1
|
Arachchillage DJ, Kitchen S. Pleiotropic Effects of Heparin and its Monitoring in the Clinical Practice. Semin Thromb Hemost 2024. [PMID: 38810964 DOI: 10.1055/s-0044-1786990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
Unfractionated heparin (UFH) was uncovered in 1916, has been used as an anticoagulant since 1935, and has been listed in the World Health Organization's Model List of Essential Medicines. Despite the availability of many other anticoagulants, the use of heparin (either low molecular weight heparin [LMWH] or UFH) is still substantial. Heparin has pleotropic effects including anticoagulant and several nonanticoagulant properties such as antiproliferative, anti-inflammatory activity, and anticomplement effects. Although UFH has been widely replaced by LMWH, UFH is still the preferred anticoagulant of choice for patients undergoing cardiopulmonary bypass surgery, extracorporeal membrane oxygenation, and patients with high-risk mechanical cardiac valves requiring temporary bridging with a parenteral anticoagulant. UFH is a highly negatively charged molecule and binds many positively charged molecules, hence has unpredictable pharmacokinetics, and variable anticoagulant effect on an individual patient basis. Therefore, anticoagulant effects of UFH may not be proportional to the dose of UFH given to any individual patient. In this review, we discuss the anticoagulant and nonanticoagulant activities of UFH, differences between UFH and LMWH, when to use UFH, different methods of monitoring the anticoagulant effects of UFH (including activated partial thromboplastin time, heparin anti-Xa activity level, and activated clotting time), while discussing pros and cons related to each method and comparison of clinical outcomes in patients treated with UFH monitored with different methods based on available evidence.
Collapse
Affiliation(s)
- Deepa J Arachchillage
- Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, London, United Kingdom
- Department of Haematology, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Steve Kitchen
- Department of Coagulation, Royal Hallamshire Hospital, Sheffield, United Kingdom
| |
Collapse
|
2
|
Gibert A, Lanoiselée J, Gouin-Thibault I, Pontis A, Azarnoush K, Petrosyan A, Grand N, Molliex S, Morel J, Gergelé L, Hodin S, Bin V, Chaux R, Delavenne X, Ollier E. Factors Influencing Unfractionated Heparin Pharmacokinetics and Pharmacodynamics During a Cardiopulmonary Bypass. Clin Pharmacokinet 2024; 63:211-225. [PMID: 38169065 DOI: 10.1007/s40262-023-01334-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Unfractionated heparin (UFH) is commonly used during cardiac surgery with a cardiopulmonary bypass to prevent blood clotting. However, empirical administration of UFH leads to variable responses. Pharmacokinetic and pharmacodynamic modeling can be used to optimize UFH dosing and perform real-time individualization. In previous studies, many factors that could influence UFH pharmacokinetics/pharmacodynamics had not been taken into account such as hemodilution or the type of UFH. Few covariates were identified probably owing to a lack of statistical power. This study aims to address these limitations through a meta-analysis of individual data from two studies. METHODS An individual patient data meta-analysis was conducted using data from two single-center prospective observational studies, where different UFH types were used for anticoagulation. A pharmacodynamic/pharmacodynamic model of UFH was developed using a non-linear mixed-effects approach. Time-varying covariates such as hemodilution and fluid infusions during a cardiopulmonary bypass were considered. RESULTS Activities of UFH's anti-activated factor/anti-thrombin were best described by a two-compartment model. Unfractionated heparin clearance was influenced by body weight and the specific UFH type. Volume of distribution was influenced by body weight and pre-operative fibrinogen levels. Pharmacodynamic data followed a log-linear model, accounting for the effect of hemodilution and the pre-operative fibrinogen level. Equations were derived from the model to personalize UFH dosing based on the targeted activated clotting time level and patient covariates. CONCLUSIONS The population model effectively characterized UFH's pharmacokinetics/pharmacodynamics in cardiopulmonary bypass patients. This meta-analysis incorporated new covariates related to UFH's pharmacokinetics/pharmacodynamics, enabling personalized dosing regimens. The proposed model holds potential for individualization using a Bayesian estimation.
Collapse
Affiliation(s)
- Audrick Gibert
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France.
