scholarly journals Appropriateness of Apixaban Dosing to Prevent Stroke in Patients with Atrial Fibrillation: A Pilot Study

2016 ◽  
Vol 69 (6) ◽  
Author(s):  
Stephanie Carlin ◽  
Jennifer Pickering ◽  
Sam Schulman

<p><strong>ABSTRACT</strong></p><p><strong>Background:</strong> The ARISTOTLE study investigated apixaban, at a dose of 5 mg PO bid, for the prevention of stroke in patients with atrial fibrillation; however, it has been noted anecdotally that many patients are receiving 2.5 mg PO bid, despite being eligible for the full dosage. A recent study examining the use of dabigatran and rivaroxaban found that many patients were receiving these medications inappropriately; however, a literature search conducted in April 2016 showed that apixaban had not been formally studied in this context.</p><p><strong>Objective:</strong> To evaluate the appropriateness of apixaban dosing for stroke prevention in patients with atrial fibrillation, relative to the dose used in the ARISTOTLE study and recommendations in the product monograph.</p><p><strong>Methods:</strong> This retrospective chart review was conducted at a 300-bed Canadian teaching hospital. All inpatients with atrial fibrillation for whom apixaban was prescribed for stroke prevention in March 2015 were considered for inclusion. The appropriateness of apixaban dosing was determined in relation to the ARISTOTLE methodology and product monograph recommendations (i.e., 5 mg PO bid, with a lower dosage of 2.5 mg PO bid if warranted on the basis of age, weight, or serum creatinine level).</p><p><strong>Results:</strong> A total of 47 patients were included, of whom 25 (53%) were receiving apixaban inconsistent with the ARISTOTLE study and the product monograph. Limitations of the current study included small sample size, single-centre setting, and retrospective design, which precluded determination of each prescriber’s rationale for dosage choice.</p><p><strong>Conclusions:</strong> Pharmacists and physicians should be vigilant in ensuring that patients with atrial fibrillation are receiving the appropriate dosage of apixaban to optimize the risk–benefit ratio of this therapy.</p><p><strong>RÉSUMÉ</strong></p><p><strong>Contexte :</strong> L’étude ARISTOTLE portait sur l’utilisation de l’apixaban pour la prévention des accidents vasculaires cérébraux (AVC) chez les patients souffrant de fibrillation auriculaire à raison d’une dose de 5 mg par voie orale deux fois par jour. Or, des observations empiriques montrent que bon nombre de patients reçoivent une dose de 2,5 mg par voie orale deux fois par jour, même s’ils se qualifient pour la pleine dose. Une étude récente portant sur l’utilisation du dabigatran et du rivaroxaban a relevé que bon nombre de patients recevaient ces médicaments de façon inappropriée. Or, une recherche bibliographique effectuée en avril 2016 a révélé que l’apixaban n’a pas été officiellement étudié dans ce contexte.</p><p><strong>Objectif :</strong> Évaluer la pertinence du schéma posologique d’apixaban pour la prévention des AVC chez les patients souffrant de fibrillation auriculaire comparativement à la dose utilisée dans l’étude ARISTOTLE et aux recommandations contenues dans la monographie de produit.</p><p><strong>Méthodes :</strong> La présente analyse rétrospective de dossiers médicaux a été menée dans un seul centre hospitalier universitaire canadien de 300 lits. Tous les patients hospitalisés atteints de fibrillation auriculaire pour qui l’on a prescrit de l’apixaban afin de prévenir l’AVC en mars 2015 ont été pris en considération. La pertinence du schéma posologique d’apixaban était établie par rapport à la méthodologie de l’étude ARISTOTLE et aux recommandations de la monographie de produit (c’est-à-dire une dose de 5 mg par voie orale deux fois par jour et une dose réduite de 2,5 mg par voie orale deux fois par jour si l’âge, le poids et le taux de créatinine sérique la justifiaient).</p><p><strong>Résultats :</strong> Au total, 47 patients ont été admis. L’administration de l’apixaban n’était pas conforme à l’étude ARISTOTLE et à la monographie de produit chez 25 (53 %) d’entre eux. Parmi les limites de la présente étude, on comptait la petite taille de l’échantillon, son déroulement dans un seul centre et l’utilisation d’un plan d’étude rétrospectif qui empêchait de<br />comprendre les raisons motivant le choix de posologie de chaque prescripteur.</p><p><strong>Conclusions :</strong> Les pharmaciens et les médecins doivent être vigilants et s’assurer que les patients atteints de fibrillation auriculaire reçoivent la posologie appropriée d’apixaban permettant d’optimiser le rapport bénéfice-risque de ce traitement.</p>

