Incidence and predictors of excessive warfarin anticoagulation in patients with atrial fibrillation—The EWA study

Jaakkola, Samuli; Nuotio, Ilpo; Kiviniemi, Tuomas; Virtanen, Raine; Issakoff, M.; Airaksinen, Juhani

doi:10.1371/journal.pone.0175975

Cited by 10 publications

(9 citation statements)

References 36 publications

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“…Several environmental, demographic and clinical factors have been implicated in the interindividual variability in response to therapy. [29][30][31] However, in this study, no association between plasma EFV concentrations and demographic markers, such as maternal…”

Section: Discussioncontrasting

confidence: 61%

Plasma efavirenz concentration inversely correlates with increased risk of cytomegalovirus infection in HIV-infected pregnant women

Mhandire

Morse²,

Maponga

et al. 2019

S Afr Med J

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Combination antiretroviral therapy (cART) has tremendously reduced HIV-associated morbidity, mortality and mother-to-child transmission (MTCT). [1] The Option B+ (lifelong cART for all HIV-infected pregnant and breastfeeding women) introduced by the World Health Organization proved to be effective, resulting in a reduction of MTCT from 33% (before ART) to <2% in sub-Saharan Africa. [2] Despite the massive success in reduction of MTCT, HIV-exposed uninfected (HEU) children experience delayed developmental milestones, disabilities and more frequent morbidities than their HIV-unexposed counterparts. [3,4] Developmental and health problems in some HEU infants occur despite maternal cART during pregnancy. Differential HIV outcomes have previously been associated with interindividual variation in response to cART. [5] The differential outcomes of cART during pregnancy are critical in the care of HEU infants who have to endure effects of in utero and postpartum exposure to antiretroviral drugs. [6] Furthermore, the increasing number of HIV-infected adolescents who grow into adulthood with a strong will to procreate, further emphasises the need to understand the factors associated with different HIV treatment outcomes in pregnancy, which also determine infant outcomes. [7] Of the utmost importance during pregnancy are antenatal diseases that may result in adverse outcomes if transmitted to the developing fetus or neonate. Antenatal infections (such as cytomegalovirus (CMV), toxoplasmosis, syphilis and rubella) are more prevalent among HIVinfected than HIV-uninfected women. [8,9] CMV is a latent beta herpesvirus that is often reactivated in immunecompromised populations such as HIV patients and pregnant women. When reactivation of CMV occurs during pregnancy, the virus can be transmitted to the fetus and/or neonate, resulting in congenital CMV (cCMV) infection. [10] Effects of cCMV may be potentially fatal and include paediatric pneumonia, neurocognitive developmental delay and sensorineural hearing loss, for which CMV is the leading non-genetic cause. [11,12] In a review by Filteau and Rowland-Jones, [13] vertical transmission of CMV in utero or in early infancy was hypothesised to be responsible for the health and developmental deficits in HIV-exposed children. cCMV is sustained by antenatal CMV infection or reactivation; hence, controlling maternal CMV infection is key in the prevention of cCMV. cART is protective against the emergence of opportunistic infections; [14] therefore, the occurrence of CMV in some but not all HIV-infected This open-access article is distributed under Creative Commons licence CC-BY-NC 4.0.

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Section: Discussioncontrasting

confidence: 61%

Plasma efavirenz concentration inversely correlates with increased risk of cytomegalovirus infection in HIV-infected pregnant women

Mhandire

Morse²,

Maponga

et al. 2019

S Afr Med J

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“…Recent intake of antibiotic or antifungal drugs, recent hospitalization and outpatient visit were the other significant temporary predictors of excessive anticoagulation with warfarin. 21 In our study, major polypharmacy was not a significant predictor for major drug interactions.…”

