DOAC plasma concentration upon hospital admission in a cohort of trauma patients. An observational real-life study

Ruoff, Chad; Schöchl, Herbert; Fritsch, Gerhard; Voelckel, Wolfgang G.; Zipperle, Johannes; Gratz, Johannes; Schmitt, Felix C. F.; Oberladstätter, Daniel

doi:10.1007/s00068-023-02334-5

Cited by 4 publications

(3 citation statements)

References 33 publications

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“…Ruoff et al reported in a cohort of 210 trauma patients, where DOAC concentration was measured upon admission, that in 14% of the investigated samples plasma levels exceeded 300 ng/ml. Moreover, this study demonstrated that patients on dabigatran, and rivaroxaban were prone to higher DOAC plasma levels in comparison with apixaban and edoxaban [16]. For dabigatran renal insufficiency was the leading cause for unexpected high plasma levels.…”

Section: Differences Between Direct Oral Anticoagulants Regarding Ble...mentioning

confidence: 71%

“…Recent studies demonstrated that currently 11-14% of hip fracture (HF) patients are on DOACs prior to injury [2,16]. Among geriatric HF patients, an elapse time >24h from admission to surgical stabilisation, is associated with higher complication rates and increased 30-day mortality [40,41].…”

Section: Impact Of Direct Oral Anticoagulants On Trauma Related Bleedingmentioning

confidence: 99%

“…Thus, a pro-haemostatic intervention must be carefully weighed against the potential risks of a reversal therapy such as TE events. Moreover, the halflife of DOACs is short and most of the patients will not be admitted with peak plasma concentrations [16]. Nevertheless, time of drug intake, comedications as well as renal and hepatic function should be assessed upon admission.…”

Section: Severity Adjusted Treatment Strategy For Trauma Patients An ...mentioning

confidence: 99%

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Direct oral anticoagulants in trauma patients

Schöchl,

Grottke,

Schmitt

2024

Current Opinion in Anaesthesiology

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Purpose of review Direct oral anticoagulants (DOACs) are increasingly prescribed for prevention of thromboembolic events. Thus, trauma care providers are facing a steadily raising number of injured patients on DOACs. Recent findings Despite a predictable pharmacokinetic profile, the resulting plasma levels of trauma patients upon admission and bleeding risks remain uncertain. Therefore, recent guidelines recommend the measurement of DOAC plasma concentrations in injured patients. Alternatively, DOAC specific visco-elastic tests assays can be applied to identify DOAC patients at bleeding risk. Bleeding complications in trauma patients on DOACs are generally higher compared to nonanticoagulated subjects, but comparable to vitamin K antagonists (VKAs). In particular, a traumatic brain injury does not carry an increased risk of intracranial bleeding due to a DOAK intake compared to VKAs. Current studies demonstrated that up to 14% of patients with a hip fracture are on DOACs prior to surgery. However, the majority can be operated safely within a 24h time window without an increased bleeding rate. Specific antagonists facilitate rapid reversal of patients on DOACs. Idarucizumab for dabigatran, and andexanet alfa for apixaban and rivaroxaban have been approved for life threatening bleeding. Alternatively, prothrombin complex concentrate can be used. Dialysis is a potential treatment option for dabigatran and haemoabsorption with special filters can be applied in patients on FXa-inhibitors. Summary Current guidelines recommend the measurement of DOAC plasma levels in trauma patients. Compared to VKAs, DOACs do not carry a higher bleeding risk. DOAC specific antagonists facilitate the individual bleeding management.

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Section: Differences Between Direct Oral Anticoagulants Regarding Ble...mentioning

confidence: 71%

Section: Impact Of Direct Oral Anticoagulants On Trauma Related Bleedingmentioning

confidence: 99%

Section: Severity Adjusted Treatment Strategy For Trauma Patients An ...mentioning

confidence: 99%

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Direct oral anticoagulants in trauma patients

Schöchl,

Grottke,

Schmitt

2024

Current Opinion in Anaesthesiology

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Impact of elevated direct factor Xa inhibitor plasma levels on perioperative blood loss in patients undergoing urgent surgery

