1
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Hardy M, Catry E, Pouplard M, Lecompte T, Mullier F. Is lupus anticoagulant testing with dilute Russell's viper venom clotting times reliable in the presence of inflammation? Res Pract Thromb Haemost 2024; 8:102536. [PMID: 39290988 PMCID: PMC11406037 DOI: 10.1016/j.rpth.2024.102536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Accepted: 07/18/2024] [Indexed: 09/19/2024] Open
Abstract
Background Testing for lupus anticoagulant (LA) is not recommended in case of inflammation as C-reactive protein (CRP) can interfere in vitro with the phospholipids present in the activated partial thromboplastin time test used to detect an LA. However, the potential interference of an acute phase protein (ie, CRP) in LA testing using the dilute Russell's viper venom (DRVV) test is poorly studied. Objectives To study the effect of inflammation, as evidenced by increased CRP levels, on DRVV tests. Methods First, a retrospective analysis (2013-2023) was performed: data on all LA workups were retrieved, and the association between CRP levels and DRVV screen, mix, and confirm clotting times was studied. Second, data on DRVV panels and CRP levels were extracted from 2 prospective studies involving intensive care unit patients to study the association between both variables. Third, CRP was added to normal pooled plasma at 6 relevant concentrations (up to 416 mg/L) to study the association between CRP itself and DRVV coagulation times. Results In the retrospective analysis, DRVV screen and confirm clotting times significantly increased as CRP increased (increase of 0.11 seconds and 0.03 seconds per 1 mg/L increase of CRP level, respectively). In the prospective analysis, only DRVV screen was prolonged with high CRP levels (increase of 0.06 seconds for a 1 mg/L increase in CRP level); DRVV screen/confirm ratio was also increased with high CRP levels. In vitro, the addition of CRP did not significantly increase any DRVV clotting times. Conclusion LA testing should be performed with much caution in the presence of inflammation as it may be associated with prolongation of both activated partial thromboplastin time and DRVV clotting times.
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Affiliation(s)
- Michael Hardy
- Institut de Recherche Expérimentale et Clinique - Pôle Mont, Université Catholique de Louvain, Louvain-la-Neuve, Belgium
- Department of Laboratory Medicine, CHU UCL Namur, Yvoir, Belgium
- Anesthesiology Department, CHU UCL Namur, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Namur, Belgium
| | - Emilie Catry
- Institut de Recherche Expérimentale et Clinique - Pôle Mont, Université Catholique de Louvain, Louvain-la-Neuve, Belgium
- Department of Laboratory Medicine, CHU UCL Namur, Yvoir, Belgium
| | - Marie Pouplard
- Department of Laboratory Medicine, CHU UCL Namur, Yvoir, Belgium
| | - Thomas Lecompte
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université de Namur, Namur, Belgium
- Faculté de Médecine de Nancy, Université de Lorraine, Nancy, France
- Division of Vascular Medicine, Centre hospitalier régional universitaire Nancy, Nancy, France
| | - François Mullier
- Institut de Recherche Expérimentale et Clinique - Pôle Mont, Université Catholique de Louvain, Louvain-la-Neuve, Belgium
- Department of Laboratory Medicine, CHU UCL Namur, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Namur, Belgium
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2
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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
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3
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Lippi G, Favaloro EJ. Pearls and Pitfalls in the Measurement of Direct Oral Anticoagulants. Semin Thromb Hemost 2024. [PMID: 38458228 DOI: 10.1055/s-0044-1782196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
Due to their widespread use, testing for direct oral anticoagulants (DOACs) has become urgent in certain clinical situations. Screening based on widely available, rapid, and simple hemostasis assays such as prothrombin time, activated partial thromboplastin time, or even diluted Russel Viper venom time may provide sufficient evidence of "over-coagulation" and could be used "in small/peripheral/spoke laboratories" as an emergency strategy, but is not thought to be reliable for driving clinical decision making. Given their good correlation with plasma concentration, urine dipsticks may be considered a valuable alternative for emergency screening, although their performance is dependent on renal function, may vary depending on the time since the last urination, and there may be problems of interfacing with the laboratory/hospital information system. Separation methods based on liquid chromatography and mass spectrometry may be clinically questionable, since they measure the concentration rather than the actual inhibitory effect of DOACs, are relatively expensive, cumbersome and time consuming, and therefore seem unsuitable for most conditions requiring urgent clinical decision making. A proposed approach therefore involves establishing a network of routine clinical laboratories, designating a reference center where DOAC tests could be available 24/7, establishing a clear diagnostic care pathway for ordering the tests from the laboratory and standard operating procedures for performing them, the use of the diluted thrombin time for dabigatran and anti-FXa assays (drug-calibrated) for rivaroxaban, apixaban, and edoxaban, as well as providing expert advice throughout the testing process, from ordering to interpretation of results.
