Newer and Better? Comparing Direct Oral Anticoagulants to Warfarin in Patients With Traumatic Intracranial Hemorrhage

2020 ◽  
Vol 86 (9) ◽  
pp. 1062-1066
Author(s):  
Joshua D. Billings ◽  
Abid D. Khan ◽  
John H. McVicker ◽  
Thomas J. Schroeppel
Keyword(s):  
Intracranial Hemorrhage ◽  
Injury Severity ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Outcome Data ◽  
Trauma Patients ◽  
Reversal Agents ◽  
Traumatic Intracranial Hemorrhage ◽  
Anticoagulated Patients

Background Direct oral anticoagulants (DOACs) have overtaken warfarin as the preferred anticoagulants for stroke prevention with atrial fibrillation and for treatment of venous thromboembolism. Despite the increased prevalence of DOACs, literature studying their impact on trauma patients with intracranial hemorrhage (ICH) remains limited. Most DOAC reversal agents have only been recently available, and concerns for worse outcomes with DOACs among this population remain. This study aims to assess the outcomes of patients with traumatic ICH taking DOACs compared with those taking warfarin. Methods A retrospective analysis of patients with traumatic ICH over a 5-year period was conducted. Demographics, injury severity, medication, and outcome data were collected for each patient. Patients taking warfarin and DOACs were compared. Results 736 patients had traumatic ICH over the study period, 75 of which were on either DOACs (25 patients) or warfarin (50 patients). The median age of the anticoagulated patients was 78 years; 52% were female, and 91% presented secondary to a fall. DOACs were reversed at close to half the rate of warfarin (40% vs 77%; P = .032). Despite this, the 2 groups had similar rates of worsening examination, need for operative intervention, and in-hospital mortality. In the follow-up, fewer patients taking DOACs had died at 6-months postinjury compared with those taking warfarin (8% vs 30%; P = .041). Discussion Despite DOACs being reversed at nearly half the rate of warfarin, patients presenting with traumatic ICH on warfarin had higher 6-month mortality suggesting a potential survival advantage for DOACs over warfarin in this population.

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

2018 ◽  
Vol 84 (6) ◽  
pp. 1010-1014 ◽  
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.

scholarly journals Reversal Strategies for Intracranial Hemorrhage Related to Direct Oral Anticoagulant Medications

2018 ◽  
Vol 2018 ◽  
pp. 1-11 ◽  
Author(s):  
Alok Dabi ◽  
Aristides P. Koutrouvelis
Keyword(s):  
Side Effects ◽  
Intracranial Hemorrhage ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Factor Xa ◽  
Coagulation Cascade ◽  
Reversal Agents ◽  
United States Food ◽  
Life Threatening

Direct oral anticoagulants (DOACs) are a new class of anticoagulants that directly inhibit either thrombin or factor Xa in the coagulation cascade. They are being increasingly used instead of warfarin or other vitamin K antagonists (VKAs). Adverse side effects of DOACs may result in hemorrhagic complications, including life-threatening intracranial hemorrhage (ICH), though to a much lesser degree than VKAs. Currently there are relatively limited indications for DOACS but their usage is certain to expand with the availability of their respective specific reversal agents. Currently, only idarucizumab (antidote for dabigatran) has been United States Food and Drug Administration- (FDA-) approved, but others (andexanet-α and ciraparantag) may be approved in near future, and the development and availability of such reversal agents have the potential to dramatically change the current anticoagulant use by providing reversal of multiple oral anticoagulants. Until all the DOACs have FDA-approved reversal agents, the treatment of the dreaded side effects of bleeding is challenging. This article is an attempt to provide an overview of the management of hemorrhage, especially ICH, related to DOAC use.

scholarly journals P142: The anticoagulated trauma patient: a Canadian experience in the era of direct oral anticoagulants

CJEM ◽  
2016 ◽  
Vol 18 (S1) ◽  
pp. S125-S125 ◽  
Author(s):  
B. Wood ◽  
A. Ackery ◽  
S. Rizoli ◽  
B. Nascimento ◽  
M. Sholzberg ◽  
...  
Keyword(s):  
Trauma Patient ◽  
Injury Severity ◽  
Hematological Parameters ◽  
Oral Anticoagulants ◽  
Demographic Data ◽  
Direct Oral Anticoagulants ◽  
Significant Proportion ◽  
Common Mechanism ◽  
Trauma Patients ◽  
Trauma Population

