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Taune VS, Zabczyk M, He S, Ågren A, Blombäck M, Wallén H, Skeppholm M. Effects of dabigatran, rivaroxaban, and apixaban on fibrin network permeability, thrombin generation, and fibrinolysis. Scand J Clin Lab Invest 2024:1-11. [PMID: 38953609 DOI: 10.1080/00365513.2024.2369993] [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: 12/05/2023] [Accepted: 06/16/2024] [Indexed: 07/04/2024]
Abstract
INTRODUCTION There are important pharmacological differences between direct oral anticoagulants (DOAC) and a deeper knowledge of how they influence different aspects of hemostasis in patients on treatment is desirable. MATERIALS AND METHODS Blood samples from patients on dabigatran (n = 23), rivaroxaban (n = 26), or apixaban (n = 20) were analyzed with a fibrin network permeability assay, a turbidimetric clotting and lysis assay, the calibrated automated thrombogram (CAT), plasma levels of thrombin-antithrombin complex (TAT) and D-dimer, as well as DOAC concentrations, PT-INR and aPTT. As a comparison, we also analyzed samples from 27 patients on treatment with warfarin. RESULTS Patients on dabigatran had a more permeable fibrin network, longer lag time (CAT and turbidimetric assay), and lower levels of D-dimer in plasma, compared with patients on rivaroxaban- and apixaban treatment, and a more permeable fibrin network than patients on warfarin. Clot lysis time was slightly longer in patients on dabigatran than in patients on rivaroxaban. Warfarin patients formed a more permeable fibrin network than patients on apixaban, had longer lag time than patients on rivaroxaban (CAT assay), and lower peak thrombin and ETP compared to patients on treatment with both FXa-inhibitors. CONCLUSIONS Results from this study indicate dabigatran treatment is a more potent anticoagulant than apixaban and rivaroxaban. However, as these results are not supported by clinical data, they are probably more related to the assays used and highlight the difficulty of measuring and comparing the effect of anticoagulants.
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Affiliation(s)
- Viktor Schutz Taune
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Michal Zabczyk
- Department of Thromboembolic Disorders, Institute of Cardiology, Medical College, John Paul II Hospital, Jagiellonian University, Kraków, Poland
| | - Shu He
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Anna Ågren
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
- Department of Molecular Medicine & Surgery (Coagulation), Karolinska Institutet, Stockholm, Sweden
| | - Margareta Blombäck
- Department of Molecular Medicine & Surgery (Coagulation), Karolinska Institutet, Stockholm, Sweden
| | - Håkan Wallén
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Mika Skeppholm
- Division of Cardiovascular Medicine, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
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2
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Tripodi A, Scalambrino E, Clerici M, Peyvandi F. Laboratory Diagnosis of Antiphospholipid Syndrome in Anticoagulated Patients. Biomedicines 2023; 11:1760. [PMID: 37371855 DOI: 10.3390/biomedicines11061760] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/06/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
The laboratory diagnosis of antiphospholipid syndrome (APS) requires the measurement of solid-phase antibodies to cardiolipin or β2-Glycoprotein-I and the search for lupus anticoagulant (LA). The diagnosis of patients whilst on anticoagulation is impaired by the difficult interpretation of results, at least for LA, owing to the fact that prolongations of clotting times induced by LA superimpose those induced by anticoagulants. This is a matter of concern as treating physicians very often need to know the APS status of their patients to make a decision on secondary antithrombotic prophylaxis. This article aims to review the effect brought about by anticoagulants on APS diagnosis and discuss the options that can be used to overcome such an effect.
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Affiliation(s)
- Armando Tripodi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
- Fondazione Luigi Villa, 20122 Milano, Italy
| | - Erica Scalambrino
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
| | - Marigrazia Clerici
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, 20122 Milano, Italy
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3
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Shaw JR, Castellucci LA, Siegal D, Carrier M. DOAC-associated bleeding, hemostatic strategies, and thrombin generation assays - a review of the literature. J Thromb Haemost 2023; 21:433-452. [PMID: 36696204 DOI: 10.1016/j.jtha.2022.11.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/24/2022] [Accepted: 11/15/2022] [Indexed: 01/26/2023]
Abstract
Direct oral anticoagulants (DOACs) account for most oral anticoagulant use. DOAC-associated bleeding events are commonly encountered in clinical practice and are associated with substantial morbidity and mortality. Both specific reversal agents and nonspecific hemostatic therapies, such as prothrombin complex concentrates, are used in the management of DOAC-associated bleeding. Measuring hemostatic efficacy and demonstrating a clinical impact from these therapies among studies of bleeding patients is challenging. Thrombin generation assays provide information on the total hemostatic potential of plasma, and have emerged as a promising modality to both measure the impact of DOACs on coagulation and to evaluate the effects of hemostatic therapies among patients with DOAC-associated bleeding. The mechanisms by which nonspecific hemostatic agents impact coagulation and thrombin generation in the context of DOAC therapy are unclear. As a result, we undertook a review of the literature using a systematic search strategy with the goal of summarizing the effects of DOACs on thrombin generation and the effects of both specific reversal agents and nonspecific hemostatic therapies on DOAC-altered thrombin generation parameters. We sought to identify clinical studies focusing on whether altered thrombin generation is associated with clinical bleeding and whether correction of altered thrombin generation parameters predicts improvements in clinical hemostasis. Lastly, we sought to outline future directions for the application of thrombin generation assays toward anticoagulation therapies and the question of anticoagulation reversal.
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Affiliation(s)
- Joseph R Shaw
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Lana A Castellucci
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - Deborah Siegal
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Carrier
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
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4
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Wang J, Lim HY, Nandurkar H, Ho P. DOAC-stop can remove direct oral anticoagulants and allow analysis by global coagulation assays. Int J Lab Hematol 2023; 45:360-367. [PMID: 36691357 DOI: 10.1111/ijlh.14020] [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: 07/26/2022] [Accepted: 12/23/2022] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Activated charcoal based compounds such as DOAC-stop™ (DS) have been developed to remove direct oral anticoagulant (DOAC) interference in-vitro. However, few studies have used this approach with global coagulation assays (GCAs), such as thrombin generation assays, which are sensitive to the effect of DOACs. METHODS Thrombin generation with and without thrombomodulin (TM) via the automated ST-Genesia system, and the overall haemostatic potential (OHP) assay, a spectrophotometric fibrin generation assay in which fibrin formation (triggered by small amounts of thrombin (overall coagulation potential, OCP)) and fibrinolysis (by the addition of thrombin and tissue plasminogen activator) were measured on (i) pooled normal plasma (PNP) spiked with varying amounts of rivaroxaban, apixaban, and dabigatran, and (ii) platelet poor plasma (PPP) from 21 non-anticoagulated adults, before and after DS addition. RESULTS Following the addition of DS to spiked PNP without thrombomodulin, thrombin and velocity index increased by 21.9% and 42.6%, respectively, while ETP increased by 6.93%. A decrease in OCP (-10.6%) and OHP (-12.7%) was observed following DS. Similar changes were seen post-DS to plasma from non-anticoagulated patients. Also in this group, pre- and post-DS thrombin generation parameters showed high correlation, with the strongest observed for ETP (R2 = 0.94). There was a strong correlation for OHP parameters, with the closest seen with OCP (R2 = 0.96) and OHP (R2 = 0.95). CONCLUSION DS causes some changes to the ETP and OHP assay, however, strong correlations were seen pre- and post-DS in all GCA parameters. These findings support the use of DS to facilitate GCA testing in anticoagulated individuals for evaluation of the underlying thrombotic state.
