DOCSLIB.ORG

Non-Vitamin K Antagonist Oral Anticoagulants, Proton Pump

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Non-Vitamin K Antagonist Oral Anticoagulants, Proton Pump Arrhythmias and sudden death Original research Heart: first published as 10.1136/heartjnl-2021-319332 on 2 August 2021. Downloaded from Non- vitamin K antagonist oral anticoagulants, proton pump inhibitors and gastrointestinal bleeds Joris Komen ,1,2 Anton Pottegård,3 Paul Hjemdahl,4 Aukje K Mantel- Teeuwisse,1 Björn Wettermark,5 Maja Hellfritzsch,3 J Hallas,3 Ron Herings,6 Lisa Smits,6 Thomas Forslund,4 Olaf Klungel1 ► Additional supplemental ABSTRACT An observational study from the USA showed material is published online Objective To evaluate if proton pump inhibitor (PPI) markedly reduced risks of UGIB associated with PPI only. To view, please visit the 6 journal online (http:// dx. doi. treatment reduces the risk of upper gastrointestinal use in patients treated with NOACs. In contrast, org/ 10. 1136/ heartjnl- 2021- bleeding (UGIB) in patients with atrial fibrillation the COMPASS trial showed no protective effect 319332). (AF) treated with non-vitamin K antagonist oral with respect to GI bleeding overall, while a subanal- anticoagulants (NOACs). ysis on gastroduodenal bleeding showed a clearly 1Clinical Pharmacology and Design We used a common protocol, common data 7 Pharmacoepidemiology, Utrecht reduced risk. However, this trial was in patients Institute of Pharmaceutical model approach to conduct a cohort study including with stable cardiovascular disease and peripheral Sciences, Utrecht University, patients with AF initiated on a NOAC in Stockholm, artery disease receiving a lower dose of rivaroxaban Utrecht, The Netherlands Denmark and the Netherlands from April 2011 until July 2 than in atrial fibrillation (AF) (5 mg two times per Department of Healthcare 2018. The outcome of interest was a UGIB diagnosed Development, Stockholm Region day). Public Healthcare Services in a secondary care inpatient setting. We used an In the absence of convincing results, the guide- Committee, Stockholm, Sweden inverse probability weighted (IPW) Poisson regression to 3 lines state that PPI treatment may be considered to Clinical Pharmacology and calculate incidence rate ratios (IRRs), contrasting PPI use reduce the risk of GIB, especially in those with a Pharmacy, Department of Public to no PPI use periods. Health, University of Southern history of GI bleeding or ulcer and patients requiring Results In 164 290 NOAC users with AF, providing 8 Denmark, Odense, Denmark concomitant use of (dual) antiplatelet therapy, a 4 272 570 years of follow- up and 39 938 years of PPI Department of Medicine, Solna, statement that was, however, removed in the most Karolinska Institute, Stockholm, exposure, 806 patients suffered a UGIB. After IPW, recent guidelines.9 As there is currently limited Sweden PPI use was associated with lower UGIB rates (IRR: 5 evidence from randomised studies regarding the Department of Pharmacy, 0.75; 95% CI: 0.59 to 0.95). On an absolute scale, Pharmacoepidemiology and effect of PPIs on UGIB in NOAC-treated patients the protective effect was modest, and was found to be Social Pharmacy, Uppsala with AF, observational data are the main source of University, Uppsala, Sweden largest in high-risk patients, classified as age 75–84 6 guidance for this clinically relevant topic. There- PHARMO Institute, Utrecht, The years (number needed to treat for 1 year (NNTY): 787), http://heart.bmj.com/ Netherlands age ≥85 years (NNTY: 667), HAS-BLED score ≥3 (NNTY: fore, the aim of the current study was to assess the 378) or on concomitant antiplatelet therapy (NNTY: 373). association between PPI use and UGIBs in patients Correspondence to Conclusion Concomitant treatment with a PPI in with AF treated with a NOAC in three Western Joris Komen, Utrecht University, European countries. Utrecht 3508 TC, The NOAC-treated patients with AF is associated with a Netherlands; j. j. komen@ uu. nl reduced risk of severe UGIB. This indicates that PPI cotreatment can be considered, in particular among the Received 11 March 2021 METHODS elderly patients, patients with a HAS- BLED score ≥3, Accepted 2 July 2021 on October 1, 2021 by guest. Protected copyright. and/or in patients on concomitant antiplatelet therapy. Database For this population- based cohort study, we used three different databases: the Swedish Healthcare Database in the Stockholm region (complete popula- tion, n=2.3 million), the nationwide Danish health INTRODUCTION registers (complete population, n=5.8 million) and Pooled results from clinical trials showed that the PHARMO Database (random sample from the treatment with non- vitamin K antagonist oral Dutch population, n=4 million). The databases anticoagulants (NOACs) significantly increased 10–12 the risk of upper gastrointestinal bleeding (UGIB) are described in detail elsewhere. All three compared with warfarin.1 Proton pump inhibitors databases contain prescription claims data from community pharmacies, registered by Anatom- © Author(s) (or their (PPIs) reduce gastric acid production and prevent employer(s)) 2021. Re- use ulcer recurrence.2 In patients on aspirin treat- ical Therapeutic Chemical codes, and all three permitted under CC BY- NC. No ment, which increases the risk of GIB,3 PPIs have databases contain medical diagnostic data from commercial re- use. See rights 4 secondary care, registered by 10th revision of the and permissions. Published been shown to reduce the risk of GIB. Therefore, by BMJ. PPI use is recommended for patients on aspirin International Statistical Classification of Diseases treatment with certain comorbidities and come- and Related Health Problems (ICD-10) codes. In To cite: Komen J, dications.5 Since clinical trials show an overall addition, the Stockholm database also contains Pottegård A, Hjemdahl P, et al. Heart Epub ahead of increased risk of UGIB associated with NOAC medical diagnostic data from primary care, also print: [please include Day treatment, it is hypothesised that cotreatment with registered by ICD-10 codes. We used a common Month Year]. doi:10.1136/ a PPI could decrease the risk of UGIB in NOAC protocol and a common data model to combine the heartjnl-2021-319332 users as well. data from the different databases. Komen J, et al. Heart 2021;0:1–6. doi:10.1136/heartjnl-2021-319332 1 Arrhythmias and sudden death Study population dyspepsia, abdominal pain, lower GI problems and other GI From each database, we included all patients dispensed a problems (see online supplemental table 1 for ICD-10 codes). Heart: first published as 10.1136/heartjnl-2021-319332 on 2 August 2021. Downloaded from NOAC with a known history of AF, defined by a registration As these comorbidities might be markers for an already present of the ICD-10 code I48 any time prior to or within 90 days UGIB, we added a 7- day lag period to the actual registration date after the first NOAC dispensing, to account for diagnostic lag.13 of the diagnosis, to avoid reverse causality in the assessment of Patients entered the cohort at the date of their first ever NOAC covariates. In addition, as these confounders might change over prescription (cohort entry date), and we included patients time, and affect both the risk of UGIB and the chance of PPI from April 2011 until July 2018. We considered a patient to prescription, we partitioned follow-up time into 91- day periods, be on continued NOAC treatment when the patient claimed a with the individual patient’s initial cohort entry date as starting prescription for a NOAC within 30 days after the calculated end point. We searched for registrations of these diagnosis codes in of the previous prescription (see online supplemental figure 1). the 3 years prior to the first day of the 91- day period. We defined We censored patients at an outcome of interest, at the calculated the time- varying comorbidities as acute if the code was regis- end of their last prescription, when they died, moved out of the tered in the 30 days prior to the first day, as current if it was region or database, or switched to warfarin treatment. Patients registered in the 30–90 days prior to the first day, as recent if it could re- enter the cohort after they stopped their treatment if was registered in the 90–365 days prior to the first day, and as restarting NOAC therapy, and follow- up was defined in a similar long- term if it was registered in the 365 days—3 years prior to manner after re- entering the cohort. All patients had to have at the first day. least 3 years of follow- up time prior to cohort entry, in order to The comedications assessed were aspirin, non- steroidal anti- adequately assess baseline characteristics. inflammatory drugs (NSAIDs), clopidogrel, other antiplatelets, oral corticosteroids, diuretics, beta blockers, calcium channel Exposure definition blockers, renin–angiotensin–aldosterone system inhibitors, During follow- up, patients were considered to be exposed to statins, oral antidiabetic drugs, insulins and antidepressants (see PPIs when they claimed a PPI prescription (see online supple- online supplemental table 1 for ATC codes). As comedications mental figure 1). They were considered exposed until the end may change over time, we used the same 91- day periods as for of the duration of their last consecutive PPI prescription. We the time- varying confounders. We looked for a prescription in considered PPI treatment to be consecutive if a new prescrip- the 180 days prior to the first day of the 91- day period. tion was claimed within the duration of the prior prescription, with another 30- day grace period added to account for irregular Statistical analysis fill patterns and minor non- compliance. We calculated the dura- We used descriptive statistics to present baseline characteris- tion of the prescription using the number of tablets dispensed, tics for each database. To describe PPI users and non-users, we thus assuming a one tablet a day dosing regimen. To avoid bias defined patients as users of a PPI if they received a PPI at some from reverse causality (ie, that patients receive a PPI because of point during follow- up.
