scholarly journals Antithrombotic treatment in COVID-19 – from theory to practical approach

2021 ◽  
Vol 24 (3) ◽  
pp. 131-136
Author(s):  
Ionela-Larisa Miftode ◽  
◽  
Angela Moloce ◽  
Radu-Stefan Miftode ◽  
Viviana Onofrei ◽  
...  
Keyword(s):  
Antiplatelet Therapy ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Clinical Status ◽  
Optimal Choice ◽  
Hospitalized Patients ◽  
Multiple Drug ◽  
Protective Effects ◽  
Antithrombotic Treatment ◽  
Increased Risk

Although initially considered a strictly respiratory pathology, the novel coronavirus disease-19 (COVID-19) has emerged as a significant prothrombotic trigger, inducing hypercoagulable status and increased risk of thrombotic events. This is due to a plethora of mechanisms, either from inflammation-induced endothelial dysfunction, overexpression of procoagulant molecules doubled by down-regulation of physiological antithrombotic pathways, or from an exagerated response to otherwise normal procoagulant stimuli. This complex association of factors define the concept of immunothrombosis, which can be influenced by several antithrombotic medications. Despite the lack of an „universal” guideline, the general consensus is to recommend antithrombotic treatment in COVID-19 patients, but its administration should take into account the patient’s clinical status, comorbidities or the other previous indications for antithrombotic treatment. This precaution is due to the multiple drug interactions with antivirals or other molecules used in COVID-19. Concerning anticoagulant treatment, heparins are the optimal choice, compared to antivitamins K and direct oral anticoagulants (DOACs), because they exhibit the most protective effects doubled by the least interactions with other substances. Hospitalized patients should receive prophylactic doses of anticoagulation, but not for the prevention of arterial thrombosis, unless they have a previous indication such as atrial fibrillation or prosthetic valve. It is generally recommended that patients on chronic anticoagulant or antiplatelet therapy for other conditions will continue their prescribed medication, here including special categories such as pregnant women. However, non-hospitalized patients with mild forms of the disease should not be initiated anticoagulant and antiplatelet therapy unless they have other indication. Continuation of prophylaxis after discharge is a matter of debate, the existing data suggesting it may be considered in those patients at high risk for venous thromboembolism (VTE) and/or who had a moderate-severe form of the disease, always assessing the bleeding risk. Further data from extensive studies are required in order to standardize the antithrombotic approach in COVID-19 patients.

scholarly journals Newer Oral Anticoagulants: Stroke Prevention and Pitfalls

2016 ◽  
Vol 10 (1) ◽  
pp. 94-104 ◽  
Author(s):  
Anand Patel ◽  
Richard P. Goddeau Jr ◽  
Nils Henninger
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Anticoagulant Effect ◽  
Therapeutic Window ◽  
Thrombin Inhibitor ◽  
Multiple Drug ◽  
Thrombotic Complication ◽  
Narrow Therapeutic Window ◽  
Increased Risk

Warfarin is very effective in preventing stroke in patients with atrial fibrillation. However, its use is limited due to fear of hemorrhagic complications, unpredictable anticoagulant effects related to multiple drug interactions and dietary restrictions, a narrow therapeutic window, frequent difficulty maintaining the anticoagulant effect within a narrow therapeutic window, and the need for inconvenient monitoring. Several newer oral anticoagulants have been approved for primary and secondary prevention of stroke in patients with non-valvular atrial fibrillation. These agents have several advantages relative to warfarin therapy. As a group, these direct oral anticoagulants (DOAC), which include the direct thrombin inhibitor, dabigatran, and the factor Xa inhibitors (rivaroxaban, apixaban, and edoxaban), are more effective than dose adjusted warfarin for prevention of all-cause stroke (including both ischemic and hemorrhagic stroke), and have an overall more favorable safety profile. Nevertheless, an increased risk of gastrointestinal bleeding (with the exception of apixaban), increased risk for thrombotic complication with sudden discontinuation, and inability to accurately assess and reverse anticoagulant effect require consideration prior to therapy initiation, and pose a challenge for decision making in acute stroke therapy.

scholarly journals Vitamin K antagonist anticoagulant usage is associated with increased incidence and progression of osteoarthritis

