1
|
Arachchillage DJ, Platton S, Hickey K, Chu J, Pickering M, Sommerville P, MacCallum P, Breen K. Guidelines on the investigation and management of antiphospholipid syndrome. Br J Haematol 2024. [PMID: 39031476 DOI: 10.1111/bjh.19635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 06/26/2024] [Indexed: 07/22/2024]
Affiliation(s)
- Deepa J Arachchillage
- Department of Haematology, Imperial College Healthcare NHS Trust, London, UK
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
| | - Sean Platton
- The Royal London Hospital Haemophilia Centre, Barts Health NHS Trust, London, UK
| | - Kieron Hickey
- Sheffield Laboratory Medicine, Department of Coagulation, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Justin Chu
- Department of Obstetrics and Gynaecology, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Matthew Pickering
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, UK
- Department of Rheumatology, Imperial College Healthcare NHS Trust, London, UK
| | - Peter Sommerville
- Department of Stroke Medicine, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Peter MacCallum
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
- Department of Clinical Haematology, Barts Health NHS Trust, London, UK
| | - Karen Breen
- Department of Haematology, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
2
|
Buckley GT, Bowen A, Crowley MP, Harte JV. Precision-weighing of raw activated charcoal using a 3D-printed micromeasure for the removal of direct oral anticoagulant-associated interferences in coagulation testing. Int J Lab Hematol 2024; 46:405-407. [PMID: 38135925 DOI: 10.1111/ijlh.14222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 12/12/2023] [Indexed: 12/24/2023]
Affiliation(s)
- Gavin T Buckley
- EOLAS Research Group, Cork University Hospital, Cork, Ireland
- Department of Haematology, Cork University Hospital, Cork, Ireland
| | - Aaron Bowen
- Department of Computer Science, Kinsale Community School, Cork, Ireland
| | - Maeve P Crowley
- EOLAS Research Group, Cork University Hospital, Cork, Ireland
- Department of Haematology, Cork University Hospital, Cork, Ireland
- Irish Network for Venous Thromboembolism Research (INViTE), Dublin, Ireland
| | - James V Harte
- EOLAS Research Group, Cork University Hospital, Cork, Ireland
- Department of Haematology, Cork University Hospital, Cork, Ireland
| |
Collapse
|
3
|
Exner T, Dangol M, Favaloro EJ. Simplified Method for Removing Direct Oral Anticoagulant Interference in Mechanical Coagulation Test Systems-A Proof of Concept. J Clin Med 2024; 13:1042. [PMID: 38398355 PMCID: PMC10889288 DOI: 10.3390/jcm13041042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 02/04/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) cause unwanted interference in various hemostasis assays, including lupus anticoagulant (LA) testing, where false positive and false negative identification may occur. DOAC Stop (DS) is an activated charcoal (AC) product used to specifically and effectively adsorb DOACs from test plasma. This process normally requires plasma treatment, centrifugation and plasma separation prior to tests, but inexperienced operators may also inadvertently transfer residual AC particles, thereby potentially adversely affecting clot detection. METHODS We hypothesized that residual DS might not be problematic for mechanical clot detection. We therefore investigated the potential impact of DS and a new DS liquid (DS-L) product on clotting tests using a mechanical clot detection system. Varying concentrations of DS were added to normal and abnormal plasmas with and without DOAC presence. Clotting tests including PT, APTT and dRVVT were performed directly in the analyzer without plasma/DS centrifugation. RESULTS DS up to double the recommended treatment level had only minor effects on all test results, despite completely obscuring visibility in the plasma/reagent mix. This confirms that the centrifugation step may be able to be omitted when using mechanical detection systems. CONCLUSIONS Should DS carryover into treated plasmas occur, this should not cause issues with testing performed on mechanical clot-sensing devices. Moreover, we hypothesize that DS can be used directly in these systems, without the need for centrifugation, thereby simplifying its many potential applications.
Collapse
Affiliation(s)
- Thomas Exner
- Haematex Research Pty Ltd., Sydney, NSW 2077, Australia; (T.E.); (M.D.)
| | - Manita Dangol
- Haematex Research Pty Ltd., Sydney, NSW 2077, Australia; (T.E.); (M.D.)
| | - Emmanuel J. Favaloro
- Haematology Department, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, Westmead Hospital, Sydney, NSW 2145, Australia
- School of Dentistry and Medical Sciences, Faculty of Science and Health, Charles Sturt University, Wagga, NSW 2650, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, NSW 2145, Australia
| |
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Molinari AC, Martini T, Banov L, Ierardi A, Leotta M, Strangio A, Santoro RC. Lupus Anticoagulant Detection under the Magnifying Glass. J Clin Med 2023; 12:6654. [PMID: 37892792 PMCID: PMC10607820 DOI: 10.3390/jcm12206654] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/29/2023] Open
Abstract
Diagnosis of antiphospholipid syndrome (APS) requires the presence of a clinical criterion (thrombosis and/or pregnancy morbidity), combined with persistently circulating antiphospholipid antibodies (aPL). Lupus anticoagulant (LA) is one of the three laboratory parameters (the others being antibodies to either cardiolipin or β2-glycoprotein I) that defines this rare but potentially devastating condition. For the search for aCL and aβ2-GP-I, traditionally measured with immunological solid-phase assays (ELISA), several different assays and detection techniques are currently available, thus making these tests relatively reliable and widespread. On the other hand, LA detection is based on functional coagulation procedures that are characterized by poor standardization, difficulties in interpreting the results, and interference by several drugs commonly used in the clinical settings in which LA search is appropriate. This article aims to review the current state of the art and the challenges that clinicians and laboratories incur in the detection of LA.
