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Cross B, Turner RM, Zhang JE, Pirmohamed M. Being precise with anticoagulation to reduce adverse drug reactions: are we there yet? THE PHARMACOGENOMICS JOURNAL 2024; 24:7. [PMID: 38443337 PMCID: PMC10914631 DOI: 10.1038/s41397-024-00329-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 02/11/2024] [Accepted: 02/15/2024] [Indexed: 03/07/2024]
Abstract
Anticoagulants are potent therapeutics widely used in medical and surgical settings, and the amount spent on anticoagulation is rising. Although warfarin remains a widely prescribed oral anticoagulant, prescriptions of direct oral anticoagulants (DOACs) have increased rapidly. Heparin-based parenteral anticoagulants include both unfractionated and low molecular weight heparins (LMWHs). In clinical practice, anticoagulants are generally well tolerated, although interindividual variability in response is apparent. This variability in anticoagulant response can lead to serious incident thrombosis, haemorrhage and off-target adverse reactions such as heparin-induced thrombocytopaenia (HIT). This review seeks to highlight the genetic, environmental and clinical factors associated with variability in anticoagulant response, and review the current evidence base for tailoring the drug, dose, and/or monitoring decisions to identified patient subgroups to improve anticoagulant safety. Areas that would benefit from further research are also identified. Validated variants in VKORC1, CYP2C9 and CYP4F2 constitute biomarkers for differential warfarin response and genotype-informed warfarin dosing has been shown to reduce adverse clinical events. Polymorphisms in CES1 appear relevant to dabigatran exposure but the genetic studies focusing on clinical outcomes such as bleeding are sparse. The influence of body weight on LMWH response merits further attention, as does the relationship between anti-Xa levels and clinical outcomes. Ultimately, safe and effective anticoagulation requires both a deeper parsing of factors contributing to variable response, and further prospective studies to determine optimal therapeutic strategies in identified higher risk subgroups.
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Affiliation(s)
- Benjamin Cross
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Richard M Turner
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
- GSK, Stevenage, Hertfordshire, SG1 2NY, UK
| | - J Eunice Zhang
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK
| | - Munir Pirmohamed
- Wolfson Centre for Personalised Medicine, Institute of Systems, Molecular and Integrative Biology, The University of Liverpool, 1-5 Brownlow Street, Liverpool, L69 3GL, UK.
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Mangion K, Vella K, Gatt A, Vella AM, Borg M, Borg-Aquilina D, Douxfils J, Camilleri L, Riva N. A comparative in vitro study of the anticoagulant effect of branded versus generic rivaroxaban. Thromb Res 2024; 235:41-51. [PMID: 38295600 DOI: 10.1016/j.thromres.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 12/04/2023] [Accepted: 01/22/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Several generic formulations of rivaroxaban were recently marketed to be used interchangeably with their branded equivalent. However, there have been no previously published studies that directly compared the in vitro anticoagulant effect of branded vs. generic rivaroxaban. The aim of this in vitro study was to compare the effects of three raw rivaroxaban materials, obtained from the branded (Xarelto®) and two generic (Rivarolto® and Rivaroxaban Sandoz®) rivaroxaban formulations on an array of coagulation assays. METHODS A pool of normal plasma was spiked with several concentrations of the three rivaroxaban (range 50-750 ng/ml). The concentrations were assessed with a rivaroxaban calibrated anti-Xa assay and confirmed by ultra-high-performance liquid chromatography-mass spectrometry coupled with tandem mass spectrometry (UHPLC-MS/MS). The following assays were performed: Prothrombin time (PT), activated Partial Thromboplastin time (aPTT), Diluted Russell's Viper Venom Test (dRVVT), Thrombin time (TT), Clauss Fibrinogen, Factor VII, VIII and IX assays, and thromboelastography. RESULTS The results obtained by the three rivaroxaban at similar concentrations were comparable. Increasing concentrations of the three rivaroxaban showed a strong positive correlation with the PT, aPTT and dRVVT assays (r > 0.95, p < 0.01 for all), and a strong negative correlation with the Factors assays (r < -0.95, p < 0.01 for all). TT and Clauss Fibrinogen were not affected by rivaroxaban. No significant difference was identified in the mean assays' results obtained by the three rivaroxaban. CONCLUSION This study showed that the branded and generic rivaroxaban exert an identical in vitro anticoagulant effect across a wide range of concentrations.
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Affiliation(s)
- Karl Mangion
- Department of Applied Biomedical Science, Faculty of Health Sciences, University of Malta, Msida, Malta.
| | - Kevin Vella
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta.
| | - Alex Gatt
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta; Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.
| | - Amy Marie Vella
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta.
| | - Marica Borg
- Coagulation Laboratory, Department of Pathology, Mater Dei Hospital, Msida, Malta.
| | - Denise Borg-Aquilina
- National Blood Transfusion Service & Mater Dei Hospital Blood Bank, Msida, Malta.
| | - Jonathan Douxfils
- University of Namur, Faculty of Medicine, Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, Namur, Belgium; Qualiblood s.a., Qualiclinics, Namur, Belgium.
| | - Liberato Camilleri
- Department of Statistics & Operations Research, Faculty of Science, University of Malta, Msida, Malta.
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta.
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Efros O, Berman A, Kenet G, Lubetsky A, Doron A, Shlomai G, Klang E, Soffer S, Barda N, Leibowitz A. Elevated International Normalized Ratio and Mortality in Hospitalized Patients Treated with Direct Oral Anticoagulants. Am J Med 2024; 137:147-153.e2. [PMID: 37926222 DOI: 10.1016/j.amjmed.2023.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 09/21/2023] [Accepted: 10/17/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Direct oral anticoagulants (DOACs) are associated with a prolongation of the prothrombin time and an increased international normalized ratio (INR). The clinical significance of these changes is unclear. This study aimed to examine the association between an elevated INR on admission and in-hospital death and long-term survival in patients treated with DOACs. METHODS Data were retrospectively retrieved from records of hospitalized patients at the Sheba Medical Center between November 2008 and July 2023. Patients were selected based on DOAC treatment, coagulation profile, and INR test done within 48 hours of hospitalization. The outcomes were in-hospital mortality and mortality in the year following hospitalization. RESULTS The study included 11,399 hospitalized patients treated with DOACs. Patients with elevated INR had a 180% higher risk of in-hospital mortality (adjusted odds ratio 2.80; 95% confidence interval, 2.30-3.39) and a 57% increased risk of death during the following year (adjusted hazard ratio 1.57; 95% confidence interval, 1.44-1.71). Similar results were observed in subgroup analyses for each DOAC. CONCLUSIONS An elevated INR on admission is associated with a higher risk for in-hospital death and increased risk for mortality during the first year following hospitalization in hospitalized patients treated with DOACs. This highlights that elevated INR levels in patients on DOACs should not be dismissed as laboratory variations due to DOAC treatment, as they may serve as a prognostic marker.
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Affiliation(s)
- Orly Efros
- National Hemophilia Center and Thrombosis & Hemostasis Institute, Sheba Medical Center, Ramat Gan, Israel; School of Medicine, Faculty of Medicine, Tel Aviv University, Israel.
| | - Aya Berman
- Dan Petah-Tikva District at Clalit Health Services, Petah-Tikva, Israel; Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Gili Kenet
- National Hemophilia Center and Thrombosis & Hemostasis Institute, Sheba Medical Center, Ramat Gan, Israel; School of Medicine, Faculty of Medicine, Tel Aviv University, Israel; Amalia Biron Research Institute of Thrombosis & Hemostasis
| | - Aharon Lubetsky
- National Hemophilia Center and Thrombosis & Hemostasis Institute, Sheba Medical Center, Ramat Gan, Israel; School of Medicine, Faculty of Medicine, Tel Aviv University, Israel
| | - Alon Doron
- School of Medicine, Faculty of Medicine, Tel Aviv University, Israel
| | - Gadi Shlomai
- School of Medicine, Faculty of Medicine, Tel Aviv University, Israel; The Division of Endocrinology, Diabetes, and Metabolism; Department of Internal Medicine "D" and Hypertension Unit
| | - Eyal Klang
- School of Medicine, Faculty of Medicine, Tel Aviv University, Israel; Arc Innovation Center, Sheba Medical Center, Ramat-Gan, Israel
| | - Shelly Soffer
- Ben-Gurion University of the Negev, Be'er Sheva, Israel; Internal Medicine B, Assuta Medical Center, Ashdod, Israel
| | - Noam Barda
- Arc Innovation Center, Sheba Medical Center, Ramat-Gan, Israel; Software and Information Systems Engineering; Epidemiology, Biostatistics and Community Health Services, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Avshalom Leibowitz
- School of Medicine, Faculty of Medicine, Tel Aviv University, Israel; Department of Internal Medicine "D" and Hypertension Unit
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Shahbazi-Derakhshi P, Abbasi M, Akbarzadeh A, Mokhtarzadeh A, Hosseinpour H, Soleymani J. A ratiometric electrochemical probe for the quantification of apixaban in unprocessed plasma samples using carbon aerogel/BFO modified glassy carbon electrodes. RSC Adv 2023; 13:21432-21440. [PMID: 37465572 PMCID: PMC10351564 DOI: 10.1039/d3ra03293k] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/02/2023] [Indexed: 07/20/2023] Open
Abstract
A novel electrochemical probe was established for the quantification of apixaban (APX) in unprocessed plasma samples. Efficiently oxidized graphene oxide aerogels (EEGO-AGs) and nano-sized Bi2Fe4O9 (BFO) particles were electrodeposited on the surface of a glassy carbon electrode (GCE). In this work, a ratiometric electrochemical method was introduced for APX detection to enhance the specificity of the probe in plasma samples. The fabricated ratiometric probe was employed for the indirect detection determination of APX using K3[Fe(CN)6]/K4[Fe(CN)6] as the redox pair. The differential pulse voltammetry technique was used to record the current alteration of the BFO/EEGO-AG-functionalized GCE probe at various APX concentrations. The probe response was proportional to the APX concentrations from 10 ng mL-1 to 10 μg mL-1 with a low limit of quantification (LLOQ) of 10 ng mL-1. After validation, this method was successfully utilized for the determination of APX in patients' plasma samples who have taken APX regularly. The fabricated chemosensor detected APX concentrations in unprocessed plasma samples with high selectivity, resulting from the physical filtering antifouling activity of aerogels.
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Affiliation(s)
- Payam Shahbazi-Derakhshi
- Pharmaceutical Analysis Research Center, Tabriz University of Medical Sciences Tabriz Iran +98 413 337 9323
- Liver and Gastrointestinal Research Center, Tabriz University of Medical Sciences Tabriz Iran
| | - Mohammad Abbasi
- Liver and Gastrointestinal Research Center, Tabriz University of Medical Sciences Tabriz Iran
| | | | - Ahad Mokhtarzadeh
- Immunology Research Center, Tabriz University of Medical Sciences Tabriz Iran
| | - Hamid Hosseinpour
- Department of Neurosurgery, Faculty of Medicine, Urmia University of Medical Sciences Urmia Iran
| | - Jafar Soleymani
- Pharmaceutical Analysis Research Center, Tabriz University of Medical Sciences Tabriz Iran +98 413 337 9323
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Chen W, Ruan Z, Lou H, Wang L, Shao R, Li F, Jiang B. Safety, pharmacokinetics and exploratory exposure-response analysis of CX3002, a novel inhibitor of Xa, in Chinese healthy subjects. Eur J Pharm Sci 2023; 185:106437. [PMID: 36990295 DOI: 10.1016/j.ejps.2023.106437] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 02/21/2023] [Accepted: 03/26/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND AND OBJECTIVE CX3002 is a structurally novel inhibitor of factor Xa, with promising prospects. This study aims to report the results of a first-in-human ascending-dose study of CX3002 in Chinese healthy subjects, and to establish an exploratory population pharmacokinetic/pharmacodynamic (PK/PD) model to investigate the exposure-response relationship of CX3002. METHODS The randomized, double-blind, placebo-controlled study included six single-dose groups and three multiple-dose groups, with a dose range of 1-30 mg. Safety, tolerability, pharmacokinetics (PK) and pharmacodynamics (PD) of CX3002 were evaluated. PK of CX3002 was analyzed using both non-compartment method and population modeling. PK/PD model was developed using nonlinear mixed effect modeling approach and was evaluated by prediction-corrected visual predictive check and bootstrap methods. RESULTS A total of 84 subjects were enrolled and all participants completed the study. CX3002 exhibited satisfactory safety and tolerability in healthy subjects. Cmax and AUC of CX3002 increased with dose from 1 mg to 30 mg, but less-than-proportional increases were observed. There was no obvious accumulation with multiple doses. Anti-Xa activity showed dose-related increases after administration of CX3002 but not placebo. The PK of CX3002 was well described by a two-compartment model with a modification of bioavailability according to dose, and anti-Xa activity was described by a Hill function. No covariate was identified significant based on the limited data in this study. CONCLUSIONS CX3002 was well tolerated and resulted in dose-related anti-Xa activity across the dose range. The PK of CX3002 were predictable, and correlated with PD effects. Continued clinical investigation of CX3002 was supported. Chinadrugtrials.org.cn identifier: CTR20190153.
