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Gosselin RC, Cuker A. Assessing Direct Oral Anticoagulants in the Clinical Laboratory. Clin Lab Med 2024; 44:551-562. [PMID: 39089758 DOI: 10.1016/j.cll.2024.04.014] [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: 08/04/2024]
Abstract
Direct oral anticoagulants (DOACs) have significant advantages over vitamin K antagonists including lack of need for routine laboratory monitoring. However, assessment of DOAC effect and concentration may be important to guide clinical management including need for DOAC reversal, particularly in acute or emergent situations. In this manuscript, the authors describe tests to screen for DOAC presence and tests that have demonstrated equivalence to gold standard testing for quantifying DOAC exposure. They also discuss the effect of DOACs on other coagulation assays and strategies for monitoring unfractionated heparin in patients with concomitant DOAC exposure.
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Affiliation(s)
- Robert C Gosselin
- Thrombosis and Hemostasis Center, University of California, Davis Health System, Sacramento, CA 95817, USA.
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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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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Metze M, Platz M, Pfrepper C, Petros S. Gerinnungsdiagnostik im klinischen Alltag – Teil 2. DIE INNERE MEDIZIN 2022; 63:736-750. [PMID: 35925265 PMCID: PMC9118186 DOI: 10.1007/s00108-022-01335-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 10/31/2022]
Abstract
Während bei einer Vitamin-K-Antagonisten-Therapie die Therapieüberwachung (International Normalized Ratio [INR]) obligat ist, gilt dies für direkte orale Antikoagulanzien (DOAK) oder niedermolekulares Heparin (NMH) nur in ausgewählten klinischen Szenarien. Bei DOAK steht die Bestimmung von Tal- und Spitzenspiegeln des Medikaments im Plasma im Vordergrund, bei NMH die Anti-Xa-Aktivität. Der Zeitpunkt der Probenabnahme in Relation zur Einnahme ist für die Bewertung essenziell. Eine neu aufgetretene Thrombozytopenie im Rahmen stationärer Behandlungen ist häufig. Einordnung der Grunderkrankung, Tag des Auftretens sowie Erfassung medikamentöser Einflüsse und ihrer Dynamik ermöglichen oft die Eingrenzung der Ursache. Die Thrombophilietestung nach venöser Thromboembolie wird aufgrund fehlender therapeutischer Konsequenz zunehmend seltener durchgeführt. Ein Antiphospholipidsyndrom darf aber nicht übersehen werden, da sowohl die Therapiedauer als auch die Wahl des Antikoagulans davon abhängen.
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Li X, Liu L, Xu B, Xiang Q, Li Y, Zhang P, Wang Y, Xie Q, Mao Y, Cui Y. Bioequivalence and pharmacodynamics of a generic dabigatran etexilate capsule in healthy Chinese subjects under fasting and fed conditions. Pharmacol Res Perspect 2020; 8:e00593. [PMID: 32338459 PMCID: PMC7184321 DOI: 10.1002/prp2.593] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 01/12/2023] Open
Abstract
To assess bioequivalence of a generic dabigatran etexilate capsule in healthy Chinese subjects under fasting and fed conditions. This was an open-label, single-center, randomized four-period crossover study with a 7-day washout period. A single oral dose of 150 mg generic dabigatran etexilate capsule (test drug) or a commercial dabigatran etexilate capsule (Pradaxa® , reference drug) was given to healthy volunteers under the fasting and fed conditions. Plasma concentrations of total and free dabigatran were detected using a validated HPLC-MS/MS method. A noncompartmental method was used for pharmacokinetic analysis and established coagulation assays were applied for pharmacodynamic analysis. The 90% CIs of the test/reference ratios of Cmax , AUC0-t , and AUC0-∞ for the total dabigatran concentration were 92.57%-106.58%, 91.63%-106.32%, and 92.54%-106.17%, respectively, under fasting condition, and 99.30%-110.74%, 98.58%-105.37%, and 97.75%-103.99%, respectively, under fed conditions. The 90% CIs of the ratios of the parameters for the free dabigatran were 93.18%-106.98%, 92.13%-107.10%, 92.89%-106.48%, respectively, under fasting condition, and 100.05%-110.89%, 99.37%-106.23%, 97.59%-103.98%, respectively, under the fed condition. Additionally, the upper limit of the 90% CIs for σWT/σWR was below 2.5. There were no significant differences in the coagulation parameters including thrombin clotting time, activated partial thromboplastin time, and anti-IIa activity between the two preparations. The generic dabigatran etexilate capsule is bioequivalent to the brand-named product in healthy Chinese volunteers under fasting and fed conditions. The two products have comparable pharmacodynamic parameters, with a good safety profile. In addition, food intake influences absorption of both products in a similar way.
