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Transcript of AHS Powerpoint Template - KTPH - Practical... · 1 Practical Considerations on the Use of Novel...
22/02/2017
1
Practical Considerations on the Use of
Novel Oral Anticoagulants (NOACs) in
Stroke Patients with Non-valvular AF
AHS-NNI Neuroscience Forum 2017
18 February 2017
Hobart Ng Tsai, PharmDSenior Pharmacist (Inpatient)
Khoo Teck Puat Hospital
Content Outline
• Brief review of NOACs mechanism of action and characteristics
• Warfarin vs. NOAC in AF patients, when do I choose what?
• What do I do on follow-up visits?
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Brief Review of NOACsPharmacology and Properties
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http://ijri.org/article.asp?issn=0971-3026;year=2015;volume=25;issue=4;spage=375;epage=379;aulast=Laroia;type=3
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5Heidbuchel H. et al. Europace. 2015;17(10):1467-507.
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Warfarin vs. NOACsWhen to choose what
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7Granger CB, Circulation. 2012;125(1):159-64. Compiled data from randomized controlled trials on warfarin vs. NOACs
In summary, NOACs are as efficacious or more efficacious than and have same
rate or less rate of bleeding compared to warfarin
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Forest plot depicting the hazard ratio for each pairwise propensity‐matched medication
comparison (dabigatran, rivaroxaban, and apixaban each vs warfarin) for stroke and systemic
embolism (S/SE), ischemic stroke, and hemorrhagic stroke.
Xiaoxi Yao et al. J Am Heart Assoc 2016;5:e003725. Real-world data on warfarin vs. NOAC
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Forest plot depicting the hazard ratio for each pairwise propensity‐matched medication
comparison (dabigatran, rivaroxaban, and apixaban each vs warfarin) for major, intracranial,
and gastrointestinal bleeding.
Xiaoxi Yao et al. J Am Heart Assoc 2016;5:e003725. Real-world data on warfarin vs. NOAC
Real-world data show that the results on efficacy and safety of NOACs from clinical
trials are seem to be preserved in practice.
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• 2016 ESC AF Guidelines:
“When oral anticoagulation is initiated in a
patient with AF who is eligible for a NOAC, a
NOAC is recommended in preference to a
Vitamin K antagonist.” (IA)
However, the question remains…who should
be on warfarin? Who should be on a NOAC?
Warfarin vs. NOACs
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Valvular AF or AF with moderate or severe rheumatic mitral stenosis
• Warfarin
Patients on warfarin with TTR >70%
• Warfarin
Warfarin vs. NOACs
http://www.cthsurgery.com/mitral-valve-replacement.html
http://www.medscape.com/viewarticle/862369#vp_2
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Warfarin vs. NOACs
Renal impairment (CrCl <50 ml/min) but not on dialysis
• Apixaban (unless CrCl <25ml/min)
• Rivaroxaban (unless CrCl <30 ml/min)
Dialysis patients
• Warfarin
http://renaltreatment.com/chronic-renal-failure/
http://www.kidneyfailureweb.com/dialysis-knowledge/1248.html
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Warfarin vs. NOACs
Older patients (≥ 75 years old)
• Apixaban
High risk for Gastrointestinal Bleeding
• Apixaban
• Dabigatran 110mg twice daily
http://blogs.nejm.org/now/index.php/gastrointestinal-bleeding/2015/02/06/
http://www.eu-patient.eu/News/News-Archive/EPF-position-on-the-rights-and-needs-of-older-patients/
• What about drug interactions?
Some medications such as rifampicin, anti-
epileptics, and HIV protease inhibitors, are
contraindicated with some NOACs.
It’s best to check with a pharmacist.
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Warfarin vs. NOACs
https://janaburson.wordpress.com/2014/03/25/drug-interactions-with-methadone/
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What to do on follow-up visits?What do I monitor?
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• Assess for the following:
Adherence
Thromboembolism/Bleeding
Concomitant medications
Hemoglobin and renal function
Monitoring Parameters
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• How often to assess renal function
CrCl/10 = frequency in months on how often
to check renal function
E.g. CrCl = 50 ml/min
CrCl/10 = 50/10 = 5 months
*Check renal function at least every 5 months
Monitoring Parameters
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• Yao X, Abraham NS, Sangaralingham LR, et al. Effectiveness and Safety of Dabigatran,
Rivaroxaban, and Apixaban Versus Warfarin in Nonvalvular Atrial Fibrillation. J Am Heart Assoc.
2016;5(6)
• Schneeweiss S, Gagne JJ, Patrick AR, Choudhry NK, Avorn J. Comparative efficacy and safety
of new oral anticoagulants in patients with atrial fibrillation. Circ Cardiovasc Qual Outcomes.
2012;5(4):480-6.
• Kirchhof P, Benussi S, Kotecha D, et al. 2016 ESC Guidelines for the management of atrial
fibrillation developed in collaboration with EACTS: The Task Force for the management of atrial
fibrillation of the European Society of Cardiology (ESC)Developed with the special contribution
of the European Heart Rhythm Association (EHRA) of the ESCEndorsed by the European
Stroke Organisation (ESO). Eur Heart J. 2016;
• Heidbuchel H, Verhamme P, Alings M, et al. Updated European Heart Rhythm Association
Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-
valvular atrial fibrillation. Europace. 2015;17(10):1467-507.
• Diener HC, Aisenberg J, Ansell J, et al. Choosing a particular oral anticoagulant and dose for
stroke prevention in individual patients with non-valvular atrial fibrillation: part 1. Eur Heart J.
2016;
• Diener HC, Aisenberg J, Ansell J, et al. Choosing a particular oral anticoagulant and dose for
stroke prevention in individual patients with non-valvular atrial fibrillation: part 2. Eur Heart J.
2016;
References
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Extra Slides
24Diener HC,et al. Eur Heart J. 2016
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25Diener HC,et al. Eur Heart J. 2016