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Shaw JR, Unachukwu U, Cyr J, Siegal DM, Castellucci LA, Dreden PV, Dowlatshahi D, Buyukdere H, Ramsay T, Carrier M. Effect of PCC on Thrombin Generation among Patients on Factor Xa Inhibitors with Major Bleeding or Needing Urgent Surgery (GAUGE): Design and Rationale. TH OPEN 2023; 7:e229-e240. [PMID: 37497426 PMCID: PMC10368490 DOI: 10.1055/s-0043-1771300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/12/2023] [Indexed: 07/28/2023] Open
Abstract
Background Direct factor Xa inhibitors (FXaIs) account for most oral anticoagulant use and FXaI-associated bleeding events are common. Clinicians have variable national and regional access to specific FXaI reversal agents such as andexanet alfa. Many centers have adopted the use of prothrombin complex concentrates (PCCs) as hemostatic therapy for FXaI-associated major bleeding events. PCC does not impact circulating FXaI levels and its mechanism of action to achieve hemostasis in FXaI-associated bleeding is uncertain. While PCC increases quantitative thrombin generation assay (TGA) parameters, it does not correct FXaI-altered thrombin generation kinetics, nor does it normalize thrombin generation. Clinical data supporting the use of PCC are based on cohort studies reporting clinical hemostatic efficacy, which is difficult to measure. The benefits of PCC for FXaI-associated bleeding beyond supportive care are uncertain. Objective GAUGE is a prospective observational study designed to measure the effects of four-factor PCC administration (Octaplex) on TGA parameters among patients with FXaI-associated bleeding or needing urgent surgery. Methods Laboratory outcomes will include the mean paired change in TGA parameters from pre- to post-PCC administration and the proportion of participants whose post-PCC TGA values fall within a defined reference range. Clinical outcomes will include hemostatic efficacy, thromboembolic complications, and all-cause death at 30 days post-PCC. Conclusion Development of a viable and universally accessible FXaI bleed management strategy is crucial. GAUGE will provide in vivo data on the effects of PCC among patients with FXaI-associated bleeding.
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Affiliation(s)
- Joseph R. Shaw
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Ubabuko Unachukwu
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Joseph Cyr
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Deborah M. Siegal
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | - Lana A. Castellucci
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Dar Dowlatshahi
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
- Brain and Mind Research Institute, Ottawa, Canada
| | - Hakan Buyukdere
- Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, Canada
| | | | - Marc Carrier
- Department of Medicine, Division of Hematology, University of Ottawa, Ottawa, Canada
- Ottawa Hospital Research Institute, Ottawa, Canada
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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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Hiramoto K, Akita N, Nishioka J, Suzuki K. Edoxaban, a Factor Xa-Specific Direct Oral Anticoagulant, Significantly Suppresses Tumor Growth in Colorectal Cancer Colon26-Inoculated BALB/c Mice. TH OPEN : COMPANION JOURNAL TO THROMBOSIS AND HAEMOSTASIS 2023; 7:e1-e13. [PMID: 36751299 PMCID: PMC9825203 DOI: 10.1055/s-0042-1758855] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 10/10/2022] [Indexed: 01/09/2023]
Abstract
Introduction Certain low-molecular-weight heparins have been reported to reduce tumor growth and metastasis in tumor cell-inoculated mouse models and cancer patients. Recently, direct oral anticoagulants (DOACs) have been widely used in patients with thromboembolism. This study was aimed at investigating the effect of DOACs, which target thrombin or factor Xa, on tumor growth in a syngeneic mouse model comprising BALB/c mice inoculated with colon cancer Colon26 cells. Materials and Methods DOACs targeting thrombin (dabigatran etexilate [DABE]) or factor Xa (rivaroxaban [RVX] and edoxaban [EDX]) were orally administered daily to male BALB/c mice inoculated with Colon26 cells, followed by analyses of tumor growth and plasma levels of coagulation- and tumor-related factors such as tissue factor (TF), plasminogen activator inhibitor-1 (PAI-1), interleukin-6 (IL-6), and matrix metalloproteinase-2 (MMP-2). Results Colon26 cells expressed significant amounts of functionally active TF. Tumor growth in Colon26-inoculated mice was significantly suppressed in DABE- or RVX-treated mice ( p <0.05) and was suppressed more significantly in EDX-treated mice ( p <0.01). Therefore, the antitumor mechanism of action of EDX was investigated next. Plasma levels of TF, PAI-1, IL-6, and MMP-2 were elevated in Colon26-inoculated mice but were significantly reduced in EDX-treated mice ( p <0.01). The expression of protease-activated receptor (PAR)1, PAR2, signal transducer and activator of transcription-3 (STAT3), cyclin D1, and Ki67 was increased in tumor tissue of Colon26-inoculated mice but (except for PAR1) was significantly decreased in tumor tissues of EDX-treated mice ( p <0.01). In addition, apoptotic cells and p53 protein levels were significantly increased in tumor tissues of EDX-treated mice. Conclusion The data suggest that among the tested DOACs, EDX significantly suppresses tumor cell proliferation via the factor Xa-PAR2 pathway, which is activated by coagulation and inflammation in Colon26-inoculated mice and induces tumor cell apoptosis.
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Affiliation(s)
- Keiichi Hiramoto
- Department of Molecular Pathobiology, Faculty of Pharmaceutical Sciences, Suzuka University of Medical Science, Suzuka-city, Mie, Japan
| | - Nobuyuki Akita
- Department of Clinical Engineering, Faculty of Medical Engineering, Suzuka University of Medical Science, Suzuka-city, Mie, Japan
| | - Junji Nishioka
- Department of Clinical Nutrition, Faculty of Health Science, Suzuka University of Medical Science, Suzuka-city, Mie, Japan
| | - Koji Suzuki
- Department of Molecular Pathobiology, Faculty of Pharmaceutical Sciences, Suzuka University of Medical Science, Suzuka-city, Mie, Japan,Address for correspondence Koji Suzuki, PhD Department of Molecular Pathobiology, Faculty of Pharmaceutical Sciences, Suzuka University of Medical Science.Minamitamagaki-cho 3500-3, Suzuka-city, Mie 513-8670Japan
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Jurk K, Rothenaicher KF, Groß K, Rossmann H, Weißer G, Schmidtmann I, Münzel T, Espinola-Klein C. Differential Inhibition of Platelet Reactivity by Dual Therapy With Aspirin and Low-Dose Rivaroxaban in Peripheral Arterial Disease: A Pilot Study. Front Cardiovasc Med 2022; 9:865166. [PMID: 35600474 PMCID: PMC9120432 DOI: 10.3389/fcvm.2022.865166] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 03/28/2022] [Indexed: 01/22/2023] Open
Abstract
Patients with peripheral arterial disease (PAD) benefit from combination therapy with acetylsalicylic acid (ASA, 100 mg, one time per day) plus low-dose rivaroxaban (2.5 mg, two times per day) compared to ASA monotherapy. In particular, major adverse cardiac and limb events were significantly reduced after peripheral endovascular revascularization (EVR). In this pilot study, the platelet activation status in vivo and platelet reactivity in vitro were longitudinally analyzed by flow cytometric assays and calibrated automated thrombography in platelet-rich plasma (PRP) from 10 patients with PAD receiving ASA (100 mg, one time per day) before EVR, ASA plus clopidogrel (75 mg, one time per day) after EVR, and ASA plus rivaroxaban (2.5 mg, two times per day) during a long-term follow-up. Platelet responsiveness to clopidogrel was compared to additional 10 patients with stable PAD and clopidogrel (75 mg, one time per day) monotherapy. ASA plus rivaroxaban treatment resulted in a significantly decreased thrombin peak in PRP for two triggers, namely, low concentration of tissue factor (TF) and thrombin, compared to ASA monotherapy. TF-controlled thrombin generation was additionally characterized by a significantly prolonged lag time in PRP and platelet-free plasma during ASA plus rivaroxaban combination therapy. In comparison, ASA plus clopidogrel treatment presented a significant reduction of the thrombin peak in PRP, which was less pronounced than during subsequent ASA plus rivaroxaban therapy. Platelet responsiveness to clopidogrel was observed for 60% of patients receiving ASA plus clopidogrel and clopidogrel monotherapy, respectively. Blocking of CD36 on the platelet surface further reduced the thrombin peak in PRP induced by TF for all three therapy regimes. Platelet activation in vivo and in response to the GPVI-agonist convulxin or thrombin in vitro was similar, whereas integrin αIIbβ3 activation and α-granule release induced by the PAR-1 activating peptide TRAP-6 were significantly diminished during ASA plus rivaroxaban treatment compared to ASA monotherapy. In conclusion, the data of this pilot study indicate an inhibitory effect of rivaroxaban on the thrombin propagation phase of CD36-sensitive platelet thrombin formation in patients with PAD treated with ASA plus rivaroxaban combination therapy, which is associated with decreased PAR-1 but not thrombin-mediated platelet activation.
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Affiliation(s)
- Kerstin Jurk
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Korbinian F. Rothenaicher
- Center for Cardiology, Cardiology III—Angiology, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Kathrin Groß
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Heidi Rossmann
- Institute for Clinical and Laboratory Medicine, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Gerhard Weißer
- Center for Cardiology, Cardiology III—Angiology, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Irene Schmidtmann
- Institute for Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Thomas Münzel
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
- Center for Cardiology, Cardiology I—General and Interventional Cardiology and Intensive Care, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
| | - Christine Espinola-Klein
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
- Center for Cardiology, Cardiology III—Angiology, University Medical Center of the Johannes Gutenberg University of Mainz, Mainz, Germany
- *Correspondence: Christine Espinola-Klein,
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5
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Fang S, Zhu BZ, Yang F, Wang Z, Xiang Q, Gong YJ. Direct oral anticoagulants compared with vitamin K antagonists for left ventricular thrombus: a systematic review and meta-analysis. Curr Pharm Des 2022; 28:1902-1910. [PMID: 35400334 DOI: 10.2174/1381612828666220408120832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 02/01/2022] [Indexed: 11/22/2022]
Abstract
Background:
Direct oral anticoagulants (DOACs) are the guideline-recommended therapy for some hypercoagulable diseases but are used off-label for left ventricular thrombus (LVT) owing to a paucity of evidence. We performed a meta-analysis to assess the safety and efficacy of DOACs compared with vitamin K antagonists (VKAs) for LVT treatment.
Methods:
We comprehensively searched PubMed, EMBASE, Cochrane Library, and Web of Science databases for studies that compared DOACs with VKAs for LVT treatment. Outcome indicators included stroke or systemic embolism (SSE), thrombus resolution, bleeding, and death. The Newcastle–Ottawa scale was used to evaluate the quality of included studies. Data were analyzed using Review Manager 5.3, and the meta-analysis is registered at PROSPERO (CRD 42020211376).
Results:
We included 12 observational studies (n = 2262 patients). SSE was similar for DOACs and VKAs groups (odds ratio [OR] = 1.01, 95% confidence interval [CI] 0.66–1.54, P = 0.95). For thrombus resolution, DOACs were not significantly different to VKAs (OR = 1.15, 95% CI 0.54–2.45, P = 0.71). DOACs and VKAs had a similar bleeding risk (OR = 0.78, 95% CI 0.45–1.35, P = 0.37). DOACs and VKAs groups had a comparable mortality (OR = 0.91, 95% CI 0.50–1.65, P = 0.76). Subgroup analysis showed that post-AMI (acute myocardial infarction) patients using DOACs had a lower risk of SSE (OR = 0.24, 95% CI 0.07–0.87, P = 0.03) and bleeding (OR = 0.38, 95% CI 0.18–0.81, P = 0.01).
Conclusion:
DOACs and VKAs showed no difference in the safety and efficacy of patients with LVT. DOACs might be superior to VKAs for LVT treatment in post-AMI patients.
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Affiliation(s)
- Shu Fang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Bao-Zhen Zhu
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Fan Yang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Zhe Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Yan-Jun Gong
- Department of Cardiology, Peking University First Hospital, Beijing, China
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6
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Changes of Drug Pharmacokinetics in Patients with Short Bowel Syndrome: A Systematic Review. Eur J Drug Metab Pharmacokinet 2021; 46:465-478. [PMID: 34196913 DOI: 10.1007/s13318-021-00696-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND OBJECTIVES Short bowel syndrome is a clinical condition defined by malabsorption of nutrients and micronutrients, most commonly following extensive intestinal resection. Due to a loss of absorptive surfaces, the absorption of orally administered drugs is also often affected. The purpose of this study was to systematically review the published literature and examine the effects of short bowel syndrome on drug pharmacokinetics and clinical outcomes. METHODS Studies were identified through searches of databases MEDLINE, EMBASE, Web of Science, and SCOPUS, in addition to hand searches of studies' reference lists. Two reviewers independently assessed studies for inclusion, yielding 50 studies involving 37 different drugs in patients with short bowel syndrome. RESULTS Evidence of decreased drug absorption was observed in 29 out of 37 drugs, 6 of which lost therapeutic effect, and 14 of which continued to demonstrate clinical benefit through drug monitoring. CONCLUSIONS The influence of short bowel syndrome on drug absorption appears to be drug-specific and dependent on the location and extent of resection. The presence of a colon in continuity may also influence drug bioavailability as it can contribute significantly to the absorption of drugs (e.g., metoprolol); likewise, drugs that have a wide absorption window or are known to be absorbed in the colon are least likely to be malabsorbed. Individualized dosing may be necessary to achieve therapeutic efficacy, and therapeutic drug monitoring, where available, should be considered in short bowel syndrome patients, especially for drugs with narrow therapeutic indices.
