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van den Besselaar AMHP, Stavelin A, Kitchen S, Bryant M, Tripodi A, Scalambrino E, Clerici M, Herbel P, Jünschke A, Meyer Dos Santos S, Meijer P, Niessen RWLM, Meijers JCM, Thelwell C, Cuker A, Kung C, Cao Z, Zander N, Iwasaki Y, Depasse F, van Rijn C, Baktawar S, Abdoel C, Cobbaert CM. Defining a metrologically traceable and sustainable calibration hierarchy of international normalized ratio for monitoring of vitamin K antagonist treatment in accordance with International Organization for Standardization (ISO) 17511:2020 standard: communication from the International Federation of Clinical Chemistry and Laboratory Medicine-SSC/ISTH working group on prothrombin time/international normalized ratio standardization. J Thromb Haemost 2024; 22:1236-1248. [PMID: 38128762 DOI: 10.1016/j.jtha.2023.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/01/2023] [Accepted: 12/07/2023] [Indexed: 12/23/2023]
Abstract
Calibration of prothrombin time (PT) in terms of international normalized ratio (INR) has been outlined in "Guidelines for thromboplastins and plasmas used to control oral anticoagulant therapy" (World Health Organization, 2013). The international standard ISO 17511:2020 presents requirements for manufacturers of in vitro diagnostic (IVD) medical devices (MDs) for documenting the calibration hierarchy for a measured quantity in human samples using a specified IVD MD. The objective of this article is to define an unequivocal, metrologically traceable calibration hierarchy for the INR measured in plasma as well as in whole blood samples. Calibration of PT and INR for IVD MDs according to World Health Organization guidelines is similar to that in cases where there is a reference measurement procedure that defines the measurand for value assignment as described in ISO 17511:2020. We conclude that, for PT/INR standardization, the optimal calibration hierarchy includes a primary process to prepare an international reference reagent and measurement procedure that defines the measurand by a value assignment protocol conforming to clause 5.3 of ISO 17511:2020. A panel of freshly prepared human plasma samples from healthy adult individuals and patients on vitamin K antagonists is used as a commutable secondary calibrator as described in ISO 17511:2020. A sustainable metrologically traceable calibration hierarchy for INR should be based on an international protocol for value assignment with a single primary reference thromboplastin and the harmonized manual tilt tube technique for clotting time determination. The primary international reference thromboplastin reagent should be used only for calibration of successive batches of the secondary reference thromboplastin reagent.
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Affiliation(s)
- Antonius M H P van den Besselaar
- Coagulation Reference Laboratory, Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, the Netherlands.
| | - Anne Stavelin
- The Norwegian Organisation for Quality Improvement of Laboratory Examinations, Bergen, Norway
| | - Steve Kitchen
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - Michelle Bryant
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK
| | - Armando Tripodi
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano and Fondazione Luigi Villa, Milano, Italy
| | - Erica Scalambrino
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano and Fondazione Luigi Villa, Milano, Italy
| | - Marigrazia Clerici
- Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano and Fondazione Luigi Villa, Milano, Italy
| | | | | | | | - Piet Meijer
- External quality Control of diagnostic Assays and Tests (ECAT) Foundation, Voorschoten, the Netherlands
| | | | - Joost C M Meijers
- Department of Molecular Hematology, Sanquin Research, Amsterdam, the Netherlands; Department of Experimental Vascular Medicine, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Craig Thelwell
- Therapeutic Reference Materials, Medicines and Healthcare Products Regulatory Agency, National Institute for Biological Standards and Control, Potters Bar, UK
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA; Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | - Claudia van Rijn
- Coagulation Reference Laboratory, Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Shanti Baktawar
- Coagulation Reference Laboratory, Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Charmane Abdoel
- Coagulation Reference Laboratory, Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, the Netherlands
| | - Christa M Cobbaert
- Coagulation Reference Laboratory, Department of Clinical Chemistry and Laboratory Medicine, Leiden University Medical Center, Leiden, the Netherlands
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Talasaz AH, Sadeghipour P, Ortega-Paz L, Kakavand H, Aghakouchakzadeh M, Beavers C, Fanikos J, Eikelboom JW, Siegal DM, Monreal M, Jimenez D, Vaduganathan M, Castellucci LA, Cuker A, Barnes GD, Connors JM, Secemsky EA, Van Tassell BW, De Caterina R, Kurlander JE, Aminian A, Piazza G, Goldhaber SZ, Moores L, Middeldorp S, Kirtane AJ, Elkind MSV, Angiolillo DJ, Konstantinides S, Lip GYH, Stone GW, Cushman M, Krumholz HM, Mehran R, Bhatt DL, Bikdeli B. Optimizing antithrombotic therapy in patients with coexisting cardiovascular and gastrointestinal disease. Nat Rev Cardiol 2024:10.1038/s41569-024-01003-3. [PMID: 38509244 DOI: 10.1038/s41569-024-01003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2024] [Indexed: 03/22/2024]
Abstract
Balancing the safety and efficacy of antithrombotic agents in patients with gastrointestinal disorders is challenging because of the potential for interference with the absorption of antithrombotic drugs and for an increased risk of bleeding. In this Review, we address considerations for enteral antithrombotic therapy in patients with cardiovascular disease and gastrointestinal comorbidities. For those with gastrointestinal bleeding (GIB), we summarize a general scheme for risk stratification and clinical evidence on risk reduction approaches, such as limiting the use of concomitant medications that increase the risk of GIB and the potential utility of gastrointestinal protection strategies (such as proton pump inhibitors or histamine type 2 receptor antagonists). Furthermore, we summarize the best available evidence and potential gaps in our knowledge on tailoring antithrombotic therapy in patients with active or recent GIB and in those at high risk of GIB but without active or recent GIB. Finally, we review the recommendations provided by major medical societies, highlighting the crucial role of teamwork and multidisciplinary discussions to customize the antithrombotic regimen in patients with coexisting cardiovascular and gastrointestinal diseases.
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Affiliation(s)
- Azita H Talasaz
- Arnold & Marie Schwartz College of Pharmacy and Health Sciences, Department of Pharmacy Practice, Long Island University, New York, NY, USA
- Division of Pharmacy, New York-Presbyterian/Columbia University Irvine Medical Center, New York, NY, USA
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Parham Sadeghipour
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Luis Ortega-Paz
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Hessam Kakavand
- Rajaie Cardiovascular Medical and Research Center, Iran University of Medical Sciences, Tehran, Iran
- Department of Clinical Pharmacy, School of Pharmacy, Iran University of Medical Sciences, Tehran, Iran
| | | | - Craig Beavers
- University of Kentucky College of Pharmacy, Lexington, KY, USA
| | - John Fanikos
- Department of Pharmacy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John W Eikelboom
- Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah M Siegal
- Division of Hematology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Manuel Monreal
- Department of Internal Medicine, Hospital Universitari Germans Trials i Pujol, Universidad Católica San Antonio de Murcia, Barcelona, Spain
| | - David Jimenez
- Respiratory Department, Hospital Ramón y Cajal and Medicine Department, Universidad de Alcalá (IRYCIS), Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, ISCIII, Madrid, Spain
| | - Muthiah Vaduganathan
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute at the University of Ottawa, Ottawa, Ontario, Canada
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Geoffrey D Barnes
- Frankel Cardiovascular Center, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jean M Connors
- Hematology Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric A Secemsky
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin W Van Tassell
- Department of Pharmacotherapy and Outcome Sciences, Virginia Commonwealth University, Richmond, VA, USA
| | - Raffaele De Caterina
- Cardiology Division, Pisa University Hospital, Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Città Sant'Angelo, Pescara, Italy
| | - Jacob E Kurlander
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Ali Aminian
- Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Gregory Piazza
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Samuel Z Goldhaber
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Thrombosis Research Group, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lisa Moores
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Saskia Middeldorp
- Department of Internal Medicine, Radboud Institute of Health Sciences (RIHS), Radboud University Medical Center, Nijmegen, Netherlands
| | - Ajay J Kirtane
- Cardiovascular Research Foundation, New York, NY, USA
- Division of Cardiology, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Dominick J Angiolillo
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL, USA
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis, Johannes Gutenberg, University of Mainz, Mainz, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregg W Stone
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mary Cushman
- University of Vermont Medical Center, Burlington, VT, USA
| | - Harlan M Krumholz
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Roxana Mehran
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Behnood Bikdeli
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- VA Ann Arbor Center for Clinical Management Research, Ann Arbor, MI, USA.
- Yale New Haven Hospital/Yale Center for Outcomes Research and Evaluation, New Haven, CT, USA.
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Allen C, Ito S, Butt A, Purcell A, Richmond R, Tormey CA, Krumholz H, Cuker A, Goshua G. Cost-effectiveness of rapid vs. in-house vs. send-out ADAMTS13 testing for immune thrombotic thrombocytopenic purpura. Blood Adv 2024:bloodadvances.2024012608. [PMID: 38502197 DOI: 10.1182/bloodadvances.2024012608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/27/2024] [Accepted: 03/11/2024] [Indexed: 03/21/2024] Open
Abstract
While awaiting confirmatory results, empiric therapy for patients suspected to have immune thrombotic thrombocytopenic purpura (iTTP) provides benefits and also accrues risks and costs. Rapid assays for ADAMTS13 may be able to avoid the cost and risk exposure associated with empiric treatment. We conducted the first cost-effectiveness evaluation of testing strategies with rapid versus traditional ADAMTS13 assays in patients with intermediate to high-risk PLASMIC scores, with and without caplacizumab use. We built a Markov cohort simulation with four clinical base-case analyses: 1) Intermediate-risk PLASMIC score with caplacizumab, 2) Intermediate-risk PLASMIC score without caplacizumab, 3) High-risk PLASMIC score with caplacizumab, 4) High-risk PLASMIC score without caplacizumab. Each of these evaluated three testing strategies: 1) rapid assay (<1-hour turnaround), 2) in-house FRET-based assay (24-hour turnaround), and 3) send-out FRET-based assay (72-hour turnaround). The primary outcome was the incremental net monetary benefit (iNMB) reported over a 3-day time horizon and across accepted willingness-to-pay thresholds in USD per quality-adjusted life-year (QALY). While accruing the same amount of QALYs, the rapid assay strategy saved up to $46,820 (95% CI $41,961-$52,486) per-patient-tested. No parameter variation changed the outcome. In probabilistic sensitivity analyses, the rapid assay strategy was favored in 100% (three base-cases and scenario analyses) and 99% (one base-case and scenario analysis) across 100,000 Monte Carlo iterations within each. Rapid ADAMTS13 testing for patients with intermediate- or high-risk PLASMIC scores yields significant per-patient cost savings, achieved by reducing the costs associated with unnecessary therapeutic plasma exchange and caplacizumab therapy in patients without iTTP.
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Affiliation(s)
- Cecily Allen
- Johns Hopkins University School of Medicine, Baltimore, Maryland, United States
| | - Satoko Ito
- Yale University School of Medicine, New Haven, Connecticut, United States
| | - Ayesha Butt
- Yale University, New Haven, Connecticut, United States
| | - Adriana Purcell
- Yale University School of Medicine, New Haven, Connecticut, United States
| | - Rhys Richmond
- Yale University, New Haven, Connecticut, United States
| | | | | | - Adam Cuker
- University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - George Goshua
- Yale University School of Medicine, New Haven, Connecticut, United States
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4
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Dawwas GK, Cuker A, Schaubel DE, Lewis JD. Effectiveness and safety of prophylactic anticoagulation among hospitalized patients with inflammatory bowel disease. Blood Adv 2024; 8:1272-1280. [PMID: 38163322 PMCID: PMC10918481 DOI: 10.1182/bloodadvances.2023011756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Revised: 12/01/2023] [Accepted: 12/01/2023] [Indexed: 01/03/2024] Open
Abstract
ABSTRACT Hospitalized patients with inflammatory bowel disease (IBD) are at increased risk of venous thromboembolism (VTE). We aimed to evaluate the effectiveness and safety of prophylactic anticoagulation compared with no anticoagulation in hospitalized patients with IBD. We conducted a retrospective cohort study using a hospital-based database. We included patients with IBD who had a length of hospital stay ≥2 days between 1 January 2016 and 31 December 2019. We excluded patients who had other indications for anticoagulation, users of direct oral anticoagulants, warfarin, therapeutic-intensity heparin, and patients admitted for surgery. We defined exposure to prophylactic anticoagulation using charge codes. The primary effectiveness outcome was VTE. The primary safety outcome was bleeding. We used propensity score matching to reduce potential differences between users and nonusers of anticoagulants and Cox proportional-hazards regression to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs). The analysis included 56 194 matched patients with IBD (users of anticoagulants, n = 28 097; nonusers, n = 28 097). In the matched sample, prophylactic use of anticoagulants (vs no use) was associated with a lower rate of VTE (HR, 0.62; 95% CI, 0.41-0.94) and with no difference in the rate of bleeding (HR, 1.05; 95% CI, 0.87-1.26). In this study of hospitalized patients with IBD, prophylactic use of heparin was associated with a lower rate of VTE without increasing bleeding risk compared with no anticoagulation. Our results suggest potential benefits of prophylactic anticoagulation to reduce the burden of VTE in hospitalized patients with IBD.
