In use product safety assessment report for enoxaparin biosimilars (INHIXA and AROVI)
Specialist Pharmacy Service
This assessment on Inhixa and Arovi (enoxaparin biosimilars) describes the in-use medication safety considerations resultant from the products' presentation or other pre-defined characteristics. Potential next steps and mitigation actions are suggested.
Cyclin-Dependent Kinase Inhibitor–Associated Thromboembolism
JAMA Oncology
An overview of the evidence that this drug class (of which palbociclib is the first in class) is associated with an increased incidence of thromboembolism. NICE support the use of palbociclib for use within its marketing authorisation.
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:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
Prolonged thromboprophylaxis with low molecular weight heparin for abdominal or pelvic surgery
Cochrane Database of Systematic Reviews
Review of 7 RCTs (n=1728) concludes prolonged thromboprophylaxis (≥14 days) with LMWH significantly reduces the risk of VTE compared to thromboprophylaxis during hospital admittance only, without increasing bleeding complications after major abdominal or pelvic surgery.
Circulation
Study (n=272,315) found triple therapy linked to high rates of major bleeding vs. dual or monotherapy. Very high major bleeding rates occurred among patients on triple therapy aged > 90 years or with CHA2DS2-VASc > 6 or with a history of major bleeding.
Journal of the American Medical Association
Retrospective study found during 754,389 person-years of anticoagulation with apixaban, dabigatran, rivaroxaban [RV], and warfarin, risk of hospitalisation for upper GI bleeding was highest for RV. PPI cotherapy (264,447 person-years) was linked to lower overall GI bleeding risk.
Apixaban to Prevent Venous Thromboembolism in Patients with Cancer
New England Journal of Medicine
RCT (n=574) found apixaban (2.5mg BD) resulted in lower rate of venous thromboembolism vs. placebo in intermediate/high-risk ambulatory patients with cancer starting chemo (12 [4.2%] vs. 28 [10.2%]; HR 0.41; 95% CI, 0.26-0.65; p<0.001) but higher rates of major bleeding episodes.
Conference report: positive results for emicizumab for paediatric haemophilia A
Biospace Inc.
Primary analysis of the HAVEN 2 study (n=85) has found that once-weekly emicizumab dosing showed a 99% reduction in treated bleeds compared to prior treatment with bypassing agents.
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:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
Circulation
Registry study (n=52,014) found an elevated mortality rate in the first month after diagnosis vs the first year (6.8 vs 4.3 100 person years for first month and first year respectively). The elevated 1-month mortality rate was mostly attributable to cardiovascular mortality.
The Lancet Respiratory Medicine
RCT (N=105) reported an improvement from baseline in mean 6-min walk distance in the treprostinil high and low dose groups (44·98 m and 4·29 m; p=0·0016). Treprostinil is an investigational prostacyclin analogue that has received orphan drug status in the EU.
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:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
JAMA Cardiology
This review of 3 RCTs (n=3943) comparing bare-metal stents (BMSs) to drug-eluting stents (DESs) with shortened duration of dual antiplatelet therapy (one month only) found DES were associated with lower risk of major adverse cardiac events and other adverse outcomes.
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:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
The role of plasminogen activators in stroke treatment: fibrinolysis and beyond
The Lancet Neurology
This review describes the pathophysiological effects of plasminogen activators and how, in the future, their non-fibrinolytic functions could be used for the treatment of patients with acute ischaemic and haemorrhagic stroke.
Practice guide to dosing of direct acting oral anticoagulants in patients with renal impairment
Specialist Pharmacy Service
This paper, focusing on use of DOACs in patients with atrial fibrillation, discusses the debate regarding the dosing of DOACs in patients with renal impairment and offers some practical advice on selecting the dose in the clinical setting.
Management of life threatening bleeds from arteriovenous fistulae and grafts
NHS Improvement
Alert signposts providers to resources produced jointly by British Renal Society and Vascular Access Society of Britain and Ireland to help staff, carers and patients recognise warning signs. Providers are asked to ensure local guidance incorporates advice in these resources.
Cochrane Database of Systematic Reviews
Review (4 trials, n=450) found no RCT evidence that percutaneous vascular interventions are superior to intravenous thrombolytic treatment with respect to functional outcome. Quality of evidence was low (outcome assessment was blinded but not treating physician/participants).
