1
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Vassart J, Tafur A, Durante M, Boucher AY, Morimont L, Walenga JM, Harenberg J, Douxfils J. The DOAC (direct oral anticoagulant) Dipstick reliably excludes residual FXa inhibitors levels in the preoperative setting. Thromb Res 2024; 239:109023. [PMID: 38761550 DOI: 10.1016/j.thromres.2024.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/25/2024] [Accepted: 04/29/2024] [Indexed: 05/20/2024]
Affiliation(s)
- Julie Vassart
- Clinical Pharmacology and Toxicology Research Unit, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Faculty of Medicine, University of Namur, Namur, Belgium
| | - Alfonso Tafur
- Vascular Medicine, Department of Medicine. NorthShore University HealthSystem, Evanston, IL, USA; University of Chicago, Pritzker School of Medicine, Chicago, IL, USA
| | - Marisa Durante
- Vascular Medicine, Department of Medicine. NorthShore University HealthSystem, Evanston, IL, USA
| | - Anne-Yseult Boucher
- Clinical Pharmacology and Toxicology Research Unit, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Faculty of Medicine, University of Namur, Namur, Belgium
| | - Laure Morimont
- Clinical Pharmacology and Toxicology Research Unit, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Faculty of Medicine, University of Namur, Namur, Belgium; QUALIblood s.a., QUALIresearch, Namur, Belgium
| | - Jeanine M Walenga
- Cardiovascular Research Institute, Stritch School of Medicine, Health Sciences Division, Loyola University Chicago, Maywood, IL, USA
| | - Job Harenberg
- Heidelberg University, Heidelberg, Germany; DOASENSE, GmbH, Heidelberg, Germany
| | - Jonathan Douxfils
- Clinical Pharmacology and Toxicology Research Unit, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Faculty of Medicine, University of Namur, Namur, Belgium; QUALIblood s.a., QUALIresearch, Namur, Belgium; Department of Biological Hematology, CHU Clermont-Ferrand, Hôpital Estaing, France.
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2
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Papageorgiou L, Hetjens S, Fareed J, Auge S, Tredler L, Harenberg J, Weiss C, Elalamy I, Gerotziafas GT. Comparison of the DOAC Dipstick Test on Urine Samples With Chromogenic Substrate Methods on Plasma Samples in Outpatients Treated With Direct Oral Anticoagulants. Clin Appl Thromb Hemost 2023; 29:10760296231179684. [PMID: 37278029 PMCID: PMC10272629 DOI: 10.1177/10760296231179684] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/02/2023] [Accepted: 05/17/2023] [Indexed: 06/07/2023] Open
Abstract
Identifying adherence to direct oral anticoagulants (DOACs) plays a major role in treatment efficacy and safety. The DOAC Dipstick can detect DOACs in urine samples of acutely diseased patients at plasma thresholds of about 30 ng/mL. A prospective observational consecutive cohort study was performed on outpatients taking DOACs. The presence of direct oral factor Xa inhibitors (DXIs) in patient urine samples were independently evaluated by visual interpretation of the DOAC Dipstick pad colors. DOAC plasma concentration was assessed using STA®-Liquid Anti-Xa and STA®-Liquid Anti-IIa chromogenic substrate assays. Positive DOAC Dipstick results were compared with a threshold plasma of DOAC concentration ≥30 ng/mL. Of 120 patients (age 55.4 + 16.1 years, female n = 63), 77 were on rivaroxaban and 43 on apixaban. Plasma concentrations were 129 ± 118 ng/mL for rivaroxaban, and 163 ± 130 ng/mL for apixaban, DOAC Dipstick test has a sensitivity of 97.2% and a positive predictive value of 89.5% at 30 ng/mL. No differences occurred between DXIs. Specificity and negative predictive value could not be determined due to the low number of true negative values. There were no differences in the interpretation of rivaroxaban and apixaban pad colors between observers (Kappa 1.0). Results show that DOAC Dipstick may be a useful tool for identifying DXIs in urine samples in an outpatient setting at a plasma threshold ≥ 30 ng/mL. Further studies should include patients treated with dabigatran, vitamin K antagonists, or other anticoagulants.
