updates in coagulation...american college of chest physicians 2016 guidelines for treatment of vte...
TRANSCRIPT
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Updates in Coagulation Thrombophilia testing and
direct oral anticoagulants
Kevin Y. Chen, MD
Hematology and Medical Oncology
October 13, 2017
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No conflicts of interest
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Introduction to thrombosis
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Hemostasis
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Coagulation cascade
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Virchow’s triad
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Overview of Acute Venous Thromboembolism
Annual incidence in U.S. = 1-2/1000 general population
Incidence increases dramatically with age >60
Standard therapy (3 or more months of anticoagulation)
Decreases the short-term recurrence rate from ~25% to ~3%
Associated with major bleeding (~1-2%/year of treatment with
warfarin)
Recurrence after stopping anticoagulation 1 year 5years Provoked by surgery ~1% ~3%
Provoked by non-surgical reversible risk factors ~5% ~15%
(e.g., estrogen, pregnancy, leg injury, flight >8 hours)
Unprovoked ~10% ~30%
Active cancer ~15%/year
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American College of Chest Physicians
2016 Guidelines for Treatment of VTE Kearon C et al., Chest 2012; 141(2 Suppl): e419S-494S (9th Edition)
Kearon C et al., Chest 2016 Feb; 149(2): 315-352 (10th Edition)
Recommendations Evidence
Strong (Grade 1)
Weak (Grade 2)
High-quality (Grade A)
Moderate-quality (Grade B)
Low-quality (Grade C)
Graded recommendations for: Proximal lower extremity DVT and PE
PE with hypotension
Distal lower extremity DVT
Superficial venous thrombosis
Upper extremity DVT
Post-thrombotic syndrome
Catheter-associated thrombosis
Splanchnic and hepatic vein thrombosis
Chronic thromboembolic pulmonary hypertension
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Acute Proximal DVT or PE
Initial Treatment Grade
For initial treatment with heparin, suggest LMWH or
fondaparinux over IV unfractionated heparin (IV UFH preferred in patients with severe renal failure or those undergoing
thrombolysis)
2B/2C
If using warfarin, initiate therapy on day 1
Continue parenteral AC for ≥5 days and until the INR ≥2.0 for
≥24 h
1B
IVC filter
Use only in patients with a contraindication to
anticoagulation
Begin a conventional course of AC if the risk of bleeding
resolves
(A permanent IVC filter is no longer considered to be an indication for
extended AC)
1B
2B
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Acute Proximal DVT or PE
* new in 2016 guidelines
Choice of Anticoagulant Grade
VTE and no cancer
Suggest a DOAC over warfarin *
In patients not treated with a DOAC, suggest warfarin over
LMWH (target INR 2.0-3.0 for all treatment durations)
2B
2C
VTE and active cancer
Suggest LMWH over warfarin or a DOAC *
2C
VTE and pregnancy
Suggest LMWH over UFH (warfarin is teratogenic, esp. 1st
TM)
Discontinue ≥24 h prior to induction or C-section
1B
1B
* new in 2016 guidelines
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Duration of Treatment for Acute VTE
Depends on estimation of:
(1) Risk of recurrence
Provoked by surgery
Provoked by non-surgical reversible risk (e.g., estrogen, pregnancy, leg injury, flight >8 hours)
First unprovoked VTE
Active cancer/ Second unprovoked VTE
(2) Risk of bleeding
~1%/y
~15%/y
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Estimation of Bleeding Risk (not validated prospectively)
Risk factors Bleeding Risk
Age >65
Age >75
Previous bleeding
Cancer
Metastatic cancer
Renal failure
Liver failure
Thrombocytopenia
Previous stroke
Diabetes
Anemia
Antiplatelet therapy
Poor anticoagulant control
Comorbidity and reduced functional
capacity
Recent surgery
Frequent falls
Alcohol abuse
NSAID use (added in 2016)
“Low” 0 risk
factors
“Moderate”1 risk
factor
“High” ≥2 risk
factors
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Estimation of Bleeding Risk
Major Bleeding After VTE (most studies assessed risk on warfarin therapy)
Initial 3 Months (%) Extended >3 Months (%/y)
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Acute Proximal DVT or PE
Duration of Treatment (symptomatic=incidental)
Grade
VTE provoked by
Surgery
Non-surgical transient risk factor
3 months
3 months
1B
1B
1st unprovoked VTE
Low/moderate bleeding risk
High bleeding risk
Indefinite
3 months
2B
1B
2nd unprovoked VTE
Low/moderate bleeding risk
High bleeding risk
Indefinite
3 months
1B/2B
2B
VTE and active cancer
Low/moderate bleeding risk
High bleeding risk
Indefinite
Indefinite
1B
2B
VTE during pregnancy
Continue until
6 wk postpartum
(3 mo minimum)
2C
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Hypercoagulable work up
“Although inherited and acquired thrombophilias
are acknowledged to increase the risk of VTE,
the majority of patients should not be tested for
thrombophilia.”
