Evaluation of Potential Drug–Drug Interactions With Direct Oral Anticoagulants in a Large Urban Hospital

2018 ◽  
Vol 33 (2) ◽  
pp. 136-141 ◽  
Author(s):  
Yoonsun Mo ◽  
Ayse Karakas-Torgut ◽  
Antony Q. Pham
Keyword(s):  
Drug Interactions ◽  
Medical Center ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Hospital Setting ◽  
Retrospective Chart Review ◽  
University Hospital ◽  
Potential Drug ◽  
Urban Hospital ◽  
Combined Use

Objective: The aim of this study is to assess patterns of potential drug–drug interactions (DDIs) with direct oral anticoagulants (DOACs) in an inpatient hospital setting. Methods: A retrospective chart review was conducted at the Brookdale University Hospital and Medical Center (BUHMC) from January 2014 to November 2016. All adult patients admitted to the BUHMC who were treated with a DOAC for at least 3 days were screened. Among them, those who received selected interacting drugs at any time during the course of DOAC therapy were included in this study. Results: This study included 165 patients with an average of 73 years (standard deviation [SD] = 12.3) and 233 cases. The most commonly used concomitant drug with a DOAC was aspirin (58%), followed by amiodarone (16%) and P2Y12 inhibitors (11%). The combined use of dual antiplatelet therapy and a DOAC was identified in 18 (6%) cases. Approximately one-third of the cases encountered were classified as the “avoidance” category. Conclusions: Despite computerized DDI alerts, potentially significant DDIs with DOACs still occur. While the present study provides insight into the current patterns of DDIs, further studies are needed to evaluate clinical outcomes of the potential DDIs with DOACs in practice.

scholarly journals Reasons for Switching from Warfarin to a Direct Oral Anticoagulant: A Retrospective Study

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 5060-5060
Author(s):  
Siavash Piran ◽  
Marlene Robinson ◽  
Erjona Kruja ◽  
Sam Schulman
Keyword(s):  
Atrial Fibrillation ◽  
Cardiac Surgery ◽  
Drug Interactions ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Retrospective Chart Review ◽  
Mechanical Valve ◽  
Adherence Rate ◽  
Valve Prosthesis ◽  
Significant Difference

Abstract Background: Direct oral anticoagulants (DOACs) are slowly replacing warfarin for the prevention of stroke in atrial fibrillation and treatment and secondary prevention of venous thromboembolism. Patients with poor time in therapeutic range (TTR) are often switched to a DOAC. Poor TTR can be due to drug interactions but if the reason is poor compliance, outcomes could be worse using a DOAC without monitoring. Methods: To understand the compliance patterns we performed a retrospective chart review in patients from the anticoagulation clinic at Hamilton General Hospital that were switched from warfarin to a DOAC from April 2013 to April 2018. Patients who were taking warfarin for ≥ 2 months for any indication, except for mechanical valve prosthesis, and who were switched to a DOAC were included. We excluded patients who had a DOAC-to-DOAC switch, patients who had no reported TTR available, and those who were temporarily on warfarin after cardiac surgery. The documented reasons for a switch from warfarin to a DOAC were compared between patients with TTR ≤ 60% and >60%. Non-adherence to international normalized ratio (INR) monitoring was considered if >20% of tests were not done or delayed for more than 2 days. Results: A total of 643 eligible patients were initially screened and 288 patients were excluded: 179 had no available TTR, 93 were temporarily on warfarin after cardiac surgery, 11 were not actually switched from warfarin to a DOAC, and 5 had a DOAC-to-DOAC switch. The remaining 355 patients were included in the analysis: 223 had a TTR ≤ 60% and 132 patients had a TTR >60%. There were no differences in the median age or gender distribution. The most common indication for anticoagulation was atrial fibrillation in both groups. The median TTR was 43% in the TTR ≤ 60% group and 71% in the TTR >60% group. The median duration on anticoagulation with warfarin was significantly longer for the TTR >60% group compared with the TTR ≤ 60% group (42 months versus 19 months; P <0.001). Apixaban was the most common DOAC of choice for the switch in both groups. The most common documented reasons for a switch in the group with a TTR >60% were: switch by another physician for unknown reason (n=36), bleeding (n=30), and patient preference (n=20). The most common reasons for a switch in those with a TTR ≤ 60% were: unstable INR readings (n=42), drug interactions (n=33), and bleeding (n=30). There was no significant difference in the rate of non-adherence with the scheduled INR monitoring (42% in the group with a TTR >60% versus 49% in those with a TTR ≤ 60%). Conclusion: We found that about half of the patients on chronic anticoagulation with warfarin and switched to a DOAC were non-adherent with the scheduled INR monitoring. This, in combination with low TTR, should alert the physician of possible non-compliance with taking DOACs. Further prospective studies are needed to examine the DOAC adherence rate and clinical outcomes in this specific population. Disclosures Schulman: Boehringer-Ingelheim: Honoraria, Research Funding; Daiichi-Sankyo: Honoraria; Sanofi: Honoraria; Bayer: Honoraria.

