Array ( [0] => {{Short description|Class of drugs}} [1] => {{cs1 config|name-list-style=vanc|display-authors=6}} [2] => {{Infobox drug class [3] => | Name = Anticoagulant [4] => | Image = Coagulation Cascade and Major Classes of Anticoagulants.png [5] => | Alt = [6] => | Use = [7] => | Caption = Coagulation cascade and major classes of anticoagulants [8] => | Biological_target = [9] => | ATC_prefix = B01 [10] => | MeshID = D00534-class [11] => | Consumer_Reports = [12] => | medicinenet = [13] => | rxlist = [14] => }} [15] => [16] => An '''anticoagulant''', commonly known as a '''blood thinner''', is a [[chemical substance]] that prevents or reduces the [[coagulation]] of [[blood]], prolonging the [[clotting time]].{{cite web |date=26 July 2021 |title=Overview: Anticoagulant medicines |url=https://www.nhs.uk/conditions/anticoagulants/ |access-date=2 June 2023 |website=Health A to Z |publisher=[[National Health Service|NHS]]}} Some occur naturally in [[hematophagy|blood-eating]] animals, such as [[leech]]es and [[mosquito]]es, which help keep the bite area unclotted long enough for the animal to obtain blood.{{cite journal |vauthors=Azzopardi EA, Whitaker IS, Rozen WM, Naderi N, Kon M |date=October 2011 |title=Chemical and mechanical alternatives to leech therapy: a systematic review and critical appraisal |url=https://www.thieme-connect.de/products/ejournals/abstract/10.1055/s-0031-1284233 |journal=Journal of Reconstructive Microsurgery |publisher=[[Thieme Medical Publishers]] |volume=27 |issue=8 |pages=481–6 |doi=10.1055/s-0031-1284233 |eissn=0743-684X |pmid=21780018 |s2cid=260192613 |url-access=subscription}}{{cite journal |vauthors=Ha YR, Oh SR, Seo ES, Kim BH, Lee DK, Lee SJ |date=April 2014 |title=Detection of heparin in the salivary gland and midgut of Aedes togoi |journal=The Korean Journal of Parasitology |publisher=The Korean Society for Parasitology and Tropical Medicine |volume=52 |issue=2 |pages=183–8 |doi=10.3347/kjp.2014.52.2.183 |eissn=2982-6799 |pmc=4028456 |pmid=24850962}} [17] => [18] => As a class of [[pharmaceutical drug|medications]], anticoagulants are used in [[therapy]] for [[thrombosis|thrombotic disorders]].{{cite journal |vauthors=Yoo HH, Nunes-Nogueira VS, Boas, PJ |date=7 February 2020 |title=Anticoagulant treatment for subsegmental pulmonary embolism |journal=[[Cochrane Library|The Cochrane Database of Systematic Reviews]] |volume=2020 |issue=2 |pages=CD010222 |doi=10.1002/14651858.CD010222.pub4 |issn=1469-493X |pmc=7004894 |pmid=32030721}} [[Oral administration|Oral]] anticoagulants (OACs) are taken by many people in [[pill (pharmacy)|pill]] or [[tablet (pharmacy)|tablet]] form, and various [[intravenous therapy|intravenous]] anticoagulant [[dosage form]]s are used in hospitals.{{cite journal |vauthors=Cohen AT, Hamilton M, Mitchell SA, Phatak H, Liu X, Bird A, Tushabe D, Batson S |date=2015-12-30 |editor-last=ten Cate |editor-first=Hugo |title=Comparison of the Novel Oral Anticoagulants Apixaban, Dabigatran, Edoxaban, and Rivaroxaban in the Initial and Long-Term Treatment and Prevention of Venous Thromboembolism: Systematic Review and Network Meta-Analysis |journal=[[PLOS One]] |volume=10 |issue=12 |pages=e0144856 |bibcode=2015PLoSO..1044856C |doi=10.1371/journal.pone.0144856 |pmc=4696796 |pmid=26716830 |doi-access=free}}{{cite journal |vauthors=Almutairi AR, Zhou L, Gellad WF, Lee JK, Slack MK, Martin JR, Lo-Ciganic WH |date=July 2017 |title=Effectiveness and Safety of Non-vitamin K Antagonist Oral Anticoagulants for Atrial Fibrillation and Venous Thromboembolism: A Systematic Review and Meta-analyses |url=https://www.clinicaltherapeutics.com/article/S0149-2918(17)30699-9/fulltext |journal=[[Clinical Therapeutics]] |volume=39 |issue=7 |pages=1456–1478.e36 |doi=10.1016/j.clinthera.2017.05.358 |pmid=28668628 |url-access=subscription}} Some anticoagulants are used in medical equipment, such as sample tubes, [[blood transfusion]] bags, [[Cardiopulmonary bypass|heart–lung machines]], and [[Kidney dialysis|dialysis]] equipment.{{cite journal |vauthors=Banfi G, Salvagno GL, Lippi G |date=2007-01-01 |title=The role of ethylenediamine tetraacetic acid (EDTA) as in vitro anticoagulant for diagnostic purposes |url=https://www.degruyter.com/document/doi/10.1515/CCLM.2007.110/ |journal=[[Clinical Chemistry and Laboratory Medicine]] |volume=45 |issue=5 |pages=565–76 |doi=10.1515/CCLM.2007.110 |pmid=17484616 |s2cid=23824484 |url-access=subscription}}{{cite journal |vauthors=Dobrovolskaia MA, McNeil SE |date=May 2015 |title=Safe anticoagulation when heart and lungs are "on vacation" |journal=[[Annals of Translational Medicine]] |volume=3 |issue=Suppl 1 |pages=S11 |doi=10.3978/j.issn.2305-5839.2015.02.03 |pmc=4437941 |pmid=26046056}} One of the first anticoagulants, [[warfarin]], was initially approved as a [[rodenticide]].{{cite journal |vauthors=[[Munir Pirmohamed|Pirmohamed M]] |date=November 2006 |title=Warfarin: almost 60 years old and still causing problems |journal=[[British Journal of Clinical Pharmacology]] |volume=62 |issue=5 |pages=509–11 |doi=10.1111/j.1365-2125.2006.02806.x |pmc=1885167 |pmid=17061959}} [19] => [20] => Anticoagulants are closely related to [[antiplatelet drug]]s and [[thrombolytic]] drugs by manipulating the various pathways of blood coagulation.{{cite journal | title = Warfarin | pmid = 29261922 | url = http://www.ncbi.nlm.nih.gov/books/NBK470313/ | access-date = 2020-01-23 | publisher = StatPearls Publishing | journal = StatPearls | year = 2020 | last1 = Patel | first1 = S. | last2 = Singh | first2 = R. | last3 = Preuss | first3 = C. V. | last4 = Patel | first4 = N. }} Specifically, antiplatelet drugs inhibit platelet aggregation (clumping together), whereas anticoagulants inhibit specific pathways of the coagulation cascade, which happens after the initial platelet aggregation but before the formation of fibrin and stable aggregated platelet products.{{cite book | vauthors = Iqbal AM, Lopez RA, Hai O | chapter = Antiplatelet Medications | pmid = 30725747 | chapter-url = http://www.ncbi.nlm.nih.gov/books/NBK537062/ | access-date = 2020-01-23 | publisher = StatPearls Publishing | title = StatPearls | year = 2020 }}{{cite journal | vauthors = Harter K, Levine M, Henderson SO | title = Anticoagulation drug therapy: a review | journal = The Western Journal of Emergency Medicine | volume = 16 | issue = 1 | pages = 11–7 | date = January 2015 | pmid = 25671002 | pmc = 4307693 | doi = 10.5811/westjem.2014.12.22933 }} [21] => [22] => Common anticoagulants include warfarin and [[heparin]].{{cite news | first1 = Ron | last1 = Winslow | first2 = Avery | last2 = Johnson | title = Race Is on for the Next Blood Thinner | url = https://www.wsj.com/articles/SB119725064671318856 | work = [[The Wall Street Journal]] | page = A12 | date = 2007-12-10 | access-date = 2008-01-06 | quote = ...in a market now dominated by one of the oldest mainstay pills in medicine: the blood thinner warfarin. At least five next-generation blood thinners are in advanced testing to treat or prevent potentially debilitating or life-threatening blood clots in surgery and heart patients. First candidates could reach the market in 2009. }} [23] => {{TOC limit}} [24] => [25] => ==Medical uses== [26] => The use of anticoagulants is a decision based on the risks and benefits of anticoagulation.{{cite journal | vauthors = Djulbegovic M, Lee AI | title = An Update on the "Novel" and Direct Oral Anticoagulants, and Long-Term Anticoagulant Therapy | journal = Clinics in Chest Medicine | volume = 39 | issue = 3 | pages = 583–593 | date = September 2018 | pmid = 30122182 | doi = 10.1016/j.ccm.2018.04.010 | s2cid = 52039169 }} The biggest risk of anticoagulation therapy is the increased risk of bleeding.{{cite journal | vauthors = Parks AL, Fang MC | title = Scoring Systems for Estimating the Risk of Anticoagulant-Associated Bleeding | journal = Seminars in Thrombosis and Hemostasis | volume = 43 | issue = 5 | pages = 514–524 | date = July 2017 | pmid = 28359135 | doi = 10.1055/s-0037-1598061 | s2cid = 1981707 }} In otherwise healthy people, the increased risk of bleeding is minimal, but those who have had recent surgery, [[cerebral aneurysm]]s, and other conditions may have too great a risk of bleeding.{{cite journal | vauthors = Zhu X | title = The hemorrhage risk of prophylactic external ventricular drain insertion in aneurysmal subarachnoid hemorrhage patients requiring endovascular aneurysm treatment: a systematic review and meta-analysis | journal = Journal of Neurosurgical Sciences | volume = 61 | issue = 1 | pages = 53–63 | date = February 2017 | pmid = 25963956 | doi = 10.23736/S0390-5616.16.03244-6 | url = http://www.minervamedica.it/index2.php?show=R38Y2017N01A0053 }}{{cite journal | vauthors = Banerjee K, Poddar K, Mick S, White J, Krishnaswamy A, Johnston D, Rodriguez L, Tuzcu EM, Kapadia S | title = Meta-Analysis of Usefulness of Anticoagulation After Transcatheter Aortic Valve Implantation | journal = The American Journal of Cardiology | volume = 120 | issue = 9 | pages = 1612–1617 | date = November 2017 | pmid = 28844512 | doi = 10.1016/j.amjcard.2017.07.059 }} Generally, the benefit of anticoagulation is preventing or reducing the progression of a thromboembolic disease.