1. Antithrombotic Therapy
Taylor B Goot MD
Assistant Professor
Department of Internal Medicine – Hospital Medicine Division
Medical Director – UNM Anticoagulation Clinic
Co-Director Antithrombotic Stewardship

2. Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy
Duration of treatment
Resumption of therapy after a bleeding event
Questions

3. Roadmap Direct oral anticoagulants Consensus nomenclature Indications
Currently approved use
Uses coming soon
Who should/shouldn’t get a DOAC

4. Direct Oral Anticoagulants
Dabigatran
Apixaban
Rivaroxaban
Edoxaban
Newly FDA Approved
Betrixaban

5. Direct oral anticoagulant
Novel oral anticoagulant
Direct oral anticoagulant
Target specific anticoagulant
International society of thrombosis and hemostasis
Barnes GD et al Recommendation on the nomenclature for oral anticoagulants: communication from the SSC of the ISTH. J Thromb Haemost Jun;13(6):

6. Indications
Prevention of stroke in the setting of non-valvular atrial fibrillation
Treatment and prevention of deep vein thrombosis and pulmonary embolism

7. The Future of DOACs New studies/further studies pending Malignancy***
Antiphospholipid antibody syndrome
Coronary artery disease***
Peripheral artery disease
Medical prophylaxis***
Cryptogenic stroke

8. Why use DOACs? Convenience Simplified initiation and cessation
Apixaban and Rivaroxaban do not require heparin at initiation
Lack of INR monitoring
No need of dietary restriction/uniformity

9. But, are they safe?

11. Major Bleeding

12. Intracranial Hemorrhage

13. Fatal Bleeding
Non-Major Bleeding
GI Bleeding

14. Use is guideline supported

15. But What if My Patient Bleeds?
Short half life, might not need reversal
Idaracuzimab
Dabigatran
Andexanet Alfa
All others

16. Who shouldn’t get a DOAC?
Severe hepatic impairment
Renal impairment
Particularly ESRD on HD
Creatinine clearance <30 ml/min
The severely obese (> kg, BMI >40)
The uninsured and/or patients with a high cost
Drug-drug interactions
Unstudied prothrombotic states
Antiphospholipid antibody syndrome
Heparin induced thrombocytopenia

17. Who shouldn’t get a DOAC? (cont)
Patients in whom medication and/or appointment adherence is an issue.

18. Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy
Duration of treatment
Resumption of therapy after a bleeding event
Questions

19. Periprocedural Bridging practices in the Setting of Atrial Fibrillation

20. Circulation. 2012;126:

21. Thromboembolic Events
Bleeding Events

23. 2015

25. BRIDGE Trial
Exclusion criteria
Mechanical heart valve, Embolism, TIA, Stroke within the last 12 weeks.
Major bleeding within the last 6 weeks
PLT < 100,000

28. What we know Stroke risk ≠ 0
Unclear if there is reduction in thromboembolic events with bridging
Clearly increased bleeding risk with bridging

29. UNM Periprocedural Anticoagulation Management Protocol

30. No need to bridge with DOACs

31. Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy
Duration of treatment
Resumption of therapy after a bleeding event
Questions

32. 35 yo, previously healthy patient presents a few weeks after a knee surgery with lower extremity swelling. A DVT is diagnosed via an expedited doppler US.
Has IUD in place with no plans to remove in near future

33. Discuss
What would you do?
What are your options?

34. Initiating warfarin VTE Atrial fibrillation
At least 5 days of overlap with a parenteral anticoagulant, until within therapeutic range on 2 measurements 24 hours apart.
Atrial fibrillation
Bridge?

35. Initiating a DOAC
Rivaroxaban and Apixaban

36. Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy
Duration of treatment
Resumption of therapy after a bleeding event
Questions

37. Duration of Therapy
More related to recurrence risk than treatment of the clot itself.

38. What do we know about recurrence risk?
3 major factors
Duration of initial treatment
Location of clot
Provoked vs Unprovoked

39. Duration of initial treatment
If you treat for
< 3 mo. risk jumps
Boutitie et al BMJ 2011;342:d3036

40. PE > Proximal DVT > Distal DVT
Boutitie et al BMJ 2011;342:d3036

41. Provoked vs Unprovoked
24 mos
Boutitie et al BMJ 2011;342:d3036

42. Paolo Prandoni et al Haematologica Feb 2007, 92 (2) 199-205; DOI: 10
Paolo Prandoni et al Haematologica Feb 2007, 92 (2)  ; DOI:  /haematol.10516

43. What is a provoking agent?
Definite
Probably
Surgery or trauma
Estrogen
Cancer
Serious medical illness
Travel
Other hormone therapy
Obesity
Antiphospholipid antibody syndrome

44. Inherited thrombophilias are not considered provoking agents or even potent risk factors.

45. Duration of therapy? Provoked? 3 Months Unprovoked? Indefinitely
As long as the provoking agent is removed.
Unprovoked? Indefinitely
At least 3 months, shoot for 6.
Initial goal is at least three months in the absence of some bleeding risk.
Risk ≠ 0 for anyone once they’ve experience a VTE

46. Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy
Duration of treatment
Resumption of therapy after a bleeding event
Questions

47. Resuming After Bleeding Events
Do they need to be on anticoagulation?
Was their bleeding risk modifiable?
Were they over-anticoagulated?

48. Should they be restarted?
Any Major Bleeding
Intracranial GI
All

49. How Long to Wait Intracranial Hemorrhage AHA
Don’t restart in Non-valvular Afib after a spontaneous lobar bleed
Non-lobar 7-10 days
European Stroke Initiative
10-14 Days
Ask the neurologist or neurosurgeon for their recommendation based on the pathology.

50. How Long to Wait GI Bleeding Retrospective analysis suggests 4-7 days
Witt DM, Delate T, Garcia DA, et al. Risk of thromboembolism, recurrent hemorrhage, and death after warfarin therapy interruption for gastrointestinal tract bleeding. Arch Intern Med 2012; 172:1484–1491
Brotman DJ, Jaffer AK. Resuming anticoagulation in the first week following gastrointestinal tract hemorrhage: should we adopt a 4-day rule? Arch Intern Med 2012; 172:1492–1493.

51. How Long to Wait Other sites?
Limited data exists, there is some suggestion of 4-14 days.

52. Roadmap Direct oral anticoagulants Bridging/Periprocedural practices
Initiating therapy
Duration of treatment
Resumption of therapy after a bleeding event
Questions

53. Questions/Discussion?
Thank you!