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Watanabe H, Hirai K, Nakazawa Y, Koike A, Tsuchiya H, Naito T. Effect of Enoxaparin and Daikenchuto Coadministration on Hepatic Disorder Markers in Gynecological Cancer Patients after Abdominal Surgery. Biol Pharm Bull 2024; 47:758-763. [PMID: 38569843 DOI: 10.1248/bpb.b24-00026] [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: 04/05/2024]
Abstract
Enoxaparin and daikenchuto are commonly administered to prevent venous thromboembolism and intestinal obstruction after gynecological malignancy surgery. However, the effects of their combined use on hepatic function are not well studied. This study aimed to clarify the effects of the coadministration of enoxaparin and daikenchuto on hepatic function. First, Japanese Adverse Drug Event Report (JADER) data were analyzed to identify signals of hepatic disorders. Second, a retrospective observational study of patients who underwent surgery for gynecological malignancies was conducted. This study defined hepatic disorders as an increase in aspartate aminotransferase (AST) or alanine aminotransaminase (ALT) levels above the reference values, using 1-h postoperative values as the baseline. The analysis of JADER data revealed an increased risk for hepatic disorders with the coadministration of enoxaparin and daikenchuto. An observational study also showed higher odds ratios (95% confidence intervals) for the occurrence of hepatic disorders in the coadministration group (4.27; 2.11-8.64) and enoxaparin alone group (2.48; 1.31-4.69) than in the daikenchuto alone group. The median increase in the ALT level was also higher in the coadministration group (34; 15-59) than in the enoxaparin alone (19; 6-38) and daikenchuto alone groups (8; 3-33). In conclusion, our study suggests that compared with the use of enoxaparin or daikenchuto alone, enoxaparin and daikenchuto coadministration increases the risk of hepatic disorders, with more significant increases in AST and ALT levels. Healthcare workers need to be aware of these potential side effects when combining these drugs after surgery for gynecological malignancies.
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Affiliation(s)
| | - Keita Hirai
- Department of Pharmacy, Shinshu University Hospital
- Department of Clinical Pharmacology and Therapeutics, Shinshu University Graduate School of Medicine
| | | | - Ayaka Koike
- Department of Pharmacy, Shinshu University Hospital
| | | | - Takafumi Naito
- Department of Pharmacy, Shinshu University Hospital
- Department of Clinical Pharmacology and Therapeutics, Shinshu University Graduate School of Medicine
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2
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Zhou FN, Gellatly RM. Management of an unintentional enoxaparin overdose: A case report and literature review. Am J Health Syst Pharm 2023; 80:1550-1556. [PMID: 37522871 DOI: 10.1093/ajhp/zxad170] [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: 07/27/2023] [Indexed: 08/01/2023] Open
Abstract
PURPOSE The aim of this article is to describe a case in which protamine was used for a low-molecular-weight heparin (LMWH) overdose and present an up-to-date review of the literature on the management of LMWH overdose in adults. SUMMARY An unintentional administration of enoxaparin 900 mg occurred in a 73-year-old man with coronavirus disease 2019-related pulmonary embolism. Management of the overdose included a protamine bolus followed by an infusion. Anti-factor Xa levels and activated partial thromboplastin time were monitored. Anti-factor Xa levels declined in a linear fashion irrespective of protamine administration. No bleeding or further thrombotic complications occurred in the patient. A review of the literature revealed that the optimal strategy to treat an LMWH overdose is unknown, with treatment of overdoses ranging from clinical observation to aggressive protamine dosing in reported cases. Although protamine effectively neutralizes unfractionated heparin, it is unable to completely reverse LMWH activity and has variable effects on laboratory measures of LMWH anticoagulant activity. CONCLUSION The current case report provides additional data to previous literature suggesting that protamine may have a limited effect in decreasing anti-factor Xa levels in LMWH overdose. Continued reporting on the management of LMWH overdoses is warranted to clarify the optimal treatment strategy.
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Affiliation(s)
- Florian N Zhou
- Department of Pharmacy, Surrey Memorial Hospital, Surrey, BC
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Rochelle M Gellatly
- Department of Pharmacy, Surrey Memorial Hospital, Surrey, BC, Canada
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
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3
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Trimolé R, Manzi H, Hosseini K, Remen T, Toussaint-Hacquard M, Camenzind E. Smoking and Activated Clotting Time during coronary angiography and angioplasty: protocol for the ACT-Tobacco trial. Res Pract Thromb Haemost 2023; 7:100083. [PMID: 36915865 PMCID: PMC10005900 DOI: 10.1016/j.rpth.2023.100083] [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: 06/28/2022] [Revised: 01/11/2023] [Accepted: 01/25/2023] [Indexed: 02/16/2023] Open
Abstract
Background During percutaneous transluminal coronary angioplasty (PTCA), activated clotting time (ACT) measurements are recommended to attest a correct anticoagulation level and, if needed, to administer further unfractionated heparin (UFH) to obtain a therapeutic ACT value. Our clinical routine led us to observe that smokers had lower ACT values after standardized UFH administration during PTCA. Procoagulant status in smokers is well documented. Objectives To determine whether tobacco negatively affects UFH anticoagulation during PTCA when evaluated by ACT. Methods The ACT-TOBACCO trial is a single-center, noninterventional, prospective study. The primary end point is the comparison of ACT values after standardized UFH administration between active smokers and nonsmokers (active smoker group vs nonsmoker group) requiring coronary angiography followed by PTCA. The main secondary end points include ACT comparison after the first and second standardized UFH administration according to the patient's smoking status (active, ex-, or nonsmoker) and the clinical presentation of ischemic cardiomyopathy: stable (silent ischemia or stable angina) or unstable (unstable angina or acute coronary syndrome without or with ST-segment elevation). Conclusions To the best of our knowledge, ACT values during PTCA between smokers and nonsmokers have not previously been compared. As current PTCA procedures increase in complexity and duration, the understanding of procoagulant risk factors such as smoking and the need for reliable anticoagulation monitoring becomes essential to balance hemorrhagic risk against thrombotic risk.