Evaluation of Direct Oral Anticoagulant Dosing and Monitoring in Two Geriatric Outpatient Clinics

2019 ◽  
Vol 34 (3) ◽  
pp. 192-205
Author(s):  
Michelle A. Howerton ◽  
Erin M. Suhrie ◽  
Amelia S. Gennari ◽  
Nancy Jones ◽  
Christine M. Ruby
Keyword(s):  
Medical Center ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Retrospective Chart Review ◽  
Office Visit ◽  
Outpatient Setting ◽  
Primary Objective ◽  
Improvement Project ◽  
Care Institute ◽  
Geriatric Center

OBJECTIVE: This study was conducted to evaluate direct oral anticoagulants (DOACs) prescribed to elderly patients in an outpatient setting, specifically evaluating if Food and Drug Administration (FDA) -approved dosing recommendations are followed.<br/> DESIGN: This study was a retrospective quality improvement project.<br/> SETTING: This study was conducted at geriatric hospital-based primary care clinics at the University of Pittsburgh Medical Center (UPMC), UPMC Senior Care Institute and UPMC Benedum Geriatric Center.<br/> PATIENTS: Subjects included were 65 years of age or older; had an office visit at UPMC Senior Care Institute or UPMC Benedum Geriatric Center from September 1, 2015, to August 31, 2017; and had a DOAC on their home medications.<br/> INTERVENTIONS: Data were obtained through retrospective chart review.<br/> MAIN OUTCOME MEASURE: The primary objective of the study was to evaluate the appropriateness of dosing of DOACs based on FDA-labeled recommendations.<br/> RESULTS: Of 232 patients included in analysis, 42.7% were found to have dosing inconsistent with FDAlabeled recommendations (47.3% apixaban, 35.8% rivaroxaban, and 31.6% dabigatran). No patients were prescribed edoxaban. The majority (72.7%) were dosed lower than FDA-recommended doses. Of all patients, the most frequent parameter (54.5%) for inappropriate dosing was patients meeting only 1 of 3 dose-reduction criteria when prescribed reduced-dose apixaban. Geriatrician and nongeriatrician prescribers had similar rates of prescribing DOACs with doses inconsistent with FDA-labeled recommendations (44.0% vs. 40.8%; P = 0.62).<br/> CONCLUSION: Results suggest that DOACs used in outpatient geriatric patients are frequently dosed inconsistent with FDA-approved dosing recommendations. Further research is needed regarding clinical outcomes in older patients receiving DOACs and in those with dose adjustments inconsistent with FDA-labeled recommendations.<br/>

scholarly journals Drug interactions of oral anticoagulants

2020 ◽  
Vol 10 (1) ◽  
pp. 70
Author(s):  
Gayathri Anil ◽  
Pradhyumna Muraleedharan ◽  
Atiya Rehman Faruqui
Keyword(s):  
Drug Interactions ◽  
Vitamin K Antagonists ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Median Number ◽  
Potential Drug ◽  
Concomitant Medications ◽  
Potential Interactions ◽  
Major Drug

