MedWorm: Coumadin

  Warfarin users appear more likely to develop brain bleeding following stroke treatment

Patients already taking warfarin who develop an acute stroke appear more likely to experience a brain hemorrhage following treatment with an intravenous clot-dissolving medication, even if their blood clotting function appears normal, according to a new study. (Source: ScienceDaily Headlines)

top  

  Warfarin-treated patients at higher risk of ICH following tPA for stroke

Researchers say their study provides important new information about a group of patients excluded from major trials of tPA for stroke, who yet represent a growing proportion of patients. For complete story visit theheart.org. (Source: theHeart.org)

top  

  Warfarin-Treated Patients at Higher Risk for ICH Following tPA for Stroke

The surprising finding is calling current practice into question. Medscape Medical News (Source: Medscape Today Headlines)

top  

  Alarm raised over INR threshold in stroke thrombolysis

Stroke patients undergoing thrombolysis are at increased risk for symptomatic intracerebral hemorrhage if they are taking warfarin, even if their international normalized ratio is within recommended limits, research suggests. (Source: MedWire News - Stroke)

top  

  Warfarin use increased risk for brain bleed after IV tissue plasminogen activator use

(Source: HemOncToday.com)

top  

  Increased Incidence of Gastrointestinal Bleeding Following Implantation of the HeartMate II LVAD

Conclusions: Although definitive source identification remains elusive, we believe that the majority of bleeding arises in the small bowel, possibly due to angiodysplasias, similar to the pathophysiology encountered in patients with aortic stenosis and GI bleeding. As we move toward wider use of the HMII and other axial continuous-flow devices in both bridge-to-transplant patients and for destination therapy, more studies will be necessary to understand the mechanisms of this obscure GI bleeding and develop treatment strategies to minimize its development. (J Card Surg ****;**:**-**) (Source: Journal of Cardiac Surgery)

top  

  Lateral sinus thrombosis as a complication of acute mastoiditis in children

We have read with great interest the recent article by Christensen et al. , which presents important clinical observations for otogenic intracranial complications. It was a well-conducted study of lateral sinus thrombosis of otitis media in children. We would like to present some comments on this problem based on our experience and literature review. Authors presented seven cases of lateral sinus thrombosis (LST) in children as complications of acute otitis media (AOM)—four cases and chronic otitis media (COM)—three cases. LST is a rare intracranial complication of otitis media which contributes to lack of clear guidelines of how to manage this entity, i.e. the time of introduction of antibiotic therapy, whether to remove clot from the sinus or to ligate internal jugular vein (IJV), et...

top  

  Warfarin Users Appear More Likely To Develop Brain Bleeding Following Stroke Treatment

CHICAGO, March 8, 2010-Patients already taking warfarin who develop an acute stroke appear more likely to experience a brain hemorrhage following treatment with an intravenous clot-dissolving medication, even if their blood clotting function... (Source: Drugs.com - Clinical Trials)

top  

  TPA raised intracerebral bleeding risk in stroke patients on warfarin

Read the full story on MD Consult: TPA raised intracerebral bleeding risk in stroke patients on warfarin (Source: MD Consult: News: Top Stories)

top  

  Symptomatic intracerebral haemorrhage among warfarin-treated patients receiving TPA for acute ischaemic stroke

Source: Arch Neurol Area: News A North American retrospective study was conducted to determine whether warfarin-treated patients with an INR < 1.7 who receive intravenous tissue plasminogen activator (TPA) for acute ischaemic stroke are at increased risk for symptomatic intracerebral haemorrhage (sICH).   The study included 107 patients with the following characteristics:   . Mean age 69.2 years . 43.9% men . Median National Institutes of Health Stroke Scale score (NIHSS) = 14 . Median onset-to-treatment time = 140 minutes . Baseline warfarin use = 12.1% . Median INR = 1.04 (range, 0.82-1.61)   The overall rate of sICH was 6.5%, but it was higher among patients taking warfarin compared with those not taking warfarin at baseline (...

top  

  Symptomatic Intracerebral Hemorrhage Among Eligible Warfarin-Treated Patients Receiving Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke [Original Contribution]

Conclusions  Despite an international normalized ratio less than 1.7, warfarin-treated patients are more likely than those not taking warfarin to experience symptomatic intracerebral hemorrhage following treatment with intravenous tissue plasminogen activator. Larger studies in this subgroup are warranted.Published online March 8, 2010 (doi:10.1001/archneurol.2010.25). (Source: Archives of Neurology)

top  

  What's Going to Be Hot at ACC 2010?

Highlights include two ACCORD analyses looking at blood pressure and lipids, the EVEREST II results with the MitraClip, the MM-WES study of warfarin genotyping, plus a range of DES, HF, and atrial-fibrillation studies that may help answer the question of what therapies work best and at the best price. Heartwire (Source: Medscape Today Headlines)

top  

  Tasigna 200mg capsules (nilotinib) - Revised SPC

This study suggests that a clinically meaningful drug-drug interaction between nilotinib and warfarin is less likely up to a dose of 25 mg of warfarin. Due to lack of steady-state data, control of warfarin pharmacodynamic markers (INR or PT) following initiation of nilotinib therapy (at least during the first 2 weeks) is recommended.   In addition, single-dose administration of Tasigna with orally administered midazolam ... (Source: NeLM - SPC Changes)

top  

  Personalized medicine in warfarin therapy

Researchers have developed a rapid, multiplexed genotyping method to identify the single nucleotide polymorphisms (SNPs) that affect warfarin dose. (Source: ScienceDaily Headlines)

top  

  Prevention of stroke in patients with patent foramen ovale

Patent foramen ovale is found in 24% of healthy adults and 38% of patients with cryptogenic stroke. This ratio and case reports indicate that patent foramen ovale and stroke are associated, probably because of paradoxical embolism. In healthy people with patent foramen ovale, embolic events are not more frequent than in controls, and therefore no primary prevention is needed. However, once ischaemic events occur, the risk of recurrence is substantial and prevention becomes an issue. Acetylsalicylic acid and warfarin reduce this risk to the same level as in patients without patent foramen ovale. Patent foramen ovale with a coinciding atrial septal aneurysm, spontaneous or large right-to-left shunt, or multiple ischaemic events potentiates the risk of recurrence. Transcatheter device closure...

top  

  Distribution of CYP2C9 and VKORC1 Risk Alleles for Warfarin Sensitivity and Resistance in the Israeli Population.

Conclusions: Individualized genotype based warfarin therapy is highly relevant in the Israeli population due to the high incidence of genetic variations associated with warfarin sensitivity in all 3 non-mixing subpopulations tested. PMID: 20210733 [PubMed - as supplied by publisher] (Source: Current Drug Safety)

top  

  Comparison of Different Antithrombotic Regimens for Patients With Atrial Fibrillation Undergoing Drug-Eluting Stent Implantation.

Conclusions: The cardiovascular benefits of triple antithrombotic therapy were confirmed by reducing the MACCE rate, and its major bleeding risk might be acceptable if the INR is closely monitored. PMID: 20208381 [PubMed - as supplied by publisher] (Source: Circulation Journal)

top  

  Journal Scan: Warfarin and Aspirin Use in Atrial Fibrillation Among Practicing Cardiologists (From the AFFECTS Registry) (Am J Cardiol 2010;Feb 22:[Epub ahead of print].)

This was an analysis of 1,461 patients (mean age 66 years) who had AF (paroxysmal in 80%) without structural heart disease and who were enrolled in a multicenter registry. Participating cardiologists were trained in the practice guidelines of the American College of Cardiology/American Heart Associa. . . (Source: Cardiosource)

top  

  Enlargement of Acute Intracerebral Hematomas in Patients on Long-Term Warfarin Treatment

Cerebrovasc Dis 2010;29:446–453 (DOI:10.1159/000289348) (Source: Karger Publishers)

top  

  RE-LY subanalysis suggests similar benefit, fewer bleeds with dabigatran in AF patients with prior stroke or TIA

A subanalysis shows that dabigatran is at least as efficacious and may be even safer than warfarin in this higher-risk subgroup. A trend toward increased MI in the overall study with dabigatran was... For complete story visit theheart.org. (Source: theHeart.org)

top  

  Daily aspirin 'not for the healthy'

Conclusion This trial has tried to answer an important question regarding who should be given aspirin to prevent a heart attack or stroke. It used a systematic method to screen people and followed a reasonably large group of patients for up to 10 years in some cases. The finding of “no statistical significance” can be an important result, and in this case suggests that any benefits from taking aspirin for this group of people are likely to be small. The risk of bleeding was also small and not technically of statistical significant. There is a non-significant trend in the results towards aspirin being harmful. As there is also a suggestion that the study may have been underpowered (planned for too few people), this implies that a larger study may have detected a significant increase ...

top  

  A Polymorphism in the VKORC1 Regulator Calumenin Predicts Higher Warfarin Dose Requirements in African Americans.

