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Fuhrmann V, Koscielny J, Vasilakis T, Andus T, Herber A, Fusco S, Roeb E, Schiefke I, Rosendahl J, Dollinger M, Caca K, Tacke F. [Use of specific antidotes in DOAC-associated severe gastrointestinal bleeding - an expert consensus - Antagonozation of direct oral anticoagulants in gastrointestinal hemorrhages]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:759-768. [PMID: 37586394 DOI: 10.1055/a-2112-1834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Gastrointestinal (GI) bleeding is one of the most common complications associated with the use of direct oral anticoagulants (DOAC). Clear algorithms exist for the emergency measures in (suspected) GI bleeding, including assessing the medication history regarding anti-platelet drugs and anticoagulants as well as simple coagulation tests during pre-endoscopic management. Platelet transfusions, fresh frozen plasma (FFP), or prothrombin complex concentrate (4F-PCC) are commonly used for optimizing the coagulation status. For severe bleeding under the thrombin inhibitor dabigatran, idarucizumab is available, and for bleeding under the factor Xa inhibitors rivaroxaban or apixaban, andexanet alfa is available as specific antidotes for DOAC antagonization. These antidotes represent emergency drugs that are typically used only after performing guideline-compliant multimodal measures including emergency endoscopy. Antagonization of oral anticoagulants should be considered for severe gastrointestinal bleeding in the following situations: (1) refractory hemorrhagic shock, (2) endoscopically unstoppable bleeding, or (3) nonavoidable delays until emergency endoscopy for life-threatening bleeding. After successful (endoscopic) hemostasis, anticoagulation (DOACs, vitamin K antagonist, heparin) should be resumed timely (i.e. usually within a week), taking into account individual bleeding and thromboembolic risk.
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Affiliation(s)
- Valentin Fuhrmann
- Klinik für Allgemeine Innere Medizin und Gastroenterologie, Heilig Geist-Krankenhaus, Köln, Germany
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Jürgen Koscielny
- Gerinnungsambulanz mit Hämophiliezentrum, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Vasilakis
- Charité Universitätsmedizin Berlin, Department of Hepatology and Gastroenterology, Berlin, Germany
| | - Tilo Andus
- Klinik für Allgemeine Innere Medizin, Gastroenterologie, Hepatologie und internistische Onkologie, Klinikum Stuttgart, Stuttgart, Germany
| | - Adam Herber
- Klinik und Poliklinik für Onkologie, Gastroenterologie, Hepatologie, Pneumologie und Infektiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Stefano Fusco
- Department of Gastroenterology, Eberhard-Karls-Universität Tübingen Medizinische Fakultät, Tübingen, Germany
| | - Elke Roeb
- Gastroenterology, Med. II, Gießen, Germany
| | - Ingolf Schiefke
- Department of Gastroenterology and Hepatology, St. George Hospital, Leipzig, Germany
- Gastroenterologie und Hepatologie am Johannisplatz, Leipzig, Germany
| | - Jonas Rosendahl
- Clinic for Internal Medicine I, University Hospital Halle, Halle, Germany
| | - Matthias Dollinger
- Medizinische Klinik I Gastroenterologie, Nephrologie und Diabetologie, Klinikum Landshut gGmbH, Landshut, Germany
- Innere Medizin I, University Hospital Ulm, Ulm, Germany
| | - Karel Caca
- Klinik für Innere Medizin, Gastroenterologie, Hämato-Onkologie, Diabetologie und Infektiologie, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Frank Tacke
- Charité Universitätsmedizin Berlin, Department of Hepatology and Gastroenterology, Berlin, Germany
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Qiao J, Tran MH. Challenges to Laboratory Monitoring of Direct Oral Anticoagulants. Clin Appl Thromb Hemost 2024; 30:10760296241241524. [PMID: 38650302 PMCID: PMC11036927 DOI: 10.1177/10760296241241524] [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: 02/09/2024] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 04/25/2024] Open
Abstract
Direct oral anticoagulants (DOACs) exert anticoagulation effect by directly inhibiting Factor Xa (rivaroxaban, apixaban, and edoxaban) or thrombin (dabigatran). Though DOACs are characterized by fixed-dose prescribing and generally do not require routine laboratory drug-level monitoring (DLM), circumstances may arise where the DLM may aid in clinical decision-making, including DOAC dose adjustment, anticoagulant class change, or decisions to withhold or administer reversal agents. We review the current literature that describes high-risk patient groups in which DLM may be beneficial for improved patient anticoagulation management and stewardship. The review also summarizes the limitations of conventional coagulation testing and discuss the emerging utility of quantitative methods for routine and rapid emergent evaluation of DOAC drug levels-in particular, the Anti-Xa activity to detect Factor Xa Inhibitors (rivaroxaban, apixaban, and edoxaban). Both technical and regulatory barriers to widespread DLM implementation are limiting factors to further clinical research that must be overcome, in order to propose universal DOAC DLM strategies and provide clinical-laboratory correlation to formally classify high-risk patient groups.
