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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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2
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Scholz I, Liakoni E, Hammann F, Grafinger KE, Duthaler U, Nagler M, Krähenbühl S, Haschke M. Effects of Hypericum perforatum (St John's wort) on the pharmacokinetics and pharmacodynamics of rivaroxaban in humans. Br J Clin Pharmacol 2020; 87:1466-1474. [PMID: 32959922 DOI: 10.1111/bcp.14553] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 08/28/2020] [Accepted: 09/09/2020] [Indexed: 12/30/2022] Open
Abstract
AIMS To investigate the influence of a cytochrome P450 CYP3A4 and efflux transporter P-glycoprotein (P-gp) inducing Hypericum perforatum extract on the pharmacokinetics and pharmacodynamics of rivaroxaban. METHODS Open-label, nonrandomized, sequential treatment interaction study. Following CYP3A4 and P-gp phenotyping using low-dose midazolam and fexofenadine, 12 healthy volunteers received a single oral dose of 20 mg rivaroxaban and rivaroxaban plasma concentrations and inhibition of the activated coagulation factor X (factor Xa) activity were measured prior to and up to 48 h postdosing. The procedures were repeated after 2 weeks' treatment with the H. perforatum extract. RESULTS The geometric mean ratios for the area under the concentration-time curve and Cmax of rivaroxaban after/before induction with the H. perforatum extract were 0.76 (90% confidence interval [CI] 0.70, 0.82) and 0.86 (90% CI 0.76, 0.97), respectively. Inhibition of factor Xa activity was reduced with a geometric mean area under the effect-time curve ratio after/before induction of 0.80 (90% CI 0.71, 0.89). No clinically significant differences were found regarding Tmax (median 1.5 vs 1 h, P = .26) and terminal elimination half-life (mean 10.6 vs 10.8 h, P = .93) of rivaroxaban. The H. perforatum extract significantly induced CYP3A4 and P-gp activity, as evidenced by phenotyping. CONCLUSION The CYP3A4/P-gp inducing H. perforatum extract caused a decrease of rivaroxaban exposure with a proportional decrease of the pharmacodynamic effect. Although the data do not justify a contraindication for the combination or a systematic adjustment of rivaroxaban dosage, avoidance of the combination or laboratory monitoring should be considered in patients taking hyperforin-containing H. perforatum extracts with rivaroxaban.
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Affiliation(s)
- Irene Scholz
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Institute of Pharmacology, University of Bern, Switzerland
| | - Evangelia Liakoni
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Institute of Pharmacology, University of Bern, Switzerland
| | - Felix Hammann
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Institute of Pharmacology, University of Bern, Switzerland
| | - Katharina Elisabeth Grafinger
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Institute of Pharmacology, University of Bern, Switzerland
| | - Urs Duthaler
- Division of Clinical Pharmacology & Toxicology, University Hospital Basel, Switzerland.,Department of Biomedicine, University of Basel, Switzerland
| | - Michael Nagler
- University Institute of Clinical Chemistry, Inselspital, Bern University Hospital, Switzerland
| | - Stephan Krähenbühl
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Division of Clinical Pharmacology & Toxicology, University Hospital Basel, Switzerland.,Department of Biomedicine, University of Basel, Switzerland
| | - Manuel Haschke
- Clinical Pharmacology and Toxicology, Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Switzerland.,Institute of Pharmacology, University of Bern, Switzerland
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3
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Kim B, Jang S, Lee YJ, Park N, Cho YU, Park CJ. The rivaroxaban-adjusted normalized ratio: use of the prothrombin time to monitor the therapeutic effect of rivaroxaban. Br J Biomed Sci 2019; 76:122-128. [DOI: 10.1080/09674845.2019.1605648] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- B Kim
- Department of Laboratory Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Republic of Korea (South Korea)
| | - S Jang
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea (South Korea)
- Asan Clinical Research Center, Seoul, Republic of Korea (South Korea)
| | - YJ Lee
- Asan Clinical Research Center, Seoul, Republic of Korea (South Korea)
| | - N Park
- Asan Clinical Research Center, Seoul, Republic of Korea (South Korea)
| | - YU Cho
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea (South Korea)
| | - CJ Park
- Department of Laboratory Medicine, University of Ulsan College of Medicine and Asan Medical Center, Seoul, Republic of Korea (South Korea)
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4
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Hankey GJ. Unanswered questions and research priorities to optimise stroke prevention in atrial fibrillation with the new oral anticoagulants. Thromb Haemost 2017; 111:808-16. [DOI: 10.1160/th13-09-0741] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 10/15/2013] [Indexed: 11/05/2022]
Abstract
SummaryThis review article discusses the following, as yet unanswered, questions and research priorities to optimise patient management and stroke prevention in atrial fibrillation with the new direct oral anticoagulants (NOACs): 1. In patients prescribed a NOAC, can the anticoagulant effects or plasma concentrations of the NOACs be measured rapidly and reliably and, if so, can “cut-off points” between which anticoagulation is therapeutic (i.e. the “therapeutic range”) be defined? 2. In patients who are taking a NOAC and bleeding (e.g. intracerebral haemorrhage), can the anticoagulant effects of the direct NOACs be reversed rapidly and, if so, can NOAC-associated bleeding and complications be minimised and patient outcome improved? 3. In patients taking a NOAC who experience an acute ischaemic stroke, to what degree of anticoagulation or plasma concentration of NOAC, if any, can thrombolysis be administered safely and effectively? 4. In patients with a recent cardioembolic ischaemic stroke, what is the optimal time to start (or re-start) anticoagulation with a NOAC (or warfarin)? 5. In anticoagulated patients who experience an intracranial haemorrhage, can anticoagulation with a NOAC be re-started safely and effectively, and if so when? 6. Are the NOACs effective and safe in multimorbid geriatric people (who commonly have atrial fibrillation and are at high risk of stroke but also bleeding)? 7. Can dose-adjusted NOAC therapy augment the established safety and efficacy of fixed-dose unmonitored NOAC therapy? 8. Is there a dose or dosing regimen for each NOAC that is as effective and safe as adjusted-dose warfarin for patients with atrial fibrillation who have mechanical prosthetic heart valves? 9. What is the long-term safety of the NOACs?
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5
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Evaluation of dabigatran, rivaroxaban and apixaban target-specific assays in a multicenter French study. Thromb Res 2017; 158:126-133. [DOI: 10.1016/j.thromres.2017.09.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Revised: 08/08/2017] [Accepted: 09/01/2017] [Indexed: 01/04/2023]
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6
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Studt JD, Alberio L, Angelillo-Scherrer A, Asmis LM, Fontana P, Korte W, Mendez A, Schmid P, Stricker H, Tsakiris DA, Wuillemin WA, Nagler M. Accuracy and consistency of anti-Xa activity measurement for determination of rivaroxaban plasma levels. J Thromb Haemost 2017; 15:1576-1583. [PMID: 28574652 DOI: 10.1111/jth.13747] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Indexed: 12/18/2022]
Abstract
Essentials Accurate determination of anticoagulant plasma concentration is important in clinical practice. We studied the accuracy and consistency of anti-Xa assays for rivaroxaban in a multicentre study. In a range between 50 and 200 μg L-1 , anti-Xa activity correlated well with plasma concentrations. The clinical value might be limited by overestimation and intra- and inter-individual variation. SUMMARY Background Determining the plasma level of direct oral anticoagulants reliably is important in the work-up of complex clinical situations. Objectives To study the accuracy and consistency of anti-Xa assays for rivaroxaban plasma concentration in a prospective, multicenter evaluation study employing different reagents and analytical platforms. Methods Rivaroxaban 20 mg was administered once daily to 20 healthy volunteers and blood samples were taken at peak and trough levels (clinicaltrials.gov NCT01710267). Anti-Xa activity was determined in 10 major laboratories using different reagents and analyzers; corresponding rivaroxaban plasma concentrations were measured by high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS). Findings Overall Pearson's correlation coefficient of anti-Xa levels and HPLC-MS results was 0.99 for Biophen® Heparin (95% CI, 0.99, 0.99), Biophen® DiXaI (95% CI, 0.99, 0.99) and STA® anti-Xa liquid (95% CI, 0.99, 1.00). Correlation was lower in rivaroxaban concentrations below 50 μg L-1 and above 200 μg L-1 . The overall bias of the Bland-Altman difference plot was 14.7 μg L-1 for Biophen Heparin, 17.9 μg L-1 for Biophen DiXal and 19.0 μg L-1 for STA anti-Xa liquid. Agreement between laboratories was high at peak level but limited at trough level. Conclusions Anti-Xa activity correlated well with rivaroxaban plasma concentrations, especially in a range between 50 and 200 μg L-1 . However, anti-Xa assays systematically overestimated rivaroxaban concentration as compared with HPLC-MS, particularly at higher concentrations. This overestimation, coupled with an apparent interindividual variation, might affect the interpretation of results in some situations.
