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Gendron N, Billoir P, Siguret V, Le Cam-Duchez V, Proulle V, Macchi L, Boissier E, Mouton C, De Maistre E, Gouin-Thibault I, Jourdi G. Is there a role for the laboratory monitoring in the management of specific antidotes of direct oral anticoagulants? Thromb Res 2024; 237:171-180. [PMID: 38626592 DOI: 10.1016/j.thromres.2024.04.005] [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: 01/03/2024] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 04/18/2024]
Abstract
Given the growing number of patients receiving direct oral anticoagulant (DOAC), patients requiring rapid neutralization is also increasing in case of major bleedings or urgent surgery/procedures. Idarucizumab is commercialized as a specific antidote to dabigatran while andexanet alfa has gained the Food and Drug Administration and the European Medicines Agency approval as an oral anti-factor Xa inhibitors antidote. Other antidotes or hemostatic agents are still under preclinical or clinical development, the most advanced being ciraparantag. DOAC plasma levels measurement allows to appropriately select patient for antidote administration and may prevent unnecessary prescription of expensive molecules in some acute clinical settings. However, these tests might be inconclusive after some antidote administration, namely andexanet alfa and ciraparantag. The benefit of laboratory monitoring following DOAC reversal remains unclear. Here, we sought to provide an overview of the key studies evaluating the safety and efficacy of DOAC reversal using the most developed/commercialized specific antidotes, to discuss the potential role of the laboratory monitoring in the management of patients receiving DOAC specific antidotes and to highlight the areas that deserve further investigations in order to establish the exact role of laboratory monitoring in the appropriate management of DOAC specific antidotes.
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Affiliation(s)
- Nicolas Gendron
- Hematology Department, Assistance Publique Hôpitaux de Paris.Centre-Université de Paris (APHP.CUP), F-75015 Paris, France; Paris Cité University, INSERM, Innovative Therapies in Haemostasis, F-75006 Paris, France.
| | - Paul Billoir
- Normandie University, UNIROUEN, INSERM U1096, Rouen University Hospital, Vascular Hemostasis Unit, F 76000 Rouen, France
| | - Virginie Siguret
- Paris Cité University, INSERM, Innovative Therapies in Haemostasis, F-75006 Paris, France; Laboratory of Hematology, Lariboisière hospital, AP-HP. Nord, F-75010 Paris, France
| | - Véronique Le Cam-Duchez
- Normandie University, UNIROUEN, INSERM U1096, Rouen University Hospital, Vascular Hemostasis Unit, F 76000 Rouen, France
| | - Valérie Proulle
- Service Hématologie Biologique et UF d'Hémostase Clinique, Hôpital Cochin, Assistance Publique Hôpitaux de Paris.Centre-Université de Paris (APHP.CUP), F-75015 Paris, France; Université Paris Cité, CRC, unité UMR_S1138, France
| | - Laurent Macchi
- University of Poitiers, INSERM 1313, IRMETIST, F-86000 Poitiers, France; CHU de Poitiers, laboratory of hematology, F-86000 Poitiers, France
| | - Elodie Boissier
- Laboratory of Hematology, University Hospital, Nantes, France
| | - Christine Mouton
- Hematology Laboratory, Hemostasis Department, Haut-Lévêque hospital, CHU, Bordeaux, France
| | | | - Isabelle Gouin-Thibault
- Univ Rennes, Rennes University Hospital, Inserm, EHESP, IRSET (Institut de Recherche en Santé, Environnement et Travail) - UMR_S, 1085, Rennes, France; Hematology Laboratory, Rennes University Hospital, Rennes, France
| | - Georges Jourdi
- Paris Cité University, INSERM, Innovative Therapies in Haemostasis, F-75006 Paris, France; Laboratory of Hematology, Lariboisière hospital, AP-HP. Nord, F-75010 Paris, France.
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Olie RH, Winckers K, Rocca B, Ten Cate H. Oral Anticoagulants Beyond Warfarin. Annu Rev Pharmacol Toxicol 2024; 64:551-575. [PMID: 37758192 DOI: 10.1146/annurev-pharmtox-032823-122811] [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: 10/03/2023]
Abstract
Direct oral anticoagulants (DOACs) have largely replaced vitamin K antagonists, mostly warfarin, for the main indications for oral anticoagulation, prevention and treatment of venous thromboembolism, and prevention of embolic stroke in atrial fibrillation. While DOACs offer practical, fixed-dose anticoagulation in many patients, specific restrictions or contraindications may apply. DOACs are not sufficiently effective in high-thrombotic risk conditions such as antiphospholipid syndrome and mechanical heart valves. Patients with cancer-associated thrombosis may benefit from DOACs, but the bleeding risk, particularly in those with gastrointestinal or urogenital tumors, must be carefully weighed. In patients with frailty, excess body weight, and/or moderate-to-severe chronic kidney disease, DOACs must be cautiously administered and may require laboratory monitoring. Reversal agents have been developed and approved for life-threatening bleeding. In addition, the clinical testing of potentially safer anticoagulants such as factor XI(a) inhibitors is important to further optimize anticoagulant therapy in an increasingly elderly and frail population worldwide.