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Affiliation(s)
- Julie Wang
- School of Medicine, Northern Health, Melbourne, Victoria, Australia.,Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia.,Department of Medicine (Northern Health), University of Melbourne, Melbourne, Victoria, Australia
| | - Hui Yin Lim
- School of Medicine, Northern Health, Melbourne, Victoria, Australia.,Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia.,Department of Medicine (Northern Health), University of Melbourne, Melbourne, Victoria, Australia
| | - Harshal Nandurkar
- Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia
| | - Prahlad Ho
- School of Medicine, Northern Health, Melbourne, Victoria, Australia.,Australian Centre for Blood Diseases, Monash University, Melbourne, Victoria, Australia.,Department of Medicine (Northern Health), University of Melbourne, Melbourne, Victoria, Australia
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5
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Novel Ex Vivo DOAC Removal Methods Reduce Interference in Lupus Anticoagulant Testing. Diagnostics (Basel) 2022; 12:diagnostics12102520. [PMID: 36292209 PMCID: PMC9601296 DOI: 10.3390/diagnostics12102520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/09/2022] [Accepted: 10/14/2022] [Indexed: 11/22/2022] Open
Abstract
Direct oral anticoagulants (DOAC) interfere in laboratory coagulation testing. The aim here was to study how commercial DOAC removal methods, DOAC Filter® and DOAC-Stop™, perform to eliminate DOAC concentrations and false positive results in lupus anticoagulant (LAC) testing. We acquired 50 patient samples with high concentrations of DOACs: apixaban (n = 18, range 68–572 ng/mL), dabigatran (n = 8, range 47–154 ng/mL), edoxaban (n = 8, range 35–580 ng/mL) and rivaroxaban (n = 16, range 69–285 ng/mL). DOACs were removed ex vivo with either DOAC Filter® (n = 28) or DOAC-Stop™ (n = 22). Additionally, commercial control and calibrator samples were studied (n = 13 for DOAC Filter®, n = 14 for DOAC-Stop™). LAC screening was performed before and after DOAC removal. Both DOAC Filter® and DOAC-Stop™ were effective in removing DOAC concentrations in samples: DOAC concentrations decreased to median of 0 ng/mL (range 0–48 ng/mL). Only one sample had more than residual 25 ng/mL of DOAC (apixaban). Before DOAC removal, 96% (48/50) of patient samples and over 90% (12/13 DOAC Filter®, 13/14 DOAC-Stop™) of control/calibrator samples were positive in the LAC screening. In patient samples, LAC screening turned negative in 61% (17/28) after DOAC Filter® and 45% (10/22) after DOAC-Stop™ treatment. All control samples became negative after DOAC removal. In conclusion, DOAC removal ex vivo reduces false positives in LAC screening. DOAC removal halved the need for confirmation or mixing tests- Although a subset of patients would require further testing, DOAC removal reduces unnecessary repeated LAC testing.
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6
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Morimont L, Donis N, Bouvy C, Mullier F, Dogné JM, Douxfils J. Laboratory Testing for the Evaluation of Phenotypic Activated Protein C Resistance. Semin Thromb Hemost 2022. [PMID: 36063850 DOI: 10.1055/s-0042-1757136] [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
Activated protein C (APC) resistance (APCR) is considered a risk factor of venous thromboembolism (VTE). The most common genetic disorder conferring APCR is a factor (F) V Leiden mutation, but many other factors are also implicated, such as other F5 mutations (e.g., FV Hong-Kong and FV Cambridge), protein S deficiency, elevated factor VIII, exogenous hormone use, pregnancy and postpartum, depending on how APCR is defined. Considering the large population affected, the detection of this phenotype is crucial. Two types of tests are currently available: clotting time-based assays (with several versions) and thrombin generation-based assays with the endogenous thrombin potential (ETP)-based assay. The purpose of this review is therefore to discuss the performances of these tests and the cases in which it would be appropriate to use one over the other. Initially, as APCR was thought to be solely related to the FV Leiden mutation, the objective was to obtain a 100% specific assay. Clotting-time based assays were thus specifically designed to detect this inherited condition. Later on, an APCR condition without a FV Leiden mutation was identified and highlighted as an independent risk factor of VTE. Therefore, the development of a less specific assay was needed and a global coagulation test was proposed, known as the ETP-based APCR assay. In light of the above, these tests should not be used for the same purpose. Clotting time-based assays should only be recommended as a screening test for the detection of FV mutations prior to confirmation by genetic testing. On the other hand, the ETP-based APC resistance assay, in addition to being able to detect any type of APCR, could be proposed as a global screening test as it assesses the entire coagulation process.
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Affiliation(s)
- Laure Morimont
- Department of Research, Qualiblood Sa, Namur, Belgium.,Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | | | - Céline Bouvy
- Department of Research, Qualiblood Sa, Namur, Belgium
| | - François Mullier
- Hematology Laboratory, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Department of Research, Qualiblood Sa, Namur, Belgium.,Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
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7
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Morimont L, Donis N, Bouvy C, Mullier F, Dogné JM, Douxfils J. Laboratory Testing for the Evaluation of Phenotypic Activated Protein C Resistance. Semin Thromb Hemost 2022; 48:680-689. [PMID: 36055270 DOI: 10.1055/s-0042-1753511] [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
Activated protein C (APC) resistance (APCR) is considered a risk factor of venous thromboembolism (VTE). The most common genetic disorder conferring APCR is a factor (F) V Leiden mutation, but many other factors are also implicated, such as other F5 mutations (e.g., FV Hong-Kong and FV Cambridge), protein S deficiency, elevated factor VIII, exogenous hormone use, pregnancy and postpartum, depending on how APCR is defined. Considering the large population affected, the detection of this phenotype is crucial. Two types of tests are currently available: clotting time-based assays (with several versions) and thrombin generation-based assays with the endogenous thrombin potential (ETP)-based assay. The purpose of this review is therefore to discuss the performances of these tests and the cases in which it would be appropriate to use one over the other. Initially, as APCR was thought to be solely related to the FV Leiden mutation, the objective was to obtain a 100% specific assay. Clotting-time based assays were thus specifically designed to detect this inherited condition. Later on, an APCR condition without a FV Leiden mutation was identified and highlighted as an independent risk factor of VTE. Therefore, the development of a less specific assay was needed and a global coagulation test was proposed, known as the ETP-based APCR assay. In light of the above, these tests should not be used for the same purpose. Clotting time-based assays should only be recommended as a screening test for the detection of FV mutations prior to confirmation by genetic testing. On the other hand, the ETP-based APC resistance assay, in addition to being able to detect any type of APCR, could be proposed as a global screening test as it assesses the entire coagulation process.
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Affiliation(s)
- Laure Morimont
- Department of Research, Qualiblood Sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | | | - Céline Bouvy
- Department of Research, Qualiblood Sa, Namur, Belgium
| | - François Mullier
- Hematology Laboratory, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Department of Research, Qualiblood Sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
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8
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Morimont L, Donis N, Bouvy C, Mullier F, Dogné JM, Douxfils J. Laboratory Testing for the Evaluation of Phenotypic Activated Protein C Resistance. Semin Thromb Hemost 2022; 48:680-689. [DOI: 10.1055/s-0042-1758162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractActivated protein C (APC) resistance (APCR) is considered a risk factor of venous thromboembolism (VTE). The most common genetic disorder conferring APCR is a factor (F) V Leiden mutation, but many other factors are also implicated, such as other F5 mutations (e.g., FV Hong-Kong and FV Cambridge), protein S deficiency, elevated factor VIII, exogenous hormone use, pregnancy and postpartum, depending on how APCR is defined. Considering the large population affected, the detection of this phenotype is crucial. Two types of tests are currently available: clotting time-based assays (with several versions) and thrombin generation-based assays with the endogenous thrombin potential (ETP)-based assay. The purpose of this review is therefore to discuss the performances of these tests and the cases in which it would be appropriate to use one over the other. Initially, as APCR was thought to be solely related to the FV Leiden mutation, the objective was to obtain a 100% specific assay. Clotting-time based assays were thus specifically designed to detect this inherited condition. Later on, an APCR condition without a FV Leiden mutation was identified and highlighted as an independent risk factor of VTE. Therefore, the development of a less specific assay was needed and a global coagulation test was proposed, known as the ETP-based APCR assay. In light of the above, these tests should not be used for the same purpose. Clotting time-based assays should only be recommended as a screening test for the detection of FV mutations prior to confirmation by genetic testing. On the other hand, the ETP-based APC resistance assay, in addition to being able to detect any type of APCR, could be proposed as a global screening test as it assesses the entire coagulation process.