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Affiliation(s)
- Jesse Qiao
- Irvine Department of Pathology and Laboratory Medicine, University of California, Orange, CA, USA
| | - Minh-Ha Tran
- Irvine Department of Pathology and Laboratory Medicine, University of California, Orange, CA, USA
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3
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Koscielny J, Birschmann I, Bauersachs R, Trenk D, Langer F, Möhnle P, Beyer-Westendorf J. [Basics for the Use of Andexanet]. Hamostaseologie 2023; 43:398-409. [PMID: 37813368 DOI: 10.1055/a-2136-2391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/11/2023] Open
Abstract
BACKGROUND For life-threatening or uncontrollable bleeding in association with the thrombin inhibitor dabigatran, the monoclonal antibody fragment idarucizumab is available, and for bleeding in association with the direct factor Xa inhibitors rivaroxaban or apixaban, the modified recombinant FXa protein andexanet is available for reversal. These antidotes represent emergency drugs that are typically used only after performing guideline-compliant multimodal measures. METHODS An interdisciplinary group of experienced experts in the fields of angiology, hematology, internal medicine, clinical pharmacology, laboratory medicine, transfusion medicine, anesthesiology, intensive care, and hemostaseology developed recommendations relevant to daily clinical practice based on the current scientific evidence. RESULTS Reversal of oral anticoagulants should be considered for severe bleeding in the following situations: (1) life-threatening bleeding or refractory hemorrhagic shock, (2) intracerebral bleeding, or (3) endoscopically unstoppable gastrointestinal bleeding. After successful hemostasis, anticoagulation (e.g., direct oral anticoagulant, vitamin K antagonist, and heparin) should be resumed promptly, taking into account individual bleeding and thromboembolic risk. DISCUSSION This article aims to facilitate the management of patients with andexanet by all medical disciplines involved, thereby ensuring optimal care of patients during bleeding episodes.
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Affiliation(s)
- J Koscielny
- Charité, Universitätsmedizin Berlin, Gerinnungsambulanz mit Hämophiliezentrum, Berlin, Germany
| | - I Birschmann
- Herz- und Diabeteszentrum Nordrhein-Westfalen, Institut für Laboratoriums- und Transfusionsmedizin, Universitätsklinik der Ruhr-Universität Bochum, Bochum, Germany
| | - R Bauersachs
- Cardioangiologisches Centrum Bethanien, CCB, Frankfurt am Main, Germany
- Center for Vascular Research, München, Germany
| | - D Trenk
- Universitätsklinikum Freiburg, Universitat-Herzzentrum, Klinik für Kardiologie und Angiologie - Klinische Pharmakologie, Bad Krozingen, Germany
| | - F Langer
- Universitätsklinikum Eppendorf, Zentrum für Onkologie, II. Medizinische Klinik und Poliklinik (Gerinnungsambulanz und Hämophiliezentrum), Hamburg, Germany
| | - P Möhnle
- Abteilung für Transfusionsmedizin, Zelltherapeutika und Hämostaseologie, LMU Klinikum München, München, Germany
| | - J Beyer-Westendorf
- Thromboseforschung und Gerinnungsstörungen, Universitätsklinikum Carl Gustav Carus, Med. Klinik I, Dresden, Germany
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Divsalar B, Kalantari T, Mohebbi S, Bahmanimehr A, Shahsavani A, Borhani-Haghighi A. Comparison of Commercial Low Molecular Weight Heparin and Homemade Anti-Xa Calibrators to a Commercial Specific Anti-Xa Calibrator for Plasma Rivaroxaban Quantification by Anti-Xa Oral Anticoagulant Plasma Concentration Chromogenic Assay. Lab Med 2022. [DOI: 10.1093/labmed/lmac137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Abstract
Objective
The main concern about measuring the concentration of rivaroxaban by anti-Xa assay in some laboratories is the lack of a commercial specific calibrator in emergencies. Therefore, this study aimed at providing a homemade anti-Xa calibrator and commercial low molecular weight heparin (LMWH) anti-Xa calibrator.
