Andexanet alfa for reversing anticoagulation: Final appraisal document
National Institute for Health and Care Excellence
In DRAFT guidance, NICE recommends andexanet alfa as an option for reversing anticoagulation from apixaban or rivaroxaban in adults with life-threatening or uncontrolled bleeding in the gastrointestinal tract, if the company provides it according to the commercial arrangement.
MHRA reports latest Yellow Card reporting data on blood clots in recipients of Covid-19 vaccines
Medicines and Healthcare products Regulatory Agency
As of 24 March, the MHRA received 22 reports of cerebral venous sinus thrombosis and 8 reports of other thrombosis events with low platelets, out of a total of 18.1 million doses of COVID-19 Vaccine AstraZeneca. The benefits of Covid-19 vaccines continue to outweigh any risks.
Circulation
This scientific statement summarises established risk factors for perioperative stroke, preoperative & intraoperative strategies to mitigate risk of stroke, suggestions for postop assessments, & treatment approaches for minimising permanent neurological dysfunction in this group.
European Heart Journal
Recommendations of latest 2017 ESC/EACTS guidelines are mostly based on expert opinion. This viewpoint provides updated therapeutic insights on antithrombotic treatment during and after transcatheter aortic valve implantation, based on recent studies and RCTs.
JCVI statement on use of the AstraZeneca COVID-19 vaccine: 7 April 2021
Joint Committee on Vaccination and Immunisation
JCVI has advised that it is preferable for adults aged <30 years without underlying health conditions that put them at higher risk of severe COVID-19 disease, to be offered an alternative COVID-19 vaccine, if available.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
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European Heart Journal
Austrian analysis (2006–07; n = 8,306,244) found strong association between cancer and arterial thromboembolism (RR 6.88; 95% CI 4.81–9.84) and venous thromboembolism (14.91; 8.90–24.95) and support concept of shared risk factors and pathobiology between these diseases.
Annals of Internal Medicine
In this retrospective American study (n= 56,336), patients with valvular AF who were new users of DOACs had lower risks for ischaemic stroke or systemic embolism (HR 0.64 [95%CI, 0.59-0.70]) and major bleeding events (HR 0.67 [CI 0.63-0.72]) vs new users of warfarin.
Thromboembolism and the Oxford–AstraZeneca COVID-19 vaccine: side-effect or coincidence?
The Lancet
Danish registry study (n=4, 915 ,426, 9 years of data) suggests that the reported number of thromboembolic events with the AZ vaccine does not seem to be increased vs incidence rates from the entire Danish population before the introduction of the vaccination programme.
AstraZeneca COVID-19 vaccine: review of very rare cases of unusual blood clots continues
European Medicines Agency
EMA's safety committee has met to discuss ongoing review of very rare cases of unusual blood clots linked to low numbers of platelets, in people vaccinated with AZ's COVID-19 vaccine (now called Vaxzevria). At present, no specific risk factors or causal link have been identified.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
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DTB select: DOAC drug interactions and risk of major bleeding
Drug and Therapeutics Bulletin
Summary and context are provided for a UK case–control study which found that use of antiplatelet drugs and SSRIs with DOACs was associated with an increased risk of major bleeds requiring hospital admission.
Warfarin dosing algorithms: A systematic review
British Journal of Clinical Pharmacology
Review (266 articles) found most algorithms have been developed in Asian and White populations and may not be applicable to under‐served populations. Few algorithms had been externally validated, assessed for clinical utility, and/or have a low risk of bias.
DTB select: Tranexamic acid should be avoided for acute gastrointestinal bleeds
Drug and Therapeutics Bulletin
Summary and context is provided on the HALT-IT trial which involved 12 000 people being treated for acute gastrointestinal bleeding, and found tranexamic acid had no effect on risk of death from bleeding but increased the risk of thromboembolism and seizures.
Association of risk factors and bleeding complications in Asian patients taking edoxaban
British Journal of Clinical Pharmacology
Trial (n=346) found weight ≤60 kg & presence of cancers could affect bleeding complications, which occurred despite proper edoxaban treatment in Asian patients. Authors suggest possibility of using more strict dosage guideline could be considered in patients of Asian ethnicities.