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Affiliation(s)
- Laure Morimont
- Department of Research, Qualiblood Sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | | | - Céline Bouvy
- Department of Research, Qualiblood Sa, Namur, Belgium
| | - François Mullier
- Hematology Laboratory, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Department of Research, Qualiblood Sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
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Taune V, Skeppholm M, Ågren A, Wikman A, Hillarp A, Wallén H. Rapid Detection of Apixaban by a ROTEM-Based Approach and Reversibility with Andexanet Alfa or DOAC-Stop. TH OPEN 2022; 6:e238-e247. [PMID: 36046206 PMCID: PMC9423941 DOI: 10.1055/s-0042-1751072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/09/2022] [Indexed: 11/04/2022] Open
Abstract
Background
A rapid test to detect apixaban treatment would be useful in acute situations such as major bleeding, urgent surgery, or in acute thrombosis.
Objective
This article aims to study if the viscoelastic test rotational thromboelastometry (ROTEM) can rapidly detect apixaban in whole blood using modified triggers based on factor Xa (FXa) or Russell viper venom (RVV).
Method
ROTEM clotting time (CT) was measured in samples from 40 patients on apixaban treatment, and in vitro in samples spiked with apixaban (20–500 ng/mL). Commercially available trigger Ex-tem was compared with modified triggers based on FXa or RVV. Reversibility of apixaban in the samples was studied; CT was measured with and without addition of DOAC-Stop or andexanet alfa, respectively, and the difference in CT was calculated (CT
diff
).
Results
Using FXa as trigger, we detected apixaban concentrations at 20 ng/mL and above with 100% sensitivity and 100% specificity in patient samples and in vitro. Corresponding data for Ex-tem were 92% sensitivity and 100% specificity in patients, and 94% sensitivity and 100% specificity in vitro, and for RVV 97% sensitivity and 94% specificity in patients, and 97% sensitivity and 100% specificity in vitro, respectively. CT
diff
data were similar. Patient sample data were obtained within 20 minutes from sampling.
Conclusion
Apixaban at low therapeutic concentrations was detected within 20 minutes, and with high sensitivity and specificity. A trigger based on FXa outperformed the commercial trigger Ex-tem and a trigger based on RVV. ROTEM with a FXa-based trigger is a promising method to detect apixaban bedside in acute settings.
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Affiliation(s)
- Viktor Taune
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Mika Skeppholm
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anna Ågren
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Agneta Wikman
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska University Hospital, Stockholm, Sweden; Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Hillarp
- Department of Translational Medicine, Clinical Chemistry Malmö, Lund University, Malmö, Sweden
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Håkan Wallén
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Sweden
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Linskens EA, De Kesel P, Devreese KMJ. Direct Oral Anticoagulant removal by a DOAC filter: Impact on lupus anticoagulant testing – Evaluation on spiked and patient samples. Res Pract Thromb Haemost 2022; 6:e12633. [PMID: 35341071 PMCID: PMC8935533 DOI: 10.1002/rth2.12633] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/01/2021] [Accepted: 10/19/2021] [Indexed: 12/13/2022] Open
Abstract
Background DOAC Filter (DF) is a new device to overcome interference in lupus anticoagulant (LAC) testing by direct oral anticoagulants (DOACs). Objectives We evaluated DOAC removal from plasma and elimination of DOAC interference in LAC testing by DF, and impact of DF on LAC assays in a representative patient cohort, including a comparison with DOAC‐Stop (DS). Methods Normal pooled plasma (NPP) was spiked with increasing concentrations of apixaban, rivaroxaban, edoxaban, and dabigatran. DOAC and LAC was measured on untreated, DF‐treated, and DS‐treated spiked samples. Coagulation parameters and thrombin generation were measured on patient samples (n = 20) before and after DF. Patients treated with DOAC, vitamin K antagonist, or heparin and nonanticoagulated patient samples (n = 139) were tested for LAC before and after DF. Results In spiked NPP, levels were below the lower limit of quantification (LLoQ) after DF/DS treatment for all DOAC concentrations. Following DF, levels were below LLoQ for 53 of 56 DOAC‐containing patient samples. Twenty‐eight of 33 LAC‐positive DOAC‐containing samples became negative after filtration, whereas 5 remained LAC‐positive (1/5 from a patient with antiphospholipid syndrome [APS]). Four LAC‐positive DOAC‐containing samples (from patients without APS), became negative after filtration, whereas they remained LAC positive after DS. In the non‐DOAC patient groups following DF, LAC changed from positive to negative in 8 (due to a procoagulant effect) and vice versa in 2 cases. Conclusion DF reduces DOAC interference in LAC testing. As incomplete DOAC removal may occur, DOAC measurements should be performed after filtration. A procoagulant effect after filtration may lead to erroneous LAC results in non–DOAC‐containing samples. Therefore, using DF should be restricted to DOAC‐containing samples.
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Affiliation(s)
- Eleni A. Linskens
- Coagulation Laboratory Department of Laboratory Medicine Ghent University Hospital Ghent Belgium
| | - Pieter De Kesel
- Coagulation Laboratory Department of Laboratory Medicine Ghent University Hospital 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
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11
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Favaloro EJ, Pasalic L. Lupus anticoagulant testing during anticoagulation, including direct oral anticoagulants. Res Pract Thromb Haemost 2022; 6:e12676. [PMID: 35316943 PMCID: PMC8922544 DOI: 10.1002/rth2.12676] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 01/27/2022] [Accepted: 02/06/2022] [Indexed: 12/23/2022] Open
Abstract
Background Lupus anticoagulants (LA) are one laboratory criterion for classification of antiphospholipid syndrome, with presence of vascular thrombosis and/or pregnancy/fetal morbidity being clinical criteria. The presence of LA is detected (or excluded) by laboratory testing, with the activated partial thromboplastin time and dilute Russell's viper venom time the most commonly used tests. Given the association of thrombosis with LA, it is no surprise that anticoagulants are used to treat or manage such patients. Objectives To review and discuss interferences from anticoagulants on LA testing, and strategies to mitigate these. Methods This narrative review assessed interference from commonly used anticoagulants, focusing on LA testing while on direct oral anticoagulants (DOACs), including use of DOAC neutralizers. Results The classical anticoagulants comprise vitamin K antagonists such as warfarin, and heparins, predominantly unfractionated heparin and low molecular weight heparin (LMWH). DOACs have emerged with favorable efficacy and safety. These comprise two classes: direct anti‐thrombin (anti‐IIa; dabigatran) or direct anti‐Xa (rivaroxaban, apixaban, edoxaban) agents. All anticoagulants affect clotting assays, although there are differences in effects according to anticoagulant and assay. Nevertheless, because of such interferences, anticoagulants can lead to false‐negative or false‐positive LA findings. Several strategies can mitigate such interferences, including avoidance of testing while patients are on such anticoagulants, temporarily switching to an anticoagulant (i.e., LMWH) with less assay interference, testing for LA at nadir levels of anticoagulants, and/or use of anticoagulant neutralizers. Conclusion Whilst the best approach is to avoid LA testing on patients taking anticoagulants; if unavoidable, testing may be facilitated by various mitigating strategies.