Load more

Recommended publications
  • What Are Anticoagulants and Antiplatelet Agents?
    ANSWERS Treatments + Tests by heart What are Blood clots are made up of red blood cells, platelets, fibrin, and white blood Anticoagulants cells (shown below). Anticoagulants and antiplatelets keep these parts from and Antiplatelet sticking together and forming a clot. Agents? Anticoagulants and antiplatelets are medicines that reduce blood clotting in an artery, vein or the heart. Doctors prescribe these to help prevent heart attacks and strokes caused by blood clots. Blood clots can block blood flow to your heart or your brain causing a heart attack or stroke. What should I know about anticoagulants? • Discuss your diet with your health care providers. Foods rich in Vitamin K can reduce the effectiveness of Anticoagulants (sometimes known as “blood thinners”) are warfarin. Vitamin K is in leafy, green vegetables, fish, medicines that delay the clotting of blood. Examples are liver, lentils, soybeans and some vegetable oils. heparin, warfarin, dabigitran, apixaban, rivoraxaban and edoxaban. • Tell your family that you take anticoagulant medicine. Anticoagulants make it harder for blood clots to form in your • Always carry your emergency medical ID card. heart, veins and arteries. They also can keep existing clots from growing larger. It’s important to follow these tips while on anticoagulants: Could anticoagulants cause problems? • Take your medications exactly as prescribed. If you do as your doctor tells you, there probably won’t be problems. But you must tell them right away if: • If you take warfarin, have regular blood tests so your health care provider can tell how the medicine is working. • You think you’re pregnant or you’re planning to get pregnant.
    [Show full text]
  • Medication Safety in Nursing Homes Change Package
    Medication Safety in Nursing Homes CHANGE PACKAGE Version 1 | June 2020 WWW.TMFNETWORKS.ORG TABLE OF CONTENTS Acronyms . 3 Introduction . 4 The Quality Improvement Process Using PDSA . 5 References . 23 Change Package Pain Management and Opioid Use 7 > Use evidence-based approaches to manage and treat acute and chronic pain . 7 > Educate residents, resident representatives, medical and clinical staff on safe use of opioids and alternative pain management strategies . 8 > Improve communication . 9 > Improve staff understanding of regulatory guidelines . .9 . Anticoagulant Medications 10 > Reduce number of ADEs Related to Anticoagulant Medications . 11 > Provide reference tools for providers . 11. > Improve communication . 12 > Provide resident education on anticoagulation therapy . .12 . > Increase staff understanding of regulatory guidelines . 13. Antipsychotic Medications 14 > Implement safe use of antipsychotic drugs in the long- and short-stay nursing home resident . 14 > Implement safe use of antipsychotic medications for those with dementia diagnosis . 15 > Improve communication . 15 > Increase staff understanding of regulatory guidelines . 16. Antimuscarinic Medications 17 > Reduce number of residents with a fall related to antimuscarinic medication . 17 > Improve communication . 18 > Increase staff understanding of regulatory guidelines . 18. Diabetes Medications 19 > Eliminate sliding-scale insulin . 20 . > Safe diabetes and medication management . 20 . > Improve communication . 21 > Reduce and prevent incidence of hypoglycemic events . 21 > Increase staff understanding of regulatory guidelines . 22. This material was developed by TMF Health Quality Institute, the Medicare Quality Innovation Network-Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. This content does not necessarily reflect CMS policy.