Introduction: The anticoagulated trauma patient is a particularly vulnerable population. Our current practice is guided by experience with patients taking vitamin K dependent antagonists (VKA, like warfarin). It is currently unknown how the increasing use of direct oral anticoagulants (DOACs) will change our trauma population. We collected data about this new subset of patients to compare their clinical characteristics to patients on pre-injury VKA therapy. Methods: Retrospective review of anticoagulated trauma patients presenting to Toronto’s two adult trauma centres, Saint Michael’s Hospital and Sunnybrook Health Sciences Centre, from June 2014-June 2015 was undertaken. Patients were recruited through the institutions’ trauma registries and were eligible if they suffered a traumatic injury and taking an oral anticoagulant pre-injury. Clinical and demographic data were extracted by a trained reviewer and analysed with descriptive statistics. Results: Our study recruited 85 patients, 33% were taking DOACs and 67% VKAs. Trauma patients on DOACs & VKAs respectively had similar baseline characteristics such as age (75.9 vs 77.4), initial injury severity score (ISS (16.9 vs 20.6)) and concomitant antiplatelet use (7.1% vs 5.4%). Both groups’ most common mechanism for injury was falls and the most common indication for anticoagulation was atrial fibrillation. Patients on DOACs tended to have lower average INR (1.25 vs 2.3) and serum creatinine (94.9 vs 127.4). Conclusion: Patients on DOACs pre-injury now account for a significant proportion of orally anticoagulated trauma patients. Patients on DOACs tended to have less derangement of basic hematological parameters complicating diagnosis and management of coagulopathy.

scholarly journals Intracranial hemorrhage in patients taking oral anticoagulants. Current possibilities for therapy

2019 ◽  
Vol 11 (3S) ◽  
pp. 82-88
Author(s):  
S. N. Yanishevsky
Keyword(s):  
Atrial Fibrillation ◽  
Intracranial Hemorrhage ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Severe Disabilities ◽  
Progression Rate ◽  
Reversal Agents ◽  
Traumatic Intracranial Hemorrhage ◽  
Hypertension Therapy ◽  
Specific Antagonist

The paper reviews an update on the possibilities of providing care for patients with spontaneous non-traumatic intracranial hemorrhage (ICH) developing in patients with atrial fibrillation who use oral anticoagulants. The incidence of ICH is shown to be considerably lower when nonvitamin K-dependent anticoagulants (NOACs) are used, but the hematoma evolution scenarios do not differ between the groups of patients receiving vitamin K antagonists or NOACs. The results of studies assessing hypertension therapy in patients with ICH are compared. The possibilities of using various reversal agents for various oral anticoagulants are also discussed. Since one of the main problems associated with increased mortality and severe disabilities is the progression rate of ICH, the possibility of using a specific antagonist can determine the choice of an anticoagulant for the primary prevention of ischemic stroke in a patient with atrial fibrillation.

Causes of Death in Patients with Venous Thromboembolism Anticoagulated with Direct Oral Anticoagulants: A Systematic Review and Meta-Analysis

2018 ◽  
Vol 44 (04) ◽  
pp. 377-387
Author(s):  
Ana Terleira-Fernández ◽  
Ramón Lecumberri ◽  
Mª Suárez-Gea ◽  
Gonzalo Calvo-Rojas ◽  
Emilio Vargas-Castrillón ◽  
...  
Keyword(s):  
Venous Thromboembolism ◽  
Web Sites ◽  
Causes Of Death ◽  
Meta Analysis ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Recurrent Venous Thromboembolism ◽  
Anticoagulated Patients ◽  
Active Cancer

AbstractDeath is more frequent than nonfatal recurrent venous thromboembolism (VTE) and major bleeding after acute VTE. The analysis of the causes of death is fundamental to explore new strategies to reduce mortality rates in these patients. The authors performed a meta-analysis to analyze mortality and independently adjudicated causes of death in anticoagulated patients due to VTE, and to evaluate potential differences between different anticoagulant schemes. They searched MEDLINE and CENTRAL, from January 1, 2000, to January 31, 2017, and performed additional searches in Web sites of regulatory agencies, clinical trial registers, and conference proceedings. Two investigators independently selected studies and extracted the data. Study quality was assessed with the Cochrane Collaboration's tool for assessing the risk of bias in randomized studies. Seven prospective randomized trials in 29,844 patients (22,025 patient-year follow-up) were included, comparing dabigatran, rivaroxaban, apixaban, and edoxaban with the standard anticoagulant treatment of VTE. A total of 718 patients died during the follow-up (3.4% per year; 95% confidence interval [CI]: 2.3–4.8). The most frequent causes of death were cancer (42%), followed by VTE (20%), infections (13%), hemorrhage (6%), heart disease (4%), and stroke (2%). There were no differences in the overall survival and causes of death according to the anticoagulant type. Concomitant active cancer during the study was significantly associated with death (odds ratio: 15.2; 95% CI: 9.2–25.1). Cancer is the leading cause of death in contemporary VTE trials. Interventions beyond anticoagulation, particularly in patients with active cancer, are needed.

