Prescrire international
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Prescrire international · Jun 2013
ReviewBleeding with dabigatran, rivaroxaban, apixaban. No antidote, and little clinical experience.
Dabigatran, rivaroxaban and apixaban are oral anticoagulants used to prevent or treat thrombosis in a variety of situations. Like all anticoagulants, these drugs can provoke bleeding. How should patients be managed if bleeding occurs during dabigatran, rivaroxaban or apixaban therapy? How can the risk of bleeding be reduced in patients who require surgery or other invasive procedures? To answer these questions, we reviewed the available literature, using the standard Prescrire methodology. ⋯ In patients at high risk of thrombosis, heparin can be proposed when the anticoagulant is withdrawn. In early 2013, difficulties in the management of bleeding and of situations in which there is a risk of bleeding weigh heavily in the balance of potential harm versus potential benefit of dabigatran, rivaroxaban and apixaban. When an oral anticoagulant is required, it is best to choose warfarin, a vitamin K antagonist, and the drug with which we have the most experience, except in those rare situations in which the INR cannot be maintained within the therapeutic range.
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Radiation exposure from CT scans exposes children to an increased risk of leukaemia and brain tumours.
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Prescrire international · May 2013
Anaphylactic reactions during anaesthesia: neuromuscular blocking agents, latex and antibiotics.
A French team investigated hypersensitivity reactions that occurred during locoregional or general anaesthesia over an 8-year period. They estimated that the incidence of anaphylactic reactions was about 1 per 10 000 anaesthetic procedures. Among the 1816 reports of anaphylactic reactions, the most commonly implicated drugs were neuromuscular blocking agents (1067 cases), latex (361 cases), and antibiotics (236 cases). ⋯ Most reactions in children were due to latex, followed by neuromuscular blocking agents and antibiotics. In practice, exposure to latex devices should be minimised, or simply avoided when possible. A history of sensitization to substances sharing allergenic sites with neuromuscular blocking agents should be investigated, and measures should be taken to protect patients.
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Prescrire international · May 2013
ReviewDeep venous thrombosis and pulmonary embolism. Part 2--Prevention of recurrences: warfarin or low-molecular-weight heparin for at least 3 months.
In patients with deep venous thrombosis or pulmonary embolism, initial treatment with low-molecular-weight heparin (LMWH) is primarily aimed at preventing thrombus extension. After this initial phase, the goal of treatment is to prevent recurrences, which can be fatal. Is it better to continue treatment of deep venous thrombosis or pulmonary embolism with LMWH or switch to an oral anticoagulant? What is the optimal duration of treatment? To answer these questions, we conducted a review of the literature using the standard Prescrire methodology. ⋯ Various clinical practice guidelines published since 2006 recommend first-line treatment with a vitamin K antagonist for at least 3 months in patients without cancer, and continuation of LMWH therapy in patients with cancer. Overall, LMWH and warfarin have similar harm-benefit balances. In practice, it is best to choose between these drugs on a case-by-case basis, taking into account patient preferences, monitoring constraints, difficulty controlling the INR, the risk of bleeding and interactions, and the cost of treatment.