Everything Your Pharmacist Wished You Knew About Anticoagulant Reversal Darrel W. Hughes, Pharm.D., BCPS University Health System & UT Health Science
|
|
- Gordon Gray
- 5 years ago
- Views:
Transcription
1 Everything Your Pharmacist Wished You Knew About Anticoagulant Reversal Darrel W. Hughes, Pharm.D., BCPS University Health System & UT Health Science Center at San Antonio Department of Pharmacotherapy & Pharmacy Services
2 Disclosure I have no relevant financial relationships to disclose relative to the content of this presentation
3 Objectives Describe strategies for managing complications of vitamin K antagonist (VKA) and direct oral anticoagulants (DOAC) Differentiate major and non-major bleeds Understand mechanisms for reversing the effects of VKA and DOAC
4 Bruised Septuagenarian 74 yo female presents to ED w/ bruising Warfarin for atrial fibrilation Reports no changes to her dose in years Recently prescribed sulfamethoxazole/trimethoprim for urinary tract infection Internationalized normalized ration (INR) is reported to be 8.6
5 Warfarin Trivia 1920 ~70% mortality of cattle in rural Wisconsin Coumarin in moldy, sweet clover WARFARIN Wisconsin Alumni Research Foundation Mainstay of antithrombotic therapy for decades 1950-???
6
7 Warfarin Inhibits vitamin K epoxide reductase Reduced synthesis Clotting factors II, VII, IX, and X Anticoagulants proteins C and S Approved uses Prophy/treatment of thromboembolic disorders Embolic complications from atrial fibrillation Valve replacement Dosing Highly variable/patient dependent
8 Warfarin Pharmacokinetics Hepatic metabolism CYP2C9 and 2C19 Onset of action ~24 to 72 hours Peak effects in 5 to 7 days 99% protein bound
9 Why is INR Supratherapeutic? Medication non-compliance Dietary non-compliance Drug interaction There is no way to know for certain
10 Warfarin & Drug Interactions Displacement from protein binding P-450 enzyme 2C9 inducers/inhibitors Reduction/destruction of gut flora Synergistic anticoagulant effect
11 She s Asymptomatic What is your plan? Hold next dose, follow up with PCP Hold next dose, 1 mg oral vit K, follow up with PCP Hold next dose, 10 mg iv vit K, admit to hospital Hold next dose, dose of prothrombin complex concentrate (PCC), fresh frozen plasma, 10 mg intravenous phytonadione, admit to ICU
12 What To Do? 355 non-bleeding patients with INR between 5.0 an 9.0 Randomized to 1.25 mg of oral vit K or placebo No major bleeding at seven days 2.5% vs. 1.1% for vit K vs. placebo, p=0.22 at 90 days More rapid and robust INR decay for vit K 50% vs. 11% had INR < 3, p < 0.001, 24 hours after vit K Risk factors for slow INR decay theoretically higher bleeding risk Advanced age Decompensated heart failure Low weekly warfarin dose Active malignancy
13 Recommendations If INR No evidence of bleeding American College of Chest Physicians guidelines recommend against routine vitamin K administration
14 Major Gastrointestinal Bleeding 37 yo male Two day history of melena Warfarin for secondary prevention of VTE INR reported 7.3 New massive hematemesis
15 Bleeding: Major vs. Non-Major Bleeding at a critical site Intracranial/CNS, pericardial, airway, hemothorax, intra-abdominal or retroperitoneal, intramuscular or intraarticular Hemodynamic instability Clinically overt bleeding Hemoglobin decrease 2 g/dl Administration of 2 units of prbcs
16 Major Bleeding and Mortality Intracranial hemorrhage 50% mortality Gastrointestinal bleeding 10% mortality Airway/nasal bleeding ~1% mortality
17 INR vs. Clotting Factors
18 VKA Reversal Product Time to Effect Duration of Effect Evidence of Efficacy Thrombosis Risk Oral Vit K 24 h Days ++++ NS IV Vit K 8-12 h Days ++++ NS FFP Immediate h ++ NS PCC Immediate h +++ Higher w/ activated PCC Recombinant factor VIIa Immediate 2-6 h + ++ IV intravenous; FFP fresh frozen plasma; PCC prothrombin (II) complex concentrate
19 Know Your History (old school) 2008 ACCP Guidelines Serious or Life-threatening bleeding associated with vitamin K anatagonist Vitamin K 10 mg IV FFP or PCC or FVIIa
20 Most Recent Recommendations Serious or Life-threatening bleeding associated with vitamin K antagonist PCC4 rather than plasma Vitamin K 5-10 mg IV Changes Bye, bye plasma? FVIIa removed PCC3???
21 Fresh Frozen Plasma (FFP) Contains coagulation factors I, II, V, VII, IX, X, XI, XIII and antithrombin INR reversal Mean INR of FFP 1.7 (1.4 to 1.9) Less effective with ongoing bleeding Disadvantages Large volumes required (20-30 ml/kg) Prolong time to patient TRALI, TACO and anaphylaxis Risk of viral transmission
22 4F PCC vs. FFP PCC FFP Onset Immediate Acquisition + infusion time Duration 3-6 hours 3-6 hours Volume Low ( ml) ml/kg (2-3 L) Risk Thrombosis TRALI, TACO, Allergic Rx, Infection Cost Mucho dinero?????