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Pavoni V, Gianesello L, Conti D, Ballo P, Dattolo P, Prisco D, Görlinger K. "In Less than No Time": Feasibility of Rotational Thromboelastometry to Detect Anticoagulant Drugs Activity and to Guide Reversal Therapy. J Clin Med 2022; 11:1407. [PMID: 35268498 PMCID: PMC8911211 DOI: 10.3390/jcm11051407] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 02/23/2022] [Accepted: 03/03/2022] [Indexed: 02/04/2023] Open
Abstract
Anticoagulant drugs (i.e., unfractionated heparin, low-molecular-weight heparins, vitamin K antagonists, and direct oral anticoagulants) are widely employed in preventing and treating venous thromboembolism (VTE), in preventing arterial thromboembolism in nonvalvular atrial fibrillation (NVAF), and in treating acute coronary diseases early. In certain situations, such as bleeding, urgent invasive procedures, and surgical settings, the evaluation of anticoagulant levels and the monitoring of reversal therapy appear essential. Standard coagulation tests (i.e., activated partial thromboplastin time (aPTT) and prothrombin time (PT)) can be normal, and the turnaround time can be long. While the role of viscoelastic hemostatic assays (VHAs), such as rotational thromboelastometry (ROTEM), has successfully increased over the years in the management of bleeding and thrombotic complications, its usefulness in detecting anticoagulants and their reversal still appears unclear.
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Affiliation(s)
- Vittorio Pavoni
- Anesthesia and Intensive Care Unit, Emergency Department and Critical Care Area, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy; (V.P.); (D.C.)
| | - Lara Gianesello
- Department of Anesthesia and Intensive Care, Orthopedic Anesthesia, University-Hospital Careggi, 50134 Florence, Italy
| | - Duccio Conti
- Anesthesia and Intensive Care Unit, Emergency Department and Critical Care Area, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy; (V.P.); (D.C.)
| | - Piercarlo Ballo
- Cardiology Unit, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy;
| | - Pietro Dattolo
- Nephrology Unit Florence 1, Santa Maria Annunziata Hospital, Bagno a Ripoli, 50012 Florence, Italy;
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy;
| | - Klaus Görlinger
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, 45147 Essen, Germany;
- Medical Department, Tem Innovations, 81829 Munich, Germany
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Khider L, Gendron N, Mauge L. Inherited Thrombophilia in the Era of Direct Oral Anticoagulants. Int J Mol Sci 2022; 23:1821. [PMID: 35163742 PMCID: PMC8837096 DOI: 10.3390/ijms23031821] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/28/2022] [Accepted: 01/29/2022] [Indexed: 12/13/2022] Open
Abstract
Severe inherited thrombophilia includes rare deficiencies of natural anticoagulants (antithrombin and proteins C and S) and homozygous or combined factor V Leiden and FII G20210A variants. They are associated with a high thrombosis risk and can impact the duration of anticoagulation therapy for patients with a venous thromboembolism (VTE) event. Therefore, it is important to diagnose thrombophilia and to use adapted anticoagulant therapy. The widespread use of direct anticoagulants (DOACs) for VTE has raised new issues concerning inherited thrombophilia. Concerning inherited thrombophilia diagnosis, DOACs are directed toward either FIIa or FXa and can therefore interfere with coagulation assays. This paper reports DOAC interference in several thrombophilia tests, including the assessment of antithrombin, protein S, and protein C activities. Antithrombin activity and clot-based assays used for proteins C and S can be overestimated, with a risk of missing a deficiency. The use of a device to remove DOACs should be considered to minimize the risk of false-negative results. The place of DOACs in the treatment of VTE in thrombophilia patients is also discussed. Available data are encouraging, but given the variability in thrombosis risk within natural anticoagulant deficiencies, evidence in patients with well-characterized thrombophilia would be useful.
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Affiliation(s)
- Lina Khider
- Service de Médecine Vasculaire, Assistance Publique Hôpitaux de Paris-Centre (AP-HP.CUP), F-75015 Paris, France;
- Innovative Therapies in Haemostasis, Université de Paris, INSERM, F-75006 Paris, France;
- Biosurgical Research Lab (Carpentier Foundation), AP-HP, F-75015 Paris, France
| | - Nicolas Gendron
- Innovative Therapies in Haemostasis, Université de Paris, INSERM, F-75006 Paris, France;
- Biosurgical Research Lab (Carpentier Foundation), AP-HP, F-75015 Paris, France
- Service d’Hématologie Biologique, Assistance Publique Hôpitaux de Paris-Centre (AP-HP.CUP), F-75015 Paris, France
| | - Laetitia Mauge
- Service d’Hématologie Biologique, Assistance Publique Hôpitaux de Paris-Centre (AP-HP.CUP), F-75015 Paris, France
- PARCC, Université de Paris, INSERM, F-75015 Paris, France
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Risk factors associated with post-extraction bleeding in patients on warfarin or direct-acting oral anticoagulants: a retrospective cohort study. Oral Maxillofac Surg 2022; 26:641-648. [PMID: 35043275 DOI: 10.1007/s10006-022-01039-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 01/06/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE The purpose of this study was to investigate the risk factors associated with post-extraction persistent bleeding in patients on warfarin or direct-acting oral anticoagulants (DOACs) and the ability of risk scores to predict post-extraction bleeding. METHODS Three hundred ninety-one patients taking warfarin or DOACs underwent tooth extractions. Various risk factors for post-extraction bleeding, including number of tooth extraction, with antiplatelet therapy, and risk scores, were investigated by univariate and multivariate analyses. A post-extraction bleeding was classified into grades 1-3. RESULTS The incidence of post-extraction bleeding was 26.8% (77 out of 287 patients; grade 1: 63, grade 2:14) in patients taking warfarin, and 26.0% (27 out of 104 patients; grade 1: 20, grade 2:7) in patients taking warfarin DOACs. Multivariate analyses showed that multiple teeth extractions and HAS-BLED scores (above 3 points) in patients taking warfarin, and only multiple teeth extractions in patients taking DOAC, were significantly associated with post-extraction bleeding, respectively. CONCLUSION Most of the post-extraction bleedings were grade 1, which can be stopped by eligibly pressing gauze by surgeons. If patients taking anticoagulants are scheduled to undergo multiple teeth extractions or their HAS-BLED score are above 3 points (if warfarin), we recommend informing patients risk of post-extraction bleeding before operation, taking carefully hemostasis, and instructing patients to bite down accurately on the gauze for longer than usual.
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Moser KA. Direct oral anticoagulant (DOAC) interference in hemostasis assays. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:129-133. [PMID: 34889400 PMCID: PMC8791165 DOI: 10.1182/hematology.2021000241] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Direct oral anticoagulants (DOACs) are a group of direct coagulation factor inhibitors including both direct thrombin inhibitors and direct factor Xa inhibitors. These medications may cause hemostasis assay interference by falsely increasing or decreasing measured values, depending on the analyte. Considering the potential for DOAC interference in a variety of hemostasis assays is essential to avoid erroneous interpretation of results. Preanalytic strategies to avoid DOAC interference include selecting alternatives to clot-based hemostasis assays in patients taking DOACs when possible and sample collection timed when the patient is off anticoagulant therapy or at the expected drug trough. Clinical laboratories may also provide educational materials that clearly describe possible interferences from DOAC, develop testing algorithms to aid in detection of DOAC in submitted samples, use DOAC-neutralizing agents to remove DOACs before continuing with testing, and write interpretive comments that explain the effects of DOAC interference in hemostasis tests. Using a combination of the described strategies will aid physicians and laboratorians in correctly interpreting hemostasis and thrombosis laboratory tests in the presence of DOACs.
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Affiliation(s)
- Karen A. Moser
- Department of Pathology, University of Utah School of Medicine, Salt Lake City, UT
- Correspondence Karen A. Moser, ARUP Laboratories, 500 Chipeta Way, Mail Stop 115-G04, Salt Lake City, UT 84108; e-mail:
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Terakami T, Nagaya S, Hayashi K, Furusho H, Fujino N, Kato T, Asakura H, Morishita E. Effect on Plasma Protein S Activity in Patients Receiving the Factor Xa Inhibitors. J Atheroscler Thromb 2021; 29:1059-1068. [PMID: 34334529 PMCID: PMC9252639 DOI: 10.5551/jat.62951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIMS Measurement of protein S (PS) activity in patients taking direct oral anticoagulants (DOACs) using reagents based on a clotting assay results in falsely high PS activity, thus masking inherited PS deficiency, which is most frequently seen in the Japanese population. In this study, we investigated the effect of factor Xa (FXa) inhibitors on PS activity using the reagent on the basis of the chromogenic assay, which was recently developed in Japan. METHODS The study enrolled 152 patients (82 males and 70 females; the average age: 68.5±14.0 years) receiving three FXa inhibitors (rivaroxaban, edoxaban, and apixaban). PS activity was measured using the reagents on the basis of the clotting and chromogenic assays. RESULTS PS activity measured by the clotting assay reagents exhibited falsely high values depending on the plasma concentrations of FXa inhibitors in patients taking either rivaroxaban or edoxaban. However, none of the three FXa inhibitors affected PS activity when measured using the chromogenic assay. CONCLUSION In patients taking rivaroxaban or edoxaban, inherited PS deficiency is likely missed because the levels of PS activity measured using the reagents based on the clotting assay are falsely high. However, we report that three FXa inhibitors do not affect PS activity measured by the chromogenic assay. When measuring the levels of PS activity in patients undergoing DOACs, the principles of each reagent should be understood. Furthermore, plasma samples must be collected at the time when plasma concentrations of DOACs are lowest or the DOAC-Stop reagent should be used.
