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Melicine S, Habay C, Ghammad W, Carré J, Diehl JL, Smadja DM, Gendron N, Helley D, Mauge L. DOAC-Remove to counteract the interference of anti-Xa oral anticoagulants on the monitoring of heparin. Int J Lab Hematol 2024. [PMID: 38803134 DOI: 10.1111/ijlh.14321] [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: 12/01/2023] [Accepted: 05/01/2024] [Indexed: 05/29/2024]
Abstract
INTRODUCTION The monitoring of unfractionated heparin (UFH) by anti-factor Xa activity (AXA) is commonly used to ensure effective anticoagulation and prevent bleeding risk. However, in patients previously treated with an anti-Xa direct oral anticoagulant (DOAC) switching to UFH therapy, there is a risk of interference that may lead to inappropriate anticoagulation. The first objective of this study was to validate DOAC-Remove to remove DOAC for measuring UFH specific AXA. The second objective was to assess the length of DOAC interference on UFH monitoring and to identify potential predictive factors. MATERIALS AND METHODS This monocentric retrospective study included all patients admitted from April 2019 to April 2021 previously treated with anti-Xa DOAC, and for whom an interference on UFH monitoring was suspected. Interference was defined as a difference in the AXA measured before and after using DOAC-Remove >2.8-fold standard deviation of the method. RESULTS Removal with DOAC-Remove was specific of DOAC (apixaban n = 42, rivaroxaban n = 41, UFH n = 20) and sufficient to avoid interference on UFH AXA measurement. The exact interference length was 6.0 days [IQR 3.0-11.0] for apixaban (n = 26) and 4.5 days [IQR 2.0-5.8] for rivaroxaban (n = 20). Among the 89 patients sorted based on an interference length ≤ or >3 days, 74 (83.1%) presented an interference greater than 3 days. Correlations were observed with age for apixaban and creatinine for rivaroxaban. CONCLUSIONS Our results suggest that DOAC-Remove could be of high interest in patients receiving UFH previously treated with an anti-Xa DOAC even if DOAC was stopped for more than 3 days.
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Affiliation(s)
- Sophie Melicine
- Hematology Department, AP-HP.CUP, Georges Pompidou European Hospital, Paris, France
| | - Capucine Habay
- Hematology Department, AP-HP.CUP, Georges Pompidou European Hospital, Paris, France
| | - Wiame Ghammad
- Hematology Department, AP-HP.CUP, Georges Pompidou European Hospital, Paris, France
| | - Julie Carré
- Hematology Department, AP-HP.CUP, Georges Pompidou European Hospital, Paris, France
| | - Jean Luc Diehl
- Innovative Therapies in Hemostasis, INSERM, University Paris Cité, Paris, France
- Intensive Care Unit, AP-HP.CUP, Georges Pompidou European Hospital, Paris, France
| | - David M Smadja
- Hematology Department, AP-HP.CUP, Georges Pompidou European Hospital, Paris, France
- Innovative Therapies in Hemostasis, INSERM, University Paris Cité, Paris, France
| | - Nicolas Gendron
- Hematology Department, AP-HP.CUP, Georges Pompidou European Hospital, Paris, France
- Innovative Therapies in Hemostasis, INSERM, University Paris Cité, Paris, France
| | - Dominique Helley
- Hematology Department, AP-HP.CUP, Georges Pompidou European Hospital, Paris, France
- PARCC, INSERM, University Paris Cité, Paris, France
| | - Laetitia Mauge
- Hematology Department, AP-HP.CUP, Georges Pompidou European Hospital, Paris, France
- PARCC, INSERM, University Paris Cité, Paris, France
