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Hamada S, Muramoto K, Akaike K, Okabayashi H, Masunaga A, Tomita Y, Ichiyasu H, Sakagami T. The impact of factor Xa inhibitors on bleeding risk in patients with respiratory diseases. Sci Rep 2024; 14:4039. [PMID: 38369531 PMCID: PMC10874933 DOI: 10.1038/s41598-024-54714-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 02/15/2024] [Indexed: 02/20/2024] Open
Abstract
It is unclear which factor Xa (FXa) inhibitors are associated with higher bleeding risk in patients with respiratory diseases, and there are no studies on the association between prothrombin time-international normalized ratio (PT-INR) and bleeding risk. We conducted a retrospective cohort study comparing 1-year-outcomes and PT-INR between patients with respiratory diseases treated with rivaroxaban (R group, n = 82) or edoxaban (E group, n = 138) for atrial fibrillation or venous thromboembolism from 2013 to 2021. The most frequent event of all bleeding discontinuations was respiratory bleeding in both groups (7.3 and 4.3%, respectively). The cumulative incidence of bleeding discontinuation was significantly higher in the R group (25.6%) than in the E group (14.4%) (hazard ratio [HR], 2.29; 95% confidence interval [CI] 1.13-4.64; P = 0.023). PT-INR after initiation of therapy significantly increased and was higher in the R group than in the E group (median value, 1.4 and 1.2, respectively; P < 0.001). Multivariate analysis using Cox proportional hazards and Fine-Gray models revealed that PT-INR after initiation of therapy was an independent risk factor of bleeding discontinuation events (HR = 4.37, 95% CI 2.57-7.41: P < 0.001). Respiratory bleeding occasionally occurs in patients receiving FXa inhibitors, and monitoring the PT-INR may need to ensure safety.
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Affiliation(s)
- Shohei Hamada
- Department of Respiratory Medicine, Kumamoto University Hospital, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan.
| | - Kei Muramoto
- Department of Respiratory Medicine, Kumamoto University Hospital, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Kimitaka Akaike
- Department of Respiratory Medicine, Kumamoto University Hospital, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Hiroko Okabayashi
- Department of Respiratory Medicine, Kumamoto University Hospital, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Aiko Masunaga
- Department of Respiratory Medicine, Kumamoto University Hospital, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Yusuke Tomita
- Department of Respiratory Medicine, Kumamoto University Hospital, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Hidenori Ichiyasu
- Department of Respiratory Medicine, Kumamoto University Hospital, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
| | - Takuro Sakagami
- Department of Respiratory Medicine, Kumamoto University Hospital, Faculty of Life Sciences, Kumamoto University, 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556, Japan
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Wu T, Wu S, Li L, Xiang J, Wang N, Chen W, Zhang J. The impact of ABCB1, CYP3A4/5 and ABCG2 gene polymorphisms on rivaroxaban trough concentrations and bleeding events in patients with non-valvular atrial fibrillation. Hum Genomics 2023; 17:59. [PMID: 37420302 DOI: 10.1186/s40246-023-00506-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Accepted: 07/03/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND The influence of genetic factors on the pharmacokinetics and clinical outcomes of rivaroxaban in patients with non-valvular atrial fibrillation (NVAF) is poorly understood. This study aimed to explore the effects of CYP3A4/5, ABCB1, and ABCG2 gene polymorphisms on the trough concentrations and the bleeding risk of rivaroxaban in NVAF patients. PATIENTS AND METHODS This study is a prospective multicenter study. The patient's blood samples were collected to detect the steady-state trough concentrations of rivaroxaban and gene polymorphisms. We visited the patients regularly at month 1, 3, 6, and 12 to record bleeding events and medications. RESULTS A total of 95 patients were enrolled in this study, and 9 gene loci were detected. For the dose-adjusted trough concentration ratio (Ctrough/D) of rivaroxaban, the homozygous mutant type was significantly lower than wild type at ABCB1 rs4148738 locus (TT vs. CC, P = 0.033), and the mutant type was significantly lower than the wild type at ABCB1 rs4728709 locus (AA + GA vs. GG, P = 0.008). ABCB1 (rs1045642, rs1128503), CYP3A4 (rs2242480, rs4646437), CYP3A5 (rs776746), and ABCG2 (rs2231137, rs2231142) gene polymorphisms had no significant effect on the Ctrough/D of rivaroxaban. For the bleeding events, we found that there were no significant differences among genotypes of all gene loci. CONCLUSION This study found for the first time that ABCB1 rs4148738 and rs4728709 gene polymorphisms had a significant impact on the Ctrough/D of rivaroxaban in NVAF patients. CYP3A4/5, ABCB1, and ABCG2 gene polymorphisms were not associated with the bleeding risk of rivaroxaban.
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Affiliation(s)
- Tingting Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Shuyi Wu
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Li Li
- Department of Pharmacy, Guizhou Provincial People's Hospital, Guiyang, China
| | - Jing Xiang
- Department of Pharmacy, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Na Wang
- Department of Pharmacy, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Wenjun Chen
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China
| | - Jinhua Zhang
- Department of Pharmacy, Fujian Maternity and Child Health Hospital College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, #18 Daoshan Road, Fuzhou, 350001, China.
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Gross PL, Chan NC. Thromboembolism in Older Adults. Front Med (Lausanne) 2021; 7:470016. [PMID: 33585495 PMCID: PMC7873530 DOI: 10.3389/fmed.2020.470016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 12/21/2020] [Indexed: 01/01/2023] Open
Abstract
Arterial and venous thromboembolism are both more common in older adults. The use of anticoagulants, the mainstay to prevent thromboembolism, requires consideration of the balance between risk and benefit. Such consideration is even more important in the very elderly in whom the risk of anticoagulant-related bleeding and thrombosis are higher. This review will focus on the challenges of implementing and managing anticoagulant therapy in older patients in an era when the options for anticoagulants include not only vitamin K antagonists (VKAs), but also direct-acting oral anticoagulants (DOACs).
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Affiliation(s)
- Peter L Gross
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
| | - Noel C Chan
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, ON, Canada
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Arcadi FA, Portaro S, Giorgianni R, Naro A, Casella C, Genovese C, Marino S, Calabrò RS. New versus Old Oral Anticoagulants: How Can We Set the Scale Needle? Considerations on a Case Report. ACTA ACUST UNITED AC 2019; 55:medicina55030071. [PMID: 30884868 PMCID: PMC6473779 DOI: 10.3390/medicina55030071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Revised: 03/07/2019] [Accepted: 03/14/2019] [Indexed: 10/28/2022]
Abstract
Ischemic stroke is a complex multifactorial disorder. Anticoagulation is a growing research area, with the main goal of preventing systemic embolization and stroke. We report the case of a 41-year-old woman with antiphospholipid syndrome who was unsuccessfully treated with Dabigatran, a new oral anticoagulant, as she developed a major stroke involving the right carotid artery, due to deep venous thrombosis with pulmonary embolism. We therefore suggest a closer monitoring of the safety and efficacy of dabigatran. Moreover, in the presence of multifactorial causes of pro-coagulation, we believe that warfarin should remain the mainstay of oral anticoagulation.
