Updated guidelines on outpatient anticoagulation. This content is owned by the AAFP. Granger CB, Vitamin K antagonists (e.g., warfarin [Coumadin]), unfractionated heparin, low-molecular-weight heparin (LMWH), and direct oral anticoagulants are commonly used for the prevention and treatment of systemic embolism associated with atrial fibrillation, stroke, and venous thromboembolism (VTE). Andexanet alfa for acute major bleeding associated with factor Xa inhibitors. Riete Investigators. Nieuwlaat R, Boehringer Ingelheim Pharmaceuticals; 2018. Cuker A, Antimicrobials Ciprofloxacin Clarithromycin (Biaxin) Erythromycin Fluconazole (Diflucan) Isoniazid Metronidazole (Flagyl) Trimethoprim/sulfamethoxazole Voriconazole (Vfend) Cardiovascular* Amiodarone Fluvastatin (Lescol) Gemfibrozil (Lopid) Lovastatin (Mevacor) Complementary and alternative medicine Devil's claw Garlic Ginkgo biloba Miscellaneous Alcohol (acute ingestion) Phenytoin (Dilantin) Sertraline (Zoloft). 36. ; 2016;14(6):1308–1313. Assessment of outcomes of treatment with oral anticoagulants in patients with atrial fibrillation and multiple chronic conditions. Pradaxa (dabigatran etexilate mesylate) capsules for oral use [prescribing information]. Giugliano RP, Question 1 â Answer ⢠⢠B. Warfarin with goal INR 2.0-3.0, clopidogrel 75 mg daily ⢠WOEST showed a significant reduction in the primary endpoint of bleeding events, the secondary endpoint of death, MI, revascularization, stroke, stent thrombosis, and even the endpoint of Sign up for the free AFP email table of contents. Comparison of an oral factor Xa inhibitor with low molecular weight heparin in patients with cancer with venous thromboembolism: results of a randomized trial (SELECT-D). Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report [published correction appears in Chest. Search dates: June 28, 2018, and May 2, 2019. Jurk K, ANNEXA-4 Investigators. et al. Alexander JH, Anticoagulant effects are delayed for five days after changes to dosing, including therapy initiation, because of the variable half-lives of previously formed circulating clotting factors.4. Pollack CV Jr, Version 1.2019. / Journals
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. Although there is a small subset of patients who may have unexpected responses to vitamin K antagonists, it is not currently recommended that patients undergo genetic testing.4. American Society of Hematology 2018 guidelines for management of venous thromboembolism: optimal management of anticoagulation therapy, Usual dosage (assess renal function before beginning direct oral anticoagulant and as clinically indicated)*. Garg J, Efficacy and safety of dual antiplatelet therapy and risk stratification tools 3.1 DAPT for the prevention of stent thrombosis 3.2 DAPT for the prevention of spontaneous myocardial infarction Chaudhury P, Vitamin K antagonists inhibit the production of vitamin K-related factors and require a minimum of five days overlap with parenteral anticoagulants, whereas direct oral anticoagulants directly inhibit factor II or factor Xa, providing more immediate anticoagulation. et al. The SELECT-D trial evaluated dalteparin with rivaroxaban in patients with active cancer.2 The study found an absolute VTE recurrence reduction of 7% at six months in favor of rivaroxaban (11% vs. 4%; hazard ratio [HR] = 0.43; 95% CI, 0.19 to 0.99).2 The major bleeding rate at six months was 4% for dalteparin and 6% for rivaroxaban (HR = 1.83; 95% CI, 0.68 to 4.96).2 Most of the major bleeding was gastrointestinal, primarily in patients with esophageal or gastroesophageal cancer. J Thromb Haemost. An advantage to evening administration is the ability to adjust or hold the dose the same day that the INR result becomes available. J Thromb Haemost. et al. Referral should be placed early postoperatively for all patients. The ACCP guidelines recommend assessing bleeding risk for patients with VTE or atrial fibrillation as an essential step to guiding treatment decisions such as the duration of treatment. Tomaselli GF, 2002;100(10):3484–3488. Direct oral anticoagulants or vitamin K antagonists can also be used for the periods before and after cardioversion. Radaideh G, The American Heart Association/American College of Cardiology/Heart Rhythm Society guidelines recommend a direct oral anticoagulant over a vitamin K antagonist, unless the patient has moderate-to-severe mitral stenosis or a mechanical heart valve. Lane DA, 2017 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants. N Engl J Med. 2018;378(7):615–624. Mazurek M, Streiff MB, Akl EA, Dosage adjustment in patients with renal impairment. Monreal M, All rights reserved. Pradaxa (dabigatran etexilate mesylate) capsules for oral use [prescribing information]. Chest. 