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Atsumi T, Chighizola CB, Fujieda Y, Mackie I, Radin M, Roubey R, Bertolaccini ML. 16th International congress on antiphospholipid antibodies task force report on antiphospholipid syndrome laboratory diagnostics and trends. Lupus 2023; 32:1625-1636. [PMID: 37933818 PMCID: PMC10666497 DOI: 10.1177/09612033231211820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2023]
Abstract
Classification criteria for antiphospholipid syndrome (APS) require IgG or IgM isotypes of the anticardiolipin (aCL) antibodies, anti-β2 glycoprotein I (anti-β2GPI) antibodies, and/or the lupus anticoagulant (LA) to satisfy the laboratory disease definition. Over the past 20 years, non-criteria antiphospholipid antibodies (aPL) directed to other proteins of the coagulation cascade (i.e. prothrombin and/or phosphatidylserine-prothrombin complex) or to some domains of β2GPI have been proposed. This task force concentrated and reviewed the literature on data including aPS/PT, antibodies to domain 4/5 of β2GPI and the newly described antibodies to protein/HLA-DR complex. In addition, we discussed testing of LA in the 'new' oral anticoagulants' era and the value of triple positivity in the risk assessment of aPL. The conclusions were presented at a special session during the 16th International Congress on aPL, Manchester, UK, September 2019.
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Affiliation(s)
- Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Cecilia B Chighizola
- Unit of Pediatric Rheumatology, ASST G. Pini - CTO, Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Yuichiro Fujieda
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Ian Mackie
- Department of Haematology, Haemostasis Research Unit, University College London, London, UK
| | - Massimo Radin
- Department of Clinical and Biological Sciences, and SCDU Nephrology and Dialysis, S. Giovanni Bosco Hospital, Center of Research of Immunopathology and Rare Diseases - Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Turin, Italy
| | - Robert Roubey
- Division of Rheumatology, Allergy & Immunology, Thurston Arthritis Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Maria Laura Bertolaccini
- Academic Department of Vascular Surgery, School of Cardiovascular and Metabolic Medicine & Sciences, King's College London, London, UK
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Ding Z, Pan H, Yang Z, Yang C, Shi H. Beyond the classics: The emerging value of anti-phosphatidylserine/prothrombin antibodies in antiphospholipid syndrome. Clin Immunol 2023; 256:109804. [PMID: 37838215 DOI: 10.1016/j.clim.2023.109804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/24/2023] [Accepted: 10/05/2023] [Indexed: 10/16/2023]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune disorder characterized by the presence of antiphospholipid antibodies (aPLs), which can lead to thrombosis and pregnancy complications. Within the diverse range of aPLs, anti-phosphatidylserine/prothrombin antibodies (aPS/PT) have gained significance in clinical practice. The detection of aPS/PT has proven valuable in identifying APS patients and stratifying their risk, especially when combined with other aPL tests like lupus anticoagulant (LA) and anti-β2-glycoprotein I (aβ2GPI). Multivariate analyses have confirmed aPS/PT as an independent risk factor for vascular thrombosis and obstetric complications, with its inclusion in the aPL score and the Global Anti-Phospholipid Syndrome Score (GAPSS) aiding in risk evaluation. However, challenges remain in the laboratory testing of aPS/PT, including the need for assay standardization and its lower sensitivity in certain patient populations. Further research is necessary to validate the clinical utility of aPS/PT antibodies in APS diagnosis, risk stratification, and management.
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Affiliation(s)
- Zetao Ding
- Department of Rheumatology and Immunology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Haoyu Pan
- Department of Rheumatology and Immunology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhixia Yang
- Department of Rheumatology and Immunology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine, Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Chengde Yang
- Department of Rheumatology and Immunology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hui Shi
- Department of Rheumatology and Immunology, Ruijin Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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Marco-Rico A, Marco-Vera P. Thrombotic Antiphospholipid Syndrome and Direct Oral Anticoagulants: Unmet Needs and Review of the Literature. Semin Thromb Hemost 2023; 49:736-743. [PMID: 36996874 DOI: 10.1055/s-0043-1767728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023]
Abstract
Patients with thrombotic antiphospholipid syndrome (APS) require long-term anticoagulation due to the high-thrombotic recurrence risk. Vitamin K antagonists (VKA) have been traditionally considered the standard of care in thrombotic APS. Nevertheless, the risk of recurrence persists with VKA. There are publications considering different intensities of anticoagulation with VKA; however, the standard-intensity anticoagulation (international normalized ratio between 2.0 and 3.0) is the most recommended. Furthermore, there is no consensus on the role of antiplatelet treatment in thrombotic APS. Nonvitamin K antagonist oral anticoagulants (NOACs) have emerged as an alternative to VKA for many indications. There are, however, discrepancies regarding the management with NOACs in thrombotic APS. In this review, we update the different clinical trials with NOACs in venous, arterial, and microvascular thrombosis and suggest how these patients should be managed in agreement with the expert panels. Although scarce data are published regarding the current role of NOACs in thrombotic APS, the clinical trials failed to demonstrate noninferiority of NOACs compared with VKA, especially in patients with triple antiphospholipid antibodies positivity and/or arterial thrombosis. Single or double antiphospholipid positivity should be analyzed on a case-by-case basis. In addition, we focus on different areas of uncertainty that still remain in thrombotic APS and NOACs. To summarize, emerging clinical trials are needed to provide robust data on the management of thrombotic APS.
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Affiliation(s)
- Ana Marco-Rico
- Department of Thrombosis and Hemostasis, Hematology Service, University General Hospital Dr. Balmis, Alicante, Spain
- Biomedical Health Research Institute (ISABIAL), University General Hospital Dr. Balmis, Alicante, Spain
| | - Pascual Marco-Vera
- Biomedical Health Research Institute (ISABIAL), University General Hospital Dr. Balmis, Alicante, Spain
- Department of Clinical Medicine, Miguel Hernández University, Alicante, Spain
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Cohen H, Werring DJ, Chandratheva A, Mittal P, Devreese KMJ, Isenberg DA. Survey on antiphospholipid syndrome diagnosis and antithrombotic treatment in patients with ischemic stroke, other brain ischemic injury, or arterial thromboembolism in other sites: communication from ISTH SSC Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibodies. J Thromb Haemost 2023; 21:2963-2976. [PMID: 37391096 DOI: 10.1016/j.jtha.2023.06.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/05/2023] [Accepted: 06/15/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND The optimal strategy for diagnosis and antithrombotic treatment of patients with antiphospholipid syndrome (APS)-associated acute ischemic stroke (AIS), transient ischemic attack (TIA), or other brain ischemic injury is poorly defined. OBJECTIVES The survey goal was to capture variations in diagnosis and antithrombotic treatment of APS-associated ischemic stroke and related disorders to inform guidance and clinical trials to define optimal management. METHODS Professional colleagues, including key opinion leaders, were invited to complete a REDCap survey questionnaire initiated by the International Society on Thrombosis and Haemostasis Scientific and Standardisation Committee Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibodies. The survey data were tallied using simple descriptive statistics. RESULTS There was generally good agreement on several aspects, including which patients to test for antiphospholipid antibodies (aPL), use of a lifelong vitamin K antagonist for AIS or recurrent TIA, and formal cognitive assessment for suspected cognitive impairment. There was less agreement on other aspects, including aPL testing for brain ischemic injury other than AIS/TIA or if an alternative cause for AIS or TIA exists; choice of aPL tests, their timing, and age cutoff; the aPL phenotype to trigger antithrombotic treatment; management for patent foramen ovale; antithrombotic treatment for first TIA or white matter hyperintensities; head magnetic resonance imaging specifications; and low-molecular-weight heparin dosing/anti-Xa monitoring in pregnancy. The survey highlighted that approximately 25% practice at dedicated APS clinics and <50% have a multidisciplinary team structure for patients with APS. CONCLUSION Much of the variation in practice reflects the lack of evidence-based recommendations. The survey results should inform the development of a more uniform multidisciplinary consensus approach to diagnosis and antithrombotic treatment.
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Affiliation(s)
- Hannah Cohen
- Department of Haematology, Cancer Institute, University College London, London, UK; Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK.
| | - David J Werring
- Stroke Research Centre, Department of Brain Repair and Rehabilitation, University College London Queen Square Institute of Neurology, London, UK; National Hospital for Neurology and Neurosurgery, Queen Square University College Hospitals NHS Foundation Trust, London, UK
| | - Arvind Chandratheva
- National Hospital for Neurology and Neurosurgery, Queen Square University College Hospitals NHS Foundation Trust, London, UK
| | - Prabal Mittal
- Department of Haematology, Cancer Institute, University College London, London, UK; Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Katrien M J Devreese
- Coagulation Laboratory, Ghent University Hospital, Ghent, Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - David A Isenberg
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK; Centre for Rheumatology, Division of Medicine, University College London, London, UK
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Abstract
Antiphospholipid syndrome (APS) is a thrombo-inflammatory disease propelled by circulating autoantibodies that recognize cell surface phospholipids and phospholipid binding proteins. The result is an increased risk of thrombotic events, pregnancy morbidity, and various other autoimmune and inflammatory complications. Although antiphospholipid syndrome was first recognized in patients with lupus, the stand alone presentation of antiphospholipid syndrome is at least equally common. Overall, the diagnosis appears to affect at least one in 2000 people. Studies of antiphospholipid syndrome pathogenesis have long focused on logical candidates such as coagulation factors, endothelial cells, and platelets. Recent work has shed light on additional potential therapeutic targets within the innate immune system, including the complement system and neutrophil extracellular traps. Vitamin K antagonists remain the mainstay of treatment for most patients with thrombotic antiphospholipid syndrome and, based on current data, appear superior to the more targeted direct oral anticoagulants. The potential role of immunomodulatory treatments in antiphospholipid syndrome management is receiving increased attention. As for many systemic autoimmune diseases, the most important future direction is to more precisely identify mechanistic drivers of disease heterogeneity in pursuit of unlocking personalized and proactive treatments for patients.
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Affiliation(s)
- Jason S Knight
- Division of Rheumatology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - D Ware Branch
- James R. and Jo Scott Research Chair, Department of Obstetrics and Gynecology, University of Utah Health and Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Thomas L Ortel
- Division of Hematology, Departments of Medicine and Pathology, Duke University, Durham, North Carolina, USA
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Moore GW. Lupus Anticoagulant Testing: Taipan Snake Venom Time with Ecarin Time as Confirmatory Test. Methods Mol Biol 2023; 2663:263-274. [PMID: 37204716 DOI: 10.1007/978-1-0716-3175-1_16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Testing for lupus anticoagulants (LA) in the presence of therapeutic anticoagulation is largely discouraged because of the risk of false-positive and false-negative results, although the ability to detect LA in this setting can be clinically valuable. Strategies such as mixing tests and anticoagulant neutralization can be effective, but have their own limitations. The prothrombin activators in venoms from Coastal Taipan and Indian saw-scaled viper snakes provide an additional analytical avenue in that they are insensitive to the effects of vitamin K antagonists and inevitably bypass the effects of direct factor Xa inhibitors. Oscutarin C in Coastal Taipan venom is phospholipid- and Ca2+-dependent, so the venom is used in a dilute phospholipid design as an LA screening test called the Taipan snake venom time (TSVT). The ecarin fraction of Indian saw-scaled viper venom is cofactor-independent and operates as a prothrombin-activated confirmatory test, the ecarin time, because the absent phospholipid precludes inhibition by LAs. Bypassing all coagulation factors except prothrombin and fibrinogen renders the assays innately more specific than other LA assays, while TSVT as a screening test has good sensitivity to LAs detected in other assays, as well as occasional antibodies unreactive in other assays.
