1
|
Hellemans A, Devriendt N, Duchateau L, Devreese KMJ, De Somer F, Bosmans T, Mampaey G, Smets P. Evaluation of the use of a heparin dose-response test in dogs to determine the optimal heparin dose during intravascular procedures and assessment of the in vitro heparin response in healthy dogs. Vet Med Sci 2024; 10:e1326. [PMID: 37987511 PMCID: PMC10951632 DOI: 10.1002/vms3.1326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/05/2023] [Accepted: 11/07/2023] [Indexed: 11/22/2023] Open
Abstract
BACKGROUND No guidelines for administering and monitoring anticoagulants intraprocedurally are currently available in dogs, despite the prevalence of procedures necessitating systemic anticoagulation with heparin. OBJECTIVES To evaluate an activated clotting time (ACT)-based heparin dose-response (HDR) test to predict the individual required heparin dose in dogs during intravascular procedures, and to investigate both the in vitro heparin - ACT and in vitro heparin - factor anti-Xa activity (anti-Xa) relationships in dogs. METHODS Blood was collected from eight healthy beagles undergoing a cardiac procedure and utilised to establish baseline ACT and for in vitro evaluation. Subsequently, 100 IU/kg heparin was administered intravenously (IV) and ACT was remeasured (HDR test). The required heparin dose for an ACT target response ≥300 s was calculated for each individual and ACT was remeasured after administration of this dose. For in vitro testing, a serial heparin blood dilution (0-0.5-1-2-4 international unit (IU)/mL) was prepared and ACT and anti-Xa were determined using whole blood and frozen plasma, respectively. RESULTS The HDR test overestimated the required heparin dose in 3/7 dogs. In vitro, ACT and anti-Xa increased significantly with increasing blood heparin concentration. Heparin - ACT was nonlinear in 4/8 dogs at heparin concentrations >2 IU/mL, whereas heparin - anti-Xa remained linear throughout the tested range. CONCLUSIONS The HDR test poorly estimated the required heparin dose in dogs. This is most likely attributed to a nonlinear heparin - ACT relationship, as observed in vitro. Anti-Xa is a promising alternative for ACT; however, unavailability as a point-of-care test and lack of in vivo target values restrict its current use.
Collapse
Affiliation(s)
- A. Hellemans
- Faculty of Veterinary MedicineSmall Animal DepartmentGhent UniversityMerelbekeBelgium
| | - N. Devriendt
- Faculty of Veterinary MedicineSmall Animal DepartmentGhent UniversityMerelbekeBelgium
| | - L. Duchateau
- Faculty of Veterinary MedicineBiometrics Research CenterGhent UniversityMerelbekeBelgium
| | - K. M. J. Devreese
- Coagulation LaboratoryFaculty of MedicineDepartment of Diagnostic SciencesGhent University HospitalGhent UniversityGhentBelgium
| | - F. De Somer
- Faculty of Medical SciencesDepartment of Cardiac SurgeryGhent UniversityGhentBelgium
- Experimental Research Laboratory of Cardiac Surgery and Circulatory PhysiologyFaculty of Medical SciencesGhent UniversityGhentBelgium
| | - T. Bosmans
- Faculty of Veterinary MedicineSmall Animal DepartmentGhent UniversityMerelbekeBelgium
| | - G. Mampaey
- Faculty of Veterinary MedicineSmall Animal DepartmentGhent UniversityMerelbekeBelgium
| | - P. Smets
- Faculty of Veterinary MedicineSmall Animal DepartmentGhent UniversityMerelbekeBelgium
| |
Collapse
|
2
|
Wu T, Wu S, Li M, Zhang J. Comparison of the Correlation Between Coagulation Indices and Rivaroxaban Concentrations. Ann Pharmacother 2024; 58:28-36. [PMID: 37125735 DOI: 10.1177/10600280231158929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND Rivaroxaban has predictable pharmacokinetics and pharmacodynamics. However, monitoring rivaroxaban concentrations should be provided for special patients with hepatic insufficiency, high bleeding risk, and high thrombotic risk. OBJECTIVE This study aimed to correlate chromogenic anti-Xa assay, prothrombin time (PT), activated partial thromboplastin time (APTT), thromboelastogram reaction time (TEG R-time), and rivaroxaban concentration measured by high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) (MS-Riva). METHODS Peripheral venous blood was collected from recruited patients 30 minutes before and 2 to 4 hours after drug administration. High-performance liquid chromatography-tandem mass spectrometry and chromogenic anti-Xa assay measured rivaroxaban concentration. Different assays were compared by Pearson correlation coefficient and Bland-Altman analysis. RESULTS A total of 104 patients with 191 plasma were included in the study. Overall analysis shows that chromogenic anti-Xa assay, PT, APTT, and TEG R-time strongly correlated with MS-Riva (r = 0.986; r = 0.884; r = 0.741; r = 0.739; P < 0.001). Rivaroxaban peak concentration detected by HPLC-MS/MS (MS-peak) showed a very strong correlation with the chromogenic anti-Xa assay (r = 0.977, P < 0.001) and moderate correlation with PT, APTT, and TEG R-time (r = 0.670; r = 0.571; r = 0.481, P < 0.001). Rivaroxaban trough concentration detected by HPLC-MS/MS (MS-trough) correlated strongly with the chromogenic anti-Xa assay (r = 0.884, P < 0.001), weakly with APTT (r = 0.313; P = 0.043), and not significantly with PT and TEG R-time (P = 0.140; P = 0.341). CONCLUSION AND RELEVANCE High-performance liquid chromatography-tandem mass spectrometry/MS is the preferred choice for monitoring peak and tough concentrations, followed by anti-Xa, while PT is only suitable for peak concentrations. This study can help the clinicians to better adjust the medication regimen and reduce the risk of recurrence of thrombosis as well as the risk of bleeding.
Collapse
Affiliation(s)
- Tingting Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Shuyi Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Meijuan Li
- Department of Pharmacy, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| |
Collapse
|
3
|
Nagy R, Hemmelgarn T, Deptola S, Hemmann B. Evaluation of Initial Enoxaparin Dosing and Antifactor Xa Levels in Infants Admitted to the Neonatal Intensive Care Unit. Biomed Hub 2024; 9:54-61. [PMID: 38616894 PMCID: PMC11014719 DOI: 10.1159/000537797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 02/05/2024] [Indexed: 04/16/2024] Open
Abstract
Introduction Infants are at risk for thrombotic conditions due to multiple risk factors such as congenital heart defects and sepsis. According to the American College of Chest Physicians (ACCP) 2012 guidelines, enoxaparin may be given for thrombotic conditions at a dose of 1.5 mg/kg/dose every 12 h for patients less than 2 months of age and 1 mg/kg/dose every 12 h for those older than 2 months. Several studies have reported that infants typically require a higher initial dose of enoxaparin to reach therapeutic antifactor Xa levels than what is currently recommended. Methods This is a single-center retrospective case-control study of hospitalized infants less than 12 months of age who received treatment with enoxaparin while admitted to the neonatal intensive care unit (NICU) at a freestanding children's hospital. The primary objective was the difference between the initial enoxaparin dose (mg/kg) compared to the enoxaparin dose in which the patient first achieved a therapeutic antifactor Xa level of 0.5-1.0 units/mL. Results A total of 56 infants were included in this study. The median enoxaparin dose at initiation was 1.5 mg/kg/dose, and the median enoxaparin dose at the first therapeutic antifactor Xa level was 1.9 mg/kg/dose (z = -12.7, p < 0.0001). There was no correlation between gestational age and weight with the enoxaparin dose required to reach a therapeutic antifactor Xa level. Conclusion Infants admitted to the NICU, specifically those less than 4 months of age, require higher initial enoxaparin dosing to reach therapeutic antifactor Xa levels than what is currently recommended.
Collapse
Affiliation(s)
- Rosemarie Nagy
- Department of Pharmacy, Nemours Children’s Hospital, Orlando, FL, USA
| | - Trina Hemmelgarn
- Department of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Stephen Deptola
- Department of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Brianna Hemmann
- Department of Pharmacy, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
4
|
Chiasakul T, Mullier F, Lecompte T, Nguyen P, Cuker A. Laboratory Monitoring of Heparin Anticoagulation in Hemodialysis: Rationale and Strategies. Semin Nephrol 2023; 43:151477. [PMID: 38290962 DOI: 10.1016/j.semnephrol.2023.151477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Unfractionated heparin (UFH) and low-molecular-weight heparins (LMWHs) are commonly used to prevent clotting of the hemodialysis extracorporeal circuit and optimize hemodialysis adequacy. There is no consensus on the optimal dosing for UFH and LMWHs during hemodialysis. In clinical practice, semiquantitative clotting scoring of the dialyzer and venous chamber may help to guide UFH and LMWH dose adjustment. Laboratory monitoring has not been shown to improve clinical outcomes and is therefore not routinely indicated in most hemodialysis patients. It might, however, be considered in select patients, such as those with extremes of body weight or history of repeated clotting or bleeding. Methods for laboratory monitoring include the activated partial thromboplastin time, activated clotting time, and antifactor Xa assays for UFH and antifactor Xa assay for LMWHs. Target ranges for anticoagulation in hemodialysis have been suggested but not clearly defined. When utilizing these tests, issues such as availability, standardization, interfering factors, and interpretation must be considered. In this narrative review, we discuss the rationale and methods of monitoring anticoagulation in hemodialysis.
