Drug-Drug and Drug-Food Interactions
European Heart Rhythm Association (EHRA): 2021 European Heart Rhythm Association Practical Guide on the Use of Non-Vitamin K Antagonist Oral Anticoagulants in Patients With Atrial Fibrillation (Steffel et al, EP Europace 2021)
This updated guidance, published by the EHRA in 2021, provides evidence-based recommendations for the use of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF), including eligibility assessment; monitoring; transitioning between other anticoagulants and DOACs; possible drug-drug interactions (DDIs); dosing adjustments in the elderly, in patients with hepatic or renal impairment, or based on body weight; management of DOAC-associated bleeding (including use of reversal agents); and periprocedural management considerations for elective or emergency procedures (including ablation and cardioversion). Special considerations for DOAC use during the COVID-19 pandemic are also included. Sample pathways to help guide decision-making are included for various clinical scenarios.
Non-vitamin K Antagonist Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: Safety Issues in the Elderly (Ajam et al, Expert Rev Clin Pharmacol 2020)
This article reviews the use of direct oral anticoagulants (DOACs) in elderly patients with atrial fibrillation (AF), high risk of stroke and bleeding, and comorbidities requiring polypharmacy. The safety, efficacy, pharmacokinetics, pharmacodynamics, drug-drug interactions, and drug-food interactions of DOACs are described. Clinical studies, guidelines for the management of AF, and expert consensus statements of US and European societies of cardiovascular diseases and cardiac electrophysiology are also reviewed. The article addresses specific challenges with the use of DOACs, including bleeding management and reversal, switching between anticoagulants (vitamin K antagonists and DOACs), and use of DOACs in patients with AF and renal impairment.
Atrial Fibrillation in COVID-19: From Epidemiological Association to Pharmacological Implications (Russo et al, J Cardiovasc Pharmacol 2020)
This article describes the pharmacological interactions between cardiovascular drugs more commonly used in atrial fibrillation (AF) management and experimental coronavirus disease 2019 (COVID-19) therapies, based on EU and US summaries of product characteristics.
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Concomitant Use of NSAIDs or SSRIs With NOACs Requires Monitoring for Bleeding (Lee et al, Yonsei Med J 2020)
This article evaluates the risk of bleeding events in patients with atrial fibrillation (AF) who use direct oral anticoagulants (DOACs) and nonsteroidal anti-inflammatory drugs (NSAIDs) or selective serotonin reuptake inhibitors (SSRIs).
Assessing Major Bleeding Risk in Atrial Fibrillation Patients Concurrently Taking Non-Vitamin K Antagonist Oral Anticoagulants and Antiepileptic Drugs (Wang et al, Eur Heart J Cardiovasc Pharmacother 2020)
This narrative review evaluates the risk of major bleeding events in patients with atrial fibrillation (AF) who take direct oral anticoagulants (DOACs) and antiepileptic drugs (AEDs) concurrently versus those who only take DOACs. Patients who take DOACs and some AEDs concurrently have a higher risk of major bleeding.
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Guidance on Short-term Management of Atrial Fibrillation in Coronavirus Disease 2019 (Rattanawong et al, J Am Heart Assoc 2020)
Drug-drug interactions between anticoagulants/antiarrhythmic drugs for atrial fibrillation and COVID-19 pharmacotherapies are described. This article summarizes the pharmacology of medications used to treat COVID-19, as well as anticoagulants and antiarrhythmic drugs. An algorithm for the management of atrial fibrillation and concomitant COVID-19 was developed based on the limited clinical data that are currently available.
Pharmacokinetics and Pharmacodynamics of Oral Anticoagulants Used in Atrial Fibrillation (Fawzy and Lip, Expert Opin Drug Metab Toxicol 2019)
This article reviews the pharmacokinetic and pharmacodynamic profiles of available vitamin K antagonists and direct oral anticoagulants (DOACs), including mechanisms of drug-drug and drug-food interactions.
Non-vitamin K Antagonist Oral Anticoagulants With Amiodarone, P-glycoprotein Inhibitors, or Polypharmacy in Patients With Atrial Fibrillation: Systematic Review and Meta-analysis (Kim et al, J Cardiol 2019)
This systematic review and meta-analysis compares the efficacy and safety of direct-acting oral anticoagulants (DOACs) versus vitamin K antagonists in patients with NVAF receiving amiodarone, P-glycoprotein inhibitor, or polypharmacy.