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Affiliation(s)
| | - Simona Portaro
- IRCCS Centro Neurolesi "Bonino-Pulejo", 98123 Messina, Italy.
| | | | - Antonino Naro
- IRCCS Centro Neurolesi "Bonino-Pulejo", 98123 Messina, Italy.
| | - Carmela Casella
- Stroke Unit, Policlinico Universitario, 98123 Messina, Italy.
| | - Carmelo Genovese
- Genovese Laboratory Medicine and Pathology, 98050 Barcellona PG, Italy.
| | - Silvia Marino
- IRCCS Centro Neurolesi "Bonino-Pulejo", 98123 Messina, Italy.
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Pandya EY, Anderson E, Chow C, Wang Y, Bajorek B. Contemporary utilization of antithrombotic therapy for stroke prevention in patients with atrial fibrillation: an audit in an Australian hospital setting. Ther Adv Drug Saf 2018; 9:97-111. [PMID: 29387335 PMCID: PMC5772521 DOI: 10.1177/2042098617744926] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 11/07/2017] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND To document antithrombotic utilization in patients with nonvalvular atrial fibrillation (NVAF), particularly, recently approved NOACs (nonvitamin K antagonist oral anticoagulants) and warfarin; and identify factors predicting the use of NOACs versus warfarin. METHODS A retrospective audit was conducted in an Australian hospital. Data pertaining to inpatients diagnosed with atrial fibrillation (AF) admitted between January and December 2014 were extracted. This included patient demographics, risk factors (stroke, bleeding), social history, medical conditions, medication history, medication safety issues, medication adherence, and antithrombotic prescribed at admission and discharge. RESULTS Among 199 patients reviewed, 84.0% were discharged on antithrombotics. Anticoagulants (± antiplatelets) were most frequently (52.0%) prescribed (two-thirds were prescribed warfarin, the remainder NOACs), followed by antiplatelets (33.0%). Among 41 patients receiving NOACs, 59.0% were prescribed rivaroxaban, 24.0% dabigatran, and 17.0% apixaban. Among patients aged 75 years and over, antiplatelets were most frequently used (37.0%), followed by warfarin (33.0%), then NOACs (14.0%). Compared with their younger counterparts, patients aged 75 years and over were significantly less likely to receive NOACs (14.0% versus 28.0%, p = 0.01). Among the 'most eligible' patients (Congestive Cardiac Failure, Hypertension (, Age ⩾ 75 years, Age= 65-74 years, Diabetes Mellitus, Stroke/ Transient Ischaemic Attack/ Thromboembolism, Vascular disease, Sex female[CHA2DS2-VASc] score ⩾2 and no bleeding risk factors), 46.0% were not anticoagulated on discharge. Patients with anaemia (68.0% versus 86.0%, p = 0.04) or a history of bleeding (65.0% versus 87.0%, p = 0.01) were less likely to receive antithrombotics compared with those without these risk factors. Warfarin therapy was less frequently prescribed among patients with cognitive impairment compared with patients with no cognitive issues (12.0% versus 23.0%, p = 0.01). Multivariate logistic regression modelling identified that patients with renal impairment were 3.6 times more likely to receive warfarin compared with NOACs (odds ratio = 3.6, 95% confidence interval = 0.08-0.90, p = 0.03, 60.0% correctly predicted; Cox and Snell R2 = 0.51, Nagelkerke R2 = 0.69). CONCLUSION Despite the availability of NOACs, warfarin remains a preferred treatment option, particularly among patients with renal impairment. The high proportion of eligible patients still being prescribed antiplatelet therapy or 'no therapy' needs to be addressed.
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Affiliation(s)
- Ekta Yogeshkumar Pandya
- University of Technology Sydney Faculty of Health, Broadway, Ultimo, Sydney, NSW 2007, Australia
| | | | - Clara Chow
- Westmead Hospital, Westmead, NSW, Australia
| | - Yishen Wang
- University of Technology Sydney Faculty of Health, Broadway, Sydney, NSW, Australia
| | - Beata Bajorek
- University of Technology Sydney Faculty of Health, Broadway, Sydney, NSW, Australia
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Rohde G, Stratmann G, Hesse C, Herth N, Schwers S, Perzborn E, Lindhoff-Last E, Mani H. Accurate determination of rivaroxaban levels requires different calibrator sets but not addition of antithrombin. Thromb Haemost 2017; 108:191-8. [DOI: 10.1160/th11-12-0832] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 04/07/2012] [Indexed: 01/12/2023]
Abstract
SummaryRivaroxaban is a direct factor Xa inhibitor, which can be monitored by anti-factor Xa chromogenic assays. This ex vivo study evaluated different assays for accurate determination of rivaroxaban levels. Eighty plasma samples from patients receiving rivaroxaban (Xarelto®) 10 mg once daily and 20 plasma samples from healthy volunteers were investigated using one anti-factor Xa assay with the addition of exogenous antithrombin and two assays without the addition of antithrombin. Two different lyophilised rivaroxaban calibration sets were used for each assay (low concentration set: 0, 14.5, 59.6 and 97.1 ng/ml; high concentration set: 0, 48.3, 101.3, 194.2 and 433.3 ng/ml). Using a blinded study design, the rivaroxaban concentrations determined by the assays were compared with concentrations measured by HPLC-MS/MS. All assays showed a linear relationship between the rivaroxaban concentrations measured by HPLC-MS/MS and the optical density of the anti-FXa assays. However, the assay with the addition of exogenous anti-thrombin detected falsely high concentrations of rivaroxaban even in plasma samples from controls who had not taken rivaroxaban (intercept values using the high calibrator set and the low calibrator set: +26.49 ng/ml and +13.71 ng/ml, respectively). Plasma samples, initially determined by the high calibrator setting and containing rivaroxaban concentrations <25 ng/ml, had to be re-run using the low calibrator setting for precise measurement. In conclusion, anti-factor Xa chromogenic assays that use rivaroxaban calibrators at different concentration levels can be used to measure accurately a wide range of rivaroxaban concentrations ex vivo. Assays including exogenous antithrombin are unsuitable for measurement of rivaroxaban.
