1
|
Bouck EG, Grinsztejn E, Mcnamara M, Stavrou EX, Wolberg AS. Thromboembolic risk with gender-affirming hormone therapy: potential role of global coagulation and fibrinolysis assays. Res Pract Thromb Haemost 2023; 7:102197. [PMID: 37822706 PMCID: PMC10562871 DOI: 10.1016/j.rpth.2023.102197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 07/14/2023] [Accepted: 07/18/2023] [Indexed: 10/13/2023] Open
Abstract
Gender-affirming hormonal therapies are a critical component of the care of transgender individuals. Transgender people are commonly prescribed estrogen or testosterone to promote male-to-female or female-to-male transitions and to preserve gender-specific characteristics long-term. However, some exogenous hormones, especially certain estrogen preparations, are an established risk factor of thrombosis. As the number of individuals seeking gender-based care is rising, there is an urgent need to identify and characterize the mechanisms underlying hormone-associated thrombosis and incorporate this information into clinical algorithms for diagnosis and management. Herein, we discuss historical evidence on the incidence of thrombosis and changes in plasma composition in transgender and cisgender cohorts. We present 3 case studies to demonstrate knowledge gaps in thrombosis risk stratification and prediction tools. We also present data from in vitro coagulation and fibrinolysis assays and discuss how information from these kinds of assays may be used to help guide the clinical management of transgender individuals.
Collapse
Affiliation(s)
- Emma G. Bouck
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| | - Eduarda Grinsztejn
- Department of Medicine, Hematology and Oncology Division, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Megan Mcnamara
- Medicine Service, Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Evi X. Stavrou
- Medicine Service, Section of Hematology-Oncology, Louise Stokes Cleveland Veterans Affairs Medical Center, Cleveland, OH, USA
- Department of Medicine, Hematology and Oncology Division, CWRU School of Medicine, Cleveland, OH, USA
| | - Alisa S. Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center, University of North Carolina, Chapel Hill, NC, USA
| |
Collapse
|
2
|
Morimont L, Donis N, Bouvy C, Mullier F, Dogné JM, Douxfils J. Laboratory Testing for the Evaluation of Phenotypic Activated Protein C Resistance. Semin Thromb Hemost 2022. [PMID: 36063850 DOI: 10.1055/s-0042-1757136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Activated protein C (APC) resistance (APCR) is considered a risk factor of venous thromboembolism (VTE). The most common genetic disorder conferring APCR is a factor (F) V Leiden mutation, but many other factors are also implicated, such as other F5 mutations (e.g., FV Hong-Kong and FV Cambridge), protein S deficiency, elevated factor VIII, exogenous hormone use, pregnancy and postpartum, depending on how APCR is defined. Considering the large population affected, the detection of this phenotype is crucial. Two types of tests are currently available: clotting time-based assays (with several versions) and thrombin generation-based assays with the endogenous thrombin potential (ETP)-based assay. The purpose of this review is therefore to discuss the performances of these tests and the cases in which it would be appropriate to use one over the other. Initially, as APCR was thought to be solely related to the FV Leiden mutation, the objective was to obtain a 100% specific assay. Clotting-time based assays were thus specifically designed to detect this inherited condition. Later on, an APCR condition without a FV Leiden mutation was identified and highlighted as an independent risk factor of VTE. Therefore, the development of a less specific assay was needed and a global coagulation test was proposed, known as the ETP-based APCR assay. In light of the above, these tests should not be used for the same purpose. Clotting time-based assays should only be recommended as a screening test for the detection of FV mutations prior to confirmation by genetic testing. On the other hand, the ETP-based APC resistance assay, in addition to being able to detect any type of APCR, could be proposed as a global screening test as it assesses the entire coagulation process.
Collapse
Affiliation(s)
- Laure Morimont
- Department of Research, Qualiblood Sa, Namur, Belgium.,Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | | | - Céline Bouvy
- Department of Research, Qualiblood Sa, Namur, Belgium
| | - François Mullier
- Hematology Laboratory, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Department of Research, Qualiblood Sa, Namur, Belgium.,Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| |
Collapse
|
3
|
Morimont L, Donis N, Bouvy C, Mullier F, Dogné JM, Douxfils J. Laboratory Testing for the Evaluation of Phenotypic Activated Protein C Resistance. Semin Thromb Hemost 2022; 48:680-689. [PMID: 36055270 DOI: 10.1055/s-0042-1753511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Activated protein C (APC) resistance (APCR) is considered a risk factor of venous thromboembolism (VTE). The most common genetic disorder conferring APCR is a factor (F) V Leiden mutation, but many other factors are also implicated, such as other F5 mutations (e.g., FV Hong-Kong and FV Cambridge), protein S deficiency, elevated factor VIII, exogenous hormone use, pregnancy and postpartum, depending on how APCR is defined. Considering the large population affected, the detection of this phenotype is crucial. Two types of tests are currently available: clotting time-based assays (with several versions) and thrombin generation-based assays with the endogenous thrombin potential (ETP)-based assay. The purpose of this review is therefore to discuss the performances of these tests and the cases in which it would be appropriate to use one over the other. Initially, as APCR was thought to be solely related to the FV Leiden mutation, the objective was to obtain a 100% specific assay. Clotting-time based assays were thus specifically designed to detect this inherited condition. Later on, an APCR condition without a FV Leiden mutation was identified and highlighted as an independent risk factor of VTE. Therefore, the development of a less specific assay was needed and a global coagulation test was proposed, known as the ETP-based APCR assay. In light of the above, these tests should not be used for the same purpose. Clotting time-based assays should only be recommended as a screening test for the detection of FV mutations prior to confirmation by genetic testing. On the other hand, the ETP-based APC resistance assay, in addition to being able to detect any type of APCR, could be proposed as a global screening test as it assesses the entire coagulation process.
Collapse
Affiliation(s)
- Laure Morimont
- Department of Research, Qualiblood Sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | | | - Céline Bouvy
- Department of Research, Qualiblood Sa, Namur, Belgium
| | - François Mullier
- Hematology Laboratory, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Department of Research, Qualiblood Sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| |
Collapse
|
4
|
Morimont L, Donis N, Bouvy C, Mullier F, Dogné JM, Douxfils J. Laboratory Testing for the Evaluation of Phenotypic Activated Protein C Resistance. Semin Thromb Hemost 2022; 48:680-689. [DOI: 10.1055/s-0042-1758162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractActivated protein C (APC) resistance (APCR) is considered a risk factor of venous thromboembolism (VTE). The most common genetic disorder conferring APCR is a factor (F) V Leiden mutation, but many other factors are also implicated, such as other F5 mutations (e.g., FV Hong-Kong and FV Cambridge), protein S deficiency, elevated factor VIII, exogenous hormone use, pregnancy and postpartum, depending on how APCR is defined. Considering the large population affected, the detection of this phenotype is crucial. Two types of tests are currently available: clotting time-based assays (with several versions) and thrombin generation-based assays with the endogenous thrombin potential (ETP)-based assay. The purpose of this review is therefore to discuss the performances of these tests and the cases in which it would be appropriate to use one over the other. Initially, as APCR was thought to be solely related to the FV Leiden mutation, the objective was to obtain a 100% specific assay. Clotting-time based assays were thus specifically designed to detect this inherited condition. Later on, an APCR condition without a FV Leiden mutation was identified and highlighted as an independent risk factor of VTE. Therefore, the development of a less specific assay was needed and a global coagulation test was proposed, known as the ETP-based APCR assay. In light of the above, these tests should not be used for the same purpose. Clotting time-based assays should only be recommended as a screening test for the detection of FV mutations prior to confirmation by genetic testing. On the other hand, the ETP-based APC resistance assay, in addition to being able to detect any type of APCR, could be proposed as a global screening test as it assesses the entire coagulation process.
Collapse
Affiliation(s)
- Laure Morimont
- Department of Research, Qualiblood Sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | | | - Céline Bouvy
- Department of Research, Qualiblood Sa, Namur, Belgium
| | - François Mullier
- Hematology Laboratory, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), Université Catholique de Louvain, CHU UCL Namur, Yvoir, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Department of Research, Qualiblood Sa, Namur, Belgium
- Department of Pharmacy, Faculty of Medicine, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| |
Collapse
|
5
|
Morimont L, Leclercq C, Didembourg M, De Gottal É, Carlo A, Gaspard U, Dogné J, Douxfils J. Analytical performance of the endogenous thrombin potential–based activated protein C resistance assay on the automated ST Genesia system. Res Pract Thromb Haemost 2022; 6:e12684. [PMID: 35425874 PMCID: PMC8988860 DOI: 10.1002/rth2.12684] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/14/2022] [Accepted: 02/18/2022] [Indexed: 11/07/2022] Open
Abstract
Background Objectives Method Results Conclusion
Collapse
Affiliation(s)
- Laure Morimont
- Qualiblood saNamurBelgium
- Department of PharmacyFaculty of MedicineNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
| | - Charline Leclercq
- Department of GynecologyCentre Hospitalier Régional de HuyLiègeBelgium
| | - Marie Didembourg
- Department of PharmacyFaculty of MedicineNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
| | - Émilie De Gottal
- Department of GynecologyCentre Hospitalier Régional de HuyLiègeBelgium
| | | | - Ulysse Gaspard
- Department of Obstetrics and GynecologyUniversity of LiègeLiègeBelgium
| | - Jean‐Michel Dogné
- Department of PharmacyFaculty of MedicineNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
| | - Jonathan Douxfils
- Qualiblood saNamurBelgium
- Department of PharmacyFaculty of MedicineNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
| |
Collapse
|
6
|
Morimont L, Haguet H, Dogné JM, Gaspard U, Douxfils J. Combined Oral Contraceptives and Venous Thromboembolism: Review and Perspective to Mitigate the Risk. Front Endocrinol (Lausanne) 2021; 12:769187. [PMID: 34956081 PMCID: PMC8697849 DOI: 10.3389/fendo.2021.769187] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/08/2021] [Indexed: 12/02/2022] Open
Abstract
Many factors must be considered and discussed with women when initiating a contraceptive method and the risk of venous thromboembolism (VTE) is one of them. In this review, we discuss the numerous strategies that have been implemented to reduce the thrombotic risk associated with combined oral contraceptives (COCs) from their arrival on the market until today. Evidences suggesting that COCs were associated with an increased risk of VTE appeared rapidly after their marketing. Identified as the main contributor of this risk, the dosage of the estrogen, i.e., ethinylestradiol (EE), was significantly reduced. New progestins were also synthetized (e.g., desogestrel or gestodene) but their weak androgenic activity did not permit to counterbalance the effect of EE as did the initial progestins such as levonorgestrel. Numerous studies assessed the impact of estroprogestative combinations on hemostasis and demonstrated that women under COC suffered from resistance towards activated protein C (APC). Subsequently, the European Medicines Agency updated its guidelines on clinical investigation of steroid contraceptives in which they recommended to assess this biological marker. In 2009, estradiol-containing COCs were marketed and the use of this natural form of estrogen was found to exert a weaker effect on the synthesis of hepatic proteins compared to EE. In this year 2021, a novel COC based on a native estrogen, i.e., estetrol, will be introduced on the market. Associated with drospirenone, this preparation demonstrated minor effects on coagulation proteins as compared with other drospirenone-containing COCs. At the present time, the standard of care when starting a contraception, consists of identifying the presence of hereditary thrombophilia solely on the basis of familial history of VTE. This strategy has however been reported as poorly predictive of hereditary thrombophilia. One rationale and affordable perspective which has already been considered in the past could be the implementation of a baseline screening of the prothrombotic state to provide health care professionals with objective data to support the prescription of the more appropriate contraceptive method. While this strategy was judged too expensive due to limited laboratory solutions, the endogenous thrombin potential-based APC resistance assay could now represent an interesting alternative.
