ABSTRACT
BACKGROUND: Recent guidelines recommend using direct oral anticoagulants (DOACs) as first-line agents in patients with non-valvular atrial fibrillation (NVAF). Research is currently investigating the use of Apixaban in underweight patients, with some results suggesting altered pharmacokinetics, decreased drug absorption, and potential overdosing in this population. This study examined the effectiveness and safety of standard Apixaban dosing in adult patients with atrial NVAF weighing less than 50 kg. METHODS: This is a retrospective cohort study conducted at King Abdulaziz Medical City (KAMC); adult patients with a body mass index (BMI) below 25 who received a standard dose of Apixaban (5 mg twice daily) were categorized into two sub-cohorts based on their weight at the time of Apixaban initiation. Underweight was defined as patients weighing ≤ 50 kg, while the control group (Normal weight) comprised patients weighing > 50 kg. We followed the patients for at least one year after Apixaban initiation. The study's primary outcome was the incidence of stroke events, while secondary outcomes included bleeding (major or minor), thrombosis, and venous thromboembolism (VTE). Propensity score (PS) matching with a 1:1 ratio was used based on predefined criteria and regression model was utilized as appropriate. RESULTS: A total of 1,433 patients were screened; of those, 277 were included according to the eligibility criteria. The incidence of stroke events was lower in the underweight than in the normal weight group at crude analysis (0% vs. 9.1%) p-value = 0.06), as well in regression analysis (OR (95%CI): 0.08 (0.001, 0.76), p-value = 0.002). On the other hand, there were no statistically significant differences between the two groups in the odds of major and minor bleeding (OR (95%CI): 0.39 (0.07, 2.03), p-value = 0.26 and OR (95%CI): 1.27 (0.56, 2.84), p-value = 0.40, respectively). CONCLUSION: This exploratory study revealed that underweight patients with NVAF who received standard doses of Apixaban had fewer stroke events compared to normal-weight patients, without statistically significant differences in bleeding events. To confirm these findings, further randomized controlled trials with larger sample sizes and longer observation durations are required.
ABSTRACT
Intracranial aneurysms, characterized by the localized dilation of cerebral arteries, pose a substantial risk of rupture, leading to severe consequences. Basilar artery aneurysms, in particular, present unique challenges due to their location and potential impact on vital brainstem structures. Advanced diagnostic imaging has improved the chances of early identification of the condition, enabling timely intervention. We discuss the case of a 54-year-old female with controlled hypertension, who presented with persistent severe headaches and neurological symptoms. Diagnostic investigations revealed a large saccular basilar artery aneurysm measuring 4.7 cm. The aneurysm exerted pressure on the brainstem. After comprehensive discussions, the patient underwent successful flow-diverter stent placement, which led to the gradual resolution of symptoms. The multidisciplinary team closely monitored the patient in the neurointensive care unit. Managing giant basilar artery aneurysms poses significant challenges due to the potentially life-threatening complications associated with it. The success in treating the presented case underscores the importance of a multidisciplinary approach involving neurosurgery, interventional radiology, and critical care in managing these patients.
ABSTRACT
Introduction: It is well-established that clinical pharmacist-managed anticoagulation services achieve superior anticoagulation control, with a positive impact. At King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia, the structure of anticoagulation management is a pharmacist-managed specialty service. With the current COVID-19 situation, measures were taken to assure the continuity of patient care by establishing tele-pharmacy anticoagulation clinics. Materials and Methods: This was a prospective study with patients prescribed anticoagulation and followed up for 3 months. Since establishing the anticoagulation virtual clinic in March 2020, 270 patients were recruited in the study. The data collected included age, gender, comorbidities, indication for anticoagulation, intended duration of treatment, warfarin dose, testing of International Normalized Ratio (INR), INR target, range of INR values, time INR that was within the therapeutic range (TTR), and complications of therapy (bleeding and/or bruises). The patients were asked to complete the pharmacist satisfaction survey (PSS) after their consultation to assess patient satisfaction with the new virtual consultation system. Linguistic and cultural validation was conducted for the questionnaire. Results: A total of 270 patients were included in the study. The mean percentage of overall INR values in the range was 59.39% ± 32.84, and the mean time with the overall INR was within the therapeutic range 57.81% ± 32.08. Thirty-one percent of the sample had good anticoagulation control (time in therapeutic range >70%). The median satisfaction score was 32 (IQR 28-36) with a maximum score of 40. Conclusion: This is the first study to assess the tele-pharmacy anticoagulation clinic's efficiency and patient satisfaction in Saudi Arabia during the COVID-19 pandemic. This type of consultation was as effective as face-to-face consultations. The study also highlighted that though the reduction in the cost of care was not substantial, there was a significant increase in resource (clinical pharmacist) utilization as a result of this model. The adoption of tele-pharmacy resulted in time savings for the clinical pharmacists who can be utilized in many other improvement projects in adult ambulatory clinics to ensure the delivery of better quality and safe patient care.
ABSTRACT
Capecitabine is an orally active prodrug of 5-fluorouracil with improved safety and efficacy that is extensively used as an antineoplastic agent. It is converted to 5-Fluorouracil in the liver and tumor tissues. In vitro assays did not reveal any significant potential for interaction between capecitabine and its metabolites with warfarin. However, several reports provided clinical evidence of such interaction resulting in an elevated international normalized ratio (INR) and bleeding. Here, we report another case of capecitabine and warfarin concurrent administration that resulted in sub- or supra- therapeutic INR without any bleeding episode or venous-thromboembolic event through the follow-up period. Moreover, a review of available management options is also presented in this paper.
ABSTRACT
BACKGROUND: Hospitalized elderly patients are at high risk of venous thromboembolism (VTE), and the appropriate use of thromboprophylaxis can significantly reduce the incidence of VTE in high-risk patients. We investigated the pattern of VTE prophylaxis administration among elderly medical patients and assessed its appropriateness based on the American College of Chest Physicians (ACCP) recommendations. METHODS: A cross-sectional single-center study was conducted between October 2019 and March 2020, including hospitalized (> 48 h), elderly (≥ 60 years), medical patients, and excluding patients receiving anticoagulant for other reason, having contraindication to thromboprophylaxis, or had VTE diagnosed within 48 h. The Padua prediction score was used to determine the patients' risk for VTE, and thromboprophylaxis use was assessed against the ACCP recommendations. RESULTS: The study included 396 patients with an average age of 75.0 ± 9.01 years, and most patients (71.7%) were classified as high risk for VTE development (Padua score ≥ 4 points). Thromboprophylaxis use was inappropriate in 27.3% of patients, of whom 85.2% were ineligible but still received thromboprophylaxis. Patients who were classified as low risk of VTE were more likely to receive inappropriate thromboprophylaxis (AOR = 76.5, 95% CI: 16.1-363.2), whereas patients with acute infection or rheumatologic disorder were less likely to receive inappropriate thromboprophylaxis (AOR = 0.46, 95% CI: 0.22-0.96). CONCLUSIONS: Although the use of thromboprophylaxis among high-risk elderly patients was reasonably adequate, a large proportion of low-risk patients were exposed to unnecessary risk through inappropriate overutilization of thromboprophylaxis. Thus, healthcare providers should accurately assess patients' risk before prescribing thromboprophylaxis to ensure patient safety.
