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Latest & greatest articles for warfarin
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Rivaroxaban versus warfarin in nonvalvular atrial fibrillation. The use of warfarin reduces the rate of ischemic stroke in patients with atrial fibrillation but requires frequent monitoring and dose adjustment. Rivaroxaban, an oral factor Xa inhibitor, may provide more consistent and predictable anticoagulation than warfarin.In a double-blind trial, we randomly assigned 14,264 patients with nonvalvular atrial fibrillation who were at increased risk for stroke to receive either rivaroxaban (...) (at a daily dose of 20 mg) or dose-adjusted warfarin. The per-protocol, as-treated primary analysis was designed to determine whether rivaroxaban was noninferior to warfarin for the primary end point of stroke or systemic embolism.In the primary analysis, the primary end point occurred in 188 patients in the rivaroxaban group (1.7% per year) and in 241 in the warfarin group (2.2% per year) (hazard ratio in the rivaroxaban group, 0.79; 95% confidence interval [CI], 0.66 to 0.96; P<0.001 for noninferiority
Apixaban versus warfarin in patients with atrial fibrillation. Vitamin K antagonists are highly effective in preventing stroke in patients with atrial fibrillation but have several limitations. Apixaban is a novel oral direct factor Xa inhibitor that has been shown to reduce the risk of stroke in a similar population in comparison with aspirin.In this randomized, double-blind trial, we compared apixaban (at a dose of 5 mg twice daily) with warfarin (target international normalized ratio, 2.0 (...) , as compared with 1.60% per year in the warfarin group (hazard ratio with apixaban, 0.79; 95% confidence interval [CI], 0.66 to 0.95; P<0.001 for noninferiority; P=0.01 for superiority). The rate of major bleeding was 2.13% per year in the apixaban group, as compared with 3.09% per year in the warfarin group (hazard ratio, 0.69; 95% CI, 0.60 to 0.80; P<0.001), and the rates of death from any cause were 3.52% and 3.94%, respectively (hazard ratio, 0.89; 95% CI, 0.80 to 0.99; P=0.047). The rate
Performance of stroke risk scores in older people with atrial fibrillation not taking warfarin: comparative cohort study from BAFTA trial. To compare the predictive power of the main existing and recently proposed schemes for stratification of risk of stroke in older patients with atrial fibrillation.Comparative cohort study of eight risk stratification scores.Trial of thromboprophylaxis in stroke, the Birmingham Atrial Fibrillation in the Aged (BAFTA) trial.665 patients aged 75 or over (...) with atrial fibrillation based in the community who were randomised to the BAFTA trial and were not taking warfarin throughout or for part of the study period.Events rates of stroke and thromboembolism.54 (8%) patients had an ischaemic stroke, four (0.6%) had a systemic embolism, and 13 (2%) had a transient ischaemic attack. The distribution of patients classified into the three risk categories (low, moderate, high) was similar across three of the risk stratification scores (revised CHADS(2), NICE, ACC
Cost-Effectiveness of Dabigatran Compared With Warfarin for Stroke Prevention in Atrial Fibrillation. Warfarin reduces the risk for ischemic stroke in patients with atrial fibrillation (AF) but increases the risk for hemorrhage. Dabigatran is a fixed-dose, oral direct thrombin inhibitor with similar or reduced rates of ischemic stroke and intracranial hemorrhage in patients with AF compared with those of warfarin.To estimate the quality-adjusted survival, costs, and cost-effectiveness (...) of dabigatran compared with adjusted-dose warfarin for preventing ischemic stroke in patients 65 years or older with nonvalvular AF.Markov decision model.The RE-LY (Randomized Evaluation of Long-Term Anticoagulation Therapy) trial and other published studies of anticoagulation. The cost of dabigatran was estimated on the basis of pricing in the United Kingdom.Patients aged 65 years or older with nonvalvular AF and risk factors for stroke (CHADS₂ score ≥1 or equivalent) and no contraindications
