1 / 134

Do’s and Don’ts of New Oral Anticoagulants 2013 Jean M. Connors, MD

Do’s and Don’ts of New Oral Anticoagulants 2013 Jean M. Connors, MD Assistant Professor of Medicine, HMS Medical Director, BWH and DFCI AMS. New oral anticoagulants How they work Tips on taking them. DEFINITIONS. COAGULATION. COAGULATION: The process by which blood forms clots.

pbullock
Download Presentation

Do’s and Don’ts of New Oral Anticoagulants 2013 Jean M. Connors, MD

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Do’s and Don’ts of New Oral Anticoagulants 2013 Jean M. Connors, MD Assistant Professor of Medicine, HMS Medical Director, BWH and DFCI AMS

  2. New oral anticoagulants How they work Tips on taking them

  3. DEFINITIONS COAGULATION COAGULATION: The process by which blood forms clots. • It is the process of stopping blood loss from a damaged vessel, wherein a damaged blood vessel wall is covered by a platelet and fibrin-containing clot to stop bleeding. http://en.wikipedia.org/wiki/Coagulation • Hemorrhage: not enough coagulation; excessive bleeding • Thrombosis: too much coagulation; coagulation in the wrong place at the wrong time

  4. scanning electron micrograph of blood clot

  5. Anticoagulants • Goal is to prevent blood clots from forming or getting bigger. • Anticoagulants do not “thin” the blood. They make it take longer to form a clot. • They work by preventing or inhibiting activation of clotting factors.

  6. Who needs anticoagulation? • Who needs anticoagulant therapy? • Atrial fibrillation--irregular heart rhythm • Deep vein thrombosis (blood clot in big vein) • Pulmonary embolus (blood clot in lung) • Mechanical heart valves • Situations with very high risk: • Orthopedic joint replacement surgery • Inherited blood clotting disorders

  7. Anticoagulants • OLD • Heparin • IV, subcutaneous • LMWH: Lovenox, Fragmin • injections • Warfarin • Only pill anticoagulant available in US until 2010

  8. Anticoagulants • NEW • Pradaxa(dabigatran) • Xarelto (rivaroxaban) • Eliquis (apixaban) • “Novel” “new” “target specific” “next-gen”

  9. Anticoagulants • NEW • Pradaxa(dabigatran) Approved in Oct 2010 to prevent strokes in atrial fibrillation. Must take twice a day.

  10. Anticoagulants • NEW • Xarelto(rivaroxaban) • Approved to prevent blood clots in orthopedic surgery patients 2011 • Approved to preevnt stroke in afib 2011 • Approved to treat DVT and PE Nov 2012 • Take once a day to prevent strokes • Twice a day for three weeks to teat blood clots then once a day

  11. Anticoagulants • NEW • Eliquis (apixaban) • Approved to prevent stroke in atrial fibrillation Dec 2012 • Must take twice a day

  12. MECHANISM OF ACTION NEW ORAL ANTICOAGULANTS • Pills are swallowed and drug enters the blood • Binds directly to the activated clotting factor to prevent it from working • Pradaxa • Binds to thrombin = direct thrombin inhibitor • Eliquis • Binds to clotting factor Xa = direct inhibitor • Xarelto • Binds to Xa = direct factor Xa inhibitor

  13. MECHANISM OF ACTION WARAFRIN • Warfarin is different. It affects the production of some coagulation factors. • Pills are swallowed. Drug enters the blood and travels to the liver. • The liver makes the clotting factors but doesn’t completely finish them so they are not able to be activated. • Vitamin K epoxide reductase • II, VII, XI, X, protein S and protein C.

