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Maier CL, Connors JM, Levy JH. Troubleshooting heparin resistance. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2024; 2024:186-191. [PMID: 39643992 DOI: 10.1182/hematology.2024000659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/09/2024]
Abstract
The term heparin resistance is likely best defined as the failure of an appropriate dose of unfractionated heparin (UFH) to achieve a predetermined level of anticoagulation. Unfortunately, and despite many prior reports, there is no established consensus as to what either the appropriate dose or the predetermined level should be. Traditionally, assays used to monitor anticoagulation with UFH have been clot based, including the activated partial thromboplastin time, used for patients on the ward or intensive care unit, and the activated clotting time, used for patients undergoing vascular interventions and cardiopulmonary bypass. Unfortunately, these tests may be highly influenced by other factors occurring in many patients, especially those with inflammation or acute infection, as noted during the COVID-19 pandemic. Many hospitals have thus moved to anti-Xa testing for heparin monitoring. Another important factor in defining heparin resistance includes dosing, whether weight-based or total daily dosing is used, as initial reports of heparin resistance described daily doses independent of body weight. Multiple causes of apparent heparin resistance include hypercoagulability, antithrombin deficiency, andexanet alfa used for direct oral anticoagulant reversal, thrombocytosis, and antiphospholipid antibody syndromes. Treatment options for managing patients with heparin resistance include weight-based dosing and administration of additional UFH, antithrombin supplementation, or the use of an alternative anticoagulant such as the direct thrombin inhibitors bivalirudin or argatroban.
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Affiliation(s)
- Cheryl L Maier
- Department of Pathology and Laboratory Medicine, Emory School of Medicine, Atlanta, GA
| | - Jean M Connors
- Department of Medicine, Hematology Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC
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2
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Youssef MR, Martinez E, Pinnock TM, Gonzalez-Estrada A, Smith MM, Smith BB. Assessment of Perioperative Protamine Reactions in Patients With Fish Allergies: A Retrospective Observational Study. J Cardiothorac Vasc Anesth 2024; 38:2925-2931. [PMID: 39261207 DOI: 10.1053/j.jvca.2024.08.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2024] [Revised: 08/10/2024] [Accepted: 08/16/2024] [Indexed: 09/13/2024]
Abstract
OBJECTIVES To retrospectively assess the incidence and severity of perioperative protamine reactions in adult patients with documented history of fish allergy. DESIGN Retrospective observational study. SETTING Large academic tertiary referral center. PARTICIPANTS Adults with fish allergies undergoing surgeries involving protamine, between January 1, 2008, and March 1, 2018. INTERVENTIONS Perioperative protamine administration in patients with documented fish allergy. MEASUREMENTS AND MAIN RESULTS Perioperative protamine and anaphylactic reactions were reviewed. A diagnosis of anaphylaxis or protamine reaction was based on clinical suspicion, perioperative events, and postoperative evaluations. Among 214 patients, 2 cases (<1%) of anaphylaxis or protamine reactions occurred. Cardiac procedures were most common (67%). The median intraoperative heparin dosage was 46,000 IU, and the median protamine dosage was 310 mg. Nearly all patients (99%) were admitted to the intensive care unit postoperatively, with a median hospital stay of 6.5 days (interquartile range, 5.2-14.6 days). There were 3 deaths (1%) within 30 days, and 15 (7%) within 1 year. CONCLUSIONS The study findings suggest that in patients with a history of fish allergy, cross-reactivity with protamine is unlikely, as anaphylaxis and/or protamine reactions were rare in this patient population in the perioperative environment. Based on these findings, this study does not recommend avoiding protamine solely based on a history of fish allergy when heparin reversal is required during surgery.
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Affiliation(s)
- Mohanad R Youssef
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ
| | - Eryberto Martinez
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ
| | - Terrique M Pinnock
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL
| | - Alexei Gonzalez-Estrada
- Division of Allergy, Asthma and Clinical Immunology, Department of Medicine, Mayo Clinic, Phoenix, AZ
| | - Mark M Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Bradford B Smith
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, AZ.
