Revue médicale suisse
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Revue médicale suisse · Mar 2014
[Complications and systemic manifestations of rheumatoid arthritis].
Rheumatoid arthritis (RA), in addition to the traditional joint damage can affect all organs as a systemic disease. Extra-articular manifestations of RA are highly variable ranging from rheumatoid nodules (most common) to rheumatoid vasculitis presenting a significant morbidity and mortality (49% at 5 years). With the new algorithms of treatment (earlier) and the use of biologics, the incidence of severe extra-articular manifestations decreases. ⋯ RA also increases cardiovascular risk and the risk of osteoporosis. It is therefore important to identify these risks and, if appropriate, treat them. Collaboration with the general practitioner is essential in this situation.
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The achievement rate of recommended low-density lipoprotein cholesterol (LDL-C) targets of < 1.8 mmol/l for secondary prevention in very high risk patients is difficult. Observational studies reported that loss of function mutation of the PCS9 was associated with LDL-C decrease level and reduction of cardiovascular events. ⋯ This approach appears safe and well-tolerated. The PCSK9 inhibitors are now tested in large phase III clinical studies to assess the long-term safety and efficacy of this new promising approach.
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Revue médicale suisse · Feb 2014
[Management of major bleeding complications in patients on long-term treatment with oral anticoagulants].
The new direct oral anticoagulants directly targeting thrombin (factor IIa) or factor-Xa, are currently used for the treatment of deep venous thrombosis and pulmonary embolism (rivaroxaban, Xarelto) or for the prevention of systemic embolism in non-valvular atrial fibrillation (rivaroxaban; dabigatran, Pradaxa; Apixaban, Eliquis). Given their ease of use, it is expected that these drugs would be widely used in such long-term indications. Beyond their effectiveness, these treatments remain anticoagulant drugs, potentially responsible for bleeding complications, and specific measures should be defined in case of occurrence of such complications.
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Direct oral anticoagulants, anti-Xa and anti-IIa, are indicated in case of atrial fibrillation or venous thromboembolic disease. Annually, one in ten patients treated by anticoagulants required a scheduled or emergent invasive procedure. Short discontinuation before an invasive procedure may lead to incomplete elimination of the drug especially in case of renal insufficiency or drug-drug interactions. ⋯ Before a procedure with a low bleeding risk, stopping direct anticoagulant 24 hours before the procedure is sufficient. In case of emergent surgery, it is proposed to delay surgery for at least one or two half-lives if possible. Prophylactic use of non-specific procoagulant drug is not recommended.