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Pozzi A, Lucà F, Gelsomino S, Abrignani MG, Giubilato S, Di Fusco SA, Rao CM, Cornara S, Caretta G, Ceravolo R, Parrini I, Geraci G, Riccio C, Grimaldi M, Colivicchi F, Oliva F, Gulizia MM. Coagulation Tests and Reversal Agents in Patients Treated with Oral Anticoagulants: The Challenging Scenarios of Life-Threatening Bleeding and Unplanned Invasive Procedures. J Clin Med 2024; 13:2451. [PMID: 38730979 PMCID: PMC11084691 DOI: 10.3390/jcm13092451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Revised: 02/22/2024] [Accepted: 04/07/2024] [Indexed: 05/13/2024] Open
Abstract
In clinical practice, the number of patients treated with direct oral anticoagulants (DOACs) has consistently increased over the years. Since anticoagulant therapy has been associated with an annual incidence of major bleeding (MB) events of approximately 2% to 3.5%, it is of paramount importance to understand how to manage anticoagulated patients with major or life-threatening bleeding. A considerable number of these patients' conditions necessitate hospitalization, and the administration of reversal agents may be imperative to manage and control bleeding episodes effectively. Importantly, effective strategies for reversing the anticoagulant effects of DOACs have been well recognized. Specifically, idarucizumab has obtained regulatory approval for the reversal of dabigatran, and andexanet alfa has recently been approved for reversing the effects of apixaban or rivaroxaban in patients experiencing life-threatening or uncontrolled bleeding events. Moreover, continuous endeavors are being made to develop supplementary reversal agents. In emergency scenarios where specific reversal agents might not be accessible, non-specific hemostatic agents such as prothrombin complex concentrate can be utilized to neutralize the anticoagulant effects of DOACs. However, it is paramount to emphasize that specific reversal agents, characterized by their efficacy and safety, should be the preferred choice when suitable. Moreover, it is worth noting that adherence to the guidelines for the reversal agents is poor, and there is a notable gap between international recommendations and actual clinical practices in this regard. This narrative review aims to provide physicians with a practical approach to managing specific reversal agents.
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Affiliation(s)
- Andrea Pozzi
- Cardiology Division Valduce Hospital, 22100 Como, Italy;
| | - Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy (C.M.R.)
| | - Sandro Gelsomino
- Cardiothoracic Department, Maastricht University Hospital, 6229 HX Maastricht, The Netherlands
| | | | - Simona Giubilato
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy;
| | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, GOM, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy (C.M.R.)
| | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy;
| | - Giorgio Caretta
- Sant’Andrea Hospital, ASL 5 Regione Liguria, 19124 La Spezia, Italy;
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 97100 Lamezia, Italy;
| | - Iris Parrini
- Cardiology Department, Mauriziano Hospital, 10128 Torino, Italy;
| | - Giovanna Geraci
- Cardiology Unit, S. Antonio Abate Hospital, ASP Trapani, 91016 Erice, Italy;
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy;
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy;
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy; (S.A.D.F.); (F.C.)
| | - Fabrizio Oliva
- Cardiology Unit, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milano, Italy;
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Heubner L, Oertel R, Tiebel O, Mehlig-Warnecke N, Beyer-Westendorf J, Mirus M, Roessler M, Renner B, Spieth PM. Monitoring of Argatroban in Critically Ill Patients: A Prospective Study Comparing Activated Partial Thromboplastin Time, Point-of-Care Viscoelastic Testing with Ecarin Clotting Time and Diluted Thrombin Time to Mass Spectrometry. Anesthesiology 2024; 140:261-271. [PMID: 37787760 DOI: 10.1097/aln.0000000000004787] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
BACKGROUND The direct thrombin inhibitor argatroban is indicated for the treatment of heparin-induced thrombocytopenia II, but it is also used off-label to treat critically ill patients presenting with heparin resistance, severe antithrombin deficiency, or hypercoagulability. Direct drug monitoring is not routinely available, and argatroban dosing is mainly based on global coagulation assays such as activated partial thromboplastin time (PTT) or diluted thrombin time (TT), both of which have limitations in patients with hypercoagulability. METHODS Blood samples were obtained from critically ill patients treated with argatroban. Activated PTT and diluted TT were measured with a STA R Max3 analyzer (STAGO Deutschland GmbH, Germany) using an argatroban-calibrated kit. Ecarin clotting time was measured using a point-of-care viscoelastic test device. Liquid chromatography with tandem mass spectrometry was performed using a reversed-phase column, a solvent gradient, and an API4000 mass spectrometer with electrospray. Correlation was described using Pearson correlation coefficient r and Bayesian multilevel regression to estimate relationships between outcomes and covariates. RESULTS From June 2021 to March 2022, 205 blood samples from 22 patients were analyzed, allowing for 195 activated PTT-liquid chromatography with tandem mass spectrometry comparisons, 153 ecarin clotting time-liquid chromatography with tandem mass spectrometry comparison, and 105 diluted TT-liquid chromatography with tandem mass spectrometry comparisons. Compared to liquid chromatography with tandem mass spectrometry, performance of argatroban quantification was best for diluted TT (r = 0.91), followed by ecarin clotting time (r = 0.58) and activated PTT (r = 0.48). Regression analysis revealed that patients with sepsis were more prone to argatroban overdosing (coefficient, 4.194; 95% credible interval, 2.220 to 6.792). CONCLUSIONS Although activated PTT monitoring of argatroban is the most commonly used test, in critically ill patients, diluted TT provides more precise measurements. Alternately, point-of-care viscoelastic ecarin clotting time also provides guidance for argatroban dosing to identify overdosing if available. The data also suggested that patients with sepsis are at greater risk for argatroban overdosing. EDITOR’S PERSPECTIVE
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Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Reinhard Oertel
- Institute of Clinical Pharmacology, Faculty of Medicine, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Oliver Tiebel
- Institute of Clinical Chemistry, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Nicole Mehlig-Warnecke
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Jan Beyer-Westendorf
- Division of Hematology and Hemostasis, Department of Medicine I Thrombosis Research, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Martin Mirus
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus", Technische Universität Dresden, Dresden, Germany
| | - Martin Roessler
- BARMER Institut für Gesundheitssystemforschung, Berlin, Germany
| | - Bertold Renner
- Institute of Clinical Pharmacology, Faculty of Medicine, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
| | - Peter Markus Spieth
- Department of Anesthesiology and Intensive Care Medicine, University Hospital "Carl Gustav Carus," Technische Universität Dresden, Dresden, Germany
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3
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Lucà F, Oliva F, Abrignani MG, Di Fusco SA, Parrini I, Canale ML, Giubilato S, Cornara S, Nesti M, Rao CM, Pozzi A, Binaghi G, Maloberti A, Ceravolo R, Bisceglia I, Rossini R, Temporelli PL, Amico AF, Calvanese R, Gelsomino S, Riccio C, Grimaldi M, Colivicchi F, Gulizia MM. Management of Patients Treated with Direct Oral Anticoagulants in Clinical Practice and Challenging Scenarios. J Clin Med 2023; 12:5955. [PMID: 37762897 PMCID: PMC10531873 DOI: 10.3390/jcm12185955] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
It is well established that direct oral anticoagulants (DOACs) are the cornerstone of anticoagulant strategy in atrial fibrillation (AF) and venous thromboembolism (VTE) and should be preferred over vitamin K antagonists (VKAs) since they are superior or non-inferior to VKAs in reducing thromboembolic risk and are associated with a lower risk of intracranial hemorrhage (IH). In addition, many factors, such as fewer pharmacokinetic interactions and less need for monitoring, contribute to the favor of this therapeutic strategy. Although DOACs represent a more suitable option, several issues should be considered in clinical practice, including drug-drug interactions (DDIs), switching to other antithrombotic therapies, preprocedural and postprocedural periods, and the use in patients with chronic renal and liver failure and in those with cancer. Furthermore, adherence to DOACs appears to remain suboptimal. This narrative review aims to provide a practical guide for DOAC prescription and address challenging scenarios.
