1
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Aakerøy R, Stokes CL, Tomić M, Hegstad S, Kristoffersen AH, Ellekjær H, Schjøtt J, Spigset O, Helland A. Serum or Plasma for Quantification of Direct Oral Anticoagulants? Ther Drug Monit 2022; 44:578-584. [PMID: 35051972 PMCID: PMC9275836 DOI: 10.1097/ftd.0000000000000956] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Accepted: 12/05/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Direct oral anticoagulants are increasingly replacing vitamin K antagonists for prevention of stroke in patients with atrial fibrillation, partly owing to the lack of a need for routine monitoring. Therapeutic drug monitoring may still be warranted under certain circumstances. It is generally assumed that serum and plasma can be interchangeably used for this purpose. The aim of this study was to investigate possible differences between the serum, citrate-plasma, and ethylenediaminetetraacetic acid (EDTA)-plasma concentrations of apixaban and rivaroxaban in a larger patient group and their relation to factor X measurements. METHODS Plasma and serum samples were drawn during the same venipuncture from patients treated with apixaban or rivaroxaban. Drug levels were measured using ultrahigh-performance liquid chromatography combined with tandem mass spectrometry. Three sample matrices were obtained from 8 healthy volunteers for measurement of factor X antigen and activity. RESULTS Mean concentrations of apixaban and rivaroxaban were 16.8% and 36.6% higher in serum than in citrate-plasma, respectively (both P < 0.001). The corresponding differences in serum versus EDTA-plasma were 4.5% for apixaban and 13.1% for rivaroxaban (both P < 0.001). Factor X antigen measurements in citrate-plasma, EDTA-plasma, serum with clot activator, and serum without additives yielded comparable results, and factor X activity was significantly higher in serum than in plasma. CONCLUSIONS Apixaban and rivaroxaban concentrations were significantly higher in serum than in plasma. The difference was more pronounced with rivaroxaban and was larger between serum and citrate-plasma than between serum and EDTA-plasma. Higher factor X activity in serum may explain the observed concentration differences. The choice of matrix is, thus, important when interpreting therapeutic drug monitoring results and in research involving analyses of direct oral anticoagulants. The authors recommend citrate-plasma as the preferred matrix.
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Affiliation(s)
- Rachel Aakerøy
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Charlotte L. Stokes
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Marija Tomić
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
| | - Solfrid Hegstad
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
| | - Ann Helen Kristoffersen
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Norwegian Organization for Quality Improvement of Laboratory Examinations (Noklus), Haraldsplass Deaconess Hospital, Bergen, Norway
| | - Hanne Ellekjær
- Department of Neuromedicine and Movement Science, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; and
- Stroke Unit, Department of Internal Medicine, St. Olav University Hospital, Trondheim, Norway
| | - Jan Schjøtt
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway
| | - Olav Spigset
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Arne Helland
- Department of Clinical Pharmacology, St. Olav University Hospital, Trondheim, Norway
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
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2
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Margetić S, Ćelap I, Lovrenčić Huzjan A, Bosnar Puretić M, Šupraha Goreta S, Čajević Glojnarić A, Delić Brkljačić D, Mioč P, Harenberg J, Hetjens S, Weiss C. DOAC Dipstick testing can reliably exclude the presence of clinically relevant DOAC concentrations in circulation. Thromb Haemost 2022; 122:1542-1548. [PMID: 35088395 PMCID: PMC9420550 DOI: 10.1055/a-1753-2748] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
In certain clinical situations, it is necessary to determine whether clinically relevant plasma levels of direct oral anticoagulants (DOACs) are present. We examined whether qualitative testing of DOACs in urine samples can exclude DOAC plasma concentrations of ≥30 ng/mL. This prospective single-center cohort study included consecutive patients treated with an oral direct factor Xa inhibitor (DXI) (apixaban,
n
= 31, rivaroxaban,
n
= 53) and direct thrombin inhibitor (DTI) (dabigatran,
n
= 44). We aimed to define the negative predictive value (NPV) and other statistical parameters of detecting DXIs and DTIs by DOAC Dipstick at plasma concentrations of ≥30 ng/mL. We also determined the best-fit threshold plasma levels using chromogenic substrate assays by logistic regression analysis. Between July 2020 and July 2021, 128 eligible patients (mean age 66 years, 55 females) were included into the study. The NPVs and sensitivities for DXI and DTI of DOAC Dipstick were 100% at ≥30 ng/mL plasma, for specificities 6 and 21% and for positive predictive values 62 and 72%, respectively. All diagnostic statistical tests improved to values between 86 and 100% at best-fitting plasma thresholds of ≥14 ng/mL for DXI and ≥19 ng/mL for DTI. Visual analysis using the DOAC Dipstick was 100% in agreement with that of the optoelectronic DOASENSE Reader for all the three DOACs.
DOAC Dipstick testing can reliably exclude the presence of DOACs in urine samples at best-fitting thresholds of >14 and >19 ng/mL in plasma. The performance of the DOAC Dipstick at detecting lower DOAC concentrations in plasma requires confirmation.
