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Santana-Otero A, Harper A, Telling N, Ortega D, Cabrera D. Magnetic coagulometry: towards a new nanotechnological tool for ex vivo monitoring coagulation in human whole blood. NANOSCALE 2024; 16:3534-3548. [PMID: 38285061 PMCID: PMC10868660 DOI: 10.1039/d3nr02593d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 12/19/2023] [Indexed: 01/30/2024]
Abstract
Blood clotting disorders consisting of unwanted blood clot formation or excessive bleeding are some of the main causes of death worldwide. However, there are significant limitations in the current methods used to clinically monitor the dynamics of clot formation in human whole blood ex vivo. Here a new magnetic coagulometry platform for testing ex vivo coagulation is described. This platform exploits the sensitivity of the out-of-phase component of alternating current (AC) magnetic susceptibility (χ'') to variations in mobility and agglomeration of magnetic nanoparticles when trapped during blood clot formation. By labelling human whole blood with magnetic nanoparticles, the out-of-phase component of AC magnetic susceptibility shows that the dynamics of blood clot formation correlates with a decrease in the out-of-phase component χ'' over time activation of coagulation. This is caused by a rapid immobilisation of nanoparticles upon blood coagulation and compaction. In contrast, this rapid fall in the out-of-phase component χ'' is significantly slowed down when blood is pre-treated with three different anticoagulant drugs. Remarkably, the system showed sensitivity towards the effect of clinically used direct oral anticoagulation (DOAC) drugs in whole blood coagulation, in contrast to the inability of clinical routine tests prothrombin time (PT) and partial thromboplastin time (PTT) to efficiently monitor this effect. Translation of this nanomagnetic approach into clinic can provide a superior method for monitoring blood coagulation and improve the efficiency of the current diagnostic techniques.
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Affiliation(s)
- Antonio Santana-Otero
- Condensed Matter Physics Department, Faculty of Sciences, University of Cádiz, Campus Universitario Rio San Pedro s/n, 11510 Puerto Real, Cádiz, Spain.
| | - Alan Harper
- School of Medicine, Keele University, Newcastle-under-Lyme, Staffordshire. ST5 5BG, UK
| | - Neil Telling
- School of Pharmacy and Bioengineering, Keele University, Guy Hilton Research Centre, Thronburrow Drive, Hartshill, Stoke on Trent, ST47QB, UK.
| | - Daniel Ortega
- Condensed Matter Physics Department, Faculty of Sciences, University of Cádiz, Campus Universitario Rio San Pedro s/n, 11510 Puerto Real, Cádiz, Spain.
- iMdea Nanociencia, Campus Universitario de Cantoblanco. C/Faraday, 9, 28049, Madrid, Spain
- Institute of Research and Innovation in Biomedical Sciences of Cádiz (INiBICA), University of Cádiz, 11002, Cádiz, Spain
| | - David Cabrera
- School of Pharmacy and Bioengineering, Keele University, Guy Hilton Research Centre, Thronburrow Drive, Hartshill, Stoke on Trent, ST47QB, UK.
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Bhat RV, Young G, Sharathkumar AA. How I treat pediatric venous thromboembolism in the DOAC era. Blood 2024; 143:389-403. [PMID: 37390311 PMCID: PMC10862368 DOI: 10.1182/blood.2022018966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 07/02/2023] Open
Abstract
ABSTRACT The direct oral anticoagulants (DOACs) rivaroxaban and dabigatran are newly licensed for the treatment and prevention of venous thromboembolism (VTE) in children and mark a renaissance in pediatric anticoagulation management. They provide a convenient option over standard-of-care anticoagulants (heparins, fondaparinux, and vitamin K antagonists) because of their oral route of administration, child-friendly formulations, and significant reduction in monitoring. However, limitations related to therapeutic monitoring when needed and the lack of approved reversal agents for DOACs in children raise some safety concerns. There is accumulating experience of safety and efficacy of DOACs in adults for a broad scope of indications; however, the cumulative experience of using DOACs in pediatrics, specifically for those with coexisting chronic illnesses, is sparse. Consequently, clinicians must often rely on their experience for treating VTE and extrapolate from data in adults while using DOACs in children. In this article, the authors share their experience of managing 4 scenarios that hematologists are likely to encounter in their day-to-day practice. Topics addressed include (1) appropriateness of indication; (2) use for special populations of children; (3) considerations for laboratory monitoring; (4) transition between anticoagulants; (5) major drug interactions; (6) perioperative management; and (7) anticoagulation reversal.
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Affiliation(s)
- Rukhmi V. Bhat
- Center for Cancer and Blood Disorders, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Guy Young
- Cancer and Blood Disorders Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Anjali A. Sharathkumar
- Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA
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3
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Gebekova ZA, Ivanov II, Asambayeva A, Skripka AI, Sokolova AA, Napalkov DA, Vuimo TA. Thrombodynamics Test in Assessing the Risk of Thrombus Formation in Patients with Atrial Fibrillation Taking Direct Oral Anticoagulants. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-09-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Aim. To evaluate thrombus characteristics in patients with atrial fibrillation (AF) taking different direct oral anticoagulants (DOACs) using Thrombodynamics test.Materials and methods. Thrombodynamics test was performed in 100 patients with paroxysmal and permanent forms of AF taking different DOACs, dose choice was done in accordance with the instructions for drugs use. For analysis samples of fresh citrated platelet-free plasma were taken just before regular DOACs dose intake (trough concentration). Statistical data processing was carried out using R software packages.Results. All patients had no history of thrombosis or bleeding before inclusion in this study. All parameters of Thrombodynamics test taken at residual concentration of DOACs were in general within reference values, that is in the area of normal coagulation: spatial clot growth rate (V) – 26.56 (25.0; 29.2) μm/min, the time to the start of clot growth (Tlag) – 1.05 (0.85; 1.27) min, initial spatial clot growth rate (Vi) – 44.3±7.7 μm/min, stationary spatial clot growth rate (Vst) – 26.5 (24.9; 28.4) μm/min, clot size (CS) – 999.7 (912.9; 1084.7) μm, clot density (D) – 22883.1±3199.9 arb. units. D was appeared to be higher in women [22947.7 (21477.5; 22947.7) vs men [22124.8 (19722.8; 22124.8), p=0.035] and Tlag was significantly higher in patients with chronic heart failure [1.2 (1.0; 1.2) vs 1.0 (0.8; 1.0), p=0.008]. A correlation was found between level of creatinine and Tlag parameter, glomerular filtration rate (GFR) and clot density. With an increase in the level of creatinine in the blood and a decrease in GFR, respectively, there was an increase in Tlag parameter (p-value 0.038); with an increase in GFR, clot density decrease (p-value 0.005).Conclusion. All parameters of Thrombodynamics test on residual concentration of DOACs were within reference values that indicated optimal anticoagulant effect of all DOACs. The obtained data of normal coagulation at the residual concentration of the anticoagulant are consistent with the previously obtained data on the safety and effectiveness of DOACs using other methods. Further studies with clinical end points are needed to assess the clinical value of this method.