2021 ◽  
Vol 8 ◽  
pp. 205435812110460
Author(s):  
Kimberly Defoe ◽  
Jenny Wichart ◽  
Kelvin Leung

Background: Patients treated with hemodialysis and prescribed warfarin typically have lower time in therapeutic range (TTR) compared to the general population. This may result in less benefit or increased risk of over anticoagulation in these patients. Objective: To assess effectiveness of use of an electronic nomogram for the management of warfarin therapy in patients treated with hemodialysis. Design: Retrospective chart review. Setting: Adult patients treated with hemodialysis. Patients: Patients on hemodialysis receiving warfarin for the management of atrial fibrillation (AF) with therapy managed by nursing led electronic nomogram. Measurements: Time in therapeutic range (as fraction and Rosendaal). Methods: Retrospective chart review over 1 year of international normalized ratio (INR) results was completed, and TTR was calculated. Comparison of patients with TTR greater than 60% to those less than 60% was completed using chi-square analysis. Results: Of 43 patients with warfarin therapy managed by the nomogram, the mean TTR was 55.2% (calculated by fraction method) or 61.2% (calculated by Rosendaal method). More than half of the patients (63.5%) had moderate to good control, defined as TTR greater than 60%. Female sex, liver disease, or history of substance use and more medication holds were associated with lower TTR. Limitations: Small sample size and retrospective nature of review. Conclusions: The results of this review supports the use of an electronic, nursing-led nomogram for the maintenance management of warfarin therapy in stable patients treated with hemodialysis, as use results in TTR greater than 60% for more than half of patients.


2019 ◽  
Vol 23 (3) ◽  
pp. 270-276 ◽  
Author(s):  
Meghan L. McPhie ◽  
Alanna C. Bridgman ◽  
Mark G. Kirchhof

Background: Although a variety of medical and surgical interventions exist for the treatment of hidradenitis suppurativa (HS), it remains a challenging disease to manage because of its variable presentation and unpredictable clinical course. Apart from the combination of clindamycin and rifampin, the success of other combination therapies is largely unknown. Objectives: The goal of our study was to examine the clinical utility of various combination therapies for the treatment of HS. Methods: We conducted a qualitative retrospective chart review of 31 patients with dermatologist-diagnosed HS who were seen at an academic teaching hospital between 2014 and 2018. Demographic data, disease location, disease severity, and treatment protocol were retrieved for analysis. Hurley stage was used to classify disease severity on initial presentation, and the International Hidradenitis Suppurativa Severity Score System (IHS4) was used to track changes across visits. Results: Of the 31 patients (Mage = 37.7 years; 67.7% female) included in the study, 6 (19.4%), 11 (35.5%), and 14 (45.2%) patients were classified as Hurley stages I, II, and III, respectively. Although no statistical results are provided because of the small sample size, we have identified several drug combinations that show promising clinical response for patients with HS based on their IHS4 score, such as isotretinoin/spironolactone for mild disease, isotretinoin or doxycycline with adalimumab for moderate disease, and cyclosporine/adalimumab for severe disease. Conclusions: This preliminary work demonstrates that HS treatment with combination therapy appears to be a promising method of disease management.


2019 ◽  
Vol 72 (6) ◽  
Author(s):  
Priscilla Shum ◽  
Gordon Klammer ◽  
Dale Toews ◽  
Arden Barry

