Direct oral anticoagulants have fewer overall drug-drug interactions (Table 65,9–13); a comparable (if not lower) bleeding rate; a shorter half-life; and fixed dosing based on indication, drug interactions, and renal or hepatic function. 100/No. Direct oral anticoagulants in patients with chronic kidney disease: patient selection and special considerations. et al. Atrial Fibrillation/Supraventricular Arrhythmias. 2017 ACC expert consensus decision pathway on management of bleeding in patients on oral anticoagulants. Ezekowitz MD, 17. An echocardiogram showed normal left ventricular function, and exercise stress test was suggestive of ischemia. N Engl J Med. 2016;14(6):1308–1313. Discontinue in patients who develop acute renal failure on rivaroxaban Prophylaxis for stroke and systemic embolism in nonvalvular atrial fibrillation: Avoid with combined P-glycoprotein and moderate CYP3A4 inhibitors and CrCl 15 to 80 mL per minute per 1.73 m2 (0.25 to 1.34 mL per second per m2), CrCl 15 to 50 mL per minute per 1.73 m2: 15 mg per day (patients with a CrCl < 30 mL per minute per 1.73 m2 were not studied in trials), Avoid with combined P-glycoprotein and strong CYP3A4 inhibitors or inducers, Total hip or knee replacement surgery: 10 mg daily for 12 days after knee replacement surgery or 35 days after hip replacement surgery, Observe for blood loss in CrCl 30 to 50 mL per minute per 1.73 m2, Avoid use in CrCl < 30 mL per minute per 1.73 m2, Avoid with combined P-glycoprotein inhibitors and moderate CYP3A4 inhibitors and CrCl 15 to 80 mL per minute per 1.73 m2, 10 mg per day after six months or longer of standard anticoagulant therapy, 15 mg twice per day with food for the first 21 days, then 20 mg per day with food for six months, Appropriate standard direct oral anticoagulant dosing in patients with a BMI ≤ 40 kg per m2 or weight ≤ 120 kg Suggest direct oral anticoagulants not be used In patients with a BMI > 40 kg per m2 or weight > 120 kg; if used in these patients, check drug-specific peak and trough levels, Take with food Starter pack for initial dosing for treatment of DVT and PE Coupons available for starter pack and maintenance dosing Information, BMI = body mass index; CrCl = creatinine clearance; CYP = cytochrome P450; DVT = deep venous thrombosis; PE = pulmonary embolism; VTE = venous thromboembolism. 2011;365(11):981–992. Akl EA, Accessed May 2, 2019. https://www.pradaxa.com, Savaysa (edoxaban) tablets, for oral use [prescribing information]. et al. Bleeding risk assessment should be performed, any modifiable risk factors addressed during each visit. Accessed May 2, 2019. https://www.bevyxxa.com/wp-content/uploads/2019/08/PI-V1.5-Clean-Word-30July-2019-linked.pdf. Witt DM, Of note, 18% of patients had a thrombotic event during 30 days of follow-up, highlighting the potential prothrombotic risk that this agent carries. Arrhythmias. Beta-blockers are recommended, starting perioperatively, to reduce the risk of postoperative atrial … Direct oral anticoagulants should be used as first-line agents for the treatment of venous thromboembolism and the prevention of stroke in patients with nonvalvular atrial fibrillation and a CHA2DS2-VASc score of 2 or higher in men and 3 or higher in women. Alexander JH, 2013;87(8):556–566. The SELECT-D trial evaluated dalteparin with rivaroxaban in patients with active cancer.2 The study found an absolute VTE recurrence reduction of 7% at six months in favor of rivaroxaban (11% vs. 4%; hazard ratio [HR] = 0.43; 95% CI, 0.19 to 0.99).2 The major bleeding rate at six months was 4% for dalteparin and 6% for rivaroxaban (HR = 1.83; 95% CI, 0.68 to 4.96).2 Most of the major bleeding was gastrointestinal, primarily in patients with esophageal or gastroesophageal cancer. Kcentra is preferred over a fresh frozen plasma infusion because of its smaller volume, faster infusion rate, and superior effectiveness in INR reduction. ARISTOTLE Committees and Investigators. Raskob GE, Dabigatran versus warfarin in patients with atrial fibrillation [published correction appears in N Engl J Med. After a baseline INR is determined, the next INR should be obtained after the patient has received two or three doses of the vitamin K antagonist. 3. Validated bleeding risk assessments such as HAS-BLED should be performed at each visit and modifiable factors should be addressed. This clinical content conforms to AAFP criteria for continuing medical education (CME). Older patients and persons with liver disease, poor nutritional status, or heart failure may require lower initiation dosages.4 Diarrhea, fever, and hyperthyroidism can also potentiate the effect of vitamin K antagonists. , see https: //www.aafp.org/dam/AAFP/documents/patient_care/clinical_recommendations/a-fib-guideline.pdf, 20 should be addressed bleeding risk with medications.: increased bleeding risk assessment should be performed at 90 days and phone follow-up at 180 days stroke. An OAC previous: Opioid use Disorder: medical treatment options, Home / Journals / AFP /.! To many drug interactions of anticoagulation, so monitoring with anti–factor Xa levels is not routinely.. 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