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Affiliation(s)
- Z. A. Gebekova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - I. I. Ivanov
- Pirogov Russian National Research Medical University
| | - A. Asambayeva
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. I. Skripka
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - A. A. Sokolova
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - D. A. Napalkov
- I.M. Sechenov First Moscow State Medical University (Sechenov University)
| | - T. A. Vuimo
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology, Oncology and Immunology
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4
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Douketis JD, Spyropoulos AC, Murad MH, Arcelus JI, Dager WE, Dunn AS, Fargo RA, Levy JH, Samama CM, Shah SH, Sherwood MW, Tafur AJ, Tang LV, Moores LK. Perioperative Management of Antithrombotic Therapy: An American College of Chest Physicians Clinical Practice Guideline. Chest 2022; 162:e207-e243. [PMID: 35964704 DOI: 10.1016/j.chest.2022.07.025] [Citation(s) in RCA: 78] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/10/2022] [Accepted: 07/11/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The American College of Chest Physicians Clinical Practice Guideline on the Perioperative Management of Antithrombotic Therapy addresses 43 Patients-Interventions-Comparators-Outcomes (PICO) questions related to the perioperative management of patients who are receiving long-term oral anticoagulant or antiplatelet therapy and require an elective surgery/procedure. This guideline is separated into four broad categories, encompassing the management of patients who are receiving: (1) a vitamin K antagonist (VKA), mainly warfarin; (2) if receiving a VKA, the use of perioperative heparin bridging, typically with a low-molecular-weight heparin; (3) a direct oral anticoagulant (DOAC); and (4) an antiplatelet drug. METHODS Strong or conditional practice recommendations are generated based on high, moderate, low, and very low certainty of evidence using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology for clinical practice guidelines. RESULTS A multidisciplinary panel generated 44 guideline recommendations for the perioperative management of VKAs, heparin bridging, DOACs, and antiplatelet drugs, of which two are strong recommendations: (1) against the use of heparin bridging in patients with atrial fibrillation; and (2) continuation of VKA therapy in patients having a pacemaker or internal cardiac defibrillator implantation. There are separate recommendations on the perioperative management of patients who are undergoing minor procedures, comprising dental, dermatologic, ophthalmologic, pacemaker/internal cardiac defibrillator implantation, and GI (endoscopic) procedures. CONCLUSIONS Substantial new evidence has emerged since the 2012 iteration of these guidelines, especially to inform best practices for the perioperative management of patients who are receiving a VKA and may require heparin bridging, for the perioperative management of patients who are receiving a DOAC, and for patients who are receiving one or more antiplatelet drugs. Despite this new knowledge, uncertainty remains as to best practices for the majority of perioperative management questions.
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Affiliation(s)
- James D Douketis
- Department of Medicine, St. Joseph's Healthcare Hamilton and McMaster University, Hamilton, ON, Canada.
| | - Alex C Spyropoulos
- Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Institute of Health Systems Science at The Feinstein Institutes for Medical Research, Manhasset, NY
| | - M Hassan Murad
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | - Juan I Arcelus
- Department of Surgery, Facultad de Medicina, University of Granada, Granada, Spain
| | - William E Dager
- Department of Pharmacy, University of California-Davis, Sacramento, CA
| | - Andrew S Dunn
- Division of Hospital Medicine, Department of Medicine, Mt. Sinai Health System, New York, NY
| | - Ramiz A Fargo
- Department of Internal Medicine, Loma Linda University Medical Center, Loma Linda, CA; Department of Internal Medicine, Riverside University Health System Medical Center, Moreno Valley, CA
| | - Jerrold H Levy
- Department of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, NC
| | - C Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP, Centre-Université Paris-Cité-Cochin Hospital, Paris, France
| | - Sahrish H Shah
- Mayo Clinic Evidence-Based Practice Center, Rochester, MN
| | | | - Alfonso J Tafur
- Department of Medicine, Cardiovascular, NorthShore University HealthSystem, Evanston, IL
| | - Liang V Tang
- Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong, University of Science and Technology, Wuhan, China
| | - Lisa K Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD
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5
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Hadanny A, Olmsted ZT, Marchese AM, Kroll K, Figueroa C, Tagney T, Tram J, DiMarzio M, Khazen O, Mitchell D, Cangero T, Sukul V, Pilitsis JG. Preoperative evaluation of coagulation status in neuromodulation patients. J Neurosurg 2022; 137:192-198. [PMID: 34826810 DOI: 10.3171/2021.8.jns211509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 08/13/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The incidence of hemorrhage in patients who undergo deep brain stimulation (DBS) and spinal cord stimulation (SCS) is between 0.5% and 2.5%. Coagulation status is one of the factors that can predispose patients to the development of these complications. As a routine part of preoperative assessment, the authors obtain prothrombin time (PT), partial thromboplastin time (PTT), and platelet count. However, insurers often cover only PT/PTT laboratory tests if the patient is receiving warfarin/heparin. The authors aimed to examine their experience with abnormal coagulation parameters in patients who underwent neuromodulation. METHODS Patients who underwent neuromodulation (SCS, DBS, or intrathecal pump implantation) over a 9-year period and had preoperative laboratory values available were included. The authors determined abnormal values on the basis of a clinical protocol utilized at their practice, which combined the normal ranges of the laboratory tests and clinical relevance. This protocol had cutoff values of 12 seconds and 39 seconds for PT and PTT, respectively, and < 120,000 platelets/μl. The authors identified risk factors for these abnormalities and described