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Affiliation(s)
- Renske H Olie
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
| | - Kristien Winckers
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
| | - Bianca Rocca
- Section of Pharmacology, Catholic University School of Medicine, Rome, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health, University of Florence, Florence, Italy
| | - Hugo Ten Cate
- Departments of Internal Medicine (Section of Vascular Medicine) and Biochemistry, Thrombosis Expertise Center, and CARIM School for Cardiovascular Diseases, Maastricht University Medical Center, Maastricht, The Netherlands;
- Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
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Shaw JR, Castellucci LA, Siegal D, Carrier M. DOAC-associated bleeding, hemostatic strategies, and thrombin generation assays - a review of the literature. J Thromb Haemost 2023; 21:433-452. [PMID: 36696204 DOI: 10.1016/j.jtha.2022.11.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 10/24/2022] [Accepted: 11/15/2022] [Indexed: 01/26/2023]
Abstract
Direct oral anticoagulants (DOACs) account for most oral anticoagulant use. DOAC-associated bleeding events are commonly encountered in clinical practice and are associated with substantial morbidity and mortality. Both specific reversal agents and nonspecific hemostatic therapies, such as prothrombin complex concentrates, are used in the management of DOAC-associated bleeding. Measuring hemostatic efficacy and demonstrating a clinical impact from these therapies among studies of bleeding patients is challenging. Thrombin generation assays provide information on the total hemostatic potential of plasma, and have emerged as a promising modality to both measure the impact of DOACs on coagulation and to evaluate the effects of hemostatic therapies among patients with DOAC-associated bleeding. The mechanisms by which nonspecific hemostatic agents impact coagulation and thrombin generation in the context of DOAC therapy are unclear. As a result, we undertook a review of the literature using a systematic search strategy with the goal of summarizing the effects of DOACs on thrombin generation and the effects of both specific reversal agents and nonspecific hemostatic therapies on DOAC-altered thrombin generation parameters. We sought to identify clinical studies focusing on whether altered thrombin generation is associated with clinical bleeding and whether correction of altered thrombin generation parameters predicts improvements in clinical hemostasis. Lastly, we sought to outline future directions for the application of thrombin generation assays toward anticoagulation therapies and the question of anticoagulation reversal.
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Affiliation(s)
- Joseph R Shaw
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada.
| | - Lana A Castellucci
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - Deborah Siegal
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marc Carrier
- Department of Medicine, University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Canada
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Stone L, Merriman E, Royle G, Hanna M, Chan H. Retrospective analysis of the effectiveness of a reduced dose of idarucizumab in dabigatran reversal. Thromb Haemost 2021; 122:1096-1103. [PMID: 34814227 DOI: 10.1055/a-1704-0630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND The recommended dose of idarucizumab, the specific reversal agent for dabigatran etexilate, is 5g. However, published data showed biochemical reversal after an initial 2.5g dose. OBJECTIVES This study aims to retrospectively compare the clinical effectiveness of 2.5g and 5g doses of idarucizumab used in dabigatran reversal in three hospitals in Auckland, New Zealand. METHODS All patients receiving idarucizumab for dabigatran reversal between 1st April 2016 and 31st December 2018 were included. The primary outcome was the likelihood of receiving a second dose of idarucizumab during the same admission. Secondary outcomes included normalisation of coagulation profiles; and 30-day thrombotic, bleeding and mortality rates. RESULTS Of 329 patients included, 206 received an upfront 2.5g dose and 123 received a 5g dose. The median age was 78 years and median creatinine clearance was 50mL/min. Most patients (62.6%) required idarucizumab for an urgent procedure, while 37.4% presented with bleeding. A 2.5g dose was not associated with an increased rate of receiving a second dose (OR 0.686, 95% CI 0.225-2.090). A similar proportion of patients in each group achieved a normal APTT (73.8% vs 80.0%, p=0.464) and dTCT (95.9% vs 91.4%, p=0.379) following idarucizumab infusion. There was no increase in the rate of death (OR 0.602, 95% CI 0.292-1.239), thrombosis (OR 0.386, 95% CI 0.107-1.396) or bleeding (OR 0.96, 95% CI 0.27-3.33) in the 2.5g dose group compared to the 5g dose group. CONCLUSIONS An initial 2.5g dose of idarucizumab appears effective for dabigatran reversal in the real-world setting.
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Affiliation(s)
- Louisa Stone
- Waitemata District Health Board, Auckland, New Zealand
| | | | | | - Merit Hanna
- Department of Haematology, Waitemata District Health Board, Auckland, New Zealand
| | - Henry Chan
- Department of Haematology, Waitemata District Health Board, Auckland, New Zealand
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Laxamana LC, Co COC, Yu JRT, Mojica CV, Iboleon-Dy MAM, Domingo AMC, Ilano KCS, Macrohon-Valdez MCZ. Dabigatran Reversal With Idarucizumab Preceding Thrombolysis in an Octogenarian Patient with Chronic Kidney Disease and Acute Stroke: A Case Report. Clin Ther 2020; 42:1840-1845. [PMID: 32778345 DOI: 10.1016/j.clinthera.2020.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 06/18/2020] [Accepted: 07/11/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE Reversing the effect of dabigatran among patients with atrial fibrillation is important to normalize coagulation profile among patients who develop serious hemorrhage from any source. However, such intervention always has the potential to cause a prothrombotic state. Among patients suspected of ischemic stroke, Idarucizumab, may be administered preceding thrombolysis. This is a considerable option when given during the critical phase of revascularization. METHODS We report the case of an 84-year old, male, banker, known hypertensive with chronic renal disease. He has non valvular atrial fibrillation receiving Dabigatran at 75 mg twice daily and presented with symptoms of right-sided weakness, right hemisensory loss, facial asymmetry, and slurring of speech equating to National Institute of Health Stroke Scale (NIHSS) of 5. After coming into the hospital for a suspected stroke, 3 hours and 25 minutes after symptoms, complete reversal of Dabigatran with Idarucizumab was administered and intravenous thrombolysis was initiated 271 minutes post ictus. There was immediate improvement of the right upper extremity weakness and dysarthria 30 minutes post infusion. At 13 days post ictus, the patient was discharged with minimal right central facial palsy and right arm drift (NIHSS 2). Brain CT scan post revascularization did not reveal any hemorrhage and anticoagulant Apixaban 2.5 mg twice daily was started and maintained thereafter. Brain Magnetic Resonance Angiogram (MRA) showed complete recanalization of the left proximal MCA after 52 days. CONCLUSION Our case showed the effectiveness and safety of giving Idarucizumab followed by thrombolysis in Dabigatran-treated atrial fibrillation with ischemic stroke. Based on this case, the procedure can be performed in an elderly population with chronic kidney disease when administered close to the limit of threshold for thrombolysis.