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Affiliation(s)
- J-D Studt
- Division of Haematology, University Hospital and University of Zurich, Zurich, Switzerland
| | - L Alberio
- Service and Central Laboratory of Haematology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - A Angelillo-Scherrer
- Department of Haematology, Inselspital, Bern University Hospital, Berne, Switzerland
- Department of Clinical Research, University of Bern, Berne, Switzerland
| | | | - P Fontana
- Division of Angiology and Haemostasis, University Hospitals of Geneva, Geneva, Switzerland
| | - W Korte
- Institute for Clinical Chemistry and Haematology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - A Mendez
- Centre for Laboratory Medicine, Cantonal Hospital Aarau, Aarau, Switzerland
| | - P Schmid
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, Lucerne, Switzerland
| | - H Stricker
- Division of Surgery, Regional Hospital La Carita, Locarno, Switzerland
| | - D A Tsakiris
- Diagnostic Haematology, University Hospital of Basel, Basel, Switzerland
| | - W A Wuillemin
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, Lucerne, Switzerland
- Department of Clinical Research, University of Berne, Berne, Switzerland
| | - M Nagler
- Department of Haematology, Inselspital, Bern University Hospital, Berne, Switzerland
- Division of Haematology and Central Haematology Laboratory, Luzerner Kantonsspital, Lucerne, Switzerland
- Department of Clinical Research, University of Berne, Berne, Switzerland
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7
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Silva VM, Scanavacca M, Darrieux F, Cavalheiro-Filho C, Strunz CC. Effects of rivaroxaban on coagulation tests in patients with non-valvular atrial fibrillation under real-life conditions. Thromb Res 2017; 154:26-27. [PMID: 28390252 DOI: 10.1016/j.thromres.2017.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 01/19/2017] [Accepted: 03/08/2017] [Indexed: 10/20/2022]
Affiliation(s)
- V M Silva
- Heart Institute (InCor), University of São Paulo Medical School Hospital, São Paulo, Brazil
| | - M Scanavacca
- Heart Institute (InCor), University of São Paulo Medical School Hospital, São Paulo, Brazil
| | - F Darrieux
- Heart Institute (InCor), University of São Paulo Medical School Hospital, São Paulo, Brazil
| | - C Cavalheiro-Filho
- Heart Institute (InCor), University of São Paulo Medical School Hospital, São Paulo, Brazil
| | - C C Strunz
- Heart Institute (InCor), University of São Paulo Medical School Hospital, São Paulo, Brazil.
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8
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Koscielny J, von Heymann C, Bauersachs R, Mouret P, Antz M. [Perioperative anticoagulation with NOAC using the example of rivaroxaban]. MMW Fortschr Med 2017; 159:18-23. [PMID: 28244023 DOI: 10.1007/s15006-017-9295-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 11/14/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Recent findings require an update of earlier recommendations on the perioperative management of non Vitamin K antagonist oral anticoagulants (NOAC). METHOD The present position paper summarises the outcomes of an expert panel discussion. RESULTS AND CONCLUSIONS Based on the pharmacokinetic profile of rivaroxaban, a preoperative interruption of 24-72 hours is recommended depending on the patient's renal function, as well as individual and surgery-related bleeding risks. Similar NOAC-free intervals are recommended for patients with epidural catheters. Elective surgery should be delayed accordingly. A low molecular weight heparin (LMWH) "bridging" (in fact "switching") should be avoided because of an increased bleeding risk. Six to 8 hours after the intervention rivaroxaban can be re-initiated or, in case of more extensive interventions or an increased bleeding risk, after 24-72 hours; if necessary this interval could by bridged with LMWH, e. g. if the thromboembolic risk is considered high. In case of emergency surgery with a rivaroxaban pause of less than 9 hours, one should be prepared for a bleeding management including the use of prothrombin concentrate (PCC). Coagulation tests have no value for predicting perioperative bleeding, in contrast to a standardised bleeding history. As an overall estimate, the PT (Quick) can be determined with a suitable reagent. Currently, rivaroxaban-specific measurements of anti Xa levels are available at few specialised centres only. Moderate to severe haemorrhages can usually be managed by temporary interruption of rivaroxaban in conjunction with local and general haemostatic measures. Life-threatening bleeding events require a specific haemostasis management including the administration of PCC; these events are rare and usually have a favourable prognosis, except for intracranial haemorrhages.
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Affiliation(s)
- Jürgen Koscielny
- Gerinnungsambulanz mit Hämophiliezentrum im ambulanten Gesundheitszentrum (AGZ), Charité - Universitätsmedizin Berlin, Campus Charité Mitte, Charitéplatz 1, Durchgang Luisenstr. 13, 10117, Berlin, Deutschland.
| | - Christian von Heymann
- Klinik für Anästhesie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Vivantes Klinikum im Friedrichshain, Berlin, Deutschland
| | - Rupert Bauersachs
- Klinikum Darmstadt GmbH, Klinik für Gefäßmedizin - Angiologie, Gefäßzentrum Darmstadt, Darmstadt, Deutschland
| | | | - Matthias Antz
- Klinik für Kardiologie, Herzzentrum Klinikum Oldenburg, Oldenburg, Deutschland
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9
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Arnao V, Riolo M, Tuttolomondo A, Pinto A, Fierro B, Aridon P. New frontiers in anticoagulation: non vitamin-K oral anticoagulants in stroke prevention. Expert Rev Neurother 2016; 17:539-552. [PMID: 27911120 DOI: 10.1080/14737175.2017.1268053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Non vitamin-K oral anticoagulants (NOACs) are direct and specific inhibitors of the coagulation factors IIa (dabigatran) and Xa (apixaban, rivaroxaban, edoxaban) which share many pharmacokinetic properties. However, indications are lacking regarding the use of NOACs during thrombolysis, surgery and bleeding events. Areas covered: In this paper, the authors retrospectively analyzed the relevant literature on the NOACs using the PubMed and Google Scholar databases. Expert commentary: Although warfarin is effective in cardioembolic stroke prevention, easier handling and more favorable risk-benefit profile often render NOACs a more preferable therapy choice for neurologists. New evidences have suggested their use in treatment of elderly people, in patients with renal insufficiency or with antiphospholipid antibody syndrome. In addition, the use of antidotes, which rapidly reverse the anticoagulant effect of the NOACs, could be useful in bleeding, during emergency procedures, or in case of overdose.
