Afib anticoag

[ventana]

So just lost a patient to a spontaneous GI bleed on Coumadin and got me thinking about the newer novel agents

 

See Pradaxa just got a reversal agent approved

 

What is everyone else doing for simple PE, DVT Afib (non-valvular) at this time

(already read uptodate but looking for what people are doing in the field)

 

 

 

Please reply only if you are commonly starting people on these meds, and not just opinions.....

[UGoLong]

We're using a fair amount of Eliquis which had a study that showed less bleeding than warfarin. We also use other of the NOACs, and also warfarin from time to time.

 

From a practical standpoint, I don't know that a reversal agent is going to help much in an emergency, as you saw with warfarin, which has one.

 

There is also a drumbeat to find an assay for NOACs so we can tell if people have them on board. Seems like a good idea.

 

Hope this helps.

[DogLovingPA]

Xarelto seems to be the anticoagulant of choice for the docs around here.  I'm in urgent care so not often prescribed by us but I have started a couple patients on it for distal symptomatic DVT's with close follow up with PCP.  I've also seen multiple patients that I've sent to the ER for simple PE, new onset a-fib go home on Xarelto as first choice.   The biggest barrier to this is often price. 

[winterallsummer]

Unless contraindicated I tend to go to xarelto > eliquis. That being said, some evidence suggest lower bleeding risk with Eliquis. Pradaxa if taken recently may be reversed partially by HD. Many Xa reversal agents in the pipeline.

 

Coumadin for advanced CKD, liver disease, VAF, etc (other CIs) and when the pt can't get the NOAC through insurance or one of the pharmacy discount programs. Typically our GI guys will help clear our pts to restart ACs if they came in for a bleed and got scoped. A good rule of thumb is that if the HAS BLED score is < or = their CHADSVasc2 score they need to be anti coagulated (if equal May consider a shared decision making process). That is just a rough rule of thumb however. I personally prefer NOACs over Coumadin even in my pts with hx of a GIB. At my hospital some are using PCC and other strategies to try to reverse NOACS although not really strongly evidence based.

[Acebecker]

Xarelto is the go-to for me when I get a patient with new onset DVT or non-valvular A-fib.  Don't see a lot of PEs in urgent care.  As above - if any contraindications, begin heparin/lovenox and Coumadin cross-over.  

 

I have a suspicion that the bid dosing of eliquis vs. the daily dosing on xarelto is the reason for more bleeds on xarelto - y'all can correct me if I'm wrong.  But daily dosing supposedly causes a higher peak plasma concentration and therefore will make bleeding a higher risk. 

 

That said, the daily dosing helps to ensure compliance which is another side of the same coin.

[Reality Check 2]

In FP, we inherit the patient back after the ER in most cases and sometimes find the Afib or DVT. We start Xarelto from our office with samples and - depending on the extent of the DVT - either bridge with a few doses of Lovenox or they get admitted if above the bifurcation or symptoms of PE. We are quite literally across the street from the hospital.

 

I see far more Xarelto than anything else. My own spouse takes Xarelto for Afib after 2 yrs of coumadin hell and an INR that was like a yo-yo. No problems on Xarelto in my house. Very few complaints or concerns from patients.

 

I inherited one patient on Pradaxa who had a DVT ON THE DRUG. He was on it for Afib.

 

I have zero patients on Eliquis and have never started it.

 

All of our local orthos are using Xarelto post op for total joints for the 30 days. They bridge in the hospital post op with Lovenox.

 

So, Xarelto is the reigning champion in my area and I feel comfortable starting people on it.

[True Anomaly]

I've also started folks on Xarelto for DVT- none for Pradaxa. No Eliquis yet. Have seen some nasty GI bleeds on Pradaxa, but that was before Kcentra

[cinntsp]

Eliquis or Xarelto depending on insurance and what copay discount cards are laying around.

[casias]

In cardiology, we started using them as they became available. After a year or so, we had a loose guideline that we followed.

 

1) Pradaxa for younger, with less risk of GI bleed. I do believe there is a slightly higher risk of GI bleed with Pradaxa, because of its mechanism of action, although we didn't see it in our patient population.

2) Eliquis for older, more likely to have GI bleed. 

3) Sometimes Xarelto, depending on pre-auth and out-of-pocket costs. The once daily dosing didn't really mean much, since all or our patients are on twice daily stuff anyway. 

 

As for warfarin, it quickly fell by the wayside in our practice. The coumadin clinic didn't pay well, and patients are difficult to control, even when done correctly. I would rather have a well-controlled patient than an educated guess.

 

When we do have occasional GI bleeds, hospitalization with fluid and a couple of units of blood, and let the effects wear off. All of the novel agents wear off quickly. Clinically, I prefer to let the novel agents wear off rather than try to reverse warfarin. It's easier, and the outcomes, at least in our practice, are about the same (hospitalization days, units transfused).

 

For DVT, here is a real-world example.

 

I had an 81-year-old who was wheelchair-bound, and had developed a thick dvt not long after Xarelto was approved for DVT. So I gave him the 15 mg bid for 21 days, then the 20 mg once daily. About 2 weeks in, he developed hematuria and hematochezia, He was not losing significant blood, and did not have to be hospitalized, but the risk was there. So I stopped the drug. About a week later, at a follow-up visit, I took him back the the vascular lab and scanned his leg. The DVT, which had a heavy clot burden before treatment, was completely resolved. This doesn't happen with warfarin, typically.

[LKPAC]

Eliquis or Xarelto depending on insurance and what copay discount cards are laying around.

 

same here.

[UGoLong]

As I noted, we use Eliquis a fair amount. Some of us have started Savaysa (not me yet), which is once daily (instead of twice) and also has data that it causes less of a bleeding risk than warfarin.