Collapse
Affiliation(s)
- Laure Morimont
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
| | - Hélène Haguet
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
| | | | - Ulysse Gaspard
- Department of Obstetrics and Gynecology, University of Liège, Liège, Belgium
| | - Jonathan Douxfils
- Research Department, Qualiblood s.a., Namur, Belgium
- Faculty of Medicine, Department of Pharmacy, Namur Research Institute for Life Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC), University of Namur, Namur, Belgium
| |
Collapse
|
7
|
Morimont L, Didembourg M, Haguet H, Modaffari É, Tillier M, Bouvy C, Lebreton A, Dogné J, Douxfils J. Interlaboratory variability of activated protein C resistance using the ETP-based APC resistance assay. Res Pract Thromb Haemost 2021; 5:e12612. [PMID: 34761157 PMCID: PMC8563922 DOI: 10.1002/rth2.12612] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/09/2021] [Accepted: 09/24/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Although the endogenous thrombin potential (ETP)-based activated protein C (APC) resistance is recommended for the development of steroid contraceptive agents, one of the main limitations of this technique was its lack of standardization, which hampered study-to-study comparison. A validated methodology that meets all the regulatory requirements in terms of analytical performances has been developed recently. To ensure a wide implementation of this test, the assessment of the interlaboratory variability was needed. METHOD The assay was implemented in three testing laboratories. First, dose-response curves were performed to locally define APC concentration leading to 90% of ETP inhibition on healthy donors. Intra- and inter-run repeatability were assessed on a reference plasma and three quality controls. To investigate the variability in results among the different testing units, 60 donor samples were analyzed at each site. RESULTS The APC concentration leading to 90% of ETP inhibition was defined at 1.21 µg/ml and 1.14 µg/ml in the two receiving units. Intra- and inter-run repeatability showed standard deviation below 3%. Analyses of the 60 donor samples showed no statistically significant difference. The sensitivity of the test in the different laboratories was maintained and subgroup analyses still reported significant differences depending on hormonal status of donors. CONCLUSION This study is the first reporting the interlaboratory variability of the ETP-based APC resistance assay. Data revealed excellent intra- and interlaboratory reproducibility. These results support the concept that this blood coagulation test provides an appropriate sensitivity irrespective of the laboratory in which analyses are performed.
Collapse
Affiliation(s)
- Laure Morimont
- Qualiblood saNamurBelgium
- Faculty of MedicineDepartment of PharmacyNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
| | - Marie Didembourg
- Faculty of MedicineDepartment of PharmacyNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
| | - Hélène Haguet
- Qualiblood saNamurBelgium
- Faculty of MedicineDepartment of PharmacyNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
| | | | - Maxence Tillier
- Service d'hématologie BiologiqueCHU Clermont‐FerrandClermont‐FerrandFrance
| | | | - Aurélien Lebreton
- Service d'hématologie BiologiqueCHU Clermont‐FerrandClermont‐FerrandFrance
| | - Jean‐Michel Dogné
- Faculty of MedicineDepartment of PharmacyNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
| | - Jonathan Douxfils
- Qualiblood saNamurBelgium
- Faculty of MedicineDepartment of PharmacyNamur Research Institute for Life Sciences (NARILIS)Namur Thrombosis and Hemostasis Center (NTHC)University of NamurNamurBelgium
| |
Collapse
|
8
|
Htut TW, Watson HG, Mackay G, Khan MM. Clinical observations in patients with cerebral venous sinus thrombosis. Br J Haematol 2021; 194:921-922. [PMID: 34137026 DOI: 10.1111/bjh.17553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Thura W Htut
- Department of Haematology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK
| | - Henry G Watson
- Department of Haematology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK
| | - Graham Mackay
- Department of Neurology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK
| | - Mohammed M Khan
- Department of Haematology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK
| |
Collapse
|
9
|
Evrard J, Morimont L, Didembourg M, Haguet H, Siriez R, Dogné JM, Douxfils J. Assessment of acquired activated protein C resistance with the FibWave and comparison with the ETP-based APC resistance. Int J Lab Hematol 2020; 43:802-812. [PMID: 33314736 DOI: 10.1111/ijlh.13427] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 11/22/2020] [Accepted: 11/23/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Activated protein C (APC) resistance is a major risk factor of venous thrombosis which may be acquired by hormonal therapy or other causes. The FibWave, a sensitive global clot-based assay design to analyze the coagulation kinetics in plasma, may be a good candidate to assess this prothrombotic state. This study aims to assess the suitability of the FibWave to differentiate the coagulation kinetics of women on oral contraceptives. MATERIALS AND METHODS Fifty-four healthy volunteers were divided into 5 groups: men [n = 13], women not using hormonal contraception [n = 12], women using second [n = 12] or third generation [n = 12] combined oral contraceptives, and women using progestin only contraceptive [n = 5]. Patients with coagulation abnormalities were also assessed [n = 8]. The APC resistance was assessed on the FibWave using exogenous APC or Protac, and on the Calibrated Automated Thrombogram using the ETP-based APC resistance assay. RESULTS Either in presence or in absence of APC or Protac, the FibWave was able to detect a hypercoagulable state in plasma samples. All combined oral contraceptives showed a lower FW-Max1 , FW-Max2, and FW-Min2 percentage of inhibition and a lower FW-Ttpeak ratio than the other groups. The sensitivity of the FibWave was similar to the one of the ETP-based APC resistance assay. CONCLUSION The FibWave is able to differentiate APC resistance levels observed in women on combined oral contraceptive. The FW-Max1 , FW-Max2, and to a lesser degree FW-Min2 were identified as the most sensitive parameters with a similar performance to the ETP-based APC resistance assay.
Collapse
Affiliation(s)
- Jonathan Evrard
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Laure Morimont
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium.,Qualiblood s.a, Namur, Belgium
| | - Marie Didembourg
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Hélène Haguet
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Romain Siriez
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - Jean-Michel Dogné
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium.,Namur Biobank-eXchange (NAB-X), University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium.,Qualiblood s.a, Namur, Belgium
| |
Collapse
|
10
|
Morimont L, Bouvy C, Delvigne AS, Dogné JM, Douxfils J. Proof of concept of a new scale for the harmonization and the standardization of the ETP-based APC resistance. J Thromb Haemost 2020; 18:895-904. [PMID: 31984653 DOI: 10.1111/jth.14745] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/23/2019] [Accepted: 01/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The evaluation of the activated protein C resistance (APCr) based on the endogenous thrombin potential (ETP) is recommended during the development of steroid contraceptives. Results are usually expressed as "normalized APC sensitivity ratio" (nAPCsr) using a reference plasma that should achieve an ETP ratio of 0.1 in presence of exogenous APC. Because of the interassay variability, achieving exactly an ETP ratio of 0.1 in each run is almost impossible, which significantly affects the theoretical 0-10 scale of nAPCsr. OBJECTIVES To compare the nAPCsr to the nAPCsr10 , a newly proposed method to express the degree of APC resistance. METHODS Individual plasma samples (n = 854) were analyzed to compare nAPCsr and nAPCsr10 . These values were obtained using the validated ETP-based APCr assay. RESULTS The Spearman correlation between nAPCsr and nAPCsr10 had a coefficient of 0.99. Linear regression showed the following equation y = 0.9315*x + 0.03942 (r2 = .97). When differences (nAPCsr10 - nAPCsr) were plotted against nAPCsr10 , the mean difference equaled 0.16% or 4.95%. The correction obtained with the use of the nAPCsr10 showed that the results of the nAPCsr were statistically different (P < .0001). CONCLUSIONS This new scale provides a harmonization and normalization of the nAPCsr. Results show a better reproducibility with the nAPCsr10 . It avoids the additional variability and the unharmonized scale introduced by the use of a reference plasma. This adapted method for the calculation of the APC resistance could provide the regulatory and scientific bodies with more reproducible and harmonized evaluations.