interventions. RESULTS Of the 1767 patients who met the inclusion criteria, 136 had abnormal preoperative laboratory values. Five of these 136 patients had values that were misclassified as abnormal because they were within the normal ranges at the outside facility where they were tested. Fifty-one patients had laboratory values outside the ranges of our protocol, but the surgeons reviewed and approved these patients without further intervention. Of the remaining 80 patients, 8 had known coagulopathies and 24 were receiving warfarin/heparin. The remaining 48 patients were receiving other anticoagulant/antiplatelet medications. These included apixaban/rivaroxaban/dabigatran anticoagulants (n = 22; mean ± SD PT 13.7 ± 2.5 seconds) and aspirin/clopidogrel/other antiplatelet medications (n = 26; mean ± SD PT 14.4 ± 5.8 seconds). Eight new coagulopathies were identified and further investigated with hematological analysis. CONCLUSIONS New anticoagulants and antiplatelet medications are not monitored with PT/PTT, but they affect coagulation status and laboratory values. Although platelet function tests aid in a subset of medications, it is more difficult to assess the coagulation status of patients receiving novel anticoagulants. PT/PTT may provide value preoperatively.
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Affiliation(s)
- Amir Hadanny
- 1Department of Neurosurgery, Albany Medical Center, Albany, New York
| | - Zachary T Olmsted
- 2Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York; and
| | - Anthony M Marchese
- 2Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York; and
| | - Kyle Kroll
- 2Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York; and
| | - Christopher Figueroa
- 2Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York; and
| | - Thomas Tagney
- 2Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York; and
| | - Jennifer Tram
- 2Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York; and
| | - Marisa DiMarzio
- 2Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York; and
| | - Olga Khazen
- 2Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York; and
| | - Dorothy Mitchell
- 2Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York; and
| | - Theodore Cangero
- 3Center Operations-Information Systems & Services, Albany Medical College, Albany, New York
| | - Vishad Sukul
- 1Department of Neurosurgery, Albany Medical Center, Albany, New York
| | - Julie G Pilitsis
- 1Department of Neurosurgery, Albany Medical Center, Albany, New York
- 2Department of Neuroscience and Experimental Therapeutics, Albany Medical College, Albany, New York; and
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6
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Gailani D. Factor XI as a target for preventing venous thromboembolism. J Thromb Haemost 2022; 20:550-555. [PMID: 35023278 PMCID: PMC9540353 DOI: 10.1111/jth.15628] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/23/2021] [Indexed: 01/10/2023]
Affiliation(s)
- David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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7
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Milner E, Ainsworth M, Gleaton M, Bookstaver D. Assessment of Anti-Xa activity in patients receiving concomitant apixaban with strong p-glycoprotein inhibitors and statins. J Clin Pharm Ther 2022; 47:668-675. [PMID: 35032137 PMCID: PMC9305439 DOI: 10.1111/jcpt.13596] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 12/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Although the apixaban Food and Drug Administration (FDA) package insert recommends dose reduction in patients administered dual strong inhibitors of p-glycoprotein (P-gp) and cytochrome P-450 (CYP) 3A4, there are limited published data regarding potential drug-drug interactions between apixaban (Eliquis) and common p-glycoprotein (P-gp) and CYP3A4 inhibitors co-administered with statins. The aim of this study was to investigate the degree of elevation relative to apixaban serum peak and trough concentration after the co-administration of amiodarone, diltiazem and statins (atorvastatin, rosuvastatin and simvastatin). METHODS Patients prescribed apixaban 5mg twice daily for at least one week were identified from the anticoagulation clinic database and contacted for potential enrolment. A total of 117 volunteers were enrolled with eight excluded due to discontinued use, resulting in 109 volunteers (44 females and 65 males delineated into age groups 40-64 and ≥65 years old) completing the observational study. Fifty-five volunteers were administered apixaban without the P-gp inhibitors amiodarone or diltiazem, with or without statins (atorvastatin, rosuvastatin and simvastatin). Fifty-four volunteers were administered apixaban with either amiodarone or diltiazem, with or without statins (atorvastatin, rosuvastatin or simvastatin). Peak and trough concentrations were assessed for each patient utilizing an apixaban anti-Xa assay. RESULTS Of the combinations studied, the mean apixaban trough concentration upon co-administration of amiodarone without a statin was elevated compared to apixaban alone (experimental 156.83 +/- 79.59 ng/ml vs. control 104.09 +/- 44.56 ng/ml; p = 0.04). The co-administration of diltiazem and rosuvastatin, and the administration of amiodarone without a statin led to greater than 1.5-fold increase in apixaban concentrations (peak experimental 315.19 +/- 157.53 ng/ml vs control 207.6 +/- 83.38 ng/ml; p = 0.08 and trough experimental 182.03 +/- 95.93 ng/ml vs control 112.32 +/- 37.78 ng/ml; p = 0.17) suggesting the need to assess dose adjustment for patients per the FDA package insert. In addition, the aggregated mean peak (p = 0.0056) and trough (p = 0.0089) elevation of CYP3A4 experimental groups (atorvastatin and simvastatin) co-administered apixaban and diltiazem were statistically significant compared with the aggregated non-CYP3A4 control groups (no statin and rosuvastatin). WHAT IS NEW AND CONCLUSION Herein, we report novel data regarding peak and trough apixaban concentrations after concomitant administration of P-gp and CYP3A4 inhibitors (amiodarone or diltiazem) co-administered with statins (atorvastatin, rosuvastatin or simvastatin). Providers should consider utilizing the apixaban anti-Xa assay or comparative heparin anti-Xa assay to determine if patients require dose reduction to decrease adverse events in high-risk patients prescribed apixaban and concomitant p-glycoprotein and CYP3A4 inhibitors amiodarone or diltiazem with and without a CYP3A4 or non-3A4 statin.
