Learning Objectives Novel Oral Anticoagulants in the Geriatric Patient: To Bleed or Not to Bleed

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Learning Objectives Novel Oral Anticoagulants in the Geriatric Patient: To Bleed or Not to Bleed"

Transcription

1 Learning Objectives Novel Oral Anticoagulants in the Geriatric Patient: To Bleed or Not to Bleed Jonathan D. Edwards, Pharm.D., BCPS, CGP Huntsville Hospital Department of Pharmacy Huntsville, Alabama n Discuss the characteristics of the ideal anticoagulant n Review the strengths and weaknesses of warfarin therapy n Review the mechanisms of action, indications, and dosing of the novel oral anticoagulants n Analyze available literature regarding bleeding risks of the novel oral anticoagulants in the elderly population n Discuss monitoring and reversal of the novel oral anticoagulants n Express key points when utilizing the novel oral anticoagulants in the elderly 2 Conflicts of Interest n Nothing to disclose Aging Trends Older Population by Age: Percent 60+, Percent 65+, and % 25% 20% 15% 10% 5% % 60+ % 65+ % 85+ 0% Reference: 1 4 The Geriatric Conundrum Safety n Clotting Risk of thromboembolism Risk of CV disease Risk of atrial fibrillation n Bleeding Risk of major bleed Risk of renal impairment n n n Warfarin Primary reason for ADE in the ED in older adults 2011 FDA Medwatch Report 1. Dabigatran 2. Warfarin Beers 2012 criteria Dabigatran 5 References:

2 The Ideal Anticoagulant Old Habits Die Hard - Warfarin n Oral n Once daily dosing n Reversibility n Low cost n Quick onset n Predictable effect n No monitoring required But available if needed n Limited or no drug interactions n Wide therapeutic index n Pros Effective Monitoring available Frequent follow-up appointments Long half life Not renally cleared Antidote Economical Familiarity n Cons Frequent monitoring Narrow therapeutic index Unpredictable response Fluctuating doses Slow onset/offset Many drug interactions Diet interactions Reference: Does New = Better? Mechanism of Action n Pros Fixed dose More predictable & stable response Rapid onset Broader therapeutic window No monitoring No diet interactions Fewer drug interactions n Cons Multiple daily doses Rapid offset Could become an issue with compliance in the elderly No monitoring available if needed Follow-up less often No reversal agent Much more expensive n Dabigatran Direct, reversible thrombin inhibitor, inhibiting both free and clotbound thrombin n Rivaroxaban & Apixaban Direct, reversible factor Xa inhibitor, inhibiting both free Xa and Xa within the prothrombinase complex Reference: 7 9 Reference: 8 10 Indications/Dosing Question n Non-valvular A-fib: 150mg bid w/ or w/out Reduce to 75mg bid if CrCl 15-30mL/min Consider reduction to 75mg bid when CrCl ml/min AND on dronedarone or systemic ketoconazole CrCl ml/min AND P-gp inhibitor Avoid use No recommendations for CrCl < 15mL/min or HD n Non-valvular A-fib: 20mg daily with. Reduce to 15mg daily if CrCl 15-50mL/min. Avoid use if CrCl < 15ml/min n Orthopedic prophylaxis 10mg daily w/ or w/out Avoid use if CrCl < 30mL/min n DVT/PE treatment: 15mg bid x 21 days, then 20mg daily with Avoid use if CrCl < 30mL/min n Non-valvular A-fib: 5mg bid w/ or w/out Reduce to 2.5mg bid if pt has 2 of the following: Age >/= 80 Wt </= 60kg SCr >/= 1.5mg/dL --OR If on strong 3A4 inhibitor + P glycoprotein inhibitor *If both criteria met, avoid use* Reference: 9 11 T.J. is an 80 year old female with non-valvular atrial fibrillation. You receive an order to initiate apixaban 5 mg po bid. Her current serum creatinine is 1.2. She is on no interacting meds and weighs 50 kg. What is the best course of action? a. Fill the medication as ordered b. Calculate the patient s creatinine clearance c. Refuse to fill the mediation due to the black box warning d. Recommend to reduce the dose to 2.5mg po bid 12 2

3 Question Efficacy Data A physician wants to save your institution money and increase patient satisfaction by bridging all his atrial fibrillation patients with a CHADS2 > 1 to warfarin using one of the novel oral anticoagulants rather than enoxaparin. Your response is: a. That is a great idea b. There is currently no data to support this practice c. It s ok as long as the INR is drawn as a trough level d. Bridging is not necessary for these patients Ischemic stroke Hemorrhagic stroke Major bleeding Intracranial bleeding dabigatran vs. VKA 0.92 vs (p=0.03) 0.10 vs vs (p=0.31) 0.30 vs ROCKET-AF rivaroxaban vs. VKA 1.34 vs (p=0.581) 0.26 vs (p=0.024) 3.6 vs. 3.4 (p=0.58) 0.5 vs. 0.7 (p=0.02) apixaban vs. VKA 0.97 vs (p=0.42) 0.24 vs vs vs GI bleeding 1.51 vs vs vs (p=0.37) *VKA = Vitamin K Antagonist 13 References: Older Population Representation (dabigatran) ROCKET-AF (rivaroxaban) (apixaban) Dabigatran (%/year) Warfarin (%/ year) RR (95% CI) P-value Mean age yrs. of age 40% 38% 31% 80 yrs 17% -- 13% Major Bleed ECH ( ) 1.18 ( ) < ( ) 1.39 ( ) < yrs 0.4% Mean weight (kg) CrCl > 50 ml/min 82% 79% 83% GI Bleed Non-GI ECH ( ) 1.79 ( ) ( ) 1.16 ( ) <0.001 References: Reference: n Bleeding risk with dabigatran increased as Age increased Creatinine Clearance decreased Concomitant aspirin use n Age could be a more dominate risk factor for bleeding than renal function in the elderly Reference: Major Bleed ICH Non-Major Bleed Fatal/Disabling Stroke ROCKET-AF Rivaroxaban (Event/100 pt yrs) Warfarin (Event/100 pt yrs) HR (95% CI) P-value 0.96 ( ) 1.11 ( ) ( ) 0.80 ( ) ( ) 1.15 ( ) ( ) 0.76 ( ) 0.72 Reference:

4 ROCKET-AF n Predictors for increased bleeding risk Renal impairment Increased diastolic blood pressure Decreased albumin levels Decreased platelet count Prior stroke P2Y12 inhibitor use Reference: Stroke/S. Embolism < 65 years 65 - Mortality < 65 years 65 - Major Bleed 65 - ICH 65 - Apixaban (%/year) Warfarin (%/year) HR (95% CI) P-value 1.16 ( ) 0.72 ( ) 0.71 ( ) ( ) 0.77 ( ) 0.91 ( ) ( ) 0.71 ( ) 0.64 ( ) ( ) 0.35 ( ) 0.34 ( ) 0.20 Reference: n More Effective Preventing stroke Reducing mortality n Less Bleeding Major bleeding Total bleeding Intracranial hemorrhage Question Which of the following statements is correct regarding bleeding rates as age increases? a. Major bleeding rates are lower with dabigatran vs. warfarin b. Major bleeding rates are lower with rivaroxaban vs. warfarin c. Intracranial hemorrhage rates are lower with the novel oral anticoagulants vs. warfarin d. Gastrointestinal bleeding rates are lower with dabigatran vs. warfarin Reference: Agent Selection in the Older Population n As age increases Embolism rates increase Major bleeding rates increase Dabigatran and rivaroxaban have higher rates compared to warfarin Apixaban has similar rates compared to warfarin Gastrointestinal bleeding rates increase Dabigatran Dyspepsia - tartaric acid Intracranial hemorrhage rates decrease Novel oral anticoagulants Kinetics t 1/2 = 12-17hrs t 1/2 = 5-13hrs t 1/2 = 6-12hrs n Pro-drug 5% bioavailability n Protein binding 35% n 80% renally eliminated n Bioavailability 50% if drug deposited directly into small intestine n Protein binding 93% n 36% renally eliminated n 50% bioavailability does not affect n Protein binding 87% n 27% renally eliminated 23 Reference:

