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Amundsen EK, Ihle-Hansen H, Kraglund KL, Hagberg G. Acute ischemic stroke and measurement of apixaban and rivaroxaban: an observational cohort implementation study. Res Pract Thromb Haemost 2024; 8:102307. [PMID: 38314168 PMCID: PMC10837088 DOI: 10.1016/j.rpth.2023.102307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 12/04/2023] [Accepted: 12/06/2023] [Indexed: 02/06/2024] Open
Abstract
Background Treatment with intravenous thrombolysis for acute ischemic stroke is contraindicated with intake of apixaban/rivaroxaban in the last 48 hours. Recent European Stroke Organization guidelines suggest that thrombolysis can be considered if anti-factor Xa activity (AFXa) is <0.5 × 103 IU/L with low-molecular-weight (LMWH) or unfractionated heparin (UFH) calibrated assays. Some centers also use apixaban/rivaroxaban-calibrated AFXa assays to identify patients with low drug concentrations. Objectives To prospectively evaluate the first year of implementation of drug-calibrated AFXa assays at our center with 2500 yearly admittances with suspected stroke. Methods Samples were analyzed on Sysmex CS-5100 instruments with Innovance anti-Xa reagents. Thrombolysis could be considered with drug concentrations <25 μg/L. Patients were registered in an institutionally approved quality register. Outcomes included (1) the number of patients receiving thrombolysis after drug measurement, (2) turn-around time for drug concentration measurements, and (3) sensitivity of LMWH/UFH AFXa to apixaban and rivaroxaban. Results Apixaban or rivaroxaban was measured in 148 samples, and 4 patients who previously would have been ineligible for thrombolysis were treated with thrombolysis. In total, thrombolysis was administered in 123 patient episodes in the study period. The median turn-around time for the drug measurements was 38 minutes. Apixaban concentrations of 25 μg/L and 50 μg/L corresponded to LMWH/UFH AFXa of 0.13 and 0.27 × 103 IU/L, respectively. There were too few rivaroxaban results for regression analysis. Conclusion Implementation of apixaban and rivaroxaban measurements led to a small increase in the number of patients receiving thrombolysis. Excluding significant concentrations of apixaban or rivaroxaban using LMWH/UFH AFXa may be feasible.
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Affiliation(s)
| | - Hege Ihle-Hansen
- Oslo Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway
| | | | - Guri Hagberg
- Oslo Stroke Unit, Department of Neurology, Oslo University Hospital, Oslo, Norway
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2
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Shaw JR, Castellucci LA, Siegal D, Carrier M. DOAC-associated bleeding, hemostatic strategies, and thrombin generation assays - a review of the literature. J Thromb Haemost 2023; 21:433-452. [PMID: 36696204 DOI: 10.1016/j.jtha.2022.11.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/24/2022] [Accepted: 11/15/2022] [Indexed: 01/26/2023]
Abstract
Direct oral anticoagulants (DOACs) account for most oral anticoagulant use. DOAC-associated bleeding events are commonly encountered in clinical practice and are associated with substantial morbidity and mortality. Both specific reversal agents and nonspecific hemostatic therapies, such as prothrombin complex concentrates, are used in the management of DOAC-associated bleeding. Measuring hemostatic efficacy and demonstrating a clinical impact from these therapies among studies of bleeding patients is challenging. Thrombin generation assays provide information on the total hemostatic potential of plasma, and have emerged as a promising modality to both measure the impact of DOACs on coagulation and to evaluate the effects of hemostatic therapies among patients with DOAC-associated bleeding. The mechanisms by which nonspecific hemostatic agents impact coagulation and thrombin generation in the context of DOAC therapy are unclear. As a result, we undertook a review of the literature using a systematic search strategy with the goal of summarizing the effects of DOACs on thrombin generation and the effects of both specific reversal agents and nonspecific hemostatic therapies on DOAC-altered thrombin generation parameters. We sought to identify clinical studies focusing on whether altered thrombin generation is associated with clinical bleeding and whether correction of altered thrombin generation parameters predicts improvements in clinical hemostasis. Lastly, we sought to outline future directions for the application of thrombin generation assays toward anticoagulation therapies and the question of anticoagulation reversal.