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Affiliation(s)
- Loula Papageorgiou
- Thrombosis Center, Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France
- Sorbonne University, INSERM UMRS-938, Team "Cancer Vessels, Biology and Therapeutics," Group "Cancer - Angiogenesis - Thrombosis," Institut Universitaire de Cancérologie, Centre de Recherche Saint Antoine, Hôpital Saint Antoine, Assistance Publique - Hôpitaux de Paris, Paris, France
- Département Interdisciplinaire d'Organisation du Parcours Patient (DIOPP), Gustave Roussy, Villejuif, France
| | - Svetlana Hetjens
- Institute for Biometrie and Biiostatstics, Medical Faculty Mannheim University of Heidelberg, Mannheim, Germany
| | - Jawed Fareed
- Hemostasis and Thrombosis Research Laboratories, Cardiovascular Institute, Vascular Biology Loyola University Medical Center, Mannheim, Germany
| | - Sanny Auge
- Service de Médecine Interne, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France
| | - Laetitia Tredler
- Service de Médecine Interne, Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France
| | - Job Harenberg
- Faculty of Medicine Mannheim, University of Heidelberg, Heidelberg, Germany
- DOASENSE GmbH, Heidelberg, Germany
| | - Christel Weiss
- Institute for Biometrie and Biiostatstics, Medical Faculty Mannheim University of Heidelberg, Mannheim, Germany
| | - Ismail Elalamy
- Thrombosis Center, Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France
- Sorbonne University, INSERM UMRS-938, Team "Cancer Vessels, Biology and Therapeutics," Group "Cancer - Angiogenesis - Thrombosis," Institut Universitaire de Cancérologie, Centre de Recherche Saint Antoine, Hôpital Saint Antoine, Assistance Publique - Hôpitaux de Paris, Paris, France
- The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
- INNOVTE, FCRIN, Paris, France
| | - Grigorios T Gerotziafas
- Thrombosis Center, Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires de l'Est Parisien, Assistance Publique Hôpitaux de Paris, Faculté de Médecine Sorbonne Université, Paris, France
- Sorbonne University, INSERM UMRS-938, Team "Cancer Vessels, Biology and Therapeutics," Group "Cancer - Angiogenesis - Thrombosis," Institut Universitaire de Cancérologie, Centre de Recherche Saint Antoine, Hôpital Saint Antoine, Assistance Publique - Hôpitaux de Paris, Paris, France
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Al Aseri Z, AlGahtani FH, Bakheet MF, Al-Jedai AH, Almubrik S. Evidence-based Management of Major Bleeding in Patients Receiving Direct Oral Anticoagulants: An Updated Narrative Review on the Role of Specific Reversal Agents. J Cardiovasc Pharmacol Ther 2023; 28:10742484231202655. [PMID: 37872658 DOI: 10.1177/10742484231202655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
The indications of direct oral anticoagulants (DOACs) have expanded over the past 15 years. DOACs are effective and safe oral anticoagulants associated with lower bleeding risks and mortality than vitamin K antagonists. However, DOAC users are prone to a considerable bleeding risk, which can occur at critical sites or lead to severe life-threatening conditions. Recent statistics indicated that major bleeding occurs in up to 6.62 DOAC users per 100 treatment years. With the increased use of DOACs in clinical practice, DOAC-associated major bleeding is expected to be encountered more frequently in the emergency department. The current international guidelines recommend specific reversal agents for the management of DOAC users with severe bleeding to reverse the anticoagulant effect and restore normal hemostasis. An individualized assessment was incorporated in specific clinical situations to guide the decision pathway of major bleeding management. However, specific reversal agents are unavailable or have limited availability in many countries, which is expected to negatively impact the clinical outcomes of DOAC-associated major bleeding. Limited real-world evidence is available from these countries regarding the clinical outcomes of patients with DOAC-associated major bleeding. This narrative review provided an updated assessment of the evidence-based approaches for the management of major bleeding in DOAC users. We also explored the clinical outcomes of patients with major bleeding from clinical settings where specific reversal agents are unavailable.