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7
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Ataga KI, Elsherif L, Wichlan D, Wogu AF, Matsui N, Pawlinski R, Cai J, Key NS. A pilot study of the effect of rivaroxaban in sickle cell anemia. Transfusion 2021; 61:1694-1698. [PMID: 33660875 DOI: 10.1111/trf.16343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/20/2021] [Accepted: 01/23/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The contribution of coagulation activation to the pathogenesis of sickle cell disease (SCD) remains incompletely defined. We evaluated the efficacy and safety of rivaroxaban, an oral direct factor Xa inhibitor, in subjects with sickle cell anemia. MATERIALS AND METHODS In this pilot, single-center, randomized, double-blind, placebo-controlled, crossover study, eligible subjects with sickle cell anemia received rivaroxaban or placebo. The effect of rivaroxaban on coagulation activation, endothelial activation, inflammation, and microvascular blood flow was evaluated. RESULTS Fourteen patients (HbSS - 14; females - 9) with mean age of 38 ± 10.6 years were randomized to receive rivaroxaban 20 mg daily or placebo for 4 weeks and, following a 2-week washout phase, were "crossed-over" to the treatment arm opposite to which they were initially assigned. Mean adherence to treatment with rivaroxaban, assessed by pill counts, was 85.6% in the first treatment period and 93.6% in the second period. Treatment with rivaroxaban resulted in a decrease from baseline of thrombin-antithrombin complex versus placebo (-34.4 ug/L [95% CI: -69.4, 0.53] vs. 0.35 ug/L [95% CI: -3.8, 4.5], p = .08), but the difference was not statistically significant. No significant differences were observed in changes from baseline of D-dimer, inflammatory, and endothelial activation markers or measures of microvascular blood flow. Rivaroxaban was well tolerated. CONCLUSIONS Rivaroxaban was safe but did not significantly decrease coagulation activation, endothelial activation, or inflammation. Rivaroxaban did not improve microvascular blood flow. Adequately powered studies are required to further evaluate the efficacy of rivaroxaban in SCD. Clinicaltrials.gov Identifier: NCT02072668.
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Affiliation(s)
- Kenneth I Ataga
- Center for Sickle Cell Disease, University of Tennessee Health Scienter Center, Memphis, Tennessee, USA
| | - Laila Elsherif
- Center for Sickle Cell Disease, University of Tennessee Health Scienter Center, Memphis, Tennessee, USA
| | - David Wichlan
- Division of Hematology and Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Adane F Wogu
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Neil Matsui
- Vanguard Therapeutics, Inc., Half Moon Bay, California, USA
| | - Rafal Pawlinski
- Division of Hematology and Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Jianwen Cai
- Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Nigel S Key
- Division of Hematology and Blood Research Center, University of North Carolina, Chapel Hill, North Carolina, USA
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8
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Evans VJ, Lawrence M, Whitley J, Johns C, Pillai S, Hawkins K, Power K, Morris K, Williams R, Evans PA. The treatment effect of rivaroxaban on clot characteristics in patients who present acutely with first time deep vein thrombosis. Clin Hemorheol Microcirc 2021; 80:139-151. [PMID: 33682699 DOI: 10.3233/ch-201030] [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] [Indexed: 12/19/2022]
Abstract
BACKGROUND The acute vascular disease deep vein thrombosis (DVT) requires oral anticoagulants to prevent progression. Monitoring therapeutic efficacy of direct oral anticoagulants (DOAC), including rivaroxaban, is problematic as no reliable test is available. Advances in rheometry have led to the development of a functional coagulation biomarker using Gel Point (GP) analysis which assesses clot structure formation. The biomarker measures incipient clot formation time (TGP) and quantifies fibrin clot structure in terms of fractal dimension (df). OBJECTIVE This study aimed to investigate clot structure formation in first time DVT and the effect of rivaroxaban treatment. METHODS This prospective observational cohort study measured the GP and standard laboratory markers at three sample points: pre-treatment and at 20 and 60 days following 15 mg BD and 20 mg OD rivaroxaban respectively. RESULTS Forty DVT patients (mean age 64 years [SD±14.8]; 23 males, 17 female) were recruited. The results show that DVT vs non-DVT patients did not have a significantly different GP profile (df: 1.72±0.06 vs 1.70±0.06 and TGP: 267±68 sec vs 262±73 sec) with both within the defined healthy index. In addition, rivaroxaban therapy increased TGP to 392 s (±135 s) after 20 days, and subsequently increased to 395 s (±194 s) at 60 days but did not significantly increase df (from 1.69±0.05 to 1.71±0.06). CONCLUSIONS The results indicate in this cohort of DVT patients there was no underlying hypercoagulable effect as determined by gel point analysis. Furthermore, the anticoagulant effect of rivaroxaban prolonged clotting, suggesting a protective effect against clot formation, without significantly reducing clot microstructural properties.
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Affiliation(s)
- V J Evans
- Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK.,Swansea University, Swansea, UK
| | - M Lawrence
- Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK.,Swansea University, Swansea, UK
| | - J Whitley
- Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK.,Swansea University, Swansea, UK
| | - C Johns
- Swansea Bay University Health Board, Swansea, UK
| | - S Pillai
- Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK.,Swansea University, Swansea, UK
| | | | - K Power
- Swansea Bay University Health Board, Swansea, UK
| | - K Morris
- Cardiff Metropolitan University, Cardiff, UK
| | | | - P A Evans
- Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK.,Swansea University, Swansea, UK
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9
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Fernández DI, Kuijpers MJE, Heemskerk JWM. Platelet calcium signaling by G-protein coupled and ITAM-linked receptors regulating anoctamin-6 and procoagulant activity. Platelets 2020; 32:863-871. [PMID: 33356720 DOI: 10.1080/09537104.2020.1859103] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Most agonists stimulate platelet Ca2+ rises via G-protein coupled receptors (GPCRs) or ITAM-linked receptors (ILRs). Well studied are the GPCRs stimulated by the soluble agonists thrombin (PAR1, PAR4), ADP (P2Y1, P2Y12), and thromboxane A2 (TP), signaling via phospholipase (PLC)β isoforms. The platelet ILRs glycoprotein VI (GPVI), C-type lectin-like receptor 2 (CLEC2), and FcγRIIa are stimulated by adhesive ligands or antibody complexes and signal via tyrosine protein kinases and PLCγ isoforms. Marked differences exist between the GPCR- and ILR-induced Ca2+ signaling in: (i) dependency of tyrosine phosphorylation; (ii) oscillatory versus continued Ca2+ rises by mobilization from the endoplasmic reticulum; and (iii) smaller or larger role of extracellular Ca2+ entry via STIM1/ORAI1. Co-stimulation of both types of receptors, especially by thrombin (PAR1/4) and collagen (GPVI), leads to a highly enforced Ca2+ rise, involving mitochondrial Ca2+ release, which activates the ion and phospholipid channel, anoctamin-6. This highly Ca2+-dependent process causes swelling, ballooning, and phosphatidylserine expression, establishing a unique platelet population swinging between vital and necrotic (procoagulant 'zombie' platelets). Additionally, the high Ca2+ status of procoagulant platelets induces a set of additional events: (i) Ca2+ dependent cleavage of signaling proteins and receptors via calpain and ADAM isoforms; (ii) microvesiculation; (iii) enhanced coagulation factor binding; and (iv) fibrin-coat formation involving transglutaminases. Given the additive roles of GPCR and ILR in Ca2+ signal generation, high-throughput screening of biomolecules or small molecules based on Ca2+ flux measurements provides a promising way to find new inhibitors interfering with prolonged high Ca2+, phosphatidylserine expression, and hence platelet procoagulant activity.
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Affiliation(s)
- Delia I Fernández
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Marijke J E Kuijpers
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Johan W M Heemskerk
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
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10
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Mehra MR, Vaduganathan M, Fu M, Ferreira JP, Anker SD, Cleland JGF, Lam CSP, van Veldhuisen DJ, Byra WM, Spiro TE, Deng H, Zannad F, Greenberg B. A comprehensive analysis of the effects of rivaroxaban on stroke or transient ischaemic attack in patients with heart failure, coronary artery disease, and sinus rhythm: the COMMANDER HF trial. Eur Heart J 2020; 40:3593-3602. [PMID: 31461239 PMCID: PMC6868495 DOI: 10.1093/eurheartj/ehz427] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 05/24/2019] [Accepted: 06/08/2019] [Indexed: 01/16/2023] Open
Abstract
AIMS Stroke is often a devastating event among patients with heart failure with reduced ejection (HFrEF). In COMMANDER HF, rivaroxaban 2.5 mg b.i.d. did not reduce the composite of first occurrence of death, stroke, or myocardial infarction compared with placebo in patients with HFrEF, coronary artery disease (CAD), and sinus rhythm. We now examine the incidence, timing, type, severity, and predictors of stroke or a transient ischaemic attack (TIA), and seek to establish the net clinical benefit of treatment with low-dose rivaroxaban. METHODS AND RESULTS In this double-blind, randomized trial, 5022 patients who had HFrEF(≤40%), elevated natriuretic peptides, CAD, and who were in sinus rhythm were treated with rivaroxaban 2.5 mg b.i.d. or placebo in addition to antiplatelet therapy, after an episode of worsening HF. The primary neurological outcome for this post hoc analysis was time to first event of any stroke or TIA. Over a median follow-up of 20.5 (25th-75th percentiles 20.0-20.9) months, 150 all-cause stroke (127) or TIA (23) events occurred (ischaemic stroke in 82% and haemorrhagic stroke in 11% of stroke events). Overall, 47.5% of first-time strokes were either disabling (16.5%) or fatal (31%). Prior stroke, low body mass index, geographic region, and the CHA2DS2-VASc score were predictors of stroke/TIA. Rivaroxaban significantly reduced the primary neurological endpoint of all-cause stroke or TIA compared with placebo by 32% (1.29 events vs. 1.90 events per 100 patient-years), adjusted for the time from index HF event to randomization and stratified by geographic region (adjusted hazard ratio 0.68, 95% confidence interval 0.49-0.94), with a number needed to treat of 164 patients per year to prevent one stroke/TIA event. The principal safety endpoint of fatal bleeding or bleeding into a critical space, occurred at a similar rate on rivaroxaban and placebo (0.44 events vs. 0.55 events per 100 patient-years). CONCLUSIONS Patients with HFrEF and CAD are at risk for stroke or TIA in the period following an episode of worsening heart failure in the absence of atrial fibrillation. Most strokes are of ischaemic origin and nearly half are either disabling or fatal. Rivaroxaban at a dose of 2.5 mg b.i.d. reduced rates of stroke or TIA compared with placebo in this population. TRIAL REGISTRATION COMMANDER HF (A Study to Assess the Effectiveness and Safety of Rivaroxaban in Reducing the Risk of Death, Myocardial Infarction, or Stroke in Participants with Heart Failure and Coronary Artery Disease Following an Episode of Decompensated Heart Failure); ClinicalTrials.gov NCT01877915.
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Affiliation(s)
- Mandeep R Mehra
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Min Fu
- Janssen Research and Development, Spring House, PA, USA
| | - João Pedro Ferreira
- Universite de Lorraine, INSERM Unite 1116, Vandoeuvre les Nancy, France.,Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Regional et Universitaire de Nancy, Vandoeuvre les Nancy, France
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, Scotland.,National Heart and Lung Institute, Imperial College London, London, England
| | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore.,Duke-National University of Singapore, Singapore.,The George Institute for Global Health, Australia.,Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Theodore E Spiro
- Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Bayer US, LLC, Whippany, NJ, USA
| | | | - Faiez Zannad
- Universite de Lorraine, INSERM Unite 1116, Vandoeuvre les Nancy, France.,Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Regional et Universitaire de Nancy, Vandoeuvre les Nancy, France
| | - Barry Greenberg
- Division of Cardiology, Department of Medicine, University of California, San Diego, La Jolla, CA, USA
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11
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Sapelkin SV, Kuznetsov MR. [Current concepts of anticoagulant and antiplatelet therapy in patients with vascular pathology]. ANGIOLOGII︠A︡ I SOSUDISTAI︠A︡ KHIRURGII︠A︡ = ANGIOLOGY AND VASCULAR SURGERY 2020; 26:16-26. [PMID: 33063748 DOI: 10.33529/angi02020305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The routine practice of a vascular surgeon is invariably associated with decreasing the risk of adverse cardiovascular events in patients presenting with either arterial or venous pathology. Antithrombotic therapy is one of the key approaches used to achieve this purpose. However, a wide variety of modern drugs inhibiting platelet aggregation and agents blocking the coagulation cascade, as well as their combinations makes the selection of the most appropriate treatment for a particular patient quite a difficult task. The choice should carefully be made taking into consideration the nosology, aetiology, accompanying diseases and therapy thereof, as well as the balance of the risk of ischaemic and haemorrhagic complications. Therefore, availability of modern antithrombotic drugs favourably contributing to a more personified approach to treatment is of utmost importance. Thus, for example, rivaroxaban, an anticoagulant belonging to the class of direct-acting oral factor Xa inhibitors, provides a possibility to select an optimal dosage and regimen for a particular patient with arterial or vascular pathology in practice of a cardiovascular surgeon.
