Can warfarin improve psychotic symptoms?

Anna GarrettAn interesting preliminary study suggests that warfarin use may lead to a decrease in and even long-term remission of psychotic symptoms in patients with schizophrenia.

A study of adults with deep vein thrombosis (DVT) showed that five patients who also had schizophrenia and who received long-term treatment with warfarin for recurrent DVT achieved full psychosis remission. In addition, these patients remained free of any psychotropic medication for 2 to 11 years.

The investigators note that the underlying mechanism could be tissue-plasminogen activator (tPA), a protein that not only promotes the dissolution of blood clots but also plays a role in neurogenesis after severe stress.

The lead author of the study commented that the results need further study and that psychiatrists should not begin prescribing warfarin for their schizophrenic patients. Larger studies, including randomized controlled trials, are also needed to clarify exactly how and if anticoagulation should be used in the treatment of psychosis.

The findings were presented at the American Psychiatric Association’s 2014 Annual Meeting.

Source: Hoirisch-Clapauch S, Nardi AE. Psychiatric remission with warfarin: should psychosis be addressed as plasminogen activator imbalance? Med Hypotheses. 2013;80(2):137-41.

Rivaroxaban offers alternative to warfarin in elderly patients with AF

Atrial fibrillation (AF) is common in elderly patients and causes an elevated risk of stroke. Studies have also shown that these patients are at higher risk of adverse effects of warfarin, which has historically been the treatment of choice. Newer anticoagulants, such as the oral factor Xa inhibitor rivaroxaban, have been shown to be non-inferior to warfarin offers an additional treatment option.

A recent subanalysis of the ROCKET AF trial looked at risks and efficacy of rivaroxaban in patients who are older than 75 years of age. In the parent study, there were 6229 patients aged ≥75 years with AF and ≥2 stroke risk factors  (mean CHADS2 score of 3.5) randomized to warfarin (target INR 2.0-3.0) or rivaroxaban (20 mg daily; 15 mg if creatinine clearance <50 mL/min). The primary end points were stroke and systemic embolism (SE). Older participants had more primary events and major bleeding than younger subjects in the parent trial; however, in the subanalysis, stroke/SE rates were similar for the warfarin and rivaroxaban groups as were major bleeding events.  

The authors concluded that the efficacy and safety of rivaroxaban relative to warfarin did not differ with age, supporting rivaroxaban as an alternative for the elderly.

Source: Halperin JL, Hankey GJ, Wojdyla DM et al. Efficacy and safety of rivaroxaban compared with warfarin among elderly patients with nonvalvular atrial fibrillation in the ROCKET AF Trial. Circulation 2014.  Published online before print June 3, 2014 doi: 10.1161/

Prasugrel use frequently inappropriate

According to a registry of patients taking prasugrel, nearly one in five is receiving the drug inappropriately or for an unapproved indication.

A review of more than 27,500 patient records from 123 U.S. practices showed that almost 14% had a documented prior history of stroke or transient ischemic attack (TIA), two conditions for which prasugrel is contraindicated. Prior stroke or TIA can increase the risk of bleeding. An additional 4.4% of patients in the analysis were taking prasugrel despite being 75 years of age or older with no diabetes or prior myocardial infarction. Prasugrel is recommended for use in the elderly only if these co-morbidities are present.

Current ACC/AHA guidelines for STEMI and unstable angina/NSTEMI give prasugrel a class I recommendation for use at the time of percutaneous coronary intervention but advise against its use (class III) in patients with a prior TIA or stroke. In TRILOGY ACS, prasugrel was no better than clopidogrel in reducing CV events in patients with ACS who were not treated invasively, and as such, the drug is not approved for medically managed patients.

Inappropriate or off-label prasugrel use was more common in patients with comorbidities, including diabetes, hypertension, dyslipidemia, atrial fibrillation, heart failure, peripheral artery disease, and coronary artery bypass grafting.

Source: Hira RS, Kennedy K, Jneid H. Frequency and practice-level variation in inappropriate and nonrecommended prasugrel prescribing: insights from the NCDR PINNACLE Registry. J Am Coll Cardiol. 2014; 63(25_PA):2876-2877.

Anna D. Garrett is a clinical pharmacist and president of Dr. Anna Garrett (www.drannagarrett.com). Her mission is to help women in midlife maximize their mojo! Contact her at info@drannagarrett.com.