“Some arguing that these tests should never be
performed.”
NEJM, Connors, 2017
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570 patients with first VTE
followed prospectively
85% had thrombophilia testing
(after anticoagulation stopped)
Recurrence rate 11%
Recurrence rate not related to
inherited thrombophilia status:
Hazard ratio 1.5 (.82-2.77)
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J Thromb Haemost 2008;6:1474
Case control study of 197
patients who had
recurrence after first VTE
and 324 control patients
Primary endpoint: Odds
ratio of recurrent
thrombosis based on those
tested and those not tested
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What are the issues with testing?
•No data supporting benefit of testing to guide
secondary or primary prophylaxis
•Results may not alter management
•Negative testing does not equate low risk
•Current tests are insufficient
•Accuracy of some testing is dependent on
timing
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Other testing:
MPN testing (JAK2, CALR,
MPL, BCR-ABL)
PNH testing (FLAER)
Elevated Factor VIII
Elevated Factor IX
Elevated Factor XI
Elevated plasminogen activator
inhibitor -1 (PAI-1)
PAI-1 promoter polymorphism
MTHFR polymorphism (677C-
>T, 1298A->C)
NEJM, Connors, 2017
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Inherited thrombophila
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Clinical characteristics
NEJM, Connors, 2017
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Antiphospholipid antibody syndrome
NEJM, Connors, 2017
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Inherited thrombophila and pregnancy
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Recommendations
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Clinical scenarios
A 33 year old male with no medical problems
suffers a fractured femur playing football. He
has surgery, but 1 week later develops calf
swelling and is found to have a DVT. His 65
year old mother was recently found to have PE
and was diagnosed with breast cancer.
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Clinical scenarios
A 23 year old with 2 younger sisters develops a
DVT while 28 weeks pregnant. Her mother had
a spontaneous PE when she was in her 30s.
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Clinical scenarios
A 36 year old female in her usual state of health
is admitted into the ICU and found to have
bilateral PE. She has a depressed EF and is
given thrombolytics. Her aunt also had DVTs in
her thirties
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Algorithm for testing
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854 patients randomized to limited
cancer screening vs limited cancer
screening with body CT
Cancer detection: 3.2% vs 4.5%
Cancers missed: 4 vs 5
Time to cancer diagnosis: 4.2mos vs
4.0mos
Cancer related mortality: 1.4% vs 0.9%
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1818 patient with unprovoked DVT treated
with coumadin
Cox regression to determine factors for
recurrence
DASH SCORE
- D: post-anticoagulation D-Dimer (+2)
- A: Age < 50 (+1)
- S: Male (+1)
- H: Hormone use (-2)
Annual risk of recurrence
1 or less: 2.1%
2: 6.4%
3+: 12.3%
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•3365 patients with VTE and had completed 6-
12 months of treatment randomized to 20mg
rivaroxaban, 10mg rivaroxaban, 100mg ASA
•Primary outcome recurrent VTE, safety
outcome of major bleeding
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Recurrent VTE
- 20mg (1.5%)
- 10mg (1.2%)
- ASA (4.4%)
Major Bleeding
- 20mg (0.5%)
- 10mg (0.4%)
- ASA (0.3%)
Non major bleeding
- 20mg (2.7%)
- 10mg (2.0%)
- ASA (1.8%)
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Take home points
•Thrombophilia testing is often not indicated
•May be clinically relevant in select patients
(especially APLAB)
•Testing should not be done at time of acute
event
•Clinical factors more relevant for duration of
anti-coagulation
•Consider age appropriate cancer screening
•Long term low dose anticoagulation may be an
option for intermediate risk patients
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Direct oral anticoagulants
“If these novel breakthrough oral anticoagulant
drugs prove to be effective across the broad
spectrum of patients in routine care and are
conscientiously priced, the worldwide impact will
be huge.”
