REAL WORLD DATA ON CHARACTERISTICS AND MANAGEMENT OF COMMUNITY PATIENTS RECEIVING ANTICOAGULATION THERAPY WHO PRESENTED WITH ACUTE BLEEDING TO THE EMERGENCY DEPARTMENT AT A REGIONAL AUSTRALIAN HOSPITAL: A PROSPECTIVE OBSERVATIONAL STUDY. Anticoagulation and bleeding ?
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Keywords
Anticoagulation, Antiplatelets, Bleeding, Reversal, DOAC, Length of Hospital stay, Outcome.
Abstract
Objective: To study patients receiving anticoagulants with or without antiplatelet therapy presenting at a regional Australian hospital with bleeding. The main aims are to explore: (1) patients’ characteristics and management provided; (2) association between the type of anticoagulant and antiplatelet agent used and the requirement of reversal; (3) and the length of hospital stay (LoS) in conjunction with bleeding episode and management.
Methods: A prospective cross-sectional review of medical records of all patients who presented at a tertiary referral centre with bleeding while receiving anticoagulation therapy between January 2016 and June 2018. Data included: demographics, investigations (kidney and liver function tests, coagulation profile, FBC), LoS, bleeding site, type of and reason for anticoagulation therapy, and management provided. Data analysis included descriptive statistics, ?2 association, and regression models.
Results: Among the 144 eligible patients, 75 (52.1%) were male, and the mean age was 76 years (SD=11.1). Gastrointestinal tract bleeding was the most common (n=48, 33.3%), followed by epistaxis (n=32, 22.2%). Atrial fibrillation was the commonest reason for anticoagulation therapy (n=65, 45.1%). Warfarin was commonly used (n=74, 51.4%), followed by aspirin (n=29, 20.1%), rivaroxaban (n=26, 18.1%), and apixaban (n=12, 8.3%). A majority had increased blood urea nitrogen (n=67, 46.5%), while 58 (40.3%) had an elevated serum creatinine level, and 59 (41.0%) had a mild reduction in eGFR. Thirty-five of the warfarinised patients (47.3%) had an INR above the target range of their condition despite normal liver function. Severe anaemia (Hb<80g/L) was reported in 88 patients (61.1%). DOACs were associated with a reduced likelihood of receiving reversal (B= -1.7, P=<.001), and with a shorter LoS (B= -4.1, P=.046) when compared with warfarin, LMWH, and antiplatelet therapy.
Conclusion: Warfarin use was common among patients who presented with acute bleeding, and the INR in many warfarinised patients exceeded the target for their condition. DOACs were associated with a reduced likelihood for receiving reversal and with a shorter LoS when compared to warfarin, LMWH, which might support wider application of DOACs into community practice.
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References
2. Noel SE, Millar JA. Current state of medical thromboprophylaxis in Australia. The Australasian Medical Journal 2014;7(2):58-63.
3. Kakkos SK, Warwick D, Nicolaides AN, Stansby GP, Tsolakis IA. Combined (mechanical and pharmacological) modalities for the prevention of venous thromboembolism in joint replacement surgery. The Journal of Bone and Joint Surgery 2012;94(6):729-734.
4. Moheimani F, Jackson DE. Venous thromboembolism: Classification, risk factors, diagnosis, and management. ISRN Hematology 2011;2011:e124610.
5. Watson HG, Chee YL. Aspirin and other antiplatelet drugs in the prevention of venous thromboembolism. Blood Reviews 2008;22(2):107-116.
6. Harter K, Levine M, Henderson SO. Anticoagulation drug therapy: a review. Western Journal of Emergency Medicine 2015;16(1):11-17.
7. Kimachi M, Furukawa TA, Kimachi K, Goto Y, Fukuma S, Fukuhara S. Direct oral anticoagulants versus warfarin for preventing stroke and systemic embolic events among atrial fibrillation patients with chronic kidney disease. Cochrane Database of Systematic Reviews 2017;2017(11):CD011373.
8. Gomez-Outes A, Terleira-Fernandez AI, Lecumberri R, Suarez-Gea ML, Vargas-Castrillon E. Direct oral anticoagulants in the treatment of acute venous thromboembolism: a systematic review and meta-analysis. Thrombosis Research 2014;134(4):774-782.
9. TGA. New oral anticoagulants - apixaban (Eliquis), dabigatran (Pradaxa) and rivaroxaban (Xarelto) Australia: The Australian Government Theraputic Goods Administration; 2015 [Available from: https://www.tga.gov.au/node/705240.
10. Ortiz-Cartagena L, Gotay AO, Acevedo J. Cost effectiveness of oral anticoagulation therapy for non-valvular atrial fibrillation patients: Warfarin versus the new oral anticoagulants rivaroxaban, dabigatran and apixaban. Journal of the American College of Cardiology 2018;71(11):A490.
11. Shoeb M, Fang MC. Assessing bleeding risk in patients taking anticoagulants. Journal of Thrombosis and Thrombolysis 2013;35(3):312-319.
