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Talari G, Demertzis ZD, Summey RD, Gill B, Kaatz S. Perioperative management of anticoagulation. Hosp Pract (1995) 2020; 48:231-240. [PMID: 32627607 DOI: 10.1080/21548331.2020.1792138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Periprocedural management of the anticoagulated patient can be as easy as continuing warfarin for a low bleeding risk procedure, holding a direct oral anticoagulant for 1 day prior and resuming 1 day later or as complex as emergent reversal with prothrombin complex concentrate, idarucizumab, or andexanet alfa. Patient-specific factors for thromboembolic risk and procedural bleeding risk determine timing of anticoagulation hold prior to and resumption after invasive procedures. Clinical trials and management studies in recent years have helped inform our approach to these patients, but much of the guidance is still based on expert consensus.
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Affiliation(s)
- Goutham Talari
- Division of Hospital Medicine, Henry Ford Hospital , Detroit, Michigan, USA
| | - Zachary D Demertzis
- Department of Internal Medicine, Henry Ford Hospital , Detroit, Michigan, USA
| | - Robert D Summey
- Division of Hospital Medicine, Henry Ford Hospital , Detroit, Michigan, USA
| | - Baljinder Gill
- Division of Hospital Medicine, Henry Ford Hospital , Detroit, Michigan, USA
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital , Detroit, Michigan, USA
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Stellpflug SJ, Bond ME, Henry KD, Engebretsen KM, Zantek ND. Intravenous Fat Emulsion Does Not Significantly Alter Clotting Markers in Dabigatran-Treated Blood. Indian J Hematol Blood Transfus 2020; 37:101-107. [PMID: 33707842 DOI: 10.1007/s12288-020-01309-5] [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: 10/14/2019] [Accepted: 06/15/2020] [Indexed: 10/24/2022] Open
Abstract
Dabigatran etexilate is an oral direct thrombin (Factor IIa) inhibitor approved for patients with atrial fibrillation and for management of risk of deep vein thrombosis and pulmonary embolism. Dabigatran offers advantages over treatment with warfarin, including limited laboratory monitoring. It is equivalent in prevention of stroke and deep vein thrombosis with essentially equivalent complication rates. In contrast to warfarin, reversal of the anticoagulation is less well established. Idarucizumab is available for reversal, however supporting research is mixed; the agent also happens to be quite expensive making availability difficult. Hemodialysis has been proposed as a method of reversal, but this is difficult in patients with life threatening hemorrhage, and is not available at many hospitals. Intravenous fat emulsion (IFE) has been used for treatment of overdose of lipophilic drugs. Most toxicologists only recommend IFE for patients in extremis after ingestion of a lipid soluble substance. Dabigatran is lipid soluble, although the pro-drug more so than the active metabolite. The authors sought to see if dabigatran-induced coagulopathy of human in vitro blood samples could be reversed with IFE. Blood samples were spiked with dabigatran or dabigatran plus IFE. Values for Ecarin clot time (ECT-primary outcome), PT/INR, and aPTT, were compared across both study arms. A total of 18 healthy volunteers were included in our study. There were no significant differences in the ECT, PT/INR, and aPTT between the dabigatran arm and the dabigatran plus IFE arm. Based on these methods, IFE does not reverse dabigatran-induced coagulopathy.
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Affiliation(s)
- Samuel J Stellpflug
- Department of Emergency Medicine, Regions Hospital, 640 Jackson Street, Saint Paul, MN 55101 USA
| | - Michael E Bond
- Department of Emergency Medicine, Regions Hospital, 640 Jackson Street, Saint Paul, MN 55101 USA
| | - Keith D Henry
- Department of Emergency Medicine, Regions Hospital, 640 Jackson Street, Saint Paul, MN 55101 USA
| | - Kristin M Engebretsen
- Department of Emergency Medicine, Regions Hospital, 640 Jackson Street, Saint Paul, MN 55101 USA
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN USA
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103
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Sairaku A, Onohara Y, Hironobe N, Matsumura H, Kihara Y, Nakano Y. Remaining activity of temporary interrupted direct oral anticoagulants and its impact on intra‐ablation heparinization in patients with atrial fibrillation: Comparisons across four drugs and two dose regimens. J Cardiovasc Electrophysiol 2020; 31:1996-2004. [DOI: 10.1111/jce.14588] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 05/13/2020] [Accepted: 05/22/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Akinori Sairaku
- Department of Cardiovascular MedicineHiroshima University Graduate School of Biomedical and Health Sciences Hiroshima Japan
| | - Yuko Onohara
- Department of Cardiovascular MedicineHiroshima University Graduate School of Biomedical and Health Sciences Hiroshima Japan
| | - Naoya Hironobe
- Department of Cardiovascular MedicineHiroshima University Graduate School of Biomedical and Health Sciences Hiroshima Japan
| | - Hiroya Matsumura
- Department of Cardiovascular MedicineHiroshima University Graduate School of Biomedical and Health Sciences Hiroshima Japan
| | - Yasuki Kihara
- Department of Cardiovascular MedicineHiroshima University Graduate School of Biomedical and Health Sciences Hiroshima Japan
| | - Yukiko Nakano
- Department of Cardiovascular MedicineHiroshima University Graduate School of Biomedical and Health Sciences Hiroshima Japan
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104
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Thirunavukkarasu S, Kalashyan H, Jickling G, Jeerakathil TJ, Jayaprakash HK, Buck BH, Shuaib A, Butcher K. Successful dabigatran reversal after subdural hemorrhage using idarucizumab in a mobile stroke unit: A case report. Medicine (Baltimore) 2020; 99:e20200. [PMID: 32481289 PMCID: PMC7249931 DOI: 10.1097/md.0000000000020200] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 02/24/2020] [Accepted: 04/08/2020] [Indexed: 11/27/2022] Open
Abstract
RATIONALE Idarucizumab is a specific reversal agent for patients with bleeding related to the anticoagulant dabigatran. There are no prior descriptions of Idarucizumab administration in the prehospital setting for intracranial hemorrhage. PATIENT CONCERNS An 82-year-old woman treated with dabigatran for atrial fibrillation developed acute focal weakness. This led to activation of emergency medical services and assessment in the mobile stroke unit (MSU). DIAGNOSIS Computed tomography of the brain performed in the MSU revealed an acute subdural hematoma. INTERVENTIONS The patient was treated with Idarucizumab in the MSU. OUTCOMES The subdural hematoma was treated with a burr hole evacuation and the patient was discharged to a rehabilitation facility without residual focal neurological deficits. LESSONS Idarucizumab can be used safely and effectively to treat dabigatran-associated intracranial hemorrhage in the prehospital setting.
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MESH Headings
- Administration, Intravenous
- Aged, 80 and over
- Antibodies, Monoclonal, Humanized/administration & dosage
- Antibodies, Monoclonal, Humanized/therapeutic use
- Antithrombins/adverse effects
- Antithrombins/therapeutic use
- Atrial Fibrillation/drug therapy
- Dabigatran/adverse effects
- Dabigatran/therapeutic use
- Emergency Medical Services
- Female
- Hematoma, Subdural/chemically induced
- Hematoma, Subdural/diagnostic imaging
- Hematoma, Subdural/drug therapy
- Hematoma, Subdural/surgery
- Humans
- Tomography, X-Ray Computed/methods
- Treatment Outcome
- Trephining/methods
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105
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Pfrepper C, Metze M, Siegemund A, Klöter T, Siegemund T, Petros S. Direct oral anticoagulant plasma levels and thrombin generation on ST Genesia system. Res Pract Thromb Haemost 2020; 4:619-627. [PMID: 32548561 PMCID: PMC7292659 DOI: 10.1002/rth2.12340] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 02/26/2020] [Accepted: 03/02/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Monitoring of anticoagulant activity of direct oral anticoagulants (DOACs) can be necessary in special situations. DOAC plasma levels have a high inter- and intraindividual variation and do not necessarily reflect the coagulation status of the patient. Thrombin generation (TG) is a global hemostatic assay with the capacity to overcome this limitation. The aim of this study was to show correlations between DOAC plasma levels and TG parameters using the fully automated ST Genesia system. METHODS A total of 380 blood samples (120 with apixaban, 79 with dabigatran, 79 with edoxaban, and 102 with rivaroxaban) from patients at different time points after DOAC intake were included in the analysis. DOAC plasma levels were analyzed using calibrated anti-Xa or anti-IIa tests. Thrombin generation was measured using the ST Genesia system and STG-DrugScreen reagent. RESULTS There was a significant correlation between the drug levels of all DOACs and the TG parameters' lag time and time to peak. Peak thrombin and velocity index show a negative correlation following an exponential regression curve with all anti-Xa DOACs but not with dabigatran. Apart from a weak correlation with rivaroxaban, there was no correlation between drug levels of all other DOACs and endogenous thrombin potential. CONCLUSION TG parameters measured with ST Genesia correlate with the drug levels of anti-Xa DOACs. Peak thrombin and velocity index are of special interest for the determination of residual anticoagulant effect at low drug levels. For dabigatran-treated patients, only lag time shows a correlation with the dabigatran plasma levels.