NEJM, Hylek, 2010
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Betrixaban FDA approved 2017
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Direct Oral Anticoagulants
Bind reversibly to the catalytic sites of their target proteases
Rivaroxaban
Dabigatran etexilate (prodrug)
Dabigatran (active drug)
In vivo
Apixaban
Edoxaban
Thrombin Factor Xa
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Coagulation cascade
Anthrombin mediated
inhibitor of Xa, Iia
- UFH
- LMWH
- Fondaparinaux
Vitamin K Antagonist
- Warfarin
Direct thrombin inhibitor
- Argatroban
- Bivalrudin
- Dabigatran
Factor Xa inhibitor
- Rivaroxaban
- Apixaban
- Edoxaban
- Betrixiban
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Dabigatran
(Pradaxa)
Rivaroxaban
(Xarelto)
Apixaban
(Eliquis)
Edoxaban
(Savaysa)
Target Thrombin Xa Xa Xa
Bioavailability 7% 80% (with food) 60% 60%
Peak action 0.5-3 hours 2-4 hours 1-3 hours 1-2 hours
Half-life 14-17 hours 7-12 hours 8-15 hours 10-14 hours
Renal clearance
80% 33% 25% 50%
Interactions P-gp P-gp
CYP3A4
P-gp
CYP3A4 P-gp
Dosing Twice daily Twice then once daily
Twice daily Once daily
Initial parenteral anticoagulation
5-10 days of heparin/LMWH
None None 5-10 days of heparin/LMWH
Monitoring None None None None
Direct Oral Anticoagulants
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Dabigatran
•Dose
–Stroke prevention in A fib: 110-150 mg bid
•110 mg dose not available in US
•For patients with CrCl 15-30: 75 mg bid
•Not recommended for CrCl < 15 or dialysis dependent
–Postop VTE prophylaxis*: 150-220 mg once daily
–VTE treatment/prevention of recurrent VTE: 150 mg bid (following
LMWH or heparin Rx)
•Less than 10% absorbed; relatively high rate of GI side effects
•Crosses the placenta – do not use during pregnancy
•Drug may degrade over time after exposure to air – must be kept in
original packaging
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Rivaroxaban
•Dose:
–Stroke prevention in nonvalvular Afib: 15-20 mg
once daily
–Post op VTE prophylaxis: 10 mg once daily
–Acute VTE treatment: 15 mg twice daily
–Secondary prevention of VTE: 20 mg once daily or
10mg daily after 6 months
–Acute coronary syndrome*: 2.5-5 mg twice daily
•Use with caution in moderate renal impairment (CrCL
30-49); 15 mg/day dose recommended
–Avoid use if CrCl < 30 (not dialyzable)
•Avoid use in severe liver disease
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Apixaban
•Dose:
–Stroke prevention in nonvalvular Afib: 5 mg bid
•2.5 mg bid if age >80, weight < 60 kg, or serum
creatinine > 1.5
–Post op VTE prophylaxis: 2.5 mg bid
–Treatment of acute VTE: 10 mg bid x 7 days, then 5
mg bid
–Secondary prevention of VTE: 2.5 mg bid after 6
months
•Lowest dependence on renal excretion of new agents
•Avoid use in severe liver disease (75% biliary excretion)
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Edoxaban
•Dose:
–Stroke prevention in Afib: 60 mg/d
•30 mg/d if CrCl 15-50 or body wt ≤ 60 kg
–Post op VTE prophylaxis*: 30 mg/d
–Treatment of acute VTE: 60 mg/d (following LMWH
or heparin Rx)
➢Avoid use if CrCl > 95 ml/min (excessive excretion
decreases efficacy)
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Betrixaban
•Dose:
–VTE (prophylaxis): Oral: 160 mg as a single dose
on day 1, followed by 80 mg once daily for 35 to 42
days
– Reduce betrixaban dose (initial and maintenance)
by 50% for patients receiving or starting P-
glycoprotein inhibitors (eg, amiodarone,
azithromycin, clarithromycin, ketoconazole,
verapamil).