| | - Julien Lanoiselée
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Isabelle Gouin-Thibault
- Laboratory of Hematology, Pontchaillou, University Hospital of Rennes, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR_S 1085, Rennes, France
| | - Adeline Pontis
- Laboratory of Hematology, Pontchaillou, University Hospital of Rennes, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail)-UMR_S 1085, Rennes, France
| | - Kasra Azarnoush
- Service de Chirurgie Cardiaque, CHU de Saint-Etienne, Saint-Etienne, France
| | - Andranik Petrosyan
- Service de Chirurgie Cardiaque, CHU de Saint-Etienne, Saint-Etienne, France
| | - Nathalie Grand
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Serge Molliex
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Jérome Morel
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Laurent Gergelé
- Département d'Anesthésie-Réanimation, CHU de Saint-Etienne, Saint-Etienne, France
| | - Sophie Hodin
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
| | - Valérie Bin
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
| | - Robin Chaux
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
- Unité de Recherche Clinique Innovation et Pharmacologie, CHU de Saint-Etienne, Saint-Etienne, France
| | - Xavier Delavenne
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
- Laboratoire de Pharmacologie Toxicologie Gaz du sang, CHU de Saint-Etienne, Saint-Etienne, France
| | - Edouard Ollier
- INSERM, U1059, Dysfonction Vasculaire et Hémostase, 20 Rue Camelinat, 42000, Saint-Étienne, France
- Unité de Recherche Clinique Innovation et Pharmacologie, CHU de Saint-Etienne, Saint-Etienne, France
| |
Collapse
|
3
|
Lasne D, Toussaint-Hacquard M, Delassasseigne C, Bauters A, Flaujac C, Savard P, Mouton C, De Maistre E, Stepanian A, Eschwège V, Delrue M, Georges JL, Gros A, Mansour A, Leroy G, Jouffroy R, Mattei M, Beurton A, Pontis A, Neuwirth M, Nedelec-Gac F, Lecompte T, Curis E, Siguret V, Gouin-Thibault I. Factors Influencing Anti-Xa Assays: A Multicenter Prospective Study in Critically Ill and Noncritically Ill Patients Receiving Unfractionated Heparin. Thromb Haemost 2023; 123:1105-1115. [PMID: 37321244 DOI: 10.1055/s-0043-1770096] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND The presence of dextran sulfate (DS) in reagents and the type of blood collection tube (citrate/citrated-theophylline-adenosine-dipyridamole [CTAD]) can lead to discrepancies between unfractionated heparin (UFH) anti-Xa levels. OBJECTIVES To evaluate the extent of the effect (1) of different reagents containing or not containing DS and (2) of the blood collection tubes, on UFH anti-Xa levels, in various clinical situations (NCT04700670). METHODS We prospectively included patients from eight centers: group (G)1, cardiopulmonary bypass (CPB) after heparin neutralization (n = 39); G2, cardiothoracic intensive care unit (ICU) after CPB (n = 35); G3, medical ICU (n = 53); G4, other medical inpatients (n = 38). Blood was collected into citrated and CTAD tubes. Chromogenic anti-Xa assays were centrally performed, using seven reagent/analyzer combinations including two without DS. The association between anti-Xa levels and covariates was tested using a linear mixed-effects model. RESULTS We analyzed 4,546 anti-Xa values from 165 patients. Median anti-Xa levels were systematically higher with reagents containing DS, whatever the patient group, with the greatest effect observed in G1 (0.32 vs. 0.05 IU/mL). Anti-Xa levels were slightly higher in CTAD than in citrate samples, irrespective of the assay. The model showed: (1) a significant dextran-patient group interaction (p < 0.0001), the effect of DS on anti-Xa levels varying from 30.9% in G4 to 296% in G1, and (2) a significant effect of CTAD, varying between patient groups (p = 0.0302). CONCLUSION The variability of anti-Xa levels with a great overestimation of the values, using a reagent containing DS, can lead to different treatment decisions, especially after heparin neutralization by protamine. Clinical consequences of these differences remain to be demonstrated.
Collapse
Affiliation(s)
- Dominique Lasne
- AP-HP, Laboratoire d'hématologie générale, Hôpital Necker, INSERM, Univ. Paris-Saclay, Le Kremlin-Bicêtre, France
| | | | | | - Anne Bauters
- CHU Lille, Institut d'Hématologie-Transfusion, Lille, France
| | - Claire Flaujac
- Laboratoire de Biologie Médicale (Secteur Hémostase), Centre Hospitalier de Versailles, André Mignot, Le Chesnay, France
| | | | - Christine Mouton
- Laboratoire Hématologie, Hôpital Haut-Lévêque, CHU Bordeaux, France
| | | | - Alain Stepanian
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | | | - Maxime Delrue
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | - Jean-Louis Georges
- Service de réanimation medico-chirurgicale, Centre Hospitalier de Versailles, André Mignot, Le Chesnay, France
| | - Antoine Gros
- Service de réanimation medico-chirurgicale, Centre Hospitalier de Versailles, André Mignot, Le Chesnay, France
| | - Alexandre Mansour
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes; Univ Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
| | | | - Romain Jouffroy
- AP-HP, Service de réanimation adulte, Hôpital Necker, Paris, France
| | - Matthieu Mattei
- Unité d'Anesthésie et Réanimation Cardiaque & Réanimation Médicale Brabois, CHRU Nancy, Nancy, France
| | - Antoine Beurton
- Department of Cardiovascular Anaesthesia and Critical care, Surgical Medical Center Magellan, Haut-Lévêque Hospital, Pessac, France
| | - Adeline Pontis
- Hématologie Biologique, Hôpital Pontchaillou, University Hospital of Rennes, Univ. Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
| | - Marie Neuwirth
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | - Fabienne Nedelec-Gac
- Hématologie Biologique, Hôpital Pontchaillou, University Hospital of Rennes, Univ. Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
| | - Thomas Lecompte
- Department of Pharmacy, Faculté de médecine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), Université de Lorraine & Université de Namur, Namur, Belgium
- Hématologie Biologique, Hôpital Pontchaillou University Hospital of Rennes, Rennes, France
| | - Emmanuel Curis
- UR 7537 BioSTM, faculté de pharmacie de Paris, université Paris Cité, Paris, France
