Patient self-management of oral anticoagulation

Self management of oral anticoagulation (OAC) has been demonstrated to improve the quality of oral anticoagulation as assessed by the percentage of INR values within the individual target range. There were tendentially less bleeding and thromboembolic complications in the group with self management of OAC. The capillary INR values of the only available monitor in Switzerland (CoaguChek, Roche Diagnostics, AG) correlated good with venous INR. Thus, self management of OAC may be a valuable alternative to conventional anticoagulation in selected and motivated patients on long term anticoagulation.     

Novel drugs for oral anticoagulation pharmacotherapy

Long-term anticoagulation with warfarin is the mainstay of treatment in patients with diseases with high thromboembolic potential, such as atrial fibrillation. However, warfarin therapy carries a number of inherent limitations, including slow onset and offset of action, interindividual variability, food and drug interactions, lack of selectivity and a narrow therapeutic window. Recently developed oral anticoagulants that selectively block key factors in the coagulation cascade, with no need for monitoring or dose adjustment, have the potential to replace warfarin in clinical practice. The safety and efficacy of these agents in patients with atrial fibrillation, venous thromboembolisms and acute coronary syndromes have been the object of numerous recent large-scale clinical investigations. This article provides an overview of the evidence currently available on the use of novel, orally available, selective anticoagulants in patients at risk for thromboembolic events.     

关于脑出血后患者重启口服抗凝药的思考

脑出血后重启口服抗凝药(oral anticoagulant,OAC)是具有挑战性的话题.目前尚无高质量的随机对照试验能获知何时以何种方式重启OAC是安全的.最近几年一些重要研究认为,脑出血后重启OAC可降低栓塞事件的发生率和长期死亡率,且不明显增加出血风险;重启OAC在非脑叶出血患者比脑叶出血患者更安全;新型抗凝剂优...     

Understanding the implications of oral anticoagulation therapy

Oral anticoagulation is an effective prophylactic or treatment measure for many indications (Baglin et al, 2005). Most patients on oral anticoagulant therapy (OAT) take the drug warfarin. This article discusses how OAT is monitored, the factors affecting the stability and control of anticoagulation, and the importance of educating patients who are on OAT.     

Spinal epidural hematoma associated with oral anticoagulation therapy

Spontaneous spinal epidural hematoma is an uncommon cause of spinal cord compression. It may be associated with various causative factors, but in many patients, anticoagulation can be implicated. It is noteworthy that many of the reported cases were anticoagulated in the therapeutic range. Spontaneous spinal epidural hematoma should be suspected in any patient receiving anticoagulant agents who complains of local or referred spinal pain associated with limb weakness, sensory deficits, or urinary retention. Early diagnosis and treatment are very important for the functional recovery of the patient. Spinal magnetic resonance imaging is the most suitable neuroradiological method for early diagnosis. Although primary management is the surgical evacuation of the spinal epidural hematoma via laminectomy, rare cases in which the patient is improving rapidly and progressively could be treated conservatively. A 22-yr-old man with a spontaneous spinal epidural hematoma who was receiving warfarin treatment for a mechanical aortic valve is presented in this article.     

Drug adherence in patients taking oral anticoagulation therapy

Oral anticoagulation has proven to reduce mortality and morbidity of thromboembolic events. One of the most important determinants of the effectiveness and safety of anticoagulation therapy is the adherence to the prescribed therapy. Vitamin K antagonists are characterized by under-utilization, a narrow therapeutic window and multiple food and drug interactions which contribute to a variable dose–response relationship with the risk of insufficient protection and/or increased bleeding risk. The “new” direct oral anticoagulants have demonstrated equal or superior protection and reduced bleeding risks compared to warfarin and are easier to use because of fixed dosing without monitoring of anticoagulation. Controlling of adherence to the direct oral anticoagulants is difficult. Therefore, continuous and regular medication intake represents a pre-requisite for achieving optimal protection. The present review aims to give an overview about the factors that affect drug adherence in patients taking oral anticoagulation drugs and discusses strategies to improve drug adherence.     

Targeting approaches to oral drug delivery

Heat shock proteins (Hsps), cyclophilins (Cyps) and FK binding proteins (FKBPs) form a family of intracellular chaperone molecules that facilitate protein folding and assembly. These stress proteins are selectively expressed in cells in response to a range of stimuli, including heat, lymphokine and microbial/viral infections. This review discusses the role of stress proteins in the HIV-1 viral life cycle, with regard to the development of specific Hsp-based therapeutic strategies against HIV-1 infection. Cumulative findings are cited implicating CypA, Hsp27, Hsp70 and FKBPs in host cell and viral activation, viral entry, assembly or formation of infectious virions. Biological response modifiers that show specific high-affinity interactions with Cyp, FKBPs and Hsps, including cyclosporins, FK-506 and cyclopentenone prostaglandins respectively, may block HIV-1 replication and infection, providing novel HIV-1 therapeutic strategies. Moreover, Hsp binding to viral complexes can enhance antiviral immunity, including natural killer (NK), antibody-dependent (ADCC), γδ T- cell and cytotoxic T-lymphocyte (CTL) activities against HIV-1 infected cells. The ability of Hsps to interact with HIV-1 viral proteins, combined with their inherent adjuvant and immunogenic properties indicates that Hsps may also serve as vehicles for antigen delivery and the design of AIDS vaccines.     