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Affiliation(s)
- Sandra Margetić
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Ivana Ćelap
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | | | | | | | - Anesa Čajević Glojnarić
- Department of Clinical Chemistry, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Diana Delić Brkljačić
- Department of Cardiovascular Diseases, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Pavao Mioč
- Department of Cardiovascular Diseases, Sestre milosrdnice University Hospital Center, Zagreb, Croatia
| | - Job Harenberg
- DOASENSE GmbH, Heidelberg, Germany, Heidelberg, Germany.,University of Heidelberg, Heidelberg, Germany
| | - Svetlana Hetjens
- Department of Medical Statistics and Biomathematics, University of Heidelberg Medical Faculty Mannheim, Heidelberg, Germany
| | - Christel Weiss
- Department of Medical Statistics and Biomathematics, University of Heidelberg Medical Faculty Mannheim, Heidelberg, Germany
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3
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Walenga JM. Can We Improve on the Rapid Assessment of Clinically Relevant Levels of Direct Acting Oral Anticoagulants (DOAC)? Clin Appl Thromb Hemost 2022; 28:10760296221096422. [PMID: 35473406 PMCID: PMC9099059 DOI: 10.1177/10760296221096422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jeanine M Walenga
- Cardiovascular Institute, 2456Loyola University Chicago, Chicago, Illinois, United States
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4
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Harenberg J, Hetjens S, Weiss C. Patients' Plasma Activity of Heparin, low-Molecular-Weight Heparin or no Anticoagulants on Urine Based DOAC Test Strips. Clin Appl Thromb Hemost 2022; 28:10760296221083667. [PMID: 35275493 PMCID: PMC8921744 DOI: 10.1177/10760296221083667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
DOAC Dipstick determines specifically the presence and absence of direct oral anticoagulants (DOACs) from patients’ urine samples and handmade test strips performed as well as the commercial version. To compare plasma activity (chromogenic substrate assays) from plasma samples with results from urine samples (DOAC test strips) of patients treated with heparin, low-molecular weight heparin (LMWH) and without anticoagulation. Plasma anti-factor Xa (aXa) activity was determined by Coamatic chromogenic substrate assay and compared to the presence of anticoagulants in urine by DOAC test strips. Patients were treated for least 5 days and samples were taken 4 hrs after administration in comparison to no treatment with an anticoagulant (n = 42). A total of 100 patients were included treated with heparin (n = 29), LMWH nadroparin (n = 29) or no anticoagulants (n = 42). Plasma aXa levels of patients treated with heparin (2 × 7.500 IU daily subcutaneously, 12 male, age 67.4 ± 11.5 years) were 0,18 IU/ml ± 0,15 IU/ml (mean, standard deviation), with LMWH (1 × 3000 IU daily subcutaneously, 15 male, age 64.2 ± 14.1 years) 0,17 IU/ml ± 0,16 IU/l, and with no anticoagulants (28 male, age 64.2 ± 15.6 years) 0,02 IU/ml ± 0.01 IU/ml. All factor Xa and thrombin inhibitor pad results of test strips were negative. We conclude that DOAC Dipstick has a high probability of not detecting heparin and LMWH in patients on treatment as well as in urine samples of patients not treated with an anticoagulant.
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Affiliation(s)
- Job Harenberg
- DOASENSE GmbH, Heidelberg, Germany.,9144Ruprecht-Karls University Heidelberg, Heidelberg, Germany
| | - Svetlana Hetjens
- Medical Faculty Mannheim, Ruprecht-Karls University Heidelberg, Heidelberg, Germany
| | - Christel Weiss
- Medical Faculty Mannheim, Ruprecht-Karls University Heidelberg, Heidelberg, Germany
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5
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Martini A, Harenberg J, Bauersachs R, Beyer-Westendorf J, Crowther M, Douxfils J, Elalamy I, Weiss C, Hetjens S. Detection of Direct Oral Anticoagulants in Patient Urine Samples by Prototype and Commercial Test Strips for DOACs - A Systematic Review and Meta-analysis. TH OPEN 2021; 5:e438-e448. [PMID: 34595388 PMCID: PMC8463133 DOI: 10.1055/s-0041-1732437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 06/28/2021] [Indexed: 01/13/2023] Open
Abstract
The DOAC Dipstick accurately detects the presence or absence of factor Xa (DXI) and thrombin inhibitor (DTI) classes of direct oral anticoagulants (DOACs) in patients' urine samples on DOAC treatment. The aim of the study was to systematically review the literature and compare the performance of prototype and commercial test strips with a meta-analysis.
A systematic literature search of electronic databases PubMed (MEDLINE) and Cochrane Library was performed. Heterogeneity between studies was calculated using the Chi-squared test and the I
2
index. A random effects model was used to pool data to compare the performance of prototype and commercial test strips.
