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Dean CL. An Overview of Heparin Monitoring with the Anti-Xa Assay. Methods Mol Biol 2023; 2663:343-353. [PMID: 37204722 DOI: 10.1007/978-1-0716-3175-1_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Heparin remains a critical therapy in hospitalized patients requiring anticoagulation. Unfractionated heparin (UFH) mediates its therapeutic effect by binding to antithrombin (AT) and inhibiting thrombin and FXa, as well as other serine proteases. Because of its complex pharmacokinetics, monitoring UFH therapy is required, which is usually achieved with either the activated partial thromboplastin time (APTT) or the anti-factor Xa (anti-Xa) assay. Low molecular weight heparin (LMWH) is fast replacing UFH, as it has a more predictable response, negating the need for routine monitoring in most cases. When required, the anti-Xa assay is used for monitoring of LMWH. The APTT has many notable limitations when used for heparin therapeutic monitoring, including biologic, preanalytical, and analytical issues. With its increasing availability, the anti-Xa assay is appealing as it is less affected by patient factors (e.g., acute-phase reactants, lupus anticoagulants, consumptive coagulopathies), known to interfere with the APTT. The anti-Xa assay has shown additional benefits, such as faster time to achieve therapeutic levels, more consistent therapeutic levels, less dose adjustments, and, overall, less tests performed during therapy. However, poor interlaboratory agreement has been observed among anti-Xa reagents, highlighting that further work needs to be done to standardize this assay for use in patient heparin monitoring.
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Amiral J, Amiral C, Dunois C. Optimization of Heparin Monitoring with Anti-FXa Assays and the Impact of Dextran Sulfate for Measuring All Drug Activity. Biomedicines 2021; 9:700. [PMID: 34205548 PMCID: PMC8235539 DOI: 10.3390/biomedicines9060700] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/08/2021] [Accepted: 06/16/2021] [Indexed: 11/22/2022] Open
Abstract
Heparins, unfractionated or low molecular weight, are permanently in the spotlight of both clinical indications and laboratory monitoring. An accurate drug dosage is necessary for an efficient and safe therapy. The one-stage kinetic anti-FXa assays are the most widely and universally used with full automation for large series, without needing exogenous antithrombin. The WHO International Standards are available for UFH and LMWH, but external quality assessment surveys still report a high inter-assay variability. This heterogeneity results from the following: assay formulation, designed without or with dextran sulfate to measure all heparin in blood circulation; calibrators for testing UFH or LMWH with the same curve; and automation parameters. In this study, various factors which impact heparin measurements are reviewed, and we share our experience to optimize assays for testing all heparin anticoagulant activities in plasma. Evidence is provided on the usefulness of low molecular weight dextran sulfate to completely mobilize all of the drug present in blood circulation. Other key factors concern the adjustment of assay conditions to obtain fully superimposable calibration curves for UFH and LMWH, calibrators' formulations, and automation parameters. In this study, we illustrate the performances of different anti-FXa assays used for testing heparin on UFH or LMWH treated patients' plasmas and obtained using citrate or CTAD anticoagulants. Comparable results are obtained only when the CTAD anticoagulant is used. Using citrate as an anticoagulant, UFH is underestimated in the absence of dextran sulfate. Heparin calibrators, adjustment of automation parameters, and data treatment contribute to other smaller differences.
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Affiliation(s)
| | - Cédric Amiral
- HYPHEN BioMed, 95000 Neuville sur Oise, France; (C.A.); (C.D.)
| | - Claire Dunois
- HYPHEN BioMed, 95000 Neuville sur Oise, France; (C.A.); (C.D.)