Clinical problems with oral anticoagulation -- 3 case reports

Two patients with severe bleeding complications under oral anticoagulant treatment are presented, in one case caused by pharmacokinetic drug interference (phenylbutazone), in the other by genetic predisposition to bleeding induced by coumarin anticoagulants. Another patient with decreasing INR due to drug interference (rifampicin) is presented as well. The possibility of drug interferences with coumarin anticoagulants has to be anticipated, whenever the medication of an orally anticoagulated patient is changed. A founder mutation of the factor IX propeptide constitutes a genetic predisposition to bleeding in patients put on coumarins. Its presence should be excluded in any patient suffering from hemorrhagic complications after starting anticoagulation when INR values are in the target range.     

Upper-airway obstruction as a complication of oral anticoagulation therapy

We treated a patient for warfarin-induced sublingual hematoma causing upper-airway obstruction. This complication of oral anticoagulation therapy is rare; only three other cases have been reported in the English literature. All reported patients developed acute respiratory embarrassment necessitating emergency airway establishment. Sublingual hematomas usually resolve spontaneously, and surgical drainage is rarely necessary.     

Update on perioperative bridging in patients on chronic oral anticoagulation

Oral anticoagulation (OAC) with vitamin K antagonists is commonly used for long-term prevention or treatment of arterial or venous thromboembolism. In the USA alone, approximately 250,000 patients will require temporary interruption of OAC annually. Managing anticoagulation in those patients on chronic OAC who require invasive procedures continues to be a major clinical dilemma. This article summarizes the existing evidence in light of the recommendations of the American College of Chest Physicians. Management of anticoagulation in the perioperative period will continue to be an important clinical challenge and an evolving area of research. If new oral anticoagulants are successful in replacing warfarin, the entire perioperative anticoagulation scene will change.     

Managing oral anticoagulation therapy: improving clinical outcomes. A review

Many physicians are reluctant to prescribe oral anticoagulation therapy (OAT) because of the fear of haemorrhagic complications. Changes in patient health, lifestyle or diet and other drugs can alter the effectiveness of oral anticoagulants. These potential interferences, added to the fact that each individual has a different reaction to these drugs, requires that therapy is monitored regularly. This article aims to review those strategies which help to achieve optimal anticoagulation control and improve the outcomes of OAT. Relevant articles were identified through a search of MEDLINE and included publications reporting on intensity of anticoagulation, the initiation of therapy and the role of pharmacogenetics, the transition from primary to secondary care, management by specialized clinics using decision support software and home‐testing. Implementation of these strategies would increase the use of oral anticoagulants by physicians and offers the potential to improve patient safety and reduce adverse events.     

Adherence to oral anticoagulation in ischemic stroke patients with atrial fibrillation

BackgroundNon-vitamin K antagonist oral anticoagulants (NOAC) have superior safety and comparable efficacy profile compared to vitamin-K antagonists (VKAs), with more convenient dosing schemes. However, issues with adherence to the NOACs remain unsolved.AimsWe sought to investigate the adherence to oral anticoagulation (OAC) and baseline factors associated with poor adherence after ischaemic stroke in patients with atrial fibrillation (AF).MethodsWe recruited hospitalised patients (2013–2019) from two prospective stroke registries in Larissa and Helsinki University Hospitals and invited survived patients to participate in a telephone interview. We assessed adherence with the Adherence to Refills and Medications Scale (ARMS) and defined poor adherence as a score of over 17. In addition to demographics, individual comorbidities, and stroke features, we assessed the association of CHA₂DS₂-VASc and SAMe-TT₂R₂ scores with poor adherence.ResultsAmong 396 patients (median age 75.0 years, interquartile range [IQR] 70–80; 57% men; median time from ischaemic stroke to interview 21 months [IQR 12–33]; median ARMS score 17 [IQR 17–19]), 56% of warfarin users and 44% of NOAC users reported poor adherence. In the multivariable regression model adjusted for site, sex, and age, poor adherence was independently associated with tertiary education, absence of heart failure, smoking history, use of VKA prior to index stroke, and prior ischaemic stroke. CHA₂DS₂-VASc and SAMe-TT₂R₂ scores were not associated with poor adherence.ConclusionsAdherence was poor in half of AF patients who survived an ischaemic stroke. Independent patient-related factors, rather than composite scores, were associated with poor adherence in these patients.

KEY MESSAGES

• Adherence was poor in half of the atrial fibrillation patients who survived an ischaemic stroke.
• Independent patient-related factors rather than composite scores were associated with poor adherence.
• The findings support the importance of recognising adherence support as a crucial part of holistic patient care recommended by recent AF guideline.