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Affiliation(s)
- Christian Pfrepper
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
| | - Michael Metze
- Department of CardiologyUniversity Hospital LeipzigLeipzigGermany
| | - Annelie Siegemund
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
- Medical ICUUniversity Hospital LeipzigLeipzigGermany
| | - Tristan Klöter
- Department of CardiologyUniversity Hospital LeipzigLeipzigGermany
| | - Thomas Siegemund
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
- Medical ICUUniversity Hospital LeipzigLeipzigGermany
| | - Sirak Petros
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
- Medical ICUUniversity Hospital LeipzigLeipzigGermany
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106
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Metze M, Pfrepper C, Klöter T, Stöbe S, Siegemund R, Siegemund T, Edel E, Laufs U, Petros S. Inhibition of thrombin generation 12 hours after intake of direct oral anticoagulants. Res Pract Thromb Haemost 2020; 4:610-618. [PMID: 32548560 PMCID: PMC7292666 DOI: 10.1002/rth2.12332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/12/2020] [Accepted: 02/02/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The residual antithrombotic activity 12 hours after intake of direct oral anticoagulants (DOACs) is of clinical relevance in the setting of bleeding or urgent surgery. OBJECTIVE To evaluate the effects of DOACs on thrombin generation 12 hours after DOAC intake in comparison to baseline and a healthy control group. METHODS Eighty patients were recruited, 20 patients for each approved DOAC: apixaban, edoxaban, rivaroxaban, and dabigatran. The patients were either to be put on anticoagulation for the first time or had stopped taking oral anticoagulation for at least 48 hours. Blood plasma was sampled before (baseline) and 12 hours after starting DOAC for quantification of drug levels and thrombin generation assayed using an automated system (ST Genesia). Sixty-one blood donors served as control group. RESULTS The factor Xa inhibitors significantly increased lag time (137%-219%) and reduced thrombin peak (47%-76%) and velocity index (17%-44%) after 12 hours compared to baseline. Dabigatran showed prolongation of lag time to 133% and time to peak to 119%. All patients had residual antithrombotic activity, with reduced thrombin generation parameters 12 hours after DOAC intake compared to baseline and to the healthy control group. This effect remained significant in patients with low residual DOAC plasma levels <50 ng/mL. CONCLUSION Thrombin generation remains reduced 12 hours after DOAC intake. While thrombin peak is particularly modified by factor Xa inhibitors, all DOACs prolong the lag time and time to thrombin peak. In the setting of bleeding or urgent surgery, the automated thrombin generation assay may assist in decision making and antidote administration.
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Affiliation(s)
- Michael Metze
- Department of CardiologyMedical Department IVUniversity Hospital LeipzigLeipzigGermany
| | - Christian Pfrepper
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
| | - Tristan Klöter
- Department of CardiologyMedical Department IVUniversity Hospital LeipzigLeipzigGermany
| | - Stephan Stöbe
- Department of CardiologyMedical Department IVUniversity Hospital LeipzigLeipzigGermany
| | - Roland Siegemund
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
| | - Thomas Siegemund
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
| | - Elvira Edel
- Institute of Transfusion MedicineUniversity Hospital LeipzigLeipzigGermany
| | - Ulrich Laufs
- Department of CardiologyMedical Department IVUniversity Hospital LeipzigLeipzigGermany
| | - Sirak Petros
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
- Medical ICUUniversity Hospital LeipzigLeipzigGermany
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107
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Lessire S, Dincq AS, Siriez R, Pochet L, Sennesael AL, Vornicu O, Hardy M, Deceuninck O, Douxfils J, Mullier F. Assessment of low plasma concentrations of apixaban in the periprocedural setting. Int J Lab Hematol 2020; 42:394-402. [PMID: 32297711 DOI: 10.1111/ijlh.13202] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 03/19/2020] [Accepted: 03/22/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Estimation of residual apixaban plasma concentrations may be requested in the management of emergencies. This study aims at assessing the performance of specific anti-Xa assays calibrated with apixaban on real-life samples with low apixaban plasma concentrations (<30 ng/mL) and on-treatment ranges, with and without interference of low-molecular-weight heparin (LMWH). METHODS The performance of the STA® -Liquid Anti-Xa assay (STA® LAX) and the low and normal procedures of the Biophen® Direct Factor Xa Inhibitors (DiXaI) assay was tested on 134 blood samples, collected from patients on apixaban, wherefrom 74 patients received LMWH after apixaban cessation. The results were compared with the liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) measurements. RESULTS The Biophen® DiXaI, Biophen® DiXaI LOW, and STA® LAX showed very good correlation with LC-MS/MS measurements in patients without LMWH administration (Spearman r .95, .99, and .98, respectively). Their limits of quantitation were defined at 48, 24, and 12 ng/mL, respectively. The Bland-Altman test measured mean bias (SD) at 5.6 (13.1), -2.5 (5.0), and -0.8 (6.1) ng/ml, respectively. The Spearman r of the Biophen® DiXaI decreased to 0.64 in presence of low apixaban concentrations. The Spearman r of the Biophen® DiXaI LOW and STA® LAX decreased to 0.39 and 0.26, respectively, in presence of LMWH. CONCLUSIONS The accuracy of the low methodologies (Biophen® DiXaI LOW and STA® LAX) is slightly improved for low apixaban plasma concentrations, compared with the normal procedure of Biophen® DiXaI. The interference of LMWH on the low methodologies is measurable, however, less important than the previously reported interference of LMWH on rivaroxaban calibrated specific anti-Xa assays.
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Affiliation(s)
- Sarah Lessire
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Anesthesiology, Yvoir, Belgium
| | - Anne-Sophie Dincq
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Anesthesiology, Yvoir, Belgium
| | - Romain Siriez
- University of Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Pharmacy, Namur, Belgium
| | - Lionel Pochet
- University of Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Pharmacy, Namur, Belgium
| | - Anne-Laure Sennesael
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Pharmacy, Yvoir, Belgium
| | - Ovidiu Vornicu
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Anesthesiology, Yvoir, Belgium
| | - Michael Hardy
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Anesthesiology, Yvoir, Belgium
| | - Olivier Deceuninck
- Université catholique de Louvain, CHU UCL Namur, Department of Cardiology, Yvoir, Belgium
| | - Jonathan Douxfils
- University of Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Pharmacy, Namur, Belgium.,Qualiblood sa, Namur, Belgium
| | - François Mullier
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Hematology Laboratory, Yvoir, Belgium
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108
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Athavale A, Jamshidi N, Roberts DM. Incomplete responses to the recommended dose of idarucizumab: a systematic review and pharmacokinetic analysis. Clin Toxicol (Phila) 2020; 58:789-800. [DOI: 10.1080/15563650.2020.1743846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Akshay Athavale
- Drug Health Services and Clinical Pharmacology and Toxicology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Nazila Jamshidi
- Drug Health Services and Clinical Pharmacology and Toxicology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Darren M. Roberts
- Department of Clinical Pharmacology and Toxicology, St. Vincent’s Hospital, Sydney, Australia
- Department of Renal Medicine and Transplantation, St. Vincent’s Hospital, Sydney, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia
- St Vincent's Clinical School, University of New South Wales, Sydney, Australia
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110
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Abstract
This article presents a focused review of the available tests to assess the effect of direct oral anticoagulants on coagulation and the use of reversal agents in the perioperative setting for practicing anesthesiologists.
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112
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Siriez R, Alpan L, Elasaad K, Devel P, Laloy J, Dogné JM, Douxfils J. Importance of measuring pharmacologically active metabolites of edoxaban: development and validation of an ultra-high-performance liquid chromatography coupled with a tandem mass spectrometry method. J Thromb Thrombolysis 2020; 49:395-403. [DOI: 10.1007/s11239-019-02030-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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113
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Nestor MA, Boling B. Reversing Direct Oral Anticoagulants in Acute Intracranial Hemorrhage. Crit Care Nurse 2020; 39:e1-e8. [PMID: 31154337 DOI: 10.4037/ccn2019160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Intracerebral hemorrhage is a major source of morbidity and mortality, accounting for 10% of all strokes. Oral anticoagulation therapy, while necessary to prevent thromboembolic complications, increases the risk of intracerebral hemorrhage and can potentially worsen bleeding in cases of acute hemorrhage. Before the introduction of direct oral anticoagulant agents in 2010, warfarin was the only option for oral anticoagulation. These new agents have an improved safety profile compared with warfarin but require different reversal strategies. Anticoagulation reversal in the setting of acute intracerebral hemorrhage is an evolving field. This article covers the most common direct oral anticoagulant medications, various available anticoagulant reversal strategies, and the latest guidelines for anticoagulation reversal in patients with acute intracranial hemorrhage.
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Affiliation(s)
- Melissa A Nestor
- Melissa A. Nestor is a neurosciences critical care pharmacist at the University of Kentucky, Lexington, Kentucky, with research interests in sepsis, neurologic injury, and ischemic stroke; Bryan Boling is an advanced practice provider with the Department of Anesthesiology, Division of Critical Care at the University of Kentucky
| | - Bryan Boling
- Melissa A. Nestor is a neurosciences critical care pharmacist at the University of Kentucky, Lexington, Kentucky, with research interests in sepsis, neurologic injury, and ischemic stroke; Bryan Boling is an advanced practice provider with the Department of Anesthesiology, Division of Critical Care at the University of Kentucky.
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Siddiqui F, Tafur A, Ramacciotti LS, Jeske W, Hoppensteadt D, Ramacciotti E, Iqbal O, Fareed J. Reversal of Factor Xa Inhibitors by Andexanet Alfa May Increase Thrombogenesis Compared to Pretreatment Values. Clin Appl Thromb Hemost 2020; 25:1076029619863493. [PMID: 31298056 PMCID: PMC6714992 DOI: 10.1177/1076029619863493] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Recombinant coagulation factor Xa (FXa), inactivated Zh-zo, also known as andexanet alfa (AA), is a modified version of human FXa that has been developed to neutralize FXa inhibitors. We studied the reversal effect of AA for these inhibitors in various anticoagulant and thrombin generation (TG) assays. Individual aliquots of normal human plasma containing 1 µg/mL of apixaban, betrixaban, edoxaban, and rivaroxaban, were supplemented with saline or AA at a concentration of 100 µg/mL. Clotting profiles include prothrombinase-induced clotting time, activated partial thromboplastin time, and prothrombin time. Factor Xa activity was measured using an amidolytic method. Thrombin generation was measured using a calibrated automated thrombogram. Differential neutralization of all 4 anticoagulants was noted in the activated clotting time and other clotting tests. The FXa activity reversal profile varied with an observed decrease in apixaban (22%), betrixaban (56%), edoxaban (28%), and rivaroxaban (49%). Andexanet alfa also led to an increased TG in comparison to saline. The peak thrombin was higher (40%), area under the curve (AUC) increased (15%), whereas the lag time (LT) decreased (17%). Andexanet alfa added at 100 µg/mL to various FXa supplemented systems resulted in reversal of the inhibitory effects, restoring the TG profile; AUC, LT, and peak thrombin levels were comparable to those of unsupplemented samples. Andexanet alfa is capable of reversing anti-Xa activity of different oral FXa inhibitors but overshoots thrombogenesis in both the saline and FXa inhibitor supplemented systems. The degree of neutralization of Xa inhibitor is specific to each agent.
