Community Practice Connections Cardiology Best Practice: Direct Acting Oral Anticoagulants (DOACs) and Reversal Agents: Updates for the Hospitalist

Release Date: March 30, 2018
Expiration Date: March 30, 2019
Media: Internet-based

Activity Overview

Anticoagulant therapy plays a vital role in treating patients and preventing serious and potentially fatal complications that result from venous thromboembolism and atrial fibrillation. Direct acting oral anticoagulants (DOACs) offer several advantages over traditional vitamin K antagonist therapy with a more predictable anticoagulant response, fewer drug interactions, and significantly less risk of hemorrhagic stroke when compared to warfarin; however, in the past, the absence of a clear, effective reversal strategy was a concern with the new oral anticoagulant agents.
 
This Best Practice® program will review the efficacy and safety of new and emerging anticoagulation reversal agents as well as the recommended strategies for DOAC reversal.  Incorporation of individual patient-specific factors will be addressed and patient cases will be used to exemplify implementation of reversal strategies. Throughout the program, we hope that you will take advantage of all the opportunities to interact with our faculty to ensure that your most pressing clinical questions are answered.

Acknowledgment of Commercial Support

This activity is supported by independent educational grants from Boehringer Ingelheim
Pharmaceuticals, Inc., and Portola Pharmaceuticals, Inc. 

Target Audience

This educational activity is intended for hospitalists, residents, surgeons, anesthesiologists, and other hospital-based providers who care for patients requiring DOAC and/or reversal agents.

Educational Objectives

At the conclusion of this activity, you should be better prepared to:
  • Describe the benefits of anticoagulation therapy with DOACs versus warfarin and discuss what factors should be considered
  • Explain who is most at risk for complications associated with the use of warfarin therapy and identify which patient population can benefit most from DOACs
  • Effectively discuss the impact DOACs may have on hospital admissions, readmissions, length of stay, and hospitalization costs
  • Summarize current and emerging reversal agents for DOACs

Faculty, Staff, and Planners’ Disclosures

Faculty
Charles V. Pollack, Jr, MA, MD, FACEP, FAAEM, FAHA, FESC, FCPP
Associate Provost for Innovation in Education, Thomas Jefferson University
Director, Jefferson Institute of Emerging Health Professions
Director, The Lambert Center for the Study of Medicinal Cannabis and Hemp
Associate Dean for CME and Strategic Partner Alliances, Thomas Jefferson University
Professor and Senior Advisor for Interdisciplinary Research and Clinical Trials
Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University
Philadelphia, Pennsylvania
 
Disclosure: Grants/Research Support: AstraZeneca, Boehringer Ingelheim, CSL Behring, Daiichi Sankyo, Janssen, Portola; Consultant: AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb/Pfizer, Janssen, Portola, Provepharm

Steven Deitelzweig, MD, MMM, SFHM, FACP, FACC
Medical Director of Regional Business Development, System Chairman, Hospital Medicine, Professor of Medicine
Ochsner Clinical School
New Orleans, Louisiana
 
Disclosure: Grants/Research Support: Bristol-Myers Squibb, Pfizer, Portola; Consultant: Bristol-Myers Squibb, Janssen, Pfizer, Portola
The staff of PER® have no relevant financial relationships with commercial interests to disclose.

Accreditation/Credit Designation

Physicians’ Education Resource®, LLC, is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
Physicians' Education Resource®, LLC, designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure Policy and Resolution of Conflicts of Interest (COI)

As a sponsor accredited by the ACCME, it is the policy of PER® to ensure fair balance, independence, objectivity, and scientific rigor in all of its CME activities. In compliance with ACCME guidelines, PER® requires everyone who is in a position to control the content of a CME activity to disclose all relevant financial relationships with commercial interests. The ACCME defines “relevant financial relationships” as financial relationships in any amount occurring within the past 12 months that creates a COI.
Additionally, PER® is required by ACCME to resolve all COI. PER® has identified and resolved all COI prior to the start of this activity by using a multistep process.