    [Show full text]
  • The Role of Corticosteroids in Primary Antiphospholipid Antibody Syndrome Presenting As Cerebral Venous Thrombosis in Young Females at Peripartum
    E. A. Ashok Kumar, P. Jijiya Bai. The role of corticosteroids in primary antiphospholipid antibody syndrome presenting as cerebral venous thrombosis in young females at peripartum. IAIM, 2016; 3(8): 97-110. Original Research Article The role of corticosteroids in primary antiphospholipid antibody syndrome presenting as cerebral venous thrombosis in young females at peripartum E. A. Ashok Kumar1*, P. Jijiya Bai2 1Professor, Department of Medicine, 2Professor, Department of Pathology, MNR Medical College and Hospital, Medak, Telangana, India *Corresponding author email: [email protected] International Archives of Integrated Medicine, Vol. 3, Issue 8, August, 2016. Copy right © 2016, IAIM, All Rights Reserved. Available online at http://iaimjournal.com/ ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) Received on: 11-07-2016 Accepted on: 30-07-2016 Source of support: Nil Conflict of interest: None declared. How to cite this article: E. A. Ashok Kumar, P. Jijiya Bai. The role of corticosteroids in primary antiphospholipid antibody syndrome presenting as cerebral venous thrombosis in young females at peripartum. IAIM, 2016; 3(8): 97-110. Abstract The clinical study of cerebral venous thrombosis in antiphospholipid antibody syndrome in young females at peripartum was done to study the incidence of antiphospholipid antibodies in highly susceptible population groups most commonly at peripartum women. The presence of these antibodies points towards increased susceptibility to thrombosis and ischemic stroke apart from other manifestations in peripartum period. The age group most affected was between 20-25 years. Most of them were primipara. Many of the patients underwent Cesarean section before the presentation with the specific neurological complaint. None of the patients gave positive history for use of oral contraceptive pills.
    [Show full text]
  • Psychoactive Properties of Culinary Spices
    Taking the spice route: Psychoactive properties of culinary spices Intoxication and toxicity can mimic psychiatric symptoms any substances that are not typically thought of as “substances of abuse” possess—when adequate- Mly dosed—clinically meaningful psychoactive properties. In addition to the more familiar effects of alcohol, psychostimulants, opioids, Cannabis, and hallucinogens, you may encounter psychiatric phenomena resulting from abuse of more obscure substances, including culinary spices. The clinician treating a patient in an apparent intoxicated state who has a negative drug screen might ask that patient if he (she) abuses spices. This might be particularly relevant when treating patients thought to have limited access to il- licit substances or those with ready access to large amounts of spices, such as prisoners, young patients, and those working in the food service industry. Abuse of spices can be a problematic diagnosis © STOCKCREATIONS Patients may misuse culinary spices to achieve euphoria, or a James A. Bourgeois, OD, MD “natural high.” They may present with medical or psychiat- Clinical Professor Vice Chair, Clinical Affairs ric symptoms, including acute altered mental status, but the Department of Psychiatry/Langley Porter Psychiatric Institute psychoactive substances are not identified on routine toxicol- University of California San Francisco ogy studies. In addition, patients may not attribute their use San Francisco, California of spices for psychoactive effect to “drugs,” because these Usha Parthasarathi, MBBS materials are legal and readily available. This may lead to Assistant Clinical Professor misdiagnosis of a systemic medical disorder or a primary psy- Ana Hategan, MD chiatric illness to explain the patient’s symptoms and initiat- Associate Clinical Professor ing a psychotropic agent and other psychiatric services when • • • • a substance abuse program might be a more appropriate clini- Department of Psychiatry and Behavioural Neurosciences cal intervention.
    [Show full text]
  • Managing Patients on Anticoagulants Who Require Oral Surgical
    Gingival Hyperplasia Related to Calcium Channel Perio & Implant Centers The Team for Jochen P. Pechak, DDS, MSD of the Monterey Bay (831) 648-8800 Blockers and Other Medications and Conditions mobile app: www.GumsRusApp.com in Silicon Valley (408) 738-3423 web: GumsRus.com alcium channel blockers are named for their ability to block the movement of calcium across mechanical channels in heart and artery walls. This causes vasodilation which reduces blood pressure. They are also used to treat angina Cand fast irregular heart rhythms. There are at least eleven channel blockers with different generic and trade names, which can be quite confusing. Nifedipine (Procardia) has the highest reported incidence of gingival hyperplasia, followed tm by diltiazem (Cardizem), amlodipine PDL (Norvasc) and verapamil (Calan). Switching to a different drug in the PerioDontaLetter same class like isradipine (Dynacirc), Medications Which Cause Jochen P. Pechak, DDS, MSD, Periodontics, Implant & Laser Dentistry Summer or reducing the dose of amlodipine to Gingival Overgrowth 5 mg, has been reported to reduce the hyperplasia. Calcium Channel Blockers Trade Name Other drugs that frequently cause (Listed in Order of Reported From Our Office Managing Patients on hyperplasia are cyclosporine, an Frequency of Overgrowth) to Yours... immunosuppressant, and phenytoin Nifedipine Adalat, Nifecard, Procardia, Tenif Anticoagulants Who Require (Dilantin), an anticonvulsant. As dentists, we are challenged with Orthodontic treatment also sometimes Diltiazem Cardizem, Dilacor, Diltiamax, the management of the many medical Oral Surgical Procedures results in hyperplasia. (See below.) Tiazac conditions and the various medications Amlodipine Lotrel, Norvasc which our patients are taking. This current issue of The or most dental patients on therapy is hardly ever needed Verapamil Covera-HS, Calan, Verelan PerioDontaLetter addresses the anticoagulants, no change in because most lasers seal the blood Felodipine Plendil management of patients on Fmedication is necessary prior to vessels.
