How to proceed with long-term anticoagulation in patient after total gastrectomy and atrial fibrillation?

Bolek, Tomáš; Samoš, Matej; Škorňová, Ingrid; Stančiaková, Lucia; Korpallová, Barbora; Galajda, Péter; Staško, Ján; Kubisz, Peter; Mokáň, Marián

doi:10.1007/s00228-018-2571-9

Cited by 6 publications

(5 citation statements)

References 12 publications

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“…Bolek et al reported a patient with diffuse large B-cell lymphoma who underwent total gastrectomy and was treated with dabigatran for atrial fibrillation. He had low dabigatran trough and peak levels and was switched to apixaban, resulting in adequate apixaban plasma concentrations at both trough and peak [ 19 ]. In 2013, Lee et al reported two patients with atrial fibrillation who had subtherapeutic dabigatran levels after gastric bypass surgery [ 17 ].…”

Section: Discussionmentioning

confidence: 99%

“…Since DOACs are absorbed predominantly in the upper gastrointestinal tract, treating patients with DOACs after gastrectomy raises concerns regarding achievement of adequate drug levels. Some smaller studies and case reports addressed the absorption of DOAC in patients after bariatric surgery [ 12 , 13 , 14 , 15 , 16 , 17 , 18 ], but to our knowledge, only one patient taking DOACs after a cancer-related gastrectomy has been reported [ 19 ].…”

Section: Introductionmentioning

confidence: 99%

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Absorption of Direct Oral Anticoagulants in Cancer Patients after Gastrectomy

et al. 2022

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Direct oral anticoagulants (DOACs) are safe and effective in cancer patients treated for venous thromboembolism (VTE) or atrial fibrillation (AF). Gastrectomy is the treatment of choice in patients with localized upper gastrointestinal cancer. DOACs are absorbed in the upper gastrointestinal tract, but to what extent is unclear. In a retrospective analysis, hospital data were searched for adult patients who underwent gastrectomy for gastroesophageal or pancreatic cancer, and DOAC therapy for VTE or AF after gastrectomy. DOAC blood levels were determined by chromogenic assays before and after administration, and thromboembolic and bleeding complications were recorded. Eleven patients (median age 76 years) received a factor Xa inhibitor (FXaI; apixaban (3), edoxaban (3), rivaroxaban (4)) or the factor IIa inhibitor dabigatran (1) for VTE (7) or AF (4) after gastrectomy. Eight patients on FXaI had anti-Xa (aXa) trough levels within the expected range (ER). In all of them, aXa levels increased upon DOAC administration. Two patients on 30 mg edoxaban had low aXa trough levels. Administration of 20 mg of rivaroxaban resulted in trough levels in the ER in one of them. None of the FXaI patients had thromboembolism, while two experienced bleeding (arterial puncture site, gastrointestinal). One dabigatran AF patient with trough and peak concentrations below the ER had strokes during 110 mg and 150 mg dabigatran administration. While on apixaban, aXa levels were in the ER, and no clinical complications occurred. DOACs, particularly FXaI, were adequately absorbed in cancer patients after gastrectomy. Our observation of recurrent thromboembolic events in a patient treated with dabigatran warrants cautious use in this specific patient population.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Absorption of Direct Oral Anticoagulants in Cancer Patients after Gastrectomy

et al. 2022

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“…Moreover, we have previously described a patient with posttotal gastrectomy (with no gastric acid secretion) and with AF in whom very low trough (28 ng/mL) and peak (55 ng/mL) dabigatran plasma levels were found despite full dabigatran etexilate dosing (150 mg/twice daily). 23 Thus, although current data suggest that acid gastric pH is essential for absorption of dabigatran etexilate, there remains a need for further studies to confirm the direct mechanism of PPIdabigatran interaction.…”