- Service d'Hématologie Biologique, Hôpital Lariboisière, AP-HP, Paris, France
| | - Virginie Siguret
- AP-HP, Service d'Hématologie Biologique, Hôpital Lariboisière, Paris Cité University, Paris, France
| | - Isabelle Gouin-Thibault
- Hématologie Biologique, Hôpital Pontchaillou, University Hospital of Rennes, Univ. Rennes, CHU Rennes, Inserm, IRSET, Rennes, France
| |
Collapse
|
4
|
Hardy M, Cabo J, Deliège A, Douxfils J, Gouin-Thibault I, Lecompte T, Mullier F. Reassessment of dextran sulfate in anti-Xa assay for unfractionated heparin laboratory monitoring. Res Pract Thromb Haemost 2023; 7:102257. [PMID: 38193053 PMCID: PMC10772882 DOI: 10.1016/j.rpth.2023.102257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/20/2023] [Accepted: 10/18/2023] [Indexed: 01/10/2024] Open
Abstract
Background Anti-Xa assays are used for unfractionated heparin (UFH) monitoring. Dextran sulfate (DS) is used in some assays to overcome the artifactual preanalytical release of platelet factor 4. However, the practical implications of this test modification have not been studied extensively. Objectives To investigate the impact of the presence of DS in the anti-Xa assay for UFH laboratory monitoring. Methods We studied factor Xa inhibition, using an assay without DS (Stago Liquid Anti-Xa), in normal pool plasma spiked with various concentrations of UFH (up to 1 IU/mL) in the presence of increasing concentrations of DS (up to 2560 μg/mL). We also investigated the effect of DS on FXa inhibition measured after the addition of UFH and heparin antagonists (protamine and Polybrene; Sigma Aldrich). Eventually, we compared the anti-Xa levels measured using the assay without DS to those measured with an assay containing DS (BIOPHEN Heparin LRT, Hyphen BioMed). Results DS per se had a detectable anti-Xa effect. FXa inhibition in UFH-spiked plasma linearly increased with increasing concentrations of added DS, with a plateau at approximately 160 μg/mL DS, at which the apparent anti-Xa level had almost doubled. In the presence of heparin antagonists, the addition of DS increased anti-Xa levels, corresponding to the dissociation of the UFH-antagonists complexes in vitro. With the anti-Xa assay containing DS, UFH inhibition was not detected. Conclusion In the presence of high concentrations of DS, FXa inhibition was much higher than that predicted from added UFH amounts, presumably related to the greater availability of UFH for interaction with antithrombin. While the relevance of measuring this "masked" heparin has not been demonstrated, the presence of DS renders the result inaccurate in the presence of protamine or Polybrene.
Collapse
Affiliation(s)
- Michael Hardy
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Hematology Laboratory, Yvoir, Belgium
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Department of Anesthesiology, Yvoir, Belgium
- Université catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Pôle Mont, Yvoir, Belgium
| | - Julien Cabo
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Hematology Laboratory, Yvoir, Belgium
| | - Antoine Deliège
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Hematology Laboratory, Yvoir, Belgium
| | - Jonathan Douxfils
- University of Namur, Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
- QUALIblood s.a., Namur, Belgium
| | | | - Thomas Lecompte
- University of Namur, Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
- CHU of Rennes, Department of Laboratory Hematology, IRSET-INSERM-1085, Rennes, France
- University of Lorraine, CHRU of Nancy, Nancy, France
| | - François Mullier
- CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Hematology Laboratory, Yvoir, Belgium
- Université catholique de Louvain, Institut de Recherche Expérimentale et Clinique, Pôle Mont, Yvoir, Belgium
- University of Namur, Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium
| |
Collapse
|
5
|
Gremillet M, Talon L, Lebreton A, Sinegre T. Monitoring heparin therapy: stability of two different anti-Xa assays using blood samples collected in citrate-containing and CTAD tubes. Thromb J 2023; 21:21. [PMID: 36803983 PMCID: PMC9942401 DOI: 10.1186/s12959-023-00465-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 02/11/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Anti-factor Xa assays and activated partial thromboplastin time (aPTT) are mainly employed to monitor patients treated with heparins. According to the Clinical and Laboratory Standards Institute and the French Working Group on Haemostasis and Thrombosis, anti-factor Xa activity and aPTT should be tested within 2 h of blood sampling for unfractionated heparin (UFH) monitoring. However, discrepancies exist depending on the used reagents and collecting tubes. The study aim was to determine the stability of aPTT and anti-factor Xa measurements using blood samples collected in citrate-containing or citrate-theophylline-adenosine-dipyridamole (CTAD) tubes and stored for up to 6 h. METHODS Patients receiving UFH or low molecular weight heparin (LMWH) were enrolled; aPTT and anti-factor Xa activity were tested using two different analyser/reagent pairs (Stago and reagent without dextran sulfate; Siemens and reagent with dextran sulfate) after 1, 4 and 6 h of sample storage as whole blood or as plasma. RESULTS For UFH monitoring, comparable anti-factor Xa activity and aPTT results were obtained with both analyser/reagent pairs when samples were stored as whole blood before plasma isolation. With samples stored as plasma, anti-factor Xa activity and aPTT were not affected up to 6 h after sampling when using the Stago/no-dextran sulfate reagent pair. With the Siemens/dextran sulfate-containing reagent, aPTT was significantly altered after 4 h of storage. For LMWH monitoring, anti-factor Xa activity remained stable (whole blood and plasma) for at least 6 h. Results were comparable with citrate-containing and CTAD tubes. CONCLUSIONS Anti-factor Xa activity in samples stored as whole blood or plasma was stable for up to 6 h, regardless of the reagent (with/without dextran sulfate)/collection tube. Conversely, aPTT was more variable because other plasma parameters can influence its measure and complicate the interpretation of its variations after 4 h.