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Affiliation(s)
- S V Sapelkin
- Vascular Surgery Department, National Medical Research Centre named after A.V. Vishnevsky under the RF Ministry of Public Health, Moscow, Russia
| | - M R Kuznetsov
- Department of Faculty Surgery #1, Pirogov Russian National Research Medical University of the RF Ministry of Public Health, Moscow, Russia
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12
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Cohen O, Levy-Mendelovich S, Ageno W. Rivaroxaban for the treatment of venous thromboembolism in pediatric patients. Expert Rev Cardiovasc Ther 2020; 18:733-741. [DOI: 10.1080/14779072.2020.1823218] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Omri Cohen
- National Hemophilia Center, Institute of Thrombosis and Hemostasis and the Amalia Biron Research Institute, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Sarina Levy-Mendelovich
- National Hemophilia Center, Institute of Thrombosis and Hemostasis and the Amalia Biron Research Institute, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Tisch Cancer Institue, Icahn School of Medicine, Mount Sinai Hospital, NY, USA
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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13
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Shaw JR, Siegal DM. Prothrombin complex concentrates for DOAC-associated bleeding, global coagulation assays, and assessments of clinical hemostasis: How to gauge the impact? Res Pract Thromb Haemost 2020; 4:677-679. [PMID: 32685875 PMCID: PMC7354417 DOI: 10.1002/rth2.12367] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 04/22/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Joseph R. Shaw
- Department of MedicineThe Ottawa Hospital Research InstituteUniversity of OttawaOttawaONCanada
| | - Deborah M. Siegal
- Division of Hematology and ThromboembolismDepartment of MedicineMcMaster UniversityHamiltonONCanada
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14
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Metze M, Pfrepper C, Klöter T, Stöbe S, Siegemund R, Siegemund T, Edel E, Laufs U, Petros S. Inhibition of thrombin generation 12 hours after intake of direct oral anticoagulants. Res Pract Thromb Haemost 2020; 4:610-618. [PMID: 32548560 PMCID: PMC7292666 DOI: 10.1002/rth2.12332] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 01/12/2020] [Accepted: 02/02/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The residual antithrombotic activity 12 hours after intake of direct oral anticoagulants (DOACs) is of clinical relevance in the setting of bleeding or urgent surgery. OBJECTIVE To evaluate the effects of DOACs on thrombin generation 12 hours after DOAC intake in comparison to baseline and a healthy control group. METHODS Eighty patients were recruited, 20 patients for each approved DOAC: apixaban, edoxaban, rivaroxaban, and dabigatran. The patients were either to be put on anticoagulation for the first time or had stopped taking oral anticoagulation for at least 48 hours. Blood plasma was sampled before (baseline) and 12 hours after starting DOAC for quantification of drug levels and thrombin generation assayed using an automated system (ST Genesia). Sixty-one blood donors served as control group. RESULTS The factor Xa inhibitors significantly increased lag time (137%-219%) and reduced thrombin peak (47%-76%) and velocity index (17%-44%) after 12 hours compared to baseline. Dabigatran showed prolongation of lag time to 133% and time to peak to 119%. All patients had residual antithrombotic activity, with reduced thrombin generation parameters 12 hours after DOAC intake compared to baseline and to the healthy control group. This effect remained significant in patients with low residual DOAC plasma levels <50 ng/mL. CONCLUSION Thrombin generation remains reduced 12 hours after DOAC intake. While thrombin peak is particularly modified by factor Xa inhibitors, all DOACs prolong the lag time and time to thrombin peak. In the setting of bleeding or urgent surgery, the automated thrombin generation assay may assist in decision making and antidote administration.
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Affiliation(s)
- Michael Metze
- Department of CardiologyMedical Department IVUniversity Hospital LeipzigLeipzigGermany
| | - Christian Pfrepper
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
| | - Tristan Klöter
- Department of CardiologyMedical Department IVUniversity Hospital LeipzigLeipzigGermany
| | - Stephan Stöbe
- Department of CardiologyMedical Department IVUniversity Hospital LeipzigLeipzigGermany
| | - Roland Siegemund
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
| | - Thomas Siegemund
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
| | - Elvira Edel
- Institute of Transfusion MedicineUniversity Hospital LeipzigLeipzigGermany
| | - Ulrich Laufs
- Department of CardiologyMedical Department IVUniversity Hospital LeipzigLeipzigGermany
| | - Sirak Petros
- Division of HemostaseologyMedical Department IUniversity Hospital LeipzigLeipzigGermany
- Medical ICUUniversity Hospital LeipzigLeipzigGermany
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15
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Comparison of the Therapeutic Effects of Rivaroxaban Versus Warfarin in Antiphospholipid Syndrome: A Systematic Review. Arch Rheumatol 2019; 35:107-116. [PMID: 32637926 DOI: 10.5606/archrheumatol.2020.7375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 05/13/2019] [Indexed: 11/21/2022] Open
Abstract
Objectives This study aims to review the studies evaluating the therapeutic effects of rivaroxaban versus those of warfarin in patients with antiphospholipid syndrome (APS). Materials and methods The study included randomized clinical trials, comparative studies, cross-sectional investigations, and case series that focused on the effects of warfarin and rivaroxaban and compared the effects of these anticoagulants in patients with APS. The relevant articles published until 2018 were searched in several databases, including PubMed, Scopus, ScienceDirect, Google Scholar, Embase, and Web of Science. Results The findings of the reviewed studies showed that rivaroxaban can be used as an effective and safe alternative to warfarin in APS patients. However, the effectiveness of rivaroxaban in the prevention of thrombosis in high-risk APS patients is suspected. Conclusion Given the high risk of using rivaroxaban in thrombotic APS patients with labile international normalized ratio (INR) or poor adherence to INR monitoring, it is not suggested to use this agent for these patients.
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16
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Siguret V, Abdoul J, Delavenne X, Curis E, Carlo A, Blanchard A, Salem JE, Gaussem P, Funck-Brentano C, Azizi M, Mismetti P, Loriot MA, Lecompte T, Gouin-Thibault I. Rivaroxaban pharmacodynamics in healthy volunteers evaluated with thrombin generation and the active protein C system: Modeling and assessing interindividual variability. J Thromb Haemost 2019; 17:1670-1682. [PMID: 31215111 DOI: 10.1111/jth.14541] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 03/21/2019] [Accepted: 06/10/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Rivaroxaban is a direct factor Xa inhibitor with substantial inter-individual pharmacokinetic (PK) variability. Pharmacodynamic (PD) variability, especially assessed with thrombin generation (TG), has been less documented. OBJECTIVES (i) To assess TG parameter time profiles in healthy volunteers, with TG being studied under different conditions and (ii) to model the relationship between rivaroxaban concentrations and TG parameters and subsequently estimate interindividual variability. METHODS Sixty healthy male volunteers (DRIVING-NCT01627665) received a single 40-mg rivaroxaban dose. Blood sampling was performed at baseline and 10 predefined time points over 24 h. The TG was investigated with the fully automated ST-Genesia system (Stago), using two tissue-factor (TF) concentrations, in the absence (-), or presence (+) of thrombomodulin (TM) for the lowest one. The PD models were built to characterize the relationships between plasma rivaroxaban concentrations and endogenous thrombin potential (ETP) or peak height induced by the lowest TF concentration. RESULTS Thrombin generation parameter time profiles with the lowest TF concentration showed a good sensitivity to rivaroxaban, especially +TM (active protein C negative feedback). The relationship between rivaroxaban concentrations and TG parameters was modeled with a sigmoidal relation. Mean rivaroxaban concentrations halving the baseline value of ETP and peak height (-TM) (C50 ) were of 284 and 33.2 ng/mL, respectively: +TM, C50 declined to 19.4 and 13.8 ng/mL, reflecting a powerful inhibitory effect. The estimated C50 population coefficients of variation were of 12.2% (-TM) and 31.3% (+TM) with the peak height models, 34.8% (+TM) with the ETP model. CONCLUSIONS This low-rivaroxaban to moderate-rivaroxaban PD variability in healthy volunteers contrasts with the substantial PK variability and deserves to be studied in different patient settings.
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Affiliation(s)
- Virginie Siguret
- INSERM UMR_S1140, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Service d'Hématologie Biologique, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Lariboisière, Paris, France
| | - Johan Abdoul
- INSERM UMR_S1140, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Xavier Delavenne
- Laboratoire de Pharmacologie -Toxicologie, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Etienne, France
- Groupe de Recherche sur la Thrombose, Université Jean Monnet, Saint-Etienne, France
| | - Emmanuel Curis
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Laboratoire de biomathématiques, plateau iB2, EA 7537 BioSTM, Faculté de pharmacie de Paris, Paris, France
- Service de biostatistiques et informatique médicale, Hôpital Saint-Louis, AP-HP, Paris, France
| | | | - Anne Blanchard
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Centre d'Investigation Clinique INSERM CIC-1418, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France
| | - Joe-Elie Salem
- Département de Pharmacologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Pitié-Salpêtrière, Paris, France
- INSERM, CIC-1421, Institut de Cardio-métabolisme et Nutrition (ICAN), UMR ICAN_1166, Sorbonne Universités, Paris, France
| | - Pascale Gaussem
- INSERM UMR_S1140, Paris, France
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Service d'Hématologie Biologique, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France
| | - Christian Funck-Brentano
- Département de Pharmacologie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Pitié-Salpêtrière, Paris, France
- INSERM, CIC-1421, Institut de Cardio-métabolisme et Nutrition (ICAN), UMR ICAN_1166, Sorbonne Universités, Paris, France
| | - Michel Azizi
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Centre d'Investigation Clinique INSERM CIC-1418, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France
- Unité d'Hypertension Artérielle, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France
| | - Patrick Mismetti
- Service de Médecine Vasculaire et Thérapeutique, Centre Hospitalier Universitaire de Saint Étienne, Saint Étienne, France
- Unité de Recherche Clinique, Innovation, Pharmacologie, Centre Hospitalier Universitaire de Saint Étienne, Saint Étienne, France
| | - Marie-Anne Loriot
- Université Paris Descartes, Sorbonne Paris Cité, Paris, France
- Service de Biochimie, Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital Européen Georges Pompidou, Paris, France
- INSERM UMR_S1147, Centre Universitaire des Saints-Pères, Paris, France
| | - Thomas Lecompte
- Unité d'Hémostase, Département de Médecine, Hôpitaux Universitaires de Genève (HUG) and GpG, Faculté de médecine, Université de Genève, Geneva, Switzerland
| | - Isabelle Gouin-Thibault
- Laboratoire d'Hématologie Biologique, Centre Hospitalier Universitaire Pontchaillou, Rennes, France
- INSERM, CIC-1414, Université de Rennes, Rennes, France
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Mischke R, Teuber M, Tiede A. Measurements of endogenous thrombin potential using the CAT method in cats: Reference values and influence of the direct factor Xa inhibitor apixaban. Res Vet Sci 2019; 127:113-121. [PMID: 31693942 DOI: 10.1016/j.rvsc.2019.08.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 08/13/2019] [Accepted: 08/27/2019] [Indexed: 11/26/2022]
Abstract
The aim of this study was to establish a thrombin generation assay (calibrated automated thrombogram, CAT) in cats by determining the precision (repeatability), reference values, and the sensitivity to anticoagulant treatment with the factor Xa inhibitor apixaban. The CAT method was performed on citrated plasma with different commercial tissue factor (TF) reagents (PPP Reagent 1 pM [LOW], PPP Reagent 5 pM, PPP Reagent 20 pM [HIGH]) according to the manufacturers` test instruction. Measurements in triplicate were performed in platelet poor plasma (PPP) of 58 healthy cats and in 6 cats at different times following the oral administration of 2.5 mg apixaban. The median CVs in healthy cats usually were < 10% with the exception of thrombin peak height measured using PPP Reagent 1 pM (14.6%). Reference values of all parameters showed marked inter-individual variability and depended largely on the TF concentration of the used activating reagent. Thrombin generation was significantly influenced by apixaban and reacted more sensitively than other tests of haemostasis including the prothrombin time, aPTT, and rotational elastometry. In conclusion, thrombin generation measured by the CAT method using commercially available reagents seems suitable for the examination of feline PPP and may be a valuable method to establish effective anticoagulant therapies for the feline patient and monitoring of such therapies in cats.
