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Gosselin RC, Cuker A. Assessing Direct Oral Anticoagulants in the Clinical Laboratory. Clin Lab Med 2024; 44:551-562. [PMID: 39089758 DOI: 10.1016/j.cll.2024.04.014] [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: 08/04/2024]
Abstract
Direct oral anticoagulants (DOACs) have significant advantages over vitamin K antagonists including lack of need for routine laboratory monitoring. However, assessment of DOAC effect and concentration may be important to guide clinical management including need for DOAC reversal, particularly in acute or emergent situations. In this manuscript, the authors describe tests to screen for DOAC presence and tests that have demonstrated equivalence to gold standard testing for quantifying DOAC exposure. They also discuss the effect of DOACs on other coagulation assays and strategies for monitoring unfractionated heparin in patients with concomitant DOAC exposure.
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Affiliation(s)
- Robert C Gosselin
- Thrombosis and Hemostasis Center, University of California, Davis Health System, Sacramento, CA 95817, USA.
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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2
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Bourguignon A, Mathews N, Tasneem S, Douketis J, Hayward CPM. Rapid diagnosis of coagulopathies from vitamin K deficiency in a consecutive case cohort evaluated by comparative assessment of factor II by 1-stage assays with prothrombin time vs Ecarin reagents. J Thromb Haemost 2024:S1538-7836(24)00449-5. [PMID: 39151703 DOI: 10.1016/j.jtha.2024.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 07/02/2024] [Accepted: 08/01/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Vitamin K (VK) deficiency (VKD) impairs γ-carboxylation of VK-dependent factors (VKDFs), resulting in higher factor (F)II levels measured by Ecarin (FIIE) reagents (that convert des-γ-carboxylated FII to meizothrombin) than by prothrombin time (FII) reagents. OBJECTIVES To evaluate FII/FIIE abnormalities among patients assessed for coagulopathies and identify findings predictive of coagulopathy improvement after VK. METHODS We retrospectively assessed consecutive cases from 2002 to 2021 with FII/FIIE tests and the sensitivity and specificity of FII/FIIE ratios and FIIE-FII differences for VKD defined as international normalized ratio correction/improvement of ≥0.5 after VK. RESULTS Two hundred ninety-two patients (males, 58.2%; adults, 85.6%; median age, 73 years) were evaluated (84.2% hospitalized, 48.3% in intensive care, 71.6% with active liver disease, and 28% deceased at discharge) and 25% to 38% had FII/FIIE findings suggestive of VKD. Among 170 patients assessed for response to VK, FII/FIIE ratios of ≤0.84 to 0.91 and FIIE-FII differences of >0.04 U/mL had similar modest sensitivity (47.7%-69.3%) and modest to good specificity (67.1%-91.5%) for VKD. FII/FIIE ratios of <0.86, suggestive of VKD (sensitivity, 47.7%; specificity, 90.2%), were more common in patients deficient in only VKDF (P = .0001), but were detected in 16% with non-VKDF deficiencies. Low FIIE was commonly associated with active liver disease (P = .0002). Patients with and without probable VKD (based on FII/FIIE ratios of <0.86) had similar mortality, bleeding, and rates of prothrombin complex concentrate and red cell transfusions (P ≥ .78), but fewer with probable VKD received plasma and fibrinogen replacement (P ≤ .024). CONCLUSION FII/FIIE comparison aids the diagnosis of VKD and predicts clinical responses to VK treatment among patients with coagulopathies.
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Affiliation(s)
- Alex Bourguignon
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada; Division of Hematology and Oncology, Department of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Natalie Mathews
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Clinical Laboratory Medicine, OPTILAB Montréal-CHU Sainte-Justine, Hematology/Oncology, Centre Hospitalier Universitaire Sainte-Justine, Montréal, Québec, Canada
| | - Subia Tasneem
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - James Douketis
- Division of Hematology & Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Medicine, St. Joseph's Healthcare, Hamilton, Ontario, Canada
| | - Catherine P M Hayward
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada; Division of Hematology & Thromboembolism, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Hematology, Hamilton Health Sciences, Hamilton, Ontario, Canada; Hematology, Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada.