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Affiliation(s)
- Lina C Laxamana
- Institute for Neurosciences, St. Luke's Medical Center- Global City, Manila, Philippines
| | - Christian Oliver C Co
- Institute for Neurosciences, St. Luke's Medical Center- Global City, Manila, Philippines.
| | - Jeryl Ritzi T Yu
- Institute for Neurosciences, St. Luke's Medical Center- Global City, Manila, Philippines
| | - Christianne V Mojica
- Institute for Neurosciences, St. Luke's Medical Center- Global City, Manila, Philippines
| | | | - Alyssa Mae C Domingo
- Institute for Neurosciences, St. Luke's Medical Center- Global City, Manila, Philippines
| | - Karen Czarina S Ilano
- Institute for Neurosciences, St. Luke's Medical Center- Global City, Manila, Philippines
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Yasaka M, Yokota H, Suzuki M, Asakura H, Yamane T, Ogi Y, Ochiai K, Nakayama D. Idarucizumab for Emergency Reversal of Anticoagulant Effects of Dabigatran: Interim Results of a Japanese Post-Marketing Surveillance Study. Cardiol Ther 2020; 9:167-188. [PMID: 32152956 PMCID: PMC7237558 DOI: 10.1007/s40119-020-00165-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Idarucizumab, a monoclonal antibody fragment, was developed to reverse the anticoagulant effect of dabigatran, and it was approved in Japan in September 2016. An all-case post-marketing surveillance is ongoing to collect data in Japanese patients treated with idarucizumab who had serious bleeding (Group A) or required an urgent procedure (Group B). METHODS The primary endpoint was the incidence of adverse drug reactions (ADRs). The secondary endpoint was the maximum extent of reversal of the anticoagulant effect of dabigatran based on activated partial thromboplastin time (aPTT) within 4 h after idarucizumab administration. RESULTS This interim analysis included 262 patients who received idarucizumab. Eighteen patients (6.9%) experienced ADRs within 4 weeks. The reversal effect of idarucizumab based on aPTT within 4 h after idarucizumab administration was assessed in 30 patients and the median maximum percentage reversal was 100%. In Group A, the median time to bleeding cessation in patients without intracranial bleeding was 3.3 h. In Group B, normal intraoperative hemostasis was reported in 63 patients (72.4%). CONCLUSIONS The results of this interim analysis suggest that idarucizumab is safe and effective for the reversal of dabigatran in Japanese patients in a real-world setting, and support the continued use of idarucizumab. TRIAL REGISTRATION ClinicalTrials.gov identifier, NCT02946931.
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Affiliation(s)
- Masahiro Yasaka
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Hiroyuki Yokota
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Tokyo, Japan
| | - Michiyasu Suzuki
- Department of Neurosurgery, Yamaguchi University School of Medicine, Yamaguchi, Japan
| | - Hidesaku Asakura
- Department of Hematology, Kanazawa University Hospital, Ishikawa, Japan
| | - Teiichi Yamane
- Department of Cardiology, Jikei University School of Medicine, Tokyo, Japan
| | - Yukako Ogi
- Medicine Division, Nippon Boehringer Ingelheim Co, Ltd., Tokyo, Japan
| | | | - Daisuke Nakayama
- Medicine Division, Nippon Boehringer Ingelheim Co, Ltd., Tokyo, Japan.
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Kietaibl AT, Kietaibl S. New Hemostatic Agents: Perioperative Anesthetic Considerations. Curr Pharm Des 2020; 25:2158-2164. [PMID: 31298165 DOI: 10.2174/1381612825666190708183127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 06/23/2019] [Indexed: 11/22/2022]
Abstract
AIM Pharmacologic agents with procoagulant effects and antidotes against antithrombotic drugs play an important role in the prevention and management of perioperative coagulopathic bleeding. The aim of this narrative review is knowledge transfer from new and renewed hemostatic agents to anesthesiologists and other physicians involved in perioperative medicine. METHODS The literature search was performed on PubMed and the Summaries of Product Characteristics of 6 pharmacologic agents of interest: fibrinogen concentrate, vonicog alfa, susoctocog alfa, idarucizumab, andexanet alfa, and argatroban. RESULTS AND DISCUSSION This review highlights renewed interest in fibrinogen concentrate, an old prohemostatic drug, in correcting hypofibrinogenemia which is a leading pathomechanism of perioperative bleeding. This review describes clinically relevant aspects for brand new recombinant prohemostatic drugs for their use in critical clinical situations: vonicog alfa for the prevention and correction of bleeding in von Willebrand syndrome, and susoctocog alfa in acquired hemophilia A. Clinical experience and increasing evidence broadened the field of applications of the old antithrombotic drug argatroban to heparin resistance. New antidotes against new antithrombotic agents revolutionized the safety of chronic antithrombotic therapy in the emergency situations of acute and trauma surgery. Information on dosing and handling of new hemostatic drugs is summarized. CONCLUSION New and potent hemostatic agents exist for perioperative use and may enrich the armamentarium of anesthesiologists. Implementation into clinical practice requires their availability and user knowledge. Sustainability of these new drugs depends on post-licensing research, cost-effectiveness, and clinical experience.
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Affiliation(s)
| | - Sibylle Kietaibl
- Sigmund Freud Private University and Department of Anesthesia and Intensive Care, Evangelical Hospital Vienna, Vienna, Austria
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Nestor MA, Boling B. Reversing Direct Oral Anticoagulants in Acute Intracranial Hemorrhage. Crit Care Nurse 2020; 39:e1-e8. [PMID: 31154337 DOI: 10.4037/ccn2019160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Intracerebral hemorrhage is a major source of morbidity and mortality, accounting for 10% of all strokes. Oral anticoagulation therapy, while necessary to prevent thromboembolic complications, increases the risk of intracerebral hemorrhage and can potentially worsen bleeding in cases of acute hemorrhage. Before the introduction of direct oral anticoagulant agents in 2010, warfarin was the only option for oral anticoagulation. These new agents have an improved safety profile compared with warfarin but require different reversal strategies. Anticoagulation reversal in the setting of acute intracerebral hemorrhage is an evolving field. This article covers the most common direct oral anticoagulant medications, various available anticoagulant reversal strategies, and the latest guidelines for anticoagulation reversal in patients with acute intracranial hemorrhage.