Collapse
Affiliation(s)
- Thita Chiasakul
- Center of Excellence in Translational Hematology, Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
| | - François Mullier
- Namur Thrombosis and Hemostasis Center, Université Catholique de Louvain, Centre Hospitalier Universitaire UCL Namur, Hematology Laboratory, Yvoir, Belgium; Institut de Recherche Expérimentale et Clinique, Pôle Mont, Université Catholique de Louvain, Yvoir, Belgium
| | - Thomas Lecompte
- Pharmacy Department, University of Namur, Namur, Belgium; Université de Lorraine, Nancy, France
| | - Philippe Nguyen
- Hematology Laboratory, Reims University Hospital, Reims, France
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
5
|
Knoerlein J, Brodbeck P, Büchsel M, Zieger B, Schmutz A. Residual anti-Xa activity in plasma of patients presenting for electively planned neuraxial regional anesthesia. Reg Anesth Pain Med 2023; 48:211-216. [PMID: 36707225 DOI: 10.1136/rapm-2022-104079] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 12/27/2022] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To determine the incidence of increased anti-Xa activity within plasma levels 24 hours after administration of therapeutic dose low-molecular-weight heparin in patients presenting for elective neuraxial anesthesia. BACKGROUND Guidelines for neuroaxial regional anesthesia for patients with antithrombotic drugs recommend time intervals for waiting. There is scientific evidence to suggest that the recommended interval of 24 hours may be insufficient in patients treated with therapeutic dose low-molecular-weight heparin. METHODS Retrospective cohort analysis of 74 patients who received therapeutic dose low-molecular-weight heparin before planned neuraxial anesthesia between April 1, 2015 and April 1, 2020 at Freiburg University Hospital. Primary endpoint was the occurrence of elevated plasma anti-Xa levels in prophylactic range or higher (>0.2 IU/mL) 24 hours after the last application of the therapeutic dose. RESULTS 24 hours after the last dose of therapeutic low-molecular-weight heparin, 18.0% of patients had elevated anti-Xa activity levels >0.2 IU/mL. A weak correlation between the time since the last administration of low-molecular-weight heparin and plasma anti-Xa levels could be found. No other risk factors were seen. CONCLUSIONS Relevant residual anticoagulant activity, as measured by plasma anti-Xa levels within a prophylactic range, is measurable 24 hours after the last administration of therapeutic dose low-molecular-weight heparin. TRIAL REGISTRATION NUMBER German Clinical Trials Register DRKS00022099.
Collapse
Affiliation(s)
- Julian Knoerlein
- Department of Anaesthesiology and Critical Care, Medical Center-University, Freiburg, Germany
| | - Philipp Brodbeck
- Department of Anaesthesiology and Critical Care, Medical Center-University, Freiburg, Germany
| | - Martin Büchsel
- Institute for Clinical Chemistry and Laboratory Medicine, Medical Center-University, Freiburg, Germany
| | - Barbara Zieger
- Division of Pediatric Hematology and Oncology, Medical Center-University Center for Pediatrics, Freiburg, Germany
| | - Axel Schmutz
- Department of Anaesthesiology and Critical Care, Medical Center-University, Freiburg, Germany
| |
Collapse
|
6
|
Zeibi Shirejini S, Carberry J, McQuilten ZK, Burrell AJC, Gregory SD, Hagemeyer CE. Current and future strategies to monitor and manage coagulation in ECMO patients. Thromb J 2023; 21:11. [PMID: 36703184 PMCID: PMC9878987 DOI: 10.1186/s12959-023-00452-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/18/2023] [Indexed: 01/27/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) can provide life-saving support for critically ill patients suffering severe respiratory and/or cardiac failure. However, thrombosis and bleeding remain common and complex problems to manage. Key causes of thrombosis in ECMO patients include blood contact to pro-thrombotic and non-physiological surfaces, as well as high shearing forces in the pump and membrane oxygenator. On the other hand, adverse effects of anticoagulant, thrombocytopenia, platelet dysfunction, acquired von Willebrand syndrome, and hyperfibrinolysis are all established as causes of bleeding. Finding safe and effective anticoagulants that balance thrombosis and bleeding risk remains challenging. This review highlights commonly used anticoagulants in ECMO, including their mechanism of action, monitoring methods, strengths and limitations. It further elaborates on existing anticoagulant monitoring strategies, indicating their target range, benefits and drawbacks. Finally, it introduces several highly novel approaches to real-time anticoagulation monitoring methods including sound, optical, fluorescent, and electrical measurement as well as their working principles and future directions for research.
Collapse
Affiliation(s)
- Saeedreza Zeibi Shirejini
- grid.1002.30000 0004 1936 7857NanoBiotechnology Laboratory, Central Clinical School, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC Australia ,grid.1002.30000 0004 1936 7857Cardiorespiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC Australia
| | - Josie Carberry
- grid.1002.30000 0004 1936 7857Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC Australia
| | - Zoe K. McQuilten
- grid.1002.30000 0004 1936 7857Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, and Department of Clinical Haematology, Monash Health, Melbourne, VIC Australia
| | - Aidan J. C. Burrell
- grid.1623.60000 0004 0432 511XSchool of Medicine, Nursing, and Health Sciences, Clayton and Intensive Care Unit, Monash University, Alfred Hospital, Melbourne, VIC Australia ,grid.1002.30000 0004 1936 7857Department of Epidemiology and Preventative Medicine, School of Public Health, Monash University, Melbourne, VIC Australia
| | - Shaun D. Gregory
- grid.1002.30000 0004 1936 7857Cardiorespiratory Engineering and Technology Laboratory, Department of Mechanical and Aerospace Engineering, Monash University, Clayton, VIC Australia
| | - Christoph E. Hagemeyer
- grid.1002.30000 0004 1936 7857NanoBiotechnology Laboratory, Central Clinical School, Australian Centre for Blood Diseases, Monash University, Melbourne, VIC Australia
| |
Collapse
|
7
|
Dean CL. An Overview of Heparin Monitoring with the Anti-Xa Assay. Methods Mol Biol 2023; 2663:343-353. [PMID: 37204722 DOI: 10.1007/978-1-0716-3175-1_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Heparin remains a critical therapy in hospitalized patients requiring anticoagulation. Unfractionated heparin (UFH) mediates its therapeutic effect by binding to antithrombin (AT) and inhibiting thrombin and FXa, as well as other serine proteases. Because of its complex pharmacokinetics, monitoring UFH therapy is required, which is usually achieved with either the activated partial thromboplastin time (APTT) or the anti-factor Xa (anti-Xa) assay. Low molecular weight heparin (LMWH) is fast replacing UFH, as it has a more predictable response, negating the need for routine monitoring in most cases. When required, the anti-Xa assay is used for monitoring of LMWH. The APTT has many notable limitations when used for heparin therapeutic monitoring, including biologic, preanalytical, and analytical issues. With its increasing availability, the anti-Xa assay is appealing as it is less affected by patient factors (e.g., acute-phase reactants, lupus anticoagulants, consumptive coagulopathies), known to interfere with the APTT. The anti-Xa assay has shown additional benefits, such as faster time to achieve therapeutic levels, more consistent therapeutic levels, less dose adjustments, and, overall, less tests performed during therapy. However, poor interlaboratory agreement has been observed among anti-Xa reagents, highlighting that further work needs to be done to standardize this assay for use in patient heparin monitoring.
Collapse
|
8
|
Volod O, Wegner J. Viscoelastic Testing in the Management of Adult Patients on Mechanical Circulatory Support Devices with Focus on Extracorporeal Membrane Oxygenation. Semin Thromb Hemost 2022; 48:814-827. [DOI: 10.1055/s-0042-1756303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
AbstractThromboembolic and hemorrhagic complications continue to remain frequent complications that significantly impact the morbidity and mortality of patients implanted with mechanical circulatory support devices (MCSDs). The severe acute respiratory syndrome caused by coronavirus 2 (SARS-CoV-2) has resulted in a number of COVID-19 patients being supported by MCSDs, specifically extracorporeal membrane oxygenation (ECMO), which in turn has created a crucial need for rapid assessment of hemostatic status in these patients to avoid bleeding and thrombotic complications. Currently, conventional plasma-based coagulation assays such as prothrombin time and activated partial thromboplastin time (aPTT) are used to assess hemostasis, and the activated clotting time (ACT) and aPTT are the most common tests used to monitor heparin anticoagulation in patients on ECMO. Unfractionated heparin remains the mainstay anticoagulation therapy for patients on ECMO. Extracorporeal Life Support Organization (ELSO) offers little guidance on the subject but does state that each institution should create its internal anticoagulation protocols. Viscoelastic assays (VEAs) are increasingly recognized by ELSO and ECMO community for their potential to assess hemostatic derangements in patients implanted with MCSDs as well as guidance for appropriate hemostatic therapy. This review focuses on the evidence for the use of viscoelastic assays to assess overall hemostasis and to guide the treatment of adult patients connected to an ECMO circuit. Limitations of the use of conventional assays, ACT, and VEA are also discussed.
Collapse
Affiliation(s)
- Oksana Volod
- Department of Pathology and Laboratory Medicine, Cedars Sinai Medical Center, Los Angeles, California
| | - Julie Wegner
- College of Health Professions, South University Online, Savannah, Georgia
| |
Collapse
|
9
|
Vermeiren P, Vandevelde A, Peperstraete H, Devreese KMJ. Monitoring of heparin therapy beyond the anti-Xa activity assay: Evaluation of a thrombin generation assay. Int J Lab Hematol 2022; 44:785-795. [PMID: 35438827 DOI: 10.1111/ijlh.13836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 02/24/2022] [Accepted: 03/15/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Global coagulation assays may be of added value to the anti-Xa assay for monitoring heparin therapy. Unlike most testing methods, the thrombin generation assay (TGA) has the ability to assess the overall function of the hemostatic system, which provides information on the anticoagulation status of patients. We compared the TGA, measured with ST Genesia® STG-DrugScreen® reagent, with the anti-Xa assay for monitoring heparin therapy in inflammatory and non-inflammatory patients. We also determined reference values for STG-DrugScreen® thrombin generation (TG) parameters. METHODS Reference values were determined on 120 healthy donors. Furthermore, a spiking experiment with unfractionated heparin (UFH) and low molecular weight heparin (LMWH) was performed, and samples of patients receiving UFH or LMWH were analyzed with ST Genesia® and the anti-Xa assay. RESULTS High discrepancy between TG parameters and anti-Xa activity was observed for low LMWH anti-Xa levels. TG parameters were affected in 36/46 (time to peak) to 42/46 (peak height) patients during UFH therapy with sub-target anti-Xa activity levels. CONCLUSION TGA seems insufficiently sensitive for low concentrations of LMWH. There may be an added value of the TGA for monitoring UFH in so-called heparin-resistant patients. Therefore, the TGA has the potential to be introduced as an additional tool for monitoring heparin therapy.
