Anticoagulation Monitoring in the Intensive Care Unit.

Patients with critical illness often display variable hypo- and hypercoagulable sequalae requiring intense monitoring and anticoagulation pharmacotherapy to prevent or treat inappropriate clot formation. It is imperative to understand the various stages of the clotting cascade and where each pharmacotherapy agent exerts its therapeutic effect. Common coagulation tests are utilized to monitor the areas of the clotting cascade and the effects that anticoagulant pharmacotherapy exhibits. Many novel coagulation tests are also in development. The purpose of this narrative review is to evaluate commonly utilized coagulation tests that monitor anticoagulation while in the intensive care unit.

Indirect antiplatelet effects of rivaroxaban in a patient with intracranial hemorrhage: An underappreciated coagulopathy of factor Xa inhibitors?

Rivaroxaban is a direct oral anticoagulant (DOAC) used for prophylaxis and treatment of many prothrombotic states. The anticoagulation effects of rivaroxaban are produced by selectively binding and inhibiting factor Xa, causing delayed thrombin generation. Additionally, the delay in thrombin generation produces an indirect, dose dependent antiplatelet effect via reduction in tissue factor platelet aggregation. As with any anticoagulant, rivaroxaban use increases a patient's risk for major and minor hemorrhagic events. With mortality rates reported as high as 25% for those who experience an intracranial hemorrhage (ICH), immediate mitigation of hematoma and hemorrhage volume expansion is imperative. Management strategies include utilizing prothrombin complex concentrates (PCC) and factor Xa inhibitor specific antidotes, such as coagulation factor Xa recombinant, inactivated-zhzo. Routine monitoring or management of DOAC induced antiplatelet effects is ill-defined and not a part of routine standard of care. We report the first case, to our knowledge, of rivaroxaban's indirect antiplatelet effects identified by platelet function assays and managed with four-factor PCC and desmopressin in a patient experiencing an ICH. Further exploration is needed to determine the true clinical impact attributed to rivaroxaban's antiplatelet effects.

Analysis of Pharmacist Interventions Used to Resolve Safety Target of Polypharmacy (STOP) Drug Interactions.

BACKGROUND: Statin drug interactions commonly increase the risk of muscle-related toxicities. The medical literature supports consultative pharmacist interventions to resolve drug interactions, but studies demonstrating autonomous pharmacist interventions are lacking. OBJECTIVE: To evaluate the complementary impact of using pharmacist-led protocols and pharmacists with prescriptive authority to resolve statin drug interactions. METHODS: Pharmacist-led protocols were developed to address gemfibrozil-statin and niacin-statin interactions. Pharmacists discontinued gemfibrozil and niacin by protocol or referred patients to the Patient Aligned Care Team (PACT) Pharmacy Clinic for individualized management. After all drug interactions were addressed, a retrospective quality improvement analysis was conducted. The primary outcome was to evaluate the impact of gemfibrozil and niacin discontinuation by protocol on patients' triglyceride (TG) laboratory results. The coprimary endpoints were the change in TGs and the percentage of patients with TGs ≥ 500 mg/dL, following pharmacist discontinuation by protocol. Secondary outcomes included the time required to resolve the interactions and a description of the PACT Clinical Pharmacy Specialists' (CPS) pharmacologic interventions. RESULTS: The gemfibrozil and niacin protocols addressed 397 drug interactions. Seventy-six patients underwent gemfibrozil discontinuation by protocol and had TG laboratory results available. TG levels decreased or increased by < 100 mg/dL for 62 patients (82%), and 1 patient (1.3%) experienced TG elevation above the threshold of 500 mg/dL. Thirty-six patients had niacin discontinued by protocol and available laboratory results. The TG levels decreased or increased by < 100 mg/dL for 33 patients (91.7%), and no patients had TG levels increase above the threshold of 500 mg/dL. The mean time required to resolve both gemfibrozil and niacin drug interactions was 15.5 minutes per patient. A total of 129 patients were referred to the PACT Pharmacy Clinic to manage gemfibrozil and niacin drug interactions. TG laboratory results were available for 80 gemfibrozil patients (74.8%) and 16 niacin patients (72.7%). The PACT CPS made 171 pharmacologic interventions to address drug interactions and the median of 2 encounters per patient. CONCLUSIONS: This single-site quality improvement analysis supports the complementary use of protocols and pharmacists with prescriptive authority to resolve statin drug interactions. These data support expanded roles for pharmacists, across settings, to mitigate select drug interactions.