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Teissandier D, Moustafa F, Denaives A, Lebecque B, Blondonnet R, Pereira B, Monfoulet LE, Sinegre T, Schmidt J, Lebreton A. Thrombin generation in real life bleeding patients on oral anticoagulants reversed (or not) with (activated) prothrombin complex concentrate. Thromb Res 2023; 223:184-193. [PMID: 36764085 DOI: 10.1016/j.thromres.2023.01.022] [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: 10/18/2022] [Revised: 01/18/2023] [Accepted: 01/21/2023] [Indexed: 01/31/2023]
Abstract
BACKGROUND Bleeding during oral anticoagulant therapy is currently codified by expert guidelines. Monitoring of coagulation during bleeding events is challenging. Our study sought to assess thrombin generation assay (TGA) in direct oral anticoagulant-treated patients without bleeding (WB), bleeding without reversal therapy (BR-), and bleeding with reversal therapy (BR+). METHODS We conducted a prospective, monocentric study from June 2015 to June 2018. For all bleeding groups, TGA was evaluated using platelet-poor plasma collected upon arrival at emergency (T0), and 30 min (T1), 6 h (T2) and 24 h (T3) after reversal therapy (if indicated) following activation by tissue factor 5 pM and phospholipids. RESULTS Overall, 292 patients participated, including 91 BR+, 94 BR-, and 107 WB patients. At T0, vitamin K antagonist reversed (VKA-BR+) patients experienced a significant decrease in TGA parameters (ETP and peak) compared with VKA without bleeding (VKA-WB). Compared with healthy controls, VKA-BR+ patients reversed by four-factor prothrombin complex concentrate (4F-PCC) displayed comparable TGA 's ETP and peak at T1, T2, and T3, whereas direct anti-Xa BR+ patients reversed by 4F-PCC or activated prothrombin complex concentrate (aPCC) reached thrombin generation parameters that exceeded normal range at T2 and T3. CONCLUSIONS In VKA-treated patients reversed by 4F-PCC, TGA parameters were normalized, whereas in rivaroxaban or apixaban-treated patients reversed by 4F-PCC or aPCC, TGA parameters exceeded normal range. Further studies are needed to compare the efficacy and safety of a different dose of reversal therapy and the impact on coagulation parameters.
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Affiliation(s)
- Dorian Teissandier
- Emergency Department, University Hospital of Clermont Ferrand, 63000 Clermont-Ferrand, France; Université Clermont Auvergne, INRAE, UNH, F-63000 Clermont-Ferrand, France.
| | - Farès Moustafa
- Emergency Department, University Hospital of Clermont Ferrand, 63000 Clermont-Ferrand, France; Université Clermont Auvergne, INRAE, UNH, F-63000 Clermont-Ferrand, France
| | - Amélie Denaives
- Hematology Department, University Hospital of Clermont Ferrand, 63000 Clermont-Ferrand, France
| | - Benjamin Lebecque
- Hematology Department, University Hospital of Clermont Ferrand, 63000 Clermont-Ferrand, France
| | - Raiko Blondonnet
- Intensive Care Unit, University Hospital of Clermont Ferrand, 63000 Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit, the Clinical Research and Innovation Direction, University Hospital of Clermont-Ferrand, 63000 Clermont-Ferrand, France
| | | | - Thomas Sinegre
- Université Clermont Auvergne, INRAE, UNH, F-63000 Clermont-Ferrand, France; Hematology Department, University Hospital of Clermont Ferrand, 63000 Clermont-Ferrand, France
| | - Jeannot Schmidt
- Emergency Department, University Hospital of Clermont Ferrand, 63000 Clermont-Ferrand, France
| | - Aurélien Lebreton
- Université Clermont Auvergne, INRAE, UNH, F-63000 Clermont-Ferrand, France; Hematology Department, University Hospital of Clermont Ferrand, 63000 Clermont-Ferrand, France