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Faraoni D, DiNardo JA. Bivalirudin: The misunderstood alternative to heparin. Paediatr Anaesth 2024; 34:394-395. [PMID: 38440919 DOI: 10.1111/pan.14868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 02/16/2024] [Indexed: 03/06/2024]
Affiliation(s)
- David Faraoni
- Arthur S. Keats Division of Pediatric Cardiovascular Anesthesia, Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - James A DiNardo
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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4
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Erdoes G, Koster A, Levy JH. Monitoring Argatroban Anticoagulation in the Critically Ill: All Tests Are Not Created Equal. Anesthesiology 2024; 140:189-191. [PMID: 38193739 DOI: 10.1097/aln.0000000000004814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Affiliation(s)
- Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Koster
- Institute of Anesthesiology and Pain Therapy, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, North Carolina
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de Fautereau-Vassel A, Mokhtarian A, Mangenot M, Krekounian O, Kousignian I, Delavenne X, Curis E, Gouin-Thibault I, Siguret V. Comparisons between diluted thrombin time, ecarin chromogenic assays, and UPLC-MS for plasma level dabigatran quantification: Results from DRIVING study. Int J Lab Hematol 2024; 46:120-127. [PMID: 37710085 DOI: 10.1111/ijlh.14166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 08/22/2023] [Indexed: 09/16/2023]
Abstract
INTRODUCTION The knowledge of dabigatran levels is helpful for decision-making in specific situations such as urgent surgery or when the question of reversal arises (uncontrolled bleeding, eligibility for thrombolysis). However, a limited number of observational studies are available regarding comparisons between quantification methods. The objective of the study was to compare dabigatran plasma levels using three assays including the reference method (high-performance liquid chromatography coupled with mass spectrometry), focusing on the agreement around the 30-50 ng/mL clinically relevant thresholds. METHODS Sixty healthy volunteers from DRIVING trial (NCT01627665) were given a single 300-mg dabigatran etexilate dose. Serial blood samplings were performed at pre-defined time points (0 to 24 h). We analyzed plasma samples using ultra-performance-liquid chromatography coupled with tandem mass spectrometry (UPLC-MS) (dabigatran reference method); ii/diluted thrombin time (dTT) (Hemoclot-DTI-Hyphen-Biomed); iii/ecarin-based chromogenic assay (ECA-II-Stago). RESULTS Nine hundred sixty samples were analyzed using the three assays (2759 values). dTT and ECA-II values were highly correlated with those of UPLC-MS (Deming regression). Most values >50 ng/mL were higher using dTT and ECA-II compared to UPLC-MS: biases were constant, +14% and +16% with dTT and ECA-II, respectively (Bland-Altman plots), suggesting that active metabolites accounted for ~15% of thrombin inhibition. Regarding values <30 ng/mL, 30-50 ng/mL, or ≥50 ng/mL, the agreement probability between dTT and ECA-II was of 90.6% [88.4-92.5] (Cohen's kappa coefficient 0.84). CONCLUSION dTT and ECA-II assays rapidly provide accurate dabigatran-level results for clinical practice, both assays being suitable in emergency, taking into account the thrombin inhibitory effect of dabigatran metabolites.
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Affiliation(s)
| | - Antoine Mokhtarian
- UR 7537 BioSTM (Biostatistics), Faculté de Pharmacie de Paris, Université Paris Cité, Paris, France
| | - Manon Mangenot
- UR 7537 BioSTM (Biostatistics), Faculté de Pharmacie de Paris, Université Paris Cité, Paris, France
| | - Ombeline Krekounian
- UR 7537 BioSTM (Biostatistics), Faculté de Pharmacie de Paris, Université Paris Cité, Paris, France
| | - Isabelle Kousignian
- UR 7537 BioSTM (Biostatistics), Faculté de Pharmacie de Paris, Université Paris Cité, Paris, France
| | - Xavier Delavenne
- Laboratoire de Pharmacologie-Toxicologie, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
| | - Emmanuel Curis
- UR 7537 BioSTM (Biostatistics), Faculté de Pharmacie de Paris, Université Paris Cité, Paris, France
- INSERM UMRS-1140, Université Paris Cité, Paris, France
- Service d'hématologie Biologique, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Isabelle Gouin-Thibault
- Laboratoire d'Hématologie, Centre Hospitalier Universitaire Pontchaillou, Univ Rennes, CHU Rennes, Inserm, IRSET UMR-S-1085, Rennes, France
| | - Virginie Siguret
- INSERM UMRS-1140, Université Paris Cité, Paris, France
- Service d'hématologie Biologique, Hôpital Lariboisière, APHP Nord, Paris, France
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Qiao J, Tran MH. Challenges to Laboratory Monitoring of Direct Oral Anticoagulants. Clin Appl Thromb Hemost 2024; 30:10760296241241524. [PMID: 38650302 PMCID: PMC11036927 DOI: 10.1177/10760296241241524] [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: 02/09/2024] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 04/25/2024] Open
Abstract
Direct oral anticoagulants (DOACs) exert anticoagulation effect by directly inhibiting Factor Xa (rivaroxaban, apixaban, and edoxaban) or thrombin (dabigatran). Though DOACs are characterized by fixed-dose prescribing and generally do not require routine laboratory drug-level monitoring (DLM), circumstances may arise where the DLM may aid in clinical decision-making, including DOAC dose adjustment, anticoagulant class change, or decisions to withhold or administer reversal agents. We review the current literature that describes high-risk patient groups in which DLM may be beneficial for improved patient anticoagulation management and stewardship. The review also summarizes the limitations of conventional coagulation testing and discuss the emerging utility of quantitative methods for routine and rapid emergent evaluation of DOAC drug levels-in particular, the Anti-Xa activity to detect Factor Xa Inhibitors (rivaroxaban, apixaban, and edoxaban). Both technical and regulatory barriers to widespread DLM implementation are limiting factors to further clinical research that must be overcome, in order to propose universal DOAC DLM strategies and provide clinical-laboratory correlation to formally classify high-risk patient groups.