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Affiliation(s)
- Zohair Al Aseri
- Departments of Emergency Medicine and Critical Care, College of Medicine, King Saud University, Riyadh, Saudi Arabia
- Adult Critical Care, Therapeutic Affairs Deputyship, Ministry of Health, Riyadh, Saudi Arabia
- Riyadh Hospital & Dar Al Uloom University, Riyadh, Saudi Arabia
| | - Farjah H AlGahtani
- Division of Hematology/Oncology, Oncology Center, Medicine Department, King Saud University, Riyadh, Saudi Arabia
| | - Majid F Bakheet
- Therapeutic Affairs Deputyship, Ministry of Health, Riyadh, Saudi Arabia
- Colleges of Medicine and Pharmacy, Al-Faisal University, Riyadh, Saudi Arabia
| | - Ahmed H Al-Jedai
- Therapeutic Affairs Deputyship, Ministry of Health, Riyadh, Saudi Arabia
- Colleges of Medicine and Pharmacy, Al-Faisal University, Riyadh, Saudi Arabia
| | - Sarah Almubrik
- Emergency Medicine, King Saud University Medical City, Riyadh, Saudi Arabia
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4
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Wu Z, Ma Y. Rapid assessment of clinically levels of direct acting oral anticoagulants in the emergency department. Acad Emerg Med 2022; 29:916-917. [PMID: 35612402 DOI: 10.1111/acem.14537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Revised: 05/22/2022] [Accepted: 05/22/2022] [Indexed: 02/05/2023]
Affiliation(s)
- Zhoupeng Wu
- Department of Vascular Surgery West China Hospital Chengdu Sichuan Province China
| | - Yukui Ma
- Department of Vascular Surgery West China Hospital Chengdu Sichuan Province China
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5
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Walenga JM. Can We Improve on the Rapid Assessment of Clinically Relevant Levels of Direct Acting Oral Anticoagulants (DOAC)? Clin Appl Thromb Hemost 2022; 28:10760296221096422. [PMID: 35473406 PMCID: PMC9099059 DOI: 10.1177/10760296221096422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jeanine M Walenga
- Cardiovascular Institute, 2456Loyola University Chicago, Chicago, Illinois, United States
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6
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Harenberg J, Hetjens S, Weiss C. Patients' Plasma Activity of Heparin, low-Molecular-Weight Heparin or no Anticoagulants on Urine Based DOAC Test Strips. Clin Appl Thromb Hemost 2022; 28:10760296221083667. [PMID: 35275493 PMCID: PMC8921744 DOI: 10.1177/10760296221083667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
DOAC Dipstick determines specifically the presence and absence of direct oral anticoagulants (DOACs) from patients’ urine samples and handmade test strips performed as well as the commercial version. To compare plasma activity (chromogenic substrate assays) from plasma samples with results from urine samples (DOAC test strips) of patients treated with heparin, low-molecular weight heparin (LMWH) and without anticoagulation. Plasma anti-factor Xa (aXa) activity was determined by Coamatic chromogenic substrate assay and compared to the presence of anticoagulants in urine by DOAC test strips. Patients were treated for least 5 days and samples were taken 4 hrs after administration in comparison to no treatment with an anticoagulant (n = 42). A total of 100 patients were included treated with heparin (n = 29), LMWH nadroparin (n = 29) or no anticoagulants (n = 42). Plasma aXa levels of patients treated with heparin (2 × 7.500 IU daily subcutaneously, 12 male, age 67.4 ± 11.5 years) were 0,18 IU/ml ± 0,15 IU/ml (mean, standard deviation), with LMWH (1 × 3000 IU daily subcutaneously, 15 male, age 64.2 ± 14.1 years) 0,17 IU/ml ± 0,16 IU/l, and with no anticoagulants (28 male, age 64.2 ± 15.6 years) 0,02 IU/ml ± 0.01 IU/ml. All factor Xa and thrombin inhibitor pad results of test strips were negative. We conclude that DOAC Dipstick has a high probability of not detecting heparin and LMWH in patients on treatment as well as in urine samples of patients not treated with an anticoagulant.
