The New An)coagulants: Prac)cal Applica)on. Ma8hew Rondina, M.D. Department of Internal Medicine University of Utah Medical Center
|
|
- Miles Hamilton
- 8 years ago
- Views:
Transcription
1 The New An)coagulants: Prac)cal Applica)on Ma8hew Rondina, M.D. Department of Internal Medicine University of Utah Medical Center
2 Learning Objec)ves 1. Understand the prac)cal considera)ons and poten)al disadvantages of the new oral an)coagulants. 2. Understand how to switch to and from the new oral an)coagulants and other agents, including their use in the peri- procedural period. 3. Recognize the limita)ons, poten)al pinalls, and educa)onal needs for effec)ve administra)on of the new an)coagulants in the real world.
3 NEW OACs: UNCHARTED WATERS IN REAL WORLD? Physicians considering dabigatran or an oral factor Xa inhibitor for individual pa)ents should be extraordinarily conserva)ve in considering whether these medica)ons are appropriate replacements for warfarin. Annals Opinion, R.P. Radecki, M.D. Annals of Internal Medicine 2012; 157:66
4 NEW OACs: POTENTIAL DISADVANTAGES? Limited Clinician Experience Unselected, Real World PopulaGons PaGent Adherence? PaGent selecgon? Drug interacgons? CrCl FU? Subop)mal dosing with CKD Switch among ACs? Periprocedural Rx? Uncertain OAC intensity Bleeding Rx? No angdote Cost: $250/mo No monitoring pt educagon Not detect adherence PaGent vigilance/ adherence (17% DC at 4mo) Increased Major Bleeding and/or Stroke/SE? Circula)on 2011; 124: Abs Blood 2012; 119:3016 Sem Thromb Haemost 2012; 38:7 Thromb Haemost 2012; 107:838
5 HOW TO CHOOSE: WARFARIN vs NEW OAC? Warfarin mandatory if: Mitral stenosis no data Prosthe)c heart valve FDA 12/2012: new OAC contraindicated REALIGN stopped early warfarin be8er Crea)nine clearance < 30 ml/min no data/toxicity Non- adherence as cause of low TTR 36% miss 20% of warfarin doses TTR Can t assess adherence to new OACs BID dosing (dabi, apixaban), short dura)on of ac)on Cannot afford new OACs - $3,000/y CAD? ACCP favors warfarin > dabi Blood 2012; 119:3016 Thromb Haemost 2012; 107:838 Arch Int Med 2007; 167:229
6 HOW TO CHOOSE: WARFARIN vs NEW OAC? Clinical consideragons favoring warfarin? TTR 70% (?) and pagent prefers warfarin S)ll, ICH with new OACs! Risk factors for new OAC accumulagon Bleeding Wt < 60 kg ± CrCl ± age 75-80y ± interac)ng drugs FluctuaGng CrCl: CHF High GI bleeding risk (dabigatran, rivaroxaban) Prior bleed, IBD, angiodysplasia, other Wt <50 kg or > 120 kg no data Blood 2012; 119:3016 Thromb Haemost 2012; 107:838
7 HOW TO CHOOSE: WARFARIN vs NEW OAC? Cost- effecgveness modeling studies (<$50,000/QALY): CHADS 2 Score Cost- effecgve? 0 ASA or No Rx 1, 2 Warfarin 3 bid No, if high bleed risk No, if TTR < 57% Dabigatran, 150 mg No, if TTR 73% New OACs cost- effecgve (not cost- saving) in pagent subsets Circula)on 2011; 123:2519, 2562 BMJ 2011; 343:d6333 Heart 2012; 98:573 Thromb Haemost 2011; 105:908