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Affiliation(s)
- Takako Terakami
- Department of Clinical Laboratory Science, Division of Health Sciences, Graduate School of Medical Science, Kanazawa University.,Department of Clinical Laboratory, Kanazawa University Hospital
| | - Satomi Nagaya
- Department of Clinical Laboratory Science, Division of Health Sciences, Graduate School of Medical Science, Kanazawa University
| | - Kenshi Hayashi
- Department of Clinical Laboratory Science, Division of Health Sciences, Graduate School of Medical Science, Kanazawa University
| | - Hiroshi Furusho
- Department of Cardiology, Ishikawa Prefectural Central Hospital
| | - Noboru Fujino
- Department of Clinical Laboratory Science, Division of Health Sciences, Graduate School of Medical Science, Kanazawa University.,Department of Cardiology, Kanazawa University Hospital
| | - Takeshi Kato
- Department of Cardiology, Kanazawa University Hospital
| | | | - Eriko Morishita
- Department of Clinical Laboratory Science, Division of Health Sciences, Graduate School of Medical Science, Kanazawa University.,Department of Hematology, Kanazawa University Hospital
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Hong J, Ahn SY, Lee YJ, Lee JH, Han JW, Kim KH, Yhim HY, Nam SH, Kim HJ, Song J, Kim SH, Bang SM, Kim JS, Mun YC, Bae SH, Kim HK, Jang S, Park R, Choi HS, Kim I, Oh D. Updated recommendations for the treatment of venous thromboembolism. Blood Res 2021; 56:6-16. [PMID: 33627521 PMCID: PMC7987480 DOI: 10.5045/br.2021.2020083] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 01/06/2021] [Accepted: 01/06/2021] [Indexed: 12/13/2022] Open
Abstract
Venous thromboembolism (VTE), which includes pulmonary embolism and deep vein thrombosis, is a condition characterized by abnormal blood clot formation in the pulmonary arteries and the deep venous vasculature. It is often serious and sometimes even fatal if not promptly and appropriately treated. Moreover, the later consequences of VTE may result in reduced quality of life. The treatment of VTE depends on various factors, including the type, cause, and patient comorbidities. Furthermore, bleeding may occur as a side effect of VTE treatment. Thus, it is necessary to carefully weigh the benefits versus the risks of VTE treatment and to actively monitor patients undergoing treatment. Asian populations are known to have lower VTE incidences than Western populations, but recent studies have shown an increase in the incidence of VTE in Asia. A variety of treatment options are currently available owing to the introduction of direct oral anticoagulants. The current VTE treatment recommendation is based on evidence from previous studies, but it should be applied with careful consideration of the racial, genetic, and social characteristics in the Korean population.
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Affiliation(s)
- Junshik Hong
- Division of Hematology-Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Department of Hematology-Oncology, Korea
| | - Seo-Yeon Ahn
- Chonnam National University Hwasun Hospital, Hwasun, Korea
| | - Yoo Jin Lee
- Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Ji Hyun Lee
- Division of Hematology and Oncology, Department of Internal Medicine, Dong-A University College of Medicine, Dong-A University Hospital, Busan, Korea
| | - Jung Woo Han
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Yonsei University College of Medicine, Yonsei University Health System, Jeonju, Korea
| | - Kyoung Ha Kim
- Department of Oncology and Hematology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Department of Internal Medicine, Jeonju, Korea
| | - Ho-Young Yhim
- Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
| | | | - Hee-Jin Kim
- Department of Laboratory Medicine & Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jaewoo Song
- Department of Laboratory Medicine, Yonsei University College of Medicine, Severance Hospital, Seoul, Korea
| | - Sung-Hyun Kim
- Division of Hematology and Oncology, Department of Internal Medicine, Dong-A University College of Medicine, Dong-A University Hospital, Busan, Korea
| | - Soo-Mee Bang
- Division of Hematology-Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jin Seok Kim
- Division of Hematology, Department of Internal Medicine, Yonsei University College of Medicine, Severance Hospital, Department of Internal Medicine, Seoul, Korea
| | - Yeung-Chul Mun
- Ewha Womans University College of Medicine, Seoul, Korea
| | - Sung Hwa Bae
- Daegu Catholic University School of Medicine, Daegu Catholic University Hospital, Daegu, Department of Laboratory Medicine, Korea
| | - Hyun Kyung Kim
- Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seongsoo Jang
- University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Rojin Park
- Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Hyoung Soo Choi
- Department of Pediatrics, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Inho Kim
- Division of Hematology-Medical Oncology, Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, Department of Hematology-Oncology, Korea
| | - Doyeun Oh
- Division of Hematology-Oncology, Department of Internal Medicine, CHA University School of Medicine, Seongnam, Korea
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12
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Chang WC, Jackson JW, Machlus KR, Wolberg AS, Ovanesov MV. Fluorescence artifact correction in the thrombin generation assay: Necessity for correction algorithms in procoagulant samples. Res Pract Thromb Haemost 2021; 5:447-455. [PMID: 33870030 PMCID: PMC8035796 DOI: 10.1002/rth2.12499] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 02/01/2021] [Accepted: 02/07/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction The thrombin generation (TG) test is a global hemostasis assay sensitive to procoagulant conditions. However, some TG assays may underestimate elevated TG when the thrombin fluorogenic substrate is depleted or fluorescence is attenuated by the inner filter effect (IFE). Objectives We sought to elucidate the extent to which procoagulant conditions require correcting for fluorogenic substrate depletion and/or IFE. Methods We analyzed corrections for substrate depletion and IFE and their effect on TG parameters in plasma samples with elevated blood coagulation factors in the presence or absence of thrombomodulin via commercial calibrated automated thrombogram (CAT) platform and in‐house software capable of internal thrombin calibration with or without CAT‐like artifact correction. Results Elevated thrombin peak height (TPH) and endogenous thrombin potential (ETP) were detected with 2× and 4× increases in blood coagulation factors I, V, VIII, IX, X, and XI, or prothrombin in the presence or absence of artifact correction. The effect of the CAT algorithm was evident in TG curves from both low procoagulant (thrombomodulin‐supplemented) and procoagulant (factor‐supplemented) plasma samples. However, in all samples, with the exception of elevated prothrombin, CAT’s correction was small (<10%) and did not affect detection of procoagulant samples versus normal plasma. For elevated prothrombin samples, uncorrected TPH or ETP values were underestimated, and CAT correction produced drastically elevated TG curves. Conclusions Our data suggest that correction for substrate consumption and IFE, as offered by the CAT algorithm, is critical for detecting a subset of extremely procoagulant samples, such as elevated prothrombin, but is not necessary for all other conditions, including elevated factors XI and VIII.
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Affiliation(s)
- William C Chang
- Office of Tissues and Advanced Therapies Center for Biologics Evaluation and Research US Food and Drug Administration Silver Spring MD USA
| | - Joseph W Jackson
- Office of Tissues and Advanced Therapies Center for Biologics Evaluation and Research US Food and Drug Administration Silver Spring MD USA
| | - Kellie R Machlus
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center University of North Carolina at Chapel Hill Chapel Hill North Carolina USA.,Vascular Biology Program, Department of Surgery Boston Children's Hospital and Harvard Medical School Boston MA USA.,Present address: Brigham and Women's Hospital Harvard Medical School Boston MA USA
| | - Alisa S Wolberg
- Department of Pathology and Laboratory Medicine and UNC Blood Research Center University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Mikhail V Ovanesov
- Office of Tissues and Advanced Therapies Center for Biologics Evaluation and Research US Food and Drug Administration Silver Spring MD USA
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13
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Kumano O, Akatsuchi K, Amiral J. Updates on Anticoagulation and Laboratory Tools for Therapy Monitoring of Heparin, Vitamin K Antagonists and Direct Oral Anticoagulants. Biomedicines 2021; 9:biomedicines9030264. [PMID: 33799956 PMCID: PMC7998518 DOI: 10.3390/biomedicines9030264] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Revised: 02/24/2021] [Accepted: 03/03/2021] [Indexed: 01/08/2023] Open
Abstract
Anticoagulant drugs have been used to prevent and treat thrombosis. However, they are associated with risk of hemorrhage. Therefore, prior to their clinical use, it is important to assess the risk of bleeding and thrombosis. In case of older anticoagulant drugs like heparin and warfarin, dose adjustment is required owing to narrow therapeutic ranges. The established monitoring methods for heparin and warfarin are activated partial thromboplastin time (APTT)/anti-Xa assay and prothrombin time – international normalized ratio (PT-INR), respectively. Since 2008, new generation anticoagulant drugs, called direct oral anticoagulants (DOACs), have been widely prescribed to prevent and treat several thromboembolic diseases. Although the use of DOACs without routine monitoring and frequent dose adjustment has been shown to be safe and effective, there may be clinical circumstances in specific patients when measurement of the anticoagulant effects of DOACs is required. Recently, anticoagulation therapy has received attention when treating patients with coronavirus disease 2019 (COVID-19). In this review, we discuss the mechanisms of anticoagulant drugs—heparin, warfarin, and DOACs and describe the methods used for the measurement of their effects. In addition, we discuss the latest findings on thrombosis mechanism in patients with COVID-19 with respect to biological chemistry.
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Affiliation(s)
- Osamu Kumano
- Research Department, HYPHEN BioMed, 155 Rue d’Eragny, 95000 Neuville sur Oise, France;
- Protein Technology, Engineering 1, Sysmex Corporation, Kobe 651-2271, Japan
- Correspondence: ; Tel.: +81-78-991-2203
| | - Kohei Akatsuchi
- R&D Division, Sysmex R&D Center Americas, Inc., Mundelein, IL 60060, USA;
| | - Jean Amiral
- Research Department, HYPHEN BioMed, 155 Rue d’Eragny, 95000 Neuville sur Oise, France;
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14
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Current use of rivaroxaban in elderly patients with venous thromboembolism (VTE). J Thromb Thrombolysis 2021; 52:863-871. [PMID: 33674983 DOI: 10.1007/s11239-021-02415-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/16/2021] [Indexed: 12/12/2022]
Abstract
Venous thromboembolism (VTE), which is characterized by pulmonary embolism and deep vein thrombosis, has become a serious public concern. Notably, over half of the patients with VTE are over 70 years of age, but elderly patients are at high risk of anti-coagulation and bleeding, which increase with age. Moreover, risk factors and frailty also show a difference between elderly patients and ordinary patients diagnosed with VTE. Rivaroxaban is a direct inhibitor of activated factor Xa and has the advantage of predictable pharmacodynamics and pharmacokinetics, no coagulation monitoring, and few drug interactions. As a first-line therapy for VTE, this drug is more advantageous than traditional therapy and exhibits good efficacy and safety for ordinary patients. However, the effectiveness and safety of rivaroxaban in elderly patients have not been fully elucidated. This article reviewed the use of rivaroxaban in elderly patients, including drug interactions, monitoring, reversal agents of rivaroxaban, and the use of small dosages of rivaroxaban in elderly patients.
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15
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Evans VJ, Lawrence M, Whitley J, Johns C, Pillai S, Hawkins K, Power K, Morris K, Williams R, Evans PA. The treatment effect of rivaroxaban on clot characteristics in patients who present acutely with first time deep vein thrombosis. Clin Hemorheol Microcirc 2021; 80:139-151. [PMID: 33682699 DOI: 10.3233/ch-201030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The acute vascular disease deep vein thrombosis (DVT) requires oral anticoagulants to prevent progression. Monitoring therapeutic efficacy of direct oral anticoagulants (DOAC), including rivaroxaban, is problematic as no reliable test is available. Advances in rheometry have led to the development of a functional coagulation biomarker using Gel Point (GP) analysis which assesses clot structure formation. The biomarker measures incipient clot formation time (TGP) and quantifies fibrin clot structure in terms of fractal dimension (df). OBJECTIVE This study aimed to investigate clot structure formation in first time DVT and the effect of rivaroxaban treatment. METHODS This prospective observational cohort study measured the GP and standard laboratory markers at three sample points: pre-treatment and at 20 and 60 days following 15 mg BD and 20 mg OD rivaroxaban respectively. RESULTS Forty DVT patients (mean age 64 years [SD±14.8]; 23 males, 17 female) were recruited. The results show that DVT vs non-DVT patients did not have a significantly different GP profile (df: 1.72±0.06 vs 1.70±0.06 and TGP: 267±68 sec vs 262±73 sec) with both within the defined healthy index. In addition, rivaroxaban therapy increased TGP to 392 s (±135 s) after 20 days, and subsequently increased to 395 s (±194 s) at 60 days but did not significantly increase df (from 1.69±0.05 to 1.71±0.06). CONCLUSIONS The results indicate in this cohort of DVT patients there was no underlying hypercoagulable effect as determined by gel point analysis. Furthermore, the anticoagulant effect of rivaroxaban prolonged clotting, suggesting a protective effect against clot formation, without significantly reducing clot microstructural properties.
