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Chao TF, Chan YH, Tsai PC, Lee HF, Chang SH, Kuo CT, Lip GYH, Chen SA, Yeh YH. Prothrombin Time-International Normalized Ratio Predicts the Outcome of Atrial Fibrillation Patients Taking Rivaroxaban. Biomedicines 2022; 10:biomedicines10123210. [PMID: 36551966 PMCID: PMC9775588 DOI: 10.3390/biomedicines10123210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 12/04/2022] [Accepted: 12/07/2022] [Indexed: 12/14/2022] Open
Abstract
Background: Although direct oral anticoagulants (DOACs) for patients with atrial fibrillation (AF) are considered to be safe, over or under anticoagulation and increased bleeding or thromboembolic risk are still considered individually. We aimed to investigate whether there is an association between prothrombin time and international normalized ratio (PT-INR) or activated partial thromboplastin time (aPTT) ratio, and the risks of ischemic stroke/systemic embolism (IS/SE) and major bleeding among AF patients taking rivaroxaban or dabigatran. Methods: This multi-center cohort study in Taiwan included 3192 AF patients taking rivaroxaban and 958 patients taking dabigatran for stroke prevention where data about PT-INR and aPTT were available. Results: For patients treated with rivaroxaban, a higher INR level was not associated with a higher risk of major bleeding compared to an INR level < 1.1. The risk of IS/SE was lower for patients having an INR ≥ 1.5 compared to those with an INR < 1.1 (aHR:0.57; [95%CI: 0.37−0.87]; p = 0.01). On-label dosing of rivaroxaban and use of digoxin were independent factors associated with an INR ≥ 1.5 after taking rivaroxaban. For patients taking dabigatran, a higher aPTT ratio was not associated with a higher risk of major bleeding. The risk of IS/SE was lower for patients having an aPTT ratio of 1.1−1.2 and 1.3−1.4 than those with an aPTT ratio < 1.1. Conclusions: In AF patients, rivaroxaban with an INR ≥ 1.5 was associated with a lower risk of IS/SE. PT-INR or aPTT ratios were not associated with bleeding events for rivaroxaban or dabigatran. INR may help predict the outcome of AF patients who take rivaroxaban.
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Affiliation(s)
- Tze-Fan Chao
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Cardiovascular Research Center, Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Yi-Hsin Chan
- The Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Microscopy Core Laboratory, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Pei-Chien Tsai
- Department and Graduate Institute of Biomedical Sciences, Chang Gung University, Taoyuan 33302, Taiwan
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Hsin-Fu Lee
- The Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Shang-Hung Chang
- The Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Center for Big Data Analytics and Statistics, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
| | - Chi-Tai Kuo
- The Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Gregory Y. H. Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool L14 3PE, UK
- Department of Clinical Medicine, Aalborg University, 9100 Aalborg, Denmark
| | - Shih-Ann Chen
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Cardiovascular Research Center, Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Yung-Hsin Yeh
- The Cardiovascular Department, Chang Gung Memorial Hospital, Taoyuan 33305, Taiwan
- College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
- Correspondence: ; Tel.: +886-(3)-3281200 (ext. 8162); Fax: +886-(3)-3271192
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Dabigatran Acylglucuronide, the Major Metabolite of Dabigatran, Shows a Weaker Anticoagulant Effect than Dabigatran. Pharmaceutics 2022; 14:pharmaceutics14020257. [PMID: 35213990 PMCID: PMC8875894 DOI: 10.3390/pharmaceutics14020257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 01/17/2022] [Accepted: 01/19/2022] [Indexed: 02/01/2023] Open
Abstract
Dabigatran (DAB) is an orally administered thrombin inhibitor. Both DAB and its main metabolite dabigatran acylglucuronide (DABG) have established anticoagulant effects. Here, we aimed to compare the relative anticoagulant effects of DABG and DAB in humans. Anticoagulant effects of DAB and DABG were measured in vitro using a thrombin generation assay. Additionally, their effects on other coagulation assays including PT, aPTT, TT, and fibrinogen were compared. Both DAB and DABG showed inhibitory effects on thrombin generation in a dose-dependent manner, but DABG exhibited a weaker inhibitory effect than that of DAB. The IC50 values of DAB and DABG on thrombin generation AUC were 134.1 ng/mL and 281.9 ng/mL, respectively. DABG also exhibited weaker anticoagulant effects than DAB on PT, aPTT, and TT. The results of the present study indicate that the anticoagulant effect of DABG, a main active DAB metabolite, is weaker than that of DAB.
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Bai CW, Ruan RX, Pan S, Huang CR, Zhang XC, Pang Y, Zheng X, Guo KJ. Application of thromboelastography in comparing coagulation difference of rivaroxaban and enoxaparin for thromboprophylaxis after total hip arthroplasty. J Orthop Surg (Hong Kong) 2021; 29:23094990211042674. [PMID: 34550034 DOI: 10.1177/23094990211042674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Purpose: The purpose of this study was to compare the coagulation difference in patients with either rivaroxaban or enoxaparin as thromboprophylaxis after total hip arthroplasty (THA) regarding thromboelastography (TEG) and routine coagulation tests. Patients and methods: Two hundred and twenty-eight patients undergoing primary THA were recruited in this study. They were divided into two groups according to a computer-generated random sequence. Patients in the rivaroxaban group received 10 mg of rivaroxaban orally once daily. Patients in the enoxaparin group received 4000 AxaIU (0.4 mL) of enoxaparin subcutaneously once daily. Rivaroxaban and enoxaparin were started 6-8 h after surgery. The administration of the anticoagulant prophylaxis was lasted for a minimum of 14 days. TEG and routine coagulation tests were performed on the day before the operation and 1 day and 7 days after the operation. Results: No difference was observed in the incidence of deep vein thrombosis (DVT) or pulmonary embolism (PE) between the two groups. There was no significant difference with regard to prothrombin time (PT), activated partial thromboplastin time (PTT), international normalized ratio (INR), and thrombin time (TT) between the two groups. However, while considering TEG, R time of the rivaroxaban group was significantly higher than that of the enoxaparin group (p = 0.003), whereas the maximum amplitude (MA) (p = 0.036) value and coagulation index (CI) (p = 0.002) value were significantly lower than those of the enoxaparin group. Conclusion: With regard to TEG analysis, there was coagulation difference in patients with rivaroxaban and those with enoxaparin as thromboprophylaxis after THA. Under recommended dose of rivaroxaban and enoxaparin, patients undergoing THA were in hypercoagulability on 7days postoperative.
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Affiliation(s)
- Chao-Wen Bai
- Department of Orthopaedic Surgery, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China.,Department of Orthopaedic Surgery, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Ru-Xin Ruan
- Department of Orthopaedic Surgery, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Sheng Pan
- Department of Orthopaedic Surgery, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Chao-Ran Huang
- Department of Orthopaedic Surgery, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xing-Chen Zhang
- Department of Orthopaedic Surgery, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yong Pang
- Department of Orthopaedic Surgery, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xin Zheng
- Department of Orthopaedic Surgery, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China.,Department of Orthopaedic Surgery, Zhujiang Hospital of Southern Medical University, Guangzhou China
| | - Kai-Jin Guo
- Department of Orthopaedic Surgery, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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Schäfer ST, Otto AC, Acevedo AC, Görlinger K, Massberg S, Kammerer T, Groene P. Point-of-care detection and differentiation of anticoagulant therapy - development of thromboelastometry-guided decision-making support algorithms. Thromb J 2021; 19:63. [PMID: 34493301 PMCID: PMC8425056 DOI: 10.1186/s12959-021-00313-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/14/2021] [Indexed: 03/25/2023] Open
Abstract
Background DOAC detection is challenging in emergency situations. Here, we demonstrated recently, that modified thromboelastometric tests can reliably detect and differentiate dabigatran and rivaroxaban. However, whether all DOACs can be detected and differentiated to other coagulopathies is unclear. Therefore, we now tested the hypothesis that a decision tree-based thromboelastometry algorithm enables detection and differentiation of all direct Xa-inhibitors (DXaIs), the direct thrombin inhibitor (DTI) dabigatran, as well as vitamin K antagonists (VKA) and dilutional coagulopathy (DIL) with high accuracy. Methods Following ethics committee approval (No 17–525-4), and registration by the German clinical trials database we conducted a prospective observational trial including 50 anticoagulated patients (n = 10 of either DOAC/VKA) and 20 healthy volunteers. Blood was drawn independent of last intake of coagulation inhibitor. Healthy volunteers served as controls and their blood was diluted to simulate a 50% dilution in vitro. Standard (extrinsic coagulation assay, fibrinogen assay, etc.) and modified thromboelastometric tests (ecarin assay and extrinsic coagulation assay with low tissue factor) were performed. Statistical analyzes included a decision tree analyzes, with depiction of accuracy, sensitivity and specificity, as well as receiver-operating-characteristics (ROC) curve analysis including optimal cut-off values (Youden-Index). Results First, standard thromboelastometric tests allow a good differentiation between DOACs and VKA, DIL and controls, however they fail to differentiate DXaIs, DTIs and VKAs reliably resulting in an overall accuracy of 78%. Second, adding modified thromboelastometric tests, 9/10 DTI and 28/30 DXaI patients were detected, resulting in an overall accuracy of 94%. Complex decision trees even increased overall accuracy to 98%. ROC curve analyses confirm the decision-tree-based results showing high sensitivity and specificity for detection and differentiation of DTI, DXaIs, VKA, DIL, and controls. Conclusions Decision tree-based machine-learning algorithms using standard and modified thromboelastometric tests allow reliable detection of DTI and DXaIs, and differentiation to VKA, DIL and controls. Trial registration Clinical trial number: German clinical trials database ID: DRKS00015704. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-021-00313-7.