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Affiliation(s)
- Jesse Qiao
- Irvine Department of Pathology and Laboratory Medicine, University of California, Orange, CA, USA
| | - Minh-Ha Tran
- Irvine Department of Pathology and Laboratory Medicine, University of California, Orange, CA, USA
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Wang XN, Song Y, Tang W, Li P, Li B. Integration of fluorescence and MALDI imaging for microfluidic chip-based screening of potential thrombin inhibitors from natural products. Biosens Bioelectron 2023; 237:115527. [PMID: 37480787 DOI: 10.1016/j.bios.2023.115527] [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: 05/03/2023] [Revised: 07/02/2023] [Accepted: 07/09/2023] [Indexed: 07/24/2023]
Abstract
The microfluidic technology provides an ideal platform for in situ screening of enzyme inhibitors and activators from natural products. This work described a surface-modified ITO glass-PDMS hybrid microfluidic chip for evaluating thrombin interaction with its potential inhibitors by fluorescence imaging and matrix-assisted laser desorption/ionization mass spectrometry imaging (MALDI MSI). The fluorescence-labeled substrate was immobilized on a conductive ITO glass slide coated with gold nanoparticles/thiol-β-cyclodextrin modified TiO2 nanowires (Au-β-CD@TiO2 NWs) via Au-S bonds. A PDMS microchannel plate was placed on top of the modified ITO slide. The premixed solutions of thrombin and candidate thrombin inhibitors were infused into the microchannels to form a microreactor environment. The enzymatic reaction was rapidly monitored by fluorescence microscopy, and MALDI MS was used to validate and quantify the enzymatic hydrolysate of thrombin to determine the enzyme kinetic process and inhibitory activities of selected flavonoids. The fluorescence and MALDI MS results showed that luteolin, cynaroside, and baicalin have good thrombin inhibitory activity and their half-maximal inhibitory concentrations (IC50) were below 30 μM. The integration of fluorescence imaging and MALDI MSI for in situ monitoring and quantifying the enzymatic reaction in a microfluidic chip is capable of rapid and accurate screening of thrombin inhibitors from natural products.
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Affiliation(s)
- Xian-Na Wang
- State Key Laboratory of Natural Medicines and School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Yahui Song
- State Key Laboratory of Natural Medicines and School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Weiwei Tang
- State Key Laboratory of Natural Medicines and School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, 210009, China
| | - Ping Li
- State Key Laboratory of Natural Medicines and School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, 210009, China.
| | - Bin Li
- State Key Laboratory of Natural Medicines and School of Traditional Chinese Pharmacy, China Pharmaceutical University, Nanjing, 210009, China.
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Zátroch I, Dinya E, Fazakas J. New under the sun: ClotPro's ECA-test detects hyperfibrinolysis in a higher number of patients, more frequently and 9 min earlier. Blood Coagul Fibrinolysis 2023; 34:99-104. [PMID: 36519572 PMCID: PMC9894133 DOI: 10.1097/mbc.0000000000001185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 10/25/2022] [Indexed: 12/23/2022]
Abstract
Liver diseases result in a re-balanced state of the haemostatic system with decreased haemostatic reserves. Increased fibrinolytic activity is commonly seen during liver transplants. The aim of this study was to assess whether ClotPro's ECA-test is able to detect hyperfibrinolysis earlier and with higher frequency than ClotPro's conventional viscoelastic assays for the intrinsic and the extrinsic coagulation pathway. From 25 liver transplant recipients, systemic blood samples were collected during surgery. Viscoelastic haemostatic assays with ClotPro's IN-test, EX-test and ECA-test were performed simultaneously from each blood sample. Hyperfibrinolysis was defined on the basis of the manufacturer's prespecified threshold value (maximal lysis >15%). The incidence of hyperfibrinolysis detected with each test was compared with the McNemar test. For each assay, lysis detection time (LDT) was calculated and analysed with the nonparametric Kruskal-Wallis test. A total of 125 tests were performed simultaneously. Compared with the IN-test and the EX-test, the ECA-test detected hyperfibrinolysis in significantly ( P < 0.001) higher number of patients (9; 11; 14, respectively) and in more measurement points (14; 18; 28, respectively). The analysis of LDT values revealed significant superiority of the ECA-test to the IN-test ( P = 0.046) and to the EX-test ( P = 0.035), indicating the profibrinolytic state of the haemostasis 8.9 ± 0.65 and 8.7 ± 0.17 min earlier, respectively. These are preliminary results of the study NCT0424637. ClotPro's ECA-test appeared to detect fibrinolysis in a higher number of patients, more frequently, and the mean time of detection was 9 min earlier than that of the IN-test and the EX-test.