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Affiliation(s)
- Valentina Arnao
- a BioNeC Dipartimento di BioMedicina Sperimentale e Neuroscienze Cliniche , Università degli Studi di Palermo , Palermo , Italy.,b Biomedical Department of Internal and Specialistic Medicine (Di.Bi.M.I.S), School of Medicina Clinica e Scienze del Comportamento , University of Palermo , Palermo , Italy
| | - Marianna Riolo
- a BioNeC Dipartimento di BioMedicina Sperimentale e Neuroscienze Cliniche , Università degli Studi di Palermo , Palermo , Italy
| | - Antonino Tuttolomondo
- c Biomedical Department of Internal and Specialistic Medicine (Di.Bi.M.I.S) , University of Palermo , Palermo , Italy
| | - Antonio Pinto
- c Biomedical Department of Internal and Specialistic Medicine (Di.Bi.M.I.S) , University of Palermo , Palermo , Italy
| | - Brigida Fierro
- a BioNeC Dipartimento di BioMedicina Sperimentale e Neuroscienze Cliniche , Università degli Studi di Palermo , Palermo , Italy
| | - Paolo Aridon
- a BioNeC Dipartimento di BioMedicina Sperimentale e Neuroscienze Cliniche , Università degli Studi di Palermo , Palermo , Italy
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Abstract
In some clinical settings laboratory measurement of direct oral anticoagulants effect is helpful in guiding medical care, such as life-threatening bleeding, need for emergency surgery, renal impairment, severe hepatic failure, extremes of body weight, or in patients with bleeding or thrombosis on therapy. This article reviews approaches to laboratory testing to assess the anticoagulant effect of these drugs. Because of the wide variation in levels measured in patients on therapy and minimal clinical data from dose adjustment, dose adjustment based on levels is not currently advised. In addition, these drugs interfere with many clot-based laboratory tests and caution is advised in interpreting these tests in patients on direct oral anticoagulants.
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Affiliation(s)
- Barbara A Konkle
- Clinical and Translational Research, Hemostasis, Platelet Immunology, and Genomics Laboratory, Bloodworks Northwest, University of Washington School of Medicine, 921 Terry Avenue, Seattle, WA 98104, USA.
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11
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Gosselin R, Grant RP, Adcock DM. Comparison of the effect of the anti-Xa direct oral anticoagulants apixaban, edoxaban, and rivaroxaban on coagulation assays. Int J Lab Hematol 2016; 38:505-13. [DOI: 10.1111/ijlh.12528] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 04/18/2016] [Indexed: 11/29/2022]
Affiliation(s)
- R. Gosselin
- Pathology and Laboratory Medicine; UC Davis Health System; Sacramento CA USA
| | - R. P. Grant
- Laboratory Corporation of America; Burlington NC USA
| | - D. M. Adcock
- Colorado Coagulation, Laboratory Corporation of America® Holdings; Englewood CO USA
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12
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Measurement of Non-Vitamin K Antagonist Oral Anticoagulants in Patient Plasma Using Heptest-STAT Coagulation Method. Ther Drug Monit 2016; 37:375-80. [PMID: 25525760 DOI: 10.1097/ftd.0000000000000157] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Non-vitamin K antagonist oral anticoagulants (NOACs) are approved for several indications for prophylaxis of thromboembolism at fixed oral doses. The analysis of NOAC activity/concentration may be required in special patient populations. Heptest coagulation assay determines both factor Xa and thrombin inhibitors. The objective of investigations is to analyze the effects of both groups of NOACs on this assay. METHODS The performance of a modified Heptest-STAT clotting assay was compared with specific chromogenic substrate assays for factor Xa (Coamatic, HemosIL) and thrombin (direct thrombin inhibitor assay and S2238 chromogenic assays) for the determination of rivaroxaban, apixaban, and dabigatran in plasma from patients on treatment. RESULTS For rivaroxaban (n = 74), the concentrations (mean and SD) of Heptest-STAT versus Coamatic and HemosIL assays were 179.3 ± 85.8 ng/mL versus 199.3 ± 105.7 ng/mL and 212.4 ± 115.9 ng/mL (P < 0.0001), and for apixaban (n = 26) 232.8 ± 10.0 ng/mL versus 178.4 ± 64.4 ng/mL (P < 0.0001) and 182.1 ± 73.1 ng/mL (P = 0.0002). For dabigatran (n = 74), the values of Heptest-STAT were 92.3 ± 65.0 ng/mL versus 124.3 ± 85.6 ng/mL (direct thrombin inhibitor assay, P < 0.0001) and 107.5 ± 59.7 ng/mL (S2238 assay, P = 0.0015), respectively. The values of the intraclass coefficient of correlation ranged from 0.64 to 0.91 (Bland-Altman analysis). CONCLUSIONS The objective of the study was achieved by demonstrating a high correlation of the Heptest-STAT coagulation assay with chromogenic assays for factor Xa inhibiting NOACs and acceptably good correlation with thrombin inhibiting NOACs in plasma samples of patients on treatment.
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13
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Gosselin RC, Adcock DM. The laboratory's 2015 perspective on direct oral anticoagulant testing. J Thromb Haemost 2016; 14:886-93. [PMID: 26791879 DOI: 10.1111/jth.13266] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 01/12/2016] [Indexed: 01/28/2023]
Abstract
The introduction of direct oral anticoagulant (DOAC) therapy into clinical use in the past 5 years has had significant impact on the clinical laboratory. Clinicians' desire to determine plasma drug presence or measure drug concentration, and more recent observations regarding the limitations and utility of coagulation testing in the setting of DOAC treatment, suggest that early published recommendations regarding laboratory testing should be reassessed. These initial recommendations, furthermore, were often based on drug-spiked plasma studies, rather than samples from patients receiving DOAC therapy. We have demonstrated that reagent sensitivity varies significantly whether drug-spiked samples or samples from DOAC-treated patients are tested. Data from drug-enriched samples must therefore be interpreted with caution or be used as a guide only. We present laboratory assays that can be used to determine drug presence and to measure drug concentration, and provide recommended testing algorithms. As DOAC therapy may significantly impact on specialty coagulation assays, we review those tests with the potential to give false-positive and false-negative results.
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Affiliation(s)
- R C Gosselin
- University of California, Davis Health System, Sacramento, CO, USA
| | - D M Adcock
- Laboratory Corporation of America® Holdings, Colorado Coagulation, Englewood, CO, USA
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14
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Masotti L, Lorenzini G, Seravalle C, Panigada G, Landini G, Cappelli R, Schulman S. Management of new oral anticoagulants related life threatening or major bleedings in real life: a brief report. J Thromb Thrombolysis 2016; 39:427-33. [PMID: 25048833 DOI: 10.1007/s11239-014-1112-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Although new oral anticoagulants (NOAs) have been marketed in many countries, concern exists about the management of bleedings related to these drugs due to the lack of specific antidotes. The aim of our study was to report on real life management of NOAs-related life-threatening or major bleedings. We report data from consecutive cases of NOAs related major bleedings admitted to 4 hospitals since NOAs became marketed in Italy. We treated 8 patients, 4 males, with mean age 84 ± 7 years, 7 of whom were on dabigatran and one on rivaroxaban. The indication for NOA was atrial fibrillation. All bleedings were spontaneous and involving the gastro-intestinal tract. At the time of bleeding all patients had a drop in hemoglobin levels over 20 g/L. Creatinine clearance was ≤30 mL/min in 4 patients. All patients received general supportive measures, 4 of 8 patients were transfused with packed red cells and one patient received platelet transfusion. Three patients were treated with tranexamic acid and one patient on dabigatran received 4-factor prothrombin complex concentrate (PCC) with bleeding cessation, although coagulation parameters were not corrected. The median time for normalization of coagulation parameters was 3 days (range 1-6 days). All patients were discharged alive and NOAs were discontinued. In NOAs related major gastro-intestinal bleeding general supportive measures seem to be effective for the majority of patients. Despite promoting bleeding cessation, 4-factor PCC does not reverse abnormal coagulation parameters.
