Items filtered by date: December 2021

Updated COVID-19 vaccination guidance: blood clotting information for healthcare professionals

Public Health England
This guidance has been updated to include antiphospholipid syndrome, interchangeability of COVID-19 vaccines, samples required for whole genome sequencing and the latest MHRA data.

 

Postoperative low molecular weight heparin bridging treatment for patients at high risk of arterial thromboembolism (PERIOP2): double blind randomised controlled trial

British Medical Journal
RCT (n=1471, Canada & India) found that in patients with AF or mechanical heart valves who had warfarin interrupted for a procedure, no significant benefit was found for postop dalteparin bridging to prevent major thromboembolism (occurred in 1.0% vs. 1.2% placebo within 90 days).

 

 

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

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Andexanet Alfa or Prothrombin Complex Concentrate for Factor Xa Inhibitor Reversal in Acute Major Bleeding : A Systematic Review and Meta-Analysis

Critical Care Medicine
Review of 21 studies (n=1716) found haemostatic effectiveness of 71% & 76% for andexanet & prothrombin complex concentrate respectively at 24hrs. Mortality rate was 23.3% & 15.8%. Analysis for controlling confounders did not demonstrate significant differences between treatments.

 

Effectiveness and safety among direct oral anticoagulants in nonvalvular atrial fibrillation: A multi-database cohort study with meta-analysis

British Journal of Clinical Pharmacology
Review of cohort studies (total n=227,679) found apixaban had a lower rate of ischaemic stroke or thromboembolism (HR 0.85, 95%CI 0.74-0.99) and major bleeding (0.61, 0.53-0.70) vs rivaroxaban. There were no significant differences in risk between apixaban and dabigatran.

 

Which is the best model to assess risk for venous thromboembolism in hospitalised patients?

British Medical Journal
Practice article notes risk assessment models (RAMs) help clinicians decide who should be offered pharmacological thromboprophylaxis, but variation exists in their composition of risk factors and thresholds for high and low risk, and there is uncertainty over the most optimal RAM.

 

 

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

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Systematic review of machine learning models for personalised dosing of heparin

British Journal of Clinical Pharmacology
Review concluded that there are limited studies of machine learning models for unfractionated heparin dosing, and none report a model ready for routine clinical use. Studies are low quality, inadequately report study factors and lack of external validation and impact analysis.

 

Total Ischemic Event Reduction with Rivaroxaban after Peripheral Arterial Revascularization in the VOYAGER PAD Trial

American Journal of Cardiology
Sub-analysis (n=6564) found rivaroxaban plus aspirin reduced total primary events (acute limb ischemia, major amputation, MI, ischemic stroke, or CV death; HR 0.86,95% CI 0.75-0.98; p=0.02) and peripheral revascularizations and VTE (0.86; 0.79-0.95; p=0.003) vs aspirin alone.

 

Single direct oral anticoagulant therapy in stable patients with atrial fibrillation beyond 1 year after coronary stent implantation

Heart
Korean study (n=4294; 94% with drug-eluting coronary stents) showed similar efficacy in preventing ischaemic events in the DOAC monotherapy vs DOAC plus antiplatelet group (HR 0.828, 95% CI 0.660 to 1.038) with lower risk of major bleeding (HR 0.690, 95% CI 0.481 to 0.989).

 

Sex Differences Among Patients With High Risk Receiving Ticagrelor With or Without Aspirin After Percutaneous Coronary Intervention: A Subgroup Analysis of the TWILIGHT Randomized Clinical Trial

JAMA Cardiology
Analysis (n= 7119) found women had a higher bleeding risk vs men, which was mostly attributable to baseline differences, whereas ischemic events were similar. Benefits of early aspirin withdrawal with continuation of ticagrelor were generally comparable in women and men.

 

Comparative Effectiveness of Aspirin Dosing in Cardiovascular Disease

New England Journal of Medicine
Open-label pragmatic trial found no differences in cardiovascular events (event rate 7.28% vs 7.51%; HR 1.02; 95% CI 0.91 to 1.14) or major bleeding (0.63% vs 0.60%; HR 1.18; 95% CI, 0.79 to 1.77) in patients with CVD assigned to 81 mg or 325 mg of aspirin daily, respectively.

 

Aspirin versus clopidogrel for chronic maintenance monotherapy after percutaneous coronary intervention (HOST-EXAM): an investigator-initiated, prospective, randomised, open-label, multicentre trial

The Lancet
Korean study found clopidogrel vs aspirin monotherapy significantly reduced composite of all-cause death, non-fatal MI, stroke, readmission due to acute coronary syndrome, and bleeding (n=5530; 24 month follow up; event rate 5.7% vs 7.7%; HR 0.73; 95% CI 0.59–0.90).