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Affiliation(s)
- Giuseppe Lippi
- Section of Clinical Biochemistry, School of Medicine, University of Verona, Verona, Italy
| | - Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), Sydney Centres for Thrombosis and Haemostasis, NSW Health Pathology, Westmead Hospital, Westmead, NSW, Australia
- Faculty of Science and Health, Charles Sturt University, Wagga Wagga, NSW, Australia
- School of Medical Sciences, Faculty of Medicine and Health, University of Sydney, Westmead Hospital, Westmead, New South Wales, Australia
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4
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Mangion K, Vella K, Gatt A, Vella AM, Borg M, Borg-Aquilina D, Douxfils J, Camilleri L, Riva N. A comparative in vitro study of the anticoagulant effect of branded versus generic rivaroxaban. Thromb Res 2024; 235:41-51. [PMID: 38295600 DOI: 10.1016/j.thromres.2024.01.017] [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: 04/01/2023] [Revised: 12/04/2023] [Accepted: 01/22/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Several generic formulations of rivaroxaban were recently marketed to be used interchangeably with their branded equivalent. However, there have been no previously published studies that directly compared the in vitro anticoagulant effect of branded vs. generic rivaroxaban. The aim of this in vitro study was to compare the effects of three raw rivaroxaban materials, obtained from the branded (Xarelto®) and two generic (Rivarolto® and Rivaroxaban Sandoz®) rivaroxaban formulations on an array of coagulation assays. METHODS A pool of normal plasma was spiked with several concentrations of the three rivaroxaban (range 50-750 ng/ml). The concentrations were assessed with a rivaroxaban calibrated anti-Xa assay and confirmed by ultra-high-performance liquid chromatography-mass spectrometry coupled with tandem mass spectrometry (UHPLC-MS/MS). The following assays were performed: Prothrombin time (PT), activated Partial Thromboplastin time (aPTT), Diluted Russell's Viper Venom Test (dRVVT), Thrombin time (TT), Clauss Fibrinogen, Factor VII, VIII and IX assays, and thromboelastography. RESULTS The results obtained by the three rivaroxaban at similar concentrations were comparable. Increasing concentrations of the three rivaroxaban showed a strong positive correlation with the PT, aPTT and dRVVT assays (r > 0.95, p < 0.01 for all), and a strong negative correlation with the Factors assays (r < -0.95, p < 0.01 for all). TT and Clauss Fibrinogen were not affected by rivaroxaban. No significant difference was identified in the mean assays' results obtained by the three rivaroxaban. CONCLUSION This study showed that the branded and generic rivaroxaban exert an identical in vitro anticoagulant effect across a wide range of concentrations.
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Affiliation(s)
- Karl Mangion
- Department of Applied Biomedical Science, Faculty of Health Sciences, University of Malta, Msida, Malta.
| | - Kevin Vella
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta.
| | - Alex Gatt
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta; Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.
| | - Amy Marie Vella
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta.
| | - Marica Borg
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta.
| | - Denise Borg-Aquilina
- National Blood Transfusion Service & Mater Dei Hospital Blood Bank, Msida, Malta.
| | - Jonathan Douxfils
- University of Namur, Faculty of Medicine, Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium; Qualiblood s.a., Qualiclinics, Namur, Belgium.
| | - Liberato Camilleri
- Department of Statistics & Operations Research, Faculty of Science, University of Malta, Msida, Malta.
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.
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5
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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.
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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.)
