51
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Delrue M, Chevillard L, Stépanian A, Dragoni A, Camoin-Jau L, Voicu S, Malissin I, Deye N, Gainnier M, Siguret V, Mégarbane B. Case series of massive direct oral anticoagulant ingestion-Treatment and pharmacokinetics data. Eur J Clin Invest 2022; 52:e13746. [PMID: 35000196 DOI: 10.1111/eci.13746] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/19/2021] [Accepted: 01/05/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOAC) are widely used due to favourable benefit/risk ratio. However, consequences of massive ingestion have been poorly investigated. OBJECTIVES We aimed to report outcome and pharmacokinetic parameters in patients who massively ingested DOACs. METHODS We conducted a 5-year cohort study including consecutive massive DOAC ingestion patients admitted to two critical care departments. Patients were managed in accordance with standards of care. We collected the main history, clinical, laboratory, management and outcome data. The time-course of plasma DOAC concentrations measured using specific assays was modelled. RESULTS Twelve patients (3F/9M; age, 55 years [41-63], median [25th-75th percentiles]) were included. Ingestions involved rivaroxaban (n = 7), apixaban (n = 3) and dabigatran (n = 2), with presumed doses of 9.4-fold [5.0-22.0] the full daily dose. Six patients received activated charcoal but no antidote nor blood-derived product. No bleeding was observed. One patient died due to refractory cardiogenic shock related to bisoprolol co-intoxication. Highest observed peak plasma concentrations were 1720 ng/ml (rivaroxaban), 750 ng/ml (apixaban) and 644 ng/ml (dabigatran). Times to reach DOAC concentration below 50 ng/ml were ~20-45 h (rivaroxaban), ~125 h (apixaban) and ~30-50 h (dabigatran). Elimination half-lives were 2.5-25.5 h (rivaroxaban), 22.0 and 36.5 h (apixaban), and 5.8 and 15.5 h (dabigatran), with substantial interindividual variability and prolongation in case of cardiovascular failure related to co-intoxicants. Charcoal administration, even if delayed, may have contributed to limit toxicity, possibly by reducing absorption and/or enteroenteric recycling. CONCLUSION No bleeding was observed in this series of massive DOAC ingestions despite elevated plasma concentrations. No patient required specific haemostatic agents. Charcoal administration should be considered to limit toxicity.
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Affiliation(s)
- Maxime Delrue
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
| | - Lucie Chevillard
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France.,INSERM, UMRS-1144, Paris University, Paris, France
| | - Alain Stépanian
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France.,EA 3518, Paris University, Paris, France
| | - Alessandra Dragoni
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France
| | | | - Sébastien Voicu
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France.,INSERM, UMRS-1144, Paris University, Paris, France
| | - Isabelle Malissin
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France.,INSERM, UMRS-1144, Paris University, Paris, France
| | - Nicolas Deye
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France
| | - Marc Gainnier
- Department of Critical Care, APHM, la Timone Hospital, Marseille, France
| | - Virginie Siguret
- Hematology Laboratory, AP-HP Lariboisière Hospital, Paris University, Paris, France.,INSERM, UMRS-1140, Paris University, Paris, France
| | - Bruno Mégarbane
- Department of Medical and Toxicological Critical Care, AP-HP Lariboisière Hospital, Paris, France.,INSERM, UMRS-1144, Paris University, Paris, France
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52
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Meihandoest T, Studt JD, Mendez A, Alberio L, Fontana P, Wuillemin WA, Schmidt A, Graf L, Gerber B, Amstutz U, Bovet C, Sauter TC, Asmis LM, Nagler M. Accuracy of a Single, Heparin-Calibrated Anti-Xa Assay for the Measurement of Rivaroxaban, Apixaban, and Edoxaban Drug Concentrations: A Prospective Cross-Sectional Study. Front Cardiovasc Med 2022; 9:817826. [PMID: 35369293 PMCID: PMC8969025 DOI: 10.3389/fcvm.2022.817826] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background Applying a single anti-Xa assay, calibrated to unfractionated heparin to measure rivaroxaban, apixaban, and edoxaban would simplify laboratory procedures and save healthcare costs. Aim We hypothesized that a heparin-calibrated anti-Xa assay would accurately measure rivaroxaban, apixaban, and edoxaban drug concentrations and correctly predict clinically relevant drug levels. Methods This analysis is part of the Simple-Xa study, a prospective multicenter cross-sectional study conducted in clinical practice. Patients treated with rivaroxaban, apixaban, or edoxaban were included. Anti-Xa activity was measured using the Siemens INNOVANCE® Heparin assay. Drug concentrations were determined using ultra-high performance liquid chromatography-tandem mass spectrometry (LC-MS/MS). Cut-off levels were determined in a derivation dataset (50% of patients) and sensitivities and specificities were calculated in a verification dataset (50% of patients). Results Overall, 845 patients were available for analysis. Correlation coefficients (r s ) between the heparin-calibrated anti-Xa assay and drug concentrations were 0.97 (95% CI 0.97, 0.98) for rivaroxaban, 0.96 (0.96, 0.97) for apixaban, and 0.96 (0.94, 0.99) for edoxaban. The area under the receiver operating characteristics curve (ROC) was 0.99 for all clinically relevant drug concentrations. In the verification dataset, the sensitivity was 94.2% (95% CI 90.8-96.6) for 30 μg L-1, 95.8% (92.4-98.0) for 50 μg L-1, and 98.7% (95.5-99.9) for 100 μg L-1. Specificities were 86.3% (79.2-91.7), 89.8% (84.5-93.7), and 88.7% (84.2-92.2), respectively. Conclusion In a large prospective study in clinical practice, a strong correlation of heparin-calibrated anti-Xa measurements with LC-MS/MS results was observed and clinically relevant drug concentrations were predicted correctly.
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Affiliation(s)
- Tamana Meihandoest
- Department of Epidemiology, Maastricht University, Maastricht, Netherlands.,Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Jan-Dirk Studt
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Adriana Mendez
- Institute for Laboratory Medicine, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Walter A Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne and University of Bern, Bern, Switzerland
| | - Adrian Schmidt
- Institute of Laboratory Medicine and Clinic of Medical Oncology and Hematology, City Hospital Zurich, Zurich, Switzerland
| | - Lukas Graf
- Center for Laboratory Medicine, St. Gallen, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Ursula Amstutz
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Cedric Bovet
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Lars M Asmis
- Centre for Perioperative Thrombosis and Haemostasis, Zurich, Switzerland
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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53
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Briete LD, Towers WF, Bone R, Nair R, Steck M, Cutshall BT, Shah SP. Perioperative Anticoagulation Management. Crit Care Nurs Q 2022; 45:119-131. [PMID: 35212652 DOI: 10.1097/cnq.0000000000000395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Management of anticoagulation in individuals undergoing operative procedures is a complex situation. Each case should be assessed individually with proper risk assessment, monitoring, and plan for perioperative and postoperative anticoagulation. Clinical evidence for the management of these patients is relatively scarce, and clinicians are often assessing each individual case with minimal guidance. This review provides nurses with a summary of available literature on the assessment, laboratory monitoring, timing of adjusting anticoagulation, and bridging prior to procedures. In addition to general perioperative anticoagulation management, this review discusses perioperative management in special populations and provides a summary on principles when anticoagulation should be resumed following a procedure.
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Affiliation(s)
- Lauren D Briete
- Department of Pharmacy, Mississippi Baptist Medical Center, Jackson (Dr Briete); Department of Pharmacy, MD Anderson Cancer Center, Houston, Texas (Dr Towers); Department of Pharmacy, Methodist University Hospital, Memphis, Tennessee (Drs Bone and Cutshall); Department of Cardiothoracic Surgery, Stanford Healthcare, Stanford, California (Mr Nair); Department of Pharmacy, Indiana University Health Arnett Hospital, Lafayette (Dr Steck); and Department of Pharmacy, Mercy Health, Janesville, Wisconsin (Dr Shah)
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54
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Prospective cohort study on the use of low molecular weight heparin calibrated anti-Xa assay for measurement of direct oral Xa inhibitors in ex vivo patient samples. Pathology 2022; 54:599-605. [DOI: 10.1016/j.pathol.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 11/21/2022]
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55
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Pavoni V, Gianesello L, Conti D, Ballo P, Dattolo P, Prisco D, Görlinger K. "In Less than No Time": Feasibility of Rotational Thromboelastometry to Detect Anticoagulant Drugs Activity and to Guide Reversal Therapy. J Clin Med 2022; 11:1407. [PMID: 35268498 PMCID: PMC8911211 DOI: 10.3390/jcm11051407] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/23/2022] [Accepted: 03/03/2022] [Indexed: 02/04/2023] Open
Abstract
Anticoagulant drugs (i.e., unfractionated heparin, low-molecular-weight heparins, vitamin K antagonists, and direct oral anticoagulants) are widely employed in preventing and treating venous thromboembolism (VTE), in preventing arterial thromboembolism in nonvalvular atrial fibrillation (NVAF), and in treating acute coronary diseases early. In certain situations, such as bleeding, urgent invasive procedures, and surgical settings, the evaluation of anticoagulant levels and the monitoring of reversal therapy appear essential. Standard coagulation tests (i.e., activated partial thromboplastin time (aPTT) and prothrombin time (PT)) can be normal, and the turnaround time can be long. While the role of viscoelastic hemostatic assays (VHAs), such as rotational thromboelastometry (ROTEM), has successfully increased over the years in the management of bleeding and thrombotic complications, its usefulness in detecting anticoagulants and their reversal still appears unclear.
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Affiliation(s)
- Vittorio Pavoni
- Anesthesia and Intensive Care Unit, Emergency Department and Critical Care Area, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy; (V.P.); (D.C.)
| | - Lara Gianesello
- Department of Anesthesia and Intensive Care, Orthopedic Anesthesia, University-Hospital Careggi, 50134 Florence, Italy
| | - Duccio Conti
- Anesthesia and Intensive Care Unit, Emergency Department and Critical Care Area, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy; (V.P.); (D.C.)
| | - Piercarlo Ballo
- Cardiology Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy;
| | - Pietro Dattolo
- Nephrology Unit Florence 1, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy;
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy;
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany;
- Medical Department, Tem Innovations, 81829 Munich, Germany
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56
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Kietaibl S, Ferrandis R, Godier A, Llau J, Lobo C, Macfarlane AJ, Schlimp CJ, Vandermeulen E, Volk T, von Heymann C, Wolmarans M, Afshari A. Regional anaesthesia in patients on antithrombotic drugs: Joint ESAIC/ESRA guidelines. Eur J Anaesthesiol 2022; 39:100-132. [PMID: 34980845 DOI: 10.1097/eja.0000000000001600] [Citation(s) in RCA: 75] [Impact Index Per Article: 37.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Bleeding is a potential complication after neuraxial and peripheral nerve blocks. The risk is increased in patients on antiplatelet and anticoagulant drugs. This joint guideline from the European Society of Anaesthesiology and Intensive Care and the European Society of Regional Anaesthesia aims to provide an evidence-based set of recommendations and suggestions on how to reduce the risk of antithrombotic drug-induced haematoma formation related to the practice of regional anaesthesia and analgesia. DESIGN A systematic literature search was performed, examining seven drug comparators and 10 types of clinical intervention with the outcome being peripheral and neuraxial haematoma. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the methodological quality of the included studies and for formulating recommendations. A Delphi process was used to prepare a clinical practice guideline. RESULTS Clinical studies were limited in number and quality and the certainty of evidence was assessed to be GRADE C throughout. Forty clinical practice statements were formulated. Using the Delphi-process, strong consensus (>90% agreement) was achieved in 57.5% of recommendations and consensus (75 to 90% agreement) in 42.5%. DISCUSSION Specific time intervals should be observed concerning the adminstration of antithrombotic drugs both prior to, and after, neuraxial procedures or those peripheral nerve blocks with higher bleeding risk (deep, noncompressible). These time intervals vary according to the type and dose of anticoagulant drugs, renal function and whether a traumatic puncture has occured. Drug measurements may be used to guide certain time intervals, whilst specific reversal for vitamin K antagonists and dabigatran may also influence these. Ultrasound guidance, drug combinations and bleeding risk scores do not modify the time intervals. In peripheral nerve blocks with low bleeding risk (superficial, compressible), these time intervals do not apply. CONCLUSION In patients taking antiplatelet or anticoagulant medications, practitioners must consider the bleeding risk both before and after nerve blockade and during insertion or removal of a catheter. Healthcare teams managing such patients must be aware of the risk and be competent in detecting and managing any possible haematomas.
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Affiliation(s)
- Sibylle Kietaibl
- From the Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna and Sigmund Freud Private University, Vienna, Austria (SK), Department of Anaesthesiology and Critical Care, Hospital Universitari i Politècnic La Fe, Valencia, Spain (RF), Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris (AG), INSERM UMRS-1140 Paris University, Paris, France (AG), Department of Anaesthesiology and Critical Care, Doctor Peset University Hospital (JL), Department of Surgery, Valencia University, Valencia, Spain (JL), Serviço de Anestesiologia Hospital das Forças Armadas, Pólo Porto, Porto, Portugal (CL), Department of Anaesthesia Pain Medicine and Critical Care, Glasgow Royal Infirmary, University of Glasgow, Glasgow, UK (AM), Department of Anaesthesia and Intensive Care Medicine, AUVA Trauma Centre Linz, Linz (CJS); Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria (CJS), Department of Anaesthesia, University Hospitals Leuven. Catholic University of Leuven, Leuven, Belgium (EV), Department of Anaesthesiology, Intensive Care and Pain Therapy, Saarland University Medical Center and Saarland University Faculty of Medicine, Homburg/Saar (TV), Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany (CVH), Department of Anaesthesia, Norfolk and Norwich University Hospital NHS Trust, Norwich, Norfolk, UK (MW), and Department of Pediatric and Obstetric Anesthesia, Juliane Marie Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (AA)
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57
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Margetić S, Ćelap I, Lovrenčić Huzjan A, Bosnar Puretić M, Šupraha Goreta S, Čajević Glojnarić A, Delić Brkljačić D, Mioč P, Harenberg J, Hetjens S, Weiss C. DOAC Dipstick testing can reliably exclude the presence of clinically relevant DOAC concentrations in circulation. Thromb Haemost 2022; 122:1542-1548. [PMID: 35088395 PMCID: PMC9420550 DOI: 10.1055/a-1753-2748] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
In certain clinical situations, it is necessary to determine whether clinically relevant plasma levels of direct oral anticoagulants (DOACs) are present. We examined whether qualitative testing of DOACs in urine samples can exclude DOAC plasma concentrations of ≥30 ng/mL. This prospective single-center cohort study included consecutive patients treated with an oral direct factor Xa inhibitor (DXI) (apixaban,
n
= 31, rivaroxaban,
n
= 53) and direct thrombin inhibitor (DTI) (dabigatran,
n
= 44). We aimed to define the negative predictive value (NPV) and other statistical parameters of detecting DXIs and DTIs by DOAC Dipstick at plasma concentrations of ≥30 ng/mL. We also determined the best-fit threshold plasma levels using chromogenic substrate assays by logistic regression analysis. Between July 2020 and July 2021, 128 eligible patients (mean age 66 years, 55 females) were included into the study. The NPVs and sensitivities for DXI and DTI of DOAC Dipstick were 100% at ≥30 ng/mL plasma, for specificities 6 and 21% and for positive predictive values 62 and 72%, respectively. All diagnostic statistical tests improved to values between 86 and 100% at best-fitting plasma thresholds of ≥14 ng/mL for DXI and ≥19 ng/mL for DTI. Visual analysis using the DOAC Dipstick was 100% in agreement with that of the optoelectronic DOASENSE Reader for all the three DOACs.
