Antiagregating agents and anticoagulants

Size: px
Start display at page:

Download "Antiagregating agents and anticoagulants"

Transcription

1 Antiagregating agents and anticoagulants

2 Causes of arterial thrombosis a) Unstable atherosclerotic plaque (crucial factor for arterial thrombosis) b) Endothelial dysfunction (more frequent - women middle age) c) Generalised hypercoagulaton For arterial thrombosis is decisive activation of thrombocyte homeostasis

3 Pathophysiology of acute coronary syndromes Soft plaque plaque disruption occlusive thrombus perfusion decrease ischemia necrosis

4 Venous thrombosis a) Blood velocity decreased (coagulation factors activaton) b) endothelial dysfunction c) generalized hypercoagulation For venous thrombosis is decisive secondary homeostasis activation

5 Antiplatelet therapy

6 TROMBOCYTE normal activation

7 ADHESION contact phase binding through vwf to subendothelial collagen trombocyte

8 ADHESION - stabilization phase binding through fibronectine, collagen, laminine and vwf subendothelial space trombocyte

9 THROMBOCYTE ADHESION

10 ACTIVATION - thrombocyte and ADP pathway (degranulation and GP IIb/IIIa receptor expresion). subendothelial space

11 ADHESION AND THROMBOCYTE AGREGATION bivalent proteins

12 Primary thrombus farmation and fibrin polymerization

13 ANTIPLATELET AGENTS 1) ADHESION BLOCKADE - GP Ib/IIa, vwf antagonists (clinical trials) 2) ACTIVATION BLOCKADE - inhibition - TXA 2., ADP, serotonine., thrombin activation (inhib. COX, TXA 2 recept., ticlopidin, clopidogrel) 3) PLATELET STABILISATION ( cyclic nukleotides) - camp (dipiridamol) or cgmp (NO donors) 4) ANTI-AGGREGATION (GP Iib/IIIa inhibition) - peptides (abciximab, eptifibatid), - fibans 1st. generation (tirofiban), 2. generation

14 Thromocyte adhesion, activation and aggregation ticlopidinc clopidogrel rec. ADP hrombine rec. heparine ridogrel thrombocyte rec. TXA2 ketanserin naftidrofuryl GPIb vwf collagen serotonine rec. GP Ia abciximab tirofiban eptifibatid IIb/IIIa IIb/IIIa vwf fibrinogen inhib. vwf IIb/IIIa IIb/IIIa Activation COX a TX synt. release TXA 2 ASA indobufen dazoxiben Vessel wall

15 Thromboxane activation inhibitors a) Cyclooxygenase inhibition (COX 1 ): - irreversible inhibition: ASA - reversible inhibition: indobufen, NSA, sulfinpyrazone b) Tromboxane syntase inhibition: dazoxibene, ozagrel c) TXA 2 receptors antagonists : ridogrel, nidrogrel

16 Acetylsalicylic acid (ASPIRIN, ASA) ireversible acetylation COX 1 (up to 7 days) farmacoeconomy highly effective optimal dose mg ( mg) 10-20% population ASA resistent indication: acute coronary ischemia (IM, unstable angina) secondary prevention (after IM, stroke, TIA, peripheral occlusion, arterial intervention) primary prevention high risk patients hypertension a diabetes

17 ASA mechanism of action Phospholipase - PLA2 trombocyte endothel COX-1 ASA indobufen arachidonic acid PGG 2 / PGH 2 COX-2 activated endothel COX-2 inhib. TXA 2 PGE 2 PGF 2a PGI 2

18 Cardiovascular mortality/morbidity decrease after ASA unstable angina 15 13,8% 10 8,3% 10,2% 5,8% placebo ASA myocardial infarction MI acute 14.4% 10.6% placebo ASA 11.7% 9.3% 5 3,5% 2,1% 5 2.2% 1.0% 0 0 CV events CV mortality nonfatal IM MI chronic placebo ASA CV events CV events nonfatal stroke stroke or TIA placebo ASA % % % % 8.1% 6.5% 4.7% % 6.3% 10.2% 6.6% 0 CV events CV mortality unstabile stroke 0 CV events CV mortality nonfatal stroke

19 ASA - CV MORTALITY AND MORBIDITY (IM, STROKE) (ANTIPLATELET TRIALIST COLLABORATION) STUDIES 3 primary prev. 20 cerebral 11 MI 11 AMI 12 AP 20 CABG/PTCA 28 peripheral 51 DVT 30 others 189 total Br Med J 1994 EVENTS COHORT ANTIPLATELET AGAINST CONTROL effect 2p < RRR ± SD 12 ± 6 % 24 ± 5 % 24 ± 4 % 26 ± 4 % 39 ± 9 % 33 ± 13 % 25 ± 10 % 42 ± 19 % 44 ± 10 % 25 ± 2 %

20 RESISTANCE TO ASA - antiaggegation effect decreased - multifactorial etiology - higher incidence of thrombotic events - 5% non-responders - 20% semi-responders

21 Competitive COX-1 inhibitors indobufen, sulfinpyrazon, Comparable effect to ASA not proven Not recomended for therapy

22 Thienopyridines O S N Cl ticlopidin (1. generation) S N C Cl clopidogrel (2. generation) O C H 3 C H 3 O O S O N F prasugrel (3. generation)

23 ADP activation inhibitors (thienopyridines) irreversibile block ADP activation More effective than ASA, Potenciation of ASA ticlopidine slow onset, agranulocytoses. clopidogrel faster onset, leukopenia rare potenciation of fibrinolysis indikations: acute coronary sy, sec. prevention., PTCA Very high price in comparison with ASA

24 TICLOPIDINE thienopyridine derivative, slow onset, full effect after 8-11 days Inhibition of ADP platelet activation (induced by collagen, adrenaline) ireversible effect for thrombocyte life span (effect disappears after days) dose 2x250 mg

25 TICLOPIDINE Indication: alergy or bad tolerance ASA CV events during ASA treatment PTCA, PTA (4 weels) Adverse events: GIT dyscomfort (with meal) neutropenia 0,5-1,0% (check blood count WBC!)