Section: Discussioncontrasting

confidence: 49%

Drug interactions of oral anticoagulants

Anil

Muraleedharan

Faruqui

2020

Int J Basic Clin Pharmacol

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Background: Oral anticoagulants (OACs) are the drugs of choice where long-term anticoagulation is needed due to convenience of dosing. But their use has potential for several drug interactions. Monitoring for potential interactions with timely management will decrease the risk of complications of anticoagulation.Methods: We aimed to assess the presence of potential drug-drug interactions in patients on oral anticoagulants for various indications. Prescriptions of a cohort of patients on oral anticoagulants were analyzed. Potential drug interactions were identified using free software available at www.drugs.com and classified into major, moderate and minor types.Results: Of the 135 patients in the study, 83 were males and mean age was 52.9±17.3 years. Most commonly used OACs were vitamin K antagonists (VKAs) (80.0%) followed by direct oral anticoagulants (DOACs) (20.0%). Median number of concomitant medications per patient was 4 (IQR 3-6). A total of 307 potential interactions were identified in 121 patients with a median of 2 interactions per patient. Of the 56 patients who had potential for major drug interactions, 45 (41.6%) were on VKAs and 11 (40.7%) on DOACs had potential to develop major interactions. Using logistic regression model, significant predictors of major drug interactions were age>60 years (OR 2.50; 95% CI 1.05-5.95; p=0.04) and presence of venous thromboembolism VTE (OR 0.09; 95% CI 0.02-0.55; p=0.01).Conclusions: This hospital-based study showed potential drug interactions with OACs. Age more than 60 years and presence of VTE were significant predictors of major interactions. Awareness of potential interactions and monitoring doses of OACs help to prevent complications of therapy.

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“…TTR was in general lower among warfarin-receiving patients with MHCs than in those without. Excessive alcohol use and substance abuse are common among patients with MHCs and have been associated with low TTR values and supratherapeutic INR values[ 25 , 34 , 46 , 58 ]. Poor OAC control in this group is likely related to alcohol enhancing the antithrombotic effects of warfarin as well as deficits in patients’ self-care capabilities, which are likely to impair systematic INR follow-up [56] Nonadherence to medication is common in patients with MHCs and may also affect poor OAC conrol [59 , 60] .…”

Section: Discussionmentioning

confidence: 99%

The impact of mental health conditions on oral anticoagulation therapy and outcomes in patients with atrial fibrillation: A systematic review and meta-analysis

Teppo

Jaakkola

Lehto

et al. 2021

American Journal of Preventive Cardiology

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One third of patients with atrial fibrillation (AF) are estimated to suffer from mental health conditions (MHCs). We conducted a systematic review and meta-analysis to investigate the impact of MHCs on the prevalence and quality of oral anticoagulation (OAC) therapy and outcomes in patients with AF. Medline database was searched for studies published before March 1st 2021 evaluating AF patients with comorbid MHCs reporting on the prevalence of OAC therapy, time in therapeutic range (TTR) in warfarin-receiving patients, adherence to OAC therapy or adverse outcomes (ischemic stroke, hemorrhage or mortality). Studies reporting on outcome events were included in the meta-analysis. The literature search yielded 17 studies including 977,535 patients that fulfilled the inclusion criteria of this review. AF patients with MHCs had a lower prevalence of OAC use and poorer TTR compared with patients without MHCs. Evidence on OAC quality in patients receiving direct oral anticoagulants (DOACs) was minimal and inconclusive. A decrease in depression-associated deficit in OAC prevalence was observed after the introduction of DOACs. Pooled analysis of five studies reporting on outcomes showed that MHCs were an independent risk factor for both stroke (RR 1.25, 95%CI 1.08–1.45, I 2 0%) and major bleeding (RR 1.17, 95%CI 1.08–1.27, I 2 27%). Data on mortality were lacking and therefore not included in the meta-analysis. Evidence on the impact of specific MHCs on the outcomes were inadequate. In conclusion, MHCs are independent risk factors for stroke and major bleeding in patients with AF. Future studies are needed to confirm the findings of this meta-analysis, to evaluate the prognostic impact of different MHCs and to clarify whether the introduction of DOACs might have improved the outcomes of these patients.

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Incidence and predictors of excessive warfarin anticoagulation in patients with atrial fibrillation—The EWA study

Cited by 10 publications

References 36 publications

Plasma efavirenz concentration inversely correlates with increased risk of cytomegalovirus infection in HIV-infected pregnant women

Plasma efavirenz concentration inversely correlates with increased risk of cytomegalovirus infection in HIV-infected pregnant women

Drug interactions of oral anticoagulants

The impact of mental health conditions on oral anticoagulation therapy and outcomes in patients with atrial fibrillation: A systematic review and meta-analysis

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