Mair,

Sahli,

Studt

et al. 2024

Transfusion

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IntroductionData on the perioperative bleeding risk associated with elevated plasma levels of direct factor Xa inhibitors (FXa inhibitors) are limited. This study examines perioperative red blood cell (RBC) loss in patients undergoing urgent surgery with a residual FXa inhibitor level exceeding 100 mcg/L and without preoperative FXa inhibitor reversal.MethodsThis retrospective analysis includes data from 32 patients who underwent urgent noncardiac surgery between 2018 and 2022. This study aims to analyze perioperative RBC loss in patients undergoing urgent surgery with a residual FXa inhibitor level exceeding 100 mcg/L and without preoperative FXa inhibitor antidote‐based reversal or unspecific treatment with 4‐factor prothrombin complex concentrate (PCC). All patients were managed using a watch‐and‐wait strategy.ResultsThe last determination of FXa inhibitor plasma concentration prior to surgery showed a median of 245 mcg/L (IQR 144–345), with a median time interval of 3.8 h (IQR 2.4–7.2) before incision. Median RBC loss during surgery was 49 mL (IQR 0–253), 189 mL (IQR 104–217) until POD1 and 254 mL (IQR 58–265) until POD3. Only one patient required intraoperative treatment with 4‐factor‐PCC and none required reversal with andexanet alfa. Linear regression models found no significant influence of FXa inhibitor plasma levels on intraoperative RBC loss. Rivaroxaban was associated with higher RBC loss until postoperative Day 1 compared with apixaban. No thromboembolic events were observed.ConclusionDespite markedly elevated plasma concentrations of residual direct FXa inhibitors, perioperative RBC loss was limited in patients undergoing urgent noncardiac surgery. The intraoperative watch‐and‐wait strategy with selective intraoperative FXa inhibitor reversal or treatment only when required appears to be an appropriate approach.

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Assessment of bleeding events in patients receiving DOACs with or without statins to treat venous thromboembolism: insights from the RIETE registry

Del Giorno,

Mazzolai,

Keller

et al. 2024

BMJ Open

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ObjectiveTo evaluate the impact of coadministering statins with direct oral anticoagulants (DOACs) on the risk of major bleeding events in patients with venous thromboembolism (VTE).DesignObservational cohort analysis based on a multicentre international registry.SettingData were extracted from the Registro Informatizado de Enfermedad TromboEmbolica Registry, which involves 205 centres across 27 countries.ParticipantsA total of 73 659 patients diagnosed with VTE were classified based on their anticoagulant therapy (DOACs) versus low-molecular-weight heparin (LMWH) or vitamin K antagonists (VKAs) and concurrent use of statins.MethodsMultivariable Cox proportional hazards models adjusted for confounding variables to assess the risk of major bleeding events stratified by the type of anticoagulant use and statin use.ResultsFrom October 2013 to February 2023, 73 659 patients were recruited: 2573 were statin users on DOACs, 14 090 were statin users on LMWH or VKA therapy, 10 088 were non-statin users on DOACs and 46 908 were non-statin users on LMWH or VKA therapy. Statin users were 10 years older and more likely to have hypertension, diabetes, renal failure or prior artery disease. During anticoagulation (median, 187 days), 1917 patients (2.6%) suffered major bleeding. Rates of major bleeding per 100 patient-years were 2.33 (95% CI 1.72 to 3.09), 3.75 (95% CI 3.43 to 4.10), 1.39 (95% CI 1.13 to 1.69) and 3.10 (95% CI 2.93 to 3.27), respectively. On multivariable analysis, patients treated with DOACs had a significantly lower risk of major bleeding compared with those on LMWH or VKA therapy (adjusted HR 0.59; 95% CI 0.48 to 0.74). The adjusted HR in statin users versus non-users was 1.03 (95% CI 0.92 to 1.14), while in statin users on DOACs versus the rest of patients, it was 1.18 (95% CI 0.79 to 1.76).ConclusionsIn patients with VTE receiving statins, long-term anticoagulation with DOACs was associated with a reduced risk of major bleeding, regardless of the statin use. These findings support the safety profile of DOACs over VKAs or LMWH in the management of VTE in patients requiring statins.

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DOAC plasma concentration upon hospital admission in a cohort of trauma patients. An observational real-life study

Cited by 4 publications

References 33 publications

Direct oral anticoagulants in trauma patients

Direct oral anticoagulants in trauma patients

Impact of elevated direct factor Xa inhibitor plasma levels on perioperative blood loss in patients undergoing urgent surgery

Assessment of bleeding events in patients receiving DOACs with or without statins to treat venous thromboembolism: insights from the RIETE registry

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