POPULARITY
12 episodes with doacs
9 episodes with doacs
5 episodes with doacs
5 episodes with doacs
4 episodes with doacs
7 episodes with doacs
4 episodes with doacs
12 episodes with doacs
6 episodes with doacs
6 episodes with doacs
5 episodes with doacs
6 episodes with doacs
6 episodes with doacs
4 episodes with doacs
3 episodes with doacs
4 episodes with doacs
6 episodes with doacs
4 episodes with doacs
This week, Kate, Mark, Gary and Henry discuss 4 great new POEMs: foot care wipes for patients at risk of diabetic foot infection, resuming DOACS following intracerebral hemorrhage in adults with a fib, treating prediabetes with tirzepatide, and more on intermittent fasting.Show linksBMJ Magic Evidence interactive review of diabetes medications. A great practice and teaching tool: https://matchit.magicevidence.org/230125dist-diabetes/#!/https://www.ncbi.nlm.nih.gov/pubmed/31574019https://pubmed.ncbi.nlm.nih.gov/39964684/ https://pubmed.ncbi.nlm.nih.gov/40023176/ttps://pubmed.ncbi.nlm.nih.gov/39536238/https://pubmed.ncbi.nlm.nih.gov/40163873/
Today, we revisit a topic that was recommended to us by Dr David Tragen of the Sunshine Coast University Hospital - the perioperative management of the direct oral anticoagulant medications or DOACs. We start with some basic revision of the mechanism of action of the DOACs and their indications before diving more closely into the recommendations for stopping and starting these medications around the time of surgery, and the implications for our anaesthetic. Feel free to email us at deepbreathspod@gmail.com if you have any questions, comments or suggestions. We love hearing from you!And don't forget to claim CPD for listening if you are a consultant or fellow. Log us as a learning session which you can find within the knowledge and skills division, and as evidence upload a screenshot of the podcast episode.Thanks for listening, and happy studying!Resources for today's episode:2021 ANZCA Blue Book: Direct Acting Oral Anticoagulants - pharmacology and perioperative considerations by Dr Kate Drummond (p147)TGA WebsiteRE-ALIGN TrialGALILEO TrialBMJ: Coagulation assessment with the new generation of oral anticoagulants by Charles Pollack JrJournal of Thrombosis and Haemostasis: Laboratory testing in patients treated with direct oral anticoagulants: a practical guide for clinicians by J. Douxfils et al. PAUSE TrialRegional Anesthesia and Acute Pain: Regional anaesthesia in the patient receiving antithrombotic or thrombolytic therapy, 5th edition (ASRA 2025 Guidelines)RE-VERSE-AD TrialFeel free to email us at deepbreathspod@gmail.com if you have any questions, comments or suggestions. We love hearing from you! And don't forget to claim CPD for listening if you are a consultant or fellow. Log us as a learning session which you can find within the knowledge and skills division, and as evidence upload a screenshot of the podcast episode. Thanks for listening, and happy studying!
Neste episódio do GeriPill, vamos direto ao ponto: qual é o melhor anticoagulante oral para pacientes idosos? Com base nas evidências científicas mais recentes e nas atualizações dos critérios de Beers, discutimos por que a apixabana se destaca como a melhor opção para idosos com fibrilação atrial não valvular. Falamos sobre: Comparação entre DOACs e varfarina em idosos; O perfil de eficácia e segurança superior da apixabana; Os alertas recentes sobre o uso de rivaroxabana e dabigatrana em idosos; Dicas práticas para ajustar a dose da apixabana na prática clínica. Se você atende idosos no seu consultório, esse episódio é essencial para tomar decisões mais seguras e embasadas!
Returning for a second study this month, the JHLT Digital Media Editors invite first author Charlotte Van Edom to discuss the paper, “Apixaban plasma levels in patients with HeartMate 3 support.” As a cardiologist in training and a PhD candidate at the University Hospitals Leuven in Belgium, Van Edom's work focuses on hemocompatibility and mechanical circulatory support, covering both short-term and long-term support. The episode explores: The evolution of the use and understanding of direct oral anticoagulants (DOACs) during LVAD support, including the increased focus on Factor Xa inhibitors Encouraging findings from the study and what clinical practices might need to change if introducing apixaban Additional studies exploring DOACs in LVAD patients For the latest studies from JHLT, visit www.jhltonline.org/current, or, if you're an ISHLT member, access your Journal membership at www.ishlt.org/jhlt. Treat or research pulmonary vascular diseases? Check out the first April episode for a study on sotatercept in PAH patients. Don't already get the Journal and want to read along? Join the International Society of Heart and Lung Transplantation at www.ishlt.org for a free subscription, or subscribe today at www.jhltonline.org.
Ben and I are back with another fantastic episode, with my knowledge once again being tested by Ben. This is a very special episode all the way from a very sunny Florence. This is our very first live recording of the podcast with a studio audience, at the European Congress of Internal Medicine. We have audience participation, back pain, DOACs and as always we reflect on the all important clinical reasoning and why we do what we do!Please get in touch with any questions or feedback a.burbridge@nhs.net
The RENOVE trial compared reduced-dose versus full-dose DOACs for extended venous thromboembolism VTE treatment in high-risk patients. While the reduced dose cut major bleeding risk by 39%
This week join our intrepid team of skeptical primary care doctors as Kate, Mark, Henry and Gary discuss a web- and text-based intervention to prevent obesity in babies, the best timing of DOAC initiation after ischemic stroke in adults with atrial fibrillation, using semaglutide for knee osteoarthritis, and the differential diagnosis of thunderclap headaches. Plus the BEST quiz ever. Links: Preventing obesity in babies: https://pubmed.ncbi.nlm.nih.gov/39489149/ https://www.ncbi.nlm.nih.gov/pubmed/39491870 Semaglutide to reduce pain in knee OA: https://pubmed.ncbi.nlm.nih.gov/39476339/ Causes of thunderclap headaches: https://www.ncbi.nlm.nih.gov/pubmed/39303457
This week we will discuss possible treatment methods for AFIB. Atrial fibrillation (AFib) is a common type of irregular heart rhythm (arrhythmia) that occurs when the upper chambers of the heart (atria) beat chaotically and out of sync with the lower chambers (ventricles). This can lead to a variety of symptoms, including: Palpitations (a feeling of a racing or irregular heartbeat) Fatigue Shortness of breath Dizziness or lightheadedness Chest discomfort AFib can increase the risk of blood clots, stroke, heart failure, and other heart-related complications. Treatment Options for AFib Management of AFib focuses on controlling the heart rate and rhythm, preventing blood clots, and addressing underlying conditions contributing to the arrhythmia. The choice of treatment depends on the individual's symptoms, overall health, and risk factors. 1. Medications Medications are often the first line of treatment for AFib. These include: Rate-Control Medications Aim to slow the heart rate to a normal range. Common drugs: Beta-blockers (e.g., metoprolol), calcium channel blockers (e.g., diltiazem, verapamil), and digoxin. Rhythm-Control Medications Help restore and maintain a normal heart rhythm. Common drugs: Antiarrhythmics like amiodarone, flecainide, or sotalol. Anticoagulants (Blood Thinners) Reduce the risk of stroke by preventing blood clots. Examples: Warfarin, direct oral anticoagulants (DOACs) like apixaban (Eliquis) or rivaroxaban (Xarelto). 2. Ablation Therapy Ablation is a minimally invasive procedure aimed at correcting the electrical signals causing AFib. It is typically recommended for individuals who: Do not respond to or cannot tolerate medications. Have recurrent or persistent AFib that significantly impacts quality of life. Types of ablation: Catheter Ablation Uses thin tubes (catheters) inserted into blood vessels to deliver energy (radiofrequency or cryotherapy) to destroy small areas of heart tissue causing abnormal electrical signals. Surgical Ablation (Maze Procedure) Often performed during open-heart surgery for other conditions, creating scar tissue to block abnormal signals. Both options have high success rates, but catheter ablation is more commonly performed due to its minimally invasive nature. Choosing the Right Treatment Deciding between medications or ablation depends on factors such as: The severity and frequency of symptoms. The presence of other medical conditions. Patient preference and lifestyle. Consultation with a cardiologist or electrophysiologist is crucial to tailor treatment to the individual's needs.
