1
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Meshulami N, Green R, Kaushik S. Anti-Xa testing for pediatric and neonatal patients on extracorporeal membrane oxygenation. Perfusion 2024; 39:1231-1237. [PMID: 37339106 DOI: 10.1177/02676591231185009] [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: 06/22/2023]
Abstract
INTRODUCTION To determine if anti-Xa testing is associated with improved outcomes for patients <19-years-old on ECMO. METHODS We evaluated the clinical benefit of anti-Xa heparin monitoring utilizing the Bleeding and Thrombosis during ECMO (BATE) database of 514 patients <19-years-old. The BATE database includes incidences of bleeding, thrombosis, and mortality. The database also describes anti-coagulation test utilization. We grouped and analyzed patients based on ECMO indication (cardiac, respiratory, or extracorporeal cardiopulmonary resuscitation [E-CPR]) and age (neonatal vs pediatric). We constructed multivariable logistic regression models to analyze the impact of anti-Xa testing on mortality, bleeding, and thrombosis in each group. RESULTS Across the entire population, anti-Xa testing did not have a significant effect on the incidence of mortality (43% with anti-Xa testing vs 49% without), bleeding (68% vs 74%), or thrombosis (37% vs 39%). However, among cardiac indicated patients on ECMO (n = 207), anti-Xa testing was significantly associated with reduced odds ratio (OR) of mortality (adjusted OR 0.527, p = .040) and bleeding (adjusted OR 0.369, p = .021). In addition, among neonatal patients on ECMO (n = 264), anti-Xa testing was associated with a significant reduction in the odds ratio of bleeding (adjusted OR 0.534, p = .046). CONCLUSION Anti-Xa testing is associated with improved outcomes among cardiac indicated and neonatal patients on ECMO. Additional research to find the optimal heparin monitoring regimen is needed to better support these critically ill patients. In the interim, we recommend clinicians consider utilizing anti-Xa assays as part of their heparin monitoring plan for neonatal and cardiac indicated patients on ECMO.
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Affiliation(s)
- Noy Meshulami
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robert Green
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Newborn Medicine, Department of Pediatrics, Kravis Children's Hospital at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shubhi Kaushik
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Pediatric Critical Care, Department of Pediatrics, Kravis Children's Hospital at Mount Sinai, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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2
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John S, Wilkinson M, Ho KM. Monitoring anti-Xa Levels to Optimize Low-Molecular-Weight-Heparin Thromboprophylaxis in High-Risk Hospitalized Patients: A Stratified Meta-Analysis. Angiology 2024; 75:249-266. [PMID: 36606749 DOI: 10.1177/00033197221150673] [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: 01/07/2023]
Abstract
It is uncertain whether monitoring or targeting anti-Xa levels is necessary when using low-molecular-weight-heparin (LMWH) to prevent venous thromboembolism (VTE). This stratified meta-analysis assessed whether monitoring trough or peak anti-Xa levels with LMWH dosing would reduce risk of VTE. Twelve non-randomized studies involving 3604 hospitalized patients met the inclusion criteria and were subject to meta-analysis. Eight studies assessed the association between VTE and peak anti-Xa levels (between .2 and .5 IU/ml) and four studies assessed the benefits of targeting the trough anti-Xa levels (>.1 IU/ml). Achieving an adequate peak or trough anti-Xa level was associated with a reduced risk of VTE (random-effects model odds ratio [OR] .52, 95% confidence interval [CI] .34-.77; P = .001, I2 = 30% and P-value for heterogeneity = .171) compared with using a fixed standard dose of LMWH. Targeting the trough level (OR .40, 95%CI 0.22-.75, P = .004) appeared to be more effective than targeting the peak level (OR .62, 95%CI 0.37-1.03, P = .066), although a formal interaction analysis did not confirm they were statistically different (ratio of ORs = 1.52, 95%CI 0.68-3.40; z score = 1.03, P = .306). Targeting a higher anti-Xa level did not appear to increase the risk of bleeding or transfusion (OR 1.20, 95%CI 0.46-3.17, P = .707).