Collapse
Affiliation(s)
- Marion Gremillet
- grid.411163.00000 0004 0639 4151CHU Clermont-Ferrand, Service d’hématologie Biologique, 1 Place Lucie Et Raymond Aubrac, 63003 Clermont-Ferrand, France
| | - Laurie Talon
- grid.411163.00000 0004 0639 4151CHU Clermont-Ferrand, Service d’hématologie Biologique, 1 Place Lucie Et Raymond Aubrac, 63003 Clermont-Ferrand, France
| | - Aurélien Lebreton
- grid.411163.00000 0004 0639 4151CHU Clermont-Ferrand, Service d’hématologie Biologique, 1 Place Lucie Et Raymond Aubrac, 63003 Clermont-Ferrand, France ,grid.494717.80000000115480420Université Clermont Auvergne, Unité de Nutrition Humaine, UMR INRAE/UCA 1019, Clermont-Ferrand, France
| | - Thomas Sinegre
- CHU Clermont-Ferrand, Service d'hématologie Biologique, 1 Place Lucie Et Raymond Aubrac, 63003, Clermont-Ferrand, France.
| |
Collapse
|
6
|
Dean CL. An Overview of Heparin Monitoring with the Anti-Xa Assay. Methods Mol Biol 2023; 2663:343-353. [PMID: 37204722 DOI: 10.1007/978-1-0716-3175-1_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Heparin remains a critical therapy in hospitalized patients requiring anticoagulation. Unfractionated heparin (UFH) mediates its therapeutic effect by binding to antithrombin (AT) and inhibiting thrombin and FXa, as well as other serine proteases. Because of its complex pharmacokinetics, monitoring UFH therapy is required, which is usually achieved with either the activated partial thromboplastin time (APTT) or the anti-factor Xa (anti-Xa) assay. Low molecular weight heparin (LMWH) is fast replacing UFH, as it has a more predictable response, negating the need for routine monitoring in most cases. When required, the anti-Xa assay is used for monitoring of LMWH. The APTT has many notable limitations when used for heparin therapeutic monitoring, including biologic, preanalytical, and analytical issues. With its increasing availability, the anti-Xa assay is appealing as it is less affected by patient factors (e.g., acute-phase reactants, lupus anticoagulants, consumptive coagulopathies), known to interfere with the APTT. The anti-Xa assay has shown additional benefits, such as faster time to achieve therapeutic levels, more consistent therapeutic levels, less dose adjustments, and, overall, less tests performed during therapy. However, poor interlaboratory agreement has been observed among anti-Xa reagents, highlighting that further work needs to be done to standardize this assay for use in patient heparin monitoring.
Collapse
|
7
|
What Do We Know about Thromboprophylaxis and Its Monitoring in Critically Ill Patients? Biomedicines 2021; 9:biomedicines9080864. [PMID: 34440068 PMCID: PMC8389559 DOI: 10.3390/biomedicines9080864] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/16/2021] [Accepted: 07/16/2021] [Indexed: 01/19/2023] Open
Abstract
Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, is an important complication in patients hospitalized in intensive care units (ICU). Thromboprophylaxis is mainly performed with Low Molecular Weight Heparin (LMWH) and, in some specific patients, with Unfractionated Heparin (UFH). These intensive units are an environment where individual patient variability is extreme and where traditional antithrombotic protocols are frequently ineffective. This was known for a long time, but the hospitalization of many patients with COVID-19 inflammatory storms suddenly highlighted this knowledge. It is therefore reasonable to propose variable antithrombotic prevention protocols based initially on a series of individual criteria (weight, BMI, and thrombotic risks). Secondly, they should be adjusted by the monitoring of anticoagulant activity, preferably by measuring the anti-Xa activity. However, we still face unresolved questions, such as once- or twice-daily LMWH injections, monitoring at the peak and/or trough, and poorly defined therapeutic targets. Equally surprisingly, we observed a lack of standardization of the anti-Xa activity kits.