8 NEW OACs: CAN WE AFFORD THEM? Hospital budget implicagons for angcoagulagon clinic: 1774 AF pa)ents: 94% eligible for dabigatran 150 mg bid Dabigatran 150 mg bid: $2464/y*; warfarin: $31/y* Labor $483/pt INR tes)ng $267/pt Warfarin Costs/y Dabigatran Costs/y MedicaGon 54,994 4,371,136 INR monitoring 473, Labor 856, (???) $1,385,494 $4,371,136 (??) *wholesale acquisi)on costs #Costs due to AE not considered Clin App Thromb Haemost 2012; 18:181
9 increase in medica)on cost far exceeds the budgetary savings from elimina)ng all costs for labor and laboratory coagula)on monitoring. Consequently, clinicians and pa)ents can expect imposi)on of external cost- control measures that may include a preferred formulary choice, prescrip)on preauthoriza)on, increasing pa)ent copayment, or an ini)al trial of generic warfarin. Clin App Thromb Haemost 2012; 18:181
10 Drug DRUG INTERACTIONS: NEW OACs Dabigatran r in Exposure Rivaroxaban/Apixaban r in Exposure *Dronedarone %?? *Azole an)fungals (eg., ketoconazole) + 150% + 160% *Amiodarone + 60% *Quinidine + 53% *Verapamil + 50% *Clarithromycin % *Ritonavir % *St. John s wort?? *Rifampicin, phenytoin, carbamazepine - 67% Cannot detect/monitor interacgon! - 50% *Contraindicated or therapy modificagon for CrCl = 30 49? Blood 2012; 119:3016
11 NEW OACs: A DARKER SIDE? Bleeding and patient selection in the community: FDA, 12/2012: 542 Dabigatran deaths in the U.S. unknown for warfarin >50% involved off-label use European Medicine Agency, 5/2012: Dabigatran deaths fewer than expected from RCTs No data presented FDA, 11/2012: Insurance/administrative data: ICH/GIB x in new warfarin vs new dabigatran users. Bloomberg News, 12/2012: >150 U.S. Lawsuits vs Boehringer-Ingeleheim
12 WHO BLEEDS ON NEW OACs? Australia/NZ Hematology Society: 78 dabigatran bleeds Age 80: 66% CrCl <50 ml/min: 58% Wt < 60 kg: 50% (mean wt = 83 kg in Phase III RCTs) Bleeding risk mulgple RFs for drug accumulagon Age 80y CrCl ml/min Wt < kg - 50% serum dabi levels CHF South Asians - 50% of AF pts 80y Medica)ons: amiodarone, dronedarone, verapamil, dil)azem, PPIs, others NEJM 2012; 366:864 J Thromb Haemost 2012; 9:2168 Circulation 2011; 124:824
13 NEW OACs: TESTING HEMOSTATIC FUNCTION If bleeding/thrombosing/urgent surgery/? Adherence: Dabigatran: Normal aptt No therapeu)c AC Normal thrombin )me No drug present Rivaroxaban: Normal PT (not INR) No therapeu)c AC Normal an)- factor Xa ac)vity No/minimal drug Apixaban: Normal an)- factor Xa ac)vity No/minimal drug No tests are useful for rougne monitoring Br J Haem 2012; 159:427
14 NEW OACs: RX OF LIFE- THREATENING BLEEDING Specific angdotes: unavailable but in development Monoclonal Ab to dabigatran, rivaroxaban Reversal of angcoagulant effect: minimal, conflicgng data Animal models Healthy subjects: measuring lab effects ex- vivo Case reports: nega)ve or conflic)ng as to benefit Siegal, Eur Heart J, on-line 12/7/2012 Am J Hem 2012; 87 (suppl1): S 141 Thromb Haemost 2012; 108:583