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Affiliation(s)
- Sunil John
- Department of Intensive Care Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Molly Wilkinson
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, WA, Australia
| | - Kwok M Ho
- Department of Intensive Care Medicine, Fiona Stanley Hospital, Perth, WA, Australia
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, WA, Australia
- Medical School, The University of Western Australia, Perth, WA, Australia
- School of Veterinary & Life Sciences, Murdoch University, Perth, WA, Australia
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3
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Raghavendran P, Tillman BF, Wheeler AP, Gailani D. Chromogenic and Clot-Based Bivalirudin Assays for Monitoring Anticoagulation. J Appl Lab Med 2023; 8:1074-1083. [PMID: 37811688 PMCID: PMC10842487 DOI: 10.1093/jalm/jfad072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 08/28/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Direct thrombin inhibitors (DTIs) are usually monitored with the activated partial thromboplastin time (aPTT) or activated clotting time (ACT). Both are complex assays with multiple enzymatic steps, and performance may be influenced by physiologic and pathologic factors unrelated to the DTI. Simpler systems, such as clot-based dilute thrombin time (dTT) and chromogenic anti-factor IIa assays, have been developed for monitoring DTIs, but there is limited data on their performance in clinical settings. METHODS Medical records of patients who received bivalirudin between March 2020 and April 2022 at a single institution were reviewed for demographic data and adverse outcomes. Plasma samples drawn for aPTT testing were analyzed with chromogenic anti-IIa and dTT bivalirudin assays. Results were compared to bivalirudin dosing. RESULTS Results of aPTT assays from 32 patients were compared with the chromogenic (n = 136) and dTT (n = 120) bivalirudin assays. Correlations between the aPTT and the chromogenic and dTT assays were poor (Spearman coefficients 0.55 and 0.62, respectively). There was a stronger correlation when results of the chromogenic and dTT assays were compared to each other (Spearman coefficient 0.92). When assay results were compared to bivalirudin dose, there were stronger correlations with the chromogenic and dTT assays than with the aPTT (Spearman coefficients 0.51, 0.63 and 0.22, respectively). CONCLUSIONS There was considerable variation between results of specific bivalirudin assays and the aPTT. While bivalirudin assay results correlated better with administered drug dose, suggesting improving reliability, more studies are needed to determine if there is correlation between testing and clinical outcomes.
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Affiliation(s)
- Prashant Raghavendran
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Benjamin F. Tillman
- Division of Hematology and Oncology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Allison P. Wheeler
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, United States
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, TN, United States
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4
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Helin T, Tirri T, Korkala H, Lappalainen K, Joutsi-Korhonen L. Laboratory Assessment of Unfractionated Heparin (UFH) with Activated Clotting Time (ACT) and Anti-Xa Activity during Peripheral Arterial Angiographic Procedure. Diagnostics (Basel) 2023; 13:diagnostics13081489. [PMID: 37189590 DOI: 10.3390/diagnostics13081489] [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: 12/28/2022] [Revised: 04/13/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023] Open
Abstract
Activated clotting time (ACT) is used in cardiac surgery for monitoring unfractionated heparin (UFH). In endovascular radiology, ACT use is less established. We aimed to test the validity of ACT in UFH monitoring in endovascular radiology. We recruited 15 patients undergoing endovascular radiologic procedure. ACT was measured with ICT Hemochron® device as point-of-care (1) before standard UFH bolus, (2) immediately after the bolus, and in some cases (3) 1 h into the procedure or a combination thereof (altogether 32 measurements). A total of two different cuvettes, ACT-LR and ACT+ were tested. A reference method of chromogenic anti-Xa was used. Blood count, APTT, thrombin time and antithrombin activity were also measured. UFH levels (anti-Xa) varied between 0.3-2.1 IU/mL (median 0.8) and correlated with ACT-LR moderately (R2 = 0.73). The corresponding ACT-LR values were 146-337 s (median 214). ACT-LR and ACT+ measurements correlated only modestly with one another at this lower UFH level, with ACT-LR being more sensitive. Thrombin time and APTT were unmeasurably high after the UFH dose, rendering them of limited use in this indication. We adopted an ACT target of >200-250 s in endovascular radiology based on this study. While ACT correlation with anti-Xa is suboptimal, the readily available point-of-care nature increases its suitability.