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Key Words
- ACS, Acute Coronary Sryndrome
- ACT, Activated Clotting Time
- AT, Antithrombin
- CathLab, Catheterization Laboratory
- LMWH, Low Molecular-Weight Heparin
- NOAC, Non-vitamin K Antagonist Oral Anticoagulants
- POC, Point-of-Care
- PT, Prothrombin Time
- PTCA, Percutaneous Transluminal Coronary Angioplasty
- SAS, Statistical Analysis System
- UFH, Unfractionated Heparin
- aPTT, Activated Partial Thromboplastin Time
- activated coagulation time
- coagulation
- coronary angiography
- heparin
- i.a., Intra-Arterial
- i.v., Intra-Venous
- percutaneous transluminal coronary angioplasty
- smoking
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Affiliation(s)
- Régis Trimolé
- Department of Cardiology, University Hospital Nancy-Brabois, Vandœuvre-lès-Nancy, France
| | - Hugo Manzi
- Department of Cardiology, Regional Hospital Metz-Thionville, Ars-Laquenexy, France
| | - Kossar Hosseini
- Clinical Research and Innovation Delegation, University Hospital Nancy-Brabois, Vandœuvre-lès-Nancy, France
| | - Thomas Remen
- Clinical Research and Innovation Delegation, University Hospital Nancy-Brabois, Vandœuvre-lès-Nancy, France
| | - Marie Toussaint-Hacquard
- Biological Hematology Laboratory, University Hospital Nancy-Brabois, Vandœuvre-lès-Nancy, France
| | - Edoardo Camenzind
- Department of Cardiology, University Hospital Nancy-Brabois, Vandœuvre-lès-Nancy, France
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Spiegelburg DT, Mannes M, Schultze A, Scheibenberger F, Müller F, Klitzing A, Messerer DAC, Nilsson Ekdahl K, Nilsson B, Huber-Lang M, Braun CK. Impact of surface coating and systemic anticoagulants on hemostasis and inflammation in a human whole blood model. PLoS One 2023; 18:e0280069. [PMID: 36634087 PMCID: PMC9836312 DOI: 10.1371/journal.pone.0280069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 12/20/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Surface compatibility with blood is critical both for scientific investigations on hemostasis and clinical applications. Regarding in vitro and ex vivo investigations, minimal alteration in physiological hemostasis is of particular importance to draw reliable conclusions on the human coagulation system. At the same time, artificial coagulation activation must be avoided, which is relevant for the patient, for example to prevent stent graft occlusion. The aim was to evaluate the advantages and disadvantages of antithrombotic and antifouling surface coatings in the context of their suitability for ex vivo incubation and the study of coagulation properties. METHODS We investigated the impact of different protocols for surface coating of synthetic material and different anticoagulants on hemostasis and platelet activation in ex vivo human whole blood. Blood samples from healthy donors were incubated in coated microtubes on a rotating wheel at 37°C. Two protocols for surface coating were analyzed for hemostatic parameters and metabolic status, a heparin-based coating (CHC, Corline Heparin Conjugate) without further anticoagulation and a passivating coating (MPC, 2-methacryloyloxethyl phosphorylcholine) with added anticoagulants (enoxaparin, ENOX; or fondaparinux, FPX). Employing the MPC-based coating, the anticoagulants enoxaparin and fondaparinux were compared regarding their differential effects on plasmatic coagulation by thrombelastometry and on platelet activation by flowcytometry and platelet function assays. RESULTS Using the CHC coating, significant coagulation cascade activation was observed, whereas parameters remained mostly unchanged with MPC-based protocols. Extended incubation caused significantly elevated levels of the soluble membrane attack complex. Neither ENOX nor FPX caused a relevant impairment of platelet function or activation capacity and thrombelastometric parameters remained unchanged with both protocols. For translational purposes, we additionally modeled endotoxemia with the MPC-based protocols by incubating with lipopolysaccharide plus/minus thrombin. While coagulation parameters remained unchanged, elevated Interleukin 8 and Matrix Metalloproteinase 9 demonstrated preserved immune cell responsiveness. CONCLUSIONS The MPC-based protocols demonstrated better hemocompatibility compared to CHC, and ENOX and FPX proved useful for additional anticoagulation. Furthermore, this simple-to-use whole blood model may be useful for experimental analyses of the early coagulatory and immunological response without decalcification.
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Affiliation(s)
- Doreen Tabea Spiegelburg
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Marco Mannes
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Anke Schultze
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Frieder Scheibenberger
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Frederik Müller
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Amadeo Klitzing
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - David Alexander Christian Messerer
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
- Department of Transfusion Medicine and Hemostaseology, University Hospital of Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Erlangen, Germany
| | - Kristina Nilsson Ekdahl
- Centre of Biomaterials Chemistry, Linnaeus University, Kalmar, Sweden
- Rudbeck Laboratory, Department of Immunology, Genetics and Pathology, Uppsala, Sweden
| | - Bo Nilsson
- Rudbeck Laboratory, Department of Immunology, Genetics and Pathology, Uppsala, Sweden
| | - Markus Huber-Lang
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
| | - Christian Karl Braun
- Institute for Clinical and Experimental Trauma Immunology, University Hospital of Ulm, Ulm, Germany
- * E-mail:
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5
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Gurbel PA, Rout A, Tantry US. Monitoring and Reversal of Anticoagulation and Antiplatelet Agents. Interv Cardiol 2022. [DOI: 10.1002/9781119697367.ch46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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GÜNDÜZ R, YİLDİZ BS, ÖZDEMIR İH, ÖZEN MB, ÇETIN N, YAVUZGİL O. ST segment yükselmesi olmayan miyokard infarktüsü olgularında enoksoparin tedavisinin etkinliğinin değerlendirilmesinde AntiFXa aktivitesi ve tromboleastogram yönteminin karşılaştırılması. CUKUROVA MEDICAL JOURNAL 2021. [DOI: 10.17826/cumj.977136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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7
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Baloo MM, Scribante J, Perrie H, Calleemalay D, Omar S. Factor Xa Levels in Patients Receiving Prophylactic Enoxaparin Sodium in the Intensive Care Unit of an Academic Hospital. Indian J Crit Care Med 2021; 25:917-919. [PMID: 34733033 PMCID: PMC8559763 DOI: 10.5005/jp-journals-10071-23879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Background: The aim of this study was to determine the anti-factor Xa levels in patients receiving enoxaparin sodium for venous thromboembolism prophylaxis in the intensive care unit (ICU). Patients and methods: Using a cross-sectional study methodology, 73 ICU patients receiving 40 mg enoxaparin sodium daily were enrolled in this study. Anti-factor Xa levels were measured following the second dose. Prophylactic and subprophylactic groups of patients were compared for age, sex, weight, body mass index, total bilirubin, serum albumin, and APACHE II score. Results: Anti-factor Xa levels were prophylactic (0.2–0.6 IU/mL) in 44 (60.3%) patients and subprophylactic (<0.2 IU/mL) in 29 (39.7%) patients. The mean (SD) actual delivered dose of enoxaparin per kilogram body weight was significantly higher, at 0.59 (0.11) mg/kg in the prophylactic group compared to 0.53 (0.13) mg/kg in the subprophylactic group (p = 0.043). The subprophylactic group had significantly lower serum albumin levels compared to the prophylactic group. The total bilirubin levels were not found to be significantly different between the two groups (p = 0.110). Conclusion: A fixed prophylactic 40 mg dose of enoxaparin was associated with a high proportion of subprophylactic anti-factor Xa levels. Weight-based dose and serum albumin level were independent predictors of achieving the prophylactic target range. How to cite this article: Baloo MM, Scribante J, Perrie H, Calleemalay D, Omar S. Factor Xa Levels in Patients Receiving Prophylactic Enoxaparin Sodium in the Intensive Care Unit of an Academic Hospital. Indian J Crit Care Med 2021;25(8):917–919.
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Affiliation(s)
- Mayank M Baloo
- Department of Anaesthesiology and Critical Care, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Juan Scribante
- Department of Anaesthesiology and Critical Care, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Helen Perrie
- Department of Anaesthesiology and Critical Care, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Daren Calleemalay
- Department of Critical Care, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
| | - Shahed Omar
- Department of Critical Care, University of the Witwatersrand, Johannesburg, Gauteng, South Africa
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8
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Kumano O, Akatsuchi K, Amiral J. Updates on Anticoagulation and Laboratory Tools for Therapy Monitoring of Heparin, Vitamin K Antagonists and Direct Oral Anticoagulants. Biomedicines 2021; 9:biomedicines9030264. [PMID: 33799956 PMCID: PMC7998518 DOI: 10.3390/biomedicines9030264] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/24/2021] [Accepted: 03/03/2021] [Indexed: 01/08/2023] Open
Abstract
Anticoagulant drugs have been used to prevent and treat thrombosis. However, they are associated with risk of hemorrhage. Therefore, prior to their clinical use, it is important to assess the risk of bleeding and thrombosis. In case of older anticoagulant drugs like heparin and warfarin, dose adjustment is required owing to narrow therapeutic ranges. The established monitoring methods for heparin and warfarin are activated partial thromboplastin time (APTT)/anti-Xa assay and prothrombin time – international normalized ratio (PT-INR), respectively. Since 2008, new generation anticoagulant drugs, called direct oral anticoagulants (DOACs), have been widely prescribed to prevent and treat several thromboembolic diseases. Although the use of DOACs without routine monitoring and frequent dose adjustment has been shown to be safe and effective, there may be clinical circumstances in specific patients when measurement of the anticoagulant effects of DOACs is required. Recently, anticoagulation therapy has received attention when treating patients with coronavirus disease 2019 (COVID-19). In this review, we discuss the mechanisms of anticoagulant drugs—heparin, warfarin, and DOACs and describe the methods used for the measurement of their effects. In addition, we discuss the latest findings on thrombosis mechanism in patients with COVID-19 with respect to biological chemistry.
