Appropriateness of direct oral anticoagulant dosing for venous thromboembolism treatment

Tran, Emmeline; Duckett, Ashley; Fisher, Sarah G.; Bohm, Nicole

doi:10.1007/s11239-017-1487-z

Cited by 15 publications

(7 citation statements)

References 24 publications

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“…Benefits of dose intensification and monitoring drug levels or coagulation assays warrants further investigation, particularly given the use of DOACs in obese patients [21]. The frequency of dosing discordance is consistent with published data [22,23]. Variation from approved doses may confer altered risk of treatment failure or adverse events.…”

Section: Discussionsupporting

confidence: 70%

Effectiveness and safety of oral anticoagulants in patients with sickle cell disease and venous thromboembolism: a retrospective cohort study

Roberts

Gaskill

Kanter-Washko

et al. 2018

J Thromb Thrombolysis

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Patients with sickle cell disease (SCD) experience initial and recurrent venous thromboembolism (VTE) more commonly and at a younger age than the general population, and it confers a higher mortality for patients with SCD. However, limited evidence is available to guide anticoagulant use for VTE treatment in this population. The primary objective of this study is to characterize the effectiveness and safety of direct oral anticoagulants (DOAC) and warfarin for VTE treatment among patients with SCD. This single-center retrospective study includes adult patients with SCD who were diagnosed with VTE. Data was obtained from review of electronic health records for the 6 months after VTE diagnosis. Among the 22 patients treated initially with a DOAC, 6 (27%) developed recurrent VTE, none experienced major bleeding, and 3 (14%) experienced clinically relevant non-major bleeding (CRNMB). Similarly, of 15 patients initially treated with warfarin, 3 (20%) developed a recurrent VTE, 1 (7%) experienced major bleeding, and 2 (13%) experienced CRNMB. Twelve patients received more than one oral anticoagulant during the study period, most commonly due to a recurrent VTE, concern for non-adherence, or subtherapeutic INR. Overall, the incidence of VTE recurrence and bleeding events were similar between groups, but occurred at a higher rate than those found in major clinical trials of anticoagulant agents. Prescribers should continue to individualize therapeutic decision-making regarding oral anticoagulant therapy for VTE treatment for individuals with SCD based on patient-specific factors and anticipated ability to adhere to the drug regimen or required monitoring.

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Section: Discussionsupporting

confidence: 70%

Effectiveness and safety of oral anticoagulants in patients with sickle cell disease and venous thromboembolism: a retrospective cohort study

Roberts

Gaskill

Kanter-Washko

et al. 2018

J Thromb Thrombolysis

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“…Consistently, a similar descriptive study on the Danish patient safety database reported that the adverse medication incidents occurred mainly in the prescribing phase, and in about 80% of incidents the errors occurred at the time of sector changes (at the admission, at the discharge or ward changes) [5]. Among different error subtypes occurring in the prescribing phase, the wrong dosage and drug omission have been repeatedly found as the most common subtype [3,6,7]. The affected patients are usually polymorbid patients in advanced ages having already high risk of bleeding [8].…”

mentioning

confidence: 60%

“…From this population, all patients admitted to our in-patient wards, from 21.08.2017-20.08.2018, who concomitantly received at least two ACs were included in the study. Subsequently, the following patients have been excluded: [1] patients who received the anticoagulants separately, no overlapping prescription [2] patients treated with the combination of heparin/ heparin analogs and vitamin-K antagonists (VKA) [3] patients receiving heparin/ heparin analogs based on a weekly schedule such as patients with hemodialysis [4] patients receiving low-dose alteplase (= < 4 mg) as a catheter locking solution [5] patients treated with the combination of VKA and direct oral anticoagulants (DOACs) during bridging from DOACs to VKA [6] patients who explicitly refused participation in research.…”

Section: Patient Populationmentioning

confidence: 99%

“…Accordingly, the AC-related errors occur in about 78% of cases in adults older than 60 and in about one third in patients older than 80 years old [9]. The studies reporting the frequency and complications of AK-related medication errors have been mostly done based on data reported to in-house or nation-wide drug safety systems [2,3,[5][6][7][8][9][10]. As many of these errors could not be detected or have not been reported by medical staff, the studies based on them could not reliably show the incidence of errors, the affected population and the rate of consequences.…”

