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Frackiewicz A, Kalaska B, Miklosz J, Mogielnicki A. The methods for removal of direct oral anticoagulants and heparins to improve the monitoring of hemostasis: a narrative literature review. Thromb J 2023; 21:58. [PMID: 37208753 DOI: 10.1186/s12959-023-00501-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 05/10/2023] [Indexed: 05/21/2023] Open
Abstract
The assessment of hemostasis is necessary to make suitable decisions on the management of patients with thrombotic disorders. In some clinical situations, for example, during thrombophilia screening, the presence of anticoagulants in sample makes diagnosis impossible. Various elimination methods may overcome anticoagulant interference. DOAC-Stop, DOAC-Remove and DOAC Filter are available methods to remove direct oral anticoagulants in diagnostic tests, although there are still reports on their incomplete efficacy in several assays. The new antidotes for direct oral anticoagulants - idarucizumab and andexanet alfa - could be potentially useful, but have their drawbacks. The necessity to remove heparins is also arising as heparin contamination from central venous catheter or therapy with heparin disturbs the appropriate hemostasis assessment. Heparinase and polybrene are already present in commercial reagents but a fully-effective neutralizer is still a challenge for researchers, thus promising candidates remain in the research phase.
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Affiliation(s)
| | - Bartlomiej Kalaska
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland.
| | - Joanna Miklosz
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
| | - Andrzej Mogielnicki
- Department of Pharmacodynamics, Medical University of Bialystok, Bialystok, Poland
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Muller M, Godet J, Delabranche X, Sattler L, Millard D, Marzak H, Mertes PM, Steib A, Grunebaum L, Jesel L, Tacquard CA. Study of Modifications Induced by Continued Direct Oral Anticoagulant Therapy during Atrial Fibrillation Ablation Procedures on Standard Hemostasis Parameters. J Clin Med 2023; 12:jcm12062236. [PMID: 36983237 PMCID: PMC10054854 DOI: 10.3390/jcm12062236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 03/05/2023] [Accepted: 03/11/2023] [Indexed: 03/15/2023] Open
Abstract
Background: Unfractionated heparin (UFH) is used as an anticoagulant during the atrial fibrillation (AF) ablation procedure to prevent the occurrence of thromboembolic events. Guidelines recommend an activated clotting time (ACT) greater than 300 s (s) based on studies of patients treated with vitamin K antagonist (VKA) for their AF. However, direct oral anticoagulants (DOACs) have supplanted VKAs in AF and are now used as first-line therapy. It is recommended not to interrupt them during the procedure, which could interfere with the ACT measures. Objective: To assess the real-life relationship between ACT, DOAC concentrations, and UFH anti-Xa activity in patients treated by uninterrupted DOAC therapy. Methods: We conducted a single-center retrospective study. We analyzed consecutive patients with AF who underwent catheter ablation under DOAC therapy. Results: In total, 40 patients were included, including 15 (37.5%), 20 (50.0%), and 5 (12.5%) on rivaroxaban, apixaban, and dabigatran, respectively. Baseline ACT was significantly lower in the apixaban group. ACT was linearly correlated with the residual concentration of apixaban and dabigatran but not with rivaroxaban. After UFH injection, ACT was linearly correlated with the anti-Xa activity, regardless of DOAC. Patients in the apixaban group received a higher total dose of UFH during the procedure to achieve a target ACT > 300 s, which resulted in significantly higher anti-Xa activity during the procedure. Conclusion: Our results raise the question of optimal management of intra-procedural heparin therapy and highlight the limitations of the ACT test, particularly in patients on apixaban.