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Affiliation(s)
- Osamu Kumano
- Research Department, HYPHEN BioMed, 155 Rue d’Eragny, 95000 Neuville sur Oise, France;
- Protein Technology, Engineering 1, Sysmex Corporation, Kobe 651-2271, Japan
- Correspondence: ; Tel.: +81-78-991-2203
| | - Kohei Akatsuchi
- R&D Division, Sysmex R&D Center Americas, Inc., Mundelein, IL 60060, USA;
| | - Jean Amiral
- Research Department, HYPHEN BioMed, 155 Rue d’Eragny, 95000 Neuville sur Oise, France;
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9
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Keshari RS, Silasi R, Popescu NI, Georgescu C, Chaaban H, Lupu C, McCarty OJT, Esmon CT, Lupu F. Fondaparinux pentasaccharide reduces sepsis coagulopathy and promotes survival in the baboon model of Escherichia coli sepsis. J Thromb Haemost 2020; 18:180-190. [PMID: 31549765 PMCID: PMC6940562 DOI: 10.1111/jth.14642] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 09/17/2019] [Indexed: 01/27/2023]
Abstract
BACKGROUND Sepsis triggers dysfunction of coagulation and fibrinolytic systems leading to disseminated intravascular coagulation (DIC) that contributes to organ failure and death. Fondaparinux (FPX) is a synthetic pentasaccharide that binds to antithrombin (AT) and selectively inhibits factor (F) Xa and other upstream coagulation proteases but not thrombin (T). OBJECTIVES We used a baboon model of lethal Escherichia coli sepsis to investigate the effects of FPX treatment on DIC, organ function, and outcome. METHODS Two experimental groups were studied: (a) E. coli challenge (n = 4); and (b) E coli plus FPX (n = 4). Bacteremia was modeled by intravenous infusion of pathogen (1-2 × 1010 CFU/kg). Fondaparinux (0.08 mg/kg) was administered subcutaneously, 3 h prior to and 8 h after bacteria infusion. RESULTS Bacteremia rapidly increased plasma levels of inhibitory complexes of AT with coagulation proteases. Activation markers of both intrinsic (FXIa-AT), and extrinsic (FVIIa-AT) pathways were significantly reduced in FPX-treated animals. Factor Xa-AT and TAT complexes were maximal at 4 to 8 h post challenge and reduced >50% in FPX-treated animals. Fibrinogen consumption, fibrin generation and degradation, neutrophil and complement activation, and cytokine production were strongly induced by sepsis. All parameters were significantly reduced, while platelet count was unchanged by the treatment. Fondaparinux infusion attenuated organ dysfunction, prolonged survival, and saved two of four challenged animals (log-rank Mantel-Cox test, P = .0067). CONCLUSION Our data indicate that FPX-mediated inhibition of coagulation prevents sepsis coagulopathy; protects against excessive complement activation, inflammation, and organ dysfunction; and provides survival benefit in E. coli sepsis.
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Affiliation(s)
- Ravi S. Keshari
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Robert Silasi
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Narcis I. Popescu
- Arthritis and Clinical Immunology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK 73104
| | - Constantin Georgescu
- Genes and Human Disease Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Hala Chaaban
- Department of Pediatrics, Neonatal and Perinatal Section, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Cristina Lupu
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Owen J. T. McCarty
- Department of Biomedical Engineering, School of Medicine, Oregon Health & Sciences University, Portland, OR
- Division of Hematology and Medical Oncology, School of Medicine, Oregon Health & Sciences University, Portland, OR
| | - Charles T. Esmon
- Coagulation Biology Laboratory, Oklahoma Medical Research Foundation, Oklahoma City, OK
| | - Florea Lupu
- Cardiovascular Biology Research Program, Oklahoma Medical Research Foundation, Oklahoma City, OK
- Departments of Cell Biology, Pathology and Internal Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK
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Rivaroxaban and dabigatran did not affect clotting profiles in plasma reconstituted with varying levels of autologous platelets to the same degree as heparin when evaluated using thromboelastography. Blood Coagul Fibrinolysis 2018; 29:521-527. [DOI: 10.1097/mbc.0000000000000751] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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11
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Kalaska B, Kamiński K, Miklosz J, Nakai K, Yusa SI, Pawlak D, Nowakowska M, Mogielnicki A, Szczubiałka K. Anticoagulant Properties of Poly(sodium 2-(acrylamido)-2-methylpropanesulfonate)-Based Di- and Triblock Polymers. Biomacromolecules 2018; 19:3104-3118. [DOI: 10.1021/acs.biomac.8b00691] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Bartlomiej Kalaska
- Department of Pharmacodynamics, Medical University of Bialystok, Mickiewicza 2c, 15-089 Bialystok, Poland
| | - Kamil Kamiński
- Faculty of Chemistry, Jagiellonian University, Gronostajowa 2, 30-387 Kraków, Poland
| | - Joanna Miklosz
- Department of Pharmacodynamics, Medical University of Bialystok, Mickiewicza 2c, 15-089 Bialystok, Poland
| | - Keita Nakai
- Department of Applied Chemistry, Graduate School of Engineering, University of Hyogo, 2167 Shosha, Himeji, Hyogo 671-2280, Japan
| | - Shin-Ichi Yusa
- Department of Applied Chemistry, Graduate School of Engineering, University of Hyogo, 2167 Shosha, Himeji, Hyogo 671-2280, Japan
| | - Dariusz Pawlak
- Department of Pharmacodynamics, Medical University of Bialystok, Mickiewicza 2c, 15-089 Bialystok, Poland
| | - Maria Nowakowska
- Faculty of Chemistry, Jagiellonian University, Gronostajowa 2, 30-387 Kraków, Poland
| | - Andrzej Mogielnicki
- Department of Pharmacodynamics, Medical University of Bialystok, Mickiewicza 2c, 15-089 Bialystok, Poland
| | - Krzysztof Szczubiałka
- Faculty of Chemistry, Jagiellonian University, Gronostajowa 2, 30-387 Kraków, Poland
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Abstract
PURPOSE OF REVIEW The traumatically injured patient is at high risk for developing venous thromboembolism. Clinical practice guidelines developed by the American College of Chest Physicians and the Eastern Association for the Surgery of Trauma recognize the importance of initiating thromboprophylaxis, but the guidelines lack specific recommendations regarding the timing and dose of pharmacologic thromboprophylaxis. We review the literature regarding initiation of thromboprophylaxis in different injuries, the use of inferior vena cava filters, laboratory monitoring, dosing regimens, and the use of antiplatelet therapy. RECENT FINDINGS Use of pharmacologic thromboprophylaxis with invasive intracranial monitors is not associated with increased bleeding complications. The initiation of low-molecular-weight heparin (LMWH) prophylaxis 48 h postinjury in blunt solid organ injury is not associated with an increase in the rate of failed nonoperative management. Antiplatelet therapy in conjunction with LMWH may help to prevent venous thromboembolism. SUMMARY In the setting of blunt traumatic brain and solid organ injury, initiation of pharmacologic thromboprophylaxis 48 h after injury is not associated with increased bleeding complications. There is no consensus or clear data showing which dosing regimen of LMWH is most effective or whether routine laboratory measurements are beneficial for determining effective thromboprophylaxis.
