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3.
Ann Pharmacother ; 54(3): 226-231, 2020 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-31578074

RESUMEN

Background: α-1 adrenergic antagonists are commonly prescribed, but there is question regarding their safety in patients at increased fall risk. Objective: The purpose of the FRAGILE study was to determine the risk for developing adverse drug events (ADEs) in veterans prescribed α-1 blockers. Methods: A single-center, retrospective, observational cohort analysis was conducted of veterans newly initiated on α-1 antagonists. Veterans were categorized into at-risk (patients who met at least 1 of 2 criteria: age 65 or older or high initial dose of α blockade) or control (veterans without either risk factor) groups. The primary outcome was the composite all-cause ADEs, including hospitalizations or emergency department (ED) visits. Secondary outcomes included number of fall-related ADEs and medication discontinuation rates with follow-up for 12 months. Results: A total of 300 veterans were evaluated. There was no significant difference in the composite outcome of all-cause ED visits between at-risk (n = 169) versus control (n = 131) groups (0.81 vs 1.17, P = 0.09) or all-cause hospitalizations (0.28 vs 0.39, P = 0.25). Seventy-three veterans in the at-risk group experienced an all-cause ADE versus 64 in the control group (P = 0.36). No significant differences in secondary outcomes were found. Fall-related side effects occurred in 8% of the total cohort. Conclusion and Relevance: Rates of all-cause or fall-related ADEs were not significantly different. An 8% discontinuation rate resulting from fall-related ADEs and high rates of coadministered medications that could increase fall risk. Pharmacists can play a key role in optimizing α-1 blocker administration.

4.
South Med J ; 112(2): 125-129, 2019 02.
Artículo en Inglés | MEDLINE | ID: mdl-30708380

RESUMEN

A poorly understood significant drug-drug interaction compounded by ineffective communication among providers at times of care transition most likely contributed to multiple thromboembolic events in an 81-year-old patient. Increased awareness of drug interactions with direct oral anticoagulants (DOACs), as well as improved communication among inpatient and outpatient providers at the time of discharge is essential in maximizing efficacy and safety outcomes in patients requiring chronic anticoagulation. When rifampin is coadministered with apixaban, a reduction in apixaban exposure results in decreased efficacy and increased risk for thromboembolic events. The delayed effect of rifampin deinduction should be considered with regard to potential drug interactions even after its discontinuation. Equally as important, patients with multiple comorbidities and polypharmacy are at significant risk from adverse drug events during the transition from hospital to home. All efforts to improve continuity of care at times of transition, including medication reconciliation, prompt delivery of discharge summaries to outpatient providers, effective communication among providers, and patient education are components of a best practices model that has the potential to lower costs, improve medication adherence, decrease adverse drug events, and reduce hospital readmissions.


Asunto(s)
Anticoagulantes/uso terapéutico , Fibrilación Atrial/tratamiento farmacológico , Coagulación Sanguínea/efectos de los fármacos , Cumplimiento de la Medicación , Conciliación de Medicamentos/métodos , Tromboembolia/tratamiento farmacológico , Terapia Trombolítica/métodos , Anciano de 80 o más Años , Fibrilación Atrial/complicaciones , Interacciones Farmacológicas , Femenino , Estudios de Seguimiento , Humanos , Tromboembolia/sangre , Tromboembolia/etiología
5.
Pharmacotherapy ; 39(1): 94-108, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-30548542