Authors: Voora D, Koboldt DC, King CR, Lenzini PA, Eby CS, Porche-Sorbet R, Deych E, Crankshaw M, Milligan PE, McLeod HL, Patel SR, Cavallari LH, Ridker PM, Grice GR, Miller RD, Gage BF Warfarin demonstrates a wide interindividual variability in response that is mediated partly by variants in cytochrome P450 2C9 (CYP2C9) and vitamin K 2,3-epoxide reductase complex subunit 1 (VKORC1). It is not known whether variants in calumenin (CALU) (vitamin K reductase regulator) have an influence on warfarin dose requirements. We resequenced CALU regions in a discovery cohort of dose outliers: patients with high (>90th percentile, n = 55) or low (<10th percentile, n = 53) warfarin dose requirements (after accounting for known genetic and nongenetic variables). One CALU variant, rs339097, was...

top  

  Fecal Occult Blood Test in Patients on Low-Dose Aspirin, Warfarin, Clopidogrel, or Non-steroidal Anti-inflammatory Drugs

Conclusion  Anticoagulants and antiplatelet medications lower the positive-predictive-value of FOBT for advance colonic neoplasia and should be stopped if clinically feasible prior to stool collection. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s10620-010-1150-4Authors Mandeep S. Sawhney, Minneapolis Veterans Affairs Medical Center Division of Gastroenterology Minneapolis MN USAHeather McDougall, Minneapolis Veterans Affairs Medical Center Division of Gastroenterology Minneapolis MN USADouglas B. Nelson, Minneapolis Veterans Affairs Medical Center Division of Gastroenterology Minneapolis MN USAJohn H. Bond, Minneapolis Veterans Affairs Medical Center Division of Gastroenterology Minneapolis MN USA Journal Digestive Diseases and SciencesOnl...

top  

  Rifampicin/warfarin interaction: Coagulation disorders: case report

(Source: Reactions)

top  

  Warfarin: Epiglottis and arytenoids haematoma in an elderly patient: case report

(Source: Reactions)

top  

  Warfarin: Skin necrosis in an elderly patient: case report

(Source: Reactions)

top  

  Newspath March, 2009 - SNP Testing for Warfarin Sensitivity

Pharmacogenomics is the study of genetic variation as it relates to a patient’s response to a given drug. Single nucleotide polymorphisms are examples of such genetic variation and can serve as a guide for the therapeutic dosing of pharmaceuticals. (Source: NewsPath - Pathology News for the Medical Community)

top  

  Warfarin Therapy And Personalized Medicine

Researchers from the Ohio State University have developed a rapid, multiplexed genotyping method to identify the single nucleotide polymorphisms (SNPs) that affect warfarin dose. The related report by Yang et al, "Rapid Genotyping of SNPs Influencing Warfarin Drug Response by SELDI-TOF Mass Spectrometry," appears in the March 2010 issue of the Journal of Molecular Diagnostics. Warfarin is an anti-coagulant that is commonly used to prevent blood clots and embolism... (Source: Health News from Medical News Today)

top  

  Warfarin Therapy And Personalized Medicine

Researchers from the Ohio State University have developed a rapid, multiplexed genotyping method to identify the single nucleotide polymorphisms (SNPs) that affect warfarin dose. The related report by Yang et al, "Rapid Genotyping of SNPs Influencing Warfarin Drug Response by SELDI-TOF Mass Spectrometry," appears in the March 2010 issue of the Journal of Molecular Diagnostics... (Source: Genetics News From Medical News Today)

top  

  Why pharmaceuticals might be called Weapons of Mass Prescription

(NaturalNews) Most people are familiar with traditional weapons of mass destruction such biological weapons, nuclear weapons and chemical weapons. The point of all such weapons of mass destruction is to inflict a large number of casualties on civilian populations as a way to cripple a nation into political or military submission.When it comes to actually deploying weapons of mass destruction (WMDs) against civilian populations, no country has murdered more innocent civilians than the United States of America through its bombing of two Japanese cities during World War II. (This isn't rhetoric, it's an historical fact.)Atomic bombs were very visible WMDs deployed in World War II as a way to force the empire of Japan to surrender to western forces. Since that time, full-scale nuclear weapons ...

top  

  Pharmaceuticals are Weapons of Mass Prescription (comic)

(NaturalNews) Most people are familiar with traditional weapons of mass destruction such biological weapons, nuclear weapons and chemical weapons. The point of all such weapons of mass destruction is to inflict a large number of casualties on civilian populations as a way to cripple a nation into political or military submission.When it comes to actually deploying weapons of mass destruction (WMDs) against civilian populations, no country has murdered more innocent civilians than the United States of America through its bombing of two Japanese cities during World War II. (This isn't rhetoric, it's an historical fact.)Atomic bombs were very visible WMDs deployed in World War II as a way to force the empire of Japan to surrender to western forces. Since that time, full-scale nuclear weapons ...

top  

  Risk Factors of Drug Interaction between Warfarin and Nonsteroidal Anti-Inflammatory Drugs in Practical Setting.

In conclusion, special caution is required when an NSAID is administered to warfarin users if patients are taking warfarin >40 mg/week and other medications interacting with warfarin. PMID: 20191029 [PubMed - in process] (Source: J Korean Med Sci)

top  

  Perioperative coagulation management – fresh frozen plasma

Clinical studies support the use of perioperative fresh frozen plasma (FFP) in patients who are actively bleeding with multiple coagulation factor deficiencies and for the prevention of dilutional coagulopathy in patients with major trauma and/or massive haemorrhage. In these settings, current FFP dosing recommendations may be inadequate. However, a substantial proportion of FFP is transfused in non-bleeding patients with mild elevations in coagulation screening tests. This practice is not supported by the literature, is unlikely to be of benefit and unnecessarily exposes patients to the risks of FFP. The role of FFP in reversing the effects of warfarin anticoagulation is dependent on the clinical context and availability of alternative agents. Although FFP is commonly transfused in patien...

top  

  Long-term Effect of Chronic Oral Anticoagulation with Warfarin after Acute Myocardial Infarction

Abstract: Background: Antiplatelet therapy is the principal component of the antithrombotic regimen after acute myocardial infarction. It remains unclear whether additional chronic oral anticoagulation (OAC) improves outcomes. We set out to evaluate the risk and benefit of long-term OAC after myocardial infarction.Methods: We pooled 10 randomized clinical trials comparing warfarin-containing regimens (OAC) with or without aspirin with non-OAC regimens with or without aspirin (No OAC) for patients with recent infarction. The primary endpoint was all-cause mortality. Other endpoints included recurrent infarction, stroke, and major bleeding. We calculated the odds ratio (OR) (fixed effect, OR (Source: The American Journal of Medicine)

top  

  Apixaban for Reduction In Stroke and Other ThromboemboLic Events in Atrial Fibrillation (ARISTOTLE) trial: Design and rationale

Atrial fibrillation (AF) is associated with increased risk of stroke that can be attenuated with vitamin K antagonists (VKAs). Vitamin K antagonist use is limited, in part, by the high incidence of complications when patients' international normalized ratios (INRs) deviate from the target range. The primary objective of ARISTOTLE is to determine if the factor Xa inhibitor, apixaban, is noninferior to warfarin at reducing the combined endpoint of stroke (ischemic or hemorrhagic) and systemic embolism in patients with AF and at least 1 additional risk factor for stroke. We have randomized 18,206 patients from over 1,000 centers in 40 countries. Patients were randomly assigned in a 1:1 ratio to receive apixaban or warfarin using a double-blind, double-dummy design. International normalized ra...

top  

  Rivaroxaban—Once daily, oral, direct factor Xa inhibition Compared with vitamin K antagonism for prevention of stroke and Embolism Trial in Atrial Fibrillation: Rationale and Design of the ROCKET AF study

Conclusion: The ROCKET AF study will determine the efficacy and safety of rivaroxaban as an alternative to warfarin for the prevention of thromboembolism in patients with AF. (Source: American Heart Journal)

top  

  Rationale and design of AVERROES: Apixaban versus acetylsalicylic acid to prevent stroke in atrial fibrillation patients who have failed or are unsuitable for vitamin K antagonist treatment

Conclusions: By evaluating the use of apixaban as a replacement for ASA in AF patients who are not treated with a VKA, the AVERROES study is addressing an important unmet clinical need. The results of AVERROES will be complementary to those of a parallel noninferiority trial comparing apixaban with VKA therapy in patients with AF who are able to receive a VKA. (Source: American Heart Journal)

top  

  Relationships between emerging measures of heart failure processes of care and clinical outcomes

Conclusions: Several evidence-based processes of care are associated with improved outcomes, can discriminate hospital-level quality of care, and could be considered as clinical performance measures. (Source: American Heart Journal)

top  

  Stroke registry: hemorrhagic vs ischemic strokes

Conclusion: There were a much greater percentage of hemorrhagic strokes in this population than would have been predicted from previous studies. This finding may be due to improvement of CT scan availability and implementation unmasking a previous underestimation of the actual percentage or to an increase in therapeutic use of antiplatelet agents and warfarin causing an increase in the incidence of hemorrhage. (Source: The American Journal of Emergency Medicine)

top  

  Blacks Much Less Likely To Know They Have Heart Condition Or To Use Treatment For It

A large nationwide study that includes neurologists from Mayo Clinic has found that blacks are substantially less likely than whites to know that they have atrial fibrillation or to use warfarin, the most common treatment for the condition. Atrial fibrillation, an abnormal heart rhythm, significantly increases risk of stroke. Warfarin is known to reduce that risk. Researchers say the findings could help explain why the black population in the U.S. has a higher incidence of both stroke and death from strokes, compared to the white population... (Source: Health News from Medical News Today)

top  

  Blacks Much Less Likely To Know They Have Heart Condition Or To Use Treatment For It

A large nationwide study that includes neurologists from Mayo Clinic has found that blacks are substantially less likely than whites to know that they have atrial fibrillation or to use warfarin, the most common treatment for the condition. Atrial fibrillation, an abnormal heart rhythm, significantly increases risk of stroke. Warfarin is known to reduce that risk... (Source: Cardiovascular / Cardiology News From Medical News Today)

top  

  Transient Global Amnesia as the Presenting Feature of Heparin-Induced Thrombocytopenia