Collapse
Affiliation(s)
- Pauline Vermeiren
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Arne Vandevelde
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | | | - Katrien M J Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| |
Collapse
|
10
|
Abstract
Patients with critical illness often display variable hypo- and hypercoagulable sequalae requiring intense monitoring and anticoagulation pharmacotherapy to prevent or treat inappropriate clot formation. It is imperative to understand the various stages of the clotting cascade and where each pharmacotherapy agent exerts its therapeutic effect. Common coagulation tests are utilized to monitor the areas of the clotting cascade and the effects that anticoagulant pharmacotherapy exhibits. Many novel coagulation tests are also in development. The purpose of this narrative review is to evaluate commonly utilized coagulation tests that monitor anticoagulation while in the intensive care unit.
Collapse
|
11
|
Mazzeffi MA, Rao VK, Dodd-O J, Del Rio JM, Hernandez A, Chung M, Bardia A, Bauer RM, Meltzer JS, Satyapriya S, Rector R, Ramsay JG, Gutsche J. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation. Anesth Analg 2021; 133:1459-1477. [PMID: 34559089 DOI: 10.1213/ane.0000000000005738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used to support patients with refractory cardiopulmonary failure. Given ECMO's increased use in adults and the fact that many ECMO patients are cared for by anesthesiologists, the Society of Cardiovascular Anesthesiologists ECMO working group created an expert consensus statement that is intended to help anesthesiologists manage adult ECMO patients who are cared for in the operating room. In the first part of this 2-part series, technical aspects of ECMO are discussed, and related expert consensus statements are provided.
Collapse
Affiliation(s)
- Michael A Mazzeffi
- From the Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mabel Chung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Amit Bardia
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca M Bauer
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Joseph S Meltzer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sree Satyapriya
- Department of Anesthesiology, Ohio State University School of Medicine, Columbus, Ohio
| | - Raymond Rector
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - James G Ramsay
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
12
|
Monteagudo-Vela M, Bowles C, Raj B, Robinson D, Simon A. Anticoagulation in syncardia total artificial heart recipients: anti-factor Xa or activated partial thromboplastin time? Interact Cardiovasc Thorac Surg 2021; 34:322-325. [PMID: 34849924 PMCID: PMC8766202 DOI: 10.1093/icvts/ivab251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 07/15/2021] [Accepted: 08/13/2021] [Indexed: 11/12/2022] Open
Abstract
Although the activated partial thromboplastin time (aPTT) has historically been the method of choice for anticoagulation monitoring in patients undergoing mechanical circulatory support with intravenous unfractionated heparin, it is being progressively superseded by the anti-factor Xa (anti-Xa) method. A retrospective single-arm, single-centre analysis of 20 patients who underwent total artificial heart implantation entailed simultaneous determinations of aPTT and anti-Xa. Agreement between these parameters was assessed using the Bland-Altman method. Despite a positive correlation between aPTT and anti-Xa, normal target ranges were poorly aligned: from 5th to 30th postoperative day, for anti-Xa values of 0.2 and 0.4 U/ml corresponding aPTT values were 52.1 and 65.2 s, 7.9 and 14.8 lower than predicted values, respectively. This was not associated with thromboembolic sequalae. It was not possible to demonstrate a significant relationship between the predictor variables (postoperative day; white blood cell count; C-reactive protein concentration; alanine transaminase and alkaline phosphatase level; bilirubin; haemoglobin; albumin and total protein concentration) and the agreement between aPTT and anti-Xa levels. In summary, when anti-Xa levels were used to guide anticoagulation therapy, corresponding aPTT levels were low with respect to target range. Methodology applied in this study is generalizable to other forms of mechanical circulatory support.
Collapse
Affiliation(s)
- María Monteagudo-Vela
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Harefield Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Christopher Bowles
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Harefield Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Binu Raj
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Harefield Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Derek Robinson
- Department of Mathematics, 3A20 Pevensey 2 Building, University of Sussex, Falmer Campus, Brighton, UK
| | - Andre Simon
- Department of Cardiothoracic Transplantation and Mechanical Circulatory Support, Harefield Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
13
|
Mazzeffi MA, Rao VK, Dodd-O J, Rio JMD, Hernandez A, Chung M, Bardia A, Bauer RM, Meltzer JS, Satyapriya S, Rector R, Ramsay JG, Gutsche J. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: an Expert Consensus Statement From the Society of Cardiovascular Anesthesiologists-Part I, Technical Aspects of Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2021; 35:3496-3512. [PMID: 34774252 DOI: 10.1053/j.jvca.2021.07.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is used to support patients with refractory cardiopulmonary failure. Given ECMO's increased use in adults and the fact that many ECMO patients are cared for by anesthesiologists, the Society of Cardiovascular Anesthesiologists ECMO working group created an expert consensus statement that is intended to help anesthesiologists manage adult ECMO patients who are cared for in the operating room. In the first part of this 2-part series, technical aspects of ECMO are discussed, and related expert consensus statements are provided.
Collapse
Affiliation(s)
- Michael A Mazzeffi
- Department of Anesthesiology and Critical Care Medicine, The George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Vidya K Rao
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose Mauricio Del Rio
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mabel Chung
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard University School of Medicine, Boston, Massachusetts
| | - Amit Bardia
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut
| | - Rebecca M Bauer
- Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
| | - Joseph S Meltzer
- Department of Anesthesiology and Perioperative Medicine, University of California Los Angeles School of Medicine, Los Angeles, California
| | - Sree Satyapriya
- Department of Anesthesiology, Ohio State University School of Medicine, Columbus, Ohio
| | - Raymond Rector
- Department of Surgery, Division of Cardiothoracic Surgery, University of Maryland Medical Center, Baltimore, Maryland
| | - James G Ramsay
- Department of Anesthesia and Perioperative Care, University of California San Francisco School of Medicine, San Francisco, California
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| |
Collapse
|
14
|
Liu Z, Xie Q, Zhang H, Mu G, Zhou S, Wang Z, Jiang J, Xiang Q, Cui Y. Target Drug-Calibrated Anti-Xa Activity Assays and Expected Peak-Trough Levels in an Asian Population: A Multicenter Study. Am J Cardiovasc Drugs 2021; 21:669-679. [PMID: 34142346 DOI: 10.1007/s40256-021-00479-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND For patients taking factor Xa (FXa) inhibitors who have life-threatening bleeding, emergency surgery, drug interactions, etc., a rapid and precise assay is needed to monitor for potential medication failure, to assess safety during periprocedural anticoagulation management, and to manage the care of chronically anticoagulated patients. Anti-factor Xa (anti-Xa) activity assays have been recommended in guidelines, but the evaluation of different calibrations of anti-Xa activity assays and the data on the recommended range are still limited, especially in the Asian population. METHODS This is a nationwide multicenter methodology exploratory study in an Asian population, including nine hospitals from Beijing, Shanghai, Liaoning, Shandong, Jiangsu, Anhui, Henan, Chongqing, and Fujian. A total of 485 healthy volunteers and 219 patients taking rivaroxaban or apixaban (single dose) were enrolled in the study. High-performance liquid chromatography-tandem mass spectrometry (HPLC-MS) was employed to detect plasma rivaroxaban and apixaban. The prothrombin time (PT), activated partial thromboplastin time (APTT), and levels of anti-Xa activity were tested as pharmacodynamic parameters in plasma samples. We evaluated the correlation of anti-Xa activity and blood concentration via HPLC-MS, and then compared the two methods of target drug-calibrated and low-molecular-weight heparin (LMWH)-antithrombin-calibrated anti-Xa activity. Correlations between variables were examined using Pearson's correlation analysis. Logistic regression was applied to evaluate significant differences in anti-Xa activity and blood concentration, using models adjusted by baseline characteristics. RESULTS The results suggested anti-Xa activity had better correlation with blood concentrations of apixaban and rivaroxaban than APTT and PT (p < 0.001). Target drug-calibrated anti-Xa activity had better correlation with HPLC-MS results at every dose level and blood collection time (p < 0.001). The expected concentrations (ng/mL) derived from rivaroxaban-calibrated assays of rivaroxaban 10 mg, 15 mg, and 20 mg were about 210, 330, and 270 at peak concentrations, and 28, 44, and 58, respectively, at the trough concentrations. CONCLUSIONS In this study, we confirm that target drug calibration of anti-Xa activity is a better quantitative detection method for oral direct FXa inhibitors than LMWH-calibrated anti-Xa activity in clinical practice, and expected peak-trough levels are recommended for the Asian population.
Collapse
Affiliation(s)
- Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, No. 6, Dahongluochang Street, Xicheng District, Beijing, 100034, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, No. 6, Dahongluochang Street, Xicheng District, Beijing, 100034, China
| | - Hanxu Zhang
- Department of Pharmacy, Peking University First Hospital, No. 6, Dahongluochang Street, Xicheng District, Beijing, 100034, China
- School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, No. 6, Dahongluochang Street, Xicheng District, Beijing, 100034, China
| | - Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, No. 6, Dahongluochang Street, Xicheng District, Beijing, 100034, China
| | - Zining Wang
- Department of Pharmacy, Peking University First Hospital, No. 6, Dahongluochang Street, Xicheng District, Beijing, 100034, China
| | - Jie Jiang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, No. 6, Dahongluochang Street, Xicheng District, Beijing, 100034, China.