RESUMEN

As overall prevalence of atrial fibrillation (AF) continues to rise, the number of patients who undergo ablation, or electrical/chemical cardioversion, to restore normal sinus rhythm continues to increase as well. As direct oral anticoagulants (DOACs) have continued to be incorporated into clinical practice for long-term anticoagulation for AF, experience with how best to manage use of DOACs during electrophysiologic procedures is evolving. This review is intended to provide health care providers with a summary of current evidence regarding the use of DOACs during cardioversion and catheter ablation and provide key considerations for their use during such electrophysiologic procedures. PubMed and MEDLINE were searched from inception through June 2018 for studies in humans comparing DOACs alone or against vitamin K antagonists (VKAs) in adult patients (> 18 yrs) who underwent cardioversion or AF catheter ablation using the following key words: "rivaroxaban," "dabigatran," "apixaban," "edoxaban," "non-vitamin K antagonists," "direct or new oral anticoagulants," "warfarin," "vitamin K antagonists," "cardioversion," "ablation of atrial fibrillation," "uninterrupted," and "catheter ablation." Four retrospective studies and three prospective trials comparing DOACs with VKA in patients undergoing cardioversion and three prospective studies in patients undergoing catheter ablation for AF were identified. Observational data and meta-analyses were also critically reviewed. Prospective trials to date suggest similar efficacy and safety with using DOACs in the setting of cardioversion and AF ablation compared to traditional therapy with VKA, with or without bridging. Injectable anticoagulant overlap can be avoided in patients receiving DOACs in the setting of cardioversion for AF. Minimal interruption in anticoagulation may be only necessary for AF ablation in those with highest bleeding risk, such as in renal dysfunction and where drug-drug interactions may increase risk for anticoagulant accumulation. Periprocedural advantages of DOACs include convenience, rapid and predictable onset of effect, improved patient satisfaction, and potential for reduced costs.


Asunto(s)
Anticoagulantes/administración & dosificación , Fibrilación Atrial/terapia , Vitamina K/antagonistas & inhibidores , Administración Oral , Adulto , Anticoagulantes/efectos adversos , Ablación por Catéter/métodos , Cardioversión Eléctrica/métodos , Humanos
6.
Am J Med ; 132(1): 38-41, 2019 01.
Artículo en Inglés | MEDLINE | ID: mdl-30053385

RESUMEN

The use of direct oral anticoagulants over traditional warfarin has increased in the United States over the past 10 years because of advantages such as ease of use, predictable pharmacokinetic response, and safety. In 2015, the U.S. Food and Drug Administration approved idarucizumab (Praxbind) for the reversal of the direct thrombin inhibitor dabigatran, but no reversal agent has been available for oral factor Xa (FXa) inhibitors until recently. Andexanet alfa was approved in May 2018, under the brand name ANDEXXA, for the reversal of 2 of FXa inhibitors, apixaban and rivaroxaban, when life-threatening or uncontrolled bleeding occurs. This accelerated approval was based on change in anti-FXa activity from baseline that indicated a reversal of the anticoagulant effect. Any expanded Food and Drug Administration indication will be contingent on results demonstrating improved hemostasis and efficacy for reversing other FXa inhibitors.


Asunto(s)
Inhibidores del Factor Xa , Factor Xa/farmacología , Hemorragia/tratamiento farmacológico , Proteínas Recombinantes/farmacología , Antídotos , Factor Xa/uso terapéutico , Hemorragia/inducido químicamente , Humanos , Proteínas Recombinantes/uso terapéutico
7.
Cardiol Rev ; 26(5): 245-254, 2018.
Artículo en Inglés | MEDLINE | ID: mdl-29621010

RESUMEN

As direct oral anticoagulants (DOACs) have demonstrated favorable efficacy and safety outcomes compared with vitamin K antagonists for the treatment and prevention of venous thromboembolism and the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, their role in the management of anticoagulation during electrophysiological procedures continues to evolve. At present, guidelines are limited regarding specific recommendations for the use of DOACs in these clinical settings. Here, we review available data regarding the risks and benefits associated with various periprocedural anticoagulation management approaches when patients receiving DOACs undergo electrophysiologic procedures including cardioversion, ablation, and device implantation. This discussion is intended to provide clinicians with an overview of available evidence and best practices to minimize the risk of both thromboembolic and bleeding events in the periprocedural setting.


