Anticoagulation Therapy Considerations in Factor VII Deficiency.

Factor VII (FVII) deficiency is the most prevalent rare bleeding disorder in the USA and affects approximately 1 out of every 500,000 people. Warfarin inhibits the synthesis of FVII, in addition to other clotting factors. Warfarin is contraindicated in patients with bleeding tendencies or blood dyscrasias; therefore, the literature regarding the use of warfarin in FVII deficiency is very limited. We report a successful re-challenge of warfarin therapy in a patient with FVII deficiency. A 70-year-old woman with FVII deficiency experienced a significant decrease in FVII activity and subsequent vaginal bleeding roughly 5 weeks after starting warfarin for atrial fibrillation. The patient was switched to aspirin therapy. Nearly 4 years later, warfarin therapy was re-attempted by a different haematologist. After 9 months, FVII activity remained in an acceptable range and no bleeding events had occurred. In addition, once the maintenance dose was established, the international normalized ratio remained within the goal range (1.5-2.0) for the majority of assessments. Regarding future considerations, we hypothesize that anticoagulants that do not directly affect FVII, such as the direct oral anticoagulants, would carry less risk of bleeding complications and therefore may be safer alternatives to warfarin to reduce the risk of thromboembolic stroke in patients with atrial fibrillation and FVII deficiency.

Using the Jigsaw Technique to Teach Clinical Controversy in a Clinical Skills Course.

OBJECTIVE: To evaluate the effectiveness and student perception of the jigsaw technique to engage students in a clinical controversy exercise and to assess student engagement level during each step of the process. DESIGN: Students were assigned individual readings pertaining to the controversy surrounding the drug oxybutynin switching from prescription to nonprescription. They met with an expert group and teaching groups during mandatory laboratory time and worked together to formulate a recommendation on the appropriateness of nonprescription conversion for a drug. ASSESSMENT: A quiz taken individually was used to measure effectiveness. Student perception and level of engagement was assessed using surveys. CONCLUSION: The jigsaw technique was successful in teaching the concepts involved in the clinical controversy. Group members rated themselves and fellow participants' level of engagement as high during both the expert group and teaching group sessions. Most students reported they learned about the same or more with the jigsaw technique compared to another cooperative learning technique used in the curriculum.

Warfarin and Rivaroxaban Duplication: A Case Report and Medication Error Analysis.

A 62-year-old African American man received unintentional duplicate anticoagulation therapy with warfarin 5 mg and rivaroxaban 20 mg daily for the treatment of recurrent pulmonary embolism. The patient presented to the anticoagulation clinic 6 days after hospital discharge with an International Normalized Ratio (INR) of 2.3 and he was instructed to continue warfarin 5 mg daily. Seven days later, he returned to the clinic with an INR >8.0 using a point-of-care device. He denied any signs or symptoms of bleeding. During the interview, he reported starting a new medication for neuropathy 5 days earlier. The clinical pharmacist contacted the dispensing pharmacy and determined rivaroxaban 20 mg was the new medication. The patient denied receiving new prescription counseling at the dispensing pharmacy. Because rivaroxaban can falsely elevate INR results, the actual INR value was unknown. To minimize the risk for recurrent venous thromboembolism, vitamin K was not administered and no warfarin doses were held. Rather, the patient was instructed to stop rivaroxaban and reduce the warfarin dose. Five days later, the patient returned with an INR of 4.3. He still had not experienced any signs or symptoms of bleeding. The patient was quickly stabilized on a warfarin maintenance dose of 22.5 mg weekly. The anticoagulation clinic pharmacist notified management at the clinic and at the dispensing pharmacy in an effort to identify process errors and prevent additional incidents.

Overactive bladder: OTC oxybutynin transdermal patch for women.

The prevalence and burden of overactive bladder (OAB) in the population is remarkable. An estimated 20 million adult women in the United States have symptoms of OAB. Despite the negative impact on their health-related quality of life, many do not seek treatment. Antimuscarinic agents for OAB have long been available only with a prescription. However, the Food and Drug Administration approved an over-the-counter (OTC) oxybutynin transdermal patch for use in women in 2013, and the product recently came to market. The availability of an OTC antimuscarinic medication for OAB introduces the opportunity for females to self-treat the condition. Prior to the prescription-to-OTC switch, the efficacy and safety data for the prescription product were evaluated. Consumer research studies guided the development of the drug label.

Ticagrelor: a novel oral antiplatelet agent.

OBJECTIVE: To review the pharmacology, clinical efficacy, and tolerability of ticagrelor and to discuss implications for use in the elderly. DATA SOURCE: A literature search was conducted in MEDLINE from 1966 to July 2010 using the MESH terms and key words AZD6140, ticagrelor, P2Y12 receptor antagonist. The search was limited to studies in English language with human subjects. STUDY SELECTION AND DATA EXTRACTION: Randomized controlled clinical trials were reviewed. References that were deemed relevant to pharmacodynamic/pharmacokinetic studies of P2Y12 antagonists and their historical background were also included. DATA SYNTHESIS: Ticagrelor is the first reversible oral P2Y12 antagonist currently undergoing Food and Drug Administration review for approval. The advantages of ticagrelor over clopidogrel are a more rapid onset of action, offset, and reversibility at the platelet P2Y12 receptor site. In the Study of Platelet Inhibition and Patient Outcomes trial, ticagrelor reduced the incidence of death as a result of cardiovascular causes, with no increase in major bleeding or bleeding related to coronary artery bypass graft (CABG) compared with clopidogrel. Subgroup analyses suggested that elderly patients may benefit more from ticagrelor than from clopidogrel. However, the increase in non-CABG-related bleeding and unique adverse events may limit ticagrelor's use in the elderly. CONCLUSION: The use of ticagrelor in the elderly should be determined on a case-by-case basis. More studies need to be conducted prior to establishing a role in therapy for the elderly.