The Lancet Neurology
RCT (n=173 per protocol) did not show that aspirin was non-inferior to vitamin K antagonists (VKAs) in treatment of cervical artery dissection (primary endpoint in 21 [23%] of 91 patients on aspirin vs. 12 [15%] of 82 on VKA (absolute difference 8%, non-inferiority p=0.55).
P2Y12 inhibitor monotherapy after coronary stenting according to type of P2Y12 inhibitor
Heart
RCT (n=2993) found that 3-month dual antiplatelet therapy (DAPT) followed by clopidogrel monotherapy provided similar rates of a composite endpoint (all-cause death, myocardial infarction or stroke at 12 months) vs 12 months DAPT (3.0% for both, HR 1.02).
Incidence and predictors of stroke in patients with rheumatic heart disease
Heart
Cohort study (n=515) notes despite wide use of oral anticoagulants, stroke (SK) remains frequent in this population (1.47 SKs per 100 patient-years), with age, AF & prior SK predictors of long-term SK; more aggressive monitoring of anticoagulation may be warranted in recurrent SK.
Drug‐drug Interactions with Warfarin: A Systematic Review and Meta‐analysis
British Journal of Clinical Pharmacology
Analysis of 72 studies (11 RCTs; total n=3,735,775) found addition of antiplatelets (OR 1.74), antimicrobials (1.63), NSAIDs (1.83) SSRIs (1.62), mirtazapine (1.75) and loop diuretics (1.92) to warfarin was associated with increased risk of clinically relevant bleeding.
Arterial and venous thromboembolism in COVID-19: a study-level meta-analysis
Thorax
Analysis (102 studies; n=64,503) found the frequency of COVID-19-related VTE was 14.7%; prevalence was higher in ICU (23.2% v 9.0%; P<0.0001). The frequency rate of overall arterial thromboembolic events was 3.9%; subgroup analyses failed to explain heterogeneity.
Antithrombotic therapy in diabetes: which, when, and for how long?
European Heart Journal
This review provides an up-to-date guide for antithrombotic management of individuals with diabetes mellitus and highlights gaps in knowledge that represent areas for future research, aiming to improve clinical outcome in this high-risk population.
HElping Alleviate the Longer-term consequences of COVID-19 (HEAL-COVID): national platform trial
HEAL-COVID
This study, which will enrol patients admitted to hospital with Covid-19 who are about to be discharged, will investigate whether apixaban (for 2 weeks) or atorvastatin (for 12 months) could prevent or reduce long-term outcomes for patients with Covid-19.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
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Heart
During 1-year follow-up of 37,990 Swedish patients, prasugrel and ticagrelor were associated with similar efficacy (risk of major adverse cardiac and cerebrovascular events: HR 1.03; 95% CI 0.86 to 1.24) and bleeding risk (2.5% vs 3.2%, adjusted HR 0.92, 95% CI 0.69 to 1.22).
JAMA Neurology
The authors discuss potential approaches and recommend a tailored approach to select patients taking DOAC with acute ischaemic stroke for thrombolysis by combining clinical and imaging information with anticoagulant activity and use of specific reversal agents only if necessary.
The International Society on Thrombosis and Haemostasis
The ISTH recommends that all eligible adults continue to receive COVID-19 vaccinations, despite the recent decisions by some countries to at least temporarily suspend the use of the AstraZeneca vaccine due to reports of thrombosis.
Diagnosis and Management of Transient Ischemic Attack and Acute Ischemic Stroke: A Review
Journal of the American Medical Association
This review provides an update on management of transient ischaemic attack and acute ischaemic stroke, emphasising advances in use of dual antiplatelet therapy and fibrinolysis vs mechanical thrombectomy for secondary and tertiary prevention.
The Lancet Neurology
Analysis of 38 hospital-based prospective cohort studies from 18 countries (n=31,550) suggests MICON risk scores, incorporating clinical variables & cerebral microbleeds, offer predictive value for long-term risks of intracranial haemorrhage & ischaemic stroke in this population.