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3
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Moussa MD, Soquet J, Lamer A, Labreuche J, Gantois G, Dupont A, Abou-Arab O, Rousse N, Liu V, Brandt C, Foulon V, Leroy G, Schurtz G, Jeanpierre E, Duhamel A, Susen S, Vincentelli A, Robin E. Evaluation of Anti-Activated Factor X Activity and Activated Partial Thromboplastin Time Relations and Their Association with Bleeding and Thrombosis during Veno-Arterial ECMO Support: A Retrospective Study. J Clin Med 2021; 10:jcm10102158. [PMID: 34067573 PMCID: PMC8156165 DOI: 10.3390/jcm10102158] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/08/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We aimed to investigate the relationship between anti-activated Factor X (anti-FXa) and activated Partial Thromboplastin Time (aPTT), and its modulation by other haemostasis co-variables during veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. We further investigated their association with serious bleeding and thrombotic complications. METHODS This retrospective single-center study included 265 adults supported by VA-ECMO for refractory cardiogenic shock from January 2015 to June 2019. The concordance of anti-FXa and aPTT and their correlations were assessed in 1699 paired samples. Their independent associations with serious bleeding or thrombotic complications were also analysed in multivariate analysis. RESULTS The concordance rate of aPTT with anti-FXa values was 50.7%, with 39.3% subtherapeutic aPTT values. However, anti-FXa and aPTT remained associated (β = 0.43 (95% CI 0.4-0.45) 10-2 IU/mL, p < 0.001), with a significant modulation by several biological co-variables. There was no association between anti-FXa nor aPTT values with serious bleeding or with thrombotic complications. CONCLUSION During VA-ECMO, although anti-FXa and aPTT were significantly associated, their values were highly discordant with marked sub-therapeutic aPTT values. These results should favour the use of anti-FXa. The effect of biological co-variables and the failure of anti-FXa and aPTT to predict bleeding and thrombotic complications underline the complexity of VA-ECMO-related coagulopathy.
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Affiliation(s)
- Mouhamed Djahoum Moussa
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
- Correspondence: ; Tel.: +33-320-445-962
| | - Jérôme Soquet
- CHU Lille, Service de Chirurgie Cardiaque, 59000 Lille, France; (J.S.); (N.R.); (A.V.)
| | - Antoine Lamer
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
- Univ. Lille, INSERM, CHU Lille, CIC-IT 1403, 59000 Lille, France
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, 59000 Lille, France; (J.L.); (A.D.)
| | - Julien Labreuche
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, 59000 Lille, France; (J.L.); (A.D.)
- CHU Lille, Department of Biostatistics, 59000 Lille, France
| | - Guillaume Gantois
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Annabelle Dupont
- CHU Lille, Pôle d’Hématologie-Transfusion, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (A.D.); (E.J.); (S.S.)
| | - Osama Abou-Arab
- Department of Anesthesiology and Critical Care Medicine, Amiens University Hospital, 80054 Amiens, France;
- MP3CV, EA7517, CURS, Jules Verne University of Picardie, 80054 Amiens, France
| | - Natacha Rousse
- CHU Lille, Service de Chirurgie Cardiaque, 59000 Lille, France; (J.S.); (N.R.); (A.V.)
| | - Vincent Liu
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Caroline Brandt
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Valentin Foulon
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | - Guillaume Leroy
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
| | | | - Emmanuel Jeanpierre
- CHU Lille, Pôle d’Hématologie-Transfusion, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (A.D.); (E.J.); (S.S.)
| | - Alain Duhamel
- Univ. Lille, CHU Lille, ULR 2694-METRICS: Évaluation des Technologies de Santé et des Pratiques Médicales, 59000 Lille, France; (J.L.); (A.D.)
- CHU Lille, Department of Biostatistics, 59000 Lille, France
| | - Sophie Susen
- CHU Lille, Pôle d’Hématologie-Transfusion, Centre de Biologie Pathologie Génétique, 59000 Lille, France; (A.D.); (E.J.); (S.S.)
| | - André Vincentelli
- CHU Lille, Service de Chirurgie Cardiaque, 59000 Lille, France; (J.S.); (N.R.); (A.V.)
| | - Emmanuel Robin
- CHU Lille, Pôle d’Anesthésie-Réanimation, 59000 Lille, France; (A.L.); (G.G.); (V.L.); (C.B.); (V.F.); (G.L.); (E.R.)
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4
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Kulig CE, Schomer KJ, Black HB, Dager WE. Activated Partial Thromboplastin Time Versus Anti-Factor Xa Monitoring of Heparin Anticoagulation in Adult Venoarterial Extracorporeal Membrane Oxygenation Patients. ASAIO J 2021; 67:411-415. [PMID: 33769995 DOI: 10.1097/mat.0000000000001246] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The preferred assay for measuring and adjusting unfractionated heparin (UFH) infusion to achieve optimal outcomes during extracorporeal membrane oxygenation (ECMO) is not well established. This retrospective cohort study explored safety and efficacy outcome differences between anti-factor Xa (anti-Xa) and activated partial thromboplastin time (aPTT) for UFH in adult venoarterial ECMO. Forty-one patients were included and analyzed. The UFH rate at first goal and time to goal were both higher in the aPTT versus anti-Xa cohort but did not achieve statistical significance (12.14 vs. 9.58 unit/kg/hour (p = 0.29), 20.22 vs. 12.05 hours (p = 0.11)). The aPTT cohort was in target goals 35.0% of the time versus 47.7% in the anti-Xa cohort (p = 0.13), above goal 41.0% vs. 17.3% (p = 0.02), and below-goal 24.0% versus 35.0% of the time (p = 0.34). Minimum heparin rates in the aPTT cohort were 6.28 vs. 3.33 unit/kg/hour in the anti-Xa cohort (p = 0.07), and the maximum UFH rate was 18.77 unit/kg/hour vs. 15.48 unit/kg/hour (p = 0.10). Our findings suggest that aPTT monitoring may result in a delay to target attainment, higher UFH rates, and overall exposure.