ABSTRACTBackground: Direct oral anticoagulants (DOACs) are indicated for prevention of stroke and embolism in patients with nonvalvular atrial fibrillation (NVAF). These agents have been shown to be non-inferior to warfarin in terms of efficacy and safety. However, their uptake in practice has been variable, and prescribed dosages may be inconsistent with manufacturer recommendations.Objectives: To evaluate patterns of oral anticoagulant use in patients with NVAF, including determination of patient characteristics associated with the prescribing of warfarin or DOACs and whether prescribed dosages of DOACs were concordant with manufacturer recommendations.Methods: This retrospective chart review was conducted from April to September 2017 at Abbotsford Regional Hospital, Abbotsford, British Columbia. Patients at least 18 years of age with NVAF and CHADS-65 score of 1 or higher were included. Patients with contraindications to oral anticoagulants, those with reversible atrial fibrillation, and those undergoing renal dialysis were excluded. The dosage of DOACs was categorized as too low, too high, or correct in relation to manufacturer recommendations for the Canadian product. Results: A total of 120 patients were included. At discharge, 83 (69%) of the patients had a prescription for DOAC, 25 (21%) had a prescription for warfarin, and 12 (10%) had no prescription for an oral anticoagulant. There were no statistically significant differences between the warfarin and DOAC groups with respect to patient characteristics. Among the 56 patients for whom a full DOAC dose was indicated, 7 (13%) received a dose that was too low. Among the 23 patients for whom a full DOAC dose was not indicated, 4 (17%) received a dose that was too high. Conclusions: At the study hospital, most patients with NVAF and CHADS-65 score of at least 1 had a discharge prescription for DOAC. Patient characteristics appeared to be similar between the warfarin and DOAC groups. For a notable proportion of patients who received a DOAC, the dosage was incorrect. Appropriate prescribing of oral anticoagulants could be further improved by education for prescribers and involvement of hospital pharmacists.RÉSUMÉContexte : Les anticoagulants oraux directs (AOD) sont indiqués pour prévenir les AVC et les embolies parmi les patients atteints de fibrillation auriculaire non valvulaire (FANV). Il a été démontré que l’efficacité et l’innocuité de ces agents n’étaient pas inférieures à la warfarine. Cependant, leur adoption dans la pratique est inégale, et les doses prescrites peuvent être contraires aux recommandations des fabricants.Objectifs : Évaluation des habitudes d’utilisation des anticoagulants oraux pour les patients atteints de FANV, y compris la définition des caractéristiques des patients associées à la prescription de la warfarine ou des AOD, ainsi que de la conformité des doses prescrites de ces derniers aux recommandations des fabricants.Méthodes : Cet examen rétrospectif des dossiers a été mené d’avril à septembre 2017 à l’Hôpital régional d’Abbotsford à Abbotsford, en Colombie-Britannique. Des patients âgés d’au moins 18 ans, atteints de FANV et ayant un score CHADS-65 d’au moins 1, ont été inclus dans l’étude. Les patients présentant une contre-indication aux anticoagulants oraux, ceux atteints de fibrillation auriculaire réversible et ceux soumis à une dialyse rénale en ont été exclus. La dose d’AOD destinés au marché canadien a été catégorisée comme trop faible, trop élevée ou correcte par rapport aux recommandations du fabricant.Résultats : Cent-vingt patients au total ont participé à l’étude. Au moment du congé, 83 (69 %) d’entre eux avaient une prescription d’AOD, 25 (21 %) avaient une prescription de warfarine et 12 (10 %) n’avaient pas de prescription d’anticoagulant oral. En ce qui concerne les caractéristiques des patients, il n’y avait aucune différence statistique notable entre les groupes ayant reçu une prescription de warfarine et ceux ayant reçu une prescription d’AOD. Des 56 patients qui avaient reçu une indication de dose complète d’AOD, sept (13 %) ont reçu une dose trop faible. Des 23 patients qui n’avaient pas reçu d’indication de dose complète d’AOD, quatre (17 %) ont reçu une dose trop élevée.Conclusions : À l’hôpital où s’est déroulée l’étude, la plupart des patients atteints de FANV et ceux ayant un score CHADS-65 d’au moins 1 recevaient une prescription d’AOD au moment du congé. Les caractéris-tiques des patients semblaient similaires entre les groupes ayant reçu une prescription de warfarine et ceux ayant reçu une prescription d’AOD. La dose d’AOD reçue par une proportion notable de patients était incorrecte. La prescription appropriée d’anticoagulants oraux pourrait encore être améliorée si on sensibilisait les prescripteurs avec la collaboration des pharmaciens d’hôpitaux.   


Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Yamin Shwe ◽  
Chunyan Cai ◽  
Anjail Z Sharrief ◽  
Amrou Sarrraj

