Top Ten Things Every Clinician Should Know About the 2018 Antithrombotic Therapy Atrial Fibrillation Guidelines

The American College of Chest Physicians (ACCP) recently updated their guideline recommendations for the use of antithrombotics for the prevention of stroke in patients with atrial fibrillation (aka the Chest Guidelines).  Find out what's new, who shouldn't receive treatment based on the CHA₂DS₂-VASc score, and why the guideline panel recommends calculating a patient's SAME-TTR score.

Guest Author:  Dylan Lindsay, PharmD

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Stop the Shots: Edoxaban vs Dalteparin in Cancer-Associated VTE Treatment

For the treatment of cancer-associated VTE, LMWHs are recommended over warfarin (Grade 2B) and DOACs (all Grade 2C).  Warfarin therapy in cancer-associated VTE is often made more difficult by wildly fluctuating international normalized ratios, procedure-related interruptions, as well as numerous drug-drug and drug-food interactions.  While DOACs have been widely used in the treatment of VTE, there is very little data supporting their use in patients with active cancer until now with the publication of the Hokusai VTE Cancer study.

Guest Authors:  Elizabeth Scheffel, PharmD and Christa George, PharmD, BCPS, BCACP, CDE

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Where is the COMPASS Taking Us? Rivaroxaban, Aspirin, or Both for Stable CVD ?

Since the introduction of direct oral anticoagulants (DOACs) less than a decade ago, use of this class has expanded beyond the prevention and treatment of venous thromboembolism and stroke prevention in the setting of atrial fibrillation. The potential role of DOACs in the secondary prevention of coronary artery disease (CAD) has been of considerable interest. In the setting of CAD, warfarin has resulted in significant more major bleeding when given either alone or in combination with antiplatelet agents when compared to aspirin alone.  Therefore, clinicians have been reluctant to embrace the combination of an anticoagulant plus an antiplatelet agent. However, could DOACs have a role in stable CAD? The COMPASS trial aimed to find an answer.

Guest Authors:  Candyce Bryant, Pharm.D., Joy Hoffman, Pharm.D., and M. Shawn McFarland, Pharm.D.

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Validating HERDOO2 - When is it Safe to Stop Therapy After an Unprovoked VTE?

According to the 2016 CHEST VTE Guidelines, at least 3 months of therapy is recommended for an unprovoked DVT or PE (Grade 1B). Thereafter, the clinician is expected to weigh the risks and benefits to determine if extended therapy is appropriate. Balancing the risk of mortality from recurrent VTE versus major bleeding has been challenging.  A validated clinical decision tool is sorely needed!  Until recently, no risk assessment tool has been validated and therefore none have been widely adopted in practice.

Guest Author:  Carol Chan, Pharm.D.

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It’s All Relative: EINSTEIN CHOICE - Rivaroxaban for Extended Secondary Prevention of VTE

For the acute treatment of venous thromboembolism, the direct oral anticoagulants (DOACs) have increasingly replaced injectable anticoagulant therapy followed by warfarin.  For patients with an unprovoked deep vein thrombosis or pulmonary embolism who may benefit from long-term extended prophylaxis for the secondary prevention of VTE, the choice is less clear. Should a DOAC be used?  If so, which one and what's the best dose?  What about low-dose aspirin? Is extended therapy needed at all?  The EINSTEIN CHOICE study adds important new insights to the growing body of literature.

Guest Author: Sarah Anderson, PharmD, BCPS

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Antithrombotic Therapy Following Stent Placement in Patients with A-Fib: Should DOACs Be Preferred?

Many patients with atrial fibrillation (AF) received triple antithrombotic therapy after undergoing a percutaneous coronary intervention (PCI) and receiving cardiac stent. Triple therapy consists of warfarin plus dual antiplatelet therapy (DAPT) with a P2Y₁₂ inhibitor and low-dose aspirin. But is triple therapy the best approach? This practice, while widely employed, is not entirely evidence-based. Moreover, the effectiveness and safety of the direct oral anticoagulants (DOACs) in this patient population is unknown.

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Crossing the Periprocedural Bridge in Patients with Atrial Fibrillation

For over two decades LMWHs have been routinely used to provide therapeutic coverage in patients who must temporarily stop warfarin. Current guidelines suggest using injectable anticoagulants during warfarin interruption (aka bridging) in patients with atrial fibrillation based on patients’ risk of arterial thrombosis. Using the CHADS₂ score to assess risk, the guidelines recommend (grade 2C) bridge therapy if the CHADS₂ score is 5 or higher and not bridging if the CHADS₂ score is 2 or lower. But what about patients with a CHADS₂ score of 3 or 4?

How Long Is Long Enough? Extending OAC After Unprovoked PE

The recommended treatment duration for a first episode of unprovoked venous thromboembolism (VTE) is, at a minimum, 3 months with extended anticoagulation favored for those who are not at high risk for bleeding.  However, the optimal duration of anticoagulation therapy remains unknown.

The Prolonged Anticoagulation Treatment for a First Episode of Idiopathic Pulmonary Embolism (PADIS-PE) study examines this question but, most importantly, provides insights about patient outcomes after anticoagulation treatment is discontinued

Managing Direct Oral Anticoagulants – What’s Our Role?

Many clinicians are questioning the role pharmacists play in anticoagulation therapy management as direct oral anticoagulants (DOACs) increasingly replace warfarin for a variety of indications. A recent study examined medication adherence and therapy management practices at Veterans Health Administration (VHA) patient care sites. Although this study does not have all the answers, it does reveal the importance of patient selection and ongoing patient monitoring – potentially key roles for pharmacists.

Anticoagulation Bridge Therapy - Risks and Benefits Examined

The ORBIT-AF study raises questions about anticoagulation therapy bridging practices.  Do the risks outweigh the benefits?