The Pharmacodynamic Effect of ELIQUIS Can Be Expected to Persist for at Least 24 Hours After the Last Dose, Ie, for About Two Drug Half Lives
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Enoxaparin Sodium Solution for Injection, Manufacturer's Standard
PRODUCT MONOGRAPH INCLUDING PATIENT MEDICATION INFORMATION PrLOVENOX® Enoxaparin sodium solution for injection 30 mg in 0.3 mL solution (100 mg/mL), pre-filled syringes for subcutaneous or intravenous injection 40 mg in 0.4 mL solution (100 mg/mL), pre-filled syringes for subcutaneous or intravenous injection 60 mg in 0.6 mL solution (100 mg/mL), pre-filled syringes for subcutaneous or intravenous injection 80 mg in 0.8 mL solution (100 mg/mL), pre-filled syringes for subcutaneous or intravenous injection 100 mg in 1 mL solution (100 mg/mL), pre-filled syringes for subcutaneous or intravenous injection 300 mg in 3 mL solution (100 mg/mL), multidose vials for subcutaneous or intravenous injection PrLOVENOX® HP Enoxaparin sodium (High Potency) solution for injection 120 mg in 0.8 mL solution (150 mg/mL), pre-filled syringes for subcutaneous or intravenous injection 150 mg in 1 mL solution (150 mg/mL), pre-filled syringes for subcutaneous or intravenous injection Manufacturer’s standard Anticoagulant/Antithrombotic Agent ATC Code: B01AB05 Product Monograph – LOVENOX (enoxaparin) Page 1 of 113 sanofi-aventis Canada Inc. Date of Initial Approval: 2905 Place Louis-R.-Renaud February 9, 1993 Laval, Quebec H7V 0A3 Date of Revision September 7, 2021 Submission Control Number: 252514 s-a version 15.0 dated September 7, 2021 Product Monograph – LOVENOX (enoxaparin) Page 2 of 113 TABLE OF CONTENTS Sections or subsections that are not applicable at the time of authorization are not listed. TABLE OF CONTENTS .............................................................................................................. -
Interindividual Variability of Apixaban Plasma Concentrations: Influence of Clinical and Genetic Factors in a Real-Life Cohort O
G C A T T A C G G C A T genes Article Interindividual Variability of Apixaban Plasma Concentrations: Influence of Clinical and Genetic Factors in a Real-Life Cohort of Atrial Fibrillation Patients Adela-Nicoleta Ro¸sian 1,2, ¸StefanHoria Ro¸sian 2,3,* , Bela Kiss 4 , Maria Georgia ¸Stefan 4, Adrian Pavel Trifa 5, Camelia Diana Ober 2, Ovidiu Anchidin 2 and Anca Dana Buzoianu 1 1 Department of Pharmacology, Toxicology and Clinical Pharmacology, Iuliu Ha¸tieganuUniversity of Medicine and Pharmacy Cluj-Napoca, 400337 Cluj-Napoca, Romania; [email protected] (A.-N.R.); [email protected] (A.D.B.) 2 “Niculae Stăncioiu” Heart Institute Cluj-Napoca, 400001 Cluj-Napoca, Romania; [email protected] (C.D.O.); [email protected] (O.A.) 3 Department of Cardiology, Heart Institute, Iuliu Ha¸tieganuUniversity of Medicine and Pharmacy Cluj-Napoca, 400001 Cluj-Napoca, Romania 4 Department of Toxicology, Faculty of Pharmacy, Iuliu Ha¸tieganuUniversity of Medicine and Pharmacy Cluj-Napoca, 400349 Cluj-Napoca, Romania; [email protected] (B.K.); [email protected] (M.G.¸S.) 5 Department of Genetics, Iuliu Ha¸tieganuUniversity of Medicine and Pharmacy Cluj-Napoca, 400349 Cluj-Napoca, Romania; [email protected] * Correspondence: [email protected]; Tel.: +4026-459-1224 Received: 11 March 2020; Accepted: 14 April 2020; Published: 17 April 2020 Abstract: (1) Background: Prescribing apixaban for stroke prevention has significantly increased in patients with non-valvular atrial fibrillation (NVAF). The ABCB1 genotype can influence apixaban absorption and bioavailability. The aim of the present study was to assess the factors that influence apixaban’s plasma level and to establish if a certain relationship has clinical relevance. -
Clinical Protocol
