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Arachchillage DJ, Kitchen S. Pleiotropic Effects of Heparin and its Monitoring in the Clinical Practice. Semin Thromb Hemost 2024. [PMID: 38810964 DOI: 10.1055/s-0044-1786990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Unfractionated heparin (UFH) was uncovered in 1916, has been used as an anticoagulant since 1935, and has been listed in the World Health Organization's Model List of Essential Medicines. Despite the availability of many other anticoagulants, the use of heparin (either low molecular weight heparin [LMWH] or UFH) is still substantial. Heparin has pleotropic effects including anticoagulant and several nonanticoagulant properties such as antiproliferative, anti-inflammatory activity, and anticomplement effects. Although UFH has been widely replaced by LMWH, UFH is still the preferred anticoagulant of choice for patients undergoing cardiopulmonary bypass surgery, extracorporeal membrane oxygenation, and patients with high-risk mechanical cardiac valves requiring temporary bridging with a parenteral anticoagulant. UFH is a highly negatively charged molecule and binds many positively charged molecules, hence has unpredictable pharmacokinetics, and variable anticoagulant effect on an individual patient basis. Therefore, anticoagulant effects of UFH may not be proportional to the dose of UFH given to any individual patient. In this review, we discuss the anticoagulant and nonanticoagulant activities of UFH, differences between UFH and LMWH, when to use UFH, different methods of monitoring the anticoagulant effects of UFH (including activated partial thromboplastin time, heparin anti-Xa activity level, and activated clotting time), while discussing pros and cons related to each method and comparison of clinical outcomes in patients treated with UFH monitored with different methods based on available evidence.
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Affiliation(s)
- Deepa J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Steve Kitchen
- Department of Coagulation, Royal Hallamshire Hospital, Sheffield, United Kingdom
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2
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Gibert A, Lanoiselée J, Gouin-Thibault I, Pontis A, Azarnoush K, Petrosyan A, Grand N, Molliex S, Morel J, Gergelé L, Hodin S, Bin V, Chaux R, Delavenne X, Ollier E. Factors Influencing Unfractionated Heparin Pharmacokinetics and Pharmacodynamics During a Cardiopulmonary Bypass. Clin Pharmacokinet 2024; 63:211-225. [PMID: 38169065 DOI: 10.1007/s40262-023-01334-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Unfractionated heparin (UFH) is commonly used during cardiac surgery with a cardiopulmonary bypass to prevent blood clotting. However, empirical administration of UFH leads to variable responses. Pharmacokinetic and pharmacodynamic modeling can be used to optimize UFH dosing and perform real-time individualization. In previous studies, many factors that could influence UFH pharmacokinetics/pharmacodynamics had not been taken into account such as hemodilution or the type of UFH. Few covariates were identified probably owing to a lack of statistical power. This study aims to address these limitations through a meta-analysis of individual data from two studies. METHODS An individual patient data meta-analysis was conducted using data from two single-center prospective observational studies, where different UFH types were used for anticoagulation. A pharmacodynamic/pharmacodynamic model of UFH was developed using a non-linear mixed-effects approach. Time-varying covariates such as hemodilution and fluid infusions during a cardiopulmonary bypass were considered. RESULTS Activities of UFH's anti-activated factor/anti-thrombin were best described by a two-compartment model. Unfractionated heparin clearance was influenced by body weight and the specific UFH type. Volume of distribution was influenced by body weight and pre-operative fibrinogen levels. Pharmacodynamic data followed a log-linear model, accounting for the effect of hemodilution and the pre-operative fibrinogen level. Equations were derived from the model to personalize UFH dosing based on the targeted activated clotting time level and patient covariates. CONCLUSIONS The population model effectively characterized UFH's pharmacokinetics/pharmacodynamics in cardiopulmonary bypass patients. This meta-analysis incorporated new covariates related to UFH's pharmacokinetics/pharmacodynamics, enabling personalized dosing regimens. The proposed model holds potential for individualization using a Bayesian estimation.