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Affiliation(s)
- Simon T Schäfer
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Munich, Germany
| | - Anne-Christine Otto
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Munich, Germany
| | | | | | - Steffen Massberg
- Department of Internal Medicine I - Cardiology, University Hospital Munich, LMU Munich, Munich, Germany
| | - Tobias Kammerer
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Munich, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Philipp Groene
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Munich, Germany. .,Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, Munich, Germany.
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5
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Dietrich EA, Davis K, Maska E, DeRemer CE. The use of apixaban as a perioperative bridge for warfarin in a patient unable to use parenteral anticoagulation: A case report. THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Burmistrova NA, Diehl BWK, Soboleva PM, Rubtsova E, Legin EA, Legin AV, Kirsanov DO, Monakhova YB. Quality Control of Heparin Injections: Comparison of Four Established Methods. ANAL SCI 2020; 36:1467-1471. [PMID: 32801287 DOI: 10.2116/analsci.20p214] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/31/2020] [Indexed: 08/09/2023]
Abstract
Heparin is an anticoagulant medication that is usually injected subcutaneously. The quality of a set of commercial heparin injections from different producers was examined by NMR, IR, UV-Vis spectroscopies and potentiometric multisensor system. The type of raw material regarding heparin animal origin and producer, heparin molecular weight and activity values were derived based on the non-targeted analysis of 1H NMR fingerprints. DOSY NMR spectroscopy was additionally used to study homogeneity and additives profile. UV-Vis and IR, being cheaper than NMR, combined with multivariate statistics were successfully applied to study excipients composition as well as semi-estimation of activity values. Potentiometric multisensor measurements were found to be an important additional source of information about inorganic composition of finished heparin formulations. All investigated instrumental techniques are useful for finished heparin injections and should be selected according to availability as well as the information and confidence required for a specific sample.
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Affiliation(s)
- Natalia A Burmistrova
- Institute of Chemistry, Saratov State University, 83 Astrakhanskaya Street, Saratov, 410012, Russia
| | - Bernd W K Diehl
- Spectral Service AG, Emil-Hoffmann-Strate 33, 50996, Köln, Germany
| | - Polina M Soboleva
- Institute of Chemistry, Saratov State University, 83 Astrakhanskaya Street, Saratov, 410012, Russia
| | - Ekaterina Rubtsova
- Institute of Chemistry, Saratov State University, 83 Astrakhanskaya Street, Saratov, 410012, Russia
- Saratov State Medical University, Bolshaya Kazachia st., 112, Saratov, 410012, Russia
| | - Eugene A Legin
- Institute of Chemistry, Saint Petersburg State University, 26 Universitetskii prospect, Petergof, St. Petersburg, 198504, Russia
| | - Andrey V Legin
- Institute of Chemistry, Saint Petersburg State University, 26 Universitetskii prospect, Petergof, St. Petersburg, 198504, Russia
| | - Dmitry O Kirsanov
- Institute of Chemistry, Saint Petersburg State University, 26 Universitetskii prospect, Petergof, St. Petersburg, 198504, Russia
| | - Yulia B Monakhova
- Institute of Chemistry, Saratov State University, 83 Astrakhanskaya Street, Saratov, 410012, Russia.
- Spectral Service AG, Emil-Hoffmann-Strate 33, 50996, Köln, Germany.
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Liu Z, Xie Q, Xiang Q, Zhang H, Mu G, Zhao Z, Hu T, Wu T, Wang N, Zhang J, Qian Y, Zhou S, Wang Z, Jiang J, Zhang Y, Song H, Cui Y. Anti-FXa-IIa activity test in Asian and its potential role for drug adherence evaluation in patients with direct oral anticoagulants: a nationwide multi-center synchronization study. Cardiovasc Diagn Ther 2020; 10:1293-1302. [PMID: 33224753 DOI: 10.21037/cdt-20-564] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The data of anti-FXa-IIa activity detection in Asian population is insufficient, and its potential role for drug adherence evaluation in patients with direct oral anticoagulants (DOACs) remains unclear. This study carried out multi-center anti-FXa-IIa activity detection in Asian, aiming to explore its applicability in Asian population and find its role in adherence evaluation. METHODS We assessed patients' self-reported adherence using the Morisky, Green, and Levine Adherence Scale (MGLS) from six hospitals. Plasma samples were collected for peak and trough concentration determination, and anti-FXa-IIa chromogenic assay was conducted using rivaroxaban/dabigatran calibrators and controls. Multivariate logistic regression models, covariate adjustment and spearman's two-tailed test were conducted in the data analysis. This study had been registered in clinical trials (NCT03666962). RESULTS In total, 271 patients taking rivaroxaban (n=149) or dabigatran (n=122) were enrolled. Among the 271 patients assessed by MGLS questionnaire, 188 persons (69.4%) showed high adherence, 77 persons (28.4%) was in intermediate adherence group, and only 6 patients (2.2%) had low adherence. Patients are more adherent dosed once daily of rivaroxaban compared to twice daily of dabigatran: 75.6% vs. 63.6%. Anti-FXa-IIa activity had good linear correlation with routine coagulation indexes (P<0.001), but no significant association was found between drug adherence and anti-FXa-IIa activity (P>0.05). CONCLUSIONS This study confirms that anti-FXa-IIa activity detection based on target drug calibrations can be used as an effective index for pharmacodynamic evaluation in Asian population, but had limited value in drug adherence evaluation for DOACs. As the limited samples, these findings could serve as a hypothesis-generating effort, and should be validated in further studies with larger sample sizes.
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Affiliation(s)
- Zhiyan Liu
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Qiufen Xie
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Qian Xiang
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
| | - Hanxu Zhang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Guangyan Mu
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zinan Zhao
- Department of Pharmacy, Beijing Hospital, Beijing, China
| | - Taotao Hu
- Department of Pharmacy, 900 Hospital of the Joint Logistics Team, Fuzhou, China
| | - Tingting Wu
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Na Wang
- Department of Pharmacy, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Medical University Union Hospital, Fuzhou, China
| | - Yan Qian
- Department of Pharmacy, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Shuang Zhou
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Zining Wang
- Department of Pharmacy, Peking University First Hospital, Beijing, China
| | - Jie Jiang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yatong Zhang
- Department of Pharmacy, Beijing Hospital, Beijing, China
| | - Hongtao Song
- Department of Pharmacy, 900 Hospital of the Joint Logistics Team, Fuzhou, China
| | - Yimin Cui
- Department of Pharmacy, Peking University First Hospital, Beijing, China.,School of Pharmaceutical Sciences, Peking University Health Science Center, Beijing, China
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Hartmann S, Biliouris K, Lesko LJ, Nowak-Göttl U, Trame MN. Quantitative Systems Pharmacology Model-Based Predictions of Clinical Endpoints to Optimize Warfarin and Rivaroxaban Anti-Thrombosis Therapy. Front Pharmacol 2020; 11:1041. [PMID: 32765265 PMCID: PMC7381140 DOI: 10.3389/fphar.2020.01041] [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: 12/17/2019] [Accepted: 06/26/2020] [Indexed: 11/25/2022] Open
Abstract
Background Tight monitoring of efficacy and safety of anticoagulants such as warfarin is imperative to optimize the benefit-risk ratio of anticoagulants in patients. The standard tests used are measurements of prothrombin time (PT), usually expressed as international normalized ratio (INR), and activated partial thromboplastin time (aPTT). Objective To leverage a previously developed quantitative systems pharmacology (QSP) model of the human coagulation network to predict INR and aPTT for warfarin and rivaroxaban, respectively. Methods A modeling and simulation approach was used to predict INR and aPTT measurements of patients receiving steady-state anticoagulation therapy. A previously developed QSP model was leveraged for the present analysis. The effect of genetic polymorphisms known to influence dose response of warfarin (CYP2C9, VKORC1) were implemented into the model by modifying warfarin clearance (CYP2C9 *1: 0.2 L/h; *2: 0.14 L/h, *3: 0.04 L/h) and the concentration of available vitamin K (VKORC1 GA: −22% from normal vitamin K concentration; AA: −44% from normal vitamin K concentration). Virtual patient populations were used to assess the ability of the model to accurately predict routine INR and aPTT measurements from patients under long-term anticoagulant therapy. Results The introduced model accurately described the observed INR of patients receiving long-term warfarin treatment. The model was able to demonstrate the influence of genetic polymorphisms of CYP2C9 and VKORC1 on the INR measurements. Additionally, the model was successfully used to predict aPTT measurements for patients receiving long-term rivaroxaban therapy. Conclusion The QSP model accurately predicted INR and aPTT measurements observed during routine therapeutic drug monitoring. This is an exemplar of how a QSP model can be adapted and used as a model-based precision dosing tool during clinical practice and drug development to predict efficacy and safety of anticoagulants to ultimately help optimize anti-thrombotic therapy.
