MANAGING BLEEDING IN THE
|
|
- James Ball
- 8 years ago
- Views:
Transcription
1 MANAGING BLEEDING IN THE SETTING OF NEW ANTICOAGULANTS: HOW DO OLD METHODS MEASURE UP? Michelle Zeller MD Clinical Hematology Fellow November 5th, 2011
2 A FRIDAY NIGHT ON-CALL WITH DR. B. LUD Very keen first year resident on-call for Hematology Case 1: Ms. N. Pain, 65 yo W, presents to ER Extreme lower right quadrant abdo pain CT shows appendicitis Pt is on warfarin for Afib, INR 2.7; Hb 125; Plt 350 Gen Sx wants to operate in 2 hours! Case 2: Mr. M. Fine, 53 yo man Presented to ER with a localized rash from a cast placed following a recent knee surgery INR 2.1, PTT 43, Fibrinogen 0.52 ER calls for urgent cryoprecipitate Case 3: Mr. B. Leeding, 45 yo man Sustains numerous traumas following MVC On a new blood thinner for recent hip surgery. The patient is being air-lifted in and will arrive in 45 minutes. Dr. B. Lud needs a plan!
3 CASE 1: MS. N. PAIN 65 yo W: Extreme lower right quadrant abdo pain CT shows appendicitis Pt is on warfarin for Afib, INR 2.7; Hb 125; Plt 350 How should she be reversed for surgery? a. 4 units Fresh Frozen Plasma + Vit K IV b. Vit K PO and left over Halloween candies c. Hold warfarin for 5 days then operate d. Prothrombin Complex Concentrate + Vit K IV e. 2 units Fresh Frozen Plasma
4 CASE 2: MR. M. FINE 53 yo man: Presented to ER with a localized rash from a cast placed following a recent knee surgery INR 2.1, PTT 43, Fibrinogen 0.52 ER calls for urgent cryoprecipitate What should Dr. B. Lud do??? a. 10 unit of Cryoprecipitate b. Conduct a detailed history and physical exam c. 4 units FFP and Vit K IV d. PCC and Vit K IV e. Benadryl for the rash and repeat blood work
5 CASE 3: MR. B. LEEDING 45 yo man: Numerous traumas, MVC On new blood thinner for recent hip surgery. The patient is being air-lifted in and will arrive in 45 minutes. What should Dr. B. Lud recommend in addition to Initiating the Trauma Transfusion Pathway??? a. rfviia b. PCC c. rfviia & PCC d. Neither rfviia nor PCC e. Not sure. Digesting lunch.
6 THE PLAN Make a PLAN Background: Hemostasis Clotting cascade Anticoagulants: Old & New Mechanisms of Action Indications Bleeding Risks Effects on routine laboratory assays Review evidence of reversal with blood products Prothrombin Complex Concentrate (PCC) Recombinant Factor VIIa (rfviia)
7 BACKGROUND Hemostasis & Clotting Cascade
8 IN VITRO CASCADE MODEL
9 CELL BASED MODEL
10 INITIATION
11 PROPAGATION
12 FIBRINOLYSIS
13 Jonworth.eu ANTICOAGULANTS Old & New
14 ANTICOAGULANTS: WHERE THEY ACT
15 WHY DO WE NEW ANTICOAGULANTS??? The OLD: Narrow therapeutic window Frequent monitoring Drug interactions Inter-patient dose variation Intra-individual dose variation The NEW: Subcutaneous administration Predictable pharmacokinetics Wide therapeutic windows Fixed dose No monitoring
16 DABIGATRAN (PRADAX) FACTOIDS Oral reversible thrombin inhibitor developed for prevention and treatment of thromboembolic disease Prescribed as fixed dosing, no monitoring required Currently approved in Canada: Primary DVT prophylaxis following hip and knee surgery 110 mg PO BID for days Prevention of stroke and central embolism in Nonvalvular AF 150 mg PO BID Half life hr Renally excreted Major Trials: RE-LY, RECOVER, RENOVATE, REMODEL Connolly SJ et al. Dabigatran versus Warfarin in Patients with Atrial Fibrillation. N Engl J Med 2009; 361:
