Assistant Professor Department of Internal Medicine Hospital Medicine Division Medical Director UNM Anticoagulation Clinic CoDirector Antithrombotic Stewardship Roadmap Direct oral anticoagulants ID: 731481
Download Presentation The PPT/PDF document "Antithrombotic Therapy Taylor B Goot MD" is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Antithrombotic Therapy
Taylor B Goot MD
Assistant Professor
Department of Internal Medicine – Hospital Medicine Division
Medical Director – UNM Anticoagulation Clinic
Co-Director Antithrombotic StewardshipSlide2
Roadmap
Direct oral anticoagulants
Bridging/Periprocedural practices
Initiating therapy
Duration of treatment
Resumption of therapy after a bleeding event
QuestionsSlide3
Roadmap
Direct oral anticoagulants
Consensus nomenclature
Indications
Currently approved use
Uses coming soon
Who should/shouldn’t get a DOACSlide4
Direct Oral Anticoagulants
Dabigatran
Apixaban
Rivaroxaban
Edoxaban
Newly FDA Approved
BetrixabanSlide5
Novel oral anticoagulant
Direct oral anticoagulant
Target specific anticoagulant
Barnes GD et al Recommendation on the nomenclature for oral anticoagulants: communication from the SSC of the ISTH. J
Thromb
Haemost
. 2015 Jun;13(6):1154-6.Slide6
Indications
Prevention of stroke in the setting of non-valvular atrial fibrillation
Treatment and prevention of deep vein thrombosis and pulmonary embolismSlide7
The Future of DOACs
New studies/further studies pending
Malignancy***
Antiphospholipid antibody syndrome
Coronary artery disease***
Peripheral artery disease
Medical prophylaxis***
Cryptogenic strokeSlide8
Why use DOACs?
Convenience
Simplified initiation and cessation
Apixaban and Rivaroxaban do not require heparin at initiation
Lack of INR monitoring
No need of dietary restriction/uniformitySlide9
But, are they safe?Slide10Slide11
Major BleedingSlide12
Intracranial HemorrhageSlide13
Fatal Bleeding
Non-Major Bleeding
GI BleedingSlide14
Use is guideline supportedSlide15
But What if My Patient Bleeds?
Short half life, might not need reversal
Idaracuzimab
Dabigatran
Andexanet
Alfa
All othersSlide16
Who shouldn’t get a DOAC?
Severe hepatic impairment
Renal impairment
Particularly ESRD on HD
Creatinine clearance <30 ml/min
The severely obese (>100-120kg, BMI >40)
The uninsured and/or patients with a high cost
Drug-drug interactionsUnstudied prothrombotic statesAntiphospholipid antibody syndromeHeparin induced thrombocytopeniaSlide17
Who shouldn’t get a DOAC? (
cont
)
Patients in whom medication and/or appointment adherence is an issue.Slide18
Reduced Dose DOACs
Reduced dose DOACs for prevention of recurrent VTE.Slide19Slide20
EINSTEIN
CHOICE
Recurrent VTE
Major Bleeding
AMPLIFY - EXT
Recurrent VTE
Major/Nonmajor BleedingSlide21
Reduced Dose DOACs
Conclusion:
In a select patient population, reduced dose DOACs reduced recurrent VTE similarly to their full dose.
Bleeding rates were decreased approaching that of ASA (rivaroxaban) or no therapy (apixaban)Slide22
Roadmap
Direct oral anticoagulants
Bridging/Periprocedural practices
Initiating therapy
Duration of treatment
Resumption of therapy after a bleeding event
QuestionsSlide23
Periprocedural Bridging practices in the Setting of Atrial FibrillationSlide24
Circulation. 2012;126:1630-1639.Slide25
Thromboembolic Events
Bleeding EventsSlide26Slide27
2015Slide28Slide29
BRIDGE Trial
Exclusion criteria
Mechanical heart valve, Embolism, TIA, Stroke within the last 12 weeks.