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3
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Tanaka KA, Levy JH. Andexanet alfa or prothrombin complex concentrate for acute reversal of oral factor Xa inhibitors: monitoring of antidote effects. Br J Anaesth 2024; 132:215-217. [PMID: 38071150 DOI: 10.1016/j.bja.2023.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/17/2023] [Accepted: 11/19/2023] [Indexed: 01/21/2024] Open
Abstract
This study in vitro comprehensively assessed reversal of the anticoagulant effects of rivaroxaban, an oral factor Xa inhibitor, using andexanet alfa and various prothrombin complex concentrate (PCC) products in a battery of tests. In static coagulation assays, andexanet alpha outperformed PCCs except for activated PCC being more effective in standard coagulation times. However, in a flow chamber model mimicking arterial shear, both andexanet alpha and high-concentration PCC restored fibrin formation, but not platelet adhesion. In the Russell's viper venom test and anti-Xa assay, only andexanet alpha could be tested for efficacy. The antidote effects of andexanet alpha and PCCs in restoring coagulation can be qualitatively or selectively demonstrated using in vitro coagulation tests.
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Affiliation(s)
- Kenichi A Tanaka
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA.
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University Medical Center, Durham, NC, USA
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Takagi K, Fukuda T, Saku K, Tayama E. A Case of Andexanet Alfa Induced Heparin Resistance in Emergent Aortic Surgery: Successful Anticoagulation Management Using Antithrombin Administration. Cureus 2023; 15:e50856. [PMID: 38249168 PMCID: PMC10798854 DOI: 10.7759/cureus.50856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Andexanet alfa (AnAl) is utilized for the urgent reversal of direct oral anticoagulants (DOACs) in cases of severe bleeding. While the guidelines from the Society of Thoracic Surgeons recommend AnAl for urgent cardiac surgery in patients treated with DOACs, concerns persist regarding the potential of AnAl to induce heparin resistance. This report details the case of an 85-year-old woman diagnosed with acute type A aortic dissection, who received AnAl due to prior edoxaban use. During the emergent aortic surgery, she exhibited heparin resistance following the administration of unfractionated heparin (UFH). The administration of antithrombin III (ATIII) significantly influenced activated clotting times, facilitating successful surgery while maintaining adequate anticoagulation. This case underscores the importance of cautious management of AnAl-induced heparin resistance during critical surgeries, emphasizing the role of ATIII supplementation for effective anticoagulation.
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Affiliation(s)
- Kazuyoshi Takagi
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University, Kurume, JPN
| | - Tomofumi Fukuda
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University, Kurume, JPN
| | - Kosuke Saku
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University, Kurume, JPN
| | - Eiki Tayama
- Division of Cardiovascular Surgery, Department of Surgery, Kurume University, Kurume, JPN
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5
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Amaral S, Lozano-Fernández T, Sabin J, Gallego A, da Silva Morais A, Reis RL, González-Fernández Á, Pashkuleva I, Novoa-Carballal R. End-on PEGylation of heparin: Effect on anticoagulant activity and complexation with protamine. Int J Biol Macromol 2023; 249:125957. [PMID: 37499705 DOI: 10.1016/j.ijbiomac.2023.125957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/20/2023] [Accepted: 07/15/2023] [Indexed: 07/29/2023]
Abstract
Heparin is the most common anticoagulant used in clinical practice but shows some downsides such as short half-life (for the high molecular weight heparin) and secondary effects. On the other hand, its low molecular weight analogue cannot be neutralized with protamine, and therefore cannot be used in some treatments. To address these issues, we conjugated polyethylene glycol (PEG) to heparin reducing end (end-on) via oxime ligation and studied the interactions of the conjugate (Hep-b-PEG) with antithrombin III (AT) and protamine. Isothermal titration calorimetry showed that Hep-b-PEG maintains the affinity to AT. Dynamic light scattering demonstrated that the Hep-b-PEG formed colloidal stable nanocomplexes with protamine instead of large multi-molecular aggregates, associated with heparin side effects. The in vitro (human plasma) and in vivo experiments (Sprague Dawley rats) evidenced an extended half-life and higher anticoagulant activity of the conjugate when compared to unmodified heparin.