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Affiliation(s)
- Emmanuel J. Favaloro
- Department of Haematology Institute of Clinical Pathology and Medical Research (ICPMR) NSW Health Pathology Westmead Hospital Westmead New South Wales Australia
- Sydney Centres for Thrombosis and Haemostasis Westmead New South Wales Australia
- Faculty of Science and Health Charles Sturt University Wagga Wagga New South Wales Australia
| | - Leonardo Pasalic
- Department of Haematology Institute of Clinical Pathology and Medical Research (ICPMR) NSW Health Pathology Westmead Hospital Westmead New South Wales Australia
- Sydney Centres for Thrombosis and Haemostasis Westmead New South Wales Australia
- Sydney University Westmead New South Wales Australia
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12
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Skaugen JM, Sayre C, Hassett AC, Chibisov I, Bontempo F, Meyer MP, Seheult JN. Performance Characteristics of DOAC-Remove for Neutralization of the Effects of Apixaban and Rivaroxaban in Lupus Anticoagulant Assays. Am J Clin Pathol 2022; 157:457-469. [PMID: 34698336 DOI: 10.1093/ajcp/aqab149] [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: 02/23/2021] [Accepted: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study established the performance characteristics of DOAC-Remove for neutralization of the effects of rivaroxaban and apixaban in lupus anticoagulant (LAC) testing. METHODS Normal donor, LAC control, and patient samples were spiked with rivaroxaban or apixaban to simulate their effects on the dilute Russell's viper venom time (dRVVT), activated partial thromboplastin time (APTT), and dilute prothrombin time (dPT). Anti-Xa activity was measured after spiking and after DOAC-Remove neutralization. Accuracy, complex precision, and reference interval verification were evaluated. RESULTS DOAC-Remove neutralized rivaroxaban and apixaban concentrations as high as 415 ng/mL and 333 ng/mL, respectively. Percentage positive and negative agreement between the baseline and postneutralization interpretations were 75% or higher for the dRVVT and APTT methods but not for the dPT method. Coefficients of variation (CVs) were 10% or less for all assays except the Staclot-LA delta, which had a standard deviation of 2.5 seconds or CV of 25% or less depending on the level. The laboratory's reference intervals were verified for the dRVVT and APTT assays after DOAC-Remove treatment but not for the dPT assays. CONCLUSIONS DOAC-Remove appears to have acceptable performance characteristics for neutralizing the effects of rivaroxaban and apixaban in the dRVVT and APTT methods but not in the dPT method.
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Affiliation(s)
- John M Skaugen
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | - Irina Chibisov
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Vitalant Coagulation Laboratory, Pittsburgh, PA, USA
| | - Franklin Bontempo
- Vitalant Coagulation Laboratory, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Jansen N Seheult
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Vitalant Coagulation Laboratory, Pittsburgh, PA, USA
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13
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Lu S, Huerman N, Li M, Ding Q, Song Y, Xu Q, Rong J, Xu J, Liu C. Evaluation of Activated Carbon Treatment on Overcoming the Interference of Rivaroxaban on the Detection of Functional Lupus Anticoagulant. Acta Haematol 2022; 145:430-439. [PMID: 35100578 DOI: 10.1159/000522324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/28/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To study the role of activated carbon in eliminating the interference of rivaroxaban in the detection of lupus anticoagulants (LA). METHODS Normal pooled plasma (NPP) was obtained as Group N1, and Group N2 took 1ml plasma from N1 and added activated carbon; Group N3 was prepared by mixing normal plasma with rivaroxaban, and Group N3 was treated with activated carbon according to our procedure, as Group N4. Plasma from 22 patients was collected before and 6-12 hours after rivaroxaban therapy, described as group P1 and group P2 respectively, and 1ml plasma was taken from Group P2 and treated with activated carbon, as Group P3. Anti-Xa and dRVVT / SCT index in each group were measured and compared. RESULTS Rivaroxaban concentrations and anti-Xa had high intercorrelations in Groups N3, and the levels of Anti-Xa and dRVVT / SCT index had high intercorrelations. After treatment with activated carbon, influence of rivaroxaban was removed, with lupus anticoagulant and coagulation factor assays not influenced. Rivaroxaban administration could affect lupus anticoagulant assay results in patients, with all LA results increased. After treatment with activated carbon, results of Anti-Xa and lupus anticoagulant tests recovered to the level before rivaroxaban therapy. CONCLUSIONS We proposed a reference procedure for the LA detection of patients using rivaroxaban by activated carbon, and activated carbon was proven to be a simple product to eliminate the interference of rivaroxaban.
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Affiliation(s)
- Songsong Lu
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Nurzat Huerman
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Meng Li
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Qingming Ding
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Ying Song
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Qinzhu Xu
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Jiang Rong
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Jian Xu
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Chen Liu
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
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14
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Moser KA. Direct oral anticoagulant (DOAC) interference in hemostasis assays. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:129-133. [PMID: 34889400 PMCID: PMC8791165 DOI: 10.1182/hematology.2021000241] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Direct oral anticoagulants (DOACs) are a group of direct coagulation factor inhibitors including both direct thrombin inhibitors and direct factor Xa inhibitors. These medications may cause hemostasis assay interference by falsely increasing or decreasing measured values, depending on the analyte. Considering the potential for DOAC interference in a variety of hemostasis assays is essential to avoid erroneous interpretation of results. Preanalytic strategies to avoid DOAC interference include selecting alternatives to clot-based hemostasis assays in patients taking DOACs when possible and sample collection timed when the patient is off anticoagulant therapy or at the expected drug trough. Clinical laboratories may also provide educational materials that clearly describe possible interferences from DOAC, develop testing algorithms to aid in detection of DOAC in submitted samples, use DOAC-neutralizing agents to remove DOACs before continuing with testing, and write interpretive comments that explain the effects of DOAC interference in hemostasis tests. Using a combination of the described strategies will aid physicians and laboratorians in correctly interpreting hemostasis and thrombosis laboratory tests in the presence of DOACs.
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Affiliation(s)
- Karen A. Moser
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT
- Correspondence Karen A. Moser, ARUP Laboratories, 500 Chipeta Way, Mail Stop 115-G04, Salt Lake City, UT 84108; e-mail:
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15
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Abstract
Venous thromboembolism (VTE) is increasingly recognised in primary and secondary care practice. The arrival of direct oral anticoagulants (DOACs) has made the management of VTE easier and more convenient. Some patients established on DOACs may need screening for underlying thrombophilias as certain thrombophilic conditions are known to confer a higher thrombosis risk, although the guidelines for when and how to test for a thrombophilia, especially in a patient taking a DOAC, are unclear. This literature review aims to examine when thrombophilia screening should take place in a patient already taking a DOAC, the effect of DOACs on thrombophilia tests, and analyse whether DOACs are safe and effective in both inherited and acquired thrombophilias.
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Affiliation(s)
- Jennifer Darlow
- Manchester Royal Infirmary, Manchester, UK; equal first authors.
| | - Holly Mould
- University of Manchester, Manchester, UK; equal first authors
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16
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Impact of a commercially available DOAC absorbent on two integrated procedures for lupus anticoagulant detection. Thromb Res 2021; 204:32-39. [PMID: 34126321 DOI: 10.1016/j.thromres.2021.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 05/28/2021] [Accepted: 06/02/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Lupus anticoagulant (LA)-detection in anticoagulated patients is an unmet need, which becomes even more cogent with the introduction of direct oral anticoagulants (DOAC) that may lead to false-positive results. AIMS We aimed to investigate the effect of a commercially available DOAC absorbent on residual drug concentrations, and on integrated procedures for LA-detection. METHODS Blood from patients treated for atrial fibrillation with either dabigatran (n = 39), rivaroxaban (n = 55), apixaban (n = 47) or edoxaban (n = 47) were collected at peak and trough, and centralized for testing with two LA integrated procedures [i.e., the silica clotting time (SCT) and dilute Russel viper venom (dRVVT)] before and after DOAC absorbent exposure. RESULTS The commercially available DOAC absorbent investigated in this study proved effective in reducing the concentrations of all the investigated DOAC, although small residual drug was detected after absorption, especially in patients on edoxaban. Results mimicking LA were observed in patients on DOAC before absorbent exposure, especially for rivaroxaban when testing was performed with dRVVT (88% rate at peak and 20% at trough) and much less with SCT (12% at peak and 8% at trough). The correspondent rate of results mimicking LA in patients on rivaroxaban after exposure was reduced [dRVVT (peak 8%, trough 4%); SCT (peak and trough 8%)], but not abolished. CONCLUSIONS Overall, in vitro DOAC absorbance by active charcoal compounds is a useful laboratory tool for LA-detection in patients on DOAC. Caution should however be exerted when used in daily practice.