23 4F PCC vs. FFP Randomized 202 patients w/ major bleeding 24 hour hemostatic efficacy 72.4% vs. 65.4% (7.1%; [95% CI, -5.8 to 19.9]) Rapid INR normalization (30 minutes) 62.2% vs 9.6% (52.6% [95%CI, 39.4 to 65.9]) Safety 66 of 103 vs. 71 of 109 patients experienced 1 adverse event Conclusion Non-inferior efficacy for surrogate primary endpoint
24 Recommendation On VKA with major bleeding at any INR Supportive care Airway, Breathing and Circulation 4-factor PCC (KCentra) Plus IV vitamin K 5-10 mg Surgical/procedural management of bleeding site
25 Headache and Aphasia 66 yo male Headache, aphasia and right sided weakness Vitals 220/118 mmhg, P101, RR 16, T 98.8, pulse ox 98% RA Neuro GCS 14 Somnolent, but responses to simple commands Pupils midpoint, equal and reactive L sided gaze preference R facial weakness & R upper > lower extremity weakness Expressive aphasia INR
26
27 Oral Anticoagulants and ICH Increases intracranial hemorrhage (ICH) risk 7-10 times >10 fold risk if over 50 years of age Increased risk dramatic if INR >4.0 ~60% ICHs occur while INR in the target range ICH risk greatest at the start of treatment 28
28 Do Early Interventions Matter? Hematoma Volume Correlates Mortality Depressed level of consciousness Hemorrhage growth ~40% of all ICH patients Growth of > 33% of baseline volume within 24 hours 29
29 Hematoma Expansion 30
30 Game Plan Hold antithrombotic therapy Vitamin K 10 mg iv piggy back Prothrombin complex concentrate (4F PCC) (Kcentra ) 4-factor PCC indicated for vitamin k antagonist reversal in patients with acute major bleeding Factor II, VII, IX, X, protein S and C 31
31 Dosing Prothrombin Complex Conc. Kcentra INR 2-3.9; 25 units/kg x 1 dose up to 2500 units INR 4-6; 35 units/kg x 1 dose up to 3500 units INR > 6; 50 units/kg x 1 dose up to 5000 units Recheck INR in 30 minutes Max dose based on 100 kg patient Don t forget iv vitamin K to avoid rebound 32
32 Prothrombin Complex Conc. Safety Contraindications: Heparin induced thrombocytopenia Disseminated intravasuclar coagulation Black boxed warning: Thromboembolic events
33 34
34 Hold The Phone! What if the patient s INR was 1.8? 35
35 Re-Examining the Evidence Phase III trial included INRs as low as 1.8 Woo et al. Retrospective review of ICH included INRs as low as 1.5 Yanamadala et al. 50% of neuro-injured patients INR had hematoma expansion > 33% 36
36 37
37 38
38 Hold The Phone! Patient takes new direct oral anticoagulant (DOAC) and not warfarin 39
39 Direct Oral Anticoagulant (DOAC) Direct Thrombin Inhibitors Dabigatran (Pradaxa ) Direct Xa Inhibitors Rivaroxaban (Xarelto ) Apixaban (Eliquis ) Edoxaban (Savaysa ) 40
40 Coagulation Cascade
41 Pharmacokinetics Profiles Dabigatran (Pradaxa ) Rivaroxaban (Xarelto ) Apixaban (Eliquis ) Dose Frequency QD-BID QD-BID BID Bioavailability (%) Peak Action (hours) Half-life (hours) Elimination (% renal) Dosing Monitoring FIXED NONE Dabigatran (Pradaxa ) Package Insert. Boehringer Ingelhein Pharmaceuticals, Inc.: Ridgefield, CT, Rivaroxaban (Xarelto ) Package Insert. Janssen Pharmaceuticals, Inc..: Titusville, NJ, Apixaban. In: DRUGDEX System [Intranet database]. Version 5.1. Greenwood Village, Colo: Thomson Healthcare.
42 Managing DOAC Bleeding Supportive care Airway, breathing, and circulation Is the bleeding major or non-major? Stop anti-coagulant Document time and amount of last dose Consider activated charcoal for dabigatran Up to 2 hours after a dose Note renal and/or hepatic impairment 43
43 Reversal Strategies: Dabigatran Dabigatran Idarucizumab (Praxbind ) approved 2015 Humanized monoclonal antibiody Binds dabigatran and metabolite with a higher affinity than thrombin ~(350 X) Neutralizes the anticoagulant effect Consider activated charcoal if ingested < 2 hours ago Consider emergent dialysis 44
44 Reversal Strategies: Dabigatran Idarucizumab Dosing Dabigatran taken within 24 hrs or hrs ago and INR/PTT 5 gram IV x 1 dose Consider additional 5 gm dose if Re-bleeding or INR/PTT 2 nd emergent surgery needed and INR/PTT Onset within minutes Hemostasis ~ 11 hours w/ 24 hr duration
45 Reversal Strategies: Dabigatran Idarucizumab Prospective, observational cohort Serious bleeding n=51 Urgent procedure n=39 Single 5 gm iv dose normalized ECT and dtt ~89% Sustained effect for 24 hours 46
46 Reversal Strategies: FXa Inhibitors Rivaroxaban/apixaban/edoxaban Supportive care Consider activated charcoal if ingested < 2 hours NOT dialyzable due to high protein binding 4F-PCC (for now) 50 units/kg x 1 dose up to 5000 units Andexanet alpha coming soon 47
47 Reversal Strategies: FXa Inhibitors Andexanet Alpha (Andexxa ) Recombinant human factor Xa protein Binds factor Xa inhibitors with high affinity Reverses anticoagulant activity Direct & indirect factor Xa inhinitors Food and Drug Administration approval May 2018 Product launch in June 2018/early 2019
48 ANNEXA-4 Study Overview Multicenter, prospective, open-label study in patients with acute major bleeding Andexanet alpha Bolus 2 hour infusion Two dosing strategy 400/480 mg Apixaban/rivaroxaban > 7 hrs prior 800/960 mg Enoxaparin, edoxoban or rivaroxaban 7 hrs prior Co-primary outcomes % change in anti-factor Xa activity Rate of excellent or good hemostatic efficacy 12 hrs
49 ANNEXA-4 Study Results Factor Xa inhibitor (n=67) Rivaroxaban (n=32), apixaban (n=31), enoxaparin (n=4) Primary bleeding site GI (n=33) or ICH (n=28) Co-primary outcomes 39% and 30% relative decrease from baseline for rivaroxaban and apixaban groups respectively 79% patients achieved excellent/good hemostasis 12 hours after andexanet 18% of patient experienced thrombotic event by 30- day follow up
50
51 Summary VKA & DOAC deplete or inhibit factors necessary for clot formation Major bleeding Critical site, hemodynamic instability, prbcs Reversal of anticoagulant effect Supplementing depleted factors Binding factor inhibitors General supportive care
52 Summary for Major Bleeding VKA 4F PCC (Kcentra ) Standard of care for life threatening bleeding in patients on warfarin Staggered dose base of patient weight and INR Vitamin K to prevent rebound coagulopathy DOAC Direct thrombin inhibitor (dabigatran) Idarucizumab Consider emergent dialysis for dabigatran Anti-Xa (apixaban, edoxaban or rivaroxaban) Andexanet alpha if available or 4F PCC 53