17 DABIGATRAN BLEEDING RISK Annual risk of any bleeding on treatment: 16.6% (1 in 6 patients) when taking 150 mg twice daily 14.7% (1 in 6.8 patients) taking 110 mg twice daily Compared to 18.4% (1 in 5.4 patients) for warfarin Annual risk of major bleeding 3.1% taking 150 mg twice daily 2.1% taking 110 mg twice daily Compared to 3.4% for warfarin Randomized Evaluation of Long-term anticoagulant therapy trial
18 DABIGARTRAN BLEEDING RISK Lower total bleeds with Dabigatran vs warfarin *2 Higher rate of major GI bleeds (1.6% vs 1.1%) vs warfarin * Similar rate of major bleeds (3.3% vs 3.6%) *
19 RIVAROXABAN (XARELTO) FACTOIDS Oral direct FXa inhibitor developed for prophylaxis and treatment of thromboembolic disease Prescribed as fixed daily dose & lab monitoring not necessary Currently approved in Canada: Primary prophylaxis post hip and knee surgery 10 mg PO OD for days Half life: 7-11hr Excreted in urine and feces Major trials: RECORD, ROCKET-AF, MAGELLEN, ATLAS, EINSTEIN
20 RIVAROXABAN BLEEDING RISK Rivaroxaban vs enoxaparin: Major bleeding event rates reported in hip surgery studies were 0.2% vs 0.1% Any bleeding events were 6.1% vs 5.8%; Major bleeding events reported in the knee surgery study were 0.6% vs 0.5% Any bleeding events were 5.0% vs 4.9%.
21
22 BACK TO CASE 1: MS. N. PAIN 65 yo W: Extreme lower right quadrant abdo pain CT shows appendicitis Pt is on warfarin for Afib, INR 2.7; Hb 125; Plt 350 Pt was reversed with PCC and Vit K IV INR of 1.3 She had her surgery with no complications Her warfarin was restarted post op
23 WHY & HOW Measuring Anticoagulants
24 WHY MEASURE? Acute trauma Emergency surgery Overdose Bridging Drug interactions Compliance Renal Insufficiency Pregnancy Obesity
25 PT/INR APTT htm
26 EFFECTS ON PT & APTT ASSAYS Agent PT/INR aptt Warfarin Sensitive Prolongs, but less useful UFH Prolongs at [high] Sensitive LMWH No clinical effect No clinical effect Fondaparinox No clinical effect No clinical effect Dabigatran Prolongs, low sensitivity Prolongs, curvilinear, variable Rivaroxaban Prolongs, poor at [low] Prolongs, variable, low sensitivity Apixaban Prolongs, unknown variability Prolongs, unknown variability Edoxaban Prolongs, variable Prolongs, variable Ecarin Clotting Time (ECT) and Thrombin Clotting Time (TT) have strong linear relationship with dabigatran PT varies in a linear fashion, with plasma concentration with a correlation coefficient r = 0.98 when Neoplastin is used for the assay (xarelto.com)
27 CASE 2: MR. M. FINE 53 yo man: Presented to ER with a localized rash from a cast placed following a recent knee surgery INR 2.1, PTT 43, Fibrinogen 0.52 Dr. B. Lud conducted a thorough history and physical exam: Mr. Fine was healthy apart from a mild rash on his leg The patient was on Rivaroxaban following knee surgery He had no signs or symptoms of bleeding No clinical, historic or physical evidence to suggest DIC
28 REVIEW OF THE EVIDENCE REVERSAL WITH BLOOD PRODUCTS
29 BLOOD PRODUCTS FOR REVERSAL OF ANTICOAGULANTS FFP PCC rfviia Protein c & s FII, VII, IX, X +/- Heparin PCC
30 THE EVIDENCE...IN RATS 2 studies using rat models Van Ryn et al.: Used FVIIa (Novoseven) and PCC (Feiba) Measured tail bleeding time & aptt Bleeding time: Control = 125s; Dabigatran = 1455s FVIIa reduced to s PCC reduced to s aptt: Control = 7; Dabigatran = 58 FVIIa reduced to PCC did not have effect on aptt Conclusions: Both FVIIa and PCC have potential reversal abilities for dabigatran. aptt might not correlate to in vivo activity of dabigatran