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Gendron N, Billoir P, Siguret V, Le Cam-Duchez V, Proulle V, Macchi L, Boissier E, Mouton C, De Maistre E, Gouin-Thibault I, Jourdi G. Is there a role for the laboratory monitoring in the management of specific antidotes of direct oral anticoagulants? Thromb Res 2024; 237:171-180. [PMID: 38626592 DOI: 10.1016/j.thromres.2024.04.005] [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] [Received: 01/03/2024] [Revised: 04/04/2024] [Accepted: 04/08/2024] [Indexed: 04/18/2024]
Abstract
Given the growing number of patients receiving direct oral anticoagulant (DOAC), patients requiring rapid neutralization is also increasing in case of major bleedings or urgent surgery/procedures. Idarucizumab is commercialized as a specific antidote to dabigatran while andexanet alfa has gained the Food and Drug Administration and the European Medicines Agency approval as an oral anti-factor Xa inhibitors antidote. Other antidotes or hemostatic agents are still under preclinical or clinical development, the most advanced being ciraparantag. DOAC plasma levels measurement allows to appropriately select patient for antidote administration and may prevent unnecessary prescription of expensive molecules in some acute clinical settings. However, these tests might be inconclusive after some antidote administration, namely andexanet alfa and ciraparantag. The benefit of laboratory monitoring following DOAC reversal remains unclear. Here, we sought to provide an overview of the key studies evaluating the safety and efficacy of DOAC reversal using the most developed/commercialized specific antidotes, to discuss the potential role of the laboratory monitoring in the management of patients receiving DOAC specific antidotes and to highlight the areas that deserve further investigations in order to establish the exact role of laboratory monitoring in the appropriate management of DOAC specific antidotes.
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Affiliation(s)
- Nicolas Gendron
- Hematology Department, Assistance Publique Hôpitaux de Paris.Centre-Université de Paris (APHP.CUP), F-75015 Paris, France; Paris Cité University, INSERM, Innovative Therapies in Haemostasis, F-75006 Paris, France.
| | - Paul Billoir
- Normandie University, UNIROUEN, INSERM U1096, Rouen University Hospital, Vascular Hemostasis Unit, F 76000 Rouen, France
| | - Virginie Siguret
- Paris Cité University, INSERM, Innovative Therapies in Haemostasis, F-75006 Paris, France; Laboratory of Hematology, Lariboisière hospital, AP-HP. Nord, F-75010 Paris, France
| | - Véronique Le Cam-Duchez
- Normandie University, UNIROUEN, INSERM U1096, Rouen University Hospital, Vascular Hemostasis Unit, F 76000 Rouen, France
| | - Valérie Proulle
- Service Hématologie Biologique et UF d'Hémostase Clinique, Hôpital Cochin, Assistance Publique Hôpitaux de Paris.Centre-Université de Paris (APHP.CUP), F-75015 Paris, France; Université Paris Cité, CRC, unité UMR_S1138, France
| | - Laurent Macchi
- University of Poitiers, INSERM 1313, IRMETIST, F-86000 Poitiers, France; CHU de Poitiers, laboratory of hematology, F-86000 Poitiers, France
| | - Elodie Boissier
- Laboratory of Hematology, University Hospital, Nantes, France
| | - Christine Mouton
- Hematology Laboratory, Hemostasis Department, Haut-Lévêque hospital, CHU, Bordeaux, France
| | | | - Isabelle Gouin-Thibault
- Univ Rennes, Rennes University Hospital, Inserm, EHESP, IRSET (Institut de Recherche en Santé, Environnement et Travail) - UMR_S, 1085, Rennes, France; Hematology Laboratory, Rennes University Hospital, Rennes, France
| | - Georges Jourdi
- Paris Cité University, INSERM, Innovative Therapies in Haemostasis, F-75006 Paris, France; Laboratory of Hematology, Lariboisière hospital, AP-HP. Nord, F-75010 Paris, France.