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Løkkebø ES, Kristoffersen AH, Stavelin A, Sølvik UØ. Effect of dabigatran treatment at therapeutic levels on point-of-care international normalized ratio (INR). Clin Chem Lab Med 2017; 55:e143-e145. [DOI: 10.1515/cclm-2016-0872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 10/01/2016] [Indexed: 11/15/2022]
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Dosage Adjustment of Dabigatran Etexilate Based on Creatinine Clearance in Patients With Cardioembolic Stroke or Atrial Fibrillation. Ther Drug Monit 2016; 38:670-676. [DOI: 10.1097/ftd.0000000000000336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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9
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Assessment of trough rivaroxaban concentrations on markers of coagulation activation in nonvalvular atrial fibrillation population. Heart Vessels 2016; 32:609-617. [DOI: 10.1007/s00380-016-0912-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 10/21/2016] [Indexed: 01/21/2023]
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Schwertner HA, Stankus JJ. Characterization of the Fluorescent Spectra and Intensity of Dabigatran and Dabigatran Etexilate: Application to HPLC Analysis with Fluorescent Detection†. J Chromatogr Sci 2016; 54:1648-1651. [PMID: 27473419 DOI: 10.1093/chromsci/bmw122] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 05/20/2016] [Indexed: 12/22/2022]
Abstract
There is considerable interest in dabigatran etexilate (Pradaxa) and its major metabolite, dabigatran, which has been shown to be an important inhibitor of thrombin and clotting. In this study, the fluorescent excitation and emission spectra of dabigatran and dabigatran etexilate were characterized. In addition, a ultra performance liquid chromatography (UPLC) and high performance liquid chromatography (HPLC) method using fluorescent detection was developed for the analysis of dabigatran. Dabigatran and dabigatran etexilate were found to have excitation and emission maxima of 310 and 375 nm and 335 and 400 nm, respectively. UPLC analysis of dabigatran standards and plasma dabigatran samples were analyzed on a reversed phase C-18 column with methanol-water (70:30, v/v) as the mobile phase. The lower limit of quantitation for dabigatran was 10.0 ng/mL for both the standards and plasma samples. Standard curves were linear from 10.0 to 1000.0 ng/mL (R2 = 0.995). Within-day coefficient of variations of the fluorometric method at 50.0, 100.0 and 500.0 ng/mL were 1.38%, 4.83% and 2.31%, respectively. The intense fluorescent properties of dabigatran permit the sensitive and specific UPLC or HPLC fluorescent analysis of dabigatran.
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Affiliation(s)
- Harvey A Schwertner
- Clinical Research, Wilford Hall Ambulatory Surgical Center, 2200 Bergquist Drive, Lackland AFB, TX 78236-5319, USA
| | - John J Stankus
- Department of Chemistry and Biochemistry, University of the Incarnate Word, 4301 Broadway, San Antonio, TX 78209, USA
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The Importance of Familiar Thrombophilias in the Clinical Practice. Novel Ways in Anticoagulant Therapy. Neuroophthalmology 2016. [DOI: 10.1007/978-3-319-28956-4_34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Adcock D, Gosselin R. Direct Oral Anticoagulants (DOACs) in the Laboratory: 2015 Review. Thromb Res 2015; 136:7-12. [DOI: 10.1016/j.thromres.2015.05.001] [Citation(s) in RCA: 115] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 04/28/2015] [Accepted: 05/02/2015] [Indexed: 11/16/2022]
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Chen CH, Chen MC, Gibbs H, Kwon SU, Lo S, On YK, Rosman A, Suwanwela NC, Tan RS, Tirador LS, Zirlik A. Antithrombotic treatment for stroke prevention in atrial fibrillation: The Asian agenda. Int J Cardiol 2015; 191:244-53. [DOI: 10.1016/j.ijcard.2015.03.369] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 03/25/2015] [Indexed: 10/23/2022]
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Douxfils J, Mullier F, Dogné JM. Dose tailoring of dabigatran etexilate: obvious or excessive? Expert Opin Drug Saf 2015; 14:1283-9. [PMID: 25994994 DOI: 10.1517/14740338.2015.1049995] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Dabigatran etexilate is used for preventing blood clots and tends to replace older anticoagulants in many of their indications. However, the 'one dose fits all' policy is subject to criticism. Recent findings assert the anxiety of the scientific community concerning the pharmacokinetic properties of dabigatran etexilate, that is, an important interindividual variability including an important genetic variant with a significant dependence of the renal function as route of elimination. AREAS COVERED This meta-opinion provides an overview of the current knowledge and evidence on the dose tailoring of dabigatran etexilate. It also discusses the remaining challenges to benefit from this perspective strategy to enhance the benefit-risk balance of dabigatran etexilate. Data were searched in the published literature and on regulatory agencies' websites. Additionally, unpublished data were searched and discussed. EXPERT OPINION Causality between dabigatran exposure and bleeding risk is now established and recommendations on how to best estimate the drug exposure are published. Additionally, simulating studies revealed that a dose adaptation based on dabigatran plasma concentration estimations could improve the benefit-risk profile of the drug. This accumulating evidence suggests that some patients under dabigatran etexilate may benefit from a tailoring of the dose beyond the ones already proposed by the manufacturer.
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Affiliation(s)
- Jonathan Douxfils
- University of Namur, Faculty of Medicine, Department of Pharmacy, Namur Research Institute for LIfe Sciences (NARILIS), Namur Thrombosis and Hemostasis Center (NTHC) , rue de Bruxelles, 61, B-5000 Namur, Belgium , Europe +32 81 72 42 92 ; +32 81 72 42 99 ;
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Non-VKA Oral Anticoagulants: Accurate Measurement of Plasma Drug Concentrations. BIOMED RESEARCH INTERNATIONAL 2015; 2015:345138. [PMID: 26090400 PMCID: PMC4452246 DOI: 10.1155/2015/345138] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 11/10/2014] [Indexed: 11/18/2022]
Abstract
Non-VKA oral anticoagulants (NOACs) have now widely reached the lucrative market of anticoagulation. While the marketing authorization holders claimed that no routine monitoring is required and that these compounds can be given at fixed doses, several evidences arisen from the literature tend to demonstrate the opposite. New data suggests that an assessment of the response at the individual level could improve the benefit-risk ratio of at least dabigatran. Information regarding the association of rivaroxaban and apixaban exposure and the bleeding risk is available in the drug approval package on the FDA website. These reviews suggest that accumulation of these compounds increases the risk of experiencing a bleeding complication. Therefore, in certain patient populations such as patients with acute or chronic renal impairment or with multiple drug interactions, measurement of drug exposure may be useful to ensure an optimal treatment response. More specific circumstances such as patients experiencing a haemorrhagic or thromboembolic event during the treatment duration, patients who require urgent surgery or an invasive procedure, or patient with a suspected overdose could benefit from such a measurement. This paper aims at providing guidance on how to best estimate the intensity of anticoagulation using laboratory assays in daily practice.
