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Antithrombotic Therapy
Taylor B Goot MD Assistant Professor Department of Internal Medicine – Hospital Medicine Division Medical Director – UNM Anticoagulation Clinic Co-Director Antithrombotic Stewardship
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Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy Duration of treatment Resumption of therapy after a bleeding event Questions
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Roadmap Direct oral anticoagulants Consensus nomenclature Indications
Currently approved use Uses coming soon Who should/shouldn’t get a DOAC
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Direct Oral Anticoagulants
Dabigatran Apixaban Rivaroxaban Edoxaban Newly FDA Approved Betrixaban
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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):
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Indications Prevention of stroke in the setting of non-valvular atrial fibrillation Treatment and prevention of deep vein thrombosis and pulmonary embolism
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The Future of DOACs New studies/further studies pending Malignancy***
Antiphospholipid antibody syndrome Coronary artery disease*** Peripheral artery disease Medical prophylaxis*** Cryptogenic stroke
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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
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But, are they safe?
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Major Bleeding
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Intracranial Hemorrhage
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Fatal Bleeding Non-Major Bleeding GI Bleeding
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Use is guideline supported
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But What if My Patient Bleeds?
Short half life, might not need reversal Idaracuzimab Dabigatran Andexanet Alfa All others
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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
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Who shouldn’t get a DOAC? (cont)
Patients in whom medication and/or appointment adherence is an issue.
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Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy Duration of treatment Resumption of therapy after a bleeding event Questions
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Periprocedural Bridging practices in the Setting of Atrial Fibrillation
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Circulation. 2012;126:
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Thromboembolic Events
Bleeding Events
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2015
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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
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What we know Stroke risk ≠ 0
Unclear if there is reduction in thromboembolic events with bridging Clearly increased bleeding risk with bridging
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UNM Periprocedural Anticoagulation Management Protocol
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No need to bridge with DOACs
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Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy Duration of treatment Resumption of therapy after a bleeding event Questions
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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
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Discuss What would you do? What are your options?
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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?
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Initiating a DOAC Rivaroxaban and Apixaban
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Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy Duration of treatment Resumption of therapy after a bleeding event Questions
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Duration of Therapy More related to recurrence risk than treatment of the clot itself.
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What do we know about recurrence risk?
3 major factors Duration of initial treatment Location of clot Provoked vs Unprovoked
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Duration of initial treatment
If you treat for < 3 mo. risk jumps Boutitie et al BMJ 2011;342:d3036
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PE > Proximal DVT > Distal DVT
Boutitie et al BMJ 2011;342:d3036
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Provoked vs Unprovoked
24 mos Boutitie et al BMJ 2011;342:d3036
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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
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What is a provoking agent?
Definite Probably Surgery or trauma Estrogen Cancer Serious medical illness Travel Other hormone therapy Obesity Antiphospholipid antibody syndrome
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Inherited thrombophilias are not considered provoking agents or even potent risk factors.
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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
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Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy Duration of treatment Resumption of therapy after a bleeding event Questions
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Resuming After Bleeding Events
Do they need to be on anticoagulation? Was their bleeding risk modifiable? Were they over-anticoagulated?
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Should they be restarted?
Any Major Bleeding Intracranial GI All
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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.
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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.
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How Long to Wait Other sites?
Limited data exists, there is some suggestion of 4-14 days.
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Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy Duration of treatment Resumption of therapy after a bleeding event Questions
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Questions/Discussion?
Thank you!
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