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Affiliation(s)
- Reinhard Mischke
- Small Animal Clinic, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, D-30559 Hannover, Germany.
| | - Maike Teuber
- Small Animal Clinic, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, D-30559 Hannover, Germany
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany.
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Abstract
Direct oral anticoagulants (DOACs) have predictable pharmacokinetics and pharmacodynamics, limited potential for drug to drug interactions, and can be given at fixed doses without the need for routine coagulation monitoring, which makes them a very attractive alternative to vitamin K antagonists. DOACs act by specifically targeting a single coagulation factor, such as Factor Xa or thrombin. Rivaroxaban is a direct Factor Xa inhibitor and has been approved for use in several thromboembolic disorders, such as the prevention of stroke and systemic embolism in adults with non-valvular atrial fibrillation and the prevention of recurrent deep vein thrombosis and pulmonary embolism in adult patients. This review aimed to provide an overview of the mechanism of action of rivaroxaban and outline its pharmacokinetic properties (absorption, distribution, metabolism, and excretion) in healthy adult subjects.
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Douxfils J, Morimont L, Bouvy C, de Saint‐Hubert M, Devalet B, Devroye C, Dincq A, Dogné J, Guldenpfennig M, Baudar J, Larock A, Lessire S, Mullier F. Assessment of the analytical performances and sample stability on ST Genesia system using the STG-DrugScreen application. J Thromb Haemost 2019; 17:1273-1287. [PMID: 31063645 PMCID: PMC6852561 DOI: 10.1111/jth.14470] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/29/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Thrombin generation testing has been used to provide information on the coagulation phenotype of patients. The most used technique is the calibrated automated thrombogram (CAT) but it suffers from a lack of standardization, preventing its implementation in routine. The ST Genesia is a new analyzer designed to assess thrombin generation based on the same principle as the CAT. Unlike the CAT system, the ST Genesia is a benchtop, fully automated analyzer, able to perform the analyses individually and not by batch, with strict control of variables such as temperature and volumes, ensuring, theoretically, maximal reproducibility. OBJECTIVES This study aimed at assessing the performance of the STG-DrugScreen application on the ST Genesia analyzer. We also aimed at exploring stability of plasma samples after freezing and defining a reference normal range. RESULTS Results demonstrated the excellent interexperiment precision of the ST Genesia and confirmed that the use of a reference plasma helps reducing the inter-experiments variability. Stability revealed that plasma samples are stable for at least 11 months at -70°C or lower, except for those containing low molecular weight heparins which have to be tested within 6 months. Freezing had no effect on the majority of thrombin generation parameters except on time to peak. CONCLUSIONS Our results suggest an easy implementation of thrombin generation with the use of ST Genesia in the routine laboratory. This will facilitate the design of multicentric studies and enable the establishment of reliable and evidence-based thresholds, which may improve the management of patients treated with anticoagulants.
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Affiliation(s)
- Jonathan Douxfils
- Department of PharmacyNamur Research Institute for Life SciencesNamur Thrombosis and Hemostasis CenterUniversity of NamurNamurBelgium
- Qualiblood s.a.NamurBelgium
| | - Laure Morimont
- Department of PharmacyNamur Research Institute for Life SciencesNamur Thrombosis and Hemostasis CenterUniversity of NamurNamurBelgium
| | | | | | - Bérangère Devalet
- Department of HematologyNamur Research Institute for Life SciencesNamur Thrombosis and Hemostasis CenterCHU UCL NamurUniversité catholique de LouvainYvoirBelgium
| | - Célia Devroye
- Hematology LaboratoryNamur Research Institute for Life SciencesNamur Thrombosis and Hemostasis CenterCHU UCL NamurUniversité catholique de LouvainYvoirBelgium
| | - Anne‐Sophie Dincq
- Department of AnesthesiologyNamur Research Institute for Life SciencesNamur Thrombosis and Hemostasis CenterCHU UCL NamurUniversité catholique de LouvainYvoirBelgium
| | - Jean‐Michel Dogné
- Department of PharmacyNamur Research Institute for Life SciencesNamur Thrombosis and Hemostasis CenterUniversity of NamurNamurBelgium
| | - Maïté Guldenpfennig
- Hematology LaboratoryNamur Research Institute for Life SciencesNamur Thrombosis and Hemostasis CenterCHU UCL NamurUniversité catholique de LouvainYvoirBelgium
| | - Justine Baudar
- Hematology LaboratoryNamur Research Institute for Life SciencesNamur Thrombosis and Hemostasis CenterCHU UCL NamurUniversité catholique de LouvainYvoirBelgium
| | - Anne‐Sophie Larock
- Department of PharmacyNamur Research Institute for Life SciencesNamur Thrombosis and Hemostasis CenterCHU UCL NamurUniversité catholique de LouvainYvoirBelgium
| | - Sarah Lessire
- Department of AnesthesiologyNamur Research Institute for Life SciencesNamur Thrombosis and Hemostasis CenterCHU UCL NamurUniversité catholique de LouvainYvoirBelgium
| | - François Mullier
- Hematology LaboratoryNamur Research Institute for Life SciencesNamur Thrombosis and Hemostasis CenterCHU UCL NamurUniversité catholique de LouvainYvoirBelgium
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Fawzy AM, Lip GYH. Pharmacokinetics and pharmacodynamics of oral anticoagulants used in atrial fibrillation. Expert Opin Drug Metab Toxicol 2019; 15:381-398. [PMID: 30951640 DOI: 10.1080/17425255.2019.1604686] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
INTRODUCTION The availability of non-vitamin K antagonist oral anti-coagulants alongside vitamin K antagonists has offered a variety of options for anti-coagulation, but has also necessitated a good understanding of the pharmacological properties of each of these drugs prior to their use, to maximise the therapeutic benefit and minimise patient harm Areas covered: This review article outlines the pharmacokinetic and pharmacodynamic profiles of the currently licensed VKAs and NOACs that are most commonly used in clinical practice, with the aim of demonstrating how variations in these characteristics influence their use in clinical practice. A literature search was conducted on PubMed using keywords and relevant articles published by the 31st of December 2018 were included. Expert opinion: The effect of a drug is determined by a combination of elements which include patient characteristics and external factors, in addition to its pharmacokinetic and pharmacodynamic properties. A good understanding of these is essential. Despite the wealth of information available, particularly on VKAs, our knowledge on the pharmacology responsible for certain drug effects and inter-individual variations is still limited. Increasing efforts are being made to understand these and include focus on pharmacogenomics and drug transporter proteins.
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Affiliation(s)
| | - Gregory Y H Lip
- b Liverpool Centre for Cardiovascular Science , University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool , UK.,c Aalborg Thrombosis Research Unit, Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
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Brunetti L, Wassef A, Sadek R, Deshpande K, Ziegler J, Na SS, Riley P, Kagan L. Anticoagulant activity of enoxaparin and unfractionated heparin for venous thromboembolism prophylaxis in obese patients undergoing sleeve gastrectomy. Surg Obes Relat Dis 2019; 15:363-373. [DOI: 10.1016/j.soard.2018.12.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/02/2018] [Accepted: 12/12/2018] [Indexed: 12/27/2022]
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Schultz NH, Holme PA, Bjørnsen S, Henriksson CE, Sandset PM, Jacobsen EM. The impact of rivaroxaban on primary hemostasis in patients with venous thrombosis. Platelets 2018; 31:43-47. [PMID: 30569801 DOI: 10.1080/09537104.2018.1557618] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Factor Xa inhibitors are safe and effective alternatives to warfarin, but several studies indicate that rivaroxaban may cause a different risk profile for bleeding. For instance, while the risk of major bleeding in general may be lower with rivaroxaban than for warfarin, the risk of gastrointestinal bleeding or abnormal uterine bleeding may be higher. The underlying mechanisms for these differences are not known, and the effect of rivaroxaban on primary hemostasis is poorly understood. The aim of this study was to investigate the effect of rivaroxaban on platelet function, P-selectin and von Willebrand factor (VWF) antigen and activity. Patients with venous thrombosis assigned to 3 months of treatment due to temporary risk factors were included. Blood was collected both during (on-treatment) and 4-6 weeks after end of treatment (without treatment). The platelet reactivity was assessed by light transmission aggregometry. P-selectin was measured by an enzyme-linked immunosorbent assay and vWF antigen and activity by latex immunoagglutination assays. Platelet reactivity during on-treatment (trough- and peak concentration) was similar to values without treatment. There was a trend toward a reduction of P-selectin during rivaroxaban treatment (peak concentration) compared to value without treatment (p = 0.06). There were no differences in vWF antigen and activity between the different time-points. We found no difference in platelet reactivity or vWF antigen/activity during rivaroxaban treatment compared with values without treatment. Apart from possibly causing a reduction of P-selectin, rivaroxaban seems not to influence primary hemostasis.
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Affiliation(s)
- Nina Haagenrud Schultz
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway.,Department of Hematology, Oslo University Hospital, Oslo, Norway.,Department of Hematology, Akershus University Hospital, Lørenskog, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Pål Andre Holme
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway.,Department of Hematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Stine Bjørnsen
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway
| | - Carola Elisabeth Henriksson
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Per Morten Sandset
- Research Institute of Internal Medicine, Oslo University Hospital, Oslo, Norway.,Department of Hematology, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
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23
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Zannad F, Anker SD, Byra WM, Cleland JGF, Fu M, Gheorghiade M, Lam CSP, Mehra MR, Neaton JD, Nessel CC, Spiro TE, van Veldhuisen DJ, Greenberg B. Rivaroxaban in Patients with Heart Failure, Sinus Rhythm, and Coronary Disease. N Engl J Med 2018; 379:1332-1342. [PMID: 30146935 DOI: 10.1056/nejmoa1808848] [Citation(s) in RCA: 242] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Heart failure is associated with activation of thrombin-related pathways, which predicts a poor prognosis. We hypothesized that treatment with rivaroxaban, a factor Xa inhibitor, could reduce thrombin generation and improve outcomes for patients with worsening chronic heart failure and underlying coronary artery disease. METHODS In this double-blind, randomized trial, 5022 patients who had chronic heart failure, a left ventricular ejection fraction of 40% or less, coronary artery disease, and elevated plasma concentrations of natriuretic peptides and who did not have atrial fibrillation were randomly assigned to receive rivaroxaban at a dose of 2.5 mg twice daily or placebo in addition to standard care after treatment for an episode of worsening heart failure. The primary efficacy outcome was the composite of death from any cause, myocardial infarction, or stroke. The principal safety outcome was fatal bleeding or bleeding into a critical space with a potential for causing permanent disability. RESULTS Over a median follow-up period of 21.1 months, the primary end point occurred in 626 (25.0%) of 2507 patients assigned to rivaroxaban and in 658 (26.2%) of 2515 patients assigned to placebo (hazard ratio, 0.94; 95% confidence interval [CI], 0.84 to 1.05; P=0.27). No significant difference in all-cause mortality was noted between the rivaroxaban group and the placebo group (21.8% and 22.1%, respectively; hazard ratio, 0.98; 95% CI, 0.87 to 1.10). The principal safety outcome occurred in 18 patients who took rivaroxaban and in 23 who took placebo (hazard ratio, 0.80; 95% CI, 0.43 to 1.49; P=0.48). CONCLUSIONS Rivaroxaban at a dose of 2.5 mg twice daily was not associated with a significantly lower rate of death, myocardial infarction, or stroke than placebo among patients with worsening chronic heart failure, reduced left ventricular ejection fraction, coronary artery disease, and no atrial fibrillation. (Funded by Janssen Research and Development; COMMANDER HF ClinicalTrials.gov number, NCT01877915 .).
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Affiliation(s)
- Faiez Zannad
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Stefan D Anker
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - William M Byra
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - John G F Cleland
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Min Fu
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Mihai Gheorghiade
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Carolyn S P Lam
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Mandeep R Mehra
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - James D Neaton
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Christopher C Nessel
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Theodore E Spiro
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Dirk J van Veldhuisen
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
| | - Barry Greenberg
- From the Université de Lorraine, INSERM Unité 1116 and Clinical Investigation Center 1433, French Clinical Research Infrastructure Network, Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional et Universitaire de Nancy, Vandoeuvre lès Nancy, France (F.Z.); the Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin (S.D.A.); Janssen Research and Development, Raritan (W.M.B., C.C.N.), and Bayer U.S., Research and Development, Pharmaceuticals, Thrombosis and Hematology Therapeutic Area, Whippany (T.E.S.) - both in New Jersey; Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, and the National Heart and Lung Institute, Imperial College London, London - both in the United Kingdom (J.G.F.C.); Janssen Research and Development, Spring House, PA (M.F.); Northwestern University, Chicago (M.G.); National Heart Centre Singapore and Duke-National University of Singapore, Singapore (C.S.P.L.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (C.S.P.L., D.J.V.); Brigham and Women's Hospital and Harvard Medical School, Boston (M.R.M.); the Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis (J.D.N.); and the Department of Medicine, Cardiology Division, University of California, San Diego, San Diego (B.G.)
