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Fehér A, Vincze I, Rudge J, Domján G, Vásárhelyi B, Karvaly GB. Assays for Monitoring Apixaban and Rivaroxaban in Emergency Settings, State-of-the-Art Routine Analysis, and Volumetric Absorptive Microsamples Deliver Discordant Results. Diagnostics (Basel) 2024; 14:1939. [PMID: 39272725 PMCID: PMC11394325 DOI: 10.3390/diagnostics14171939] [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: 07/07/2024] [Revised: 08/28/2024] [Accepted: 08/31/2024] [Indexed: 09/15/2024] Open
Abstract
Our aim was to compare the performance of complementary clinical laboratory approaches to monitoring exposure to apixaban and rivaroxaban, the most prescribed direct-acting oral anticoagulants (DOAC's): an automated commercial anti-Xa chromogenic assay suitable for emergency and pre-surgery testing and a laboratory-developed liquid chromatography-tandem mass spectrometry (LC-MS/MS) method employed for non-emergency analysis in plasma and in dried blood volumetric absorptive microsamples (VAMS) collectible by the patients in their homes. The full validation of the LC-MS/MS method was performed. Cross-validation of the methodologies was accomplished by processing 60 specimens collected for whole blood count and DOAC monitoring in a central clinical laboratory. For VAMS samples, dried plasma and whole blood calibrators were found to be suitable, and a cycle run for seven days could be implemented for rational and economic sample processing. The anti-Xa chromogrenic assay and the LC-MS/MS method delivered discordant plasma analyte concentrations. Moreover, the lack of agreement between plasma and VAMS concentrations was observed. Clinical laboratories must be aware of the differences between the performance of apixaban and rivaroxaban LC-MS/MS and anti-Xa assays. Hematocrit must always be measured along with VAMS samples to obtain accurate results.
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Affiliation(s)
- Adrienne Fehér
- Department of Laboratory Medicine, Semmelweis University, H-1089 Budapest, Hungary
| | - István Vincze
- Department of Laboratory Medicine, Semmelweis University, H-1089 Budapest, Hungary
| | - James Rudge
- Trajan Scientific & Medical, Milton Keynes MK8 0AB, UK
| | - Gyula Domján
- Department of Internal Medicine and Oncology, Semmelweis University, H-1083 Budapest, Hungary
| | - Barna Vásárhelyi
- Department of Laboratory Medicine, Semmelweis University, H-1089 Budapest, Hungary
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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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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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Riahi N, Rozen L, Demulder A. Usefullness of Heparin Calibrated Anti-Xa Activity to Assess Anticoagulant Activity of Apixaban and Rivaroxaban in Emergency Patients Scheduled for Acute Interventions. J Clin Med 2023; 12:6785. [PMID: 37959250 PMCID: PMC10647510 DOI: 10.3390/jcm12216785] [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: 09/05/2023] [Revised: 10/16/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
(1) Background: Direct oral anticoagulants (DOACs) require monitoring in some critical clinical situations. The specific tests for DOAC monitoring are not yet available in all labs. The aim of this study was to evaluate if a unique, more widespread heparin-calibrated anti-Xa assay could be suitable to estimate the concentrations of apixaban and rivaroxaban in order to establish an algorithm helping our clinicians in their therapeutic decision for patients treated with DOACs in emergencies. (2) Methods: A first retrospective part allowed us to determine of a conversion factor between the measured DOAC concentration and the deducted anti-Xa heparin activity based on optic density. During the second prospective part, both DOAC concentration (ng/mL) and anti-Xa activity heparin (UI/mL) were measured on the same sample, and the previously determined conversion factor was applied to each UI/mL value. We then compared the calculated and measured DOAC concentration values. (3) Results: The analysis of the derivation cohort confirmed a good correlation, especially between the anti-Xa heparin activity and the apixaban concentrations (r = 0.97). Additionally, we determined heparin-calibrated anti-Xa assay cut-offs for invasive procedures at 0.3 UI/mL and for intravenous thrombolysis at 0.51 UI/mL using ROC curves with a sensitivity at 98% and specificity at 95% for 0.3 UI/mL and a sensitivity at 97.7% and specificity at 88.2% for the cut-off of 0.51 UI/mL. In the validation cohort, we confirmed the agreement between measured and calculated DOAC concentrations for the low values, especially around cut-offs with an excellent negative predictive value for 0.51 UI/mL (94% for apixaban and 100% for rivaroxaban) and a good negative predictive value for 0.3 UI/mL (83.3% for apixaban and 85.7% for rivaroxaban). (4) Conclusions: Our results confirm that it is possible to correctly predict or exclude the presence of apixaban/rivaroxaban in emergency situations when specific tests are not readily available.
