Anticoagulants Presentation, Kenneth Acha MD
IEHP Formulary:
Rivaroxaban should be taken with food, and it interacts with cytochrome P450 3A4 and P-glycoprotein inhibitors. Dabigatran may be affected by P-glycoprotein inducers or inhibitors. Dose adjustment may be required for these medications.
Weakness of DOACS
- High cost.
- Many don’t have reversal agents. Only dabigatran has it. Idarucizumab (Praxbind), a monoclonal antibody that binds dabigatran in the serum.
- Shorter half-lives than warfarin. That means missed doses or premature discontinuation increases the risk of thrombotic events.
- Renal elimination. The elimination of DOACs is more dependent on renal function than with warfarin, dose adjustment may be required for patients with chronic kidney disease.
- No data for pregnant women, active cancer patients, and morbidly obese people. The initial studies of the DOACs excluded these populations. As such, there are no data to guide therapy in these groups
Serious bleeding on a DOAC other than dabigatran.
For patients experiencing a devastating bleed, such as intracranial hemorrhage, treatment includes:
- stopping the DOAC,
- Start supportive therapy; and
- Give activated charcoal,
- antifibrinolytic agents, and
- prothrombin complex concentrate (PCC)
- Hemodialysis should be considered for severe cases in patients taking dabigatran. It is not effective for patients taking factor Xa inhibitors.
AAFP 2017
For patients with recurrent VTE who are already taking an oral anticoagulant, LMWH is recommended over other oral anticoagulants.
For patients with recurrent VTE who are taking a LMWH, the dose should be increased by 25% to 33%.
“If there are no contraindications, current guidelines recommend anticoagulation for a minimum of three months for PE and proximal DVT. If a reversible provoking factor is identified as the cause of VTE, anticoagulation beyond three months is not recommended. Extended anticoagulation is recommended for patients with an unprovoked VTE and low risk of bleeding.8,9 Indefinite anticoagulation is recommended for patients with a second VTE and low or moderate risk of bleeding.”
The difference between antiplatelets and anticoagulants.
Novel Oral Anticoagulants, Part I
Novel oral Anticoagulants, Part II
Novel oral Anticoagulants, Part III
Mnemonic for the Anticoagulants
Anticoagulants and Thrombolytics
Anticoagulation and thrombolysis
Anticoagulation 2/2 to atrial fibrillation
CHA2DS2-VASc score: The CHADS2 score is a clinical prediction rule for estimating the risk of stroke in patients with non-rheumatic atrial fibrillation (AF)