Acute ischemic stroke on anti-Xa inhibitors: Pharmacokinetics and outcomes

Basso, Colin; Goldstein, Eric; Xing, Dan; Rana, Maheen; Shu, Liqi; Chen, Casandra; Sweeney, Joseph; Stretz, Christoph; Smith, Eric E.; Gurol, M. Edip; Havenon, Adam de; Burton, Tina; Fussell-Louie, David; Furie, Karen L.; Yaghi, Shadi

doi:10.1016/j.jstrokecerebrovasdis.2022.106612

Cited by 3 publications

(4 citation statements)

References 9 publications

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“…Conventional anticoagulation with heparin or direct oral anticoagulants on top of rt-PA cannot be envisioned in AIS due to the obvious risk of precipitating hemorrhagic transformation [ 149 ]. New drugs targeting factors XI and XII could provide adjuvant anticoagulant therapies well suited for AIS treatment because of their increased safety profile.…”

Section: Toward New Adjuvant Therapies For Improved Intravenous Throm...mentioning

confidence: 99%

Thrombus composition and thrombolysis resistance in stroke

Ho‐Tin‐Noé

Desilles

Mazighi

2023

Research and Practice in Thrombosis and Haemostasis

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Section: Toward New Adjuvant Therapies For Improved Intravenous Throm...mentioning

confidence: 99%

Thrombus composition and thrombolysis resistance in stroke

Ho‐Tin‐Noé

Desilles

Mazighi

2023

Research and Practice in Thrombosis and Haemostasis

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“…Anti-Xa level measurement is potentially more widely available compared to DOAC level measurement and correlates well with drug levels. 9 In summary, the study provides time-critical, preliminary data for thrombolysis (primarily using alteplase) among patients with AIS with recent DOAC use presenting within the standard thrombolysis time window. Despite the limitations of the study design and enrolled population, these data may be used by clinicians to make individualized decisions regarding thrombolysis among patients with recent DOAC use.…”

Section: Related Article Page 233mentioning

confidence: 99%

“…However, the study lacks data on recently emerging anti Xa measurement-based selection for thrombolysis. Anti-Xa level measurement is potentially more widely available compared to DOAC level measurement and correlates well with drug levels …”

mentioning

confidence: 99%

Building Evidence on Safety of Thrombolysis for Patients Undergoing Direct Oral Anticoagulant Treatment

Mistry

2023

JAMA Neurol

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Nearly 20% of patients with acute ischemic stroke (AIS) are undergoing direct oral anticoagulant (DOAC) treatment at the time of their stroke. 1 Common indications for DOACs among these patients include stroke prevention from atrial fibrillation, treatment of venous and pulmonary thrombosis, and coronary and peripheral atherosclerotic disease. Novel indications for DOAC use are expected to emerge and may increase the proportion of patients with AIS who are undergoing treatment with DOACs. Current US and European acute stroke treatment guidelines recommend withholding intravenous thrombolysis (thrombolysis), a morbidity-and mortality-saving AIS treatment for patients with recent a DOAC use. 2,3 DOACs have emerged as preferred anticoagulants over vitamin K antagonists due to a favorable safety profile, particularly a lower risk of severe systemic and intracranial hemorrhage (ICH). 4 However, if this translates into a lower risk of hemorrhagic complications of thrombolysis for AIS in the setting of DOAC treatment is yet to be definitively determined as data supporting this practice are limited and heterogenous. The present study by Meinel et al 5 meaningfully advances the field by generating these critical data. Comparative analyses of different patient selection paradigms for thrombolysis in the presence of DOACs provide additional, timely relevance to the study.In this international, multicenter, observational, retrospective analysis of individual patient data from 64 centers, the authors included 832 patients with AIS undergoing intravenous thrombolysis who had ingested a DOAC agent within 48 hours of hospital arrival. Additionally, 32 375 control patients who had received intravenous thrombolysis without prior anticoagulation treatment (defined as having a therapeutic international normalized ratio with vitamin K antagonists or known DOAC treatment) were included for comparison. A priori calculation of the sample size required to detect differences in the primary outcome was not performed. Compared to the control population, patients with recent DOAC ingestion were older and had more comorbidities. They were more likely to have a large vessel occlusion but also had a higher rate of endovascular treatment (62% vs 55%). Dabigatran was the most frequently used DOAC (n = 342, 41%), followed by rivaroxaban (n = 258, 31%) and apixaban (n = 163, 20%). In terms of patient selection strategies used for thrombolysis, DOAC reversal was performed using idarucizumab among 252 patients (30%) receiving dabigatran (no other reversal agents were used among patients receiving other DOACs), 225 patients (27%) had DOAC plasma levels measured, and the remaining 355 patients (43%) had neither plasma drug levels or DOAC re-

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“…Thrombosis (ischemic stroke or systemic embolism) and bleeding while on DOAC is still a challenging clinical phenomenon in the management of future long-term anticoagulation. Patients with ischemic stroke on DOAC have a high 90-day mortality (35.1% reported in previous study), with the majority of deaths due to the stroke itself [ 2 ]. The unfavorable clinical course can also be seen in DOAC-treated patients who suffer from adverse bleeding.…”

Section: Introductionmentioning

confidence: 99%

Tailored Direct Oral Anticoagulation in Patients with Atrial Fibrillation: The Future of Oral Anticoagulation?

Samoš

Bolek

Stančiaková

et al. 2022

JCM

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Direct oral anticoagulants (DOAC) are currently the drug of choice for drug prevention of stroke or systemic embolism in patients with atrial fibrillation (AF). However, repeated ischemic stroke or systemic embolism and bleeding while on DOAC is still a challenging clinical phenomenon in the management of future long-term anticoagulation. It is not known whether tailoring the DOAC therapy to achieve optimal therapeutic drug levels could improve the clinical course of DOAC therapy. To be able to tailor the therapy, it is necessary to have a valid laboratory method for DOAC level assessment, to be aware of factors influencing DOAC levels and to have clinical options to tailor the treatment. Furthermore, the data regarding clinical efficacy/safety of tailored DOAC regimes are still lacking. This article reviews the current data on tailored direct oral anticoagulation in patients with AF.

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Acute ischemic stroke on anti-Xa inhibitors: Pharmacokinetics and outcomes

Cited by 3 publications

References 9 publications

Thrombus composition and thrombolysis resistance in stroke

Thrombus composition and thrombolysis resistance in stroke

Building Evidence on Safety of Thrombolysis for Patients Undergoing Direct Oral Anticoagulant Treatment

Tailored Direct Oral Anticoagulation in Patients with Atrial Fibrillation: The Future of Oral Anticoagulation?

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