31 THE EVIDENCE... IN MICE Zhou, W et al. Mice received 2 doses of dabigatran (DE) followed injection that caused ICH, followed coags, MRI Mice were given one of: Saline PCC Murine FFP rfviia ICH size: Control = 7.8 mm3 vs mm with increasing doses of DE 77% of max volume reached in 1hr; 86% in 3 hrs. Hematoma growth was prevented by administering PCC Mortality approached control in group treated with PCC Minimal or no effect with FFP or rviia Conclusion: PCC prevent excess expansion of ICH in murine model exposed to dabigatran
32 THE EVIDENCE... IN HUMANS Eerenberg at al.: Randomized, double blind, placebo controlled cross-over study in healthy subjects Twelve healthy male subjects Grp A: rivaroxaban 20 mg BID x 2.5 days Grp B: dabigatran 150 mg BID x 2.5 days PCC or placebo Wash out of eleven days Grp A: dabigatran 150 mg BID x 2.5 days Grp B: rivaroxaban 20 mg BID x 2.5 days PCC or placebo PCC (Cofact) FII, VII, IX, X, C, S & antithrombin (no heparin) 50 U PCC/kg Circulation 2011, 124:
33 RESULTS OF LABORATORY ASSAYS Rivaroxaban Pre PCC Rivaroxaban Post PCC PT Significantly prolonged Completely normalized ETP Decreased Normalized Dabigatran Pre PCC Dabigatran Post PCC ETPlt Prolonged No change aptt Significantly prolonged No change TT Immeasurable (>120 sec) No change ECT Significantly prolonged Further increased! ETP: Endogenous thrombin potential (lt = lag time) ECT: Ecarin clotting time
34 STUDY CONCLUSIONS First study in human investigating the effects of PCC in reversing new anticoagulants PCC neutralizes anticoagulant laboratory effect of rivaroxaban but had no effect on dabigatran Numerous study limitations makes applying these results to bleeding patients in clinical practice difficult.
35 BACK TO CASE #3 Mr. B. Leeding arrived with multiple injuries and was initiated on the transfusion trauma pathway. He was taking Dabigatran Unfortunately, he continued to bleed... What should Dr. B. Lud recommend in addition to continuing along the pathway??? a. rfviia b. PCC c. rfviia & PCC d. Neither rfviia, nor PCC
36 REVERSAL OF RIVAROXABAN Activated charcoal to reduce absorption Supportive treatment: mechanical compression, surgical interventions, fluid replacement hemodynamic support, blood product or component transfusion If life-threatening bleeding cannot be controlled by the above measures, administration of recombinant Factor VIIa may be considered. PCC s might play a role in limiting bleeding and reversing anticoagulant activity Protamine sulfate and vitamin K are not useful No evidence to support use of systemic haemostatics desmopressin, aprotinin, tranexamic acid Not dialyzable - high plasma protein binding
37 REVERSAL OF DABIGATRAN Activated charcoal to reduce absorption Supportive treatment: mechanical compression, surgical interventions, fluid replacement hemodynamic support, blood product or component transfusion Dialysis: studies have shown it can remove ~60% PCC and rfviia might have beneficial role in reversal Protamine sulfate and vitamin K are not useful No evidence to support use of systemic haemostatics desmopressin, aprotinin, tranexamic acid
38 FOOD FOR THOUGHT: Dabigatran & Rivaroxaban are becoming more widely used These medications effect coagulation assays There is insufficient evidence to support use of rfviia & PCC in reversal but they may have a role in the future