Collapse
Affiliation(s)
- Angelo Claudio Molinari
- Thrombosis and Hemostasis Unit, IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy; (A.C.M.); (L.B.)
| | - Tiziano Martini
- Immuno-Haematology and Transfusion Medicine, Center for Congenital Bleeding Disorders, Cesena General Hospital, 47521 Cesena, Italy
| | - Laura Banov
- Thrombosis and Hemostasis Unit, IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy; (A.C.M.); (L.B.)
| | - Antonella Ierardi
- Hemostasis and Thrombosis Unit, Azienda Ospedaliero Universitaria Dulbecco, 88100 Catanzaro, Italy; (A.I.); (M.L.); (A.S.); (R.C.S.)
| | - Marzia Leotta
- Hemostasis and Thrombosis Unit, Azienda Ospedaliero Universitaria Dulbecco, 88100 Catanzaro, Italy; (A.I.); (M.L.); (A.S.); (R.C.S.)
| | - Alessandra Strangio
- Hemostasis and Thrombosis Unit, Azienda Ospedaliero Universitaria Dulbecco, 88100 Catanzaro, Italy; (A.I.); (M.L.); (A.S.); (R.C.S.)
| | - Rita Carlotta Santoro
- Hemostasis and Thrombosis Unit, Azienda Ospedaliero Universitaria Dulbecco, 88100 Catanzaro, Italy; (A.I.); (M.L.); (A.S.); (R.C.S.)
| |
Collapse
|
6
|
Buckley GT, Murphy B, Fleming N, Crowley MP, Harte JV. Removing direct oral factor Xa inhibitor interferences from routine and specialised coagulation assays using a raw activated charcoal product. Clin Chim Acta 2023; 550:117565. [PMID: 37769932 DOI: 10.1016/j.cca.2023.117565] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/19/2023] [Accepted: 09/21/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are increasingly prescribed for the prevention and treatment of thrombosis. However, DOACs are associated with extensive interference in coagulation assays. Herein, we evaluate raw activated charcoal (AC) as an adsorbent material, to minimise DOAC-associated interferences in routine and specialised coagulation parameters on CS-series analysers (Sysmex, Kobe, Japan). METHODS Commercial human-derived non-anticoagulated plasma materials, with or without increasing concentrations of anticoagulant, were assayed for routine and specialised coagulation parameters before and after treatment with AC. RESULTS Treatment of non-anticoagulated plasma with raw AC had minimal impact on routine and specialised coagulation parameters available on the CS-series; however, clinically relevant prolongations of certain activated partial thromboplastin time (APTT)-based assays were observed after treatment. Furthermore, in apixaban- and rivaroxaban-containing plasma material, AC efficiently adsorbed therapeutic and supratherapeutic DOAC concentrations; and, treatment with raw AC resolved DOAC-associated interferences on all affected routine and specialised coagulation parameters. CONCLUSIONS Overall, raw AC efficiently adsorbed apixaban and rivaroxaban from human-derived plasma, without significantly affecting the majority of underlying routine and specialised coagulation parameters available on CS-series analysers.
Collapse
Affiliation(s)
- Gavin T Buckley
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland; EOLAS Research Group, Cork University Hospital, Wilton, Cork, Ireland
| | - Ber Murphy
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland
| | - Niamh Fleming
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland
| | - Maeve P Crowley
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland; EOLAS Research Group, Cork University Hospital, Wilton, Cork, Ireland; Irish Network for Venous Thromboembolism Research (INViTE), Ireland
| | - James V Harte
- Department of Haematology, Cork University Hospital, Wilton, Cork, Ireland; EOLAS Research Group, Cork University Hospital, Wilton, Cork, Ireland.
| |
Collapse
|
7
|
Tripodi A, Scalambrino E, Clerici M, Peyvandi F. Laboratory Diagnosis of Antiphospholipid Syndrome in Anticoagulated Patients. Biomedicines 2023; 11:1760. [PMID: 37371855 DOI: 10.3390/biomedicines11061760] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/06/2023] [Accepted: 06/12/2023] [Indexed: 06/29/2023] Open
Abstract
The laboratory diagnosis of antiphospholipid syndrome (APS) requires the measurement of solid-phase antibodies to cardiolipin or β2-Glycoprotein-I and the search for lupus anticoagulant (LA). The diagnosis of patients whilst on anticoagulation is impaired by the difficult interpretation of results, at least for LA, owing to the fact that prolongations of clotting times induced by LA superimpose those induced by anticoagulants. This is a matter of concern as treating physicians very often need to know the APS status of their patients to make a decision on secondary antithrombotic prophylaxis. This article aims to review the effect brought about by anticoagulants on APS diagnosis and discuss the options that can be used to overcome such an effect.
Collapse
Affiliation(s)
- Armando Tripodi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
- Fondazione Luigi Villa, 20122 Milano, Italy
| | - Erica Scalambrino
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
| | - Marigrazia Clerici
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
| | - Flora Peyvandi
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, 20122 Milan, Italy
- Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, 20122 Milano, Italy
| |
Collapse
|
8
|
Novelli C, Pradella P, Papandrea M, Montaruli B. Direct oral anticoagulant adsorption and laboratory detection of lupus anticoagulant. Blood Coagul Fibrinolysis 2023; 34:199-205. [PMID: 37017015 DOI: 10.1097/mbc.0000000000001214] [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: 04/06/2023]
Abstract
Direct oral anticoagulants (DOACs) interfere with many coagulation assays, mostly in lupus anticoagulant (LA) detection, causing false positive and negative results. Despite guidelines recommendations, LA testing may be important during anticoagulation when the clinician has to decide whether to prolong or discontinue the drug. OBJECTIVES In this study, the effect of activated charcoal (DOAC-Stop, DS) as a DOAC-adsorbent was investigated on samples from DOACs treated and untreated patients. BASIC METHODS 165 plasma samples with a LA request were collected in three laboratories: 105 were from patients receiving DOACs and 60 were from nonanticoagulated patients with 30 LA negative and 30 LA positive. All coagulation screening assays and LA assays were evaluated before and after DS treatment. RESULTS The adsorption technique reduced DOACs concentration below the Lower Limit of Quantification. For nonanticoagulated patients: no significant difference in ratio results of coagulation screening (prothrombin time, activated partial thromboplastin time and thrombin time) and LA tests were observed before and after addition of DS in LA positive and negative patients. Every LA was correctly classified. For anticoagulated patients: a statistically significant difference was found for coagulation screening assays and LA assays. Final LA conclusions changed after DS addition from positive to negative in 58.9% of patients (more frequently with Rivaroxaban) and from negative to positive in 8% of patients (more frequently with Apixaban). CONCLUSIONS Our study suggests that DOAC-Stop can be used in daily laboratory practice to remove DOACs interference for a more accurate assessment of LA that is essential for diagnosis and management of APS patients.