DOAC Dipstick testing can reliably exclude the presence of DOACs in urine samples at best-fitting thresholds of >14 and >19 ng/mL in plasma. The performance of the DOAC Dipstick at detecting lower DOAC concentrations in plasma requires confirmation.
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Affiliation(s)
- Sandra Margetić
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Ivana Ćelap
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | | | | | | | - Anesa Čajević Glojnarić
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Diana Delić Brkljačić
- Department of Cardiovascular Diseases, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Pavao Mioč
- Department of Cardiovascular Diseases, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Job Harenberg
- DOASENSE GmbH, Heidelberg, Germany, Heidelberg, Germany.,University of Heidelberg, Heidelberg, Germany
| | - Svetlana Hetjens
- Department of Medical Statistics and Biomathematics, University of Heidelberg Medical Faculty Mannheim, Heidelberg, Germany
| | - Christel Weiss
- Department of Medical Statistics and Biomathematics, University of Heidelberg Medical Faculty Mannheim, Heidelberg, Germany
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58
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Artang R, Dias JD, Walsh M, Bliden K, Nielsen JD, Anderson M, Thurston BC, Tantry US, Hartmann J, Gurbel PA. Measurement of Anticoagulation in Patients on Dabigatran, Rivaroxaban, and Apixaban Therapy by Novel Automated Thrombelastography. TH OPEN 2022; 5:e570-e576. [PMID: 34984316 PMCID: PMC8718262 DOI: 10.1055/a-1692-1415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 11/04/2021] [Indexed: 10/25/2022] Open
Abstract
Background Direct-acting oral anticoagulants (DOACs) do not require monitoring. Measurement of DOAC effect would be useful in the event of bleeding, trauma, and thromboembolism while on anticoagulation. We evaluated the effectiveness of the investigational DOAC assays on the TEG®6s Hemostasis Analyzer to assess the anticoagulant effect of DOACs in patients treated for atrial fibrillation or deep vein thrombosis (DVT). Methods Patients on treatment for a minimum of 7 days with standard doses of dabigatran, rivaroxaban, and apixaban were included. DOAC plasma concentrations and TEG®6s Reaction (R)-time were measured and correlated. The sensitivity, specificity, and negative predictive value (NPV) of R-time to detect DOAC concentrations of ≥30, ≥50, and ≥100 ng/mL were calculated. Results A total of 189 patients were included, ( n = 50) on apixaban, ( n = 62) on rivaroxaban, ( n = 53) on dabigatran, and ( n = 24) on no DOAC were studied. Using the direct thrombin inhibitor (DTI) channel, R-time demonstrated strong linear correlation with dabigatran levels (r = 0.93, p < 0.0001). Using the antifactor Xa (AFXa) channel, R-time demonstrated strong nonlinear correlation with rivaroxaban and apixaban levels ( r s = 0.92 and 0.84, respectively, p < 0.0001 for both). R-time revealed strong sensitivity and NPV in detecting low DOAC levels for the predefined concentrations. Conclusion R-time measured by TEG®6s DOAC-specific cartridge has a strong correlation with concentrations of the most commonly used DOACs with high sensitivity and NPV for detecting lower drug levels that are considered clinically relevant for patients in need of antidote, or prior to urgent surgery. Further studies to determine the relation of R-time to clinical outcomes are warranted.
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Affiliation(s)
- Ramin Artang
- Essentia Health St. Mary's Heart and Vascular Center, Duluth, Minnesota, United States.,Bispebjerg University of Copenhagen Hospital, Department of Cardiology, Copenhagen, Denmark
| | - Joao D Dias
- Haemonetics Corp., Braintree, Massachusetts, United States
| | - Mark Walsh
- Memorial Hospital of South Bend, Department of Energy Medicine, Sound Bend, Indiana, United States
| | - Kevin Bliden
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
| | - Jorn D Nielsen
- Bispebjerg University of Copenhagen Hospital, Department of Cardiology, Copenhagen, Denmark
| | - Maren Anderson
- University of Minnesota School of Medicine, Duluth, Minnesota, United States
| | - Brian C Thurston
- Spartanburg Regional Medical Center, Division of Surgery, Spartanburg, South Carolina, United States
| | - Udaya S Tantry
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
| | - Jan Hartmann
- Haemonetics Corp., Braintree, Massachusetts, United States
| | - Paul A Gurbel
- Sinai Center for Thrombosis Research and Drug Development, Sinai Hospital of Baltimore, Baltimore, Maryland, United States
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59
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Burnett AE. Perioperative consultative hematology: can you clear my patient for a procedure? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:521-528. [PMID: 34889442 PMCID: PMC8791149 DOI: 10.1182/hematology.2021000287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Periprocedural management of antithrombotics is a common but challenging clinical scenario that renders patients vulnerable to potential adverse events such as bleeding and thrombosis. Over the past decade, periprocedural antithrombotic approaches have changed considerably with the advent of direct oral anticoagulants (DOACs), as well as a paradigm shift away from bridging in many warfarin patients. Successfully navigating this high-risk period relies on a number of individualized patient assessments conducted within a framework of standardized, systematic approaches. It also requires a thorough understanding of antithrombotic pharmacokinetics, multidisciplinary coordination of care, and comprehensive patient education and empowerment. In this article, we provide clinicians with a practical, stepwise approach to periprocedural management of antithrombotic agents through case-based examples of relevant clinical scenarios.
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60
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Merli GJ, Kraft WK, Eraso LH, Galanis T, Thomson LJ, Ouma GO, Viscusi E, Gong JZ, Lam E. Apixaban Discontinuation for Invasive Or major Surgical procedures (ADIOS): A prospective cohort study. Vasc Med 2021; 27:269-276. [PMID: 34809507 DOI: 10.1177/1358863x211047270] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Apixaban pharmacokinetic properties and some clinical reports suggest cessation 48 hours prior to surgery is safe, but this has not been demonstrated in a naturalistic setting. We sought to measure the residual apixaban exposure in patients who had apixaban held as part of standard of care perioperative management. Methods: This was a prospective, observational study of patients in whom apixaban plasma concentration and anti-Xa activity were measured while at steady state apixaban dosing and again immediately prior to surgery. Clinical management of cessation and resumption of apixaban was at the discretion of the treating physician. Results: Paired blood samples were provided by 111 patients. Ninety-four percent (104/111) of patients had measured apixaban concentrations of ⩽ 30 ng/mL. Only one patient had a value > 50 ng/mL. The median time between the self-reported last dose and presurgery blood sampling was 76 hours (range 32-158) for those who achieved concentrations ⩽ 30 ng/mL and 59 hours (range 49-86) for those > 30 ng/mL. Measured anti-Xa activity correlated well with apixaban exposure. Clinically significant nonmajor bleeding was reported in one patient at 1 week postsurgery. There was one venous thromboembolic event and one stroke in the perioperative period. Conclusion: In a naturalistic setting with a heterogeneous patient population, apixaban discontinuation for at least 48 hours before a procedure resulted in a clinically insignificant degree of anticoagulation prior to a surgical procedure. ClinicalTrials.gov Identifier: NCT02935751.
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Affiliation(s)
- Geno J Merli
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Walter K Kraft
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA, USA
| | - Luis H Eraso
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Taki Galanis
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA.,Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lynda J Thomson
- Department of Pharmacy, Thomas Jefferson University, Philadelphia, PA, USA
| | - Geoffrey O Ouma
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eugene Viscusi
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jerald Z Gong
- Department of Pathology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Edwin Lam
- Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, PA, USA.,Departments of Pharmacy, Clinical Pharmacokinetics Research Unit, National Institutes of Health, Bethesda, MD, USA
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61
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Wallwork S, Wang Y, Chaiwatanatorn K, Cole Sinclair M. Prothrombin complex concentrates for the urgent reversal of apixaban and rivaroxaban - an Australian retrospective cohort study. Intern Med J 2021; 53:803-811. [PMID: 34779569 DOI: 10.1111/imj.15621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/30/2021] [Accepted: 11/07/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Direct acting oral anticoagulants (DOACs) are now commonly prescribed medications. Urgent reversal of their anticoagulant effect is sometimes required in emergency situations. In Australia, a specific reversal agent for factor Xa (FXa)- inhibitor DOACs is not available. Instead, two non-specific haemostatic agents, activated prothrombin complex concentrate (aPCC) and 3 factor-prothrombin complex concentrate (3F-PCC), are used off-label despite a paucity of evidence for their effectiveness or safety. METHODS We conducted a single-centre retrospective cohort study to investigate the use of aPCC and 3F-PCC for patients on FXa-inhibitor DOACs who present with a significant bleeding event or who require urgent surgery. The primary outcome was haemostatic efficacy according to prespecified criteria. Safety outcomes included the thromboembolic event rate and all-cause mortality during the hospital admission. RESULTS A total of 51 patients were included in the study (36 patients who had a spontaneous bleeding even (SBE) and 15 non-bleeding patients who required urgent perioperative management). Thirty-one patients received aPCC and 20 patients received 3F-PCC. Haemostasis was adjudicated as effective in all assessable patients (n = 50; 100%). Thromboembolic events occurred in three patients who received aPCC and one patient who received 3F-PCC. All-cause mortality was 7.8% (4 patients). CONCLUSIONS Both aPCC and 3F-PCC are useful adjuncts for the management of patients who require urgent reversal of the anticoagulant effect of FXa-inhibitor DOACs. However, the risk of thromboembolism in this patient group requires careful consideration. Prospective, comparator studies are needed along with the development of guidelines that reflect the availability of haemostatic agents in Australia. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Yang Wang
- St Vincent's Hospital, Melbourne, Australia
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62
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Hanigan S, Barnes GD. DOAC drug levels: Does "knowing" lead to safer care? Thromb Res 2021; 208:127-128. [PMID: 34768096 DOI: 10.1016/j.thromres.2021.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 10/27/2021] [Accepted: 10/29/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Sarah Hanigan
- University of Michigan College of Pharmacy, Ann Arbor, MI, USA
| | - Geoffrey D Barnes
- University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA.
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Abstract
From preoperative medications to intraoperative needs to postoperative thromboprophylaxis, anticoagulants are encountered throughout the perioperative period. This review focuses on coagulation testing clinicians utilize to monitor the effects of these medications.
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64
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Davis SEB, Dehne KA, Rubinos CA, Lau WK, Northam KA. Difficulties Detecting Clinically Relevant Factor Xa Inhibitor Levels Prior to Reversal With Andexanet Alfa for Intracranial Hemorrhage. Neurohospitalist 2021; 12:276-279. [PMID: 35419146 PMCID: PMC8995585 DOI: 10.1177/19418744211048013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Coagulation factor Xa (recombinant), inactivated-zhzo (andexanet alfa) is approved for reversal of life-threatening bleeding with rivaroxaban and apixaban use. Clinical decision-making to initiate reversal is reliant on dose taken and timing of last dose. In practice, timing of last dose may be unknown, and the turnaround time for drug-specific anti-factor Xa levels at some institutions may be prolonged, leaving clinicians balancing a difficult decision with limited tools. This report includes a series of 3 patients who presented to our institution with an intracranial hemorrhage and received andexanet alfa for apixaban reversal. These cases highlight the challenges clinicians are facing when using andexanet alfa for emergent rivaroxaban or apixaban reversal when the timing of last dose is unknown, or patients fall outside of the recommended timeframe for use and clinically relevant drug levels are still suspected. Based on our experiences, we encourage other institutions to evaluate their abilities to rapidly and accurately detect the presence of clinically relevant rivaroxaban and apixaban levels when utilizing andexanet alfa.
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Affiliation(s)
| | - Kelly A. Dehne
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Clio A. Rubinos
- Department of Neurology, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Winnie K. Lau
- Department of Neurology, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Kalynn A. Northam
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
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Towers W, Nguyen SN, Ruegger MC, Salazar E, Donahue KR. Apixaban and Rivaroxaban Anti-Xa Level Monitoring Versus Standard Monitoring in Hospitalized Patients With Acute Kidney Injury. Ann Pharmacother 2021; 56:656-663. [PMID: 34541895 DOI: 10.1177/10600280211046087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Oral direct factor Xa inhibitors (FxaIs) are renally eliminated; thus, acute kidney injury (AKI) may increase the risk for drug accumulation and bleeding. There is minimal data describing the effects of AKI on FxaI anti-Xa levels or clinical outcomes. OBJECTIVE To compare anti-Xa level monitoring with standard monitoring in patients who experience AKI on apixaban or rivaroxaban. METHODS This retrospective study included patients admitted within a large hospital system from May 2016 to October 2020. Patients were included if they received apixaban or rivaroxaban prior to AKI. Patients were stratified into 1 of 2 groups: those with anti-Xa level monitoring or those who received standard monitoring. The primary outcome was major bleeding as defined by the International Society of Thrombosis and Haemostasis. RESULTS A total of 196 patients were included in the final analysis. Major bleeding occurred in 2 patients who received anti-Xa level monitoring, compared with 14 patients who received standard monitoring (2.1% vs 14%; P < 0.01). Variables identified as predictors of major bleeding included a documented history of liver disease (adjusted odds ratio = 3.17; 95% CI = 1.04-9.67; P = 0.04) and antiplatelet use (adjusted odds ratio = 4.18; 95% CI = 1.28-13.7; P = 0.02). CONCLUSION AND RELEVANCE This is the first study to demonstrate that anti-Xa level monitoring was associated with a significant reduction in major bleeding compared with standard monitoring in patients with AKI who received apixaban or rivaroxaban. The optimal management of antithrombotic medications in patients with AKI and recent exposure to an FxaI requires further investigation.
