Vitamin K antagonist use: evidence of the difficulty of achieving and maintaining target INR range and subsequent consequences

Schein, Jeff; White, C Michael; Nelson, Winnie W.; Kluger, Jeffrey; Mearns, Elizabeth S.; Coleman, Craig I.

doi:10.1186/s12959-016-0088-y

Cited by 49 publications

(61 citation statements)

References 67 publications

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“…In our cohort, 22.4% of BCS patients on VKAs did not achieve target INR despite repeated dose modification over a median period of 3 months and were switched over to dabigatran. Previous studies have reported that up to 20–30% of patients were not achieving the target INR, similar to our observation . DOACs have overcome several of the limitations associated with VKAs including a faster onset of action (0.5–4 h), shorter half‐life (12–17 h), and no primary food and drug interactions and have obviated the need for INR monitoring .…”

Section: Discussionsupporting

confidence: 88%

Dabigatran as an oral anticoagulant in patients with Budd–Chiari syndrome post‐percutaneous endovascular intervention

Sharma

Kumar

Rout

et al. 2019

J of Gastro and Hepatol

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Background and Aim Anticoagulants play an important role in the management of Budd–Chiari syndrome. There is a paucity of data on the efficacy and safety of direct‐acting oral anticoagulants—dabigatran, among patients with Budd–Chiari syndrome. Methods In a retrospective analysis of prospectively maintained data, the stent patency rates, major bleeding episode, and a composite endpoint of major bleed and/or mortality rates were compared between Budd–Chiari syndrome patients treated with dabigatran (n = 36) or vitamin K antagonists (n = 62) following endovascular intervention. Results The baseline characteristics, including sites of block and types of interventions, were similar between the two groups. The mean duration of follow‐up in the dabigatran and vitamin K antagonist groups was 10.5 ± 6.7 and 14.1 ± 6.9 months (P = 0.006), respectively. The endovascular stent patency rates were comparable between the dabigatran and vitamin K antagonist groups at 6 months (91% vs 96.5%) and 12 months (91% vs 93%), P = 0.296 (log‐rank test), respectively. Major bleeding events were comparable between the dabigatran and vitamin K antagonist groups at 6 months (3.5% vs 2%) and 12 months (3.5% vs 6.5%), P = 0.895 (log‐rank test), respectively. The composite endpoint of mortality and major bleed was comparable between dabigatran and vitamin K antagonists at 6 months (4% vs 5%) and 12 months (4% vs 8%), P = 0.875 (log‐rank test), respectively. Conclusions Dabigatran, as compared with vitamin K antagonists, is associated with similar stent patency rates and complications among patients with Budd–Chiari syndrome post‐endovascular intervention.

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Section: Discussionsupporting

confidence: 88%

Dabigatran as an oral anticoagulant in patients with Budd–Chiari syndrome post‐percutaneous endovascular intervention

Sharma

Kumar

Rout

et al. 2019

J of Gastro and Hepatol

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“…25 The TTR should be above 65%, which is difficult to achieve in clinical routine. 26 Heparins as well as heparinoids can also be used in patients with impaired renal function. Elimination of unfractionated heparin is independent of the renal function.…”

Section: Anticoagulation With Vitamin K Antagonists Heparins or Hepmentioning

confidence: 99%

Direct oral anticoagulants in patients with chronic kidney disease: patient selection and special considerations

Lutz

Jurk²,

Schinzel³

2017

IJNRD

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Many patients with chronic kidney disease (CKD) receive anticoagulation or antiplatelet therapy due to atrial fibrillation, coronary artery disease, thromboembolic disease, or peripheral artery disease. The treatment usually includes vitamin K antagonists (VKAs) and/or platelet aggregation inhibitors. The direct oral anticoagulants (DOAC) inhibiting factor Xa or thrombin represent an alternative for VKAs. In patients with acute and chronic kidney disease, caution is warranted, as DOACs can accumulate as they are partly eliminated by the kidneys. Thus, they can potentially increase the bleeding risk in patients with CKD. In patients with an estimated glomerular filtration rate (eGFR) above 60 mL/min, DOACs can be used safely with greater efficacy and safety as compared to VKAs. In patients with CKD 3, DOACs are as effective as VKAs with a lower bleeding rate. The more the renal function declines, the lower is the advantage of DOACs over VKAs. Thus, use of DOACs should be avoided in patients with an eGFR below 30 mL/min, particularly, the compounds with a high renal elimination. Available data suggest that DOACs can also be used safely in older patients. In this review, use of DOACs in comparison with VKAs, heparins, and heparinoids, together with special considerations in patients with impaired renal function will be discussed.