39 QUESTIONS?
40 REFERENCES Battinelli EM. Reversal of new anticoagulants. Circulation. 2011, 124: Calatzis A, Peetz D, Haas S, Spannagl M, Rudin K, Wilmer M. Prothrombinase-induced clotting time assay for determination of the anticoagulant effects of unfractionated and low-molecular-weight heparins, fondaparinux, and thrombin inhibitors. Am J Clin Pathol Sep;130(3): Eerenberg ES. Et al. Reversal of rivaroxaban and dabigatran by prothrombin complex concentrate: a randomized, placebo controlled, crossover study in healthy subjects. Circulation. 2011, 124: Hillarp, A et al. Effects of the oral, direct factor Xa inhibitor rivaroxaban on commonly used coagulation assays. Journal of Thrombosis and Haemostasis. 2010;9: Lindahl, TL et al. Effects of the oral, direct thrombin inhibito dabigatran on five common coagulation assays Thrombosis and Haemostasis105: Samama MM and Guinet C. Laboratory assessment of new anticoagulants. Clin chem Eikelboom, JW (31 May 2011). "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 Connolly, SJ; Ezekowitz, MD; Yusuf, S et al. (September 2009). "Dabigatran versus warfarin in patients with atrial fibrillation" (PDF). N Engl J Med 361 (12): Tinel H, Huetter J, Perzborn E. RECOMBINANT FACTOR VIIA PARTIALLY REVERSES THE ANTICOAGULANT EFFECT OF HIGH-DOSE RIVAROXABAN A NOVEL, ORAL, DIRECT FACTOR XA INHIBITOR IN RATS. J Thromb Haemost 2007; 5 Supplement 2: P-W-652 Van Ryn et al. Dabigatran Etexilate a novel, reversible, oral direct thrombin inhibitor: Interpretation of coagulation assays and reversa lof anticoagulant activity. Thrombosis and Hemostasis 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 concenetrate. Haematologica 2008; 93(s1):148 Zhou, W et al. Hemostatic therapy in experimental intracerebral hemorrhage associated with the direct thrombin inhibitor dabigatran. Stroke, 2011;42
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 information5/21/2012. 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 informationStop 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 informationNew Oral Anticoagulants
Laboratory Monitoring of New Oral Anticoagulants.....What you need to know Rita Selby MD Medical Director, Coagulation Laboratories Uniersity Health Network & Sunnybrook HSC Uniersity of Toronto The 15
More informationDVT/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 informationDisclosure. Warfarin
Disclosure No conflicts of interest to disclose Reversal Strategies for Novel Oral Anticoagulants Noelle de Leon, PharmD, BCPS Critical Care Pharmacist, Department of Pharmaceutical Services Assistant
More information48 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 informationDabigatran (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 informationSession 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 informationReversal of Antiplatelet and Anticoagulant Therapy: What You Need To Know. Ronald Walsh, MD Chief Medical Officer Community Blood Services
Reversal of Antiplatelet and Anticoagulant Therapy: What You Need To Know Ronald Walsh, MD Chief Medical Officer Community Blood Services HEMOSTATIC PROCESS Initiation and formation of the platelet plug
More informationImpact 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 informationLAMC 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 informationAnticoagulation 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 informationTo assist clinicians in the management of minor, major, and/or life-threatening bleeding in patients receiving new oral anticoagulants (NOACs).
MANAGEMENT OF BLEEDING IN PATIENTS WHO ARE RECEIVING A NEW ORAL ANTICOAGULANT (DABIGATRAN, RIVAROXABAN, APIXABAN) TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: To assist clinicians
More informationReversing 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 informationNew 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 informationSpeaker 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 informationXabans 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 informationDisclosure. Outline. Objectives. I have no actual or potential conflict of interest in relation to this presentation.
