DOCSLIB.ORG

Original Article Comparison of Anticoagulant and Antiplatelet

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Original Article Comparison of Anticoagulant and Antiplatelet Int J Clin Exp Med 2017;10(11):15359-15367 www.ijcem.com /ISSN:1940-5901/IJCEM0057429 Original Article Comparison of anticoagulant and antiplatelet therapy in patients with ST-segment elevation myocardial infarction undergoing primary percutaneous coronary intervention (PCI) Qianhui Li, Yin Xiang, Yong Tang, Yachen Zhang Department of Cardiology, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China Received December 8, 2016; Accepted October 5, 2017; Epub November 15, 2017; Published November 30, 2017 Abstract: Objective: The aim of this study was to investigate the safety and efficacy of bivalirudin plus ticagrelor com- pared with heparin plus clopidogrel in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI). Methods: 630 patients with ST-segment elevation myocardial infarction undergoing PCI were divided into a bivalirudin plus ticagrelor group and a heparin plus clopidogrel group. Patients assigned to ticagrelor were given a loading dose of 180 mg orally before PCI, followed by a maintenance dose of 90 mg twice a day. Clopidogrel was initiated with a loading dose of 600 mg and carried on with a mainte- nance dose of at least 75 mg every day. Bivalirudin or heparin was given to patients during the PCI. Results: At the end of 12-month follow-up, net adverse clinical events were observed in 32 patients (10.4%) of 308 given bivali- rudin plus ticagrelor and 58 patients (18.4%) of 315 given heparin plus clopidogrel [relative risk (RR), 0.564; 95% confidence interval (CI), 0.377-0.843; P=0.004]. The composite ischemic endpoint of death, re-infarction, target vessel revascularization, or stroke did not significantly differ between the two groups (RR, 0.670; 95% CI, 0.384- 1.169; P=0.155). The rate of 12-month bleeding in the bivalirudin plus ticagrelor group was lower than that in the heparin plus clopidogrel group (4.2% versus 9.2%, P=0.013; RR=0.458; 95% CI, 0.243-0.865). In addition, bivali- rudin combined with ticagrelor did not raise the incidence of 12-month stent thrombosis in the present study (0.6% vs 1.3% respectively, P=0.686). Conclusions: Among patients with STEMI undergoing primary PCI, bivalirudin plus ticagrelor reduced net adverse clinical events compared with heparin plus clopidogrel. This observation was mainly attributed to a decrease in bleeding events in the bivalirudin plus ticagrelor group, without statistical differences in major adverse cardiac or cerebral events or stent thrombosis compared with the heparin plus clopidogrel group. Keywords: Bivalirudin, ticagrelor, heparin, clopidogrel, percutaneous coronary intervention (PCI) Introduction tion myocardial infarction (STEMI) patients ad- mitted to a hospital in time [1, 3]. Adjunctive Coronary artery heart diseases, especially antithrombotic and antiplatelet agents are re- acute myocardial infarction, are the most com- quired to sustain patency of the infarct-related mon cause of death worldwide. More than 700 artery during and after PCI. It is necessary to million people die from coronary artery disease find a balance between safety and efficacy. each year, accounting for 12.8% among all- cause mortality. In Europe, one out of every six In a previous study, bivalirudin and ticagrelor men and one out of every seven women die respectively showed considerable benefits [4, of myocardial infarction [1]. Coronary artery 5]. In the Harmonizing Outcomes with Reva- plaque fissures cause platelet aggregation, scularization and Stents in Acute Myocardial adhesion, and thrombosis, giving rise to partial Infarction (HORIZONS-AMI) trial, STEMI patients or overall obstructive coronary arteries, which undergoing primary PCI showed reduced net is the pathophysiological basis of acute myo- clinical outcomes after pretreatment with clopi- cardial infarction [2]. Primary percutaneous dogrel and the direct thrombin inhibitor bivaliru- coronary intervention (PCI) is the main treat- din compared with heparin plus glycoprotein ment strategy among acute ST-segment eleva- (GP) IIb/IIIa inhibitors [6]. This result was attrib- Anticoagulant and antiplatelet therapy in patients with STEMI uted to a lower rate of major bleeding. Ne- months; surgical operation within 1 month; ao- vertheless, there was a high incidence of acute rtic dissection; infectious endocarditis; blood (<24 h) stent thrombosis after PCI with bivaliru- pressure >180/110 mmHg; known hemoglobin din [6]. Ticagrelor is an oral P2Y12 anti-platelet <100 g/L; thrombocytopenia; severe liver or drug that can provide a fast and invertible an- kidney dysfunction; history of bronchial asth- ti-platelet aggregation effect [7-10]. Ticagrelor ma; CABG; allergies or prohibitions to the study was once compared with clopidogrel in the drugs; patient unwilling or unable to submit Platelet Inhibition and Patient Outcomes (PL- informed consent. ATO) trial [11], which was a large-scale, pro- spective, randomized trial. Regardless