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Affiliation(s)
- Luca Masotti
- Internal Medicine, Santa Maria Nuova Hospital, Florence, Italy,
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15
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Chan NC, Bhagirath V, Dale BJ, Eikelboom JW. Evaluating coagulation tests in patients with atrial fibrillation using direct oral anticoagulants. Expert Rev Cardiovasc Ther 2015; 13:1213-23. [DOI: 10.1586/14779072.2015.1096779] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
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16
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Sié P. [Laboratory coagulation tests in patients treated by direct oral anticoagulants (DOACs)]. Presse Med 2015; 44:772-8. [PMID: 26248706 DOI: 10.1016/j.lpm.2015.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 06/01/2015] [Indexed: 10/23/2022] Open
Abstract
Routine clotting time assays (Prothrombin Time/INR, activated Partial Thromboplastin Time [aPTT]) are prolonged at variable extent by direct oral anticoagulants (DOAC), according to the assay, the reagent and the type of DOAC. These assays are not reliable for monitoring the intensity of treatment and the measurement of the plasma level of the DOAC is usually not required. At high concentrations, DOAC interfere with the routine clotting assays, making them difficult to interpret. In critical situations such as major bleeding or urgent invasive procedure, the measurement of DOAC level and its kinetics are simple and useful to manage the patient.
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Affiliation(s)
- Pierre Sié
- CHU de Toulouse, hôpital Rangeuil, laboratoire d'hématologie, TSA 50032, 31059 Toulouse, France.
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17
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Gosselin RC, Francart SJ, Hawes EM, Moll S, Dager WE, Adcock DM. Heparin-Calibrated Chromogenic Anti-Xa Activity Measurements in Patients Receiving Rivaroxaban. Ann Pharmacother 2015; 49:777-83. [DOI: 10.1177/1060028015578451] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Determination of plasma rivaroxaban concentration may be necessary in certain clinical situations. Rivaroxaban concentration can be accurately and rapidly determined using a chromogenic anti–activated factor X (factor Xa) assay with specific drug calibrator material. However, there are currently no Food and Drug Administration (FDA)-approved rivaroxaban calibrators available in the United States. Objective: To determine whether FDA-approved commercial kits for measuring heparin anti–factor Xa activity can be used to assess rivaroxaban concentrations when calibrated for unfractionated heparin or low-molecular-weight heparins. Methods: Trough and peak samples were taken from 30 patients taking rivaroxaban as part of their routine care for atrial fibrillation or venous thromboembolism. The samples were tested using 3 different FDA-approved commercial kits for measuring heparin anti–factor Xa activity. Results: There was acceptable correlation between rivaroxaban levels and heparin anti–factor Xa activity using Berichrom and COAMATIC heparin kits. The STA liquid heparin method was the most sensitive to presence of rivaroxaban. Conclusion: This study demonstrates a strong correlation, but variability between kits, for assessing rivaroxaban concentrations using heparin anti–factor Xa assays. The extent of the heparin calibration curve significantly limits the measurable rivaroxaban range, and this application may be useful only for trough samples. The STA liquid heparin, being exquisitely sensitive to rivaroxaban, may be suitable for ruling out presence of the drug. The routine use of heparin-calibrated anti–factor Xa assays to quantify rivaroxaban is not advocated, and when applied, it must be used with caution and limitations clearly understood.
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Affiliation(s)
| | | | | | - Stephan Moll
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
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18
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Comparison of Methods to Determine Rivaroxaban anti-factor Xa activity. Thromb Res 2015; 135:394-7. [DOI: 10.1016/j.thromres.2014.11.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Revised: 11/05/2014] [Accepted: 11/17/2014] [Indexed: 11/23/2022]
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19
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Du S, Krämer S, Giese C, Weiss C, Wehling M, Krämer R, Harenberg J. Chromogenic assays for measurement of rivaroxaban from EDTA anticoagulated plasma samples. Thromb Haemost 2015; 113:1149-51. [PMID: 25608910 DOI: 10.1160/th14-10-0869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Accepted: 12/10/2014] [Indexed: 11/05/2022]
Affiliation(s)
| | | | | | | | | | | | - Job Harenberg
- Job Harenberg, MD, Clinical Pharmacology, Medical Faculty Mannheim, Ruprecht-Karls University Heidelberg, Maybachstrasse. 14, 68169 Mannheim, Germany, E-mail:
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20
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Abstract
Abstract
Target-specific oral anticoagulants are approved for use for the prevention of stroke in atrial fibrillation and for the prevention and treatment of venous thrombosis without the need for laboratory monitoring. However, there are clinical settings in which laboratory measurement of anticoagulant effect is needed. These may include patients with life-threatening bleeding or those requiring emergency surgery, in the setting of renal or hepatic failure, or patients with thrombosis on therapy. This chapter reviews the use of laboratory testing to assess the anticoagulant effect of these drugs. In addition, because these drugs can interfere with other laboratory testing, available data on these interactions are presented.
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21
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Gosselin RC, (Adcock) Funk DM, Taylor JM, Francart SJ, Hawes EM, Friedman KD, Moll S. Comparison of Anti-Xa and Dilute Russell Viper Venom Time Assays in Quantifying Drug Levels in Patients on Therapeutic Doses of Rivaroxaban. Arch Pathol Lab Med 2014; 138:1680-4. [DOI: 10.5858/arpa.2013-0750-oa] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context
Rivaroxaban is a new oral anticoagulant that functions as a direct anti-Xa inhibitor. Although routine monitoring is not required, measurement of plasma concentrations may be necessary in certain clinical situations. Routine coagulation assays, such as the prothrombin time and, to a lesser degree, activated partial thromboplastin time, correlate with drug concentration, but because of reagent variability, these methods are not reliable for determining rivaroxaban anticoagulation.
Objective
To compare different methods and calibrators for measuring rivaroxaban, including the chromogenic anti-Xa assay, which, when calibrated with a rivaroxaban standard, may be more appropriate for determining anticoagulation.
Design
We compared measured rivaroxaban concentrations with the same anti-Xa kit but used different calibrators, with different anti-Xa kits but the same calibrators, with antithrombin-supplemented anti-Xa kit versus nonsupplemented kits, and with 2 methods based on rivaroxaban-calibrated, high-phospholipid, dilute Russell viper venom time. Regression and paired t test statistics were used to determine correlation and significant differences among methods and calibrator sources.
Results
Although there was strong correlation, statistically significant biases existed among methods that report rivaroxaban levels. A single-source calibrator did not alleviate those differences among methods. High-phospholipid Russell viper venom reagents correlated with rivaroxaban concentration but were not better than chromogenic anti-Xa methods.
Conclusions
Rivaroxaban-calibrated, anti-Xa measurements correlate well, but the clinical significance of the variation with rivaroxaban measurements is uncertain. The antithrombin-supplemented, anti-Xa method should be avoided for measuring rivaroxaban.
