Directly to a DOAC? Safety of Alternatives to Warfarin for Anticoagulation in Heart Transplantation

Tremblay-Gravel, Maxime; Alexander, Kevin M.; Czobor, Peter; Lee, R.; Foroutan, Farid; Yang, Weiguang; Hayes, Anna; Hiesinger, William; Ross, Heather J.; Khush, Kiran K.; Teuteberg, Jeffrey J.; Moayedi, Yasbanoo

doi:10.1016/j.healun.2019.01.991

Cited by 4 publications

(6 citation statements)

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“…A total of 115 of 459 HTX recipients (25.1%) required OACs, including 60 patients with DOACs (52.2%) and 55 patients with VKAs (47.8%). This frequency of OACs after HTX is in line with findings by Tremblay-Gravel and colleagues [ 35 ] who reported 80 of 426 HTX recipients (18.8%) on OACs, including 57 patients with DOACs (71.3%), as well as with findings by Kim and colleagues [ 33 ] who reported 18 of 55 HTX recipients (32.7%) on OACs, including 7 patients with DOACs (38.9%).…”

Section: Discussionsupporting

confidence: 91%

“…Clinical management of HTX recipients frequently involves the treatment of atrial arrhythmias or thromboembolic events implying the need for OACs [ 10 , 11 , 12 , 13 , 14 , 15 , 16 ]. However, data about OACs in HTX recipients, especially about the efficacy and safety of DOACs, are scarce and mainly based on case series or small sample size studies [ 17 , 18 , 19 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ]. We, therefore, performed the largest known study about the frequency, indications, and complications of DOACs after HTX.…”

Section: Discussionmentioning

confidence: 99%

“…In addition, several studies showed similar or even better efficacy and safety of DOACs over VKAs for the treatment of AF and VTE in the general population [ 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 ]. However, data on the efficacy and safety of DOACs in HTX recipients are very limited as they are often derived from small sample-size studies [ 17 , 18 , 19 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 ].…”

Section: Introductionmentioning

confidence: 99%

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Oral Anticoagulants after Heart Transplantation—Comparison between Vitamin K Antagonists and Direct Oral Anticoagulants

Darche,

Fabricius,

Helmschrott

et al. 2023

JCM

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Aims: Patients after heart transplantation (HTX) often require oral anticoagulants (OACs) due to atrial arrhythmias or thromboembolic events but little is known about the post-transplant use of direct oral anticoagulants (DOACs). We investigated the frequency, indications, and complications of DOACs and vitamin K antagonists (VKAs) after HTX. Methods: We screened all adult patients for the use of post-transplant OACs who underwent HTX at Heidelberg Heart Center between 2000 and 2021. Patients were stratified by type of OAC (DOAC or VKA) and by DOAC agents (apixaban, dabigatran, edoxaban, or rivaroxaban). Indications for OACs comprised atrial fibrillation, atrial flutter, pulmonary embolism, upper and lower extremity deep vein thrombosis, as well as intracardiac thrombus. Results: A total of 115 of 459 HTX recipients (25.1%) required OACs, including 60 patients with DOACs (52.2%) and 55 patients with VKAs (47.8%). Concerning DOACs, 28 patients were treated with rivaroxaban (46.7%), 27 patients with apixaban (45.0%), and 5 patients with edoxaban (8.3%). We found no significant differences between both groups concerning demographics, immunosuppressive drugs, concomitant medications, indications for OACs, ischemic stroke, thromboembolic events, or OAC-related death. Patients with DOACs after HTX had a significantly lower one-year rate of overall bleeding complications (p = 0.002) and a significantly lower one-year rate of gastrointestinal hemorrhage (p = 0.011) compared to patients with VKAs after HTX in the Kaplan–Meier estimator. Conclusions: DOACs were comparable to VKAs concerning the risk of ischemic stroke, thromboembolic events, or OAC-related death but were associated with significantly fewer bleeding complications in HTX recipients.

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Section: Discussionsupporting

confidence: 91%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Oral Anticoagulants after Heart Transplantation—Comparison between Vitamin K Antagonists and Direct Oral Anticoagulants

Darche,

Fabricius,

Helmschrott

et al. 2023

JCM

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“…In 80 heart transplant patients, more bleeding with warfarin therapy than with DOACs was observed with no overall difference in bleeding complications following endomyocardial biopsy (odds ratio, 4.55; CI, 1.2-16.2). 102 Further study is needed to firmly evaluate the risk of bleeding with DOACs versus VKA in tissue biopsies in SOT recipients.…”

Section: Posttransplant Considerationsmentioning

confidence: 99%

A Review of Direct-acting Oral Anticoagulants and Their Use in Solid Organ Transplantation

et al. 2022

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Direct-acting oral anticoagulant (DOAC) use has increased dramatically since their introduction because of the growing evidence of proven efficacy and enhanced safety compared with warfarin and the low-molecular-weight heparins in the general population. Unfortunately, there is a dearth of quality data regarding the safety and efficacy of the DOACs in patients awaiting organ transplant and those who received a solid organ transplant. This review aims to evaluate the available literature and considerations regarding anticoagulation use in transplant recipients, focusing on preoperative, perioperative, and postoperative DOAC use.

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“…Prior to 2020, reports on the DOAC use among SOT recipients were limited to single‐center, retrospective case series without control arms (Table 1). 17–42 Among the abstracts from ATC and ISHLT, the incidences of major bleeding (0%–23%) and composite bleeding (0%–37%) ranged widely, and the incidence of thrombotic events was also variable (0%–21%).…”

Section: Safety and Efficacy Of Doac In Solid Organ Transplantmentioning

confidence: 99%

Use of direct‐acting oral anticoagulants in solid organ transplantation: A systematic review

et al. 2020

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The use of direct‐acting oral anticoagulants (DOACs) has increased secondary to the mounting evidence for comparable efficacy and potentially superior safety to vitamin K antagonists (VKAs) in the general population. However, insufficient data regarding DOAC use in solid organ transplant (SOT) recipients and numerous pharmacokinetic and pharmacodynamic considerations limit their use in this highly selected patient population. A systematic review of recent clinical evidence on the safety and efficacy of DOACs compared to VKAs in SOT recipients was conducted. Additional considerations including transplant‐specific strategies for DOAC reversal and common pharmacokinetic/pharmacodynamic concerns were also reviewed. Although current evidence is limited to single‐center retrospective analyses, DOACs, especially apixaban, appear to be a safe and effective alternative to VKAs for SOT recipients with stable graft function and without drug‐drug interactions. Reliable data on DOAC reversal at the time of transplant surgery are lacking, and clinicians should consider idarucizumab, andexanet alfa, and other non‐specific reversal agents on an individual patient basis. There is no evidence supporting deviations from the Food and Drug Administration labeling recommendations for DOAC dosing in the setting of drug‐drug interactions, obesity, and renal function, especially in patients on hemodialysis.

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Directly to a DOAC? Safety of Alternatives to Warfarin for Anticoagulation in Heart Transplantation

Cited by 4 publications

References 0 publications

Oral Anticoagulants after Heart Transplantation—Comparison between Vitamin K Antagonists and Direct Oral Anticoagulants

Oral Anticoagulants after Heart Transplantation—Comparison between Vitamin K Antagonists and Direct Oral Anticoagulants

A Review of Direct-acting Oral Anticoagulants and Their Use in Solid Organ Transplantation

Use of direct‐acting oral anticoagulants in solid organ transplantation: A systematic review

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