2013;11(9):1647–1654. AHA Scientific Statement 927 N early 400000 coronary artery bypass graft surgery (CABG) procedures are performed annually in the United States. Lane DA, An arterial graft should not be used to bypass the right coronary artery with less than a critical stenosis (<90%). Accessed February 4, 2019. https://www.aafp.org/dam/AAFP/documents/patient_care/clinical_recommendations/a-fib-guideline.pdf, 20. First episode of distal DVT attributed to a surgery or reversible risk factor: If without severe symptoms or risk factors of extension, suggest serial ultrasonography surveillance for two weeks instead of anticoagulation (grade 2C); if surveillance shows extension, recommend anticoagulation (grade 2C if it does not extend into proximal vessels; grade 1B if it extends into proximal vessels), If severe symptoms or risk factors of extension, recommend three months treatment over extended use (grade 1B), Risk factors for extension: unexplained D-dimer results; extensive DVT (> 5 cm) and/or involving multiple veins; close to proximal vein; unprovoked; cancer; previous VTE; inpatient, LMWH over direct oral anticoagulants (grade 2C) and vitamin K antagonists (grade 2B), Extended therapy (lifelong) recommended (grade 1B if low bleeding risk, grade 2B if high bleeding risk), Suggest changing to LMWH if recurrence while on vitamin K antagonist or direct oral anticoagulant (grade 2C) If recurrence while on LMWH, suggest increasing dose by one-fourth to one-third (grade 2C), After two episodes of unprovoked DVT or PE, extended therapy if low (grade 1B) or moderate (grade 2B) bleeding risk, three months suggested over extended therapy (lifelong) if high bleeding risk (grade 1B), Following completion of anticoagulation therapy, when indicated, Suggest aspirin if unprovoked proximal DVT or PE (grade 2B) and patient elects to discontinue anticoagulation, *—The 2019 National Comprehensive Cancer Network guidelines on cancer-associated VTE includes rivaroxaban and edoxaban as first-line options. Romiti GF, Idarucizumab (Praxbind) is a monoclonal antibody fragment that binds directly to dabigatran, leading to 88% to 98% of patients having concentrations of unbound dabigatran in safe levels within 15 minutes of administration and hemostasis restoration at a median of 11.4 hours.29 For patients taking dabigatran, idarucizumab is recommended for life-threatening or ongoing bleeding, as well as the need to reverse for emergent procedures. Although LMWH has a similar bleeding risk and lower heparin-induced thrombocytopenia risk compared with unfractionated heparin, a patient with a history of heparin-induced thrombocytopenia should not take LMWH.1, Enoxaparin (Lovenox) 1 mg per kg subcutaneously every 12 hours or 1.5 mg per kg subcutaneously every 24 hours, Enoxaparin 1 mg per kg subcutaneously every 24 hours if CrCl < 30 mL per minute per 1.73 m2 (0.50 mL per second per m2), ASH guidelines suggest not routinely monitoring anti–factor Xa levels forpatients who are obese or those with renal impairment, Unfractionated heparin and LMWH considered equally effective and safe Unfractionated heparin may be better for patients with high bleeding risk because of short half-life and reversibility Unfractionated heparin may be favorable in patients with CrCl < 30 mL per minute per 1.73 m2 LMWH has lower incidence of heparin-induced thrombocytopenia but should not be used in patients with previous episode, Dalteparin (Fragmin) 200 units per kg subcutaneously once daily, Use with caution and monitor anti–factor Xa levels in patients with CrCl < 30 mL per minute per 1.73 m2, Fondaparinux (Arixtra) Weight < 110 lb (50 kg): 5 mg subcutaneously daily Weight 110 to 220 lb (50 to 100 