Asunto(s)
Anticoagulantes/administración & dosificación , Fibrilación Atrial/terapia , Cardioversión Eléctrica , Electrodiagnóstico , Tromboembolia Venosa/prevención & control , Administración Oral , Fibrilación Atrial/complicaciones , Humanos , Tromboembolia Venosa/etiología
8.
Vasc Health Risk Manag ; 13: 325-342, 2017.
Artículo en Inglés | MEDLINE | ID: mdl-28860793

RESUMEN

Direct oral anticoagulants (DOACs) are recognized by evidence-based treatment guidelines as the first-line option for the treatment of venous thromboembolism and prevention of stroke and systemic embolism in nonvalvular atrial fibrillation. As use of these anticoagulants has become favored over the past several years, reported bleeding-related adverse drug events with these agents has increased. In randomized clinical trials, all DOACs have a reduced risk for intracranial hemorrhage, while major and other bleeding results have varied among the agents compared to vitamin K antagonists. We have reviewed the bleeding incidence and severity from randomized and real-world data in patients receiving DOACs in an effort to provide the clinician with a critical review of bleeding and offer practical considerations for avoiding adverse events with these anticoagulants.


Asunto(s)
Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Coagulación Sanguínea/efectos de los fármacos , Hemorragia/inducido químicamente , Administración Oral , Sistemas de Registro de Reacción Adversa a Medicamentos , Anticoagulantes/economía , Análisis Costo-Beneficio , Costos de los Medicamentos , Hemorragia/diagnóstico , Hemorragia/epidemiología , Humanos , Incidencia , Vigilancia de Productos Comercializados , Ensayos Clínicos Controlados Aleatorios como Asunto , Sistema de Registros , Medición de Riesgo , Factores de Riesgo , Índice de Severidad de la Enfermedad , Resultado del Tratamiento
10.
Am J Med ; 130(8): 900-906, 2017 08.
Artículo en Inglés | MEDLINE | ID: mdl-28390791

RESUMEN

Edoxaban is the most recently approved factor Xa inhibitor within the class of direct oral anticoagulants (DOACs). Like other DOACs, edoxaban was approved by the US Food and Drug Administration for treatment of venous thromboembolism and prevention of stroke in patients with nonvalvular atrial fibrillation. Similar to other DOACs, edoxaban has fewer drug-drug interactions than warfarin and does not require routine laboratory monitoring. Unlike other DOACs, edoxaban has yet to be approved for secondary or postoperative venous thromboembolism thromboprophylaxis. Currently no antidote for edoxaban is available. To optimally prescribe agents in the DOAC class, it is critical that providers 1) understand how the agents compare; and 2) identify specific settings in which one agent may be preferred over another.


Asunto(s)
Inhibidores del Factor Xa/uso terapéutico , Piridinas/uso terapéutico , Tiazoles/uso terapéutico , Tromboembolia Venosa/tratamiento farmacológico , Administración Oral , Inhibidores del Factor Xa/administración & dosificación , Inhibidores del Factor Xa/farmacología , Humanos , Piridinas/administración & dosificación , Piridinas/farmacología , Tiazoles/administración & dosificación , Tiazoles/farmacología , Tromboembolia Venosa/prevención & control
12.
Cardiol Rev ; 24(6): 310-315, 2016.
Artículo en Inglés | MEDLINE | ID: mdl-27548686

RESUMEN

Direct oral anticoagulants (DOACs), originally developed as an alternative for vitamin K antagonists, are shifting the landscape of antithrombotic therapy. DOACs such as dabigatran, rivaroxaban, apixaban, and edoxaban offer enhancements in safety, convenience, and efficacy compared with warfarin. However, as choices for oral anticoagulation therapy have increased, so has the need for effectual antidotes before urgent surgical procedures and for the reversal of serious adverse events caused by DOACs. To date, one antidote has been FDA approved in the United States for the reversal of dabigatran, and two antidotes are undergoing phase 2and 3clinical trials. This review will summarize currently available and developing data for DOAC antidotes: idarucizumab, exanet alfa, and ciraparantag.