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Affiliation(s)
- V J Evans
- Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK.,Swansea University, Swansea, UK
| | - M Lawrence
- Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK.,Swansea University, Swansea, UK
| | - J Whitley
- Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK.,Swansea University, Swansea, UK
| | - C Johns
- Swansea Bay University Health Board, Swansea, UK
| | - S Pillai
- Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK.,Swansea University, Swansea, UK
| | | | - K Power
- Swansea Bay University Health Board, Swansea, UK
| | - K Morris
- Cardiff Metropolitan University, Cardiff, UK
| | | | - P A Evans
- Welsh Centre for Emergency Medicine Research, Morriston Hospital, Swansea Bay University Health Board, Swansea, UK.,Swansea University, Swansea, UK
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16
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Azuhata T, Hayakwa M, Maekawa K, Komatsu T, Kuwana T, Kawano D, Nakamura K, Kinoshita K, Wada T, Tanjoh K. Supernormal Antithrombin Activity Is an Independent Predictor of In-Hospital Mortality in Patients With Sepsis: A Retrospective Observational Study. Clin Appl Thromb Hemost 2021; 26:1076029620912827. [PMID: 32299224 PMCID: PMC7288796 DOI: 10.1177/1076029620912827] [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] [Indexed: 11/15/2022] Open
Abstract
Supernormal antithrombin (AT) activity is rare in patients with sepsis. This study compared mortality rate of patients with sepsis and supernormal AT activity with that of other patients. This retrospective study included patients with sepsis from 42 intensive care units (ICUs) in Japan. Patients were included if their AT activity was measured on ICU admission, and if they did not receive AT concentrate. They were categorized into low, normal, and supernormal with respective AT activity of ≤70%, >70% to ≤100%, and >100%. The primary outcome was hospital in-patient mortality. Nonlinear regression analysis showed that mortality risk gradually increased with AT activity in the supernormal range, but without statistical significance. Survival rate was significantly lower in low (67%) and supernormal (57%) AT groups than in the normal AT group (79%; P < .001 and P = .008, respectively). After adjusting for disease severity and AT activity on day 2, supernormal AT activity was the only independent predictor of mortality. Sepsis with supernormal AT activity associated with high mortality, independent of disease severity, might be a predictor of in-hospital mortality.
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Affiliation(s)
- Takeo Azuhata
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan.,Department of General and Acute Medicine, Seitokai Azuhata Hospital, Ibaraki, Japan
| | - Mineji Hayakwa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Kunihiko Maekawa
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Tomohide Komatsu
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Tsukasa Kuwana
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Daisuke Kawano
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan.,Department of General and Acute Medicine, Seitokai Azuhata Hospital, Ibaraki, Japan
| | - Kazuhiro Nakamura
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan.,Department of General and Acute Medicine, Seitokai Azuhata Hospital, Ibaraki, Japan
| | - Kosaku Kinoshita
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Takeshi Wada
- Department of Emergency Medicine, Hokkaido University Hospital, Sapporo, Japan
| | - Katsuhisa Tanjoh
- Division of Emergency and Critical Care Medicine, Department of Acute Medicine, Nihon University School of Medicine, Tokyo, Japan.,Department of General and Acute Medicine, Seitokai Azuhata Hospital, Ibaraki, Japan
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17
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Effects of rivaroxaban and dabigatran on global hemostasis in patients with atrial fibrillation. Blood Coagul Fibrinolysis 2021; 31:243-252. [PMID: 32141885 DOI: 10.1097/mbc.0000000000000907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
: The study was aimed to evaluate the effects of two standard doses of rivaroxaban and dabigatran on global hemostatic assays in patients with atrial fibrillation. The study included 52 patients treated with rivaroxaban (15/20 mg), 50 on dabigatran (110/150 mg) and 20 healthy individuals. Platelet-poor plasma was used for determination of three global hemostatic assays, namely endogenous thrombin potential (ETP), calibrated automated thrombogram (CAT) and overall hemostasis potential (OHP). Rivaroxaban and dabigatran reduced ETP (P < 0.01) although OHP (P < 0.05) was diminished only by dabigatran. Strong correlations were noticed between ETP parameters and the plasma concentrations of rivaroxaban (ETP, r = -0.51; c-max, r = -0.85; t-lag, r = 0.83; t-max, r = 0.66) as well as with plasma concentration of dabigatran (ETP, r = -0.75; c-max, r = -0.74; t-lag, r = 0.73; t-max, r = 0.52). Analysis of dabigatran concentrations under 50 ng/ml showed that ETP parameter has area under the concentration-time curve-receiver operating characteristic value of 0.879 (95% confidence interval 0.776-0.980). Dabigatran treatment paradoxically increased area under the concentration-time curve and peak values although rivaroxaban decreased peak values (P < 0.01). However, significant correlation between CAT parameters and plasma concentration of both direct oral anticoagulants was not observed. We confirmed that the CAT assay is inappropriate for estimation of dabigatran effects and is not fully sensitive as regards rivaroxaban. The ETP assay can potentially be the appropriate method for estimation of global hemostatic capacity as regards both direct oral anticoagulants. The role of OHP needs to be confirmed in additional studies. ETP parameter of chromogenic assay has promising potential in exclusion of high plasma concentrations of dabigatran.
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18
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Unami N, Ise Y, Suzuki H. Anticoagulant activity of apixaban can be estimated by multiple regression analysis. J Arrhythm 2020; 36:1032-1038. [PMID: 33335621 PMCID: PMC7733564 DOI: 10.1002/joa3.12435] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 08/21/2020] [Accepted: 09/02/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Information on apixaban anticoagulant activity is required to prevent major bleeding or thrombosis during its use. METHODS We enrolled 194 patients with nonvalvular atrial fibrillation (NVAF) in whom warfarin was replaced with apixaban: 105 (54.1%) received the standard dose of apixaban (5 mg twice daily [BID]; 5 mg group) and 89 (45.9%) received a reduced dose (2.5 mg BID; 2.5 mg group). Multiple regression analysis was performed to predict the prothrombin time of apixaban (PTa) based on factors including age, body weight (BW), serum creatinine, and CHA2DS2-VASc score. RESULTS PTa and PT of warfarin (PTw) were significantly correlated in both groups (correlation coefficient R = 0.239 [P = .014] in the 5 mg group; R = 0.248 [P = .019] in the 2.5 mg group). PTa in the 5 mg group was predicted as follows: 16.952-0.036 × BW +0.299 × CHA2DS2-VASc score (P < .0004; R = 0.378). However, in the 2.5 mg group, PTa could not be predicted. The mean of the predicted and measured PTa values in the 5 mg group was 15.6 s, which was similar to the mean measured PTa of 15.5 s in the 2.5 mg group. CONCLUSIONS PT can be predicted by a formula including simple clinical parameters in patients receiving the standard dose of apixaban. This simple predictive formula may help to stratify bleeding and thrombosis risks in patients treated with apixaban.
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Affiliation(s)
- Naoko Unami
- Department of Pharmaceutical ServicesNippon Medical School HospitalBunkyo‐kuJapan
| | - Yuya Ise
- Department of Pharmaceutical ServicesNippon Medical School HospitalBunkyo‐kuJapan
| | - Hidenori Suzuki
- Department of PharmacologyGraduate School of MedicineNippon Medical SchoolBunkyo‐kuJapan
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19
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Wong ECC, Worfolk LA, Sahud M, Dlott JS. Prevalence of Suspected Direct Oral Anticoagulant Interference on Thrombophilia Testing at a US National Reference Laboratory. Clin Chem 2020; 66:618-620. [PMID: 32206783 DOI: 10.1093/clinchem/hvaa044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2020] [Indexed: 11/14/2022]
Affiliation(s)
- Edward C C Wong
- Department of Coagulation, Quest Diagnostics Nichols Institute, Chantilly, VA.,George Washington School of Medicine and Health Sciences, Department of Pediatrics and Pathology, Children's National Hospital, Washington, DC
| | - Laura A Worfolk
- Department of Coagulation, Quest Diagnostics Nichols Institute, Chantilly, VA
| | - Mervyn Sahud
- Quest Diagnostics Nichols Institute, San Juan Capistrano, CA
| | - Jeffrey S Dlott
- Department of Coagulation, Quest Diagnostics Nichols Institute, Chantilly, VA
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20
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Strickland SW, Palkimas S, Acker M, Bazydlo LAL. A Novel Laboratory Assay to Monitor Unfractionated Heparin Dosing in Patients Taking Apixaban Prior to Hospital Admission. J Appl Lab Med 2020; 6:378-386. [PMID: 32995844 DOI: 10.1093/jalm/jfaa084] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 04/09/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION When monitoring heparin, anti-Xa assays are susceptible to interference from apixaban taken before admission and can result in inappropriate dose adjustments that can negatively affect patient care. METHODS We derived a novel assay, termed corrected heparin (CH), using quantified values from a chromogenic anti-Xa assay with heparin calibrators before and after heparinase treatment to eliminate any interference from apixaban within the patient sample. We retrospectively assessed 469 specimens from 72 patients at our institution who had their unfractionated heparin infusion monitored using the CH assay because of known apixaban use. These patients were included in the study if they had detectable apixaban levels (>0.1 IU/mL by anti-Xa). RESULTS The analytical performance of the assay was evaluated, and precision was found to be 8.8% within 1 day and 13.3% over multiple days, with acceptable linearity (R2 = 0.997). Evaluation of clinical performance was compared with the partial thromboplastin time (PTT), showing a lack of correlation similar to comparisons between the PTT and anti-Xa assay (Blood Coagul Fibrinolysis 1993;4:635-8). The mean time to a therapeutic result in this cohort was 10 hours and 10 minutes. The CH assay was used to determine how long the apixaban was detected by the anti-Xa assay. The majority of patients (80%) still had measurable anti-Xa assay interference from apixaban at 24 hours after the last apixaban dose. CONCLUSIONS We have developed and evaluated an assay capable of quantifying heparin in the presence of apixaban. This assay showed acceptable performance in both analytical and clinical performance.
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Affiliation(s)
- Sydney W Strickland
- Department of Pathology, University of Virginia Health System, Charlottesville, VA
| | - Surabhi Palkimas
- Department of Pharmacy, University of Virginia Health System, Charlottesville, VA.,Department of Pharmacy, University of Colorado Health, Charlottesville, VA
| | - Mary Acker
- Medical Laboratories, University of Virginia Health System, Charlottesville, VA
| | - Lindsay A L Bazydlo
- Department of Pathology, University of Virginia Health System, Charlottesville, VA
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21
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Siriez R, Dogné JM, Gosselin R, Laloy J, Mullier F, Douxfils J. Comprehensive review of the impact of direct oral anticoagulants on thrombophilia diagnostic tests: Practical recommendations for the laboratory. Int J Lab Hematol 2020; 43:7-20. [PMID: 32946681 DOI: 10.1111/ijlh.13342] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/24/2020] [Accepted: 08/26/2020] [Indexed: 12/28/2022]
Abstract
There is a laboratory and clinical need to know the impact of direct oral anticoagulants (DOACs) on diagnostic tests to avoid misinterpretation of results. Although the regulatory labelling documents provide some information about the influences of each DOAC on diagnostic tests, these are usually limited to some of the most common tests and no head to head comparison is available. In this paper, we report the impact of DOACs on several thrombophilia tests, including assessment of antithrombin, protein S and protein C activity assays, detection of activated protein C resistance and assays used for lupus anticoagulant. Results are compared and discussed with data obtained from literature. The final goal of this comprehensive review is to provide practical recommendations for laboratories to avoid misdiagnosis due to oral direct factor Xa (FXa) or IIa (FIIa) inhibitors. Overall, oral direct FXa (apixaban, betrixaban, edoxaban and rivaroxaban) and FIIa (dabigatran) antagonists may affect clot-based thrombophilia diagnostic tests resulting in false-positive or false-negative results. An effect on FIIa-based thrombophilia diagnostic tests is observed with dabigatran but not with anti-FXa DOACs and conversely for FXa-based thrombophilia diagnostic tests. No impact was observed with antigenic/chromogenic methods for the assessment of protein S and C activity. In conclusion, interpretation of thrombophilia diagnostic tests results should be done with caution in patients on DOACs. The use of a device/chemical compound able to remove or antagonize the effect of DOACs or the development of new diagnostic tests insensitive to DOACs should be considered to minimize the risk of false results.