Disclosure I have no actual or potential conflict of interest in relation to this presentation. Sarah Lombardo, MD., MSc. General Surgery, University of Utah September 9, 2015 Objectives Outline Recognize
More informationComparison 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 informationCritical Bleeding Reversal Protocol
Critical Bleeding Reversal Protocol Coagulopathy, either drug related or multifactorial, is a major contributing factor to bleeding related mortality in a variety of clinical settings. Standard therapy
More informationThe 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 informationBlood products and pharmaceutical emergencies
Blood products and pharmaceutical emergencies Kasey L. Bucher PharmD, BCPS Clinical Specialist, Emergency Medicine Mercy Health Saint Mary s September 12, 2013 Disclosures None significancemagazine.com
More informationTitle of Guideline. Thrombosis Pharmacist)
Title of Guideline Contact Name and Job Title (author) Guideline for patients receiving Rivaroxaban (Xarelto ) requiring Emergency Surgery or treatment for Haemorrhage Julian Holmes (Haemostasis and Thrombosis
More informationSTARTING, 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 information3/3/2015. 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 informationReversal of Anticoagulants at UCDMC
Reversal of Anticoagulants at UCDMC Introduction: Bleeding complications are a common concern with the use of anticoagulant agents. In selected situations, reversing or neutralizing the effects of an anticoagulant
More informationNnEeWw 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 informationReversal of Old and New Antithrombotic Drugs. Mike Makris
Reversal of Old and New Antithrombotic Drugs Mike Makris BCSH guidelines Guidelines on oral anticoagulation with warfarin fourth edition 1 Guideline on the urgent or emergency reversal of antithrombotic
More informationDe effecten van Cofact op Rivaroxaban plasma in trombine generatie assays
De effecten van Cofact op Rivaroxaban plasma in trombine generatie assays In vitro assessment, using thrombin generation, of the applicability of Prothrombin Complex Concentrate as an antidote for Rivaroxaban
More informationMCHENRY WESTERN LAKE COUNTY EMS SYSTEM OPTIONAL CE ADVANCED LEVEL (EMTP, PHRN, ECRN) August 2013. Anticoagulants
MCHENRY WESTERN LAKE COUNTY EMS SYSTEM OPTIONAL CE ADVANCED LEVEL (EMTP, PHRN, ECRN) August 2013 Anticoagulants Anticoagulants are agents that prevent the formation of blood clots. Before we can talk about
More informationUSE AND INTERPRETATION OF LABORATORY COAGULATION TESTS IN PATIENTS WHO ARE RECEIVING A NEW ORAL ANTICOAGULANT (DABIGATRAN, RIVAROXABAN, APIXABAN)
USE AND INTERPRETATION OF LABORATORY COAGULATION TESTS IN PATIENTS WHO ARE RECEIVING A NEW ORAL ANTICOAGULANT (DABIGATRAN, RIVAROXABAN, APIXABAN) TARGET AUDIENCE: All Canadian health care professionals:
More informationNew 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 informationRecommendation for the Reversal of Novel Anticoagulants in Emergent Situations
Lauren Edwards PharmD Candidate 2016 Truman Medical Center, Lakewood Preceptor: Dr. Melissa Gabriel June 11, 2015 Recommendation for the Reversal of Novel Anticoagulants in Emergent Situations Background
More informationNo more rat poison? New oral anticoagulants and perioperative considerations
1 No more rat poison? New oral anticoagulants and perioperative considerations Jerrold H. Levy, MD, FAHA, FCCM Professor Department of Anesthesiology/Critical Care Duke University School of Medicine Durham,
More informationWarfarin and Novel Anti-Coagulants: Management Before and After the Cath Lab
Warfarin and Novel Anti-Coagulants: Management Before and After the Cath Lab Drew Baldwin, MD Virginia Mason Seattle, Washington NCVH May 28, 2015 2:30 pm I have no disclosures. Stroke risk reduction in
More informationPost-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 informationMaking Sense of the Newer Anticoagulants