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Affiliation(s)
- Fakiha Siddiqui
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
- Fakiha Siddiqui, Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA.
| | - Alfonso Tafur
- Northshore Cardiovascular Institute, NorthShore University HealthSystem, Skokie, IL, USA
| | | | - Walter Jeske
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
| | - Debra Hoppensteadt
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
| | - Eduardo Ramacciotti
- Vascular and Endovascular Surgery, Santa Casa School of Medicine, São Paulo, Brazil
| | - Omer Iqbal
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
| | - Jawed Fareed
- Cardiovascular Research Institute, Loyola University Chicago, Health Sciences Division, Maywood, IL, USA
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115
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Dopsaj V. Practical issues in measuring the anticoagulant effect of direct oral anticoagulants. ARHIV ZA FARMACIJU 2020. [DOI: 10.5937/arhfarm2005297d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
The classical oral anticoagulants are increasingly being replaced in clinical practice by new antithrombotic drugs, which act by enabling direct inhibition of coagulation factor IIa (FIIa) or factor Xa (FXa). These drugs have multiple acronyms, including NOACs (new, non-vitamin K antagonist) or DOACs (direct oral anticoagulants), and currently include dabigatran (FIIa inhibitor), and rivaroxaban, apixaban, and edoxaban (FXa inhibitors). These drugs are approved for stroke prevention in patients with non-valvular atrial fibrillation and the prevention and treatment of venous thromboembolism. The "mantra" that DOACs do not require laboratory monitoring is not entirely correct because laboratory testing for drug effects is needed in many situations, because they influence hemostasis tests and in situations in which urgent measurement of DOACs is required. This should be very important to consider in the clinical situation for numbers of indications and increasing numbers of patients on DOACs therapy. The main aim of this article is to provide practical issues to general laboratory testing for DOACs, as well as to help avoid diagnostic errors associated with hemostasis testing. The assays for DOAC quantification must be available in medical centers on a whole day basis, to facilitate optimal drug management in conditions when things go wrong or in urgent cases of immediate reversal of anticoagulation or appropriate administration of a specific antidote.
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116
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Levy JH, Welsby I. Andexanet Alfa Use in Patients Requiring Cardiopulmonary Bypass: Quo Vadis? A A Pract 2019; 13:477. [DOI: 10.1213/xaa.0000000000001115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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117
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Margetić S, Ćelap I, Delić Brkljačić D, Pavlović N, Šupraha Goreta S, Kobasić I, Lovrenčić-Huzjan A, Bašić Kes V. Chromogenic anti-FXa assay calibrated with low molecular weight heparin in patients treated with rivaroxaban and apixaban: possibilities and limitations. Biochem Med (Zagreb) 2019; 30:010702. [PMID: 31839722 PMCID: PMC6904970 DOI: 10.11613/bm.2020.010702] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 09/15/2019] [Indexed: 12/05/2022] Open
Abstract
Introduction Clinical application of rivaroxaban and apixaban does not require therapeutic monitoring. Commercial anti-activated factor X (anti-FXa) inhibition methods for all anti-FXa drugs are based on the same principle, so there are attempts to evaluate potential clinical application of heparin-calibrated anti-FXa assay as an alternative method for direct FXa inhibitors. We aimed to evaluate relationship between anti-FXa methods calibrated with low molecular weight heparin (LMWH) and with drug specific calibrators, and to determine whether commercial LMWH anti-FXa assay can be used to exclude the presence of clinically relevant concentrations of rivaroxaban and apixaban. Materials and methods Low molecular weight heparin calibrated reagent (Siemens Healthineers, Marburg, Germany) was used for anti-FXa activity measurement. Innovance heparin (Siemens Healthineers, Marburg, Germany) calibrated with rivaroxaban and apixaban calibrators (Hyphen BioMed, Neuville-sur-Oise, France) was used for quantitative determination of FXa inhibitors. Results Analysis showed good agreement between LMWH calibrated and rivaroxaban calibrated activity (κ = 0.76) and very good agreement with apixaban calibrated anti-Xa activity (κ = 0.82), respectively. Low molecular weight heparin anti-FXa activity cut-off values of 0.05 IU/mL and 0.1 IU/mL are suitable for excluding the presence of clinically relevant concentrations (< 30 ng/mL) of rivaroxaban and apixaban, respectively. Concentrations above 300 ng/mL exceeded upper measurement range for LMWH anti-FXa assay and cannot be determined by this method. Conclusion Low molecular weight heparin anti-FXa assay can be used in emergency clinical conditions for ruling out the presence of clinically relevant concentrations of rivaroxaban and apixaban. However, use of LMWH anti-FXa assay is not appropriate for their quantitative determination as an interchangeable method.
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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
| | - Diana Delić Brkljačić
- Department of Cardiovascular Diseases, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Nikola Pavlović
- Department of Cardiovascular Diseases, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Sandra Šupraha Goreta
- Department of Biochemistry and Molecular Biology, Faculty of Pharmacy and Biochemistry, University of Zagreb, Croatia
| | - Ivana Kobasić
- Department of Neurology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | | | - Vanja Bašić Kes
- Department of Neurology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
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118
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Sarode R. Direct oral anticoagulant monitoring: what laboratory tests are available to guide us? HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:194-197. [PMID: 31808890 PMCID: PMC6913449 DOI: 10.1182/hematology.2019000027] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Direct oral anticoagulants (DOACs) are increasingly used in the treatment and prophylaxis of thromboembolism because of several advantages over vitamin K antagonists, including no need for laboratory monitoring. However, it has become increasingly important in certain clinical scenarios to know either actual DOAC concentration (quantitative) or presence of DOAC (qualitative). These clinical conditions include patients presenting with major bleeding or requiring urgent surgery who may need a reversal or hemostatic agent, extremes of body weight, failed therapy, etc. Prothrombin time and activated partial thromboplastin time are variably affected by factor Xa inhibitors (FXaIs) and direct thrombin inhibitor (DTI), respectively, depending on reagents' sensitivity, and hence, they cannot be relied on confidently. Thrombin time is highly sensitive to very low amounts of DTI; thus, normal value rules out a clinically significant amount. Liquid chromatography mass spectrometry accurately measures DOAC levels but is clinically impractical. Dilute thrombin time and ecarin-based assays using appropriate calibrators/controls provide an accurate DTI level. Anti-Xa assay using corresponding FXaI calibrators/controls provides accurate drug levels. However, these assays are not readily available in the United States compared with some other parts of the world. Heparin assays using anti-Xa activity often have a linear relationship with calibrated FXaI assays, especially at the lower end of on-therapy levels, and they may provide rapid assessment of drug activity for clinical decision making. Currently, there is very limited knowledge of DOAC effect on viscoelastic measurements. Although there is uniformity in expression of DOAC concentrations in nanograms per milliliter, a universal FXaI DOAC assay is urgently needed.
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Affiliation(s)
- Ravi Sarode
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas, TX
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Hirsh J, Eikelboom JW, Chan NC. Fifty years of research on antithrombotic therapy: Achievements and disappointments. Eur J Intern Med 2019; 70:1-7. [PMID: 31679885 DOI: 10.1016/j.ejim.2019.10.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 10/17/2019] [Indexed: 11/18/2022]
Abstract
The achievements with antithrombotic therapy over the past 50 years have been monumental and the disappointments relatively few. In this review, we will discuss, chronologically, the major developments of the two recognized classes of antithrombotics - anticoagulants and antiplatelet agents.
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Affiliation(s)
- Jack Hirsh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - John W Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada
| | - Noel C Chan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada.
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120
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Steffel J, Verhamme P, Potpara TS, Albaladejo P, Antz M, Desteghe L, Haeusler KG, Oldgren J, Reinecke H, Roldan-Schilling V, Rowell N, Sinnaeve P, Collins R, Camm AJ, Heidbüchel H. The 2018 European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation. Eur Heart J 2019; 39:1330-1393. [PMID: 29562325 DOI: 10.1093/eurheartj/ehy136] [Citation(s) in RCA: 1270] [Impact Index Per Article: 254.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The current manuscript is the second update of the original Practical Guide, published in 2013 [Heidbuchel et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF) and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. The European Heart Rhythm Association (EHRA) set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group identified 20 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 20 topics are as follows i.e., (1) Eligibility for NOACs; (2) Practical start-up and follow-up scheme for patients on NOACs; (3) Ensuring adherence to prescribed oral anticoagulant intake; (4) Switching between anticoagulant regimens; (5) Pharmacokinetics and drug-drug interactions of NOACs; (6) NOACs in patients with chronic kidney or advanced liver disease; (7) How to measure the anticoagulant effect of NOACs; (8) NOAC plasma level measurement: rare indications, precautions, and potential pitfalls; (9) How to deal with dosing errors; (10) What to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a potential risk of bleeding; (11) Management of bleeding under NOAC therapy; (12) Patients undergoing a planned invasive procedure, surgery or ablation; (13) Patients requiring an urgent surgical intervention; (14) Patients with AF and coronary artery disease; (15) Avoiding confusion with NOAC dosing across indications; (16) Cardioversion in a NOAC-treated patient; (17) AF patients presenting with acute stroke while on NOACs; (18) NOACs in special situations; (19) Anticoagulation in AF patients with a malignancy; and (20) Optimizing dose adjustments of VKA. Additional information and downloads of the text and anticoagulation cards in different languages can be found on an EHRA website (www.NOACforAF.eu).
