anticoagulation doacs presentation final (003)€¦ · 4/25/2020 7 site of action of direct factor...

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Objectives for the Indications of Direct Oral Factor Xa Anticoagulants

• Identify patients suitable for Direct Acting Oral Anticoagulants (DOACs).

• Know PK/PD issues impacting dosing and safety of DOACs

• Recognize patient factors that may influence the choice of anticoagulant.

• Obesity• Liver disease• Renal disease• Age• Comorbidities

• Manage bleeding issues associated with DOACs

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Patient Case

• ET is a 77 yo woman admitted for Bilateral PE and A. fib.

• Home Meds: Carvedilol 6.25mg PO BID

• Weight 75kg Height 5’5”

• GFR 30ml/min/m2

• Enoxaparin 100mg (1.5mg/kg/d) SC Daily started

• What oral anticoagulant would you start and for how long?

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Antithrombotic Drugs

Antiplatelet Drugs

Anticoagulants

Fibrinolytic Agents

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Indirect InhibitorsHeparinLMWHFondaparinux (Arixtra®)

Direct Thrombin InhibitorsArgatrobanBivalirudin (Angiomax®)Dabigatran (Pradaxa®)

Vitamin K AntagonistWarfarin (Coumadin®)

Oral Factor Xa InhibitorsRivaroxaban (Xarelto®)Apixaban ( Eliquis®)Edoxaban (Savaysa®)Betrixaban (Bevyxxa®)

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Coagulation Issues

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Risk Factors for VTE

• Age >60 years

• Expected hospitalization ≥3 days

• Active cancer

• History of stroke

• Active hormonal treatment

• ICU or CCU stay

• Acute infection requiring hospitalization

• Inherited or acquired thrombophilia

• Active pregnancy in second or third trimester

• Limited mobility

• BMI >35 kg/m2

• Previous VTE or superficial view thrombosis

• Current lower‐limb paralysis

• Prior central venous catheter or transvenous pacemaker

• Chronic respiratory failure

• Reduced mobility

• Chronic venous insufficiency

• Rheumatological disorder

• D‐dimer ≥2× ULN

• Trauma or surgery (≤1 month ago)

• Decompensated heart failure (New York Heart Association class III or IV)

Annals of Pharmacotherapy 2018, Vol. 52(6) 554–561 7

Prothrombotic State in Coexistent AF and CKD

Nature reviews Nephrology 2018;14:337‐351 8

Relative Changes in Thrombotic Factors in Liver Disease

↓Prothrombin ↑ Von Willebrands factor↓Thrombin ↑ Dura on of Thrombin Ac va on↓ An thrombin ↑ Thrombin Receptors on hepa c Stellate cells↓ Protein C & S↓ Plasminogen↓ Platelets

Seminars in Liver Disease 2019; 39(2):195‐208Thromb Haemost 2019; 119(02): 246‐253World J Gastroenterol. 2016; 22(4): 1541–1550

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Systemic Inflammation

Tissue Changes and Damage Leading to Coagulopathies

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Systemic InflammationRoles of Anticoagulation

https://www.everydayhealth.com/healthy‐living‐pictures/inside‐the‐human‐body.aspx

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Cancer Immunol Res 2013;1:77‐84 12

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Inflammatory Processes Leading to Coagulopathy

Front. Pharmacol. 2019 10:1420J Nat Sci. 2017 April ; 3(4)

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Systemic inflammation A. fib and Thrombogenesis

Front. Pharmacol. 2019 10:1420.

Systemic Inflammation Mediators• Interleulin (IL‐2)• TNF ‐α

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Pharmacological strategies to control hyperacoagulability and heart inflammation

Front. Pharmacol. 2019 10:142015

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Atrial fibrillation and Stroke

National Heart Lung and Blood Institute (NIH) 16

Direct Factor Xa Oral Inhibitors

Overview

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Khachatryan T, et.al Review of Direct Oral Anticoagulants and Guide for Effective Drug Utilization American Journal of Cardiovascular Drugs April 3 2019 DOI: 10.1007/s40256‐019‐00344‐6

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Site of Action of Direct Factor Xa Oral Inhibitors on the Coagulation Cascade

19European Heart Journal Supplements (2018) 20 (Supplement E), E12–E15

Direct Factor Xa Oral InhibitorsClass Review

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Direct Factor Xa Oral Inhibitors Indications

