anticoagulant therapy. After an initial treatment phase, extended treatment is effective to prevent recurrence after a first event but this is at the expense of a continued risk of bleeding. Ideally, patients at a high risk of recurrence and low risk of bleeding continue anticoagulant therapy, and for those at low risk of recurrence the duration of treatment can be limited. Identifying these patients, however, is difficult. Duration of treatment after a first VTE provoked by a transient risk factor should be limited to 3 months. Although guidelines suggest extended treatment for all patients after unprovoked VTE unless bleeding risk is high, we emphasize that the long-term risks of recurrent VTE off anticoagulation are uncertain whereas the risk of bleeding associated with anticoagulant therapy increases with age. In the absence of evidence of replaced mortality or improved quality of life with extended anticoagulant treatment, we suggest a limited duration for most patients after a first VTE. Extended treatment can be considered, based mainly on patient preference.
Topics: Anticoagulants; Drug Administration Schedule; Hemorrhage; Humans; Risk Assessment; Secondary Prevention; Venous Thromboembolism
PubMed: 22734929
DOI: 10.1111/j.1365-2141.2012.09196.x -
Implementation Science : IS May 2023Direct oral anticoagulant medications are commonly used to treat or prevent thrombotic conditions, such as pulmonary embolism, deep vein thrombosis, and atrial... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
Direct oral anticoagulant medications are commonly used to treat or prevent thrombotic conditions, such as pulmonary embolism, deep vein thrombosis, and atrial fibrillation. However, up to 10-15% of patients receiving these medications get unsafe doses based on a patient's kidney or liver function, potential interactions with other medications, and indication for taking the medication. Alert systems may be beneficial for improving evidence-based prescribing, but can be burdensome and are not currently able to provide monitoring after the initial prescription is written.
METHODS/DESIGN
This study will improve upon existing alert systems by testing novel medication alerts that encourage collaboration between prescribers (e.g., physicians, nurse practitioners, physician assistants) and expert pharmacists working in anticoagulation clinics. The study will also improve upon the existing alert system by incorporating dynamic long-term monitoring of patient needs and encouraging collaboration between prescribers and expert pharmacists working in anticoagulation clinics. Incorporating state-of-the-art user-centered design principles, prescribing healthcare providers will be randomized to different types of electronic health record medication alerts when a patient has an unsafe anticoagulant prescription. We will identify which alerts are most effective at encouraging evidence-based prescribing and will test moderators to tailor alert delivery to when it is most beneficial. The aims of the project are to (1) determine the effect of notifications targeting existing inappropriate DOAC prescriptions; (2) examine the effect of alerts on newly prescribed inappropriate DOACs; and (3) examine changes in the magnitude of effects over time for both the new prescription alerts and existing prescription notifications for inappropriate DOACs over the 18-month study period.
DISCUSSION
Findings from this project will establish a framework for implementing prescriber-pharmacist collaboration for high-risk medications, including anticoagulants. If effectively implemented at the more than 3000 anticoagulation clinics that exist nationally, hundreds of thousands of patients taking direct oral anticoagulants stand to benefit from safer, evidence-based healthcare.
TRIALS REGISTRATION
NCT05351749.
Topics: Humans; Pharmacists; Anticoagulants; Inappropriate Prescribing; Atrial Fibrillation; Prescriptions
PubMed: 37189171
DOI: 10.1186/s13012-023-01273-4 -
International Ophthalmology Clinics 2020Use of anticoagulant therapy has increased in patients presenting for ophthalmic surgery over the past decade. The decision of whether or not to discontinue...
Use of anticoagulant therapy has increased in patients presenting for ophthalmic surgery over the past decade. The decision of whether or not to discontinue anticoagulant medications prior to ophthalmic surgeries is nuanced and ultimately based on multiple factors including the type of surgery and the patient’s comorbidities and risk profile. In the setting of cataract surgery, no increased risk of bleeding with anticoagulation was observed in a large prospective study, which suggests that anticoagulation should not be interrupted for the average-risk patient on anticoagulation. In other types of ophthalmic surgery, expert opinion and studies are divided on the perioperative management of anticoagulant therapy. Preoperative thromboembolic risk stratification, intraoperative techniques to minimize bleeding, and postoperative management are also reviewed to generate more comprehensive recommendations on ophthalmic perioperative management of anticoagulation.