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Korostelev M, Bihan K, Ferreol L, Tissot N, Hulot JS, Funck-Brentano C, Zahr N. Simultaneous determination of rivaroxaban and dabigatran levels in human plasma by high-performance liquid chromatography-tandem mass spectrometry. J Pharm Biomed Anal 2014; 100:230-235. [PMID: 25173108 DOI: 10.1016/j.jpba.2014.08.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 07/31/2014] [Accepted: 08/06/2014] [Indexed: 11/25/2022]
Abstract
A sensitive and accurate liquid chromatography method with mass spectrometry detection was developed and validated for the quantification of dabigatran (Pradaxa(®)) and rivaroxaban (Xarelto(®)). (13)C6-dabigatran and (13)C6-rivaroxaban were used as the internal standard. A single-step protein precipitation was used for plasma sample preparation. This method was validated with respect to linearity, selectivity, inter- and intra-day precision and accuracy, limit of quantification and stability. The lower limit of quantification was 2.5ng/mL for both drugs in plasma.
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Affiliation(s)
- Marie Korostelev
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421, F-75013 Paris, France
| | - Kevin Bihan
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421, F-75013 Paris, France
| | - Lison Ferreol
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421, F-75013 Paris, France
| | - Nadine Tissot
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421, F-75013 Paris, France
| | - Jean-Sebastien Hulot
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421, F-75013 Paris, France; Sorbonne University, UPMC Univ Paris 06, Faculty of Medicine, Department of Pharmacology and UMR ICAN 1166, F-75013 Paris, France; INSERM, CIC-1421 and UMR ICAN 1166, F-75013 Paris, France
| | - Christian Funck-Brentano
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421, F-75013 Paris, France; Sorbonne University, UPMC Univ Paris 06, Faculty of Medicine, Department of Pharmacology and UMR ICAN 1166, F-75013 Paris, France; INSERM, CIC-1421 and UMR ICAN 1166, F-75013 Paris, France
| | - Noël Zahr
- AP-HP, Pitié-Salpêtrière Hospital, Department of Pharmacology and CIC-1421, F-75013 Paris, France.
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Kitchen S, Gray E, Mackie I, Baglin T, Makris M. Measurement of non-Coumarin anticoagulants and their effects on tests of Haemostasis: Guidance from the British Committee for Standards in Haematology. Br J Haematol 2014; 166:830-41. [DOI: 10.1111/bjh.12975] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Steve Kitchen
- Sheffield Haemophilia and Thrombosis Centre; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
| | - Elaine Gray
- Haemostasis section; Biotherapeutics Group; National Institute for Biological Standards and Control; Potters Bar UK
| | - Ian Mackie
- Haemostasis Research Unit; Department of Haematology; University College London; London UK
| | - Trevor Baglin
- Department of Haematology; Addenbrooke's Hospital; Cambridge UK
| | - Mike Makris
- Sheffield Haemophilia and Thrombosis Centre; Sheffield Teaching Hospitals NHS Trust; Sheffield UK
- Department of Cardiovascular Science; University of Sheffield; Sheffield UK
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Samama MM. Coagulation Assays in Patients with New Oral Anticoagulants (NOACs): Why? When? Drug Dev Res 2013. [DOI: 10.1002/ddr.21118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Meyer Michel Samama
- Cochin-Broca-Hôtel Dieu University Hospital; Department of Hematology; Paris France
- Biomnis Laboratory; Ivry-sur-Seine France
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Bloemen S, De Laat M, De Laat B, Hemker HC, Al Dieri R. Will One Size of Anticoagulant Dosage Fit All? Drug Dev Res 2013. [DOI: 10.1002/ddr.21097] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Scaglione F. New oral anticoagulants: comparative pharmacology with vitamin K antagonists. Clin Pharmacokinet 2013; 52:69-82. [PMID: 23292752 DOI: 10.1007/s40262-012-0030-9] [Citation(s) in RCA: 135] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
New oral anticoagulants (OACs) that directly inhibit Factor Xa (FXa) or thrombin have been developed for the long-term prevention of thromboembolic disorders. These novel agents provide numerous benefits over older vitamin K antagonists (VKAs) due to major pharmacological differences. VKAs are economical and very well characterized, but have important limitations that can outweigh these advantages, such as slow onset of action, narrow therapeutic window and unpredictable anticoagulant effect. VKA-associated dietary precautions, monitoring and dosing adjustments to maintain international normalized ratio (INR) within therapeutic range, and bridging therapy, are inconvenient for patients, expensive, and may result in inappropriate use of VKA therapy. This may lead to increased bleeding risk or reduced anticoagulation and increased risk of thrombotic events. The new OACs have rapid onset of action, low potential for food and drug interactions, and predictable anticoagulant effect that removes the need for routine monitoring. FXa inhibitors, e.g. rivaroxaban and apixaban, are potent, oral direct inhibitors of prothrombinase-bound, clot-associated or free FXa. Both agents have a rapid onset of action, a wide therapeutic window, little or no interaction with food and other drugs, minimal inter-patient variability, and display similar pharmacokinetics in different patient populations. Since both are substrates, co-administration of rivaroxaban and apixaban with strong cytochrome P450 (CYP) 3A4 and permeability glycoprotein (P-gp) inhibitors and inducers can result in substantial changes in plasma concentrations due to altered clearance rates; consequently, their concomitant use is contraindicated and caution is required when used concomitantly with strong CYP3A4 and P-gp inducers. Although parenteral oral direct thrombin inhibitors (DTIs), such as argatroban and bivalirudin, have been on the market for years, DTIs such as dabigatran are novel synthetic thrombin antagonists. Dabigatran etexilate is a low-molecular-weight non-active pro-drug that is administered orally and converted rapidly to its active form, dabigatran--a potent, competitive and reversible DTI. Dabigatran has an advantage over the indirect thrombin inhibitors, unfractionated heparin and low-molecular-weight heparin, in that it inhibits free and fibrin-bound thrombin. The reversible binding of dabigatran may provide safer and more predictable anticoagulant treatment than seen with irreversible, non-covalent thrombin inhibitors, e.g. hirudin. Dabigatran shows a very low potential for drug-drug interactions. However, co-administration of dabigatran etexilate with other anticoagulants and antiplatelet agents can increase the bleeding risk. Although the new agents are pharmacologically better than VKAs--particularly in terms of fixed dosing, rapid onset of action, no INR monitoring and lower risk of drug interactions--there are some differences between them: the bioavailability of dabigatran is lower than rivaroxaban and apixaban, and so the dabigatran dosage required is higher; lower protein binding of dabigatran reduces the variability related to albuminaemia. The risk of metabolic drug-drug interactions also appears to differ between OACs: VKAs > rivaroxaban > apixaban > dabigatran. The convenience of the new OACs has translated into improvements in efficacy and safety as shown in phase III randomized trials. The new anticoagulants so far offer the greatest promise and opportunity for the replacement of VKAs.