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Affiliation(s)
- Robert C. Gosselin
- From the Department of Pathology and Laboratory Medicine, University of California, Davis Health System, Sacramento (Mr Gosselin); Colorado Coagulation, Corporation of America Holdings, Englewood (Dr Funk and Mr Taylor); the Departments of Pharmacy (Drs Francart, Hawes, and Moll) and Family Medicine (Dr Hawes) and the Hemophilia and Thrombosis Center (Dr Moll), University of North Carolina, Chapel Hill, NC; and the Hemostasis Reference Laboratory, Blood Center of Wisconsin, Milwaukee (Dr Friedman)
| | - Dorothy M. (Adcock) Funk
- From the Department of Pathology and Laboratory Medicine, University of California, Davis Health System, Sacramento (Mr Gosselin); Colorado Coagulation, Corporation of America Holdings, Englewood (Dr Funk and Mr Taylor); the Departments of Pharmacy (Drs Francart, Hawes, and Moll) and Family Medicine (Dr Hawes) and the Hemophilia and Thrombosis Center (Dr Moll), University of North Carolina, Chapel Hill, NC; and the Hemostasis Reference Laboratory, Blood Center of Wisconsin, Milwaukee (Dr Friedman)
| | - J. Michael Taylor
- From the Department of Pathology and Laboratory Medicine, University of California, Davis Health System, Sacramento (Mr Gosselin); Colorado Coagulation, Corporation of America Holdings, Englewood (Dr Funk and Mr Taylor); the Departments of Pharmacy (Drs Francart, Hawes, and Moll) and Family Medicine (Dr Hawes) and the Hemophilia and Thrombosis Center (Dr Moll), University of North Carolina, Chapel Hill, NC; and the Hemostasis Reference Laboratory, Blood Center of Wisconsin, Milwaukee (Dr Friedman)
| | - Suzanne J. Francart
- From the Department of Pathology and Laboratory Medicine, University of California, Davis Health System, Sacramento (Mr Gosselin); Colorado Coagulation, Corporation of America Holdings, Englewood (Dr Funk and Mr Taylor); the Departments of Pharmacy (Drs Francart, Hawes, and Moll) and Family Medicine (Dr Hawes) and the Hemophilia and Thrombosis Center (Dr Moll), University of North Carolina, Chapel Hill, NC; and the Hemostasis Reference Laboratory, Blood Center of Wisconsin, Milwaukee (Dr Friedman)
| | - Emily M. Hawes
- From the Department of Pathology and Laboratory Medicine, University of California, Davis Health System, Sacramento (Mr Gosselin); Colorado Coagulation, Corporation of America Holdings, Englewood (Dr Funk and Mr Taylor); the Departments of Pharmacy (Drs Francart, Hawes, and Moll) and Family Medicine (Dr Hawes) and the Hemophilia and Thrombosis Center (Dr Moll), University of North Carolina, Chapel Hill, NC; and the Hemostasis Reference Laboratory, Blood Center of Wisconsin, Milwaukee (Dr Friedman)
| | - Kenneth D. Friedman
- From the Department of Pathology and Laboratory Medicine, University of California, Davis Health System, Sacramento (Mr Gosselin); Colorado Coagulation, Corporation of America Holdings, Englewood (Dr Funk and Mr Taylor); the Departments of Pharmacy (Drs Francart, Hawes, and Moll) and Family Medicine (Dr Hawes) and the Hemophilia and Thrombosis Center (Dr Moll), University of North Carolina, Chapel Hill, NC; and the Hemostasis Reference Laboratory, Blood Center of Wisconsin, Milwaukee (Dr Friedman)
| | - Stephan Moll
- From the Department of Pathology and Laboratory Medicine, University of California, Davis Health System, Sacramento (Mr Gosselin); Colorado Coagulation, Corporation of America Holdings, Englewood (Dr Funk and Mr Taylor); the Departments of Pharmacy (Drs Francart, Hawes, and Moll) and Family Medicine (Dr Hawes) and the Hemophilia and Thrombosis Center (Dr Moll), University of North Carolina, Chapel Hill, NC; and the Hemostasis Reference Laboratory, Blood Center of Wisconsin, Milwaukee (Dr Friedman)
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22
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Point-of-Care Coagulation Testing for Assessment of the Pharmacodynamic Anticoagulant Effect of Direct Oral Anticoagulant. Ther Drug Monit 2014; 36:624-31. [DOI: 10.1097/ftd.0000000000000064] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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23
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Harenberg J, Krämer S, Du S, Zolfaghari S, Schulze A, Krämer R, Weiss C, Wehling M, Lip GYH. Measurement of rivaroxaban and apixaban in serum samples of patients. Eur J Clin Invest 2014; 44:743-52. [PMID: 24931429 PMCID: PMC4143952 DOI: 10.1111/eci.12291] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Accepted: 06/11/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND The determination of rivaroxaban and apixaban from serum samples of patients may be beneficial in specific clinical situations when additional blood sampling for plasma and thus the determination of factor Xa activity is not feasible or results are not plausible. MATERIALS AND METHODS The primary aim of this study was to compare the concentrations of rivaroxaban and apixaban in serum with those measured in plasma. Secondary aims were the performance of three different chromogenic methods and concentrations in patients on treatment with rivaroxaban 10 mg od (n = 124) or 20 mg od (n = 94) or apixaban 5 mg bid (n = 52) measured at different time. RESULTS Concentrations of rivaroxaban and apixaban in serum were about 20-25% higher compared with plasma samples with a high correlation (r = 0·79775-0·94662) using all assays (all P < 0·0001). The intraclass correlation coefficients were about 0·90 for rivaroxaban and 0·55 for apixaban. Mean rivaroxaban concentrations were higher at 2 and 3 h compared with 1 and 12 h after administration measured from plasma and serum samples (all P-values < 0·05) and were not different between 1 vs. 12 h (plasma and serum). CONCLUSIONS The results indicate that rivaroxaban and apixaban concentrations can be determined specifically from serum samples.
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Affiliation(s)
- Job Harenberg
- Department of Clinical Pharmacology, Medical Faculty Mannheim, Ruprecht-Karls University Heidelberg, Mannheim, Germany
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24
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Stöllberger C, Finsterer J. Concerns about the use of new oral anticoagulants for stroke prevention in elderly patients with atrial fibrillation. Drugs Aging 2014; 30:949-58. [PMID: 24170233 DOI: 10.1007/s40266-013-0119-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The prevalence of atrial fibrillation (AF) and the embolic risk increase with age. Elderly AF patients are undertreated with vitamin K antagonists (VKA). The new oral anticoagulants (NOAC) dabigatran, rivaroxaban and apixaban have been shown to be non-inferior to VKA for stroke prevention in AF. We summarize the knowledge about primary and secondary stroke prevention by NOAC in AF patients >75 years of age. A literature search was carried out using the terms 'dabigatran', 'rivaroxaban', 'apixaban', 'elderly', 'octogenarians', 'atrial fibrillation' and 'anticoagulation' from 1998 to 2013. Randomized clinical trials, longitudinal studies, case series and case reports were included. Whereas studies investigating the use of VKA for stroke prevention in the 1990s were carried out by industry-independent institutions, all NOAC-investigating trials were sponsored by the manufacturers of the respective drugs. Frail elderly people were not represented in NOAC-investigating trials because of various exclusion criteria, and only one-third of patients were aged >75 years. A subgroup analysis from the dabigatran-investigating trial indicated that elderly patients might have a higher risk for extracranial bleeding complications with NOAC than with VKA. Further concerns about the use of NOAC in the elderly are the high prevalence of renal insufficiency in AF patients >75 years of age, the largely unknown risk of drug-drug and drug-food interactions, the lack of easily available laboratory monitoring tests of anticoagulant activity and the lack of an antidote. There is a need for independent studies comparing the efficacy and risk of side effects of NOAC with that of VKA in elderly AF patients.
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25
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Carter NJ, Plosker GL. Rivaroxaban: a review of its use in the prevention of stroke and systemic embolism in patients with atrial fibrillation. Drugs 2014; 73:715-39. [PMID: 23677801 DOI: 10.1007/s40265-013-0056-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Rivaroxaban (Xarelto(®)), a direct factor Xa inhibitor, is approved for the prevention of stroke and systemic embolism in patients with atrial fibrillation (AF) in Canada or those with nonvalvular AF (NVAF) in the EU, US and Japan. It is administered at a fixed oral dose and generally does not require routine monitoring of coagulation parameters. In the ROCKET AF trial in patients with NVAF and a moderate to high risk of stroke, oral rivaroxaban 20 mg once daily (15 mg once daily in patients with moderate renal impairment) was noninferior to oral dose-adjusted warfarin once daily in preventing primary endpoint events (i.e. stroke and systemic embolism) in the per-protocol population (primary noninferiority analysis) and superior in the on-treatment safety population (primary superiority analysis). Several ROCKET AF subgroup analyses indicated that the treatment effect of rivaroxaban was consistent across patient subgroups stratified according to baseline factors, including the presence or absence of previous stroke or transient ischaemic attack. Patients with moderate renal impairment receiving the reduced rivaroxaban dosage (15 mg once daily) showed a treatment effect consistent with that seen with rivaroxaban 20 mg once daily in patients with normal renal function. The tolerability profile of rivaroxaban was generally acceptable in ROCKET AF, with no significant difference between rivaroxaban and warfarin in the incidence of major or nonmajor clinically-relevant bleeding events (primary safety endpoint). In the Japanese ROCKET AF trial, rivaroxaban 15 mg once daily (10 mg once daily in patients with moderate renal impairment) was noninferior to oral dose-adjusted warfarin once daily in the incidence of major or nonmajor clinically-relevant bleeding (primary study outcome). Thus, rivaroxaban is a reasonable alternative to warfarin for the prevention of stroke and systemic embolism in patients with NVAF.