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Affiliation(s)
- 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
| | - Robert Gosselin
- Thrombosis and Hemostasis Center, Davis Health System, University of California, Sacramento, California
| | - Julie Laloy
- Department of Pharmacy, Namur Nanosafety Center (NNC),, Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium
| | - François Mullier
- Laboratory Hematology, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), CHU UCL Namur, Université catholique de Louvain, 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
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22
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Uchida M, Ohmi A, Fujiwara R, Fukushima K, Doi A, Azuma K, Tsujimoto H. Treatment with rivaroxaban and monitoring of coagulation profiles in two dogs with venous thromboembolism. J Vet Med Sci 2020; 82:1271-1276. [PMID: 32655095 PMCID: PMC7538330 DOI: 10.1292/jvms.19-0605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Two dogs with immune-mediated hemolytic anemia complicated with thromboembolism were presented. Both of the dogs were initially treated with immunosuppressive therapy in conjunction with dalteparin and clopidogrel. Although the immunosuppressive therapy was effective, peritoneal effusion due to thromboembolism was observed during the course of the disease in these dogs. After initiation of rivaroxaban treatment, peritoneal effusion decreased immediately in parallel with the normalization of D-dimer, antithrombin (AT), and thrombin-antithrombin complex (TAT). Hematochezia, cutaneous hemorrhage, and hematuria were observed as adverse events after administration of rivaroxaban in one case. Rivaroxaban was effective for the control of thromboembolism secondary to immune-mediated hemolytic anemia, and D-dimer, AT, and TAT were useful to monitor the status of thromboembolic disease in dogs.
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Affiliation(s)
- Mona Uchida
- Department of Veterinary Clinical Pathobiology, Graduate School of Agricultural and Life Sciences, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan
| | - Aki Ohmi
- Veterinary Medical Center, Graduate School of Agricultural and Life Sciences, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan
| | - Reina Fujiwara
- Veterinary Medical Center, Graduate School of Agricultural and Life Sciences, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan
| | - Kenjiro Fukushima
- Veterinary Medical Center, Graduate School of Agricultural and Life Sciences, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan
| | - Akihiro Doi
- Veterinary Medical Center, Graduate School of Agricultural and Life Sciences, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan
| | - Kazushi Azuma
- Veterinary Medical Center, Graduate School of Agricultural and Life Sciences, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan
| | - Hajime Tsujimoto
- Department of Veterinary Internal Medicine, Graduate School of Agricultural and Life Sciences, The University of Tokyo, 1-1-1 Yayoi, Bunkyo-ku, Tokyo 113-8657, Japan
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Sevenet P, Cucini V, Hervé T, Depasse F, Carlo A, Contant G, Mathieu O. Evaluation of DOAC Filter, a new device to remove direct oral anticoagulants from plasma samples. Int J Lab Hematol 2020; 42:636-642. [DOI: 10.1111/ijlh.13267] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/27/2020] [Accepted: 05/27/2020] [Indexed: 12/17/2022]
Affiliation(s)
| | | | - Tristan Hervé
- Clinical Development Diagnostica Stago Asnières‐sur‐Seine France
| | - François Depasse
- Clinical Development Diagnostica Stago Asnières‐sur‐Seine France
| | - Audrey Carlo
- Global Marketing Diagnostica Stago Asnières‐sur‐Seine France
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Bhardwaj P, Petersen LB, Binko TS, Petersen JR, Fornitz GG. Slightly elevated international normalized ratio predicts bleeding episodes in patients treated with direct oral anticoagulants. J Int Med Res 2020. [PMCID: PMC7294381 DOI: 10.1177/0300060519894439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction Patients treated with direct oral anticoagulants (DOACs) are at increased bleeding risk. It is therefore of increasing interest to identify predictors of bleeding episodes to increase safety during treatment with DOACs. Methods This retrospective cohort study systematically reviewed medical records of 235 patients treated with either apixaban, rivaroxaban or dabigatran for non-valvular atrial fibrillation or venous thromboembolism and collected data on the international normalized ratio (INR) and all bleeding episodes. Results INR ≥ 1.5 was significantly associated with increased risk of minor and major bleeding events in patients treated with direct factor Xa inhibitors. This association was not present in patients treated with dabigatran. However, a high negative predictive value was identified for INR < 1.5 for all drugs. The relative risks of bleeding episodes in patients with INR ≥ 1.5 and INR < 1.5 were 5.1 and 0.20, respectively. Conclusions Our results demonstrate a strong correlation between INR and risk of bleeding episodes during DOAC treatment. INR < 1.5 was a strong negative predictor for low bleeding risk independent of indication or choice of drug, and INR ≥ 1.5 was associated with increased risk of bleeding episodes in patients treated with direct factor Xa-inhibitors.
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Affiliation(s)
- Priya Bhardwaj
- Department of Cardiology, Slagelse Hospital, Region Seeland – Denmark
| | | | - Tomas Sorm Binko
- Department of Cardiology, Amager Hospital, Capital Region – Denmark
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Abstract
This article presents a focused review of the available tests to assess the effect of direct oral anticoagulants on coagulation and the use of reversal agents in the perioperative setting for practicing anesthesiologists.
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Abstract
Rivaroxaban is a direct oral anti-factor Xa anticoagulant. It has recently been suggested that rivaroxaban may affect platelet function in vitro; however, little is known about the clinical impact of this likely antiplatelet effect and whether this probable phenomenon is dose-dependent. Our aim was to determine whether rivaroxaban at 4 different doses inhibits direct platelet aggregation. We included adult patients of both sexes and who were allocated to one of the following groups depending on the prescribed daily dose of rivaroxaban: 5, 10, 15, and 20 mg. In 80 patients (20 patients/group), the percentage of platelet aggregation was determined by means of platelet aggregometry tests before and after rivaroxaban use. Basal samples were obtained before starting rivaroxaban and 1 month after treatment, both 2 and 24 hours after the last dose of the drug (12 hours after in the case of rivaroxaban 5 mg). We used 5 platelet agonists: adenosine diphosphate, epinephrine, arachidonic acid, collagen, and thrombin. There were no significant changes in the percentage of platelet aggregation before and after rivaroxaban use independently of the dose administered and the agonist used. Our results have clearly shown that rivaroxaban, even at a high dose, does not directly affect platelet aggregation.
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Global thromboelastometry in patients receiving direct oral anticoagulants: the RO-DOA study. J Thromb Thrombolysis 2019; 49:251-258. [DOI: 10.1007/s11239-019-01956-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Kopytek M, Ząbczyk M, Malinowski KP, Undas A, Natorska J. DOAC-Remove abolishes the effect of direct oral anticoagulants on activated protein C resistance testing in real-life venous thromboembolism patients. ACTA ACUST UNITED AC 2019; 58:430-437. [DOI: 10.1515/cclm-2019-0650] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Accepted: 08/15/2019] [Indexed: 01/15/2023]
Abstract
Abstract
Background
Direct oral anticoagulants (DOACs) may cause false results of activated protein C resistance (APC-R) ratio. DOAC-Remove, a new reagent based on activated carbon, has been designed to eliminate the interference of DOACs on coagulation assays. The aim of the study was to investigate whether the use of DOAC-Remove enables to determine APC-R in patients treated with DOACs.
Methods
We assessed 74 venous thromboembolism (VTE) patients, including 25 on rivaroxaban, 25 on apixaban and 24 taking dabigatran. APC-R was determined using the Russell Viper Venom Time (RVVT)-based clotting test. APC-R and DOAC concentrations were tested at baseline and following DOAC-Remove. Thrombophilia, including factor V Leiden (FVL) mutation was tested.
Results
FVL mutation was found in 20 (27%) patients. The APC-R ratio at baseline was measurable in 43 patients (58.1%), including 20 (80%) on rivaroxaban, 19 (76%) on apixaban and four (16.7%) on dabigatran. In patients with measurable APC-R at baseline, the ratio >2.9 was found in 23 patients (53.5%). In 16 (37.2%) subjects APC-R ratio <1.8 suggested FVL mutation which was genetically confirmed. Four (9.3%) FVL carriers on dabigatran showed negative/equivocal APC-R results. In 11 (14.9%) patients taking rivaroxaban or apixaban, in whom blood was collected 2–5 h since the last dose, we observed unmeasurable APC-R. DOAC-Remove almost completely eliminated all plasma DOACs. After addition of DOAC-Remove all APC-R ratios were measurable. In four FVL carriers on dabigatran with false negative APC-R, DOAC-Remove resulted in APC-R ratios <1.8.
Conclusions
DOAC-Remove effectively reduces DOACs concentration in plasma, which enables FVL testing using APC-R.
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Affiliation(s)
- Magdalena Kopytek
- John Paul II Hospital , Kraków , Poland
- Institute of Cardiology, Jagiellonian University Medical College , Kraków , Poland
| | - Michał Ząbczyk
- John Paul II Hospital , Kraków , Poland
- Institute of Cardiology, Jagiellonian University Medical College , Kraków , Poland
| | | | - Anetta Undas
- John Paul II Hospital , Kraków , Poland
- Institute of Cardiology, Jagiellonian University Medical College , Kraków , Poland
| | - Joanna Natorska
- John Paul II Hospital , Kraków , Poland
- Institute of Cardiology, Jagiellonian University School of Medicine , 80 Pradnicka St , 31-202 Kraków , Poland
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Moore GW, Van Cott EM, Cutler JA, Mitchell MJ, Adcock DM. Recommendations for clinical laboratory testing of activated protein C resistance; communication from the SSC of the ISTH. J Thromb Haemost 2019; 17:1555-1561. [PMID: 31317658 DOI: 10.1111/jth.14532] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 06/04/2019] [Accepted: 06/05/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Gary W Moore
- Diagnostic Haemostasis and Thrombosis, Viapath Analytics, Guy's & St Thomas' Hospitals, London, UK
| | | | - Jacqueline A Cutler
- Molecular Haemostasis and Thrombosis, Viapath Analytics, Guy's & St Thomas' Hospitals, London, UK
| | - Michael J Mitchell
- Molecular Haemostasis and Thrombosis, Viapath Analytics, Guy's & St Thomas' Hospitals, London, UK
| | - Dorothy M Adcock
- Colorado Coagulation, Laboratory Corporation of America Holdings, Englewood, Colorado
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Smock KJ, Moser KA. What have we learned from coagulation laboratory participation in external quality programs? Int J Lab Hematol 2019; 41 Suppl 1:49-55. [DOI: 10.1111/ijlh.12998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/02/2019] [Accepted: 02/07/2019] [Indexed: 02/04/2023]
Affiliation(s)
- Kristi J. Smock
- Department of PathologyUniversity of Utah Health Sciences Center and ARUP Laboratories Salt Lake City Utah
| | - Karen A. Moser
- Department of PathologyUniversity of Utah Health Sciences Center and ARUP Laboratories Salt Lake City Utah
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Park SH, Seo YH, Park PW, Kim KH, Seo JY, Lee HT, Kwoun WJ, Ahn JY. Evaluation of global laboratory methods and establishing on-therapy ranges for monitoring apixaban and rivaroxaban: Experience at a single institution. J Clin Lab Anal 2019; 33:e22869. [PMID: 30860622 PMCID: PMC6595315 DOI: 10.1002/jcla.22869] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 02/01/2019] [Accepted: 02/03/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Apixaban and rivaroxaban are approved for the prevention and treatment of deep vein thrombosis (DVT), pulmonary embolism (PE), and embolic stroke in atrial fibrillation (AF) patients. The aim of this study was to find appropriate methods of monitoring the anticoagulant effects of are direct oral anticoagulants (DOACs) and establish on-therapy ranges using conventional tests. METHODS A total of 184 samples were collected from 91 patients receiving DOACs. Concentrations of apixaban and rivaroxaban in plasma were accessed by an anti-factor Xa chromogenic assay. PT, APTT, antithrombin, D-dimer, dRVVT screen/confirm, FDP, and fibrinogen levels were measured. On-therapy ranges were calculated by substituting previously reported trough plasma concentrations of DOACs. RESULTS Anti-factor Xa chromogenic assay-based DOACs levels were 26.0-279.5 (115.9 ± 56.5) ng/mL for apixaban at 2.5 mg BID, 19.9-565.1 (205.3 ± 162.4) ng/mL for apixaban at 5 mg BID, 2.3-395.3 (205.3 ± 162.4) ng/mL for rivaroxaban at 15 mg OD, 3.6-494.8 (119.6 ± 95.1) ng/mL for rivaroxaban at 20 mg OD, and 9.6-431.4 (140.8 ± 113.6) ng/mL for rivaroxaban at 15 mg BID. PT (%), antithrombin, and dRVVT confirm tests showed good correlation with plasma apixaban levels. Plasma rivaroxaban concentrations were correlated well with PT (sec), PT (%),and dRVVT confirm results. On-therapy ranges established for dRVVT confirm test by linear regression were as follows: 1.32-1.52 for apixaban 2.5 mg BID, 1.12-1.75 for apixaban 5 mg BID, 1.11-1.78 for rivaroxaban 15 mg OD, 1.09-1.64 for rivaroxaban 20 mg OD, and 1.22-1.81 for rivaroxaban 20 mg BID. CONCLUSIONS Apixaban concentrations were well correlated with PT (%), antithrombin, and dRVVT confirm test. Rivaroxaban concentrations showed good correlation with PT (sec), PT (%), and dRVVT confirm test.