Collapse
Affiliation(s)
- Chiara Novelli
- Transfusion Center and Haematology Laboratory, ASST Ovest Milanese, Legnano Hospital, Legnano
| | - Paola Pradella
- Transfusion Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina, University Hospital, Trieste
| | - Maria Papandrea
- Laboratory Analysis, Azienda Ospedaliera Ordine Mauriziano, Turin, Italy
| | - Barbara Montaruli
- Laboratory Analysis, Azienda Ospedaliera Ordine Mauriziano, Turin, Italy
| |
Collapse
|
9
|
Vercruyssen J, Meeus P, Bailleul E. Resolving DOAC interference on antithrombin activity testing on a FXa based method by the use of activated carbon. Clin Chim Acta 2023; 538:216-220. [PMID: 36574540 DOI: 10.1016/j.cca.2022.11.011] [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: 12/17/2021] [Revised: 08/05/2022] [Accepted: 11/07/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) may cause falsely increased levels of antithrombin (AT) activity depending on the AT activity method and the specific target of the DOAC. Activated carbon (AC) has proven to remove DOAC interference on PT, aPTT and LA assays. We evaluate whether AC could be useful to resolve DOAC interference on AT assays. METHODS Normal pooled plasma (NPP) was diluted to obtain AT activity of 25 %, 50 % and 75 % respectively. The diluted NPPs were spiked with DOACs (apixaban, edoxaban, dabigatran and rivaroxaban) in concentrations of respectively 100, 250 and 500 ng/ml. DOAC concentrations and AT activity were tested at baseline and after treatment with 20 mg/ml AC. AT activity was measured with a FXa-based method (HemosIL Liquid Antithrombin®, Werfen). RESULTS All DOAC concentrations were below the limit of quantification (LoQ) after addition of AC. DOAC interference on AT activity testing was removed by adding AC, resulting in correctly diagnosing low levels of AT for all dilutions. The influence of DOACs on AT activity was directly correlated to the concentration of the DOAC. As expected, only the anti-FXa DOACs influenced the used assay. CONCLUSIONS AC effectively removes anti-FXa DOAC interference on FXa-based AT assays.
Collapse
Affiliation(s)
- Jill Vercruyssen
- Laboratory of Biochemistry and Hematology, Onze-Lieve-Vrouw Ziekenhuis, Moorselbaan 164, 9300 Aalst, Belgium.
| | - Peter Meeus
- Laboratory of Biochemistry and Hematology, Onze-Lieve-Vrouw Ziekenhuis, Moorselbaan 164, 9300 Aalst, Belgium
| | - Els Bailleul
- Laboratory of Biochemistry and Hematology, Onze-Lieve-Vrouw Ziekenhuis, Moorselbaan 164, 9300 Aalst, Belgium
| |
Collapse
|
10
|
Novel Ex Vivo DOAC Removal Methods Reduce Interference in Lupus Anticoagulant Testing. Diagnostics (Basel) 2022; 12:diagnostics12102520. [PMID: 36292209 PMCID: PMC9601296 DOI: 10.3390/diagnostics12102520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Revised: 10/09/2022] [Accepted: 10/14/2022] [Indexed: 11/22/2022] Open
Abstract
Direct oral anticoagulants (DOAC) interfere in laboratory coagulation testing. The aim here was to study how commercial DOAC removal methods, DOAC Filter® and DOAC-Stop™, perform to eliminate DOAC concentrations and false positive results in lupus anticoagulant (LAC) testing. We acquired 50 patient samples with high concentrations of DOACs: apixaban (n = 18, range 68–572 ng/mL), dabigatran (n = 8, range 47–154 ng/mL), edoxaban (n = 8, range 35–580 ng/mL) and rivaroxaban (n = 16, range 69–285 ng/mL). DOACs were removed ex vivo with either DOAC Filter® (n = 28) or DOAC-Stop™ (n = 22). Additionally, commercial control and calibrator samples were studied (n = 13 for DOAC Filter®, n = 14 for DOAC-Stop™). LAC screening was performed before and after DOAC removal. Both DOAC Filter® and DOAC-Stop™ were effective in removing DOAC concentrations in samples: DOAC concentrations decreased to median of 0 ng/mL (range 0–48 ng/mL). Only one sample had more than residual 25 ng/mL of DOAC (apixaban). Before DOAC removal, 96% (48/50) of patient samples and over 90% (12/13 DOAC Filter®, 13/14 DOAC-Stop™) of control/calibrator samples were positive in the LAC screening. In patient samples, LAC screening turned negative in 61% (17/28) after DOAC Filter® and 45% (10/22) after DOAC-Stop™ treatment. All control samples became negative after DOAC removal. In conclusion, DOAC removal ex vivo reduces false positives in LAC screening. DOAC removal halved the need for confirmation or mixing tests- Although a subset of patients would require further testing, DOAC removal reduces unnecessary repeated LAC testing.
Collapse
|
11
|
Ong J, Bennett A. A review of laboratory considerations in thrombophilia testing. Pathology 2022; 54:835-841. [DOI: 10.1016/j.pathol.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 08/29/2022] [Accepted: 09/04/2022] [Indexed: 10/14/2022]
|
12
|
Vandevelde A, Devreese KMJ. Laboratory Diagnosis of Antiphospholipid Syndrome: Insights and Hindrances. J Clin Med 2022; 11:jcm11082164. [PMID: 35456258 PMCID: PMC9025581 DOI: 10.3390/jcm11082164] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/08/2022] [Indexed: 12/11/2022] Open
Abstract
Diagnosis of antiphospholipid syndrome (APS) requires the presence of a clinical criterion (thrombosis and/or pregnancy morbidity), combined with persistently circulating antiphospholipid antibodies (aPL). Currently, laboratory criteria aPL consist of lupus anticoagulant (LAC), anticardiolipin antibodies (aCL) IgG/IgM, and anti-β2 glycoprotein I antibodies (aβ2GPI) IgG/IgM. Diagnosis and risk stratification of APS are complex and efforts to standardize and optimize laboratory tests have been ongoing since the initial description of the syndrome. LAC detection is based on functional coagulation assays, while aCL and aβ2GPI are measured with immunological solid-phase assays. LAC assays are especially prone to interference by anticoagulation therapy, but strategies to circumvent this interference are promising. Alternative techniques such as thrombin generation for LAC detection and to estimate LAC pathogenicity have been suggested, but are not applicable yet in routine setting. For aCL and aβ2GPI, a lot of different assays and detection techniques such as enzyme-linked immunosorbent and chemiluminescent assays are available. Furthermore, a lack of universal calibrators or standards results in high variability between the different solid-phase assays. Other non-criteria aPL such as anti-domain I β2 glycoprotein I and antiphosphatidylserine/prothrombin antibodies have been suggested for risk stratification purposes in APS, while their added value to diagnostic criteria seems limited. In this review, we will describe laboratory assays for diagnostic and risk evaluation in APS, integrating applicable guidelines and classification criteria. Current insights and hindrances are addressed with respect to both laboratory and clinical implications.