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Affiliation(s)
- Gary W Moore
- Research and Development, Technoclone Herstellung von Diagnostika und Arzneimitteln GmbH, Vienna, Austria.
- Specialist Haemostasis Unit, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
- Department of Natural Sciences, Faculty of Science and Technology, Middlesex University London, London, UK.
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Moore GW. Lupus Anticoagulant Testing: Dilute Prothrombin Time (dPT). Methods Mol Biol 2023; 2663:275-288. [PMID: 37204717 DOI: 10.1007/978-1-0716-3175-1_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Lupus anticoagulants (LA) rarely affect routine prothrombin time assays because the high phospholipid (PL) content in thromboplastin reagents tends to overwhelm the antibodies. Dilution of thromboplastin to create a dilute prothrombin time (dPT) screening test renders the assay sensitive to the presence of LA. Technical and diagnostic performances are enhanced if recombinant thromboplastins are employed in place of tissue-derived reagents. Presence of an LA cannot be deduced from an elevated screening test alone since other coagulation disturbances can prolong clotting times. Confirmatory testing with less dilute or undiluted thromboplastin reveals the PL-dependent nature of LA by reducing the clotting time relative to that of the screening test. Where appropriate, such as a known or suspected coagulation factor deficiency, mixing tests are valuable in correcting factor deficiencies and evidencing inhibitory properties of LA, to increase diagnostic specificity. Although LA testing is commonly restricted to dilute Russell's viper venom time and activated partial thromboplastin time, dPT is sensitive to LA unreactive in those assays, and inclusion in routine testing increases detection rates of clinically significant antibodies.
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Affiliation(s)
- Gary W Moore
- Research and Development, Technoclone Herstellung von Diagnostika und Arzneimitteln GmbH, Vienna, Austria.
- Specialist Haemostasis Unit, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
- Department of Natural Sciences, Faculty of Science and Technology, Middlesex University London, London, UK.
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Noble H, Crossette-Thambiah C, Odho Z, Karawitage N, Logan K, Pericleous C, Laffan M, Arachchillage DJ. Frequency and Clinical Significance Anti-PS/PT Antibodies in Patients with Antiphospholipid Syndrome - Single Centre Observational Study in the United Kingdom. Semin Thromb Hemost 2022. [PMID: 36318961 DOI: 10.1055/s-0042-1757633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Hithin Noble
- Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, London, United Kingdom
| | - Christina Crossette-Thambiah
- Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Zain Odho
- Department of Laboratory medicine, Royal Brompton Hospital, London, United Kingdom
| | - Nilanthi Karawitage
- Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, London, United Kingdom
| | - Karen Logan
- Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, London, United Kingdom
| | - Charis Pericleous
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Mike Laffan
- Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Deepa J Arachchillage
- Department of Immunology and Inflammation, Centre for Haematology, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College Healthcare NHS Trust, London, United Kingdom
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Abstract
Lupus anticoagulant (LA) is one of the three criteria antiphospholipid antibodies (aPLs) employed in classification, and by default diagnosis, of antiphospholipid syndrome (APS). Detection of LA is not via calibrated assays but is based on functional behavior of the antibodies in a medley of coagulation assays. A prolonged clotting time in a screening test is followed by demonstration of phospholipid dependence and inhibitory properties in confirmatory and mixing tests, respectively, which are modifications of the parent screening test. Complications arise because no single screening test is sensitive to every LA, and no test is specific for LA, because they are prone to interference by other causes of elevated clotting times. Several screening tests are available but the pairing of dilute Russell's viper venom time (dRVVT) with LA-sensitive activated partial thromboplastin time (aPTT) is widely used and recommended because it is proven to have good detection rates. Nonetheless, judicious use of other assays can improve diagnostic performance, such as dilute prothrombin time to find LA unreactive with dRVVT and aPTT, and the recently validated Taipan snake venom time with ecarin time confirmatory test that are unaffected by vitamin K antagonist and direct factor Xa inhibitor anticoagulation. Expert body guidelines and their updates have improved harmonization of laboratory practices, although some issues continue to attract debate, such as the place of mixing tests in the medley hierarchy, and areas of data manipulation such as assay cut-offs and ratio generation. This article reviews current practices and challenges in the laboratory detection of LA.
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Affiliation(s)
- Gary W Moore
- Haemostasis Unit, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,Department of Natural Sciences, Faculty of Science and Technology, Middlesex University, London, United Kingdom
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Lu S, Huerman N, Li M, Ding Q, Song Y, Xu Q, Rong J, Xu J, Liu C. Evaluation of Activated Carbon Treatment on Overcoming the Interference of Rivaroxaban on the Detection of Functional Lupus Anticoagulant. Acta Haematol 2022; 145:430-439. [PMID: 35100578 DOI: 10.1159/000522324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/28/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To study the role of activated carbon in eliminating the interference of rivaroxaban in the detection of lupus anticoagulants (LA). METHODS Normal pooled plasma (NPP) was obtained as Group N1, and Group N2 took 1ml plasma from N1 and added activated carbon; Group N3 was prepared by mixing normal plasma with rivaroxaban, and Group N3 was treated with activated carbon according to our procedure, as Group N4. Plasma from 22 patients was collected before and 6-12 hours after rivaroxaban therapy, described as group P1 and group P2 respectively, and 1ml plasma was taken from Group P2 and treated with activated carbon, as Group P3. Anti-Xa and dRVVT / SCT index in each group were measured and compared. RESULTS Rivaroxaban concentrations and anti-Xa had high intercorrelations in Groups N3, and the levels of Anti-Xa and dRVVT / SCT index had high intercorrelations. After treatment with activated carbon, influence of rivaroxaban was removed, with lupus anticoagulant and coagulation factor assays not influenced. Rivaroxaban administration could affect lupus anticoagulant assay results in patients, with all LA results increased. After treatment with activated carbon, results of Anti-Xa and lupus anticoagulant tests recovered to the level before rivaroxaban therapy. CONCLUSIONS We proposed a reference procedure for the LA detection of patients using rivaroxaban by activated carbon, and activated carbon was proven to be a simple product to eliminate the interference of rivaroxaban.
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Affiliation(s)
- Songsong Lu
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Nurzat Huerman
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Meng Li
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Qingming Ding
- Department of Pharmacy, Peking University People's Hospital, Beijing, China
| | - Ying Song
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Qinzhu Xu
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Jiang Rong
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Jian Xu
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
| | - Chen Liu
- Department of Clinical Laboratory, Peking University People's Hospital, Beijing, China
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White D, Moore GW, Besser M, MacDonald S, Thomas W. Direct oral anticoagulants-Remove versus Taipan snake venom time for detection of a lupus anticoagulant in patients taking oral direct factor Xa inhibitors. Res Pract Thromb Haemost 2022; 6:e12648. [PMID: 35106431 PMCID: PMC8784856 DOI: 10.1002/rth2.12648] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 11/18/2021] [Accepted: 11/24/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND The optimal method of detecting a lupus anticoagulant (LA) for patients taking direct factor Xa inhibitor (DFXaI) direct oral anticoagulants (DOACs) remains controversial. Methods include charcoal adsorption of the DOACs to allow testing with the activated partial thromboplastin time (APTT) and dilute Russell viper venom time (dRVVT), or use of the DFXaI-insensitive Taipan snake venom time (TSVT) and Ecarin time (ET) assays on neat plasma. OBJECTIVES The objective was to compare the utility of APTT and dRVVT analysis following DOAC Remove against TSVT/ET on untreated plasma for LA detection in spiked plasmas and routine clinical samples for patients on DFXaIs. PATIENTS/METHODS Various LA-negative and LA-positive samples were assayed by APTT, dRVVT, and TSVT/ET, and then separately spiked with rivaroxaban, apixaban, and edoxaban calibrators to a concentration of ~190 ng/ml and the assays repeated on spiked plasma before and after DOAC Remove treatment. Testing of 284 consecutive samples from DFXaI-anticoagulated patients by APTT/dRVVT and TSVT/ET before and after DOAC Remove treatment was undertaken. RESULTS In the spiking model, we found that both TSVT/ET and DOAC Remove strategies generally distinguished LA-negative and LA-positive samples, but some false-positive LA results occurred. In the investigation of 284 consecutive patient samples on DFXaIs, the percentage agreement for LA detection in neat samples tested by TSVT/ET versus APTT and dRVVT after DOAC Remove treatment was 90% (Cohen kappa 0.12). CONCLUSION Our data highlight uncertainty and disagreement for testing LA in patients on DFXaI. Further studies are required.
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Affiliation(s)
- Danielle White
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Gary W Moore
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
- Faculty of Science and Technology Middlesex University London UK
| | - Martin Besser
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Stephen MacDonald
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
| | - Will Thomas
- Department of Haematology Cambridge University Hospitals NHS Foundation Trust Cambridge UK
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Recurrent Implantation Failure-Is It the Egg or the Chicken? LIFE (BASEL, SWITZERLAND) 2021; 12:life12010039. [PMID: 35054432 PMCID: PMC8777926 DOI: 10.3390/life12010039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 12/15/2021] [Accepted: 12/22/2021] [Indexed: 12/31/2022]
Abstract
Recurrent implantation failure (RIF) is an undefined, quite often, clinical phenomenon that can result from the repeated failure of embryo transfers to obtain a viable pregnancy. Careful clinical evaluation prior to assisted reproduction can uncover various treatable causes, including endocrine dysfunction, fibroid(s), polyp(s), adhesions, uterine malformations. Despite the fact that it is often encountered and has a critical role in Assisted Reproductive Technique (ART) and human reproduction, RIF’s do not yet have an agreed-on definition, and its etiologic factors have not been entirely determined. ART is a complex treatment with a variable percentage of success among patients and care providers. ART depends on several factors that are not always known and probably not always the same. When confronted with repeated ART failure, medical care providers should try to determine whether the cause is an embryo or endometrium related. One of the most common causes of pregnancy failure is aneuploidy. Therefore, it is likely that this represents a common cause of RIF. Other RIF potential causes include immune and endometrial factors; however, with a very poorly defined role. Recent data indicate that the possible endometrial causes of RIF are very rare, thereby throwing into doubt all endometrial receptivity assays. All recent reports indicate that the true origin of RIF is probably due to the “egg”.