Background: Acute ischemic stroke (AIS) due to proximal carotid artery occlusion (pCAO) can be associated with significant neurological deficits and poor outcome without timely intervention and successful reperfusion. Intravenous thrombolytics (IT) have low recanalization rates in pCAO and these patients were excluded from recent randomized controlled trials which showed superiority of endovascular therapy (EVT) over IT. Purpose: The purpose of this study is to investigate clinical outcomes in AIS due to pCAO treated with medical vs. endovascular treatment. Methods: We conducted a retrospective chart review of patients who underwent IT or EVT±IT for all types of pCAO from January 2008 to June 2015. Our primary outcome was the functional outcome at discharge measured by modified Rankin score (mRS) 0-3. The secondary outcomes were hemorrhagic transformation (HT), neurological worsening (NW), symptomatic hemorrhage (sICH) and death. Logistic regression analysis was used to compare outcomes between the two groups. Results: A total of 133 patients were included in the study. Baseline characteristics are depicted in table 1. There were no significant differences between the two groups. IV tPA was given in 56% IT vs. 72% EVT (p=0.14). While there was a shift towards better outcomes in the mRS distribution in EVT group (22% vs. 16%) as shown in Figure 1, the treatment effect did not reach significance (OR 1.71, 95% CI (0.55, 5.34), p=0.35). There was also no difference in HT (26% vs. 14%, p=0.14), or NW (26% vs. 21%, p=0.6). However, sICH was higher in EVT (3.7% vs. 0%, p=0.2). Conclusion: Our study did not show difference in discharge functional outcomes between EVT and IT in AIS with pCAO. Our results are limited by small sample size and retrospective nature. Future prospective studies randomizing patients to medical vs. endovascular treatments are warranted to guide management.


2012 ◽  
Vol 9 (1) ◽  
pp. 13-18 ◽  
Author(s):  
AK Kumar Hemanth ◽  
V Sudha ◽  
G Ramachandran

Introduction: Treatment of tuberculosis (TB) requires a combination of drugs. Isoniazid (INH) and pyrazinamide (PZA) are key components of the fi rst-line regimen used in the treatment of TB and monitoring these drug levels in plasma would help in better patient care. The objective of the study is to develop and validate a simple and rapid high performance liquid chromatographic method for simultaneous determination of INH and PZA in human plasma. Methodology: The method involved deproteinisation of plasma with para hydroxy benzaldehyde and trifl uoroacetic acid and analysis using a reversed-phase C8 column and UV detection at 267nm. The fl ow rate was set at 1.5 ml/min at ambient temperature. The accuracy, linearity, precision, specifi city, stability and recovery of the method were evaluated. The method was applied to estimate plasma INH and PZA collected from six children with TB. Results: Well resolved peaks of PZA and INH at retention times of 3.2 and 6.1 minutes respectively were obtained. The assay was linear from 0.25 - 10.0 ìg/ml for INH and 1.25 – 50.0 ìg/ml for PZA. The within-day and between-day relative standard deviation for standards were below 10%. The average recoveries of INH and PZA from plasma were 104 and 102% respectively. Conclusions: A rapid and accurate method for simultaneous determination of INH and PZA in plasma was validated. The assay spans the concentration range of clinical interest. The easy sample preparation and small sample size makes this assay highly suitable for pharmacokinetic studies of INH and PZA in TB patients. SAARC Journal of Tuberculosis, Lung Diseases & HIV/AIDS 2012; IX (1) 13-18 DOI: http://dx.doi.org/10.3126/saarctb.v9i1.6960


Author(s):  
Zhengyi Zhu ◽  
Qi Yu ◽  
Ganggang Qi ◽  
Jufei Yang ◽  
Yinghua Ni ◽  
...  

Tetracycline may cause tooth discoloration when used in young children during tooth development. Whether tigecycline, a tetracycline derivative, has either a similar adverse event or not remains unclear. We assessed the discoloration of the permanent teeth of patients <8 years old after tigecycline exposure. These patients were identified through a retrospective chart review in a Chinese children’s hospital. Those who had at least one erupted permanent tooth after tigecycline exposure were interviewed, examined, and photographed by an experienced pediatric dentist and independently assessed by another senior dentist to detect tetracycline-like tooth discoloration. We identified 101 patients who were exposed to tigecycline, 12 of whom were included. The mean dose of tigecycline was 2.3 mg/kg/day (standard deviation, 0.6), and the median duration was 12.5 days (interquartile range [IQR], 8.0 to 19.3). The median age of exposure was 5.2 years (IQR, 4.5 to 7.4), and the median age of dental examination was 9.1 years (IQR, 9.0 to 10.3). Two patients (16.7%) developed yellow discoloration: a girl having yellow discoloration with white-to-yellow opacities in the upper lateral incisors and lower incisors, and a boy with a suspicious buccal yellow discoloration and enamel dysplasia in the second molars. The incidence and extent of tigecycline-associated dental adverse events remain unclear due to the small sample size and inadequate follow-up period.