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17
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Farkh C, Ellouze S, Gounelle L, Sad Houari M, Duchemin J, Proulle V, Fontenay M, Delavenne X, Jourdi G. A Diagnostic Solution for Lupus Anticoagulant Testing in Patients Taking Direct Oral FXa Inhibitors Using DOAC Filter. Front Med (Lausanne) 2021; 8:683357. [PMID: 34136510 PMCID: PMC8200390 DOI: 10.3389/fmed.2021.683357] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 04/19/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Direct oral factor Xa (FXa) inhibitors interfere with lupus anticoagulant (LA) assays challenging antiphospholipid syndrome diagnosis in treated patients. We evaluated a new device, called DOAC Filter, and its usefulness in this setting. It is a single-use filtration cartridge in which FXa inhibitor compounds are trapped by non-covalent binding while plasma is filtered through a solid phase. Patient samples were analyzed before and after filtration: 38 rivaroxaban, 41 apixaban, and 68 none. Anticoagulant plasma concentrations were measured using specific anti-Xa assays and HPLC-MS/MS. LA testing was performed using dilute Russell Viper Venom Time (dRVVT) and Silica Clotting Time (SCT). Baseline median [min-max] concentrations were 64.8 [17.6; 311.4] for rivaroxaban and 92.1 ng/mL [37.1; 390.7] for apixaban (HPLC-MS/MS). They were significantly correlated with anti-Xa assay results (r = 0.98 and r = 0.94, respectively). dRVVT was positive in 92% rivaroxaban and 72% apixaban and SCT in 28 and 41% of samples, respectively. Post-filtration, median % of neutralization was 100% with rivaroxaban and apixaban concentrations of, respectively, <2 [<2-2.4] and <2 ng/mL [<2-9.6] using HPLC-MS/MS. No significant effect of DOAC Filter was observed on LA testing in controls (n = 31) and LA-positive (n = 37) non-anticoagulated samples. dRVVT and SCT remained positive in, respectively, 16 and 8% of rivaroxaban and 41 and 18% of apixaban samples. DOAC Filter would be an easy-to-use device allowing FXa inhibitor removal from plasma samples, limiting their interference with LA testing in treated patients.
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Affiliation(s)
- Carine Farkh
- Service d'Hématologie Biologique, AP-HP, Center-Université de Paris, Hôpital Cochin, Paris, France
| | - Syrine Ellouze
- Service d'Hématologie Biologique, AP-HP, Center-Université de Paris, Hôpital Cochin, Paris, France
| | - Louis Gounelle
- Service d'Hématologie Biologique, AP-HP, Center-Université de Paris, Hôpital Cochin, Paris, France
| | - Mama Sad Houari
- Service d'Hématologie Biologique, AP-HP, Center-Université de Paris, Hôpital Cochin, Paris, France
| | - Jérôme Duchemin
- Service d'Hématologie Biologique, AP-HP, Center-Université de Paris, Hôpital Cochin, Paris, France
| | - Valérie Proulle
- Service d'Hématologie Biologique, AP-HP, Center-Université de Paris, Hôpital Cochin, Paris, France
| | - Michaela Fontenay
- Service d'Hématologie Biologique, AP-HP, Center-Université de Paris, Hôpital Cochin, Paris, France.,Institut Cochin, CNRS UMR8104, INSERM U1016, Université De Paris, Paris, France
| | - Xavier Delavenne
- Institut National de la Santé et de la Recherche Médicale U1059, Dysfonctions Vasculaires et de L'Hémostase, Université de Lyon, Saint-Étienne, France.,Laboratoire de Pharmacologie, Toxicologie, Gaz du Sang, CHU de Saint-Etienne, Saint-Étienne, France
| | - Georges Jourdi
- Service d'Hématologie Biologique, AP-HP, Center-Université de Paris, Hôpital Cochin, Paris, France.,Université de Paris, Innovative Therapies in Haemostasis, Inserm UMR_S1140, Paris, France.,Faculté de Pharmacie, Université de Montréal, Montreal, QC, Canada.,Center de Recherche de L'Institut de Cardiologie de Montréal, Montreal, QC, Canada
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18
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Douxfils J, Adcock DM, Bates SM, Favaloro EJ, Gouin-Thibault I, Guillermo C, Kawai Y, Lindhoff-Last E, Kitchen S, Gosselin RC. 2021 Update of the International Council for Standardization in Haematology Recommendations for Laboratory Measurement of Direct Oral Anticoagulants. Thromb Haemost 2021; 121:1008-1020. [PMID: 33742436 DOI: 10.1055/a-1450-8178] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 2018, the International Council for Standardization in Haematology (ICSH) published a consensus document providing guidance for laboratories on measuring direct oral anticoagulants (DOACs). Since that publication, several significant changes related to DOACs have occurred, including the approval of a new DOAC by the Food and Drug Administration, betrixaban, and a specific DOAC reversal agent intended for use when the reversal of anticoagulation with apixaban or rivaroxaban is needed due to life-threatening or uncontrolled bleeding, andexanet alfa. In addition, this ICSH Working Party recognized areas where additional information was warranted, including patient population considerations and updates in point-of-care testing. The information in this manuscript supplements our previous ICSH DOAC laboratory guidance document. The recommendations provided are based on (1) information from peer-reviewed publications about laboratory measurement of DOACs, (2) contributing author's personal experience/expert opinion and (3) good laboratory practice.
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Affiliation(s)
- Jonathan Douxfils
- Department of Pharmacy-Namur Thrombosis and Hemostasis Center, University of Namur, Namur, Belgium.,Qualiblood SA, Namur, Belgium
| | - Dorothy M Adcock
- Laboratory Corporation of America, Burlington North Carolina, United States
| | - Shannon M Bates
- Department of Medicine, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Haemostasis and Thrombosis, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
| | | | - Cecilia Guillermo
- Hospital de Clínicas "Dr Manuel Quintela," Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Yohko Kawai
- Sanno Hospital, Laboratory Medicine, Tokyo, Japan
| | - Edelgard Lindhoff-Last
- Cardiology Angiology Center Bethanien, CCB Vascular Center, CCB Coagulation Center, Frankfurt, Germany
| | - Steve Kitchen
- Royal Hallamshire Hospital, Coagulation Sheffield, South Yorks, United Kingdom
| | - Robert C Gosselin
- Hemophilia Treatment Center, University of California, Davis Health System, Sacramento, California, United States
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19
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Riva N, Vella K, Hickey K, Gatt P, Grima C, Zammit D, Ageno W, Kitchen S, Makris M, Gatt A. The effect of DOAC-Stop ® on several oral and parenteral anticoagulants. Int J Lab Hematol 2021; 43:O171-O175. [PMID: 33595175 DOI: 10.1111/ijlh.13487] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 12/31/2020] [Accepted: 01/29/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Kevin Vella
- Coagulation Medicine Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta
| | - Kieron Hickey
- Sheffield Haemophilia and Thrombosis Centre, University of Sheffield, Sheffield, UK
| | - Peter Gatt
- Clinical Perfusion Services, Mater Dei Hospital, Msida, Malta
| | - Charlie Grima
- Clinical Perfusion Services, Mater Dei Hospital, Msida, Malta
| | - Daniel Zammit
- Coagulation Medicine Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Steve Kitchen
- Sheffield Haemophilia and Thrombosis Centre, University of Sheffield, Sheffield, UK
| | - Michael Makris
- Sheffield Haemophilia and Thrombosis Centre, University of Sheffield, Sheffield, UK
| | - Alex Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.,Coagulation Medicine Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta
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20
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Siriez R, Dogné JM, Gosselin R, Laloy J, Mullier F, Douxfils J. Comprehensive review of the impact of direct oral anticoagulants on thrombophilia diagnostic tests: Practical recommendations for the laboratory. Int J Lab Hematol 2020; 43:7-20. [PMID: 32946681 DOI: 10.1111/ijlh.13342] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 12/28/2022]
Abstract
There is a laboratory and clinical need to know the impact of direct oral anticoagulants (DOACs) on diagnostic tests to avoid misinterpretation of results. Although the regulatory labelling documents provide some information about the influences of each DOAC on diagnostic tests, these are usually limited to some of the most common tests and no head to head comparison is available. In this paper, we report the impact of DOACs on several thrombophilia tests, including assessment of antithrombin, protein S and protein C activity assays, detection of activated protein C resistance and assays used for lupus anticoagulant. Results are compared and discussed with data obtained from literature. The final goal of this comprehensive review is to provide practical recommendations for laboratories to avoid misdiagnosis due to oral direct factor Xa (FXa) or IIa (FIIa) inhibitors. Overall, oral direct FXa (apixaban, betrixaban, edoxaban and rivaroxaban) and FIIa (dabigatran) antagonists may affect clot-based thrombophilia diagnostic tests resulting in false-positive or false-negative results. An effect on FIIa-based thrombophilia diagnostic tests is observed with dabigatran but not with anti-FXa DOACs and conversely for FXa-based thrombophilia diagnostic tests. No impact was observed with antigenic/chromogenic methods for the assessment of protein S and C activity. In conclusion, interpretation of thrombophilia diagnostic tests results should be done with caution in patients on DOACs. The use of a device/chemical compound able to remove or antagonize the effect of DOACs or the development of new diagnostic tests insensitive to DOACs should be considered to minimize the risk of false results.