of tre- Randomization and treatment atment strategy with or without ST-segment elevation, PLATO showed that ticagrelor had a Patients were randomly assigned 1:1 to receive lower rate of death, myocardial infarction, and bivalirudin plus ticagrelor or heparin plus clo- stroke than clopidogrel. In patients with STE- pidogrel after admission. Bivalirudin (Salubris ACS undergoing PCI, ticagrelor did not increa- Pharmaceuticals Co) was initiated as an intra- se incidence of major bleeding but reduced venous bolus of 0.75 mg/kg followed by infu- several secondary end points, including defi- sion of 1.75 mg/kg/h during the PCI procedure nite stent thrombosis [5]. Prasugrel plus biva- and for at least 30 minutes after PCI until he- lirudin is superior to a strategy based on clo- parin administration. Patients receiving tica- pidogrel plus heparin in terms of net clinical grlor (AstraZeneca Pharmaceuticals) were gi- outcome in STEMI patients with planned pri- ven a loading dose of 180 mg orally, followed mary PCI [12]. Whether a combination of bi- by a maintenance dose of 90 mg twice a day. valirudin and ticagrelor may have synergistic The heparin was granted a bolus dose of 100 effects with respect to ischemic and bleeding U/kg per current guidelines [1, 13, 14]. Sub- complications remains unclear. The study ai- sequent heparin was accorded with the target med at assessing the safety and efficacy of activated clotting time of 250-300 s. Clopido- bivalirudin plus ticagrelor versus clopidogrel grel (Sanofi Pharmacy) was initiated with a plus heparin for ST-segment elevation myocar- loading dose of 600 mg and carried on with a dial infarction patients during and after PCI. maintenance dose of at least 75 mg every day. If clopidogrel had already been taken prior to Materials and methods the study, an additional loading dose was gi- ven to reach a goal loading dose of 600 mg. Ethics statement On condition that the no-reflow phenomenon or other thrombotic complications occurs, tem- The study procedures were reviewed and ap- porary emergency use of tirofiban was allowed. proved by the medical ethics committee of Xinhua Hospital, Shanghai Jiaotong University All patients who had not been taking long-term School of Medicine. All patients signed inform- aspirin received an oral loading dose of 300 mg ed consent forms before randomization. aspirin prior to the randomization followed by a maintenance dose of 100 mg once daily. Study population End points and definitions All 630 patients with ST-segment elevation MI (STEMI) were recruited at Xinhua Hospital, To gain comprehensive information concerning Shanghai Jiaotong University School of Me- compliance and any occurrence of adverse dicine between October 2015 and February events, patients were followed up by special 2016. Patients were eligible for enrollment if clinic reexamination, telephones, and e-mail they were aged 18 to 80 years with STEMI with- for 12 months after randomization or until de- in 12 hours from symptom onset, or within 12 ath occurred before 12 months. Seven patients to 24 hours presented with lasting chest pain dropped out during the study period in bivaliru- or new left bundle-branch block. The major din plus ticagrelor group. exclusion criteria were as follows: cardiogenic shock; thrombolytic and anticoagulant admi- The primary end point was a composite of net nistered within 48 hours; history of major blee- adverse clinical events (NACE), including major ding or hemorrhagic tendency in the past three adverse cardiac or cerebral events (MACCE) 15360 Int J Clin Exp Med 2017;10(11):15359-15367 Anticoagulant and antiplatelet therapy in patients with STEMI defined by the Bleeding Aca- demic Research Consortium (BARC) [15]. Secondary end points were major adverse cardiac or ce- rebral events and any bleed- ing at 12 months. In the BA- RC study, types 2-5 were con- sidered to require clinical inter- vention. BARC types 3-5 were regarded as major clinical ble- eding events. At 12 months, extra safety end points includ- ed stent thrombosis per Aca- demic Research Consortium criteria [16]. Statistical analysis Statistical analyses were two- sided test (P<0.05) and per- formed with SPSS version 19.0. Continuous data were conveyed as the mean ± stan- Figure 1. Patient dard deviation, and categori- disposition in the trial. cal variables were summariz- ed using frequencies and per- centages. Basic clinical char- acteristics were compared be- Table 1. Baseline characteristics of the two groupsa tween two groups using the student’s t-test, the chi-square Bivalirudin Heparin + test, or the Fisher exact test. Characteristics + ticagrelor clopidogrel P (n=308) (n=315) The clinical endpoint events were assessed by means of Age, mean ± SD, y 66.39±10.35 67.76±10.21 0.098 the chi-square test or Fisher Men, No. (%) 219 (71.3) 233 (74.0) 0.461 exact test. The main analysis Body mass index, mean ± SD 24.37±0.58 24.45±0.56 0.089 was performed to evaluate dif- Medical history, No. (%) ference in the light of primary Diabetes 103 (33.4) 127 (40.3) 0.081 endpoint at 12 months.
