Anticoagulation news items. Week commencing 21st September 2020
The Lancet Haematology
Meta-analysis of individual participant data from 14 of 20 eligible RCTs (n=8278) found LMWH was associated with a lower VTE risk (adjusted RR 0.58; 95% CI 0.47-0.71), but there was no survival benefit. Risk of minor bleeding (1.34; 1.19-1.51), but not major, was increased.
NICE issues draft updated guideline on the management of atrial fibrillation
National Institute for Health and Care Excellence
This DRAFT guideline, which will update CG180 (published June 2014), will cover the diagnosis and management of AF in adults. It aims to ensure people receive the best care to help prevent complications, such as a stroke, and side effects of treatment, such as bleeding.
Cochrane Database of Systematic Reviews
Updated review identified 2 studies (n=1135) and noted they did not provide evidence to support this use; and studies did not report on the outcome of catheter occlusion, days of catheter patency, episodes of catheter‐related bloodstream infection and other side effects.
JAMA Cardiology
In prespecified analysis of RCT (n=171), occurrence & severity of migraine attacks (MAs) decreased over time with low percentage of patients with MAs at 6-12-month follow-up; only 1% with new-onset MAs after cessation of clopidogrel at 3 months after atrial septal defect closure.
Vonicog alfa for the treatment and prevention of bleeding in adults with von Willebrand disease
NHS England
NHS England will commission vonicog alfa for the treatment and prevention of bleeding in adults with von Willebrand disease in accordance with the criteria outlined in these documents.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
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Anticoagulation news items. Week commencing 14th September 2020
European Journal of Hospital Pharmacy
Spanish retrospective cohort study reported higher risk of bleeding with dalteparin in patients with renal insufficiency (RI) vs those with normal renal function (n=367; 17.9% vs 7.3%) and identified RI (MDRD-4 (Modification of Diet in Renal Disease) <50 mL/min) as a risk factor.
Specialist Pharmacy Service
This Q&A offers guidance on what factors should be considered when calculating a LMWH treatment dose following a VTE in non-pregnant adult patients with a high body weight, defined as more than 120 kg.
Interventions for preventing venous thromboembolism in adults undergoing knee arthroscopy
Cochrane Database of Systematic Reviews
Updated review (8 studies;n= 3818) found there is a small risk that healthy adult patients undergoing knee arthroscopy will develop venous thromboembolism & there is moderate‐ to low‐certainty evidence of no benefit from use of LMWH, aspirin or rivaroxaban in reducing this risk.
Premature permanent discontinuation of apixaban or warfarin in patients with atrial fibrillation
Heart
Posthoc analysis of ARISTOTLE found premature permanent discontinuation of study drug was common, less frequent in patients on apixaban than warfarin and followed by high 30-day rates of death, TED &major bleeding, but no significant difference in clinical outcomes between groups.
Cochrane Database of Systematic Reviews
This review (11 studies; n=1672) found the combination of heparin plus aspirin during the course of pregnancy may increase live birth rate in women with persistent antiphospholipid antibodies compared to aspirin treatment alone; safety is uncertain due to the lack of reporting.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
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Anticoagulation news items. Week commencing 7th September 2020
PharmaTimes
The company disclosed in a US Securities and Exchange Commission filing that European Medicines Agency has asked for full 52-week results from 134 patients taking part in ongoing phase III study and potential submission of data is anticiparted by end of first quarter of 2021.
Treatment of distal deep vein thrombosis
Cochrane Database of Systematic Reviews
Review of 8 RCTs (n=1,239) found evidence of benefit for anticoagulation therapy using vitamin K antagonists with little or no difference in major bleeding events although there was an increase in clinically relevant non‐major bleeding vs no intervention or placebo.
Journal of the American Medical Association
RCT (n=1,063) found that, among patients with moderate to severe traumatic brain injury, out-of-hospital tranexamic acid administration within 2 hours of injury vs placebo did not significantly improve 6-month neurologic outcome as measured by the Glasgow Outcome Scale.
Scottish Medicines Consortium
Andexanet alfa intravenous infusion is approved for adult patients treated with a direct factor Xa inhibitor (apixaban or rivaroxaban) when reversal of anticoagulation is needed due to life-threatening or uncontrolled bleeding.
Low molecular weight heparin for prevention of microvascular occlusion in digital replantation
Cochrane Database of Systematic Reviews
In this updated review (4 RCTs, n=258) low to very low‐certainty evidence showed no benefit from low molecular weight compared to unfractionated heparin on success rates of replantation or affect microvascular insufficiency due to vessel occlusion.