Methods
The anti-Xa plasma concentration of rivaroxaban was measured in 70 patients using a commercial specific anti-Xa calibrator, a commercial LMWH anti-Xa calibrator, and a homemade anti-Xa calibrator.
Results
We demonstrated a significant correlation and agreement (P < .001) between LMWH-calibrated anti-Xa and the commercial specific calibrator. A significant correlation (P < .001) was found between homemade calibrated anti-Xa made by normal pooled plasma and that calibrated with a commercial specific drug. The nonspecific homemade and LMWH calibrators had excellent agreement (P < .001) and can be used interchangeably.
Conclusion
Our data showed that for estimating rivaroxaban concentrations, the LMWH calibrator could be used as an alternative calibrator in the anti-Xa assay.
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Affiliation(s)
- Bita Divsalar
- Division of Hematology and Blood Banking, Department of Laboratory Sciences, School of Paramedical Sciences, Shiraz University of Medical Sciences , Shiraz , Iran
- Diagnostic Laboratory Sciences and Technology Research Center, School of Paramedical Sciences, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Tahereh Kalantari
- Division of Hematology and Blood Banking, Department of Laboratory Sciences, School of Paramedical Sciences, Shiraz University of Medical Sciences , Shiraz , Iran
- Diagnostic Laboratory Sciences and Technology Research Center, School of Paramedical Sciences, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Soheila Mohebbi
- Division of Hematology and Blood Banking, Department of Laboratory Sciences, School of Paramedical Sciences, Shiraz University of Medical Sciences , Shiraz , Iran
- Diagnostic Laboratory Sciences and Technology Research Center, School of Paramedical Sciences, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Ardeshir Bahmanimehr
- Thalassemia and Hemophilia Genetic, PND Research Center, Dastgheib Hospital, Shiraz University of Medical Sciences , Shiraz , Iran
| | - Amin Shahsavani
- Thalassemia and Hemophilia Genetic, PND Research Center, Dastgheib Hospital, Shiraz University of Medical Sciences , Shiraz , Iran
- Hematology Research Center, Shiraz University of Medical Sciences , Shiraz , Iran
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Direct oral anticoagulants (DOACs): From the laboratory point of view. ACTA PHARMACEUTICA (ZAGREB, CROATIA) 2022; 72:459-482. [PMID: 36651369 DOI: 10.2478/acph-2022-0034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/09/2022] [Indexed: 01/20/2023]
Abstract
Direct oral anticoagulants (DOACs) represent a new generation of drugs that have been increasingly used in the prevention and treatment of thromboembolic states. According to the mechanism of anticoagulant action, DOACs are divided into two groups: direct inhibitors of thrombin (dabigatran) and direct inhibitors of activated factor X (FXa) (rivaroxaban, apixaban, edoxaban, betrixaban). Compared to the vitamin K antagonists, DOACs are superior in terms of onset of action, pharmacokinetic and pharmacodynamics properties and fixed daily dose without the need for routine coagulation monitoring. Despite these advantages, there are clinical conditions in which laboratory measurement of DOACs should be performed. Although DOACs have an impact on screening haemostasis assays (prothrombin time, PT; activated partial thromboplastin time, aPTT; and thrombin time, TT), these tests are not appropriate for quantifying drug levels. Therefore, specific quantitative methods (LC-MS/MS as a gold standard method for all DOACs, coagulometric and chromogenic assays for dabigatran, and chromogenic anti-Xa assays with drug-specific calibrators for inhibitors of FXa) should only be used for determination of DOACs concentration. The aim of this review is to present all aspects of laboratory assessment of DOACs, including pre-analytical, analytical and post-analytical factors in the overall testing process with a special accent on the available specific quantitative methods for measurement of DOACs in circulation.