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Affiliation(s)
- Melissa A Nestor
- Melissa A. Nestor is a neurosciences critical care pharmacist at the University of Kentucky, Lexington, Kentucky, with research interests in sepsis, neurologic injury, and ischemic stroke; Bryan Boling is an advanced practice provider with the Department of Anesthesiology, Division of Critical Care at the University of Kentucky
| | - Bryan Boling
- Melissa A. Nestor is a neurosciences critical care pharmacist at the University of Kentucky, Lexington, Kentucky, with research interests in sepsis, neurologic injury, and ischemic stroke; Bryan Boling is an advanced practice provider with the Department of Anesthesiology, Division of Critical Care at the University of Kentucky.
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Omae T, Koh K, Kumemura M, Sakuraba S, Katsuda Y. Perioperative management of patients with atrial fibrillation receiving anticoagulant therapy. J Anesth 2019; 33:551-561. [PMID: 31069541 DOI: 10.1007/s00540-019-02653-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 05/03/2019] [Indexed: 12/16/2022]
Abstract
The number of patients with atrial fibrillation (AF) and the number of patients indicated for anticoagulant therapy have been increasing because AF would affect patient survival due to thromboembolism. Once AF develops, following the disappearance of pulsation, the circumstances within the atrium become prothrombotic and thrombus formation within the left atrium occurs in patients with AF. In recent years, not only warfarin but also new oral anticoagulants were introduced clinically and have become used as oral anticoagulants. In the perioperative period, the risk of major hemorrhage needs to be reduced. On the other hand, the suspension of anticoagulant therapy and neutralization of anticoagulant effects elevate the risk of thrombosis. The perioperative management of patients receiving anticoagulant therapy is different from that of scheduled surgery and emergency surgery. In addition, knowledge of the characteristics of each oral anticoagulant is required at drug cessation and resumption. Unlike warfarin, which has been used in the past five decades, direct oral anticoagulants (DOACs) do not have sensitive indicators such as prothrombin time-international normalized ratio. To avoid major hemorrhages and thromboembolism, quantitative assays can be implemented for DOAC monitoring and for reversal therapies in perioperative settings.
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Affiliation(s)
- Takeshi Omae
- Department of Anesthesiology and Pain Clinic, Juntendo University Shizuoka Hospital, Izunokuni, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan.
| | - Keito Koh
- Department of Anesthesiology and Pain Clinic, Juntendo University Shizuoka Hospital, Izunokuni, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
| | - Masateru Kumemura
- Department of Anesthesiology and Pain Clinic, Juntendo University Shizuoka Hospital, Izunokuni, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
| | - Sonoko Sakuraba
- Department of Anesthesiology and Pain Clinic, Juntendo University Shizuoka Hospital, Izunokuni, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
| | - Yosuke Katsuda
- Department of Anesthesiology and Pain Clinic, Juntendo University Shizuoka Hospital, Izunokuni, 1129 Nagaoka, Izunokuni, Shizuoka, 410-2295, Japan
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Grottke O, van Ryn J, Zentai C, Gan G, Honickel M, Rossaint R, ten Cate H, Spronk HMH. Volume replacement strategies do not impair the binding of dabigatran to idarucizumab: Porcine model of hemodilution. PLoS One 2019; 14:e0209350. [PMID: 30615630 PMCID: PMC6322768 DOI: 10.1371/journal.pone.0209350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 12/04/2018] [Indexed: 11/25/2022] Open
Abstract
Background Idarucizumab is a humanized Fab fragment that specifically reverses dabigatran anticoagulation. In trauma, volume expanders are used for resuscitation to compensate for blood loss and hemorrhagic shock, but it is unknown whether volume expanders influence the binding of dabigatran to its antidote. Using a porcine dilutional coagulopathy model, this study investigated whether volume replacement strategies affect binding of dabigatran to idarucizumab. Methods Twenty-five male pigs were treated orally with dabigatran etexilate (30 mg/kg bid) for 3 days. The following day, animals were anesthetized, infused with dabigatran (total dose 0.645 mg/kg) to achieve supratherapeutic concentrations, and randomized 1:1:1:1:1 (n = 5 per group) to control (no hemodilution) or hemodilution where ~50% of blood volume was substituted with Ringer’s solution, 6% hydroxyethyl starch 130/0.4, 6% hydroxyethyl starch 200/0.5 or 4% gelatin. Idarucizumab was then administered intravenously (30 mg/kg) and serial blood samples were taken for up to 24 hours to measure diluted thrombin time (corresponding with dabigatran activity), total dabigatran (bound to antidote and free drug) and a panel of coagulation parameters. Results Mean plasma dabigatran levels were 617 ± 16 ng/mL after infusion and 600 ± 114 ng/mL after ~50% hemodilution with no significant differences between groups. Following treatment with idarucizumab, plasma concentrations of unbound dabigatran decreased markedly, with similar reductions in all groups. Dabigatran-induced prolongation of coagulation parameters was rapidly reversed in all groups. Conclusion This study indicates that several volume expanders used for resuscitation in trauma do not interfere with the binding of idarucizumab to dabigatran.
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Affiliation(s)
- Oliver Grottke
- Department of Anesthesiology, RWTH Aachen University Hospital, Aachen, Germany
- * E-mail:
| | - Joanne van Ryn
- Department of CardioMetabolic Diseases Research, Boehringer Ingelheim GmbH & Co. KG, Biberach, Germany
| | - Christian Zentai
- Department of Anesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Guanfa Gan
- Boehringer Ingelheim Pharmaceuticals, Inc., Ridgefield, Connecticut, United States of America
| | - Markus Honickel
- Department of Anesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Rolf Rossaint
- Department of Anesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Hugo ten Cate
- Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Henri M. H. Spronk
- Laboratory for Clinical Thrombosis and Haemostasis, Department of Internal Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
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Toyoda K, Yamagami H, Koga M. Consensus Guides on Stroke Thrombolysis for Anticoagulated Patients from Japan: Application to Other Populations. J Stroke 2018; 20:321-331. [PMID: 30309227 PMCID: PMC6186921 DOI: 10.5853/jos.2018.01788] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 07/19/2018] [Accepted: 08/13/2018] [Indexed: 01/13/2023] Open
Abstract
Development of direct oral anticoagulants and their antidotes has led to the need to reconsider the eligibility of acute stroke patients who have been taking oral anticoagulants for intravenous thrombolysis. Officially authorized Japanese guidelines on this issue were revised twice at the time of approval for clinical use of direct oral anticoagulants and idarucizumab, a specific reversal agent for dabigatran. A unique recommendation in the latest Japanese clinical guides was that thrombolysis can be recommended if the time of the last dose of direct oral anticoagulants exceeds 4 hours and if commonly available anticoagulation markers are normal or subnormal, i.e., international normalized ratio of prothrombin time <1.7 and activated partial thromboplastin time <1.5 times the baseline value (≤40 seconds only as a guide). These criteria are partly supported by the findings of domestic multicenter and single-center surveys that symptomatic or asymptomatic intracranial hemorrhage following thrombolysis was rare under the conditions of the criteria. Even for dabigatran users, stroke thrombolysis can be considered without pretreatment by idarucizumab if patients meet the above criteria. If not, direct mechanical thrombectomy can be considered without pretreatment by idarucizumab or thrombolysis, and use of idarucizumab, followed immediately by thrombolysis, can be considered only when thrombectomy cannot be quickly performed. These clinical guides are practical and to some extent economical, but they have some limitations, including lack of corroborating information from sufficient numbers of relevant cases. The guides will be further modified based on the results of future research.