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Affiliation(s)
- Ghadeer K. Dawwas
- Division of Epidemiology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Adam Cuker
- Departments of Medicine and Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Douglas E. Schaubel
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - James D. Lewis
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Harenberg J, Gosselin RC, Cuker A, Becattini C, Pabinger I, Poli S, Weitz J, Ageno W, Bauersachs R, Celap I, Choi P, Douketis J, Douxfils J, Elalamy I, Falanga A, Fareed J, Favaloro EJ, Gerotziafas G, Herkner H, Hetjens S, Heubner L, Klamroth R, Langer F, Lip GYH, Grory BM, Margetić S, Merrelaar A, Pikta M, Renne T, Schulman S, Schwameis M, Strbian D, Tafur A, Vassart J, Violi F, Walenga J, Weiss C. Algorithm for Rapid Exclusion of Clinically Relevant Plasma Levels of Direct Oral Anticoagulants in Patients Using the DOAC Dipstick: An Expert Consensus Paper. Thromb Haemost 2024. [PMID: 38316416 DOI: 10.1055/a-2261-1811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
BACKGROUND With the widespread use of direct oral anticoagulants (DOACs), there is an urgent need for a rapid assay to exclude clinically relevant plasma levels. Accurate and rapid determination of DOAC levels would guide medical decision-making to (1) determine the potential contribution of the DOAC to spontaneous or trauma-induced hemorrhage; (2) identify appropriate candidates for reversal, or (3) optimize the timing of urgent surgery or intervention. METHODS AND RESULTS The DOAC Dipstick test uses a disposable strip to identify factor Xa- or thrombin inhibitors in a urine sample. Based on the results of a systematic literature search followed by an analysis of a simple pooling of five retrieved clinical studies, the test strip has a high sensitivity and an acceptably high negative predictive value when compared with levels measured with liquid chromatography tandem mass spectrometry or calibrated chromogenic assays to reliably exclude plasma DOAC concentrations ≥30 ng/mL. CONCLUSION Based on these data, a simple algorithm is proposed to enhance medical decision-making in acute care indications useful primarily in hospitals not having readily available quantitative tests and 24/7. This algorithm not only determines DOAC exposure but also differentiates between factor Xa and thrombin inhibitors to better guide clinical management.
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Affiliation(s)
- Job Harenberg
- Ruprecht Karls University of Heidelberg, Heidelberg, Germany
- DOASENSE GmbH, Heidelberg, Germany
| | - Robert C Gosselin
- Davis Health System, Thrombosis and Hemostasis Center, University of California, Sacramento, California, United States
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Cecilia Becattini
- Internal and Emergency Medicine -Stroke Unit, University of Perugia, Perugia PG, Italy
| | - Ingrid Pabinger
- Clinical Division of Hematology and Hemostaseology, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, University Hospital, Tubingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tubingen, Germany
| | - Jeffrey Weitz
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Rupert Bauersachs
- GefasCentrum, CCB - Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
| | - Ivana Celap
- Department of Clinical Chemistry, University Hospital Center Sestre, Zagreb, Croatia
- Faculty of Pharmacy and Biochemistry, University of Zagreb, Croatia
| | - Philip Choi
- Neurosciences, Box Hill Hospital, Eastern Health, Melbourne, Victoria, Australia
- Eastern Health Clinical School, Monash University, Australia
| | - James Douketis
- Department Biochemistry and Biomedical Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Research for Life Sciences, Namur, Belgium
- Qualiblood s.a., Department of Research and Development, Namur, Belgium
| | - Ismail Elalamy
- Service d'Hematologie Biologique Hopital Tenon, Hopitaux Universitaires Est Parisien, Assistance Publique Hopitaux de Paris, Paris, France
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - Anna Falanga
- Department of Transfusion Medicine and Hematology, Hospital Papa Giovanni XXIII, Bergamo, Italy
- University of Milan Bicocca, Monza, Italy
| | - Jawed Fareed
- Department of Molecular Pharmacology & Neuroscience, Loyola University Medical Center, Maywood, Illinois, United States
| | - Emmanuel J Favaloro
- Department of Haematology, Sydney Centres for Thrombosis and Haemostasis, Institute of Clinical Pathology and Medical Research (ICPMR), Westmead Hospital, Westmead, NSW, Australia
- Faculty of Science and Health, Charles Sturt University, Wagga Wagga, NSW, Australia
| | - Grigorios Gerotziafas
- INSERM, UMR_S 938, Research Group Cancer, Biology and Therapeutics, Centre de recherche Saint-Antoine (CRSA), Institut Universitaire de Cancerologie, Sorbonne Universite, Paris, France
- Thrombosis Center, Tenon-Saint Antoine, Hopitaux Universitaires de l'Est Parisien, Assistance Publique Hopitaux de Paris (APHP), France
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Svetlana Hetjens
- Department of Statistics, Medical Faculty Mannheim, Ruprecht Karls University of Heidelberg, Mannheim, Germany
| | - Lars Heubner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus," Technische Universitat Dresden, Germany
| | - Robert Klamroth
- Vascular Medicine and Haemostaseology, Vivantes Klinikum im Friedrichschain, Berlin, Germany
| | - Forian Langer
- II. Medizinische Klinik und Poliklinik, Universitatsklinikum Eppendorf, Hamburg, Germany
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, United Kingdom
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Brian Mac Grory
- Department of Neurology, Duke University, Durham, North Carolina, United States
| | - Sandra Margetić
- GefasCentrum, CCB - Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
- School of Medicine, Catholic University of Croatia, Zagreb, Croatia
| | - Anne Merrelaar
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Marika Pikta
- Department of Laboratory Medicine, North Estonia Medical Centre, Tallinn, Estonia
- Department of Health Technologies, Tallinn University of Technology, Tallinn, Estonia
| | - Thomas Renne
- Institute of Clinical Chemistry and Laboratory Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sam Schulman
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
- Thrombosis and Atherosclerosis Research Institute, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Michael Schwameis
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Alfonso Tafur
- Department of Medicine, Vascular Medicine, NorthShore University Health System, Evanston, Illinois, United States
- Pritzker School of Medicine, University of Chicago, Chicago, Illinois, United States
| | - Julie Vassart
- Department of Pharmacy, Namur Research for Life Sciences, Namur, Belgium
| | - Francesco Violi
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Jeanine Walenga
- Cardiovascular Research Institute, Loyola University Chicago, Maywood, Illinois, United States
| | - Christel Weiss
- Department of Statistics, Medical Faculty Mannheim, Ruprecht Karls University of Heidelberg, Mannheim, Germany
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Joseph K, Cuker A, Peltier S, Reding MT, Cheng D, Han X, Pishko AM. The impact of obesity on chronic pain in patients with haemophilia: A multicentre retrospective analysis. Haemophilia 2024; 30:567-570. [PMID: 38385966 DOI: 10.1111/hae.14962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/12/2024] [Accepted: 02/01/2024] [Indexed: 02/23/2024]
Affiliation(s)
- Keerthy Joseph
- Department of Medicine, Mercy Catholic Medical Center, Darby, Pennsylvania, USA
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Skye Peltier
- Public Health Programs and Surveillance, American Thrombosis and Hemostasis Network, ATHN, USA
| | - Mark T Reding
- Center for Bleeding and Clotting Disorders, University of Minnesota, Minneapolis, Minnesota, USA
| | - Dunlei Cheng
- Eli Lilly and Company, Indianapolis, Indiana, USA
| | - Xiaoyan Han
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Allyson M Pishko
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Chiasakul T, Mullier F, Lecompte T, Nguyen P, Cuker A. Laboratory Monitoring of Heparin Anticoagulation in Hemodialysis: Rationale and Strategies. Semin Nephrol 2024:151477. [PMID: 38290962 DOI: 10.1016/j.semnephrol.2023.151477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Unfractionated heparin (UFH) and low-molecular-weight heparins (LMWHs) are commonly used to prevent clotting of the hemodialysis extracorporeal circuit and optimize hemodialysis adequacy. There is no consensus on the optimal dosing for UFH and LMWHs during hemodialysis. In clinical practice, semiquantitative clotting scoring of the dialyzer and venous chamber may help to guide UFH and LMWH dose adjustment. Laboratory monitoring has not been shown to improve clinical outcomes and is therefore not routinely indicated in most hemodialysis patients. It might, however, be considered in select patients, such as those with extremes of body weight or history of repeated clotting or bleeding. Methods for laboratory monitoring include the activated partial thromboplastin time, activated clotting time, and antifactor Xa assays for UFH and antifactor Xa assay for LMWHs. Target ranges for anticoagulation in hemodialysis have been suggested but not clearly defined. When utilizing these tests, issues such as availability, standardization, interfering factors, and interpretation must be considered. In this narrative review, we discuss the rationale and methods of monitoring anticoagulation in hemodialysis.
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Affiliation(s)
- Thita Chiasakul
- Center of Excellence in Translational Hematology, Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.
| | - François Mullier
- Namur Thrombosis and Hemostasis Center, Université Catholique de Louvain, Centre Hospitalier Universitaire UCL Namur, Hematology Laboratory, Yvoir, Belgium; Institut de Recherche Expérimentale et Clinique, Pôle Mont, Université Catholique de Louvain, Yvoir, Belgium
| | - Thomas Lecompte
- Pharmacy Department, University of Namur, Namur, Belgium; Université de Lorraine, Nancy, France
| | - Philippe Nguyen
- Hematology Laboratory, Reims University Hospital, Reims, France
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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8
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Dhopeshwarkar N, Yang W, Hennessy S, Rhodes JM, Cuker A, Leonard CE. Combining Super Learner with high-dimensional propensity score to improve confounding adjustment: A real-world application in chronic lymphocytic leukemia. Pharmacoepidemiol Drug Saf 2024; 33:e5678. [PMID: 37609668 PMCID: PMC10841179 DOI: 10.1002/pds.5678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/28/2023] [Accepted: 08/02/2023] [Indexed: 08/24/2023]
Abstract
PURPOSE High-dimensional propensity score (hdPS) is a semiautomated method that leverages a vast number of covariates available in healthcare databases to improve confounding adjustment. A novel combined Super Learner (SL)-hdPS approach was proposed to assist with selecting the number of covariates for propensity score inclusion, and was found in plasmode simulation studies to improve bias reduction and precision compared to hdPS alone. However, the approach has not been examined in the applied setting. METHODS We compared SL-hdPS's performance with that of several hdPS models, each with prespecified covariates and a different number of empirically-identified covariates, using a cohort study comparing real-world bleeding rates between ibrutinib- and bendamustine-rituximab (BR)-treated individuals with chronic lymphocytic leukemia in Optum's de-identified Clinformatics® Data Mart commercial claims database (2013-2020). We used inverse probability of treatment weighting for confounding adjustment and Cox proportional hazards regression to estimate hazard ratios (HRs) for bleeding outcomes. Parameters of interest included prespecified and empirically-identified covariate balance (absolute standardized difference [ASD] thresholds of <0.10 and <0.05) and outcome HR precision (95% confidence intervals). RESULTS We identified 2423 ibrutinib- and 1102 BR-treated individuals. Including >200 empirically-identified covariates in the hdPS model compromised covariate balance at both ASD thresholds. SL-hdPS balanced more covariates than all individual hdPS models at both ASD thresholds. The bleeding HR 95% confidence intervals were generally narrower with SL-hdPS than with individual hdPS models. CONCLUSION In a real-world application, hdPS was sensitive to the number of covariates included, while use of SL for covariate selection resulted in improved covariate balance and possibly improved precision.
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Affiliation(s)
- Neil Dhopeshwarkar
- Center for Real-World Effectiveness and Safety of Therapeutics and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wei Yang
- Center for Real-World Effectiveness and Safety of Therapeutics and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sean Hennessy
- Center for Real-World Effectiveness and Safety of Therapeutics and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joanna M Rhodes
- Division of Hematology/Medical Oncology, Department of Medicine, Northwell Health, New Hyde Park, New York, USA
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charles E Leonard
- Center for Real-World Effectiveness and Safety of Therapeutics and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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9
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Djulbegovic B, Hozo I, Cuker A, Guyatt G. Improving methods of clinical practice guidelines: From guidelines to pathways to fast-and-frugal trees and decision analysis to develop individualised patient care. J Eval Clin Pract 2023. [PMID: 38073027 DOI: 10.1111/jep.13953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Revised: 11/16/2023] [Accepted: 11/20/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Current methods for developing clinical practice guidelines have several limitations: they are characterised by the "black box" operation-a process with defined inputs and outputs but an incomplete understanding of its internal workings; they have "the integration problem"-a lack of framework for explicitly integrating factors such as patient preferences and trade-offs between benefits and harms; they generate one recommendation at a time that typically are not connected in a coherent analytical framework; and they apply to "average" patients, while clinicians and their patients seek advice tailored to individual circumstances. METHODS We propose augmenting the current guideline development method by converting evidence-based pathways into fast-and-frugal decision trees (FFTs) and integrating them with generalised decision curve analysis to formulate clear, individualised management recommendations. RESULTS We illustrate the process by developing recommendations for the management of heparin-induced thrombocytopenia (HIT). We converted evidence-based pathways for HIT, developed by the American Society of Hematology, into an FFT. Here, we consider only thrombotic complications and major bleeding. We leveraged the predictive potential of FFTs to compare the effects of argatroban, bivalirudin, fondaparinux, and direct oral anticoagulants (DOACs) using generalised decision curve analysis. We found that DOACs were superior to other treatments if the FFT-predicted probability of HIT exceeded 3%. CONCLUSIONS The proposed analytical framework connects guidelines, pathways, FFTs, and decision analysis, offering risk-tailored personalised recommendations and addressing current guideline development critiques.
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Affiliation(s)
- Benjamin Djulbegovic
- Division of Medical Hematology and Oncology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Iztok Hozo
- Department of Mathematics, Indiana University Northwest, Gary, Indiana, USA
| | - Adam Cuker
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
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10
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Cheung MC, Kunkle R, Plovnick R, Lottenberg R, Rezende SM, Silverstein R, Pai M, Seftel M, Cuker A. ASH Clinical Practice Guidelines: strategies to stay up-to-date. Blood Adv 2023; 7:6707-6709. [PMID: 37738156 PMCID: PMC10641472 DOI: 10.1182/bloodadvances.2023011481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 09/07/2023] [Accepted: 09/10/2023] [Indexed: 09/24/2023] Open
Affiliation(s)
- Matthew C Cheung
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rob Kunkle
- American Society of Hematology, Washington, DC
| | | | - Richard Lottenberg
- Division of Hematology and Oncology, University of Florida, Gainesville, FL
| | - Suely M Rezende
- Department of Internal Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Roy Silverstein
- Medical College of Wisconsin and Versiti Blood Research Institute, Milwaukee, WI
| | - Menaka Pai
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Matthew Seftel
- University of British Columbia and Canadian Blood Services, Vancouver, BC, Canada
| | - Adam Cuker
- Hematology, University of Pennsylvania, Philadelphia, PA
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11
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Akl EA, Cuker A, Mustafa RA, Nieuwlaat R, Stevens A, Schünemann HJ. Prospective collaborative recommendation development: a novel model for more timely and trustworthy guidelines. J Clin Epidemiol 2023; 162:156-159. [PMID: 37648070 DOI: 10.1016/j.jclinepi.2023.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 08/14/2023] [Accepted: 08/23/2023] [Indexed: 09/01/2023]
Affiliation(s)
- Elie A Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada.