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“…Drug utilisation research (DUR) is frequently conducted to analyse the use of drugs, and a core aspect is adherence to drug treatment, defined as the extent to which patients take drugs according to prescribing instructions . Nonadherence to drugs is widespread and has been linked to increases in morbidity, premature death, and health care expenditure; especially nonadherence to drugs with complex pharmacological profiles such as warfarin and other vitamin K antagonists (VKAs) is known to negatively affect treatment outcomes …”

Section: Introductionmentioning

confidence: 99%

“…1 Nonadherence to drugs is widespread [1][2][3] and has been linked to increases in morbidity, premature death, and health care expenditure; 1,4,5 especially nonadherence to drugs with complex pharmacological profiles such as warfarin and other vitamin K antagonists (VKAs) is known to negatively affect treatment outcomes. [6][7][8][9] Warfarin is used for multiple cardiovascular conditions, and high discontinuation rates of warfarin treatment have been reported in clinical trials and observational studies; [10][11][12] poor adherence has been ascribed to a variety of issues, from the occurrence of bleeding events to the inconvenience of treatment. 6,[13][14][15] As warfarin is widely used long-term in patients with atrial fibrillation (AF)-a common condition causing irregular heartbeat and, as such, a major independent risk factor for stroke 16,17 -efforts to replace warfarin have resulted in 4 new direct oral anticoagulants (DOACs) being introduced since 2008: dabigatran, a direct thrombin inhibitor, and rivaroxaban, apixaban, and edoxaban, direct factor Xa inhibitors.…”

mentioning

confidence: 99%

Use of direct oral anticoagulants in patients with atrial fibrillation in Scotland: Applying a coherent framework to drug utilisation studies

Mueller

Alvarez-Madrazo

Robertson

et al. 2017

Pharmacoepidemiology and Drug

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PurposeTo report the use of direct oral anticoagulants (DOACs) for stroke prevention in patients with atrial fibrillation in Scotland and advocate the standardisation of drug utilisation research methods.MethodsRetrospective cohort study using linked administrative data. Patients included those with a diagnosis of atrial fibrillation (confirmed in hospital) who received a first prescription for a DOAC (dabigatran, rivaroxaban, or apixaban) from September 2011 to June 2014. Drug utilisation measures included discontinuation, persistence, and adherence.ResultsA total of 5398 patients (mean CHA2DS2‐VASc score 2.98 [SD 1.71], 89.7% with ≥5 concomitant medicines) were treated with DOACs for a median of 228 days (interquartile range 105‐425). Of 35.6% who discontinued DOAC treatment, 11.0% switched to warfarin, and 48.3% reinitiated DOACs. Persistence after 12 and 18 months was 75.9% and 69.8%, respectively. Differences between individual DOACs were observed: Discontinuation rates ranged from 20.4% (apixaban) to 60.6% (dabigatran) and 12 months persistence from 60.1% (dabigatran) to 85.5% (apixaban). Adherence to treatment with all DOACs was good: Overall DOAC median medication refill adherence was 102.9% (interquartile range 88.9%‐115.5%), and 82.3% of patients had a medication refill adherence > 80%.ConclusionsIn Scotland, adherence to DOAC treatment was good, and switching from DOAC to warfarin was low. However, discontinuation and persistence rates were variable—although treatment interruptions were often temporary.To decrease the inconsistencies in drug utilisation methods and facilitate meaningful study comparison, the use of a coherent framework—using a combination of discontinuation, persistence, and adherence—and the standardisation of measurements is advocated.

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Vitamin K antagonist use: evidence of the difficulty of achieving and maintaining target INR range and subsequent consequences

Cited by 49 publications

References 67 publications

Dabigatran as an oral anticoagulant in patients with Budd–Chiari syndrome post‐percutaneous endovascular intervention

Dabigatran as an oral anticoagulant in patients with Budd–Chiari syndrome post‐percutaneous endovascular intervention

Direct oral anticoagulants in patients with chronic kidney disease: patient selection and special considerations

Use of direct oral anticoagulants in patients with atrial fibrillation in Scotland: Applying a coherent framework to drug utilisation studies

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