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Shen X, Qiu E, Liu Z, Zhu X, Zeng Y. Effectiveness and safety of rivaroxaban for anticoagulation therapy in COVID-19: A meta-analysis of randomized controlled trials. Saudi Med J 2024; 45:341-348. [PMID: 38657982 PMCID: PMC11147572 DOI: 10.15537/smj.2024.45.4.20230728] [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] [Received: 10/06/2023] [Accepted: 02/16/2024] [Indexed: 04/26/2024] Open
Abstract
OBJECTIVES To evaluate the effectiveness and safety of rivaroxaban anticoagulation in COVID-19 patients. METHODS PubMed, Embase, Cochrane Library electronic databases, and ClinicalTrials.gov were searched to identify all relevant randomized controlled trial studies from December 2019 to July 2023. RESULTS A total of 6 randomized controlled trials, which included a total of 3323 patients, were considered for evaluation. Overall, short-term all-cause mortality and hospitalization rates were not significantly different between the rivaroxaban and control groups. Thrombotic events were significantly reduced in the rivaroxaban prophylaxis group compared to the placebo control group. However, the reduction in thrombotic events was not significantly different between rivaroxaban therapy and heparin or low-molecular-weight heparin (LMWH). Rivaroxaban prophylaxis and the therapeutic dose may be associated with a higher rate of overall bleeding rate, but major bleeding rates did not differ substantially. CONCLUSION Rivaroxaban may reduce thrombotic events in COVID-19 patients, but it does not appear to have an advantage over heparin or LMWH, and it may increase the risk of bleeding.INPLASY Reg. No.: INPLASY 202370097.
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Affiliation(s)
- Xiangbo Shen
- From the Department of Pulmonary and Critical Care Medicine (Shen), Jiangxi PingXiang People’s Hospital, Pingxiang, Jiangxi Province, from the Department of Trauma Center (Qiu, Zhu, Zeng); and from the Department of Critical Care Medicine (Liu), Zhuzhou Central Hospital, Zhuzhou, Hunan Province, China.
| | - Eryue Qiu
- From the Department of Pulmonary and Critical Care Medicine (Shen), Jiangxi PingXiang People’s Hospital, Pingxiang, Jiangxi Province, from the Department of Trauma Center (Qiu, Zhu, Zeng); and from the Department of Critical Care Medicine (Liu), Zhuzhou Central Hospital, Zhuzhou, Hunan Province, China.
| | - Zhao Liu
- From the Department of Pulmonary and Critical Care Medicine (Shen), Jiangxi PingXiang People’s Hospital, Pingxiang, Jiangxi Province, from the Department of Trauma Center (Qiu, Zhu, Zeng); and from the Department of Critical Care Medicine (Liu), Zhuzhou Central Hospital, Zhuzhou, Hunan Province, China.
| | - Xiaopeng Zhu
- From the Department of Pulmonary and Critical Care Medicine (Shen), Jiangxi PingXiang People’s Hospital, Pingxiang, Jiangxi Province, from the Department of Trauma Center (Qiu, Zhu, Zeng); and from the Department of Critical Care Medicine (Liu), Zhuzhou Central Hospital, Zhuzhou, Hunan Province, China.
| | - Yiqian Zeng
- From the Department of Pulmonary and Critical Care Medicine (Shen), Jiangxi PingXiang People’s Hospital, Pingxiang, Jiangxi Province, from the Department of Trauma Center (Qiu, Zhu, Zeng); and from the Department of Critical Care Medicine (Liu), Zhuzhou Central Hospital, Zhuzhou, Hunan Province, China.