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Affiliation(s)
- Nada Riahi
- Department of Hematology, Laboratoire Hospitalier Universitaire de Bruxelles LHUB-ULB, Université Libre de Bruxelles ULB, 1020 Brussels, Belgium; (N.R.); (A.D.)
| | - Laurence Rozen
- Department of Hematology, Laboratoire Hospitalier Universitaire de Bruxelles LHUB-ULB, Université Libre de Bruxelles ULB, 1020 Brussels, Belgium; (N.R.); (A.D.)
- Laboratory of Hematology, CHU-Brugmann, 1020 Brussels, Belgium
| | - Anne Demulder
- Department of Hematology, Laboratoire Hospitalier Universitaire de Bruxelles LHUB-ULB, Université Libre de Bruxelles ULB, 1020 Brussels, Belgium; (N.R.); (A.D.)
- Laboratory of Hematology, CHU-Brugmann, 1020 Brussels, Belgium
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Villapalos-García G, Zubiaur P, Ochoa D, Soria-Chacartegui P, Navares-Gómez M, Matas M, Mejía-Abril G, Casajús-Rey A, Campodónico D, Román M, Martín-Vílchez S, Candau-Ramos C, Aldama-Martín M, Abad-Santos F. NAT2 phenotype alters pharmacokinetics of rivaroxaban in healthy volunteers. Biomed Pharmacother 2023; 165:115058. [PMID: 37385211 DOI: 10.1016/j.biopha.2023.115058] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 07/01/2023] Open
Abstract
Rivaroxaban is a direct inhibitor of factor Xa, a member of direct oral anticoagulant group of drugs (DOACs). Despite being a widely extended alternative to vitamin K antagonists (i.e., acenocoumarol, warfarin) the interindividual variability of DOACs is significant, and may be related to adverse drug reaction occurrence or drug inefficacy, namely hemorrhagic or thromboembolic events. Since there is not a consistent analytic practice to monitor the anticoagulant activity of DOACs, previously reported polymorphisms in genes coding for proteins responsible for the activation, transport, or metabolism of DOACs were studied. The study population comprised 60 healthy volunteers, who completed two randomized, crossover bioequivalence clinical trials between two different rivaroxaban formulations. The effect of food, sex, biogeographical origin and 55 variants (8 phenotypes and 47 single nucleotide polymorphisms) in drug metabolizing enzyme genes (such as CYP2D6, CYP2C9, NAT2) and transporters (namely, ABCB1, ABCG2) on rivaroxaban pharmacokinetics was tested. Individuals dosed under fasting conditions presented lower tmax (2.21 h vs 2.88 h, β = 1.19, R2 =0.342, p = 0.012) compared to fed volunteers. NAT2 slow acetylators presented higher AUC∞ corrected by dose/weight (AUC∞/DW; 8243.90 vs 7698.20 and 7161.25 h*ng*mg /ml*kg, β = 0.154, R2 =0.250, p = 0.044), higher Cmax/DW (1070.99 vs 834.81 and 803.36 ng*mg /ml*kg, β = 0.245, R2 =0.320, p = 0.002), and lower tmax (2.63 vs 3.19 and 4.15 h, β = -0.346, R2 =0.282, p = 0.047) than NAT2 rapid and intermediate acetylators. No other association was statistically significant. Thus, slow NAT2 appear to have altered rivaroxaban pharmacokinetics, increasing AUC∞ and Cmax. Nonetheless, further research should be conducted to verify NAT2 involvement on rivaroxaban pharmacokinetics and to determine its clinical significance.