5 Question J.W. is an 82 year old female with non-valvular atrial fibrillation. Her physician would like to place J.W. on dabigatran. Which of the following pharmacokinetic factors is the most important to evaluate in this patient? Monitoring PT Little effect aptt 2.3 x baseline 1.8 x baseline 1.2 x baseline ECT 5.2 x baseline NA NA a. Absorption b. Distribution c. Metabolism d. Excretion TT 27 x baseline NA NA Anti-Xa NA 22% w/5 mg 68% w/30 mg INR 1.8 x baseline NR 1.5 x baseline NR 25 References: Reversal Additional Considerations in Older Patients Oral activated charcoal In vitro No Data No Data Hemodialysis Humans No Data No Data Fresh frozen plasma Activated factor VIIa Mice No Data No Data Rat Rat & Baboon No Data 3-factor PCC No Data No Data No Data 4-factor PCC Human & Rat Human No Data n Living situation Do they have a way to get to the coumadin clinic? n Functional status Issues with opening medication bottles Dabigatran packaging issues n Cognitive impairment BID dosing Dose adjustments n Frailty Increased falling risk Less likely to leave home n Adherence Quick offset medications Complex dosing regimens n Cost Can the patient afford the medication? References: References: Formulation/Cost Increased Risk of ADEs Dabigatran Capsule n Do not open, crush, or chew Opening capsule increases bioavailability by 75% n Approx $3.25 per capsule Rivaroxaban Tablet n Can crush the 15 and 20mg Do not deliver into the proximal small intestine n Approx $5.00 per tab Apixaban Tablet n No recommendation on crushing n Approx $3.80 per tab n Extreme old age n Use of high risk medications n Use of narrow-therapeutic medications n Presence of 6 or more illnesses n History of prior adverse drug reaction n Low body weight n Decrease renal function n Polypharmacy References: Reference:

6 Safe Use of Anticoagulants in the Elderly Patient Education in Older Patients n Provider Education When to use each agent Appropriate dosing Appropriate transitions n Patient Selection Novel oral anticoagulants Warfarin n Agent Selection criteria Algorithm Check list n Systems in Place Transitions Monitoring Inappropriate warfarin monitoring is associated with worse anticoagulation control n Renal function Age-related decline n Drug interactions Polypharmacy n Patient Education Evaluate comprehension n Generally poor knowledge about warfarin therapy 81% had no knowledge about its benefits 45-70% had insufficient knowledge about potential risks 64% unaware that medications & diet can affect INR n Improved patient knowledge regarding warfarin Associated with improved adherence and outcomes Good understanding 85% well controlled Poor understanding 63% well controlled Higher bleeding rates n Ability to recall knowledge declines with age Written information Reference: References: Patient Education Key Points Selecting the appropriate candidate n What is it? n Why am I taking it? n Administration What to do if missed dose Dabigatran Do not open capsules Keep in original bottle Rivaroxaban Take with n Adverse drug event potential n Adherence Don t stop taking the medication Notify primary care physician of any planned procedures Pill boxes (NOT dabigatran) n Drug / Drug Interactions OTCs n Drug / Food Interactions n Follow up / Monitoring n Do they have an approved indication? n Do they have unstable INRs? Make sure this is not compliance related n Do they have road blocks to INR monitoring? n Do they have adequate renal function? n Do they have compliance issues? n Will the new agent cause any major drug interactions? 33 Reference: Which agent to choose? Conclusion n What s the indication? n Will compliance be an issue? n Will the medication need to be crushed? n Are drug interactions present? n Can the patient afford the medication? n History of bleeding problems? n History of gastrointestinal problems? n Patient selection Living situation Functional status Cognitive impairment Frailty Adherence Cost n Agent selection Bleeding risk Renal function Weight Gastrointestinal effects Drug interactions Adherence n Education and follow up are required for safe use of these medications

7 Case JE, an 82 year old male with non-valvular atrial fibrillation, is a resident of a local nursing home. His physician would like to change his current anticoagulation therapy from warfarin to one of the novel oral anticoagulants due to his fluctuating INR values. JE has been taking warfarin for approximately 2 years during which time his INR fluctuates drastically from 1.5 to 4.5. His past medical history includes hypertension, diabetes, gastrointestinal bleed, J-tube placement, and osteoarthritis. His calculated creatinine clearance is 45 ml/min and weighs 55 kg. He is currently not taking any interacting medications. Question Which of the following is the best option for changing his anticoagulation therapy? a. Initiate dabigatran 150 mg po BID b. Initiate dabigatran 75 mg po BID c. Initiate apixaban 2.5 mg po BID d. Initiate rivaroxaban 15 mg po daily References References 1. Projections for 2010 through 2050 are from: Table 12. Projections of the Population by Age and Sex for the United States: 2010 to 2050, U.S. Census Bureau; Release Date: August 14, Budnitz DS, et al. National Surveillance of Emergency Department Visits for Outpatient Adverse Drug Events. JAMA. 2006;296: Budnitz DS, et al. Emergency Hospitalizations for Adverse Drug Events in Older Americans. NEJM. 2011;365: American Geriatrics Society 2012 Beers Criteria Update Expert Panel. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc Apr;60(4): Rojas-Hernandez CM, Garcia DA. The novel oral anticoagulants. Semin Thromb Hemost Mar;39(2): Cabral KP, et al. Future directions of stroke prevention in atrial fibrillation: the potential impact of novel anticoagulants and stroke risk stratification. J Thromb Haemost. 2011;9(3): Scaglione F. New oral anticoagulants: comparative pharmacology with vitamin K antagonists. Clin Pharmacokinet Feb;52(2): Perez A, Eraso LH, Merli GJ. Implications of new anticoagulants in primary practice. Int J Clin Pract Feb;67(2): Connolly S.J., et al. Dabigatran versus Warfarin in Patients with Atrial Fibrillation. NEJM. 2009;361: Patel M.R., et al. Rivaroxaban versus Warfarin in Nonvalvular Atrial Fibrillation. NEJM 2011;365: Granger C.B., et al. Apixaban versus Warfarin in Patients with Atrial Fibrillation. NEJM. 2011;365: Eikelboom JW, et al. Risk of Bleeding With 2 Doses of Dabigatran Compared With Warfarin in Older and Younger Patients With Atrial Fibrillation: An Analysis of the Randomized Evaluation of Long-Term Anticoagulant Therapy (RE-LY) Trial. Circulation. 2011;123: Halperin JL, et al. Efficacy and Safety of Rivaroxaban Compared with Warfarin Among Elderly Patients with Nonvalvular Atrial Fibrillation in the ROCKET-AF Trial. Stroke. 2012;43:A Halvorsen S, et al. Efficacy and Safety of Apixaban Compared with Warfarin According to Age for Stroke Prevention in Atrial Fibrillation. JACC. 2013;61(10):E Hellwig T, Gulseth M. New oral therapies for the prevention and treatment of venous thromboembolism. Am J Health Syst Pharm Jan 15;70(2): Eriksson BI, et al. Comparative Pharmacodynamics and Pharmacokinetics of Oral Direct Thrombin and Factor Xa Inhibitors in Development. Clin Pharmacokinet. 2009;48: Barrett YC, et al. Clinical laboratory measurement of direct factor Xa inhibitors: Anti-Xa assay is preferable to prothrombin time assay. Thromb Haemost. 2010;104: Kubitza D, et al. Safety, pharmacodynamics, and pharmacokinetics of BAY an oral, direct Factor Xa inhibitor after multiple dosing in healthy male subjects. Eur J Clin Pharmacol. 2005;61: van Ryn J, et al. Dabigatran etexilate a novel, reversible, oral direct thrombin inhibitor: Interpretation of coagulation assays and reversal of anticoagulant activity. Thromb Haemost. 2010;103: van Ryn J, et al. Reversibility of the anticoagulant effect of high doses of the direct thrombin inhibitor dabigatran, by recombinant factor VIIa or activated prothrombin complex concentrate. Haematologica. 2008;93(supp 1):abstr Marlu R, et al. Effect of non-specific reversal agents on anticoagulant activity of dabigatran and rivaroxaban. Thromb Haemost. 2012;108: Kaatz S, et al. Guidance on the emergent reversal of oral thrombin and factor Xa inhibitors. Am J Hematol. 2012;87:S141-S Hylek EM. Translating the Results of Randomized Trials into Clinical Practice: The Challenge of Warfarin Candidacy Among Hospitalized Elderly Patients With Atrial Fibrillation. Stroke. 2006;37: Sudlow M, et al. Prevalence of atrial fibrillation and eligibility for anticoagulants in the community. Lancet. 1998;352(9135): Man-Son-Hing M, et al. Choosing Antithrombotic Therapy for Elderly Patients With Atrial Fibrillation Who Are at Risk for Falls. Arch Intern Med. 1999;159: Image of a dabigatran capsule. Photograph. n.d. Web. 03 Dec Image of a rivaroxaban tablet. Photograph. n.d. Web. 03 Dec Image of a apixaban tablet. Photograph. n.d. Web. 03 Dec Fouts MM, et al. Identification of Elderly Nursing Facility Residents at High Risk for Drug-Related Problems. Consult Pharm. 1997;12: Rose AJ, et al. Gaps in Monitoring During Oral Anticoagulation: Insights Into Care Transitions, Monitoring Barriers, and Medication Nonadherence. CHEST. 2013;143(3): Ansell JE. Empowering Patients to Monitor and Manage Oral Anticoagulation Therapy. JAMA. 1999;281(2): Kagansky N, et al. Safety of Anticoagulation Therapy in Well-informed Older Patients. Arch Intern Med. 2004;164: Roddie A, et al. Clin Lab Haematol. 1988;10: Nasser S, et al. Challenges of Older Patients Knowledge About Warfarin Therapy. J Prim Care & Comm Health. 2012;3(1): Weitz JI, Gross PL. New oral anticoagulants: which one should my patient use? Hematology Am Soc Hematol Educ Program. 2012;2012: Novel Oral Anticoagulants in the Geriatric Patient: To Bleed or Not to Bleed Jonathan D. Edwards, Pharm.D., BCPS, CGP 7

