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Managing Anticoagulation Interruptions

Managing Anticoagulation Interruptions | Heart and Vascular Health | Scoop.it

On the ClotBlog with Dr. Samuel Z. Goldhaber, at theheart.org on Medscape speaking to you from the American College of Cardiology Scientific Symposium in Washington, DC. Today, I have a special guest and a special friend, Dr. Seth Bilazarian. Seth, welcome to the ClotBlog.

Today I wanted to discuss with you a problem that you and I get calls and emails about over and over again, and that is how to safely interrupt anticoagulation. There are several different levels that we can quickly talk about, including cataract surgery and colonoscopy, but then we can go into the more nitty gritty area of what do we do with patients who have mechanical heart valves. Let's start with cataract surgery. Do you ever instruct your patients to interrupt their anticoagulation?

Seth Bilazarian, MD's insight:

Discussion between a leading academic on thrombosis (Dr Goldhaber) and a community based practitioner (me) on the complexity of managing anti-coagulation around the time of a procedure or surgery.

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Thanks for the great plug on twitter : John Mandrola, MD ‏@drjohnm 

Grt discussion on interrupting anticoagulation w/@DrSethdb & Dr Goldhaber http://www.medscape.com/viewarticle/824855?utm_source=twitterfeed&utm_medium=twitter&nbsp;… < Like this topic b/c #judgement critical.

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Rethinking Warfarin for Atrial Fibrillation

Rethinking Warfarin for Atrial Fibrillation | Heart and Vascular Health | Scoop.it

Full-page newspaper advertisements and a series of television commercials have urged patients with atrial fibrillation to “rethink warfarin” in favor of Eliquis (apixaban – Bristol-Myers Squibb). Apixaban is the latest of 3 new oral anticoagulants now competing with warfarin (Coumadin, and others) for the oral anticoagulant market.

Seth Bilazarian, MD's insight:

The authors of the medical letter have rightly urged clinicians to consider warfarin as a good alternative in patients who are clinically stable on warfarin and doing well. I certainly agree with this. However it accounts for only a minority of patients. My estimate is that only about 10% of patients have stable warfarin therapy.

For myself, I created mnemonic to try to help me quickly go through the important issues for determining whether a patient was a good candidate for one of the novel oral anticoagulants (Praqdaxa, Xarelto, Eliquis). CRABI is the one I use and the "I"is for instability on warfarin. To viewer download the slides from my blog checkout.

 http://news.theheart.org/static/drop/Private-practive-theheartorg-Dr-Seth-Bilazarian-KISS-CRABI.ppt

 

 

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What to do about bridging with novel oral anticoagulants

What to do about bridging with novel oral anticoagulants | Heart and Vascular Health | Scoop.it

Sharing a rare moment of person-to-person time during the scientific sessions in San Francisco, Dr Seth Bilazarian asks Dr. Samuel Goldhaber how he goes about bridging with "Novel oral anticoagulants" (NOACs) #dabigatran, #rivaroxaban, and #apixaban.

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Caution on initial bleeding risk with warfarin

Caution on initial bleeding risk with warfarin | Heart and Vascular Health | Scoop.it

My comment: We have new options for patients with atrial fibrillation.  These new drugs Pradaxa and Xarelto are under scrutiny because they are new nadn bleeding hazard has been reprted.  This study helps us understand that warfarin (coumadin) also has significcant risk and the risk is high in the first week of starting thsi medicine.  This early hazard but be an advatage for the newer options.

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Rates of serious bleeding among patients taking warfarin are much higher than those found in clinical trials of the drug and are even greater during the first month of use, according to a five-year study of 125,195 seniors with atrial fibrillation.

The findings complicate an already difficult decision-making process for patients with atrial fibrillation (AF) and highlight the importance of careful management of warfarin, especially during the first month of use, experts said. Warfarin is a generic anticoagulant that is marketed under brand names such as Coumadin and Jantoven.

Compared with clinical trials for warfarin that found serious hemorrhaging rates of between 1% and 3% per year, bleeding problems are more common in real-life clinical practice, said the study, published Nov. 26 in the Canadian Medical Assn. Journal. In the study, the overall rate of hemorrhaging — bleeds serious enough to send patients to the hospital — was 3.8% per person, per year.

However, during the first month of treatment, the annualized hemorrhage rates were 11.8% in all patients and 16.7% among patients with higher risk of stroke. 

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Pradaxa (dabigatran) Safety Review of Serious Bleeding Events by FDA

UPDATED 11/02/2012. Results of FDAs Mini-Sentinel assessment indicate that bleeding rates associated with new use of Pradaxa do not appear to be higher than bleeding rates associated with new use of warfarin.
My comment -= I hope this review by the FDA reassures patients that the use of Pradaxa is safe as an alternative to warfarin,. This adds to the randomized trial RE-L. Patients are being unnecessarily frightened by TV ads by malpractice attorneys and decisions about options fro treatment are being complicated without reason.,
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JAMA Article Says FDA Let Risky Drugs Hit Market

JAMA Article Says FDA Let Risky Drugs Hit Market | Heart and Vascular Health | Scoop.it

My comment: Do you want your drug approvals too fast or too slow? As a practioner I would like access to new therapies for my patients so we can make best decisions based on our assessment of the risks & benefts from the avaialble data.  Making drugs available does not require them to be used.  Not approving drugs absolutely prevents us from using them.

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An FDA effort to speed approval of new medicines allowed drugs onto the market without proper safety analysis, according to two drug-safety experts.