Making Sense of the Newer Anticoagulants Brian Tiffany, MD, PhD, FACEP Dept of Emergency Medicine Chandler Regional Medical Center Mercy Gilbert Medical Center I M FROM ARIZONA! DISCLOSURES No relevant
More informationNON-VITAMIN K ORAL ANTICOAGULANT REVERSAL
DISCLAIMER: These guidelines were prepared by the Department of Surgical Education, Orlando Regional Medical Center. They are intended to serve as a general statement regarding appropriate patient care
More informationLaboratory 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 informationRecommendations 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 informationEMMC Guide on Management of Anticoagulant and Anti-Platelet Agent Associated Bleeding Complications in Adults. February, 2013
EMMC Guide on Management of Anticoagulant and Anti-Platelet Agent Associated Bleeding Complications in Adults February, 2013 1 Quick Index To Reversal Recommendations Anti-Platelet Medications Page P2Y12
More informationPrescriber Guide. 20mg. 15mg. Simply Protecting More Patients. Simply Protecting More Patients
Prescriber Guide 20mg Simply Protecting More Patients 15mg Simply Protecting More Patients 1 Dear Doctor, This prescriber guide was produced by Bayer Israel in cooperation with the Ministry of Health as
More informationQUICK REFERENCE. Mary Cushman 1 Wendy Lim 2 Neil A Zakai 1. University of Vermont 2. McMaster University
QUICK REFERENCE Clinical Practice Guide on Antithrombotic Drug Dosing and Management of Antithrombotic Drug- Associated Bleeding Complications in Adults February 2014* Mary Cushman 1 Wendy Lim 2 Neil A
More informationNew 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 informationNON-VITAMIN K ORAL ANTICOAGULANT REVERSAL
DISCLAIMER: These guidelines were prepared by the Department of Surgical Education, Orlando Regional Medical Center. They are intended to serve as a general statement regarding appropriate patient care
More informationHow does warfarin work? We know itʼs a vitamin k antagonist, but what does that mean? What's really getting antagonized?
Anticoagulation reversal Vitamin K antagonists and New Oral Anticoagulants Robert Orman, MD Warfarin How does warfarin work? We know itʼs a vitamin k antagonist, but what does that mean? What's really
More informationThe 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 informationNew 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 informationNEWER 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 informationThe 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 informationClinical Guideline N/A. November 2013
State if the document is a Trust Policy/Procedure or a Clinical Guideline Clinical Guideline Document Title: Document Number 352 Version Number 1 Name and date and version number of previous document (if
More informationRivaroxaban (Xarelto ) by
Essentia Health Med Moment Short Video Tune-Up A brief overview of a new medication, or important new medication information Rivaroxaban (Xarelto ) by Richard Mullvain RPH BCPS (AQC) Current - August 2011
More informationDr Gordon Royle Haematologist, Middlemore Hospital
The New Oral Anticoagulants (NOACs) Dr Gordon Royle Haematologist, Middlemore Hospital Disclaimers Boehringer-Ingelheim Bayer Sanofi Douglas Pharmaceuticals Preventing disasters: lessons learned A cautionary
More informationPulmonary Embolism Treatment Update
UC SF Pulmonary Embolism Treatment Update Jeffrey Tabas, MD Professor UCSF School of Medicine Emergency Department San Francisco General Hospital sf g h Disclosure No Financial Relationships to Disclose
More informationTraditional 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 informationTime 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 informationWhat to do in case of hemorragia. L Camoin Jau Service d Hématologie APHM Marseille
What to do in case of hemorragia with NOAC? L Camoin Jau Service d Hématologie APHM Marseille Disclosure Boehringer Bayer Daishi Sanofi BMS Pharmacodynamic and kinetic properties of new oral anticoagulants.