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Margraf DJ, Seaburg S, Beilman GJ, Wolfson J, Gipson JC, Chapman SA. Propensity score adjusted comparison of three-factor versus four-factor prothrombin complex concentrate for emergent warfarin reversal: a retrospective cohort study. BMC Emerg Med 2020; 20:93. [PMID: 33243152 PMCID: PMC7691107 DOI: 10.1186/s12873-020-00386-z] [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: 06/30/2020] [Accepted: 11/12/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Prothrombin Complex Concentrates (PCC) are prescribed for emergent warfarin reversal (EWR). The comparative effectiveness and safety among PCC products are not fully understood. METHODS Patients in an academic level one trauma center who received PCC3 or PCC4 for EWR were identified. Patient characteristics, PCC dose and time of dose, pre- and post-INR and time of measurement, fresh frozen plasma and vitamin K doses, and patient outcomes were collected. Patients whose pre-PCC International Normalized Ratio (INR) was > 6 h before PCC dose or the pre-post PCC INR was > 12 h were excluded. The primary outcome was achieving an INR ≤ 1.5 post PCC. Secondary outcomes were the change in INR over time, post PCC INR, thromboembolic events (TE), and death during hospital stay. Logistic regression modelled the primary outcome with and without a propensity score adjustment accounting for age, sex, actual body weight, dose, initial INR value, and time between INR measurements. Data are reported as median (IQR) or n (%) with p < 0.05 considered significant. RESULTS Eighty patients were included (PCC3 = 57, PCC4 = 23). More PCC4 patients achieved goal INR (87.0% vs. 31.6%, odds ratio (OR) = 14.4, 95% CI: 3.80-54.93, p < 0.001). This result remained true after adjusting for possible confounders (AOR = 10.7, 95% CI: 2.17-51.24, p < 0.001). The post-PCC INR was lower in the PCC4 group (1.3 (1.3-1.5) vs. 1.7 (1.5-2.0)). The INR change was greater for PCC4 (2.3 (1.3-3.3) vs. 1.1 (0.6-2.0), p = 0.003). Death during hospital stay (p = 0.52) and TE (p = 1.00) were not significantly different. CONCLUSIONS PCC4 was associated with a higher achievement of goal INR than PCC3. This relationship was observed in the unadjusted and propensity score adjusted results.
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Affiliation(s)
- David J Margraf
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, 7-115E Weaver-Densford Hall, 308 Harvard St. SE, Minneapolis, MN, 55455, USA
| | - Scott Seaburg
- Department of Pharmacy Services, North Memorial Health Hospital, Robbinsdale, MN, USA
| | - Gregory J Beilman
- Division of Critical Care & Acute Care Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Julian Wolfson
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Jonathan C Gipson
- Trauma and Acute Care Surgery, North Memorial Health Hospital, Robbinsdale, MN, USA
| | - Scott A Chapman
- Department of Experimental and Clinical Pharmacology, College of Pharmacy, University of Minnesota, 7-115E Weaver-Densford Hall, 308 Harvard St. SE, Minneapolis, MN, 55455, USA.
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Rhoney DH, Chester KW, Darsey DA. Optimal Dosage and Administration Practices for Vitamin K Antagonist Reversal With 4-Factor Prothrombin Complex Concentrate. Clin Appl Thromb Hemost 2020. [PMCID: PMC7573754 DOI: 10.1177/1076029620947474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Expert consensus and international guidelines recommend urgent co-administration of vitamin K and 4-factor prothrombin complex concentrates (4F-PCCs) to rapidly reverse VKA-related bleeding. This narrative review examined real-world evidence and strategies to optimize international normalized ratio (INR) reversal, hemostasis, and outcomes in patients receiving 4F-PCC in this setting. Key determinants for success include the appropriate use of alternative dosing and administration strategies, such as fixed dosing and increased infusion speed, adherence to institutional guidelines, and removing significant institutional barriers to reduce time to treatment. In the opinion of authors, minimizing the time to treatment with 4F-PCCs is of paramount importance when treating patients with VKA-related bleeding. Practices that safely and feasibly shorten the time to administration should be included in guidelines for institutions responsible for anticoagulant care, and adhered to in centers that perform invasive procedures on patients receiving VKA therapy. Further studies are required to optimize use of 4F-PCC, particularly in relation to the ideal dosing strategy and the role of INR.