 

 

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

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Sex‐influence on the time in therapeutic range (TTR) during oral anticoagulation with coumarin derivatives: systematic review and meta‐analysis

British Journal of Clinical Pharmacology
Review of 22 studies (n=110 to 104,505 of which 183,612 women [45%]) found an association between female sex and worse oral anticoagulation control (OR for TTR=0.87; 95% CI=0.78-0.96; p=0.006, based on meta-analysis of 15 studies).

 

Anticoagulant Use for Atrial Fibrillation Among Persons With Advanced Dementia at the End of Life

JAMA Internal Medicine
Study of 15,217 nursing home residents with AF and advanced dementia in US found ~30% remained on anticoagulation (AC) in last 6 months of life, underscoring fact that whilst there is well-defined threshold for starting AC for AF, there is no clear standard for stopping it.

 

Tranexamic acid and bleeding in patients treated with non-vitamin K oral anticoagulants undergoing dental extraction: The EXTRACT-NOAC randomized clinical trial

PLOS Medicine
RCT (n=218) found use of 10% tranexamic acid mouthwash does not seem to reduce rate of periprocedural or early postop oral bleeding (OB) up to day 7 vs. placebo (occurred in 26.4% vs 28.6%,respectively), but appears to reduce delayed bleeds & postop OB if multiple teeth extracted.

 

Venous thromboembolism

The Lancet
This Seminar focuses on recent (past 5 years) advances in epidemiology, pathophysiology, diagnosis, treatment, and prevention of deep vein thrombosis of the legs and pulmonary embolism. Future directions are also discussed.

 

Andexanet alfa for reversing anticoagulation from apixaban or rivaroxaban - guidance (TA697)

National Institute for Health and Care Excellence
Andexanet alfa is recommended as an option for reversing anticoagulation from apixaban or rivaroxaban in adults with life-threatening or uncontrolled bleeding, only if requirements met as outlined in guidance.

 

Effectiveness and safety of oral anticoagulants in elderly patients with atrial fibrillation

Heart
Nationwide cohort study of patients ≥75 years (n=30,401) found that when initiating oral anticoagulation for AF, standard and reduced dose DOACs had similar risks of stroke/systemic embolism as warfarin and lower or similar risks of 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:

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

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Prior use of therapeutic anticoagulation does not protect against COVID‐19 related clinical outcomes in hospitalized patients: a propensity score‐matched cohort study

British Journal of Clinical Pharmacology
Retrospective Dutch study (n=1154) found no associations between prior therapeutic anticoagulation use (16% of population) and mortality (RR 1.02; 95% CI; 0.80‐1.30) or length of hospital stay (7.0 vs 7.0 days, p=0.69), except lower risk of pulmonary embolism (0.19; 0.05‐0.80).

 

Atrial fibrillation: diagnosis and management- Updated guidance (NG196)

National Institute for Health and Care Excellence
Updates include use of tools to calculate risk of bleeding when considering use of anticoagulants, role of newer anti-clotting drugs, and use of treatments that aim to destroy or isolate the abnormal sources of electrical impulses in the heart that may be driving AF (ablation).

 

Is there a circannual variation in the anticoagulation control of warfarin?

European Journal of Hospital Pharmacy
This retrospective study (n=204) found no significant intra-individual differences in mean time in therapeutic range. Patients with poor anticoagulation control, high INR variability and high warfarin sensitivity index was not significantly different between the seasons.

 

Genotype‐guided antiplatelet treatment versus conventional therapy: A systematic review and meta‐analysis

British Journal of Clinical Pharmacology
Review of 16 studies (n=10,561, 8 studies were RCTs) found lower rates of major adverse cardiovascular events (RR 0.56, 95%CI 0.44‐0.73), stent thrombosis (0.40, 0.24‐0.67) and myocardial infarction (0.45, 0.35‐0.58) with genotype‐guided vs conventional treatment.

 

Tranexamic Acid for the Prevention of Blood Loss after Cesarean Delivery

New England Journal of Medicine
RCT (n=4551) found tranexamic acid resulted in a significantly lower incidence (LI) of calculated estimated blood loss >1000ml or red-cell transfusion by day 2 vs. placebo (26.7% vs. 31.6%, risk ratio, 0.84; 95% CI, 0.75-0.94; p=0.003), but not LI of haemorrhage-related outcomes.

 

Arterial events, venous thromboembolism, thrombocytopenia, and bleeding after vaccination with Oxford-AstraZeneca ChAdOx1-S in Denmark and Norway: population based cohort study

British Medical Journal
Study (n=281,264) notes increased rates of VTE events (standardised morbidity ratio 1.97; 95% CI, 1.50 to 2.54 and 11 [5.6 to 17.0] excess events per 100 000 vaccinations) including cerebral venous thrombosis, but the absolute risks were small.