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Affiliation(s)
- Sandra Amaral
- 3B's Research Group, I3B's Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, 4805-017 Barco, Portugal; ICVS/3B's - PT Government Associate Laboratory, University of Minho, Portugal
| | - Tamara Lozano-Fernández
- NanoImmunoTech, Edificio CITEXVI Fonte das Abelleiras s/n, Campus Universitario de Vigo, 36310 Vigo, Pontevedra, Spain
| | - Juan Sabin
- AFFINImeter Scientific & Development Team, Software 4 Science Developments, Santiago de Compostela, A Coruña 15782, Spain; Departamento de Física Aplicada, Facultad de Física, Universidad de Santiago de Compostela, Santiago de Compostela, Spain
| | - Amanda Gallego
- NanoImmunoTech, Edificio CITEXVI Fonte das Abelleiras s/n, Campus Universitario de Vigo, 36310 Vigo, Pontevedra, Spain
| | - Alain da Silva Morais
- 3B's Research Group, I3B's Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, 4805-017 Barco, Portugal; ICVS/3B's - PT Government Associate Laboratory, University of Minho, Portugal
| | - Rui L Reis
- 3B's Research Group, I3B's Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, 4805-017 Barco, Portugal; ICVS/3B's - PT Government Associate Laboratory, University of Minho, Portugal
| | - África González-Fernández
- NanoImmunoTech, Edificio CITEXVI Fonte das Abelleiras s/n, Campus Universitario de Vigo, 36310 Vigo, Pontevedra, Spain; CINBIO, Universidade de Vigo, Campus Universitario de Vigo, 36310 Vigo, Pontevedra, Spain; Instituto de Investigación Sanitaria Galicia Sur (IIS-GS), Hospital Alvaro Cunqueiro, Estrada Clara Campoamor, 36312 Vigo, Pontevedra, Spain
| | - Iva Pashkuleva
- 3B's Research Group, I3B's Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, 4805-017 Barco, Portugal; ICVS/3B's - PT Government Associate Laboratory, University of Minho, Portugal.
| | - Ramon Novoa-Carballal
- 3B's Research Group, I3B's Research Institute on Biomaterials, Biodegradables and Biomimetics, University of Minho, Headquarters of the European Institute of Excellence on Tissue Engineering and Regenerative Medicine, 4805-017 Barco, Portugal; ICVS/3B's - PT Government Associate Laboratory, University of Minho, Portugal.
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Kitaura A, Iwamoto T, Hamasaki S, Tsukimoto S, Nakajima Y. Successful Nafamostat Mesilate Administration for Andexanet Alfa-Induced Heparin Resistance. Cureus 2023; 15:e44003. [PMID: 37746371 PMCID: PMC10516723 DOI: 10.7759/cureus.44003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
Andexanet alfa is an analog of activated factor X and is used as an antagonist of anti-activated factor X agents. Andexanet alfa is useful for hemostasis in emergent bleeding during direct oral anticoagulant administration, which contributes to safety. In patients undergoing surgery with cardiopulmonary bypass because of heparin resistance, anesthesiologists are faced with a choice of anticoagulants. Herein, we experienced anesthesia for vascular prostheses with cardiopulmonary bypass for acute aortic dissection in a patient who had received andexanet alfa preoperatively. Heparin was initially used as the anticoagulant during cardiopulmonary bypass; however, despite the administration of large doses and antithrombin III preparations, anticoagulation was insufficient. Therefore, nafamostat mesilate was administered and sufficient anticoagulation was attained. The patient completed surgery under cardiopulmonary bypass, coagulation function was recovered shortly after withdrawal, and no obvious adverse effects were observed.
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7
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Angelillo-Scherrer A, Casini A, Studt JD, Gerber B, Alberio LA, Fontana P. Recommendations for the use of andexanet alfa in the management of bleeding in patients on oral factor Xa inhibitors in Switzerland: Guideline from the Working Party Hemostasis of the Swiss Society of Hematology. Swiss Med Wkly 2023; 153:40113. [PMID: 37499160 DOI: 10.57187/smw.2023.40113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
Anticoagulants are essential in preventing and treating thrombosis. Unfortunately, their use is accompanied by an enhanced risk of bleeding. Since the introduction of direct oral anticoagulants (DOACs), the risk of major bleeding has been reduced but not eliminated. Major bleeding events related to the use of factor Xa inhibitors can be challenging to manage. In recent years, four-factor prothrombin complex concentrates have been used in patients with severe bleeding taking oral direct factor Xa inhibitors (apixaban, edoxaban and rivaroxaban). Andexanet alfa (OndexxyaTM, AstraZeneca AG) is a specially designed recombinant version of human factor Xa that acts as a decoy receptor to reverse the effects of factor Xa inhibitors. Since 2 December 2020, andexanet alfa has been used in Switzerland for adult patients receiving apixaban or rivaroxaban when reversal of anticoagulation is required because of life-threatening or uncontrolled bleeding. However, the use of andexanet alfa remains a challenge owing to its cost, the reported thrombotic complications and the fact that its efficacy mainly relates to intracranial haemorrhage. Moreover, the use of nonspecific reversal agents together with andexanet alfa is controversial. The present recommendations on the use of andexanet alfa in the management of bleeding in patients on factor Xa inhibitors in Switzerland were developed by a group of Swiss experts from the Working Party Hemostasis of the Swiss Society of Hematology. These recommendations aim to provide support to clinicians in their decision-making in the management of patients with major bleeding receiving factor Xa inhibitors.