More informationOral 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 informationCoagulation issues and bridging. Joost van Veen Consultant Haematologist - STHFT
Coagulation issues and bridging Joost van Veen Consultant Haematologist - STHFT new oral anticoagulants NOAC New oral anticoagulants NOAC Novel oral anticoagulants NOAC Non vitamin K oral anticoagulants
More informationNew 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 informationNew Anticoagulants: What to Use What to Avoid
New Anticoagulants: What to Use What to Avoid Bruce Davidson, MD, MPH Clinical Professor of Medicine Pulmonary and Critical Care Medicine Division University of Washington School of Medicine Seattle USA
More informationNew Oral Anticoagulants. How safe are they outside the trials?
New Oral Anticoagulants How safe are they outside the trials? Objectives The need for anticoagulant therapy Indications for anticoagulation Traditional anticoagulant therapies Properties of new oral anticoagulants
More informationHow To Understand The History Of Analgesic Drugs
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 informationAnalyzing 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 informationDr Gordon Royle Haematologist, Middlemore Hospital
The New Oral Anticoagulants (NOACs) Dr Gordon Royle Haematologist, Middlemore Hospital Disclaimers Boehringer-Ingelheim Bayer Sanofi Douglas Pharmaceuticals Preventing disasters: lessons learned A cautionary
More informationNovel Anticoagulants
Novel Anticoagulants Mark T. Reding, MD Associate Professor of Medicine Division of Hematology, Oncology, and Transplantation Director, Center for Bleeding and Clotting Disorders University of Minnesota
More informationReversing novel anticoagulants to divert catastrophe SEAN P. WILSON, MD DEPARTMENT OF EMERGENCY MEDICINE HENRY FORD HOSPITAL, DETROIT, MI
Reversing novel anticoagulants to divert catastrophe SEAN P. WILSON, MD DEPARTMENT OF EMERGENCY MEDICINE HENRY FORD HOSPITAL, DETROIT, MI Novel anticoagulants? Dabigatran (Pradaxa) Stroke and systemic
More informationNow We Got Bad Blood: New Anticoagulant Reversal
Now We Got Bad Blood: New Anticoagulant Reversal Kellie Rodriguez, PharmD, BCPS PGY2 Emergency Medicine Pharmacy Resident UF Health Jacksonville January 2016 Objectives 1. Review current treatment strategies
More informationAnticoagulation 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 informationCONTEMPORARY REVERSAL OF ANTICOAGULATION
CONTEMPORARY REVERSAL OF ANTICOAGULATION Michael S. McHale, M.D., F.A.C.P. Avera Medical Group Hematology & Oncology Medications Coumadin / Warfarin Unfractionated Heparin Low Molecular Weight Heparin
More informationThe Brave New (Anticoagulant) World
The Brave New (Anticoagulant) World Diane M. Birnbaumer, M.D., FACEP Emeritus Professor of Medicine University of California, Los Angeles Senior Clinical Educator Department of Emergency Medicine Harbor-UCLA
More informationNew 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 informationAnticoagulation Essentials! Parenteral and Oral!