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Affiliation(s)
- Fabiana Lucà
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy
| | - Fabrizio Oliva
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | | | - Stefania Angela Di Fusco
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
| | - Iris Parrini
- Cardiology Department, Ospedale Mauriziano, 10128 Turin, Italy
| | - Maria Laura Canale
- Cardiology Department, Nuovo Ospedale Versilia Lido di Camaiore Lucca, 55049 Camaiore, Italy
| | - Simona Giubilato
- Cardiology Department, Cannizzaro Hospital, 95126 Catania, Italy
| | - Stefano Cornara
- Arrhytmia Unit, Division of Cardiology, Ospedale San Paolo, Azienda Sanitaria Locale 2, 17100 Savona, Italy
| | | | - Carmelo Massimiliano Rao
- Cardiology Department, Grande Ospedale Metropolitano, AO Bianchi Melacrino Morelli, 89129 Reggio Calabria, Italy
| | - Andrea Pozzi
- Cardiology Division Valduce Hospital, 22100 Como, Italy
| | - Giulio Binaghi
- Department of Cardiology, Azienda Ospedaliera Brotzu, 09047 Cagliari, Italy
| | - Alessandro Maloberti
- Cardiology Department De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy
| | - Roberto Ceravolo
- Cardiology Unit, Giovanni Paolo II Hospital, 88046 Lamezia, Italy
| | - Irma Bisceglia
- Integrated Cardiology Services, Department of Cardio-Thoracic-Vascular, Azienda Ospedaliera San Camillo Forlanini, 00152 Rome, Italy
| | - Roberta Rossini
- Cardiology Unit, Ospedale Santa Croce e Carle, 12100 Cuneo, Italy;
| | - Pier Luigi Temporelli
- Division of Cardiac Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS, 28010 Gattico-Veruno, Italy
| | | | | | - Sandro Gelsomino
- Cardiovascular Research Institute, Maastricht University, 6211 LK Maastricht, The Netherlands
| | - Carmine Riccio
- Cardiovascular Department, Sant’Anna e San Sebastiano Hospital, 81100 Caserta, Italy
| | - Massimo Grimaldi
- Department of Cardiology, General Regional Hospital “F. Miulli”, 70021 Bari, Italy
| | - Furio Colivicchi
- Clinical and Rehabilitation Cardiology Department, San Filippo Neri Hospital, ASL Roma 1, 00135 Roma, Italy
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4
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Gosselin RC. Ecarin-Based Methods for Measuring Thrombin Inhibitors. Methods Mol Biol 2023; 2663:355-367. [PMID: 37204723 DOI: 10.1007/978-1-0716-3175-1_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Ecarin is a venom from the saw-scaled viper, Echis carinatus, which catalyzes prothrombin into meizothrombin. This venom is used in several hemostasis laboratory assays, including ecarin clotting time (ECT) and ecarin chromogenic assays (ECA). The use of these ecarin-based assays was first implemented as a tool for monitoring the infusion of a direct thrombin inhibitor, hirudin. Subsequently, this method has been more recently employed for measuring either the pharmacodynamic or pharmacokinetic properties of the oral direct thrombin inhibitor, dabigatran. In this chapter, the procedure for performing manual ECT and automated and manual ECA for measuring thrombin inhibitors is described.
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Affiliation(s)
- Robert C Gosselin
- Thrombosis & Hemostasis Center, University of California, Davis Health System, Sacramento, CA, USA
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5
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Davidson S. Assays to Monitor Bivalirudin. Methods Mol Biol 2023; 2663:369-380. [PMID: 37204724 DOI: 10.1007/978-1-0716-3175-1_24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Bivalirudin (Angiomax, Angiox) is a parenteral direct thrombin inhibitor (DTI) that is used for patients with heparin-induced thrombocytopenia (HIT), where heparin cannot be used due to the risk of thrombosis. Bivalirudin is also licensed for use in cardiology procedures (e.g., percutaneous transluminal coronary angioplasty; PTCA). Bivalirudin is a synthetic analogue of hirudin found in the saliva of the medicinal leech and has a relatively short half-life of ~25 min. Several assays can be used to monitor bivalirudin; these include the activated partial thromboplastin time (APTT), activated clotting time (ACT), ecarin clotting time (ECT), an ecarin-based chromogenic assay, thrombin time (TT), the dilute TT, and the prothrombinase-induced clotting time (PiCT). Drug concentrations can also be measured using liquid chromatography tandem mass spectrometry (LC/MS) and clotting or chromogenic-based assays with specific drug calibrators and controls.
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Affiliation(s)
- Simon Davidson
- Division of Medicine, University College London, London, UK
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Heubner L, Mirus M, Vicent O, Güldner A, Tiebel O, Beyer-Westendorf J, Fries D, Spieth PM. Point of care coagulation management in anesthesiology and critical care. Minerva Anestesiol 2022; 88:615-628. [PMID: 35416466 DOI: 10.23736/s0375-9393.22.16380-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Point of care (POC) devices are increasingly used in the ICU and in anesthesia. Besides POC-devices for blood gas analysis, several devices are available for coagulation measurements. Although basic principles for thromboelastographic measurements are not novel, some promising developments were made during the last decade improving both user-friendliness and measurement reliability. For instance, POC measurements of activated clotting time (ACT) for heparin monitoring is still regarded as standard-of-care in cardiac interventions and surgery. In the field of anesthesia and intensive care medicine, POC-devices for thromboelastographic and platelet aggregation measurements are widely used. Their impact in case of bleeding and patient blood management for cardiothoracic and trauma surgery is well known. Moreover, there are promising concepts for anticoagulation monitoring including new oral anticoagulant drugs. Coagulation POC-devices may also identify patients at specific risk for thromboembolic events quickly. On the other hand, benefits of POC-devices need to be balanced against limitations, which include technical restrictions and operator related errors, mainly affecting reproducibility and interpretation of results. Therefore, it is recommendable to consider results of POC-coagulation testing in comparison to standard laboratory tests (SLT). Nevertheless, in urgent or emergency situations POC results enable fast decision making to optimize patient care.
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Affiliation(s)
- Lars Heubner
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany. -
| | - Martin Mirus
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Oliver Vicent
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Andreas Güldner
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Oliver Tiebel
- Institute of Clinical Chemistry, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Division of Hematology and Hemostasis, Department of Medicine I, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Dietmar Fries
- Department for General and Surgical Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
| | - Peter M Spieth
- Department of Anesthesiology and Critical Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany
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7
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Jafari Z, Bandehpour M, Gheflat S, Mohammadi N, Kazemi B. Cloning, Expression and Purification of Full-length Recombinant Ecarin and Comparing Its Expression and Function with Its Truncated Form. IRANIAN JOURNAL OF PHARMACEUTICAL RESEARCH 2022; 21:e123791. [PMID: 35765508 PMCID: PMC9191215 DOI: 10.5812/ijpr.123791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 11/05/2021] [Accepted: 11/07/2021] [Indexed: 11/16/2022]
Abstract
: Ecarin is a metalloproteinase found in snake venom (SVMP) with an important role in coagulation and control of hemostasis. It can specifically produce active-thrombin from prethrombin-2 and does not differentiate between normal and abnormal prothrombin. It is used in diagnostic tests and to evaluate the treatment process of many diseases. There are many drawbacks associated with separating these compounds from snake venom. Therefore, in this study, full-length recombinant Ecarin (r-Ecarin) was cloned, expressed, and purified in eukaryotic host cells. To determine the most effective form of the enzyme, r-Ecarin was compared with the recombinant truncated form, which has only the metalloprotease domain of the protein (r-Ecamet) in terms of function and expression. Briefly, A DNA construct composed of sequence-encoding Ecarin was designed and cloned into pCAGGS expression vector and, subsequently, expressed in Chinese Hamster Ovary (CHO) cells. To identify the enzymatic activity of expressed protein, a bioactivity assay was performed. Blood coagulation time and expression levels of r-Ecarin and r-Ecamet proteins were compared. Also, a histopathological assessment was carried out on the liver of mice treated with these proteins. Comparison of r-Ecarin and r-Ecamet expression pattern demonstrated that full-length Ecarin expression has at least 2-fold higher expression in eukaryotic cells. Determination of r-Ecarin function proved that this protein is capable of prothrombin cleavage and producing thrombin. Comparison of PT test results between the r-Ecarin and r-Ecamet showed that there is a significant difference in the activity of the two enzymes and the full-length protein coagulates the blood in less time.
