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Browsing by Author "Noseworthy, Peter A."
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Item Drug Interactions Affecting Oral Anticoagulant Use(American Heart Association, 2022) Mar, Philip L.; Gopinathannair, Rakesh; Gengler, Brooke E.; Chung, Mina K.; Perez, Arturo; Dukes, Jonathan; Ezekowitz, Michael D.; Lakkireddy, Dhanunjaya; Lip, Gregory Y. H.; Miletello, Mike; Noseworthy, Peter A.; Reiffel, James; Tisdale, James E.; Olshansky, Brian; American Heart Association Electrocardiography & Arrhythmias Committee of the Council of Clinical Cardiology; Medicine, School of MedicineOral anticoagulants (OAC) are medications commonly used in patients with atrial fibrillation and other cardiovascular conditions. Both warfarin and direct oral anticoagulants (DOAC) are susceptible to drug-drug interactions (DDI). DDI are an important cause of adverse drug reactions and exact a large toll on the healthcare system. DDI for warfarin mainly involve moderate to strong inhibitors / inducers of cytochrome P450 (CYP) 2C9, which is responsible for the elimination of the more potent S-isomer of warfarin. However, inhibitor / inducers of CYP3A4 and CYP1A2 may also cause DDI with warfarin. Recognition of these precipitating agents along with increased frequency of monitoring when these agents are initiated or discontinued will minimize the impact of warfarin DDI. DOAC DDI are mainly affected by medications strongly affecting the permeability glycoprotein (P-gp), and to a lesser extent, strong CYP3A4 inhibitors / inducers. Dabigatran and edoxaban are affected by P-gp modulation. Strong inducers of CYP3A4 or P-gp should be avoided in all patients taking DOAC unless previously proven to be otherwise safe. Simultaneous strong CYP3A4 and P-gp inhibitors should be avoided in patients taking apixaban and rivaroxaban. Concomitant antiplatelet / anticoagulant use confers additive risk for bleeding, but their combination is unavoidable in many cases. Minimizing duration of concomitant anticoagulant/antiplatelet therapy as indicated by evidence-based clinical guidelines is the best way to reduce the risk of bleeding.Item Effect of Shared Decision-Making for Stroke Prevention on Treatment Adherence and Safety Outcomes in Patients With Atrial Fibrillation: A Randomized Clinical Trial(American Heart Association, 2022) Noseworthy, Peter A.; Branda, Megan E.; Kunneman, Marleen; Hargraves, Ian G.; Sivly, Angela L.; Brito, Juan P.; Burnett, Bruce; Zeballos-Palacios, Claudia; Linzer, Mark; Suzuki, Takeki; Lee, Alexander T.; Gorr, Haeshik; Jackson, Elizabeth A.; Hess, Erik; Brand-McCarthy, Sarah R.; Shah, Nilay D.; Montori, Victor M.; SDM4AFib (Shared Decision-Making for Atrial Fibrillation) Trial Investigators; Medicine, School of MedicineBackground: Guidelines promote shared decision‐making (SDM) for anticoagulation in patients with atrial fibrillation. We recently showed that adding a within‐encounter SDM tool to usual care (UC) increases patient involvement in decision‐making and clinician satisfaction, without affecting encounter length. We aimed to estimate the extent to which use of an SDM tool changed adherence to the decided care plan and clinical safety end points. Methods and Results: We conducted a multicenter, encounter‐level, randomized trial assessing the efficacy of UC with versus without an SDM conversation tool for use during the clinical encounter (Anticoagulation Choice) in patients with nonvalvular atrial fibrillation considering starting or reviewing anticoagulation treatment. We conducted a chart and pharmacy review, blinded to randomization status, at 10 months after enrollment to assess primary adherence (proportion of patients who were prescribed an anticoagulant who filled their first prescription) and secondary adherence (estimated using the proportion of days for which treatment was supplied and filled for direct oral anticoagulant, and as time in therapeutic range for warfarin). We also noted any strokes, transient ischemic attacks, major bleeding, or deaths as safety end points. We enrolled 922 evaluable patient encounters (Anticoagulation Choice=463, and UC=459), of which 814 (88%) had pharmacy and clinical follow‐up. We found no differences between arms in either primary adherence (78% of patients in the SDM arm filled their first prescription versus 81% in UC arm) or secondary adherence to anticoagulation (percentage days covered of the direct oral anticoagulant was 74.1% in SDM versus 71.6% in UC; time in therapeutic range for warfarin was 66.6% in SDM versus 64.4% in UC). Safety outcomes, mostly bleeds, occurred in 13% of participants in the SDM arm and 14% in the UC arm. Conclusions: In this large, randomized trial comparing UC with a tool to promote SDM against UC alone, we found no significant differences between arms in primary or secondary adherence to anticoagulation or in clinical safety outcomes.