Collapse
Affiliation(s)
- Laure Morimont
- Qualiblood sa, Namur, Belgium
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences, University of Namur, Namur, Belgium
| | | | | | - Jean-Michel Dogné
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences, University of Namur, Namur, Belgium
| | - Jonathan Douxfils
- Qualiblood sa, Namur, Belgium
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, NAmur Research Institute for LIfe Sciences, University of Namur, Namur, Belgium
| |
Collapse
|
11
|
Dulíček P, Chrobák L, Kalousek I, Pešavová L, Pecka M, Stránský P. Is Factor V Leiden a Risk Factor for Fetal Loss? ACTA MEDICA (HRADEC KRÁLOVÉ) 2019. [DOI: 10.14712/18059694.2019.150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
A successful pregnancy is dependent on the development of adequate placental circulation. The abnormalities of placental vasculature may result in a number of gestational pathologies, including fetal loss. The aim of our study was to determine whether women with f V Leiden are at an increased risk of pregnancy loss. For this purpose we assessed three groups of women. In a prospective group we examined 30 females with spontaneous abortions for f V Leiden. In a retrospective group we assessed the frequency of abortions in 80 women (l72 pregnancies) with f V Leiden (72 heterozygous, 8 homozygous) from 57 unrelated families. In a control group we evaluated the frequency of abortions in 45 women without f V Leiden. Factor V Leiden was found in 3% of women in the 1st group. Fetal loss occurred in 10% of women in the 2nd group and in 9% in the 3rd group. Factor V Leiden was not found to be a risk factor for fetal loss in our study group.
Collapse
|
12
|
De Lucia D, De Vita F, Orditura M, Renis V, Belli A, Conte M, di Grazia M, Iacoviello L, Donati MB, Catalano G. Hypercoagulable State in Patients with Advanced Gastrointestinal Cancer: Evidence for an Acquired Resistance to Activated Protein C. TUMORI JOURNAL 2018; 83:948-52. [PMID: 9526590 DOI: 10.1177/030089169708300615] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aims and background Thromboembolic complications are common in patients with cancer and represent the second cause of death in patients with overt malignant disease. The aim of this study was to investigate the activated protein C pathway in cancer. Methods We studied the coagulation cascade, natural clotting inhibitors, fibrinolytic proteins and resistance to activated protein C in 20 patients with advanced gastrointestinal cancer and 84 volunteers by measuring PT, APTT, fibrinogen, AT III, PC, PS, APC resistance, fibrinolytic system (PLG, ANPL, PAI-1 and t-PA) and activation peptides (D-Dimers, prothrombin 0 fragment 1+2/F1+2). Results Laboratory tests confirmed coagulation abnormalities in cancer patients. Fibrinogen, D-Dimers and F1+2 were increased, while t-PA activity was significantly lower than that of controls. APC resistance was higher in cancer patients compared to the control group (55% vs 2%; P < 0.0001). Excess thrombin generation was manifested by increased F1+2 plasma levels in APC-resistant cancer patients. Genetic analyses showed that only one patient with a poor response to APC carried a factor V R506Q mutation in exon 10. Conclusions Our findings show a high prevalence of APC resistance in cancer, compatible with an acquired defect in the APC pathway.
Collapse
Affiliation(s)
- D De Lucia
- Institute of General Pathology and Oncology, II University of Naples, Italy
| | | | | | | | | | | | | | | | | | | |
Collapse
|
13
|
Gerlach M, Föhre B, Keh D, Riess H, Falke K, Gerlach H. Global and Extended Coagulation Monitoring during Extracorporeal Lung Assist with Heparin-Coated Systems in ARDS Patients. Int J Artif Organs 2018. [DOI: 10.1177/039139889702000107] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Heparin-coated systems for extracorporeal lung-assist (ECLA) were developed to reduce hemorrhagic risk by lowering the systemic heparinization, monitored by global tests, e.g. activated coagulation time (ACT) and activated partial thromboplastin time (APTT). Since this strategy gives no insight into procoagulant states, five ARDS patients receiving ECLA with heparin-coated systems were investivated for changes in coagulation using both global and extended tests. During ECLA onset the APTT and ACT were within or near normal ranges, platelets decreased 76.5% within 48h, fibrinogen decreased 28.7%, thrombin-antithrombin-III complexes were elevated before ECLA (53 μg/L), but demonstrated an additional peak (238 μg/L), plasminogen-activator-inhibitor-1 increased 12-fold, and the C1-inhibitor dropped 14.1%. In conclusion, after the onset of ECLA from a previous prethrombotic state, the precoagulant, anticoagulant, fibrinolytic and complement systems were activated in a similar way to that reported for non-heparinized systems with high-dose heparin. This was however only monitored by an extended test panel which was unable to predict thromboembolic events during ECLA.
Collapse
Affiliation(s)
- M. Gerlach
- Clinic for Anesthesiology and Critical Care Medicine, Virchow-Klinikum of the Humboldt University, Berlin - Germany
| | - B. Föhre
- Clinic for Anesthesiology and Critical Care Medicine, Virchow-Klinikum of the Humboldt University, Berlin - Germany
| | - D. Keh
- Clinic for Anesthesiology and Critical Care Medicine, Virchow-Klinikum of the Humboldt University, Berlin - Germany
| | - H. Riess
- Medical Clinic, Department of Hematology and Hemostaseology, Virchow-Klinikum of the Humboldt University, Berlin - Germany
| | - K.J. Falke
- Clinic for Anesthesiology and Critical Care Medicine, Virchow-Klinikum of the Humboldt University, Berlin - Germany
| | - H. Gerlach
- Clinic for Anesthesiology and Critical Care Medicine, Virchow-Klinikum of the Humboldt University, Berlin - Germany
| |
Collapse
|
14
|
Abstract
SummaryAn overview is given on the method and the applications of thrombin generation assays. Thrombin generation assays provide a tool which can be used to trace the entire thrombin formation and inactivation of a plasma sample. Therefore they are principally different from traditional global assays like PT and aPTT and promise new opportunities for the assessment of bleeding or thrombotic risks.
Collapse
|
15
|
Tanratana P, Ellery P, Westmark P, Mast AE, Sheehan JP. Elevated Plasma Factor IXa Activity in Premenopausal Women on Hormonal Contraception. Arterioscler Thromb Vasc Biol 2017; 38:266-274. [PMID: 29097362 DOI: 10.1161/atvbaha.117.309919] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 10/12/2017] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Combined oral contraceptives induce a reversible hypercoagulable state with an enhanced risk of venous thromboembolism, but the underlying mechanism(s) remain unclear. Subjects on combined oral contraceptives also demonstrate a characteristic resistance to APC (activated protein C) in the thrombin generation assay. Here, we report the potential role of plasma factor IXa (FIXa) as a mechanism for hormone-induced systemic hypercoagulability. APPROACH AND RESULTS A novel assay was used to determine FIXa activity in plasma samples from volunteer blood donors. Plasma from 36 premenopausal females on hormonal contraception and 35 not on hormonal contraception, 35 postmenopausal females, and 10 males were analyzed for FIXa activity, total PS (protein S), total tissue factor pathway inhibitor (TFPI), and TFPI-α antigen. Premenopausal females on hormonal contraception demonstrated significantly increased FIXa activity and decreased TFPI-α compared with the other groups. Remarkably, FIXa values were not normally distributed in the hormonal contraception group, but skewed toward the high end. Plasma FIXa activity inversely correlated with both TFPI-α and total PS antigen. Ex vivo determination of TF-dependent FIX activation in FV-deficient plasma demonstrated that inhibitory anti-TFPI antibodies enhanced FIXa generation by 2- to 3-fold, whereas addition of 75 nmol/L PS reduced FIXa generation by ≈2-fold. Further, increasing FIXa concentration enhanced APC resistance during TF-triggered plasma thrombin generation. CONCLUSIONS Elevation of plasma FIXa activity in association with reductions in TFPI-α and PS is a potential mechanism for systemic hypercoagulability and resistance to APC in premenopausal females on hormonal contraception.
Collapse
Affiliation(s)
- Pansakorn Tanratana
- From the Department of Pathology and Laboratory Medicine (P.T.), Department of Medicine/Hematology-Oncology (P.W., J.P.S.), University of Wisconsin School of Medicine and Public Health, Madison; Department of Pharmacology, Faculty of Science, Mahidol University, Bangkok, Thailand (P.T.); Blood Research Institute, Blood Center of Wisconsin, Milwaukee (P.E., A.E.M.); and School of Biomedical Sciences, Curtin University, Perth, Western Australia, Australia (P.E.)
| | - Paul Ellery
- From the Department of Pathology and Laboratory Medicine (P.T.), Department of Medicine/Hematology-Oncology (P.W., J.P.S.), University of Wisconsin School of Medicine and Public Health, Madison; Department of Pharmacology, Faculty of Science, Mahidol University, Bangkok, Thailand (P.T.); Blood Research Institute, Blood Center of Wisconsin, Milwaukee (P.E., A.E.M.); and School of Biomedical Sciences, Curtin University, Perth, Western Australia, Australia (P.E.)
| | - Pamela Westmark
- From the Department of Pathology and Laboratory Medicine (P.T.), Department of Medicine/Hematology-Oncology (P.W., J.P.S.), University of Wisconsin School of Medicine and Public Health, Madison; Department of Pharmacology, Faculty of Science, Mahidol University, Bangkok, Thailand (P.T.); Blood Research Institute, Blood Center of Wisconsin, Milwaukee (P.E., A.E.M.); and School of Biomedical Sciences, Curtin University, Perth, Western Australia, Australia (P.E.)
| | - Alan E Mast
- From the Department of Pathology and Laboratory Medicine (P.T.), Department of Medicine/Hematology-Oncology (P.W., J.P.S.), University of Wisconsin School of Medicine and Public Health, Madison; Department of Pharmacology, Faculty of Science, Mahidol University, Bangkok, Thailand (P.T.); Blood Research Institute, Blood Center of Wisconsin, Milwaukee (P.E., A.E.M.); and School of Biomedical Sciences, Curtin University, Perth, Western Australia, Australia (P.E.)
| | - John P Sheehan
- From the Department of Pathology and Laboratory Medicine (P.T.), Department of Medicine/Hematology-Oncology (P.W., J.P.S.), University of Wisconsin School of Medicine and Public Health, Madison; Department of Pharmacology, Faculty of Science, Mahidol University, Bangkok, Thailand (P.T.); Blood Research Institute, Blood Center of Wisconsin, Milwaukee (P.E., A.E.M.); and School of Biomedical Sciences, Curtin University, Perth, Western Australia, Australia (P.E.).