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Outcomes and Implementation Research Unit, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Reem A Mustafa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Adrienne Stevens
- Centre for Immunization Readiness, Public Health Agency of Canada, Ottawa, Ontario, Canada
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
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12
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van Tienhoven XA, Pishko AM, Chiang E, Cuker A, Marshall AL. Documentation of Menstrual Concerns in Women with Inherited Bleeding Disorders: A Single Center Retrospective Cohort Study. J Obstet Gynaecol Can 2023; 45:637-641. [PMID: 37209785 DOI: 10.1016/j.jogc.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 05/04/2023] [Accepted: 05/05/2023] [Indexed: 05/22/2023]
Affiliation(s)
| | - Allyson M Pishko
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Philadelphia, USA
| | - Elaine Chiang
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Philadelphia, USA
| | - Adam Cuker
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Philadelphia, USA
| | - Ariela L Marshall
- Department of Medicine, Division of Hematology-Oncology, University of Pennsylvania, Philadelphia, USA.
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13
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Tarantino MD, Hardesty B, Metjian A, Ortel TL, Chen J, Badejo K, Ma A, Cuker A, Rajasekhar A, Friedman KD, Janbain M. Real-world safety and effectiveness of recombinant porcine sequence factor VIII in acquired haemophilia A: A non-interventional, post-authorization safety study. Haemophilia 2023; 29:1259-1268. [PMID: 37584309 DOI: 10.1111/hae.14832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 06/29/2023] [Accepted: 07/07/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Recombinant porcine factor VIII (rpFVIII, susoctocog alfa) is indicated for the treatment of bleeding episodes in adults with acquired haemophilia A (AHA). AIM To provide long-term real-world safety and effectiveness data for rpFVIII in the management of AHA bleeding episodes. METHODS US PASS (NCT02610127) was a multicentre, uncontrolled, open-label, post-marketing safety surveillance study conducted in adults with AHA. Data were collected retrospectively or prospectively for 180 days after rpFVIII treatment. The primary outcome was the incidence of treatment-related serious adverse events (SAEs). Secondary outcomes included haemostatic effectiveness of rpFVIII and rpFVIII utilization. RESULTS Fifty-three patients were enrolled from December 2015 to June 2019 (prospective, n = 30; retrospective, n = 23). Six patients experienced seven treatment-related SAEs (incidence 12.0%). The most common treatment-related SAE was FVIII inhibition (inhibiting antibodies to rpFVIII; incidence 8.0%, 95% CI: 2.2-19.2). Five patients reported seven thromboembolic events; one was an SAE and possibly related to rpFVIII. Of bleeding events treated with rpFVIII, 80.3% (57/71) of bleeds resolved with rpFVIII. The median (range) dose of rpFVIII per infusion was 50 (10-300) units/kg, with a median (range) of 6.0 (1-140) infusions and a median (range) time from bleed onset to bleed resolution of 14.0 (2.0-132.7) days. CONCLUSION In this real-world study of rpFVIII for AHA, no new safety signals were identified compared with previous clinical trial findings. Eighty percent of bleeds resolved with rpFVIII treatment.
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Affiliation(s)
| | - Brandon Hardesty
- Indiana Hemophilia and Thrombosis Center, Indianapolis, Indiana, USA
| | - Ara Metjian
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Jie Chen
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Kayode Badejo
- Takeda Development Center Americas, Inc., Cambridge, Massachusetts, USA
| | - Alice Ma
- University of North Carolina, Chapel Hill, North Carolina, USA
| | - Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anita Rajasekhar
- Department of Hematology/Oncology, University of Florida Health, Gainesville, Florida, USA
| | - Kenneth D Friedman
- Medical College of Wisconsin and Versiti/Blood Center of Wisconsin, Milwaukee, Wisconsin, USA
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14
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Byrne M, Mattison R, Bercovitz R, Lottenberg R, Rezende SM, Silverstein R, Terrell D, Kunkle R, Smith D, Bollard C, Haberichter S, Holter-Chakrabarty J, Pai M, Cheung M, Cuker A, Seftel M, Djulbegovic B. Identifying experts for clinical practice guidelines: perspectives from the ASH Guideline Oversight Subcommittee. Blood Adv 2023; 7:4323-4326. [PMID: 37186271 PMCID: PMC10424133 DOI: 10.1182/bloodadvances.2023010039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 04/17/2023] [Accepted: 04/17/2023] [Indexed: 05/17/2023] Open
Affiliation(s)
| | - Ryan Mattison
- Department of Medicine, Division of Hematology/Oncology, University of Wisconsin-Madison, Madison, WI
| | | | - Richard Lottenberg
- Department of Medicine, Division of Hematology/Oncology, University of Florida, Gainesville, FL
| | - Suely M. Rezende
- Department of Internal Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Roy Silverstein
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Deirdra Terrell
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Rob Kunkle
- American Society of Hematology, Washington, DC
| | - Deion Smith
- American Society of Hematology, Washington, DC
| | - Catherine Bollard
- Children's National Medical/George Washington University, Washington, DC
| | | | - Jennifer Holter-Chakrabarty
- Department of Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Menaka Pai
- Department of Medicine, Division of Hematology and Thromboembolism, McMaster University, Hamilton, ON, Canada
| | | | - Adam Cuker
- Department of Pathology/Laboratory Medicine, University of Pennsylvania, Philadelphia, PA
| | - Matthew Seftel
- Department of Medicine, Division of Hematology, University of British Columbia and Canadian Blood Services, Vancouver, BC, Canada
| | - Benjamin Djulbegovic
- Department of Medicine, Division of Hematology/Medical Oncology, Medical University of South Carolina, Charleston, SC
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15
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Vesely SK, King A, Vettese E, Heller JG, Cuker A, Calhoun C, Stock W, Homer M, Fritz J, Sung L. Influence of participant and reviewer characteristics in application scores for a hematology research training program. Blood Adv 2023; 7:4064-4071. [PMID: 36939221 PMCID: PMC10388723 DOI: 10.1182/bloodadvances.2023009792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 03/08/2023] [Accepted: 03/10/2023] [Indexed: 03/21/2023] Open
Abstract
The American Society of Hematology Clinical Research Training Institute (CRTI) is a clinical research training program with a competitive application process. The objectives were to compare application scores based on applicant and reviewer sex and underrepresented minority (URM) status. We included applications to CRTI from 2003 to 2019. The application scores were transformed into a scale from 0 to 100 (100 was the strongest). The factors considered were applicant and reviewer sex and URM status. We evaluated whether there was an interaction between the characteristics and time related to application scores. In total, 713 applicants and 2106 reviews were included. There was no significant difference in scores according to applicant sex. URM applicants had significantly worse scores than non-URM applicants (mean [standard error] 67.9 [1.56] vs 71.4 [0.63]; P = .0355). There were significant interactions between reviewer sex and time (P = .0030) and reviewer URM status and time (P = .0424); thus, results were stratified by time. For the 2 earlier time periods, male reviewers gave significantly worse scores than did female reviewers; this difference did not persist for the most recent time period. The URM reviewers did not give significantly different scores across time periods. URM applicants received significantly lower scores than non-URM applicants. The impact of reviewer sex and URM status changed over time. Although male reviewers gave lower scores in the early periods, this effect did not persist in the late period. Efforts are required to mitigate the impact of applicant URM status on application scores.
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Affiliation(s)
- Sara K. Vesely
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Allison King
- Division of Pediatric Hematology/Oncology and Division of Public Health Sciences in Department of Surgery, Washington University School of Medicine Program in Occupational Therapy, St. Louis, MO
| | - Emily Vettese
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON
| | - John G. Heller
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Cecelia Calhoun
- Section of Hematology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Wendy Stock
- Department of Medicine, University of Chicago Comprehensive Cancer Center, Chicago, IL
| | | | - Josel Fritz
- American Society of Hematology, Washington, DC
| | - Lillian Sung
- Program in Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, ON
- The Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, ON
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16
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El-Khoueiry AB, Clarke J, Neff T, Crossman T, Ratia N, Rathi C, Noto P, Tarkar A, Garrido-Laguna I, Calvo E, Rodón J, Tran B, O'Dwyer PJ, Cuker A, Abdul Razak AR. Phase 1 study of GSK3368715, a type I PRMT inhibitor, in patients with advanced solid tumors. Br J Cancer 2023; 129:309-317. [PMID: 37237172 PMCID: PMC10338470 DOI: 10.1038/s41416-023-02276-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 03/28/2023] [Accepted: 04/06/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND GSK3368715, a first-in-class, reversible inhibitor of type I protein methyltransferases (PRMTs) demonstrated anticancer activity in preclinical studies. This Phase 1 study (NCT03666988) evaluated safety, pharmacokinetics, pharmacodynamics, and preliminary efficacy of GSK3368715 in adults with advanced-stage solid tumors. METHODS In part 1, escalating doses of oral once-daily GSK3368715 (50, 100, and 200 mg) were evaluated. Enrollment was paused at 200 mg following a higher-than-expected incidence of thromboembolic events (TEEs) among the first 19 participants, resuming under a protocol amendment starting at 100 mg. Part 2 (to evaluate preliminary efficacy) was not initiated. RESULTS Dose-limiting toxicities were reported in 3/12 (25%) patients at 200 mg. Nine of 31 (29%) patients across dose groups experienced 12 TEEs (8 grade 3 events and 1 grade 5 pulmonary embolism). Best response achieved was stable disease, occurring in 9/31 (29%) patients. Following single and repeat dosing, GSK3368715 maximum plasma concentration was reached within 1 h post dosing. Target engagement was observed in the blood, but was modest and variable in tumor biopsies at 100 mg. CONCLUSION Based on higher-than-expected incidence of TEEs, limited target engagement at lower doses, and lack of observed clinical efficacy, a risk/benefit analysis led to early study termination. TRIAL REGISTRATION NUMBER NCT03666988.
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Affiliation(s)
- Anthony B El-Khoueiry
- University of Southern California Norris Comprehensive Cancer Center, 1441 Eastlake Ave, Los Angeles, CA, USA.
| | - James Clarke
- GSK, Gunnels Wood Road, Stevenage, Hertfordshire, SG1 2NY, UK
| | - Tobias Neff
- GSK, 1250 S Collegeville Road, Collegeville, PA, USA
- Merck&Co, North Wales, PA, USA
| | - Tim Crossman
- GSK, Gunnels Wood Road, Stevenage, Hertfordshire, SG1 2NY, UK
| | - Nirav Ratia
- GSK, Gunnels Wood Road, Stevenage, Hertfordshire, SG1 2NY, UK
| | - Chetan Rathi
- GSK, 1250 S Collegeville Road, Collegeville, PA, USA
| | - Paul Noto
- GSK, 1250 S Collegeville Road, Collegeville, PA, USA
- Adaptimmune LLC, Philadelphia, PA, USA
| | - Aarti Tarkar
- GSK, 1250 S Collegeville Road, Collegeville, PA, USA
| | | | - Emiliano Calvo
- START Madrid-CIOCC, Centro Integral Oncológico Clara Campal, Calle Oña, 10, 28050, Madrid, Spain
| | - Jordi Rodón
- Investigational Cancer Therapeutics Department, University of Texas MD Anderson Cancer Center, 1400 Holcombe Blvd Unit 455, 8th Floor, Houston, TX, USA
| | - Ben Tran
- Peter MacCallum Cancer Centre (PMCC), 305 Grattan Street, Melbourne, VIC, 3000, Australia
| | - Peter J O'Dwyer
- University of Pennsylvania, Abramson Cancer Center, 3400 Civic Center Blvd, Philadelphia, PA, USA
| | - Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, USA
| | - Albiruni R Abdul Razak
- Phase 1 Program, Princess Margaret Cancer Centre, 610 University Ave, Toronto, M5G2M9, ON, Canada
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17
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May J, Westbrook B, Cuker A. Heparin-induced thrombocytopenia: An illustrated review. Res Pract Thromb Haemost 2023; 7:100283. [PMID: 37601013 PMCID: PMC10439402 DOI: 10.1016/j.rpth.2023.100283] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 05/25/2023] [Accepted: 05/31/2023] [Indexed: 08/22/2023] Open
Abstract
Heparin-induced thrombocytopenia (HIT) is an immune-mediated adverse drug effect from unfractionated or low-molecular-weight heparin that results in thrombocytopenia and potentially catastrophic thrombosis. HIT occurs due to the development of platelet-activating antibodies against multimolecular complexes of platelet factor 4 and heparin. Given the frequency of thrombocytopenia and heparin use among hospitalized patients, calculation of the 4Ts Score is recommended to identify patients at increased likelihood of HIT and direct further evaluation. In patients with an intermediate or high probability 4Ts Score, an immunoassay and functional assay are recommended to confirm or refute the diagnosis of HIT. Heparin avoidance and initiation of nonheparin anticoagulation are the mainstays of acute HIT management. In this illustrated review, we provide visual summaries of the diagnosis and management of HIT, highlighting connections between pathophysiology and clinical care as well as summarizing efforts in quality improvement in the field. We further emphasize common pitfalls and pearls in diagnosis and management to encourage evidence-based care. We include graphical representation of the unique challenges of HIT with cardiopulmonary bypass and also delineate autoimmune HIT and its subtypes.