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Affiliation(s)
- Erin Milner
- Dwight D. Eisenhower Army Medical Center, Ft Gordon, Georgia, USA.,Department of Chemistry and Life Science, United States Military Academy, West Point, New York, USA.,Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
| | - Michael Ainsworth
- Department of Chemistry and Life Science, United States Military Academy, West Point, New York, USA
| | - Melinda Gleaton
- Dwight D. Eisenhower Army Medical Center, Ft Gordon, Georgia, USA
| | - David Bookstaver
- Dwight D. Eisenhower Army Medical Center, Ft Gordon, Georgia, USA
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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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Identification of the factor XII contact activation site enables sensitive coagulation diagnostics. Nat Commun 2021; 12:5596. [PMID: 34552086 PMCID: PMC8458485 DOI: 10.1038/s41467-021-25888-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 08/31/2021] [Indexed: 11/08/2022] Open
Abstract
Contact activation refers to the process of surface-induced activation of factor XII (FXII), which initiates blood coagulation and is captured by the activated partial thromboplastin time (aPTT) assay. Here, we show the mechanism and diagnostic implications of FXII contact activation. Screening of recombinant FXII mutants identified a continuous stretch of residues Gln317-Ser339 that was essential for FXII surface binding and activation, thrombin generation and coagulation. Peptides spanning these 23 residues competed with surface-induced FXII activation. Although FXII mutants lacking residues Gln317-Ser339 were susceptible to activation by plasmin and plasma kallikrein, they were ineffective in supporting arterial and venous thrombus formation in mice. Antibodies raised against the Gln317-Ser339 region induced FXII activation and triggered controllable contact activation in solution leading to thrombin generation by the intrinsic pathway of coagulation. The antibody-activated aPTT allows for standardization of particulate aPTT reagents and for sensitive monitoring of coagulation factors VIII, IX, XI.
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10
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McRae HL, Militello L, Refaai MA. Updates in Anticoagulation Therapy Monitoring. Biomedicines 2021; 9:262. [PMID: 33800804 PMCID: PMC8001784 DOI: 10.3390/biomedicines9030262] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/27/2021] [Accepted: 03/03/2021] [Indexed: 11/29/2022] Open
Abstract
In the past six decades, heparin and warfarin were the primary anticoagulants prescribed for treatment and prophylaxis of venous thromboembolism worldwide. This has been accompanied by extensive clinical knowledge regarding dosing, monitoring, and reversal of these anticoagulants, and the resources required to do so have largely been readily available at small and large centers alike. However, with the advent of newer oral and parenteral anticoagulants such as low molecular weight heparins, factor Xa inhibitors, and direct thrombin inhibitors in recent years, new corresponding practice guidelines have also emerged. A notable shift in the need for monitoring and reversal agents has evolved as well. While this has perhaps streamlined the process for physicians and is often desirable for patients, it has also left a knowledge and resource gap in clinical scenarios for which urgent reversal and monitoring is necessary. An overview of the currently available anticoagulants with a focus on the guidelines and available tests for anticoagulant monitoring will be discussed in this article.
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Affiliation(s)
| | | | - Majed A. Refaai
- Department of Pathology and Laboratory Medicine, Transfusion Medicine Division, Hemostasis and Thrombosis Unit, University of Rochester Medical Center, Rochester, NY 14642, USA; (H.L.M.); (L.M.)
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11
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Yavasoglu NG, Eren Y, Tatar IG, Yalcınkaya I. Infarct Volumes of Patients with Acute Ischemic Stroke Receiving Direct Oral Anticoagulants due to Non-Valvular Atrial Fibrillation. Ann Indian Acad Neurol 2021; 24:27-31. [PMID: 33911376 PMCID: PMC8061530 DOI: 10.4103/aian.aian_568_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Revised: 06/29/2020] [Accepted: 10/14/2020] [Indexed: 12/03/2022] Open
Abstract
Direct oral anticoagulants (DOACs) have been shown to decrease the risk of ischemic stroke in non-valvular atrial fibrillation (NVAF). This study aims to investigate whether DOACs result in a significant change in lesion volume and the severity of the subsequent disability in patients who have experienced a stroke.