The author has no disclosures

The author has no disclosures Mary Bradbury, PharmD, BCPS Clinical Pharmacy Specialist, Cardiac Surgery September 18, 2012 Mary.bradbury@inova.org This presentation will discuss unlabeled and investigational use of products The author

More information

PGY1 Pharmacy Practice St. Vincent Hospital PGY2 Ambulatory Care St. Vincent Primary Care Center

PGY1 Pharmacy Practice St. Vincent Hospital PGY2 Ambulatory Care St. Vincent Primary Care Center Speaker Introduction Jessica Wilhoite, PharmD, BCACP Doctor of Pharmacy: Purdue University Postgraduate Residency Training: PGY1 Pharmacy Practice St. Vincent Hospital PGY2 Ambulatory Care St. Vincent

More information

Speaker Disclosure. Outline. Pharmacist Objectives. Patient Case. Outline 9/4/2014

Speaker Disclosure. Outline. Pharmacist Objectives. Patient Case. Outline 9/4/2014 Speaker Disclosure Matthew K. Pitlick, Pharm.D., BCPS St. Louis College of Pharmacy/VA St. Louis HCS mpitlick@stlcop.edu Matthew K. Pitlick, Pharm.D., BCPS declares no conflicts of interest, real or apparent,

More information

New Anticoagulation Options for Stroke Prevention in Atrial Fibrillation. Joy Wahawisan, Pharm.D., BCPS April 25, 2012

New Anticoagulation Options for Stroke Prevention in Atrial Fibrillation. Joy Wahawisan, Pharm.D., BCPS April 25, 2012 New Anticoagulation Options for Stroke Prevention in Atrial Fibrillation Joy Wahawisan, Pharm.D., BCPS April 25, 2012 Stroke in Atrial Fibrillation % Stroke 1991;22:983. Age Range (years) CHADS 2 Risk

More information

Devang M. Desai, MD, FACC, FSCAI Chief of Interventional Cardiology Director of Cardiac Catheterization Lab St. Mary s Hospital and Regional Medical

Devang M. Desai, MD, FACC, FSCAI Chief of Interventional Cardiology Director of Cardiac Catheterization Lab St. Mary s Hospital and Regional Medical Devang M. Desai, MD, FACC, FSCAI Chief of Interventional Cardiology Director of Cardiac Catheterization Lab St. Mary s Hospital and Regional Medical Center A.Fib affects 2.2 million Americans. The lifetime

More information

FDA Approved Oral Anticoagulants

FDA Approved Oral Anticoagulants FDA Approved Oral Anticoagulants Generic (Trade Name) Warfarin (Coumadin, Jantoven ) 1 FDA approved indication Prophylaxis and treatment of venous thromboembolism (VTE) Prophylaxis and treatment of thromboembolic

More information

Novel Anticoagulation Agents DISCLOSURES. Objectives ATRIAL FIBRILLATION TRIALS. NOAC Comparison 6/12/2015

Novel Anticoagulation Agents DISCLOSURES. Objectives ATRIAL FIBRILLATION TRIALS. NOAC Comparison 6/12/2015 Novel Anticoagulation Agents DISCLOSURES James W. Haynes, MD Department of Family Medicine Univ of TN Health Science Center (Chattanooga) Objectives Understand mechanism of action behind the NOAC agents

More information

The 50-year Quest to Replace Warfarin: Novel Anticoagulants Define a New Era. CCRN State of the Heart 2012 June 2, 2012

The 50-year Quest to Replace Warfarin: Novel Anticoagulants Define a New Era. CCRN State of the Heart 2012 June 2, 2012 The 50-year Quest to Replace Warfarin: Novel Anticoagulants Define a New Era CCRN State of the Heart 2012 June 2, 2012 Disclosures I have I have been involved in trials of new anticoagulants and have received

More information

Dabigatran (Pradaxa) Guidelines

Dabigatran (Pradaxa) Guidelines Dabigatran (Pradaxa) Guidelines Dabigatran is a new anticoagulant for reducing the risk of stroke in patients with atrial fibrillation. Dabigatran is a direct thrombin inhibitor, similar to warfarin, without

More information

4/9/2015. Risk Stratify Our Patients. Stroke Risk in AF: CHADS2 Scoring system JAMA 2001; 285: 2864-71

4/9/2015. Risk Stratify Our Patients. Stroke Risk in AF: CHADS2 Scoring system JAMA 2001; 285: 2864-71 Anticoagulation in the 21 st Century Adam Karpman, D.O. Saint Francis Medical Center/Oklahoma State University Medical Center Disclosures: None Atrial Fibrillation Most common arrhythmia in clinical practice.

More information

48 th Annual Meeting. Non-VKA Oral Anticoagulants: Prevention & Treatment of Bleeding. Terminology. Disclosure. Public Health Impact.