{{cite web|url=https://medlineplus.gov/bloodthinners.html|title=Blood Thinners|website=medlineplus.gov|access-date=2020-01-23}} Some indications for anticoagulant therapy that are known to have benefit from therapy include: [27] => * [[Atrial fibrillation]] — commonly forms an [[Right atrium|atrial appendage]] clot{{cite journal | vauthors = Sharma M, Cornelius VR, Patel JP, Davies JG, Molokhia M | title = Efficacy and Harms of Direct Oral Anticoagulants in the Elderly for Stroke Prevention in Atrial Fibrillation and Secondary Prevention of Venous Thromboembolism: Systematic Review and Meta-Analysis | journal = Circulation | volume = 132 | issue = 3 | pages = 194–204 | date = July 2015 | pmid = 25995317 | pmc = 4765082 | doi = 10.1161/CIRCULATIONAHA.114.013267 }} [28] => * [[Coronary artery disease]]{{cite journal | vauthors = Moustafa A, Ruzieh M, Eltahawy E, Karim S | title = Antithrombotic therapy in patients with atrial fibrillation and coronary artery disease | journal = Avicenna Journal of Medicine | volume = 9 | issue = 4 | pages = 123–128 | date = 2019 | pmid = 31903386 | pmc = 6796304 | doi = 10.4103/ajm.AJM_73_19 | doi-access = free }} [29] => * [[Deep vein thrombosis]] — can lead to pulmonary embolism{{cite journal | vauthors = Kearon C, Akl EA, Ornelas J, Blaivas A, Jimenez D, Bounameaux H, Huisman M, King CS, Morris TA, Sood N, Stevens SM, Vintch JR, Wells P, Woller SC, Moores L | title = Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report | journal = Chest | volume = 149 | issue = 2 | pages = 315–352 | date = February 2016 | pmid = 26867832 | doi = 10.1016/j.chest.2015.11.026 }} [30] => * Ischemic [[stroke]]{{cite journal | vauthors = Kapil N, Datta YH, Alakbarova N, Bershad E, Selim M, Liebeskind DS, Bachour O, Rao GH, Divani AA | title = Antiplatelet and Anticoagulant Therapies for Prevention of Ischemic Stroke | journal = Clinical and Applied Thrombosis/Hemostasis | volume = 23 | issue = 4 | pages = 301–318 | date = May 2017 | pmid = 27461564 | doi = 10.1177/1076029616660762 | s2cid = 43296498 | doi-access = free }} [31] => * [[Hypercoagulable]] states (e.g., [[Factor V Leiden]]) — can lead to deep vein thrombosis{{cite journal | vauthors = Skelley JW, White CW, Thomason AR | title = The use of direct oral anticoagulants in inherited thrombophilia | journal = Journal of Thrombosis and Thrombolysis | volume = 43 | issue = 1 | pages = 24–30 | date = January 2017 | pmid = 27734187 | doi = 10.1007/s11239-016-1428-2 | s2cid = 24650202 }} [32] => * Mechanical heart valves{{cite journal | vauthors = Poli D, Antonucci E, Pengo V, Migliaccio L, Testa S, Lodigiani C, Coffetti N, Facchinetti R, Serricchio G, Falco P, Mangione C, Masottini S, Ruocco L, De Caterina R, Palareti G | title = Mechanical prosthetic heart valves: Quality of anticoagulation and thromboembolic risk. The observational multicenter PLECTRUM study | journal = International Journal of Cardiology | volume = 267 | pages = 68–73 | date = September 2018 | pmid = 29957264 | doi = 10.1016/j.ijcard.2018.04.042 | s2cid = 49588203 }} [33] => * [[Myocardial infarction]]{{cite journal | vauthors = Almony GT, Lefkovits J, Topol EJ | title = Antiplatelet and anticoagulant use after myocardial infarction | journal = Clinical Cardiology | volume = 19 | issue = 5 | pages = 357–65 | date = May 1996 | pmid = 8723593 | doi = 10.1002/clc.4960190506 | s2cid = 103327 | doi-access = free }} [34] => * [[Pulmonary embolism]]{{cite journal | vauthors = Konstantinides SV, Barco S, Lankeit M, Meyer G | title = Management of Pulmonary Embolism: An Update | journal = Journal of the American College of Cardiology | volume = 67 | issue = 8 | pages = 976–90 | date = March 2016 | pmid = 26916489 | doi = 10.1016/j.jacc.2015.11.061 | doi-access = free }} [35] => * [[Restenosis]] from stents{{cite journal | vauthors = Dong Z, Zheng J | title = Anticoagulation after coronary stenting: a systemic review | journal = British Medical Bulletin | volume = 123 | issue = 1 | pages = 79–89 | date = September 2017 | pmid = 28910988 | doi = 10.1093/bmb/ldx018 | s2cid = 3800129 | doi-access = free }} [36] => * Cardiopulmonary bypass (or any other surgeries requiring temporary aortic occlusion){{cite journal | vauthors = Lander H, Zammert M, FitzGerald D | title = Anticoagulation management during cross-clamping and bypass | journal = Best Practice & Research. Clinical Anaesthesiology | volume = 30 | issue = 3 | pages = 359–70 | date = September 2016 | pmid = 27650345 | doi = 10.1016/j.bpa.2016.07.002 }} [37] => * Heart failure{{Citation|last1=Thomas|first1=Isac|title=Anticoagulation Therapy and NOACs in Heart Failure|date=2016|work=Heart Failure|volume=243|pages=515–535|editor-last=Bauersachs|editor-first=Johann|publisher=Springer International Publishing|doi=10.1007/164_2016_126|pmid=28233177|isbn=978-3-319-59658-7|last2=EncisoSilva|first2=Jorge|last3=Schlueter|first3=Michelle|last4=Greenberg|first4=Barry|editor2-last=Butler|editor2-first=Javed|editor3-last=Sandner|editor3-first=Peter}} [38] => [39] => In these cases, anticoagulation therapy [[Thrombosis prophylaxis|prevents the formation]] or growth of dangerous clots.{{cite journal | vauthors = Raschi E, Bianchin M, De Ponti R, De Ponti F, Ageno W | title = Emerging therapeutic uses of direct-acting oral anticoagulants: An evidence-based perspective | journal = Pharmacological Research | volume = 120 | pages = 206–218 | date = June 2017 | pmid = 28366835 | doi = 10.1016/j.phrs.2017.03.026 | s2cid = 36716760 }} [40] => [41] => The decision to begin therapeutic anticoagulation often involves the use of multiple bleeding risk predictable outcome tools as non-invasive pre-test stratifications due to the potential for bleeding while on blood thinning agents. Among these tools are [[HAS-BLED]],{{cite web | url = http://www.mdcalc.com/has-bled-score-for-major-bleeding-risk/| title = HAS-BLED Score for Major Bleeding risk| publisher = MDCalc | access-date = 2014-08-15}} ATRIA,{{cite web | url = http://www.mdcalc.com/atria-bleeding-risk-score/| title = ATRIA Bleeding Risk | publisher = MDCalc | access-date = 2014-08-15}} HEMORR2HAGES,{{cite web|url=https://www.mdcalc.com/hemorr2hages-score-major-bleeding-risk|title=HEMORR₂HAGES Score for Major Bleeding Risk|website=MDCalc|language=en|access-date=2020-01-23}} and [[CHA2DS2-VASc]].{{cite web | url = http://www.mdcalc.com/cha2ds2-vasc-score-for-atrial-fibrillation-stroke-risk/| title = CHA2DS2-VASc | publisher = MDCalc | access-date = 2014-08-15}} The risk of bleeding using the risk assessment tools above must then be weighed against thrombotic risk to formally determine the patient's overall benefit in starting anticoagulation therapy.{{cite journal | vauthors = Zhu W, He W, Guo L, Wang X, Hong K | title = The HAS-BLED Score for Predicting Major Bleeding Risk in Anticoagulated Patients With Atrial Fibrillation: A Systematic Review and Meta-analysis | journal = Clinical Cardiology | volume = 38 | issue = 9 | pages = 555–61 | date = September 2015 | pmid = 26418409 | pmc = 6490831 | doi = 10.1002/clc.22435 }} [42] => [43] => There is no evidence to indicate that adding anticoagulant therapy to standard treatment has a benefit for people with cerebral small vessel disease but not dementia, and there is an increased risk of a person with this disease experiencing a bleed with this approach.{{cite journal |last1=Kwan |first1=Joseph |last2=Hafdi |first2=Melanie |last3=Chiang |first3=Lorraine L W |last4=Myint |first4=Phyo K |last5=Wong |first5=Li Siang |last6=Quinn |first6=Terry J |date=2022-07-13 |editor-last=Cochrane Dementia and Cognitive Improvement Group |title=Antithrombotic therapy to prevent cognitive decline in people with small vessel disease on neuroimaging but without dementia |journal=Cochrane Database of Systematic Reviews |language=en |volume=2022 |issue=7 |pages=CD012269 |doi=10.1002/14651858.CD012269.pub2 |pmc=9281623 |pmid=35833913}} [44] => [45] => ==Adverse effects== [46] => The most serious and common adverse side effects associated with anticoagulants are increased risk of bleeding, both nonmajor and major bleeding events.{{cite journal | vauthors = Yee J, Kaide CG | title = Emergency Reversal of Anticoagulation | journal = The Western Journal of Emergency Medicine | volume = 20 | issue = 5 | pages = 770–783 | date = August 2019 | pmid = 31539334 | pmc = 6754204 | doi = 10.5811/westjem.2018.5.38235 }} The bleeding risk depends on the class of anticoagulant agent used, the patient's age, and pre-existing health conditions. Warfarin has an estimated incidence of bleeding of 15-20% per year and a life-threatening bleeding rate of 1-3% per year.{{cite journal | vauthors = Zareh M, Davis A, Henderson S | title = Reversal of warfarin-induced hemorrhage in the emergency department | journal = The Western Journal of Emergency Medicine | volume = 12 | issue = 4 | pages = 386–92 | date = November 2011 | pmid = 22224125 | pmc = 3236169 | doi = 10.5811/westjem.2011.3.2051 }} Newer non-vitamin K antagonist oral anticoagulants appear to have fewer life-threatening bleeding events than warfarin.{{cite journal | vauthors = Ageno W, Donadini M | title = Breadth of complications of long-term oral anticoagulant care | journal = Hematology. American Society of Hematology. Education Program | volume = 2018 | issue = 1 | pages = 432–438 | date = November 2018 | pmid = 30504343 | pmc = 6245998 | doi = 10.1182/asheducation-2018.1.432 }}{{cite journal | vauthors = Ageno W, Mantovani LG, Haas S, Kreutz R, Monje D, Schneider J, van Eickels M, Gebel M, Zell E, Turpie AG | title = Safety and effectiveness of oral rivaroxaban versus standard anticoagulation for the treatment of symptomatic deep-vein thrombosis (XALIA): an international, prospective, non-interventional study | journal = The Lancet. Haematology | volume = 3 | issue = 1 | pages = e12-21 | date = January 2016 | pmid = 26765643 | doi = 10.1016/S2352-3026(15)00257-4 }} Additionally, patients aged 80 years or more may be especially susceptible to bleeding complications, with a rate of 13 bleeds per 100 person-years.{{cite journal | vauthors = Hylek EM, Evans-Molina C, Shea C, Henault LE, Regan S | title = Major hemorrhage and tolerability of warfarin in the first year of therapy among elderly patients with atrial fibrillation | journal = Circulation | volume = 115 | issue = 21 | pages = 2689–96 | date = May 2007 | pmid = 17515465 | doi = 10.1161/CIRCULATIONAHA.106.653048 | s2cid = 8881388 | doi-access = free }} Bleeding risk is especially important to consider in patients with renal impairment and NOAC therapy because all NOACs, to some extent, are excreted by the kidneys.{{cite journal | vauthors = Turpie AG, Purdham D, Ciaccia A | title = Nonvitamin K antagonist oral anticoagulant use in patients with renal impairment | journal = Therapeutic Advances in Cardiovascular Disease | volume = 11 | issue = 9 | pages = 243–256 | date = September 2017 | pmid = 28651452 | pmc = 5562140 | doi = 10.1177/1753944717714921 }} Thus, patients with renal impairment may be at higher risk of increased bleeding.