| |
Collapse
|
16
|
Farris M, Bastianelli C, Rosato E, Brosens I, Benagiano G. Pharmacodynamics of combined estrogen-progestin oral contraceptives: 2. effects on hemostasis. Expert Rev Clin Pharmacol 2017; 10:1129-1144. [DOI: 10.1080/17512433.2017.1356718] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Manuela Farris
- Department of Gynecology, Obstetrics and Urology, Sapienza, University of Rome, Rome, Italy
- AIED, Rome, Italy
| | - Carlo Bastianelli
- Department of Gynecology, Obstetrics and Urology, Sapienza, University of Rome, Rome, Italy
| | - Elena Rosato
- Department of Gynecology, Obstetrics and Urology, Sapienza, University of Rome, Rome, Italy
| | - Ivo Brosens
- LIFE, Leuven Institute for Fertility and Embryology, Leuven, Belgium
| | - Giuseppe Benagiano
- Department of Gynecology, Obstetrics and Urology, Sapienza, University of Rome, Rome, Italy
| |
Collapse
|
17
|
Gemrnati D, Serino ML, Mari R, Verzola I, Moratelli S, Ballerini G. Different Anticoagulant Response to Activated Protein C (APC test) and to Agkistrodon Contortix Venom (ACV test) in a Family with FV-R506Q Substitution. Clin Appl Thromb Hemost 2016. [DOI: 10.1177/107602969700300304] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
To identify the defect(s) responsible for the thrombotic condition affecting a 55-year-old male and his family, we have utilized a new methodological approach (ProC Global®, Istituto Behring, Milan, Italy) to screen the global anticoagulant activity of the protein C pathway, a defect that accounts for the majority of inherited thrombophilias. The test is based on the activation of endogenous protein C in plasma by Protac®, derived from Agkistrodon contortix snake venom (ACV test). Nineteen members of the family were investigated, 11 showed low responsiveness to ACV (normalized ACV ratios < 0.66; normal > 1. 12); in these individuals specific assays of protein C (PC) and protein S (PS) levels and normalized activated protein C ratios (n-APC-r) were performed. A second test evaluating response to APC, using the classic commercial APC test (n-APC-r 1), detected only 10 subjects with abnormal responses : the propositus and two members of the family with n-APC-r 1 values < 0.54, indicating the homozygous state for the R506Q factor V gene mutation, and seven with values ranging 0.69-0.83, consistent with the heterozygous condition (normal > 0.85). Although only ten subjects presented with low n-APC-r 1 values, DNA analysis, in agreement with the ACV test, detected 11 individual with factor V-R506Q substitution (two homozygotes and nine heterozygotes). Thus the classical APC test failed to identify the APC resistance phenotype in two heterozygous subjects whose values were clearly normal (1.05) in the first case and homozygous (0.53) in the second. The ACV test, however, and the modified APC test with test plasma 1/5 diluted in factor V-deficient plasma (n-APC-r 2) completely matched the DNA analysis. A phenotype/genotype correlation was observed in dilutions higher than 1/3 test plasma factor V-deficient plasma. The presence of unknown mechanisms that influence plasma response to exogenous preformed APC (normal at high factor V-deficient plasma dilutions) but not endogenous ACV activated PC was suspected. The suspected low levels of proteins C and S found in several R506Q members of the family were excluded by reassaying the anticoagulant activities at higher plasma dilution ; this supports the known influence of factor V Leiden on functional PC and PS clotting activity. We conclude that the ACV test is appropriate to evaluate the APC resistance condition, but for a firm diagnosis DNA analysis together with the modified APC test are strongly advised even in the presence of unquestionable APC-r values. Key Words: APC resistance-Factor V Leiden-APC test-ACV test-Diagnosis-Inherited thrombophilia.
Collapse
Affiliation(s)
- Donate Gemrnati
- Center for the Study of Haemostasis and Thrombosis, University of Ferrara, Ferrara, Italy
| | - Maria L. Serino
- Center for the Study of Haemostasis and Thrombosis, University of Ferrara, Ferrara, Italy
| | - Rosella Mari
- Center for the Study of Haemostasis and Thrombosis, University of Ferrara, Ferrara, Italy
| | - Isabella Verzola
- Center for the Study of Haemostasis and Thrombosis, University of Ferrara, Ferrara, Italy
| | - Stefano Moratelli
- Center for the Study of Haemostasis and Thrombosis, University of Ferrara, Ferrara, Italy
| | - Giorgio Ballerini
- Center for the Study of Haemostasis and Thrombosis, University of Ferrara, Ferrara, Italy
| |
Collapse
|
18
|
Sayinalp N, Haznedaroğlu IC, Aksu S, Büyükaşik Y, Göker H, Parlak H, Ozcebe OI, Kirazli S, Dündar SV, Gürgey A. The Predictability of Factor V Leiden (FV:Q506) Gene Mutation via Clotting-Based Diagnosis of Activated Protein C Resistance. Clin Appl Thromb Hemost 2016; 10:265-70. [PMID: 15247984 DOI: 10.1177/107602960401000309] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
After the discovery of activated protein C resistance (APCR) due to factor V Leiden mutation and the causal relationship of the phenomenon with clinical thromboembolism, a wide variety of functional clotting-based assays were developed for testing of APCR in relation to the specific DNA-based analysis of FV:Q506 Leiden. The aim of this study is to assess a clotting-based APCR assay using procoagulant crotalidae snake venom with respect to the sensitivity, specificity, and predictability for the presence of the factor V Leiden mutation. APCR testing and factor V DNA analyses have been performed concurrently on 319 patient specimens. APCR values of the patients with homozygous factor V Leiden mutation (70.4±13.5 s) were significantly lower (p<0.001) in comparison to the subjects with the heterozygous mutation (87.6±13.4 s). The assay is highly sensitive (98.7%) and specific (91.9%) for the screening of factor V Leiden mutation. The sensitivity and specificity of the APCR testing reached to 100% below the cut-off value of 120 s among the patients with homozygous factor V Leiden mutation. Therefore, this method could help the desired effective optimal screening strategy for the laboratory search of hereditary thrombophilia focusing on the diagnosis of APCR due to FV:Q506.
Collapse
Affiliation(s)
- N Sayinalp
- Hacettepe University Medical School, Department of Hematology, Ankara, Turkey.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
19
|
Al-Allawi NAS, Shamdeen MY, Mohammed QO, Ahmed AS. Activated protein C resistance and antiphospholipid antibodies in recurrent fetal loss: experience of a single referral center in northern iraq. Indian J Hematol Blood Transfus 2014; 30:364-9. [PMID: 25435743 PMCID: PMC4243407 DOI: 10.1007/s12288-014-0348-6] [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] [Received: 08/17/2013] [Accepted: 01/28/2014] [Indexed: 12/01/2022] Open
Abstract
The current study was initiated to determine the prevalence of activated protein C (APC) resistance, factor V Leiden and antiphospholipid antibodies (APA) in Iraqi women with recurrent fetal loss (RFL), and evaluate the outcome of intervention in those with such states. For this purpose a total of 103 Iraqi women referred to a major teaching hospital in Northern Iraq with two or more consecutive fetal losses, as well as 100 age matched women with no history of fetal loss and at least one live birth were enrolled. After appropriate clinical evaluation, the enrolled subjects were tested for APA as well as APC resistance. Subjects who were APC resistant were further tested for factor V Leiden mutation using a polymerase chain reaction and reverse hybridization. Patients with documented APA and/or with APC resistance, were put on low dose aspirin with or without low molecular weight heparin during pregnancy, and followed for a minimum of 5 years. The results revealed that among patients' group, APA were detected in 19.4 % compared to 1.0 % of the controls (OR 23.9, p = 0.00005). On the other hand, APC resistance was documented in 9.7 % compared to 1.0 % of the controls (OR 10.6, p = 0.01). Factor V Leiden was detected in 3.9 % of patients and 1 % of the controls (p = 0.38). Among 17 patients with APA available for follow up, there were 24 pregnancies, 18 of which ended with live births (75 %). While among the ten patients who had factor V Leiden or were APC resistant non-carriers, there were 13 pregnancies, 12 ended with live births (92.3 %). In conclusion, this study has demonstrated that among the enrolled Iraqi women, APA and APCR and not factor V Leiden were significantly associated with RFL, and that treatment with aspirin (with or without low molecular weight heparin) had lead to live births in 80.6 % of pregnancies.
Collapse
Affiliation(s)
- Nasir A. S. Al-Allawi
- />Department of Pathology, College of Medicine, University of Duhok, 9 Azadi Hospital Rd, Duhok, 1014AM Iraq
| | - Maida Y. Shamdeen
- />Department of Obstetrics and Gynecology, College of Medicine, University of Duhok, Duhok, Iraq
| | | | | |
Collapse
|
20
|
Effects of oral contraceptives on selected parameters of the homeostatic control system in young women having a sudden disorder of the auditory and/or balance system. Eur Arch Otorhinolaryngol 2013; 272:321-6. [PMID: 24337825 PMCID: PMC4293499 DOI: 10.1007/s00405-013-2853-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 11/30/2013] [Indexed: 11/17/2022]
Abstract
The purpose of the paper was to assess the effects of oral contraceptives on selected parameters of the homeostatic control system in women having a sudden disorder of the auditory and/or balance system. The study included 105 young women divided into two groups: Group I—52 women with the disorder of the auditory and/or balance system using hormonal contraceptives for at least 2 months, aged 20–49; and Group II—53 women without any disorder of the auditory and/or balance system using hormonal contraceptives for at least 2 months, aged 18–40. The patients included in the study underwent a full otoneurological evaluation, detailed laryngological diagnostics and an evaluation of selected parameters of the homeostatic control system—fibrinogen level, D-dimer level, evaluation of APTT and PT indicator, plasma estradiol and progesterone with the Roche Cobas analyser by means of chemiluminescence. The vertigo occurring in the study group was most often central (59.6 % of cases), mixed with compensation in 36.6 % of cases, and peripheral only in 3.8 % of cases, indicating labyrinth damage in 40.4 % of cases. An analysis of the progesterone level, considering the menstrual cycle phase in the group, showed that its value was abnormal in 51.0 % of women in the study group and 47.1 % in the control group. In their own studies, the authors observed that the estradiol level in the plasma, considering the menstrual cycle phase in the study group, was abnormal in 41.2 % of women and that the differences in its concentration were statistically significant in the study and control groups (p = 0.005), which may have a negative impact on the possibility of a thromboembolic episode.