53 Questions?
Update on Oral Anticoagulants. Dr. Miten R. Patel Cancer Specialists of North Florida Cell
Update on Oral Anticoagulants Dr. Miten R. Patel Cancer Specialists of North Florida Cell 904-451-9820 Email miten.patel@csnf.us Overview Highlights of the 4 new approved oral anticoagulants Results from
More informationReversal Agents for Anticoagulants Understanding the Options. Katisha Vance, MD, FACP Alabama Oncology January 28, 2017
Reversal Agents for Anticoagulants Understanding the Options Katisha Vance, MD, FACP Alabama Oncology January 28, 2017 Objectives Appropriately recommend reversal agents for Vitamin K antagonists Appropriately
More informationChapter 1 The Reversing Agents
Available Strategies to Reverse Anticoagulant Medications Michael L. Smith, Pharm. D., BCPS, CACP East Region Pharmacy Clinical Manager Hartford HealthCare Objectives: Describe the pharmacological agents
More informationManaging Bleeding in the Patient on DOACs
Managing Bleeding in the Patient on DOACs Spring 2016 Jean M. Connors, MD Anticoagulation Management Services BWH/DFCI Hemostatic Antithrombotic Stewardship BWH Assistant Professor of Medicine, HMS Conflicts
More informationUpdates in Anticoagulation for Atrial Fibrillation and Venous Thromboembolism
Disclosures Updates in Anticoagulation for Atrial Fibrillation and Venous Thromboembolism No financial conflicts of interest Member of the ABIM Focused- Practice in Hospital Medicine Self Examination Process
More informationAnticoagulation Task Force
Anticoagulation Task Force Newest Recommendations Donald Zabriskie, BPharm, MBA, RPh Pharmacy Patient Care Services Cleveland Clinic- Fairview Hospital THE DRUGS THE PERFECT ANTICOAGULANT Oral administration
More informationREVERSAL STRATEGIES FOR ORAL ANTICOAGULATION
REVERSAL STRATEGIES FOR ORAL ANTICOAGULATION Wesley R. Zemrak, Pharm.D., BCPS Clinical Pharmacy Specialist, Anticoagulation Maine Medical Center, Portland, ME zemraw@mmc.org 1 OBJECTIVES 1. Discuss the
More informationAdult Reversal of Anticoagulation and Anti-platelet Agents for Life- Threatening Bleeding or Emergency Surgery Protocol
Adult Reversal of Anticoagulation and Anti-platelet Agents for Life- Threatening Bleeding or Emergency Surgery Protocol Page Platelet Inhibitors 2 Aspirin, Clopidogrel (Plavix), Prasugrel (Effient) & Ticagrelor
More informationOral Anticoagulants Update. Elizabeth Renner, PharmD, BCPS, BCACP, CACP Outpatient Cardiology and Anticoagulation
Oral Anticoagulants Update Elizabeth Renner, PharmD, BCPS, BCACP, CACP Outpatient Cardiology and Anticoagulation Objectives List the direct oral anticoagulant (DOAC) drugs currently available Describe
More informationIntroduction. Blood Pressure
Introduction Spontaneous intracerebral hemorrhage (ICH) is a major cause of morbidity and mortality worldwide [1]. Of a number of factors that have been linked to ICH (e.g., higher rates in Asians and
More informationWhat s new with DOACs? Defining place in therapy for edoxaban &
What s new with DOACs? Defining place in therapy for edoxaban & Use of DOACs in cardioversion Caitlin M. Gibson, PharmD, BCPS Assistant Professor, Department of Pharmacotherapy University of North Texas
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 informationChallenges in Coagulation
Challenges in Coagulation Michael H. Rosove, MD Clinical Professor of Medicine UCLA Division of Hematology-Oncology April 30, 2016 Vitamin K Deficiency Vitamin K1 source from diet Vitamin K2 source from
More informationThe INR: No Need Anymore? Daniel Blanchard, MD Professor of Medicine Director, Cardiology Fellowship Program UCSD Sulpizio Cardiovascular Center
The INR: No Need Anymore? Daniel Blanchard, MD Professor of Medicine Director, Cardiology Fellowship Program UCSD Sulpizio Cardiovascular Center What is the INR? Tissue Factor (Factor III) is added to