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Affiliation(s)
- Jori May
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Brian Westbrook
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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18
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Cuker A, Buckley B, Mousseau MC, Barve AA, Haenig J, Bussel JB. Early initiation of second-line therapy in primary immune thrombocytopenia: insights from real-world evidence. Ann Hematol 2023:10.1007/s00277-023-05289-0. [PMID: 37300567 DOI: 10.1007/s00277-023-05289-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 05/20/2023] [Indexed: 06/12/2023]
Abstract
To compare patients with primary immune thrombocytopenia (ITP) prescribed early (within 3 months of initial ITP treatment) second-line treatment (eltrombopag, romiplostim, rituximab, immunosuppressive agents, splenectomy) with or without concomitant first-line therapy to those who received only first-line therapy. This real-world retrospective cohort study of 8268 patients with primary ITP from a large US-based database (Optum® de-identified Electronic Health Record [EHR] dataset) combined electronic claims and EHR data. Outcomes included platelet count, bleeding events, and corticosteroid exposure 3 to 6 months after initial treatment. Baseline platelet counts were lower in patients receiving early second-line therapy (10‒28 × 109/L) versus those who did not (67 × 109/L). Counts improved and bleeding events decreased from baseline in all treatment groups 3 to 6 months after the start of therapy. Among the very few patients for whom follow-up treatment data were available (n = 94), corticosteroid use was reduced during the 3- to 6-month follow-up period in patients who received early second-line therapy versus those who did not (39% vs 87%, p < 0.001). Early second-line treatment was prescribed for more severe cases of ITP and appeared to be associated with improved platelet counts and bleeding outcomes 3 to 6 months after initial therapy. Early second-line therapy also appeared to reduce corticosteroid use after 3 months, although the small number of patients with follow-up data on treatment precludes any substantive conclusions. Further research is needed to determine whether early second-line therapy has an effect on the long-term course of ITP.
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Affiliation(s)
- Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, 3 Dulles, 3400 Spruce Street, Philadelphia, PA, USA.
| | | | | | | | | | - James B Bussel
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
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Sanfilippo KM, Cuker A. TPO-RAs and ITP remission: cause or coincidence? Blood 2023; 141:2790-2791. [PMID: 37289475 DOI: 10.1182/blood.2023020243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023] Open
Affiliation(s)
- Kristen M Sanfilippo
- Washington University School of Medicine St. Louis
- John Cochran St. Louis Veterans Administration Medical Center
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20
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Whitworth H, Amankwah EK, Betensky M, Castellucci LA, Cuker A, Goldenberg NA, Male C, Rinzler E, Zia A, Raffini L. Updated guidance for efficacy and safety outcomes for clinical trials in venous thromboembolism in children: communication from the ISTH SSC Subcommittee on Pediatric and Neonatal Thrombosis and Hemostasis. J Thromb Haemost 2023; 21:1666-1673. [PMID: 36921919 PMCID: PMC10472337 DOI: 10.1016/j.jtha.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/15/2023] [Accepted: 03/02/2023] [Indexed: 03/15/2023]
Abstract
Despite the growing number of pediatric antithrombotic clinical trials, standardized safety and efficacy outcome definitions for pediatric venous thromboembolism (VTE) clinical trials have not been updated since 2011. Many recent trials have adapted the recommended definitions, leading to heterogeneity in outcomes and limiting our ability to compare studies. The International Society on Thrombosis and Haemostasis Scientific and Standardization Subcommittee (SSC) on Pediatric and Neonatal Thrombosis and Hemostasis organized a Task Force to update the efficacy and safety outcome definitions for pediatric VTE clinical trials. The outcome definitions used in the recent pediatric antithrombotic trials, definitions recommended for adult studies, and regulatory guidelines were summarized and reviewed by the Task Force as the basis for this updated guidance. Major updates to the efficacy outcomes include the removal of VTE-related mortality as a part of a composite primary outcome and explicit inclusion of all deep venous anatomic sites. Safety outcomes were updated to include a new bleeding severity category: patient important bleeding, no intervention, which encompasses bleeding for which a patient seeks care but there is no change in management. Menstrual bleeding can now be included in any bleeding category when the criteria are met. We hope that these updated outcome definitions will allow the investigators to focus on clinically relevant and patient-important outcomes and provide standardization to facilitate continued high-quality evidence for the use of antithrombotic therapies in children.
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Affiliation(s)
- Hilary Whitworth
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.
| | - Ernest K Amankwah
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA; Division of Quantitative Science, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Marisol Betensky
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA; Division of Hematology, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Neil A Goldenberg
- Institute for Clinical and Translational Research, Johns Hopkins All Children's Hospital, St Petersburg, Florida, USA; Departments of Pediatrics and Medicine, Divisions of Hematology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christoph Male
- Department of Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Elliot Rinzler
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Ayesha Zia
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Leslie Raffini
- Division of Hematology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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21
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Barnes GD, Ageno W, Castellucci LA, Chiasakul T, Eslick R, Ferreiro JL, Gailani D, Gorog DA, Lip GYH, Raffini L, Rezende SM, Weitz JI, Cuker A. Recommendation on the nomenclature for anticoagulants: updated communication from the International Society on Thrombosis and Haemostasis Scientific and Standardization Commitee on the Control of Anticoagulation. J Thromb Haemost 2023; 21:1381-1384. [PMID: 36796485 PMCID: PMC10629847 DOI: 10.1016/j.jtha.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 02/06/2023] [Accepted: 02/06/2023] [Indexed: 02/16/2023]
Abstract
Oral anticoagulation therapy has evolved beyond vitamin K antagonists to include oral direct thrombin inhibitors and factor Xa inhibitors. Collectively known as "direct oral anticoagulants," this class of medications represents the current standard of care for the prevention and treatment of common thrombotic disorders, including atrial fibrillation and venous thromboembolism. Medications that target factors XI/XIa and XII/XIIa are currently under investigation for several thrombotic and nonthrombotic conditions. Given that these emerging medications will likely have distinct risk-benefit profiles to the current direct oral anticoagulants, may have different routes of administration, and could be used for unique clinical conditions (e.g., hereditary angioedema), the International Society on Thrombosis and Haemostasis Subcommittee on Control of Anticoagulation assembled a writing group to make recommendations on the nomenclature of anticoagulant medications. With input from the broader thrombosis community, the writing group recommends that anticoagulant medications be described by the route of administration and specific targets (e.g., oral factor XIa inhibitor).
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Affiliation(s)
- Geoffrey D Barnes
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan, USA.
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Lana A Castellucci
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada. https://twitter.com/LanaCastellucci
| | - Thita Chiasakul
- Department of Medicine, Research Unit in Translational Hematology, Division of Hematology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand. https://twitter.com/JoyThitaC
| | - Renee Eslick
- Department of Haematology, Canberra Health Services, Garran, Australia. https://twitter.com/Renee_Eslick
| | - José L Ferreiro
- Department of Cardiology, Bellvitge University Hospital, and Bio-Heart Cardiovascular Diseases Research Group, Bellvitge Biomedical Research Institute (IDIBELL), CIBERCV, L'Hospitalet de Llobregat, Spain
| | - David Gailani
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Diana A Gorog
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK; Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Leslie Raffini
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Suely M Rezende
- Department of Internal Medicine, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA. https://twitter.com/CukerMD
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22
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Cuker A, Tkacz J, Manjelievskaia J, Haenig J, Maier J, Bussel JB. Overuse of corticosteroids in patients with immune thrombocytopenia (ITP) between 2011 and 2017 in the United States. EJHaem 2023; 4:350-357. [PMID: 37206283 PMCID: PMC10188501 DOI: 10.1002/jha2.684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/04/2023] [Accepted: 03/17/2023] [Indexed: 05/21/2023]
Abstract
Corticosteroids (CSs) are standard first-line therapy for immune thrombocytopenia (ITP). Prolonged exposure is associated with substantial toxicity; thus guidelines recommend avoidance of prolonged CS treatment and early use of second-line therapies. However, real-world evidence on ITP treatment patterns remains limited. We aimed to assess real-world treatment patterns in patients with newly-diagnosed ITP, using two large US healthcare databases (Explorys and MarketScan) between January 1, 2011 and July 31, 2017. Adults with ITP, ≥12 months of database registration prior to diagnosis, ≥1 ITP treatment, and ≥1 month enrollment following initiation of first ITP treatment were included (n = 4066 Explorys; n = 7837 MarketScan). Information on lines of treatment (LoTs) was collected. As expected, CSs were the most common first-line treatment (Explorys, 87.9%; MarketScan, 84.5%). However, CSs remained by far the most common treatment (Explorys ≥77%; MarketScan ≥85%) across all subsequent LoTs. Second-line treatments such as rituximab (12.0% Explorys; 24.5% MarketScan), thrombopoietin receptor agonists (11.3% Explorys; 15.6% MarketScan), and splenectomy (2.5% Explorys; 8.1% MarketScan) were used much less frequently. CS use is widespread in the US in patients with ITP across all LoTs. Quality improvement initiatives are needed to reduce CS exposure and bolster use of second-line treatments.
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Affiliation(s)
- Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory MedicinePerelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | | | | | | | | | - James B Bussel
- Pediatric Hematology/OncologyWeill Cornell MedicineNew YorkNew YorkUSA
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23
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Dhopeshwarkar N, Yang W, Hennessy S, Rhodes JM, Cuker A, Leonard CE. Bleeding with concomitant ibrutinib and oral anticoagulant therapy: A population-based cohort study. Am J Hematol 2023; 98:E49-E52. [PMID: 36459586 PMCID: PMC9931637 DOI: 10.1002/ajh.26802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 11/23/2022] [Accepted: 11/26/2022] [Indexed: 12/03/2022]
Affiliation(s)
- Neil Dhopeshwarkar
- Center for Real-world Effectiveness and Safety of Therapeutics and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
| | - Wei Yang
- Center for Real-world Effectiveness and Safety of Therapeutics and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
| | - Sean Hennessy
- Center for Real-world Effectiveness and Safety of Therapeutics and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
| | - Joanna M. Rhodes
- Division of Hematology/Medical Oncology, Department of Medicine, Northwell Health (New Hyde Park, New York, US)
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
| | - Charles E. Leonard
- Center for Real-world Effectiveness and Safety of Therapeutics and the Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania (Philadelphia, Pennsylvania, US)
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24
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Ragni MV, Young G, Batsuli G, Bisson E, Carpenter SL, Croteau SE, Cuker A, Curtis RG, Denne M, Ewenstein B, Federizo A, Frick N, Funkhouser K, George LA, Hoots WK, Jobe SM, Krava E, Langmead CJ, Lewis RJ, López J, Malec L, Mann Z, Miles ME, Neely E, Neufeld EJ, Pierce GF, Pipe SW, Pitler LR, Raffini L, Schnur KM, Shavit JA. Building the foundation for a community-generated national research blueprint for inherited bleeding disorders: facilitating research through infrastructure, workforce, resources and funding. Expert Rev Hematol 2023; 16:107-127. [PMID: 36920855 DOI: 10.1080/17474086.2023.2181781] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND The National Hemophilia Foundation (NHF) conducted extensive, inclusive community consultations to guide prioritization of research in coming decades in alignment with its mission to find cures and address and prevent complications enabling people and families with blood disorders to thrive. RESEARCH DESIGN AND METHODS With the American Thrombosis and Hemostasis Network, NHF recruited multidisciplinary expert working groups (WG) to distill the community-identified priorities into concrete research questions and score their feasibility, impact, and risk. WG6 was charged with identifying the infrastructure, workforce development, and funding and resources to facilitate the prioritized research. Community input on conclusions was gathered at the NHF State of the Science Research Summit. RESULTS WG6 detailed a minimal research capacity infrastructure threshold, and opportunities to enable its attainment, for bleeding disorders centers to participate in prospective, multicenter national registries. They identified challenges and opportunities to recruit, retain, and train the diverse multidisciplinary care and research workforce required into the future. Innovative collaborative approaches to trial design, resource networking, and funding to surmount obstacles facing research in rare disorders were elucidated. CONCLUSIONS The innovations in infrastructure, workforce development, and resources and funding proposed herein may contribute to facilitating a National Research Blueprint for Inherited Bleeding Disorders.