Background: Oral anticoagulants (OACs) are the drugs of choice where long-term anticoagulation is needed due to convenience of dosing. But their use has potential for several drug interactions. Monitoring for potential interactions with timely management will decrease the risk of complications of anticoagulation.Methods: We aimed to assess the presence of potential drug-drug interactions in patients on oral anticoagulants for various indications. Prescriptions of a cohort of patients on oral anticoagulants were analyzed. Potential drug interactions were identified using free software available at www.drugs.com and classified into major, moderate and minor types.Results: Of the 135 patients in the study, 83 were males and mean age was 52.9±17.3 years. Most commonly used OACs were vitamin K antagonists (VKAs) (80.0%) followed by direct oral anticoagulants (DOACs) (20.0%). Median number of concomitant medications per patient was 4 (IQR 3-6). A total of 307 potential interactions were identified in 121 patients with a median of 2 interactions per patient. Of the 56 patients who had potential for major drug interactions, 45 (41.6%) were on VKAs and 11 (40.7%) on DOACs had potential to develop major interactions. Using logistic regression model, significant predictors of major drug interactions were age>60 years (OR 2.50; 95% CI 1.05-5.95; p=0.04) and presence of venous thromboembolism VTE (OR 0.09; 95% CI 0.02-0.55; p=0.01).Conclusions: This hospital-based study showed potential drug interactions with OACs. Age more than 60 years and presence of VTE were significant predictors of major interactions. Awareness of potential interactions and monitoring doses of OACs help to prevent complications of therapy.

Potential Drug Interactions Between Cannabinoids and Its Derivatives and Oral Anticoagulants

2021 ◽  
pp. 001857872098543
Author(s):  
McKenzie Paduch ◽  
Angela R. Thomason
Keyword(s):  
Drug Interactions ◽  
English Language ◽  
Case Reports ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Thromboembolic Events ◽  
Potential Drug ◽  
Risk Of Bleeding ◽  
Increased Risk ◽  
Potential Risks

The increase use of cannabidiol containing products poses potential risks with high-alert medications such as oral anticoagulants. To review the use of cannabidiol and its’ derivatives with oral anticoagulants, searches (2005-May 2020) were performed by PubMed, Google Scholar, and ClinicalTrials.gov. Articles were limited to English-language only. The results yielded 4 case reports evaluating the potential drug interactions between cannabinoids and its’ derivatives and oral anticoagulants. These case reports show the potential for drug interactions when using warfarin and cannabidiol containing products. At time of publication, there were no published articles on drug interactions between cannabidiol and the direct oral anticoagulants. Further research is needed to conclude drug interactions are associated with an increased risk of bleeding or thromboembolic events in these patients.

scholarly journals Potential drug–drug interactions with direct oral anticoagulants in elderly hospitalized patients

2017 ◽  
Vol 8 (10) ◽  
pp. 319-328 ◽  
Author(s):  
Heather L. Forbes ◽  
Thomas M. Polasek
Keyword(s):  
Drug Interactions ◽  
Product Information ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Plasma Concentrations ◽  
Hospitalized Patients ◽  
Local Health ◽  
Potential Drug ◽  
Potential Ddis ◽  
Elderly Hospitalized Patients