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Affiliation(s)
- Zohreh Jafari
- Department of Medical Biotechnology, School of Advanced Technologies in Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mojgan Bandehpour
- Cellular and Molecular Biology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Shivasadat Gheflat
- Cellular and Molecular Biology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Nasrin Mohammadi
- Department of Biology, Science and Research Branch, Islamic Azad University, Tehran, Iran
| | - Bahram Kazemi
- Department of Medical Biotechnology, School of Advanced Technologies in Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Cellular and Molecular Biology Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Corresponding Author: Department of Medical Biotechnology, School of Advanced Technologies in Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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8
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Abstract
Snake venoms have evolved primarily to immobilize and kill prey, and consequently, they contain some of the most potent natural toxins. Part of that armory is a range of hemotoxic components that affect every area of hemostasis, which we have harnessed to great effect in the study and diagnosis of hemostatic disorders. The most widely used are those that affect coagulation, such as thrombin-like enzymes unaffected by heparin and direct thrombin inhibitors, which can help confirm or dispute their presence in plasma. The liquid gold of coagulation activators is Russell's viper venom, since it contains activators of factor X and factor V. It is used in a range of clotting-based assays, such as assessment of factor X and factor V deficiencies, protein C and protein S deficiencies, activated protein C resistance, and probably the most important test for lupus anticoagulants, the dilute Russell's viper venom time. Activators of prothrombin, such as oscutarin C from Coastal Taipan venom and ecarin from saw-scaled viper venom, are employed in prothrombin activity assays and lupus anticoagulant detection, and ecarin has a valuable role in quantitative assays of direct thrombin inhibitors. Snake venoms affecting primary hemostasis include botrocetin from the jararaca, which can be used to assay von Willebrand factor activity, and convulxin from the cascavel, which can be used to detect deficiency of the platelet collagen receptor, glycoprotein VI. This article takes the reader to every area of the diagnostic hemostasis laboratory to appreciate the myriad applications of snake venoms available in diagnostic practice.
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Affiliation(s)
- Gary William Moore
- Department of Haematology, Specialist Haemostasis Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom.,Faculty of Science and Technology, Middlesex University London, London, United Kingdom
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9
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Dunois C. Laboratory Monitoring of Direct Oral Anticoagulants (DOACs). Biomedicines 2021; 9:biomedicines9050445. [PMID: 33919121 PMCID: PMC8143174 DOI: 10.3390/biomedicines9050445] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/08/2021] [Accepted: 04/13/2021] [Indexed: 11/16/2022] Open
Abstract
The introduction of direct oral anticoagulants (DOACs), such as dabigatran, rivaroxaban, apixaban, edoxaban, and betrixaban, provides safe and effective alternative to previous anticoagulant therapies. DOACs directly, selectively, and reversibly inhibit factors IIa or Xa. The coagulation effect follows the plasma concentration-time profile of the respective anticoagulant. The short half-life of a DOAC constrains the daily oral intake. Because DOACs have predictable pharmacokinetic and pharmacodynamic responses at a fixed dose, they do not require monitoring. However in specific clinical situations and for particular patient populations, testing may be helpful for patient management. The effect of DOACs on the screening coagulation assays such as prothrombin time (PT), activated partial thromboplastin time (APTT), and thrombin time (TT) is directly linked to reagent composition, and clotting time can be different from reagent to reagent, depending on the DOAC's reagent sensitivity. Liquid chromatography-mass spectrometry (LC-MS/MS) is considered the gold standard method for DOAC measurement, but it is time consuming and requires expensive equipment. The general consensus for the assessment of a DOAC is clotting or chromogenic assays using specific standard calibrators and controls. This review provides a short summary of DOAC properties and an update on laboratory methods for measuring DOACs.
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Affiliation(s)
- Claire Dunois
- HYPHEN BioMed, Sysmex Group, 95000 Neuville sur Oise, France
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10
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Overview and Practical Application of Coagulation Assays in Managing Anticoagulation with Direct Oral Anticoagulants (DOACs). ACTA ACUST UNITED AC 2020. [DOI: 10.1007/s40495-020-00232-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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11
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Johnson LA, de Jersey J, Masci PP, Zhao KN, Bennett NC, Dimeski G, Grant M, Lavin MF. Progress Curve Analysis of the one stage chromogenic assay for ecarin. Anal Biochem 2020; 608:113907. [PMID: 32814078 DOI: 10.1016/j.ab.2020.113907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 11/26/2022]
Abstract
Snake venom prothrombin activators such as Ecarin are readily assayed by continuous spectrophotometric monitoring of p-nitroaniline production in a one step assay containing prothrombin and a p-nitroanilide peptide substrate for thrombin. The coupled reactions result in accelerating p-nitroaniline (pNA) production over the course of the assay giving non-linear progress curves, from which initial velocities are not readily obtained. Most studies therefore resort to approximate estimates of activity, based on the absorbance reached at an arbitrary time. A simple kinetic analysis of the coupled reactions shows that the early points of such curves should be fitted by second order polynomials, representing the accelerating reaction rate in μmol pNA/min/min. The first derivative of the polynomial then gives the increasing velocity of pNA production in μmol pNA/min over the time course of the assay. We demonstrate here that, with the substrate S2238, these rates can be converted to absolute thrombin concentrations using the Michaelis-Menten equation, substituted with values for kcat and Km. These thrombin concentrations increase linearly over the time course of the assay allowing the activity to be expressed in units, defined as μmol product/min, most commonly used to report enzyme activity.
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Affiliation(s)
- Lambro A Johnson
- Centre for Kidney Disease Research-Venomics Research, School of Medicine, The University of Queensland, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia.
| | - John de Jersey
- School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, QLD, 4078, Australia
| | - Paul P Masci
- Centre for Kidney Disease Research-Venomics Research, School of Medicine, The University of Queensland, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
| | - Kong-Nan Zhao
- Centre for Kidney Disease Research-Venomics Research, School of Medicine, The University of Queensland, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia; Centre for Clinical Research, The University of Queensland, Royal Brisbane & Women's Hospital Campus, Herston, Brisbane, QLD, 4029, Australia
| | - Nigel C Bennett
- Centre for Kidney Disease Research-Venomics Research, School of Medicine, The University of Queensland, Translational Research Institute, 37 Kent Street, Woolloongabba, QLD, 4102, Australia
| | - Goce Dimeski
- Chemical Pathology, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, Brisbane, QLD, 4102, Australia; School of Chemistry and Molecular Biosciences, The University of Queensland, Brisbane, QLD, 4078, Australia
| | - Michael Grant
- Q-Sera Pty Ltd, 278 Collins St, Melbourne, Vic, 3000, Australia
| | - Martin F Lavin
- Centre for Clinical Research, The University of Queensland, Royal Brisbane & Women's Hospital Campus, Herston, Brisbane, QLD, 4029, Australia
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12
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Gosselin RC, Douxfils J. Ecarin based coagulation testing. Am J Hematol 2020; 95:863-869. [PMID: 32350907 DOI: 10.1002/ajh.25852] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/06/2020] [Accepted: 04/08/2020] [Indexed: 12/15/2022]
Abstract
Ecarin is derived from venom of Echis carinatus, and will activate prothrombin into meizothrombin which will then cleave fibrinogen to result in clot formation. Ecarin based testing has been described for decades, but these assays were typically restricted to reference or speciality coagulation laboratories. This test was initially described for the assessment of direct thrombin inhibitors (eg, bivalirudin lepirudin, or argatroban) and was not affected by heparins or heparinoids. Ecarin based assays were rarely used for anticoagulation monitoring until the emergence of the direct oral thrombin inhibitor dabigatran etexilate in 2010. As this test was mentioned in the prescribing information for dabigatran etexilate, there was increased interest for use by clinical laboratories as the preferred method for assessing the anticoagulant effect of this drug. The purpose of this document is to review the current status of ecarin based assays for assessing dabigatran. This is with the understanding that these methods can also be exploited for determining the anticoagulation effect of parenteral direct thrombin inhibitors, such as argatroban and bivalirudin.
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Affiliation(s)
- Robert C. Gosselin
- Davis Health System, Thrombosis and Hemostasis CenterUniversity of California Sacramento California
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13
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Heparin-Induced Thrombocytopenia. Platelets 2019. [DOI: 10.1016/b978-0-12-813456-6.00041-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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14
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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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Comuth WJ, Haase AM, Henriksen LØ, Malczynski J, van de Kerkhof D, Münster AMB. Cholestatic liver injury as a side-effect of dabigatran and the use of coagulation tests in dabigatran intoxication and after reversal by idarucizumab in bleeding and sepsis. Scandinavian Journal of Clinical and Laboratory Investigation 2017; 78:1-5. [PMID: 29148292 DOI: 10.1080/00365513.2017.1402127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Idarucizumab, an antidote specific for dabigatran, became available recently. Dabigatran is not associated with increased risk of hepatotoxicity in comparison with warfarin, but it is seen as a rare side-effect. Cases of cholestatic liver injury due to dabigatran have not been reported previously. We present a case of severe gastro-intestinal bleeding with underlying dabigatran intoxication in a patient with renal failure and the effect of reversal of dabigatran using idaruzicumab on coagulation assays. International normalized ratio (INR) and activated partial thromboplastin time (APTT) results were elevated in a setting of sepsis, possibly due to liver failure. INR and APTT can be elevated if sepsis is complicated by disseminated intravascular coagulation (DIC) or liver failure, making it challenging to determine dabigatrans contribution to their prolongation. A rebound effect after administration of idarucizumab and slow elimination of dabigatran due to reduced kidney function could be detected using the Hemoclot® diluted thrombin time (dTT) in this situation, in contrast to with non-dilutional assays. Before admission, cholestatic liver injury started shortly after initiation of dabigatran etexilate therapy. As no other cause was found, this liver injury was likely to be drug-induced. Bleeding cessated promptly after administration of idarucizumab in dabigatran intoxication. In conclusion, the anticoagulant effect of dabigatran can be measured by Hemoclot® dTT in sepsis and cholestatic liver injury was seen as a possible rare side-effect of dabigatran treatment.
