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Melek M, Ari H, Ari S, Cilgin MC, Yarar M, Huysal K, Ağca FV, Bozat T. In vitro evaluation of anticoagulant therapy management when urgent percutaneous coronary intervention is required in rivaroxaban-treated patients. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2023; 396:3221-3232. [PMID: 37209152 DOI: 10.1007/s00210-023-02533-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 05/15/2023] [Indexed: 05/22/2023]
Abstract
We investigated in vitro the management of intraprocedural anticoagulation in patients requiring immediate percutaneous coronary intervention (PCI) while using regular direct oral anticoagulants (DOACs). Twenty-five patients taking 20 mg of rivaroxaban once daily comprised the study group, while five healthy volunteers included the control group. In the study group, a beginning (24 h after the last rivaroxaban dose) examination was performed. Then, the effects of basal and four different anticoagulant doses (50 IU/kg unfractionated heparin (UFH), 100 IU/kg UFH, 0.5 mg/kg enoxaparin, and 1 mg/kg enoxaparin) on coagulation parameters were investigated at the 4th and 12th h following rivaroxaban intake. The effects of four different anticoagulant doses were evaluated in the control group. The anticoagulant activity was assessed mainly by anti-factor Xa (anti-Xa) levels. Beginning anti-Xa levels were significantly higher in the study group than in the control group (0.69 ± 0.77 IU/mL vs. 0.20 ± 0.14 IU/mL; p < 0.05). The study group's 4th and 12th-h anti-Xa levels were significantly higher than the beginning level (1.96 ± 1.35 IU/mL vs. 0.69 ± 0.77 IU/mL; p < 0.001 and 0.94 ± 1.21 IU/mL vs. 0.69 ± 0.77 IU/mL; p < 0.05, respectively). Anti-Xa levels increased significantly in the study group with the addition of UFH and enoxaparin doses at the 4th and 12th h than the beginning (p < 0.001 at all doses). The safest anti-Xa level (from 0.94 ± 1.21 to 2.00 ± 1.02 IU/mL) was achieved 12 h after rivaroxaban with 0.5 mg/kg enoxaparin. Anticoagulant activity was sufficient for urgent PCI at the 4th h after rivaroxaban treatment, and additional anticoagulant administration may not be required at this time. Twelve hours after taking rivaroxaban, administering 0.5 mg/kg of enoxaparin may provide adequate and safe anticoagulant activity for immediate PCI. This experimental study result should confirm with clinical trials (NCT05541757).
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Affiliation(s)
- Mehmet Melek
- Department of Cardiology, Bursa Postgraduate Hospital, Bursa, Turkey
| | - Hasan Ari
- Department of Cardiology, Bursa Postgraduate Hospital, Bursa, Turkey.
| | - Selma Ari
- Department of Cardiology, Bursa Postgraduate Hospital, Bursa, Turkey
| | - Mehmet Can Cilgin
- Department of Cardiology, Bursa Postgraduate Hospital, Bursa, Turkey
| | - Mücahit Yarar
- Department of Cardiology, Bursa Postgraduate Hospital, Bursa, Turkey
| | - Kagan Huysal
- Department of Biochemistry, Bursa Postgraduate Hospital, Bursa, Turkey
| | | | - Tahsin Bozat
- Department of Cardiology, Bursa Postgraduate Hospital, Bursa, Turkey
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2
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Heubner L, Vicent O, Beyer-Westendorf J, Spieth PM. Bleeding management in patients with direct oral anticoagulants. Minerva Anestesiol 2023; 89:707-715. [PMID: 37079285 DOI: 10.23736/s0375-9393.23.17230-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Abstract
Bleeding events in patients under direct oral anticoagulation (DOAC) can be life-threating but are commonly not related to drug overdose. However, a relevant DOAC plasma concentration impairs the hemostasis and should therefore be ruled out immediately after hospital admission. The effect of DOAC is typically not visible in standard coagulation tests such as activated partial thrombin time or thromboplastin time. Specific anti-Xa or anti-IIa assays allow a specific drug monitoring, but they are too time-consuming in critical bleeding events and typically not available 24 h/7 d in routine care. Recent advantages in point-of-care (POC) testing might improve patient care by early exclusion of relevant DOAC levels, but sufficient validation is still lacking. POC urine analysis help to exclude DOAC in emergency patients, but does not provide a quantitative information about plasma concentration. POC viscoelastic testing (VET) can determine the DOAC effect on clotting time and helps further to reveal other concomitant bleeding disorders in emergency, e.g., factor deficiency or hyperfibrinolysis. If a relevant plasma concentration of the DOAC is assumed or was proven by either laboratory assays or POC testing, restoration of factor IIa or factor IIa activity is key for effective hemostasis. Limited evidence suggests that specific reversals for DOAC, e.g., idarucizumab for dabigatran and andexanet alfa for apixaban or rivaroxaban, might be superior to increasing thrombin generation by administration of prothrombin complex concentrates. To determinate, if DOAC reversal is indicated or not, time from last intake, anti-Xa/dTT values or results from POC tests can be considered. This experts' opinion provides a feasible decision algorithm for clinical practice.
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Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany -
| | - Oliver Vicent
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Jan Beyer-Westendorf
- Unit of Thrombosis Research, Division of Hematology and Hemostasis, Department of Medicine I, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany
| | - Peter M Spieth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Technische Universität Dresden (TU Dresden), Dresden, Germany
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3
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Burger A, Studt JD, Mendez A, Alberio L, Fontana P, Wuillemin WA, Schmidt A, Graf L, Gerber B, Bovet C, Sauter TC, Binder NB, Nagler M. Determination of Anti-Xa Inhibitor Plasma Concentrations Using a Universal Edoxaban Calibrator. Diagnostics (Basel) 2023; 13:2128. [PMID: 37371023 DOI: 10.3390/diagnostics13122128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 06/18/2023] [Accepted: 06/19/2023] [Indexed: 06/29/2023] Open
Abstract
A universal calibrator for the determination of all anti-Xa inhibitors would support laboratory processes. We aimed to test the clinical performance of an anti-Xa assay utilizing a universal edoxaban calibrator to determine clinically relevant concentrations of all anti-Xa inhibitors. Following a pilot study, we enrolled 553 consecutive patients taking rivaroxaban, edoxaban, or apixaban from nine study centers in a prospective cross-sectional study. The Technochrom® anti-Xa assay was conducted using the Technoview® edoxaban calibrator. Using ultra-high-performance liquid chromatography-tandem mass spectrometry (LC-MS/MS), anti-Xa inhibitor drug concentrations were determined. Sensitivities and specificities to detect three clinically relevant drug concentrations (30 µgL-1, 50 µgL-1, 100 µgL-1) were determined. Overall, 300 patients treated with rivaroxaban, 221 with apixaban, and 32 with edoxaban were included. The overall correlation coefficient (rs) was 0.95 (95% CI 0.94, 0.96). An area under the receiver operating characteristic curve of 0.96 for 30 µgL-1, 0.98 for 50 µgL-1, and 0.99 for 100 µgL-1 was found. The sensitivities were 92.3% (95% CI 89.2, 94.6), 92.7% (89.4, 95.1), and 94.8% (91.1, 97.0), respectively (specificities 82.2%, 93.7%, and 94.4%). In conclusion, the clinical performance of a universal, edoxaban-calibrated anti-Xa assay was solid and most drug concentrations were predicted correctly.
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Affiliation(s)
- Annika Burger
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University Hospital Zurich, University of Zurich, 8006 Zurich, Switzerland
| | - Adriana Mendez
- Institute for Laboratory Medicine, Kantonsspital Aarau, 5001 Aarau, Switzerland
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, Centre Hospitalier Universitaire Vaudois (CHUV), 1011 Lausanne, Switzerland
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospital, 1205 Geneva, Switzerland
| | - Walter A Wuillemin
- Division of Hematology, Hematology Laboratory, Cantonal Hospital of Lucerne, University of Bern, 3012 Bern, Switzerland
| | - Adrian Schmidt
- Institute of Laboratory Medicine, Clinic of Medical Oncology and Hematology, Municipal City Hospital Zurich Triemli, 8063 Zurich, Switzerland
| | - Lukas Graf
- Centre for Laboratory Medicine, 9001 St. Gallen, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, 6500 Bellinzona, Switzerland
| | - Cédric Bovet
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, 3010 Bern, Switzerland
| | - Nikolaus B Binder
- Technoclone Herstellung von Diagnostika und Arzneimitteln GmbH, 1230 Vienna, Austria
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, 3010 Bern, Switzerland
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Beyer-Westendorf J, Köhler C. Direct Oral Anticoagulants: Laboratory Challenges and Antidotes. Hamostaseologie 2023; 43:37-43. [PMID: 36807818 DOI: 10.1055/a-1987-3559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
The use of direct oral anticoagulants (DOACs) is increasing in patients needing treatment of venous thromboembolism (VTE) and stroke prevention in atrial fibrillation (SPAF). This is due to the net clinical benefit in comparison to vitamin K antagonists (VKAs). The rise in DOAC use is accompanied by a remarkable reduction in heparin and VKA prescriptions. However, this rapid change in anticoagulation patterns brought new challenges to patients, prescribers, laboratories, and emergency physicians. Patients have new liberties concerning nutritional habits and comedication and no longer need frequent monitoring or dose adjustments. Still, they have to comprehend that DOACs are potent anticoagulants that may cause or contribute to bleeding. Challenges for the prescriber include decision pathways for choosing the right anticoagulant and dosage for a specific patient and to change bridging practice in case of invasive procedures. Laboratory personnel are challenged by DOAC due to limited 24/7 availability of specific DOAC quantification tests and by the impact of DOAC on routine coagulation assays and thrombophilia tests. Challenges for the emergency physician result from the increasing age of DOAC anticoagulated patients, the difficulties to establish last intake of DOAC type and dosage, to interpret coagulation test results in emergency situations, and to make decisions for or against DOAC reversal strategies in acute bleeding or urgent surgery. In conclusion, although DOACs make long-term anticoagulation safer and more convenient for patients, DOACs pose challenge to all healthcare providers involved in anticoagulation decisions. The key to correct patient management and optimal outcome therefore lies in education.
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Affiliation(s)
- Jan Beyer-Westendorf
- Department of Medicine I, Universitätsklinikum "Carl Gustav Carus," Dresden, Germany
| | - Christina Köhler
- Department of Medicine I, Universitätsklinikum "Carl Gustav Carus," Dresden, Germany
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5
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The Role of Anti-Factor Xa Activity in the Management of Ecchymosis in Patients Receiving Rivaroxaban after Total Knee Arthroplasty. J Clin Med 2023; 12:jcm12031161. [PMID: 36769808 PMCID: PMC9917433 DOI: 10.3390/jcm12031161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/30/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023] Open
Abstract
This study aims to evaluate the efficacy of anti-factor Xa activity (aFXa) in predicting ecchymosis after total knee arthroplasty (TKA). One hundred and two unilateral primary TKA patients were recruited consecutively in this prospective observational study. Participants received rivaroxaban (10 mg p.o. qd) from postoperative day 1 (POD1) to POD35 and were divided into a non-ecchymosis group (group A) and an ecchymosis group (group B). AFXa was assessed as the primary outcome on POD1 and POD3. Prothrombin time (PT), activated partial thromboplastin time (APTT) and thromboelastography (TEG) were recorded both preoperatively and postoperatively (on POD1 and POD3). Other outcomes, including venous thromboembolism (VTE), blood loss and wound complications were also collected and compared. As a result, 27.5% of the participants (n = 28) were allocated into group B. Demographic data were comparable between the two groups. The aFXa levels in group B were significantly higher than those in group A on POD1 and POD3, and the aFXa level was assessed as an independent risk factor for ecchymosis. The cut-off value of aFXa was determined to be 121.38 ng/mL at maximal Youden index, associated with area under the receiver operating characteristics curve of 0.67. Group B experienced significantly more blood loss and wound complications than group A. No statistical difference was detected regarding PT, APTT and TEG parameters. AFXa is a promising parameter to predict ecchymosis after TKA. Patients with aFXa > 121.38 ng/mL should be considered as high-risk population for postoperative ecchymosis and may require intense monitoring or dosage modification of anticoagulants.