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Affiliation(s)
- Jan Steffel
- Department of Cardiology, University Heart Center Zurich, Rämistrasse 100, CH-8091 Zurich, Switzerland
| | - Peter Verhamme
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | | | | | | | - Lien Desteghe
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Karl Georg Haeusler
- Center for Stroke Research Berlin and Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jonas Oldgren
- Uppsala Clinical Research Center and Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Holger Reinecke
- Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany
| | | | | | - Peter Sinnaeve
- Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Ronan Collins
- Age-Related Health Care & Stroke-Service, Tallaght Hospital, Dublin Ireland
| | - A John Camm
- Cardiology Clinical Academic Group, Molecular & Clinical Sciences Institute, St George's University, London, UK, and Imperial College
| | - Hein Heidbüchel
- Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium.,Antwerp University and University Hospital, Antwerp, Belgium
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Ebner M, Birschmann I, Peter A, Härtig F, Spencer C, Kuhn J, Rupp A, Blumenstock G, Zuern CS, Ziemann U, Poli S. Limitations of Specific Coagulation Tests for Direct Oral Anticoagulants: A Critical Analysis. J Am Heart Assoc 2019; 7:e009807. [PMID: 30371316 PMCID: PMC6404908 DOI: 10.1161/jaha.118.009807] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background During treatment with direct oral anticoagulants (DOAC), coagulation assessment is required before thrombolysis, surgery, and if anticoagulation reversal is evaluated. Limited data support the accuracy of DOAC‐specific coagulation assays around the current safe‐for‐treatment threshold of 30 ng/mL. Methods and Results In 481 samples obtained from 96 patients enrolled at a single center, DOAC concentrations were measured using Hemoclot direct thrombin inhibitor assay, Biophen direct thrombin inhibitor assay or ecarin clotting time for dabigatran, chromogenic anti‐Xa assay (AXA) for factor Xa inhibitors (rivaroxaban, apixaban) and ultraperformance liquid chromatography–tandem mass spectrometry as reference. All dabigatran‐specific assays had high sensitivity to concentrations >30 ng/mL, but specificity was lower for Hemoclot direct thrombin inhibitor assay (78.2%) than for Biophen direct thrombin inhibitor assay (98.9%) and ecarin clotting time (94.6%). AXA provided high sensitivity and specificity for rivaroxaban, but low sensitivity for apixaban (73.8%; concentrations up to 82 ng/mL were misclassified as <30 ng/mL). If no DOAC‐specific calibration for AXA is available, results 2‐fold above the upper limit of normal indicate relevant rivaroxaban concentrations. For apixaban, all elevated results should raise suspicion of relevant anticoagulation. Conclusions DOAC‐specific tests differ considerably in diagnostic performance for concentrations close to the currently accepted safe‐for‐treatment threshold. Compared with Biophen direct thrombin inhibitor assay and ecarin clotting time, limited specificity of Hemoclot direct thrombin inhibitor assay poses a high risk of unnecessary anticoagulation reversal or treatment delays in patients on dabigatran. While AXA accurately detected rivaroxaban, the impact of low apixaban levels on the assay was weak. Hence, AXA results need to be interpreted with extreme caution when used to assess hemostatic function in patients on apixaban. Clinical Trial Registration URL: https://www.clinicaltrials.gov. Unique identifiers: NCT02371044, NCT02371070.
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Affiliation(s)
- Matthias Ebner
- 1 Department of Internal Medicine and Cardiology Charité University Medicine Berlin Campus Virchow Klinikum Berlin Germany.,2 Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
| | - Ingvild Birschmann
- 3 Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center Ruhr University Bad Oeynhausen Germany
| | - Andreas Peter
- 4 Division of Endocrinology, Diabetology, Angiology, Nephrology and Clinical Chemistry Department of Internal Medicine University Hospital Tübingen Germany.,5 Institute for Diabetes Research and Metabolic Diseases of the Helmholtz Centre Munich University of Tübingen Germany.,6 German Centre for Diabetes Research (DZD) Neuherberg Germany
| | - Florian Härtig
- 2 Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
| | - Charlotte Spencer
- 2 Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
| | - Joachim Kuhn
- 3 Institute for Laboratory and Transfusion Medicine, Heart and Diabetes Center Ruhr University Bad Oeynhausen Germany
| | - André Rupp
- 7 Department of Neurology University Hospital Heidelberg Heidelberg Germany
| | - Gunnar Blumenstock
- 8 Department of Clinical Epidemiology and Applied Biometry University of Tübingen Germany
| | - Christine S Zuern
- 9 Department of Cardiology and Cardiovascular Medicine University Hospital Tübingen Germany.,10 Department of Cardiology and Cardiovascular Research Institute Basel (CRIB) University Hospital Basel Switzerland
| | - Ulf Ziemann
- 2 Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
| | - Sven Poli
- 2 Department of Neurology with Focus on Neurovascular Diseases and Neurooncology and Hertie Institute for Clinical Brain Research University Hospital Tübingen Germany
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122
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Bloemen S, Zwaveling S, Mullier F, Douxfils J. Concomitant assessment of rivaroxaban concentration and its impact on thrombin generation. Thromb Res 2019; 184:8-15. [PMID: 31677449 DOI: 10.1016/j.thromres.2019.09.037] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 09/15/2019] [Accepted: 09/17/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Reliable assays to measure direct oral anticoagulant (DOAC) levels and their activity in critical situations are needed. Drug levels alone are not representative of the effect of DOACs on an individual's coagulation. We developed a technique that provides direct assessment of the global effect of rivaroxaban on the individual's coagulation in addition to plasma concentrations. METHODS DOAC concentrations were determined in fifty patients using rivaroxaban, with the new assay, Xross-CAT. The effect of rivaroxaban on coagulation (activity) was measured with thrombin generation (TG) in platelet poor plasma using 5 pM tissue factor on the same device. The levels were validated with the Biophen DiXal assay. The prothrombin time (PT) and dilute Russell viper venom time (dRVVT) were performed to estimate the effect on coagulation. RESULTS The variability of Xross-CAT was below 12%. Xross-CAT correlates well with Biophen DiXaI (rs = 0.885). The bias, determined by Bland-Altman analysis, was 4.9% and the Passing-Bablok equation was y = 1.1x - 2.1. The correlation of plasma levels with TG was moderate (ETP rs = -0.548; Peak rs = -0.559), as for the PT (rs = 0.739) and the dRVVT (rs = 0.692). CONCLUSIONS Xross-CAT shows a good correlation with Biophen DiXaI that was previously confirmed to accurately assess rivaroxaban levels. Bleeding and thrombotic complications are not necessarily associated with drug levels and could be influenced by concomitant risk factors. The main benefit of Xross-CAT is that it can be performed simultaneously with thrombin generation, providing an overview of the global anticoagulation status of a patient in relation to circulating DOAC levels.
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Affiliation(s)
- Saartje Bloemen
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands.
| | - Suzanne Zwaveling
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - François Mullier
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Namur Thrombosis and Hemostasis Center, NARILIS, Yvoir, Belgium
| | - Jonathan Douxfils
- University of Namur, Department of Pharmacy, Namur Research Institute for Life Sciences, Namur Thrombosis and Hemostasis Center, Namur, Belgium; QUALIblood s.a., Namur, Belgium
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123
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Kaserer A, Kiavialaitis GE, Braun J, Schedler A, Stein P, Rössler J, Spahn DR, Studt JD. Impact of rivaroxaban plasma concentration on perioperative red blood cell loss. Transfusion 2019; 60:197-205. [PMID: 31682296 DOI: 10.1111/trf.15560] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 09/26/2019] [Accepted: 09/26/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND This study investigates the impact of preoperative calculated rivaroxaban (RXA) plasma concentration on perioperative red blood cell (RBC) loss. STUDY DESIGN AND METHODS In this retrospective single-center study, we identified patients with RXA intake according to a preoperative determination of RXA levels within 96 hours before surgery. RXA plasma concentration at the beginning of surgery was then calculated from the last RXA intake using a single-compartment pharmacokinetic model with four categories of RXA concentration (≤20, 21-50, 51-100, and >100 μg/L). Patients were classified into surgery with high (≥500 mL) or low (<500 mL) expected blood loss. Perioperative bleeding was determined by calculating RBC loss. RESULTS We analyzed 308 surgical interventions in 298 patients during the period from January 2012 to July 2018. Among patients undergoing surgery with low expected blood loss, RBC loss varied from 164 mL (standard deviation [SD], 189) to 302 mL (SD, 397) (p = 0.66), and no association of calculated RXA concentration with RBC loss was observed. In patients undergoing surgery with high expected blood loss, we found a significant correlation of calculated RXA concentration with RBC loss (Pearson's correlation coefficient, 0.29; p = 0.002). RBC loss increased with rising RXA concentration from 575 mL (SD, 365) at RXA concentration of 20 μg/L or less up to 1400 mL (SD, 1300) at RXA concentration greater than 100 μg/L. RXA concentration greater than 100 μg/L was associated with a significant increase of in RBC loss of 840 mL (95% confidence interval, 360-1300; p < 0.001). Transfusion of RBC and fresh frozen plasma units tended to increase in patients with RXA concentrations greater than 100 μg/L. The proportion of patients treated with prothrombin complex concentrate and coagulation factor XIII concentrate increased significantly with higher RXA concentrations. CONCLUSION Only in surgery with high expected blood loss, a calculated RXA concentration of greater than 100 μg/L was associated with a significant increase of perioperative RBC loss.
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Affiliation(s)
- Alexander Kaserer
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | | | - Julia Braun
- Departments of Epidemiology and Biostatistics, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Andreas Schedler
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Philipp Stein
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Julian Rössler
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Jan-Dirk Studt
- Division of Hematology, University and University Hospital Zurich, Zurich, Switzerland
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Roldán Rabadán I, Alonso de Leciñana M, Barba Martín R, Páramo Fernández JA. Security profile of direct anticoagulants. Preferred use in atrial fibrillation. CLINICA E INVESTIGACION EN ARTERIOSCLEROSIS : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ARTERIOSCLEROSIS 2019; 31:263-270. [PMID: 31213323 DOI: 10.1016/j.arteri.2019.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 02/12/2019] [Accepted: 03/01/2019] [Indexed: 06/09/2023]
Abstract
A multidisciplinary panel of cardiologists, neurologists, internal medicine and specialists in hemostasis and thrombosis has elaborated this document showing recent scientific evidences supporting a better profile of direct oral anticoagulants (DOACs) versus vitaminK antagonists (VKA), as well as the indications of specific antidotes and hemostatic agents to reverse the anticoagulant effects of DOACs. The analysis reinforces the best profile of DOACs and its special benefit in patients with basal high hemorrhagic risk.