Using PRISMA reporting guidelines, four of 1,081 publications were eligible for inclusion in the meta-analysis: three reporting on prototype (DXI
n
= 658, DTI
n
= 586) and one on commercial test strips (DXI
n
= 451, DTI
n
= 429). Sensitivity and specificity of DXI and DTI detection did not differ significantly between the prototype and commercial test strips. Odds ratios were 0.718 and 0.365 for sensitivity and 1.211 and 1.072 for specificity of DXI and DTI (p-values between 0.3334 and 1.000), respectively. The pooled sensitivity and specificity values for DXI were 0.968 (
p
= 0.1290, I
2
47.1%) and 0.979 (
p
= 0.1965, I
2
35.9%), and for DTI 0.993 (
p
= 0.1870, I
2
37.5%) and 0.993 (
p
= 0.7380, I
2
0%), respectively.
Prototype and commercial DOAC test strips did not differ in their ability to detect DXI and DTI in patient urine samples. This supports the confidence in use of the DOAC Dipstick test, although it needs to be validated in specific patient populations.
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Affiliation(s)
- Andrea Martini
- Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Job Harenberg
- Ruprecht-Karls-University, Heidelberg, Germany.,DOASENSE GmbH, Heidelberg, Germany
| | - Rupert Bauersachs
- Department of Vascular Medicine, Klinikum Darmstadt GmbH, Darmstadt, Germany
| | - Jan Beyer-Westendorf
- Thrombosis Research Unit, Department of Medicine I, Division Hematology, University Hospital "Carl Gustav Carus" Dresden, Dresden, Germany
| | - Mark Crowther
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, Ontario, Canada
| | - Jonathan Douxfils
- Department of Pharmacy, Namur Thrombosis and Hemostasis Centre (NTHC), Namur Research Institute for Life Sciences (NARILIS), University of Namur, Namur, Belgium.,Qualiblood sa, Namur, Belgium
| | - Ismail Elalamy
- Hematology and Thrombosis Centre, Hôpital Tenon, INSERM U938, Sorbonne Université, AP-HP, France.,I M Sechenov First Moscow State Medical University, Department of Obstetrics and Gynecology, Russia
| | - Christel Weiss
- Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
| | - Svetlana Hetjens
- Department of Medical Statistics and Biomathematics, Medical Faculty Mannheim, Ruprecht-Karls-University Heidelberg, Mannheim, Germany
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6
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Toorop MMA, Lijfering WM, Scheres LJJ. The relationship between DOAC levels and clinical outcomes: The measures tell the tale. J Thromb Haemost 2020; 18:3163-3168. [PMID: 32979033 PMCID: PMC7756566 DOI: 10.1111/jth.15104] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/26/2020] [Accepted: 09/14/2020] [Indexed: 12/14/2022]
Abstract
Direct oral anticoagulants (DOACs) are increasingly used for treatment and prevention of thromboembolic diseases, used in fixed dose regimens. Although their safety and efficacy profiles are considered optimal, clinical events still occur. Given that anticoagulation treatment is a delicate balance between clotting and bleeding, it is possible that an optimal target spot exists where the effect of anticoagulation achieves both the lowest possible risk of bleeding and thrombosis. Other currently available anticoagulants (ie, vitamin K antagonists and heparins) provide important clues for this. If such a target spot exists, tailored DOAC therapy may further benefit patients. This opinion article summarizes the current available evidence that suggests that such a tailored strategy could work. It also describes research suggestions for conducting studies in patient populations such as patients with extremes of body weight or impaired kidney function to evaluate whether tailored treatment with DOACs could lead to better patient outcomes.
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Affiliation(s)
- Myrthe M. A. Toorop
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Willem M. Lijfering
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
| | - Luuk J. J. Scheres
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Internal MedicineRadboud University Medical CenterNijmegenThe Netherlands
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7
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Wiesen MHJ, Fietz C, Jübner M, Iwersen-Bergmann S, Andresen-Streichert H, Müller C, Streichert T. Quantification of direct-acting oral anticoagulants: Application of a clinically validated liquid chromatography-tandem mass spectrometry method to forensic cases. Drug Test Anal 2020; 13:419-426. [PMID: 32959964 DOI: 10.1002/dta.2930] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 12/23/2022]
Abstract
In certain forensic cases, a quantification of direct-acting oral anticoagulants (DOACs) can be necessary. We evaluate the applicability of a previously described liquid chromatography-tandem mass spectrometry (LC-MS/MS) methodology for the determination of DOACs in plasma to postmortem specimen. Postmortem internal quality control (PIQC) samples were prepared in pooled blank postmortem heart blood, femoral blood, cerebrospinal fluid (CSF), and urine as well in plasma. To examine the application of the clinical method to forensic cases, the main validation parameters were reinvestigated using PIQC samples. Postmortem samples of 12 forensic cases with evidence of previous rivaroxaban intake and unknown bleeding disorders were analyzed. Interday variability remained within the acceptance criterion of ±15%. Matrix effects were comparable in blank plasma and postmortem matrix extracts. After 4 weeks of storage in the refrigerator, no relevant decrease of DOACs was evident. After 96 h of storage at room temperature, a slight decrease in edoxaban concentration was observed in CSF and urine, while plasma edoxaban decreased by about 50%. Median (range) rivaroxaban concentrations determined in specimen of forensic cases were as follows: heart blood (n = 6), 17.2 ng/ml (<LOQ, 56.6 ng/ml); femoral blood (n = 12), 27.6 ng/ml (<LOQ, 110.5 ng/ml); CSF (n = 7), 11.7 ng/ml (<LOQ, 17.5 ng/ml); urine (n = 6), 275.7 ng/ml (14.5-870.9 ng/ml). The median heart/femoral blood rivaroxaban ratio was 1.2 (n = 5). Exemplary, a forensic case with detection of edoxaban in femoral blood, CSF, and urine, is presented. DOACs can be detected in postmortem heart and femoral blood, CSF, and urine specimen by LC-MS/MS. Based on limited forensic cases, no significant redistribution was evident for rivaroxaban, which was found at highest concentrations in urine.