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Affiliation(s)
- Margaret V Ragni
- Department of Hematology/Oncology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Medical and Scientific Advisory Council, National Hemophilia Foundation, New York, New York, USA
| | - Guy Young
- Cancer and Blood Disorders Institute, Children's Hospital Los Angeles, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Glaivy Batsuli
- Department of Pediatrics, Emory University, Atlanta, Georgia, USA.,Aflac Cancer and Blood Disorders Center of Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Emily Bisson
- Hemostasis & Thrombosis Center, Connecticut Children's, Hartford, Connecticut, USA
| | - Shannon L Carpenter
- Department of Pediatric Hematology/Oncology, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Stacy E Croteau
- Boston Hemophilia Treatment Center, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Adam Cuker
- Penn Comprehensive Hemophilia Program, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Randall G Curtis
- Hematology Utilization Group Study (HUGS), University of Southern California, Los Angeles, California, USA.,Patient Reported Outcomes, Burdens and Experiences (PROBE) Washington, DC, USA
| | - Michael Denne
- Hematology and Rare Disease, Takeda, Cincinnati, Ohio, USA
| | - Bruce Ewenstein
- Takeda Development Center Americas, Inc, Cambridge, Massachusetts, USA
| | - Amber Federizo
- Hemostasis and Thrombosis Center of Nevada, Las Vegas, Nevada, USA
| | - Neil Frick
- National Hemophilia Foundation, New York, New York, USA
| | - Kerry Funkhouser
- Foundation for Women & Girls with Blood Disorders, Montclair, New Jersey, USA
| | - Lindsey A George
- Department of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - W Keith Hoots
- Division of Blood Diseases and Resources, National Heart, Lung and Blood Institute, National Institutes of Health; Health and Human Services, Bethesda, Maryland, USA
| | - Shawn M Jobe
- Department of Pediatrics and Human Development, Michigan State University College of Medicine, East Lansing, Michigan, USA
| | - Emily Krava
- Department of Hematology-Oncology, Children's Hospital Los Angeles, Los Angeles, California, USA
| | | | | | - José López
- Bloodworks Northwest, Seattle, Washington, USA.,Department of Hematology, University of Washington, School of Medicine, Seattle, Washington, USA
| | - Lynn Malec
- Blood Research Institute, Versiti, Milwaukee, Wisconsin, USA
| | - Ziva Mann
- National Hemophilia Foundation, New York, New York, USA.,Ascent Leadership Networks, Newton, Massachusetts, USA
| | - Moses E Miles
- American Thrombosis and Hemostasis Network, Rochester, New York, USA
| | - Emma Neely
- National Hemophilia Foundation, New York, New York, USA
| | - Ellis J Neufeld
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee, USA.,Department of Pediatric Medicine, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Glenn F Pierce
- World Federation of Hemophilia, Montréal, Québec, Canada
| | - Steven W Pipe
- Medical and Scientific Advisory Council, National Hemophilia Foundation, New York, New York, USA.,Division of Pediatric Hematology and Oncology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lisa R Pitler
- Alliance for Clinical Trials in Oncology Foundation, Chicago, Illinois, USA
| | - Leslie Raffini
- Hemostasis and Thrombosis Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kathaleen M Schnur
- Hemophilia Center of Western Pennsylvania, Pittsburgh, Pennsylvania, USA
| | - Jordan A Shavit
- Division of Pediatric Hematology and Oncology, University of Michigan, Ann Arbor, Michigan, USA.,Human Genetics, University of Michigan, Ann Arbor.,Hemophilia and Coagulation Disorders Program, University of Michigan, Ann Arbor, Michigan, USA
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25
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Chiasakul T, Crowther M, Cuker A. Four-Factor Prothrombin Complex Concentrate for the Treatment of Oral Factor Xa Inhibitor-Associated Bleeding: A Meta-analysis of Fixed Versus Variable Dosing. Res Pract Thromb Haemost 2023; 7:100107. [PMID: 37063756 PMCID: PMC10099316 DOI: 10.1016/j.rpth.2023.100107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/17/2023] [Accepted: 02/23/2023] [Indexed: 03/12/2023] Open
Abstract
Background The optimal dosing strategy of four-factor prothrombin complex concentrate (4F-PCC) to treat oral factor Xa (FXa) inhibitor-associated bleeding has not been established. Objectives To evaluate the effectiveness and safety of fixed versus variable 4F-PCC dosing for the management of FXa inhibitor-associated bleeding. Methods A systematic literature search and meta-analysis of clinical studies was performed using PubMed, Embase, and Cochrane databases from inception to January 2022. The primary outcomes included hemostatic effectiveness, mortality, and thromboembolic events. Secondary outcomes included 4F-PCC usage, total length of stay in hospital and in intensive care units, and time to 4F-PCC administration. The pooled incidence or mean was calculated using a random-effects model and compared between the 2 dosing strategies. Results Twenty-five studies were included and data from 1,760 patients (fixed dosing, n = 228; variable dosing, n = 1,532) were analyzed. There were no significant differences in hemostatic effectiveness, thromboembolic events, or mortality rates between the dosing strategies. Hospital length of stay was significantly longer in the fixed-dosing group, with a mean stay of 7.4 days (95% CI: 3.6-11.1) compared to 5.9 days (95% CI: 5.5-6.3) in the variable-dosing group (P < 0.001). The mean initial 4F-PCC dose was significantly higher with variable dosing than fixed dosing (38 IU/kg; 95% CI: 32-44 vs. 27 IU/kg; 95% CI: 26-28, P < 0.001). Conclusions A fixed-dosing strategy appears to be a safe and effective alternative to variable weight-based dosing and was associated with lower 4F-PCC usage. However, direct comparative studies are needed to confirm these results.
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Al-Samkari H, Jiang D, Gernsheimer T, Liebman H, Lee S, Bernheisel C, Wojdyla M, Vredenburg M, Cuker A. Durability of Platelet Response After Switching to Avatrombopag From Eltrombopag or Romiplostim in Immune Thrombocytopenia. Res Pract Thromb Haemost 2023; 7:100134. [PMID: 37193124 PMCID: PMC10182312 DOI: 10.1016/j.rpth.2023.100134] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 03/08/2023] [Accepted: 03/10/2023] [Indexed: 03/31/2023] Open
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27
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Affiliation(s)
- Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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28
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Goshua G, Sinha P, Kunst N, Pischel L, Lee AI, Cuker A. Cost-effectiveness of second-line therapies in adults with chronic immune thrombocytopenia. Am J Hematol 2023; 98:122-130. [PMID: 35147241 PMCID: PMC9365880 DOI: 10.1002/ajh.26497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 02/04/2023]
Abstract
Major options for second-line therapy in adults with chronic immune thrombocytopenia (ITP) include splenectomy, rituximab, and thrombopoietin receptor agonists (TRAs). The American Society of Hematology guidelines recommend rituximab over splenectomy, TRAs over rituximab, and splenectomy or TRAs while noting a lack of evidence on the cost-effectiveness of these therapies. Using prospective, observational, and meta-analytic data, we performed the first cost-effectiveness analysis of second-line therapies in chronic ITP, from the perspective of the U.S. health system. Over a 20-year time-horizon, our six-strategy Markov model shows that a strategy incorporating early splenectomy, an approach at odds with current guidelines and clinical practice, is the cost-effective strategy. All four strategies utilizing TRAs in the first or second position cost over $1 million per quality-adjusted life-year, as compared to strategies involving early use of splenectomy and rituximab. In a probabilistic sensitivity analysis, early use of splenectomy and rituximab in either order was favored in 100% of 10 000 iterations. The annual cost of TRAs would have to decrease over 80% to begin to become cost-effective in any early TRA strategy. Our data indicate that effectiveness of early TRA and late TRA strategies is similar with the cost significantly greater with early TRA strategies. Contrary to current practice trends and guidelines, early use of splenectomy and rituximab, rather than TRAs, constitutes cost-effective treatment in adults with chronic ITP.
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Affiliation(s)
- George Goshua
- Section of Hematology, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Pranay Sinha
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts, USA
| | - Natalia Kunst
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Boston, Massachusetts, USA
| | - Lauren Pischel
- Section of Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Alfred Ian Lee
- Section of Hematology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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29
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Nilius H, Cuker A, Haug S, Nakas C, Studt JD, Tsakiris DA, Greinacher A, Mendez A, Schmidt A, Wuillemin WA, Gerber B, Kremer Hovinga JA, Vishnu P, Graf L, Kashev A, Sznitman R, Bakchoul T, Nagler M. A machine-learning model for reducing misdiagnosis in heparin-induced thrombocytopenia: A prospective, multicenter, observational study. EClinicalMedicine 2023; 55:101745. [PMID: 36457646 PMCID: PMC9706528 DOI: 10.1016/j.eclinm.2022.101745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Diagnosing heparin-induced thrombocytopenia (HIT) at the bedside remains challenging, exposing a significant number of patients at risk of delayed diagnosis or overtreatment. We hypothesized that machine-learning algorithms could be utilized to develop a more accurate and user-friendly diagnostic tool that integrates diverse clinical and laboratory information and accounts for complex interactions. METHODS We conducted a prospective cohort study including 1393 patients with suspected HIT between 2018 and 2021 from 10 study centers. Detailed clinical information and laboratory data were collected, and various immunoassays were conducted. The washed platelet heparin-induced platelet activation assay (HIPA) served as the reference standard. FINDINGS HIPA diagnosed HIT in 119 patients (prevalence 8.5%). The feature selection process in the training dataset (75% of patients) yielded the following predictor variables: (1) immunoassay test result, (2) platelet nadir, (3) unfractionated heparin use, (4) CRP, (5) timing of thrombocytopenia, and (6) other causes of thrombocytopenia. The best performing models were a support vector machine in case of the chemiluminescent immunoassay (CLIA) and the ELISA, as well as a gradient boosting machine in particle-gel immunoassay (PaGIA). In the validation dataset (25% of patients), the AUROC of all models was 0.99 (95% CI: 0.97, 1.00). Compared to the currently recommended diagnostic algorithm (4Ts score, immunoassay), the numbers of false-negative patients were reduced from 12 to 6 (-50.0%; ELISA), 9 to 3 (-66.7%, PaGIA) and 14 to 5 (-64.3%; CLIA). The numbers of false-positive individuals were reduced from 87 to 61 (-29.8%; ELISA), 200 to 63 (-68.5%; PaGIA) and increased from 50 to 63 (+29.0%) for the CLIA. INTERPRETATION Our user-friendly machine-learning algorithm for the diagnosis of HIT (https://toradi-hit.org) was substantially more accurate than the currently recommended diagnostic algorithm. It has the potential to reduce delayed diagnosis and overtreatment in clinical practice. Future studies shall validate this model in wider settings. FUNDING Swiss National Science Foundation (SNSF), and International Society on Thrombosis and Haemostasis (ISTH).
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Affiliation(s)
- Henning Nilius
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Sigve Haug
- Mathematical Institute, University of Bern, Bern, Switzerland
- Albert Einstein Center for Fundamental Physics and Laboratory for High Energy Physics, University of Bern, Bern, Switzerland
| | - Christos Nakas
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Laboratory of Biometry, School of Agriculture, University of Thessaly, Volos, Greece
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University and University Hospital Zurich, Zurich, Switzerland
| | | | - Andreas Greinacher
- Institut für Immunologie und Transfusionsmedizin, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Adriana Mendez
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Adrian Schmidt
- Clinic of Medical Oncology and Hematology, Municipal Hospital Zurich Triemli, Zurich, Switzerland
| | - Walter A. Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne and University of Bern, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Johanna A. Kremer Hovinga
- Department of Hematology and Central Hematology Laboratory, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Prakash Vishnu
- Division of Hematology, CHI Franciscan Medical Group, Seattle, United States
| | - Lukas Graf
- Cantonal Hospital of St Gallen, Switzerland
| | | | - Raphael Sznitman
- ARTORG Center for Biomedical Engineering Research, University of Bern, Bern, Switzerland
| | - Tamam Bakchoul
- Centre for Clinical Transfusion Medicine, University Hospital of Tübingen, Tübingen, Germany
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Corresponding author. Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland.
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Abstract
Abnormal bleeding in patients with liver disease may result from elevated portal pressure and varix formation, reduced hepatic synthesis of coagulation proteins, qualitative platelet dysfunction, and/or thrombocytopenia. Major mechanisms of thrombocytopenia in liver disease include splenic sequestration and impaired platelet production due to reduced thrombopoietin production. Alcohol and certain viruses may induce marrow suppression. Immune thrombocytopenia (ITP) may co-occur in patients with liver disease, particularly those with autoimmune liver disease or chronic hepatitis C. Drugs used for the treatment of liver disease or its complications, such as interferon, immunosuppressants, and antibiotics, may cause thrombocytopenia. Periprocedural management of thrombocytopenia of liver disease depends on both individual patient characteristics and the bleeding risk of the procedure. Patients with a platelet count higher than or equal to 50 000/µL and those requiring low-risk procedures rarely require platelet-directed therapy. For those with a platelet count below 50 000/µL who require a high-risk procedure, platelet-directed therapy should be considered, especially if the patient has other risk factors for bleeding, such as abnormal bleeding with past hemostatic challenges. We often target a platelet count higher than or equal to 50 000/µL in such patients. If the procedure is elective, we prefer treatment with a thrombopoietin receptor agonist; if it is urgent, we use platelet transfusion. In high-risk patients who have an inadequate response to or are otherwise unable to receive these therapies, other strategies may be considered, such as a trial of empiric ITP therapy, spleen-directed therapy, or transjugular intrahepatic portosystemic shunt placement.
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Affiliation(s)
- Hana I Lim
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Pishko A, Cuker A. Early-onset heparin-induced thrombocytopenia after cardiac surgery: Should we lose sleep? J Thromb Haemost 2022; 20:2491-2493. [PMID: 36271465 DOI: 10.1111/jth.15840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 12/01/2022]
Affiliation(s)
- Allyson Pishko
- Division of Hematology & Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adam Cuker
- Division of Hematology & Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Dawwas GK, Cuker A, Barnes GD, Lewis JD, Hennessy S. Apixaban Versus Rivaroxaban in Patients With Atrial Fibrillation and Valvular Heart Disease : A Population-Based Study. Ann Intern Med 2022; 175:1506-1514. [PMID: 36252244 PMCID: PMC10878325 DOI: 10.7326/m22-0318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Although apixaban and rivaroxaban are commonly used in patients with atrial fibrillation (AF) and valvular heart disease (VHD), there is limited evidence comparing the 2 drugs in these patients. OBJECTIVE To emulate a target trial of effectiveness and safety of apixaban and rivaroxaban in patients with AF and VHD. DESIGN New-user, active comparator, cohort study design. SETTING Commercial health insurance database from 1 January 2013 to 31 December 2020. PATIENTS New users of apixaban or rivaroxaban who had a diagnosis of AF and VHD before initiation of anticoagulant therapy. MEASUREMENTS The primary effectiveness outcome was a composite of ischemic stroke or systemic embolism. The primary safety outcome was a composite of gastrointestinal or intracranial bleeding. Cox proportional hazards regression with a robust variance estimator was used to estimate hazard ratios (HRs) and 95% CIs. RESULTS When compared with rivaroxaban in a propensity score-matched cohort of 19 894 patients (9947 receiving each drug), apixaban was associated with a lower rate of ischemic stroke or systemic embolism (HR, 0.57 [95% CI, 0.40 to 0.80]) and bleeding (HR, 0.51 [CI, 0.41 to 0.62]). The absolute reduction in the probability of stroke or systemic embolism with apixaban compared with rivaroxaban was 0.0026 within 6 months and 0.011 within 1 year of treatment initiation. The absolute reduction in the probability of bleeding events with apixaban compared with rivaroxaban was 0.012 within 6 months and 0.019 within 1 year of treatment initiation. LIMITATION Short follow-up time and inability to ascertain some types of VHD. CONCLUSION In this study of patients with AF and VHD, patients receiving apixaban had a lower risk for ischemic stroke or systemic embolism and for bleeding when compared with those receiving rivaroxaban. PRIMARY FUNDING SOURCE National Institutes of Health.
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Affiliation(s)
- Ghadeer K Dawwas
- Center for Real-world Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (G.K.D.)
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (A.C.)
| | - Geoffrey D Barnes
- Department of Internal Medicine, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, Michigan (G.D.B.)
| | - James D Lewis
- Center for Real-world Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, and Division of Gastroenterology and Hepatology, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (J.D.L.)
| | - Sean Hennessy
- Center for Real-world Effectiveness and Safety of Therapeutics, Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, and Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (S.H.)