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Affiliation(s)
- Caitlin E Kulig
- University of California, Davis Medical Center, Sacramento, California
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Billoir P, Clavier T, Guilbert A, Barbay V, Chrétien MH, Fresel M, Abriou C, Girault C, Le Cam Duchez V. Is citrate theophylline adenosine dipyridamole (CTAD) better than citrate to survey unfractionated heparin treatment? Has delayed centrifugation a real impact on this survey? J Thromb Thrombolysis 2020; 48:277-283. [PMID: 31098816 DOI: 10.1007/s11239-019-01882-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Unfractionated heparin (UFH) is the main anticoagulant used in intensive care unit. The anticoagulant effect is monitored by activated partial thrombin time (aPTT) and anti-Xa activity (anti-Xa) measurement. However, delayed centrifugation induces platelet factor 4 (PF4) release and anti-Xa decrease. Several studies have concluded that aPTT and anti-Xa measurement should be performed within 2 h in citrated anticoagulant but may be delayed longer in Citrate Theophylline Adenosine and Dypiridamol (CTAD) anticoagulant. The objective of this study was to compare the stability of both aPTT and anti-Xa in citrate and CTAD samples, and to determine the effect of delayed centrifugation on both aPTT, anti-Xa results, and PF4 release in citrate samples only. aPTT and anti-Xa were measured in citrate and CTAD anticoagulant samples from 93 patients. Delayed centrifugation was performed in citrate samples from 31 additional patients, with hourly aPTT and anti-Xa measurement from 1 to 6 h. In 14 of these last patients, PF4 release was also evaluated with Human CXCL4/PF4 Quantikine ELISA Kit. We observed a significant correlation between citrate and CTAD anticoagulant for aPTT (r2 = 0.94) and anti-Xa (r2 = 0.95). With Bland-Altman correlation, a minor bias was observed for anti-Xa (- 0.025 ± 0.041). Delayed centrifugation in citrated anticoagulant showed an excellent concordance from 1 to 4 h for aPTT (- 4.0 ± 5.3 s) and anti-Xa (1.10-9 ± 0.058 UI/ml) measurements. Moreover, PF4 release was not different between 1 h (31.5 ± 14.7 ng/ml) and 4 h (33.8 ± 11.8 ng/ml). We have demonstrated that anti-Xa measurement for unfractionated heparin should be done 4 h in citrated plasma and that CTAD was not better than citrate. However, these initial findings require confirmation using other aPTT and calibrated anti-Xa assays.
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Affiliation(s)
- Paul Billoir
- Rouen University Hospital, Vascular Hemostasis Unit, 76031, Rouen, France.
- Normandie Univ, UNIROUEN, INSERM U1096, Rouen, France.
- Service d'Hématologie Biologique, Centre hospitalier Universitaire Charles Nicolle, 1 rue de Germont, 76031, Rouen, France.