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Affiliation(s)
- Audrick Gibert
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France.
| | - Julien Lanoiselée
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Isabelle Gouin-Thibault
- Laboratory of Hematology, Pontchaillou, University Hospital of Rennes, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR_S 1085, Rennes, France
| | - Adeline Pontis
- Laboratory of Hematology, Pontchaillou, University Hospital of Rennes, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR_S 1085, Rennes, France
| | - Kasra Azarnoush
- Service de Chirurgie Cardiaque, CHU de Saint-Etienne, Saint-Etienne, France
| | - Andranik Petrosyan
- Service de Chirurgie Cardiaque, CHU de Saint-Etienne, Saint-Etienne, France
| | - Nathalie Grand
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Serge Molliex
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Jérome Morel
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Laurent Gergelé
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Sophie Hodin
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
| | - Valérie Bin
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
| | - Robin Chaux
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
- Unité de Recherche Clinique Innovation et Pharmacologie, CHU de Saint-Etienne, Saint-Etienne, France
| | - Xavier Delavenne
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
- Laboratoire de Pharmacologie Toxicologie Gaz du sang, CHU de Saint-Etienne, Saint-Etienne, France
| | - Edouard Ollier
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
- Unité de Recherche Clinique Innovation et Pharmacologie, CHU de Saint-Etienne, Saint-Etienne, France
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Lasne D, Toussaint-Hacquard M, Delassasseigne C, Bauters A, Flaujac C, Savard P, Mouton C, De Maistre E, Stepanian A, Eschwège V, Delrue M, Georges JL, Gros A, Mansour A, Leroy G, Jouffroy R, Mattei M, Beurton A, Pontis A, Neuwirth M, Nedelec-Gac F, Lecompte T, Curis E, Siguret V, Gouin-Thibault I. Factors Influencing Anti-Xa Assays: A Multicenter Prospective Study in Critically Ill and Noncritically Ill Patients Receiving Unfractionated Heparin. Thromb Haemost 2023; 123:1105-1115. [PMID: 37321244 DOI: 10.1055/s-0043-1770096] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND The presence of dextran sulfate (DS) in reagents and the type of blood collection tube (citrate/citrated-theophylline-adenosine-dipyridamole [CTAD]) can lead to discrepancies between unfractionated heparin (UFH) anti-Xa levels. OBJECTIVES To evaluate the extent of the effect (1) of different reagents containing or not containing DS and (2) of the blood collection tubes, on UFH anti-Xa levels, in various clinical situations (NCT04700670). METHODS We prospectively included patients from eight centers: group (G)1, cardiopulmonary bypass (CPB) after heparin neutralization (n = 39); G2, cardiothoracic intensive care unit (ICU) after CPB (n = 35); G3, medical ICU (n = 53); G4, other medical inpatients (n = 38). Blood was collected into citrated and CTAD tubes. Chromogenic anti-Xa assays were centrally performed, using seven reagent/analyzer combinations including two without DS. The association between anti-Xa levels and covariates was tested using a linear mixed-effects model. RESULTS We analyzed 4,546 anti-Xa values from 165 patients. Median anti-Xa levels were systematically higher with reagents containing DS, whatever the patient group, with the greatest effect observed in G1 (0.32 vs. 0.05 IU/mL). Anti-Xa levels were slightly higher in CTAD than in citrate samples, irrespective of the assay. The model showed: (1) a significant dextran-patient group interaction (p < 0.0001), the effect of DS on anti-Xa levels varying from 30.9% in G4 to 296% in G1, and (2) a significant effect of CTAD, varying between patient groups (p = 0.0302). CONCLUSION The variability of anti-Xa levels with a great overestimation of the values, using a reagent containing DS, can lead to different treatment decisions, especially after heparin neutralization by protamine. Clinical consequences of these differences remain to be demonstrated.