" the FDA could strike a better balance of safety versus innovation by insisting that companies produce more safety and effectiveness data soon after the drug is approved—and by insisting on automatic withdrawal of a drug if the data don't materialize. "Once a drug is approved, it is often very difficult to put the genie back in the bottle,"

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Anticoagulation in AF: Fork in the road or four-way-stop?

Anticoagulation in AF: Fork in the road or four-way-stop? | Heart and Vascular Health | Scoop.it

The FDA's recent decisions on novel anticoagulants in atrial fibrillation have stirred debate and generated some consternation. For the clinical practitioner, how can we efficiently and effectively communicate the issues related to anticoagulation choice to the patient?  Dr Bilazarian proposes -CRABI:

C - Prescription coverage?
R - Normal renal function?
A - Early adopter?
B - GI bleeding?
I - Instability on warfarin?

Download the powerpoint presentation and the comparative Excel sheet.

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Blood Thinners: JAMA patient page

Blood Thinners: JAMA patient page | Heart and Vascular Health | Scoop.it

There are 2 types of blood thinners, anticoagulants and antiplatelet drugs. Blood clots can cause problems when they prevent blood from flowing freely, especially to the heart and brain. Sometimes a doctor may not want a patient’s blood to clot as easily and will prescribe a blood thinner.

Seth Bilazarian, MD's insight:

Nice graphic that helps patients understand the differences between antiplatelet & anticoagulant therapy. This is an important source of confusion for patient's who believe that aspirin is an effective therapy for stroke prevention in atrial fibrillation (it is not).  Another potential confusion is why blood thinners or anticoagulants like warfarin or the newer agents (Pradaxa, Xarelto, Eliquis) are not effective treatments after placement of a stent in the coronary artery. Antiplatelet therapies like Plavix, Effient, or Brilinta are needed.

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Deborah Verran's curator insight, May 18, 1:56 AM

This is a good example of the type of reliable factual online information that is available to patients. Some transplant recipients will end up having to take these types of medications (for the appropriate indications). Hence the importance of this particular information.

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Novel Oral Anticoagulant transitions

Novel Oral Anticoagulant transitions | Heart and Vascular Health | Scoop.it

In my clinical practice, this is one of the most frequent things that I am asked to address -- whether it is dual antiplatelet therapy, stopping antiplatelet therapy in general, or stopping anticoagulants and adopting NOACs. It has been a challenge, but we have pretty good data to help guide decisions about NOACs, and this has been extensively covered.

But the issue about NOAC transitions is that we don't have a lot of data. It is uncharted territory. Making sense of NOAC transitions is something that I am trying to address for myself and sharing here in this blog to you as the "co-pupil" or "co-traveler" in this difficult area.

Seth Bilazarian, MD's insight:

My attempt to manage the topic of transitions with novel oral anti-coagulants (Pradaxa, Xarelto, Eliquis) - stiopping, starting, holding these agents for procedures. Interested in other physicians insights on this topic.

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Eliquis: New Medication for Atrial Fibrillation

An in-depth conversation between Pentucket Medical cardiologists Seth Bilazarian and Sunny Srivastava, focusing on a newly released medicine to reduce the risks of atrial fibrillation. The latest among recently approved blood thinners, Eliquis joins Pradaxa and Xarelto as an alternative to Coumadin, a drug that has been in use since the 1950s. Like Pradaxa and Xarelto, Eliquis has been shown to reduce risk of stroke and bleeding, as well as mortality. All the new drugs eliminate the need for regular blood testing that Coumadin necessitates.

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Warfarin in the Prevention of Stroke Associated with Nonrheumatic Atrial Fibrillation — NEJM

Warfarin in the Prevention of Stroke Associated with Nonrheumatic Atrial Fibrillation — NEJM | Heart and Vascular Health | Scoop.it

20 years ago today the SPINAF trial was published.  This was one of the last studies to compare warfarin to placebo in atrial fibrillation (Afib)  for the prevention of stroke.  For the lsat 20 years warfarin has been the standard of care.  Anticoagulants (blood thinners) prevent stroke in Afib.  After this there were only a few more studues that were done comparing warfarin to placebo or aspirin (SPAF-II in 1994)  because it was felt to not be ethical since the benefits of warfarin are so clear for stroke prevnetion.  

AIn teh US, we've had only warfarin (coumadin) until 2 years ago (10/2010) when the first of the novel oral anticoagulants (NOACs) were introduced.  Pradaxa (dabigatran) and Xarelto (rivaroxaban) are now available in the US.  We expext Eliquis (apixiban) in 2013 with others to follow.

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Pradaxa turns 19 (in dog years)

Pradaxa turns 19 (in dog years) | Heart and Vascular Health | Scoop.it

As Pradaxa (dabigatran) celebrates its second anniversary since FDA approval, the clock is ticking to 2018, when its first patent is set to expire.  What are the impediments to new blood thinners despite a strong set of data from the development of this first in class new blood thinner. My thoughts in theheart.org Vlog.

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It's official: New Oral Antithrombotic Agents in Nonvalvular AF now in guidelines

It's official: New Oral Antithrombotic Agents in Nonvalvular AF now in guidelines | Heart and Vascular Health | Scoop.it

The new oral anticoagulants (NOAC): dabigatran (Pradaxa) and rivaroxaban (Xarelto), both FDA approved, and apixaban (Eliquis), which has not been approved, can all be considered for stroke prevention in nonvalvular atrial fibrillation, a science advisory from AHA/ ASA stated.

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