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Affiliation(s)
- Martin H J Wiesen
- Faculty of Medicine and University Hospital Cologne, Pharmacology at the Laboratory Center, Therapeutic Drug Monitoring, University of Cologne, Cologne, Germany
| | - Cornelia Fietz
- Faculty of Medicine and University Hospital Cologne, Pharmacology at the Laboratory Center, Therapeutic Drug Monitoring, University of Cologne, Cologne, Germany
| | - Martin Jübner
- Faculty of Medicine and University Hospital Cologne, Institute of Legal Medicine, University of Cologne, Cologne, Germany
| | | | - Hilke Andresen-Streichert
- Faculty of Medicine and University Hospital Cologne, Institute of Legal Medicine, University of Cologne, Cologne, Germany
| | - Carsten Müller
- Faculty of Medicine and University Hospital Cologne, Pharmacology at the Laboratory Center, Therapeutic Drug Monitoring, University of Cologne, Cologne, Germany
| | - Thomas Streichert
- Faculty of Medicine and University Hospital Cologne, Pharmacology at the Laboratory Center, Therapeutic Drug Monitoring, University of Cologne, Cologne, Germany.,Faculty of Medicine and University Hospital Cologne, Institute for Clinical Chemistry, University of Cologne, Cologne, Germany
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8
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Maji D, Opneja A, Suster MA, Bane KL, Wilson BM, Mohseni P, Stavrou EX. Monitoring DOACs with a Novel Dielectric Microsensor: A Clinical Study. Thromb Haemost 2020; 121:58-69. [PMID: 32877954 DOI: 10.1055/s-0040-1715589] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND There are acute settings where assessing the anticoagulant effect of direct oral anticoagulants (DOACs) can be useful. Due to variability among routine coagulation tests, there is an unmet need for an assay that detects DOAC effects within minutes in the laboratory or at the point of care. METHODS We developed a novel dielectric microsensor, termed ClotChip, and previously showed that the time to reach peak permittivity (T peak) is a sensitive parameter of coagulation function. We conducted a prospective, single-center, pilot study to determine its clinical utility at detecting DOAC anticoagulant effects in whole blood. RESULTS We accrued 154 individuals: 50 healthy volunteers, 49 rivaroxaban patients, 47 apixaban, and 8 dabigatran patients. Blood samples underwent ClotChip measurements and plasma coagulation tests. Control mean T peak was 428 seconds (95% confidence interval [CI]: 401-455 seconds). For rivaroxaban, mean T peak was 592 seconds (95% CI: 550-634 seconds). A receiver operating characteristic curve showed that the area under the curve (AUC) predicting rivaroxaban using T peak was 0.83 (95% CI: 0.75-0.91, p < 0.01). For apixaban, mean T peak was 594 seconds (95% CI: 548-639 seconds); AUC was 0.82 (95% CI: 0.73-0.91, p < 0.01). For dabigatran, mean T peak was 894 seconds (95% CI: 701-1,086 seconds); AUC was 1 (p < 0.01). Specificity for all DOACs was 88%; sensitivity ranged from 72 to 100%. CONCLUSION This diagnostic study using samples from "real-world" DOAC patients supports that ClotChip exhibits high sensitivity at detecting DOAC anticoagulant effects in a disposable portable platform, using a miniscule amount of whole blood (<10 µL).