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Affiliation(s)
- Sonja Hartmann
- Center for Pharmacometrics & Systems Pharmacology, Department of Pharmaceutics, University of Florida, Orlando, FL, United States
| | - Konstantinos Biliouris
- Center for Pharmacometrics & Systems Pharmacology, Department of Pharmaceutics, University of Florida, Orlando, FL, United States
| | - Lawrence J Lesko
- Center for Pharmacometrics & Systems Pharmacology, Department of Pharmaceutics, University of Florida, Orlando, FL, United States
| | - Ulrike Nowak-Göttl
- Thrombosis & Hemostasis Treatment Center, Institute of Clinical Chemistry, University of Schleswig-Holstein, Germany
| | - Mirjam N Trame
- Center for Pharmacometrics & Systems Pharmacology, Department of Pharmaceutics, University of Florida, Orlando, FL, United States
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9
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Schäfer ST, Wiederkehr T, Kammerer T, Acevedo AC, Feil K, Kellert L, Görlinger K, Hinske LC, Groene P. Real-time detection and differentiation of direct oral anticoagulants (rivaroxaban and dabigatran) using modified thromboelastometric reagents. Thromb Res 2020; 190:103-111. [PMID: 32335421 DOI: 10.1016/j.thromres.2020.04.019] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 04/10/2020] [Accepted: 04/15/2020] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Timely measurement of direct oral anticoagulants (DOACs) is challenging, though clinically important. We tested the hypotheses, that thromboelastometry is able to detect dabigatran and rivaroxaban and discriminates between dabigatran and rivaroxaban as representatives of the two groups of DOACs. METHODS AND MATERIALS We conducted a prospective-observational study: In-vitro dose-effect-curves for rivaroxaban and dabigatran were performed (n = 10). Ex-vivo: Patients with indication of DOAC treatment (stroke; dabigatran/rivaroxaban) were included (n = 21). Blood samples were analyzed before first intake, at first estimated peak level and at 24 h after first but before following intake and 3 h after 24 h-intake. Standard and modified thromboelastometric-assays, using low tissue factor concentrations (TFTEM) or ecarin (ECATEM) were used. Receiver-operating-characteristics-curve-analysis (ROC), regression-analysis and two-way-ANOVA were performed. RESULTS In-vitro: TFTEM detected dabigatran and rivaroxaban (ROC_AUC: 0.99; sensitivity/specificity: 100%/98%) but could not discriminate. Dabigatran prolongs CTECATEM whereas rivaroxaban did not. Clotting Time (CT)-ratio TFTEM/ECATEM discriminated highly sensitive (100%) and specific (100%) between dabigatran and rivaroxaban even at very low concentrations (ROC_AUC:1.0). CTECATEM correlated with dabigatran spiked concentrations (r = 0.9985; p < 0.001) and CTTFTEM (r = 0.9363; p = 0.006) with rivaroxaban. Similarly results could be demonstrated with patient data: We confirmed the performance for the differentiation of CT-ratio TFTEM/ECATEM (sensitivity 100%/specificity 100%) at any time after first intake of either DOAC. CONCLUSION The thromboelastometric tests TFTEM and ECATEM detect and differentiate rivaroxaban and dabigatran. Further investigations evaluate the other DOACs and the differentiation to phenprocoumon. However, results need to be confirmed in a larger study, and especially cut off values for differentiation need to be calculated from a larger sample size.
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Affiliation(s)
| | - Tobias Wiederkehr
- Department of Anaesthesiology, University Hospital, LMU Munich, Germany
| | - Tobias Kammerer
- Department of Anaesthesiology, University Hospital, LMU Munich, Germany; Institute of Anaesthesiology, Heart and Diabetes Centre NRW, Ruhr University Bochum, Germany
| | | | - Katharina Feil
- Department of Neurology, University Hospital, LMU Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Germany
| | | | | | - Philipp Groene
- Department of Anaesthesiology, University Hospital, LMU Munich, Germany.
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11
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Li T, Yuan D, Yuan J. Antithrombotic Drugs-Pharmacology and Perspectives. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1177:101-131. [PMID: 32246445 DOI: 10.1007/978-981-15-2517-9_4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Thrombosis, the localized clotting of blood that affects arterial or venous circulation, is one of the leading causes of death worldwide. Arterial thrombosis is commonly initiated by vascular endothelial injury, while venous thrombosis mainly stems from blood stasis. Despite these differences, platelet adhesion, activation and aggregation, and fibrin formation as a result of coagulation constitute the fundamental processes of thrombus formation. Antithrombotic drugs permitted on the clinical currently can dramatically reduce major adverse cardiovascular events; however, they can also increase the bleeding risk. Discovery of antithrombotic drugs that can effectively prevent thrombosis while sparing bleeding side effects remains unmet medical need. In this chapter, we provide an overview on the pathophysiology of thrombosis, followed by introduction of each class of antithrombotic drugs including their pharmacology, clinical applications and limitations. Practical challenges and future perspectives of antithrombotic drugs are discussed in the last part of this chapter.
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Affiliation(s)
- Tianyu Li
- Department of Cardiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Deshan Yuan
- Department of Cardiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jinqing Yuan
- Department of Cardiology, Fuwai Hospital, National Center of Cardiovascular Diseases, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
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12
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Tomić M. The preoperative management of dabigatran and its specific antidote idarucizumab in patients with nonvalvular atrial fibrillation: Case reports. ARHIV ZA FARMACIJU 2020. [DOI: 10.5937/arhfarm2005310t] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Dabigatran is a novel oral anticoagulant preferred due to its ease of use, favorable pharmacokinetics, decreased potential for drug-drug interactions, and the lack of monitoring requirements. With the growing use of dabigatran, it is important to highlight that dabigatran increases the risk of hemorrhage after some procedures. Therefore, when dabigatran is used before the elective or urgent procedures, it is necessary to compare the thromboembolic event risk with the relative risk of bleeding. Before the approval of a reversal agent, the lack of specific antidotes had been the major limitation against the widespread utilization of dabigatran. In October 2015, idarucizumab, a humanized monoclonal antigen-binding antibody fragment capable of reversing the anticoagulant activity of dabigatran, has been introduced into the market to be used in lifethreatening bleeding or urgent surgery. In this manuscript, the preoperative management of dabigatran and the initial experience of using idarucizumab in a patient with nonvalvular atrial fibrillation were described. We propose that the option of dabigatran reversal needs to be considered in patients with nonvalvular atrial fibrillation. However, additional research is needed to define optimal perioperative management of dabigatran and other novel oral anticoagulants, especially in high bleeding risk patients, and to determine whether pre-procedure coagulation testing should be performed.
