management of doac in clinical praxis · before surgery and how to resume doac after surgery local...
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Professor Peter J SvenssonCentre for Thrombosis and Haemostasis, SUS , Malmö
Management of DOAC in clinical praxis
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Disclosures for[Peter J Svensson]
• ACCP Guidelines 2012• Auricula (Chairman)
• Bayer• Boeringer Ingelheim• Pfizer / BMS
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Prevalence of atrial fibrillation> 2.5 % in the general population
Andersson et al JIM 2012, SBU 2013 aprilFriberg et al JIM 2013
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Indications for OAC
Atrial fibrillation > 80%VTE 10%Mechanical heart valves 5%Other 5%
Increase of OAC with 5-10% per year 30 % is over the age of 80 years among patients with OAC
Auricula 2014
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Different laboratory tests(coagulation-tests)
1.Tests that are availbale in most laboratories, easy to perform and semiquantitative for use in ie emergency situations. The test shouldindicating supra or subtherapeuticanticoagulation
2. Test that gives quantitative results todetermine the anticoagulant effect (drug level)3 (HPCL-tandem mass spectrometry)
J Throm Haemost 2013; 11: 756-60
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Substancegroup
Substancegroup
Direct FIIa‐
inhibitors
1. Screening‐methodsaffected
1. Screening‐methodsaffected
INR
APTT
2.Methods for measuring/ monitoring
2.Methods for measuring/ monitoring
Thrombintime (TT)
ECT
Karin Strandberg 2013
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Substancegroup
Substancegroup
Direct FXa‐
inhibitors
1. Screening‐methodsaffected
1. Screening‐methodsaffected
APTT
INR
2.Methods for measuring/ monitoring
2.Methods for measuring/ monitoring
Anti Xa‐activity
Karin Strandberg 2013
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Effect of FII and FX inhibitores on coagulation assays FII
EffectFII
MeasuringFX
EffectFX
Measuring
PT (INR) + ‐ (+) ?
APTT ++ Qualitative + Qualitative
Thrombin time +++ Qualitative ‐ ‐
Diluted TT ++ Quantitative ‐ ‐
ACT + ? + ?
Ecarin clotting time
++ Quantitative
Anti‐ IIa assay(chromogenic)
++ Quantitative ‐ ‐
Anti‐ Xa assay(chromogenic)
‐ ‐ ++ Quantitative
J Throm Haemost 2013; 11: 756-60
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How I handle DOAC in my clinical practice
Anticoagulation clinic; 12.000 patientsDOAC >3000 patientsStart on DOACsInformation (nurse 15- 20 minutes)Basic laboratory tests ( Hemoglobin, platlets and coagulation test APTT INR and kidney function eGFR)First year on DOAC eGFR 3, 6 and 12 months after start.
Bergman et al Thromb Res. 2013
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How I handle DOAC in my clinical practice
Strategies to minimize the risk of bleedingReview the patients risk factors; age, weight, renal functionPrescribe the dose of DOAC that is recommendedHave a strategy for discontinue DOAC before surgery and how to resume DOAC after surgeryLocal guidelines / Education!!!!
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DOAC – broad terapeutic window
Dose, concentration or intensity of anticoagulation
Broad terapeutic
window
NOAC
BleedingThrombosis
Dabigatran ~ 50-200 ng/mlRivaroxaban ~ 25-400 ng/mlApixaban ~ < 300 ng/ml ??
FDA
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Steady State
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Peak and Trough
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Peak and Trough
Cuker. J Thrombosis and Thrombolysis 2015
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• Is kidney function important to measure and monitor for DOAC ??
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CKD Chronic Kidney Disese
CKD*-stadium Description GFR*
(mL/min/1,73 m2)No CKD Normal ≥90
1 Normal with i.e. proteinuria ≥90
2 Mild 60–893 Moderate 30–594 Severe 15–29
5Kidney failure
<15 or dialysisESRD*
*GFR = glomerulär filtrationshastighet; Njurskada definieras som t ex mikroalbuminuri; CKD = chronic kidney disease; ESRD = end-stage renal disease (terminal njursvikt)1. Koro CE, et al. Clin Ther 2009; 31: 2608–17. 2. National Kidney Foundation. Am J Kidney Dis 2002;39(suppl1):S1–S266.
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Prevalence of kidney dysfunction in patients with AF
• eGFR = estimated glomerular filtration rate
• MDRD = modified diet in renal disease
• LM = Lund –Malmö
• eGFR(MDRD) = 175 × (p‐Cr/88.4)− 1.154 ×age− 0.203 × 0.742 (if female) × 1.212 (if Afro‐American)
Jönsson et al. Thromb Res. 2011 Oct;128(4):34
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Effect on DOAC plasma level.
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Effect on DOAC plasma level increase or decrease
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One possible way to handle a clinical situation
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Trough plasma concentrations of dabigatran: concomitant treatment dabigatran 110 mg BID and dronedarone 400 mg BID
Median trough concentration of dabigatran 150 mg bid without concomitant dronedarone was 93 ng/ml (10th to 90th percentile 39.8-215), in the RE-LY substudy
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What is the size of the”bridging” issue
Peri-Procedual Bleeding and Thromboembolic Events with Dabigatran compared to Warfarin: Results from the RE-LY trail
A total of 4591 (25%) patients underwent at least one invasive procedure during the study.Pacemaker/ICD 10%Dental procedure 10%Different Diagnostic procedures 10%Cataract removal 9.5%Colonoscopy 9%Hip or knee Replacement 6%
Circulation 2012; 126:343-48
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Kidney function and half life of DOAC
eGFR(ml/min)
Dabigatran Apixaban Edoxaban Rivaroxaban
>80 12-17h 12h 10-14h 5-9h (yngre)11-13h (äldre)
60-80 14h 14h 8.6h 8.5h30-60 18h 17h 9.4h 9h15-30 28h 17h 17h 9.5h≤15 No data No data No data N data
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Patients undergoing a planned intervention or surgery
• Low risk 1 day
• High risk 2 days
• fX , eGFR 15‐30, high risk 3 days
• fII, eGFR 15‐30, högrisk 4 days
Douketis et al-J Thromb HaemostasOnline October 2015
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Clinical situation were DOAC theoretically could be measured
• Bleeding
• Emergancy surgery
• Body weigt (low or high)
• Renal failure
• Trauma
• Trombolysis
• Antidot
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Sweden warfarin vs DOAC
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Conclusion and Callenges
Older and more complex patients with more co-morbidity Kidney functionFollow – up important (register)
How to interpretate test results (compare to LMWH) i.e. dos adjustmentEstablish reference interval
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Malmö Centre for Thrombosis and Haemostasis
THANKS