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Affiliation(s)
- Willemijn J Comuth
- a Department of Clinical Biochemistry , Hospital Unit West, Herning and Holstebro , Denmark.,b Department of Cardiology , Hospital Unit West , Herning , Denmark.,c Faculty of Health , Institute of Clinical Medicine, Aarhus University , Aarhus , Denmark
| | - Anne-Mette Haase
- d Department of Medicine , Hospital Unit West , Herning , Denmark
| | - Linda Ø Henriksen
- a Department of Clinical Biochemistry , Hospital Unit West, Herning and Holstebro , Denmark
| | - Jerzy Malczynski
- b Department of Cardiology , Hospital Unit West , Herning , Denmark
| | - Daan van de Kerkhof
- e Department of Clinical Biochemistry , Catharina Hospital , Eindhoven , the Netherlands
| | - Anna-Marie B Münster
- f Unit for Thrombosis Research , University of Southern Denmark , Esbjerg , Denmark.,g Department of Clinical Biochemistry , Hospital of South West Denmark , Esbjerg , Denmark
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Seidel H, Kolde HJ. Monitoring of Argatroban and Lepirudin: What is the Input of Laboratory Values in "Real Life"? Clin Appl Thromb Hemost 2017; 24:287-294. [PMID: 28320219 DOI: 10.1177/1076029617699087] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Monitoring of direct thrombin inhibitors (DTIs) in patients with heparin-induced thrombocytopenia (HIT) is primarily performed using the activated partial thromboplastin time (aPTT). This assay is poorly standardized, reagent dependent, and not DTI specific. We compared aPTT, thrombin time (TT), and prothrombin time (PT) to drug levels obtained by the ecarin chromogenic assay (ECA). We analyzed 495 samples of patients with confirmed or suspected HIT on treatment with either argatroban (n = 37) or lepirudin (n = 80). Mean DTI levels ± standard deviation (SD) were 0.41 ± 0.36 µg/mL for argatroban and 0.20 ± 0.21 µg/mL for lepirudin. Results of aPTT were highly variable: 67 ± 22 seconds for argatroban and 55 ± 20 seconds for lepirudin. Significant correlations ( P < .01) were found between ECA-based DTI level and TT (argatroban, r = .820 and lepirudin, r = .830), PT (argatroban, r = -.544), and aPTT (lepirudin, r = .572). However, there was no correlation of aPTT with argatroban or PT with lepirudin concentration. Multiple regression analyses revealed that the TT predicted 54% of argatroban and 42% of lepirudin levels, but no significant impact was seen for PT or aPTT. The aPTT-guided monitoring of DTI therapy leads to a high percentage of patients with inaccurate plasma levels, hence resulting to either undertreatment or overtreatment. Knowledge of baseline values prior to DTI therapy and inclusion of clinical settings are essential for dosing DTIs when using aPTT. However, due to several limitations of aPTT, monitoring according to exact plasma concentrations as obtained by specific tests such as ECA may be more appropriate.
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Affiliation(s)
- Holger Seidel
- 1 Centrum für Blutgerinnungsstörungen und Transfusionsmedizin (CBT), Bonn, Germany.,2 Department of Experimental and Clinical Hemostasis, Hemotherapy and Transfusion Medicine, Heinrich Heine University Medical Center, Dusseldorf, Germany
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Abstract
Direct oral anticoagulants (DOACs) can be quantified using methods that can be performed in any clinical or research laboratory using manual or automated instrument platforms. Dabigatran etexilate, the oral direct thrombin inhibitor, can be quantified by drug-calibrated clot or chromogenic-based assays using either thrombin or ecarin as substrates. Oral direct anti-Xa inhibitors, such as rivaroxaban, apixaban, and edoxaban, can be quantified with drug-calibrated anti-Xa kits or reagents as typically used for measuring heparins (unfractionated, low molecular weight, or pentasaccharides).
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Affiliation(s)
- Robert C Gosselin
- Department of Pathology and Laboratory Medicine, Davis Health System, University of California, 4400 V Street, Sacramento, CA, 95817, USA.
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center, Namur Research Institute for Life Sciences, University of Namur, Namur, Belgium
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Vanderwerf JD, Kumar MA. Management of neurologic complications of coagulopathies. HANDBOOK OF CLINICAL NEUROLOGY 2017; 141:743-764. [PMID: 28190445 DOI: 10.1016/b978-0-444-63599-0.00040-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Coagulopathy is common in intensive care units (ICUs). Many physiologic derangements lead to dysfunctional hemostasis; these may be either congenital or acquired. The most devastating outcome of coagulopathy in the critically ill is major bleeding, defined by transfusion requirement, hemodynamic instability, or intracranial hemorrhage. ICU coagulopathy often poses complex management dilemmas, as bleeding risk must be tempered with thrombotic potential. Coagulopathy associated with intracranial hemorrhage bears directly on prognosis and outcome. There is a paucity of high-quality evidence for the management of coagulopathies in neurocritical care; however, data derived from studies of patients with intraparenchymal hemorrhage may inform treatment decisions. Coagulopathy is often broadly defined as any derangement of hemostasis resulting in either excessive bleeding or clotting, although most typically it is defined as impaired clot formation. Abnormalities in coagulation testing without overt clinical bleeding may also be considered evidence of coagulopathy. This chapter will focus on acquired conditions, such as organ failure, pharmacologic therapies, and platelet dysfunction that are associated with defective clot formation and result in, or exacerbate, intracranial hemorrhage, specifically spontaneous intraparenchymal hemorrhage and traumatic brain injury.
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Affiliation(s)
- J D Vanderwerf
- Department of Neurology, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - M A Kumar
- Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care, Perelman School of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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Husted S, Verheugt FWA, Comuth WJ. Reversal Strategies for NOACs: State of Development, Possible Clinical Applications and Future Perspectives. Drug Saf 2016; 39:5-13. [PMID: 26519420 DOI: 10.1007/s40264-015-0357-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The non-vitamin K antagonist oral anticoagulants (NOACs) are used for thromboembolic prophylaxis of patients with atrial fibrillation and in the treatment as well as secondary prophylaxis of patients with venous thromboembolism. Even though NOACs have a better safety profile than vitamin K antagonists (VKAs), there will still be bleeding complications on NOAC treatment. In some cases, stopping the NOAC and non-drug-related management such as manual compression and interventional endoscopy will be sufficient to stop the bleeding. In more serious bleeding events and before acute surgery, coagulation factor concentrates or NOAC-specific antidotes could be used. Coagulation factor concentrates can be used in patients with haemophilia and to reverse the effect of VKAs but, in NOAC-treated patients, results are inconsistent and these agents could potentially have pro-thrombotic effects. Specific antidotes for NOACs are expected to be on the market soon. Phase III clinical trials with a humanized antibody fragment directed against dabigatran (idarucizumab) and recombinant, modified factor Xa (andexanet alfa) are ongoing. A molecule (aripazine) with broad activity against various anticoagulants including NOACs is currently undergoing phase II trials. For use of these specific antidotes, it is desirable that measurements for coagulation activity with a short response delay are widely available for the different NOACs and further research in this field is needed. Furthermore, guidelines for antidote use, including general measures for the treatment of NOAC-related bleeding, should be available.
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Affiliation(s)
- Steen Husted
- Department of Medicine, Hospital Unit West, Herning, Denmark
| | - Freek W A Verheugt
- Department of Cardiology, Heartcenter, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | - Willemijn J Comuth
- Department of Medicine, Hospital Unit West, Herning, Denmark. .,Department of Clinical Biochemistry, Hospital Unit West, Gl. Landevej 61, 7400, Herning, Denmark.