  14. MECHANISM OF ACTION WARAFRIN • It takes a number of days (4-6) to get the full anticoagulant effects of warfarin. • Dose needed for same level of anticoagulation from person to person is different. • Many factors can affect or interfere with how warfarin works in the liver • Vitamin K in the diet • Alcohol, antibiotics and other medications that affect the same enzymes in the liver

  15. NewAnticoagulants • How are they different from warfarin? • Rapid onset of activity • Warfarin: 3-5days • New drugs: 2-4 hours • Same dose covers a wide range of people • 110-220 pounds

  16. NewAnticoagulants • How are they different from warfarin? • No need for testing drug levels • coagulation tests are affected and abnormal but there is no target range • No need to watch diet vitamin K containing foods alcohol most antibiotics

  17. New Anticoagulants • DO • Take your medication at the same time every day. • Xarelto 15 mg and 20 mg dose, take with real meal. • IF • You miss a dose do not take it close to the next dose if you are taking Eliquis or Pradaxa twice a day. • Take it when you remember for Xarelto but then get back on an every 24 hour schedule. • You miss 2 doses in a row, or 2 days, you will not be anticoagulated.

  18. New Anticoagulants • DON’T • Start one of these medications without checking with your doctor: • Antifungal or yeast treatment medications • Fluconazole (Diflucan) • Anti-seizure medications • (Dilantin, carbamazapine) • Antibiotics for tuberculosis (TB) or certain staph infections • (rifampin) • Treatment for HIV or AIDS • Certain cardiac medications for heart abnormalities • Others on package inserts

  19. New Anticoagulants • DO • Tell your doctor if you have a history of bleeding from ulcers or the intestines before starting one of these drugs. • Do call your doctor if you are throwing up, have diarrhea, or are dehydrated, especially if your kidneys do not work well.

  20. New Anticoagulants • DO • Let dentists, surgeons, and others who do procedures, know that you are on an anticoagulant. • Most ask only about Coumadin/warfarin • Contact your doctor’s office to let them know that you will be having a procedure. • No need for “bridging”, most require stopping 2 days before.

  21. New Anticoagulants • Are they “better” than warfarin? • Some drugs and doses work equally as well as warfarin. • Some drugs and doses work better than warfarin, or have lower specific bleeding side effects. • GI bleeding side effects can be worse than warfarin with some drugs.

  22. New Anticoagulants • Maybe not better, just different. • One standard drug dose may not be correct dose for people at extremes of weight, or with strong blood clotting disorders. • Not measuring levels is easier but in certain situations you may want or need to measure levels, we currently can not do this. • No good reversal agents such as vitamin K or FFP/plasma for warfarin.

  23. New Anticoagulants • DON’T • Take one of these drugs if you have a mechanical heart valve (RE-ALIGN trial) • You are on dialysis • Probably should not take if • You are pregnant • You have active cancer and getting chemotherapy • You have lupus anticoagulant/antiphospholipid syndrome

  24. New Anticoagulants Anticoagulation is anticoagulation! • The major side effect of any anticoagulant is bleeding. • As with warfarin DO call your doctor if: • Youhave unusual or prolonged bleeding • You hit your head or have other moderate trauma

  25. This is This is Prada Pradaxa Do they cost more than warfarin?

  26. Anticoagulants • 60 years of experience with warfarin. • Less than 6 years with new agents. • The more stable your INR, the higher your TTR, the smaller the differences are between new drugs and warfarin.

  27. Anticoagulants Work with your healthcare team to determine if one of these new oral anticoagulants is right for you.

  28. A Patients Guide to Managing Warfarin Around the Time of Surgery and Procedures Andrea Resseguie, Pharm.D., CACP, R.Ph. Brigham & Women’s Hospital Anticoagulation Management Service November 2, 2013

  29. Learning Objectives • Review the risks of continuing warfarin therapy while having surgery or a procedure • Identify situations when warfarin should be stopped for surgery/ procedure • When warfarin is stopped, estimate clotting risk to determine if a bridging agent should be used

  30. Background • Some patients may require an elective surgery or procedure while on warfarin therapy • Continuation of warfarin for an upcoming surgery/ procedure may increase the risk of bleeding • Some patients may need to stop taking warfarin around the time of surgery/ procedure to minimize this bleeding risk