that the frequencies of allelic variants of the CYP2C9 and VKORC1 genes responsible for altered warfarin metabolism were 31 and 59 per cent, respectively (Byron & Dear 2007). There are two brands of warfarin currently on the market in Australia, Coumadin (offered as 1, 2 or 5 mg tablets) and Mavaran (offered as 1, 3 or 5 mg tablets). Dosage will depend on the patient’s INR. Once an ideal dose is established patients usually require one tablet per day, with each prescription containing 50 tablets. In the calendar (...) ://clinicaltrials.gov/ct2/show/NCT00904293 [Accessed 25th January]. FDA (2007). FDA Approves Updated Warfarin (Coumadin) Prescribing Information. New genetic information may help providers improve initial dosing estimates of the anticoagulant for individual patients. [Internet]. Food and Drug Administration. Available from: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/2007/ucm108967. htm [Accessed Jonas, D. E. & McLeod, H. L. (2009). 'Genetic and clinical factors relating to warfarin dosing', Trends
Fibrate/statin initiation in warfarin users and gastrointestinal bleeding risk To evaluate whether initiation of a fibrate or statin increases the risk of hospitalization for gastrointestinal bleeding in warfarin users.We used Medicaid claims data (1999-2003) to perform an observational case-control study nested within person-time exposed to warfarin in those > or =18 years (n=353,489). Gastrointestinal bleeding cases were matched to 50 controls based on index date and state.Chronic warfarin
Warfarin vs. Aspirin For Atrial Fibrillation Stroke Prevention Warfarin vs. Aspirin For Atrial Fibrillation Stroke Prevention – TheNNTTheNNT Oral anticoagulants versus antiplatelet agents in non-valvular atrial fibrillation for stroke prevention (and no prior stroke) 60 for prevented stroke In Summary, for those who took warfarin instead of aspirin (for 1.9 years): Benefits in NNT 98.8% saw no benefit 1.6% were helped by preventing 1 stroke 0.3% were helped by avoiding a systemic embolism 1 (...) . The overall risk of stroke ranges from 2.5% to 4% per year. Both anti-platelet agents and oral anticoagulants reduce this risk, but both also increase the risk of hemorrhagic stroke and other bleeding. The review compared anti-platelet agents to anticoagulants in patients with atrial fibrillation but no history of stroke or transient ischemic attack. Eight randomized trials with 9598 subjects were included, with most examining warfarin versus aspirin (75 to 325 mg/day). The target INR range for subjects
Warfarin for Atrial Fibrillation Stroke Prevention Warfarin for Atrial Fibrillation Stroke Prevention – TheNNTTheNNT Oral anticoagulants in non-valvular atrial fibrillation for primary stroke prevention (no prior stroke) 25 for prevented stroke In Summary, for those who took the warfarin (for 1.5 years): Benefits in NNT 96% saw no benefit 4% were helped by preventing 1 stroke 2.4% were helped by avoiding death 1 in 25 were helped (preventing stroke ) 1 in 42 were helped (preventing death from (...) factor for strokes. The overall risk ranges from 2.5% to 4% per year. Oral anticoagulants (OAC) reduce this risk, but also increase the risk of hemorrhagic stroke and major bleeding. The review compared warfarin with placebo for prevention of stroke in patients with atrial fibrillation but no history of strokes (or transient ischemic attacks). Five high quality trials with 2313 participant were included, most examining warfarin versus placebo. The warfarin group achieved a mean INR between 2.0
Effectiveness of pharmacist-participated warfarin therapy management: a systematic review and meta-analysis Untitled Document The CRD Databases will not be available from 08:00 BST on Friday 4th October until 08:00 BST on Monday 7th October for essential maintenance. We apologise for any inconvenience.