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Metalloproteases Affecting Blood Coagulation, Fibrinolysis and Platelet Aggregation from Snake Venoms: Definition and Nomenclature of Interaction Sites. Toxins (Basel) 2016; 8:toxins8100284. [PMID: 27690102 PMCID: PMC5086644 DOI: 10.3390/toxins8100284] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 09/21/2016] [Accepted: 09/22/2016] [Indexed: 01/08/2023] Open
Abstract
Snake venom metalloproteases, in addition to their contribution to the digestion of the prey, affect various physiological functions by cleaving specific proteins. They exhibit their activities through activation of zymogens of coagulation factors, and precursors of integrins or receptors. Based on their structure–function relationships and mechanism of action, we have defined classification and nomenclature of functional sites of proteases. These metalloproteases are useful as research tools and in diagnosis and treatment of various thrombotic and hemostatic conditions. They also contribute to our understanding of molecular details in the activation of specific factors involved in coagulation, platelet aggregation and matrix biology. This review provides a ready reference for metalloproteases that interfere in blood coagulation, fibrinolysis and platelet aggregation.
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Abstract
New oral anticoagulants (NOAC) are the latest addition to anticoagulant armamentarium. Unlike traditional anti-coagulants like warfarin, lab monitoring and management of bleeding complications secondary to these agents is different. As more and more patients are being switched to these drugs, interventional radiologists in particular will benefit from a clinical review of NOAC.
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Affiliation(s)
- Sandeep T Laroia
- Deaprtment of Radiology, University of Iowa Hospitals and Clinic, Iowa City, Iowa, USA
| | - Steven Morales
- Deaprtment of Radiology, University of Iowa Hospitals and Clinic, Iowa City, Iowa, USA
| | - Archana T Laroia
- Deaprtment of Radiology, University of Iowa Hospitals and Clinic, Iowa City, Iowa, USA
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Monitoring of hematological and hemostatic parameters in neurocritical care patients. Neurocrit Care 2015; 21 Suppl 2:S168-76. [PMID: 25208669 DOI: 10.1007/s12028-014-0023-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Anemia and bleeding are paramount concerns in neurocritical care and often relate to the severity of intracranial hemorrhage. Anemia is generally associated with worse outcomes, and efforts to minimize anemia through reduced volume of blood sampled are encouraged. Point-of-care-testing reliably detects the use of non-steroidal anti-inflammatory drugs that may worsen bleeding and reduce platelet activity, particularly in patients with intracerebral hemorrhage. How best to monitor the effect of platelet transfusion or platelet-activating therapy is not well studied. For patients known to take novel oral anticoagulants, drug-specific coagulation tests before neurosurgical intervention are prudent.
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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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Helin TA, Lemponen M, Hjemdahl P, Rönquist-Nii Y, Lassila R, Joutsi-Korhonen L. From laboratory to clinical practice: Dabigatran effects on thrombin generation and coagulation in patient samples. Thromb Res 2015; 136:154-60. [DOI: 10.1016/j.thromres.2015.04.032] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Revised: 04/07/2015] [Accepted: 04/24/2015] [Indexed: 02/05/2023]
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Non-VKA Oral Anticoagulants: Accurate Measurement of Plasma Drug Concentrations. BIOMED RESEARCH INTERNATIONAL 2015; 2015:345138. [PMID: 26090400 PMCID: PMC4452246 DOI: 10.1155/2015/345138] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 11/10/2014] [Indexed: 11/18/2022]
Abstract
Non-VKA oral anticoagulants (NOACs) have now widely reached the lucrative market of anticoagulation. While the marketing authorization holders claimed that no routine monitoring is required and that these compounds can be given at fixed doses, several evidences arisen from the literature tend to demonstrate the opposite. New data suggests that an assessment of the response at the individual level could improve the benefit-risk ratio of at least dabigatran. Information regarding the association of rivaroxaban and apixaban exposure and the bleeding risk is available in the drug approval package on the FDA website. These reviews suggest that accumulation of these compounds increases the risk of experiencing a bleeding complication. Therefore, in certain patient populations such as patients with acute or chronic renal impairment or with multiple drug interactions, measurement of drug exposure may be useful to ensure an optimal treatment response. More specific circumstances such as patients experiencing a haemorrhagic or thromboembolic event during the treatment duration, patients who require urgent surgery or an invasive procedure, or patient with a suspected overdose could benefit from such a measurement. This paper aims at providing guidance on how to best estimate the intensity of anticoagulation using laboratory assays in daily practice.
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Baruch L. Laboratory Monitoring of Anticoagulant Medications: Focus on Novel Oral Anticoagulants. Postgrad Med 2015; 125:135-45. [DOI: 10.3810/pgm.2013.03.2647] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Douxfils J, Lessire S, Dincq AS, Hjemdahl P, Rönquist-Nii Y, Pohanka A, Gourdin M, Chatelain B, Dogné JM, Mullier F. Estimation of dabigatran plasma concentrations in the perioperative setting. An ex vivo study using dedicated coagulation assays. Thromb Haemost 2014; 113:862-9. [PMID: 25519251 DOI: 10.1160/th14-09-0808] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 11/07/2014] [Indexed: 11/05/2022]
Abstract
The perioperative management of dabigatran is challenging, and recommendations based on activated partial thromboplastin time (aPTT) and thrombin time (TT) are unsatisfactory. Dedicated coagulation tests have limitations at plasma concentrations < 50 ng/ml. Therefore, a more sensitive test, which is available 24/7, is required. It was the aim of this study to investigate the performance of the Hemoclot Thrombin Inhibitors® LOW (HTI LOW) kit, a diluted thrombin time, and the STA® - ECA II(ECA-II) kit, a chromogenic variant of the ecarin clotting time, that were developed to measure low dabigatran concentrations, compared to reference dabigatran analysis by liquid chromatography tandem mass-spectrometry (LC-MS/MS). This study included 33 plasma samples from patients treated with dabigatran etexilate who had plasma concentrations < 200 ng/ml. HTI LOW and ECA-II were performed along with HTI, aPTT (STA®-C. K.Prest® and SynthasIL®) and TT (STA® - Thrombin). All procedures were performed according to recommendations by the manufacturers. Linear (or curvilinear) correlations and Bland-Altman analyses were calculated. For free dabigatran concentrations < 50 ng/ml, the R² of linear correlations were 0.69, 0.84 and 0.61, with HTI, HTI LOW and ECA-II, respectively. The R² for TT, STA®-C. K.Prest® and SynthasIL® were 0.67, 0.42 and 0.15. For HTI, HTI LOW and ECA-II, Bland-Altman analyses revealed mean differences of -6 ng/ml (95 %CI: -25-14 ng/ml), 1 ng/ml (95 %CI: -18-19 ng/ml) and -1 ng/ml (95 %CI: -25-23 ng/ml), demonstrating that tests dedicated to measuring low concentrations are more accurate than HTI. In conclusion, the use of HTI LOW or ECA-II to assess low plasma dabigatran concentrations is supported by our findings.
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Affiliation(s)
- Jonathan Douxfils
- Jonathan Douxfils, Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, B-5000, Belgium, E-mail:
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Schmitz EMH, Boonen K, van den Heuvel DJA, van Dongen JLJ, Schellings MWM, Emmen JMA, van der Graaf F, Brunsveld L, van de Kerkhof D. Determination of dabigatran, rivaroxaban and apixaban by ultra-performance liquid chromatography - tandem mass spectrometry (UPLC-MS/MS) and coagulation assays for therapy monitoring of novel direct oral anticoagulants. J Thromb Haemost 2014; 12:1636-46. [PMID: 25142183 DOI: 10.1111/jth.12702] [Citation(s) in RCA: 120] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Accepted: 08/10/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Three novel direct oral anticoagulants (DOACs) have recently been registered by the Food and Drug Administration and European Medicines Agency Commission: dabigatran, rivaroxaban, and apixaban. To quantify DOACs in plasma, various dedicated coagulation assays have been developed. OBJECTIVE To develop and validate a reference ultra-performance liquid chromatography - tandem mass spectrometry (UPLC-MS/MS) method and to evaluate the analytical performance of several coagulation assays for quantification of dabigatran, rivaroxaban, and apixaban. METHODS The developed UPLC-MS/MS method was validated by determination of precision, accuracy, specificity, matrix effects, lower limits of detection, carry-over, recovery, stability, and robustness. The following coagulation assays were evaluated for accuracy and precision: laboratory-developed (LD) diluted thrombin time (dTT), Hemoclot dTT, Pefakit PiCT, ECA, Liquid anti-Xa, Biophen Heparin (LRT), and Biophen DiXal anti-Xa. Agreement between the various coagulation assays and UPLC-MS/MS was determined with random samples from patients using dabigatran or rivaroxaban. RESULTS The UPLC-MS/MS method was shown to be accurate, precise, sensitive, stable, and robust. The dabigatran coagulation assay showing the best precision, accuracy and agreement with the UPLC-MS/MS method was the LD dTT test. For rivaroxaban, the anti-factor Xa assays were superior to the PiCT-Xa assay with regard to precision, accuracy, and agreement with the reference method. For apixaban, the Liquid anti-Xa assay was superior to the PiCT-Xa assay. CONCLUSIONS Statistically significant differences were observed between the various coagulation assays as compared with the UPLC-MS/MS reference method. It is currently unknown whether these differences are clinically relevant. When DOACs are quantified with coagulation assays, comparison with a reference method as part of proficiency testing is therefore pivotal.