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Affiliation(s)
- Debnath Maji
- Department of Electrical, Computer, and Systems Engineering, Case Western Reserve University, Cleveland, Ohio, United States
| | - Aman Opneja
- Hematology and Oncology Division, Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, United States.,Division of Hematology-Oncology, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Michael A Suster
- Department of Electrical, Computer, and Systems Engineering, Case Western Reserve University, Cleveland, Ohio, United States
| | - Kara L Bane
- Division of Hematology-Oncology, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Brigid M Wilson
- Geriatric Research Education and Clinical Center, Louis Stokes Cleveland Veterans Administration Medical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States.,Division of Infectious Diseases and HIV Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States
| | - Pedram Mohseni
- Department of Electrical, Computer, and Systems Engineering, Case Western Reserve University, Cleveland, Ohio, United States
| | - Evi X Stavrou
- Division of Hematology-Oncology, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, United States.,Section of Hematology-Oncology, Department of Medicine, Louis Stokes Cleveland Veterans Administration Medical Center, VA Northeast Ohio Healthcare System, Cleveland, Ohio, United States
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9
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Wu X, Wang L, Peng Y, Wu F, Cao J, Chen X, Wu W, Yang H, Xing M, Zhu Y, Shi Y, Zhuang S. Quantitative analysis of direct oral anticoagulant rivaroxaban by terahertz spectroscopy. Analyst 2020; 145:3909-3915. [PMID: 32301471 DOI: 10.1039/d0an00268b] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Rivaroxaban, as a direct oral anticoagulant, has been widely used in the treatment and prevention of thrombosis disease (TD). However, even if the same dose of rivaroxaban is taken, different pathophysiological characteristics of TD patients determine the differences in plasma concentrations between individuals, leading to the difficulties of dosage selection and plasma concentration control. Conventional rivaroxaban detection methods, including prothrombin time method, anti-Xa assay and liquid chromatography-tandem mass spectrometry (LC-MS/MS), are not widely used in clinical practice due to the limitations of accuracy, speed and cost. Here, we present a simple quantitative detection method for rivaroxaban by terahertz (THz) spectroscopy. Combining density functional theory (DFT) method and THz spectroscopy, the THz absorption peaks of rivaroxaban and the corresponding low-frequency vibrational modes are studied theoretically and experimentally. We find linear relationships between the amplitudes of these characteristic peaks and the concentrations of rivaroxaban. Based on these linear functions, we can analyse the rivaroxaban concentration with a detection time of 1 minute per test and the lowest detection limit of 2 μmol mL-1. As compared to Raman spectroscopy method (its detection limit is about 80 μmol mL-1), our method has more potential and is practical for the clinical quantitative detection of rivaroxaban as well as other direct oral anticoagulants.
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Affiliation(s)
- Xu Wu
- Terahertz Technology Innovation Research Institute, Shanghai Key Lab of Modern Optical System, Terahertz Science Cooperative Innovation Center, University of Shanghai for Science and Technology, Shanghai, P. R. China.
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10
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Soff GA, Mones J, Wilkins C, Devlin S, Haegler‐Laube E, Wills J, Sarasohn DM, Juluru K, Singer M, Miao Y, Batista J, Mantha S. Rivaroxaban treatment of cancer-associated venous thromboembolism: Memorial Sloan Kettering Cancer Center institutional experience. Res Pract Thromb Haemost 2019; 3:349-356. [PMID: 31294321 PMCID: PMC6611365 DOI: 10.1002/rth2.12215] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 04/11/2019] [Accepted: 04/12/2019] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Low-molecular-weight heparin has been the preferred treatment of cancer-associated thrombosis (CAT); however, emerging data support the use of direct oral anticoagulants (DOACs). OBJECTIVES The Memorial Sloan Kettering Cancer Center Clinical Pathway has served as the institutional guideline for the use of rivaroxaban to treat CAT since 2014. Key elements are to recommend against use of a DOAC in patients with active gastrointestinal (GI) or genitourinary tract lesions, and a prespecified dose reduction in the elderly (75+ years old). We present our institutional experience for treatment of CAT. METHODS From January 2014 through September 2016, 1072 patients began rivaroxaban treatment for CAT; 91.9% had a solid tumor, 8.1% had hematologic malignancies, and 75% of patients with solid tumors had metastatic disease. All patients with CAT treated with rivaroxaban were included in this analysis, regardless of adherence to the Clinical Pathway. RESULTS The 6-month cumulative incidence of recurrent venous thromboembolism and major bleeding were 4.2% (95% confidence interval [CI], 2.7%-5.7%) and 2.2% (95% CI, 1.1%-3.2%), respectively. The incidence of clinically relevant non-major bleeding leading to discontinuation of rivaroxaban for at least 7 days was 5.5% (95% CI, 3.7%-7.1%), and 73.3% of major bleeds occurred in the GI tract. The 6-month cumulative mortality rate was 22.2% (95% CI, 19.4%-24.9%). The elderly had similar rates of recurrent thrombosis and bleeding as those aged under 75 years. CONCLUSION Our institutional experience suggests that in appropriately selected patients, rivaroxaban may be used for treatment of CAT with promising safety and efficacy.