Cytochrome P450 gene test to establish the correct warfarin dose in patients requiring oral anti-coagulant therapy Cytochrome P450 gene test to establish the correct warfarin dose in patients requiring oral anti-coagulant therapy Cytochrome P450 gene test to establish the correct warfarin dose in patients requiring oral anti-coagulant therapy Mundy L, Hiller JE Record Status This is a bibliographic record of a published health technology assessment from a member of INAHTA. No evaluation (...) of the quality of this assessment has been made for the HTA database. Citation Mundy L, Hiller JE. Cytochrome P450 gene test to establish the correct warfarin dose in patients requiring oral anti-coagulant therapy. Adelaide: Adelaide Health Technology Assessment (AHTA). Horizon Scanning Prioritising Summary Volume 26. 2010 Authors' conclusions Polymerase chain reaction is an accurate means of identifying genetic mutations. All techniques discussed in this summary use PCR and other molecular techniques
Efficacy and safety of dabigatran compared with warfarin at different levels of international normalised ratio control for stroke prevention in atrial fibrillation: an analysis of the RE-LY trial. Effectiveness and safety of warfarin is associated with the time in therapeutic range (TTR) with an international normalised ratio (INR) of 2·0-3·0. In the Randomised Evaluation of Long-term Anticoagulation Therapy (RE-LY) trial, dabigatran versus warfarin reduced both stroke and haemorrhage. We aimed (...) to investigate the primary and secondary outcomes of the RE-LY trial in relation to each centre's mean TTR (cTTR) in the warfarin population.In the RE-LY trial, 18 113 patients at 951 sites were randomly assigned to 110 mg or 150 mg dabigatran twice daily versus warfarin dose adjusted to INR 2·0-3·0. Median follow-up was 2·0 years. For 18 024 patients at 906 sites, the cTTR was estimated by averaging TTR for individual warfarin-treated patients calculated by the Rosendaal method. We compared the outcomes
2010LancetControlled trial quality: predicted high
Modeling the cost-effectiveness of prothrombin complex concentrate compared with fresh frozen plasma in emergency warfarin reversal in the United Kingdom Modeling the cost-effectiveness of prothrombin complex concentrate compared with fresh frozen plasma in emergency warfarin reversal in the United Kingdom Modeling the cost-effectiveness of prothrombin complex concentrate compared with fresh frozen plasma in emergency warfarin reversal in the United Kingdom Guest JF, Watson HG, Limaye S Record (...) Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary This study examined the cost-effectiveness of using prothrombin complex concentrate, compared with fresh frozen plasma, for emergency warfarin reversal in patients with a life-threatening
Uninterrupted warfarin for periprocedural anticoagulation in catheter ablation of typical atrial flutter: a safe and cost-effective strategy Uninterrupted warfarin for periprocedural anticoagulation in catheter ablation of typical atrial flutter: a safe and cost-effective strategy Uninterrupted warfarin for periprocedural anticoagulation in catheter ablation of typical atrial flutter: a safe and cost-effective strategy Finlay M, Sawhney V, Schilling R, Thomas G, Duncan E, Hunter R, Virdi G (...) , Abrams D, Sporton S, Dhinoja M, Earley M Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary The objective was to examine the clinical and economic impact of warfarin versus heparin for patients undergoing catheter ablation for typical atrial
A policy model to evaluate the benefits, risks and costs of warfarin pharmacogenomic testing A policy model to evaluate the benefits, risks and costs of warfarin pharmacogenomic testing A policy model to evaluate the benefits, risks and costs of warfarin pharmacogenomic testing Meckley LM, Gudgeon JM, Anderson JL, Williams MS, Veenstra DL Record Status This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary (...) of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. CRD summary This study examined the cost-effectiveness of genetic testing to adjust the warfarin dose, using a model based on the international normalised ratio, for patients with atrial fibrillation who had just started long-term warfarin therapy. The authors concluded that warfarin pharmacogenomic testing provided some clinical benefit, but with significant
The net clinical benefit of warfarin anticoagulation in atrial fibrillation. Guidelines recommend warfarin use in patients with atrial fibrillation solely on the basis of risk for ischemic stroke without antithrombotic therapy. These guidelines rely on ischemic stroke rates observed in older trials and do not explicitly account for increased risk for hemorrhage.To quantify the net clinical benefit of warfarin therapy in a cohort of patients with atrial fibrillation.Mixed retrospective (...) prevented by warfarin minus intracranial hemorrhages attributable to warfarin, multiplied by an impact weight. The base-case impact weight was 1.5, reflecting the greater clinical impact of intracranial hemorrhage versus thromboembolism.Patients accumulated more than 66 000 person-years of follow-up. The adjusted net clinical benefit of warfarin for the cohort overall was 0.68% per year (95% CI, 0.34% to 0.87%). Adjusted net clinical benefit was greatest for patients with a history of ischemic stroke
Should we be applying warfarin pharmacogenetics to clinical practice? No, not now. The U.S. Food and Drug Administration modified warfarin labeling in 2007 to suggest, but not mandate, pharmacogenetic testing. Genetic analysis is now commercially available. However, results predict only one third of all dosing variation, the value of testing in reducing bleeding and thrombosis rates remains unproved, and cost-effectiveness is not established. Careful consideration of clinical factors (...) that influence dosing, conscientious prothrombin time monitoring, and sage dosage adjustment remain paramount in warfarin management. Further study is required before routine warfarin pharmacogenetic testing can be recommended.