48 th Annual Meeting. Non-VKA Oral Anticoagulants: Prevention & Treatment of Bleeding. Terminology. Disclosure. Public Health Impact. 48 th Annual Meeting Terminology Non-VKA Oral Anticoagulants: Prevention & Treatment of Bleeding Stacy A. Voils, PharmD, MS, BCPS Navigating the Oceans of Opportunity Target-specific oral anticoagulants

More information

New anticoagulants: Monitoring or not Monitoring? Not Monitoring

New anticoagulants: Monitoring or not Monitoring? Not Monitoring The 2 nd World Congress on CONTROVERSIES IN HEMATOLOGY (COHEM) Barcelona, Spain September 6 8, 2012 New anticoagulants: Monitoring or not Monitoring? Not Monitoring Anna Falanga, MD Immunohematology and

More information

Xarelto (Rivaroxaban)

Xarelto (Rivaroxaban) Xarelto (Rivaroxaban) Hightly selective, reversible, direct oral FXa inhibitor Maxium concentratiion after 2 to 4 hrs High bioavailability(66%),increase with food ( suggest with food) 1/3 from renal excretion,

More information

NEWER ANTICOAGULANTS: FOCUS ON STROKE PREVENTION IN ATRIAL FIBRILLATION AND DEEP VEIN THROMBOSIS/PULMONARY EMBOLISM

NEWER ANTICOAGULANTS: FOCUS ON STROKE PREVENTION IN ATRIAL FIBRILLATION AND DEEP VEIN THROMBOSIS/PULMONARY EMBOLISM NEWER ANTICOAGULANTS: FOCUS ON STROKE PREVENTION IN ATRIAL FIBRILLATION AND DEEP VEIN THROMBOSIS/PULMONARY EMBOLISM Carol Lee, Pharm.D., Jessica C. Song, M.A., Pharm.D. INTRODUCTION For many years, warfarin

More information

New Treatments for Stroke Prevention in Atrial Fibrillation. John C. Andrefsky, MD, FAHA NEOMED Internal Medicine Review course May 5 th, 2013

New Treatments for Stroke Prevention in Atrial Fibrillation. John C. Andrefsky, MD, FAHA NEOMED Internal Medicine Review course May 5 th, 2013 New Treatments for Stroke Prevention in Atrial Fibrillation John C. Andrefsky, MD, FAHA NEOMED Internal Medicine Review course May 5 th, 2013 Classification Paroxysmal atrial fibrillation (AF) Last < 7

More information

Analyzing Clinical Trial Findings of the Efficacy and Safety Profiles of Novel Anticoagulants for Stroke Prevention in Atrial Fibrillation

Analyzing Clinical Trial Findings of the Efficacy and Safety Profiles of Novel Anticoagulants for Stroke Prevention in Atrial Fibrillation Analyzing Clinical Trial Findings of the Efficacy and Safety Profiles of Novel Anticoagulants for Stroke Prevention in Atrial Fibrillation Drew Baldwin, MD Virginia Mason Seattle, Washington NCVH May 29,

More information

1/12/2016. What s in a name? What s in a name? NO.Anti-Coagulation. DOACs in clinical practice. Practical aspects of using

1/12/2016. What s in a name? What s in a name? NO.Anti-Coagulation. DOACs in clinical practice. Practical aspects of using What s in a name? Practical aspects of using DOACs (Direct Oral Anticoagulants) James L. Sebastian, MD, MACP Professor of Medicine (GIM) Medical College of Wisconsin February 5, 2016 DOAC NOAC NOAC ODI

More information

DVT/PE Management with Rivaroxaban (Xarelto)

DVT/PE Management with Rivaroxaban (Xarelto) DVT/PE Management with Rivaroxaban (Xarelto) Rivaroxaban is FDA approved for the acute treatment of DVT and PE and reduction in risk of recurrence of DVT and PE. FDA approved indications: Non valvular

More information

5/21/2012. Perioperative Use Issues. On admission: During hospitalization:

5/21/2012. Perioperative Use Issues. On admission: During hospitalization: Dabigatran and Rivaroxaban: Challenges in the Perioperative Setting Claudia Swenson, Pharm.D., CDE, BC-ADM, FASHP Central Washington Hospital Wenatchee, WA claudia.swenson@cwhs.com Dabigatran and Rivaroxaban:

More information

Oral Anticoagulants: What s New?

Oral Anticoagulants: What s New? Oral Anticoagulants: What s New? Sallie Young, Pharm.D., BCPS (AQ-Cardiology) Clinical Pharmacy Specialist, Cardiology Penn State Hershey Medical Center syoung1@hmc.psu.edu August 2012 Oral Anticoagulant

More information

Disclosures. New Developments in Oral Anticoagulants: Treating and Preventing Embolic Events in the 21 st Century

Disclosures. New Developments in Oral Anticoagulants: Treating and Preventing Embolic Events in the 21 st Century New Developments in Oral Anticoagulants: Treating and Preventing Embolic Events in the 21 st Century David Stewart, PharmD, BCPS Associate Professor of Pharmacy Practice East Tennessee State University

More information

DABIGATRAN ETEXILATE TARGET Vitamin K epoxide reductase WARFARIN RIVAROXABAN APIXABAN

DABIGATRAN ETEXILATE TARGET Vitamin K epoxide reductase WARFARIN RIVAROXABAN APIXABAN TARGET SPECIFIC ORAL ANTICOAGULANTS (TSOACs) This document is intended as a guideline only and should not replace sound clinical judgment Please refer to UNMH formulary in Lexicomp for approved use(s)

More information

3/25/14. To Clot or Not What s New In Anticoagulation? Clotting Cascade. Anticoagulant drug targets. Anita Ralstin, MS CNS CNP. Heparin.

3/25/14. To Clot or Not What s New In Anticoagulation? Clotting Cascade. Anticoagulant drug targets. Anita Ralstin, MS CNS CNP. Heparin. To Clot or Not What s New In Anticoagulation? Anita Ralstin, MS CNS CNP 1 Clotting Cascade 2 Anticoagulant drug targets Heparin XI VIII IX V X VII LMWH II Warfarin Fibrin clot 1 Who Needs Anticoagulation

More information

Comparison between New Oral Anticoagulants and Warfarin

Comparison between New Oral Anticoagulants and Warfarin Comparison between New Oral Anticoagulants and Warfarin Warfarin was the mainstay of oral anticoagulant therapy until the recent discovery of more precise targets for therapy. In recent years, several

More information

1/7/2012. Objectives. Epidemiology of Atrial Fibrillation(AF) Stroke in AF. Stroke Risk Stratification in AF

1/7/2012. Objectives. Epidemiology of Atrial Fibrillation(AF) Stroke in AF. Stroke Risk Stratification in AF Objectives Atrial Fibrillation and Prevention of Thrombotic Complications: Therapeutic Update Andrea C. Flores Pharm.D Pharmacy Resident at the Miami VA Healthcare System Review the epidemiology, pathophysiology

More information

The New Oral Anticoagulants: When and When Not to Use Them Philip C. Comp, M.D., Ph.D. Professor of Medicine, University of Oklahoma Health Sciences

The New Oral Anticoagulants: When and When Not to Use Them Philip C. Comp, M.D., Ph.D. Professor of Medicine, University of Oklahoma Health Sciences The New Oral Anticoagulants: When and When Not to Use Them Philip C. Comp, M.D., Ph.D. Professor of Medicine, University of Oklahoma Health Sciences Center September 25, 2015 Question: With which of the

More information

Impact of new (direct) oral anticoagulants in patient blood management

Impact of new (direct) oral anticoagulants in patient blood management Impact of new (direct) oral anticoagulants in patient blood management Yulia Lin, MD, FRCPC, CTBS Transfusion Medicine & Hematology, Sunnybrook Health Sciences Centre Dept of Laboratory Medicine & Pathobiology,