Generic Trade FDA Indications

↓ Stroke in NVAF Treatment DVT/PE VTE Prophylaxis

Apixiban Eliquis Yes Yes1 Yes2

Betrixaban Bevyxxa No No Yes

Edoxaban Savaysa Yes Yes1 No

Rivaroxaban3 Xarelto Yes Yes Yes2

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FDA Approved Indications1 Following initial therapy‐ 5‐10 days of parenteral anticoagulant2 Prophylaxis of DVT, which may lead to PE in patients undergoing knee and hip surgery3 Reduce the risk of major cardiovascular events in patients with chronic CAD or peripheral artery disease (PAD)

Annals of Pharmacotherapy 2018, Vol. 52(6) 554–561

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Pharmacology of Direct Factor Xa Oral Inhibitors

• Direct, reversible inhibitor of factor Xa

• Inhibits free and clot‐bound factor Xa

• Inhibits prothrombinase ac vity → ↓Thrombin genera on and thrombus

• No direct platelet ac vity → ↓ thrombin induced platelet aggrega on

• Inhibition is dose dependent

Ther Drug Monit 2019;41(2):180–191J Thromb Thrombolysis 2016;41:15‐31

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PharmacokineticsApixabanEliquis®

RivaroxabanXarelto®

EdoxabanSavaysa®

BetrixabanBevyxxa®

Bioavailability >50%Small intestine

Incomplete absorption1st pass metabolism

80‐100% at 10mg dose66% at 20mg dose

Doses ≥ 15mg give with food

62% 34%Meal ≤ 6 h prior will decreaseplasma concentration

Onset: t max(hrs) 3‐4 2.5‐4 1‐2 2.5‐4

Terminal t1/2 (hrs) 12 (8‐15) (SS 3 days)

5‐9 (11‐13 Elderly) (SS 3 days)

10‐14(SS 3 days)

35‐45PD t1/2 19‐27 hrs

(SS 4 days)

Renal Elimination (%) 25 66 (36% as unchanged drug)

35‐50 66 (36% as unchanged drug)

Hemodialysis Not Dialyzable Not Dialyzable Not Dialyzable Not Dialyzable

CYP 450 Metabolism <32% 57% <25% <1%

Drugs (2019) 79:291–302Clin Pharmacokinet (2014) 53:1–16Seminars in Liver Dis 2019;39

PD t½: pharmacodynamic half‐life

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Indications and Dosing of Direct Factor Xa Oral Inhibitors

Apixaban(Eliquis®)

Betrixaban(Bevyxxa®)

Edoxaban(Savaysa®)

Rivaroxaban(Xarelto®)

Prevention/Treatment VTE 10mg po BID X 7 days then 5mg po BID X 6 months

VTE Prevention only160mg po day 1 followed by 80mg po daily for 35‐42 days

60 mg Daily >60kg30mg Daily ≤60kg

15mg po BID X 21 days followed by 20mg daily

(Doses ≤ Bioavailability same with fasting or food )

NonValvular A. fib (NVAF) 5mg po BID2.5mg po BID if patient >80yo, BW<60kg, ESRD

‐ 60 mg DailyDo not use edoxaban for NVAF if CrCl

is >95 mL/minute

20mg po QD with evening meals

Post –Op DVT ProphylaxisKnee/Hip

Hip: 2.5mg BID X 35 daysKnee: 2.5mg BID X 12 days

‐ ‐ 10mg po QD 10‐14 days(may extend to 35 days)

Acute Coronary Syndrome (ACS) (off‐label)

5mg po BID ‐ ‐ 2.5mg PO BID + ASA+Clopidogrel(X 1 year)

Heparin Induced Thrombocytopenia (off‐label)

10mg po BID X 7 days then 5mg po BID until platelet count

returns

‐‐

15mg BID with food X 21 days followed by 20mg QD until

platelet count returns

Conversion from Warfarin INR<2 Stop warfarin and start betrixaban when INR < lower limit of therapeutic range

INR<2.5 (some experts recommend starting when as close as possible to 2.0)1

INR<3.0

Khachatryan T, et.al Review of Direct Oral Anticoagulants and Guide for Effective Drug Utilization American Journal of Cardiovascular Drugs April 3 2019 DOI: 10.1007/s40256‐019‐00344‐6The Journal of Clinical Pharmacology 2016: 56(5) 628–636.NEJM 2019; 380;16:1509‐1524 AUGUSTUS TrialJ Am Heart Assoc. 2018;7:e010854. DOI: 10.1161/JAHA.118.010854

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Renal Dosing GuidelinesApixabanEliquis®

BetrixabanBevyxxa®

EdoxabanSavaysa®


Oral: ↓ dose with any 2 below:• Age ≥80 years, • body weight ≤60 kg• serum creatinine ≥1.5 mg/dL

CLCr> 30ml/min ClCr≥51ml/minClCr> 95ml/min Avoid

ClCr>50ml/min

NVAF 5 mg twice daily Any 2 above 2.5mg BID*

160mg daily Day #1then 80mg daily

• Weight >60 kg: 60 mg daily.