Collapse
Affiliation(s)
- Arne Vandevelde
- Department of Diagnostic Sciences, Ghent University, 9000 Gent, Belgium;
- Coagulation Laboratory, Ghent University Hospital, 9000 Gent, Belgium
| | - Katrien M. J. Devreese
- Department of Diagnostic Sciences, Ghent University, 9000 Gent, Belgium;
- Coagulation Laboratory, Ghent University Hospital, 9000 Gent, Belgium
- Correspondence:
| |
Collapse
|
13
|
Linskens EA, De Kesel P, Devreese KMJ. Direct Oral Anticoagulant removal by a DOAC filter: Impact on lupus anticoagulant testing – Evaluation on spiked and patient samples. Res Pract Thromb Haemost 2022; 6:e12633. [PMID: 35341071 PMCID: PMC8935533 DOI: 10.1002/rth2.12633] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/01/2021] [Accepted: 10/19/2021] [Indexed: 12/13/2022] Open
Abstract
Background DOAC Filter (DF) is a new device to overcome interference in lupus anticoagulant (LAC) testing by direct oral anticoagulants (DOACs). Objectives We evaluated DOAC removal from plasma and elimination of DOAC interference in LAC testing by DF, and impact of DF on LAC assays in a representative patient cohort, including a comparison with DOAC‐Stop (DS). Methods Normal pooled plasma (NPP) was spiked with increasing concentrations of apixaban, rivaroxaban, edoxaban, and dabigatran. DOAC and LAC was measured on untreated, DF‐treated, and DS‐treated spiked samples. Coagulation parameters and thrombin generation were measured on patient samples (n = 20) before and after DF. Patients treated with DOAC, vitamin K antagonist, or heparin and nonanticoagulated patient samples (n = 139) were tested for LAC before and after DF. Results In spiked NPP, levels were below the lower limit of quantification (LLoQ) after DF/DS treatment for all DOAC concentrations. Following DF, levels were below LLoQ for 53 of 56 DOAC‐containing patient samples. Twenty‐eight of 33 LAC‐positive DOAC‐containing samples became negative after filtration, whereas 5 remained LAC‐positive (1/5 from a patient with antiphospholipid syndrome [APS]). Four LAC‐positive DOAC‐containing samples (from patients without APS), became negative after filtration, whereas they remained LAC positive after DS. In the non‐DOAC patient groups following DF, LAC changed from positive to negative in 8 (due to a procoagulant effect) and vice versa in 2 cases. Conclusion DF reduces DOAC interference in LAC testing. As incomplete DOAC removal may occur, DOAC measurements should be performed after filtration. A procoagulant effect after filtration may lead to erroneous LAC results in non–DOAC‐containing samples. Therefore, using DF should be restricted to DOAC‐containing samples.
Collapse
Affiliation(s)
- Eleni A. Linskens
- Coagulation Laboratory Department of Laboratory Medicine Ghent University Hospital Ghent Belgium
| | - Pieter De Kesel
- Coagulation Laboratory Department of Laboratory Medicine Ghent University Hospital Ghent Belgium
| | - Katrien M. J. Devreese
- Coagulation Laboratory Department of Laboratory Medicine Ghent University Hospital Ghent Belgium
- Department of Diagnostic Sciences Ghent University Ghent Belgium
| |
Collapse
|
14
|
Favaloro EJ, Pasalic L. Lupus anticoagulant testing during anticoagulation, including direct oral anticoagulants. Res Pract Thromb Haemost 2022; 6:e12676. [PMID: 35316943 PMCID: PMC8922544 DOI: 10.1002/rth2.12676] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Revised: 01/27/2022] [Accepted: 02/06/2022] [Indexed: 12/23/2022] Open
Abstract
Background Lupus anticoagulants (LA) are one laboratory criterion for classification of antiphospholipid syndrome, with presence of vascular thrombosis and/or pregnancy/fetal morbidity being clinical criteria. The presence of LA is detected (or excluded) by laboratory testing, with the activated partial thromboplastin time and dilute Russell's viper venom time the most commonly used tests. Given the association of thrombosis with LA, it is no surprise that anticoagulants are used to treat or manage such patients. Objectives To review and discuss interferences from anticoagulants on LA testing, and strategies to mitigate these. Methods This narrative review assessed interference from commonly used anticoagulants, focusing on LA testing while on direct oral anticoagulants (DOACs), including use of DOAC neutralizers. Results The classical anticoagulants comprise vitamin K antagonists such as warfarin, and heparins, predominantly unfractionated heparin and low molecular weight heparin (LMWH). DOACs have emerged with favorable efficacy and safety. These comprise two classes: direct anti‐thrombin (anti‐IIa; dabigatran) or direct anti‐Xa (rivaroxaban, apixaban, edoxaban) agents. All anticoagulants affect clotting assays, although there are differences in effects according to anticoagulant and assay. Nevertheless, because of such interferences, anticoagulants can lead to false‐negative or false‐positive LA findings. Several strategies can mitigate such interferences, including avoidance of testing while patients are on such anticoagulants, temporarily switching to an anticoagulant (i.e., LMWH) with less assay interference, testing for LA at nadir levels of anticoagulants, and/or use of anticoagulant neutralizers. Conclusion Whilst the best approach is to avoid LA testing on patients taking anticoagulants; if unavoidable, testing may be facilitated by various mitigating strategies.
Collapse
Affiliation(s)
- Emmanuel J. Favaloro
- Department of Haematology Institute of Clinical Pathology and Medical Research (ICPMR) NSW Health Pathology Westmead Hospital Westmead New South Wales Australia
- Sydney Centres for Thrombosis and Haemostasis Westmead New South Wales Australia
- Faculty of Science and Health Charles Sturt University Wagga Wagga New South Wales Australia
| | - Leonardo Pasalic
- Department of Haematology Institute of Clinical Pathology and Medical Research (ICPMR) NSW Health Pathology Westmead Hospital Westmead New South Wales Australia
- Sydney Centres for Thrombosis and Haemostasis Westmead New South Wales Australia
- Sydney University Westmead New South Wales Australia
| |
Collapse
|
15
|
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.
