Hospital Length Of Stay: Does Rivaroxaban Reduce Inpatient Stay Compared To Warfarin Among Patients With Non-Valvular Atrial Fibrillation?
François LalibertéDominic PilonM. RautWoodrow NelsonWilliam H. OlsonGuillaume GermainJeffrey ScheinPatrick Lefèbvre
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Several new oral anticoagulants such as rivaroxaban (which targets Factor Xa) and dabigatran etexilate (which targets thrombin) are in advanced stages of clinical development and are already available for clinical use in some countries. Although these agents do not require routine coagulation monitoring, assays to assess the level of anticoagulation may be of assistance in certain circumstances such as in case of overdose, in patients with a hemorrhagic or thromboembolic event during treatment, or to assess compliance. Moreover, the influence of the new oral anticoagulants on routine coagulation tests must be recognized. The prothrombin time is not suitable for rivaroxaban measurement for several reasons, and the routinely used international normalized ratio for monitoring the vitamin K antagonists cannot be applied to rivaroxaban. Development of universal assays is challenging because the new oral anticoagulants have different targets, and even those with the same target have variable effects on routine coagulation assays. Focusing on rivaroxaban, there is emerging evidence that an anti-Factor Xa assay that uses rivaroxaban-containing plasma calibrators may provide the optimal method for determining plasma rivaroxaban concentrations.
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Rivaroxaban is a Direct Oral Anticoagulant (DOAC), which has six licensed indications, including the use for prevention of stroke and systemic embolism with non-valvular Atrial Fibrillation (AF) and the treatment of Venous Thromboembolism (VTE). The pharmacokinetics and the pharmacogenetics of rivaroxaban are reviewed by the author because of a previously reported case of a 43-year-old Caucasian female, who was diagnosed with popliteal and calf Deep Venous Thrombosis (DVT) while on anticoagulation treatment in the form of rivaroxaban 20 mg PO daily. This treatment was started because of a previously verified bilateral Pulmonary Embolism (PE) 5 months earlier. Rivaroxaban is more frequently used in clinical practice, and many physicians are aware that rivaroxaban requires adaptation mainly on the patient's renal function. However, there is still a need to increase awareness of rivaroxaban's interactions with drugs that share its pathways when the hepatic CYP450 and/or P-gp/BCRP are involved. These pathways are utilized by several medications, which are used in cardiovascular and neurological diseases, and the treatment of infections. These interactions can result in under or overexposure to rivaroxaban, which both effects can be detrimental. The author makes several cautious suggestions to decrease the incidence of under/overexposure of rivaroxaban. Physicians, including primary care physicians, could receive a clinical course focusing on DOACs for anticoagulation treatment or direct clinical training within a short-term Anticoagulation Team (ACT) stewardship program concerning adequate prescriptions of rivaroxaban/DOAC as well as their interactions. Also, patients who are elderly and/or with polypharmacy while taking rivaroxaban require more frequent controls. Furthermore, research exploring the effects of ABCG1, ABCG2, CYP3A4, CYP3A5, and Drug-Drug Interactions (DDI), is warranted. Finally, there is a need to identify a validated method for measuring rivaroxaban in primary care.
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The main treatment for Antiphospholipid syndrome (APS) is long-term anticoagulation with an oral vitamin K antagonist, although these are associated with numerous problems. Rivaroxaban is a direct anti-factor Xa inhibitor, with a predictable anti-coagulant effect at fixed doses. There are limited reports of rivaroxaban use in APS. We present four cases of patients with APS who received rivaroxaban treatment for six months without thrombosis recurrence or bleeding. Three of the patients received rivaroxaban as initial therapy. In the systematic review, only five patients were treated with rivaroxaban as a thromboprophylaxis. Of the 71 cases of rivaroxaban use including our study, there were seven cases (9.9%) of thrombosis recurrence and two reports of bleeding. The efficacy of rivaroxaban in APS patients was at least equal to warfarin therapy. This report and systematic review suggest that rivaroxaban can be considered cautiously as a thromboprophylactic or alternative therapy for warfarin in patients with APS.
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Aim Warfarin is a cornerstone for the prevention of thromboembolism in atrial fibrillation (AF), and several efforts have been taken to increase its usage and safety, including risk stratification schemes. Our aim was to investigate the temporal trends in initiation of warfarin and its effects on incidence of bleeding and thromboembolism in patients with new-onset atrial fibrillation 1996–2011. Methods All patients with a first-time diagnosis of non-valvular atrial fibrillation were identified from nationwide administrative registries. Trends were determined by linear regression. Results In total 153,682 patients were included. Initiation of warfarin increased from 14% to 41% (p<0.0001). Events of thromboembolism decreased from 3.9% to 2.6% annually (p<0.0001). The greatest decline in thromboembolic events was observed for patients with a CHA2DS2VASc score >1, where the annual decline was -0.12% (95%CI: -0.161; -0.084)) for those treated with warfarin and -0.073% (95%CI: -0.116;-0.030)) for those not treated with warfarin. Bleeding increased from 3.3% to 3.9% (p = 0.043). For those with a CHA2DS2VASc score >1 annual bleeding rates increased by 0.095% (95%CI: -0.025; -0.165) in warfarin treated and by 0.056% (95%CI: -0.013; -0.100) in patients not treated with warfarin. Conclusion Warfarin use increased by nearly a 3-fold between 1996 and 2011. During the same period, thromboembolic events declined by a third and bleeding increased by a fifth, suggesting a beneficial effect associated with higher warfarin use. Notably, a small decline in thromboembolic events and increase in bleeding events was observed for the untreated population, suggesting a changing risk profile of AF patients.