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Affiliation(s)
- Soon Ho Park
- Department of Laboratory Medicine, Hongcheon Asan Hospital, Gangwon, Korea
| | - Yiel-Hea Seo
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Pil-Whan Park
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Kyung-Hee Kim
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Ja Young Seo
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hwan Tae Lee
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Woo-Jae Kwoun
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jeong-Yeal Ahn
- Department of Laboratory Medicine, Gachon University Gil Medical Center, Incheon, Korea
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Evans LA, Tansey C, Wiebe M, Sloan CQ, Patlogar JE, Northcutt S, Murphy LA, Nakamura RK. A prospective evaluation of rivaroxaban on haemostatic parameters in apparently healthy dogs. Vet Med Sci 2019; 5:317-324. [PMID: 30848104 PMCID: PMC6682794 DOI: 10.1002/vms3.161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
The purpose of this study was to determine the effect of rivaroxaban (RIV) on haemostatic parameters assessed by prothrombin time (PT), activated partial thromboplastin time (aPTT) and kaolin‐activated thromboelastography (TEG) in apparently healthy dogs administered 1 mg kg−1 orally once daily for 1 week. Eleven dogs had a baseline complete blood count (CBC), fibrinogen, platelet count, serum chemistry profile, PT, aPTT, and TEG performed. Each dog was then administered approximately 1.0 mg kg−1 of RIV orally once daily for 1 week and the CBC, fibrinogen, platelet count, serum chemistry profile, PT, aPTT, and TEG was re‐evaluated. Any side effects attributed to RIV were noted at this time. One dog was excluded due to identification of a macrocytic thrombocytopenia on pre‐treatment blood work. The remaining 10 enrolled dogs completed the study. Dogs received a median dose of 1.02 mg kg−1 (range 0.94–1.17 mg kg−1) of RIV once daily and was associated with a significant increase in pulse, packed cell volume, total solids, platelet count, fibrinogen and a significant decrease in mean corpuscular haemoglobin and mean corpuscular haemoglobin concentration. There was no significant change in PT, aPTT or any TEG parameters. The RIV appeared well tolerated with one dog having one episode of vomiting on day 4 but otherwise no other side effects were identified clinically or on recheck blood work. The results of this study suggests that RIV at a dose of 1 mg kg−1 orally once daily is safe and well tolerated but does not cause a significant prolongation of PT, aPTT or TEG parameters.
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Affiliation(s)
- Liam A Evans
- Inland Valley Veterinary Specialists and Emergency Center, Upland, California, USA
| | - Colleen Tansey
- Inland Valley Veterinary Specialists and Emergency Center, Upland, California, USA
| | - Melissa Wiebe
- Inland Valley Veterinary Specialists and Emergency Center, Upland, California, USA
| | | | - Jeffrey E Patlogar
- Inland Valley Veterinary Specialists and Emergency Center, Upland, California, USA
| | - Sarah Northcutt
- Inland Valley Veterinary Specialists and Emergency Center, Upland, California, USA
| | - Lisa A Murphy
- Veterinary Specialty Center of Delaware, New Castle, Delaware, USA
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Winther-Larsen A, Hvas AM. Clinical impact of direct oral anticoagulant measuring in a real-life setting. Thromb Res 2019; 175:40-45. [DOI: 10.1016/j.thromres.2019.01.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/16/2019] [Accepted: 01/23/2019] [Indexed: 01/27/2023]
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Wu HD, Cao HY, Song ZK, Yang S, Tang ML, Liu Y, Qin L. Considerations for routine coagulation monitoring with rivaroxaban: A case report and review of the literature. World J Clin Cases 2019; 7:382-388. [PMID: 30746380 PMCID: PMC6369389 DOI: 10.12998/wjcc.v7.i3.382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 12/04/2018] [Accepted: 12/21/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Rivaroxaban is a non-vitamin K antagonist oral anticoagulant that does not require coagulation monitoring based on current recommendations. Our goal is to explore whether routine coagulation monitoring should not be required for all patients receiving oral rivaroxaban, what relationship between routine coagulation abnormalities and bleeding, and how to deal with the above clinical situations through our case and review of the literature.
CASE SUMMARY We report a 67-year-old woman with a history of atrial fibrillation who presented to the hospital with worsening dyspnea and cough. Based on electrocardiogram, venous compression ultrasonography, and computed tomography pulmonary angiography, the diagnosis of atrial fibrillation, deep venous thrombosis, and acute pulmonary embolism was confirmed. Her coagulation assays and renal function were normal on admission; she was not underweight, did not have a history of hemorrhagic disease, and her CHA2DS2-VAS, HAS-BLED, and simplified Pulmonary Embolism Severity Index scores were 3, 0, and 0, respectively. Oral rivaroxaban (15 mg twice daily) was administered. The following day, she presented gastrointestinal and gum bleeding, combined with coagulation abnormalities. Following cessation of rivaroxaban, her bleeding stopped and tests improved over the next 2 d. Rivaroxaban was begun again 3 d after recovery. However, she again presented with gastrointestinal and gum bleeding and the abnormal tests, and the therapy was discontinued. At 30-d follow-up after discharge, she presented normal coagulation tests without bleeding.
CONCLUSION Although current guidelines recommend that using non-vitamin K antagonist oral anticoagulants including rivaroxaban do not require coagulation monitoring, a small number of patients may develop routine coagulation test changes and bleeding during rivaroxaban therapy, especially in the elderly. Clinicians should pay attention to these patients and further obtain evidence in practice.
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Affiliation(s)
- Hai-Di Wu
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Hong-Yan Cao
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Zi-Kai Song
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Shuo Yang
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Ming-Long Tang
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Yang Liu
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
| | - Ling Qin
- Department of Cardiology, First Hospital of Jilin University, Changchun 130031, Jilin Province, China
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Spahn DR, Beer JH, Borgeat A, Chassot PG, Kern C, Mach F, Nedeltchev K, Korte W. NOACs in Anesthesiology. Transfus Med Hemother 2019; 46:282-293. [PMID: 31700511 DOI: 10.1159/000491400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 06/17/2018] [Indexed: 12/29/2022] Open
Abstract
Background Due to increasing use of new oral anticoagulants (NOACs), clinicians are faced more and more frequently with clinical issues related to these drugs. Objective The objective of this publication is to make practical suggestions for the perioperative management of NOACs as well as for their handling in overdoses and bleedings. Recommendations In elective surgery and creatinine clearance ≥ 50 ml/min, a NOAC should be discontinued 24-36 h before the intervention, and even earlier in case of reduced kidney function. In emergency interventions that cannot be delayed, the management is dependent on the NOAC plasma levels. With levels ≤ 30 ng/ml, surgery can be performed. With levels >30 ng/ml, reversal agents should be considered. In low bleeding risk surgery, NOACs can be re-started 24 h after the intervention, which is prolonged to 48-72 h after surgery with high bleeding risk. In case of NOAC overdose and minor bleedings, temporary discontinuation and supportive care are usually sufficient to control the situation. In severe or life-threatening bleedings, nonspecific and specific reversal agents should be considered.
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Affiliation(s)
- Donat R Spahn
- Institute of Anesthesiology, University and University Hospital Zurich, Zurich, Switzerland
| | - Jürg-Hans Beer
- Department of Internal Medicine, Cantonal Hospital of Baden, Baden, Switzerland
| | - Alain Borgeat
- Department of Anesthesiology, Balgrist University Hospital, Zurich, Switzerland
| | - Pierre-Guy Chassot
- Formerly Department of Anesthesiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Christian Kern
- Department of Anesthesiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - François Mach
- Department of Internal Medicine, University Hospitals of Geneva (HUG), Geneva, Switzerland
| | | | - Wolfgang Korte
- Center for Laboratory Medicine; Hemostasis and Hemophilia Center, St. Gallen, Switzerland
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Wakui M, Fujimori Y, Katagiri H, Nakamura S, Kondo Y, Kuroda Y, Nakagawa T, Shimizu N, Murata M. Assessment of in vitro effects of direct thrombin inhibitors and activated factor X inhibitors through clot waveform analysis. J Clin Pathol 2018; 72:244-250. [DOI: 10.1136/jclinpath-2018-205517] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/20/2018] [Accepted: 11/20/2018] [Indexed: 12/14/2022]
Abstract
AimsClot waveform analysis (CWA) has been reported to extend the interpretation of clotting time measurement. The parameters obtained from successive derivatives of the clotting reaction curves reflect the rates of activation of individual coagulation factors, theoretically dissecting the cascade pathway. This study aims to assess the in vitro effects of direct thrombin inhibitors (DTIs) and activated factor X (FXa) inhibitors.MethodsCWA was applied to the activated partial thromboplastin time (APTT) assay of plasma samples spiked with each drug. For CWA of APTT measurement curves (APTT-CWA), the positive mode of clotting reaction curves was defined as the direction towards fibrin generation.ResultsAll the maximum positive values in the successive derivatives were decreased dependently on the concentrations of each drug. Moreover, the negative values in the second and third derivatives appeared putatively due to consumption of thrombin and factor FXa, respectively, to form complexes with plasma serine protease inhibitors. The decrease of the maximum negative values observed dependently on the concentrations of each drug appeared to be consistent with the decreased generation of thrombin and factor FXa. The analysis of Hill coefficients of each drug in the dose–response of changes in the APTT-CWA parameters revealed a difference in anticoagulant cooperativity between DTIs versus FXa inhibitors.ConclusionsThe APTT-CWA demonstrated evidence for the blockade of thrombin-positive feedback by DTIs and FXa inhibitors and that for the differences in anticoagulant cooperativity between them. The results demonstrate the usability of CWA for assessment of anticoagulation and provide insights into direct anticoagulants.