kg): 7.5 mg subcutaneously daily Weight > 220 lb: 10 mg subcutaneously daily, Use with caution in patients with CrCl 30 to 50 mL per minute per 1.73 m2 (0.50 to 0.83 mL per second per m2) Contraindicated in patients with CrCl < 30 mL per minute per 1.73 m2, Routine monitoring not suggested; if elected for monitoring, use anti–factor Xa levels with fondaparinux as the reference standard for the assay, LMWH and fondaparinux have comparable effectiveness and safety Longer half-life for fondaparinux is advantageous (daily dosing) and potentially troublesome (adverse effects and lack of reversibility) Although not U.S. Food and Drug Administration approved for heparin-induced thrombocytopenia, fondaparinux has been used for the management of these patients. Ruff CT, Braunwald E, Find all the guideline recommendations in PowerPoint format here. Edoxaban should be initiated with LMWH or unfractionated heparin for five days.37. Evidence-based adjustment of warfarin (Coumadin) doses. Evaluate other P-glycoprotein inhibitors on an individual basis. et al. 13.1 Early graft failure. ‡—Estimated retail price of brand-name medications based on information obtained at https://www.goodrx.com (accessed April 4, 2019). Accessed May 2, 2019. https://dsi.com/prescribing-information-portlet/getPIContent?productName=Savaysa&inline=true, 13. Heparin or LMWH should be administered at initiation of the vitamin K antagonist and be continued for a minimum of five days and until the international normalized ratio (INR) is in the targeted therapeutic range for a minimum of 24 hours. Late Hospital Care, Hospital Discharge, and Posthospital Discharge Care e376 7. ; Witt DM, Nieuwlaat R, Clark NP, et al. Clark NP, Umland EM. Kearon C, N Engl J Med. Dabigatran versus warfarin in patients with atrial fibrillation [published correction appears in. 2018;2(22):3257–3291. The ACC published an expert consensus decision pathway in 2017 on the management of bleeding for patients taking oral anticoagulants.28 Management of bleeding for patients taking vitamin K antagonists depends on the severity of the bleed. The ACC/AHA recommends CABG over PCI for improved survival in patients with comorbid DM and multivessel CAD, particularly with use of LIMA GRAFT (CLASS I). In patients who have had acute ischemic stroke, the prevalence of comorbid atrial fibrillation is increasing, and atrial fibrillation–associated strokes have a higher mortality rate.17 One study found that treatment decisions are often not guideline adherent.18 The CHADS2 (congestive heart failure; hypertension; age 75 years or older; diabetes mellitus; prior stroke, transient ischemic attack, or thromboembolism [doubled]) tool (https://www.mdcalc.com/chads2-score-atrial-fibrillation-stroke-risk) or CHA2DS2-VASc (congestive heart failure; hypertension; age 75 years or older [doubled]; diabetes mellitus; prior stroke, transient ischemic attack, or thromboembolism [doubled]; vascular disease; age 65 to 74 years; sex category) tool (https://www.mdcalc.com/cha2ds2-vasc-score-atrial-fibrillation-stroke-risk) can be used to estimate the risk of stroke. Accessed May 2, 2019. http://www.janssenlabels.com/package-insert/product-monograph/prescribing-information/XARELTO-pi.pdf, 11. Angelini D, Am Fam Physician. 1999;78(5):285–291. 2017;70(24):3042–3067. Hokusai VTE Cancer Investigators. Usually administered for a 10-12 day period.2 2. Holbrook A, ; Bleeding risk assessment should be performed, any modifiable risk factors addressed during each visit. J Am Coll Cardiol. Patients receiving vitamin K antagonist therapy should be treated using a systematic process to optimize effectiveness and minimize adverse effects. Amp ; inline=true, 13 initial and recurrent thromboembolic disease, version 2.2018,! Monitoring with anti–factor Xa levels is not routinely recommended, Alexander JH, McMurray JJ et. Phone follow-up at 180 days Lensing AW, Piccioli A, Shantha G, Kim YH, et al for... Crossed-Over to an OAC the American Academy of Family Physicians placed early postoperatively for all patients after.! A history of myocardial infarction and left ventricular dysfunction are also recommended for all patients after.... 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