2) This program is supported by an educational grant from AstraZeneca & is intended for an audience of #healthcare providers. Statement of accreditation & faculty disclosures https://t.co/gvXca4G9Xm. Prior programs, still available for CE/#CME credit, at https://t.co/AAl1dsba2F.
— cardio-met (@cardiomet_CE) February 22, 2023
4a) Add to that the fact that the fastest growing demographic among #trauma patients are also #geriatric patients, and they have ⬆️risk of having an indication for #anticoagulation . . . pic.twitter.com/F68qAGlalx
— cardio-met (@cardiomet_CE) February 22, 2023
4c) The use of #anticoagulants is on the rise across the global population and major #trauma can happen to anyone.
— cardio-met (@cardiomet_CE) February 22, 2023
The most commonly prescribed anticoagulants for new starts in 🇺🇸 today are anti-FXa drugs (primarily #apixaban, #rivaroxaban) pic.twitter.com/oBmwM4N9E9
6b) In pts with normal renal function, the half-life of each #DOAC can predict the duration of effect. Prolonged anticoagulation occurs with ⬇️ renal function, & with rare #DDIs, esp w/ drugs that strongly inhibit the P-glycoprotein #PgP transporter and #cytochrome P450 systems.
— cardio-met (@cardiomet_CE) February 22, 2023
7b) This means that a decision whether or not to #reverse #anticoagulation in #hemorrhaging patients is usually based on history, severity of bleeding, history of last intake (when known), and renal function.
— cardio-met (@cardiomet_CE) February 22, 2023
9a) For pts who present w/bleeding, #DOAC concentrations > 50 ng/ml have been suggested in the literature as warranting consideration of reversal, while the threshold for major surgery has been suggested to be 30 ng/ml.
— cardio-met (@cardiomet_CE) February 22, 2023
10) Trauma patients may require reversal agents if suspected or determined to have significantly impaired coagulation, regardless of the need for surgery.
— cardio-met (@cardiomet_CE) February 22, 2023
Even though #DOACs have ⬆️safety compared to warfarin, major 🩸🩸is still a bad actor!
See https://t.co/LqPYArk9mp. pic.twitter.com/lJM1ykotdg
12) If reversal IS indicated, then one must choose between specific #reversal or nonspecific factor #repletion. With anti-FXa DOACs, that's a choice between, respectively, #andexanet_alfa and a prothrombin complex concentrate, typically #4F_PCC.
— cardio-met (@cardiomet_CE) February 22, 2023
13b) However, prior to #Andexanet, #PCCs have been extensively used in an off-label fashion, to questionable effect.
— cardio-met (@cardiomet_CE) February 22, 2023
14a) It is important to note that #andexanet_ alfa is not FDA approved for use to #reverse #anticoagulation before surgery in a non-bleeding patient. It is, however, approved to treat serious or life-threatening bleeding, for which the hemorrhaging #multitrauma patient qualifies.
— cardio-met (@cardiomet_CE) February 22, 2023
15a) So, what ARE the pertinent data for #andexanet reversal in trauma?
— cardio-met (@cardiomet_CE) February 22, 2023
🩸 due to its short half-life, it is given as a bolus followed by a 2-h continuous infusion.
🩸High- or low-dose selection for both the bolus and the infusion is based on ⏲️since last use, dose, & which aFXa
15c)
— cardio-met (@cardiomet_CE) February 22, 2023
🩸 #Andexanet does have effects on other drugs that bind Xa, such as #UFH. Cardiac/vascular surg pts who will require unfractionated heparin intra-op should use an alternate agent to maintain #aPTT
16a) Reports of the use of #andexanet in bleeding patients who subsequently required surgery have been published. See 🔓https://t.co/xhI3ocbebb , where n=8, 7 of whom underwent neurosurgical procedures.
— cardio-met (@cardiomet_CE) February 22, 2023
16c) Let's be clear: efficacy and safety of #andexanet to reverse Xa inhibitor anticoagulant effects in patients without bleeding before emergency surgery or procedural intervention has not yet been investigated in a formal clinical trial.
— cardio-met (@cardiomet_CE) February 22, 2023
17a) The alternative? Again, no @US_FDA-approved options here, but treatment of DOAC-influenced bleeding patients with #PCCs were being used in practice before the availability of #andexanet_alfa.
— cardio-met (@cardiomet_CE) February 22, 2023
17c) No direct comparison of #PCC vs andexanet has been performed. A retrospective study looked at PCC for reversing warfarin in 264 patients, 40 pts on #apixaban, & 40 on #rivaroxaban ➡️ no stat sig diff in overall 🪦at 30d . . .
— cardio-met (@cardiomet_CE) February 22, 2023
17e) A systematic review of the use of prothrombin complex concentrate to reverse Xa inhibitors in the setting of major bleeding could not reach a definitive conclusion regarding efficacy: 🔓 https://t.co/OZMIQzH9sJ.
— cardio-met (@cardiomet_CE) February 22, 2023
18b)
— cardio-met (@cardiomet_CE) February 22, 2023
3⃣ There is no on-label treatment for reversal in the setting of surgery, but #andexanet can potentially be used as medical treatment that is continued into the OR.
4⃣ There are no conclusive data on #PCC in DOAC-treated trauma pts.
19) So what have you learned? Anti-#FXa levels are rarely available stat, but if you have access to them in a rapid timeframe, a level of what is generally thought to warrant reversal in a bleeding patient?
— cardio-met (@cardiomet_CE) February 22, 2023
21) How’d you do? Correct answers are C for 19 and D for 20. Just keep in mind you won’t often have timely levels to guide your decision-making in major #trauma patients. And #dabiagtran is an anti-IIa #DOAC; apixaban can reverse anti-Xa’s.
— cardio-met (@cardiomet_CE) February 22, 2023
22) And just like that, you just earned 0.5hr 🆓CE/#CME! Go to https://t.co/y0mql5FgeB and claim your credit! I am @nielsmd and I 🙏 you for joining us! FOLLOW US for more #accredited education delivered wholly on Twitter!#FOAMed @MedTweetorials #surgtwitter #traumatwitter
— cardio-met (@cardiomet_CE) February 22, 2023