| | - Thomas Clavier
- Department of Anesthesiology and Critical Care, Rouen University Hospital, 76031, Rouen, France
- Univ Rouen, Inserm, U1096, 76000, Rouen, France
| | - Arnaud Guilbert
- Department of Anesthesiology and Critical Care, Rouen University Hospital, 76031, Rouen, France
| | - Virginie Barbay
- Rouen University Hospital, Vascular Hemostasis Unit, 76031, Rouen, France
| | | | - Marielle Fresel
- Rouen University Hospital, Vascular Hemostasis Unit, 76031, Rouen, France
| | - Caroline Abriou
- Department of Anesthesiology and Critical Care, Rouen University Hospital, 76031, Rouen, France
| | - Christophe Girault
- Department of Medical Intensive Care, Normandie Univ, Unirouen, UPRES EA-3830, Rouen, France
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Coons JC, Iasella CJ, Thornberg M, Fitzmaurice MG, Goehring K, Jablonski L, Leader D, Meyer A, Seo H, Benedict NJ, Smith RE. Clinical outcomes with unfractionated heparin monitored by anti-factor Xa vs. activated partial Thromboplastin time. Am J Hematol 2019; 94:1015-1019. [PMID: 31243789 DOI: 10.1002/ajh.25565] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 06/14/2019] [Accepted: 06/24/2019] [Indexed: 12/11/2022]
Abstract
Anti-factor Xa (anti-Xa) monitoring of unfractionated heparin (UFH) is associated with less time to achieve therapeutic anticoagulation compared to the activated partial thromboplastin time (aPTT). However, it is unknown whether clinical outcomes differ between these methods of monitoring. The aim of this research was to compare the rate of venous thrombosis and bleeding events in patients that received UFH monitored by anti-Xa compared to the aPTT. A retrospective review of electronic health records identified adult patients that received UFH given intravenously (IV) for ≥2 days, with either anti-Xa or aPTT monitoring at an academic tertiary care hospital. This was a pre/post study design conducted between January 1 to December 30, 2014 (aPTT), and January 1 to December 30, 2016 (anti-Xa). All UFH adjustments were based on institutional nomograms. The primary outcome was venous thrombosis and the secondary outcome was bleeding, both of which occurred between UFH administration and discharge from the index hospitalization. A total of 2500 patients were in the anti-Xa group and 2847 patients aPTT group. Venous thrombosis occurred in 10.2% vs 10.8% of patients in the anti-Xa and aPTT groups, respectively (P = .49). Bleeding occurred in 33.7% vs 33.6% of patients in the anti-Xa and aPTT groups, respectively (P = .94). Anti-Xa monitoring was not an independent predictor of either outcome in multivariate logistic regression analyses. Our study found no difference in clinical outcomes between anti-Xa and aPTT-based monitoring of UFH IV.
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Affiliation(s)
- James C. Coons
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
- Department of Pharmacy and Therapeutics, UPMC Presbyterian‐Shadyside Hospital Pittsburgh Pennsylvania
| | - Carlo J. Iasella
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
- Department of Pharmacy and Therapeutics, UPMC Presbyterian‐Shadyside Hospital Pittsburgh Pennsylvania
| | - Megan Thornberg
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
| | - Mary Grace Fitzmaurice
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
| | - Kimberly Goehring
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
| | - Lindsay Jablonski
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
| | - Dominic Leader
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
| | - Abby Meyer
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
| | - Hangil Seo
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
| | - Neal J. Benedict
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy Pittsburgh Pennsylvania
- Department of Pharmacy and Therapeutics, UPMC Presbyterian‐Shadyside Hospital Pittsburgh Pennsylvania
| | - Roy E. Smith
- Department of Pharmacy and Therapeutics, UPMC Presbyterian‐Shadyside Hospital Pittsburgh Pennsylvania
- Hematology/Oncology Division, UPMC Presbyterian‐Shadyside Hospital Pittsburgh Pennsylvania
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7
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Ciplea AM, Laeer S, Burckhardt BB. A feasibility study prior to an international multicentre paediatric study to assess pharmacokinetic/pharmacodynamic sampling and sample preparation procedures, logistics and bioanalysis. Contemp Clin Trials Commun 2018; 12:32-39. [PMID: 30225392 PMCID: PMC6139604 DOI: 10.1016/j.conctc.2018.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Revised: 07/24/2018] [Accepted: 08/20/2018] [Indexed: 11/16/2022] Open
Abstract
Background Variability in pre-analytical procedures such as blood sampling, sample preparation and transport can substantially influence bioanalytical results and subsequently impair reliability of data gathered during clinical trials. Especially in vulnerable populations, all efforts should be made to facilitate high-quality data extraction excluding unnecessary or repeated intervention. Methods The EU-funded LENA project (Labeling of Enalapril from Neonates up to Adolescents) included a feasibility study in its preparatory procedures prior to first-in-child studies. Derived from a regular study visit, it encompassed all procedures, from sampling of two study-specific drugs and four sensitive humoral parameters to bioanalysis, to evaluate the quality of obtained samples and applicability of logistical and bioanalytical procedures. Drug administration to healthy adults was circumvented by pre-spiking the blood collection tubes with a drug solution. Five clinical sites were evaluated. Results Clinical teams' preparedness and applicability of required sampling procedures was investigated in 18 volunteers, on-site. 97% of collected pharmacokinetic (PK) samples and 93% of samples for humoral parameters were obtained eligibly. Results met expectations, though one team had to be re-trained and performed a re-run. Planned procedures for sampling, sample preparation, transport and analysis were found to be suitable for being applied within paediatric trials. Conclusion The concept of the presented feasibility study that simultaneously assesses PK/PD sampling, sample preparation, logistics and bioanalysis proved to be a promising tool for trial preparation. It revealed improperly installed processes and bottlenecks that required adjustments prior to start of recruitment. It facilitated high-quality conduct from the first moment of paediatric pivotal studies.