A 57-year-old man developed transient global amnesia within an hour of bolus unfractionated heparin administration on day 4 post-mitral valve replacement. Both immunoglobulin G-specific enzyme-linked immunosorbent assay and serotonin release assay were strongly positive for the antibodies that cause heparin-induced thrombocytopenia. The patient's cognitive functions returned to normal following discontinuation of unfractionated heparin and warfarin and commencement of lepirudin infusion. (J Card Surg ****;**:**-**) (Source: Journal of Cardiac Surgery)

top  

  Warfarin sensitivity falls after valve surgery

Research indicates that a decrease in sensitivity to warfarin in the months after heart valve surgery may place patients at risk for receiving subtherapeutic anticoagulant therapy. (Source: MedWire News - Thrombosis)

top  

  Pre-eclampsia Associated with Carotid Dissection and Stroke in a Young Woman

We report a 24-year-old woman who developed an acute stroke 14 days postpartum after a complicated pregnancy. Her left internal carotid artery was found to be occluded, presumably secondary to a carotid dissection. Her neurologic symptoms resolved and she was treated with short-term warfarin therapy and blood pressure control. (Source: Journal of Stroke and Cerebrovascular Diseases)

top  

  The Stroke Practice Improvement Network: A Quasiexperimental Trial of a Multifaceted Intervention to Improve Quality

Conclusion: Implementation of site-specific interventions for quality improvement of specific measures in stroke was difficult to achieve in a 6-month time frame and led to improved adherence for only one of 3 PMs. Studies with a longer intervention period and more sites are required to determine whether tailored interventions can enhance stroke improvement. (Source: Journal of Stroke and Cerebrovascular Diseases)

top  

  New Drug As Effective As Warfarin In Preventing Strokes In Atrial Fibrillation Patients With Prior Stroke Or TIA

The drug dabigatran was as effective as the currently recommended drug warfarin in preventing a subsequent stroke among people with atrial fibrillation and prior stroke or transient ischemic attack and it did so with less bleeding according to late-breaking science presented at the American Stroke Association's International Stroke Conference 2010. Dabigatran is a member of a new class of anti-clotting drugs called direct thrombin inhibitors... (Source: Health News from Medical News Today)

top  

  New Drug As Effective As Warfarin In Preventing Strokes In Atrial Fibrillation Patients With Prior Stroke Or TIA

The drug dabigatran was as effective as the currently recommended drug warfarin in preventing a subsequent stroke among people with atrial fibrillation and prior stroke or transient ischemic attack and it did so with less bleeding according to late-breaking science presented at the American Stroke Association's International Stroke Conference 2010... (Source: Stroke / Neuroprotection News From Medical News Today)

top  

  Current Blood Thinners Face Tough Competition

Studies provide more evidence that newcomers hold mettle against warfarin, aspirin Source: HealthDay Related MedlinePlus Pages: Blood Thinners, Stroke (Source: MedlinePlus Health News)

top  

  Personalized warfarin therapy developed

COLUMBUS, Ohio, Feb. 26 (UPI) -- U.S. researchers say their new rapid, genotyping method can help clinicians choose appropriate doses of the blood thinner warfarin for individual patients. (Source: Health News - UPI.com)

top  

  Decreasing warfarin sensitivity during the first three months after heart valve surgery: Implications for dosing

Conclusions: Patients steadily become less sensitive to warfarin during the first months after heart valve surgery. This leads to subtherapeutic anticoagulation. A dosing algorithm that takes increasing requirements into account is proposed. This algorithm will need to be validated prospectively. (Source: Thrombosis Research)

top  

  Blacks much less likely to know they have heart condition or to use treatment for it, says Mayo Clinic researcher

A large nationwide study that includes neurologists from Mayo Clinic has found that blacks are substantially less likely than whites to know that they have atrial fibrillation or to use warfarin, the most common treatment for the condition. (Source: Mayo Clinic Research News)

top  

  Blacks much less likely to know they have heart condition or to use treatment for it, says Mayo Clinic researcher

A large nationwide study that includes neurologists from Mayo Clinic has found that blacks are substantially less likely than whites to know that they have atrial fibrillation or to use warfarin, the most common treatment for the condition. (Source: Mayo Clinic Jacksonville News)

top  

  Blacks much less likely to know they have heart condition or to use treatment for it, says Mayo Clinic researcher

A large nationwide study that includes neurologists from Mayo Clinic has found that blacks are substantially less likely than whites to know that they have atrial fibrillation or to use warfarin, the most common treatment for the condition. (Source: News from Mayo Clinic)

top  

  Blacks less likely to know they have heart condition or to use treatment for it, says Mayo Clinic

(Mayo Clinic) A large nationwide study that includes neurologists from Mayo Clinic has found that blacks are substantially less likely than whites to know that they have atrial fibrillation or to use warfarin, the most common treatment for the condition. Atrial fibrillation, an abnormal heart rhythm, significantly increases risk of stroke. Warfarin is known to reduce that risk. (Source: EurekAlert! - Medicine and Health)

top  

  Blacks less likely to know they have heart condition or to use treatment for it, study suggests

A large nationwide study has found that blacks are substantially less likely than whites to know that they have atrial fibrillation or to use warfarin, the most common treatment for the condition. Atrial fibrillation, an abnormal heart rhythm, significantly increases risk of stroke. Warfarin is known to reduce that risk. (Source: ScienceDaily Headlines)

top  

  Thrombus in the distal aortic arch after apicoaortic conduit for severe aortic stenosis [Case report - Valves]

We report an uncommon case of thrombogenesis in the distal aortic arch after apicoaortic conduit (AAC) for severe aortic stenosis (AS). A 71-year-old woman underwent AAC with a bioprosthetic valve for severe AS because of heavy calcification of the ascending aorta. Although anticoagulant therapy with warfarin was performed, a postoperative computed tomographic (CT) scan revealed a thrombus in the distal aortic arch. Cine magnetic resonance imaging (MRI) revealed stagnation of the blood flow at that site. Administration of warfarin was continued. A follow-up CT-scan showed a marked reduction of the thrombus at six months after the surgery. A follow-up MRI revealed that the antegrade flow through the native aortic valve was decreased at one year after the surgery. We suggest that thrombogene...

top  

  Racial Disparities in Awareness and Treatment of Atrial Fibrillation. The REasons for Geographic and Racial Differences in Stroke (REGARDS) study.

CONCLUSIONS: Blacks were less likely than whites to be aware of having AF or to be treated with warfarin. Potential reasons for the racial disparity in warfarin treatment warrant further investigation. PMID: 20190000 [PubMed - as supplied by publisher] (Source: Stroke)

top  

  Heart failure

New evidence; conclusions changed for: Angiotensin II receptor blockers for diastolic heart failure One RCT added comparing irbesartan versus placebo found no significant difference between irbesartan and placebo in all-cause mortality or in hospital admission for cardiovascular causes at a mean follow-up of 49.5 months. Evidence for effect of irbesartan on hospital admission for cardiovascular disease differs from evidence previously reported for candesartan for this outcome. Effects of angiotensin II receptor blockers as a class in treatment of diastolic heart failure is unclear. Categorisation changed from Likely to be beneficial to Unknown effectiveness. New evidence; conclusion confirmed for: Multidisciplinary intervent...

top  

  Bleeding Risk on Warfarin Among Elderly Patients With Atrial Fibrillation

Poli et al. () observed different rates of major hemorrhage between patients younger than 80 years of age and 80 years of age and older. As discussed by the authors, these rates differed considerably from the rates of major hemorrhage observed among similarly aged cohorts by Hylek et al. (). We want to highlight an important methodological issue in the authors' calculation of event rates. The authors state, “the overall exposure to warfarin for each patient was calculated in relation to aging, before and after his/her 80th birthday.” Thus, the authors allowed crossover of prevalent warfarin survivors from the younger cohort to the age ≥80 years inception cohort. At the time of enrollment, the baseline age ≥80 years cohort numbered 180 patients. Yet, in Table 1 of their article (), ...

top  

  Reply

We studied a cohort of atrial fibrillation patients on oral anticoagulant treatment for stroke prophylaxis (). Our patients were routinely followed by the Anticoagulation Clinic of our institution with a median follow-up of 2.7 years, and some of them for as long as 13 years. At the beginning of warfarin treatment, the mean age of our cohort was 75 years; therefore, many patients reached the age of 80 years during follow-up. As stated in the article, we decided to analyze the occurrence of adverse events in relation to aging to evaluate whether aging itself could be correlated with an increase in bleeding risk that exceeds the advantages of stroke prevention. In reporting clinical characteristics of patients, we referred to baseline patients' conditions as well as for those who switched fr...

top  

  Personalized medicine in warfarin therapy

(American Journal of Pathology) Researchers from the Ohio State University have developed a rapid, multiplexed genotyping method to identify the single nucleotide polymorphisms (SNPs) that affect warfarin dose. The related report by Yang et al., "Rapid Genotyping of SNPs Influencing Warfarin Drug Response by SELDI-TOF Mass Spectrometry," appears in the March 2010 issue of the Journal of Molecular Diagnostics. (Source: EurekAlert! - Medicine and Health)

top  

  Treatment of Coagulopathy in Intracranial Hemorrhage

Opinion statement  Intracranial hemorrhage (ICH) complicated by coagulopathy is a medical emergency, which can delay neurosurgical intervention, lead to larger hematoma size, and increase mortality until the coagulopathy is corrected. Prompt recognition of coagulopathy during ICH is essential for correct, rapid treatment to reduce ongoing bleeding and improve survival. The proper treatment of a coagulopathic ICH patient is centered on rapid identification of the coagulopathic defect and correction of the underlying coagulopathy to stop acute bleeding. Patients with coagulopathic ICH require admission to a neuro-intensive unit care with management of airway, oxygenation, and systemic arterial and cerebral perfusion pressure; optimization of serum glucose; aggressive treatmen...

top  

  Dabigatran: An End to Warfarin?

