electronic Medicines compendium
Information has been added on weight based dosing as has warning that in patients with existing CV risk factors, substitiution therapy with FVIII may increase CV risk. ADR data from trial in treatment naïve patients, aged 0 to 6 years have been added.
Revised SPC: Xarelto (rivaroxaban) 2.5 mg film-coated tablets
electronic Medicines compendium
DRESS syndrome and anaphylactic reactions have been added to SPC as adverse effects. SPC has been amended to advise interaction with fluconazole/erythromycin/clarythromycin is likely not clinically relevant in most patients but can be potentially significant in high-risk patients.
JAMA Neurology
Review of 5 RCTS (n=39,398) found 15 to 20mg dose of rivaroxaban (RV) once daily is linked to increased risks of intracranial haemorrhage vs. aspirin (2 trials; OR, 3.31; 95% CI, 1.42-7.72), while smaller daily doses of RV and apixaban were not, suggesting dose dependent risk.
Revised SPC: Eliquis (apixaban) 2.5 mg film-coated tablets
electronic Medicines compendium
The SPC has been updated to advise that care should be taken if patients are treated concomitantly with SSRIs or SNRIs, due to the increased bleeding risk.
Effect of aspirin in vascular surgery in patients from a randomized clinical trial (POISE‐2)
British Journal of Surgery
RCT (n=10,010) found that perioperative withdrawal of chronic aspirin therapy did not increase cardiovascular or vascular occlusive complications (HR for death or MI = 1.48, 95% CI 0.71-3.09 for aneurysm repair and 1.16, 0.62-2.17 for surgery for occlusive vascular 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:
http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services
Revised SPC: Brilique (ticagrelor) products
electronic Medicines compendium
Timing of discontinuation of ticagrelor prior to elective surgery has been changed from 7 to 5 days.
Circulation
This review aims to provide a brief summary on physiology of haemostasis, review key studies on DOAC safety and efficacy in AF catheter ablation, and identify current gaps in knowledge on intraprocedural anticoagulation and monitoring.
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 Vascular Surgery
Review of 14 studies (10 RCTs) found that dual antiplatelet therapy (DAPT) reduces rates of major adverse cardiac events, major adverse cardiac and cerebrovascular events, and mortality compared with use of mono APT after revascularisation in peripheral arterial disease.
JAMA Internal Medicine
Restrospective review (single centre, n=1,408) found that almost all isolated subsegmental pulmonary embolisms (SSPEs) were anticoagulated with a similar frequency to more proximal embolisms and that treatment was associated with harm (e.g. bleeding).
Circulation
On the basis of pivotal clinical trials this group recommended that a DOAC be preferred over a vitamin K antagonist as the oral anticoagulant of choice. This document provides a focused update on the rationale for the new expert consensus–derived recommendations.
CHMP negative opinion: Dexxience (betrixaban) for the prevention of venous thromboembolism
European Medicines Agency
A previous negative opinion was confirmed after re-examination. The CHMP considered that the study did not satisfactorily show efficacy when used for preventing blood clots in patients admitted to hospital for recent medical illness. Also, those given betrixaban had more bleeding.
CHMP positive opinion: Xarelto (rivaroxaban) licence extension
European Medicines Agency
The license extension is for use (as 2.5mg tablets in combination with aspirin) for the prevention of atherothrombotic events in adult patients with coronary artery disease or symptomatic peripheral artery disease at high risk of ischaemic events.
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 the American Medical Association
Based on a Cochrane review of 15 trials it is concluded that for every 1000 patients treated for about 10 months with the combination instead of aspirin alone there will be 13 and 23 fewer cases of MI and stroke respectively but 9 additional cases of major bleeding.
British Journal of General Practice
Analysis of data from the national Quality and Outcomes Framework showed that the percentage of patients prescribed anticoagulants for atrial fibrillation increased from 65.1% to 77.9% between 2012/13 and 2015/16 but 9 out of 10 CCGs still do not achieve 90% anticoagulation.
Revised SPC: Revolade (eltrombopag) tablets
electronic Medicines compendium
Eltrombopag is highly coloured and so has the potential to interfere with some laboratory tests eg total bilirubin and creatinine testing. If the laboratory results and clinical observations are inconsistent, re-testing using another method is advised.
British Medical Journal
Review (7 RCTs; n=3913) found that patent foramen ovale closure prevents recurrent stroke relative to antiplatelet therapy, but not anticoagulants, and is associated with procedural complications and persistent atrial fibrillation in adults aged <60 years with cryptogenic stroke.
