Novel anticoagulants

Abstract

The magnitude of gastrointestinal risk is still unclear because of paucity of literature. Current risk-stratification models are incomplete and cannot be used solely to predict future risk. The periendoscopic management requires an understanding of drug half-life, metabolism and patient's ability to excrete the agent. Acute bleeding management relies on fluid resuscitation to promote renal excretion of active metabolite, withholding the doses and timely management of endoscopic stigmata. The administration of coagulation factors (fresh frozen plasma, prothrombin complex concentrates or recombinant activated FVII) is more successful in reversing the activity of the upstream inhibitors of coagulation (rivaroxaban and apixaban) than dabigatran which is a direct thrombin inhibitor.

Gastrointestinal bleeding in patients on novel oral anticoagulants: Risk, prevention and management

“…However, it should be acknowledged that patients with an increased risk of thromboembolism usually have one or more of the comorbidities included in the HAS-BLED score, which predispose them to bleeding. Other risk factors for GIB [ e.g ., Helicobacter pylori (HP) infection, colonic diverticulosis, or presence of angiodysplasias] should also be considered in the decision making when prescribing NOACs[47]. Concurrent use of antiplatelet agents and NSAIDs also increases the bleeding risk and should factor into the decision making.…”

“…Other preventive measures include the use of appropriate dosage with reference to the CrCl, institution of renal protective measures ( e.g ., avoiding NSAIDs and herbs), correction of modifiable risk factors ( e.g ., HP eradication, alcohol abstinence, avoidance of co-administration of antiplatelet agents or NSAIDs). For patients identified to be at high risk for GIB ( e.g ., HAS-BLED score ≥ 3, history of previous GIB), prescription of gastroprotective agents[1,10,47] and use of apixaban or low-dose dabigatran (110 mg b.i.d) are recommended[6,50]. However, it is also important to note that lower dose of NOACs is less efficacious in stroke prevention[26].…”

Antithrombotic treatment in elderly patients with atrial fibrillation: a practical approach

“…In case of treatment with DOACs, dosage should be carefully taken according to age (dabigatran and apixaban), creatinine clearance (all DOACs) and previous history of gastrointestinal bleeding. In addition, the use of non-steroidal anti-inflammatory drugs, antiplatelet agents as well as alcohol use should be avoided [ 20 , 30 – 34 ].…”

The understanding and management of stroke risk in patients with atrial fibrillation in Northern British Columbia

“…For example, when searching the CINAHL databases using the Boolean phrase "antithrombotic therapy" AND "nonadherence", twenty-nine articles were found. Of these, eleven articles were chosen and analyzed relating to nonadherence of antithrombotic medications such as aspirin, warfarin and novel oral anticoagulants (Abraham & Castillo, 2013;Chao et al, 2012;Gattellari et al, 2008;Howitt & Armstrong, 1999;Kääriäinen, Paukama, & Kyngäs, 2012;Nutescu, 2013;Sattari & Lowenthal, 2011;Tulner et al, 2010;Waterman et al, 2004). There is a large body of literature that has supported the use of anticoagulation in this population, and these are well integrated within clinical guidelines.…”

“…For example, a patient's experience with a major or minor bleeding event is a known factor in discontinuing antithrombotic medication (Abraham & Castillo, 2013;Tulner et al, 2010) and some patients remain unwilling to take anticoagulation, in particular warfarin, despite being at high risk of stroke. The systematic review by Ogilvie, Newton, Welner, Cowell, and Lip (2010) supports that patients with AF at a high risk for stroke are commonly under treated with antithrombotic therapy.…”