Collapse
|
8
|
Amiral J, Amiral C, Dunois C. Optimization of Heparin Monitoring with Anti-FXa Assays and the Impact of Dextran Sulfate for Measuring All Drug Activity. Biomedicines 2021; 9:700. [PMID: 34205548 PMCID: PMC8235539 DOI: 10.3390/biomedicines9060700] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/08/2021] [Accepted: 06/16/2021] [Indexed: 11/22/2022] Open
Abstract
Heparins, unfractionated or low molecular weight, are permanently in the spotlight of both clinical indications and laboratory monitoring. An accurate drug dosage is necessary for an efficient and safe therapy. The one-stage kinetic anti-FXa assays are the most widely and universally used with full automation for large series, without needing exogenous antithrombin. The WHO International Standards are available for UFH and LMWH, but external quality assessment surveys still report a high inter-assay variability. This heterogeneity results from the following: assay formulation, designed without or with dextran sulfate to measure all heparin in blood circulation; calibrators for testing UFH or LMWH with the same curve; and automation parameters. In this study, various factors which impact heparin measurements are reviewed, and we share our experience to optimize assays for testing all heparin anticoagulant activities in plasma. Evidence is provided on the usefulness of low molecular weight dextran sulfate to completely mobilize all of the drug present in blood circulation. Other key factors concern the adjustment of assay conditions to obtain fully superimposable calibration curves for UFH and LMWH, calibrators' formulations, and automation parameters. In this study, we illustrate the performances of different anti-FXa assays used for testing heparin on UFH or LMWH treated patients' plasmas and obtained using citrate or CTAD anticoagulants. Comparable results are obtained only when the CTAD anticoagulant is used. Using citrate as an anticoagulant, UFH is underestimated in the absence of dextran sulfate. Heparin calibrators, adjustment of automation parameters, and data treatment contribute to other smaller differences.
Collapse
Affiliation(s)
| | - Cédric Amiral
- HYPHEN BioMed, 95000 Neuville sur Oise, France; (C.A.); (C.D.)
| | - Claire Dunois
- HYPHEN BioMed, 95000 Neuville sur Oise, France; (C.A.); (C.D.)
| |
Collapse
|
9
|
Schaefer B, Hausfeld A, Martin M, Steele P, Martin J, Reher SR, Lane A, Luchtman-Jones L. Impact of exogenous antithrombin on low molecular weight heparin anti-Xa activity assays in a pediatric and young adult leukemia and lymphoma cohort with variable antithrombin levels. Pediatr Blood Cancer 2020; 67:e28654. [PMID: 32841498 DOI: 10.1002/pbc.28654] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/30/2020] [Accepted: 07/22/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Low molecular weight heparin (LMWH) remains the most commonly prescribed pediatric anticoagulant. There is debate whether LMWH anti-Xa assays with or without exogenous antithrombin (AT) best reflect anticoagulation effect, and how much discrepancy exists between assay types. OBJECTIVES We assessed the effect of variable AT activity on LMWH anti-Xa levels in plasma samples from anticoagulated pediatric and young adult acute lymphoblastic leukemia and lymphoma (ALL/L) patients, using two instruments and their commercial kits with and without exogenous AT (ie, four platforms). METHODS We analyzed LMWH anti-Xa levels on 60 plasma samples with known AT activity from 12 enoxaparin-treated ALL/L patients, using four commercial kits from Siemens and Stago containing AT or not, on Siemens BCS and Stago STA R Max, respectively. RESULTS Of 236/240 samples with interpretable results, mean AT activity was 80% (46-138%). Correlation was acceptable for published kit ranges of LMWH anti-Xa levels when comparing kits containing AT (r = 0.82, P < .0001), or not (r = 0.93, P < .0001), and within a manufacturer (Berichrom to Innovance, r = 0.92, P < .0001; Stachrom to STA-Liquid Anti-Xa r = 0.98, P < .0001). LMWH anti-Xa levels were lower in platforms without added AT (P < .0001). For Stago kits, this effect increased when AT < 70% (P = .001, n = 19, mean 56%). Assay variability, measured as mean percent difference, was less pronounced with Stago kits (14.7%, n = 49) than Siemens (41.9%, n = 50). CONCLUSIONS Although LMWH levels from anti-Xa assays with added AT trend higher than in those without, correlation was fairly good between platforms in pediatric ALL/L plasmas, even when AT activity was <70%.