 

 

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

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Announcement regarding AstraZeneca vaccine and next steps

NHS England
This letter which follows the updated guidance from the MHRA and the independent Joint Committee on Vaccination and Immunisation, sets out the criteria for administration of the Astra Zeneca vaccine following reports of concurrent thrombosis and thrombocytopenia.

 

Thrombosis and Thrombocytopenia after ChAdOx1 nCoV-19 Vaccination

New England Journal of Medicine
Article reports 5 Norwegian cases (age 32 to 54 years) of severe venous thrombosis and thrombocytopenia 7 to 10 days after first vaccine dose, all whom had high level of antibodies to platelet factor 4–polyanion complexes, but no previous exposure to heparin.

 

Thrombotic Thrombocytopenia after ChAdOx1 nCov-19 Vaccination

New England Journal of Medicine
Report describes 11 German/Austrian pts (9 women; median age 36 years) who developed immune thrombotic thrombocytopenia mediated by platelet-activating antibodies against PF4, which clinically mimics autoimmune heparin-induced thrombocytopenia, 5 to 16 days after vaccination.

 

Screening and management of atrial fibrillation in primary care

British Medical Journal
This review explores the epidemiology, screening, and risk assessment of AF, as well as management of its symptoms (rate and various rhythm control options) and stroke risk (anticoagulation and other treatments), and offers a model for integration of components of AF care.

 

Biomarker-based risk prediction with the ABC-AF scores in patients with atrial fibrillation not receiving oral anticoagulation

Circulation
Data from 2 trials(n=4305) found the ABC-AF scores showed better discrimination vs traditional risk scores & were recalibrated for precise risk estimation in patients not on anticoagulants & could provide improved decision support regarding treatment of individual patient with AF.

 

Guided versus standard antiplatelet therapy in patients undergoing percutaneous coronary intervention: a systematic review and meta-analysis

The Lancet
Review (11 RCTs, 3 observational) found guided selection of antiplatelets was associated with a reduction in major adverse cardiovascular events (RR 0.78, 95% CI 0.63–0.95, p=0.015) and other individual outcomes vs standard therapy; outcomes varied according to strategy used.

 

Adverse Events Associated With the Addition of Aspirin to Direct Oral Anticoagulant Therapy Without a Clear Indication

JAMA Internal Medicine
Cohort study (n=3280 at 4 anticoag clinics in Michigan) found ~one-third of patients with AF and/or VTE on a DOAC received aspirin without clear indication, and concurrent use was linked to increased bleeding vs. DOAC monotherapy (6.0 vs. 31.6 bleeds/100 patient years, p= 0.01).

 

microINR for anticoagulation therapy (MIB257)

National Institute for Health and Care Excellence
Evidence summary is provided for this portable device for self-measurement of INR. Reduced blood sample size is an innovative aspect. Evidence comes from 5 observational comparative studies vs laboratory-based and alternative point-of-care meters.

 

 

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

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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.

 

Perioperative Neurological Evaluation and Management to Lower the Risk of Acute Stroke in Patients Undergoing Noncardiac, Nonneurological Surgery: A Scientific Statement From the American Heart Association/American Stroke Association

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.

 

Management of antithrombotic therapy in patients undergoing transcatheter aortic valve implantation: a consensus document of the ESC Working Group on Thrombosis and the European Association of Percutaneous Cardiovascular Interventions (EAPCI), in collaboration with the ESC Council on Valvular Heart Disease

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:

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

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Relative risk of arterial and venous thromboembolism in persons with cancer vs. persons without cancer—a nationwide analysis

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.

 

Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients With Valvular Atrial Fibrillation: A Population-Based Cohort Study

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:

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

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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.

 

Aspirin versus anticoagulation in cervical artery dissection (TREAT-CAD): an open-label, randomised, non-inferiority trial

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:

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

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Prasugrel versus ticagrelor in patients with myocardial infarction undergoing percutaneous coronary intervention

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).

 

Administering Thrombolysis for Acute Ischemic Stroke in Patients Taking Direct Oral Anticoagulants: To Treat or How to Treat

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.

 

International Society on Thrombosis and Haemostasis (ISTH) statement on the AstraZeneca COVID-19 vaccine and thrombosis

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.

 

Development of imaging-based risk scores for prediction of intracranial haemorrhage and ischaemic stroke in patients taking antithrombotic therapy after ischaemic stroke or transient ischaemic attack: a pooled analysis of individual patient data from cohort studies

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.

 

COVID-19 Vaccine AstraZeneca: benefits still outweigh the risks despite possible link to rare blood clots with low blood platelets

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.

 

Effect of Intermediate-Dose vs Standard-Dose Prophylactic Anticoagulation on Thrombotic Events, Extracorporeal Membrane Oxygenation Treatment, or Mortality Among Patients With COVID-19 Admitted to the Intensive Care Unit - The INSPIRATION Randomized Clinical Trial

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:

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

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