    [Show full text]
  • Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits
    Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration Center for Behavioral Health Statistics and Quality ACKNOWLEDGMENTS This report was prepared for the Substance Abuse and Mental Health Services Administration (SAMHSA) by RTI International (a trade name of Research Triangle Institute, Research Triangle Park, NC) under contract number HHSP23320095651WC, with SAMHSA, U.S. Department of Health and Human Services (HHS). Rong Cai served as the Government Project Officer. PUBLIC DOMAIN NOTICE All material appearing in this publication is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS. RECOMMENDED CITATION Substance Abuse and Mental Health Services Administration, Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. (SMA) 13-4760, DAWN Series D-39. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. ELECTRONIC ACCESS This publication may be downloaded from http://store.samhsa.gov. Or please call SAMHSA at 1-877-SAMHSA-7 (1-877-726-4727) (English and Español). ORIGINATING OFFICE Center for Behavioral Health Statistics and Quality Substance Abuse and Mental Health Services
    [Show full text]
  • Antiplatelet Agents Vs. Anticoagulation for Stroke & Tia
    ANTIPLATELET AGENTS VS. ANTICOAGULATION FOR STROKE & TIA David Lee Gordon, M.D., FAAN, FANA, FAHA Professor and Chair Department of Neurology The University of Oklahoma Health Sciences Center OU Neurology ANTIPLATELET AGENTS VS. ANTICOAGULATION FOR STROKE & TIA Learning Objectives . Describe the two main ways that blood clots using nonmedical terms . List the 6 ischemic stroke etiologies . Determine the optimal antithrombotic therapy for secondary prevention of ischemic stroke based on ischemic stroke etiology . Relate the rationale for prescribing anticoagulation rather than antiplatelet agents in patients with ischemic stroke of unknown cause OU Neurology THE BLOOD Unique substance that fluctuates between two forms . Liquid –to transport blood cells, oxygen, glucose, other chemistries, etc. within the vascular system . Glue – to seal injured artery or vein & prevent blood loss – Scab & clot (= thrombus) are examples of blood as glue – Glue (scab/clot) forms for 1 of 2 reasons: • Platelets (white clot) – like Velcro – Stick to bumpy surfaces inside arteries – If the inner lining of the artery (endothelium) is normal, platelets do NOT cause thrombus formation • Clotting factors (red clot) – like powdered Jello – Exist in balance with natural blood thinners – Clump when blood is stagnant or when unopposed by natural blood thinners OU Neurology BLOOD‐THINNING THERAPY . Antithrombotic therapy is a general term for all blood‐thinning medications . There are 2 types of antithrombotic therapy – Antiplatelet agents –anti‐Velcro medicines – Anticoagulants –anti‐Jello medicines OU Neurology ISCHEMIC STROKE & TIA PATHOPHYSIOLOGY Ischemia (low blood flow) to focal area of brain . Usually due to thromboembolus (floating blood clot) – Thrombus = blood clot – Embolus = floating plug – Blood clot forms in vascular system (arteries or heart), travels downstream, plugs a brain artery .