More information

Kevin Saunders MD CCFP Rivergrove Medical Clinic Wellness Institute @ SOGH April 17 2013

Kevin Saunders MD CCFP Rivergrove Medical Clinic Wellness Institute @ SOGH April 17 2013 Kevin Saunders MD CCFP Rivergrove Medical Clinic Wellness Institute @ SOGH April 17 2013 Family physician with Rivergrove Medical Clinic Practice in the north end since 1985 Medical Director of the Wellness

More information

AHA/ASA Scientific Statement Oral Antithrombotic Agents for the Prevention of Stroke in Atrial Fibrillation

AHA/ASA Scientific Statement Oral Antithrombotic Agents for the Prevention of Stroke in Atrial Fibrillation AHA/ASA Scientific Statement Oral Antithrombotic Agents for the Prevention of Stroke in Atrial Fibrillation A Statement for Healthcare Professionals from the American Heart Association/American Stroke

More information

Stop the Bleeding: Management of Drug-induced Coagulopathy. Stacy A. Voils, PharmD, BCPS Critical Care Specialist, Neurosurgery

Stop the Bleeding: Management of Drug-induced Coagulopathy. Stacy A. Voils, PharmD, BCPS Critical Care Specialist, Neurosurgery Stop the Bleeding: Management of Drug-induced Coagulopathy Stacy A. Voils, PharmD, BCPS Critical Care Specialist, Neurosurgery Objectives Discuss contemporary management of warfarin reversal in patients

More information

Antiplatelet and Antithrombotic Therapy. Dr Curry Grant Stroke Prevention Clinic Quinte Health Care

Antiplatelet and Antithrombotic Therapy. Dr Curry Grant Stroke Prevention Clinic Quinte Health Care Antiplatelet and Antithrombotic Therapy Dr Curry Grant Stroke Prevention Clinic Quinte Health Care Disclosure of Potential for Conflict of Interest Dr. F.C. Grant Atrial Fibrillation FINANCIAL DISCLOSURE:

More information

New Oral Anticoagulants

New Oral Anticoagulants Disclosures The New Oral Anticoagulants: Are they better than Warfarin? Alan P. Agins, Ph.D. does not have any actual or potential conflicts of interest in relation to this CE activity. Alan Agins, Ph.D.

More information

STROKE PREVENTION IN ATRIAL FIBRILLATION

STROKE PREVENTION IN ATRIAL FIBRILLATION STROKE PREVENTION IN ATRIAL FIBRILLATION OBJECTIVE: To guide clinicians in the selection of antithrombotic therapy for the secondary prevention of ischemic stroke and arterial thromboembolism in patients

More information

STROKE PREVENTION IN ATRIAL FIBRILLATION. TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: ABBREVIATIONS: BACKGROUND:

STROKE PREVENTION IN ATRIAL FIBRILLATION. TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: ABBREVIATIONS: BACKGROUND: STROKE PREVENTION IN ATRIAL FIBRILLATION TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: To guide clinicians in the selection of antithrombotic therapy for the secondary prevention

More information

Xabans Good for What Ails Ya? Brian Tiffany, MD, PhD, FACEP Dept of Emergency Medicine Chandler Regional Medical Center Mercy Gilbert Medical Center

Xabans Good for What Ails Ya? Brian Tiffany, MD, PhD, FACEP Dept of Emergency Medicine Chandler Regional Medical Center Mercy Gilbert Medical Center Xabans Good for What Ails Ya? Brian Tiffany, MD, PhD, FACEP Dept of Emergency Medicine Chandler Regional Medical Center Mercy Gilbert Medical Center DISCLOSURES No relevant financial disclosures I will

More information

STARTING, SWITCHING OR STOPPING NEW ORAL ANTICOAGULANTS: A Practical Approach

STARTING, SWITCHING OR STOPPING NEW ORAL ANTICOAGULANTS: A Practical Approach STARTING, SWITCHING OR STOPPING NEW ORAL ANTICOAGULANTS: A Practical Approach Jeffrey I Weitz, MD, FRCP(C), FACP Professor of Medicine and Biochemistry McMaster University Canada Research Chair in Thrombosis

More information

New Oral Anticoagulant Drugs What monitoring if any is required?

New Oral Anticoagulant Drugs What monitoring if any is required? New Oral Anticoagulant Drugs What monitoring if any is required? Michelle Williamson Supervising Scientist High Throughput Haematology Pathology Queensland PAH Laboratory Overview Background What new oral

More information

New Anticoagulants- Dabigatran/Rivaroxaban

New Anticoagulants- Dabigatran/Rivaroxaban New Anticoagulants- Dabigatran/Rivaroxaban JOHN NOVIASKY, PHARMD, BCPS, FNYSCHP CGH AT UPSTATE UNIVERSITY HOSPITAL SYRACUSE NY Objectives Describe the risks and benefits of dabigatran therapy Describe

More information

Management of atrial fibrillation. Satchana Pumprueg, MD Sirin Apiyasawat, MD Thoranis Chantrarat, MD

Management of atrial fibrillation. Satchana Pumprueg, MD Sirin Apiyasawat, MD Thoranis Chantrarat, MD Management of atrial fibrillation Satchana Pumprueg, MD Sirin Apiyasawat, MD Thoranis Chantrarat, MD Antithrombotic therapy in atrial fibrillation Satchana Pumprueg, MD AF has serious consequences Independent

More information

} Most common arrhythmia. } Incidence increases with age. } Anticoagulants approved for AF

} Most common arrhythmia. } Incidence increases with age. } Anticoagulants approved for AF Deniz Yavas, PharmD PGY-2 Ambulatory Care Pharmacy Resident Detroit Veterans Affairs Medical Center } Most common arrhythmia 0.4-1% of Americans (2.2 mil people) 1,2 } Incidence increases with age 6% (65

More information

Anticoagulation and Reversal

Anticoagulation and Reversal Anticoagulation and Reversal John Howard, PharmD, BCPS Clinical Pharmacist Internal Medicine Affiliate Associate Clinical Professor South Carolina College of Pharmacy Disclosures I have no Financial, Industry,

More information

Traditional anticoagulants

Traditional anticoagulants TEGH Family Practice Clinic Day April 4, 03 Use of Anticoagulants in 03: What s New (and What Isn t) Bill Geerts, MD, FRCPC Director, Thromboembolism Program, Sunnybrook HSC Professor of Medicine, University

More information

Session 3 Topics. Argatroban. Argatroban. Drug Use and Adverse Effects. Laboratory Monitoring of Anticoagulant Therapy

Session 3 Topics. Argatroban. Argatroban. Drug Use and Adverse Effects. Laboratory Monitoring of Anticoagulant Therapy ~~Marshfield Labs Presents~~ Laboratory Monitoring of Anticoagulant Therapy Session 3 of 4 Michael J. Sanfelippo, M.S. Technical Director, Coagulation Services Session 3 Topics Direct Thrombin Inhibitors:

More information

Objectives. New and Emerging Anticoagulants. Objectives (continued) 2/18/2014. Development of New Anticoagulants

Objectives. New and Emerging Anticoagulants. Objectives (continued) 2/18/2014. Development of New Anticoagulants Objectives New and Emerging Anticoagulants Adraine Lyles, PharmD, BCPS Clinical Pharmacy Specialist VCU Medical Center Describe the pharmacology of the novel oral anticoagulants Discuss the clinical evidence

More information

Disclosure/Conflict of Interest

Disclosure/Conflict of Interest NEW ORAL ANTICOAGULANTS: WHAT EVERY PHARMACIST SHOULD KNOW LORI B. HORNSBY, PHARMD, BCPS ASSOCIATE CLINICAL PROFESSOR AUHSOP CLINICAL PHARMACIST MIDTOWN MEDICAL CENTER OUTPATIENT CLINIC COLUMBUS, GEORGIA