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A Review of Direct-acting Oral Anticoagulants and Their Use in Solid Organ Transplantation. Transplantation 2022; 106:2143-2154. [PMID: 35642975 DOI: 10.1097/tp.0000000000004195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Direct-acting oral anticoagulant (DOAC) use has increased dramatically since their introduction because of the growing evidence of proven efficacy and enhanced safety compared with warfarin and the low-molecular-weight heparins in the general population. Unfortunately, there is a dearth of quality data regarding the safety and efficacy of the DOACs in patients awaiting organ transplant and those who received a solid organ transplant. This review aims to evaluate the available literature and considerations regarding anticoagulation use in transplant recipients, focusing on preoperative, perioperative, and postoperative DOAC use.
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Meihandoest T, Studt JD, Mendez A, Alberio L, Fontana P, Wuillemin WA, Schmidt A, Graf L, Gerber B, Amstutz U, Bovet C, Sauter TC, Asmis LM, Nagler M. Accuracy of a Single, Heparin-Calibrated Anti-Xa Assay for the Measurement of Rivaroxaban, Apixaban, and Edoxaban Drug Concentrations: A Prospective Cross-Sectional Study. Front Cardiovasc Med 2022; 9:817826. [PMID: 35369293 PMCID: PMC8969025 DOI: 10.3389/fcvm.2022.817826] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background Applying a single anti-Xa assay, calibrated to unfractionated heparin to measure rivaroxaban, apixaban, and edoxaban would simplify laboratory procedures and save healthcare costs. Aim We hypothesized that a heparin-calibrated anti-Xa assay would accurately measure rivaroxaban, apixaban, and edoxaban drug concentrations and correctly predict clinically relevant drug levels. Methods This analysis is part of the Simple-Xa study, a prospective multicenter cross-sectional study conducted in clinical practice. Patients treated with rivaroxaban, apixaban, or edoxaban were included. Anti-Xa activity was measured using the Siemens INNOVANCE® Heparin assay. Drug concentrations were determined using ultra-high performance liquid chromatography-tandem mass spectrometry (LC-MS/MS). Cut-off levels were determined in a derivation dataset (50% of patients) and sensitivities and specificities were calculated in a verification dataset (50% of patients). Results Overall, 845 patients were available for analysis. Correlation coefficients (r s ) between the heparin-calibrated anti-Xa assay and drug concentrations were 0.97 (95% CI 0.97, 0.98) for rivaroxaban, 0.96 (0.96, 0.97) for apixaban, and 0.96 (0.94, 0.99) for edoxaban. The area under the receiver operating characteristics curve (ROC) was 0.99 for all clinically relevant drug concentrations. In the verification dataset, the sensitivity was 94.2% (95% CI 90.8-96.6) for 30 μg L-1, 95.8% (92.4-98.0) for 50 μg L-1, and 98.7% (95.5-99.9) for 100 μg L-1. Specificities were 86.3% (79.2-91.7), 89.8% (84.5-93.7), and 88.7% (84.2-92.2), respectively. Conclusion In a large prospective study in clinical practice, a strong correlation of heparin-calibrated anti-Xa measurements with LC-MS/MS results was observed and clinically relevant drug concentrations were predicted correctly.
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Affiliation(s)
- Tamana Meihandoest
- Department of Epidemiology, Maastricht University, Maastricht, Netherlands.,Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Jan-Dirk Studt
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Adriana Mendez
- Institute for Laboratory Medicine, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Walter A Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne and University of Bern, Bern, Switzerland
| | - Adrian Schmidt
- Institute of Laboratory Medicine and Clinic of Medical Oncology and Hematology, City Hospital Zurich, Zurich, Switzerland
| | - Lukas Graf
- Center for Laboratory Medicine, St. Gallen, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Ursula Amstutz
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Cedric Bovet