– Severe renal impairment: avoid use
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Efficacy of DOACs for treatment of acute VTE
J Thromb Haemost 2014;12:320
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J Thromb Haemost 2014;12:320
Safety of DOACs for treatment of acute VTE
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DOACS in atrial fibrillation
Ruff et al, Lancet 2013
Dabigatran 150 mg bid
Rivaroxaban 20 mg qd
Apixaban 5 mg bid
Edoxaban 60 mg qd
Combined
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J Thromb Haemost 2014;12:107
Symptomatic VTE
Total VTE +
All-cause mortality
Major bleeding
DOACs in VTE prophylaxis after total hip
arthroplasty
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Dabigatran
(Pradaxa)
Rivaroxaban
(Xarelto)
Apixaban
(Eliquis)
Edoxaban
(Savaysa)
Betrixaban (Bevyxxa)
Non-valvular a fib stroke
prophylaxis ✔ ✔ ✔ ✔
Initial DVT/PE treatment ✔ after 5-10
d heparin ✔ ✔ ✔ after 5-10
d heparin
Extended-duration
DVT/PE treatment ✔ ✔ ✔
Knee replacement VTE
prophylaxis ✔ ✔
Hip replacement VTE
prophylaxis ✔ ✔ ✔
Hip fracture VTE
prophylaxis
Medical VTE prophylaxis ✔
Acute coronary
syndrome
Heparin-induced
thrombocytopenia
FDA-approved Indications
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Drug effects on coagulation tests
•PT/INR and PTT are relatively insensitive to the
effects of DOACs
–Reagent-dependent – results will vary among labs
•Normal PT and PTT do not rule out significant
blood level of DOAC
•If PT or PTT elevated → assume significant
blood levels of DOAC
•Thrombin time very sensitive to dabigatran
effect – normal TT implies no drug on board
–Direct Xa inhibitors do not affect TT
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Monitoring
•Dabigatran:
–Modified thrombin time assay (Hemoclot®)
•Rivaroxaban, apixaban, edoxaban:
–Anti-Xa activity (similar to LMWH assay)
•Neither assay FDA-approved or widely available now
•When to consider measuring drug level:
–Detect/quantify overdose
–Screen for drug accumulation (eg, impaired renal or liver
function)
–Assure low drug level prior to surgery
➢Limited usefulness for assessing compliance due to
short drug half-lives
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Reversal agents
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Blood 2014;124(15):2450-2458
Data from 12 RCTs of DOACs involving 102,607 patients
Major bleeding
RR 0.72
[0.62-0.85]
Fatal bleeding
RR 0.53
[0.43-0.64]
Intracranial bleeding
RR 0.43
[0.37-0.50]
Major GI bleeding
RR 0.94
[0.75-1.19]
Risk Ratios Comparing DOACs to Warfarin
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Kaatz et al. Am J Hematol 2012; 87: S141-5
Reversal of Direct Oral Anticoagulants
(<2 h)
(?) (?)