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Affiliation(s)
- Tuukka Helin
- Department of Clinical Chemistry, HUS Diagnostic Center, Helsinki University Hospital, P.O. Box 720, 00029 Helsinki, Finland
- Department of Clinical Chemistry, University of Helsinki, 00014 Helsinki, Finland
| | - Tomi Tirri
- Department of Clinical Chemistry, HUS Diagnostic Center, Helsinki University Hospital, P.O. Box 720, 00029 Helsinki, Finland
- Department of Clinical Chemistry, University of Helsinki, 00014 Helsinki, Finland
| | - Heidi Korkala
- Department of Radiology, HUS Diagnostic Center, Helsinki University Hospital, P.O. Box 320, 00029 Helsinki, Finland
| | - Kimmo Lappalainen
- Department of Radiology, HUS Diagnostic Center, Helsinki University Hospital, P.O. Box 320, 00029 Helsinki, Finland
| | - Lotta Joutsi-Korhonen
- Department of Clinical Chemistry, HUS Diagnostic Center, Helsinki University Hospital, P.O. Box 720, 00029 Helsinki, Finland
- Department of Clinical Chemistry, University of Helsinki, 00014 Helsinki, Finland
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5
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Apipongrat D, Police P, Lamool R, Butthep P, Chantkran W. Validation of high concentrated thrombin time assay for unfractionated heparin monitoring. J Clin Lab Anal 2022; 36:e24695. [PMID: 36099012 PMCID: PMC9550976 DOI: 10.1002/jcla.24695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/31/2022] [Accepted: 08/29/2022] [Indexed: 11/24/2022] Open
Abstract
Background The high concentrated thrombin time (hcTT), a thrombin time modified by increasing the thrombin concentration, is a possible alternative assay to activated partial thromboplastin time (aPTT) in unfractionated heparin (UFH) monitoring. This study aimed to determine the optimal thrombin concentration used in the hcTT assay for UFH monitoring. Methods A total of 30 blood samples obtained from healthy volunteers were included in this study. Thrombin concentrations of 10.0, 15.0, 20.0, and 25.0 IU/ml were used in the hcTT assay. The consistency between the hcTT and anti‐FXa assays was evaluated. To validate the hcTT assay, linearity, repeatability, reproducibility, and diagnostic performance of the assay were assessed. Results The hcTT assay using thrombin concentration of 15.0 IU/ml showed a strong correlation to the anti‐FXa assay with R2 of 0.72 and the Spearman's correlation coefficient (rs) of 0.97 (95% CI, 0.96–0.98). Within‐run and day‐to‐day run variabilities of the assay were satisfactory (all coefficients of variation <10%). We found an excellent correlation between the results which were measured using different reagents with intra‐ or inter‐laboratory instruments. Notably, as compared to the aPTT assay, the hcTT assay showed a significantly better performance in identifying the samples which contain UFH at the supratherapeutic level, with an AUC of 0.97 vs. 0.91, p = 0.049. Conclusion The hcTT assay can be used as an alternative assay for UFH therapy monitoring. A further study using clinical samples is recommended to confirm the appropriateness of the hcTT assay for clinical application.
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Affiliation(s)
- Dollapak Apipongrat
- Division of Hematology, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand
| | - Pornnapa Police
- Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Rattapan Lamool
- Division of Hematology, Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand
| | - Punnee Butthep
- Department of Medical Technology, Faculty of Allied Health Sciences, Pathumthani University, Pathumthani, Thailand
| | - Wittawat Chantkran
- Department of Pathology, Phramongkutklao College of Medicine, Bangkok, Thailand
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6
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Sathanantham V, Alberio L, Bovet C, Fontana P, Gerber B, Graf L, Mendez A, Sauter TC, Schmidt A, Studt JD, Wuillemin WA, Nagler M. Prothrombinase-Induced Clotting Time to Measure Drug Concentrations of Rivaroxaban, Apixaban, and Edoxaban in Clinical Practice: A Cross-Sectional Study. LIFE (BASEL, SWITZERLAND) 2022; 12:life12071027. [PMID: 35888115 PMCID: PMC9324795 DOI: 10.3390/life12071027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 11/17/2022]
Abstract
Prothrombinase-induced clotting time (PiCT) is proposed as a rapid and inexpensive laboratory test to measure direct oral anticoagulant (DOAC) drug levels. In a prospective, multicenter cross-sectional study, including 851 patients, we aimed to study the accuracy of PiCT in determining rivaroxaban, apixaban, and edoxaban drug concentrations and assessed whether clinically relevant drug levels could be predicted correctly. Citrated plasma samples were collected, and the Pefakit® PiCT was utilized. Ultra-high performance liquid chromatography-tandem mass spectrometry (LC-MS/MS) was performed to measure drug concentrations. Cut-off levels were established using receiver-operating characteristics curves. We calculated sensitivities and specificities with respect to clinically relevant drug concentrations. Spearman’s correlation coefficient between PiCT and drug concentrations was 0.85 in the case of rivaroxaban (95% CI 0.82, 0.88), 0.66 for apixaban (95% CI 0.60, 0.71), and 0.78 for edoxaban (95% CI 0.65, 0.86). The sensitivity to detect clinically relevant drug concentrations was 85.1% in the case of 30 µg L−1 (95% CI 82.0, 87.7; specificity 77.9; 72.1, 82.7), 85.7% in the case of 50 µg L−1 (82.4, 88.4; specificity 77.3; 72.5, 81.5), and 85.1% in the case of 100 µg L−1 (80.9, 88.4; specificity 73.2%; 69.1, 76.9). In conclusion, the association of PiCT with DOAC concentrations was fair, and the majority of clinically relevant drug concentrations were correctly predicted.