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confidence: 99%

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Therapeutic duplication of anticoagulants: a retrospective study of frequency and consequences in a tertiary referral hospital

et al. 2020

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Background: Anticoagulants are commonly prescribed in medical practices and could be of significant harm in the case of medication errors. We conducted a retrospective observational study to determine the frequency and consequences of the therapeutic duplication of anticoagulants (TDA). As a secondary objective, we aimed to determine the characteristics of the population in which TDA occurs. Methods: We conducted a retrospective observational study among admitted patients who concomitantly received at least two anticoagulants from August 2017 to August 2018. Results: A total of 107 patients with TDA are included in the research. The patients with TDA have a mean age of 73. The TDA population has a high rate of associated comorbidities with 69% of patients having arterial hypertonia, 40% with chronic kidney disease, 26% with a history of malignancy, and 20.5% with a history of stroke. More than 65% of patients were under anticoagulation before admission, mostly due to atrial fibrillation. The TDA occurred in more than 95% of cases in the first week or the last week of hospitalization. Patients had a high risk of bleeding prior to the TDA-event with about 62.5% of TDA patients having a HAS-BLED score at least 3. A total of 8 patients showed a significant Hemoglobin (Hb)-drop of at least 10 g/L within 24 h after TDA-event. Two patients had a new or worsened hematuria following TDA-event. Conclusion: TDA occurred in 0.8% of patients who were under anticoagulation and in 6.7% of patients who received direct oral anticoagulants (DOACs). TDA led in about 7.4% of cases to hemoglobin-relevant bleeding. The old patients with significant comorbidities and a high HAS-BLED score were mainly affected. The female gender and presence of anemia independently predicted the occurrence of bleeding following TDA.

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“…However, this has been reported to be as high as 10 to 20% in other studies. 13,28,29 We demonstrated that these patients could be identified quickly through our nurse-led pathway and that timely corrective action and education were easily instituted by telephone.…”

Section: Risk Factors For Bleeding or Recurrencementioning

confidence: 91%

Utility of a Nurse-Led Pathway for Patients with Acute Venous Thromboembolism Discharged on Rivaroxaban: A Prospective Cohort Study

Lim

Indran

Cummins

et al. 2018

Semin Thromb Hemost

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The highest risk of adverse events for patients with acute venous thromboembolism (VTE) is during the early anticoagulation period. However, no established model exists for early clinical monitoring of patients treated with non–vitamin K antagonist oral anticoagulants (NOACs). The authors' aim was to evaluate the utility of a nurse-led pathway to minimize adverse events in acute VTE patients starting on rivaroxaban. The rivaroxaban VTE treatment pathway is a prospective cohort study of consecutive patients with objectively confirmed VTE between July 2015 and May 2017. Primary outcome was the proportion of patients identified at major risk of adverse events (bleeding or recurrent VTE). Secondary outcomes were rates of interventions, major or clinically relevant nonmajor bleeding (CRNMB), recurrent VTE, and all-cause mortality at 90 days. Among 304 participants, 5% (n = 15) were identified to be at major and 9% (n = 28) at possible risk for adverse events. Appropriate interventions to prevent harm were required in 40 patients. Rates of major bleeding, CRNMB, recurrence, and all-cause mortality were 0.3% (95% confidence interval [CI]: 0.1–1.8), 7.2% (95% CI: 4.8–10.7), 1.0 (95% CI: 0.3–2.9), and 1.6% (95% CI: 0.7–3.8), respectively. In conclusion, following discharge of acute VTE patients, a nurse-led pathway identified one in seven (14%) patients at major or possible risk of adverse events. Preemptive interventions to reduce harm translated into the low rates of bleeding and recurrence. The authors' experience highlights the feasibility and importance of a structured clinical surveillance pathway for acute VTE patients initiating NOAC therapy.

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Appropriateness of direct oral anticoagulant dosing for venous thromboembolism treatment

Cited by 15 publications

References 24 publications

Effectiveness and safety of oral anticoagulants in patients with sickle cell disease and venous thromboembolism: a retrospective cohort study

Effectiveness and safety of oral anticoagulants in patients with sickle cell disease and venous thromboembolism: a retrospective cohort study

Therapeutic duplication of anticoagulants: a retrospective study of frequency and consequences in a tertiary referral hospital

Utility of a Nurse-Led Pathway for Patients with Acute Venous Thromboembolism Discharged on Rivaroxaban: A Prospective Cohort Study

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