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, No. 6, Dahongluochang Street, Xicheng District, Beijing, 100034, China.
- School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China.
- Institute of Clinical Pharmacology, Peking University, Beijing, China.
| |
Collapse
|
15
|
Abstract
From preoperative medications to intraoperative needs to postoperative thromboprophylaxis, anticoagulants are encountered throughout the perioperative period. This review focuses on coagulation testing clinicians utilize to monitor the effects of these medications.
Collapse
|
16
|
Hollestelle MJ, van der Meer FJM, Meijer P. Quality performance for indirect Xa inhibitor monitoring in patients using international external quality data. Clin Chem Lab Med 2021; 58:1921-1930. [PMID: 32441664 DOI: 10.1515/cclm-2020-0130] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/30/2020] [Indexed: 01/20/2023]
Abstract
Objectives Chromogenic anti-activated factor X (FXa) assays are currently the "gold standard" for monitoring indirect anticoagulants. However, anti-FXa has been shown to vary according to the choice of reagents. In the present study, the performance of anti-FXa measurement was evaluated in order to gain more insight into the clinical applications. Furthermore, the longitudinal coefficient of variation (CV) was studied to investigate whether there is improvement over time. Methods Laboratory tests results were evaluated for samples spiked with unfractionated heparin (UFH), low-molecular-weight-heparin (LMWH), fondaparinux and danaparoid sodium. External quality assessment (EQA) data from multiple years were used from more than 100 laboratories. Results Comparison of the results for all methods showed significant differences in measured values between the frequently used methods (ANOVA: p < 0.001). The largest differences were observed for LMWH and UFH measurements. These differences may be caused by differences in method composition, such as the addition of dextran sulphate. Substantial interlaboratory variation in anti-FXa monitoring was observed for all parameters, particularly at low concentrations. Our results showed that below 0.35 IU/mL, the CVs for UFH and LMWH increase dramatically and results below this limit should be used with caution. Conclusions Our study demonstrates that the choice of the anti-FXa method is particularly important for UFH and LMWH measurement. The variation in measurements may have an effect on clinical implications, such as therapeutic ranges. Furthermore, the longitudinal EQA data demonstrated a constant performance and, in at least 50% of the cases, improvement in the CV% of the anti-Xa results over time.
Collapse
Affiliation(s)
- Martine J Hollestelle
- External Quality Control for Assays and Tests (ECAT) Foundation, Voorschoten, The Netherlands
| | - Felix J M van der Meer
- Department of Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Piet Meijer
- External Quality Control for Assays and Tests (ECAT) Foundation, Voorschoten, The Netherlands
| |
Collapse
|
17
|
Ozment CP, Scott BL, Bembea MM, Spinella PC. Anticoagulation and Transfusion Management During Neonatal and Pediatric Extracorporeal Membrane Oxygenation: A Survey of Medical Directors in the United States. Pediatr Crit Care Med 2021; 22:530-541. [PMID: 33750092 DOI: 10.1097/pcc.0000000000002696] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To compare current practices within the United States of anticoagulation management and blood transfusion in neonatal and pediatric extracorporeal membrane oxygenation patients with a 2013 international report. DESIGN Cross-sectional survey distributed between August and December 2019. SETTING Extracorporeal Life Support Organization-registered neonatal and pediatric extracorporeal membrane oxygenation centers in the United States. PARTICIPANTS Extracorporeal membrane oxygenation medical directors. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Eighty-three medical directors at 108 centers responded. After removing four duplicate responses, 79 surveys were analyzed. Seventy-nine percent (n = 62) report a written extracorporeal membrane oxygenation protocol for both anticoagulation and blood product management. Ninety-four percent (n = 74) report unfractionated heparin as their primary anticoagulant; the remaining use the direct thrombin inhibitor, bivalirudin. Ninety percent (n = 71) report measuring antifactor Xa levels. Most centers report using a combination of assays to monitor heparin therapy, either antifactor Xa and activated partial thromboplastin time (54%) or more commonly antifactor Xa and activated clotting time (68%). Forty-one percent use viscoelastic tests to aid management. Goal monitoring levels and interventions generated by out of range values are variable. Fifty-one percent will replace antithrombin. Platelet transfusion thresholds vary by age and center with ranges from 50,000 to 100,000 cells/µL. Eighty-two percent of respondents are willing to participate in a randomized controlled trial comparing anticoagulation strategies for patients receiving extracorporeal membrane oxygenation. CONCLUSIONS Compared with the 2013 pediatric population, extracorporeal membrane oxygenation center anticoagulation and blood transfusion approaches continue to vary widely. Most report continued use of heparin as their primary anticoagulant and follow a combination of monitoring assays with the majority using the antifactor Xa assay in their practices, a significant shift from prior results. Antithrombin activity levels and viscoelastic tests are followed by a growing number of centers. Platelet transfusion thresholds continue to vary widely. Future research is needed to establish optimal anticoagulation and blood transfusion management.
Collapse
Affiliation(s)
- Caroline P Ozment
- Department of Anesthesiology and Critical Care, Johns Hopkins University, Baltimore, MD
| | - Briana L Scott
- Department of Anesthesiology and Critical Care, Johns Hopkins University, Baltimore, MD
| | - Melania M Bembea
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| | - Philip C Spinella
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, MO
| |
Collapse
|
18
|
Gordon SE, Heath TS, McMichael ABV, Hornik CP, Ozment CP. Evaluation of Heparin Anti-Factor Xa Levels Following Antithrombin Supplementation in Pediatric Patients Supported With Extracorporeal Membrane Oxygenation. J Pediatr Pharmacol Ther 2020; 25:717-722. [PMID: 33214783 DOI: 10.5863/1551-6776-25.8.717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2020] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Thrombotic events are potential complications in patients receiving extracorporeal membrane oxygenation (ECMO) necessitating the use of systemic anticoagulation with heparin. Heparin works by potentiating the effects of antithrombin (AT), which may be deficient in critically ill patients and can be replaced. The clinical benefits and risks of AT replacement in children on ECMO remain incompletely understood. METHODS This single-center, retrospective study reviewed 28 neonatal and pediatric patients supported on ECMO at a tertiary care hospital between April 1, 2013, and October 31, 2014, who received at least 1 dose of AT during their ECMO course. The primary outcome of the study was the change in anti-factor Xa levels after pooled human AT supplementation. Secondary outcomes included the percentage of anti-factor Xa levels within the therapeutic range surrounding AT administration; survival to decannulation; 30 days after cannulation and discharge; time to first circuit change; and incidence of bleeding and thrombotic events. RESULTS A total of 78 doses of AT were administered during the study period. The mean increase in anti-factor Xa level following AT administration in patients without a ≥10% concurrent change in heparin was 0.075 ± 0.13 international units/mL. A greater percentage of anti-factor Xa levels were therapeutic for the 48 hours following AT administration (64.2% vs 38.6%). Survival and adverse events were similar to Extracorporeal Life Support Organization averages, with the exception of a higher incidence of intracranial hemorrhage. CONCLUSIONS Patients experienced a small but significant increase in anti-factor Xa level and a greater percentage of therapeutic anti-factor Xa levels following AT supplementation.
Collapse
Affiliation(s)
- Sharon E Gordon
- Department of Pharmacy (SEG), Children's Hospital Colorado, Aurora, CO
| | - Travis S Heath
- Department of Pharmacy (TSH), Duke University Hospital, Durham, NC
| | - Ali B V McMichael
- Department of Pediatrics (ABVM), University of Texas Southwestern Medical Center, Dallas, TX
| | | | - Caroline P Ozment
- Department of Pediatrics (CPO), Duke University Hospital, Durham, NC
| |
Collapse
|
19
|
Schaefer B, Hausfeld A, Martin M, Steele P, Martin J, Reher SR, Lane A, Luchtman-Jones L. Impact of exogenous antithrombin on low molecular weight heparin anti-Xa activity assays in a pediatric and young adult leukemia and lymphoma cohort with variable antithrombin levels. Pediatr Blood Cancer 2020; 67:e28654. [PMID: 32841498 DOI: 10.1002/pbc.28654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/30/2020] [Accepted: 07/22/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Low molecular weight heparin (LMWH) remains the most commonly prescribed pediatric anticoagulant. There is debate whether LMWH anti-Xa assays with or without exogenous antithrombin (AT) best reflect anticoagulation effect, and how much discrepancy exists between assay types. OBJECTIVES We assessed the effect of variable AT activity on LMWH anti-Xa levels in plasma samples from anticoagulated pediatric and young adult acute lymphoblastic leukemia and lymphoma (ALL/L) patients, using two instruments and their commercial kits with and without exogenous AT (ie, four platforms). METHODS We analyzed LMWH anti-Xa levels on 60 plasma samples with known AT activity from 12 enoxaparin-treated ALL/L patients, using four commercial kits from Siemens and Stago containing AT or not, on Siemens BCS and Stago STA R Max, respectively. RESULTS Of 236/240 samples with interpretable results, mean AT activity was 80% (46-138%). Correlation was acceptable for published kit ranges of LMWH anti-Xa levels when comparing kits containing AT (r = 0.82, P < .0001), or not (r = 0.93, P < .0001), and within a manufacturer (Berichrom to Innovance, r = 0.92, P < .0001; Stachrom to STA-Liquid Anti-Xa r = 0.98, P < .0001). LMWH anti-Xa levels were lower in platforms without added AT (P < .0001). For Stago kits, this effect increased when AT < 70% (P = .001, n = 19, mean 56%). Assay variability, measured as mean percent difference, was less pronounced with Stago kits (14.7%, n = 49) than Siemens (41.9%, n = 50). CONCLUSIONS Although LMWH levels from anti-Xa assays with added AT trend higher than in those without, correlation was fairly good between platforms in pediatric ALL/L plasmas, even when AT activity was <70%.
