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1.
Direct Oral Anticoagulants in End-Stage Renal Disease.
Klil-Drori, AJ, Tagalakis, V
Seminars in thrombosis and hemostasis. 2018;(4):353-363
Abstract
Patients with end-stage renal disease (ESRD) were excluded from pivotal clinical trials with oral anticoagulants. While such patients are at an increased risk of venous and arterial thromboembolism, their risk of bleeding is also elevated. It is thus of little surprise that stroke prevention with vitamin K antagonists (VKAs) in ESRD patients with atrial fibrillation is controversial, with observational evidence ranging from beneficial to harmful. This uncertainty extends to the less studied use of VKAs for venous thromboembolism in ESRD. The direct oral anticoagulants (DOACs) apixaban and rivaroxaban have now permissive labeling in the United States for atrial fibrillation in patients with ESRD; this expanded labeling has not yet occurred either in Europe or for venous thromboembolism. This review summarizes the current evidence for the pharmacology of DOACs in ESRD as well as their utilization and safety in patients with ESRD and atrial fibrillation.
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2.
Clinical Pharmacokinetics and Drug Interactions of Doravirine.
Wilby, KJ, Eissa, NA
European journal of drug metabolism and pharmacokinetics. 2018;(6):637-644
Abstract
Doravirine is a new HIV-1 non-nucleoside reverse transcriptase inhibitor that has demonstrated a good efficacy and safety profile in clinical trials. It has a therapeutic profile that makes it an attractive option for treatment of HIV-1 infection. As such, there has been an increase in the published literature regarding the pharmacokinetics of doravirine and potential for drug-drug interactions. This review aimed to identify pharmacokinetic literature pertaining to doravirine, used findings from the literature to summarize its pharmacokinetic profile, and finally evaluated literature describing actual and potential drug interactions. Review findings show doravirine is well-absorbed, exhibits moderate protein binding activity, and is extensively metabolized by cytochrome P450 enzymes (specifically CYP3A). It has an elimination half-life of 12-21 h. Gender, age, moderate hepatic impairment, and co-administration with food did not greatly alter doravirine's pharmacokinetic profile. Drug interaction studies have shown doravirine does not affect the pharmacokinetics of dolutegravir or atorvastatin but may have its pharmacokinetics altered by rifampicin (rifampin) and other rifamycins (CYP3A inducers) and ritonavir (CYP3A inhibitor). No clinically significant interactions were noted between doravirine and an antacid (aluminum-magnesium), pantoprazole, ledipasvir/sofosbuvir, or elbasvir/grazoprevir. Further study is needed to better understand doravirine's efficacy and safety profile when co-administered with other agents known to be CYP inducers or inhibitors.
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3.
Self-Assembly of Bolaamphiphilic Molecules.
Dhasaiyan, P, Prasad, BLV
Chemical record (New York, N.Y.). 2017;(6):597-610
Abstract
The current buzzword in science and technology is self-assembly and molecular self-assembly is one of the most prominent fields as far as research in chemical and biological sciences is concerned. Generally, self-assembly of molecules occurs through weak non-covalent interactions like hydrogen bonding, π-π stacking, hydrophobic effects, etc. Inspired by many natural systems consisting of self-assembled structures, scientists have been trying to understand their formation and mimic such processes in the laboratory to create functional "smart" materials, which respond to temperature, light, pH, electromagnetic field, mechanical stress, and/or chemical stimuli. These responses are usually manifested as remarkable changes from the molecular (e. g., conformational state, hierarchical order) to the macroscopic level (e. g., shape, surface properties). Many molecules such as peptides, viruses, and surfactants are known to self-assemble into different structures. Among them, glycolipids are the new entries in the area of molecules that are being investigated for their self-assembly characteristics. Among the different classes of glycolipids like rhamnolipids and trehalose lipids, owing to their biological preparations and their structural novelty, sophorolipids (SLs) are evoking greater interest among researchers. Sophorolipids are a class of asymmetric bolas bearing COOH groups at one end and sophorose (dimeric glucose linked by an unusual β(1→2) linkage). The extreme membrane stability of Archaea, attributed to the membrane-spanning bolas (tetraether glycolipids), has inspired chemists to unravel the molecular designs that underpin the self-assembly of bolaamphiphilic molecules. Apart from these self-assembled structures, bolaamphiphiles find applications in many fields such as drug delivery, membrane mimicking, siRNA therapies, etc. The first part of this Personal Account presents some possible self-assembled structures of bolaamphiphiles and their mechanism of formation. The later part covers our work on one of the typical bolaamphiphiles known as sophorolipids.
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4.
Meta-analysis of efficacy and safety of apixaban and uninterrupted apixaban therapy compared to vitamin K antagonists in patients undergoing catheter ablation for atrial fibrillation.