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Affiliation(s)
- Vepusha Sathanantham
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (V.S.); (C.B.)
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, CHUV, Lausanne University Hospital, 1011 Lausanne, Switzerland;
| | - Cédric Bovet
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (V.S.); (C.B.)
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospital, 1205 Geneva, Switzerland;
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, 6500 Bellinzona, Switzerland;
- Faculty of Medicine, University of Zurich, 8091 Zurich, Switzerland
| | - Lukas Graf
- Centre for Laboratory Medicine St. Gallen, 9001 St. Gallen, Switzerland;
| | - Adriana Mendez
- Department of Laboratory Medicine, Cantonal Hospital Aarau, 5001 Aarau, Switzerland;
| | - Thomas C. Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, 3010 Bern, Switzerland;
| | - Adrian Schmidt
- Clinic of Medical Oncology and Hematology, Institute of Laboratory Medicine, City Hospital Waid and Triemli, 8063 Zurich, Switzerland;
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University and University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Walter A. Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne, 6000 Lucerne, Switzerland;
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Correspondence:
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7
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Jimaja WE, Stirnemann J, Fontana P, Blondon KS. Improving safety of unfractionated heparin: a retrospective, quasi-experimental, observational study of the impact of a pocket card and a computerised prescription aid tool in the University Hospitals of Geneva. BMJ Open 2022; 12:e056912. [PMID: 35292499 PMCID: PMC8928257 DOI: 10.1136/bmjopen-2021-056912] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Despite the rapid rise of direct oral anticoagulants, unfractionated heparin (UFH) remains the mainstay anticoagulant in specific situations such as severe renal failure, perioperative setting or in critical care units. However, its titration is often challenging. OBJECTIVES To investigate the effect of a pocket card and a computerised prescription aid tool (CPAT) on the quality of UFH anticoagulation. DESIGN Monocentric retrospective, quasi-experimental, observational study. SETTING Inpatient primary care centre between 1 January 2016 and 31 December 2019. PARTICIPANTS >18 years-old treated with therapeutic UFH for more than 24 hours. There were 819 and 1169 anticoagulation episodes before and after intervention, respectively. INTERVENTION In October 2017, we implemented a pocket card with evidence-based recommendation for therapeutic UFH initiation, monitoring and dosing adaptation. In October 2019, we implemented a CPAT in a group subset. PRIMARY AND SECONDARY OUTCOMES The primary outcome was the time needed to reach a therapeutic anti-Xa before and after the implementation of the pocket card. The secondary outcomes included a subgroup analysis assessing the effect of the CPAT. Other secondary outcomes were the anti-Xa status (infratherapeutic, therapeutic or supratherapeutic) at 7 and 24 hours of UFH treatment. RESULTS We found a significant increase in the time to reach therapeutic dosing with pocket card-guided recommendations implementation (10.1 vs 14 hours, HR of 0.8, 95% CI: 0.70 to 0.93). However, the CPAT was associated with a significant decrease in the time needed to reach the therapeutic range (13.9 vs 7.1 hours, HR of 1.74, 95% CI: 1.17 to 2.60). CONCLUSION Although we observed an increase in time to reach therapeutic anti-Xa with the pocket card, possibly due to a selection bias (use of activated partial thromboplastin time for monitoring before the pocket card), the implementation of CPAT significantly decreased the delay for effective therapy. Further studies are needed to confirm these findings, and to determine the optimal initial dose of UFH anticoagulation.