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Affiliation(s)
- William Towers
- Houston Methodist Hospital-Texas Medical Center, Houston, TX, USA
| | | | | | - Eric Salazar
- Houston Methodist Hospital-Texas Medical Center, Houston, TX, USA
| | - Kevin R Donahue
- Houston Methodist Hospital-Texas Medical Center, Houston, TX, USA
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Braun G. [Management of bleeding in patients on antithrombotic therapy]. Med Klin Intensivmed Notfmed 2021; 116:491-498. [PMID: 34463792 DOI: 10.1007/s00063-021-00848-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 06/24/2021] [Accepted: 07/12/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Severe bleeding under antithrombotic therapy is common and challenging in intensive care medicine; on the one hand, rapid bleeding control must be achieved and, on the other hand, thromboembolic complications must be avoided. AIMS The paper will provide a brief overview of direct oral anticoagulants, therapeutic options and precise instructions for dealing with severe bleeding. RESULTS In addition to general measures in direct oral anticoagulant (DOAC)-associated major bleeding, prothrombin complex concentrate (PCC), idarucizumab and andexanet alfa are available as specific antidote therapy. In case of bleeding under heparin therapy, protamine sulfate is available as a possible antidote. CONCLUSIONS In particular, the importance of andexanet alfa in the treatment of factor Xa inhibitor-associated bleeding requires further investigation.
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Affiliation(s)
- Georg Braun
- Intensivzentrum, Medizinische Klinik 3 am Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
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67
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De Maria C, Galante A, Fasoli A, De Gottardi A. When and how to use direct oral anticoagulants in patients with advanced chronic liver disease? Curr Opin Pharmacol 2021; 60:111-116. [PMID: 34403992 DOI: 10.1016/j.coph.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022]
Abstract
Direct oral anticoagulants (DOACs) emerged as effective and safe alternatives to traditional anticoagulants for the prevention and treatment of venous thromboembolic disease and the prevention of stroke in non-valvular atrial fibrillation. Patients with advanced chronic liver disease (ACLD) have a higher risk of thromboembolism and bleeding than patients with normal liver function. Therefore, anticoagulation and, in particular, direct oral anticoagulants play a central role. Portal vein thrombosis is a relatively frequent complication in patients with ACLD, but its treatment remains challenging. DOACs have been introduced in clinical practice and demonstrated similar efficacy and safety profiles compared with vitamin K antagonist and heparins. However, further data about the use of DOACs in patients suffering from ACLD are needed. This review summarizes current knowledge in terms of anticoagulation in patients with ACLD and focuses on the available data about the use of DOACs in this population.
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Affiliation(s)
- Costanza De Maria
- Gastroenterology and Hepatology, Ente Ospedaliero Cantonale, Switzerland
| | - Antonio Galante
- Gastroenterology and Hepatology, Ente Ospedaliero Cantonale, Switzerland
| | - Alberto Fasoli
- Gastroenterology and Hepatology, Ente Ospedaliero Cantonale, Switzerland
| | - Andrea De Gottardi
- Gastroenterology and Hepatology, Ente Ospedaliero Cantonale, Switzerland; Facoltà di Scienze Biomediche, Università Della Svizzera Italiana, Lugano, Switzerland.
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Zepeski AE, Faine BA, Merrill AE, Sutamtewagul G, Bhagavathi S. Utilization of anti-factor Xa levels to guide reversal of oral factor Xa inhibitors in the emergency department. Am J Health Syst Pharm 2021; 79:e20-e26. [PMID: 34363457 PMCID: PMC8385943 DOI: 10.1093/ajhp/zxab326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Purpose Oral factor Xa inhibitors (FXaIs) are increasingly utilized for outpatient anticoagulation therapy; however, laboratory monitoring is not routinely used to assess the safety and efficacy of these agents. We aimed to evaluate the role of chromogenic anti–factor Xa (anti-Xa) assays in the emergency department (ED) in the setting of patients with an acute bleed or requiring emergent procedures. Methods A retrospective review of anti-Xa levels obtained in the ED between June 1, 2019, and April 30, 2020, was completed. Data were collected to describe the clinical setting of anti-Xa level collection, oral FXaIs used before admission, administration of reversal agents, and patient disposition to further characterize the role of anti-Xa levels in the management of rivaroxaban and apixaban reversal. Results Thirty anti-Xa levels were included in the final analysis. The median time from sample collection to anti-Xa assay result was 45.9 minutes (interquartile range, 35.3-54.7 minutes). Eleven patients (37%) received anticoagulation reversal after their anti-Xa levels were determined. Anticoagulation reversal agents included either activated prothrombin complex concentrates (aPCCs) or prothrombin complex concentrates (PCCs). Anti-Xa levels were collected in 2 patients who had received PCCs before arrival at our ED. Of the patients with anti-Xa levels below 30 ng/mL, none received aPCCs or PCCs after their anti-Xa levels were determined. Anti-Xa assays were used to rule out the presence of FXaIs in 3 patients. Conclusion This study illustrates the novel role of anti-Xa levels in managing patients with an emergent need for reversal in the ED. The assay may be used to rule out the presence of oral FXaIs and avoid unnecessary administrations of anticoagulation reversal agents.
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Affiliation(s)
- Anne E Zepeski
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
- Department of Pharmacy Practice and Science, University of Iowa College of Pharmacy, Iowa City, IA, USA
- Address correspondence to Dr. Zepeski (). Twitter: @annezepeski
| | - Brett A Faine
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
- Department of Pharmacy Practice and Science, University of Iowa College of Pharmacy, Iowa City, IA, USA
| | - Anna E Merrill
- Department of Pathology, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Grerk Sutamtewagul
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
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Oberladstätter D, Schlimp CJ, Zipperle J, Osuchowski MF, Voelckel W, Grottke O, Schöchl H. Impact of Idarucizumab and Andexanet Alfa on DOAC Plasma Concentration and ClotPro ® Clotting Time: An Ex Vivo Spiking Study in A Cohort of Trauma Patients. J Clin Med 2021; 10:jcm10163476. [PMID: 34441771 PMCID: PMC8396852 DOI: 10.3390/jcm10163476] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/28/2021] [Accepted: 07/31/2021] [Indexed: 12/01/2022] Open
Abstract
Specific antagonists have been developed for the reversal of direct oral anticoagulants (DOAC). We investigated the impact of these reversal agents on the plasma concentration and visco-elastic test results of dabigatran and factor Xa inhibitors. After baseline measurements of dabigatran, the plasma concentration, and the visco-elastic ClotPro® ecarin clotting time (ECA-CT), we added the reversal agent Idarucizumab in vitro and these two analyses were repeated. Likewise, the baseline plasma concentration of apixaban, edoxaban, and rivaroxaban as well as ClotPro® Russell’s viper venom test clotting time (RVV-CT) were measured and reanalyzed following Andexanet alfa spiking. We analyzed fifty blood samples from 37 patients and 10 healthy volunteers. Idarucizumab decreased the measured dabigatran plasma concentration from 323.9 ± 185.4 ng/mL to 5.9 ± 2.3 ng/mL and ECA-CT from 706.2 ± 344.6 s to 70.6 ± 20.2 s, (all, p < 0.001). Andexanet alfa decreased the apixaban concentration from 165.1 ± 65.5 ng/mL to 9.8 ± 8.1 ng/mL, edoxaban from 152.4 ± 79.0 ng/mL to 36.4 ± 19.2 ng/mL, and rivaroxaban from 153.2 ± 111.8 ng/mL to 18.1 ± 9.1 ng/mL (all p < 0.001). Andexanet alfa shortened the RVV-CT of patients with apixaban from 239.2 ± 71.7 s to 151.1 ± 30.2 s, edoxaban from 288.2 ± 65.0 s to 122.7 ± 37.1 s, and rivaroxaban from 225.9 ± 49.3 s to 103.7 ± 12.1 s (all p < 0.001). In vitro spiking of dabigatran-containing blood with Idarucizumab substantially reduced the plasma concentration and ecarin-test clotting time. Andexanet alfa lowered the concentration of the investigated factor Xa-inhibitors but did not normalize the RVV-CT. In healthy volunteers’ blood, Idarucizumab spiking had no impact on ECA-CT. Andexanet alfa spiking of non-anticoagulated blood prolonged RVV-CT (p = 0.001), potentially as a consequence of a competitive antagonism with human factor Xa.
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Affiliation(s)
- Daniel Oberladstätter
- AUVA Trauma Centre Salzburg, Department of Anaesthesiology and Intensive Care Medicine, Academic Teaching Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria; (W.V.); (H.S.)
- AUVA Trauma Research Centre, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, 1200 Vienna, Austria; (C.J.S.); (J.Z.); (M.F.O.)
- Correspondence: ; Tel.: +43-(0)59393-44368
| | - Christoph J. Schlimp
- AUVA Trauma Research Centre, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, 1200 Vienna, Austria; (C.J.S.); (J.Z.); (M.F.O.)
- AUVA Trauma Centre Linz, Department of Anaesthesiology and Intensive Care Medicine, 4010 Linz, Austria
| | - Johannes Zipperle
- AUVA Trauma Research Centre, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, 1200 Vienna, Austria; (C.J.S.); (J.Z.); (M.F.O.)
| | - Marcin F. Osuchowski
- AUVA Trauma Research Centre, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, 1200 Vienna, Austria; (C.J.S.); (J.Z.); (M.F.O.)
| | - Wolfgang Voelckel
- AUVA Trauma Centre Salzburg, Department of Anaesthesiology and Intensive Care Medicine, Academic Teaching Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria; (W.V.); (H.S.)
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, 52074 Aachen, Germany;
| | - Herbert Schöchl
- AUVA Trauma Centre Salzburg, Department of Anaesthesiology and Intensive Care Medicine, Academic Teaching Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria; (W.V.); (H.S.)
- AUVA Trauma Research Centre, Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, 1200 Vienna, Austria; (C.J.S.); (J.Z.); (M.F.O.)
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Härtig F, Birschmann I, Peter A, Hörber S, Ebner M, Sonnleitner M, Spencer C, Bombach P, Stefanou MI, Kuhn J, Mengel A, Ziemann U, Poli S. Point-of-care testing of coagulation in patients treated with edoxaban. J Thromb Thrombolysis 2021; 50:632-639. [PMID: 32436010 PMCID: PMC7515947 DOI: 10.1007/s11239-020-02143-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Edoxaban, alongside other direct oral anticoagulants (DOAC), is increasingly used for prevention of thromboembolism, including stroke. Despite DOAC therapy, however, annual stroke rate in patients with atrial fibrillation remains 1–2%. Rapid exclusion of relevant anticoagulation is necessary to guide thrombolysis or reversal therapy but, so far, no data exists on the effect of edoxaban on available point-of-care test systems (POCT). To complete our previous investigation on global coagulation-POCT for the detection of DOAC, we evaluated whether CoaguChek®-INR (CC-INR) is capable of safely ruling out edoxaban concentrations above the current treatment thresholds of 30/50 ng/mL in a blood sample. We studied patients receiving a first dose of edoxaban; excluding subjects receiving other anticoagulants. Six blood samples were collected from each patient: before drug intake, 0.5, 1, 2 and 8 h after intake, and at trough (24 h). CC-INR and mass spectrometry for edoxaban concentrations were performed for each time-point. One hundred and twenty blood samples from 20 patients contained 0–302 ng/mL of edoxaban. CC-INR ranged from 0.9 to 2.3. Pearson’s correlation coefficient showed strong correlation between CC-INR and edoxaban concentrations (r = 0.73, p < 0.001). Edoxaban concentrations > 30 and > 50 ng/mL were ruled out by CC-INR ≤ 1.0 and ≤ 1.1, respectively, with high specificity (> 95%), and a sensitivity of 44% (95%-confidence interval: 30–59%) and 86% (74–93%), respectively. Our study represents the first evaluation of coagulation-POCT in edoxaban-treated patients. CC-POCT is suitable to safely exclude clinically relevant edoxaban concentrations prior to thrombolysis, or guide reversal therapy in stroke patients.
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Affiliation(s)
- Florian Härtig
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Tübingen, Germany
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Ruhr University, Bad Oeynhausen, Germany
| | - Andreas Peter
- Department for Diagnostic Laboratory Medicine, Institute for Clinical Chemistry and Pathobiochemistry, University Hospital Tuebingen, Tübingen, Germany
| | - Sebastian Hörber
- Department for Diagnostic Laboratory Medicine, Institute for Clinical Chemistry and Pathobiochemistry, University Hospital Tuebingen, Tübingen, Germany
| | - Matthias Ebner
- Department of Nephrology and Medical Intensive Care, Charité - University Medicine Berlin, Berlin, Germany
| | - Matthias Sonnleitner
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Tübingen, Germany
| | - Charlotte Spencer
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Tübingen, Germany
| | - Paula Bombach
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Tübingen, Germany
| | - Maria-Ioanna Stefanou
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Tübingen, Germany
| | - Joachim Kuhn
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Ruhr University, Bad Oeynhausen, Germany
| | - Annerose Mengel
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Tübingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Tübingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, and Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Tübingen, Germany.