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Margetić S, Ćelap I, Delić Brkljačić D, Pavlović N, Šupraha Goreta S, Kobasić I, Lovrenčić-Huzjan A, Bašić Kes V. Chromogenic anti-FXa assay calibrated with low molecular weight heparin in patients treated with rivaroxaban and apixaban: possibilities and limitations. Biochem Med (Zagreb) 2019; 30:010702. [PMID: 31839722 PMCID: PMC6904970 DOI: 10.11613/bm.2020.010702] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 09/15/2019] [Indexed: 12/05/2022] Open
Abstract
Introduction Clinical application of rivaroxaban and apixaban does not require therapeutic monitoring. Commercial anti-activated factor X (anti-FXa) inhibition methods for all anti-FXa drugs are based on the same principle, so there are attempts to evaluate potential clinical application of heparin-calibrated anti-FXa assay as an alternative method for direct FXa inhibitors. We aimed to evaluate relationship between anti-FXa methods calibrated with low molecular weight heparin (LMWH) and with drug specific calibrators, and to determine whether commercial LMWH anti-FXa assay can be used to exclude the presence of clinically relevant concentrations of rivaroxaban and apixaban. Materials and methods Low molecular weight heparin calibrated reagent (Siemens Healthineers, Marburg, Germany) was used for anti-FXa activity measurement. Innovance heparin (Siemens Healthineers, Marburg, Germany) calibrated with rivaroxaban and apixaban calibrators (Hyphen BioMed, Neuville-sur-Oise, France) was used for quantitative determination of FXa inhibitors. Results Analysis showed good agreement between LMWH calibrated and rivaroxaban calibrated activity (κ = 0.76) and very good agreement with apixaban calibrated anti-Xa activity (κ = 0.82), respectively. Low molecular weight heparin anti-FXa activity cut-off values of 0.05 IU/mL and 0.1 IU/mL are suitable for excluding the presence of clinically relevant concentrations (< 30 ng/mL) of rivaroxaban and apixaban, respectively. Concentrations above 300 ng/mL exceeded upper measurement range for LMWH anti-FXa assay and cannot be determined by this method. Conclusion Low molecular weight heparin anti-FXa assay can be used in emergency clinical conditions for ruling out the presence of clinically relevant concentrations of rivaroxaban and apixaban. However, use of LMWH anti-FXa assay is not appropriate for their quantitative determination as an interchangeable method.
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Affiliation(s)
- Sandra Margetić
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Ivana Ćelap
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Diana Delić Brkljačić
- Department of Cardiovascular Diseases, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Nikola Pavlović
- Department of Cardiovascular Diseases, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Sandra Šupraha Goreta
- Department of Biochemistry and Molecular Biology, Faculty of Pharmacy and Biochemistry, University of Zagreb, Croatia
| | - Ivana Kobasić
- Department of Neurology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | | | - Vanja Bašić Kes
- Department of Neurology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
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14
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Monakhova YB, Fareed J, Yao Y, Diehl BW. Anticoagulant activity of porcine heparin: Structural-property relationship and semi-quantitative estimation by nuclear magnetic resonance (NMR) spectrometry. J Pharm Biomed Anal 2019; 174:639-643. [DOI: 10.1016/j.jpba.2019.06.036] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2019] [Revised: 06/11/2019] [Accepted: 06/25/2019] [Indexed: 11/16/2022]
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15
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Morotti A, Goldstein JN. WITHDRAWN: Anticoagulant-associated intracerebral hemorrhage. BRAIN HEMORRHAGES 2019. [DOI: 10.1016/j.hest.2019.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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16
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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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Affiliation(s)
- Moritake Iguchi
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
| | - Masaharu Akao
- Department of Cardiology, National Hospital Organization Kyoto Medical Center
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18
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Ramacciotti E, Aguiar VCR, Júnior VC, Casella IB, Zerati AE, Fareed J. Edoxaban for Venous Thromboembolism Treatment-The New Kid on The Block for Latin America. A Practical Guide. Clin Appl Thromb Hemost 2018; 24:340S-349S. [PMID: 30486661 PMCID: PMC6714848 DOI: 10.1177/1076029618812955] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Edoxaban, a direct factor Xa inhibitor (FXa), is the fourth direct oral anticoagulant
(DOAC) approved for clinical use in the treatment of venous thromboembolism (VTE) in Latin
America, following global approvals for this indication. Edoxaban features some particular
characteristics when compared to the previously approved DOACs. This review summarizes the
main properties of edoxaban, the outcomes results of its pivotal global clinical trials
and the peculiar clinical features of this compound. This practical guide aims to help
Latin America clinicians understand edoxaban, its proper indication and its use for the
appropriate patients with VTE.
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Affiliation(s)
- Eduardo Ramacciotti
- Vascular Surgery, Santa Casa de Sao Paulo School of Medical Sciences, São Paulo, Brazil.,Vascular Surgery, Hospital e Maternidade Dr. Christóvão da Gama, Santo André, São Paulo, Brazil.,Hemostasis & Thrombosis Research Laboratories at Loyola University Medical Center, Maywood, IL, USA
| | | | | | | | | | - Jawed Fareed
- Hemostasis & Thrombosis Research Laboratories at Loyola University Medical Center, Maywood, IL, USA
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19
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Willmann S, Zhang L, Mayer H, Siegmund HU, Tanigawa T, Kaneko M, Peters G, Weitz JI, Berkowitz SD, Burghaus R. Comment on model-based meta-analysis to evaluate optimal doses of direct oral factor Xa inhibitors in atrial fibrillation patients. Blood Adv 2018; 2:3193-3195. [PMID: 30482761 PMCID: PMC6258927 DOI: 10.1182/bloodadvances.2018027078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 10/29/2018] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Liping Zhang
- Global Clinical Pharmacology, Janssen Research & Development LLC, Raritan, NJ
| | - Hannah Mayer
- Clinical Pharmacometrics, Bayer AG, Leverkusen, Germany
| | | | | | - Masato Kaneko
- Clinical Sciences Japan, Bayer Yakuhin Ltd., Osaka, Japan
| | - Gary Peters
- Cardiovascular and Metabolism, Janssen Research & Development LLC, Raritan, NJ
| | - Jeffrey I Weitz
- Department of Medicine and
- Department of Biochemistry and Biomedical Sciences, McMaster University and the Thrombosis & Atherosclerosis Research Institute, Hamilton, ON, Canada; and
| | | | - Rolf Burghaus
- Clinical Pharmacometrics, Bayer AG, Wuppertal, Germany
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20
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Watson VL, Louis N, Seminara BV, Muizelaar JP, Alberico A. Proposal for the Rapid Reversal of Coagulopathy in Patients with Nonoperative Head Injuries on Anticoagulants and/or Antiplatelet Agents: A Case Study and Literature Review. Neurosurgery 2018; 81:899-909. [PMID: 28368482 DOI: 10.1093/neuros/nyx072] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Accepted: 02/01/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Emergency room physicians, trauma teams, and neurosurgeons are seeing increasing numbers of head-injured patients on anticoagulants, many of whom are nonoperative. Head injury and anticoagulation can lead to devastating consequences. These patients need immediate evaluation and often reversal of anticoagulation in order to decrease their high rates of morbidity and mortality. OBJECTIVE To review data on the prevalence, risks, treatment, and complications of head-injured anticoagulated patients and provide a proposal for their anticoagulant management, and imaging requirements. METHODS A PubMed database search was performed for articles on the prevalence, risks, treatment, and complications of patients who have sustained a head injury while on anticoagulant or antiplatelet agents. RESULTS A total of 1877 articles were found, of which 64 were selected for use based on direct relevance, information quality, and contribution of the article to the current understanding of anticoagulated head injury patients. CONCLUSION There are very few guidelines for the management of nonoperative head-injured patients. Rapid reversal guided by international normalized ratio values, Platelet Function Assays, computed tomography imaging of the head, and physical exam is suggested. The proposal presented in this paper enables patient management to begin quickly in a systematic approach, with the goal of achieving a significant decrease in the morbidity and mortality for the anticoagulated head-injured patient. Rapid reversal can potentially decrease mortality by as much as 38%.
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Affiliation(s)
- Victoria L Watson
- Department of Neurosurgery, Marshall University's Joan C. Edwards School of Medicine, 1600 Medical Center Drive, Huntington, West Virginia
| | - Nundia Louis
- Universidad Autonoma de Guadalajara, 110 Gallery Circle, San Antonio, Texas
| | - Brittany V Seminara
- Department of Neurosurgery, Marshall University's Joan C. Edwards School of Medicine, 1600 Medical Center Drive, Huntington, West Virginia
| | - J Paul Muizelaar
- Department of Neurosurgery, Marshall University's Joan C. Edwards School of Medicine, 1600 Medical Center Drive, Huntington, West Virginia
| | - Anthony Alberico
- Department of Neurosurgery, Marshall University's Joan C. Edwards School of Medicine, 1600 Medical Center Drive, Huntington, West Virginia
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21
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Kim PY, Yeh CH, Dale BJ, Leslie BA, Stafford AR, Fredenburgh JC, Hirsh J, Weitz JI. Mechanistic Basis for the Differential Effects of Rivaroxaban and Apixaban on Global Tests of Coagulation. TH OPEN 2018; 2:e190-e201. [PMID: 31249942 PMCID: PMC6524873 DOI: 10.1055/s-0038-1649507] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 03/26/2018] [Indexed: 02/07/2023] Open
Abstract
Rivaroxaban and apixaban are both small molecules that reversibly inhibit factor Xa. Compared with rivaroxaban, apixaban has minimal effects on the prothrombin time and activated partial thromboplastin time. To investigate this phenomenon, we used a factor Xa-directed substrate in a buffer system. Although rivaroxaban and apixaban inhibited factor Xa with similar K i values at equilibrium, kinetic measurements revealed that rivaroxaban inhibited factor Xa up to 4-fold faster than apixaban ( p < 0.001). Using a discontinuous chromogenic assay to monitor thrombin production by prothrombinase in a purified system, rivaroxaban was 4-fold more potent than apixaban (K i values of 0.7 ± 0.3 and 2.9 ± 0.5 nM, respectively; p = 0.02). Likewise, in thrombin generation assays in plasma, rivaroxaban prolonged the lag time and suppressed endogenous thrombin potential to a greater extent than apixaban. To characterize how the two inhibitors differ in recognizing factor Xa, inhibition of prothrombinase was monitored in real-time using a fluorescent probe for thrombin. The data were fit using a mixed-inhibition model and the individual association and dissociation rate constants were determined. The association rates for the binding of rivaroxaban to either free factor Xa or factor Xa incorporated into the prothrombinase complex were 10- and 1,193-fold faster than those for apixaban, respectively, whereas dissociation rates were about 3-fold faster. Collectively, these findings suggest that rivaroxaban and apixaban differ in their capacity to inhibit factor Xa and provide a plausible explanation for the observation that rivaroxaban has a greater effect on global tests of coagulation than apixaban.