2021 ◽  
Vol 80 (5) ◽  
pp. 598-604
Author(s):  
Cindy G Boer ◽  
Ingrid Szilagyi ◽  
N Long Nguyen ◽  
Tuhina Neogi ◽  
Ingrid Meulenbelt ◽  
...  
Keyword(s):  
Vitamin K ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Vitamin K Antagonist ◽  
Matrix Gla Protein ◽  
Study Cohort ◽  
Single Nucleotide Variants ◽  
Increased Risk ◽  
Coagulation Proteins ◽  
Clinical Prevention

ObjectivesVitamin K is hypothesised to play a role in osteoarthritis (OA) pathogenesis through effects on vitamin K-dependent bone and cartilage proteins, and therefore may represent a modifiable risk factor. A genetic variant in a vitamin K-dependent protein that is an essential inhibitor for cartilage calcification, matrix Gla protein (MGP), was associated with an increased risk for OA. Vitamin K antagonist anticoagulants (VKAs), such as warfarin and acenocoumarol, act as anticoagulants through inhibition of vitamin K-dependent blood coagulation proteins. VKAs likely also affect the functioning of other vitamin K-dependent proteins such as MGP.MethodsWe investigated the effect of acenocoumarol usage on progression and incidence of radiographic OA in 3494 participants of the Rotterdam Study cohort. We also examined the effect of MGP and VKORC1 single nucleotide variants on this association.ResultsAcenocoumarol usage was associated with an increased risk of OA incidence and progression (OR=2.50, 95% CI=1.94–3.20), both for knee (OR=2.34, 95% CI=1.67–3.22) and hip OA (OR=2.74, 95% CI=1.82–4.11). Among acenocoumarol users, carriers of the high VKORC1(BB) expression haplotype together with the MGP OA risk allele (rs1800801-T) had an increased risk of OA incidence and progression (OR=4.18, 95% CI=2.69–6.50), while this relationship was not present in non-users of that group (OR=1.01, 95% CI=0.78–1.33).ConclusionsThese findings support the importance of vitamin K and vitamin K-dependent proteins, as MGP, in the pathogenesis of OA. Additionally, these results may have direct implications for the clinical prevention of OA, supporting the consideration of direct oral anticoagulants in favour of VKAs.

scholarly journals Therapeutic endoscopy-related GI bleeding and thromboembolic events in patients using warfarin or direct oral anticoagulants: results from a large nationwide database analysis

Gut ◽  
2017 ◽  
Vol 67 (10) ◽  
pp. 1805-1812 ◽  
Author(s):  
Naoyoshi Nagata ◽  
Hideo Yasunaga ◽  
Hiroki Matsui ◽  
Kiyohide Fushimi ◽  
Kazuhiro Watanabe ◽  
...  
Keyword(s):  
Propensity Score ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Injection Sclerotherapy ◽  
Endoscopic Variceal Ligation ◽  
Gi Bleeding ◽  
Endoscopic Injection ◽  
Endoscopic Procedures ◽  
Increased Risk ◽  
Significant Difference

ObjectiveTo compare the risks of postendoscopy outcomes associated with warfarin with direct oral anticoagulants (DOACs), taking into account heparin bridging and various types of endoscopic procedures.DesignUsing the Japanese Diagnosis Procedure Combination database, we identified 16 977 patients who underwent 13 types of high-risk endoscopic procedures and took preoperative warfarin or DOACs from 2014 to 2015. One-to-one propensity score matching was performed to compare postendoscopy GI bleeding and thromboembolism between the warfarin and DOAC groups.ResultsIn the propensity score-matched analysis involving 5046 pairs, the warfarin group had a significantly higher proportion of GI bleeding than the DOAC group (12.0% vs 9.9%; p=0.002). No significant difference was observed in thromboembolism (5.4% vs 4.7%) or in-hospital mortality (5.4% vs 4.7%). The risks of GI bleeding and thromboembolism were greater in patients treated with warfarin plus heparin bridging or DOACs plus bridging than in patients treated with DOACs alone. Compared with percutaneous endoscopic gastrostomy, patients who underwent endoscopic submucosal dissection, endoscopic mucosal resection and haemostatic procedures including endoscopic variceal ligation or endoscopic injection sclerotherapy were at the highest risk of GI bleeding among the 13 types of endoscopic procedures, whereas those who underwent lower polypectomy endoscopic sphincterotomy or endoscopic ultrasound-guided fine needle aspiration were at moderate risk.ConclusionThe risk of postendoscopy GI bleeding was higher in warfarin than DOAC users. Heparin bridging was associated with an increased risk of bleeding and did not prevent thromboembolism. The bleeding risk varied by the type of endoscopic procedure.