Collapse
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
| |
Collapse
|
16
|
Moser KA. Direct oral anticoagulant (DOAC) interference in hemostasis assays. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:129-133. [PMID: 34889400 PMCID: PMC8791165 DOI: 10.1182/hematology.2021000241] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Direct oral anticoagulants (DOACs) are a group of direct coagulation factor inhibitors including both direct thrombin inhibitors and direct factor Xa inhibitors. These medications may cause hemostasis assay interference by falsely increasing or decreasing measured values, depending on the analyte. Considering the potential for DOAC interference in a variety of hemostasis assays is essential to avoid erroneous interpretation of results. Preanalytic strategies to avoid DOAC interference include selecting alternatives to clot-based hemostasis assays in patients taking DOACs when possible and sample collection timed when the patient is off anticoagulant therapy or at the expected drug trough. Clinical laboratories may also provide educational materials that clearly describe possible interferences from DOAC, develop testing algorithms to aid in detection of DOAC in submitted samples, use DOAC-neutralizing agents to remove DOACs before continuing with testing, and write interpretive comments that explain the effects of DOAC interference in hemostasis tests. Using a combination of the described strategies will aid physicians and laboratorians in correctly interpreting hemostasis and thrombosis laboratory tests in the presence of DOACs.
Collapse
Affiliation(s)
- Karen A. Moser
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT
- Correspondence Karen A. Moser, ARUP Laboratories, 500 Chipeta Way, Mail Stop 115-G04, Salt Lake City, UT 84108; e-mail:
| |
Collapse
|
17
|
Úlehlová J, Piskláková B, Ivanovová E, Procházková J, Bradáčová P, Kvasnička A, Friedecký D, Slavík L. Evaluation of the Determination of Dabigatran, Rivaroxaban, and Apixaban in Lupus Anticoagulant-Positive Patients. Diagnostics (Basel) 2021; 11:diagnostics11112027. [PMID: 34829374 PMCID: PMC8623477 DOI: 10.3390/diagnostics11112027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/22/2021] [Accepted: 10/27/2021] [Indexed: 11/16/2022] Open
Abstract
Background: The effect of direct oral anticoagulants (DOAC) on laboratory tests dependent on the production of their targets, factor IIa and factor Xa, is a well-known problem and can cause both false positive and negative results. In particular, the situation in patients who develop lupus anticoagulant (LA) antibodies is highly complex. To evaluate the effectiveness of DOAC therapy in lupus-positive patients, 31 samples were enrolled in this retrospective study. All patient samples were spiked with three types of DOAC (dabigatran, DABI; rivaroxaban, RIVA; and apixaban, API) in a concentration that significantly influenced the screening test for LA and thus can mask the presence of LA. Subsequently, the DOAC was always unbound by the DOAC-Stop procedure. DOAC levels before and after binding were determined by functional assays, followed by liquid chromatography coupled with mass spectrometry (LC-MS) analysis. Methods: The determination of DOAC levels was performed by direct thrombin assay and determination of anti-Xa activity with specific calibration as functional tests for DABI and xabans (API and RIVA). To determine concentration levels of API, DABI, and RIVA, our in-house LC-MS method was used. Results: The results of LA-positive samples show significant differences between functional tests and the LC-MS method both before and after DOAC binding. Conclusions: The acute findings of the presence of LA-type antibodies fundamentally affects the determination of DOAC by functional tests, and in this case, it is necessary to use LC-MS analysis to determine the true value. If patients treated with DOAC develop LA of medium and higher titers, we do not recommend checking DOAC levels with functional tests.
Collapse
Affiliation(s)
- Jana Úlehlová
- Department of Hematology-Oncology, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (J.Ú.); (J.P.); (P.B.)
| | - Barbora Piskláková
- Laboratory for Inherited Metabolic Disorders, Department of Clinical Biochemistry, Palacký University and University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (B.P.); (E.I.); (A.K.)
| | - Eliška Ivanovová
- Laboratory for Inherited Metabolic Disorders, Department of Clinical Biochemistry, Palacký University and University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (B.P.); (E.I.); (A.K.)
| | - Jana Procházková
- Department of Hematology-Oncology, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (J.Ú.); (J.P.); (P.B.)
| | - Pavla Bradáčová
- Department of Hematology-Oncology, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (J.Ú.); (J.P.); (P.B.)
| | - Aleš Kvasnička
- Laboratory for Inherited Metabolic Disorders, Department of Clinical Biochemistry, Palacký University and University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (B.P.); (E.I.); (A.K.)
| | - David Friedecký
- Laboratory for Inherited Metabolic Disorders, Department of Clinical Biochemistry, Palacký University and University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (B.P.); (E.I.); (A.K.)
- Correspondence: (D.F.); (L.S.); Tel.: +420-585852619 (D.F.); +420-585855350 (L.S.)
| | - Luděk Slavík
- Department of Hematology-Oncology, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, 779 00 Olomouc, Czech Republic; (J.Ú.); (J.P.); (P.B.)
- Correspondence: (D.F.); (L.S.); Tel.: +420-585852619 (D.F.); +420-585855350 (L.S.)
| |
Collapse
|
18
|
Impact of a commercially available DOAC absorbent on two integrated procedures for lupus anticoagulant detection. Thromb Res 2021; 204:32-39. [PMID: 34126321 DOI: 10.1016/j.thromres.2021.06.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 05/28/2021] [Accepted: 06/02/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Lupus anticoagulant (LA)-detection in anticoagulated patients is an unmet need, which becomes even more cogent with the introduction of direct oral anticoagulants (DOAC) that may lead to false-positive results. AIMS We aimed to investigate the effect of a commercially available DOAC absorbent on residual drug concentrations, and on integrated procedures for LA-detection. METHODS Blood from patients treated for atrial fibrillation with either dabigatran (n = 39), rivaroxaban (n = 55), apixaban (n = 47) or edoxaban (n = 47) were collected at peak and trough, and centralized for testing with two LA integrated procedures [i.e., the silica clotting time (SCT) and dilute Russel viper venom (dRVVT)] before and after DOAC absorbent exposure. RESULTS The commercially available DOAC absorbent investigated in this study proved effective in reducing the concentrations of all the investigated DOAC, although small residual drug was detected after absorption, especially in patients on edoxaban. Results mimicking LA were observed in patients on DOAC before absorbent exposure, especially for rivaroxaban when testing was performed with dRVVT (88% rate at peak and 20% at trough) and much less with SCT (12% at peak and 8% at trough). The correspondent rate of results mimicking LA in patients on rivaroxaban after exposure was reduced [dRVVT (peak 8%, trough 4%); SCT (peak and trough 8%)], but not abolished. CONCLUSIONS Overall, in vitro DOAC absorbance by active charcoal compounds is a useful laboratory tool for LA-detection in patients on DOAC. Caution should however be exerted when used in daily practice.