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Affiliation(s)
- Denise H. Rhoney
- UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | | | - Damon A. Darsey
- University of Mississippi, School of Medicine, Jackson, MS, USA
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Ashikhmina E, Johnson PM, Aganga DO, Nuttall GA, Lahr BD, Schaff HV, Dearani JA. Thrombin Generation and Antithrombin Activity in Infants Undergoing Cardiopulmonary Bypass—An Exploratory Study. J Cardiothorac Vasc Anesth 2020; 34:2083-2090. [DOI: 10.1053/j.jvca.2019.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 12/05/2019] [Accepted: 12/07/2019] [Indexed: 11/11/2022]
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Erdoes G, Koster A, Ortmann E, Meesters MI, Bolliger D, Baryshnikova E, Martinez Lopez De Arroyabe B, Ahmed A, Lance MD, Ranucci M, von Heymann C, Agarwal S, Ravn HB. A European consensus statement on the use of four-factor prothrombin complex concentrate for cardiac and non-cardiac surgical patients. Anaesthesia 2020; 76:381-392. [PMID: 32681570 DOI: 10.1111/anae.15181] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2020] [Indexed: 02/06/2023]
Abstract
Modern four-factor prothrombin complex concentrate was designed originally for rapid targeted replacement of the coagulation factors II, VII, IX and X. Dosing strategies for the approved indication of vitamin K antagonist-related bleeding vary greatly. They include INR and bodyweight-related protocols as well as fixed dose regimens. Particularly in the massively bleeding trauma and cardiac surgery patient, four-factor prothrombin complex concentrate is used increasingly for haemostatic resuscitation. Members of the Transfusion and Haemostasis Subcommittee of the European Association of Cardiothoracic Anaesthesiology performed a systematic literature review on four-factor prothrombin complex concentrate. The available evidence has been summarised for dosing, efficacy, drug safety and monitoring strategies in different scenarios. Whereas there is evidence for the efficacy of four-factor prothrombin concentrate for a variety of bleeding scenarios, convincing safety data are clearly missing. In the massively bleeding patient with coagulopathy, our group recommends the administration of an initial bolus of 25 IU.kg-1 . This applies for: the acute reversal of vitamin K antagonist therapy; haemostatic resuscitation, particularly in trauma; and the reversal of direct oral anticoagulants when no specific antidote is available. In patients with a high risk for thromboembolic complications, e.g. cardiac surgery, the administration of an initial half-dose bolus (12.5 IU.kg-1 ) should be considered. A second bolus may be indicated if coagulopathy and microvascular bleeding persists and other reasons for bleeding are largely ruled out. Tissue-factor-activated, factor VII-dependent and heparin insensitive point-of-care tests may be used for peri-operative monitoring and guiding of prothrombin complex concentrate therapy.
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Affiliation(s)
- G Erdoes
- Department of Anaesthesiology and Pain Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - A Koster
- Institute for Anaesthesiology, Heart and Diabetes Centre NRW, Ruhr-University Bochum, Bad Oeynhausen, Germany
| | - E Ortmann
- Department of Anaesthesia, Kerckhoff Heart and Lung Centre, Bad Nauheim, Germany
| | - M I Meesters
- Department of Anaesthesiology, University Medical Centre Utrecht, The Netherlands
| | - D Bolliger
- Department of Anaesthesia, Prehospital Emergency Medicine, and Pain Therapy, University Hospital Basel, Switzerland
| | - E Baryshnikova
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | | | - A Ahmed
- Department of Anaesthesia, University Hospitals of Leicester NHS Trust, UK.,Department of Cardiovascular Sciences, University of Leicester, UK
| | - M D Lance
- Hamad Medical Corporation, HMC, Anaesthesiology, ICU and Peri-operative Medicine, Doha, Qatar
| | - M Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - C von Heymann
- Department of Anaesthesia, Intensive Care Medicine, Emergency Medicine and Pain Therapy, Vivantes Klinikum im Friedrichshain, Berlin, Germany
| | - S Agarwal
- Department of Anaesthesia, Manchester University Hospitals, Manchester, UK
| | - H B Ravn
- Department of Cardiothoracic Anaesthesiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
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Zwaveling S, Bloemen S, de Laat B, ten Cate H, ten Cate-Hoek A. Calibrated Automated Thrombinography (CAT), a Tool to Identify Patients at Risk of Bleeding during Anticoagulant Therapy: A Systematic Review. TH OPEN 2018; 2:e291-e302. [PMID: 31249953 PMCID: PMC6524885 DOI: 10.1055/s-0038-1672183] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 08/01/2018] [Indexed: 12/14/2022] Open