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Moore GW, Jones PO, Platton S, Hussain N, White D, Thomas W, Rigano J, Pouplard C, Gray E, Devreese KMJ. International multicenter, multiplatform study to validate Taipan snake venom time as a lupus anticoagulant screening test with ecarin time as the confirmatory test: Communication from the ISTH SSC Subcommittee on Lupus Anticoagulant/Antiphospholipid Antibodies. J Thromb Haemost 2021; 19:3177-3192. [PMID: 34192404 DOI: 10.1111/jth.15438] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/08/2021] [Accepted: 06/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Lupus anticoagulant (LA) assays are compromised in anticoagulated patients, and existing strategies to overcome the interferences have limitations. The prothrombin-activating Taipan snake venom time (TSVT) screening test and ecarin time (ET) confirmatory test are innately insensitive to vitamin K antagonists (VKA) and direct factor Xa inhibitors (DFXaI). OBJECTIVES Validate standardized TSVT/ET reagents for LA detection, in a multicenter, multiplatform study. PATIENTS/METHODS Six centers from four countries analyzed samples with TSVT/ET from 81 nonanticoagulated patients with LA, patients with established antiphospholipid syndrome (APS), and proven persistent LA who were either not anticoagulated (n = 120) or were anticoagulated with VKAs (n = 180) or DFXaIs (n = 71). Additionally, 339 nonanticoagulated LA-negative patients, and 575 anticoagulated non-APS patients (172 VKA, 403 DFXaI) were tested. Anticoagulant spiking experiments were performed and 112 samples containing potential interferences (i.e., direct thrombin inhibitors) were tested. Results were evaluated against locally derived cutoffs. Imprecision was evaluated. RESULTS Cutoffs were remarkably similar despite use of different analyzers and donor populations. Cutoffs for TSVT ratio, ET ratio, percent correction, and normalized TSVT ratio/ET ratio ranged between 1.08 and 1.10, 1.09 and 1.12, 9.3% and 14.8%, and 1.10 and 1.15, respectively. Coefficients of variation for TSVT and ET ratios were ≤5.0%. TSVT/ET exhibited sensitivity, specificity, and negative and positive predictive values of 78.2%/95.0%/86.3%/91.5%, respectively, with established APS as the LA-positive population, and 86.9%/95.0%/76.8%/97.4%, respectively, with triple-positive APS. Interference was seen with direct thrombin inhibitors, unfractionated heparin, and low molecular weight heparins, but not VKAs or DFXaIs. CONCLUSIONS TSVT/ET are validated for LA detection in nonanticoagulated patients and those on VKAs or DFXaIs.
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Affiliation(s)
- Gary W Moore
- Department of Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, UK
- Specialist Haemostasis Unit, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Faculty of Science and Technology, Middlesex University, London, UK
| | - Paul O Jones
- Department of Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, UK
| | - Sean Platton
- The Royal London Hospital Haemophilia Centre, Barts Health NHS Trust, London, UK
| | - Nadia Hussain
- Clinical Biochemistry Department, Barts Health NHS Trust, London, UK
| | - Danielle White
- Specialist Haemostasis Unit, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Will Thomas
- Specialist Haemostasis Unit, Department of Haematology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Joseph Rigano
- Haematology Department, Alfred Health, Melbourne, Vic., Australia
| | - Claire Pouplard
- Department of Hemostasis, University Hospital of Tours, University of Tours, Tours, France
| | - Elaine Gray
- Haemostasis Section, The National Institute for Biological Standards and Control, Potters Bar, UK
| | - Katrien M J Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
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14
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Abstract
Snake venoms have evolved primarily to immobilize and kill prey, and consequently, they contain some of the most potent natural toxins. Part of that armory is a range of hemotoxic components that affect every area of hemostasis, which we have harnessed to great effect in the study and diagnosis of hemostatic disorders. The most widely used are those that affect coagulation, such as thrombin-like enzymes unaffected by heparin and direct thrombin inhibitors, which can help confirm or dispute their presence in plasma. The liquid gold of coagulation activators is Russell's viper venom, since it contains activators of factor X and factor V. It is used in a range of clotting-based assays, such as assessment of factor X and factor V deficiencies, protein C and protein S deficiencies, activated protein C resistance, and probably the most important test for lupus anticoagulants, the dilute Russell's viper venom time. Activators of prothrombin, such as oscutarin C from Coastal Taipan venom and ecarin from saw-scaled viper venom, are employed in prothrombin activity assays and lupus anticoagulant detection, and ecarin has a valuable role in quantitative assays of direct thrombin inhibitors. Snake venoms affecting primary hemostasis include botrocetin from the jararaca, which can be used to assay von Willebrand factor activity, and convulxin from the cascavel, which can be used to detect deficiency of the platelet collagen receptor, glycoprotein VI. This article takes the reader to every area of the diagnostic hemostasis laboratory to appreciate the myriad applications of snake venoms available in diagnostic practice.
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Affiliation(s)
- Gary William Moore
- Department of Haematology, Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,Faculty of Science and Technology, Middlesex University London, London, United Kingdom
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15
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Baker SA, Jin J, Pfaffroth C, Vu T, Zehnder JL. DOAC-Stop in lupus anticoagulant testing: Direct oral anticoagulant interference removed in most samples. Res Pract Thromb Haemost 2021; 5:314-325. [PMID: 33733031 PMCID: PMC7938630 DOI: 10.1002/rth2.12472] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 11/14/2020] [Accepted: 11/20/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The use of direct oral anticoagulants (DOACs) is a convenient therapeutic option for patients at risk of thrombosis. DOACs interfere with clot-based testing for the identification of lupus anticoagulant antibodies (LACs) in patients with antiphospholipid syndrome (APS), a common cause of acquired thrombotic disease. OBJECTIVES To evaluate a commercially available reagent DOAC-Stop for the removal of DOAC interference encountered in LAC testing. PATIENTS/METHODS We collected a cohort of 73 test samples from patients on DOAC therapy identified at a large institutional coagulation laboratory from March to December 2019, along with samples from 40 LAC positive and negative control patients not on therapy. Samples were treated with DOAC-Stop and tested for anti-Xa activity and thrombin time for the removal of apixaban, rivaroxaban, argatroban, and dabigatran activity from patient samples. Treated and untreated samples were tested using the activated partial thromboplastin time, silica clotting time, and dilute Russell's viper venom time to evaluate the reliability and utility of DOAC-Stop. RESULTS DOAC-Stop markedly reduced DOAC interference from test samples (P < .05). DOAC-Stop had no effect on LAC testing in the absence of DOAC therapy, permitting the identification of all LAC positive and negative controls. DOAC-Stop removed false positives and false negatives resulting from DOAC interference and allows the identification of patients meeting criteria for the diagnosis of APS by LAC testing, as well as the detection of patients on rivaroxaban who are triple positive for APS. CONCLUSIONS DOAC-Stop is an effective adjunct for the clinical laboratory faced with DOAC interference in LAC testing.
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Affiliation(s)
| | - Jing Jin
- Department of Special Coagulation Clinical LaboratoryStanford Health CarePalo AltoCAUSA
| | - Christopher Pfaffroth
- Department of Special Coagulation Clinical LaboratoryStanford Health CarePalo AltoCAUSA
| | - Trang Vu
- Department of Special Coagulation Clinical LaboratoryStanford Health CarePalo AltoCAUSA
| | - James L. Zehnder
- Department of PathologyStanford University School of MedicineStanfordCAUSA
- Division of HematologyStanford University School of MedicineStanfordCAUSA
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16
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Siriez R, Dogné JM, Gosselin R, Laloy J, Mullier F, Douxfils J. Comprehensive review of the impact of direct oral anticoagulants on thrombophilia diagnostic tests: Practical recommendations for the laboratory. Int J Lab Hematol 2020; 43:7-20. [PMID: 32946681 DOI: 10.1111/ijlh.13342] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 12/28/2022]
Abstract
There is a laboratory and clinical need to know the impact of direct oral anticoagulants (DOACs) on diagnostic tests to avoid misinterpretation of results. Although the regulatory labelling documents provide some information about the influences of each DOAC on diagnostic tests, these are usually limited to some of the most common tests and no head to head comparison is available. In this paper, we report the impact of DOACs on several thrombophilia tests, including assessment of antithrombin, protein S and protein C activity assays, detection of activated protein C resistance and assays used for lupus anticoagulant. Results are compared and discussed with data obtained from literature. The final goal of this comprehensive review is to provide practical recommendations for laboratories to avoid misdiagnosis due to oral direct factor Xa (FXa) or IIa (FIIa) inhibitors. Overall, oral direct FXa (apixaban, betrixaban, edoxaban and rivaroxaban) and FIIa (dabigatran) antagonists may affect clot-based thrombophilia diagnostic tests resulting in false-positive or false-negative results. An effect on FIIa-based thrombophilia diagnostic tests is observed with dabigatran but not with anti-FXa DOACs and conversely for FXa-based thrombophilia diagnostic tests. No impact was observed with antigenic/chromogenic methods for the assessment of protein S and C activity. In conclusion, interpretation of thrombophilia diagnostic tests results should be done with caution in patients on DOACs. The use of a device/chemical compound able to remove or antagonize the effect of DOACs or the development of new diagnostic tests insensitive to DOACs should be considered to minimize the risk of false results.
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Affiliation(s)
- Romain Siriez
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Robert Gosselin
- Thrombosis and Hemostasis Center, Davis Health System, University of California, Sacramento, California
| | - Julie Laloy
- Department of Pharmacy, Namur Nanosafety Center (NNC),, Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - François Mullier
- Laboratory Hematology, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), CHU UCL Namur, Université catholique de Louvain, Namur, Belgium
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium.,Qualiblood s.a, Namur, Belgium
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17
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Moore GW. Alternative assays to dRVVT and aPTT for lupus anticoagulant detection. Am J Hematol 2020; 95:992-998. [PMID: 32311119 DOI: 10.1002/ajh.25836] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 04/13/2020] [Indexed: 01/15/2023]
Abstract
Lupus anticoagulants (LA) are heterogeneous antibodies and no single assay will detect every LA. Consequently, testing is commonly undertaken with both dilute Russell's viper venom time (dRVVT) and LA-responsive activated partial thromboplastin time (aPTT) to maximize detection rates. Although a huge body of evidence attests to the diagnostic utility of these assays, they have limitations that can render them unreliable in certain circumstances. Other assays are available for detecting LA but unfamiliarity, variable availability and technical concerns expressed in guidelines contribute to less usage than dRVVT and aPTT. However, assays such as Taipan snake venom time and Textarin time are insensitive to anticoagulants that compromise dRVVT and aPTT, and assays such as dilute prothrombin time can detect LA unreactive in dRVVT and aPTT. The pros and cons of alternative assays to dRVVT and APTT for LA detection are discussed.
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Affiliation(s)
- Gary W. Moore
- Specialist Haemostasis UnitAddenbrooke's Hospital Cambridge UK
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18
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Hillarp A, Strandberg K, Gustafsson KM, Lindahl TL. Unveiling the complex effects of direct oral anticoagulants on dilute Russell's viper venom time assays. J Thromb Haemost 2020; 18:1866-1873. [PMID: 32294291 DOI: 10.1111/jth.14829] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 04/02/2020] [Accepted: 04/02/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Dilute Russell viper venom time (dRVVT) assays can be affected by direct oral anticoagulants (DOACs), which may cause false-positive results. However, there are conflicting results indicating significant differences between different reagents and DOACs. OBJECTIVES To evaluate the effect of DOACs on dRVVT assays. MATERIAL AND METHODS Samples were prepared by adding DOAC (dabigatran, rivaroxaban, apixaban, or edoxaban) to pooled normal plasma in the concentration range 0 to 800 µg/L. Six integrated dRVVT reagents were used, all composed of a screen assay (low phospholipid content) and a confirm assay (high phospholipid content). The screen/confirm dRVVT results were expressed as normalized ratios. To further evaluate the observed differences between tests and DOACs, addition of synthetic phospholipids was used. RESULTS The dRVVT ratios increased dose dependently for all DOACs, with four of the six tests and the DOAC rivaroxaban having the greatest effect. With one test, the ratios were almost unaffected with increasing DOAC concentration, whereas another test revealed a negative dose dependency for all DOACs. Variable DOAC effects can be explained by different effects on dRVVT screen and confirm clotting time. Adding synthetic phospholipids to samples containing rivaroxaban resulted in greatly reduced screen clotting times and thereby lower calculated dRVVT ratios. CONCLUSIONS There is a great variability in the dRVVT test result with different DOACs. The dRVVT ratios are unaffected for some reagents and this can be explained by an equal dose-dependent effect on both screen and confirm assays. The phospholipid type and content of the different reagents may contribute to the observed differences.