University of British Columbia Hospitals: Implementation of an Emergency Department Atrial Fibrillation and Flutter Pathway Improves Rates of Appropriate Anticoagulation, Reduces Length of Stay and Thirty-Day Revisit Rates for Congestive Heart Failure (Barbic et al, CJEM 2017 and SUPPL)
This article describes implementation of an evidence-based AF clinical pathway in the EDs of St. Paul’s Hospital and Mount St. Joseph Hospital at the University of British Columbia in Canada, dosing considerations based on age, body weight, drug-drug interactions (DDIs), and renal impairment, and recommendations for outpatient follow-up.
Old and New Oral Anticoagulants: Food, Herbal Medicines and Drug Interactions (Di Minno et al, Blood Rev 2017)
This is a review of potential pharmacokinetic and/or pharmacodynamic alterations and associated clinical implications that result from interactions between vitamin K antagonists or direct oral anticoagulants (DOACs) and food or herbal, over-the-counter (OTC), or prescription medications. Combinations that should be used with caution or avoided are identified.
American Heart Association (AHA): Management of Patients on Non-Vitamin K Antagonist Oral Anticoagulants in the Acute Care and Periprocedural Setting: A Scientific Statement From the American Heart Association (Raval et al, Circulation 2017)
This scientific statement from the AHA describes the management of direct oral anticoagulants (DOACs) in patients needing interruption or reversal of anticoagulation because of an acute bleed or procedural intervention, including in patients undergoing cardioversion or ablation. Sample pathways for these scenarios are provided. The pharmacology, potential drug-drug interactions (DDIs), and reversal of individual DOACs are compared, and guidance on transitioning between oral anticoagulants, based on the prescribing information of individual DOACs, is included.
Drug-Drug Interactions of Non-Vitamin K Oral Anticoagulants (Voukalis et al, Expert Opin Drug Metab Toxicol 2016)
This is a review of clinically important drug-drug interactions (DDIs) known to affect the pharmacokinetics and/or pharmacodynamics of direct oral anticoagulants (DOACs). DOAC dosage adjustments in patients treated with an interacting medication are highlighted.
American College of Cardiology (ACC): Practical Management of Anticoagulation in Patients With Atrial Fibrillation (Kovacs et al, J Am Coll Cardiol [JACC] 2015)
Includes considerations for the management of direct oral anticoagulants (DOACs) in patients with nonvalvular atrial fibrillation (NVAF) that are based on the consensus recommendations of experts from multiple specialties as part of the ACC’s Anticoagulation Initiative. Topics include initiation and interruption of anticoagulation, quality of anticoagulation care, management of major and minor bleeding (including when and how to use reversal agents [sample pathway included]), and treatment of special populations, such as those with various comorbid cardiovascular diseases (including those with stents) and those undergoing ablation or cardioversion. Comparisons of the risks and benefits of DOACs, dosing considerations in patients with hepatic or renal impairment, and potential drug-drug interactions are provided, along with periprocedural considerations and guidance on transitioning between anticoagulants. A list of topics to cover in patient education encounters is also provided.
University of North Texas Health Science Center: Pharmacology, Benefits, Unaddressed Questions, and Pragmatic Issues of the Newer Oral Anticoagulants for Stroke Prophylaxis in Non-valvular Atrial Fibrillation and Proposal of a Management Algorithm (Rosanio et al, Int J Cardiol 2014)
This narrative review provides an overview of the pharmacology, efficacy, and safety of direct oral anticoagulants (DOACs) in patients with NVAF. The evidence-based anticoagulation management pathway used at the University of North Texas Health Science Center is provided, along with recommendations for anticoagulation in patients with renal impairment, the elderly, patients with AF and comorbid acute coronary syndromes (ACS) and/or undergoing coronary stenting, and patients planning to undergo ablation.
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US Department of Agriculture: Nutrient Lists: Vitamin K Nutrient Content in Food
A list of vitamin K content in food, by serving size, is maintained by the US Department of Agriculture.
US Food and Drug Administration (9/26/2016): Drug Development and Drug Interactions: Table of Substrates, Inhibitors and Inducers
A list of cytochrome P450 substrates, inhibitors, and inducers implicated in drug-drug interactions is maintained by the US FDA.