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Abstract

COVID-19 increases the risk of atrial fibrillation (AF) and thrombotic complications, particularly in severe cases, leading to higher mortality rates. Anticoagulation is the cornerstone to reduce thromboembolic risk in patients with AF. Considering the risk of hepatotoxicity in patients with severe COVID-19 as well as the risk of drug–drug interactions, drug-induced hepatotoxicity and bleeding, the ANIBAL protocol was developed to facilitate the anticoagulation approach at discharge after COVID-19 hospitalization. However, since the publication of the original algorithm, relevant changes have occurred. First, treatment of COVID-19 pneumonia has been modified with the use of dexamethasone or remdesivir during the first week in patients that require oxygen therapy, and of dexamethasone and/or tocilizumab or baricitinib during the second week in patients that necessitate supplementary oxygen or with a high inflammation state, respectively. On the other hand, metabolic syndrome is common in patients with AF as well as metabolic-associated fatty liver disease, and this could negatively impact the prognosis of patients with COVID-19, including high transaminase levels in patients treated with immunomodulators. The EHRA guidelines update also introduce some interesting changes in drug–drug interaction patterns with the reduction of the level of the interaction with dexamethasone, which is of paramount importance in this clinical context. Considering the new information, the protocol, named ANIBAL II, has been updated. In this new protocol, the anticoagulant of choice in patients with AF after COVID-19 hospitalization is provided according to three scenarios: with/without dexamethasone treatment at discharge and normal hepatic function, transaminases ≤2 times the upper limit of normal, or transaminases >2 times the upper limit of normal.

Keywords: atrial fibrillation, COVID-19, dabigatran, direct oral anticoagulants, hepatotoxicity, MAFLD, metabolic syndrome.

Citation: Cerezo-Manchado JJ, Meca Birlanga O, García de Guadiana Romualdo L, Gil-Ortega I, Martínez Francés A, Iturbe-Hernandez T. Dabigatran in patients with atrial fibrillation after COVID-19 hospitalization: an update of the ANIBAL* protocol. Drugs Context. 2022;11:2021-9-4. https://doi.org/10.7573/dic.2021-9-4

Contributions: All authors contributed extensively to the work presented in this paper. All authors have contributed significantly to the conception, design, or acquisition of data, or analysis and interpretation of data. All authors have participated in drafting, reviewing, and/or revising the manuscript and have approved its submission. All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this article, take responsibility for the integrity of the work as a whole, and have given their approval for this version to be published.

Disclosure and potential conflicts of interest: JJCM reports non-financial support from Boehringer Ingelheim during the conduct of the study and personal fees from Boehringer Ingelheim, Pfizer, Bayer and Daichii-Sankyo outside the submitted work. The rest of the authors have nothing to disclose. The International Committee of Medical Journal Editors (ICMJE) Potential Conflicts of Interests form for the authors is available for download at: https://www.drugsincontext.com/wp-content/uploads/2021/12/dic.2021-9-4-COI.pdf

Acknowledgements: Content Ed provided writing and editorial support, which was funded by the Fundación para la Formación e Investigación Sanitarias de la Región de Murcia, though an unrestricted grant from Boehringer Ingelheim Spain. Boehringer Ingelheim was given the opportunity to review the manuscript for medical and scientific accuracy as it relates to Boehringer Ingelheim substances, as well as intellectual property considerations.

Funding declaration: Funded by the Fundación para la Formación e Investigación Sanitarias de la Región de Murcia, though an unrestricted grant from Boehringer Ingelheim Spain.

Copyright: Copyright © 2022 Cerezo-Manchado JJ, Meca Birlanga O, García de Guadiana Romualdo L, Gil-Ortega I, Martínez Francés A, Iturbe- Hernandez T. Published by Drugs in Context under Creative Commons License Deed CC BY NC ND 4.0 which allows anyone to copy, distribute and transmit the article provided it is properly attributed in the manner specified below. No commercial use without permission.

Correct attribution: Copyright © 2022 Cerezo-Manchado JJ, Meca Birlanga O, García de Guadiana Romualdo L, Gil-Ortega I, Martínez Francés A, Iturbe-Hernandez T. https://doi.org/10.7573/dic.2021-9-4. Published by Drugs in Context under Creative Commons License Deed CC BY NC ND 4.0.

Article URL: https://www.drugsincontext.com/dabigatran-in-patients-with-atrial-fibrillation-after-covid-19-hospitalization-an-update-of-the-anibal-protocol

Correspondence: Juan José Cerezo-Manchado, Department of Hematology, Hospital Clínico Universitario Santa Lucía, Cartagena, Spain. C. Minarete, s/n, 30202 Cartagena, Murcia, Spain. Email: jjcerezo@ucam.edu

Provenance: Submitted; externally peer reviewed.

Submitted: 5 October 2021; Accepted: 2 December 2021; Publication date: 24 January 2022.

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