Collapse
|
21
|
Abstract
There is now compelling evidence that use of oral contraceptives and postmenopausal hormonal therapies containing various estrogens is associated with a weak, but clinically relevant risk of both arterial and venous thrombosis. The increased risk is related to type and dose of both estrogen and combined progestagen and mode of delivery. Treatment induces mainly subtle changes in individual components of the coagulation and fibrinolytic systems, but the overall effect is the induction of a prothrombotic phenotype. This brief review summarizes some of the mechanisms responsible the prothrombotic effects of such treatment.
Collapse
Affiliation(s)
- Per Morten Sandset
- Oslo University Hospital Rikshospitalet, Department of Haematology and Research Institute of Internal Medicine, University of Oslo, Oslo, Norway.
| |
Collapse
|
22
|
Wpływ działania doustnych środków antykoncepcyjnych na wybrane parametry układu hemostazy u młodych kobiet z nagłym zaburzeniem czynności układu równowagi. Otolaryngol Pol 2013; 67:25-9. [DOI: 10.1016/j.otpol.2012.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 09/12/2012] [Accepted: 09/28/2012] [Indexed: 11/22/2022]
|
23
|
Tchaikovski S, Tans G, Rosing J. Venous thrombosis and oral contraceptives: current status. WOMENS HEALTH 2012; 2:761-72. [PMID: 19803829 DOI: 10.2217/17455057.2.5.761] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The use of oral contraceptives is associated with an increased risk of venous thrombosis. It is now generally accepted that women who use oral contraceptives that contain so-called third-generation progestins (desogestrel or gestodene) are exposed to a twofold higher risk of venous thrombosis than women who use oral contraceptives that contain the second-generation progestin levonorgestrel. Coagulation studies demonstrated that oral contraceptives increase the plasma level of prothrombin, decrease the level of protein S and induce acquired activated protein C resistance. The changes in hemostatic parameters can explain why women who use oral contraceptives are exposed to an increased risk of venous thrombosis and why the risk is further increased in third-generation oral contraceptive users.
Collapse
Affiliation(s)
- Svetlana Tchaikovski
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands.
| | | | | |
Collapse
|
24
|
Guermazi S, Znazen R. [Activated protein C resistance and factor V Leiden: clinical interest]. PATHOLOGIE-BIOLOGIE 2011; 59:281-285. [PMID: 19896782 DOI: 10.1016/j.patbio.2009.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Accepted: 05/15/2009] [Indexed: 05/28/2023]
Abstract
Activated protein C resistance (APCR) is a coagulation abnormality often linked to FV Leiden mutation, a single nucleotide G1691A substitution resulting in arginine 506→glutamine missense factor V mutation. FV Leiden has a frequency of 20 to 30% in groups of patients with venous thrombosis while it is of 4 to 10% in normal subjects. FV Leiden is considered as a weak risk factor of thrombosis except in homozygote. FV Leiden is implicated in deep venous thrombosis occurrence. Duration of oral anticoagulant treatment is six months in patients developing a first venous thrombosis except in patients with combined defects or a clinical context suggesting a high risk of severe relapse. Detection of APCR by coagulation methods is often used in first intention with a high specificity if plasmas tested are diluted in factor V deficient plasma. Genotyping study is essential to establish the heterozygote or homozygote statute and certain teams perform it directly. Nevertheless, APCR not related to FV Leiden could be an independent thrombosis risk factor. APCR and FV Leiden are included in laboratory investigations of thrombophilic markers in patients less than 50 years with venous thrombosis. In arterial thrombosis, FV Leiden implication is weak or absent. FV Leiden increases the risk of thrombosis in other situations as in patients with cancer. An association with recurrent miscarriages and other vasculoplacental complications is also reported in many studies but the data concerning the efficacy of antithrombotic treatment to prevent recurrence are currently insufficient.
Collapse
Affiliation(s)
- S Guermazi
- Laboratoire d'hématologie, hôpital Charles-Nicolle, boulevard du 9 avril, 1006 Tunis, Tunisie.
| | | |
Collapse
|
25
|
Scobie GA, Ho ST, Dolan G, Kalsheker NA. Development of a rapid DNA screening procedure for the Factor V Leiden mutation. Mol Pathol 2010; 49:M361-3. [PMID: 16696104 PMCID: PMC408088 DOI: 10.1136/mp.49.6.m361] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Aim-To develop a rapid, simple and highly specific DNA screening procedure based on the amplification refractory mutation system (ARMS) to detect the Leiden mutation in whole blood.Methods-ARMS PCR amplification primers with additional mismatches at either -2 or -3, which greatly improves specificity, were constructed to detect the normal Factor V gene and the Leiden mutation in whole blood samples from patients with abnormal clotting results.Results-Construction of ARMS primers with either an additional mismatch at -2 or -3 at the 3' end of the primer could be used to detect the Leiden mutation in 0.5 mu1 whole blood in under three hours. Primers destabilised at position -3 could be used at a lower annealing temperature, which gave greater sensitivity and are now routinely used. A control set of primers was included in the same reaction to act as a positive control.Conclusions-This rapid and specific assay for the factor V Leiden mutation is a useful addition to the investigation of patients with or at risk from thrombovascular disease.
Collapse
Affiliation(s)
- G A Scobie
- Division of Clinical Laboratory Sciences, Department of Clinical Chemistry, Queens Medical Centre, Nottingham
| | | | | | | |
Collapse
|
26
|
Bogdanova N, Markoff A. Hereditary thrombophilic risk factors for recurrent pregnancy loss. J Community Genet 2010; 1:47-53. [PMID: 22460204 DOI: 10.1007/s12687-010-0011-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Accepted: 05/26/2010] [Indexed: 11/26/2022] Open
Abstract
This review summarizes current knowledge about the role of hereditary hypercoagulation factors predisposing to thrombophilia-associated recurrent fetal loss. Thrombophilias are a major cause of adverse pregnancy outcome, playing a role in the etiology of up to 40% of cases worldwide. Hereditary thrombophilic predispositions to recurrent pregnancy wastage include genetic lesions in blood coagulation factors II and V as well as natural anticoagulants antithrombin, protein C, and protein S. Furthermore, methylenetetrahydrofolate reductase gene variants conferring higher thrombophilia risk in combination with these mutations and the newly described annexin A5 gene M2 promoter allele are associated with repeated fetal loss. The review gives a concise description of the molecular defects arising from the genetic changes, of the role these factors play in the timing and definition of fetal loss, and risk estimates from available studies and meta-analysis. This knowledge is instrumental for a more precise assessment of individual risks for repeated fetal loss and should guide therapeutic strategies, where relevant. Since the average childbearing age increases in Western societies, the importance of a timely diagnosis of fetal loss predisposition is increasing.
Collapse
Affiliation(s)
- Nadja Bogdanova
- Institute of Human Genetics, Westfalian-Wilhelms University of Muenster, Vesaliusweg 12-14, 48149, Münster, Germany,
| | | |
Collapse
|
27
|
Zakharova MY, Meyer RM, Brandy KR, Datta YH, Joseph MS, Schreiner PJ, Rao GH, Divani AA. Risk Factors for Heart Attack, Stroke, and Venous Thrombosis Associated With Hormonal Contraceptive Use. Clin Appl Thromb Hemost 2010; 17:323-31. [DOI: 10.1177/1076029610368670] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The search for a safe and effective method of contraception has been ongoing for centuries. During the last century, a variety of hormonal contraceptives, including combined hormonal oral contraceptives (COCs), have been introduced into the market. COCs have evolved through modifications of different hormonal components to minimize the risk of thrombotic events including stroke, myocardial infarction, and venous thrombosis. The evolution of COC development led to the reduction in the estrogen dose, in an attempt to lower the risk of vascular diseases. Although the risk of thrombotic events due to COC use has been substantially reduced since their inception, the quest for developing safer methods of birth control continues. It is of great interest to study coagulation effects of newer COCs, as well as progestin only, as rigorously as older COCs.
Collapse
Affiliation(s)
- Marina Y. Zakharova
- Minnesota Stroke Initiative, Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Rachel M. Meyer
- Minnesota Stroke Initiative, Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Kyle R. Brandy
- Minnesota Stroke Initiative, Department of Neurology, University of Minnesota, Minneapolis, MN, USA
| | - Yvonne H. Datta
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Marilyn S. Joseph
- Department of Obstetrics and Gynecology, University of Minnesota, Minneapolis, MN, USA
| | - Pamela J. Schreiner
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Gundu H. Rao
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Afshin A. Divani
- Minnesota Stroke Initiative, Department of Neurology, University of Minnesota, Minneapolis, MN, USA,
| |
Collapse
|
28
|
Abstract
Proteolytic inactivation of factors Va (FVa) and VIIIa (FVIIIa) by activated protein C (APC) and its cofactors protein S and factor V (FV) is a key process in the physiological down-regulation of blood coagulation. Functional abnormalities of this pathway, which manifest themselves in vitro as a poor anticoagulant response of plasma to added APC (APC resistance), are prevalent in the general population and are associated with an increased risk of venous thrombosis. APC resistance was originally discovered in thrombophilic families and later shown to be associated with the common FV Arg506Gln (FV(Leiden)) mutation, which abolishes one of the APC-cleavage sites in FV. Although FV(Leiden) is the major cause of hereditary APC resistance, it is becoming increasingly clear that several other genetic and acquired conditions contribute to APC resistance and thereby increase the risk of venous thrombosis. This paper reviews the multifactorial etiology of APC resistance and discusses its clinical implications.