Load more

Recommended publications
  • Kengrexal, INN-Cangrelor Tetrasodium
    ANNEX I SUMMARY OF PRODUCT CHARACTERISTICS 1 1. NAME OF THE MEDICINAL PRODUCT Kengrexal 50 mg powder for concentrate for solution for injection/infusion 2. QUALITATIVE AND QUANTITATIVE COMPOSITION Each vial contains cangrelor tetrasodium corresponding to 50 mg cangrelor. After reconstitution 1 mL of concentrate contains 10 mg cangrelor. After dilution 1 mL of solution contains 200 micrograms cangrelor. Excipient with known effect Each vial contains 52.2 mg sorbitol. For the full list of excipients, see section 6.1. 3. PHARMACEUTICAL FORM Powder for concentrate for solution for injection/infusion. White to off-white lyophilised powder. 4. CLINICAL PARTICULARS 4.1 Therapeutic indications Kengrexal, co-administered with acetylsalicylic acid (ASA), is indicated for the reduction of thrombotic cardiovascular events in adult patients with coronary artery disease undergoing percutaneous coronary intervention (PCI) who have not received an oral P2Y12 inhibitor prior to the PCI procedure and in whom oral therapy with P2Y12 inhibitors is not feasible or desirable. 4.2 Posology and method of administration Kengrexal should be administered by a physician experienced in either acute coronary care or in coronary intervention procedures and is intended for specialised use in an acute and hospital setting. Posology The recommended dose of Kengrexal for patients undergoing PCI is a 30 micrograms/kg intravenous bolus followed immediately by 4 micrograms/kg/min intravenous infusion. The bolus and infusion should be initiated prior to the procedure and continued for at least two hours or for the duration of the procedure, whichever is longer. At the discretion of the physician, the infusion may be continued for a total duration of four hours, see section 5.1.