Circulation
Paper reports that ABC-stroke and ABC-bleeding risk scores which comprise clinical variables and CV biomarkers to estimate risk of stroke/systemic embolic events and bleeding, respectively, were well-calibrated and outperformed the CHA2DS2-VASc and HAS-BLED scores, respectively.
Self‐poisoning with 60 tablets of Apixaban, a pharmacokinetics case report
British Journal of Clinical Pharmacology
Apixaban was eliminated following first order elimination with a calculated half‐life of 10.8 h. Anti‐Xa activity seems to be linearly related to concentration up to 4000 μg/ l. This report suggests use of activated charcoal should be effective up to 17 h after a massive intake.
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:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
British Journal of General Practice
An evaluation of 23 practices found that an automated risk assessment for stroke in AF and prompting during consultations are feasible and generally acceptable, but did not overcome concerns about frailty and risk of haemorrhage as barriers to anticoagulant uptake.
Revised SPCs: Plavix (clopidogrel) 75 and 300mg tablets
electronic Medicines compendium
Insulin autoimmune syndrome has been added to SPCs as an adverse effect (unknown frequency). This can lead to severe hypoglycaemia, particularly in patients with HLA DRA4 subtype (more frequent in the Japanese population).
Timing of anticoagulation after recent ischaemic stroke in patients with atrial fibrillation
The Lancet Neurology
This Rapid Review summarises and critically reviews current guidelines and new published data, and gives an overview of ongoing investigator-initiated randomised controlled trials of oral anticoagulation timing after ischaemic stroke associated with atrial fibrillation.
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:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
Journal of Thrombosis and Haemastasis
This US retrospective study (26,894 people with cancer-associated venous thrombosis), found that the bleeding risk with DOACs was similar to warfarin and low molecular weight heparin. There was however heterogeneity in bleeding risk with DOACs by cancer type.
Annals of Internal Medicine
Review of 220 articles aimed to compare the effectiveness of medical and procedural therapies in preventing thromboembolic events and bleeding complications in adults with non-valvular AF. It found DOACs are at least as effective and safe as warfarin for patients.
Circulation
In RE-VERSE AD trial, idarucizumab showed rapid/complete reversal of dabigatran activity in nearly all patients with GI bleeding; complete reversal in 118 of 121 (97.5%) with elevated diluted thrombin time at presentation and 95 of 131 (72.5%) with elevated ecarin clotting time.
Rivaroxaban vs warfarin in high-risk patients with antiphospholipid syndrome
Blood
Trial (n=120) was terminated early due to an excess of events in the rivaroxaban group compared to warfarin (7 thromboembolic events; 4 ischemic stroke and 3 myocardial infarction vs. 0 events, respectively). Major bleeding occurred in 4 vs. 2 patients, respectively.
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:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
Extended treatment of venous thromboembolism: a systematic review and network meta-analysis
Heart
Review of 16 studies (n=22,000) found that, for extended treatment, vitamin K antagonists (VKAs) and direct oral anticoagulants reduced the risk of recurrent venous thromboembolisms vs aspirin. The risk of bleeding was higher with high and standard intensity VKAs however.
NIHR Signal: The blood-thinner apixaban is less likely to cause major bleeding than warfarin
National Institute for Health Research Signal
Expert commentary is provided for a cohort study which found a lower rate of major bleeding with apixaban vs warfarin (HR 0.66, 95%CI 0.54- 0.79). Residual confounding is likely however, and these data should only be considered supportive of randomised trials, not replacing them.
Venous Thromboembolism: Advances in Diagnosis and Treatment
Journal of the American Medical Association
Amongst other points, this review of 32 studies from the US perspective notes that the introduction of direct oral anticoagulants has allowed for a simplified treatment and has made extended secondary prevention more acceptable.
European Heart Journal
A patent foramen ovale is implicated in pathogenesis of a number of medical conditions; however, the subject remains controversial and no official statements have been published. This paper reviews available trial evidence and defines principles needed to guide decision making.
Association of Genetic Variants With Warfarin-Associated Bleeding Among Patients of African Descent
Journal of the American Medical Association
This case-control study (n=215) in patients of African descent found that 4 single nucleotide polymorphisms on chromosome 6 were associated with an increased risk of major bleeding at INR<4. Authors highlight that validations in an independent prospective cohort is required.
Spontaneous splenic rupture due to rivaroxaban
Drug and Therapeutics Bulletin
This summary describes the fifth case report of of spontaneous splenic rupture of a patient treated with rivaroxaban and highlights that this has also been reported with apixaban and dabigatran. It suggests key learning points, including checking for drug interactions.