{{cite journal | vauthors = Weir MR, Kreutz R | title = Influence of Renal Function on the Pharmacokinetics, Pharmacodynamics, Efficacy, and Safety of Non-Vitamin K Antagonist Oral Anticoagulants | journal = Mayo Clinic Proceedings | volume = 93 | issue = 10 | pages = 1503–1519 | date = October 2018 | pmid = 30286834 | doi = 10.1016/j.mayocp.2018.06.018 | s2cid = 52922296 | doi-access = free }} [47] => [48] => In people with cancer, a systematic review has found warfarin had no effect on death rate or the risk of blood clots.{{cite journal|last1=Kahale|first1=Lara A|last2=Hakoum|first2=Maram B|last3=Tsolakian|first3=Ibrahim G|last4=Matar|first4=Charbel F|last5=Barba|first5=Maddalena|last6=Yosuico|first6=Victor ED|last7=Terrenato|first7=Irene|last8=Sperati|first8=Francesca|last9=Schünemann|first9=Holger|last10=Akl|first10=Elie A|date=2017-12-29|title=Oral anticoagulation in people with cancer who have no therapeutic or prophylactic indication for anticoagulation|journal=Cochrane Database of Systematic Reviews|volume=12|issue=12 |pages=CD006466|doi=10.1002/14651858.cd006466.pub6|issn=1465-1858|pmc=6389337|pmid=29285754}} However, it did increase the risk of major bleeding in 107 more people per 1000 population and minor bleeding in 167 more people per 1000 population. Apixaban had no effect on mortality, recurrence of blood clots in blood vessels, or major or minor bleeding. However, this finding comes only from one study. [49] => [50] => Nonhemorrhagic adverse events are less common than hemorrhagic adverse events but should still be monitored closely. Nonhemorrhagic adverse events of warfarin include skin [[necrosis]], limb gangrene, and purple toe syndrome.{{cite journal | vauthors = Ageno W, Gallus AS, Wittkowsky A, Crowther M, Hylek EM, Palareti G | title = Oral anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines | journal = Chest | volume = 141 | issue = 2 Suppl | pages = e44S–e88S | date = February 2012 | pmid = 22315269 | pmc = 3278051 | doi = 10.1378/chest.11-2292 }} Skin necrosis and limb gangrene are most commonly observed on the third to eighth day of therapy.{{cite journal | vauthors = Verhagen H | title = Local haemorrhage and necrosis of the skin and underlying tissues, during anti-coagulant therapy with dicumarol or dicumacyl | journal = Acta Medica Scandinavica | volume = 148 | issue = 6 | pages = 453–67 | date = 2009-04-24 | pmid = 13171021 | doi = 10.1111/j.0954-6820.1954.tb01741.x }}{{cite journal | vauthors = Weinberg AC, Lieskovsky G, McGehee WG, Skinner DG | title = Warfarin necrosis of the skin and subcutaneous tissue of the male external genitalia | journal = The Journal of Urology | volume = 130 | issue = 2 | pages = 352–4 | date = August 1983 | pmid = 6876290 | doi = 10.1016/S0022-5347(17)51147-7 }} The exact pathogenesis of skin necrosis and limb gangrene is not completely understood but it is believed to be associated with warfarin's effect on inhibiting the production of protein C and protein S.{{cite journal | vauthors = Broekmans AW, Bertina RM, Loeliger EA, Hofmann V, Klingemann HG | title = Protein C and the development of skin necrosis during anticoagulant therapy | journal = Thrombosis and Haemostasis | volume = 49 | issue = 3 | pages = 251 | date = June 1983 | pmid = 6688309 | doi = 10.1055/s-0038-1657378 | s2cid = 38261767 }}{{cite journal | vauthors = Grimaudo V, Gueissaz F, Hauert J, Sarraj A, Kruithof EK, Bachmann F | title = Necrosis of skin induced by coumarin in a patient deficient in protein S | journal = BMJ | volume = 298 | issue = 6668 | pages = 233–4 | date = January 1989 | pmid = 2522326 | pmc = 1835547 | doi = 10.1136/bmj.298.6668.233 }} Purple toe syndrome typically develops three to eight weeks after initiation of warfarin therapy.{{cite journal | vauthors = Talmadge DB, Spyropoulos AC | title = Purple toes syndrome associated with warfarin therapy in a patient with antiphospholipid syndrome | journal = Pharmacotherapy | volume = 23 | issue = 5 | pages = 674–7 | date = May 2003 | pmid = 12741443 | doi = 10.1592/phco.23.5.674.32200 | s2cid = 28632135 }}{{cite journal | vauthors = Raj K, Collins B, Rangarajan S | title = Purple toe syndrome following anticoagulant therapy | journal = British Journal of Haematology | volume = 114 | issue = 4 | pages = 740 | date = September 2001 | pmid = 11564060 | doi = 10.1046/j.1365-2141.2001.03107.x | s2cid = 20482173 }} Other adverse effects of warfarin are associated with depletion of vitamin K, which can lead to inhibition of G1a proteins and growth arrest-specific gene 6, which can lead to increased risk of arterial calcification and heart valve, especially if too much Vitamin D is present.{{cite journal | vauthors = Adams J, Pepping J | title = Vitamin K in the treatment and prevention of osteoporosis and arterial calcification | journal = American Journal of Health-System Pharmacy | volume = 62 | issue = 15 | pages = 1574–81 | date = August 2005 | pmid = 16030366 | doi = 10.2146/ajhp040357 | url = http://www.scicompdf.se/osteolis/adams_2005.pdf }}{{cite journal | vauthors = Danziger J | title = Vitamin K-dependent proteins, warfarin, and vascular calcification | journal = Clinical Journal of the American Society of Nephrology | volume = 3 | issue = 5 | pages = 1504–10 | date = September 2008 | pmid = 18495950 | pmc = 4571144 | doi = 10.2215/CJN.00770208 }} Warfarin's interference with G1a proteins has also been linked to abnormalities in fetal bone development in mothers who were treated with warfarin during pregnancy.{{cite journal | vauthors = Pettifor JM, Benson R | title = Congenital malformations associated with the administration of oral anticoagulants during pregnancy | journal = The Journal of Pediatrics | volume = 86 | issue = 3 | pages = 459–62 | date = March 1975 | pmid = 1113236 | doi = 10.1016/S0022-3476(75)80986-3 }}{{cite journal | vauthors = Hall JG, Pauli RM, Wilson KM | title = Maternal and fetal sequelae of anticoagulation during pregnancy | journal = The American Journal of Medicine | volume = 68 | issue = 1 | pages = 122–40 | date = January 1980 | pmid = 6985765 | doi = 10.1016/0002-9343(80)90181-3 }} Long-term warfarin and heparin usage have also been linked to osteoporosis.{{cite journal | vauthors = Gage BF, Birman-Deych E, Radford MJ, Nilasena DS, Binder EF | title = Risk of osteoporotic fracture in elderly patients taking warfarin: results from the National Registry of Atrial Fibrillation 2 | journal = Archives of Internal Medicine | volume = 166 | issue = 2 | pages = 241–6 | date = January 2006 | pmid = 16432096 | doi = 10.1001/archinte.166.2.241 | doi-access = free }} [51] => [52] => Another potentially severe complication associated with heparin use is called heparin-induced thrombocytopenia (HIT).{{cite journal | vauthors = Baroletti SA, Goldhaber SZ | title = Heparin-induced thrombocytopenia | journal = Circulation | volume = 114 | issue = 8 | pages = e355-6 | date = August 2006 | pmid = 16923760 | doi = 10.1161/CIRCULATIONAHA.106.632653 | doi-access = free }} There are two distinct types: HIT 1) immune-mediated and 2) non-immune-mediated. Immune-mediated HIT most commonly arises five to ten days after exposure to heparin.{{cite journal | vauthors = Warkentin TE, Greinacher A, Koster A, Lincoff AM | title = Treatment and prevention of heparin-induced thrombocytopenia: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition) | journal = Chest | volume = 133 | issue = 6 Suppl | pages = 340S–380S | date = June 2008 | pmid = 18574270 | doi = 10.1378/chest.08-0677 }} Pathogenesis of immune-mediated HIT is believed to be caused by heparin-dependent immunoglobulin antibodies binding to platelet factor 4/heparin complexes on platelets, leading to widespread platelet activation.{{cite journal | vauthors = Linkins LA, Hu G, Warkentin TE | title = Systematic review of fondaparinux for heparin-induced thrombocytopenia: When there are no randomized controlled trials | journal = Research and Practice in Thrombosis and Haemostasis | volume = 2 | issue = 4 | pages = 678–683 | date = October 2018 | pmid = 30349886 | pmc = 6178656 | doi = 10.1002/rth2.12145 }} [53] => [54] => == Interactions == [55] => [56] => Foods and [[food supplement]]s with blood-thinning effects include [[nattokinase]], [[lumbrokinase]], [[beer]], [[bilberry]], [[celery]], [[Cranberry|cranberries]], [[fish oil]], [[garlic]], [[ginger]], [[ginkgo]], [[ginseng]], [[green tea]], [[horse chestnut]], [[licorice]], [[Niacin (nutrient)|niacin]], [[onion]], [[papaya]], [[pomegranate]], [[red clover]], [[soybean]], [[St. John's wort]], [[turmeric]], [[wheatgrass]], and [[willow]] bark.{{cite journal | vauthors = Wittkowsky AK | title = Drug interactions update: drugs, herbs, and oral anticoagulation | journal = Journal of Thrombosis and Thrombolysis | volume = 12 | issue = 1 | pages = 67–71 | date = September 2001 | pmid = 11711691 | doi = 10.1023/A:1012742628628 | s2cid = 22447084 }}{{cite journal|last1=Rui|first1=Tian-Qi|last2=Zhang|first2=Liang|last3=Qiao|first3=Hong-Zhi|last4=Huang|first4=Ping|last5=Qian|first5=Shuai|last6=Li|first6=Jun-Song|last7=Chen|first7=Zhi-Peng|last8=Fu|first8=Ting-Ming|last9=Di|first9=Liu-Qing|last10=Cai|first10=Baochang|date=January 2016|title=Preparation and Physicochemical and Pharmacokinetic Characterization of Ginkgo Lactone Nanosuspensions for Antiplatelet Aggregation|journal=Journal of Pharmaceutical Sciences|language=en|volume=105|issue=1|pages=242–249|doi=10.1016/j.xphs.2015.10.002|pmid=26852855}}{{cite journal|last1=Yun|first1=Yeo-Pyo|last2=Do|first2=Jae-Ho|last3=Ko|first3=Sung-Ryong|last4=Ryu|first4=Shi-Yong|last5=Kim|first5=Jung-Hyo|last6=Song|first6=Ho-Cheol|last7=Park|first7=Young-Doo|last8=Ahn|first8=Kyoo-Seok|last9=Kim|first9=Sung-Hoon|date=October 2001|title=Effects of Korean red ginseng and its mixed prescription on the high molecular weight dextran-induced blood stasis in rats and human platelet aggregation|journal=Journal of Ethnopharmacology|language=en|volume=77|issue=2–3|pages=259–264|doi=10.1016/S0378-8741(01)00303-8|pmid=11535373}} Many herbal supplements have blood-thinning properties, such as [[danshen]] and [[feverfew]].