Asunto(s)
Anticoagulantes , Antídotos , Dabigatrán/antagonistas & inhibidores , Humanos
13.
Am J Pharm Educ ; 80(1): 4, 2016 Feb 25.
Artículo en Inglés | MEDLINE | ID: mdl-26941430

RESUMEN

OBJECTIVE: To assess first-year (P1) pharmacy students' studying behaviors and perceptions after implementation of a new computerized "composite examination" (CE) testing procedure. METHODS: Student surveys were conducted to assess studying behavior and perceptions about the CE before and after its implementation. RESULTS: Surveys were completed by 149 P1 students (92% response rate). Significant changes between survey results before and after the CE included an increase in students' concerns about the limited number of questions per course on each examination and decreased concerns about the time allotted and the inability to write on the CEs. Significant changes in study habits included a decrease in cramming (studying shortly before the test) and an increase in priority studying (spending more time on one course than another). CONCLUSION: The CE positively changed assessment practice at the college. It helped overcome logistic challenges in computerized testing and drove positive changes in study habits.


Asunto(s)
Educación en Farmacia , Evaluación Educacional , Percepción/fisiología , Farmacéuticos/psicología , Estudiantes de Farmacia/psicología , Adulto , Curriculum , Femenino , Humanos , Masculino , Persona de Mediana Edad , Encuestas y Cuestionarios , Adulto Joven
14.
Ann Pharmacother ; 50(6): 486-501, 2016 06.
Artículo en Inglés | MEDLINE | ID: mdl-26917821

RESUMEN

OBJECTIVE: To review clinical data on direct oral anticoagulants (DOACs) used in the acute treatment of venous thromboembolism (VTE) as well as practical considerations when using these products. DATA SOURCES: Searches of PubMed and Google Scholar for VTE, deep vein thrombosis, pulmonary embolism, and relevant drug international nonproprietary names were conducted. Additional online searches were conducted for prescribing information. STUDY SELECTION AND DATA EXTRACTION: Relevant articles on dabigatran, rivaroxaban, apixaban, and edoxaban for the management of VTE compared with oral vitamin K antagonists (VKAs; published between 1966 and December 2015) were reviewed and summarized, together with information on dosing, pharmacokinetics/pharmacodynamics, and drug-drug interactions. DATA SYNTHESIS: The DOACs have the potential to circumvent many of the disadvantages of VKAs. At a minimum, they greatly increase the available therapeutic options, thus providing a greater opportunity for clinicians to select a management option that best fits the needs of individual patients. Despite the significant advance that DOACs represent, they are not without risk and require careful consideration of a number of clinical issues to optimize safety and efficacy. CONCLUSIONS: The emergence of DOACs for the management of thromboembolic disorders represents a paradigm shift from oral VKAs. The DOACs provide similar efficacy and improved safety in selected patients as compared with VKAs. Clinicians treating VTE need to be familiar with the intricacies involved in using these agents, including the appropriate dose selection for the relevant indication, avoidance of drug-drug and drug-disease interactions, and consideration of dose adjustments in specific clinical situations, such as organ dysfunction.


Asunto(s)
Anticoagulantes/uso terapéutico , Embolia Pulmonar/tratamiento farmacológico , Tromboembolia Venosa/tratamiento farmacológico , Trombosis de la Vena/tratamiento farmacológico , Administración Oral , Anticoagulantes/administración & dosificación , Anticoagulantes/farmacocinética , Dabigatrán/administración & dosificación , Dabigatrán/farmacocinética , Dabigatrán/uso terapéutico , Interacciones Farmacológicas , Humanos , Pirazoles/administración & dosificación , Pirazoles/farmacocinética , Pirazoles/uso terapéutico , Piridinas/administración & dosificación , Piridinas/farmacocinética , Piridinas/uso terapéutico , Piridonas/administración & dosificación , Piridonas/farmacocinética , Piridonas/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como Asunto , Rivaroxabán/administración & dosificación , Rivaroxabán/farmacocinética , Rivaroxabán/uso terapéutico , Tiazoles/administración & dosificación , Tiazoles/farmacocinética , Tiazoles/uso terapéutico , Resultado del Tratamiento
15.
Ann Pharmacother ; 50(2): 141-51, 2016 Feb.
Artículo en Inglés | MEDLINE | ID: mdl-26681442