Topics: Administration, Oral; Anticoagulants; Humans; Ophthalmologic Surgical Procedures; Perioperative Care
PubMed: 32576719
DOI: 10.1097/IIO.0000000000000316 -
The American Journal of Emergency... Nov 2016Direct oral anticoagulants (DOACs) are a relatively recent addition to the oral anticoagulant armamentarium, and provide an alternative to the use of vitamin K... (Review)
Review
Direct oral anticoagulants (DOACs) are a relatively recent addition to the oral anticoagulant armamentarium, and provide an alternative to the use of vitamin K antagonists such as warfarin. Regardless of the type of agent used, bleeding is the major complication of anticoagulant therapy. The decision to restart oral anticoagulation following a major hemorrhage in a previously anticoagulated patient is supported largely by retrospective studies rather than randomized clinical trials (mostly with vitamin K antagonists), and remains an issue of individualized clinical assessment: the patient's risk of thromboembolism must be balanced with the risk of recurrent major bleeding. This review provides guidance for clinicians regarding if and when a patient should be re-initiated on DOAC therapy following a major hemorrhage, based on the existing evidence.
Topics: Antithrombins; Clinical Decision-Making; Dabigatran; Factor Xa Inhibitors; Gastrointestinal Hemorrhage; Humans; Intracranial Hemorrhages; Practice Guidelines as Topic; Risk Assessment; Thromboembolism
PubMed: 27697440
DOI: 10.1016/j.ajem.2016.09.049 -
Hematology. American Society of... Dec 2022Estrogen exposure, in the setting of pregnancy, the postpartum state, combined hormonal contraceptives (CHCs), or hormone therapy use, has been clearly associated with...
Estrogen exposure, in the setting of pregnancy, the postpartum state, combined hormonal contraceptives (CHCs), or hormone therapy use, has been clearly associated with increased rates of venous thromboembolism (VTE). Although recurrence rates are low in these settings, up to 70% of anticoagulated menstruating individuals experience abnormal or heavy menstrual bleeding (HMB), which commonly results in iron deficiency with or without anemia. Patients taking rivaroxaban appear to experience higher rates of HMB compared with those on apixaban, dabigatran, or warfarin. HMB can often be diagnosed in a single visit with a good menstrual history assessing for factors with a known association with increased or heavy bleeding, such as changing pads or tampons more often than every 2 hours, clots larger than a quarter, and iron deficiency (ferritin <50 ng/mL). HMB can be managed with hormonal therapies, including those associated with VTE risk, such as CHCs and depot-medroxyprogesterone acetate (DMPA). In many cases, continuing CHCs or DMPA while a patient is therapeutically anticoagulated is reasonable, so long as the therapy is discontinued before anticoagulation is stopped. Modification of the anticoagulation regimen, such as decreasing to a prophylactic dose in the acute treatment period, is not currently recommended. For patients who are currently pregnant, low-molecular-weight heparin (LMWH) is still standard of care during pregnancy; routine monitoring of anti-factor Xa levels is not currently recommended. Warfarin or LMWH may be considered in the postpartum setting, but direct-acting oral anticoagulants are currently not recommended for lactating patients.