26 CLOPIDOGREL irreversible blockade platelet activation (and aggregation) mediated by ADP faster onset safer (rare neutropenia) dosage: 75 mg daily, first dose 300 mg, effect after 4-6 h., steady state after 3-7 d expensive

27 CLOPIDOGREL Effect - potentiation by ASA indications: acute coronary syndrome (up to 6-12 m after attack), coronary interventions (PTCA + stent, prim. PTCA) secundary prevention of atherosclerosis (not very effective) PTCA Percutaneous Transluminal Coronary Angioplasty

28 CV mortality (MI/stroke) changes after treatment with clopidogrel N:

29 ASA and clopidogrel secondary prevention- CV mortality/morbiditu (CAPRIE) stroke 7,3% MI - 3,7% Peripheral vascular disease 23,8% Total decrease 8,7% ASA better clopidogrel better

30 krevní průtok (% poklesu) ASA - clopidogresl combination - potentiation klopidogrel + ASA klopidogrel ASA placebo Herbert JM et al. Thromb Haemost 1998; 80: t (min.)

31 PRASUGREL thienopyridin ireversible block P2Y12 receptors Pro-drug metabolic activation resistance rare peroral, onset of actiity during 30 min faster onset.

32 PRASUGREL thienopyridin indications: acute coronary syndrome (up to 6-12 m after attack), coronary interventions (PTCA + stent, prim. PTCA) secundary prevention of atherosclerosis (not very effective)

33 příhody (%) Clopidogrel against prasugrelu mortality (12 měs.) CV+, IM, stroke clopidogrel prasugrel o 19% NNT = prasugrel bleeding clopidogrel dny NNH = 167

34 F Ticagrelor HO O N N N HN N N S F HO OH non-thienopyridine - P2Y 12 receptor block reversibile receptor inhibition peroral, quick onset (1-2 h) safer, but short acting very promissing for subacute treatment

35 10 Comparison of ADP receptor inhibitors acute CV events %* 19%* 16%* -20 CURRENT klopidogrel 75 vs 150 mg TRITON prasugrel PLATO ticagrelor

36 GPIIb/IIIa receptor antagonists

37 Mechanism of action GP IIb/IIIa antagonists

38 GP IIb/IIIa antagonists - accute coronary syndrome, including interventions (most effective) - economy more expensive (app US $) - peptides: abciximab (REOPRO) - antibodies eptifibatide (INTEGRILIN) - cyclic peptide - nonpeptide (fibans) 1. generation: parenteral - tirofibane (AGGRASTAT) peroral (orbo-, xemilo-, sibrafiban, ) 2. generation: higher affinity to receptors, other effects (roxi-, cromo-, frada-, lefradafiban)

39 GP IIb/IIIa inhibitors - mechanism of proagregating activity receptor conformational changes inactive active binding inhibitor fibrinogen GP IIb/IIIa GP IIb/IIIa site GP IIb/IIIa trombocyte

40 Abciximab (ReoPro) - Monoclonal antibody combination of 2 fragments - Specific binding to IIb/IIIa receptor - Long lastin effect (fading for 14 days) - High affinity to receptors Optimal effect for prevention and treatment of thrombotic complications after coronary interventions High price

41 small peptides IIb/IIIa peptide antagonists eptifibatid Imitate aminoacid sequention of fibrinogene chain (arginin-glycin-aspartin) Shorter effect in comparison with abciximab eptifibatid (cyclic heptapeptide) Main indication acute coronary events (nonq-mi) high risk patients

42 Non-peptide GP IIb/IIIa antagonists Tirofibane synthetic nucleoside analogue Injections Quick oncet of action Short acting - effect 4 8 hours Derived from Viper venom Indications non-stabile angina, PTCA

43 IIb/IIIa receptor antagonists clinical use PTCA Percutaneous Transluminal Coronary Angioplasty Acute coronary syndrom, mainly MI PTCA with thrombotic complicatons (local) Pharmacological treatment of non-q MI at risk patients Pharmacological treatment of AMI

44 NEW ANTIPLATELET AGENTS TRIFLUSAL (inhibition platelet COX), similar to ASA, better tolerability RIDOGREL (combination - block TXA 2 receptor and synthesis.), better than ASA (AMI) TROMBOSTATIN (oligopeptide, blocking thrombocyte thrombin receptor PAR-1, bradykinine degradating product), preclinical testing ANAGRELID - nonspecific inhibition of platelet activation (ADP, thrombin, collagen), for acute corronary syndrome only

45 Rational use of antiplatelet therapy Ischemic hearth disease acut form only (i.e. MI ) ASA, clopidogrel, eptifibatide, tirofiban (ticlopidine) Secondary prevention atherosclerosis after MI, stroke, TIA ASA, clopidogrel, event. ticlopidine) stable AP, silent ischemia, peripheral ischemia ASA, clopidogrel, event. ticlopidine Primary prevention of high risk patinets ASA After revascularisation interventions (stent) - ASA, clopidogrel, ticlopidine, abciximab, event. eptifibatid or tirofiban Atrial fibrilation (when anticoagulants are contraindicated) ASA

46 Anticoagulants

47 Secondary homeostasis erytrocytes trapping

48 coagulation system internal system external system XIa VIIa/TF ANTICOAGULATION IX IXa IX VIII VIIIa VIIIi VIIa/TF X Xa X V Va Vi act. protein C prot. S prot. C prothrombin thrombin XIII thrombomodulin fibrinogen fibrin fibrin net plazmin fibrin degradation product