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6
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Meihandoest T, Studt JD, Mendez A, Alberio L, Fontana P, Wuillemin WA, Schmidt A, Graf L, Gerber B, Amstutz U, Bovet C, Sauter TC, Asmis LM, Nagler M. Accuracy of a Single, Heparin-Calibrated Anti-Xa Assay for the Measurement of Rivaroxaban, Apixaban, and Edoxaban Drug Concentrations: A Prospective Cross-Sectional Study. Front Cardiovasc Med 2022; 9:817826. [PMID: 35369293 PMCID: PMC8969025 DOI: 10.3389/fcvm.2022.817826] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/22/2022] [Indexed: 11/13/2022] Open
Abstract
Background Applying a single anti-Xa assay, calibrated to unfractionated heparin to measure rivaroxaban, apixaban, and edoxaban would simplify laboratory procedures and save healthcare costs. Aim We hypothesized that a heparin-calibrated anti-Xa assay would accurately measure rivaroxaban, apixaban, and edoxaban drug concentrations and correctly predict clinically relevant drug levels. Methods This analysis is part of the Simple-Xa study, a prospective multicenter cross-sectional study conducted in clinical practice. Patients treated with rivaroxaban, apixaban, or edoxaban were included. Anti-Xa activity was measured using the Siemens INNOVANCE® Heparin assay. Drug concentrations were determined using ultra-high performance liquid chromatography-tandem mass spectrometry (LC-MS/MS). Cut-off levels were determined in a derivation dataset (50% of patients) and sensitivities and specificities were calculated in a verification dataset (50% of patients). Results Overall, 845 patients were available for analysis. Correlation coefficients (r s ) between the heparin-calibrated anti-Xa assay and drug concentrations were 0.97 (95% CI 0.97, 0.98) for rivaroxaban, 0.96 (0.96, 0.97) for apixaban, and 0.96 (0.94, 0.99) for edoxaban. The area under the receiver operating characteristics curve (ROC) was 0.99 for all clinically relevant drug concentrations. In the verification dataset, the sensitivity was 94.2% (95% CI 90.8-96.6) for 30 μg L-1, 95.8% (92.4-98.0) for 50 μg L-1, and 98.7% (95.5-99.9) for 100 μg L-1. Specificities were 86.3% (79.2-91.7), 89.8% (84.5-93.7), and 88.7% (84.2-92.2), respectively. Conclusion In a large prospective study in clinical practice, a strong correlation of heparin-calibrated anti-Xa measurements with LC-MS/MS results was observed and clinically relevant drug concentrations were predicted correctly.
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Affiliation(s)
- Tamana Meihandoest
- Department of Epidemiology, Maastricht University, Maastricht, Netherlands.,Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Jan-Dirk Studt
- Department of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Adriana Mendez
- Institute for Laboratory Medicine, Kantonsspital Aarau AG, Aarau, Switzerland
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, CHUV, Lausanne University Hospital, Lausanne, Switzerland
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospitals, Geneva, Switzerland
| | - Walter A Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne and University of Bern, Bern, Switzerland
| | - Adrian Schmidt
- Institute of Laboratory Medicine and Clinic of Medical Oncology and Hematology, City Hospital Zurich, Zurich, Switzerland
| | - Lukas Graf
- Center for Laboratory Medicine, St. Gallen, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Ursula Amstutz
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Cedric Bovet
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Lars M Asmis
- Centre for Perioperative Thrombosis and Haemostasis, Zurich, Switzerland
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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7
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Prospective cohort study on the use of low molecular weight heparin calibrated anti-Xa assay for measurement of direct oral Xa inhibitors in ex vivo patient samples. Pathology 2022; 54:599-605. [DOI: 10.1016/j.pathol.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 11/21/2022]
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8
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Perifanis V, Neokleous N, Tsakiris DA. Update on laboratory testing and hemostasis assessment in patients receiving direct oral anticoagulants (DOACs). THROMBOSIS UPDATE 2021. [DOI: 10.1016/j.tru.2021.100084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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9
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Willekens G, Studt JD, Mendez A, Alberio L, Fontana P, Wuillemin WA, Schmidt A, Graf L, Gerber B, Bovet C, Sauter TC, Nagler M. A universal anti-Xa assay for rivaroxaban, apixaban, and edoxaban measurements: method validation, diagnostic accuracy and external validation. Br J Haematol 2021; 193:1203-1212. [PMID: 33954979 PMCID: PMC8252105 DOI: 10.1111/bjh.17470] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 03/19/2021] [Indexed: 11/28/2022]
Abstract
A universal anti‐Xa assay for the determination of rivaroxaban, apixaban and edoxaban drug concentrations would simplify laboratory procedures and facilitate widespread implementation. Following two pilot studies analysing spiked samples and material from 698 patients, we conducted a prospective multicentre cross‐sectional study, including 867 patients treated with rivaroxaban, apixaban or edoxaban in clinical practice to comprehensively evaluate a simple, readily available anti‐Xa assay that would accurately measure drug concentrations and correctly predict relevant levels in clinical practice. Anti‐Xa activity was measured by an assay calibrated with low‐molecular‐weight heparin (LMWH) in addition to ultra‐high performance liquid chromatography‐tandem mass spectrometry (LC‐MS/MS). As an external validation, LMWH‐calibrated anti‐Xa activity was also determined in nine external laboratories. The LMWH‐calibrated anti‐Xa activity correlated strongly with rivaroxaban, apixaban or edoxaban drug levels [rs = 0·98, 95% confidence interval (CI) 0·98–0·98]. The sensitivity for the clinically relevant cut‐off levels of 30, 50 and 100 µg/l was 96·2% (95% CI 94·4–97·4), 96·4% (95% CI 94·4–97·7) and 96·7% (95% CI 94·3–98·1) respectively. Concordant results were obtained in the external validation study. In conclusion, a universal, LMWH‐calibrated anti‐Xa assay accurately measured rivaroxaban, apixaban and edoxaban concentrations and correctly predicted relevant drug concentrations in clinical practice.
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Affiliation(s)
- Guido Willekens
- Department of Epidemiology, Maastricht University, Maastricht, the Netherlands.,Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan-Dirk Studt
- Division of Medical Oncology and Hematology, University Hospital Zurich, Zurich, Switzerland
| | - Adriana Mendez
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Lorenzo Alberio
- Service and Central Laboratory of Hematology, Lausanne University Hospital (CHUV) and University of Lausanne, Lausanne, Switzerland
| | - Pierre Fontana
- Division of Angiology and Hemostasis, Geneva University Hospital, Geneva, Switzerland
| | - Walter A Wuillemin
- Division of Hematology and Central Hematology Laboratory, Cantonal Hospital of Lucerne, University of Bern, Bern, Switzerland
| | - Adrian Schmidt
- Institute of Laboratory Medicine and Clinic of Medical Oncology and Hematology, City Hospital Waid and Triemli, Zurich, Switzerland
| | - Lukas Graf
- Cantonal Hospital of St Gallen, St Gallen, Switzerland
| | - Bernhard Gerber
- Clinic of Hematology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Cedric Bovet
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Thomas C Sauter
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Michael Nagler
- Department of Clinical Chemistry, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.,Department of Hematology, Inselspital, Bern University Hospital, Bern, Switzerland
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10
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Current use of rivaroxaban in elderly patients with venous thromboembolism (VTE). J Thromb Thrombolysis 2021; 52:863-871. [PMID: 33674983 DOI: 10.1007/s11239-021-02415-5] [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] [Accepted: 02/16/2021] [Indexed: 12/12/2022]
Abstract
Venous thromboembolism (VTE), which is characterized by pulmonary embolism and deep vein thrombosis, has become a serious public concern. Notably, over half of the patients with VTE are over 70 years of age, but elderly patients are at high risk of anti-coagulation and bleeding, which increase with age. Moreover, risk factors and frailty also show a difference between elderly patients and ordinary patients diagnosed with VTE. Rivaroxaban is a direct inhibitor of activated factor Xa and has the advantage of predictable pharmacodynamics and pharmacokinetics, no coagulation monitoring, and few drug interactions. As a first-line therapy for VTE, this drug is more advantageous than traditional therapy and exhibits good efficacy and safety for ordinary patients. However, the effectiveness and safety of rivaroxaban in elderly patients have not been fully elucidated. This article reviewed the use of rivaroxaban in elderly patients, including drug interactions, monitoring, reversal agents of rivaroxaban, and the use of small dosages of rivaroxaban in elderly patients.
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11
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Zhang S, Xie J, Cao G, Lei Y, Huang Q, Pei F. Six-Dose Intravenous Tranexamic Acid Regimen Further Inhibits Postoperative Fibrinolysis and Reduces Hidden Blood Loss following Total Knee Arthroplasty. J Knee Surg 2021; 34:224-232. [PMID: 31434149 DOI: 10.1055/s-0039-1694768] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
There is no consensus regarding the ideal dosages and times of multiple-dose intravenous tranexamic acid (IV-TXA) administration in total knee arthroplasty (TKA). This study aimed to assess the effect of six-dose IV-TXA with the total dosage more than 6 g on postoperative fibrinolysis and hidden blood loss (HBL) after primary TKA. A total of 175 patients were randomized into three groups to receive placebo (group A), or a single preoperative dose of 20 mg/kg IV-TXA (group B), or six-dose IV-TXA from the beginning of the procedure to subsequent 24 hours with the total dosage more than 6 g (group C). The calculated HBL, maximum hemoglobin (Hb) drop, transfusion rate, and the incidence of thromboembolic events were compared among groups. The levels of fibrinolysis parameters in plasma including fibrin(-ogen) degradation products (FDP) and D-dimer were measured at six time points from preoperatively to 3-month postoperative period. The mean HBL and maximum Hb drop in group C (515.51 ± 245.79 mL, and 2.06 ± 0.73 g/dL, respectively) were significantly lower than those in groups B (756.06 ± 226.79 mL, p < 0.001; and 2.77 ± 0.78 g/dL, p < 0.001, respectively) and A (987.65 ± 275.38 mL, p < 0.001; and 3.49 ± 0.86 g/dL, p < 0.001, respectively). Such differences were also detected between groups A and B (p < 0.001 and p < 0.001, respectively). The levels of FDP and D-dimer in plasma were lower in group C than those in groups B and A on postoperative 24, 48, 72 hours (p < 0.001 for all). No episode of transfusion occurred, and the incidence of thromboembolic events were similar among groups (p > 0.05). The administration of six-dose IV-TXA during the first 24 hours resulted in reduced HBL following TKA without a measured increase in thromboembolic events.
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Affiliation(s)
- Shaoyun Zhang
- Department of Orthopedics, The Third Hospital of Mianyang Sichuan Mental Health Center, Mianyang, People's Republic of China.,Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Jinwei Xie
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Guorui Cao
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Yiting Lei
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Qiang Huang
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, People's Republic of China
| | - Fuxing Pei
- Department of Orthopedics, West China Hospital, Sichuan University, Chengdu, People's Republic of China
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12
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Maji D, Opneja A, Suster MA, Bane KL, Wilson BM, Mohseni P, Stavrou EX. Monitoring DOACs with a Novel Dielectric Microsensor: A Clinical Study. Thromb Haemost 2020; 121:58-69. [PMID: 32877954 DOI: 10.1055/s-0040-1715589] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND There are acute settings where assessing the anticoagulant effect of direct oral anticoagulants (DOACs) can be useful. Due to variability among routine coagulation tests, there is an unmet need for an assay that detects DOAC effects within minutes in the laboratory or at the point of care. METHODS We developed a novel dielectric microsensor, termed ClotChip, and previously showed that the time to reach peak permittivity (T peak) is a sensitive parameter of coagulation function. We conducted a prospective, single-center, pilot study to determine its clinical utility at detecting DOAC anticoagulant effects in whole blood. RESULTS We accrued 154 individuals: 50 healthy volunteers, 49 rivaroxaban patients, 47 apixaban, and 8 dabigatran patients. Blood samples underwent ClotChip measurements and plasma coagulation tests. Control mean T peak was 428 seconds (95% confidence interval [CI]: 401-455 seconds). For rivaroxaban, mean T peak was 592 seconds (95% CI: 550-634 seconds). A receiver operating characteristic curve showed that the area under the curve (AUC) predicting rivaroxaban using T peak was 0.83 (95% CI: 0.75-0.91, p < 0.01). For apixaban, mean T peak was 594 seconds (95% CI: 548-639 seconds); AUC was 0.82 (95% CI: 0.73-0.91, p < 0.01). For dabigatran, mean T peak was 894 seconds (95% CI: 701-1,086 seconds); AUC was 1 (p < 0.01). Specificity for all DOACs was 88%; sensitivity ranged from 72 to 100%. CONCLUSION This diagnostic study using samples from "real-world" DOAC patients supports that ClotChip exhibits high sensitivity at detecting DOAC anticoagulant effects in a disposable portable platform, using a miniscule amount of whole blood (<10 µL).