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Affiliation(s)
| | | | - Raquel Barba Martín
- Servicio de Medicina Interna, Hospital Universitario Rey Juan Carlos, Móstoles, Madrid, España
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125
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Sairaku A, Nakano Y, Onohara Y, Hironobe N, Matsumura H, Shimizu W, Kihara Y. Residual anticoagulation activity in atrial fibrillation patients with temporary interrupted direct oral anticoagulants: Comparisons across 4 drugs. Thromb Res 2019; 183:119-123. [DOI: 10.1016/j.thromres.2019.10.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 08/25/2019] [Accepted: 10/02/2019] [Indexed: 11/25/2022]
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127
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Cost comparison of andexanet versus prothrombin complex concentrates for direct factor Xa inhibitor reversal after hemorrhage. J Thromb Thrombolysis 2019; 49:121-131. [DOI: 10.1007/s11239-019-01973-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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128
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Ofek F, Barchel D, Perets N, Ziv-Baran T, Mahajna A, Filipovich-Rimon T, Garach-Jehoshua O, Berlin M, Berkovitch M. International Normalized Ratio as a Screening Test for Assessment of Anticoagulant Activity for Patients Treated With Rivaroxaban or Apixaban: A Pilot Study. Front Pharmacol 2019; 10:1177. [PMID: 31649541 PMCID: PMC6792346 DOI: 10.3389/fphar.2019.01177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/13/2019] [Indexed: 12/29/2022] Open
Abstract
Introduction: In patients treated with direct oral anti activated factor X (anti-FXa) anticoagulants such as apixaban and rivaroxaban, there are several emergency and non-emergency conditions in which anticoagulation activity should be measured. The validity of the common global clotting tests, prothrombin time and international normalized ratio (PT/INR) for determination of blood levels of these drugs, has been widely investigated. As the anticoagulation activity evaluation “calibrated anti-FXa” of these drugs is relatively more expensive and less available, we aimed to build a prediction model for anticoagulation activity assessment based on INR values. Methods and Findings: One hundred sixty samples from 80 hospitalized patients treated with apixaban or rivaroxaban were tested using PT/INR and Anti-FXa chromogenic assay. Two blood samples, trough and peak, were collected from each subject. Participants were randomly divided into two equal groups. One group (n = 40) was used to build the model, which was validated by the second group (n = 40). There was a strong correlation between anti-FXa concentrations and INR in rivaroxaban treated patients (r = 0.899, p < 0.001). Therefore, we were able to build a formula for rivaroxaban patient group which reliably represent the relationship between these two parameters. The correlation in apixaban treated patients was less predictive (r = 0.798, p < 0.001) and the formula suggested could not be validated. Conclusions: In our study, we developed a formula that estimates the anticoagulant activity of rivaroxaban by obtaining INR values. Where anti-FXa assay is unavailable, our proposed formula may be considered as a screening test for rivaroxaban.
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Affiliation(s)
- Fanny Ofek
- Pharmacy Department, Assaf Harofeh Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Dana Barchel
- Internal Department, Assaf Harofeh Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nofar Perets
- Institute for Drug Research, School of Pharmacy, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Tomer Ziv-Baran
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ahmad Mahajna
- Internal Department, Assaf Harofeh Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Talia Filipovich-Rimon
- Division of Hematology, Assaf Harofeh Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Osnat Garach-Jehoshua
- Division of Hematology, Assaf Harofeh Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Maya Berlin
- Clinical Pharmacology and Toxicology Unit, Assaf Harofeh Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Matitiahu Berkovitch
- Clinical Pharmacology and Toxicology Unit, Assaf Harofeh Medical Center, Affiliated to Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Núñez-Navarro NE, Santana FM, Parra LP, Zacconi FC. Surfing the Blood Coagulation Cascade: Insight into the Vital Factor Xa. Curr Med Chem 2019; 26:3175-3200. [PMID: 29376487 DOI: 10.2174/0929867325666180125165340] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Revised: 12/28/2017] [Accepted: 01/11/2018] [Indexed: 01/19/2023]
Abstract
Factor Xa (FXa) plays a key role in haemostasis, it is a central part of the blood coagulation cascade which catalyzes the production of thrombin and leads to clot formation and wound closure. Therefore, FXa is an attractive target for the development of new anticoagulant agents. In this review, we will first describe the molecular features of this fundamental protein in order to understand its mechanism of action, an essential background for the design of novel inhibitors by means of synthetic organic chemistry or using peptides obtained from recombinant methodologies. Then, we will review the current state of the synthesis of novel direct FXa inhibitors along with their mechanisms of action. Finally, approved reversal agents that aid in maintaining blood haemostasis by using these commercial drugs will also be discussed.
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Affiliation(s)
- Nicolás E Núñez-Navarro
- Department of Organic Chemistry, Faculty of Chemistry, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Department of Chemical and Bioprocesses Engineering, School of Engineering, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Fabián M Santana
- Department of Organic Chemistry, Faculty of Chemistry, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Loreto P Parra
- Department of Chemical and Bioprocesses Engineering, School of Engineering, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Flavia C Zacconi
- Department of Organic Chemistry, Faculty of Chemistry, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Institute for Biological and Medical Engineering, Schools of Engineering, Medicine and Biological Sciences, Pontificia Universidad Catolica de Chile, Santiago, Chile.,Research Center for Nanotechnology and Advanced Materials "CIEN-UC", Pontificia Universidad Catolica de Chile, Santiago, Chile
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130
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[Perioperative management of trauma surgery patients treated with direct oral anticoagulants]. Unfallchirurg 2019; 122:633-645. [PMID: 31367841 DOI: 10.1007/s00113-019-0693-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
As the population gets older the prevalence of atrial fibrillation and venous thromboembolism also increases. Therefore, more patients require anticoagulation and currently direct oral anticoagulants (DOAC), such as dabigatran etexilate, apixaban, rivaroxaban and edoxaban are preferred to vitamin K antagonists (VKA), mainly because of the more favorable risk-benefit profile with respect to bleeding. Older patients in particular frequently present at the accident and emergency department due to falls and an increased risk of fractures. The perioperative management of these patients who are treated with DOACs is a challenge in the clinical routine and needs special consideration. This article discusses these issues in an interdisciplinary approach and develops strategies for the perioperative management of patients treated with DOACs and undergoing trauma or orthopedic surgery.
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131
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Malyszko J, Lopatowska P, Mlodawska E, Musialowska D, Malyszko JS, Tomaszuk-Kazberuk A. Atrial fibrillation in kidney transplant recipients: is there a place for the novel drugs? Nephrol Dial Transplant 2019; 33:1304-1309. [PMID: 28992319 DOI: 10.1093/ndt/gfx265] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Accepted: 07/15/2017] [Indexed: 01/06/2023] Open
Abstract
Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia of high clinical importance, occurring in 2% of the general population and in 19-24% in patients with chronic kidney disease. It is a well-known risk factor for cardiovascular morbidity and mortality. Kidney transplant recipients with a history of AF were associated with significantly higher rate of ischaemic strokes, graft failure and post-transplant mortality. AF occurs in over 7% of kidney transplant recipients in the first 3 years after transplantation and is associated with reduced graft and patient survival. The incidence of stroke in patients after kidney transplantation (KTx) is higher than the general population, but markedly lower than those on dialysis. Oral anticoagulation (OAC) therapy is recommended in AF patients at high risk of stroke. There are no randomized studies assessing OAC in patients after KTx and there are no specific recommendations and guidelines on therapeutic strategies in these patients. KTx recipients are a vulnerable population, exposed to variations in renal function, being at higher risk of bleeding and thrombotic complications, with possible interactions with immunosuppression. Surely, there is a place for novel oral anticoagulants (NOACs) in this group of patients as long as the summary of product characteristics is followed, as they are a valuable anticoagulation therapy. On one hand, they are at least as effective as warfarin; on the other hand NOACs are safer, especially when it comes to intracranial haemorrhages. However, NOACs seem to be underused in this population as they are excreted via kidney, may interact with immunosuppressive therapy and physicians need more experience and confidence in their administration. Percutaneous left atrial appendage occlusion procedure may also be considered as an opportunity for this group of patients, in particular in the presence of contraindications to anticoagulation.
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Affiliation(s)
- Jolanta Malyszko
- 2nd Department of Nephrology and Hypertension with Dialysis Unit, Medical University, Bialystok, Poland
| | | | | | - Dominika Musialowska
- 2nd Department of Nephrology and Hypertension with Dialysis Unit, Medical University, Bialystok, Poland
| | - Jacek S Malyszko
- 1st Department of Nephrology and Transplantology with Dialysis Unit, Medical University, Bialystok, Poland
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132
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Hollestelle MJ, Meijer P. International external quality assessment for measurements of direct oral anticoagulants: results and recommendations. Br J Haematol 2019; 188:460-464. [DOI: 10.1111/bjh.16179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 07/01/2019] [Accepted: 07/08/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Martine J. Hollestelle
- External quality Control for Assays and Tests (ECAT) Foundation Voorschoten The Netherlands
| | - Piet Meijer
- External quality Control for Assays and Tests (ECAT) Foundation Voorschoten The Netherlands
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133
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Prothrombin Complex Concentrates for Perioperative Vitamin K Antagonist and Non-vitamin K Anticoagulant Reversal. Anesthesiology 2019; 129:1171-1184. [PMID: 30157037 DOI: 10.1097/aln.0000000000002399] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Vitamin K antagonist therapy is associated with an increased bleeding risk, and clinicians often reverse anticoagulation in patients who require emergency surgical procedures. Current guidelines for rapid anticoagulation reversal for emergency surgery recommend four-factor prothrombin complex concentrate and vitamin K coadministration. The authors reviewed the current evidence on prothrombin complex concentrate treatment for vitamin K antagonist reversal in the perioperative setting, focusing on comparative studies and in the context of intracranial hemorrhage and cardiac surgery. The authors searched Cochrane Library and PubMed between January 2008 and December 2017 and retrieved 423 English-language papers, which they then screened for relevance to the perioperative setting; they identified 36 papers to include in this review. Prothrombin complex concentrate therapy was consistently shown to reduce international normalized ratio rapidly and control bleeding effectively. In comparative studies with plasma, prothrombin complex concentrate use was associated with a greater proportion of patients achieving target international normalized ratios rapidly, with improved hemostasis. No differences in thromboembolic event rates were seen between prothrombin complex concentrate and plasma, with prothrombin complex concentrate also demonstrating a lower risk of fluid overload events. Overall, the studies the authors reviewed support current recommendations favoring prothrombin complex concentrate therapy in patients requiring vitamin K antagonist reversal before emergency surgery.
