Direct oral anticoagulants or vitamin K antagonists in emergencies: comparison of management in an observational study

Baker, R; Gilmore, Grace; Chen, V.; Tiao, Jonathan R; Ch'ih, John J.; Tan, Chee‐Wee; Hankey, Graeme J.; Chen, V.; Young, Laura; Merriman, Eileen; Curnow, Jennifer; Gallus, Alexander; Boey, J.; Tan, Chee Wee; McRae, Simon; Hugman, A; Joseph, Joanne; Harper, Paul; Brighton, Timothy; Royle, Gordon; Crowther, Helen; Tran, H; Campbell, Peter J.; Baker, Robert D.

doi:10.1016/j.rpth.2023.100196

Cited by 3 publications

(1 citation statement)

References 66 publications

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“…Given the delay in results of DOAC levels (median 1–2 days) because of a lack of an in‐house assay, this suggests that DOAC levels did not influence the decision to proceed with urgent surgery or reversal of bleeding, but if they had been available to clinicians at the time, they might have informed decisions regarding the administration of reversal agents/haemostatic agents in bleeding patients or prior to urgent surgery. However, a recently published Australian multicentre observational study in patients on VKAs or DOACs presenting with major haemorrhage or requiring urgent haemostatic restoration prior to urgent surgery with a median time of 52 min (IQR 24.8–206.7) from sample collection to receipt in the laboratory demonstrated a poor relationship of DOAC levels with administration of a haemostatic reversal agent 24 …”

Section: Discussionmentioning

confidence: 99%

Retrospective study of clinical settings, indications and consequences of measurement of direct oral anticoagulant plasma levels in Northern Tasmania, Australia

Lim,

Mohamed

2024

Internal Medicine Journal

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BackgroundRoutine monitoring of direct oral anticoagulant (DOAC) levels is not recommended but may be useful in certain clinical situations. There is a knowledge gap regarding the clinical use of DOAC levels in Australian hospitals.AimsTo evaluate the clinical settings, indications and changes to anticoagulant management associated with DOAC levels in a tertiary hospital in Northern Tasmania, Australia.MethodsPatients with one or more DOAC levels (dabigatran, rivaroxaban or apixaban) requested between January 2017 and December 2022 were identified. Retrospective chart review was performed to evaluate the clinical settings, indications, adequacy of request information and changes to clinical management associated with the measurement of DOAC levels.ResultsOne hundred and twenty‐nine DOAC measurements (54 rivaroxaban, 66 apixaban and nine dabigatran) were performed in 98 patients between January 2017 and December 2022. Annual requests for DOAC levels increased significantly between 2017 and 2019 and remained stable between 2020 and 2021 but declined in 2022. Overall, the most common indication for a DOAC level was renal impairment, followed by bleeding and recurrent thrombosis. Approximately 25% of requests were for acute bleeding with a reversal/haemostatic agent given in 45% of patients, while 10% were prior to urgent surgery. Measurement of DOAC levels was associated with a change in management in 50% of cases. 10% of requests did not specify anticoagulant history.ConclusionTrends in requests for DOAC levels have changed over time. Clinician education regarding the importance of providing specific anticoagulant history is essential. Future prospective studies investigating the clinical utility of DOAC levels in different clinical settings are needed.

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Section: Discussionmentioning

confidence: 99%

Retrospective study of clinical settings, indications and consequences of measurement of direct oral anticoagulant plasma levels in Northern Tasmania, Australia

Lim,

Mohamed

2024

Internal Medicine Journal

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Massive Transfusion/Hemorrhage Protocols Versus Goal-Directed Bleeding Management: Science Gone Eerie?