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Arachchillage DRJ, Alavian S, Griffin J, Gurung K, Szydlo R, Karawitage N, Laffan M. Efficacy and safety of prothrombin complex concentrate in patients treated with rivaroxaban or apixaban compared to warfarin presenting with major bleeding. Br J Haematol 2018; 184:808-816. [DOI: 10.1111/bjh.15705] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 11/05/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Deepa R. J. Arachchillage
- Department of Haematology; Imperial College Healthcare NHS Trust Imperial College London; London UK
- Centre for Haematology; Imperial College London; London UK
- Department of Haematology; Royal Brompton Hospital; London UK
| | - Sharon Alavian
- Department of Haematology; Imperial College Healthcare NHS Trust Imperial College London; London UK
| | - Jessica Griffin
- Department of Haematology; Imperial College Healthcare NHS Trust Imperial College London; London UK
| | - Kamala Gurung
- Department of Haematology; Imperial College Healthcare NHS Trust Imperial College London; London UK
| | - Richard Szydlo
- Department of Haematology; Imperial College Healthcare NHS Trust Imperial College London; London UK
| | - Nilanthi Karawitage
- Department of Haematology; Imperial College Healthcare NHS Trust Imperial College London; London UK
| | - Mike Laffan
- Department of Haematology; Imperial College Healthcare NHS Trust Imperial College London; London UK
- Centre for Haematology; Imperial College London; London UK
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Platton S, Hunt C. Influence of
DOAC
Stop on coagulation assays in samples from patients on rivaroxaban or apixaban. Int J Lab Hematol 2018; 41:227-233. [DOI: 10.1111/ijlh.12950] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 10/16/2018] [Accepted: 11/01/2018] [Indexed: 12/29/2022]
Affiliation(s)
- Sean Platton
- The Royal London Hospital Haemophilia Centre Barts Health NHS Trust The Royal London Hospital London UK
| | - Christina Hunt
- Haematology Laboratory Barts Health NHS Trust The Royal London Hospital London UK
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Testing and monitoring direct oral anticoagulants. Blood 2018; 132:2009-2015. [DOI: 10.1182/blood-2018-04-791541] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 09/06/2018] [Indexed: 12/19/2022] Open
Abstract
Abstract
Direct oral anticoagulants (DOACs) have significantly improved the care of patients requiring anticoagulation. With similar or better efficacy and safety outcomes and easier use in the outpatient setting compared with the standard-of-care vitamin K antagonists and low molecular weight heparin, DOACs are now endorsed as first-line treatment of indications including prevention of stroke and systemic embolism in nonvalvular atrial fibrillation and treatment of venous thromboembolism. DOACs are easy-to-use oral agents that offer simple dosing and short half-lives, with no need to test levels because of the wide therapeutic window and limited drug-drug interactions. After almost a decade of DOAC use, the question of testing DOAC levels in certain clinical situations has become the focus of debate. Although guidance for using routine coagulation tests is available, these tests are inadequate for optimal care. DOAC-specific tests have been developed but have limited availability in Europe and less availability in the United States. None are licensed. DOAC testing may be useful in the setting of critical clinical situations such as life-threatening bleeding or need for emergent surgery, especially with the availability of DOAC reversal agents. Patients with characteristics that fall outside the normal range may benefit from the guidance that DOAC testing could offer. Obstacles to adopting DOAC testing have been raised, such as test reliability and staffing costs; however, these problems are rapidly being resolved. Further investigation of the role of DOAC testing is needed to explore its full potential and role in clinical practice.
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Hillarp A, Strandberg K, Baghaei F, Fagerberg Blixter I, Gustafsson KM, Lindahl TL. Effects of the oral, direct factor Xa inhibitor edoxaban on routine coagulation assays, lupus anticoagulant and anti-Xa assays. Scandinavian Journal of Clinical and Laboratory Investigation 2018; 78:575-583. [DOI: 10.1080/00365513.2018.1522664] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Andreas Hillarp
- Department of Clinical Chemistry and Transfusion Medicine, Halland County Hospital, Halmstad, Sweden
| | - Karin Strandberg
- Department of Clinical Chemistry, University and Regional Laboratories Region Skåne, Malmö, Sweden
| | - Fariba Baghaei
- Department of Medicine, Coagulation Centre, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Inger Fagerberg Blixter
- Department of Clinical Chemistry and Transfusion Medicine, Institute of Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kerstin M. Gustafsson
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
| | - Tomas L. Lindahl
- Department of Clinical and Experimental Medicine, Linköping University, Linköping, Sweden
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Scheres LJJ, Lijfering WM, Middeldorp S, Cheung YW, Barco S, Cannegieter SC, Coppens M. Measurement of coagulation factors during rivaroxaban and apixaban treatment: Results from two crossover trials. Res Pract Thromb Haemost 2018; 2:689-695. [PMID: 30349888 PMCID: PMC6178718 DOI: 10.1002/rth2.12142] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 06/29/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Prediction models for venous thromboembolism recurrence will likely be improved by adding levels of coagulation factors. Risk assessment is ideally performed during anticoagulant treatment, however, the influence of direct oral anticoagulants on coagulation factors is uncertain. OBJECTIVE To assess the influence of rivaroxaban and apixaban on several coagulation factor levels. METHODS In two crossover trials we assessed the influence of rivaroxaban and apixaban intake on factor (F)VIII, FXI and FXII-activity and fibrinogen, von Willebrand factor (VWF:Ag), and d-dimer levels. At three sessions with a washout period in between, blood was taken from 12 healthy male individuals immediately before intake of rivaroxaban 15 mg twice daily (n = 6) or apixaban 10 mg twice daily (n = 6) and three hours after the last intake. RESULTS Overall, measured levels were lower after rivaroxaban/apixaban intake. The paired mean difference after rivaroxaban intake was -38 IU/dL (95% CI -43; -33) for FVIII:C, -29 U/dL (95% CI -45; -12) for FXI:C, -22 IU/dL (95% CI -43; -1) for FXII:C, -0.11 g/L (95% CI -0.25; 0.03) for fibrinogen, -7 IU/dL (95% CI -18; 3) for VWF:Ag, -27 ng/mL (95% CI -50; -4) for d-dimer and -0.36 (95% CI -0.57; -0.15) for Ln d-dimer. After apixaban intake this was -29 IU/dL (95% CI -38; -21) for FVIII:C, -29 IU/dL (95% CI -36; -22) for FXI:C, -19 IU/dL (95% CI -24; -15) for FXII:C, -0.18 g/L (95% CI -0.33; 0.03) for fibrinogen, -52 ng/mL (95% CI -100; -4) for d-dimer, 0.25 (-0.60; 0.09) for Ln d-dimer and 1 IU/dL (95% CI -7; 9) for VWF:Ag. CONCLUSION FVIII:C, FXI:C, FXII:C, and d-dimer measurements were influenced by rivaroxaban/apixaban intake, while fibrinogen and VWF:Ag were not.
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Affiliation(s)
- Luuk J. J. Scheres
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Willem M. Lijfering
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Department of Internal Medicine, Section Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Saskia Middeldorp
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
| | - Yuk W. Cheung
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
| | - Stefano Barco
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
- Center for Thrombosis and HemostasisUniversity Medical Center of the Johannes Gutenberg UniversityMainzGermany
| | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Department of Internal Medicine, Section Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
| | - Michiel Coppens
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
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Tao J, Bukanova EN, Akhtar S. Safety of 4-factor prothrombin complex concentrate (4F-PCC) for emergent reversal of factor Xa inhibitors. J Intensive Care 2018; 6:34. [PMID: 29942519 PMCID: PMC6001072 DOI: 10.1186/s40560-018-0303-y] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 05/31/2018] [Indexed: 12/27/2022] Open
Abstract
Background Although factor Xa inhibitors have become a popular choice for chronic oral anticoagulation, effective drug reversal remains difficult due to a lack of specific antidote. Currently, 4-factor prothrombin complex concentrate (4F-PCC) is considered the treatment of choice for factor Xa inhibitor-related major bleeding. However, safety of 4F-PCC and its risk of thrombosis when used for this off-label purpose remain unclear. The purpose of this retrospective study is to determine the rate of thromboembolism when 4F-PCC is used for the emergent reversal of factor Xa inhibitors. Methods We conducted a single-center retrospective review of medical records between 2013 and 2017. Patients were included if they received 4F-PCC to reverse rivaroxaban, apixaban, or edoxaban for emergent invasive procedures or during episodes of major bleeding defined as bleeding with hemodynamic instability, fall in hemoglobin of 2 g/dL, or bleeding requiring blood transfusion. Thrombotic events including myocardial infarction, pulmonary embolism, deep vein thrombosis, cerebral vascular accident, and arterial thrombosis of the limb or mesentery were recorded if they occurred within 14 days of 4F-PCC administration. Data was analyzed using point and interval estimation to approximate the rate and confidence interval of thromboembolic events. Results Forty-three patients were identified in our review. Doses of 4F-PCC were determined by the treating physician and mainly ranged from 25 to 50 IU/kg. Twenty-two patients (51.2%) received both sequential compression devices (SCDs) and subcutaneous heparin for DVT prophylaxis. Twenty-one patients (48.8%) were placed on SCDs only. Three patients received concomitant FFP. Thrombotic events within 14 days of 4F-PCC administration occurred in 1 out of 43 patients (2.1%, 95% CI [0.1–12.3]). This thrombotic event was an upper extremity DVT which occurred 1 day after the patient received 1325 IU (25 IU/kg) of 4F-PCC to reverse rivaroxaban for traumatic intracranial hemorrhage. The patient was taken for emergent decompressive craniotomy after rivaroxaban reversal. In patients who did not undergo surgery or who underwent minor invasive procedures, no thrombotic events were noted. Conclusion Based on our preliminary data, the thromboembolic rate of 4F-PCC when given at a dose of 25–50 IU/kg to emergently reverse rivaroxaban and apixaban appears acceptable. Since many patients who require 4F-PCC to emergently reverse factor Xa inhibitors will be at high risk of developing thrombotic events, practitioners should be highly vigilant of these complications. Large, multicenter prospective trials are needed to further determine this risk.
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Affiliation(s)
- Jing Tao
- Department of Anesthesiology, Yale School of Medicine, 333 Cedar Street, TMP 3, PO Box 20805, New Haven, CT 06520-8051 USA
| | - Elena N Bukanova
- Department of Anesthesiology, Yale School of Medicine, 333 Cedar Street, TMP 3, PO Box 20805, New Haven, CT 06520-8051 USA
| | - Shamsuddin Akhtar
- Department of Anesthesiology, Yale School of Medicine, 333 Cedar Street, TMP 3, PO Box 20805, New Haven, CT 06520-8051 USA
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Favresse J, Lardinois B, Sabor L, Devalet B, Vandepapeliere J, Braibant M, Lessire S, Chatelain B, Jacqmin H, Douxfils J, Mullier F. Evaluation of the DOAC-Stop® Procedure to Overcome the Effect of DOACs on Several Thrombophilia Screening Tests. TH OPEN 2018; 2:e202-e209. [PMID: 31249943 PMCID: PMC6524876 DOI: 10.1055/s-0038-1657785] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/21/2018] [Indexed: 11/04/2022] Open
Abstract
The impact of direct oral anticoagulants (DOACs) on laboratory assays used for thrombophilia testing (e.g., antithrombin, protein S, protein C, lupus anticoagulant and activated protein-C resistance) is a well-known issue and may cause false-positive and -negative results. Therefore, the correct interpretation of tests that are performed in patients taking DOACs is mandatory to prevent misclassification and the subsequent clinical consequences. We aimed at evaluating the efficiency of a new and simple procedure (DOAC-Stop®; Haematex Research, Hornsby, Australia) to overcome the effect of all DOACs in real-life settings and to assess the percentage of erroneous results due to the presence of DOACs on thrombophilia screening tests. For this purpose, 135 DOAC-treated patients (38 apixaban, 40 dabigatran, 15 edoxaban, and 42 rivaroxaban) and 20 control patients were enrolled. A significant drop in apixaban, dabigatran, edoxaban, and rivaroxaban plasma concentrations following the DOAC-Stop® treatment was observed (74.8–8.2 ng/mL [
p
< 0.0001], 95.9–4.7 ng/mL [
p
< 0.0001], 102.1–8.8 ng/mL [
p
= 0.001], and 111.3–7.0 ng/mL [
p
< 0.0001], respectively). The DOAC-Stop® treatment was mostly effective to overcome the effect of DOACs on PTT-LA, dilute Russell's viper venom time (dRVVT) screen, and dRVVT confirm tests. Using our procedures, false-positive results due to DOACs were observed only with lupus anticoagulant tests (up to 75%) and fell to zero after the DOAC-Stop® procedure, regardless of the DOAC considered. In conclusion, the DOAC-Stop® adsorbent procedure appeared to be an effective and simple way to overcome the interference of DOAC on coagulation tests and should facilitate the interpretation of thrombophilia screening tests in patients taking DOACs.