Collapse
|
19
|
Farkh C, Ellouze S, Gounelle L, Sad Houari M, Duchemin J, Proulle V, Fontenay M, Delavenne X, Jourdi G. A Diagnostic Solution for Lupus Anticoagulant Testing in Patients Taking Direct Oral FXa Inhibitors Using DOAC Filter. Front Med (Lausanne) 2021; 8:683357. [PMID: 34136510 PMCID: PMC8200390 DOI: 10.3389/fmed.2021.683357] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 04/19/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Direct oral factor Xa (FXa) inhibitors interfere with lupus anticoagulant (LA) assays challenging antiphospholipid syndrome diagnosis in treated patients. We evaluated a new device, called DOAC Filter, and its usefulness in this setting. It is a single-use filtration cartridge in which FXa inhibitor compounds are trapped by non-covalent binding while plasma is filtered through a solid phase. Patient samples were analyzed before and after filtration: 38 rivaroxaban, 41 apixaban, and 68 none. Anticoagulant plasma concentrations were measured using specific anti-Xa assays and HPLC-MS/MS. LA testing was performed using dilute Russell Viper Venom Time (dRVVT) and Silica Clotting Time (SCT). Baseline median [min-max] concentrations were 64.8 [17.6; 311.4] for rivaroxaban and 92.1 ng/mL [37.1; 390.7] for apixaban (HPLC-MS/MS). They were significantly correlated with anti-Xa assay results (r = 0.98 and r = 0.94, respectively). dRVVT was positive in 92% rivaroxaban and 72% apixaban and SCT in 28 and 41% of samples, respectively. Post-filtration, median % of neutralization was 100% with rivaroxaban and apixaban concentrations of, respectively, <2 [<2-2.4] and <2 ng/mL [<2-9.6] using HPLC-MS/MS. No significant effect of DOAC Filter was observed on LA testing in controls (n = 31) and LA-positive (n = 37) non-anticoagulated samples. dRVVT and SCT remained positive in, respectively, 16 and 8% of rivaroxaban and 41 and 18% of apixaban samples. DOAC Filter would be an easy-to-use device allowing FXa inhibitor removal from plasma samples, limiting their interference with LA testing in treated patients.
Collapse
Affiliation(s)
- Carine Farkh
- Service d'Hématologie Biologique, AP-HP, Center-Université de Paris, Hôpital Cochin, Paris, France
| | - Syrine Ellouze
- Service d'Hématologie Biologique, AP-HP, Center-Université de Paris, Hôpital Cochin, Paris, France
| | - Louis Gounelle
- Service d'Hématologie Biologique, AP-HP, Center-Université de Paris, Hôpital Cochin, Paris, France
| | - Mama Sad Houari
- Service d'Hématologie Biologique, AP-HP, Center-Université de Paris, Hôpital Cochin, Paris, France
| | - Jérôme Duchemin
- Service d'Hématologie Biologique, AP-HP, Center-Université de Paris, Hôpital Cochin, Paris, France
| | - Valérie Proulle
- Service d'Hématologie Biologique, AP-HP, Center-Université de Paris, Hôpital Cochin, Paris, France
| | - Michaela Fontenay
- Service d'Hématologie Biologique, AP-HP, Center-Université de Paris, Hôpital Cochin, Paris, France.,Institut Cochin, CNRS UMR8104, INSERM U1016, Université De Paris, Paris, France
| | - Xavier Delavenne
- Institut National de la Santé et de la Recherche Médicale U1059, Dysfonctions Vasculaires et de L'Hémostase, Université de Lyon, Saint-Étienne, France.,Laboratoire de Pharmacologie, Toxicologie, Gaz du Sang, CHU de Saint-Etienne, Saint-Étienne, France
| | - Georges Jourdi
- Service d'Hématologie Biologique, AP-HP, Center-Université de Paris, Hôpital Cochin, Paris, France.,Université de Paris, Innovative Therapies in Haemostasis, Inserm UMR_S1140, Paris, France.,Faculté de Pharmacie, Université de Montréal, Montreal, QC, Canada.,Center de Recherche de L'Institut de Cardiologie de Montréal, Montreal, QC, Canada
| |
Collapse
|
20
|
Devreese KMJ. Testing for antiphospholipid antibodies: Advances and best practices. Int J Lab Hematol 2021; 42 Suppl 1:49-58. [PMID: 32543059 DOI: 10.1111/ijlh.13195] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/24/2020] [Accepted: 03/10/2020] [Indexed: 01/19/2023]
Abstract
The diagnosis of antiphospholipid syndrome (APS) relies on the detection of circulating antiphospholipid antibodies (aPL). Currently, lupus anticoagulant (LAC), anticardiolipin (aCL), and antibeta2-glycoprotein I antibodies (aβ2GPI) IgG or IgM are included as laboratory criteria if persistently present. Progress has been made on the standardization of tests as guidelines on LAC testing and immunological assays for aCL and aβ2GPI are published. However, LAC measurement remains a complicated procedure with many pitfalls and interfered by anticoagulant therapy. Solid-phase assays for aCL and aβ2GPI still show interassay differences. These methodological issues make the laboratory diagnosis of APS challenging. In the interpretation of aPL results, antibody profiles help in identifying patients at risk. Noncriteria aPL, such as antibodies against the domain I of beta2-glycoprotein (aDI) and antiphosphatidylserine-prothrombin (aPS/PT) antibodies have been studied in the last years and may be useful in risk stratification of APS patients. But, aDI and aPS/PT are not included in the current diagnostic criteria and testing in daily practice is not recommended as these antibodies have no added value in the diagnosis of APS. This review will focus on the technical aspects of the laboratory methods, the clinical relevance of assays and interpretation of aPL results in the diagnosis of APS.