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Affiliation(s)
- Xin Li
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Lihua Liu
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Bing Xu
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Qian Xiang
- Department of PharmacyPeking University First HospitalBeijingThe People’s Republic of China
| | - Yuan Li
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Ping Zhang
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Yangyang Wang
- Department of PharmacyThe Third Hospital of ChangshaChangshaThe People’s Republic of China
| | - Qiufen Xie
- Department of PharmacyPeking University First HospitalBeijingThe People’s Republic of China
| | - Yong Mao
- Chengdu Brilliant Pharmaceutical Co. LtdChengduThe People’s Republic of China
| | - Yimin Cui
- Department of PharmacyPeking University First HospitalBeijingThe People’s Republic of China
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Pharmacokinetic and Pharmacodynamic Drug Monitoring of Direct-Acting Oral Anticoagulants: Where Do We Stand? Ther Drug Monit 2019; 41:180-191. [DOI: 10.1097/ftd.0000000000000594] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Douxfils J, Ageno W, Samama CM, Lessire S, Ten Cate H, Verhamme P, Dogné JM, Mullier F. Laboratory testing in patients treated with direct oral anticoagulants: a practical guide for clinicians. J Thromb Haemost 2018; 16:209-219. [PMID: 29193737 DOI: 10.1111/jth.13912] [Citation(s) in RCA: 226] [Impact Index Per Article: 37.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Indexed: 11/30/2022]
Abstract
Click to hear Dr Baglin's perspective on the role of the laboratory in treatment with new oral anticoagulants SUMMARY: One of the key benefits of the direct oral anticoagulants (DOACs) is that they do not require routine laboratory monitoring. Nevertheless, assessment of DOAC exposure and anticoagulant effects may become useful in various clinical scenarios. The five approved DOACs (apixaban, betrixaban, dabigatran etexilate, edoxaban and rivaroxaban) have different characteristics impacting assay selection and the interpretation of results. This article provides an updated overview on (i) which test to use (and their advantages and limitations), (ii) when to assay DOAC levels, (iii) how to interpret the results relating to bleeding risk, emergency situations and perioperative management, and (iv) what is the impact of DOACs on routine and specialized coagulation assays. Assays for anti-Xa or anti-IIa activity are the preferred methods when quantitative information is useful, although the situations in which to test for DOAC levels are still debated. Different reagent sensitivities and variabilities in laboratory calibrations impact assay results. International calibration standards for all specific tests for each DOAC are needed to reduce the inter-laboratory variability and allow inter-study comparisons. The impact of the DOACs on hemostasis testing may cause false-positive or false-negative results; however, these can be minimized by using specific assays and collecting blood samples at trough concentrations. Finally, prospective clinical trials are needed to validate the safety and efficacy of proposed laboratory thresholds in relation to clinical decisions. We offer recommendations on the tests to use for measuring DOACs and practical guidance on laboratory testing to help patient management and avoid diagnostic errors.