• Weight ≤60 kg: 30 mg daily.

ClCr >50ml/min20mg daily

ClCr 15 to 50 mL/min15mg daily*

ClCr<15ml/minContraindicated

Prevention/Treatment VTE

10 mg twice daily for 7 days followed by 5 mg twice

daily.

≥15 to <30ml/min ClCr 15 to 50 mL/minute30mg daily

DVT 15mg BID X 21 days then 20mg daily

DVT prophylaxis following Knee and Hip replacement surgery

2.5 mg twice daily beginning 12 to 24 hours

postoperative

80mg daily Day #1 then40mg dailyESRD/HD

No Guidelines

ESRDAvoid

ClCr<30ml/minAvoid

Ther Drug Monit. 2019;41(2):180‐191.The American Journal of Medicine 2019; 132:1078‐1083Circulation. 2015;131:972‐979Semin Thromb Hemost 2018;44:353–363

* Increased Risk of bleeding when compared to patients on full dose and non‐severe CKD or ESRD

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Dose Interruption in Patients Having Invasive Procedures

Apixaban(Eliquis®)


Edoxaban(Savaysa®)


24‐48hrs min, depending on bleeding risk

Anticoagulant effect expected to persist for ≥72 hours.

Low risk:24 hoursHigh risk:72 hours

24hrs minimum, with 3‐5 days depending on Renal Function

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Adverse Reaction Risk Factors of Direct Factor Xa Oral Inhibitors

• Age• GFR• Number of Drugs taken

• ≤ 5 17%• > 5 83%• Comorbidities

• Atrial fibrillation 76%• Hypertension 72%• Diabetes 44% • Renal failure 30%

Current Drug Safety Volume 15 , Issue 1 , 2020 27

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Adverse Reactions of Direct Factor Xa Oral Inhibitors

ApixabanEliquis®


EdoxabanSavaysa®

BetrixabanBevyxxa®

BleedingMajor ≤15%Minor ≤ 2%

Liver toxicityGastrointestinal disordersAngioedemaAlopecia

BleedingPruritusAbdominal painLiver toxicityDizziness, InsomniaAngioedemaAlopecia

BleedingSkin rashLiver toxicityAngioedema

BleedingHypertensionHeadacheHypokalemiaDiarrhea

Res Pract Thromb Haemost. 2017;1:90–92

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Drug‐Drug Interactions of Direct Factor Xa Oral InhibitorsCYP 450 System

Pharmacokinetic Pharmacodynamic

↓DOAC concentra on ↑ DOAC concentra on ↑ bleeding risk

CYP3A4 Inducers CYP 3A4 Inhibitors Antithrombotic Agents

• Carbamazepine• Phenobarbital• Phenytoin• Rifampin• St. John’s Wort

• Azithromycin• Clarithromycin• Diltiazem• Dronedarone• Ketoconazole• Itraconazole• Ritonavir• Verapamil

• Antiplatelets• Aspirin• NSAIDs• SNRIs/SSRIs• Thrombolytics

Barr D, Epps QJ. Journal of Thrombosis and Thrombolysis 2019; 47:146–154Frontiers in Neurology 2018;9:1‐10.