{{cite journal|last1=Choi|first1=Songie|last2=Oh|first2=Dal-Seok|last3=Jerng|first3=Ui Min|date=2017-08-10|editor-last=Borrelli|editor-first=Francesca|title=A systematic review of the pharmacokinetic and pharmacodynamic interactions of herbal medicine with warfarin|journal=PLOS ONE|language=en|volume=12|issue=8|pages=e0182794|doi=10.1371/journal.pone.0182794|issn=1932-6203|pmc=5552262|pmid=28797065|bibcode=2017PLoSO..1282794C|doi-access=free}} Multivitamins that do not interact with clotting are available for patients on anticoagulants.{{cite journal|last1=Kurnik|first1=Daniel|last2=Lubetsky|first2=Aharon|last3=Loebstein|first3=Ronen|last4=Almog|first4=Shlomo|last5=Halkin|first5=Hillel|date=November 2003|title=Multivitamin Supplements May Affect Warfarin Anticoagulation in Susceptible Patients|journal=Annals of Pharmacotherapy|language=en|volume=37|issue=11|pages=1603–1606|doi=10.1345/aph.1D102|pmid=14565795|s2cid=43777757|issn=1060-0280}} [57] => [58] => However, some foods and supplements encourage clotting.{{cite journal|last1=Harder|first1=Sebastian|last2=Thürmann|first2=Petra|date=June 1996|title=Clinically Important Drug Interactions with Anticoagulants: An Update|journal=Clinical Pharmacokinetics|language=en|volume=30|issue=6|pages=416–444|doi=10.2165/00003088-199630060-00002|pmid=8792056|s2cid=22389544|issn=0312-5963}} These include [[alfalfa]], [[avocado]], [[cat's claw]], [[coenzyme Q10]], and dark leafy greens such as [[spinach]].{{cite journal|last1=Lippi|first1=Giuseppe|last2=Mattiuzzi|first2=Camilla|last3=Franchini|first3=Massimo|date=April 2016|title=Vegetables intake and venous thromboembolism: a systematic review|journal=Blood Coagulation & Fibrinolysis|language=en|volume=27|issue=3|pages=242–245|doi=10.1097/MBC.0000000000000427|pmid=27023878|s2cid=33380206|issn=0957-5235}}{{cite web|url=https://www.rxlist.com/avocado/supplements.htm|title=Avocado: Health Benefits, Uses, Side Effects, Dosage & Interactions|website=RxList|language=en|access-date=2020-01-23}} Excessive intake of the food mentioned above should be avoided while taking anticoagulants, or if coagulability is being monitored, their intake should be kept approximately constant so that anticoagulant dosage can be maintained at a level high enough to counteract this effect without fluctuations in coagulability.{{cite journal|last1=Dentali|first1=Francesco|last2=Crowther|first2=Mark|last3=Galli|first3=Matteo|last4=Pomero|first4=Fulvio|last5=Garcia|first5=David|last6=Clark|first6=Nathan|last7=Spadafora|first7=Laura|last8=Witt|first8=Daniel|last9=Ageno|first9=Walter|last10=for the WARPED Investigators|date=2016-05-27|title=Effect of Vitamin K Intake on the Stability of Treatment with Vitamin K Antagonists: A Systematic Review of the Literature|journal=Seminars in Thrombosis and Hemostasis|language=en|volume=42|issue=6|pages=671–681|doi=10.1055/s-0036-1581105|pmid=27232386|s2cid=24822900 |issn=0094-6176}}{{cite web|url=https://www.drugs.com/warfarin.html|title=Warfarin Uses, Dosage, Side Effects|website=Drugs.com|language=en|access-date=2020-01-23}} [59] => [60] => [[Grapefruit]] interferes with some anticoagulant drugs, increasing the time it takes for them to be metabolized out of the body, and should be eaten with caution when on anticoagulant drugs.{{cite journal|last1=Sullivan|first1=Dawn M.|last2=Ford|first2=Marjorie A.|last3=Boyden|first3=Thomas W.|date=1998-08-01|title=Grapefruit juice and the response to warfarin|journal=American Journal of Health-System Pharmacy|language=en|volume=55|issue=15|pages=1581–1583|doi=10.1093/ajhp/55.15.1581|pmid=9706183|issn=1079-2082}} [61] => [62] => Anticoagulants are often used to treat acute [[deep vein thrombosis|deep-vein thrombosis]].{{cite journal|last1=Di Nisio|first1=Marcello|last2=van Es|first2=Nick|last3=Büller|first3=Harry R|date=December 2016|title=Deep vein thrombosis and pulmonary embolism|journal=The Lancet|language=en|volume=388|issue=10063|pages=3060–3073|doi=10.1016/S0140-6736(16)30514-1|pmid=27375038|s2cid=25712161}}{{cite journal|last1=Koehl|first1=Jennifer L|last2=Hayes|first2=Bryan D.|last3=Al-Samkari|first3=Hanny|last4=Rosovsky|first4=Rachel|date=2020-01-23|title=A comprehensive evaluation of apixaban in the treatment of venous thromboembolism|journal=Expert Review of Hematology|volume=13|issue=2|language=en|pages=155–173|doi=10.1080/17474086.2020.1711731|pmid=31958251|s2cid=210842354|issn=1747-4086}} People using anticoagulants to treat this condition should avoid using [[bed rest]] as a complementary treatment because there are clinical benefits to continuing to walk and remaining mobile while using anticoagulants in this way.{{Citation |author1 = American Physical Therapy Association |author1-link = American Physical Therapy Association |date = 15 September 2014 |title = Five Things Physicians and Patients Should Question |publisher = American Physical Therapy Association |work = [[Choosing Wisely]]: an initiative of the [[ABIM Foundation]] |url = http://www.choosingwisely.org/doctor-patient-lists/american-physical-therapy-association/ |access-date = 15 September 2014}}, which cites [63] => * {{cite journal | vauthors = Aissaoui N, Martins E, Mouly S, Weber S, Meune C | title = A meta-analysis of bed rest versus early ambulation in the management of pulmonary embolism, deep vein thrombosis, or both | journal = International Journal of Cardiology | volume = 137 | issue = 1 | pages = 37–41 | date = September 2009 | pmid = 18691773 | doi = 10.1016/j.ijcard.2008.06.020 }} [64] => * {{cite journal | vauthors = Anderson CM, Overend TJ, Godwin J, Sealy C, Sunderji A | title = Ambulation after deep vein thrombosis: a systematic review | journal = Physiotherapy Canada | volume = 61 | issue = 3 | pages = 133–40 | year = 2009 | pmid = 20514175 | pmc = 2787576 | doi = 10.3138/physio.61.3.133 }} Bed rest while using anticoagulants can harm patients in circumstances in which it is not medically necessary. [65] => [66] => ==Types== [67] => Several anticoagulants are available. Warfarin, other coumarins, and heparins have long been used.{{cite journal|last1=Di Minno|first1=Alessandro|last2=Frigerio|first2=Beatrice|last3=Spadarella|first3=Gaia|last4=Ravani|first4=Alessio|last5=Sansaro|first5=Daniela|last6=Amato|first6=Mauro|last7=Kitzmiller|first7=Joseph P.|last8=Pepi|first8=Mauro|last9=Tremoli|first9=Elena|last10=Baldassarre|first10=Damiano|date=July 2017|title=Old and new oral anticoagulants: Food, herbal medicines and drug interactions|journal=Blood Reviews|language=en|volume=31|issue=4|pages=193–203|doi=10.1016/j.blre.2017.02.001|pmid=28196633|doi-access=free|hdl=2434/476466|hdl-access=free}} Since the 2000s, several agents have been introduced that are collectively referred to as '''direct oral anticoagulants''' ('''DOACs'''), previously named '''novel oral anticoagulants''' ('''NOACs''') or '''non-vitamin K antagonist oral anticoagulants'''.{{cite journal|last1=Almarshad|first1=Feras|last2=Alaklabi|first2=Ali|last3=Bakhsh|first3=Ebtisam|last4=Pathan|first4=Aslam|last5=Almegren|first5=Mosaad|date=December 2018|title=Use of direct oral anticoagulants in daily practice|journal=American Journal of Blood Research|language=en|volume=8|issue=4|pages=57–72|pmid=30697449|pmc=6334188 }}{{cite journal|last1=Verdecchia|first1=Paolo|last2=Angeli|first2=Fabio|last3=Aita|first3=Adolfo|last4=Bartolini|first4=Claudia|last5=Reboldi|first5=Gianpaolo|date=April 2016|title=Why switch from warfarin to NOACs?|journal=Internal and Emergency Medicine|language=en|volume=11|issue=3|pages=289–293|doi=10.1007/s11739-016-1411-0|pmid=26972708|s2cid=25807727|issn=1828-0447}}{{cite journal|last1=Diener|first1=Hans-Christoph|last2=Ntaios|first2=George|last3=O'Donnell|first3=Martin|last4=Easton|first4=J. Donald|date=2018-09-22|title=Non-vitamin-K oral anticoagulants (NOACs) for the prevention of secondary stroke|journal=Expert Opinion on Pharmacotherapy|language=en|volume=19|issue=14|pages=1597–1602|doi=10.1080/14656566.2018.1515913|pmid=30152249|s2cid=52099757|issn=1465-6566}}{{cite journal|last1=Pol|first1=Derk|last2=Curtis|first2=Claire|last3=Ramkumar|first3=Satish|last4=Bittinger|first4=Logan|date=April 2019|title=NOACs Now Mainstream for the Use of Anticoagulation in Non-Valvular Atrial Fibrillation in Australia|journal=Heart, Lung and Circulation|language=en|volume=28|issue=4|pages=e40–e42|doi=10.1016/j.hlc.2018.03.010|pmid=29861320|s2cid=44103560}} These agents include direct thrombin inhibitor ([[dabigatran]]) and factor Xa inhibitor ([[rivaroxaban]], [[apixaban]], [[betrixaban]] and [[edoxaban]]), and they have been shown to be as good or possibly better than the coumarins with less serious side effects.{{cite journal | vauthors = Werdan K, Braun-Dullaeus R, Presek P | title = Anticoagulation in atrial fibrillation: NOAC's the word | journal = Deutsches Ärzteblatt International | volume = 110 | issue = 31–32 | pages = 523–4 | date = August 2013 | pmid = 24069072 | pmc = 3782018 | doi = 10.3238/arztebl.2013.0523 | quote = Things have changed dramatically with the introduction of the new oral anticoagulants (NOACs) — dabigatran, a factor IIa (thrombin) inhibitor, and the factor Xa inhibitors rivaroxaban and apixaban. Clinical trials have shown them therapeutically superior, or at least non-inferior, to VKAs, with less serious side effects. }} The newer anticoagulants (NOACs/DOACs) are more expensive than the traditional ones and should be used in caring for patients with kidney problems.{{cite journal|last1=Heine|first1=Gunnar H.|last2=Brandenburg|first2=Vincent|last3=Schirmer|first3=Stephan H.|date=2018-04-27|title=Orale Antikoagulation bei chronischer Nierenerkrankung und Vorhofflimmern|journal=Deutsches Ärzteblatt Online|volume=115|issue=17|pages=287–294|doi=10.3238/arztebl.2018.0287|issn=1866-0452|pmc=5974258|pmid=29789105}} [68] => [69] => ===Coumarins (vitamin K antagonists)=== [70] => {{Further|Vitamin K antagonist}} [71] => These oral anticoagulants are derived from [[coumarin]] found in many plants. A prominent member of this class, [[warfarin]] (Coumadin), was found to be the anticoagulant most prescribed in a large multispecialty practice.