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Affiliation(s)
- Paul Y Kim
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Calvin H Yeh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada.,Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Brian J Dale
- Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada.,School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Beverly A Leslie
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Alan R Stafford
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - James C Fredenburgh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Jack Hirsh
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada.,Department of Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
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22
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Henskens YMC, Gulpen AJW, van Oerle R, Wetzels R, Verhezen P, Spronk H, Schalla S, Crijns HJ, ten Cate H, ten Cate-Hoek A. Detecting clinically relevant rivaroxaban or dabigatran levels by routine coagulation tests or thromboelastography in a cohort of patients with atrial fibrillation. Thromb J 2018; 16:3. [PMID: 29434525 PMCID: PMC5793444 DOI: 10.1186/s12959-017-0160-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 12/29/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Traditional coagulation tests are included in emergency guidelines for management of patients on direct oral anticoagulants (DOACs) who experience acute bleeding or require surgery. We determined the ability of traditional coagulation tests and fast whole blood thromboelastography (ROTEM®) to screen for anticoagulation activity of dabigatran and rivaroxaban as low as 30 ng/mL. METHODS One hundred eighty-four citrated blood samples (75 dabigatran, 109 rivaroxaban) were collected from patients with non-valvular atrial fibrillation (NVAF), to perform screening tests from different manufacturers, (diluted, D) PT, aPTT, TT and ROTEM®. The activity of DOACs was quantitatively determined by clot detection assays: Hemoclot DTT and DiXaI test (Biophen), on CS2100 (Siemens). The clotting time (CT) of INTEM and EXTEM ROTEM® (Werfen) were used as test parameters. RESULTS Dabigatran, ≥ 30 ng/mL, was accurately detected by five coagulation tests: APTT Actin FSL (93%), PT Neoplastin (93%), APTT Cephascreen, Thromboclotin, and Thrombin (all 100%), but not by PT Innovin (49%). CT-EXTEM (91%) was sufficiently sensitive, but not CT-INTEM (52%). APTT Cephascreen and Thrombin showed good linearity (R2 = 0.71,R2 = 0.72). For the other tests linearity was moderate to poor. Rivaroxaban was accurately detected by PT Neoplastin (98%) and less so by APTT Cephascreen (85%). In addition, rivaroxaban was also accurately detected by CT-INTEM (96%). PT Neoplastin showed good linearity (R2 = 0.81), all other tests had moderate to poor linearity. CONCLUSION In patients with NVAF, the ability of routine coagulation tests to detect the presence of significant levels of DOACs is test and reagent dependent. CT-INTEM and CT-EXTEM may be fast whole blood alternatives. TRIAL REGISTRATION The Institutional Review Board of the MUMC approved this study (December 2011, project number 114069).
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Affiliation(s)
- Yvonne M. C. Henskens
- Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Anouk J. W. Gulpen
- Laboratory for Clinical Thrombosis and Hemostasis, Internal medicine, CARIM, Maastricht, The Netherlands
- Internal medicine, MUMC+, Maastricht, The Netherlands
| | - René van Oerle
- Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
- Laboratory for Clinical Thrombosis and Hemostasis, Internal medicine, CARIM, Maastricht, The Netherlands
| | - Rick Wetzels
- Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Paul Verhezen
- Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Henri Spronk
- Laboratory for Clinical Thrombosis and Hemostasis, Internal medicine, CARIM, Maastricht, The Netherlands
| | - Simon Schalla
- Department of Cardiology, Cardiovascular center MUMC+, Maastricht, The Netherlands
| | - Harry J. Crijns
- Department of Cardiology, Cardiovascular center MUMC+, Maastricht, The Netherlands
| | - Hugo ten Cate
- Laboratory for Clinical Thrombosis and Hemostasis, Internal medicine, CARIM, Maastricht, The Netherlands
- Internal medicine, MUMC+, Maastricht, The Netherlands
| | - Arina ten Cate-Hoek
- Central Diagnostic Laboratory, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
- Thrombosis Expertise Centre, Vascular medicine, Cardiovascular Centre MUMC+, Maastricht, The Netherlands
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23
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Ten Cate H, Henskens YM, Lancé MD. Practical guidance on the use of laboratory testing in the management of bleeding in patients receiving direct oral anticoagulants. Vasc Health Risk Manag 2017; 13:457-467. [PMID: 29263674 PMCID: PMC5732550 DOI: 10.2147/vhrm.s126265] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Direct oral anticoagulants (DOACs) have demonstrated a favorable benefit–risk profile in several thromboembolic disorders and are increasingly used in routine clinical practice. A number of real-world studies on DOACs are ongoing, and data published so far have shown broadly similar outcomes to those demonstrated in the respective phase III trials. Despite their beneficial attributes, bleeding risk (as with any other anticoagulants) is often a concern for physicians when prescribing DOACs, particularly in elderly patients, those with significant comorbidities, and other high-risk patient populations. Although the absence of routine coagulation monitoring is an advantage of the DOACs, measuring their anticoagulant effect and/or plasma drug levels may be helpful in certain clinical scenarios to help patient management and improve outcomes. In this paper, practical guidance and recommendations are provided for clinical situations in which the test results may aid clinical decision-making, including patients with life-threatening bleeding events, patients without bleeding but with test results indicating a risk of bleeding, for those patients with a suspected thromboembolism while receiving a DOAC, or prior to patients undergoing elective or urgent surgical procedures. Finally, appropriate monitoring of the DOACs could be of substantial benefit to patients, and there is a high potential for development in this area in the future.
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Affiliation(s)
- Hugo Ten Cate
- Department of Internal Medicine, Cardiovascular Research Institute
| | | | - Marcus D Lancé
- Department of Anaesthesiology, Maastricht University Medical Centre, Maastricht, the Netherlands
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24
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Interventional Spine and Pain Procedures in Patients on Antiplatelet and Anticoagulant Medications (Second Edition). Reg Anesth Pain Med 2017; 43:225-262. [DOI: 10.1097/aap.0000000000000700] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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25
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Alonso-Canovas A, Mimbrera ADF, Maza SSDL, Alvarez-Velasco R, Zarza B, Masjuan J, Kawiorski MM. Successful intravenous thrombolysis in acute ischaemic stroke in a patient on rivaroxaban treatment. Thromb Haemost 2017; 111:557-8. [DOI: 10.1160/th13-06-0472] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 10/04/2013] [Indexed: 11/05/2022]
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26
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Dogné JM, Mullier F, Chatelain B, Rönquist-Nii Y, Malmström RE, Hjemdahl P, Douxfils J. Comparison of calibrated dilute thrombin time and aPTT tests with LC-MS/MS for the therapeutic monitoring of patients treated with dabigatran etexilate. Thromb Haemost 2017; 110:543-9. [DOI: 10.1160/th13-03-0202] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 05/27/2013] [Indexed: 11/05/2022]
Abstract
SummaryWays to monitor dabigatran etexilate (DE) therapy would be useful in certain situations. Functional assays such as aPTT or Hemoclot® Thrombin Inhibitor (HTI) have been proposed to evaluate dabigatran concentrations, but previous findings are based on in vitro studies and results must be confirmed in clinical samples. The aim of this study was to compare aPTT and HTI measurements with liquid chromatography- tandem mass spectrometry (LC-MS/MS) measurements of dabigatran in plasma samples from DE treated patients. Seventy-one plasma samples were included. aPTT was performed using STA-CKPrest® and SynthASil®. HTI was performed according to instructions from the manufacturer. The LC-MS/MS method utilised dabigatran- d3 as internal standard. The plasma concentration range was 0 to 645 ng/ml as measured by LC-MS/MS. Overall, the HTI and LC-MS/ MS analyses correlated well (r2=0.97). The Bland-Altman analysis showed a mean difference of 9 ng/ml (SD: 20 ng/ml). However, the HTI performed poorly at concentrations <50 ng/ml. LC-MS/MS was sensitive (limit of quantification 1.1 ng/ml) and specific for dabigatran. The aPTT methods did not correlate well with plasma concentrations measured by LC-MS/MS (r2 = 0.59 with SynthASil® and 0.50 with STACKPrest ®). In conclusion, the poor sensitivity, the important inter-individual variability, and the poor correlation with LC-MS/MS preclude the use of aPTT to estimate dabigatran concentrations. Due to its small inter-individual variability and good agreement with LC-MS/MS measurements, we recommend the use of HTI assays to rather accurately estimate concentrations of dabigatran <50 ng/ml. Quantification of lower dabigatran levels in DE-treated patients requires the “reference” LC-MS/MS method.