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24
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Chung CC, Lin YK, Chen YC, Kao YH, Yeh YH, Chen YJ. Factor Xa inhibition by rivaroxaban regulates fibrogenesis in human atrial fibroblasts with modulation of nitric oxide synthesis and calcium homeostasis. J Mol Cell Cardiol 2018; 123:128-138. [PMID: 30213724 DOI: 10.1016/j.yjmcc.2018.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 08/19/2018] [Accepted: 09/07/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Rivaroxaban, a widely used factor Xa inhibitor in reducing stroke in atrial fibrillation (AF) patients has multiple biological effects with activation of protease-activated receptor (PAR) signaling. Atrial fibrosis plays a critical role in the pathophysiology of AF. In this study, we evaluated whether rivaroxaban regulates atrial fibroblast activity and its underlying mechanisms. METHODS AND RESULTS Migration, proliferation analyses, nitric oxide (NO) production assay, calcium fluorescence imaging, and western blots were conducted in human atrial fibroblasts with or without rivaroxaban (100 nmol/L or 300 nmol/L) and co-administration of L-NAME (L-NG-nitro arginine methyl ester, 100 μmol/L), EGTA (Ethylene glycol tetra-acetic acid, 1 mmol/L), thrombin (0.5 U/mL), PAR1 agonist peptide (TFLLR-NH2, 100 μmol/L), PAR1 inhibitor (SCH79797, 0.5 μmol/L) and PAR2 inhibitor (GB83, 10 μmol/L). Atrial fibrosis was examined in isoproterenol (100 mg/kg, subcutaneous injection)-treated rats with or without rivaroxaban (10 mg/kg/day orally for 14 consecutive days). Rivaroxaban reduced the migration, pro-collagen type I production, and proliferation of atrial fibroblasts. Rivaroxaban decreased phosphorylated endothelial NO synthase (eNOS) (Thr 495, an inhibitory phosphorylated site of eNOS), and calcium (Ca2+) entry, and increased NO production. Moreover, L-NAME blocked the effects of rivaroxaban on fibroblast collagen and NO production. In the presence of EGTA, the migratory capability was similarly decreased in atrial fibroblasts with and without treatment with rivaroxaban (100 nmol/L), which suggests that rivaroxaban decreases migratory capability of atrial fibroblasts by inhibiting Ca2+ entry. Additionally, rivaroxaban significantly attenuated the effects of thrombin, and TFLLR-NH2 on migratory, proliferative, and pro-collagen type I production capability in atrial fibroblasts. SCH79797 or GB83 decreased pro-collagen type I production, migration, and proliferation capability in fibroblasts, but combined SCH79797 or GB83 with and without rivaroxaban had similar fibroblast activity. Moreover, rivaroxaban significantly decreased atrial fibrosis in isoproterenol-treated rats. CONCLUSIONS Rivaroxaban (100-300 nmol/L) regulates atrial fibroblast activity and atrial fibrosis by increasing NO production and decreasing Ca2+ entry through inhibition of PAR signaling.
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Affiliation(s)
- Cheng-Chih Chung
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yung-Kuo Lin
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yao-Chang Chen
- Department of Biomedical Engineering, National Defense Medical Center, Taipei, Taiwan
| | - Yu-Hsun Kao
- Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Department of Medical Education and Research, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Yung-Hsin Yeh
- Cardiovascular Department, Chang Gung Memorial Hospital, Linkou, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Jen Chen
- Division of Cardiology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Cardiovascular Medicine, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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25
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Sivaraja M, Pozzi N, Rienzo M, Lin K, Shiau TP, Clemens DM, Igoudin L, Zalicki P, Chang SS, Estiarte MA, Short KM, Williams DC, Datta A, Di Cera E, Kita DB. Reversible covalent direct thrombin inhibitors. PLoS One 2018; 13:e0201377. [PMID: 30071045 PMCID: PMC6072017 DOI: 10.1371/journal.pone.0201377] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 07/13/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION In recent years, the traditional treatments for thrombotic diseases, heparin and warfarin, are increasingly being replaced by novel oral anticoagulants offering convenient dosing regimens, more predictable anticoagulant responses, and less frequent monitoring. However, these drugs can be contraindicated for some patients and, in particular, their bleeding liability remains high. METHODS We have developed a new class of direct thrombin inhibitors (VE-DTIs) and have utilized kinetics, biochemical, and X-ray structural studies to characterize the mechanism of action and in vitro pharmacology of an exemplary compound from this class, Compound 1. RESULTS We demonstrate that Compound 1, an exemplary VE-DTI, acts through reversible covalent inhibition. Compound 1 inhibits thrombin by transiently acylating the active site S195 with high potency and significant selectivity over other trypsin-like serine proteases. The compound inhibits the binding of a peptide substrate with both clot-bound and free thrombin with nanomolar potency. Compound 1 is a low micromolar inhibitor of thrombin activity against endogenous substrates such as fibrinogen and a nanomolar inhibitor of the activation of protein C and thrombin-activatable fibrinolysis inhibitor. In the thrombin generation assay, Compound 1 inhibits thrombin generation with low micromolar potency but does not increase the lag time for thrombin formation. In addition, Compound 1 showed weak inhibition of clotting in PT and aPTT assays consistent with its distinctive profile in the thrombin generation assay. CONCLUSION Compound 1, while maintaining strong potency comparable to the current DTIs, has a distinct mechanism of action which produces a differentiating pharmacological profile. Acting through reversible covalent inhibition, these direct thrombin inhibitors could lead to new anticoagulants with better combined efficacy and bleeding profiles.
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Affiliation(s)
- Mohanram Sivaraja
- Verseon Corporation, Fremont, California, United States of America
- * E-mail:
| | - Nicola Pozzi
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, Missouri, United States of America
| | - Matthew Rienzo
- Verseon Corporation, Fremont, California, United States of America
| | - Kenneth Lin
- Verseon Corporation, Fremont, California, United States of America
| | - Timothy P. Shiau
- Verseon Corporation, Fremont, California, United States of America
| | | | - Lev Igoudin
- Verseon Corporation, Fremont, California, United States of America
| | - Piotr Zalicki
- Verseon Corporation, Fremont, California, United States of America
| | | | | | - Kevin M. Short
- Verseon Corporation, Fremont, California, United States of America
| | | | - Anirban Datta
- Verseon Corporation, Fremont, California, United States of America
| | - Enrico Di Cera
- Edward A. Doisy Department of Biochemistry and Molecular Biology, Saint Louis University School of Medicine, St. Louis, Missouri, United States of America
| | - David B. Kita
- Verseon Corporation, Fremont, California, United States of America
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Shaw JR, Siegal DM. Pharmacological reversal of the direct oral anticoagulants-A comprehensive review of the literature. Res Pract Thromb Haemost 2018; 2:251-265. [PMID: 30046727 PMCID: PMC6055488 DOI: 10.1002/rth2.12089] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 01/31/2018] [Indexed: 11/11/2022] Open
Abstract
The direct oral anticoagulants (DOACs) are used for stroke prevention in atrial fibrillation (SPAF) and the prevention and treatment of venous thromboembolic disease (VTE). Although DOAC-associated bleeding events are less frequent as compared to vitamin K antagonists, there is significant concern surrounding physicians' ability to evaluate and manage DOAC-associated bleeding when it does occur. Idarucizumab is a specific reversal agent for dabigatran and is the agent of choice for dabigatran reversal in the setting of major bleeding or urgent surgery/procedures. There are no commercially available specific reversal agents for the direct Xa inhibitors. Although they have not been rigorously studied in DOAC-treated patients requiring urgent anticoagulant reversal, limited evidence from in vitro studies, animal bleeding models, human volunteer studies (in vivo and in vitro) and case series suggest that coagulation factor replacement with prothrombin complex concentrate (PCC) and activated PCC (FEIBA) may contribute to hemostasis. However, the safety and efficacy of these agents and the optimal dosing strategies remain uncertain.
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Affiliation(s)
- Joseph R Shaw
- Division of Hematology Department of Medicine The Ottawa Hospital Ottawa ON Canada.,Ottawa Hospital Research Institute Ottawa ON Canada.,Faculty of Medicine University of Ottawa Ottawa ON Canada
| | - Deborah M Siegal
- Division of Hematology and Thromboembolism Department of Medicine McMaster University Hamilton ON Canada.,Population Health Research Institute McMaster University Hamilton ON Canada
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Thrombin generation estimates the anticoagulation effect of direct oral anticoagulants with significant interindividual variability observed. Blood Coagul Fibrinolysis 2018; 29:148-154. [DOI: 10.1097/mbc.0000000000000678] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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28
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Cohen H, Hunt BJ, Efthymiou M, Arachchillage DRJ, Mackie IJ, Clawson S, Sylvestre Y, Machin SJ, Bertolaccini ML, Ruiz-Castellano M, Muirhead N, Doré CJ, Khamashta M, Isenberg DA. Rivaroxaban versus warfarin to treat patients with thrombotic antiphospholipid syndrome, with or without systemic lupus erythematosus (RAPS): a randomised, controlled, open-label, phase 2/3, non-inferiority trial. LANCET HAEMATOLOGY 2018; 3:e426-36. [PMID: 27570089 PMCID: PMC5010562 DOI: 10.1016/s2352-3026(16)30079-5] [Citation(s) in RCA: 280] [Impact Index Per Article: 46.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 07/01/2016] [Accepted: 07/04/2016] [Indexed: 12/27/2022]
Abstract
Background Rivaroxaban is established for the treatment and secondary prevention of venous thromboembolism, but whether it is useful in patients with antiphospholipid syndrome is uncertain. Methods This randomised, controlled, open-label, phase 2/3, non-inferiority trial, done in two UK hospitals, included patients with antiphospholipid syndrome who were taking warfarin for previous venous thromboembolism, with a target international normalised ratio of 2·5. Patients were randomly assigned 1:1 to continue with warfarin or receive 20 mg oral rivaroxaban daily. Randomisation was done centrally, stratified by centre and patient type (with vs without systemic lupus erythematosus). The primary outcome was percentage change in endogenous thrombin potential (ETP) from randomisation to day 42, with non-inferiority set at less than 20% difference from warfarin in mean percentage change. Analysis was by modified intention to treat. Other thrombin generation parameters, thrombosis, and bleeding were also assessed. Treatment effect was measured as the ratio of rivaroxaban to warfarin for thrombin generation. This trial is registered with the ISRCTN registry, number ISRCTN68222801. Findings Of 116 patients randomised between June 5, 2013, and Nov 11, 2014, 54 who received rivaroxaban and 56 who received warfarin were assessed. At day 42, ETP was higher in the rivaroxaban than in the warfarin group (geometric mean 1086 nmol/L per min, 95% CI 957–1233 vs 548, 484–621, treatment effect 2·0, 95% CI 1·7–2·4, p<0·0001). Peak thrombin generation was lower in the rivaroxaban group (56 nmol/L, 95% CI 47–66 vs 86 nmol/L, 72–102, treatment effect 0·6, 95% CI 0·5–0·8, p=0·0006). No thrombosis or major bleeding were seen. Serious adverse events occurred in four patients in each group. Interpretation ETP for rivaroxaban did not reach the non-inferiority threshold, but as there was no increase in thrombotic risk compared with standard-intensity warfarin, this drug could be an effective and safe alternative in patients with antiphospholipid syndrome and previous venous thromboembolism. Funding Arthritis Research UK, Comprehensive Clinical Trials Unit at UCL, LUPUS UK, Bayer, National Institute for Health Research Biomedical Research Centre.