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Affiliation(s)
- Nese G Yavasoglu
- Department of Neurology, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Turkey
| | - Yasemin Eren
- Department of Neurology, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Turkey
| | - Idil G Tatar
- Department of Radiology, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Turkey
| | - Irfan Yalcınkaya
- Department of Radiology, Dışkapı Yıldırım Beyazıt Training and Research Hospital, Ankara, Turkey
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12
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Effects of rivaroxaban and dabigatran on global hemostasis in patients with atrial fibrillation. Blood Coagul Fibrinolysis 2021; 31:243-252. [PMID: 32141885 DOI: 10.1097/mbc.0000000000000907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
: The study was aimed to evaluate the effects of two standard doses of rivaroxaban and dabigatran on global hemostatic assays in patients with atrial fibrillation. The study included 52 patients treated with rivaroxaban (15/20 mg), 50 on dabigatran (110/150 mg) and 20 healthy individuals. Platelet-poor plasma was used for determination of three global hemostatic assays, namely endogenous thrombin potential (ETP), calibrated automated thrombogram (CAT) and overall hemostasis potential (OHP). Rivaroxaban and dabigatran reduced ETP (P < 0.01) although OHP (P < 0.05) was diminished only by dabigatran. Strong correlations were noticed between ETP parameters and the plasma concentrations of rivaroxaban (ETP, r = -0.51; c-max, r = -0.85; t-lag, r = 0.83; t-max, r = 0.66) as well as with plasma concentration of dabigatran (ETP, r = -0.75; c-max, r = -0.74; t-lag, r = 0.73; t-max, r = 0.52). Analysis of dabigatran concentrations under 50 ng/ml showed that ETP parameter has area under the concentration-time curve-receiver operating characteristic value of 0.879 (95% confidence interval 0.776-0.980). Dabigatran treatment paradoxically increased area under the concentration-time curve and peak values although rivaroxaban decreased peak values (P < 0.01). However, significant correlation between CAT parameters and plasma concentration of both direct oral anticoagulants was not observed. We confirmed that the CAT assay is inappropriate for estimation of dabigatran effects and is not fully sensitive as regards rivaroxaban. The ETP assay can potentially be the appropriate method for estimation of global hemostatic capacity as regards both direct oral anticoagulants. The role of OHP needs to be confirmed in additional studies. ETP parameter of chromogenic assay has promising potential in exclusion of high plasma concentrations of dabigatran.
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Havrdová M, Saari TI, Jalonen J, Peltoniemi M, Kurkela M, Vahlberg T, Tienhaara A, Backman JT, Olkkola KT, Schramko A. Relationship of Edoxaban Plasma Concentration and Blood Coagulation in Healthy Volunteers Using Standard Laboratory Tests and Viscoelastic Analysis. J Clin Pharmacol 2020; 61:522-530. [PMID: 33027547 DOI: 10.1002/jcph.1758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 09/16/2020] [Indexed: 11/09/2022]
Abstract
The capability of viscoelastic measurement parameters to screen anticoagulation activity of edoxaban in relation to its plasma concentrations was evaluated in 15 healthy male volunteers. Blood samples were drawn before the oral administration of edoxaban 60 mg and 2, 4, 6, 8, and 24 hours after administration. At each time, standard coagulation tests were performed, blood viscoelastic properties were measured with a thromboelastometry device ROTEM delta analyzer (Instrumentation Laboratory, Werfen, Barcelona, Spain), and edoxaban plasma concentrations were measured. Our primary interest was the possible correlation between edoxaban plasma concentrations and values for ROTEM ExTEM, and FibTEM. We also studied the correlation of edoxaban plasma concentrations with the results of standard coagulation tests. We saw the effect of a single dose of edoxaban most clearly in clotting time (CT) of ROTEM ExTEM and FibTEM. Changes in these parameters correlated significantly with edoxaban plasma concentrations up to 6 hours from the ingestion of the drug. Activated partial thromboplastin time, prothrombin time, and anti-factor Xa were also affected. Peak changes were observed 2 and 4 hours after administration of edoxaban. The changes were mostly reversed after 8 hours. In conclusion, ROTEM CT correlates significantly with edoxaban plasma concentrations and can be used to estimate the effect of edoxaban. ROTEM should be considered as part of the assessment of coagulation, with the big advantage of being readily available on site.
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Affiliation(s)
- Martina Havrdová
- Emergency Medical Services, Hospital District of Southwest Finland, Turku, Finland.,Department of Anesthesiology and Intensive Care, University of Turku, Turku, Finland
| | - Teijo I Saari
- Department of Anesthesiology and Intensive Care, University of Turku, Turku, Finland.,Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - Jouko Jalonen
- Department of Anesthesiology and Intensive Care, University of Turku, Turku, Finland.,Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - Marko Peltoniemi
- Department of Anesthesiology and Intensive Care, University of Turku, Turku, Finland.,Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - Mika Kurkela
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, and the Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Tero Vahlberg
- Department of Clinical Medicine, Biostatistics, University of Turku, Turku, Finland
| | - Anri Tienhaara
- Hematology Laboratory, Tykslab, Turku University Hospital, Turku, Finland
| | - Janne T Backman
- Department of Clinical Pharmacology, University of Helsinki and Helsinki University Hospital, and the Individualized Drug Therapy Research Program, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Klaus T Olkkola
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
| | - Alexey Schramko
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and HUS Helsinki University Hospital, Helsinki, Finland
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14
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Strickland SW, Palkimas S, Acker M, Bazydlo LAL. A Novel Laboratory Assay to Monitor Unfractionated Heparin Dosing in Patients Taking Apixaban Prior to Hospital Admission. J Appl Lab Med 2020; 6:378-386. [PMID: 32995844 DOI: 10.1093/jalm/jfaa084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/09/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION When monitoring heparin, anti-Xa assays are susceptible to interference from apixaban taken before admission and can result in inappropriate dose adjustments that can negatively affect patient care. METHODS We derived a novel assay, termed corrected heparin (CH), using quantified values from a chromogenic anti-Xa assay with heparin calibrators before and after heparinase treatment to eliminate any interference from apixaban within the patient sample. We retrospectively assessed 469 specimens from 72 patients at our institution who had their unfractionated heparin infusion monitored using the CH assay because of known apixaban use. These patients were included in the study if they had detectable apixaban levels (>0.1 IU/mL by anti-Xa). RESULTS The analytical performance of the assay was evaluated, and precision was found to be 8.8% within 1 day and 13.3% over multiple days, with acceptable linearity (R2 = 0.997). Evaluation of clinical performance was compared with the partial thromboplastin time (PTT), showing a lack of correlation similar to comparisons between the PTT and anti-Xa assay (Blood Coagul Fibrinolysis 1993;4:635-8). The mean time to a therapeutic result in this cohort was 10 hours and 10 minutes. The CH assay was used to determine how long the apixaban was detected by the anti-Xa assay. The majority of patients (80%) still had measurable anti-Xa assay interference from apixaban at 24 hours after the last apixaban dose. CONCLUSIONS We have developed and evaluated an assay capable of quantifying heparin in the presence of apixaban. This assay showed acceptable performance in both analytical and clinical performance.