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Affiliation(s)
- Gerald A. Soff
- Department of Medicine/Division of Hematologic OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew York
| | - Jodi Mones
- Department of Medicine/Division of Hematologic OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew York
| | - Cy Wilkins
- Department of Medicine/Division of Hematologic OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew York
| | - Sean Devlin
- Department of BiostatisticsMemorial Sloan Kettering Cancer CenterNew YorkNew York
| | - Eva Haegler‐Laube
- Department of Cardiology, InselspitalBern University HospitalUniversity of BernBernSwitzerland
| | - Jonathan Wills
- Department of Information SystemsMemorial Sloan Kettering Cancer CenterNew YorkNew York
| | - Debra M. Sarasohn
- Department of RadiologyMemorial Sloan Kettering Cancer CenterNew YorkNew York
| | - Krishna Juluru
- Department of RadiologyMemorial Sloan Kettering Cancer CenterNew YorkNew York
| | - Michael Singer
- Department of Information SystemsMemorial Sloan Kettering Cancer CenterNew YorkNew York
| | - Yimei Miao
- Department of Medicine/Division of Hematologic OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew York
| | - Jeanette Batista
- Department of Medicine/Division of Hematologic OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew York
| | - Simon Mantha
- Department of Medicine/Division of Hematologic OncologyMemorial Sloan Kettering Cancer CenterNew YorkNew York
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11
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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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Havig SM, Lea D, Krpo M, Skari RM, Gustavsen I, Høiseth G. Fatal Adverse Event with Dabigatran in Elderly Patient with Reduced Kidney Function. Basic Clin Pharmacol Toxicol 2018; 123:221-226. [DOI: 10.1111/bcpt.12985] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 02/04/2018] [Indexed: 01/22/2023]
Affiliation(s)
- Stine Marie Havig
- Division of Laboratory Medicine; Department of Forensic Sciences; Oslo University Hospital; Oslo Norway
- Division of Laboratory Medicine; Department of Pharmacology; Oslo University Hospital; Oslo Norway
| | - Dordi Lea
- Department of Pathology; Stavanger University Hospital; Stavanger Norway
| | - Maja Krpo
- Division of Laboratory Medicine; Department of Forensic Sciences; Oslo University Hospital; Oslo Norway
| | - Ragnhild Margrete Skari
- Division of Laboratory Medicine; Department of Forensic Sciences; Oslo University Hospital; Oslo Norway
| | - Ingebjørg Gustavsen
- Division of Laboratory Medicine; Department of Pharmacology; Oslo University Hospital; Oslo Norway
| | - Gudrun Høiseth
- Division of Laboratory Medicine; Department of Forensic Sciences; Oslo University Hospital; Oslo Norway
- Department of Psychopharmacology; Diakonhjemmet Hospital; Oslo Norway
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Position Paper on laboratory testing for patients on direct oral anticoagulants. A Consensus Document from the SISET, FCSA, SIBioC and SIPMeL. BLOOD TRANSFUSION = TRASFUSIONE DEL SANGUE 2017; 16:462-470. [PMID: 29106357 DOI: 10.2450/2017.0124-17] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 07/13/2017] [Indexed: 01/17/2023]
Abstract
Although direct oral anticoagulants (DOAC) do not require dose-adjustment on the basis of laboratory test results, the measurement of their anticoagulant effect is useful in special situations. This position paper issued by the Italian Scientific Societies that are mainly involved in the management of patients on DOAC is aimed at providing guidance to care-givers on which tests should be used and the situations in which testing is useful. The guidance is based on the data from the literature so far available and/or on consensus among experts.
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Serrano-Sánchez V, Ripollés-de Ramón J, Collado-Yurrita L, Vaello-Checa I, Colmenero-Ruiz C, Helm A, Ciudad-Cabañas MJ, Serrano-Cuenca V. New horizons in anticoagulation: Direct oral anticoagulants and their implications in oral surgery. Med Oral Patol Oral Cir Bucal 2017; 22:e601-e608. [PMID: 28809374 PMCID: PMC5694183 DOI: 10.4317/medoral.21862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 05/14/2017] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Thrombotic disorders remain a leading cause of death in the Western World. For decades, vitamin K antagonists used in the prevention of this pathology, such as warfarin or sintrom, were the only oral agents available for long-term anticoagulation, in spite of their disadvantages. MATERIAL AND METHODS An electronic database search was carried out on MedLine and The Cochrane Library Plus, without restrictions on the type of study nor dates, in English and Spanish. Abstracts were reviewed, and complete articles if necessary, considering all articles that included recommendations on DOACs and oral surgery. RESULTS In recent years, the so-called "new oral anticoagulants" have been introduced in clinical practice to treat those patients whose medical conditions require long-term anticoagulant treatment, replacing traditional oral anticoagulants. CONCLUSIONS The new oral anticoagulants represent new therapeutic options, with a number of advantages such as poor interaction with food, minor drug interactions, and do not require periodic dose adjustments or routine controls. The purpose of this review is to establish an update on the new oral anticoagulants: Dabigatran, Rivarozaban, Apixaban and Edoxaban.