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Affiliation(s)
- Debnath Maji
- Department of Electrical, Computer, and Systems Engineering, Case Western Reserve University, Cleveland, Ohio, United States
| | - Aman Opneja
- Hematology and Oncology Division, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States.,Division of Hematology-Oncology, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Michael A Suster
- Department of Electrical, Computer, and Systems Engineering, Case Western Reserve University, Cleveland, Ohio, United States
| | - Kara L Bane
- Division of Hematology-Oncology, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Brigid M Wilson
- Geriatric Research Education and Clinical Center, Louis Stokes Cleveland Veterans Administration Medical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States.,Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Pedram Mohseni
- Department of Electrical, Computer, and Systems Engineering, Case Western Reserve University, Cleveland, Ohio, United States
| | - Evi X Stavrou
- Division of Hematology-Oncology, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States.,Section of Hematology-Oncology, Department of Medicine, Louis Stokes Cleveland Veterans Administration Medical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States
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13
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Margetić S, Ćelap I, Delić Brkljačić D, Pavlović N, Šupraha Goreta S, Kobasić I, Lovrenčić-Huzjan A, Bašić Kes V. Chromogenic anti-FXa assay calibrated with low molecular weight heparin in patients treated with rivaroxaban and apixaban: possibilities and limitations. Biochem Med (Zagreb) 2019; 30:010702. [PMID: 31839722 PMCID: PMC6904970 DOI: 10.11613/bm.2020.010702] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 09/15/2019] [Indexed: 12/05/2022] Open
Abstract
Introduction Clinical application of rivaroxaban and apixaban does not require therapeutic monitoring. Commercial anti-activated factor X (anti-FXa) inhibition methods for all anti-FXa drugs are based on the same principle, so there are attempts to evaluate potential clinical application of heparin-calibrated anti-FXa assay as an alternative method for direct FXa inhibitors. We aimed to evaluate relationship between anti-FXa methods calibrated with low molecular weight heparin (LMWH) and with drug specific calibrators, and to determine whether commercial LMWH anti-FXa assay can be used to exclude the presence of clinically relevant concentrations of rivaroxaban and apixaban. Materials and methods Low molecular weight heparin calibrated reagent (Siemens Healthineers, Marburg, Germany) was used for anti-FXa activity measurement. Innovance heparin (Siemens Healthineers, Marburg, Germany) calibrated with rivaroxaban and apixaban calibrators (Hyphen BioMed, Neuville-sur-Oise, France) was used for quantitative determination of FXa inhibitors. Results Analysis showed good agreement between LMWH calibrated and rivaroxaban calibrated activity (κ = 0.76) and very good agreement with apixaban calibrated anti-Xa activity (κ = 0.82), respectively. Low molecular weight heparin anti-FXa activity cut-off values of 0.05 IU/mL and 0.1 IU/mL are suitable for excluding the presence of clinically relevant concentrations (< 30 ng/mL) of rivaroxaban and apixaban, respectively. Concentrations above 300 ng/mL exceeded upper measurement range for LMWH anti-FXa assay and cannot be determined by this method. Conclusion Low molecular weight heparin anti-FXa assay can be used in emergency clinical conditions for ruling out the presence of clinically relevant concentrations of rivaroxaban and apixaban. However, use of LMWH anti-FXa assay is not appropriate for their quantitative determination as an interchangeable method.
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Affiliation(s)
- Sandra Margetić
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Ivana Ćelap
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Diana Delić Brkljačić
- Department of Cardiovascular Diseases, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Nikola Pavlović
- Department of Cardiovascular Diseases, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Sandra Šupraha Goreta
- Department of Biochemistry and Molecular Biology, Faculty of Pharmacy and Biochemistry, University of Zagreb, Croatia
| | - Ivana Kobasić
- Department of Neurology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | | | - Vanja Bašić Kes
- Department of Neurology, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
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14
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Standard coagulation assays alone are not sufficient to exclude surgically relevant rivaroxaban plasma concentrations. Perioper Med (Lond) 2019; 8:15. [PMID: 31832179 PMCID: PMC6864962 DOI: 10.1186/s13741-019-0128-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 10/16/2019] [Indexed: 11/10/2022] Open
Abstract
Background While mainly larger hospitals have introduced routine anti-Xa assays for rivaroxaban (RXA), these are not readily available to smaller hospitals often relying on routine coagulation tests such as prothrombin time (PT) and activated partial thromboplastin time (aPTT). The aim of our study was to investigate the effect of RXA plasma concentration on the standard coagulation tests PT (Quick test and INR) and aPTT in a large group of real-life patients. We further assessed whether normal results of these standard coagulation assays are sufficient to exclude surgically relevant RXA plasma concentration, defined as > 50 mcg/l. Methods This retrospective study included all patients between 2012 and 2016 where anti-Xa (calibrated for RXA), PT (Quick test and INR), and/or aPTT were determined from the same sample. PT is expressed as Quick value (% of normal plasma pool). In total, 1027 measurements in 622 patients were eligible for analysis: 752 measurements of 505 patients for Quick/INR and 594 measurements of 417 patients for aPTT. Results A moderate correlation of PT/Quick (Pearson's correlation coefficient − 0.59; p < 0.001), INR (Pearson's correlation coefficient 0.5; p < 0.001), and aPTT (Pearson's correlation coefficient 0.53; p < 0.001) with RXA plasma concentration was observed. However, in 50% of all samples with a normal PT/Quick, in 25% of all samples with a normal INR and in 80% of all samples with a normal aPTT residual RXA plasma concentration was surgically relevant. Conclusion Although a moderate correlation of RXA plasma concentration with PT/Quick, INR, and aPTT was observed, standard coagulation assays are not sufficient to exclude surgically relevant RXA plasma concentrations.
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15
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Global thromboelastometry in patients receiving direct oral anticoagulants: the RO-DOA study. J Thromb Thrombolysis 2019; 49:251-258. [DOI: 10.1007/s11239-019-01956-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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16
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Mischke R, Teuber M, Tiede A. Measurements of endogenous thrombin potential using the CAT method in cats: Reference values and influence of the direct factor Xa inhibitor apixaban. Res Vet Sci 2019; 127:113-121. [PMID: 31693942 DOI: 10.1016/j.rvsc.2019.08.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 08/13/2019] [Accepted: 08/27/2019] [Indexed: 11/26/2022]
Abstract
The aim of this study was to establish a thrombin generation assay (calibrated automated thrombogram, CAT) in cats by determining the precision (repeatability), reference values, and the sensitivity to anticoagulant treatment with the factor Xa inhibitor apixaban. The CAT method was performed on citrated plasma with different commercial tissue factor (TF) reagents (PPP Reagent 1 pM [LOW], PPP Reagent 5 pM, PPP Reagent 20 pM [HIGH]) according to the manufacturers` test instruction. Measurements in triplicate were performed in platelet poor plasma (PPP) of 58 healthy cats and in 6 cats at different times following the oral administration of 2.5 mg apixaban. The median CVs in healthy cats usually were < 10% with the exception of thrombin peak height measured using PPP Reagent 1 pM (14.6%). Reference values of all parameters showed marked inter-individual variability and depended largely on the TF concentration of the used activating reagent. Thrombin generation was significantly influenced by apixaban and reacted more sensitively than other tests of haemostasis including the prothrombin time, aPTT, and rotational elastometry. In conclusion, thrombin generation measured by the CAT method using commercially available reagents seems suitable for the examination of feline PPP and may be a valuable method to establish effective anticoagulant therapies for the feline patient and monitoring of such therapies in cats.
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Affiliation(s)
- Reinhard Mischke
- Small Animal Clinic, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, D-30559 Hannover, Germany.
| | - Maike Teuber
- Small Animal Clinic, University of Veterinary Medicine Hannover, Foundation, Bünteweg 9, D-30559 Hannover, Germany
| | - Andreas Tiede
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany.
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17
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Spahn DR, Bouillon B, Cerny V, Duranteau J, Filipescu D, Hunt BJ, Komadina R, Maegele M, Nardi G, Riddez L, Samama CM, Vincent JL, Rossaint R. The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:98. [PMID: 30917843 PMCID: PMC6436241 DOI: 10.1186/s13054-019-2347-3] [Citation(s) in RCA: 663] [Impact Index Per Article: 132.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Accepted: 02/06/2019] [Indexed: 12/24/2022]
Abstract
Background Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources. Methods The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were re-examined and revised based on scientific evidence that has emerged since the previous edition and observed shifts in clinical practice. New recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. Results Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group’s belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms. Conclusions A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient. Electronic supplementary material The online version of this article (10.1186/s13054-019-2347-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Donat R Spahn
- Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Bertil Bouillon
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Vladimir Cerny
- Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, CZ-40113, Usti nad Labem, Czech Republic.,Centre for Research and Development, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic, Sokolska 581, CZ-50005, Hradec Kralove, Czech Republic.,Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine in Hradec Kralove, Charles University, Simkova 870, CZ-50003, Hradec Kralove, Czech Republic.,Department of Anaesthesia, Pain Management and Perioperative Medicine, QE II Health Sciences Centre, Dalhousie University, Halifax, 10 West Victoria, 1276 South Park St, Halifax, NS, B3H 2Y9, Canada
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, F-94275, Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, RO-022328, Bucharest, Romania
| | - Beverley J Hunt
- King's College and Departments of Haematology and Pathology, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Radko Komadina
- Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty Ljubljana University, SI-3000, Celje, Slovenia
| | - Marc Maegele
- Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109, Cologne, Germany
| | - Giuseppe Nardi
- Department of Anaesthesia and ICU, AUSL della Romagna, Infermi Hospital Rimini, Viale Settembrini, 2, I-47924, Rimini, Italy
| | - Louis Riddez
- Department of Surgery and Trauma, Karolinska University Hospital, S-171 76, Solna, Sweden
| | - Charles-Marc Samama
- Hotel-Dieu University Hospital, 1, place du Parvis de Notre-Dame, F-75181, Paris Cedex 04, France
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070, Brussels, Belgium
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
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Park SH, Seo YH, Park PW, Kim KH, Seo JY, Lee HT, Kwoun WJ, Ahn JY. Evaluation of global laboratory methods and establishing on-therapy ranges for monitoring apixaban and rivaroxaban: Experience at a single institution. J Clin Lab Anal 2019; 33:e22869. [PMID: 30860622 PMCID: PMC6595315 DOI: 10.1002/jcla.22869] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 02/01/2019] [Accepted: 02/03/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Apixaban and rivaroxaban are approved for the prevention and treatment of deep vein thrombosis (DVT), pulmonary embolism (PE), and embolic stroke in atrial fibrillation (AF) patients. The aim of this study was to find appropriate methods of monitoring the anticoagulant effects of are direct oral anticoagulants (DOACs) and establish on-therapy ranges using conventional tests. METHODS A total of 184 samples were collected from 91 patients receiving DOACs. Concentrations of apixaban and rivaroxaban in plasma were accessed by an anti-factor Xa chromogenic assay. PT, APTT, antithrombin, D-dimer, dRVVT screen/confirm, FDP, and fibrinogen levels were measured. On-therapy ranges were calculated by substituting previously reported trough plasma concentrations of DOACs. RESULTS Anti-factor Xa chromogenic assay-based DOACs levels were 26.0-279.5 (115.9 ± 56.5) ng/mL for apixaban at 2.5 mg BID, 19.9-565.1 (205.3 ± 162.4) ng/mL for apixaban at 5 mg BID, 2.3-395.3 (205.3 ± 162.4) ng/mL for rivaroxaban at 15 mg OD, 3.6-494.8 (119.6 ± 95.1) ng/mL for rivaroxaban at 20 mg OD, and 9.6-431.4 (140.8 ± 113.6) ng/mL for rivaroxaban at 15 mg BID. PT (%), antithrombin, and dRVVT confirm tests showed good correlation with plasma apixaban levels. Plasma rivaroxaban concentrations were correlated well with PT (sec), PT (%),and dRVVT confirm results. On-therapy ranges established for dRVVT confirm test by linear regression were as follows: 1.32-1.52 for apixaban 2.5 mg BID, 1.12-1.75 for apixaban 5 mg BID, 1.11-1.78 for rivaroxaban 15 mg OD, 1.09-1.64 for rivaroxaban 20 mg OD, and 1.22-1.81 for rivaroxaban 20 mg BID. CONCLUSIONS Apixaban concentrations were well correlated with PT (%), antithrombin, and dRVVT confirm test. Rivaroxaban concentrations showed good correlation with PT (sec), PT (%), and dRVVT confirm test.