{{Cite journal |vauthors=Efird LE, Chasler J, Alexander GC, McGuire M |date=Jun 21, 2016 |title=Prescribing Patterns of Novel Anticoagulants Within a Statewide Multispecialty Practice |url=https://www.pharmacytimes.com/view/prescribing-patterns-of-novel-anticoagulants-within-a-statewide-multispecialty-practice |journal=American Journal of Pharmacy Benefits |volume=8 |issue=3 |pages=97–102}} The anticoagulant effect takes at least 48 to 72 hours to develop. Where an immediate effect is required, [[heparin]] is given concomitantly. These anticoagulants are used to treat patients with [[deep-vein thrombosis]] (DVT) and [[pulmonary embolism]] (PE) and to prevent emboli in patients with [[atrial fibrillation]] (AF), and mechanical [[prosthetic heart valve]]s. Other examples are [[acenocoumarol]], [[phenprocoumon]], [[atromentin]], and [[phenindione]].{{citation needed|date=November 2021}} [72] => [73] => The coumarins [[brodifacoum]] and [[difenacoum]] are used as mammalicides (particularly as [[rodenticide]]s) but are not used medically.{{citation needed|date=August 2022}} [74] => [75] => ===Heparin and derivative substances=== [76] => Heparin is the most widely used intravenous clinical anticoagulant worldwide.{{cite journal | vauthors = Linhardt RJ | title = 2003 Claude S. Hudson Award address in carbohydrate chemistry. Heparin: structure and activity | journal = Journal of Medicinal Chemistry | volume = 46 | issue = 13 | pages = 2551–64 | date = June 2003 | pmid = 12801218 | doi = 10.1021/jm030176m }} [[Heparin]] is a naturally occurring [[glycosaminoglycan]]. There are three major categories of heparin: unfractionated heparin (UFH), low molecular weight heparin (LMWH), and ultra-low-molecular weight heparin (ULMWH).{{cite journal | vauthors = Onishi A, St Ange K, Dordick JS, Linhardt RJ | title = Heparin and anticoagulation | journal = Frontiers in Bioscience | volume = 21 | issue = 7 | pages = 1372–92 | date = June 2016 | pmid = 27100512 | doi = 10.2741/4462 }} Unfractionated heparin is usually derived from [[pig]] intestines and bovine lungs.{{cite journal | vauthors = Casu B, Naggi A, Torri G | title = Re-visiting the structure of heparin | journal = Carbohydrate Research | volume = 403 | pages = 60–8 | date = February 2015 | pmid = 25088334 | doi = 10.1016/j.carres.2014.06.023 }} UFH binds to the enzyme inhibitor [[antithrombin]] III (AT), causing a conformational change that results in its activation.{{cite journal | vauthors = Seo Y, Andaya A, Leary JA | title = Preparation, separation, and conformational analysis of differentially sulfated heparin octasaccharide isomers using ion mobility mass spectrometry | journal = Analytical Chemistry | volume = 84 | issue = 5 | pages = 2416–23 | date = March 2012 | pmid = 22283665 | pmc = 3296823 | doi = 10.1021/ac203190k }} The activated AT then inactivates [[factor Xa]], [[thrombin]], and other coagulation factors.{{cite journal | vauthors = Allingstrup M, Wetterslev J, Ravn FB, Møller AM, Afshari A | title = Antithrombin III for critically ill patients: a systematic review with meta-analysis and trial sequential analysis | journal = Intensive Care Medicine | volume = 42 | issue = 4 | pages = 505–520 | date = April 2016 | pmid = 26862016 | pmc = 2137061 | doi = 10.1007/s00134-016-4225-7 }} Heparin can be used ''[[in vivo]]'' (by injection), and also ''[[in vitro]]'' to prevent blood or plasma clotting in or on medical devices. In [[venipuncture]], [[Vacutainer]] brand blood collecting tubes containing heparin usually have a green cap.{{citation needed|date=November 2021}} [77] => [78] => ====Low molecular weight heparin (LMWH)==== [79] => [[Low molecular weight heparin]] (LMWH) is produced through a controlled depolymerization of unfractionated heparin. LMWH exhibits a higher anti-Xa/anti-IIa activity ratio and is useful as it does not require monitoring of the [[APTT]] [[coagulation]] parameter and has fewer side effects. [80] => [81] => ===Synthetic pentasaccharide inhibitors of factor Xa=== [82] => * [[Fondaparinux]] is a synthetic sugar composed of the five sugars (pentasaccharides) in heparin that bind to antithrombin. It is a smaller molecule than low molecular-weight heparin. [83] => * [[Idraparinux]] [84] => * [[Idrabiotaparinux]] [85] => [86] => === Direct oral === [87] => The direct oral anticoagulants (DOACs) were introduced in and after 2008.{{cite journal|date=2019-07-16|title=Human medicines European public assessment report (EPAR): Pradaxa, dabigatran etexilate, Arthroplasty, Replacement,Venous Thromboembolism, Date of authorisation: 17/03/2008, Revision: 29, Status: Authorised|journal=Case Medical Research|doi=10.31525/cmr-1321569|s2cid=241319098|issn=2643-4652}} There are five DOACs currently on the market: [[dabigatran]], [[rivaroxaban]], [[apixaban]], [[edoxaban]] and [[betrixaban]].{{cite journal | vauthors = Douxfils J, Ageno W, Samama CM, Lessire S, Ten Cate H, Verhamme P, Dogné JM, Mullier F | title = Laboratory testing in patients treated with direct oral anticoagulants: a practical guide for clinicians | journal = Journal of Thrombosis and Haemostasis | volume = 16 | issue = 2 | pages = 209–219 | date = February 2018 | pmid = 29193737 | doi = 10.1111/jth.13912 | s2cid = 46865986 | url = https://lirias.kuleuven.be/handle/123456789/611680 | doi-access = free }} They were also previously referred to as "new/novel" and "non-vitamin K antagonist" oral anticoagulants (NOACs).{{cite journal | vauthors = Udayachalerm S, Rattanasiri S, Angkananard T, Attia J, Sansanayudh N, Thakkinstian A | title = The Reversal of Bleeding Caused by New Oral Anticoagulants (NOACs): A Systematic Review and Meta-Analysis | journal = Clinical and Applied Thrombosis/Hemostasis | volume = 24 | issue = 9_suppl | pages = 117S–126S | date = September 2018 | pmid = 30176738 | pmc = 6714855 | doi = 10.1177/1076029618796339 }} [88] => [89] => Compared to warfarin, DOACs have a rapid onset action and relatively short half-lives; hence, they carry out their function more rapidly and effectively, allowing drugs to reduce their anticoagulation effects quickly.{{cite web |url=http://www.sdcep.org.uk/wp-content/uploads/2015/09/SDCEP-Anticoagulants-Guidance.pdf |title=Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs |date=August 2015 |publisher=Scottish Dental Clinical Effectiveness Programme |access-date=2016-03-09 |archive-date=2017-03-28 |archive-url=https://web.archive.org/web/20170328223906/http://www.sdcep.org.uk/wp-content/uploads/2015/09/SDCEP-Anticoagulants-Guidance.pdf |url-status=dead }} Routine monitoring and dose adjustments of DOACs are less important than for warfarin, as they have better predictable anticoagulation activity. DOAC monitoring, including laboratory monitoring and a complete medication review, should generally be conducted before initiation of a DOAC, 1–3 months after initiation, and then every 6–12 months afterwards.{{cite journal|last1=Chen|first1=Ashley|last2=Stecker|first2=Eric|last3=A. Warden|first3=Bruce|date=2020-06-15|title=Direct Oral Anticoagulant Use: A Practical Guide to Common Clinical Challenges|journal=Journal of the American Heart Association: Cardiovascular and Cerebrovascular Disease|volume=9|issue=13|pages=e017559|doi=10.1161/JAHA.120.017559|issn=2047-9980|pmc=7670541|pmid=32538234}} [90] => [91] => Both DOACs and warfarin are equivalently effective, but compared to warfarin, DOACs have fewer drug interactions, no known dietary interactions, a wider therapeutic index, and have conventional dosing that does not require dose adjustments with constant monitoring.{{cite web | url = https://www.bhf.org.uk/heart-matters-magazine/medical/drug-cabinet/novel-anticoagulants | title = Novel anticoagulants | work = Heart Matters Magazine | publisher = British Heart Foundation | access-date = 2016-03-09 | archive-date = 2017-10-26 | archive-url = https://web.archive.org/web/20171026222846/https://www.bhf.org.uk/heart-matters-magazine/medical/drug-cabinet/novel-anticoagulants | url-status = dead }}{{cite journal | vauthors = Clark NP | title = Role of the anticoagulant monitoring service in 2018: beyond warfarin | journal = Hematology. American Society of Hematology. Education Program | volume = 2018 | issue = 1 | pages = 348–352 | date = November 2018 | pmid = 30504331 | pmc = 6246023 | doi = 10.1182/asheducation-2018.1.348 }} However, there is no countermeasure for most DOACs, unlike for warfarin; nonetheless, the short half-lives of DOACs will allow their effects to recede swiftly. A reversal agent for dabigatran, [[idarucizumab]], is currently available and approved for use by the FDA. Rates of adherence to DOACs are only modestly higher than adherence to warfarin among patients prescribed these drugs. Thus, adherence to anticoagulation is often poor despite hopes that DOACs would lead to higher adherence rates.{{cite journal|last1=Ozaki|first1=Aya F.|last2=Choi|first2=Austin S.|last3=Le|first3=Quan T.|last4=Ko|first4=Dennis T.|last5=Han|first5=Janet K.|last6=Park|first6=Sandy S.|last7=Jackevicius|first7=Cynthia A.|date=2020|title=Real-World Adherence and Persistence to Direct Oral Anticoagulants in Patients With Atrial Fibrillation: A Systematic Review and Meta-Analysis|journal=Circulation: Cardiovascular Quality and Outcomes|volume=13|issue=3|pages=e005969|doi=10.1161/CIRCOUTCOMES.119.005969|issn=1941-7705|pmid=32148102|s2cid=212640015|doi-access=free}} [92] => [93] => DOACs are significantly more expensive than warfarin, but the patients on DOACs may experience reduced lab costs as they do not need to monitor their INR. [94] => [95] => ====Direct factor Xa inhibitors==== [96] => {{main|Direct Xa inhibitor}} [97] => Drugs such as [[rivaroxaban]], [[apixaban]] and [[edoxaban]] work by inhibiting factor Xa directly (unlike heparins and fondaparinux, which work via antithrombin activation). [98] => Also included in this category are [[betrixaban]] from Portola Pharmaceuticals, the discontinued [[darexaban]] (YM150) from Astellas, and, more recently, the discontinued [[letaxaban]] (TAK-442) from Takeda and [[eribaxaban]] (PD0348292) from Pfizer. [99] => Betrixaban is significant as it was in 2018, the only oral factor Xa inhibitor approved by the FDA for use in acutely medically ill patients.