Evaluation of bleeding in patients receiving direct oral anticoagulants

Abstract

Direct oral anticoagulants (DOACs) are recognized by evidence-based treatment guidelines as the first-line option for the treatment of venous thromboembolism and prevention of stroke and systemic embolism in nonvalvular atrial fibrillation. As use of these anticoagulants has become favored over the past several years, reported bleeding-related adverse drug events with these agents has increased. In randomized clinical trials, all DOACs have a reduced risk for intracranial hemorrhage, while major and other bleeding results have varied among the agents compared to vitamin K antagonists. We have reviewed the bleeding incidence and severity from randomized and real-world data in patients receiving DOACs in an effort to provide the clinician with a critical review of bleeding and offer practical considerations for avoiding adverse events with these anticoagulants.

Effect of concomitant antiplatelet therapy in patients with nonvalvular atrial fibrillation initiating non‐vitamin K antagonists

“…This reduces the bias originated by subsequent changes in antiplatelet therapy, usually discontinuation, which are less likely to happen within the first months after OAC initiation, but it is also when bleeding complications are more frequent. 41 These first 3 months were, however, excluded from the analysis in other studies, 31,33 as they were based on concomitant antiplatelet use at 3 months instead of at randomization. Another reason for this result could be the higher use of P2Y12 inhibitors (mostly clopidogrel) in our cohort.…”

Interindividual Variability of Apixaban Plasma Concentrations: Influence of Clinical and Genetic Factors in a Real-Life Cohort of Atrial Fibrillation Patients

“…Major bleeding was defined according to the criteria of the International Society on Thrombosis and Haemostasis-clinically overt and associated with a decrease in hemoglobin level of ≥2.0 g/dL; need for two units of erythrocyte mass transfusion; fatal or symptomatic hemorrhages in a critical organ (intracranial, pericardial, retroperitoneal) [20]. Clinically relevant non-major (CRNM) bleeding was defined as overt bleedings that did not meet the criteria for major bleeding but were associated with medical intervention, interruption or discontinuation of apixaban, or impairment of daily life activities [21]. Minor bleeding was defined as non-clinically consequential overt bleedings that did not meet the criteria for major or CRNM bleeding.…”

Successful treatment of heparin‐induced thrombocytopenia with apixaban in a patient with chronic kidney disease requiring hemodialysis

“…A recent literature review suggested that DOACs are highly efficacious in this scenario, although most patients included in the report were treated with rivaroxaban 3. Among DOACs, apixaban is the least dependent on renal clearance of the direct factor Xa inhibitors and might be the one with the smallest bleeding risk 4. As a matter of fact, there is some pharmacokinetic evidence to support the use of an adjusted dose of apixaban in patients on HD 5.…”