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Cuker A, Tseng EK, Nieuwlaat R, Angchaisuksiri P, Blair C, Dane K, DeSancho MT, Diuguid D, Griffin DO, Kahn SR, Klok FA, Lee AI, Neumann I, Pai A, Righini M, Sanfilippo KM, Siegal DM, Skara M, Terrell DR, Touri K, Akl EA, Al Jabiri R, Al Jabiri Y, Barbara AM, Bognanni A, Boulos M, Brignardello-Petersen R, Charide R, Colunga-Lozano LE, Dearness K, Darzi AJ, Hussein H, Karam SG, Mansour R, Morgano GP, Morsi RZ, Muti-Schünemann G, Nadim MK, Philip BA, Qiu Y, Benitez YR, Stevens A, Solo K, Wiercioch W, Mustafa RA, Schünemann HJ. American Society of Hematology living guidelines on the use of anticoagulation for thromboprophylaxis in patients with COVID-19: January 2022 update on the use of therapeutic-intensity anticoagulation in acutely ill patients. Blood Adv 2022; 6:4915-4923. [PMID: 35503027 PMCID: PMC9068240 DOI: 10.1182/bloodadvances.2022007561] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/18/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND COVID-19-related acute illness is associated with an increased risk of venous thromboembolism (VTE). OBJECTIVE These evidence-based guidelines from the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in making decisions about the use of anticoagulation in patients with COVID-19. METHODS ASH formed a multidisciplinary guideline panel that included patient representatives and applied strategies to minimize potential bias from conflicts of interest. The McMaster University GRADE Centre supported the guideline development process and performed systematic evidence reviews (through November 2021). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess evidence and make recommendations, which were subject to public comment. This is an update to guidelines published in February 2021 as part of the living phase of these guidelines. RESULTS The panel made one additional recommendation. The panel issued a conditional recommendation in favor of therapeutic-intensity over prophylactic-intensity anticoagulation in patients with COVID-19-related acute illness who do not have suspected or confirmed VTE. The panel emphasized the need for an individualized assessment of risk of thrombosis and bleeding. The panel also noted that heparin (unfractionated or low molecular weight) may be preferred because of a preponderance of evidence with this class of anticoagulants. CONCLUSION This conditional recommendation was based on very low certainty in the evidence, underscoring the need for additional, high-quality, randomized controlled trials comparing different intensities of anticoagulation in patients with COVID-19-related acute illness.
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Affiliation(s)
- Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Eric K. Tseng
- Division of Hematology/Oncology, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Pantep Angchaisuksiri
- Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Kathryn Dane
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| | - Maria T. DeSancho
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY
| | | | - Daniel O. Griffin
- Division of Infectious Diseases, College of Physicians & Surgeons of Columbia University, New York, NY
- Research and Development at United Health Group, Minnetonka, MN
- Prohealth NY, Lake Success, NY
| | - Susan R. Kahn
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Frederikus A. Klok
- Department of Medicine – Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Alfred Ian Lee
- Section of Hematology, Yale School of Medicine, New Haven, CT
| | - Ignacio Neumann
- Department of Internal Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Ashok Pai
- Division of Hematology & Oncology, Kaiser Permanente, Oakland/Richmond, CA
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | | | - Deborah M. Siegal
- Department of Medicine and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | | | - Deirdra R. Terrell
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | | | - Elie A. Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | | | | | - Angela M. Barbara
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Antonio Bognanni
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Mary Boulos
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Romina Brignardello-Petersen
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Rana Charide
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Luis E. Colunga-Lozano
- Department of Clinical Medicine, Health Science Center, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Karin Dearness
- Library Services, St. Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
| | - Andrea J. Darzi
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Heba Hussein
- Oral Medicine and Periodontology Department, Faculty of Dentistry, Cairo University, Cairo, Egypt
| | - Samer G. Karam
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Razan Mansour
- Office of Scientific Affairs and Research, King Hussein Cancer Center, Amman, Jordan
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Rami Z. Morsi
- Department of Neurology, University of Chicago, Chicago, IL
| | - Giovanna Muti-Schünemann
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Menatalla K. Nadim
- Department of Clinical Pathology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Binu A. Philip
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Yuan Qiu
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Yetiani Roldan Benitez
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Adrienne Stevens
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Karla Solo
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Reem A. Mustafa
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
- Department of Internal Medicine, Division of Nephrology, University of Kansas Medical Center, Kansas City, KS
| | - Holger J. Schünemann
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
- Institut für Evidence in Medicine, Medical Center & Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Cuker A, Tseng EK, Schünemann HJ, Angchaisuksiri P, Blair C, Dane K, DeSancho MT, Diuguid D, Griffin DO, Kahn SR, Klok FA, Lee AI, Neumann I, Pai A, Righini M, Sanfilippo KM, Siegal DM, Skara M, Terrell DR, Touri K, Akl EA, Al Jabiri R, Al Jabiri Y, Boulos M, Brignardello-Petersen R, Charide R, Colunga-Lozano LE, Dearness K, Darzi AJ, Karam SG, Morgano GP, Morsi RZ, Philip BA, Benitez YR, Stevens A, Solo K, Wiercioch W, Mustafa RA, Nieuwlaat R. American Society of Hematology living guidelines on the use of anticoagulation for thromboprophylaxis for patients with COVID-19: March 2022 update on the use of anticoagulation in critically ill patients. Blood Adv 2022; 6:4975-4982. [PMID: 35748885 PMCID: PMC9236618 DOI: 10.1182/bloodadvances.2022007940] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/13/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND COVID-19-related critical illness is associated with an increased risk of venous thromboembolism (VTE). OBJECTIVE These evidence-based guidelines of the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in decisions about the use of anticoagulation for patients with COVID-19. METHODS ASH formed a multidisciplinary guideline panel, including 3 patient representatives, and applied strategies to minimize potential bias from conflicts of interest. The McMaster University Grading of Recommendations Assessment, Development and Evaluation (GRADE) Centre supported the guideline development process, including performing systematic evidence reviews (up to January 2022). The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients. The panel used the GRADE approach to assess evidence and make recommendations, which were subject to public comment. This is an update to guidelines published in February 2021 and May 2021 as part of the living phase of these guidelines. RESULTS The panel made 1 additional recommendation: a conditional recommendation for the use of prophylactic-intensity over therapeutic-intensity anticoagulation for patients with COVID-19-related critical illness who do not have suspected or confirmed VTE. The panel emphasized the need for an individualized assessment of thrombotic and bleeding risk. CONCLUSIONS This conditional recommendation was based on very low certainty in the evidence, underscoring the need for additional, high-quality, randomized controlled trials comparing different intensities of anticoagulation for patients with COVID-19-related critical illness.
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Affiliation(s)
- Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Eric K. Tseng
- Division of Hematology/Oncology; St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
| | - Holger J. Schünemann
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
- Institut für Evidence in Medicine, Medical Center & Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Pantep Angchaisuksiri
- Division of Hematology, Department of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | | | - Kathryn Dane
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| | - Maria T. DeSancho
- Division of Hematology-Oncology, Department of Medicine, Weill Cornell Medicine, New York Presbyterian Hospital, New York, NY
| | | | - Daniel O. Griffin
- Division of Infectious Diseases, College of Physicians & Surgeons of Columbia University, New York, NY
- Research and Development at United Health Group, Minnetonka, MN
- Prohealth NY, Lake Success, NY
| | - Susan R. Kahn
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Frederikus A. Klok
- Department of Medicine–Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, the Netherlands
| | - Alfred Ian Lee
- Section of Hematology, Yale School of Medicine, New Haven, CT
| | - Ignacio Neumann
- Escuela de Medicina, Facultad de Medicina y Ciencia, Universidad San Sebastian, Santiago, Chile
| | - Ashok Pai
- Division of Hematology & Oncology, Kaiser Permanente, Oakland/Richmond, CA
| | - Marc Righini
- Division of Angiology and Hemostasis, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | | | - Deborah M. Siegal
- Department of Medicine and the Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | | | - Deirdra R. Terrell
- Department of Biostatistics and Epidemiology, Hudson College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | | | - Elie A. Akl
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | | | | | - Mary Boulos
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Romina Brignardello-Petersen
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Rana Charide
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon
| | - Luis E. Colunga-Lozano
- Department of Clinical Medicine, Health Science Center, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Karin Dearness
- Library Services, St. Joseph’s Healthcare Hamilton, Hamilton, ON, Canada
| | - Andrea J. Darzi
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Samer G. Karam
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Gian Paolo Morgano
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Rami Z. Morsi
- Department of Neurology, University of Chicago, Chicago, IL; and
| | - Binu A. Philip
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Yetiani Roldan Benitez
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Adrienne Stevens
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Karla Solo
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Wojtek Wiercioch
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
| | - Reem A. Mustafa
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
- Department of Internal Medicine, Division of Nephrology, University of Kansas Medical Center, Kansas City, KS
| | - Robby Nieuwlaat
- Department of Health Research Methods, Evidence, and Impact, Michael G. DeGroote Cochrane Canada and GRADE Centres, McMaster University, Hamilton, ON, Canada
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Dhopeshwarkar N, Yang W, Hennessy S, Rhodes JM, Cuker A, Leonard CE. Rate of major bleeding with ibrutinib versus bendamustine-rituximab in chronic lymphocytic leukemia: A population-based cohort study. Am J Hematol 2022; 97:E332-E335. [PMID: 35713560 PMCID: PMC10368070 DOI: 10.1002/ajh.26632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 06/03/2022] [Accepted: 06/13/2022] [Indexed: 11/12/2022]
Affiliation(s)
- Neil Dhopeshwarkar
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, PerelmanSchool of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Wei Yang
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, PerelmanSchool of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, PerelmanSchool of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Joanna M. Rhodes
- Division of Hematology/Medical Oncology, Department of Medicine, Northwell Health, New Hyde Park, New York, USA
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Charles E. Leonard
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology, and Informatics, PerelmanSchool of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Dawwas GK, Cuker A, Rothstein A, Hennessy S. Trends in post-discharge prophylactic anticoagulant use among stroke patients in the United States between 2006 and 2019. J Stroke Cerebrovasc Dis 2022; 31:106700. [PMID: 35964533 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 07/28/2022] [Accepted: 08/01/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Stroke is an independent risk factor for venous thromboembolism (VTE). Although the risk of VTE persists after hospital discharge, information on the utilization of anticoagulants among stroke patients after discharge remains limited. OBJECTIVE To evaluate changes in post-discharge thromboprophylaxis among stroke patients between 2006 and 2019. METHODS We conducted a retrospective repeated cross-sectional analysis using a commercial healthcare insurance database in the United States. We included patients aged ≥ 18 years with incident stroke diagnosis and assessed prophylactic use of anticoagulants in the 30 days following hospital discharge including low-molecular-weight heparin (enoxaparin ≤40 mg/day, dalteparin ≤5000 IU/day), unfractionated heparin ≤5000 IU/ twice daily or 3 times a day, apixaban 2.5 mg twice daily, and rivaroxaban 10 mg/day. Patients with atrial fibrillation, VTE, mechanical heart valves, cancer, antiphospholipid antibody syndrome, and users of therapeutic doses of anticoagulants were excluded. We used the Cochrane-Armitage test to assess changes in the use of anticoagulants across the study period. RESULTS There was a small increase in the overall use of post-discharge prophylactic anticoagulants among stroke patients between 2006 and 2019 from 0.5% to 1.9%. The use of heparin decreased from 0.5% in 2006 to 0.3% in 2019 (P-value for trend = 0.001). In contrast, the use of apixaban or rivaroxaban increased from 0.1% in 2013 to 1.6% in 2019 (P-value for trend < 0.001). Apixaban was more commonly used than rivaroxaban. CONCLUSIONS In this population-based study of stroke patients, we found that post-discharge anticoagulant use remains low through 2019. Prophylactic use of heparin or rivaroxaban was relatively low but the use of apixaban increased over the study period. Further research is needed to determine if these agents are safe and effective for VTE prevention in stroke patients.
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Affiliation(s)
- Ghadeer K Dawwas
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104-4865, United States; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States.
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Aaron Rothstein
- Department of Neurology, University of Pennsylvania , Philadelphia, PA, United States
| | - Sean Hennessy
- Center for Pharmacoepidemiology Research and Training, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104-4865, United States; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States; Department of Systems Pharmacology and Translational Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
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El Mikati IK, Khabsa J, Harb T, Khamis M, Agarwal A, Pardo-Hernandez H, Farran S, Khamis AM, El Zein O, El-Khoury R, Schünemann HJ, Akl EA, Alonso-Coello P, Alper BS, Amer YS, Arayssi T, Barker JM, Bouakl I, Boutron I, Brignardello-Petersen R, Carandang K, Chang S, Chen Y, Cuker A, El-Jardali F, Florez I, Ford N, Grove J, Guyatt GH, Hazlewood GS, Kredo T, Lamontagne F, Langendam MW, Lewin S, Macdonald H, McFarlane E, Meerpohl J, Munn Z, Murad MH, Mustafa RA, Neumann I, Nieuwlaat R, Nowak A, Pardo JP, Qaseem A, Rada G, Righini M, Rochwerg B, Rojas-Reyes MX, Siegal D, Siemieniuk R, Singh JA, Skoetz N, Sultan S, Synnot A, Tugwell P, Turner A, Turner T, Venkatachalam S, Welch V, Wiercioch W. A Framework for the Development of Living Practice Guidelines in Health Care. Ann Intern Med 2022; 175:1154-1160. [PMID: 35785533 DOI: 10.7326/m22-0514] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Living practice guidelines are increasingly being used to ensure that recommendations are responsive to rapidly emerging evidence. OBJECTIVE To develop a framework that characterizes the processes of development of living practice guidelines in health care. DESIGN First, 3 background reviews were conducted: a scoping review of methods papers, a review of handbooks of guideline-producing organizations, and an analytic review of selected living practice guidelines. Second, the core team drafted the first version of the framework. Finally, the core team refined the framework through an online survey and online discussions with a multidisciplinary international group of stakeholders. SETTING International. PARTICIPANTS Multidisciplinary group of 51 persons who have experience with guidelines. MEASUREMENTS Not applicable. RESULTS A major principle of the framework is that the unit of update in a living guideline is the individual recommendation. In addition to providing definitions, the framework addresses several processes. The planning process should address the organization's adoption of the living methodology as well as each specific guideline project. The production process consists of initiation, maintenance, and retirement phases. The reporting should cover the evidence surveillance time stamp, the outcome of reassessment of the body of evidence (when applicable), and the outcome of revisiting a recommendation (when applicable). The dissemination process may necessitate the use of different venues, including one for formal publication. LIMITATION This study does not provide detailed or practical guidance for how the described concepts would be best implemented. CONCLUSION The framework will help guideline developers in planning, producing, reporting, and disseminating living guideline projects. It will also help research methodologists study the processes of living guidelines. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Ibrahim K El Mikati
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon (I.K.M., J.K.)
| | - Joanne Khabsa
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon (I.K.M., J.K.)
| | - Tarek Harb
- Faculty of Medicine, American University of Beirut, Beirut, Lebanon (T.H.)
| | - Mohamed Khamis
- Emergency Medicine Department, American University of Beirut, Beirut, Lebanon (M.K.)
| | - Arnav Agarwal
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada, and MAGIC Evidence Ecosystem Foundation, Oslo, Norway (A.A.)
| | - Hector Pardo-Hernandez
- Iberoamerican Cochrane Centre, Sant Pau Biomedical Research Institute, Barcelona, and CIBER Epidemiología y Salud Pública, Madrid, Spain (H.P.)
| | - Sarah Farran
- Clinical Pathology Department, American University of Beirut, Beirut, Lebanon (S.F.)
| | - Assem M Khamis
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, United Kingdom (A.M.K.)
| | - Ola El Zein
- Saab Medical Library, American University of Beirut, Beirut, Lebanon (O.E.)
| | - Rayane El-Khoury
- Infectious Disease Epidemiology Group and World Health Organization Collaborating Centre for Disease Epidemiology Analytics on HIV/AIDS, Sexually Transmitted Infections, and Viral Hepatitis, Weill Cornell Medicine-Qatar, Cornell University, Qatar Foundation - Education City, Doha, Qatar (R.E.)
| | - Holger J Schünemann
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (H.J.S.)
| | - Elie A Akl
- Clinical Research Institute, American University of Beirut, Beirut, Lebanon, and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada (E.A.A.)