Collapse
Affiliation(s)
- E Castoldi
- Department of Biochemistry, Maastricht University, Maastricht, the Netherlands
| | | |
Collapse
|
29
|
Tchaikovski SN, Rosing J. Mechanisms of estrogen-induced venous thromboembolism. Thromb Res 2010; 126:5-11. [PMID: 20163835 DOI: 10.1016/j.thromres.2010.01.045] [Citation(s) in RCA: 143] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Revised: 01/21/2010] [Accepted: 01/24/2010] [Indexed: 12/14/2022]
Abstract
The use of oral contraceptives (OC) is a well established risk factor for venous thrombosis. It has been known for many years that almost all haemostatic parameters i.e. plasma levels of coagulation factors, anticoagulant proteins and proteins involved in the fibrinolytic pathway change during OC use. The discovery of several risk factors of venous thrombosis in the 1990s shed new light on the association between the effects of OC on the haemostatic system and the increased risk of venous thrombosis. In this review, we summarize the current knowledge on the effects of different kinds of hormonal contraceptives (OC, transdermal contraceptives, vaginal ring and levonorgestrel-releasing intrauterine device) on haemostatic variables and the relationship between the changes of these variables and the risk of venous thrombosis.
Collapse
Affiliation(s)
- Svetlana N Tchaikovski
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | | |
Collapse
|
30
|
|
31
|
Middeldorp S, van Hylckama Vlieg A. Does thrombophilia testing help in the clinical management of patients? Br J Haematol 2008; 143:321-35. [PMID: 18710381 DOI: 10.1111/j.1365-2141.2008.07339.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Saskia Middeldorp
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.
| | | |
Collapse
|
32
|
Abstract
Inherited thrombophilia can be defined as a genetically determined predisposition to the development of thromboembolic complications. Since the discovery of activated protein C resistance in 1993, several additional disorders have been described and, at present, it is possible to identify an inherited predisposition in about 60 to 70% of patients with such complications. These inherited prothrombotic risk factors include qualitative or quantitative defects of coagulation factor inhibitors, increased levels or function of coagulation factors, defects of the fibrinolytic system, altered platelet function, and hyperhomocysteinemia. In this review, the main inherited prothrombotic risk factors are analyzed from epidemiological, laboratory, clinical, and therapeutic points of view. Finally, we discuss the synergism between genetic and acquired prothrombotic risk factors in particular conditions such as childhood and pregnancy.
Collapse
Affiliation(s)
- Massimo Franchini
- Servizio di Immunoematologia e Trasfusione, Azienda Ospedaliera di Verona, Verona, Italy.
| | | | | | | | | |
Collapse
|
33
|
Muthukumar N. Cerebral venous sinus thrombosis and thrombophilia presenting as pseudo-tumour syndrome following mild head injury. J Clin Neurosci 2008; 11:924-7. [PMID: 15519881 DOI: 10.1016/j.jocn.2003.10.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2003] [Accepted: 10/03/2003] [Indexed: 02/07/2023]
Abstract
Cerebral venous sinus thrombosis (CVT) after mild head injury is infrequent. A 38-year-old patient presented with a Glasgow Coma score (GCS) of 15 after a road traffic accident. CT scan revealed a temporal contusion. He was treated with measures to prevent cerebral oedema and anticonvulsants. Three weeks later he presented with features of pseudo-tumour syndrome. Investigations revealed the presence of cerebral venous sinus thrombosis, protein C deficiency and elevated titres of antiphospholipid antibodies. He was treated with anticoagulants and showed improvement. This case report highlights that multiple "hits" may lead to CVT and hence laboratory screening of patients with CVT is necessary even if the clinical situation seemingly provides sufficient explanation for a thrombotic event. The presence of acquired and inherited causes of thrombophilia need not always lead to symptomatic thrombosis. As illustrated by this case, a second hit, such as trauma, may be the precipitating factor that unmasks the prothrombotic state.
Collapse
|
34
|
Majluf-Cruz A, Moreno-Hernández M, Ruiz-de-Chávez-Ochoa A, Monroy-García R, Majluf-Cruz K, Guardado-Mendoza R, Molina-Ávila I, Isordia-Salas I, Corona-de la Peña N, Vargas-Vorackova F, Vela-Ojeda J, García-Chávez J. Activated Protein C Resistance and Factor V Leiden in Mexico. Clin Appl Thromb Hemost 2007; 14:428-37. [DOI: 10.1177/1076029607306807] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
A common cause of hereditary thrombophilia is activated protein C resistance (APCR), and most cases result from factor V Leiden mutation. An APCR phenotype without association with factor V Leiden has been described. This transversal, observational, nonrandomized study evaluated these 2 phenomena in healthy indigenous and mestizo Mexican subjects (n = 4345), including 600 Mexican natives. No indigenous subjects had APCR, but 82 mestizo subjects did. After retesting, 50 subjects had a negative test. The remaining 32 subjects had factor V Leiden, giving a 0.85% prevalence of factor V Leiden in the mestizo Mexican population. Only 31% of APCR carriers had factor V Leiden. These results show a very low prevalence of APCR and factor V Leiden in Mexico. Except for factor V Leiden, there are no other mutations in the factor V gene responsible for the APCR phenotype. Acquired APCR is nearly twice as prevalent as the inherited variant.
Collapse
Affiliation(s)
- Abraham Majluf-Cruz
- Unidad de Investigación Médica en Trombosis, Hemostasia y Aterogénesis, Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico, , amajlufc@ gmail.com
| | - Manuel Moreno-Hernández
- Unidad de Investigación Médica en Trombosis, Hemostasia y Aterogénesis, Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico
| | - Adriana Ruiz-de-Chávez-Ochoa
- Unidad de Investigación Médica en Trombosis, Hemostasia y Aterogénesis, Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico
| | - Rosario Monroy-García
- Unidad de Investigación Médica en Trombosis, Hemostasia y Aterogénesis, Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico
| | - Karim Majluf-Cruz
- Unidad de Investigación Médica en Trombosis, Hemostasia y Aterogénesis, Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico
| | - Rodolfo Guardado-Mendoza
- Unidad de Investigación Médica en Trombosis, Hemostasia y Aterogénesis, Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico
| | - Irma Molina-Ávila
- Unidad de Investigación Médica en Trombosis, Hemostasia y Aterogénesis, Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico
| | - Irma Isordia-Salas
- Unidad de Investigación Médica en Trombosis, Hemostasia y Aterogénesis, Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico
| | - Norma Corona-de la Peña
- Unidad de Investigación Médica en Trombosis, Hemostasia y Aterogénesis, Instituto Mexicano del Seguro Social (IMSS), Mexico City, Mexico
| | - Florencia Vargas-Vorackova
- Departamento de Gastroenterología, Instituto Nacional de la Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Jorge Vela-Ojeda
- Departamento de Hematología, Hospital de Especialidades, Centro Médico La Raza, IMSS, Mexico City, Mexico
| | - Jaime García-Chávez
- Departamento de Hematología, Hospital de Especialidades, Centro Médico La Raza, IMSS, Mexico City, Mexico
| |
Collapse
|
35
|
The cost-benefit ratio of screening pregnant women for thrombophilia. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2007; 5:189-203. [PMID: 19204775 DOI: 10.2450/2007.0022-07] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Accepted: 06/07/2007] [Indexed: 11/21/2022]
|
36
|
Sarig G, Brenner B. Identifying women at high risk of venous thrombosis before administration of hormone therapy. WOMEN'S HEALTH (LONDON, ENGLAND) 2007; 3:131-134. [PMID: 19803846 DOI: 10.2217/17455057.3.2.131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Galit Sarig
- Rambam Health Care Campus, Thrombosis and Hemostasis Unit, Haifa 31096, Israel.
| | | |
Collapse
|
37
|
Demirol A, Guven S, Guvendag Guven ES, Kirazli S, Gurgan T, Ayhan A. Comparison of the effects of tibolone and estrogen therapy on hemostasis in surgical menopause: a randomized, double-blind, placebo-controlled study. Fertil Steril 2007; 87:842-8. [PMID: 17222829 DOI: 10.1016/j.fertnstert.2006.08.090] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2005] [Revised: 08/04/2006] [Accepted: 08/04/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To examine the effects of unopposed estrogen (E) and tibolone therapy on coagulation and natural anticoagulant systems in surgical menopause. DESIGN A randomized, double-blind, placebo-controlled study. SETTING University hospital clinic in Turkey. PATIENT(S) Ninety healthy surgically postmenopausal women. INTERVENTION(S) Ninety surgically postmenopausal women were randomized into three groups: unopposed conjugated ET (0.625 mg/d, group 1), tibolone (2.5 mg/d, group 2), and identical tablets of placebo (group 3). MAIN OUTCOME MEASURE(S) Effects on parameters in the clotting cascade at baseline and after 24 weeks of treatment. RESULT(S) After 6 months, fibrinogen, lipoprotein (a), and factor VIIa were decreased, and activated partial thromboplastin time was increased significantly in the ET group compared with in the placebo group. However, tibolone significantly decreased only the serum levels of factor VIIa and factor IX and prolonged the activated partial thromboplastin time, compared with placebo group. In addition, conjugated ET caused a significantly greater decrease in serum fibrinogen level than did tibolone. CONCLUSION(S) Neither E nor tibolone therapy led to activation of coagulation in the surgically menopausal women. Both preparations changed the overall hemostatic balance to a more fibrinolytic state.
Collapse
Affiliation(s)
- Aygul Demirol
- Clinic for Womens' Health, Infertility, and IVF Center, Ankara, Turkey
| | | | | | | | | | | |
Collapse
|
38
|
Agrawal YK, Vaidya H, Bhatt H, Manna K, Brahmkshatriya P. Recent advances in the treatment of thromboembolic diseases: Venous thromboembolism. Med Res Rev 2007; 27:891-914. [PMID: 17318813 DOI: 10.1002/med.20100] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Venous thromboembolic diseases are the major concern of rising cost of healthcare and are commonest health problem across the globe. Both genetic and acquired risk factors are believed to be strongly linked with these diseases. Commonly encountered problems to the therapy include dose fixing and routine monitoring, yet some serious problems of bleeding also necessitate the immediate need to develop new agents. The review is primarily concerned with the new developments in the treatment of thromboembolic diseases. Therapeutic applications of anticoagulants, antiplatelets, and thrombolytics have been discussed in enough detail.