Section: Does Ppi Impact Dabigatran Plasma Levels?mentioning

confidence: 91%

“…PPI could have a direct protective effect on gastric mucosa, 25 or the gastroprotection could be due to a reduction in dabigatran plasma levels. 19,20,22,23 Considering above-mentioned facts regarding the impact of PPI on dabigatran plasma levels, and that the incidence of bleeding events on DT correlate positively with dabigatran plasma levels, 24 it seems that the reduction of dabigatran levels in patients receiving PPI could be, at least in part, responsible for the reduction of gastric bleeds in patients on long-term DT. 12 However, further studies regarding this issue would be needed to resolve the question.…”

Section: Does Ppi Impact Dabigatran Plasma Levels?mentioning

confidence: 99%

Proton Pump Inhibitors and Dabigatran Therapy: Impact on Gastric Bleeding and Dabigatran Plasma Levels

Bolek

Samoš

Škorňová

et al. 2019

Semin Thromb Hemost

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Dabigatran etexilate, a direct thrombin inhibitor, is now frequently used for long-term pharmacological prevention of stroke or systemic embolism in patients with atrial fibrillation. However, such long-term dabigatran therapy (DT) significantly increases the risk of upper gastrointestinal (GI) bleeding. This increased risk of gastric bleeds might be reduced with gastroprotective agents, such as proton pump inhibitors (PPIs). PPIs coadministrated with dabigatran reduce the risk of upper GI bleeding in patients on long-term oral DT. Nevertheless, there is heated discussion regarding interactions between PPI and dabigatran that lead to decreases in dabigatran plasma levels. This article reviews up to date data about the risk of gastric bleeding on dabigatran, the impact of PPI on the reduction of gastric bleeding, and the interaction between PPI and dabigatran leading to decreased dabigatran plasma levels.

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“…Dabigatran should be avoided in patients who underwent gastrectomy or major proximal or distal intestinal resections, according to isolated reports [22]. There is uncertainty about the efficacy of apixaban in patients after gastrointestinal operation [52][53][54]. However, apixaban could be a therapeutic option for patients who have undergone gastric procedures (sleeve gastrectomy, laparoscopic adjustable gastric banding and laparoscopic Roux-en-Y gastric bypass surgery) based on the only available study on the pharmacology of apixaban after bariatric surgery and theoretical knowledge that apixaban absorption is pH independent [22,54].…”

Section: Doac Treatment In Patients After Gastrointestinal Surgerymentioning

confidence: 99%

The Clinical Significance of Drug–Food Interactions of Direct Oral Anticoagulants

Grześk

Rogowicz

Wołowiec

et al. 2021

IJMS

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Cardiovascular diseases are the most common cause of death in the world. For almost 60 years, vitamin K antagonists (VKAs) were the mainstay of anticoagulation therapy, but in recent years direct oral anticoagulants (DOACs) have become the anticoagulant treatment of choice. DOACs were initially considered drugs with no significant food interactions; however, clinical observations from daily practice have proved otherwise as interactions with food ingredients have been reported. Food, dietary supplements or herbs may contain substances that, when administered concomitantly with DOACs, can potentially affect the plasma concentration of the drugs. The aim of this paper was to evaluate the clinical significance of drug–food interactions of DOACs, such as dabigatran, rivaroxaban, apixaban, edoxaban and betrixaban. Patients treated with anticoagulants should avoid products containing St. John’s wort and take special care with other food ingredients. As the interest in dietary supplements is on the rise, healthcare providers can contribute to the development of well-designed clinical trials on interactions between DOACs and food, and distribute sufficient knowledge about the proper use of these supplements among patients.

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How to proceed with long-term anticoagulation in patient after total gastrectomy and atrial fibrillation?

Cited by 6 publications

References 12 publications

Absorption of Direct Oral Anticoagulants in Cancer Patients after Gastrectomy

Absorption of Direct Oral Anticoagulants in Cancer Patients after Gastrectomy

Proton Pump Inhibitors and Dabigatran Therapy: Impact on Gastric Bleeding and Dabigatran Plasma Levels

The Clinical Significance of Drug–Food Interactions of Direct Oral Anticoagulants

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