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Affiliation(s)
- Soon Ho Park
- Department of Laboratory Medicine, Hongcheon Asan Hospital, Gangwon, Korea
| | - Yiel-Hea Seo
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Pil-Whan Park
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Kyung-Hee Kim
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Ja Young Seo
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hwan Tae Lee
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Woo-Jae Kwoun
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jeong-Yeal Ahn
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
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19
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Kröll D, Nett PC, Borbély YM, Schädelin S, Bertaggia Calderara D, Alberio L, Stirnimann G. The effect of bariatric surgery on the direct oral anticoagulant rivaroxaban: the extension study. Surg Obes Relat Dis 2018; 14:1890-1896. [DOI: 10.1016/j.soard.2018.08.025] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Revised: 08/20/2018] [Accepted: 08/27/2018] [Indexed: 01/06/2023]
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20
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Yao J, Feng B, Zhang Z, Li C, Zhang W, Guo Z, Zhao H, Zhou L. Blood Coagulation Testing Smartphone Platform Using Quartz Crystal Microbalance Dissipation Method. SENSORS 2018; 18:s18093073. [PMID: 30217015 PMCID: PMC6164724 DOI: 10.3390/s18093073] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 09/06/2018] [Accepted: 09/06/2018] [Indexed: 11/16/2022]
Abstract
Blood coagulation function monitoring is important for people who are receiving anticoagulation treatment and a portable device is needed by these patients for blood coagulation self-testing. In this paper, a novel smartphone based blood coagulation test platform was proposed. It was developed based on parylene-C coated quartz crystal microbalance (QCM) dissipation measuring and analysis. The parylene-C coating constructed a robust and adhesive surface for fibrin capturing. The dissipation factor was obtained by measuring the frequency response of the sensor. All measured data were sent to a smartphone via Bluetooth for dissipation calculation and blood coagulation results computation. Two major coagulation indexes, activated partial thromboplastin time (APTT) and prothrombin time (PT) were measured on this platform compared with results by a commercial hemostasis system in a clinical laboratory. The measurement results showed that the adjusted R-square (R2) value for APTT and PT measurements were 0.985 and 0.961 respectively. The QCM dissipation method for blood coagulation measurement was reliable and effective and the platform together with the QCM dissipation method was a promising solution for point of care blood coagulation testing.
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Affiliation(s)
- Jia Yao
- CAS Key Laboratory of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou 215163, China.
- School of Electronic and Information Engineering, Soochow University, Suzhou 215006, China.
| | - Bin Feng
- CAS Key Laboratory of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou 215163, China.
| | - Zhiqi Zhang
- CAS Key Laboratory of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou 215163, China.
| | - Chuanyu Li
- CAS Key Laboratory of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou 215163, China.
- University of Chinese Academy of Sciences, Beijing 100049, China.
| | - Wei Zhang
- CAS Key Laboratory of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou 215163, China.
| | - Zhen Guo
- CAS Key Laboratory of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou 215163, China.
| | - Heming Zhao
- School of Electronic and Information Engineering, Soochow University, Suzhou 215006, China.
| | - Lianqun Zhou
- CAS Key Laboratory of Bio-Medical Diagnostics, Suzhou Institute of Biomedical Engineering and Technology, Chinese Academy of Sciences, Suzhou 215163, China.
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Thom I, Cameron G, Robertson D, Watson HG. Measurement of rivaroxaban concentrations demonstrates lack of clinical utility of a PT, dPT and APTT test in estimating levels. Int J Lab Hematol 2018; 40:493-499. [PMID: 29718586 DOI: 10.1111/ijlh.12846] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 03/14/2018] [Indexed: 01/02/2023]
Abstract
INTRODUCTION Rivaroxaban concentrations were measured in 127 inpatient samples using an HPLC-MS/MS assay. METHODS We compared this measurement with a calibrated anti-Xa assay and performed PT, aPTT and dilute PT tests to assess the value of clot-based assays in clinical decision-making. RESULTS The correlation between the anti-Xa assay and the HPLC-MS/MS at therapeutic concentrations was strong (R2 = 0.98). The PT, RecombiPlasTin 2G, and aPTT, Actin FS, showed a linear dose-response but poor correlation (R2 = 0.32 and 0.44, respectively) and at dilutions of 1 in 150 to 1 in 750 the dilute PT assay also showed poor correlation with rivaroxaban concentrations measured by specific assays. A normal PT or aPTT alone did not identify a likely safe rivaroxaban concentration to allow surgery or invasive procedures, but the combination of normal PT and aPTT identified a group of patients with rivaroxaban levels less than 90 ng/mL. Combined normal PT and aPTT had specificity and sensitivity of 0.97 (95% CI 0.92-0.99) and 0.37 (95% CI 0.1-0.74) for a rivaroxaban concentration < 32 ng/mL. CONCLUSIONS The PT and aPTT show poor correlation with rivaroxaban levels measured by calibrated anti-Xa and HPLC-MS/MS assays. A normal combined PT and APTT identified low rivaroxaban levels with high specificity but lacked sensitivity. The dPT assay at several dilutions could not be used to quantify rivaroxaban in clinical samples. The utility of these PT, aPTT and dilute PT assays in a clinical setting is very limited, and results generated must be interpreted with caution.
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Affiliation(s)
- I Thom
- Department of Haematology, Aberdeen Royal Infirmary, Aberdeen, UK
| | - G Cameron
- Rowett Institute, University of Aberdeen, Aberdeen, UK
| | - D Robertson
- Laboratory Medicine IT Department, Aberdeen Royal Infirmary, Aberdeen, UK
| | - H G Watson
- Department of Haematology, Aberdeen Royal Infirmary, Aberdeen, UK
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22
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Tripodi A, Chantarangkul V, Legnani C, Testa S, Tosetto A. Interlaboratory variability in the measurement of direct oral anticoagulants: results from the external quality assessment scheme. J Thromb Haemost 2018; 16:565-570. [PMID: 29322630 DOI: 10.1111/jth.13949] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Indexed: 01/11/2023]
Abstract
Essentials Tests for direct oral anticoagulants (DOACs) are not widely applied. These tests are perceived to be difficult to run and subjected to large between-lab variation. We carried out proficiency testing surveys for DOAC testing in Italy. Interlab variability was small and similar to that of the international normalised ratio. SUMMARY Background Tests for direct oral anticoagulants (DOACs) are not widely available. The perception that they are difficult to perform and are subject to large between-laboratory variation makes their implementation difficult. Aims We carried out proficiency-testing surveys for DOACs within the activity of the external quality-assessment scheme of the Italian Federation of Thrombosis Centers. Design Participants were provided with coded freeze-dried plasmas without or with graded concentrations of the three main DOACs, and asked to measure prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time and DOAC concentrations with dedicated tests. The results were centralized for statistical analysis. Results and conclusions All participants (n = 235) reported results for PT and APTT, and approximately one-third reported results for DOAC concentration. PT and APTT showed variable responsiveness to DOACs: PT was more responsive to rivaroxaban than to dabigatran or apixaban. APTT was more responsive to dabigatran than to rivaroxaban or apixaban. The thrombin time ratio (test/normal) was close to unity for plasmas without dabigatran, and was high (i.e. 7.6-fold or 15.4-fold longer than the plasma free from the drug) for plasmas containing dabigatran at low (i.e. 42 ng mL-1 ) or high (i.e. 182 ng mL-1 ) concentration. Dedicated tests were responsive to the respective drugs, and their interlaboratory variability was relatively small (overall coefficients of variation of 8.7%, 8.4% or 10.3% for dabigatran, rivaroxaban and apixaban, respectively) and was comparable to that observed within the same survey for the International Normalized Ratio (i.e. 11.4%). In conclusion, tests for DOAC measurement performed reasonably well in a national quality-control scheme. Regulatory authorities should urgently issue recommendations on their use, and clinical laboratories should make them available.
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Affiliation(s)
- A Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy
- IRCCS Cà Granda Maggiore Hospital Foundation, Milan, Italy
| | - V Chantarangkul
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Milano, Italy
- IRCCS Cà Granda Maggiore Hospital Foundation, Milan, Italy
| | - C Legnani
- Department of Angiology and Blood Coagulation, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | - S Testa
- Hemostasis and Thrombosis Center, Department of Laboratory Medicine, AO Istituti Ospitalieri, Cremona, Italy
| | - A Tosetto
- Hematology Department, S. Bortolo Hospital, Vicenza, Italy
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Luscher TF, Steffel J. Vitamin K antagonists. Hamostaseologie 2017; 32:249-57. [DOI: 10.5482/ha-12050008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 08/28/2012] [Indexed: 11/05/2022] Open
Abstract
SummaryFor the last decades, anticoagulation for stroke prevention in atrial fibrillation (AF) as well as for the prophylaxis and long-term treatment of venous thromboembolism has been entirely based on vitamin K antagonists (VKA). Although very effective under optimal conditions, long-term treatment with these drugs is flawed by the fact that the time in the therapeutic range frequently is suboptimal due to biological factors, drug interactions and compliance.The direct thrombin inhibitor dabigatran, as well as the direct FXa inhibitors rivaroxaban and apixaban provide more consistent anticoagulation and have proven their efficacy and safety against VKAs in several large scale randomized clinical trials for stroke prevention in atrial fibrillation as well as for the treatment and prevention of venous thromboembolism. In view of these convincing data and other advantages such as the lack of mandatory monitoring and only few drug interactions,VKAs will most likely be replaced in a majority of patients for these indications. Based on the most recent trial evidence, the current review discusses the role of VKA treatmentand that of the novel anticoagulants.
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Kreutz R, Llau J, Norrving B, Haas S, Turpie A. Management consensus guidance for the use of rivaroxaban – an oral, direct factor Xa inhibitor. Thromb Haemost 2017; 108:876-86. [PMID: 23014816 DOI: 10.1160/th12-03-0209] [Citation(s) in RCA: 131] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Accepted: 08/22/2012] [Indexed: 12/31/2022]
Abstract
SummaryA number of novel oral anticoagulants that directly target factor Xa or thrombin have been developed in recent years. Rivaroxaban and apixaban (direct factor Xa inhibitors) and dabigatran etexilate (a direct thrombin inhibitor) have shown considerable promise in large-scale, randomised clinical studies for the management of thromboembolic disorders, and have been approved for clinical use in specific indications. Rivaroxaban is licensed for the prevention of venous thromboembolism in patients undergoing elective hip or knee replacement surgery, the treatment of deep-vein thrombosis and prevention of recurrent venous thromboembolism, and for stroke prevention in patients with non-valvular atrial fibrillation. Based on the clinical trial data for rivaroxaban, feedback on its use in clinical practice and the authors’ experience with the use of rivaroxaban, practical guidance for the use of rivaroxaban in special patient populations and specific clinical situations is provided. Although most recommendations are in line with the European summary of product characteristics for the approved indications, additional and, in several areas, different recommendations are given based on review of the literature and the authors’ clinical experience.