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27
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Kvint S, Schuster J, Kumar MA. Neurosurgical applications of viscoelastic hemostatic assays. Neurosurg Focus 2017; 43:E9. [DOI: 10.3171/2017.8.focus17447] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Patients taking antithrombotic agents are very common in neurosurgical practice. The perioperative management of these patients can be extremely challenging especially as newer agents, with poorly defined laboratory monitoring and reversal strategies, become more prevalent. This is especially true with emergent cases in which rapid reversal of anticoagulation is required and the patient’s exact medical history is not available. With an aging patient population and the associated increase in diseases such as atrial fibrillation, it is expected that the use of these agents will continue to rise in coming years. Furthermore, thromboembolic complications such as deep venous thrombosis, pulmonary embolism, and myocardial infarction are common complications of major surgery. These trends, in conjunction with a growing understanding of the hemostatic process and its contribution to the pathophysiology of disease, stress the importance of the complete evaluation of a patient’s hemostatic profile in guiding management decisions. Viscoelastic hemostatic assays (VHAs), such as thromboelastography and rotational thromboelastometry, are global assessments of coagulation that account for the cellular and plasma components of coagulation. This FDA-approved technology has been available for decades and has been widely used in cardiac surgery and liver transplantation. Although VHAs were cumbersome in the past, advances in software and design have made them more accurate, reliable, and accessible to the neurosurgeon. VHAs have demonstrated utility in guiding intraoperative blood product transfusion, identifying coagulopathy in trauma, and managing postoperative thromboprophylaxis. The first half of this review aims to evaluate and assess VHAs, while the latter half seeks to appraise the evidence supporting their use in neurosurgical populations.
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Affiliation(s)
| | | | - Monisha A. Kumar
- Departments of 1Neurosurgery and
- 2Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
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28
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Direct Oral Anticoagulants Form Thrombus Different From Warfarin in a Microchip Flow Chamber System. Sci Rep 2017; 7:7399. [PMID: 28785005 PMCID: PMC5547037 DOI: 10.1038/s41598-017-07939-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 07/05/2017] [Indexed: 01/24/2023] Open
Abstract
Direct oral anticoagulants (DOACs) have low risk of intracranial hemorrhage compared to warfarin. We sought to clarify the different mechanisms responsible for suppression of bleeding events using the Total Thrombus-formation Analysis System (T-TAS), a flow-microchip chamber with thrombogenic surfaces. Blood samples were obtained at Off- and On-anticoagulant (trough) from 120 consecutive patients with atrial fibrillation (warfarin; n = 29, dabigatran; n = 19, rivaroxaban; n = 47, apixaban; n = 25), which were used for T-TAS to compute the area under the curve (AUC) (AR10-AUC30) in the AR chip, and to measure plasma concentrations of DOACs at On-anticoagulant. In addition, the two-dimensional area covered by thrombi (%) in the capillary was analyzed every 3 minutes after sample applications. The AR10-AUC30 correlated weakly and negatively with plasma concentrations of DOACs, and the levels at On-anticoagulant were lower in all groups than at Off-anticoagulant. AR10-AUC30 levels at Off- and On-anticoagulant were identical among the groups. The thrombi areas in early phase were significantly larger in rivaroxaban and apixaban than warfarin and dabigatran groups. The findings suggested that visual analysis of the AR-chip can identify the differential inhibitory patterns of warfarin and DOACs on thrombus formation under flow condition.
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Ofek F, Bar Chaim S, Kronenfeld N, Ziv-Baran T, Berkovitch M. International Normalized Ratio Is Significantly Elevated With Rivaroxaban and Apixaban Drug Therapies: A Retrospective Study. Clin Ther 2017; 39:1003-1010. [DOI: 10.1016/j.clinthera.2017.04.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 03/29/2017] [Accepted: 04/09/2017] [Indexed: 11/17/2022]
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The assessment of anticoagulant activity to predict bleeding outcome in atrial fibrillation patients receiving dabigatran etexilate. Blood Coagul Fibrinolysis 2017; 27:389-95. [PMID: 26991859 DOI: 10.1097/mbc.0000000000000558] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Special circumstances may require the measurement of the anticoagulant effect of dabigatran etexilate. No data currently link any given coagulation test to bleeding outcomes in patients receiving dabigatran etexilate for atrial fibrillation. Nonvalvular atrial fibrillation patients receiving dabigatran etexilate of 110 mg (DE110) or 150 mg (DE150) were consecutively enrolled. The hemoclot thrombin inhibitor (HTI) assay, prothrombin time, and activated partial thromboplastin time (APTT) measurements were correlated with bleeding events during a prospective follow-up. There were 17 bleeding events (8.2%) in 208 patients (74.7 ± 10.3 years old, 67.9% male, median follow-up: 364 days), whereas 15 patients with bleeding events used DE110. Compared with DE110, the patients receiving DE150 were younger and more often male and had lower HAS-BLED and CHA2DS2VASc scores and better renal function. Patients' HTI levels were very variable (DE110, 10-90th percentile: 20.5-223.9 ng/ml). A receiver-operator characteristic curve gave a median cutoff HTI level of 117.7 ng/ml to predict bleeding events (C-statistics: 0.65; P = 0.036), but no cutoff could be determined for prothrombin time or APTT. Based on the Kaplan-Meier analysis, a dabigatran etexilate level greater than 117.7 ng/ml was associated with a higher bleeding rate (15.4% vs. 4.9%, P = 0.01). After multivariate Cox regression analysis, HTI levels, history of stroke, and male sex were independent risk factors for bleeding events. Dabigatran etexilate-HTI levels were independently associated with bleeding in patients receiving routine clinical care. Blood sampling at multiple time points might be needed to increase reliability because of high variation of dabigatran etexilate-HTI levels.
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Deer TR, Narouze S, Provenzano DA, Pope JE, Falowski SM, Russo MA, Benzon H, Slavin K, Pilitsis JG, Alo K, Carlson JD, McRoberts P, Lad SP, Arle J, Levy RM, Simpson B, Mekhail N. The Neurostimulation Appropriateness Consensus Committee (NACC): Recommendations on Bleeding and Coagulation Management in Neurostimulation Devices. Neuromodulation 2017; 20:51-62. [DOI: 10.1111/ner.12542] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 09/15/2016] [Accepted: 09/15/2016] [Indexed: 12/15/2022]
Affiliation(s)
| | - Samer Narouze
- Summa Western Reserve Hospital; Cuyahoga Falls OH USA
| | | | | | | | | | | | | | | | | | | | | | - Shivanand P. Lad
- Division of Neurosurgery; Duke University Medical Center; Durham NC USA
| | - Jeffrey Arle
- Neurosurgery, Beth Israel Deaconess Medical Center; Boston MA USA
| | | | - Brian Simpson
- Department of Neurosurgery; University Hospital of Wales; Cardiff UK
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Yorkgitis BK, Zhang J, Rappold JF. Non-Vitamin K Antagonist Oral Anticoagulants: The Clinician's New Challenge. J Osteopath Med 2016; 115:612-21. [PMID: 26414714 DOI: 10.7556/jaoa.2015.122] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Millions of US patients are prescribed oral anticoagulants. Traditionally, oral anticoagulation was achieved with vitamin K antagonists (VKAs). In recent years, non-VKA oral anticoagulants (NOACs) have emerged that provide an effective and convenient alternative to VKAs. These agents possess very different pharmacologic properties from what the medical community has grown accustom to with the VKAs. Thus, a new knowledge base is required for NOACs. One particular challenge with the NOACs is the lack of specific reversal agent, resulting in difficulties correcting the coagulopathy induced by these drugs when needed. A review of the current literature is presented to assist clinicians in gaining knowledge of the NOACs to care for patients.