Off-Label Disclosure and Disclaimer

This CME activity may or may not discuss investigational, unapproved, or off-label use of drugs. Participants are advised to consult prescribing information for any products discussed. The information provided in this CME activity is for continuing medical and nursing education purposes only, and is not meant to substitute for the independent clinical judgment of a physician relative to diagnostic, treatment, or management options for a specific patient’s medical condition. The opinions expressed in the content are solely those of the individual faculty members and do not reflect those of PER®.

CME Provider Contact Information

Physicians’ Education Resource®, LLC
2 Clarke Drive
Suite 110
Cranbury, NJ 08512
info@gotoper.com

Hardware and Software Requirements 

Supported Browsers
Internet Explorer v.7 or greater (for Windows) | Mozilla Firefox v.2 or greater (for Windows, Mac, Linux)

Minimum System Requirements (Windows)
  • A Pentium-based PC or compatible computer
  • At least 64MB of RAM
  • Windows 95/98/NT/ME/2000/XP/Vista system software
  • Screen resolution of 1024 x 786 or larger recommended
  • PDF Reader: Adobe Reader 5.0 or higher, Foxit Reader 2.0 or likewise
Minimum System Requirements (Mac OS)
  • A PowerPC processor-based Macintosh computer
  • At least 64MB of RAM
  • Mac OS 7.5 or later
  • Screen resolution of 1024 x 786 or larger recommended
  • PDF Reader: Adobe Reader 5.0 or higher, Foxit Reader 2.0 or likewise

Recap 1: DOAC therapy (paradigm shift!) for the prevention of stroke in nonvalvular atrial fibrillation and venous thromboembolism

The online continuing medical education activity, DOACs and Reversal Agents Community Practice Connection™, provides health care providers with engaging instruction on how to incorporate direct acting oral anticoagulants (DOACs) into their treatment regimens for the management of nonvalvular atrial fibrillation (NVAF) and prevention of venous thromboembolic events (VTEs). Leading experts Charles V. Pollack, MD, and Steven Deitelzweig, MD, answer key questions, supported by the presentation of clinical science, about current and evolving treatment standards and DOAC therapy for appropriate patients. This first of 3 PER Pulse™ Recaps from the program focuses on the paradigm shift in the prevention of stroke in NVAF and VTE.
 
Dr. Pollack discusses the changing treatment paradigm and the role of DOAC therapy in the prevention of stroke in NVAF and VTE.
  • DOACs are indicated for the prevention of stroke and AF, and also for the treatment and prevention of VTE. The DOACs as a class represent a pharmacologic advance over vitamin K antagonists (VKAs), even those that are bridged with low-molecular-weight heparin (LMWH). These drugs are much easier for patients to use. There are few drug-drug and drug-diet interactions, dosing is simpler, and titration is not required. These drugs are at least as safe and effective. In the case of dabigatran and apixaban, they are more effective than warfarin in reducing stroke risk in AF.
  • Currently, there are not a lot of prospective data on switching patients from a VKA to any of the available DOACs. One of the biggest concerns with VKAs is intracranial bleed, especially in older patients. Among the DOAC class, there is a 50% to 70% reduction in the likelihood of intracranial bleeds compared with VKAs in patients older than 75 years. The risk of intracranial bleed in warfarin-treated patients is significant in these high-risk individuals.
  • The RE-COVER I and RE-COVER II trials led to the approval of dabigatran for use in the prevention of stroke and VTE. These studies evaluated the treatment of DVT and pulmonary embolism in patients who were started on a subcutaneous LMWH, typically enoxaparin, not bridged, who transitioned to dabigatran between day 2 and day 5. These studies showed equivalent safety and efficacy between VKA and DOAC therapy.
  • Reversal agents for the newer anticoagulants are of increasing interest. The approval of idarucizumab to reverse the anticoagulation effects of dabigatran has led to improved outcomes in life-threatening bleeding that is not hemostatic. Additional reversal agents are being evaluated.
Although we see fewer bleeding events with the increasing use of DOAC therapy, hemorrhagic events still occur. It is essential for health care professionals to discuss anticoagulation options with their patients.






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