15 SUMMARY OF STUDIES EVALUATING Oral ac)vated charcoal* NOAC REVERSAL Apixaban Dabigatran Rivaroxaban No data In vitro No data Hemodialysis No data Human volunteers No data Hemoperfusion # with Oral charcoal No data In vitro No data FFP No data Mouse model No data Ac)vated factor VIIa No data Rat model Rat and baboon models 3- factor PCC No data No data No data 4- factor PCC** No data Human volunteers and rat model *If drug intake within several hours **Not available in U.S. #Extracorporeal passage of volume over adsorbant surface (e.g. charcoal) Human volunteers Adapted from Am J Hematol 2012; 87:S
16 PRO- THROMBIN COMPLEX CONCENTRATES U.S. Availability Factors Present Trade Name Associated with Thrombosis? 3- Factor PCC Yes II, IX, X (low VII levels) Profilnine SD Bebulin VH Yes Ac)vated 4- Factor PCC Yes II, IX, X, VIIa FEIBA NF Yes Highest Risk? 4- Factor PCC No II, VII, IX, X Beriplex Octaplex Yes Dosed ~ units/kg body weight No need to thaw prior to administra)on or match blood type Also usually contain small amounts of endogenous ACs (PC/PS) May more rapidly correct coagulopathy due to VKA (vs. FFP) 2012 ACCP: Preferred over FFP (Grade 2C) Am J Hematol 2012; 87:S Blood Transfusion 2011; 9: Chest 2012; 141:e152S-184S
17 BLEEDING ON NEW OAC Mild DC new OAC No AC effect a er 24-48h if CrCl normal Severe DC new OAC Verify Gme of last dose Oral Charcoal if < 4h since administragon Stabilize, support, monitor Rx bleeding site FFP not likely useful Reversal needed for life- threatening bleeding Am J Hem 2012; 87(Suppl 1):S141
18 *May precipitate thromboembolism use only if life- threatening bleeding Am J Hem 2012; 87(Suppl 1):S141 LIFE- THREATENING BLEEDING ON NEW OAC Reversal needed Dabi: aptt > 1.0 X control Riva, apixa: an)factor Xa Rx Dabigatran assay Rivaroxaban Apixaban Hemodialysis Yes No No Hemoperfusion Unclear Possible Possible 4- factor PCC* Possible Possible Possible FEIBA Possible Possible Possible 3- factor PCC* Unclear Unclear Unclear rfviia* Unclear Unclear Unclear Ac)vated charcoal Yes Yes Yes
19 HOW TO SWITCH TO/FROM DABIGATRAN OR RIVAROXABAN? Warfarin Dabi or Riva: start D/R when INR < 2.0 D or R Warfarin: calculate creagnine clearance (egfr) CrCl, ml/min Dabigatran: start W # days before stop D Rivaroxaban: start W # days before stop R > Stop D or - 1 R on day 0 above Off dabi 1-2 days for lab INR to be useful Do not use point- of- care INR tesgng - OveresGmates INR on dabi (riva?) Blood 2012; 119:3016 van Ryn J, Am J Med epub 2/2012
20 HOW TO SWITCH TO/FROM DABIGATRAN OR RIVAROXABAN? Enoxaparin bid D or R: Start D or R hours a er last dose enoxaparin Dalteparin qd D or R: Start D or R hours a er last dose dalteparin IV UFH D or R: Start D or R within 2h of stopping IV UH Dabigatran LMWH or IV UFH: Start LMWH/IV UFH 12h a er last dose dabi if CrCl 30; wait longer if CrCl < 30 (?) Rivaroxaban LMWH or IV UFH: Start LMWH/IV UFH 24h a er last dose riva if CrCl 30; wait longer if CrCl < 30 (?) (PI: First dose of LMWH/UFH at )me next riva dose would be due) Circ J 2011; 75:1539 Xarelto PI
21 DRUG Dabigatran, 150 mg bid Rivaroxaban, 20 mg qd Apixaban, 5 mg bid PERIPROCEDURAL USE OF NEW OACs: PRE- OP CrCl Ml/min > > > Last Dose Pre- op: Low Bleeding Risk Surgery 2d: Skip 2 doses 3d: Skip 4 doses 2d: Skip 1 dose 2d: Skip 1 dose 2d: Skip 2 doses 3d: Skip 4 doses *Dabigatran: ü a PTT 24h pre- op Rivaroxaban/Apixaban: ü an)- factor Xa 24h pre- op Last Dose Pre- op: High Bleeding Risk Surgery* 3d: Skip 4 doses 4-5 d: Skip 6-8 doses 3d: Skip 2 doses 3d: Skip 2 doses 3d: Skip 4 doses 4d: Skip 6 doses Blood 2012; 120:2954