Collapse
Affiliation(s)
- Y K Agrawal
- Institute of Pharmacy, Nirma University of Science and Technology, Sarkhej-Gandhinagar Highway, Ahmedabad 382481, Gujarat, India.
| | | | | | | | | |
Collapse
|
39
|
Torres JD, Cardona H, Alvarez L, Cardona-Maya W, Castañeda SA, Quintero-Rivera F, Cadavid A, Bedoya G, Tobón L. Inherited thrombophilia is associated with deep vein thrombosis in a Colombian population. Am J Hematol 2006; 81:933-7. [PMID: 16917913 DOI: 10.1002/ajh.20733] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The development of venous thromboembolism is influenced by a variety of genetic and environmental risk factors. A few studies have ascertained whether thrombophilic defects are risk factors for venous thromboembolism in Latin American populations with a variable degree of admixture, such as the Colombian population. To address this issue, we conducted a case-control study involving 100 consecutive patients with deep vein thrombosis and 114 healthy controls from the Hospital Universitario San Vicente de Paúl, Medellín, Colombia. Activated protein C resistance (APC resistance) was detected in 25/99 patients vs. 6/114 controls (OR = 6.08, 95% CI = 2.23-17.47). Ten of 100 patients carried the factor V Leiden mutation vs. 1/114 controls (OR = 12.56, 95% CI = 1.61-267). APC resistance was associated with the factor V Leiden mutation in only 10/25 patients. The prothrombin G20210A mutation was found in 4/100 patients, but none of the controls (P < 0.05). There was no significant difference in the proportion of homozygous carriers of methylenetetrahydrofolate reductase C677T variant among patients and controls. In conclusion, in our studied population, factor V Leiden, APC resistance, and prothrombin G20210A were associated with an increased risk of deep vein thrombosis. However, the frequencies of these thrombophilic defects and of APC resistance associated with factor V Leiden was lower than the corresponding frequencies previously reported for Caucasian populations. Further study is required to assess the influence of ethnicity on thrombophilia.
Collapse
Affiliation(s)
- J D Torres
- Grupo de Investigación en Trombosis, Universidad de Antioquia-Hospital Universitario San Vicente de Paúl, Medellín, Colombia.
| | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
Worldwide, hundreds of millions of women use exogenous estrogens in contraceptives or for postmenopausal hormone replacement. Exogenous estrogens increase the risk for venous and arterial thrombosis. This article reviews the use of exogenous sex hormones in women with thrombophilia.
Collapse
Affiliation(s)
- Isobel D Walker
- Glasgow Royal Infirmary, 3rd Floor Macewen Building, Castle Street, Glasgow, Scotland, G4 0SF, United Kingdom.
| |
Collapse
|
41
|
Tripodi A. Issues concerning the laboratory investigation of inherited thrombophilia. ACTA ACUST UNITED AC 2006; 9:181-6. [PMID: 16392896 DOI: 10.1007/bf03260089] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Inherited thrombophilia, defined as an increased familial tendency to develop thrombosis, may be due to congenital deficiencies or abnormalities of antithrombin, protein C or protein S; to the presence of a point mutation in the factor V gene (G1691A, factor V Leiden) leading to a poor anticoagulant response to activated protein C; or to the presence of a mutation in the prothrombin gene (G20210A) leading to increased plasma levels of prothrombin. The laboratory investigation of inherited thrombophilia should be limited to patients with a history of venous thromboembolism and, if positive, to their family members even though they are still asymptomatic. There is no indication for indiscriminate screening of the general population or screening of asymptomatic women before prescribing oral contraceptives. Testing should be based on the phenotype for antithrombin, protein C and protein S; on the phenotype and genotype (factor V Leiden mutation) for activated protein C resistance; and on the genotype (G20210A mutation) for hyperprothrombinemia. Phenotypic testing should be performed no sooner than three months after acute thrombotic events and at least 2 weeks after discontinuation of oral anticoagulant treatment.
Collapse
Affiliation(s)
- Armando Tripodi
- Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Department of Internal Medicine and Dermatology, University and IRCCS Maggiore Hospital, Milan, Italy.
| |
Collapse
|
42
|
Mahjoub T, Mtiraoui N, Tamim H, Hizem S, Finan RR, Nsiri B, Almawi WY. Association between adverse pregnancy outcomes and maternal factor V G1691A (Leiden) and prothrombin G20210A genotypes in women with a history of recurrent idiopathic miscarriages. Am J Hematol 2005; 80:12-9. [PMID: 16138341 DOI: 10.1002/ajh.20419] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Thrombophilia was implicated in the development of pregnancy complications, including recurrent idiopathic pregnancy loss, and is aggravated in women who are carriers of factor V G1691A (FV Leiden) and prothrombin (PRT) G20210A single-nucleotide polymorphisms (SNPs). Previous studies examined the role of FV-Leiden and PRT G20210A in recurrent pregnancy loss with conflicting results. Here we examined the prevalence of FV Leiden and PRT G20210A SNPs, in 200 women with 3 or more consecutive early (n = 87), late (n = 41), or early-late (n = 72) recurrent pregnancy losses, and 200 age-matched fertile parous control women. APC resistance (APCR) was detected functionally (measuring the activated clotting time triggered by activated factor X in presence of a fixed amount of purified APC), and FV-Leiden and PRT G20210A genotypes were assessed by PCR. The frequency of the mutant FV (0.1400 vs. 0.0276; P < 0.001) but not PRT 20210 (0.0100 vs. 0.0225; P = 0.159) allele was higher in patients than controls, respectively. APC resistance with factor V Leiden was seen in 27% of patients compared to 11.5% of controls, while APC resistance without factor V Leiden was seen in 12.5% of patients compared to 9.5% of controls. Regression analysis demonstrated that the significant predictors for early abortion was FV Leiden; those for late abortion were oral contraceptive, APCR, and FV Leiden; and predictors for early-late abortions were oral contraceptives, obesity, FV Leiden, and smoking. APC resistance and FV Leiden, as well as combination of both, are common thrombotic defects seen in women with idiopathic recurrent pregnancy loss, thus testing for these is recommended in women who have experienced recurrent miscarriages.
Collapse
Affiliation(s)
- Touhami Mahjoub
- Research unit of Haematological and Autoimmune Diseases, Faculty of Pharmacy, Monastir, Center University, Tunisia
| | | | | | | | | | | | | |
Collapse
|
43
|
Schreiber MA, Differding J, Thorborg P, Mayberry JC, Mullins RJ. Hypercoagulability Is Most Prevalent Early after Injury and in Female Patients. ACTA ACUST UNITED AC 2005; 58:475-80; discussion 480-1. [PMID: 15761339 DOI: 10.1097/01.ta.0000153938.77777.26] [Citation(s) in RCA: 164] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hypercoagulability after injury is a major source of morbidity and mortality. Recent studies indicate that there is a gender-specific risk in trauma patients. This study was performed to determine the course of coagulation after injury and to determine whether there is a gender difference. We hypothesized that hypercoagulability would occur early after injury and that there would be no difference between men and women. METHODS This was a prospective cohort study. Inclusion criteria were admission to the intensive care unit, Injury Severity Score > 4, and the ability to obtain consent from the patient or a relative. A Thrombelastograph (TEG) analysis was performed and routine coagulation parameters and thrombin-antithrombin complexes were measured within 24 hours of injury and then daily for 4 days. RESULTS Sixty-five patients met criteria for entry into the study. Their mean age was 42 +/- 17 years and their mean Injury Severity Score was 23 +/- 12. Forty patients (62%) were men. The prevalence of a hypercoagulable state by TEG was 62% on day 1 and 26% on day 4 (p < 0.01). Women were significantly more hypercoagulable on day 1 than men as measured by the time to onset of clotting (women, 2.9 +/- 0.7 minutes; men, 3.9 +/- 1.5 minutes; p < 0.01; normal, 3.7-8.3 minutes). Mean platelet counts, international normalized ratios, and partial thromboplastin times were within normal limits throughout the study. Thrombin activation as measured by thrombin-antithrombin complexes decreased from 34 +/- 15 microg/L on day 1 to 18 +/- 8 microg/L (p < 0.01) on day 4, consistent with the prevalence of hypercoagulability by TEG. CONCLUSION Hypercoagulability after injury is most prevalent during the first 24 hours. Women are more hypercoagulable than men early after injury. The TEG is more sensitive than routine coagulation assays for the detection of a hypercoagulable state.
Collapse
|
44
|
Abstract
Abstract
Over the last decade we have witnessed an avalanche of newly identified risk factors for venous thrombosis. This has advanced our knowledge of its etiology, because more determinants have been described and because the underlying concepts have received a new and broader understanding.
Venous thrombosis is a common multicausal disease occurring as the result of interacting genetic, environmental and behavioral risk factors. Some of these have been known since medieval times, such as the increased risk of thrombosis during immobilization in pregnancy and after childbirth (although retained milk of the breast-feeding mother was seen as the primary cause for the latter). Pregnancy and puerperium still cause thrombosis, as do exogenous hormones in oral contraceptives and hormonal replacement therapy. Furthermore, the immobilization in the puerperium of the old days translates directly to situations of immobilization in current times, such as prolonged travel in airplanes or excessive electronic gaming.
While pedigrees with abundant thrombosis were observed in the early 1900s, the first cause of heritable thrombophilia (antithrombin deficiency) was discovered in 1965, with the subsequent identification of deficiencies of protein C and protein S in the early 1980s. These were uncommon and strong risk factors, whereas the more recently discovered genetic variants are common and weak, and cause disease only in the presence of other factors.
