허혈뇌졸중에서 비타민 K 비의존경구항응고제의 사용

박형종,유준상 대한신경과학회 2022 대한신경과학회지 Vol.40 No.1

Atrial fibrillation (AF) is associated with an increased incidence of ischemic stroke and transient ischemic attack. A confluence of various factors such as blood stasis, endothelial dysfunction, and prothrombotic state could be contributing to the thrombogenesis in AF. Anticoagulation is the first-line therapy for the prevention of thromboembolism by AF. In current days, non-vitamin K dependent oral anticoagulants (NOAC) are considered as the preferred choice of anticoagulants to prevent ischemic stroke in patients with AF. NOACs have comparable good efficacy and better safety with a predictable anticoagulant effect without the routine coagulation monitoring compared to vitamin K dependent oral anticoagulant. However, the proper use of NOACs needs a careful approach to many practical aspects for balancing the preventing thromboembolic events and bleeding risk. Thus, understanding the drug metabolism and indication of NOAC for a specific situation is essential. In this article, we review major clinical trials, the mechanism, and the use of NOACs in the actual clinical setting of managing ischemic stroke patients Atrial fibrillation (AF) is associated with an increased incidence of ischemic stroke and transient ischemic attack. A confluence of various factors such as blood stasis, endothelial dysfunction, and prothrombotic state could be contributing to the thrombogenesis in AF. Anticoagulation is the first-line therapy for the prevention of thromboembolism by AF. In current days, non-vitamin K dependent oral anticoagulants (NOAC) are considered as the preferred choice of anticoagulants to prevent ischemic stroke in patients with AF. NOACs have comparable good efficacy and better safety with a predictable anticoagulant effect without the routine coagulation monitoring compared to vitamin K dependent oral anticoagulant. However, the proper use of NOACs needs a careful approach to many practical aspects for balancing the preventing thromboembolic events and bleeding risk. Thus, understanding the drug metabolism and indication of NOAC for a specific situation is essential. In this article, we review major clinical trials, the mechanism, and the use of NOACs in the actual clinical setting of managing ischemic stroke patients.

Discontinuation of Anticoagulant or Antiplatelet Therapy for Transrectal Ultrasound-Guided Prostate Biopsies: A Single-Center Experience

Omer A Raheem,Rowan G Casey,David J Galvin,Rustom P Manecksha,Haradikar Varadaraj,TED McDermott,Ronald Grainger,Thomas H Lynch 대한비뇨의학회 2012 Investigative and Clinical Urology Vol.53 No.4

Purpose: Historically, it was thought that hemorrhagic complications were increased with transrectal ultrasound-guided prostate biopsies (TRUS biopsy) of patients receiving anticoagulation/antiplatelet therapy. However, the current literature supports the continuation of anticoagulation/antiplatelet therapy without additional morbidity. We assessed our experience regarding the continuation of anticoagulation/antiplatelet therapy during TRUS biopsy. Materials and Methods: A total of 91 and 98 patients were included in the anticoagulation/antiplatelet (group I) and control (group II) groups, respectively. Group I subgroups consisted of patients on monotherapy or dual therapy of aspirin, warfarin, clopidogrel, or low molecular weight heparin. The TRUS biopsy technique was standardized to 12 cores from the peripheral zones. Patients completed a questionnaire over the 7 days following TRUS biopsy. The questionnaire was designed to assess the presence of hematuria, rectal bleeding, and hematospermia. Development of rectal pain, fever, and emergency hospital admissions following TRUS biopsy were also recorded. Results: The patients’ mean age was 65 years (range, 52 to 74 years) and 63.5 years (range, 54 to 74 years) in groups I and II, respectively. The overall incidence of hematuria was 46% in group I compared with 63% in group II (p=0.018). The incidence of hematospermia was 6% and 10% in groups I and II, respectively. The incidence of rectal bleeding was similar in group I (40%) and group II (39%). Statistical analysis was conducted by using Fisher exact test. Conclusions: There were fewer hematuria episodes in anticoagulation/antiplatelet patients. This study suggests that it is not necessary to discontinue anticoagulation/antiplatelet treatment before TRUS biopsy. Purpose: Historically, it was thought that hemorrhagic complications were increased with transrectal ultrasound-guided prostate biopsies (TRUS biopsy) of patients receiving anticoagulation/antiplatelet therapy. However, the current literature supports the continuation of anticoagulation/antiplatelet therapy without additional morbidity. We assessed our experience regarding the continuation of anticoagulation/antiplatelet therapy during TRUS biopsy. Materials and Methods: A total of 91 and 98 patients were included in the anticoagulation/antiplatelet (group I) and control (group II) groups, respectively. Group I subgroups consisted of patients on monotherapy or dual therapy of aspirin, warfarin, clopidogrel, or low molecular weight heparin. The TRUS biopsy technique was standardized to 12 cores from the peripheral zones. Patients completed a questionnaire over the 7 days following TRUS biopsy. The questionnaire was designed to assess the presence of hematuria, rectal bleeding, and hematospermia. Development of rectal pain, fever, and emergency hospital admissions following TRUS biopsy were also recorded. Results: The patients’ mean age was 65 years (range, 52 to 74 years) and 63.5 years (range, 54 to 74 years) in groups I and II, respectively. The overall incidence of hematuria was 46% in group I compared with 63% in group II (p=0.018). The incidence of hematospermia was 6% and 10% in groups I and II, respectively. The incidence of rectal bleeding was similar in group I (40%) and group II (39%). Statistical analysis was conducted by using Fisher exact test. Conclusions: There were fewer hematuria episodes in anticoagulation/antiplatelet patients. This study suggests that it is not necessary to discontinue anticoagulation/antiplatelet treatment before TRUS biopsy.