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Affiliation(s)
- J Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Centre (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
- Qualiblood s.a., Namur, Belgium
| | - W Ageno
- Department of Clinical and Experimental Medicine, University of Insubria, Varese, Italy
| | - C-M Samama
- Cochin University Hospital, Department of Anaesthesiology and Intensive Care, Université Paris Descartes, Paris, France
| | - S Lessire
- Department of Anaesthesiology, Namur Thrombosis and Haemostasis Centre (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - H Ten Cate
- Department of Internal Medicine, Maastricht University Medical Centre and Cardiovascular Research Institute (CARIM), Maastricht, the Netherlands
| | - P Verhamme
- Department of Cardiovascular Sciences, Vascular Medicine and Haemostasis, University of Leuven, Leuven, Belgium
| | - J-M Dogné
- Department of Pharmacy, Namur Thrombosis and Hemostasis Centre (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - F Mullier
- CHU UCL Namur, Laboratory Hematology, Namur Thrombosis and Haemostasis Centre (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université catholique de Louvain, Yvoir, Belgium
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Ihde ES, Zamudio S, Loh JM, Zhu Y, Woytanowski J, Rosen L, Liu M, Buckley B. Application of a novel mass spectrometric (MS) method to examine exposure to Bisphenol-A and common substitutes in a maternal fetal cohort. HUMAN AND ECOLOGICAL RISK ASSESSMENT : HERA 2017; 24:331-346. [PMID: 31588171 PMCID: PMC6777866 DOI: 10.1080/10807039.2017.1381831] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Accepted: 09/16/2017] [Indexed: 05/26/2023]
Abstract
The use of Bisphenol A (BPA) has widely been replaced in consumer products by analogs BPB, BPE, BPF, BPS, and BPAF. Recent studies have linked these substitutes to similar adverse health outcomes as BPA, including disruption of endocrine pathways in animal and human studies. We designed a novel MS method, developed specifically for this study, to capture the most relevant BPA alternatives, BPB, BPE, BPF, BPS, BPAF and 4-NP in human blood and urine to quantify potential in utero exposures. To our knowledge, this is the first study to explore in utero exposure to these BPA analogs and the first U.S. study to test for BPA in maternal/fetal pairs. The method was run on 30 paired maternal urine and fetal cord blood samples from mothers undergoing elective Caesarean sections. 90% of mothers and 77% of babies tested positive for at least one BP analog. 83% of mothers tested positive for BPAF, 60% for BPS, 57% for BPB, 17% for BPF and 7% for BPA. 57% of babies tested positive for BPAF and 50% for BPF. BPA and BPB were detected in one cord blood sample each. BPS was not detected in cord blood. BPE was not detected in any fetal cord blood or maternal urine samples. These findings demonstrate the pervasiveness of some BP analogs in pregnant women and their babies at birth.
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Affiliation(s)
- Erin Speiser Ihde
- The Deirdre Imus Environmental Health Center®, Hackensack University Medical Center, 30 Prospect Ave, Research Building, Hackensack NJ 07601, USA
| | - Stacy Zamudio
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Surgery, Hackensack University Medical Center, 30 Prospect Ave, Hackensack NJ 07601, USA
| | - Ji Meng Loh
- Dept. of Mathematical Sciences, NJ Institute of Technology, University Heights, Newark, NJ 07102, USA
| | - Yalin Zhu
- Dept. of Mathematical Sciences, NJ Institute of Technology, University Heights, Newark, NJ 07102, USA
| | - John Woytanowski
- St. George’s University School of Medicine, Grenada, West Indies
- Drexel University College of Medicine, Dept. of Internal Medicine, 2900 W. Queen Lane, Philadelphia, PA 19129, USA
| | - Lawrence Rosen
- The Deirdre Imus Environmental Health Center®, Hackensack University Medical Center, 30 Prospect Ave, Research Building, Hackensack NJ 07601, USA
| | - Min Liu
- Environmental and Occupational Health Sciences Institute, Rutgers University, 170 Frelinghuysen Road, Piscataway, NJ08854, USA
| | - Brian Buckley
- Environmental and Occupational Health Sciences Institute, Rutgers University, 170 Frelinghuysen Road, Piscataway, NJ08854, USA
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Samuelson BT, Cuker A. Measurement and reversal of the direct oral anticoagulants. Blood Rev 2016; 31:77-84. [PMID: 27625113 DOI: 10.1016/j.blre.2016.08.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/24/2016] [Accepted: 08/29/2016] [Indexed: 12/27/2022]
Abstract
Direct oral anticoagulants (DOACs) offer noninferior efficacy and improved safety compared to vitamin K antagonists (VKAs) for the prevention and treatment of venous thromboembolism and for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation. Unlike VKAs, DOACs do not require routine laboratory monitoring of anticoagulant effect and dose adjustment. In certain situations, however, laboratory assessment of anticoagulant effect may be desirable. Here we review the utility of currently available assays for assessment of DOAC effect and recommend an optimal assessment strategy for each drug, including calibrated dilute thrombin time or ecarin-based assays for dabigatran and calibrated anti-Xa activity assays for the factor Xa inhibitors. We also discuss reversal strategies, both specific and nonspecific, for each drug, including the preferential use of idarucizumab for the reversal of dabigatran and two agents, andexanet and ciraparantag, currently under development for the reversal of rivaroxaban, apixaban, and edoxaban.
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Affiliation(s)
- Bethany T Samuelson
- Division of Hematology, Department of Medicine, University of Washington, 1100 Fairview Ave N D5-100, Seattle, WA 98109, USA.
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, PA 19104, USA.
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