49 ANTICOAGULANTS possibility for action thrombin inhib. - direct (hirudines, ximelagatran, agatroban, efegatran) - indirect (heparine, LMWH others) f. Xa inhibitors direct (xabans) - indirect (heparine, LMWH, pentasacharids - fondaparinux) 5) vitamine K dependent factors inhibition (vitamine K antagonists)

50 ANTICOAGULANTS mechanism of action 1. Thrombin inhibitors - direct /hirudines,ximelagatran, gatroban, efegatran) - indirect (heparines, LMWH) 2. Factor Xa inhibitors direct (xabans) - indirect (heparine, LMWH, pentasacharids - fondaparinux) 3. vitamin K dependent factors inhibition (vitamine K antagonists)

51 coagulation system internal system external system ANTICOAGULATION XIa VIIa/TF heparines, pentasacharides IX IXa IX VIII VIIIa VIIIi VIIa/TF i X Xa X V Va Vi act. protein C prot. S prot. C prothrombin htrombin XIII thrombomodulin fibrinogen fibrin fibrin net plazmin fibrin degradation product heparines, hirudins, ximelagatran

52 THROMBIN INHIBITORS a) indirect (heparine, LMWH) - no inhibition for thrombin bind to fibrin or f.xa b) direct (hirudines, competitive and noncompetitive inhibitors) - strong antithrombotic effect

53 INDIRECT THROMBIN INHIBITORS DIRECT TROMBIN INHIBITORS AT III TROMBIN Catalyt. site MELAGATRAN Reversible blockade of catalytic site THROMBIN LMWH, UFH ATIII mediated blockade of catalytic site for heparine activation HIRUDINE reversible blockade of fibrine catalytic and binding site THROMBIN

54 HEPARINE - UFH Sulphonyl-mucopolysacharide Continuous infusion necessary (sc. aplication uncertain) dosage prediction questionable (binding, variable farmacokinetic) Inability to inactivate thrombin bind to fibrin Neutralised by platelet factor 4 Induced trombocytopenie (HIT), bleeding Average effective dose 30 thousands IU 24h Neutralised by protamin sulfate Replaced in most indications by LMWH

55 Mechanism of action AT III Fibrinogen binding site THROMBN AT III catalytic site for f. Xa a thrombin TROMBIN f.xa UFH UFH, LMWH UFH LMWH AT III THROMBIN TROMBIN b i n d i n g AT AT III III AT III f.xa PENTASACHARIDS

56 Heparine fractionisation heparin (UFH) pentasacharids LMWH

57 Low molecular weight heparins (LMWH) Heparin depolymerisation (15 sacharides units) Higher inhibition fxa and lower thrombin (LMWH with longer chain higher trombin inhibition) Inability to inhibit thrombin bind to fibrin Longer effect Predictable effekt Good s.c. resorptione Lower incidence of trombocytopenie (HIT) Incomplete neutralization by protamine

58 Low molecular weight heparins (LMWH) mol.weight anti-xa/anti-iia UFH heparin Heparin ,0 dalteparin Fragmin ,7 enoxaparin Clexane ,8 nadroparin Fraxiparin ,6 parnaparin Fluxu ,7 reviparin Clivarin ,5 tinzaparin Logiparin ,9

59 % distribuce Diferences between LMWH sacharide iunits enoxaparin bemiparin reviparin parnaparin nadroparin dalteparin tinzaparin

60 PENTASACHARIDES - f.xa INHIBITORS selective factor Xa block, analog from pentasacharid sequence of heparinu, activate ATIII advatages: easy dosing, longer effect, predictable effect AT AT III III disadvantage: no antidote known AT III f.xa fondaparinux: prevention and treatment of perioperative TED and AKS better prophylaxisthan LMWH in DVT registered and reimbursed indaparinux: aplication 1x weekly

61 Hirudin, bivalirudin, lepirudin, desirudin direct trombin inhibitors reversibile blockade of the catalytic and binding side of fibrin proteins, parenteral aplication relat. shorter effect ( min) indication: heparin induced trombocytopenia - HIT (antibodies vs. compl. heparin and PF4) AKS, intervention (PTCA,..) DVT, pulmonary embolia TROMBIN

62 Hirudin, bivalirudin, lepirudin, desirudin hirudin natural protein Hirudo officinalis bivalirudin, lepirudin, desirudin analogs with better resorption, longer halflife and higer afinity to trombin High cost, practically rarely used metaanalysis show only not signif. lower mortality in AKS compared with standart therapy (ASA, LMWH)

63 Gatrans direct thrombin inhibitors

64 Dabigatran (Pradaxa) Direct binding to thrombin catalytic center without AT thrombin inhibition (free and even bind to fibrin) dabigatran fibrinová síť trombin katalyt. místo

65 Dabigatran Peroral (bioavailability of pro-drug 6%) Low variability response (not necessary monitoring of effect) Renal elimination Hepatic metabolism

66 Dabigatran Direct reversible thrombin inhibition peroral Quick onset (max. effect after 1 hour) Long lasting effect ( 2x daily) Indication: prevention and treatment TE comparable to LMWH For stroke prevention better than warafarin

67 kumulativní riziko Dabigatran vs warfarin atrial fibrialtion - thrombotic comlications (RELY) warfarin dabigatran 2x110 mg dabigatran 2x150 mg RR 0.91 (95% CI: ) p<0.001 (NI) p=0.34 (Sup) RRR 34% RR 0.66 (95% CI: ) p<0.001 (NI) p<0.001 (Sup) roky Connolly SJ., et al. NEJM

68 Ximelagatran oral prodrug with conversion to melagatran excellent resorption and bioavailability reversibile inhibitor of trombin 2x daily, without monitoring need lower variability compared to warfarin (less interactions) TROMBIN Indication: prevention anad FT treatment, longterm anticoagulation in TED prevention

