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Direct oral anticoagulants show better safety and effectiveness versus warfarin in patients with val

Embargoed news from Annals of Internal Medicine

American College of Physicians

Research News

Below please find summaries of new articles that will be published in the next issue of Annals of Internal Medicine. The summaries are not intended to substitute for the full articles as a source of information. This information is under strict embargo and by taking it into possession, media representatives are committing to the terms of the embargo not only on their own behalf, but also on behalf of the organization they represent.

1. Direct oral anticoagulants show better safety and effectiveness versus warfarin in patients with valvular atrial fibrillation

Abstract: https://www.acpjournals.org/doi/10.7326/M20-6419

URL goes live when the embargo lifts

A study of more than 56,000 patients with valvular atrial fibrillation in the United States found that new users of direct oral anticoagulants (DOACs) had lower risks for ischemic stroke or systemic embolism and major bleeding events, compared with new users of warfarin. Results from a comparative effectiveness study are published in Annals of Internal Medicine.

Warfarin has been the mainstay therapy to prevent stroke, but drawbacks include a narrow therapeutic window, dose-response variability, and many interactions with drugs and food. Randomized clinical trials have demonstrated that DOACs have similar or superior antithrombotic effects to warfarin and lower bleeding risk. While DOACs are increasingly being used in place of warfarin, evidence about their effectiveness and safety in patients with valvular atrial fibrillation remains limited.

Researchers from the Perelman School of Medicine at the University of Pennsylvania used data from a practice-based commercial healthcare database to assess the safety and effectiveness of DOAC versus warfarin for adults with valvular atrial fibrillation who were newly prescribed either medication. The primary effectiveness outcome was a composite of ischemic stroke or systemic embolism. The primary safety outcome was a composite of intracranial or gastrointestinal bleeding. Among a total of 56,336 patients matched on propensity score, use of DOACs was associated with greater effectiveness defined by the study endpoint compared with warfarin with fewer major bleeding events. These results were consistent for apixaban and rivaroxaban. With dabigatran, results were consistent for major bleeding, but now for effectiveness.

According to the authors, these findings should help to guide anticoagulant choices for patients with valvular atrial fibrillation.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. The corresponding author, Ghadeer K. Dawwas, MSc, MBA, PhD, can be reached through Lauren Ingeno at lauren.ingeno@pennmedicine.upenn.edu.

2. VEXAS syndrome could be underlying cause of refractory arthritis in middle-aged or older men

Abstract: https://www.acpjournals.org/doi/10.7326/L21-0023

URL goes live when the embargo lifts

Clinicians should be aware that VEXAS syndrome may be the underlying cause of peripheral, migratory arthritis of small and medium joints in middle-aged and older men, especially in men with refractory disease and/or chondritis or unexplained skin or hematological involvement. A brief case report is published in Annals of Internal Medicine.

VEXAS syndrome is a serious, potentially fatal, inflammatory condition which develops in men and causes unexplained fever and painful skin rashes, and affects the bone marrow with a pattern suggestive of myelodysplasia. The syndrome has only recently been identified and joint involvement was not detailed on the initial description of the syndrome.

Researchers from Angers University Hospital, Angers, France, report the case of a 66-year-old man without previous medical problems who had a 5-year history of chronic, progressive inflammatory arthritis. The patient was treated as rheumatoid arthritis first with methotrexate and then with many biological agents, but symptoms did not improve. Rather, the clinical picture was getting worse with the occurrence of macrocytic anemia and chondritis. A reanalysis of previous bone marrow aspirations found multiple vacuoles in the cytoplasm of the myeloid and erythroid precursor cells, which are highly suggestive for the VEXAS syndrome. The presence of a somatic mutation in UBA1 gene confirmed the diagnosis.

According to the researchers, this case shows that VEXAS syndrome could be to blame for refractory arthritis-type symptoms. Clinicians should be aware of this possibility when treating such patients.

Media contacts: For an embargoed PDF, please contact Angela Collom at acollom@acponline.org. The corresponding author, Geoffrey Urbanski, MD, MSc, can be reached directly at urbanskigeoffrey@gmail.com.

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