Collapse
Affiliation(s)
- Beverly Schaefer
- Department of Pediatric Hematology Oncology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.,Department of Pediatric Hematology and Oncology, Roswell Park Comprehensive Cancer Center, Buffalo, New York
| | - Adriane Hausfeld
- Cincinnati Children's Hospital Medical Center, Cancer and Blood Disease Institute, Cincinnati, Ohio
| | - Matthew Martin
- Cincinnati Children's Hospital Medical Center, Cancer and Blood Disease Institute, Cincinnati, Ohio
| | - Paul Steele
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pathology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Jan Martin
- Cincinnati Children's Hospital Medical Center, Cancer and Blood Disease Institute, Cincinnati, Ohio
| | - Sandra R Reher
- Division of Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Adam Lane
- Cincinnati Children's Hospital Medical Center, Cancer and Blood Disease Institute, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lori Luchtman-Jones
- Cincinnati Children's Hospital Medical Center, Cancer and Blood Disease Institute, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| |
Collapse
|
10
|
Smahi M, De Pooter N, Hollestelle MJ, Toulon P. Monitoring unfractionated heparin therapy: Lack of standardization of anti-Xa activity reagents. J Thromb Haemost 2020; 18:2613-2621. [PMID: 32573889 DOI: 10.1111/jth.14969] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/02/2020] [Accepted: 06/08/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION One of the main advantages of using anti-Xa instead of activated partial thromboplastin time in monitoring of unfractionated heparin (UFH) therapy relies on its hypothesized standardization, with a unique therapeutic range defined to be 0.30 to 0.70 IU/mL. The aim of the present study was to compare the inter-reagent agreement of anti-Xa activity. METHODS Citrate tubes were obtained from 104 inpatients on UFH. Plasma samples were stored frozen in aliquots at -70°C before being shipped to three accredited coagulation laboratories to be evaluated for anti-Xa activity using their routine assay(s). Pooled normal plasmas spiked with dilutions of the 6th International Standard of UFH to achieve anti-Xa activities up to 1.0 IU/mL were evaluated using the same techniques. RESULTS In the plasmas from patients on UFH, the median anti-Xa activity ranged from 0.37 IU/mL with one reagent to 0.57 IU/mL with another; results were in between (0.45 IU/mL) using two other reagents. Comparisons of results obtained using the different reagents demonstrated unacceptable bias up to 0.24 IU/mL between some reagents (41% difference). The concordance as whether anti-Xa activities measured using different reagents were within or outside the therapeutic range was between 0.411 and 0.939 (kappa). Similar discrepancy was demonstrated for anti-Xa activities when evaluating normal plasma spiked with the International Standard. A discrepancy of the same order of magnitude was demonstrated in the 2017 External Quality Assessment Program provided by the External Quality Control in Assays and Tests exercises. CONCLUSIONS The reported discrepancy between test results obtained using different anti-Xa assays clearly suggests a lack of standardization of that assay with potentially significant impact on the patients' anticoagulation.
Collapse
Affiliation(s)
- Motalib Smahi
- Hematology Department, Simone Veil Hospital, Eaubonne, France
| | | | - Martine J Hollestelle
- External quality Control for Assays and Tests (ECAT) Foundation, Voorschoten, The Netherlands
| | - Pierre Toulon
- Hematology Department, Université Côte d'Azur, CHU Nice, Nice, France
| |
Collapse
|
11
|
Billoir P, Clavier T, Guilbert A, Barbay V, Chrétien MH, Fresel M, Abriou C, Girault C, Le Cam Duchez V. Is citrate theophylline adenosine dipyridamole (CTAD) better than citrate to survey unfractionated heparin treatment? Has delayed centrifugation a real impact on this survey? J Thromb Thrombolysis 2020; 48:277-283. [PMID: 31098816 DOI: 10.1007/s11239-019-01882-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Unfractionated heparin (UFH) is the main anticoagulant used in intensive care unit. The anticoagulant effect is monitored by activated partial thrombin time (aPTT) and anti-Xa activity (anti-Xa) measurement. However, delayed centrifugation induces platelet factor 4 (PF4) release and anti-Xa decrease. Several studies have concluded that aPTT and anti-Xa measurement should be performed within 2 h in citrated anticoagulant but may be delayed longer in Citrate Theophylline Adenosine and Dypiridamol (CTAD) anticoagulant. The objective of this study was to compare the stability of both aPTT and anti-Xa in citrate and CTAD samples, and to determine the effect of delayed centrifugation on both aPTT, anti-Xa results, and PF4 release in citrate samples only. aPTT and anti-Xa were measured in citrate and CTAD anticoagulant samples from 93 patients. Delayed centrifugation was performed in citrate samples from 31 additional patients, with hourly aPTT and anti-Xa measurement from 1 to 6 h. In 14 of these last patients, PF4 release was also evaluated with Human CXCL4/PF4 Quantikine ELISA Kit. We observed a significant correlation between citrate and CTAD anticoagulant for aPTT (r2 = 0.94) and anti-Xa (r2 = 0.95). With Bland-Altman correlation, a minor bias was observed for anti-Xa (- 0.025 ± 0.041). Delayed centrifugation in citrated anticoagulant showed an excellent concordance from 1 to 4 h for aPTT (- 4.0 ± 5.3 s) and anti-Xa (1.10-9 ± 0.058 UI/ml) measurements. Moreover, PF4 release was not different between 1 h (31.5 ± 14.7 ng/ml) and 4 h (33.8 ± 11.8 ng/ml). We have demonstrated that anti-Xa measurement for unfractionated heparin should be done 4 h in citrated plasma and that CTAD was not better than citrate. However, these initial findings require confirmation using other aPTT and calibrated anti-Xa assays.
