CONCOMITANT PREHOSPITAL USE OF DIRECT ORAL ANTICOAGULANTS AND ANTIPLATELET AGENTS IN CRITICALLY ILL PATIENTS, PRESCRIBING PRACTICES AND OUTCOMES: A SINGLE ACADEMIC CENTER EXPERIENCE

Background Published reports consistently describe incomplete delivery of prescribed enteral nutrition. Which specific step in the process delays or interferes with the administration of a full dose of nutrients is unclear. Objectives To assess factors associated with interruptions in enteral nutrition in critically ill patients receiving mechanical ventilation. Methods An observational prospective study of 59 consecutive patients who required mechanical ventilation and were receiving enteral nutrition was done in an 18-bed medical intensive care unit of an academic center. Data were collected prospectively on standardized forms. Steps involved in the feeding process from admission to discharge were recorded, each step was timed, and delivery of nutrition was quantified. Results Patients received approximately 50% (mean, 1106.3; SD, 885.9 Cal) of the prescribed caloric needs. Enteral nutrition was interrupted 27.3% of the available time. A mean of 1.13 interruptions occurred per patient per day; enteral nutrition was interrupted a mean of 6 (SD, 0.9) hours per patient each day. Prolonged interruptions were mainly associated with problems related to small-bore feeding tubes (25.5%), increased residual volumes (13.3%), weaning (11.7%), and other reasons (22.8%). Placement and confirmation of placement of the small-bore feeding tube were significant causes of incomplete delivery of nutrients on the day of admission. Conclusions Delivery of enteral nutrition in critically ill patients receiving mechanical ventilation is interrupted by practices embedded in the care of these patients. Evaluation of the process reveals areas to improve the delivery of enteral nutrition.

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Clinical impact of the perioperative management of oral anticoagulants in bleeding after colonic endoscopic mucosal resection

BMC Gastroenterology ◽

10.1186/s12876-019-1124-8 ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 4

Author(s):

Shoko Ono ◽

Marin Ishikawa ◽

Kana Matsuda ◽

Momoko Tsuda ◽

Keiko Yamamoto ◽

...

Keyword(s):

Endoscopic Mucosal Resection ◽

Perioperative Management ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Multivariate Logistic Regression Analysis ◽

Antiplatelet Agents ◽

Bleeding Risk ◽

Clinical Impact ◽

Antithrombotic Agents ◽

Mucosal Resection

Abstract Background Heparin bridging therapy (HBT) is indeed related to a high frequency of bleeding after endoscopic mucosal resection (EMR). In this study, our aim was to investigate clinical impact of management of oral anticoagulants without HBT in bleeding after colonic EMR. Methods From data for patients who underwent consecutive colonic EMR, the relationships of patient factors and procedural factors with the risk of bleeding were analysed. Our management of antithrombotic agents was based on the shortest cessation as follows: the administration of warfarin was generally continued within the therapeutic range, and direct oral anticoagulants (DOACs) were not administered on the day of the procedure. We calculated bleeding risks after EMR in patients who used antithrombotic agents and evaluated whether perioperative management of anticoagulants without HBT was beneficial for bleeding. Results A total of 1734 polyps in 825 EMRs were analysed. Bleeding occurred in 4.0% of the patients and 1.9% of the polyps. The odds ratios for bleeding using multivariate logistic regression analysis were 3.67 in patients who used anticoagulants and 4.95 in patients who used both anticoagulants and antiplatelet agents. In patients with one-day skip of DOACs, bleeding occurred in 6.5% of the polyps, and there were no significant differences in bleeding risk between HBT and continuous warfarin or one-day skip DOACs. Conclusions The use of oral anticoagulants was related to bleeding after colonic EMR, and perioperative management of oral anticoagulants based on the shortest cessation without HBT would be clinically acceptable.

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Rates and Determinants for the Use of Anticoagulation Treatment before Stroke in Patients with Known Atrial Fibrillation

Cerebrovascular Diseases Extra ◽

10.1159/000506923 ◽

2020 ◽

Vol 10 (2) ◽

pp. 44-49

Author(s):

Michela Giustozzi ◽

Giancarlo Agnelli ◽

Silvia Quattrocchi ◽

Monica Acciarresi ◽

Andrea Alberti ◽

...

Keyword(s):

Atrial Fibrillation ◽

Ischemic Stroke ◽

Medical Information ◽

Treatment Guidelines ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Antiplatelet Agents ◽

Anticoagulant Treatment ◽

Anticoagulation Treatment

Introduction and Objective: Even though the introduction of less cumbersome anticoagulant agents has improved, the rates ofoverall anticoagulant treatment in eligible patients with atrial fibrillation (AF) remain to be defined. We aimed to assess the rates of and determinants for the use of anticoagulation treatment before stroke in patients with known AF since the introduction of direct oral anticoagulants (DOAC) in clinical practice. Methods: Consecutive patients admitted to an individual stroke unit, from September 2013 through July 2019, for acute ischemic stroke or transient ischemic attack (TIA) with known AF before the event were included in the study. Logistic regression analysis was used to identify independent predictors of the use of anticoagulant treatment. Results: Overall, 155 patients with ischemic stroke/TIA and known AF were included in this study. Among 152 patients with a CHA2DS2-VASc score >1, 43 patients were not receiving any treatment, 47 patients were receiving antiplatelet agents, and the remaining 62 patients were on oral anticoagulants. Among 34 patients on DOAC, 13 were receiving a nonlabeled reduced dose and 18 out of 34 patients on vitamin K antagonists had an INR value <2 at the time of admission. Before stroke, only 34 out of 155 patients (21.9%) were adequately treated according to current guidelines. Previous stroke/TIA was the only independent predictor of the use of anticoagulant therapy. Conclusions: Only 21.9% of the patients hospitalized for a stroke or TIA with known AF before the event were adequately treated according to recent treatment guidelines. It is important to improve medical information about the risk of AF and the efficacy of anticoagulants in stroke prevention.