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Background: The aims of this study were to investigate the effects of rivaroxaban on routine coagulation assays using our local, widely available, reagents and to study the relationship between sensitive coagulation assays and bleeding risk caused by rivaroxaban.Methods: Prothrombin time (PT), activated partial thromboplastin time (APTT) and anti-factor Xa (FXa) chromogenic assays (Biophen DiXaI) and inhibition of FXa activity were performed in normal pooled plasma (NPP) spiked with rivaroxaban and plasma samples from patients treated with rivaroxaban.Results: In vitro, the linear correlation coefficient of measured concentrations of rivaroxaban, by Biophen DiXaI, and spiked concentrations of rivaroxaban was 0.99. PT and APTT showed good linear correlation with rivaroxaban concentrations, while other assays showed poor correlation. In vivo, PT showed a moderate linear correlation with rivaroxaban concentrations while APTT had a weak correlation with rivaroxaban concentrations. In vitro and in vivo, the rivaroxaban concentrations, measured by Biophen DiXaI, always showed good correlation with the inhibition of FXa activity, and PT values showed moderate correlation with the inhibition of FXa activity.Conclusions: Biophen DiXaI can be considered as a quantitative method to monitor the anticoagulation activity of rivaroxaban, and could be used to evaluate bleeding risk caused by rivaroxaban. The PT reagent (Thrombosis S) could be considered as a rough method to monitor the anticoagulation activity of rivaroxaban and evaluate bleeding risk caused by rivaroxaban.
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The objective of this study was to examine and evaluate the frequency of bleeding and serious drug interactions among patients with atrial fibrillation (AF) treated with oral anticoagulant [Warfarin]. A random sample of 59 patients from Al-Watni government hospital in Nablus with a principal or secondary discharge diagnosis of AF was identified. All drug and clinical data were abstracted from the patient's files. We excluded patients who were less than 65 years of age, or left the hospital against medical advice, and those whose AF was transient or could not be confirmed. Of the original 59 AF patients, 19 were cliagnosed who were discharged on Warfarin. The mean age for these patients was 71.7 years. Among the patients discharged on Warfarin, 94.7 % had one or more drug – drug interactions that could lead to increased risk of bleeding. Many patients discharged on Warfarin were having multiple interacting drugs. Patient counseling and follow-up monitoring are essential and should be carried out to minimize the risk of bleeding and other complications. الاهداف: اختبار وتقييم احتمالية الإصابة بالنزيف والتداخلات الدوائية عند المرضى المصابين ب atrial fibrillation ويستخدمون المميعات الدموية (warfarin). طريقة البحث: عينة عشوائية مكونة من 59 مريضا"" تم تشخيصهم ب atrial fibrillation في المستشفى الوطني الحكومي – نابلس. وقد تم استخلاص جميع الأدوية والمعلومات السريرية من ملفات المرضى. كما تم استثناء المرضى الذين تقل اعمارهم عن 65 سنة، أو الذين خرجوا من المستشفى خلافا"" لنصيحة الطبيب، أو اولئك الذين كانو يعانون من حالة atrial fibrillation مؤقتة أو لم يتم تأكيدها. النتائج: لقد توصلت الدراسة إلى أنه من أصل 59 مريضا"" مصاباً atrial fibrillation، هناك 19 مريضا"" تم اخراجهم من المستشفى بوصفة warfarin. وكان معدل أعمار هؤلاء المرضى 71.7 سنة. ومن بين المرضى الذين تم صرف دواء warfarin لهم كان 94.7% لديهم تداخلات دوائية (واحد أو أكثر) من هذه التداهلات قد تؤدي الى خطر النزيف. المناقشة والاستنتاج: عدد كبير من المرضى الذين تم صرف دواء warfarin
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Background: Cystic echinococcosis is a clinically complex chronic parasitic disease and a major socioeconomic problem in endemic areas. The safety of liver resection in elderly patients is often debated among medical professionals. We analyzed the postoperative morbidity and mortality rates of elderly patients who underwent surgery at our unit.Methods: We retrospectively evaluated patients with liver hydatid cysts which were surgically removed at our unit. Patients were divided into two groups: Group 1 (patients < 70 years), and Group 2 (patients ≥ 70 years). Propensity score matching (PSM) and comparative analyses between groups were performed.Results: The unmatched cohort consisted of 279 patients (Group 1: 244; Group 2: 35). After PSM, we compared the outcomes for 56 patients from Group 1 to 31 patients from Group 2. A higher rate of severe complications was observed in Group 2 (25.8% vs 5.36%, p = 0.014). No difference was found in the rates of infectious, cardiorespiratory, or hemorrhagic complications between both groups, and in the mortality rate either (0.00% vs 6.45%, p = 0.124).Conclusions: Liver surgery in selected elderly patients is safe and practicable. The low postoperative morbidity rate in these patients is acceptable, albeit higher, due to their comorbidities.
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