Ffion Davies, MBChB, FRCPCH, FRCEM - Managing Major Bleeding in Patients Receiving DOACs: Data, Developments, and Decision-Making in the ED
Ffion Davies, MBChB, FRCPCH, FRCEM - Managing Major Bleeding in Patients Receiving DOACs: Data, Developments, and Decision-Making in the ED
Ffion Davies, MBChB, FRCPCH, FRCEM - Managing Major Bleeding in Patients Receiving DOACs: Data, Developments, and Decision-Making in the ED
Ffion Davies, MBChB, FRCPCH, FRCEM - Managing Major Bleeding in Patients Receiving DOACs: Data, Developments, and Decision-Making in the ED
Ffion Davies, MBChB, FRCPCH, FRCEM - Managing Major Bleeding in Patients Receiving DOACs: Data, Developments, and Decision-Making in the ED
Ffion Davies, MBChB, FRCPCH, FRCEM - Managing Major Bleeding in Patients Receiving DOACs: Data, Developments, and Decision-Making in the ED
Ffion Davies, MBChB, FRCPCH, FRCEM - Managing Major Bleeding in Patients Receiving DOACs: Data, Developments, and Decision-Making in the ED
In this podcast recorded in early September, James Cave (Editor-in-Chief) and David Phizackerley (Deputy Editor) talk about the October issue of DTB. They discuss the editorial that highlights the work of the Common Sense in Oncology movement and its aim "to counteract the trend towards irrational, industry-designed, profit-driven cancer drug development" - https://dtb.bmj.com/content/62/10/146. They talk about the results of a systematic review and meta-analysis of two randomised controlled trials that assessed the effect of treating people who have device-detected subclinical atrial fibrillation (AF) with a direct oral anticoagulant - https://dtb.bmj.com/content/62/10/147. The main article discusses the management of hypertension in older people - https://dtb.bmj.com/content/62/10/149. They begin by highlighting an article* that considers the challenges associated with the introduction of new drugs for the treatment of Alzheimer's disease. *Walsh S, Merrick R, Milne R, et al. Considering challenges for the new Alzheimer's drugs: clinical, population, and health system perspectives. Alzheimers Dement. 2024. doi: 10.1002/alz.14108. [Epub ahead of print 4 Aug 2024]. https://alz-journals.onlinelibrary.wiley.com/doi/10.1002/alz.14108 Please subscribe to the DTB podcast to get episodes automatically downloaded to your mobile device and computer. Also, please consider leaving us a review or a comment on the DTB Podcast iTunes podcast page. If you want to contact us please email dtb@bmj.com. Thank you for listening.
Editor's Summary by Mary McGrae McDermott, MD, Deputy Editor of JAMA, the Journal of the American Medical Association, for the September 10, 2024, issue.
Stay ahead with the newest cardiology research findings that could change your clinical practice! STUDY #1: First up, we explore new data on edoxaban dosage for older patients with atrial fibrillation. If we could give older patients a lower dose of edoxaban to reduce the risk of bleeding, will they still benefit from a lower risk for stroke? Zimerman, A, Braunwald, E, Steffel, J, et al. 2024. Dose reduction of edoxaban in patients 80 years and older with atrial fibrillation: Post hoc analysis of the ENGAGE AF-TIMI 48 randomized clinical trial. JAMA Cardiol. Published online. (https://doi.org/10.1001/jamacardio.2024.1793) STUDY #2: Next, we delve into the nuanced world of invasive versus noninvasive treatment of non-ST-segment elevation myocardial infarction (NSTEMI). You'll find out if mortality rates go up when we use a less invasive approach. Kunadian, V, Mossop, H, Shields, C, et al. 2024. Invasive treatment strategy for older patients with myocardial infarction. N Engl J Med. Published online. (https://doi.org/10.1056/NEJMoa2407791) STUDY #3: Lastly, we break down the latest findings on chelation therapy in patients with stable coronary artery disease and diabetes. Tune it to see whether the latest data challenges your perspective on the efficacy of EDTA in reducing cardiovascular risks. Lamas, GA, Anstrom, KJ, Navas-Acien, A, et al. 2024. Edetate disodium-based chelation for patients with a previous myocardial infarction and diabetes: TACT2 randomized clinical trial. JAMA. Published online. (https://doi.org/10.1001/jama.2024.11463) Join us to uncover these critical insights, discussions, and more. Let's turn data into actionable wisdom and elevate your cardiology practice. Learn more with Medmastery's courses: ECG Mastery Program (34 CME) Get a Basic or Pro account, or, get a Trial account. Show notes: Visit us at https://www.medmastery.com/podcasts/cardiology-podcast.
Pedro Magno e Kaue Malpighi falam sobre o passo a passo da prescrição de rivaroxabana e apixabana: quando indicar? o que orientar o paciente? qual dose tomar? Tudo nesse episódio! No Guia TdC comentamos sobre como reverter o sangramento associado aos DOACs. Você pode ler esse tópico gratuitamente, basta clicar no link abaixo e fazer o login: Manejo de Sangramento Maior em Pacientes em Uso de Anticoagulante Oral | Guia TdC (tadeclinicagem.com.br) Referência: Konstantinides SV, Meyer G, Becattini C, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41(4):543-603. doi:10.1093/eurheartj/ehz405 Hindricks G, Potpara T, Dagres N, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS) [published correction appears in Eur Heart J. 2021 Feb 1;42(5):507. doi: 10.1093/eurheartj/ehaa798] Siontis KC, Zhang X, Eckard A, et al. Outcomes Associated With Apixaban Use in Patients With End-Stage Kidney Disease and Atrial Fibrillation in the United States [published correction appears in Circulation. 2018 Oct 9;138(15):e425. doi: 10.1161/CIR.0000000000000620]. Circulation. 2018;138(15):1519-1529. doi:10.1161/CIRCULATIONAHA.118.035418 Holt A, Strange JE, Rasmussen PV, et al. Bleeding Risk Following Systemic Fluconazole or Topical Azoles in Patients with Atrial Fibrillation on Apixaban, Rivaroxaban, or Dabigatran. Am J Med. 2022;135(5):595-602.e5. doi:10.1016/j.amjmed.2021.11.008 Beyer-Westendorf J, Siegert G. Of men and meals. J Thromb Haemost. 2015;13(6):943-945. doi:10.1111/jth.12973
In this week's issue Patients taking warfarin were more likely to experience vitreous or macular hemorrhage with progression to neovascular AMD compared to DOACs. Several biomarkers show promise in predicting corneal involvement in infectious conjunctivitis. Paracentral acute middle maculopathy (PAMM) was shown to independently increase the risk of future cardiovascular events.
Pharmacogenomics plays a critical role in personalised medicine, as some adverse drug reactions are genetically determined. Adverse drugs reactions (ADRs) account for 6.5% of hospital admissions in the UK, and the application of pharmacogenomics to look at an individuals response to drugs can significantly enhance patient outcomes and safety. In this episode, our guests discuss how genomic testing can identify patients who will respond to medications and those who may have adverse reactions. We hear more about Genomics England's collaboration with the Medicines and Healthcare products Regulatory Agency in the Yellow Card Biobank and our guests discuss the challenges of implementing pharmacogenomics into the healthcare system. Our host Vivienne Parry, Head of Public Engagement at Genomics England, is joined by Anita Hanson, Research Matron and the Lead Research Nurse for clinical pharmacology at Liverpool University Hospitals NHS Foundation Trust, and Professor Bill Newman, Professor of translational genomic medicine at the Manchester Center for Genomic Medicine, and Professor Matt Brown, Chief Scientific Officer at Genomics England. "I think we're moving to a place where, rather than just doing that one test that might be relevant to one drug, we'd be able to do a test which at the same price would generate information that could be relevant at further points in your life if you were requiring different types of medicine. So, that information would then be available in your hospital record, in your GP record, that you could have access to it yourself. And then I think ultimately what we would really love to get to a point is where everybody across the whole population just has that information to hand when it's required, so that they're not waiting for the results of a genetic test, it's immediately within their healthcare record." To learn more about Jane's lived experience with Stevens-Johnson syndrome, visit The Academy of Medical Sciences' (AMS) YouTube channel. The story, co-produced by Areeba Hanif from AMS, provides an in-depth look at Jane's journey. You can watch the video via this link: https://www.youtube.com/watch?v=v4KJtDZJyaA Want to learn more about personalised medicine? Listen to our Genomics 101 episode where Professor Matt Brown explains what it is in less than 5 minutes: https://www.genomicsengland.co.uk/podcasts/genomics-101-what-is-personalised-medicine You can read the transcript below or download it here: https://www.genomicsengland.co.uk/assets/documents/Podcast-transcripts/Can-genomic-testing-prevent-adverse-drug-reactions.docx Vivienne: Hello and welcome to Behind the Genes. Bill: What we've seen is that the limited adoption so far in the UK and other countries has focused particularly on severe adverse drug reactions. They've been easier to identify and there's a clear relationship between some drugs and some genetic changes where that information is useful. So, a good example has been the recent adoption of pharmacogenetic testing for a gene called DPYD for patients undergoing cancer treatment, particularly breast and bowel cancer. And if you have an absence of the enzyme that that gene makes, if you're given that treatment, then you can end up on intensive care and die, so it's a really significant side effect. But as you say, the most common side effects aren't necessarily fatal, but they can have a huge impact upon people and on their wellbeing. Vivienne: My name's Vivienne Parry and I'm head of public engagement at Genomics England, and today we'll be discussing the critical role of pharmacogenomics in personalised medicine, highlighting its impact on how well medicines work, their safety, and on patient care. I'm joined today by Professor Bill Newman, professor of translational genomic medicine at the Manchester Centre for Genomic Medicine, Anita Hanson, research matron, a fabulous title, and lead research nurse for clinical pharmacology at the Liverpool University Hospital's NHS Foundation Trust, and Professor Matt Brown, chief scientific officer for Genomics England. And just remember, if you enjoy today's episode, we'd love your support, so please like, share and rate us on wherever you listen to your podcasts. So, first question to you, Bill, what is pharmacogenomics? Bill: Thanks Viv. I think there are lots of different definitions, but how I think of pharmacogenetics is by using genetic information to inform how we prescribe drugs, so that they can be safer and more effective. And we're talking about genetic changes that are passed down through families, so these are changes that are found in lots of individuals. We all carry changes in our genes that are important in how we transform and metabolise medicines, and how our bodies respond to them. Vivienne: Now, you said pharmacogenetics. Is it one of those medicine things like tomato, tomato, or is there a real difference between pharmacogenetics and pharmacogenomics? Bill: So, people, as you can imagine, do get quite irate about this sort of thing, and there are lots of people that would contest that there is a really big important difference. I suppose that pharmacogenetics is more when you're looking at single changes in a relatively small number of genes, whereas pharmacogenomics is a broader definition, which can involve looking at the whole genome, lots of genes, and also whether those genes are switched on or switched off, so the expression levels of those genes as well would encompass pharmacogenomics. But ultimately it's using genetic information to make drug prescription safer and more effective. Vivienne: So, we're going to call it pharmacogenomics and we're talking about everything, that's it, we'll go for it. So Matt, just explain if you would the link between pharmacogenomics and personalised medicine. And I know that you've done a big Genomics 101 episode about personalised medicine, but just very briefly, what's the link between the two? Matt: So, personalised medicine's about using the right dose of the right drug for the right individual. And so pharmacogenomics helps you with not only ensuring that you give a medication which doesn't cause problems for the person who receives it, so an adverse drug reaction, but also that they're actually getting the right dose. Of course, people's ability to metabolise, activate and respond to drugs genetically is often genetically determined, and so sometimes you need to adjust the dose up or down according to a person's genetic background. Vivienne: Now, one of the things that we've become very aware of is adverse drug reactions, and I think they account for something like six and a half percent of all hospital admissions in the UK, so it's absolutely huge. Is that genetically determined adverse drug reactions? Matt: So, the answer to that is we believe so. There's quite a bit of data to show that you can reduce the risk of people needing a hospital admission by screening genetic markers, and a lot of the very severe reactions that lead to people being admitted to hospital are very strongly genetically determined. So for example, there are HLA types that affect the risk of adverse drug reactions to commonly used medications for gout, for epilepsy, some HIV medications and so on, where in many health services around the world, including in England, there are already tests available to help prevent those leading to severe reactions. It's likely though that actually the tests we have available only represent a small fraction of the total preventable adverse drug reactions were we to have a formal pre-emptive pharmacogenomics screening programme. Vivienne: Now, I should say that not all adverse drug reactions are genetic in origin. I mean, I remember a rather nasty incident on the night when I got my exam results for my finals, and I'd actually had a big bee sting and I'd been prescribed antihistamines, and I went out and I drank rather a lot to celebrate, and oh my goodness me, I was rather ill [laughter]. So, you know, not all adverse drug reactions are genetic in origin. There are other things that interact as well, just to make that clear to people. Matt: Yes, I think that's more an interaction than an adverse drug reaction. In fact frankly, the most common adverse drug reaction in hospitals is probably through excess amounts of water, and that's not medically determined, that's the prescription. Vivienne: Let me now come to Anita. So, you talk to patients all the time about pharmacogenomics in your role. You've been very much involved in patient and public involvement groups at the Wolfson Centre for Personalised Medicine in Liverpool. What do patients think about pharmacogenomics? Is it something they welcome? Anita: I think they do welcome pharmacogenomics, especially so with some of the patients who've experienced some of the more serious, life threatening reactions. And so one of our patients has been doing some work with the Academy of Medical Sciences, and she presented to the Sir Colin Dollery lecture in 2022, and she shared her story of having an adverse drug reaction and the importance of pharmacogenomics, and the impact that pharmacogenomics can have on patient care. Vivienne: Now, I think that was Stevens-Johnson syndrome. We're going to hear in a moment from somebody who did experience Stevens-Johnson's, but just tell us briefly what that is. Anita: Stevens-Johnson syndrome is a potentially life threatening reaction that can be caused by a viral infection, but is more commonly caused by a medicine. There are certain groups of medicines that can cause this reaction, such as antibiotics or anticonvulsants, nonsteroidal anti-inflammatories, and also a drug called allopurinol, which is used to treat gout. Patients have really serious side effects to this condition, and they're often left with long-term health complications. The morbidity and mortality is considerable as well, and patients often spend a lot of time in hospital and take a long time to recover. Vivienne: And let's now hear from Jane Burns for someone with lived experience of that Stevens-Johnson syndrome. When Jane Burns was 19, the medicine she took for her epilepsy was changed. Jane: I remember waking up and feeling really hot, and I was hallucinating, so I was taken to the Royal Liverpool Hospital emergency department by my parents. When I reached A&E, I had a temperature of 40 degrees Celsius. I was given Piriton and paracetamol, and the dermatologist was contacted. My mum had taken my medication to hospital and explained the changeover process with my epilepsy medication. A decision was made to discontinue the Tegretol and I was kept in for observation. Quite rapidly, the rash was changing. Blisters were forming all over my body, my mouth was sore and my jaw ached. My temperature remained very high. It was at this point that Stevens-Johnson syndrome, or SJS, was diagnosed. Over the next few days, my condition deteriorated rapidly. The rash became deeper in colour. Some of the blisters had burst, but some got larger. I developed ulcers on my mouth and it was extremely painful. I started to lose my hair and my fingernails. As I had now lost 65 percent of my skin, a diagnosis of toxic epidermal necrolysis, or TEN, was made. Survivors of SJS TEN often suffer with long-term visible physical complications, but it is important to also be aware of the psychological effects, with some patients experiencing post-traumatic stress disorder. It's only as I get older that I realise how extremely lucky I am to have survived. Due to medical and nursing expertise, and the research being conducted at the time, my SJS was diagnosed quickly and the medication stopped. This undoubtedly saved my life. Vivienne: Now, you've been looking at the development of a passport in collaborating with the AMS and the MHRA. Tell me a bit more about that. Anita: Yes, we set up a patient group at the Wolfson Centre for Personalised Medicine approximately 12 years ago, and Professor Sir Munir Pirmohamed and I, we wanted to explore a little bit more about what was important to patients, really to complement all the scientific and clinical research activity within pharmacogenomics. And patients recognised that, alongside the pharmacogenomic testing, they recognised healthcare professionals didn't really have an awareness of such serious reactions like Stevens-Johnson syndrome, and so they said they would benefit from having a My SJS Passport, which is a booklet that can summarise all of the important information about their care post-discharge, and this can then be used to coordinate and manage their long-term healthcare problems post-discharge and beyond. And so this was designed by survivors for survivors, and it was then evaluated as part of my PhD, and the findings from the work suggest that the passport is like the patient's voice, and it really does kind of validate their diagnosis and raises awareness of SJS amongst healthcare professionals. So, really excellent findings from the research, and the patients think it's a wonderful benefit to them. Vivienne: So, it's a bit like a kind of paper version of the bracelet that you sometimes see people wearing that are on steroids, for instance. Anita: It is like that, and it's wonderful because it's a handheld source of valuable information that they can share with healthcare professionals. And this is particularly important if they're admitted in an emergency and they can't speak for themselves. And so the passport has all that valuable information, so that patients aren't prescribed that drug again, so it prevents them experiencing a serious adverse drug reaction again. Vivienne: So, Stevens-Johnson, Bill, is a really scary side effect, but what about the day to day benefits of pharmacogenomics for patients? Bill: So, what we've seen is that the limited adoption so far in the UK and other countries has focused particularly on severe adverse drug reactions. They've been easier to identify and there's a clear relationship between some drugs and some genetic changes where that information is useful. So a good example has been the recent adoption of pharmacogenetic testing for a gene called DPYD for patients undergoing cancer treatment, particularly breast and bowel cancer. And if you have an absence of the enzyme that that gene makes, if you're given that treatment, then you can end up on intensive care and die, so it's a really significant side effect. But as you say, the most common side effects aren't necessarily fatal, but they can have a huge impact upon people and on their wellbeing. And it's not just in terms of side effects. It's in terms of the effectiveness of the medicine. Because if a person is prescribed a medicine that doesn't or isn't going to work for them then it can take them longer to recover, to get onto the right medicine. That can have all sorts of detrimental effects. And so when we're thinking about introducing pharmacogenetics more broadly rather than just on a single drug or a single gene basis, we're thinking about that for common drugs like antidepressants, painkillers, statins, the drugs that GPs are often prescribing on a regular basis to a whole range of patients. Vivienne: So, to go back to you, Anita, we're really talking about dose here, aren't we, whether you need twice the dose or half the dose depending on how quickly your body metabolises that particular medicine. How do patients view that? Anita: Well, the patient in question who presented for the Academy of Medical Sciences, I mean, her take on this was, she thinks pharmacogenetics is wonderful because it will allow doctors and nurses to then prescribe the right drug, but also to adapt the dose accordingly to make sure that they get the best outcome, which provides the maximum benefit while also minimising any potential harm. And so from her perspective, that was one of the real benefits of pharmacogenomics. But she also highlighted about the benefits for future generations, the fear of