scholarly journals Intracranial Hemorrhage following Lumbar Puncture in a Patient on Apixaban

2019 ◽  
Vol 11 (3) ◽  
pp. 277-283 ◽  
Author(s):  
Priyanka Vijapura ◽  
Michael J. Maniaci
Keyword(s):  
Atrial Fibrillation ◽  
Case Report ◽  
Lumbar Puncture ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Evidence Based ◽  
Nonvalvular Atrial Fibrillation ◽  
Practice Recommendations ◽  
Diagnostic Lumbar Puncture ◽  
Evidence Based Guidelines

Currently, clinical practice recommendations regarding patients in need of emergent lumbar puncture who are taking direct oral anticoagulants (DOACs) are based upon expert opinion, as evidence-based guidelines are unavailable. We present the case of an 80-year-old Caucasian lady who underwent diagnostic lumbar puncture for presumed meningitis while on therapeutic apixaban for nonvalvular atrial fibrillation. She was subsequently found to have bilateral subdural hematomas. This case report reviews both the current criteria for computerized tomography brain imaging prior to lumbar puncture as well as the bleeding risks of lumbar puncture while on a DOAC.

scholarly journals Use of Guidelines for Reducing Stroke Risk in Patients With Nonvalvular Atrial Fibrillation: A Review From a Latin American Perspective

2017 ◽  
Vol 24 (1) ◽  
pp. 22-32 ◽  
Author(s):  
Carlos Cantú-Brito ◽  
Gisele Sampaio Silva ◽  
Sebastián F. Ameriso
Keyword(s):  
Atrial Fibrillation ◽  
Latin America ◽  
Latin American ◽  
Stroke Risk ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Evidence Based ◽  
Scoring Methods ◽  
Essential Components ◽  
Evidence Based Guidelines

Atrial fibrillation (AF) is a prominent risk factor for stroke and a leading cause of death and disability throughout Latin America. Contemporary evidence-based guidelines for the management of AF and stroke incorporate the use of practical and relatively simple scoring methods to estimate both stroke and bleeding risk, in order to assist in matching patients with appropriate interventions. This review examines consistencies and differences among guidelines for reducing stroke risk in patients with AF, assessing the role of user-friendly scoring methods to determine appropriate patients for anticoagulation and other treatment options. Current options include warfarin and direct oral anticoagulants such as dabigatran, rivaroxaban, apixaban, and edoxaban. These agents have been found to be superior or noninferior to standard vitamin K antagonist anticoagulation in large randomized trials. Potential benefits of these agents mainly include lower ischemic stroke rates, reduced intracranial bleeding, no need for regular monitoring, and fewer drug–drug and drug–food interactions. Expert opinions regarding clinical situations for which data are presently lacking, such as emergency bleeding and stroke in anticoagulated patients, are also provided. Enhanced attention and adherence to evidence-based guidelines are essential components for a strategy to reduce stroke morbidity and mortality across Latin America.

scholarly journals Safety and timing of resuming dabigatran after major gastrointestinal bleeding reversed by idarucizumab

2018 ◽  
Vol 6 ◽  
pp. 2050313X1775333 ◽  
Author(s):  
Gian Galeazzo Riario Sforza ◽  
Francesco Gentile ◽  
Fabio Stock ◽  
Francesco Caggiano ◽  
Enrica Chiocca ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Case Report ◽  
Major Bleeding ◽  
Acute Treatment ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Oral Vitamin ◽  
Bleeding Events ◽  
Massive Rectal Bleeding

The recent introduction of direct oral anticoagulants, including rivaroxaban, dabigatran, apixaban, and edoxaban, for the acute treatment and secondary prevention of venous thromboembolism and in atrial fibrillation has been shown to provide greater clinical benefit than oral vitamin K antagonists. However, direct oral anticoagulants are associated with adverse events, the most common being major bleeding; such events require the reversal of the anticoagulant effects by specific agents. In this case report, we describe an 87-year-old female with atrial fibrillation treated with dabigatran who had massive rectal bleeding. Idarucizumab 5 g (2 × 2.5 g/50 mL) was successfully used to reverse dabigatran effect; subsequent to this, treatment with dabigatran was resumed, and there were no further bleeding events. This suggests that dabigatran can be safely restarted after major bleeding, but this outcome needs to be confirmed in studies involving larger groups of patients.

scholarly journals Switching to Another Oral Anticoagulant and Drug Discontinuation Among Elderly Patients With Nonvalvular Atrial Fibrillation Treated With Different Direct Oral Anticoagulants