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Bailleul E, Chatelain B, Demulder A, Devreese K, Douxfils J, Jochmans K, Mullier F, Wijns W, Soumali MR, Coucke W, Vernelen K, Walle PVD, Blerk MV. Influence of dabigatran and rivaroxaban on routine coagulation assays. Thromb Haemost 2017; 113:154-64. [DOI: 10.1160/th14-02-0161] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 08/02/2014] [Indexed: 11/05/2022]
Abstract
SummaryThe Belgian national External Quality Assessment Scheme performed a nationwide survey using lyophilised plasma samples spiked with dabigatran or rivaroxaban to demonstrate to the Belgian clinical laboratories how these drugs affect their routine coagulation assays prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen and antithrombin. Virtually all Belgian laboratories performing routine coagulation testing (189/192) participated in the survey. Both, dabigatran and rivaroxaban significantly prolonged the PT and aPTT in a concentration- and reagent-dependent manner. PT reagents were more influenced by rivaroxaban than by dabigatran and aPTT reagents more influenced by dabigatran than by rivaroxaban. Among PT reagents, Neoplastin R® was the most sensitive to rivaroxaban and Innovin ® and Thromborel S® the least sensitive. Converting PT results to INR only increased the variability between reagents. Among aPTT reagents, Actin FSL® was the least sensitive to dabigatran while the other aPTT reagents showed slightly higher sensitivities. The presence of dabigatran led to falsely reduced fibrinogen concentrations when measured with a low thrombin concentration reagent. The presence of dabigatran caused an overestimation of the antithrombin level when measured with a thrombin-based activity assay and the presence of rivaroxaban an overestimation of the antithrombin level when measured with a FXa-based assay. Instrument-related differences were found for all tested parameters. In conclusion, this paper provides detailed information on the effect of dabigatran and rivaroxaban on routine coagulation assays as performed with a large number of reagent/instrument combinations.
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Hesse C, Stratmann G, Lindhoff-Last E, Mani H. Ex vivo effects of low-dose rivaroxaban on specific coagulation assays and coagulation factor activities in patients under real life conditions. Thromb Haemost 2017; 109:127-36. [DOI: 10.1160/th12-04-0228] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 09/13/2012] [Indexed: 01/28/2023]
Abstract
SummaryGlobal coagulation assays display variable effects at different concentrations of rivaroxaban. The aim of this study is to quantify the ex vivo effects of low-dose rivaroxaban on thrombophilia screening assays and coagulation factor activities based on the administration time, and to show how to mask possible interferences. Plasma samples from 40 patients receiving rivaroxaban 10 mg daily were investigated to measure activities of clotting factor II, V, VII, VIII, IX, XI, XII and XIII; protein C- and protein S-levels; lupus anticoagulants; anticardiolipin IgG and IgM; D-dimer, heparin-platelet factor 4 (HPF4) antibodies and screening tests for von Willebrand disease (VWD). Two hours after rivaroxaban administration, the activities of clotting factors were significantly decreased to different extents, except for factor XIII. Dilution of plasma samples resulted in neutralisation of these interferences. The chromogenic protein C activity assay was not affected by rivaroxaban. Depending on the timing of tablet intake in relation to blood sampling protein S activity was measured falsely high when a clotting assay was used. False-positive results for lupus anticoagulants were observed depending on the assay system used and the administration time of rivaroxaban. ELISA-based assays such as anticardiolipin IgG and IgM, D-dimer, HPF4-antibodies and the turbidimetric assays for VWD were not affected by rivaroxaban. Specific haemostasis clotting tests should be performed directly prior to rivaroxaban intake. Assay optimisation in the presence of rivaroxaban can be achieved by plasma dilution. Immunologic assays are not influenced by rivaroxaban, while chromogenic assays can be used, when they do not depend on factor Xa.
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Chatelain B, Chatelain C, Douxfils J, Dogné JM, Mullier F. Edoxaban: Impact on routine and specific coagulation assays. Thromb Haemost 2017; 115:368-81. [DOI: 10.1160/th15-05-0415] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 08/10/2015] [Indexed: 11/05/2022]
Abstract
SummaryAssessment of plasma concentration/effect of edoxaban may be useful in some situations. Also, clinicians need to know how routine coagulation assays are influenced. It was our aim to determine coagulation tests useful for the assessment of edoxaban’s pharmacodynamics and provide recommendations for the interpretation of haemostasis diagnostic tests. Edoxaban was spiked at concentrations ranging from 0 to 1,000 ng/ml in platelet-poor plasma which covers the on-therapy range (from ± 25 ng/ml at Ctrough to ± 170 ng/ml at Cmax). aPTT, PT, dRVVT, chromogenic anti-Xa assays, TGA and a large panel of haemostasis diagnostic tests were performed using several reagents. A concentration-dependent prolongation of aPTT, PT and dRVVT was observed. The effect was dependent on the reagents. FXa chromogenic assays showed high sensitivity and a linear correlation depending on the methodology. TGA may be useful to assess the pharmacodynamics of edoxaban but its turnaround time and the lack of standardisation are limitations. Edoxaban impairs the assessment of lupus anticoagulant, protein S (clotting method), APC-R, antithrombin (FXa-based assay) and measurement of clotting factor activity. Immunological assays and assays acting below the FXa are not influenced by edoxaban. In conclusion, some PT reagents could be used to estimate edoxaban activity. Chromogenic anti-Xa assays are required to assess the plasma concentration. TGA may be useful but requires standardisation. In case of thrombophilia or in the exploration of a haemorrhagic event, immunological assays should be recommended, when applicable. Standardisation of the time between the last intake and the sampling is mandatory to provide a proper assessment of the result.Supplementary Material to this article is available online at www.thrombosis-online.com.
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Rohde G, Stratmann G, Hesse C, Herth N, Schwers S, Perzborn E, Lindhoff-Last E, Mani H. Accurate determination of rivaroxaban levels requires different calibrator sets but not addition of antithrombin. Thromb Haemost 2017; 108:191-8. [DOI: 10.1160/th11-12-0832] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 04/07/2012] [Indexed: 01/12/2023]
Abstract
SummaryRivaroxaban is a direct factor Xa inhibitor, which can be monitored by anti-factor Xa chromogenic assays. This ex vivo study evaluated different assays for accurate determination of rivaroxaban levels. Eighty plasma samples from patients receiving rivaroxaban (Xarelto®) 10 mg once daily and 20 plasma samples from healthy volunteers were investigated using one anti-factor Xa assay with the addition of exogenous antithrombin and two assays without the addition of antithrombin. Two different lyophilised rivaroxaban calibration sets were used for each assay (low concentration set: 0, 14.5, 59.6 and 97.1 ng/ml; high concentration set: 0, 48.3, 101.3, 194.2 and 433.3 ng/ml). Using a blinded study design, the rivaroxaban concentrations determined by the assays were compared with concentrations measured by HPLC-MS/MS. All assays showed a linear relationship between the rivaroxaban concentrations measured by HPLC-MS/MS and the optical density of the anti-FXa assays. However, the assay with the addition of exogenous anti-thrombin detected falsely high concentrations of rivaroxaban even in plasma samples from controls who had not taken rivaroxaban (intercept values using the high calibrator set and the low calibrator set: +26.49 ng/ml and +13.71 ng/ml, respectively). Plasma samples, initially determined by the high calibrator setting and containing rivaroxaban concentrations <25 ng/ml, had to be re-run using the low calibrator setting for precise measurement. In conclusion, anti-factor Xa chromogenic assays that use rivaroxaban calibrators at different concentration levels can be used to measure accurately a wide range of rivaroxaban concentrations ex vivo. Assays including exogenous antithrombin are unsuitable for measurement of rivaroxaban.
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Hawes EM, Deal AM, Adcock DM, Gosselin R, Jeanneret C, Friedman KD, Moll S, Francart SJ. Performance of coagulation tests in patients on therapeutic doses of rivaroxaban. Thromb Haemost 2017; 111:1133-40. [DOI: 10.1160/th13-10-0871] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 12/10/2013] [Indexed: 01/28/2023]
Abstract
SummaryKnowledge of anticoagulation status during rivaroxaban therapy is desirable in certain clinical situations. It was the study objective to determine coagulation tests most useful for assessing rivaroxaban’s anticoagulant effect. Peak and trough blood samples from 29 patients taking rivaroxaban 20 mg daily were collected. Mass spectrometry and various coagulation assays were performed. “On-therapy range” was defined as the rivaroxaban concentrations determined by LC-MS/ MS. A “misprediction percentage” was calculated based on how often results of each coagulation assay were in the normal reference range, while the rivaroxaban concentration was in the “on-therapy” range. The on-therapy range was 8.9 – 660 ng/ml. The misprediction percentages for prothrombin time (PT) and activated partial thromboplastin time (aPTT), using multiple reagents and coagulometers, ranged from 10% – 52% and 31% – 59%, respectively. PT, aPTT and activated clotting time (ACT) were insensitive to trough rivaroxaban: 59%, 62%, and 80% of samples had a normal result, respectively. Over 95% of PT and ACT values were elevated at peak. Four different rivaroxaban calibrated anti-Xa assays had R2 values >0.98, demonstrating strong correlations with rivaroxaban drug levels. In conclusion, PT, aPTT and ACT are often normal in patients on therapeutic doses of rivaroxaban. However, PT and ACT may have clinical utility at higher drug plasma levels. Rivaroxaban calibrated anti-factor Xa assays can accurately identify low and high on-therapy rivaroxaban drug levels and, therefore, have superior utility in all clinical situations where assessment of anticoagulation status may be beneficial.This trial is registered at www.clinicaltrials.gov (#NCT01743898).
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Evaluation of dabigatran, rivaroxaban and apixaban target-specific assays in a multicenter French study. Thromb Res 2017; 158:126-133. [DOI: 10.1016/j.thromres.2017.09.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 08/08/2017] [Accepted: 09/01/2017] [Indexed: 01/04/2023]
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Studt JD, Alberio L, Angelillo-Scherrer A, Asmis LM, Fontana P, Korte W, Mendez A, Schmid P, Stricker H, Tsakiris DA, Wuillemin WA, Nagler M. Accuracy and consistency of anti-Xa activity measurement for determination of rivaroxaban plasma levels. J Thromb Haemost 2017; 15:1576-1583. [PMID: 28574652 DOI: 10.1111/jth.13747] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Indexed: 12/18/2022]
Abstract
Essentials Accurate determination of anticoagulant plasma concentration is important in clinical practice. We studied the accuracy and consistency of anti-Xa assays for rivaroxaban in a multicentre study. In a range between 50 and 200 μg L-1 , anti-Xa activity correlated well with plasma concentrations. The clinical value might be limited by overestimation and intra- and inter-individual variation. SUMMARY Background Determining the plasma level of direct oral anticoagulants reliably is important in the work-up of complex clinical situations. Objectives To study the accuracy and consistency of anti-Xa assays for rivaroxaban plasma concentration in a prospective, multicenter evaluation study employing different reagents and analytical platforms. Methods Rivaroxaban 20 mg was administered once daily to 20 healthy volunteers and blood samples were taken at peak and trough levels (clinicaltrials.gov NCT01710267). Anti-Xa activity was determined in 10 major laboratories using different reagents and analyzers; corresponding rivaroxaban plasma concentrations were measured by high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS). Findings Overall Pearson's correlation coefficient of anti-Xa levels and HPLC-MS results was 0.99 for Biophen® Heparin (95% CI, 0.99, 0.99), Biophen® DiXaI (95% CI, 0.99, 0.99) and STA® anti-Xa liquid (95% CI, 0.99, 1.00). Correlation was lower in rivaroxaban concentrations below 50 μg L-1 and above 200 μg L-1 . The overall bias of the Bland-Altman difference plot was 14.7 μg L-1 for Biophen Heparin, 17.9 μg L-1 for Biophen DiXal and 19.0 μg L-1 for STA anti-Xa liquid. Agreement between laboratories was high at peak level but limited at trough level. Conclusions Anti-Xa activity correlated well with rivaroxaban plasma concentrations, especially in a range between 50 and 200 μg L-1 . However, anti-Xa assays systematically overestimated rivaroxaban concentration as compared with HPLC-MS, particularly at higher concentrations. This overestimation, coupled with an apparent interindividual variation, might affect the interpretation of results in some situations.