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Husted S, Wallentin L, Andreotti F, Arnesen H, Bachmann F, Baigent C, Huber K, Jespersen J, Kristensen S, Lip GYH, Morais J, Rasmussen L, Siegbahn A, Verheugt FWA, Weitz JI, De Caterina R. Parenteral anticoagulants in heart disease: Current status and perspectives (Section II). Thromb Haemost 2017; 109:769-86. [DOI: 10.1160/th12-06-0403] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 12/25/2012] [Indexed: 11/05/2022]
Abstract
SummaryAnticoagulants are a mainstay of cardiovascular therapy, and parenteral anticoagulants have widespread use in cardiology, especially in acute situations. Parenteral anticoagulants include unfractionated heparin, low-molecular-weight heparins, the synthetic pentasaccharides fondaparinux, idraparinux and idrabiotaparinux, and parenteral direct thrombin inhibitors. The several shortcomings of unfractionated heparin and of low-molecular-weight heparins have prompted the development of the other newer agents. Here we review the mechanisms of action, pharmacological properties and side effects of parenteral anticoagulants used in the management of coronary heart disease treated with or without percutaneous coronary interventions, cardioversion for atrial fibrillation, and prosthetic heart valves and valve repair. Using an evidence-based approach, we describe the results of completed clinical trials, highlight ongoing research with currently available agents, and recommend therapeutic options for specific heart diseases.
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14
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Yost GW, Steinhubl SR. Monitoring and Reversal of Anticoagulation and Antiplatelet Agents. Interv Cardiol 2016. [DOI: 10.1002/9781118983652.ch49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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15
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Kalaska B, Kaminski K, Miklosz J, Yusa SI, Sokolowska E, Blazejczyk A, Wietrzyk J, Kasacka I, Szczubialka K, Pawlak D, Nowakowska M, Mogielnicki A. Heparin-binding copolymer reverses effects of unfractionated heparin, enoxaparin, and fondaparinux in rats and mice. Transl Res 2016; 177:98-112.e10. [PMID: 27456749 DOI: 10.1016/j.trsl.2016.06.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 06/23/2016] [Accepted: 06/28/2016] [Indexed: 11/19/2022]
Abstract
The parenteral anticoagulants may cause uncontrolled and life-threatening bleeding. Protamine, the only registered heparin antidote, is partially effective against low-molecular weight heparins, completely ineffective against fondaparinux and may cause unacceptable toxicity. Therefore, we aimed to develop a synthetic compound for safe and efficient neutralization of all parenteral anticoagulants. We synthesized pegylated PMAPTAC block copolymers, and then, we selected a lead heparin-binding copolymer (HBC). We assessed the effectiveness of HBC in the model of arterial thrombosis electrically induced in the carotid artery of rats by measuring thrombus weight, bleeding time, activated partial thromboplastin time, activated clotting time, and anti-factor Xa activity. The intravital tissue distribution, the cardiorespiratory, and organ toxicity were monitored. HBC diminished antithrombotic and anticoagulant effects of unfractionated heparin. Moreover, it stopped bleeding and completely reversed the enhancement of clotting times and anti-factor Xa activity caused by enoxaparin or fondaparinux. We observed slight pulmonary congestion and cell infiltration, but the cardiorespiratory parameters remained unchanged. We found a strong signal of fluorescently-labeled HBC in the urine, and a weaker in the liver and in the kidney. No signs of hepatic or nephrotoxicity were observed in the blood biochemistry or histopathologic examination. We developed a copolymer efficiently neutralizing effects of heparins in the living organism, which shows a very promising efficacy/safety profile and may help in the management of uncontrolled bleeding resulting from an anticoagulant injection. HBC could enable the safe replacement of unfractionated heparin with low-molecular weight heparins in patients undergoing cardiac surgery and complex vascular procedures.
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Affiliation(s)
- Bartlomiej Kalaska
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Kamil Kaminski
- Faculty of Chemistry, Jagiellonian University, Krakow, Poland
| | - Joanna Miklosz
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Shin-Ichi Yusa
- Department of Applied Chemistry, Graduate School of Engineering, University of Hyogo, Himeji, Hyogo, Japan
| | - Emilia Sokolowska
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Agnieszka Blazejczyk
- Department of Experimental Oncology, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland
| | - Joanna Wietrzyk
- Department of Experimental Oncology, Ludwik Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Sciences, Wroclaw, Poland
| | - Irena Kasacka
- Department of Histology and Cytophysiology, Medical University of Bialystok, Bialystok, Poland
| | | | - Dariusz Pawlak
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | | | - Andrzej Mogielnicki
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland.
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Abstract
PURPOSE OF REVIEW Blood coagulation exists to halt excessive blood loss. It is paradoxical that surgery and trauma simultaneously represent major risk factors for both hemorrhagic and thrombotic complications. A summary of the available evidence used to guide contemporary approaches to perioperative care will be reviewed. RECENT FINDINGS Although the advent of factor-specific products has safely allowed for intervention on patients with congenital hemostatic defects, the presence of an increasingly complex surgical population (chronic liver disease, traumatic injuries, and requirements for chronic anticoagulation) has renewed concerns about hemorrhagic risks. However, the past three decades of clinical sciences have supported a re-emphasis on the prevention of venous thromboembolism (VTE), a major cause of morbidity and mortality in hospitalized surgical patients. There is now an abundance of data confirming the robust risk:benefit ratio of antithrombotic prophylaxis in the vast majority of surgical patients, regardless of their medical comorbidities. SUMMARY Perioperative hemorrhage is a natural risk of any surgical intervention and deserves careful evaluation and prompt intervention. However, in order to support ongoing efforts in the prevention of medical errors, the application of evidence-based guidelines for the prophylaxis of VTE in surgical patients must become a standard part of daily practice.
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Monitoring low molecular weight heparins at therapeutic levels: dose-responses of, and correlations and differences between aPTT, anti-factor Xa and thrombin generation assays. PLoS One 2015; 10:e0116835. [PMID: 25625201 PMCID: PMC4308107 DOI: 10.1371/journal.pone.0116835] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 12/15/2014] [Indexed: 11/19/2022] Open
Abstract
Background Low molecular weight heparins (LMWH’s) are used to prevent and treat thrombosis. Tests for monitoring LMWH’s include anti-factor Xa (anti-FXa), activated partial thromboplastin time (aPTT) and thrombin generation. Anti-FXa is the current gold standard despite LMWH’s varying affinities for FXa and thrombin. Aim To examine the effects of two different LMWH’s on the results of 4 different aPTT-tests, anti-FXa activity and thrombin generation and to assess the tests’ concordance. Method Enoxaparin and tinzaparin were added ex-vivo in concentrations of 0.0, 0.5, 1.0 and 1.5 anti-FXa international units (IU)/mL, to blood from 10 volunteers. aPTT was measured using two whole blood methods (Free oscillation rheometry (FOR) and Hemochron Jr (HCJ)) and an optical plasma method using two different reagents (ActinFSL and PTT-Automat). Anti-FXa activity was quantified using a chromogenic assay. Thrombin generation (Endogenous Thrombin Potential, ETP) was measured on a Ceveron Alpha instrument using the TGA RB and more tissue-factor rich TGA RC reagents. Results Methods’ mean aPTT at 1.0 IU/mL LMWH varied between 54s (SD 11) and 69s (SD 14) for enoxaparin and between 101s (SD 21) and 140s (SD 28) for tinzaparin. ActinFSL gave significantly shorter aPTT results. aPTT and anti-FXa generally correlated well. ETP as measured with the TGA RC reagent but not the TGA RB reagent showed an inverse exponential relationship to the concentration of LMWH. The HCJ-aPTT results had the weakest correlation to anti-FXa and thrombin generation (Rs0.62–0.87), whereas the other aPTT methods had similar correlation coefficients (Rs0.80–0.92). Conclusions aPTT displays a linear dose-respone to LMWH. There is variation between aPTT assays. Tinzaparin increases aPTT and decreases thrombin generation more than enoxaparin at any given level of anti-FXa activity, casting doubt on anti-FXa’s present gold standard status. Thrombin generation with tissue factor-rich activator is a promising method for monitoring LMWH’s.
