Therapeutic Anticoagulation (Heparin) in the Management of Severe COVID-19 (SARS-CoV-2 Positive) Patients

Chief Medical Officer
Alert advises not to use therapeutic dose UFH or LMWH for patients with COVID-19, unless there is a standard indication (e.g. acute VTE), as the REMAP-CAP study has reported therapeutic dose of heparin does not improve clinical outcome in the critical care setting.

Pfizer-BioNTech COVID-19 Vaccine use in anticoagulation and bleeding disorders

Specialist Pharmacy Service
This page summarises and signposts Information on use of the vaccine in patients who are receiving anticoagulants or have a bleeding disorder.

Letter sent to Healthcare Professionals: Ondexxya (andexanet alfa)

Portola
Letter advises to avoid use of andexanet alfa before heparinisation (e.g. during surgery) because it causes unresponsiveness to anticoagulant effects of heparin and results of coagulation tests might be misleading when both given within a short time of one another.

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

Discontinuation of oral anticoagulation in atrial fibrillation and risk of ischaemic stroke

Heart
Population-based cohort study with nested case–control analysis (76 882 UK;41526 Denmark) found pts who discontinued oral anticoagulation therapy had a two to threefold higher risk of ischaemic stroke vs current users (UK OR 2.99; 95% CI 2.31 to 3.86: Denmark 2.30; 1.79 to 2.95).

Bleeding with Apixaban and Dalteparin in Patients with Cancer-Associated Venous Thromboembolism: Results from the Caravaggio Study

Thrombosis and Haemostasis
Study reports no excess in GI bleeding in patients who received apixaban, including those with GI cancer; major bleeding occurred in 22 of 576 on apixaban (3.8%) and in 23 of 579 patients on dalteparin (4.0%). The sites of major bleeding were similar between the two groups.

Stroke Prevention in Atrial Fibrillation: Looking Forward

Circulation
Review summarises the major advances in stroke prevention for patients with atrial fibrillation during the past 30 years and focuses on novel diagnostic and treatment approaches currently under investigation in ongoing clinical trials.

Erythromycin: caution required due to cardiac risks (QT interval prolongation); drug interaction with rivaroxaban

Medicines and Healthcare products Regulatory Agency
Erythromycin should not be given to patients with a history of QT interval prolongation or ventricular cardiac arrhythmia. A potential drug interaction between rivaroxaban and erythromycin resulting in increased risk of bleeding has also 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:

http://www.evidence.nhs.uk/about-evidence-services/content-and-sources/medicines-information/new-medicines-awareness-services

Dabigatran etexilate for the treatment of acute venous thromboembolism in children (DIVERSITY): a randomised, controlled, open-label, phase 2b/3, non-inferiority trial

The Lancet Haematology
RCT (n=328) found age/weight adjusted dabigatran non-inferior to standard of care (LMWH/unfractionated heparin/vit K antagonists/fondaparinux) for the composite efficacy endpoint of thrombus resolution, & no recurrent VTE or VTE-death: 42%vs 46%; p<0.0001).

Short dual antiplatelet therapy followed by P2Y12 inhibitor monotherapy vs. prolonged dual antiplatelet therapy after percutaneous coronary intervention with second-generation drug-eluting stents: a systematic review and meta-analysis of randomized clinical trials

European Heart Journal
Review (5 RCTs, n=32,145) reports 1–3 months of dual antiplatelet therapy (DAPT) followed by P2Y12 inhibitor single antiplatelet therapy is associated with lower major bleeding and similar stent thrombosis, all-cause death, myocardial infarction & stroke vs. prolonged DAPT.

Association Between Prehospital Tranexamic Acid Administration and Outcomes of Severe Traumatic Brain Injury

JAMA Neurology
Prospective study (n=1,827) found prehospital tranexamic acid increased mortality in patients with isolated severe traumatic brain injury (OR 4.49; 95% CI, 1.57-12.87; p=0.005), highlighting need for judicious use of the drug when there is no evidence for extracranial haemorrhage.

Meta-Analysis of Safety and Efficacy of Direct Oral Anticoagulants Versus Warfarin According to Time in Therapeutic Range in Atrial Fibrillation

American Journal of Cardiology
Review of RCTs investigating time in therapeutic range (TTR) found, across all TTR levels, DOACs had lower risk of stroke or systemic embolism vs warfarin (HR 0.73, 95%CI 0.61-0.88). There was a lower risk of major bleeding for DOACs vs warfarin in medium or low TTR only.

Risk factors for emergency department revisit in elderly patients with gastrointestinal bleeding secondary to anticoagulant therapy

European Journal of Hospital Pharmacy
Study in 80 patients on oral anticoagulants who visited the emergency department (ED) for gastrointestinal bleeding found 13.7% revisited the ED for bleeding episodes 30 days after hospital discharge, with no particular differences between the types of anticoagulant prescribed.

Retinal vascular occlusions

The Lancet
This review article looks at management of retinal vascular occlusions, which are common causes of visual impairment. Acute management of retinal artery occlusions involves a multidisciplinary approach, whereas treatment of retinal vein occlusions is provided by ophthalmologists.

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

Implementing point-of-care D-dimer tests for deep vein thrombosis (DVT)

City Health Care Partnership CIC

NG158 recommends considering the use of POC D-dimer tests as an alternative to laboratory D-dimer tests. Since implementing the tests, the main advantage has been the reduction in time from the person presenting, to diagnosis and receiving treatment.

Bleeding risk with rivaroxaban compared with vitamin K antagonists in patients aged 80 years or older with atrial fibrillation

Heart
Prospective cohort study (n=1,903) found major bleeding was significantly lower with rivaroxaban as compared to use of vitamin K antagonists (7.4 vs 14.6 per 100 patient years, HR 0.66, 95% CI 0.43-0.99). This was largely driven by lower risk of intracerebral bleeding.

Inappropriate Prescriptions of Direct Oral Anticoagulants among Patients with Atrial Fibrillation in General Practice: a Cross-sectional Analysis of the French CACAO Cohort Study

British Journal of General Practice
In this analysis (n=438), 39.4% received at least one inappropriate DOAC prescription – mainly under-dosing (31.3%). Factors independently associated with under-dosing were older age, those with kidney failure, a higher risk for ischemic stroke and/or a higher risk for bleeding.

Differences in risk factors for anticoagulant‐related nephropathy between warfarin and direct oral anticoagulants: analysis of the Japanese Adverse Drug Event Report database

British Journal of Clinical Pharmacology
This short report describes research suggesting the risk factors for kidney injury in people using warfarin (male sex and age ≥80 years) were different to those in people using DOACs (weight ≥80 kg and use of dabigatran); these factors may be associated with bleeding 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