22 DRUG PERIPROCEDURAL USE OF NEW OACs: POST- OP Resume Rx: Low Bleeding Risk Surgery Resume Rx: High Bleeding Risk Surgery Dabigatran 24 h post op h post op* Rivaroxaban 24 h post op h post op* Apixaban 24 h post op h post op* *High TE risk: consider prophylac)c dose LMWH un)l restart new OAC Blood 2012; 120:2954
23 NEW OACs: INITIAL PATIENT ASSESSMENT ü Risk factors for drug accumulagon: Age 75y CrCl = ml/min Wt <50 kg Concurrent interac)ng drugs ü Risk factors for low pagent adherence: 21-25% DC rate Ability to afford Ability to take dabi, apixa bid Pa)ent preference vs warfarin ü Risk factors for bleeding: reverse if possible HAS- BLED score Prior GI bleeding Need (?) for concurrent ASA Blood 2012; 119:3016 Int Soc Thromb Haemost, J Thromb Haemost 2012; on- line 10/22
24 NEW OACs: PATIENT EDUCATION! Benefits/risks vs warfarin: ICH ± Ischemic Stroke ± GI bleeding ± Major bleeding Cost Consequence of non- adherence: Response to missed doses Drug interacgons: New drug repor)ng Periprocedural management Brochures Face- to- Face AC Clinic opgmal!
25 NEW OACs: FOLLOW- UP/ MONITORING Follow- up interval of q 3-12 months determined by: Renal func)on: baseline instability likelihood Bleeding risk: eg., HAS- BLED score 3 Interac)ng medica)on risk: polypharmacy Low adherence risk: 21-25% DC rate in RCTs Int Soc Thromb Haemost, J Thromb Haemost 2012, online 10/22
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 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 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 informationNovel Oral Anticoagulants (NOACs) Prescriber Update 2013
Novel Oral Anticoagulants (NOACs) Prescriber Update 2013 Indications/Contraindications Indications Orthopedic VTE Prophylaxis VTE Treatment Stroke Prevention for non-valvular AF Contraindications 150 mg
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 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 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 informationNovel 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 informationAdvances in An+coagula+on
Advances in An+coagula+on Laurajo Ryan PharmD, MSc, BCPS, CDE Clinical Associate Professor The University of Texas at Aus+n College of Pharmacy UTHSCSA School of Medicine Pharmcotherapy Research Educa+on
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 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 informationManagement of invasive procedures and bleeding compica5ons in pa5ents on NOACs
Management of invasive procedures and bleeding compica5ons in pa5ents on NOACs Michiel Coppens MD PhD Internist- Vascular Medicine Academic Medical Center, Amsterdam, The Netherlands McMaster University,
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 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 informationNovel OAC s : How should we use them?