69 Xabans direct inhibition of f. Xa rivaroxaban, apixaban, otamixaban, edoxaban,

70 Rivaroxaban (Xarelto) Reversible inhibition of f. Xa (even bind to fibrin) Direct effect without AT Strong inhibition of thrombin activaton, but not thrombin activity rivaroxaban f. Xa katalyt. místo

71 Rivaroxaban peroral t 1/2 6-9 hours, 1-2x daily Small variability in response Prevention of TE after ortopedic operations, atrial fibrilation, DVT treatment comparable to enoxaparine

72 incidence (%) Rivaroxaban enoxaparin hip operations TEN total RRR 70% TEN severe RRR 88% enoxaparin rivaroxaban TEN sympt. bleeding 0 3.7% 1.1% 2.0% 0.2% 0.5% 0.3% 0.1% 0.3%

73 kumulativní výskyt (%) Rivaroxaban vs warfarin atrial fibrilation stroke prevention rivaroxaban warfarin výskyt příhod warfarin 21% rivaroxaban HR (95% CI): 0,79 (0,66, 0,96 P-value Non-Inferiority: < Days Studie ROCKET AF

74 Apixaban direct f. Xa inhibition Peroral and injections Standard effect, no monitoring t 1/ hours, 1-2x daily Low risk of interactions

75 Apixaban For prevention of TE after ortopediv operatins better than enoxaparine For prevention of strojke during atrial fibrialtion better than ASA and warfarin

76 COAGULATION SYSTEM internal pathway external pathway ANTICOAGULATION SYSTEM XIa VIIa/TF heparin, pentasacharides IX IXa IX VIII VIIIa VIIIi VIIa/TF X Xa X V Va Vi akt. prot. C prot. S prot. C protrombin trombin XIII trombomodulin fibrinogen fibrin fibrin net plazmin degradation fibrin products heparin, hirudines,ximelagatran

77 vitamin K warfarin

78 Vitamin K antagonist- WARFARIN - Synthesis inhibition of vitamin K dependrnt factors (coagul. and anticoagul.) - Currentlythe only registered orally effective anticoagul. - good bioavailab., plasma protein binding - 5x effective stereoizomer metabol. CYP 2C9 - Signif. interindivid. variability metabol., interaction with food and other drugs, vit. K in food - Monitoring the (INR) effect is essential - First stage of treatment procoagul. effect (inhib. synt. anticoagul. factors), suuitable combination with LMWH

79 COAGULATION SYSTEM internal pathway external pathway ANTICOAGULATION SYSTEM XIa VIIa/TF IX IXa IX VIII VIIIa VIIIi VIIa/TF X Xa X V Va Vi act. prot. C prot. S prot. C protrombin trombin XIII trombomodulin fibrinogen fibrin fibrin net plasmin degradation fibrin products antivitamines K tpa

80 warfarin KUMATOX - jed na potkany a myši

81 CYP2C9 Polymorfism via CYP2C9 metabolism 15-20% of drugs - ASA and NSAIDs, warfarin, sulphonamides, phenitoin, barbiturates, - activation of AT 1 rec. blockers (sartanes) > 30 types of polymorfism: slow, medium and quick metabolism Impact of CYP2C9*2 (10-20% population) CYP2C9*3 (6-9% population) slow metabol. significanz slow down degradation of warfarin (5-27x clearence), risc of bleeding

82 poměr rizika Narrow therapeutic window warfarinu 15 rrisk trombembolisme terapeutic window Risk of bleeding INR INR < INR > 4.0

83 Warfarin indications Prevention of embolism Atrial fibrialtion Valvular prosthesis Chronic thromboembolis Pulnomal artery embolism Trombofilic disiease

84 Warfarin contraindications Coagulopathy, High risk of bleeding - Gastric ulcer Crohn disease, High hypertension gravidity

85 Bleeding during warfarin treatment WARFARIN Stop treatment vitamin K 1 p.o. (1-10 mg), event. i.v.. Fresh frozen plazma i.v. Prothromplex human coagulation factors II (prothrombin), VII, IX, X -?? Riziko krvácení po 7. dekádě, u jaterní či renální insuf., po iktu, při anamnéze krvácení, u diabetu,

86 Arterial trombosis treatment - fibrinolysis activation

87 FIBRINOLYSIS SCHEME Tissue-type (t-pa) plasmin Urokinase type (u-pa) activators plasminogen activators inhibitors PAI-1 PAI-2 PAI-3 plasminogen Plazmin inhibitors plasmin 2 -antiplasmin 2 -makroglobulin FIBRIN fibrin degradation products

88 Fibrin and fibrinolysis polymerisation scheme fibrinogen trombin faktor XIIIa Fibrin dimer fibrin polymer plasmin fibrin net Fibrin degradation products

89 Advantages and disadvantages of essential fibrinolytics streptokinases: effective, cost effective, antigenic, hypotension release r-tpa: quick and very effective, nonantigenic, select. short term effect, very expensive anistreplases: quick effect (bolus), long lasting (APSAC) antigenic, average price urokinases: effective, bolus, neantigenic, expensive

90 Fibrinolytics derivatives from t-pa (longer lasting effect, higher specificity to fibrin) alteplasis lanoteplasis TNK reteplasis

91 Trombolysis efect related to delay from onset of MI attack Reduced Mortality (%)

92

93 ANTI-PLATELET TREATMENT POSSIBILITIES 1) adhesis inhibitors: monocl. antibodies versus vwf and platelet rec.gpi 2) activation inhibitors: a) tromboxan activation blockers: COX blockers (ASA, indobufen) TX rec. inhibitors (ridogrel) tromboxan-synthasis inhibitor (dazoxiben) b) ADP rec. blockers: tiklopidin, klopidogrel c) serotonin rec. blockers: naftidrofuryl, ketanserin d) trombin rec. blocker: inhibitory trombinu e) multipotent platelet rec. blockers: (anagrelid) 3) agregation inhibitors: GPIIb/IIIa rec. antag. (abciximab, integrilin, epitifibatid, II. generation: roxifiban, lotrafiban, fradafiban) 4) platelet stabilisation : via camp (dipyridamol) or cgpm (NO donators)