More information

Reversing the New Anticoagulants

Reversing the New Anticoagulants Reversing the New Anticoagulants Disclosure Susan C. Lambe, MD Assistant Clinical Professor Department of Emergency Medicine University of California, San Francisco Roadmap for today 1 Roadmap for today

More information

The Role of the Newer Anticoagulants

The Role of the Newer Anticoagulants The Role of the Newer Anticoagulants WARFARIN = Coumadin DAGIBATRAN = Pradaxa RIVAROXABAN = Xarelto APIXABAN = Eliquis INDICATION DABIGATRAN (Pradaxa) RIVAROXABAN (Xarelto) APIXABAN (Eliquis) Stroke prevention

More information

Goals 6/6/2014. Stroke Prevention in Atrial Fibrillation: New Oral Anti-Coagulants No More INRs. Ashkan Babaie, MD

Goals 6/6/2014. Stroke Prevention in Atrial Fibrillation: New Oral Anti-Coagulants No More INRs. Ashkan Babaie, MD Stroke Prevention in Atrial Fibrillation: New Oral Anti-Coagulants No More INRs Ashkan Babaie, MD Arrhythmia Service Providence Heart Clinic June 8 th, 2014 Goals Discuss the data behind approval of NOACs

More information

Disclosures. Objectives 4/25/2014. Novel Anticoagulants in the Elderly

Disclosures. Objectives 4/25/2014. Novel Anticoagulants in the Elderly Novel Anticoagulants in the Elderly Bahar Matusik, PharmD, BCPS Assistant Professor Department of Pharmacy Practice & Administration University of Saint Joseph, School of Pharmacy Disclosures Dr. Bahar

More information

New Anticoagulants: Are we Ready to Replace Warfarin? Carole Goodine, RPh Horizon Health Network Stroke Conference 2011

New Anticoagulants: Are we Ready to Replace Warfarin? Carole Goodine, RPh Horizon Health Network Stroke Conference 2011 New Anticoagulants: Are we Ready to Replace Warfarin? Carole Goodine, RPh Horizon Health Network Stroke Conference 2011 Warfarin Decreases stroke risk by 60-70% Superior to ASA and ASA plus clopidogrel

More information

Oral Anticoagulation in Older Persons The Next Generation

Oral Anticoagulation in Older Persons The Next Generation Oral Anticoagulation in Older Persons The Next Generation Luis Viana B.Sc. Phm., Pharm D (candidate), M.Ed., ACPR, CGP Clinical Consultant Pharmacist, Medical Pharmacies Group Limited Adjunct Clinical

More information

New oral anticoagulants and antiplatelets: Where do they fit? Meredith Hollinger, PharmD BCPS

New oral anticoagulants and antiplatelets: Where do they fit? Meredith Hollinger, PharmD BCPS New oral anticoagulants and antiplatelets: Where do they fit? Meredith Hollinger, PharmD BCPS Clinical Pharmacy Specialist, Cardiology September 2012 Objectives Describe the mechanisms of action for novel

More information

The New Anticoagulants are Here! Do you know how to use them? Arrhythmia Winter School February 11 th, 2012. Jeff Healey

The New Anticoagulants are Here! Do you know how to use them? Arrhythmia Winter School February 11 th, 2012. Jeff Healey The New Anticoagulants are Here! Do you know how to use them? Arrhythmia Winter School February 11 th, 2012 Jeff Healey RELY: A New Era in AF Connolly SJ et al. N Engl J Med 2009;361:1139-1151 ROCKET-AF:

More information

New Oral Anticoagulants

New Oral Anticoagulants New Oral Anticoagulants Tracy Minichiello, MD Associate Professor of Medicine Chief, San FranciscoVA Anticoagulation and Thrombosis Service Ansell, J. Hematology Copyright 2010 American Society of Hematology.

More information

DOACs. What s in a name? or TSOACs. Blood Clot. Darra Cover, Pharm D. Clot Formation DOACs work here. Direct Oral AntiCoagulant

DOACs. What s in a name? or TSOACs. Blood Clot. Darra Cover, Pharm D. Clot Formation DOACs work here. Direct Oral AntiCoagulant DOACs NOACs or TSOACs Generic Name DOACs Brand Name Mechanism of Action Direct Xa Inhibitor Direct Thrombin Inhibitor Dabigatran Pradaxa X Rivaroxaban Xarelto X Darra Cover, Pharm D Apixaban Eliquis X

More information

New Oral AntiCoagulants (NOAC) in 2015

New Oral AntiCoagulants (NOAC) in 2015 New Oral AntiCoagulants (NOAC) in 2015 William R. Hiatt, MD Professor of Medicine and Cardiology University of Colorado School of Medicine President CPC Clinical Research Disclosures Received research

More information

Long term anticoagulant therapy in patients with atrial fibrillation at high risk of stroke: a new scenario after RE-LY trial

Long term anticoagulant therapy in patients with atrial fibrillation at high risk of stroke: a new scenario after RE-LY trial Long term anticoagulant therapy in patients with atrial fibrillation at high risk of stroke: a new scenario after RE-LY trial Camillo Autore Università di Roma Sapienza II Facoltà di Medicina e Chirurgia

More information

Anticoagulants in Atrial Fibrillation

Anticoagulants in Atrial Fibrillation Anticoagulants in Atrial Fibrillation Starting and Stopping Them Safely Carmine D Amico, D.O. Overview Learning objectives Introduction Basic concepts Treatment strategy & options Summary 1 Learning objectives

More information

Recommendations on Use of Dabigatran in Atrial Fibrillation

Recommendations on Use of Dabigatran in Atrial Fibrillation Recommendations on Use of Dabigatran in Atrial Fibrillation Developed by participants from the Section of Hematology/Oncology and Section of Cardiology, and Faculty of Pharmacy, University of Manitoba

More information

New Anticoagulants for the Treatment of Thromboembolism With a little subplot on superficial thrombophlebitis. Mark Crowther

New Anticoagulants for the Treatment of Thromboembolism With a little subplot on superficial thrombophlebitis. Mark Crowther New Anticoagulants for the Treatment of Thromboembolism With a little subplot on superficial thrombophlebitis Mark Crowther 1 Disclosures Advisory Boards in last 24 months Pfizer, Alexion, Bayer, CSL Behring,

More information

TSOAC Initiation Checklist

TSOAC Initiation Checklist Task Establish appropriate dose based on anticoagulant selected, indication and patient factors such as renal function. Evaluate for medication interactions that may necessitate TSOAC dose adjustment.