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Affiliation(s)
- E M H Schmitz
- Clinical Laboratory, Catharina Hospital, Eindhoven, The Netherlands; Laboratory of Chemical Biology and Institute of Complex Molecular Systems, Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands; Expert Center Clinical Chemistry Eindhoven, Eindhoven, The Netherlands
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Abstract
A lack of consensus on anticoagulant reversal during acute trauma is compounded by an aging population and the expanding spectrum of new anticoagulation agents. Developments in laboratory assays and transfusion medicine, including thromboelastography, recombinant factors, and factor concentrates, have revolutionized care for anticoagulated trauma patients. Accordingly, clinicians must be fully aware of drug mechanisms, assays to determine drug activity, and appropriate reversal strategies for patients on anticoagulants. Drugs include vitamin K antagonists, direct thrombin inhibitors, direct factor Xa inhibitors, low molecular weight heparin, and antiplatelet agents. This article discusses the appropriate assessment and management of trauma patients receiving these agents.
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Lind SE, Boyle ME, Fisher S, Ishimoto J, Trujillo TC, Kiser TH. Comparison of the aPTT with alternative tests for monitoring direct thrombin inhibitors in patient samples. Am J Clin Pathol 2014; 141:665-74. [PMID: 24713737 DOI: 10.1309/ajcpgtcex7k4gxqo] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES The activated partial thromboplastin time (aPTT) test has been used for years to monitor parenteral direct thrombin inhibitors (DTIs) and unfractionated heparin. Because the aPTT correlates poorly with unfractionated heparin levels, we hypothesized that the aPTT may not be the best test for monitoring parenteral DTIs. METHODS Using 235 excess plasma specimens from 82 adult patients receiving treatment with DTIs (argatroban, bivalirudin, or dabigatran), we compared the aPTT with the ecarin chromogenic assay (ECA), the dilute thrombin time (dTT) test, and the prothrombinase-induced clotting time (PiCT) test. RESULTS The aPTT correlated poorly with each of the other tests in both bivalirudin- and argatroban-containing samples (r(2) = 0.04-0.23). The ECA and dTT exhibited the best correlations (r(2) = 0.66-0.93). Intermediate correlations were seen when the results of the PiCT were plotted against the dTT or ECA (r(2) = 0.46-0.58). Nineteen specimens obtained from six patients receiving dabigatran showed a good correlation between the dTT and the ECA (r(2) = 0.92). CONCLUSIONS The aPTT does not correlate well with other tests that might be used to monitor parental DTI administration. Further studies are needed to evaluate the clinical usefulness of alternative tests and their correlation with clinical outcomes.
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Affiliation(s)
- Stuart E. Lind
- Departments of Medicine and Pathology, University of Colorado School of Medicine, Aurora, CO
| | - Mary Ellen Boyle
- Clinical Laboratories, University of Colorado Hospital, Aurora, CO
| | - Sheila Fisher
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO
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Kumar R, Smith RE, Henry BL. A Review of and Recommendations for the Management of Patients With Life-Threatening Dabigatran-Associated Hemorrhage. J Intensive Care Med 2014; 30:462-72. [DOI: 10.1177/0885066614527417] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2013] [Accepted: 12/31/2013] [Indexed: 12/22/2022]
Abstract
Dabigatran is an oral direct thrombin inhibitor that is approved for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation. Dabigatran has several advantages over warfarin including predictable pharmacokinetics and pharmacodynamics which eliminates the need for routine laboratory monitoring, superiority over warfarin in preventing stroke, or systemic embolism without having an increased risk of bleeding. However, as with any anticoagulant, there remains a real chance of bleeding, including major or life-threatening hemorrhage. Many physicians feel comfortable managing bleeding complications on older anticoagulants like warfarin and heparin, due to extensive experience with the medications along with antidotes to reverse their effects as well as established protocols for treating anticoagulant-associated hemorrhage. However, most physicians have limited clinical experience with dabigatran, there is no specific antidote for dabigatran reversal and there is a paucity of protocols, guidelines, and recommendations for how to manage dabigatran-associated hemorrhage. In this review, we present a case series of patients admitted to our institution for management of bleeding while receiving dabigatran. We retrospectively reviewed these cases to evaluate the efficacy and rationale of the various anticoagulation reversal strategies employed in the context of the existing evidence found in the literature. Specific focus is placed on the therapies utilized and the coagulation studies used to manage these patients.
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Affiliation(s)
- Rohit Kumar
- Division of Hematology-Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Roy E. Smith
- Division of Hematology-Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Brian L. Henry
- Department of Cardiology and the Vascular Medicine Institute, University of Pittsburgh Medical Center Heart and Vascular Institute, Pittsburgh, PA, USA
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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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Gosselin RC, Dwyre DM, Dager WE. Measuring Dabigatran Concentrations Using a Chromogenic Ecarin Clotting Time Assay. Ann Pharmacother 2013; 47:1635-40. [DOI: 10.1177/1060028013509074] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | - Denis M. Dwyre
- University of California-Davis Health System, Sacramento, CA, USA
| | - William E. Dager
- University of California-Davis Health System, Sacramento, CA, USA
- University of California-San Francisco School of Pharmacy, CA, USA
- University of California-Davis School of Medicine, CA, USA
- Touro School of Pharmacy, Vallejo, CA, USA
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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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Nickel KF, Laux V, Heumann R, von Degenfeld G. Thrombin has biphasic effects on the nitric oxide-cGMP pathway in endothelial cells and contributes to experimental pulmonary hypertension. PLoS One 2013; 8:e63504. [PMID: 23785394 PMCID: PMC3681801 DOI: 10.1371/journal.pone.0063504] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 04/06/2013] [Indexed: 01/29/2023] Open
Abstract
Background A potential role for coagulation factors in pulmonary arterial hypertension has been recently described, but the mechanism of action is currently not known. Here, we investigated the interactions between thrombin and the nitric oxide-cGMP pathway in pulmonary endothelial cells and experimental pulmonary hypertension. Principal Findings Chronic treatment with the selective thrombin inhibitor melagatran (0.9 mg/kg daily via implanted minipumps) reduced right ventricular hypertrophy in the rat monocrotaline model of experimental pulmonary hypertension. In vitro, thrombin was found to have biphasic effects on key regulators of the nitric oxide-cGMP pathway in endothelial cells (HUVECs). Acute thrombin stimulation led to increased expression of the cGMP-elevating factors endothelial nitric oxide synthase (eNOS) and soluble guanylate cyclase (sGC) subunits, leading to increased cGMP levels. By contrast, prolonged exposition of pulmonary endothelial cells to thrombin revealed a characteristic pattern of differential expression of the key regulators of the nitric oxide-cGMP pathway, in which specifically the factors contributing to cGMP elevation (eNOS and sGC) were reduced and the cGMP-hydrolyzing PDE5 was elevated (qPCR and Western blot). In line with the differential expression of key regulators of the nitric oxide-cGMP pathway, a reduction of cGMP by prolonged thrombin stimulation was found. The effects of prolonged thrombin exposure were confirmed in endothelial cells of pulmonary origin (HPAECs and HPMECs). Similar effects could be induced by activation of protease-activated receptor-1 (PAR-1). Conclusion These findings suggest a link between thrombin generation and cGMP depletion in lung endothelial cells through negative regulation of the nitric oxide-cGMP pathway, possibly mediated via PAR-1, which could be of relevance in pulmonary arterial hypertension.