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Stability of direct oral anticoagulants in whole blood and plasma from patients in steady state treatment. Thromb Res 2016; 148:107-110. [DOI: 10.1016/j.thromres.2016.10.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 10/18/2016] [Accepted: 10/24/2016] [Indexed: 11/23/2022]
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Husted S, Verheugt FWA, Comuth WJ. Reversal Strategies for NOACs: State of Development, Possible Clinical Applications and Future Perspectives. Drug Saf 2016; 39:5-13. [PMID: 26519420 DOI: 10.1007/s40264-015-0357-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The non-vitamin K antagonist oral anticoagulants (NOACs) are used for thromboembolic prophylaxis of patients with atrial fibrillation and in the treatment as well as secondary prophylaxis of patients with venous thromboembolism. Even though NOACs have a better safety profile than vitamin K antagonists (VKAs), there will still be bleeding complications on NOAC treatment. In some cases, stopping the NOAC and non-drug-related management such as manual compression and interventional endoscopy will be sufficient to stop the bleeding. In more serious bleeding events and before acute surgery, coagulation factor concentrates or NOAC-specific antidotes could be used. Coagulation factor concentrates can be used in patients with haemophilia and to reverse the effect of VKAs but, in NOAC-treated patients, results are inconsistent and these agents could potentially have pro-thrombotic effects. Specific antidotes for NOACs are expected to be on the market soon. Phase III clinical trials with a humanized antibody fragment directed against dabigatran (idarucizumab) and recombinant, modified factor Xa (andexanet alfa) are ongoing. A molecule (aripazine) with broad activity against various anticoagulants including NOACs is currently undergoing phase II trials. For use of these specific antidotes, it is desirable that measurements for coagulation activity with a short response delay are widely available for the different NOACs and further research in this field is needed. Furthermore, guidelines for antidote use, including general measures for the treatment of NOAC-related bleeding, should be available.
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Affiliation(s)
- Steen Husted
- Department of Medicine, Hospital Unit West, Herning, Denmark
| | - Freek W A Verheugt
- Department of Cardiology, Heartcenter, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Willemijn J Comuth
- Department of Medicine, Hospital Unit West, Herning, Denmark. .,Department of Clinical Biochemistry, Hospital Unit West, Gl. Landevej 61, 7400, Herning, Denmark.
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Assessment of trough rivaroxaban concentrations on markers of coagulation activation in nonvalvular atrial fibrillation population. Heart Vessels 2016; 32:609-617. [DOI: 10.1007/s00380-016-0912-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 10/21/2016] [Indexed: 01/21/2023]
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Abstract
Large clinical trials have demonstrated that new oral anticoagulants (NOACs) are at least as efficient as vitamin K antagonists (VKAs) in preventing thromboembolic events, while providing a better safety profile. The relatively stable pharmacokinetics and pharmacodynamics, the reduced reports on food and drug interactions, and the wide therapeutic windows of NOACs appear to provide a more predictable anticoagulant effect than that observed with VKAs, enabling the use of fixed doses without the need for monitoring. However, the safe implementation of NOACs may require additional judgment, and one should not have the erroneous impression that NOACs are free from interactions or that inter- and intra-individual variability is absent with NOACs. In fact, a consensus seems to have been reached concerning the usefulness of "circumstantial" testing in certain clinical scenarios. Recent data also suggest that factors such as intercurrent diseases, drug interactions, and inexplicable variability may occasionally alter the anticoagulant effect of NOACs. Furthermore, the issue of nonadherence, already high in VKA-treated patients, may represent an even greater clinical concern with NOACs, given their short half-lives. This review aims to underline the main arguments that support the need for NOAC monitoring, at least in selected categories of patients. Additionally, an overview of classic coagulation assays and novel laboratory techniques that may provide a tool for NOAC monitoring is also provided.
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Abstract
OPINION STATEMENT Direct oral anticoagulants (DOAC) are an attractive therapeutic option for anticoagulant treatment in the setting of venous thromboembolism or non-valvular atrial fibrillation. These drugs overall appear to have a lower risk of life-threatening hemorrhage than the vitamin K antagonists. In addition, they demonstrate more predictable and stable pharmacokinetics. Measurement of the degree of anticoagulation is desirable in patients with DOAC-associated hemorrhage, but commonly available coagulation assays show poor sensitivity for degree of DOAC effect. DOAC-specific tests are time consuming and not widely available. All coagulation tests should be interpreted considering the timing of last intake and renal function. When life-threatening bleeding occurs, hemostasis should be restored as rapidly as possible. Non-specific prohemostatic drugs may have a role in DOAC reversal, and specific antidotes are at different stages of development. In this review, we provide a summary of DOAC characteristics and an overview of the different therapeutic options available for DOAC reversal.
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A novel coagulation parameter monitoring bleeding tendency of Chinese nonvalvular atrial fibrillation patients prescribing dabigatran etexilate. Blood Coagul Fibrinolysis 2016; 27:563-7. [DOI: 10.1097/mbc.0000000000000467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Yorkgitis BK. Direct oral anticoagulants for venous thromboembolism treatment and prophylaxis. JAAPA 2016; 29:24-9. [PMID: 27359069 DOI: 10.1097/01.jaa.0000488690.65799.b0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Direct oral anticoagulants are a popular option for prevention and treatment of venous thromboembolism. However, they possess significantly different pharmacologic properties from warfarin. This article reviews approved direct oral anticoagulants, their indications, pharmacologic properties, monitoring, and reversal strategies.
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Affiliation(s)
- Brian K Yorkgitis
- Brian K. Yorkgitis practices in the Division of Acute Care Surgery at the University of Florida-Jacksonville. The author has disclosed no potential conflicts of interest, financial or otherwise
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Management Overview: Taking a Patient with Intracranial Hemorrhage Related to Direct Oral Anticoagulants to the Operating Room. World Neurosurg 2016; 90:262-267. [DOI: 10.1016/j.wneu.2016.02.070] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Revised: 02/13/2016] [Accepted: 02/15/2016] [Indexed: 11/23/2022]
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Direct-Acting Oral Anticoagulants: Practical Considerations for Emergency Medicine Physicians. Emerg Med Int 2016; 2016:1781684. [PMID: 27293895 PMCID: PMC4884797 DOI: 10.1155/2016/1781684] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/11/2016] [Accepted: 03/29/2016] [Indexed: 01/01/2023] Open
Abstract
Nonvalvular atrial fibrillation- (NVAF-) related stroke and venous thromboembolism (VTE) are cardiovascular diseases associated with significant morbidity and economic burden. The historical standard treatment of VTE has been the administration of parenteral heparinoid until oral warfarin therapy attains a therapeutic international normalized ratio. Warfarin has been the most common medication for stroke prevention in NVAF. Warfarin use is complicated by a narrow therapeutic window, unpredictable dose response, numerous food and drug interactions, and requirements for frequent monitoring. To overcome these disadvantages, direct-acting oral anticoagulants (DOACs)—dabigatran, rivaroxaban, apixaban, and edoxaban—have been developed for the prevention of stroke or systemic embolic events (SEE) in patients with NVAF and for the treatment of VTE. Advantages of DOACs include predictable pharmacokinetics, few drug-drug interactions, and low monitoring requirements. In clinical studies, DOACs are noninferior to warfarin for the prevention of NVAF-related stroke and the treatment and prevention of VTE as well as postoperative knee and hip surgery VTE prophylaxis, with decreased bleeding risks. This review addresses the practical considerations for the emergency physician in DOAC use, including dosing recommendations, laboratory monitoring, anticoagulation reversal, and cost-effectiveness. The challenges of DOACs, such as the lack of specific laboratory measurements and antidotes, are also discussed.
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Ruff CT, Ansell JE, Becker RC, Benjamin EJ, Deicicchi DJ, Mark Estes NA, Ezekowitz MD, Fanikos J, Fareed J, Garcia D, Giugliano RP, Goldhaber SZ, Granger C, Healey JS, Hull R, Hylek EM, Libby P, Lopes RD, Mahaffey KW, Mega J, Piazza G, Sasahara AA, Sorond FA, Spyropoulos AC, Walenga JM, Weitz JI. North American Thrombosis Forum, AF Action Initiative Consensus Document. Am J Med 2016; 129:S1-S29. [PMID: 27126598 DOI: 10.1016/j.amjmed.2016.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The North American Thrombosis Forum Atrial Fibrillation Action Initiative consensus document is a comprehensive yet practical briefing document focusing on stroke and bleeding risk assessment in patients with atrial fibrillation, as well as recommendations regarding anticoagulation options and management. Despite the breadth of clinical trial data and guideline recommendation updates, many clinicians continue to struggle to synthesize the disparate information available. This problem slows the uptake and utilization of updated risk prediction tools and adoption of new oral anticoagulants. This document serves as a practical and educational reference for the entire medical community involved in the care of patients with atrial fibrillation.