The Combination of Oral Anticoagulant and Antiplatelet Therapies: Stay One Step Ahead

2020 ◽  
Vol 25 (5) ◽  
pp. 391-398
Author(s):  
Fabiana Lucà ◽  
Simona Giubilato ◽  
Stefania Angela Di Fusco ◽  
Angelo Leone ◽  
Stefano Poli ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Venous Thromboembolism ◽  
Antiplatelet Therapy ◽  
Oral Anticoagulant ◽  
Acute Coronary Syndromes ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Clinical Scenarios ◽  
Coronary Syndromes

Antithrombotic drugs, which include antiplatelets and anticoagulants, are effective in prevention and treatment of many cardiovascular disorders such as acute coronary syndromes, stroke, and venous thromboembolism and are among the drugs most commonly prescribed worldwide. The advent of direct oral anticoagulants, which are safer alternatives to vitamin K antagonists and do not require laboratory monitoring, has revolutionized the treatment of nonvalvular atrial fibrillation and venous thromboembolism. The combination of oral anticoagulant and antiplatelet therapy is required in many conditions of great clinical impact such as the coexistence of atrial fibrillation and coronary artery disease, with indication to percutaneous coronary intervention. However, strategies that combine anticoagulant and antiplatelet therapies lead to a significant increase in bleeding rates and it is crucial to find the right combination in the single patient in order to optimize the ischemic and bleeding risk. The aim of this review is to explore the evidence and controversies regarding the optimal combination of anticoagulant and antiplatelet therapy through the consideration of past dogmas and new perspectives from recent clinical trials and to propose a tailored therapeutic approach, according to specific clinical scenarios and individual patient characteristics. In particular, we separately explored the clinical settings of stable and acute coronary syndromes and percutaneous revascularization in patients with atrial fibrillation.

Anticoagulation Regimens and Interventional Pain Procedures

2018 ◽  
Author(s):  
Christine Oryhan ◽  
Kevin Vorenkamp ◽  
Daniel Warren
Keyword(s):  
Chronic Pain ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Patient Characteristics ◽  
The United States ◽  
Bleeding Complications ◽  
Risk Of Bleeding ◽  
Increased Risk ◽  
Spinal Epidural ◽  
The Ideal

With the aging population and new anticoagulant medications, such as direct oral anticoagulants, being marketed in the United States, it is very important for pain physicians to be aware of the anticoagulants available and how they affect the safety of interventional pain procedures. In addition to anticoagulant and antiplatelet medications, other medications commonly used in the chronic pain population may put patients at increased risk of bleeding complications. Certain patient characteristics, particularly in the chronic pain population, may also increase a patient’s risk of bleeding. The chapter reviews common and emerging anticoagulant and antiplatelet medications and the ideal holding time before or after interventional pain procedures, particularly in the spine. The chapter also discusses the diagnosis, treatment, and outcomes of spinal epidural hematomas.

scholarly journals Comparative effectiveness and safety of low-strength and high-strength direct oral anticoagulants compared with warfarin: a sequential cohort study

BMJ Open ◽  
2019 ◽  
Vol 9 (5) ◽  
pp. e026486 ◽  
Author(s):  
Nicole L Pratt ◽  
Emmae Ramsay ◽  
Lisa M Kalisch Ellett ◽  
Katherine Duszynski ◽  
Sepehr Shakib ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Cohort Study ◽  
Propensity Score ◽  
Ischaemic Stroke ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
High Strength ◽  
Risk Of Bleeding ◽  
Increased Risk ◽  
Low Strength