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Affiliation(s)
- Anne Angelillo-Scherrer
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alessandro Casini
- Division of Angiology and Hemostasis, Geneva University Hospital, Geneva, Switzerland
| | - Jan-Dirk Studt
- University Clinic of Hematology, Zurich University Hospital, Zurich, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Lorenzo A Alberio
- Service and Central Laboratory of Hematology, Lausanne University Hospital, Lausanne, Switzerland
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospital, Geneva, Switzerland
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8
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Levy JH, Ghadimi K, Kizhakkedathu JN, Iba T. What's fishy about protamine? Clinical use, adverse reactions, and potential alternatives. J Thromb Haemost 2023; 21:1714-1723. [PMID: 37062523 DOI: 10.1016/j.jtha.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/30/2023] [Accepted: 04/04/2023] [Indexed: 04/18/2023]
Abstract
Protamine, a highly basic protein isolated from salmon sperm, is the only clinically available agent to reverse the anticoagulation of unfractionated heparin. Following intravenous administration, protamine binds to heparin in a nonspecific electrostatic interaction to reverse its anticoagulant effects. In clinical use, protamine is routinely administered to reverse high-dose heparin anticoagulation in cardiovascular procedures, including cardiac surgery with cardiopulmonary bypass. Despite the lack of supportive evidence regarding protamine's effectiveness to reverse low-molecular-weight heparin, it is recommended in guidelines with low-quality evidence. Different dosing strategies have been reported for reversing heparin in cardiac surgical patients based on empiric dosing, pharmacokinetics, or point-of-care measurements of heparin levels. Protamine administration is associated with a spectrum of adverse reactions that range from vasodilation to life-threatening cardiopulmonary dysfunction and shock. The life-threatening responses appear to be hypersensitivity reactions due to immunoglobulin E and/or immunoglobulin G antibodies. However, protamine and heparin-protamine complexes can activate complement inflammatory pathways and inhibit other coagulation factors. Although alternative agents for reversing heparin are not currently available for clinical use, additional research continues evaluating novel therapeutic approaches.
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Affiliation(s)
- Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina, USA.
| | - Kamrouz Ghadimi
- Departments of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jayachandran N Kizhakkedathu
- Centre for Blood Research, Department of Pathology and Laboratory Medicine, The School of Biomedical Engineering, The University of British Columbia, Vancouver, British Colombia, Canada
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
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Hogwood J, Mulloy B, Lever R, Gray E, Page CP. Pharmacology of Heparin and Related Drugs: An Update. Pharmacol Rev 2023; 75:328-379. [PMID: 36792365 DOI: 10.1124/pharmrev.122.000684] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 02/17/2023] Open
Abstract
Heparin has been used extensively as an antithrombotic and anticoagulant for close to 100 years. This anticoagulant activity is attributed mainly to the pentasaccharide sequence, which potentiates the inhibitory action of antithrombin, a major inhibitor of the coagulation cascade. More recently it has been elucidated that heparin exhibits anti-inflammatory effect via interference of the formation of neutrophil extracellular traps and this may also contribute to heparin's antithrombotic activity. This illustrates that heparin interacts with a broad range of biomolecules, exerting both anticoagulant and nonanticoagulant actions. Since our previous review, there has been an increased interest in these nonanticoagulant effects of heparin, with the beneficial role in patients infected with SARS2-coronavirus a highly topical example. This article provides an update on our previous review with more recent developments and observations made for these novel uses of heparin and an overview of the development status of heparin-based drugs. SIGNIFICANCE STATEMENT: This state-of-the-art review covers recent developments in the use of heparin and heparin-like materials as anticoagulant, now including immunothrombosis observations, and as nonanticoagulant including a role in the treatment of SARS-coronavirus and inflammatory conditions.