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Affiliation(s)
- Dominique Lasne
- AP-HP, Laboratoire d'hématologie générale, Hôpital Necker, INSERM, Univ. Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | | | - Anne Bauters
- CHU Lille, Institut d'Hématologie-Transfusion, Lille, France
| | - Claire Flaujac
- Laboratoire de Biologie Médicale (Secteur Hémostase), Centre Hospitalier de Versailles, André Mignot, Le Chesnay, France
| | | | - Christine Mouton
- Laboratoire Hématologie, Hôpital Haut-Lévêque, CHU Bordeaux, France
| | | | - Alain Stepanian
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | | | - Maxime Delrue
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | - Jean-Louis Georges
- Service de réanimation medico-chirurgicale, Centre Hospitalier de Versailles, André Mignot, Le Chesnay, France
| | - Antoine Gros
- Service de réanimation medico-chirurgicale, Centre Hospitalier de Versailles, André Mignot, Le Chesnay, France
| | - Alexandre Mansour
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes; Univ Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
| | | | - Romain Jouffroy
- AP-HP, Service de réanimation adulte, Hôpital Necker, Paris, France
| | - Matthieu Mattei
- Unité d'Anesthésie et Réanimation Cardiaque & Réanimation Médicale Brabois, CHRU Nancy, Nancy, France
| | - Antoine Beurton
- Department of Cardiovascular Anaesthesia and Critical care, Surgical Medical Center Magellan, Haut-Lévêque Hospital, Pessac, France
| | - Adeline Pontis
- Hématologie Biologique, Hôpital Pontchaillou, University Hospital of Rennes, Univ. Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
| | - Marie Neuwirth
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | - Fabienne Nedelec-Gac
- Hématologie Biologique, Hôpital Pontchaillou, University Hospital of Rennes, Univ. Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
| | - Thomas Lecompte
- Department of Pharmacy, Faculté de médecine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université de Lorraine & Université de Namur, Namur, Belgium
- Hématologie Biologique, Hôpital Pontchaillou University Hospital of Rennes, Rennes, France
| | - Emmanuel Curis
- UR 7537 BioSTM, faculté de pharmacie de Paris, université Paris Cité, Paris, France
- Service d'Hématologie Biologique, Hôpital Lariboisière, AP-HP, Paris, France
| | - Virginie Siguret
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | - Isabelle Gouin-Thibault
- Hématologie Biologique, Hôpital Pontchaillou, University Hospital of Rennes, Univ. Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
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Hardy M, Cabo J, Deliège A, Douxfils J, Gouin-Thibault I, Lecompte T, Mullier F. Reassessment of dextran sulfate in anti-Xa assay for unfractionated heparin laboratory monitoring. Res Pract Thromb Haemost 2023; 7:102257. [PMID: 38193053 PMCID: PMC10772882 DOI: 10.1016/j.rpth.2023.102257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/20/2023] [Accepted: 10/18/2023] [Indexed: 01/10/2024] Open
Abstract
Background Anti-Xa assays are used for unfractionated heparin (UFH) monitoring. Dextran sulfate (DS) is used in some assays to overcome the artifactual preanalytical release of platelet factor 4. However, the practical implications of this test modification have not been studied extensively. Objectives To investigate the impact of the presence of DS in the anti-Xa assay for UFH laboratory monitoring. Methods We studied factor Xa inhibition, using an assay without DS (Stago Liquid Anti-Xa), in normal pool plasma spiked with various concentrations of UFH (up to 1 IU/mL) in the presence of increasing concentrations of DS (up to 2560 μg/mL). We also investigated the effect of DS on FXa inhibition measured after the addition of UFH and heparin antagonists (protamine and Polybrene; Sigma Aldrich). Eventually, we compared the anti-Xa levels measured using the assay without DS to those measured with an assay containing DS (BIOPHEN Heparin LRT, Hyphen BioMed). Results DS per se had a detectable anti-Xa effect. FXa inhibition in UFH-spiked plasma linearly increased with increasing concentrations of added DS, with a plateau at approximately 160 μg/mL DS, at which the apparent anti-Xa level had almost doubled. In the presence of heparin antagonists, the addition of DS increased anti-Xa levels, corresponding to the dissociation of the UFH-antagonists complexes in vitro. With the anti-Xa assay containing DS, UFH inhibition was not detected. Conclusion In the presence of high concentrations of DS, FXa inhibition was much higher than that predicted from added UFH amounts, presumably related to the greater availability of UFH for interaction with antithrombin. While the relevance of measuring this "masked" heparin has not been demonstrated, the presence of DS renders the result inaccurate in the presence of protamine or Polybrene.
