scholarly journals How confident are pharmacists in providing pharmaceutical care on anticoagulants? A cross-sectional, self-administered questionnaire study in Borneo, Malaysia

2021 ◽  
Vol 14 (1) ◽  
Author(s):  
Sze Ling Tan ◽  
Zai Yang Yong ◽  
Jerry Ee Siung Liew ◽  
Hadzliana Zainal ◽  
Sania Siddiqui
Keyword(s):  
Pharmaceutical Care ◽  
Confidence Level ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Low Molecular Weight ◽  
Low Molecular Weight Heparins ◽  
Cross Sectional ◽  
Perceived Reasons ◽  
Self Administered Questionnaire

Abstract Background Anticoagulants are the cornerstone therapy for the management of venous thromboembolism (VTE) and atrial fibrillation (AF). Pharmacists should be confident and equipped with the skill and updated knowledge in managing anticoagulation therapy. Objective To explore self-reported confidence level of pharmacists, perceived reasons influencing their confidence and socio-demographic associated with high confidence level in the area of anticoagulation. Methods A cross-sectional, self-administered questionnaire survey was carried out among fully registered pharmacists who work in selected government hospitals and clinics in Borneo, Malaysia, from January 2019 to February 2020. Results Overall, responses from 542 fully registered pharmacists were obtained. Proportion of respondents who claimed confident in providing necessary information to patient receiving warfarin (n = 479, 88.3%) was significantly higher (p < 0.001) compared to low molecular weight heparins (n = 317, 58.5%) and direct oral anticoagulants (n = 211, 38.9%). Respondents’ perceived reasons that may influence their confidence level include experience in dealing with anticoagulants’ cases (n = 469, 86.5%), knowledge on anticoagulants (n = 394, 72.7%) and knowledge on diseases needing anticoagulation therapy (n = 311, 57.4%). Practising as ward pharmacist and “always” dealing with anticoagulants during their practice were the socio-demographic that significantly associated with high confidence level of pharmacist in providing pharmaceutical care on all types of anticoagulants (p < 0.05). Conclusion Pharmacists were found more confident in providing pharmaceutical care on warfarin compared to low molecular weight heparins and direct oral anticoagulants. Continuous educational and training programmes on the use of anticoagulants should be carried out to enhance pharmacists’ confidence in supporting patients’ care.

Safety and efficacy of direct oral anticoagulants for venous thromboembolism and stroke prophylaxis in patients with hematologic malignancies

2019 ◽  
Vol 26 (2) ◽  
pp. 351-360 ◽  
Author(s):  
Stephanie Kim ◽  
Jennifer Namba ◽  
Aaron M Goodman ◽  
Thi Nguyen ◽  
Ila M Saunders
Keyword(s):  
Molecular Weight ◽  
Venous Thromboembolism ◽  
Major Bleeding ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Hematologic Malignancies ◽  
Low Molecular Weight ◽  
Direct Oral Anticoagulant ◽  
Low Molecular Weight Heparins ◽  
Bleeding Events

Purpose Low-molecular-weight heparins are currently the recommended antithrombotic therapy for treatment and prevention of malignancy-related venous thromboembolism. Currently, the evidence evaluating direct oral anticoagulants versus low-molecular-weight heparins or a vitamin K antagonist in cancer patients with hematologic malignancies is limited. We evaluated the safety and efficacy of direct oral anticoagulants for venous thromboembolism treatment or stroke prevention for non-valvular atrial fibrillation in patients with hematologic malignancies. Methods This was a retrospective evaluation of adult patients with hematologic malignancies who received at least one dose of the Food and Drug Administration-approved direct oral anticoagulant for venous thromboembolism treatment or stroke prevention. We determined the frequency of major bleeding events, non-major bleeding events, stroke, systemic embolism, appropriateness of initial direct oral anticoagulant doses, holding practices prior to procedures, and the rate of all-cause mortality. An analysis was also performed to compare the incidence of bleeding between patients with a history of hematopoietic stem cell transplant to non-transplant patients. Results A total of 103 patients were identified, with the majority of patients receiving rivaroxaban for venous thromboembolism treatment. Major bleeding events occurred in four patients and no fatal bleeding events occurred. Non-major bleeding occurred in 29 patients, most commonly epistaxis and bruising. Two patients experienced a systemic embolism while on direct oral anticoagulant therapy. Conclusion Direct oral anticoagulants may be a safe and effective alternative for anticoagulation therapy in patients with hematologic malignancies. However, larger prospective studies comparing direct oral anticoagulants to low-molecular-weight heparins or vitamin K antagonists are warranted to compare efficacy and safety outcomes in this patient population.