Update on Antiplatelets and anticoagulants. Outlines. Antiplatelets and Anticoagulants 1/23/2013. Timir Paul, MD, PhD

Update on Antiplatelets and anticoagulants. Outlines. Antiplatelets and Anticoagulants 1/23/2013. Timir Paul, MD, PhD Update on Antiplatelets and anticoagulants Timir Paul, MD, PhD Antiplatelets Indications Doses Long term use (beyond 12 months) ASA and combination use of NSAIDS ASA resistance Plavix resistance Plavix

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

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

Anticoagulant therapy

Anticoagulant therapy Anticoagulation: The risks Anticoagulant therapy 1990 2002: 600 incidents reported 120 resulted in death of patient 92 deaths related to warfarin usage 28 reports related to heparin usage Incidents in

More information

Antiplatelet and Antithrombotics From clinical trials to guidelines

Antiplatelet and Antithrombotics From clinical trials to guidelines Antiplatelet and Antithrombotics From clinical trials to guidelines Ashraf Reda, MD, FESC Prof and head of Cardiology Dep. Menofiya University Preisedent of EGYBAC Chairman of WGLVR One of the big stories

More information

Use of Antithrombotic Agents In The Presence Of Neuraxial Anesthesia

Use of Antithrombotic Agents In The Presence Of Neuraxial Anesthesia Use of Antithrombotic Agents In The Presence Of Neuraxial Anesthesia Insertion, removal or presence of a catheter in selected sites can place a patient who is antithrombotic agent at risk for a local bleeding

More information

Breaking Old Habits: Use of the New Oral Anticoagulants in Clinical Practice

Breaking Old Habits: Use of the New Oral Anticoagulants in Clinical Practice Breaking Old Habits: Use of the New Oral Anticoagulants in Clinical Practice Antiplatelets and oral anticoagulants Aspirin Plavix Prasugrel Ticagrelor Apixaban Rivaroxaban Dabigatran- Direct thrombin inhibitor

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

Reversal 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 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 information

New Anticoagulants: What to Use What to Avoid

New 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 information

MCHENRY 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 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 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

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

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

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

Disclosure. New Agents for Treatment of DVT. Prevalence of DVT VTE. Normal Hemostasis 7/17/2015. Mark Oliver, MD, RVT, RPVI,FSVU

Disclosure. 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 information

What we all Needs to Know about New and Old Anticoagulant and Antiplatelet Drugs. None related to this presentation 11/22/2012

What we all Needs to Know about New and Old Anticoagulant and Antiplatelet Drugs. None related to this presentation 11/22/2012 What we all Needs to Know about New and Old Anticoagulant and Antiplatelet Drugs Marvin A Wayne, MD, FACEP, FAAEM Associate Clinical Professor University of Washington, EMS Medical Director Whatcom County,

More information

Venous Thrombo-Embolism (VTE) Therapy current challenges & opportunities

Venous Thrombo-Embolism (VTE) Therapy current challenges & opportunities Venous Thrombo-Embolism (VTE) Therapy current challenges & opportunities Asher Winder M.D. Director, Department of Hematology Wolfson Medical Center כנס האיגוד הישראלי לפרמקולוגיה קלינית 2012 04-May-2012

More information

New Oral Anticoagulants in Children: Should They Be Prescribed For Special (Off Label) Situation? No

New Oral Anticoagulants in Children: Should They Be Prescribed For Special (Off Label) Situation? No : Should They Be Prescribed For Special (Off Label) Situation? No Alan D. Michelson, M.D. Professor of Pediatrics and Professor of Medicine Harvard Medical School Director, Center for Platelet Research

More information

New Anticoagulation Agents

New Anticoagulation Agents New Anticoagulation Agents Use of New and Older Therapeutic Agents in the Treatment Regimen Michelle Geddes Case 1 40 year old woman with idiopathic proximal DVT. Previous heparin allergy (wheals, hives)

More information

Are there sufficient indications for switching to new anticoagulant agents

Are 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 information

L'aspirina è diventata obsoleta nell'era dei nuovi inbitori P2Y12? Leonardo Bolognese MD, FESC, FACC Cardiovascular Department, Arezzo, Italy ISO 9001

L'aspirina è diventata obsoleta nell'era dei nuovi inbitori P2Y12? Leonardo Bolognese MD, FESC, FACC Cardiovascular Department, Arezzo, Italy ISO 9001 L'aspirina è diventata obsoleta nell'era dei nuovi inbitori P2Y12? Leonardo Bolognese MD, FESC, FACC Cardiovascular Department, Arezzo, Italy Scientific Advances and Cardiovascular Mortality Nabel and

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

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

NEW ANTIPLATELET AGENTS: An ideal platelet agent would have the following characteristics: 1. quick onset 2. reversible 3. benefit to patients 4.