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Siddiqui F, Antic D, Tafur A, Bontekoe E, Hoppensteadt D, Gerotziafas G, Elalamy I, Fareed J. Thrombin Generation Profile in Various Lymphoma Sub-Groups and Its Augmentation by Andexanet Alfa. Clin Appl Thromb Hemost 2021; 26:1076029620983466. [PMID: 33372544 PMCID: PMC7783880 DOI: 10.1177/1076029620983466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The prevalence of thrombosis in lymphoma patients is reportedly high and ranges
from 3-10%. Vascular malfunction and inflammatory processes further contribute
to the thrombotic activation process in these patients. Andexanet alfa (AA) is
an antidote for factor Xa inhibitors and its usage has been reported with
thrombotic complications. This study was designed to compare the effect of AA on
the thrombin generation (TG) potential. Blood samples from 78 patients with
confirmed diagnosis of non-Hodgkin lymphoma (NHL), Hodgkin lymphoma (HL) and
Chronic lymphocytic leukemia (CLL) were collected from the University of
Belgrade Clinic, Serbia. Normal human plasma (NHP) was used for referencing
purposes. Individual samples were supplemented with AA at 100 ug/ml. TG studies
were carried out using a commercially available fluorogenic substrate method. TG
parameters such as peak thrombin (PT), lag time (LT) and area under the curve
(AUC) were compiled. Cumulatively, lymphoma patients showed an increase in LT
compared to NHP which decreases with AA. The PT and AUC levels were decreased
compared to NHP and increases with AA. Upon sub-grouping of lymphoma patients,
PT levels for all sub-groups were increased with AA. The AUC values increased
for HL and NHL and decreased for CLL with AA. Variations in lag time were noted
in all 3 sub-groups. Lymphoma represents a heterogenous group of patients where
both the hypercoagulable state and inflammatory responses simultaneously occur.
Increased thrombin generation in post AA supplemented samples suggest that the
use of this agent may potentially be associated with thrombotic
complications.
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Affiliation(s)
- Fakiha Siddiqui
- Department of Pathology and Laboratory Medicine, Cardiovascular Research Institute, Hemostasis and Thrombosis Research Division, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
| | - Darko Antic
- Head of Intensive care unit, Lymphoma Centre, Clinic for Hematology, Clinical Center Serbia, University of Belgrade, Belgrade, Serbia.,Department of Internal Medicine, University of Belgrade, Belgrade, Serbia
| | - Alfonso Tafur
- Northshore Cardiovascular Institute, NorthShore University Health Systems, Skokie, IL, USA
| | - Emily Bontekoe
- Department of Pathology and Laboratory Medicine, Cardiovascular Research Institute, Hemostasis and Thrombosis Research Division, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
| | - Debra Hoppensteadt
- Department of Pathology and Laboratory Medicine and Department of Pharmacology and Neuroscience, Cardiovascular Research Institute, Hemostasis and Thrombosis Research Division, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
| | - Grigoris Gerotziafas
- Head of Thrombosis and Haemostasis Unit, Co-Chair of Thrombosis Center, Service d'Hématologie Biologique, Tenon, University Hospital, France.,Cancer Biology and Therapeutics, Centre de Recherche Saint-Antoine, INSERM U938 and Université Pierre et Marie Curie, Paris, France
| | - Ismail Elalamy
- Service d'Hématologie Biologique, Hôpital Tenon UPMC EA3499, Paris, France
| | - Jawed Fareed
- Department of Pathology and Laboratory Medicine and Department of Pharmacology and Neuroscience, Cardiovascular Research Institute, Hemostasis and Thrombosis Research Division, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
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Volod O, Rollins-Raval M, Goodwin AJ, Higgins RA, Long T, Chandler WL, Harris NS, Pham HP, Isom JA, Moser K, Olson JD, Smock KJ, VanSandt A, Wool G, Chen D. The Interlaboratory Performance in Measurement of Dabigatran and Rivaroxaban: Results of the College of American Pathologists External Quality Assessment Program. Arch Pathol Lab Med 2021; 146:145-153. [PMID: 34133726 DOI: 10.5858/arpa.2020-0633-cp] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2021] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Assessing direct oral anticoagulant (DOAC) drug levels by reliable laboratory assays is necessary in a number of clinical scenarios. OBJECTIVE.— To evaluate the performance of DOAC-specific assays for various concentrations of dabigatran and rivaroxaban, assess the interlaboratory variability in measurement of these DOACs, and investigate the responsiveness of the routine clotting assays to various concentrations of these oral anticoagulants. DESIGN.— College of American Pathologists proficiency testing survey data from 2013 to 2016 were summarized and analyzed. RESULTS.— For dabigatran, the interlaboratory coefficient of variation (CV) of ecarin chromogenic assay was broad (ranging from 7.5% to 29.1%, 6.3% to 15.5%, and 6.8% to 9.0% for 100-ng/mL, 200-ng/mL, and 400-ng/mL targeted drug concentrations, respectively). The CV for diluted thrombin time for dabigatran was better overall (ranging from 11.6% to 17.2%, 9.3% to 12.3, and 7.1% to 11.2% for 100 ng/mL, 200 ng/mL, and 400 ng/mL, respectively). The rivaroxaban-calibrated anti-Xa assay CVs also showed variability (ranging from 11.5% to 22.2%, 7.2% to 10.9%, and 6.4% to 8.1% for 50-ng/mL, 200-ng/mL, and 400-ng/mL targeted drug concentrations, respectively). The prothrombin time (PT) and activated partial thromboplastin time (aPTT) showed variable dose and reagent-dependent responsiveness to DOACs: PT was more responsive to rivaroxaban and aPTT to dabigatran. The undiluted thrombin time showed maximum prolongation across all 3 dabigatran concentrations, making it too sensitive for drug-level monitoring, but supporting its use as a qualitative screening assay. CONCLUSIONS.— DOAC-specific assays performed reasonably well. While PT and aPTT cannot be used safely to determine DOAC degree of anticoagulation, a normal thrombin time excludes the presence of dabigatran.
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Affiliation(s)
- Oksana Volod
- From the Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California (Volod)
| | - Marian Rollins-Raval
- The Department of Pathology, The University of New Mexico, Albuquerque (Rollins-Raval)
| | - Andrew J Goodwin
- The Department of Pathology, University of Vermont Medical Center, Burlington (Goodwin IV)
| | - Russell A Higgins
- The Department of Pathology and Laboratory Medicine, University of Texas Health, San Antonio (Higgins, Olson)
| | - Thomas Long
- Biostatistics, College of American Pathologists, Northfield, Illinois (Long)
| | - Wayne L Chandler
- The Department of Pathology and Laboratory Medicine, Seattle Children's Hospital, Seattle, Washington (Chandler)
| | - Neil S Harris
- The Department of Pathology, University of Florida Health, Gainesville (Harris)
| | - Huy P Pham
- National Marrow Donor Program, Seattle Collection Center, Seattle, Washington (Pham)
| | - James Alexander Isom
- The Department of Pathology, University of South Florida Moffitt Cancer Center, Tampa (Isom)
| | - Karen Moser
- The Department of Pathology, University of Utah, Salt Lake City (Moser, Smock)
| | - John D Olson
- The Department of Pathology and Laboratory Medicine, University of Texas Health, San Antonio (Higgins, Olson)
| | - Kristi J Smock
- The Department of Pathology, University of Utah, Salt Lake City (Moser, Smock)
| | - Amanda VanSandt
- The Department of Pathology Oregon Health & Science University, Portland (VanSandt)
| | - Geoffrey Wool
- The Department of Pathology and Laboratory Medicine, University of Chicago, Chicago, Illinois (Wool)
| | - Dong Chen
- The Department of Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, Minnesota (Chen)
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73
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Bourdin M, Perrotin D, Mathieu O, Herve T, Depasse F, Lu G, Conley PB, Contant G. Measuring residual anti-Xa activity of direct factor Xa inhibitors after reversal with andexanet alfa. Int J Lab Hematol 2021; 43:795-801. [PMID: 34092030 PMCID: PMC8453859 DOI: 10.1111/ijlh.13591] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/26/2021] [Accepted: 04/28/2021] [Indexed: 11/28/2022]
Abstract
Introduction Andexanet alfa (AnXa) was developed for anticoagulant effect reversal of direct factor Xa inhibitors (DXaI) (apixaban, rivaroxaban, edoxaban) in emergency situations. Regular anti‐Xa assays are not suitable to evaluate anti‐Xa activity after AnXa administration because of the high sample dilution resulting in the AnXa‐DXaI dissociation which gives inaccurately high DXaI measured concentrations. This study aimed at developing dedicated STA‐Liquid anti‐Xa test set‐ups for accurately measuring DXaI after reversal with AnXa. Methods Modified anti‐Xa test set‐ups, with reduced sample dilution, were developed to overcome regular assays limitations and to improve measured accuracy with results comparable to Portola microplate reference method used in clinical studies. Both regular and optimized assays were used to measure DXaI concentration in AnXa‐containing samples. Quality controls, normal pooled plasma spiked with five DXaI and three AnXa concentrations, samples from DXaI‐treated patients spiked with AnXa and ex vivo healthy volunteers having received both DXaI and AnXa were used. Results The lower limit of quantitation of optimized anti‐Xa assays was <10 ng/mL with CVs ≤10%. DXaI samples containing 300 ng/mL and 1 µmol/L AnXa resulted in DXaI residual concentrations of 29‐72 ng/mL depending on the DXaI (76%‐90% reversal), compared to 20‐28 ng/mL with reference method (92%‐94% reversal) and 135‐165 ng/mL with regular assays (about 50% reversal). Conclusion Modified test set‐ups are automated alternative to reference method with improved precision and reproducibility. They can be run in all laboratories where regular anti‐Xa assays are performed using commercially available reagents.
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Affiliation(s)
| | | | | | - Tristan Herve
- Diagnostica Stago Clinical and Pharmaceutical Development, Asnières-sur-Seine, France
| | - François Depasse
- Diagnostica Stago Clinical and Pharmaceutical Development, Asnières-sur-Seine, France
| | - Genmin Lu
- Portola, a subsidiary of Alexion, South San Francisco, CA, USA
| | - Pamela B Conley
- Portola, a subsidiary of Alexion, South San Francisco, CA, USA
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74
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Jaspers T, Shudofsky K, Huisman MV, Meijer K, Khorsand N. A meta-analysis of andexanet alfa and prothrombin complex concentrate in the treatment of factor Xa inhibitor-related major bleeding. Res Pract Thromb Haemost 2021; 5:e12518. [PMID: 34084991 PMCID: PMC8143276 DOI: 10.1002/rth2.12518] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 03/14/2021] [Accepted: 03/16/2021] [Indexed: 11/08/2022] Open
Abstract
Background Andexanet alfa (andexanet) and prothrombin complex concentrate (PCC) are both reversal agents for major bleeding in patients using factor Xa inhibitors (FXaIs). Our aim was to evaluate the current evidence for the effectiveness and safety of andexanet and PCC in a systematic review and meta-analysis. Objectives Primary objective was hemostatic effectiveness. Secondary objectives were thromboembolic event rate and mortality. Methods A systematic review was performed in PubMed and Embase. Studies describing the effectiveness and/or safety of PCC or andexanet in patients with major bleeding using FXaIs were included. Meta-analysis was performed using a random-effects model. Results Seventeen PCC studies, 3 andexanet studies, and 1 study describing PCC and andexanet were included, comprising 1428 PCC-treated and 396 andexanet-treated patients. None of the included studies had control groups, hampering a pooled meta-analysis to compare the two reversal agents. Separate analyses for andexanet and PCC were performed. In subgroup analysis, the pooled proportion of patients with effective hemostasis in studies that used Annexa-4 criteria demonstrated a hemostatic effectiveness of 0.85 (95% confidence interval [CI], 0.80-0.90) in PCC and 0.82 (95% CI, 0.78-0.87) in andexanet studies. The pooled proportion of patients with thromboembolic events was 0.03 (95% CI, 0.02-0.04) in PCC and 0.11 (95% CI, 0.04-0.18) in andexanet studies. Conclusion Based on the available evidence with low certainty from observational studies, PCC and andexanet demonstrated a similar, effective hemostasis in the treatment of major bleeding in patients using FXaIs. Compared to PCC, the thromboembolic event rate appeared higher in andexanet-treated patients.
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Affiliation(s)
- Tessa Jaspers
- Department of Clinical Pharmacy and Pharmacology University Medical Centre Groningen Groningen The Netherlands
| | - Kimberly Shudofsky
- Department of Hospital Pharmacy Viecuri Medical Center Venlo The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis Leiden University Medical Center Leiden The Netherlands
| | - Karina Meijer
- Department of Hematology University Medical Center Groningen Groningen The Netherlands
| | - Nakisa Khorsand
- Department of Hospital Pharmacy OLVG Amsterdam The Netherlands
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75
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Le Mao R, Tromeur C, Couturaud F. A case of acute pulmonary embolism with severe haemoptysis. Thromb Res 2021; 208:199-201. [PMID: 34045054 DOI: 10.1016/j.thromres.2021.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Revised: 04/14/2021] [Accepted: 05/13/2021] [Indexed: 11/29/2022]
Abstract
Haemoptysis is a potentially life-threatening symptom, which require immediate management. Haemoptysis is a challenging situation because the potential numerous causes lead to strongly different therapeutic options (medical, surgical, systematic embolization). When haemoptysis occurred at the acute phase of pulmonary embolism, anticoagulation should be stopped and inferior vena cava filter is justified. Based on a case report of massive haemoptysis related to pulmonary infarction (i.e., no other causes) in a patient with a unprovoked intermediate high-risk pulmonary embolism, we describe the dilemma set in the paradox between the need for stopping anticoagulation and the need to treat the cause of haemoptysis which is also anticoagulation. If anticoagulation should be stopped, however, the optimal management regarding the use of specific reversal agents or prothrombotic plasma concentrates remains uncertain and weakly documented. After haemoptysis has been resolved, there is also uncertainty on restarting anticoagulation modalities. Regarding long-term management, the decision to stop at three months or to prolong indefinitely based on international recommendation is also challenging in the case of unprovoked severe pulmonary embolism. In this particularly high risk situation, multidisciplinary expertise is essential.