(Source: AccessMedicine Updates)

top  

  Eptacog (recombinant Factor VIIa) for warfarin-induced intracranial bleeding

Source: American Journal of Health-System Pharmacy Area: News A narrative review concludes that eptacog may be a potential alternative or adjunct to standard therapy with fresh-frozen plasma and vitamin K in patients with warfarin-induced intracranial bleeding.   Intracranial haemorrhage (ICH) is a serious condition and will be exacerbated by warfarin and related anticoagulant drugs. Prompt reversal of anticoagulation is essential to allow surgical procedures to be carried out if necessary: administration of fresh-frozen plasma and vitamin K is the current standard, however eptacog may be a possible alternative as it rapidly affects the INR and is easily administered. The authors review the limited published evidence for eptacog in this situation, which is restricted to case repo...

top  

  Dilated Cardiomyopathy and Role of Antithrombotic Therapy.

CONCLUSIONS:: To date, there is no agreement on appropriate antithrombotic treatment (if any) for primary thromboembolism prophylaxis in patients with dilated cardiomyopathy with sinus rhythm. In recent years, several promising prospective trials were terminated prematurely due to inadequate enrollment. The Warfarin Aspirin-Reduced Cardiac Ejection Fraction trial may provide evidence regarding the use of anticoagulation for patients with decreased myocardial function. PMID: 20186041 [PubMed - as supplied by publisher] (Source: The American Journal of the Medical Sciences)

top  

  Chronic Atrial Fibrillation Is Associated With Reduced Survival After Aortic and Double Valve Replacement [ORIGINAL ARTICLES: ADULT CARDIAC]

Conclusions Chronic AF negatively affects survival after AVR with or without CABG and DVR with a mechanical prosthesis. Prospective randomized evaluation of AF ablation is suggested for these patients. (Source: The Annals of Thoracic Surgery)

top  

  Warfarin Can Be Stopped at Three to Six Months Postablation of AF, But Editorial Urges Caution

Despite the positive findings, an editorial calls the study hypothesis-generating, and notes that the AF field needs a prospective randomized clinical trial, one that includes standardized methods to assess and characterize recurrence of AF and to determine the incidence/prevalence of stroke. Heartwire (Source: Medscape Today Headlines)

top  

  Coagulation factor VIIa (recombinant) for warfarin-induced intracranial hemorrhage.

Conclusion Use of factor VIIa (recombinant) may be considered for reversal of anticoagulation in patients with warfarin-associated ICH. However, patients should be screened for increased risk of thrombosis before administration of the drug. PMID: 20172985 [PubMed - in process] (Source: American Journal of Health-System Pharmacy : AJHP)

top  

  Man With Painful Skin Lesion

[Ann Emerg Med. 2010;55:302.] A 53-year-old man presented with a painful skin lesion on his left lower leg, without trauma. The lesion was initially pruritic and had appeared spontaneously 2 weeks earlier. The patient had been evaluated 1 week earlier and was prescribed clindamycin for presumed cellulitis. Despite this, the lesion continued to grow. The patient had a history of peripheral vascular disease and had resumed receiving warfarin sodium for this 1 week before appearance of the lesion. On physical examination, the patient was afebrile, with a 5-cm-×-7-cm nonraised area of ecchymosis with an erythematous border on the anterior left lower leg (). (Source: Annals of Emergency Medicine)

top  

  Chronic Atrial Fibrillation Is Associated With Reduced Survival After Aortic and Double Valve Replacement.

CONCLUSIONS: Chronic AF negatively affects survival after AVR with or without CABG and DVR with a mechanical prosthesis. Prospective randomized evaluation of AF ablation is suggested for these patients. PMID: 20172119 [PubMed - as supplied by publisher] (Source: The Annals of Thoracic Surgery)

top  

  Herbal products may pose danger for heart patients

3 out of 5 stars Use of Herbal Products and Potential Interactions in Patients with Cardiovascular Diseases. Tachjian A et al.  J Am Coll Cardiol Feb 9, 2010;55:515-25. Abstract Use of unregulated herbal remedies is common and increasing dramatically among patients also taking prescription medicines. Unfortunately, these herbal products can have detrimental effects of their own, as well as potential interactions with other medications.  This review, form the Mayo Clinic, searched PubMed and Medline databases for the years 1966 to 2009 to identify medical literature related to herbs and cardiovascular disease. Among the authors’ findings: • Many herbal products can potentially increase bleeding, especially in patients on warfarin, aspirin, and anti-platelet drugs.  Such herbal pr...

top  

  Urgent warfarin reversal: know your options.

Authors: Pendergrast J PMID: 20177848 [PubMed - as supplied by publisher] (Source: Canadian Journal of Anaesthesia)

top  

  Choosing the right statin/fibrate for warfarin users

(Source: Reactions)

top  

  Why Are We So Bad in Primary Care at Initiating Warfarin in Atrial Fibrillation Patients?

“The Auricle” provides support for primary care physicians in initiating and managing anticoagulation for patients with atrial fibrillation. British Journal of Cardiology (Source: Medscape Today Headlines)

top  

  Sex-Related Differences in the Risk Factor Profile and Medications of Patients With Atrial Fibrillation Recruited in J-TRACE.

Conclusions: Sex-related differences were observed in the risk factor profile and medications of Japanese patients with AF. CHADS2 score was higher in women than in men. PMID: 20173301 [PubMed - as supplied by publisher] (Source: Circulation Journal)

top  

  Warfarin can be stopped at three to six months postablation of AF, but editorial urges caution

Despite the positive findings, an editorial calls the study hypothesis-generating, and notes that the AF field needs a prospective randomized clinical trial, one that includes standardized methods to... For complete story visit theheart.org. (Source: theHeart.org)

top  

  Skin exposure to micro- and nano-particles can cause haemostasis in zebrafish larvae.

Authors: McLeish JA, Chico TJ, Taylor HB, Tucker C, Donaldson K, Brown SB Low mass ambient exposure to airborne particles is associated with atherothrombotic events that may be a consequence of the combustion-derived nanoparticle content. There is concern also over the potential cardiovascular impact of manufactured nanoparticles. To better understand the mechanism by which toxic airborne particles can affect cardiovascular function we utilised zebrafish as a genetically tractable model. Using light and confocal fluorescence video-microscopy, we measured heart-rate and blood flow in the dorsal aorta and caudal artery of zebrafish larvae that had been exposed to a number of toxic and non-toxic microparticles and nanoparticles. Diesel exhaust particles (DEP), carboxy-charged LatexTM bead...

top  

  Do Not Stop the Warfarin Until …⁎

Prevention of thromboembolism is a principal aim of atrial fibrillation management. Although the mechanisms underlying thrombogenesis in atrial fibrillation are clearly complex and remain only partly understood, it is intuitive that restoration and reliable maintenance of sinus rhythm is probably the best preventive strategy against thromboembolism. Over the past decade, catheter ablation has emerged as a potential cure for atrial fibrillation. Many centers worldwide have been reporting relatively high success rates with few associated complications after ablation of atrial fibrillation in selected patient populations. Particularly with increasing use of this therapy has come an obvious need finally to answer one of the most important questions related to this therapy, namely does long-ter...

top  

  Cardiac Resynchronization Therapy Device Implantation in Patients with Therapeutic International Normalized Ratios

Conclusions: Our findings suggest that implantation of CRT-Ds without interruption of warfarin therapy in patients at high risk of thromboembolic events is a safe alternative to routine bridging therapy. This strategy is associated with reduced risk of pocket hematomas and shorter length of hospital stay. (PACE 2010; 1[ndash]7) (Source: Pacing and Clinical Electrophysiology : PACE)

top  

  Characteristics of ambulatory anticoagulant adverse drug events: a descriptive study

Conclusions: Ambulatory warfarin-related ADEs have significant patient and healthcare utilization consequences in the form of bleeding events and associated hospital admissions. Recommendations for improvement in anticoagulation management include use of information technology to assist monitoring and follow-up documentation, avoid drug interactions, and engage patients in their care. (Source: Thrombosis Journal)

top  

  New Insights into the Structural Features and Functional Relevance of Human Cytochrome P450 2C9. Part II.

Authors: Mo SL, Zhou ZW, Yang LP, Wei MQ, Zhou SF Part I of this article published in the previous issue of Current Drug Metabolism discussed the substrate specificity, inhibitor selectivity and structure-activity relationship (SAR) of human CYP2C9. The features of CYP2C9 pharmacophore and SAR models have been elaborated. Part II of this article will address the homology models of CYP2C9, data from site-directed mutagenesis studies, and crystal structural features of CYP2C9. The heteroactivation of CYP2C9 and its interactions with other CYPs will also be discussed. A number of ligand-based and homology models of CYP2C9 have been reported and this has provided insights into the binding of ligands to the active site of CYP2C9. Site-directed mutagenesis studies have revealed that a number...

top  

  Do 5-fluorouracil therapies alter CYP2C19 metaboliser status?