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134
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Perlman A, Hochberg-Klein S, Choshen Cohen L, Dagan G, Hirsh-Raccah B, Horwitz E, Aldouby-Bier G, Negev T, Matok I, Azoulay L, Kalish Y, Muszkat M. Management strategies of the interaction between direct oral anticoagulant and drug-metabolizing enzyme inducers. J Thromb Thrombolysis 2019; 47:590-595. [PMID: 30617727 DOI: 10.1007/s11239-018-01804-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Little is known regarding the management of direct oral anticoagulants (DOACs) in patients with enzyme-inducing drugs (EID). The use of EID may lead to sub-therapeutic concentrations of DOACs and to treatment failure. Thus, many patients on EIDs cannot benefit from the advantages of DOACs. This was a retrospective study, evaluating the management of hospitalized patients with DOACs. Characteristics of hospitalized patients with a prescription for DOACs, with and without EIDs, were summarized and evaluated, and management strategies addressing the potential interaction were documented, including the use of DOAC concentration monitoring. During the period evaluated, 1596 hospitalized patients with prescriptions for DOACs were identified. Most patients received apixaban (n = 1227, 77%), followed by rivaroxaban (240, 15%), and dabigatran (129, 8%). Twenty-two patients (1.4%) had concomitant EIDs. Demographic and clinical characteristics of hospitalized patients with DOACs were similar in those receiving EID and those not. Management strategies included stopping DOAC or EID (41%), and DOAC dose increase (14%). During management of these interactions, DOAC concentrations were measured for 11 of 22 patients and were below the 5th percentile of expected concentration for six of these patients. The management of patients with DOAC concentration measurement differed significantly from those without (p = 0.005), as they were much less likely to have one of the medications stopped and more often had the DOACs' dose increased. Among hospitalized patients with DOACs, EIDs are not rare. DOAC concentrations are often low in the presence of EIDs. DOAC concentration monitoring may be useful in settings requiring both DOAC and EIDs.
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Affiliation(s)
- Amichai Perlman
- Pharmacy Division, Hadassah Hebrew University Medical Center, Jerusalem, Israel.,Department of Medicine, Hadassah Hebrew University Medical Center, Mt Scopus, 91540, Jerusalem, Israel.,Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sarit Hochberg-Klein
- Department of Medicine, Hadassah Hebrew University Medical Center, Mt Scopus, 91540, Jerusalem, Israel.,Department of Epidemiology, Biostatistics, and Occupational Health, Centre for Clinical Epidemiology, Jewish General Hospital, Lady Davis Institute, Montreal, Canada
| | - Lotan Choshen Cohen
- Department of Medicine, Hadassah Hebrew University Medical Center, Mt Scopus, 91540, Jerusalem, Israel
| | - Gil Dagan
- Department of Medicine, Hadassah Hebrew University Medical Center, Mt Scopus, 91540, Jerusalem, Israel
| | - Bruria Hirsh-Raccah
- Pharmacy Division, Hadassah Hebrew University Medical Center, Jerusalem, Israel.,Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Cardiology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Ehud Horwitz
- Pharmacy Division, Hadassah Hebrew University Medical Center, Jerusalem, Israel.,Department of Medicine, Hadassah Hebrew University Medical Center, Mt Scopus, 91540, Jerusalem, Israel
| | - Gefen Aldouby-Bier
- Pharmacy Division, Hadassah Hebrew University Medical Center, Jerusalem, Israel.,Department of Oncology, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Tamar Negev
- Pharmacy Division, Hadassah Hebrew University Medical Center, Jerusalem, Israel.,Department of Orthopedics, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Ilan Matok
- Division of Clinical Pharmacy, Institute for Drug Research, School of Pharmacy, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Laurent Azoulay
- Department of Epidemiology, Biostatistics, and Occupational Health, Centre for Clinical Epidemiology, Jewish General Hospital, Lady Davis Institute, Montreal, Canada.,Gerald Bronfman Department of Oncology, McGill University, Montreal, Canada
| | - Yosef Kalish
- Department of Hematology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Mordechai Muszkat
- Department of Medicine, Hadassah Hebrew University Medical Center, Mt Scopus, 91540, Jerusalem, Israel.
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135
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Serrano CV, Soeiro ADM, Leal TCAT, Godoy LC, Biselli B, Hata LA, Martins EB, Abud-Manta ICK, Tavares CAM, Cardozo FAM, Oliveira MTD. Statement on Antiplatelet Agents and Anticoagulants in Cardiology - 2019. Arq Bras Cardiol 2019; 113:111-134. [PMID: 31411300 PMCID: PMC6684187 DOI: 10.5935/abc.20190128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Carlos V Serrano
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil
- Hospital Israelita Albert Einstein, São Paulo, SP - Brazil
- Hospital Beneficência Portuguesa Mirante, São Paulo, SP - Brazil
| | - Alexandre de M Soeiro
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil
- Hospital Beneficência Portuguesa Mirante, São Paulo, SP - Brazil
| | - Tatiana C A Torres Leal
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Lucas C Godoy
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Bruno Biselli
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Luiz Akira Hata
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Eduardo B Martins
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Isabela C K Abud-Manta
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil
- Hospital Israelita Albert Einstein, São Paulo, SP - Brazil
| | - Caio A M Tavares
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil
| | - Francisco Akira Malta Cardozo
- Instituto do Coração do Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP - Brazil
- Hospital Beneficência Portuguesa Mirante, São Paulo, SP - Brazil
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136
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Glund S, Coble K, Gansser D, Stangier J, Hoermann K, Pollack CV, Reilly P. Pharmacokinetics of idarucizumab and its target dabigatran in patients requiring urgent reversal of the anticoagulant effect of dabigatran. J Thromb Haemost 2019; 17:1319-1328. [PMID: 31050868 PMCID: PMC6852568 DOI: 10.1111/jth.14476] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 04/02/2019] [Accepted: 04/16/2019] [Indexed: 12/13/2022]
Abstract
BACKGROUND Idarucizumab is a monoclonal antibody fragment that reverses dabigatran anticoagulation. Pharmacokinetics (PK) of idarucizumab have been described in healthy, elderly, or renally impaired (RI) volunteers, but PK data in patients are lacking. OBJECTIVES This analysis describes the PK of idarucizumab and its target dabigatran in bleeding/surgical patients. PATIENTS AND METHODS Results from the Reversal Effects of Idarucizumab on Active Dabigatran study, a prospective, multicenter, single-arm study demonstrated the reversal of dabigatran anticoagulation by idarucizumab in patients with uncontrollable bleeding (group A) or who needed urgent surgery (group B). Idarucizumab and unbound dabigatran concentrations, immunogenicity, and pharmacodynamics were assessed. RESULTS Total and unbound dabigatran levels at baseline were 165 ng/mL vs 110 ng/mL and 103 ng/mL vs 69.5 ng/mL in group A and B patients, respectively. Maximum plasma concentrations and area under the curves (AUC0-24 ) of idarucizumab in group A vs B, respectively, were 24 900 nmol/L vs 25 000 nmol/L and 76 600 nmol/h/L vs 68 000 nmol/h/L. Idarucizumab AUC0-24 increased by 38% in mild, 90% in moderate, and 146% in severe RI patients vs normal renal function. Hepatic impairment or geographical region had no relevant effect on idarucizumab PK. Idarucizumab immediately decreased unbound dabigatran concentration (<20 ng/mL). A linear correlation was observed between unbound dabigatran and diluted thrombin time and ecarin clotting time. Antidrug antibody titers were low (1-64 at day 30; 0-16 at day 90) and had no impact on idarucizumab PK and pharmacodynamics. CONCLUSION Idarucizumab PK in target patients was consistent with phase I data. Patient characteristics had no impact on PK, whereas RI increased the exposure of idarucizumab and dabigatran. TRIAL REGISTRATION NUMBER ClinicalTrials.gov NCT02104947.
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Affiliation(s)
- Stephan Glund
- Boehringer Ingelheim Pharma GmbH and Co. KGBiberach an der RissGermany
| | - Kelly Coble
- Boehringer Ingelheim Pharmaceuticals, IncRidgefieldConnecticut
| | - Dietmar Gansser
- Boehringer Ingelheim Pharma GmbH and Co. KGBiberach an der RissGermany
| | - Joachim Stangier
- Boehringer Ingelheim Pharma GmbH and Co. KGBiberach an der RissGermany
| | - Karin Hoermann
- Boehringer Ingelheim Pharma GmbH and Co. KGBiberach an der RissGermany
| | | | - Paul Reilly
- Boehringer Ingelheim Pharmaceuticals, IncRidgefieldConnecticut
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137
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Abstract
There are no clear and consistent guidelines on how to utilize DOAC assays, and reports on the use of DOAC levels in clinical practice is limited. The objective of this study was to analyze why DOAC levels are ordered, how the results affect clinical decision-making, and to determine if DOAC assays are utilized appropriately. This was a retrospective chart review study analyzing 150 dabigatran, rivaroxaban, and apixaban levels performed at a single institution. The majority of DOAC assays were ordered in situations or special patient populations where confirming absence or detecting presence of drug may be useful. The most common indication for ordering assays was prior to an invasive procedure. Most DOAC levels were timed appropriately but peak levels were most likely to be incorrectly ordered. Clinical decisions following level results depended on indication for ordering and were most commonly used to determine whether or not to proceed with an invasive procedure. The results of our study suggest while DOAC assays are generally ordered for useful indications, there is still a lack of understanding of when levels should be drawn and how to interpret DOAC assay results.