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Affiliation(s)
- Gonzalo Villapalos-García
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Pablo Zubiaur
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain; Division of Clinical Pharmacology, Toxicology & Therapeutic Innovation, Children's Mercy Research Institute (CMRI), Kansas City, MO, USA.
| | - Dolores Ochoa
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Paula Soria-Chacartegui
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Marcos Navares-Gómez
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Miriam Matas
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Gina Mejía-Abril
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Ana Casajús-Rey
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Diana Campodónico
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Manuel Román
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Samuel Martín-Vílchez
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Carmen Candau-Ramos
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Marina Aldama-Martín
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain
| | - Francisco Abad-Santos
- Clinical Pharmacology Department, Hospital Universitario de La Princesa, Instituto Teófilo Hernando, Instituto de Investigación Sanitaria La Princesa (IP), School of Medicine, Universidad Autónoma de Madrid, Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
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6
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Heubner L, Vicent O, Beyer-Westendorf J, Spieth PM. Bleeding management in patients with direct oral anticoagulants. Minerva Anestesiol 2023; 89:707-715. [PMID: 37079285 DOI: 10.23736/s0375-9393.23.17230-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Bleeding events in patients under direct oral anticoagulation (DOAC) can be life-threating but are commonly not related to drug overdose. However, a relevant DOAC plasma concentration impairs the hemostasis and should therefore be ruled out immediately after hospital admission. The effect of DOAC is typically not visible in standard coagulation tests such as activated partial thrombin time or thromboplastin time. Specific anti-Xa or anti-IIa assays allow a specific drug monitoring, but they are too time-consuming in critical bleeding events and typically not available 24 h/7 d in routine care. Recent advantages in point-of-care (POC) testing might improve patient care by early exclusion of relevant DOAC levels, but sufficient validation is still lacking. POC urine analysis help to exclude DOAC in emergency patients, but does not provide a quantitative information about plasma concentration. POC viscoelastic testing (VET) can determine the DOAC effect on clotting time and helps further to reveal other concomitant bleeding disorders in emergency, e.g., factor deficiency or hyperfibrinolysis. If a relevant plasma concentration of the DOAC is assumed or was proven by either laboratory assays or POC testing, restoration of factor IIa or factor IIa activity is key for effective hemostasis. Limited evidence suggests that specific reversals for DOAC, e.g., idarucizumab for dabigatran and andexanet alfa for apixaban or rivaroxaban, might be superior to increasing thrombin generation by administration of prothrombin complex concentrates. To determinate, if DOAC reversal is indicated or not, time from last intake, anti-Xa/dTT values or results from POC tests can be considered. This experts' opinion provides a feasible decision algorithm for clinical practice.
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Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany -
| | - Oliver Vicent
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Jan Beyer-Westendorf
- Unit of Thrombosis Research, Division of Hematology and Hemostasis, Department of Medicine I, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Peter M Spieth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany
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Burger A, Studt JD, Mendez A, Alberio L, Fontana P, Wuillemin WA, Schmidt A, Graf L, Gerber B, Bovet C, Sauter TC, Binder NB, Nagler M. Determination of Anti-Xa Inhibitor Plasma Concentrations Using a Universal Edoxaban Calibrator. Diagnostics (Basel) 2023; 13:2128. [PMID: 37371023 DOI: 10.3390/diagnostics13122128] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/18/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023] Open
Abstract
A universal calibrator for the determination of all anti-Xa inhibitors would support laboratory processes. We aimed to test the clinical performance of an anti-Xa assay utilizing a universal edoxaban calibrator to determine clinically relevant concentrations of all anti-Xa inhibitors. Following a pilot study, we enrolled 553 consecutive patients taking rivaroxaban, edoxaban, or apixaban from nine study centers in a prospective cross-sectional study. The Technochrom® anti-Xa assay was conducted using the Technoview® edoxaban calibrator. Using ultra-high-performance liquid chromatography-tandem mass spectrometry (LC-MS/MS), anti-Xa inhibitor drug concentrations were determined. Sensitivities and specificities to detect three clinically relevant drug concentrations (30 µgL-1, 50 µgL-1, 100 µgL-1) were determined. Overall, 300 patients treated with rivaroxaban, 221 with apixaban, and 32 with edoxaban were included. The overall correlation coefficient (rs) was 0.95 (95% CI 0.94, 0.96). An area under the receiver operating characteristic curve of 0.96 for 30 µgL-1, 0.98 for 50 µgL-1, and 0.99 for 100 µgL-1 was found. The sensitivities were 92.3% (95% CI 89.2, 94.6), 92.7% (89.4, 95.1), and 94.8% (91.1, 97.0), respectively (specificities 82.2%, 93.7%, and 94.4%). In conclusion, the clinical performance of a universal, edoxaban-calibrated anti-Xa assay was solid and most drug concentrations were predicted correctly.