항응고제/항혈소판제와 프로톤펌프억제제 병용의 경제성 평가에 대한 체계적 문헌고찰

이연우(Yeon-Woo Lee),권순홍(Sun-Hong Kwon),김나현(Na-Hyun Kim),이의경(Eui-Kyung Lee) 대한약학회 2022 약학회지 Vol.66 No.5

Anticoagulants/antiplatelets are effective in preventing cardiovascular diseases (CVDs). However, as an adverse effect, the risk of upper gastrointestinal bleeding (UGIB) leads to additional costs due to increased treatment and decreased quality of life. Accordingly, the administration of proton pump inhibitors (PPI) is recommended to prevent UGIB. We conducted a systematic review of economic evaluations of PPI co-therapy for patients taking long-term anticoagulants/ antiplatelets to prevent CVDs to examine the cost effectiveness of PPI co-therapy. We searched literature from PubMed and EMBASE with keywords including types of economic evaluations and active ingredients of anticoagulants and antiplatelets on 13/07/2022. Two independent reviewers conducted a systematic review. As a result, six economic evaluation studies were identified. All studies compared PPI co-therapy with low-dose aspirin to prevent CVDs. We confirmed the cost-effectiveness of PPI co-therapy with the respective incremental cost-effectiveness ratio (ICER) in each base case. In the sensitivity analyses, the PPI cost and adherence influenced the ICER the most. The quality of reporting, which was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist, was 87-96%. In the present study, we found that PPI co-therapy was cost-effective and tended to improve the patient’s life years and quality-adjusted life years. These results can be used as evidence for further economic evaluation studies to verify the costeffectiveness of anticoagulants/antiplatelets and PPI co-therapy.

Survey of Botulinum Toxin Injections in Anticoagulated Patients: Korean Physiatrists’ Preference in Controlling Anticoagulation Profile Prior to Intramuscular Injection

JANGYONGJUN,박근영,Jihye Park,Asayeon Choi,김수연,Chris Boulias,Chetan P. Phadke,Farooq Ismail,임선 대한재활의학회 2016 Annals of Rehabilitation Medicine Vol.40 No.2

Objective To evaluate Korean physiatrists’ practice of performing intramuscular botulinum toxin injection in anticoagulated patients and to assess their preference in controlling the bleeding risk before injection.Methods As part of an international collaboration survey study, a questionnaire survey was administered to 100 Korean physiatrists. Physiatrists were asked about their level of experience with botulinum toxin injection, the safe international normalized ratio range in anticoagulated patients undergoing injection, their tendency for injecting into deep muscles, and their experience of bleeding complications.Results International normalized ratio <2.0 was perceived as an ideal range for performing Botulinum toxin injection by 41% of the respondents. Thirty-six respondents replied that the international normalized ratio should be lowered to sub-therapeutic levels before injection, and 18% of the respondents reported that anticoagulants should be intentionally withheld and discontinued prior to injection. In addition, 20%–30% of the respondents answered that they were uncertain whether they should perform the injection regardless of the international normalized ratio values. About 69% of the respondents replied that they did have any standardized protocols for performing botulinum toxin injection in patients using anticoagulants. Only 1 physiatrist replied that he had encountered a case of compartment syndrome.Conclusion In accordance with the lack of consensus in performing intramuscular botulinum toxin injection in anticoagulated patients, our survey shows a wide range of practices among many Korean physiatrists; they tend to avoid botulinum toxin injection in anticoagulated patients and are uncertain about how to approach these patients. The results of this study emphasize the need for formulating a proper international consensus on botulinum toxin injection management in anticoagulated patients.