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Affiliation(s)
- Michael Hardy
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Hematology Laboratory, Yvoir, Belgium
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Department of Anesthesiology, Yvoir, Belgium
- Université catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Pôle Mont, Yvoir, Belgium
| | - Julien Cabo
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Hematology Laboratory, Yvoir, Belgium
| | - Antoine Deliège
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Hematology Laboratory, Yvoir, Belgium
| | - Jonathan Douxfils
- University of Namur, Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
- QUALIblood s.a., Namur, Belgium
| | | | - Thomas Lecompte
- University of Namur, Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
- CHU of Rennes, Department of Laboratory Hematology, IRSET-INSERM-1085, Rennes, France
- University of Lorraine, CHRU of Nancy, Nancy, France
| | - François Mullier
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Hematology Laboratory, Yvoir, Belgium
- Université catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Pôle Mont, Yvoir, Belgium
- University of Namur, Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
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Hogwood J, Mulloy B, Lever R, Gray E, Page CP. Pharmacology of Heparin and Related Drugs: An Update. Pharmacol Rev 2023; 75:328-379. [PMID: 36792365 DOI: 10.1124/pharmrev.122.000684] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 02/17/2023] Open
Abstract
Heparin has been used extensively as an antithrombotic and anticoagulant for close to 100 years. This anticoagulant activity is attributed mainly to the pentasaccharide sequence, which potentiates the inhibitory action of antithrombin, a major inhibitor of the coagulation cascade. More recently it has been elucidated that heparin exhibits anti-inflammatory effect via interference of the formation of neutrophil extracellular traps and this may also contribute to heparin's antithrombotic activity. This illustrates that heparin interacts with a broad range of biomolecules, exerting both anticoagulant and nonanticoagulant actions. Since our previous review, there has been an increased interest in these nonanticoagulant effects of heparin, with the beneficial role in patients infected with SARS2-coronavirus a highly topical example. This article provides an update on our previous review with more recent developments and observations made for these novel uses of heparin and an overview of the development status of heparin-based drugs. SIGNIFICANCE STATEMENT: This state-of-the-art review covers recent developments in the use of heparin and heparin-like materials as anticoagulant, now including immunothrombosis observations, and as nonanticoagulant including a role in the treatment of SARS-coronavirus and inflammatory conditions.
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Affiliation(s)
- John Hogwood
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Barbara Mulloy
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Rebeca Lever
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Elaine Gray
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
| | - Clive P Page
- Sackler Institute of Pulmonary Pharmacology, Institute of Pharmaceutical Science, King's College London, London, United Kingdom (B.M., E.G., C.P.P.); National Institute for Biological Standards and Control, South Mimms, Hertfordshire, United Kingdom (J.H., E.G.) and School of Pharmacy, University College London, London, United Kingdom (R.L.)
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Amiral J. Editorial for the Special Issue of Monitoring Anticoagulants. Biomedicines 2022; 10:biomedicines10010155. [PMID: 35052834 PMCID: PMC8773630 DOI: 10.3390/biomedicines10010155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/04/2022] [Accepted: 01/06/2022] [Indexed: 02/06/2023] Open
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