scholarly journals Direct Oral Anticoagulants in Cancer Patients. Time for a Change in Paradigm

Cancers ◽  
2020 ◽  
Vol 12 (5) ◽  
pp. 1144 ◽  
Author(s):  
Marek Z. Wojtukiewicz ◽  
Piotr Skalij ◽  
Piotr Tokajuk ◽  
Barbara Politynska ◽  
Anna M. Wojtukiewicz ◽  
...  
Keyword(s):  
Cancer Patients ◽  
Randomized Clinical Trials ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Current Evidence ◽  
Low Molecular Weight ◽  
Treatment And Prevention ◽  
Prevention Of Cancer ◽  
Selection Of

Thrombosis is a more common occurrence in cancer patients compared to the general population and is one of the main causes of death in these patients. Low molecular weight heparin (LMWH) has been the recognized standard treatment for more than a decade, both in cancer-related thrombosis and in its prevention. Direct oral anticoagulants (DOACs) are a new option for anticoagulation therapy. Recently published results of large randomized clinical trials have confirmed that DOAC may be a reasonable alternative to LMWH in cancer patients. The following review summarizes the current evidence on the safety and efficacy of DOAC in the treatment and prevention of cancer-related thrombosis. It also draws attention to the limitations of this group of drugs, knowledge of which will facilitate the selection of optimal therapy.

scholarly journals Direct oral anticoagulants versus low molecular weight heparins for the treatment of cancer-associated thrombosis: a cost-effectiveness analysis

2021 ◽  
Vol 19 (1) ◽  
Author(s):  
Kaidireyahan Wumaier ◽  
Wenqian Li ◽  
Naifei Chen ◽  
Jiuwei Cui
Keyword(s):  
Molecular Weight ◽  
Cost Effectiveness ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Low Molecular Weight ◽  
Test Model ◽  
Low Molecular Weight Heparins ◽  
Gastrointestinal Malignancy ◽  
Cancer Associated Thrombosis ◽  
The Cost

Abstract Background Recently, direct oral anticoagulants (DOACs) have been included in guidelines for the treatment of cancer-associated thrombosis (CAT) to be extended to suitable cancer patients. The purpose of this study was to compare the cost-effectiveness of using DOACs and low molecular weight heparins (LMWHs) for treating CAT from the perspective of the Chinese healthcare system. Methods A Markov model was constructed to estimate the cost-effectiveness of the two strategies with a 6-month and 5-year time horizon. Input parameters were either sourced from the clinical trial, published literature. The primary outcome of the model was reported as incremental cost-effectiveness ratios (ICERs). Sensitivity analyses were performed to test model uncertainty. Results The 6-month cost of DOACs was $ 654.65 with 0.40 quality adjusted life-years (QALYs) while the 6-month cost of LMWHs was $USD 1719.31 with 0.37 QALYs. Similarly, treatment with DOACs had a lower cost ($USD 657.85 vs. $USD 1716.56) and more health benefits (0.40 QALYs vs. 0.37 QALYs) than treatment with LMWHs in a subgroup of patients with gastrointestinal malignancy. We found treatment with DOACs would result in a large reduction in cost ($USD 1447.22 vs. $USD 3374.70) but a small reduction in QALYs (3.07 QALYs vs. 3.09 QALYs) compared with LMWHs over a 5-year time frame, resulting in an ICER of $USD 112895.50/QALYs. Sensitivity analysis confirmed the robustness of the results. Conclusion As compared to LMWHs, DOACs can be a cost-saving anticoagulant choice for the treatment of CAT in the general oncology population and gastrointestinal malignancy population.

scholarly journals Prevention and treatment of thrombosis in cancer and oncohematological patients

2021 ◽  
Vol 16 (4) ◽  
pp. 40-49
Author(s):  
O. V. Somonova ◽  
A. L. Elizarova ◽  
T. V. Davydova
Keyword(s):  
Molecular Weight ◽  
Cancer Patients ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Low Molecular Weight ◽  
Low Molecular Weight Heparins ◽  
Oncological Patient ◽  
Risk Of Death ◽  
Prevention And Treatment ◽  
Thrombotic Complications

The purpose of the review is to highlight the current possibilities for the prevention and treatment of venous thrombotic complications in patients with cancer.The data of 52 scientific sources published in the Russian and foreign press in 1997–2020 are considered.Cancer patients are at high risk of thrombotic complications, which worsen the outcome of anticancer treatment and are one of the leading causes of death. Thrombosis in an oncological patient increases the risk of death by 30 times, which is associated with fatal thromboembolism and a more aggressive course of the disease. The leading role in the pathogenesis of thrombotic complications is played by disorders in the hemostasis system caused both by the tumor itself and by therapy. Low molecular weight heparins are considered the basis for specific prophylaxis of thromboembolic complications in cancer patients. The use of low molecular weight heparins after surgery and during chemotherapy effectively reduces the incidence of venous thrombosis. Direct oral anticoagulants are promising drugs for oral administration and are indicated as one of the treatment options for patients with tumor-associated thrombosis with a low risk of bleeding and no drug interactions with ongoing systemic chemotherapy.