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Affiliation(s)
- Christian T Ruff
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
| | - Jack E Ansell
- Hofstra North Shore/LIJ School of Medicine, Hempstead, NY
| | - Richard C Becker
- University of Cincinnati College of Medicine, University of Cincinnati Medical Center, Ohio
| | - Emelia J Benjamin
- Boston University School of Medicine and Public Health, Boston Medical Center, Boston, Mass
| | | | - N A Mark Estes
- Tufts Medical Center, Tufts University School of Medicine, Boston, Mass
| | - Michael D Ezekowitz
- Lankenau Medical Center, Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pa
| | - John Fanikos
- Massachusetts College of Pharmacy, Brigham and Women's Hospital, Northeastern University School of Pharmacy, Boston, Mass
| | - Jawed Fareed
- Loyola University Medical Center, Loyola University Chicago Stritch School of Medicine, Ill
| | - David Garcia
- University of Washington Medical Center, University of Washington School of Medicine, Seattle, Wash
| | - Robert P Giugliano
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Samuel Z Goldhaber
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Christopher Granger
- Duke University Medical Center, Duke University School of Medicine, Durham, NC
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Russell Hull
- Foothills Medical Center, University of Calgary, Alberta, Canada
| | - Elaine M Hylek
- Boston University School of Medicine and Public Health, Boston Medical Center, Boston, Mass
| | - Peter Libby
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Renato D Lopes
- Duke University Medical Center, Duke University School of Medicine, Durham, NC
| | - Kenneth W Mahaffey
- Stanford University Medical Center, Stanford University School of Medicine, Calif
| | - Jessica Mega
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Gregory Piazza
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Arthur A Sasahara
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Farzaneh A Sorond
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | | | - Jeanine M Walenga
- Loyola University Medical Center, Loyola University Chicago Stritch School of Medicine, Ill
| | - Jeffrey I Weitz
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
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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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Sciascia S, Lopez-Pedrera C, Cecchi I, Pecoraro C, Roccatello D, Cuadrado MJ. Non-vitamin K antagonist oral anticoagulants and antiphospholipid syndrome. Rheumatology (Oxford) 2016; 55:1726-35. [DOI: 10.1093/rheumatology/kev445] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Indexed: 01/08/2023] Open
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Lai YF, Neo JK, Cheen MHH, Kong MC, Tai BC, Ng HJ. Comparison of Medication Adherence and Treatment Persistence between New Oral Anticoagulant and Warfarin among Patients. ANNALS OF THE ACADEMY OF MEDICINE, SINGAPORE 2016. [DOI: 10.47102/annals-acadmedsg.v45n1p12] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction: This study aimed to compare medication adherence and treatment persistence of patients on warfarin versus rivaroxaban in Singapore. A secondary objective was to identify significant covariates influencing adherence. Materials and Methods: A retrospective cohort study was conducted where data from September 2009 to October 2014 was retrieved from the hospital electronic databases. Prescription records of rivaroxaban patients with 3 months or more of continuous prescription were extracted and compared against those of patients on warfarin. Primary outcome of adherence was determined based on the medication possession ratio (MPR), while treatment persistence was determined by outpatient clinic appointment gaps. Results: A total of 94 rivaroxaban and 137 warfarin users were analysed by complete case analysis. The MPR of warfarin patients was lower than rivaroxaban patients by 10% (95% CI, 6.4% to 13.6%; P <0.0001). Also, there were more warfarin patients who had gaps in treatment persistence compared to those prescribed rivaroxaban (8.0% vs 1.1%; P = 0.03). Significant factors affecting medication adherence were age and duration of anticoagulant use. For every 10-year increase in age, MPR increased by 1.7% (95% CI, 0.7% to 2.8%). Similarly, for every year increase in duration of use, MPR increased by 1.8% (95% CI, 0.6% to 3.0%). Race, gender, concomitant medication and type of residence were not found to be significant covariates in the multivariable analysis. Conclusion: Patients on rivaroxaban are likely to be more adherent to their prescribed oral anticoagulant with increasing age and duration of treatment influencing adherence.
Key words: Compliance, Medication possession ratio, Oral anticoagulation, Rivaroxaban
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Affiliation(s)
| | | | | | | | - Bee Choo Tai
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
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Douketis JD, Wang G, Chan N, Eikelboom JW, Syed S, Barty R, Moffat KA, Spencer FA, Blostein M, Schulman S. Effect of standardized perioperative dabigatran interruption on the residual anticoagulation effect at the time of surgery or procedure. J Thromb Haemost 2016; 14:89-97. [PMID: 26512880 DOI: 10.1111/jth.13178] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Indexed: 11/30/2022]
Abstract
UNLABELLED ESSENTIALS: Anticoagulants need to be stopped preprocedure so there is little or no remaining anticoagulant effect. We assessed the residual anticoagulant effect with standardized interruption for patients on dabigatran. With this protocol, 80-86% of patients had no residual anticoagulant effect at the time of a procedure. A standardized perioperative dabigatran protocol appears to be safe, but requires further study. BACKGROUND In patients taking dabigatran who require treatment interruption for a surgery/procedure, a sufficient interruption interval is needed so that there is little or no residual anticoagulant effect at the time of the surgery/procedure. METHODS A prospective cohort study of patients receiving dabigatran (110 mg or 150 mg twice daily) who required an elective surgery/procedure and received a standardized dabigatran interruption protocol based on surgery/procedure bleeding risk and renal function was performed. Before the surgery/procedure, a blood sample was taken for measurement of the prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), and dilute thrombin time (dTT). We determined the proportion of all patients and those having a high bleeding risk surgery/procedure with normal coagulation test results at the time of the surgery/procedure. The APTT and dTT were considered to be most likely to reflect a dabigatran anticoagulant effect. Patients were followed up for 30 days postprocedure to assess for bleeding and thromboembolism. RESULTS One hundred and eighty-one patients were studied: 118 with low bleeding risk, and 63 with high bleeding risk. For all patients, the proportions with normal PT, APTT, TT dTT levels were 92.8%, 79.6%, 33.1%, and 80.7%, respectively. In patients with high bleeding risk, the proportions with normal PT, APTT, TT dTT levels were 93.7%, 85.7%, 57.1%, and 87.3%, respectively. During follow-up, there was one (0.6%) major bleed, there were nine (5.0%) minor bleeds, and there was one (0.6%) transient ischemic attack. CONCLUSIONS In patients receiving dabigatran who require an elective surgery/procedure, a standardized interruption protocol yielded 80-86% of patients with no residual anticoagulant effect at the time of surgery/procedure, and with a low incidence of bleeding.
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Affiliation(s)
- J D Douketis
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - G Wang
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - N Chan
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - J W Eikelboom
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - S Syed
- Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - R Barty
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - K A Moffat
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Hamilton Regional Laboratory Medicine Program, McMaster University, Hamilton, Ontario, Canada
| | - F A Spencer
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - M Blostein
- Department of Medicine, McGill University, Montréal, Quebec, Canada
| | - S Schulman
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
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Ramos-Esquivel A. Monitoring anticoagulant therapy with new oral agents. World J Methodol 2015; 5:212-215. [PMID: 26713281 PMCID: PMC4686418 DOI: 10.5662/wjm.v5.i4.212] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 08/21/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Thromboembolic disease is a major leading cause of mortality and morbidity in industrialized countries. Currently, the management of these patients is challenging due to the availability of new drugs with proven efficacy and security compared to traditional oral vitamin K antagonists. These compounds are characterized by a predictable pharmacokinetic profile for which blood monitoring is not routinely needed. Nevertheless, some data have suggested inter-patient variability in the anticoagulant effect of these drugs, raising concerns about their effectiveness and safety. Although mass-spectrometry is the gold standard to determine drug plasma concentrations, this method is not widely available in every-day practice and some coagulation assays are commonly used to determine the anticoagulant effect of these drugs. The present review aims to summarize the current knowledge regarding the clinical question of how and when to monitor patients with new anticoagulant oral agents.
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Chan NC, Bhagirath V, Dale BJ, Eikelboom JW. Evaluating coagulation tests in patients with atrial fibrillation using direct oral anticoagulants. Expert Rev Cardiovasc Ther 2015; 13:1213-23. [DOI: 10.1586/14779072.2015.1096779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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