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Affiliation(s)
- Katrin F. Nickel
- Cardiology Research, Bayer HealthCare AG, Wuppertal, Germany
- Department of Molecular Medicine and Surgery, Karolinska Institutet and University Hospital, Stockholm, Sweden
| | - Volker Laux
- Cardiology Research, Bayer HealthCare AG, Wuppertal, Germany
| | - Rolf Heumann
- Biochemistry II – Molecular Neurobiochemistry, Ruhr-University Bochum, Bochum, Germany
| | - Georges von Degenfeld
- Common Mechanism Research, Bayer HealthCare AG, Wuppertal, Germany, and Institute for Research in Operative Medicine, University of Witten/Herdecke, Cologne, Germany
- * E-mail:
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Javedani PP, Horowitz BZ, Clark WM, Lutsep HL. Dabigatran etexilate: management in acute ischemic stroke. Am J Crit Care 2013; 22:169-76. [PMID: 23455868 DOI: 10.4037/ajcc2013125] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
A 54-year-old man treated with dabigatran experienced new onset of a stroke with a score of 9 on the National Institutes of Health Stroke Scale. Administration of recombinant tissue plasminogen activator (rtPA) was not recommended because of the dabigatran therapy. Angiography showed occlusion of the left middle cerebral artery by an embolic thrombus. Suction thrombectomy achieved flow through the inferior division of the artery. Computed tomography of the head showed possible intracranial hemorrhage, and dabigatran reversal was attempted with prothrombin complex concentrate and recombinant factor VIIa. Coagulation studies before administration of the reversal blood products showed a partial thromboplastin time of 30.3 seconds; 1 hour after administration, the partial thromboplastin time was 28.5 seconds. No evidence of intracranial hemorrhage was apparent on repeated computed tomography scans of the brain. He was discharged with aspirin and warfarin and a stroke score of 8. (American Journal of Critical Care. 2013;22:169-176) The use of long-term oral anticoagulation is indicated for prevention of cardiac thromboembolism in selected patients with nonvalvular atrial fibrillation. With the emergence of new potent oral agents- including the selective direct thrombin inhibitor dabigatran-clinicians must become familiar with the management of such patients. In this case report, we present a man who had an acute ischemic stroke while taking dabigatran and discuss the medical decision making regarding management issues.
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Affiliation(s)
- Parisa P. Javedani
- Parisa P. Javedani is an emergency medicine resident at the University of Arizona, Tucson. At the time this was written, she was was a fourth-year student in the School of Medicine
| | - B. Zane Horowitz
- B. Zane Horowitz is a professor in the Department of Emergency Medicine
| | - Wayne M. Clark
- Wayne M. Clark is a professor in the Department of Neurology
| | - Helmi L. Lutsep
- Helmi L. Lutsep is vice chair and professor in the Department of Neurology, Oregon Health & Science University, Portland, Oregon
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Schaden E, Schober A, Hacker S, Kozek-Langenecker S. Ecarin modified rotational thrombelastometry: a point-of-care applicable alternative to monitor the direct thrombin inhibitor argatroban. Wien Klin Wochenschr 2013; 125:156-9. [PMID: 23440521 DOI: 10.1007/s00508-013-0327-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Accepted: 01/28/2013] [Indexed: 11/29/2022]
Abstract
PURPOSE Adequate monitoring of the effect of the direct thrombin inhibitor argatroban may facilitate individualized dosing and perioperative management of anticoagulation. Ecarin Clotting Time is proposed for this purpose, but has the major disadvantage of limited availability. There is a point-of-care applicable ecarin-activated test modification for rotational thrombelastometry (ROTEM®) which is sensitive to direct thrombin inhibitors. The aim of the study was to evaluate the correlation between argatroban concentration and this ecarin modified thrombelastometry (EMT). METHODS In this in vitro experiment, blood drawn from healthy volunteers was spiked with argatroban at clinically relevant concentrations and analyzed with ROTEM® using EMT. The main endpoint was the clotting time (CT). RESULTS EMT-CT was prolonged with increasing argatroban concentrations (from 83.3 ± 6.7 s without argatroban to 743.5 ± 138.2 s at 2 μg/ml argatroban). The correlation between argatroban concentration and EMT-CT was high (r = 0.94) and statistically significant (p < 0.01). CONCLUSION These promising preclinical results mandate further clinical research to determine an EMT-CT target range regarding the clinical outcomes of thrombosis and bleeding.
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Affiliation(s)
- Eva Schaden
- Department of Anaesthesiology, General Intensive Care and Pain Control, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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38
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Heparin-Induced Thrombocytopenia. Platelets 2013. [DOI: 10.1016/b978-0-12-387837-3.00042-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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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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Dumkow LE, Voss JR, Peters M, Jennings DL. Reversal of dabigatran-induced bleeding with a prothrombin complex concentrate and fresh frozen plasma. Am J Health Syst Pharm 2012; 69:1646-50. [DOI: 10.2146/ajhp120055] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Reversible crystallization of argatroban after subcutaneous application in pigs. THROMBOSIS 2012; 2012:560513. [PMID: 22988498 PMCID: PMC3439991 DOI: 10.1155/2012/560513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 07/17/2012] [Indexed: 11/18/2022]
Abstract
Argatroban is a thrombin inhibitor used as anticoagulant in patients with heparin-induced thrombocytopenia. It is usually administered as an intravenous bolus followed by infusion. Nevertheless, its pharmacokinetics after subcutaneous administration is unknown. The aim of this study was to assess the pharmacokinetics of two different formulations of argatroban in pigs after subcutaneous administration. Antithrombotic activity in plasma was determined by ecarin chromogenic assay. To visualize the formation of crystals, argatroban was administered to rats into the subcutaneous tissue exposed after removing the skin, and the injection site was photographed at different times. After subcutaneous administration of a sorbitol/ethanol formulation of argatroban in pigs was observed a slow absorption phase was followed by long-lasting levels of this inhibitor. C(max) and AUC((0-24)) showed dose-dependent increases, while elimination half-life and t(max) value did not change significantly with dose. In contrast, saline-dissolved argatroban showed a faster absorption phase followed by a shorter elimination half-life. Argatroban dissolved in sorbitol/ethanol leads to long-lasting plasma levels due to the formation and permanent dissolution of a crystalline depot at the injection place. This represents a simple way to deliver argatroban continuously over an extended period which can be beneficial for prophylaxis or treatment of chronic coagulations disorders.
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Verma A, Chhibber V, Emhoff T, Klinger D. Promise and challenges of anticoagulation with dabigatran. Clin Kidney J 2012; 5:336-8. [PMID: 25874093 PMCID: PMC4393474 DOI: 10.1093/ckj/sfs068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Accepted: 05/16/2012] [Indexed: 11/14/2022] Open
Abstract
Dabigatran, marketed as Pradaxa (Boehringer Ingelheim) in the USA, is a direct thrombin inhibitor that holds great promise. It has been shown to reduce the risk of stroke and venous thromboembolism with similar if not greater efficacy than warfarin and with far fewer side effects. However, like other anticoagulants, it can cause severe bleeding complications and lacks a specific antidote with proven efficacy. The patient presented here was on dabigatran and sustained a traumatic intracranial hemorrhage (ICH). The ICH continued to progress despite prompt initiation of 3h of hemodialysis in an effort to remove the offending drug from the circulation. Through this case report, we highlight the challenges of anticoagulation with dabigatran including the lack of routine testing for monitoring its effect and of a specific antidote. We also discuss the potential role of dialysis in treating patients with life-threatening bleeding on dabigatran.
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Affiliation(s)
- Ashish Verma
- Division of Renal Medicine , University of Massachusetts Medical School , Worcester, MA , USA
| | - Vishesh Chhibber
- Department of Transfusion Medicine , University of Massachusetts Medical School , Worcester, MA , USA
| | - Timothy Emhoff
- Department of Trauma Surgery & Surgical Critical Care , University of Massachusetts Medical School , Worcester, MA , USA
| | - Dagmar Klinger
- Division of Renal Medicine , University of Massachusetts Medical School , Worcester, MA , USA
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Hellwig TR, Peitz GJ, Gulseth MP. High-dose argatroban for treatment of heparin-induced thrombocytopenia with thrombosis: a case report and review of laboratory considerations. Am J Health Syst Pharm 2012; 69:490-5. [PMID: 22382479 DOI: 10.2146/ajhp110147] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
PURPOSE A case report describing high-dose argatroban for the treatment of heparin-induced thrombocytopenia (HIT) with thrombosis and associated considerations in interpreting laboratory monitoring data are presented. SUMMARY A 51-year-old woman with an extensive history of coronary artery disease arrived at the emergency department with complaints of chest pain. The patient was admitted, and coronary artery bypass graft surgery was ultimately performed. The patient had a baseline platelet count of 177,000 cells/μL. During hospitalization, the patient received heparin, and her platelet count dropped to 12,000 cells/μL 13 days after the initiation of heparin. The patient developed swelling around a peripherally inserted central catheter and later developed deep vein thrombosis. An argatroban infusion of 2 μg/kg/min was initiated, with a target activated partial thromboplastin time (aPTT) of 40-80 seconds. After 5 days of therapy, the patient had increased swelling in her right arm and an aPTT of 56 seconds. Her goal aPTT was subsequently increased. Six days later, the patient developed a left-lower-extremity DVT despite aPTTs within the goal range. A new aPTT target of >75 seconds was set. The infusion rate was increased to 15.5 μg/kg/min to attain the target aPTT. Results of an in vitro test led to an alternative interpretation of aPTT and International Normalized Ratio values that aided in the monitoring of argatroban during the high-dose infusion. CONCLUSION A patient with HIT with thrombosis was successfully treated with unusually high dosages of argatroban and may have had serum argatroban concentrations exceeding what has commonly been thought to be the therapeutic range.