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Affiliation(s)
- John Hogwood
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Barbara Mulloy
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Rebeca Lever
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Elaine Gray
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Clive P Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
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Beller JP, Mangunta VR, Kern JA. Nonvitamin K oral anticoagulants in cardiac surgery: Continuing education continues to evolve. J Thorac Cardiovasc Surg 2022:S0022-5223(22)01153-9. [DOI: 10.1016/j.jtcvs.2022.10.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 10/25/2022] [Indexed: 11/19/2022]
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Müther M, Schwindt W, Mesters RM, Minnerup J, Stracke P, Holling M, Wiendl H, Stummer W. Andexanet-Alfa-Associated Heparin Resistance in the Context of Hemorrhagic Stroke. Neurocrit Care 2022; 37:372-376. [PMID: 35931915 PMCID: PMC9519708 DOI: 10.1007/s12028-022-01573-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/08/2022] [Indexed: 11/28/2022]
Abstract
Background With a growing number of patients on new oral anticoagulants, interest in reversal agents is rising. Andexanet alfa is used for reversal of factor Xa inhibitors in intracranial hemorrhage. Methods We provide a brief review on andexanet-alfa-associated heparin resistance and discuss potentially critical situations from different clinical perspectives. Results Case reports point out that andexanet alfa can cause unresponsiveness to heparin, leading to catastrophic events. As a result, regulatory bodies have issued warning notices to avoid heparinization parallel to the use of andexanet alfa. Conclusions Although well known to hematologists, the phenomenon is underrecognized among stroke clinicians. However, patients with intracranial hemorrhage frequently undergo endovascular or surgical interventions that require periprocedural administration of heparin.
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Affiliation(s)
- Michael Müther
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Münster, Germany.
| | - Wolfram Schwindt
- Section of Interventional Neuroradiology, Department of Radiology, University Hospital Münster, Münster, Germany
| | - Rolf Michael Mesters
- Department of Medicine A-Hematology, Oncology, Hemostaseology, and Pneumology, University Hospital Münster, Münster, Germany
| | - Jens Minnerup
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Paul Stracke
- Section of Interventional Neuroradiology, Department of Radiology, University Hospital Münster, Münster, Germany
| | - Markus Holling
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Heinz Wiendl
- Department of Neurology With Institute of Translational Neurology, University Hospital Münster, Münster, Germany
| | - Walter Stummer
- Department of Neurosurgery, University Hospital Münster, Albert-Schweitzer-Campus 1, Münster, Germany
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12
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Bolliger D, Mauermann E, Erdoes G. A New Tool in the Management of Direct-Acting Oral Anticoagulants in Emergency Cardiac Surgery. J Cardiothorac Vasc Anesth 2022; 36:1645-1647. [PMID: 35351396 DOI: 10.1053/j.jvca.2022.02.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/23/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel Bolliger
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Eckhard Mauermann
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Medicine, Inselspital/University Hospital Bern, Bern, Switzerland
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13
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May JE, Siniard RC, Taylor LJ, Marques MB, Gangaraju R. From Activated Partial Thromboplastin Time to Antifactor Xa and Back Again. Am J Clin Pathol 2021; 157:321-327. [PMID: 34562001 PMCID: PMC8891818 DOI: 10.1093/ajcp/aqab135] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/14/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Monitoring is essential to safe anticoagulation prescribing and requires close collaboration among pathologists, clinicians, and pharmacists. METHODS We describe our experience in the evolving strategy for laboratory testing of unfractionated heparin (UFH). RESULTS An intrainstitutional investigation revealed significant discordance between activated partial thromboplastin time (aPTT) and antifactor Xa (anti-Xa) assays, prompting a transition from the former to the latter in 2013. With the increasing use of oral factor Xa inhibitors (eg, apixaban, rivaroxaban, edoxaban, betrixaban), which interfere with the anti-Xa assay, we adapted our protocol again to incorporate aPTT in patients admitted on oral Xa inhibitors who require transition to UFH. CONCLUSIONS Our experience demonstrates key challenges in anticoagulation and highlights the importance of clinical pathologists in helping health systems adapt to the changing anticoagulation landscape.
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Affiliation(s)
- Jori E May
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, USA,Corresponding author: Jori E. May, MD;
| | - Rance Chad Siniard
- Division of Laboratory Medicine, Department of Pathology, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Laura J Taylor
- UAB Coagulation Service, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Marisa B Marques
- Division of Laboratory Medicine, Department of Pathology, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Radhika Gangaraju
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, USA,Institute for Cancer Outcomes and Survivorship, School of Medicine, University of Alabama at Birmingham, Birmingham, USA
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14
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Affiliation(s)
- Jerrold H Levy
- From the Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC (J.H.L.); and the Hematology Division, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School - both in Boston (J.M.C.)
| | - Jean M Connors
- From the Departments of Anesthesiology, Critical Care, and Surgery, Duke University School of Medicine, Durham, NC (J.H.L.); and the Hematology Division, Department of Medicine, Brigham and Women's Hospital, and Harvard Medical School - both in Boston (J.M.C.)
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