Ukaigwe, A, Shrestha, P, Karmacharya, P, Hussain, SK, Samii, S, Gonzalez, MD, Wolbrette, D, Naccarrelli, GV
Journal of interventional cardiac electrophysiology : an international journal of arrhythmias and pacing. 2017;(2):223-233
Abstract
BACKGROUND Apixaban is a Factor Xa inhibitor increasingly being used for stroke prevention in atrial fibrillation (AF). Although several studies have been done, the efficacy and safety of apixaban during the peri-procedural period of AF ablation remains unclear. We sought to systematically review pooled data from these various studies to evaluate thromboembolic and bleeding risks in patients undergoing catheter ablation for AF who are treated with apixaban (interrupted and uninterrupted). METHODS Studies comparing anticoagulation with apixaban or vitamin K antagonists (VKA) in patients undergoing ablation for AF were identified via an electronic search of MEDLINE, EMBASE, clinical trials.gov, and Cochrane Library from inception to January 2016. Study-specific risk ratios were calculated and combined with a fixed-effects model meta-analysis. RESULTS In the analysis of 2100 pooled patients, thromboembolic complications (TE) occurred in 14/778 (1.80 %) patients in the apixaban group (AG) compared to 20/1322 patients in the VKA group (RR 1.03, 95 % CI 0.55-1.90, p = 0.93, I 2 = 0 %). Major bleeding occurred in 9/778 (1.2 %) of the AG compared to 20/1322 (1.51 %) in the VKA group (RR 1.03, 95 % CI 0.55-1.90, p = 0.93, I 2 = 0 %). In uninterrupted apixaban group (uAG), TE occurred in 4/585 (0.68 %) patients in the uAG compared to 6/910 (0.66 %) in VKA group (RR 0.86, 95 % CI 0.25-2.95, p = 0.81, I 2 = 0 %). Major bleeding occurred in 5/585 (0.85 %) in uAG compared to 7/910 (0.77 %) in the VKA group (RR 1.20, 95 % CI 0.37-3.88, p = 0.76, I 2 = 0 %). CONCLUSION Our study demonstrates patients treated with apixaban and VKA during the peri-procedural period for AF ablation have similar rates of TE and bleeding complications. Interrupted and uninterrupted apixaban strategies were associated with similar outcomes.
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5.
New oral anticoagulants and dual antiplatelet therapy: Focus on apixaban.
Pelliccia, F, Rollini, F, Marazzi, G, Greco, C, Gaudio, C, Angiolillo, DJ, Rosano, G
International journal of cardiology. 2016;:154-158
Abstract
The combination of AF and coronary artery disease not only is a common clinical setting, it is also a complex setting to deal with anticoagulation and antiplatelet therapy, and it is associated with significantly higher mortality rates. Unfortunately, there are no sufficient data available to optimally guide clinical practice in such settings. This review focuses specifically on newer oral anticoagulants (NOACs) associated with dual antiplatelet therapy (DAPT) in patients with coronary artery disease undergoing percutaneous coronary intervention (PCI). There are no randomized studies comparing vitamin K antagonists and NOACs in patients with AF undergoing PCI either for acute coronary syndromes or for stable patients, i.e. those patients who have an indication to receive DAPT. Moreover, new antiplatelet agents such as ticagrelor and prasugrel have entered the market for acute coronary syndromes. So far, there are no large-scale randomized studies published evaluating these newer antiplatelet agents in patients with AF receiving either vitamin K antagonists or NOACs, adding to the uncertainty on how to use these antithrombotics in combination when both coronary artery disease (unstable or stable patients) and AF converge in a given patient. The lack of large outcome trials and the large number of possible combinations are reflected in the wide variety of practices in the real world. To date, given the lack of data, watchfulness when using NOACs as component of DAPT or triple oral antithrombotic therapy is warranted.
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6.
Preventing Thrombosis to Improve Outcomes in Heart Failure Patients.
Shantsila, E, Lip, GY
Progress in cardiovascular diseases. 2016;(4):386-92
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Abstract
Heart failure (HF) is associated with an increased risk of thrombotic events, particularly if this condition is accompanied by atrial fibrillation (AF). Many HF patients have background coronary artery disease (CAD) making them prone to coronary thrombosis resulting in myocardial infarction or sudden death. Oral anticoagulation is essential in the vast majority of HF patients with AF with non-vitamin K based anticoagulants being a suitable alternative to warfarin. In contrast, aspirin alone does not provide adequate stroke prevention in such patients. In HF without AF, oral anticoagulation should not be routinely used, and antiplatelet agents should be prescribed in patients with background CAD. This review provides an overview of prothrombotic factors and antithrombotic management of patients with HF.
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7.
Meta-Analysis of Efficacy and Safety of Apixaban in Patients Undergoing Catheter Ablation for Atrial Fibrillation.