{{cite journal | vauthors = Lekura J, Kalus JS | title = Overview of betrixaban and its role in clinical practice | journal = American Journal of Health-System Pharmacy | volume = 75 | issue = 15 | pages = 1095–1102 | date = August 2018 | pmid = 29941506 | doi = 10.2146/ajhp170785 | s2cid = 49418996 }} Darexaban development was discontinued in September 2011; in a trial for prevention of recurrences of myocardial infarction in addition to dual antiplatelet therapy (DAPT), the drug did not demonstrate effectiveness, and the risk of bleeding was increased by approximately 300%.{{cite journal | vauthors = Steg PG, Mehta SR, Jukema JW, Lip GY, Gibson CM, Kovar F, Kala P, Garcia-Hernandez A, Renfurm RW, Granger CB | title = RUBY-1: a randomized, double-blind, placebo-controlled trial of the safety and tolerability of the novel oral factor Xa inhibitor darexaban (YM150) following acute coronary syndrome | journal = European Heart Journal | volume = 32 | issue = 20 | pages = 2541–54 | date = October 2011 | pmid = 21878434 | pmc = 3295208 | doi = 10.1093/eurheartj/ehr334 }} The development of letaxaban for acute coronary syndrome was discontinued in May 2011 following negative results from a Phase II study.{{cite web | first1 = Joseph | last1 = Dwyer | first2 = Conor | last2 = Walsh | title = First Time European Approval for Xarelto in ACS | publisher = Decision Resources | date = May 2013 | url = http://decisionresources.com/The-Decision-Resources-Blog/May-2013/European-Approval-for-Xarelto-in-ACS-052913 | archive-url = https://web.archive.org/web/20140719173801/http://decisionresources.com/The-Decision-Resources-Blog/May-2013/European-Approval-for-Xarelto-in-ACS-052913 | archive-date=2014-07-19 }} [100] => [101] => ====Direct thrombin inhibitors==== [102] => {{main|Direct thrombin inhibitor}} [103] => Another type of anticoagulant is the [[direct thrombin inhibitor]].{{cite journal | vauthors = Di Nisio M, Middeldorp S, Büller HR | title = Direct thrombin inhibitors | journal = The New England Journal of Medicine | volume = 353 | issue = 10 | pages = 1028–40 | date = September 2005 | pmid = 16148288 | doi = 10.1056/NEJMra044440 | url = https://pure.uva.nl/ws/files/4020551/45334_205943y.pdf }} Current members of this class include the bivalent drugs [[hirudin]], [[lepirudin]], and [[bivalirudin]] and the monovalent drugs [[argatroban]] and [[dabigatran]]. An oral direct thrombin inhibitor, [[ximelagatran]] (Exanta), was denied approval by the [[Food and Drug Administration]] (FDA) in September 2004{{cite web | title = Exanta | work = Ask Dr. Stephan Moll | publisher = The Thrombophilia Awareness Project | url = http://www.fvleiden.org/ask/73.html | archive-url = https://web.archive.org/web/20110525194419/http://www.fvleiden.org/ask/73.html | archive-date = 25 May 2011 }} and was pulled from the market entirely in February 2006 after reports of severe liver damage and heart attacks.{{cite web | title = Exanta™ (ximelagatran) Study report summaries | url = http://www.astrazenecaclinicaltrials.com/article/512052.aspx | archive-url = https://archive.today/20060318061448/http://www.astrazenecaclinicaltrials.com/article/512052.aspx | url-status = dead | archive-date = 2006-03-18 | work = AstraZeneca Clinical Trials }} In November 2010, [[dabigatran Etexilate|dabigatran etexilate]] was approved by the FDA to prevent thrombosis in [[atrial fibrillation]]. [104] => [105] => ==== Relevance to dental treatments ==== [106] => As in any invasive procedure, patients on anticoagulation therapy have an increased risk for bleeding, and caution should be used along with local [[hemostasis|hemostatic]] methods to minimize bleeding risk during the operation as well as postoperatively.{{cite journal | vauthors = Manfredi M, Dave B, Percudani D, Christoforou J, Karasneh J, Diz Dios P, Glick M, Kumar N, Lockhart PB, Patton LL | title = World workshop on oral medicine VII: Direct anticoagulant agents management for invasive oral procedures: A systematic review and meta-analysis | journal = Oral Diseases | volume = 25 | issue = S1 | pages = 157–173 | date = June 2019 | pmid = 31140701 | doi = 10.1111/odi.13086 | s2cid = 169034257 }} However, with regards to DOACs and invasive dental treatments, there has not been enough clinical evidence and experience to prove any reliable adverse effects, relevance or interaction between these two.{{cite journal | vauthors = Bensi C, Belli S, Paradiso D, Lomurno G | title = Postoperative bleeding risk of direct oral anticoagulants after oral surgery procedures: a systematic review and meta-analysis | journal = International Journal of Oral and Maxillofacial Surgery | volume = 47 | issue = 7 | pages = 923–932 | date = July 2018 | pmid = 29627150 | doi = 10.1016/j.ijom.2018.03.016 | s2cid = 4697607 }} Further clinical prospective studies on DOACs are required to investigate the bleeding risk and hemostasis associated with surgical and dental procedures.{{cite journal | vauthors = Costantinides F, Rizzo R, Pascazio L, Maglione M | title = Managing patients taking novel oral anticoagulants (NOAs) in dentistry: a discussion paper on clinical implications | journal = BMC Oral Health | volume = 16 | pages = 5 | date = January 2016 | pmid = 26822674 | pmc = 4731944 | doi = 10.1186/s12903-016-0170-7 | doi-access = free }} [107] => [108] => Recommendations of modifications to the usage/dosage of DOACs before dental treatments are made based on the balance of the bleeding risk of each procedure and also the individual's own bleeding risks and renal functionality.{{cite journal | vauthors = Kosyfaki P, Att W, Strub JR | title = The dental patient on oral anticoagulant medication: a literature review | journal = Journal of Oral Rehabilitation | volume = 38 | issue = 8 | pages = 615–33 | date = August 2011 | pmid = 21073495 | doi = 10.1111/j.1365-2842.2010.02184.x }} With low-bleeding-risk dental procedures, it is recommended that DOACs be continued by the patient to avoid any increase in the risk of a thromboembolic event.{{cite journal | vauthors = van Diermen DE, van der Waal I, Hoogstraten J | title = Management recommendations for invasive dental treatment in patients using oral antithrombotic medication, including novel oral anticoagulants | journal = Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology | volume = 116 | issue = 6 | pages = 709–16 | date = December 2013 | pmid = 24120910 | doi = 10.1016/j.oooo.2013.07.026 }}{{cite journal | vauthors = Shi Q, Xu J, Zhang T, Zhang B, Liu H | title = Post-operative Bleeding Risk in Dental Surgery for Patients on Oral Anticoagulant Therapy: A Meta-analysis of Observational Studies | journal = Frontiers in Pharmacology | volume = 8 | pages = 58 | date = 2017-02-08 | pmid = 28228727 | pmc = 5296357 | doi = 10.3389/fphar.2017.00058 | doi-access = free }} For dental procedures with a higher risk of bleeding complications (i.e. complex extractions, adjacent extractions leading to a large wound, or more than three extractions), the recommended practice is for the patient to miss or delay a dose of their DOAC before such procedures to minimize the effect on bleeding risk.{{cite web|url=https://www.sdcep.org.uk/wp-content/uploads/2015/09/SDCEP-Anticoagulants-Guidance.pdf|title=Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs: Dental Clinical Guidance|website=Scottish Dental Clinical Effectiveness Programme|access-date=2020-01-09|archive-date=2017-03-28|archive-url=https://web.archive.org/web/20170328223906/http://www.sdcep.org.uk/wp-content/uploads/2015/09/SDCEP-Anticoagulants-Guidance.pdf|url-status=dead}} [109] => [110] => ===Antithrombin protein therapeutics=== [111] => The antithrombin protein is used as a [[Biologic medical product|protein therapeutic]] that can be purified from human plasma{{cite web|url=http://www.talecris-pi.info/inserts/thrombate.pdf|title=Thrombate III label|url-status=dead|archive-url=https://web.archive.org/web/20121115050430/http://www.talecris-pi.info/inserts/thrombate.pdf|archive-date=2012-11-15}} or produced recombinantly (for example, Atryn, produced in the milk of [[Genetic engineering|genetically modified]] goats).{{cite web|url=https://www.fda.gov/BiologicsBloodVaccines/BloodBloodProducts/ApprovedProducts/LicensedProductsBLAs/FractionatedPlasmaProducts/ucm134042.htm|title=Fractionated Plasma Products - ATryn| author = Center for Biologics Evaluation and Research|website=www.fda.gov|date=24 April 2019}}{{cite web|url=https://www.fda.gov/downloads/BiologicsBloodVaccines/BloodBloodProducts/ApprovedProducts/LicensedProductsBLAs/FractionatedPlasmaProducts/UCM134045.pdf|title=Antithrombin (Recombinant) US Package Insert ATryn for Injection February 3, 2009|website=[[Food and Drug Administration]]}} [112] => [113] => The FDA approves Antithrombin as an anticoagulant for preventing clots before, during, or after surgery or birthing in patients with hereditary antithrombin deficiency. [114] => [115] => ===Other=== [116] => Many other anticoagulants exist in [[research and development]], [[diagnostics]], or as drug candidates. [117] => * [[Batroxobin]], a [[toxin]] from [[snake]] [[venom]], clots platelet-rich plasma without affecting [[platelet]] functions (cleaves [[fibrinogen]]). [118] => * [[Hementin]] is an anticoagulant protease from the salivary glands of the giant Amazon leech, ''[[Haementeria ghilianii]]''. [119] => * [[Vitamin E]] [120] => * [[Alcoholic beverage]] [121] => [122] => [123] => ==Reversal agents== [124] => [125] => With the growing number of patients taking oral anticoagulation therapy, studies into reversal agents are gaining increasing interest due to major bleeding events and the need for urgent anticoagulant reversal therapy.