NEW ANTIPLATELET AGENTS: An ideal platelet agent would have the following characteristics: 1. quick onset 2. reversible 3. benefit to patients 4. NEW ANTIPLATELET AGENTS: An ideal platelet agent would have the following characteristics: 1. quick onset 2. reversible 3. benefit to patients 4. universal response 5. excellent safety profile 6. able

More information

An#- Coagulant An#- Thrombo#c An#- Platelet Drugs

An#- Coagulant An#- Thrombo#c An#- Platelet Drugs An#- Coagulant An#- Thrombo#c An#- Platelet Drugs 1 ANTICOAGULANT CLASSES INHIBITORS OF CLOTTING FACTOR SYNTHESIS WARFARIN (COUMADIN ) Rivaroxaban (Xarelto ) INHIBITORS OF THROMBIN HEPARIN, LEPIRUDIN (REFLUDAN

More information

Management of Patients on Anticoagulants. Haemostasis. Coagulation cascade. Cell-based model 19/11/2013

Management of Patients on Anticoagulants. Haemostasis. Coagulation cascade. Cell-based model 19/11/2013 Management of Patients on Anticoagulants National Coal Mining Museum 11 Nov 2013 Navneet Lad StR Special Care Dentistry Aims: Discuss the different anti-platelet drugs available. Discuss the new generation

More information

To aid practitioners in prescribing unfractionated heparin and low-molecular-weight heparins to patients.

To aid practitioners in prescribing unfractionated heparin and low-molecular-weight heparins to patients. UNFRACTIONATED HEPARIN AND LOW-MOLECULAR-WEIGHT HEPARIN TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVE: To aid practitioners in prescribing unfractionated heparin and low-molecular-weight

More information

Dual Antiplatelet Therapy. Stephen Monroe, MD FACC Chattanooga Heart Institute

Dual Antiplatelet Therapy. Stephen Monroe, MD FACC Chattanooga Heart Institute Dual Antiplatelet Therapy Stephen Monroe, MD FACC Chattanooga Heart Institute Scope of Talk Identify the antiplatelet drugs and their mechanisms of action Review dual antiplatelet therapy in: The medical

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

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

Duration of Dual Antiplatelet Therapy After Coronary Stenting

Duration of Dual Antiplatelet Therapy After Coronary Stenting Duration of Dual Antiplatelet Therapy After Coronary Stenting C. DEAN KATSAMAKIS, DO, FACC, FSCAI INTERVENTIONAL CARDIOLOGIST ADVOCATE LUTHERAN GENERAL HOSPITAL INTRODUCTION Coronary artery stents are

More information

Antikoagulation und antithrombotische Therapie bei Herzerkrankungen

Antikoagulation und antithrombotische Therapie bei Herzerkrankungen Antikoagulation und antithrombotische Therapie bei Herzerkrankungen Christian Sticherling Kardiologie Dimitrios Tsakiris Hämatologie Einsatz der Antikoagulation und antithrombotischen Therapie in der Kardiologie

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

indications November 2 nd, 2012 Dalhousie University

indications November 2 nd, 2012 Dalhousie University + New oral anticoagulants: A review of current indications November 2 nd, 2012 Dr. Sudeep Shivakumar, Hematology Dalhousie University + Objectives es To review indications for anticoagulation To discuss

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

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

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

Per Morten Sandset p.m.sandset@medisin.uio.no. Hemostasis parameters and medication prior to radiological interventions

Per Morten Sandset p.m.sandset@medisin.uio.no. Hemostasis parameters and medication prior to radiological interventions Per Morten Sandset p.m.sandset@medisin.uio.no Hemostasis parameters and medication prior to radiological interventions The challenge Familial or acquired defects in the hemostatic system that dispose for

More information

Critical Bleeding Reversal Protocol

Critical 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 information

Note: Page numbers in italics indicate figures. Page numbers followed by a t indicate tables.

Note: Page numbers in italics indicate figures. Page numbers followed by a t indicate tables. INDEX Note: Page numbers in italics indicate figures. Page numbers followed by a t indicate tables. Acquired bleeding disorders, 37-57 acquired combined inhibitor to factor V and thrombin, 55 acquired

More information

New Approaches to, and Indications for, Antiplatelet Therapy

New Approaches to, and Indications for, Antiplatelet Therapy New Approaches to, and Indications for, Antiplatelet Therapy Kenneth A. Bauer, MD Professor of Medicine, Harvard Medical School Chief, Hematology Section, VA Boston Healthcare System Director, Thrombosis

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

New Oral Anticoagulants. July 2012

New Oral Anticoagulants. July 2012 New Oral Anticoagulants July 2012 Objectives Review coagulation cascade and previous treatment options for anticoagulation Understand points of interaction within coagulation cascade and new oral agents

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

Cardiology Medications New Drugs, New Guidelines

Cardiology Medications New Drugs, New Guidelines Cardiology Medications New Drugs, New Guidelines Ken Kester, PharmD, JD Pharmacy Team Leader Nebraska Heart Hospital August 4, 2014 Cardiology Medications Objectives The attendee will understand Indications,

More information

Anticoagulation Therapy Update

Anticoagulation Therapy Update Anticoagulation Therapy Update JUDY R. WALLING, FNP-BC ARRHYTHMIA MANAGEMENT MUSC CARDIOLOGY Outline Who do we anticoagulate? Review classes of Anticoagulants Review examples of Anticoagulants Review CHADS2

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 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

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

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

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

Hot Topics: Current PFO Recommendations and Loop Monitoring/Cryptogenic Stroke.

Hot Topics: Current PFO Recommendations and Loop Monitoring/Cryptogenic Stroke. Hot Topics: Current PFO Recommendations and Loop Monitoring/Cryptogenic Stroke. Favoriteplus.com www.heartrhythmcharity.org.uk www.forbes.com Victor J. Mazza, MD Assistant Professor of Medicine Cardiology,

More information

23/06/2014. Implications for the Gastroenterologist. No financial interests I am not a hematologist

23/06/2014. Implications for the Gastroenterologist. No financial interests I am not a hematologist Implications for the Gastroenterologist Dr. Daniel Sadowski Royal Alexandra Hospital Edmonton, Ab. No financial interests I am not a hematologist 65 y.o. male referred for iron deficiency anemia (FIT positive)