    [Show full text]
  • Heparin Induced Thrombocytopenia – Adult – Inpatient– Clinical Practice Guideline
    Heparin Induced Thrombocytopenia – Adult – Inpatient– Clinical Practice Guideline Table of Contents EXECUTIVE SUMMARY ........................................................................................................... 2 SCOPE ...................................................................................................................................... 6 METHODOLOGY ...................................................................................................................... 6 DEFINITIONS (OPTIONAL): ..................................................................................................... 7 INTRODUCTION ....................................................................................................................... 7 RECOMMENDATIONS .............................................................................................................. 7 BENEFITS/HARMS OF IMPLEMENTATION ...........................................................................17 IMPLEMENTATION PLAN AND TOOLS ........................ERROR! BOOKMARK NOT DEFINED. REFERENCES .........................................................................................................................17 APPENDIX A ............................................................................................................................17 Note: Active Table of Contents Click to follow link CPG Contact for Changes: CPG Contact for Content: Name: Philip J Trapskin, PharmD,BCPS Name: Anne E. Rose, PharmD Phone Number: 263-1328 Phone Number:
    [Show full text]
  • Anticoagulation Dosing Guideline for Adult COVID-19 Patients
    Anticoagulation Dosing Guideline for Adult COVID-19 Patients Enoxaparin is the preferred first line anticoagulant for patients diagnosed with COVID-19. The incidence of HIT with enoxaparin is less than 1%. VTE Prophylaxis: VTE prophylaxis will be considered for COVID-19 patients who are low risk. Low risk COVID-19 patient 1. Not receiving mechanical ventilation 2. D-Dimer < 6 mg/L 3. ESRD on iHD without clotting Kidney Function BMI (kg/m2) Dosing of Enoxaparin Concern for HIT or LMWH Failure CrCL ≥ 30 mL/min 18.5-39.9 30mg SUBQ Q12H Consult Hematology 40-49.9 40mg SUBQ Q12H ≥ 50 60mg SUBQ Q12H CrCL < 30 mL/min 18.5-39.9 30mg SUBQ Q24H Consult Hematology OR ≥ 40 40mg SUBQ Q24H ESRD/AKI on RRT Special Population: < 18.5 (or weight < 50kg) Heparin 2500 SUBQ Q8H Consult Hematology *Contraindications: Platelets < 25 K/uL or Fibrinogen < 50 mg/dL or active bleeding Therapeutic anticoagulation Therapeutic anticoagulation will be considered for COVID-19 patients who are considered high risk or diagnosed with an acute VTE. High risk COVID-19 patient (for all hospitalized patients): Receiving mechanical ventilation AND D-dimer > 6 mg/L OR Acute kidney injury (Scr increase 0.3 mg/dL above baseline) +/- CVVHD/AVVHD/SLED or IHD with clotting Anti-Xa level goals for enoxaparin therapy (when indicated): 1. Therapeutic peak LMWH level (Drawn 4 hours after 3rd dose): 0.6-1 anti-Xa units/mL 2. Therapeutic trough LMWH level (Drawn 1 hour prior to 3rd dose): < 0.5 anti-Xa units/mL Kidney Function BMI Dosing of Enoxaparin Concern for HIT or (kg/m2) LMWH
    [Show full text]
  • 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,
    [Show full text]
  • Legemiddelforbruket I Norge 2012–2016 Drug Consumption in Norway 2012–2016
    2017:1 LEGEMIDDELSTATISTIKK EVT STIKKTITTEL INN HER Legemiddelforbruket i Norge 2012–2016 Drug Consumption in Norway 2012–2016 ISSN 1890-9647 Legemiddelforbruket i Norge 2012–2016 Drug Consumption in Norway 2012–2016 Solveig Sakshaug Hanne Strøm Christian Berg Hege Salvesen Blix Irene Litleskare Tove Granum Utgitt av Folkehelseinstituttet / Published by Norwegian Institute of Public Health Området for Psykisk og fysisk helse Avdeling for Legemiddelepidemiologi Mars 2017 Tittel/Title: Legemiddelstatistikk 2017:1 Legemiddelforbruket i Norge 2012-2016/Drug Consumption in Norway 2012-2016 Forfattere/Authors: Solveig Sakshaug (redaktør) Hanne Strøm Christian Berg Hege Salvesen Blix Irene Litleskare Tove Granum Bestilling/Order: Rapporten kan lastes ned som pdf på Folkehelseinstituttets nettsider: www.fhi.no/ The report is available as pdf format only and can be downloaded from the www.fhi.no Layout omslag: www.fetetyper.no Kontaktinformasjon/Contact information Folkehelseinstituttet/Norwegian Institute of Public Health P.O.Box 4404 Nydalen N-0403 Oslo Tel: +47 21 07 70 00 ISSN: 1890-9647 ISBN 978-82-8082-826-2 elektronisk utgave Sitering/Citation: Sakshaug, S (red), Legemiddelforbruket i Norge 2012-2016 [Drug Consumption in Norway 2012-2016], Legemiddelstatistikk 2017:1, Oslo: Folkehelseinstituttet, 2017. Tidligere utgaver/Previous editions: 1977: Legemiddelforbruket i Norge 1974 - 1976 1978: Legemiddelforbruket i Norge 1975 - 1977 1980: Legemiddelforbruket i Norge 1975 - 1979 1981: Legemiddelforbruket i Norge 1980 1982: Legemiddelforbruket