RESUMEN

OBJECTIVE: To evaluate direct comparisons of bivalirudin versus unfractionated heparin (UFH) as anticoagulants during ST-segment elevation myocardial infarction (STEMI) in patients undergoing primary percutaneous coronary intervention (PPCI). DATA SOURCES: Relevant information was identified through a search of MEDLINE (1966-September 2015), International Pharmaceutical Abstracts (1960-September 2015), and Cochrane Databases (publications archived until September 2015) using the terms bivalirudin, unfractionated heparin, ST-segment elevation myocardial infarction, and primary percutaneous coronary intervention. STUDY SELECTION AND DATA EXTRACTION: English-language randomized controlled trials and meta-analyses were eligible for inclusion for data review of STEMI where PPCI was performed. DATA SYNTHESIS: Either bivalirudin or UFH is recommended in the setting of STEMI where PPCI is to be performed. Bivalirudin is touted for its predictable pharmacokinetics, effects on thrombin-mediated platelet inhibition, and favorable outcomes with regard to adverse bleeding profiles, whereas UFH, the gold standard anticoagulant during PPCI, remains a viable treatment strategy. Only recently have direct comparisons of UFH and bivalirudin during PPCI become available. The evidence available is complicated by variances in use of glycoprotein IIb/IIIa inhibitors (GPIs), P2Y12 inhibitors, access sites, and anticoagulant dosing strategies. We provide a review of contemporary trials and advancements in this area. CONCLUSIONS: When compared to UFH with limited use of GPI, available evidence demonstrates that bivalirudin reduces bleeding at the expense of increasing risk for acute stent thrombosis. Further randomized studies are needed to determine the potential benefits of a post-PCI infusion of bivalirudin to reduce the risk for acute stent thrombosis, long-term follow-up beyond 30 days, and mortality.


Asunto(s)
Heparina/uso terapéutico , Fragmentos de Péptidos/uso terapéutico , Intervención Coronaria Percutánea , Anticoagulantes/uso terapéutico , Antitrombinas/uso terapéutico , Hemorragia/inducido químicamente , Heparina/efectos adversos , Hirudinas , Humanos , Infarto del Miocardio/terapia , Inhibidores de Agregación Plaquetaria/uso terapéutico , Ensayos Clínicos Controlados Aleatorios como Asunto , Proteínas Recombinantes/uso terapéutico
16.
Drugs ; 75(4): 377-95, 2015 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-25758742

RESUMEN

Cilostazol is a unique antiplatelet agent that has been commercially available for over two decades. As a phosphodiesterase III inhibitor, it reversibly inhibits platelet aggregation yet also possesses vasodilatory and antiproliferative properties. It has been widely studied in a variety of disease states, including peripheral arterial disease, cerebrovascular disease, and coronary artery disease with percutaneous coronary intervention. Overall, cilostazol appears to be a promising agent in the management of these disease states with a bleeding profile comparable to placebo; even when combined with other antiplatelet agents, cilostazol does not appear to increase the rate of bleeding. Despite the possible benefit of cilostazol, its use is limited by tolerability as some patients often report drug discontinuation due to headache, diarrhea, dizziness, or increased heart rate. To date, it has been predominantly studied in the Asian population, making it difficult to extrapolate these results to a more diverse patient population. This paper discusses the evolving role of cilostazol in the treatment of vascular diseases.


Asunto(s)
Enfermedad Arterial Periférica/tratamiento farmacológico , Inhibidores de Agregación Plaquetaria/uso terapéutico , Tetrazoles/uso terapéutico , Animales , Cilostazol , Hemorragia/inducido químicamente , Hemorragia/diagnóstico , Humanos , Claudicación Intermitente/diagnóstico , Claudicación Intermitente/tratamiento farmacológico , Enfermedad Arterial Periférica/diagnóstico , Inhibidores de Agregación Plaquetaria/efectos adversos , Tetrazoles/efectos adversos , Resultado del Tratamiento
17.
Nurse Pract ; 39(11): 45-51, 2014 Nov 16.
Artículo en Inglés | MEDLINE | ID: mdl-25325525

RESUMEN

Almost 50% of serious adverse events with statin therapy are attributed to unfavorable drug-drug combinations. This article reviews updated FDA warnings on capping the dose of simvastatin, recent package insert labeling changes of particular statins that address combinations with potent cytochrome P450 inhibitors, and current renal dosing recommendations for statins.