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Affiliation(s)
- Hannah Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK; Haemostasis Research Unit, Department of Haematology, University College London, London, UK.
| | - Beverley J Hunt
- Department of Thrombosis and Haemophilia, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK; Department of Haematology, King's College London, London, UK
| | - Maria Efthymiou
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | | | - Ian J Mackie
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Simon Clawson
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Yvonne Sylvestre
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Samuel J Machin
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Maria L Bertolaccini
- Academic Department of Vascular Surgery, Cardiovascular Division, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Maria Ruiz-Castellano
- Lupus Research Unit, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Nicola Muirhead
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Caroline J Doré
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Munther Khamashta
- Lupus Research Unit, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK; Lupus Research Unit, Division of Women's Health, King's College London, London, UK
| | - David A Isenberg
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK; Centre for Rheumatology, Division of Medicine, University College London, London, UK
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Schenk B, Goerke S, Beer R, Helbok R, Fries D, Bachler M. Four-factor prothrombin complex concentrate improves thrombin generation and prothrombin time in patients with bleeding complications related to rivaroxaban: a single-center pilot trial. Thromb J 2018; 16:1. [PMID: 29344007 PMCID: PMC5763793 DOI: 10.1186/s12959-017-0158-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 12/21/2017] [Indexed: 12/25/2022] Open
Abstract
Background Direct oral anticoagulants (DOACs) pose a great challenge for physicians in life-threatening bleeding events. The aim of this study was to test the efficacy of reversing the DOAC rivaroxaban using four-factor PCC (prothrombin complex concentrate), a non-specific reversing agent. Methods Patients with life-threatening bleeding events during rivaroxaban treatment were included and administered 25 U kg−1 of PCC. Blood samples were collected immediately prior to as well as after PCC treatment at predefined time intervals. The primary endpoint was defined as the difference in thrombin generation (TG) parameters ETP (endogenous thrombin potential) and Cmax (peak thrombin generation) prior to and ten minutes subsequent to PCC treatment. Results Thirteen patients, of whom the majority suffered from intra-cranial haemorrhage (ICH) or subdural haemorrhage (SDH), were included and administered PCC. The results show that the ETP (TG) significantly (p = 0.001) improved by 68% and Cmax (TG) by 54% (p = 0.001) during PCC treatment. In addition, the Quick value (prothrombin time: QuickPT) significantly improved by 28% and the activated partial thromboplastin time (aPTT) was decreased by 7% ten minutes after PCC administration. Cmax was reduced at baseline, but not ETP, aPTT or QuickPT. Lag time until initiation (TG, tlag), thromboelastometry clotting time (CTEXTEM) and time to peak (TG, tmax) correlated best with measured rivaroxaban levels and were out of normal ranges at baseline, but did not improve after PCC administration. In 77% of the patients bleeding (ICH/SDH-progression) ceased following PCC administration. During the study three participants passed away due to other complications not related to PCC treatment. The possibility of thrombosis formation was also evaluated seven days after administering PCC and no thromboses were found. Conclusions This study shows that use of PCC improved ETP, Cmax, QuickPT and aPTT. However, of these parameters, only Cmax was reduced at the defined baseline. It can be concluded that CTEXTEM, tlag and tmax correlated best with the measured rivaroxaban levels. The study drug was found to be safe. Nonetheless, additional studies specifically targeting assessment of clinical endpoints should be performed to further confirm these findings. Clinical trial registration EudraCT trial No. 2013–004484-31. Electronic supplementary material The online version of this article (10.1186/s12959-017-0158-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Bettina Schenk
- 1Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Stephanie Goerke
- 2Department of Neurosurgery, Medical University of Innsbruck, Anichstr. 35, Innsbruck, 6020 Austria.,3Department of Anatomy, Histology and Embryology, Division of Clinical and Functional Anatomy, Medical University of Innsbruck, Anichstr. 35, Innsbruck, 6020 Austria
| | - Ronny Beer
- 4Department of Neurology, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Raimund Helbok
- 4Department of Neurology, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Dietmar Fries
- 1Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria
| | - Mirjam Bachler
- 1Department of General and Surgical Intensive Care Medicine, Medical University of Innsbruck, Anichstr. 35, 6020 Innsbruck, Austria.,5Institute for Sports Medicine, Alpine Medicine and Health Tourism, UMIT - University for Health Sciences, Medical Informatics and Technology, Eduard Wallnöfer Zentrum 1, 6060 Hall in Tirol, Austria
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Abstract
SummaryAn overview is given on the method and the applications of thrombin generation assays. Thrombin generation assays provide a tool which can be used to trace the entire thrombin formation and inactivation of a plasma sample. Therefore they are principally different from traditional global assays like PT and aPTT and promise new opportunities for the assessment of bleeding or thrombotic risks.
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Bertaggia-Calderara D, Kröll D, Gerschheimer C, Nicolas N, Nett P, Stirnimann G, Alberio L. Effect of Rivaroxaban on thrombin generation in vivo. A study in obese patients. Int J Lab Hematol 2017; 40:e11-e14. [DOI: 10.1111/ijlh.12767] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- D. Bertaggia-Calderara
- Division of Hematology and Central Hematology Laboratory; CHUV, Lausanne University Hospital and University of Lausanne; Lausanne Switzerland
| | - D. Kröll
- Department of Visceral Surgery and Medicine; Inselspital, Bern University Hospital and University of Bern; Bern Switzerland
| | - C. Gerschheimer
- Division of Hematology and Central Hematology Laboratory; CHUV, Lausanne University Hospital and University of Lausanne; Lausanne Switzerland
| | - N. Nicolas
- Division of Hematology and Central Hematology Laboratory; CHUV, Lausanne University Hospital and University of Lausanne; Lausanne Switzerland
| | - P. Nett
- Department of Visceral Surgery and Medicine; Inselspital, Bern University Hospital and University of Bern; Bern Switzerland
| | - G. Stirnimann
- Department of Visceral Surgery and Medicine; Inselspital, Bern University Hospital and University of Bern; Bern Switzerland
| | - L. Alberio
- Division of Hematology and Central Hematology Laboratory; CHUV, Lausanne University Hospital and University of Lausanne; Lausanne Switzerland
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Janion-Sadowska A, Natorska J, Siudut J, Zabczyk M, Stanisz A, Undas A. Plasma fibrin clot properties in the G20210A prothrombin mutation carriers following venous thromboembolism: the effect of rivaroxaban. Thromb Haemost 2017; 117:1739-1749. [DOI: 10.1160/th17-01-0060] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 06/11/2017] [Indexed: 11/05/2022]
Abstract
SummaryWe sought to investigate whether the G20210A prothrombin mutation modifies plasma fibrin clot properties in patients after venous thromboembolism (VTE) and how rivaroxaban treatment affects these alterations. We studied 34 prothrombin mutation heterozygous carriers and sex- and age-matched 34 non-carriers, all at least three months since the first VTE episode, before and during treatment with rivaroxaban. Clot permeability (Ks) and clot lysis time (CLT) with or without elimination of thrombin activatable fibrinolysis inhibitor (TAFI) were assessed at baseline, 2–6 hours (h) after and 20–25 h after intake of rivaroxaban (20 mg/day). At baseline, the prothrombin mutation group formed denser clots (Ks −12 %, p=0.0006) and had impaired fibrinolysis (CLT +14 %, p=0.004, and CLT-TAFI +13 %, p=0.03) compared with the no mutation group and were similar to those observed in 15 healthy unrelated prothrombin mutation carriers. The G20210A prothrombin mutation was the independent predictor for Ks and CLT before rivaroxaban intake. At 2–6 h after rivaroxaban intake, clot properties improved in both G20210A carriers and non-carriers (Ks +38 %, and +37 %, CLT −25 % and −25 %, CLT-TAFI −20 % and −24 %, respectively, all p<0.001), but those parameters were worse in the prothrombin mutation group (Ks −12.8 %, CLT +17 %, CLT-TAFI +13 %, all p<0.001). Rivaroxaban concentration correlated with fibrin clot properties. After 20–25 h since rivaroxaban intake most clot properties returned to baseline. Rivaroxaban-related differences in clot structure were confirmed by scanning electron microscopy images. In conclusion, rivaroxaban treatment, though improves fibrin clot properties, cannot abolish more prothrombotic fibrin clot phenotype observed in prothrombin mutation carriers following VTE.
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Marlu R, Hodaj E, Paris A, Albaladejo P, Crackowski J, Pernod G. Effect of non-specific reversal agents on anticoagulant activity of dabigatran and rivaroxaban. Thromb Haemost 2017; 108:217-24. [DOI: 10.1160/th12-03-0179] [Citation(s) in RCA: 456] [Impact Index Per Article: 65.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 04/18/2012] [Indexed: 12/12/2022]
Abstract
SummaryThe new anticoagulants dabigatran and rivaroxaban can be responsible for haemorrhagic complications. As for any anticoagulant, bleeding management is challenging. We aimed to test the effect of all putative haemostatic agents on the anticoagulant activity of these new drugs using thrombin generation tests. In an ex vivo study, 10 healthy white male subjects were randomised to receive rivaroxaban (20 mg) or dabigatran (150 mg) in one oral administration. After a two weeks washout period, they received the other anticoagulant. Venous blood samples were collected just before drug administration (H0) and 2 hours thereafter. Reversal of anticoagulation was tested in vitro using prothrombin complex concentrate (PCC), rFVIIa or FEIBA® at various concentrations. Rivaroxaban affects quantitative and kinetic parameters, including the endogenous thrombin potential (ETP-AUC and more pronouncedly the thrombin peak), the lag-time and time to peak. PCC strongly corrected ETP-AUC, whereas rFVIIa only modified the kinetic parameters. FEIBA corrected all parameters. Dabigatran specially affects the kinetics of thrombin generation with prolonged lag-time and time to peak. Although PCC increased ETP-AUC, only rFVIIa and FEIBA corrected the altered lag-time. For both anticoagulants, lower doses of FEIBA, corresponding to a quarter to half the dose usually used, have potential reversal profile of interest. In conclusion, some non-specific reversal agents appear to be able to reverse the anticoagulant activity of rivaroxaban or dabigatran. However, clinical evaluation is needed regarding haemorrhagic situations, and a meticulous risk-benefit evaluation regarding their use in this context is required.
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Horinaka S, Sugawara R, Yonezawa Y, Ishimitsu T. Factor Xa inhibition by rivaroxaban in the trough steady state can significantly reduce thrombin generation. Br J Clin Pharmacol 2017; 84:79-87. [PMID: 28888219 PMCID: PMC5736851 DOI: 10.1111/bcp.13429] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 08/17/2017] [Accepted: 09/01/2017] [Indexed: 12/01/2022] Open
Abstract
AIMS The aim of the present study was to demonstrate evidence of reduced thrombin generation at the trough plasma rivaroxaban concentration. METHODS A single-centre, prospective, nonrandomized, drug-intervention, self-controlled study was conducted in 51 anticoagulation therapy-naïve patients with nonvalvular atrial fibrillation. Plasma rivaroxaban concentration was measured by liquid chromatography tandem mass spectrometry (LC-MS/MS) and the anti-factor Xa chromogenic assay. Partial thrombin time (PT), protein C activity, and protein S antigen, prothrombin fragment 1 + 2 (F1 + 2), D-dimer, thrombomodulin (TM), thrombin-antithrombin complex (TAT), plasminogen activator inhibitor-1 (PAI-1) and tissue factor pathway inhibitor (TFPI) levels were also measured at the trough steady state after 4 weeks of rivaroxaban treatment and compared with baseline. RESULTS Plasma concentrations obtained by the LC-MS/MS and anti-Xa assays were correlated (r = 0.841, P < 0.001). The mean concentration of rivaroxaban at the trough steady state was 23.6 ng ml-1 , at which F1 + 2, TAT and D-dimer had decreased from the baseline values (P < 0.0001, P = 0.029 and P < 0.005, respectively). PT was prolonged (+0.59 s, P < 0.0001). TFPI increased from baseline to the trough steady state in the first to third quartile groups (+0.79 pg ml-1 , P = 0.048). By contrast, PAI-1, protein C activity, protein S antigen and TM remained within the normal range at the trough steady state. CONCLUSIONS Residual plasma rivaroxaban at the trough steady state may explain the antithrombin effect of rivaroxaban in patients with nonvalvular atrial fibrillation.