Conclusions  Although 5FU is not a substrate for hepatic drug metabolising CYP enzymes, it may interfere with the synthesis of CYP2C19. Decreased activity of a related enzyme, CYP2C9, following 5FU has been reported previously. Down regulation of CYP2C9 and CYP2C19 synthesis by 5FU therapies may explain the adverse effect of 5FU on the clinical disposition of warfarin and phenytoin. Content Type Journal ArticleCategory Short CommunicationDOI 10.1007/s00280-010-1277-1Authors N. A. Helsby, The University of Auckland Faculty of Medical and Health Sciences Auckland New ZealandW. Y. Lo, The University of Auckland Faculty of Medical and Health Sciences Auckland New ZealandP. Thompson, Auckland District Health Board Auckland Regional Cancer and Blood Service Auckland New Ze...

top  

  Review: Antithrombotic drugs for patients with ischaemic stroke and transient ischaemic attack to prevent recurrent major vascular events

Source: Lancet Neurology Area: News The Lancet Neurology has featured a review of the evidence for use of antithrombotic therapies to prevent stroke and other major vascular events among patients with transient ischaemic attack (TIA) and ischaemic stroke.  The following topics and evidence supporting these are discussed:   . Prevention of recurrent ischaemic stroke of arterial origin, using aspirin, clopidogrel, aspirin plus extended-release dipyridamole, other antithrombotic regimens, and promising future antithrombotic regimens . Prevention of recurrent ischaemic stroke of cardiac origin using aspirin, warfarin, aspirin and clopidogrel versus warfarin, aspirin and clopidogrel versus aspirin alone, aspirin and warfarin, direct thrombin inhibitors, factor Xa inhibi...

top  

  The net clinical benefit of warfarin anticoagulation in atrial fibrillation.

Authors: Budhraja V PMID: 20157146 [PubMed - in process] (Source: Annals of Internal Medicine)

top  

  The net clinical benefit of warfarin anticoagulation in atrial fibrillation.

Authors: Singer DE, Chang Y, Go AS PMID: 20157145 [PubMed - in process] (Source: Annals of Internal Medicine)

top  

  The net clinical benefit of warfarin anticoagulation in atrial fibrillation.

Authors: Bussey H PMID: 20157144 [PubMed - in process] (Source: Annals of Internal Medicine)

top  

  Duplication of the inferior vena cava in a patient presenting for IVC filter placement.

We present the case of a 45- year-old male with factor V leiden and protein C deficiency, who required cessation of warfarin anticoagulation in preparation for cervical laminectomy. The patient had a duplicated IVC and required placement of a caval filter in each IVC. PMID: 20175061 [PubMed - as supplied by publisher] (Source: The Journal of Vascular Access)

top  

  Delayed Epistaxis in External Dacryocystorhinostomy: Rate and Risk Factors [Original Article]

Conclusion  The risk of delayed epistaxis should be similar for patients taking or not taking anticoagulant agents if their use is stopped within a defined period of time before DCR. (Source: Archives of Otolaryngology)

top  

  Warfarin after anterior myocardial infarction in current era of dual antiplatelet therapy: a randomized feasibility trial

Abstract  In the current era of early revascularization and routine use of dual antiplatelet therapy, the incremental benefit of warfarin to reduce the incidence of left ventricular thrombus (LVT) in patients with impaired left ventricular ejection fraction post anterior ST-elevation myocardial infarction (aSTEMI), remains uncertain. The purpose of this study is to assess the feasibility of evaluating the added benefit and safety of triple therapy (TT-warfarin, ASA, and clopidogrel) versus dual therapy (DT-ASA and clopidogrel) in patients at risk of LVT post aSTEMI. Design: Open-label randomized controlled trial. Inclusion: aSTEMI, ejection fraction <40%, and no evidence of LVT. Exclusion: contraindication to, or alternate indication for anticoagulation. Intervention: TT...

top  

  Incidence of recurrent venous thromboembolism and of chronic thromboembolic pulmonary hypertension in patients after a first episode of pulmonary embolism

Abstract  After a first episode of pulmonary embolism (PE), two major problems need to be considered: risk of recurrence when anticoagulation is stopped, and risk of chronic thromboembolic pulmonary hypertension (CTPH). We followed prospectively consecutive patients who survived a first episode of PE, with or without deep vein thrombosis, to assess the incidence of venous thromboembolism (VTE) recurrences and of symptomatic and asymptomatic CTPH. After 3–6 months of oral anticoagulant therapy (OAT) patients underwent transthoracic echocardiography for measuring transtricuspid (rV-rA) gradient. When rV-rA gradient was >35 mmHg further evaluations were performed to rule in or out CTPH. During follow-up patients who developed persistent dyspnea were re-evaluated....

top  

  Nevirapine/fluindione/warfarin interaction: Fluindione inefficacy and decreased plasma warfarin concentration following an interaction with nevirapine: case report

(Source: Reactions)

top  

  Warfarin: Haemocholecyst in an elderly patient: case report

(Source: Reactions)

top  

  [Review] Antithrombotic drugs for patients with ischaemic stroke and transient ischaemic attack to prevent recurrent major vascular events

Aspirin is widely used for the prevention of recurrent stroke in patients with transient ischaemic attack (TIA) and ischaemic stroke of arterial origin, because it is effective and inexpensive. Clopidogrel and the combination of aspirin and extended-release dipyridamole are more effective than aspirin, but are also much more expensive. No other antithrombotic regimens provide significant advantages over aspirin, although cilostazol and the novel platelet protease activated receptor-1 antagonist, SCH 530348, are currently being evaluated. For patients with TIA and ischaemic stroke of cardiac origin due to atrial fibrillation, vitamin K antagonists (VKAs) are highly effective in preventing recurrent ischaemic stroke but have important limitations and are thus underused. Antiplatelet therapy ...

top  

  Fibrate/statin Initiation in Warfarin Users Ups Risk of GI Bleeding

Initiation of a fibrate or statin that inhibits CYP3A4 enzymes -- including fenofibrate, gemfibrozil, fluvastatin, simvastatin, and atorvastatin -- increases the risk of hospitalization for GI bleeding in chronic warfarin users, according to a report in the February issue of the American Journal of Medicine. Reuters Health Information (Source: Medscape Medical News Headlines)

top  

  Malabsorption-Associated Warfarin Resistance

An unusual case of warfarin malabsorption is described. American Journal of Health-System Pharmacy (Source: Medscape Today Headlines)

top  

  Combined renal cancer drugs help some patients

Combined therapy doesn't increase survival but may improve remissionsRelated items from OnMedicaHerceptin of benefit in more breast cancer casesMortality higher if using paroxetine and tamoxifenCancer survival rates not improved much in a decade Warfarin is not the answer for thromboses in cancer patientsChemo plus tamoxifen better than tamoxifen alone (Source: OnMedica Latest News)

top  

  Maintaining vascular access: the management of hemodialysis arteriovenous grafts.

Authors: Schild AF For the nephrologist and surgeon, maintaining vascular access is a significant challenge in hemodialysis (HD), because the portal is vulnerable to infection, stenosis, and thrombus. Vascular access options for HD include the placement of arteriovenous (AV) fistulas, AV grafts, and double-lumen, cuffed central vein catheters. Catheter use is generally associated with higher rates of infection and could compromise the adequacy of HD. Primary AV fistulas, which are generally recommended and provide excellent HD access, are not always the ideal choice for certain patients, such as the elderly or patients with diabetes mellitus. AV grafts allow for a large surface area available for cannulation, and thrombosed grafts have longer patency rates after revision than do revise...

top  

  Combined oral anticoagulants and antiplatelets: benefits and risks

Abstract  Combined antiplatelet and anticoagulant therapy has been suggested for those clinical conditions in which conventional antithrombotic regimens have shown suboptimal efficacy, and in patients with indication for both: antiplatelet and anticoagulant therapy. Clinical trials aimed at assessing the clinical benefit of the association with respect to mono-therapy have been conducted in patients with atrial fibrillation, in patients with recent myocardial infarction, and in patients with prosthetic heart valves. Overall, a favorable benefit-risk profile of combined therapy in comparison to anticoagulant alone has been observed in patients with mechanical prosthetic heart valves and in those with coronary artery disease while no clear advantage has been shown in patients...

top  

  Prevalence and Clinical Characteristics Associated With Left Atrial Appendage Thrombus in Fully Anticoagulated Patients Undergoing Catheter-Directed Atrial Fibrillation Ablation

Conclusion: Despite full anticoagulation, 3.6% of patients undergoing AF ablation had LAA thrombus. We recommend that all patients, regardless of LV function or left atrial size, should undergo preprocedural TEE to exclude the presence of LAA thrombus. (J Cardiovasc Electrophysiol, Vol. pp. 1-4) (Source: Journal of Cardiovascular Electrophysiology)

top  

  Intermedin inhibits vascular calcification by increasing the level of matrix {gamma}-carboxyglutamic acid protein

Conclusion Reduced endogenous IMD levels are associated with increased mineralization in vivo, and administration of IMD inhibits VC development by increasing cMGP levels. IMD may be an endogenous vasoprotective factor for VC. (Source: Cardiovascular Research)

top  

  A Phenotype-Genotype Approach to Predicting CYP450 and P-Glycoprotein Drug Interactions With the Mixed Inhibitor/Inducer Tipranavir/Ritonavir.