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Affiliation(s)
- Sydney W Strickland
- Department of Pathology, University of Virginia Health System, Charlottesville, VA
| | - Surabhi Palkimas
- Department of Pharmacy, University of Virginia Health System, Charlottesville, VA.,Department of Pharmacy, University of Colorado Health, Charlottesville, VA
| | - Mary Acker
- Medical Laboratories, University of Virginia Health System, Charlottesville, VA
| | - Lindsay A L Bazydlo
- Department of Pathology, University of Virginia Health System, Charlottesville, VA
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15
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Tyler PD, Yang LM, Snider SB, Lerner AB, Aird WC, Shapiro NI. New Uses for Thromboelastography and Other Forms of Viscoelastic Monitoring in the Emergency Department: A Narrative Review. Ann Emerg Med 2020; 77:357-366. [PMID: 32988649 DOI: 10.1016/j.annemergmed.2020.07.026] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 07/10/2020] [Accepted: 07/14/2020] [Indexed: 12/17/2022]
Abstract
Patients frequently visit the emergency department with conditions that place them at risk of worse outcomes when accompanied by coagulopathy. Routine tests of coagulation-prothrombin time, partial thromboplastin time, platelets, and fibrinogen-have shortcomings that limit their use in providing emergency care. One alternative is to investigate coagulation disturbance with viscoelastic monitoring (VEM), a coagulation test that measures the timing and strength of blood clot development in real time. VEM is widely used and studied in cardiac surgery, liver transplant surgery, anesthesia, and trauma. In this article, we review the technique of VEM and the biologic rationale of using it in addition to routine tests of coagulation in emergency clinical situations. Then, we review the evidence (or lack thereof) for using VEM in the diagnosis and treatment of specific conditions. Finally, we describe the limitations of the test and future directions for clinical use and research in emergency medicine.
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Affiliation(s)
- Patrick D Tyler
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
| | - Lauren M Yang
- Department of Medicine, Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Samuel B Snider
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Adam B Lerner
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - William C Aird
- Department of Medicine, Division of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, MA
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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16
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Jakowenko N, Nguyen S, Ruegger M, Dinh A, Salazar E, Donahue KR. Apixaban and rivaroxaban anti-Xa level utilization and associated bleeding events within an academic health system. Thromb Res 2020; 196:276-282. [PMID: 32947066 PMCID: PMC7474843 DOI: 10.1016/j.thromres.2020.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 07/30/2020] [Accepted: 09/01/2020] [Indexed: 12/20/2022]
Abstract
Background Oral factor Xa inhibitors (FXaI) can be administered in fixed doses without the need for routine laboratory monitoring. Anti-Xa assays can estimate anticoagulant effect for specific FXaI's. The aim of this study was to characterize anti-Xa levels in patients taking apixaban or rivaroxaban with major bleeding events. Methods Apixaban and rivaroxaban anti-Xa assays ordered within our hospital system from May 2016 to September 2019 were evaluated. The primary outcome was major bleeding events defined by International Society of Thrombosis and Haemostasis criteria. Median anti-Xa levels for each FXaI were calculated for those with and without major bleeding, as well as those who did and did not receive reversal agents. Results A total of 606 anti-Xa levels were analyzed. There were 146 major bleeding events documented, with the most common site being intracranial (63%). Median anti-Xa levels in patients with and without major bleeding were similar, whereas those on apixaban therapy who received reversal agents typically had higher anti-Xa levels (73 ng/mL vs. 153 ng/mL, p = 0.0019). Factors significantly associated with increased odds of bleeding were an age > 80 years, inappropriately high dosing regimens, and modest anti-Xa levels (100–300 ng/mL) for rivaroxaban specifically. Conclusions Older age and inappropriately high dosing regimens were associated with major bleeding in patients taking apixaban and rivaroxaban. Further investigation into the utility of anti-Xa levels for FXaI is warranted. Quantification and assessment of anticoagulation can be accomplished with factor Xa inhibitor (FXaI) specific anti-Xa levels Elderly patients and those on inappropriately high dosing regimens may be at an elevated risk for major bleeding It is unclear if elevated anti-Xa levels confer a direct increased risk for bleeding in the absence of other factors Anti-Xa levels are useful for confirmed or suspected bleeding, clearance for parenteral anticoagulation, and prior to an emergent procedure
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Affiliation(s)
- Nicholas Jakowenko
- Department of Pharmacy, Houston Methodist Hospital - Texas Medical Center, Houston, TX 77030, United States of America.