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Nambiar VK, Dhanya TS, Ajai AV. Successful Revascularization of Acute Middle Cerebral Artery Occlusion by Intravenous Thrombolysis While on Apixaban. Ann Indian Acad Neurol 2017; 20:161-162. [PMID: 28615907 PMCID: PMC5470155 DOI: 10.4103/aian.aian_422_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Vivek K Nambiar
- Division of Stroke, Centre of Neurosciences, Amrita Institute Medical Sciences, Kochi, Kerala, India
| | - T S Dhanya
- Division of Stroke, Centre of Neurosciences, Amrita Institute Medical Sciences, Kochi, Kerala, India
| | - Amrutha V Ajai
- Division of Stroke, Centre of Neurosciences, Amrita Institute Medical Sciences, Kochi, Kerala, India
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Derogis PBM, Sanches LR, de Aranda VF, Colombini MP, Mangueira CLP, Katz M, Faulhaber ACL, Mendes CEA, Ferreira CEDS, França CN, Guerra JCDC. Determination of rivaroxaban in patient's plasma samples by anti-Xa chromogenic test associated to High Performance Liquid Chromatography tandem Mass Spectrometry (HPLC-MS/MS). PLoS One 2017; 12:e0171272. [PMID: 28170419 PMCID: PMC5295670 DOI: 10.1371/journal.pone.0171272] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 01/17/2017] [Indexed: 12/11/2022] Open
Abstract
Rivaroxaban is an oral direct factor Xa inhibitor, therapeutically indicated in the treatment of thromboembolic diseases. As other new oral anticoagulants, routine monitoring of rivaroxaban is not necessary, but important in some clinical circumstances. In our study a high-performance liquid chromatography-tandem mass spectrometry (HPLC-MS/MS) method was validated to measure rivaroxaban plasmatic concentration. Our method used a simple sample preparation, protein precipitation, and a fast chromatographic run. It was developed a precise and accurate method, with a linear range from 2 to 500 ng/mL, and a lower limit of quantification of 4 pg on column. The new method was compared to a reference method (anti-factor Xa activity) and both presented a good correlation (r = 0.98, p < 0.001). In addition, we validated hemolytic, icteric or lipemic plasma samples for rivaroxaban measurement by HPLC-MS/MS without interferences. The chromogenic and HPLC-MS/MS methods were highly correlated and should be used as clinical tools for drug monitoring. The method was applied successfully in a group of 49 real-life patients, which allowed an accurate determination of rivaroxaban in peak and trough levels.
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Affiliation(s)
| | | | | | | | | | - Marcelo Katz
- Hospital Israelita Albert Einstein, São Paulo, Brazil
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Harenberg J. Laboratory determination of old and new targeted anticoagulant agents for prevention of bleeding and thrombotic events in cancer patients. Thromb Res 2017; 140 Suppl 1:S165-7. [PMID: 27067972 DOI: 10.1016/s0049-3848(16)30117-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
A two-fold prolongation of activated partial thromboplastin time (APTT) is established as therapeutic range for therapy with unfractionated heparin, hirudin and argatroban. The international normalized ratio (INR) of 2 to 3 is required to maintain anticoagulation in the therapeutic range of vitamin K antagonists. The therapeutic range of anti-factor Xa activity during therapy with low-molecular weight heparins and danaparoid are less well and of direct oral anticoagulants (DOAC) poorly defined. The relation of aPTT and INR values to thrombotic and bleeding events are well established despite a large variation of values in affected patients. The relation of coagulation values of the other anticoagulants to clinical events is open. The value of determination in cancer patients is higher because of the increased risk for thrombotic and bleeding events of this patient group. Several activities are currently undertaken to certify methods for in vitro diagnostic testing for DAOCs.
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Affiliation(s)
- Job Harenberg
- Medical Faculty Mannheim, University of Heidelberg, Maybachstrasse 14, 68169 Mannheim, Germany.
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Arnao V, Riolo M, Tuttolomondo A, Pinto A, Fierro B, Aridon P. New frontiers in anticoagulation: non vitamin-K oral anticoagulants in stroke prevention. Expert Rev Neurother 2016; 17:539-552. [PMID: 27911120 DOI: 10.1080/14737175.2017.1268053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Non vitamin-K oral anticoagulants (NOACs) are direct and specific inhibitors of the coagulation factors IIa (dabigatran) and Xa (apixaban, rivaroxaban, edoxaban) which share many pharmacokinetic properties. However, indications are lacking regarding the use of NOACs during thrombolysis, surgery and bleeding events. Areas covered: In this paper, the authors retrospectively analyzed the relevant literature on the NOACs using the PubMed and Google Scholar databases. Expert commentary: Although warfarin is effective in cardioembolic stroke prevention, easier handling and more favorable risk-benefit profile often render NOACs a more preferable therapy choice for neurologists. New evidences have suggested their use in treatment of elderly people, in patients with renal insufficiency or with antiphospholipid antibody syndrome. In addition, the use of antidotes, which rapidly reverse the anticoagulant effect of the NOACs, could be useful in bleeding, during emergency procedures, or in case of overdose.