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Affiliation(s)
- Job Harenberg
- DOASENSE GmbH, Heidelberg, Germany.,9144Ruprecht-Karls University Heidelberg, Heidelberg, Germany
| | - Svetlana Hetjens
- Medical Faculty Mannheim, Ruprecht-Karls University Heidelberg, Heidelberg, Germany
| | - Christel Weiss
- Medical Faculty Mannheim, Ruprecht-Karls University Heidelberg, Heidelberg, Germany
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7
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Martini A, Harenberg J, Bauersachs R, Beyer-Westendorf J, Crowther M, Douxfils J, Elalamy I, Weiss C, Hetjens S. Detection of Direct Oral Anticoagulants in Patient Urine Samples by Prototype and Commercial Test Strips for DOACs - A Systematic Review and Meta-analysis. TH OPEN 2021; 5:e438-e448. [PMID: 34595388 PMCID: PMC8463133 DOI: 10.1055/s-0041-1732437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 06/28/2021] [Indexed: 01/13/2023] Open
Abstract
The DOAC Dipstick accurately detects the presence or absence of factor Xa (DXI) and thrombin inhibitor (DTI) classes of direct oral anticoagulants (DOACs) in patients' urine samples on DOAC treatment. The aim of the study was to systematically review the literature and compare the performance of prototype and commercial test strips with a meta-analysis.
A systematic literature search of electronic databases PubMed (MEDLINE) and Cochrane Library was performed. Heterogeneity between studies was calculated using the Chi-squared test and the I
2
index. A random effects model was used to pool data to compare the performance of prototype and commercial test strips.
Using PRISMA reporting guidelines, four of 1,081 publications were eligible for inclusion in the meta-analysis: three reporting on prototype (DXI
n
= 658, DTI
n
= 586) and one on commercial test strips (DXI
n
= 451, DTI
n
= 429). Sensitivity and specificity of DXI and DTI detection did not differ significantly between the prototype and commercial test strips. Odds ratios were 0.718 and 0.365 for sensitivity and 1.211 and 1.072 for specificity of DXI and DTI (p-values between 0.3334 and 1.000), respectively. The pooled sensitivity and specificity values for DXI were 0.968 (
p
= 0.1290, I
2
47.1%) and 0.979 (
p
= 0.1965, I
2
35.9%), and for DTI 0.993 (
p
= 0.1870, I
2
37.5%) and 0.993 (
p
= 0.7380, I
2
0%), respectively.
Prototype and commercial DOAC test strips did not differ in their ability to detect DXI and DTI in patient urine samples. This supports the confidence in use of the DOAC Dipstick test, although it needs to be validated in specific patient populations.
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Affiliation(s)
- Andrea Martini
- Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Job Harenberg
- Ruprecht-Karls-University, Heidelberg, Germany.,DOASENSE GmbH, Heidelberg, Germany
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Darmstadt, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine I, Division Hematology, University Hospital "Carl Gustav Carus" Dresden, Dresden, Germany
| | - Mark Crowther
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Centre (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium.,Qualiblood sa, Namur, Belgium
| | - Ismail Elalamy
- Hematology and Thrombosis Centre, Hôpital Tenon, INSERM U938, Sorbonne Université, AP-HP, France.,I M Sechenov First Moscow State Medical University, Department of Obstetrics and Gynecology, Russia
| | - Christel Weiss
- Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Svetlana Hetjens
- Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
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Harenberg J, Martini A, Du S, Krämer S, Weiss C, Hetjens S. Performance Characteristics of DOAC Dipstick in Determining Direct Oral Anticoagulants in Urine. Clin Appl Thromb Hemost 2021; 27:1076029621993550. [PMID: 33733904 PMCID: PMC7983466 DOI: 10.1177/1076029621993550] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Testing for direct oral anticoagulants (DOACs) in patient urine may facilitate medical treatment decisions. The aim of this study was to investigate interobserver variability by 2 independent observers compared to laboratory staff in the visual interpretation of factor Xa (DXI) and thrombin inhibitors (DTI) using the DOAC Dipstick test. We also examined whether test pads reacted to other anticoagulants and abnormal urine colors. The colors of the DOAC Dipstick direct factor Xa inhibitor and thrombin inhibitor pads were interpreted with 100% accuracy (95% confidence interval 0.862 to 1.000) for urine samples from persons treated with apixaban (n = 26), rivaroxaban (n = 24), and dabigatran (n = 29) and without anticoagulant therapy (n = 29). The factor Xa and thrombin inhibitor pads did not interact with heparin, nadroparin, fondaparinux, or coumadin. One µg/mL r-Hirudin and 6 µg/mL argatroban interacted with the DTI pad; however, this is unlikely to cause clinical problems because dabigatran is unlikely to be administered together with r-Hirudin and argatroban in clinical circumstances. Abnormal urine color was reliably detected by the urine color pad, so can prevent false interpretation of the DOAC Dipstick pad colors. In conclusion, we have demonstrated that interobserver variability when interpreting the DOAC Dipstick test strip is low and that factor Xa and thrombin inhibitor pads do not react to other anticoagulants such as heparins and coumadin. R-Hirudin and argatroban can be detected by the thrombin inhibitor pad and abnormal urine colors can be detected by the urine color pad to prevent false interpretation of the results in patient urine samples.