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Affiliation(s)
- J-D Studt
- Division of Haematology, University Hospital and University of Zurich, Zurich, Switzerland
| | - L Alberio
- Service and Central Laboratory of Haematology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - A Angelillo-Scherrer
- Department of Haematology, Inselspital, Bern University Hospital, Berne, Switzerland
- Department of Clinical Research, University of Bern, Berne, Switzerland
| | | | - P Fontana
- Division of Angiology and Haemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - W Korte
- Institute for Clinical Chemistry and Haematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - A Mendez
- Centre for Laboratory Medicine, Cantonal Hospital Aarau, Aarau, Switzerland
| | - P Schmid
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, Lucerne, Switzerland
| | - H Stricker
- Division of Surgery, Regional Hospital La Carita, Locarno, Switzerland
| | - D A Tsakiris
- Diagnostic Haematology, University Hospital of Basel, Basel, Switzerland
| | - W A Wuillemin
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, Lucerne, Switzerland
- Department of Clinical Research, University of Berne, Berne, Switzerland
| | - M Nagler
- Department of Haematology, Inselspital, Bern University Hospital, Berne, Switzerland
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, Lucerne, Switzerland
- Department of Clinical Research, University of Berne, Berne, Switzerland
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Determination of edoxaban equivalent concentrations in human plasma by an automated anti-factor Xa chromogenic assay. Thromb Res 2017; 155:121-127. [PMID: 28535438 DOI: 10.1016/j.thromres.2017.05.005] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/28/2017] [Accepted: 05/06/2017] [Indexed: 11/20/2022]
Abstract
INTRODUCTION This phase I, open-label, multiple-dose, two-treatment study assessed the relationship between edoxaban equivalent concentration derived from an anti-FXa assay with the summed concentration of edoxaban and its active metabolite, M-4, as assessed by liquid chromatography coupled with tandem mass spectrometry (LC/MS/MS). This study also assessed the relationship between edoxaban plasma concentrations assessed by LC/MS/MS in sodium citrate and lithium heparin tubes. MATERIALS AND METHODS Healthy volunteers were randomized to receive once-daily edoxaban 60mg or 90mg for 5days (15 participants per treatment group). Serial blood samples were collected for analysis by LC/MS/MS and by the anti-FXa assay. Edoxaban equivalent levels were assessed using a commercially available anti-FXa activity assay with an edoxaban-specific setup. RESULTS AND CONCLUSIONS The day 5 concentration estimates were significantly correlated between the 2 assays (P<0.0001 for both edoxaban doses). The geometric least squares mean (GLSM) ratio (90% confidence interval) for edoxaban equivalent concentrations vs edoxaban + M-4 concentrations was 114.3% (108.2-120.8) for edoxaban 60mg (P<0.0001) and 113.0% (107.1-119.2) for edoxaban 90mg (P=0.0002). The GLSM ratio for edoxaban concentrations in sodium citrate vs lithium heparin tubes for 60-mg and 90-mg edoxaban doses were 82.8% (78.5-87.3) and 83.9% (79.1-89.0), respectively. In this study, an anti-FXa chromogenic assay with edoxaban-specific calibrators and controls demonstrated good accuracy in estimating edoxaban concentrations across a wide range of concentrations relative to LC/MS/MS at steady state following the administration of once-daily edoxaban for 5days.
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Gessoni G, Valverde S, Valle L, Gessoni F, Caruso P, Valle R. Lack of rivaroxaban influence on a prothrombinase-based assay for the detection of activated C protein resistance: an Italian ex vivo and in vitro study in normal subjects and factor V Leiden carriers. Int J Lab Hematol 2017; 39:418-422. [PMID: 28318106 DOI: 10.1111/ijlh.12647] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 02/03/2017] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Activated protein C resistance (APCr) leads to hypercoagulability and is due, often but not exclusively, to Factor V Leiden (FVL). The aim of this study was to assess the ex vivo and in vitro interference of the direct factor Xa inhibitor rivaroxaban (RIV) on a prothrombinase-based assay for APCr detection. METHODS An ex vivo study was performed on fresh plasma samples obtained from 44 subjects with FV wild-type and seven with FVL heterozygous, all treated with RIV. An in vitro study was performed on 15 plasma samples (six from normal subjects, six from heterozygous, and three from homozygous FVL carriers, all frozen specimens) spiked with RIV. RIV concentration was evaluated using a chromogenic assay, and APCr was evaluated by a prothrombinase-based assay. RESULTS No significant interference of RIV on APCr results obtained by a prothrombinase-based assay was observed for drug concentrations up to 400 ng/mL in FV wild-type and FVL carriers (homozygous and heterozygous). These results were confirmed both ex vivo and in vitro. CONCLUSIONS RIV did not significantly interfere with the prothrombinase-based assay used for the assessment of APCr, and this was observed to occur independently of FV status. However, only concentrations up to 400 ng/mL were tested and, therefore, what occurs in the presence of higher doses remains to be investigated.
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Affiliation(s)
- G Gessoni
- Trasfusional Deptartment of Venetian District, Ospedale dell'Angelo, Mestre, Venice, Italy
| | - S Valverde
- Laboratory Medicine, Ospedale Madonna della Navicella, Chioggia, Venice, Italy
| | - L Valle
- Cardiology and Intensive Coronary Unit, Ospedale Madonna della Navicella, Chioggia, Venice, Italy
| | - F Gessoni
- Laboratory Medicine, Ospedale Madonna della Navicella, Chioggia, Venice, Italy
| | | | - R Valle
- Cardiology and Intensive Coronary Unit, Ospedale Madonna della Navicella, Chioggia, Venice, Italy
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Kröll D, Stirnimann G, Vogt A, Lai DLL, Borbély YM, Altmeier J, Schädelin S, Candinas D, Alberio L, Nett PC. Pharmacokinetics and pharmacodynamics of single doses of rivaroxaban in obese patients prior to and after bariatric surgery. Br J Clin Pharmacol 2017; 83:1466-1475. [PMID: 28121368 DOI: 10.1111/bcp.13243] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 01/17/2017] [Accepted: 01/23/2017] [Indexed: 01/05/2023] Open
Abstract
AIMS Venous thromboembolism is an important cause of postoperative morbidity and mortality in bariatric surgery. Studies of direct oral anticoagulants (DOACs) are not available in this surgical field. The objective of this phase 1 clinical trial was to investigate pharmacokinetic and pharmacodynamic (PK/PD) parameters of rivaroxaban in bariatric patients. METHODS In this single-centre study, obese patients received single oral doses of rivaroxaban (10 mg) 1 day prior to and 3 days after bariatric surgery. PK and PD parameters were assessed at baseline and during 24 h after drug ingestion. RESULTS Six Roux-en-Y gastric bypass patients and six sleeve gastrectomy patients completed the study. Mean rivaroxaban area under plasma concentration-time curve, peak plasma concentration, time to peak plasma concentration and terminal half-life were 971.9 μg·h l-1 (coefficient of variation: 10.6), 135.3 μg l-1 (26.7), 1.5 h and 13.1 h (34.1) prior to and 1165.8 (21.9), 170.0 (15.9), 1.5 and 8.9 (44.6) postsurgery for SG patients and 933.7 μg·h l-1 (22.3), 136.5 μg l-1 (10.7), 1.5 h und 13.8 h (46.6) prior to and 1029.4 (7.4), 110.8 (31.8), 2.5 and 15 (60.0) postsurgery for Roux-en-Y gastric bypass patients, respectively. Prothrombin fragments (F1 + 2) decreased during the first 12 hours and increased thereafter in the pre- and the postbariatric setting. Thrombin-antithrombin complexes dropped within 1-3 h in the prebariatric setting and remained low after surgery until they increased at 24 h postdose. Rivaroxaban was well tolerated and no relevant safety issues were observed. CONCLUSIONS Bariatric surgery does not appear to alter PK of rivaroxaban in a clinically relevant way. Effective prophylactic postbariatric anticoagulation is supported by changes in PD.
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Affiliation(s)
- Dino Kröll
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Guido Stirnimann
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Andreas Vogt
- Department of Anaesthesiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Desirée Lin Lee Lai
- Department of Anaesthesiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Yves Michael Borbély
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Julia Altmeier
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Sabine Schädelin
- Department of Clinical Research, Clinical Trial Unit, Spitalstrasse 12, 4031, Basel, Switzerland
| | - Daniel Candinas
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Lorenzo Alberio
- Division of Haematology and Central Haematology Laboratory, Centre Hospitalier Universitaire Vaudois, University of Lausanne, CH 1011, Lausanne, Switzerland
| | - Philipp C Nett
- Department of Visceral Surgery and Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland
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Sagheer S, McRae S. Prolongation of prothrombin time in the presence of rivaroxaban: is this the only cause? Intern Med J 2017; 47:225-227. [PMID: 28201865 DOI: 10.1111/imj.13343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 08/08/2016] [Accepted: 10/28/2016] [Indexed: 11/29/2022]
Abstract
Rivaroxaban is an oral direct Xa inhibitor that can lead to prolongation of prothrombin time and activated partial thromboplastin time. However, these basic coagulation tests are not specific for the anticoagulant effect of rivaroxaban and other confounding factors should be considered while interpreting the test results. We report a case of a patient on rivaroxaban, where underlying factor VII deficiency led to confusion in the interpretation of prothrombin time results and delayed her surgery.
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Affiliation(s)
- Safoorah Sagheer
- Haematology Division, SA Pathology, Adelaide, South Australia, Australia
| | - Simon McRae
- Haematology Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Dager W, Hellwig T. Current knowledge on assessing the effects of and managing bleeding and urgent procedures with direct oral anticoagulants. Am J Health Syst Pharm 2017; 73:S14-26. [PMID: 27147455 DOI: 10.2146/ajhp150960] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
PURPOSE Current knowledge on managing major bleeding events with available hemostatic agents, including their combined use with potential reversal agents, in patients taking direct oral anticoagulant (DOACs) is reviewed. SUMMARY Over the past five years, a new generation of oral agents, the DOACs, has emerged as commonly used anticoagulants for stroke prevention in non-valvular atrial fibrillation, and treatment or secondary prevention of venous thromboembolism. Management of a bleeding event in the setting of DOAC therapy should take into account the relative risks of bleeding and thrombosis, which will determine the degree of anticoagulant reversal required. In the setting of a major (critical) bleeding event associated with notable blood loss, management may include transfusions of blood products to sustain the function of organ systems, and the availability of specific reversal agents will provide additional options for bleeding management. Beyond withholding the DOAC and providing supportive management that addresses any factors contributing to the bleeding event, clinicians may desire to expedite the removal of any anticoagulation effects. In general, this is accomplished by either removing or neutralizing the anticoagulant or by independently establishing hemostasis. CONCLUSION With or without reversal agents, patients may require supportive management such as mechanical pressure, volume support, transfusions of blood products, and, depending on the situation, surgery to repair the bleeding source. Specific reversal agents are currently under development or have recently been approved for the urgent management of bleeding events or the facilitation of invasive procedures in patients receiving DOACs.