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Kitchen S, Gray E, Mackie I, Baglin T, Makris M. Measurement of non-Coumarin anticoagulants and their effects on tests of Haemostasis: Guidance from the British Committee for Standards in Haematology. Br J Haematol 2014; 166:830-41. [DOI: 10.1111/bjh.12975] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Steve Kitchen
- Sheffield Haemophilia and Thrombosis Centre; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - Elaine Gray
- Haemostasis section; Biotherapeutics Group; National Institute for Biological Standards and Control; Potters Bar UK
| | - Ian Mackie
- Haemostasis Research Unit; Department of Haematology; University College London; London UK
| | - Trevor Baglin
- Department of Haematology; Addenbrooke's Hospital; Cambridge UK
| | - Mike Makris
- Sheffield Haemophilia and Thrombosis Centre; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
- Department of Cardiovascular Science; University of Sheffield; Sheffield UK
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Ingle RG, Agarwal AS. A world of low molecular weight heparins (LMWHs) enoxaparin as a promising moiety—A review. Carbohydr Polym 2014; 106:148-53. [DOI: 10.1016/j.carbpol.2014.01.100] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 01/21/2014] [Accepted: 01/30/2014] [Indexed: 12/23/2022]
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Bhatty S, Ali A, Shetty R, Sumption KF, Topaz O, Jovin IS. Contemporary anticoagulation therapy in patients undergoing percutaneous intervention. Expert Rev Cardiovasc Ther 2014; 12:451-61. [PMID: 24506409 DOI: 10.1586/14779072.2014.885839] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The proper use of anticoagulants is crucial for ensuring optimal patient outcomes post percutaneous interventions in the cardiac catheterization laboratory. Anticoagulant agents such as unfractionated heparin, a thrombin inhibitor; low-molecular weight heparins, predominantly Factor Xa inhibitors; fondaparinux, a Factor Xa inhibitor and bivalirudin, a direct thrombin inhibitor have been developed to target various steps in the coagulation cascade to prevent formation of thrombin. Optimal anticoagulation achieves the correct balance between thrombosis and bleeding and is related to optimal outcomes with minimal complications. This review will discuss the mechanisms and appropriate use of current and emerging anticoagulant therapies used during percutaneous interventions.
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Affiliation(s)
- Shaun Bhatty
- Department of Internal Medicine, Cardiovascular Division, Virginia Commonwealth University Health System/Medical College of Virginia, Richmond, VA, USA
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Abstract
Since percutaneous transluminal coronary angioplasty was first described and the breakthrough studies of the role of stents were reported, the evolution in anticoagulation and antiplatelet therapy used during percutaneous coronary intervention (PCI) has reduced periprocedural ischemic events and stent thrombosis. Although greater combinations and doses of anticoagulation with antiplatelets seem to provide the best protection against thrombogenic and embolic events, there is a significant trade-off with a higher risk of major and minor bleeding episodes. This review article expands on each of the commonly used antiplatelet and anticoagulants used at time of PCI, focusing on drug monitoring and reversal.
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Affiliation(s)
- Gregory W Yost
- Department of Cardiology, Geisinger Medical Center, 100 North Academy Avenue, Danville, PA 17822, USA.
| | - Steven R Steinhubl
- Department of Cardiology, Geisinger Medical Center, 100 North Academy Avenue, Danville, PA 17822, USA
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A novel method for the direct determination of heparin concentration during cardiopulmonary bypass surgery. Clin Chem Lab Med 2013; 51:2037-43. [DOI: 10.1515/cclm-2013-0278] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Accepted: 05/24/2013] [Indexed: 11/15/2022]
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Kluft C, Meijer P, Kret R, Burggraaf J. Preincubation in the Prothrombinase-induced Clotting Time test (PiCT) is necessary for in vitro evaluation of fondaparinux and to be avoided for the reversible, direct factor Xa inhibitor, rivaroxaban. Int J Lab Hematol 2012; 35:379-84. [PMID: 23151091 DOI: 10.1111/ijlh.12027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 09/03/2012] [Indexed: 11/27/2022]
Abstract
INTRODUCTION There is no clear consensus about tests in vitro that are suitable for evaluating various factor Xa inhibitors. The availability of reversible and irreversible inhibitors further complicates the application of available assays. METHODS We evaluated the suitability of the prothrombinase-induced clotting test (PiCT) for fondaparinux and rivaroxaban, as representatives for irreversible and reversible inhibition of factor Xa, with specific attention to preincubation times prior to re-calcification, in the context of automate program limitations. RESULTS We demonstrate that the PiCT assay requires a preincubation step to allow inhibitory activity by fondaparinux. Without this step, inhibition in the test is minimal and lacking sufficient dynamic range. In contrast, to measure the reversible inhibition by rivaroxaban, we found any preincubation introduced an artifact in inhibition as exemplified by a biphasic pattern and only the test without a preincubation phase gave informative results. CONCLUSION It is concluded that PiCT in its format with two steps is suitable for fondaparinux evaluation, while its format without preincubation (the one-addition format) is suitable for reversible inhibitors such as rivaroxaban. Unfortunately, both types of inhibitors cannot be compared in vitro in a single assay format.
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Affiliation(s)
- C Kluft
- Centre for Human Drug Research, Leiden, The Netherlands.
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Abstract
Lupus anticoagulants are autoantibodies that are associated with an increased risk of thromboembolic events and adverse pregnancy outcomes. They are identified by a systematic, laboratory-based approach that includes the following steps: 1) prolongation of a phospholipid-dependent screening assay, 2) demonstration of an inhibitory activity by mixing studies with healthy pooled plasma, and 3) documentation that the inhibitory activity is phospholipid dependent. Laboratory testing can be complicated by several variables, however, including preanalytical factors, multiple reagents and testing platforms, and difficulties with interpreting the results. Guidelines have been developed through several professional organizations that build upon the steps listed above and provide guidance to improve the reproducibility of test results. This article reviews the guidelines developed by the Lupus Anticoagulant/Phospholipid Dependent Antibodies Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis and addresses several common issues encountered during testing for these clinically relevant autoantibodies.
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Ortel TL. Antiphospholipid syndrome: laboratory testing and diagnostic strategies. Am J Hematol 2012; 87 Suppl 1:S75-81. [PMID: 22473619 DOI: 10.1002/ajh.23196] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Accepted: 03/05/2012] [Indexed: 12/13/2022]
Abstract
The antiphospholipid syndrome (APS) is diagnosed in patients with recurrent thromboembolic events and/or pregnancy loss in the presence of persistent laboratory evidence for antiphospholipid antibodies. Diagnostic tests for the detection of antiphospholipid antibodies include laboratory assays that detect anticardiolipin antibodies, lupus anticoagulants, and anti-β(2)-glycoprotein I antibodies. These assays have their origins beginning >60 years ago, with the identification of the biologic false positive test for syphilis, the observation of "circulating anticoagulants" in certain patients with systemic lupus erythematosus, the identification of cardiolipin as a key component in the serologic test for syphilis, and the recognition and characterization of a "cofactor" for antibody binding to phospholipids. Although these assays have been used clinically for many years, there are still problems with the accurate diagnosis of patients with this syndrome. For example, lupus anticoagulant testing can be difficult to interpret in patients receiving anticoagulant therapy, but most patients with a thromboembolic event will already be anticoagulated before the decision to perform the tests has been made. In addition to understanding limitations of the assays, clinicians also need to be aware of which patients should be tested and not obtain testing on patients unlikely to have APS. New tests and diagnostic strategies are in various stages of development and should help improve our ability to accurately diagnose this important clinical disorder.