Collapse
Affiliation(s)
- Paul Billoir
- Rouen University Hospital, Vascular Hemostasis Unit, 76031, Rouen, France.
- Normandie Univ, UNIROUEN, INSERM U1096, Rouen, France.
- Service d'Hématologie Biologique, Centre hospitalier Universitaire Charles Nicolle, 1 rue de Germont, 76031, Rouen, France.
| | - Thomas Clavier
- Department of Anesthesiology and Critical Care, Rouen University Hospital, 76031, Rouen, France
- Univ Rouen, Inserm, U1096, 76000, Rouen, France
| | - Arnaud Guilbert
- Department of Anesthesiology and Critical Care, Rouen University Hospital, 76031, Rouen, France
| | - Virginie Barbay
- Rouen University Hospital, Vascular Hemostasis Unit, 76031, Rouen, France
| | | | - Marielle Fresel
- Rouen University Hospital, Vascular Hemostasis Unit, 76031, Rouen, France
| | - Caroline Abriou
- Department of Anesthesiology and Critical Care, Rouen University Hospital, 76031, Rouen, France
| | - Christophe Girault
- Department of Medical Intensive Care, Normandie Univ, Unirouen, UPRES EA-3830, Rouen, France
| | | |
Collapse
|
12
|
Ignjatovic V, Than J, Summerhayes R, Newall F, Horton S, Cochrane A, Monagle P. Hemostatic response in paediatric patients undergoing cardiopulmonary bypass surgery. Pediatr Cardiol 2011; 32:621-7. [PMID: 21360266 DOI: 10.1007/s00246-011-9929-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2010] [Accepted: 02/07/2011] [Indexed: 12/25/2022]
Abstract
This prospective, single-center cohort study aimed to evaluate the hemostatic response during and after Cardiopulmonary Bypass (CPB) surgery in a large cohort of children up to 6 years of age. Blood samples were drawn at eight time points: post-induction of anesthesia, pre-unfractionated heparin (UFH), post-UFH, post-initiation of bypass, pre-protamine, post-protamine, post-chest-closure, and 6 h post-chest-closure. As expected, all measures of the UFH effect increased significantly post-UFH bolus and decreased post-protamine administration. However, thrombin generation remained inhibited compared to baseline values despite the post-UFH reversal by protamine. We also demonstrate that residual UFH effect is not responsible for the ongoing inhibition of thrombin observed post-protamine administration. The significant increase in both free and total tissue factor pathway inhibitor levels during the CPB surgery might contribute to the persistent thrombin generation/endogenous thrombin potential inhibition post-protamine administration. This study makes a significant and novel contribution by investigating the physiological mechanisms behind the degree of thrombin inhibition by UFH and the residual levels of thrombin inhibition that continue despite protamine reversal and provides a new foundation for future interventional studies in the setting of paediatric CPB surgery.
Collapse
Affiliation(s)
- Vera Ignjatovic
- Haematology Research Laboratory, Murdoch Children's Research Institute, Flemington Road, Parkville, Melbourne, VIC 3052, Australia.
| | | | | | | | | | | | | |
Collapse
|
13
|
Honchel R, Carraway J, Gopee N, Callicott R, Chen J, Patton R, Xu Q, Zalkkar J, Laniyonu A, Krefting I, Cato M, Robie-Suh K, Rieves R. A dose-response study in animals to evaluate the anticoagulant effect of the stage 2 unfractionated heparin USP monograph change. Regul Toxicol Pharmacol 2011; 60:318-22. [PMID: 21549797 DOI: 10.1016/j.yrtph.2011.04.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 04/21/2011] [Accepted: 04/23/2011] [Indexed: 11/16/2022]
Abstract
The United States Pharmacopeia (USP) monograph for unfractionated heparin (UFH) was revised in October 2009. This revision was anticipated, based upon in vitro tests, to reduce UFH potency by approximately 10%. To study the potential in vivo consequences of the monograph change, we evaluated activated partial thromboplastin time (aPTT) and activated clotting time (ACT) responses in animals. Female mini-pigs and monkeys (n=8/species) were administered intravenously 60, 54, 48, or 42 U/kg and 50, 45, 40, or 35 U/kg "old" (pre-USP revision) UFH, respectively, in a Williams 4×4 crossover design. Blood samples for aPTT and ACT were collected at 15 min after dosing. The same study design was then repeated using "new" (post-USP revision) UFH. Mean "new" UFH aPTT and ACT values were generally lower than those for "old" UFH although individual animal responses varied considerably. The aPTT and ACT response was generally dose-proportional for both "old" and "new" UFH. These studies indicate that the USP monograph alteration for UFH may result in a modest reduction in the anticoagulant response across a population, but the variability in animal responses underscores the importance of individualization of clinical UFH dosing and the importance of anticoagulant test monitoring.