National Institute for Health and Care Excellence
In DRAFT guidance, NICE recommends andexanet alfa as an option for reversing anticoagulation from apixaban or rivaroxaban in adults with life-threatening or uncontrolled bleeding, only if the bleed is in the GI tract and it is provided according to the commercial arrangement.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
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Anticoagulation news items. Week commencing 31st August 2020
Annals of Internal Medicine
Study notes COVID-19 mainly involves lungs, causing diffuse alveolar damage and acute respiratory insufficiency. Autopsy findings (n=10) found death may be caused by thrombosis observed in segmental and subsegmental pulmonary arterial vessels despite prophylactic anticoagulation.
Circulation
In RCT (n=499≥1 saphenous vein graft [SVGs]), addition of ticagrelor to standard aspirin did not reduce SVG occlusion at one year after CABG (occlusion rate, ticagrelor group 10.5% vs. 9.1% placebo group; OR 1.29; 95% CI: 0.73 -2.30; p=0.38).
Aspirin with or without Clopidogrel after Transcatheter Aortic-Valve Implantation
New England Journal of Medicine
RCT (n=665) found incidence of bleeding (15.1% vs. 26.6%; risk ratio, 0.57; 95% CI, 0.42-0.77; p=0.001) and composite of bleeding or thromboembolic events at 1 year were significantly less frequent with aspirin compared to aspirin plus clopidogrel administered for 3 months.
Low-Dose Edoxaban in Very Elderly Patients with Atrial Fibrillation
New England Journal of Medicine
RCT in 984 Japanese patients (aged ≥80 years) found once-daily 15mg dose of edoxaban superior to placebo in preventing stroke/systemic embolism (event rate 2.3% vs. 6.7%; HR 0.34; 95% CI 0.19 to 0.61;p<0.001), and did not result in significantly higher incidence of major bleeding.
The Lancet
RCT (n=2338; South Korea) found prasugrel-based dose de-escalation strategy from 1 month after PCI reduced risk of net adverse clinical outcomes (HR 0.70; 95% CI,0.52–0.92), up to 1 year, mainly driven by reduction in bleeding (0.48; 0.32–0.73), without increase in ischaemia.
European Heart Journal
Guidance covers diagnosis, risk assessment and outcomes, pharmacological & invasive treatments, MI with non-obstructive coronary arteries and alternative diagnoses, special populations, long-term management, quality measures, management strategy, key messages and gaps in evidence.
Circulation
Secondary analysis of a study (n=14,005) found that, in those ≥80 years, the incidence of the primary ischaemic outcome was similar for ticagrelor and clopidogrel, but ticagrelor was associated with a 17% and 48% higher risk of death & bleeding, respectively.
European Heart Journal
Analysis of the ENTRUST-AF PCI trial (n=1,506) found the difference in primary bleeding endpoint between edoxaban with P2Y12 inhibitor vs vitamin K antagonist with aspirin and P2Y12 inhibitor was nonsignificant, and consistent between acute and chronic coronary syndrome cohorts.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
Anticoagulation news items. Week commencing 17th and 24th August 2020
The Lancet Haematology
In this Canadian RCT (n=74) eltrombopag was non-inferior to IV immunoglobulin; with perioperative platelet targets achieved in 79% on eltrombopag and 61% on IV immunoglobulin (absolute risk difference 17.8%, p for non-inferiority=0.005). Eltrombopag was linked to 1 case of PE.
Cochrane Database of Systematic Reviews
Current evidence (34 RCTs; n=1960) does not support overall superiority of any anticoagulant. Compared to unfractionated heparin, citrate probably reduces major bleeding and probably has little or no effect on preventing clotting or death at 28 days. Further studies are required.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
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Anticoagulation news items. Week commencing 10th August 2020
Management of Acute Pulmonary Embolism
Journal of the American Medical Association
This guidelines synopsis focuses on 2019 guidance from the European Society of Cardiology on diagnosis and management of acute pulmonary embolism, a common and potentially fatal disease with an estimated incidence of 0.7 to 1.4 per 1000 person-years.
Venous Thromboembolism Risk Assessment in Psychiatric Inpatients Audit
Sussex Partnership NHS Foundation Trust
The aim of this audit was to assess the use of VTE risk assessments and management of high-risk groups of psychiatric inpatients, and identify and implement ways in which VTE risk assessment can be carried out more systematically.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
Anticoagulation news items. Week commencing 3rd August 2020
Circulation
Review (24 RCTs, n=79,073) found short-term (<6-month) dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitor (e.g. clopidogrel) monotherapy reduces major bleeding, while extended-term (>12-month), reduces myocardial infarction at the expense of more bleeding events.
Cochrane Database of Systematic Reviews
Review (5 RCTs, n=8,373) found no meaningful difference in efficacy outcomes between NOAC and vitamin K antagonists following percutaneous coronary interventions in people with non‐valvular atrial fibrillation; but NOACs may reduce risk of hospitalisation for adverse events.