  31. Background cont. • If warfarin needs to be stopped this may increase the risk of having a blood clot • Individual circumstances will be carefully reviewed before a decision on modifying warfarin therapy is made • Estimate of bleeding risks • Estimate of clotting risks • Bridging agents, like unfractionated heparin (UFH) or low-molecular weight heparin (LMWH), can be used to minimize the risk of having a blood clot in high-risk patients

  32. Surgery/ Procedures & Estimate of Bleeding Risk • Risk of bleeding in patients taking warfarin is dependent upon: • Age • Presence of other disease states (high blood pressure, liver or kidney disease) • Bleeding tendency or predisposition • Stability of anticoagulation • Use of other anticoagulant/ antiplatelet agents • Type of surgery /procedure • Prolonged, complex, and major surgery is much more likely to cause significant bleeding problems than short, simple, and minor surgical procedures

  33. Low Procedural Bleeding Risk

  34. High Procedural Bleeding Risk

  35. Specific Recommendations: Procedure-Related Bleeding Risk from Gastrointestinal Procedures

  36. Warfarin & Surgical/ Procedural Bleeding Risk • Most patients can undergo low risk surgery/ procedures without stopping warfarin • Warfarin may either be continued at or below the low end of the therapeutic INR range • More complex or high risk surgery/ procedures require discontinuation of warfarin

  37. Clotting Risk if Warfarin is Stopped • Risk varies by indication: • Mechanical Heart Valve • Atrial Fibrillation (A Fib) • History of Blood Clot • Deep Vein Thrombosis (DVT) • Pulmonary Embolism (PE) • Other indications: Acute Coronary Syndrome, Peripheral Vascular Disease

  38. High Risk

  39. Moderate Risk

  40. Low Risk

  41. Clotting Risk/ Use of Bridging Agent High risk: Use bridging agent Moderate risk: May consider using a bridging agent Low risk: No bridging agent necessary

  42. Bridging Anticoagulation • Bridging can be defined as the administration of a short-acting anticoagulant during the interruption of warfarin • Goal of bridging is to minimize the time patients are not being anticoagulated • Minimizes patients risk of blood clot

  43. Bridging Anticoagulation cont. • Decisions about bridging should be based upon the individual patient and surgery-related factors • In addition to high-risk patients already discussed, bridging may be considered: • Active coronary or peripheral vascular disease • Previous clot during interruption of warfarin therapy • Major cardiac or vascular surgery

  44. Anticoagulants used for Bridging • UFH • LMWH • Lovenox (enoxaparin) • Fragmin (dalteparin) • Arixtra (fondaparinux)

  45. Developing a Specific Plan for Managing Warfarin around the Time of Surgery/ Procedure • Once bleeding risk and clotting risk have been evaluated: plan for management of warfarin can be established • Decision to use a bridging agent is made

  46. Interruption of Warfarin • After stopping warfarin, it usually takes 2-3 days for the INR to fall below 2.0, and 4-6 days for the INR to normalize • The time required for the INR to normalize after stopping warfarin may be longer in patients receiving higher-intensity anticoagulation (Ex: INR range 2.5 - 3.5) and in elderly patients • Once the INR is 1.5 or below, surgery can be performed with relative safety in most cases, although a normalized INR is typically required in patients undergoing surgery / procedure associated with a high bleeding risk

  47. Timing of Warfarin Resumption • Warfarin may be restarted 12-24 hours after surgery/ procedure, typically the evening of surgery/ procedure • If warfarin is resumed alone, without UFH/ LMWH bridging, a full anticoagulant effect will take 4-6 days to occur

  48. Summary • For minor surgery/ procedure (low bleed risk) warfarin usually does not need to be stopped • However, still important to check that INR is not too high • Warfarin should be stopped for surgery/ procedure when there is a high bleeding risk • For most patients, hold warfarin 4 - 5 days to reach a normal INR • Also, if high clotting risk bridging is may be necessary

More Related