Why switch from warfarin to NOACs?

Verdecchia, Paolo; Angeli, Fabio; Aita, Adolfo; Bartolini, Claudia; Reboldi, Gianpaolo

doi:10.1007/s11739-016-1411-0

Cited by 41 publications

(30 citation statements)

References 21 publications

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“…For patients who are not able to monitor international normalized ratio (INR) frequently or reach a stable INR, it would be beneficial to switch warfarin to NOACs [13]. However, switching from warfarin to NOACs may bring no benefit to patients who had stable anticoagulation [14]. Holding a small number of patients, NOACs have revealed a higher average cost per patient and occupied a larger part of total cost in OAC nowadays.…”

Section: Discussionmentioning

confidence: 99%

Trends of ambulatory oral anticoagulant prescription in five major cities of China, 2012–2017

Shan

2020

BMC Health Serv Res

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Background: The introduction of non-VKA oral anticoagulants (NOACs) has changed the landscape of preventing thromboembolism events in many countries. However, the prescription trends of oral anticoagulant (OAC) in China are still unclear, which were evaluated in this study through data extracted and summarized from 5 major cities as representatives. Methods: This study was designed as a time-series study which was based on pharmacy prescription data. Analysis was performed on yearly aggregated visits and expenditure. The results were also stratified by indications and specialties. Results: A total of 189,006 prescriptions of 67 hospitals in 6 years were included in the study. The average growth rates of overall visit and expenditure of OAC were 15.8 and 57.5%, respectively. The share of warfarin decreased and NOACs had taken 92% of cost, covering 28% of patients in 2017. The more frequently used NOACs were rivaroxaban and dabigatran. The use of OAC was differed by indication and specialty. Conclusion: The use of NOACs was found increasing rapidly in both visits and cost, sharing a majority of cost with a minority of patients. Attentions should be paid on the rational use of NOACs.

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Section: Discussionmentioning

confidence: 99%

Trends of ambulatory oral anticoagulant prescription in five major cities of China, 2012–2017

Shan

2020

BMC Health Serv Res

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“…Compared with vitamin K antagonists (VKAs), these drugs have a more predictable anticoagulant effect, without the need for routine monitoring. 1 DOACs also show lower risk of major bleeding and fatal bleeding than VKAs in randomized controlled trials. [2][3][4] Despite the advantages of DOACs over VKAs, several uncertainties about their benefit-risk profile remain, 5 such as concomitant use with potential drug-drug interaction.…”

Section: Introductionmentioning

confidence: 99%

Risk of major bleeding among users of direct oral anticoagulants combined with interacting drugs: A population‐based nested case–control study

Zhang

Souverein

Gardarsdóttir

et al. 2020

Brit J Clinical Pharma

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Aims: To assess the association between concurrent use of potential pharmacokinetic or pharmacodynamic interacting drugs and major bleeding among direct oral anticoagulant (DOAC) users. Methods:We performed a case-control study nested in a cohort of new users of DOACs (dabigatran etexilate, apixaban or rivaroxaban). Data were obtained from the UK Clinical Practice Research Datalink linked to Hospital Episode Statistics (2008)(2009)(2010)(2011)(2012)(2013)(2014)(2015). Cases were patients hospitalized having a primary diagnosis of major bleeding. Up to 4 controls were matched on age, sex, index date and region. Odds ratios (ORs) for the risk of major bleeding were assessed by conditional logistic regression analysis and adjusted for well-known covariates for the risk of bleeding. Results:We identified 393 patients with a major bleeding from a total of 23 492 new users of DOACs and 1494 matched controls. Most subjects were users of rivaroxaban (58.8%) on the index date. The concurrent use of pharmacodynamic interacting drugs was associated with an increased risk of major bleeding (21.6% of cases vs 13.5% of controls, adjusted odds ratio [aOR] 1.92; 95% confidence interval [CI], 1.40-2.66). For the antiplatelet drugs the aOR was 2.01 (95% CI, 1.29-3.11) and for the selective serotonin reuptake inhibitors the aOR was 1.68 (95% CI, 1.10-2.59).We found no increased risk of major bleeding for concurrent use of pharmacokinetic interacting drugs vs DOACs alone (45.0 vs 51.2%; aOR: 0.77; 95% CI: 0.53-1.10).Conclusion: Among patients taking DOACs the concurrent use of antiplatelet drugs or selective serotonin reuptake inhibitors was associated with increased risk of major bleeding, while pharmacokinetic interacting drugs do not increase this risk. K E Y W O R D S apixaban, bleeding, dabigatran, drug interactions, rivaroxaban

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“…Approximately 1 in 6 patients per year treated with warfarin undergo invasive surgical procedure and are required to discontinue treatment prior to the event [8]. In order to minimize the risk of perioperative bleeding, guidelines suggest that warfarin therapy is stopped 5 days before an invasive procedure [1,[9][10][11].…”

Section: Discussionmentioning

confidence: 99%

Validation of an algorithm to predict decline in INR following warfarin cessation in patients undergoing invasive procedures

Kampouraki

Wynne

Avery

et al. 2019

J Thromb Thrombolysis

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Patients on warfarin are required to withdraw from treatment for a fixed period (normally 5 days) prior to an invasive procedure. However, the anticoagulant effect of warfarin subsides at different rates among different patients, exposing some to increased risk of either thrombosis or bleeding. In a recent study in patients awaiting surgery, following warfarin cessation the INR declined slower over time in those with two CYP2C9 variant alleles, increasing age, weight and number of comorbidities and that INR decline was faster in those with higher maintenance INR value. Subsequently, we developed an algorithm which predicts INR decline in individual patients after 5 days of warfarin cessation. The current study validated the algorithm. An independent cohort of patients completing a short course of warfarin took part in the study. INR values for subsequent 9 days and CYP2C9 genotype were available. The predicted INR decline (INR day 1-INR day 5) was compared to the observed one (where an INR check on day 5 was unavailable, INR was estimated using a linear approximation model). There was a strong correlation between the decline in INR by day 5 and that predicted from the algorithm for the 117 patients (r = 0.949, p < 0.001). The algorithm was precise, with low degree of bias and variance of the prediction error. The algorithm can accurately predict the INR decline following warfarin cessation in individual adult patients. The use of this easily adoptable algorithm can reduce cancellation or delays of planned surgical procedures. Keywords Warfarin • International normalized ratio • Algorithm • Cytochrome P-450 CYP2C9 • Genotype Highlights • The effect of warfarin subsides at different rates among different patients based upon individual patient characteristics. • An algorithm predicting the fall in INR within 5 days in individual patients was validated. • There was a strong and significant correlation between the observed and predicted fall in INR. • The validated algorithm can accurately predict the fall in INR after warfarin cessation for individual patients and is easy to implement in clinic.

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Why switch from warfarin to NOACs?

Cited by 41 publications

References 21 publications

Trends of ambulatory oral anticoagulant prescription in five major cities of China, 2012–2017

Trends of ambulatory oral anticoagulant prescription in five major cities of China, 2012–2017

Risk of major bleeding among users of direct oral anticoagulants combined with interacting drugs: A population‐based nested case–control study

Validation of an algorithm to predict decline in INR following warfarin cessation in patients undergoing invasive procedures

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