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Key Words
- ACE, Angiotensin-converting-enzyme
- Clinical trial
- Cmax, maximum serum concentration
- ELISA, Enzyme-linked immunosorbent assay
- EMA, European Medicines Agency
- EU, European Union
- FDA, U.S. Food and Drug Administration
- Feasibility
- GCP, Good Clinical Practice
- LC-MS/MS, Liquid chromatography-tandem mass spectrometry
- LENA, Labeling of Enalapril from Neonates up to Adolescents
- PD, Pharmacodynamic(s)
- PK, Pharmacokinetic(s)
- Pharmacodynamic
- Pharmacokinetic
- Pilot
- RAA system, Renin-angiotensin-aldosterone system
- RIA, Radioimmunoassay
- Training concept
- pp, Percentage points
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Affiliation(s)
- Agnes Maria Ciplea
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-University, Dusseldorf, Germany
| | - Stephanie Laeer
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-University, Dusseldorf, Germany
| | - Bjoern Bengt Burckhardt
- Institute of Clinical Pharmacy and Pharmacotherapy, Heinrich-Heine-University, Dusseldorf, Germany
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8
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Byun JH, Jang IS, Kim JW, Koh EH. Establishing the heparin therapeutic range using aPTT and anti-Xa measurements for monitoring unfractionated heparin therapy. Blood Res 2016; 51:171-174. [PMID: 27722127 PMCID: PMC5054248 DOI: 10.5045/br.2016.51.3.171] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/25/2016] [Accepted: 07/08/2016] [Indexed: 12/20/2022] Open
Abstract
Background Unfractionated heparin (UFH) has unstable pharmacokinetics and requires close monitoring. The activated partial thromboplastin time (aPTT) test has been used to monitor UFH therapy for decades in Korea, but its results can be affected by numerous variables. We established an aPTT heparin therapeutic range (HTR) corresponding to therapeutic anti-Xa levels for continuous intravenous UFH administration, and used appropriate monitoring to determine if an adequate dose of UFH was applied. Methods A total of 134 ex vivo samples were obtained from 71 patients with a variety of thromboembolisms. All patients received intravenous UFH therapy and were enrolled from June to September 2015 at Gyeongsang National University Hospital. All laboratory protocols were in accordance with the Clinical and Laboratory Standards Institute guidelines and the College of American Pathologist requirements for aPTT HTR. Results An aPTT range of 87.1 sec to 128.7 sec corresponded to anti-Xa levels of 0.3 IU/mL to 0.7 IU/mL for HTR under our laboratory conditions. Based on their anti-Xa levels, blood specimen distribution were as follows: less than 0.3 IU/mL, 65.7%; 0.3–0.7 IU/mL (therapeutic range), 33.6%; and more than 0.7 IU/mL, 0.7%. No evidence of recurring thromboembolism was observed. Conclusion Using the conventional aPTT target range may lead to inappropriate dosing of UFH. Transitioning from the aPTT test to the anti-Xa assay is required to avoid the laborious validation of the aPTT HTR test, even though the anti-Xa assay is more expensive.