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Affiliation(s)
- Andreas Hillarp
- Department of Clinical Chemistry and Transfusion Medicine, Halland County Hospital, Halmstad, Sweden
| | - Karin Strandberg
- Clinical Chemistry, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | - Kerstin M Gustafsson
- Department of Biomedical and Clinical Sciences, Clinical Chemistry, Linköping University, Linköping, Sweden
| | - Tomas L Lindahl
- Department of Biomedical and Clinical Sciences, Clinical Chemistry, Linköping University, Linköping, Sweden
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19
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Functional lupus anticoagulant testing in a large retrospective cohort of thrombosis patients with direct oral anticoagulants. Sci Rep 2020; 10:12221. [PMID: 32699227 PMCID: PMC7376154 DOI: 10.1038/s41598-020-69199-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 07/08/2020] [Indexed: 01/05/2023] Open
Abstract
Functional tests for lupus anticoagulants (LA) as part of a thrombophilia workup are commonly performed in patients under anticoagulant therapy that may interfere with assay results. There is no consensus on how these tests should be assessed in patients on direct oral anticoagulants (DOACs). In this retrospective cohort study, we analysed data from patients with a history of thrombosis in whom dilute Russell viper venom time (dRVVT), LA-sensitive aPTT, and solid phase assays for antiphospholipid antibodies (aPL) were performed (n = 3,147, thereof 588 on rivaroxaban, 144 on apixaban, 1,179 on other anticoagulant drugs). The dRVVT ratio was correlated with rivaroxaban (r = 0.30, P < 10-4) but not with apixaban plasma levels. The LA-sensitive aPTT/aPTT ratio showed no correlation with DOAC levels. Correspondingly, the rate of patients with abnormal dRVVT test was significantly higher (P < 10-4) under rivaroxaban (88%) than in thrombosis patients without anticoagulant medication (6%), independent from their aPL plasma levels. No isolated positive results of functional LA testing in patients on anticoagulants could be confirmed in repeated testing after discontinuation of the medication (n = 40). These data indicate that rivaroxaban should be discontinued before functional LA testing is performed. However, viable interpretation of these tests appears to be less affected in patients on apixaban.
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20
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Tripodi A, Cohen H, Devreese KMJ. Lupus anticoagulant detection in anticoagulated patients. Guidance from the Scientific and Standardization Committee for lupus anticoagulant/antiphospholipid antibodies of the International Society on Thrombosis and Haemostasis. J Thromb Haemost 2020; 18:1569-1575. [PMID: 32619349 DOI: 10.1111/jth.14846] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 03/16/2020] [Accepted: 04/10/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND The laboratory detection of lupus anticoagulants (LA) in anticoagulated patients represents a challenge and there is no consensus on the types of assays/procedures to be adopted. OBJECTIVES This communication of the International Society on Thrombosis and Haemostasis (ISTH), Scientific and Standardization Committee (SSC) aims to give guidance on the procedures to be adopted. METHODS Members of the ISTH-SSC on Lupus Anticoagulant/Antiphospholipid Antibodies reviewed the literature to search for evidence on the most appropriate assays/procedures to be adopted. RESULTS Anticoagulants are able to interfere with the tests used for LA detection, giving rise to occasional false-positive or false-negative LA. Some commercial tests include in their composition heparin-neutralizers able to quench unfractionated or low molecular weight heparin up to 1.0 U/mL. LA tests are less affected by low molecular weight heparin, but caution is needed in the interpretation of results. Vitamin K antagonists (VKAs) may affect LA detection. Dilution of test plasma into pooled normal plasma is not a reliable solution as false-negative or false-positive LA may occur. Direct oral anticoagulants (DOACs) affect LA detection. Hence, it is not recommended to attempt LA detection in those patients. The use of DOAC adsorbents is a promising solution and should be further investigated on LA-positive and LA-negative patient populations. Taipan/Ecarin tests may be a solution for VKAs and anti-FXa DOACs, but independent evidence on their value and standardized kits is needed. CONCLUSIONS LA detection during anticoagulation remains a challenge, especially for VKAs. DOAC removal by in vitro addition to plasma of appropriate absorbents is promising.
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Affiliation(s)
- Armando Tripodi
- Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center and Fondazione Luigi Villa, Milano, Italy
| | - Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Katrien M J Devreese
- Coagulation Laboratory, Department of Diagnostic Sciences, Ghent University Hospital, Ghent, Belgium
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21
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Balbi GGM, Pacheco MDS, Monticielo OA, Funke A, Danowski A, Santiago MB, Staub HL, Rêgo J, de Andrade DCO. Antiphospholipid Syndrome Committee of the Brazilian Society of Rheumatology position statement on the use of direct oral anticoagulants (DOACs) in antiphospholipid syndrome (APS). Adv Rheumatol 2020; 60:29. [PMID: 32460902 DOI: 10.1186/s42358-020-00125-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 04/08/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The term Direct Oral Anticoagulants (DOACs) refers to a group of drugs that inhibit factor Xa or thrombin. Even though their use for treating different thrombotic or prothrombotic conditions is increasing recently, there is no compelling evidence indicating that those medications are safe in all antiphospholipid syndrome (APS) patients. METHODOLOGY To address this issue, specialists from the Antiphospholipid Syndrome Committee of the Brazilian Society of Rheumatology performed a comprehensive review of the literature regarding DOACs use in APS to answer the three following questions: (1) potential mechanisms of action of these drugs that could be relevant to APS pathogenesis, (2) DOACs interference on lupus anticoagulant testing, and (3) the efficacy of DOACs in APS. POSITION STATEMENT After critically reviewing the relevant evidence, the authors formulated 8 Position Statements about DOACs use in APS. CONCLUSION DOACs should not be routinely used in APS patients, especially in those with a high-risk profile (triple positivity to aPL, arterial thrombosis, and recurrent thrombotic events). In addition, DOACs interferes with LA testing, leading to false-positive results in patients investigating APS.
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Affiliation(s)
- Gustavo Guimarães Moreira Balbi
- Serviço de Reumatologia, Hospital Universitário, Universidade Federal de Juiz de Fora (UFJF), Av. Eugênio do Nascimento, s/n - Dom Bosco, Juiz de Fora, MG, 36038-330, Brazil.
| | - Marcelo de Souza Pacheco
- Serviço de Reumatologia, Hospital Federal dos Servidores do Estado (HFSE), Rio de Janeiro, RJ, Brazil
| | - Odirlei Andre Monticielo
- Serviço de Reumatologia, Departamento de Medicina Interna, Hospital de Clínicas de Porto Alegre (HCPA), Universidade Federal do Rio Grande do Sul (UFGRS), Porto Alegre, RS, Brazil
| | - Andreas Funke
- Serviço de Reumatologia, Hospital de Clínicas, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil
| | - Adriana Danowski
- Serviço de Reumatologia, Hospital Federal dos Servidores do Estado (HFSE), Rio de Janeiro, RJ, Brazil
| | - Mittermayer Barreto Santiago
- Serviço de Reumatologia, Universidade Federal da Bahia (HUPES) e Escola Baiana de Medicina e Saúde Pública, Salvador, BA, Brazil
| | - Henrique Luiz Staub
- Serviço de Reumatologia, Escola de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, RS, Brazil
| | - Jozelia Rêgo
- Serviço de Reumatologia, Faculdade de Medicina, Universidade Federal de Goiás (UFG), Goiânia, GO, Brazil
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22
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Booth S, Burton K, Hunt B, Desborough M. Antiphospholipid syndrome and challenges with direct oral anticoagulants. Br J Hosp Med (Lond) 2020; 81:1-11. [PMID: 32468937 DOI: 10.12968/hmed.2020.0080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Direct oral anticoagulants have become the mainstay of the management of venous thromboembolism and atrial fibrillation, and long-term anticoagulation is indicated for those at high risk of further thrombotic events. This includes patients diagnosed with antiphospholipid syndrome, for whom the 'triple positive' laboratory combination of lupus anticoagulant, β2-glycoprotein-1 and anti-cardiolipin antibodies signify those at greatest risk. Data from meta-analysis and randomised control trials have raised the concern that direct oral anticoagulants may be less effective than vitamin K antagonists for the prevention of thrombosis in patients with thrombotic antiphospholipid syndrome, particularly those with the triple positive profile. This article reviews the diagnosis of thrombotic antiphospholipid syndrome, strategies for testing without interruption of anticoagulation, evidence concerning the safety of direct oral anticoagulants in this setting, and the implications for current investigation and management of unprovoked venous thromboembolism.
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Affiliation(s)
- Stephen Booth
- Department of Oncology, University of Oxford, Oxford, UK
| | - Kieran Burton
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Beverley Hunt
- Haemophilia and Thrombosis Centre, St Thomas' Hospital, London, UK
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23
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Arachchillage DRJ, Laffan M. What is the appropriate anticoagulation strategy for thrombotic antiphospholipid syndrome? Br J Haematol 2020; 189:216-227. [PMID: 32108324 DOI: 10.1111/bjh.16431] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 10/22/2019] [Indexed: 12/18/2022]
Abstract
Antiphospholipid syndrome (APS) is an autoimmune prothrombotic disorder mediated by a heterogeneous group of autoantibodies collectively known as antiphospholipid antibodies (aPL). They include lupus anticoagulant (LA), IgG and IgM anticardiolipin antibodies (aCL) and anti-β2-glycoprotein I (anti-β2GPI) antibodies. It has been shown that those patients with all three aPL (triple positive) are at highest risk of both a first thrombotic event and of a recurrence, despite anticoagulation. In response to publication of a meta-analysis and a randomised controlled trial assessing the safety and efficacy of rivaroxaban versus warfarin in triple-positive APS with venous and/or arterial thrombosis, the Medicines and Healthcare Products Regulatory Agency (MHRA) and European Medicines Agency (EMA) issued recommendations that direct-acting oral anticoagulant (DOACs) should not be used for secondary prevention of thrombosis in all APS patients (although they did draw specific attention to the high risk of triple-positive patients). As there is less evidence for patients with single- or dual-positive patients with APS, this may be an over-interpretation of the data. In this review, we explore the available evidence on safety and efficacy of DOACs in thrombotic APS, the problem of detecting LA while on DOAC, and provide some practical guidance for managing this problem.
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Affiliation(s)
- Deepa R J Arachchillage
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK.,Centre for Haematology, Department of Inflammation and Immunology, Imperial College London, London, UK.,Department of Haematology, Royal Brompton Hospital, London, UK
| | - Mike Laffan
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK.,Centre for Haematology, Department of Inflammation and Immunology, Imperial College London, London, UK
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24
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Arachchillage DRJ, Gomez K, Alikhan R, Anderson JAM, Lester W, Laffan M. Addendum to British Society for Haematology Guidelines on Investigation and Management of Antiphospholipid syndrome, 2012 (
Br. J.