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Affiliation(s)
- Julien Favresse
- Université Catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Namur Thrombosis and Hemostasis Center, NARILIS, Yvoir, Belgium
| | - Benjamin Lardinois
- Université Catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Namur Thrombosis and Hemostasis Center, NARILIS, Yvoir, Belgium
| | - Lina Sabor
- Université Catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Namur Thrombosis and Hemostasis Center, NARILIS, Yvoir, Belgium
| | - Bérangère Devalet
- Department of Hematology, CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - Julie Vandepapeliere
- Department of Hematology, CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - Maximilien Braibant
- Department of Pharmacy, CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - Sarah Lessire
- Department of Anesthesiology, CHU UCL Namur, Namur Thrombosis and Hemostasis Center, Université Catholique de Louvain, Yvoir, Belgium
| | - Bernard Chatelain
- Université Catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Namur Thrombosis and Hemostasis Center, NARILIS, Yvoir, Belgium
| | - Hugues Jacqmin
- Université Catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Namur Thrombosis and Hemostasis Center, NARILIS, Yvoir, Belgium
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Université de Namur, Yvoir, Belgium.,QUALIblood SA, Namur, Belgium
| | - François Mullier
- Université Catholique de Louvain, CHU UCL Namur, Hematology Laboratory, Namur Thrombosis and Hemostasis Center, NARILIS, Yvoir, Belgium
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Activated protein C resistance in patients following venous thromboembolism receiving rivaroxaban versus vitamin K antagonists: assessment using Russell viper venom time-based assay. Blood Coagul Fibrinolysis 2018; 28:309-315. [PMID: 27636904 DOI: 10.1097/mbc.0000000000000597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
: Activated protein C resistance (APC-R) is assessed as part of thrombophilia screening, preferably in patients not taking oral anticoagulants. Rivaroxaban is known to alter some APC-R assays. To our knowledge, there have been no reports on the effect of rivaroxaban on the Russell viper venom time (RVVT)-based APC-R assay in real-life patients. In 168 consecutive outpatients suspected of having venous thromboembolism because of thrombophilia, APC-R was determined using the RVVT-based ProC Ac R assay (Siemens, Marburg, Germany). Patients receiving rivaroxaban or vitamin K antagonists were eligible. We measured rivaroxaban concentrations using the anti-Xa Biophen DiXal assay (Hyphen Biomed, Neuville-Sur-Oise, France) and factor V Leiden using the real-time PCR. APC-R was detected in 23 (28%) patients on rivaroxaban (n = 81) administrated 2-48 h since the blood draw, 15 (28%) patients on vitamin K antagonists (n = 54), and in four (12%) patients off anticoagulation (n = 33). Compared with nonanticoagulated patients, APC-R ratios were similar in patients on rivaroxaban, without any correlation with rivaroxaban concentrations (from 0 to 303 μg/l). None of the patients on rivaroxaban were found to have false-negative or false-positive APC-R ratios. Rivaroxaban concentrations up to 300 μg/l do not affect results of the ProC Ac R RVVT-based assay, which could be recommended in patients referred to a clinic for thrombophilia screening in whom the time since the last dose of rivaroxaban is uncertain.
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Thrombin generation estimates the anticoagulation effect of direct oral anticoagulants with significant interindividual variability observed. Blood Coagul Fibrinolysis 2018; 29:148-154. [DOI: 10.1097/mbc.0000000000000678] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Point of Care Testing (POCT) to assess drug concentration in patients treated with non-vitamin K antagonist oral anticoagulants (NOACs). Thromb Res 2018; 163:100-104. [DOI: 10.1016/j.thromres.2018.01.044] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 01/04/2018] [Accepted: 01/25/2018] [Indexed: 11/23/2022]
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Lindhoff-Last E. Direct oral anticoagulants (DOAC) - Management of emergency situations. Hamostaseologie 2017; 37:257-266. [PMID: 29582928 DOI: 10.5482/hamo-16-11-0043] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
The worldwide increase in the aging population and the associated increase in the prevalence of atrial fibrillation and venous thromboembolism as well as the widespread use of direct oral anticoagulants (DOAC) have resulted in an increase of the need for the management of bleeding complications and emergency operations in frail, elderly patients, in clinical practice. When severe bleeding occurs, general assessment should include evaluation of the bleeding site, onset and severity of bleeding, renal function, and concurrent medications with focus on anti-platelet drugs and nonsteroidal anti-inflammatory drugs (NSAID). The last intake of the DOAC and its residual concentration are also relevant. The site of bleeding should be immediately localized, anticoagulation should be interrupted, and local measures to stop bleeding should be taken. In life-threatening bleeding or emergency operations immediate reversal of the antithrombotic effect may be indicated. If relevant residual DOAC-concentrations are expected and surgery cannot be postponed, prothrombin complex concentrate (PCC) and/or a specific antidote should be given. While idarucizumab, the specific antidote for dabigatran, has been recently approved for clinical use, the recombinant factor X protein andexanet alfa, an antidote for the reversal of inhibitors of coagulation factor Xa, and ciraparantag, a universal antidote, are not available. Future cohort studies are necessary to assess the efficacy and safety of specific and unspecific reversal agents in "real-life" conditions. This was the rationale for introducing the RADOA-registry (RADOA: Reversal Agent use in patients treated with Direct Oral Anticoagulants or vitamin K antagonists), a prospective non-interventional registry, which will evaluate the effects of specific and unspecific reversal agents in patients with life-threatening bleeding or emergency operations either treated with DOACs or vitamin K antagonists.
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van Montfoort M, Meijers J. Anticoagulation beyond direct thrombin and factor Xa inhibitors: indications for targeting the intrinsic pathway? Thromb Haemost 2017; 110:223-32. [DOI: 10.1160/th12-11-0803] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Accepted: 05/07/2013] [Indexed: 11/05/2022]
Abstract
SummaryAntithrombotic drugs like vitamin K antagonists and heparin have been the gold standard for the treatment and prevention of thromboembolic disease for many years. Unfortunately, there are several disadvantages of these antithrombotic drugs: they are accompanied by serious bleeding problems, it is necessary to monitor the therapeutic window, and there are various interactions with food and other drugs. This has led to the development of new oral anticoagulants, specifically inhibiting either thrombin or factor Xa. In terms of effectiveness, these drugs are comparable to the currently available anticoagulants; however, they are still associated with issues such as bleeding, reversal of the drug and complicated laboratory monitoring. Vitamin K antagonists, heparin, direct thrombin and factor Xa inhibitors have in common that they target key proteins of the haemostatic system. In an attempt to overcome these difficulties we investigated whether the intrinsic coagulation factors (VIII, IX, XI, XII, prekallikrein and high-molecular-weight kininogen) are superior targets for anticoagulation. We analysed epidemiological data concerning thrombosis and bleeding in patients deficient in one of the intrinsic pathway proteins. Furthermore, we discuss several thrombotic models in intrinsic coagulation factor-deficient animals. The combined results suggest that intrinsic coagulation factors could be suitable targets for anticoagulant drugs.
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Bailleul E, Chatelain B, Demulder A, Devreese K, Douxfils J, Jochmans K, Mullier F, Wijns W, Soumali MR, Coucke W, Vernelen K, Walle PVD, Blerk MV. Influence of dabigatran and rivaroxaban on routine coagulation assays. Thromb Haemost 2017; 113:154-64. [DOI: 10.1160/th14-02-0161] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Accepted: 08/02/2014] [Indexed: 11/05/2022]
Abstract
SummaryThe Belgian national External Quality Assessment Scheme performed a nationwide survey using lyophilised plasma samples spiked with dabigatran or rivaroxaban to demonstrate to the Belgian clinical laboratories how these drugs affect their routine coagulation assays prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen and antithrombin. Virtually all Belgian laboratories performing routine coagulation testing (189/192) participated in the survey. Both, dabigatran and rivaroxaban significantly prolonged the PT and aPTT in a concentration- and reagent-dependent manner. PT reagents were more influenced by rivaroxaban than by dabigatran and aPTT reagents more influenced by dabigatran than by rivaroxaban. Among PT reagents, Neoplastin R® was the most sensitive to rivaroxaban and Innovin ® and Thromborel S® the least sensitive. Converting PT results to INR only increased the variability between reagents. Among aPTT reagents, Actin FSL® was the least sensitive to dabigatran while the other aPTT reagents showed slightly higher sensitivities. The presence of dabigatran led to falsely reduced fibrinogen concentrations when measured with a low thrombin concentration reagent. The presence of dabigatran caused an overestimation of the antithrombin level when measured with a thrombin-based activity assay and the presence of rivaroxaban an overestimation of the antithrombin level when measured with a FXa-based assay. Instrument-related differences were found for all tested parameters. In conclusion, this paper provides detailed information on the effect of dabigatran and rivaroxaban on routine coagulation assays as performed with a large number of reagent/instrument combinations.
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50
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Marlu R, Hodaj E, Paris A, Albaladejo P, Crackowski J, Pernod G. Effect of non-specific reversal agents on anticoagulant activity of dabigatran and rivaroxaban. Thromb Haemost 2017; 108:217-24. [DOI: 10.1160/th12-03-0179] [Citation(s) in RCA: 456] [Impact Index Per Article: 65.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 04/18/2012] [Indexed: 12/12/2022]
Abstract
SummaryThe new anticoagulants dabigatran and rivaroxaban can be responsible for haemorrhagic complications. As for any anticoagulant, bleeding management is challenging. We aimed to test the effect of all putative haemostatic agents on the anticoagulant activity of these new drugs using thrombin generation tests. In an ex vivo study, 10 healthy white male subjects were randomised to receive rivaroxaban (20 mg) or dabigatran (150 mg) in one oral administration. After a two weeks washout period, they received the other anticoagulant. Venous blood samples were collected just before drug administration (H0) and 2 hours thereafter. Reversal of anticoagulation was tested in vitro using prothrombin complex concentrate (PCC), rFVIIa or FEIBA® at various concentrations. Rivaroxaban affects quantitative and kinetic parameters, including the endogenous thrombin potential (ETP-AUC and more pronouncedly the thrombin peak), the lag-time and time to peak. PCC strongly corrected ETP-AUC, whereas rFVIIa only modified the kinetic parameters. FEIBA corrected all parameters. Dabigatran specially affects the kinetics of thrombin generation with prolonged lag-time and time to peak. Although PCC increased ETP-AUC, only rFVIIa and FEIBA corrected the altered lag-time. For both anticoagulants, lower doses of FEIBA, corresponding to a quarter to half the dose usually used, have potential reversal profile of interest. In conclusion, some non-specific reversal agents appear to be able to reverse the anticoagulant activity of rivaroxaban or dabigatran. However, clinical evaluation is needed regarding haemorrhagic situations, and a meticulous risk-benefit evaluation regarding their use in this context is required.
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