    [Show full text]
  • Antithrombotic Agents in the Management of Sepsis
    Antithrombotic Agents in the Management of Sepsis !"#$ Loyola University Medical Center, Maywood, Illinois-60153, USA ABSTRACT Sepsis, a systemic inflammatory syndrome, is a response to infection and when associated with mul- tiple organ dysfunction is termed, severe sepsis. It remains a leading cause of mortality in the critically ill. The response to the invading bacteria may be considered as a balance between proinflammatory and antiinflammatory reaction. While an inadequate proinflammatory reaction and a strong antiinflammatory response could lead to overwhelming infection and death of the patient, a strong and uncontrolled pro- inflammatory response, manifested by the release of proinflammatory mediators may lead to microvas- cular thrombosis and multiple organ failure. Endotoxin triggers sepsis by releasing various mediators inc- luding tumor necrosis factor-alpha and interleukin-1(IL-1). These cytokines activate the complement and coagulation systems, release adhesion molecules, prostaglandins, leukotrienes, reactive oxygen speci- es and nitric oxide (NO). Other mediators involved in the sepsis syndrome include IL-1, IL-6 and IL-8; arachidonic acid metabolites; platelet activating factor (PAF); histamine; bradykinin; angiotensin; comp- lement components and vasoactive intestinal peptide. These proinflammatory responses are counterac- ted by IL-10. Most of the trials targeting the different mediators of proinflammatory response have failed due a lack of correct definition of sepsis. Understanding the exact pathophysiology of the disease will enable better treatment options. Targeting the coagulation system with various anticoagulant agents inc- luding antithrombin, activated protein C (APC), tissue factor pathway inhibitor (TFPI) is a rational appro- ach. Many clinical trials have been conducted to evaluate these agents in severe sepsis.
    [Show full text]
  • Legemiddelforbruket I Norge 2014–2018 Drug Consumption in Norway 2014–2018
    LEGEMIDDELSTATISTIKK 2019:1 Legemiddelforbruket i Norge 2014–2018 Drug Consumption in Norway 2014–2018 Legemiddelforbruket i Norge 2014–2018 Drug Consumption in Norway 2014–2018 Solveig Sakshaug Kristine Olsen Christian Berg Hege Salvesen Blix Live Storehagen Dansie Irene Litleskare Tove Granum Utgitt av Folkehelseinstituttet/Published by Norwegian Institute of Public Health Område for Helsedata og digitalisering Avdeling for Legemiddelstatistikk Mai 2019 Tittel/Title: Legemiddelstatistikk 2019:1 Legemiddelforbruket i Norge 2014–2018/Drug Consumption in Norway 2014–2018 Forfattere/Authors: Solveig Sakshaug (redaktør) Kristine Olsen Christian Berg Hege Salvesen Blix Live Storehagen Dansie Irene Litleskare Tove Granum Bestilling: Rapporten kan lastes ned som pdf på Folkehelseinstituttets nettsider: www.fhi.no The report is only available as pdf from www.fhi.no Grafisk design omslag: Fete Typer Kontaktinformasjon/Contact information: Folkehelseinstituttet/Norwegian Institute of Public Health P.O.Box 222 Skøyen N-0213 Oslo Tel: +47 21 07 70 00 ISSN:1890-9647 ISBN elektronisk utgave: 978-82-8406-011-8 Sitering/Citation: Sakshaug, S (red), Legemiddelforbruket i Norge 2014–2018 [Drug Consumption in Norway 2014–2018], Legemiddelstatistikk 2019:1, Oslo: Folkehelseinstituttet, 2019. Tidligere utgaver/Previous editions: 1977: Legemiddelforbruket i Norge 1974–1976 1978: Legemiddelforbruket i Norge 1975–1977 1980: Legemiddelforbruket i Norge 1975–1979 1981: Legemiddelforbruket i Norge 1980 1982: Legemiddelforbruket i Norge 1977–1981 1984: Legemiddelforbruket
    [Show full text]
  • Angiox, INN-Bivalirudin