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Affiliation(s)
- Francesco Scaglione
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milano, Italy.
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Samama MM, Contant G, Spiro TE, Perzborn E, Le Flem L, Guinet C, Gourmelin Y, Rohde G, Martinoli JL. Laboratory assessment of rivaroxaban: a review. Thromb J 2013; 11:11. [PMID: 23822763 PMCID: PMC3726412 DOI: 10.1186/1477-9560-11-11] [Citation(s) in RCA: 117] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 06/24/2013] [Indexed: 11/15/2022] Open
Abstract
Research into new anticoagulants for preventing and treating thromboembolic disorders has focused on targeting single enzymes in the coagulation cascade, particularly Factor Xa and thrombin, inhibition of which greatly decreases thrombin generation. Based on the results of phase III clinical trials, rivaroxaban, a direct Factor Xa inhibitor, has been approved in many countries for the management of several thromboembolic disorders. Owing to its predictable pharmacokinetic and pharmacodynamic characteristics, fixed-dose regimens are used without the need for routine coagulation monitoring. In situations where assessment of rivaroxaban exposure may be helpful, anti-Factor Xa chromogenic assays (in tandem with standard calibration curves generated with the use of rivaroxaban calibrators and controls) could be used. It is important to note that test results will be affected by the timing of blood sampling after rivaroxaban intake. In addition, the anti-Factor Xa method measures the drug concentration and not the intensity of the drug’s anticoagulant activity, and a higher than expected rivaroxaban plasma level does not necessarily indicate an increased risk of bleeding complications. Therefore, clinicians need to consider test results in relation to the pharmacokinetics of rivaroxaban and other patient risk factors associated with bleeding.
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Affiliation(s)
- Meyer Michel Samama
- Hôtel-Dieu University Hospital, 1 place du Paris Notre-Dame, Paris 75004, 4ème, Paris, France.
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Smythe MA, Fanikos J, Gulseth MP, Wittkowsky AK, Spinler SA, Dager WE, Nutescu EA. Rivaroxaban: practical considerations for ensuring safety and efficacy. Pharmacotherapy 2013; 33:1223-45. [PMID: 23712587 DOI: 10.1002/phar.1289] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Rivaroxaban is the first agent available within a new class of anticoagulants called direct factor Xa inhibitors. Rivaroxaban is approved for use in the United States for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, for the prevention of deep vein thrombosis in patients undergoing total hip replacement and total knee replacement, for the treatment of deep vein thrombosis and pulmonary embolism, and for the reduction in risk of recurrence of deep vein thrombosis and pulmonary embolism (with additional indications under review). Rivaroxaban dose and frequency of administration vary depending on the indication. As of result of predictable pharmacokinetics and pharmacodynamics, a fixed dose of rivaroxaban is administered without routine coagulation testing. Rivaroxaban has a short half-life, undergoes a dual mode of elimination (hepatic and renal), and is a substrate for P-glycoprotein. Rivaroxaban has a lower potential for drug interactions compared with warfarin. Despite the advantages of a once/day fixed-dose oral agent, in many clinical situations limited evidence is available to guide optimal management of rivaroxaban therapy. In this article, we review the available evidence and provide recommendations where possible for such situations including the desire to monitor the anticoagulation intensity, use in special patient populations, managing drug interactions, and transitioning across anticoagulant agents. Potential strategies for reversing rivaroxaban's anticoagulant effect are reviewed. Health systems will need to perform a systematic safety evaluation and ensure that numerous hospital policies related to anticoagulation are updated to include rivaroxaban. A comprehensive approach to education is needed for clinicians, patients, and technical support personnel involved in patient interactions to ensure safe use.
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Affiliation(s)
- Maureen A Smythe
- Department of Pharmacy Practice, Wayne State University, Detroit, Michigan; Department of Pharmaceutical Services, Beaumont Hospital, Royal Oak, Michigan
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Bloemen S, Hemker HC, Al Dieri R. Large inter-individual variation of the pharmacodynamic effect of anticoagulant drugs on thrombin generation. Haematologica 2012; 98:549-54. [PMID: 23100275 DOI: 10.3324/haematol.2012.073601] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Anticoagulation by a standard dosage of an inhibitor of thrombin generation presupposes predictable pharmacokinetics and pharmacodynamics of the anticoagulant. We determined the inter-individual variation of the effect on thrombin generation of a fixed concentration of direct and antithrombin-mediated inhibitors of thrombin and factor Xa. Thrombin generation was determined by calibrated automated thrombinography in platelet-poor plasma from 44 apparently healthy subjects which was spiked with fixed concentrations of otamixaban, melagatran, unfractionated heparin, dermatan sulfate and pentasaccharide. The variability of the inhibitory effect of the different anticoagulants within the population was determined using the coefficient of variation, i.e. the standard deviation expressed as a percentage of the mean. The inter-individual coefficients of variation of the endogenous thrombin potential and peak height before inhibition were 18% and 16%, respectively and became 20%-24% and 24%-43% after inhibition. The average inhibition of endogenous thrombin potential and peak height (ETP, peak) brought about by the anticoagulants was respectively: otamixaban (27%, 83%), melagatran (56%, 63%), unfractionated heparin (43%, 58%), dermatan sulfate (68%, 57%) and pentasaccharide (25%, 67%). This study demonstrates that the addition of a fixed concentration of any type of anticoagulant tested causes an inhibition that is highly variable from one individual to another. In this respect there is no difference between direct inhibitors of thrombin and factor Xa and heparin(-like) inhibitors acting on the same factors.