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Affiliation(s)
- István Zátroch
- Department of Anesthesiology and Intensive Therapy, Uzsoki Hospital
| | - Elek Dinya
- Institute of Digital Health Sciences, Semmelweis University
| | - János Fazakas
- Department of Surgery, Transplantation and Intervetional Gastroenterology and Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
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9
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Wang Z, Lauko J, Kijas AW, Gilbert EP, Turunen P, Yegappan R, Zou D, Mata J, Rowan AE. Snake venom-defined fibrin architecture dictates fibroblast survival and differentiation. Nat Commun 2023; 14:1029. [PMID: 36823141 PMCID: PMC9950370 DOI: 10.1038/s41467-023-36437-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 02/01/2023] [Indexed: 02/25/2023] Open
Abstract
Fibrin is the provisional matrix formed after injury, setting the trajectory for the subsequent stages of wound healing. It is commonly used as a wound sealant and a natural hydrogel for three-dimensional (3D) biophysical studies. However, the traditional thrombin-driven fibrin systems are poorly controlled. Therefore, the precise roles of fibrin's biophysical properties on fibroblast functions, which underlie healing outcomes, are unknown. Here, we establish a snake venom-controlled fibrin system with precisely and independently tuned architectural and mechanical properties. Employing this defined system, we show that fibrin architecture influences fibroblast survival, spreading phenotype, and differentiation. A fine fibrin architecture is a key prerequisite for fibroblast differentiation, while a coarse architecture induces cell loss and disengages fibroblast's sensitivity towards TGF-β1. Our results demonstrate that snake venom-controlled fibrin can precisely control fibroblast differentiation. Applying these biophysical principles to fibrin sealants has translational significance in regenerative medicine and tissue engineering.
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Affiliation(s)
- Zhao Wang
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, St Lucia, QLD, 4072, Australia
| | - Jan Lauko
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, St Lucia, QLD, 4072, Australia
| | - Amanda W Kijas
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, St Lucia, QLD, 4072, Australia
| | - Elliot P Gilbert
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, St Lucia, QLD, 4072, Australia.,Australian Centre for Neutron Scattering, Australian Nuclear Science and Technology Organisation, Lucas Heights, NSW, 2234, Australia
| | - Petri Turunen
- Microscopy Core Facility, Institute of Molecular Biology, Mainz, 55128, Germany
| | - Ramanathan Yegappan
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, St Lucia, QLD, 4072, Australia
| | - Dongxiu Zou
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, St Lucia, QLD, 4072, Australia
| | - Jitendra Mata
- Australian Centre for Neutron Scattering, Australian Nuclear Science and Technology Organisation, Lucas Heights, NSW, 2234, Australia
| | - Alan E Rowan
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, St Lucia, QLD, 4072, Australia.
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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: 11] [Impact Index Per Article: 11.0] [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.
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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
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11
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Gosselin RC. Ecarin-Based Methods for Measuring Thrombin Inhibitors. Methods Mol Biol 2023; 2663:355-367. [PMID: 37204723 DOI: 10.1007/978-1-0716-3175-1_23] [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
Ecarin is a venom from the saw-scaled viper, Echis carinatus, which catalyzes prothrombin into meizothrombin. This venom is used in several hemostasis laboratory assays, including ecarin clotting time (ECT) and ecarin chromogenic assays (ECA). The use of these ecarin-based assays was first implemented as a tool for monitoring the infusion of a direct thrombin inhibitor, hirudin. Subsequently, this method has been more recently employed for measuring either the pharmacodynamic or pharmacokinetic properties of the oral direct thrombin inhibitor, dabigatran. In this chapter, the procedure for performing manual ECT and automated and manual ECA for measuring thrombin inhibitors is described.