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Drug‐Drug Interactions of Direct Factor Xa Oral InhibitorsP‐glycoprotein Inhibitors

Xa Inhibitors

P‐gp Inhibitors

Antimicrobials GI Agents HIV Protease Inhibitors

Neurologic Agents

Cardiac Agents

• Azoles• Itraconazole• Posaconazole

• Clarithromycin• Erythromycin• Fluoroquinolones• Ketoconazole• Rifampin

• H2 Receptor Blockers• PPIs

• Indinavir• Lopinavir• Maraviroc• Nelfinavir• Ritonavir• Saquinavir• Tipranavir

• Amitriptyline• Chlorpromazine• Haloperidol• Sertraline• Venlafaxine

• Amiodarone• Atorvastatin• Carvedilol• Diltiazem• Dronedarone• Nicardipine• Verapamil

Apixaban ↑ levels ↑ levels ↑ levels ↑ levels ↑ levels

Betrixaban ↑ levels ↑ levels ↑ levels ↑ levels ↑ levels

Edoxaban ↑ levels ↑ levels ↑ levels ↑ levels ↑ levels

Rivaroxaban ↑ levels ↑ levels ↑ levels ↑ levels ↑ levels

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J Am Coll Cardiol 2013;61:2495–502Journal of Cardiology 2019; 73: 515–521Hematology Am Soc Hematol Educ Program. 2018 Nov 30; 2018(1): 339–347.

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Reversal Options for Direct OralFactor Xa InhibitorsApixaban(Eliquis®)


Edoxaban(Savaysa®)


Andexanet alfa(Andexxa®)

≤5 mg ≤ 8 hours or unknown period of time: Initial, 400 mg IV bolus at target rate of 30 mg/min; follow with 4 mg/min (480mg) continuous IV infusion for up to 120 minutes

80mg800mg bolus 4h after last betrixabandose followed by 2h infusion8mg/minPhase II study

≤40 mg400 mg IV bolus at target rate of 30 mg/min; follow with 4 mg/min (480mg) continuous IV infusion for up to 120 minutes. Phase II study

≤10 mg ≤ 8 hours or unknown time: Initial, 400 mg IV bolus at target rate of 30 mg/min; follow with 4 mg/min (480mg) continuous IV infusion for up to 120 minutes. 1

>5 mg (or unknown dose) ≤8 hours or unknown period of time: Initial, 800 mg IV bolus at target rate of 30 mg/min; follow with 8 mg/min (960mg)continuous IV infusion for up to 120 minutes

>40 mg800 mg IV bolus at target rate of 30 mg/min; follow with 8 mg/min (960mg) continuous IV infusion for up to 120 minutes.

10 mg (or unknown dose) ≤8 hours or unknown period of time: Initial, 800 mg IV bolus at target rate of 30 mg/min; follow with 8 mg/min (960mg) continuous IV infusion for up to 120 minutes. 1

Onset: 2 minutesPharmacodynamic half‐life ≈1hr

Onset: 2 minutesPharmacodynamic half‐life ≈1hr

4‐factor PCC (Kcentra®)

25‐50 IU/kg 25‐50 IU/kg 25‐50 IU/kg 25‐50 IU/kg

Ciraparantag‐Investigational


4‐factor PCC (Kcentra®)Prothrombin Complex Concentrate (Human) [(Factors II, VII, IX, X), Protein C, and Protein S]

1. Product Information: ANDEXXA(R) lyophilized powder for intravenous injection, coagulation factor Xa recombinant, inactivated‐zhzo lyophilized powder for intravenous injection. Portola Pharmaceuticals, Inc (per manufacturer), South San Francisco, CA, 2018.

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Andexanet alfa Reversal PrecautionsImmunologic Cardiovascular Hematologic Neurologic Respiratory Death

Re‐elevation or incomplete reversal of anti‐FXa activity has been reported

• Acute MI• Cardiac arrest• Cardiogenic shock• CHF• Non‐sustained VT

• DVT• Venous

thromboembolism

• Embolic stroke• Ischemic stroke

• Acute RF• Pneumonia• PE

14‐18%


4‐factor PCC (Kcentra®)Prothrombin Complex Concentrate (Human) [(Factors II, VII, IX, X), Protein C, and Protein S]

Product Information: ANDEXXA(R) lyophilized powder for intravenous injection, coagulation factor Xa recombinant, inactivated‐zhzo lyophilized powder for intravenous injection. Portola Pharmaceuticals, Inc (per manufacturer), South San Francisco, CA, 2018.

