Search

The solid organ transplant community is slow to adopt the routine practice of using direct oral anticoagulants. Rivaroxaban and apixaban share common metabolic pathways with tacrolimus. This study aimed to clarify the impact of rivaroxaban/apixaban on tacrolimus troughs. Fifty solid organ transplant recipients with concomitant use of tacrolimus and rivaroxaban/apixaban were retrospectively assessed for changes in tacrolimus troughs and dose. Average dose-adjusted tacrolimus troughs and average tacrolimus total daily doses prior to and after rivaroxaban/apixaban initiation were compared. Subgroup analyses evaluating rivaroxaban and apixaban individually were performed. Rivaroxaban was prescribed to 18 recipients, and apixaban was prescribed to 32 recipients. Transplanted organs included kidney (n = 22), lung (n = 18), liver (n = 7), simultaneous pancreas and kidney (n = 1), and simultaneous kidney and liver (n = 2). The median doseadjusted tacrolimus trough and tacrolimus total daily dose prior to rivaroxaban/apixaban initiation was 2.15 ng/mL/mg (IQR 1.17, 3.37) and 4 mg (IQR 1.88, 6.25), respectively. The median dose-adjusted tacrolimus trough and tacrolimus total daily dose after rivaroxaban/apixaban initiation was 2.16 ng/mL/mg (IQR 1.24, 4.10) and 3.55 mg (IQR 1.5, 6.35), respectively. No significant difference was found between average dose-adjusted tacrolimus troughs or tacrolimus total daily doses before and after rivaroxaban/apixaban initiation or in the individual subgroup analyses for rivaroxaban/apixaban. It is unlikely that initiating rivaroxaban/apixaban affects tacrolimus troughs or requires tacrolimus dose adjustment. This study does not elucidate if tacrolimus affects rivaroxaban/apixaban pharmacokinetics or pharmacodynamics.

Background/Objective: Patients with intracranial hemorrhage (ICH) have a 30-day mortality rate up to 52%, and the risk of mortality is increased in patients with disease-induced coagulopathy such as cirrhosis. The objective of this study was to evaluate whether 4F-PCC administration mitigates hematoma expansion in ICH patients with cirrhosis not currently receiving anticoagulation therapy compared to standard of care therapies. Methods: This was a single-center, retrospective study comparing adult patients with ICH and history of cirrhosis who received 4F-PCC versus standard of care therapies. The primary outcome was rate of ICH expansion within 24 hours after admission. Results: A total of 58 patients were included with 21 who received 4FPCC vs 37 who received standard of care therapies. The 4F-PCC group had a significantly higher number of patients with Child Pugh Class C cirrhosis (85.7% vs. 48.6%, P = 0.006), higher baseline INR (1.7 vs. 1.4, P = 0.001) and more patients with a spontaneous cause of hemorrhage (61.9% vs. 29.7%, P = 0.01). Stable follow-up head CT was achieved in 68.4% of patients who received 4F-PCC versus 72.7% of patients treated with standard of care therapies ( P = 0.11). Patients who received 4F-PCC had a significantly greater change in INR within 24 hours (-0.2 vs. 0, P = 0.02) and higher rate of mortality (61.9% vs. 18.9%, P = 0.001). Baseline INR > 2 and surgical evacuation for ICH were associated with decreased odds of stable follow-up head CT in the multivariate logistic regression model. Conclusions: A single dose of 4F-PCC did not significantly improve the rate of stable head CT at 24 hours in patients with ICH and cirrhosis. Randomized clinical trials with larger patient populations are warranted to fully determine the role of 4F-PCC in this unique population.

Deep vein thrombosis (DVT) and pulmonary embolism (PE) are complications of hospitalization leading to increased morbidity and mortality. Routine surveillance ultrasound has become common practice in some intensive care units (ICU) to detect DVT early and initiate anticoagulation, preventing complications. However, initiating anticoagulants for asymptomatic DVT treatment may increase risk of hemorrhage. The objective of this study was to investigate the value of routine surveillance ultrasound in early DVT diagnosis in Neuro ICU patients. This is a retrospective review of patients diagnosed with DVT during admission to the Neuro ICU at University Hospital from January 1, 2012, through December 31, 2017. Patients were identified through International Classification of Diseases 9th and 10th Revision codes for DVT and PE, screened for inclusion criteria, and then classified as surveillance group or symptom-driven group based on intervention received. Primary outcome was time to DVT diagnosis. Secondary outcome included clinically significant hemorrhage identified by anticoagulation treatment discontinuation for suspected hemorrhage or new or expanding hemorrhage on head computerized tomography (CT). A total of 116 patients were identified, with 50 included: 27 were classified as surveillance and 23 as symptom-driven. Seven patients (surveillance = 3 and symptom-driven = 4) were diagnosed with only PE and were excluded from primary outcome. Median time to DVT diagnosis was similar at 148 h for surveillance versus 172 h for symptom driven (p = 0.2). There was no difference in treatment discontinuation rates (surveillance 21% vs symptom 31%; p = 0.4). Of the 27 patients with follow-up head CT, two in the surveillance group and two in the symptom-driven group showed a new or expanding hemorrhage. Routine surveillance ultrasound did not lead to significantly earlier DVT diagnosis. Hemorrhagic events were not different between groups. Utility of surveillance ultrasound in this population should be evaluated in large, prospective trials before routine use can be recommended.