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Affiliation(s)
- Raphael Le Mao
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, CIC INSERM 1412, Brest, France; EA3878, Univ Brest, Brest, France
| | - Cécile Tromeur
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, CIC INSERM 1412, Brest, France; EA3878, Univ Brest, Brest, France
| | - Francis Couturaud
- Département de Médecine Interne et Pneumologie, Centre Hospitalo-Universitaire de Brest, CIC INSERM 1412, Brest, France; EA3878, Univ Brest, Brest, France.
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76
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Willekens G, Studt JD, Mendez A, Alberio L, Fontana P, Wuillemin WA, Schmidt A, Graf L, Gerber B, Bovet C, Sauter TC, Nagler M. A universal anti-Xa assay for rivaroxaban, apixaban, and edoxaban measurements: method validation, diagnostic accuracy and external validation. Br J Haematol 2021; 193:1203-1212. [PMID: 33954979 PMCID: PMC8252105 DOI: 10.1111/bjh.17470] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/19/2021] [Indexed: 11/28/2022]
Abstract
A universal anti‐Xa assay for the determination of rivaroxaban, apixaban and edoxaban drug concentrations would simplify laboratory procedures and facilitate widespread implementation. Following two pilot studies analysing spiked samples and material from 698 patients, we conducted a prospective multicentre cross‐sectional study, including 867 patients treated with rivaroxaban, apixaban or edoxaban in clinical practice to comprehensively evaluate a simple, readily available anti‐Xa assay that would accurately measure drug concentrations and correctly predict relevant levels in clinical practice. Anti‐Xa activity was measured by an assay calibrated with low‐molecular‐weight heparin (LMWH) in addition to ultra‐high performance liquid chromatography‐tandem mass spectrometry (LC‐MS/MS). As an external validation, LMWH‐calibrated anti‐Xa activity was also determined in nine external laboratories. The LMWH‐calibrated anti‐Xa activity correlated strongly with rivaroxaban, apixaban or edoxaban drug levels [rs = 0·98, 95% confidence interval (CI) 0·98–0·98]. The sensitivity for the clinically relevant cut‐off levels of 30, 50 and 100 µg/l was 96·2% (95% CI 94·4–97·4), 96·4% (95% CI 94·4–97·7) and 96·7% (95% CI 94·3–98·1) respectively. Concordant results were obtained in the external validation study. In conclusion, a universal, LMWH‐calibrated anti‐Xa assay accurately measured rivaroxaban, apixaban and edoxaban concentrations and correctly predicted relevant drug concentrations in clinical practice.
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Affiliation(s)
- Guido Willekens
- Department of Epidemiology, Maastricht University, Maastricht, the Netherlands.,Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Adriana Mendez
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospital, Geneva, Switzerland
| | - Walter A Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne, University of Bern, Bern, Switzerland
| | - Adrian Schmidt
- Institute of Laboratory Medicine and Clinic of Medical Oncology and Hematology, City Hospital Waid and Triemli, Zurich, Switzerland
| | - Lukas Graf
- Cantonal Hospital of St Gallen, St Gallen, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Cedric Bovet
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Hematology, Inselspital, Bern University Hospital, Bern, Switzerland
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77
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Doshi BS, Ellison AM. Diagnosis and Management of Pediatric Venous Thromboembolism: New Therapies on the Horizon. Pediatr Emerg Care 2021; 37:273-279. [PMID: 33903287 DOI: 10.1097/pec.0000000000002431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT The incidence of venous thromboembolism (VTE) is increasing in pediatric patients. Prompt recognition and evaluation of VTE in young patients could prevent significant morbidity or mortality. In contrast to VTE in adults, current treatment guidelines are largely based on expert opinion as limited randomized controlled trial data exist about the appropriate management in pediatric patients with traditional anticoagulants. However, recently approved direct-acting oral anticoagulants in adults are also being investigated in pediatric VTE and these data could inform future evidence-based treatment principles. Thus, healthcare providers must be well informed about the management of pediatric VTE and the data from these trials to date. This continuing medical education article will provide a summary of management of pediatric VTE with particular emphasis on emerging direct-acting oral anticoagulants.
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78
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Sukumar S, Cabero M, Tiu S, Fang MC, Kogan SC, Schwartz JB. Anti-factor Xa activity assays of direct-acting oral anticoagulants during clinical care: An observational study. Res Pract Thromb Haemost 2021; 5:e12528. [PMID: 34013157 PMCID: PMC8114026 DOI: 10.1002/rth2.12528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 04/09/2021] [Accepted: 04/14/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Direct-acting oral anticoagulants (DOACs) are increasingly used to prevent and treat thromboembolism. Although measurement of DOAC concentrations is not currently recommended as part of routine patient care, measurement of DOAC concentrations with anti-factor Xa activity assays have recently become clinically available. OBJECTIVES Our goal was to determine the clinical conditions under which DOAC concentration measurements are requested. MATERIALS AND METHODS Retrospective electronic medical record analysis of indications for DOAC concentration measurements by anti-factor Xa activity assay at a single academic medical center from July 2015 through April 2020. RESULTS AND CONCLUSIONS Ninety-one DOAC concentration measurements were made in 69 patients: 28 received apixaban and 41 received rivaroxaban. The most frequent indication for concentration measurement was drug exposure assessment (38/69; 55%) in patients with potentially altered pharmacokinetics (altered absorption or clearance), recurrent thromboembolic events, or possible medication nonadherence. Fourteen of 69 patients had repeated measurements during preoperative evaluation before emergent surgery; one-third of those with detectable levels upon presentation had repeated measurements until concentrations were undetectable. Levels were undetectable in 4 of 4 patients scheduled for elective surgery. Eleven of 69 patients had DOAC measurements in the setting of major bleeding; 5 of these 11 received a specific DOAC reversal agent. While most of the observed indications appear in clinical guidelines, altered absorption does not. Overall, clinicians are requesting DOAC concentration measurements to evaluate drug exposure in patients with conditions that might alter the absorption or clearance of the DOAC, to evaluate surgical bleeding risk, and in the setting of major bleeding.
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Affiliation(s)
- Smrithi Sukumar
- School of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Melissa Cabero
- Clinical Laboratory of UCSF Medical CenterSan FranciscoCAUSA
| | - Sharon Tiu
- Clinical Laboratory of UCSF Medical CenterSan FranciscoCAUSA
| | - Margaret C. Fang
- Department of MedicineUniversity of CaliforniaSan FranciscoCAUSA
| | - Scott C. Kogan
- Laboratory MedicineUniversity of CaliforniaSan FranciscoCAUSA
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79
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Nguyen SN, Ruegger MC, Salazar E, Dreucean D, Tatara AW, Donahue KR. Evaluation of Anti-Xa Apixaban and Rivaroxaban Levels With Respect to Known Doses in Relation to Major Bleeding Events. J Pharm Pract 2021; 35:836-845. [PMID: 33840278 DOI: 10.1177/08971900211009075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although not routinely recommended, anti-Xa level monitoring for apixaban or rivaroxaban may be useful in certain clinical scenarios. There are currently no laboratory standards, therapeutic ranges, or proven correlation between anti-Xa levels and clinical outcomes. OBJECTIVE This study describes the utilization, application, and association of anti-Xa levels with clinical outcomes in patients receiving apixaban or rivaroxaban. METHODS This retrospective, descriptive study included adult inpatients within the Houston Methodist System on apixaban or rivaroxaban with at least one anti-Xa level ordered subsequent to administered doses. The primary endpoint was major bleeding according to International Society on Thrombosis and Haemostasis criteria. Secondary endpoints included reasons for anti-Xa level ordering, anti-Xa levels at different time intervals post-dose, and thrombotic events. Pre-specified subgroup analyses were performed to further evaluate the primary endpoint. RESULTS The study population consisted of 169 patients and 234 anti-Xa levels. Twenty-nine levels were obtained in context of major bleeding. The majority of levels were not drawn as peak levels 2-4 hours post-dose, however remained quantifiable above typical observed levels within this timeframe and well beyond 24 hours post-dose. Patient characteristics with major bleeding included elderly age, acute renal impairment, and low body weight. At least 14 unique reasons for anti-Xa level ordering were identified. Twenty-nine levels were associated with thrombotic events. CONCLUSION Anti-Xa levels may be useful for assessment of current drug concentrations, immediate safety of therapy, and guidance for possible clinical interventions. Dose titration and reversal therapies based on anti-Xa level results in major bleeding warrant further research.
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Affiliation(s)
- Steffany N Nguyen
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
| | - Melanie C Ruegger
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
| | - Eric Salazar
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Diane Dreucean
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
| | | | - Kevin R Donahue
- Department of Pharmacy, Houston Methodist Hospital, Houston, TX, USA
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80
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Abstract
Intracerebral hemorrhage is a stroke subtype with high mortality and poor functional outcome in survivors. Its main causes are hypertension, cerebral amyloid angiopathy, and anticoagulant treatment. Hematomas have a high frequency of expansion in the first hours after symptom onset, a process associated with neurologic deterioration and poor outcome. Control of severe hypertension, reversal of anticoagulant effect, and management of increased intracranial pressure are the mainstays of management of intracerebral hemorrhage in the acute phase. Surgical evacuation of the hematoma by conventional craniotomy does not improve outcomes, but minimally invasive techniques may be a valuable approach that deserves further evaluation.
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Affiliation(s)
- Carlos S Kase
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA.
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Johns Hopkins University, Baltimore, MD, USA
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81
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Douxfils J, Adcock DM, Bates SM, Favaloro EJ, Gouin-Thibault I, Guillermo C, Kawai Y, Lindhoff-Last E, Kitchen S, Gosselin RC. 2021 Update of the International Council for Standardization in Haematology Recommendations for Laboratory Measurement of Direct Oral Anticoagulants. Thromb Haemost 2021; 121:1008-1020. [PMID: 33742436 DOI: 10.1055/a-1450-8178] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 2018, the International Council for Standardization in Haematology (ICSH) published a consensus document providing guidance for laboratories on measuring direct oral anticoagulants (DOACs). Since that publication, several significant changes related to DOACs have occurred, including the approval of a new DOAC by the Food and Drug Administration, betrixaban, and a specific DOAC reversal agent intended for use when the reversal of anticoagulation with apixaban or rivaroxaban is needed due to life-threatening or uncontrolled bleeding, andexanet alfa. In addition, this ICSH Working Party recognized areas where additional information was warranted, including patient population considerations and updates in point-of-care testing. The information in this manuscript supplements our previous ICSH DOAC laboratory guidance document. The recommendations provided are based on (1) information from peer-reviewed publications about laboratory measurement of DOACs, (2) contributing author's personal experience/expert opinion and (3) good laboratory practice.
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Affiliation(s)
- Jonathan Douxfils
- Department of Pharmacy-Namur Thrombosis and Hemostasis Center, University of Namur, Namur, Belgium.,Qualiblood SA, Namur, Belgium
| | - Dorothy M Adcock
- Laboratory Corporation of America, Burlington North Carolina, United States
| | - Shannon M Bates
- Department of Medicine, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Haemostasis and Thrombosis, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
| | | | - Cecilia Guillermo
- Hospital de Clínicas "Dr Manuel Quintela," Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Yohko Kawai
- Sanno Hospital, Laboratory Medicine, Tokyo, Japan
| | - Edelgard Lindhoff-Last
- Cardiology Angiology Center Bethanien, CCB Vascular Center, CCB Coagulation Center, Frankfurt, Germany
| | - Steve Kitchen
- Royal Hallamshire Hospital, Coagulation Sheffield, South Yorks, United Kingdom
| | - Robert C Gosselin
- Hemophilia Treatment Center, University of California, Davis Health System, Sacramento, California, United States
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82
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Heparin Anti-Xa Activity, a Readily Available Unique Test to Quantify Apixaban, Rivaroxaban, Fondaparinux, and Danaparoid Levels. Anesth Analg 2021; 132:707-716. [PMID: 32833716 DOI: 10.1213/ane.0000000000005114] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Despite their usefulness in perioperative and acute care settings, factor-Xa inhibitor-specific assays are scarcely available, contrary to heparin anti-Xa assay. We assessed whether the heparin anti-Xa assay can (1) be used as a screening test to rule out apixaban, rivaroxaban, fondaparinux, and danaparoid levels that contraindicate invasive procedures according to current guidelines (>30 ng·mL-1, >30 ng·mL-1, >0.1 µg·mL-1, and >0.1 IU·mL-1, respectively), (2) quantify the anticoagulant level if found significant, that is, if it exceeded the abovementioned threshold. METHODS In the derivation cohort then in the validation cohort, via receiver operating characteristics (ROC) curve analysis, we evaluated the ability of heparin anti-Xa assay to detect levels of factor-Xa inhibitors above or below the abovementioned safety thresholds recommended for an invasive procedure (screening test). Among samples with relevant levels of factor-Xa inhibitor, we determined the conversion factor linking the measured level and heparin anti-Xa activity in a derivation cohort. In a validation cohort, the estimated level of each factor-Xa inhibitor was thus inferred from heparin anti-Xa activity. The agreement between measured and estimated levels of factor-Xa inhibitors was assessed. RESULTS Among 989 (355 patients) and 756 blood samples (420 patients) in the derivation and validation cohort, there was a strong linear relationship between heparin anti-Xa activities and factor-Xa inhibitors measured level (r = 0.99 [95% confidence interval {CI}, 0.99-0.99]). In the derivation cohort, heparin anti-Xa activity ≤0.2, ≤0.3, <0.1, <0.1 IU·mL-1 reliably ruled out a relevant level of apixaban, rivaroxaban, fondaparinux, and danaparoid, respectively (area under the ROC curve ≥0.99). In the validation cohort, these cutoffs yielded excellent classification accuracy (≥96%). If this screening test indicated relevant level of factor-Xa inhibitor, estimated and measured levels closely agreed (Lin's correlation coefficient close to its maximal value: 95% CI, 0.99-0.99). More than 96% of the estimated levels fell into the predefined range of acceptability (ie, 80%-120% of the measured level). CONCLUSIONS A unique simple test already widely used to assay heparin was also useful for quantifying these 4 other anticoagulants. Both clinical and economic impacts of these findings should be assessed in a specific study.