Background: To determine the prevalence and nature of potential drug–drug interactions (DDIs) with direct oral anticoagulants (DOACs) in elderly hospitalized patients. Methods: This was a retrospective observational study. Inclusion criteria were: aged over 65 years; taking apixaban, rivaroxaban or dabigatran; and admitted to the Repatriation General Hospital between April 2014 and July 2015. A list of clinically relevant ‘perpetrator’ drugs was compiled from product information, the Australian Medicines Handbook, the Australian National Prescribing Service resources, and local health network guidelines. The prevalence and nature of potential DDIs with DOACs was determined by comparing inpatient drug charts with the list of perpetrator drugs. Results: There were 122 patients in the study with a mean age of 82 years. Most patients had nonvalvular atrial fibrillation and were taking DOACs to prevent thrombotic stroke (83%). Overall, 45 patients (37%) had a total of 54 potential DDIs. Thirty-five patients had potential pharmacodynamic DDIs with antidepressants, nonsteroidal anti-inflammatory drugs and antiplatelets (35/122, 29%). Nineteen patients had potential pharmacokinetic DDIs (19/122, 16%). Of these, 68% (13/19) were taking drugs that increase DOAC plasma concentrations (amiodarone, erythromycin, diltiazem or verapamil) and 32% (6/19) were taking drugs that decrease DOAC plasma concentrations (carbamazepine, primidone or phenytoin). There were no cases of patients taking contraindicated interacting drugs. Discussion: Potential DDIs with DOACs in elderly hospital inpatients are relatively common, particularly interactions that may increase the risk of bleeding. The risk–benefit ratio of DOACs in elderly patients on polypharmacy should always be carefully considered.

scholarly journals Pharmacist Interventions Regarding the Appropriateness of Apixaban, Rivaroxaban, Dabigatran, and Warfarin in a University-Affiliated Outpatient Clinic

2016 ◽  
Vol 32 (6) ◽  
pp. 245-252 ◽  
Author(s):  
Haley M. Phillippe ◽  
Bradley M. Wright ◽  
Kathryn E. Bowerman ◽  
Miranda R. Andrus
Keyword(s):  
Primary Care ◽  
Renal Function ◽  
Drug Interactions ◽  
Outpatient Clinic ◽  
Warfarin Therapy ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Retrospective Chart Review ◽  
Bleeding Risk ◽  
Hepatic Function

Background: Direct oral anticoagulants (DOACs) have become available recently as an alternative to warfarin in appropriate patients. Few studies have been conducted that evaluate pharmacist-managed services for the management of the DOACs. Objective: To review the appropriateness of DOAC therapy and warfarin therapy in adult patients in a university-affiliated outpatient clinic and the need for further monitoring of these agents. Methods: A retrospective chart review was conducted of patients receiving a DOAC or warfarin therapy. Indication, dose, duration, age, weight, adherence, drug interactions, bleeding risk/history, renal function, and hepatic function were evaluated for DOACs and warfarin. If prescribed warfarin, international normalized ratio readings were also obtained. The pharmacists made verbal recommendations to primary care prescribers regarding findings, and changes to therapy were reviewed and documented. Results: A total of 175 patient charts were reviewed (49% DOACs, 51% warfarin). Twenty-five percent of prescribed DOACs should have been avoided due to inappropriate indication or renal function. The majority of these were switched to warfarin after discussion with the primary care provider. Of patients prescribed DOACs, 22% had a history of poor adherence to therapy and half of these were switched to warfarin. An additional 24% of prescribed DOACs were inappropriate due to incorrect dosing, major drug interactions, and/or renal dosing; however, these medications could be appropriate if adjustments are made. Nineteen percent of patients on warfarin therapy would be a candidate for DOAC therapy. Conclusion: Although there were limitations to this analysis, the results demonstrate that additional intervention is needed to improve appropriate prescribing and monitoring of the DOACs. Pharmacists can meet this need by providing medication reviews of novel anticoagulants and educating physicians.

scholarly journals Drug-drug interactions with direct oral anticoagulants: practical recommendations for clinicians

2021 ◽  
Author(s):  
Terrier Jean ◽  
Gaspar Frédéric ◽  
Fontana Pierre ◽  
Daali Youssef ◽  
Reny Jean-Luc ◽  
...  
Keyword(s):  
Drug Interactions ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Practical Recommendations

Risk Factors for Post-Thrombotic Syndrome in Patients With a First Proximal Deep Venous Thrombosis Treated With Direct Oral Anticoagulants