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Affiliation(s)
- Saartje Bloemen
- Synapse BV and Department of Biochemistry, Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands
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Douxfils J, Mullier F, Loosen C, Chatelain C, Chatelain B, Dogné JM. Assessment of the impact of rivaroxaban on coagulation assays: laboratory recommendations for the monitoring of rivaroxaban and review of the literature. Thromb Res 2012; 130:956-66. [PMID: 23006523 DOI: 10.1016/j.thromres.2012.09.004] [Citation(s) in RCA: 140] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 08/23/2012] [Accepted: 09/03/2012] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Rivaroxaban does not require monitoring nor frequent dose adjustment. However, searching for the optimal dose in the individual patient may be useful in some situations. AIM To determine which coagulation assay could be used to assess the impact of rivaroxaban on haemostasis and provide guidelines for the interpretation of routine lab tests. MATERIALS Rivaroxaban was spiked at concentrations ranging from 11 to 1,090 ng/mL in plateletpoor plasma. A large panel of coagulation assays was tested. RESULTS A concentration dependent prolongation of aPTT, PT, dPT, PiCT was observed. PT and dPT were the most sensitive chronometric assays but results varied depending on the reagent (Triniclot PT Excel S>Recombiplastin 2G>Neoplastin R>Neoplastin CI+>Triniclot PT Excel>Triniclot PT HTF>Innovin). FXa chromogenic assays showed the highest sensitivity. In TGA, Cmax was the most sensitive parameter with the tissue factor induced pathway. Rivaroxaban interferes on haemostasis diagnostic tests such the measurement of clotting factors, fibrinogen, antithrombin, proteins C and S, activated protein-C resistance and Xa-based chomogenic assays. CONCLUSIONS PT may be used as screening test to assess the risk of bleedings. A more specific and sensitive assay such as Biophen DiXaI using calibrators should be used to confirm the concentration of rivaroxaban. We also propose cut-off associated with a bleeding or thrombosis risk based on pharmacokinetic studies. Standardization of the time between the last intake of rivaroxaban and the sampling is mandatory.
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Affiliation(s)
- Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, B-5000, Belgium.
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Dufour B, Toussaint-Hacquard M, Kearney-Schwartz A, Manckoundia MDP, Laurain MC, Joly L, Deibener J, Wahl D, Lecompte T, Benetos A, Perret-Guillaume C. Glomerular filtration rate estimated by Cockcroft-Gault formula better predicts anti-Xa levels than modification of the diet in renal disease equation in older patients with prophylactic enoxaparin. J Nutr Health Aging 2012; 16:647-52. [PMID: 22836708 DOI: 10.1007/s12603-012-0072-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Accepted: 09/30/2011] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Older people have an increased risk of low molecular weight heparin accumulation leading to an increased bleeding risk. The objective of this study was to assess whether reduced glomerular filtration rate (GFR), estimated by the Cockcroft-Gault or modification of the diet in renal disease (MDRD) equations, indicates drug accumulation by increased anti-Xa levels in older subjects receiving prophylactic enoxaparin treatment. DESIGN Cohort study. SETTING Acute geriatric units in Nancy Hospital. PARTICIPANTS Ninety-two consenting consecutive patients, 65 and older, confined to bed for an acute medical condition requiring enoxaparin for prevention of venous thromboembolism, and hospitalized for at least six days were enrolled. MEASUREMENTS Serum creatinine and peak plasma anti-Xa levels 3 to 4 hours after the daily injection of enoxaparin were measured at days 3, 6, 9 and 12 (first dose of enoxaparin at day one). Analyses of variance for repeated measures were used to evaluate significant predictors of peak anti-Xa activity in univariate and multivariate analyses. RESULTS A significant correlation was observed between anti-Xa activity and GFR estimated with the Cockcroft formula r=0.43. Following univariate analysis, the three factors associated with higher anti-Xa levels were a lower Cockcroft-Gault GFR (p=0.0002), female gender (p=0.0003) and a lower bodyweight (p<.0001). No significant association between anti-Xa levels and MDRD GFR (p=0.33) was observed. Following multivariate analysis, female gender (p=0.02), bodyweight (p=0.04) and Cockcroft GFR (p=0.05) remained independent determinants of anti-Xa levels. CONCLUSION In hospitalized patients older than 65 years old, the Cockcroft-Gault equation, in contrast to the MDRD equation, is able to predict the risk of higher anti-Xa levels.
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Affiliation(s)
- B Dufour
- Geriatric Unit, Hôpital de Brabois, CHU Nancy, Nancy, France
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Neue Antikoagulanzien bei Vorhofflimmern. Herz 2012; 37:378-83. [DOI: 10.1007/s00059-012-3618-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Pulmonary embolism is the third most common cause of death from cardiovascular disease after heart attack and stroke. Sequelae occurring after venous thromboembolism include chronic thromboembolic pulmonary hypertension and post-thrombotic syndrome. Venous thromboembolism and atherothrombosis share common risk factors and the common pathophysiological characteristics of inflammation, hypercoagulability, and endothelial injury. Clinical probability assessment helps to identify patients with low clinical probability for whom the diagnosis of venous thromboembolism can be excluded solely with a negative result from a plasma D-dimer test. The diagnosis is usually confirmed with compression ultrasound showing deep vein thrombosis or with chest CT showing pulmonary embolism. Most patients with venous thromboembolism will respond to anticoagulation, which is the foundation of treatment. Patients with pulmonary embolism should undergo risk stratification to establish whether they will benefit from the addition of advanced treatment, such as thrombolysis or embolectomy. Several novel oral anticoagulant drugs are in development. These drugs, which could replace vitamin K antagonists and heparins in many patients, are prescribed in fixed doses and do not need any coagulation monitoring in the laboratory. Although rigorous clinical trials have reported the effectiveness and safety of pharmacological prevention with low, fixed doses of anticoagulant drugs, prophylaxis remains underused in patients admitted to hospital at moderate risk and high risk for venous thromboembolism. In this Seminar, we discuss pulmonary embolism and deep vein thrombosis of the legs.
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Affiliation(s)
- Samuel Z Goldhaber
- Brigham and Women's Hospital, Department of Medicine, Harvard Medical School, Cardiovascular Division, Boston, MA 02115, USA.
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Abstract
The complexities of oral anticoagulation with warfarin have led to the search for more practical alternative agents. Novel direct factor IIa inhibitors and direct factor Xa inhibitors currently in development can be administered at a fixed dose and do not require routine coagulation monitoring and ongoing dosage adjustment to ensure their effectiveness and safety. A number of phase III trials of these agents for the prevention of venous thromboembolism associated with orthopedic surgery and acute medical illness, for the treatment of venous thromboembolism, and for stroke prevention in patients with atrial fibrillation have been completed, with almost universally positive results. If these novel agents are approved for use in the United States, the future of oral anticoagulant therapy will allow a more nuanced approach to drug selection than has been available in the past. Attention to drug interactions and renal function will be required, as methods to measure the presence of these agents are not precise, cannot quantify the degree of anticoagulant present, and are influenced by the changes in serum drug concentrations during the dosing interval. In the future, patient preferences and the pharmacokinetic and pharmacodynamic characteristics of individual drugs will be able to be matched to optimize therapy. These new agents represent a new paradigm for anticoagulation that promises to improve patient care in the long term.
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Affiliation(s)
- Ann K Wittkowsky
- Department of Pharmacy, University of Washington School of Pharmacy, Seattle, Washington, USA.