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ApixabanApixabanEliquis®

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Direct Acting Factor Xa InhibitorsApixaban (Eliquis®)

FDA Approved Indications1

• Reduce the risk of stroke in patients with NVAF

• DVT prophylaxis following Knee and Hip replacement surgery

• DVT and Pulmonary Embolism treatment

New Uses

• Antithrombotic Therapy after Acute Coronary Syndrome or PCI in Atrial Fibrillation2

• Heparin‐induced thrombocytopenia 3,4

1. FDA www.accessdata.fda.gov2. N Engl J Med 2019; 380:1509‐15243. https://clinicaltrials.gov/ct2/html/images/ct.gov‐nlm‐nih‐logo.png4. Pharmacotherapy 2019;39(8):837–853

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• Pharmacokinetics• Effects of other agents‐

• ↑anti‐Xa activity

• LMWH

• UFH

• Fondaparinux

• P2Y12 agents (Clopidogrel)

• VKA

• Dipyridamole

• Dextran

• Glycoprotein IIb/IIIa inhibitors

Clinical Pharmacokinetics (2019) 58:1265–1279 35


• Pharmacokinetics• Serum levels achieved up to 10mg dose are proportional

• Studies have demonstrated a direct relationship between drug clearance and ClCr.• Age – AUC higher as age increases, but impact is small and age alone is not a dose determining factor.

• Body Weight – extremes in weight effect AUC and Cmax but benefit‐risk not effected and body weight alone is not a dose determining factor.

• Sex – AUC higher in men vs women but sex alone is not a dose determining factor.

• Race – AUC higher in Asian vs non‐Asian patients but race alone is not a dose determining factor.

• Renal – AUC increases proportionally as renal function decreases

• Hepatic – AUC changes for Child‐Pugh A and B are minimal, but as hepatic function worsens the loss if inherent clotting factors may increase bleeding.


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Dosing

• Nonvalvular atrial fibrillation (to prevent stroke and systemic embolism): • Oral: 5 mg twice daily unless patient has any 2 of the following:

• Age ≥80 years

• Body weight ≤60 kg

• Serum creatinine ≥1.5 mg/dL (133 mcmol/L)

• Reduce dose to 2.5 mg twice daily.

• Venous thromboembolism:• Deep vein thrombosis and/or pulmonary embolism treatment:

• Oral: 10 mg twice daily for 7 days followed by 5 mg twice daily.

• Total hip arthroplasty or total knee arthroplasty (alternative to low‐molecular‐weight heparin):

• Oral: 2.5 mg twice daily beginning 12 to 24 hours postoperatively



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Direct Acting Factor Xa InhibitorsRivaroxaban (Xarelto®)

FDA Approved Indications • Coronary artery disease (stable) or peripheral artery disease

• Reduction in the risk of recurrence of deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients at continued risk of DVT and PE.

• Prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation.

• Treatment of DVT or PE.

• Prophylaxis of venous thromboembolism (VTE) and VTE‐related death during hospitalization and posthospitaldischarge in adults admitted for an acute medical illness who are at risk for thromboembolic complications due to moderate or severe restricted mobility and other risk factors for VTE and not at high risk of bleeding.

• Venous thromboembolism prophylaxis in total hip or knee arthroplasty: Postoperative thromboprophylaxis of DVT, which may lead to PE in patients undergoing total hip arthroplasty or total knee arthroplasty.

Additional Options

• Acute coronary syndrome (after stabilization with initial management) + ASA

• Treatment of Heparin‐induced thrombocytopenia

• Superficial vein thrombosis, acute symptomatic

Rivaroxaban (Xarelto®) package insert 39

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Direct Acting Factor Xa InhibitorsRivaroxaban (Xarelto®)

Dosing• Coronary artery disease (stable) or peripheral artery disease (prevention of major cardiovascular events):

• Oral: 2.5 mg twice daily; administer in combination with daily low dose aspirin.

• HIT with or without thrombosis: • Oral: 15 mg twice daily with food for 21 days or until platelet count recovery, whichever is longer, followed by 20 mg once daily with food.

• Nonvalvular atrial fibrillation (to prevent stroke and systemic embolism): • Oral: 20 mg once daily with the evening meal.

• Total hip arthroplasty or total knee arthroplasty (alternative to LMWH): • Oral: 10 mg once daily initiated at least 6 to 10 hours after surgery or when hemostasis established.