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Affiliation(s)
- Jung-Hyun Byun
- Department of Laboratory Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Korea
| | - In-Seok Jang
- Department of Thoracic and Cardiovascular Surgery, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Korea
| | - Jong Woo Kim
- Department of Thoracic and Cardiovascular Surgery, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Korea
| | - Eun-Ha Koh
- Department of Laboratory Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Korea.; Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
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9
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Dale BJ, Chan NC, Eikelboom JW. Laboratory measurement of the direct oral anticoagulants. Br J Haematol 2015; 172:315-36. [DOI: 10.1111/bjh.13810] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Brian J. Dale
- School of Pharmacy and Medical Sciences; University of South Australia; Adelaide South Australia Australia
| | - Noel C. Chan
- Population Health Research Institute; Hamilton Ontario Canada
| | - John W. Eikelboom
- Population Health Research Institute; Hamilton Ontario Canada
- Department of Medicine; McMaster University; Hamilton Ontario Canada
- Thrombosis and Atherosclerosis Research Institute; Hamilton Ontario Canada
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10
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Underestimation of unfractionated heparin therapy assessment due to platelet activation when using partial-draw (pediatric) citrate collection tubes. Thromb Res 2014; 134:1117-22. [DOI: 10.1016/j.thromres.2014.08.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2014] [Revised: 08/15/2014] [Accepted: 08/17/2014] [Indexed: 11/19/2022]
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11
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Lindhoff-Last E, Ansell J, Spiro T, Samama MM. Laboratory testing of rivaroxaban in routine clinical practice: when, how, and which assays. Ann Med 2013; 45:423-9. [PMID: 23746003 DOI: 10.3109/07853890.2013.801274] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
A number of target-specific oral anticoagulants (TSOAs) have been developed in recent years, and some have shown considerable promise in large-scale, randomized clinical trials in the prevention and treatment of thromboembolism. Unlike traditional anticoagulants, such as vitamin K antagonists, these TSOAs exhibit predictable pharmacokinetics and pharmacodynamics. Among these agents, rivaroxaban, a direct Factor Xa inhibitor, has been approved for clinical use in many countries for the management of several thromboembolic disorders. As with the other TSOAs, rivaroxaban is given at fixed doses without routine coagulation monitoring. However, in certain patient populations or special clinical circumstances, measurement of drug exposure may be useful, such as in suspected overdose, in patients with a haemorrhagic or thromboembolic event during treatment with an anticoagulant, in those with acute renal failure, or in patients who require urgent surgery. This article summarizes the influence of rivaroxaban on commonly used coagulation assays and provides practical guidance on laboratory testing of rivaroxaban in routine practice. Both quantitative measurement (using the anti-Factor Xa method) and qualitative measurement (using prothrombin time, expressed in seconds) are discussed, together with some practical considerations when performing these tests and interpreting the test results.
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Affiliation(s)
- Edelgard Lindhoff-Last
- Division of Angiology and Hemostaseology, Department of Internal Medicine, University Hospital Frankfurt, Germany. edelgard.lindhoff -
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12
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Samama MM. Which test to use to measure the anticoagulant effect of rivaroxaban: the anti-factor Xa assay. J Thromb Haemost 2013; 11:579-80. [PMID: 23398670 DOI: 10.1111/jth.12165] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- M M Samama
- Cochin-Hôtel-Dieu University Hospital, Paris, France; Biomnis Laboratory, Ivry, France
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13
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Harenberg J, Krämer R, Giese C, Marx S, Weiss C, Wehling M. Determination of rivaroxaban by different factor Xa specific chromogenic substrate assays: reduction of interassay variability. J Thromb Thrombolysis 2012; 32:267-71. [PMID: 21811937 PMCID: PMC3170460 DOI: 10.1007/s11239-011-0622-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Rivaroxaban and other oral direct factor Xa inhibitors (ODiXa) are currently developed for prophylaxis and treatment of thromboembolic diseases using fixed doses. Although routine monitoring is not required, assessing the intensity of anticoagulation may be useful under certain clinical conditions. ODiXa prolong coagulation times of several clotting assays and, thus, their concentration may be determined in factor Xa specific chromogenic substrate assays. So far, no standardized and validated assay is commercially available. Here, five methods (A through E) are studied and optimized to reduce interassay variability. Human pooled plasma was spiked by a serial dilution of rivaroxaban (25–900 ng/ml). The release of para-nitroaniline from the chromogenic substrates was measured by the optical density (OD) at 405 nm. Method B was identified to yield the lowest sum of deviations from the mean value of the OD concentration curve calculated from all assays. Spline functions were developed for OD versus concentration curves for all methods. The calculated OD versus concentration curves overlapped for all methods. The coefficient of variation for all assays and concentrations of rivaroxaban decreased from 25.3 ± 11.4% using the original data to 3.8 ± 2.2% using the calculated data (P < 0.0001). The robustness of the chromogenic assay (method B) remains to be corroborated in interlaboratory comparisons.
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Affiliation(s)
- Job Harenberg
- Department of Clinical Pharmacology, University Heidelberg, Maybachstrasse 14, Mannheim, Germany.