MHRA confirms people should continue to receive COVID-19 vaccine AstraZeneca
Medicines and Healthcare products Regulatory Agency
Following rigorous scientific review of all available data, MHRA said available evidence does not suggest venous thromboembolism is caused by COVID-19 Vaccine AstraZeneca and benefits of the vaccines against COVID-19 continue to outweigh any risks.
European Medicines Agency
The European PRAC has concluded its preliminary review of a signal of blood clots in people vaccinated with COVID-19 Vaccine AstraZeneca and confirmed its benefits in combating the still widespread threat of COVID-19 continue to outweigh the risk of side effects.
Journal of the American Medical Association
This study in Iran (n=600; 562 in primary analysis) found no difference between routine use of intermediate dose (enoxaparin 1mg/kg daily) and standard prophylactic anticoagulation (enoxaparin 40mg daily) in terms of the composite primary endpoint (45.7% v 44.1%).
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
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EClinical Medicine
Analysis of 607 of 1113 records in Mayo Clinic Electronic Health Record database found that COVID-19 patients administered unfractionated heparin but not enoxaparin had higher rates of 28-day mortality (risk ratio: 4.3; 95% CI; 1.8-10.2).
New England Journal of Medicine
Review covers vasoconstrictors, tranexamic acid, cauterisation, anterior nasal packing, resorbable/non-resorbable packing, salvage bleeding control, posterior packing, ligation & endovascular embolisation, patients on anticoagulant and antiplatelets, and patient education.
European Medicines Agency
Several cases of immune thrombocytopenia, an adverse event of special interest, were reported in the EudraVigilance database. The PRAC will carry out an in-depth review of all the available data for these three vaccines, to decide if a causal relationship is confirmed or not.
Reuters Health
A World Health Organization expert advisory committee is currently looking at AstraZeneca's COVID-19 vaccine after some countries suspended its use, following reports of the formation of blood clots in some people who have been vaccinated.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
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Cochrane Database of Systematic Reviews
Review (19 RCTs; n=1943) found more frequent complete clot lysis after thrombolysis (TS) with/without additional clot removal strategies and post‐thrombotic syndrome incidence was slightly reduced. Systemically administered and catheter‐directed TS have similar effectiveness.
British Journal of Clinical Pharmacology
Analysis of 4 cohorts (UK, Spain, Germany, Denmark,n = 251,719) found reduction in bleeding risk for DOACs doesn't resemble reductions found in trials. This could be at least partially attributable to nonadherence and limited external validity of trials, reflecting real‐life settings.
Beyond dexamethasone, emerging immuno‐thrombotic therapies for COVID‐19
British Journal of Clinical Pharmacology
Understanding mechanisms underpinning hyperinflammation & coagulopathy is essential to formulating rationale therapeutic approaches beyond use of dexamethasone. Article reviews pathophysiology thought to underlie COVID‐19 with clinical correlates and therapies being investigated.
British Journal of Clinical Pharmacology
UK study found oral anticoagulant (OAC) prescriptions among patients with AF and dementia/cognitive impairment increased by 39.8% between 2000 and 2015. Characteristics related to frailty (e.g. history of falls, polypharmacy) were associated with lower odds of OAC prescription.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
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European Heart Journal
This commentary discusses dual pathway inhibition therapy (DPI; aspirin + low dose direct oral anticoagulant) post coronary artery bypass graft surgery. The authors summarise available data, noting limited data in this specific patient cohort and call for further research.
Cochrane Database of Systematic Reviews
This review of 34 studies (n=1960) found the available evidence does not support the superiority of any anticoagulant to another. Further studies are needed to identify patient populations in which CRRT should commence with no pharmacological anticoagulation or with citrate.