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Affiliation(s)
- Thomas L Ortel
- Division of Hematology, Duke University Medical Center, Durham, North Carolina, USA.
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Comparison of the anticoagulant response of a novel fluorogenic anti-FXa assay with two commercial anti-FXa chromogenic assays. Thromb Res 2011; 128:e166-70. [DOI: 10.1016/j.thromres.2011.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 07/22/2011] [Accepted: 08/02/2011] [Indexed: 10/17/2022]
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Role of factor xa inhibitors in cancer-associated thrombosis: any new data? Adv Hematol 2011; 2011:196135. [PMID: 22013445 PMCID: PMC3195274 DOI: 10.1155/2011/196135] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2011] [Revised: 08/10/2011] [Accepted: 08/11/2011] [Indexed: 12/12/2022] Open
Abstract
The association between cancer and venous thromboembolism (VTE) has been well documented in the literature. Prevention and treatment of VTE in cancer patients is imperative. Typically, the mainstay regimen for VTE prevention and treatment has been anticoagulation therapy, unless contraindicated. This therapy consists of unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), factor Xa inhibitor, or vitamin K antagonist (VKA). Current guidelines recommend LMWH over VKA for the treatment of VTE in cancer patients. Factor-specific anticoagulants have been proven safe and effective, and recently factor Xa inhibitors have emerged as a treatment alternative to heparins and VKA. Currently, three factor Xa inhibitors have been identified: fondaparinux (the only one approved so far by the US Food and Drug Administration), idraparinux (in clinical trials), and idrabiotaparinux (in clinical trials). This paper will examine the role of these agents, focusing on fondaparinux, for the prevention and treatment of VTE in cancer patients.
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Gulati A, Faed JM, Isbister GK, Duffull SB. Development and Evaluation of a Prototype of a Novel Clotting Time Test to Monitor Enoxaparin. Pharm Res 2011; 29:225-35. [DOI: 10.1007/s11095-011-0537-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 07/07/2011] [Indexed: 11/30/2022]
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Perry DJ, Fitzmaurice DA, Kitchen S, Mackie IJ, Mallett S. Point-of-care testing in haemostasis. Br J Haematol 2010; 150:501-14. [PMID: 20618331 DOI: 10.1111/j.1365-2141.2010.08223.x] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Point-of-care testing (POCT) in haematology has seen a significant increase in both the spectrum of tests available and the number of tests performed annually. POCT is frequently undertaken with the belief that this will reduce the turnaround time for results and so improve patient care. The most obvious example of POCT in haemostasis is the out-of-hospital monitoring of the International Normalized Ratio in patients receiving a vitamin K antagonist, such as warfarin. Other areas include the use of the Activated Clotting Time to monitor anticoagulation for patients on cardio-pulmonary bypass, platelet function testing to identify patients with apparent aspirin or clopidogrel resistance and thrombelastography to guide blood product replacement during cardiac and hepatic surgery. In contrast to laboratory testing, POCT is frequently undertaken by untrained or semi-trained individuals and in many cases is not subject to the same strict quality control programmes that exist in the central laboratory. Although external quality assessment programmes do exist for some POCT assays these are still relatively few. The use of POCT in haematology, particularly in the field of haemostasis, is likely to expand and it is important that systems are in place to ensure that the generated results are accurate and precise.
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Affiliation(s)
- David J Perry
- Department of Haematology, Addenbrooke's Hospital, Cambridge, UK.
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Uchikawa Y, Ikegami T, Masuda Y, Ohno Y, Mita A, Urata K, Nakazawa Y, Terada M, Miyagawa S. Administration of dalteparin based on the activated clotting time for prophylaxis of hepatic vessel thrombosis in living donor liver transplantation. Transplant Proc 2010; 41:3784-90. [PMID: 19917388 DOI: 10.1016/j.transproceed.2009.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2009] [Accepted: 04/13/2009] [Indexed: 12/17/2022]
Abstract
Beginning in 2004, dalteparin doses based on activated clotting time (ACT) were administered for hepatic vessel thrombosis prophylaxis in living donor liver transplantation (LDLT). We verified the feasibility of this new therapy by comparing it with the previous one. From 1993 through 2008, 42 metabolic liver patients who underwent LDLT were divided into two groups. Group A (1993-2003, n = 32) was administered a fixed dalteparin dose and a large amount of fresh frozen plasma (FFP); Group B (2004-2008, n = 10) was administered an appropriate dosage of dalteparin to maintain the ACT levels from 140 to 150 seconds and a small amount of FFP. Group B was administered a lesser amount of FFP and more dalteparin. This resulted in longer activated partial thromboplastin time, lower fibrinogen degradation products D-dimer, and lower aspartate aminotransferase levels compared to group A; all differences were significant. Group B showed neither thrombotic nor hemorrhagic complications. Anticoagulation therapy comprising adjustment of the dalteparin dose based on ACT reduces thrombotic complications without increasing hemorrhagic complications. ACT measurement is a simple, reliable method for bedside monitoring of dalteparin anticoagulant effects for LDLT.
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Affiliation(s)
- Y Uchikawa
- Department of Surgery, Shinshu University School of Medicine, Nagano, Japan
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Sanfelippo MJ, Tillema VB. Automated assay for fondaparinux (Arixtra) on the Dade Behring BCS XP. Am J Clin Pathol 2009; 132:608-12. [PMID: 19762539 DOI: 10.1309/ajcpa8knnllcv4ji] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
An assay for fondaparinux (Arixtra) is described based on a modified commercial assay for heparin. The assay is automated on a Dade Behring BCS XP (Siemens Healthcare Diagnostics, Deerfield, IL) and uses the inhibition of activated factor X to quantitate the drug. The assay was unaffected by platelet contamination or the presence of warfarin. The assay was affected by the antithrombin level, and the value obtained in the assay decreased significantly when the antithrombin level was less than 60%. The assay is, however, not specific for fondaparinux. Specimens containing unfractionated or low-molecular-weight heparin will yield results by this assay that will not be an accurate estimation of concentration.
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Affiliation(s)
- Michael J. Sanfelippo
- Department of Hematology/Coagulation Services, Marshfield Labs, Marshfield Clinic, Marshfield, WI
| | - Veronica B. Tillema
- Department of Hematology/Coagulation Services, Marshfield Labs, Marshfield Clinic, Marshfield, WI
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Thrombelastography versus AntiFactor Xa levels in the assessment of prophylactic-dose enoxaparin in critically ill patients. ACTA ACUST UNITED AC 2009; 66:1509-15; discussion 1515-7. [PMID: 19509608 DOI: 10.1097/ta.0b013e3181a51e33] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A standard dose of enoxaparin is frequently used for deep venous thrombosis (DVT) prophylaxis. Evidence suggests inconsistent bioavailability in intensive care unit (ICU) patients. Antifactor Xa activity (anti-Xa) has been used to monitor enoxaparin dosing but its accuracy and availability are problematic. Thrombelastography (TEG) is used to evaluate coagulation in diverse settings. The purpose of this study was to analyze whether TEG could be used to predict which enoxaparin-treated patients would develop DVT. METHODS Two hundred sixty-one simultaneous enoxaparin-active (active) and enoxaparin-neutralized (neutral) TEGs were performed in 61 surgical ICU patients over four consecutive days. Patient characteristics and anti-Xa were collected. DVT screening was per ICU protocol. RESULTS Mean (+/-SEM) age was 54 (+/-2.3) years and Acute Physiology and Chronic Health Evaluation II score was 17 (+/-0.7). There were 30 trauma and 31 general surgery patients (69% men). The DVT rate was 28%. Time to clot formation (R) and percent lysis at 30 minutes were different between active versus neutralized blood (p < 0.001). R time was 1.5 minutes shorter in patients with DVT versus those without (p < 0.001) indicating hypercoagulability in DVT patients. Anti-Xa levels were similar in patients with (0.135 +/- 0.012) and without (0.135 +/- 0.007) DVT (p = 0.97). There were no differences in age, body mass index, injury severity score, Acute Physiology and Chronic Health Evaluation II score, or trauma status between DVT and non-DVT groups. CONCLUSIONS TEG demonstrates differences between enoxaparin-neutralized and enoxaparin-active blood in ICU patients that may be used to guide dosing. TEG differentiates enoxaparin-treated patients who subsequently develop DVT while anti-Xa levels do not. TEG demonstrates an enoxaparin-related increase in fibrinolysis.