{{cite journal|last1=Tornkvist |first1= Max|last2=Smith|first2=J. Gustav|last3=Labaf|first3=Ashkan|date=February 2018|title=Current evidence of oral anticoagulant reversal: A systematic review|journal=Thrombosis Research|language=en|volume=162|pages=22–31|doi= 10.1016/j.thromres.2017.12.003 |pmid=29258056}} Reversal agents for warfarin are more widely studied, and established guidelines for reversal exist due to a longer history of use of warfarin and the ability to get a more accurate measurement of anticoagulation effect in a patient via measuring the INR (International Normalized Ratio).{{cite journal|last=Hanley|first=J P|date=2004-11-01|title=Warfarin reversal|journal=Journal of Clinical Pathology|language=en|volume=57|issue=11|pages=1132–1139|doi=10.1136/jcp.2003.008904|issn=0021-9746|pmc=1770479|pmid=15509671}} In general, vitamin K is most commonly used to reverse the effect of warfarin in non-urgent settings.{{cite journal|last1=Makris|first1=M.|last2=Greaves|first2=M.|last3=Phillips|first3=W. S.|last4=Kitchen|first4=S.|last5=Rosendaal|first5=F. R.|last6=Preston|first6=E. F.|date=March 1997|title=Emergency oral anticoagulant reversal: the relative efficacy of infusions of fresh frozen plasma and clotting factor concentrate on correction of the coagulopathy|journal=Thrombosis and Haemostasis|volume=77|issue=3|pages=477–480|issn=0340-6245|pmid=9065997|doi=10.1055/s-0038-1655992|s2cid=45458169 }} However, in urgent settings or settings with extremely high INR (INR >20), hemostatic reversal agents such as fresh frozen plasma (FFP), [[recombinant factor VIIa]], and prothrombin complex concentrate (PCC) have been utilized with proven efficacy.{{cite journal|last1=Chai-Adisaksopha|first1=Chatree|last2=Hillis|first2=Christopher|last3=Siegal|first3=Deborah M.|last4=Movilla|first4=Ron|last5=Heddle|first5=Nancy|last6=Iorio|first6=Alfonso|last7=Crowther|first7=Mark|date=September 2016|title=Prothrombin complex concentrates versus fresh frozen plasma for warfarin reversal A systematic review and meta-analysis|journal=Thrombosis and Haemostasis|language=en|volume=116|issue=11|pages=879–890|doi=10.1160/TH16-04-0266|pmid=27488143|s2cid=4733615 |issn=0340-6245}} Specifically with warfarin, four-factor PCC (4F-PCC) has been shown to have superior safety and mortality benefits compared to FPP in lowering INR levels. [126] => [127] => Although specific antidotes and reversal agents for DOACs are not as widely studied, [[idarucizumab]] (for dabigatran) and [[andexanet alfa]] (for factor Xa inhibitor) have been used in clinical settings with varying efficacy. Idarucizumab is a monoclonal antibody, approved by the US FDA in 2015, that reverses the effect of dabigatran by binding to both free and thrombin-bound dabigatran.{{cite journal|last=Pakraftar|first=Sam|date=2014|title=Dabigatran etixilate and traumatic brain injury: Evolving anticoagulants require evolving care plans|journal=World Journal of Clinical Cases|language=en|volume=2|issue= 8|pages= 362–6 |doi=10.12998/wjcc.v2.i8.362|issn=2307-8960|pmc=4133427|pmid=25133148 |doi-access=free }}{{cite journal|last1=Ryn|first1=Joanne van |last2=Stangier|first2=Joachim|last3=Haertter|first3=Sebastian|last4=Liesenfeld|first4=Karl-Heinz|last5=Wienen|first5=Wolfgang |last6=Feuring|first6=Martin|last7=Clemens|first7=Andreas|date=2010|title=Dabigatran etexilate – a novel, reversible, oral direct thrombin inhibitor: Interpretation of coagulation assays and reversal of anticoagulant activity|journal=Thrombosis and Haemostasis |language=en|volume=103|issue=6|pages=1116–1127|doi=10.1160/TH09-11-0758|pmid=20352166|s2cid=37404563 |issn=0340-6245}} Andexanet alfa is a recombinant modified human factor Xa decoy that reverses the effect of factor Xa inhibitors by binding at the active sites of factor Xa inhibitor and making it catalytically inactive.{{cite journal|last1=Siegal|first1=Deborah M.|last2=Curnutte|first2=John T.|last3= Connolly|first3=Stuart J.|last4=Lu|first4=Genmin|last5=Conley|first5=Pamela B.|last6=Wiens|first6=Brian L.|last7=Mathur|first7=Vandana S.|last8=Castillo|first8=Janice|last9=Bronson|first9=Michele D.|last10=Leeds|first10=Janet M.|last11=Mar|first11=Florie A.|date= 2015-12-17|title=Andexanet Alfa for the Reversal of Factor Xa Inhibitor Activity|journal=New England Journal of Medicine|language=en |volume=373|issue=25|pages=2413–2424|doi=10.1056/NEJMoa1510991|pmid=26559317|issn=0028-4793|doi-access=free}}{{cite journal|last1=Connolly |first1=Stuart J.|last2=Milling|first2=Truman J.|last3=Eikelboom|first3=John W.|last4=Gibson|first4=C. Michael|last5=Curnutte|first5=John T.|last6=Gold|first6=Alex|last7=Bronson|first7=Michele D.|last8=Lu|first8=Genmin|last9=Conley|first9=Pamela B.|last10=Verhamme|first10= Peter|last11=Schmidt|first11=Jeannot|date=2016-09-22|title=Andexanet Alfa for Acute Major Bleeding Associated with Factor Xa Inhibitors |journal=New England Journal of Medicine|language=en|volume=375 |issue=12|pages=1131–1141|doi=10.1056/NEJMoa1607887|issn=0028-4793 |pmc=5568772|pmid=27573206}} Andexanet alfa was approved by the US FDA in 2018.{{Citation|last1=Reed|first1=Mirembe|title= Andexanet Alfa |url= http://www.ncbi.nlm.nih.gov/books/NBK519499/|work=StatPearls|publisher=StatPearls Publishing|pmid=30137783|access-date=2020-01-23|last2=Tadi|first2=Prasanna|last3=Nicolas|first3=Diala|year=2020}} Another drug called ciraparantag, a potential reversal agent for direct factor Xa inhibitors, is still under investigation.{{cite journal|last1=Ansell|first1=Jack E.|last2= Bakhru|first2=Sasha H.|last3=Laulicht|first3=Bryan E.|last4=Steiner|first4=Solomon S.|last5=Grosso|first5=Michael A.|last6=Brown |first6=Karen|last7=Dishy|first7=Victor|last8=Lanz|first8=Hans J.|last9=Mercuri|first9=Michele F.|last10=Noveck|first10=Robert J.|last11=Costin|first11=James C.|date=February 2017|title=Single-dose ciraparantag safely and completely reverses anticoagulant effects of edoxaban|journal=Thrombosis and Haemostasis|language=en|volume=117 |issue=2|pages=238–245|doi=10.1160/TH16-03-0224|issn=0340-6245|pmc= 6260118 |pmid=27853809}} Additionally, hemostatic reversal agents have also been used with varying efficacy to reverse the effects of DOACs.{{cite journal|last1=Eerenberg|first1=Elise S.|last2=Kamphuisen|first2=Pieter W.|last3=Sijpkens|first3=Meertien K.|last4= Meijers |first4=Joost C.|last5=Buller|first5=Harry R.|last6=Levi|first6=Marcel|date=2011-10-04|title=Reversal of Rivaroxaban and Dabigatran by Prothrombin Complex Concentrate: A Randomized, Placebo-Controlled, Crossover Study in Healthy Subjects|journal=Circulation |language=en|volume=124|issue=14|pages=1573–1579|doi=10.1161/CIRCULATIONAHA.111.029017|pmid=21900088|s2cid=961167|issn=0009-7322|doi-access=free}}{{cite journal|last1= Marlu|first1=Raphael|last2= Hodaj|first2=Enkelejda|last3=Paris|first3=Adeline|last4= Albaladejo|first4=Pierre |last5= Crackowski|first5=Jean|last6=Pernod|first6=Gilles|date=2012|title=Effect of non-specific reversal agents on anticoagulant activity of dabigatran and rivaroxaban: A randomised crossover ex vivo study in healthy volunteers|journal=Thrombosis and Haemostasis|language=en|volume=108|issue=8|pages=217–224|doi=10.1160/TH12-03-0179|pmid=22627883|s2cid=28694620 |issn=0340-6245}} [128] => [129] => ==Coagulation inhibitor measurement== [130] => A '''Bethesda unit''' ('''BU''') is a measure of blood [[coagulation inhibitor]] activity. It is the amount of inhibitor that will inactivate half of a [[coagulation|coagulant]] during the incubation period.{{cite web |url=http://www.biology-online.org/dictionary/Bethesda_unit |title=Bethesda unit |work=Biology Online |access-date=2009-02-14 }} It is the standard measure used in the United States and is so named because it was adopted as a standard at a conference in [[Bethesda, Maryland]].{{cite book |title=Handbook of Hematologic Pathology |last=Schumacher |first=Harold Robert |year=2000 |publisher=[[Informa Health Care]] |isbn=978-0-8247-0170-3 |page=583 }} [131] => [132] => ==Laboratory use== [133] => If blood is allowed to clot, [[Medical laboratory|laboratory]] instruments, blood transfusion bags, and medical and surgical equipment will get clogged up and non-operational. In addition, test tubes used for laboratory blood tests will have chemicals added to stop blood clotting. Besides heparin, most of these chemicals [[chelation|bind]] [[calcium]] ions, preventing the coagulation proteins from using them. [134] => * [[Ethylenediaminetetraacetic acid]] (EDTA) strongly and irreversibly chelates (binds) calcium ions, preventing blood from clotting. [135] => * [[Citrate]] is in liquid form in the tube and is used for coagulation tests and blood transfusion bags. It binds calcium but not as strongly as EDTA. The correct proportion of this anticoagulant to blood is crucial because of the dilution, which can be reversed with the addition of calcium. Formulations include plain [[Monosodium citrate|sodium citrate]], [[acid-citrate-dextrose]], and more. [136] => * [[Oxalate]] has a mechanism similar to that of citrate. It is the anticoagulant used in fluoride/oxalate tubes to determine glucose and lactate levels. The fluoride inhibits [[glycolysis]], which can throw off blood sugar measurements. Citrate/fluoride/EDTA tubes work better in this regard.