scholarly journals The Prevention and treatment of cancer-associated thrombosis

2020 ◽  
Vol 27 (5) ◽  
Author(s):  
S. Ng ◽  
M. Carrier
Keyword(s):  
Low Molecular Weight Heparin ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Standard Of Care ◽  
Low Molecular Weight ◽  
Safe Alternative ◽  
Patients With Cancer ◽  
Increased Risk ◽  
Cancer Associated Thrombosis

Cancer is a hypercoagulable state with an associated increased risk of venous thromboembolism (vte) that is further amplified in individuals who undergo chemotherapy. Compared with patients having cancer alone or vte alone, patients who develop cancer-associated vte have a significantly poorer prognosis. The risks of recurrent vte despite appropriate anticoagulation therapy and of bleeding are also higher in patients with cancer than in those without. For those reasons, the prevention and appropriate management of cancer-associated thrombosis is of paramount importance. Although low-molecular-weight heparin has been the standard of care for the prevention and treat­ment of cancer-associated thrombosis, direct oral anticoagulants are increasingly being adopted as an effective and safe alternative.

How I treat and prevent venous thrombotic complications in patients with lymphoma

Blood ◽  
2021 ◽  
Author(s):  
Robert A Schmidt ◽  
Agnes YY Lee
Keyword(s):  
Trial Design ◽  
Randomized Trials ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Low Molecular Weight ◽  
Common Complication ◽  
Low Molecular Weight Heparins ◽  
Relative Risks ◽  
Thrombotic Complications ◽  
The Individual

Venous thromboembolism (VTE) is a common complication occurring in 5-10% of patients with lymphoma. As the complexity of lymphoma management has increased with novel therapies, so too has the treatment of VTE. Therapeutic options for the treatment of cancer-associated VTE have expanded from only warfarin and low-molecular-weight heparins (LMWHs) to include the direct oral anticoagulants (DOACs) apixaban, edoxaban and rivaroxaban. There have been no head-to-head trials comparing different DOACs in this setting and randomized trials comparing a DOAC with LMWH dalteparin differ in trial design and results. Drug-drug interactions, drug-specific side effects and patient selection are important considerations when prescribing anticoagulant therapy. In all patients, the relative risks of thrombosis and bleeding, the availability of the anticoagulant, and the life expectancy of the patient are vital elements in selecting the most appropriate anticoagulant (which can vary over time) for the individual patient. We describe the intricacies and challenges of treating thrombotic complications in patients with lymphoma with an emphasis on evidence and guideline-based care.

scholarly journals An Untoward Effect: Anticoagulation Therapy in Cancer Patients Leads to Gastrointestinal Bleeding and Increased Mortality

2018 ◽  
Vol 3 (12) ◽  
Author(s):  
Dr. Arine Mathew
Keyword(s):  
Causes Of Death ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Anticoagulation Therapy ◽  
Morbidity And Mortality ◽  
Major Surgery ◽  
Low Molecular Weight ◽  
High Morbidity ◽  
Public Concern ◽  
Patients With Cancer

Cancer, a condition involving uncontrolled division of cells, ranks second among leading causes of death worldwide.[1] According to an estimate, cancer will contribute 609,640 deaths in the year 2018 in United States.[2] Therefore, cancer is a major public concern as it has high morbidity and mortality rates. The patients with cancer are at high risk of developing venous thromboembolism (VTE) as it is a hypercoagulable state.[3] Therefore, thrombotic events are a major cause of morbidity and mortality among the patients with cancer.[4,5] Recommendations of anticoagulation in acute VTE are same in the patients with or without cancer.[3] Anticoagulation prophylaxis and therapy is recommended in the patients with cancer who are hospitalized with acute illness or undergoing major surgery and those who have developed VTE, respectively.[6] Usually, low molecular weight heparin (LMWH), vitamin K antagonist (VKA) and direct oral anticoagulants are used for the treatment of VTE in the patients with cancer. The purpose of this anticoagulation is to prevent extension, recurrence and embolism of thrombus. However, higher recurrence of VTE and risk of bleeding complicates the treatment.

scholarly journals Clinical Outcomes with Direct Oral Anticoagulants Compared to Low Molecular Weight Heparins in the Treatment of Cancer-Associated Venous Thromboembolism