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Cuker A, Lal L, Roy A, Elliott C, Carlyle M, Martin C, Haenig J, Viana R. Thrombopoietin receptor agonist discontinuation rates and reasons among patients with immune thrombocytopenia: a study of administrative claims linked with medical chart review. Ann Hematol 2022; 101:1915-1924. [PMID: 35849155 DOI: 10.1007/s00277-022-04888-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 06/04/2022] [Indexed: 11/01/2022]
Abstract
Administrative claims provide a rich data source for retrospective studies of real-world clinical practice, yet some important data may be inconsistent or unavailable. This study explored factors influencing discontinuation of thrombopoietin receptor agonists (TPO-RAs) among patients with immune thrombocytopenia (ITP), by adding medical chart abstraction for additional details. Adult (≥ 18 years) patients with continuous commercial or Medicare Advantage with Part D health insurance coverage were included. Inclusion criteria were ≥ 1 claim for eltrombopag or romiplostim and ≥ 2 diagnoses of ITP between December 31, 2017, and January 1, 2020. Providers were asked to provide access to medical charts for abstraction. The analyses included only patients who discontinued TPO-RA and described patient characteristics, treatment patterns, platelet values, and reasons for discontinuation. Among 207 ITP patients treated with a TPO-RA, 137 (66%) discontinued treatment during the observation period. The mean TPO-RA treatment duration was 185 days. Mean platelet count at the time of discontinuation was 197 × 109/L. The most common reason for discontinuation was improvement of the patient's condition (42%). Other reasons included worsening of ITP/lack of response (12%), adverse events (12%), and cost-related or social reasons (23%). No reason was reported for 10%. Notably 26% of patients who discontinued remained off all ITP therapy for the remainder of the study, with a mean treatment-free period of 262 days. These results emphasize that some patients with ITP are able to discontinue TPO-RA therapy and achieve durable treatment-free periods.
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Affiliation(s)
- Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Anuja Roy
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
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Luo C, Du J, Cuker A, Lautenbach E, Asch DA, Poland GA, Tao C, Chen Y. Comparability of clinical trials and spontaneous reporting data regarding COVID-19 vaccine safety. Sci Rep 2022; 12:10946. [PMID: 35768434 PMCID: PMC9243073 DOI: 10.1038/s41598-022-13809-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/27/2022] [Indexed: 11/09/2022] Open
Abstract
Severe adverse events (AEs) after COVID-19 vaccination are not well studied in randomized controlled trials (RCTs) due to rarity and short follow-up. To monitor the safety of COVID-19 vaccines ("Pfizer" vaccine dose 1 and 2, "Moderna" vaccine dose 1 and 2, and "Janssen" vaccine single dose) in the U.S., especially regarding severe AEs, we compare the relative rankings of these vaccines using both RCT and the Vaccine Adverse Event Reporting System (VAERS) data. The risks of local and systemic AEs were assessed from the three pivotal COVID-19 vaccine trials and also calculated in the VAERS cohort consisting of 559,717 reports between December 14, 2020 and September 17, 2021. AE rankings of the five vaccine groups calculated separately by RCT and VAERS were consistent, especially for systemic AEs. For severe AEs reported in VAERS, the reported risks of thrombosis and GBS after Janssen vaccine were highest. The reported risk of shingles after the first dose of Moderna vaccine was highest, followed by the second dose of the Moderna vaccine. The reported risk of myocarditis was higher after the second dose of Pfizer and Moderna vaccines. The reported risk of anaphylaxis was higher after the first dose of Pfizer vaccine. Limitations of this study are the inherent biases of the spontaneous reporting system data, and only including three pivotal RCTs and no comparison with other active vaccine safety surveillance systems.
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Affiliation(s)
- Chongliang Luo
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Division of Public Health Sciences, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Jingcheng Du
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ebbing Lautenbach
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Asch
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, Philadelphia, PA, USA
| | - Gregory A Poland
- Mayo Clinic Vaccine Research Group, Mayo Clinic, Rochester, MN, USA
| | - Cui Tao
- School of Biomedical Informatics, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Yong Chen
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Leonard Davis Institute of Health Economics, Philadelphia, PA, USA.
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40
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Evans CR, Cuker A, Crowther M, Pishko AM. Prophylactic fresh frozen plasma versus prothrombin complex concentrate for preprocedural management of the coagulopathy of liver disease: A systematic review. Res Pract Thromb Haemost 2022; 6:e12724. [PMID: 36204546 PMCID: PMC9124952 DOI: 10.1002/rth2.12724] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 03/19/2022] [Accepted: 04/04/2022] [Indexed: 11/23/2022] Open
Abstract
Background The optimal prophylactic preprocedural management of patients with coagulopathy due to liver disease is not known. Objectives Our objective was to compare the efficacy and safety of fresh frozen plasma (FFP) with prothrombin complex concentrate (PCC) in the preprocedural management of patients with coagulopathy of liver disease. Methods We conducted a systematic review to examine published evidence regarding treatment with FFP or PCC in adults with coagulopathy of liver disease undergoing an invasive procedure. Direct comparisons and single‐arm studies were eligible. Efficacy outcomes included major bleeding, mortality, and correction of prothrombin time (PT) and/or international normalized ratio (INR). Safety outcomes included thrombosis and transfusion‐related complications. Results A total of 95 articles were identified for full‐text review. Nine studies were eligible and included in the review. No randomized trials comparing FFP versus PCC were identified. Only two studies directly compared FFP versus PCC. In these studies, PCC appeared to result in higher rates of correction of PT/INR, but bleeding outcomes were not different. In the single‐arm studies, bleeding events appeared low overall. Volume overload was the most common recorded adverse event in patients receiving FFP. Thromboembolic events occurred rarely, but exclusively in the PCC group. Due to heterogeneity in study definitions and bias, meta‐analysis was not possible. Our study found no evidence to favor a specific product over another. Conclusions Insufficient data exist on the effects of FFP versus PCC administration before invasive procedures in patients with coagulopathy of liver disease to make conclusions with respect to relative efficacy or safety.
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Affiliation(s)
- Christina R. Evans
- Department of Medicine Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Adam Cuker
- Department of Medicine Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
- Department of Pathology and Laboratory Medicine Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Mark Crowther
- Department of Medicine McMaster University Hamilton Ontario Canada
| | - Allyson M. Pishko
- Department of Medicine Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
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Dawwas GK, Cuker A, Connors JM, Barnes GD. Apixaban has superior effectiveness and safety compared to rivaroxaban in patients with commercial healthcare coverage: A population-based analysis in response to CVS 2022 formulary changes. Am J Hematol 2022; 97:E173-E176. [PMID: 35147235 PMCID: PMC8986609 DOI: 10.1002/ajh.26494] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 12/27/2022]
Affiliation(s)
- Ghadeer K. Dawwas
- Center for Pharmacoepidemiology Research and Training, Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Jean Marie Connors
- Division of Hematology Brigham and Women's Hospital, Harvard Medical School Boston Massachusetts USA
| | - Geoffrey D. Barnes
- Department of Internal Medicine Frankel Cardiovascular Center, University of Michigan Ann Arbor Michigan USA
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Kleiboer B, Layer MA, Cafuir LA, Cuker A, Escobar M, Eyster ME, Kraut E, Leavitt AD, Lentz SR, Quon D, Ragni MV, Thornhill D, Wang M, Key NS, Buckner TW. Postoperative bleeding complications in patients with hemophilia undergoing major orthopedic surgery: A prospective multicenter observational study. J Thromb Haemost 2022; 20:857-865. [PMID: 35080347 PMCID: PMC8940712 DOI: 10.1111/jth.15654] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Persons with hemophilia (PWH) are at risk for chronic hemophilic arthropathy (HA). Joint replacement surgery may be used to relieve intractable pain and/or restore joint function. OBJECTIVES This multicenter, prospective, observational cohort study evaluated the rate of bleeding during the postoperative period after total hip (THA) or knee arthroplasty (TKA). PATIENTS/METHODS We included PWH of any severity ≥18 years of age who were undergoing THA or TKA. Clinical decisions were made at the discretion of the treating physician according to local standards of care. Clinical data were prospectively recorded. Major bleeding was defined as bleeding in a critical site, bleeding that resulted in either a 2 g/dl or greater decrease in hemoglobin during any 24-h period, or transfusion of two or more units of packed red blood cells. RESULTS One hundred thirty-one procedures (98 TKA and 33 THA) were performed, 39 (29.8%) of which were complicated by major bleeding, including 46% of THA and 25% of TKA. The risk of major bleeding was increased in THA compared to TKA (OR 2.50, p = .05), and by the presence of an inhibitor (OR 4.29, p = .04), increased BMI (OR 4.49 and 6.09 for overweight and obese, respectively, compared to normal BMI, each p < .01), and non-use of an antifibrinolytic medication (OR 3.00, p = .03). Neither continuous clotting factor infusion (versus bolus infusion) nor pharmacologic thromboprophylaxis were associated with bleeding risk. CONCLUSIONS The bleeding risk remains substantial after THA and TKA in PWH, despite factor replacement. Use of antifibrinolytic medications is associated with decreased risk.
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Affiliation(s)
- Brendan Kleiboer
- Department of Medicine and UNC Blood Research Center, University of North Carolina
| | - Marcus A. Layer
- Department of Medicine and UNC Blood Research Center, University of North Carolina
| | | | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Miguel Escobar
- McGovern Medical School, University of Texas Health Science Center at Houston
| | | | - Eric Kraut
- The Ohio State University Hemostasis and Thrombosis Center
| | - Andrew D. Leavitt
- Department of Laboratory Medicine and Department of Internal Medicine, University of California San Francisco
| | - Steven R. Lentz
- Department of Internal Medicine, University of Iowa Carver College of Medicine
| | - Doris Quon
- Orthopaedic Hemophilia Treatment Center, Orthopaedic Institute for Children
| | - Margaret V. Ragni
- Department of Medicine and Clinical and Translational Science, University of Pittsburgh School of Medicine
| | | | | | - Nigel S. Key
- Department of Medicine and UNC Blood Research Center, University of North Carolina
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Al-Samkari H, Jiang D, Gernsheimer T, Liebman H, Lee S, Wojdyla M, Vredenburg M, Cuker A. Adults with immune thrombocytopenia who switched to avatrombopag following prior treatment with eltrombopag or romiplostim: A multicentre US study. Br J Haematol 2022; 197:359-366. [PMID: 35179784 PMCID: PMC9306832 DOI: 10.1111/bjh.18081] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/15/2022] [Accepted: 01/26/2022] [Indexed: 12/12/2022]
Abstract
Patients with immune thrombocytopenia (ITP) may respond to one thrombopoietin receptor agonist (TPO-RA) but not another. Limited data are available describing outcomes in patients who switched from romiplostim or eltrombopag to avatrombopag, a newer oral TPO-RA. We performed a retrospective observational study of adults with ITP who switched from eltrombopag or romiplostim to avatrombopag at four US tertiary ITP referral centres. Forty-four patients were included, with a mean ITP duration of 8.3 years and a median (range) of four prior ITP treatments. On avatrombopag, 41/44 patients (93%) achieved a platelet response (≥50 × 109 /l) and 38/44 patients (86%) achieved a complete response (≥100 × 109 /l). In all patients, the median platelet count on eltrombopag or romiplostim was 44 × 109 /l vs 113 × 109 /l on avatrombopag (p < 0.0001); in patients switched for ineffectiveness of romiplostim/eltrombopag, it was 28 × 109 /l on romiplostim/eltrombopag vs 88 × 109 /l on avatrombopag (p = 0.025). Fifty-seven percent of patients receiving concomitant ITP medications before switching discontinued them after switching, including 63% of patients receiving chronic corticosteroids. In a heavily pretreated chronic ITP population, avatrombopag was effective following therapy with romiplostim or eltrombopag, with high response rates even in patients with inadequate response to a prior TPO-RA.