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Affiliation(s)
- Valentina Arnao
- a BioNeC Dipartimento di BioMedicina Sperimentale e Neuroscienze Cliniche , Università degli Studi di Palermo , Palermo , Italy.,b Biomedical Department of Internal and Specialistic Medicine (Di.Bi.M.I.S), School of Medicina Clinica e Scienze del Comportamento , University of Palermo , Palermo , Italy
| | - Marianna Riolo
- a BioNeC Dipartimento di BioMedicina Sperimentale e Neuroscienze Cliniche , Università degli Studi di Palermo , Palermo , Italy
| | - Antonino Tuttolomondo
- c Biomedical Department of Internal and Specialistic Medicine (Di.Bi.M.I.S) , University of Palermo , Palermo , Italy
| | - Antonio Pinto
- c Biomedical Department of Internal and Specialistic Medicine (Di.Bi.M.I.S) , University of Palermo , Palermo , Italy
| | - Brigida Fierro
- a BioNeC Dipartimento di BioMedicina Sperimentale e Neuroscienze Cliniche , Università degli Studi di Palermo , Palermo , Italy
| | - Paolo Aridon
- a BioNeC Dipartimento di BioMedicina Sperimentale e Neuroscienze Cliniche , Università degli Studi di Palermo , Palermo , Italy
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Abstract
OPINION STATEMENT Direct oral anticoagulants (DOAC) are an attractive therapeutic option for anticoagulant treatment in the setting of venous thromboembolism or non-valvular atrial fibrillation. These drugs overall appear to have a lower risk of life-threatening hemorrhage than the vitamin K antagonists. In addition, they demonstrate more predictable and stable pharmacokinetics. Measurement of the degree of anticoagulation is desirable in patients with DOAC-associated hemorrhage, but commonly available coagulation assays show poor sensitivity for degree of DOAC effect. DOAC-specific tests are time consuming and not widely available. All coagulation tests should be interpreted considering the timing of last intake and renal function. When life-threatening bleeding occurs, hemostasis should be restored as rapidly as possible. Non-specific prohemostatic drugs may have a role in DOAC reversal, and specific antidotes are at different stages of development. In this review, we provide a summary of DOAC characteristics and an overview of the different therapeutic options available for DOAC reversal.
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Samuelson BT, Cuker A. Measurement and reversal of the direct oral anticoagulants. Blood Rev 2016; 31:77-84. [PMID: 27625113 DOI: 10.1016/j.blre.2016.08.006] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/24/2016] [Accepted: 08/29/2016] [Indexed: 12/27/2022]
Abstract
Direct oral anticoagulants (DOACs) offer noninferior efficacy and improved safety compared to vitamin K antagonists (VKAs) for the prevention and treatment of venous thromboembolism and for the prevention of stroke and systemic embolism in nonvalvular atrial fibrillation. Unlike VKAs, DOACs do not require routine laboratory monitoring of anticoagulant effect and dose adjustment. In certain situations, however, laboratory assessment of anticoagulant effect may be desirable. Here we review the utility of currently available assays for assessment of DOAC effect and recommend an optimal assessment strategy for each drug, including calibrated dilute thrombin time or ecarin-based assays for dabigatran and calibrated anti-Xa activity assays for the factor Xa inhibitors. We also discuss reversal strategies, both specific and nonspecific, for each drug, including the preferential use of idarucizumab for the reversal of dabigatran and two agents, andexanet and ciraparantag, currently under development for the reversal of rivaroxaban, apixaban, and edoxaban.
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Affiliation(s)
- Bethany T Samuelson
- Division of Hematology, Department of Medicine, University of Washington, 1100 Fairview Ave N D5-100, Seattle, WA 98109, USA.
| | - Adam Cuker
- Department of Medicine and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, PA 19104, USA.
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Drouet L, Bal dit Sollier C, Steiner T, Purrucker J. Measuring non-vitamin K antagonist oral anticoagulant levels: When is it appropriate and which methods should be used? Int J Stroke 2016; 11:748-58. [DOI: 10.1177/1747493016659671] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2016] [Accepted: 05/27/2016] [Indexed: 12/26/2022]
Abstract
Background Although the need for an emergency intervention may merit laboratory measurement of non-vitamin K antagonist oral anticoagulant (NOAC) concentration or anticoagulant activity, NOACs are not supposed to require routine monitoring due to their stable pharmacological profiles compared with warfarin. Aims To examine situations where NOAC measurement may be useful and to provide information about methodologies available to measure NOAC-related anticoagulation activity. Summary of review The routine coagulation tests, including prothrombin time, thrombin time, activated partial thromboplastin time, and international normalized ratio, have variable sensitivities to NOACs. Tests have been developed for use with specific NOACs, e.g. diluted thrombin time or chromogenic factor Xa assays. In emergency situations, such as severe bleeding, stroke, or a requirement for urgent surgery or procedures, there may be a need to assess anticoagulant activity to guide clinical decision making. In cases where neutralization of the anticoagulant effect is warranted, specific reversal agents are likely to become invaluable medical tools. Evidence to date suggests that dosing decisions for NOACs based on clinical features (e.g. age or renal function) can help optimize the benefit–risk balance without assessment of anticoagulant activity in non-emergency routine situations. Conclusions Regular monitoring of NOAC levels does not provide benefits and cannot be recommended at present. In some specific circumstances, e.g. severe bleeding, before urgent surgery, or before thrombolysis, measurement may be beneficial to assess whether a patient is actively anticoagulated. The availability of NOAC-specific reversal agents may change management practices in emergencies.
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Affiliation(s)
- Ludovic Drouet
- Hôpital Lariboisière, Paris, France and Paris VII University, Paris, France
| | | | - Thorsten Steiner
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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