Authors: Dumond JB, Vourvahis M, Rezk NL, Patterson KB, Tien HC, White N, Jennings SH, Choi SO, Li J, Wagner MJ, La-Beck NM, Drulak M, Sabo JP, Castles MA, Macgregor TR, Kashuba AD The effects of tipranavir/ritonavir (TPV/r) on hepatic and intestinal P-glycoprotein (P-gp) and cytochrome P450 (CYP) enzyme activity were evaluated in 23 volunteers. The subjects received oral (p.o.) caffeine, warfarin + vitamin K, omeprazole, dextromethorphan, and midazolam and digoxin (p.o. and intravenous (i.v.)) at baseline, during the first three doses of TPV/r (500 mg/200 mg b.i.d.), and at steady state. Plasma area under the curve (AUC)(0-infinity) and urinary metabolite ratios were used for quantification of protein activities. A single dose of TPV/r had no effect on the activity of CYP1A2 and CYP2C...

top  

  The use of anticoagulants improves biochemical control of localized prostate cancer treated with radiotherapy

Substantial experimental evidence suggests that anticoagulants (ACs) may inhibit cancer growth and metastasis, although the limited data from clinical trials have been inconsistent. The potential antineoplastic effect of ACs was investigated in patients who received radiotherapy for localized prostate cancer.The study cohort consisted of 662 patients with adenocarcinoma of the prostate who received radiotherapy (RT) with curative intent. Among those 622 men, 243 (37%) were receiving ACs (warfarin, clopidogrel, and/or aspirin). All patients received external-beam RT, permanent seed implantation, or a combination of both. Prostate-specific antigen (PSA) values were monitored for biochemical control of disease.At a median follow-up of 49 months, the biochemical control rate at 4-years was sig...

top  

  A case of Hughes–Stovin syndrome associated with hyperhomocysteinemia

We report a case of Hughes–Stovin syndrome (HSS) associated with hyperhomocysteinemia. A 24-year-old man who has no clinical features suggestive of Behcet’s disease was admitted for hemoptysis and dyspnea. Radiological and laboratory evaluation revealed multifocal pulmonary artery aneurysms involving bilateral segmental pulmonary artery, thrombi in right atrium and ventricle, and hyperhomocysteinemia. Accordingly, HSS associated with hyperhomocysteinemia was diagnosed, and the clinical and radiological improvement was achieved after treatment with prednisolone, warfarin, and folic acid. Content Type Journal ArticleCategory Case ReportDOI 10.1007/s10067-010-1393-7Authors Hyun-Ok Kim, Gyeongsang National University College of Medicine Department of Internal Medicine and Institut...

top  

  Thromboembolism in Atrial Fibrillation

In conclusion, atrial fibrillation predisposes to thromboembolism. If ischemic stroke or systemic thromboembolism occurs, early diagnosis and treatment can improve outcomes. The thromboembolic risks are reduced by guideline-adherent antithrombotic therapy with warfarin or aspirin. Future directions may include self-monitoring of the international normalized ratio and novel anticoagulants. (Source: The American Journal of Cardiology)

top  

  Periprocedural Anticoagulation Management of Patients With Venous Thromboembolism.

CONCLUSIONS: Thromboembolism, bleeding, and death among VTE patients in whom anticoagulation is temporarily interrupted for an invasive procedure is low. Cancer patients require particular care given their propensity for both clotting and bleeding. PMID: 20139361 [PubMed - as supplied by publisher] (Source: Arteriosclerosis, Thrombosis and Vascular Biology)

top  

  Warfarin Use in AF Is Unrelated to Stroke, Bleeding Risk: Study

Warfarin is under-prescribed when acute coronary syndrome is complicated by atrial fibrillation, and its use does not correlate with risk scores, research shows. Reuters Health Information (Source: Medscape Medical News Headlines)

top  

  Herbal medicines affect heart drugs

Conclusion This review has looked at a serious topic using acceptable methods. There are several difficulties due to the fact they found little good quality research on the topic: Most of the research into the harms from these drugs is from single case reports or case series. This is regarded as low-level evidence, because without a control group it is not possible to say for certain what caused the events and what the background rates of these incidents (such as bleeding) are in the general population. There is no detail on how the researchers selected the articles or how many they found in their search. A fully systematic review would describe the number of studies identified by the search and the detailed methods of each study. As this report has not done this, the reader is una...

top  

  Predictors of Warfarin Use in Atrial Fibrillation Patients in the Inpatient Setting

(Source: American Journal of Cardiovascular Drugs)

top  

  Warfarin-Induced Skin Necrosis

Warfarin-induced skin necrosis is a rare and potentially life-threatening complication of warfarin therapy. This case report explores the challenges of dealing with vitamin K antagonist therapy. Southern Medical Journal (Source: Medscape Today Headlines)

top  

  Role of Orally Available Antagonists of Factor Xa in the Treatment and Prevention of Thromboembolic Disease: Focus on Rivaroxaban.

Authors: Morell J, Sullivan B, Khalabuda M, McBride BF Interpatient variability in the safety and efficacy of oral anticoagulation with warfarin presents several challenges to clinicians, thus underscoring the emergent need for new orally available anticoagulants with predictable pharmacokinetic and pharmacodynamic profiles and ability to target circulating clotting factors. Seven compounds including rivaroxaban, apixaban, betrixaban, and eribaxaban are orally available direct inhibitors of activated factor X currently in development for the prevention and treatment of venous thromboembolism and for thromboprophylaxis in patients with atrial fibrillation or following an acute coronary syndrome. At doses used in phase 2 and 3 clinical trials, rivaroxaban and apixaban demonstrated a pred...

top  

  Comparative efficacy and safety of the novel oral anticoagulants dabigatran, rivaroxaban and apixaban in preclinical and clinical development.

Authors: Ufer M Therapeutic oral anticoagulation is still commonly achieved by administration of warfarin or other vitamin K antagonists that are associated with an untoward pharmacokinetic / pharmacodynamic (PK/PD) profile leading to a high incidence of bleeding complications or therapeutic failure. Hence, there is an unmet medical need of novel easy-to-use oral anticoagulants with improved efficacy and safety. Recent developments include the identification of non-peptidic small-molecules that selectively inhibit certain serine proteases within the coagulation cascade. Of these, the thrombin inhibitor dabigatran and factor Xa inhibitor rivaroxaban have recently been licensed for thromboprophylaxis after orthopaedic surgery mainly in Europe. In addition, the factor Xa inhibitor apixaba...

top  

  Sustiva 50mg and 200mg capsules (efavirenz) - Revised SPC

Source: Manufacturer notification Area: Other Library Updates > SPC Changes Section 4.5 (Interaction with other medicinal products and other forms of interaction) has been updated with information on the use of efavirenz and anticoagulants: Warfarin/Efavirenz Interaction not studied. Plasma concentrations and effects of warfarin are potentially increased or decreased by efavirenz. Dose adjustment of warfarin may be required. Section 4.8 (Undesirable effects) has been updated to include flushing, tinnitus and tremor in the post-marketing experience paragraph. (Source: NeLM - SPC Changes)

top  

  Dabigatran Versus Warfarin in the Treatment of Acute Venous Thromboembolism

Conclusion: A fixed dose of dabigatran, an oral anticoagulant that does not require monitoring, is as effective as warfarin in the treatment of acute venous thromboembolism (VTE) and has a similar safety profile. (Source: Journal of Vascular Surgery)

top  

  Antithrombotic and fibrinolytic drugs for retinal vein occlusion: A systematic review and a call for action.

Authors: Squizzato A, Manfredi E, Bozzato S, Dentali F, Ageno W Optimal management of retinal vein occlusion (RVO) is still a matter of debate. Antithrombotic and fibrinolytic drugs have been investigated after demonstration of a role of thrombosis in the complex pathogenesis of the disease. Aim of our study was to systematically summarise best available evidence on the acute treatment and on the secondary prevention of RVO with antithrombotic and fibrinolytic drugs. A computer-assisted search of the MEDLINE and EMBASE electronic databases up to January 2009 was performed. Two review authors selected all published randomised controlled trials (RCTs) from the search, assessed study quality and extracted data. Based on Jadad's score, RCTs were stratified into three quality categories. A ...

top  

  Data Spotty on Supplement-Drug Interactions: Unlike glucosamine plus warfarin, most combo complications are not well documented.

Data are lacking on the adverse events that potentially can arise from the millions of people taking nutritional supplements along with pharmaceuticals, but researchers are making some headway in sorting the real causes for concern from the unfounded worries. (Source: Rheumatology News)

top  

  Acute deep vein thrombus due to May-Thurner syndrome

A 63-year-old white woman with a history of hypertension, hyperlipidemia, hypothyroidism, and transient ischemic attack, on Premarin, presented with a 2-week history of worsening edema and pain on the left side of the lower extremity associated with purplish discoloration and decreased temperature after a prolonged car travel. Physical examination revealed 2+ edema from the midthigh to the toes associated with purpuric discoloration. All arterial pulses were 4+. Ultrasound examination demonstrated an acute deep vein thrombus extending from the external iliac veins down throughout the visualized veins of the left calf. The patient was started on intravenous heparin and underwent venogram with subsequent thrombolysis. After 48 hours of alteplase infusion, balloon angioplasty was performed an...

top  

  New adjuvants to enhance anticoagulant activity of Warfarin.

Authors: Stromich JJ, Weber AK, Mirzaei YR, Caldwell MD, Lewis DE New adjuvants of warfarin anticoagulant activity have been developed. These compounds, which are 1,4-methano-1,2,3,4-tetrahydroanthracene-9,10-diol derivatives, act synergistically with warfarin to potentiate its anticoagulant effect. None of the compounds tested is an effective oral anticoagulant in the absence of warfarin. PMID: 20167480 [PubMed - as supplied by publisher] (Source: Bioorganic & Medicinal Chemistry Letters)

top  

  Arthroscopy on anticoagulated patients: a retrospective evaluation of postoperative complications.