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Affiliation(s)
- Marie Muller
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Julien Godet
- Groupe Méthodes en Recherche Clinique (GMRC), Hôpitaux Universitaires de Strasbourg, Hôpital Civil, 67000 Strasbourg, France
| | - Xavier Delabranche
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Laurent Sattler
- Laboratoire d’Hématologie, Unité Hémostase, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - David Millard
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Halim Marzak
- Service de Cardiologie, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Paul Michel Mertes
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Annick Steib
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Lelia Grunebaum
- Laboratoire d’Hématologie, Unité Hémostase, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
| | - Laurence Jesel
- Service de Cardiologie, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
- UMR 1260 INSERM Nanomedecine Regenerative, CRBS, Strasbourg University, 67200 Strasbourg, France
| | - Charles Ambroise Tacquard
- Department of Anesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, 67000 Strasbourg, France
- Correspondence:
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Dingus SJ, Smith AR, Dager WE, Zochert S, Nothdurft SA, Gulseth MP. Comparison of Managing Factor Xa Inhibitor to Unfractionated Heparin Transitions by aPTT Versus a Treatment Guideline Utilizing Heparin Anti-Xa Levels. Ann Pharmacother 2022; 56:1289-1298. [PMID: 35499336 DOI: 10.1177/10600280221090211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND There are inadequate data on the optimal strategy for transitioning factor Xa inhibitors (FXai; apixaban, rivaroxaban) to unfractionated heparin (UFH) infusions. OBJECTIVE In patients transitioning from an FXai to an UFH infusion, this study compared the safety and efficacy of monitoring UFH infusions using an activated partial thromboplastin time (aPTT) titration scale versus utilizing an UFH-calibrated anti-Xa titration scale aided by a novel institutional guideline. METHODS A retrospective cohort analysis was conducted on adult patients transitioning from an FXai to an UFH infusion at 2 medical centers from June 1, 2018, to November 1, 2020. One institution utilized aPTT while the other institution primarily used UFH-calibrated anti-Xa. The primary endpoint was a composite of death, major bleeding, or new thrombosis during the hospitalization with a planned noninferiority analysis. Secondary outcomes were also collected including the amount and duration of UFH administered between cohorts. RESULTS The incidence rate of the primary composite endpoint was 6.3% in the anti-Xa group and 11% in the aPTT group (P < 0.001 for noninferiority, P = 0.138 for superiority) meeting noninferiority criteria. No statistical differences were seen in new thrombosis, major bleeding, or any bleeding. CONCLUSION AND RELEVANCE This represents the first report of a comparison between aPTT versus anti-Xa monitoring in relation to clinical outcomes for patients transitioning from an FXai to an UFH infusion. A transition guideline primarily utilizing an UFH-calibrated anti-Xa assay appears to be a safe alternative to aPTT monitoring and can aid facilities in the management of patients during these complex transitions.
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Affiliation(s)
- Scott J Dingus
- Department of Pharmacy, Platte Health Center Avera, Platte, SD, USA
| | - Alex R Smith
- Department of Pharmaceutical Services, Sanford USD Medical Center, Sioux Falls, SD, USA
| | - William E Dager
- Department of Pharmacy, UC Davis Medical Center, Sacramento, CA, USA
| | - Sara Zochert
- Department of Pharmaceutical Services, Sanford USD Medical Center, Sioux Falls, SD, USA
| | - Salli A Nothdurft
- Department of Pharmaceutical Services, Sanford USD Medical Center, Sioux Falls, SD, USA
| | - Michael P Gulseth
- Department of Pharmaceutical Services, Sanford USD Medical Center, Sioux Falls, SD, USA
- Department of Internal Medicine, Sanford School of Medicine, University of South Dakota, Sioux Falls, SD, USA
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Jakimczuk A, Kalaska B, Kamiński K, Miklosz J, Yusa SI, Pawlak D, Szczubiałka K, Mogielnicki A. Monitoring of Anticoagulant Activity of Dabigatran and Rivaroxaban in the Presence of Heparins. J Clin Med 2022; 11:jcm11082236. [PMID: 35456329 PMCID: PMC9028841 DOI: 10.3390/jcm11082236] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 04/12/2022] [Accepted: 04/15/2022] [Indexed: 02/01/2023] Open
Abstract
The routine monitoring of direct oral anticoagulants (DOACs) may be considered in patients with renal impairment, patients who are heavily obese, or patients requiring elective surgery. Using the heparin-binding copolymer (HBC) and polybrene, we aimed to develop a solution for monitoring the anticoagulant activity of DOACs in human plasma in the interfering presence of unfractionated heparin (UFH) and enoxaparin. The thrombin time (TT) and anti-factor Xa activity were monitored in pooled plasma from healthy volunteers. In these tests, plasma with dabigatran or rivaroxaban was mixed with UFH or enoxaparin and then incubated with HBC or polybrene, respectively. HBC and polybrene neutralized heparins and enabled monitoring of anticoagulant activity of dabigatran in the TT test. Both agents allowed for accurate measurement of anti-factor Xa activity in the plasma containing rivaroxaban and heparins in the concentration range reached in patients’ blood. Here, we present diagnostic tools that may improve the control of anticoagulation by eliminating the contamination of blood samples with heparins and enabling the monitoring of DOACs’ activity.