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Lars M Asmis
- Centre for Perioperative Thrombosis and Haemostasis, Zurich, Switzerland
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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8
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Prospective cohort study on the use of low molecular weight heparin calibrated anti-Xa assay for measurement of direct oral Xa inhibitors in ex vivo patient samples. Pathology 2022; 54:599-605. [DOI: 10.1016/j.pathol.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 11/21/2022]
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Milner E, Ainsworth M, Gleaton M, Bookstaver D. Assessment of Anti-Xa activity in patients receiving concomitant apixaban with strong p-glycoprotein inhibitors and statins. J Clin Pharm Ther 2022; 47:668-675. [PMID: 35032137 PMCID: PMC9305439 DOI: 10.1111/jcpt.13596] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 12/14/2021] [Accepted: 12/15/2021] [Indexed: 12/27/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVES Although the apixaban Food and Drug Administration (FDA) package insert recommends dose reduction in patients administered dual strong inhibitors of p-glycoprotein (P-gp) and cytochrome P-450 (CYP) 3A4, there are limited published data regarding potential drug-drug interactions between apixaban (Eliquis) and common p-glycoprotein (P-gp) and CYP3A4 inhibitors co-administered with statins. The aim of this study was to investigate the degree of elevation relative to apixaban serum peak and trough concentration after the co-administration of amiodarone, diltiazem and statins (atorvastatin, rosuvastatin and simvastatin). METHODS Patients prescribed apixaban 5mg twice daily for at least one week were identified from the anticoagulation clinic database and contacted for potential enrolment. A total of 117 volunteers were enrolled with eight excluded due to discontinued use, resulting in 109 volunteers (44 females and 65 males delineated into age groups 40-64 and ≥65 years old) completing the observational study. Fifty-five volunteers were administered apixaban without the P-gp inhibitors amiodarone or diltiazem, with or without statins (atorvastatin, rosuvastatin and simvastatin). Fifty-four volunteers were administered apixaban with either amiodarone or diltiazem, with or without statins (atorvastatin, rosuvastatin or simvastatin). Peak and trough concentrations were assessed for each patient utilizing an apixaban anti-Xa assay. RESULTS Of the combinations studied, the mean apixaban trough concentration upon co-administration of amiodarone without a statin was elevated compared to apixaban alone (experimental 156.83 +/- 79.59 ng/ml vs. control 104.09 +/- 44.56 ng/ml; p = 0.04). The co-administration of diltiazem and rosuvastatin, and the administration of amiodarone without a statin led to greater than 1.5-fold increase in apixaban concentrations (peak experimental 315.19 +/- 157.53 ng/ml vs control 207.6 +/- 83.38 ng/ml; p = 0.08 and trough experimental 182.03 +/- 95.93 ng/ml vs control 112.32 +/- 37.78 ng/ml; p = 0.17) suggesting the need to assess dose adjustment for patients per the FDA package insert. In addition, the aggregated mean peak (p = 0.0056) and trough (p = 0.0089) elevation of CYP3A4 experimental groups (atorvastatin and simvastatin) co-administered apixaban and diltiazem were statistically significant compared with the aggregated non-CYP3A4 control groups (no statin and rosuvastatin). WHAT IS NEW AND CONCLUSION Herein, we report novel data regarding peak and trough apixaban concentrations after concomitant administration of P-gp and CYP3A4 inhibitors (amiodarone or diltiazem) co-administered with statins (atorvastatin, rosuvastatin or simvastatin). Providers should consider utilizing the apixaban anti-Xa assay or comparative heparin anti-Xa assay to determine if patients require dose reduction to decrease adverse events in high-risk patients prescribed apixaban and concomitant p-glycoprotein and CYP3A4 inhibitors amiodarone or diltiazem with and without a CYP3A4 or non-3A4 statin.