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Affiliation(s)
- Tina M Gu
- Department of Pharmacy, University of Washington, 1959 NE Pacific St., EA-146, Seattle, WA, 98195, USA.
| | - David A Garcia
- Division of Hematology, University of Washington, Seattle, WA, USA
| | - Daniel E Sabath
- Department of Laboratory Medicine, University of Washington, Seattle, WA, USA
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138
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Wagner J, Lock JF, Kastner C, Klein I, Krajinovic K, Löb S, Germer CT, Wiegering A. Perioperative management of anticoagulant therapy. Innov Surg Sci 2019; 4:144-151. [PMID: 33977124 PMCID: PMC8059348 DOI: 10.1515/iss-2019-0004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 06/24/2019] [Indexed: 11/15/2022] Open
Abstract
About 10% of patients taking a chronic, oral anticoagulant therapy require an invasive procedure that can be associated with an increased risk for peri-interventional or perioperative bleeding. Depending on the risk for thromboembolism and the risk for bleeding, the physician has to decide whether the anticoagulant therapy should be interrupted or continued. Patient characteristics such as age, renal function and drug interactions must be considered. The perioperative handling of the oral anticoagulant therapy differs according to the periprocedural bleeding risk. Patients requiring a procedure with a minor risk for bleeding do not need to pause their anticoagulant therapy. For procedures with an increased risk for perioperative bleeding, the anticoagulant therapy should be adequately paused. For patients on a coumarin derivative with a high risk for a thromboembolic event, a perioperative bridging therapy with a low molecular weight heparin is recommended. Due to an increased risk for perioperative bleeding in patients on a bridging therapy, it is not recommended in patients with a low risk for thromboembolism. For patients taking a non-vitamin K oral anticoagulant, a bridging therapy is not recommended due to the fast onset and offset of the medication.
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Affiliation(s)
- Johanna Wagner
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, Medical Center Julius-Maximilians, University of Wuerzburg, Oberduerrbacherstr. 6, 97080 Wuerzburg, Germany
| | - Johan F Lock
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany
| | - Carolin Kastner
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany
| | - Ingo Klein
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany
| | - Katica Krajinovic
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany
| | - Stefan Löb
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany
| | - Christoph-Thomas Germer
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany
| | - Armin Wiegering
- Department of General, Visceral, Transplantation, Vascular and Pediatric Surgery, University Hospital Würzburg, Wüerzburg, Germany.,Comprehensive Cancer Center Mainfranken, Würzburg, Germany.,Department of Biochemistry and Molecular Biology, University of Würzburg, Würzburg, Germany
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139
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Artang R, Anderson M, Nielsen JD. Fully automated thromboelastograph TEG 6s to measure anticoagulant effects of direct oral anticoagulants in healthy male volunteers. Res Pract Thromb Haemost 2019; 3:391-396. [PMID: 31294326 PMCID: PMC6611480 DOI: 10.1002/rth2.12206] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 03/06/2019] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND The ability to assess the hemostatic effect of the direct oral anticoagulant (DOACs) may be valuable in clinical situations such as bleeding or thrombosis, before urgent surgery, or reversal of anticoagulation. We sought to assess the anticoagulant effect of DOACs with the new-generation fully automated thrombelastograph TEG 6s using resonance-frequency viscoelasticity measurements and disposable multichannel microfluidic cartridges. METHODS A single dose of oral dabigatran 150 mg, rivaroxaban 20 mg, or apixaban 5 mg was given to 9 healthy males. Phlebotomy was performed at 0, 1, and 3 hours after administration of DOAC. TEG parameters were measured using TEG _6s. Concentrations of DOACs were measured using chromogenic assays. The TEG parameters were correlated to the DOAC concentrations. RESULTS The reaction time (R) demonstrated the strongest response to DOAC intake. There were no correlations between other TEG parameters and DOAC concentrations. Using the direct thrombin inhibitor (DTI) channel, R was significantly correlated with dabigatran levels (r = 0.94, P < 0.0001). Using the anti-factor Xa (AFXa) channel, R was significantly correlated with rivaroxaban and apixaban levels (r = 0.93 and r = 0.83, respectively; P < 0.0001 for both). R >2.5 minutes for dabigatran (DTI channel), >2.5 minutes for apixaban, and >1.8 minutes for rivaroxaban (AFXa channel) were associated with 100% sensitivity and ≥ 90% specificity to detect DOAC levels of ≥ 50 ng/mL. CONCLUSION We have demonstrated that TEG _6s R has significant correlation with DOAC blood concentrations and has potential for monitoring the DOAC's effect on hemostasis with reasonable sensitivity in the small sample analyzed. This novel technology is easy to use on a small volume of whole blood without requiring a specialized laboratory. Further study is warranted to correlate R with clinical outcomes.
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Affiliation(s)
- Ramin Artang
- Essentia Health St. Mary's Heart and Vascular CenterDuluthMinnesota
- Bispebjerg University HospitalUniversity of CopenhagenKobenhavnDenmark
| | - Maren Anderson
- Essentia Health St. Mary's Heart and Vascular CenterDuluthMinnesota
- University of Minnesota School of MedicineMinneapolisMinnesota
| | - Jorn D. Nielsen
- Bispebjerg University HospitalUniversity of CopenhagenKobenhavnDenmark
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140
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Kruger PC, Eikelboom JW, Douketis JD, Hankey GJ. Deep vein thrombosis: update on diagnosis and management. Med J Aust 2019; 210:516-524. [DOI: 10.5694/mja2.50201] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Paul C Kruger
- Fiona Stanley Hospital Perth WA
- PathWest Laboratory Medicine Perth WA
- Population Health Research Institute Hamilton Canada
| | - John W Eikelboom
- Population Health Research Institute Hamilton Canada
- Hamilton Health Sciences Hamilton Canada
| | - James D Douketis
- Hamilton Health Sciences Hamilton Canada
- St. Joseph's Healthcare HamiltonMcMaster University Hamilton Canada
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141
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Modified ROTEM for the detection of rivaroxaban and apixaban anticoagulant activity in whole blood. Eur J Anaesthesiol 2019; 36:449-456. [DOI: 10.1097/eja.0000000000000903] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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142
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Abstract
PURPOSE OF REVIEW Despite the increasing use of NOACs, there is still uncertainty on how to treat NOAC patients presenting with neurological emergencies. Initial assessment of coagulation status is challenging but essential in these patients to provide best-possible treatment in case of ischemic or hemorrhagic stroke. Meanwhile, anticoagulation reversal strategies have been suggested; yet, the optimal management is still unestablished. The current review aims to provide up-to-date information on (i) how to identify patients with NOAC intake, (ii) which therapies are feasible in the setting of ischemic and hemorrhagic stroke as well as traumatic intracranial hemorrhage, and (iii) how to proceed with patients requiring emergency lumbar puncture. RECENT FINDINGS Despite several expert opinions, there is still an ongoing debate which NOAC patients presenting with ischemic stroke may benefit from recanalizing strategies and whether these treatment approaches can be performed safely. Results from two phase IV trials investigating the efficacy of NOAC-specific reversal agents in case of major bleeding seem promising with regard to hemostatic parameters, but these antidotes have not been verified to clinically benefit patients, and approval by authorities in parts is still pending. Specific reversal agents are on the way and will provide new treatment options in patients with NOAC-related ischemic and hemorrhagic stroke. Up to now, the decision which patients should undergo recanalizing treatment for ischemic stroke, or which specific pharmacological reversal treatment in hemorrhagic stroke should be initiated, has to be made cautiously on an individual basis after assessing hemostatic parameters.
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Affiliation(s)
- Stefan T Gerner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University Hospital Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany.
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143
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Lavalle C, Straito M, Caroli A, Piro A, Giunta G, Mariani MV, Fedele F. Rivaroxaban in atrial fibrillation cardioversion: an update. Ther Clin Risk Manag 2019; 15:613-626. [PMID: 31118649 PMCID: PMC6504667 DOI: 10.2147/tcrm.s201162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 04/08/2019] [Indexed: 01/02/2023] Open
Abstract
Currently, atrial fibrillation (AF) is the most common sustained cardiac arrhythmia, with a prevalence of about 2-3% in the general population, representing a powerful risk factor for stroke and systemic thromboembolism and increased mortality and morbidity. Restoration of sinus rhythm is an important treatment option in AF and has a high success rate, but there is the need for an effective anticoagulation strategy to reduce the risk of embolic events. Anticoagulation with vitamin K antagonists is often associated with failure to achieving effective international normalized ratio. In this setting, recent data have led to extended approval for rivaroxaban in clinical practice, because it is effective and safe in patients with AF undergoing cardioversion, avoiding additional health costs and related time loss, while improving patient satisfaction. The present report provides an overview of the main randomized controlled trial and the main real-life studies, documenting the use of rivaroxaban in patients with non-valvular AF who underwent the cardioversion procedure. Considering that novel non-vitamin K antagonist oral anticoagulants in left atrial appendage thrombi resolution is still unknown in the real-world practice, the main findings on the use of rivaroxaban in this setting are also discussed.