CLINICAL PROTOCOL Subject: Page Protocol # EMERGENT TREATMENT OF PATIENTS WITH BLEEDING AND 1 of 4 NMH CCP 07.0024 CLOTTING EMERGENCIES WHO ARE TAKING NOVEL ORAL ANTICOAGULANTS Version: 1.0 Title: Revision of: Effective Date: EMERGENT TREATMENT OF PATIENTS WITH BLEEDING AND NEW 04/29/2013 CLOTTING EMERGENCIES WHO ARE TAKING NOVEL ORAL Removal Date: ANTICOAGULANT APIXABAN (ELIQUIS) I. PURPOSE: To standardize management of patients with bleeding and clotting emergencies who are taking novel oral anticoagulants (NOACs). This protocol covers emergent reversal and ischemic stroke in patients on apixaban (Eliquis) therapy. II. CLINICAL PROTOCOL: A. The NOAC apixaban (Eliquis) is FDA approved for stroke prevention in patients with atrial fibrillation. This agent presents clinicians with several challenges because there are no specific antidotes, and no readily available quantitative assay to determine the degree of anticoagulation in a patient on this therapy. B. Patients taking this agent are likely to present to the hospital with; 1. life-threatening bleeding (e.g., intracerebral hemorrhage or GI bleeding), or a need for an emergent invasive procedure (surgery, cardiac Catherization) 2. acute ischemic stroke. The administration of tissue plasminogen activator (IV tPA) in the setting of NOAC use is potentially dangerous. C. There are no accepted evidence-based guidelines for managing these situations. This protocol is a consensus of clinicians from stroke, neurology, neurosurgery, hematology, neurocritical care, laboratory medicine, cardiology, and pharmacy. III. REVERSAL PROTOCOL FOR PATIENTS WITH SEVERE/LIFE-THREATENING BLEEDING TAKING APIXABAN (ELIQUIS) A. Inclusion criteria: 1. Patient has taken any dose of apixaban within last 48 hours. a. If time of last dose is unknown, but patient is suspected of having taken apixaban in last 48 hours, and PT is abnormal and 2. -
STUDY PROTOCOL Study Information Title Apixaban Drug
Apixaban B0661076NON-INTERVENTIONAL STUDY PROTOCOL Final, 15-Feb-2016 NON-INTERVENTIONAL (NI) STUDY PROTOCOL Study information Title Apixaban drug utilization study in Stroke prevention in atrial fibrillation (SPAF) Protocol number B0661076 AEMPS Code PFI-API-2016-01 Protocol version identifier 4.0 Date of last version of protocol 15-Feb-2016 Active substance Apixaban B01AF02 Medicinal product Eliquis® Research question and objectives Evaluate the apixaban utilization according to the approved SPAF indication and recommendations by EMA. The study objectives are: Objective 1: To characterise patients using apixaban according to demographics, comorbidity, risk of thromboembolic events (CHADS2 and CHA2DS2-Vasc scores), risk of bleeding events (HAS-BLED score), comedications and compare it with the profile of patients treated with VKA, dabigatran and rivaroxaban. Objective 2: Describe the level of appropriate usage according to the posology recommended in the apixaban SmPC. Objective 3: Describe the potential interactions with other drugs prescribed concomitantly according with the SmPC recommendations. Objective 4: Estimate the level of apixaban adherence by the medication possession ratio (MPR) and discontinuation rates and compare it with VKA, dabigatran and CT24-GSOP-RF03 NI Study Protocol Template; Version 3.0, Effective Date 10-Oct-2014 Pfizer Confidential Page 1 of 28 Apixaban B0661076NON-INTERVENTIONAL STUDY PROTOCOL Final, 15-Feb-2016 rivaroxaban cohort. Objective 5: To analyze INR (International Normalized Ratio) values during the last 12 months and to obtain TTR (Time in Therapeutic Range) values in patients previously treated with VKA and, during the whole study period for those in the cohort treated with VKA Author Ángeles Quijada Manuitt, IDIAP Jordi Gol Rosa Morros Pedrós, IDIAP Jordi Gol Jordi Cortés, IDIAP Jordi Gol José Chaves Puertas, Pfizer SLU Sponsor Pfizer S.L.U Avda. -
Standard-Dose Apixaban After Very Low-Dose Thrombolysis for Acute Intermediate-High Risk Acute Pulmonary Embolism
SAFE-LYSE | STUDY PROTOCOL Standard-dose Apixaban AFtEr Very Low-dose ThromboLYSis Title: for Acute Intermediate-high Risk Acute Pulmonary Embolism Short Title: SAFE-LYSE Protocol Version: Issue Date: 28/AUG/2019 Principal Victor Tapson1,2, Aaron Weinberg1,2 Investigators: Sub Investigators: Sam Torbati1, Susan Jackman1, Niree Hindoyan1, Joseph Meza1 1Cedars-Sinai Medical Center 8700 Beverly Blvd Los Angeles, CA 90048 Affiliations: 2Cedars-Sinai Medical GrouP 200 N. Robertson Blvd. Beverly Hills, CA 90211 Victor TaPson 8730 Alden Drive, W155 Primary Contact: Los Angeles, CA 90048 (919) 971-6441 Investigator-Initiated Bristol-Myers Squibb Company (BMS) Study Funded By: Version 8.0 | Date: 28Aug2019 1 