Survey of Botulinum Toxin Injections in Anticoagulated Patients: Korean Physiatrists' Preference in Controlling Anticoagulation Profile Prior to Intramuscular Injection

Yongjun Jang,Geun-Young Park,Jihye Park,Asayeon Choi,Soo Yeon Kim,Chris Boulias,Chetan P. Phadke,Farooq Ismail,Sun Im 대한재활의학회 2016 Annals of Rehabilitation Medicine Vol.40 No.3

Objective To evaluate Korean physiatrists' practice of performing intramuscular botulinum toxin injection in anticoagulated patients and to assess their preference in controlling the bleeding risk before injection. Methods As part of an international collaboration survey study, a questionnaire survey was administered to 100 Korean physiatrists. Physiatrists were asked about their level of experience with botulinum toxin injection, the safe international normalized ratio range in anticoagulated patients undergoing injection, their tendency for injecting into deep muscles, and their experience of bleeding complications. Results International normalized ratio <2.0 was perceived as an ideal range for performing Botulinum toxin injection by 41% of the respondents. Thirty-six respondents replied that the international normalized ratio should be lowered to sub-therapeutic levels before injection, and 18% of the respondents reported that anticoagulants should be intentionally withheld and discontinued prior to injection. In addition, 20%–30% of the respondents answered that they were uncertain whether they should perform the injection regardless of the international normalized ratio values. About 69% of the respondents replied that they did have any standardized protocols for performing botulinum toxin injection in patients using anticoagulants. Only 1 physiatrist replied that he had encountered a case of compartment syndrome. Conclusion In accordance with the lack of consensus in performing intramuscular botulinum toxin injection in anticoagulated patients, our survey shows a wide range of practices among many Korean physiatrists; they tend to avoid botulinum toxin injection in anticoagulated patients and are uncertain about how to approach these patients. The results of this study emphasize the need for formulating a proper international consensus on botulinum toxin injection management in anticoagulated patients.

Association of Gender With Clinical Outcomes in a Contemporary Cohort of Patients With Atrial Fibrillation Receiving Oral Anticoagulants

Boyoung Joung,Minjeong Kim,Jun Kim,Jin-Bae Kim,Junbeom Park,Jin-Kyu Park,Ki-Woon Kang,Jaemin Shim,Eue-Keun Choi,Young Soo Lee,Hyung Wook Park 대한심장학회 2022 Korean Circulation Journal Vol.52 No.8

Background and Objectives: In patients with atrial fibrillation (AF), females taking vitamin K antagonist are at higher risk of stroke or systemic embolism (SSE), bleeding and all-cause death than males. This study investigated the relationship between sex and adverse clinical events in a contemporary AF patient cohort taking anticoagulation. Methods: This prospective multicenter AF registry study comprised 6,067 patients with AF (mean age, 70±9 years; men, 59%) with intermediate to high risk of stroke (CHA2DS2-VAscore ≥1) and receiving oral anticoagulation therapy. Adverse clinical outcomes, including SSE, bleeding, death were evaluated in patients stratified by sex and anticoagulation patterns. Results: Women were older and used more direct oral anticoagulants (85% vs. 78%, p<0.001) than men. During a median (25th and 75th percentiles) follow-up of 30 (24, 38) months, the incidence rate and risk of SSE (0.7 in women vs. 0.7 in men per 100 person-years) and major bleeding (0.1 in women vs. 0.1 in men per 100 person-years) were not different between the sexes. However, women had a lower all-cause death rate (0.4 in women vs. 0.6 in men per 100 person-years, hazard ratio: 0.48, 95% confidence interval: 0.25–0.91, p=0.025) than men. Conclusions: In contemporary anticoagulation for AF, SSE and major bleeding risks did not differ between sexes. However, women showed a lower risk of all-cause death rate than men, indicating that the use of oral anticoagulants for treating AF in females does not appear to be a risk factor for adverse clinical events.