More information

Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Brief Comparison of Four Agents

Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Brief Comparison of Four Agents Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Brief Comparison of Four Agents Abbreviations AF: Atrial fibrillation ARISTOTLE: Apixaban for Reduction in Stroke and Other Thromboembolic

More information

Time of Offset of Action The Trial

Time of Offset of Action The Trial New Antithrombotic Agents DISCLOSURE Relevant Financial Relationship(s) Speaker Bureau - None Consultant Amgen Tom DeLoughery, MD FACP FAWM Oregon Health and Sciences University What I am Talking About

More information

Non- Valvular Atrial Fibrillation and Stroke Prevention: Which OAC Do I Choose. Warfarin vs the NOACs

Non- Valvular Atrial Fibrillation and Stroke Prevention: Which OAC Do I Choose. Warfarin vs the NOACs Non- Valvular Atrial Fibrillation and Stroke Prevention: Which OAC Do I Choose Warfarin vs the NOACs Dr. Lori McIntosh D.O. Board Certified Neurologist Objectives Be able to list the current options of

More information

Anticoagulation Dosing at UCDMC Indication Agent Standard Dose Comments and Dose Adjustments VTE Prophylaxis All Services UFH 5,000 units SC q 8 h

Anticoagulation Dosing at UCDMC Indication Agent Standard Dose Comments and Dose Adjustments VTE Prophylaxis All Services UFH 5,000 units SC q 8 h Indication Agent Standard Dose Comments and Dose Adjustments VTE Prophylaxis All Services UFH 5,000 units SC q 8 h See EMR adult VTE prophylaxis CI order set Enoxaparin See service specific dosing Assess

More information

Management for Deep Vein Thrombosis and New Agents

Management for Deep Vein Thrombosis and New Agents Management for Deep Vein Thrombosis and New Agents Mark Malesker, Pharm.D., FCCP, FCCP, FASHP, BCPS Professor of Pharmacy Practice and Medicine Creighton University 5 th Annual Creighton Cardiovascular

More information

The speakers have attested that their presentation will be free of all commercial bias toward a specific company and its products.

The speakers have attested that their presentation will be free of all commercial bias toward a specific company and its products. Update on New Anticoagulants (Apixaban, Dabigatran and Rivaroxaban) Patient Safety Daniel B. DiCola, MD and Paul Ament,, Pharm.D Excela Heath, Latrobe, PA Disclosures: Paul Ament discloses that he receives

More information

Cardiovascular Subcommittee of PTAC Meeting held 27 February 2014. (minutes for web publishing)

Cardiovascular Subcommittee of PTAC Meeting held 27 February 2014. (minutes for web publishing) Cardiovascular Subcommittee of PTAC Meeting held 27 February 2014 (minutes for web publishing) Cardiovascular Subcommittee minutes are published in accordance with the Terms of Reference for the Pharmacology

More information

New Anticoagulants: When and Why Should I Use Them? Disclosures

New Anticoagulants: When and Why Should I Use Them? Disclosures Winship Cancer Institute of Emory University New Anticoagulants: When and Why Should I Use Them? Christine L. Kempton, MD, MSc Associate Professor of Pediatrics and Hematology and Medical Oncology Hemophilia

More information

Venous Thromboembolism: Long Term Anticoagulation. Dan Johnson, Pharm.D.

Venous Thromboembolism: Long Term Anticoagulation. Dan Johnson, Pharm.D. Venous Thromboembolism: Long Term Anticoagulation Dan Johnson, Pharm.D. Disclosures No financial relationships with products discussed Off-label use of drug therapy always discussed Objectives Review clinical

More information

NOACS AND AF PEARLS AND PITFALLS DR LAURA YOUNG HAEMATOLOGIST

NOACS AND AF PEARLS AND PITFALLS DR LAURA YOUNG HAEMATOLOGIST NOACS AND AF PEARLS AND PITFALLS DR LAURA YOUNG HAEMATOLOGIST NGAIRE IS 70 YEARS OLD AND IN AF. SHE HAS NO MURMURS, NORMAL BLOOD PRESSURE, EGFR OF 65ML/MIN AND NO SIGNIFICANT PAST MEDICAL HISTORY. REGARDING

More information

Post-ISTH review: Thrombosis-I New Oral Anticoagulants 臺 大 醫 院 內 科 部 血 液 科 周 聖 傑 醫 師

Post-ISTH review: Thrombosis-I New Oral Anticoagulants 臺 大 醫 院 內 科 部 血 液 科 周 聖 傑 醫 師 Post-ISTH review: Thrombosis-I New Oral Anticoagulants 臺 大 醫 院 內 科 部 血 液 科 周 聖 傑 醫 師 The antithrombotic efficacy is limited but the risk of bleeding is indefinite Fuster V et al. Circulation 2011;123:e269-e367

More information

New Oral Anticoagulants. Pharmacological considerations

New Oral Anticoagulants. Pharmacological considerations New Oral Anticoagulants Pharmacological considerations New oral anticoagulants The ideal anticoagulant. Metabolic pathways Drug-drug interactions One dose fits all??? Special sub-groups of patients. NOAC

More information

Rivaroxaban A new oral anti-thrombotic Dr. Hisham Aboul-Enein Professor of Cardiology Benha University 12/1/2012

Rivaroxaban A new oral anti-thrombotic Dr. Hisham Aboul-Enein Professor of Cardiology Benha University 12/1/2012 Rivaroxaban A new oral anti-thrombotic Dr. Hisham Aboul-Enein Professor of Cardiology Benha University 12/1/2012 Agenda Ideal anticoagulant. Drawbacks of warfarin. Rivaroxaban in clinical trails. Present

More information

9/8/2014. None. Identify the under-recognized risk of cardioembolic stroke in untreated and undertreated. morbidity, mortality and cost burdens

9/8/2014. None. Identify the under-recognized risk of cardioembolic stroke in untreated and undertreated. morbidity, mortality and cost burdens Optimizing Anticoagulation Therapy for Older Adults with Atrial Fibrillation: The New Oral Agents" None Disclosures Brad Hein, PharmD Associate Professor of Pharmacy The University of Cincinnati Winkle

More information

LAMC Reversal Agent Guideline for Anticoagulants 2013. Time to resolution of hemostasis (hrs) Therapeutic Options

LAMC Reversal Agent Guideline for Anticoagulants 2013. Time to resolution of hemostasis (hrs) Therapeutic Options LAMC Reversal Agent Guideline for Anticoagulants 2013 Medication resolution of hemostasis (hrs) Intervention Administration Instructions Heparin 3-4 Protamine 1mg IV for every 100 units of heparin Slow

More information

Anticoagulation in Atrial Fibrillation

Anticoagulation in Atrial Fibrillation Anticoagulation in Atrial Fibrillation Parag P. Patel, MD FACC Disclosures Eliquis Speakers Bureau 1 Clinical Scenario Ms. L is a 76F admitted to the stroke service with a dense right sided hemiparesis

More information

The management of cerebral hemorrhagic complications during anticoagulant therapy

The management of cerebral hemorrhagic complications during anticoagulant therapy The management of cerebral hemorrhagic complications during anticoagulant therapy Maurizio Paciaroni Stroke Unit Division of Cardiovascular Medicine University of Perugia - Italy Perugia Stroke Registry

More information

Anticoagulation Management Insanity: doing the same thing over and over again and expecting different results. Case 1

Anticoagulation Management Insanity: doing the same thing over and over again and expecting different results. Case 1 2011 MFMER slide-1 Anticoagulation Management Insanity: doing the same thing over and over again and expecting different results Fadi Elias Shamoun, MD Mayo Clinic in Arizona Albert Einstein Anticoagulation

More information

Three new/novel oral anticoagulants (NOAC) have been licensed in Ireland since 2008:

Three new/novel oral anticoagulants (NOAC) have been licensed in Ireland since 2008: Key Points to consider when prescribing NOACs Introduction Three new/novel oral anticoagulants (NOAC) have been licensed in Ireland since 2008: Dabigatran Etexilate (Pradaxa ) 75mg, 110mg, 150mg. Rivaroxaban

More information

Analytical Specifications RIVAROXABAN

Analytical Specifications RIVAROXABAN Page 1 of 9 ANALYTE NAME AND STRUCTURE - RIVAROXABAN SYNONYMS Xarelto CATEGORY Anticoagulant TEST CODE PURPOSE Therapeutic Drug Monitoring GENERAL RELEVANCY BACKGROUND Xarelto (rivaroxaban) is an orally

More information

NnEeWw DdEeVvEeLlOoPpMmEeNnTtSs IiıNn OoRrAaLl AaNnTtIiıCcOoAaGgUuLlAaTtIiıOoNn AaNnDd RrEeVvEeRrSsAaLl