More informationProthrombin Complex Concentrate- Octaplex. Octaplex
Prothrombin Complex Concentrate- Concentrated Factors Prothrombin Complex Concentrate (PCC) 3- factor (factor II, IX, X) 4-factor (factors II, VII, IX, X) Activated 4-factor (factors II, VIIa, IX, X) Coagulation
More informationReversal of DOACs Breakthroughs and Their Aftermath
Reversal of DOACs Breakthroughs and Their Aftermath Geno J Merli, MD, MACP, FSVM, FHM Professor Medicine & Surgery Co-Director Jefferson Vascular Center Sidney Kimmel Medical College Thomas Jefferson University
More informationPractical Considerations for Using Oral Anticoagulants in Patients with Chronic Kidney Disease
Practical Considerations for Using Oral Anticoagulants in Patients with Chronic Kidney Disease Cyrille K. Cornelio, Pharm.D. PGY2 Cardiology Pharmacy Resident The University of Oklahoma College of Pharmacy
More information3/25/2016. Objectives for Pharmacists. Stop the Bleeding! New Reversal Agents. Objectives for Pharmacy Technicians. Assessment Pre-test
Objectives for Pharmacists Stop the Bleeding! New Reversal Agents Gary D Peksa, Pharm.D., BCPS Clinical Pharmacy Specialist, Emergency Medicine Rush University Medical Center Review current strategies
More informationA Cascade of Updates: Hot Topics in Anticoagulation
A Cascade of Updates: Hot Topics in Anticoagulation Heather A. Powell, PharmD, BCPS Assistant Professor of Clinical Sciences Roosevelt University College of Pharmacy Golden L. Peters, PharmD, BCPS Associate
More informationReversal of Novel Oral Anticoagulants. Angelina The, MD March 22, 2016
Reversal of Novel Oral Anticoagulants Angelina The, MD March 22, 2016 Argatroban Bivalirudin Enoxaparin Lepirudin Heparin Dabigatran Apixaban 1939 1954 1998 2000 1999 2001 10/2010 7/2011 12/2012 1/2015
More informationADMINISTRATIVE CLINICAL Page 1 of 6
ADMINISTRATIVE CLINICAL Page 1 of 6 Anticoagulant Guidelines #2: REVERSAL OF OR MANAGEMENT OF BLEEDING WITH ANTICOAGULANTS Origination Date: Revision Date: Reviewed Date: 09/12 09/12, 01/13, 11/13, 11/15
More informationUPDATE OF NEUROCRITICAL CARE PHARMACOTHERAPY. Vera Wilson, PharmD, BCPS Emergency Services Clinical Pharmacy Specialist Johnson City Medical Center
UPDATE OF NEUROCRITICAL CARE PHARMACOTHERAPY Vera Wilson, PharmD, BCPS Emergency Services Clinical Pharmacy Specialist Johnson City Medical Center DISCLOSURE STATEMENT OF FINANCIAL INTEREST I, Vera Wilson,
More informationUpdate on the Management of Cancer Associated VTE
Update on the Management of Cancer Associated VTE Jean M. Connors, MD 2018 Master Class Course Anticoagulation Management Services BWH/DFCI Hemostatic Antithrombotic Stewardship BWH Associate Professor
More informationDo s and Don t of DOACs DISCLOSURE
Do s and Don t of DOACs Tom DeLoughery, MD MACP FAWM Oregon Health and Sciences University DISCLOSURE Relevant Financial Relationship(s) Speaker Bureau - None Consultant/Research none Content Expert: Elsevier
More informationDisclosure and Conflict of Interest
A Cascade of Updates: Hot Topics in Anticoagulation Heather A. Powell, PharmD, BCPS Assistant Professor of Clinical Sciences Roosevelt University College of Pharmacy Golden L. Peters, PharmD, BCPS Associate
More informationEmergent Anticoagulation Reversal
U N C M E D I C A L C E N T E R G U I D E L I N E Emergent Anticoagulation Reversal I. PURPOSE: The purpose of these instructions is to provide guidelines for the reversal of or management of bleeding
More informationLeading the Charge in Anticoagulation Reversal: Benefits, Risks, and Key Factors in Application to the Traumatically Injured Patient
Leading the Charge in Anticoagulation Reversal: Benefits, Risks, and Key Factors in Application to the Traumatically Injured Patient Emily Hutchison, PharmD BCPS Clinical Pharmacy Specialist, Trauma/Adult
More informationWelcome to the New England QIN-QIO Medication Safety Webinar!