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:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
The Lancet Haematology
Dutch RCT (n=865) found that, using the UK tariff for EQ-5D for ascertaining Quality Adjusted Life Years, an individualised strategy was more effective in clinical outcomes and less costly than standard 2 years of elastic stocking compression therapy.
Circulation
This review summarises the mechanisms involved in the high ischaemic and bleeding risk of patients with chronic kidney disease CKD and the risk–benefit ratio of potent antiplatelet drugs during acute coronary syndrome.
Medicines and Healthcare products Regulatory Agency
MHRA advises that rivaroxaban treatment in patients who undergo transcatheter aortic valve replacement should be stopped and switched to standard of care. It notes rivaroxaban is not licensed for thromboprophylaxis in patients with prosthetic heart valves, and should not be used.
Atrial fibrillation, antithrombotic treatment, and cognitive aging: A population-based study
Neurology
Swedish cohort study (n=2685) found AF linked to faster global cognitive decline and an increased risk of all cause dementia in older people (HR 1.40, 95% CI, 1.11–1.77). Use of anticoagulant drugs (but not antiplatelets) may reduce dementia risk in this group (0.40; 0.18–0.92).
Surgery versus thrombolysis for initial management of acute limb ischaemia
Cochrane Database of Systematic Reviews
This updated review (5 RCTs; nil new) concludes there is currently no evidence in favour of either initial thrombolysis or initial surgery as the preferred option in terms of limb salvage, amputation, or death; thrombolysis may be associated with higher risk of complications.
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:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
Journal of Alzheimer's Disease
Review of 27 trials found fewer people with dementia (DM) received oral anticoagulation (AC) vs. people without DM (32 v. 48%) but there was no difference in composite of embolic events/MI/all-cause death. People with DM had higher bleeding risk and poorer AC control on warfarin.
Cochrane Database of Systematic Reviews
Review of 9 studies (n=1,044) found insufficient evidence to demonstrate benefit or harm of using anticoagulants with or without aspirin versus aspirin alone in people with antiphospholipid antibodies and a history of recurrent pregnancy loss and with no such history.
NIHR Signal: Two antiplatelet drugs may prevent further strokes but increase major bleeds
National Institute for Health Research Signal
Expert commentary is provided for an RCT which found that clopidogrel plus aspirin resulted in fewer ischaemic events, but more major bleeds vs aspirin. There may be a place for dual anti-platelets, but UK practice is clopidogrel monotherapy, and the comparator here was aspirin.
British Medical Journal
RCT (n=870) found dual antiplatelet therapy (DAPT) to 6 months was non-inferior to DAPT for 12 months in patients with event-free STEMI at 6 months after primary PCI with second generation drug-eluting stents (HR 0.73, 95% CI, 0.41-1.27, p=0.26, and p=0.004 for non-inferiority).
Circulation
Analysis of 4 substudies found no difference in stroke/systemic embolism, major bleeding, or death linked to procedures requiring temporary interruption of DOACs /warfarin (WF). For procedures using uninterrupted anticoagulation, DOACs had 38% lower risk of major bleeding vs. WF.
Anticoagulation for perioperative thromboprophylaxis in people with cancer
Cochrane Database of Systematic Reviews
Review (20 RCTs; n=9771) found no difference between perioperative thromboprophylaxis with low molecular weight heparin (LMWH) vs unfractionated heaparin and LMWH vs fondaparinux in their effects on mortality, thromboembolic outcomes, major bleeding, or minor bleeding.
The Lancet Haematology
Sub group analysis (n=534) found that rivaroxaban was associated with fewer recurrent stroke events than aspirin (4.8 versus 2.6 events/100 person-years) but this effect was not statistically significant.
Rivaroxaban vs warfarin in high-risk patients with antiphospholipid syndrome
Blood
This study comparing rivaroxaban and warfarin (target INR 2.5) in high-risk patients with thrombotic antiphospholipid syndrome was terminated prematurely (120 patients enrolled) due to an excess of events in the rivaroxaban group (19% v 3% with warfarin).
Biospace Inc.
Approval was based on data from the Phase III HAVEN 3 and HAVEN 4 trials, which showed it was associated with clinically meaningful reductions in treated bleeds compared to no prophylaxis. In the EU it is currently approved only for use in patients with factor VIII inhibitors.
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:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