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Affiliation(s)
- Natalie J Carter
- Adis, 41 Centorian Drive, Private Bag 65901, Mairangi Bay, North Shore, 0754, Auckland, New Zealand.
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26
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Nakashima MO, Rogers HJ. Hypercoagulable states: an algorithmic approach to laboratory testing and update on monitoring of direct oral anticoagulants. Blood Res 2014; 49:85-94. [PMID: 25025009 PMCID: PMC4090343 DOI: 10.5045/br.2014.49.2.85] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 06/17/2014] [Accepted: 06/19/2014] [Indexed: 12/19/2022] Open
Abstract
Hypercoagulability can result from a variety of inherited and, more commonly, acquired conditions. Testing for the underlying cause of thrombosis in a patient is complicated both by the number and variety of clinical conditions that can cause hypercoagulability as well as the many potential assay interferences. Using an algorithmic approach to hypercoagulability testing provides the ability to tailor assay selection to the clinical scenario. It also reduces the number of unnecessary tests performed, saving cost and time, and preventing potential false results. New oral anticoagulants are powerful tools for managing hypercoagulable patients; however, their use introduces new challenges in terms of test interpretation and therapeutic monitoring. The coagulation laboratory plays an essential role in testing for and treating hypercoagulable states. The input of laboratory professionals is necessary to guide appropriate testing and synthesize interpretation of results.
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Affiliation(s)
- Megan O Nakashima
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, OH, United States
| | - Heesun J Rogers
- Department of Laboratory Medicine, Cleveland Clinic, Cleveland, OH, United States
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27
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Hankey GJ, Norrving B, Hacke W, Steiner T. Management of acute stroke in patients taking novel oral anticoagulants. Int J Stroke 2014; 9:627-32. [PMID: 24891030 PMCID: PMC4149783 DOI: 10.1111/ijs.12295] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 04/07/2014] [Indexed: 12/18/2022]
Abstract
Each year, 1·0–2·0% of individuals with atrial fibrillation and 0·1–0·2% of those with venous thromboembolism who are receiving one of the novel oral anticoagulants (dabigatran, rivaroxaban, or apixaban) can be expected to experience an acute ischemic stroke. Additionally, 0·2–0·5% of individuals with atrial fibrillation who are receiving one of the novel oral anticoagulants can be expected to experience an intracranial hemorrhage. This opinion piece addresses the current literature and offers practical approaches to the management of patients receiving novel oral anticoagulants who present with an ischemic or hemorrhagic stroke. Specifically, we discuss the role of thrombolysis in anticoagulated patients with acute ischemic stroke and factors to consider concerning restarting anticoagulation after acute ischemic and hemorrhagic stroke.
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Affiliation(s)
- Graeme J Hankey
- School of Medicine and Pharmacology, The University of Western Australia, Perth, Western Australia, Australia
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28
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Harenberg J, Du S, Weiss C, Krämer R, Hoppensteadt D, Walenga J. Report of the Subcommittee on Control of Anticoagulation on the determination of the anticoagulant effects of apixaban: communication from the SSC of the ISTH. J Thromb Haemost 2014; 12:801-4. [PMID: 24597497 DOI: 10.1111/jth.12547] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Indexed: 01/05/2023]
Affiliation(s)
- J Harenberg
- Medical Faculty Mannheim, Department of Clinical Pharmacology, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
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29
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Altman R, Gonzalez CD. Simple and rapid assay for effect of the new oral anticoagulant (NOAC) rivaroxaban: preliminary results support further tests with all NOACs. Thromb J 2014; 12:7. [PMID: 24656069 PMCID: PMC3974190 DOI: 10.1186/1477-9560-12-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 02/27/2014] [Indexed: 01/26/2023] Open
Abstract
Background New oral anticoagulant (NOAC) drugs are known to influence the results of some routine hemostasis tests. Further data are needed to enable routine assessment of the effects of NOAC on clotting parameters in some special circumstances. Methods Following administration of rivaroxaban to patients, at the likely peak and trough activity times, we assessed the effects on prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), and clotting time using Russell’s viper venom, and in the presence of phospholipids and calcium reagent available as DVVreagent® and DVVconfirm®. The data were used to determine an adequate NOAC plasma level based on anticoagulant activities expressed as a ratio (patients/normal, R-C). Results DVVconfirm as R-C could be rapidly performed, and the results were reasonably sensitive for rivaroxaban and probably for other FX inhibitors. This assay is not influenced by lupus anticoagulant and heparin, does not require purified NOAC as control, and will measure whole-plasma clotting activity. Conclusions We propose a cut-off R-C value of 4.52 ± 0.33 for safety, but clinical studies are needed to establish whether this cut-off is useful for identifying patients at increased risk of hemorrhage or exhibiting low anticoagulation effect. It also seems possible that normal R-C could indicate an absence of anticoagulant activity when rivaroxaban is discontinued due to episodes of uncontrolled bleeding during anticoagulation or for emergency surgery.
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Affiliation(s)
- Raul Altman
- Centro de Trombosis de Buenos Aires, Viamonte 2008, Buenos Aires 1056, Argentina.
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30
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Mani H, Kasper A, Lindhoff-Last E. Measuring the anticoagulant effects of target specific oral anticoagulants-reasons, methods and current limitations. J Thromb Thrombolysis 2014; 36:187-94. [PMID: 23512159 DOI: 10.1007/s11239-013-0907-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
To simplify and optimize oral anticoagulation, new target-specific oral anticoagulants (TSOAs) have been developed. The direct thrombin-inhibitor dabigatran and the direct factor Xa inhibitors rivaroxaban, apixaban and edoxaban are the first such compounds to receive approval in certain countries for various indications. Due to the predictable pharmacokinetic and pharmacodynamic profiles of these drugs, routine monitoring of patients receiving TSOA therapy has not been considered necessary. However, it has now been realized that in routine clinical settings, there are several situations where it may be prudent to assess the level of TSOA anticoagulation. Several studies evaluating the influence of TSOAs on various coagulation assays have been performed to identify systems that can be used to monitor these drugs. With a particular focus on dabigatran and rivaroxaban, we will describe and discuss the potential of several methods for measuring the anticoagulant effect of TSOAs, as well as their methodological limitations and the restrictions in transferring their results into clinical context.
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Affiliation(s)
- Helen Mani
- Division of Vascular Medicine, Department of Internal Medicine, Johann Wolfgang Goethe-University Hospital Frankfurt/Main, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany.