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Affiliation(s)
- William Dager
- University of California Davis Medical Center, Sacramento, CA.
| | - Thaddaus Hellwig
- South Dakota State University College of Pharmacy, Sioux Falls, SDSanford USD Medical Center, Sioux Falls, SD
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Samuelson BT, Cuker A, Siegal DM, Crowther M, Garcia DA. Laboratory Assessment of the Anticoagulant Activity of Direct Oral Anticoagulants: A Systematic Review. Chest 2017; 151:127-138. [PMID: 27637548 PMCID: PMC5310120 DOI: 10.1016/j.chest.2016.08.1462] [Citation(s) in RCA: 206] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 07/26/2016] [Accepted: 08/24/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are the treatment of choice for most patients with atrial fibrillation and/or noncancer-associated venous thromboembolic disease. Although routine monitoring of these agents is not required, assessment of anticoagulant effect may be desirable in special situations. The objective of this review was to summarize systematically evidence regarding laboratory assessment of the anticoagulant effects of dabigatran, rivaroxaban, apixaban, and edoxaban. METHODS PubMed, Embase, and Web of Science were searched for studies reporting relationships between drug levels and coagulation assay results. RESULTS We identified 109 eligible studies: 35 for dabigatran, 50 for rivaroxaban, 11 for apixaban, and 13 for edoxaban. The performance of standard anticoagulation tests varied across DOACs and reagents; most assays, showed insufficient correlation to provide a reliable assessment of DOAC effects. Dilute thrombin time (TT) assays demonstrated linear correlation (r2 = 0.67-0.99) across a range of expected concentrations of dabigatran, as did ecarin-based assays. Calibrated anti-Xa assays demonstrated linear correlation (r2 = 0.78-1.00) across a wide range of concentrations for rivaroxaban, apixaban, and edoxaban. CONCLUSIONS An ideal test, offering both accuracy and precision for measurement of any DOAC is not widely available. We recommend a dilute TT or ecarin-based assay for assessment of the anticoagulant effect of dabigatran and anti-Xa assays with drug-specific calibrators for direct Xa inhibitors. In the absence of these tests, TT or APTT is recommended over PT/INR for assessment of dabigatran, and PT/INR is recommended over APTT for detection of factor Xa inhibitors. Time since last dose, the presence or absence of drug interactions, and renal and hepatic function should impact clinical estimates of anticoagulant effect in a patient for whom laboratory test results are not available.
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Affiliation(s)
- Bethany T Samuelson
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA.
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Deborah M Siegal
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Mark Crowther
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - David A Garcia
- Department of Medicine, Division of Hematology, University of Washington, Seattle, WA
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Ing Lorenzini K, Daali Y, Fontana P, Desmeules J, Samer C. Rivaroxaban-Induced Hemorrhage Associated with ABCB1 Genetic Defect. Front Pharmacol 2016; 7:494. [PMID: 28066243 PMCID: PMC5165251 DOI: 10.3389/fphar.2016.00494] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 12/02/2016] [Indexed: 01/03/2023] Open
Abstract
We report a patient who presented a non-ST segment elevation myocardial infarction in the context of severe normocytic hypochromic anemia related to gastrointestinal bleeding, 3 months after switching anticoagulant from the vitamin K antagonist acenocoumarol to the direct oral anticoagulant rivaroxaban. High levels of both anti-Xa activity and rivaroxaban plasma concentrations were measured despite rivaroxaban withdrawal, suggesting reduced elimination/drug clearance. Estimated half-life was 2–3 times longer than usually reported. The patient is a homozygous carrier of ABCB1 variant alleles, which could have participated to reduced elimination of rivaroxaban. Furthermore, CYP3A4/5 phenotyping showed moderately reduced enzyme activity. Drug-drug interaction with simvastatin may have contributed to decreased rivaroxaban elimination. Although in the present case moderate acute renal failure probably played a role, more clinical data are required to elucidate the impact of ABCB1 polymorphism on rivaroxaban pharmacokinetics and bleeding complications.
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Affiliation(s)
- Kuntheavy Ing Lorenzini
- Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva Geneva, Switzerland
| | - Youssef Daali
- Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva Geneva, Switzerland
| | - Pierre Fontana
- Division of Angiology and Haemostasis, University Hospitals of Geneva Geneva, Switzerland
| | - Jules Desmeules
- Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva Geneva, Switzerland
| | - Caroline Samer
- Division of Clinical Pharmacology and Toxicology, University Hospitals of Geneva Geneva, Switzerland
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Arnao V, Riolo M, Tuttolomondo A, Pinto A, Fierro B, Aridon P. New frontiers in anticoagulation: non vitamin-K oral anticoagulants in stroke prevention. Expert Rev Neurother 2016; 17:539-552. [PMID: 27911120 DOI: 10.1080/14737175.2017.1268053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Non vitamin-K oral anticoagulants (NOACs) are direct and specific inhibitors of the coagulation factors IIa (dabigatran) and Xa (apixaban, rivaroxaban, edoxaban) which share many pharmacokinetic properties. However, indications are lacking regarding the use of NOACs during thrombolysis, surgery and bleeding events. Areas covered: In this paper, the authors retrospectively analyzed the relevant literature on the NOACs using the PubMed and Google Scholar databases. Expert commentary: Although warfarin is effective in cardioembolic stroke prevention, easier handling and more favorable risk-benefit profile often render NOACs a more preferable therapy choice for neurologists. New evidences have suggested their use in treatment of elderly people, in patients with renal insufficiency or with antiphospholipid antibody syndrome. In addition, the use of antidotes, which rapidly reverse the anticoagulant effect of the NOACs, could be useful in bleeding, during emergency procedures, or in case of overdose.
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Affiliation(s)
- Valentina Arnao
- a BioNeC Dipartimento di BioMedicina Sperimentale e Neuroscienze Cliniche , Università degli Studi di Palermo , Palermo , Italy.,b Biomedical Department of Internal and Specialistic Medicine (Di.Bi.M.I.S), School of Medicina Clinica e Scienze del Comportamento , University of Palermo , Palermo , Italy
| | - Marianna Riolo
- a BioNeC Dipartimento di BioMedicina Sperimentale e Neuroscienze Cliniche , Università degli Studi di Palermo , Palermo , Italy
| | - Antonino Tuttolomondo
- c Biomedical Department of Internal and Specialistic Medicine (Di.Bi.M.I.S) , University of Palermo , Palermo , Italy
| | - Antonio Pinto
- c Biomedical Department of Internal and Specialistic Medicine (Di.Bi.M.I.S) , University of Palermo , Palermo , Italy
| | - Brigida Fierro
- a BioNeC Dipartimento di BioMedicina Sperimentale e Neuroscienze Cliniche , Università degli Studi di Palermo , Palermo , Italy
| | - Paolo Aridon
- a BioNeC Dipartimento di BioMedicina Sperimentale e Neuroscienze Cliniche , Università degli Studi di Palermo , Palermo , Italy
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Lessire S, Douxfils J, Pochet L, Dincq AS, Larock AS, Gourdin M, Dogné JM, Chatelain B, Mullier F. Estimation of Rivaroxaban Plasma Concentrations in the Perioperative Setting in Patients With or Without Heparin Bridging. Clin Appl Thromb Hemost 2016; 24:129-138. [PMID: 27811211 DOI: 10.1177/1076029616675968] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Estimation of residual rivaroxaban plasma concentrations may be requested before invasive procedures and some patients at high thromboembolic risk will have a bridging therapy with heparins when rivaroxaban is interrupted. OBJECTIVE The objective of this study was to assess the performance of the STA-Liquid Anti-Xa assay (STA LAX) and the low and normal procedures of the Biophen Direct Factor Xa Inhibitors (DiXaI) assay, in patients with and without bridging with low-molecular-weight heparins (LMWHs). MATERIALS AND METHODS Seventy-nine blood samples were collected from 77 patients on rivaroxaban at CTROUGH or before an invasive procedure. Rivaroxaban plasma concentrations were estimated using Biophen DiXaI, Biophen DiXaI LOW, and STA LAX and compared to liquid chromatography coupled with mass spectrometry (LC-MS/MS) measurements. Stratifications were performed according to heparin bridging. RESULTS The Biophen DiXaI LOW and STA LAX showed better correlation with LC-MS/MS measurements than Biophen DiXaI in patients not bridged with LMWH (R: 0.97, 0.96, and 0.91, respectively). However, the performance of Biophen DiXaI LOW and STA LAX decreased when residual LMWH activity was present (R: 0.18 and 0.19 respectively) demonstrating that these tests are not specific to rivaroxaban. CONCLUSION In patients not bridged with LMWH, we suggest to use the Biophen DiXaI LOW and STA LAX for the estimation of rivaroxaban concentrations <50 ng/mL. These results should be confirmed on a larger cohort of patients. Patients bridged with LMWH have inaccurate estimates of low levels of rivaroxaban and the 3 assays studied should not be used to estimate if it is safe to perform a procedure.
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Affiliation(s)
- Sarah Lessire
- 1 Department of Anesthesiology, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium.,2 Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- 2 Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Lionel Pochet
- 2 Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Anne-Sophie Dincq
- 1 Department of Anesthesiology, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Anne-Sophie Larock
- 3 Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Maximilien Gourdin
- 1 Department of Anesthesiology, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Jean-Michel Dogné
- 2 Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Bernard Chatelain
- 4 Haematology Laboratory, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - François Mullier
- 4 Haematology Laboratory, Namur Thrombosis and Hemostasis Center (NTHC), NAmur Research Institute for LIfe Sciences (NARILIS), Université catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
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Douxfils J, Pochet L, Lessire S, Vancraeynest C, Dogné JM, Mullier F. Mass spectrometry in the therapeutic drug monitoring of direct oral anticoagulants. Useful or useless? Trends Analyt Chem 2016. [DOI: 10.1016/j.trac.2016.01.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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Lim MS, Chapman K, Swanepoel P, Enjeti AK. Sensitivity of routine coagulation assays to direct oral anticoagulants: patient samples versus commercial drug-specific calibrators. Pathology 2016; 48:712-719. [PMID: 27780603 DOI: 10.1016/j.pathol.2016.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Revised: 07/13/2016] [Accepted: 07/18/2016] [Indexed: 12/21/2022]
Abstract
Most studies on the sensitivities of coagulation assays to direct oral anticoagulants (DOACs) are based on normal plasma spiked with anticoagulant in the laboratory. Recent studies have shown that reagent sensitivity varies significantly depending on whether spiked or patient samples are used. The aim of this study was to compare the sensitivities of routine coagulation assays in patient samples and commercial drug specific calibrators using commonly used activated partial thromboplastin time (APTT) and prothrombin time (PT) reagents (i.e., Actin FS and Neoplastine CI Plus for APTT and PT, respectively) in Australian laboratories. Samples collected at Pathology North Hunter (PN-H) for dabigatran (n=39), rivaroxaban, (n=56) or apixaban levels (n=22) between February 2013 and November 2015 were analysed and compared to two different commercial drug specific calibrators from different manufacturers for each DOAC. Our results show that dabigatran (Hyphen and Technoclone) and rivaroxaban (Stago) calibrators tend to overestimate the APTT but are similar to patient samples for PT. A cut-off DOAC level of 50 ng/mL based on results from patient samples within the laboratory can be used as the lower limit which will result in prolongation of APTT for dabigatran (sensitivity 96%, n=25) and PT for rivaroxaban (sensitivity 97%, n=29), respectively. Individual laboratories should be familiar with the sensitivity of their coagulation reagents to different DOACs including differences between patient samples versus different commercial drug specific calibrators.