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Affiliation(s)
- Joseph R Shaw
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Lana A Castellucci
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - Deborah Siegal
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Carrier
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
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3
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Metze M, Siegemund A, Siegemund T, Klöter T, Stöbe S, Laufs U, Petros S, Pfrepper C. The dose–response of direct oral anticoagulants is non‐linear at plasma levels below 100 ng/ml. Int J Lab Hematol 2022; 45:e60-e63. [PMID: 36539973 DOI: 10.1111/ijlh.14004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 11/30/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Michael Metze
- Department of Cardiology, Medical Department IV University Hospital Leipzig Leipzig Germany
| | | | | | - Tristan Klöter
- Department of Cardiology, Medical Department IV University Hospital Leipzig Leipzig Germany
| | - Stephan Stöbe
- Department of Cardiology, Medical Department IV University Hospital Leipzig Leipzig Germany
| | - Ulrich Laufs
- Department of Cardiology, Medical Department IV University Hospital Leipzig Leipzig Germany
| | - Sirak Petros
- Medical ICU University Hospital Leipzig Leipzig Germany
- Division of Hemostaseology, Medical Department I University Hospital Leipzig Leipzig Germany
| | - Christian Pfrepper
- Division of Hemostaseology, Medical Department I University Hospital Leipzig Leipzig Germany
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4
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Shaw JR, Li N, Nixon J, Moffat KA, Spyropoulos AC, Schulman S, Douketis JD. Coagulation assays and direct oral anticoagulant levels among patients having an elective surgery or procedure. J Thromb Haemost 2022; 20:2953-2963. [PMID: 36200348 DOI: 10.1111/jth.15901] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/27/2022] [Accepted: 09/29/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND The Perioperative Anticoagulation Use for Surgery Evaluation study prospectively evaluated a prespecified periprocedural interruption strategy of direct oral anticoagulants (DOACs) among patients with atrial fibrillation. Coagulation testing is widely available and frequently requested prior to invasive procedures. Coagulation assays display poor sensitivity to clinically relevant DOAC concentrations. OBJECTIVES Determine the utility of routinely available coagulation testing at predicting a DOAC concentration of <30 ng/ml among patients in the preprocedural setting. METHODS We calculated the sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive and negative likelihood ratio (LR+ and LR-) of a normal coagulation assay result for identifying patients with a preprocedural DOAC level < 30 ng/ml. RESULTS We identified weak or very weak correlations between coagulation assay results and DOAC levels in the preprocedural setting, except for a moderate correlation between the thrombin time (TT) and dabigatran concentrations (ρ = 0.68; p < .001). The prothrombin time (PT) and activated partial thromboplastin time (APTT) demonstrated modest sensitivity (78.9% to 88.2%) and PPVs (76.4% to 93.1%) but poor specificity (13.2% to 53.3%) and NPVs (16.3% to 30.2%) across all three DOACs. A normal TT was associated with 100% specificity and PPV values for a dabigatran level < 30 ng/ml. A normal APTT among patients on dabigatran was associated with an LR+ of 1.671 (95% confidence interval [CI] 1.297, 2.154) and an LR- of 0.395 (95% CI 0.207, 0.751) for levels <30 ng/ml. CONCLUSIONS The PT and APTT perform poorly at safely identifying patients with negligible DOAC levels in the preprocedural setting.
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Affiliation(s)
- Joseph R Shaw
- Department of Medicine, University of Ottawa, and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Na Li
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Computing and Software, McMaster University, Hamilton, Ontario, Canada
| | - Joanne Nixon
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Karen A Moffat
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Regional Laboratory Medicine Program, Hamilton, Ontario, Canada
| | - Alex C Spyropoulos
- The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Department of Medicine, Northwell Health at Lenox Hill Hospital, New York, New York, USA
| | - Sam Schulman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Obstetrics and Gynecology, I.M. Schenov First Moscow State Medical University, Moscow, Russia
| | - James D Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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5
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Evrard J, Siriez R, Bouvy C, Favresse J, Yildiz H, Hainaut P, Mullier F, Dogné J, Douxfils J. Comparison of analytical performances between clot waveform analysis and
FibWave
in edoxaban‐treated patients and healthy controls. Res Pract Thromb Haemost 2022; 6:e12804. [PMID: 36349263 PMCID: PMC9634266 DOI: 10.1002/rth2.12804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 08/10/2022] [Accepted: 08/18/2022] [Indexed: 11/06/2022] Open
Abstract
Introduction The activated partial thromboplastin time (aPTT) and the prothrombin time (PT) are widely available coagulation parameters which are however poor predictors of the anticoagulant effect of direct oral anticoagulants (DOACs). Some coagulometers use the clot waveform analysis (CWA) to assess the clotting time but mainly based on a unique parameter. The improvement of these methodologies and the evaluation of the other waveform parameters may increase the sensitivity to DOACs. Objectives To assess the performance of an improved clot waveform an method (i.e. FibWave) to detect the impact of edoxaban on the coagulation and the fibrinolytic systems. Methods Seventy‐one samples from patients treated with edoxaban collected at minimum concentration (CTROUGH) and/or maximum concentration (CMAX), and 45 control samples were included. The aPTT‐ and PT‐based CWA as well as the FibIn, FibEx, and FibLysis methodologies of the FibWave were implemented and performed on an ACL‐TOP 700. Results PT and FibEx clotting time were strongly correlated to edoxaban concentration (Pearson r = 0.80 and 0.89, respectively). The FibEx clotting time allowed a better discrimination for samples with 30 and 50 ng/ml of edoxaban compared to PT (cutoffs of 96.5 and 114.2 s for the FibEx versus a unique cutoff of 13.1 s for the PT). The fibrinolytic process was impaired in the presence of edoxaban in a dose‐dependent manner. Conclusion FibEx is more sensitive than aPTT‐ and PT‐based CWA for the detection of the clinically relevant anticoagulant level of edoxaban.