    [Show full text]
  • Escitalopram Oxalate
    HIGHLIGHTS OF PRESCRIBING INFORMATION --------------WARNINGS AND PRECAUTIONS------------­ These highlights do not include all the information Clinical Worsening/Suicide Risk: Monitor for clinical needed to use Lexapro® safely and effectively. See full worsening, suicidality and unusual change in behavior, prescribing information for Lexapro®. especially, during the initial few months of therapy or at times of dose changes (5.1). Lexapro® (escitalopram oxalate) Tablets Serotonin Syndrome: Serotonin syndrome has been Lexapro® (escitalopram oxalate) Oral Solution reported with SSRIs and SNRIs, including Lexapro, both Initial U.S. Approval: 2002 when taken alone, but especially when co-administered WARNING: Suicidality and Antidepressant Drugs with other serotonergic agents (including triptans, See full prescribing information for complete boxed tricyclic antidepressants, fentanyl, lithium, tramadol, warning. tryptophan, buspirone, amphetamines, and St. John’s Increased risk of suicidal thinking and behavior in Wort). If such symptoms occur, discontinue Lexapro and children, adolescents and young adults taking initiate supportive treatment. If concomitant use of antidepressants for major depressive disorder (MDD) Lexapro with other serotonergic drugs is clinically and other psychiatric disorders. Lexapro is not warranted, patients should be made aware of a potential approved for use in pediatric patients less than 12 increased risk for serotonin syndrome, particularly during years of age (5.1). treatment initiation and dose increases (5.2). Discontinuation of Treatment with Lexapro: A gradual reduction in dose rather than abrupt cessation is -------------------RECENT MAJOR CHANGES---------------- recommended whenever possible (5.3). Warnings and Precautions (5.2) 1/2017 Seizures: Prescribe with care in patients with a history of seizure (5.4). --------------INDICATIONS AND USAGE------------------- Activation of Mania/Hypomania: Use cautiously in Lexapro® is a selective serotonin reuptake inhibitor (SSRI) patients with a history of mania (5.5).
    [Show full text]
  • Anticoagulant and Antithrombotic Therapy: Globally Applied According to Local Geographical Selection Criteria
    6 Editorial Page 1 of 6 Anticoagulant and antithrombotic therapy: globally applied according to local geographical selection criteria Antithrombotic therapy is applied to prevent or treat thrombosis in patients in a variety of clinical settings (1-5). As overview, antithrombotic therapy comprises two main classes of drugs, the anticoagulants (which inhibit various aspects of the coagulation pathways) and the antiplatelet agents (which inhibit platelet function). The anticoagulants include both parental agents such as heparin, and oral agents such as vitamin K antagonists (VKAs) (i.e., primarily warfarin) and direct oral anticoagulants (DOACs) (which include dabigatran, rivaroxaban, apixaban and edoxaban). The antiplatelet agents comprise a wide variety of drugs, but in the community setting are mostly aspirin and anti-P2Y12 receptor agents. In this series of the journal, a wide variety of papers of general or specific interest have been collated for the AOB readership. The series begins with an exploration of global anticoagulation trends, first as specifically determined using Google Trends data (6). An electronic search simultaneously using the search terms “warfarin” AND “dabigatran” AND “rivaroxaban” AND “apixaban” AND “edoxaban”, without any applied language or geographical restrictions was carried out for a period in late 2018. Overall, warfarin (55.0%) yielded the largest number of Google searches among the five oral anticoagulants throughout the study period, followed by apixaban (22.5%), rivaroxaban (18.3%), edoxaban (4.1%) and dabigatran (0.1%). Thus, warfarin remained the predominantly searched anticoagulant agent around the world at that time. Compared to other oral anticoagulant drugs, rivaroxaban was more popular in China and in some South-American countries, apixaban was especially popular in some North-European and Latin American countries, whilst edoxaban and dabigatran were not often searched for in any country worldwide.