Haematol
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2012; 157: 47–58): use of direct acting oral anticoagulants. Br J Haematol 2020; 189:212-215. [DOI: 10.1111/bjh.16308] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/26/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Deepa R. J. Arachchillage
- Department of Haematology Imperial College Healthcare NHS Trust London UK
- Centre for Haematology Imperial College London London UK
| | - Keith Gomez
- Katherine Dormandy Haemophilia Centre and Thrombosis Unit Royal Free London NHS Foundation Trust London UK
| | - Raza Alikhan
- Haemophilia and Thrombosis Centre University Hospital of Wales Cardiff UK
| | | | - Will Lester
- Centre for Clinical Haematology University Hospitals Birmingham NHS Foundation Trust Birmingham UK
| | - Mike Laffan
- Department of Haematology Imperial College Healthcare NHS Trust London UK
- Centre for Haematology Imperial College London London UK
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25
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Vivero A, Kitahara S, Runge A, Volod O. Consultative Interpretation for Lupus Anticoagulant by Expert Pathologist Reduces False-Positive Rates in the Era of Direct Oral Anticoagulants. J Appl Lab Med 2020; 5:73-82. [PMID: 31811080 DOI: 10.1373/jalm.2019.029835] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 06/26/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND The diagnosis of antiphospholipid syndrome requires detection of antiphospholipid antibodies (aPL). A retrospective review of our testing practices revealed that societal recommendations for lupus anticoagulant (LA) testing as part of aPL testing are largely not followed by clinicians, and there was a high proportion of positive LA results. Increasing direct oral anticoagulant (DOAC) usage creates additional challenges in identifying LA. This prompted us to establish an order set with pathologist consultation ("LA panel") and testing algorithm to reduce false-positive LA and to ensure optimal LA identification and best practices for interpretation and follow-up. METHODS The laboratory database was reviewed to determine the number of LA tests ordered and rate of LA positivity before and after the LA panel was instituted. We assessed the impact of pathologist consultation to minimize false-positive findings and on following diagnostic guidelines. RESULTS LA panels were ordered for 1146 patients. LA was detected in 10% (111 of 1146) by dilute Russel viper venom time (dRVVT) normalized ratio [includes dRVVT screen (dRVVTs) positive/lupus-sensitive partial thromboplastin time (PTT-LA) positive and dRVVTs positive/PTT-LA negative] and 20% (228 of 1146) by Staclot-LA (includes dRVVTs negative/PTT-LA positive and dRVVTs positive/confirm negative). There was a reduction of false-positive LA by Staclot-LA; previously, 48% positive. We saw increased cancellation of LA testing for interfering anticoagulants [6.8% (16 of 236) vs 14.4% (55 of 383); P = 0.0061]. There was also increased adherence to follow-up LA testing [3% (8 of 236) vs 13.8% (53 of 383); P ≤ 0.001]. CONCLUSIONS Creating a predetermined order set and testing algorithm with pathologist consultation improved LA testing interpretation and diagnostic follow-up testing.
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Affiliation(s)
- Angelica Vivero
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Sumire Kitahara
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Alice Runge
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Oksana Volod
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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26
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Comparison of the Therapeutic Effects of Rivaroxaban Versus Warfarin in Antiphospholipid Syndrome: A Systematic Review. Arch Rheumatol 2019; 35:107-116. [PMID: 32637926 DOI: 10.5606/archrheumatol.2020.7375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 05/13/2019] [Indexed: 11/21/2022] Open
Abstract
Objectives This study aims to review the studies evaluating the therapeutic effects of rivaroxaban versus those of warfarin in patients with antiphospholipid syndrome (APS). Materials and methods The study included randomized clinical trials, comparative studies, cross-sectional investigations, and case series that focused on the effects of warfarin and rivaroxaban and compared the effects of these anticoagulants in patients with APS. The relevant articles published until 2018 were searched in several databases, including PubMed, Scopus, ScienceDirect, Google Scholar, Embase, and Web of Science. Results The findings of the reviewed studies showed that rivaroxaban can be used as an effective and safe alternative to warfarin in APS patients. However, the effectiveness of rivaroxaban in the prevention of thrombosis in high-risk APS patients is suspected. Conclusion Given the high risk of using rivaroxaban in thrombotic APS patients with labile international normalized ratio (INR) or poor adherence to INR monitoring, it is not suggested to use this agent for these patients.
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Efthymiou M, Mackie IJ, Lane PJ, Andrade D, Willis R, Erkan D, Sciascia S, Krillis S, Bison E, Borges Galhardo Vendramini M, Romay-Penabad Z, Qi M, Tektonidou M, Ugarte A, Chighizola C, Belmont HM, Aguirre MA, Ji L, Branch DW, de Jesus G, Fortin PR, Andreoli L, Petri M, Cervera R, Rodriguez E, Knight JS, Atsumi T, Vega J, Sevim E, Bertolaccini ML, Pengo V, Cohen H. Comparison of real world and core laboratory lupus anticoagulant results from the Antiphospholipid Syndrome Alliance for Clinical Trials and International Networking (APS ACTION) clinical database and repository. J Thromb Haemost 2019; 17:2069-2080. [PMID: 31364274 DOI: 10.1111/jth.14596] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Accepted: 07/25/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Variability remains a challenge in lupus anticoagulant (LA) testing. OBJECTIVE To validate LA test performance between Antiphospholipid Syndrome Alliance for Clinical Trials and International Networking (APS ACTION) Core laboratories and examine agreement in LA status between Core and local/hospital laboratories contributing patients to this prospective registry. METHODS Five Core laboratories used the same reagents, analyzer type, protocols, and characterized samples for LA validation. Non-anticoagulated registry samples were retested at the corresponding regional Core laboratories and anticoagulated samples at a single Core laboratory. Categorical agreement and discrepancies in LA status between Core and local/hospital laboratories were analyzed. RESULTS Clotting times for the reference/characterized plasmas used for normalized ratios were similar between Core laboratories (CV <4%); precision and agreement for LA positive/negative plasma were similar (all CV ≤5%) in the four laboratories that completed both parts of the validation exercise; 418 registry samples underwent LA testing. Agreement for LA positive/negative status between Core and local/hospital laboratories was observed in 87% (115/132) non-anticoagulated and 77% (183/237) anticoagulated samples. However, 28.7% (120/418) of samples showed discordance between the Core and local/hospital laboratories or equivocal LA results. Some of the results of the local/hospital laboratories might have been unreliable in 24.7% (41/166) and 23% (58/252) of the total non-anticoagulated and anticoagulated samples, respectively. Equivocal results by the Core laboratory might have also contributed to discordance. CONCLUSIONS Laboratories can achieve good agreement in LA performance by use of the same reagents, analyzer type, and protocols. The standardized Core laboratory results underpin accurate interpretation of APS ACTION clinical data.
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Affiliation(s)
- Maria Efthymiou
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Ian J Mackie
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Philip J Lane
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | | | - Rohan Willis
- Antiphospholipid Standardization Laboratory, University of Texas Medical Branch, Galveston, TX, USA
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases, University of Turin, Turin, Italy
| | - Steven Krillis
- Department of Infectious Diseases, Immunology and Sexual Health, St George Hospital, Sydney, NSW, Australia
| | | | | | - Zurina Romay-Penabad
- Antiphospholipid Standardization Laboratory, University of Texas Medical Branch, Galveston, TX, USA
| | - Miao Qi
- Department of Infectious Diseases, Immunology and Sexual Health, St George Hospital, Sydney, NSW, Australia
| | | | - Amaia Ugarte
- Internal Medicine, Hospital Universitario Cruces, Barakaldo, País Vasco, Spain
| | | | | | | | - Lanlan Ji
- Rheumatology and Immunology Department, Peking University First Hospital, Beijing, China
| | - D Ware Branch
- University of Utah and Intermountain Healthcare, Salt Lake City, UT, USA
| | | | - Paul R Fortin
- CHU de Quebec - Université Laval, Quebec, QC, Canada
| | - Laura Andreoli
- Rheumatology and Clinical Immunology, Spedali Civili, Brescia, Italy
- Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Michelle Petri
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ricard Cervera
- Department of Autoimmune Diseases, Hospital Clínic Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | | | - Jason S Knight
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | | | - Joann Vega
- University Hospital Padova, Padova, Italy
| | - Ecem Sevim
- University Hospital Padova, Padova, Italy
| | - Maria Laura Bertolaccini
- Academic Department of Vascular Surgery, School of Cardiovascular Medicine & Sciences, King's College London, London, UK
| | - Vittorio Pengo
- Department of Infectious Diseases, Immunology and Sexual Health, St George Hospital, Sydney, NSW, Australia
| | - Hannah Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
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Ząbczyk M, Kopytek M, Natorska J, Undas A. The effect of DOAC-Stop on lupus anticoagulant testing in plasma samples of venous thromboembolism patients receiving direct oral anticoagulants. ACTA ACUST UNITED AC 2019; 57:1374-1381. [DOI: 10.1515/cclm-2018-1197] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 01/07/2019] [Indexed: 01/01/2023]
Abstract
Abstract
Background
Direct oral anticoagulants (DOACs) cause false positive lupus anticoagulant (LA) results. We assessed the impact of DOAC-Stop, reversing in vitro effects of DOACs, on LA testing in anticoagulated patients.
Methods
We assessed 75 venous thromboembolism patients aged 44.5±14.6 years. Blood samples were collected 2–28 h since intake of DOACs, including 50 patients on rivaroxaban, 20 on dabigatran and five on apixaban. LA testing was performed at baseline and after DOAC-Stop treatment. Positive LA was defined as the normalized (patient/standard plasma clotting time) LA screening and screening (LA1)/confirmation (LA2) ratios exceeding 1.2.
Results
LA diluted Russell’s viper venom time (dRVVT) normalized screening test revealed abnormal results in 73 (97.3%) and activated partial thromboplastin time (APTT)-LA in 49 (65.3%) patients. In six (8%) patients, antiphospholipid syndrome (APS) was diagnosed. dRVVT LA1/LA2 was abnormal in 35 (50.7%) patients taking DOACs. The APTT ratio was normal in all studied subjects. DOAC-Stop completely removed dabigatran and reduced by 98% rivaroxaban and by 92.3% apixaban concentrations (all p<0.05). After DOAC-Stop screening dRVVT remained prolonged in 34 (49.3%) patients (p<0.001), while dRVVT LA1/LA2 was abnormal in six (8.7%) subjects, with no association with DOAC concentrations at baseline and after DOAC-Stop. The APTT-LA screening test remained prolonged in five (7.2%) patients, while the APTT LA1/LA2 ratio was normal in those subjects. DOAC-Stop did not influence LA testing in APS patients.
Conclusions
Application of DOAC-Stop effectively reduced plasma DOAC concentrations leading to appropriate dRVVT results in up to 97% of VTE patients.
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Celińska-Löwenhoff M, Zabczyk M, Iwaniec T, Plens K, Musiał J, Undas A. Reduced plasma fibrin clot permeability is associated with recurrent thromboembolic events in patients with antiphospholipid syndrome. Rheumatology (Oxford) 2018; 57:1340-1349. [DOI: 10.1093/rheumatology/key089] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
| | - Michal Zabczyk
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Teresa Iwaniec
- Department of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Krzysztof Plens
- Data Analysis Center, Krakow Cardiovascular Research Institute, Krakow, Poland
| | - Jacek Musiał
- Department of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Anetta Undas
- Department of Medicine, Jagiellonian University Medical College, Krakow, Poland
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
- John Paul II Hospital, Center for Research and Medical Technologies, Krakow, Poland
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30
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Cohen H, Efthymiou M, Isenberg DA. Use of direct oral anticoagulants in antiphospholipid syndrome. J Thromb Haemost 2018; 16:1028-1039. [PMID: 29624847 DOI: 10.1111/jth.14017] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Indexed: 12/20/2022]
Abstract
The direct oral anticoagulants (DOACs) are therapeutic alternatives to warfarin and other vitamin K antagonists (VKAs), and constitute the standard of care for many indications. VKAs constitute the conventional therapy for the treatment and secondary thromboprophylaxis of thrombotic antiphospholipid syndrome (APS), but are often problematic, owing to the variable sensitivity of thromboplastins to lupus anticoagulant. Thus, the International Normalized Ratio may not accurately reflect anticoagulation intensity, or be clinically effective. Definition of the current role of DOACs in the treatment of APS is based on limited clinical trial data and information from other sources, including manufacturers' data, case series or cohort studies, and expert consensus. The Rivaroxaban in Antiphospholipid Syndrome (RAPS) randomized controlled trial (RCT), which had a laboratory surrogate primary outcome measure, suggests that rivaroxaban has the potential to be an effective and convenient alternative to warfarin in thrombotic APS patients with a single venous thromboembolism event requiring standard-intensity anticoagulation. However, further studies, in particular to provide better long-term efficacy and safety data, are needed before it can be widely recommended. APS patients are clinically heterogeneous, with the risk of recurrent thrombosis and the intensity of anticoagulation being influenced by their clinical phenotype and risk profile. DOAC trials involving homogeneous thrombotic APS populations, with the antiphospholipid antibody status well defined, will help to optimize the appropriate treatment in APS patient subgroups. Ongoing and emerging DOAC RCTs should provide further information to guide the use of DOACs in APS patients. Optimal identification of APS patients is a key step in working towards improved therapeutic strategies in these individuals.