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14
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Duschek N, Vafaie M, Skrinjar E, Hirsch K, Waldhör T, Hübl W, Bergmayr W, Knoebl P, Assadian A. Comparison of enoxaparin and unfractionated heparin in endovascular interventions for the treatment of peripheral arterial occlusive disease: a randomized controlled trial. J Thromb Haemost 2011; 9:2159-67. [PMID: 21910821 DOI: 10.1111/j.1538-7836.2011.04501.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although unfractionated heparin (UFH) is an effective antithrombotic agent in endovascular interventions for the treatment of peripheral occlusive arterial disease (PAOD), it produces a highly variable anticoagulant response. Intravenous (i.v.) enoxaparin might be an effective and safe alternative. PATIENTS AND METHODS In a prospective, open-label, randomized, single-center trial, 210 patients with PAOD (Fontaine stage IIb to IV) were randomly assigned in a 1 (UFH): 2 (enoxaparin) fashion to receive an i.v. bolus of 60 units UFH per kg body weight or 0.5 mg enoxaparin per kg body weight, respectively, before endovascular intervention. The primary composite endpoint assessed the clinical performance of enoxaparin by comparing the peri-interventional rate of thromboembolia/occlusion (efficacy) of endovascularly reconstructed areas, of bleeding according to the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO) criteria (safety) and of any necessary re-intervention for any percutaneous transluminal angioplasty (PTA)-related bleeding. The secondary endpoint evaluated anti-factor (F)Xa levels during intervention. RESULTS The primary composite endpoint showed a better performance of enoxaparin (10.5% vs. 2.5% absolute difference - 8.0%; P < 0.05). The concomitant use of acetylsalicylic acid (ASA) significantly (P < 0.05) increased the risk of a complication in the UFH group, but not in the enoxaparin group. Within 15 min, anti-Xa levels were reached by 63.7% of patients treated with enoxaparin and only by 39.1% with UFH. CONCLUSION Enoxaparin has a better performance than UFH in endovascular interventions for the treatment of PAOD. In patients with concomitant use of ASA, the risk of complications with UFH increases significantly compared with enoxaparin.
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Affiliation(s)
- N Duschek
- Department of Vascular and Endovascular Surgery, Wilhelminenspital, Vienna Center for Public Health, Department of Epidemiology, Medical University of Vienna, Vienna, Austria.
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15
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Guervil DJ, Rosenberg AF, Winterstein AG, Harris NS, Johns TE, Zumberg MS. Activated partial thromboplastin time versus antifactor Xa heparin assay in monitoring unfractionated heparin by continuous intravenous infusion. Ann Pharmacother 2011; 45:861-8. [PMID: 21712506 DOI: 10.1345/aph.1q161] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Unfractionated heparin (UFH) has been used clinically for 5 decades. Despite being a cornerstone of anticoagulation, UFH is limited by its unpredictable pharmacokinetic profile, which makes close laboratory monitoring necessary. The most common methods for monitoring UFH are the activated partial thromboplastin time (aPTT) and antifactor Xa heparin assay (anti-Xa HA), but both present challenges, and the optimal method to monitor UFH remains unclear. OBJECTIVE To compare the performance of the aPTT with the anti-Xa HA for efficiency and safety of monitoring intravenous UFH infusions. METHODS This was a single-center, retrospective, observational cohort study conducted in an 852-bed academic medical center. RESULTS One hundred patients receiving intravenous UFH for a variety of indications were enrolled in the study; 50 were assigned to each group. The mean (SD) time to achieve therapeutic anticoagulation was significantly less in the anti-Xa HA group compared with the aPTT group (28 [16] vs 48 [26] hours, p < 0.001). In addition, a greater percentage of anti-Xa HA patients compared to aPTT patients achieved therapeutic anticoagulation at 24 hours (OR 3.5; 95% CI 1.5 to 8.7) and 48 hours (OR 10.9; 95% CI 3.3 to 44.2). Patients in the anti-Xa HA group also had more test values within the therapeutic range (66% vs 42%, p < 0.0001). A significant difference was seen between the 2 groups in the number of aPTT or anti-Xa HA tests performed per 24 hours (p < 0.0001) and number of infusion rate changes per 24 hours (p < 0.01), both favoring the anti-Xa HA group. CONCLUSIONS Monitoring intravenous UFH infusions with the anti-Xa HA, compared to the aPTT, achieves therapeutic anticoagulation more rapidly, maintains the values within the goal range for a longer time, and requires fewer adjustments in dosage and repeated tests.
