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Antithrombotic Therapy

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Presentation on theme: "Antithrombotic Therapy"— Presentation transcript:

1 Antithrombotic Therapy
Taylor B Goot MD Assistant Professor Department of Internal Medicine – Hospital Medicine Division Medical Director – UNM Anticoagulation Clinic Co-Director Antithrombotic Stewardship

2 Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy Duration of treatment Resumption of therapy after a bleeding event Questions

3 Roadmap Direct oral anticoagulants Consensus nomenclature Indications
Currently approved use Uses coming soon Who should/shouldn’t get a DOAC

4 Direct Oral Anticoagulants
Dabigatran Apixaban Rivaroxaban Edoxaban Newly FDA Approved Betrixaban

5 Direct oral anticoagulant
Novel oral anticoagulant Direct oral anticoagulant Target specific anticoagulant International society of thrombosis and hemostasis Barnes GD et al Recommendation on the nomenclature for oral anticoagulants: communication from the SSC of the ISTH. J Thromb Haemost Jun;13(6):

6 Indications Prevention of stroke in the setting of non-valvular atrial fibrillation Treatment and prevention of deep vein thrombosis and pulmonary embolism

7 The Future of DOACs New studies/further studies pending Malignancy***
Antiphospholipid antibody syndrome Coronary artery disease*** Peripheral artery disease Medical prophylaxis*** Cryptogenic stroke

8 Why use DOACs? Convenience Simplified initiation and cessation
Apixaban and Rivaroxaban do not require heparin at initiation Lack of INR monitoring No need of dietary restriction/uniformity

9 But, are they safe?

10

11 Major Bleeding

12 Intracranial Hemorrhage

13 Fatal Bleeding Non-Major Bleeding GI Bleeding

14 Use is guideline supported

15 But What if My Patient Bleeds?
Short half life, might not need reversal Idaracuzimab Dabigatran Andexanet Alfa All others

16 Who shouldn’t get a DOAC?
Severe hepatic impairment Renal impairment Particularly ESRD on HD Creatinine clearance <30 ml/min The severely obese (> kg, BMI >40) The uninsured and/or patients with a high cost Drug-drug interactions Unstudied prothrombotic states Antiphospholipid antibody syndrome Heparin induced thrombocytopenia

17 Who shouldn’t get a DOAC? (cont)
Patients in whom medication and/or appointment adherence is an issue.

18 Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy Duration of treatment Resumption of therapy after a bleeding event Questions

19 Periprocedural Bridging practices in the Setting of Atrial Fibrillation

20 Circulation. 2012;126:

21 Thromboembolic Events
Bleeding Events

22

23 2015

24

25 BRIDGE Trial Exclusion criteria Mechanical heart valve, Embolism, TIA, Stroke within the last 12 weeks. Major bleeding within the last 6 weeks PLT < 100,000

26

27

28 What we know Stroke risk ≠ 0
Unclear if there is reduction in thromboembolic events with bridging Clearly increased bleeding risk with bridging

29 UNM Periprocedural Anticoagulation Management Protocol

30 No need to bridge with DOACs

31 Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy Duration of treatment Resumption of therapy after a bleeding event Questions

32 35 yo, previously healthy patient presents a few weeks after a knee surgery with lower extremity swelling. A DVT is diagnosed via an expedited doppler US. Has IUD in place with no plans to remove in near future

33 Discuss What would you do? What are your options?

34 Initiating warfarin VTE Atrial fibrillation
At least 5 days of overlap with a parenteral anticoagulant, until within therapeutic range on 2 measurements 24 hours apart. Atrial fibrillation Bridge?

35 Initiating a DOAC Rivaroxaban and Apixaban

36 Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy Duration of treatment Resumption of therapy after a bleeding event Questions

37 Duration of Therapy More related to recurrence risk than treatment of the clot itself.

38 What do we know about recurrence risk?
3 major factors Duration of initial treatment Location of clot Provoked vs Unprovoked

39 Duration of initial treatment
If you treat for < 3 mo. risk jumps Boutitie et al BMJ 2011;342:d3036

40 PE > Proximal DVT > Distal DVT
Boutitie et al BMJ 2011;342:d3036

41 Provoked vs Unprovoked
24 mos Boutitie et al BMJ 2011;342:d3036

42 Paolo Prandoni et al Haematologica Feb 2007, 92 (2) 199-205; DOI: 10
Paolo Prandoni et al Haematologica Feb 2007, 92 (2)  ; DOI:  /haematol.10516

43 What is a provoking agent?
Definite Probably Surgery or trauma Estrogen Cancer Serious medical illness Travel Other hormone therapy Obesity Antiphospholipid antibody syndrome

44 Inherited thrombophilias are not considered provoking agents or even potent risk factors.

45 Duration of therapy? Provoked? 3 Months Unprovoked? Indefinitely
As long as the provoking agent is removed. Unprovoked? Indefinitely At least 3 months, shoot for 6. Initial goal is at least three months in the absence of some bleeding risk. Risk ≠ 0 for anyone once they’ve experience a VTE

46 Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy Duration of treatment Resumption of therapy after a bleeding event Questions

47 Resuming After Bleeding Events
Do they need to be on anticoagulation? Was their bleeding risk modifiable? Were they over-anticoagulated?

48 Should they be restarted?
Any Major Bleeding Intracranial GI All

49 How Long to Wait Intracranial Hemorrhage AHA
Don’t restart in Non-valvular Afib after a spontaneous lobar bleed Non-lobar 7-10 days European Stroke Initiative 10-14 Days Ask the neurologist or neurosurgeon for their recommendation based on the pathology.

50 How Long to Wait GI Bleeding Retrospective analysis suggests 4-7 days
Witt DM, Delate T, Garcia DA, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for gastrointestinal tract bleeding. Arch Intern Med 2012; 172:1484–1491 Brotman DJ, Jaffer AK. Resuming anticoagulation in the first week following gastrointestinal tract hemorrhage: should we adopt a 4-day rule? Arch Intern Med 2012; 172:1492–1493.

51 How Long to Wait Other sites?
Limited data exists, there is some suggestion of 4-14 days.

52 Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy Duration of treatment Resumption of therapy after a bleeding event Questions

53 Questions/Discussion?
Thank you!


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