Angiology ◽  
2022 ◽  
pp. 000331972110708
Author(s):  
Luca Spiezia ◽  
Elena Campello ◽  
Chiara Simion ◽  
Anna Poretto ◽  
Fabio Dalla Valle ◽  
...  
Keyword(s):  
Risk Factors ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
University Hospital ◽  
First Episode ◽  
Minimum Period ◽  
Vein Thrombosis ◽  
Post Thrombotic Syndrome ◽  
Age Range ◽  
Deep Vein

The incidence of post-thrombotic syndrome (PTS) in patients with deep vein thrombosis (DVT) treated with direct oral anticoagulants (DOACs) remains a matter of debate. Hence, our endeavor to investigate a large cohort of patients with a first episode of proximal DVT treated with DOACs to ascertain the incidence and predisposing risk factors for PTS. All consecutive patients referred to the Thrombotic and Haemorrhagic Diseases Unit of Padova University Hospital (Italy) between January 2014 and January 2018 for a first episode of proximal DVT were considered for enrollment. Participants received DOACs for a minimum period of 3 months. PTS was assessed using the Villalta score up to 36 months after DVT diagnosis. Among 769 enrolled patients (M/F 353/416, age range 26–87 years), 152 (19.8%) developed PTS and 30 (3.9%) developed severe PTS. The adjusted hazard ratio was significant for obesity (1.64, 95% CI 1.28–2.39) and DVT site (femoral and/or iliac veins vs popliteal vein) (1.23, 95% CI 1.15–3.00). The incidence of PTS is not negligible in patients with proximal DVT despite the use of DOACs. We identified obesity and iliofemoral DVT as possible risk factors for PTS. Larger prospective studies are needed to confirm our findings and optimize therapeutic strategies.

Hemostatic and thrombotic disorders in the pediatric patient

Blood ◽  
2021 ◽  
Author(s):  
Sarah H. O'Brien ◽  
Ayesha Zia
Keyword(s):  
Venous Thromboembolism ◽  
Prediction Models ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Hospital Setting ◽  
Von Willebrand Disease ◽  
Assessment Tools ◽  
Excessive Bleeding ◽  
The Past ◽  
New Treatment

This review focuses on significant advances in the field of pediatric hemostasis and thrombosis, with a focus on published studies within the past decade. The evaluation and management of patients with excessive bleeding remain a cornerstone of consultative hematology. We will describe the development of validated bleeding assessment tools relevant to pediatric practice, laboratory advances in the evaluation of von Willebrand Disease, and a shift in clinical practice regarding the interpretation of normal coagulation studies in patients with significant bleeding phenotypes. There have also been critical advances in the management of hemostatic disorders. This review highlights new treatment paradigms in hemophilia and the rise of multidisciplinary medical homes for women living with bleeding disorders. Given the continued increase in the incidence of thrombosis, particularly in the hospital setting, a full call to arms against pediatric venous thromboembolism is now essential. This review will describe recently completed clinical trials of direct oral anticoagulants in children and adolescents and ongoing work to elucidate the appropriate duration of therapy for children with provoked thrombosis. Recent work regarding the prevention of pediatric venous thromboembolism is highlighted, including studies of thromboprophylaxis and the development of risk-prediction models for hospital-acquired thrombosis. Finally, we review advances in our understanding of post-thrombotic sequelae and the need for continued refinement of our evaluation tools. Despite the significant advances in pediatric hemostasis and thrombosis over the past decade, many unanswered questions remain for the next generation of investigators.

THU-130-Management strategies for drug drug interactions between direct oral anticoagulants and hepatitis C directly acting agents: A multicentre review

2019 ◽  
Vol 70 (1) ◽  
pp. e216-e217 ◽  
Author(s):  
Alison Boyle ◽  
Katherine Davidson ◽  
Caroline Cassidy ◽  
Aniqa Afzal ◽  
Anthony Pratt ◽  
...  
Keyword(s):  
Hepatitis C ◽  
Drug Interactions ◽  
Oral Anticoagulants ◽  
Direct Oral Anticoagulants ◽  
Management Strategies
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