Arterial and venous thromboembolism in COVID-19: a study-level meta-analysis
Thorax
This meta-analysis of 102 studies (n=64503) found patients admitted to the ICU for severe COVID-19 had a high risk of VTE. Further studies are needed to determine the specific effects of COVID-19 on the risk of thrombosis in less severe forms of the disease.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
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Revised SPC: Plavix (clopidogrel) 300 mg film-coated tablets
electronic Medicines compendium
SPC have been updated with licence extension for use in combination with aspirin in adult patients with moderate to high-risk transient ischaemic attack (ABCD2-[1] score ≥4) or minor ischaemic stroke (NIHSS-[2] ≤3) within 24 hours of an event.
Comparative effectiveness of oral anticoagulants in everyday practice
Heart
Registry study (n=25,551) found DOACs were associated with a lower risk of all-cause mortality vs VKAs (3.6 vs 4.8 per 100 patient years, HR 0.79, 95%CI 0.70-0.89) and major bleeding (1.0 vs 1.4, 0.77, 0.61-0.98) with similar risk of non-haemorrhagic stroke or systemic embolism.
Circulation
Review of this study found that although pretreatment endogenous factor Xa activity was significantly higher in women than in men, treatment with edoxaban resulted in eventual similar endogenous factor Xa activity, and the efficacy profile was similar between sexes.
Thombosis Research
Review (18 studies) findings do not support use of prediction models to weigh risks for recurrence and bleeding when deciding to anticoagulated patients after initial treatment of VTE. Important methodological limitations and insufficient predictive accuracy were found.
Direct oral anticoagulants in treatment of cerebral venous thrombosis: a systematic review
BMJ Open
Review of 33 studies (1 RCT, 5 observational cohorts and 27 case series, total n=594) concludes that the evidence for DOACs in cerebral venous thrombosis is limited, but suggests sufficient safety and efficacy vs standard therapy. Further rigorous trials are needed.
Prophylactic anticoagulation for patients in hospital with covid-19
British Medical Journal
This editorial discusses research to date on thromboprophylaxis in patients admitted to hospital with Covid-19 including the interim results from three separate RCTs (anticoagulation arm of REMAP-CAP, ATTACC, and ACTIV4a), widely available before peer-review.
Primary prophylaxis for venous thromboembolism in ambulatory cancer patients receiving chemotherapy
Cochrane Database of Systematic Reviews
This updated review (32 RCTs [6 new]; n=15,678) found LMWH reduce, and direct factor Xa inhibitors may reduce, incidence of symptomatic VTE; both likely increase risk of major bleeding. Evidence for use of thromboprophylaxis with other anticoagulants is limited.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
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Revised SPC: Xarelto (rivaroxaban) film-coated tablets – all strengths
electronic Medicines compendium
SPC updated with license extension for the treatment of venous thromboembolism (VTE) and prevention of VTE recurrence in children and adolescents aged less than 18 years and weighing from 30 kg to 50 kg after at least 5 days of initial parenteral anticoagulation treatment.
British Medical Journal
Study of patients admitted to hospital with Covid-19 (n=4297) found receipt of thromboprophylaxis within 24 hours of admission was associated with lower 30-day mortality (14.3% v 18.7% no anticoagulation; HR 0.73, 95% CI 0.66 to 0.81) with no increased risk of severe bleeding.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
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DOAC Dipstick for detecting direct oral anticoagulants - Medtech innovation briefing [MIB248]
National Institute for Health and Care Excellence
This briefing describes the DOASENSE DOAC Dipstick, which is used for detecting direct oral anticoagulants (DOACs) in urine. A summary of the main relevant evidence is presented along with uncertainties in the evidence, the technology's potential place in therapy and its cost.
PharmaTimes
It will be licensed for treatment and prevention of venous thromboembolism recurrence in children from birth to below 18 years old, at least five days after initial parenteral anticoagulation treatment.
Management of Antithrombotic Therapy after Acute Coronary Syndromes
New England Journal of Medicine
This review article notes antithrombotic therapy is a central component of treatment after acute coronary syndromes; however, balancing the benefit with the bleeding risk is still controversial. Clinical research and recommended approaches to management are reviewed.
The above records have been identified by UKMi and feature in the NICE Medicines Awareness Service. Further details on this service can be found at:
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