한방병원 입원 허혈성 뇌경색 환자에서 한방 의료보험용 엑스산제와 항혈소판제 및 항응고제의 병용투여 현황

한수련(Su-Ryun Han),박성환(Sung-Hwan Park),안영민(Young-Min Ahn),안세영(Se-Young Ahn),이병철(Byung-Cheol Lee) 대한한의학회 2011 대한한의학회지 Vol.32 No.2

간경변증 환자에서 항응고제 치료

정재연 ( Jae Youn Cheong ) 대한소화기학회 2017 대한소화기학회지 Vol.70 No.5

Cirrhotic patients have bleeding tendencies due to the lack of coagulation factors and thrombocytopenia. However, decreased levels of procoagulants are also accompanied by decreased levels of natural anticoagulants. However, there have been contrasting reports. It has been reported that patients with cirrhosis are at risk for thrombotic complications, including portal vein thrombosis and venous thromboembolism. Physicians consider active anticoagulation for prophylaxis and treatment of portal vein thrombosis and/or venous thromboembolism in cirrhotic patients with high risk of thrombosis. Concurrently, there are safety concerns regarding the risk of bleeding from anticoagulants in people with advanced liver disease. Further prospective studies are required to determine not only if cirrhotic patients benefit from receiving anticoagulation therapy for preventing thrombotic complications, but also to determine which prophylactic regimen is most appropriate. (Korean J Gastroenterol 2017;70:218-222)

New Oral Anticoagulants란?

장성원 대한상부위장관ㆍ헬리코박터학회 2016 Korean Journal of Helicobacter Upper Gastrointesti Vol.16 No.4

For the last half century, vitamin K antagonists (VKAs) have been used for treatment and prevention of venous thromboembolism and stroke prevention in patients with atrial fibrillation. However, their fragile pharmacokinetics, need for routine laboratory monitoring and dose adjustments complicated the use of these drugs. Recently, new oral anticoagulants (NOACs) have overcome the limitation of VKA therapy and shows favorable outcomes and better safety, especially for patients with intracranial hemorrhage, both in phase III clinical trials and real-world registry. Currently available NOACs are one thrombin inhibitor, dabigatran, and three Xa inhibitors, rivaroxaban, apixaban, and edoxaban. This review covers the pharmacokinetics, published pivotal clinical trials, and dose adjustments in chronic kidney disease. The reimbursement criteria, discontinuation during elective surgical procedure, issues on reversal agents are also discussed.

응급실에 내원한 비출혈 환자에서 Rapidrhino^® 패킹의 효용성

김범준 ( Bumjoon Kim ),권문오 ( Moon Oh Kwon ),양찬주 ( Chan Joo Yang ),조인수 ( In Soo Cho ),이기일 ( Ki-il Lee ) 대한응급의학회 2017 대한응급의학회지 Vol.28 No.3

Purpose: Although there are many treatment options for managing epistaxis, little is known about their outcomes in the emergency department (ED). In this study, we evaluated the management of epistaxis, especially comparing the efficacy between Rapidrhino^® and Merocel^®. Methods: A retrospective review of patients with epistaxis visiting the ED between January 2010 and June 2016 was performed. Haemostatic properties of packs were initially measured in the ED, and after the removal of packs in the otorhinolaryngology clinic. Subgroup analyses were performed in a similar fashion for patients receiving and not receiving anticoagulants or the antiplatelet. Results: The initial success rates for Rapidrhino^® and Merocel^® were both high (90.3%, 86.3%, respectively). Rebleeding rates for Rapidrhino^® and Merocel^® were 41.4% and 56.3%, respectively. Overall, there was a significant difference between the two types of packs in recurrence (p=0.032). Particularly, in patients with anticoagulants, the initial success rates of Rapidrhino^® were higher than that of Merocel^® (88.6%, 76.2%, respectively, p=0.222). The rebleeding rate of Rapidrhino^® was much lower than that of Merocel^® (54.3%, 85.7%, respectively, p=0.016). In the Rapidrhino^® group, the rebleeding rate varied according to the packing removal date (p=0.001). Conclusion: Rapidrhino^® and Merocel^® are equally effective in the initial arrest of epistaxis in the ED. Rapidrhino^® may be more effective in controlling haemorrage on removal, particularly in patients with anticoagulants. Patients with epistaxis could be treated with Rapidrhino^® in the ED, which could be removed in the outpatient clinic one day later.