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Affiliation(s)
- H Cohen
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK
| | - M Efthymiou
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - D A Isenberg
- Centre for Rheumatology, Division of Medicine, University College London, London, UK
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
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31
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Favresse J, Lardinois B, Sabor L, Devalet B, Vandepapeliere J, Braibant M, Lessire S, Chatelain B, Jacqmin H, Douxfils J, Mullier F. Evaluation of the DOAC-Stop® Procedure to Overcome the Effect of DOACs on Several Thrombophilia Screening Tests. TH OPEN 2018; 2:e202-e209. [PMID: 31249943 PMCID: PMC6524876 DOI: 10.1055/s-0038-1657785] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/21/2018] [Indexed: 11/04/2022] Open
Abstract
The impact of direct oral anticoagulants (DOACs) on laboratory assays used for thrombophilia testing (e.g., antithrombin, protein S, protein C, lupus anticoagulant and activated protein-C resistance) is a well-known issue and may cause false-positive and -negative results. Therefore, the correct interpretation of tests that are performed in patients taking DOACs is mandatory to prevent misclassification and the subsequent clinical consequences. We aimed at evaluating the efficiency of a new and simple procedure (DOAC-Stop®; Haematex Research, Hornsby, Australia) to overcome the effect of all DOACs in real-life settings and to assess the percentage of erroneous results due to the presence of DOACs on thrombophilia screening tests. For this purpose, 135 DOAC-treated patients (38 apixaban, 40 dabigatran, 15 edoxaban, and 42 rivaroxaban) and 20 control patients were enrolled. A significant drop in apixaban, dabigatran, edoxaban, and rivaroxaban plasma concentrations following the DOAC-Stop® treatment was observed (74.8–8.2 ng/mL [
p
< 0.0001], 95.9–4.7 ng/mL [
p
< 0.0001], 102.1–8.8 ng/mL [
p
= 0.001], and 111.3–7.0 ng/mL [
p
< 0.0001], respectively). The DOAC-Stop® treatment was mostly effective to overcome the effect of DOACs on PTT-LA, dilute Russell's viper venom time (dRVVT) screen, and dRVVT confirm tests. Using our procedures, false-positive results due to DOACs were observed only with lupus anticoagulant tests (up to 75%) and fell to zero after the DOAC-Stop® procedure, regardless of the DOAC considered. In conclusion, the DOAC-Stop® adsorbent procedure appeared to be an effective and simple way to overcome the interference of DOAC on coagulation tests and should facilitate the interpretation of thrombophilia screening tests in patients taking DOACs.
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Affiliation(s)
- Julien Favresse
- Université Catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Namur Thrombosis and Hemostasis Center, NARILIS, Yvoir, Belgium
| | - Benjamin Lardinois
- Université Catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Namur Thrombosis and Hemostasis Center, NARILIS, Yvoir, Belgium
| | - Lina Sabor
- Université Catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Namur Thrombosis and Hemostasis Center, NARILIS, Yvoir, Belgium
| | - Bérangère Devalet
- Department of Hematology, CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - Julie Vandepapeliere
- Department of Hematology, CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - Maximilien Braibant
- Department of Pharmacy, CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - Sarah Lessire
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - Bernard Chatelain
- Université Catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Namur Thrombosis and Hemostasis Center, NARILIS, Yvoir, Belgium
| | - Hugues Jacqmin
- Université Catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Namur Thrombosis and Hemostasis Center, NARILIS, Yvoir, Belgium
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Université de Namur, Yvoir, Belgium.,QUALIblood SA, Namur, Belgium
| | - François Mullier
- Université Catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Namur Thrombosis and Hemostasis Center, NARILIS, Yvoir, Belgium
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32
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Martinuzzo ME, Forastiero R, Duboscq C, Barrera LH, López MS, Ceresetto J, Penchasky D, Oyhamburu J. False-positive lupus anticoagulant results by DRVVT in the presence of rivaroxaban even at low plasma concentrations. Int J Lab Hematol 2018; 40:e99-e101. [DOI: 10.1111/ijlh.12865] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- M. E. Martinuzzo
- Laboratorio Central; Hospital Italiano de Buenos Aires; CABA Argentina
- Instituto Universitario del Hospital Italiano; Buenos Aires, CABA Argentina
| | | | - C. Duboscq
- Servicio de Hematología del Hospital Británico; Buenos Aires, CABA Argentina
| | - L. H. Barrera
- Laboratorio Central; Hospital Italiano de Buenos Aires; CABA Argentina
- Instituto Universitario del Hospital Italiano; Buenos Aires, CABA Argentina
| | - M. S. López
- Laboratorio Central; Hospital Italiano de Buenos Aires; CABA Argentina
- Instituto Universitario del Hospital Italiano; Buenos Aires, CABA Argentina
| | - J. Ceresetto
- Servicio de Hematología del Hospital Británico; Buenos Aires, CABA Argentina
| | - D. Penchasky
- Servicio de Hematología del Hospital Italiano de Buenos Aires; Ciudad Autónoma de Buenos Aires Argentina
| | - J. Oyhamburu
- Laboratorio Central; Hospital Italiano de Buenos Aires; CABA Argentina
- Instituto Universitario del Hospital Italiano; Buenos Aires, CABA Argentina
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33
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Interference of DOACs in different DRVVT assays for diagnosis of lupus anticoagulants. Thromb Res 2018; 165:101-106. [DOI: 10.1016/j.thromres.2018.03.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 02/15/2018] [Accepted: 03/12/2018] [Indexed: 11/22/2022]
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34
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Ratzinger F, Lang M, Belik S, Jilma-Stohlawetz P, Schmetterer KG, Haslacher H, Perkmann T, Quehenberger P. Lupus-anticoagulant testing at NOAC trough levels. Thromb Haemost 2018; 116:235-40. [DOI: 10.1160/th16-02-0081] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 03/31/2016] [Indexed: 01/17/2023]
Abstract
SummaryNon-vitamin K antagonist oral anticoagulants (NOAC), including rivaroxaban, apixaban or dabigatran, regularly show relevant effects on coagulation tests, making the interpretation of results difficult. The aim of this study was to evaluate possible interferences of NOACs in trough level concentrations in lupus anticoagulant (LA) testing. Citrate plasma specimens of 30 healthy volunteers were spiked with rivaroxaban, apixaban or dabigatran in four plasma concentration levels at or below trough NOAC levels. The NOAC concentration was measured using dedicated surrogate concentration tests and a stepwise diagnostic procedure for LA-testing was applied using screening, mixing and confirmatory testing. Results were compared to NOAC-free specimens. Starting with a plasma concentration of 12.5 ng/ml, dabigatran-spiked specimens showed significant prolongations in the lupus anticoagulant-sensitive activated partial thromboplastin time (aPTT-LA) as well as in the Dilute Russell viper venom time (dRVVT), leading to 43.3% false positives in confirmatory testing in the dRVVT. In contrast, rivaroxaban, beginning with 7.5 ng/ml, exclusively affected dRVVT-based tests. In confirmatory tests, 30.0% of rivaroxaban-spiked specimens showed false positive results. Starting with 18.75 ng/ml apixaban, a significant prolongation of the dRVVT and up to 20.7% false positives in confirmatory tests were found. In contrast to other NOACs tested, apixaban did not present with a dose-dependent increase of the dRVVT ratio. In conclusion, the rate of false positive results in LA-testing is unacceptably high at expected trough levels of NOACs. Even at plasma concentrations below the LLOQ of commercially available surrogate tests, LA testing is best avoided in patients with NOAC therapy.
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Cohen H, Hunt BJ, Efthymiou M, Arachchillage DRJ, Mackie IJ, Clawson S, Sylvestre Y, Machin SJ, Bertolaccini ML, Ruiz-Castellano M, Muirhead N, Doré CJ, Khamashta M, Isenberg DA. Rivaroxaban versus warfarin to treat patients with thrombotic antiphospholipid syndrome, with or without systemic lupus erythematosus (RAPS): a randomised, controlled, open-label, phase 2/3, non-inferiority trial. LANCET HAEMATOLOGY 2018; 3:e426-36. [PMID: 27570089 PMCID: PMC5010562 DOI: 10.1016/s2352-3026(16)30079-5] [Citation(s) in RCA: 278] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Revised: 07/01/2016] [Accepted: 07/04/2016] [Indexed: 12/27/2022]
Abstract
Background Rivaroxaban is established for the treatment and secondary prevention of venous thromboembolism, but whether it is useful in patients with antiphospholipid syndrome is uncertain. Methods This randomised, controlled, open-label, phase 2/3, non-inferiority trial, done in two UK hospitals, included patients with antiphospholipid syndrome who were taking warfarin for previous venous thromboembolism, with a target international normalised ratio of 2·5. Patients were randomly assigned 1:1 to continue with warfarin or receive 20 mg oral rivaroxaban daily. Randomisation was done centrally, stratified by centre and patient type (with vs without systemic lupus erythematosus). The primary outcome was percentage change in endogenous thrombin potential (ETP) from randomisation to day 42, with non-inferiority set at less than 20% difference from warfarin in mean percentage change. Analysis was by modified intention to treat. Other thrombin generation parameters, thrombosis, and bleeding were also assessed. Treatment effect was measured as the ratio of rivaroxaban to warfarin for thrombin generation. This trial is registered with the ISRCTN registry, number ISRCTN68222801. Findings Of 116 patients randomised between June 5, 2013, and Nov 11, 2014, 54 who received rivaroxaban and 56 who received warfarin were assessed. At day 42, ETP was higher in the rivaroxaban than in the warfarin group (geometric mean 1086 nmol/L per min, 95% CI 957–1233 vs 548, 484–621, treatment effect 2·0, 95% CI 1·7–2·4, p<0·0001). Peak thrombin generation was lower in the rivaroxaban group (56 nmol/L, 95% CI 47–66 vs 86 nmol/L, 72–102, treatment effect 0·6, 95% CI 0·5–0·8, p=0·0006). No thrombosis or major bleeding were seen. Serious adverse events occurred in four patients in each group. Interpretation ETP for rivaroxaban did not reach the non-inferiority threshold, but as there was no increase in thrombotic risk compared with standard-intensity warfarin, this drug could be an effective and safe alternative in patients with antiphospholipid syndrome and previous venous thromboembolism. Funding Arthritis Research UK, Comprehensive Clinical Trials Unit at UCL, LUPUS UK, Bayer, National Institute for Health Research Biomedical Research Centre.
