HHE Cardiovascular supplement 2018 - Page 21

Dabigatran Rivaroxaban Apixaban Edoxaban Prodrug Active drug Active drug Active drug Direct Direct Direct Direct 80% 33% 27% 50% p.o. p.o. p.o. p.o. 2–3h 2–4h 3–4h 1–2h 12–14h 7–12h 8–14h 10–14h Medium Medium Medium Medium AE Anticoagulant effect AT Antithrombin FPX Fondaparinux LMWH Low molecular weight heparin UFH Unfractionated heparin VKA Vitamin K antagonist Dabigatran Anti-Xa Anti-factor Xa activity aPTT Activated prothrombin time FPX Fondaparinux INR International normalised ratio LMWH Low molecular weight heparin od Once daily UFH Unfractionated heparin VKA Vitamin K antagonist Rivaroxaban Apixaban Edoxaban Regular dosage Not recommended Regular dosage Not recommended# Not recommended Not recommended 2 x 75mg/day ((10mg od))* (2x5mg/d) > 80y or < 60kg reduced dosage Contraindicated (2.5mg twice daily)* Outside the setting of elective joint arthroplasty, meaningful subgroup analyses of patients with CKD are rare. Therefore, recommendations derived from joint replacement surgeries are considered references for postoperative VTE prevention also in other indications. Many of those – elderly – patients with CKD undergoin g surgery are on long-term anticoagulation therapy prior to the operation due to AF or VTE. Nowadays, most of these patients receive DOACs. Yet, there still is a relevant proportion of patients treated with VKA for these indications or others. Although minor procedures can be performed in most patients while on trough levels of DOACs or in the lower part of the therapeutic INR-range, major surgeries or interventions with an increased risk of haemorrhage require normal hemostasis. For DOACs an interruption for 2–5 days (Table 2) depending on the specific DOAC as well as on renal function seems to be a safe strategy. Bridging of VKA anticoagulation by LMWH in the context of AF has recently become a matter of discussion. 15 Yet, it needs to be stressed that in patients with sRI or ERD, having a clear cut indication for anticoagulation therapy, bridging via application of UFH may be less convenient, but safer than the use of LMWH. Postoperative Not recommended ((30mg od))* anticoagulation in these patients may be initiated with a prophylactic dose for some days before – stepwise – escalation to the therapeutic dose, depending on the postoperative bleeding risk. Full dose anticoagulation therapy in patients with CKD and VTE Prospective randomised trials in general populations with VTE have demonstrated that anticoagulation therapy significantly decreases recurrent VTE to a larger extend than it increases hemorrhagic complications. 6 This beneficial effect of treatment has been confirmed in observational studies and registries. In large registration studies patients with acute VTE (or AF) and mRI have been included and subgroup analysis demonstrated a comparable ‘net-benefit’ of therapeutic anticoagulation with numerically higher rates of thromboembolic events and bleeding complications compared with patients with a GFR >60ml/min. 5-7 However, patients with sRI or CHD were largely excluded. Thus, prospective evidence as well as systematic reviews and meta-analyses for patients suffering from sRI or ESRD/CHD and acute VTE are not available. However, tens of thousands of patients with AF and CHD treated with warfarin have been analysed with heterogeneous results. 6,17 Thus, any clear benefit of VKA in the CHD 21 HHE 2018 | hospitalhealthcare.com As long as GFR is >30ml/min, standard dosages of LMWH or most DOACs can safely be applied