Collapse
Affiliation(s)
- Katrien M J Devreese
- Department of Laboratory Medicine, Coagulation Laboratory, Ghent University Hospital, Ghent, Belgium.,Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| |
Collapse
|
21
|
Baker P, Platton S, Gibson C, Gray E, Jennings I, Murphy P, Laffan M. Guidelines on the laboratory aspects of assays used in haemostasis and thrombosis. Br J Haematol 2020; 191:347-362. [PMID: 32537743 DOI: 10.1111/bjh.16776] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Peter Baker
- Oxford Haemophilia and Thrombosis Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sean Platton
- Haemophilia Centre, Barts Health NHS Trust, London, UK
| | - Claire Gibson
- Specialist Haemostasis, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Elaine Gray
- Haemostasis Section, Biotherapeutics Group, National Institute for Biological Standards and Controls, Hertfordshire, UK
| | | | - Paul Murphy
- Department of Haematology, the Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Mike Laffan
- Centre for Haematology, Imperial College and Hammersmith Hospital, London, UK
| |
Collapse
|
22
|
Devreese KMJ, de Groot PG, de Laat B, Erkan D, Favaloro EJ, Mackie I, Martinuzzo M, Ortel TL, Pengo V, Rand JH, Tripodi A, Wahl D, Cohen H. Guidance from the Scientific and Standardization Committee for lupus anticoagulant/antiphospholipid antibodies of the International Society on Thrombosis and Haemostasis: Update of the guidelines for lupus anticoagulant detection and interpretation. J Thromb Haemost 2020; 18:2828-2839. [PMID: 33462974 DOI: 10.1111/jth.15047] [Citation(s) in RCA: 206] [Impact Index Per Article: 51.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 07/14/2020] [Accepted: 07/31/2020] [Indexed: 12/13/2022]
Abstract
This guidance focuses on methodological aspects of lupus anticoagulant (LA) testing, as well as interpretation of results for clinicians. The main changes in how to test for LA compared with the International Society on Thrombosis and Haemostasis Scientific and Standardization Committee 2009 guidelines, in the preanalytical phase are more detailed recommendations on how to handle testing in anticoagulated patients, and the timing of testing. Also, routine coagulation tests are advised to obtain more information on the coagulation background of the patient, and when necessary, anti-Xa activity measurement for heparins or specific assays for direct oral anticoagulants should be performed. The three-step procedure with two test systems (diluted Russell's viper venom time and activated partial thromboplastin time [aPTT]) is essentially not changed. Silica remains the preferable activator in the aPTT assays, but ellagic acid is not excluded. We advise simultaneous performance of the mixing and confirmatory step, in each sample with a prolonged screening test. The confirmatory step can also be performed on a mixture of patient plasma and normal pooled plasma. Cutoff values should be established in-house on at least 120 normals, with transference of the manufacturer's cutoffs as an alternative. Reporting of results has not been changed, although more attention is focused on what clinicians should know. Patient selection for LA testing has been expanded.
Collapse
Affiliation(s)
- Katrien M J Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| | - Philip G de Groot
- Synapse Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Bas de Laat
- Synapse Research Institute, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Doruk Erkan
- Barbara Volcker Center for Women and Rheumatic Diseases, Hospital for Special Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
| | - Ian Mackie
- Haemostasis Research Unit, Research Haematology Department, University College London, London, UK
| | - Marta Martinuzzo
- Laboratorio Central del Hospital Italiano de Buenos Aires, Departamento de Bioquímica Aplicada, Instituto Universitario del Hospital Italiano, Buenos Aires, Argentina
| | - Thomas L Ortel
- Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
- Department of Pathology, Duke University Medical Center, Durham, NC, USA
| | - Vittorio Pengo
- Thrombosis Research Laboratory, Department of Cardio-Thoracic-Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Jacob H Rand
- Department of Pathology & Laboratory Medicine, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, IRCCS Cà Granda Maggiore Policlinico Hospital Foundation, Milano, Italy
- Fondazione Luigi Villa, Milano, Italy
| | - Denis Wahl
- Vascular Medicine Division and Competence Center for Rare Vascular and Systemic Autoimmune Diseases, Nancy University Hospital, Nancy, France
- INSERM UMR-S 1116, University of Lorraine, Nancy, France
| | - 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
| |
Collapse
|
23
|
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.
Collapse
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
| |
Collapse
|
24
|
De Kesel PM, Devreese KMJ. Direct oral anticoagulant adsorption: Impact on lupus anticoagulant testing-Review of the literature and evaluation on spiked and patient samples. J Thromb Haemost 2020; 18:2003-2017. [PMID: 32400112 DOI: 10.1111/jth.14894] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) interfere with lupus anticoagulant (LAC) testing. DOAC-Stop (D-S) represents a preanalytical strategy to cope with this issue. OBJECTIVES To assess D-S's ability to remove DOACs from plasma and overcome DOAC interference in LAC assays and to evaluate D-S's applicability in a representative patient cohort with routine LAC request. METHODS Apixaban (30-933 ng/mL), edoxaban (31-1060 ng/mL), rivaroxaban (35-1020 ng/mL), and dabigatran (20-360 ng/mL) were spiked to normal plasma. Aliquots were treated with D-S or untreated before DOAC and LAC testing. Patient samples containing DOAC (n = 43), vitamin K antagonists (n = 25), heparins (n = 21), or no anticoagulants (n = 63) were tested for LAC before and after D-S. RESULTS Spiking experiments revealed false-positive LAC from low concentrations of DOACs except for apixaban. Following D-S, DOAC levels were below lower limits of quantification, except for apixaban at the highest concentration, and no false-positive LAC was obtained. DOAC levels were below lower limits of quantification after D-S in 39/43 DOAC-containing patient samples. For 23/29 LAC-positive DOAC-containing samples, LAC tests became negative after D-S, whereas 3/6 samples remaining positive were from patients with (high probability for) antiphospholipid syndrome. In the non-DOAC-treated groups, LAC changed from positive to negative in 10 and vice versa in 2 cases. CONCLUSIONS D-S limits DOAC interference in LAC assays. DOAC concentration measurement should be performed in D-S treated samples because incomplete removal may occur. Applying D-S to vitamin K antagonist-containing, heparin-containing, or not-anticoagulated samples may lead to erroneous LAC results. Therefore, D-S should only be used in plasma from DOAC-treated patients.
Collapse
Affiliation(s)
- Pieter M De Kesel
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
| | - Katrien M J Devreese
- Coagulation Laboratory, Department of Laboratory Medicine, Ghent University Hospital, Ghent, Belgium
- Department of Diagnostic Sciences, Ghent University, Ghent, Belgium
| |
Collapse
|
25
|
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.