her son taking the same medicine and experiencing the same reaction. And so I think her concerns were, if we have pharmacogenetic testing for a panel of medicines, as Bill mentioned then, then perhaps this would be fantastic for our children as they grow up, and we can identify and predict and prevent these type of reactions happening to future generations. Vivienne: And some of these drugs, Bill, are really very common indeed, something like codeine. Just tell us about codeine, ‘cos it's something – whenever I tell this to friends [laughter], they're always completely entranced by the idea that some people don't need nearly as much codeine as others. Bill: Yeah, so codeine is a drug that's very commonly used as a painkiller. To have its real effect, it needs to be converted in the body to a different drug called morphine, and that is done by an enzyme which is made by a gene called CYP2D6. And we all carry changes in CYP2D6, and the frequency of those variants, whether they make the gene work too much or whether they make it work too little, they vary enormously across the world, so that if you go to parts of Africa, about 30 percent of the population will make more of the CYP2D6, and so they will convert the codeine much more quickly, whereas if you go to the UK, maybe up to ten percent of the white population in the UK just won't be converting codeine to morphine at all, so they won't get any benefit from the drug. So at both ends, you have some people that don't respond and some people that respond a little bit too much so that they need either an alternative drug or they need a different dose. Vivienne: So, all those people who say, you know, “My headache hasn't been touched by this painkiller,” and we say, “What a wimp you're being,” actually, it's to do with genetics. Bill: Yeah, absolutely. There's a biological reason why people don't – not for everybody, but for a significant number of people, that's absolutely right, and we can be far more tailored in how we prescribe medication, and get people onto painkillers that work for them much more quickly. Vivienne: And that's so interesting that it varies by where you come from in the world, because that means we need to give particular attention – and I'm thinking, Anita, to working with patients from different community groups, to make sure that they understand the need for pharmacogenomics. Anita: I think that's really important, Vivienne, and I think we are now having discussions with the likes of Canada SJS awareness group, and also people have been in touch with me from South Africa because people have requested the passport now to be used in different countries, because they think it's a wonderful tool, and it's about raising awareness of pharmacogenomics and the potential benefits of that, and being able to share the tools that we've got to help patients once they've experienced a serious reaction. Vivienne: So, pharmacogenomics clearly is important in the prevention of adverse drug reactions, better and more accurate prescribing, reduced medicines wastage. Does this mean that it's also going to save money, Bill, for the NHS? Bill: Potentially. It should do if it's applied properly, but there's lots of work to make sure that not only are we using the right evidence and using the right types of tests in the laboratory, but we're getting the information to prescribers, so to GPs, to pharmacists, to hospital doctors, in a way that is understandable and meaningful, such that they can then act upon that information. So, the money will only be saved and then can be reused for healthcare if the whole process and the whole pathway works, and that information is used effectively. Vivienne: So, a lot of research to make sure that all of that is in place, and to demonstrate the potential cost savings. Bill: Yes. I mean, there are very nice studies that have been done already in parts of the world that have shown that the savings that could be accrued for applying pharmacogenetics across common conditions like depression, like in patients to prevent secondary types of strokes, are enormous. They run into hundreds of millions of pounds or dollars. But there is an initial investment that is required to make sure that we have the testing in place, that we have the digital pathways to move the information in place, and that there's the education and training, so that health professionals know how to use the information. But the potential is absolutely enormous. Vivienne: Matt, can I turn now to the yellow card. So, people will be very familiar with the yellow card system. So, if you have an adverse reaction, you can send a yellow card in – I mean, literally, it is a yellow card [laughter]. It does exactly what it says on the tin. You send a yellow card to the MHRA, and they note if there's been an adverse effect of a particular medicine. But Genomics England is teaming up with the MHRA to do something more with yellow cards, and we're also doing this with the Yellow Card Biobank. Tell us a bit more. Matt: So, yellow card's a great scheme that was set up decades ago, initially starting off, as you said, with literally yellow cards, but now actually most submissions actually come online. And it's important to note that submissions can come not just from healthcare providers, but majority of submissions actually come from patients themselves, and that people should feel free, if they feel they've had an adverse drug reaction, to report that themselves rather than necessarily depending on a medical practitioner or the healthcare provider to create that report. So, Genomics England is partnering with the MHRA in building what's called the Yellow Card Biobank, the goal of which is to identify genetic markers for adverse drug reactions earlier than has occurred in the past, so that we can then introduce genetic tests to prevent these adverse drug reactions much sooner than has occurred previously. So, what we're doing is basically at the moment we're doing a pilot, but the ultimate plan is that in future, patients who report a serious adverse drug reaction through the Yellow Card Biobank will be asked to provide a sample, a blood sample, that we then screen. We do a whole genome sequence on it, and then combine these with patients who've had like adverse drug reactions and identify genetic markers for that adverse drug reaction medication earlier, that can then be introduced into clinical practice earlier. And this should reduce by decades the amount of time between when adverse drug reactions first start occurring with medications and us then being able to translate that into a preventative mechanism. Vivienne: And will that scheme discover, do you think, new interactions that you didn't know about before? Or do you expect it to turn up what you already know about? Matt: No, I really think there's a lot of discovery that is yet to happen here. In particular, even for drugs that we know cause adverse drug reactions, mostly they've only been studied in people of European ancestry and often in East Asian ancestry, but in many other ancestries that are really important in the global population and in the UK population, like African ancestry and South Asian ancestries, we have very little data. And even within Africa, which is an area which is genetically diverse as the rest of the world put together, we really don't know what different ethnicities within Africa, actually what their genetic background is with regard to adverse drug reactions. The other thing I'd say is that there are a lot of new medications which have simply not been studied well enough. And lastly, that at the moment people are focused on adverse drug reactions being due to single genetic variants, when we know from the model of most human diseases that most human diseases are actually caused by combinations of genetic variants interacting with one another, so-called common disease type genetics, and that probably is similarly important with regard to pharmacogenomics as it is to overall human diseases. That is, it's far more common that these are actually due to common variants interacting with one another rather than the rare variants that we've been studying to date. Vivienne: So, it's a kind of cocktail effect, if you like. You know, you need lots of genes working together and that will produce a reaction that you may not have expected if you'd looked at a single gene alone. Matt: That's absolutely correct, and there's an increasing amount of evidence to show that that is the case with medications, but it's really very early days for research in that field. And the Yellow Card Biobank will be one of many approaches that will discover these genetic variants in years to come. Vivienne: Now, Matt's a research scientist. Bill, you're on the frontline in the NHS. How quickly can this sort of finding be translated into care for people in the NHS? Bill: So, really quickly is the simple answer to that, Viv. If we look at examples from a number of years ago, there's a drug called azathioprine that Matt has used lots in some of his patients. In rheumatology, it's used for patients with inflammatory bowel disease. And the first studies that showed that there was a gene that was relevant to having bad reactions to that drug came out in the 1980s, but it wasn't until well into this century, so probably 30-plus years later that we were routinely using that test in clinical medicine. So, there was an enormous lot of hesitancy about adopting that type of testing, and a bit of uncertainty. If you move forward to work that our colleague Munir Pirmohamed in Liverpool has done with colleagues in Australia like Simon Mallal around HIV medicine, there was this discovery that a drug called abacavir, that if you carried a particular genetic change, that you had a much higher risk of having a really severe reaction to that. The adoption from the initial discovery to routine, worldwide testing happened within four years. So, already we've seen a significant change in the appetite to move quickly to adopt this type of testing, and I see certainly within the NHS and within other health systems around the world, a real desire to adopt pharmacogenetics into routine clinical practice quickly and at scale, but also as part of a broader package of care, which doesn't just solely focus on genetics, but thinks about all the other parts that are important in how we respond to medication. So, making sure we're not on unusual combinations of drugs, or that we're taking our medicine at the right time and with food or not with food, and all of those other things that are really important. And if you link that to the pharmacogenetics, we're going to have a much safer, more effective medicines world. Vivienne: I think one of the joys of working at Genomics England is that you see some of this work really going into clinical practice very fast indeed. And I should say actually that the Wolfson Centre for Personalised Medicine, the PPI group that Anita looks after so well, they've been very important in recruiting people to Yellow Card Biobank. And if anyone's listening to this, Matt, and wants to be part of this, how do they get involved? Or is it simply