More information

Rivaroxaban for acute coronary syndromes

Rivaroxaban for acute coronary syndromes Northern Treatment Advisory Group Rivaroxaban for acute coronary syndromes Lead author: Nancy Kane Regional Drug & Therapeutics Centre (Newcastle) May 2014 2014 Summary Current long-term management following

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

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

ANESTHESIA FOR PATIENTS WITH CORONARY STENTS FOR NON CARDIAC SURGERY. Dr. Mahesh Vakamudi. Professor and Head

ANESTHESIA FOR PATIENTS WITH CORONARY STENTS FOR NON CARDIAC SURGERY. Dr. Mahesh Vakamudi. Professor and Head ANESTHESIA FOR PATIENTS WITH CORONARY STENTS FOR NON CARDIAC SURGERY Dr. Mahesh Vakamudi Professor and Head Department of Anesthesiology, Critical Care and Pain Medicine Sri Ramachandra University INTRODUCTION

More information

Optimizing Anticoagulation Selection for Your Patient. C. Andrew Brian MD, FACC NCVH 2015

Optimizing Anticoagulation Selection for Your Patient. C. Andrew Brian MD, FACC NCVH 2015 Optimizing Anticoagulation Selection for Your Patient C. Andrew Brian MD, FACC NCVH 2015 Who Needs to Be Anticoagulated and What is the Patient s Risk? 1. Atrial Fibrillation ( nonvalvular ) 2. What regimen

More information

New Oral Anticoagulants. How safe are they outside the trials?

New 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 information

What You Should NOAC About the New Anticoagulants. Dr Calum Young Cardiologist

What You Should NOAC About the New Anticoagulants. Dr Calum Young Cardiologist What You Should NOAC About the New Anticoagulants Dr Calum Young Cardiologist Overview The Burden of AF What s Wrong With Warfarin? The Era of NOACs NOACs in New Zealand Clinical Trials with NOACs Potential

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

The Brave New (Anticoagulant) World

The 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 information

What s New in Stroke?

What s New in Stroke? 5 th McMaster University Review Course in INTERNAL MEDICINE What s New in Stroke? Robert Hart, M.D. HHS / McMaster Stroke Program Department of Medicine (Neurology) McMaster University Hamilton, Ontario

More information

Lupus anticoagulant Pocket card

Lupus anticoagulant Pocket card Lupus anticoagulant Pocket card Issue number 5 2012 Antiphospholipid Syndrome 1 The antiphospholipid syndrome (APS) is diagnosed in patients with recurrent thromboembolic events and /or pregnancy loss

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

Drugs that alter. blood coagulation. Brush up on your knowledge of these potentially life-saving drugs. By Amy M. Karch, RN, MS

Drugs that alter. blood coagulation. Brush up on your knowledge of these potentially life-saving drugs. By Amy M. Karch, RN, MS PHARMACOLOGY REVIEW: Drugs that alter blood coagulation Brush up on your knowledge of these potentially life-saving drugs. By Amy M. Karch, RN, MS THE VASCULAR SYSTEM delivers oxygen and nutrients to all

More information

Pharmacology of Antiplatelet and Anticoagulants Agents

Pharmacology of Antiplatelet and Anticoagulants Agents Pharmacology of Antiplatelet and Anticoagulants Agents 1 2 Antiplatelet Therapy: Common Oral Agents Acetylsalicylic acid (ASA) Clopidogrel bisulfate* Trade Name Aspirin Plavix Class Salicylate Thienopyridine

More information

Rivaroxaban (Xarelto ) by

Rivaroxaban (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 information

xaban) Policy covered: Coverage of following criteria: the following those who meet the or Hip Xarelto is For those impacted by this policy.

xaban) Policy covered: Coverage of following criteria: the following those who meet the or Hip Xarelto is For those impacted by this policy. Xarelto (rivarox xaban) Policy Number: 5.01.575 Origination: 06/2014 Last Review: 07/2015 Next Review: 07/2016 Policy BCBSKC will provide coverage for Xarelto when it is determined to be medically necessary

More information

Financial Disclosures. Learning Objectives 05/06/2015. None

Financial Disclosures. Learning Objectives 05/06/2015. None ANTITHROMBOTIC MANAGEMENT PRE AND POST ENDOSCOPY Dustin Loomes, MD, FRCPC, Advanced training in Inflammatory Bowel Disease University of Alberta Hospital, Edmonton, AB St. Paul s Hospital, Vancouver, BC

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

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

Cardiology Medications New Drugs, New Guidelines

Cardiology Medications New Drugs, New Guidelines Cardiology Medications New Drugs, New Guidelines Ken Kester, PharmD, JD Pharmacy Team Leader Nebraska Heart Hospital August 4, 2014 CARDIOLOGY MEDICATIONS Objectives The attendee will understand Indications,

More information

Anticoagulation at the end of life. Rhona Maclean Rhona.maclean@sth.nhs.uk

Anticoagulation at the end of life. Rhona Maclean Rhona.maclean@sth.nhs.uk Anticoagulation at the end of life Rhona Maclean Rhona.maclean@sth.nhs.uk Content Anticoagulant Therapies Indications for anticoagulation Venous thromboembolism (VTE) Atrial Fibrillation Mechnical Heart

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

WOEST TRIAL- NO ASPIRIN IN STENTED PATIENTS REQUIRING ANTICOAGULATION. Van Crisco, MD, FACC, FSCAI First Coast

WOEST TRIAL- NO ASPIRIN IN STENTED PATIENTS REQUIRING ANTICOAGULATION. Van Crisco, MD, FACC, FSCAI First Coast WOEST TRIAL- NO ASPIRIN IN STENTED PATIENTS REQUIRING ANTICOAGULATION Van Crisco, MD, FACC, FSCAI First Coast Conflicts of Interest I have been a paid consultant and speaker for AstraZeneca, makers of