European Heart Journal
RCT (n=662) found that either continued or interrupted direct oral anticoagulants (dabigatran, rivaroxaban, or apixaban) was a reasonable management strategy at the time of device surgery (primary outcome of clinically significant haematoma occurred in 2.1% of both arms; p=0.97).
Andexxa—An Antidote for Apixaban and Rivaroxaban
Journal of the American Medical Association
This Medical Letter review discusses the mechanism of action, adverse effects, and cost associated with coagulation factor Xa that was approved by the FDA for reversal of the anticoagulant effect of apixaban and rivaroxaban.
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
Revised SPC: Xarelto (rivaroxaban) tablets - all strengths
electronic Medicines compendium
DRESS syndrome (Drug reaction with eosinophilia and systemic symptoms) noted in post-marketing reports (frequency very rare). Interaction with fluconazole/ erythromycin/clarythromycin not clinically relevant in most patients but potentially significant in high-risk patients.
Eltrombopag (Revolade): reports of interference with bilirubin and creatinine test results
Medicines and Healthcare products Regulatory Agency
Eltrombopag can cause serum discolouration and interference with the test results of creatinine and bilirubin. If these laboratory results are inconsistent with clinical observations, request re-testing using another method to determine the validity of the result.
Fatal or Irreversible Bleeding and Ischemic Events With Rivaroxaban in Acute Coronary Syndrome
Journal of the American College of Cardiology
Review of ATLAS ACS 2-TIMI 51 trial found that addition of rivaroxaban 2.5mg bd to aspirin and clopidogrel/ticlodipine was associated with 105 (95% CI 6-204) fewer fatal or irreversible events (including ischaemic and haemorrhagic events), per 10,000 patient years vs dual therapy.
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
BMJ Open
Study (n=3309) found that atrial fibrillation (AF) occurred more frequently in patients admitted with recurrent (30.2%) vs first stroke (17.1%). Of 666 (20.1%) patients with history of AF, 45.3% were anticoagulated, 41.9% untreated and 12.8% deemed unsuitable for anticoagulation.
Anticoagulation and Antiplatelet Strategies After On-X Mechanical Aortic Valve Replacement
Journal of the American College of Cardiology
RCT (n=576) found, that for low thrombotic risk patients, dual antiplatelet therapy had higher rates of thromboembolism vs warfarin plus aspirin (3.12% vs 0.29% per patient/year, p=0.02).
Journal of the American Medical Association
RCT (n=313) found that in those with non-disabling stroke, treatment with alteplase did not increase the likelihood of favourable functional outcome at 90 days vs aspirin. Symptomatic intracranial haemorrhage was more common with alteplase (3.2% vs 0%, p<0.05).
New product: AROVI (enoxaparin biosimilar) pre-filled syringes with safety device
electronic Medicines compendium
This enoxaparin biosimilar comes as 2,000 IU (20mg/0.2ml), 4,000 IU (40mg/0.4ml), 6,000 IU (60mg/0.6ml), 8,000 IU (80mg/0.8ml), 10,000 IU (100mg/1ml), 12,000 IU (120mg/0.8ml) and 15,000 IU (150mg/1ml) pre-filled syringes with safety device.
NHS England
NHS England will routinely commission this specialised treatment. The arrangements and criteria for funding of this treatment for the population in England is outlined in this policy document.
NHS England
NHS England will routinely commission this specialised treatment. The arrangements and criteria for funding of this treatment for the population in England is outlined in this policy document.
Outcomes in anticoagulated patients with atrial fibrillation and with mitral or aortic valve disease
Heart
Analysis (n=14,793) found in anticoagulated AF patients, aortic stenosis (AS) is linked to higher risk of stroke/systemic embolism, bleeding/death. Efficacy and safety benefits of apixaban vs. warfarin were consistent regardless of presence of mitral/aortic regurgitation or AS.
Prevalence and treatment of atrial fibrillation in UK general practice from 2000 to 2016
Heart
17 sequential cross-sectional analyses found prevalence of recorded AF has increased from 2000 to 2016 (2.14 to 3.29%); anticoagulation of eligible patients with AF has more than doubled (35.4 to 75.5% in high stroke risk group), alongside decrease in use in ineligible patients.