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Affiliation(s)
- Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroshi Yamagami
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Grottke O, Lier H, Hofer S. [Management of hemorrhage in patients treated with direct oral anticoagulants]. Anaesthesist 2018; 66:679-689. [PMID: 28455651 DOI: 10.1007/s00101-017-0313-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The introduction of nonvitamin K antagonistic, direct oral anticoagulants (DOAC) made thromboembolic prophylaxis easier for patients. For many physicians, however, there is still uncertainty about monitoring, preoperative discontinuation, and restarting of DOAC therapy. Guidelines for the management of bleeding are provided, but require specific therapeutic skills in the management of diagnostics and therapy of acute hemorrhage. Small clinical studies and case reports indicate that unspecific therapy with prothrombin complex concentrates (PCC) and activated PCC (aPCC) concentrate may reverse DOAC-induced anticoagulation. However, PCC or aPCC at higher doses potentially provoke thromboembolic complications. However, idarucizumab, a specific, fast-acting, antidote for dabigatran, provides immediate and sustained reversal with no intrinsic or prohemostatic activity. This review article provides an overview of the pharmacology and potential risk of DOAC and the management in the perioperative period with a focus of current concepts in the treatment of DOAC-associated bleeding.
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Affiliation(s)
- O Grottke
- Klinik für Anästhesiologie, Experimentelle Hämostaseologie, Universitätsklinikum RWTH Aachen, Pauwelsstraße 30, 52074, Aachen, Deutschland.
| | - H Lier
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Köln (AöR), Köln, Deutschland
| | - S Hofer
- Klinik für Anästhesie, Intensiv- und Notfallmedizin, Westpfalz-Klinikum GmbH, Kaiserslautern, Deutschland
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13
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Ohya Y, Makihara N, Wakisaka K, Morita T, Ago T, Kitazono T, Takaba H. Thrombolytic Therapy in Severe Cardioembolic Stroke After Reversal of Dabigatran with Idarucizumab: Case Report and Literature Review. J Stroke Cerebrovasc Dis 2018; 27:e128-e131. [PMID: 29555397 DOI: 10.1016/j.jstrokecerebrovasdis.2018.02.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 02/12/2018] [Indexed: 02/04/2023] Open
Abstract
Whether idarucizumab, an antidote of dabigatran, can be used effectively and safely before thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) in patients with stroke undergoing treatment with dabigatran remains unknown. We herein describe a 57-year-old man who developed severe cardioembolic stroke with a National Institutes of Health Stroke Scale score of 22 in the left middle cerebral artery territory while undergoing treatment with dabigatran for nonvalvular atrial fibrillation and who was treated with rt-PA after the reversal of dabigatran with idarucizumab. The thrombolytic therapy following the use of idarucizumab significantly improved the patient's neurological symptoms without hemorrhagic complications, although acute arterial occlusion of the right lower limb was found during the clinical course.
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Affiliation(s)
- Yuichiro Ohya
- Department of Cerebrovascular Medicine, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, Japan; Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.
| | - Noriko Makihara
- Department of Cerebrovascular Medicine, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, Japan
| | - Kayo Wakisaka
- Department of Cerebrovascular Medicine, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, Japan
| | - Takao Morita
- Department of Cerebrovascular Medicine, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, Japan
| | - Tetsuro Ago
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hitonori Takaba
- Department of Cerebrovascular Medicine, Kyushu Central Hospital of the Mutual Aid Association of Public School Teachers, Fukuoka, Japan
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14
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Akman N, Braunschweig T, Honickel M, Schütt K, Schöchl H, Stoppe C, Rossaint R, Grottke O. Reversal of dabigatran by intraosseous or intravenous idarucizumab in a porcine polytrauma model. Br J Anaesth 2018; 120:978-987. [PMID: 29661415 DOI: 10.1016/j.bja.2018.01.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 01/05/2018] [Accepted: 01/31/2018] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Idarucizumab is licensed to reverse dabigatran in life-threatening haemorrhage. Establishment of venous access can be challenging, and the intraosseous (IO) route is a potentially life-saving alternative. In this study, we compared the efficacy and safety of IO or intravenous (i.v.) idarucizumab for dabigatran reversal in a porcine polytrauma model. METHODS Male pigs (n=21) received oral dabigatran etexilate (30 mg kg-1 bid) for 3 days. On the 4th day, animals received dabigatran infusion and were randomised 1:1:1 to receive IO saline (control), i.v. idarucizumab (60 mg kg-1), or IO idarucizumab (60 mg kg-1), or animals were included in a sham group (n=7). Study treatment was administered after polytrauma and the animals were monitored for 240 min, or until death. Coagulation status was monitored by thromboelastometry, thromboelastography, and thrombin measurements. RESULTS Total blood loss was lowest in sham animals [521 (52) ml, P<0.01 vs all other groups], and comparable in the two idarucizumab groups [IO: 1085 (102) ml vs i.v.: 1142 (125) ml], and highest in the control group [4065 (557) ml, P<0.001 vs all other groups]. Survival to 240 min was 100% in the sham group and both idarucizumab groups, and 14% in the control group. IO and i.v. idarucizumab promptly normalised global coagulation assays and thrombin generation. Thromboelastography showed a strong correlation between dabigatran concentrations and R-time (R2=0.90 and 0.89) in idarucizumab-treated animals. CONCLUSIONS Intravenous and intraosseous idarucizumab were comparable for reversing dabigatran in a porcine trauma model. Dabigatran reversal could be monitored using fully automated thromboelastography.