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Affiliation(s)
- Annika Burger
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University Hospital Zurich, University of Zurich, 8006 Zurich, Switzerland
| | - Adriana Mendez
- Institute for Laboratory Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospital, 1205 Geneva, Switzerland
| | - Walter A Wuillemin
- Division of Hematology, Hematology Laboratory, Cantonal Hospital of Lucerne, University of Bern, 3012 Bern, Switzerland
| | - Adrian Schmidt
- Institute of Laboratory Medicine, Clinic of Medical Oncology and Hematology, Municipal City Hospital Zurich Triemli, 8063 Zurich, Switzerland
| | - Lukas Graf
- Centre for Laboratory Medicine, 9001 St. Gallen, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, 6500 Bellinzona, Switzerland
| | - Cédric Bovet
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, 3010 Bern, Switzerland
| | - Nikolaus B Binder
- Technoclone Herstellung von Diagnostika und Arzneimitteln GmbH, 1230 Vienna, Austria
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
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8
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Panigada M, Meli A, Forastieri Molinari A, Grazioli L, Giani M, Ceriani D, Bianchi C, Passarelli MT, Consonni D, Grasselli G. Agreement Between Viscoelastic Coagulation Monitor (VCM), TEG 5000, and Coagulation Tests in Critically Ill Patients: A Multicenter Study. ASAIO J 2023; 69:e230-e239. [PMID: 37019087 DOI: 10.1097/mat.0000000000001932] [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: 04/07/2023] Open
Abstract
The performance of viscoelastic coagulation monitor (VCM) compared with TEG 5000 (TEG) is unknown. In this multicenter study, the authors evaluated the agreement among VCM/TEG parameters and their relationship with standard coagulation tests in critically ill patients. Viscoelastic coagulation monitor, TEG, and laboratory samples were analyzed simultaneously. Viscoelastic coagulation monitor/TEG agreement was computed by Bland and Altman's plots, association with laboratory parameters was studied with Spearman's correlation coefficient and random-intercept linear models. One-hundred and twenty-seven patients enrolled, 320 paired observations: 210 (65.6%) under unfractioned heparin (UFH), 94 (29.4%) under low molecular weight heparin (LMWH), 16 (5.0%) no heparin. Under UFH prolonged clot formation times and reduced the amplitude of viscoelastic tracings on both devices, especially on TEG. The type of heparin affected the agreement between VCM/TEG homolog parameters. Reaction time (TEG-R) resulted 23.1 min longer than the homolog clotting time (VCM-CT) under UFH; maximum amplitude (TEG-MA) resulted 29.5 mm higher than maximum clot firmness (VCM-MCF) under LMWH. Weak correlation was observed between VCM-CT/TEG-R and activated partial thromboplastin time (aPTT)/anti-Xa; no correlation was found between VCM-alpha/TEG-angle and fibrinogen concentration. Viscoelastic coagulation monitor-MCF showed strong (LWMH) to moderate (UFH) correlation with platelet count, while TEG-MA only showed lower correlation. Viscoelastic coagulation monitor and TEG are differently affected by heparin. The platelet count is well represented by VCM-MCF even during UFH administration.