through the yellow card? Matt: So at the moment, the Yellow Card Biobank is focusing on alopurinol. Vivienne: So, that's a medicine you take for gout. Matt: Which I use a lot in my rheumatology clinical practice. And direct acting oral anticoagulants, DOACs, which are used for vascular disease therapies and haemorrhage as a result of that. So, the contact details are available through the MHRA website, but I think more importantly, it's just that people be aware of the yellow card system itself, and that if they do experience adverse drug reactions, that they do actually complete a report form, ‘cos I think still actually a lot of adverse drug reactions go unreported. Vivienne: I'm forgetting of course that we see Matt all the time in the Genomics England office and we don't think that he has any other home [laughter] than Genomics England, but of course he still sees some patients in rheumatology clinic. So, I want to now look to the future. I mean, I'm, as you both know, a huge enthusiast for pharmacogenomics, ‘cos it's the thing that actually, when you talk to patients or just the general public, they just get it straight away. They can't think why, if you knew about pharmacogenomics, why you wouldn't want to do it. But it's not necessarily an easy thing to do. How can we move in the future, Bill, to a more proactive approach for pharmacogenomics testing? Where would we start? Bill: Yes, so I think we've built up really good confidence that pharmacogenetics is a good thing to be doing. Currently, we're doing that predominantly at the point when a patient needs a particular medicine. That's the time that you would think about doing a genetic test. And previously, that genetic test would only be relevant for that specific drug. I think we're moving to a place where, rather than just doing that one test that might be relevant to one drug, we'd be able to do a test which at the same price would generate information that could be relevant at further points in your life if you were requiring different types of medicine. So, that information would then be available in your hospital record, in your GP record, that you could have access to it yourself. And then I think ultimately what we would really love to get to a point is where everybody across the whole population just has that information to hand when it's required, so that they're not waiting for the results of a genetic test, it's immediately within their healthcare record. That's what we'd call pre-emptive pharmacogenetic testing, and I think that's the golden land that we want to reach. Vivienne: So for instance, I might have it on my NHS app, and when I go to a doctor and they prescribe something, I show my app to the GP, or something pops up on the GP's screen, or maybe it's something that pops up on the pharmacist's screen. Bill: I think that's right. I think that's what we're looking to get to that point. We know that colleagues in the Netherlands have made some great progress at developing pathways around that. There's a lot of public support for that. And pharmacists are very engaged in that. In the UK, the pharmacists, over the last few years, have really taken a very active role to really push forward this area of medicine, and this should be seen as something that is relevant to all people, and all health professionals should be engaged with it. Vivienne: And on a scale of one to ten, how difficult is it going to be to implement in the NHS? Bill: So, that's a difficult question. I think the first thing is identifying what the challenges are. So I have not given you a number, I've turned into a politician, not answered the question. So, I think what has happened over the last few years, and some of our work within the NHS Network of Excellence in pharmacogenetics and some of the other programmes of work that have been going on, is a really good, honest look at what it is we need to do to try to achieve pharmacogenetics implementation and routine use. I don't think the challenge is going to be predominantly in the laboratory. I think we've got phenomenal laboratories. I think we've got great people doing great genetic testing. I think the biggest challenges are going to be about how you present the data, and that data is accessible. And then ensuring that health professionals really feel that this is information that isn't getting in the way of their clinical practice, but really making a difference and enhancing it, and of benefit both to the healthcare system but more importantly to the patients. Vivienne: Now, when I hear you both talk, my mind turns to drug discovery and research, and Matt, I'm quite sure that that's right at the top of your mind. Tell us how pharmacogenomics can help in drug discovery and research. Matt: So, pharmacogenomics, I think actually just genetic profiling of diseases in itself just to start off with is actually a really good way of identifying new potential therapeutic targets, and also from derisking drug development programmes by highlighting likely adverse drug reactions of medications that are being considered for therapeutic trials, or targets that are being considered for therapeutic development. Pharmacogenomics beyond that is actually largely about – well, it enables drug development programmes by enabling you to target people who are more likely to respond, and avoid people who are more likely to have adverse drug reactions. And so that therapeutic index of the balance between likely efficacy versus likely toxicity, genetics can really play into that and enable medications to be used where otherwise they might have failed. This is most apparent I think in the cancer world. A classic example there, for example, is the development of a class of medications called EGFR inhibitors, which were developed for lung cancer, and in the initial cancer trials, actually were demonstrated to be ineffective, until people trialled them in East Asia and found that they were effective, and that that turns out to be because the type of cancers that respond to them are those that have mutations in the EGFR gene, and that that's common in East Asians. We now know that, wherever you are in the world, whether you're East Asian or European or whatever, if you have a lung adenocarcinoma with an EGFR mutation, you're very likely to respond to these medications. And so that pharmacogenomic discovery basically rescued a class of medication which is now probably the most widely used medication for lung adenocarcinomas, so a huge beneficial effect. And that example is repeated across multiple different cancer types, cancer medication types, and I'm sure in other fields we'll see that with expansive new medications coming in for molecularly targeted therapies in particular. Vivienne: So, smaller and more effective trials rather than larger trials that perhaps seem not to work but actually haven't been tailored enough to the patients that are most likely to benefit. Matt: Yeah, well, particularly now that drug development programmes tend to be very targeted at specific genetic targets, pharmacogenetics is much more likely to play a role in identifying patients who are going to respond to those medications. So, I think many people in the drug development world would like to see that, for any significant drug development programme, there's a proper associated pharmacogenomic programme to come up with molecular markers predicting a response. Vivienne: We're going to wrap up there. Thank you so much to our guests, Bill Newman, Anita Hanson, Matt Brown, and our patient Jane Burns. Thank you so much for joining us today to discuss pharmacogenomics in personalised medicine, and the benefits, the challenges and the future prospects for integrating pharmacogenomics into healthcare systems. And if you'd like to hear more podcasts like this, please subscribe to Behind the Genes. It's on your favourite podcast app. Thank you so much for listening. I've been your host, Vivienne Parry. This podcast was edited by Bill Griffin at Ventoux Digital and produced by the wonderful Naimah. Bye for now.
Direct oral anticoagulants (DOACs) are commonly used to treat patients with atrial fibrillation and venous thromboembolism. Author James D. Douketis, MD, from McMaster University discusses with JAMA Deputy Editor Kristin L. Walter, MD, MS, the management of DOACs in patients undergoing an elective or emergency surgery or procedure. Related Content: Perioperative Management of Patients Taking Direct Oral Anticoagulants
The JournalFeed podcast for the week of August 5-9, 2024.Monday Spoon Feed: For acute ischemic stroke patients with recent DOAC ingestion who (1) had their DOAC level measured, (2) had DOAC reversal with idarucizumab, or (3) inadvertently received thrombolytics with DOAC subsequently discovered, there was not evidence of increased significant intracranial hemorrhage associated with off-label thrombolytic therapy.Friday Spoon Feed:In patients with large vessel occlusions(LVO) presenting 4.5-24 hours after onset, without access to endovascular thrombectomy (ET), tenecteplase(TNK) administration bested standard medical treatment(SMT) in 90-day disability-free recovery.
William H. Sauer, MD, FHRS, CCDS, Brigham and Women's Hospital is joined by Rod S. Passman, MD, FHRS, Northwestern University and Graham Peigh, MD, MS, Northwestern Memorial Hospital to discuss the direct oral anticoagulants (DOACs) reduce stroke risk in patients with device-detected atrial fibrillation (DD-AFib) but increase major bleeding risk. The time to benefit (TTB) and time to harm (TTH) are not well quantified. https://www.hrsonline.org/education/TheLead https://www.heartrhythmjournal.com/article/S1547-5271(24)02812-1/fulltext#secsectitle0055 Host Disclosure(s): W. Sauer: Honoraria/Speaking/Consulting: Biotronik, Biosense Webster, Inc., Abbott, Boston Scientific, Research: Medtronic Contributor Disclosure(s): G. Peigh: Nothing to disclose R. Passman: Research: AHA Foundation Award, Abbott Medical, NIH/NHLBI, Apple Inc., Royalty Income: UpToDate, Inc, Honoraria/Speaking/Consulting: Janssen Pharmaceuticals, Boston Scientific, Membership on Advisory Committees: Medtronic, iRhythm Technologies This episode has .25 ACE credits associated with it. If you want credit for listening to this episode, please visit the episode page on HRS365 https://www.heartrhythm365.org/URL/TheLeadEpisode73
The JournalFeed podcast for the week of July 29 – August 2, 2024.These are summaries from just 2 of the 5 articles we cover every week! For access to more, please visit JournalFeed.org for details about becoming a member.Thursday Spoon Feed:This retrospective study found increased use of unfractionated heparin (UFH) relative to low-molecular weight heparin (LMWH) and direct oral anticoagulants (DOACs) over time, despite guidelines recommending LMWH or DOACs as first-line treatment for most patients with acute pulmonary embolism (PE).Friday Spoon Feed:Anticoagulation is the cornerstone of managing acute pulmonary embolism (PE), but initial management strategies in the intensive care unit (ICU) for sicker patients* with acute PE lack consensus guidelines. This reviews the available evidence and provides guidance.