Welcome to the New England QIN-QIO Medication Safety Webinar! Thank you for joining. Our presentation will begin shortly. If you haven t already, please dial in to the audio line: 888-895-6448 Passcode:
More informationINR as a Biomarker: Anticoagulation in Atrial Fib, Heart Failure, and Cardiovascular Disease Daniel Blanchard, MD, FACC, FAHA
INR as a Biomarker: Anticoagulation in Atrial Fib, Heart Failure, and Cardiovascular Disease Daniel Blanchard, MD, FACC, FAHA Professor of Medicine Director, Cardiology Fellowship Program Sulpizio Cardiovascular
More informationReversal of Direct Oral Anticoagulants. Why are we now seeing so many patients on DOACs? Objectives. DOAC: Recurrent VTE. DOAC: Intracranial Bleeding
Reversal of Direct Oral Anticoagulants Cameron D Griffiths, MD, FRCPC Clinical Assistant Professor Division of Hematology UBC Objectives Review efficacy and safety data for Direct Oral Anticoagulants (DOACs)
More informationDirect Oral Anticoagulant Reversal
08 June 2018 No. 08 Direct Oral Anticoagulant Reversal M Khattab Moderator: E Hodgson School of Clinical Medicine Discipline of Anaesthesiology and Critical Care CONTENTS INTRODUCTION... 3 Pharmacokinetics
More informationReversal of direct oral anticoagulants in the patient with GI bleeding. Marc Carrier
Reversal of direct oral anticoagulants in the patient with GI bleeding Marc Carrier Disclosure Faculty: Dr. Marc Carrier Relationships with commercial interests: Grants/Research Support: Leo Pharma, Bristol
More information3/19/2012. What is the indication for anticoagulation? Has the patient previously been on warfarin? If so, what % of the time was the INR therapeutic?
Abigail E. Miller, PharmD, BCPS Clinical Specialist, Cardiology University of North Carolina Hospitals I have no personal financial relationships with the manufacturers of the products to disclose. Boehringer
More informationManaging Hemorrhagic Complications of Non-Vitamin K Antagonist Oral Anticoagulants
Managing Hemorrhagic Complications of Non-Vitamin K Antagonist Oral Anticoagulants MICHAEL E. MULLINS MD FAACT FACEP Washington University School Of Medicine Chair, BJH Anticoagulation Subcommittee Chair,
More informationProfessional Practice Minutes December 7, 2016
Professional Practice Minutes December 7, 2016 **New Opportunity for Patient Education** We can now request the educational videos we want our patients to watch after our visit. Video topics include colon
More informationDirect Oral Anticoagulants An Update
Oct. 26, 2017 Direct Oral Anticoagulants An Update Kathleen Heintz, DO, FACC Assistant Professor of Medicine Cooper Heart Institute Direct Oral Anticoagulants: DISCLAIMERS No Conflicts of Interest So what
More informationGuideline for Treatment of Head Injury in the Anticoagulated Patient
Guideline for Treatment of Head Injury in the Anticoagulated Patient GUIDELINE: GUIDELINE FOR TREATMENT OF HEAD INJURY IN THE ANTICOAGULATED PATIENT BACKGROUND: Chronic anticoagulation therapy is used
More informationOral Anticoagulation Drug Class Prior Authorization Protocol
Oral Anticoagulation Drug Class Prior Authorization Protocol Line of Business: Medicaid P & T Approval Date: February 21, 2018 Effective Date: April 1, 2018 This policy has been developed through review
More informationEmergency Management of Patients on Direct Oral Anticoagulants (DOACs)
Emergency Management of Patients on Direct Oral Anticoagulants (DOACs) Dr Tina Biss Consultant Haematologist Newcastle upon Tyne Hospitals NHS Foundation Trust NE RTC Annual Education Symposium 11 th October
More informationUse of Anticoagulant Reversal Agents
Use of Anticoagulant Reversal Agents Lori Shutter, MD shutterla@upmc.edu Vice Chair of Education Director, Neurocritical Care Program Professor, Critical Care Medicine, Neurology & Neurosurgery University
More informationAdvances in Anticoagulation
May 18, 2017 Advances in Anticoagulation Wei Ling Lau, MD Assistant Professor, Nephrology University of California, Irvine Talk Outline High stroke risk in CKD population Warfarin off-target effects on
More informationThe INR: No Need Anymore? Daniel Blanchard, MD Professor of Medicine Director, Cardiology Fellowship Program UCSD Sulpizio Cardiovascular Center
The INR: No Need Anymore? Daniel Blanchard, MD Professor of Medicine Director, Cardiology Fellowship Program UCSD Sulpizio Cardiovascular Center What is the INR? Tissue Factor (Factor III) is added to
More informationManaging Perioperative Anticoagulation. Edie Shen MD
Managing Perioperative Anticoagulation Edie Shen MD Anticoagulation VKA Warfarin (Coumadin) DOACs Direct Thrombin Inhibitor Dabigatran (Pradaxa) Factor Xa Inhibitor Rivaroxaban(Xarelto) Apixaban(Eliquis)
More informationGuidance for management of bleeding in patients taking the new oral anticoagulant drugs: rivaroxaban, dabigatran or apixaban
Guidance for management of bleeding in patients taking the new oral anticoagulant drugs: rivaroxaban, dabigatran or apixaban Purpose The aim of this guidance is to outline the management of patients presenting
More informationReversal of Action: Addressing the Unmet Need for Universal Antidotes to Factor Xa Anticoagulants. Disclosures
Reversal of Action: Addressing the Unmet Need for Universal Antidotes to Factor Xa Anticoagulants Daniel Pallin, MD, MPH Harvard Medical School Brigham and Women s Hospital Boston, Massachusetts Disclosures
More informationThe Direct Oral Anticoagulants: Practical Considerations. David Garcia, MD University of Washington Seattle Cancer Care Alliance September 2015
The Direct Oral Anticoagulants: Practical Considerations David Garcia, MD University of Washington Seattle Cancer Care Alliance September 2015 Disclosure Occasional consultant to : BMS, Pfizer, Daiichi
More informationAnticoagulants: Agents, Pharmacology and Reversal