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Affiliation(s)
- Robert C Gosselin
- Thrombosis & Hemostasis Center, University of California, Davis Health System, Sacramento, CA, USA
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12
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Davidson S. Assays to Monitor Bivalirudin. Methods Mol Biol 2023; 2663:369-380. [PMID: 37204724 DOI: 10.1007/978-1-0716-3175-1_24] [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
Bivalirudin (Angiomax, Angiox) is a parenteral direct thrombin inhibitor (DTI) that is used for patients with heparin-induced thrombocytopenia (HIT), where heparin cannot be used due to the risk of thrombosis. Bivalirudin is also licensed for use in cardiology procedures (e.g., percutaneous transluminal coronary angioplasty; PTCA). Bivalirudin is a synthetic analogue of hirudin found in the saliva of the medicinal leech and has a relatively short half-life of ~25 min. Several assays can be used to monitor bivalirudin; these include the activated partial thromboplastin time (APTT), activated clotting time (ACT), ecarin clotting time (ECT), an ecarin-based chromogenic assay, thrombin time (TT), the dilute TT, and the prothrombinase-induced clotting time (PiCT). Drug concentrations can also be measured using liquid chromatography tandem mass spectrometry (LC/MS) and clotting or chromogenic-based assays with specific drug calibrators and controls.
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Affiliation(s)
- Simon Davidson
- Division of Medicine, University College London, London, UK
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13
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Zhao KN, Masci P, Dimeski G, Johnson L, Grant M, de Jersey J, Lavin MF. Potential Application of Recombinant Snake Prothrombin Activator Ecarin in Blood Diagnostics. Biomolecules 2022; 12:1704. [PMID: 36421717 PMCID: PMC9687618 DOI: 10.3390/biom12111704] [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: 10/05/2022] [Revised: 11/07/2022] [Accepted: 11/10/2022] [Indexed: 08/30/2023] Open
Abstract
We describe here the purification and cloning of a codon-optimized form of the snake prothrombin activator ecarin from the saw scaled viper (Echis carinatus) expressed in mammalian cells. Expression of recombinant ecarin (rEcarin) was carried out in human embryonic kidney cells (HEK) cells under conditions for the development and performance of a novel and scalable recombinant snake ecarin to industry standards. Clotting performance of the rEcarin was established in recalcified citrated whole blood, plasma, and fresh whole blood and found to be comparable to native ecarin (N-Ecarin). Furthermore, hemolysis was observed with N-Ecarin at relatively high doses in both recalcified citrated and fresh whole blood, while clotting was not observed with rEcarin, providing an important advantage for the recombinant form. In addition, rEcarin effectively clotted both recalcified citrated whole blood and fresh whole blood containing different anticoagulants including heparin, warfarin, dabigatran, Fondaparinux, rivaroxaban and apixaban, forming firm clots in the blood collection tubes. These results demonstrate that rEcarin efficiently clots normal blood as well as blood spiked with high concentrations of anticoagulants and has great potential as an additive to blood collection tubes to produce high quality serum for analyte analysis in diagnostic medicine.
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Affiliation(s)
- Kong-Nan Zhao
- Australian Institute of Biotechnology and Nanotechnology, St Lucia Campus, The University of Queensland, Brisbane, QLD 4072, Australia
- Centre for Kidney Disease Research-Venomics Research, School of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Paul Masci
- Centre for Kidney Disease Research-Venomics Research, School of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Goce Dimeski
- Chemical Pathology, Princess Alexandra Hospital, Woolloongabba, Brisbane, QLD 4102, Australia
- School of Chemistry and Molecular Biosciences, St Lucia Campus, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Lambro Johnson
- Australian Institute of Biotechnology and Nanotechnology, St Lucia Campus, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Michael Grant
- Q-Sera Pty Ltd., Level 9, 31 Queen St, Melbourne, VIC 3000, Australia
| | - John de Jersey
- School of Chemistry and Molecular Biosciences, St Lucia Campus, The University of Queensland, Brisbane, QLD 4072, Australia
| | - Martin F. Lavin
- Australian Institute of Biotechnology and Nanotechnology, St Lucia Campus, The University of Queensland, Brisbane, QLD 4072, Australia
- Centre for Clinical Research, RBWH Campus, The University of Queensland, Brisbane, QLD 4029, Australia
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14
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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.
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15
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Mohammadi N, Bandehpour M, Sotoodehnejadnematalahi F, Kazemi B. Prokaryotic expression, evaluation, and prediction of the structure and function of the ecarin metalloproteinase domain. Proteins 2021; 90:802-809. [PMID: 34739152 DOI: 10.1002/prot.26275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Revised: 10/20/2021] [Accepted: 10/21/2021] [Indexed: 11/08/2022]
Abstract
Ecarin is one of the most widely used drug compounds in blood clotting experiments and is used to monitor and treat many diseases such as cancer, liver, lupus, and cardiovascular disease. The metalloproteinase domain is known as the active site of ecarin. In this study, an ecarin metalloproteinase cassette was designed and synthesized in the pUC57 vector. The gene fragment was released and cloned into the pET-28a vector and expressed in Escherichia coli. The recombinant protein was confirmed by western blotting. Enzyme activity was estimated by a laboratory coagulation test, and prothrombin time and tertiary structure were determined by using the Iterative Threading ASSEmbly Refinement (I-TASSER) server. Data from blood clotting tests for the produced ecarin activity were analyzed using an independent t test. As per I-TASSER server prediction, model 1 with the highest confidence score 0.95, template modeling score (0.84 ± 0.08), and root mean square deviation (3.5 ± 2.4 Å) was considered as the best model, and the 2e3xA enzyme was more similar to the target protein. The predictive results helped to better understand the relationship between the structure and function of the ecarin metalloproteinase domain. Also, the production of this active site in the prokaryotic expression system, which is simpler and more cost-effective than the production of the eukaryotic system, showed that this recombinant ecarin could be used as a substitute for the raw snake venom of Echis carinatus because it converts prothrombin into thrombin, and its activity, as estimated using the prothrombin time test, was found to be faster than normal ecarin.