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Drug-drug interactions in an era of multiple anticoagulants: a focus on clinically relevant drug interactions

Hematology ◽

10.1182/asheducation-2018.1.339 ◽

2018 ◽

Vol 2018 (1) ◽

pp. 339-347 ◽

Cited By ~ 6

Author(s):

Sara R. Vazquez

Keyword(s):

Drug Interaction ◽

Adverse Events ◽

Drug Interactions ◽

Selective Serotonin Reuptake Inhibitors ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Management Strategies ◽

Antiplatelet Agents ◽

Anticoagulant Drug ◽

Interaction Management

Abstract Oral anticoagulants are commonly prescribed but high risk to cause adverse events. Skilled drug interaction management is essential to ensure safe and effective use of these therapies. Clinically relevant interactions with warfarin include drugs that modify cytochrome 2C9, 3A4, or both. Drugs that modify p-glycoprotein may interact with all direct oral anticoagulants, and modifiers of cytochrome 3A4 may interact with rivaroxaban and apixaban. Antiplatelet agents, nonsteroidal anti-inflammatory drugs, and serotonergic agents, such as selective serotonin reuptake inhibitors, can increase risk of bleeding when combined with any oral anticoagulant, and concomitant use should be routinely assessed. New data on anticoagulant drug interactions are available almost daily, and therefore, it is vital that clinicians regularly search interaction databases and the literature for updated management strategies. Skilled drug interaction management will improve outcomes and prevent adverse events in patients taking oral anticoagulants.

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Antiplatelet agents and anticoagulants increased the bleeding risk of bedside percutaneous dilational tracheostomy in critically ill patients

Journal of the Formosan Medical Association ◽

10.1016/j.jfma.2019.10.014 ◽

2020 ◽

Vol 119 (7) ◽

pp. 1193-1200 ◽

Cited By ~ 1

Author(s):

Yen-Hsiang Huang ◽

Chien-Hua Tseng ◽

Ming-Cheng Chan ◽

Bor-Jen Lee ◽

Chih-Hung Lin ◽

...

Keyword(s):

Critically Ill ◽

Critically Ill Patients ◽

Antiplatelet Agents ◽

Bleeding Risk ◽

Percutaneous Dilational Tracheostomy

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Concomitant Use of Direct Oral Anticoagulants with Antiplatelet Agents and the Risk of Major Bleeding in Patients with Nonvalvular Atrial Fibrillation

The American Journal of Medicine ◽

10.1016/j.amjmed.2018.10.008 ◽

2019 ◽

Vol 132 (2) ◽

pp. 191-199.e12 ◽

Cited By ~ 13

Author(s):

Antonios Douros ◽

Christel Renoux ◽

Hui Yin ◽

Kristian B. Filion ◽

Samy Suissa ◽

...

Keyword(s):

Atrial Fibrillation ◽

Major Bleeding ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Antiplatelet Agents ◽

Nonvalvular Atrial Fibrillation

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Cost Analysis of Direct Oral Anticoagulants Compared with Warfarin in Patients with Blunt Traumatic Intracranial Hemorrhages

The American Surgeon ◽

10.1177/000313481808400657 ◽

2018 ◽

Vol 84 (6) ◽

pp. 1010-1014 ◽

Cited By ~ 1

Author(s):

Laura C. Lamb ◽

Monica Difiori ◽

Christopher Comey ◽

James Feeney

Keyword(s):

Hospital Admission ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Cost Benefit ◽

Antiplatelet Agents ◽

Trauma Patients ◽

Reimbursement Rate ◽

Reversal Agents ◽

Level Ii ◽

Traumatic Intracranial Hemorrhage

Direct oral anticoagulants (DOACs) are rapidly gaining popularity as alternatives to warfarin in the prevention of stroke or systemic embolic events because of the simplicity of their dosing and lack of monitoring requirement. Many physicians feared that these novel agents would be cost-prohibitive not only in their administration but also in their sequelae of bleeding, given the few reversal agents available. Whereas the medication itself is more expensive than traditional warfarin, the total cost of a hospital admission has not been compared between patients on DOACs and warfarin who have sustained a blunt traumatic intracranial hemorrhage (ICH). We conducted a retrospective review of our hospital's trauma database from June 2011 through September 2015 at our Level II trauma center of patients who suffered from an ICH who were anticoagulated at the time of their trauma. Patients who died during their hospital admission or were exclusively on antiplatelet agents were excluded. Of the 136 patients studied, 79 were on warfarin and 57 were on a DOAC at the time of their presentation for a traumatic ICH. The average charged cost for the hospital stay of a patient with an ICH was significantly higher for patients on warfarin compared with DOACs [$70,384.08 vs $49,226.66 (P = 0.02)]. The average reimbursement rate for the hospital was also significantly higher for those patients on warfarin as compared with those on DOACs [$23,922.93 vs $14,705.77 (P = 0.02)]. DOACs are associated with a significant cost benefit in patients admitted for blunt traumatic ICHs when compared with those on warfarin.

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