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Affiliation(s)
- N Akman
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - T Braunschweig
- Department of Pathology, RWTH Aachen University Hospital, Aachen, Germany
| | - M Honickel
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - K Schütt
- Department of Internal Medicine I, RWTH Aachen University Hospital, Aachen, Germany
| | - H Schöchl
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Research Centre, Vienna, Austria; Department of Anaesthesiology and Intensive Care Medicine, AUVA Emergency Hospital, Salzburg, Austria
| | - C Stoppe
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - R Rossaint
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany
| | - O Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, Aachen, Germany.
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15
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Abstract
Direct oral anticoagulants are becoming increasingly popular in outpatient use. These medications have lacked specific reversal agents. However, this is changing. The Federal Food and Drug Administration approved idarucizumab for reversal of dabigatran in 2016, and another agent, andexanet alfa, is currently in clinical trials for reversal of rivaroxaban and apixaban. This article examines the efficacy and safety of these emerging reversal agents, as well as other historical agents for reversal of direct oral anticoagulants.
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16
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Albisetti M, Schlosser A, Brueckmann M, Gropper S, Glund S, Tartakovsky I, Brandão LR, Reilly PA. Rationale and design of a phase III safety trial of idarucizumab in children receiving dabigatran etexilate for venous thromboembolism. Res Pract Thromb Haemost 2018; 2:69-76. [PMID: 30046708 PMCID: PMC5868044 DOI: 10.1002/rth2.12053] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 09/26/2017] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The incidence of venous thromboembolism (VTE) in children has been increasing. Anticoagulants are the mainstay of treatment but are associated with bleeding events that may be life-threatening. Idarucizumab is a fragment antigen-binding (fab) that provides immediate, complete, and sustained reversal of dabigatran's anticoagulant effects in adults. OBJECTIVE AND METHODS This phase III, open-label, single-arm, multicenter, multinational trial will assess the safety of idarucizumab in children participating in two ongoing trials investigating dabigatran etexilate. Eligible patients will be children with VTE (aged 0-≤18 years; n = ~5) with life-threatening or uncontrolled bleeding (group A), and children who require emergency surgery/urgent procedures for a condition other than bleeding (group B). Patients will receive idarucizumab up to 5 g as two consecutive intravenous infusions over 5-10 minutes each, as two 10-15-minute drips or as two bolus injections (15 minutes apart) and will be monitored for 30 days. The primary endpoint will be the safety of idarucizumab assessed by the occurrence of drug-related adverse events (including immune reactions) and all-cause mortality. Secondary endpoints will be the reversal of dabigatran anticoagulant effects assessed by changes in diluted thrombin time and ecarin clotting time, time to achieve complete reversal and the duration of the reversal and bleeding severity (group A). The formation of antidrug antibodies at 30 days post-dose and cessation of bleeding will also be assessed. CONCLUSION This study will report the safety of idarucizumab in children with VTE who require rapid reversal of the anticoagulant effects of dabigatran. Clinical trial registration: NCT02815670.
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Affiliation(s)
- Manuela Albisetti
- Hematology DepartmentUniversity Children's HospitalZurichSwitzerland
| | - Arno Schlosser
- Department of Clinical DevelopmentBoehringer Ingelheim bvAlkmaarthe Netherlands
| | - Martina Brueckmann
- Clinical Development and Medical AffairsBoehringer Ingelheim Pharma GmbH & Co. KGIngelheimGermany
- Faculty of Medicine MannheimUniversity of HeidelbergMannheimGermany
| | - Savion Gropper
- Clinical Development and Medical AffairsBoehringer Ingelheim Pharma GmbH & Co. KGIngelheimGermany
| | - Stephan Glund
- Translational Medicine and Clinical PharmacologyBoehringer Ingelheim Pharma GmbH & Co. KGBiberachGermany
| | - Igor Tartakovsky
- Clinical Development and Medical AffairsBoehringer Ingelheim Pharma GmbH & Co. KGIngelheimGermany
| | - Leonardo R. Brandão
- Department of PediatricsDivision of Haematology/OncologyUniversity of TorontoThe Hospital for Sick ChildrenTorontoONCanada
| | - Paul A. Reilly
- Clinical DevelopmentBoehringer Ingelheim Pharmaceuticals, Inc.RidgefieldCTUSA
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17
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Eikelboom JW, Kozek-Langenecker S, Exadaktylos A, Batorova A, Boda Z, Christory F, Gornik I, Kėkštas G, Kher A, Komadina R, Koval O, Mitic G, Novikova T, Pazvanska E, Ratobilska S, Sütt J, Winder A, Zateyshchikov D. Emergency care of patients receiving non-vitamin K antagonist oral anticoagulants. Br J Anaesth 2017; 120:645-656. [PMID: 29576106 DOI: 10.1016/j.bja.2017.11.082] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 09/06/2017] [Accepted: 09/15/2017] [Indexed: 01/19/2023] Open
Abstract
Non-vitamin K antagonist oral anticoagulants (NOACs), which inhibit thrombin (dabigatran) and factor Xa (rivaroxaban, apixaban, edoxaban) have been introduced in several clinical indications. Although NOACs have a favourable benefit-risk profile and can be used without routine laboratory monitoring, they are associated-as any anticoagulant-with a risk of bleeding. In addition, treatment may need to be interrupted in patients who need surgery or other procedures. The objective of this article, developed by a multidisciplinary panel of experts in thrombosis and haemostasis, is to provide an update on the management of NOAC-treated patients who experience a bleeding episode or require an urgent procedure. Recent advances in the development of targeted reversal agents are expected to help streamline the management of NOAC-treated patients in whom rapid reversal of anticoagulation is required.