2021 ◽  
Vol 17 (3) ◽  
pp. 423-428
Author(s):  
A. A. Sokolova ◽  
A. I. Skripka ◽  
I. I. Ivanov ◽  
V. V. Kogay ◽  
A. I. Listratov ◽  
...  

Aim. To evaluate the relationship between albumin to creatinine ratio (ACR) in a single and 24-hours urine spots and chronic kidney disease (CKD) progression pace in patients with atrial fibrillation, CKD and diabetes mellitus.Material and methods. 60 patients with atrial fibrillation (AF) and CKD were enrolled, study duration was 15 months. The patients were divided into two groups depending on the presence of DM. Total number of ACR tests was 170, dynamics of CKD progression was estimated with CKD-EPI formula for first visit and 15th month’s follow-up.Results. The median score of CHA2DS2VASс scale was 4 [3;5]. The risk of hemorrhagic complications in both groups was low (median score 1 [1;1]. There is a strong statistically significant correlation between ACR in a single and 24-hours urine spots (p<0.001). No significant changes in kidney function within 15 months were found (GFR 53 [46;59] ml/min/1.73 m2 vs 50.5 [45.63] ml/min/1.73 m2 for patients with diabetes mellitus [DM] [p=0.94] and GFR 52.5 [46.58] ml/min/1.73 m2 vs 50 [44.58] ml/min/1.73 m2 for patients without DM [p=0.711]). When comparing the renal function of patients with and without DM after 15 months statistically significant differences were also not found (p = 0.510).Conclusion. In respect that assessment of single sample ACR is much more practical and reliable, this method might replace traditional 24-hours urine assessment in future. However, due to the small sample size and the presence of wide discrepancies in individual cases, which can be associated with preanalytical errors in urine collection, large randomized clinical trials are needed to confirm the obtained data.


2020 ◽  
Vol 2020 ◽  
pp. 1-3
Author(s):  
Abdullah Alajaji ◽  
Jagannath Chandra Shekaran ◽  
Omar Mohammed Aldhabbah ◽  
Hajar Abdullah Alhindi ◽  
Nouf Salem Almazyad ◽  
...  

Background. Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) are life-threatening conditions caused by drug reactions. There are multiple causative drugs and different risk factors associated with SJS/TEN. Objectives. To study the epidemiology of SJS/TEN and associated mortality rate in Qassim region, Saudi Arabia. Methodology. A retrospective chart review of all patients with the diagnosis of SJS/TEN who were admitted to King Fahad Specialist Hospital (KFSH) in Qassim region, Saudi Arabia, for the period between Jan 2014 to Jan 2019. The Careware information health system is used at KFSH, and patients were identified searching the diagnosis SJS/TEN. Results. Total of 10 patients with diagnosis of SJS/TEN were admitted to KFSH for the period from Jan 2014 to Jan 2019. Antibiotics were the culprit in 5 out of 10 patients. 9 out of 10 patients survived with good outcome. One patient with the diagnosis of TEN died, given extensive skin involvement complicated by sepsis. Conclusion. Despite the limitation of this study given small sample size, this is the first study of its kind that discusses the epidemiology of SJS/TEN in Saudi Arabia. We found the estimated incidence rate of SJS/TEN in Qassim region to be 7.6 cases per million person-years. Antibiotics and antiepileptics were the culprits in 8 out of 10 patients.


2018 ◽  
Vol 33 (10) ◽  
pp. 1729-1736 ◽  
Author(s):  
Luyuan Zhang ◽  
Xiaolin Hou ◽  
Yunchong Fu ◽  
Miao Fang ◽  
Ning Chen

A novel method was developed for the determination of 129I in aerosol samples with the apparent advantages of high sensitivity and small sample size requirement.


1974 ◽  
Vol 57 (1) ◽  
pp. 130-133 ◽  
Author(s):  
Henry P Fleming ◽  
Roger L Thompson ◽  
JOHN L Etchells

Abstract A simple, accurate method for determining carbon dioxide in fermenting cucumber brines is described. The method involves distillation of carbon dioxide from the acidified brine into standardized sodium hydroxide inside a closed jar. The sample is injected by a syringe and needle through a rubber serum stopper placed in the jar cap, into an acid solution. A small vial of sodium hydroxide placed inside the jar traps the carbon dioxide as it distills from the acidified solution. After being held in the jar 24 hr at 37°C, the vial is removed; the remaining base is titrated to the phenolphthalein end point with standardized hydrochloric acid. Advantages of the method include a limited working time, minimized loss of carbon dioxide during analysis, and a relatively small sample size.


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