Anticoagulants: Agents, Pharmacology and Reversal Lori B Heller, M.D. Cardiac Anesthesiology Swedish Heart and Vascular Institute Medical Director, Swedish Blood Management Clinical Instructor, University
More informationReversal of Oral Anticoagulation in Critical Care. Andrew C. Faust, PharmD, BCPS Critical Care Pharmacy Specialist Texas Health Presbyterian Dallas
Reversal of Oral Anticoagulation in Critical Care Andrew C. Faust, PharmD, BCPS Critical Care Pharmacy Specialist Texas Health Presbyterian Dallas Conflicts of Interest No conflicts to report Objectives
More informationNew and old anticoagulants. Anticoagulation Focus on Direct Oral Anticoagulants
Anticoagulation Focus on Direct Oral Anticoagulants Tzu-Fei Wang, MD Assistant Professor Department of Internal Medicine Division of Hematology The Ohio State University Wexner Medical Center Objectives
More informationGUIDELINES FOR MANAGEMENT OF BLEEDING AND EXCESSIVE ANTICOAGULATION WITH ORAL ANTICOAGULANTS
GUIDELINES FOR MANAGEMENT OF BLEEDING AND EXCESSIVE ANTICOAGULATION WITH ORAL ANTICOAGULANTS This guideline covers the management of patients being treated with Vitamin K antagonists (VKA): Warfarin Acenocoumarol
More informationALL BLEEDING STOPS EVENTUALLY! PATRICK C. CULLINAN, DO FCCM, FACOI, FACOEP SAN ANTONIO, TX
ALL BLEEDING STOPS EVENTUALLY! PATRICK C. CULLINAN, DO FCCM, FACOI, FACOEP SAN ANTONIO, TX NO DISCLOSURES! OBJECTIVES Discuss different types of DOACs Discuss the pharmacokinetics of the DOACs Discuss
More informationBLOOD DISEASE RESEARCH FOUNDATION
BLOOD DISEASE RESEARCH FOUNDATION BLOOD DISEASE RESEARCH FOUNDATION The mission of Blood Disease Research Foundation is to support hematological research, e.g. by donating grants for thesis work and abstract
More informationLet s Gi e The So ethi g To Clot About: Controversies in Anticoagulation
Let s Gi e The So ethi g To Clot About: Controversies in Anticoagulation Janna Beavers, MS, PharmD, BCPS Cardiology Clinical Pharmacy Specialist WakeMed Health & Hospitals Raleigh, NC March 13, 2018 Pharmacist
More informationChallenging Anticoagulation Case Studies. Earl J. Hope, M.D. Tower Health Cardiology
Challenging Anticoagulation Case Studies Earl J. Hope, M.D. Tower Health Cardiology Financial Disclosures Nothing to disclose Objectives: 1. Understand indications for heparin bridging. 2. Recognize the
More informationContent 1. Relevance 2. Principles 3. Manangement
Intracranial haemorrhage and anticoagulation Department of Neurology,, Germany Department of Neurology, Heidelberg University Hospital, Germany Department of Clinical Medicine Copenhagen University, Denmark
More informationLatest News and Clinical Applications of NOACs: What about Antidotes?
Optimizing outcomes in Atrial Fibrillation Latest News and Clinical Applications of NOACs: What about Antidotes? McMaster Cardiology Update September 11, 2015 Agenda Real world data on the use of NOACs
More informationClinical issues which drug for which patient
Anticoagulants - a matter of heart! Towards a bright future? Clinical issues which drug for which patient Sabine Eichinger Dept. of Medicine I Medical University of Vienna/Austria Conflicts of interest
More informationReversal Agents for NOACs (Novel Oral Anticoagulants)
Reversal Agents for NOACs (Novel Oral Anticoagulants) Current status and future challenges Paul A Reilly, PhD Clinical Research, Boehringer Ingelheim, Inc CSRC Symposium Washington DC Oct 18, 2016 Atrial
More informationThe DOACs. Update on Anticoagulation 10/20/2017. Dabigatran (Pradaxa ) Rivaroxaban (Xarelto ) Apixaban (Eliquis ) Edoxaban (Savaysa ) Objectives
Objectives Update on Anticoagulation JEFF REIST PHARMD, BCPS CLINICAL ASSOCIATE PROFESSOR UNIVERSITY OF IOWA COLLEGE OF PHARMACY At the conclusion of this program, the participant should be able to: List
More informationIdarucizumab for Dabigatran Reversal Pollack CV, Reilly PA, Eikelboom J, et al. N Engl J Med 2015; 373(6):
Idarucizumab for Dabigatran Reversal Pollack CV, Reilly PA, Eikelboom J, et al. N Engl J Med 2015; 373(6):511-520. Objective: To measure the safety of idarucizumab to reverse dabigatran anticoagulant effects
More informationAppendix 3 PCC Warfarin Reversal
Appendix 3 PCC Warfarin Reversal Reversal of Warfarin and Analogues 1. Principle of Procedure Guidelines for the Reversal of Oral-anticoagulation in the Event of Life Threatening Haemorrhage Prothrombin
More informationNOACs for Primary and Secondary Stroke Prevention: From Clinical Trials to Real-World Data To Practical Considerations
NOACs for Primary and Secondary Stroke Prevention: From Clinical Trials to Real-World Data To Practical Considerations Mark J. Alberts, MD, FAHA Hartford HealthCare Hartford, CT USA AF confers an increased
More informationNew Age Anticoagulants: Bleeding Considerations
Ontario Regional Blood Coordinating Network March 23, 2012 New Age Anticoagulants: Bleeding Considerations Bill Geerts, MD, FRCPC Thromboembolism Specialist, Sunnybrook HSC Professor of Medicine, University
More informationNew Options for Anticoagulation Reversal: A Practical Approach
New Options for Anticoagulation Reversal: A Practical Approach Hyung Wook Park Chonnam National University Hospital, Gwangju, Korea 4 NOACs Prevention of TE No. of events (%/yr..) NOAC Warfarin HR 95%
More informationTreatment of anticoagulant-associated intracerebral haemorrhage
Treatment of anticoagulant-associated intracerebral haemorrhage Adrian Parry-Jones NIHR Clinician Scientist & Honorary Consultant Neurologist Manchester Academic Health Science Centre, Salford Royal NHS
More informationDrug Use Criteria: Direct Oral Anticoagulants
Texas Vendor Drug Program Drug Use Criteria: Oral Anticoagulants Publication History 1. Developed March 2017. 2. Revised February 2018. Notes: Information on indications for use or diagnosis is assumed
More informationAfib, Stroke, and DOAC. Albert Luo, MD. Cardiology Lindsey Frischmann, DO. Neurology Xiao Cai, MD. HBS