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Affiliation(s)
- Erin Milner
- Dwight D. Eisenhower Army Medical Center, Ft Gordon, Georgia, USA.,Department of Chemistry and Life Science, United States Military Academy, West Point, New York, USA.,Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
| | - Michael Ainsworth
- Department of Chemistry and Life Science, United States Military Academy, West Point, New York, USA
| | - Melinda Gleaton
- Dwight D. Eisenhower Army Medical Center, Ft Gordon, Georgia, USA
| | - David Bookstaver
- Dwight D. Eisenhower Army Medical Center, Ft Gordon, Georgia, USA
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Schäfer ST, Otto AC, Acevedo AC, Görlinger K, Massberg S, Kammerer T, Groene P. Point-of-care detection and differentiation of anticoagulant therapy - development of thromboelastometry-guided decision-making support algorithms. Thromb J 2021; 19:63. [PMID: 34493301 PMCID: PMC8425056 DOI: 10.1186/s12959-021-00313-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/14/2021] [Indexed: 03/25/2023] Open
Abstract
Background DOAC detection is challenging in emergency situations. Here, we demonstrated recently, that modified thromboelastometric tests can reliably detect and differentiate dabigatran and rivaroxaban. However, whether all DOACs can be detected and differentiated to other coagulopathies is unclear. Therefore, we now tested the hypothesis that a decision tree-based thromboelastometry algorithm enables detection and differentiation of all direct Xa-inhibitors (DXaIs), the direct thrombin inhibitor (DTI) dabigatran, as well as vitamin K antagonists (VKA) and dilutional coagulopathy (DIL) with high accuracy. Methods Following ethics committee approval (No 17–525-4), and registration by the German clinical trials database we conducted a prospective observational trial including 50 anticoagulated patients (n = 10 of either DOAC/VKA) and 20 healthy volunteers. Blood was drawn independent of last intake of coagulation inhibitor. Healthy volunteers served as controls and their blood was diluted to simulate a 50% dilution in vitro. Standard (extrinsic coagulation assay, fibrinogen assay, etc.) and modified thromboelastometric tests (ecarin assay and extrinsic coagulation assay with low tissue factor) were performed. Statistical analyzes included a decision tree analyzes, with depiction of accuracy, sensitivity and specificity, as well as receiver-operating-characteristics (ROC) curve analysis including optimal cut-off values (Youden-Index). Results First, standard thromboelastometric tests allow a good differentiation between DOACs and VKA, DIL and controls, however they fail to differentiate DXaIs, DTIs and VKAs reliably resulting in an overall accuracy of 78%. Second, adding modified thromboelastometric tests, 9/10 DTI and 28/30 DXaI patients were detected, resulting in an overall accuracy of 94%. Complex decision trees even increased overall accuracy to 98%. ROC curve analyses confirm the decision-tree-based results showing high sensitivity and specificity for detection and differentiation of DTI, DXaIs, VKA, DIL, and controls. Conclusions Decision tree-based machine-learning algorithms using standard and modified thromboelastometric tests allow reliable detection of DTI and DXaIs, and differentiation to VKA, DIL and controls. Trial registration Clinical trial number: German clinical trials database ID: DRKS00015704. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-021-00313-7.
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Affiliation(s)
- Simon T Schäfer
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Munich, Germany
| | - Anne-Christine Otto
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Munich, Germany
| | | | | | - Steffen Massberg
- Department of Internal Medicine I - Cardiology, University Hospital Munich, LMU Munich, Munich, Germany
| | - Tobias Kammerer
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Munich, Germany.,Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Philipp Groene
- Department of Anaesthesiology, University Hospital Munich, LMU Munich, Munich, Germany. .,Klinikum der Universität München, Ludwig-Maximilians-Universität München, Marchioninistraße 15, 81377, Munich, Germany.
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11
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Kalaria SN, Zhu H, Liu Q, Florian J, Wang Y, Schwartz J. Influence of age on the relationship between apixaban concentration and anti-factor Xa activity in older patients with non-valvular atrial fibrillation. Int J Cardiol 2021; 331:109-113. [PMID: 33529664 DOI: 10.1016/j.ijcard.2021.01.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 12/29/2020] [Accepted: 01/07/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND/OBJECTIVES Despite lower major bleeding rates associated with direct oral anticoagulants (DOACs) as compared to conventional warfarin therapy, bleeding rates remain higher in older patients compared to younger patients suggesting a potential role for DOAC measurements. The objective of this study is to examine the effect of age on the relationship between apixaban concentrations and anti-Factor Xa activity in patients with non-valvular atrial fibrillation (NVAF). METHODS This is a retrospective analysis based on a database created using data from the ARISTOTLE study. Outpatient, stable adult patients with NVAF receiving apixaban were included in this study. Data collection consisted of apixaban concentration, anti-Factor Xa activity, age, weight, creatinine, and co-medications. RESULTS The database composed of 2058 patients receiving apixaban. Distribution of race, NVAF subtype, and aspirin use was fairly similar across each age quantile. Older patients received a higher number of co-medications and received the 2.5 mg apixaban dose more often as compared to younger patients (22% vs. < 1%). Linear regression demonstrated that the unadjusted slope for apixaban concentration effect on anti-Factor Xa activity was similar across each age quantile. Although, the overall adjusted linear regression analysis demonstrated that the age by concentration interaction was statistically significant, relative differences in anti-Factor Xa activity (< 8%) were not clinically meaningful. CONCLUSION Data on apixaban concentrations and anti-Factor Xa activity from a pivotal randomized double-blind study of apixaban for the prevention of stroke in NVAF patients have confirmed that the chromogenic anti-Factor Xa activity assay can accurately assess apixaban concentrations in patients regardless of age. Age was not associated with a clinically relevant change in the apixaban vs. anti-Factor Xa activity response relationship and target ranges are unchanged.