Topics: Pregnancy; Humans; Female; Heparin, Low-Molecular-Weight; Lactation; Anticoagulants; Venous Thromboembolism; Warfarin; Menorrhagia; Iron Deficiencies
PubMed: 36485151
DOI: 10.1182/hematology.2022000401 -
Acta Pharmaceutica (Zagreb, Croatia) Dec 2022Direct oral anticoagulants (DOACs) represent a new generation of drugs that have been increasingly used in the prevention and treatment of thromboembolic states.... (Review)
Review
Direct oral anticoagulants (DOACs) represent a new generation of drugs that have been increasingly used in the prevention and treatment of thromboembolic states. According to the mechanism of anticoagulant action, DOACs are divided into two groups: direct inhibitors of thrombin (dabigatran) and direct inhibitors of activated factor X (FXa) (rivaroxaban, apixaban, edoxaban, betrixaban). Compared to the vitamin K antagonists, DOACs are superior in terms of onset of action, pharmacokinetic and pharmacodynamics properties and fixed daily dose without the need for routine coagulation monitoring. Despite these advantages, there are clinical conditions in which laboratory measurement of DOACs should be performed. Although DOACs have an impact on screening haemostasis assays (prothrombin time, PT; activated partial thromboplastin time, aPTT; and thrombin time, TT), these tests are not appropriate for quantifying drug levels. Therefore, specific quantitative methods (LC-MS/MS as a gold standard method for all DOACs, coagulometric and chromogenic assays for dabigatran, and chromogenic anti-Xa assays with drug-specific calibrators for inhibitors of FXa) should only be used for determination of DOACs concentration. The aim of this review is to present all aspects of laboratory assessment of DOACs, including pre-analytical, analytical and post-analytical factors in the overall testing process with a special accent on the available specific quantitative methods for measurement of DOACs in circulation.
Topics: Dabigatran; Chromatography, Liquid; Administration, Oral; Tandem Mass Spectrometry; Anticoagulants
PubMed: 36651369
DOI: 10.2478/acph-2022-0034 -
Blood Purification 2017Effective delivery of continuous renal replacement therapy (CRRT) depends on the longevity of the filter and circuit used in the CRRT machine. Safe and effective... (Review)
Review
Effective delivery of continuous renal replacement therapy (CRRT) depends on the longevity of the filter and circuit used in the CRRT machine. Safe and effective anticoagulation is crucial for maintaining the patency of these circuits. In children, heparin and citrate are the commonly used anticoagulants but they are limited by serious side effects and thus calls for meticulous monitoring. In conditions where neither of these can be used, prostacyclin can be an effective alternative. Prostacyclin is a platelet inhibitor that can be safely used as an efficient anticoagulant in CRRT. When combined with heparin, it induces a heparin-sparing effect, which can reduce the dosage and side effects of heparin. Furthermore, there is no need for performing time-consuming monitoring tests. Although prostacyclin seems to be an attractive option, there is scanty evidence about its use as an anticoagulant in CRRT in children. We review the evidence and practicalities, and propose a guideline for the use of prostacyclin as an anticoagulant in children requiring CRRT.
Topics: Anticoagulants; Blood Coagulation; Child; Cost-Benefit Analysis; Drug Monitoring; Epoprostenol; Humans; London; Meta-Analysis as Topic; Platelet Aggregation Inhibitors; Practice Guidelines as Topic; Renal Replacement Therapy
PubMed: 28118627
DOI: 10.1159/000452754 -
Pathophysiology of Haemostasis and...Numerous large randomized controlled trials have assessed the benefit of prophylactic anticoagulation for venous thromboembolism in selected patients. However, few... (Review)
Review
Numerous large randomized controlled trials have assessed the benefit of prophylactic anticoagulation for venous thromboembolism in selected patients. However, few trials were conducted in elderly patients, as this issue was not addressed in this specific population,or as elderly patients were excluded of these studies. Therefore, as the risk of a first episode of venous thromboembolism (in surgical and in medical setting) and the risk of a major anticoagulant-related bleeding are both increased in elderly subjects, the results of the main available studies can not be extrapolated to this population. Consequently, in practice, the balance between expected benefit and risk of prophylactic anticoagulation should be carefully assessed for each individual elderly patient taking in account the specific risk of venous thromboembolism in elderly in the absence of anticoagulation, the risk of anticoagulant related bleeding according to the type of anticoagulant treatment and the intrinsic risk of bleeding of elderly subjects and, lastly, the available guideline recommendations. In order to improve such evaluation, it is anticipated that further prophylactic studies are needed in elderly patients. In addition, the development of anticoagulation clinics and new oral anticoagulants should help to reduce anticoagulant related bleeding for an equivalent, or an increased, benefit.