Abstract
Background Bleeding is a feared adverse event during anticoagulant treatment. In patients on vitamin K antagonists, most bleedings occur with the international normalized ratio (INR) in the therapeutic range. Currently, identification of high-risk patients via laboratory methods is not reliable. In this systematic review, we assessed the ability of calibrated automated thrombin generation (CAT-TG) to predict bleeding in patients on anticoagulant treatment. Methods A systematic search was executed in three databases: Medline, Embase, and Cochrane. Results Seven studies were included; two were of good methodological quality. One study showed that patients on warfarin with INRs in range (2-3) admitted for hemorrhage ( n = 28), had lower CAT-TG levels (endogenous thrombin potential [ETP]: 333 ± 89 nM/min) than patients on warfarin admitted for other reasons (ETP: 436 ± 207 nM/min; p < 0.001). Another study found no difference in ETP or peak levels between bleeding and nonbleeding patients in PPP or PRP. When measured in whole blood, both levels were significantly lower in patients with bleeding compared with nonbleeding patients (median [interquartile range, IQR] ETP: 182.5 [157.2-2,847 nM/min] vs. median [IQR] ETP: 256.2 [194.9-344.2 nM/min]; p < 0.001) and median [IQR] peak: 23.9 [19.6-41.8 nM] vs. median [IQR] peak: 39.1 [24.9-53.2 nM]; p < 0.05). From the remaining studies, four suggested that CAT-TG is more sensitive in detecting hemostatic abnormalities than INR and one article found ETP and INR to be equally useful. However, insufficient data were provided to validate these conclusions. Conclusion Studies investigating the direct association between decreased CAT-TG values and hemorrhagic events are rare. Therefore, the clinical consequences of low CAT-TG values remain to be further investigated.
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Affiliation(s)
- Suzanne Zwaveling
- Laboratory for Clinical Thrombosis and Hemostasis, Internal Medicine and Biochemistry, Maastricht University, Maastricht, The Netherlands
- Synapse Research Institute, Maastricht, The Netherlands
| | | | - Bas de Laat
- Synapse Research Institute, Maastricht, The Netherlands
| | - Hugo ten Cate
- Laboratory for Clinical Thrombosis and Hemostasis, Internal Medicine and Biochemistry, Maastricht University, Maastricht, The Netherlands
| | - Arina ten Cate-Hoek
- Laboratory for Clinical Thrombosis and Hemostasis, Internal Medicine and Biochemistry, Maastricht University, Maastricht, The Netherlands
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Heparin supplement counteracts the prohemostatic effect of prothrombin complex concentrate and factor IX concentrate: An in vitro evaluation. Thromb Res 2016; 139:102-10. [PMID: 26916304 DOI: 10.1016/j.thromres.2016.01.017] [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] [Received: 10/28/2015] [Revised: 01/20/2016] [Accepted: 01/24/2016] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Coagulation factor concentrates like factor IX (FIX) and prothrombin complex concentrate (PCC) can contain anticoagulant substances that may hamper their procoagulant effectiveness in the treatment of hemophilia B or reversal of oral anticoagulation, as well as the laboratory assessment thereof. The aim of the present study was to evaluate the influence of anticoagulant heparin supplement on the prohemostatic potential of different PCCs and FIX concentrates. MATERIALS AND METHODS Prohemostatic potential was evaluated in vitro employing PT/aPTT, thrombography (TGA) and thromboelastography (TEG) with FIX deficient plasma, vitamin K antagonist (VKA)-anticoagulated plasma and plasma anticoagulated with rivaroxaban. RESULTS Most PCCs contained heparin, while heparin was detected in 1 out of 4 examined FIX concentrates. All heparin-containing clotting factor concentrates showed severely hampered prohemostatic effects when therapeutic doses were added to anticoagulated plasmas. Upon heparin removal, comparable prohemostatic effects were observed. Of importance is the notion that the anticoagulant effect of heparin was enhanced by rivaroxaban, resulting in a 7 fold increased PT sensitivity towards heparin in the presence of 500μg/L rivaroxaban. CONCLUSIONS Compositional differences between clotting factor concentrates should be taken into account. Therapeutic levels of heparin may be co-infused when treating emergency bleeds with high prohemostatic drug doses, particularly those recommended in the reversal of non-VKA anticoagulants such as rivaroxaban by PCC. Given the relative short half-life of heparin compared to vitamin K-dependent clotting factors, an anticoagulant heparin effect shortly after concentrate infusion should be considered clinically and while interpreting laboratory coagulation parameters.
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