Authors: Flanigan DC, Muchow R, Orwin J, Graf B Anticoagulation is commonly needed for multiple medical conditions. The indications to discontinue anticoagulation for a simple procedure are controversial. Other surgical subspecialties have shown that keeping patients on warfarin during a simple procedure is safe. The purpose of this retrospective study was to evaluate the postoperative complications encountered for patients undergoing simple arthroscopic procedures while on warfarin. We hypothesized that anticoagulated patients undergoing simple arthroscopic procedures would have few surgical bleeding complications.Arthroscopic procedures performed over a 10-year period on warfarin-anticoagulated patients were retrospectively evaluated. Data collected included the procedure and orthope...

top  

  Warfarin use in post-ACS AF reduces 6-month mortality, MI

Warfarin use at discharge from hospital improves short-term outcomes in patients with atrial fibrillation complicated by acute coronary syndromes, suggest study findings. (Source: MedWire News - Thrombosis)

top  

  Warfarin Allergy: An Easy Solution

No Abstract. (Source: Clinical Cardiology)

top  

  Warfarin and skin necrosis

1.5 out of 5 stars Warfarin-Induced Skin Necrosis. Inayatullah S et al.  South Med J Jan 2010;103:74-75. Abstract Warfarin-induced skin necrosis (WISN) is a rare (estimated prevalence 0.01 – 0.1%) but severe condition that all clinicians should be aware of.  It usually occurs within 1-10 days of starting warfarin, and is probably related to a drug-induced relative deficiency of the anticoagulation factor protein C, creating a paradoxical hypercoagulable state. The presence of WISN is often heralded by paresthesias or a sensation of pressure or discomfort.  This is followed by painful, localized hemorrhagic or erythematous lesions. This short case report reminds us that WISN exists, but is otherwise so confused and lacking in detail that it is not worth tracking down.  The authors...

top  

  Fetotoxicity of warfarin anticoagulation

Conclusion  The final consensus over LMWH and warfarin in the first trimester is yet to be finalised. The treatment of warfarin embryopathy is symptomatic. Long term sequels in survivors are still not known. Content Type Journal ArticleCategory Short CommunicationDOI 10.1007/s00404-010-1369-5Authors Sumit Mehndiratta, UCMS and GTB Hospital Department of Pediatrics Dilshad Garden Delhi IndiaAmita Suneja, UCMS and GTB Hospital Department of Gynecology and Obstetrics Dilshad Garden Delhi IndiaBindiya Gupta, UCMS and GTB Hospital Department of Gynecology and Obstetrics Dilshad Garden Delhi IndiaShuchi Bhatt, UCMS and GTB Hospital Department of Radiology Dilshad Garden Delhi India Journal Archives of Gynecology and ObstetricsOnline ISSN 1432-0711Print ISSN 0932-0067 (...

top  

  Increased anticoagulant activity of warfarin used in combination with doxifluridine

Conclusions  It is important that physicians closely monitor anticoagulant activity in patients concomitantly receiving doxifluridine and warfarin, and appropriately adjust the dose of warfarin. Content Type Journal ArticleCategory Original ArticleDOI 10.1007/s00280-010-1249-5Authors Masaru Nakajima, Iida Municipal Hospital 438 Yawata-machi, Iida-shi Nagano 395-8502 JapanTomoo Genda, Iida Municipal Hospital 438 Yawata-machi, Iida-shi Nagano 395-8502 JapanMayu Suehira, Drug Lifetime Management Center 7-3-1 Hongo, Bunkyo-ku Tokyo 113-0033 JapanHiroki Satoh, The University of Tokyo Laboratory of Drug Informatics, Graduate School of Pharmaceutical Sciences 7-3-1 Hongo, Bunkyo-ku Tokyo 113-0033 JapanAkiko Miki, The University of Tokyo Laboratory of Drug Informatics, Graduate...

top  

  Improving Anticoagulation Control in Hospitalized Elderly Patients on Warfarin

To determine the effect of patient characteristics and of specific guidelines that were developed for managing warfarin therapy in older adults and included in an in-house computer program on anticoagulation quality. Thirteen-month observational study. Acute care, extended care, and rehabilitation geriatric wards of a teaching hospital in Paris, France. Hospitalized patients (N=307, mean age 86.1 ± 6.1) treated with warfarin with a therapeutic international normalized ratio range of 2.0 to 3.0. Patients were assigned according to care unit to the computer-generated dosing group (CGD) or the standard management group (SM; usual physician-based care). Relationships between anticoagulation quality criteria and covariates (age, sex, warfarin indication, treatment phase, follow-up duration, mo...

top  

  Late-term results of tissue-engineered vascular grafts in humans

Conclusion: Tissue-engineered vascular grafts can be used as conduits in patients with single ventricle physiology. Graft stenosis is the primary mode of graft failure. Further follow-up and investigation for the mechanism of stenosis are warranted. (Source: The Journal of Thoracic and Cardiovascular Surgery)

top  

  Massive Rectus Sheath Hematoma with Spontaneous Bladder Perforation - A Cases Series

Conclusions: Spontaneous bladder perforation is a potential complication of massive rectus sheath hematoma. All patients in our series were elderly females on therapeutic anticoagulation. The etiology for the RSH was unclear in all cases and but might be due to needle injury during subcutaneous injection. Management is mostly the same as that for RSH in addition to CBI. Antibiotics are not routinely indicated. In hospital care in these patients is complex and requires a group of closely working specialists including surgeons, physicians and intensivists. (Source: Journal of Surgical Research)

top  

  Percutaneous closure of the left atrial appendage: A finger in the dyke?

Atrial fibrillation (AF) is common but rarely is life-threatening, yet technological innovation aimed at modification of the arrhythmic substrate has advanced rapidly. In contrast, stroke associated with AF is a common and serious cause of morbidity and mortality, yet the mainstay of stroke prophylaxis in 2010 remains dose-adjusted warfarin, a venerable pesticide approved for human use in the 1950s. (Source: Heart Rhythm)

top  

  Warfarin Use and Outcomes in Patients with Atrial Fibrillation Complicating Acute Coronary Syndromes

Conclusion: Warfarin is associated with better 6-month outcomes among patients with atrial fibrillation complicating an acute coronary syndrome, but its use is not related to CHADS2 score or bleeding risk. (Source: The American Journal of Medicine)

top  

  Variations in Perioperative Warfarin Management: Outcomes and Practice Patterns at Nine Hospitals

Abstract: Background: Before surgery, most patients receiving oral anticoagulation require temporary cessation of treatment. Physicians sometimes substitute heparin or low-molecular-weight heparin for oral anticoagulation in the perioperative setting (“bridging therapy”). We sought to characterize rates of bridging therapy use at 9 clinical centers to determine the extent to which the use of bridging is explained by clinical characteristics of patients (vs physician style) and to determine the 30-day incidence of thrombotic and bleeding complications.Methods: This was a prospective, multicenter, observational study. Periprocedural bridging anticoagulation was classified as none, prophylactic-dose heparin/low-molecular-weight heparin, or full-dose heparin/low-molecular-weight heparin. W...

top  

  Fibrate/Statin Initiation in Warfarin Users and Gastrointestinal Bleeding Risk

Conclusions: Initiation of a fibrate or statin that inhibits CYP3A4 enzymes, including atorvastatin, was associated with an increased risk of hospitalization for gastrointestinal bleeding. Initiation of pravastatin, which is mainly excreted unchanged, was not associated with an increased risk. (Source: The American Journal of Medicine)

top  

  Why Are We Ignoring Guideline Recommendations?

In the current issue of The American Journal of Medicine, Lopes et al report discouraging news. They examined a large cohort of patients taken from 3 large randomized double-blind clinical trials and asked the question: “Are patients in these trials who were in atrial fibrillation being treated with antithrombotic therapy in accordance with widely accepted guidelines?” Unfortunately, only a small percentage (13.5%) of the patients with atrial fibrillation in these trials were, in fact, receiving indicated prophylactic antithrombotic therapy with warfarin. This is not an unusual finding. Many other studies have documented that guideline recommendations are followed for a disappointingly small portion of inpatients and outpatients. It has become clear that in daily clinical practice, gui...

top  

  Case of livedoid vasculopathy with peripheral neuropathy successfully treated with low-dose warfarin

We report herein a case of a 28-year-old woman with persistent livedo racemosa and recurrent ulcerations on the lower extremities. The clinical presentation, together with histopathological findings of vascular occlusion without overt vasculitis in the dermis, led to the diagnosis of livedoid vasculopathy. The patient experienced recurrence of ulcerations and developed peripheral neuropathy affecting the distal extremities during the course of treatment with sarpogrelate hydrochloride. The skin lesions and neurological symptoms improved dramatically after adding low-dose warfarin potassium to the treatment regimen. This case suggests that administration of low-dose warfarin is an effective therapy of choice for patients with livedoid vasculopathy. (Source: The Journal of Dermatology)

top  

  New Oral Anticoagulants on the Horizon

Two new oral anticoagulants are poised to replace warfarin as the only choice for long-term anticoagulation. Medscape Nurses (Source: Medscape Internal Medicine Headlines)

top  

  The Impact of Intestinal Failure on Oral Drug Absorption: A Review

Conclusion  The input of specialist pharmacists is necessary in the management of these patients to ensure that appropriate drugs and formulations are prescribed in a timely manner to optimize absorption and resultant efficacy. Content Type Journal ArticleCategory Review ArticleDOI 10.1007/s11605-009-1151-9Authors Nicola Ward, University Hospitals of Leicester NHS Trust Pharmacy Department, Leicester Royal Infirmary Infirmary Square Leicester LE1 5WW UK Journal Journal of Gastrointestinal SurgeryOnline ISSN 1873-4626Print ISSN 1091-255X (Source: Journal of Gastrointestinal Surgery)

top  

  Antiphospholipid Antibody Syndrome: Coexistence of Left Ventricular Apical Thrombus and Deep Vein Thrombosis Causing Pulmonary Thromboembolism in a Patient with Systemic Lupus Erythematosus