Pulmonary embolism: update on management and controversies
British Medical Journal
Review covers epidemiology, diagnosis, PE in pregnancy and cancer, thrombophilia testing, antiphospholipid syndrome, recurrent PE, risk assessment, outpatient versus inpatient management, choice of anticoagulation treatment, long term effects of PE and emerging treatments.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
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Anticoagulation news items. Week commencing 27th July 2020
The Lancet Haematology
In review of 86 RCTs, 52 of them, with data from >70 000 patients, were positive, with significantly increased VTE risk in patients in control vs. treatment groups (RR 2·74; 95% CrI 2·32–3·31,p<0·0001). Meta-analysis found causal effect of VTE prevention on mortality was null.
Management of anticoagulant-refractory thrombotic antiphospholipid syndrome
The Lancet Haematology
In this Viewpoint, authors discuss management, including general strategies to minimise thrombotic risk, intensification of anticoagulation, addition of antiplatelet agent, adjunctive treatment for thrombosis, immunomodulatory therapy, complement inhibition, and vascular options.
Alteplase for Acute Ischemic Stroke in Patients Aged >80 Years
Stroke
Pooled analyses of individual patient data from 7 RCTs of alteplase (n=6035) and registry studies support a positive benefit–risk profile of alteplase for acute ischaemic stroke, in patients aged >80 years, when administered according to other European regulatory criteria.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
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Anticoagulation news items. Week commencing 20th July 2020
DTB select: MHRA DOAC safety reminder
Drug and Therapeutics Bulletin
It is noted that there has been a considerable increase in use of DOACs and a move to switch to them from warfarin during coronavirus pandemic due to less onerous monitoring, but it is stressed regular monitoring of renal function and appropriate dose adjustment still needed.
Annals of Internal Medicine
Subgroup analysis (n=3997) found that in elderly or low-weight patients with ACS, a reduced dose of prasugrel compared with the standard dose of ticagrelor is associated with maintained anti-ischaemic efficacy while protecting these patients against the excess risk for bleeding.
JAMA Internal Medicine
RCT (n=922 pts,244 clinicians) found shared decision-making (SDM) encounter tool (individualised risk estimates & compares anticoagulant treatment options across issues of importance to patients) improved several measures of SDM quality and clinician satisfaction vs standard care.
Thrombosis in Hospitalized Patients With COVID-19 in a New York City Health System
Journal of the American Medical Association
Among 3334 patients, a thrombotic event occurred in 16.0% and was independently associated with mortality (HR 1.82; 95% CI, 1.54-2.15; P < .001). D-dimer level at presentation was independently associated with thrombotic events, consistent with an early coagulopathy.
British Journal of Clinical Pharmacology
Review of 12 studies (5,829 patients with CYP2C19 loss‐of‐function alleles) found those given ticagrelor or prasugrel had a lower risk of MACE (RR=0.52), CV death (0.41), all cause death (0.44) and stent thrombosis (0.55) than those who received clopidogrel (all p<0.05).
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
Anticoagulation news items. Week commencing 13th July 2020
Pulmonary embolism in COVID-19 patients: a French multicentre cohort study
European Heart Journal
Study (n=1,240) identified independent risk factors linked to occurrence of PE in COVID-19 patients, including clinical and biological variables at admission, but these do not include traditional thrombo-embolic risk factors, highlighting major role of inflammation & coagulopathy.
Circulation
Analysis of 20 studies (61,147 patients; 6849 events) found Factor V Leiden (FVL) was not linked to increased risk of subsequent atherothrombotic events and mortality in high-risk patients with established and treated CHD, thus not supporting routine assessment of FVL status.
Ticagrelor and Aspirin or Aspirin Alone in Acute Ischemic Stroke or TIA
New England Journal of Medicine
RCT (n=11,016) found composite of stroke or death within 30 days was lower with ticagrelor–aspirin vs. aspirin alone (5.5. vs. 6.6%;HR 0.83; 95% CI, 0.71-0.96; p=0.02) but incidence of disability did not differ significantly and severe bleeding was more frequent with ticagrelor.
New England Journal of Medicine
Review covers initial evaluation and imaging, use of alteplase within and after 4.5 hours of stroke onset, mechanical thrombectomy within and after 6 hours of stoke onset, tenecteplase, antithrombotic agents, and general medical & supportive care.
Atrial fibrillation and the prothrombotic state: revisiting Virchow’s triad in 2020
Heart
This review concludes that the mechanisms contributing to a pro-thrombotic state in AF fulfils Virchow's triad, and that improved understanding of the various factors involved in thrombus formation will allow better clinical risk stratification and targeted therapies in AF.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
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