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Affiliation(s)
- Shamir N Kalaria
- Center for Translational Medicine, University of Maryland, School of Pharmacy, Baltimore, MD, United States of America
| | - Hao Zhu
- Office of Clinical Pharmacology, US Food and Drug Administration, White Oak, MD, United States of America
| | - Qi Liu
- Office of Clinical Pharmacology, US Food and Drug Administration, White Oak, MD, United States of America
| | - Jeffrey Florian
- Office of Clinical Pharmacology, US Food and Drug Administration, White Oak, MD, United States of America
| | - Yaning Wang
- Office of Clinical Pharmacology, US Food and Drug Administration, White Oak, MD, United States of America
| | - Janice Schwartz
- Department of Medicine, University of California San Francisco, School of Medicine, San Francisco, CA, United States of America.
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Lessire S, Dincq AS, Siriez R, Pochet L, Sennesael AL, Vornicu O, Hardy M, Deceuninck O, Douxfils J, Mullier F. Assessment of low plasma concentrations of apixaban in the periprocedural setting. Int J Lab Hematol 2020; 42:394-402. [PMID: 32297711 DOI: 10.1111/ijlh.13202] [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: 12/13/2019] [Revised: 03/19/2020] [Accepted: 03/22/2020] [Indexed: 12/29/2022]
Abstract
INTRODUCTION Estimation of residual apixaban plasma concentrations may be requested in the management of emergencies. This study aims at assessing the performance of specific anti-Xa assays calibrated with apixaban on real-life samples with low apixaban plasma concentrations (<30 ng/mL) and on-treatment ranges, with and without interference of low-molecular-weight heparin (LMWH). METHODS The performance of the STA® -Liquid Anti-Xa assay (STA® LAX) and the low and normal procedures of the Biophen® Direct Factor Xa Inhibitors (DiXaI) assay was tested on 134 blood samples, collected from patients on apixaban, wherefrom 74 patients received LMWH after apixaban cessation. The results were compared with the liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS) measurements. RESULTS The Biophen® DiXaI, Biophen® DiXaI LOW, and STA® LAX showed very good correlation with LC-MS/MS measurements in patients without LMWH administration (Spearman r .95, .99, and .98, respectively). Their limits of quantitation were defined at 48, 24, and 12 ng/mL, respectively. The Bland-Altman test measured mean bias (SD) at 5.6 (13.1), -2.5 (5.0), and -0.8 (6.1) ng/ml, respectively. The Spearman r of the Biophen® DiXaI decreased to 0.64 in presence of low apixaban concentrations. The Spearman r of the Biophen® DiXaI LOW and STA® LAX decreased to 0.39 and 0.26, respectively, in presence of LMWH. CONCLUSIONS The accuracy of the low methodologies (Biophen® DiXaI LOW and STA® LAX) is slightly improved for low apixaban plasma concentrations, compared with the normal procedure of Biophen® DiXaI. The interference of LMWH on the low methodologies is measurable, however, less important than the previously reported interference of LMWH on rivaroxaban calibrated specific anti-Xa assays.
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Affiliation(s)
- Sarah Lessire
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Anesthesiology, Yvoir, Belgium
| | - Anne-Sophie Dincq
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Anesthesiology, Yvoir, Belgium
| | - Romain Siriez
- University of Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Pharmacy, Namur, Belgium
| | - Lionel Pochet
- University of Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Pharmacy, Namur, Belgium
| | - Anne-Laure Sennesael
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Pharmacy, Yvoir, Belgium
| | - Ovidiu Vornicu
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Anesthesiology, Yvoir, Belgium
| | - Michael Hardy
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Anesthesiology, Yvoir, Belgium
| | - Olivier Deceuninck
- Université catholique de Louvain, CHU UCL Namur, Department of Cardiology, Yvoir, Belgium
| | - Jonathan Douxfils
- University of Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Department of Pharmacy, Namur, Belgium.,Qualiblood sa, Namur, Belgium
| | - François Mullier
- Université catholique de Louvain, CHU UCL Namur, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Hematology Laboratory, Yvoir, Belgium
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