Collapse
Affiliation(s)
- Beverly Schaefer
- Department of Pediatric Hematology Oncology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Pediatric Hematology and Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Adriane Hausfeld
- Cincinnati Children's Hospital Medical Center, Cancer and Blood Disease Institute, Cincinnati, Ohio
| | - Matthew Martin
- Cincinnati Children's Hospital Medical Center, Cancer and Blood Disease Institute, Cincinnati, Ohio
| | - Paul Steele
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pathology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jan Martin
- Cincinnati Children's Hospital Medical Center, Cancer and Blood Disease Institute, Cincinnati, Ohio
| | - Sandra R Reher
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Adam Lane
- Cincinnati Children's Hospital Medical Center, Cancer and Blood Disease Institute, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lori Luchtman-Jones
- Cincinnati Children's Hospital Medical Center, Cancer and Blood Disease Institute, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
20
|
Mazzeffi M. Patient Blood Management in Adult Extracorporeal Membrane Oxygenation Patients. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00384-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
21
|
Milito C, McRae H, Victor A, Refaai MA, Schmidt AE. Persistent Rivaroxaban Effect Due to Impaired Renal Clearance and Medication Effects. Lab Med 2020; 51:211-216. [PMID: 31340380 DOI: 10.1093/labmed/lmz044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Rivaroxaban (Xarelto; Johnson & Johnson Services, Inc) is a direct oral anticoagulant (DOAC) that works by directly inhibiting the active site of factor Xa (FXa). Rivaroxaban is metabolized and cleared via the kidney and liver. The results of various studies have shown that patients with severe renal impairment should receive reduced dosages of rivaroxaban or another anticoagulant due to impaired clearance. Although it is not required, monitoring rivaroxaban is useful in some conditions; however, the assays required for such monitoring are not readily available. Herein, we present a case of a 68-year-old Caucasian male patient who was receiving rivaroxaban (20 mg/day) for atrial flutter and had mild renal impairment. The patient was found to have increased effect of rivaroxaban due to further impairment of renal clearance caused by several renally cleared medications. This case highlights the importance of closely examining the renal function of and medication list for a patient before starting DOACs such as rivaroxaban.
Collapse
Affiliation(s)
- Chelsea Milito
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
| | - Hannah McRae
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
| | - Adrienne Victor
- Department of Hematology and Oncology, University of Rochester Medical Center, Rochester, New York
| | - Majed A Refaai
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
| | - Amy E Schmidt
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, New York
| |
Collapse
|
22
|
Erroneous Activated Coagulation Time During Atrial Flutter Ablation. Case Rep Anesthesiol 2020; 2020:3842051. [PMID: 31970000 PMCID: PMC6969646 DOI: 10.1155/2020/3842051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Revised: 09/29/2019] [Accepted: 10/30/2019] [Indexed: 11/17/2022] Open
Abstract
When performing left-sided catheter ablation, anticoagulation is used to prevent formation of thrombi that might embolize. After heparin administration, appropriate anticoagulation is confirmed by measuring Activated Coagulation Time (ACT). We report a case during which ACT results were erroneous, and review alternatives to the ACT under such circumstances.
Collapse
|
23
|
Ourri B, Francoia JP, Monard G, Gris JC, Leclaire J, Vial L. Dendrigraft of Poly-l-lysine as a Promising Candidate To Reverse Heparin-based Anticoagulants in Clinical Settings. ACS Med Chem Lett 2019; 10:917-922. [PMID: 31223448 DOI: 10.1021/acsmedchemlett.9b00090] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Accepted: 05/08/2019] [Indexed: 12/14/2022] Open
Abstract
By using a combination of experimental and computational experiments, we demonstrated that a second-generation dendrigraft of poly-l-lysine neutralizes the anticoagulant activity of unfractionated heparin, low-molecular-weight heparin, and fondaparinux more efficiently than protamine does in human plasma, making this synthetic polymer a promising surrogate of this problematic protein in clinical settings.
Collapse
Affiliation(s)
- Benjamin Ourri
- Univ. Lyon, Univ. Claude Bernard Lyon 1, ICBMS UMR CNRS 5246, 43 Boulevard du 11 Novembre 1918, 69622 Villeurbanne Cedex, France
| | - Jean-Patrick Francoia
- Univ. Montpellier, IBMM UMR 5247 CNRS, Place Eugène Bataillon, 34296 Montpellier Cedex 5, France
| | - Gerald Monard
- Univ. Lorraine, LPCT UMR 7019 CNRS, Boulevard des Aiguillettes B.P. 70239, 54506 Vandoeuvre-les-Nancy, France
| | - Jean-Christophe Gris
- Department of Hematology, Nı̂mes University Hospital, University of Montpellier, 30029 Nîmes Cedex 9, France
- The First I.M. Sechenov Moscow State Medical University, Moscow 119146, Russian Federation
| | - Julien Leclaire
- Univ. Lyon, Univ. Claude Bernard Lyon 1, ICBMS UMR CNRS 5246, 43 Boulevard du 11 Novembre 1918, 69622 Villeurbanne Cedex, France
| | - Laurent Vial
- Univ. Lyon, Univ. Claude Bernard Lyon 1, ICBMS UMR CNRS 5246, 43 Boulevard du 11 Novembre 1918, 69622 Villeurbanne Cedex, France
- Univ. Montpellier, IBMM UMR 5247 CNRS, Place Eugène Bataillon, 34296 Montpellier Cedex 5, France
| |
Collapse
|
24
|
Connors JM, Gregor S, Crandall D, Netuka I, Mehra MR. Low-intensity anti-coagulation using Vitamin K antagonists and Factor X activity: A validation analysis of the MAGENTUM-1 study. J Heart Lung Transplant 2019; 38:668-669. [PMID: 31128601 DOI: 10.1016/j.healun.2019.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 02/27/2019] [Indexed: 11/17/2022] Open
Affiliation(s)
- Jean Marie Connors
- Division of Hematology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Stanislav Gregor
- Department of Hospital Pharmacy, Institute for Clinical and Experimental Medicine, Prague, Czech Republic; Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Daniel Crandall
- Global Clinical, Heart Failure, Abbott, Burlington, Massachusetts, USA
| | - Ivan Netuka
- Department of Cardiovascular Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
| | - Mandeep R Mehra
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
25
|
Fabbro M, Dunn S, Rodriguez-Blanco YF, Jain P. A Narrative Review for Perioperative Physicians of the 2017 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants. J Cardiothorac Vasc Anesth 2019; 33:290-301. [DOI: 10.1053/j.jvca.2018.07.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Indexed: 01/21/2023]
|
26
|
Yin OQ, Antman EM, Braunwald E, Mercuri MF, Miller R, Morrow D, Ruff CT, Truitt K, Weitz JI, Giugliano RP. Linking Endogenous Factor Xa Activity, a Biologically Relevant Pharmacodynamic Marker, to Edoxaban Plasma Concentrations and Clinical Outcomes in the ENGAGE AF-TIMI 48 Trial. Circulation 2018; 138:1963-1973. [DOI: 10.1161/circulationaha.118.033933] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Ophelia Q.P. Yin
- Daiichi-Sankyo Pharma Development, Basking Ridge, NJ (O.Q.P.Y., M.F.M., R.M., K.T.)
| | - Elliott M. Antman
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (E.M.A., E.B., D.M., C.T.R., R.P.G.)
| | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (E.M.A., E.B., D.M., C.T.R., R.P.G.)
| | - Michele F. Mercuri
- Daiichi-Sankyo Pharma Development, Basking Ridge, NJ (O.Q.P.Y., M.F.M., R.M., K.T.)
| | - Raymond Miller
- Daiichi-Sankyo Pharma Development, Basking Ridge, NJ (O.Q.P.Y., M.F.M., R.M., K.T.)
| | - David Morrow
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (E.M.A., E.B., D.M., C.T.R., R.P.G.)
| | - Christian T. Ruff
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (E.M.A., E.B., D.M., C.T.R., R.P.G.)
| | - Kenneth Truitt
- Daiichi-Sankyo Pharma Development, Basking Ridge, NJ (O.Q.P.Y., M.F.M., R.M., K.T.)
| | - Jeffrey I. Weitz
- McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada (J.I.W.)
| | - Robert P. Giugliano
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (E.M.A., E.B., D.M., C.T.R., R.P.G.)
| |
Collapse
|
27
|
Leffert L, Butwick A, Carvalho B, Arendt K, Bates SM, Friedman A, Horlocker T, Houle T, Landau R, Dubois H, Fernando R, Houle T, Kopp S, Montgomery D, Pellegrini J, Smiley R, Toledo P. The Society for Obstetric Anesthesia and Perinatology Consensus Statement on the Anesthetic Management of Pregnant and Postpartum Women Receiving Thromboprophylaxis or Higher Dose Anticoagulants. Anesth Analg 2018; 126:928-944. [DOI: 10.1213/ane.0000000000002530] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
28
|
Ikejiri M, Wada H, Tone S, Wakabayashi H, Hasegawa M, Matsumoto T, Fujimoto N, Yamada N, Ito M, Nakatani K, Sudo A. Comparison of three different anti-Xa assays in major orthopedic surgery patients treated with direct oral anticoagulant. Thromb J 2017; 15:27. [PMID: 29046616 PMCID: PMC5637253 DOI: 10.1186/s12959-017-0150-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 09/14/2017] [Indexed: 12/13/2022] Open
Abstract
Background Measurement of edoxaban plasma concentration has been gathering attention in major orthopedic surgery patients receiving edoxaban for the prevention of venous thromboembolism (VTE). Methods The anti-Xa activity was measured one hour after edoxaban intake using 3 different assays in 200 patients after major orthopedic surgery. Results The anti-Xa activities on Day 8 were significantly higher than those on Day 4 and those on Day 4 were significantly higher than those on Day 1. The anti-Xa activities in two assays closely correlated with each other, but the other anti-Xa assay did not correlated with other two assays. The anti-Xa activities as detected in the three Xa assays were significantly higher in the patients without deep vein thrombosis (DVT) than in those with DVT on Day 4. Additionally, there were no significant differences in the anti-Xa activities of assays A, B and C between patients with and without massive bleeding (MB) on Days 1, 4, 8 and 15. Conclusion The results of this study suggest that anti-Xa level could be predictive of the risk of VTE, but not of the risk of massive bleeding.