NnEeWw DdEeVvEeLlOoPpMmEeNnTtSs IiıNn OoRrAaLl AaNnTtIiıCcOoAaGgUuLlAaTtIiıOoNn AaNnDd RrEeVvEeRrSsAaLl NnEeWw DdEeVvEeLlOoPpMmEeNnTtSs IiıNn OoRrAaLl AaNnTtIiıCcOoAaGgUuLlAaTtIiıOoNn AaNnDd RrEeVvEeRrSsAaLl Mikele Wissing, RN June 2014 Introduction until recently, was the unrivaled medication for treatment

More information

3/3/2015. Patrick Cobb, MD, FACP March 2015

3/3/2015. Patrick Cobb, MD, FACP March 2015 Patrick Cobb, MD, FACP March 2015 I, Patrick Cobb, MD, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict

More information

RR 0.88 (95% CI: 0.77 1.00) P=0.051 (superiority) 3.75

RR 0.88 (95% CI: 0.77 1.00) P=0.051 (superiority) 3.75 ALL-CAUSE MORTALITY RR 0.88 (95% CI: 0.77 1.00) P=0.051 (superiority) Rate per year (%) 5.0 4.0 3.0 2.0 1.0 0 3.64 D150 mg BID 3.75 D110 mg BID RR 0.91 (95% CI: 0.80 1.03) P=0.13 (superiority) 4.13 Warfarin

More information

Novel oral anticoagulant (NOAC) for stroke prevention in atrial fibrillation Special situations

Novel oral anticoagulant (NOAC) for stroke prevention in atrial fibrillation Special situations Novel oral anticoagulant (NOAC) for stroke prevention in atrial fibrillation Special situations Dardo E. Ferrara MD Cardiac Electrophysiology North Cascade Cardiology PeaceHealth Medical Group Which anticoagulant

More information

AF, Stroke Risk and New Anticoagulants

AF, Stroke Risk and New Anticoagulants Carmarthen Cardiac Update Course AF, Stroke Risk and New Anticoagulants Dr Hamsaraj Shetty, B.Sc, FRCP (London & Edinburgh) Consultant Physician & Honorary Senior Lecturer University Hospital of Wales,Cardiff

More information

Bridging the Gap: How to Transition from the NOACs to Warfarin

Bridging the Gap: How to Transition from the NOACs to Warfarin Bridging the Gap: How to Transition from the NOACs to April 24 th 2015 UAN: 0048-0000-15-034-L01-P Amanda Styer, Pharm.D. Marion General Hospital, OhioHealth Objectives: 1. Review labeling regarding transition

More information

Anticoagulation For Atrial Fibrillation

Anticoagulation For Atrial Fibrillation Anticoagulation For Atrial Fibrillation New Agents In A New Era Arjun V Gururaj, MD Arrhythmia and Electrophysiology Nevada Heart and Vascular Center Disclosures Biotronik Speaker Clinical investigator

More information

Anticoagulation: How Do I Pick From All the Choices? Jeffrey H. Neuhauser, DO, FACC BHHI Primary Care Symposium February 28, 2014

Anticoagulation: How Do I Pick From All the Choices? Jeffrey H. Neuhauser, DO, FACC BHHI Primary Care Symposium February 28, 2014 Anticoagulation: How Do I Pick From All the Choices? Jeffrey H. Neuhauser, DO, FACC BHHI Primary Care Symposium February 28, 2014 Atrial Fibrillation 2 Atrial Fibrillation The most common arrhythmia encountered

More information

Comparative Anticoagulation

Comparative Anticoagulation Comparative Anticoagulation Laurajo Ryan, PharmD, MSc, BCPS, CDE Clinical Associate Professor The University of Texas at Austin College of Pharmacy The University of Texas Health Science Center Pharmacotherapy

More information

Out with the Old and in with the New? Target Specific Anticoagulants for Atrial Fibrillation

Out with the Old and in with the New? Target Specific Anticoagulants for Atrial Fibrillation Out with the Old and in with the New? Target Specific Anticoagulants for Atrial Fibrillation Goal Statement Pharmacists and technicians will gain knowledge in the use of target specific oral anticoagulants

More information

Limitations of VKA Therapy

Limitations of VKA Therapy Fibrillazione Atriale Non Valvolare Ischemia o Emorragia le Due Utopie Rivali nella Scelta dei NAO Gianluca Botto, MD, FESC, UO Elettrofisiologia, Dip Medicina Limitations of VKA Therapy Unpredictable

More information

Laboratory Testing in Patients on Novel Oral Anticoagulants (NOACs)

Laboratory Testing in Patients on Novel Oral Anticoagulants (NOACs) Laboratory Testing in Patients on Novel Oral Anticoagulants (NOACs) Dr. Art Szkotak artur.szkotak@albertahealthservices.ca University of Alberta Hospital Edmonton, AB NOACs Direct Thrombin Inhibitors (DTI):

More information

Atrial Fibrillation: Stroke and Thromboprophylaxis. Derek Waller

Atrial Fibrillation: Stroke and Thromboprophylaxis. Derek Waller Atrial Fibrillation: Stroke and Thromboprophylaxis Derek Waller Atrial Fibrillation in the Elderly: Risk of Stroke Framingham study AGE 50-59 60-69 70-79 80-89 Prevalence of AF % Attributable Risk of AF

More information

The Anticoagulated Patient A Hematologist s Perspective

The Anticoagulated Patient A Hematologist s Perspective The Anticoagulated Patient A Hematologist s Perspective Deborah M. Siegal MD MSc FRCPC Clinical Scholar Division of Hematology and Thromboembolism Thrombosis Canada Research Fellow McMaster University

More information

Failure or significant adverse effects to all of the alternatives: Eliquis and Xarelto

Failure or significant adverse effects to all of the alternatives: Eliquis and Xarelto This policy has been developed through review of medical literature, consideration of medical necessity, generally accepted medical practice standards, and approved by the IEHP Pharmacy and Therapeutics

More information

MANAGING BLEEDING IN THE

MANAGING BLEEDING IN THE MANAGING BLEEDING IN THE SETTING OF NEW ANTICOAGULANTS: HOW DO OLD METHODS MEASURE UP? Michelle Zeller MD Clinical Hematology Fellow November 5th, 2011 A FRIDAY NIGHT ON-CALL WITH DR. B. LUD Very keen

More information

Managing Anticoagulation for Atrial Fibrillation 2015

Managing Anticoagulation for Atrial Fibrillation 2015 Managing Anticoagulation for Atrial Fibrillation 2015 Vikranth Gongidi, DO FACC FACOI Indian River Medical Center Vero Beach, FL Atrial Fibrillation Background and Guidelines Decisions to anticoagulate

More information

COMPARISON OF NEW ORAL ANTICOAGULANTS AND FREQUENTLY- ASKED QUESTIONS FROM PATIENTS. TARGET AUDIENCE: All Canadian health care professionals.

COMPARISON OF NEW ORAL ANTICOAGULANTS AND FREQUENTLY- ASKED QUESTIONS FROM PATIENTS. TARGET AUDIENCE: All Canadian health care professionals. COMPARISON OF NEW ORAL ANTICOAGULANTS AND FREQUENTLY- ASKED QUESTIONS FROM PATIENTS AND PHYSICIANS TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVES: To provide a comparison of the new

More information

New Oral Anticoagulants (NOACs)

New Oral Anticoagulants (NOACs) New Oral Anticoagulants (NOACs) Dabigatran (Pradaxa) Rivaroxaban (Xarelto) Apixaban (Eliquis) Edoxaban (Savaysa) Janice Lawson, MD Tallahassee Memorial Hospital Cancer and Hematology Specialists Disclosure

More information