Risk of bleeding with vitamin K antagonists compared with low-molecular-weight heparin after orthopedic surgery: a reply to a rebuttal

Background Venous thromboembolic events (VTEs) are common and potentially fatal complications in cancer patients, and they are responsible for the second most common cause of death. Low molecular weight heparin (LMWH) is the gold-standard treatment, but the costs involved limit its use, especially in developing countries. Recently, the oral anticoagulant rivaroxaban, which directly inhibits factor Xa, was approved for VTE treatment. Methods We conducted a retrospective analysis from January 2009 to February 2014 with patients who had cancer and VTE who were receiving rivaroxaban. We compared the efficacy, safety, and cost of rivaroxaban and low molecular weight heparin (LMWH) alone or followed by vitamin K antagonists. Results Forty-one patients were identified, with a median age of 62.5 years. The most frequent tumor histology was adenocarcinoma (78%), which was most often found in the colon (26.8%). Most participants had advanced disease and an implanted central venous catheter. Patients’ VTE risk-assessment scores were low (12.5%), intermediate (50%), and high (35.5%). Pulmonary thromboembolism was reported in 41.4% of patients, but inferior limb thrombosis was reported only in 14.6%; 43.9% of patients received enoxaparin before starting rivaroxaban. Rivaroxaban was used for a median time of 5.5 months. Nonmajor bleeding was reported in 12.2% of patients, and rethrombosis was reported in 12.2%. In our study, rivaroxaban was as safe and effective as enoxaparin/vitamin K antagonists ( P = .54 and P = .25, respectively) or LMWH ( P = .46 and P = .29, respectively). Conclusion Although our study was a retrospective analysis, our results suggest that in this cohort of oncologic patients, rivaroxaban was safe and effective. Its oral route and lower cost make it an attractive alternative to LMWH, improving management of patients with cancer in low-income countries. Additional studies are necessary to confirm our data.

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Starting anticoagulation with vitamin k antagonists alone or with concomitant low-molecular weight heparin for non-valvular atrial fibrillation

European Journal of Internal Medicine ◽

10.1016/j.ejim.2018.09.016 ◽

2019 ◽

Vol 59 ◽

pp. e14-e15

Author(s):

Edurne Sarrate ◽

Francisco Gual-Capllonch ◽

Marc Sorigue

Keyword(s):

Atrial Fibrillation ◽

Molecular Weight ◽

Vitamin K ◽

Low Molecular Weight Heparin ◽

Vitamin K Antagonists ◽

Low Molecular Weight

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Differential inhibition of thrombin generation by vitamin K antagonists alone and associated with low-molecular-weight heparin

Thrombosis and Haemostasis ◽

10.1160/th08-10-0653 ◽

2009 ◽

Vol 102 (07) ◽

pp. 42-48 ◽

Cited By ~ 12

Author(s):

Grigoris T. Gerotziafas ◽

Charlotte Dupont ◽

Alex C. Spyropoulos ◽

Mohamed Hatmi ◽

Meyer M. Samama ◽

...

Keyword(s):

Molecular Weight ◽

Vitamin K ◽

Low Molecular Weight Heparin ◽

Thrombin Generation ◽

Vitamin K Antagonists ◽

Low Molecular Weight ◽

Plasma Samples ◽

Thrombin Generation Assay ◽

International Normalised Ratio ◽

Inhibition Of Thrombin

SummaryVitamin K antagonists (VKA) treatment starts with co-administration of low-molecular-weight heparin (LMWH). The anticoagulation induced by the two drugs is still not well determined. In the present study we used thrombin generation assay to evaluate the hypo-coagulation induced by treatment with VKA and by the combination of VKA with LMWH. Tissue factor triggered thrombin generation in platelet-poor plasma was assessed in samples from 15 healthy volunteers, 97 samples from patients treated with VKA and 41 samples from patients receiving enoxaparin and VKA. Patients were classified according to international normalised ratio (INR) level (<2, 2–3 and >3).In plasma samples from patients treated with VKA having INR 2–3 the inhibition of thrombin generation reached 50% compared to controls. In samples with INR>3 this inhibition was 80%. In samples from patients receiving both LMWH and VKA, thrombin generation was significantly decreased compared to the controls and VKA group. In samples with an INR 2–3 obtained from patients treated with LMWH and VKA, the inhibition of thrombin generation was similar to that observed in samples with an INR>3 obtained from VKA treated patients. Thrombin generation assay is sensitive to detect the global the anticoagulant effect produced by the association of LMWH and VKA. For equal INR dual anticoagulant treatment induces significantly more profound inhibition of thrombin generation compared to treatment with VKA alone. The clinical relevance of this observation merits to be studied in prospective studies in patients with defined indications of anticoagulant therapy.

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Vitamin K antagonists versus low-molecular-weight heparin for the long term treatment of symptomatic venous thromboembolism

Cochrane Database of Systematic Reviews ◽

10.1002/14651858.cd002001.pub3 ◽

2017 ◽

Author(s):

Alina Andras ◽

Adriano Sala Tenna ◽

Marlene Stewart

Keyword(s):

Molecular Weight ◽

Venous Thromboembolism ◽

Vitamin K ◽

Low Molecular Weight Heparin ◽

Vitamin K Antagonists ◽

Term Treatment ◽

Low Molecular Weight ◽

Long Term Treatment

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Newer Oral Anticoagulants in the Treatment of Acute Portal Vein Thrombosis in Patients with and without Cirrhosis

International Journal of Hepatology ◽

10.1155/2018/8432781 ◽

2018 ◽

Vol 2018 ◽

pp. 1-9 ◽

Cited By ~ 24

Author(s):

P. Priyanka ◽

J. T. Kupec ◽

M. Krafft ◽

N. A. Shah ◽

G. J. Reynolds

Keyword(s):

Molecular Weight ◽

Portal Vein ◽

Portal Vein Thrombosis ◽

Vitamin K ◽

Low Molecular Weight Heparin ◽

Vitamin K Antagonists ◽

Oral Anticoagulants ◽

Direct Oral Anticoagulants ◽

Low Molecular Weight ◽

Vein Thrombosis

Background. Newer oral anticoagulants (NOACs) are being utilized increasingly for the treatment of venous thromboembolism (VTE). NOAC use is the standard of care for stroke prophylaxis in nonvalvular atrial fibrillation and treatment of acute VTE involving extremities and pulmonary embolism. In contrast, most guidelines in the literature support the treatment of acute portal vein thrombosis (PVT) with low molecular weight heparin (LMWH) and vitamin K antagonists (VKA). Literature evaluating NOAC use in the treatment of acute portal vein thrombosis is sparse. This review focuses on the safety and efficacy of the use of NOACs in the treatment of acute PVT in patients, with or without concomitant cirrhosis, based on the most recent data available in the current literature. Methods. A systematic review was conducted through a series of advanced searches in the following medical databases: PubMed, BioMed Central, Cochrane, and Google Scholar. Keywords utilized were as follows: NOAC, DOAC (direct oral anticoagulants), portal vein thrombosis, rivaroxaban, apixaban, dabigatran, and edoxaban. Articles related to newer anticoagulant use in patients with portal vein thrombosis were included. Results. The adverse events, including bleeding events (major and minor) and the failure of anticoagulation (propagation of thrombus or recurrence of PVT), are similar between the NOACs and traditional anticoagulants for the treatment of acute PVT, irrespective of the presence of cirrhosis. Conclusions. Newer oral anticoagulants are safe and efficacious alternatives to traditional anticoagulation with low molecular weight heparin and vitamin K antagonists in the treatment of acute portal vein thrombosis with or without cirrhosis.

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