We report a 36-year-old woman with a 1-year history of systemic lupus erythematosus who was admitted with acute onset of dyspnea and chest pain. She presented with a classic medical history of antiphospholipid antibody syndrome, including spontaneous abortion, deep venous thrombosis, and clinical manifestations of lupus activation. The differential diagnosis was made after a detailed history and examinations with transthoracic/transesophageal echocardiography, deep venous ultrasonography, chest computed tomography, and coronary angiography. This case demonstrates a left ventricular apical thrombus in angiographically normal coronary arteries and also deep vein thrombosis causing acute pulmonary thromboembolism. Antiaggregant and anticoagulant therapies were initiated as a result of the pre...

top  

  Thrombus Formation After Successful Stapler Exclusion of the Left Atrial Appendage

A 67-year-old man with atrial fibrillation presented with stroke 7 weeks after stapler exclusion of his left atrial appendage (LAA), surgical maze procedure, and bioprosthetic aortic valve replacement. Transesophageal echocardiogram (mid-esophageal view at 90°) noted an excluded LAA without persistent flow and a large mobile echodensity consistent with a thrombus attached to the level of the presumed staple line of the LAA, prolapsing through the mitral valve (, Online Video 1). The patient was fully anticoagulated with warfarin and in sinus rhythm. In a recent study, Kanderian et al. () described a high rate of unsuccessful surgical LAA closure. There is interest in surgical and percutaneous approaches for closure of the LAA to reduce the risk of stroke. Although surgeons might routinely...

top  

  Left atrial appendage exclusion: State-of-the-art

This article aims to review the current evidence for LAA exclusion in patients with AF. © 2009 Wiley-Liss, Inc. (Source: Catheterization and Cardiovascular Interventions)

top  

  Use of preventive medications declines rapidly after stroke

A new study shows persistent use of secondary-prevention medications, including antihypertensive agents, antiplatelets, statins, and warfarin, quickly falls off during first two years after a stroke. For complete story visit theheart.org. (Source: theHeart.org)

top  

  Use of Preventive Medications Declines Rapidly After Stroke

A new study shows persistent use of secondary prevention medications, including antihypertensive agents, antiplatelets, statins, and warfarin, quickly falls off during the first 2 years after a stroke. Medscape Medical News (Source: Medscape PublicHealth Headlines)

top  

  CVN: Dabigatran

Heart Minute: Dabigatran not Inferior to Warfarin (Source: Cardiosource)

top  

  ACP Journal Club. Higher-dose dabigatran reduced stroke, but not major hemorrhage, more than warfarin in atrial fibrillation.

Authors: Klein L PMID: 20083817 [PubMed - in process] (Source: Annals of Internal Medicine)

top  

  Lethal epiphyseal stippling in the foetus and neonate; pathological implications

Abstract  Autopsy reports accumulated since 1991 contained 30 cases in which routine radiological investigation had demonstrated radio-dense stippling of the epiphyses. The case histories, pregnancy progress, clinical manifestations, cytogenetic investigations, and autopsy findings have been tabulated and analysed for the purpose of diagnostic discrimination. Firm diagnoses were obtained in eight instances: warfarin embryopathy—three, trisomy 18—three, lethal multiple pterygium syndrome—one. Other possible but unconfirmed diagnoses were chromosomal aneuploidy—three, sonic hedgehog phenotype—one, CHARGE association—one, intrauterine infection—one. The value of autopsy in foetuses and neonates with lethal epiphyseal stippling syndromes is exemplified by the dete...

top  

  Kinetics of Hematoma Expansion in Murine Warfarin-Associated Intracerebral Hemorrhage.

CONCLUSIONS: PoC allows repeated benchside INR measurements in individual mice which reflect the level of anticoagulation. Stronger anticoagulation results in larger hematoma volumes. As hematoma enlargement occurs mainly during the first hours, potential hemostatic therapies should be tested early in this OAC-ICH model. PMID: 20085756 [PubMed - as supplied by publisher] (Source: Brain Research)

top  

  Induction of Tolerance to Warfarin after Anaphylaxis with a Desensitization Protocol

Cardiology 2010;115:174–175 (DOI:10.1159/000275922) (Source: Karger Publishers)

top  

  Safety of atrial fibrillation ablation with novel multi-electrode array catheters on uninterrupted anticoagulation—a single-center experience

Conclusion  Despite the larger diameter and increased stiffness of multi-electrode array catheters and their deflectable transseptal sheaths, their use for catheter ablation in patients with atrial fibrillation on uninterrupted warfarin in this single-center experience does not appear to be unsafe, and thus, an adequately powered multicenter prospective randomized controlled trial should be considered. Content Type Journal ArticleDOI 10.1007/s10840-009-9457-9Authors Christopher Ruslan Hayes, St Vincent’s University Hospital Cardiac Arrhythmia Service Elm Park Dublin IrelandDavid Keane, St Vincent’s University Hospital Cardiac Arrhythmia Service Elm Park Dublin Ireland Journal Journal of Interventional Cardiac ElectrophysiologyOnline ISSN 1572-8595Print ISSN...

top  

  Thin Is In: AFib and Anticoagulants

This article was first published in the Fall 2009 edition of DukeMed Magazine. (Source: DukeHealth.org: Duke Health Features)

top  

  Reversal of vitamin K antagonists prior to urgent surgery.

CONCLUSIONS: In order to limit the blood loss associated with surgery and the management of uncontrolled bleeding, PCC is an important addition to our therapeutic armamentarium in the reversal of vitamin K antagonists. PMID: 20077167 [PubMed - as supplied by publisher] (Source: Canadian Journal of Anaesthesia)

top  

  An Evaluation of the Early Pharmacodynamic Response After Simultaneous Initiation of Warfarin and Amiodarone.

The objective of this study was to assess whether simultaneous initiation of warfarin and amiodarone results in early alteration of the international normalized ratio (INR) response to warfarin. Patients initiated on warfarin and amiodarone during the same hospitalization were included in the amiodarone (AMIO) group. Patients initiated on warfarin alone (n = 42) were identified for the CONTROL group. The AMIO and CONTROL groups were matched based on age, gender, and ejection fraction <40% using propensity score matching (final n = 18 patients per group). Total and average daily warfarin dose was lower in the AMIO group, yet INR values were similar on each day between the 2 groups. More patients in the AMIO group had an INR greater than 2 during the 5-day observation period as compared t...

top  

  Persistent Use of Secondary Preventive Drugs Declines Rapidly During the First 2 Years After Stroke.

CONCLUSIONS: Persistent secondary prevention treatment declines rapidly during the first 2 years after stroke, particularly for statins and warfarin. Effective interventions to improve persistent secondary prevention after stroke need to be developed. PMID: 20075360 [PubMed - as supplied by publisher] (Source: Stroke)

top  

  Potential interaction between MonaVie Active and Warfarin.

Authors: Katcher S, Leung S PMID: 20065263 [PubMed - in process] (Source: American Journal of Health-System Pharmacy : AJHP)

top  

Top Viagra Store

A first shop in the series of one-pill shops is rightfully viagra-targeted. The index page offers only Viagra, both generic and original.It is possible to purchase other ED products from other pagers, but the main accent is on Viagra.

top-viagra-store.com

Indian Meds

A most recent indian-themed, ethnic site. Includes generic and original (brand) products. al our standard navigational tools and support options are available. This site converts nicely on general pharmaceutical traffic as it has products for vurtually any need.

indianmeds.org

Friendly ED Pharmacy

Many ED customers are anxious about the status their orders. This special friendly site is here to solve the problem. "State of the art" design features high usability and clearly visible support options. All this helps to satisfy even the most demanding customer and results in increased sales ratio.

friendly-ed-pharmacy.com

Popular ED Products

This ED site offers simplistic design that gets right to the point - this IS the site for ED. Popular ED list the top selling products and converts best on ED-targeted, pill-specific traffic.

popular-ed-products.com

Perfect ED Store

This site is just right for ED customers. All ED products are conveniently listed at main page, allowing to make an easy choice. Our regular Sample Pills Offer is emphasized here. Customers can try new products and are likely to return for more refills.

perfect-ed-store.com

Worlds Best Pharmacy

The name says it all. This is the best online pharmacy on the web. The index page is set to show the most polular ED products, while the menu and quicksearch allow to find products in other categories.

worlds-best-pharmacy.com

Delhi Drugs

This Indian-themed site offers a completely new design. All our generic products are availabe and can easily be located with the help of quicksearch feature. Includes our latest shopping engine and billing page.

www.delhi-drugs.com

Indian Generics

Many customers are looking for Indian drugs, and this site is designed specifically for such customers. It includes many generic products, modern design, translated into 7 languages and prices in both USD and Euros. Also it uses our latest shopping engine and billing page.

www.indian-generics.com