Novel OAC s : How should we use them? Jean C. Grégoire MD, FRCP(c), FACC, FACP Associate Professor, Université de Montréal, IntervenJonal Cardiologist, InsJtut de cardiologie de Montréal Disclosures Speaker
More informationΠΟΙΟ ΑΝΤΙΠΗΚΤΙΚΟ ΓΙΑ ΤΟΝ ΑΣΘΕΝΗ ΜΟΥ? ΚΛΙΝΙΚΑ ΠΑΡΑΔΕΙΓΜΑΤΑ. Σωκράτης Παστρωμάς Καρδιολόγος Νοσοκομείο Ερρίκος Ντυνάν
ΠΟΙΟ ΑΝΤΙΠΗΚΤΙΚΟ ΓΙΑ ΤΟΝ ΑΣΘΕΝΗ ΜΟΥ? ΚΛΙΝΙΚΑ ΠΑΡΑΔΕΙΓΜΑΤΑ Σωκράτης Παστρωμάς Καρδιολόγος Νοσοκομείο Ερρίκος Ντυνάν The AF epidemic Mayo Clinic data (assuming a continued increase in the AF incidence) Mayo
More informationNew Oral Anticoagulants (NOACs)
New Oral Anticoagulants (NOACs) Dabigatran (Pradaxa) Rivaroxaban (Xarelto) Apixaban (Eliquis) Edoxaban (Savaysa) Janice Lawson, MD Tallahassee Memorial Hospital Cancer and Hematology Specialists Disclosure
More 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 informationThe Role of the Newer Anticoagulants
The Role of the Newer Anticoagulants WARFARIN = Coumadin DAGIBATRAN = Pradaxa RIVAROXABAN = Xarelto APIXABAN = Eliquis INDICATION DABIGATRAN (Pradaxa) RIVAROXABAN (Xarelto) APIXABAN (Eliquis) Stroke prevention
More 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 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 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 informationCOMPARISON OF NEW ORAL ANTICOAGULANTS AND FREQUENTLY- ASKED QUESTIONS FROM PATIENTS. TARGET AUDIENCE: All Canadian health care professionals.
COMPARISON OF NEW ORAL ANTICOAGULANTS AND FREQUENTLY- ASKED QUESTIONS FROM PATIENTS AND PHYSICIANS TARGET AUDIENCE: All Canadian health care professionals. OBJECTIVES: To provide a comparison of the new
More 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 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 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 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 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 informationThe 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 informationNew Anticoagulants. Stroke Prevention in AF Commencing Novel Oral Anticoagulants (NOACs) in the GP Setting. 30-Oct-14
Stroke Prevention in AF Commencing Novel Oral Anticoagulants (NOACs) in the GP Setting A/Prof Michael Nguyen Fremantle Hospital Access Cardiology General Practice Education Day Oct 2014 ORAL TTP889 Rivaroxaban
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 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 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 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 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 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 informationAnticoagulation: How Do I Pick From All the Choices? Jeffrey H. Neuhauser, DO, FACC BHHI Primary Care Symposium February 28, 2014
Anticoagulation: How Do I Pick From All the Choices? Jeffrey H. Neuhauser, DO, FACC BHHI Primary Care Symposium February 28, 2014 Atrial Fibrillation 2 Atrial Fibrillation The most common arrhythmia encountered
More informationNOACS AND AF PEARLS AND PITFALLS DR LAURA YOUNG HAEMATOLOGIST
NOACS AND AF PEARLS AND PITFALLS DR LAURA YOUNG HAEMATOLOGIST NGAIRE IS 70 YEARS OLD AND IN AF. SHE HAS NO MURMURS, NORMAL BLOOD PRESSURE, EGFR OF 65ML/MIN AND NO SIGNIFICANT PAST MEDICAL HISTORY. REGARDING
More informationNon- Valvular Atrial Fibrillation and Stroke Prevention: Which OAC Do I Choose. Warfarin vs the NOACs
Non- Valvular Atrial Fibrillation and Stroke Prevention: Which OAC Do I Choose Warfarin vs the NOACs Dr. Lori McIntosh D.O. Board Certified Neurologist Objectives Be able to list the current options of
More 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 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 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 informationTSOAC Initiation Checklist
Task Establish appropriate dose based on anticoagulant selected, indication and patient factors such as renal function. Evaluate for medication interactions that may necessitate TSOAC dose adjustment.