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Affiliation(s)
- Shigeo Horinaka
- Department of Cardiology and Nephrology, Dokkyo Medical University, Tochigi, Japan
| | - Rie Sugawara
- Department of Cardiology and Nephrology, Dokkyo Medical University, Tochigi, Japan
| | - Yutaka Yonezawa
- Department of Cardiology and Nephrology, Dokkyo Medical University, Tochigi, Japan
| | - Toshihiko Ishimitsu
- Department of Cardiology and Nephrology, Dokkyo Medical University, Tochigi, Japan
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Chang C, Hoyos M, Owusu Y, Elewa H. Direct Oral Anticoagulant Use in Atypical Thrombosis-Related Conditions. Ann Pharmacother 2017; 52:185-197. [PMID: 28918657 DOI: 10.1177/1060028017731850] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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36
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Tshikudi DM, Tripathi MM, Hajjarian Z, Van Cott EM, Nadkarni SK. Optical sensing of anticoagulation status: Towards point-of-care coagulation testing. PLoS One 2017; 12:e0182491. [PMID: 28771571 PMCID: PMC5542647 DOI: 10.1371/journal.pone.0182491] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Accepted: 07/19/2017] [Indexed: 11/18/2022] Open
Abstract
Anticoagulant overdose is associated with major bleeding complications. Rapid coagulation sensing may ensure safe and accurate anticoagulant dosing and reduce bleeding risk. Here, we report the novel use of Laser Speckle Rheology (LSR) for measuring anticoagulation and haemodilution status in whole blood. In the LSR approach, blood from 12 patients and 4 swine was placed in disposable cartridges and time-varying intensity fluctuations of laser speckle patterns were measured to quantify the viscoelastic modulus during clotting. Coagulation parameters, mainly clotting time, clot progression rate (α-angle) and maximum clot stiffness (MA) were derived from the clot viscoelasticity trace and compared with standard Thromboelastography (TEG). To demonstrate the capability for anticoagulation sensing in patients, blood samples from 12 patients treated with warfarin anticoagulant were analyzed. LSR clotting time correlated with prothrombin and activated partial thromboplastin time (r = 0.57-0.77, p<0.04) and all LSR parameters demonstrated good correlation with TEG (r = 0.61-0.87, p<0.04). To further evaluate the dose-dependent sensitivity of LSR parameters, swine blood was spiked with varying concentrations of heparin, argatroban and rivaroxaban or serially diluted with saline. We observed that anticoagulant treatments prolonged LSR clotting time in a dose-dependent manner that correlated closely with TEG (r = 0.99, p<0.01). LSR angle was unaltered by anticoagulation whereas TEG angle presented dose-dependent diminution likely linked to the mechanical manipulation of the clot. In both LSR and TEG, MA was largely unaffected by anticoagulation, and LSR presented a higher sensitivity to increased haemodilution in comparison to TEG (p<0.01). Our results establish that LSR rapidly and accurately measures the response of various anticoagulants, opening the opportunity for routine anticoagulation monitoring at the point-of-care or for patient self-testing.
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Affiliation(s)
- Diane M. Tshikudi
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Markandey M. Tripathi
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Zeinab Hajjarian
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Elizabeth M. Van Cott
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Seemantini K. Nadkarni
- Wellman Center for Photomedicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
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Ozawa S, Nelson T. Clinical Application of Prothrombin Complex Concentrate in Blood Management in Patients. Crit Care Nurse 2017; 37:49-56. [PMID: 28365649 DOI: 10.4037/ccn2017333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Management of patients receiving anticoagulants is a major factor in achieving better outcomes. Anticoagulant therapy may need to be discontinued or rapidly reversed before urgent surgery or invasive procedures. In these situations, treatment with concentrated vitamin K, fresh frozen plasma, and/or clotting factors can achieve more rapid anticoagulant reversal than can drug discontinuation alone. Activated prothrombin complex concentrate is used to treat hemophiliac patients with acquired factor VIII inhibitors. Nonactivated prothrombin complex concentrates are used for anticoagulant reversal. The concentrates are effective within minutes of dosing, providing a nearly immediate decrease in the international normalized ratio. The concentrates are lyophilized powders that can be quickly reconstituted, do not require ABO blood typing before use, and contain 25 times the concentration of vitamin K-dependent clotting factors compared with fresh frozen plasma. Studies suggest that the concentrates are associated with better clinical end points than is fresh frozen plasma.
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Affiliation(s)
- Sherri Ozawa
- Sherri Ozawa is the clinical director, Institute for Patient Blood Management and Bloodless Medicine and Surgery, Englewood Hospital and Medical Center, Englewood, NJ, and the executive director of the Society for the Advancement of Blood Management. .,Tiffany Nelson is the clinical director, patient blood management, and the transfusion safety officer for the Florida Hospital System, Orlando, Florida.
| | - Tiffany Nelson
- Sherri Ozawa is the clinical director, Institute for Patient Blood Management and Bloodless Medicine and Surgery, Englewood Hospital and Medical Center, Englewood, NJ, and the executive director of the Society for the Advancement of Blood Management.,Tiffany Nelson is the clinical director, patient blood management, and the transfusion safety officer for the Florida Hospital System, Orlando, Florida
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An in-vitro evaluation of direct thrombin inhibitor and factor Xa inhibitor on tissue factor-induced thrombin generation and platelet aggregation: a comparison of dabigatran and rivaroxaban. Blood Coagul Fibrinolysis 2017; 27:882-885. [PMID: 26757012 DOI: 10.1097/mbc.0000000000000509] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Dabigatran and rivaroxaban may simultaneously inhibit coagulation and platelet activation. This study aimed to reveal the in-vitro effects of dabigatran and rivaroxaban on thrombin generation and platelet aggregation (PAg) derived via tissue factor (TF) pathway. Citrated blood was obtained from six healthy adults (26-60 years old) and pretreated with increasing concentrations of dabigatran or rivaroxaban. Plasmatic endogenous thrombin potential (ETP) was measured by the calibrated automated thrombogram method. The whole blood PAg was evaluated via a kinetic counting method. TF produced an ETP of 1904.69 ± 121.42 nmol min and a PAg of 78 ± 5%. Dabigatran and rivaroxaban concentration-dependently reduced ETP with half-maximal inhibitory concentrations of 460.1 ± 1.4 and 678.1 ± 1.4 nmol/l, and inhibited PAg with half-maximal inhibitory concentrations of 119.5 ± 1.5 and 77.5 ± 1.6 nmol, respectively. Dabigatran and rivaroxaban significantly inhibit TF-induced hypercoagulation and platelet activation in vitro in a concentration-dependent manner. Rivaroxaban displays stronger inhibition on thrombin generation and PAg than dabigatran.
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Samuelson BT, Cuker A, Siegal DM, Crowther M, Garcia DA. Laboratory Assessment of the Anticoagulant Activity of Direct Oral Anticoagulants: A Systematic Review. Chest 2017; 151:127-138. [PMID: 27637548 PMCID: PMC5310120 DOI: 10.1016/j.chest.2016.08.1462] [Citation(s) in RCA: 219] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 07/26/2016] [Accepted: 08/24/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are the treatment of choice for most patients with atrial fibrillation and/or noncancer-associated venous thromboembolic disease. Although routine monitoring of these agents is not required, assessment of anticoagulant effect may be desirable in special situations. The objective of this review was to summarize systematically evidence regarding laboratory assessment of the anticoagulant effects of dabigatran, rivaroxaban, apixaban, and edoxaban. METHODS PubMed, Embase, and Web of Science were searched for studies reporting relationships between drug levels and coagulation assay results. RESULTS We identified 109 eligible studies: 35 for dabigatran, 50 for rivaroxaban, 11 for apixaban, and 13 for edoxaban. The performance of standard anticoagulation tests varied across DOACs and reagents; most assays, showed insufficient correlation to provide a reliable assessment of DOAC effects. Dilute thrombin time (TT) assays demonstrated linear correlation (r2 = 0.67-0.99) across a range of expected concentrations of dabigatran, as did ecarin-based assays. Calibrated anti-Xa assays demonstrated linear correlation (r2 = 0.78-1.00) across a wide range of concentrations for rivaroxaban, apixaban, and edoxaban. CONCLUSIONS An ideal test, offering both accuracy and precision for measurement of any DOAC is not widely available. We recommend a dilute TT or ecarin-based assay for assessment of the anticoagulant effect of dabigatran and anti-Xa assays with drug-specific calibrators for direct Xa inhibitors. In the absence of these tests, TT or APTT is recommended over PT/INR for assessment of dabigatran, and PT/INR is recommended over APTT for detection of factor Xa inhibitors. Time since last dose, the presence or absence of drug interactions, and renal and hepatic function should impact clinical estimates of anticoagulant effect in a patient for whom laboratory test results are not available.
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Affiliation(s)
- Bethany T Samuelson
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA.
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Deborah M Siegal
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - David A Garcia
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA
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Schenk B, Würtinger P, Streif W, Sturm W, Fries D, Bachler M. Ex vivo reversal of effects of rivaroxaban evaluated using thromboelastometry and thrombin generation assay. Br J Anaesth 2016; 117:583-591. [PMID: 27623677 PMCID: PMC5091332 DOI: 10.1093/bja/aew259] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2016] [Indexed: 01/08/2023] Open
Abstract
Background In major bleeding events, the new direct oral anticoagulants pose a great challenge for physicians. The aim of the study was to test for ex vivo reversal of the direct oral anticoagulant rivaroxaban with various non-specific reversal agents: prothrombin complex concentrate (PCC), activated prothrombin complex concentrate (aPCC), recombinant activated factor VII (rFVIIa), and fibrinogen concentrate (FI). Methods Blood was obtained from healthy volunteers and from patients treated with rivaroxaban. Blood samples from healthy volunteers were spiked with rivaroxaban to test the correlation between rivaroxaban concentration and coagulation tests. Patient blood samples were spiked with various concentrations of the above-mentioned agents and analysed using thromboelastometry and thrombin generation. Results When added in vitro, rivaroxaban was significantly (P<0.05) correlated with ROTEM® thromboelastometry EXTEM (extrinsic coagulation pathway) clotting time (CT), time to maximal velocity (MaxV−t), and with all measured thrombin generation parameters. In vivo, CT, MaxV−t, lag time, and peak thrombin generation (Cmax) were significantly correlated with rivaroxaban concentrations. Regarding reversal of rivaroxaban, all tested agents significantly (P<0.05) reduced EXTEM CT, but to different extents: rFVIIa by 68%, aPCC by 47%, PCC by 17%, and FI by 9%. Only rFVIIa reversed EXTEM CT to baseline values. Both PCC (+102%) and aPCC (+232%) altered overall thrombin generation (area under the curve) and increased Cmax (+461% for PCC, +87.5% for aPCC). Conclusions Thromboelastometry and thrombin generation assays do not favour the same reversal agents for rivaroxaban anticoagulation. Controlled clinical trials are urgently needed to establish doses and clinical efficacy of potential reversal agents. Clinical trial registration EudracCT trial no. 213-00474-30.
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Affiliation(s)
- B Schenk
- Department of General and Surgical Intensive Care Medicine
| | - P Würtinger
- Central Institute for Medical and Chemical Laboratory Diagnostics
| | | | - W Sturm
- Department of Internal Medicine, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - D Fries
- Department of General and Surgical Intensive Care Medicine
| | - M Bachler
- Department of General and Surgical Intensive Care Medicine
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Tsantes AE, Kyriakou E, Ikonomidis I, Katogiannis K, Papadakis I, Douramani P, Kopterides P, Kapsimali V, Lekakis J, Tsangaris I, Bonovas S. Comparative Assessment of the Anticoagulant Activity of Rivaroxaban and Dabigatran in Patients With Nonvalvular Atrial Fibrillation: A Noninterventional Study. Medicine (Baltimore) 2016; 95:e3037. [PMID: 27057830 PMCID: PMC4998746 DOI: 10.1097/md.0000000000003037] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
There is a shortage of data in everyday clinical practice about the anticoagulant effects caused by the new oral anticoagulants (NOAs). Our aim was to estimate the intensity of anticoagulant activity induced by rivaroxaban 20 mg qd and dabigatran 110 mg bid among patients with nonvalvular atrial fibrillation (NV-AF).We studied 20 patients with NV-AF treated with dabigatran, and 20 patients treated with rivaroxaban. We performed conventional coagulation tests, thrombin generation (TG) test, thromboelastometry (ROTEM), and epinephrine-induced light transmission aggregometry (LTA) in all 40 patients and 20 controls. Hemoclot Thrombin Inhibitors (HTI) and Factor Xa Direct Inhibitor (DiXaI) assay were used to measure dabigatran and rivaroxaban plasma levels, respectively.Measurements of all assays estimating anticoagulant activity across the 2 patient groups were similar, except for aPTT. Patients on dabigatran exhibited statistically significantly prolonged aPTT values (P < 0.001). In LTA, patients on dabigatran also showed decreased aggregation compared to those on rivaroxaban (P = 0.045). Regarding the TG test, there was no association between endogenous thrombin potential (ETP) and rivaroxaban plasma levels (P = 0.33) as opposed to dabigatran levels (P < 0.001), but significant correlations were observed between rivaroxaban plasma concentrations and kinetic parameters of TG assay (Tlag, P = 0.045; Tmax, P = 0.016; and Cmax, P = 0.003).Based on ROTEM and TG assays, the anticoagulant effects induced by the 2 drugs given in the specific dose regimens in real-world patients were comparable. Only platelet aggregation was found to be more affected by dabigatran as compared to rivaroxaban.