    authorised ANNEX I SUMMARY OF PRODUCT CHARACTERISTICS longer no product Medicinal 1 1. NAME OF THE MEDICINAL PRODUCT Angiox 250 mg powder for concentrate for solution for injection or infusion. 2. QUALITATIVE AND QUANTITATIVE COMPOSITION Each vial contains 250 mg bivalirudin. After reconstitution 1 ml contains 50 mg bivalirudin. After dilution 1 ml contains 5 mg bivalirudin. For the full list of excipients see section 6.1. 3. PHARMACEUTICAL FORM Powder for concentrate for solution for injection or infusion (powder for concentrate). White to off-white lyophilised powder. authorised 4. CLINICAL PARTICULARS 4.1 Therapeutic indications Angiox is indicated as an anticoagulant in adult patients undergoing percutaneous coronary intervention (PCI), including patients with ST-segment elevationlonger myocardial infarction (STEMI) undergoing primary PCI. Angiox is also indicated for the treatment of adult patientsno with unstable angina/non-ST segment elevation myocardial infarction (UA/NSTEMI) planned for urgent or early intervention. Angiox should be administered with acetylsalicylic acid and clopidogrel. 4.2 Posology and method of administration Angiox should be administeredproduct by a physician experienced in either acute coronary care or in coronary intervention procedures. Posology Patients undergoing PCI, including patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary PCI The recommended dose of bivalirudin for patients undergoing PCI is an intravenous bolus of 0.75Medicinal mg/kg body weight followed immediately by an intravenous infusion at a rate of 1.75 mg/kg body weight/hour for at least the duration of the procedure. The infusion of 1.75 mg/kg body weight/hour may be continued for up to 4 hours post-PCI and at a reduced dose of 0.25 mg/kg body weight/hour for an additional 4 – 12 hours as clinically necessary.
    [Show full text]
  • Cleveland Clinic Anticoagulation Management Program (C-Camp)
    CLEVELAND CLINIC ANTICOAGULATION MANAGEMENT PROGRAM (C-CAMP) 1 Table of Contents I. EXECUTIVE SUMMARY ......................................................................................................................................... 6 II. VENOUS THROMBOEMBOLISM RISK ASSESSMENT AND PROPHYLAXIS ............................................. 9 III. RECOMMENDED PROPHYLAXIS OPTIONS FOR THE PREVENTION OF VENOUS THROMBOEMBOLISM. ........................................................................................................................................ 10 IIIA. RECOMMENDED PROPHYLAXIS OPTIONS FOR THE PREVENTION OF VENOUS THROMBOEMBOLISM BASED ON RISK FACTOR ASSESSMENT ............................................................. 12 A) UNFRACTIONATED HEPARIN (UFH) ................................................................................................................... 14 B) LOW MOLECULAR WEIGHT HEPARIN (LMWH) ENOXAPARIN (LOVENOX®) .............................................. 14 C) FONDAPARINUX/ (ARIXTRA®) …………………………………………………………………………..……16 D) RIVAROXABAN (XARELTO®) .......................................................................................................................... 16 E) DESIRUDIN (IPRIVASK®)………………………………………………………………………………..…….17 F) WARFARIN/COUMADIN®) ............................................................................................................................... 16 G) ASPIRIN……………………………………………………………………………………………………..……18 H) INTERMITTENT PNEUMATIC COMPRESSION DEVICES .....................................................................................
    [Show full text]
  • Transition of Anticoagulants 2016
    Transition of Anticoagulants 2016 Van Hellerslia, PharmD, BCPS, CACP, Clinical Assistant Professor of Pharmacy Practice, Brand Generic Temple University School of Pharmacy, Philadelphia, PA Angiomax bivalirudin Arixtra fondaparinux Pallav Mehta, MD, Assistant Professor of Medicine, Coumadin warfarin Division of Hematology/Oncology, Eliquis apixaban MD Anderson Cancer Center at Cooper Fragmin dalteparin Lovenox enoxaparin Reviewer: Kelly Rudd, PharmD, BCPS, CACP, Clinical Specialist, Anticoagulation, Pradaxa dabigatran Savaysa edoxaban Bassett Medical Center, Cooperstown, New York 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/enoxaparin and warfarin 12 hours after last dose of apixaban and discontinue parenteral anticoagulant when INR is therapeutic ≥2). Apixaban Dabigatran, Wait 12 hours from last dose of apixaban to initiate dabigatran, edoxaban, or rivaroxaban. Edoxaban, or Rivaroxaban Argatroban Apixaban, Start apixaban, dabigatran, edoxaban, or rivaroxaban within 2 hours of stopping argatroban. Dabigatran, Edoxaban, or Rivaroxaban Argatroban Enoxaparin/ If no hepatic insufficiency, start parenteral anticoagulant within 2 hours of stopping Dalteparin/ argatroban. If there is hepatic insufficiency, start parenteral anticoagulant after 2-4 hours of Fondaparinux/ stopping argatroban. Heparin *The use of enoxaparin/dalteparin/heparin assumes the patient does not have heparin allergy or heparin-induced thrombocytopenia. Argatroban Warfarin Argatroban must be continued when warfarin is initiated and co-administration should continue for at least 5 days. Argatroban elevates the INR.