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BetrixabanBevyxxa®

Betrixaban

FDA Approved Indications Additional Options

VTE prevention in acute medically ill hospitalizedpatients

Pending: Prevention of thromboembolism in atrialfibrillation

Seminars in Thrombosis & Hemostasis 2019;45 (5): 490-501

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Edoxaban

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Edoxaban(Savaysa®)

Direct Acting Factor Xa InhibitorsEdoxaban (Savaysa®)

FDA Approved Indications

• Reduction in the Risk of Stroke and Systemic Embolism in Nonvalvular Atrial Fibrillation

• Treatment of Deep Vein Thrombosis and Pulmonary Embolism

Additional Options

• Prevention of stroke after Transcatheter aortic valve implantation (TAVR)

• American Heart Journal 2018;205:63‐69

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Direct Thrombin InhibitorDabigatran (Pradaxa®)

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DabigatranDabigatranPradaxa®

Direct Acting Thrombin InhibitorDabigatran (Pradaxa®)

FDA Indications• Reduce the risk of stroke and systemic embolism in

patients with non-valvular atrial fibrillation

• Treatment of DVT and PE in patients who have been treated with a parenteral anticoagulant for 5-10 days

• Reduce the risk of recurrence of DVT and PE in patients who have been previously treated

• Prophylaxis of DVT and PE in patients who have undergone hip replacement surgery

Additional Options

Coagulation Pathway

Arterioscler Thromb Vasc Biol. 2012;32:569-574Circulation. 2011;123:1436–1450Annu. Rev. Med. 2011. 62:41–57

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Pharmacokinetics

Dabigatran

Bioavailability 3‐7%

Onset: t max(hrs) 0.5‐2

Terminal t1/2 (hrs) 12‐14

Duration (hrs) 24

Renal Elimination 80%

Hemodialysis Removes 57% over 4 hrs

Substrate of P-glycoprotein/ABCB1 Major

Drugs (2019) 79:291–302Clin Pharmacokinet (2014) 53:1–16Seminars in Liver Dis 2019;39

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Circulation. 2011;123:1436‐1450.

Direct Thrombin InhibitorDabigatran (Pradaxa®)

Indication Dosing

Reduction in Risk of Stroke andSystemic Embolism in Non-valvular AF

• CrCl >30 mL/min:• CrCl 15 to 30 mL/min:• CrCl <15 mL/min or on dialysis:

• 150 mg twice daily• 75 mg twice daily• Dosing recommendations cannot be provided

• CrCl 30 to 50 mL/min with concomitant use of P-gpinhibitors:

• CrCl <30 mL/min with concomitant use of P-gpinhibitors:

• Reduce dose to 75 mg twice daily if given with P-gp inhibitors

• Avoid co-administration

• Treatment of DVT and PE• Reduction in the Risk of

Recurrence of DVT and PE

• CrCl >30 mL/min:• CrCl <30 mL/min or on dialysis:

• 150mg twice daily• Dosing recommendations NOT provided

CrCl <50 mL/min with concomitant use of P-gp inhibitors: Avoid co-administration

Prophylaxis of DVT and PE FollowingHip Replacement Surgery

• CrCl >30 mL/min:

• CrCl <30 mL/min or on dialysis:

• 110 mg for first day, then 220 mg once daily

• Dosing recommendations cannot be provided

CrCl <50 mL/min with concomitant use of P-gp inhibitors: Avoid co-administration

Dabigatran Reversal AgentIdarucizumab (Praxbind®)

• Dose: IV 5gm administered as 2 separate 2.5gm doses no more than 15 minutes apart 1,2,3

• Additional full dose may be considered if clinically relevant bleeding together with elevated coagulation parameters is observed.

• Administration: Two consecutive infusions or Bolus injection by injecting both vials consecutively one after another via syringe.

• MOA: Binds specifically to dabigatran and its acylglucuronide metabolites with an affinity for dabigatran that is ~350 times greater than that of thrombin, and neutralizes the anticoagulant effect within minutes

• Source: Humanized monoclonal antibody fragment (Fab)

• Risks: Thromboembolic events in patients with underlying disease states placing them at risk for embolic events.

• Restarting Antithrombotic Therapy: Resumption of anticoagulant therapy should be considered as soon as medically appropriate.

Pradaxa® treatment can be initiated 24 hours after administration of PRAXBIND® 1

1. Package insert Copyright © 2018 Boehringer Ingelheim International GmbH2. N Engl J Med. 2015;373(6):511-5203. N Engl J Med. 2017;377(5):431-441

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Patient Case

• ET is a 77 yo woman admitted for Bilateral PE and A. fib.

• Home Meds: Carvedilol 6.25mg PO BID

• Weight 75kg Height 5’5”

• GRF 30ml/min/m2

• Enoxaparin 100mg (1.5mg/kg/d) SC Daily started

• What oral anticoagulant would you start and for how long?

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Summary53

anticoagulation doacs presentation final (003)€¦ · 4/25/2020 7 site of action of direct factor...

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