More information

Therapeutic Class Overview Oral Anticoagulants

Therapeutic Class Overview Oral Anticoagulants Therapeutic Class Overview Oral Anticoagulants Therapeutic Class Overview/Summary: The oral anticoagulants, dabigatran etexilate mesylate (Pradaxa ), rivaroxaban (Xarelto ), and warfarin (Coumadin, Jantoven

More information

East Kent Prescribing Group

East 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 information

THE BENEFITS OF RIVAROXABAN (XARELTO ) ACROSS MULTIPLE INDICATIONS AND THE RELEVANCE TO CARDIOLOGISTS

THE BENEFITS OF RIVAROXABAN (XARELTO ) ACROSS MULTIPLE INDICATIONS AND THE RELEVANCE TO CARDIOLOGISTS THE BENEFITS OF RIVAROXABAN (XARELTO ) ACROSS MULTIPLE INDICATIONS AND THE RELEVANCE TO CARDIOLOGISTS Ingo Ahrens, Christoph Bode Cardiology and Angiology I, Heart Center Freiburg University, Freiburg,

More information

Managing Anticoagulants, Antiplatelets, and NSAIDS in the Interventional Radiology Setting. Amy Huggins, BSN, RN

Managing Anticoagulants, Antiplatelets, and NSAIDS in the Interventional Radiology Setting. Amy Huggins, BSN, RN Managing Anticoagulants, Antiplatelets, and NSAIDS in the Interventional Radiology Setting Amy Huggins, BSN, RN Objectives 1 2 3 4 5 Recognize bleeding risk based on classes of IR procedures Differentiate

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

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

Cilostazol versus Clopidogrel after Coronary Stenting

Cilostazol versus Clopidogrel after Coronary Stenting Cilostazol versus Clopidogrel after Coronary Stenting Seong-Wook Park, MD, PhD, FACC Division of Cardiology, Asan Medical Center University of Ulsan College of Medicine Seoul, Korea AMC, 2004 Background

More information

Antithromboticthrombotic Monitoring

Antithromboticthrombotic Monitoring Introduction to Antithromboticthrombotic Monitoring 1 Topics What is thrombosis, and why is it significant? Coagulation Cascade Pathways of coagulation, anticoagulation, and fibrinolysis Thrombophilia

More information

DUAL ANTIPLATELET THERAPY. Dr Robert S Mvungi, MD(Dar), Mmed (Wits) FCP(SA), Cert.Cardio(SA) Phy Tanzania Cardiac Society Dar es Salaam Tanzania

DUAL ANTIPLATELET THERAPY. Dr Robert S Mvungi, MD(Dar), Mmed (Wits) FCP(SA), Cert.Cardio(SA) Phy Tanzania Cardiac Society Dar es Salaam Tanzania DUAL ANTIPLATELET THERAPY Dr Robert S Mvungi, MD(Dar), Mmed (Wits) FCP(SA), Cert.Cardio(SA) Phy Tanzania Cardiac Society Dar es Salaam Tanzania DUAL ANTIPLATELET THERAPY (DAPT) Dual antiplatelet regimen

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

NHS FORTH VALLEY Rivaroxaban for Stroke Prevention in Atrial Fibrillation

NHS FORTH VALLEY Rivaroxaban for Stroke Prevention in Atrial Fibrillation NHS FORTH VALLEY Rivaroxaban for Stroke Prevention in Atrial Fibrillation Date of First Issue 06/06/2012 Approved 06/06/2012 Current Issue Date 29/10/2014 Review Date 29/10/2016 Version 1.4 EQIA Yes 01/06/2012

More information

EMMC 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 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 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

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

Committee Approval Date: September 12, 2014 Next Review Date: September 2015

Committee 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 information

Anticoagulation Essentials! Parenteral and Oral!

Anticoagulation 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 information

ABOUT XARELTO CLINICAL STUDIES

ABOUT XARELTO CLINICAL STUDIES ABOUT XARELTO CLINICAL STUDIES FAST FACTS Xarelto (rivaroxaban) is a novel, oral direct Factor Xa inhibitor. On September 30, 2008, the European Commission granted marketing approval for Xarelto for the

More information

Guidelines for the Management of Anticoagulant and Anti-Platelet Agent Associated Bleeding Complications in Adults

Guidelines for the Management of Anticoagulant and Anti-Platelet Agent Associated Bleeding Complications in Adults Guidelines for the Management of Anticoagulant and Anti-Platelet Agent Associated Bleeding Complications in Adults Purpose: To be used as a common tool for all practitioners involved in the care of patients

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

Platelet Function analysis using Multiple Electrode Aggregometry (Multiplate )

Platelet Function analysis using Multiple Electrode Aggregometry (Multiplate ) Platelet Function analysis using Multiple Electrode Aggregometry (Multiplate ) Multiplate platelet function analysis in whole blood based on impedance aggregometry Multiplate instrument 5 channels for

More information

SCRN Medication Review. Susan M. Gaunt MS APRN ACNS-BC CCRN CNRN Gwinnett Medical Center

SCRN Medication Review. Susan M. Gaunt MS APRN ACNS-BC CCRN CNRN Gwinnett Medical Center SCRN Medication Review Susan M. Gaunt MS APRN ACNS-BC CCRN CNRN Gwinnett Medical Center Objectives To explain the indications, contraindications, interaction, timing, dosing, side effects of: Thrombolytics

More information

Thrombosis 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 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 information

Low Molecular Weight Heparin. All Wales Medicines Strategy Group (AWMSG) Recommendations and advice

Low Molecular Weight Heparin. All Wales Medicines Strategy Group (AWMSG) Recommendations and advice Low Molecular Weight Heparin All Wales Medicines Strategy Group (AWMSG) Recommendations and advice Starting Point Low Molecular Weight Heparin (LMWH): Inhibits factor Xa and factor IIa (thrombin) Small

More information