ObjectivesThe aim of this study was to compare effectiveness and safety of low-strength and high-strength direct oral anticoagulants (DOACs) with warfarin in the Australian Veteran population.DesignSequential cohort study using inverse probability of treatment weighting (IPTW) and propensity score matching. Initiators of high-strength (apixaban 5 mg, dabigatran 150 mg, rivaroxaban 20 mg) and low-strength DOACS (apixaban 2.5 mg, dabigatran 110 mg, rivaroxaban 15 mg) were compared with warfarin initiators.SettingAustralian Government Department of Veterans’ Affairs claims database.Participants4836 patients who initiated oral anticoagulants (45.8%, 26.0% and 28.2% on low-strength, high-strength DOACs and warfarin, respectively) between August 2013 and March 2015. Mean age was 85, 75 and 83 years for low-strength, high-strength DOACs and warfarin initiators, respectively.Main outcome measuresOne-year risk of hospitalisation for ischaemic stroke, any bleeding event or haemorrhagic stroke. Secondary outcomes were 1-year risk of hospitalisation for myocardial infarction and death.ResultsUsing the IPTW method, no difference in risk of ischaemic stroke or bleeding was found with low-strength DOACs compared with warfarin. As a class, no increased risk of myocardial infarction was found for low-strength DOACs, however, risk was elevated for apixaban (HR 2.25, 95% CI 1.23 to 4.13). For high-strength DOACs, no difference was found for ischaemic stroke compared with warfarin, however, there was a significant reduction in risk of bleeding events (HR 0.63, 95% CI 0.44 to 0.89) and death (HR 0.40, 95% CI 0.28 to 0.58). Propensity score matching showed no difference in risk of ischaemic stroke or bleeding.ConclusionWe found that in the practice setting both DOAC formulations were similar to warfarin with regard to effectiveness and had no increased risk of bleeding.

scholarly journals Update on Direct Oral AntiCoagulants (DOACs)

Phlebologie ◽  
2018 ◽  
Vol 47 (03) ◽  
pp. 137-145
Author(s):  
C. Rosenthal ◽  
C. von Heymann ◽  
J. Koscielny
Keyword(s):  
Elective Surgery ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Patient Characteristics ◽  
Clinical Decision ◽  
Major Surgery ◽  
Preoperative Treatment ◽  
Risk Of Bleeding ◽  
Increased Risk ◽  
Meta Analyses

SummaryRecent findings require an update of previous recommendations for the perioperative use of Direct Oral AntiCoagulants (DOACs). A break in preoperative treatment of 24-96 hours is recommended based on the pharmacokinetic profiles of DOACs and depends on individual patient characteristics, their renal and possibly liver function, and their surgery-related risk of bleeding. In cases of renal or hepatic insufficiency, whether to extend the preoperative interruption of IIa- and Xa-inhibitors is a clinical decision that must be reached on an individual patient basis. In cases of epidural or spinal anaesthesia, more conservative pausing-intervals are recommended due to the risk of persistent neurologic deficits (e.g., paraplegia) following the development of spinal subdural and epidural haematomas. Elective surgery should be postponed according to these recommendations. Preoperative “bridging” with LMWH (more precisely referred to as “switching”) should be omitted due to a significantly increased risk of bleeding. In addition, the incidence of perioperative thromboembolic risks, such as DVT, PE, and stroke, are no different whether interruption or „switching” is undertaken. Postoperatively, the DOACs can be reinstituted within the first 24 hours. In cases of major surgery or if there is a higher risk of bleeding, resumption of DOACS should only begin after 24-72 hours. In patients with an elevated thromboembolic risk, transient postoperative LMWH administration can be recommended during this period.Interaction of DOACs with other drugs usually occurs during the absorption, transport and elimination of these drugs. Therefore, substance-specific restrictions and recommendations should be observed during these times. In everyday clinical practice, webbased, independent information portals on drug-interactions are very helpful in providing safe and rapid information about potential interactions when DOACs are used in combination with other drugs, especially during perioperative management.Non-adherence to medications is a worldwide problem that has dangerous and costly consequences. Present data suggest that persistence is the primary factor that supports adherence. Despite the adherence data presented in the DOACS approval studies (e.g., persistence in the treatment of acute venous thromboembolism has been reported to be between 94-99%), the first registries and meta-analyses provide sobering results regarding the incidence of persistence and the success rate of interventions designed to improve adherence with DOACs in cases of long-term usage.Nachdruck aus und zu zitieren als: Hämostaseologie 2017; 37: 267–275 https://doi.org/10.5482/HAMO-16-10-1657856

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