Collapse
|
45
|
Rosendaal FR. Venous thrombosis: the role of genes, environment, and behavior. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2005:1-12. [PMID: 16304352 DOI: 10.1182/asheducation-2005.1.1] [Citation(s) in RCA: 88] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Over the last decade we have witnessed an avalanche of newly identified risk factors for venous thrombosis. This has advanced our knowledge of its etiology, because more determinants have been described and because the underlying concepts have received a new and broader understanding. Venous thrombosis is a common multicausal disease occurring as the result of interacting genetic, environmental and behavioral risk factors. Some of these have been known since medieval times, such as the increased risk of thrombosis during immobilization in pregnancy and after childbirth (although retained milk of the breast-feeding mother was seen as the primary cause for the latter). Pregnancy and puerperium still cause thrombosis, as do exogenous hormones in oral contraceptives and hormonal replacement therapy. Furthermore, the immobilization in the puerperium of the old days translates directly to situations of immobilization in current times, such as prolonged travel in airplanes or excessive electronic gaming. While pedigrees with abundant thrombosis were observed in the early 1900s, the first cause of heritable thrombophilia (antithrombin deficiency) was discovered in 1965, with the subsequent identification of deficiencies of protein C and protein S in the early 1980s. These were uncommon and strong risk factors, whereas the more recently discovered genetic variants are common and weak, and cause disease only in the presence of other factors.
Collapse
Affiliation(s)
- Frits R Rosendaal
- Leiden Univ. Med.Center, PO Box 9600, C9-P, 2300 RC Leiden, Netherlands.
| |
Collapse
|
46
|
Duschek EJJ, Neele SJ, Thomassen MCLGD, Rosing J, Netelenbos C. Effect of raloxifene on activated protein C (APC) resistance in postmenopausal women and on APC resistance and homocysteine levels in elderly men. Blood Coagul Fibrinolysis 2004; 15:649-55. [PMID: 15613919 DOI: 10.1097/00001721-200412000-00004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Raloxifene, a selective estrogen receptor modulator, like hormonal replacement therapy increases the risk of venous thromboembolism in postmenopausal women. A possible explanation for the increased thrombotic risk could be an increase in acquired resistance to activated protein C (APC). In two randomized, placebo-controlled, double-blind studies we determined the effect of raloxifene on the normalized APC sensitivity ratios (nAPCsr). The nAPCsr were determined with the thrombin generation-based APC resistance test. In the first study 83 postmenopausal women (age, 51.1 +/- 2.7 years) randomly received daily 0.625 mg conjugated equine estrogen and 2.5 mg medroxyprogesterone acetate (n=17), 60 mg raloxifene (n=23), 150 mg raloxifene (n=20) or placebo (n=23) for 24 months. At baseline and after 6, 12 and 24 months the nAPCsr were measured. In the second study 30 elderly men (age, 64.4 +/- 2.4 years) randomly received 120 mg raloxifene (n=15) or placebo (n=15) for 3 months. At baseline and after 3 months the nAPCsr and fasting homocysteine levels were measured. In postmenopausal women conjugated equine estrogen/medroxyprogesterone acetate significantly increased the nAPCsr from 1.26 +/- 0.82 to 2.87 +/- 0.86 at 24 months (P <0.0005 compared with placebo). Raloxifene had no significant effect on nAPCsr compared with placebo in both women and men. The results did not change after excluding carriers of factor V Leiden. Also fasting homocysteine levels were not affected by raloxifene in the aging men. It is concluded that raloxifene, in contrast to combined hormonal replacement therapy, does not increase APC resistance.
Collapse
Affiliation(s)
- Erik J J Duschek
- Department of Endocrinology, VU University Medical Center, Amsterdam, The Netherlands.
| | | | | | | | | |
Collapse
|
47
|
Alhenc-Gelas M, Plu-Bureau G, Guillonneau S, Kirzin JM, Aiach M, Ochat N, Scarabin PY. Impact of progestagens on activated protein C (APC) resistance among users of oral contraceptives. J Thromb Haemost 2004; 2:1594-600. [PMID: 15333036 DOI: 10.1111/j.1538-7836.2004.00894.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Oral contraceptive (OC) use is associated with an increased risk of venous thromboembolism. Previous data reported higher thrombotic risk in women using third-generation combined OC than in those using second generation OC. The difference could be explained by differential effects of progestagens on plasma sensitivity to activated protein C (APC). The main purpose of this cross-sectional study was to assess the influence of a progestagen-only OC (chlormadinone acetate) as well as the effect of several combined OC with different progestagen components on APC resistance. The effect of APC on endogenous thrombin potential (ETP) was investigated in the plasma of healthy women using either combined OC (n=82) or progestagen-only OC (n=28), and in non-users (n=64). Carriers of factor V Leiden were excluded. Compared with non-users, there was no significant change in APC resistance in women using progestagen-only OC. Women who used combined OC were less sensitive to APC than non-users (P < 0.001) and the difference was significantly more pronounced in women using third-generation OC (n=41) than in those who used second-generation OC containing levonorgestrel (n=22) (P < 0.05). Compared with OC containing levonorgestrel, use of norethisterone-containing OC (n = 9) was associated with an increased resistance to APC (P < 0.05). Women who used cyproterone-containing OC (n = 10) were less sensitive to APC than those using third-generation OC (P < 0.05) or second-generation OC containing levonorgestrel (P < 0.05). Protein S, factor II and FVIII levels explained in part the OC-related changes in APC sensitivity variations. ETP-based APC resistance may contribute to explain why different brands of OC can be associated with different levels of thrombogenicity.
Collapse
Affiliation(s)
- M Alhenc-Gelas
- Service d'Hématologie Biologique A, Hôpital Européen Georges Pompidou (AP-HP), Paris
| | | | | | | | | | | | | |
Collapse
|
48
|
Tans G, van Hylckama Vlieg A, Thomassen MCLGD, Curvers J, Bertina RM, Rosing J, Rosendaal FR. Activated protein C resistance determined with a thrombin generation-based test predicts for venous thrombosis in men and women. Br J Haematol 2003; 122:465-70. [PMID: 12877675 DOI: 10.1046/j.1365-2141.2003.04443.x] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Activated protein C (APC) resistance, determined with a thrombin-generation-based APC resistance test, may explain risk differences of venous thrombosis in users of second- and third-generation oral contraceptives (OC). To clinically validate this test, we analysed the Leiden thrombophilia case-control study (474 patients with a first episode of deep vein thrombosis and 474 age- and sex-matched control subjects). Data for men and women were analysed separately. As hormonal status in women is known to strongly influence the APC sensitivity ratio (APCsr), additional strata (OC use and menopausal state) were defined. The APCsr was higher in all patients than in control subjects. Odds ratios (OR), using the 90th percentile of all control subjects (APCsr > 4.5) as cut-off, were: 7.5 [95% confidence interval (CI) 1.6-33.8] for men, 3.0 (95% CI 1.0-8.8) for premenopausal women not using OC, 4.8 (95% CI 1.6-14.7) for premenopausal women using OC and 4.7 (95% CI 1.4-15.6) for postmenopausal women. After excluding the carriers of factor V Leiden, the OR became infinite for men (no control had an APCsr > 4.5), 1.4 (95% CI 0.2-8.2) for premenopausal women not using OC, 3.4 (95% CI 1.1-10.8) for premenopausal women using OC and 3.6 (95% CI 0.6-20.5) for postmenopausal women. A high APCsr, determined with the thrombin-generation-based APC resistance test, predicts venous thrombotic risk, in populations with and without factor V Leiden. In addition, acquired APC resistance resulting from OC use predicts an increased risk for venous thrombosis independent of factor V Leiden.
Collapse
Affiliation(s)
- Guido Tans
- Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
49
|
Abstract
Hundreds of millions of women worldwide use either oral contraceptives or postmenopausal hormone replacement. The use of oral contraceptives leads to an increased risk of venous thrombosis, of myocardial infarction, of stroke and of peripheral artery disease, the risks of which are highest during the first year of use. Women with coagulation abnormalities have a higher risk of venous thrombosis when they use oral contraceptives (or postmenopausal hormones) than women without these abnormalities. The risk of venous thrombosis is also higher for preparations containing desogestrel or gestodene (third-generation progestogens) than for those containing levonorgestrel (second-generation progestogens). A previous thrombosis as well as obesity also increase the risk of oral contraceptive-related thrombosis. Hormone replacement therapy increases the risk of venous thrombosis, and has no beneficial, and possibly even a detrimental, effect on the risk of arterial disease. The risk of arterial disease in oral contraceptive users and users of hormone replacement therapy is at most weakly affected by the presence of prothrombotic abnormalities.
Collapse
Affiliation(s)
- F R Rosendaal
- Department of Clinical Epidemiology, Leiden University Medical Center, The Netherlands.
| | | | | | | |
Collapse
|
50
|
Bloemenkamp KWM, Helmerhorst FM, Rosendaal FR, Vandenbroucke JP. Thrombophilias and gynaecology. Best Pract Res Clin Obstet Gynaecol 2003; 17:509-28. [PMID: 12787541 DOI: 10.1016/s1521-6934(03)00015-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
In gynaecology, women are exposed to sex steroids when using oral contraceptives, hormone replacement therapy or when undergoing in vitro fertilization treatment and ovulation induction. Oral contraceptives and the use of hormone replacement therapy increase the risk of venous thrombosis. The risk is highest in the first year of use and higher among women with clotting defects. Women taking third-generation oral contraceptives have an almost twofold increased risk of venous thrombosis compared with those taking second-generation oral contraceptives. Inherited clotting defects, which are themselves risk factors of venous thrombosis, (e.g. factor V Leiden mutation, deficiency of protein C, protein S or antithrombin, high plasma levels of factor VIII, and prothrombin mutation) appear synergistically increase the risk of venous thrombosis caused by oral contraceptives. Recent studies also point to an interaction between hormone replacement therapy and coagulation defects in causing venous thrombosis. Emerging studies show that in vitro fertilization treatment and ovulation induction are also risk factors for venous thrombosis; the role of coagulation defects in this association is not yet clear.
Collapse
Affiliation(s)
- Kitty W M Bloemenkamp
- Department of Obstetrics, Gynaecology and Reproductive Medicine, Leiden University Medical Center, P.O. Box 9600, RC 2300, Leiden, The Netherlands.
| | | | | | | |
Collapse
|