The Lancet
Analysis of 10 trials of aspirin in primary prevention (n=117,279) found low doses (75–100mg) were only effective in preventing vascular events in patients weighing <70kg, and had no benefit in 80% men and~ 50% women ≥70kg. Higher doses were only effective in patients ≥70kg.
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 Medical Journal
Trial (n=132 231 warfarin [WF],7744 dabigatran,37 863 rivaroxaban [RV],18 223 apixaban [AP] users) found AP to be safest drug with reduced risks of major, intracranial and GI bleeding vs. WF. RV and low dose AP were, however, linked to increased risks of all-cause mortality.
British Journal of General Practice
This study found the proportion of eligible AF patients prescribed anticoagulants improved from 65.1% in 2012/2013 to 77.9% in 2015/2016, with considerable increases in the eligible population as a result of decreased exception reporting and the use of the CHA2DS2VASc score.
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
Retrospective cohort study (n=2351 on apixaban; 23,172 on warfarin) found apixaban use may be linked to lower risk of major bleeding vs. warfarin (HR 0.72, 95% CI 0.59-0.87; P<0.001) with standard 5mg BD dose also linked to reductions in thromboembolic and mortality risk.
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
Antithrombotic Therapy for Peripheral Artery Disease in 2018
Journal of the American Medical Association
This article, form the US perspective, reviews current evidence and makes recommendations on antithrombotic therapy in patients with or without ischaemic limb symptoms, as well as in patients with or without manifest coronary or cerebrovascular disease.
Can small volume intramuscular injections be given to patients taking oral anticoagulants?
Specialist Pharmacy Service
Q+A notes most of published studies relate to IM influenza vaccination in patients on older anticoagulants. Data are limited and some findings are contradictory. There is very little published information about the risks of adverse effects with DOACs and IM injections.
The Lancet Haematology
Study (n= 176,001 matched to 880,005 non-pregnant) found 42-day risk of venous thromboembolism after induced abortion is double that of matched non-pregnant woman (30.1 v. 13.5/100,000; HR 2.23, 95% CI, 1.61–3.08), but is significantly lower than after livebirth (0.16; 0.12–0.22).
Roche introduces CoaguChek Vantus system with built in Bluetooth® technology in US
Biospace Inc.
Roche says this is first self-testing device for coagulation monitoring with built in Bluetooth technology. Patients can use tablet/smartphone with compatible app to send results via wireless connectivity, enabling healthcare providers to receive patients' INR results.
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
American Journal of Cardiology
Analysis of 8 studies (n=2439) found dual antiplatelets (vs. mono) linked to increased risk at 30 days of all-cause mortality, major/life-threatening bleeding, and major vascular complications without decrease in ischaemic complications;at 6 months, excess bleeding risk persisted.
The Lancet Haematology
Data from CATS cohort (n=1423) were used to select prognostic variables for inclusion in clinical prediction model. Two in final model that were externally validated (tumour-site category/ D-dimer) predicted risk of venous thromboembolism in ambulatory patients with solid cancers.
National Institute for Health Research Signal
Expert commentary is provided for an RCT which found aspirin as effective as rivaroxaban at preventing VTE post hip or knee surgery. While there are implications for savings, the key message is that postoperative prophylaxis is the most important factor for attenuating VTE risk.
British Journal of Clinical Pharmacology
Cohort study (n=413,116) found an increasing adjusted rate difference of GI bleeding for SSRIs vs no SSRIs as kidney function deteriorated (2.0 events per 1000 person-years for no CKD vs 7.9 events per 1000 person-years for CKD stage 4/5, p-trend = 0.001).
Antithrombotic Therapy for Peripheral Artery Disease in 2018
Heart
This article reviews cardiovascular risk stratification of patients with peripheral artery disease and current standards of practice for use of antiplatelet and anticoagulant therapies.
Revised SPC: Eliquis (apixaban) 2.5 mg film-coated tablets
electronic Medicines compendium
The SPC has been amended to state that 'apixaban can be initiated or continued in NVAF patients who may require cardioversion', and to include detail on dose in relation to cardioversion. Data from the EMANATE study (conducted in patients undergoing cardioversion) has been added.
The Lancet
In this study (n=1,754), the incidence of the primary composite endpoint was lower in those randomised to dabigatran 110mg BD (11% vs 15% with placebo; HR 0.72; 95% CI 0.55-0.93; p=0.0115), with no significant increase in major bleeding (3% v 4%; HR 0.92; 0.55-1.53; p=0.76).
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