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Affiliation(s)
- Mauro Panigada
- From the Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Meli
- From the Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Lorenzo Grazioli
- Department of Anesthesia and Intensive Care, ASST Papa Giovanni, Bergamo, Italy
| | - Marco Giani
- Department of Emergency and Intensive Care, ASST Monza, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Daniele Ceriani
- Department of Anesthesia and Intensive Care, A. Manzoni Hospital, ASST Lecco, Lecco, Italy
| | - Cecilia Bianchi
- Department of Anesthesia and Intensive Care, ASST Papa Giovanni, Bergamo, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Maria Teresa Passarelli
- Department of Emergency and Intensive Care, ASST Monza, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Dario Consonni
- Epidemiology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giacomo Grasselli
- From the Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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9
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Brakta C, Stépanian A, Reiner P, Delrue M, Mazighi M, Curis E, Siguret V. Practical Nomogram Predicting Apixaban or Rivaroxaban Concentrations from Low-Molecular-Weight Heparin Anti-Xa Values: Special Interest in Acute Ischemic Stroke Patients. J Stroke 2023; 25:126-131. [PMID: 36592965 PMCID: PMC9911839 DOI: 10.5853/jos.2022.03034] [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] [Received: 09/25/2022] [Accepted: 11/23/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND AND PURPOSE In patients with acute ischemic stroke (AIS) using a direct oral factor-Xa anticoagulant (DOAC) during the last 48 hours, a fixed plasma heparin-calibrated anti-Xa activity (0.5 IU/mL) was proposed as a threshold below which patients could be eligible for thrombolysis and/or thrombectomy. Besides, specific DOAC-calibrated anti-Xa thresholds up to 50 ng/mL have been proposed. However, specific DOAC assays are not widely available contrarily to low-molecularweight heparin (LMWH) anti-Xa activity. We developed and validated a nomogram for predicting apixaban and rivaroxaban concentrations based on LMWH anti-Xa assay. METHODS Our prospective study included apixaban (n=325) and rivaroxaban (n=276) patients. On the same sample, we systematically measured specific DOAC concentration and LMWH anti-Xa activity, using STA®-Liquid-Anti-Xa (Stago) and specific DOAC- or LMWH-calibrators, respectively. The nomogram was built using quantifiable values for both assays on the derivation cohorts with a log-linear regression model. Model performances including sensitivity, specificity, and true positive rate for different thresholds were checked on the validation cohorts. RESULTS The models built from the derivation cohorts predicted that values <30 ng/mL and <50 ng/ mL DOAC thresholds corresponded to LMWH-anti-Xa values <0.10 IU/mL and <0.64 IU/mL for apixaban; <0.10 IU/mL and <0.71 IU/mL for rivaroxaban. The model accurately predicted apixaban/ rivaroxaban concentrations in the validation cohort. CONCLUSIONS This easy-to-use nomogram, developed with our reagent, allowed accurately predicting DOAC concentrations based on LMWH-anti-Xa results in emergency situations such as AIS when drug-specific assessments are not rapidly available. Using DOAC <50 ng/mL equivalent threshold, instead of the fixed LMWH <0.5 IU/mL one, would allow proposing thrombolysis to more patients.
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Affiliation(s)
- Charlyne Brakta
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Alain Stépanian
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France,EA 3518, Université de Paris Cité, Paris, France
| | - Peggy Reiner
- Département de Neurologie, Unité Neuro-vasculaire, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Maxime Delrue
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France,Département de Neurologie, Unité Neuro-vasculaire, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Mikaël Mazighi
- Département de Neurologie, Unité Neuro-vasculaire, Hôpital Lariboisière, APHP Nord, Paris, France
| | - Emmanuel Curis
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France,UR 7537 BioSTM (Biostatistics), Faculté de Pharmacie de Paris, Université Paris Cité, Paris, France
| | - Virginie Siguret
- Service d’hématologie – Hémostase clinique, Hôpital Lariboisière, APHP Nord, Paris, France,INSERM UMRS-1140, Université de Paris Cité, Paris, France,Correspondence: Virginie Siguret Department of Hematology, Thrombosis Unit, Lariboisière Hospital (AP-HP), INSERM UMRS-1140, University Paris Cité, 2 rue Ambroise Paré 75010, Paris, France Tel: +33-6-63-53-37-55 Fax: +33-1-49-95-64-11 E-mail:
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10
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Valke LLFG, Rijpma S, Meijer D, Schols SEM, van Heerde WL. Thrombin generation assays to personalize treatment in bleeding and thrombotic diseases. Front Cardiovasc Med 2022; 9:1033416. [PMID: 36440026 PMCID: PMC9684194 DOI: 10.3389/fcvm.2022.1033416] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/26/2022] [Indexed: 07/30/2023] Open
Abstract
Treatment of bleeding and thrombotic disorders is highly standardized and based on evidence-based medicine guidelines. These evidence-based treatment schemes are well accepted but may lead to either insufficient treatment or over-dosing, because the individuals' hemostatic properties are not taken into account. This can potentially introduce bleeding or thrombotic complications in individual patients. With the incorporation of pharmacokinetic (PK) and pharmacodynamic (PK-PD) parameters, based on global assays such as thrombin generation assays (TGAs), a more personalized approach can be applied to treat either bleeding or thrombotic disorders. In this review, we will discuss the recent literature about the technical aspects of TGAs and the relation to diagnosis and management of bleeding and thrombotic disorders. In patients with bleeding disorders, such as hemophilia A or factor VII deficiency, TGAs can be used to identify patients with a more severe bleeding phenotype and also in the management with non-replacement therapy and/or bypassing therapy. These assays have also a role in patients with venous thrombo-embolism, but the usage of TGAs in patients with arterial thrombosis is less clear. However, there is a potential role for TGAs in the monitoring of (long-term) antithrombotic therapy, for example with the use of direct oral anticoagulants. Finally this review will discuss controversies, limitations and knowledge gaps in relation to the introduction of TGAs to personalize medicine in daily medical practice.