Thrombomodulin as a marker for bleeding complications during warfarin treatment The major adverse effect of warfarin treatment is hemorrhage. Several risk factors for bleeding complications are also risk factors for thromboembolic events, making the clinical decision to initiate or withhold anticoagulant treatment difficult. Specific markers that solely identify patients at high risk of bleeding would have great clinical impact. This study aimed to test if thrombomodulin (TM) concentrations (...) were associated with bleeding complications, cardiovascular events, or mortality in long-term anticoagulant-treated patients.In a longitudinal cohort study we followed up 719 patients receiving warfarin treatment for a mean duration of 4.2 years. All bleeding complications causing hospitalization were registered and classified. Soluble TM antigen (sTM) concentration in plasma was measured with an enzyme-linked immunosorbent assay method.During the follow-up time, 113 clinically relevant bleeding
Randomized Trial of Warfarin, Aspirin, and Clopidogrel in Patients With Chronic Heart Failure: The Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) Trial Chronic heart failure remains a major cause of mortality and morbidity. The role of antithrombotic therapy in patients with chronic heart failure has long been debated. The objective of this study was to determine the optimal antithrombotic agent for heart failure patients with reduced ejection fractions who are in sinus (...) rhythm.This prospective, randomized clinical trial of open-label warfarin (target international normalized ratio of 2.5 to 3.0) and double-blind treatment with either aspirin (162 mg once daily) or clopidogrel (75 mg once daily) had a 30-month enrollment period and a minimum of 12 months of treatment. We enrolled 1587 men and women >/=18 years of age with symptomatic heart failure for at least 3 months who were in sinus rhythm and had left ventricular ejection fraction of =35%. The primary outcome
Estimation of the warfarin dose with clinical and pharmacogenetic data. Genetic variability among patients plays an important role in determining the dose of warfarin that should be used when oral anticoagulation is initiated, but practical methods of using genetic information have not been evaluated in a diverse and large population. We developed and used an algorithm for estimating the appropriate warfarin dose that is based on both clinical and genetic data from a broad population (...) base.Clinical and genetic data from 4043 patients were used to create a dose algorithm that was based on clinical variables only and an algorithm in which genetic information was added to the clinical variables. In a validation cohort of 1009 subjects, we evaluated the potential clinical value of each algorithm by calculating the percentage of patients whose predicted dose of warfarin was within 20% of the actual stable therapeutic dose; we also evaluated other clinically relevant indicators.In
Cost-effectiveness of using pharmacogenetic information in warfarin dosing for patients with nonvalvular atrial fibrillation. Variants in genes involved in warfarin metabolism and sensitivity affect individual warfarin requirements and the risk for bleeding. Testing for these variant alleles might allow more personalized dosing of warfarin during the induction phase. In 2007, the U.S. Food and Drug Administration changed the labeling for warfarin (Coumadin, Bristol-Myers Squibb, Princeton, New (...) Jersey), suggesting that clinicians consider genetic testing before initiating therapy.To examine the cost-effectiveness of genotype-guided dosing versus standard induction of warfarin therapy for patients with nonvalvular atrial fibrillation.Markov state transition decision model.MEDLINE searches and bibliographies from relevant articles of literature published in English.Outpatients or inpatients requiring initiation of warfarin therapy. The base case was a man age 69 years with newly diagnosed