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Affiliation(s)
- J W Eikelboom
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.
| | - S Kozek-Langenecker
- Department of Anaesthesia and Intensive Care, Evangelical Hospital Vienna, Vienna, Austria
| | - A Exadaktylos
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - A Batorova
- Department of Haematology and Transfusion Medicine, Faculty of Medicine of Comenius University, and University Hospital, Bratislava, Slovakia
| | - Z Boda
- Department of Internal Medicine, Thrombosis and Haemostasis Centre, University of Debrecen, Debrecen, Hungary
| | - F Christory
- Medical Education Global Solutions, Paris, France
| | - I Gornik
- Intensive Care Unit, Department of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia; University of Zagreb School of Medicine, Zagreb, Croatia
| | - G Kėkštas
- Department of Anaesthesiology and Intensive Care, Vilnius University Hospital Santariškių Klinikos, Vilnius, Lithuania
| | - A Kher
- Laboratory of Biological Hematology, Hôtel-Dieu University Hospital, Paris, France
| | - R Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Celje, Slovenia
| | - O Koval
- Department of Hospital Therapy No. 2, Dnipropetrovsk State Medical Academy, Dnipropetrovsk, Ukraine
| | - G Mitic
- Thrombosis and Haemostasis Unit, Centre of Laboratory Medicine, Clinical Centre of Vojvodina, and Faculty of Medicine, University of Novi Sad, Novi Sad, Serbia
| | - T Novikova
- Department of Cardiology, Northwestern Medical University I. I. Mechnikov, and Vascular Centre, Pokrovskaya City Hospital, Saint Petersburg, Russian Federation
| | - E Pazvanska
- Department Anaesthesia and Intensive Care, 4th City Hospital, Sofia, Bulgaria
| | - S Ratobilska
- Intensive Care Unit, Pauls Stradins Clinical University Hospital, Riga, Latvia
| | - J Sütt
- Anaesthesiology and Intensive Care Clinic, Tartu University Hospital, Tartu, Estonia
| | - A Winder
- Department of Hematology, Thrombosis and Hemostasis Unit, Wolfson Medical Center, Holon, Israel
| | - D Zateyshchikov
- Primary Vascular Department, City Clinical Hospital No. 51, Moscow, Russia
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18
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Goriacko P, Yaghdjian V, Koleilat I, Sinnett M, Shukla H. The Use of Idarucizumab for Dabigatran Reversal in Clinical Practice: A Case Series. P & T : A PEER-REVIEWED JOURNAL FOR FORMULARY MANAGEMENT 2017; 42:699-703. [PMID: 29089726 PMCID: PMC5642159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
PURPOSE To describe the use of idarucizumab (Praxbind, Boehringer Ingelheim) in routine clinical practice at a large urban academic medical center. SUMMARY Seven total doses of idarucizumab were administered to six unique patients from October 31, 2015, to October 31, 2016. The reversal agent was used in conjunction with local bleeding control measures, blood product transfusions, and acid-suppressive therapy. In 86% of cases, idarucizumab administration resulted in a successful cessation of bleeding by clinical assessment. Two patients expired due to coexisting conditions. Idarucizumab was administered to patients with normal baseline coagulation tests in 43% of cases. No adverse reactions related to idarucizumab were reported. CONCLUSIONS Idarucizumab administration resulted in successful resolution of bleeding by clinical assessment. The therapy for acute bleeding with use of dabigatran (Pradaxa, Boehringer Ingelheim) remains supportive care, in addition to idarucizumab in cases of severe or uncontrolled bleeding. Development of institution-specific protocols and better guidance for using baseline coagulation tests are needed.
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19
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Dzeshka MS, Pastori D, Lip GYH. Direct oral anticoagulant reversal: how, when and issues faced. Expert Rev Hematol 2017; 10:1005-1022. [PMID: 28901221 DOI: 10.1080/17474086.2017.1379896] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
INTRODUCTION The number of atrial fibrillation (AF) patients requiring thrombo-prophylaxis with oral anticoagulation is greatly increasing. The introduction of non-vitamin K oral anticoagulants (NOACs) in addition to standard therapy with dose-adjusted warfarin has increased the therapeutic options for AF patients. Despite a generally better safety profile of the NOACs, the risk of major bleedings still persists, and the management of serious bleeding is a clinical challenge. Areas covered: In the current review, risk of major bleeding in patients taking NOACs and general approaches to manage bleeding depending on severity, with a particular focus on specific reversal agents, are discussed. Expert commentary: Due to short half-life of NOACs compared to warfarin, discontinuation of drug, mechanical compression, and volume substitution are considered to be sufficient measures in most of bleeding cases. In case of life-threatening bleeding or urgent surgery, hemostasis can be achieved with non-specific reversal agents (prothrombin complex concentrates) in patients treated with factor Xa inhibitor until specific antidotes (andexanet α and ciraparantag) will receive approval. Thus far, idarucizumab has been the only reversal agent approved for dabigatran.
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Affiliation(s)
- Mikhail S Dzeshka
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,b Grodno State Medical University , Grodno , Belarus
| | - Daniele Pastori
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,c Department of Internal Medicine and Medical Specialties , Sapienza University of Rome , Rome , Italy
| | - Gregory Y H Lip
- a Institute of Cardiovascular Sciences , University of Birmingham , Birmingham , UK.,d Aalborg Thrombosis Research Unit, Department of Clinical Medicine , Aalborg University , Aalborg , Denmark
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20
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Vornicu O, Larock AS, Dincq AS, Douxfils J, Dogné JM, Mullier F, Lessire S. Idarucizumab for the treatment of hemorrhage and dabigatran reversal in patients requiring urgent surgery or procedures. Expert Opin Biol Ther 2017; 17:1275-1296. [DOI: 10.1080/14712598.2017.1349749] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Ovidiu Vornicu
- Department of Anesthesiology, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Anne-Sophie Larock
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Department of Pharmacy, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Anne-Sophie Dincq
- Department of Anesthesiology, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| | - Jonathan Douxfils
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Université de Namur, Namur, Belgium
| | - Jean-Michel Dogné
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Université de Namur, Namur, Belgium
| | - François Mullier
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Hematology Laboratory, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Sarah Lessire
- Department of Anesthesiology, Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC) – NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Université de Namur, Namur, Belgium
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21
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Martin AC, Godier A, Smadja DM, Mauge L, Fischer AM. [State of the art: Direct oral anticoagulants and transfusion]. Transfus Clin Biol 2017; 24:154-159. [PMID: 28673500 DOI: 10.1016/j.tracli.2017.05.019] [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: 05/30/2017] [Accepted: 05/31/2017] [Indexed: 11/29/2022]
Abstract
Direct oral anticoagulants (DOAC) are indicated for stroke prevention in atrial fibrillation and for the prevention and treatment of venous thromboembolism. As any anticoagulant, they are associated with a bleeding risk. Management of DOAC-induced bleeding is challenging. Idarucizumab, antidote for dabigatran, is currently available and is part of the therapeutic strategy, whereas antidotes for anti-Xa agents are under development. Activated or non-activated prothrombin concentrates are proposed, although their efficacy to reverse DOAC is uncertain. We propose an update on DOAC-associated bleeding management, integrating the availability of idarucizumab and the critical place of DOAC concentration measurements.