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83
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Härtig F, Birschmann I, Peter A, Hörber S, Ebner M, Sonnleitner M, Spencer C, Bombach P, Stefanou MI, Tünnerhoff J, Mengel A, Kuhn J, Ziemann U, Poli S. Point-of-care testing for emergency assessment of coagulation in patients treated with direct oral anticoagulants including edoxaban. Neurol Res Pract 2021; 3:9. [PMID: 33641678 PMCID: PMC7919064 DOI: 10.1186/s42466-021-00105-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/11/2021] [Indexed: 01/31/2023] Open
Abstract
Background Direct oral anticoagulants (DOAC) including edoxaban are increasingly used for stroke prevention in atrial fibrillation. Despite treatment, annual stroke rate in these patients remains 1–2%. Rapid assessment of coagulation would be useful to guide thrombolysis or reversal therapy in this growing population of DOAC/edoxaban-treated stroke patients. Employing the Hemochron™ Signature Elite point-of-care test system (HC-POCT), clinically relevant plasma concentrations of dabigatran and rivaroxaban can be excluded in a blood sample. However, no data exists on the effect of edoxaban on HC-POCT results. We evaluated whether edoxaban plasma concentrations above the current treatment thresholds for thrombolysis or anticoagulation reversal (i.e., 30 and 50 ng/mL) can be ruled out with the HC-POCT. Methods We prospectively studied patients receiving a first dose of edoxaban. Six blood samples were collected from each patient: before, 0.5, 1, 2, 8, and 24 h after drug intake. HC-POCT-based INR (HC-INR), activated clotting time (HC-ACT+ and HC-ACT-LR), activated partial thromboplastin time (HC-aPTT), and mass spectrometry for edoxaban plasma concentrations were performed at each time-point. We calculated correlations, receiver operating characteristics (ROC) and test-specific cut-offs for ruling out edoxaban concentrations > 30 and > 50 ng/mL in a blood sample. Results One hundred twenty blood samples from 20 edoxaban-treated patients were analyzed. Edoxaban plasma concentrations ranged from 0 to 512 ng/mL. HC-INR/HC-ACT+/HC-ACT-LR/HC-aPTT ranged from 0.7–8.3/78–310 s/65–215 s/19–93 s, and Pearson’s correlation coefficients showed moderate to very strong correlations with edoxaban concentrations (r = 0.95/0.79/0.70/0.60). With areas under the ROC curve of 0.997 (95% confidence interval: 0.991–0.971) and 0.989 (0.975–1.000), HC-INR most reliably ruled out edoxaban concentrations > 30 and > 50 ng/mL, respectively, and HC-INR results ≤1.5 and ≤ 2.1 provided specificity/sensitivity of 98.6% (91.2–99.9)/98.0% (88.0–99.9) and 96.8% (88.0–99.4)/96.5% (86.8–99.4). Conclusions Our study represents the first systematic evaluation of the HC-POCT in edoxaban-treated patients. Applying sufficiently low assay-specific cut-offs, the HC-POCT may not only be used to reliably rule out dabigatran and rivaroxaban, but also very low edoxaban concentrations in a blood sample. Because the assay-specific cut-offs were retrospectively defined, further investigation is warranted. Trial registration ClinicalTrials.gov, registration number: NCT02825394, registered on: 07/07/2016, URL Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00105-4.
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Affiliation(s)
- Florian Härtig
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Ruhr University, Bad Oeynhausen, Germany
| | - Andreas Peter
- Department of Diagnostic Laboratory Medicine, Institue for Clinical Chemistry and Pathobiochemistry, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Sebastian Hörber
- Department of Diagnostic Laboratory Medicine, Institue for Clinical Chemistry and Pathobiochemistry, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Matthias Ebner
- Department of Nephrology and Medical Intensive Care, Charité University Medicine, Berlin, Germany
| | - Matthias Sonnleitner
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Charlotte Spencer
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Paula Bombach
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Maria-Ioanna Stefanou
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Johannes Tünnerhoff
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Annerose Mengel
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Joachim Kuhn
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Ruhr University, Bad Oeynhausen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, University Hospital, Eberhard-Karls University Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany. .,Hertie Institute for Clinical Brain Research, Eberhard-Karls University Tübingen, Tübingen, Germany.
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84
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Renon F, Rago A, Liccardo B, D'Andrea A, Riegler L, Golino P, Nigro G, Russo V. Direct Oral Anticoagulants Plasma Levels Measurement: Clinical Usefulness from Trials and Real-World Data. Semin Thromb Hemost 2021; 47:150-160. [PMID: 33636746 DOI: 10.1055/s-0041-1723770] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Measurement of direct oral anticoagulants (DOACs) activity is not routinely necessary. Indeed, evaluation of DOACs plasmatic concentration is discouraged for the majority of patients, due to the lack of outcome data supporting this approach. Nevertheless, DOAC measurements may be useful in emergency situations such as serious bleeding events, need for urgent invasive procedures, and acute ischemic stroke or in managing anticoagulation in "special populations" not adequately studied in clinical trials, for example the very elderly or those at the extremes of body weight. The aim of this review is to describe and summarize the methods for DOACs activity evaluation and the settings in which their plasma level measurement may be indicated, analyzing indications from scientific societies and evidence from clinical trials, as well as real world data on the usefulness of DOACs plasma levels "monitoring."
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Affiliation(s)
- Francesca Renon
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Anna Rago
- Department of Cardiology, Monaldi Hospital, Naples, Italy
| | | | - Antonello D'Andrea
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore, Italy
| | - Lucia Riegler
- Unit of Cardiology and Intensive Coronary Care, Umberto I Hospital, Nocera Inferiore, Italy
| | - Paolo Golino
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Gerardo Nigro
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
| | - Vincenzo Russo
- Division of Cardiology, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli" Monaldi Hospital, Naples, Italy
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85
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Gendron N, Chocron R, Philippe A, Le Beller C, Lillo-le Louët A, Smadja DM. Appropriate Use of Idarucizumab for Dabigatran Reversal According to the International Society on Thrombosis and Hemostasis and French Working Group on Perioperative Hemostasis: A French Retrospective Study. J Cardiothorac Vasc Anesth 2021; 35:3141-3142. [PMID: 33715947 DOI: 10.1053/j.jvca.2021.02.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Nicolas Gendron
- Université de Paris, Innovative Therapies in Hemostasis, INSERM; Hematology Department and Biosurgical Research Lab, (Carpentier Foundation) Assistance Publique Hôpitaux de Paris, Centre-Université de Paris (APHP-CUP), 75015, Paris, France
| | - Richard Chocron
- Université de Paris, PARCC, INSERM; Emergency Department, Assistance Publique Hôpitaux de Paris, Centre-Université de Paris (APHP-CUP), 75015, Paris, France
| | - Aurélien Philippe
- Université de Paris, Innovative Therapies in Hemostasis, INSERM; Hematology Department and Biosurgical Research Lab, (Carpentier Foundation) Assistance Publique Hôpitaux de Paris, Centre-Université de Paris (APHP-CUP), 75015, Paris, France
| | - Christine Le Beller
- Université de Paris, Innovative Therapies in Hemostasis, INSERM; Département de Pharmacovigilance, Assistance Publique Hôpitaux de Paris, Centre-Université de Paris (APHP-CUP), 75015, Paris, France
| | - Agnès Lillo-le Louët
- Université de Paris, Innovative Therapies in Hemostasis, INSERM; Département de Pharmacovigilance, Assistance Publique Hôpitaux de Paris, Centre-Université de Paris (APHP-CUP), 75015, Paris, France
| | - David M Smadja
- Université de Paris, Innovative Therapies in Hemostasis, INSERM; Hematology Department and Biosurgical Research Lab, (Carpentier Foundation) Assistance Publique Hôpitaux de Paris, Centre-Université de Paris (APHP-CUP), 75015, Paris, France; F-CRIN INNOVTE, Saint-Étienne, France
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86
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Alwis S, Raja SG. Emergency cardiac surgery for patients on NOACs in the NOAC era - Perspective. Int J Surg 2021; 87:105893. [PMID: 33577930 DOI: 10.1016/j.ijsu.2021.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 02/02/2021] [Indexed: 11/25/2022]
Abstract
Excessive bleeding is an important cause of morbidity and mortality after cardiac surgery. Bleeding after cardiac surgery is multifactorial. Adherence to the proverbial 6 Ps remains the cornerstone of any strategy for management of postoperative bleeding after cardiac surgery. Recent years have seen a surge in the number of patients who have been prescribed novel oral anticoagulants (NOACs) for the prevention and treatment of thromboembolic events. This phenomenon has significant repercussions particularly for patients presenting for emergency cardiac surgery. The published evidence guiding management of such patients is limited and in the form of expert consensus. Plasma levels of NOAC >30 ng/ml necessitate specific therapeutic interventions to tackle excessive bleeding attributed to NOAC intake. Current recommendation is to consider using specific reversal agent if available. Otherwise, use of prothrombin complex concentrates is recommended.
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Affiliation(s)
- Shehani Alwis
- Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom
| | - Shahzad G Raja
- Department of Cardiac Surgery, Harefield Hospital, London, United Kingdom.
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87
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Kalaria SN, Zhu H, Liu Q, Florian J, Wang Y, Schwartz J. Influence of age on the relationship between apixaban concentration and anti-factor Xa activity in older patients with non-valvular atrial fibrillation. Int J Cardiol 2021; 331:109-113. [PMID: 33529664 DOI: 10.1016/j.ijcard.2021.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/29/2020] [Accepted: 01/07/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND/OBJECTIVES Despite lower major bleeding rates associated with direct oral anticoagulants (DOACs) as compared to conventional warfarin therapy, bleeding rates remain higher in older patients compared to younger patients suggesting a potential role for DOAC measurements. The objective of this study is to examine the effect of age on the relationship between apixaban concentrations and anti-Factor Xa activity in patients with non-valvular atrial fibrillation (NVAF). METHODS This is a retrospective analysis based on a database created using data from the ARISTOTLE study. Outpatient, stable adult patients with NVAF receiving apixaban were included in this study. Data collection consisted of apixaban concentration, anti-Factor Xa activity, age, weight, creatinine, and co-medications. RESULTS The database composed of 2058 patients receiving apixaban. Distribution of race, NVAF subtype, and aspirin use was fairly similar across each age quantile. Older patients received a higher number of co-medications and received the 2.5 mg apixaban dose more often as compared to younger patients (22% vs. < 1%). Linear regression demonstrated that the unadjusted slope for apixaban concentration effect on anti-Factor Xa activity was similar across each age quantile. Although, the overall adjusted linear regression analysis demonstrated that the age by concentration interaction was statistically significant, relative differences in anti-Factor Xa activity (< 8%) were not clinically meaningful. CONCLUSION Data on apixaban concentrations and anti-Factor Xa activity from a pivotal randomized double-blind study of apixaban for the prevention of stroke in NVAF patients have confirmed that the chromogenic anti-Factor Xa activity assay can accurately assess apixaban concentrations in patients regardless of age. Age was not associated with a clinically relevant change in the apixaban vs. anti-Factor Xa activity response relationship and target ranges are unchanged.
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Affiliation(s)
- Shamir N Kalaria
- Center for Translational Medicine, University of Maryland, School of Pharmacy, Baltimore, MD, United States of America
| | - Hao Zhu
- Office of Clinical Pharmacology, US Food and Drug Administration, White Oak, MD, United States of America
| | - Qi Liu
- Office of Clinical Pharmacology, US Food and Drug Administration, White Oak, MD, United States of America
| | - Jeffrey Florian
- Office of Clinical Pharmacology, US Food and Drug Administration, White Oak, MD, United States of America
| | - Yaning Wang
- Office of Clinical Pharmacology, US Food and Drug Administration, White Oak, MD, United States of America
| | - Janice Schwartz
- Department of Medicine, University of California San Francisco, School of Medicine, San Francisco, CA, United States of America.
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88
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Härtig F, Birschmann I, Peter A, Ebner M, Spencer C, Gramlich M, Richter H, Kuhn J, Lehmann R, Blumenstock G, Zuern CS, Ziemann U, Poli S. Specific Point-of-Care Testing of Coagulation in Patients Treated with Dabigatran. Thromb Haemost 2021; 121:782-791. [PMID: 33469905 PMCID: PMC8180376 DOI: 10.1055/s-0040-1721775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND AND PURPOSE Accurate and rapid assessment of coagulation status is necessary to guide thrombolysis or reversal of anticoagulation in stroke patients, but commercially available point-of-care (POC) assays are not suited for coagulation testing in patients treated with direct oral anticoagulants (DOACs). We aimed to evaluate the direct thrombin monitoring (DTM) test card by Helena Laboratories (Texas, United States) for anti-IIa-specific POC coagulation testing, hypothesizing that its POC-ecarin clotting time (POC-ECT) accurately reflects dabigatran plasma concentrations. METHODS A prospective single-center diagnostic study (ClinicalTrials.gov-identifier: NCT02825394) was conducted enrolling patients receiving a first dose of dabigatran and patients already on dabigatran treatment. Blood samples were collected before drug intake and 0.5, 1, 2, 8, and 12 hours after intake. POC-ECT was performed using whole blood (WB), citrated blood (CB), and citrated plasma (CP). Dabigatran plasma concentrations were determined by mass spectrometry. RESULTS In total, 240 blood samples from 40 patients contained 0 to 275 ng/mL of dabigatran. POC-ECT with WB/CB/CP ranged from 20 to 186/184/316 seconds. Pearson's correlation coefficient showed a strong correlation between dabigatran concentrations and POC-ECT with WB/CB/CP (R2 = 0.78/0.90/0.92). Dabigatran concentrations >30 and >50 ng/mL (thresholds for thrombolysis, surgery, and reversal therapy according to clinical guidelines) were detected by POC-ECT with WB/CB/CP (>36/35/45 and >43/45/59 seconds) with 95/97/97 and 96/98/97% sensitivity, and 81/87/94 and 74/60/91% specificity. CONCLUSION This first study evaluating DOAC-specific POC coagulation testing revealed an excellent correlation of POC-ECT with actual dabigatran concentrations. Detecting clinically relevant dabigatran levels with high sensitivity/specificity, the DTM assay represents a suitable diagnostic tool in acute stroke, hemorrhage, and urgent surgery.
