In July, we will be highlighting information on antiplatelet and anticoagulant medications, both old and new. The webinar and the Ask-the-Expert segment, will focus not only on the pharmacological mechanisms of these drugs, but the controversies surrounding their benefits, risks and reversal strategies, if available or adequate.
As our aging population continues to grow, more patients with high risk cardiovascular disease will be identified and thus follows the most certain escalated use of these medications to prevent and treat associated thromboembolic (TE) events.
Of course, if you speak with our surgical, emergency or anesthesia colleagues, they will categorically state that these drugs are the bane of their existence. Their concerns are well-founded and include the potential increased bleeding risk with elective or emergency surgeries, the appropriate time to discontinue medications prior to surgery without incurring more risk for TE phenomena, availability of reversal agents/antidotes in the event of severe hemorrhage, and how to reinstitute or bridge patients in the perioperative period.
Each of these scenarios is real, quite complex, and without clear answers. These drugs pose significant problems as well, for transfusion services. Requests for blood components are on the rise and this results in increased risks from transfusions that often are ineffective or unnecessary. This is particularly true in those facilities that lack the laboratory capabilities for assessment of platelet function or validated tests targeted for the newer anti-Xa anticoagulant agents. One might be surprised to know that, if tested, many patients are not adequately inhibited or anticoagulated due to non-compliance or genetic variations. Even with currently available testing, not all of these drugs are accurately monitored. And, of course, don’t forget that the direct thrombin inhibitors have no available FDA-approved tests to identify or monitor supratherapeutic levels, much less a ready and effective antidote!
So the pharmaceutical companies that heavily market and clearly push these medications into the view of healthcare providers AND the public have backed us into a corner and into a most precarious position. These July educational segments will hopefully provide insight, even if not complete comfort, with the antiplatelet and anticoagulant medications that are indeed a permanent fixture in our medical and transfusion practices. I shall leave you with two references that speak quite pragmatically to the dilemmas surrounding these ever-present drugs. Those of us in the blood management “world” must continue to provide information, consultation and our most vigilant precautionary advice when it comes to these agents.
- Bracey A, Reyes M, Chen A et al. “How do we manage patients treated with antithrombotic therapy in the perioperative interval.” Transfusion, 2011;51:2066-2077.
- Dzik W “Reversal of drug-induced anticoagulation: old solutions and new problems.” Transfusion, 2012 (supplement); 52: 45S-55S.