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Affiliation(s)
- Hannah Cohen
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, UK; Haemostasis Research Unit, Department of Haematology, University College London, London, UK.
| | - Beverley J Hunt
- Department of Thrombosis and Haemophilia, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK; Department of Haematology, King's College London, London, UK
| | - Maria Efthymiou
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | | | - Ian J Mackie
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Simon Clawson
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Yvonne Sylvestre
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Samuel J Machin
- Haemostasis Research Unit, Department of Haematology, University College London, London, UK
| | - Maria L Bertolaccini
- Academic Department of Vascular Surgery, Cardiovascular Division, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Maria Ruiz-Castellano
- Lupus Research Unit, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Nicola Muirhead
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Caroline J Doré
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Munther Khamashta
- Lupus Research Unit, Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK; Lupus Research Unit, Division of Women's Health, King's College London, London, UK
| | - David A Isenberg
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK; Centre for Rheumatology, Division of Medicine, University College London, London, UK
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36
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Moore GW, Peyrafitte M, Dunois C, Amiral J. Newly developed dilute Russell's viper venom reagents for lupus anticoagulant detection with improved specificity. Lupus 2018; 27:95-104. [PMID: 28549386 DOI: 10.1177/0961203317711773] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2023]
Abstract
Background Dilute Russell's viper venom time (dRVVT) is indispensible in lupus anticoagulant (LA) detection yet commercial reagents from different suppliers perform variably, no gold standard assays exist and therapeutic anticoagulation interference is problematic. Objective The objective of this study was to compare a new formulation dRVVT with two currently available dRVVTs. Materials and methods Life Diagnostics (LD) dRVVT and Stago PTT-LA were routinely used for lupus anticoagulant detection, plus Taipan snake venom time/ecarin time (TSVT/ET) for patients on warfarin or rivaroxaban. Siemens dRVVT and the new HYPHEN BioMed (HBM) dRVVT were tested with 193 patient samples. Group 1, 59 non-anticoagulated patients (NAPs) LA-positive in LD dRVVT; Group 2, 15 PTT-LA-positive/dRVVT-negative NAPs; Group 3, 24 LA-positive warfarinized patients; Group 4, 13 patients on rivaroxaban; Group 5, 62 LA-negative thrombotic NAPs; Group 6, 20 warfarinized, non-antiphospholipid syndrome patients. Results Accepting that the Life Diagnostics reagents were acting as a pseudo-gold standard, Siemens dRVVT detected 56/59, (95%) Group 1 LA and HBM dRVVT 46/59, (76%), one each from Group 2, and Siemens dRVVT detected one in Group 5. The lower HBM dRVVT detection rate mainly concerned weaker LA, where between-reagent concordance is problematic. All Group 3 patients appeared LA-positive in undiluted plasma with Siemens dRVVT, as did 16/24 (67%) with HBM dRVVT but the fewer LA-positives in mixing tests better mapped to clear LA-positives with LD dRVVT. LD and Siemens dRVVTs exhibited 87% and 95% false-positivity for Group 6 whilst HBM dRVVT had none. Increasing the cut-off improved accuracy. Applying higher cut-offs improved accuracy in Group 4 patients. Conclusion HBM dRVVT exhibited improved specificity, mainly due to less interference by anticoagulation, but reduced sensitivity, compared to the other dRVVTs employed.
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Affiliation(s)
- G W Moore
- 1 Department of Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' Hospitals, London, UK
| | | | - C Dunois
- 2 HYPHEN BioMed, Neuville-sur-Oise, France
| | - J Amiral
- 2 HYPHEN BioMed, Neuville-sur-Oise, France
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37
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Amiral J, Peyrafitte M, Dunois C, Vissac AM, Seghatchian J. Anti-phospholipid syndrome: Current opinion on mechanisms involved, laboratory characterization and diagnostic aspects. Transfus Apher Sci 2017; 56:612-625. [PMID: 28803708 DOI: 10.1016/j.transci.2017.07.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Anti-phospholipid syndrome is a complex and severe clinical situation, associated with symptoms such as recurrent thrombosis, arterial or venous, at any site, pregnancy loss, and other related syndromes. These clinical burdens, are highly variable from patient to patient, and are associated with biological abnormalities, such as the presence of the Lupus Anticoagulant or phospholipid dependent antibodies, confirmed on two occasions at least 12 weeks apart. From the diagnosis standpoint, both, functional (clotting) or immunological assays, are difficult to standardize and to optimize, due to the absence of reference material, or a characteristic clinical group, and international reference preparations. Large cohort studies are necessary for defining the usefulness of each assay, in terms of specificity, sensitivity, accuracy and for following-up the disease evolution. Clotting assays are based on Activated Partial Thromboplastin Time (APTT) and diluted Russell Viper Venom Time (dRVVT), performed at low and high phospholipid concentration, or on 1:1 mixtures of tested sample and a normal plasma pool. They allow evaluation of the paradoxal effects of LAs, which are pro-thrombotic in vivo, and anticoagulant in vivo. Use of synthetic phospholipids improves assay specificities and sensitivities, especially in patients treated with anticoagulants. Immunoassays can also be used for testing phospholipid dependent antibodies, first identified and measured as anti-cardiolipin antibodies, but now characterized as targeted to phospholipid cofactor proteins: mainly β2GP1 (which exposes cryptic epitopes upon binding to phospholipids), and in some cases prothrombin, and more rarely Protein S, Factor XIII, Protein Z or Annexin V. Use of optimized assays designed with well-characterized anionic phospholipids, then complexed with highly purified phospholipid cofactor protein (mainly β2GP1), offers a better link between reactivity and clinical associations, than the former assays which were empirically designed with cardiolipin. Standardization also remains complicated due to the absence of international standards and harmonized quantitation units. Validation on large cohorts of negative and positive patients remains the key approach for defining assay performance and clinical usefulness. Laboratory practice for all these methods is now greatly facilitated thanks to the use of automated instruments and dedicated software. Along with clinical criteria, laboratory assays are of great usefulness for identification and confirmation of the anti-phospholipid syndrome and they allow disease follow-up when appropriate patient management is in place.
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Affiliation(s)
- Jean Amiral
- SH-Consulting, Andrésy, France; Scientific and Technical Advisor for Hyphen BioMed, Sysmex Group, Neuville-sur-Oise, France.
| | | | - Claire Dunois
- Clinical Studies Director, HYPHEN BioMed, Neuville-sur-Oise, France
| | | | - Jerard Seghatchian
- International Consultancy in Blood Components Quality/Safety Improvement, Audit/Inspection and DDR Strategies, London, UK.
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Seheult JN, Meyer MP, Bontempo FA, Chibisov I. The Effects of Indirect- and Direct-Acting Anticoagulants on Lupus Anticoagulant Assays: A Large, Retrospective Study at a Coagulation Reference Laboratory. Am J Clin Pathol 2017; 147:632-640. [PMID: 28525532 DOI: 10.1093/ajcp/aqx035] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES To investigate the effects of indirect- and direct-acting anticoagulants on the interpretation of lupus anticoagulant (LAC) assays. METHODS A retrospective database review was performed to identify all LAC panels from November 2012 to November 2015. The positivity rates for three LAC tests were compared among various anticoagulant medications. RESULTS This analysis included 7,721 LAC panels. Direct oral anticoagulants, warfarin, and unfractionated heparin (UFH) were associated with higher LAC positivity rates compared with patients not receiving documented anticoagulation (83% for argatroban, 58% for dabigatran, 72% for rivaroxaban, 53% for apixaban, 56% for warfarin, and 36% for UFH vs 29% for no anticoagulation, P < .025). Direct thrombin inhibitors mainly affected the activated partial thromboplastin time-based assays and the tissue thromboplastin inhibition index (TTI), while direct factor Xa inhibitors mainly affected the TTI and the dilute Russell viper venom ratio. CONCLUSIONS Results of LAC testing performed while patients are receiving anticoagulant therapies should be interpreted with caution to avoid misdiagnosing patients with the antiphospholipid syndrome and potentially committing them to long-term anticoagulation therapy.
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Affiliation(s)
| | - Michael P Meyer
- Coagulation Laboratory, Institute for Transfusion Medicine, Pittsburgh, PA
| | - Franklin A Bontempo
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh School of Medicine, PA ; and
- Coagulation Laboratory, Institute for Transfusion Medicine, Pittsburgh, PA
| | - Irina Chibisov
- From the Department of Pathology and
- Coagulation Laboratory, Institute for Transfusion Medicine, Pittsburgh, PA
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39
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Detection of lupus anticoagulant in the era of direct oral anticoagulants. Autoimmun Rev 2017; 16:173-178. [DOI: 10.1016/j.autrev.2016.12.010] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Accepted: 10/12/2016] [Indexed: 12/31/2022]
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Samuelson BT, Cuker A, Siegal DM, Crowther M, Garcia DA. Laboratory Assessment of the Anticoagulant Activity of Direct Oral Anticoagulants: A Systematic Review. Chest 2017; 151:127-138. [PMID: 27637548 PMCID: PMC5310120 DOI: 10.1016/j.chest.2016.08.1462] [Citation(s) in RCA: 206] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 07/26/2016] [Accepted: 08/24/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are the treatment of choice for most patients with atrial fibrillation and/or noncancer-associated venous thromboembolic disease. Although routine monitoring of these agents is not required, assessment of anticoagulant effect may be desirable in special situations. The objective of this review was to summarize systematically evidence regarding laboratory assessment of the anticoagulant effects of dabigatran, rivaroxaban, apixaban, and edoxaban. METHODS PubMed, Embase, and Web of Science were searched for studies reporting relationships between drug levels and coagulation assay results. RESULTS We identified 109 eligible studies: 35 for dabigatran, 50 for rivaroxaban, 11 for apixaban, and 13 for edoxaban. The performance of standard anticoagulation tests varied across DOACs and reagents; most assays, showed insufficient correlation to provide a reliable assessment of DOAC effects. Dilute thrombin time (TT) assays demonstrated linear correlation (r2 = 0.67-0.99) across a range of expected concentrations of dabigatran, as did ecarin-based assays. Calibrated anti-Xa assays demonstrated linear correlation (r2 = 0.78-1.00) across a wide range of concentrations for rivaroxaban, apixaban, and edoxaban. CONCLUSIONS An ideal test, offering both accuracy and precision for measurement of any DOAC is not widely available. We recommend a dilute TT or ecarin-based assay for assessment of the anticoagulant effect of dabigatran and anti-Xa assays with drug-specific calibrators for direct Xa inhibitors. In the absence of these tests, TT or APTT is recommended over PT/INR for assessment of dabigatran, and PT/INR is recommended over APTT for detection of factor Xa inhibitors. Time since last dose, the presence or absence of drug interactions, and renal and hepatic function should impact clinical estimates of anticoagulant effect in a patient for whom laboratory test results are not available.
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Affiliation(s)
- Bethany T Samuelson
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA.