    [Show full text]
  • The Printed Journal Includes an Image Merely for Illustration
    Comment 6 Fox KA, Poole-Wilson P, Clayton TC, et al. 5-year outcome of an interventional 11 Rao SV, O’Grady K, Pieper KS, et al. Impact of bleeding severity on clinical strategy in non-ST-elevation acute coronary syndrome: the British Heart outcomes among patients with acute coronary syndromes. Am J Cardiol Foundation RITA 3 randomised trial. Lancet 2005; 366: 914–20. 2005; 96: 1200–06. 7 Lagerqvist B, Husted S, Kontny F, and The Fast Revascularisation during 12 Stone GW, McLaurin BT, Cox DA, for the ACUITY Investigators. InStability in Coronary artery disease (FRISC-II) Investigators. 5-year Bivalirudin for patients with acute coronary syndromes. N Engl J Med outcomes in the FRISC-II randomised trial of an invasive versus a 2006; 355: 2203–16. non-invasive strategy in non-ST elevation acute coronary syndrome: 13 The OASIS-6 Trial Group. Eff ects of fondaparinux on mortality and a follow-up study. Lancet 2006; 368: 998–1004. reinfarction in patients with acute ST-segment elevation myocardial 8 Stone GW, Moses JW, Ellis SG, et al. Safety and effi cacy of sirolimus- and infarction: the OASIS-6 randomized trial. JAMA 2006; 295: 1519–30. paclitaxel-eluting coronary stents. N Engl J Med 2007; 356: 998–1008. 14 Rosamond W, Flegal K, Friday G, for the American Heart Association 9 Eikelboom JW, Mehta SR, Anand SS, Xie C, Fox KA, Yusuf S. Adverse impact Statistics Committee and Stroke Statistics Subcommittee. Heart disease of bleeding on prognosis in patients with acute coronary syndromes. and stroke statistics—2007 update: a report from the American Heart Circulation 2006; 114: 774–82.
    [Show full text]
  • Guidelines for Using Bivalirudin During Cardiopulmonary Bypass Surgery
    Guidelines for Using Bivalirudin During Cardiopulmonary Bypass Surgery During cardiopulmonary bypass procedures, systemic anticoagulation to prevent thrombosis in the patient as well as the circuit is utilized. Heparin is the most common agent used, but in selective circumstances, alternate form of anticoagulation may be considered. In patients with heparin induced thrombocytopenia (HIT), heparin resistance, or significant thrombosis while on therapeutic heparin, alternative anticoagulation management using a direct thrombin inhibitor (DTI) may be desired. Patients with organ failure will have elimination rates substantially longer than observed in healthier individuals. Bivalirudin has the shortest elimination half-life among all DTI’s with lower dependence on renal or liver function for removal (~80% enzymatic) which is a benefit in patients who have a high risk of bleeding, organ failure, or who may require an invasive procedure. Bivalirudin can also be removed by hemofiltration. Of note, bivalirudin is primarily metabolized by thrombin and blood proteases, which results in loss of effect and potential coagulation when blood is stagnant, such as at the cardiopulmonary bypass (CPB) circuit filter, in the surgical field, or at the cannulas tips when off CPB. Thus, gelling of pooled blood in the surgical may occur with bivalirudin and may not reflect insufficient levels of anticoagulation. The dosing presented below is a guide to aid in the initiation of bivalirudin infusion during CPB surgery; however alterations may occur based on the clinical presentation of the patient (e.g. patient’s renal function, bleeding and clotting risks, ability to transfuse). The Anticoagulation Service can be contacted for assistance with dosing in CPB.
    [Show full text]