SAFE-LYSE | STUDY PROTOCOL STUDY SYNOPSIS Funding Provided by BMS/Pfizer Alliance Standard-dose Apixaban AFtEr Very Low-dose ThromboLYSis for Protocol Title Acute Intermediate-high Risk Acute Pulmonary Embolism (SAFE-LYSE) Pulmonary embolism (PE) is a major cause of mortality in the United States, with an estimated 100,000 deaths annually and uP to 30% of Patients dying within the first month of diagnosis. Recent guidelines now risk-stratify intermediate-risk PE Patients to intermediate-low and intermediate-high risk categories, but consensus on treatment for those Patients are controversial, as compared to that of high or low-risk Patients. Because of an increased risk of major, non-major, and intracranial bleeding and an uncertain effect on survival and Post-thrombotic complications, thrombolysis is not routinely recommended in the guidelines for intermediate- risk Patients. However, studies have evaluated half-dose (50 mg dose) tissue Plasminogen activator (tPA) and this aPPears to be effective for treating PE with a reduced yet still significant risk of bleeding. -
New Age of Anticoagulants
New Age of Anticoagulants DP Suresh MD FACC FSCAI Director, Heart and Vascular Group ST Elizabeth Physicians, KY Associate Professor of Medicine, University of Cincinnati. Low-Molecular-Weight Heparins Potential Advantages: • Lack of binding to plasma proteins and endothelium • Good bioavailability • Stable dose response • Long half-life • Resistance does not develop Direct Factor Xa inhibition Tissue XIIa factor XIa VIIa IXa ×Xa Factor II (prothrombin) Fibrinogen Fibrin clot Factor Xa inhibitors FXa may be a better target than thrombin – Has few functions outside coagulation (compared with thrombin) – Has a wider therapeutic window than thrombin (separation of efficacy and bleeding), in vitro – Thrombin inhibitors are associated with rebound thrombin generation – no evidence with FXa inhibitors – Efficacy of heparin-based anticoagulants improves as selectivity for FXa increases: UFH < LMWH < fondaparinux New anticoagulants ORAL PARENTERAL TF/VIIa TFPI (tifacogin) TTP889 X IX IXa APC (drotrecogin alfa) VIIIa sTM (ART-123) Rivaroxaban Apixaban Va AT Fondaparinux LY517717 Xa YM150 Idraparinux DU-176b PRT-054021 II DX-9065a Ximelagatran Otamixaban Dabigatran IIa Fibrinogen Fibrin Adapted from Weitz & Bates, J Thromb Haemost 2005 Oral Factor Xa inhibitors Clinical development Rivaroxaban (JNJ/Bayer) Phase IIb Phase III Apixaban (BMS) Phase III YM150 (Astellas) Phase IIb DU-176b (Daiichi) Phase IIb LY517717 (Lilly) Phase IIb 813893 (GSK) Phase I/II PRT054021(Portola) Phase II Stroke: A significant cause of poor health and Death • Stroke accounts for nearly 10% of all deaths worldwide • The number of strokes per year is predicted to rise dramatically as the population ages • About 20-30% strokes are cardio embolic and 15% relate to AF • Strokes in patients with AF are more severe and have worse outcomes than strokes in people without AF • AF almost doubles the death rate from stroke. -
Edoxaban Switch Programme - Frequently Asked Questions
Edoxaban Switch Programme - Frequently Asked Questions What should I tell patients? NHS Tayside is reviewing all patients currently receiving a Direct Oral Anticoagulant (DOAC) for stroke prevention in NV-AF(non-valvular atrial fibrillation) Edoxaban has been identified as the first choice DOAC. It is similarly effective to the other DOAC options but costs considerably less Clinical experts in Tayside are supporting the use of edoxaban All newly diagnosed NV-AF patients will be started on edoxaban as 1st choice for those unsuitable for warfarin Existing patients already on a DOAC for NV-AF are to be reviewed and considered for switch to edoxaban This will help to ensure that the money available to spend on medicines is being used appropriately Is edoxaban as good as the other DOACs? Yes, the evidence is that it is as effective as warfarin and the other DOACs. It is licensed for this indication and has been recommended by the Scottish Medicines Consortium Other Scottish Health Boards are also considering the use of edoxaban A recent Health Improvement Scotland (HIS) summary (http://www.healthcareimprovementscotland.org/our_work/cardiovascular_dis ease/programme_resources/doac_review_report.aspx) is consistent with this Tayside switch recommendation Lead clinicians from cardiology, stroke, vascular medicine, relevant MCN’s and haematology are all supportive of this Tayside guidance on the basis of current evidence Will we need to do a further switch if the price of other DOACs falls? The rebate on edoxaban is in place for five -