More 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 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 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 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 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 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 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 informationUpdate 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 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 informationPractical everyday use of NOACs. Dr. Elisabetta Toso SOC Cardiologia Ospedale Cardinal Massaia - Asti
Practical everyday use of NOACs Dr. Elisabetta Toso SOC Cardiologia Ospedale Cardinal Massaia - Asti THE NEW ANTICOAGULANTS HISTORY Oral Inhibitors Edoxaban Apixaban Betrixaban EXPLORE-Xa Phase II trial
More informationNovel oral anticoagulants (NOACs): novel problems and their solutions
Novel oral anticoagulants (NOACs): novel problems and their solutions Martin H. Ellis MD Hematology Institute and Blood Bank Meir Medical Center January 2013 OVERVIEW NOACs in clinical use Review of pivotal
More informationDISCLOSURES CONFLICT CATEGORY. No conflict of interest to disclose
DISCLOSURES CATEGORY Employment Research support Scientific advisory board Consultancy Speakers bureau Major stockholder Patents Honoraria Travel support Other CONFLICT No conflict of interest to disclose
More informationNew Oral Anticoagulants. Pharmacological considerations
New Oral Anticoagulants Pharmacological considerations New oral anticoagulants The ideal anticoagulant. Metabolic pathways Drug-drug interactions One dose fits all??? Special sub-groups of patients. NOAC
More informationThe 50-year Quest to Replace Warfarin: Novel Anticoagulants Define a New Era. CCRN State of the Heart 2012 June 2, 2012
The 50-year Quest to Replace Warfarin: Novel Anticoagulants Define a New Era CCRN State of the Heart 2012 June 2, 2012 Disclosures I have I have been involved in trials of new anticoagulants and have received
More 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 informationNew Oral AntiCoagulants (NOAC) in 2015
New Oral AntiCoagulants (NOAC) in 2015 William R. Hiatt, MD Professor of Medicine and Cardiology University of Colorado School of Medicine President CPC Clinical Research Disclosures Received research
More informationDisclosure: Dr. Smith has no actual or potential conflict of interest associated with this presentation.
Disclosure: Dr. Smith has no actual or potential conflict of interest associated with this presentation. Michael Smith, Pharm. D., BCPS, CACP Pharmacy Clinical Manager William Backus Hospital You were
More informationAppendix C Factors to consider when choosing between anticoagulant options and FAQs
Appendix C Factors to consider when choosing between anticoagulant options and FAQs Choice of anticoagulant for non-valvular* atrial fibrillation: Clinical decision aid Patients should already be screened
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 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 informationFDA Approved Oral Anticoagulants
FDA Approved Oral Anticoagulants Generic (Trade Name) Warfarin (Coumadin, Jantoven ) 1 FDA approved indication Prophylaxis and treatment of venous thromboembolism (VTE) Prophylaxis and treatment of thromboembolic
More 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 informationEfficacy in Hip Arthroplasty. Efficacy in Knee Arthroplasty. Adverse Effects. Drug Interactions
Objectives Just for the RECORD: Rivaroxaban joins the US Anticoagulation Arsenal Anne P. Spencer, PharmD, FCCP, BCPS (AQ Cardiology) Cardiovascular Care Pharmacy Specialist Roper Saint Francis Healthcare
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 informationAn#coagulant Choices in Renal Impairment
An#coagulant Choices in Renal Impairment Karen Shalansky, Pharm.D. Pharmacotherapeu#c Specialist, Nephrology Vancouver General Hospital Clinical Professor Faculty of Pharmaceu#cal Sciences, UBC karen.shalansky@vch.ca
More informationDisclosures. I have served as an advisory board member, consultant, speaker, and / or received research funding from: Sanofi-Aventis
TSOACs: Glee Lenoir, Pharm D. Pharmacy Clinical Coordinator The Medical Center Nursing Conference March 2015 Disclosures I have served as an advisory board member, consultant, speaker, and / or received
More informationGoals 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 information4/9/2015. 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 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 informationNew Anticoagulants and GI bleeding
New Anticoagulants and GI bleeding DR DANNY MYERS MD FRCP(C) CLINICAL ASSISTANT PROFESSOR OF MEDICINE, UBC Conflicts of Interest None I am unbiased in the use of NOAC s vs Warfarin based on risk benefit
More informationDisclosure/Conflict of Interest
NEW ORAL ANTICOAGULANTS: WHAT EVERY PHARMACIST SHOULD KNOW LORI B. HORNSBY, PHARMD, BCPS ASSOCIATE CLINICAL PROFESSOR AUHSOP CLINICAL PHARMACIST MIDTOWN MEDICAL CENTER OUTPATIENT CLINIC COLUMBUS, GEORGIA
More 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 informationAntiplatelet 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 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 informationHow To Treat Aneuricaagulation
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 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 informationNew Oral Anticoagulants Who Gets What for Atrial Fibrillation and Venous Thromboembolism?
