Anticoagulation news items. Weeks commencing 24th May 2021
Critical Care Medicine
Review of 21 studies (n=1716) found haemostatic effectiveness of 71% & 76% for andexanet & prothrombin complex concentrate respectively at 24hrs. Mortality rate was 23.3% & 15.8%. Analysis for controlling confounders did not demonstrate significant differences between treatments.
British Journal of Clinical Pharmacology
Review of cohort studies (total n=227,679) found apixaban had a lower rate of ischaemic stroke or thromboembolism (HR 0.85, 95%CI 0.74-0.99) and major bleeding (0.61, 0.53-0.70) vs rivaroxaban. There were no significant differences in risk between apixaban and dabigatran.
Which is the best model to assess risk for venous thromboembolism in hospitalised patients?
British Medical Journal
Practice article notes risk assessment models (RAMs) help clinicians decide who should be offered pharmacological thromboprophylaxis, but variation exists in their composition of risk factors and thresholds for high and low risk, and there is uncertainty over the most optimal RAM.
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. Weeks commencing 17th May 2021
Systematic review of machine learning models for personalised dosing of heparin
British Journal of Clinical Pharmacology
Review concluded that there are limited studies of machine learning models for unfractionated heparin dosing, and none report a model ready for routine clinical use. Studies are low quality, inadequately report study factors and lack of external validation and impact analysis.
American Journal of Cardiology
Sub-analysis (n=6564) found rivaroxaban plus aspirin reduced total primary events (acute limb ischemia, major amputation, MI, ischemic stroke, or CV death; HR 0.86,95% CI 0.75-0.98; p=0.02) and peripheral revascularizations and VTE (0.86; 0.79-0.95; p=0.003) vs aspirin alone.
Heart
Korean study (n=4294; 94% with drug-eluting coronary stents) showed similar efficacy in preventing ischaemic events in the DOAC monotherapy vs DOAC plus antiplatelet group (HR 0.828, 95% CI 0.660 to 1.038) with lower risk of major bleeding (HR 0.690, 95% CI 0.481 to 0.989).
JAMA Cardiology
Analysis (n= 7119) found women had a higher bleeding risk vs men, which was mostly attributable to baseline differences, whereas ischemic events were similar. Benefits of early aspirin withdrawal with continuation of ticagrelor were generally comparable in women and men.
Comparative Effectiveness of Aspirin Dosing in Cardiovascular Disease
New England Journal of Medicine
Open-label pragmatic trial found no differences in cardiovascular events (event rate 7.28% vs 7.51%; HR 1.02; 95% CI 0.91 to 1.14) or major bleeding (0.63% vs 0.60%; HR 1.18; 95% CI, 0.79 to 1.77) in patients with CVD assigned to 81 mg or 325 mg of aspirin daily, respectively.
The Lancet
Korean study found clopidogrel vs aspirin monotherapy significantly reduced composite of all-cause death, non-fatal MI, stroke, readmission due to acute coronary syndrome, and bleeding (n=5530; 24 month follow up; event rate 5.7% vs 7.7%; HR 0.73; 95% CI 0.59–0.90).
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. Weeks commencing 10th May 2021
British Journal of Clinical Pharmacology
Review of 22 studies (n=110 to 104,505 of which 183,612 women [45%]) found an association between female sex and worse oral anticoagulation control (OR for TTR=0.87; 95% CI=0.78-0.96; p=0.006, based on meta-analysis of 15 studies).
Anticoagulant Use for Atrial Fibrillation Among Persons With Advanced Dementia at the End of Life
JAMA Internal Medicine
Study of 15,217 nursing home residents with AF and advanced dementia in US found ~30% remained on anticoagulation (AC) in last 6 months of life, underscoring fact that whilst there is well-defined threshold for starting AC for AF, there is no clear standard for stopping it.
PLOS Medicine
RCT (n=218) found use of 10% tranexamic acid mouthwash does not seem to reduce rate of periprocedural or early postop oral bleeding (OB) up to day 7 vs. placebo (occurred in 26.4% vs 28.6%,respectively), but appears to reduce delayed bleeds & postop OB if multiple teeth extracted.
The Lancet
This Seminar focuses on recent (past 5 years) advances in epidemiology, pathophysiology, diagnosis, treatment, and prevention of deep vein thrombosis of the legs and pulmonary embolism. Future directions are also discussed.
Andexanet alfa for reversing anticoagulation from apixaban or rivaroxaban - guidance (TA697)
National Institute for Health and Care Excellence
Andexanet alfa is recommended as an option for reversing anticoagulation from apixaban or rivaroxaban in adults with life-threatening or uncontrolled bleeding, only if requirements met as outlined in guidance.
Effectiveness and safety of oral anticoagulants in elderly patients with atrial fibrillation
Heart
Nationwide cohort study of patients ≥75 years (n=30,401) found that when initiating oral anticoagulation for AF, standard and reduced dose DOACs had similar risks of stroke/systemic embolism as warfarin and lower or similar risks of bleeding.
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. Weeks commencing 26th April & 3rd May 2021
British Journal of Clinical Pharmacology
Retrospective Dutch study (n=1154) found no associations between prior therapeutic anticoagulation use (16% of population) and mortality (RR 1.02; 95% CI; 0.80‐1.30) or length of hospital stay (7.0 vs 7.0 days, p=0.69), except lower risk of pulmonary embolism (0.19; 0.05‐0.80).
Atrial fibrillation: diagnosis and management- Updated guidance (NG196)
National Institute for Health and Care Excellence
Updates include use of tools to calculate risk of bleeding when considering use of anticoagulants, role of newer anti-clotting drugs, and use of treatments that aim to destroy or isolate the abnormal sources of electrical impulses in the heart that may be driving AF (ablation).
Is there a circannual variation in the anticoagulation control of warfarin?
European Journal of Hospital Pharmacy
This retrospective study (n=204) found no significant intra-individual differences in mean time in therapeutic range. Patients with poor anticoagulation control, high INR variability and high warfarin sensitivity index was not significantly different between the seasons.
British Journal of Clinical Pharmacology
Review of 16 studies (n=10,561, 8 studies were RCTs) found lower rates of major adverse cardiovascular events (RR 0.56, 95%CI 0.44‐0.73), stent thrombosis (0.40, 0.24‐0.67) and myocardial infarction (0.45, 0.35‐0.58) with genotype‐guided vs conventional treatment.
Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery
New England Journal of Medicine
RCT (n=4551) found tranexamic acid resulted in a significantly lower incidence (LI) of calculated estimated blood loss >1000ml or red-cell transfusion by day 2 vs. placebo (26.7% vs. 31.6%, risk ratio, 0.84; 95% CI, 0.75-0.94; p=0.003), but not LI of haemorrhage-related outcomes.
British Medical Journal
Study (n=281,264) notes increased rates of VTE events (standardised morbidity ratio 1.97; 95% CI, 1.50 to 2.54 and 11 [5.6 to 17.0] excess events per 100 000 vaccinations) including cerebral venous thrombosis, but the absolute risks were small.
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