| | - Steffany Nguyen
- Department of Pharmacy, Houston Methodist Hospital - Texas Medical Center, Houston, TX 77030, United States of America
| | - Melanie Ruegger
- Department of Pharmacy, Houston Methodist Hospital - Texas Medical Center, Houston, TX 77030, United States of America
| | - Ashley Dinh
- Department of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States of America
| | - Eric Salazar
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital - Texas Medical Center, Houston, TX 77030, United States of America
| | - Kevin R Donahue
- Department of Pharmacy, Houston Methodist Hospital - Texas Medical Center, Houston, TX 77030, United States of America
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17
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Overview and Practical Application of Coagulation Assays in Managing Anticoagulation with Direct Oral Anticoagulants (DOACs). ACTA ACUST UNITED AC 2020. [DOI: 10.1007/s40495-020-00232-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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18
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Ćelap I, Margetić S, Brčić M, Mihić R. Analytical verification and comparison of chromogenic assays for dabigatran, rivaroxaban and apixaban determination on BCSXP and STA Compact Max analysers. Biochem Med (Zagreb) 2020; 30:010706. [PMID: 32063729 PMCID: PMC6999186 DOI: 10.11613/bm.2020.010706] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2019] [Accepted: 12/03/2019] [Indexed: 11/01/2022] Open
Abstract
Introduction The aim of the study was to perform analytical verification and comparison of chromogenic assays for determination of dabigatran, rivaroxaban and apixaban concentration on BCSXP and STA Compact Max analysers. Materials and methods Precision, linearity, measurement uncertainty estimation and determination of limit of blank, limit of determination and limit of quantification were calculated. Analytical performance specifications were set according to manufacturer specifications and literature data on between laboratory variability. Comparison of the methods was done using Bland-Altman and Passing-Bablok regression analysis. Results Obtained results have shown acceptable precision on STA Compact Max only for dabigatran (CV = 3.5%) at lower concentration level comparing to manufacturer declaration (CV = 3.6%). On BCSXP, the highest coefficient of variation has been shown for apixaban (6.1%) at lower concentration level. Within laboratory precision was not met on STA Compact Max for all assays. Bland-Altman analysis has shown statistically significant bias for dabigatran (23.2%, 95%CI 11.2 - 35.3; P < 0.001) and apixaban (8.4%, 95%CI 1.2 - 15.6; P = 0.023). Passing-Bablok regression analysis has shown systematic and proportional deviation between methods for rivaroxaban (y = 6.52 (2.94 to 11.83) + 0.84 (0.80 to 0.89) x. Conclusion Chromogenic assays for dabigatran, rivaroxaban and apixaban on BCSXP and STA Compact Max analysers are shown as methods with satisfactory long-term analytical performance specifications for determination of direct oral anticoagulants in clinical laboratories. However, we cannot recommend interchangeable use because of the significant bias between assays.
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Affiliation(s)
- Ivana Ćelap
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Sandra Margetić
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Marija Brčić
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Roman Mihić
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
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19
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Onundarson PT, Flygenring B. Oral anticoagulant monitoring: Are we on the right track? Int J Lab Hematol 2019; 41 Suppl 1:40-48. [PMID: 31069986 DOI: 10.1111/ijlh.13008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/22/2019] [Accepted: 02/22/2019] [Indexed: 12/21/2022]
Abstract
Vitamin K antagonists (VKAs) cannot be administered without regular monitoring in order to assure their efficacy and safety. Indeed, if well managed, the VKAs appear to be no less efficacious or safe than the newer direct oral anticoagulants (DOACs). Although it is claimed that no regular monitoring of the DOACs is needed, their levels are increasingly being measured under a variety of circumstances, for example, prior to surgery, in suspected overdose, to confirm effective reversal, in patients with malabsorption and to assess patient compliance. Although no therapeutic range has been identified for the DOACs, it has been demonstrated for dabigatran and edoxaban that their antithrombotic effect increases gradually with increasing concentrations and that the risk of major bleeding also gradually increases. Furthermore, it has been determined that almost all dabigatran-related thrombotic events occur in patients with the lowest quartile concentration of the drug. This suggests that to assure an ideal effect of DOACs in all patients taking them, some form of regular monitoring and dose tailoring should be performed. For the vitamin K antagonists, the best outcome is obtained using formal algorithms and centralized management. Furthermore, data suggest that replacing the standard prothrombin time as a monitoring test may increase the stability of VKA anticoagulation with consequent reduction in thromboembolism without an increase in bleeding. Thus, it is likely that the outcome of all current oral anticoagulants can be improved in the coming years by improving monitoring and tailoring their effect.
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Affiliation(s)
- Pall T Onundarson
- Landspitali/The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Bjorn Flygenring
- Landspitali/The National University Hospital of Iceland, Reykjavik, Iceland
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20
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Hawkins RB, Raymond SL, Hartjes T, Efron PA, Larson SD, Andreoni KA, Thomas EM. Review: The Perioperative Use of Thromboelastography for Liver Transplant Patients. Transplant Proc 2018; 50:3552-3558. [PMID: 30577236 DOI: 10.1016/j.transproceed.2018.07.032] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/09/2018] [Accepted: 07/18/2018] [Indexed: 12/12/2022]
Abstract
Thromboelastography (TEG) is a viscoelastic test that allows rapid evaluation of clot formation and fibrinolysis from a sample of whole blood. TEG is increasingly utilized to guide blood product resuscitation in surgical patients and transfusions for liver transplant patients. Patients with severe liver failure have significant derangement of their clotting function due to impaired production of procoagulant and anticoagulant factors. Traditional coagulation studies are limited by the short time needed for the result and provide little information about the dynamics and strength of clot formation. In addition, traditional coagulation studies do not correlate well with bleeding episodes and may lead to over-transfusion of various blood products. Evidence is less robust regarding the use of TEG for transfusion management decisions in severe liver failure patients awaiting, undergoing, or immediately after liver transplant surgery. However, the available evidence suggests that systematic implementation of TEG rather than traditional coagulation studies results in the administration of fewer blood products without increased mortality or complications. The purpose of this study is to review the literature regarding the use of TEG in liver failure patients prior to liver transplant, intraoperatively, and postoperatively. Additional high-quality randomized controlled studies should be performed to evaluate the use of TEG to guide transfusion decisions, particularly in the postoperative period following liver transplantation.
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Affiliation(s)
- R B Hawkins
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - S L Raymond
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - T Hartjes
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA; University of Florida College of Nursing, Gainesville, FL, USA
| | - P A Efron
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - S D Larson
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - K A Andreoni
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - E M Thomas
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA.