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Affiliation(s)
- Wedali E Jimaja
- Medecine, Division of general internal medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - Jerome Stirnemann
- Medecine, Division of general internal medicine, University Hospitals of Geneva, Geneva, Switzerland
- Faculty of medecine, University of Geneva, Geneva, Switzerland
| | - Pierre Fontana
- Faculty of medecine, University of Geneva, Geneva, Switzerland
- Medicine, Division of angiology and hemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - Katherine S Blondon
- Faculty of medecine, University of Geneva, Geneva, Switzerland
- Medical directorate, University Hospitals of Geneva, Geneva, Switzerland
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8
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Amiral J, Amiral C, Dunois C. Optimization of Heparin Monitoring with Anti-FXa Assays and the Impact of Dextran Sulfate for Measuring All Drug Activity. Biomedicines 2021; 9:700. [PMID: 34205548 PMCID: PMC8235539 DOI: 10.3390/biomedicines9060700] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/08/2021] [Accepted: 06/16/2021] [Indexed: 11/22/2022] Open
Abstract
Heparins, unfractionated or low molecular weight, are permanently in the spotlight of both clinical indications and laboratory monitoring. An accurate drug dosage is necessary for an efficient and safe therapy. The one-stage kinetic anti-FXa assays are the most widely and universally used with full automation for large series, without needing exogenous antithrombin. The WHO International Standards are available for UFH and LMWH, but external quality assessment surveys still report a high inter-assay variability. This heterogeneity results from the following: assay formulation, designed without or with dextran sulfate to measure all heparin in blood circulation; calibrators for testing UFH or LMWH with the same curve; and automation parameters. In this study, various factors which impact heparin measurements are reviewed, and we share our experience to optimize assays for testing all heparin anticoagulant activities in plasma. Evidence is provided on the usefulness of low molecular weight dextran sulfate to completely mobilize all of the drug present in blood circulation. Other key factors concern the adjustment of assay conditions to obtain fully superimposable calibration curves for UFH and LMWH, calibrators' formulations, and automation parameters. In this study, we illustrate the performances of different anti-FXa assays used for testing heparin on UFH or LMWH treated patients' plasmas and obtained using citrate or CTAD anticoagulants. Comparable results are obtained only when the CTAD anticoagulant is used. Using citrate as an anticoagulant, UFH is underestimated in the absence of dextran sulfate. Heparin calibrators, adjustment of automation parameters, and data treatment contribute to other smaller differences.
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Affiliation(s)
| | - Cédric Amiral
- HYPHEN BioMed, 95000 Neuville sur Oise, France; (C.A.); (C.D.)
| | - Claire Dunois
- HYPHEN BioMed, 95000 Neuville sur Oise, France; (C.A.); (C.D.)
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9
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Willekens G, Studt JD, Mendez A, Alberio L, Fontana P, Wuillemin WA, Schmidt A, Graf L, Gerber B, Bovet C, Sauter TC, Nagler M. A universal anti-Xa assay for rivaroxaban, apixaban, and edoxaban measurements: method validation, diagnostic accuracy and external validation. Br J Haematol 2021; 193:1203-1212. [PMID: 33954979 PMCID: PMC8252105 DOI: 10.1111/bjh.17470] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/19/2021] [Indexed: 11/28/2022]
Abstract
A universal anti‐Xa assay for the determination of rivaroxaban, apixaban and edoxaban drug concentrations would simplify laboratory procedures and facilitate widespread implementation. Following two pilot studies analysing spiked samples and material from 698 patients, we conducted a prospective multicentre cross‐sectional study, including 867 patients treated with rivaroxaban, apixaban or edoxaban in clinical practice to comprehensively evaluate a simple, readily available anti‐Xa assay that would accurately measure drug concentrations and correctly predict relevant levels in clinical practice. Anti‐Xa activity was measured by an assay calibrated with low‐molecular‐weight heparin (LMWH) in addition to ultra‐high performance liquid chromatography‐tandem mass spectrometry (LC‐MS/MS). As an external validation, LMWH‐calibrated anti‐Xa activity was also determined in nine external laboratories. The LMWH‐calibrated anti‐Xa activity correlated strongly with rivaroxaban, apixaban or edoxaban drug levels [rs = 0·98, 95% confidence interval (CI) 0·98–0·98]. The sensitivity for the clinically relevant cut‐off levels of 30, 50 and 100 µg/l was 96·2% (95% CI 94·4–97·4), 96·4% (95% CI 94·4–97·7) and 96·7% (95% CI 94·3–98·1) respectively. Concordant results were obtained in the external validation study. In conclusion, a universal, LMWH‐calibrated anti‐Xa assay accurately measured rivaroxaban, apixaban and edoxaban concentrations and correctly predicted relevant drug concentrations in clinical practice.
