Thrombocytopenia Induced by Direct Oral Anticoagulants: a Clinical Case and Literature Review

The last decade has dramatically changed the strategy of anticoagulant therapy in patients with atrial fibrillation. Direct oral anticoagulants have replaced vitamin K antagonists: either direct thrombin blockers (dabigatran) or factor IIa blockers (apixaban, rivaroxaban, edoxaban). According to the regulatory domestic and foreign documents, the use of direct oral anticoagulants in patients with atrial fibrillation has priority in comparison with vitamin K antagonists, since they have a predictable anticoagulant effect, the possibility of taking fixed doses without the need for routine anticoagulant monitoring, rapid onset and termination of action, relatively low potential for food and drug interactions. Direct oral anticoagulants are used for the prevention of thromboembolic complications in patients with atrial fibrillation, for the prevention of deep vein thrombosis in patients who have undergone surgery on the knee or hip joints, for emergency treatment and secondary prevention of deep vein thrombosis and pulmonary embolism. Alertness to side effects tends to focus on the likelihood of bleeding, with the possibility of other side effects of direct oral anticoagulants receiving less attention or going unnoticed. These mainly include liver damage, kidney damage and a number of other rare adverse reactions. The finding of isolated thrombocytopenia in patients taking direct oral anticoagulants may be associated with a high risk of life-threatening bleeding. The article analyzes published data on the occurrence of thrombocytopenia associated with the intake of direct oral anticoagulants, and presents a clinical case of thrombocytopenia while taking apixaban

ATRIAL FIBRILLATION AND HEART FAILURE: APPROACHES TO ANTITHROMBOTIC THERAPY

The recent epidemiological data presented, on the prevalence, incidence of atrial fibrillation and comorbid heart failure. The main evidence provided on the risk increase for thromboembolic complications in this category of patients, efficacy data provided, as safety, of the direct oral anticoagulants in atrial fibrillation patients with heart failure, that might facilitate decisions on optimal anticoagulation for this category of patients

Rivaroxaban-Associated Hepatotoxicity: a Clinical Case and Literature Review

Direct oral anticoagulants (not vitamin K antagonists), unlike standard oral anticoagulants (e.g. warfarin), have a predictable manifestation of the anticoagulant effect and the possibility of using a fixed dose without the need for constant monitoring of the anticoagulant effect. The rapid onset and cessation of the effect of direct oral anticoagulants, the relatively low likelihood of interaction with food and other drugs compared to warfarin, have expanded the possibilities of anticoagulant therapy.Direct oral anticoagulants, particularly rivaroxaban, are widely used for deep vein thrombosis/pulmonary embolism prevention and treatment, and for stroke prevention in patients with atrial fibrillation. Awareness of side effects is mostly associated with bleeding risks while other problems with the use of this medication attract less physicians’ attention. These side effects mainly include liver damage and some other rare side effects. This article describes a clinical case of rivaroxaban-associated drug-induced liver injury in patient with first diagnosed atrial fibrillation and normal baseline liver enzymes. A literature review focused on this problem is also presented

The Risk of Myocardial Infarction in Patients with Atrial Fibrillation Taking a Direct Thrombin Inhibitor: Myths and Reality

The purpose of this review is to analyze the results of randomized clinical trials, meta-analyses of cohort and observational studies in real clinical practice on the influence of dabigatran etexilate on the risk of myocardial infarction in patients with atrial fibrillation. A pivotal RE-LY study on dabigatran use in patients with atrial fibrillation did not show statistically significant differences in the frequency of myocardial infarction between any of the doses of dabigatran and warfarin, and the risk of coronary events did not depend on the presence of coronary heart disease or myocardial infarction in the patient's history. Subsequently, a number of meta-analyses have reported an increased risk of myocardial infarction when dabigatran was administered to patients with atrial fibrillation. In general, these studies were characterized by conflicting data, which did not allow to draw any definite conclusions regarding the use of dabigatran in relation to the risk of myocardial infarction. Two FDA cohort observational studies were published in 2014 and 2017, and the former was significantly criticized by experts, and the results of the second study did not provide a definitive answer to the question about the importance of the effect of dabigatran on the development of myocardial infarction in patients with atrial fibrillation. Even more "confusing" the problem arose after the publication of meta-analyses of randomized trials, which showed that the risk of myocardial infarction was increased in patients treated with direct oral anticoagulants compared to patients treated with warfarin. This review provides high quality evidence for the efficacy of dabigatran in preventing myocardial infarction and other vascular complications in patients with atrial fibrillation

Surgery of secondary glaucoma in patients with operated retinal detachment induced by emulsified silicone oil

