Drug, Duration and Dose Michael B Streiff, MD FACP Professor of Medicine and Pathology Medical Director, Johns Hopkins Anticoagulation Service Johns Hopkins Comprehensive Hemophilia Treatment Center Chairman, VTE Guideline Committee for the National Comprehensive Cancer Network
22
Embed
Drug, Duration and Dose · Why we need warfarin-Antiphospholipid syndrome • Prospective RCT in triple positive APS • Riva 20 mg (15 mg CrCl 30-50) v. warfarin (INR 2-3) • Rivaroxaban
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Drug, Duration and Dose
Michael B Streiff, MD FACP
Professor of Medicine and Pathology
Medical Director, Johns Hopkins Anticoagulation Service
Johns Hopkins Comprehensive Hemophilia Treatment Center
Chairman, VTE Guideline Committee for the National Comprehensive Cancer Network
Disclosures- Michael B. Streiff, MD
• Research support
– AHRQ
– Boehringer-Ingelheim
– Janssen
– NIH/NHLBI
– PCORI
– Portola
– Roche
• Consulting
– Bayer
– CSL Behring
– Daiichi-Sankyo
– Janssen
– Pfizer
– Portola
• Educational Grants
– Covidien
Why we need warfarin- Body weight
• Nearly 40% of US adults were obese in 2014 (Ogden CL, et al. NCHS
Data Brief, No. 219. 2015)
• Limited number of patients with extremes of body weight in DOAC RCTs (De Caterina R Clin Card Res 2017)
• Weight > 100 kg associated with 2-fold risk of recurrent VTE in RECOVER pooled analysis (Schulman S Circulation 2014)
• Real world survey of 1353 Afib DOAC pts. noted low weight pts. 4-fold higher risk of major bleed (Park CS Heart Rhythm 2016)
• DOAC peak plasma levels below 5th percentile in 21 percent of patients with weight > 120 kg (Piran S et al RPTH 2018)
• ISTH SSC Guidance document suggests DOACs should not be used in patients > 120 kg or BMI > 40 kg/M2 (Martin K et al. JTH
2016)
Why we need warfarin- Renal Disease
• All DOACs cleared to some extent by kidneys
• DOAC drug levels increase with decreasing renal function
• Patients with poor renal function excluded from the RCTs of DOACS in VTE
– Only 5-8% of participants had CrCl 30-50 ml/min
• Apixaban has been associated with equivalent bleeding and lower thromboembolism in AF
– Retrospective cohort not an RCT
Fanikos J et al Am J Med 2017; Sionitis K et al Circulation 2018