Asunto(s)
Inhibidores Enzimáticos del Citocromo P-450/administración & dosificación , Inhibidores de Hidroximetilglutaril-CoA Reductasas/administración & dosificación , Daño del Paciente/prevención & control , Simvastatina/administración & dosificación , Inhibidores Enzimáticos del Citocromo P-450/efectos adversos , Interacciones Farmacológicas , Etiquetado de Medicamentos , Quimioterapia Combinada/efectos adversos , Humanos , Inhibidores de Hidroximetilglutaril-CoA Reductasas/efectos adversos , Guías de Práctica Clínica como Asunto , Medición de Riesgo , Simvastatina/efectos adversos , Estados Unidos , United States Food and Drug Administration
19.
Pharmacotherapy ; 33(6): 650-64, 2013 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-23553464

RESUMEN

Current prescribing practices for venous thromboembolism (VTE) prophylaxis and treatment are suboptimal, particularly regarding the use of appropriate prophylaxis in accordance with evidence-based guidelines. Failure to prevent avoidable VTE is associated with a substantial clinical and economic burden, due not only to the initial event, but also to VTE recurrence and long-term sequelae. Quality improvement initiatives such as the Surgical Care Improvement Project, the Centers for Medicare and Medicaid Services, the National Quality Forum, and The Joint Commission have developed performance measures to address the shortfall and improve adherence with best-practice recommendations. Several studies have highlighted the benefits of pharmacist-led anticoagulation services for reducing the occurrence of VTE and bleeding complications while reducing excess hospitalization and health care costs. By assuming responsibility for anticoagulation management, pharmacists can ensure that at-risk patients receive the correct drug at the correct dose for the correct duration, from initial presentation to outpatient follow-up. Increasing continuity of care in this manner will ultimately improve patient outcomes and reduce costs. Pharmacists can also play a key role in helping hospitals achieve performance measures by aiding in the development and implementation of local VTE guidelines, policies, and other quality improvement initiatives; by helping to establish critical pathways with protocols; and by providing valuable education for other health care professionals and patients alike. Pharmacists are in an ideal position to facilitate achievement of VTE-related performance measures and can thus substantially contribute to the much-needed improvement in current VTE prevention and care.


Asunto(s)
Servicios Farmacéuticos/organización & administración , Farmacéuticos/organización & administración , Tromboembolia Venosa/prevención & control , Anticoagulantes/administración & dosificación , Anticoagulantes/efectos adversos , Anticoagulantes/uso terapéutico , Continuidad de la Atención al Paciente/organización & administración , Medicina Basada en la Evidencia , Adhesión a Directriz , Costos de la Atención en Salud , Hemorragia/inducido químicamente , Hemorragia/prevención & control , Humanos , Guías de Práctica Clínica como Asunto , Rol Profesional , Tromboembolia Venosa/tratamiento farmacológico , Tromboembolia Venosa/economía
20.
J Pharm Pract ; 26(4): 382-8, 2013 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-23178416

RESUMEN

Angiotensin-converting enzyme inhibitors (ACE-Is) are the primary medication class implicated in drug-associated angioedema. Angioedema is most common early in ACE-I therapy, yet episodes can occur late in therapy and have been reported even as late as 10 years after single treatment initiation. We present a case of a 65-year-old African American woman who experienced 2 episodes of angioedema, with the second being life threatening after receiving several concomitant agents known to cause angioedema, most notably lisinopril for 11 years.


Asunto(s)
Angioedema/inducido químicamente , Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , Lisinopril/efectos adversos , Anciano , Femenino , Humanos
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