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Affiliation(s)
- Romain Siriez
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Robert Gosselin
- Thrombosis and Hemostasis Center, Davis Health System, University of California, Sacramento, California
| | - Julie Laloy
- Department of Pharmacy, Namur Nanosafety Center (NNC),, Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - François Mullier
- Laboratory Hematology, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), CHU UCL Namur, Université catholique de Louvain, Namur, Belgium
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium.,Qualiblood s.a, Namur, Belgium
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21
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Interference of DOAC stop and DOAC remove in the thrombin generation assay and coagulation assays. Thromb Res 2020; 192:96-99. [DOI: 10.1016/j.thromres.2020.04.044] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 02/29/2020] [Accepted: 04/29/2020] [Indexed: 01/12/2023]
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22
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De Kesel PM, Devreese KMJ. Direct oral anticoagulant adsorption: Impact on lupus anticoagulant testing-Review of the literature and evaluation on spiked and patient samples. J Thromb Haemost 2020; 18:2003-2017. [PMID: 32400112 DOI: 10.1111/jth.14894] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) interfere with lupus anticoagulant (LAC) testing. DOAC-Stop (D-S) represents a preanalytical strategy to cope with this issue. OBJECTIVES To assess D-S's ability to remove DOACs from plasma and overcome DOAC interference in LAC assays and to evaluate D-S's applicability in a representative patient cohort with routine LAC request. METHODS Apixaban (30-933 ng/mL), edoxaban (31-1060 ng/mL), rivaroxaban (35-1020 ng/mL), and dabigatran (20-360 ng/mL) were spiked to normal plasma. Aliquots were treated with D-S or untreated before DOAC and LAC testing. Patient samples containing DOAC (n = 43), vitamin K antagonists (n = 25), heparins (n = 21), or no anticoagulants (n = 63) were tested for LAC before and after D-S. RESULTS Spiking experiments revealed false-positive LAC from low concentrations of DOACs except for apixaban. Following D-S, DOAC levels were below lower limits of quantification, except for apixaban at the highest concentration, and no false-positive LAC was obtained. DOAC levels were below lower limits of quantification after D-S in 39/43 DOAC-containing patient samples. For 23/29 LAC-positive DOAC-containing samples, LAC tests became negative after D-S, whereas 3/6 samples remaining positive were from patients with (high probability for) antiphospholipid syndrome. In the non-DOAC-treated groups, LAC changed from positive to negative in 10 and vice versa in 2 cases. CONCLUSIONS D-S limits DOAC interference in LAC assays. DOAC concentration measurement should be performed in D-S treated samples because incomplete removal may occur. Applying D-S to vitamin K antagonist-containing, heparin-containing, or not-anticoagulated samples may lead to erroneous LAC results. Therefore, D-S should only be used in plasma from DOAC-treated patients.
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Affiliation(s)
- Pieter M De Kesel
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, 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
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23
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Tripodi A, Cohen H, Devreese KMJ. Lupus anticoagulant detection in anticoagulated patients. Guidance from the Scientific and Standardization Committee for lupus anticoagulant/antiphospholipid antibodies of the International Society on Thrombosis and Haemostasis. J Thromb Haemost 2020; 18:1569-1575. [PMID: 32619349 DOI: 10.1111/jth.14846] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/16/2020] [Accepted: 04/10/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The laboratory detection of lupus anticoagulants (LA) in anticoagulated patients represents a challenge and there is no consensus on the types of assays/procedures to be adopted. OBJECTIVES This communication of the International Society on Thrombosis and Haemostasis (ISTH), Scientific and Standardization Committee (SSC) aims to give guidance on the procedures to be adopted. METHODS Members of the ISTH-SSC on Lupus Anticoagulant/Antiphospholipid Antibodies reviewed the literature to search for evidence on the most appropriate assays/procedures to be adopted. RESULTS Anticoagulants are able to interfere with the tests used for LA detection, giving rise to occasional false-positive or false-negative LA. Some commercial tests include in their composition heparin-neutralizers able to quench unfractionated or low molecular weight heparin up to 1.0 U/mL. LA tests are less affected by low molecular weight heparin, but caution is needed in the interpretation of results. Vitamin K antagonists (VKAs) may affect LA detection. Dilution of test plasma into pooled normal plasma is not a reliable solution as false-negative or false-positive LA may occur. Direct oral anticoagulants (DOACs) affect LA detection. Hence, it is not recommended to attempt LA detection in those patients. The use of DOAC adsorbents is a promising solution and should be further investigated on LA-positive and LA-negative patient populations. Taipan/Ecarin tests may be a solution for VKAs and anti-FXa DOACs, but independent evidence on their value and standardized kits is needed. CONCLUSIONS LA detection during anticoagulation remains a challenge, especially for VKAs. DOAC removal by in vitro addition to plasma of appropriate absorbents is promising.