Abstract WMP98: A Nationwide Study of Non-traumatic Intracranial Hemorrhage in Patients Receiving Direct Oral Anticoagulant Therapy: J-Aspect Study

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Ryota Kurogi ◽  
Kunihiro Nishimura ◽  
Akiko Kada ◽  
Satoru Kamitani ◽  
Kuniaki Ogasawara ◽  
...  
Keyword(s):  
Intracranial Hemorrhage ◽  
Oral Anticoagulant Therapy ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Nationwide Survey ◽  
Annual Number ◽  
Prescription Data ◽  
Nationwide Study ◽  
Number Of Patients ◽  
Traumatic Intracranial Hemorrhage

Background and purpose: The incidence of non-traumatic intracranial hemorrhage (ICH) during treatment with direct oral anticoagulants (DOACs) is lower than that during warfarin treatment. The characteristics of intracranial hemorrhage during DOAC therapy, however, remain unclear. Therefore, we performed a nationwide survey in Japan to examine the clinical characteristics and outcomes of DOAC-associated ICH using data obtained from the Japanese Diagnosis Procedure Combination (DPC)-based Payment System. Methods: We analyzed the data of 1,567 patients with ICH (DOAC-associated ICH, 88; warfarin-associated ICH, 1,479) who were urgently hospitalized at 575 institutions across Japan from April 2010 to March 2013 for whom prescription data before admission were available. Results: The annual number of patients with all anticoagulant (DOAC or warfarin)- associated ICH in each year from 2010 to 2013 was 226, 252, 426, and 663, representing 15.7%, 15.4%, 16.1%, and 16.1% of all ICH cases in the same period, respectively. There was an increase in the proportion of patients who presented with DOAC-associated ICH in all anticoagulant-associated ICH in each year from 2010 to 2013 (0%→0.4%→3.8%→10.7%). The proportion of patients with impaired consciousness (three-digit score on Japan Coma Scale) at admission (DOAC, 19.3%; Warfarin, 25.4%; P=0.20), in-hospital mortality within 7 days (DOAC, 11.4%; Warfarin, 19.5%; P=0.06), and mRS score of 5-6 at discharge (DOAC, 27.3%; Warfarin, 37.4%; P=0.06) were lower in the patients with DOAC-associated ICH. The rates of surgery for hematoma removal were significantly lower in the patients with DOAC-associated ICH (NOAC, 2.3%; Warfarin, 9.7%; P=0.019). Conclusions: This is the largest nationwide study of DOAC-associated ICH in a real-world situation in Japan, revealing that the patients with DOAC-associated ICH had better clinical outcomes compared with warfarin-associated ICH, probably due to milder hemorrhage at admission.

scholarly journals Intracranial hemorrhage with direct oral anticoagulants in patients with brain metastases

2020 ◽  
Vol 4 (24) ◽  
pp. 6291-6297
Author(s):  
Avi Leader ◽  
Eva N. Hamulyák ◽  
Brian J. Carney ◽  
Maya Avrahami ◽  
Jelijn J. Knip ◽  
...  
Keyword(s):  
Brain Metastases ◽  
Intracranial Hemorrhage ◽  
Cumulative Incidence ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Limited Data ◽  
Imaging Studies ◽  
Brain Tumor Diagnosis ◽  
Cancer Associated Thrombosis

Abstract Direct oral anticoagulants (DOACs) are increasingly prescribed in treatment of cancer-associated thrombosis, but limited data exist regarding safety of DOACs in patients with brain metastases. We aimed to determine the incidence of intracranial hemorrhage (ICH) in patients with brain metastases receiving DOACs or low-molecular-weight heparin (LMWH) for venous thromboembolism or atrial fibrillation. An international 2-center retrospective cohort study was designed. Follow-up started on the first day of concomitant anticoagulation and brain tumor diagnosis. At least 2 brain imaging studies were mandated. The primary outcome was the cumulative incidence of any spontaneous ICH at 12-month follow-up with death as a competing risk. Major ICH was defined as spontaneous, ≥10 mL in volume, symptomatic, or requiring surgical intervention. Imaging studies were centrally reviewed by a neuroradiologist blinded for anticoagulant type. PANWARDS (platelets, albumin, no congestive heart failure, warfarin, age, race, diastolic blood pressure, stroke) score for prediction of ICH was calculated. We included 96 patients with brain metastases (41 DOAC, 55 LMWH). The 12-month cumulative incidence of major ICH was 5.1% in DOAC-treated patients and 11.1% in those treated with LMWH (hazard ratio [HR], 0.45; 95% confidence interval [CI], 0.09-2.21). When anticoagulation was analyzed as a time-varying covariate, the risk of any ICH did not differ between DOAC- and LMWH-treated patients (HR, 0.98; 95% CI, 0.28-3.40). PANWARDS score was not associated with ICH risk. This international 2-center study suggests comparable safety of LMWH and DOACs in patients with brain metastases.

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