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21
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Hillarp A, Strandberg K, Baghaei F, Fagerberg Blixter I, Gustafsson KM, Lindahl TL. Effects of the oral, direct factor Xa inhibitor edoxaban on routine coagulation assays, lupus anticoagulant and anti-Xa assays. Scandinavian Journal of Clinical and Laboratory Investigation 2018; 78:575-583. [DOI: 10.1080/00365513.2018.1522664] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Andreas Hillarp
- Department of Clinical Chemistry and Transfusion Medicine, Halland County Hospital, Halmstad, Sweden
| | - Karin Strandberg
- Department of Clinical Chemistry, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | - Fariba Baghaei
- Department of Medicine, Coagulation Centre, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Inger Fagerberg Blixter
- Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kerstin M. Gustafsson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Tomas L. Lindahl
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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22
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Jabet A, Stepanian A, Golmard JL, Flaujac C, Joly BS, Gouin-Thibault I, Siguret V. Are Screening Tests Reliable to Rule Out Direct Oral Anticoagulant Plasma Levels at Various Thresholds (30, 50, or 100 ng/mL) in Emergency Situations? Chest 2018; 153:288-290. [DOI: 10.1016/j.chest.2017.09.047] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/12/2017] [Accepted: 09/24/2017] [Indexed: 11/25/2022] Open
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23
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Sinauridze EI, Vuimo TA, Tarandovskiy ID, Ovsepyan RA, Surov SS, Korotina NG, Serebriyskiy II, Lutsenko MM, Sokolov AL, Ataullakhanov FI. Thrombodynamics, a new global coagulation test: Measurement of heparin efficiency. Talanta 2017; 180:282-291. [PMID: 29332812 DOI: 10.1016/j.talanta.2017.12.055] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 12/14/2017] [Accepted: 12/17/2017] [Indexed: 01/06/2023]
Abstract
The actual coagulation status may be reliably measured using only highly sensitive global functional tests; however, they are not numerous and all of them have disadvantages. Thrombodynamics (TD), a novel global coagulation test, is sensitive to hypo- and hypercoagulable states. The main properties of this test were investigated, and its capabilities for hemostasis analysis were verified through pharmacodynamic monitoring of the most widely used anticoagulants, heparins. The anticoagulant effects in the plasma of donors (n = 20) and patients after hip replacement (n = 20) spiked with unfractionated heparin or enoxaparin were measured in vitro to eliminate the influence of pharmacokinetic factors. Sensitivity for heparins was compared for activated partial thromboplastin time, thrombin generation tests and TD. TD was shown to reliably characterize the pharmacodynamics of any heparin in the entire range of its prophylactic and therapeutic concentrations. Inter-individual variability for the anticoagulant action of heparins was also calculated using the TD data. This variability did not differ between the investigated groups and did not exceed 12% and 20% for the stationary clot growth rate in the presence of unfractionated heparin and enoxaparin, respectively. That finding was in accordance with the values determined earlier using the thrombin generation test. The study results showed that TD has advantages over the other global methods of coagulation analysis. These advantages are good standardization, high reproducibility, independence of the parameter values from patient age and gender, and a narrower parameter distribution in a normal population. These results indicate that TD is a promising universal assessment method that improves the quality of hemostasis analysis because it more reliably detects deviations from the parameters' reference values.
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Affiliation(s)
- Elena I Sinauridze
- Laboratory of Biophysics, Dmitriy Rogachev National Medical Research Center of Pediatric Hematology, Oncology, and Immunology, Samory Mashela str., 1, GSP-7, Moscow 117997, Russia; Laboratory of Biophysics of the Cell, Center for Theoretical Problems of Physicochemical Pharmacology, Russian Academy of Sciences, Kosygina str., 4, Moscow 119334, Russia.
| | - Tatiana A Vuimo
- Laboratory of Translational Medicine, Dmitriy Rogachev National Medical Research Center of Pediatric Hematology, Oncology, and Immunology, Samory Mashela str., 1, GSP-7, Moscow 117997, Russia.
| | - Ivan D Tarandovskiy
- Laboratory of Physical Biochemistry, National Research Center for Hematology, Novyi Zykovskii pr., 4, Moscow 125167, Russia.
| | - Ruzanna A Ovsepyan
- Laboratory of Translational Medicine, Dmitriy Rogachev National Medical Research Center of Pediatric Hematology, Oncology, and Immunology, Samory Mashela str., 1, GSP-7, Moscow 117997, Russia.
| | - Stepan S Surov
- Laboratory of Biophysics of the Cell, Center for Theoretical Problems of Physicochemical Pharmacology, Russian Academy of Sciences, Kosygina str., 4, Moscow 119334, Russia.
| | - Natalia G Korotina
- Scientific Department, Hematological Corporation HemaCore LLC, Nauchnyi pr., 20, build. 2, Moscow 117246, Russia.
| | - Ilya I Serebriyskiy
- Scientific Department, Hematological Corporation HemaCore LLC, Nauchnyi pr., 20, build. 2, Moscow 117246, Russia.
| | - Maxim M Lutsenko
- Department of Low Invasive Surgery, Treatment and Rehabilitation Center, Ivankovskoe shosse, 3, Moscow 125367, Russia.
| | - Alexander L Sokolov
- Department of Low Invasive Surgery, Treatment and Rehabilitation Center, Ivankovskoe shosse, 3, Moscow 125367, Russia.
| | - Fazoil I Ataullakhanov
- Laboratory of Biophysics, Dmitriy Rogachev National Medical Research Center of Pediatric Hematology, Oncology, and Immunology, Samory Mashela str., 1, GSP-7, Moscow 117997, Russia; Laboratory of Biophysics of the Cell, Center for Theoretical Problems of Physicochemical Pharmacology, Russian Academy of Sciences, Kosygina str., 4, Moscow 119334, Russia; Scientific Department, Hematological Corporation HemaCore LLC, Nauchnyi pr., 20, build. 2, Moscow 117246, Russia; Department of Physics, Moscow State University, Leninskie Gory, 1, build. 2, GSP-1, Moscow 119991, Russia; Department of Biological and Medical Physics, Moscow Institute of Physics and Technology, Institutskii per., 9, Dolgoprudny, Moscow Region 141701, Russia.
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