Purpose. To evaluate the efficacy of silicone oil induced secondary glaucoma surgery using shunt-drains.Material and methods. The study included 10 patients (10 eyes) aged 38-73 years. All patients had been previously operated for rhegmatogenous retinal detachment with vitreous cavity tamponade by silicone oil. The tamponade duration ranged from 1 year or more. All patients underwent the surgery for the secondary glaucoma induced by emulsified silicone oil. Either leucosapphire explantodrains or polymer micro-shunts were implanted in these patients. The follow-up period was 6 months.Results. There were no any intra-operative complications. Ciliochoroidal detachment occurred in 5 cases, hyphema – in 2 cases. Intraocular pressure after surgery was 20mmHg within a month. Subsequently, antihypertensive drugs were prescribed for 1 patient, and another 1 patient underwent transscleral cyclophotocoagulation. Expansion of visual field limits was 7-15°, improvement of visual functions was from hundredths to tenths.Conclusion. Glaucoma in eyes with previously operated retinal detachment, and complicated by the alteration of anterior chamber angle under the influence of emulsified silicone oil, requires a more radical approach to a surgical treatment with application of drains.The leucosapphire explantodrain and polymer micro-shunt show a sufficiently high hypotensive efficiency in relatively the same surgical technique

EXPERIENCE OF SURGICAL TREATMENT OF PROLIFERATIVE DIABETIC RETINOPATHY

The study included 48 vitreoretinal surgeries performed during 2014-2015 in 39 patients with advanced fibrovascular stage of proliferative diabetic retinopathy. Visual acuity before the surgery averaged from pr. l. certae to 0.01. In 7 cases patients underwent intravitreal injection of Lucentis 2-3 weeks before the surgery. The surgery was performed according to the standard 3-port 25 G vitrectomy. In some cases, short-term tamponade of vitreous cavity by fluid perfluororganic compounds (PFOS) was performed for 2-3 days. This was due to prolonged bleeding during the surgery. In these cases, fibrinolytic of direct action (hemasa) was injected directly to the blood clot. In 4 cases circular retinotomy was needed. In 35 cases tamponade was made by silicone oil 5700 cSt, in 13 - by air-gas mixture. In cases of air-gas tamponade 3 patients had a relapse. After vitreous cavity revision it was plugged with silicone oil 5700 cSt. In 17 cases visual function remained unchanged, in 18 cases the changes were imperceptible, in 9 cases visual acuity improved to 0.2, in 3 cases -visual function increased to 0.4 and in 1 patient - to 0.7. In postoperative period IOP increased in 7 cases. In 5 of these cases compensation was achieved with antihypertensive drugs. 1n one case the patient was implanted leukosapphire drainage, and in one more case transscleral cyclophotocoagulation about terminal aching glaucoma was performed. The silicone oil was removed in 6 patients at the period of 6 months up to 2 years

Cardiology Research Institute, Tomsk National Research Medical Center

Aim. To test the hypothesis that the combined use of ivabradine (If inhibitor) and ranolazine (late sodium channel blocker) can reduce the ventricular rate in patients with permanent atrial fibrillation (AF) resistant to standard heart rate-lowering therapy.Material and methods. The study included 25 patients with a permanent AF and an uncontrolled ventricular rate. All patients had NYHA class I-III heart failure with preserved ejection fraction. Patients took ivabradine 2,5 mg twice daily and ranolazine 250 mg twice daily. Twenty-four Holter monitoring was performed after 1, 2, 4 weeks and at the end of the study. The follow-up lasted 8 weeks.Results. In 68% and 16% of patients, strict and lenient rate control was achieved, respectively. There was no ventricular rate decrease in 12% of patients. Adverse effects developed in 4% of subjects.Conclusion. The combined use of ivabradine and ranolazine in patients with a permanent AF and uncontrolled ventricular rate reduces the rate without QT prolongation or reducing left ventricular contractile function. The findings support the hypothesis that the suppression of If current and dominant fibrillation frequency may be a new goal of permanent AF therapy. Prospective, randomized studies are needed to determine the role of drugs for ventricular rate control in patients with permanent AF and to study the effects on efficacy, safety, hospitalization frequency, and other clinical outcomes

Antiretroviral therapy effect on specific antibodies spectrum changes to HIV-1 individual antigenes from persons infected with different virus subtypes

Aim. To estimate the antibodies (Ab) level to HIV-1 antigens in persons infected with virus various subtypes, which received and didn’t receive antiretroviral therapy (ART).Materials and methods. Blood serum samples of HIV-1-infected with subtypes A1, B and C (ART+) — 40 persons, (ART-) — 29 persons. Ab were determined by modified linear immunoassay. Positivity indices for each antigen were calculated for each sample.Results. Multidirectional changes in the Ab level to HIV-1 antigens were revealed in persons infected with virus various subtypes at the ART background and without it.Conclusion. The study of Ab spectrum changes in persons infected with virus various subtypes at the ART background is promising for the additional dynamic criteria development for HIV infection progress estimation