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31
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Ploen R, Sun L, Zhou W, Heitmeier S, Zorn M, Jenetzky E, Veltkamp R. Rivaroxaban does not increase hemorrhage after thrombolysis in experimental ischemic stroke. J Cereb Blood Flow Metab 2014; 34:495-501. [PMID: 24346690 PMCID: PMC3948130 DOI: 10.1038/jcbfm.2013.226] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 10/21/2013] [Accepted: 11/15/2013] [Indexed: 12/30/2022]
Abstract
The management of acute ischemic stroke during anticoagulation with a novel oral anticoagulant (NOAC) is challenging because intravenous thrombolysis is contraindicated because of a putative increased risk of intracerebral hemorrhagic complications. We examined the risk of secondary postischemic hemorrhage after thrombolysis in rodents pretreated with rivaroxaban or warfarin. Mice were pretreated with either rivaroxaban (30 mg/kg), warfarin (target international normalized ratio 2 to 3) or vehicle. After 2 or 3 hours, middle cerebral artery occlusion (MCAO), mice received 9 mg/kg recombinant tissue plasminogen activator. Twenty-four hours after MCAO, secondary hemorrhage was quantified using a macroscopic hemorrhage score and hemoglobin spectrophotometry. Blood-brain barrier (BBB) permeability was measured by Evans Blue spectrofluorometry. To increase the validity of our findings, experiments were also performed using a thromboembolic model in anticoagulated rats. Infarct size did not differ among groups. Pretreatment with warfarin led to significantly more secondary hemorrhage compared with rivaroxaban and nonanticoagulated controls after 2- and 3-hour ischemia in mice as well as in rats. Blood-brain barrier permeability was significantly higher in the warfarin group compared with rivaroxaban and control. Thus, rivaroxaban in contrast to warfarin does not increase secondary hemorrhage after thrombolysis in experimental cerebral ischemia. Less effects of rivaroxaban on postischemic BBB permeability may account for this difference.
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Affiliation(s)
- Robert Ploen
- Department of Neurology, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Li Sun
- Department of Neurology, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Wei Zhou
- Department of Neurology, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Markus Zorn
- Department of Internal Medicine I, Ruprecht-Karls-University, Heidelberg, Germany
| | - Ekkehart Jenetzky
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Roland Veltkamp
- Department of Neurology, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
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32
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Samama MM, Amiral J, Guinet C, Flem LL, Seghatchian J. Monitoring plasma levels of factor Xa inhibitors: how, why and when? Expert Rev Hematol 2014; 6:155-64. [DOI: 10.1586/ehm.13.11] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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33
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Abstract
During recent years, three new anticoagulants (dabigatran, rivaroxaban and apixaban) have been introduced to the market, probably with one more anticoagulant (edoxaban) in the next 2 years. This review is not intended to compare the efficacy and risks of these new agents, but rather to detail the advantages and limitations. The pharmacokinetic characteristics of these drugs have few drug and food interactions, predictable dose responses, and rapid onset and offset, thus resulting in simplified management of the patient requiring anticoagulant therapy. No routine laboratory monitoring is required. A somewhat unexpected, but exciting observation involving the new anticoagulants, is the uniform reduction in intracranial bleeding by one-half compared with warfarin. The potential limitations of the new anticoagulants include uncertainty regarding assessment of drug levels, safe drug levels for major surgery, management of major bleeding, renal dependence, multiple dose regimens, adherence in the absence of frequent monitoring and unknown, rare side effects that were not captured in the trials. This review should clarify some of these concerns.
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Affiliation(s)
- S Schulman
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada; Karolinska Institutet, Stockholm, Sweden
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Engelbrecht S, Wood EM, Cole-Sinclair MF. Clinical transfusion practice update: haemovigilance, complications, patient blood management and national standards. Med J Aust 2013; 199:397-401. [PMID: 24033212 DOI: 10.5694/mja13.10070] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 07/29/2013] [Indexed: 11/17/2022]
Abstract
Blood transfusion is not without risk. Although the risks of HIV and hepatitis transmission have diminished, haemovigilance programs highlight that other significant transfusion hazards remain. Sepsis from bacterial contamination is the most common residual infectious hazard in developed countries, and events due to clerical error are problematic. Unnecessary transfusions should be avoided. New national guidelines on patient blood management (PBM) emphasise holistic approaches, including strategies to reduce transfusion requirements. Perioperative PBM should incorporate preoperative haemoglobin and medication optimisation, intraoperative blood conservation, and consideration of restrictive postoperative transfusion and cell-salvage techniques. When massive transfusion is required, hospitals should implement massive transfusion protocols. These protocols reduce mortality, improve communication and facilitate adequate provision of blood products. They should include multidisciplinary team involvement and guidelines for use of blood components and adjunctive agents. Although fresh frozen plasma to red blood cell and platelet to red blood cell ratios of ≥ 1 : 2 appear to reduce mortality in trauma patients who receive massive transfusion, there is insufficient evidence to recommend specific ratios. Systematic reviews have found no significant benefit of recombinant activated factor VII in critical bleeding, and an increase in thromboembolic events; specialist haematology advice is therefore recommended when considering use of this agent. The National Safety and Quality Health Service Standards address use of blood and blood products, and provide important transfusion principles for adoption by all clinicians. Storage of red cells in additive solution results in changes, known as the "storage lesion", and studies to determine the clinical effect of the age of blood at transfusion are ongoing.
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Affiliation(s)
- Sunelle Engelbrecht
- Department of Research and Development, Australian Red Cross Blood Service, Melbourne, VIC, Australia.
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Samama MM. Coagulation Assays in Patients with New Oral Anticoagulants (NOACs): Why? When? Drug Dev Res 2013. [DOI: 10.1002/ddr.21118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Meyer Michel Samama
- Cochin-Broca-Hôtel Dieu University Hospital; Department of Hematology; Paris France
- Biomnis Laboratory; Ivry-sur-Seine France
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Gouin-Thibault I, Flaujac C, Delavenne X, Quenet S, Horellou MH, Laporte S, Siguret V, Lecompte T. Assessment of apixaban plasma levels by laboratory tests: suitability of three anti-Xa assays. A multicentre French GEHT study. Thromb Haemost 2013; 111:240-8. [PMID: 24172843 DOI: 10.1160/th13-06-0470] [Citation(s) in RCA: 92] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 09/19/2013] [Indexed: 11/05/2022]
Abstract
While laboratory monitoring is not required in patients treated with apixaban, a direct factor-Xa inhibitor, assessment of its concentration is useful in some critical situations. However, few data are available on its effect on coagulation tests and on the suitability of anti-Xa assays for its quantification. It was the objective of this study to identify laboratory tests suitable for apixaban concentration assessment. Coagulation tests - PT and aPTT- and anti-Xa assays were performed in apixaban-spiked plasma samples. To evaluate the sensitivity of PT and aPTT to apixaban, we conducted a first monocenter part, with a wide range of concentrations (50-1,000 ng/ml), a large panel of reagents (20 reagents), and two coagulometers (STAR®, Stago and ACL TOP®, IL), and a second multicenter part involving 13 laboratories using either a common PT reagent (RecombiPlastin2G®) or the local PT and aPTT reagents. In the multicentre part, five blinded apixaban-spiked plasma samples (0/100/200/400/800 ng/ml - checked by HPLC-MS/MS) were used; apixaban concentrations were measured with three anti-Xa assays, apixaban calibrators and controls (Stago). PT and aPTT tests using a large panel of reagents displayed a low sensitivity to a wide range of apixaban concentrations. The concentrations to double PT ranged from 400 to >1,000 ng/ml with the 10 reagents. With the three anti-Xa assays, inter-laboratory precision and accuracy were below 11% and 12%, respectively. In conclusion, whereas PT and aPTT tests were not sensitive enough to detect apixaban, the three anti-Xa assays tested using lyophilised apixaban calibrators and controls allowed to reliably quantify a wide range of apixaban concentrations.