Afib, Stroke, and DOAC Albert Luo, MD. Cardiology Lindsey Frischmann, DO. Neurology Xiao Cai, MD. HBS Disclosure of Relevant Financial Relationships I have no relevant financial relationships with commercial
More informationChapter 1 Introduction
Chapter 1 Introduction There are several disorders which carry an increased risk of thrombosis, clots that interfere with normal circulation, including: venous thromboembolism (VTE), comprising both deep
More informationGuidelines 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 informationNibal R. Chamoun, Pharm.D., BCPS Clinical Assistant Professor of Pharmacy Practice at the Lebanese American University Clinical Pharmacy Coordinator
Nibal R. Chamoun, Pharm.D., BCPS Clinical Assistant Professor of Pharmacy Practice at the Lebanese American University Clinical Pharmacy Coordinator at LAUMCRH Review the mechanism of action, indications
More informationAndexanet alfa in Factor Xa Inhibitor-Associated Acute Major Bleeding
Andexanet alfa in Factor Xa Inhibitor-Associated Acute Major Bleeding Stuart J. Connolly, M.D., Truman J. Milling, Jr., M.D., John W. Eikelboom, M.D., C. Michael Gibson, M.D., John T. Curnutte, M.D., Ph.D.,
More informationUpdate on the NOAC s: 2018 Daniel Blanchard, MD, FACC, FAHA
Update on the NOAC s: 2018 Daniel Blanchard, MD, FACC, FAHA Professor of Medicine Director, Cardiology Fellowship Program Sulpizio Cardiovascular Center UC San Diego The NOACS, chronologically Dabigatran:
More informationEmergent Reversal of Oral Anticoagulation: Review of Current Treatment Strategies
AACN Advanced Critical Care Volume 25, Number 1, pp. 5-12 2014 AACN ECG Challenges Earnest Alexander, PharmD, and Gregory M. Susla, PharmD Department Editors Emergent Reversal of Oral Anticoagulation:
More informationNew Anticoagulants Therapies
New Anticoagulants Therapies Rachel P. Rosovsky, MD, MPH October 22, 2015 Conflicts of Interest No disclosures 2 Agenda 3 Historical perspective Novel oral anticoagulants Stats Trials Approval Concerns/Limitations
More informationTrue/False: Idarucizumab can be utilized for the management of bleeding associated with dabigatran.
Discuss the role of idarucizumab for the management of bleeding associated with dabigatran Understand dosing, preparation and administration of idarucizumab I have no financial interest/arrangement or
More informationAnticoagulation Reversal and Treatment Strategies in Major Bleeding: Update 2016
Review Article in Major Bleeding: Update 2016 Steve Christos, DO, MS* Robin Naples, MD * Presence Resurrection Medical Center, Department of Emergency Medicine, Chicago, Illinois Lewis Katz School of Medicine
More informationTreatment Options and How They Work
Treatment Options and How They Work Robin Offord Director of Clinical Pharmacy UCL Hospitals NHS Foundation Trust robin.offord@uclh.nhs.uk Introducing the term anticoagulant... What they do Inhibit the
More informationNew Oral Anticoagulants in treatment of VTE, PE DR.AMR HANAFY (LECTURER OF CARDIOLOGY ) ASWAN UNIVERSITY
New Oral Anticoagulants in treatment of VTE, PE DR.AMR HANAFY (LECTURER OF CARDIOLOGY ) ASWAN UNIVERSITY Fact VTE is deadly! It nibbles after it bites! The 30-day mortality rates for first-time DVT or
More informationDrug Class Monograph
Drug Class Monograph Class: Oral Anticoagulants Drug: Coumadin (warfarin), Eliquis (apixaban), Pradaxa (dabigatran), Savaysa (edoxaban), arelto (rivaroxaban) Formulary Medications: Eliquis (apixaban),
More informationa. A pharmacist may order a baseline SCr per protocol
UNITYPOINT HEALTH - MARSHALLTOWN Marshalltown, Iowa PHARMACY POLICY AND PROCEDURE Subject: Anticoagulant Therapy Per Practice Protocol (Formerly Anticoagulant therapy #NPSG.03.05.01) Inpatient Warfarin
More informationUnder Triage and Anticoagulants in the Geriatric Trauma Population Fragile Must be Italian. Barry McKenzie, MD St. Vincent Healthcare
Under Triage and Anticoagulants in the Geriatric Trauma Population Fragile Must be Italian Barry McKenzie, MD St. Vincent Healthcare Objectives Describe the increasing frequency of trauma patients being
More informationDOAC for VTE. Direct Oral Anticoagulants Clint Shedd DNP, FNP-BC Emory University
DOAC for VTE Direct Oral Anticoagulants Clint Shedd DNP, FNP-BC Emory University No disclosures Direct Oral Anticoagulants Understand VTE and the ACCP s position on it List the DOACs available in the US
More informationANTICOAGULATION RELATED BLEEDING - GUIDELINE SUMMARY
ANTICOAGULATION RELATED BLEEDING - GUIDELINE SUMMARY Click here for the full Thrombosis Prevention Investigation and Management of Anticoagulation Guideline Click on the appropriate link below: o START
More informationTSHP 2014 Annual Seminar 1
Debate: Versus the Rest of the World for Stroke Prevention in Non-valvular Atrial Fibrillation Matthew Wanat, PharmD, BCPS Clinical Assistant Professor University of Houston College of Pharmacy Clinical
More informationIschemic and hemorrhagic strokes in the context of the direct acting oral anticoagulants
Ischemic and hemorrhagic strokes in the context of the direct acting oral anticoagulants Van Hellerslia, PharmD, BCPS, CACP Clinical Assistant Professor Temple University School of Pharmacy Over 4 million
More informationDirect Oral Anticoagulants
Direct Oral Anticoagulants Holly Jahn, PharmD, CACP Objectives Identify the FDA approved indications for use, appropriate dosing, and monitoring parameters for each direct oral anticoagulant. Distinguish
More informationDiscuss the role of idarucizumab for the management of bleeding associated with dabigatran
Discuss the role of idarucizumab for the management of bleeding associated with dabigatran Understand dosing, preparation and administration of idarucizumab I have no financial interest/arrangement or
More informationCopyright 2017 Wolters Kluwer Health, Inc. All rights reserved.