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Affiliation(s)
- A-C Martin
- Service de cardiologie, service de santé des armées, hôpital d'instruction des armées Percy, 92025 Clamart, France; Inserm UMR-S 1140, faculté de pharmacie, université Paris-Descartes, 75006 Paris, France
| | - A Godier
- Inserm UMR-S 1140, faculté de pharmacie, université Paris-Descartes, 75006 Paris, France; Service d'anesthésie réanimation, fondation Adolphe-de-Rothschild, 75019 Paris, France
| | - D M Smadja
- Inserm UMR-S 1140, faculté de pharmacie, université Paris-Descartes, 75006 Paris, France; Service d'hématologie biologique, hôpital européen Georges-Pompidou, AP-HP, inserm UMR-S1140, 20, rue Leblanc, 75015 Paris, France.
| | - L Mauge
- Service d'hématologie biologique, hôpital européen Georges-Pompidou, AP-HP, inserm UMR-S1140, 20, rue Leblanc, 75015 Paris, France; Inserm U970, PARCC (Paris cardiovascular research center), université Paris-Descartes, Sorbonne Paris-cité, 75019 Paris, France
| | - A-M Fischer
- Service d'hématologie biologique, hôpital européen Georges-Pompidou, AP-HP, inserm UMR-S1140, 20, rue Leblanc, 75015 Paris, France; Inserm U970, PARCC (Paris cardiovascular research center), université Paris-Descartes, Sorbonne Paris-cité, 75019 Paris, France
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22
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Dubois V, Dincq AS, Douxfils J, Ickx B, Samama CM, Dogné JM, Gourdin M, Chatelain B, Mullier F, Lessire S. Perioperative management of patients on direct oral anticoagulants. Thromb J 2017; 15:14. [PMID: 28515674 PMCID: PMC5433145 DOI: 10.1186/s12959-017-0137-1] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2016] [Accepted: 05/04/2017] [Indexed: 12/31/2022] Open
Abstract
Direct oral anticoagulants (DOACs) have been licensed worldwide for several years for various indications. Each year, 10-15% of patients on oral anticoagulants will undergo an invasive procedure and expert groups have issued several guidelines on perioperative management in such situations. The perioperative guidelines have undergone numerous updates as clinical experience of emergency management has increased and perioperative studies including measurement of residual anticoagulant levels have been published. The high inter-patient variability of DOAC plasma levels has challenged the traditional recommendation that perioperative DOAC interruption should be based only on the elimination half-life of DOACs, especially before invasive procedures carrying a high risk of bleeding. Furthermore, recent publications have highlighted the potential danger of heparin bridging use when DOACs are stopped before an invasive procedure. As antidotes are progressively becoming available to manage severe bleeding or urgent procedures in patients on DOACs, accurate laboratory tests have become the standard to guide their administration and their actions need to be well understood by clinicians. This review aims to provide a systematic approach to managing patients on DOACs, based on recent updates of various perioperative guidance, and highlighting the advantages and limits of recommendations based on pharmacokinetic properties and laboratory tests.
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Affiliation(s)
- Virginie Dubois
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
| | - Anne-Sophie Dincq
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| | - Jonathan Douxfils
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université de Namur, Department of Pharmacy, Faculty of Medecine, Namur, Belgium
| | - Brigitte Ickx
- Université Libre de Bruxelles, Erasme University Hospital,Department of Anesthesiology, Brussels, Belgium
| | - Charles-Marc Samama
- Université Paris Descartes, Cochin University Hospital,Department of Anesthesiology and Intensive Care, Paris, France
| | - Jean-Michel Dogné
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université de Namur, Department of Pharmacy, Faculty of Medecine, Namur, Belgium
| | - Maximilien Gourdin
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
| | - Bernard Chatelain
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Yvoir, Belgium
| | - François Mullier
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
- Université catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Yvoir, Belgium
| | - Sarah Lessire
- Université catholique de Louvain, CHU UCL Namur, Department of Anesthesiology, Yvoir, Belgium
- Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute of LIfe Sciences (NARILIS), Namur, Belgium
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23
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Ng FC, Bice J, Rodda A, Lee-Archer M, Crompton DE. Adverse clinical outcomes after dabigatran reversal with idarucizumab to facilitate acute stroke thrombolysis. J Neurol 2017; 264:591-594. [PMID: 28168523 DOI: 10.1007/s00415-017-8410-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 01/30/2017] [Accepted: 01/30/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Felix C Ng
- Department of Neurology, Northern Health, Epping, Melbourne, VIC, 3076, Australia.
| | - James Bice
- Department of Neurology, Northern Health, Epping, Melbourne, VIC, 3076, Australia
| | - Anne Rodda
- Department of Neurology, Northern Health, Epping, Melbourne, VIC, 3076, Australia
| | - Matthew Lee-Archer
- Department of Neurology, Northern Health, Epping, Melbourne, VIC, 3076, Australia
| | - Douglas E Crompton
- Department of Neurology, Northern Health, Epping, Melbourne, VIC, 3076, Australia
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