Collapse
Affiliation(s)
- R Honchel
- Division of Medical Imaging Products, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, MD 20993, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Heparinmonitoring. Hamostaseologie 2010. [DOI: 10.1007/978-3-642-01544-1_71] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
15
|
Liu M, Yue X, Dai Z, Ma Y, Xing L, Zha Z, Liu S, Li Y. Novel thrombo-resistant coating based on iron-polysaccharide complex multilayers. ACS APPLIED MATERIALS & INTERFACES 2009; 1:113-123. [PMID: 20355762 DOI: 10.1021/am800042v] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The biocompatibility of iron-polysaccharide complexes has been well-documented. Herein, a stable thrombo-resistant coating was fabricated by consecutive adsorption of Fe (III) and polysaccharides including heparin (Hep) and dextran sulfate (DS) onto various surface by layer-by-layer self-assembly technique via both electrostatic interaction and chemical complexation process. The absorbance at 350 nm increased linearly with the number of Fe3+/Hep multilayer, indicating the formation of multilayer structure and the uniform coating. Compared with (Fe3+/Hep)10, the (Fe3+/DS/Fe3+/Hep)5 coating was more hydrophilic and stable due to the incorporation of DS. The activated partial thromboplastin time (APTT) and platelet adhesion assays showed that both (Fe3+/Hep)10 and (Fe3+/DS/Fe3+/Hep)5 coated surfaces were anticoagulant. The complexing with ferric ions did not compromise the catalytic capacity of heparin to promote antithrombin(III)-mediated thrombin inactivation. Chromogenic assays for heparin activity proved definitively that the inhibition of locally produced thrombin was contributed to the thromboresistance of the surface-bound heparin. The surface with Hep or DS as the outmost layer showed stronger anticoagulant activity than Fe3+, indicating that the outermost layer of the coating played a key role in anticoagulant activity. The utilization of dextran sulfate/heparin surfaces was more advantageous than merely the heparin surface for improving blood-contacting medical devices for long-term usage.
Collapse
Affiliation(s)
- Meng Liu
- Nanomedicine and Biosensor Laboratory, Bio-X Center, and State Key Laboratory of Urban Water Resources and Environment (SKLUWRE), Harbin Institute of Technology, Harbin, China
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Ignjatovic V, Summerhayes R, Gan A, Than J, Chan A, Cochrane A, Bennett M, Horton S, Shann F, Lane G, Ross-Smith M, Monagle P. Monitoring Unfractionated Heparin (UFH) therapy: Which Anti Factor Xa assay is appropriate? Thromb Res 2007; 120:347-51. [PMID: 17118432 DOI: 10.1016/j.thromres.2006.10.006] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2006] [Revised: 10/09/2006] [Accepted: 10/10/2006] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Anti-Factor Xa (Anti-Xa) assays specifically determine the anticoagulant activity of UFH by measuring the ability of heparin-bound Antithrombin (AT) to inhibit a single enzyme, Factor Xa (FXa). Recent improvements in the automation, cost-effectiveness and accessibility of the assay to clinicians, have resulted in the Anti-Xa assay becoming a part of daily clinical practice in many institutions. OBJECTIVES We hypothesized that different Anti-Xa assays have different applicability for use in clinical settings, depending on the amount of UFH administered. This was investigated in a tertiary paediatric institution. MATERIALS AND METHODS Samples were collected from children receiving Low-dose of UFH of at least 10 IU/kg/h, with or without a previous bolus of up to 25 IU/kg/h, within the previous 6 h in the PICU and HDU. High-dose UFH population consisted of children undergoing Cardiac Catheterization (CC), who received a bolus of UFH of 100 IU/kg body weight, 30 min prior to sampling. RESULTS AND CONCLUSIONS The Anti-Xa activity for a given dose of UFH was found to vary significantly based on the Anti-Xa assay and the population being monitored. Our study suggests that the MODIFIED COMATIC Anti-Xa assay provides the best physiological measure of the UFH effect in children, as it does not introduce sources of error, such as exogenous AT, which may increase the measured ant Factor Xa activity, nor Dextran Sulphate which can displace plasma protein bound heparin and once again leading to falsely elevated assay results. Further studies that include assessment of clinical outcomes are required to confirm the applicability of use of this particular assay in monitoring UFH therapy.
Collapse
Affiliation(s)
- Vera Ignjatovic
- Department of Clinical Haematology, Royal Children's Hospital, Melbourne, Australia.
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|