Lu, D, Liu, Q, Wang, K, Zhang, QI, Shan, QJ
Pacing and clinical electrophysiology : PACE. 2016;(1):54-9
Abstract
BACKGROUND The efficacy and safety of apixaban in patients undergoing catheter ablation (CA) for atrial fibrillation (AF) are little investigated. METHODS The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE were searched up to September 2015. Four literatures comparing apixaban with vitamin K antagonists (VKAs) were included. Data were pooled in Review Manager Software, using Mantel-Haenszel methods with a fixed-effects model. The funnel plots and Egger's test were used to examine publication bias. Heterogeneity was assessed using the I(2) test. Risk ratios (RR) and 95% confidence intervals (CI) of each study were calculated and pooled. RESULTS No significant differences were observed in rates of total bleeding (RR = 0.91, 95% CI [0.57, 1.46], I(2) = 0.0%), thromboembolic complications (RR = 0.75, 95% CI [0.03, 18.22], I(2) = 0.0%), or total events (RR = 0.90, 95% CI [0.56, 1.44], I(2) = 0.0%) between apixaban and VKAs group. The frequency of major bleeding was similar between apixaban and VKAs group (RR = 1.34, 95% CI [0.34, 5.30], I(2) = 0.0%). CONCLUSION Apixaban was as effective and safe as VKAs in the periprocedural period of CA.
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8.
New treatments in idiopathic pulmonary fibrosis.
Strâmbu, I
Pneumologia (Bucharest, Romania). 2016;(3):127-32
Abstract
Idiopathic pulmonary fibrosis is a chronic fibrotic pulmonary disease of unknown origin, with an unfavourable prognosis, leading to death by respiratory failure in most patients within 3-5 years ofdiagnosis. Several drugs were studied for the treatment of this disease, and most of them were not able to stop the relentless evolution of the disease (warfarin, corticosteroids in combination with azathioprine, N-acetylcysteine, ambrisentan, bosentan, sildenafil, antiacids). Two novel drugs, pirfenidone and nintedanib, proved effective in reducing lung function decline, improving the patient’s quality of life, and increasing the patient’s probability of survival. These drugs were approved by international health authorities for use in the treatment of IPF patients. The paper refers also to the status of IPF patients in Romania, where epidemiological data are not known, and where the disease is most likely severely underdiagnosed. Patients are typically diagnosed late, and are therefore in advanced stages of the disease. A proactive attitude, in favour of identification and early diagnosis of IPF patients is highly needed in order to offer to these patients the opportunity of treatment, improved survival, and a better quality of life.
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9.
Efficacy and safety of novel anticoagulants versus vitamin K antagonists in patients with mild and moderate to severe renal insufficiency: Focus on apixaban.
Pelliccia, F, Rosanio, S, Marazzi, G, Poggi, S, Tanzilli, A, Greco, C, Gaudio, C, Rosano, G
International journal of cardiology. 2016;:77-81
Abstract
The high risk of both stroke and major bleeding in atrial fibrillation (AF) patients with chronic kidney disease (CKD) defines an important population for whom the assessment of the balance between the risk of ischemic stroke and of bleeding is essential. The use of novel oral anticoagulants (NOACs) may be a viable option in this population due to their greater net clinical benefit than warfarin, as demonstrated by the results of the clinical phase III trials. NOACs have been found to have a greater net clinical benefit than warfarin in patients at high risk of either stroke (CHADS2≥1 or CHA2DS2-VASc score≥2) or bleeding (HAS-BLED≥3). Noteworthy, it has been found also a positive net clinical benefit with apixaban and dabigatran 110mg BID in patients with CHADS2 score=0 and HAS-BLED score≥3. At CHA2DS2-VASc score=1, apixaban and both doses of dabigatran were superior to warfarin in terms of the net clinical benefit. Available scientific evidence might help in clinical decision-making regarding the use of NOACs in patients with CKD who are at high risk for both stroke and bleeding. Overall, current findings provide a rationale for the choice of apixaban or rivaroxaban over dabigatran in patients with AF and stage III CKD. Out of the NOACs, only apixaban has been recently approved for the use in patients with end-stage renal dysfunction on hemodialysis (the recommended dose of 5mg twice daily should be halved in patients with body weight of ≤60kg and or age≥80years).
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10.
[Non-VKA oral anticoagulants: an update for the clinical biologists].
Mullier, F, Douxfils, J, Tamigniau, A, Dogné, JM, Horellou, MH, Flaujac, C, Chatelain, B, Goffinet, C, Samama, MM, Gouin-Thibault, I
Annales de biologie clinique. 2015;(3):333-44
Abstract
Non-VKA oral anticoagulants (NOACs), thanks to their ease of use and their similar or superior safety/efficacy profiles versus warfarin, have now widely reached the lucrative market of anticoagulation. However, while the marketing authorization holders always claim, in a quite unclear way that no monitoring is required, accumulative evidence and cases of major bleeding have been described in the literature and reported by spontaneous reporting systems at the regulator's level. These compounds are usually given at fixed doses without routine coagulation monitoring. However, new data suggests that an assessment of the response at the individual level could improve the benefit-risk ratio of, at least dabigatran. Therefore, in certain patient populations, i.e. acute or chronic renal impairment or multiple drug interactions, measurement of drug exposure may be useful to ensure an optimal treatment response. More specific circumstances such as patients experiencing a haemorrhagic or thromboembolic event during the treatment duration, patients who require urgent surgery or an invasive procedure, or patient with a suspected overdose could benefit from such a measurement. This article aims at providing guidance on how to best estimate the intensity of anticoagulation using laboratory assays in daily practice.