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Affiliation(s)
- Jonathan Evrard
- Department of PharmacyUniversité de Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS)NamurBelgium
| | - Romain Siriez
- Department of PharmacyUniversité de Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS)NamurBelgium
| | | | - Julien Favresse
- Department of PharmacyUniversité de Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS)NamurBelgium
- Department of Laboratory MedicineClinique Saint‐Luc BougeNamurBelgium
| | - Halil Yildiz
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint‐LucUniversité Catholique de LouvainBrusselsBelgium
| | - Philippe Hainaut
- Department of Internal Medicine and Infectious Diseases, Cliniques Universitaires Saint‐LucUniversité Catholique de LouvainBrusselsBelgium
| | - François Mullier
- Hematology LaboratoryUniversité Catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS)YvoirBelgium
| | - Jean‐Michel Dogné
- Department of PharmacyUniversité de Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS)NamurBelgium
| | - Jonathan Douxfils
- Department of PharmacyUniversité de Namur, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS)NamurBelgium
- Qualiblood s.a.NamurBelgium
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6
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Merrelaar AE, Bögl MS, Buchtele N, Merrelaar M, Herkner H, Schoergenhofer C, Harenberg J, Douxfils J, Siriez R, Jilma B, Spiel AO, Schwameis M. Performance of a Qualitative Point-of-Care Strip Test to Detect DOAC Exposure at the Emergency Department: A Cohort-Type Cross-Sectional Diagnostic Accuracy Study. Thromb Haemost 2022; 122:1723-1731. [PMID: 35785816 PMCID: PMC9512583 DOI: 10.1055/s-0042-1750327] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
An accurate point-of-care test for detecting effective anticoagulation by direct oral anticoagulants (DOACs) in emergencies is an unmet need. We investigated the accuracy of a urinary qualitative strip test (DOAC Dipstick) to detect relevant DOAC exposure in patients who presented to an emergency department. In this prospective single-center cohort-type cross-sectional study, adults on DOAC treatment were enrolled. We assessed clinical sensitivity and specificity of DOAC Dipstick factor Xa and thrombin inhibitor pads to detect DOAC plasma levels ≥30 ng/mL using urine samples as the testing matrix. Liquid chromatography coupled with tandem-mass spectrometry was used as the reference standard method for plasma and urine measurement of DOAC concentrations. Of 293 patients enrolled, 265 patients were included in the analysis, of whom 92 were treated with rivaroxaban, 65 with apixaban, 77 with edoxaban, and 31 with dabigatran. The clinical sensitivity and specificity of the dipstick on urine samples to detect ≥30 ng/mL dabigatran plasma levels were 100% (95% confidence interval [CI]: 87–100%) and 98% (95% CI: 95–99%), respectively. The sensitivity and specificity of the dipstick to detect ≥30 ng/mL factor Xa inhibitor plasma levels were 97% (95% CI: 94–99%) and 69% (95% CI: 56–79%), respectively. The DOAC Dipstick sensitively identified effective thrombin and factor Xa inhibition in a real-world cohort of patients presenting at an emergency department. Therefore, the dipstick might provide a valuable test to detect relevant DOAC exposure in emergencies, although further studies will be needed to confirm these findings.