2019 ◽  
Vol 25 ◽  
pp. 107602961987024 ◽  
Author(s):  
Christine L. Baker ◽  
Amol D. Dhamane ◽  
Jigar Rajpura ◽  
Jack Mardekian ◽  
Oluwaseyi Dina ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Elderly Patients ◽  
Oral Anticoagulant ◽  
Cox Regression ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Drug Discontinuation ◽  
Research Database ◽  
Nonvalvular Atrial Fibrillation ◽  
Study Population

We compared the risks of switching to another oral anticoagulant (OAC) and discontinuation of direct oral anticoagulants (DOACs) among elderly patients with nonvalvular atrial fibrillation (NVAF) who were prescribed rivaroxaban or dabigatran versus apixaban. Patients (≥65 years of age) with NVAF prescribed DOACs (January 1, 2013 to September 30, 2017) were identified from the Humana research database and grouped into DOAC cohorts. Cox regression analyses were used to evaluate whether the risk for switching to another OAC or discontinuing index DOACs differed among cohorts. Of the study population (N = 38 250), 55.9% were prescribed apixaban (mean age: 78.6 years; 49.8% female), 37.3% rivaroxaban (mean age: 77.4 years; 46.7% female), and 6.8% dabigatran (mean age: 77.0 years; 44.0% female). Compared to patients prescribed apixaban, patients prescribed rivaroxaban (hazard ratio [HR]: 2.08; 95% confidence interval [CI], 1.92-2.25; P < .001) or dabigatran (HR: 3.74; 95% CI, 3.35-4.18, P < .001) had a significantly higher risk of switching to another OAC during the follow-up; compared to patients prescribed apixaban, the risks of discontinuation were also higher for patients treated with rivaroxaban (HR: 1.10; 95% CI, 1.07-1.13, P < .001) or dabigatran (HR: 1.29; 95% CI, 1.23-1.35, P < .001).

scholarly journals Anticoagulant Utilization and Direct Oral Anticoagulant Prescribing in Patients with Nonvalvular Atrial Fibrillation

2019 ◽  
Vol 72 (6) ◽  
Author(s):  
Priscilla Shum ◽  
Gordon Klammer ◽  
Dale Toews ◽  
Arden Barry
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulant ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Renal Dialysis ◽  
Retrospective Chart Review ◽  
Patient Characteristics ◽  
Nonvalvular Atrial Fibrillation ◽  
Patients Âgés ◽  
Fibrillation Auriculaire

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.   

scholarly journals Direct Oral Anticoagulants in Atrial Fibrillation Patients With Concomitant Hyperthyroidism

2020 ◽  
Vol 105 (9) ◽  
pp. 2893-2904
Author(s):  
Yi-Hsin Chan ◽  
Lung-Sheng Wu ◽  
Lai-Chu See ◽  
Jia-Rou Liu ◽  
Shang-Hung Chang ◽  
...  
Keyword(s):  
Atrial Fibrillation ◽  
Major Bleeding ◽  
Lower Risk ◽  
Randomized Clinical Trials ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Study Groups ◽  
Research Database ◽  
Nonvalvular Atrial Fibrillation ◽  
Asian Patients

Abstract Objective Patients with hyperthyroidism were excluded from the randomized clinical trials of direct oral anticoagulants (DOACs) for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF). Methods We performed a nationwide retrospective cohort study using data from the Taiwan National Health Insurance Research Database. We enrolled 3213 and 1181 NVAF patients with hyperthyroidism who were taking DOACs and warfarin, respectively, from June 1, 2012 to December 31, 2017. We also enrolled 53 591 and 16 564 NVAF patients without hyperthyroidism, taking DOACs and warfarin, respectively. We used propensity score stabilized weights (PSSWs) to balance covariates across the study groups. We also used 1:4 matching on both taking DOACs, with (n = 3213) and without hyperthyroidism (n = 12 852); and both taking warfarin, with (n = 1181) and without hyperthyroidism (n = 4724). Results After PSSW, DOAC had a comparable risk of ischemic stroke/systemic embolism (IS/SE) and a lower risk of major bleeding (hazard ratio [HR] 0.65; 95% confidential interval [CI], 0.44–0.96; P = 0.0295) than warfarin among patients with hyperthyroidism. There were comparable risks of IS/SE and major bleeding between those patients with and without hyperthyroidism. However, among patients taking warfarin, those with hyperthyroidism had a lower risk of IS/SE than those without hyperthyroidism (HR 0.61; 95% CI, 0.43–0.86; P = 0.0050). Conclusion Among NVAF Asian patients with concomitant hyperthyroidism, DOACs may be an effective and safer alternative to warfarin. Thromboprophylaxis with DOACs may be considered for such patients, and it is important to validate this finding in further prospective study.

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