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Zhang P, Huang W, Wang L, Bao L, Jia ZJ, Bauer SM, Goldman EA, Probst GD, Song Y, Su T, Fan J, Wu Y, Li W, Woolfrey J, Sinha U, Wong PW, Edwards ST, Arfsten AE, Clizbe LA, Kanter J, Pandey A, Park G, Hutchaleelaha A, Lambing JL, Hollenbach SJ, Scarborough RM, Zhu BY. Discovery of betrixaban (PRT054021), N-(5-chloropyridin-2-yl)-2-(4-(N,N-dimethylcarbamimidoyl)benzamido)-5-methoxybenzamide, a highly potent, selective, and orally efficacious factor Xa inhibitor. Bioorg Med Chem Lett 2009; 19:2179-85. [DOI: 10.1016/j.bmcl.2009.02.111] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 02/25/2009] [Accepted: 02/26/2009] [Indexed: 10/21/2022]
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Zhang P, Bao L, Fan J, Jia ZJ, Sinha U, Wong PW, Park G, Hutchaleelaha A, Scarborough RM, Zhu BY. Anthranilamide-based N,N-dialkylbenzamidines as potent and orally bioavailable factor Xa inhibitors: P4 SAR. Bioorg Med Chem Lett 2009; 19:2186-9. [DOI: 10.1016/j.bmcl.2009.02.114] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 02/25/2009] [Accepted: 02/26/2009] [Indexed: 11/29/2022]
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Abstract
Fondaparinux is a new anticoagulant that interacts with antithrombin III and activated coagulation factor X resulting in an inhibition of the coagulation system. It has been successful in doses of 2.5 mg for thromboprophylaxis as well as in higher therapeutic doses of 5-7.5 mg. No optimal method for monitoring the effects of fondaparinux has been proposed. The aim of the present study was to investigate whether a viscoelastic coagulation analyzer, the Sonoclot (Sienco, Denver, Colorado, USA), could be used for in-vitro monitoring of fondaparinux. Different concentrations of fondaparinux were added in vitro to whole blood taken from eight volunteers. The blood samples mixed with the various amounts of fondaparinux were analyzed using the Sonoclot. The whole-blood activated partial thromboplastin time with the Hemochron Jr (ITC, Edison, New Jersey, USA) was used as the reference coagulation analysis. All analyses were started expeditiously, within 30 s from sampling, and were performed at 37 degrees C. The values of the Sonoclot parameter clot rate, which measures the rate of fibrin formation, fibrin polymerization and platelet-fibrin interactions, were significantly correlated to increasing concentrations of fondaparinux (R = -0.90). The Sonoclot parameters of activated coagulation time, time to peak and clot retraction had weaker, but still significant, correlations to fondaparinux concentrations. At prophylactic doses (0.38 microg/ml blood) the clot rate decreased 15% compared with the initial unanticoagulated value, whereas at therapeutic doses (1.53 microg/ml blood) there was a 27% decrease. In conclusion, the Sonoclot parameter clot rate could be of clinical value to individualize the fondaparinux dosage, especially the higher, therapeutic, dosages.
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Neue Methode zur Direkten Bestimmung der Heparinkonzentration im Blut. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2007. [DOI: 10.1007/s00398-007-0582-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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McRae SJ, Ginsberg JS. New anticoagulants for the prevention and treatment of venous thromboembolism. Vasc Health Risk Manag 2007; 1:41-53. [PMID: 17319097 PMCID: PMC1993925 DOI: 10.2147/vhrm.1.1.41.58936] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Anticoagulant therapy is effective at preventing the development of venous thromboembolism in high-risk patients, and reduces morbidity and mortality in individuals with established thromboembolic disease. Vitamin K antagonists and heparins are currently the most commonly used anticoagulant drugs, but they have practical limitations. Therefore, new antithrombotic agents with predictable dose-responses (thereby decreasing the need for monitoring without compromising efficacy or safety), ideally available in an oral formulation and with a rapidly reversible anticoagulant effect, are needed. New drugs fulfilling some of the above criteria have been developed and have proven to be effective agents for the treatment and prevention of venous thromboembolism.
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Affiliation(s)
- Simon J McRae
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
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Agrawal YK, Vaidya H, Bhatt H, Manna K, Brahmkshatriya P. Recent advances in the treatment of thromboembolic diseases: Venous thromboembolism. Med Res Rev 2007; 27:891-914. [PMID: 17318813 DOI: 10.1002/med.20100] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Venous thromboembolic diseases are the major concern of rising cost of healthcare and are commonest health problem across the globe. Both genetic and acquired risk factors are believed to be strongly linked with these diseases. Commonly encountered problems to the therapy include dose fixing and routine monitoring, yet some serious problems of bleeding also necessitate the immediate need to develop new agents. The review is primarily concerned with the new developments in the treatment of thromboembolic diseases. Therapeutic applications of anticoagulants, antiplatelets, and thrombolytics have been discussed in enough detail.
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Affiliation(s)
- Y K Agrawal
- Institute of Pharmacy, Nirma University of Science and Technology, Sarkhej-Gandhinagar Highway, Ahmedabad 382481, Gujarat, India.
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SreeHarsha CK, Rajasekaran S, Dhanasekararaja P. Spontaneous complete recovery of paraplegia caused by epidural hematoma complicating epidural anesthesia: a case report and review of literature. Spinal Cord 2005; 44:514-7. [PMID: 16317425 DOI: 10.1038/sj.sc.3101869] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
STUDY DESIGN Case report. SETTING Tertiary referral spinal surgery center in South India. OBJECTIVES To report a patient who developed epidural hematoma following epidural anesthesia causing acute paraplegia. Surgery was avoided due to concomitant gastrointestinal bleeding and poor general condition. Patient showed early signs of recovery with complete resolution of neurological deficits in 12 weeks. CONCLUSION Surgery can be avoided in patients who show early signs of neurological recovery following epidural hematoma.