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Affiliation(s)
- Job Harenberg
- Ruprecht-Karls-University, Heidelberg, Germany.,DOASENSE GmbH, Heidelberg, Germany
| | - Andrea Martini
- Department of Medical Statistics, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Shanshan Du
- Ruprecht-Karls-University, Heidelberg, Germany
| | | | - Christel Weiss
- Department of Medical Statistics, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Svetlana Hetjens
- Department of Medical Statistics, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
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9
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Lei R, Huo R, Mohan C. Current and emerging trends in point-of-care urinalysis tests. Expert Rev Mol Diagn 2020; 20:69-84. [PMID: 31795785 PMCID: PMC7365142 DOI: 10.1080/14737159.2020.1699063] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 11/26/2019] [Indexed: 02/06/2023]
Abstract
Introduction: The development of point-of-care testing (POCT) has made clinical diagnostics available, affordable, rapid, and easy to use since the 1990s.The significance of this platform rests on its potential to empower patients to monitor their own health status more frequently, in the convenience of their home, so that diseases can be diagnosed at the earliest possible time-point. Recent advances have expanded traditional formats such as qualitative or semi-quantitative dipsticks and lateral flow immunoassays to newer platforms such as microfluidics and paper-based assays where signals can be measured quantitatively using handheld devices.Areas covered: This review discusses: (1) working principles and operating mechanisms of both existing and emerging POCT platforms, (2) urine analytes measured using POCT in comparison to the laboratory or clinical 'gold standard,' and (3) limitations of existing POCT and expectations of emerging POCT in urinalysis.Expert opinion: Currently, a variety of biological samples such as urine, saliva, serum, plasma, and other fluids can be applied to POCT for quick diagnosis, especially in resource-limited settings. Emerging platforms will increasingly empower individuals to monitor their health status through frequent urine analysis even from their homes. The impact of these emerging technologies on healthcare is likely to be transformative.
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Affiliation(s)
- Rongwei Lei
- Department of Biomedical Engineering, University of Houston, Houston, TX
| | - Rannon Huo
- Department of Biomedical Engineering, University of Houston, Houston, TX
| | - Chandra Mohan
- Department of Biomedical Engineering, University of Houston, Houston, TX
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Dias JD, Lopez-Espina CG, Ippolito J, Hsiao LH, Zaman F, Muresan AA, Thomas SG, Walsh M, Jones AJ, Grisoli A, Thurston BC, Artang R, Bilden KP, Hartmann J, Achneck HE. Rapid point-of-care detection and classification of direct-acting oral anticoagulants with the TEG 6s: Implications for trauma and acute care surgery. J Trauma Acute Care Surg 2019; 87:364-370. [DOI: 10.1097/ta.0000000000002357] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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11
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Maegele M, Grottke O, Schöchl H, Sakowitz OA, Spannagl M, Koscielny J. Direct Oral Anticoagulants in Emergency Trauma Admissions. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 113:575-82. [PMID: 27658470 DOI: 10.3238/arztebl.2016.0575] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Revised: 05/17/2016] [Accepted: 05/17/2016] [Indexed: 01/22/2023]
Abstract