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Affiliation(s)
- Isabelle Gouin-Thibault
- Isabelle Gouin Thibault, Laboratoire d'Hématologie, Groupe Hospitalier Cochin-Hôtel Dieu, 27, rue du Faubourg Saint-Jacques, 75 679 Paris Cedex 14, France, Tel.: +33 1 42 34 84 47, Fax: +33 1 58 41 19 97, E-mail:
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Measuring or Monitoring of Novel Anticoagulants: Which Laboratory Test to Request? CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2013. [DOI: 10.1007/s40138-013-0029-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Imberti D, Benedetti R. Practical Management of Rivaroxaban for the Treatment of Venous Thromboembolism. Clin Appl Thromb Hemost 2013; 21:309-18. [DOI: 10.1177/1076029613503397] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Traditional anticoagulants, such as low-molecular-weight heparin and vitamin K antagonists, have been the mainstay for the treatment of venous thromboembolism (VTE) in the hospital setting and after discharge. These anticoagulants are effective but are associated with some limitations that may lead to their underuse. Based on the results of the EINSTEIN clinical trial program, the oral, direct factor Xa inhibitor rivaroxaban is approved for the treatment of acute deep vein thrombosis (DVT) and pulmonary embolism (PE) and for the prevention of recurrent VTE. The single-drug approach with rivaroxaban is now available in both the hospital and the outpatient settings and may overcome some of the limitations of traditional agents. This review provides hospital physicians with an overview of the practical management of rivaroxaban and a critical evaluation of its use for the treatment of DVT and PE, including in specific clinical settings and special patient populations.
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Affiliation(s)
- Davide Imberti
- Medical Department, Internal Medicine Unit, Hospital of Piacenza, Haemostasis and Thrombosis Center, Piacenza, Italy
| | - Raffaella Benedetti
- Medical Department, Internal Medicine Unit, Hospital of Piacenza, Haemostasis and Thrombosis Center, Piacenza, Italy
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Abstract
New, target specific, oral anticoagulants have been shown to be safe and effective in prevention and treatment of thromboembolism without laboratory monitoring. However, clinical use of the drugs dabigatran, rivaroxaban, and apixaban requires laboratory measurement of their anticoagulant effect in specific clinical situations. This paper reviews the data available on use of screening and specialized testing to measure the anticoagulant effect and drug levels in patients prescribed these medications. Their effect on other coagulation assays is also reviewed.
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Affiliation(s)
- Barbara A Konkle
- Puget Sound Blood Center, University of Washington School of Medicine, Seattle, WA, USA.
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Di Minno G, Ricciardi E, Scalera A. Laboratory tests during direct oral anticoagulant treatment? No. Intern Emerg Med 2013; 8:367-70. [PMID: 23686689 DOI: 10.1007/s11739-013-0948-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2013] [Accepted: 04/20/2013] [Indexed: 11/24/2022]
Affiliation(s)
- Giovanni Di Minno
- Dipartimento di Medicina Clinica e Chirurgia, Clinica Medica, Università degli Studi di Napoli Federico II Napoli, Via S. Pansini 5, Naples, Italy.
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Samama MM, Contant G, Spiro TE, Perzborn E, Le Flem L, Guinet C, Gourmelin Y, Rohde G, Martinoli JL. Laboratory assessment of rivaroxaban: a review. Thromb J 2013; 11:11. [PMID: 23822763 PMCID: PMC3726412 DOI: 10.1186/1477-9560-11-11] [Citation(s) in RCA: 118] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 06/24/2013] [Indexed: 11/15/2022] Open
Abstract
Research into new anticoagulants for preventing and treating thromboembolic disorders has focused on targeting single enzymes in the coagulation cascade, particularly Factor Xa and thrombin, inhibition of which greatly decreases thrombin generation. Based on the results of phase III clinical trials, rivaroxaban, a direct Factor Xa inhibitor, has been approved in many countries for the management of several thromboembolic disorders. Owing to its predictable pharmacokinetic and pharmacodynamic characteristics, fixed-dose regimens are used without the need for routine coagulation monitoring. In situations where assessment of rivaroxaban exposure may be helpful, anti-Factor Xa chromogenic assays (in tandem with standard calibration curves generated with the use of rivaroxaban calibrators and controls) could be used. It is important to note that test results will be affected by the timing of blood sampling after rivaroxaban intake. In addition, the anti-Factor Xa method measures the drug concentration and not the intensity of the drug’s anticoagulant activity, and a higher than expected rivaroxaban plasma level does not necessarily indicate an increased risk of bleeding complications. Therefore, clinicians need to consider test results in relation to the pharmacokinetics of rivaroxaban and other patient risk factors associated with bleeding.
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Affiliation(s)
- Meyer Michel Samama
- Hôtel-Dieu University Hospital, 1 place du Paris Notre-Dame, Paris 75004, 4ème, Paris, France.
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Abstract
Orally active small molecules that selectively and specifically inhibit coagulation serine proteases have been developed for clinical use. Dabigatran etexilate, rivaroxaban and apixaban are given at fixed doses and do not require monitoring. In most circumstances, these drugs have predictable bioavailability, pharmacokinetic effects, and pharmacodynamic effects. However, there will be clinical circumstances when assessment of the anticoagulant effect of these drugs will be required. The effect of these drugs on laboratory tests has been determined in vitro by spiking normal samples with a known concentration of active compound, or ex vivo by using plasma samples from volunteers and patients. Data on the sensitivity of different reagents are now available, and so guidance as to the effect and interpretation of a test result is now possible. Laboratories should be aware of the sensitivity of their own assays to each drug. This may be achieved by using appropriate calibrated plasma samples.
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Affiliation(s)
- T Baglin
- Department of Haematology, Addenbrooke's Hospital, Cambridge University Hospitals NHS Trust, Cambridge, UK.
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Smythe MA, Fanikos J, Gulseth MP, Wittkowsky AK, Spinler SA, Dager WE, Nutescu EA. Rivaroxaban: practical considerations for ensuring safety and efficacy. Pharmacotherapy 2013; 33:1223-45. [PMID: 23712587 DOI: 10.1002/phar.1289] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Rivaroxaban is the first agent available within a new class of anticoagulants called direct factor Xa inhibitors. Rivaroxaban is approved for use in the United States for the prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, for the prevention of deep vein thrombosis in patients undergoing total hip replacement and total knee replacement, for the treatment of deep vein thrombosis and pulmonary embolism, and for the reduction in risk of recurrence of deep vein thrombosis and pulmonary embolism (with additional indications under review). Rivaroxaban dose and frequency of administration vary depending on the indication. As of result of predictable pharmacokinetics and pharmacodynamics, a fixed dose of rivaroxaban is administered without routine coagulation testing. Rivaroxaban has a short half-life, undergoes a dual mode of elimination (hepatic and renal), and is a substrate for P-glycoprotein. Rivaroxaban has a lower potential for drug interactions compared with warfarin. Despite the advantages of a once/day fixed-dose oral agent, in many clinical situations limited evidence is available to guide optimal management of rivaroxaban therapy. In this article, we review the available evidence and provide recommendations where possible for such situations including the desire to monitor the anticoagulation intensity, use in special patient populations, managing drug interactions, and transitioning across anticoagulant agents. Potential strategies for reversing rivaroxaban's anticoagulant effect are reviewed. Health systems will need to perform a systematic safety evaluation and ensure that numerous hospital policies related to anticoagulation are updated to include rivaroxaban. A comprehensive approach to education is needed for clinicians, patients, and technical support personnel involved in patient interactions to ensure safe use.
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Affiliation(s)
- Maureen A Smythe
- Department of Pharmacy Practice, Wayne State University, Detroit, Michigan; Department of Pharmaceutical Services, Beaumont Hospital, Royal Oak, Michigan
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Abstract
New oral anticoagulants are given at fixed daily doses without laboratory dose adjustment for prevention of venous thromboembolism following elective total knee- and hip replacement, for treatment and prevention of recurrent events of acute venous thromboembolism, and for prevention of embolic events in atrial fibrillation. However, it may be necessary to determine the anticoagulant effect of new oral anticoagulants in special patient populations such as in elderly, for renal impairment, before operation, bleeding or thrombotic episodes and to monitor self-compliance. Oral factor Xa and oral thrombin inhibitors influence dose dependently global and specific coagulation assays. Standardization of assays is currently undertaken. Determination of the new oral anticoagulants in serum samples would facilitate blood sampling and analysis from samples taken and stored for creatinine or other biochemical parameters. Point of care methods from plasma or urine for the new oral anticoagulants would improve patient care. First data demonstrate the feasibility of such assays in urine.
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