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Affiliation(s)
- Guido Willekens
- Department of Epidemiology, Maastricht University, Maastricht, the Netherlands.,Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Adriana Mendez
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospital, Geneva, Switzerland
| | - Walter A Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne, University of Bern, Bern, Switzerland
| | - Adrian Schmidt
- Institute of Laboratory Medicine and Clinic of Medical Oncology and Hematology, City Hospital Waid and Triemli, Zurich, Switzerland
| | - Lukas Graf
- Cantonal Hospital of St Gallen, St Gallen, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Cedric Bovet
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Hematology, Inselspital, Bern University Hospital, Bern, Switzerland
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10
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Dias JD, Lopez-Espina CG, Panigada M, Dalton HJ, Hartmann J, Achneck HE. Cartridge-Based Thromboelastography Can Be Used to Monitor and Quantify the Activity of Unfractionated and Low-Molecular-Weight Heparins. TH OPEN 2019; 3:e295-e305. [PMID: 31523746 PMCID: PMC6742498 DOI: 10.1055/s-0039-1696658] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Accepted: 07/25/2019] [Indexed: 01/22/2023] Open
Abstract
Thromboelastography is increasingly utilized in the management of bleeding and thrombotic complications where heparin management remains a cornerstone. This study assessed the feasibility of the cartridge-based TEG
®
6s system (Haemonetics Corp., Braintree, Massachusetts, United States) to monitor and quantify the effect of unfractionated and low-molecular-weight heparin (UFH and LMWH). Blood samples from healthy donors were spiked with UFH (
n
= 23; 0–1.0 IU/mL) or LMWH (enoxaparin;
n
= 22; 0–1.5 IU/mL). Functional fibrinogen maximum amplitude (CFF.MA), RapidTEG activated clotting time (CRT.ACT), and kaolin and kaolin with heparinase reaction time (CK.R and CKH.R) were evaluated for their correlation with heparin concentrations, as well as the combination parameters ΔCK.R − CKH.R, ratio CK.R/CKH.R, and ratio CKH.R/CK.R. Nonlinear mixed-effect modelling was used to study the relationship between concentrations and parameters, and Bayesian classification modelling for the prediction of therapeutic ranges. CK.R and CRT.ACT strongly correlated with the activity of LMWH and UFH (
p
< 0.001). Using combination parameters, heparin activity could be accurately quantified in the range of 0.05 to 0.8 IU/mL for UFH and 0.1 to 1.5 IU/mL for LMWH. CRT.ACT was able to quantify heparin activity at higher concentrations but was only different from the reference range (
p
< 0.05) at >0.5 IU/mL for UFH and >1.5 IU/mL for LMWH. Combination parameters classified blood samples into subtherapeutic, therapeutic, and supratherapeutic heparin ranges, with an accuracy of >90% for UFH, and >78% for LMWH. This study suggests that TEG 6s can effectively monitor and quantify heparin activity for LMWH and UFH. Additionally, combination parameters can be used to classify blood samples into therapeutic ranges based on heparin activity.
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Affiliation(s)
| | | | - Mauro Panigada
- Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico, Milan, Italy
| | - Heidi J Dalton
- Department of Pediatrics, Inova Health and Vascular Institute, Falls Church, Virginia, United States
| | - Jan Hartmann
- Haemonetics Corporation, Braintree, Massachusetts, United States
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