New Oral Anticoagulants Who Gets What for Atrial Fibrillation and Venous Thromboembolism? Kathryn Hassell, MD Professor of Medicine, Division of Hematology University of Colorado Denver Disclosures No
More informationDirect Oral Anticoagulants (DOACs) Who Gets What?
Direct Oral Anticoagulants (DOACs) Who Gets What? Kathryn Hassell, MD Professor of Medicine, Division of Hematology University of Colorado Denver Disclosures No financial or commercial conflicts of interest
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 informationNORTH WEST LONDON GUIDANCE ANTITHROMBOTIC MANAGEMENT OF ATRIAL FIBRILLATION
North West London CardioVascular & Stroke Network NORTH WEST LONDON GUIDANCE ON ANTITHROMBOTIC MANAGEMENT OF ATRIAL FIBRILLATION Key Messages 1. Efforts should be made to identify patients with Atrial
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 informationNo INRs! RNs Role Caring for Patients on Oral Anticoagulant Therapy. Cheryl Hill BSP, ACPR
No INRs! RNs Role Caring for Patients on Oral Anticoagulant Therapy Cheryl Hill BSP, ACPR Conflict of Interest No real or potential conflict to disclose Objectives Oral Anticoagulation History Dabigatran
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 informationClinical Assistant Professor University of Kansas School of Pharmacy. Objectives
New Oral Anticoagulants Tiffany R. Shin, PharmD, BCACP Clinical Assistant Professor University of Kansas School of Pharmacy 1 Objectives Discuss the advantages and disadvantages of the new oral anticoagulants
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 informationHow To Increase Warfarin
Anticoagulants for venous thromboembolic disease- Optimizing the old, ushering in the new. Daniel A. Forman, DO RPS Hematology Oncology daniel.forman@readinghealth.org 610 509 5067 cell RHS Anticoagulation
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 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 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 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 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 informationPractical Aspects of Novel Oral Anticoagulants (NOACs)
Practical Aspects of Novel Oral Anticoagulants (NOACs) Edith Nutescu, Pharm.D., FCCP Clinical Professor University of Illinois at Chicago College of Pharmacy University of Illinois Hospital & Health Sciences
More information1/7/2012. Objectives. Epidemiology of Atrial Fibrillation(AF) Stroke in AF. Stroke Risk Stratification in AF
Objectives Atrial Fibrillation and Prevention of Thrombotic Complications: Therapeutic Update Andrea C. Flores Pharm.D Pharmacy Resident at the Miami VA Healthcare System Review the epidemiology, pathophysiology
More informationAnticoagulation Management Insanity: doing the same thing over and over again and expecting different results. Case 1
2011 MFMER slide-1 Anticoagulation Management Insanity: doing the same thing over and over again and expecting different results Fadi Elias Shamoun, MD Mayo Clinic in Arizona Albert Einstein Anticoagulation
More informationManagement 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 informationDisclosures. Objective (NRHS) Self Assessment #2
Development and Implementation of a Protocol for Reversing the Effects of Anticoagulants for Use in a Community Hospital Samantha Sepulveda, Pharm.D. PGY1 Pharmacy Resident Norman Regional Health System
More information