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Affiliation(s)
- Anne E Merrelaar
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Magdalena S Bögl
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Nina Buchtele
- Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Marieke Merrelaar
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | | | - Job Harenberg
- Ruprecht-Karls-University, Heidelberg, Germany.,Doasense GmbH, Heidelberg, Germany
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, University of Namur, Namur, Belgium.,Qualiblood s.a., Department of Research and Development, Namur, Belgium
| | - Romain Siriez
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, University of Namur, Namur, Belgium
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Alexander O Spiel
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.,Department of Emergency Medicine, Klinik Ottakring, Vienna, Austria
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
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7
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Perifanis V, Neokleous N, Tsakiris DA. Update on laboratory testing and hemostasis assessment in patients receiving direct oral anticoagulants (DOACs). THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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8
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Metze M, Klöter T, Stöbe S, Rechenberger B, Siegemund R, Siegemund T, Laufs U, Petros S, Pfrepper C. Plasma levels do not predict thrombin generation in patients taking direct oral anticoagulants. Int J Lab Hematol 2021; 43:1539-1548. [PMID: 34097808 DOI: 10.1111/ijlh.13618] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/04/2021] [Accepted: 05/14/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND The antithrombotic effect of direct oral anticoagulants (DOAC) in specific clinical scenarios is difficult to assess. OBJECTIVE This study aimed to evaluate the effect of DOAC on thrombin generation (TG) in relation to their plasma level. METHODS Eighty patients newly started on anticoagulation were included, 20 patients for each DOAC-apixaban, edoxaban, rivaroxaban, and dabigatran. Plasma was sampled before DOAC (baseline), at plasma peak time, 6 and 12 hours after starting DOAC for quantification of drug levels and TG. RESULTS The baseline TG before DOAC intake showed inter-individual variability. All DOACs significantly prolonged lag time (LT) and time to peak (TTP), but did not change endogenous thrombin potential (ETP). Anti-Xa inhibitors but not dabigatran reduced thrombin peak, but the effect of apixaban at plasma peak was less pronounced (factor 1.6). LT and TTP prolongation of dabigatran was lower compared to anti-Xa inhibitors. All DOACs showed a nonlinear dose-response relationship, with the greatest antithrombotic effect at lower DOAC plasma levels. The inhibition of TG parameters between baseline and peak was parallel between individual patients but the coefficient of variation of TG was lower compared to drug levels. CONCLUSION The antithrombotic effect at DOAC peak plasma level measured by TG depends on the patient-specific baseline TG level and the drug-specific inhibition by the particular DOAC. Although peak plasma levels have a high variability, the variation of TG is lower compared to drug levels. Therefore, TG assays may be superior to plasma levels in the assessment of the intensity of anticoagulation.
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Affiliation(s)
- Michael Metze
- Department of Cardiology, Medical Department IV, University Hospital Leipzig, Leipzig, Germany
| | - Tristan Klöter
- Department of Cardiology, Medical Department IV, University Hospital Leipzig, Leipzig, Germany
| | - Stephan Stöbe
- Department of Cardiology, Medical Department IV, University Hospital Leipzig, Leipzig, Germany
| | | | | | | | - Ulrich Laufs
- Department of Cardiology, Medical Department IV, University Hospital Leipzig, Leipzig, Germany
| | - Sirak Petros
- Medical ICU, University Hospital Leipzig, Leipzig, Germany.,Division of Hemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
| | - Christian Pfrepper
- Division of Hemostaseology, Medical Department I, University Hospital Leipzig, Leipzig, Germany
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9
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Douxfils J, Adcock DM, Bates SM, Favaloro EJ, Gouin-Thibault I, Guillermo C, Kawai Y, Lindhoff-Last E, Kitchen S, Gosselin RC. 2021 Update of the International Council for Standardization in Haematology Recommendations for Laboratory Measurement of Direct Oral Anticoagulants. Thromb Haemost 2021; 121:1008-1020. [PMID: 33742436 DOI: 10.1055/a-1450-8178] [Citation(s) in RCA: 89] [Impact Index Per Article: 29.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 2018, the International Council for Standardization in Haematology (ICSH) published a consensus document providing guidance for laboratories on measuring direct oral anticoagulants (DOACs). Since that publication, several significant changes related to DOACs have occurred, including the approval of a new DOAC by the Food and Drug Administration, betrixaban, and a specific DOAC reversal agent intended for use when the reversal of anticoagulation with apixaban or rivaroxaban is needed due to life-threatening or uncontrolled bleeding, andexanet alfa. In addition, this ICSH Working Party recognized areas where additional information was warranted, including patient population considerations and updates in point-of-care testing. The information in this manuscript supplements our previous ICSH DOAC laboratory guidance document. The recommendations provided are based on (1) information from peer-reviewed publications about laboratory measurement of DOACs, (2) contributing author's personal experience/expert opinion and (3) good laboratory practice.
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Affiliation(s)
- Jonathan Douxfils
- Department of Pharmacy-Namur Thrombosis and Hemostasis Center, University of Namur, Namur, Belgium.,Qualiblood SA, Namur, Belgium
| | - Dorothy M Adcock
- Laboratory Corporation of America, Burlington North Carolina, United States
| | - Shannon M Bates
- Department of Medicine, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Haemostasis and Thrombosis, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
| | | | - Cecilia Guillermo
- Hospital de Clínicas "Dr Manuel Quintela," Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Yohko Kawai
- Sanno Hospital, Laboratory Medicine, Tokyo, Japan
| | - Edelgard Lindhoff-Last
- Cardiology Angiology Center Bethanien, CCB Vascular Center, CCB Coagulation Center, Frankfurt, Germany
| | - Steve Kitchen
- Royal Hallamshire Hospital, Coagulation Sheffield, South Yorks, United Kingdom
| | - Robert C Gosselin
- Hemophilia Treatment Center, University of California, Davis Health System, Sacramento, California, United States
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