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Affiliation(s)
- Armando Tripodi
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy
| | - Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Katrien M J Devreese
- Coagulation Laboratory, Department of Diagnostic Sciences, Ghent University Hospital, Ghent, Belgium
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Sevenet P, Cucini V, Hervé T, Depasse F, Carlo A, Contant G, Mathieu O. Evaluation of DOAC Filter, a new device to remove direct oral anticoagulants from plasma samples. Int J Lab Hematol 2020; 42:636-642. [DOI: 10.1111/ijlh.13267] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/27/2020] [Accepted: 05/27/2020] [Indexed: 12/17/2022]
Affiliation(s)
| | | | - Tristan Hervé
- Clinical Development Diagnostica Stago Asnières‐sur‐Seine France
| | - François Depasse
- Clinical Development Diagnostica Stago Asnières‐sur‐Seine France
| | - Audrey Carlo
- Global Marketing Diagnostica Stago Asnières‐sur‐Seine France
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Exner T, Rigano J, Favaloro EJ. The effect of DOACs on laboratory tests and their removal by activated carbon to limit interference in functional assays. Int J Lab Hematol 2020; 42 Suppl 1:41-48. [DOI: 10.1111/ijlh.13196] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | - Joseph Rigano
- Haematology Department Alfred Hospital Melbourne Vic. Australia
| | - Emmanuel J. Favaloro
- Laboratory Haematology Institute of Clinical Pathology and Medical Research (ICPMR) NSW Health Pathology Westmead Hospital Sydney NSW Australia
- Sydney Centres for Thrombosis and Haemostasis Westmead Hospital Sydney NSW Australia
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Bavalia R, Abdoellakhan R, Brinkman HJM, Brekelmans MPA, Hamulyák EN, Zuurveld M, Hutten BA, Westerweel PE, Olie RH, ten Cate H, Kruip M, Middeldorp S, Meijer K, Coppens M. Emergencies on direct oral anticoagulants: Management, outcomes, and laboratory effects of prothrombin complex concentrate. Res Pract Thromb Haemost 2020; 4:569-581. [PMID: 32548555 PMCID: PMC7292661 DOI: 10.1002/rth2.12336] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 02/04/2020] [Accepted: 02/25/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND In the initial absence of specific reversal agents for factor Xa inhibitors (FXa-Is), prothrombin complex concentrate (PCC) as a hemostatic agent has been recommended by guidelines. Since 2017, idarucizumab has been registered for dabigatran reversal. Still, data on the clinical outcome of direct oral anticoagulant (DOAC)-related emergencies (major bleeding or urgent interventions) is scarce. In addition, it is unknown to what extent PCC restores thrombin generation in FXa-I-related emergencies. Our aim was to describe management and clinical outcomes of DOAC-related emergencies and to assess the laboratory effect of PCC in patients with FXa-I emergencies. METHODS In this prospective cohort study in 5 Dutch hospitals, patients presenting with DOAC-related emergencies were eligible. The primary outcome was effective hemostasis according to the ISTH definition. Safety outcomes were 30-day mortality and thromboembolic rate. In patients treated with PCC, additional blood samples were taken to assess the effect on thrombin generation. RESULTS We included 101 patients with major bleeding (FXa-I, 76; dabigatran, 25) and 21 patients requiring an urgent intervention (FXa-I, 16; dabigatran, 5). Of patients with major bleeding, 67% were treated with PCC or idarucizumab. Effective hemostasis, 30-day mortality, and thromboembolism rate were 67%, 22%, and 1%, respectively. In a subset of bleeding patients on FXa-I managed with PCC, thrombin generation increased, with 96% immediately after PCC administration. In patients requiring an urgent intervention, effective hemostasis, 30-day mortality, and thromboembolic rate were 95%, 14%, and 5%. CONCLUSIONS Effective hemostasis was achieved in the majority of patients presenting with DOAC-related emergencies;, thromboembolic complications were rare, and mortality was quite high.
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Affiliation(s)
- Roisin Bavalia
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Rahat Abdoellakhan
- Department of HematologyUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Herm Jan M. Brinkman
- Department of Molecular and Cellular HemostasisSanquin ResearchAmsterdamThe Netherlands
| | - Marjolein P. A. Brekelmans
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Eva N. Hamulyák
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Marleen Zuurveld
- Department of Molecular and Cellular HemostasisSanquin ResearchAmsterdamThe Netherlands
| | - Barbara A. Hutten
- Department of Clinical Epidemiology, Biostatistics and BioinformaticsAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Peter E. Westerweel
- Department of Internal MedicineAlbert Schweitzer HospitalDordrechtThe Netherlands
| | - Renske H. Olie
- Department of Internal MedicineMaastricht University Medical Center+MaastrichtThe Netherlands
| | - Hugo ten Cate
- Department of Internal MedicineMaastricht University Medical Center+MaastrichtThe Netherlands
| | - Marieke Kruip
- Department of HematologyErasmus University Medical CenterRotterdamThe Netherlands
| | - Saskia Middeldorp
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - Karina Meijer
- Department of HematologyUniversity Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Michiel Coppens
- Department of Vascular MedicineAmsterdam Cardiovascular SciencesAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
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Slavik L, Jacova J, Friedecky D, Ulehlova J, Tauber Z, Prochazkova J, Hlusi A, Palova M. Evaluation of the DOAC-Stop Procedure by LC-MS/MS Assays for Determining the Residual Activity of Dabigatran, Rivaroxaban, and Apixaban. Clin Appl Thromb Hemost 2020; 25:1076029619872556. [PMID: 31523979 PMCID: PMC6829642 DOI: 10.1177/1076029619872556] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The effect of direct oral anticoagulants (DOACs) on laboratory tests dependent on the
production of their targets, factor IIa and factor Xa (FXa), is a well-known problem and
can cause both false positive and negative results. Therefore, the correct interpretation
of tests performed in patients receiving DOACs is necessary to avoid misclassification and
subsequent clinical consequences. However, even with significant experience, there are
situations where it is not possible to assess the influence of some methods. Particularly
important is the situation in the diagnosis of lupus anticoagulants using the dilute
Russell viper venom timetest, which is based on direct FXa activation. A very promising
solution to this situation is offered by the DOAC laboratory balancing procedure
DOAC-Stop. For evaluating the effectiveness of this procedure, 60 (20 apixaban, 20
dabigatran, and 20 rivaroxaban) patients treated with DOACs were enrolled. All patient
samples were analyzed for the presence of individual DOAC types and subsequently subjected
to the DOAC-Stop procedure.We evaluated its effectiveness by our own high-performance
liquid chromatography-coupled tandem mass spectrometrymethod, which simultaneously sets
all high-sensitivity DOACs. Unlike coagulation tests based on the determination of the
residual effects of DOACs on target enzymes, which is complicated by extensive
interindividual variation, this methodology is highly specific and sensitive.The DOAC-Stop
procedure eliminated dabigatran from 99.5%, rivaroxaban from 97.9%, and apixaban from
97.1% of participants in our group. Residual amounts did not exceed 2.7 ng/mL for
dabigatran, 10.9 ng/mL for rivaroxaban, or 13.03 ng/mL for apixaban, which are safe values
that do not affect either screening or special coagulation tests.
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Affiliation(s)
- L Slavik
- Department of Hemato-Oncology, Faculty of Medicine and Dentistry, Palacký University Olomouc and University Hospital Olomouc, Czech Republic
| | - J Jacova
- Department of Clinical Biochemistry, Palacký University Olomouc and University Hospital Olomouc, Czech Republic
| | - D Friedecky
- Department of Clinical Biochemistry, Palacký University Olomouc and University Hospital Olomouc, Czech Republic
| | - J Ulehlova
- Department of Hemato-Oncology, Faculty of Medicine and Dentistry, Palacký University Olomouc and University Hospital Olomouc, Czech Republic
| | - Z Tauber
- Department of Histology and Embryology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - J Prochazkova
- Department of Hemato-Oncology, Faculty of Medicine and Dentistry, Palacký University Olomouc and University Hospital Olomouc, Czech Republic
| | - A Hlusi
- Department of Hemato-Oncology, Faculty of Medicine and Dentistry, Palacký University Olomouc and University Hospital Olomouc, Czech Republic
| | - M Palova
- Department of Hemato-Oncology, Faculty of Medicine and Dentistry, Palacký University Olomouc and University Hospital Olomouc, Czech Republic
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De Kesel PM, Devreese KM. The effect of unfractionated heparin, enoxaparin, and danaparoid on lupus anticoagulant testing: Can activated carbon eliminate false-positive results? Res Pract Thromb Haemost 2020; 4:161-168. [PMID: 31989098 PMCID: PMC6971310 DOI: 10.1002/rth2.12264] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 09/12/2019] [Accepted: 09/14/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Heparins and heparinoids interfere with functional clotting assays used for lupus anticoagulant (LAC) detection. However, current guidelines for LAC testing do not provide clear guidance on this matter. OBJECTIVES We aimed to assess to effect of unfractionated heparin (UFH), enoxaparin, and danaparoid on LAC assays over broad anti-Xa activity ranges and to evaluate whether activated carbon (AC) is able to neutralize these effects. METHODS UFH (0.1-3.0 IU/mL), enoxaparin (0.2-2.9 IU/mL), and danaparoid (0.6-2.2 IU/mL) were spiked to normal pooled plasma. AC was added at multiple activity levels. Anti-Xa assays and LAC tests were performed on all samples using Stago analyzers and reagents. RESULTS Abnormal activated partial thromboplastin time (APTT) screening and mixing tests were obtained at the lowest levels for all compounds. Abnormal APTT confirmation tests were seen from 2.5 and 1.9 anti-Xa IU/mL for enoxaparin and danaparoid, respectively. Abnormal dilute Russell's viper venom test (dRVVT) screening tests were obtained from 1.6, 1.4, and 1.1 anti-Xa IU/mL for UFH, enoxaparin, and danaparoid, respectively. Mixing tests were abnormal from 2.5 and 1.3 anti-Xa IU/mL for enoxaparin and danaparoid, respectively. Abnormal dRVVT confirmation results were seen for danaparoid only from 1.9 anti-Xa IU/mL. AC was unable to neutralize anti-Xa activity in plasma and overcome the effect of the tested anticoagulants on LAC assays but may cause prolongation of APTT clotting times. CONCLUSIONS UFH, enoxaparin, and danaparoid clearly affected LA tests; however, false-positive LAC conclusions were obtained at supratherapeutic enoxaparin and danaparoid levels only. AC may prolong APTT screen clotting times, requiring 3-step testing to avoid potential misdiagnosis of LAC.