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Affiliation(s)
- Nasrin Mohammadi
- Department of Biology, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Mojgan Bandehpour
- Cellular and Molecular Biology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Biotechnology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Bahram Kazemi
- Cellular and Molecular Biology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Department of Biotechnology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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16
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Siguret V, Boissier E, Maistre ED, Gouin-Thibault I, James C, Lasne D, Mouton C, Godon A, Nguyen P, Lecompte T, Ajzenberg N, Bauters A, Béjot Y, Crassard I, Dahmani B, Desconclois C, Flaujac C, Frère C, Godier A, Gruel Y, Hézard N, Jourdi G, Kuadjovi C, Laurichesse M, Mémier V, Mourey G, Reiner P, Tardy B, Toussaint-Hacquard M. GFHT Proposals On The Practical Use Of Argatroban - With Specifics Regarding Vaccine-Induced Immune Thrombotic Thrombocytopaenia (VITT). Anaesth Crit Care Pain Med 2021; 40:100963. [PMID: 34673303 DOI: 10.1016/j.accpm.2021.100963] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/01/2021] [Indexed: 11/29/2022]
Abstract
Argatroban is a direct anti-IIa (thrombin) anticoagulant, administered as a continuous intravenous infusion; it has been approved in many countries for the anticoagulant management of heparin-induced thrombocytopaenia (HIT). Argatroban was recently proposed as the non-heparin anticoagulant of choice for the management of patients diagnosed with Vaccine-induced Immune Thrombotic Thrombocytopaenia (VITT). Immunoglobulins are also promptly intravenously administered in order to rapidly improve platelet count; concomitant therapy with steroids is also often considered. An ad hoc committee of the French Working Group on Haemostasis and Thrombosis members has worked on updated and detailed proposals regarding the management of anticoagulation with argatroban, based on previously released guidance for HIT, and adapted for VITT. In case of VITT, the initial dose to be preferred is 1.0 µg x kg-1 x min-1, with further dose-adjustments based on iterative and frequent clinical and laboratory assessments. It is strongly advised to involve a health practitioner experienced in the management of difficult cases in haemostasis. The first laboratory assessment should be performed 4 hours after the initiation of argatroban infusion, with further controls at 2-4-hour intervals until steady state, and at least once daily thereafter. Importantly, full anticoagulation should be rapidly achieved in case of widespread thrombosis. Cerebral vein thrombosis (which is typical of VITT) should not call for an overly cautious anticoagulation scheme. Argatroban administration requires baseline laboratory assessment and should rely on an anti-IIa assay to derive argatroban plasma levels using a dedicated calibration, with a target range between 0.5 and 1.5 µg/mL. Target argatroban plasma levels can be refined based on meticulous appraisal of risk factors for bleeding and thrombosis, on frequent reassessments of clinical status with appropriate vascular imaging, and on the changes in daily platelet counts. Regarding the use of aPTT, baseline value and possible causes for alterations of the clotting time must be taken into account. Specifically, in case of VITT, an aPTT ratio (patient's / mean normal clotting time) between 1.5 and 2.5 is suggested, to be refined according to the sensitivity of the reagent to the effect of a direct thrombin inhibitor. The sole use of aPTT is discouraged: one has to resort to a periodical check with an anti-IIa assay at least, with the help of a specialised laboratory if necessary. Dose modifications should proceed in a stepwise manner with 0.1 to 0.2 µg x kg-1 x min-1 up- or downward changes, taking into account the initial dose, laboratory results, and the whole individual setting. Nomograms are available to adjust the infusion rate. Haemoglobin level, platelet count, fibrinogen plasma level and liver tests should be periodically checked, depending on the clinical status, the more so when unstable.