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Affiliation(s)
- Argirios E Tsantes
- From the Laboratory of Haematology and Blood Bank Unit, "Attiko" Hospital(AET, EK, PD); Second Cardiology Department, "Attiko" Hospital(II, KK, IP, JL); Second Department of Critical Care Medicine, "Attiko" Hospital(PK, IT); Department of Microbiology (VK), School of Medicine, National and Kapodistrian University of Athens, Athens, Greece; and Humanitas Clinical and Research Center (SB), Rozzano, Milan, Italy
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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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Barco S, Whitney Cheung Y, Coppens M, Hutten BA, Meijers JCM, Middeldorp S. In vivoreversal of the anticoagulant effect of rivaroxaban with four-factor prothrombin complex concentrate. Br J Haematol 2015; 172:255-61. [DOI: 10.1111/bjh.13821] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Accepted: 09/22/2015] [Indexed: 12/18/2022]
Affiliation(s)
- Stefano Barco
- Department of Vascular Medicine; Academic Medical Centre; University of Amsterdam; Amsterdam the Netherlands
- Department of Internal Medicine; IRCCS Policlinico “San Matteo” Foundation; University of Pavia; Pavia Italy
| | - Y. Whitney Cheung
- Department of Vascular Medicine; Academic Medical Centre; University of Amsterdam; Amsterdam the Netherlands
| | - Michiel Coppens
- Department of Vascular Medicine; Academic Medical Centre; University of Amsterdam; Amsterdam the Netherlands
| | - Barbara A. Hutten
- Department of Clinical Epidemiology, Biostatistics & Bioinformatics; Academic Medical Centre; University of Amsterdam; Amsterdam the Netherlands
| | - Joost C. M. Meijers
- Department of Experimental Vascular Medicine; Academic Medical Centre; University of Amsterdam; Amsterdam the Netherlands
- Department of Plasma Proteins; Sanquin Research; Amsterdam the Netherlands
| | - Saskia Middeldorp
- Department of Vascular Medicine; Academic Medical Centre; University of Amsterdam; Amsterdam the Netherlands
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Bernardi E, Carbone G, Dentali F. How to manage patients on rivaroxaban in the emergency department: a statement of the Italian society of emergency medicine advisory board. Eur J Emerg Med 2015; 23:320-9. [PMID: 26351974 DOI: 10.1097/mej.0000000000000322] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Rivaroxaban, a new oral anticoagulant, has been approved in many countries and its everyday use in clinical practice is increasing. Thus, the chances for an emergency physician to encounter rivaroxaban-treated patients in emergency situations have increased. Here, the authors address the main issues in terms of the prescription of rivaroxaban and the management of these patients in cases of minor or major bleeding, urgent surgery, atrial fibrillation requiring cardioversion, acute ischemic stroke, ST-elevation myocardial infarction, and new onset of atrial fibrillation in recent ST-elevation myocardial infarction. The recommendations reached are based on a literature review and a panel discussion of the advisory board of SIMEU, the Italian Society of Emergency Medicine.
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Affiliation(s)
- Enrico Bernardi
- aDepartment of Emergency Medicine, ULSS n.7, Pieve di Soligo (TV) bPast President of SIMEU (Società Italiana di Medicina d'Emergenza e Urgenza), the Italian Society of Emergency Medicine. Department of Emergency Medicine and Surgery, Hospital 'Gradenigo', Torino cDepartment of Clinical Medicine, Insubria University, Varese, Italy
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Cohen H, Doré CJ, Clawson S, Hunt BJ, Isenberg D, Khamashta M, Muirhead N. Rivaroxaban in antiphospholipid syndrome (RAPS) protocol: a prospective, randomized controlled phase II/III clinical trial of rivaroxaban versus warfarin in patients with thrombotic antiphospholipid syndrome, with or without SLE. Lupus 2015; 24:1087-94. [PMID: 25940537 PMCID: PMC4527976 DOI: 10.1177/0961203315581207] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 03/17/2015] [Indexed: 12/31/2022]
Abstract
INTRODUCTION The current mainstay of the treatment of thrombotic antiphospholipid syndrome (APS) is long-term anticoagulation with vitamin K antagonists (VKAs) such as warfarin. Non-VKA oral anticoagulants (NOACs), which include rivaroxaban, have been shown to be effective and safe compared with warfarin for the treatment of venous thromboembolism (VTE) in major phase III prospective, randomized controlled trials (RCTs), but the results may not be directly generalizable to patients with APS. AIMS The primary aim is to demonstrate, in patients with APS and previous VTE, with or without systemic lupus erythematosus (SLE), that the intensity of anticoagulation achieved with rivaroxaban is not inferior to that of warfarin. Secondary aims are to compare rates of recurrent thrombosis, bleeding and the quality of life in patients on rivaroxaban with those on warfarin. METHODS Rivaroxaban in antiphospholipid syndrome (RAPS) is a phase II/III prospective non-inferiority RCT in which eligible patients with APS, with or without SLE, who are on warfarin, target international normalized ratio (INR) 2.5 for previous VTE, will be randomized either to continue warfarin (standard of care) or to switch to rivaroxaban. Intensity of anticoagulation will be assessed using thrombin generation (TG) testing, with the primary outcome the percentage change in endogenous thrombin potential (ETP) from randomization to day 42. Other TG parameters, markers of in vivo coagulation activation, prothrombin fragment 1.2, thrombin antithrombin complex and D-dimer, will also be assessed. DISCUSSION If RAPS demonstrates i) that the anticoagulant effect of rivaroxaban is not inferior to that of warfarin and ii) the absence of any adverse effects that cause concern with regard to the use of rivaroxaban, this would provide sufficient supporting evidence to make rivaroxaban a standard of care for the treatment of APS patients with previous VTE, requiring a target INR of 2.5.
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Affiliation(s)
- H Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - C J Doré
- University College London Comprehensive Clinical Trials Unit, Gower Street, London, UK
| | - S Clawson
- University College London Comprehensive Clinical Trials Unit, Gower Street, London, UK
| | - B J Hunt
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK Department of Haematology, Kings College London, London, UK
| | - D Isenberg
- Centre for Rheumatology Research, Division of Medicine, University College London, London, UK
| | - M Khamashta
- Department of Rheumatology, Guy's and St Thomas' NHS Foundation Trust, London, UK Department of Rheumatology, Kings College London, London, UK
| | - N Muirhead
- University College London Comprehensive Clinical Trials Unit, Gower Street, London, UK
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Non-VKA Oral Anticoagulants: Accurate Measurement of Plasma Drug Concentrations. BIOMED RESEARCH INTERNATIONAL 2015; 2015:345138. [PMID: 26090400 PMCID: PMC4452246 DOI: 10.1155/2015/345138] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 11/10/2014] [Indexed: 11/18/2022]
Abstract
Non-VKA oral anticoagulants (NOACs) have now widely reached the lucrative market of anticoagulation. While the marketing authorization holders claimed that no routine monitoring is required and that these compounds can be given at fixed doses, several evidences arisen from the literature tend to demonstrate the opposite. New data suggests that an assessment of the response at the individual level could improve the benefit-risk ratio of at least dabigatran. Information regarding the association of rivaroxaban and apixaban exposure and the bleeding risk is available in the drug approval package on the FDA website. These reviews suggest that accumulation of these compounds increases the risk of experiencing a bleeding complication. Therefore, in certain patient populations such as patients with acute or chronic renal impairment or with multiple drug interactions, measurement of drug exposure may be useful to ensure an optimal treatment response. More specific circumstances such as patients experiencing a haemorrhagic or thromboembolic event during the treatment duration, patients who require urgent surgery or an invasive procedure, or patient with a suspected overdose could benefit from such a measurement. This paper aims at providing guidance on how to best estimate the intensity of anticoagulation using laboratory assays in daily practice.
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Perzborn E, Heitmeier S, Laux V. Effects of Rivaroxaban on Platelet Activation and Platelet-Coagulation Pathway Interaction: In Vitro and In Vivo Studies. J Cardiovasc Pharmacol Ther 2015; 20:554-62. [PMID: 25848131 PMCID: PMC4598653 DOI: 10.1177/1074248415578172] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 02/19/2015] [Indexed: 12/04/2022]
Abstract
Introduction: Activation of coagulation and platelets is closely linked, and arterial thrombosis involves coagulation activation as well as platelet activation and aggregation. In these studies, we investigated the possible synergistic effects of rivaroxaban in combination with antiplatelet agents on thrombin generation and platelet aggregation in vitro and on arterial thrombosis and hemostasis in rat models. Materials and Methods: Thrombin generation was measured by the Calibrated Automated Thrombogram method (0.5 pmol/L tissue factor) using human platelet-rich plasma (PRP) spiked with rivaroxaban (15, 30, or 60 ng/mL), ticagrelor (1.0 µg/mL), and acetylsalicylic acid (ASA; 100 µg/mL). Tissue factor-induced platelet aggregation was measured in PRP spiked with rivaroxaban (15 or 30 ng/mL), ticagrelor (1 or 3 µg/mL), or a combination of these. An arteriovenous (AV) shunt model in rats was used to determine the effects of rivaroxaban (0.01, 0.03, or 0.1 mg/kg), clopidogrel (1 mg/kg), ASA (3 mg/kg), and combinations on arterial thrombosis. Results: Rivaroxaban inhibited thrombin generation in a concentration-dependent manner and the effect was enhanced with ticagrelor and ticagrelor plus ASA. Rivaroxaban and ticagrelor also concentration-dependently inhibited tissue factor-induced platelet aggregation, and their combination increased the inhibition synergistically. In the AV shunt model, rivaroxaban dose-dependently reduced thrombus formation. Combining subefficacious or weakly efficacious doses of rivaroxaban with ASA or ASA plus clopidogrel increased the antithrombotic effect. Conclusion: These data indicate that the combination of rivaroxaban with single or dual antiplatelet agents works synergistically to reduce platelet activation, which may in turn lead to the delayed/reduced formation of coagulation complexes and vice versa, thereby enhancing antithrombotic potency.
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Affiliation(s)
| | - Stefan Heitmeier
- Acute Care Diseases Research, Bayer Pharma AG, Wuppertal, Germany
| | - Volker Laux
- Acute Care Diseases Research, Bayer Pharma AG, Wuppertal, Germany
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Results of rotational thromboelastometry, coagulation activation markers and thrombin generation assays in orthopedic patients during thromboprophylaxis with rivaroxaban and enoxaparin. Blood Coagul Fibrinolysis 2015; 26:136-44. [DOI: 10.1097/mbc.0000000000000203] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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49
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Hidalgo F, Gómez-Luque A, Ferrandis R, Llau JV, de Andrés J, Gomar C, Sierra P, Castillo J, Torres LM. [Perioperative management of direct oral anticoagulant in emergency surgery and bleeding. Haemostasis monitoring and treatment]. ACTA ACUST UNITED AC 2015; 62:450-60. [PMID: 25702199 DOI: 10.1016/j.redar.2015.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 01/02/2015] [Accepted: 01/09/2015] [Indexed: 10/24/2022]
Abstract
There is an almost unanimous consensus on the management of the direct new oral anticoagulants, dabigatran, rivaroxaban, and apixaban in elective surgery. However, this general consensus does not exist in relation with the direct new oral anticoagulants use in emergency surgery, especially in the bleeding patient. For this reason, a literature review was performed using the MEDLINE-PubMed. An analysis was made of the journal articles, reviews, systematic reviews, and practices guidelines published between 2000 and 2014 using the terms "monitoring" and "reversal". From this review, it was shown that the routine tests of blood coagulation, such as the prothrombin time and activated partial thromboplastin time, have a limited efficacy in the perioperative control of blood coagulation in these patients. There is currently no antidote to reverse the effects of these drugs, although the possibility of using concentrated prothrombin complex and recombinant activated factor vii has been suggested for the urgent reversal of the anticoagulant effect.
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Affiliation(s)
- F Hidalgo
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Clínica Universidad de Navarra, Pamplona, Navarra, España
| | - A Gómez-Luque
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, España.
| | - R Ferrandis
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, España
| | - J V Llau
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Clínico Universitario de Valencia, Universidad de Valencia, Valencia, España
| | - J de Andrés
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Consorcio Hospital General Universitario de Valencia, Universidad de Valencia, Valencia, España
| | - C Gomar
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Clínic de Barcelona, Universitat de Barcelona, Barcelona, España
| | - P Sierra
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Fundación Puigvert (IUNA), Barcelona, España
| | - J Castillo
- Servicio de Anestesiología, Hospital del Mar, Barcelona, España
| | - L M Torres
- Servicio de Anestesiología, Reanimación y Tratamiento del Dolor, Hospital Universitario Puerta del Mar, Cádiz, España
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Christensen LD, Vinter-Jensen L, Rasmussen HH, Kristensen SR, Larsen TB. Rivaroxaban as anticoagulant therapy in short bowel syndrome. Report of three cases. Thromb Res 2015; 135:568-70. [PMID: 25592650 DOI: 10.1016/j.thromres.2015.01.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Revised: 12/30/2014] [Accepted: 01/01/2015] [Indexed: 10/24/2022]
Affiliation(s)
- Line Dahlstrøm Christensen
- Centre for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark.
| | - Lars Vinter-Jensen
- Centre for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | - Henrik Højgaard Rasmussen
- Centre for Nutrition and Bowel Disease, Department of Gastroenterology, Aalborg University Hospital, Aalborg, Denmark
| | | | - Torben Bjerregaard Larsen
- Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark; Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Faculty of Health, Aalborg University, Aalborg, Denmark
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