Rtpa) for the Treatment of Hepatic Veno-Occlusive Disease (VOD
Bone Marrow Transplantation, (1999) 23, 803–807 1999 Stockton Press All rights reserved 0268–3369/99 $12.00 http://www.stockton-press.co.uk/bmt Recombinant tissue plasminogen activator (rtPA) for the treatment of hepatic veno-occlusive disease (VOD) S Kulkarni1, M Rodriguez2, A Lafuente2, P Mateos2, J Mehta1, S Singhal1, R Saso3, D Tait4, JG Treleaven3 and RL Powles1 Departments of 1Medical Oncology, 3Haematology and 4Radiotherapy, Royal Marsden NHS Trust, Sutton, Surrey, UK; and 2Haematology Department, Hospital La Paz, Madrid, Spain Summary: clinical syndrome characterized by hyperbilirubinemia, hepatomegaly and fluid retention,2,3 and results from dam- Seventeen patients who developed hepatic veno-occlus- age to structures in zone 3 of the liver acinus.4 In patients ive disease (VOD) following hematopoietic stem cell who have undergone hematopoietic stem cell transplan- transplantation were treated with recombinant tissue tation, chemoradiotherapy-induced endothelial cell damage plasminogen activator (rtPA) with or without heparin. is likely to be responsible for the pathogenesis of vessel rtPA was started a median of 13 days post transplant obstruction.5 (range 4–35). All patients received rtPA at a dose of 10 Treatment of established VOD has primarily been sup- mg/day as a starting dose, and 12 patients also received portive and any specific measures have resulted in little heparin (1500 U bolus; then 100 U/kg/day as a continu- impact on outcome. Based on the available evidence for ous i.v. infusion). The median number of days of rtPA involvement of hemostatic mechanisms and cytokines in therapy was 2.5 (1–12). The median total serum biliru- the pathogenesis of VOD,6–8 anti-thrombotic and anti-cyto- bin level was 116 mmol/l (range 63–194) at the begin- kine agents have been assessed for their role in treatment. -
SIGN 129 • Antithrombotics: Indications and Management
Help us to improve SIGN guidelines - click here to complete our survey SIGN 129 • Antithrombotics: indications and management A national clinical guideline Updated June 2013 Evidence KEY TO EVIDENCE STATEMENTS AND GRADES OF RECOMMENDATIONS LEVELS OF EVIDENCE 1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias 1+ Well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias 1 - Meta-analyses, systematic reviews, or RCTs with a high risk of bias High quality systematic reviews of case control or cohort studies ++ 2 High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal Well conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the 2+ relationship is causal 2 - Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal 3 Non-analytic studies, eg case reports, case series 4 Expert opinion GRADES OF RECOMMENDATION Note: The grade of recommendation relates to the strength of the evidence on which the recommendation is based. It does not reflect the clinical importance of the recommendation. At least one meta-analysis, systematic review, or RCT rated as 1++, and directly applicable to the target population; or A A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population, and demonstrating overall consistency of results -
Emergency Management of Patients on Direct Oral Anticoagulants (Doacs)