BACKGROUND Direct (non-vitamin-K-dependent) oral anticoagulants (DOAC) are given as an alternative to vitamin K antagonists (VKA) to prevent stroke and embolic disease in patients with atrial fibrillation that is not due to pathology of the heart valves. Fatal hemorrhage is rarer when DOACs are given (nonvalvular atrial fibrillation: odds ratio [OR] 0.68; 95% confidence interval [95% CI: 0.48; 0.96], and venous thromboembolism: OR 0.54; [0.22; 1.32]). 48% of emergency trauma patients need an emergency operation or early surgery. Clotting disturbances elevate the mortality of such patients to 43%, compared to 17% in patients without a clotting disturbance. This underscores the impor tance of the proper, targeted treatment of trauma patients who are aking DOAC. METHODS This review is based on articles retrieved by a selective search in PubMed and on a summary of expert opinion and the recommendations of the relevant medical specialty societies. RESULTS Peak DOAC levels are reached 2-4 hours after the drug is taken. In patients with normal renal and hepatic function, no drug accumulation, and no drug interactions, the plasma level of DOAC 24 hours after administration is generally too low to cause any clinically relevant risk of bleeding. The risk of drug accumulation is higher in patients with renal dysfunction (creatinine clearance [CrCl] of 30 mL/min or less). Dabigatran levels can be estimated from the thrombin time, ecarin clotting time, and diluted thrombin time, while levels of factor Xa inhibitors can be estimated by means of calibrated chromogenic anti-factor Xa activity tests. Routine clotting studies do not reliably reflect the anticoagulant activity of DOAC. Surgery should be postponed, if possible, until at least 24-48 hours after the last dose of DOAC. For patients with mild, non-life threatening hemorrhage, it suffices to discontinue DOAC; for patients with severe hemorrhage, there are special treatment algorithms that should be followed. CONCLUSION DOACs in the setting of hemorrhage are a clinical challenge in the traumatological emergency room because of the inadequate validity of the relevant laboratory tests. An emergency antidote is now available only for dabigatran.
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Affiliation(s)
- Marc Maegele
- Department of Trauma and Orthopedic Sugery, Cologne-Merheim Medical Center (CMMC), Witten/Herdecke University, Cologne and Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Campus Cologne-Merheim, Cologne, Experimental Hemostaseology, Department of Anesthesiology, University Hospital RWTH Aachen, Aachen, Department of Anesthesiology and Intensive Care Medicine, AUVA Emergency Hospital, Salzburg (Austria), Department of Neurosurgery, Ludwigsburg Hospital, Ludwigsburg, Department of Anesthesiology, Ludwig Maximilian University of Munich, Munich, Institute for Transfusion Medicine, Charité University Medicine Berlin, Berlin
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12
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Koscielny J, Rosenthal C, von Heymann C. Nicht-Vitamin-K-abhängige orale Antikoagulanzien. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0289-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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13
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Arnao V, Riolo M, Tuttolomondo A, Pinto A, Fierro B, Aridon P. New frontiers in anticoagulation: non vitamin-K oral anticoagulants in stroke prevention. Expert Rev Neurother 2016; 17:539-552. [PMID: 27911120 DOI: 10.1080/14737175.2017.1268053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Non vitamin-K oral anticoagulants (NOACs) are direct and specific inhibitors of the coagulation factors IIa (dabigatran) and Xa (apixaban, rivaroxaban, edoxaban) which share many pharmacokinetic properties. However, indications are lacking regarding the use of NOACs during thrombolysis, surgery and bleeding events. Areas covered: In this paper, the authors retrospectively analyzed the relevant literature on the NOACs using the PubMed and Google Scholar databases. Expert commentary: Although warfarin is effective in cardioembolic stroke prevention, easier handling and more favorable risk-benefit profile often render NOACs a more preferable therapy choice for neurologists. New evidences have suggested their use in treatment of elderly people, in patients with renal insufficiency or with antiphospholipid antibody syndrome. In addition, the use of antidotes, which rapidly reverse the anticoagulant effect of the NOACs, could be useful in bleeding, during emergency procedures, or in case of overdose.