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Affiliation(s)
- C K SreeHarsha
- Spine Surgery, Ganga Hospital, Coimbatore, Tamil Nadu, India
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Affiliation(s)
- Shannon M Bates
- Department of Medicine, McMaster University, Henderson Research Centre, Hamilton, Ontario, Canada
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Carlsson SC, Mattsson C, Eriksson UG, Sarich TC, Wåhlander K, Eliasson A, Karlson BW, Sheth SB, Held P. A review of the effects of the oral direct thrombin inhibitor ximelagatran on coagulation assays. Thromb Res 2005; 115:9-18. [PMID: 15567447 DOI: 10.1016/j.thromres.2004.07.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2004] [Revised: 06/30/2004] [Accepted: 07/01/2004] [Indexed: 10/26/2022]
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Liestøl S, Wisløff F. Effect of subcutaneous administration of dalteparin on lupus anticoagulant assays. Thromb Res 2004; 115:509-17. [PMID: 15792683 DOI: 10.1016/j.thromres.2004.11.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2004] [Revised: 11/15/2004] [Accepted: 11/16/2004] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Treatment with unfractionated heparin (UH) is known to affect screening tests for lupus anticoagulant (LA). False positive test results are common because confirmatory steps lack sufficient specificity to distinguish between LA and the presence of heparin. In this study, we wanted to see if therapeutic levels of low-molecular weight heparin (LMWH) may cause false positive tests for LA or alter the LA test results in LA-positive patients. We also wanted to evaluate the need to include heparin-neutralizing agents in the reagents. MATERIALS AND METHODS Six healthy subjects without LA and six LA-positive patients were given 100 IU/kg dalteparin subcutaneously (s.c.). Samples for three in-house and two commercially available LA tests were taken before and 4 h after the injection. LA test results were calculated as normalized screening/confirm ratios or as recommended by the manufacturers. RESULTS With both healthy subjects and LA patients, only small and clinically unimportant differences in mean clotting times and final test results were seen 4 h after subcutaneous dalteparin injections, at anti-FXa activities within the therapeutic range. CONCLUSIONS Our study with dalteparin suggests that LMWH therapy with plasma concentrations within the therapeutic range does not cause false positive tests for LA when normalized screening/confirm ratios are applied; nor do test results for LA-positive patients seem to be significantly altered. Heparin-neutralizing agents did not influence test performance.
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Affiliation(s)
- Sigurd Liestøl
- Haematological Research Laboratory, Medical Clinic, Ullevål University Hospital, N-0407 Oslo, Norway.
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Abstract
Treatment of venous thromboembolism (VTE) usually starts with concomitant administration of heparin or low-molecular-weight heparin (LMWH) and a vitamin K antagonist. The parenteral anticoagulant, which is given for at least 5 days, is stopped once the vitamin K antagonist produces a therapeutic level of anticoagulation. Although the introduction of LMWH has simplified the initial treatment of VTE, problems remain. LMWH must be given by daily subcutaneous (SC) injection and vitamin K antagonists require routine coagulation monitoring, which is inconvenient for patients and physicians. Recently, 3 new anticoagulants have been introduced in an attempt to overcome these limitations. These include fondaparinux and idraparinux, synthetic analogs of the pentasaccharide sequence that mediates the interaction of heparin and LMWH with antithrombin, and ximelagatran, an orally active inhibitor of thrombin. These agents produce a predictable anticoagulant response; thus, routine coagulation monitoring is unnecessary. Because they do not bind to platelets or platelet factor 4, fondaparinux and idraparinux do not cause heparin-induced thrombocytopenia (HIT). Unlike vitamin K antagonists, ximelagatran has a rapid onset of action, thereby obviating the need for concomitant administration of a parenteral anticoagulant when starting treatment. The lack of an antidote for these new agents is a drawback, particularly for idraparinux, which has a long half-life.
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Affiliation(s)
- Jeffrey I Weitz
- McMaster University and Henderson Research Centre, Hamilton, Ontario, Canada.
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You WK, Choi WS, Koh YS, Shin HC, Jang Y, Chung KH. Functional characterization of recombinant batroxobin, a snake venom thrombin-like enzyme, expressed fromPichia pastoris. FEBS Lett 2004; 571:67-73. [PMID: 15280019 DOI: 10.1016/j.febslet.2004.06.060] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2004] [Revised: 06/10/2004] [Accepted: 06/25/2004] [Indexed: 11/26/2022]
Abstract
A thrombin-like enzyme of Bothrops atrox moojeni venom, batroxobin, specifically cleaves fibrinogen alpha chain, resulting in the formation of non-crosslinked fibrin clots. The cDNA encoding batroxobin was cloned, expressed in Pichia pastoris and the molecular function of purified recombinant protein was also characterized. The recombinant batroxobin had an apparent molecular weight of 33 kDa by SDS-PAGE analysis and biochemical activities similar to those of native batroxobin. The purified recombinant protein strongly converted fibrinogen into fibrin clot in vitro, and shortened bleeding time and whole blood coagulation time in vivo. However, it did not make any considerable alterations on other blood coagulation factors. Several lines of experimental evidence in this study suggest that the recombinant batroxobin is a potent pro-coagulant agent.
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Affiliation(s)
- Weon-Kyoo You
- R&D Center, Biobud Co. Ltd., Seoul 120-110, Republic of Korea
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Abstract
Fondaparinux is the first synthetic selective factor-Xa inhibitor. It is indicated for prophylaxis of deep vein thrombosis in patients undergoing hip fracture, hip replacement, and knee replacement surgeries. In these patients, fondaparinux appears to be more efficacious than enoxaparin. It is a safe and effective, but expensive, alternative to the available antithrombotic agents. Its long half-life allows for once-daily dosing, yet a truly viable antidote is not available in the event of overanticoagulation. Trials are currently underway to determine its efficacy and safety for the treatment of deep vein thrombosis, unstable angina, and acute myocardial infarction, as well as its role in coronary angioplasty.
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Affiliation(s)
- Nina N Wong
- Department of Pharmacy, Montefiore Medical Center, Bronx, NY 10467, USA.
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Saw J, Kereiakes DJ, Mahaffey KW, Applegate RJ, Braden GA, Brent BN, Brodie BR, Groce JB, Levine GN, Leya F, Moliterno DJ. Evaluation of a novel point-of-care enoxaparin monitor with central laboratory anti-Xa levels. Thromb Res 2003; 112:301-6. [PMID: 15041274 DOI: 10.1016/j.thromres.2004.01.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2003] [Accepted: 01/13/2004] [Indexed: 11/22/2022]
Abstract
BACKGROUND Measurement of enoxaparin's anticoagulant activity has been limited to specialized coagulation laboratories and has been impractical for areas needing rapid results, such as during coronary angioplasty. A new point-of-care device, Rapidpoint ENOX, was recently developed to measure clotting times with enoxaparin use. OBJECTIVES To correlate ENOX times with anti-Xa levels among patients receiving enoxaparin. METHODS A total of 166 patients receiving enoxaparin for the prevention of deep venous thrombosis or as treatment during acute coronary syndromes or angioplasty were prospectively studied. Citrated and non-citrated whole-blood (CWB and NCWB) samples were obtained at baseline and peak enoxaparin activity. ENOX times were measured with whole-blood, and the Stachrom anti-Xa assay was performed on the plasma from the remainder of the samples. The Pearson correlation coefficient was used to assess the relationship between these two assays. RESULTS There was a strong linear correlation between the ENOX times and the anti-Xa activities for both CWB (r=0.89, p<0.001) and NCWB (r=0.82, p<0.001) when considering all 332 samples (baseline and peak). When baseline samples were excluded, the correlation remained strong for CWB ENOX times and anti-Xa levels (r=0.84, p<0.001), but was only moderate for NCWB (r=0.73, p<0.001). A CWB ENOX time of </=160 s corresponded to anti-Xa level of </=0.5 IU/ml in 95% (188/197) of patients. A CWB ENOX time >/=200 s corresponded to anti-Xa levels >/=0.8 IU/ml in 96% (93/96) of patients. CONCLUSIONS Rapidpoint ENOX times correlate strongly to anti-Xa activities measured by the Stachrom Heparin Assays for citrated whole-blood samples. This novel test can be used for rapid bedside measurements of enoxaparin anticoagulant activity.
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Affiliation(s)
- Jacqueline Saw
- Department of Cardiovascular Medicine, The Cleveland Clinic Foundation, Cleveland, OH, USA
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