Major bleeding within the last 6 weeks
PLT < 100,000Slide30Slide31Slide32
What we know
Stroke risk ≠ 0
Unclear if there is reduction in thromboembolic events with bridging
Clearly increased bleeding risk with bridgingSlide33
UNM Periprocedural Anticoagulation Management ProtocolSlide34
No need to bridge with DOACs
https://www.sec.gov/Archives/edgar/data/1269021/000156459015001190/g201503021954430491802.jpgSlide35
Roadmap
Direct oral anticoagulants
Bridging/Periprocedural practices
Initiating therapy
Duration of treatment
Resumption of therapy after a bleeding event
QuestionsSlide36
35
yo
, previously healthy patient presents a few weeks after a knee surgery with lower extremity swelling. A DVT is diagnosed via an expedited doppler US.
Has IUD in place with no plans to remove in near futureSlide37
Discuss
What would you do?
What are your options?Slide38
Initiating warfarin
VTE
At least 5 days of overlap with a parenteral anticoagulant, until within therapeutic range on 2 measurements 24 hours apart.
Atrial fibrillation
Bridge?Slide39
Initiating a DOAC
Rivaroxaban and ApixabanSlide40
Roadmap
Direct oral anticoagulants
Bridging/Periprocedural practices
Initiating therapy
Duration of treatment
Resumption of therapy after a bleeding event
QuestionsSlide41
Duration of Therapy
More related to recurrence risk than treatment of the clot itself.Slide42
What do we know about recurrence risk?
3 major factors
Duration of initial treatment
Location of clot
Provoked vs UnprovokedSlide43
Duration of initial treatment
If you treat for
< 3 mo.
risk jumps
Boutitie
et al BMJ
2011;342:d3036Slide44
PE > Proximal DVT > Distal DVT
Boutitie
et al BMJ
2011;342:d3036Slide45
Provoked vs Unprovoked
24
mos
Boutitie
et al BMJ
2011;342:d3036Slide46
Paolo
Prandoni
et al
Haematologica
Feb 2007, 92 (2) 199-205;
DOI:
10.3324/haematol.10516Slide47
What is a provoking agent?
Definite
Surgery or trauma
Estrogen
Cancer
Serious medical illness
Probably
Travel
Other hormone therapyObesityAntiphospholipid antibody syndromeSlide48
Inherited
thrombophilias
are
not
considered provoking agents or even potent risk factors.Slide49
Duration of therapy?
Provoked? 3 Months
As long as the provoking agent is removed.
Unprovoked? Indefinitely
At least 3 months, shoot for 6.
Initial goal is at least three months in the absence of some bleeding risk.
Risk ≠ 0 for anyone once they’ve experience a VTESlide50
Roadmap
Direct oral anticoagulants
Bridging/Periprocedural practices
Initiating therapy
Duration of treatment
Resumption of therapy after a bleeding event
QuestionsSlide51
Resuming After Bleeding Events
Do they need to be on anticoagulation?
Was their bleeding risk modifiable?
Were they over-anticoagulated?Slide52
Should they be restarted?
Any Major Bleeding
Intracranial
GI
AllSlide53
How Long to Wait
Intracranial Hemorrhage
AHA
Don’t restart in Non-valvular
Afib
after a spontaneous lobar bleed
Non-lobar 7-10 days
European Stroke Initiative10-14 DaysAsk the neurologist or neurosurgeon for their recommendation based on the pathology.Slide54
How Long to Wait
GI Bleeding
Retrospective analysis suggests 4-7 days
Witt DM, Delate T, Garcia DA, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for gastrointestinal tract bleeding. Arch Intern Med 2012; 172:1484–1491
Brotman
DJ, Jaffer AK. Resuming anticoagulation in the first week following gastrointestinal tract hemorrhage: should we adopt a 4-day rule? Arch Intern Med 2012; 172:1492–1493. Slide55
How Long to Wait
Other sites?
Limited data exists, there is some suggestion of 4-14 days.Slide56
Roadmap
Direct oral anticoagulants
Bridging/Periprocedural practices
Initiating therapy
Duration of treatment
Resumption of therapy after a bleeding event
QuestionsSlide57
Questions/Discussion?
Thank you!
tgoot@salud.unm.edu