Collapse
Affiliation(s)
- Makoto Ikejiri
- Department of Central Laboratory, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hideo Wada
- Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Tsu, Japan.,Department of Laboratory Medicine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu -City, Mie-ken 514-8507 Japan
| | - Shine Tone
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hiroki Wakabayashi
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masahiro Hasegawa
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Takeshi Matsumoto
- Department of Blood Transfusion Service, Mie University Graduate School of Medicine, Tsu, Japan
| | - Naoki Fujimoto
- Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, Tsu, Japan
| | - Norikazu Yamada
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masaaki Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Kaname Nakatani
- Department of Central Laboratory, Mie University Graduate School of Medicine, Tsu, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| |
Collapse
|
29
|
Lee KCL, Baker L, Mallett S, Riddell A, Chowdary P, Alibhai H, Chang YM, Priestnall S, Stanzani G, Davies N, Mookerjee R, Jalan R, Agarwal B. Hypercoagulability progresses to hypocoagulability during evolution of acetaminophen-induced acute liver injury in pigs. Sci Rep 2017; 7:9347. [PMID: 28839178 PMCID: PMC5571150 DOI: 10.1038/s41598-017-09508-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 07/26/2017] [Indexed: 02/06/2023] Open
Abstract
Increases in prothrombin time (PT) and international normalised ratio (INR) characterise acute liver injury (ALI) and failure (ALF), yet a wide heterogeneity in clotting abnormalities exists. This study defines evolution of coagulopathy in 10 pigs with acetaminophen (APAP)-induced ALI compared to 3 Controls. APAP administration began at 0 h and continued to ‘ALF’, defined as INR >3. In APAP pigs, INR was 1.05 ± 0.02 at 0 h, 2.15 ± 0.43 at 16 h and > 3 at 18 ± 1 h. At 12 h thromboelastography (TEG) demonstrated increased clot formation rate, associated with portal vein platelet aggregates and reductions in protein C, protein S, antithrombin and A Disintegrin and Metalloprotease with Thrombospondin type 1 repeats–13 (ADAMTS-13) to 60%, 24%, 47% and 32% normal respectively. At 18 ± 1 h, INR > 3 was associated with: hypocoagulable TEG profile with heparin-like effect; falls in thrombin generation, Factor V and Factor VIII to 52%, 19% and 17% normal respectively; further decline in anticoagulants; thrombocytopenia; neutrophilia and endotoxemia. Multivariate analysis, found that ADAMTS-13 was an independent predictor of a hypercoagulable TEG profile and platelet count, endotoxin, Protein C and fibrinogen were independent predictors of a hypocoagulable TEG profile. INR remained normal in Controls. Dynamic changes in coagulation occur with progression of ALI: a pro-thrombotic state progresses to hypocoagulability.
Collapse
Affiliation(s)
- Karla Chui Luan Lee
- Department of Clinical Science and Services, The Royal Veterinary College, University of London, Hertfordshire, UK. .,Liver Failure Group, Institute of Liver and Digestive Health, University College London Medical School Royal Free Campus, London, UK.
| | - Luisa Baker
- Department of Clinical Science and Services, The Royal Veterinary College, University of London, Hertfordshire, UK
| | - Susan Mallett
- Department of Anaesthesia, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Anne Riddell
- Katherine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Pratima Chowdary
- Katherine Dormandy Haemophilia and Thrombosis Centre, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Hatim Alibhai
- Department of Clinical Science and Services, The Royal Veterinary College, University of London, Hertfordshire, UK
| | - Yu-Mei Chang
- Department of Research Support, The Royal Veterinary College, University of London, Hertfordshire, UK
| | - Simon Priestnall
- Department of Pathobiology and Population Sciences, The Royal Veterinary College, University of London, Hertfordshire, UK
| | - Giacomo Stanzani
- Department of Clinical Science and Services, The Royal Veterinary College, University of London, Hertfordshire, UK
| | - Nathan Davies
- Liver Failure Group, Institute of Liver and Digestive Health, University College London Medical School Royal Free Campus, London, UK
| | - Rajeshwar Mookerjee
- Liver Failure Group, Institute of Liver and Digestive Health, University College London Medical School Royal Free Campus, London, UK
| | - Rajiv Jalan
- Liver Failure Group, Institute of Liver and Digestive Health, University College London Medical School Royal Free Campus, London, UK
| | - Banwari Agarwal
- Department of Intensive Care Medicine, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| |
Collapse
|
30
|
A case that illustrates the challenges of managing pregnant patients with antithrombin deficiency: More questions than answers. Thromb Res 2017; 157:1-6. [PMID: 28667866 DOI: 10.1016/j.thromres.2017.06.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2017] [Revised: 06/17/2017] [Accepted: 06/23/2017] [Indexed: 11/20/2022]
Abstract
Using an illustrative case of a patient with antithrombin (AT) deficiency who developed a recurrent venous thromboembolism (VTE) in pregnancy despite therapeutic low-molecular-weight heparin (LMWH), we highlight what is known in the literature and address areas of controversy through a series of questions around the case. The questions we address include the role of anti-Xa monitoring for patients with past VTE on antepartum LMWH, what treatment regimen is recommended for pregnant patients who develop a recurrent VTE while on therapeutic anticoagulation, the role of antepartum AT concentrate prophylaxis, and the management of labor/delivery, epidural anesthesia and postpartum anticoagulation. We also describe practical considerations for use of AT concentrate, including teaching our patient to self-infuse AT concentrate at home with support of a hemophilia treatment center (HTC), and the direct and indirect costs of AT concentrate for secondary prophylaxis.
Collapse
|
31
|
Residual Enoxaparin Activity, Anti-Xa Levels, and Concerns About the American Society of Regional Anesthesia and Pain Medicine Anticoagulation Guidelines. Reg Anesth Pain Med 2017; 42:432-436. [DOI: 10.1097/aap.0000000000000617] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
32
|
Ikejiri M, Wada H, Yamaguchi T, Miyazaki S, Hasegawa M, Wakabayashi H, Asanuma K, Sakaguchi A, Matsumoto T, Ohishi K, Fujimoto N, Yamada N, Ito M, Katayama N, Sudo A. Comparison of three different anti-Xa assays in major orthopedic surgery patients treated with fondaparinux. Int J Hematol 2016; 103:554-9. [PMID: 26922193 DOI: 10.1007/s12185-016-1963-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 02/09/2016] [Accepted: 02/12/2016] [Indexed: 10/22/2022]
Abstract
Anti-Xa assays are useful for monitoring the effects of selective anti-Xa drugs, such as fondaparinux, in the prophylaxis of deep vein thrombosis. In the present study, anti-Xa activity was measured using three different assays, Testzym(®) Heparin S, STA(®)-Liquid Anti-Xa and HemosIL(®) Liquid Heparin. Anti-Xa activity in each assay gradually increased from day one after administration to day eight, and still remained on day 15. Although there were significant differences in anti-Xa activity among the three assays, the activity showed significant correlation across assays. There were no significant differences in the anti-Xa activity between patients with and without DVT or between patients with and without massive bleeding on day one before and after administration, day four, day eight and day 15. Anti-Xa activity in each assay was weakly correlated with antithrombin (AT) activity. The AT activity in patients were significantly higher on days four, eight and 15 compared with day one before and after administration, suggesting that AT activity increases following the administration of fondaparinux. The three anti-Xa assay kits tested are useful for monitoring fondaparinux treatment in orthopedic surgery patients.
Collapse
Affiliation(s)
- Makoto Ikejiri
- Department of Central Laboratory, Mie University Hospital, Tsu, Japan
| | - Hideo Wada
- Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie-ken, 514-8507, Japan.
| | - Toshio Yamaguchi
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Shinichi Miyazaki
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masahiro Hasegawa
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Hiroki Wakabayashi
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Kunihiro Asanuma
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Akane Sakaguchi
- Department of Central Laboratory, Mie University Hospital, Tsu, Japan
| | - Takeshi Matsumoto
- Department of Blood Transfusion Service, Mie University Hospital, Tsu, Japan
| | - Kohshi Ohishi
- Department of Blood Transfusion Service, Mie University Hospital, Tsu, Japan
| | - Naoki Fujimoto
- Department of Molecular and Laboratory Medicine, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie-ken, 514-8507, Japan
| | - Norikazu Yamada
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masaaki Ito
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Naoyuki Katayama
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Akihiro Sudo
- Department of Orthopaedic Surgery, Mie University Graduate School of Medicine, Tsu, Japan
| |
Collapse
|
33
|
Smythe MA, Priziola J, Dobesh PP, Wirth D, Cuker A, Wittkowsky AK. Guidance for the practical management of the heparin anticoagulants in the treatment of venous thromboembolism. J Thromb Thrombolysis 2016; 41:165-86. [PMID: 26780745 PMCID: PMC4715846 DOI: 10.1007/s11239-015-1315-2] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Venous thromboembolism (VTE) is a serious and often fatal medical condition with an increasing incidence. Despite the changing landscape of VTE treatment with the introduction of the new direct oral anticoagulants many uncertainties remain regarding the optimal use of traditional parenteral agents. This manuscript, initiated by the Anticoagulation Forum, provides clinical guidance based on existing guidelines and consensus expert opinion where guidelines are lacking. This specific chapter addresses the practical management of heparins including low molecular weight heparins and fondaparinux. For each anticoagulant a list of the most common practice related questions were created. Each question was addressed using a brief focused literature review followed by a multidisciplinary consensus guidance recommendation. Issues addressed included initial anticoagulant dosing recommendations, recommended baseline laboratory monitoring, managing dose adjustments, evidence to support a relationship between laboratory tests and meaningful clinical outcomes, special patient populations including extremes of weight and renal impairment, duration of necessary parenteral therapy during the transition to oral therapy, candidates for outpatient treatment where appropriate and management of over-anticoagulation and adverse effects including bleeding and heparin induced thrombocytopenia. This article concludes with a concise table of clinical management questions and guidance recommendations to provide a quick reference for the practical management of heparin, low molecular weight heparin and fondaparinux.