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Douxfils J, Mullier F, Robert S, Chatelain C, Chatelain B, Dogné JM. Impact of dabigatran on a large panel of routine or specific coagulation assays. Laboratory recommendations for monitoring of dabigatran etexilate. Thromb Haemost 2012; 107:985-97. [PMID: 22438031 DOI: 10.1160/th11-11-0804] [Citation(s) in RCA: 257] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 02/08/2012] [Indexed: 11/05/2022]
Abstract
Due to low bioavailability and high inter-individual variability, monitoring of dabigatran may be required in specific situations to prevent the risk of bleedings or thrombosis. The aim of the study was to determine which coagulation assay(s) could be used to assess the impact of dabigatran on secondary haemostasis. Dabigatran was spiked at concentrations ranging from 4.7 ng/ml to 943.0 ng/ml in pooled citrated human platelet-poor plasma. The following clotting assays were performed: prothrombin time (PT); activated partial thromboplastin time (aPTT); thrombin time (TT); ecarin clotting time (ECT); ecarin chromogenic assay (ECA); prothrombinase-induced clotting time (PiCT); activated clotting time (ACT); Hemoclot Thrombin Inhibitor (HTI) and thrombin generation assay (TGA). A concentration-dependent prolongation of PT, dPT, and aPTT was observed with aPTT being the more sensitive test. The results varied mostly due to the clotting reagent. HTI, ECT and TGA were the most sensitive tests but are not available 24 hours a day. In addition, HTI showed a linear correlation with a good reproducibility. Dabigatran induced a concentration-dependent delay and inhibition of tissue factor-induced TGA. Cut-offs related with higher risk of bleedings or thrombosis were defined for each reagent of aPTT and HTI. In conclusion, aPTT could be used for the monitoring of dabigatran and as screening test for the risk of overdose. However, because of its higher sensitivity, good reproducibility, excellent linear correlation at all doses, its simplicity of use, and possibilities of automation, HTI should be considered as the gold-standard.
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Affiliation(s)
- Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Belgium
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Samama MM, Contant G, Spiro TE, Perzborn E, Flem LL, Guinet C, Gourmelin Y, Martinoli JL. Evaluation of the Prothrombin Time for Measuring Rivaroxaban Plasma Concentrations Using Calibrators and Controls. Clin Appl Thromb Hemost 2012; 18:150-8. [DOI: 10.1177/1076029611426282] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
This study evaluated the prothrombin time (PT) assay for the measurement of plasma concentrations of rivaroxaban using calibrators and controls. The intra- and interlaboratory precision of the measurement was investigated in a field trial involving 21 laboratories. Each laboratory was provided with rivaroxaban calibrators and control plasma samples containing different concentrations of rivaroxaban, and PT reagents. The evaluation was carried out over 2 consecutive weeks using centrally provided and local PT reagents. A calibration curve was produced each day (for inter-run precision), and day-to-day precision was evaluated by testing 3 control plasma samples. A large interlaboratory variation (in seconds) was observed with local PT reagents. The results were less variable when expressed as rivaroxaban concentrations (ng/mL) or when central PT reagent was used (STA Neoplastine CI Plus). The widely available PT assay, in conjunction with rivaroxaban calibrators, may be useful for the measurement of peak plasma levels of rivaroxaban.
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Affiliation(s)
- Meyer Michel Samama
- Hôtel-Dieu University Hospital, Paris, France
- Biomnis Laboratories R&D, Ivry-sur-Seine, France
| | | | | | | | - Lena Le Flem
- Biomnis Laboratories R&D, Ivry-sur-Seine, France
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Ageno W, Gallus AS, Wittkowsky A, Crowther M, Hylek EM, Palareti G. Oral anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e44S-e88S. [PMID: 22315269 PMCID: PMC3278051 DOI: 10.1378/chest.11-2292] [Citation(s) in RCA: 1016] [Impact Index Per Article: 84.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2011] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The objective of this article is to summarize the published literature concerning the pharmacokinetics and pharmacodynamics of oral anticoagulant drugs that are currently available for clinical use and other aspects related to their management. METHODS We carried out a standard review of published articles focusing on the laboratory and clinical characteristics of the vitamin K antagonists; the direct thrombin inhibitor, dabigatran etexilate; and the direct factor Xa inhibitor, rivaroxaban RESULTS The antithrombotic effect of each oral anticoagulant drug, the interactions, and the monitoring of anticoagulation intensity are described in detail and discussed without providing specific recommendations. Moreover, we describe and discuss the clinical applications and optimal dosages of oral anticoagulant therapies, practical issues related to their initiation and monitoring, adverse events such as bleeding and other potential side effects, and available strategies for reversal. CONCLUSIONS There is a large amount of evidence on laboratory and clinical characteristics of vitamin K antagonists. A growing body of evidence is becoming available on the first new oral anticoagulant drugs available for clinical use, dabigatran and rivaroxaban.
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Affiliation(s)
| | | | | | - Mark Crowther
- McMaster University, St. Joseph's Hospital, Hamilton, ON, Canada
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Harenberg J, Krämer R, Giese C, Marx S, Weiss C, Wehling M. Determination of rivaroxaban by different factor Xa specific chromogenic substrate assays: reduction of interassay variability. J Thromb Thrombolysis 2012; 32:267-71. [PMID: 21811937 PMCID: PMC3170460 DOI: 10.1007/s11239-011-0622-5] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Rivaroxaban and other oral direct factor Xa inhibitors (ODiXa) are currently developed for prophylaxis and treatment of thromboembolic diseases using fixed doses. Although routine monitoring is not required, assessing the intensity of anticoagulation may be useful under certain clinical conditions. ODiXa prolong coagulation times of several clotting assays and, thus, their concentration may be determined in factor Xa specific chromogenic substrate assays. So far, no standardized and validated assay is commercially available. Here, five methods (A through E) are studied and optimized to reduce interassay variability. Human pooled plasma was spiked by a serial dilution of rivaroxaban (25–900 ng/ml). The release of para-nitroaniline from the chromogenic substrates was measured by the optical density (OD) at 405 nm. Method B was identified to yield the lowest sum of deviations from the mean value of the OD concentration curve calculated from all assays. Spline functions were developed for OD versus concentration curves for all methods. The calculated OD versus concentration curves overlapped for all methods. The coefficient of variation for all assays and concentrations of rivaroxaban decreased from 25.3 ± 11.4% using the original data to 3.8 ± 2.2% using the calculated data (P < 0.0001). The robustness of the chromogenic assay (method B) remains to be corroborated in interlaboratory comparisons.
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Affiliation(s)
- Job Harenberg
- Department of Clinical Pharmacology, University Heidelberg, Maybachstrasse 14, Mannheim, Germany.