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Affiliation(s)
- Florian Härtig
- Department of Neurology & Stroke, Eberhard Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Ingvild Birschmann
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Ruhr University, Bad Oeynhausen, Germany
| | - Andreas Peter
- German Centre for Diabetes Research (DZD), Neuherberg, Germany.,Institute for Diabetes Research and Metabolic Diseases, Helmholtz Centre Munich, University of Tübingen, Tübingen, Germany.,Institute for Clinical Chemistry and Pathobiochemistry, Department for Diagnostic Laboratory Medicine, Tübingen, Germany
| | - Matthias Ebner
- Department of Neurology & Stroke, Eberhard Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard Karls University of Tübingen, Tübingen, Germany.,Department of Internal Medicine and Cardiology, Campus Virchow Hospital, Charité, Berlin, Germany
| | - Charlotte Spencer
- Department of Neurology & Stroke, Eberhard Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard Karls University of Tübingen, Tübingen, Germany
| | | | - Hardy Richter
- Department of Neurology & Stroke, Eberhard Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Joachim Kuhn
- Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center, Ruhr University, Bad Oeynhausen, Germany
| | - Rainer Lehmann
- German Centre for Diabetes Research (DZD), Neuherberg, Germany.,Institute for Diabetes Research and Metabolic Diseases, Helmholtz Centre Munich, University of Tübingen, Tübingen, Germany.,Institute for Clinical Chemistry and Pathobiochemistry, Department for Diagnostic Laboratory Medicine, Tübingen, Germany
| | - Gunnar Blumenstock
- Department of Clinical Epidemiology and Applied Biometry, University of Tübingen, Tübingen, Germany
| | - Christine S Zuern
- Department of Cardiology, University Hospital Tübingen, Germany.,Department of Cardiology and Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard Karls University of Tübingen, Tübingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard Karls University of Tübingen, Tübingen, Germany.,Hertie Institute for Clinical Brain Research, Eberhard Karls University of Tübingen, Tübingen, Germany
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89
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Ząbczyk M, Natorska J, Kopytek M, Malinowski KP, Undas A. The Effect of Direct Oral Anticoagulants on Antithrombin Activity Testing Is Abolished by DOAC-Stop in Venous Thromboembolism Patients. Arch Pathol Lab Med 2021; 145:99-104. [PMID: 33367661 DOI: 10.5858/arpa.2020-0021-oa] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Direct oral anticoagulants (DOACs) may cause false negative results of antithrombin (AT) deficiency screening. OBJECTIVE.— To evaluate the impact of DOAC-Stop, an agent reversing in vitro effects of DOACs, on AT testing in anticoagulated patients. DESIGN.— We assessed 130 venous thromboembolism patients aged 46.7 ± 13.5 years. Blood samples were collected 2 to 27 hours after DOAC intake from 49 patients on rivaroxaban, 54 on apixaban, and 27 on dabigatran. Antithrombin activity was assessed using the activated factor X (FXa)-based and the activated factor II (FIIa)-based method twice, before and after DOAC-Stop treatment, together with plasma DOAC levels using coagulometric assays. RESULTS.— The use of DOAC-Stop did not influence AT activity measured using the FIIa-based assay, whereas there was a marked decrease in AT activity determined using the FXa-based assay (ΔAT = 16.9%; 95% CI, 12.9%-19.1%). The AT-FIIa assay revealed decreased AT level (<79%) in all 10 (7.7%) genetically confirmed AT-deficient patients treated with rivaroxaban or apixaban (n = 5 each), whereas the AT-FXa assay showed decreased AT activity (<83%) in 2 subjects on rivaroxaban and 1 on apixaban with low plasma DOAC concentrations (<90 ng/mL). After DOAC-Stop median AT-FXa activity lowered from 83.5% (interquartile range, 66%-143%) to 65.5% (interquartile range, 57%-75%; P = .005; ΔAT = 18%) in AT-deficient patients, without any false negative results. The ΔAT in the FXa-based assay correlated with rivaroxaban and apixaban concentrations in the AT-deficient patients (r = 0.99, P < .001). CONCLUSIONS.— Application of DOAC-Stop enables reliable evaluation of AT deficiency screening in patients taking rivaroxaban or apixaban and tested using the FXa-based method.
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Affiliation(s)
- Michał Ząbczyk
- From the Institute of Cardiology, Jagiellonian University Medical College and John Paul II Hospital, Kraków, Poland (Ząbczyk, Natorska, Kopytek, Undas)
| | - Joanna Natorska
- From the Institute of Cardiology, Jagiellonian University Medical College and John Paul II Hospital, Kraków, Poland (Ząbczyk, Natorska, Kopytek, Undas)
| | - Magdalena Kopytek
- From the Institute of Cardiology, Jagiellonian University Medical College and John Paul II Hospital, Kraków, Poland (Ząbczyk, Natorska, Kopytek, Undas)
| | - Krzysztof P Malinowski
- Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland (Malinowski)
| | - Anetta Undas
- From the Institute of Cardiology, Jagiellonian University Medical College and John Paul II Hospital, Kraków, Poland (Ząbczyk, Natorska, Kopytek, Undas)
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90
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Gendron N, Chocron R, Billoir P, Brunier J, Camoin-Jau L, Tuffigo M, Faille D, Teissandier D, Gay J, de Raucourt E, Suner L, Bonnet C, Martin AC, Lasne D, Ladhari C, Lebreton A, Bertoletti L, Ajzenberg N, Gaussem P, Morange PE, Le Cam Duchez V, Viallon A, Roy PM, Lillo-le Louët A, Smadja DM. Dabigatran Level Before Reversal Can Predict Hemostatic Effectiveness of Idarucizumab in a Real-World Setting. Front Med (Lausanne) 2020; 7:599626. [PMID: 33392223 PMCID: PMC7772865 DOI: 10.3389/fmed.2020.599626] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 11/10/2020] [Indexed: 02/04/2023] Open
Abstract
Background: Idarucizumab has been included in guidelines for the management of bleeding or surgical procedure in dabigatran-treated patients without need for biological monitoring. The aim of the study was to assess the prognostic value of dabigatran plasma level before reversal to test the hemostatic efficacy of idarucizumab. The secondary objectives were (i) to analyze plasma dabigatran level according to the risk of rebound and (ii) to evaluate the incidence of post-reversal non-favorable clinical outcomes (including thromboembolism, bleeding, antithrombotic, and death) and antithrombotic resumption. Methods and Results: This was an observational multicentric cohort study, which included all French patients who required idarucizumab for dabigatran reversal. Between May 2016 and April 2019, 87 patients from 21 French centers were enrolled. Patients received idarucizumab for overt bleeding (n = 61), urgent procedures (n = 24), or overdose without bleeding (n = 2). Among patients with major bleeding (n = 57), treatment with idarucizumab was considered effective in 44 (77.2%) of them. Patients who did not achieve effective hemostasis after reversal had a significantly higher mean level of plasma dabigatran at baseline (524.5 ± 386 vs. 252.8 ng/mL ± 235, p = 0.033). Furthermore, patients who did not achieve effective hemostasis after reversal had less favorable outcomes during follow-up (46.2 vs. 81.8%, p = 0.027). ROC curve identified a cutoff of 264 ng/mL for dabigatran level at admission to be predictive of ineffective hemostasis. No plasma dabigatran rebound was observed after reversal in patients with dabigatran plasma level < 264 ng/mL at baseline. Conclusion: This retrospective study shows that dabigatran level before reversal could predict hemostatic effectiveness and dabigatran plasma rebound after idarucizumab injection.
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Affiliation(s)
- Nicolas Gendron
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, Paris, France.,Hematology Department and Biosurgical Research Lab (Carpentier Foundation), AH-HP, Georges Pompidou European Hospital, Paris, France
| | - Richard Chocron
- Université de Paris, PARCC, INSERM, Paris, France.,Emergency Department, AH-HP, Georges Pompidou European Hospital, Paris, France
| | - Paul Billoir
- Normandie Univ, UNIROUEN, INSERM Rouen University Hospital, Vascular Hemostasis Unit, Rouen, France
| | - Julien Brunier
- CHU-Pellegrin, Laboratory of Hematology, Bordeaux, France
| | | | - Marie Tuffigo
- CHU Angers, Laboratory of Hematology, Angers, France
| | - Dorothée Faille
- Université de Paris, Laboratory of Vascular Translational Science, INSERM, Paris, France.,Laboratory of Hematology, AH-HP, Bichat Hospital, Paris, France
| | - Dorian Teissandier
- CHU Clermont-Ferrand, Emergency Medicine Department, Clermont-Ferrand, France
| | - Juliette Gay
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, Paris, France.,Hematology Department, AH-HP, Georges Pompidou European Hospital, Paris, France
| | - Emmanuelle de Raucourt
- Université de Paris, LVTS, INSERM, Paris, France.,Hematology Department, AP-HP, Hôpital Beaujon, Clichy, France
| | - Ludovic Suner
- Sorbonne Université, Inserm, Centre de Recherche Saint-Antoine, AP-HP, Hôpital Saint-Antoine, Hématologie Biologique, Paris, France
| | - Corentin Bonnet
- CHU Sud Réunion, Anaestesiology Department, Saint-Pierre, La Réunion, France
| | - Anne-Céline Martin
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, Paris, France.,Cardiology Department, AH-HP, Georges Pompidou European Hospital, Paris, France
| | - Dominique Lasne
- AP-HP, CHU Necker-Enfants Malades, Department of Biogical Hematology, Paris, France
| | - Chayma Ladhari
- CHU Montpellier, Centre Régional de Pharmacovigilance, Montpellier, France
| | - Aurélien Lebreton
- CHU Clermont-Ferrand, Laboratory of Hematology, Clermont-Ferrand, France
| | - Laurent Bertoletti
- Service de Médecine Vasculaire et Thérapeutique, CHU de Saint-Étienne, INSERM, Université Jean-Monnet, INSERM, CHU de Saint-Étienne, Saint-Étienne, France.,F-CRIN INNOVTE, Saint-Étienne, France
| | - Nadine Ajzenberg
- Université de Paris, Laboratory of Vascular Translational Science, INSERM, Paris, France.,Laboratory of Hematology, AH-HP, Bichat Hospital, Paris, France
| | - Pascale Gaussem
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, Paris, France.,Hematology Department, AH-HP, Georges Pompidou European Hospital, Paris, France
| | - Pierre-Emmanuel Morange
- AP-HM, CHU Timone, Laboratory of Hematology, Marseille, France.,F-CRIN INNOVTE, Saint-Étienne, France.,C2VN, Aix Marseille Univ, INSERM, INRAE, C2VN, Marseille, France
| | - Véronique Le Cam Duchez
- Normandie Univ, UNIROUEN, INSERM Rouen University Hospital, Vascular Hemostasis Unit, Rouen, France
| | - Alain Viallon
- CHU Saint-Étienne, Emergency Department, Saint-Étienne, France
| | - Pierre-Marie Roy
- F-CRIN INNOVTE, Saint-Étienne, France.,CHU Angers, Emergency Department and Vascular Medicine Ward, Université d'Angers, MITOVASC Institut, UMR (CNRS 6015-INSERM 1083), Angers, France
| | - Agnès Lillo-le Louët
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, Paris, France.,Département de Pharmacovigilance, AH-HP, Georges Pompidou European Hospital, Paris, France
| | - David M Smadja
- Université de Paris, Innovative Therapies in Haemostasis, INSERM, Paris, France.,Hematology Department and Biosurgical Research Lab (Carpentier Foundation), AH-HP, Georges Pompidou European Hospital, Paris, France.,F-CRIN INNOVTE, Saint-Étienne, France
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91
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Paul C, Baby M, Anthraper AR, K K. NOACs: an emerging class of oral anticoagulants-a review article. FUTURE JOURNAL OF PHARMACEUTICAL SCIENCES 2020. [DOI: 10.1186/s43094-020-00114-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
AbstractBackgroundNOACs, commonly known as novel oral anticoagulants, are the non-vitamin K antagonist oral anticoagulants which are relatively newer in the market. It has displaced vitamin K antagonists, notably warfarin, for many indications. These agents are dabigatran, rivaroxaban, apixaban, and edoxaban.Main bodyThe drugs are licenced to prevent stroke and also systemic embolism in patients on treatment for atrial fibrillation and prevent venous thromboembolism. Rivaroxaban and apixaban are approved for prophylaxis of thrombus following surgical hip or knee arthroplasty. The recent surveys reveal that use of NOACs has steeply increased due to its safety profile and convenience to use. Also, the studies have shown that NOACs have lesser bleeding complications and associated mortality in contrast to traditional anticoagulants. The upcoming years are known to be NOACs’ age due to the significant findings in this area.ConclusionTherefore, a basic understanding on these drugs is highly recommended to provide a better service to the patients. This article aims to provide quick and brief information on the novel class of drugs. It equips an overview of NOAC and deals with the following areas: (i) pharmacology, (ii) laboratory methods, (iii) peri-operative management, (iv) advantages, (v) challenges, and (vi) future.
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92
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Haastrup SB, Hellfritzsch M, Nybo M, Hvas AM, Grove EL. Real-world experience with reversal of dabigatran by idarucizumab. Thromb Res 2020; 197:179-184. [PMID: 33227654 DOI: 10.1016/j.thromres.2020.11.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 11/02/2020] [Accepted: 11/04/2020] [Indexed: 01/17/2023]
Abstract
AIMS Idarucizumab reverses the anticoagulant effect of dabigatran. We aimed to investigate real-world experience with idarucizumab and associated clinical outcomes. METHODS We conducted a retrospective observational case series on dabigatran users treated with idarucizumab. Using electronic patient records, we identified patients from December 2015 (market introduction) to 31 December 2019 from the Central Denmark Region, covering approximately 1.3 million inhabitants. Treatment indications included need of acute surgery, major bleeding, dabigatran intoxication and need of thrombolysis. Outcomes were defined according to treatment indication, and adverse events were defined as bleeding, thrombosis or death within 30 days of infusion. RESULTS A total of 46 dabigatran users were treated with idarucizumab. All patients except one received dabigatran due to atrial fibrillation. Indications for idarucizumab use were need of acute surgery in 22 (48%), severe bleeding in 20 (43%), dabigatran intoxication in three (7%), and prior to thrombolysis in acute stroke in one (2%) patient. There were no reports of excessive bleeding during surgery in patients reversed just prior to surgery. For patients presenting with severe bleeding, all but one achieved effective haemostasis. Among all patients receiving idarucizumab, six (13%) experienced bleeding within 30 days after infusion. None experienced thromboembolic complications. At 30 days follow-up, 38 (83%) patients were alive of whom 35 (92%) had restarted anticoagulant treatment. CONCLUSION This study of real-world application of idarucizumab demonstrated effectiveness in terms of surgery performed without excessive bleeding and cessation of severe bleeding in dabigatran-treated patients. Safety appeared high as no patients experienced thromboembolic complications within 30 days.