Collapse
Affiliation(s)
| | | | - Paul P Dobesh
- University of Nebraska Medical Center College of Pharmacy, Omaha, NE, USA
| | | | - Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ann K Wittkowsky
- University of Washington School of Pharmacy, 1959 NE Pacific St Box 356015, Seattle, WA, 98195, USA.
| |
Collapse
|
34
|
Wei MY, Ward SM. The Anti-Factor Xa Range For Low Molecular Weight Heparin Thromboprophylaxis. Hematol Rep 2015; 7:5844. [PMID: 26733269 PMCID: PMC4691677 DOI: 10.4081/hr.2015.5844] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2015] [Indexed: 11/28/2022] Open
Abstract
Low molecular weight heparins (LMWHs) are now the mainstay option in the prevention and treatment of venous thromboembolism. In some patients receiving therapeutic doses of LMWH, activity can be measured by quantifying the presence of Anti-factor Xa (AFXa) for dose adjustment. However, currently there are no guidelines for LMWH monitoring in patients on thromboprophylactic, doses, despite certain patient populations may be at risk of suboptimal dosing. This review found that while the AFXa ranges for therapeutic levels of LMWHs are relatively well defined in the literature, prophylactic ranges are much less clear, thus making it difficult to interpret current research data. From the studies published to date, we concluded that a reasonable AFXa target range for LMWH deep venous thromboses prophylaxis might be 0.2-0.5 IU/mL.
Collapse
Affiliation(s)
- Matthew Y Wei
- Eastern Health Surgical Research Group, Monash University , Melbourne, VIC, Australia
| | - Salena M Ward
- Eastern Health Surgical Research Group, Monash University , Melbourne, VIC, Australia
| |
Collapse
|
35
|
Adatya S, Uriel N, Yarmohammadi H, Holley CT, Feng A, Roy SS, Reding MT, John R, Eckman P, Zantek ND. Anti-factor Xa and activated partial thromboplastin time measurements for heparin monitoring in mechanical circulatory support. JACC-HEART FAILURE 2015; 3:314-22. [PMID: 25770404 DOI: 10.1016/j.jchf.2014.11.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 11/22/2014] [Accepted: 11/25/2014] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This study investigated the relationship between anti-factor Xa (anti-FXa) and activated partial thromboplastin time (aPTT) for monitoring intravenous unfractionated heparin (IV-UFH) in patients with continuous-flow left ventricular assist devices (CF-LVADs). BACKGROUND CF-LVADs have become mainstream therapy for patients with advanced heart failure. Thromboembolic events, device thrombosis, and bleeding continue to be a challenge with this technology. Adequate anticoagulation is required to prevent these adverse events. METHODS A prospective study of consecutive patients implanted with a CF-LVAD was conducted. Paired samples were considered concordant if aPTT values fell into expected ranges for subtherapeutic, therapeutic, and supratherapeutic anti-FXa levels. Heparin dosing was on the basis of anti-Xa levels. RESULTS A total of 340 paired values from 38 patients were evaluated. Anti-FXa and aPTT were discordant in 253 samples (74.4%), with a high degree of variability in aPTT for any given anti-FXa level (r(2) = 0.57). Results were discordant in 104 samples (63.8%) from patients undergoing bridging therapy with warfarin and in 149 samples (84.2%) from patients with device obstruction and/or hemolysis (p < 0.001). The most common pattern of discordance was a supratherapeutic aPTT value despite a therapeutic anti-FXa level (49.1% for bridging vs. 75.8% for device obstruction and/or hemolysis; p < 0.001). CONCLUSIONS Levels of aPTT were disproportionately prolonged relative to the corresponding anti-FXa levels in CF-LVAD patients, particularly those with device obstruction. Hemolysis and warfarin administration may falsely elevate aPTT, resulting in overestimation of heparin concentration and under-anticoagulation. Use of aPTT and anti-FXa to guide heparin therapy may lead to different estimates of heparin concentration in the same patient.
Collapse
Affiliation(s)
- Sirtaz Adatya
- Department of Medicine, Cardiology Division, University of Minnesota, Minneapolis, Minnesota.
| | - Nir Uriel
- Department of Medicine, Cardiology Division, University of Chicago, Chicago, Illinois
| | - Hirad Yarmohammadi
- Department of Medicine, Cardiology Division, University of Minnesota, Minneapolis, Minnesota
| | - Christopher T Holley
- Department of Medicine, Cardiology Division, University of Minnesota, Minneapolis, Minnesota
| | - Amy Feng
- Department of Medicine, Cardiology Division, University of Minnesota, Minneapolis, Minnesota
| | - Samit S Roy
- Department of Medicine, Cardiology Division, University of Minnesota, Minneapolis, Minnesota
| | - Mark T Reding
- Department of Medicine, Division of Hematology, Oncology and Transplantation, University of Minnesota, Minneapolis, Minnesota
| | - Ranjit John
- Department of Medicine, Cardiology Division, University of Minnesota, Minneapolis, Minnesota
| | - Peter Eckman
- Department of Medicine, Cardiology Division, University of Minnesota, Minneapolis, Minnesota
| | - Nicole D Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, Minnesota
| |
Collapse
|
36
|
Casella IB, Puech-Leão P. Generic versus branded enoxaparin in prophylaxis and treatment of vein thrombosis. Rev Assoc Med Bras (1992) 2015; 61:44-50. [DOI: 10.1590/1806-9282.61.01.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 06/03/2014] [Indexed: 11/22/2022] Open
Abstract
Objectives: to compare the biological efficacy of generic enoxaparin (HeptronTM) versus branded Sanofi-Aventis enoxaparin for prophylaxis and treatment of lower-extremity deep venous thrombosis (DVT) in a prospective, randomized, open-label study. Methods: patients with diagnosed lower-extremity DVT (therapeutic branch, n=57) and patients requiring venous thromboembolism (VTE) prophylaxis after arterial vascular surgery or major lower-extremity amputations (prophylactic branch, n=57) were randomized to receive generic or branded enoxaparin for up to seven days. Enoxaparin activity was measured by estimating blood anti-factor Xa levels at the peak plasma concentration. As secondary outcomes, development or progression of VTE events, major adverse events and major bleeding events were considered for efficacy and safety comparisons. Results: DVT therapy: twenty-five patients received generic enoxaparin while 32 received branded enoxaparin (subcutaneous, 1 mg/kg BID). Mean percentages of anti-factor Xa levels within the target ranges were 62 ± 35.4% and 67.5 ± 24.7%, respectively (p= .035 for non-inferiority). No patient presented DVT progression, clinically detectable pulmonary embolism, or major bleeding events in any subgroup. DVT prophylaxis: Thirty patients received generic enoxaparin and 27 received branded enoxaparin (subcutaneous, 40 mg/day). Mean percentages of anti-factor Xa levels within the target ranges were 77.9 ± 30.9% and 77.8 ± 32.9%, respectively (p = .009 for non-inferiority). There were no cases of VTE or major bleeding events in any subgroup. Conclusion: generic and branded enoxaparins exhibited similar in vivo responses as measured by the anti-factor Xa activity, as well as similar clinical efficacy and safety outcomes.
Collapse
|
37
|
Comparison of Methods to Determine Rivaroxaban anti-factor Xa activity. Thromb Res 2015; 135:394-7. [DOI: 10.1016/j.thromres.2014.11.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 11/05/2014] [Accepted: 11/17/2014] [Indexed: 11/23/2022]
|
38
|
Egan G, Ensom MHH. Measuring anti-factor xa activity to monitor low-molecular-weight heparin in obesity: a critical review. Can J Hosp Pharm 2015; 68:33-47. [PMID: 25762818 PMCID: PMC4350497 DOI: 10.4212/cjhp.v68i1.1423] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND The choice of whether to monitor anti-factor Xa (anti-Xa) activity in patients who are obese and who are receiving low-molecular-weight heparin (LMWH) therapy is controversial. To the authors' knowledge, no systematic review of monitoring of anti-Xa activity in such patients has been published to date. OBJECTIVE To systematically ascertain the utility of monitoring anti-Xa concentrations for LMWH therapy in obese patients. DATA SOURCES MEDLINE (1946 to September 2014), the Cochrane Database of Systematic Reviews, Embase (1974 to September 2014), PubMed (1947 to September 2014), International Pharmaceutical Abstracts (1970 to September 2014), and Scopus were searched using the terms obesity, morbid obesity, thrombosis, venous thrombosis, embolism, venous thromboembolism, pulmonary embolism, low-molecular weight heparin, enoxaparin, dalteparin, tinzaparin, anti-factor Xa, anti-factor Xa monitoring, anti-factor Xa activity, and anti-factor Xa assay. The reference lists of retrieved articles were also reviewed. STUDY SELECTION AND DATA EXTRACTION English-language studies describing obese patients treated with LMWH or reporting anti-Xa activity were reviewed using a 9-step decision-making algorithm to determine whether monitoring of LMWH therapy by means of anti-Xa activity in obesity is warranted. Studies published in abstract form were excluded. DATA SYNTHESIS The analysis showed that anti-Xa concentrations are not strongly associated with thrombosis or hemorrhage. In clinical studies of LMWH for thromboprophylaxis in bariatric surgery, orthopedic surgery, general surgery, and medical patients, and for treatment of venous thrombo embolism and acute coronary syndrome, anti-Xa activity can be predicted from dose of LMWH and total body weight; no difference in clinical outcome was found between obese and non-obese participants. CONCLUSIONS Routinely determining anti-Xa concentrations in obese patients to monitor the clinical effectiveness of LMWH is not warranted on the basis of the current evidence. Circumstances where measurement of anti-Xa concentration may help in clinical decision-making in either obese or non-obese patients would be cases where elimination of LMWH is impaired or there is an unexpected clinical response, as well as to confirm compliance with therapy or to identify deviation from predicted pharmacokinetics.