12. Hamidi M, Zeeshan M, Sakran JV, Kulvatunyou N, O'Keeffe T, Northcutt A, Zakaria ER, Tang A, Joseph B. Direct oral anticoagulants vs low-molecular-weight heparin for thromboprophylaxis in nonoperative pelvic fractures. Journal of the American College of Surgeons 2018;228(1):89-97.
13. Bungard TJ, Ritchie B, Bolt J, Semchuk WM. Management of acute venous thromboembolism among a cohort of patients discharged directly from the emergency department. BMJ Open 2018;8(10):e022064.
14. Scheres LJJ, Lijfering WM, Middeldorp S, Cheung YW, Barco S, Cannegieter SC, Coppens M. Measurement of coagulation factors during rivaroxaban and apixaban treatment: results from two crossover trials. Research and Practice in Thrombosis and Haemostasis 2018;2(4):689-695.
15. Ebner M, Birschmann I, Peter A, Hartig F, Spencer C, Kuhn J, Rupp A, Blumenstock G, Zuern CS, Ziemann U, Poli S. Limitations of specific coagulation tests for direct oral anticoagulants: a critical analysis. Journal of the American Heart Association 2018;7(19):e009807.
16. Dhakal P, Rayamajhi S, Verma V, Gundabolu K, Bhatt VR. Reversal of anticoagulation and management of bleeding in patients on anticoagulants. Clinical and Applied Thrombosis/Hemostasis 2017;23(5):410-415.
17. Anderson I, Cifu AS. Management of bleeding in patients taking oral anticoagulants. JAMA Journal of American Medical Association 2018;319(19):2032-2033.
18. Eikelboom J, Merli G. Bleeding with direct oral anticoagulants vs warfarin: clinical experience. The American Journal of Emergency Medicine 2016;34(11S):S33-S40.
19. Almegren M. Reversal of direct oral anticoagulants. Vascular Health and Risk Management 2017;13:287-292.
20. Qureshi W, Mittal C, Patsias I, Garikapati K, Kuchipudi A, Cheema G, Elbatta M, Alirhayim Z, Khalid F. Restarting anticoagulation and outcomes after major gastrointestinal bleeding in atrial fibrillation. The American Journal of Cardiology 2014;113(4):662-668.
21. Witt DM. What to do after the bleed: resuming anticoagulation after major bleeding. American Society of Hematology Education Program 2016;2016(1):620-624.
22. Lamb LC, DiFiori M, Comey C, Feeney J. Cost analysis of direct oral anticoagulants compared with warfarin in patients with blunt traumatic intracranial hemorrhages. American Surgeon 2018;84(6):1010-1014.
23. Sarkies MN, Bowles KA, Skinner EH, Mitchell D, Haas R, Ho M, Salter K, May K, Markham D, O’Brien L, Plumb S, Haines TP. Data collection methods in health services research: hospital length of stay and discharge destination. Applied Clinical Informatics 2015;6(1):96-109.
24. Brasel KJ, Lim HJ, Nirula R, Weigelt JA. Length of stay: an appropriate quality measure? Archives of Surgery 2007;142(5):461-465.
25. IBM SPSS Statistics for Windows [program]. 26.1 version. NY, USA: IBM Corporation, 2020.
26. PenaRosas JP, Cusick S, Lynch S. Haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. World Health Organization. 2011. Available from: https://apps.who.int/iris/bitstream/handle/10665/85839/WHO_NMH_NHD_MNM_11.1_eng.pdf?ua=1.
27. Liew J, Mathers S. Guideline for the Prevention of Venous Thromboembolism (VTE) in Adult Hospitalised Patients. Queensland Health. Queensland, Australia, 2018. Available from: https://www.health.qld.gov.au/__data/assets/pdf_file/0031/812938/vte-prevention-guideline.pdf.
28. Raschi E, Bianchin M, Ageno W, De Ponti R, De Ponti F. Risk–benefit profile of direct-acting oral anticoagulants in established therapeutic indications: an overview of systematic reviews and observational studies. Drug Safety 2016;39(12):1175-1187.
29. Wallace R, Anderson MA, See K, Gorelik A, Irving L, Manser R. Venous thromboembolism management practices and knowledge of guidelines: a survey of Australian haematologists and respiratory physicians. Internal Medicine Journal 2017;47(4):436-446.
30. Adcock DM, Gosselin R. Direct Oral Anticoagulants (DOACs) in the laboratory: 2015 review. Thrombosis Research 2015;136(1):7-12.
31. Badreldin H. Hospital length of stay in patients initiated on direct oral anticoagulants versus warfarin for venous thromboembolism: a real-world single-center study. Journal of Thrombosis and Thrombolysis 2018;46(1):16-21.
32. Charlton B, Adeboyeje G, Barron JJ, Grady D, Shin J, Redberg RF. Length of hospitalization and mortality for bleeding during treatment with warfarin, dabigatran, or rivaroxaban. PLoS One 2018;13(3):e0193912.
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Professor Alhossain A. Khalafallah, Faculty of Health Sciences, Launceston, University of Tasmania, Tasmania, 7249, Australia
Department of Haematology and Medicine
Specialist Care Australia
Launceston, TAS 7250
Australia