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Affiliation(s)
- Simone Bonde Haastrup
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark
| | - Maja Hellfritzsch
- Department of Clinical Pharmacology, Aarhus University Hospital, Aarhus, Denmark; Department of Cardiology, Herning Regional Hospital, Herning, Denmark
| | - Mads Nybo
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Anne-Mette Hvas
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark; Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Erik Lerkevang Grove
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark; Department of Cardiology, Aarhus University Hospital, Aarhus, Denmark.
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93
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Evrard J, Hardy M, Dogné JM, Lessire S, Maloteau V, Mullier F, Douxfils J. Are the DOAC plasma level thresholds appropriate for clinical decision-making? A reappraisal using thrombin generation testing. Int J Lab Hematol 2020; 43:e48-e51. [PMID: 33037773 DOI: 10.1111/ijlh.13356] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 09/04/2020] [Accepted: 09/05/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Jonathan Evrard
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Michaël Hardy
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université catholique de Louvain, Yvoir, Belgium.,Hematology Laboratory, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université catholique de Louvain, Yvoir, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium.,Namur Biobank-eXchange (NAB-X), University of Namur, Namur, Belgium
| | - Sarah Lessire
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université catholique de Louvain, Yvoir, Belgium
| | - Vincent Maloteau
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - François Mullier
- Hematology Laboratory, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université catholique de Louvain, Yvoir, Belgium
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium.,Qualiblood s.a, Namur, Belgium
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94
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Oberladstätter D, Voelckel W, Schlimp C, Zipperle J, Ziegler B, Grottke O, Schöchl H. A prospective observational study of the rapid detection of clinically-relevant plasma direct oral anticoagulant levels following acute traumatic injury. Anaesthesia 2020; 76:373-380. [PMID: 32946123 DOI: 10.1111/anae.15254] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2020] [Indexed: 12/15/2022]
Abstract
In urgent clinical situations, such as trauma, urgent surgery or before thrombolysis, rapid quantification of direct oral anticoagulant plasma drug levels is warranted. Using the ClotPro® analyser, we assessed two novel viscoelastic tests for detection of clinically-relevant plasma drug levels in trauma patients. The ecarin clotting time was used to assess the plasma concentration of dabigatran and Russell´s viper venom clotting time to determine the plasma concentration of direct factor Xa inhibitors. In parallel, plasma concentrations were analysed using plasma-based chromogenic assays. A total of 203 simultaneous measurements were performed. Strong to very strong linear correlations were detected between ecarin clotting time and plasma concentration of dabigatran (r = 0.9693), and between Russell´s viper venom clotting time and plasma concentrations of apixaban (r = 0.7391), edoxaban (r = 0.9251) and rivaroxaban (r = 0.8792), all p < 0.001. An ecarin clotting time ≥ 189 seconds provided 100% sensitivity and 90% specificity for detecting plasma dabigatran concentrations ≥ 50 ng.ml-1 . Corresponding Russell´s viper venom clotting time cut-off values were ≥ 136 seconds for apixaban (80% sensitivity, 88% specificity), ≥ 168 seconds for edoxaban (100% sensitivity, 100% specificity) and ≥ 177 seconds for rivaroxaban (90% sensitivity, 100% specificity). Detection of drug levels ≥ 100 ng.ml-1 was also investigated: for dabigatran, an ecarin clotting time ≥ 315 seconds yielded 92% sensitivity and 100% specificity; while Russell´s viper venom clotting time cut-offs of 191, 188 and 196 seconds were calculated for apixaban (67% sensitivity, 88% specificity), edoxaban (100% sensitivity, 75% specificity) and rivaroxaban (100% sensitivity, 91% specificity), respectively. We have demonstrated strong positive correlations between plasma drug levels and clotting time values in the specific ClotPro assays. Cut-off values for detecting clinically-relevant drug levels showed high levels of sensitivity and specificity.
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Affiliation(s)
- D Oberladstätter
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - W Voelckel
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria
| | - C Schlimp
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - J Zipperle
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
| | - B Ziegler
- Department of Anaesthesiology and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - O Grottke
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - H Schöchl
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria.,Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, Vienna, Austria
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95
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Levy JH, Connors JM. Andexanet Alfa Use in Cardiac Surgical Patients: A Xa Inhibitor and Heparin Reversal Agent. J Cardiothorac Vasc Anesth 2020; 35:265-266. [PMID: 33067086 DOI: 10.1053/j.jvca.2020.09.091] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 09/07/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC.
| | - Jean M Connors
- Department of Medicine, Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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96
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Jakowenko N, Nguyen S, Ruegger M, Dinh A, Salazar E, Donahue KR. Apixaban and rivaroxaban anti-Xa level utilization and associated bleeding events within an academic health system. Thromb Res 2020; 196:276-282. [PMID: 32947066 PMCID: PMC7474843 DOI: 10.1016/j.thromres.2020.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 07/30/2020] [Accepted: 09/01/2020] [Indexed: 12/20/2022]
Abstract
Background Oral factor Xa inhibitors (FXaI) can be administered in fixed doses without the need for routine laboratory monitoring. Anti-Xa assays can estimate anticoagulant effect for specific FXaI's. The aim of this study was to characterize anti-Xa levels in patients taking apixaban or rivaroxaban with major bleeding events. Methods Apixaban and rivaroxaban anti-Xa assays ordered within our hospital system from May 2016 to September 2019 were evaluated. The primary outcome was major bleeding events defined by International Society of Thrombosis and Haemostasis criteria. Median anti-Xa levels for each FXaI were calculated for those with and without major bleeding, as well as those who did and did not receive reversal agents. Results A total of 606 anti-Xa levels were analyzed. There were 146 major bleeding events documented, with the most common site being intracranial (63%). Median anti-Xa levels in patients with and without major bleeding were similar, whereas those on apixaban therapy who received reversal agents typically had higher anti-Xa levels (73 ng/mL vs. 153 ng/mL, p = 0.0019). Factors significantly associated with increased odds of bleeding were an age > 80 years, inappropriately high dosing regimens, and modest anti-Xa levels (100–300 ng/mL) for rivaroxaban specifically. Conclusions Older age and inappropriately high dosing regimens were associated with major bleeding in patients taking apixaban and rivaroxaban. Further investigation into the utility of anti-Xa levels for FXaI is warranted. Quantification and assessment of anticoagulation can be accomplished with factor Xa inhibitor (FXaI) specific anti-Xa levels Elderly patients and those on inappropriately high dosing regimens may be at an elevated risk for major bleeding It is unclear if elevated anti-Xa levels confer a direct increased risk for bleeding in the absence of other factors Anti-Xa levels are useful for confirmed or suspected bleeding, clearance for parenteral anticoagulation, and prior to an emergent procedure
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Affiliation(s)
- Nicholas Jakowenko
- Department of Pharmacy, Houston Methodist Hospital - Texas Medical Center, Houston, TX 77030, United States of America.
| | - Steffany Nguyen
- Department of Pharmacy, Houston Methodist Hospital - Texas Medical Center, Houston, TX 77030, United States of America
| | - Melanie Ruegger
- Department of Pharmacy, Houston Methodist Hospital - Texas Medical Center, Houston, TX 77030, United States of America
| | - Ashley Dinh
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States of America
| | - Eric Salazar
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital - Texas Medical Center, Houston, TX 77030, United States of America
| | - Kevin R Donahue
- Department of Pharmacy, Houston Methodist Hospital - Texas Medical Center, Houston, TX 77030, United States of America
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97
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Rossi JM, Diamond SL. Scalable manufacture of a disposable, storage-stable eight-channel microfluidic device for rapid testing of platelet, coagulation, and drug function under whole blood flow. BIOMICROFLUIDICS 2020; 14:054103. [PMID: 33014235 PMCID: PMC7527242 DOI: 10.1063/5.0023312] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 09/17/2020] [Indexed: 05/04/2023]
Abstract
Custom polydimethylsiloxane (PDMS) microfluidic devices allow for small-volume human blood research under hemodynamic conditions of bleeding and clotting. However, issues of PDMS molding/assembly, bio-coating, and sample preparation often limit their point-of-care use. We aim to develop a microfluidic device that has the same utility as previously established PDMS devices but which is more usable in point-of-care operation. We designed an injection-molded 1 × 3 in.2 device with eight flow paths crossing a bio-printed surface of a collagen/tissue factor. The device is rapidly primed and compatible with multi-channel pipetting (<0.5 ml blood) and operates under venous or arterial shear rates using constant flow rate or constant pressure modes. Platelet and fibrin deposition were monitored dynamically by the imaging of immunofluorescence. For whole blood clotting at a wall shear rate of 200 s-1, the intrachip CV at 400 s for platelet and fibrin deposition was 10% and the interdonor CV at 400 s was 30% for platelet and 22% for fibrin deposition (across 10 healthy donors). No significant difference was detected for samples tested on a new chip vs a chip stored for 6 months at 4 °C. Using the fibrin signal, dose-response testing of whole blood revealed IC50's of 120 nM for rivaroxaban and apixaban, and 60 nM for dabigatran. A complete reversal of apixaban inhibition was observed for an equimolar addition of Xa DOAC reversal agent Andexanet Alfa. We demonstrate the ability to manufacture single-use, storage-stable eight-channel chips. In clinical settings, such chips may help evaluate patient bleeding risk, therapy choice, drug activity, or reversal.
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Affiliation(s)
| | - Scott L. Diamond
- Author to whom correspondence should be addressed:. Tel.: +1 215 573 5704. Fax: +1 215 573 6815
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98
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Overview and Practical Application of Coagulation Assays in Managing Anticoagulation with Direct Oral Anticoagulants (DOACs). ACTA ACUST UNITED AC 2020. [DOI: 10.1007/s40495-020-00232-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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99
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Creeper K, Stafford A, Reynolds S, Samida S, P'Ng S, Glennon D, Seymour H, Grove C. Outcomes and anticoagulation use for elderly patients that present with an Acute Hip Fracture: multi‐centre, retrospective analysis. Intern Med J 2020; 52:418-425. [DOI: 10.1111/imj.15007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 07/15/2020] [Accepted: 08/04/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Katherine Creeper
- Haematology Department, NedlandsSir Charles Gairdner Hospital Western Australia
- PathWest Laboratory Medicine, Nedlands Western Australia
| | - Andrew Stafford
- School of Pharmacy and Biomedical SciencesCurtin University of Technology Bentley Western Australia
| | - Sophie Reynolds
- Royal Perth Hospital Department of Geriatric Medicine Perth Western Australia
| | - Sapna Samida
- Royal Perth Hospital Department of Geriatric Medicine Perth Western Australia
| | - Stephanie P'Ng
- PathWest Laboratory Medicine, Nedlands Western Australia
- Department of HaematologyFiona Stanley Hospital Murdoch Western Australia
| | - Denise Glennon
- Department of Rehabilitation and Aged CareSir Charles Gairdner Hospital Nedlands Western Australia
| | - Hannah Seymour
- Department of Geriatrics and Aged CareFiona Stanley Hospital Murdoch Western Australia
| | - Carolyn Grove
- Haematology Department, NedlandsSir Charles Gairdner Hospital Western Australia
- PathWest Laboratory Medicine, Nedlands Western Australia
- School of Medicine and PharmacologyUniversity of Western Australia Nedlands Western Australia
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100
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Zhang H, Liu Z, Mu G, Wang Z, Zhou S, Xie Q, Ma L, Wang Z, Hu K, Gong Y, Jiang J, Xiang Q, Cui Y. Diagnostic performance of coagulation indices for direct oral anticoagulant concentration. Thromb Res 2020; 195:171-179. [PMID: 32711233 DOI: 10.1016/j.thromres.2020.07.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 07/10/2020] [Accepted: 07/14/2020] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Different coagulation indices for direct oral anticoagulants (DOACs) exist in clinical practice, but limited data are available for the diagnostic power of these indices. This review and meta-analysis aims to explore the diagnostic value of coagulation indices for DOACs. MATERIALS AND METHODS PubMed, Web of Science, EMBASE, Clinical Trials.gov, and the Cochrane Library were searched from inception of each database to 15 February 2020. Studies reporting a relationship between coagulation indices and the gold standard (liquid chromatography/tandem mass spectrometry) were included in the analysis. RESULTS Sixteen articles from 9169 citations evaluating the performance of coagulation indices were included in this review. A total of 236, 273, 273 rivaroxaban samples were included to assess the diagnostic power of anti-Xa activity (AXA), prothrombin time (PT), combined PT and activated partial thromboplastin time, respectively. A total of 268 dabigatran samples were included to assess the diagnostic performance of diluted thromboplastin time (dTT). AXA calibrated by rivaroxaban showed a sensitivity of 0.98 (95% confidence interval (CI): 0.91-0.99) and a specificity of 0.98 (95% CI: 0.94-0.99) at the threshold of 30 ng/mL. For dabigatran, the combined sensitivity of dTT was 0.76 (95% CI: 0.66-0.84) and combined specificity was 0.97 (95% CI: 0.92-0.99). CONCLUSIONS DOAC-specific calibrated AXA was a good index to indicate concentration for rivaroxaban and apixaban. More studies on edoxaban and betrixaban are in need. Diluted TT, thrombin inhibitor assay, and ecarin-based assays were potential to measure dabigatran concentration. Due to the limited data, results should be validated in the future.
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Affiliation(s)
- Hanxu Zhang
- Department of Pharmacy, Peking University First Hospital, Beijing, China; School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China; School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Lingyue Ma
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zining Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Kun Hu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Yanjun Gong
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Jie Jiang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China.
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China; School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China.
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