Dr Deborah Siegal joins us for a discussion on the recent paper, The Efficacy and Safety of Andexanet Alfa in Patients With Acute Gastrointestinal Bleeding While Taking Factor Xa Inhibitors: An ANNEXA-4 Sub-analysis. In this wide-ranging discussion she reviews the results of the sub-analysis and the need for anticoagulant reversal for acute GI bleeding. This discussion provides her perspective on the issue of bleeding with DOACs and the challenges in patient management.Dr. Deborah Siegal MD MSc FRCPC is a clinician-scientist hematologist (thrombosis medicine) at The Ottawa Hospital, Associate Professor of Medicine and School of Epidemiology and Public Health at the University of Ottawa, and Scientist at the Ottawa Hospital Research Institute. Her primary research interest is improving the safety of anticoagulant therapy including optimizing the management of anticoagulant-related bleeding complications, restarting anticoagulants after bleeding, perioperative management of anticoagulants, and antithrombotic therapies for ischemic stroke in patients with cancer. Dr Siegal is a member of the board of directors of Thrombosis Canada. Reference:Siegal DM, Forbes N, Eikelboom J, Beyer-Westendorf J, Cohen AT, Xu L, Connolly SJ, Crowther M. The Efficacy and Safety of Andexanet Alfa in Patients With Acute Gastrointestinal Bleeding While Taking Factor Xa Inhibitors: An ANNEXA-4 Subanalysis. Circulation. 2024 Apr 16;149(16):1315-8.https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.123.066933Follow us on Twitter:@ThrombosisCan@debsiegalSupport the Show.https://thrombosiscanada.caTake a look at our healthcare professional and patient resources, videos and publications on thrombosis from the expert members of Thrombosis Canada
Direct oral anticoagulants (DOACs) are the standard of care for stroke prevention in most patients with nonvalvular atrial fibrillation (NVAF). Data on the safety and efficacy of DOACS in patients with obesity are limited and, at times, contradictory. What would you recommend for a patient with a BMI>40: warfarin, which requires periodic monitoring and dose adjustments, or a DOAC, which may not be as effective? Guest Authors: Taylor M. Benavides, PharmD, BCPS and Elizabeth B. Hearn, PharmD, BCACP Music by Good Talk
Welcome to the latest episode of Cardiology Digest, where we chart a course through groundbreaking studies that are shaping cardiology practice! STUDY #1: First, we discuss the nuanced world of drug interactions involving diltiazem and direct-acting oral anticoagulants like apixaban and rivaroxaban. Tune in as we scrutinize the study's limitations and practical implications for your patients with atrial fibrillation. Ray, WA, Chung, CP, Stein, CM, et al. 2024. Serious bleeding in patients with atrial fibrillation using diltiazem with apixaban or rivaroxaban. JAMA. 18: 1565–1575. (https://jamanetwork.com/journals/jama/article-abstract/2817546) STUDY #2: Next, we turn our attention to a case-control study examining the bleeding risks associated with the combination of selective serotonin reuptake inhibitors and anticoagulants in patients with atrial fibrillation. Are the bleeding risks substantial enough to rethink this combination therapy, or are there scenarios where the benefits outweigh the dangers? We'll leave no stone unturned. Rahman, AA, Platt, RW, Beradid, S, et al. 2024. Concomitant use of selective serotonin reuptake inhibitors with oral anticoagulants and risk of major bleeding. JAMA. 3: e243208. (https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2816687) STUDY #3: Finally, we explore a fascinating meta analysis that looked at renal denervation and its long-term efficacy in controlling blood pressure. See how renal denervation stacks up against traditional antihypertensive medications and what you need to consider when thinking about incorporating it into your treatment arsenal. Sesa-Ashton, G, Nolde, JM, Muente, I, et al. 2024. Long-term blood pressure reductions following catheter-based renal denervation: A systematic review and meta-analysis. Hypertension. 6: e63–e70. (https://www.ahajournals.org/doi/10.1161/HYPERTENSIONAHA.123.22314) Join us to explore the potential impacts of these studies, the ongoing debates they spark within the cardiology community, and to see how these findings could influence your clinical decisions. Learn more with these courses: Atrial Fibrillation Essentials (1 CME): Pacemaker Essentials (5 CME) Pacemaker Essentials Workshop (1 CME) Get a Basic or Pro account, or, get a Trial account. Show notes: Visit us at https://www.medmastery.com/podcasts/cardiology-podcast.
Background: In May of 2018, Andexanet alfa gained accelerated approval by the FDA for the reversal direct oral anticoagulants (DOACs) despite a lack of robust evidence for use. The 2022 AHA/ASA guidelines give the drug a level 2A recommendation and recommend it over the use of 4F-PCC (Greenberg 2022). FDA approval alongside guideline endorsement has ... Read more The post ANNEXA-1: Andexanet Alfa Associated with Harm in DOAC Reversal appeared first on REBEL EM - Emergency Medicine Blog.
HelixTalk - Rosalind Franklin University's College of Pharmacy Podcast
In this episode, we discuss principles for medication use in the geriatric patient population and summarize the updated 2023 American Geriatrics Society Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. Key Concepts The Beer's Criteria was originally developed by Dr. Mark Beers in 1991 to identify medications in which the risks may outweigh the benefits in nursing home patients. This list is now maintained by the American Geriatrics Society and includes a variety of drug safety information related to elderly patients including medications that are considered potentially inappropriate (Table 2 and 3), medications used with caution (Table 4), drug-drug interactions (Table 5), drugs with renal dose adjustments (Table 6), and drugs with anticholinergic properties (Table 7). The newest update prefers apixaban over other DOACs for VTE and atrial fibrillation in elderly patients. This is a very controversial recommendation given that other guidelines (e.g. from the ACC/AHA) have not published a similar preference of one DOAC over another. Many of the medications that are potentially inappropriate involve drugs that have anticholinergic properties and drugs that increase the risk of incoordination and falls. Other resources exist to guide drug therapy decisions in elderly patients. As an example, the STOPP/START criteria (published in the European Geriatric Medicine journal) outlines drugs to avoid but also drugs to consider in elderly patients. References By the 2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 Updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J AM Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372. O'Mahony D, Cherubini A, Guiteras AR, Denkinger M, Beuscart JB, Onder G, Gudmundsson A, Cruz-Jentoft AJ, Knol W, Bahat G, van der Velde N, Petrovic M, Curtin D. STOPP/START criteria for potentially inappropriate prescribing in older people: version 3. Eur Geriatr Med. 2023 Aug;14(4):625-632. doi: 10.1007/s41999-023-00777-y.
Interview with Devon Brameier, BM, BCh, Senior Clinical Research Coordinator, Dept. of Orthopaedic Surgery, Harvard Medical School Orthopaedic Trauma Initiative, Brigham and Women's Hospital. We discuss their paper entitled “Use of Direct Oral Anticoagulants Among Patients With Hip Fracture Is Not an Indication to Delay Surgical Intervention” from the March 2024 Journal of Orthopaedic Trauma.
This podcast episode features Dr. Barbara Gunka and Dr. Siraj Mithoowani discussing their research on how bariatric surgery affects direct oral anticoagulants (DOACs).Bariatric surgery is increasingly used to fight obesity-related health problems. However, these patients often need DOACs to prevent blood clots due to surgery and obesity.The concern is that bariatric surgery might change how the body absorbs DOACs. This could make the medications less effective. There's limited data on long-term DOAC use after bariatric surgery.Dr. Gunka and Dr. Mithoowani's study investigated DOAC levels in patients after bariatric surgery. They looked at patients who received any type of bariatric surgery, took a DOAC for any reason, and had their DOAC levels measured afterwards.Tune in to hear the full discussion about the study's findings and their implications for DOAC use after bariatric surgery.Reference:Gunka, B., Mackenzie, D., Hughes, T., Sardo, L., Bayadinova, J., Siegal, D. M., ... & Mithoowani, S. (2024). Pharmacokinetics of direct oral anticoagulants after bariatric surgery: A retrospective cohort study. Thrombosis Research, 235, 15-17.Support the showhttps://thrombosiscanada.caTake a look at our healthcare professional and patient resources, videos and publications on thrombosis from the expert members of Thrombosis Canada
Deepthy Varghese, MSN, ACNP, FNP, Northside Hospital, is joined by Gregory Lip, MD., University of Liverpool, and Elaine Y. Wan, MD, FHRS Columbia University, Cardiology to discuss the limitations of current clinical decision tools for assessing bleeding risk in individuals with atrial fibrillation (AF) taking direct-acting oral anticoagulants (DOACs). Conducted as a secondary analysis of the RE-LY trial and validated in multiple cohorts, the study introduces the DOAC Score as a personalized risk assessment tool. The DOAC Score incorporates various covariates such as age, creatinine clearance, underweight status, medical history, and medication use to estimate the comparative risk for major bleeding. The risk prediction model demonstrated robust performance, outperforming the HAS-BLED score in terms of predictive accuracy. Internal and external validation in diverse cohorts, including the GARFIELD-AF registry, COMBINE-AF pooled clinical trial cohort, and administrative databases, confirmed the score's reliability in stratifying bleeding risk among individuals on different DOACs. The DOAC Score represents a significant advancement in tailoring risk assessments for bleeding in AF patients receiving DOAC therapy, contributing to more informed clinical decision-making. https://www.hrsonline.org/education/TheLead https://www.ahajournals.org/doi/10.1161/CIRCULATIONAHA.123.064556 Host Disclosure(s): D. Varghese: No relevant financial relationships with ineligible companies to disclose. Contributor Disclosure(s): G. Lip: Honoraria, Speaking, and Consulting: Bristol-Myers Squibb, Pfizer, Inc., Daiichi E. Wan: Honoraria, Speaking, and Consulting: Medtronic, National Institutes for Health, Sanofi, Boston Scientific, Research: Zoll Medical Corp. This episode has .25 ACE credits associated with it. If you want credit for listening to this episode, please visit the episode page on HRS365 https://www.heartrhythm365.org/URL/TheLeadEpisode54
This week join us as Kate, Mark, Henry and Gary discuss clinical prediction tool for patients using DOACs for atrial fibrillation, the benefits of cognitively enhanced tai chi, whether high dose recombinant flu vaccine is useful in adults 50-64, and watching patients with symptomatic gallstone disease.