Görlinger,

Kapoor

2024

JCCC

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Key questions in bleeding management are “Why does my patient bleed?” and “How to fix it?” To answer the first question, the high negative predictive value of viscoelastic testing can be used to identify coagulopathic bleeding. Accordingly, goal-directed bleeding management (GDBM) guided by viscoelastic testing has been shown to be an effective and essential part of the second pillar of patient blood management (PBM) with the aim to improve patients’ outcomes and safety. Patient’s medical and drug history – with a focus on medication with oral anticoagulants and antiplatelet drugs – are important in emergency, urgent, and elective surgery. Furthermore, risk scores have been developed and validated for traumatic and obstetric hemorrhage and can be helpful tools to predict severe hemorrhage and the need for massive transfusion. Acidosis, hypocalcemia, anemia, and hypothermia (“diamond of death in trauma”) are important basic conditions for hemostasis and good predictors of coagulopathy and should be closely monitored by blood gas analysis and corrected in bleeding patients. Earlier time to hemostasis was associated with decreased mortality in trauma studies. Therefore, GDBM aims to stop the bleeding as soon as possible and avoid the main killers in blood transfusion: Transfusion-associated circulatory overload, transfusion-related acute lung injury, transfusion-related immune modulation, and thrombosis. Thromboelastometry-guided bleeding management follows the concepts of Good Medical Practice and Precision Medicine. Here, rotational thromboelastometry (ROTEM)-guided bleeding management algorithms are using a stepwise approach based on the sequence “Treat first what kills first:” (1) Fibrinolysis management, (2) clot firmness management, (3) thrombin generation management, and (4) avoidance of hypercoagulability and thrombosis. Here, thromboelastometry can not only identify patients with hypercoagulability and increased risk of thrombosis but also ROTEM-guided bleeding management can avoid thromboembolic complications, too. This may support the idea of personalized antithrombotic therapy guided by viscoelastic testing in the postoperative period. Finally, PBM is not about blood transfusion: It is about patients’ outcomes. Accordingly, several meta-analyses based on more than 20 randomized controlled trials on the effect of viscoelastic testing-guided perioperative bleeding management did not only demonstrate a significant reduction in transfusion requirements but also a significant reduction in mortality and postoperative acute kidney injury. The reduction in postoperative acute kidney injury again has a significant impact on long-term survival. Accordingly, recent PBM guidelines recommend the implementation of viscoelastic testing-guided bleeding management algorithms with a 1B or 1A recommendation. This is also addressed in the World Health Organization policy brief about the urgent need to implement PBM in all member states in a timely manner. However, even if the number of national activities is increasing, there is still a long way to go.

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Anticoagulant drugs for patients with atrial fibrillation on dialysis: a systematic analysis and network meta-analysis

Shen,

Zhang,

et al. 2023

Front. Pharmacol.

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Objective: A lack of clarity persists regarding the efficacy and risks associated with direct oral anticoagulants (DOACs) in end-stage renal disease (ESRD) patients with atrial fibrillation (AF) undergoing dialysis, primarily due to limited retrospective studies. Therefore, the objective of this study was to evaluate the existing data and propose a practical protocol for the clinical utilization of DOACs in ESRD patients with AF undergoing dialysis.Methods: PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for clinical studies evaluating DOACs in ESRD patients with AF on dialysis published up to 2 February 2023. DOACs included warfarin, dabigatran, apixaban, edoxaban, and rivaroxaban. The outcomes were mortality, ischemic stroke, hemorrhagic stroke, any stroke, gastrointestinal bleeding, major bleeding, intracranial bleeding, and minor bleeding.Results: Compared with placebo, apixaban (HR = 0.97, 95% CI: 0.88–1.07), rivaroxaban (HR = 0.91, 95% CI: 0.76–1.10), and warfarin (HR = 0.96, 95% CI: 0.90–1.01) did not reduce mortality. Regarding direct comparisons of mortality, the comparisons of warfarin vs. apixaban (HR = 0.99, 95% CI: 0.92–1.06), placebo vs. warfarin (HR = 1.04, 95% CI: 0.99–1.11), and rivaroxaban vs. warfarin (HR = 0.96, 95% CI: 0.80–1.14) did not significantly reduce mortality. Based on the surface under the cumulative ranking curve, rivaroxaban (75.53%), warfarin (62.14%), and apixaban (45.6%) were the most effective interventions for managing mortality, and placebo (16.74%) was the worst.Conclusion: In conclusion, rivaroxaban demonstrated efficacy in reducing mortality and the incidence of ischemic stroke, gastrointestinal bleeding, and intracranial hemorrhage. Dabigatran is recommended for the prevention of hemorrhagic stroke. However, caution should be exercised due to the risk of major bleeding. Warfarin can effectively reduce minor bleeding but does not offer significant protection against gastrointestinal or intracranial bleeding. Apixaban was not recommended for mortality reduction or for preventing ischemic or hemorrhagic strokes. Further research will be necessary to establish specific clinical protocols.

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Direct oral anticoagulants or vitamin K antagonists in emergencies: comparison of management in an observational study

Cited by 3 publications

References 66 publications

Retrospective study of clinical settings, indications and consequences of measurement of direct oral anticoagulant plasma levels in Northern Tasmania, Australia

Retrospective study of clinical settings, indications and consequences of measurement of direct oral anticoagulant plasma levels in Northern Tasmania, Australia

Massive Transfusion/Hemorrhage Protocols Versus Goal-Directed Bleeding Management: Science Gone Eerie?

Anticoagulant drugs for patients with atrial fibrillation on dialysis: a systematic analysis and network meta-analysis

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