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Affiliation(s)
- Ming Sheng Lim
- Haematology Department, Calvary Mater Hospital, Waratah, Australia.
| | - Kent Chapman
- Pathology North Hunter, NSW Pathology, Australia
| | | | - Anoop K Enjeti
- Haematology Department, Calvary Mater Hospital, Waratah, Australia; Pathology North Hunter, NSW Pathology, Australia; University of Newcastle, Australia; Hunter Cancer Research Alliance, Australia; Hunter Medical Research Institute, Newcastle, NSW, Australia
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Abstract
Large clinical trials have demonstrated that new oral anticoagulants (NOACs) are at least as efficient as vitamin K antagonists (VKAs) in preventing thromboembolic events, while providing a better safety profile. The relatively stable pharmacokinetics and pharmacodynamics, the reduced reports on food and drug interactions, and the wide therapeutic windows of NOACs appear to provide a more predictable anticoagulant effect than that observed with VKAs, enabling the use of fixed doses without the need for monitoring. However, the safe implementation of NOACs may require additional judgment, and one should not have the erroneous impression that NOACs are free from interactions or that inter- and intra-individual variability is absent with NOACs. In fact, a consensus seems to have been reached concerning the usefulness of "circumstantial" testing in certain clinical scenarios. Recent data also suggest that factors such as intercurrent diseases, drug interactions, and inexplicable variability may occasionally alter the anticoagulant effect of NOACs. Furthermore, the issue of nonadherence, already high in VKA-treated patients, may represent an even greater clinical concern with NOACs, given their short half-lives. This review aims to underline the main arguments that support the need for NOAC monitoring, at least in selected categories of patients. Additionally, an overview of classic coagulation assays and novel laboratory techniques that may provide a tool for NOAC monitoring is also provided.
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Nonvitamin K antagonist oral anticoagulant activity: challenges in measurement and reversal. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:273. [PMID: 27659071 PMCID: PMC5034528 DOI: 10.1186/s13054-016-1422-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background Four nonvitamin K antagonist oral anticoagulants (NOACs) are approved for the prevention of stroke in patients with nonvalvular atrial fibrillation and for the treatment of venous thromboembolism. These include the direct thrombin inhibitor dabigatran and the direct factor Xa inhibitors rivaroxaban, apixaban, and edoxaban. Bleeding is a complication for all anticoagulants and concerns regarding bleeding risk and the suitability of effective reversal strategies may be a barrier to their prescription. Despite the reduced risk of bleeding compared with vitamin K antagonists, questions persist regarding the management of bleeding related to NOAC use. Main text To date, although a number of assays are responsive to NOACs, no single routine laboratory test has been identified to accurately measure the clinical anticoagulation state of patients on NOACs or established as a reliable predictor of bleeding risk. In addition, the establishment of a reliable human bleeding model to test novel inhibitors of the coagulation cascade has proved challenging. Although routine monitoring of anticoagulant levels is not necessary in patients taking NOACs, anticoagulant reversal and a means of measuring reversal may be required for patients who present with bleeding or require urgent surgery. Prothrombin complex concentrates are pooled plasma products containing varying amounts of inactive vitamin K-dependent clotting factors in addition to vitamin K-dependent proteins and can replenish factors in the intrinsic and extrinsic coagulation cascade, reversing an anticoagulant effect. Only one agent, idarucizumab, has been approved for rapid reversal of dabigatran-induced anticoagulation and one more agent, andexanet alfa, has been submitted for approval to reverse the anticoagulatory effects of direct and indirect factor Xa inhibitors. Conclusions This review discusses the laboratory tests available for assessing anticoagulation, human models of bleeding, and the use of current strategies—including prothrombin complex concentrates for reversal of anticoagulation by NOACs—to manage bleeding in patients.
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Abstract
In some clinical settings laboratory measurement of direct oral anticoagulants effect is helpful in guiding medical care, such as life-threatening bleeding, need for emergency surgery, renal impairment, severe hepatic failure, extremes of body weight, or in patients with bleeding or thrombosis on therapy. This article reviews approaches to laboratory testing to assess the anticoagulant effect of these drugs. Because of the wide variation in levels measured in patients on therapy and minimal clinical data from dose adjustment, dose adjustment based on levels is not currently advised. In addition, these drugs interfere with many clot-based laboratory tests and caution is advised in interpreting these tests in patients on direct oral anticoagulants.
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Affiliation(s)
- Barbara A Konkle
- Clinical and Translational Research, Hemostasis, Platelet Immunology, and Genomics Laboratory, Bloodworks Northwest, University of Washington School of Medicine, 921 Terry Avenue, Seattle, WA 98104, USA.
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Schenk B, Würtinger P, Streif W, Sturm W, Fries D, Bachler M. Ex vivo reversal of effects of rivaroxaban evaluated using thromboelastometry and thrombin generation assay. Br J Anaesth 2016; 117:583-591. [PMID: 27623677 PMCID: PMC5091332 DOI: 10.1093/bja/aew259] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2016] [Indexed: 01/08/2023] Open
Abstract
Background In major bleeding events, the new direct oral anticoagulants pose a great challenge for physicians. The aim of the study was to test for ex vivo reversal of the direct oral anticoagulant rivaroxaban with various non-specific reversal agents: prothrombin complex concentrate (PCC), activated prothrombin complex concentrate (aPCC), recombinant activated factor VII (rFVIIa), and fibrinogen concentrate (FI). Methods Blood was obtained from healthy volunteers and from patients treated with rivaroxaban. Blood samples from healthy volunteers were spiked with rivaroxaban to test the correlation between rivaroxaban concentration and coagulation tests. Patient blood samples were spiked with various concentrations of the above-mentioned agents and analysed using thromboelastometry and thrombin generation. Results When added in vitro, rivaroxaban was significantly (P<0.05) correlated with ROTEM® thromboelastometry EXTEM (extrinsic coagulation pathway) clotting time (CT), time to maximal velocity (MaxV−t), and with all measured thrombin generation parameters. In vivo, CT, MaxV−t, lag time, and peak thrombin generation (Cmax) were significantly correlated with rivaroxaban concentrations. Regarding reversal of rivaroxaban, all tested agents significantly (P<0.05) reduced EXTEM CT, but to different extents: rFVIIa by 68%, aPCC by 47%, PCC by 17%, and FI by 9%. Only rFVIIa reversed EXTEM CT to baseline values. Both PCC (+102%) and aPCC (+232%) altered overall thrombin generation (area under the curve) and increased Cmax (+461% for PCC, +87.5% for aPCC). Conclusions Thromboelastometry and thrombin generation assays do not favour the same reversal agents for rivaroxaban anticoagulation. Controlled clinical trials are urgently needed to establish doses and clinical efficacy of potential reversal agents. Clinical trial registration EudracCT trial no. 213-00474-30.
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Affiliation(s)
- B Schenk
- Department of General and Surgical Intensive Care Medicine
| | - P Würtinger
- Central Institute for Medical and Chemical Laboratory Diagnostics
| | | | - W Sturm
- Department of Internal Medicine, Medical University of Innsbruck, Anichstrasse 35, Innsbruck 6020, Austria
| | - D Fries
- Department of General and Surgical Intensive Care Medicine
| | - M Bachler
- Department of General and Surgical Intensive Care Medicine
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Samuelson BT, Cuker A. Measurement and reversal of the direct oral anticoagulants. Blood Rev 2016; 31:77-84. [PMID: 27625113 DOI: 10.1016/j.blre.2016.08.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/24/2016] [Accepted: 08/29/2016] [Indexed: 12/27/2022]
Abstract
Direct oral anticoagulants (DOACs) offer noninferior efficacy and improved safety compared to vitamin K antagonists (VKAs) for the prevention and treatment of venous thromboembolism and for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation. Unlike VKAs, DOACs do not require routine laboratory monitoring of anticoagulant effect and dose adjustment. In certain situations, however, laboratory assessment of anticoagulant effect may be desirable. Here we review the utility of currently available assays for assessment of DOAC effect and recommend an optimal assessment strategy for each drug, including calibrated dilute thrombin time or ecarin-based assays for dabigatran and calibrated anti-Xa activity assays for the factor Xa inhibitors. We also discuss reversal strategies, both specific and nonspecific, for each drug, including the preferential use of idarucizumab for the reversal of dabigatran and two agents, andexanet and ciraparantag, currently under development for the reversal of rivaroxaban, apixaban, and edoxaban.
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Affiliation(s)
- Bethany T Samuelson
- Division of Hematology, Department of Medicine, University of Washington, 1100 Fairview Ave N D5-100, Seattle, WA 98109, USA.
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, PA 19104, USA.
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Platton S, Bowles L, MacCallum P. Effects of rivaroxaban on routine coagulation screening tests using commonly used reagents. Br J Haematol 2016; 179:511-513. [DOI: 10.1111/bjh.14230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Sean Platton
- Haemophilia Centre; Barts Health NHS Trust; Royal London Hospital; London UK
| | - Louise Bowles
- Haemophilia Centre; Barts Health NHS Trust; Royal London Hospital; London UK
| | - Peter MacCallum
- Queen Mary's School of Medicine and Dentistry; London UK
- Wolfson Institute of Preventive Medicine; London UK
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Measurement of Non-Vitamin K Antagonist Oral Anticoagulants in Patient Plasma Using Heptest-STAT Coagulation Method. Ther Drug Monit 2016; 37:375-80. [PMID: 25525760 DOI: 10.1097/ftd.0000000000000157] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Non-vitamin K antagonist oral anticoagulants (NOACs) are approved for several indications for prophylaxis of thromboembolism at fixed oral doses. The analysis of NOAC activity/concentration may be required in special patient populations. Heptest coagulation assay determines both factor Xa and thrombin inhibitors. The objective of investigations is to analyze the effects of both groups of NOACs on this assay. METHODS The performance of a modified Heptest-STAT clotting assay was compared with specific chromogenic substrate assays for factor Xa (Coamatic, HemosIL) and thrombin (direct thrombin inhibitor assay and S2238 chromogenic assays) for the determination of rivaroxaban, apixaban, and dabigatran in plasma from patients on treatment. RESULTS For rivaroxaban (n = 74), the concentrations (mean and SD) of Heptest-STAT versus Coamatic and HemosIL assays were 179.3 ± 85.8 ng/mL versus 199.3 ± 105.7 ng/mL and 212.4 ± 115.9 ng/mL (P < 0.0001), and for apixaban (n = 26) 232.8 ± 10.0 ng/mL versus 178.4 ± 64.4 ng/mL (P < 0.0001) and 182.1 ± 73.1 ng/mL (P = 0.0002). For dabigatran (n = 74), the values of Heptest-STAT were 92.3 ± 65.0 ng/mL versus 124.3 ± 85.6 ng/mL (direct thrombin inhibitor assay, P < 0.0001) and 107.5 ± 59.7 ng/mL (S2238 assay, P = 0.0015), respectively. The values of the intraclass coefficient of correlation ranged from 0.64 to 0.91 (Bland-Altman analysis). CONCLUSIONS The objective of the study was achieved by demonstrating a high correlation of the Heptest-STAT coagulation assay with chromogenic assays for factor Xa inhibiting NOACs and acceptably good correlation with thrombin inhibiting NOACs in plasma samples of patients on treatment.
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Direct-Acting Oral Anticoagulants: Practical Considerations for Emergency Medicine Physicians. Emerg Med Int 2016; 2016:1781684. [PMID: 27293895 PMCID: PMC4884797 DOI: 10.1155/2016/1781684] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 03/11/2016] [Accepted: 03/29/2016] [Indexed: 01/01/2023] Open
Abstract
Nonvalvular atrial fibrillation- (NVAF-) related stroke and venous thromboembolism (VTE) are cardiovascular diseases associated with significant morbidity and economic burden. The historical standard treatment of VTE has been the administration of parenteral heparinoid until oral warfarin therapy attains a therapeutic international normalized ratio. Warfarin has been the most common medication for stroke prevention in NVAF. Warfarin use is complicated by a narrow therapeutic window, unpredictable dose response, numerous food and drug interactions, and requirements for frequent monitoring. To overcome these disadvantages, direct-acting oral anticoagulants (DOACs)—dabigatran, rivaroxaban, apixaban, and edoxaban—have been developed for the prevention of stroke or systemic embolic events (SEE) in patients with NVAF and for the treatment of VTE. Advantages of DOACs include predictable pharmacokinetics, few drug-drug interactions, and low monitoring requirements. In clinical studies, DOACs are noninferior to warfarin for the prevention of NVAF-related stroke and the treatment and prevention of VTE as well as postoperative knee and hip surgery VTE prophylaxis, with decreased bleeding risks. This review addresses the practical considerations for the emergency physician in DOAC use, including dosing recommendations, laboratory monitoring, anticoagulation reversal, and cost-effectiveness. The challenges of DOACs, such as the lack of specific laboratory measurements and antidotes, are also discussed.
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