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UPLC MS/MS assay for routine quantification of dabigatran – A direct thrombin inhibitor – In human plasma. J Pharm Biomed Anal 2012; 58:152-6. [DOI: 10.1016/j.jpba.2011.09.018] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Revised: 08/17/2011] [Accepted: 09/18/2011] [Indexed: 11/20/2022]
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Samama MM, Contant G, Spiro TE, Perzborn E, Guinet C, Gourmelin Y, Le Flem L, Rohde G, Martinoli JL. Evaluation of the anti-factor Xa chromogenic assay for the measurement of rivaroxaban plasma concentrations using calibrators and controls. Thromb Haemost 2011; 107:379-87. [PMID: 22187012 DOI: 10.1160/th11-06-0391] [Citation(s) in RCA: 178] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Accepted: 10/30/2011] [Indexed: 12/14/2022]
Abstract
Rivaroxaban is an oral, direct factor Xa inhibitor. Routine coagulation monitoring is not required, but a quantitative determination of rivaroxaban concentrations might be useful in some clinical circumstances. This multicentre study assessed the suitability of the anti-factor Xa chromogenic assay for the measurement of rivaroxaban plasma concentrations (ng/ml) using rivaroxaban calibrators and controls, and the inter-laboratory precision of the measurement. Twenty-four centres in Europe and North America were provided with sets of rivaroxaban calibrators (0, 41, 209 and 422 ng/ml) and a set of rivaroxaban pooled human plasma controls (20, 199 and 662 ng/ml; the concentrations were unknown to the participating laboratories). The evaluation was carried out over 10 days by each laboratory using local anti-factor Xa reagents as well as the centrally provided reagent, a modified STA® Rotachrom® assay. A calibration curve was produced each day, and the day-to-day precision was evaluated by testing three human plasma controls. When using the local anti-factor Xa reagents, the mean rivaroxaban concentrations (measured/actual values) were: 17/20, 205/199 and 668/662 ng/ml, and the coefficient of variance (CV) was 37.0%, 13.7% and 14.1%, respectively. When the modified STA Rotachrom method was used, the measured/actual values were: 18/20, 199/199 and 656/662 ng/ml, and the CV was 19.1%, 10.9% and 10.0%, respectively. The results suggest that, by using rivaroxaban calibrators and controls, the anti-factor Xa chromogenic method is suitable for measuring a wide range of rivaroxaban plasma concentrations (20-660 ng/ml), which covers the expected rivaroxaban plasma levels after therapeutic doses.
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Eerenberg ES, van Es J, Sijpkens MK, Büller HR, Kamphuisen PW. New anticoagulants: moving on from scientific results to clinical implementation. Ann Med 2011; 43:606-16. [PMID: 21864021 DOI: 10.3109/07853890.2011.606829] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Vitamin K antagonists (VKA) are the only registered oral anticoagulants for the treatment of venous thromboembolism (VTE). VKA have an unpredictable and highly variable effect on coagulation, with a high risk of under- and over-treatment. Novel anticoagulants, such as dabigatran and rivaroxaban, could be a very welcome replacement for VKA, as they show a predictable anticoagulant effect. Results of several phase II and III studies have shown the efficacy and safety of dabigatran and rivaroxaban in the prophylaxis and treatment of VTE, and for the prevention of stroke in atrial fibrillation. It remains to be shown whether these new anticoagulants have the same safety profile in daily clinical practice, where more vulnerable patients will be treated. Lack of information on the proper monitoring method or antidote in case of bleeding may also hinder the translation from science to clinical practice.
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Affiliation(s)
- Elise S Eerenberg
- Department of Vascular Medicine, Academic Medical Centre , Amsterdam , the Netherlands
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Van Es J, Eerenberg ES, Kamphuisen PW, Büller HR. How to prevent, treat, and overcome current clinical challenges of VTE. J Thromb Haemost 2011; 9 Suppl 1:265-74. [PMID: 21781263 DOI: 10.1111/j.1538-7836.2011.04334.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Venous thromboembolism (VTE) is most commonly initially treated with low molecular weight heparin (LMWH), fondaparinux, or unfractionated heparin, in combination with vitamin-K antagonists (VKA) for long-term treatment. VKA have some drawbacks, however, which has led to the development of new anticoagulants. Most of these new drugs can be administered orally, and have been investigated in several phase III clinical trials. The benefits of these anticoagulants include their stable therapeutic effect, reduced interactions with other medication and food, and, therefore, the reduced need for regular monitoring. The duration of anticoagulant treatment for VTE is usually 3-12 months, but depends on the balance between the risks of recurrent thrombosis, major bleeding, and the patient's preference. Clinical decision rules to assess the risk of recurrence to tailor the duration of anticoagulant treatment are being investigated. The beneficial aspects of novel anticoagulants may prolong the duration of treatment. VTE treatment should be adjusted in special patient groups, such as in cases of malignancy, renal failure, pregnancy, or obesity. In this review, the current and future aspects of the treatment of VTE are explored.
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Affiliation(s)
- J Van Es
- Department of Vascular Medicine, Academic Medical Centre, Amsterdam, the Netherlands
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Al Dieri R, Hemker HC. Monitoring new oral antithrombotics: what we should know before we can decide. J Thromb Haemost 2010; 8:2833-5. [PMID: 20854371 DOI: 10.1111/j.1538-7836.2010.04057.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
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Abstract
Pulmonary embolism (PE) cannot be diagnosed solely on a clinical basis, because of the lack of sensitivity and specificity of clinical signs and symptoms. Pulmonary angiography is invasive and resource demanding. Because the prevalence of PE is relatively low (20% or less) amongst individuals who are clinically suspected of having the disease, submitting all of them to imaging (multi-detector CT angiography or ventilation/perfusion lung scintigraphy) would not be cost-effective. Therefore, diagnostic algorithms have been developed that include clinical probability assessment and D-dimer measurement to select the patients who require noninvasive imaging. Once the diagnosis is suspected or confirmed, therapy must be started to avoid potentially fatal recurrence. Treatment starts for an initial 3-month period with a 5-day course of parenteral unfractionated or low-molecular-weight heparin or fondaparinux overlapping with and followed by oral vitamin K antagonists monitored to maintain an international normalized ratio of 2-3. This initial period of 3 months may then be followed by a long-term secondary prevention period in patients who experience an idiopathic thromboembolic event and are at low risk of bleeding. New oral anticoagulants that do require patient monitoring and might exhibit a more favourable benefit-risk balance are currently under extensive clinical testing and might change the situation in the near future. A critical appraisal of the contemporary management of suspected PE is given in this overview with the discussion of 10 practical questions.
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Affiliation(s)
- H Bounameaux
- Division of Angiology and Hemostasis, Department of Internal Medicine, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland.
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Díaz-Cremades JM, Ruano JA, Fernández-Fuertes F. When a virtue becomes a problem. The new oral anticoagulants. J Thromb Haemost 2010; 8:1868-9. [PMID: 20456755 DOI: 10.1111/j.1538-7836.2010.03902.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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