Collapse
Affiliation(s)
- Gregory Egan
- BScPharm, ACPR, PharmD, is a Clinical Pharmacy Specialist in Neurology, Vancouver General Hospital, Vancouver, British Columbia
| | - Mary H H Ensom
- BS(Pharm), PharmD, FASHP, FCCP, FCSHP, FCAHS, is a Professor in the Faculty of Pharmaceutical Sciences and Distinguished University Scholar, The University of British Columbia, and a Clinical Pharmacy Specialist, Children's and Women's Health Centre of British Columbia, Vancouver, British Columbia. She is also the Editor of the CJHP
| |
Collapse
|
39
|
Burger CF, Schlesinger JJ. Intravenous warfarin and heparin-induced thrombocytopenia: making the diagnosis, management, modern monitoring, and multidisciplinary care. Ann Pharmacother 2013; 48:286-91. [PMID: 24259642 DOI: 10.1177/1060028013511060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To describe the diagnosis, management, and monitoring of a patient with heparin-induced thrombocytopenia (HIT) with thrombosis and simultaneous bleeding risk treated with argatroban and transitioned to intravenous (IV) warfarin secondary to the inability to administer enteral medications. CASE SUMMARY A 71-year-old man was admitted to the surgical intensive care unit (SICU) following aortic valve repair, coronary artery bypass, and ascending aortic aneurysm repair. On postoperative day 9, he was found to have a pulmonary embolism, and therapeutic heparin was started. The following day, his platelet count was found to have dropped precipitously. HIT was diagnosed, heparin was discontinued, and argatroban was initiated. On postoperative day 22, anticoagulation was discontinued because of massive gastrointestinal bleeding. On postoperative day 35, multiple venous thromboses were found, and argatroban was restarted. The patient developed a high-output enterocutaneous fistula, eliminating the option of enteral route of medication administration. The multidisciplinary SICU team transitioned the patient from argatroban to IV warfarin for long-term anticoagulation. The international normalized ratio was monitored and remained therapeutic throughout his admission without further thrombotic complications. DISCUSSION HIT occurs when antibodies develop to heparin-platelet factor 4 complexes, causing simultaneous hypercoagulability and thrombocytopenia. It is diagnosed based on both clinical factors and laboratory testing. Treatment includes discontinuation of all forms of heparin; initiation of a nonheparin anticoagulant, such as argatroban; and transition to warfarin. CONCLUSIONS IV warfarin is a therapeutic option for patients with malabsorption issues. A multidisciplinary team in an intensive care setting optimizes cost-effective, patient-centered, and safe care.
Collapse
|
40
|
Wool GD, Lu CM. Pathology consultation on anticoagulation monitoring: factor X-related assays. Am J Clin Pathol 2013; 140:623-34. [PMID: 24124140 DOI: 10.1309/ajcpr3jtok7nkdbj] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES To review various anticoagulation therapies and related laboratory monitoring issues, with a focus on factor X-related chromogenic assays. METHODS A case-based approach is used to review pertinent published literatures and product inserts of anticoagulation drugs and to look back on clinical use of factor X-related chromogenic assays. RESULTS The number of anticoagulants available to clinicians has increased greatly in the past decade. Whether and how these anticoagulants should be monitored are areas of uncertainty for clinicians, which can lead to misuse of laboratory assays and suboptimal patient management. Factor X-related assays are of particular concern because of the similar and often confusing test names. Based on a common clinical case scenario and literature review regarding anticoagulant monitoring, an up-to-date discussion and review of the various factor X-related assays are provided, focusing on the differences in test designs and clinical utilities between the chromogenic anti-Xa and chromogenic factor X activity assays. CONCLUSIONS Anticoagulation therapy and related laboratory monitoring are rapidly evolving areas of clinical practices. A good knowledge of relevant laboratory assays and their clinical applications is necessary to help optimize patient care.
Collapse
Affiliation(s)
- Geoffrey D. Wool
- Department of Laboratory Medicine, University of California San Francisco and Laboratory Medicine Service, Veterans Affairs Medical Center, San Francisco, CA
| | - Chuanyi M. Lu
- Department of Laboratory Medicine, University of California San Francisco and Laboratory Medicine Service, Veterans Affairs Medical Center, San Francisco, CA
| |
Collapse
|
41
|
Hasegawa M, Wada H, Wakabayashi H, Yoshida K, Miyamoto N, Asanuma K, Matsumoto T, Ohishi K, Shimokariya Y, Yamada N, Uchida A, Sudo A. The relationships among hemostatic markers, the withdrawal of fondaparinux due to a reduction in hemoglobin and deep vein thrombosis in Japanese patients undergoing major orthopedic surgery. Clin Chim Acta 2013; 425:109-13. [PMID: 23876378 DOI: 10.1016/j.cca.2013.07.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 07/11/2013] [Accepted: 07/11/2013] [Indexed: 01/24/2023]
Abstract
BACKGROUND The relationships among the hemostatic markers, the development of deep vein thrombosis (DVT) and the withdrawal of fondaparinux due to a reduction in the hemoglobin levels were examined. METHODS Two-hundred twenty-one Japanese patients who underwent major orthopedic surgery and were treated with 1.5mg of fondaparinux instead of 2.5mg of fondaparinux were studied. Forty-seven of 221 patients discontinued fondaparinux treatment (withdrawal group) and 37 patients developed DVT. RESULTS The age, frequency of total knee arthroplasty (TKA), withdrawal of fondaparinux, reduction of hemoglobin and the plasma levels of soluble fibrin (SF), D-dimer and fibrinogen and fibrin degradation product (FDP) on day 1 after the operation were significantly higher in the patients with DVT. Elevated SF, D-dimer or FDP levels were associated with the risk for DVT. The age, frequency of TKA or DVT, anti-Xa activity and the creatinine, FDP and D-dimer levels were significantly higher in the withdrawal group. An anti-Xa level >0.33 mg/l and an elevated D-dimer or FDP level were associated with the risk of withdrawal. CONCLUSION The age and SF levels, TKA and withdrawal of fondaparinux were related to the risk of DVT, and the anti-Xa activity, creatinine level and DVT were related to the risk of withdrawal of fondaparinux due to a reduction in hemoglobin.
Collapse
|
42
|
Takemoto CM, Streiff MB, Shermock KM, Kraus PS, Chen J, Jani J, Kickler T. Activated partial thromboplastin time and anti-xa measurements in heparin monitoring: biochemical basis for discordance. Am J Clin Pathol 2013; 139:450-6. [PMID: 23525615 DOI: 10.1309/ajcps6ow6dynognh] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
We examined the concordance of heparin levels measured by a chromogenic anti-Xa assay and the activated partial thromboplastin time (APTT) during unfractionated heparin therapy (UFH) and the biochemical basis for differences between these measures. We also investigated the endogenous thrombin potential (ETP) as a possible measure of anticoagulation. Paired measures of anti-Xa and APTT were performed on 569 samples from 149 patients on UFH. The anti-Xa values and the APTT were concordant in only 54% of measurements. One hundred twelve samples from 59 patients on UFH were assayed for APTT, anti-Xa, factor II, factor VIII, and ETP. Supratherapeutic APTT values but therapeutic anti-Xa results had decreased factor II activity. Subtherapeutic APTT but therapeutic anti-Xa values had high factor VIII activity. ETP correlated with anticoagulation status and UFH dose. In conclusion, factor II and VIII activity contributes to discordance between APTT and anti-Xa results. ETP measurements may provide an additional assessment of anticoagulation status.
Collapse
Affiliation(s)
- Clifford M. Takemoto
- Department of Pediatric Hematology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael B. Streiff
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Kenneth M. Shermock
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pharmacy, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Peggy S. Kraus
- Department of Pharmacy, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Junnan Chen
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jayesh Jani
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Thomas Kickler
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
43
|
Bedside anti-Xa measurement for therapeutic assessment of a prophylactic anticoagulation regimen. Crit Care 2013. [PMCID: PMC3642634 DOI: 10.1186/cc12286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
44
|
Mikuni M, Fujii S, Yaoeda H. [Stereophotography of the ocular fundus. 2. Observation method]. Thromb J 1969; 12:24. [PMID: 25750588 PMCID: PMC4351835 DOI: 10.1186/1477-9560-12-24] [Citation(s) in RCA: 38] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 10/06/2014] [Indexed: 01/09/2023] Open
Abstract
Traditional anticoagulant agents such as vitamin K antagonists (VKAs), unfractionated heparin (UFH), low molecular weight heparins (LMWHs) and fondaparinux have been widely used in the prevention and treatment of thromboembolic diseases. However, these agents are associated with limitations, such as the need for regular coagulation monitoring (VKAs and UFH) or a parenteral route of administration (UFH, LMWHs and fondaparinux). Several non-VKA oral anticoagulants (NOACs) are now widely used in the prevention and treatment of thromboembolic diseases and in stroke prevention in non-valvular atrial fibrillation. Unlike VKAs, NOACs exhibit predictable pharmacokinetics and pharmacodynamics. They are therefore usually given at fixed doses without routine coagulation monitoring. However, in certain patient populations or special clinical circumstances, measurement of drug exposure may be useful, such as in suspected overdose, in patients experiencing a hemorrhagic or thromboembolic event during the treatment’s period, in those with acute renal failure, in patients who require urgent surgery or in case of an invasive procedure. This article aims at providing guidance on laboratory testing of classic anticoagulants and NOACs.
Collapse
|