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Wong S, Slingerland J, Dickerson JA, Pak J, Roach GD, Saifee NH. Development of a Rapid Qualitative Screen for Anticoagulant Presence. J Appl Lab Med 2024; 9:305-315. [PMID: 38101950 DOI: 10.1093/jalm/jfad081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 09/01/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) and fondaparinux with stable pharmacokinetics are commonly used anticoagulants for outpatient care. Due to the lack of monitoring requirements, drug-specific assays are not available in most hospital laboratories, but drug levels are needed in some urgent/emergency situations. This study describes the development of a qualitative screen for the presence of DOAC or fondaparinux using coagulation tests found in most laboratories. METHODS The DOAC screen is composed of a heparin anti-Xa activity assay and thrombin time (TT) assay. The STA®-Liquid-Anti-Xa assay calibrated with Stago Multi Hep® and STA®-TT were run on STA-R Max® analyzers. The anti-Xa activity and TT assays were repeated 5 times in samples of commercially available calibrators and controls for each drug: fondaparinux, dabigatran, rivaroxaban, apixaban, and edoxaban. Statistical analysis and correlations were performed for anti-Xa activity and TT results for each drug and pooled normal plasma. RESULTS A significant correlation was found between heparin-calibrated anti-Xa levels and fondaparinux, rivaroxaban, apixiban, and edoxaban (r2 = 0.99-1.0). Dabigatran showed a strong linear correlation (r2 = 0.99) with TT. Anti-Xa levels >0.3 IU/mL and TT >25 seconds were determined as cutoffs at our lab for the detection of clinically relevant drug levels of factor Xa inhibitor and direct thrombin inhibitor, respectively. CONCLUSIONS Our study demonstrates that commonly available heparin anti-Xa activity and TT assays can be used to qualitatively detect DOACs and fondaparinux and provides a method to establish a qualitative interpretation.
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Affiliation(s)
- Selena Wong
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, United States
- Department of Laboratory Medicine and Pathology, Seattle Children's Hospital, Seattle, WA, United States
| | - Jenna Slingerland
- Department of Laboratory Medicine and Pathology, Seattle Children's Hospital, Seattle, WA, United States
| | - Jane A Dickerson
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, United States
- Department of Laboratory Medicine and Pathology, Seattle Children's Hospital, Seattle, WA, United States
| | - Jennifer Pak
- Department of Pharmacy, Seattle Children's Hospital, Seattle, WA, United States
| | - Gavin D Roach
- Division of Pediatric Hematology-Oncology, Seattle Children's Hospital and University of Washington, Seattle, WA, United States
| | - Nabiha H Saifee
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA, United States
- Department of Laboratory Medicine and Pathology, Seattle Children's Hospital, Seattle, WA, United States
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Qiao J, Tran MH. Challenges to Laboratory Monitoring of Direct Oral Anticoagulants. Clin Appl Thromb Hemost 2024; 30:10760296241241524. [PMID: 38650302 PMCID: PMC11036927 DOI: 10.1177/10760296241241524] [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] [Received: 02/09/2024] [Revised: 03/05/2024] [Accepted: 03/07/2024] [Indexed: 04/25/2024] Open
Abstract
Direct oral anticoagulants (DOACs) exert anticoagulation effect by directly inhibiting Factor Xa (rivaroxaban, apixaban, and edoxaban) or thrombin (dabigatran). Though DOACs are characterized by fixed-dose prescribing and generally do not require routine laboratory drug-level monitoring (DLM), circumstances may arise where the DLM may aid in clinical decision-making, including DOAC dose adjustment, anticoagulant class change, or decisions to withhold or administer reversal agents. We review the current literature that describes high-risk patient groups in which DLM may be beneficial for improved patient anticoagulation management and stewardship. The review also summarizes the limitations of conventional coagulation testing and discuss the emerging utility of quantitative methods for routine and rapid emergent evaluation of DOAC drug levels-in particular, the Anti-Xa activity to detect Factor Xa Inhibitors (rivaroxaban, apixaban, and edoxaban). Both technical and regulatory barriers to widespread DLM implementation are limiting factors to further clinical research that must be overcome, in order to propose universal DOAC DLM strategies and provide clinical-laboratory correlation to formally classify high-risk patient groups.
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Affiliation(s)
- Jesse Qiao
- Irvine Department of Pathology and Laboratory Medicine, University of California, Orange, CA, USA
| | - Minh-Ha Tran
- Irvine Department of Pathology and Laboratory Medicine, University of California, Orange, CA, USA
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