CardioNerds co-founder Dr. Amit Goyal, series co-chair Dr. Colin Blumenthal, and episode lead Dr. Anushka Tandon to discuss pharmacologic anticoagulation options in atrial fibrillation with Drs. Ashley Lochman and Chris Domenico. The case-based review helps clarify some key concepts, such as when warfarin is preferred for anticoagulation, who may be a good DOAC (direct-acting oral anticoagulant) candidate, how to choose an appropriate DOAC agent, and how to manage anticoagulation therapy in patients already on antiplatelet therapies. Notes were drafted by Dr. Anushka Tandon. The episode audio was edited by student Dr. Shivani Reddy. This CardioNerds Atrial Fibrillation series is a multi-institutional collaboration made possible by contributions of stellar fellow leads and expert faculty from several programs, led by series co-chairs, Dr. Kelly Arps and Dr. Colin Blumenthal. This episode was planned and recorded prior to the release of the 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation. Please refer to this guideline document for the most updated recommendations. We have collaborated with VCU Health to provide CME. Claim free CME here! CardioNerds Atrial Fibrillation PageCardioNerds Episode PageCardioNerds AcademyCardionerds Healy Honor Roll CardioNerds Journal ClubSubscribe to The Heartbeat Newsletter!Check out CardioNerds SWAG!Become a CardioNerds Patron! Pearls and Quotes - Anticoagulation Pharmacology Avoid potentially fatal errors with this terminology tip for correctly referencing non-warfarin oral anticoagulant agents: it's DOAC (like, please DO use AntiCoagulation), not NOAC (imagine someone interpreting that as “NO AntiCoagulation for this patient” at discharge – yikes)! Sometimes, an oldie really is a goodie – warfarin is recommended over DOACs for patients with mechanical heart valves, moderate-to-severe mitral stenosis, anti-phospholipid antibody syndrome (APLS), left ventricular (LV) thrombus, higher INR goals, or DOAC failure. Patient preference and medication costs should also be considered – at the end of the day, “the best drug is the drug that a patient is willing to take!” Standard-dose rivaroxaban or apixaban may be considered for use in patients weighing >120kg or with BMI >40; use of other DOACs should be limited to pts weighing =/< 120kg or with BMI =/< 40. The pharmacists involved in this podcast promise they don't have stock in apixaban! It just often happens to be the preferred DOAC option in certain scenarios – think patients with severe renal impairment (including ESRD) or with an increased risk for bleeding events (including older adults, those with a history of GI bleed, etc). In general, dual therapy (DOAC or warfarin + P2Y12 inhibitor) is non-inferior to triple therapy (oral anticoagulant + P2Y12 inhibitor + aspirin) at preventing thrombotic events but is associated with a lower risk of bleeding events. Most patients can be transitioned to dual therapy after 7-30 days on triple therapy post-percutaneous coronary intervention. What's that on the horizon? Factor XI inhibitors may become the breakout stars of anticoagulation – multiple investigational agents are being studied for their potential to reduce thrombotic risk without significantly increasing bleeding risk in patients with indications for anticoagulation therapy…at least that's the theorize hope. Watch this space! Notes - Anticoagulation Pharmacology In which cases is warfarin preferred over DOACs in patients with atrial fibrillation? Long-term anticoagulation with warfarin is indicated in patients with atrial fibrillation and either a mechanical valve or moderate-to-severe mitral stenosis (i.e., valvular atrial fibrillation as defined in the 2019 AHA/ACC/HRS guidelines on atrial fibrillation [1]). The REALIGN trial [2] showed increased rates of thromboembolic and bleeding complications with dabigatran vs.
In this week's episode we delve into the world of cardiac catheterization and speak with Assistant Professor of Pediatrics at USC, Dr. Neil Patel about a recent work he co-authored at Children's LA about continuation of anti-coagulation during catheterization. Does AC have to be stopped to safely perform a catheterization? Are there certain cases or patients in whom the risk may be especially high? What about NOACs or DOACs? When should closure devices be considered? These are amongst the questions posed to Dr. Patel this week.DOI: 10.1007/s00246-023-03097-x
I am thrilled to introduce you to Midge Bowers.Not only is Midge a Clinical Professor and Director of the cardiovascular specialty at Duke University School of Nursing, she practices as a nurse practitioner in a Heart Failure Access Clinic.She's an expert in cardiology, a seasoned healthcare educator, and shares so much incredible knowledge in this jam-packed episode.In this episode, we covered:The importance of looking beyond creatinine levelsHow to focus on practical aspects of echosDemystifying anticoagulation choicesPractical tips on adjusting Warfarin dosagesReversal agents and safety measuresThis barely scratches the surface of the wealth of information Midge provides.0:00 - 3:35 - Introduction and Overview3:36 - 8:39 - Importance of Monitoring Creatinine and GFR 8:40 - 15:06 - Impact of New Medications on Kidney Function15:07 - 20:30 - Understanding Echo Results: Akinesia, Hypokinesia, and EF20:31 - 25:01 - Interpreting Trends in Echo Reports25:02 - 31:17 - Anticoagulation Choices: Warfarin vs. DOACs 31:18 - 38:15 - Adjusting Warfarin Dosages and INR Monitoring38:16 - 42:42 - Assessing Bleeding Risks with CHADS-VASc and HAS-BLED 42:43 - 46:03 - Reversal Agents and Safety in Anticoagulation46:04 - 53:41 - Managing DOACs in Different Clinical Scenarios Read the full blog here.______________________________Please note: This episode is intended only for medical providers and students learning to be medical providers. Hosted on Acast. See acast.com/privacy for more information.
Join us as we review recent practice-changing articles on VKAs vs DOACs in frail adults with atrial fibrillation, RSV vaccine for adults over 60, how much does blood pressure cuff size matter, cotton fever in people who inject drugs, new bloating and belching guidelines, and does pip-tazo cause more AKI than cefepime. Fill your brain hole with a delicious stack of hotcakes! Featuring Paul Williams (@PaulNWilliamz), Rahul Ganatra (@rbganatra), and Matt Watto (@doctorwatto). Claim CME for this episode at curbsiders.vcuhealth.org! Episodes | Subscribe | Spotify | Swag! |Mailing List | Contact | CME! Credits Written and Hosted by: Rahul Ganatra MD, MPH; Paul Williams, MD, FACP, Matthew Watto MD, FACP Cover Art: Matthew Watto MD, FACP Reviewer: Sai Achi, MD Technical Production: Pod Paste Showrunners: Matthew Watto MD, FACP; Paul Williams MD, FACP Show Segments Intro, disclaimer VKAs vs DOACs in frail adults with atrial fibrillation, RSV vaccine for adults over 60, how much does blood pressure cuff size matter? cotton fever in people who inject drugs, new bloating and belching guidelines, does pip-tazo cause more AKI than cefepime? Outro Sponsor: Pathway Download the Pathway app for free today. Sponsor: Locumstory Get a comprehensive view of locums and decide if it's right for you at locumstory.com.
EPs know blood thinners increase the risk of intracranial bleeding, and there are many classes of blood thinners, each with a different risk profile. Dr. Pregerson delves into antiplatelet agents, warfarin, and DOACs. Read more in the Show Notes.