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Affiliation(s)
- Lars L. F. G. Valke
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
| | - Sanna Rijpma
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Danielle Meijer
- Department of Laboratory Medicine, Laboratory of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Saskia E. M. Schols
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
| | - Waander L. van Heerde
- Department of Hematology, Radboud University Medical Center, Nijmegen, Netherlands
- Hemophilia Treatment Center, Nijmegen, Netherlands
- Enzyre BV, Novio Tech Campus, Nijmegen, Netherlands
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11
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Sathanantham V, Alberio L, Bovet C, Fontana P, Gerber B, Graf L, Mendez A, Sauter TC, Schmidt A, Studt JD, Wuillemin WA, Nagler M. Prothrombinase-Induced Clotting Time to Measure Drug Concentrations of Rivaroxaban, Apixaban, and Edoxaban in Clinical Practice: A Cross-Sectional Study. LIFE (BASEL, SWITZERLAND) 2022; 12:life12071027. [PMID: 35888115 PMCID: PMC9324795 DOI: 10.3390/life12071027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 11/17/2022]
Abstract
Prothrombinase-induced clotting time (PiCT) is proposed as a rapid and inexpensive laboratory test to measure direct oral anticoagulant (DOAC) drug levels. In a prospective, multicenter cross-sectional study, including 851 patients, we aimed to study the accuracy of PiCT in determining rivaroxaban, apixaban, and edoxaban drug concentrations and assessed whether clinically relevant drug levels could be predicted correctly. Citrated plasma samples were collected, and the Pefakit® PiCT was utilized. Ultra-high performance liquid chromatography-tandem mass spectrometry (LC-MS/MS) was performed to measure drug concentrations. Cut-off levels were established using receiver-operating characteristics curves. We calculated sensitivities and specificities with respect to clinically relevant drug concentrations. Spearman’s correlation coefficient between PiCT and drug concentrations was 0.85 in the case of rivaroxaban (95% CI 0.82, 0.88), 0.66 for apixaban (95% CI 0.60, 0.71), and 0.78 for edoxaban (95% CI 0.65, 0.86). The sensitivity to detect clinically relevant drug concentrations was 85.1% in the case of 30 µg L−1 (95% CI 82.0, 87.7; specificity 77.9; 72.1, 82.7), 85.7% in the case of 50 µg L−1 (82.4, 88.4; specificity 77.3; 72.5, 81.5), and 85.1% in the case of 100 µg L−1 (80.9, 88.4; specificity 73.2%; 69.1, 76.9). In conclusion, the association of PiCT with DOAC concentrations was fair, and the majority of clinically relevant drug concentrations were correctly predicted.
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Affiliation(s)
- Vepusha Sathanantham
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (V.S.); (C.B.)
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, CHUV, Lausanne University Hospital, 1011 Lausanne, Switzerland;
| | - Cédric Bovet
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, 3010 Bern, Switzerland; (V.S.); (C.B.)
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospital, 1205 Geneva, Switzerland;
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, 6500 Bellinzona, Switzerland;
- Faculty of Medicine, University of Zurich, 8091 Zurich, Switzerland
| | - Lukas Graf
- Centre for Laboratory Medicine St. Gallen, 9001 St. Gallen, Switzerland;
| | - Adriana Mendez
- Department of Laboratory Medicine, Cantonal Hospital Aarau, 5001 Aarau, Switzerland;
| | - Thomas C. Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, 3010 Bern, Switzerland;
| | - Adrian Schmidt
- Clinic of Medical Oncology and Hematology, Institute of Laboratory Medicine, City Hospital Waid and Triemli, 8063 Zurich, Switzerland;
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University and University Hospital Zurich, 8091 Zurich, Switzerland;
| | - Walter A. Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne, 6000 Lucerne, Switzerland;
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
- Correspondence:
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