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Affiliation(s)
- Virginie Siguret
- Hématologie biologique - Hôpital Lariboisière (AP-HP), UMR_S1140, Université de Paris, Paris, France.
| | - Elodie Boissier
- Laboratoire d'hématologie, Hôpital Laënnec, CHU de Nantes, France
| | | | | | - Chloé James
- Laboratoire d'hématologie, CHU de Bordeaux, Pessac, France
| | - Dominique Lasne
- Hématologie biologique - Hôpital Necker-Enfants malades (AP-HP), Paris, UMR_S1176 Université Paris Saclay, Le Kremlin Bicêtre, France
| | | | | | | | - Thomas Lecompte
- Départements de médecine, Hôpitaux Universitaires de Genève, Unité d'hémostase, & Faculté de Médecine - GpG, Université de Genève, Genève, Suisse
| | | | - Anne Bauters
- Service d'hématologie et transfusion, Université de Lille, CHU de Lille, Lille, France
| | | | - Isabelle Crassard
- Neurologie, Hôpital Lariboisière (APHP), FHU NeuroVasculaire, Université de Paris, Paris, France
| | - Bouhadjar Dahmani
- Hémostase et Thrombose, Centre Hospitalier Princesse Grace de Monaco, Monaco
| | | | - Claire Flaujac
- Laboratoire de biologie médicale, secteur hémostase, CH de Versailles, Le Chesnay, France
| | - Corinne Frère
- Hématologie Biologique, Hôpital Pitié Salpêtrière (AP-HP); Sorbonne Université, UMRS 1166, Institut hospitalo-universitaire ICAN, Paris, France
| | - Anne Godier
- Département d'Anesthésie Réanimation, Hôpital Européen Georges Pompidou (AP-HP), Paris, France
| | - Yves Gruel
- Hématologie biologique, CHU Tours, Tours, France
| | | | - Georges Jourdi
- Centre de recherche, Institut de Cardiologie de Montréal, Faculté de Pharmacie, Université de Montréal, Canada
| | - Charlène Kuadjovi
- Laboratoire du GCS Nord-Ouest Val d'Oise, CH Pontoise, Pontoise, France
| | | | - Vincent Mémier
- Laboratoire d'Hématologie, CHU Toulouse, Toulouse, France
| | - Guillaume Mourey
- Laboratoire d'Hématologie et d'Immunologie, Établissement Français du Sang Bourgogne -Franche-Comté, Besançon, France
| | - Peggy Reiner
- Service d'hématologie et transfusion, Université de Lille, CHU de Lille, Lille, France
| | - Brigitte Tardy
- INSERM U1059, Université J Monnet, Saint Etienne, France
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17
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Abstract
From preoperative medications to intraoperative needs to postoperative thromboprophylaxis, anticoagulants are encountered throughout the perioperative period. This review focuses on coagulation testing clinicians utilize to monitor the effects of these medications.
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18
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Abstract
Snake venoms have evolved primarily to immobilize and kill prey, and consequently, they contain some of the most potent natural toxins. Part of that armory is a range of hemotoxic components that affect every area of hemostasis, which we have harnessed to great effect in the study and diagnosis of hemostatic disorders. The most widely used are those that affect coagulation, such as thrombin-like enzymes unaffected by heparin and direct thrombin inhibitors, which can help confirm or dispute their presence in plasma. The liquid gold of coagulation activators is Russell's viper venom, since it contains activators of factor X and factor V. It is used in a range of clotting-based assays, such as assessment of factor X and factor V deficiencies, protein C and protein S deficiencies, activated protein C resistance, and probably the most important test for lupus anticoagulants, the dilute Russell's viper venom time. Activators of prothrombin, such as oscutarin C from Coastal Taipan venom and ecarin from saw-scaled viper venom, are employed in prothrombin activity assays and lupus anticoagulant detection, and ecarin has a valuable role in quantitative assays of direct thrombin inhibitors. Snake venoms affecting primary hemostasis include botrocetin from the jararaca, which can be used to assay von Willebrand factor activity, and convulxin from the cascavel, which can be used to detect deficiency of the platelet collagen receptor, glycoprotein VI. This article takes the reader to every area of the diagnostic hemostasis laboratory to appreciate the myriad applications of snake venoms available in diagnostic practice.
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Affiliation(s)
- Gary William Moore
- Department of Haematology, Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,Faculty of Science and Technology, Middlesex University London, London, United Kingdom
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19
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Gardiner C, Coleman R, de Maat MPM, Dorgalaleh A, Echenagucia M, Gosselin RC, Ieko M, Kitchen S. International Council for Standardization in Haematology (ICSH) laboratory guidance for the verification of haemostasis analyser-reagent test systems. Part 2: Specialist tests and calibrated assays. Int J Lab Hematol 2021; 43:907-916. [PMID: 33876567 DOI: 10.1111/ijlh.13550] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 03/28/2021] [Accepted: 04/02/2021] [Indexed: 12/28/2022]
Abstract
Before a new method is used for clinical testing, it is essential that it is evaluated for suitability for its intended purpose. This document gives guidance for the performance, verification and implementation processes required by regulatory and accreditation bodies. It covers the planning and verification of specialist haemostatic tests, including factor assays, D-dimers, direct anticoagulants and thrombophilia testing.