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Deborah M Siegal
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - David A Garcia
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA
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Depreter B, Devreese KM. Dilute Russell’s viper venom time reagents in lupus anticoagulant testing: a well-considered choice. ACTA ACUST UNITED AC 2017; 55:91-101. [DOI: 10.1515/cclm-2016-0245] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Accepted: 05/07/2016] [Indexed: 01/09/2023]
Abstract
AbstractBackground:Lupus anticoagulant (LAC) detection represents diagnostic challenges among which the multitude of available reagents and interference by anticoagulant treatment. One of the two advised tests is the dilute Russell’s viper venom time (dRVVT). However, it is currently not clear whether all dRVVT reagents may be considered equivalent. The objective of the study was to evaluate the diagnostic performance of two dRVVT reagents, with special attention to the influence of anticoagulant therapy.Methods:STA®-Staclot®dRVV Screen/Confirm (Stago, Asnières-sur-Seine, France) and dRVT-LS/dRVTL-LR (Haematex, Hornsby, Australia) were evaluated on 443 patient samples [358 consecutive patients with LAC request including six antiphospholipid syndrome (APS) patients, 18 non-consecutively selected APS patients and 37 vitamin K antagonists (VKA)-treated and 30 direct oral anticoagulants (DOAC)-treated non-APS patients]. Additionally, pooled normal plasma (PNP) was spiked with factor deficient plasma (n=33) and DOAC calibrators (n=21) to evaluate sensitivity for factor deficiencies and false-positivity rates, respectively.Results:A higher number of samples were defined as LAC positive by Stago vs. Haematex [11.5% (41/358) vs. 3.63% (13/358)]. Most discordances were in the VKA and DOAC group. Haematex was less prone to VKA-related factor deficiencies, explaining the absence of false-positive LAC results in VKA-treated non-APS patients compared to 10.8% with Stago. We observed no false-positive LAC ratios with Haematex in DOAC-spiked PNP and a lower number in DOAC-treated non-APS patients. However, increased specificity seemed to be at cost of a reduced sensitivity as Haematex showed less positive APS patient samples (45.8% vs. 87.5%).Conclusions:dRVVT reagents differ in LAC sensitivity and for VKA and DOAC interference.
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Pengo V, Bison E, Banzato A, Zoppellaro G, Jose SP, Denas G. Lupus Anticoagulant Testing: Diluted Russell Viper Venom Time (dRVVT). Methods Mol Biol 2017; 1646:169-176. [PMID: 28804828 DOI: 10.1007/978-1-4939-7196-1_14] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Diluted Russell Viper Venom Time (dRVVT) has become the most popular test to detect Lupus Anticoagulant (LA). dRVVT is more sensitive than other global tests employed to detect LA and is not affected by inhibitors of factor VIII or IX. The test is most successfully implemented if you observe three steps in its execution: screening, mixing, and confirmatory studies. Interference due to the presence of heparin in tested plasma must be excluded by means of thrombin time (TT). The prior use of Vitamin K Antagonists (VKAs) or Non-vitamin K Oral Anticoagulants (NOACs) must also be evaluated by means of International Normalized Ratio, or specific tests, respectively.
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Affiliation(s)
- Vittorio Pengo
- Department of Cardiac, Thoracic and Vascular Sciences, Clinical Cardiology, Thrombosis Centre, University of Padova Medical School, via Giustiniani2, 35128, Padova, Italy.
| | - Elisa Bison
- Department of Cardiac, Thoracic and Vascular Sciences, Clinical Cardiology, Thrombosis Centre, University of Padova Medical School, via Giustiniani2, 35128, Padova, Italy
| | - Alessandra Banzato
- Department of Cardiac, Thoracic and Vascular Sciences, Clinical Cardiology, Thrombosis Centre, University of Padova Medical School, via Giustiniani2, 35128, Padova, Italy
| | - Giacomo Zoppellaro
- Department of Cardiac, Thoracic and Vascular Sciences, Clinical Cardiology, Thrombosis Centre, University of Padova Medical School, via Giustiniani2, 35128, Padova, Italy
| | - Seena Padayattil Jose
- Department of Cardiac, Thoracic and Vascular Sciences, Clinical Cardiology, Thrombosis Centre, University of Padova Medical School, via Giustiniani2, 35128, Padova, Italy
| | - Gentian Denas
- Department of Cardiac, Thoracic and Vascular Sciences, Clinical Cardiology, Thrombosis Centre, University of Padova Medical School, via Giustiniani2, 35128, Padova, Italy
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Pouplard C, Vayne C, Berthomet C, Guery EA, Delahousse B, Gruel Y. The Taipan snake venom time can be used to detect lupus anticoagulant in patients treated by rivaroxaban. Int J Lab Hematol 2016; 39:e60-e63. [DOI: 10.1111/ijlh.12611] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- C. Pouplard
- Department of Haematology-Haemostasis; Trousseau hospital; Tours France
- Unité Mixte de Recherche Centre National de la Recherche Scientifique 7292 and Université François Rabelais; Tours France
| | - C. Vayne
- Department of Haematology-Haemostasis; Trousseau hospital; Tours France
- Unité Mixte de Recherche Centre National de la Recherche Scientifique 7292 and Université François Rabelais; Tours France
| | - C. Berthomet
- Department of Haematology-Haemostasis; Trousseau hospital; Tours France
| | - E. A. Guery
- Department of Haematology-Haemostasis; Trousseau hospital; Tours France
- Unité Mixte de Recherche Centre National de la Recherche Scientifique 7292 and Université François Rabelais; Tours France
| | - B. Delahousse
- Department of Haematology-Haemostasis; Trousseau hospital; Tours France
| | - Y. Gruel
- Department of Haematology-Haemostasis; Trousseau hospital; Tours France
- Unité Mixte de Recherche Centre National de la Recherche Scientifique 7292 and Université François Rabelais; Tours France
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Moore GW. Current Controversies in Lupus Anticoagulant Detection. Antibodies (Basel) 2016; 5:E22. [PMID: 31558003 PMCID: PMC6698846 DOI: 10.3390/antib5040022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 11/17/2016] [Accepted: 11/18/2016] [Indexed: 01/19/2023] Open
Abstract
Antiphospholipid syndrome is an autoimmune, acquired thrombophilia diagnosed when vascular thrombosis or pregnancy morbidity are accompanied by persistent antiphospholipid antibodies. Lupus anticoagulants (LA) are one of the criteria antibodies but calibration plasmas are unavailable and they are detected by inference based on antibody behaviour in a medley of coagulation-based assays. Elevated screening tests suggest the presence of a LA, which is confirmed with mixing tests to evidence inhibition and confirmatory tests to demonstrate phospholipid-dependence. At least two screening tests of different principle must be used to account for antibody heterogeneity and controversy exists on whether assays, in addition to dilute Russell's viper venom time and activated partial thromboplastin time, should be employed. A variety of approaches to raw data manipulation and interpretation attract debate, as does inclusion or exclusion of mixing studies in circumstances where the presence of a LA is already evident from other results. Therapeutic anticoagulation compromises coagulation-based assays but careful data interpretation and use of alternative reagents can detect or exclude LA in specific circumstances, and this aspect of LA detection continues to evolve. This review focuses on the main areas of debate in LA detection.
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Affiliation(s)
- Gary W Moore
- Diagnostic Haemostasis & Thrombosis Laboratories, Department of Haemostasis and Thrombosis, Viapath Analytics, Guy's & St. Thomas' NHS Foundation Hospitals Trust, 4th floor North Wing, St. Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK.
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Dufrost V, Risse J, Zuily S, Wahl D. Direct Oral Anticoagulants Use in Antiphospholipid Syndrome: Are These Drugs an Effective and Safe Alternative to Warfarin? A Systematic Review of the Literature. Curr Rheumatol Rep 2016; 18:74. [DOI: 10.1007/s11926-016-0623-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Taipan snake venom time coupled with ecarin time enhances lupus anticoagulant detection in nonanticoagulated patients. Blood Coagul Fibrinolysis 2016; 27:477-80. [DOI: 10.1097/mbc.0000000000000486] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Chighizola CB, Raschi E, Banzato A, Borghi MO, Pengo V, Meroni PL. The challenges of lupus anticoagulants. Expert Rev Hematol 2016; 9:389-400. [PMID: 26789237 DOI: 10.1586/17474086.2016.1140034] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The term "lupus anticoagulant" (LA) refers to a heterogeneous group of immunoglobulins behaving as acquired in vitro inhibitors of coagulation. These antibodies, namely anti-β2GPI and anti-prothrombin antibodies, induce the in vitro elongation of clotting time interfering with phospholipid-dependent coagulation cofactors. Positive LA is associated with thrombosis and pregnancy complications, providing one of the three laboratory criteria for the classification of the anti-phospholipid syndrome. LA is the strongest predictor of clinical events, especially when associated with other anti-phospholipid antibodies. Much more controversial is the risk conveyed by isolated and weak LA. LA detection is technically laborious, envisaging screening, mixing and confirming tests. Hopefully critical issues in LA detection, such as the interference of anticoagulants, will be overcome, in the next future.
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Affiliation(s)
- Cecilia Beatrice Chighizola
- a Department of Clinical Sciences and Community Health , University of Milan , Milan , Italy.,b Experimental Laboratory of Immunological and Rheumatologic Researches , Istituto Auxologico Italiano , Milan , Italy
| | - Elena Raschi
- b Experimental Laboratory of Immunological and Rheumatologic Researches , Istituto Auxologico Italiano , Milan , Italy
| | - Alessandra Banzato
- c Clinical Cardiology, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Science , University of Padua , Padua , Italy
| | - Maria Orietta Borghi
- a Department of Clinical Sciences and Community Health , University of Milan , Milan , Italy.,b Experimental Laboratory of Immunological and Rheumatologic Researches , Istituto Auxologico Italiano , Milan , Italy
| | - Vittorio Pengo
- c Clinical Cardiology, Thrombosis Centre, Department of Cardiac Thoracic and Vascular Science , University of Padua , Padua , Italy
| | - Pier Luigi Meroni
- a Department of Clinical Sciences and Community Health , University of Milan , Milan , Italy.,b Experimental Laboratory of Immunological and Rheumatologic Researches , Istituto Auxologico Italiano , Milan , Italy.,d Department of Rheumatology , Istituto Ortopedico Gaetano Pini , 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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Depreter B, Devreese KM. Differences in lupus anticoagulant final conclusion through clotting time or Rosner index for mixing test interpretation. ACTA ACUST UNITED AC 2016; 54:1511-6. [DOI: 10.1515/cclm-2015-0978] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 01/18/2016] [Indexed: 11/15/2022]
Abstract
AbstractLupus anticoagulant (LAC) testing includes a screening, mixing and confirmation step. Although recently published guidelines on LAC testing are a useful step towards standardization, a lack of consensus remains whether to express mixing tests in clotting time (CT) or index of circulating anticoagulant (ICA). The influence of anticoagulant therapy, e.g. vitamin K antagonists (VKA) or direct oral anticoagulants (DOAC) on both methods of interpretation remains to be investigated. The objective of this study was to contribute to a simplification and standardization of the LAC three-step interpretation on the level of the mixing test.Samples from 148 consecutive patients with LAC request and prolonged screening step, and 77 samples from patients non-suspicious for LAC treated with VKA (n=37) or DOAC (n=30) were retrospectively evaluated. An activated partial thromboplastin time (aPTT) and dilute Russell’s viper venom time (dRVVT) were used for routine LAC testing. The supplemental anticoagulant samples were tested with dRVVT only. We focused on the interpretation differences for mixing tests expressed as CT or ICA and compared the final LAC conclusion within each distinct group of concordant and discordant mixing test results.Mixing test interpretation by CT resulted in 10 (dRVVT) and 16 (aPTT) more LAC positive patients compared to interpretation with ICA. Isolated prolonged dRVVT screen mix ICA results were exclusively observed in samples from VKA-treated patients without suspicion for LAC.We recommend using CT in respect to the 99th percentile cut-off for interpretation of mixing steps in order to reach the highest sensitivity and specificity in LAC detection.
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