Emergency Management of Patients on Direct Oral Anticoagulants (DOACs) Dr Tina Biss Consultant Haematologist Newcastle upon Tyne Hospitals NHS Foundation Trust NE RTC Annual Education Symposium 11 th October 2016 The extent of the problem ≈1-2% of the UK population are anticoagulated 70000 60000 AF 70% VTE 25% 50000 Other 5% 40000 30000 20000 10000 0 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014 90 80 8% of individuals 70 >80 years of age are anticoagulated 60 50 40 30 20 10 0 0 20 40 60 80 100 Age distribution of patients on warfarin 2010 2016 Apixaban Rivaroxaban Warfarin Dabigatran Edoxaban Targets of Direct Oral Anticoagulants ORAL PARENTERAL TF/VIIa TTP889 TFPI (tifacogin) X IX Xa Inhibitors : IXa APC (drotrecogin alfa) VIIIa Rivaroxaban sTM (ART-123) Apixaban Edoxaban Va AT LY517717 Indirect Xa inhibitors YM150 Xa Fondaparinux PRT-054021 Idraparinux II SSR-126517 Direct Xa Inhibitors IIa Inhibitors DX-9065a Ximelagatran IIa Otamixaban Dabigatran Fibrinogen Fibrin TF=tissue factor Adapted from Weitz JI et al. J Thromb Haemost. 2005;3:1843-1853. The ideal anticoagulants? • Oral administration • Rapid onset of action • Relatively short half-life • Predictable pharmacokinetics No need for monitoring • Few drug or dietary interactions • Modest risk of bleeding • Rapidly reversible Predictable dose-response relationship No monitoring required Few drug interactions No dietary interactions Current agents and licensed indications Dabigatran Rivaroxaban Apixaban Edoxaban (IIa inhibitor (Xa inhibitor) (Xa inhibitor) (Xa inhibitor) -
Transition of Anticoagulants 2019
Transition of Anticoagulants 2019 Van Hellerslia, PharmD, BCPS, CACP, Brand Generic Clinical Assistant Professor of Pharmacy Practice, Angiomax bivalirudin Temple University School of Pharmacy, Philadelphia, PA Arixtra fondaparinux Bevyxxa betrixaban Pallav Mehta, MD, Assistant Professor of Medicine, Coumadin warfarin Division of Hematology/Oncology, Eliquis apixaban MD Anderson Cancer Center at Cooper, Camden, NJ Fragmin dalteparin Lovenox enoxaparin Reviewer: Kelly Rudd, PharmD, BCPS, CACP, Pradaxa dabigatran Clinical Specialist, Anticoagulation, Bassett Medical Center, Savaysa edoxaban Cooperstown, NY Xarelto rivaroxaban From To Action Apixaban Argatroban/ Wait 12 hours after last dose of apixaban to initiate parenteral anticoagulant. In cases of Bivalirudin/ high bleeding risk, consider omitting initial bolus when transitioning to heparin infusion. Enoxaparin/ Dalteparin/ Fondaparinux/ Heparin Apixaban Warfarin When going from apixaban to warfarin, consider the use of parenteral anticoagulation as a bridge (eg, start heparin infusion or therapeutic enoxaparin AND warfarin 12 hours after last dose of apixaban and discontinue parenteral anticoagulant when INR is therapeutic). Apixaban affects INR so that initial INR measurements during the transition may not be useful for determining the appropriate dose of warfarin. Apixaban Betrixaban, Wait 12 hours from last dose of apixaban to initiate betrixaban, dabigatran, edoxaban, or Dabigatran, rivaroxaban. Edoxaban, or Rivaroxaban Argatroban Apixaban, Start apixaban, betrixaban, dabigatran, -
(Dipotassium Salt) and Heparin on the Estimation of Packed Cell Volume
J Clin Pathol: first published as 10.1136/jcp.19.2.196 on 1 March 1966. Downloaded from J. clin. Path. (1966), 19, 196 Effect of ethylene-diamine-tetra-acetic acid (dipotassium salt) and heparin on the estimation of packed cell volume C. A. PENNOCK AND K. W. JONES From the Department of Haematology, Gibson Laboratories, Radcliffe Infirmary, Oxford SYNOPSIS The effect of varying concentrations of ethylene-diamine-tetra-acetic acid (E.D.T.A.) (dipotassium salt) and heparin on the estimation of packed cell volume has been studied using a microhaematocrit method. Varying concentrations of E.D.T.A. can produce serious errors in estimation of packed cell volume (P.C.V.) and reliable results are only obtained within the range of 1 to 2 mg./ml. Heparin is a more suitable anticoagulant for this investigation as varying the con- centration has little effect. Storage with either anticoagulant at suitable concentrations for 24 hours at room temperature has little influence on the results. The estimation ofthe packed cell volume (P.C.V.) is bottles are often returned to this laboratory contain- regarded as a reliable investigation in the diagnosis ing less than the recommended amount of blood.copyright. of anaemia, and errors in the estimation of mean Ethylene-diamine-tetra-acetic acid is known to corpuscular haemoglobin concentration (M.C.H.C.) cause distortion and shrinkage of red cells and are thought to be due more often to errors in the to affect the estimation of P.C.V. by conventional estimation of haemoglobin than of the P.C.V.