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6
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Taune V, Skeppholm M, Ågren A, Wikman A, Hillarp A, Wallén H. Rapid Detection of Apixaban by a ROTEM-Based Approach and Reversibility with Andexanet Alfa or DOAC-Stop. TH OPEN 2022; 6:e238-e247. [PMID: 36046206 PMCID: PMC9423941 DOI: 10.1055/s-0042-1751072] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/09/2022] [Indexed: 11/04/2022] Open
Abstract
Background
A rapid test to detect apixaban treatment would be useful in acute situations such as major bleeding, urgent surgery, or in acute thrombosis.
Objective
This article aims to study if the viscoelastic test rotational thromboelastometry (ROTEM) can rapidly detect apixaban in whole blood using modified triggers based on factor Xa (FXa) or Russell viper venom (RVV).
Method
ROTEM clotting time (CT) was measured in samples from 40 patients on apixaban treatment, and in vitro in samples spiked with apixaban (20–500 ng/mL). Commercially available trigger Ex-tem was compared with modified triggers based on FXa or RVV. Reversibility of apixaban in the samples was studied; CT was measured with and without addition of DOAC-Stop or andexanet alfa, respectively, and the difference in CT was calculated (CT
diff
).
Results
Using FXa as trigger, we detected apixaban concentrations at 20 ng/mL and above with 100% sensitivity and 100% specificity in patient samples and in vitro. Corresponding data for Ex-tem were 92% sensitivity and 100% specificity in patients, and 94% sensitivity and 100% specificity in vitro, and for RVV 97% sensitivity and 94% specificity in patients, and 97% sensitivity and 100% specificity in vitro, respectively. CT
diff
data were similar. Patient sample data were obtained within 20 minutes from sampling.
Conclusion
Apixaban at low therapeutic concentrations was detected within 20 minutes, and with high sensitivity and specificity. A trigger based on FXa outperformed the commercial trigger Ex-tem and a trigger based on RVV. ROTEM with a FXa-based trigger is a promising method to detect apixaban bedside in acute settings.
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Affiliation(s)
- Viktor Taune
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Mika Skeppholm
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Anna Ågren
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Agneta Wikman
- Division of Clinical Immunology and Transfusion Medicine, Department of Laboratory Medicine, Karolinska University Hospital, Stockholm, Sweden; Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Andreas Hillarp
- Department of Translational Medicine, Clinical Chemistry Malmö, Lund University, Malmö, Sweden
- Department of Medical Biochemistry, Oslo University Hospital, Oslo, Norway
| | - Håkan Wallén
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine, Karolinska Institutet, Stockholm, Sweden
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7
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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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8
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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.
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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:
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9
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Skaugen JM, Sayre C, Hassett AC, Chibisov I, Bontempo F, Meyer MP, Seheult JN. Performance Characteristics of DOAC-Remove for Neutralization of the Effects of Apixaban and Rivaroxaban in Lupus Anticoagulant Assays. Am J Clin Pathol 2022; 157:457-469. [PMID: 34698336 DOI: 10.1093/ajcp/aqab149] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 07/30/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES This study established the performance characteristics of DOAC-Remove for neutralization of the effects of rivaroxaban and apixaban in lupus anticoagulant (LAC) testing. METHODS Normal donor, LAC control, and patient samples were spiked with rivaroxaban or apixaban to simulate their effects on the dilute Russell's viper venom time (dRVVT), activated partial thromboplastin time (APTT), and dilute prothrombin time (dPT). Anti-Xa activity was measured after spiking and after DOAC-Remove neutralization. Accuracy, complex precision, and reference interval verification were evaluated. RESULTS DOAC-Remove neutralized rivaroxaban and apixaban concentrations as high as 415 ng/mL and 333 ng/mL, respectively. Percentage positive and negative agreement between the baseline and postneutralization interpretations were 75% or higher for the dRVVT and APTT methods but not for the dPT method. Coefficients of variation (CVs) were 10% or less for all assays except the Staclot-LA delta, which had a standard deviation of 2.5 seconds or CV of 25% or less depending on the level. The laboratory's reference intervals were verified for the dRVVT and APTT assays after DOAC-Remove treatment but not for the dPT assays. CONCLUSIONS DOAC-Remove appears to have acceptable performance characteristics for neutralizing the effects of rivaroxaban and apixaban in the dRVVT and APTT methods but not in the dPT method.