Paras Soni / 123RF RSAL AGENTS REVERSAL AGENTS REVERSAL AGENTS REVERSAL AGENTS REVERSAL AGENTS REVERSAL AGENTS REVERSAL AGENTS REVERSAL VERSAL AGENTS REVERSAL AGENTS REVERSAL AGENTS REVERSAL AGENTS REVERSAL
More informationRole of NOACs in AF Management. From Evidence to Real World Data Focus on Cardioversion
Role of NOACs in AF Management. From Evidence to Real World Data Focus on Cardioversion John Rickard MD, MPH Staff Electrophysiologist Cleveland Clinic Agenda NOACs: Update on Real World Data NOAC reversal:
More informationCanadian Society of Internal Medicine Annual Meeting 2016 Montreal, QC
Canadian Society of Internal Medicine Annual Meeting 2016 Montreal, QC DEBATE: DOAC vs Good Old Warfarin André Roussin MD, FRCP, CSPQ CHUM and ICM/MHI Associate professor University of Montreal A. Roussin
More informationAnticoagulation with Direct oral anticoagulants (DOACs) and advances in peri-procedural interruption of anticoagulation-- Bridging
Anticoagulation with Direct oral anticoagulants (DOACs) and advances in peri-procedural interruption of anticoagulation-- Bridging Scott C. Woller, MD Co-Director, Thrombosis Program Intermountain Medical
More informationAn Overview of Non Vitamin-K Antagonist Oral Anticoagulants. Helen Williams Consultant Pharmacist for CV Disease South London
An Overview of Non Vitamin-K Antagonist Oral Anticoagulants Helen Williams Consultant Pharmacist for CV Disease South London Contents Drugs and drug classes Licensed indications and NICE recommendations
More informationNew Antithrombotic Agents
New Antithrombotic Agents Tom DeLoughery, MD FACP FAWM Oregon Health and Sciences University DISCLOSURE Relevant Financial Relationship(s) Speaker Bureau None What I am Talking About 1. New Antithrombotic
More informationAnticoagulation: Novel Agents
Anticoagulation: Novel Agents Scott C. Woller, MD Medical Director, Anticoagulation Management, Intermountain Healthcare Central Region, co-director Venous Thromboembolism Program, Intermountain Medical
More informationNew Antithrombotic Agents DISCLOSURE
New Antithrombotic Agents DISCLOSURE Relevant Financial Relationship(s) Speaker Bureau None Research Alexion (PNH) delought@ohsu.edu Tom DeLoughery, MD FACP FAWM Oregon Health and Sciences University What
More informationNewer Oral Anticoagulants and Available Reversal Agents. Cara L. Leos, Pharm D, BCPS AQ Cardiology Baptist Medical Center South Montgomery, AL
Newer Oral Anticoagulants and Available Reversal Agents Cara L. Leos, Pharm D, BCPS AQ Cardiology Baptist Medical Center South Montgomery, AL Disclosure Speakers bureau Boehringer Ingelheim As each of
More informationDebate: New Generation Anti-Coagulation Agents are a Better Choice than Warfarin in the Management of AF
Debate: New Generation Anti-Coagulation Agents are a Better Choice than Warfarin in the Management of AF Bradley P. Knight, MD Director of Cardiac Electrophysiology Bluhm Cardiovascular Institute Northwestern
More informationFact or Fiction? All Patients Will Use NOACS Instead of Warfarin in 10 Years:
All Patients Will Use NOACS Instead of Warfarin in 10 Years: Fact or Fiction? Cash Casey, MD Advocate Medical Group/ Midwest Heart Specialists December 3 rd, 2016 Disclosures Advisory board/speakers bureau:
More informationPerioperative Management of Novel Oral Anticoagulants (NOACs) Hardy Shah PharmD NEANA March 2017
Perioperative Management of Novel Oral Anticoagulants (NOACs) Hardy Shah PharmD NEANA March 2017 Disclosures Presenter has no actual or potential conflicts of interest in relation to this program Question
More information