    [Show full text]
  • Combining Antiplatelets and Anticoagulants Example
    Visual summary Combining antiplatelets and anticoagulants Antiplatelets Oral anticoagulants APL OAC Dual therapy Direct oral anticoagulants For dual antiplatelet therapy, DOAC Monotherapy These are thought to be a safe a P2Y inhibitor can be added: WAR Warfarin ASP Aspirin + 12 alternative to warfarin, although Warfarin is the most there remains uncertainty Aspirin should be prescribed CLO Clopidogrel commonly used about risks versus benefits as the first-line antiplatelet anticoagulant agent unless the patient is PRA Prasugrel intolerant or has a compelling API Apixaban Ticagrelor contraindication TIC Patients should be prescribed the lower licenced dose of a DAB Dabigatran DOAC when combined with Combining novel P2Y12 inhibitors with oral anticolaguants RIV Rivaroxaban increases risk of bleeding, and cannot currently be recommended an antiplatelet Example clinical scenarios 1 Cardiovascular disease 2 Non-valvular atrial brillation Primary prevention Generally, patients who have an acute coronary syndrome and/or undergo percutaneous coronary intervention could benefit from: Antiplatelets are not licensed for the primary prevention of cardiovascular disease. However, ASP there is weak evidence that aspirin may confer 4-6 months ASP CLO OAC some benefit in patients who are hypertensive and Triple therapy + + have impaired renal function or elevated risk of CVD If a patient develops an indication for an OAC, To complete 12 months APL OAC this should replace the antiplatelet agent ASP OAC Dual therapy + Secondary prevention After 12 months Combination and duration Antiplatelet therapy is recommended for the As per secondary depends on stroke risk, bleeding APL secondary prevention of cardiovascular disease prevention of CVD risk, and clinical setting In patients who are at high risk of bleeding, the use of bare-metal If a patient develops an indication for an OAC: stents over drug-eluting stents is recommended to shorten dual Stable coronary Very high risk for antiplatelet and anticoagulant therapy to four weeks.
    [Show full text]
  • Cholestagel, INN-Colesevelam Hydrochloride
    ANNEX I SUMMARY OF PRODUCT CHARACTERISTICS 1 1. NAME OF THE MEDICINAL PRODUCT Cholestagel 625 mg film-coated tablets 2. QUALITATIVE AND QUANTITATIVE COMPOSITION Each tablet contains 625 mg colesevelam (as hydrochloride). For the full list of excipients, see section 6.1. 3. PHARMACEUTICAL FORM Film-coated tablet (tablet). Off-white, capsule-shaped film-coated tablets imprinted with “C625” on one side. 4. CLINICAL PARTICULARS 4.1 Therapeutic indications Cholestagel co-administered with a 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase inhibitor (statin) is indicated as adjunctive therapy to diet to provide an additive reduction in low-density lipoprotein cholesterol (LDL-C) levels in adult patients with primary hypercholesterolaemia who are not adequately controlled with a statin alone. Cholestagel as monotherapy is indicated as adjunctive therapy to diet for reduction of elevated total-cholesterol and LDL-C in adult patients with primary hypercholesterolaemia, in whom a statin is considered inappropriate or is not well-tolerated. Cholestagel can also be used in combination with ezetimibe, with or without a statin, in adult patients with primary hypercholesterolaemia, including patients with familial hypercholesterolaemia (see section 5.1). 4.2 Posology and method of administration Posology Combination therapy The recommended dose of Cholestagel for combination with a statin with or without ezetimibe is 4 to 6 tablets per day. The maximum recommended dose is 6 tablets per day taken as 3 tablets twice per day with meals or 6 tablets taken once per day with a meal. Clinical trials have shown that Cholestagel and statins can be co-administered or dosed apart, and that Cholestagel and ezetimibe can be co- administered or dosed apart.
    [Show full text]
  • Lipotropics, Other
    Lipotropics, Other Therapeutic Class Review (TCR) October 2, 2020 No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, digital scanning, or via any information storage or retrieval system without the express written consent of Magellan Rx Management. All requests for permission should be mailed to: Magellan Rx Management Attention: Legal Department 6950 Columbia Gateway Drive Columbia, Maryland 21046 The materials contained herein represent the opinions of the collective authors and editors and should not be construed to be the official representation of any professional organization or group, any state Pharmacy and Therapeutics committee, any state Medicaid Agency, or any other clinical committee. This material is not intended to be relied upon as medical advice for specific medical cases and nothing contained herein should be relied upon by any patient, medical professional or layperson seeking information about a specific course of treatment for a specific medical condition. All readers of this material are responsible for independently obtaining medical advice and guidance from their own physician and/or other medical professional in regard to the best course of treatment for their specific medical condition. This publication, inclusive of all forms contained herein, is intended to be educational in nature and is intended to be used for informational purposes only. Send comments and suggestions to [email protected]. October 2020 Proprietary Information. Restricted Access – Do not disseminate or copy without approval. © 2004-2020 Magellan Rx Management. All Rights Reserved. FDA-APPROVED INDICATIONS Agents in this class are indicated as adjuncts to dietary modifications for the treatment of various dyslipidemias.
    [Show full text]