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Affiliation(s)
- Thaddaus R Hellwig
- Department of Pharmacy Practice, College of Pharmacy, South Dakota State University, Brookings, USA.
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Douxfils J, Mullier F, Robert S, Chatelain C, Chatelain B, Dogné JM. Impact of dabigatran on a large panel of routine or specific coagulation assays. Laboratory recommendations for monitoring of dabigatran etexilate. Thromb Haemost 2012; 107:985-97. [PMID: 22438031 DOI: 10.1160/th11-11-0804] [Citation(s) in RCA: 257] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Accepted: 02/08/2012] [Indexed: 11/05/2022]
Abstract
Due to low bioavailability and high inter-individual variability, monitoring of dabigatran may be required in specific situations to prevent the risk of bleedings or thrombosis. The aim of the study was to determine which coagulation assay(s) could be used to assess the impact of dabigatran on secondary haemostasis. Dabigatran was spiked at concentrations ranging from 4.7 ng/ml to 943.0 ng/ml in pooled citrated human platelet-poor plasma. The following clotting assays were performed: prothrombin time (PT); activated partial thromboplastin time (aPTT); thrombin time (TT); ecarin clotting time (ECT); ecarin chromogenic assay (ECA); prothrombinase-induced clotting time (PiCT); activated clotting time (ACT); Hemoclot Thrombin Inhibitor (HTI) and thrombin generation assay (TGA). A concentration-dependent prolongation of PT, dPT, and aPTT was observed with aPTT being the more sensitive test. The results varied mostly due to the clotting reagent. HTI, ECT and TGA were the most sensitive tests but are not available 24 hours a day. In addition, HTI showed a linear correlation with a good reproducibility. Dabigatran induced a concentration-dependent delay and inhibition of tissue factor-induced TGA. Cut-offs related with higher risk of bleedings or thrombosis were defined for each reagent of aPTT and HTI. In conclusion, aPTT could be used for the monitoring of dabigatran and as screening test for the risk of overdose. However, because of its higher sensitivity, good reproducibility, excellent linear correlation at all doses, its simplicity of use, and possibilities of automation, HTI should be considered as the gold-standard.
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Affiliation(s)
- Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Center (NTHC), Namur Research Institute for LIfe Sciences (NARILIS), University of Namur, Belgium
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Ageno W, Gallus AS, Wittkowsky A, Crowther M, Hylek EM, Palareti G. Oral anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e44S-e88S. [PMID: 22315269 PMCID: PMC3278051 DOI: 10.1378/chest.11-2292] [Citation(s) in RCA: 1016] [Impact Index Per Article: 84.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2011] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The objective of this article is to summarize the published literature concerning the pharmacokinetics and pharmacodynamics of oral anticoagulant drugs that are currently available for clinical use and other aspects related to their management. METHODS We carried out a standard review of published articles focusing on the laboratory and clinical characteristics of the vitamin K antagonists; the direct thrombin inhibitor, dabigatran etexilate; and the direct factor Xa inhibitor, rivaroxaban RESULTS The antithrombotic effect of each oral anticoagulant drug, the interactions, and the monitoring of anticoagulation intensity are described in detail and discussed without providing specific recommendations. Moreover, we describe and discuss the clinical applications and optimal dosages of oral anticoagulant therapies, practical issues related to their initiation and monitoring, adverse events such as bleeding and other potential side effects, and available strategies for reversal. CONCLUSIONS There is a large amount of evidence on laboratory and clinical characteristics of vitamin K antagonists. A growing body of evidence is becoming available on the first new oral anticoagulant drugs available for clinical use, dabigatran and rivaroxaban.
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Affiliation(s)
| | | | | | - Mark Crowther
- McMaster University, St. Joseph's Hospital, Hamilton, ON, Canada
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Results of a consensus meeting on the use of argatroban in patients with heparin-induced thrombocytopenia requiring antithrombotic therapy - a European Perspective. Thromb Res 2011; 129:426-33. [PMID: 22178575 DOI: 10.1016/j.thromres.2011.11.041] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Revised: 11/22/2011] [Accepted: 11/24/2011] [Indexed: 02/07/2023]
Abstract
Argatroban has been introduced as an alternative parenteral anticoagulant for HIT-patients in several European countries in 2005. In 2009 a panel of experts discussed their clinical experience with argatroban balancing risks and benefits of argatroban treatment in managing the highly procoagulant status of HIT-patients. This article summarizes the main conclusions of this round table discussion. An ongoing issue is the appropriate dosing of argatroban in special patient groups. Therefore, dosing recommendations for different HIT-patient groups (ICU patients; non-ICU patients, paediatric patients, and for patients undergoing renal replacement therapies) are summarized in this consensus statement. Because of the strong correlation between argatroban dosing requirements and scores used to characterize the severity of illness (APACHE; SAPS, SOFA) suitable dosing nomograms are given. This consensus statement contributes to clinically relevant information on the appropriate use and monitoring of argatroban based on the current literature, and provides additional information from clinical experience. As the two other approved drugs for HIT, danaparoid and lepirudin are either currently not available due to manufacturing problems (danaparoid) or will be withdrawn from the market in 2012 (lepirudin), this report should guide physicians who have limited experience with argatroban how to use this drug safely in patients with HIT.
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Kappel A, Stephan S, Christ G, Haude-Barten A, Dahm M, Schwarz H, Fischer B, Hahn M, Althaus H, Ehm M, Vitzthum F. Coagulation assays based on the Luminescent Oxygen Channeling Immunoassay technology1). Clin Chem Lab Med 2011; 49:855-60. [DOI: 10.1515/cclm.2011.132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Salmela B, Joutsi-Korhonen L, Saarela E, Lassila R. Comparison of monitoring methods for lepirudin: Impact of warfarin and lupus anticoagulant. Thromb Res 2010; 125:538-44. [DOI: 10.1016/j.thromres.2010.02.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Revised: 02/01/2010] [Accepted: 02/02/2010] [Indexed: 10/19/2022]
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49
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Schaden E, Kozek-Langenecker SA. Direct thrombin inhibitors: pharmacology and application in intensive care medicine. Intensive Care Med 2010; 36:1127-37. [PMID: 20425104 DOI: 10.1007/s00134-010-1888-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Accepted: 03/24/2010] [Indexed: 01/31/2023]
Abstract
PURPOSE Anticoagulation is part of the daily routine of intensive care physicians. As the possibilities of pharmacological anticoagulation are becoming more numerous and diverse, intensive care physicians have to be familiar with indications, contraindications, dosing, and reversal of many different substances. This paper presents an overview of the substance group of direct thrombin inhibitors (DTI) indicated for alternative anticoagulation in intensive care medicine. METHODS The review is a synopsis of scientific evidence, expert opinion, open forum commentary, and clinical feasibility data. RESULTS AND CONCLUSIONS Due to their antithrombotic potential without direct activation of platelets, DTI could offer potential advantages over heparins and vitamin K antagonists in critically ill patients, especially regarding heparin-induced thrombocytopenia. Because of multiple organ dysfunction, organ failure, and comedications, simple extrapolation of results of medical to critically ill patients is not permissible. The fine line between thrombosis and bleeding in intensive care patients requires cautious dosing and close drug monitoring. Studies dealing with DTI in the intensive care setting are of utmost clinical interest.
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Affiliation(s)
- Eva Schaden
- Department of Anesthesiology, General Intensive Care and Pain Management, Medical University of Vienna, Währinger Guertel 18-20, 1090, Vienna, Austria.
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50
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Monitoring von direkten Thrombininhibitoren. Hamostaseologie 2010. [DOI: 10.1007/978-3-642-01544-1_72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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