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Affiliation(s)
- Aleksandra Jakimczuk
- Department of Pharmacodynamics, Medical University of Bialystok, 15-089 Bialystok, Poland; (A.J.); (J.M.); (D.P.); (A.M.)
| | - Bartlomiej Kalaska
- Department of Pharmacodynamics, Medical University of Bialystok, 15-089 Bialystok, Poland; (A.J.); (J.M.); (D.P.); (A.M.)
- Correspondence: (B.K.); (K.K.); Tel.: +48-85-748-5660 (B.K.); +48-660589819 (K.K.)
| | - Kamil Kamiński
- Faculty of Chemistry, Jagiellonian University, Gronostajowa 2, 30-387 Krakow, Poland;
- Correspondence: (B.K.); (K.K.); Tel.: +48-85-748-5660 (B.K.); +48-660589819 (K.K.)
| | - Joanna Miklosz
- Department of Pharmacodynamics, Medical University of Bialystok, 15-089 Bialystok, Poland; (A.J.); (J.M.); (D.P.); (A.M.)
| | - Shin-Ichi Yusa
- Department of Applied Chemistry, Graduate School of Engineering, University of Hyogo, Himeji 671-2280, Japan;
| | - Dariusz Pawlak
- Department of Pharmacodynamics, Medical University of Bialystok, 15-089 Bialystok, Poland; (A.J.); (J.M.); (D.P.); (A.M.)
| | - Krzysztof Szczubiałka
- Faculty of Chemistry, Jagiellonian University, Gronostajowa 2, 30-387 Krakow, Poland;
| | - Andrzej Mogielnicki
- Department of Pharmacodynamics, Medical University of Bialystok, 15-089 Bialystok, Poland; (A.J.); (J.M.); (D.P.); (A.M.)
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Plum MD, Hedrick JN, Hockman R, Bazydlo L, Palkimas S. The Relationship between the Initial Anti-factor Xa Measurement and the Duration of Direct Oral Anticoagulant Influence in Patients Transitioning to Heparin. Pharmacotherapy 2020; 40:880-888. [PMID: 32677060 DOI: 10.1002/phar.2444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/26/2020] [Accepted: 06/09/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Anticoagulation monitoring during transition from direct oral anticoagulants (DOAC) to heparin infusions is a significant challenge. Factor Xa inhibitors influence the heparin calibrated antifactor Xa assay. The University of Virginia (UVA) Medical Center utilized a corrected antifactor Xa assay (c-AXA) during this transition period, which removes DOAC-mediated antifactor Xa activity (d-AXA) and reflects heparin-specific activity. Currently, the duration of this influence is not well described. STUDY OBJECTIVE This study had two aims: to determine if the initial d-AXA is predictive of the duration of DOAC influence and to further characterize this influence among different patient populations. METHODS This retrospective study included adult patients admitted to UVA Medical Center between September 2016 and March 2017, with c-AXA measurements, who received apixaban or rivaroxaban within 48 hours before heparin initiation. A Pearson correlation test, Kaplan-Meier Survival Analysis, and multivariate linear regression were used to assess the relationship between initial d-AXA and duration of influence. RESULTS Sixty-eight patients met inclusion criteria and were maintained on either apixaban (85%) or rivaroxaban (15%) before heparin initiation. The initial d-AXA ranged from 0.11 to 3.27 IU/ml. The mean duration of influence was 69.3 ± 46.2 hours, with a median duration of 62.7 hours. No strong correlation was identified between initial d-AXA and duration of influence (R2 = 0.124). Presence of interacting medications significantly increased duration of influence (p=0.012). No significant difference in duration of influence existed between patients with normal renal function and those with dynamic renal function (p=0.84), or with body mass index (BMI) greater than 40 kg/m2 (p=0.16). CONCLUSIONS The initial d-AXA was not predictive of duration of influence in patients transitioning from DOACs to heparin infusion; however, the median duration of influence suggests influence may be present for longer than currently stated in the literature, especially in those taking interacting medications.
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Affiliation(s)
- Michelle D Plum
- Department of Pharmacy, Tufts Medical Center, Boston, Massachusetts, USA
| | - John N Hedrick
- Department of Pharmacy, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Rebecca Hockman
- Department of Pharmacy, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Lindsay Bazydlo
- Department of Pathology, University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Surabhi Palkimas
- Department of Pharmacy, University of Colorado Health, Aurora, Colorado, USA
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