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Affiliation(s)
- Valentina Arnao
- a BioNeC Dipartimento di BioMedicina Sperimentale e Neuroscienze Cliniche , Università degli Studi di Palermo , Palermo , Italy.,b Biomedical Department of Internal and Specialistic Medicine (Di.Bi.M.I.S), School of Medicina Clinica e Scienze del Comportamento , University of Palermo , Palermo , Italy
| | - Marianna Riolo
- a BioNeC Dipartimento di BioMedicina Sperimentale e Neuroscienze Cliniche , Università degli Studi di Palermo , Palermo , Italy
| | - Antonino Tuttolomondo
- c Biomedical Department of Internal and Specialistic Medicine (Di.Bi.M.I.S) , University of Palermo , Palermo , Italy
| | - Antonio Pinto
- c Biomedical Department of Internal and Specialistic Medicine (Di.Bi.M.I.S) , University of Palermo , Palermo , Italy
| | - Brigida Fierro
- a BioNeC Dipartimento di BioMedicina Sperimentale e Neuroscienze Cliniche , Università degli Studi di Palermo , Palermo , Italy
| | - Paolo Aridon
- a BioNeC Dipartimento di BioMedicina Sperimentale e Neuroscienze Cliniche , Università degli Studi di Palermo , Palermo , Italy
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14
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Arian D, Harenberg J, Krämer R. A Chromogenic and Fluorogenic Peptide Substrate for the Highly Sensitive Detection of Proteases in Biological Matrices. J Med Chem 2016; 59:7576-83. [DOI: 10.1021/acs.jmedchem.6b00652] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Dumitru Arian
- Anorganisch-Chemisches
Institut, Universität Heidelberg, Im Neuenheimer Feld 270, 69120 Heidelberg, Germany
| | - Job Harenberg
- Medical Faculty Mannheim, Universität Heidelberg, Maybachstrasse
14, 68169 Mannheim, Germany
| | - Roland Krämer
- Anorganisch-Chemisches
Institut, Universität Heidelberg, Im Neuenheimer Feld 270, 69120 Heidelberg, Germany
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15
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Non-VKA Oral Anticoagulants: Accurate Measurement of Plasma Drug Concentrations. BIOMED RESEARCH INTERNATIONAL 2015; 2015:345138. [PMID: 26090400 PMCID: PMC4452246 DOI: 10.1155/2015/345138] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 11/10/2014] [Indexed: 11/18/2022]
Abstract
Non-VKA oral anticoagulants (NOACs) have now widely reached the lucrative market of anticoagulation. While the marketing authorization holders claimed that no routine monitoring is required and that these compounds can be given at fixed doses, several evidences arisen from the literature tend to demonstrate the opposite. New data suggests that an assessment of the response at the individual level could improve the benefit-risk ratio of at least dabigatran. Information regarding the association of rivaroxaban and apixaban exposure and the bleeding risk is available in the drug approval package on the FDA website. These reviews suggest that accumulation of these compounds increases the risk of experiencing a bleeding complication. Therefore, in certain patient populations such as patients with acute or chronic renal impairment or with multiple drug interactions, measurement of drug exposure may be useful to ensure an optimal treatment response. More specific circumstances such as patients experiencing a haemorrhagic or thromboembolic event during the treatment duration, patients who require urgent surgery or an invasive procedure, or patient with a suspected overdose could benefit from such a measurement. This paper aims at providing guidance on how to best estimate the intensity of anticoagulation using laboratory assays in daily practice.
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16
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Ing E, Douketis J. New oral anticoagulants and oculoplastic surgery. Can J Ophthalmol 2014; 49:123-7. [PMID: 24767215 DOI: 10.1016/j.jcjo.2013.11.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Revised: 10/23/2013] [Accepted: 11/14/2013] [Indexed: 02/08/2023]
Abstract
The use of oral anticoagulants is increasing because of the rising prevalence of atrial fibrillation and other cardiovascular diseases that occur in an aging population. In the last decade, several new oral anticoagulants have emerged, comprising the direct thrombin inhibitor dabigatran and the factor Xa inhibitors apixaban and rivaroxaban. Although these new anticoagulants may not affect clear corneal cataract surgery, their use will impact the management of patients having eyelid, orbital, and nasolacrimal procedures. The objective of this review is to provide a concise and practical approach to the perioperative management of patients who require an oculoplastic procedure and are receiving these new anticoagulants.
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Affiliation(s)
- Edsel Ing
- Department of Ophthalmology and Vision Sciences, University of Toronto, Toronto, Ont.
| | - James Douketis
- Department of Medicine, McMaster University, Hamilton, Ont
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