Anticoagulation Essentials! Parenteral and Oral! Anti-Xa and Anti-IIa! Parenteral Anticoagulants! Heparin family (indirect anti-xa and anti-iia):! UFH! LMWH (enoxaparin, fondaparinux)! Direct thrombin
More informationNew oral anticoagulants and haemorrhage
New oral anticoagulants and haemorrhage Dr Tina Biss Consultant Haematologist Newcastle Hospitals NHS Trust Too much to lose Durham Conference Centre 14 th November 2012 Disclosures/Conflicts of interest
More informationAnalytical 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 informationDisclosure. New Agents for Treatment of DVT. Prevalence of DVT VTE. Normal Hemostasis 7/17/2015. Mark Oliver, MD, RVT, RPVI,FSVU
New Agents for Treatment of DVT Disclosure PI Adopt and Amplify trials Mark Oliver, MD, RVT, RPVI,FSVU BMS and Pfizer Speaker VTE Venous Thromboembolism Recognized DVT s New : 170,000 Recurrent : 90,000
More informationNovel 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 informationEast Kent Prescribing Group
East Kent Prescribing Group Rivaroxaban (Xarelto ) Safety Information Approved by the East Kent Prescribing Group. Approved by: East Kent Prescribing Group (Representing Ashford CCG, Canterbury and Coastal
More informationBreadth of indications matters One drug for multiple indications
Breadth of indications matters One drug for multiple indications Sylvia Haas, MD, PhD Formerly of the Technical University of Munich Munich, Germany Disclosures: Sylvia Haas 1 Novel oral anticoagulants:
More informationXarelto (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 informationExperience matters: Practical management in your hospital
Experience matters: Practical management in your hospital Dr AGG Turpie McMaster University, Hamilton, ON, Canada Disclosures AGG Turpie has acted as a consultant for Bayer HealthCare, Janssen, Sanofi-Aventis,
More informationDevang 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 informationAre there sufficient indications for switching to new anticoagulant agents
Are there sufficient indications for switching to new anticoagulant agents Meyer Michel Samama et Gregoris Gerotziafas Groupe Hémostase-Thrombose Hôtel-Dieu, Hôpital Tenon, Paris & Biomnis Ivry/seine,
More informationThe 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 informationNHS FORTH VALLEY RIVAROXABAN AS TREATMENT FOR DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM IN ADULTS
NHS FORTH VALLEY RIVAROXABAN AS TREATMENT FOR DEEP VEIN THROMBOSIS AND PULMONARY EMBOLISM IN ADULTS Date of First Issue 01/12/ 2012 Approved 15/11/2012 Current Issue Date 29/10/2014 Review Date 29/10/2016
More informationAnticoagulants. Denver Health April 12, 2011
New Oral Anticoagulants Rebecca Hanratty, MD Denver Health April 12, 2011 Overview Why we need alternatives to warfarin Review of the 3 new oral anticoagulants Results from major trials: Thromboprophylaxis
More informationXarelto and the New Orals
Xarelto and the New Orals in the ER Peter L. Gross MD M.D., MSc M.Sc., FRCP(c) Associate Professor Thrombosis and Atherosclerosis Research Institute McMaster University Thrombosis Clinic Director, Juravinski
More informationCardiology Update 2014
Cardiology Update 2014 Update on the Novel Oral Anticoagulants (NOACS) Raymond Kawasaki, MD AMG Cardiology December 6, 2014 Disclosures I have no disclosures relevant to this presentation Contents I. The
More information1/12/2016. 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 informationOral 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 informationDABIGATRAN 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 informationThe new oral anticoagulants & the future of haemostasis laboratory testing. Alcohol: the good, the bad and the ugly
The new oral anticoagulants & the future of haemostasis laboratory testing Emmanuel J Favaloro Diagnostic Haemostasis Laboratory, Institute of Clinical Pathology & Medical Research, ICPMR, Pathology West,
More informationObjectives. 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 informationCommittee Approval Date: September 12, 2014 Next Review Date: September 2015
Medication Policy Manual Policy No: dru361 Topic: Pradaxa, dabigatran Date of Origin: September 12, 2014 Committee Approval Date: September 12, 2014 Next Review Date: September 2015 Effective Date: November
More informationHow To Compare The 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 informationThrombosis and Hemostasis
Thrombosis and Hemostasis Wendy Lim, MD, MSc, FRCPC Associate Professor, Department of Medicine McMaster University, Hamilton, ON Overview To review the important developments in venous thromboembolism
More informationThrombosis management: A time for change practical management with NOACs Dr Wala Elizabeth Medical Director, Bayer Healthcare
Thrombosis management: A time for change practical management with NOACs Dr Wala Elizabeth Medical Director, Bayer Healthcare Kenya Association of Physicians Conference 10 th May 2013 New anticoagulants:
More informationManagement 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 information3/25/14. 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