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 1237-1237 ◽  
Author(s):  
Deborah Y. Park ◽  
Shyam K. Poudel ◽  
Xuefei Jia ◽  
Mailey Lynn Wilks ◽  
Vicki Pinkava ◽  
...  
Keyword(s):  
Major Bleeding ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Low Molecular Weight ◽  
Gastrointestinal Cancers ◽  
Low Molecular Weight Heparins ◽  
Bleeding Events ◽  
Common Cancer ◽  
Cancer Types ◽  
Recurrent Vte

Abstract Background: Emerging data suggest that treatment of cancer-associated venous thromboembolism (VTE) with direct oral anticoagulants (DOACs) results in lower recurrence rate compared to low molecular weight heparins (LMWHs) at 6 months but with concern for increase in bleeding risks. The objective of this study was to determine occurrence of major bleeding as well as recurrent VTE events on treatment with DOACs or LMWHs in a cohort study. Methods: The cancer-associated thrombosis (CAT) clinic is a centralized service for care of cancer patients with suspected deep venous thrombosis (DVT) and/or pulmonary embolism (PE) established at the Tausig Cancer Institute of the Cleveland Clinic. We conducted a prospective cohort study of patients referred to this clinic between 8/2014 through 1/2018. The demographics, cancer types, VTE characteristics, treatment courses, and outcomes (VTE recurrence, major or clinically relevant nonmajor [CRNM] bleeding) were recorded for these patients. Standards of treatment at the CAT clinic shifted in late 2017 from use of LMWH, enoxaparin, to a DOAC, rivaroxaban for cancer-associated VTE. Current exclusion criteria for rivaroxaban use include recent active bleeding, GFR < 30 mL/min, severe hepatic impairment, thrombocytopenia (platelet count < 50,000), and/or expected malabsorption at the level of stomach or small bowel. For cancer patients considered at higher risk of bleeding, including patients with luminal gastrointestinal cancers with an intact primary; cancers at risk of bleeding from genitourinary tract, bladder or nephrostomy tubes; or patients with active mucosal abnormalities such as duodenal ulcers, gastritis/esophagitis or colitis, treatment with LMWHs is preferred. Major or CRNM bleeding was determined according to definitions outlined by the International Society on Thrombosis and Haemostasis. Results: The study population included 258 patients with acute VTE. Of these, 239 patients had DVT (93%), 34 had PE (14%), 15 had both (6.2%), and 3 had visceral vein thromboses (1.2%). The patients were 53% male with a median age of 65 ± 16 years. The most common cancer types were hematologic malignancies (19.5%, n = 50), primary brain tumors (11.2%, n = 29), lung (8.5%, n = 22), breast (7.0%, n = 18), and pancreatic cancers (6.6%, n = 17). Enoxaparin monotherapy was prescribed for 72.1% (n = 179 of 248) of patients. Other treatments included rivaroxaban (17.3%, n = 43), apixaban (0.8%, n = 2), warfarin (2.8%, n = 7), dalteparin (0.4%, n = 1), or no anticoagulation (3.2%, n = 8). Major bleeding occurred in 5% (n = 12 of 241) of patients treated with anticoagulation at 6 months of the initial event, including 5.0% (n = 9 of 179) of patients on enoxaparin and 4.7% (n = 2 of 43) of patients on rivaroxaban, and these differences were not significant (p > 0.95) (Figure 1). CRNM bleeding was observed in 16.2% (n = 29 of 179) of patients on enoxaparin and 11.6% (n = 5 of 43) of patients on rivaroxaban. The common cancer types for patients with major bleeding events included primary brain tumors (n = 4), genitourinary cancers (n = 2) and gastrointestinal cancers (n = 2) (Table 1). The 1-year incident rate of recurrent VTE was 11% for patients treated with enoxaparin and 9% for those treated with DOACs, and 2-year rate was 13% and 11%, respectively (Figure 2). Overall, there was no significant difference in the VTE recurrence rate calculated by the competing risk model between patients on enoxaparin compared to rivaroxaban (p = 0.19). Conclusions: Bleeding events of patients treated with enoxaparin was comparable to rivaroxaban for both major and CRNM bleeding events in this carefully selected real-world population. Patients receiving rivaroxaban reported a statistically insignificant but lower rate of recurrent VTE compared to those receiving enoxaparin. These findings support a recent change in ISTH guidance recommending rivaroxaban or edoxaban as initial treatment of cancer-associated VTE in selected patients. Disclosures Khorana: Sanofi: Consultancy; Bayer: Consultancy; Janssen: Consultancy; Pfizer: Consultancy.

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