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Affiliation(s)
- Carlo Lavalle
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, “Sapienza” University of Rome, Policlinico Umberto I, Rome, Italy
| | - Martina Straito
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, “Sapienza” University of Rome, Policlinico Umberto I, Rome, Italy
| | - Annalisa Caroli
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, “Sapienza” University of Rome, Policlinico Umberto I, Rome, Italy
| | - Agostino Piro
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, “Sapienza” University of Rome, Policlinico Umberto I, Rome, Italy
| | - Giuseppe Giunta
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, “Sapienza” University of Rome, Policlinico Umberto I, Rome, Italy
| | - Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, “Sapienza” University of Rome, Policlinico Umberto I, Rome, Italy
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrological, Anesthesiological and Geriatric Sciences, “Sapienza” University of Rome, Policlinico Umberto I, Rome, Italy
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144
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Maier CL, Asbury WH, Duncan A, Robbins A, Ingle A, Webb A, Stowell SR, Roback JD. Using an old test for new tricks: Measuring direct oral anti-Xa drug levels by conventional heparin-calibrated anti-Xa assay. Am J Hematol 2019; 94:E132-E134. [PMID: 30734369 DOI: 10.1002/ajh.25434] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 01/31/2019] [Accepted: 02/05/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Cheryl L. Maier
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory MedicineEmory University School of Medicine Atlanta Georgia
| | | | - Alexander Duncan
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory MedicineEmory University School of Medicine Atlanta Georgia
- Special Coagulation Laboratory, Emory Medical Laboratory Atlanta Georgia
| | - Adele Robbins
- Department of PharmacyEmory University Hospital Atlanta Georgia
| | - Ann Ingle
- Special Coagulation Laboratory, Emory Medical Laboratory Atlanta Georgia
| | - Adam Webb
- Departments of Neurology and NeurosurgeryEmory University School of Medicine Atlanta Georgia
| | - Sean R. Stowell
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory MedicineEmory University School of Medicine Atlanta Georgia
| | - John D. Roback
- Center for Transfusion and Cellular Therapies, Department of Pathology and Laboratory MedicineEmory University School of Medicine Atlanta Georgia
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145
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Dias JD, Lopez-Espina CG, Ippolito J, Hsiao LH, Zaman F, Muresan AA, Thomas SG, Walsh M, Jones AJ, Grisoli A, Thurston BC, Artang R, Bilden KP, Hartmann J, Achneck HE. Rapid point-of-care detection and classification of direct-acting oral anticoagulants with the TEG 6s: Implications for trauma and acute care surgery. J Trauma Acute Care Surg 2019; 87:364-370. [DOI: 10.1097/ta.0000000000002357] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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146
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Favresse J, Hardy M, van Dievoet MA, Sennesael AL, Douxfils J, Samama CM, Vornicu O, Dincq AS, Lessire S, Mullier F. Andexanet alfa for the reversal of factor Xa inhibitors. Expert Opin Biol Ther 2019; 19:387-397. [DOI: 10.1080/14712598.2019.1599355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- J Favresse
- Namur Thrombosis and Haemostasis Center, Hematology Laboratory, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - M Hardy
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Haemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - MA van Dievoet
- St-Luc University Hospital and Catholic University of Louvain, Department of Laboratory Medicine, Hematology Laboratory, Brussels, Belgium
| | - AL Sennesael
- Department of Pharmacy, Namur Thrombosis and Haemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
| | - J Douxfils
- Department of Pharmacy, Namur Thrombosis and Haemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
- Qualiblood s.a., Namur, Belgium
| | - CM Samama
- Department of Anaesthesiology and Intensive Care Medicine, Cochin University Hospital, Paris Descartes University, Paris, France
| | - O Vornicu
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Haemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - AS Dincq
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Haemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - S Lessire
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Haemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - F Mullier
- Namur Thrombosis and Haemostasis Center, Hematology Laboratory, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
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147
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Pastori D, Menichelli D, Gingis R, Pignatelli P, Violi F. Tailored Practical Management of Patients With Atrial Fibrillation: A Risk Factor-Based Approach. Front Cardiovasc Med 2019; 6:17. [PMID: 30915342 PMCID: PMC6422871 DOI: 10.3389/fcvm.2019.00017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/12/2019] [Indexed: 12/25/2022] Open
Abstract
The management of antithrombotic therapy for thromboprophylaxis in patients with atrial fibrillation (AF) has been recently evolved by the progressive replacement of vitamin K antagonists with the non-vitamin K antagonist oral anticoagulants (NOACs). However, while these drugs are effective in reducing ischemic stroke/systemic embolism, a still high rate of cardiovascular events is present in the AF population. A tailored integrated approach to patients with AF is therefore necessary to reduce both thromboembolic events and cardiovascular disease. This approach should consist in the assessment of individual risk factors for ischemic and bleeding events in order to choose the most appropriate anticoagulant treatment according to patient's characteristics and preference. To this purpose, several risk scores have been developed and validated to stratify thromboembolic and hemorrhagic risk. This review provides an individual-based strategy for the management of patients with AF, from a risk-factor based approach to a tailored prescription and monitoring of NOACs. In particular, we reported an updated practical management strategy for AF patients in specific clinical situations such as those (1) experiencing a major bleeding, (2) requiring a switch to another antithrombotic regimen, (3) restarting anticoagulation after acute ischemic stroke, (4) suffering from an acute coronary artery disease (acute coronary syndrome or undergoing cardiac revascularization).
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Affiliation(s)
| | | | | | | | - Francesco Violi
- I Clinica Medica, Atherothrombosis Centre, Department of Internal Medicine and Medical Specialties of Sapienza University, Rome, Italy
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148
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Wiegele M, Schöchl H, Haushofer A, Ortler M, Leitgeb J, Kwasny O, Beer R, Ay C, Schaden E. Diagnostic and therapeutic approach in adult patients with traumatic brain injury receiving oral anticoagulant therapy: an Austrian interdisciplinary consensus statement. Crit Care 2019; 23:62. [PMID: 30795779 PMCID: PMC6387521 DOI: 10.1186/s13054-019-2352-6] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2018] [Accepted: 02/10/2019] [Indexed: 12/11/2022] Open
Abstract
There is a high degree of uncertainty regarding optimum care of patients with potential or known intake of oral anticoagulants and traumatic brain injury (TBI). Anticoagulation therapy aggravates the risk of intracerebral hemorrhage but, on the other hand, patients take anticoagulants because of an underlying prothrombotic risk, and this could be increased following trauma. Treatment decisions must be taken with due consideration of both these risks. An interdisciplinary group of Austrian experts was convened to develop recommendations for best clinical practice. The aim was to provide pragmatic, clear, and easy-to-follow clinical guidance for coagulation management in adult patients with TBI and potential or known intake of platelet inhibitors, vitamin K antagonists, or non-vitamin K antagonist oral anticoagulants. Diagnosis, coagulation testing, and reversal of anticoagulation were considered as key steps upon presentation. Post-trauma management (prophylaxis for thromboembolism and resumption of long-term anticoagulation therapy) was also explored. The lack of robust evidence on which to base treatment recommendations highlights the need for randomized controlled trials in this setting.
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Affiliation(s)
- Marion Wiegele
- Department of Anaesthesia, Critical Care and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Herbert Schöchl
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, Dr. Franz Rehrl Platz 5, 5020 Salzburg, Austria
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Vienna, Austria
| | - Alexander Haushofer
- Central Laboratory, Klinikum Wels-Grieskirchen, Grieskirchner Str. 42, 4600 Wels, Austria
| | - Martin Ortler
- Department of Neurosurgery, Krankenhaus Rudolfstiftung, Juchgasse 25, 1030 Vienna, Austria
- Department of Neurosurgery, Medical University of Innsbruck, Innrain 52, Christoph-Probst-Platz, 6020 Innsbruck, Austria
| | - Johannes Leitgeb
- University Departments of Orthopaedics and Trauma Surgery, Division of Trauma Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Oskar Kwasny
- Department for Surgery and Sports Traumatology, Kepler University Hospital–Med Campus III, Krankenhausstraße 9, 4020 Linz, Austria
| | - Ronny Beer
- Neurocritical Care, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020 Innsbruck, Austria
| | - Cihan Ay
- Department of Medicine I, Clinical Division of Haematology and Haemostaseology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
| | - Eva Schaden
- Department of Anaesthesia, Critical Care and Pain Medicine, Division of General Anaesthesia and Intensive Care Medicine, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria
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149
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Wang JJ, Villeneuve E, Gosselin S. Poor outcomes after dabigatran-associated intracranial hemorrhage despite idarucizumab reversal. TOXICOLOGY COMMUNICATIONS 2019. [DOI: 10.1080/24734306.2019.1572268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- Josh J. Wang
- Department of Emergency Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Eric Villeneuve
- Department of Pharmacy, McGill University Health Centre, Montréal, Québec, Canada
| | - Sophie Gosselin
- Department of Emergency Medicine, McGill University Health Centre, Montréal, Québec, Canada
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150
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Abu-Fanne R, Stepanova V, Litvinov RI, Abdeen S, Bdeir K, Higazi M, Maraga E, Nagaswami C, Mukhitov AR, Weisel JW, Cines DB, Higazi AAR. Neutrophil α-defensins promote thrombosis in vivo by altering fibrin formation, structure, and stability. Blood 2019; 133:481-493. [PMID: 30442678 PMCID: PMC6356988 DOI: 10.1182/blood-2018-07-861237] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/17/2018] [Indexed: 02/06/2023] Open
Abstract
Inflammation and thrombosis are integrated, mutually reinforcing processes, but the interregulatory mechanisms are incompletely defined. Here, we examined the contribution of α-defensins (α-defs), antimicrobial proteins released from activated human neutrophils, on clot formation in vitro and in vivo. Activation of the intrinsic pathway of coagulation stimulates release of α-defs from neutrophils. α-Defs accelerate fibrin polymerization, increase fiber density and branching, incorporate into nascent fibrin clots, and impede fibrinolysis in vitro. Transgenic mice (Def++) expressing human α-Def-1 developed larger, occlusive, neutrophil-rich clots after partial inferior vena cava (IVC) ligation than those that formed in wild-type (WT) mice. IVC thrombi extracted from Def++ mice were composed of a fibrin meshwork that was denser and contained a higher proportion of tightly packed compressed polyhedral erythrocytes than those that developed in WT mice. Def++ mice were resistant to thromboprophylaxis with heparin. Inhibiting activation of the intrinsic pathway of coagulation, bone marrow transplantation from WT mice or provision of colchicine to Def++ mice to inhibit neutrophil degranulation decreased plasma levels of α-defs, caused a phenotypic reversion characterized by smaller thrombi comparable to those formed in WT mice, and restored responsiveness to heparin. These data identify α-defs as a potentially important and tractable link between innate immunity and thrombosis.
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Affiliation(s)
- Rami Abu-Fanne
- Department of Clinical Biochemistry, Hadassah-Hebrew University, Jerusalem, Israel
| | | | - Rustem I Litvinov
- Department of Cell and Developmental Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; and
- Institute of Fundamental Medicine and Biology, Kazan Federal University, Kazan, Russia
| | - Suhair Abdeen
- Department of Clinical Biochemistry, Hadassah-Hebrew University, Jerusalem, Israel
| | - Khalil Bdeir
- Department of Pathology and Laboratory Medicine and
| | - Mohamed Higazi
- Department of Clinical Biochemistry, Hadassah-Hebrew University, Jerusalem, Israel
| | - Emad Maraga
- Department of Clinical Biochemistry, Hadassah-Hebrew University, Jerusalem, Israel
| | - Chandrasekaran Nagaswami
- Department of Cell and Developmental Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; and
| | - Alexander R Mukhitov
- Department of Cell and Developmental Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; and
| | - John W Weisel
- Department of Cell and Developmental Biology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; and
| | | | - Abd Al-Roof Higazi
- Department of Clinical Biochemistry, Hadassah-Hebrew University, Jerusalem, Israel
- Department of Pathology and Laboratory Medicine and
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