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Eerenberg et al. Circulation 2011; 124(14): 1573-9
Reversal of Rivaroxaban by 4-factor PCC (50
IU/kg)
in Healthy Volunteers
Rivaroxaban
PT
Dabigatran
aPTT
Dabigatran
Thrombin time
placebo
PCC
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Idarucizumab (Praxbind) for Dabigatran Reversal
Pollack et al., N Engl J Med 2015 Aug 6;373(6):511-20
Idarucizumab (Praxbind®) is a monoclonal antibody fragment
that binds to dabigatran with high affinity (350x that of
thrombin)
5 mg of idarucizumab (2 x 2.5 mg vials) completely reverses
the anticoagulant effect of dabigatran when the drug is taken
at usual recommended doses
This effect occurs within minutes of drug administration and
restores normal hemostasis (NEJM 2015; 373:511)
Idarucizumab approved by FDA in October 2015
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• 503 patients enrolled, 301 uncontrolled
bleeding, 202 required urgent procedure
• Primary end point reversal measure by dilute
thrombin time
• Median maximum percentage reversal was
100%
• Median time to cessation of bleeding 2.5 hours,
median time to procedure 1.6 hours
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Idarucizumab (Praxbind) for Dabigatran Reversal
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Figures from Nature Medicine 19, 402-4 (2013)
Andexanet alfa for Reversal of Xa Inhibitors
Recombinant factor Xa variant Lacks the γ-carboxyglutamic acid domain required for phospholipid binding
Alanine substituted for serine in the active site (catalytically inactive)
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Andexanet alfa for Reversal of Xa Inhibitors
Siegal et al., N Engl J Med 2015 Dec 17;373(25):2413-24
Study Design
Healthy volunteers (50-75 years old) housed at a study site for 8 days
Apixaban study: 5 mg PO BID x 3.5 days, then Andexanet 400 mg IV bolus +/- 4
mg/min continuous IV infusion for 2 h OR placebo
Rivaroxaban study: 20 mg PO QD x 4 days, then Andexanet 800 mg IV bolus +/-
8 mg/min continuous IV infusion for 2 h OR placebo
Primary outcome: percent change in anti-factor Xa activity
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Bolus plus infusion
Andexanet alfa for Reversal of Xa Inhibitors
Siegal et al., N Engl J Med 2015 Dec 17;373(25):2413-24
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Conclusions
Andexanet reversed the anticoagulant activity of apixaban and rivaroxaban within
minutes
Rapid onset and offset of action (provides flexibility of treatment?)
No serious adverse events (1 patient with hives)
No antibodies against factor X or Xa detected at 43 days
Andexanet alfa for Reversal of Xa Inhibitors
Siegal et al., N Engl J Med 2015 Dec 17;373(25):2413-24
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67 patients with acute major bleeding within 18
hours of receiving anti Xa inhibitor
• Mean time from ED arrival to rx: 4.8 hours
• Decrease in antiXa activity:
–89% and 93% (after bolus, during 2hour infusion)
–39% and 30% (4 hours after infusion complete)
• Good/excellent clinical hemostasis 12 hours after: 79%
• Thrombotic event rate: 18% at 30 days
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Transition to DOAC
•Unfractionated heparin to DOAC:
–Start DOAC when UFH infusion stopped
•LMWH to DOAC:
–Start DOAC 2 h before next scheduled sq dose of
LMWH
•Warfarin to DOAC:
–When INR < 2.0
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Transition from DOAC
•DOAC to parenteral anticoagulant:
–CrCl >30: start 12 hours after last NOAC dose
–CrCl <30: start 24 hours after last NOAC dose
•DOAC to warfarin:
–CrCl >50: start warfarin 3 days before NOAC
stopped
–CrCl 31-50: start warfarin 2 days before NOAC
stopped
–CrCl 15-30: start warfarin 1 day before NOAC
stopped
➢Remember that NOACs can prolong PT/INR
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Perioperative management
•Stop DOAC at least 3 drug half-lives prior to
surgery
–Dabigatran: 42-51 h
–Rivaroxaban: 15-27 h
–Apixaban: 24-48 h
•Allow more time if:
–Age > 75
–Impaired renal or liver function
–High bleeding risk
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Recurrent VTE While on Anticoagulation
Approach to Treatment Grade
If recurrence on warfarin or a DOAC
Evaluate for true recurrence, compliance, or
malignancy
Switch to LMWH for at least 1 month *
2C
If recurrence on long-term LMWH and patient is
compliant
Increase dose of LMWH by 25% to 33% *
2C
* new in 2016 guidelines
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Cost per month
• Rivaroxaban (20 mg/day) : $290
• Dabigatran (150 mg bid): $290
• Apixaban (5 mg bid): $147
• Warfarin (7.5 mg/day): $31
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Patients selection for DOAC
• Patients who have unstable INR on warfarin
not due to poor compliance
• Adequate renal & hepatic function
• No mechanical valve
• Not pregnant (drugs cross placenta)
• Not at extremes of weight (can’t adjust dose)
• Not at high risk of lower GI bleeding