Join us as we review recent articles and news featured in The DIGEST #43 and #44, including bempedoic acid to lower cardiovascular risk, Alpha-Gal Syndrome, tick bites and meat allergy, orforglipron an oral GLP1 agonist for weight loss, zuranolone for postpartum depression, DOACs for VTE of malignancy, monoclonal antibodies (mAbs) for Dementia, cytisinicline for smoking cessation, and two kiwis a day for constipation. Fill your brain hole with a delicious stack of hotcakes! Featuring Drs. Paul Williams (@PaulNWilliamz), Nora Taranto (@norataranto), and Matt Watto (@doctorwatto). Claim free CME for this episode at curbsiders.vcuhealth.org! Episodes | Subscribe | Spotify | Swag! |Mailing List | Contact | Free CME! Credits Written and Hosted by: Nora Taranto MD; Paul Williams, MD, FACP, Matthew Watto MD, FACP Cover Art: Matthew Watto MD, FACP Reviewers: Nora Taranto MD; Paul Williams, MD, FACP, Matthew Watto MD, FACP Technical Production: Pod Paste Showrunners: Matthew Watto MD, FACP; Paul Williams MD, FACP Sponsor: Netsuite Download NetSuite's popular KPI Checklist, designed to give you consistently excellent performance for free, at NetSuite.com/CURBSIDERS Sponsor: Locumstory Get a comprehensive view of locums and decide if it's right for you at locumstory.com. Sponsor: Grammarly Go to grammarly.com/GO to download for FREE today. Sponsor: Pathway Download the Pathway app today by visiting pathway.md Show Segments Intro, disclaimer Bempedoic Acid for CV risk reduction DOACs to prevent recurrent VTE of malignancy Cytisinicline for smoking cessation Alpha-Gal Syndrome, tick bites, and meat allergy Zuranolone for postpartum depression Orforglipron, an oral GLP1 agonist, for weight management mAbs for Alzheimer's dementia Kiwis to prevent constipation Outro
GLP-1 agonists in HFpEF, DOACs for subclinical AF, renal denervation, and the matter of remaining in the profession are the topics John Mandrola, MD, discusses in this week's podcast. This podcast is intended for healthcare professionals only. To read a partial transcript or to comment, visit: https://www.medscape.com/twic I. Obesity and HFpEF GLP-1 Agonists in HFpEF With Obesity: Are We There Yet? https://www.medscape.com/viewarticle/993980 Wegovy Scores HFpEF Benefits in People With Obesity https://www.medscape.com/viewarticle/995844 - Semaglutide in Obese Patients With HFpEF https://www.nejm.org/doi/full/10.1056/NEJMoa2306963 - Rationale/Protocol Paper https://doi.org/10.1016/j.jchf.2023.05.010 II. DOAC for Subclinical AF - NOAH-AFNET 6 Rationale/Protocol https://doi.org/10.1016/j.ahj.2017.04.015 - NOAH-AFNET 6 Trial Results https://www.nejm.org/search?q=NOAH+AFNET III. Renal Denervation ReCor Renal Denervation System Safe, Effective: FDA Panel https://www.medscape.com/viewarticle/995741 FDA Panel Split on Efficacy of Spyral Renal Denervation https://www.medscape.com/viewarticle/995800 SPYRAL HTN-ON MED https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00455-X/fulltext IV. Maintenance of Certification As MOC Debate Heats Up, Cardiology Societies Weigh In https://www.medscape.com/viewarticle/moc-debate-heated-cardiology-societies-weigh-2023a1000jju Features Mandrola's 5 Things to Look for at the Upcoming ESC 2023 https://www.medscape.com/viewarticle/995614 You may also like: Medscape editor-in-chief Eric Topol, MD, and master storyteller and clinician Abraham Verghese, MD, on Medicine and the Machine https://www.medscape.com/features/public/machine The Bob Harrington Show with Stanford University Chair of Medicine, Robert A. Harrington, MD. https://www.medscape.com/author/bob-harrington Questions or feedback, please contact: news@medscape.net
HelixTalk - Rosalind Franklin University's College of Pharmacy Podcast
In this episode, we announce the second iteration of the HelixTalk Drug Superlative Awards -- awards given to medications on the market that are outstanding or notorious. In announcing these completely fictitious awards, we review key clinical pearls and pitfalls that every clinician should be aware of with these notable medications. Key Concepts The award for the most unique phase III patient population for a widely used medication goes to … Pneumovax-23 (PPSV-23) for its predecessor versions that were studied in South African novice gold miners. The award for the most misunderstood boxed warning goes to … all of the DOACs (but specifically apixaban and rivaroxaban). In particular, due to BOTH an increased risk of thrombosis and bleeding when switching from a DOAC to warfarin therapy in patients with atrial fibrillation. The award for the biggest difference between pharmacokinetic properties and pharmacodynamic effects goes to … aspirin due to its short-half life and short duration of analgesic effect and yet very prolonged antiplatelet effect. The award for the drug that should be dispensed with extra toilet paper … TIE between irinotecan and clindamycin. The most common dose-limiting adverse effect of irinotecan is diarrhea – loperamide is extensively used in these patients. Clindamycin earns the award because it is the antibiotic most associated with Clostridium difficile-associated diarrhea (CDAD). References Smit P, Oberholzer D, Hayden-Smith S, Koornhof HJ, Hilleman MR. Protective efficacy of pneumococcal polysaccharide vaccines. JAMA. 1977;238(24):2613-2616. Farrar JL, Childs L, Ouattara M, et al. Systematic Review and Meta-Analysis of the Efficacy and Effectiveness of Pneumococcal Vaccines in Adults. Pathogens. 2023;12(5):732. Published 2023 May 19. doi:10.3390/pathogens12050732 Pavia M, Bianco A, Nobile CG, Marinelli P, Angelillo IF. Efficacy of pneumococcal vaccination in children younger than 24 months: a meta-analysis. Pediatrics. 2009;123(6):e1103-e1110. doi:10.1542/peds.2008-3422 Deshpande A, Pasupuleti V, Thota P, Pant C, Rolston DD, Sferra TJ, Hernandez AV, Donskey CJ. Community-associated Clostridium difficile infection and antibiotics: a meta-analysis. J Antimicrob Chemother. 2013 Sep;68(9):1951-61. doi: 10.1093/jac/dkt129.
Today we are joined by Dr. Brian Locke, recently graduated pulmonary-critical care fellow, who takes us on a journey of avoiding statistical fallacies. Does metformin reduce the likelihood of long COVID? Should we give platelet transfusions to thrombocytopenic patients before central line placement? Did the CANVAS trial change practice in cancer associated thrombosis? Should patients with a stroke due to atrial fibrillation start oral anticoagulation earlier or later? We discuss all these questions on more on today's episode. Check it out! Metformin for Long COVIDDefinition of Post Acute Sequelae of Sars-CoV-2 InfectionPlatelet Transfusion before CVC Placement in Thrombocytopenia DOACs vs LMWH in Cancer Associated VTEEarly vs Late Anticoagulation for Stroke with AFMusic from Uppbeat (free for Creators!):https://uppbeat.io/t/soundroll/dopeLicense code: NP8HLP5WKGKXFW2R
The Elective Rotation: A Critical Care Hospital Pharmacy Podcast
Show notes at pharmacyjoe.com/episode827. In this episode, I'll discuss early as compared with later initiation of direct oral anticoagulants (DOACs) in patients with atrial fibrillation who have had an acute ischemic stroke. The post 827: Early vs Late Anticoagulation in Stroke Due to Atrial Fibrillation appeared first on Pharmacy Joe.
The Elective Rotation: A Critical Care Hospital Pharmacy Podcast
Show notes at pharmacyjoe.com/episode827. In this episode, I ll discuss early as compared with later initiation of direct oral anticoagulants (DOACs) in patients with atrial fibrillation who have had an acute ischemic stroke. The post 827: Early vs Late Anticoagulation in Stroke Due to Atrial Fibrillation appeared first on Pharmacy Joe.
HelixTalk - Rosalind Franklin University's College of Pharmacy Podcast
In this episode, we will discuss all things peripheral arterial disease – definitions, staging, clinical presentation, risk factors, goals of therapy, and guideline-directed medication therapy recommendations including the newest evidence for the use of DOACs. Key Concepts Addressing modifiable risk factors (weight loss, smoking cessation, blood pressure and blood glucose control, dyslipidemia, structured exercise program, etc.) are recommended for the treatment of PAD. Single antiplatelet therapy with either aspirin 81 mg or clopidogrel 75 mg daily are recommended in patients to reduce stroke, MI and other vascular deaths in symptomatic (1A) and asymptomatic patients (IIa- C-EO). Rivaroxaban 2.5 mg BID, when added to aspirin 81 mg daily, is superior to aspirin alone in preventing composite outcome of stroke, MI, and CV death in PAD patients with recent revascularization surgery for PAD but increases the risk of major bleeding. In the absence of heart failure, cilostazol is effective in improving symptoms, quality of life, and increasing walking distance in patients with intermittent claudication. References Gerhard-Herman MD, Gornik HL, Barrett C, et al. 2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135:e686–e725. https://doi.org/10.1161/CIR.0000000000000470 Criqui MH, Matsushita K, Aboyans V, et al. Lower Extremity Peripheral Artery Disease: Contemporary Epidemiology, Management Gaps, and Future Directions: A Scientific Statement From the American Heart Association. Circulation. 2021;144:e171–e191. https://doi.org/10.1161/CIR.0000000000001005 Alonso-Coello P, Bellmunt S, McGorrian C, Anand SS, Guzman R, Criqui MH, Akl EA, Vandvik PO, Lansberg MG, Guyatt GH, Spencer FA. Antithrombotic therapy in peripheral artery disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e669S-e690S. doi: 10.1378/chest.11-2307. PMID: 22315275; PMCID: PMC3278062. Eikelboom JW, Connolly SJ, Bosch J, et al. Rivaroxaban with or without aspirin in stable cardiovascular disease. N Engl J Med. 2017; 377:1319-1330. https://www.nejm.org/doi/full/10.1056/nejmoa1709118 Bonaca MP, Bauersachs RM, Anand SS, et al. Rivaroxaban in peripheral arterial disease after revascularization. N Engl J Med. 2020; 382:1994-2004. https://www.nejm.org/doi/full/10.1056/nejmoa2000052
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