Topics: Aged; Anticoagulants; Humans; Risk Assessment; Venous Thrombosis
PubMed: 15692245
DOI: 10.1159/000083830 -
The Cochrane Database of Systematic... Jun 2014Elevation of pulmonary pressure is no longer a rare disease, given its multifactorial etiology. However data on the actual incidence of this condition are still limited,... (Review)
Review
BACKGROUND
Elevation of pulmonary pressure is no longer a rare disease, given its multifactorial etiology. However data on the actual incidence of this condition are still limited, and controversies regarding its management are ongoing. Use of anticoagulation in the management of pulmonary hypertension is based on the presence of in situ thrombosis in the patient with pulmonary arterial hypertension (PAH) and on retrospective evidence of clinical benefit. Current practice is dependent mostly on expert opinion and individualised experience. The real benefit of its use in different types of pulmonary hypertension is still debatable, and the therapeutic target of the international normalised ratio (INR) among treated patients remains inconclusive. Adverse outcomes associated with anticoagulants are significant and can include fatal haemorrhage. Justification for the use of this intervention requires critical evaluation of randomised controlled trials.
OBJECTIVES
1. To evaluate the effectiveness of, and potential adverse events associated with, anticoagulation in the management of pulmonary hypertension (PH).2. To evaluate the effective therapeutic INR in pulmonary hypertensive patients receiving anticoagulants (North American centres 1.5 to 2.5, European centres 2.0 to 3.0).
SEARCH METHODS
We identified trials through searches of the following databases.Cochrane Airways Group Trials Register; Cochrane Central Register of Controlled Trials (CENTRAL), part of The Cochrane Library; MEDLINE (Ovid); EMBASE (Ovid); CINAHL (EBSCOhost); Clinical trials.gov and the World Health Organization (WHO) trials portal. The trial search date was 28 March 2014.
SELECTION CRITERIA
We planned to include only randomised controlled trials. Participants with PH with co-morbidities including medical conditions requiring long-term anticoagulation were to be included. We also planned to include trials comparing any anticoagulant with placebo.
DATA COLLECTION AND ANALYSIS
Review authors (IE and HE) independently appraised all identified citations to establish their relevance for inclusion in the review. IE and HE independently screened the titles and abstracts of all identified potential studies for inclusion.
MAIN RESULTS
No eligible trials were identified for inclusion in this review.
AUTHORS' CONCLUSIONS
No eligible studies were identified for inclusion in this review. Although our review of available non-randomised studies shows beneficial effect, this finding should be interpreted with caution since there are likely to be biases associated with their design and our methods were not designed to identify, appraise and summarise evidence from them. So that better decisions can be made regarding the effectiveness of this intervention, well-designed randomised controlled trials are needed.
Topics: Anticoagulants; Humans; Hypertension, Pulmonary; International Normalized Ratio; Placebos
PubMed: 24887213
DOI: 10.1002/14651858.CD010695.pub2 -
American Family Physician Feb 1999Warfarin is the oral anticoagulant most frequently used to control and prevent thromboembolic disorders. Prescribing the dose that both avoids hemorrhagic complications... (Review)
Review
Warfarin is the oral anticoagulant most frequently used to control and prevent thromboembolic disorders. Prescribing the dose that both avoids hemorrhagic complications and achieves sufficient suppression of thrombosis requires a thorough understanding of the drug's unique pharmacology. Warfarin has a complex dose-response relationship that makes safe and effective use a challenge. For most indications, the dose is adjusted to maintain the patient's International Normalized Ratio (INR) at 2 to 3. Because of the delay in factor II (prothrombin) suppression, heparin is administered concurrently for four to five days to prevent thrombus propagation. Loading doses of warfarin are not warranted and may result in bleeding complications. Interactions with other drugs must be considered, and therapy in elderly patients requires careful management. Current dosing recommendations are reviewed, and practical guidelines for the optimal use of warfarin are provided.
Topics: Anticoagulants; Dose-Response Relationship, Drug; Drug Administration Schedule; Hemorrhage; Humans; International Normalized Ratio; Risk Factors; Warfarin
PubMed: 10029789
DOI: No ID Found