Collapse
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
| |
Collapse
|
26
|
Abstract
PURPOSE OF THE REVIEW This review focuses on the laboratory tests necessary for the diagnosis of antiphospholipid syndrome (APS). For the interpretation of the results of the tests for antiphospholipid antibodies (aPL), understanding of all pitfalls and interferences is necessary. RECENT FINDINGS Progress has been made on the standardization of aPL tests and current guidelines for detection of lupus anticoagulant (LAC), anticardiolipin antibodies (aCL), and antibeta2-glycoprotein I antibodies (aβ2GPI) are useful tools. LAC measurement remains a complex procedure with many pitfalls and interference by anticoagulant therapy. Solid phase assays for aCL and aβ2GPI still show inter-assay differences. Measuring LAC, aCL, and aβ2GPI allows making antibody profiles that help in identifying patients at risk. Other aPL, such as antibodies against domain I of beta2-glycoprotein I (aDI) and antiphosphatidylserine-prothrombin (aPS/PT) antibodies, may be useful in risk stratification of APS patients, but are not included in the current diagnostic criteria as no added value in the diagnosis of APS has been illustrated so far. The laboratory diagnosis of APS remains challenging. LAC, aCL, aβ2GPI IgG, and IgM should be performed to increase diagnostic efficacy, with an integrated interpretation of all results and an interpretative comment. A close interaction between clinical pathologists and clinicians is mandatory.
Collapse
Affiliation(s)
- Katrien M J Devreese
- Department of Laboratory Medicine, Coagulation Laboratory, Ghent University Hospital, Corneel Heymanslaan 10, 9000, Ghent, Belgium. .,Department of Diagnostic Sciences, Ghent University, Ghent, Belgium.
| |
Collapse
|
27
|
Exner T, Rigano J, Favaloro EJ. The effect of DOACs on laboratory tests and their removal by activated carbon to limit interference in functional assays. Int J Lab Hematol 2020; 42 Suppl 1:41-48. [DOI: 10.1111/ijlh.13196] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | - Joseph Rigano
- Haematology Department Alfred Hospital Melbourne Vic. Australia
| | - Emmanuel J. Favaloro
- Laboratory Haematology Institute of Clinical Pathology and Medical Research (ICPMR) NSW Health Pathology Westmead Hospital Sydney NSW Australia
- Sydney Centres for Thrombosis and Haemostasis Westmead Hospital Sydney NSW Australia
| |
Collapse
|
28
|
De Kesel PM, Devreese KM. The effect of unfractionated heparin, enoxaparin, and danaparoid on lupus anticoagulant testing: Can activated carbon eliminate false-positive results? Res Pract Thromb Haemost 2020; 4:161-168. [PMID: 31989098 PMCID: PMC6971310 DOI: 10.1002/rth2.12264] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 09/12/2019] [Accepted: 09/14/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Heparins and heparinoids interfere with functional clotting assays used for lupus anticoagulant (LAC) detection. However, current guidelines for LAC testing do not provide clear guidance on this matter. OBJECTIVES We aimed to assess to effect of unfractionated heparin (UFH), enoxaparin, and danaparoid on LAC assays over broad anti-Xa activity ranges and to evaluate whether activated carbon (AC) is able to neutralize these effects. METHODS UFH (0.1-3.0 IU/mL), enoxaparin (0.2-2.9 IU/mL), and danaparoid (0.6-2.2 IU/mL) were spiked to normal pooled plasma. AC was added at multiple activity levels. Anti-Xa assays and LAC tests were performed on all samples using Stago analyzers and reagents. RESULTS Abnormal activated partial thromboplastin time (APTT) screening and mixing tests were obtained at the lowest levels for all compounds. Abnormal APTT confirmation tests were seen from 2.5 and 1.9 anti-Xa IU/mL for enoxaparin and danaparoid, respectively. Abnormal dilute Russell's viper venom test (dRVVT) screening tests were obtained from 1.6, 1.4, and 1.1 anti-Xa IU/mL for UFH, enoxaparin, and danaparoid, respectively. Mixing tests were abnormal from 2.5 and 1.3 anti-Xa IU/mL for enoxaparin and danaparoid, respectively. Abnormal dRVVT confirmation results were seen for danaparoid only from 1.9 anti-Xa IU/mL. AC was unable to neutralize anti-Xa activity in plasma and overcome the effect of the tested anticoagulants on LAC assays but may cause prolongation of APTT clotting times. CONCLUSIONS UFH, enoxaparin, and danaparoid clearly affected LA tests; however, false-positive LAC conclusions were obtained at supratherapeutic enoxaparin and danaparoid levels only. AC may prolong APTT screen clotting times, requiring 3-step testing to avoid potential misdiagnosis of LAC.
Collapse
Affiliation(s)
- Pieter M.M. De Kesel
- Coagulation LaboratoryDepartment of Laboratory MedicineGhent University HospitalGhentBelgium
| | - Katrien M.J. Devreese
- Coagulation LaboratoryDepartment of Laboratory MedicineGhent University HospitalGhentBelgium
| |
Collapse
|
29
|
Diagnosis and management of congenital thrombophilia in the era of direct oral anticoagulants. Thromb Res 2019; 185:72-77. [PMID: 31775061 DOI: 10.1016/j.thromres.2019.11.008] [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: 09/05/2019] [Revised: 10/31/2019] [Accepted: 11/11/2019] [Indexed: 01/08/2023]
Abstract
Direct oral anticoagulants (DOAC)s are often preferred to other anticoagulants as they are more practical and do not require routine laboratory monitoring. Less is known about their use in congenital thrombophilia. Efficacy of DOACs in congenital thrombophilia, effect of DOACs and other anticoagulants on diagnostic tests as well as efficacy and safety of anticoagulant use in this population is still a matter of debate. In this review we intended to analyze the potential pitfalls of testing for thrombophilia in patients using DOACs and vitamin K antagonists (VKA)s as well as to suggest strategies to improve diagnostic accuracy in this setting. We also reviewed the literature for evidence regarding the safety and efficacy of DOACs in patients with congenital thrombophilia. Some evidence was found supporting the use of DOACs in low risk thrombophilia, although evidence for their use in high risk thrombophilia is limited to small series and case reports. Our findings support the generation of better evidence to support DOAC use for congenital thrombophilia, especially in the high risk subgroups.
Collapse
|