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Affiliation(s)
- John M Skaugen
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | - Irina Chibisov
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Vitalant Coagulation Laboratory, Pittsburgh, PA, USA
| | - Franklin Bontempo
- Vitalant Coagulation Laboratory, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Jansen N Seheult
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Vitalant Coagulation Laboratory, Pittsburgh, PA, USA
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10
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Zdenek CN, Chowdhury A, Haw GYH, Violette A, Fourmy R, Christ T, Vonk FJ, Fry BG. Taxon-selective venom variation in adult and neonate Daboia russelii (Russell's Viper), and antivenom efficacy. Toxicon 2022; 205:11-19. [PMID: 34752826 DOI: 10.1016/j.toxicon.2021.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 10/16/2021] [Accepted: 11/03/2021] [Indexed: 10/19/2022]
Abstract
Major variations in venom composition can occur between juvenile and adult venomous snakes. However, due to logistical constraints, antivenoms are produced using adult venoms in immunising mixtures, possibly resulting in limited neutralisation of juvenile snake venoms. Daboia russelii is one of the leading causes of snakebite death across South Asia. Its venom is potently procoagulant, causing stroke in prey animals but causing in humans consumptive coagulopathy-a net anticoagulant state-and sometimes death resulting from hemorrhage. In this in vitro study, we compared the venom activity of-and antivenom efficacy against-six 2-week-old D. russelii relative to that of their parents. Using a coagulation analyser, we quantified the relative coagulotoxicity of these venoms in human, avian, and amphibian plasma. The overall potency on human plasma was similar across all adult and neonate venoms, and SII (Serum Institute of India) antivenom was equipotent in neutralising these coagulotoxic effects. In addition, all venoms were also similar in their action upon avian plasma. In contrast, the neonate venoms were more potent on amphibian plasma, suggesting amphibians make up a larger proportion of neonate diet than adult diet. A similar venom potency in human and avian plasmas but varying selectivity for amphibian plasma suggests ontogenetic differences in toxin isoforms within the factor X or factor V activating classes, thereby providing a testable hypothesis for future transcriptomics work. By providing insights into the functional venom differences between adult and neonate D. russelii venoms, we hope to inform clinical treatment of patients envenomated by this deadly species and to shed new light on the natural history of these extremely medically important snakes.
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Affiliation(s)
- Christina N Zdenek
- Venom Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, Qld, 4072, Australia
| | - Abhinandan Chowdhury
- Venom Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, Qld, 4072, Australia
| | - Grace Y H Haw
- Venom Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, Qld, 4072, Australia
| | - Aude Violette
- Alphabiotoxine Laboratory Sprl, Barberie 15, 7911, Montroeul-au-bois, Belgium
| | - Rudy Fourmy
- Alphabiotoxine Laboratory Sprl, Barberie 15, 7911, Montroeul-au-bois, Belgium
| | | | - Freek J Vonk
- Naturalis Biodiversity Center, Leiden, the Netherlands; Division of BioAnalytical Chemistry, Amsterdam Institute of Molecular and Life Sciences, Vrije Universiteit Amsterdam, De Boelelaan 1085, 1081, HV, Amsterdam, the Netherlands.
| | - Bryan G Fry
- Venom Evolution Lab, School of Biological Sciences, University of Queensland, St Lucia, Qld, 4072, Australia.
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11
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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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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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13
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Kumano O, Amiral J, Dunois C, Peyrafitte M, Moore GW. Applying index of circulating anticoagulant to mixing tests with lupus anticoagulant screen and confirm reagents can distinguish with high specificity between lupus anticoagulants and direct factor Xa inhibitors. Int J Lab Hematol 2021; 43:771-778. [PMID: 33974363 DOI: 10.1111/ijlh.13571] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 04/11/2021] [Accepted: 04/14/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Lupus anticoagulants (LA) are detected by prolongation of clotting times for dilute Russell's viper venom time (dRVVT) and activated partial thromboplastin time (APTT) screening tests. Direct oral anticoagulants (DOACs) can interfere with both screening and confirmatory tests. The present study aimed to investigate the influence of direct factor Xa inhibitors (DiXaIs) on screen, confirm and mixing tests and establish a method for differentiation from other sample types. MATERIALS AND METHODS A total of 257 samples including nonanticoagulated LA positive, LA positive with DiXaIs, factor deficiency, FVIII inhibitors, warfarin and non-APS DiXaIs were tested. APTT reagents Cephen LS/Cephen and dRVVT reagents LA1/LA2 were used, respectively, to screen/confirm the study group. Index of circulating anticoagulant (ICA) was calculated from clotting times based on the following formula as ICA screening and ICA confirmation. ICA= (1:1 Mix sample - Normal pooled plasma) / Screen patient x 100. An ICA matrix was established which suggested the presence of a DiXaI when both ICA screening and confirmation were above the cut-off. When only ICA screening is elevated, LA is suspected. RESULTS Sensitivity and specificity of the ICA matrix were 52.2% and 92.8% for DiXaIs and 38.1% and 96.7% for LA in APTT, and 61.2% and 92.9% for DiXaIs and 22.2% and 88.4% for LA in dRVVT, respectively. CONCLUSION The ICA matrix achieved high specificity with a lower apparent sensitivity for DiXaI samples comparatively to other devices but due only to less interferences: the matrix could contribute to differentiating DiXaIs from LA in samples where anticoagulation status is unknown.