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Affiliation(s)
- Pieter M.M. De Kesel
- Coagulation LaboratoryDepartment of Laboratory MedicineGhent University HospitalGhentBelgium
| | - Katrien M.J. Devreese
- Coagulation LaboratoryDepartment of Laboratory MedicineGhent University HospitalGhentBelgium
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Ząbczyk M, Kopytek M, Natorska J, Undas A. The effect of DOAC-Stop on lupus anticoagulant testing in plasma samples of venous thromboembolism patients receiving direct oral anticoagulants. ACTA ACUST UNITED AC 2019; 57:1374-1381. [DOI: 10.1515/cclm-2018-1197] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/07/2019] [Indexed: 01/01/2023]
Abstract
Abstract
Background
Direct oral anticoagulants (DOACs) cause false positive lupus anticoagulant (LA) results. We assessed the impact of DOAC-Stop, reversing in vitro effects of DOACs, on LA testing in anticoagulated patients.
Methods
We assessed 75 venous thromboembolism patients aged 44.5±14.6 years. Blood samples were collected 2–28 h since intake of DOACs, including 50 patients on rivaroxaban, 20 on dabigatran and five on apixaban. LA testing was performed at baseline and after DOAC-Stop treatment. Positive LA was defined as the normalized (patient/standard plasma clotting time) LA screening and screening (LA1)/confirmation (LA2) ratios exceeding 1.2.
Results
LA diluted Russell’s viper venom time (dRVVT) normalized screening test revealed abnormal results in 73 (97.3%) and activated partial thromboplastin time (APTT)-LA in 49 (65.3%) patients. In six (8%) patients, antiphospholipid syndrome (APS) was diagnosed. dRVVT LA1/LA2 was abnormal in 35 (50.7%) patients taking DOACs. The APTT ratio was normal in all studied subjects. DOAC-Stop completely removed dabigatran and reduced by 98% rivaroxaban and by 92.3% apixaban concentrations (all p<0.05). After DOAC-Stop screening dRVVT remained prolonged in 34 (49.3%) patients (p<0.001), while dRVVT LA1/LA2 was abnormal in six (8.7%) subjects, with no association with DOAC concentrations at baseline and after DOAC-Stop. The APTT-LA screening test remained prolonged in five (7.2%) patients, while the APTT LA1/LA2 ratio was normal in those subjects. DOAC-Stop did not influence LA testing in APS patients.
Conclusions
Application of DOAC-Stop effectively reduced plasma DOAC concentrations leading to appropriate dRVVT results in up to 97% of VTE patients.
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Favaloro EJ, Gilmore G, Arunachalam S, Mohammed S, Baker R. Neutralising rivaroxaban induced interference in laboratory testing for lupus anticoagulant (LA): A comparative study using DOAC Stop and andexanet alfa. Thromb Res 2019; 180:10-19. [DOI: 10.1016/j.thromres.2019.05.013] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 05/14/2019] [Accepted: 05/21/2019] [Indexed: 12/25/2022]
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Frans G, Meeus P, Bailleul E. Resolving DOAC interference on aPTT, PT, and lupus anticoagulant testing by the use of activated carbon. J Thromb Haemost 2019; 17:1354-1362. [PMID: 31102433 DOI: 10.1111/jth.14488] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 05/08/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) affect laboratory coagulations tests. Activated carbon (AC) can be used for adsorption of DOACs during acute human intoxications. OBJECTIVES This study evaluates whether AC can also be used to resolve DOAC interference on in vitro clotting tests (prothrombin time [PT], activated partial thromboplastin time [aPTT], and lupus anticoagulant [LA] assays). PATIENTS/METHODS Interference on PT, aPTT, Liquid anti-FXa, DTI, and LA screening/confirmation (SCT and dRVVT) was determined by spiking citrated plasma from 5 adult controls with 0, 20, 40, 80, 120, or 160 mg/mL AC. DOAC concentrations, PT, and aPTT were compared before and after AC addition to citrated plasma from patients receiving DOACs (n = 29), low molecular weight heparin (n = 10), and coumarin (n = 10) therapy. Samples from 69 LA screened patients were compared before and after AC addition. RESULTS A concentration of 20 mg/mL AC had the lowest interference and was selected for further experiments. After AC addition, all DOAC concentrations were below the limit of quantification in the 29 treated patients, except for 2 apixaban samples. AC removed DOAC interference on PT and aPTT but had no impact on results obtained during coumarin or low molecular weight heparin therapy. Of 15 LA samples with interference resulting from DOAC therapy, 14 samples became negative and 1 positive after AC addition. Interference from coumarin therapy was not resolved. All 19 LA negative samples remained negative. AC treatment of the negative pooled plasma was required to avoid false-negative LA results in 21 known LA-positive samples. CONCLUSIONS AC selectively removes DOAC interference on PT, aPTT, and LA assays.
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Affiliation(s)
- Glynis Frans
- Department of Laboratory Medicine, Onze-Lieve-Vrouw Ziekenhuis, Aalst, Belgium
| | - Peter Meeus
- Department of Laboratory Medicine, Onze-Lieve-Vrouw Ziekenhuis, Aalst, Belgium
| | - Els Bailleul
- Department of Laboratory Medicine, Onze-Lieve-Vrouw Ziekenhuis, Aalst, Belgium
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Cox‐Morton S, MacDonald S, Thomas W. A diagnostic solution for haemostasis laboratories for patients taking direct oral anticoagulants using DOAC‐Remove. Br J Haematol 2019; 187:377-385. [DOI: 10.1111/bjh.16091] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 05/20/2019] [Indexed: 12/14/2022]
Affiliation(s)
- Sally Cox‐Morton
- Haemophilia and Thrombophilia Centre Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Stephen MacDonald
- Haemophilia and Thrombophilia Centre Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Will Thomas
- Haemophilia and Thrombophilia Centre Cambridge University Hospitals NHS Foundation Trust Cambridge UK
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Gosselin RC, Adcock DM, Douxfils J. An update on laboratory assessment for direct oral anticoagulants (DOACs). Int J Lab Hematol 2019; 41 Suppl 1:33-39. [PMID: 31069969 DOI: 10.1111/ijlh.12992] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 01/18/2019] [Accepted: 01/25/2019] [Indexed: 01/24/2023]
Abstract
The first direct oral anticoagulant (DOAC) to be approved for clinical use was dabigatran, a direct thrombin inhibitor, in 2010. Since that time, four additional DOACs, all direct anti-Xa inhibitors, have been approved, including rivaroxaban, apixaban, edoxaban and betrixaban. Our knowledge about the effect of DOACs on laboratory testing, as well as the use of the laboratory for measuring DOACs has been an evolving process. These drugs are not routinely monitored in the same fashion as coumadin, but there is an increasing demand on the laboratory to have the capacity to adequately assess DOAC anticoagulant effect (pharmacodynamics) or levels (pharmacokinetics) in either emergent or the routine situations. This manuscript provides an update on laboratory guidance and progress of methods for measuring DOACs.
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Affiliation(s)
- Robert C Gosselin
- UC Davis Health System, Hemophilia Treatment Center, Sacramento, California
| | | | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium.,Qualiblood s.a, Namur, Belgium
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