{{cite journal |last1=Norman |first1=Mikaela |last2=Jones |first2=Ian |title=The shift from fluoride/oxalate to acid citrate/fluoride blood collection tubes for glucose testing — The impact upon patient results |journal=Clinical Biochemistry |date=May 2014 |volume=47 |issue=7–8 |pages=683–685 |doi=10.1016/j.clinbiochem.2014.01.011|pmid=24463230 }} [137] => [138] => ==Dental considerations for long-term users== [139] => Dental practitioners play an important role in the early detection of anticoagulant overdose through oral manifestations, as the patient does not show any symptoms. Dental treatment of patients taking anticoagulant or antiplatelet medication raises safety concerns in terms of the potential risk of bleeding complications following invasive dental procedures. Therefore, certain guidelines for the dental care of patients taking these drugs are needed. [140] => [141] => '''Detecting overdose''' [142] => [143] => An overdose of anticoagulants usually occurs in people who have heart problems and need to take anticoagulants in the long term to reduce the risk of stroke from their high blood pressure. [144] => [145] => An [[Prothrombin time|International Normalised Ratio (INR)]] test would be recommended to confirm the overdose so that the dosage can be adjusted to an acceptable standard. The INR test measures the time it takes for a clot to form in a blood sample relative to a standard. [146] => [147] => An INR value of 1 indicates a level of coagulation equivalent to that of an average patient not taking warfarin, and values greater than 1 indicate a longer clotting time and, thus, a longer bleeding time. [148] => [149] => '''Assessing bleeding risk''' [150] => [151] => There are two main parts to the assessment of bleeding risk: [152] => * Assessment of the likely risk of bleeding associated with the required dental procedure [153] => * Assessment of the patient's individual-level bleeding risk [154] => [155] => '''Managing bleeding risk''' [156] => [157] => A patient who is on anticoagulants or [[Antiplatelet drug|antiplatelet]] medications may undergo dental treatments which are unlikely to cause bleeding, such as local anesthesia injection, basic gum charting, removal of plaque, calculus and stain above the gum level, direct or indirect fillings which are above the gingiva, [[root canal treatment]], taking impression for denture or crown and fitting or adjustment of [[Orthodontics|orthodontic appliances]].  For all these procedures, it is recommended that the dentist treat the patient following the normal standard procedure and taking care to avoid any bleeding. [158] => [159] => For a patient who needs to undergo dental treatments which are more likely to cause bleeding, such as simple tooth extractions (1-3 teeth with small wound size), drainage of swelling inside the mouth, periodontal charting, [[Scaling and root planing|root planing]],  direct or indirect filling which extends below the gingiva, complex filling, flap raising procedure, gingival recontouring and biopsies, the dentist needs to take extra precautions apart from the standard procedure. The recommendations{{cite web|url=https://www.scottishdental.org/management-of-dental-patients-taking-anticoagulants-or-antiplatelet-drugs-new-guidance-from-sdcep/|title=Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs – New guidance from SDCEP {{!}} Scottish Dental|date=15 September 2015 |language=en-GB|access-date=2020-02-20}} are as follows: [160] => * if the patient has another medical condition or is taking other medication that may increase bleeding risk, consult the patient's general medical practitioner or specialist [161] => * if the patient is on a short course of anticoagulant or antiplatelet therapy, delay the non-urgent, invasive procedure until the medication has been discontinued [162] => * plan treatment for early in the day and week, where possible, to allow time for the management of prolonged bleeding or re-bleeding if it occurs [163] => * perform the procedure as traumatically as possible, use appropriate local measures and only discharge the patient once [[hemostasis]] has been confirmed [164] => * if travel time to emergency care is a concern, place particular emphasis at the time of the initial treatment on the use of measures to avoid complications [165] => * advise the patient to take [[paracetamol]], unless contraindicated, for pain relief rather than [[Nonsteroidal anti-inflammatory drug|NSAIDs]] such as [[aspirin]], [[ibuprofen]], [[diclofenac]] or [[naproxen]] [166] => * provide the patient with written post-treatment advice and emergency contact details [167] => * follow the specific recommendations and advice given for the management of patients taking different anticoagulants or antiplatelet drugs [168] => [169] => There is general agreement that in most cases, treatment regimens with older anticoagulants (e.g., warfarin) and antiplatelet agents (e.g., [[clopidogrel]], [[ticlopidine]], [[prasugrel]], [[ticagrelor]], and/or aspirin) should not be altered before dental procedures. The risks of stopping or reducing these medication regimens (i.e., [[Venous thrombosis|thromboembolism]], [[stroke]], [[myocardial infarction]]) far outweigh the consequences of prolonged bleeding, which can be controlled with local measures. In patients with other existing medical conditions that can increase the risk of prolonged bleeding after dental treatment or receiving other therapy that can increase bleeding risk, dental practitioners may wish to consult the patient's physician to determine whether care can safely be delivered in a primary care office. Any suggested modification to the medication regimen before dental surgery should be done in consultation and on the advice of the patient's physician. [170] => [171] => Based on limited evidence, the consensus appears to be that in most patients who are receiving the newer direct-acting oral anticoagulants (i.e., dabigatran, rivaroxaban, apixaban, or edoxaban) and undergoing dental treatment (in conjunction with usual local measures to control bleeding), no change to the anticoagulant regimen is required. In patients deemed to be at higher risk of bleeding (e.g., patients with other medical conditions or undergoing more extensive procedures associated with higher bleeding risk), consideration may be given, in consultation with and on advice of the patient's physician, to postponing the timing of the daily dose of the anticoagulant until after the procedure; timing the dental intervention as late as possible after last dose of anticoagulant; or temporarily interrupting drug therapy for 24 to 48 hours. [172] => [173] => ==Research== [174] => A substantial number of compounds are being investigated for use as anticoagulants. The most promising ones act on the [[contact activation system]] ([[factor XII]]a and [[factor XI]]a); it is anticipated that this may provide agents that prevent thrombosis without conferring a risk of bleeding.{{cite journal |last1=Fredenburgh |first1=James C |last2=Weitz |first2=Jeffrey I |title=New Anticoagulants: Moving Beyond the Direct Oral Anticoagulants |journal=Journal of Thrombosis and Haemostasis |date=12 October 2020 |volume=19 |issue=1 |pages=20–29 |doi=10.1111/jth.15126|pmid=33047462 |s2cid=222320654 |doi-access=free }} [175] => [176] => {{as of|2021|11}}, the direct factor XIa inhibitor [[milvexian]] is in Phase II clinical trials for the prevention of an embolism after surgery.{{cite journal | vauthors = Weitz JI, Strony J, Ageno W, Gailani D, Hylek EM, Lassen MR, Mahaffey KW, Notani RS, Roberts R, Segers A, Raskob GE | title = Milvexian for the Prevention of Venous Thromboembolism | journal = The New England Journal of Medicine | date = November 2021 | volume = 385 | pmid = 34780683 | issue=23 | pages=2161–2172|doi = 10.1056/NEJMoa2113194 | pmc = 9540352 | s2cid = 244132392 }} [177] => [178] => == See also == [179] => * [[Hypercoagulability in pregnancy]] [180] => * [[CHADS2 score]] [181] => * [[Direct factor Xa inhibitors]] [182] => [183] => == References == [184] => {{reflist}} [185] => [186] => == External links == [187] => * [http://www.ahrq.gov/patients-consumers/diagnosis-treatment/treatments/btpills/stayactive.html Staying Active and Healthy with Blood Thinners] by the Agency for Healthcare Research and Quality [188] => * [http://www.pharmaceutical-journal.com/news-and-analysis/infographics/new-oral-anticoagulants-for-stroke-prevention-in-atrial-fibrillation/20201755.article New oral anticoagulants for stroke prevention in atrial fibrillation] [189] => {{Antithrombotics}} [190] => {{Major Drug Groups}} [191] => [192] => [[Category:Anticoagulants|*]] [193] => [[Category:Blood tests]] [194] => [[Category:Medical signs]] [] => )
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Anticoagulant

Anticoagulants are medications that prevent the formation of blood clots in the body. This Wikipedia page provides an in-depth overview of anticoagulants, including their history, mechanism of action, types, and clinical uses.

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This Wikipedia page provides an in-depth overview of anticoagulants, including their history, mechanism of action, types, and clinical uses. The page begins with a brief introduction to the concept of blood clotting and the importance of maintaining a delicate balance in the coagulation process. It then delves into the historical development of anticoagulants, starting with the discovery of heparin in the early 20th century and the subsequent creation of various anticoagulant drugs. The mechanism of action section explains how anticoagulants work to inhibit clot formation, emphasizing different targets in the coagulation cascade such as thrombin or factor Xa. It also highlights the importance of coagulation tests, such as the prothrombin time (PT) and activated partial thromboplastin time (aPTT), in monitoring anticoagulant therapy. The page further explores the different types of anticoagulants, including oral agents like warfarin, direct oral anticoagulants (DOACs), and parenteral anticoagulants such as heparin and low molecular weight heparins (LMWHs). Each class is described in detail, with information on their pharmacokinetics, dosing, and side effects. Clinical uses of anticoagulants are a significant focus of the page, with detailed explanations of their indications in various medical conditions, including atrial fibrillation, venous thromboembolism, deep vein thrombosis, and pulmonary embolism. The page also sheds light on anticoagulant use during pregnancy, in children, and during surgeries. Furthermore, the page provides a comprehensive overview of the risks and complications associated with anticoagulant therapy, such as bleeding events and interactions with other medications. It concludes with a discussion on the future direction of anticoagulation therapy, including emerging novel agents and potential advancements in the field. Overall, this Wikipedia page offers a comprehensive and detailed resource on anticoagulants, making it an invaluable tool for anyone seeking information on the topic.

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