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Affiliation(s)
- David J Guervil
- Department of Pharmacy, Shands Hospital, University of Florida, Gainesville, FL, USA.
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16
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Toulon P, Abecassis L, Smahi M, Ternisien C. Monitoring treatments with unfractionated heparin: CTAD must be used instead of citrate as the anticoagulant solution when using partial-draw collection tubes. Results of a multicenter evaluation. Thromb Res 2010; 126:536-42. [PMID: 20950840 DOI: 10.1016/j.thromres.2010.08.029] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Revised: 08/11/2010] [Accepted: 08/22/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND Sampling small volumes of blood may be necessary, particularly in pediatric patients, or in case of difficult or recurrent venipunctures. METHODS Routine hemostasis test results evaluated in partial- and full-draw evacuated polymer tubes obtained in 4 centers were compared. RESULTS No relevant discrepancy (Bland-Altman) was found between test results measured in partial- and full-draw tubes obtained from untreated patients and from patients on vitamin K-antagonist or low molecular weight heparin. In patients on unfractionated heparin (UFH), significantly lower anti-FXa activity [median=0.29IU/mL (range:0.04-1.15) vs. 0.39 (0.05-1.25), n=89, p<0.0001] and shorter aPTT were measured in partial-draw tubes. This discrepancy was likely to be related to the release of higher amounts of PF4 after increased platelet activation in partial-draw tubes. As CTAD is known to counteract platelet activation, we then collected blood into partial-draw CTAD tube and full-draw citrate tube. Both in patients on UFH and in untreated patients, no relevant difference could be demonstrated for all studied parameters (Bland-Altman), including aPTT and anti-FXa activity, even if analytical comparison showed significantly higher anti-FXa activity in partial-draw CTAD than in full-draw citrated tubes with a mean bias of 0.02 IU/mL, identical throughout the measuring range. CONCLUSIONS These results suggest that samples collected into partial-draw citrate tubes allow accurate routine coagulation testingin all patients but those requiring UFH assessment,in which their use led to a significant underestimation ofanticoagulation. In such cases, partial-draw tubes containing CTAD could be validly used to monitor heparin therapy as well as to perform routine coagulation testing.
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Affiliation(s)
- Pierre Toulon
- Université Nice Sophia-Antipolis, Faculté de Médecine, CHU Saint Roch, Service d'Hématologie Biologique, Nice, France.
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17
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Heparinmonitoring. Hamostaseologie 2010. [DOI: 10.1007/978-3-642-01544-1_71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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18
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Breuhl EL, Moore G, Brooks MB, Scott-Moncrieff JC. A prospective study of unfractionated heparin therapy in dogs with primary immune-mediated hemolytic anemia. J Am Anim Hosp Assoc 2009; 45:125-33. [PMID: 19411648 DOI: 10.5326/0450125] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Unfractionated heparin therapy was initiated at a standard dosage of 300 IU/kg subcutaneously q 6 hours to 18 dogs with immune-mediated hemolytic anemia. Heparin's prolongation of activated partial thromboplastin time and change in factor Xa inhibition (anti-Xa activity) were serially monitored during the first 40 hours of therapy. During the initial 40 hours, only eight of 18 dogs had attained anti-Xa activities of > or =0.35 U/mL. No dogs had clinical signs of hemorrhage. Fifteen dogs survived to discharge; 11 dogs were alive at 1 year, and thrombosis was identified in three of six nonsurvivors that were necropsied.
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Affiliation(s)
- Elizabeth L Breuhl
- Department of Veterinary Clinical Sciences, School of Veterinary Medicine, Lynn Hall, Purdue University, West Lafayette, Indiana 47907, USA
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Management of pregnant women with mechanical heart valve prosthesis: Thromboprophylaxis with Low molecular weight heparin. Thromb Res 2009; 124:262-7. [DOI: 10.1016/j.thromres.2008.12.005] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 11/27/2008] [Accepted: 12/09/2008] [Indexed: 11/20/2022]
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20
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Winkler AM, Sheppard CA, Fantz CR. Laboratory Monitoring of Heparin: Challenges and Opportunities. Lab Med 2007. [DOI: 10.1309/b0xgvjyd9ahwptf4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Anne M. Winkler
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Chelsea A. Sheppard
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
| | - Corinne R. Fantz
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA
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