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Affiliation(s)
- Osamu Kumano
- Protein Technology, Engineering 1, Sysmex Corporation, Kobe, Japan
| | - Jean Amiral
- Research Department, Hyphen BioMed, Neuville sur Oise, France
| | - Claire Dunois
- Research Department, Hyphen BioMed, Neuville sur Oise, France
| | | | - Gary W Moore
- Department of Haematology, Specialist Haemostasis Unit, Addenbrooke's Hospital, Cambridge, UK.,Faculty of Science and Technology, Middlesex University, London, UK.,Department of Haemostasis and Thrombosis, Viapath Analytics, St. Thomas' Hospital, London, UK
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Douxfils J, Adcock DM, Bates SM, Favaloro EJ, Gouin-Thibault I, Guillermo C, Kawai Y, Lindhoff-Last E, Kitchen S, Gosselin RC. 2021 Update of the International Council for Standardization in Haematology Recommendations for Laboratory Measurement of Direct Oral Anticoagulants. Thromb Haemost 2021; 121:1008-1020. [PMID: 33742436 DOI: 10.1055/a-1450-8178] [Citation(s) in RCA: 96] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In 2018, the International Council for Standardization in Haematology (ICSH) published a consensus document providing guidance for laboratories on measuring direct oral anticoagulants (DOACs). Since that publication, several significant changes related to DOACs have occurred, including the approval of a new DOAC by the Food and Drug Administration, betrixaban, and a specific DOAC reversal agent intended for use when the reversal of anticoagulation with apixaban or rivaroxaban is needed due to life-threatening or uncontrolled bleeding, andexanet alfa. In addition, this ICSH Working Party recognized areas where additional information was warranted, including patient population considerations and updates in point-of-care testing. The information in this manuscript supplements our previous ICSH DOAC laboratory guidance document. The recommendations provided are based on (1) information from peer-reviewed publications about laboratory measurement of DOACs, (2) contributing author's personal experience/expert opinion and (3) good laboratory practice.
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Affiliation(s)
- Jonathan Douxfils
- Department of Pharmacy-Namur Thrombosis and Hemostasis Center, University of Namur, Namur, Belgium.,Qualiblood SA, Namur, Belgium
| | - Dorothy M Adcock
- Laboratory Corporation of America, Burlington North Carolina, United States
| | - Shannon M Bates
- Department of Medicine, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Haemostasis and Thrombosis, Institute of Clinical Pathology and Medical Research, NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia
| | | | - Cecilia Guillermo
- Hospital de Clínicas "Dr Manuel Quintela," Facultad de Medicina, Universidad de la República, Montevideo, Uruguay
| | - Yohko Kawai
- Sanno Hospital, Laboratory Medicine, Tokyo, Japan
| | - Edelgard Lindhoff-Last
- Cardiology Angiology Center Bethanien, CCB Vascular Center, CCB Coagulation Center, Frankfurt, Germany
| | - Steve Kitchen
- Royal Hallamshire Hospital, Coagulation Sheffield, South Yorks, United Kingdom
| | - Robert C Gosselin
- Hemophilia Treatment Center, University of California, Davis Health System, Sacramento, California, United States
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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: 14] [Impact Index Per Article: 4.7] [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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