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Affiliation(s)
- Chris Gardiner
- Haemostasis Research Unit, University College London, London, U.K
| | - Robyn Coleman
- Department of Haematology, Sullivan Nicolaides Pathology, Bowen Hills, QLD, Australia
| | - Moniek P M de Maat
- Department of Haematology, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Akbar Dorgalaleh
- Department of Hematology and Blood Transfusion, School of Allied Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Marión Echenagucia
- Centro Nacional de Hemofilia, Banco Municipal de Sangre del Distrito Capital, Caracas, Venezuela
| | - Robert C Gosselin
- Thrombosis and Hemostasis Center, University of California, Davis Health System, Sacramento, CA, USA
| | - Masahiro Ieko
- Department of Hematology/Clinical Laboratory, Iwate Prefectural Chubu Hospital, Kitakami, Japan
| | - Steve Kitchen
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, U.K
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20
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Douxfils J, Adcock DM, Bates SM, Favaloro EJ, Gouin-Thibault I, Guillermo C, Kawai Y, Lindhoff-Last E, Kitchen S, Gosselin RC. 2021 Update of the International Council for Standardization in Haematology Recommendations for Laboratory Measurement of Direct Oral Anticoagulants. Thromb Haemost 2021; 121:1008-1020. [PMID: 33742436 DOI: 10.1055/a-1450-8178] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 2018, the International Council for Standardization in Haematology (ICSH) published a consensus document providing guidance for laboratories on measuring direct oral anticoagulants (DOACs). Since that publication, several significant changes related to DOACs have occurred, including the approval of a new DOAC by the Food and Drug Administration, betrixaban, and a specific DOAC reversal agent intended for use when the reversal of anticoagulation with apixaban or rivaroxaban is needed due to life-threatening or uncontrolled bleeding, andexanet alfa. In addition, this ICSH Working Party recognized areas where additional information was warranted, including patient population considerations and updates in point-of-care testing. The information in this manuscript supplements our previous ICSH DOAC laboratory guidance document. The recommendations provided are based on (1) information from peer-reviewed publications about laboratory measurement of DOACs, (2) contributing author's personal experience/expert opinion and (3) good laboratory practice.
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Affiliation(s)
- Jonathan Douxfils
- Department of Pharmacy-Namur Thrombosis and Hemostasis Center, University of Namur, Namur, Belgium.,Qualiblood SA, Namur, Belgium
| | - Dorothy M Adcock
- Laboratory Corporation of America, Burlington North Carolina, United States
| | - Shannon M Bates
- Department of Medicine, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Haemostasis and Thrombosis, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
| | | | - Cecilia Guillermo
- Hospital de Clínicas "Dr Manuel Quintela," Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Yohko Kawai
- Sanno Hospital, Laboratory Medicine, Tokyo, Japan
| | - Edelgard Lindhoff-Last
- Cardiology Angiology Center Bethanien, CCB Vascular Center, CCB Coagulation Center, Frankfurt, Germany
| | - Steve Kitchen
- Royal Hallamshire Hospital, Coagulation Sheffield, South Yorks, United Kingdom
| | - Robert C Gosselin
- Hemophilia Treatment Center, University of California, Davis Health System, Sacramento, California, United States
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21
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Moore GW. Alternative assays to dRVVT and aPTT for lupus anticoagulant detection. Am J Hematol 2020; 95:992-998. [PMID: 32311119 DOI: 10.1002/ajh.25836] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/13/2020] [Indexed: 01/15/2023]
Abstract
Lupus anticoagulants (LA) are heterogeneous antibodies and no single assay will detect every LA. Consequently, testing is commonly undertaken with both dilute Russell's viper venom time (dRVVT) and LA-responsive activated partial thromboplastin time (aPTT) to maximize detection rates. Although a huge body of evidence attests to the diagnostic utility of these assays, they have limitations that can render them unreliable in certain circumstances. Other assays are available for detecting LA but unfamiliarity, variable availability and technical concerns expressed in guidelines contribute to less usage than dRVVT and aPTT. However, assays such as Taipan snake venom time and Textarin time are insensitive to anticoagulants that compromise dRVVT and aPTT, and assays such as dilute prothrombin time can detect LA unreactive in dRVVT and aPTT. The pros and cons of alternative assays to dRVVT and APTT for LA detection are discussed.
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Affiliation(s)
- Gary W. Moore
- Specialist Haemostasis UnitAddenbrooke's Hospital Cambridge UK
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