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Affiliation(s)
- Hanny Al-Samkari
- Division of Hematology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Debbie Jiang
- Division of Hematology, University of Washington, Seattle, Washington, USA.,Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - Terry Gernsheimer
- Division of Hematology, University of Washington, Seattle, Washington, USA.,Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - Howard Liebman
- Hematology, University of Southern California-Keck School of Medicine, California, Los Angeles, USA
| | - Susie Lee
- Hematology, University of Southern California-Keck School of Medicine, California, Los Angeles, USA
| | - Matthew Wojdyla
- Dova Pharmaceuticals, a Sobi company, Durham, North Carolina, USA
| | | | - Adam Cuker
- Department of Medicine and Department of Pathology & Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Dawwas GK, Leonard CE, Lewis JD, Cuker A. Risk for Recurrent Venous Thromboembolism and Bleeding With Apixaban Compared With Rivaroxaban: An Analysis of Real-World Data. Ann Intern Med 2022; 175:20-28. [PMID: 34871048 DOI: 10.7326/m21-0717] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Apixaban and rivaroxaban are replacing vitamin K antagonists for the treatment of venous thromboembolism (VTE) in adults; however, head-to-head comparisons remain limited. OBJECTIVE To assess the effectiveness and safety of apixaban compared with rivaroxaban in patients with VTE. DESIGN Retrospective new-user cohort study. SETTING U.S.-based commercial health care insurance database from 1 January 2015 to 30 June 2020. PARTICIPANTS Adults with VTE who were newly prescribed apixaban or rivaroxaban. MEASUREMENTS The primary effectiveness outcome was recurrent VTE, a composite of deep venous thrombosis and pulmonary embolism. The primary safety outcome was a composite of gastrointestinal and intracranial bleeding. RESULTS Of 49 900 eligible patients with VTE, 18 618 were new users of apixaban and 18 618 were new users of rivaroxaban. Median follow-up was 102 days (25th, 75th percentiles: 30, 128 days) among apixaban and 105 days (25th, 75th percentiles: 30, 140 days) among rivaroxaban users. After propensity score matching, apixaban (vs. rivaroxaban) was associated with a lower rate for recurrent VTE (hazard ratio, 0.77 [95% CI, 0.69 to 0.87]) and bleeding (hazard ratio, 0.60 [CI, 0.53 to 0.69]). The absolute reduction in the probability of recurrent VTE with apixaban versus rivaroxaban was 0.006 (CI, 0.005 to 0.011) within 2 months and 0.011 (CI, 0.011 to 0.013) within 6 months of initiation. The absolute reduction in the probability of gastrointestinal and intracranial bleeding with apixaban versus rivaroxaban was 0.011 (CI, 0.010 to 0.011) within 2 months and 0.015 (CI, 0.013 to 0.015) within 6 months of initiation. LIMITATION Short follow-up. CONCLUSION In this population-based cohort study, patients with VTE who were new users of apixaban had lower rates for recurrent VTE and bleeding than new users of rivaroxaban. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Ghadeer K Dawwas
- University of Pennsylvania, Philadelphia, Pennsylvania (G.K.D., C.E.L., J.D.L., A.C.)
| | - Charles E Leonard
- University of Pennsylvania, Philadelphia, Pennsylvania (G.K.D., C.E.L., J.D.L., A.C.)
| | - James D Lewis
- University of Pennsylvania, Philadelphia, Pennsylvania (G.K.D., C.E.L., J.D.L., A.C.)
| | - Adam Cuker
- University of Pennsylvania, Philadelphia, Pennsylvania (G.K.D., C.E.L., J.D.L., A.C.)
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45
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Viana R, D'Alessio D, Grant L, Cooper N, Arnold D, Morgan M, Provan D, Cuker A, Hill QA, Tomiyama Y, Ghanima W. Psychometric Evaluation of ITP Life Quality Index (ILQI) in a Global Survey of Patients with Immune Thrombocytopenia. Adv Ther 2021; 38:5791-5808. [PMID: 34704193 PMCID: PMC8572218 DOI: 10.1007/s12325-021-01934-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Accepted: 09/23/2021] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Immune thrombocytopenia (ITP) is an autoimmune disorder caused by immunologic destruction of otherwise normal platelets. Patients and physicians differ in their views pertaining to the limitations imposed on patients' daily lives by ITP and its treatment. Poor understanding of ITP symptoms can result in misdiagnosis and complex treatment patterns, and affect patient health-related quality of life (HRQoL). The ITP Life Quality Index (ILQI) is a 10-item patient-reported outcome measure developed for clinical practice to aid discussions between patients and physicians. This research aimed to validate the psychometric properties of the ILQI using data collected in the ITP World Impact Survey (I-WISh). METHODS I-WISh data containing responses to the ILQI from 1507 patients with ITP across 13 countries worldwide was subject to psychometric analysis to evaluate the structure, reliability and validity of the ILQI and assess scoring cut-offs. RESULTS The ILQI has an overarching unidimensional structure, supporting a total score including all 10 items. Reliability was supported (Cronbach's alpha = 0.90). ILQI scores monotonically increased with ITP severity. ILQI scores correlated with measures of fatigue and emotional well-being, supporting construct validity. Differential item functioning (DIF) analyses showed that ILQI item responses were interpreted similarly between the USA and other Western countries. It was suggested that previous clinical cut-off score of 20 for "impaired HRQoL" was reduced to 17 and a cut-off of 23-25 (rather than 30) was suggested to assess "significantly impaired HRQoL". CONCLUSION The validity and reliability of the ILQI to assess HRQoL of patients with ITP is supported. The revised cut-off scores for the ILQI will aid patient-centric decision-making.
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Affiliation(s)
| | | | - Laura Grant
- Adelphi Values Ltd, Adelphi Mill, Grimshaw Lane, Bollington, Cheshire, SK10 5JB, UK.
| | - Nichola Cooper
- Department of Haematology, Hammersmith Hospital, Imperial College London, London, UK
| | - Donald Arnold
- Department of Medicine, McMaster Centre for Transfusion Research, McMaster University, Hamilton, ON, Canada
| | | | - Drew Provan
- Academic Haematology Unit, Blizard Institute, Barts and The School of Medicine and Dentistry, London, UK
| | - Adam Cuker
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Quentin A Hill
- Leeds Teaching Hospital NHS Trust, St James' University Hospital, Leeds, UK
| | - Yoshiaki Tomiyama
- Department of Blood Transfusion, Osaka University Hospital, Suita, Japan
| | - Waleed Ghanima
- Ostfold Hospital Trust, Gralum, Norway
- Department of Hematology, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Dawwas GK, Barnes GD, Dietrich E, Cuker A, Leonard CE, Genuardi MV, Lewis JD. Cardiovascular and major bleeding outcomes with antiplatelet and direct oral anticoagulants in patients with acute coronary syndrome and atrial fibrillation: A population-based analysis. Am Heart J 2021; 242:71-81. [PMID: 34450051 DOI: 10.1016/j.ahj.2021.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/18/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are replacing warfarin for stroke prevention in patients with atrial fibrillation (AF). OBJECTIVE To assess the effectiveness and safety of concomitant treatment with antiplatelet-DOAC compared to antiplatelet-warfarin in patients with acute coronary syndrome (ACS) and AF. DESIGN Retrospective propensity score-matched cohort study using United States-based commercial healthcare database from January 2016 to June 2019. PARTICIPANTS New-users of antiplatelet-DOAC and antiplatelet-warfarin who initiated the combined therapy within 30 days following incident ACS diagnosis. MEASUREMENTS Primary study outcomes were recurrent cardiovascular diseases (CVD) (ie, a composite of stroke and myocardial infarction) and major bleeding events identified via discharge diagnoses. We controlled for potential confounders via propensity score matching (PSM). We generated marginal hazard ratios (HRs) via Cox proportional hazards regression using a robust variance estimator while adjusting for calendar time. RESULTS After PSM, a total of 2,472 persons were included (1,236 users of antiplatelet-DOAC and 1,236 users of antiplatelet-warfarin). The use of antiplatelet-DOAC (vs. antiplatelet-warfarin) was associated with a reduced rate of recurrent CVD (adjusted HR 0.72, 95% confidence interval [CI], 0.56-0.92) and major bleeding events (adjusted HR, 0.49, 95% CI 0.33-0.72). LIMITATIONS Residual confounding. CONCLUSIONS In real-world data of AF patients with concurrent ACS, the use of antiplatelet-DOAC following ACS diagnosis was associated with a lower rate of recurrent CVD and major bleeding events compared with antiplatelet-warfarin. These findings highlight a potential promising role for DOACs in patients with ACS and AF requiring combined antiplatelet therapy.
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Egert D, Jorge V, Cuker A, Varadi G. Falsely positive heparin-induced thrombocytopenia antibody testing in severe hyperbilirubinemia. Res Pract Thromb Haemost 2021; 5:e12608. [PMID: 34765859 PMCID: PMC8576178 DOI: 10.1002/rth2.12608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Revised: 09/20/2021] [Accepted: 10/06/2021] [Indexed: 11/30/2022] Open
Abstract
Heparin‐induced thrombocytopenia (HIT) is a life‐threatening pathologic reaction to heparin‐based products. Diagnosis of this condition can be confounded by other comorbidities or by acute illness—oftentimes presenting challenging clinical dilemmas, particularly in critically ill patients. A 67‐year‐old woman was admitted with liver failure and severe hyperbilirubinemia. She developed thrombocytopenia after prophylactic heparin exposure. Subsequent quantitative latex immunoturbidimetric assay (LIA) HIT antibody testing was intermediately positive. Confirmatory serotonin release assay testing subsequently returned negative. Platelet factor4–dependent P‐selectin expression assay also returned negative, suggesting false positivity of the initial LIA tests. Concern was raised that hyperbilirubinemia (total bilirubin, 55.5 mg/dL) interfered with the original assay. Further testing with a separate HIT ELISA assay, which includes multiple washes and dilutions of the serum in order to effectively remove bilirubin, returned negative. Medical providers must consider the possibility of false‐positive LIA testing when evaluating for HIT in the setting of severe hyperbilirubinemia.
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Affiliation(s)
- Daniel Egert
- Internal Medicine Albert Einstein Medical Center Philadelphia Pennsylvania USA
| | - Vinicius Jorge
- Hematology/Oncology Albert Einstein Medical Center Philadelphia Pennsylvania USA
| | - Adam Cuker
- Hematology/Oncology Perelman School of Medicine University of Pennsylvania Philadelphia Pennsylvania USA
| | - Gabor Varadi
- Hematology/Oncology Albert Einstein Medical Center Philadelphia Pennsylvania USA
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Dawwas GK, Barnes GD, Cuker A, Lewis JD. Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients With Valvular Atrial Fibrillation. Ann Intern Med 2021; 174:1490. [PMID: 34662171 DOI: 10.7326/l21-0565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Ghadeer K Dawwas
- Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James D Lewis
- Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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49
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Pishko AM, Cuker A. Thrombosis After Vaccination With Messenger RNA-1273: Is This Vaccine-Induced Thrombosis and Thrombocytopenia or Thrombosis With Thrombocytopenia Syndrome? Ann Intern Med 2021; 174:1468-1469. [PMID: 34181441 PMCID: PMC8251937 DOI: 10.7326/m21-2680] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
In their article, Sangli and colleagues described catastrophic thrombosis after the second dose of the SARS-CoV-2 messenger RNA–1273 vaccine from Moderna. The editorialists discuss vaccine-induced thrombosis and thrombocytopenia and thrombosis with thrombocytopenia syndrome and why this case cannot be definitively attributed to the vaccine. They also note that the remarkable speed with which clinicians and scientists have recognized this rare entity and developed evidence-based diagnosis and treatment guidelines should bolster public confidence in postlicensure vaccine safety monitoring.
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Affiliation(s)
- Allyson M Pishko
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Adam Cuker
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Khaja MS, Obi AT, Sharma AM, Cuker A, McCann SS, Thukral S, Matson JT, Hofmann LV, Charalel R, Kanthi Y, Meek ME, Meissner MH, White SB, Williams DM, Vedantham S. Optimal Medical Therapy Following Deep Venous Interventions: Proceedings from the Society of Interventional Radiology Foundation Research Consensus Panel. J Vasc Interv Radiol 2021; 33:78-85. [PMID: 34563699 DOI: 10.1016/j.jvir.2021.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 09/11/2021] [Accepted: 09/15/2021] [Indexed: 12/17/2022] Open
Abstract
The optimal medical management of patients following endovascular deep venous interventions remains ill-defined. As such, the Society of Interventional Radiology Foundation (SIRF) convened a multidisciplinary group of experts in a virtual Research Consensus Panel (RCP) to develop a prioritized research agenda regarding antithrombotic therapy following deep venous interventions. The panelists presented the gaps in knowledge followed by discussion and ranking of research priorities based on clinical relevance, overall impact, and technical feasibility. The following research topics were identified as high priority: 1) characterization of biological processes leading to in-stent stenosis/rethrombosis; 2) identification and validation of methods to assess venous flow dynamics and their effect on stent failure; 3) elucidation of the role of inflammation and anti-inflammatory therapies; and 4) clinical studies to compare antithrombotic strategies and improve venous outcome assessment. Collaborative, multicenter research is necessary to answer these questions and thereby enhance the care of patients with venous disease.
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Affiliation(s)
- Minhaj S Khaja
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health, Charlottesville, Virginia.
| | - Andrea T Obi
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Aditya M Sharma
- Division of Cardiovascular Medicine, Department of Medicine, University of Virginia Health, Charlottesville, Virginia
| | - Adam Cuker
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sara S McCann
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health, Charlottesville, Virginia
| | - Siddhant Thukral
- School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - John T Matson
- Division of Vascular and Interventional Radiology, Department of Radiology and Medical Imaging, University of Virginia Health, Charlottesville, Virginia
| | - Lawrence V Hofmann
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Resmi Charalel
- Department of Radiology, Division of Interventional Radiology, New York Presbyterian Hospital/Weill Cornell Medicine, New York, New York
| | - Yogendra Kanthi
- Laboratory of Vascular Thrombosis and Inflammation, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Mary E Meek
- Division of Interventional Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Mark H Meissner
- Department of Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Sarah B White
- Department of Radiology, Division of Vascular and Interventional Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David M Williams
- Division of Vascular and Interventional Radiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Suresh Vedantham
- Mallinckrodt Institute of Radiology, Washington University in St. Louis, St. Louis, Missouri
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